INTO THE CLOUD: The Near Future of Healthcare Information Technology

Carl Spitzer, MD

Many would argue that prognosticating is a fool’s game. Most things that happen are beyond our control or anticipation, so why bother? While this lack of control may be true for many endeavors with indeterminate time horizons, we can anticipate the near future--say the next three to five years--in healthcare information technology. In turn, our anticipation can help us prepare to meet that future. By looking to what’s just over the next hill, we can invest our precious time and money wisely, and continue to focus our attention where it’s most needed: on taking care of patients.

What follows are some of the big trends emerging in healthcare information technology. The list is by no means exhaustive, but it does represent a few key areas that I believe will see considerable movement in the next few years.

Analytics

With federal stimulus money driving adoption of Electronic Medical Records (EMRs) at an unprecedented pace, vast quantities of patients’ clinical data are being captured electronically. But what of it? All that effort learning new ways of documenting, not to mention the money spent--surely it’s not all about making doctors’ notoriously difficult-to-read notes more legible, right? Right. All that data locked up in EMRs has tremendous potential.

The clinical data in EMRs represents our collective wisdom and experience in treating patients, over long periods of time. Analyzing that data allows us to ferret out the treatments that are most effective, clinically and economically, and move away from those that are least effective. The tools that crunch these vast quantities of data fall under the heading of “analytics.” Depending on where the analytic engine is focused, we can determine best practices for given conditions over large segments of the population, or narrow the lens to provide data about our particular patients.

Once those data are crunched, the resultant knowledge needs to be presented in a usable form. Arguably, presenting the information at the point of care--that is, at the moment we’re making a decision about how we’re going to treat a patient--offers the greatest opportunity to impact our practice positively. In the next few years, look for tools that integrate clinical decision support into our EMRs.

Once we’ve made a diagnosis of pneumonia or congestive heart failure, to take just two examples, our EMR will guide us (silently, gently, and with minimal intrusion, I hope) to prescribe the most clinically- and cost-effective treatment for our patient, taking into account their demographics, coexisting conditions, other medications, allergies, and insurance formulary. And just slightly further down the road, an individual’s specific genome will be incorporated into their EMR, so as our knowledge of the interplay between genetics and therapeutics matures, that too will be used to guide treatment.

Health Information Exchanges

Obviously, if our patients’ healthcare data remain locked in our office EMR, we won’t be able to contribute to the population-based knowledge that analytics provides, nor to provide our colleagues with the data they need to treat our shared patients. In order to unlock the full potential of that data, it needs to be shared. Such sharing occurs through the mechanism of a health information exchange (HIE).

Think of an HIE as the network of dendrites and synapses that tie the axons of our EMRs together. HIEs can be organized at multiple levels: within networks of providers as might be found within an Accountable Care Organization, or across larger regional (and presumably more loosely affiliated) networks of providers. HIEs might even be organized hierarchically, with a local or “private” HIE tying into larger “public” HIEs to share epidemiologic, syndromic and population-based research data.

HIEs provide tools for controlling access to patient data depending on patient or provider preference as well as privacy regulations. The correct information is routed to where it needs to go, and kept away from unauthorized or prying eyes. De-identified patient data can be shared with agencies that provide disease surveillance, or that do larger population-based studies of treatments. Thus, HIEs can provide for data ubiquity as well as access control.

Mobility

Chances are good that you’re carrying a smartphone in your pocket. These tiny technological powerhouses were the stuff of science fiction just a few decades ago. And, I’ll argue, they are one of the keys to the near-term technological future of healthcare. Smartphones provide anytime/anywhere access to our now ubiquitously accessible patient data, make us universally accessible (where’s the off button on this thing?), and provide more computational power in the palm of our hands than would fit in a building 30 years ago.

Smartphones make pagers obsolete with access to HIPAA-compliant text messages and voicemail, and they provide real-time access to high-resolution radiology images. Patients interact with apps that monitor their progress in managing chronic diseases and provide us early alerts when things are heading south (see “Telemedicine” and “Body Area Networks” below). In the near future, look for vendors to be releasing full-featured mobile versions of their EMRs, thus untethering the practice of medicine from the office forever.

Cloud Computing

We hear much talk of “the cloud” these days. But what exactly does it signify? Essentially, cloud computing is nothing more than computing power that is moved away from our desktop computers to distant data centers to which we are connected through a network, typically the Internet. These data centers provide a level of abstraction to clinical computing that frees us from having to think about maintaining our own servers and computing infrastructure, and particularly from having to worry about the security implications of that infrastructure.

Hardly a day goes by where I don’t read of another significant security breach that results in thousands of patients’ Protected Health Information being released to the general public in violation of HIPAA. Where the conventional wisdom to date has been that we don’t want our patients’ private data residing in anonymous “server farms” for fear of just such a breach, many in the field are coming to realize that the personnel, expertise and infrastructure required to secure our patients’ data presents such a large onus that it is actually cost-effective and more secure to offload these tasks to specialists who can provide these services--in the cloud. Look for more of these cloud-based hosting services in the near future of health information technology.

Body Area Networks

Last May the FCC approved allocation of radio spectrum dedicated to wireless medical monitoring devices. This development dovetails with the trend toward embedding low-cost, high-sensitivity sensors in just about everything. Many smartphones, for example, already include multiple sensors, such as accelerometers, GPS receivers and cameras.

When sensors are implanted in or attached to people, the resulting “body area networks” will transmit multiple streams of data simultaneously, including EKG, EEG, vital signs, blood glucose, other blood chemistries, and fall detectors. Many other sensors and data types are doubtless just around the corner. Body area networks will spring up in healthcare facilities, of course, but will also be present in patients’ homes. This deluge of home sensor information will travel via the Internet and will require systems to store, index, analyze and abstract all that data. Look for developments in cloud infrastructure to act as an intermediary between clinicians and this next wave of patient information.

Telemedicine

Telemedicine is a term that encompasses email, text, voice and video interactions with healthcare providers. It’s being promulgated as a solution for rural areas, where access to specialty care is restricted. It’s also being proposed as one way to address the growing shortage of primary care providers.

My prediction is that the next few years will see a growth of telemedicine services not just for rural populations, but also for urban and suburban patients who will come to value the convenience of a doctor’s visit without having to leave home. Coupled with ubiquitous sensors and body area networks, the need to visit the office will diminish. With new reimbursement models for provision of remote services, offering telemedicine appointments can reduce office overhead, increase patient satisfaction and offer a way for physicians in competitive markets to differentiate themselves.

Patient-centric Records

With health records moving from the silos of office-based paper records into a cloud-based virtual world, our patients will expect to have access to that stream. We’ll see greater adoption of personal health records (PHRs), where patients can view lab and radiology reports, problem and medication lists, and even visit notes (if their providers allow it). Portals that provide access to these PHRs will allow patients to request prescription refills and schedule office or telemedicine visits.

Look to some form of patient-centric record becoming the true longitudinal health record--that is, a record of a patient’s medical history over long stretches of time and space. Where these records actually live and who controls “ownership” of them are among the issues that need to be worked out, but there is no doubt that we will soon see increasing autonomy and individual control of PHRs.

Usability

The federal HITECH Act providing incentives for adopting EMRs stipulates that end users hit targets for “meaningful use” (MU) of these tools. Qualifying for funds requires that we meet specific MU functionality measures in a number of clearly delineated areas. Some of these areas are mandatory, but others are selected from a menu. For the last few years, vendors have been scrambling to provide the MU target features in their EMRs. Further complicating matters, Meaningful Use Stage 2 will soon go into effect, requiring additional functionality. Needless to say, some of this functionality has been built with usability of the features given short shrift.

Usability is a commodity that’s hard to define--we know when a particular tool is usable when our consciousness of interacting with it seems to disappear. The tool just does what it’s supposed to do, and you don’t need elaborate training or a manual to work it. Similarly, we know when something has poor usability: it crashes frequently, requires us to memorize complex steps to get our work done, or makes us adapt to the tool, rather than vice versa. “Death by a thousand clicks,” as one of my colleagues refers to it--we know it all too well.

My most profound hope for the future of health information technology is what I’m going to conclude with as a prediction: that usability will become the key differentiating feature that stratifies the marketplace and crowns the eventual winners. Vendors who can build the tools that seem to disappear in our hands and allow us to take care of patients seamlessly will garner loyal followers by the tens of thousands. EMR makers: Are you up to the challenge? I’m predicting that you are. Don’t let us down.

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Dr. Spitzer is an emergency physician and chief medical informatics officer at Marin General Hospital.

Email: spitzec@maringeneral.org