Author Archives: Ed Butler

$900m offered for healthcare delivery and payment innovations for Medicaid, Medicare, and CHIP

The Funding Opportunity Announcement was published yesterday for the second round of Health Care Innovation Awards. (see details here). CMS held a conference call and I attended to get a better understanding of what this might mean to health innovators.

I developed the IT portion of a proposal for the CMS Health Innovation Round One in 2012 on an exciting proposal to improve preventive health through a combination of health risk assessments and coaching. It was fun, (but we did not win). Like many others, now is the time to be forming ideas and teams. There will be a conference call on May 28th that will provide more details. Here is what we know now-

(1) this round is focused on outpatient and post-acute care settings, not what happens in hospitals. Four categories are defined in the FOA, although in the call it was acknowledged that the categories are overlapping and that a given proposal may support multiple categories.

(2) this round focused tightly on the implementation of new payment and service delivery models. It is not about new therapeutic protocols, clinical trials, or new technology products. Technology can be part of the new payment and service delivery model, but it is not the point.

(3) This is about saving Medicare, Medicaid, and CHIP per capita expenditures while improving the quality of care, patient experience, and the the health of populations. A clear preference for multipayer solutions was emphasized. It is open to a wide variety of organizations, including state and local governments, “convener” organizations, faith-based organizations, as well as healthcare delivery organizations.

In the weeks ahead I will be discussing this funding opportunity with other health innovation-minded organizations. Please let me know if you’re interested in talking about it.

Ed Butler

Reinventing the Health Insurance Business

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The Stanford School of Business has a program In Healthcare Innovation as part of its executive program and each year hosts a one day “summit” event. It was planned by a team of faculty, alumni, and students who attempted to balance perspectives of payers, patients, providers, and healthcare innovators. Because the theme this year was IT-enabled disruption, I felt that I really had to to go down to Palo Alto to be there in person.

Mark Bertolini, CEO of Aetna, gave a fascinating talk on the future of health insurance. Technological and economic forces are accelerating change in the healthcare industry globally. The two primary technological forces are Internet and the global adoption of mobile devices. The two primary economic forces accelerating change in the US are (a) the challenged hospital revenue model and (b) the end of independent physician practices. He noted that 70% of medical practices are now owned by hospitals, up from only 25% 10 years ago.

Hospital profit centers, such as diagnostic imaging, are turning into cost centers as a result of reimbursement changes. The convergence of medical practices and hospital systems combined with reimbursement changes that no longer incentivize volume overvalue our rapidly transforming the industry.

Bertolini pointed out that in China there are 270 million mobile devices and 538 million Internet users. In both India and China the growth of the Internet is starting from mobile platforms, thus skipping prior generations of Web technology. Both countries face major challenges and the current US healthcare system does not provide an attractive model. The opportunities for healthcare innovation in developing countries are very interesting to Aetna.

Aetna has acquired a number of health IT companies in recent years and has assembled a tech stack that is “payor agnostic”. I thought it was especially interesting when Bertolini said “I would rather have Banner Health (one of their integrated delivery system customers) on the health insurance exchange with our technology than to have Aetna on the exchange”. The strategic implication of his statement that “We don’t sell members, we convert patients” is a shift from directly insuring populations to becoming a provider of capital, IT, and underwriting expertise to risk-bearing care delivery organizations. He asserted that “the sick ones are the most profitable because we can manage this risk better using our technology”. He asserted “population management is a consumer centric model”. This equation of population health management (payer perspective) with the consumer at the center (personalized) is the strategic kernel.

Bertolini had just returned from China where he snapped this picture of thousands of unoccupied new housing units being constructed in Shenzhen China in a region that aspires to become China’s Silicon Valley (a point not lost on this Stanford audience).

Aetna has concluded a joint venture deal to assist China in its development of the ‘health care of the future”. Bertolini did not go into details about the venture but said that this is a 300 million RMB program and it is based on principles of population health management. China faces a challenge of having 29% of its population over the age of 65 by the year 2030. He noted that this joint venture is not building an insurance product but one that can be underwritten. That said, one of the hottest insurance products in China is a policy for high net worth individuals that will evacuate them for Tertiary and Quaternary care.

The Affordable Care Act exchanges open in October 2013 will unleash a disruptive wave that will ripple through the US healthcare system. Bertolini expects that the long-term effects of this to be dramatic.

I was especially intrigued by Bertolini’s comments on the shift in health care finances towards consumers. In western and southern Europe we are already beginning to see the fight over the social contract promises made after World War II. These are promises that cannot be sustained. In the US the debate is really about the social contract. That is one reason that “The shift to healthcare consumerism is unstoppable and inexorable”, he asserted.

“If we do population health management right we don’t need benefit plans. In this context Bertolini mentioned SCAN, a social HMO in San Diego County. In his vision of the future healthcare financing will be outcomes based and will include such measures as happiness, rather than a discrete set of specific covered services.

“For this to be effective we must have price transparency. We need to move to bundled payments.”

My take-away from this talk is that the future of health insurance in the US is going to be disrupted by IT-enabled care delivery systems who learn quickly how to manage the health of populations and how to combine the network value of this population (via underwriting) with more effective evidence-based resource management. Bertolini did not say this, but it made me wonder about the economic viability of regional payers who do not have the scale to make the kind of investments Aetna is making or the enlightened leadership necessary to guide these tradition-bound and risk-averse organizations. Clearly, Aetna has a major head start.

In future blog posts I’ll comment on the other Health Innovation Summit sessions about recasting patients as consumers, innovation efforts in care delivery organizations, the changing roles of physicians and allied health professions in a reinvented global healthcare system, and what this means for entrepreneurs.

To watch the videos of the 2013 Stanford Health Innovation Summit, including Mark Bertolini’s talk, click here.

StartUp Weekend- 54 Hours from Idea to Product

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I spent the weekend of April 5-7 2013 at Startup Weekend. It was hosted at Facebook’s engineering offices with spectacular views of the South Lake Union neighborhood of Seattle. In this blog post I’ll summarize what surprised me the most about the event.

Above is the view from the 18th floor Facebook office. There was a large wall one could write on, and various toys to play with.

I’d heard that Facebook provides its employees with food- it’s true. There were chefs there all weekend cooking for us. It was delicious.

Over 100 people attended the 54 hour marathon to take product concepts from idea to demo and investment pitch to a panel of judges. The attendees were software developers, designers, and business people. The attendees reflected the considerable ethnic diversity of the Seattle tech community. Ages ranged from teens to boomers, with the vast majority in (my guestimate) mid 20’s to mid-30’s. Coaches included angel investors and others knowledgeable about the Seattle startup ecosystem.

Friday night we heard 41 product concepts quickly presented to the group in 30-second bursts (including mine). Each participant was given 4 votes (sticky dots that would be attached to the sheets of paper with the concept name). Ideas ranged from an app that would bounce any long email you receive with an admonition to shorten it, to a service that would help people negotiate complex medical bills. The 41 ideas were quickly winnowed to about 17.

The biggest “aha” moment for me was when I realized that my initial dismissive reaction to many of these concepts was so very different from the wisdom of the crowd. While two of my initial 4 picks did made it to the final presentations, I was astonished by the strange ideas that received a lot of votes from my colleagues. On reflection, that makes sense. My first reaction when I heard about Twitter 5 years ago was similarly dismissive. Now Twitter has 200 million users and I depend on it for networking and as a primary news feed. This weekend helped me to “unlearn” my habitual responses and learn to see new patterns that may actually turn out to be useful.

Everyone I saw worked incredibly hard all weekend on market research, business plan development, and software design/development. On our product team we agreed to use the Lean Canvas- a one page business case summary focused on the fundamental questions every startup has to solve.

My team swung for the fences, as one of the judges pointed out. We pitched a music collaboration platform to rival SoundCloud. The software engineers described it as “Github for Musicians”, but that tagline would likely be gibberish to our target segment. My biggest surprise of the weekend was who “won” the overall competition. The winning idea began as an app that would “bounce” long emails, along with an a message instructing the sender to shorten it. After the team was formed, over the weekend the “bouncing” functionality evolved from the main idea to an optional setting. The product pivoted from being an obnoxious bounce-back mechanism into a natural language processing aid for coaching employees to focus their email communications. This addresses a big problem within large organizations of email overload. The initial use case from Friday night turned out not to be the winning idea- but it led, through the iterative process of discovery, to a winning idea. The power of a successful start-up idea is that it contains a kernel of utility that can be guided towards a satisfying a customer need enough so that someone will pay for it.

Renewal and Reinvention at the Bloedel Reserve

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I moved from the east coast to the Pacific Northwest about 12 years ago and live next to the Bloedel Reserve. I have noticed that the seasons change more slowly here than in Virginia. I walk the 2 mile path through Bloedel several times a week and over the past decade have watched the seasons slowly change.

Bloedel is a special place for me because it was designed to be experienced holistically. There are no signs identifying the plants and trees. It appears to be- and is- a natural landscape, even though throughout these woods some of the trees and beautiful flowering plants are often from China, Southeast Asia, and other parts of the world. It is very much an integrated world garden that incorporates the observer into a unified spiritual journey. It is quite a remarkable experience and I recommend it highly. It is located on Agate Point and the north end of Bainbridge Island.

Richard Brown directed the Reserve for 30 years retired in 2009 and new leadership came in during the funding shortfalls experienced during the Great Recession. This younger leadership was less concerned with preserving the founders’ vision and has been increasingly changing it to be more appealing to a broader audience. First to go was the requirement to make a reservation to walk the grounds. There have also been more events catering to a mass audience, like the dollhouses and train exhibit during the holiday season and various entertainment events in the summer. The Gatehouse is now a gift store. These changes have indeed resulted in an increase in membership, financial sustainability, and I am glad more people are enjoying the reserve as a result.

Last summer the area down by the waterfall was cleared of many older trees so that more of the specimen flowering plants can be displayed. I hope that that the Founder’s original emphasis on a holistic spiritual experience from the reserve does not give way to a permanent exotic botanicals showcase.

This year a team is going to Kyoto to study the ancient Japanese gardens there so that the lovely Bloedel Japanese Garden can be “overhauled”. I have to admit that I feel concerned about some of these changes. It is more than resistance to change- I have been a change agent all my life. A generational change is happening to institutions all around us. Just as the generation of Prentice and Virginia Bloedel passed the reserve 25 years ago to leaders in the “baby boomer” generation, the leadership of many institutions is being assumed by members of Generation X – people born in the 60’s, 70’s and early 80’s, and even to Gen Y born in the late 80′s and 90′s.

The changing of the generations is like the changing of the seasons and is a positive sign of rebirth and renewal. The creative tension between preserving the best of the past and the exploration of new directions is a constructive one both in business and in the custodianship of our heritage. Constructive engagement and open dialog is necessary to make this work. For more about the Bloedel Reserve see www.bloedelreserve.org.

Ed Butler

Washington Health Insurance Exchange Update

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The Washington Health Benefit Exchange was created in 2011 as a public-private partnership to establish the online marketplace for consumers and small business to gain access to the Qualified Health Plans provided under the Affordable Care Act. The organization is not a government agency, but because it receives public funds it must comply with the open meetings laws. Its budget is about $174m from 2011-14, with approximately $64m going into the build of the online marketplace. It is expected to have 130,000 enrollees by January 2014 and 280,000 by the end of 2014. It is operating as a “startup with deep pockets”, as described by one of its board members.

I attended the Washington-Alaska Healthcare Financial Management Association Conference recently. I found the session on the Washington Exchange to be enlightening. The program consisted of two speakers, Phil Dyer, a Board Member of the Exchange, and Robert Nakahara, its Chief Financial Officer. Nakahara’s background is quite impressive, as a former Premera Blue Cross CFO, and former CFO of an innovative new concierge medical practice (QLiance).

Phil Dyer is a senior Vice President at Kibble & Prentice, an insurance brokerage firm. He served in the Washington legislature in the 1990’s and now heads his firm’s medical malpractice brokerage. He described the Exchange as being “Medicaid on steroids” because it incorporates not only the state’s Medicaid population into its online marketplace, but also includes everyone in the state eligible for federal tax credits. In April the Exchange will begin certifying the Qualified Health Plans (QHP’s) in preparation for the online sales of these new health policies in October.

Dyer described the Exchange’s role as premium aggregator as being a “seminal change” that will disrupt the small group insurance market. He predicts that employers large enough to be self-insured will do so (approximately 250 employees and higher), and that the smaller employers will adopt a defined contribution model similar to the way employers over the past 20 years have migrated to 401-k programs instead of pension plans. If his prediction comes true this will be very challenging for today’s health insurance companies. My prediction is that this will intensify the competition for the hearts, minds, and wallets of the individual consumers- including those currently covered by their employer policies. The traditional health insurance business model for mid-sized employer groups will be history if Dyer’s view of the future proves correct. We will know the answer within the next 36 months. This may provide new opportunities for health care delivery systems capable of prospering in an increased risk environment.

Within a few weeks the advertising campaigns will begin in Washington State to build public awareness of the new brand- “Washington HealthPlanFinder”. Nakahara showed us a timeline that has the Exchange being ready for final testing by September 2013 in time for a go-live of October 2013. Nakahara expressed confidence that this is realistic and achievable. Dyer also seemed optimistic about the Washington Exchange’s ability to be live in October, as the law requires, while expressing serious doubts that the federal exchange and other states will be ready by October. Washington was one of the earlier movers in this area and will likely benefit from the extra months of preparation. Whether the healthcare delivery networks will be ready for an additional 200,000 new patients is a separate- and important- question.

Dyer predicts that the premiums for individual coverage will increase dramatically for 2014. The health insurance industry has been warning about this for quite some time. Actuarial Value is the percentage of total average costs for covered benefits that a plan will cover. Dyer made the point that the actuarial value (AV) of the new QHPs for the “Bronze” level of coverage is 60%, for Silver it is 70%, and for Gold it is 80%. By comparison, Dyer stated that for the two largest payers in the state that the individual plans only currently cover about 47% of costs for covered benefits. With a 23% difference between what current plans provide and the new minimal coverage package it is clear that all of the payers will have to raise rates a minimum of 23%, and for many consumers this will come as a rather large sticker shock. The federal subsidies may take some of the pressure off for some of the population, but for some people currently on individual health plans there could be a doubling of premiums by January. The fact that they are getting much better coverage will need to be clearly explained or the “Affordable” in “Affordable Care Act” may become fodder for late night TV comedians by the end of 2013.

The success of the Health Insurance Exchanges will be the first major test of the insurance-reform model first introduced in Massachusetts and now being implemented on a national scale. I welcome the experiment, and remain cautiously optimistic that individual market consumers will remember the increased actuarial value as they pay their mandatory premiums.
Ed Butler

3 Reasons To Postpone ICD-10

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Six years ago I worked on a program to implement an advanced system of clinical terminology for the National Health Service in England. The exciting new terminology was called SNOMED-CT. The “old” terminology was ICD-10. I remember the terminology advisory meetings with clinicians and administrators about the limitations of ICD-10 and how SNOMED-CT would improve health informatics in the NHS. I have deja vu when I see similar arguments being made for implementing ICD-10 in the US,(see the HIMSS Open Letter to HHS published Feb 7th), The push for standardized terminology is important for our healthcare system, but it is essential that this nation-wide mobilization around terminology infrastructure be able to deliver the promised benefits. It is becoming increasingly clear that ICD-10 is not the breakthrough we need.

I returned to the US in 2006 and worked with GE Healthcare and its development partners to develop more advanced knowledge solutions for health care. In my consulting practice I have focused on patient engagement and this has given me a new perspective on the need for actionable and expressive clinical terminology. This is a time to carefully consider the consequences of our choices.

I believe that the federal mandate to convert to ICD-10-CM by October 2014 will be a step backwards. Here’s why-

Credibility,once lost is hard to regain. The advertised benefits of ICD-10-CM migration are grossly overstated. Just as many of us experienced in January 2000, the recollection of the pain to continue business as usual beyond Y2k was like having recovered from the flu. After the pain of implementing ICD-10, no one will want to touch clinical terminology infrastructure again for a generation. The hyped ICD-10 benefits of eliminating waste, population health, cost savings, patient experience will be revealed as empty promises. The arguments in favor of keeping the October 2014 deadline stated in the HIMSS letter are an example of wistful thinking and will not stand the light of day once the real pain of the migration begins.
ICD-10 is not worth it. The April 2012 Health Affairs article by Chris Chute, Stan Huff, John Halamka,and others presents compelling evidence that “the practical ability of ICD-10 to capture content typically contained in clinical records is not measurably better or worse than that of ICD-9-CM”. They conclude that “ICD-10 CM conversion is expensive, arduous, disruptive, and of limited direct clinical benefit”. The authors of this analysis are among the most respected health informatics thought leaders in the world. The calls for delaying the implementation fo ICD-10 is not a rear-guard action by change-resisters but an appeal to reason by some of the most effective health change agents of our time.
ICD-11 will be better because of its intrinsic alignment with SNOMED-CT. The investments made by the US healthcare industry to date in preparing for ICD-10 are not entirely wasted if transformed into an infrastructure that supports ICD-11 prior to its deployment. Let’s avoid having to do another big terminology upgrade in a few years- or worse, being stuck for another 30 years with a labor-intensive administrative classification ontology in a world that needs clinical relevance. Please, let’s not populate patient databases with ICD-10 terms that only add complexity and provide minimal benefit to patients. A migration to ICD-11 and SNOMED-CT, properly orchestrated with ACO’s, payers, clinicians, and especially patients, offers a more credible approach that will spark innovation. Let’s take it.

That is why I believe the ICD-10 terminology conversion should be re-envisioned with an additional two or three more years so that it becomes worthy of the investment. With all due respect to the hard work of those who have been implementing ICD-10, let’s get it right this time. We may not have another chance for a generation.

Marissa Mayer: Innovation and execution are natural opposites

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Bloomberg’s Eric Schatzker had a great interview with Yahoo CEO Marissa Mayer last week at the World Economic Forum in Davos Switzerland. I’ve included a link to it below. It is worth watching their discussion of innovation and execution.

Fast forward to minute 3:20 in the video above- Mayer discusses the hypothesis that the opposite of innovation is not “status quo”, but rather “execution”. In other words, innovation is the opposite of execution. She describes how hard it is for businesses like Yahoo to stay focused on executing their existing web-centric business while at the same time innovating into the mobile experience.

I have experienced this dynamic in payers, physician groups, and in major health IT vendors. I have been a player on both sides of this divide. I’ve been an innovation guerrilla, protecting and nurturing a new product concept that would open new market opportunities from those who would kill it. I’ve also been among the innovation killers, jealously eyeing a promising new product concept as competition for a more “strategic” solution as seen from the eyes of the legacy business. These are natural, normal processes in every organization, and for that reason management needs to separate the innovation team from the old business, carefully manage interactions between the old and new models, and let the new team try things out with actively involved customers. Executive sponsorship and mutual respect among all stakeholders is critical for this to succeed. I wish her well as she steers Yahoo towards their future.

Three Trends to Watch in Health Insurance Reform in 2013

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I began the new year at Cape Lookout, a 15.5 million year old basalt flow jutting 2 miles into the Pacific ocean along the Oregon coast.The picture above was snapped a little after noon on January 1, 2013, looking south about 2/3 of the way out. It was unexpectedly clear on this pleasantly sunny winter day.

Less clear is the outlook for 2013 as the US gears up for the implementation of the most disruptive provisions of the Affordable Care Act. As a health innovation consultant and as a parent of a 25 year-old who will “age out” of our family insurance plan this year I am paying special attention to the market dynamics around individual health insurance. My son will be a consumer in the individual health insurance market twice this year- in April, when he turns 26, and then again in October as the new “Qualified Health Plans” for 2014 become available through the state’s Health Insurance Exchange.

Aside from possible budget complications for the Affordable Care Act this year, there are three major dynamics to watch as an early indicator of whether the promise of healthcare reform will continue to enjoy public support-

1. Individual coverage prices

The much touted reform that requires insurance companies to insure everyone, including those with pre-existing conditions, also means that the medical costs for individuals with expensive medical needs are now in the same pool as everyone else. The premiums for healthy young individuals are likely go higher than they are today. HHS has recently published proposed regulations with a risk adjustment mechanism similar to that successfully used in Medicare Advantage to discourage insurance companies from structuring their benefit designs to primarily appeal to healthy people. No one really knows how this risk adjustment will work. Time will tell how insurance companies price this uncertainty into their rates for 2014. It is quite possible that the new availability of health coverage for millions who have lacked it may spike utilization of long deferred but necessary care. Someone is paying for this- no surprise, it is the rate payers, (whether subsidized or not) who bear the costs for the reform. Therefore, sticker shock may be the most common experience in late 2013, a fact that will come as a big surprise to many who may still be under the impression that Obamacare is socialized medicine. It remains to be seen whether the prices are so high that many people will have to pay tax penalties to remain uninsured.

2. Narrower Provider Networks

Part of the value delivered to consumers by insurance companies is their provider networks. Insurance companies negotiate prices for care delivery based in part on volume. This is especially the case with hospital coverage. If a payer can deliver a higher volume of patients to a provider, the provider is more likely to give them better rates (ultimately translating into lower premium costs for the consumer). It’s the economics of the volume discount. Thus an individual’s choice of hospitals will likely be limited (or tiered- with higher prices for going beyond the inner circle). The strategic question for consumers is how the insurance companies have narrowed their hospital and specialist networks- is it based on quality of care or is it purely a matter of charges? A close look at the provider networks will be increasingly important for consumers.

3. Health Insurance Exchange Implementations

Having been through many healthcare IT implementations over my career, it is astonishing to consider the speed at which states and the federal governments are implementing Health Insurance Exchanges (HIX). Federal officials have announced that 17 states and the District of Columbia are implementing their own exchanges. A federal exchange will be available for the states that chose not to run their own exchanges. These will be the online market places that enable hundreds of thousands of individuals to chose from a set of bronze, silver, and gold health plans. Establishing and testing all of these HIX’s presents technical and operational challenges for health insurers serving multiple states. For all of them to be up and running smoothly in a little over 9 months will take many minor miracles.

2013 will be a pivotal year for health care reform, even without any political drama over the budget supporting implementation of the Affordable Care Act. The winds of change are upon us- and so the year 2013 begins.

Spotlight on health innovation at Datapalooza 2012

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Who do you think addressed 1600 attendees at the Health Data Initiative “Datapalooza” in Washington DC in early June 2012? Was it former Senate Republican leader Bill Frist delivering praise for NIH funding of personalized medicine research? The Obama administration’s Secretary of HHS Kathleen Sibelius describing efforts to constrain government healthcare spending? Rock star Jon Bon Jovi describing an iPhone app to refer homeless people to nearby assistance? Yes, all of the above. Healthcare IT innovation is hot, and at least for the moment seems to transcend the partisan bickering of a tough election year.

I traveled to DC from Seattle to attend this event so that I could explore some of the health IT innovations that have emerged in the past couple of years. Having spent 20 years in healthcare I am amazed at the pace at which new products are coming to market, fueled by unprecedented access to web and mobile apps by hundreds of millions of people. There is also a great deal of entrepreneurial activity stimulated by investors, incubators, and by institutions offering relatively small “challenge” opportunities whereby teams win prizes (typically less than $50k) for innovative solutions. The premise behind the “Datapalooza” is that government and other institutions can create an ecosystem based on standardized access to publicly funded data resources that can create the conditions in for innovation to thrive and create new markets. It appears to be working.

I tabulated the companies showcased at the Datapalooza to see how many were focused on patients, providers, or health administrators/planners. This is not a large enough sample size for making market generalizations, but I thought it was useful to see who turned up at the event. Given the subject matter of the conference, one might have expected the majority of companies to focus on the needs of data analysts in health companies and government agencies. But as the chart below shows, of the 49 products that I profiled, 45% were consumer-facing apps.

Most of the 15 products targeting management were dashboards for monitoring status of key performance measures or predictive analytics for stratifying populations for specific interventions. Only 5 products targeted clinicians, which surprised me.

Most of the products were appealing and had innovative aspects. Three products stand out has having truly disruptive potential: Cake Health, which provides patients tools to manage their healthcare expenses, Private Practice, an EMR for nurse-midwives and their patients, and Parental Health’s MISTY product aimed at helping seniors stay in their homes, and includes the ability for their children and others to monitor their well-being.

The highlight of the event for me was the ACO forum, moderated by Atul Gawande, surgeon, author, and New Yorker staff writer. His address is on youtube at http://www.youtube.com/watch?v=BAp_lieYydU. The session involved a panel of Pioneer Accountable Care Organizations discussing their challenges and needs for health IT. Seven companies then pitched to the audience and the panel responded with their comments on each of the applications. What was striking to me was that while the panel was polite to each of the presenting companies, most fell flat. Only one or two applications generated any significant interest from the ACO panelists because they felt that they already had good enough coverage. This should be a red flag to investors. There was a clear indication from the pioneer ACO leaders that there are far too many new products on the market for them to pay attention to, and they prefer fewer technology partners to help them adopt new capabilities.

The Engaged Patient: Convergence of Medical Informatics and Integrated Healthcare Marketing

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Awareness of “Patient Engagement” has grown over the past 5 years and will certainly accelerate now that it is included as part of the Stage 2 “meaningful use” proposed rules. The notion of consumer engagement initially grew from the advertising industry as a by-product of the increasingly interactive internet phenomena of consumers posting comments on corporate blogs. Razorfish, a consumer marketing firm, in 2011 argued that “Engagement isn’t just about a channel. It is about the consumer’s relationship with a brand, his or her ability to choose how and when to engage, and the value each channel represents.” In the health care context, there are many channels- from the nurse at the doctor’s office to the patient portal online. Patient engagement, to be successful, has to begin and end with the patient, on their terms, with their values and priorities first and foremost.

Increasingly consumers have immediate access to the views of their peers on many different subjects, not least of which is health care. A 2011 Pew Internet study on “peer to peer Healthcare” shows that “one in five internet users have gone online to find others who might have health concerns similar to theirs.” According to Susannah Fox, associate director at the Pew Internet & American Life project, more than 80% of internet users have looked online for health information. 10% of adult cell phone users have signed up for a health application,, although many may have only used it once. Johns Hopkins University currently has 49 official studies underway as part of its Global mHealth Initiative to determine which mobile health applications actually work.

Innovation often occurs at the intersection of different industries and disciplines. The MIT Media Lab is a famed example of an interdisciplinary hotspot, where structured serendipity, contempt for silos, playful invention, and a group of “open minded and dangerously creative people” produce breakthroughs. Within healthcare the promise of engaging patients, especially those with chronic conditions, has the potential of dramatically improving their health outcomes and decreasing costs of complications. This is where the intersection of marketing and health informatics can have a breakthrough impact.

Integrated Marketing arose as a solution to the fragmentation of marketing communications. I like the definition from the Centre for Integrated Marketing below:

Integrated Marketing is an holistic discipline using the fractal concept of wholeness, where the whole is present in each part, as in DNA, to develop congruent, sustainable and high-value brand experience for all stakeholders.

In the case of Integrated Marketing, the starting point is core identity, and this is then articulated as strategy through the business model, products, brand, vision, cultural values and business evaluation (amongst others). It is also communicated in creative ways through marcoms and service/touch points.

When applied to Patient Engagement, the core “”DNA” is the patient’s own need to act, in collaboration with others, towards a better outcome. This need is especially accessible to integrated care delivery systems with shared risk for patient outcomes, such as Accountable Care Organizations and managed care systems.

In the April/June 2012 issue of the Journal of Ambulatory Care Management Angela Coulter, of the Department of Public Health at Oxford University, outlines the evidence supporting Patient Engagement. She outlines three areas where the evidence is strongest that patient engagement has beneficial effects: (1) improving health literacy, (2) shared decision making, and (3) care process improvement.

The Board of the American Medical Informatics Association published a white paper in 2009 that defined the core content for a medical subspecialty in clinical informatics in 4 areas: clinical informatics, clinical decision making and process improvement, health information systems, and leadership/change management.

This core content is, of course, centered on the clinical context and care delivery organization medical and IT infrastructure. These are necessary areas for effective use of clinical informatics within and across the healthcare delivery system. To me, what to me seems missing in this content is a patient-centric orientation. This is not a criticism, but an observation that because the focus of the clinical informaticist is predominantly on improving care within the care delivery organization, through better work flow and improved clinical decision support for the medical, nursing, and allied health professionals. The “engaged patient” can be part of this vision, and in the better health organization patient engagement is incorporated into clinical guidelines and care protocols.

The Electronic Health Record (EHR) is a key element of patient engagement. Patients need broader access to their record- far beyond the current proposed rule to provide access within 4 days. Patient engagement does not begin or end with the EHR. When it comes to actually connecting with patients outside the care environment (where patients live and interact most of their lives) it takes a different mindset and an expanded set of tools that are connected to the Patient’s life in a more holistic way that goes beyond “health care”. This is precisely the problem-space addressed by integrated marketing. The opportunities for collaboration between marketing and clinical informatics professionals has never been greater.

Future posts will explore innovations in social media, mobile applications, and health services organizations to create an engagement model supporting patients actively involved in their own journeys towards better health outcomes.

Ed Butler, CEO Agate Point Consulting LLC

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