executive Summary

Introduction—Contextualizing the Chaos

American health care is in a transitional phase, generally “dubbed managed care.” Meanwhile the role of information technology is becoming a key influence, and will be a, if not the, prime catalyst of change in the next 10 years. Health care is waking up to the fact that it’s an information intensive industry which has under-invested in information management, yet the technologies that can help that management are evolving even faster than the changes in health care. The goal of this report is to help you put that technology evolution in context. To do that we’ve grouped technologies, their applications, and some processes that rely on new technologies, in 13 “clusters” that we judge will have a significant impact on health care. In the second half of the report, we assess where these technologies will have greatest impact, and raise some issues for HIO members to consider.

Section One—Technology Clusters

The current information and communications revolution has been and will be driven by technology advances in microprocessors, software tools, memory storage and databases, networking and the Internet, and a host of related technologies. For health care the impact of these advances will translate into 13 clusters over the next ten years.

· Cluster 1: Clinical Information Interfaces A combination of better tools and physicians (and other clinicians) who are more comfortable with computers, and/or economically incentivized to use them, will drive the adoption of the components of the long awaited Electronic Medical Record (EMR). The availability of portable, more user friendly information appliances, and other interfaces into computing systems such as voice recognition, will allow physicians to view both more and more relevant information about their patients, and to input their clinical observations electronically.To help physicians use that technology, and in order for the information to influence decisions at the point of care, there will be greater study of the clinical decision-making process as a whole.

· Cluster 2: Analytics and Outcomes Analysis of clinical and other data sets, in particular trying to analyze the connection between interventions and outcomes, will be a growth industry. The technology applications allowing this will include data-mining, intelligent search engines, 3-D computer visualization, and decision support systems that rely on adaptive learning. In the next few years we’ll see much greater abstracting of clinical data from administrative records. Longer term, better and larger clinical databases, agreement on natural language codification (primarily of physicians’ clinical observations), and on standardized objective measurement of outcomes, will enable better understanding of interventions and outcomes. They’ll also enable better tracking of who—both clinicians and patients—is performing well or badly.

· Cluster 3: Tools, Middleware and Enterprise Infrastructure Health care organizations will begin to take advantage of new software and hardware technologies to change their enterprise-wide processes. The three related forms of technology used will be (a) infrastructure technologies, such as enhanced and higher capacity networks (b) middleware which connects disparate legacy systems, and (c) software, like object-oriented authoring tools and object request brokers which will integrate heterogeneous legacy systems. Because of the flexibility and economies of scale these technologies allow, it will make economic sense for health care organizations to increasingly outsource both their development (i.e. adopt generic solutions), and the management of the networks and systems they allow.

· Cluster 4: Patient, Provider and Plan Management Systems A combination of technologies—like contract administration software, and Web- and phone-based communications and transactions—and processes that use them—like disease management, customer call centers, and multi-provider information exchange—will enable both the automation of current activities and the development of new ones. There’ll be three main types of activity: management of chronic-care; automated administration of provider networks (and creation of new organizations enabled by technology); and more automation of customer services, such as online enrollment.

· Cluster 5: Patient and Consumer Empowerment Technologies Over the next ten years, a convergence of Internet use, more sophisticated interactive voice response (IVR), and TV and video-on-demand will give patients much more information about their health care needs. Patient groups themselves, especially in the cancer, AIDS and depression communities, have been using the Internet to exchange medical information for some time. Plans and providers will “mainstream” this information flow to patients, and begin to integrate it into the wider medical care process.

· Cluster 6: Telemedicine and Collaboration Groupware We don’t believe that any significant proportion of health care will be delivered remotely in the next ten years. Nonetheless, the lowering cost of communication technologies of all types combined with new Medicare funding for telemedicine originating in underserved rural areas will provide (finally!) the push telemedicine needs to get it out of the pilot phase. This will mean growth in video-consults, remote radiology readings, and remote education—the traditional telemedicine applications. But we’ll also see new applications like video and audio links to support emergency workers, and increased collaboration in cyberspace among clinicians separate by time or distance.

· Cluster 7: Transaction Technologies and Standards Over the next ten years virtually every administrative transaction in health care will become electronic, standardized, and often automated. Many transaction types such as materials management and pharmacy claims are close to this point now. Transactions that are currently mostly paper- or phone-based such as physician claims, prescription writing or eligibility verification, will migrate to electronic formats, encouraged by the growing use of standards required by the 1996 HIPAA legislation. The technology to support this automation of administrative transactions—such as networked access to databases via the Web and IVR—will also increasingly allow clinicians to order tests, pharmaceuticals, and supplies, and initiate other clinical processes directly via information systems.

· Cluster 8: Security and Authentication A combination of business need, consumer demands and regulation will drive the adoption of protocols and technology to ensure the security of medical data. Technologies developed mostly for the defense and financial industries, such as data encryption, digital certification, and hardware and software that protect network integrity, will enable health care organizations to meet those requirements. Their challenge will be in implementing the processes that go along with better security without that interrupting their general business activities.

· Cluster 9: Diagnostic Imaging, Analysis and Distribution The last 20 years has seen an explosion of medical imaging technologies. That will continue as new uses are developed for technologies like CT and Ultrasound, and new ways are found to excite atoms to produce better images. The other feature of the next ten years will be the integration of the digitized images with information systems, which will allow both wider distribution of the images, and better analysis and image pattern search technologies. The viewing quality of computer-represented radiological images will dramatically improve which will them help win acceptance with radiologists.

· Cluster 10: Genomics and Bio-Informatics The Human Genome project is part of a major trend enabling advances in genetic diagnostic technology, gene therapy and other related therapies like xeno-transplantation. These genetics-related advances rely on the use of computing power for their investigation and results. They also contribute to databases like Genbank, which will be used widely in drug development. Along with progress in the genetics field, better computing power will stimulate pharmaceutical development in two other ways. Simulation of diseases on computers (rather than in vitro or in vivo) will enable better assessment of the result of drug interventions that should result in more effective clinical trials. Meanwhile new software that enables the recording of clinical observations and results in clinical trials should enable what has been largely a manual process to become automated and dramatically reduce the cost of their administration and the consequent delays in getting drugs through the approval process and onto the market.

· Cluster 11: Communications and Remote Telemetry Moving monitoring technologies, and the telecommunications and networking they need to communicate with remote information systems, into homes and smaller medical facilities will be an area of focus over the next 10 years. There will be an explosion in the number of sensors used in patient monitoring technologies such as blood pressure cuffs, glucose monitors, and immune assay kits. These sensors will have their digital signals integrated into providers’ information systems. Particularly in the remote care of the chronically ill who tend to be high resource users, better patient monitoring will allow analysis of and reaction to abnormal results, or the absence of them. This should ensure that more cases receive appropriate management.

· Cluster 12: Improved Epidemiology Assessment A combination of new initiatives and new applications of technologies are enabling state, national and international agencies to map outbreaks and follow disease trends. This tracking will require a combination and analysis of once disparate information that will be driven by the combination of computer visualization, satellite imaging and sensors, geographic information systems and better data on health care use, health status and outcomes.

· Cluster 13: Medical Device Miniaturization Miniaturization, a major trend in medical technology in the 1980s and 1990s, will increasingly allow sensors to interface between computers and the real world. These systems will store their results—whether images or data—on computing systems and interface directly with them, using technologies such as digital video. The main impact will be seen in two related uses of miniaturized devices: embedded bio-sensors that will be consistently monitored by remote information systems; and miniaturized surgical devices that can be introduced to the body temporarily without any surgical procedure.

Linking the Clusters: There are links between all the clusters, not only in the underlying technologies but also in the actual way that they are used and interrelate. Figure 1 shows some of the closer links between the clusters.

Figure 1—Cluster Links

Source: IFTF

Section Two—Rating the Clusters for Impact

Having identified the technology clusters and some of the links between them, we looked at the impact of the clusters on six different areas within the broad industry we call health care: Patient care; Physicians and clinicians; Care administration (for plans and payers); Medical research; Health care suppliers, including Rx research; Public policy; and “Wall Street” investment dollars. After that we determined which of the specific technologies that comprise the clusters would be the most important for those areas.

The overall impact of the clusters. Some clusters, such as patient, plan and provider management systems, will matter to most areas. Others will impact one area dramatically, like genomics and bio-informatics impacting medical suppliers and pharmaceutical research. We ranked Cluster 4: Patient, plan and provider management systems, Cluster 2: Analytics and Outcomes, and Cluster 10: Genomics and bio-informatics, as having the most impact overall. We judged a second group of clusters to have almost as significant an impact. Those are Cluster 1: Clinical information interfaces, Cluster 5: Patient and consumer empowerment technologies, and Cluster 12: Communications and remote telemetry.

The impact of specific technologies. Although it’s the combination of the technology clusters that we’ve described that will bring the greatest change to health care, certain individual technologies that are part of one or more clusters will have a significant impact in several areas of health care. We judged the most important individual cluster component “technologies” to be: Outcomes and quality analysis, including data mining and on-line analytical processing (OLAP) technologies; Clinical trial automation; Physician education systems; Remote monitoring of patients; Patient empowerment and information technologies; and Organization of health care delivery “processes.”

The ones to watch? What the most important and impactful clusters and technologies have in common is a focus on patients—and on measuring, monitoring, and trying to explain the results of the care they receive. It also means a key role for technologies designed to influence the outcomes of patients’ behavior and their interactions with the system. Although there will be tremendous advances in health care processes across the board driven by all of the technologies we’ve identified, in general we expect more impact from those patient based technologies relative to that of provider systems technologies.

Conclusion—Some Pertinent Issues

In this exercise issues come up that don’t have any clear place in a synthesis or rating. Several of these are worth some attention for anyone considering the impact of technology on health care’s future.

· Technologies for Patient Management rather than Providers A slow trend to decentralized patient care management will mean that patient empowerment and monitoring technologies will increase in importance relative to provider-centered technologies. The key question is whether the system as a whole is able to use those technologies to create new ways of managing the chronically ill. Expect much experimentation in this arena, and let’s hope that some of it is successful before the mass of the baby boomers hit Medicare in the years after 2010.

· The Security, Privacy and Genetics Conundrum There are a couple of uncertainties about how the privacy and security issue will impact health care. One is whether legislation will seriously hinder sharing of information between organizations and hence development of new forms of care management, or just be a challenge in terms of systems implementation. The other is how big the impact of the privacy implications of genetics research (and any resulting legislation) will be on the delivery and insurance markets. That could range from an inconvenience to completely changing the way the insurance market operates.

· A Question on the Cost of Remote Monitoring We’re firm believers that sensors will have a big impact, but that’s somewhat dependent on their cost. If the FDA approval process means that they stay relatively expensive, their adoption could be delayed. But the key issue is whether remote monitoring enables direct replacement of labor costs, especially whether it is cost-effective to spend the money for the technology needed to monitor the high-risk chronically ill.

· The “Network” Between Technologies and Business Processes In the future health care organizations cannot allow “clusters” of technology to mean “islands” of technology. Technology strategists will have to integrate technologies while the business strategy of their organizations will often be moving towards contract networks, virtual organizations, and “atomization.”

· The Ongoing Circular Relationship Between Technology and Health System Change These technologies are emerging fast whether health care is ready or not. Their rate of adoption will depend on whether the financial incentives in the system support the integration or the continued fragmentation of patient care. How fast those incentives change depends largely on how Medicare rewards providers. But every player in health care will need to have a response to the technology change the clusters are bringing.