- Kaveh Safavi
Kaveh Safavi works for Accenture, a global company that provides management, technology and outsourcing consultation and services. Safavi is the company’s resident expert on all things health reform and was in Salt Lake City recently for the America’s Health Insurance Plans annual conference, where he spoke about the three IT trends that will affect health care—big data, social technology, and personalization technology.
What's the big drama with health care—is it all caused by Obamacare?
The trends and forces that push on the health-care system are there regardless of what goes on with any particular policy. You hear the talk of affordability. The pace of increase of health-care costs is moving at a faster pace than the overall economy, and therefore it continues to consume a greater portion of the economy, and essentially crowds out other expenses. On a state level, the state has certain responsibilities, including education, so as health-care costs go up, the state has to choose: Is it going to provide health coverage or is it going to provide education? How do we actually change health-care costs? At the end of the day, to spend less on health care, either less health-care services have to be provided, or the people who provide services have to get paid less. Neither of those are ideal.
Are there inefficiencies that the industry can just fix?
When you look at inefficiencies in health care—say, overuse and underuse—there are good examples where no one would argue that there are services that are being provided that didn’t need to be because information wasn’t available. You went to a doctor and then went to another doctor and they re-ordered the same tests. There are also much closer calls—what’s the right frequency to get a test, or to get a screening result, what’s a reasonable amount of value that you should attach to extending life for cancer. And these are not easy questions to answer.
Won’t costs go down when everyone is in the system?
We talk about things like prevention, and treatment of complications that come from untreated diseases. The reality is, that actually costs money, because you’re taking situations where people got no care, and you’re now providing care. There’s this notion that people without health insurance forgo treatment that results in complications that result in higher long-term care. So we want to give economic incentives for them to get health care early. That ultimately adds net cost to the system. Here’s the interesting thing about these untreated diseases: if you have an untreated disease, it’s quite possible that you’re going to get a complication, and maybe die early from the complication, but never enter the health-care system. So from a health-care perspective, you’re maybe not that expensive; you’re outside the system.
But in order to gain the social and economic benefits to society, we want to treat you, and that’s an expense to the health-care system. What happened in the Affordable Care Act is coverage expansions and subsidies created costs from the baseline, and we already had a cost problem. So we had to offset the costs that came by expanding health insurance, plus take it down even farther, because the overall trajectory for health-care costs was already too fast. So a lot of the discussion is what is a reasonable, rational way to rein in health-care cost expansion?
Health care is getting more expensive; are patients being better served?
One of the challenges of the way health care is organized is it’s always been organized around the health care delivery system, not around the patients. And whether it’s demographics—younger people—or just our experiences in other parts of society, we have different expectations on how we’re going to get treated by the health care system. People want to have access to their own information. They want to be able to make their appointments online. Well, the system doesn’t respond to that at all. As a society, we pay a lot for health care—are we getting our money’s worth? The consumerism issue is the idea that the health-care system is not responding like the rest of society is to our expectations of how we should engage.
What’s a health-information exchange? (note correction below)
Information about your health care has been created by you going to a number of different health-care providers over your lifetime. Parts of your story exist in different places. If you had an illness and someone wanted to understand what your medical history is, they’d want to see it all, but it lives in different places. The concept of exchange is the ability for you or the doctor treating you to get the full view—also potentially for researchers, who want to understand a disease that you or I might have, to get the full view. So the idea of exchange is exchange between organizations that have parts of your story, and provide the best possible care—and see patterns.
Doesn’t this raise a privacy issue?
There’s a technical problem, and then there are the policy problems. Once we’ve made it possible for someone to see information about you across time and settings, then the question is, under what circumstances? And there’s the government perspective on privacy and there’s the personal perspective on privacy. So I may, on a personal level, be less willing to share my personal information than the government’s policy on privacy allows.
How do you enforce the regulatory level and the personal level? One of the debates is whether you have to opt into a program or whether you have to opt out of a program. If you ask people to opt in, for any number of reasons that have nothing to do with what they care about—they’re too lazy, they forget—so they never get the benefit of it. But if you go to the opt-out model—everybody’s in unless they opt out—there’s the concern that someone won’t opt out in time, and something will happen that they won’t be happy with. These are not questions that can and should be answered by health care organizations. These are policy questions. They don’t belong to doctors or hospitals or insurance companies to decide.
You’ve been quoted in national newspapers about a delay in the switch to ICD-10—what exactly is that?
We’ve been using a particular system for medical billing for two decades. The rest of the world adopted a more advanced system—think of it as going from 7,000 codes to 70,000 codes. The reason they went to that is because the only real form of information we have to do analysis or research, trying to find out what treatments are effective or cost effective, has always been in the billing data. The billing data was really not designed to tell us about people’s clinical condition, but we’ve figured out a way to approximate, based on a diagnoses, procedure and age, but it was a blunt instrument—it was right maybe 30 percent of the time. And medical records themselves didn’t exist in electronic format, and if they did exist, most of the information ended up being in unstructured data—scanned-in reports. Scanning in a report with words doesn’t make that information accessible. I can’t tell your allergies from a scanned-in piece of paper. We don’t have a foreseeable source of primary medical data, so we need to go to the billing data.
The international movement to go from ICD-9 to ICD-10 was to give more granular specificity to billing data for the purpose of health-care-services research. The United States was one of the last countries to accept that standard. That requires billing systems to change—both on the doctor’s end and on the insurance end—in a very specific way, at cost. Their argument is, “For the purposes of being paid, you don’t need any of this information. From the matter of research, public health, public policy, it’s useful, but why are you making us incur the cost of putting these systems in place when the benefit isn’t to the transaction we’re doing?” And that was essentially what the political question was—we’re already strapped, our reimbursements are already going down, you’re already heaping a series of regulations and responsibilities on us, and on top of that you’re telling us to take our billing system from one that exists to one that’s more complicated, but for no benefit to me. Where we landed on was, that’s true, but the benefit to society is worth the investment. But in the context of everything that was going on, this wasn’t really in the ACA, it was a matter of regulatory policy that was going on in parallel, the government said, we’re going to delay implementation and give you more time—spread costs out a little bit longer, take some of the pressure off.
What is “big data”?
Big data means a large amount of data—there is so much information being created in health care—medical records, gene information, devices that monitor your body and generate data. In 2015, as a globe, we will generate as much data in that year as 120,000 times all written words for all of history. And there will be two computer devices per man, woman and child on Earth. That’s a lot of data. And people are realizing this big giant mass of data and saying, “I can use that information to create associations I never understood before. I can start to see relationships, I can start to answer questions I never could before.” When you have large amounts of data, you can see low-frequency events and study them.
How does social technology affect health care? Is that like when my hospital wants me to “like” them on Facebook?
We understand and realize that humans are social by nature, and technology allows for that nature to be expressed. So, the example we give is Facebook. Facebook is the most-visted website in the United Sates, even more than Google or e-mail. It’s a platform—Facebook is for entertainment or communication. In health care, we’re starting to see it in other things, the creation of original medical information and a platform for self-care and self-service.
There’s a social site called Patients Like Me, and it was designed for patients with serious clinical illnesses to find other patients with those illnesses and learn from them. Most people with a really serious illness would say, “No doctor or nurse can really understand what I’m going through.” In the pre-Internet days, you had to go to the hospital on a Tuesday night to meet other people like you, in a support group. Now you can look for people like you, and have conversations with them in real time. But it’s more than just that kind of a conversation—they actually create original insights.
The other version of this is that there are certain diseases that are thought to spread through social media. Obesity is one of these. The risk of being obese is related primarily to whether your friends or your friends’ friends are obese—regardless of the distance between them. People are trying to figure out how to change eating habits. You might go in and say, “I want to solve childhood obesity, so I’m going to change the food in the school.” Well, that may or may not work. There are still skinny kids who are eating at school, because they’re eating differently than the heavy kids. Some conditions have a social contagion, and when we understand them, we can use technology to find and map, and then use technology to deploy an intervention. Health care has to understand that social software is dominant in what we do in our private lives, and it is actually quite relevant in health care—it’s going to be a tool that’s going to be used.
A lot of people seek guidance from Yahoo! Answers when they have a weird spot or an unusual itch. Is that a good trend?
I don’t think it matters whether it’s a good thing or not—it’s a thing. Before the Internet, people would go ask their neighbor, whose sister was a nurse, "What do you think about this spot?" We know people have been solving their problems informally forever. Which is more likely to be right: going to your neighbor, whose sister’s cousin was a nurse, or going on Yahoo Answers and asking a question? There’s a decent chance that the person answering the question might actually know the answer to it. I think that what this recognizes is that people want to take care of themselves. People want to use technology to solve their own problems. That doesn’t mean they don’t want access to a doctor. It’s not instead of going to a doctor.
What is technology that personalizes care—am I going to get my own in-house robot doctor?
Increasingly, in all parts of our lives, our expectation is that the experience is more personal. There are several elements to what makes something personal—knowing who I am, engaging me in some fashion, meeting me on my terms—that might be some technology. This idea of personalization that is going on in health care is going on in a very strong way. Some of it is access to devices, some of it is in terms of augmentation of reality, which is the intersection of a real experience and an information experience. The best example of augmentation of reality is in sports. If you watch football on television, you’d see the line of scrimmage drawn on the field, and you’d see all the statistics. Physically being there in person isn’t as engaging as watching it with all the information. So, what sports franchises had to do was bring the TV into the stadium or people wouldn’t come to the stadium. This, to me, is the same evolution we’re going to go through.
In health, our care model is that the best, most personal form of service is in-person service. One of the things we’ve realized is that tele-health—doctor in one location, patient in another—for a while, it was better than nothing. Now, this is not just better than nothing, but patients actually like this better. I still have the doctor, but here’s the advantage. A patient’s ear is being examined. In a normal way, you go to a doctor and he looks in your ear, and the doctor sees your eardrum but you don’t see anything, you don’t know what they’re looking at. With an electronic otoscope, one end goes in the patient’s ear and the other end the doctor sees the image. [With the tele-visit], the patient can see the eardrum. It actually creates a more compelling experience. What people want is a personal experience, not an in-person experience. An in-person visit with a well-meaning physician who doesn’t know anything about you, doesn’t let you see anything, versus an interaction with a person who’s not actually in person but has all this information, might actually be more interesting. Technology allows that to happen. And it changes supply and demand. Now a doctor can be in one location and serve patients in many locations.
Correction: Due to a transcription error, an incorrect question was posed to Safavi in the July 5 edition of City Weekly. The question that currently reads: “What’s a health-information exchange?” corrects that error. We apologize for any confusion this error may have caused.