/knowledge/youtube-series-with-don-rucker/whats-next-for-fhir

Joe Gagnon:

Don, good to spend some time with you.

We’re going to have some fun talking to our audience here about lots of different topics relating to healthcare. Maybe I’ll just sort of jump us into the beginning of this a little bit with the idea of establishing that this is the first time we’re doing one of these. We’re going to talk today less about specifics, about 1upHealth.

Joe Gagnon:

I’m the CEO of 1upHealth, Joe Gagnon. Don Rucker is our Chief Strategy Officer. In our conversation, we’re going to explore how our industry is going to transform a role that will play in that. Some big ideas and sort of tap into some of your experience when you were the National Coordinator. See if we can do for this health system, broadly speaking, what we’ve all been hoping would happen over the past few years.

Joe Gagnon:

Why don’t we start with a bit of a world view. From lots of conversations you and I have had there’s this world view that says we’re on the cusp of some significant shifts in health, healthcare broadly. Which one is that, the public in the role of consumer mindset that comes to play is going to make for a more accountable and a more effective industry.

Joe Gagnon:

We’ll move into a little bit later on the relationships between payers and providers and the implications to them. Then maybe even talk a little tech for a few minutes. Why don’t we start with, this world where, will we move from patients or member to customer and what are the implications of that in the industry?

Don Rucker:

Yeah. I think we all have a sense that there’s something missing in healthcare. It’s not a consumer friendly experience and the more you’ve been a patient, the more you’re sort of aware of that. If you try to figure out reasoning by analogies, I used to say in school, whatever that meant, to the rest of our lives, I think what you’re going to see in healthcare fueled by frankly, the public dissatisfaction, it’s an issue in most elections, somehow, maybe not at all, but many elections. That means there’s a constant political pressure, both on the agencies and on Congress and the Executive Branch to change and fiddle with the laws and fiddle with the rules and stuff.

Don Rucker:

I think what you’re going to see as we look at this though, and looking at the rest of our lives, it’s going to be way more connected. We are now digital. Our smartphones are a part of us, really. I think what you’re going to see is future clinical interactions are going to be about constant data coming in and out of our smartphones and us as patients.

Don Rucker:

That might be conversations fueled by apps, alerts, reminders, that type of world. It may also be either separate from the smartphone or with a smartphone, what’s called, the internet of things. Whether that is sensors for your heart rate. I think I have a product here that [crosstalk 00:04:24] to manufacturers that monitor heart rates. Whether that is for diabetes, for breathing, for gait, for neurologic illnesses, whatever those things are. It’s that, internet of things. So I think we’re going to see the consumer interaction with care being much more digital.

Joe Gagnon:

It’s really interesting, because I think there’s a lot of this that we feel. It’s probably because in many of the other parts of our lives, we’ve been affected by consumerization.

Don Rucker:

Yeah.

Joe Gagnon:

The travel industry. We don’t have to go to the travel agent anymore to get a seat on American Airlines flight. We can just go on our phone and see that inventory. We don’t have to get in our car to drive to the store. We can buy a medium t-shirt from REI and it’ll be there tomorrow, if necessary. We have Amazon that’s redefined and Instacart that’s redefined our interaction with anything as simple as groceries.

Joe Gagnon:

We’ve come to sort of this world where that is somewhat of our expectations. But healthcare, I would often say education are operating off of systems that were designed probably in the 1800s, where there was one book. That’s why we had a one room school room. Everyone had to go there, because there was only one book. Now we got the digital world and we’re still sending kids to a school room.

Joe Gagnon:

In healthcare it was, you had to go see the doctor because that’s the only way care could be administrated. And they created this one document called a medical record that was supposed to have all the information about you. It seems like many of these systems in health did not contemplate a truly digital world, that’s empowered in a consumer world.

Joe Gagnon:

Interestingly enough, we don’t really pay directly. It still has some work to do, but it looks like it’s the early stage of what we’ve gone through in other industries. Would you say that’s a good characterization of where we are and then what’s possible?

Don Rucker:

Yeah, I think when you look, it is interesting just as we are recording this, last week there was a quest for information from one of the federal agencies on prior authorization, the massive provider payer patient dissatisfaction with just that one thing. I think when you take it up a level, the conversation that we need to empower consumers means we have to have a different conversation in the provider payer space as well.

Don Rucker:

Today, utilization management, whether that is prior authorization or the quality measure game almost, if you will, or things like narrow networks that do utilization management by great restrictions on where we go. All of those are tremendous consumer dissatisfiers. They’re just tremendous. That whole bandwidth of communication is just, every time you look at it’s a big dissatisfier.

Don Rucker:

I think modern technology now allows us to think, what would be a better conversation between providers and payers that is, maybe natively digital, real time, continuous, less intrusive uses all the information that we’ve already captured, as opposed to reentering it in a form. Folks entering information from the electronic medical record in a PDF is not what we’re talking about with digital here. We’re talking about something vastly different.

Joe Gagnon:

Yeah.

Don Rucker:

I think we have to absolutely think about rejiggering that conversation. Frankly, I think the people who succeed in re-imagining that conversation and are first there, are going to be the winners. That has been the case in every other part of this digital app world. We know those winners because they are today household names.

Joe Gagnon:

Yeah. I think we all feel like data matters to our lives in ways that we could never have imagined. Whether our marketers using that to send us a custom message. Whether we’re using it for banking. Then in health, you would think that timely data is maybe the most important. If you have an issue in your blood test, you would want to know that instantly. If you were trying to get a more comprehensive view of how payment history should affect current payment, you would think that more data would be better in timely data.

Joe Gagnon:

It seems like there’s a lot of data in the health system, but not acted on, in a very timely way or a comprehensive way. Is there something that’s happening in that space that we should all be thinking about, how that would advantage us both as the consumer patient, as much as the healthcare provider or the payer?

Don Rucker:

We don’t have a lot of real time data in healthcare, interesting enough. Now, if you’re sitting in ICU wired for sound, as it were, that’s different. But in our lives, as consumers as we go about our business, none of it’s real time. We’re sort of socialized to wait for the test results. The bill is going to come sometime.

Don Rucker:

It’s the height of great performance as a CFO in a health delivery system if you can get your AR days down to 50 or something or 45. Days, right? Like where else would that be?

Joe Gagnon:

Yeah.

Don Rucker:

Where else would that kind of performance be really acceptable? The challenge is, in healthcare for various reasons in the past, we haven’t had the kinds of platforms that support that. I mean, when you think of your provider world or your payer world today, I’m talking about big delivery system providers and big payers, they’re typically a mix of a transactional system, the “EMR”. Then there’s an analytic system often called, online analytic processing, or OAP, that is a relational database sitting behind that.

Don Rucker:

Ditto for the payers. They have claims analysis, the claims edits. Then they have their analytic frameworks. That’s sort of what it is today. However, when you look at what is really needed for that consumer experience, we’ve talked about, you need two very different things that those classes of systems are just not designed to provide, fundamentally not designed to provide.

Don Rucker:

For that richer, real time consumer experience, you need lots of real time analytic power. You have to be able to calculate the digital product instantaneously on demand. It even goes beyond serving an ad, because you searched for something 10 minutes earlier.

Joe Gagnon:

Yeah.

Don Rucker:

Then miraculously, as you’re watching YouTube, the ad appears. It even goes beyond that. You also need, of course then, really powerful, real time APIs to serve the combination of analytics and whatever data fields you have. You need an absolutely different infrastructure as you look today. Hard to imagine that scalability and performance in that, would run on anything but native cloud.

Joe Gagnon:

I know we’re going to get into some of these topics in a deeper way in future sessions of our series. But if we start to open up this data, there’s always this worry about privacy and security and making sure that it’s used properly. Because, we love the idea of maybe that data could help me, but is it going to be used appropriately? Thoughts on where we are with the data part of this and security and privacy.

Don Rucker:

I think, my observation of being asked probably thousands of questions about this in my prior role frankly… And it took me a while to think about it, but I think first of all, we have to separate security and privacy. There are many, many definitions of security and privacy. But, I would say operationally security is protecting things from people that have just no right to the data whatsoever. Somebody hacking in from a different country or outright data theft.

Don Rucker:

We have pretty good mechanisms to do that. You got to protect servers. You got to protect passwords. But we know the drill. We know how to do that. It can be painful at times. We know how to do that.

Don Rucker:

The much more complicated issue is privacy in healthcare. That really is the rub here. Now, a lot of times our privacy concerns are really about insurability and being able to get insurance when you actually dig into a lot of why people don’t want to have their information out there.

Don Rucker:

When you look at privacy, we have to think richly about things like identification. We have to think about the related authentication, authorization and consent. Who are you? What do you allow others to use of your information? And what have others given you? That would be parents, children, caregivers, those types of relationships.

Don Rucker:

When you look at all those, we don’t have great mechanisms because our data representations, again, we talked about those transactional systems and the analytics, they’re not designed for granular privacy. It was just never a thought. They’re just not designed for modern concepts of privacy.

Don Rucker:

This is bedeviling for folks in substance abuse in the 42 CFR regulations on substance abuse or emancipated minors or birth control. There are many issues, varies by state. You have to follow those state laws. In all of those, you want granular controlled privacy. Interestingly enough, I think part of what appeals to us about the 1upHealth stack, obviously we work here, so it’s self-serving. But it’s the first time I’ve ever seen field-level security for every field natively built in. That’s a mouthful, probably more than a YouTube type of video. It’s worth considering how you feel privacy in the modern digital world and do it in a way that doesn’t create more consumer pain.

Joe Gagnon:

Yeah. I think, what we would believe and want to believe is that, if we understand what the problem is, we could solve for it. Number two, if you get enough benefit, you’re willing to share. We share data every day.

Don Rucker:

Right, a credit card or cell phone, our search history. Yeah, every single… or geolocation, every single thing is known about us. [crosstalk 00:16:40].

Joe Gagnon:

Where you’ve been. What you did.

Don Rucker:

Yeah. There’s not a thing that isn’t known about you almost.

Joe Gagnon:

But we feel like we get enough value so that we don’t object. I think we probably could solve for this with some good thought. We’re going to probably wrap up in a couple minutes. But one of the things to think about Don is we, you endeavor down this series, is trying to sort of imagine this future state world. Where, our lives, we are living longer, better, happier, more productive lives. It’s costing less. That we’ve made healthcare somewhat democratized. It’s not just for the privileged to get good care. It’s everyone.

Joe Gagnon:

We know that the majority of the system is funded by healthy people for the people who aren’t so healthy. We want to do all of the right things. And at $3.8 trillion, we probably have enough spend. But there’s a big system and it’s complicated with a lot of stakeholders. Give credit to you and the government, when you are there for making a push to say, “There’s going to be some standards that we think are going to set a foundation for the day when we all get our head wrapped around, we can do this better.”

Joe Gagnon:

We can’t accept it the way it is. We’re not going to… Certainly at 1upHealth we want to be a contributor to building the infrastructure, first level, which gives you that ability to rethink. Then the application level that’ll give you the ability to communicate and connect. Then that analytic level to get some insights and deliver better cost and better care.

Joe Gagnon:

Maybe we’ll just tease it out here with a few things. There are some standards that have been put together that are going to allow us not to have arguments about things that sort of shouldn’t matter. Like who cares how data transmits over a phone line. We just want it to do that. Right? The same thing with, we don’t know what standards or operating system are on our phone.

Joe Gagnon:

Just give us a quick rundown on some of the standards that we’re going to end up talking about in future sessions, all in the context of really transforming the industry and giving the opportunity need to just make it better for all of us.

Don Rucker:

Well that was the data standard that we’re talking about here is FHIR. Which is the acronym is FHIR, Fast Healthcare Information Resources. Nobody even knows… Good acronyms, nobody and knows what they stand for anymore, so you have to think, “What was that again?”

Don Rucker:

Why FHIR? I think it’s really an evolution of about 30 years of work on knowing what works in healthcare and what doesn’t. But the real revolution of FHIR is, it is just layered straight on top of the modern web JSON data standard, JavaScript object notation, that powers essentially every app on your smartphone. For folks, pretty much every app on your smartphone actually is just a little shell that communicates with backend servers. It’s using JSON data to do all of this analytics.

Don Rucker:

That’s what we’ve just been talking about, richly powerful APIs with real time backend analytics services. That’s exactly the nature of the architecture we’ve been talking about to have consumer friendliness in healthcare.

Don Rucker:

I’s sort of hard to imagine anything else, when you look at the technical stack, the capabilities. You can read it with human eyeballs. You don’t need to be a programmer to do it. You can leverage the entire learning of the entire software industry globally to use these things. So it’s not just healthcare be-spoke things. It really allows modern computing behaviors.

Don Rucker:

We talked about the payer provider, what those conversations might look like in the modern world. They’re going to be much richer. Nobody’s going to be filling out PDFs and then sending them by fax. This is all going to be automatic in the back background. The critical point of service being the only thing that is exposed. The same way as we see it for every other app that we use.

Don Rucker:

When you just have that critical point of service or activity exposed and compute underneath, hidden on all of the other things, obviously one of the questions is, “What kind of platforms would actually allow you to do that with the scale and power?”

Don Rucker:

Obviously, that’s been quite exciting for us at 1up, to work on a platform that we believe is unique in that closeness to modern data, big data. Big data is velocity, variety and volume. That’s the classic discussion of big data. Each of those things and sort of, you can walk back to a platform.

Don Rucker:

Whether in the future, providers and payers use our stuff or other things or whatever, but somehow they’re going to have to come to something that has huge volume scale and speed, but also allows very fine grained atomic variety to have these rich, personalized behaviors.

Don Rucker:

People all talk about individualized healthcare, personalized healthcare, but you need a totally different architecture to do that from what we have. That’s part of the amazing journey that we’re all collectively on.

Joe Gagnon:

You know, I think it’s exciting Don, because one, basically acknowledging the technologies here already for us to use. We have some really good ideas collectively in the industry. We have a welcome consumer who wants it to be better. I think the healthcare practitioners would be excited about it as well.

Joe Gagnon:

Now it’s about getting on this journey and figuring it out, making it real, bringing it to life. That’s what we’re going to spend the future on with you, is talking about how we bring this to life, both through some of the work we’re doing in the industry more broadly. We’d love to hear from anyone who has any questions they’d love us to touch on. We’ll be back with you very soon with our next episode. Thanks for watching.

Don Rucker:

Thank you.