By Sreedhar Kajeepeta
In its jobs report titled Preparing the Workers of Today for the Jobs of Tomorrow, the President’s Council of Economic Advisers (CEA) forecasted in mid-2009 that, at an aggregate level, the economy of 2016 would resemble that of 2008 and the healthcare industry would be the largest source of job growth. (See Fig. 1.) The U.S. Bureau of Labor Statistics further supports this forecast with its updated Occupational Employment Projections report, which predicts a 48 percent growth in jobs related to healthcare support—including IT—compared to a 35 percent growth in healthcare practice and a 12 percent growth in other occupations for the 2000 to 2016 period. (See Fig. 2.)
As for the sheer size of the healthcare industry, a report on digital healthcare from the Insight Research Corp. puts the number at $2.3 trillion to represent the ecosystem of providers, payers, and pharmaceuticals in the U.S. alone. The global number is $4.5 trillion. The organization predicts that the industry will grow to a size of $4.1 trillion in the U.S. by 2016, at the current growth rate of 6.9 percent per year.
It is estimated that these numbers will take healthcare from being 15 percent of gross domestic product (GDP) to 20 percent of GDP. At the current level of 15 percent, the U.S. has the most expensive healthcare system among the industrialized nations, according to a report by the Congressional Budget Office.
In the coming years, what will be asked of us is not just direct support alone for this phenomenal growth in the industry; digital healthcare will also be expected to be the enabler of improved care and reduced costs. That’s a big responsibility as well as a great opportunity. If we split digital healthcare into IT—or applications, and telecom—or infrastructure, the growth projections are: Healthcare IT (HIT) would grow from $30 billion in 2008 to $38 billion in 2013, according to Gartner, at a compound annual growth rate (CAGR) of close to 4.9 percent; and telecom services for healthcare will grow from $7.5 billion to $11.8 billion at a CAGR of 8.4 percent during the same period, according to Insight.
So, how are these massive projections expected to translate into innovations in the business of modern healthcare, and how will they in turn drive changes in IT? Let us look at these two aspects of the anticipated growth.
Business of Healthcare
The predominant business transformation patterns emerging in the industry are the shifts toward outpatient and interdisciplinary care. These are not replacement solutions but are rather complementary in nature and could herald a new future for healthcare—one that is more patient-centric and cost-effective. Based on the nature of an ailment, a balanced use of these techniques together with traditional forms of care delivery could result in a truly socially responsible practice of medicine. Infrastructural and technological support for outpatient and interdisciplinary care is sorely lacking at a majority of healthcare facilities today and hence, these trends are also expected to benefit more from the proposed new investments.
Although some critics deride it as an extension of the fast-food syndrome, outpatient care is and will be on the rise. It is sought after by payers and patients alike for the obvious reasons of cost reduction and expediency of treatment and by providers as an avenue of growth. It is expected that outpatient services will grow by 17 percent over the next 10 years as opposed to the overall growth of 10 percent for all services from medical facilities.
Although technically an inpatient service, short-stay—fewer than two days—care is expected to grow by 173 percent in the next 10 years. This agile practice of care delivery will also place greater emphasis on: a wider adoption of various forms of diagnostic imaging, such as positron emission tomography, computed tomography, and magnetic resonance imaging; minimally invasive treatment procedures—with the use of robotics and image-guided surgery; and process improvements, such as clinical adjacency and remote patient monitoring.
The fragmented approach of multidisciplinary care in which we meet different caregivers in a sequence has been the norm so far, if not for any other reason than for convenience and, to some degree, accountability. Although it may be more practical from a billing standpoint, it is not the most effective form of treating a patient with an acute problem.
Interdisciplinary care, on the other hand, represents a significant philosophical and logistical shift. It won’t be easy to implement, but it is highly necessary for improving timeliness and effectiveness of care. It ensures that, at the granularity of a consultation, all related caregivers agree on the best course of action for treatment. As a speedier and more well-thought-out form of care delivery, it continues to evolve, reaching out to a wider ecosystem of caregivers while going beyond the traditional list of practitioners, such as primary physicians, specialists, and nurses.
The new workforce for these shifts in care would include scientists, such as molecular pathologists, genetic pharmacologists, and super radiologists, each with their own unique and complementary roles to play. As advances in genetics and related curative therapies continue the fight against such debilitating illnesses as cancer, diabetes, Lou Gehrig’s decease, and coronary thrombosis, they need to be backed up by process innovations such as interdisciplinary care to continue to close the gap between scientific innovations and care delivery.
Besides these big-process transformations, there are many tactical items on the business agenda in which the upcoming growth would be reflected. These are priorities that are time-bound—by 2014—and are mandated in some fashion by the Office of the National Coordinator (ONC) for HIT.
The American Recovery and Reinvestment Act (ARRA) of 2009 further advances the cause of these initiatives by providing incentives to the tune of $20 billion for HIT alone. They are aimed at promoting widespread implementations of electronic medical records (EMRs) and enabling interoperability and accessibility—through health information exchanges (HIEs)—of those records to create composite electronic health records (EHRs) to enhance quality and accuracy of treatment.
Through certification of "meaningful use," qualified providers started receiving incentive payments from 2011 onward through Medicare or Medicaid. In essence, meaningful use requires that the EHR systems are operational and are being used to collect and share patient information to support improved clinical care.
Meaningful use criteria for physicians are broader than those for hospitals. Physicians should be compliant with e-prescribing, electronic reporting of clinical quality data, and connectivity of EHRs with electronic exchange of health information. Hospitals must comply with all of that except e-prescribing.
Other priorities include systems such as computerized physician order entry, health information portals, social networking sites, and various aspects of telemedicine, such as remote patient care. Another priority is a new method of encoding, called ICD-10, which is aimed at improving accountability and details of diagnosis to reduce improper prescribing. ICD-10 does it by offering more granular and globally accepted diagnostic codes. ICD-10 compliance must be achieved by October 1, 2013.
Technology in Healthcare
From the above list of business imperatives, it is easy to see where and how technology—both infrastructure and application—should be aligning and stretching to not only support the rate of change in healthcare, but also to influence it.
On the infrastructure side, growth in WAN and LAN—fiber-optic and copper for 10GbE/40GbE and beyond—technologies coupled with their wireless counterparts—4G through WiMAX and LTE—would create the required healthcare enterprise that can always be at service. Broadband connectivity to desktop/handheld computers and to robotics and medical imaging devices at the point of care is perhaps the most justified use case for broadband and wireless connectivity among all applicable industrial situations.
This type of infrastructure would enable transformations such as outpatient and interdisciplinary care by reducing the inherent logistical conflicts involved. Telepresence and the use of radio-frequency identification (RFID) technology would be key requirements for enabling telemedicine and supporting growth in outpatient care. And, as a broader convenience for any type of payment, the near-field communication (NFC)-based mobile payment solutions improve the efficiencies and customer experience of outpatient care.
On the application side, be it through the use of packages from the likes of Cerner, McKesson, Eclipsys, Epic, and others or through custom development, the tactical business priorities listed above can be best supported by deploying them on internal or external private clouds that act as integrated enterprise application platforms. Support for service-oriented architecture (SOA), event-driven architecture (EDA), and real-time ubiquitous data access, or enterprise mobility, have to be the key characteristics of these platforms in order for them to fully support the new business charters. The much-needed, unified, and most current context of the patient, which includes health and scheduling details, can only be delivered through such platforms.
As one of the killer applications of 2012, big data is on everyone’s mind. Healthcare can perhaps be one of the best application areas for this technology, given the market positioning that emphasizes big value and reduced time-to-value cycle. Healthcare has many business scenarios and requirements that could use the help.
Such healthcare applications for big data include: analysis of federated—and of course, anonymized—clinical medical data; medical supply chain and logistics; many aspects of hospital— or provider—management, including infrastructure, staff, and patients; mining of financial medical data that payers can leverage to introduce efficiencies related to quality of care and preventive health; and analysis of genomic data for pharmaceutical companies.
Big data, coupled with SOA, healthcare enterprise applications, and HIE technologies, is a key enabler for supporting the renewed focus on meaningful use, quality of care, and pay-for performance of caregivers.
Social networking is also beginning to show its relevance in healthcare, especially in areas related to knowledge sharing regarding wellness and patient/subscriber communities, and self-service portals. As with any enterprise, payers and providers have a business obligation to be present on social sites to the degree that the nuances/sensitivities of the industry would permit.
Although cloud computing is very compelling for its business case of improved service and lower costs, its adoption for key functions will take time until all concerns related to patient safety are addressed. But the adoption has nevertheless begun with many of the packages being made available in a Software-as-a-Service (SaaS) model.
The SaaS model would promote faster compliance with federal mandates by keeping a centrally maintained copy of the software, which keeps pace with evolving standards, and would enable broader implementation by providing relief from capital expenditure concerns with its pay-as-you-go pricing model. Likewise, the adoption of social networking is in its infancy and is sure to grow beyond the current obligatory activities to mainstream commerce and some aspects of patient care.
When it comes to the high-performance computing (HPC) needs of research and development in healthcare, cloud computing actually becomes more of a necessity. Processor-intensive tasks of biomedical analysis at pharmaceutical companies represent one such scenario. Companies such as Eli Lilly are already leading the way in this area by using the cloud—a 64-node Linux cluster—to make an elastic HPC platform available to its scientists. Healthcare is also beginning to use the cloud for business process as a service (BPaaS) to support claims processing for payers and suites of practice management solutions for small clinics. (See Table 1.)
The economic and business transformations that await the healthcare industry are quite unparalleled in nature. They represent a major obligation for all for us who support the industry. We can meet the financial and service-level goals by leveraging advancements in all areas of IT, including networking—such as broadband, wireless, and mobility—and computing, such as cloud, applications, data, and integration technologies. The industry is hurting and is calling us.
Healthcare IT can play a big role in bringing down the overall costs, but more importantly, in making a significant contribution toward raising the quality of care and improving the measures of wellbeing, such as life expectancy, which currently is one of the lowest among industrial nations.