Shared Care Solutions
This week I am talking to Dr Chris Hobson, Chief Medical Officer, Orion Health (@OrionHealth), a population health and precision medicine company focused on data to support the delivery of the best possible care. Chris started out working in hospitals medicine for 6 years and spent time in primary care in New Zealand before starting work at South Auckland health where he got involved in delivering integrated healthcare and creating the necessary IT infrastructure. They developed an integrated software record that was very successful for shared care and population health management giving Chris an opportunity to focus on the technology and he transitioned into OrionHealth
In a recent post on HealthIT Answers Chris offered 5 essential questions clinicians need to ask about precision medicine, which is the medicine we all want but it has been challenging to deliver and we discuss personalized medicine and the interplay with population health. As we heard my interview Moving to the Patient Home getting personalized care starts with the capture of local individual data that drives both the insights as well as the personalization of treatment. But how do we link all the data elements that go far beyond the genomic data and the importance of the share care record?
We talk about different health systems from around the world from Canada, New Zealand, the United Kingdom and how these differences have made information sharing easier and what we can learn from them. As Chris points out
“you get what you incentivize and in the US we have a Fee for Service System”
However the good news is the US Healthcare systems is starting to move towards Accountable Care Organizations and a shared care model that drives better health all round.
Listen in to hear our discussion on the importance of Health Infomration Exchanges, how solving interoperability requires incremental steps that start with basic standards that work but are imperfect (remember “don’t let perfection stand in the way of progress”). You can hear Chris talk about the journey of developing successful shared records and the positive impact he expects to see from the most recent standard FHIR and how the recent regulatory changes on information blocking will bring about some welcome positive changes to healthcare, and what he learnt from New Zealand that only had 7 EHR vendors that to chose from.
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
Today I’m delighted to be joined by Dr. Chris Hobson. He is the chief medical officer for Orion health. Chris, thanks for joining me today. Thank you so much for having me, my neck, it’s a real pleasure to be here. So as I do, always, I think it’s important to get a little bit of background, so you have a hint of an accident, I can certainly tell at least the general area that’s from, but it brings a little bit of interesting experience your role. Tell us a little bit about your background and how you arrived at this role and what you’re doing.
Chris Hobson
And, uh, Ryan, if you weren’t sure, so the accent is from New Zealand. I’ve been in North America for 20 years, but the accent doesn’t, doesn’t drop, I’ll just listen to me.My kids say I’m North American. So that sounds
Nick van Terheyden
like a lot of common.
Chris Hobson
You can’t be James as a parent because you don’t sound like him. So, coming from New Zealand, you know, it’s a small country on the other side of the world. Known I think for innovation and for some things and you know, the current way that we’ve handled the covid 19 pandemic has really kind of raised the credibility of New Zealand and some of these ways. But my own personal journey was I sort of six years in hospital medicine 10 years in primary care. And it’s kind of I knew I was obsessed with it and computers trying to find a way and I kind of stumbled on a job at South Auckland health in New Zealand and they said well, what we want is to do integrated care and you can be responsible for the it and reaching between the hospital and the community. So we put together a lot of different software Where solutions but also business models for how we could work better with the community. The basic problem was there was a high rate of meningitis that was seen as in the surrounding area that’s really higher if meningitis. And then we realized that it was actually in the poor part of town. And it was parts that are traditionally where the indigenous First Nations populations were living, Pacific Islanders and Maori. And so we kind of got into this whole thing where the hospital was being overloaded and struggling to meet the needs of the community in which it served. So from there, you know, the software that we developed was very successful, and things like disease management, and also this concept of an integrated record. The idea we had at the time was the patient seen in the community, or seen in the hospital, the provider who sees the patient would know all about them. So we inadvertently kind of stumbled from the needs of a poor, overcrowded part of town into this whole place of integration and interoperability. So joined a Ryan and done various different roles. Currently, one of the two pieces to my role is, one is the clinical care. So are we meeting the needs of clinicians? What’s the direction, but the other part of my role is, is what we call thought leadership. So try to see what’s happening in the next year or two. I try, I try not to look out, you know, five years, I think, anyway, it’s relatively easy to look ahead five years, and there’s going to be quantum computing and blah, blah, blah, to try to look ahead one or two years. For the US market, which is our biggest market, we’ve got really COVID-19, the equity issues are really big as well, so and the two are entangled. So there’s, those are the kind of the business drivers for our clients. But also, CMS and o and C have these new rules that they want, they want fire API’s. And so we’ve also got to meet the compliance things. So it gives us a full plate of Thanks for 21 I think for our clients even more. So if I’m, you know, population health manager or an IT manager, I’m trying to understand what’s going on. And I’ve got to react to all these urgent needs with COVID. And yet, I’ve also got to meet new rules and regulations.
Nick van Terheyden
So it’s really interesting, you talk about project predictions. And you know, other things I would say about that, the further out you go, the less likely you are to be held accountable for this. So I’m going to predict 50 years from now we are xy and z. Now, there are some people that are good at that. But, you know, I think it’s right. We’re sort of closer in and, obviously, you know, your capacity to see into that clinical experience, I think is essential. You know, one of the things that really strikes me about this is the sort of the balance between personal healthcare, which is really a, I want to say a rising activity, a rising focus, people talk about personalized healthcare, I know, I always say I want personalized medicine, I don’t want the, you know, run of the mill for the 1000s or millions I want just beneath me.
Chris Hobson
But how does that interact with the sort of population base statistics? And how do you see all of that into play? A very interesting topic. So absolutely as personalized medicine, we’re going down, you’re going down a path of genomic for instance, to understand better exactly what each individual’s susceptibility to disease, even at a less advanced kind of level, to really personalize the care of a patient, you need to know all about them, and then come up with a plan that’s unique to their needs. Where we’ve kind of got to on that space is the ability to pull more and more types of data. So, for instance, I listened with great interest to your interview with Medtronic, Chief Medical Officer and cardiac rhythms. So this personalized medicine again, in a sense, because patients at home and you can get this data which previously you couldn’t get. So on the personalized space where we’ve got to is we’ve got the clinical data that claims data, the patient generated data, and I think that’s very important the patient, what their perceptions and what their ideas and needs are. The social data as much as we can get it which has a big influence behavior and the dynomax and Personalized Medicine is often framed as genomic medicine very similar. From our perspective, it’s more knowing all about that patient so that you can deliver the best care for that individual patient. So, population level is obviously of interest to people who write the checks for software, as well as healthcare, transformation, all these other things. So, if I’m a payer in the US, or a Minister of Health, you know, in the UK, I want to see, I will need to be able to show it right as no surprise today, I need to have to show somehow that COVID-19 is getting better. But even before COVID, I need to show that in the UK, especially in New Zealand, wait times are coming down, or I need to show that you know, the mortality from from cancer is improving. So the population level, you need to know all about what’s happening in that population. And then you need to know whether the interventions that you’re putting in place are actually working. So we kind of hit on this shared care record, or health information exchange in the US. In the UK, we have a number of sites in Scotland and in England, and in Ireland, that use the shared care record. So that various counties in Scotland, all of the health care activity that happens in that county is all in one place. And then across Scotland, we have our deployments in multiple counties. And you can be in one county and look at the activity and the other counties. So in the US, it’s more things statewide. So show me Give me all of the data in New Mexico. So recently, kind of worked in the state of New Mexico, partly for the Department of Health, partly for the providers, put together a complete solution. So I can treat my individual patient really well. But as the Department of Health, I can also see what’s happening, I can see where the COVID cases are happening in New Mexico to then I can drag resources appropriately to today.
Nick van Terheyden
So as you think about that sort of interplay between the two, you know, you talk a lot about health exchanges, and, you know, the shared care model. What strikes me about the challenge there is, interoperability seems it’s a never ending problem. I mean, it’s been a problem. In soccer. Remember, it was a problem when we had paper notes, because we couldn’t read anybody else’s writing. Now, it’s a digital problem. How do we go about solving that?
Chris Hobson
Well, I think it’s incremental to, you know, not to be to singing your praises. I mean, the truth is somewhere in between, I think, the standard HL seven v two message, which gives you a lab result, you know, electronically, that’s been around since early 1990s. So one of my experiences in primary care in New Zealand was I had, so let’s say 1995, I had a full service EMR. I had automatic electronic lab results and radiology results. By 2000. I wasn’t, it was I was involved in installing, but you know, electronic documents, discharge letters and things like that. So to some extent, we did have, we do have, and we did have interoperability, for instance, in New Zealand. And I know, a number of other countries that Denmark and certainly a lot of the UK, actually had achieved a lot in interoperability terms, you know, fairly early on in the piece. Over time, what’s happened is h o seven, decided, and rightly, I think, but was tricky at the time, that the v2, the simple messages weren’t going to meet the full needs of healthcare. So they wanted to have a better XML based, fuller description of the patient to exchange. And so in the US, we’ve done a lot with what the CCDA is the continuity of care document, and now with fire. So, fire, again, is an excellent, fundamentally it’s an XML specification for healthcare. And we’ve looked been looking at it for probably four or five years now. I can tell you that it is a very good standard. I think that’s first and foremost. The reality is that the five vision for is a very good standard for describing health care. And I think we have, I really think we just have to say, okay, quit all of us. This shouldn’t be this so shall it be that let’s let’s go with the fire. I have, you know, round the very edges have found that odd thing where it doesn’t quite sounds like still needs a bit of work. But that’s all it’s it’s a really good standard switch brings us to When will we achieve it. So 2021 is going to be very interesting because CMS to know and see have these new rules and they are expecting and then demanding that health organizations will be able to exchange data using a fire standard. Now, the really interesting from a policy perspective in the US is going to be the information locking principle. So the issue is, over the years, one of the things that’s held interoperability back to us in terms of actually achieving it, in the US has been that as a role hospitals and health systems are all competing. So some of our clients were able to convince providers and their state, they would go around the mall and say, Okay, let’s agree not to compete on the data. So even going back 1015 years, for instance, in the state of Maine, they were able to convince all of the providers in Maine, not to compete on the data. So share the data, we can compete on quality, and, you know, waiting times and all those good things, but we’ll agree to share data. Unfortunately, across the entire population in the US, there has been still a lot of competitive pressures, which make people reluctant to share data. So hence the information blocking rules, which will come into force this year. And it’s going to be very interesting. I think everyone’s really watching that. It now means as a provider, you can’t retreat and say, Well, this is HIPAA protected. So I’m not going to tell you the data about a patient because it’s you know, everyone retreats to privacy. That’s the theory. In the reality, of course, devils in the detail and exactly how well we find people’s ability to steer between maintaining the privacy of health data, which is also such a huge topic. And then the ability to share it. We’ve got the fire API’s. We’ve got the information blocking rules. So 2021 is going to be the year to watch for sure.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist and today I’m talking to Dr. Chris Thompson, he is the chief medical officer for Orion health, we were just talking about inflammation blocking which hot topic today. And Chris was just explaining that, you know, new regulations that an enacted and it sort of suggests that maybe part of the reason that you’ve seen success in some of these other countries is that we don’t have information blocking, because that’s not about technical problems. It’s about economic issues that drove some of that. So I wonder if, you know, the differences in these systems, has helped some of the progress that I guess we’ve seen in some of these other countries and with, you know, the other clients. And I know you and I share a little bit of heritage in terms of different systems. And I’m not here to sort of suggest, you know, we should all move to this. But you’ve obviously got personal experience for other systems. Any thoughts on that and the impact and where we might see some change, perhaps driven by COVID? Maybe?
Chris Hobson
Yeah, so I think, first and foremost, upfront, it is easier to do things like interoperability and some of these things, it is easy to do those in New Zealand, in Denmark, we’ve done a enormously, you know, referenceable, highly exciting project in Alberta. But Alberta has 4 million people with a single payer, and a lot of control over everything that moves. So in all of these discussions, I always like to say when it comes to the US, we have to acknowledge upfront, you know, 330 million people, so that’s six times the UK more or less five or six times the size of the UK. So right up front, you’ve got a much larger population. And a lot more heterogeneity is just baked in to the, to the population. So you could say the Canadian model works very well, at one level that we have individual provinces, and we’ve been really successful at providing shade care records across many of the provinces of Canada. But then Canada’s only 40 million in each province, apart from Ontario is, you know, less than five minutes five to 7 million. So it’s just easier. And I do think we have to get the funding model right is we’re saying You get what you incentivize. And, again, I think I’m really hopeful in the US that the understanding that fee for service has meant when you pay for services, you get more services doesn’t mean you get improved quality. So head, you know, head, our toes in the water around accountable care organizations and other value based care models. And maybe I think that 30% of the US population are now covered by an accountable care organization. So it’s a good model. And it works. But But each, you know, bigger games, you’re so much heterogeneity, you have health systems, like the Kaiser and the guising. With both payer and fund, or or the church based organizations, Adventist health and so on. And so it’s just harder. When you look at the EMRs. In the US, there’s well over 100, different EMRs. So EHS, it’s just a different order of difficulty to integrate with them. Then, in New Zealand, we had seven. And I remember, I went round, all seven EMR vendors said, you got to play ball, your competitors, or your competitors are playing ball. One insight from those days actually was the new vendor on the block was always keen to do the latest, latest standard. And we didn’t really even have to pay them. But maybe if we gave them $5,000, they would be very grateful. And the incumbent vendor was like, wow, you know, we’ve got half of the primary care practices in New Zealand, so you’re gonna have to talk to us. So, you know, they cost us a lot more to bring them around a lot more time and effort. So even in a small country, you get the same kind of dynamics.
Nick van Terheyden
So we were hopefully on our way to sort of providing interoperability to help exchange information, maybe learning from some of these other systems. One of the things that I continue to hear about, and I know you think about a lot is this sort of virtual care and the digital front door, that, you know, has to be part of our future, not just because we’re all sort of confined to this matrix world that we’ve lived in for the last several months. But, you know, it makes a lot of sense. I mean, I think people are realized suddenly, Oh, actually, virtual care works. Not all the time. But, you know, instead of getting in the car driving pocket, all those things, and the digital enablement. You know, once you’ve got that fixed, once everybody got their cameras, and you know, all that technology, how do we go about what are the steps to get is that
Chris Hobson
so yeah, there’s no going back now, I think we’ve proven virtual care works. And people have got the got the technology. So the interesting piece on the virtual care of courses, so on the one hand, the patient’s absolutely love it. From a patient perspective, you know, I mean, myself, I, the other day, I had to see somebody, somebody, and you know, instead of going there and sitting away in the waiting room with a whole lot of other people, and then getting in front of them, and, you know, last minute, which would take three or four hours, you know, it could even take up my afternoon, I was able to sit at my desk, do my stuff, 10 minute phone call consultation, I’m happy, they’re happy. Everybody’s. So that’s the patient side of it. I think patients are very happy with virtual care, and two sides. So from the physician perspective, I think we do just, we still live with anxiety about whether it’s safe. What if we need to examine the patient, you can easily examine them over the phone or whatever. So there’s still that end, you know, I just need to see you. Well, okay, but why is the response from the patient but from the physician, it’s, I’m just so used to see I can put so much together. So that’s one part. The other part, of course, is the payers willingness to keep funding virtual health. So as part of COVID regulations, there was a lot of levers and rules and regulations changed, which enabled us to charge for a virtual consultation of more or less the same rates as as an in person consultation. So the payers will have a role to play obviously. And as we go forward, if we have to keep going to the virtual care. The other The only other thing just to say is so virtual care for COVID. When COVID is the dominant thing and every patient seems to have COVID. With maybe we’ve proven you can virtual care for a lot of simple things and you can virtual care for COVID You know, we’ve really are really concerned, the patient was the breast lump the patient with you know about cancer, who’s being left at home. And so we have kind of put those those people have suffered, I think a lot of normal care hasn’t been happening. So we have seen an increase in the death rate, that seems to be more than just explainable by COVID. So I think that’s also a little bit of an open question. If someone has bleeding from the bow, can you handle that? Just as well, virtually? And I think obviously, that becomes a point where you have to go in and see somebody and sleeves rolled up without what’s going on.
Nick van Terheyden
Yeah, I think no disagreement there. It’s not a replacement. It’s augmentation. And obviously, you know, the appropriate use and application for the right instance, in the closing minutes, if you could just tell us, where do you see things going? What’s your sort of view of the future? project out? 10 years? No, no, wait, you said five years? I’ll give you that? Where do you see us? And what are you excited about?
Chris Hobson
So to answer the second question, first, I’m excited that as we’ve accumulated more and more data, we are able to make better predictions across a population. So an example would be we did a study of we have the population of patients attached to say, a payer or a state. And we can comb through, find all the newly pregnant woman, and find using artificial intelligence and so on, find those who are at risk of having a high risk pregnancy, identify those people and then put them on a better plan. So that’s one view of the future where we can look through the population, find the problems and address them. I totally, absolutely concede that we need privacy, and we need to be very aware of that. But let’s take it for now that we have the fleet only using it for the purpose of attended a health care, then I think, as we look it out. So on the non technical side, aided by AI, I’d like to say that we can find the problems we can find, and that we can do something to help. So we can show that there’s a lot more COVID in a poor part of town, and overcrowded central workers. And we can send that the other hope is that the system will start to respond. And population base funding does get you there, you now need to care about those people at the bottom of the heap. So that’s what I really like to say, technology wise, I think, obviously, everything’s going for the cell phone, everything’s computing power is increasing relentlessly. I again, I would, I would like to just see more of the humanizing aspects to technology being considered, I think the information, the disinformation and what we’ve learned through Facebook and all that, if we can start to address those things, then I think we actually have a bright future. You know, technology can actually make a real positive difference to people’s lives. I can see how, but it is going to be on us to avoid the downsides and the negatives, which, you know, unfortunately, show they can happen.
Nick van Terheyden
Fantastic. Well, as usual, we’ve run out of time, so it just remains for me to thank you for joining me. Fantastic, interesting journey and exciting and positive potential. Chris, thanks for joining me today.
Chris Hobson
Thank you so much, Nicholas. Real pleasure
