Will IoT Improve Healthcare?

IoT promises transformation of healthcare industry by increasing efficiency, lowering costs and putting the focus back on better patient care. For those who have tried, what are the results? What are some of the related challenges that healthcare CIOs are facing while trying to maximize ROI from related investment?

Contributor

- Dr. John Showalter, Chief Health Information Officer, University of Mississippi Medical Center

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Transcript

Sanjog Aul [00:00:22]:

Hello, and welcome listeners. The topic for discussion is Will IoT Improve Healthcare? And, we invite you to join the discussion on Twitter, using these hashtags, #health care, #IoT, and #healthIT, and our guest for today’s show is, Dr. John Showalter, who’s the Chief Health Information Officer with the University of Mississippi Medical Center. Hi, John. How are you?

Dr. John Showalter [00:00:50]:

I’m good, Sanjog Aul. Thank you for having me on the show today.

Sanjog Aul [00:00:54]:

Oh, beautiful, and I know it’s just a little windy out there, but we still will have fun. Right?

Dr. John Showalter [00:00:58]:

Yeah. We’ll have a good time.

Sanjog Aul [00:01:00]:

Great. So talking about health care and, of course, we are looking at this IoT mega trend where it’s touching all different industries. When it comes to health care, what is so special? Why? What’s so compelling that we can say, yes, if we were to invest in it, where already there’s so much transformation going on in health care, this is gonna further take us to the next level?

Dr. John Showalter [00:01:24]:

So, the promise of IoT is really about getting health care out of the clinic and health care out of the hospital and the ED and getting health care into the home. The Internet of Things and the ability for sensors to talk to machines and machines to analyze the data really changes the paradigm from health care just occurring between a nurse and a patient or a physician and a patient in a health care setting and brings it to their home and allows us to really figure out what’s going on with their health and move more towards wellness and health than just acute care.

Sanjog Aul [00:01:59]:

Alright. So when it comes to your ability to work with multiple organizations in your ecosystem, would you say IoT is very internal to an organization when it comes to health care, or does it really show its real value when you connect across ecosystem or across value chain partners?

Dr. John Showalter [00:02:22]:

Yeah. I think it shows its greatest potential when it’s focused on the patient. The patients clearly cut across payer and delivery systems and health systems, and interact with health care in a variety of ways, and when we keep the patient at the center of it, I think we begin to actually recognize the potential. UMC Center for Telehealth has actually done some pilots and is beginning to work with insurance companies doing home monitoring where we have blood pressure cuffs in the home, glucometers for measuring blood glucose levels for diabetics in the homes, and those automatically send signals back to a system that is curating the data and analyzing it and throwing alerts up to nurses so that if the glucose is out of control 2 times in a row, an alert comes to the nurse, the nurse can call or ping in through a mobile device and say, Let’s do a video chat about what’s going on with your blood glucose and get it under control, and our initial pilots with that have shown a marked reduction in the use of emergency departments, use of hospitals, and when extrapolated to this data showing multimillion-dollar cost savings for the insurance company while making the patient more healthy. Where it becomes problematic is the payment system of health care. So the health system doesn’t necessarily benefit financially by keeping patients out of the hospital. So they have to work on payment models with the insurance companies where the insurance company saves money, the patient’s healthier, and the health system still maintains enough margin to stay open. Okay.

Sanjog Aul [00:04:04]:

So when you talk about the issues related to the health devices connecting to mobile phones, etcetera, is that the innovation that you’re referring to? Would you say that innovation essentially is already there or was already there? What new did you do? Because we’re sure that health devices were made a little intelligent. They were supposed to transmit some data maybe, to other connected devices, but maybe not to a mobile phone. So is that extension what you’re calling as the value proposition of IoT?

Dr. John Showalter [00:04:40]:

I, so to answer your question, we’ve actually had some form of this technology for a while.

Sanjog Aul [00:04:47]:

That’s what I was referring to. Yes.

Dr. John Showalter [00:04:50]:

I remember in 2004, 2005, my grandfather had had a heart attack, and it damaged his heart enough that it didn’t squeeze well, so he got congestive heart failure, and he got sent home with a scale that he plugged into his telephone jack, and he stepped on his scale every day, and it measured his weight as well as asking questions like, are you having trouble breathing? Do you have chest pain? And it had voice recognition and yes, no, and then it sent off to a nurse and said, your patient’s gained 3 pounds and said he’s having trouble breathing, and his phone would ring and they’d say, hey. Let’s talk about how you’re feeling. So we’ve had that kind of technology for a while, and I think the innovation is we’re actually beginning to use it and consider it widely as something that we should use in health care. There’s a lot of discussion about let’s bring Uber to health care. I want to bring OnStar to health care. If you think about the technology behind OnStar, there’s a sensor in your bumper that’s measuring how much pressure is on the bumper, and it’s always measuring and always measuring, and then suddenly, there’s tons and tons of force on the sensor and then no force, and the sensor sends off its signal, and there’s a register that there’s a head-on collision, and at the same time, it’s registering as a head-on collision, and the airbags have gone off. The OnStar system is scanning for an available operator and dialing your car so that about the time you’re beginning to recover from the airbag deploying, you’re getting a, hey, Mr. Showalter, are you okay? Hey, Mr. Showalter, are you okay? Hey, you haven’t answered. I’m gonna dispatch an ambulance to you. That kind of technology intervention has existed outside of health care, but we don’t have the technology in place where people are walking around their homes and then suddenly they haven’t moved for 2 hours, but they’re not in their bedroom or they’re in their bathroom and somebody contacted them and said, hey. Are you okay? Or do I need to dispatch somebody to your house to check on you? When we start talking about that level of sensor to machine, machine to machine, machine to communication technology, we begin to change how we can impact patients’ lives, how we can let people age in their homes, how we can keep people out of the hospital. There hasn’t just been that much focus on it. I think with the real talk from the era of things starting 2, 3 years ago, that conversation has picked up, but I don’t think it’s really that the technology is innovative. It’s using it in the process of delivering care that’s innovative.

Sanjog Aul [00:07:37]:

So, within health care, once the patient reaches a hospital or a clinic or an emergency center, at that time, if you look at the way health care has to be imparted, you’ve still seen that that’s kind of an area which is covered, or would you think there is innovation possible as well? Or is it simply limited to the notification or proactive monitoring we’re talking about here?

Dr. John Showalter [00:08:03]:

Well, I think proactive monitoring is where we need to get to. I’d actually say that once they get to the inside of the hospital, we’ve swung the pendulum the other way. We have so much monitoring going on without the application level, the Web of Things, looking at all the data that we’re just overwhelming nurses and techs and physicians with data, and we’re not giving them the knowledge that they need. We need to take that data and turn it into actual knowledge that’s going to benefit the patients. We just did an assessment and we are currently alarming 10 times a second in our hospital. So there are 100 alarms going off every minute in our hospital, and clearly that is too many for anyone to actually act on or keep up with. So we need to take the information that we’re producing because those alarms are even one level up from data. They’re information, but they’re not actual

Dr. John Showalter [00:08:58]:

knowledge, and we still need to put better algorithms and better knowledge bases behind that information to reduce that to a level where we can actually intervene for the good of the patient.

Sanjog Aul [00:09:09]:

So when you just mentioned these alarms going off, would you say that IoT’s implementation may already be in place among the health care devices and that’s why they’re triggering each other’s alarm? But then IoT doesn’t only mean thinking only at device level or at the data generation level, but also at the analytics. Would you take that also under the IoT purview and say that all devices in the hospital, whether starting from proactive monitoring to someone actually reaching a hospital, are all under that IoT umbrella in which the analytic is also embedded, and that’s when you start looking at trivial triggers versus the ones we have to act upon?

Dr. John Showalter [00:09:51]:

Yes. I think we’re definitely in the sensor to machine realm in health care. So we’ve got lots of sensors deployed, lots of patients hooked up to heart monitors, blood pressure cuffs, oxygen monitors for their breathing, and we’ve really focused on the sensor to machine getting the physiologic data into an electronic format and put some thought around the analytics, but they’re really crude thoughts like, let me know when the heart rate is above 90, or let me know when the heart rate’s below 30. They’re not deep algorithms that are based on knowledge bases, and there is some discussion about is there a difference between the Internet of Things and the Web of Things where the Web’s the application layer, but that layer where we’re doing machine to machine with algorithms and sorting, and especially the machine communication aspect is where we’re going to get our bang for the buck, and we’re getting some innovation in there, but there’s still a lot of concern about secure messaging, privacy, and how to do that level of communication and actually get people to act.

Sanjog Aul [00:11:06]:

Now when you are looking at anyone who is coming in and you are trying to help them get better, how is the business side of it looking at it? Is it, again, a better mousetrap, or would you say this is fundamentally changing in the way a patient’s satisfaction goes up there? Hopefully, a patient doesn’t have to come back again, but the way they get healed, you get more referrals because you just are simply better at giving the overall experience. Where is it adding value thinking business?

Dr. John Showalter [00:11:36]:

Yeah. So I think the disruptive force is the concept of delivering care in the patient’s home or delivering the care where the patient is. I see the Internet of Things as an enabler to that, not so much the fundamental disruptor, but when we talk about what we’re doing with home health, we’re identifying patients that have had trouble controlling their diabetes, and we’re sending them home with a tablet device and biometric devices and a glucometer. So we’re sending them home with the things to measure their blood pressure, measure the sugar in their blood, and they’re checking in with a counselor, which is a nurse coach, weekly, but the nurse coaches are also there to reach out when things aren’t responding the way they’re supposed to be, that their glucose isn’t coming down the way we thought it would, that their blood pressure is not coming down the way that they thought it would, and that is shown for the pilot group that they worked with to have no ED visits or hospital visits for 6 months with a group that was heavily involved and engaged with that, and the cost savings to the insurance company were in the orders of hundreds of thousands for less than 100 patients. So the business benefit is really on the insurer side. In Mississippi, we’ve taken that to ensure that we will have benefit on the provider side by requiring insurance companies to pay for that kind of activity. There’s actually a daily fee we can charge the insurance companies for monitoring those patients at home with those types of devices. I think Mississippi is currently the only state that requires that type of reimbursement. Without changes to those reimbursements, there’s not a lot of benefit to the hospitals, or the providers. There are some payment benefits to the hospitals with not having patients readmitted and some programs from Medicare, but on the ambulatory clinic side, it’s just free work that makes patients healthier and that’s not a sustainable model, but I think we are moving into an era where providers and nurses and care coordinators really want patients to be able to stay home and not have to come into the clinic and see the doctor unless it’s absolutely necessary. We used to have lots of appointments for blood pressure checks and sugar checks, and we’re trying to get past the point where someone actually has to come into the office and do that.

Sanjog Aul [00:14:02]:

Let’s take a quick break, listeners. We’ll be right back and what we have to do here is to not just look at how the health care organization will benefit because at the end goal as we see that in the United States alone, we spend over 18% of our GDP on health care each year, and if that’s the case, then we definitely have to do something to reduce health care costs. So yes, IoT may provide that disruptive experience and perhaps patient satisfaction, but if people are not able to afford health care then it doesn’t really matter. So what can IoT do to be able to address this cost problem? And what are the related assumptions and exclusions we’re making if we are to claim that IoT can indeed help reduce costs? Please stay tuned listeners. We’ll be right back.

Speaker 0 [00:14:57]:

Today, enterprise technology is both strategic and global. Each week on CTN CIO Talk Network, IT thought leaders from around the world share their experience with listeners as they discuss with Sanjog Aul how they are trimming costs and partnering with business to innovate and help IT become more competitive, better care for customers, and improve the corporate bottom line. If you want to keep up with IT thought leadership, listen to CTN, CIO Talk Network with Sanjog Aul at ciotalknetwork.com. You are listening to CTN CIO Talk Network with Sanjog Aul. To learn more about our program, please visit ciotalknetwork.com. Now back to the show.

Sanjog Aul [00:15:52]:

Welcome back. So, yes, we can be very good in giving patients satisfaction and other things. Now I am personally also appealing to all people in health care to say figure out a way to reduce health care. So now with that said, John, what can IoT do?

Dr. John Showalter [00:16:10]:

So there’s this concept in health care, especially in hospitals, where they say no margin, no mission, which means if we’re not able to make at least enough money to cover our bills, we can’t stay open and deliver care. Unfortunately and shockingly, I think we’re getting close to that at the national level. Now when it is 18% of GDP and climbing, we’re gonna have to do something to bend the cost curve, and the Institute of Medicine talks about the triple aim in bending the cost curve, better health care, better health, lower cost, and I do think that the Internet of Things is gonna be an enabler for that. We really do need to figure out how the payers, the providers, the patients, and the technology companies can all work together. So if you look at what really costs money in the United States, our two biggest things are chronic disease and the sequelae of chronic disease. So diabetes, hypertension, heart failure, heart disease, it’s a pretty short list of things that cost us a lot of money, and then medications, and lots and lots of expenditure on medications, and a lot of that medication is spent on paying for the treatment of chronic disease. So if we can get patients who have diabetes to control their glucose, they don’t develop heart disease, they don’t develop kidney failure, they don’t need dialysis, and it becomes about improving the health of our population is really how we’re gonna bend this cost curve. So when we were talking about the partnership we have with our patients on the whole monitoring, so they’re agreeing to have coaching every week. They’re agreeing to use these devices that transmit signals and information back to a central software that sorts through them. Our payers are agreeing to pay for it, and we’re saving hundreds of thousands of dollars on that care while making the patients healthier. We’ve extrapolated it to the state, and if we were able to have that kind of benefit for all of our diabetics in the state, we’d have a $180,000,000 cost savings a year for treatment of diabetes in our state. Now, of course, you’re dealing with a pilot group that’s engaged and you’re not going to have 100% penetration, but even if we were 50% successful, we’re talking about spending over $100,000,000 less a year in care for diabetes, heart failure, and the other chronic diseases, and now we’re talking about hundreds of millions of dollars a year that we’re not spending while making patients healthier, and to me, that’s how we’re gonna bend this cost curve. We’re gonna actually have to disrupt the current model of care where you stay in your home until you’re too sick to stand it, and then you go and see a doctor, and then you may or may not have the support to treat your chronic disease that made you feel so sick that you had to go to the doctor in the first place. We’re gonna have to meet people where they live and really change from acute care, sick care to wellness and population health, and I don’t think we’re gonna get there until we have the ability to work with people in their homes and utilize the technology that connects their homes to their care team.

Sanjog Aul [00:19:28]:

So, with that said, you’re essentially saying take health care to the patient versus the patient coming to the health care place where they can get health care. That’s the key here, and, of course, that’s a great dream, and to some extent organizations and people are coming together to make that happen. Now what are some of the challenges in relation to that?

Dr. John Showalter [00:19:48]:

So in a rural state like Mississippi, one of our challenges is still broadband access. These technologies don’t work very well over a 56k modem, and we solve lots of areas and actually some of our sickest areas where we still don’t have broadband access. So the first piece of the Internet of Things is the connection, and if you don’t have the infrastructure for the connection, then you can’t monitor. The second piece is then adoption from the patients and willingness to allow this to occur in their home and for them to be monitored and watched and helped, and you really have to build that engagement and try to convince them that this new model of care is going to benefit them because it seems so odd and so out of place in our system, but if you go to other health care systems, it’s the norm. So I spent 2 months when I was in medical school working in a public clinic in Chile, and when they had their diabetics, they followed them and they came back every 2 months, and if you missed your appointment, you went to their house. If they couldn’t drive, you got in an ambulance and you went to their house, and we delivered care for their chronic disease patients in their home routinely if they had any difficulty getting to the physicians, and that was the first time that I realized that United States health care system probably had it really backwards. I mean, we drove into the country, and we went to a house where they were still using a fire pit for cooking their meals and had a low ceiling and didn’t have electricity, but they still were getting the same exact health care as somebody that was in town with a car and driving to their appointments, and right now in the United States, if you’re someplace that doesn’t have a car and you don’t have electricity and you’re out in the country, the doctors aren’t coming to you to make sure that your diabetes is under control. I think we can get there with technology, but to me that’s the bigger disruptive force is just the concept that we’re going to care for patients in that manner.

Sanjog Aul [00:22:02]:

So from what you just mentioned, it looks like health care organizations may be ready, even the patients who are supposed to get the health care are ready to embrace it. The public infrastructure is the bottleneck. Is that what you’re telling?

Dr. John Showalter [00:22:18]:

So I think there are two things that are the bottleneck. In Mississippi, the public infrastructure is the bottleneck, and I think that’s going to continue to be a bottleneck. As we get more and more information flowing, even broadband might get bottlenecked in some areas depending on the population, depending on what the choke points are on those. The other is the payment method because a primary care clinic might want to offer this service to their patients and might think it absolutely is the best thing, but they don’t have any reimbursement model for it. They have no way for the insurance company to pay them for their time, and thus they can’t provide the service. They can’t provide the technology because the payment model doesn’t support it.

Sanjog Aul [00:23:06]:

Now everyone can keep pointing fingers at each other, but who’s supposed to step up?

Dr. John Showalter [00:23:11]:

So I actually think Mississippi is a great model, and Medicare and Medicaid are now over 50% of our payer population in the United States, and I think the legislature needs to either step up or those payers step up and say, we recognize that this is something that we can do, that we can pay for this, that it benefits our patients, it’s the right thing to do, and I would really like statewide legislatures to do it because then they can actually make sure that the private insurance companies do it. So I think the patients and the health care providers need to get together and say, we want to deliver this kind of care. We want to make sure this is going to happen, and we are going to use our legislative process and regulatory process to say, this must be a covered service. You can’t not provide it, and we did it in Mississippi and we’re seeing the benefits from it and we’re able to roll up in scale and are having much different conversations than we have had in the past about how we’re actually going to care for our patients, and are looking at how to keep them healthy and keep them out of the hospital because we have a revenue stream that I wouldn’t go as far as to say it’s a profit center, but we have a revenue stream that will cover the cost of us providing better care.

Sanjog Aul [00:24:40]:

Now we can definitely get on the soapbox and say how helpless we feel because there are a number of things which would prevent us from being able to realize that dream, but then given what we have today, and if you were to innovate, leveraging IoT in it as a technology and also as an underlying foundation for that information and communication superhighway, what can you do today to see if there is a reasonable impact we can make on health care?

Dr. John Showalter [00:25:12]:

So I’ve been amazed, now that we’re having these conversations, how low the cost to delivering these services are. There are a number of vendors out there that are ready for this market to explode and will deliver devices to patients’ homes for $40–$50 a month and provide the sensor aspect and the machine-to-machine analytics aspect, and then the providers are able to do the monitoring. I think we just need to start. I think we are kind of in this perpetual waiting for the perfect storm. We have the classic thing we have in research, which is, seven studies say it works, one study says it doesn’t work. There’s probably some nuance in that one study that explains why it didn’t work in your area, but we’re held back by the one study that said it didn’t work when we have many more that show the gains, and I think we just need as a populace to start requesting it from our providers. Hey, I just found out that my mom has diabetes. Do you have any of these tools? And there are some national groups that are providing some of these services as well. So I think we need to step forward and start asking for it, especially as the informed population and begin to bring it to our health care providers as a request. If as patients we are passive and don’t request it and just wait for health care providers to decide to roll it out, I think we’re missing an opportunity to take ownership of our own health.

Sanjog Aul [00:26:57]:

So let’s take, for example, your organization. So you also are part of the ecosystem where there are certain things you cannot control. What are some of the baby steps that can be taken today and which you may be already in, in the works at your end, which you are trying to leverage so that you can deploy IoT, try to utilize it to whatever degree, and make an incremental impact, maybe not significant, but at least an incremental impact in the way health care really delivers value, whether helping, in terms of better care or reducing cost.

Dr. John Showalter [00:27:32]:

So when we’re talking broadly about the Internet of Things and baby steps, we are using our mobile. We have a portal that goes to the mobile device for EHR. We’re using that and pushing that to have patients enter their own health histories, starting to have them enter their own medications. I think those are very small incremental baby steps. We’re even pushing the mobile devices some surveys about, did you understand your prescription, did you understand your instructions, did you get your prescriptions filled, and trying to do some mobile communication, which on the definition of Internet of Things might be a little bit of a stretch to include, but we’re moving down that path where patients are engaging more and more with their care. We have taken much more than baby steps with sending patients home with mobile devices with the applications on them to monitor their own blood pressure, monitor their own glucose, and we’re providing much more education about home monitoring and when to contact your physician, as well and opening up channels of communications through the mobile devices, not just picking up the phone and calling somebody.

Sanjog Aul [00:28:47]:

So, let’s take a quick break, listeners. We’ll be right back, and what we should discuss here is what would that team look like which will help enable this, basically, IoT delivering the value for health care. So would you change anything in the makeup of the team? Would you change anything in the vision? And maybe would you change anything in the application portfolio that you have today in order for you to say, okay. I’m ready for IoT. Maybe if I can get started here when the rest of the world changes or becomes more conducive, I can scale. So are you ready as a health care organization and in your department as a health care CIO? Please stay tuned listeners. We’ll be right back.

Speaker 0 [00:29:35]:

Today, enterprise technology is both strategic and global. Each week on CTN CIO Talk Network, IT thought leaders from around the world share their experience with listeners as they discuss with Sanjog Aul how they are trimming costs and partnering at ciotalknetwork.com. You are listening to CTN CIO Talk Network with Sanjog Aul. Now back to the show.

Sanjog Aul [00:30:27]:

Welcome back. So, John, the question is, are we ready? And what have you done to be ready with IoT as one of the tools in your arsenal, which when leveraged properly will really create value. Yes. We have issues with the public infrastructure or other challenges or limitations, but what are we doing? Are we doing what is needed for us to be ready?

Dr. John Showalter [00:30:51]:

Yeah. So I think the University of Mississippi Medical Center is doing what needs to be done to be ready. You brought up a great point about the team, and I think one of the interesting things as we’ve gone down this journey about the team is that you really need a vendor partner, at least in my opinion, that’s going to manage the IoT devices. So getting devices into a patient’s home, getting them back, getting them refurbished and cleaned and redeployed is a whole factory-type process in and of itself and not something that I think most health systems or care providers want to take on. I mean, I know as a physician that’s I don’t want to be worried about whether or not there’s another iPad or Android device ready to deploy out to the next patient that needs it. I just want to know that I have a patient and that they’ll have it arrive at their house. As well as those partners also tend to have the Internet of Things application layer and the analytics and the flags and the rules engines that let you know that something’s out of whack and that you should go talk to that patient. So I think finding and choosing that partner and exploring that and figuring out which one is the right fit for your organization is a really big step that even if you’re not quite ready to tackle it, there are a plethora of options out there right now, and they range from just sensor technology to full-on suites. Figuring out which rates for you is going to take time and a challenge, and actually, I think exploring them will help you figure out what options and delivery methods you want to use. So I would very much encourage people to begin looking at those vendors and figuring out who that member of their team’s going to be.

Dr. John Showalter [00:32:37]:

On the inside of the team, you definitely need nurses that can coach via chat, which is a skill that either they need to develop or one they just innately have because inpatient discussions versus discussions over an iPhone are slightly different. Everything is in your facial expressions, whereas in person, everything is in your body posture and your language.

Sanjog Aul [00:33:06]:

Alright. So go ahead.

Dr. John Showalter [00:33:08]:

Oh, no. Go ahead.

Sanjog Aul [00:33:10]:

Yeah. So what you just mentioned is that you will have the people and the business side you want to see get ready to adopt the IoT and then in your technology. What about your application portfolio?

Dr. John Showalter [00:33:23]:

So, on the application portfolio, we’ve just now begun to try to integrate the application we have for the home monitoring and the IoT with our EHR as well as the sensor technology inside the hospital with our EHR and are in active discussions with both vendors about what clinical information we have in the EHR that’s going to impact their rules engines and our ability to get better information, have people dedicated to trying to integrate that information and put the data models together. So that’s a member of the team that you’re going to have to have to do this well: the internal member that’s connecting the dots between your existing infrastructure and your vendor’s application.

Sanjog Aul [00:34:14]:

So we spoke about the team. How about the management? Does management take IoT as just a geeky problem, which you will figure out as the chief information officer, or do they actually see this as an enabler of a better health care delivery platform? And then are they also looking at it as a cost saving so they are supporting it, championing it, and helping work with the other public infrastructure people to make sure they pave the way so that you can deliver the platform, which will benefit every one of us?

Dr. John Showalter [00:34:47]:

Our management’s taking it extremely seriously. It hasn’t quite raised to a full strategic priority, but definitely is a strategic initiative and our telehealth is a strategic priority as a larger concept. We have over 200 telehealth sites where we have physician-to-physician, physician-to-nurse interaction delivering care in the acute setting. So the home monitoring is a new area for us, but it’s definitely an initiative where we have support. We have support with our government relations group working with the legislature to make sure that the legislature is informed and able to support measures that support moving to care in the home. We have groups that are out there working on grants and funding sources to improve the public infrastructure, get broadband to more areas so that we can deliver this service to those as well. We’ve paid for some of those lines to be run out to some of our rural sites so that we have provided it to a whole community because we’re providing it to our hospital, and we are very much not viewing this as

Dr. John Showalter [00:36:03]:

a geeky thing that we’re not sure what we’re going to do with. They’re very much viewing getting patients cared for in their home and their chronic diseases under control as an imperative for the state. That being said, I don’t think most of our management would refer to anything close to the Internet of Things. They use terms like home monitoring, telehealth, remote sensors maybe would be the closest that they got, but as the delivery method concept, they’re very much on board, and they are trusting us to be a little bit geeky and figure out the nuts and bolts to get it done.

Sanjog Aul [00:36:44]:

Now what about the tools and technologies? We know any evolving technology paradigm has its own interesting challenges where you may try something, but then you figure out that it’s not fully cooked yet. So what would be your take on the current state of not just the probes and sensors because those are just devices, but this whole technology toolset, if you will, that’s been made available for health care in specific?

Dr. John Showalter [00:37:15]:

Yeah. I think

Sanjog Aul [00:37:18]:

Go ahead.

Dr. John Showalter [00:37:19]:

Sorry. I think that the machine-to-machine communication piece is the part that we are really trying to figure out the most. We have patients that take the virtual coaching piece and engage with it to the point that they think it’s the best health care experience they’ve ever had, and other patients that hate talking on their iPad or Android device that’s been deployed to them, and the question of how do you motivate a patient to better behavior after you’ve gotten sensor messages that said their behavior is not supporting their health, I think is the biggest challenge, and we are struggling through that. I’m not even sure we have best practices down yet, and I suspect that one of the things that’s going to come into play there will be some of the additional data sets that could be brought into the sensor data for the algorithms, more of the socioeconomic and behavioral determinants of care.

Sanjog Aul [00:38:26]:

And when you look at the overall this whole space, the way it is supposed to evolve in order for it to really start becoming what you would like it to be, is there a holy grail version that you have in mind which you’re benchmarking it against?

Dr. John Showalter [00:38:44]:

I don’t know that I have a Holy Grail version in health care. Again, I think there are Holy Grail type versions of using the Internet of Things, and I think OnStar is a great example. The concept that an ambulance could be dispatched to a car crash before the driver even recovered from the airbag getting deployed is amazing. Growing up in rural Pennsylvania, there was more than one car wreck where it was hours until the wreck was even discovered. So to think that it could be discovered in subsecond time and be dispatched immediately is huge, and from a trauma health care setting, I think that tangentially applies to improving trauma care. If every car was equipped with a sensor that dispatched emergency services if they needed it, trauma care would probably improve, and I think there is that kind of holy grail outside. We’re still not quite there in the population chronic disease management, but if I knew that you were going to have a heart attack in the next 6 hours and I could send an ambulance to your house and you could be brought into the hospital and we could prevent that heart attack before it happened, that’s probably a holy grail type scenario. I don’t think we’re 5 years away from that. I think we’re probably more than 10, but I don’t think that 20 years from now that’s really an unreasonable type thing for us to be thinking about achieving.

Sanjog Aul [00:40:23]:

Privacy, security, governance, compliance. Health care and these items go hand in hand, and when you look at any technology which expands the data flow outside of an organization’s boundary or even within it, it could raise concern, and it has caused problems in the past. How are you battling

Dr. John Showalter [00:40:46]:

that? So security is definitely a concern. Security and privacy are going to be on balance with patients’ health just the way that security and freedom are in balance right now on a national level. So we’ve been battling that by being ultra conservative. So the devices that our patients get are locked-down, single-use devices, sending encrypted packets of information, but it means that we have to send a dedicated device to the patient’s house. It means that they can’t just use their iPhone or use the blood pressure cuff they got from the pharmacy; they have to use this packet of stuff that we send them that increases the cost and limits the availability and makes us be more selective on who we’re dealing with and who we’re working with. So it is secured, the privacy is protected, but it is restricting the ability to deploy the technology, and I think we’re going to have to work through that balance as more applications become available, more sensors can be connected to mobile devices, and things become cheaper and cheaper, and people start monitoring their stuff at home and connecting it to their care team, and that’s going to cause privacy and security concerns, and those apps are going to be more or less secure, and depending on what the terms and conditions were when you download the application, you may have volunteered to share all of your information that you didn’t really mean to.

Sanjog Aul [00:42:34]:

So let’s take a quick break. We’ll be right back, and while we’re talking about this privacy and security, and of course, we have to adhere to them, there will always be this sense of paranoia or a concern, but you are essentially trying to hedge your bets. Are you allowed to hedge your bets by selectively implementing things related to IoT, which will allow you to eat the cake and have it too. What would that look like and to what degree with what degree of caution should we move forward so that we are not losing our shirt in favor of doing technology innovation and improving health care. Please stay tuned, listeners. We’ll be right back.

Speaker 0 [00:43:27]:

Sanjog Aul [00:44:17]:

Welcome back. So whether it’s a concern or a paranoia, in any of those cases, it has the potential to undermine what you could otherwise achieve leveraging IoT for health care. What is being done to allay those fears and concerns so that we are not getting paralyzed?

Dr. John Showalter [00:44:40]:

Yeah. So, unfortunately, I don’t think there’s been a lot done to allay those fears. When headlines are coming out that 60%, 70% of patients have had a breach after the Anthem breach last year, the fears are really there and the government hack where they were able to get employment information from the government servers increased the level of paranoia. People have a lot of trust in our financial system. We use lots of credit cards. We use tap-and-go technology. Most people don’t just carry cash so that their purchases can’t be tracked. That information is resold and tracked, and we’ve had major breaches with Target and Home Depot, but people still use their credit cards, and there’s not the same sense of concern that people have when they’re talking about their health data. People are much more concerned about their blood pressure tracing and their glucose tracing than they are about swiping their credit card. I haven’t completely understood all of that. I think there’s a lot of history with regard to bias against people with health conditions in the past in the US. There are still definite bias in place. On the health care provider side, I think I’ve had a lot of those bias trained out of me and had lots of training that those aren’t ethical and we’re very aware of them, but outside there’s very much concern about what it’s going to be. I actually just read an article advising people to not get genetic testing because there’s no legislation that says life insurance can’t use that genetic testing against them, and pointing out that the rules about not delivering coverage based upon a predetermined condition only apply to health insurance, they don’t apply to disability insurance, they don’t apply to life insurance, so that if you get a genetic test done that shows you’re genetically predisposed to cancer, your health insurance company can’t use that against you, but your disability insurance company or your life insurance company could. So I think there’s a lot of concern that people have that’s valid, that there’s just a big unknown, and the unknown is the scariest. What’s going to happen if my medical record actually is breached? What’s going to happen if I have my blood pressure tracing hacked? What does that mean? What is somebody going to do with that? And there’s been some scary things with people proving that they can hack into IV pumps. Now they haven’t really done anything. We’re not sure what people are going to do if they hack into an IV pump, but there definitely is concern that they could do something, and that something is ill defined and we’re very scared of what that ill-defined piece is, and I don’t think we’re doing enough to educate patients about what the real risks are versus the real benefits, and pushing to them that in many aspects, at least in my medical opinion, the health benefits from this type of technology greatly outweigh the potential privacy issues that could come from it. If we can help you control your diabetes and you don’t need to be on dialysis for 10 years, that seems very worth the potential of breaching your glucometer information to me.

Sanjog Aul [00:48:10]:

Now if you were to talk about the government, the way the government is coming to support what you’re trying to do internally at an organizational level, what is happening at that level? What’s happening at the macro level? Because we did say that there are problems.

Dr. John Showalter [00:48:30]:

Oh, definitely. From a state level, I feel like Mississippi has a ton of support. Mississippi is fully aware that from a chronic disease population health level, we are last or next to last in the nation, and that we need to be extremely proactive about treating our patients with diabetes, treating our patients with heart failure, improving our detection of cancer, and getting out to our rural population, the state legislature has been extremely supportive. I would say that the federal legislature has not been as supportive, and of course, at the federal level, you’re ranging across healthy states and unhealthy states, and the motivations are different. The amount that private insurance and private companies are helping the infrastructure is different, but we haven’t seen a lot of movement on the national level, at the ONC level, the legislative level, the CMS level, of really making delivery of care at home using the Internet of Things something that is a mantra that they’re going to push forward to bend that cost curve. I think they’re looking at improving acute care as bending the cost curve. They’re setting up ACOs, accountable care organizations, to try to encourage systems to make these changes, but they’re not dictating it or directing it as a way that we need to head, and I think we have enough information now that there really should be more of a directionality towards this, that we know that we can provide better care meeting patients where they live. We know that intuitively, but now we have the technology and some research to support it, and I think that’s the way we’re gonna bend the cost curve, but the legislature, the government level has not necessarily come to that same conclusion, and they’re definitely not driving it hard to get people to do it.

Sanjog Aul [00:50:28]:

And, when you’re looking at the culture within the organization, which is supposed to fundamentally shift when you’re going to try to do things outside of the organizational boundaries, and you would like them to acquire skills which are truly not natural to them because many health care workers are tenured. What are you doing to take care of that part?

Dr. John Showalter [00:50:51]:

Yeah. So I tell lots of people when they ask me why I keep working in Mississippi because there’s a bit of a bias against Mississippi, but the reason I keep working in Mississippi is that I’ve never been with a medical group that’s more on mission, is more committed to their patients and to the health of their patients than the group I’m working with now. We have a really easy time saying, This looks like a good direction, and do the skills that you’re going to need to learn. We implemented our electronic health record in one day across 1,500 providers and 8,000 nurses, and had this huge big bang go live and had great results. So they’re very willing to change for the benefit of the patient. So we’ve had a lot of luck using telehealth, having them change their care models to somebody else doing remote blood pressure, someone else doing assessments and providing oversight and trying to get that model into the home. I think we’re ahead of the curve from a lot of places. We’re also very overwhelmed with patients. We have more ambulatory patients than we can care for with the number of providers we have. We have more patients coming to the hospital than we have room to take care of. So we’re very willing to get their care in their home and keep them out of our acute settings, because we have enough work in volume in the acute setting. So we don’t have any perverse motivation to keep them coming to us.

Sanjog Aul [00:52:26]:

And, one final message from you for any fellow health information officers who are listening to this or may get their hands to this podcast. What’s your message to them if they are going to go on this IoT journey, and we know things are not perfect yet, but what can they do, new and different or more, to get the most value out of IoT?

Dr. John Showalter [00:52:52]:

So I would say that they should start identifying their partners. They should definitely jump in and figure out the direction they want to head, and then pick their low-hanging fruit because there’s going to be low-hanging fruit whether it’s their diabetic population or their heart failure population or their medically complex population. It’s going to be really easy to identify a cohort of patients that would benefit from extra attention, especially attention in their home, and just get started with a reasonable sized pilot and learn the lessons that you’re going to have to learn as an organization to build and be ready for this expansion. Because I think the external drive to expand this type of care is going to come in the next 2 to 5 years.

Sanjog Aul [00:53:40]:

Thank you so much, John, for sharing your insights on how IoT can improve health care.

Dr. John Showalter [00:53:46]:

I appreciate the opportunity to be on the show, Sanjog Aul.

Sanjog Aul [00:53:49]:

Thank you so much again, and listeners, would like to invite you to join us on Twitter and follow and contribute towards our discussion on LinkedIn and subscribe to our newsletters and podcasts. We have a brand new website. Enjoy looking at it. Give us feedback so that we can keep growing and improving. Thank you so much again for listening.

TagsCTN Talk Show Healthcare IT Internet of Things

Contributors

Dr. John Showalter, Chief Health Information Officer, University of Mississippi Medical Center

Dr. John Showalter is an influential thought leader on the innovative use of health information technology, devices, and data to drive improvements in healthcare delivery. Dr. Showalter serves as the Chief Health Information Officer at the ... More View all posts

Transcript

Sanjog: Taking about healthcare, and of course we are looking at this IoT mega-trend where it is touching all different industries. When it comes to healthcare, what is so special, why? What’s so compelling that we can say, yes, if we were to invest in and while already there so much transformation going on in healthcare. This is going to further take us to the next level. So the promise of IoT is really about getting healthcare out of the hospital and getting healthcare into homes.

The Internet of Things gives sensors the ability to talk to machines and machine analyze the data, which really changes the paradigm of healthcare just occurring between a nurse and a patient or a physician and a patient in health care setting, and brings it to their home and allows us to really figure out what’s going on with their health and move more towards wellness in house than just acute care.

So, when it comes to your ability to work with the multiple organizations in your ecosystem, would you say, IoT is very internal to an organization when it comes to health care or does it really show it’s real value when you tech across ecosystem and value chain partners?

John: I think it shows IoT’s greatest potential is when it is focused on the patient. A patient clearly cut across payer, delivery systems and health systems and interacts with health care in a variety of ways. And when we keep the patient at the center of it, I think we begin to actually recognize the potential. UMMC, Center for Telehealth has actually done some pilots and it’s beginning to work with insurance companies doing whole monitoring where we have blood pressure cuffs in the home, and glucometers for measuring blood glucose levels for diabetics in the homes. And those automatically send signals back to a system that is curating the data, analyzing them and throwing alerts up to nurses. So that if the glucose is out of control two times in a row, an alert comes to the nurse, the nurse can call or ping them through a mobile device and say, let’s do a video chat about what’s going on with your blood glucose and get it under control.

And our initial pilots with that have shown marked reduction in the use of emergency departments, use of hospitals and when extrapolated to the state, it has shown multimillion dollar cost savings for the insurance company while making the patient healthier. But where it becomes problematic is the payment system health care. So the health system doesn’t necessarily benefit financially by keeping patients out of the hospital. So they have to work on payment models with the insurance companies where the insurance company saves money the patients healthier and the health system still maintains enough margin to stay open.

Sanjog: Okay. So when you talk about issues related to the health devices connecting to mobile phones, would you say that innovation essentially is already there or was already there? So what new did you do? Because we assume that if health devices were made a little intelligent, they would transmit some data or interact with other connected devices but maybe not to a mobile phone. So is that the extension is what you’re calling as the value proposition of IoT?

John: I remember in 2004, 2005, my grandfather had had a heart attack. So the diagnosis was a congestive heart failure and he got sent home with a scale that was plugged into his telephone jack. And he stepped on a scale every day and it measured his weight as well as asked him questions like, are you having trouble breathing, do you have chest pain? And it had recognition yes and no, and then it was sent to a nurse and said, your patients gained three pounds and said, he is having trouble breathing and his phone would ring and they’d say, “Hey, let’s talk about how you’re feeling.” So we’ve had that kind of technology for a while and I think the innovation is we’re actually beginning to use it and consider it widely, but this is something that we should use in health care.

There’s a lot of discussion about let’s bring Uber kind of innovation to health care. I want to bring OnStar to healthcare, if you think about the technology behind on the start, there’s a sensor in your bumper that’s measuring how much pressure is on the bumper and it’s always measuring and always measuring. And then suddenly, there’s tons and tons of the force on the sensor and then no force. And the sensor sends off its signal and there’s a register that there’s a head on collision. And at the same time, it’s register and there’s a head on collision. And the airbags have gone off. It’s scanning on the start system for an overhaul of the operator and dialing your car so that about the time you’re beginning to recover from the airbag deployed and you’re getting, “Hey Mr. Showalter are you okay? Hey, Mr. Showalter, are you okay? If you haven’t answered I’m going to dispatch an ambulance to you.” That kind of technology intervention has existed outside of healthcare but we don’t have– the technology in place where people are walking around their homes, and then suddenly they haven’t moved for two hours but they’re not in their bedroom or they’re in their bathroom and somebody contacting them and saying, “Hey, are you okay? Or do I need to dispatch somebody to your house to check on you?”

When we started talking about that level of tech – from sensor to machine, machine to machine, machine to communication technology, we begin to change how we can impact patients’ lives, how we can let people age in their homes, how we can keep people out of a hospital. And there hasn’t just been that much focus on it. I think with the real talk in the interest, things are starting to change. But I don’t think it’s really the technology that is innovative, but its application in the process of delivering care that is innovative.

Sanjog: So within the healthcare, like so once the patient reaches a hospital or a clinic or an emergency center, at that time if you look at the way health care has to be imparted, you think there’s innovation that’s possible or is it simply limited to the notification or is it proactive monitoring what we’re talking here?

John: Well, I think proactive monitoring is where we need to get to and actually say that once we get to the inside the hospital, we’ve swung the pendulum the other way. We have so much monitoring going on without the application level. With all the data, we’re just overwhelming nurses and techs and physicians with data. We’re not giving them the knowledge that they need. We need to take that data and turn it into actual knowledge that’s going to benefit the patient. We just did an assessment that there are a hundred alarms going off every minute in our hospital. And clearly that is too many for anyone to actually act on or keep up with. So we need to take the information that we’re producing because these alarms may be one level up from data, but they’re not generating actual knowledge, and we still need to put better algorithms and better knowledge bases behind that information to reduce that to a level where we can actually intervene for the good of the patient.

Sanjog: So when you just mention about it these alarms going off, so would you say that IoT’s own implementation may already be in place among the health care devices and that’s why they’re triggering each other’s alarm? But then it doesn’t only mean thinking at a device level or at the data generation level. But also at the analytics level, would you take that also under the IoT per units to say that, okay all the devices in the hospital, whether starting from proactive monitoring or taking someone to a hospital. It’s the IoT umbrella under which the analytics is also embedded and that’s when you start looking at trivial triggers versus the ones which really are the ones we have to act upon?

John: Yes, I think we’re definitely in the sensor to machine realm in health care. So we’ve got lots of sensors deployed, lots of patients locked up the heart monitors, blood pressure cuffs, oxy monitors for their breathing. And we’ve really focused on these sensor to machine, getting the physiological data into an electronic format and put some thought around the analytics but they’re really crude thoughts like let me know when the heart rate is above 90 or let me know when the heart rates below 30. They’re not deep algorithms that are based on knowledge bases and there is some discussion about– if there are difference between the Internet of Things and the web of things, where the web is the application layer but that layer is where we’re redoing machine to machine with algorithms and sorting, and especially the machine communication aspect is where we’re going to get our bang for the buck. And we’re getting some innovation in there. But there’s still a lot of concern about secure messaging, privacy, and how to do that level of communication and actually get people to act.

Sanjog: When you’re looking at anyone who is coming in and you are trying to help them get better. How is the business side of it looking at it? Is it again a better mousetrap or would you say this is fundamentally changing in the way a patient satisfaction goes up there, hopefully a patient doesn’t have to come back again but the way they get healed, you get more referrals because you just start simply better at giving the overall experience, where is it adding value thinking business?

John: So, I think that disruptive forces is the concept of delivering care in the patient’s home or delivering the care where the patient is. I see the Internet of Things as an enabler and not so much the fundamental disruptor. But when we talk about what we’re doing with home health, we’re identifying patients that have had trouble controlling their diabetes. And we’re sending them home with a tablet device and biometric devices and a glucometer. So we’re sending them home with the things to measure their blood pressure, measure their sugar, and their blood. They’re checking in with a counselor, which is a nurse coach, weekly but the nurse coaches are also there to reach out when things aren’t responding the way they’re supposed to be that their glucose isn’t coming down the way we thought it would, and that their blood pressure was not coming down the way that they thought it would. And that is shown for the pilot group that they worked with, to have no ED visits or hospital visits for six months with a group that was heavily involved and engaged with that and the cost savings to the insurance company were in the orders of hundreds of thousands for less than hundred patients.

So the business benefit is really on the insurers’ side. In Mississippi, we’ve taken that to ensure that we will have benefit on the provider side by requiring insurance companies to pay for that kind of activity. There’s actually a daily fee we can charge the insurance companies for monitoring those patients at home with those types of devices. I think Mississippi is currently the only state that requires that type of reimbursement. Without changes to those reimbursements, there’s not a lot of benefit to the hospitals or the providers. There are some payment benefits to the hospitals with not having patients re-admitted in some programs from Medicare but on the ambulatory clinic side, it’s just that free work that makes patients healthier and that’s a lot of sustainable model. But I think we are moving into an era where providers and nurses and care coordinators really want patients to be able to stay home and not have to come into the clinic and see the doctor, unless it is absolutely necessary. We used to have lots of appointments for blood pressure checks and sugar checks and we’re trying to get past to the point where someone actually has to come into the office and do that.

Sanjog: Let’s take a quick break listeners, we will be right back. And what we have to do here is to not just look at how the health care organization will benefit because at the end goal, as we see that in United States alone, we spend over 18% of our GDP on health care each year. And if that’s the case, then we definitely have to do something to reduce health care cost. So yes, IoT may provide that disruptive experience and perhaps patient satisfaction. But if people are not able to afford health care then it doesn’t really matter. So what can IoT do to address this cost problem and what are the related assumptions and exclusions for making them, if we are to claim that IoT can indeed help reduced cost. Stay tuned listeners, we will be right back.

[break] [advertisements]

Sanjog: Welcome back. So yes, we can be very good in giving patient satisfaction among other things. Now I am personally also appealing to all people in health care to say, figure out a way to reduce health care cost. Now with that said John, what can IoT do?

John: Sure. So there’s this concept in health care, especially in hospitals, where there say no margin, no mission –which means that if we’re not able to make at least enough money to cover our bills, we can stay open and deliver care. Unfortunately and shockingly, I think we’re getting close to that at a national level. Now when it is 18% of GDP and climbing, we’re going to have to do something to bend the cost curve. The Institute of Medicine talks about the American Academy of Aesthetic Medicine (AAAM) in bending the cost curve and providing better health care, and better health lower cost. And I do think that the Internet of Things is going to be an enabler for that. We really do need to figure out how the payers, the providers, the patients and the technology companies can all work together. So if you look at what really costs money in the United States, our two biggest things are chronic disease and symptoms of chronic disease, so diabetes, hypertension, heart failure, heart disease. It’s a pretty short list of things that cost us a lot of money and their medication. Lots and lots of expenditure on medication and a lot of that medication is spent on paying for the treatment of chronic disease.

So if we can get patients who have diabetes to control their glucose they don’t develop heart disease, they don’t develop kidney failure, they don’t need dialysis and it becomes about improving the health of our population is really how we’re going to bend this cost curve. So when we were talking about the partnership, we have with our patients on the whole monitoring and so, there are agreeing that have coaching every week, they’re agreeing to use these devices that transmit signals and information back to a central software that sorts through them. Our payers are agreeing to pay for it and we’re saving hundreds of thousands of dollars on that care while making the patients healthier. We’ve extrapolated it to the state and if we were able to have that kind of benefit for all of our diabetics in the state, we would have a 180 million dollar cost savings a year for treatment of diabetes in our state.

Now of course, you’re dealing with a pilot group that’s engaged and you’re not going to have a 100% penetration but even if we were 50% successful, we’re talking about spending less than– over a 100 million dollars less a year in care for diabetes and full on heart failure, the other chronic diseases and now we’re talking about hundreds of millions of dollars a year that we’re not spending while making patients healthier. To me that’s how we’re going to bend the cost curve. We’re going to actually have to disrupt the current model of care, where you stay in your home until you’re too sick to stand it and then you go and see a doctor. And then, you may or may not have the support to treat your chronic disease that means you feel so sick that you have to go to the doctor in the first place. We’re going to have to meet people where they live and really change from acute care, sick care to wellness and population health. And I don’t think we’re going to get there until we have the ability to work with people in their homes and utilize the technology that connects their homes to their care team.

Sanjog: So with that said, so you’re essentially saying take health care to the patient versus patient coming to the health care, the place where they can get health care that’s the key here. And of course, that’s a great dream. To some extent, people, the organizations and people are coming together to make that happen. Now what are some of the challenges in relation to that?

John: Sure. So, in a rural state like Mississippi, one of our challenges is still broadband access. These technologies don’t work very well over a 56K Modem. And we solve lots of areas and actually some of our sickest areas where we still don’t have broadband access. So the first piece of the Internet of Things is the connection and if you don’t have the infrastructure for the connection, then you can’t monitor. The second piece is then adoption from the patience and willingness to allow this to occur in their home and for them to be monitored and watched and helped. And you really have to build that engagement and try to convince them that this new model of care is for them, is going to benefit them because it seems so odd and so out of place in our system. But if you go to other health care systems, it’s the norm. So I spent two months when I was in medical school working in a public clinic in Chile. And when they had their diabetics, they followed home and they came back every two months and if you miss your appointment, you went to their house. They couldn’t drive, you got in an ambulance and you went to their house. And we delivered care for their chronic disease patients in their home routinely, if they had any difficulty getting to the physicians. And that was the first time that I realize that United States health care system probably had it backwards.

We drove into the country and we went to a house where they were still using a fire pit for cooking their meals and had a low ceiling and didn’t have electricity. But they still were getting the same exact healthcare as somebody that was in town with a car and driving to their appointment. And right now in the United States, if you’re someplace that doesn’t have a car and you don’t have electricity and you’re out in the country, the doctors won’t come to make sure that your diabetes is under control. I think we can get there with technology but to me, the bigger disruptive force is just the concept that we’re going to care for patients in that manner.

Sanjog: So what all you just mention, it looks like that, okay, health care organizations may be ready. Even that the potential, like the patients who are supposed to get the healthcare or receive the health care are, they are ready to embrace it. The public infrastructure is the bottleneck, is that what you’re telling?

John: So I think there are two things that are the bottleneck. In Mississippi the public infrastructure the bottleneck. And I think that’s going to continue to be a bottleneck, as we get more and more information flowing even broadband might get bottleneck, in some areas depending on the population, depending on what the choke points are on those. The other is the payment method because a primary care clinic might want to offer this service to their patients and might think it absolutely is the best thing. But they don’t have any reimbursement model for it. They have no way for the insurance company to pay them for their time and thus they can’t provide the service, they can’t provide the technology because the payment model doesn’t support it.

Sanjog: Now everyone can keep pointing fingers at each other but who’s supposed to step up?
John: So I actually think Mississippi is a great model and Medicare and Medicaid are now over 50% of our payer population in the United States and I think that the legislature needs to either step up or those payers step up and say, we recognize that this is something that we can do that we can pay for this, that it benefits our patients, it’s the right thing to do and I would really like state wide legislators to do it because then they can actually make sure that the private insurance companies do it. So I think that the patients and the healthcare providers need to get together and say, we want to deliver this kind of care, we want to do, make sure this is going to happen and we’re going to use our legislative process and regulatory process to say, this must be a covered service. You can’t not provide it. We did it in Mississippi and we’re seeing the benefits from it and we’re able to grow up in scale and are having much different conversations than we have had in the past about how we’re actually going to care for patients. And are looking at how to keep them healthy and keep them out of the hospital because we have a revenue stream that– I wouldn’t go as far to say as a profit center but we have a revenue stream that will cover the costs of us providing better care.

Sanjog: Now we can definitely get on the soapbox and say how helpless we feel because there are number of things which would prevent us from being able to realize that dream but then given what we have today and if you were to innovate leveraging IoT, in it has a technology and also as an underlying foundation for that communication, superhighway if you will, the information and communication, superhighway, what can you do today to see if there is a reasonable impact we can make on health care?

John: So I mean, I’ve been amazed now that we’re having these conversations how low the cost to delivering these services are there and number of vendors out there that are ready for this market to explode and will deliver devices to patient’s homes for $40, $50 dollars a month and provide the sensor aspect and the machine to machine analytics aspects. And then the providers are able to do the monitoring I think. We just need to start. Like I think we are kind of in this perpetual waiting for the perfect storm. We have the classic thing we have in research which is seven studies say it works, one study says it doesn’t work, there’s probably some nuance in that one study that this is why it didn’t work in your area but we’re held back by the one study that said it didn’t work when we have many more that that show the gains. And I think we just need as a populace to start requesting it from our providers. Hey, I just found out that my mom has diabetes, do you have any of these tools? And there are some national groups that are provided some of these services as well.

So I think we need to step forward and start asking for it, especially as we inform population and begin to bring it to our health care providers as a request, if as patients we are passive and don’t request it and just wait for health care providers to decide to roll it out, I think we’re missing that opportunity to take ownership of our own health.

Sanjog: So, take for example your organization. So you also are part of the ecosystem where there are certain things you cannot control. What are some of the baby steps that can be taken today and which you maybe already in– those maybe in the works if you are and which you are trying to leverage so that you can deploy IoT, try to utilize it to whatever degree and make an incremental impact, maybe not significant but at least an incremental impact in the way health care really delivers value, whether helping in terms of better care or reducing cost.

John: Sure. So when we’re talking broadly about the Internet of Things and baby steps, we are using our mobile– we have a portal that goes to the mobile device for EHR. We’re using that and pushing that patients enter their own health histories, starting to have them enter their own medications. I think those are various small incremental baby steps, we’re even pushing to mobile devices some surveys about, did you understand your prescription, did you understand your instructions, did you get prescriptions filled? And trying to do some mobile communication which on the definition of Internet of Things might be a little bit of a stretch to include. We’re moving down that path where patients are engaging more and more with their care. We have taken much more than baby steps with sending in patient’s home with mobile devices with the applications on them to monitor their own– blood pressure monitor their own glucose. And we’re providing much more education about home monitoring and when to contact your physician as well and opening up channels of communications through mobile devices, not just picking up the phone and calling somebody.

Sanjog: Let’s take a quick break listeners, we will be right back. And what we should discuss here is what would that team look like, which will help enable this IoT– Basically IoT delivering the value for health care. So would you change anything in the makeup of the team, would you change anything in the vision and maybe would you change anything in the application portfolio that you have today? In order for you to say, okay, I’m ready for IoT, maybe if I can get started here when the rest of the world changes or becomes more conducive, I can scale. So are you ready as in health care organization and in your department as a health care CIO. Please stay tuned listeners, we will be right back.

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Sanjog: Welcome back. So John, the question is, are we ready? And what have you done to be ready with the IoT as one of the tools in your arsenal which been leveraged properly will really create value. Yes, we have issues with public infrastructure or other challenges or limitations. But what are we doing? Are we doing what is needed for us to be ready?

John: So I think the University of Mississippi Medical Center is doing what these are already– you brought up a great point about the team. And I think one of the interesting things that we have gone down this journey about the team, is that you really need a vendor partner. At least in my opinion that’s going to manage the IoT devices. So getting devices into a patient’s home, getting them back, getting them refurbished cleaned and redeployed is a whole factory type process in of itself. And not something that I think most health system or care providers want to take on. I mean I know as a physician that I don’t want to be worried about whether or not there’s another iPad or Android device ready to deploy out to the next patient that needs it I just want to know that I have a patient then that tells how to arrive at their house.

As well as those partners also tend to have the Internet of Things application layer and the analytics and the flags and the rules engines that lets you know that something’s out of whack and they usually go talk to that patients. I think finding in choosing that partner and exploring that and figuring out which one is the right fit for your organization is it really big step that even if you’re not quite ready to tackle it, there are a plethora of options out there right now and they range from just sensor technology to full on suites. And figuring out which rates for you is going to take time and a challenge. And actually I think exploring them will help you figure out what options and deliveries methods you want to use. So I would very much encourage people to begin looking at those vendors and figure out who that member of their team is going to be–

And then on the inside of the team, you definitely need nurses that can coach via chat which is a skill that either they need to develop or one that is a neatly have. Because in patient discussions versus discussions over an iPhone or slightly different, everything’s in your facial expressions, whereas in person everything’s in your body posture and your language.

Sanjog: What you just mention is that you will have the people and the business side you want to see get ready to adopt the IoT and then in your technology. What about your application portfolio?

John: On the application portfolio, we’ve just now begun to try to integrate the application we have for the whole monitory and the IoT, with our EHR as well as the sensor technology inside the hospital with our EHR and active discussions with both vendors about what clinical information, we have in the EHR that’s going to impact their rules engines and our ability to get better information. People dedicated to trying to integrate that information and put the data models together. So it’s a member of the team that you’re going to have to have to do this well as the internal member that’s connecting the dots between your existing infrastructure and your vendors application.

Sanjog: So we spoke about the team, how about the management? Does management take IoT is just a geeky problem which you will figure it out as the chief information officer or they actually see this as an enabler of a better health care delivery platform and are they also looking at it as a cost saving so they are supporting it, championing it and helping work with the other public infrastructure people to make sure they pave the way so that you can deliver the platform which will benefit everyone of us?

John: Our managements take an extremely seriously. They haven’t quite raised to a full strategic priority but definitely is a strategic initiative and our Telehealth is a strategic priority as a larger concept. We have over 200 Telehealth sites where we have physician to physician, physician to nurse interaction delivering care in the acute setting. So, the whole monitoring is a new area for us but it’s definitely an initiative where we have support, we have support with our government relations group working with the legislature to make sure that the legislature is informed and able to support measures that support moving to care in the home. We have groups that are out there, are working on grants and funding sources to improve the public infrastructure to get broadband to more areas so that we can deliver this service to those as well. We’ve paid for some of those lines to be run out to some of the rural sites, so that we have provided it to a whole community because we’re providing it to our hospital.

We are very much not viewing it as a geeky thing that we’re not sure what we’re going to do with. They’re very much getting patients cared for in their home and their chronic disease is under control as an imperative for the state. That being said, I don’t think most of our management would refer to anything close to the Internet of Things. They used terms like home monitoring, Telehealth, Remote Sensors, maybe would be the closest that they got. But as the delivery method concept, they’re very much on board. And they are trusting us to be a little bit geeky and figure out the nuts and bolts to get it done.

Sanjog: Now what about the tools and technologies? We know any evolving technology paradigm has its own interesting challenges where you may try something but then you figure out that it’s not fully cooked yet, so what’s your take on the current state of how not just the probes and sensors because those are just devices. But this whole technology or technology toolset if you will that’s been made available for health care in specific?

John: I think that the machine to communication piece is the part that we are really trying to figure out the most. We have patients that take the virtual coaching piece and engage with it to the point where they think it’s the best healthcare experience they’ve ever had and other patients that hate talking on their iPad or Android device that’s been deployed to them. The question of how do you motivate a patient to better behavior after you’ve got a sensor messages that said their behavior is not supporting their health. I think is the biggest challenge and we are struggling through that. I’m not even sure we have best practices down yet. And I suspect that one of the things that’s going to come into play there will be some of the additional datasets that could be brought into the sensor data for the algorithms, more of the social economic behavioral determinants of care.

Sanjog: And when you look at the overall, this whole space, the way it is supposed to evolve in order for it to really start becoming what you would like it to be, is there a Holy Grail version that you have in mind which you are benchmarking it against?

John: I don’t know that I have a holy grail of version in healthcare. Again, I think there are a Holy Grail type versions of using the Internet of Things. And I think onStart is a great example. The concept that an ambulance could be dispatched to a car crash before the driver even recovered from the airbag getting deployed is amazing. And growing up in rural Pennsylvania there was more than one car wreck where it was hours until the wreck was even discovered. So to think that it could be discovered in sub second time and – it help dispatched immediately. It’s huge from a trauma health care setting and I think that tangentially applies to improving trauma care. If every car was equipped with a sensor that dispatched emergency services if they needed it, trauma care would probably improve. And I think there is that kind of holy grail outside, we were still not quite there in the population chronic disease management but if I knew that you were going to have a heart attack in the next six hours and I could send an ambulance to your house and you could be brought in the hospital and we could prevent that heart attack before it happened, that’s probably a holy grail type scenario. I don’t think we’re five years away from that and I think we’re probably more than ten but I don’t think that 20 years from now that that’s really an on reasonable type thing for us to be thinking about achieving.

Sanjog: Privacy, Security, Governance, Compliance, in healthcare and these items go hand in hand. And when you look at any technology which expands the data flow outside often organizations boundary or even within it, it could raise concern and it has caused problems in the past. How are you battling that?

John: So, security is definitely a concern. Security and privacy are going to be on balance with patient’s health just the way that security and freedom are in balance right now on a national level. We’ve been battling that by being ultra conservative. So the devices that our patients get are locked down single use devices encrypted, sending encrypted packets and information but it means that we have to send a dedicated device to the patient’s house, it means that they can’t just use their iPhone or use the blood pressure cuff, they got from the pharmacy that they have to use this packet of stuff that we send them. That increases the cost and limits the availability and makes us being more selective on who we’re dealing with and who we’re working with. So it is secure, the privacy is protected but it is restricting the ability to deploy the technology. And I think we’re going to have to work through that balance as more applications become available, more sensors can be connected to mobile devices and things become cheaper and cheaper and people start monitoring their stuff at home and connecting it to their phone. And then wanting to share it with their care team. And that’s going to cause privacy and security concerns and those apps are going to be more or less secure and depending on what the terms of conditions were when you download the application, you may have volunteered to share all your information that you didn’t really need to.

Sanjog: Let’s take a quick break listeners, we will be right back. And while we’re talking about this privacy and security, and of course we have to adhere to them. There will always be this sense of paranoia or it is a fear of turning into paranoia or just a concern. But you are essentially trying to hedge your bets, are you allowed to hedge your bets by selectively implementing things related to IoT which will allow you to eat the cake and have it too. What would that look like and in what degree, with what degree of caution we should move forward so that to be are not losing our shirt in favor of doing technology innovation and improving health care? Please stay tune listeners, we will be right back.

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Sanjog: Welcome back. So, whether it’s a concern or a paranoia in any of those cases, it has the potential to undermine what you could otherwise achieve leveraging IoT for health care. What is being done to allay those fears and concerns so that we are not getting paralyzed?

John: Yeah. Unfortunately, I don’t think there’s going to a lot done to allay those fears and when the headlines are coming out that 60%, 70% of patients have had a breach after the anthem breach last year. Fears are really there and the government hack where they were able to get employment information from the government servers. It increased the level of paranoia. People have a lot of trust in our financial system. We used lots of credit cards, we used tap and go technology. Most people don’t just carry cash so that their purchases can be tracked. That information is resold and tracked and we’ve had major breaches with Target and Home Depot. But people still use their credit cards and there’s not the same sense of concern that people have when they’re talking about their health data. People are much more concerned about their blood pressure tracing and their glucose tracing, then they are about swiping their credit card. I haven’t completely understood all of that. I think there’s a lot of history with regard to biased against people of both conditions in the past in the US. There are still definite biased in place. On the health care provider side, I think I’ve had a lot of those biased trained out of that, had lots of training that those are ethical and we’re very aware of them but outside there’s very much concern about what is going to be.

And I actually just read an article advising people to not get genetic testing because there’s no legislation that says life insurance can’t use that genetic testing against them. Pointing out that the rules about– the rules against delivering coverage based upon a predetermined condition only apply the health insurance, they don’t buy the disability insurance, they don’t apply to life insurance. So that if you get a genetic test done, that shows you’re genetically predisposed to cancer. Yeah, your health insurance company can’t use that against you but your disability insurance company or your life insurance company could. So I think there’s a lot of concern that people have that valid but there’s just a big unknown. And the unknown is the scariest. Well, I don’t know what’s going to happen if my medical record actually breaches, what’s going to happen if I have my blood pressure tracing hacked, what does that mean? And what are some of the going to do with that? And there’s been some scary things with people proving that they can hack into IV pumps. They haven’t really done anything, we’re not sure what people are going to do if they hack into an IV pump. But there definitely is concern that they could do something and that something is ill defined and we’re very scared of what that ill defined piece is. And I don’t think we’re doing enough to educate patients about what the real risk are versus the real benefits and pushing to them that in many aspects at least the my medical opinion, the health benefits from this type of technology, greatly outweigh the potential privacy issues that could come from it. If we can help you control your diabetes and you don’t need to be on dialysis for ten years. That seems very worth the potential of breaching your glucometer information to me.

Sanjog: If you were to talk about the way the government is coming to support what you’re trying to do internally at an organizational level, what is happening at that level, what’s happening at the macro level? Because we did say that there are problems.

John: Oh definitely. From a state level, I feel like Mississippi has a ton of support. Mississippi is fully aware that from a chronic disease population health level, we are last or next in last in the nation. And we need to be extremely proactive about treating our patients with diabetes, treating our patients of heart failure, improving our detection of cancer and getting out to our rural population. The state legislature have been extremely supportive. I would say the federal legislature has not been as supportive. And of course, the federal level your engine– across healthy states and non-healthy states. And the motivations are different, the amount that private insurance and private companies are helping, the infrastructure is different but we haven’t seen a lot of movement on the national level at the– ONC level, the legislative level, the CMS level of really making delivery of care at home using the Internet of Things, is something that is a mantra that they’re going to push forward to bend that cost curve.

I think they’re looking at improving acute care has been in the cost curve. They’re setting up ACOs, Accountable Care Organization to to try to encourage systems to make these changes but they’re not dictating it or directing it as a way that we need to head. I think we have enough information now that they really should be more of the directionality towards this that we know that we can provide better care meeting patients where they live. We know that intuitively but now we have the technology and some research to support it and I think that’s the way we’re going to bend the cost curve. But the legislature the government level has not necessarily come to that same conclusion that they’re definitely not driving it. Hard to get people to do it.

Sanjog: When you’re looking at the culture within the organization which is supposed to fundamentally shift when you’re going to try to do things outside of the organizational boundaries. And you would like them to acquire skills which are truly, not natural to them because many health care workers are tenured. What are you doing to do take care of that part?

John: Yes. I tell a lot of people when they ask me why I keep working in Mississippi because there’s a bit of a bias against Mississippi. But the reason I keep working in Mississippi that I’ve never been with a medical group that’s more on mission, is more committed to their patients and to the health of our patients than the group I’m working with now. We have a really easy time saying, this looks like a good direction and these are skills that you’re going to need to learn. We implemented our electronic health record in one day across 1500 providers and 8000 nurses. And had this huge big bang go live and had great results. So they’re very willing to change the benefit of the patient. So we’ve had a lot of luck using Telehealth, having them change their care models to somebody else doing remote blood pressure, someone else doing assessments and providing oversight and trying to get that model into the home. I think we’re ahead of the curve from a lot of places, we’re also very overwhelmed with patients, we have more ambulatory patients than we can care for, with the number of providers we have. We have more patients coming to the hospital than, we have room to take care of. So we’re very willing to get their care in their home and keep them out of our acute settings. Because we have enough work and volume in the acute settings. So, we don’t have any for versed motivation to keep them coming to us.

Sanjog: And one final message from you for any fellow health information officers who are listening to this or may get their hands to this podcast. What’s your message to them if they are going to go on this IoT journey and we know things are not perfect yet but they still– what can they do, new and different or more to get the most value out of IoT.

John: So I would say that they should start identifying their partners. They should definitely jump in and figure out the direction they want to head. And then pick their low hanging fruit because there is going to be a low hanging fruit whether it’s, they’re diabetic population or they’re heart failure population or they’re medically complex population. It’s going to be really easy to identify a cohort of patients that would benefit from extra attention, especially attention in their home. And just get started with a reasonable size pilot and learn the lessons that you’re going to have to learn as an organization to build and be ready for this expansion because I think the external drive to expand the type of care is going to come in the next two to five years.

Sanjog: Thank you so much John for sharing your insights on how IoT, can improve health care.

John: I appreciate the opportunity to be on the show, Sanjog.

Sanjog: Thank you so much again. And listeners, I would like to invite you to join us on Twitter and follow and contribute towards our discussion on LinkedIn and subscribe to our newsletters and podcast. We have a brand new website, enjoy looking at it, give us feedback so that we can keep growing and improving. Thank you so much again for listening.

Will IoT Improve Healthcare?

Contributors

Dr. John Showalter, Chief Health Information Officer, University of Mississippi Medical Center

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