24 March 2022

Postcard from the possible future – Orlando, Florida HIMSS 2022

Government HIMSS Interoperability

After a nearly two year covid hiatus the largest digital health meeting in the world is back (almost) and suddenly, the US is light years ahead of Australia in digital health innovation, thinking and implementation.

After the huge success of Disneyland Anaheim California, which launched in 1955, Walt Disney, realising that 70% of the population of the US resided East of the Mississippi river, went hunting for an East coast location for something even bigger than Anaheim. 

Of all possible locations, he found it flying over swampland in Orlando Florida, where, at the time, for every 16 residents, of which there was only about 80,000 back then (over 2 million today), there was one alligator. That’s a lot of alligators. 

When news first hit the press that Disney was planning on transforming empty swamp wasteland in nowheresville Florida, into the next big thing in family entertainment, the press pounced on the project as the likely biggest white elephant in the history of theme parks, and the probable beginning of the end of the Disney company’s incredible run of success and growth.  

Disney, as he did so much through his career, broke ranks with convention and “the norm”, saw a future, and then went about obsessively building it.  

Disneyland Orlando not only cemented the Disney Company’s future (it remains one of the largest media and entertainment companies globally today), it anchored Orlando’s future. Today, Orlando is the convention capital of the world, attracting some 75 million visitors per year, and is the most visited city in the US (not New York). 

Choosing Orlando as the site for the return of the largest digital health meeting in the world, HIMSS (Health Information and Management Systems Society) has some echoes of Walt Disney flying over vast tracts of alligator-infested swampland looking for his future in 1963. 

For one thing, between a federated healthcare framework, the slow but sure descent into madness that makes funding mainly a private sector function, various fragmented federal and state government topups to a dysfunctional private funding model (mainly Medicare and Medicaid now), and then layers of civil rights and privacy legislation that make identity confirmation and matching a nightmare, the US healthcare system was, and remains to a large extent, the mother of all alligator-infested swamps. 

But like Disney, groups of digital health professionals, and some key federal government personnel, developed a vision of digital health in the country more than a decade ago, that all this mess could be significantly cleaned up by connecting everything in the system and allowing seamless sharing of healthcare data, not just among providers, but among providers, tech vendors, and patients. 

That vision culminated five years ago in the 21st Century Cures Act, a piece of legislation that mandated that all providers and technology vendors must align their systems to common web-based data sharing standards, or literally, go to gaol. Sensibly the government minders of this legislation gave industry a five-year “get your act together” period, and did much to facilitate and assist both providers and vendors to get up to speed. 

At the time, the digital health vendor lobby was largely furious. They said it would create system wide mayhem and failure. But the government, which for the entire period remained bipartisan on the legislation and the intent of the legislation, stood firm. 

Less than two years before the compliance deadline for the Cures Act, covid hit. 

Until that point, the biggest thing in digital health in the US was that after 30 years of talking about using electronic health records (EHRs), after 2010, the country actually embraced the technology. Use of EHRs by physicians and other allied health professionals went from about 12% in 2013, to nearly 90% in 2019.  

With the Cures Act, the US had the opportunity to start building itself out of the swamp.  

If you can connect all points of the system, with trust, you would be on a journey of revolutionising the efficiency of delivery, and laying a genuine platform for starting to tackle health equity, a problem which has been vastly exacerbated in the US by the private payment paradigm. 

The challenge for digital health leaders in the US was surely more immense even than what Walt Disney faced when he first decided to transform vast acreage of swampland in Orlando. 

How do you mould the magic of digital for good in healthcare: for much more equity in delivery, to reduce spiralling costs of delivery, and, even, to improve delivery? 

Before covid everyone talked about emerging data sharing cloud-based technologies for health in a manner that felt like it might take another 30 years to get going in any meaningful way. 

With covid, and the official start of the Cures Act on 5 April 2021, the US had the base ability for meaningful application of these technologies, at scale, literally within weeks: new digital cloud enabling technologies catapulted telehealth, AI, data analytics, and data sharing resources and standards onto the front line of managing the covid crisis. 

As if to underline the escalation, in the US in the last two years, venture capital, often the harbinger of market futures, decided to invest over $US65 billion in digital health startups. In the two years prior, only about $US7 billion had been invested. 

Clearly, covid has sparked generational change in how people view the opportunity of digital health, and most importantly, in how they are starting to deploy it. 

With most providers and vendors all aligned on being able to share their data seamlessly, the explosion in opportunity has been phenomenal. 

So it was that I decided this year’s HIMSS might be one of the most interesting ones to attend, and got a plane to risk life and limb, with 28,000 unmasked delegates in a muggy Florida convention centre. 

In some ways, the HIMSS crowd is the legacy crowd. The healthcare IT nerds that have been doing the hard yards at the digital coal face for the past 30 years, and struggling with EHR implementation seemingly forever, within a hugely risk-adverse and regulated sector, mind-boggling fragmented sources of care and funding sources to manage and silos of isolated data and technology.   

After working hard for about a decade this crowd has managed to make interoperability work within single-provider environments such as one hospital pretty well.  

But after years of getting this to work, their solutions weren’t usually able to share data outside of their organisation with other providers, vendors and, of course patients. 

The Cures Act and covid have thrust massive change upon the traditional HIMSS delegate at such high velocity that there is real risk of multiplying errors in environments where tolerance for error is measured in life and death.  

So things are getting pretty stressful. 

HIMSS, though pushing itself as a global organisation, particularly in the development of interoperability standards such as HL7 and FHIR, is still very US centric in its focus. 

It sort of has to be.  

If you compare the US health system to Australia, the UK, and parts of Western Europe, particularly the Scandinavian countries, it is the mother of all train wrecks in terms of fragmentation of care provision and funding: a melting pot of every feasible problem and complexity you might have in terms of interoperability, open data, payments and data sharing. 

There is some irony in that within some HMOs (health management organisations), which are, essentially, private health insurer-run vertically integrated closed health ecosystems, you can see the leading edge of interoperable care delivery. They are driving hard at profitability and therefore efficiency via vertical integration of interoperable services. There is no separation of primary, allied and tertiary care, as there is in Australia. HMOs are one integrated unit, largely interoperable as far as data-sharing goes. 

But HMOs (at least the good ones) are the Rolls Royce end of care in the US. They are expensive and to a large degree elite. Only about 23% of Americans are members of an HMO. Once outside this environment, the nature of services and how they are funded is much messier, a combination of employer-funded private insurance services that often fall short of being able to fund serious health issues, and state and federal government programs such as Medicare and Medicaid.  

Joining all the pieces together in this jigsaw to somehow provide power to the patient in this system, and optimising efficiency where possible, is where the US government has placed most of its focus in the last decade. The Cures Act and “meaningful use” is in some respects just the start of a vast long-term program to allow every aspect of the system to share data for efficiency and safety, and most importantly, for patient empowerment. 

In Australia we love to say we are global leaders in digital health. We will point to the quality and cost of care versus the mess of other countries, particularly the US, as some sort of proof of how good our digital health effort has been.  

The truth is, we are huge laggards in digital health now, and we’ve been lucky so far. We’ve been spoilt by our universal national system of care (Medicare) and by our relatively simple funding paradigm. 

The US is a messed up healthcare system, delivering expensive and poor outcomes, but it’s precisely because of this, that its digital health efforts are far more advanced than our own.  

The US healthcare system is a burning platform (and an alligator-infested swamp). Faced with such a massive mess, the US federal government had nowhere to go but force the co-ordination digital health development across its country in a manner that so far, Australia doesn’t believe in, or pontificates about. 

And this is why the US, despite what people say about its healthcare system, has massively leapfrogged Australia in innovation in digital health, and has a lot to teach Australia about the right path to optimising health through better co-ordinated and connected digital health. 

Australia, thankfully, still has a lot of advantages in a system that is generationally more cohesive compared to the US as a result of foresight of our government in the past to be the major centralised funder of healthcare services. We have huge natural advantage via Medicare and our relatively small size.  

We have managed to develop some smart one-off infrastructure for digital health, such as our unique health user identifier system (the US is a big mess here as just identifying and trusting that someone is who they say they are is a big deal). 

We’ve also managed to pull off one or two neat national interoperability collaborations which prove we are capable of co-operating for the greater good. Our best collaboration has been electronic prescribing and script exchanges. Our worst, by far, and it’s still anchoring us in the past, is the My Health Record. 

But here’s the rub. Cohesive system, IHI, My Health Record or not, if we don’t require that our providers and vendors talk to each other in a standard manner – FHIR and open APIs largely – then we will never have a system that is interoperable and capable of delivering the sort of flexibility needed to manage our impending chronic care crisis, and possibly more importantly, empowering our patients properly by giving them access to usable and actionable system data about themselves.  

If we don’t have the sort of interoperability that common web sharing standards and infrastructure is enabling now in the US, we will squander money and people’s wellbeing and lives. At scale. 

I’m sitting now at just one of many HIMSS interoperability panels and one of the panellists has just summed up by saying to the audience: “Interoperability is here and getting better …it’s not coming any more.” 

Compare that to Australia, where a colleague texted me as she watched an equivalent interoperability panel held at Healthcare Week in Sydney, saying that it looks like between the power and influence of the vendor lobby group the Medical Software Industry Association (MSIA), and a coming election, the federal government, which was talking tough on interoperability standards for providers and vendors just a few months back, might be backing away from the idea. 

Which means we are now six years behind the US on interoperability, and starting to drift backwards at speed. 

If the federal government is going to mandate, incentivise, or even better, “co-ordinate” the universal adoption of sharing common standards and infrastructure for interoperability in Australia, it will be a minimum of three years until we can say what the panellist at HIMSS said today. And it might well be more. 

In the US it took five years between the announcement of the 21st Century Cures Act, which mandated that every provider and vendor must be interoperable to basic modern web sharing standards, and the formal start of the law last year. 

Now the US is moving at speed setting up clusters of health information exchanges which all talk to each other.  

In the major HIMSS digital health exhibition, the largest digital health vendor exhibition in the world, 95% of the vendors showing their wares were delivering their products on fully cloud based platforms, all with FHIR or equivalent web sharing enabled interfaces.  

In other words, on premise server-based vendors are already a thing of the past in the US. An anachronism. 

In Australia, more than 88% of the vendors who are members of the MSIA are legacy on premise-based vendors. This is simply backward now. 

Off the back of this vital alignment of providers and vendors in the US now, healthcare innovation is thriving. Start-ups are building apps for patients that can access all the data they need to start creating huge value for patients, and huge system efficiencies as well. 

And VCs are opening their wallets because they know that finally, some form of democratisation of healthcare data is here, and transformation can proceed properly in the healthcare sector, as it has in every other major market sector many years ago. 

This happened because the US government provided a clear investor roadmap in the Cures Act legislation. Investors had certainty so they started building future companies that could manage the new ecosystem, such Redox and Gorilla Health, both of which help providers build and maintain their connectivity through the various emerging health information exchanges in the country.   

They are the sort of businesses you would see starting in Australia if we had similar certainty for investors. 

In an interoperable future where everyone is required to be FHIR or equivalent enabled at some point in the future, some of our current vendors, such as Healthlink and Medical Objects would not exist in their current form. But you can imagine with the right leadership and money, a group like Medical Objects developing itself into a modern interlocutor company like Redox, providing FHIR and other information exchange services for providers. 

The big buzz phrase at this HIMSS this year is “health equity”. In every respect, “health equity”, which is empowering patients to get a much better deal from their healthcare system by allowing them proper access to their own data, is not feasible without a proper web sharing standards framework. 

In Australia, we a fiddling while interoperability Rome burns. 

We are doing that in part because while we are on a burning platform, we can’t feel the heat enough yet. We are slow boiling interoperability frogs. 

Yes, there are huge implications for a vendor community that is almost all legacy, by mandating alignment on modern web sharing standards and infrastructure. It will be very hard for a lot of vendors, some will go broke and most will need help. 

But we can’t sit back and pretend the vendor community, and even providers, are going to naturally move over time to these technologies and standards. 

Even if we did really think that, we no longer have the time to wait for it to somehow happen. 

Without leading our providers and vendors to water, or if need be, forcing them to drink, we will not be able to undertake a modern, standards based and technology enabled “health equity” journey for Australians. 

Which means we will really have screwed things up big time. Much bigger even than we have with the My Health Record (which by the way won’t work ever if we don’t make vendors and providers equalise on data sharing standards anyway). 

The very strange realisation from visiting HIMSS 2022 is that the US is so far in front of Australia now in trying to sort out its mess, you’d have to say that the government together with the provider and vendor community here, have created the opportunity for the country to significantly improve the future health of their citizens. 

We in Australia, for some unfathomable reason, are still talking about the most basic elements of starting the journey. And throwing around idiotic arguments about making a business case to do it. 

If the US can do it, with what is surely one of the most fragmented and messed up healthcare systems in the world, what is stopping Australia from doing it? 

You simply can’t think or say, “the vendor community won’t survive such regulation, there needs to be evolution not revolution”, or worse, the “vendor and provider community will get there naturally”. They won’t. The jump is just too big and requires universal system alignment for it to be done without some form of government help. 

Commercially, our local vendor community is stuck a long way in the past, milking legacy systems. They can’t change without some form of government intervention and help because most of them can’t afford to change. Commercially it doesn’t make any sense.  

“Health equity” a decade ago in the US, seemed a laughably unrealistic objective. Now the US is making inroads, and based on some of the working demonstrations of interoperability at HIMSS 2022 things are only just getting started. 

Australia must bite the web-sharing standards bullet. 

We need to look after our vendor community as we do it, for sure, but we can’t sit back and keep wondering if interoperability in our system will just happen naturally (or magically even).  

It won’t.  

We need to be courageous, creative and bold, now.  

We need to start showing some leadership. 

Just like Walt Disney did on that plane flying over the Florida swamplands in 1963.