AI May Cure The Ills In Healthcare Tech

As our healthcare system struggles toward a model in which consumers are at the center of the equation, technology is playing a rapidly increasing role in smoothing their way through the ecosystem. Consumers are demanding a better healthcare experience, but there’s a massive collision coming between the exabytes of global health data and consumer health and insurance illiteracy.

“Interoperability” describes a set of American regulatory initiatives that are in play right now and will drive change in the industry for years to come. As president of a healthcare technology company, I believe them to be as significant as any changes to the system made in this century, including the introduction of HIPAA privacy regulations and the Affordable Care Act.

Among them are requirements that health plans must share information about a member’s past claims experience, such that a member’s history now travels from plan to plan with them. Other information-sharing regulations make enormous amounts of health and insurance data directly available to patients, most likely downloadable to their smartphones. Some health plan portals and apps are already providing volumes more data than they did just a year ago.

Poor Literacy Equals Worse Care

This creates a new set of hazards. Research results show that low health insurance literacy among consumers has negative impacts on health. For example, when consumers don’t understand that certain health screenings are free, they are more likely to skip them. High deductibles can discourage people from seeking care due to uncertainty about potential costs. A limited understanding of health concepts and terminology will hamper receiving appropriate care. The results of research from the Centers for Disease Control indicate that complex health information confuses nine out of 10 Americans. Although no consumer should be expected to have a scientist-level understanding of medical terminology, the level of basic health knowledge is dangerously lacking.

What’s likely to happen when people receive their first smartphone-full of medical terms in Latin abbreviations, industry insurance codes and administrative jargon? I expect that most will turn to their keyboards, as Google already receives more than 1 billion health queries every day. There’s an abundance of symptom-checkers online, many of which are worse than no information at all.

As it is, some providers already find themselves spending an inordinate amount of precious patient encounter time clarifying, explaining and overcoming information consumers have mustered through internet searches. Whether patients have self-diagnosed or are filled with anxiety-driven questions about their genetic profiles, they’re taxing the system in new ways. I’m all for consumers advocating for their health, but unfiltered data in the hands of the anxious or unschooled can burn up resources or lead to poor decisions.

Current Tools Are Still Primitive

In addition to encouraging consumers to become more educated, I believe we should put artificial intelligence (AI) to work in translating insurance and medical jargon into actionable data for patients. Machine-learning (ML) and natural language processing (NLP) models can decipher complex medical terminology into simple, consumer-friendly language. AI and NLP can serve as translators and clarifiers, sifting a vast universe of diagnostic and treatment data, as well as insurance coding and terminology. AI and NLP models can push structured and unstructured data, as well as noisy data, to apps in ways that make the information consumable. This will allow patients to manage their health, their worries and their finances.

Creative minds are already at work on this conundrum for patient portals, but the tools are still primitive. Smartphones are likely to require even more sophistication but hold the promise of greater interactivity and real-time responses.

The freedom of patients to have their own health data has been an objective for many years, but the wheels of legislation and regulatory implementation have turned slowly because the complexity and the stakes are high. Technology will be the essential tool making the “back end” of healthcare more streamlined and intelligent. New treatments, pharmaceuticals and surgical robots capture the headlines, but the work done behind the scenes is just as revolutionary.

Big Fail #5: Underestimating Long-Term Ownership

If a health plan takes the DIY path, what happens to its knowledge resources over time? In the “build” scenario, an organization owns the product and every challenge that comes with it. If something breaks or becomes obsolete, will the resources to keep it up be available? Will the organization be poised to chase innovation as its competitors are sure to do? Can the plan command the talent in the marketplace to keep its unicorn solution operating at peak value? When development talent and expertise erode, it will mean trouble. The expertise to train users and provide day-to-day technical support is critical to long-term success.

Management should prepare for an ongoing tide of integration requests. Contracting and partnership for these becomes a perpetual administrative function – another cost often overlooked.

As a health plan executive, ask yourself when considering the “buy or build” argument whether there is already a mature solution on the market that will do the job. In healthcare, smart vendors have already developed an interoperability infrastructure necessitated by recent government regulations. Look for this kind of commitment from any vendor in your own industry because it could make buying a solution even easier – it certainly does in the case of healthcare.

Executives should weigh what they hope to gain from building a proprietary solution when the hard work has already been done for them. Will this give them a competitive advantage? Do they have a realistic view of the risk and ROI? Can they invest sufficiently in the initial architecture to build a comprehensive solution?

We are a nation of do-it-yourselfers who take pride in self-sufficiency, but knowing when to tap the real experts is a strength, not a weakness. Remember the adage to “do only what you do best.”

Asking hard and far-reaching questions now will help you avoid Big Fail #5.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.

Big Fail #4: Trusting Newcomers Who Don’t Get It

In HealthEdge’s recent survey of 220 health plan executives, respondents cited increasing member satisfaction as their top strategic goal for 2021. When asked what steps they plan to take to achieve their goals, “improve engagement strategies” topped the list.

Laser-focused on customer service and outreach, payers are looking for new ways to enhance the member experience by leveraging digital technologies that enable improved communication, real-time data sharing, and personalized services, while increasing operational efficiencies.

Investing in digital health is on the rise. Rock Health reported, “It’s been quite a ride this past year watching digital health catapult from a niche sector to a mainstream market. The first half of 2021 closed with $14.7B invested across 372 US digital health deals with a $39.6M average deal size.”

The report added, “Even at its six-month mark, 2021 already surpassed 2020’s overall funding record.”

With the emergence of cloud-computing, API capabilities, artificial intelligence, virtual health, mobile apps, and more, the healthcare industry has seen a boom in digital technology startups with solutions aimed at improving care and lowering costs.

The digital disruption puts tremendous pressure on payers and providers to invest in next-generation technology or get left behind.

In this environment, health plan executives should be especially wary of vendors with “DIY” applications who are trying to enter their industry for the first time. Over-confident players with simplistic approaches underestimate the industry’s intricacies around lines of business, regulation, data, clinical practice, financial dynamics and consumer trends. Decision-makers should skip entities with a core focus elsewhere or who are spreading themselves across too many disparate businesses.

Vendors with success in other segments of the economy aren’t guaranteed the same outcomes elsewhere. No business should settle for being someone else’s experiment. That’s key to avoiding Big Fail #4.

Don’t miss the final installment of the 5 Big Fails of DIY Software. The last segment talks about the big-picture, long-term costs associated with your DIY platform.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.

Big Fail #3: Unrealistic Costs and Timelines

“63 percent of executives report the pace of digital transformation for their organization is accelerating … Big changes today require bold leadership – and prioritizing tech.”– Accenture Research Global Survey 2021.

The healthcare industry is undergoing a period of digital transformation, forcing payers to prioritize their modernization efforts.

As a colleague at HealthEdge, Len Rosignoli, VP of Customer Success, recently noted in a blog post, an increasing number of health plans see value in using technology to meet their business strategies. “That’s why we’re seeing an increased focus on aligning IT and the business – the partnership has become even more essential,” he said.

But without a clear strategy, payers risk wasting time and money building or patching solutions that provide a quick fix for immediate needs, but cannot support the future of digital health.

Even worse, history indicates that when decision-makers insist on building or patching their own solutions, they are likely to underestimate the cost and timeline.

Research shows that among 1,471 information technology projects studied, the average cost overrun was 27 percent, a figure pushed higher by the one in six projects that spiraled completely out of control. The worst of these saw cost overruns of 200 percent and schedule delays of 70 percent. Researchers say IT has a disproportionate number of runaway projects.

There are other costs to consider. A firm developing a proprietary solution absorbs the entire cost of development, where vendor solutions can distribute development costs and innovations across multiple customers. Since a vendor solution has a much shorter and safer timeline, it offers greater cost predictability over time.

It’s easy to be caught up in your do-it-yourself (DIY) ambitions, but being realistic about costs and deadlines may lead you to choose the right vendor instead, avoiding Big Fail #3.

Check out the #4 Big Fail of DIY software in this space soon. Hint: It’s all about the perils of trusting newcomers to healthcare.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.

The 5 Big Fails of DIY Software: #2: Letting Your Legacy System Hang On

At HealthEdge, we frequently hear from health plan executives struggling with homegrown legacy solutions that have become obsolete. Their users have developed a hodge-podge of manual workarounds to accommodate a growing set of deficiencies, right down to Excel spreadsheets and double-entering data into disparate systems. Add to that the complexity of the healthcare ecosystem today and you have a recipe for dysfunction.

Industry consolidation is a growing trend in the payer space today. The steady stream of mergers and acquisitions results in multiple systems, point solutions, and dissonant architectures jamming up the flow of information in many organizations. With legacy systems, outdated technology and latent data and delays, the quality of care suffers, backlogs pile up, and opportunities to support innovation evaporate.

As the Everest Group noted in a blog post, “The healthcare payer industry is plagued with notoriously old infrastructure. While healthcare payers are working to increase data transparency, offer member-centric solutions, and adopt a value-based care model, they’re obstructed by high reliance on dated, disconnected and non-interoperable systems.”

The disjointed systems and manual processes waste time, introduce manual errors into workflows and can eventually destabilize the software program. Staff and customers eventually bear the brunt of this.

Knowing when to put your legacy system out of its misery is a critical multiplier for success. That’s why letting it hang on too long is Big Fail #2.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” 

The 5 Big Fails of DIY Software: #1 Getting Out of Your Lane

More than ever, health plan executives see their IT and business strategies as deeply intertwined:

According to Accenture Research Global Survey 2021, 83 percent of IT and business executives say business and technology strategies are becoming inseparable – even indistinguishable. Furthermore, 77 percent say that their technology architecture is becoming critical to their organization’s success.

Yet, for anyone leading an organization, cost is always a top consideration.

What executive hasn’t asked themselves at some time, “Couldn’t we just build this software ourselves?” It’s not unheard of to wonder whether in-house development will deliver a less expensive custom product. These decision-makers should heed the cautionary tales of “build” decisions that resulted in longer timelines, cost overruns and poor results. No less than General Electric embarked on an ambitious in-house digital transformation that quickly became mired in organizational dysfunction and conflicting priorities that have dragged on for years. I believe there are many more “build” stories that never generate headlines because they remain internal failures that no one wants to discuss.

The scenario is even more complicated in healthcare.

When Altruista’s parent company, HealthEdge, recently asked 222 health plan leaders what steps they plan to take to achieve their organizational goals this year, 59 percent said they plan to modernize their technology and 50 percent plan to make a significant investment in innovation, up from just 19 percent in 2018. It’s clear they see the importance of technology investment, but will they choose wisely?

As the president of a high-tech company serving health plans, I can tell you that our customers operate in one of the world’s most challenging environments. Reinventing the wheel just doesn’t make sense, especially in ecosystems like healthcare that are defined by flux. I would advise organizations in any industry to stay focused on their core mission. Developing software is not the strong suit of anyone outside of technology, and executives are advised to rely on the expertise of people who have devoted their careers to software development.

In an era of highly specialized knowledge, it only makes sense to trust the innovators who have purpose-built a platform for your exact needs and who will continue to stay ahead of the market. Therefore, the key to avoiding Big Fail #1 is to stay in your lane.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.”