CHIME Digital Health Most Wired National Trends 2021: A Thought Leadership Roundtable

Introduction

CHIME recently hosted a thought leadership roundtable featuring members of the College of Healthcare Information Management Executives (CHIME) for discussion of current trends in digital health. Topics were selected based on analysis from the CHIME Digital Health Most Wired National Trends 2021 report. Chief information officers (CIOs), chief information security officers (CISOs) and other digital health leaders provided perspective on patient engagement, patient portals, telemedicine, cybersecurity, remote work, AI and more. CHIME President and CEO Russell Branzell moderated the roundtable.

CHIME members participating:

• Andrew Burchett, Chief Medical Information Officer, Avera Health
• Jeff Cash, Senior Vice President, Chief Information Officer, Mercy Medical Center, Cedar Rapids, Iowa
• Mark Clark, Vice President, Information Technology, University of Colorado Health
• Michael Garcia, Senior Vice President, Chief Information Officer, Jackson Health System
• Kim Gordon, Senior Vice President, IS Applications, Spectrum Health
• Michael Mistretta, Senior Vice President, Chief Information Officer, Virginia Hospital Center
• Donna Roach, Chief Information Officer, University of Utah Health

Representatives from sponsor firms participating:

• Dick Flanigan, Senior Vice President, Cerner
• Gus Malezis, Chief Executive Officer, Imprivata
• Mark McArdle, Chief Products & Design Officer, Imprivata
• Edward Marx, Chief Digital Officer, Tech Mahindra Health & Life Sciences
• Anthony Binge, Senior Vice President, Tech Mahindra Health & Life Sciences

Summary

The CHIME Digital Health Most Wired Survey serves as a “Digital Health Check” for healthcare organizations around the world. By assessing digital innovation and advanced technologies, the survey honors top-performing organizations with certification based on their level of achievement.

As digital transformation in healthcare accelerated during the COVID-19 pandemic, the Digital Health Most Wired program also grew exponentially. More than 36,000 facilities participated in the program in 2021—a total that reflects a 1400 percent growth in participation since 2018. With questions customized each year to reflect changes in the healthcare ecosystem, the survey provides a valuable road map for forward-thinking organizations as they strategize for a digital future.

Each year, CHIME analyzes the survey results and publishes a Digital Health Most Wired National Trends report to track the state of the industry in digital health. Through the report, digital health leaders, the press, and the public can follow the annual progress of new technologies and emerging best practices.

In this roundtable discussion, members of CHIME and the CHIME Foundation discussed the results of the 2021 survey, including patient engagement, patient portals, telehealth, cybersecurity, migrating data to the cloud, remote workforce, hiring/retention, AI, ML, and process automation.

Patient engagement

The Most Wired National Trends 2021 report found significant growth across the board in patient engagement, including increasing numbers of patients using digital portals, mobile apps, real-time news/blog feeds and electronic insurance cards.

Roundtable participants discussed the reasons behind a strong commitment to digital engagement that has taken center stage in many organizations.

“No matter what industry you’re in, consumers expect that access will be easy and data-driven,” stated Kim Gordon, SVP, IS Applications, Spectrum Health. “We’re not any different from any other industry: unless we make it simple for patients and allow them to engage with us digitally, we won’t be ahead of the game. It’s just expected, and unless we make it simple, we will lose patients to those who can do so.”

Patients need strong connection because they are often going through tough times when they contact healthcare providers. “In healthcare, it’s even more critical to have consumer engagement,” said Anthony Binge, SVP, Tech Mahindra Health & Life Sciences. “It’s an emotional time for patients. They’re going through something that may be a matter of life and death, and if they don’t feel they’re cared about, they will get upset and disconnect. It’s a really tough spot to be in.”

For many patient populations, continuing engagement over time can significantly improve a patient’s health outcomes.

“We serve a rural environment,” said Andrew Burchett, CMIO, Avera Health, “and patient engagement dovetails with all our population health initiatives. We need to move from episodic to continual care, and patient engagement is the pillar that stands on.”

Burchett mentioned elements of patient engagement including patient-generated health data, family and proxy, support and care provided to the patients, health maintenance, wellness programs, food/nutrition efforts, and maintaining contact with patients throughout the year. “One example is connecting with our gestational diabetes patients to lower morbidity and mortality,” Burchett said. “And we literally keep in contact with those moms every day to pull that off.”

Other provider organizations find that patient engagement may be key to drive consumer loyalty in a competitive market. “We are in a major metropolitan area in Washington, D.C., and we’re the last independent hospital system in that market,” said Michael Mistretta, VP, CIO, Virginia Hospital Center. “15 or 20 years ago, the physicians were your salesmen, but that’s not the case anymore. The only way you’re going to be able to compete is by attracting the patient. We have the highest patient satisfaction scores in the state of Virginia: we’re either number one or number two every year because it’s such an intense focus for us. It’s what drives patients to us, and that’s how we compete in the market space.”

Patient engagement through portals and mobile devices carries additional benefits beyond building consumer loyalty, including noticeable improvements to efficiency.

“Because of our new email services and our portals, we don’t get the volume of phone calls we used to get,” said Jeff Cash, SVP, CIO, Mercy Medical Center. “The bill pay has been great for us. When people go online, it’s more convenient for them that we’ve set up their own customized terms. Increased engagement also helps with our no-show rates, because we remind patients of their appointment times, and we can allow them to change their schedules on demand.”

Patients have indicated that the convenience of consolidated records behind a single digital front door can also be a game changer in how they choose their health care.

“Patient engagement has created a new front door for everything we do,” said Mark Clark, VP, Information Technology, University of Colorado Health. “The more we can give that patient –the more we can consolidate for them—the more it differentiates us as a provider. We have patients giving us feedback directly, saying, ‘I have switched primary care providers to make sure I can have a consolidated record.’”

 For many organizations, the pressures of COVID-19 accelerated the migration of patients to the digital front door and became the chief catalyst in the increasing use of portals and apps noted by the 2021 survey.

“Throughout the pandemic, when it came to vaccinations, to testing, we wanted folks to know that we are here for them,” said Michael Garcia, VP, CIO, Jackson Health System. “So, we made sure that folks knew how to log into the portal, and how to book future appointments. Now, anytime they come in, they know that we’re also integrated with Apple and with Android applications.”

Participants also reported increased engagement after soliciting feedback from patient advisory groups. “When we built our app, we brought them in and asked what they wanted in the app,” Mistretta said. “And it’s a screaming success now. We have one to two thousand downloads a month on the app.”

Telemedicine

The urgent need for distanced healthcare delivery after the onset of the pandemic caused telehealth appointments to skyrocket in 2020. Though those numbers leveled out and dropped off somewhat in the 2021 survey, telehealth continues to retain a much more prominent role across the industry than it did before the pandemic.

“We’re seeing benefits from telemedicine in specialty care. Behavioral health is our huge success story,” said Burchett. “Patients love it—providers love it. The access is better. And the other one is infectious disease. We can spread our small group of infectious disease doctors over our entire footprint much more easily with telemedicine than we could before. The same is true for perinatology.”

Roundtable participants reported that despite some declines from peak numbers in telehealth seen in 2020, demand continues for virtual care delivery. Patients appreciate the convenience, and many do not want to come into a physical clinic for routine care that can be managed by virtual appointments instead.

The changes to add flexibility in telehealth regulations from the Center for Medicare & Medicaid Services (CMS) made a critical difference for many providers in their ability to deliver telehealth.

“When Medicare opened up the doors to allow reimbursement for virtual health appointments, that changed everything,” said Cash. “It made it much easier. We went from five or six a day to 700 or 800 a day, nearly overnight, because the platform was there and ready to go.”

Provider organizations see telehealth as another differentiator for patients. “It’s easy access,” said Clark. “It goes back to the question of how you provide an easy front door for the consumers? Through the COVID process, we went from 600 unique new patients a day to over 1100 new patients a day. And those telemedicine numbers are staying pretty flat—they’re dropping a little, but they’re staying high. The differentiation of having these services is making a huge impact on the draw of patients to our services.”

Telehealth can also help in the quest to move from fee-for-service to value-based care. “We’ve put a stake in the ground that says within the next five years, we want to be 50% value-based care,” said Gordon. “All of the virtual care and patient engagement, that is all going to be part of value-based care. It’s a mind shift, and that’s what we’re trying to get our clinicians to see.”

University of Utah Health CIO Donna Roach also pointed to the need for a cultural shift to bring more physicians onboard with the addition of telehealth to the front lines of patient care. Roach noted that while some physicians are strongly in favor of telehealth and outreach to the community, others still feel that the patients should visit their offices in person. The fee-for-service model can cause physicians to see telehealth as counterproductive to the financial model. “The current goal is getting our physicians to shift their thinking a little, and getting that shift done culturally. Then I think we have a lot of opportunity.”

Cybersecurity

Survey results show that while improvements in cybersecurity continue, the pace of change remains relatively slow compared to rapid advancements in other areas of digital health. Roundtable participants emphasized the continuing need for investment in cyber security in an era of increasing threats.

“We see the number of attacks increasing on a regular basis,” said Burchett. “I don’t think we have a choice to relax or not continue to invest in it.”

“Attackers will mimic your exact home page or email setup,” Garcia noted. “With one click, someone would install and establish their connection. So really, it’s all about behavior analytics. Analyzing behavior patterns of equipment has really been helping us.”

In healthcare organizations with an academic side, education about cybersecurity becomes necessary when ideology about academic freedom leads to online activities that could jeopardize security. “We’ve had to educate people,” Roach said. “Our new president of the university has made cybersecurity one of his top issues, which is very helpful.”

Roach added that having leadership support from the top makes it easier to develop a unified security policy, under which individual departments can’t continue to operate noncompliant servers that would present a risk.

Participants report that while there is a great need for continuing progress in cybersecurity, nonetheless, the past few years have brought necessary changes. “Now, there’s almost a standard,” said Mistretta. “Most organizations have some sort of security consulting and auditing. Most have a basic tool set in place.” The focus for the near future, Mistretta said, will be on two major areas: training to fix the security breaches caused by human behaviors, and improving recovery after a security incident.

One key component of cybersecurity is validating identity to prevent imposters from accessing the system with fake credentials or stolen credentials. “We think an email address is an identity, and frankly, it isn’t,” explained Gus Malezis, CEO of Imprivata. “We need to get more structured in truly validating who an individual is before they enter the system. Because once they’re in, you have a lot of recovery to do.” 

Migrating to the cloud

Many organizations have begun to move data out of onsite data centers and into the cloud to be hosted by third-party vendors. Some leaders see a migration to the cloud as a way to focus on essentials.

“We’ve always been in the information business versus the tech business,” said Clark. “So, the more we can minimize the tech side of it—the more we quit chasing nuts and bolts and keeping the blinking lights on—the more we can focus on the process and the people and how to make ourselves more efficient.”

Others saw challenges in the cloud hosting trend. “It’s too expensive,” said Cash. “We can make a large capital purchase [for onsite data centers] and run everything for three to five years, sometimes longer. We can virtualize servers and get multiple things running on the same hardware now, so hardware maintenance costs have dropped considerably. My experience with the online vendors is that they’re pulling more profit away than they probably should. With those economies of scale, our prices should be going down, but when we do an ROI on it, moving to a subscription model is more expensive.”

Cerner SVP Dick Flanigan agreed that to serve providers well, the subscription model needs to answer some of the objections that CIOs have raised. The model must respond to drops in volume with drops in price, just as prices increase when volumes increase. “This model has got to be sensitive to up, down, all sides, and it has to be sensitive to crisis, like what we just went through,” Flanigan said, referring to the pandemic. “Our view is that going into the SaaS business model, clients will need to have the confidence that the transition to SaaS will not negatively affect their overall cost for technology and services.”  

Other participants noted that cloud migration can lead to efficiency benefits. “I’m thrilled when I can move something to the cloud,” Gordon said. “It’s so much easier to manage. It’s cheaper from a staffing perspective, and you’re always getting updates. But it’s always a challenge for budget allocation and choosing capital versus operational expenditure. I think there’s going to be a shift, eventually, as strategic goals change, so it won’t matter as much where the money comes from.”

Hiring and retention in a remote work environment

Hiring and retaining staff from a workforce already short on certain types of skilled professionals became even more challenging with the pressures of the pandemic across the healthcare industry. Complicating the new workforce culture even further now is the widespread post-pandemic move to remote work.

“We have a massive worldwide shortage in talent—not just IT talent and cybersecurity talent, but nursing talent, physician talent, and more,” said Russell Branzell, President and CEO of CHIME. “With remote work, our workforce management had to change completely, and we’re not seeing a significant return to work in buildings yet.”

Some participants saw benefits to the new remote work culture. “We love it from a productivity perspective,” Garcia said. “And we can cast a wider net for resources.”

“We do a survey every quarter with our staff,” Roach said. “They respond that they love working from home. And we have a very young population, which means lots of staff with young children at home. If the children are too young to be vaccinated, then they may be at risk of contracting COVID from a parent who comes into an office, but not from a parent who works at home. This is part of the equation when you’re taking care of a mobile workforce.”

CIOs and other leaders are also navigating the complexities of hiring from outside their states now that the workforce can be remote. Many CIOs are now hiring from states in which they have never hired before. Participants pointed out that hiring from some states such as California and Arizona can be so complicated due to employment law in those states that they simply cannot consider hiring residents of those states.

Several leaders also described challenges that come with competing for hires in a national market.

“In the Midwest, there are great pockets of good IT people,” Cash explained. “Now, the people hiring from the coast have a pretty easy time recruiting because they can offer those Midwestern staff a 30 to 60 percent pay bump based on market salaries in their coastal states. But if you’re an organization in the Midwest, it can be really hard to hold on to your team because we can’t compete with that kind of pay gap.”

Mistretta agreed. “We’ve had people from New York calling our folks and saying, ‘You don’t have to move. We’re going to give you New York City wages while you live down there.’”

With frontline providers also resigning from the workforce in rising numbers reported in the national media, it is clear that retention will be an ongoing issue across the industry and one that will require continued action and vision from leaders.

Looking ahead: AI, ML and process automation

When asked to name the most important trends for the industry’s future, many of the participants agreed that AI, ML and process automation will play an increasingly important role in health care.

“AI and automation are the two big ones,” said Burchett. “Our AI right now focuses on pharmacogenomics and care planning for our patients. We don’t use it widely outside of oncology. And then the other big question is whether we move to the cloud, and when.”

“Process automation and the digital front door will be key—those are the kinds of things we’re working through,” Garcia said. “With the talent struggles we’re all having, if we could automate the low-hanging fruit, that would be crucial.”

“I don’t know that I would say it’s only AI, but it’s productivity, and AI is one mechanism to gain productivity,” said Mistretta. “Many of these new processes and technologies that are coming out are going to be used to even further enhance that patient experience and drive quality initiatives. So, the focus will be productivity and your input, your intake, how you’re influencing care, how you’re standardizing, and how you can use AI to do that.”

“Various kinds of discrete AI tools are going to make a difference and give you actionable data,” Cash stated.

Roach added that another key element will be determining how to apply “responsible” AI. Some applications of AI have contained algorithmic bias leading to unforeseen negative impacts on certain consumer populations, so leaders will have to carefully evaluate possible outcomes before implementing each AI tool.

Flanigan agreed. “We’re studying the ethical use of AI and very active in it. And the industry will have to deal in a major way with privacy. All digital partners are going to have to comply with the privacy ecosystem. Their free rein of not having to protect patient information is coming to an end. So as organizations build digital front doors, they will have to build privacy protections around patient data.”

“We have to build on some of the success we’ve already seen,” Clark said. “The virtual health centers, the AI, the digital front door, we’re going to have to keep getting better and better at those still very young technologies. In healthcare, we still think of our business in silos that don’t register from a patient’s perspective. We need to blur those lines a lot more. And the patient experience, AI, virtual management and pushing information out to the patient is really going to help support that, but we also need to change the behaviors that go along with the silos.”

Malezis agreed on a need for the industry to address fragmentation behind the scenes as organizations emphasize patient experience. “I think the challenge with patient experience is that there’s been a lot of thought put into it recently, but there’s also a lot of fragmentation, which means that the burden is falling on the provider to assemble the systems. That has to change to become more like a consumer experience—very simple. There will be more streamlining of the distribution of information and services.”

Binge questioned whether hospital-at-home might be an influential trend. Roach responded that while it could be a possibility, the policy of CMS would have a major impact on growth. Bundled payments currently encourage health care systems to save money by providing services in a patient’s home rather than in more expensive facilities. “If the bundling gets pulled,” Roach said, “I think you’ll see a lot of hospital-at-homes leaving the market.”

Conclusion

The CHIME Digital Health Most Wired National Trends 2021 report identified a number of trends that show rapid ongoing transformation in how healthcare is delivered. CHIME’s digital health leaders agreed with the central importance of increasing patient engagement through a digital front door. They also affirmed the need to continue investment and training in cybersecurity, given the continuing threat of cyberattack and the relatively slow pace of improvement in security compared to some other areas of digital innovation.

Opinion varied on the merits of migrating information from data centers to the cloud, with relative costs and budget allocation taking the central role in the debate. The continuation of remote work has changed the landscape of hiring and retention, while offering many benefits for workers and improving efficiency. Roundtable participants agreed that the digital front door, AI, ML and process automation will be crucial areas of focus for the near future, along with increased security measures to protect patient information as the workforce remains mobile and data moves to the cloud.

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To learn more about the Digital Health Most Wired program and how to earn certification in 2022, visit the program website.

This thought leadership roundtable was written by Rosslyn Elliott, CHIME Editor, and brought to you by Cerner, The HCI Group, and Imprivata.