The CHIL Healthcare Industry Model: Actors, Relationships, Processes

A graphical conceptual framework is presented, enabling attendees to assimilate more of the detail that will be presented during the Workshop, and to advance personal learning when back in the workplace.  The model frames the major actors, relationships, processes, and major concepts that comprise the U.S. healthcare system.

U.S. Healthcare Assessment: Sustained Cost and Quality Crisis

What is a national Healthcare System? Key facts and statistics; cost and quality; history and culture; macro industry structure; how money moves through the system; nature, size, concentration and priorities of sectors and how they intersect and interoperate; role of government; regulatory and other influencing bodies.

Key Healthcare Trends: Policy, Structure, and Business Model

Major areas of stress, transformation and innovation; patient-centricity; consumer power in political battle; from Fee-for-Service to Value-Based Care; population health; personalization of medicine based on new molecular science and high-powered analytics; pressure on hospitals; epic struggle over healthcare for the poor; focus on social determinants of health; despair, homelessness, loneliness, mental health, opioids; Medicare Advantage as template for the future; rumbles of fundamental disruption.

National Patient Population: Bifurcation Nation

Who is the US Healthcare user?  Size; segmentation by demographics, geography, and other measures; access to care; health status; shifts and trends; Social Determinants of Health; forecasts.

Care Delivery Systems: When You’ve Seen One…

Overview of all major types of Outpatient (”Ambulatory”), In-Patient (“Hospital”), Long-Term Care, Medical and Diagnostic Lab facilities; primary care groups; specialist practices; multispecialty groups; IPAs; walk-in clinics and urgent care centers; community hospitals; independent regional hospitals; academic medical centers; national hospital conglomerates; large specialist hospitals (e.g. MD Anderson); labs.

Healthcare Financing and Insurance: Paying the Bills

What is health insurance? The concept of risk.  Global healthcare models (private, public, single-payer, multi-payer); U.S. hybrid model; insurance, the risk pool, indemnity, and managed care; the concept of risk; types of health insurance and how they work; provider reimbursement; claims, fee-for-service and the shift to fee-for-value; government role as provider, payer, and regulator; government payment programs (Medicare, Medicaid, CHIP, Trinet, etc.); private insurers and main products; Medicare Advantage success factors, core competencies, and growing applicability to other segments.

Life Science: Development, Drugs, Devices

Industry participants; motivations, priorities, and concerns; scientific discovery and productization process and requirements; how pharma and device makers interact with consumers, providers, and payers; role of PBMs and device distributors; CROs; clinical trial operations, limitations, and trends.

Regulators and Regulation: Law, Standards, and Certification

Review of all major legislation from Medicare and Medicaid creation in 1965 through MACRA and 21st Century Cures; overview of major agencies and bureaus (including CMS, FDA, CDC, ONC, NCQA, NIH, NCPDP) and their associated regulatory responsibilities, frameworks, and priorities.

The CHIL Healthcare Industry Model: Actors, Relationships, Processes

HIT Market Landscape: Extraordinary Times and Forecast

Principal market segments (patient, provider, payer, pharma, CRO, government, vendor, integrator); principal functional categories (e.g., legacy back-end claims systems, EMRs, clearinghouse networks, HIEs, clinical decision support and population health systems, drug discovery platforms, analytics, etc.); core system requirements; HIT market size, forecast, and growth drivers; leading vendors; technology trends and state of adoption; standards overview; regulations that apply in sector and when dealing with other sectors.

Major Technology Systems: By Sector and Cross-Sector

Drill-down on architectures and features of categories that are most significant (e.g. EMR, claims) or central to disruptive innovation (e.g. clinical integration, risk management, consumer digital health).

HIT Standards: Ground Rules

HL7, FHIR, CDA/CCD, X12, DICOM, cybersecurity, ISO (general, and for devices), etc.

HIT Terminologies: (Un)Common Languages

Review of terminologies critical to data normalization and reliability, knowledge development, and clinical information sharing: ICD-10, CPT, Loinc, Snomed, RxNorm, NDC.

Healthcare Data and Data Models: One Example: Patient Visit

What is Data Modeling? Unique data modeling and management requirements of healthcare; leading healthcare data models; principal entities, nomenclatures, and semantic frameworks; Master Data Management; provider data and network management; data rights and restrictions with regard to contracts and to regulators.

HL7: Major Clinical Transport

HL7 as architecture, language, and standards body; HL7 technology as framework and toolset for exchange, integration, sharing, and retrieval of electronic health information; understanding problematic upgrade and split user base between releases V2 and V3; overview of high-level conceptual architecture and component application model, document, and messaging standards.

FHIR: Fire from Below

Review of latest HL7 standard, currently in Draft Standard for Trial Use (DSTU), a user-driven effort to move HL7 into a better leadership position; combination of V2 and V3 features to support heterogeneity; current status including support among EMR vendors.

C-CDA and CCD: Dominant Clinical Data Structures

Review of HL7’s Clinical Document Architecture, supporting many key document types in nested structures including document level (e.g., Discharge Summary), Section level (e.g., Allergies or Medications), and Entry level (Observations or Procedures).

Healthcare Technology Trends: Look Over Yonder

Review of important technology trends, both those in substantial production use and those largely in development mode, including: Artificial Intelligence;  consumer adoption of portals, digital health apps, and mobile; Cloud/AWS; big data assembly; HIE and HIE-as-a-Service; Telemedicine; population health and precision analytics; robotics; NLP and cognitive computing; potential role of next-generation EMRs as trustworthy platforms; blockchain; virtual and augmented reality; OMICs; digital assistants (e.g., Alexa); Internet of Things, wearables, and monitors; Real-World Evidence (RWE) for pharma.