Microsoft is best known for its key role in the computing revolution. Less well known is the role Microsoft plays today in the health industry, but a similar revolution is underway and once again the company is at the center. Responsible for helping customers and partners navigate that change is Dr. Simon Kos, chief medical officer. What is a doctor doing working for a technology company? “No, I don’t provide medical services to employees!” Kos quips.
Whilst practicing critical care medicine in Australia, he saw firsthand just how fragmented information in healthcare was, and recognised the risk that posed to patient care. An interest in technology became a career as Kos explored first Electronic Medical Record (EMR) systems, then later a much broader portfolio as he ran the health division for Microsoft Australia. His current role might be different in scope and scale, but the industry challenges remain. “Digital transformation is underway all around us, and will dramatically change how we deliver and receive health services.”
A time of change
Health today is at an inflection point. On the one hand, standard operating procedures and a risk averse culture foster predictable, high quality care. On the other however, healthcare costs are unsustainable and new models of care are required, largely to address the increased burden of chronic disease in our modern society. This paradox – an industry resistant to change that fundamentally needs to reinvent itself – is playing out across the globe. “The Microsoft health vertical is substantial, with over 168,000 health customers and an estimated 30,000 partners, we have a broad base for telemetry,” Kos explains.
Central to the Microsoft business model is the concept of partnership. “We essentially have two core functions. Engineer high quality, interoperable software platforms, and support partners who use those platforms to create solutions,” Kos rationalizes. He goes on to note that it is common for health organizations to have thousands of applications in their technology portfolio, and an ecosystem approach is required to manage information effectively.
This aggregate view allows Microsoft to spot emerging technology trends, view cutting-edge innovation, and disseminate best-practice. He goes on to say: “Healthcare IT has historically been focused on automation through systems of record, like the EMR. That’s an important step, but just the start of the journey. Unlocking value through systems of insight, collaboration and innovation is where transformation occurs.”
So, if the EMR isn’t the end-state, what does digital transformation look like in health? Microsoft uses a model based on the Quadruple aim.
In fact, this model might just as readily be applied to other industries like retail or banking, because the drivers of digital transformation are affecting every industry. “Think about how booking travel, shopping online, catching a ride, or even just watching a movie, has changed in the last decade. As consumers, we expect more today. Now think about the patient experience. We’ve got a long way to go,” Kos observes. Most health organizations have a portfolio of initiatives underway that map to these four pillars, whether they’ve consciously thought about it in this framework or not.
We’ve all experienced the healthcare system at some point. It can be frustrating, scary, and confusing. “It’s one of the only industries I know where information needs to be kept totally private yet shared with everyone,” Kos says. What does patient engagement look like? At the simplest level, it’s technology that promotes the patient to an active, empowered position in the care relationship. That could be as simple as a patient view into the clinical care record, online meal ordering, or a kiosk check-in process. Many organizations have already replaced bedside entertainment systems with patient infotainment systems, allowing patients to access contextual, accurate and personalized health information, and even interact with the care team. Where could it lead? “I see precision medicine, medical wearables, and the connected patient home as aspirational goals. The technology is not the limiting factor,” says Kos.
Patient engagement strategies are about more than simply adding a pleasant veneer to a healthcare encounter. “That wouldn’t be transformation,” explains Kos. He illustrates using an example from Children’s Mercy Hospital in Kansas City. They changed how they monitor certain cardiac conditions at home, replacing the traditional three-ring binder with an online record shared in real-time with the care team. The addition of video footage from the webcam has made a dramatic improvement, and they have decreased the mortality of hypoplastic left heart syndrome from 20 percent to almost zero. The story is publicly available on YouTube and well worth a watch: https://youtu.be/qtbNiwM-BF4
This model is currently being rolled out to other hospitals nationally, and will redefine the prognosis for this condition. As a model of care however, it could just as readily be applied to any other condition that would benefit from remote monitoring – acute or chronic. Similarly, tools that empower the patient or carers with information about their condition, allow them to document and monitor progress, and interact with their care team, can improve the experience and outcomes of care.
Empowering care teams
“We have to move beyond the EMR. It’s a poor proxy for communication,” Kos begins. He continues to note that whilst many US health systems have spent hundreds of millions or even billions of dollars on their EMR systems, the spend has not boosted productivity or improved clinical workflow. A digital health record is important, but when coupled with a last-century pager system for communication, a disorganized intranet for policies and procedures, or a manual clinical education process, the potential value goes unrecognized. “The growth of shadow IT in health is phenomenal. I see clinicians using personal email addresses, swapping patient files over personal cloud storage, texting patient images and EMR screenshots on their personal phones, even using personal messaging services for patient handover or online groups for clinical research.” Kos observes that clinicians aren’t trying to be rogue with medical information, but they are frustrated with the tools that they are expected to use in the workplace.
There are better ways to help clinicians communicate, collaborate, team together and learn. For each insecure consumer cloud service, there is an enterprise grade, HIPAA compliant alternative. Kos points to the Office 365 suite as an example that hosts email, calendaring, messaging, telephony, webcasting, groups, intranet, business intelligence, social networking and more. “The irony is that many health organizations own this technology, yet haven’t rolled out these capabilities to their clinicians.” Is better communication and collaboration the end-goal? Again, Kos describes it as building blocks for transformation. “Using these digital capabilities to deliver care in new ways is the objective. Telemedicine for example, or centers of excellence on enterprise social networking.” One of the most radical initiatives involves augmented reality. Case Western Reserve University is using the new technology to reinvent the whole way they teach medical students anatomy, going as far as to remove cadavers from their curriculum in favour of holograms. Its story can be seen here: https://youtu.be/SKpKlh1-en0
Optimize outcomes and operations
“Health is data rich and information poor,” says Kos, who goes on to say that the data collected in clinical systems is generally for operational, communication, or medico-legal purposes. Most systems do not store information in a way that makes analytics easy, and an enterprise-wide view across systems doesn’t emerge organically. “For an industry that prides itself on being evidence based, health does a poor job of using the most recent and relevant evidence – their own!” Kos exclaims. He sees analytics as a continuum spanning retrospective reporting, real-time dashboarding, predictive analytics, and even proscriptive decision-making using cognitive services and machine learning. Even relatively basic initiatives like patient journey-boards and KPI dashboards can have a huge impact on baselining performance, identifying bottlenecks and streamlining operations.
Kos notes that predictive analytics is being successfully used today to help identify patients ready for discharge, or keep chronic disease patients out of the hospital. In addition to being good for the patient, managing readmissions well can boost the financials of any health organization operating under a pay-for-outcomes model. He uses Imagine Care at Dartmouth Hitchcock as an example. Imagine Care equips chronic disease sufferers with wearable devices like heart rate monitors, connected glucometers, and smart scales that monitor their biometric parameters. The volume of information transmitted is massive, but using machine models a predicted risk of admission can be generated. Then clinicians from the Imagine Care can call down on high risk patients, attempting to catch a flare before hospitalization is required. This story is part of the push toward population health management in the US, and can be viewed here: https://youtu.be/HMgSLSO_-ls
Going forward, Kos sees a real role for cognitive services in health. “We have an asymmetry of information, and the scarce time of the clinician is the bottleneck in redressing the balance.” Microsoft makes cognitive services available as APIs to developers to create bot agents. He calls this conversational computing, and sees it applied to everything from the logistics of figuring out what health services are covered by your plan, to assisted medical triage for non-urgent care. “The things cognitive services can do today is quite remarkable. They can ‘hear’ by interpreting your spoken voice, they can ‘see’ by analysing pictures, and they can even predict how you are feeling. The more information we feed a machine model, the smarter it becomes.” For a fascinating view on how this has come together to revolutionize the life of one blind man, see the story here: https://youtu.be/R2mC-NUAmMk
Transform the continuum
Some of the most exciting models of care leverage cloud computing. This is currently the primary focus for Microsoft. Once viewed with scepticism by the health industry due to perceived security or control limitations, the cloud is now undeniably being embraced by health organizations around the world. Indeed, Gartner predicts that within this decade organizations will be going to the cloud precisely because it is more secure than the on premises counterpart. Part of this momentum is driven by cost efficiencies and outsourcing, but there is another motivator that is becoming increasingly apparent – some capabilities are only possible in the cloud.
“The cloud is essentially a global supercomputer, that you can access on demand and pay only for what you use. You get all the benefits, yet the cost is spread across all the users. Kind of like timeshare,” Kos reflects. The virtually unlimited storage pool makes medical imaging storage cost effective, or any other big data scenario for that matter. The incredible processing power makes genomic sequencing feasible. Machine learning and artificial intelligence are most practical in the cloud. Aggregations of software as a service providers, like an enterprise app store, allow organizations to discover, trial and deploy new applications with a minimum of risk and hassle. Kos sees the potential of the cloud to defragment all the data silos that frustrate holistic health information management.
The cloud can also be a place for partnerships. Application developer Gojo teamed up with hand hygiene specialist Purell to create an innovative approach to combat hospital acquired infections. By combining information from activity monitors about staff traffic into a patient room, together with usage feedback from the hand sanitizer dispenser, it is now possible to track with accuracy handwashing compliance. See the story here: https://youtu.be/_pQNoLKrSoA .
Making cloud computing trustworthy is a key priority. Part of that involves making sure it is secure, and Microsoft invests over a billion dollars annually to that end. Just as important though is making sure that the cloud can be used compliantly, so Microsoft has invested in industry certifications like HIPAA through a Business Associates Agreement, HITECH, and FedRAMP. Keeping information private, being transparent about datacentre operations, and allowing users the controls to manage their own data round out the trust story.
The importance of partnership
Operating within the nucleus of Microsoft is a global partner network with entry criteria set deliberately low, so any development organisation using Microsoft technology can join through an online signup process. This is intended to bootstrap entrepreneurs, providing immediate benefits like access to technical support, training, and programs like Bizspark that subsidize development licensing costs and provide a certain amount of free cloud hosting each month.
The network is tiered, allowing partners to differentiate their product or capabilities through certification, and at the higher levels to tap into co-marketing and co-selling directly with Microsoft. “For health organizations, this means an ecosystem of partners on a common technology platform providing capability, choice and competition.” Kos summarizes. For more information about the Microsoft Partner Network see here: https://partner.microsoft.com/en-us/
Kos sees change accelerating for the health industry. The sector is not immune from digital disruption that has changed so many other sectors and redefined our perspectives. Moving beyond digitization into transformation is the new challenge, and health organizations across the globe are rallying with innovation. “This is ultimately why I continue with healthcare IT over clinical medicine. For me, the choice is between changing the world one patient at a time, or having impact on a global scale. I see Microsoft playing a key role in the digital transformation of healthcare,” Kos concludes.
 Bodenheimer, T. & Sinsky, C. "From Triple to Quadruple Aim: Care of the patient requires care of the
provider" Ann Fam Med Nov/Dec 2014, vol. 12 no. 6 673-576