“There’s not a single part of our ecosystem that hasn’t been negatively impacted. There’s been disruption all the way to the core.”
It would be difficult to sum up 2020 more accurately. Healthcare, like most industries, was turned on its head, and those in leadership roles were forced to pivot quickly and find ways to continue to provide care through the most difficult of situations. They also figured out how to leverage that disruption to accelerate innovation, particularly in areas that had long lagged behind, including digital health and supply chain management.
With this “new normal,” however, comes a new set of challenges for leaders, according to Hal Wolf, president at CEO of HIMSS. During a recent interview, he talked about how the pandemic has affected not just health systems but vendors, the weakness that were exposed by Covid-19, and how HIMSS is working to turn those into opportunities as we move forward.
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- The change healthcare has undergone has been “immense,” with areas of resistance that had held digital health back in the past “crumbling out of necessity.”
- For healthcare IT leaders, the real question is, “as we pull away from the emergency declarations, what will that new normal look like,” particularly now that consumers have experienced digital health.
- “There is ambiguity on how reimbursement will be managed moving forward. And that ambiguity is freezing up plans on how to take advantage of full telehealth capabilities.”
- The key weaknesses that were exposed during Covid? Lack of a national patient identifier, lack of a solid infrastructure for population health, and the lack of an integrated supply chain.
Q&A with Hal Wolf
Gamble: Where are you now? Are you in Chicago area?
Wolf: No, I live in Denver, Colorado, in the mountains. I split my time between the two. I’ve doing that from the beginning. When I was fortunate enough to join HIMSS, one of the critical questions was whether I could do this from Denver. It’s actually worked out quite well because prior to the pandemic, 60 percent of our organization was working from home. We’ve always been very proactive in providing that type of infrastructure, and so the ability to scale up to 100 percent from home was actually not a significant leap for our IT department. That’s about the only thing that I would say was beneficial in leading to all of this. I think we’re all trying to find little silver linings in this tragedy.
Gamble: Exactly. One thing that struck me is how much care delivery has changed, and really how the whole industry has transformed. What are your thoughts around that?
Wolf: Kate, it has been significant. I recently met with a group of people from Milan, Italy, which was the initial place where COVID-19 flared up, with Seattle shortly behind it. The change has been immense. We went from an encounter-based paradigm that many of us have worked very hard through the years to turn into a digital health environment, recognizing the challenge in healthcare that is coming, as well as the consumer preference. Overnight, areas of resistance — which could have been anything from the culture of medical groups not wanting to adopt, or regulatory challenges that have existed in the United States, for example — crumbled out of necessity.
And so we’ve seen this incredible acceleration in the use of digital health, through emails, video, and even components of home-based monitoring. A lot of those happened through different areas of opportunity, meaning that the government decided to give a dispensation on geographic restrictions or patient homes as a care site.
But real question is, as we pull away from the emergency declarations, what will that new normal look like? I think we’ll see real pressure for continued digital health or telehealth. It’s inevitable, because the consumers have gotten hold of it; systems have broken the coefficient of friction, going back to my physics days. They’ve adopted it. Those who could scale up big did that, and those who weren’t ready for it had to scale with something. And now that they’ve caught their breath, they’re going back into another wave.
Across the industry and around the globe, people are saying, ‘Okay, this is real. I have to do it, and it needs to be at scale. What is my strategy? How do I make sure the foundation is there?’ We threw a lot of stuff against the wall. Now we have to take a step back and think through those dependencies and what we need to be successful. That’s where we’re hearing from systems that are reaching out to us. They’re asking for support and looking for maturity models.
If you look at it statistically, we’ve seen it go from less than a half a percent all the way up to 20 percent of encounters being done this way. It seems to be settling in around 6 percent nationally, according to the latest figures. I’m sure they’ll go up and down, but bottom line is that it’s significantly more than it was before.
Gamble: What do you think we’re going to see as the emergency measures drop away? Do you think we’ll see a loosening of some of the restrictions?
Wolf: There are a few areas I think will be under very strong pressure. I’m not going to try and prognosticate what Congress will do — if I was really good at that, I’d have a whole different career — but there a few things that really need to be sustained. We made some changes in geographic restrictions where we’re allowing telehealth to be used outside of just rural areas. We’re doing it in cities now. We reduced the number of days of engagement from 14 down to two, but it sounds like they want to go back to 14. we’re certainly advocating for at least a maximum of six from a HIMSS point of view.
The patient home as a service site is absolutely critical here. It’s the ability for that reimbursement to take place with something generating from the home and the communication in that spot. We also saw, and we will continue, to see a shift in scope of practice. Physicians are now out of the stream of basic encounters and taking care of many of the very important, but routine things they’ve always done. A lot of nurse practitioners, MAs and clinicians have stepped up to fill that gap — that’s a shift in scope of practice, and it’s something we have to do anyway. We have significant gaps in the number of clinicians in this country and around the world. Globally, we have around 7.5 to 8 million unfilled positions from a clinical point of view. If you look at the WHO data, by 2035, that will be up to almost 14 million. In the United States, there are anywhere between 56,000 and 125,000 primary care physicians retiring in the next 10 to 15 years.
Who’s going to fill those spots? There isn’t anyone right now, because our medical schools are cranking out individuals at a rate of less than 3 percent who go into family care or primary care. Everything is geared toward specialty care. This gets into a change of practice that only digital health can fill. When you pull all of that together and you start thinking about remote patient-monitoring, we need to solve this problem. What is the reimbursement? We need to follow the money.
We had a CXO session recently with about 45 individuals, including physician, clinical, IT, and executive leaders. And we talked about, where are we going? What are we going to do? There is ambiguity on how reimbursement will be managed moving forward, and that ambiguity is freezing up strategy plans on how to take advantage of full telehealth capabilities. The reimbursement schedules are going to force us to go backwards a little bit, unless we can get the attention of HSS and CMS in their recommendations, as well as congressional approval as well. We’re working on all of that right now; we’re getting ready to write some letters and continue those discussions.
Gamble: When you look at how the industry responded, it was impressive. We heard stories about how quickly organizations were able to ramp up to telehealth. But what about weaknesses that may have been exposed? Where do you think there are opportunities for improvement?
Wolf: Let’s start with the basics. First of all, the challenge in following an individual who is moving between different entities for their care. We don’t have a national patient ID, and so we don’t have the ability to make sure I can follow the person I’m talking to in one setting when I hand them off to another setting. It’s a safety concern, and it leads to duplicate tasks. And so I think one of the biggest gaps that has popped up, particularly during the pandemic, is the need for a national patient ID. That’s important.
Second, we saw the infrastructure from a population health standpoint really struggle. We’ve always had a gap. HIMSS in particular pushed very hard and was one of a number of organizations that was able to help secure $500 million in the Cares Act just before the pandemic took over. There’s another $450 million in the House bill that went to the Senate, and so we’ve got to hope that a compromise occurs. We need to rebuild our backend data environment. We lack reporting in this country; we saw the CDC using the Johns Hopkins database to find out how many people were in the ICUs. That’s scary. From a long-term standpoint, we need federal, state and local funding. It’s absolutely critical.
In the end, you have to have what I like to refer to as just-in-time information and data. I won’t use the phrase ‘real-time’ because from an IT standpoint, that’s almost a myth. We have immediate needs for the patient record. Every time someone walks into an ICU or a clinical setting, we have a short-term need from population health such as pandemic information. And of course, long-term information for actuarial events to understand where the population is moving in general. That whole population health data environment has been critical for us.
We saw some improvements in HIEs across the country. They were banding together and exchanging information faster than before. We saw an increase in analytic tools, which was positive, but they need to get deeper and more robust. And finally, we saw some gaps in our ability to do robust testing and tracking. We need be able to do trace management.
The one thing we don’t talk about enough inside healthcare is our integrated supply chain. The supply chain is not just how many things do I have on a shelf in a closet, but also, how much it cost. It’s that, but it’s also, where did it come from? What is my secondary source? What are the quality controls I need to have in my supply chain? How do I match up the consumption of supplies against outcomes for quality control purposes? These are things we saw that opened up.
Nothing was as amazing as our frontline workers. Nothing is as amazing as the effort they’ve put in. But for goodness sake, let’s give them some support. Let’s give them a fighting chance. Heroism along those lines is amazing, but we’ve got to do a better job supporting them.
Gamble: A lot of good points there. What do you think are the biggest challenges when it comes to supply chain management? Is it a factor that it falls under different areas in some organizations?
Wolf: I think it’s more just an issue of focus. We have never been terribly sophisticated in healthcare with our use of supply chain. You’re beginning to see bundles of supply chain groups come together for group purchasing and things like that, but it’s definitely in pockets. I’ll give you two examples, one negative and one positive.
The negative one was when there was a recall of breast implants. When that happened, we didn’t have good records as to which particular breast implants went into which individual, and it was difficult to go back and try to reconstruct. That’s a quality control issue.
On the positive side — and I witnessed this myself in my previous organization — we did a tremendous study on knee replacements. Knee replacements are great. There was a 98.5 percent versus a 97.5 percent approval of two different suppliers; 1 percent makes a big difference though when you’re doing tens of thousands in a year. That’s one way of marking it.
Then the second is, how do we think about our quality control around segmentation and the use of supplies? A titanium knee might be fantastic for a 24-year-old who’s a runner and they are going to be running the rest of their lives. But would you put a titanium knee in an 80-year-old when a high-grade plastic would be lighter, and would give them incredible wear for what would be hopefully a very long time? And so, we’re learning how to use these levels of segmentation in supply chain. That’s point one.
Secondly, aggregating that information, not only in the US and regionally, but around the globe, will help identify where we have problems — for example, if there’s something in the supply chain that isn’t doing well — and how to get those alarms to go off faster for recalls. And of course, manage all the bar coding and other things that sit inside the supply chain system and allow us to match them to the individuals.
That’s a level of sophistication. Retail has done it for years and years. They even do things on a consignment basis. For example, Gap figured out how to put a pair of jeans on the shelf and that it never actually owns until the moment of sale where transfers from the manufacturer, to Gap, to the person buying it. And the information is immediately uploaded back to the original wholesaler or manufacturer letting them know that a replacement was needed. It also lets them know what was in the warehouse and what they need to do from a supply standpoint. That’s out there and that’s been going on forever; and in healthcare we’re realizing that we’re behind the curve, especially after what we went through with our protected gear.