By Robert Rowley, MD
A recent article in The Commonwealth Fund blog, “Envisioning a Digital Health Advisor,” raises the question of being able to use smartphone apps to get real-time, accurate and personalized guidance for health concerns. While one can envision the convenience, affordability and peace of mind that would result from their use, such services face a number of hurdles before they become reality. As a result, the “digital revolution” has not yet greatly affected most people’s interactions with the health care system.
These challenges fall into two main categories: fiscal/policy and technology.
Fiscal and policy issues. In a fee-for-service environment, the only way that healthcare practitioners get paid is to have face-to-face encounters with patients. This creates heavy bias against promoting technologies that streamline non-face-to-face interactions. However, as we move away from that model and more towards value-based care, where global risk-based payments are made to delivery organizations (hospitals, patient centered medical homes, accountable care organizations, etc.), then there is more incentive to use new technologies that reduce unnecessary in-office encounters. In such an environment, face-to-face encounters are actually a cost center, not a profit center, and positive health outcomes of populations are rewarded.
We are not yet in a fully value-based environment. Fee-for-service remains dominant, though this will be changing over the next few years, hurried along by the seismic shifts in physician reimbursement policy announced by the Federal government in its draft MACRA rule. Aligning the way that healthcare is paid for with technologies that facilitate self-care and improved care – that is what is needed from a fiscal and policy perspective in order for Digital Health Advisor-style technologies to flourish.
Technology issues. The biggest technical barrier to achieving this vision is the state of health data. Created by legacy Electronic Health Records (EHR) systems, health data is largely fragmented into institution-centered silos. Sometimes those silos are large, but they are still silos. Exchanging individual records between silos, using increasingly standardized vocabularies (code sets) and message formats (ADT messages, C-CDAs, even FHIR objects), is where much current effort is being spent. But that does not solve the problem of data fragmentation.