It’s the stuff of futuristic daydreams. Implantable sensors that can detect signs of a potential health problem and send alerts to your smartphone, like a “check engine” light for your body. A straight-out-of-Star-Trek handheld medical scanner you can use to diagnose your own problems and alert your physician. A capsule-shaped sensor you can swallow so your doctor can perform your annual physical via phone or tablet, even while you’re at work or — better still — out on the links.
Only these aren’t daydreams at all. These are just a small sampling of the health care innovations that will be market-ready in the near future. Health-related mobile apps are booming as well, growing at a rate of 25 percent a year.
These technologies will become a part of the increasingly interconnected environment of health care devices, which already includes common technology such as radiology equipment, dialysis machines and the smartphone in the pocket of every practitioner.
The Looming Cloud
The Internet of (medical) Things is part of the push toward modern, patient-focused health care. It is at the core of the telemedicine movement and it is poised to expand access to care at a crucial point in the evolution of health care reform. But there is an ominous cloud hanging over all of this progress.
Health care systems are under siege like never before. Experts report a worsening trend in the frequency and complexity of cyber attacks on health care networks, with a sharp increase over the past year.
“The advanced persistent threats that we’ve been fighting on behalf of our clients in government and defense for the past five years have now shifted into the health care arena,” said Tom Patterson, director of global cybersecurity consulting with CSC.
“Companies are being targeted; adversaries are spending more than a year breaking in, escalating their privileges, looking around, customizing specific malware to defeat their specific defenses, and then either exfiltrating data or doing the damage they wanted to do. That type of attack is light years ahead of most health care companies’ defenses.”
A report published in February by the SANS Institute painted an overwhelmingly dire picture of cyber threats in health care. Between September 2012 and October 2013, researchers identified 375 U.S. health care organizations that were compromised — many of whom are still unaware that they’ve been compromised. HIPAA and the HITECH Act forced health care organizations to take comprehensive measures to protect patient data or face heavy fines. The trouble is that compliance doesn’t necessarily equal security, and systems unrelated to protected health information (PHI) are getting less attention.
The SANS study found that hackers were infiltrating devices such as radiology imaging software, conferencing systems, printers, Web cameras and mail servers. With each new device and application connected to health care networks, security experts warn, a new window opens for hackers to exploit, widening the available attack surface.
“There are two types of companies, those that have been hacked, and those that don’t know they’ve been hacked,” said Kurtis Suhs, vice president and national technology and privacy product manager for Ironshore.
Unfortunately, the ones that don’t know about it yet could be in deeper trouble than they could ever imagine.
While much ado is made of the cost of data breaches in the retail sector, the impact of a disruption to the health care delivery system could be far more chilling. Imagine hackers taking control of the life-support devices in every critical care unit of a 25-hospital health care system. Imagine if they could gain control of every medication-delivery pump in the network, delivering lethal doses to dozens of patients.
What if malware from a random smartphone could infect every diagnostic device across the network, scrambling readings and making it impossible for doctors to treat patients? These scenarios are already possible — more possible than most would care to think about.
“The health care ecosystem is one of the most critical infrastructures for any country,” said Andrea Fiumicelli, vice president and general manager of healthcare and life sciences for CSC. “Preventing health care delivery from working for even a few hours could have a massive impact on a national level.”
“Both terrorist groups and hacktivist groups spend a lot of time trying to disrupt other parts of critical infrastructure,” added CSC’s Patterson, “but the easier it becomes to disrupt the actual health of the target humans, the more we’re going to see them slipping into that arena as well.”
The ability to commandeer medical devices makes health care systems a prime target for extortionists as well, experts said.
Video: This Technology Outlook 2020 looks at global megatrends and technologies affecting the health care sector.
Beth Berger, national director of Arthur J. Gallagher’s health care practice, used the example of how equipment servicing can be done
remotely via Internet-based diagnostics.
“What if somebody hacked into that and recalibrated [equipment] … ? What if I told this hospital that unless you wire me X amount of dollars, I can shut down the life support on all the people in your hospital? And let me show you for two minutes.”
The prevailing opinion among experts is that the health care industry lags far behind most other industries in terms of making real improvements to cyber security. However, it’s fairly easy to understand why.
“You really have to have empathy for health care providers these days,” said Katherine Keefe, breach response services director for the Beazley Group.
“They’re facing so many changes and cyber is just one of them. They’ve got dwindling reimbursements, changing payment methodologies, increased regulation and heightened expectations about providing care to more people who [now] have insurance under the health reform act. … I feel like we just have to help them.”
Help is coming, albeit slowly. CSC’s Patterson said the FDA is moving toward classifying certain medical devices as industrial control (IC) devices, which will subject them to stringent security controls.
Meanwhile several web-based medical apps and programs are getting certified by Underwriters Laboratories, according to Dr. Bill Bithoney, senior adviser at BDO Consulting and a member of the health care practice.
But health care organizations need to look inward and start changing the way they think about cyber security, beginning with the way they think about the growing network of peer-to-peer devices.
“Everything is going to be connected in the health care space very quickly and it’s going to come from multiple different vendors,” said Patterson. “It’s all going to start talking to each other on its own. … The health providers aren’t necessarily going to have a single point of control for all these devices. So if you don’t have a security scheme that takes that into account, you’re at real risk.”
“Years ago, it was all about perimeter security,” said Ironshore’s Suhs. “It was, ‘You’ve got to buy our firewall and antivirus to prevent the bad things from happening.’
“The security paradigm has changed today. I don’t think there’s a way you can prevent a data breach.
“It’s a matter of how do you detect it. Those that can quickly detect are those that can probably cost contain the breach in an effective way. … From an underwriting standpoint, that’s the paradigm I have.”
Kevin Kalinich, cyberrisk global practice leader for Aon Risk Solutions, warned against trying to solve the problem by throwing more money at IT.
Before deciding on a strategy, health care entities would be well served to take an enterprise risk management approach to protecting their systems, he said.
Organizations must ask themselves, “How do we check in the patient? How do we collect their information? How do we decide who has access to patient information?” Armed with a better understanding of how the system works together as a whole, then they can begin to identify their vulnerabilities.
“It’s crucial to balance IT security with appropriate policies and procedures,” said Kalinich. “It’s about knowing what you should be doing and what you should not be doing with Internet-connected medical devices. Each department needs to be on the same page about what they should be doing and that includes their third-party providers. It’s a culture issue.
“Insurance and cyber security go hand in hand,” he added. “The underwriters will give you more comprehensive coverage for a cheaper price if you have good ERM.”
Patterson added that insurance companies also need to look inward, and think about creating cyber products that deliver real value to insureds.
“Cyber insurance hasn’t been tied to real security — it’s always been actuarially based.
“What I want to see the industry evolve to is, ‘Here’s the probability of this happening. So if you take these tangible steps, it will make you more secure, so the probability goes down, so your risk goes down, your insurance [premium] goes down.’ It becomes much more of a useful policy,” he said.
“That makes all the sense in the world and I think that’s what companies would love to buy today if they believed in it,” Patterson said.
Beazley’s Keefe agreed.
“The folks in the markets who can deliver solutions that make sense and add value and really make a difference are the ones that will be the leaders.”
Complete coverage on the inevitable cyber threat:
Risk managers are waking up to the reality that the cyber risk landscape has changed.
Cyber: The New CAT. It’s not a matter of if, but when. Cyber risk is a foundation-level exposure that must be viewed with the same gravity as a company’s property, liability or workers’ comp risks.
Disabled Autos. It’s alarmingly easy for a hacker to take control of a driverless vehicle, tampering with braking systems or scrambling the GPS.
Unmanned Risk. The dark side of remote-controlled drones, which have already been hacked — by students.
An Electrifying Threat. There is a very real possibility hackers could devastate the nation’s power grids — for a potentially extended period of time.
Risk Technology: Risk Managers Lead from Within
This year marks my twentieth in the risk management field. Now I would never call myself a risk manager. Far from it: I’m a computer geek, and proud of it. Today we refer to the Internet, Cloud, Mobile and Big Data, but I’ve been working with technology my entire life. So much has changed in those twenty years. Networking computers together was rudimentary and extremely limited when I started. Now everything, and everyone, is interconnected, and that has changed everything.
That interconnectivity has allowed organizations to move away from the isolated, siloed processes of the past, and produced dramatic changes in the way we conduct our business and our lives. I’ve watched risk management evolve from a department called upon primarily when things go wrong, to a pervasive philosophy for running a successful business. Fewer and fewer risk managers I speak to work in isolation, reacting to claims as they come in. Rather they are a collaborative lynchpin to manage risk. They don’t wait for bad things to happen. They proactively put safety programs in place, analyze loss data and make their organizations more risk-aware. They know an enormous amount about the inner workings of their organization, its suppliers, distributors, vendors and team members. This is a fundamental transition from a middle management, administrative function, to an executive level function that is key to the organization’s success.
But risk managers are increasingly finding that email and spreadsheets are clumsy, inefficient, and ultimately create obstacles to managing risk throughout their company. With the speed and global reach of business, when even ‘local’ businesses rely on a far-flung supply chain, yesterday’s technology introduces risk, inefficiencies and increased levels of error. Today’s business demands technology that facilitates decisions for tomorrow’s business challenges. Organizations need a platform – a platform that provides secure, efficient and consistent methods of communicating risk-related events and data. Fortunately this need comes at a time when we have a convergence of technologies that can make this vision a reality.
This is a fundamental transition from a middle management, administrative function, to an executive level function that is key to the organization’s success.
Just imagine running your business on technology of twenty years ago. Sending paper memos (when CC referred to a literal ‘carbon copy’), using a phone tethered to your desk, taking delivery of policy documents in hard copy – oh wait, they still do that. Would that put your business at a competitive disadvantage? Of course it would – and risk management would suffer too.
Risk management no longer has to take a back seat to other parts of the organization. Quite the opposite. By leveraging commercial cloud platforms, the pervasiveness of the Internet and the interconnectivity of everyone and everything, the risk management team can be the most modern, forward-looking part of the company. Risk management has become the bellwether of change – actually bearing the standard for technology-enabled collaboration and productivity across the organization. Imagine that.
Medication Monitoring Achieves Better Outcomes
There are approximately three million workplace injuries in any given year. Many, if not the majority, involve the use of prescription medications and a significant portion of these medications is for pain. In fact, prescription medications are so prevalent in workers’ compensation that they account for 70% of total medical spend, with roughly one third being Schedule II opioids (Helios; NCCI; WCRI; et al.). According to the U.S. Drug Enforcement Administration (DEA), between the years of 1997 and 2007, the daily milligram per person use of prescription opioids in the United States rose 402%, increasing from an average of 74 mg to 369 mg. The Centers for Disease Control and Prevention (CDC) reports that, in 2012, health care providers wrote 259 million prescriptions—enough for every American adult to have a bottle of pills—and 46 people die every day from an overdose of prescription painkillers in the US. Suffice to say, the appropriate use of opioid analgesics continues to be a serious issue in the United States.
Stakeholders throughout the workers’ compensation industry are seeking solutions to bend the curve away from misuse and abuse and these concerning statistics. Change is happening: The American College of Occupational and Environmental Medicine (ACOEM) and the Work Loss Data Institute have published updated guidelines to promote more clinically appropriate use of opioids in the treatment of occupational injuries. State legislatures are implementing and enhancing prescription drug monitoring programs (PDMPs). The Food and Drug Association (FDA) is rescheduling medications. Pharmaceutical manufacturers are creating abuse-deterrent formulations. Meanwhile payers, generally in concert with their pharmacy benefit manager (PBM), are expending considerable effort to build global medication management programs that emphasize proactive utilization management to ensure injured workers are receiving the right medication at the right time.
A variety of factors can still influence the outcome of a workers’ compensation claim. Some are long-recognized for their affect on a claim; for example, body part, nature of injury, state of jurisdiction, and regulatory policy. In contrast, prescribing practices and physician demographics are perhaps a bit unexpected given the more contemporary data analysis showing their influence on outcomes. Such is the case for medication monitoring. Medication monitoring tools promote patient safety, confirm adherence, and identify potential high-risk, high-cost claims. Three of the more common medication monitoring tools include:
- Urine Drug Testing (UDT) is an analysis of the injured worker’s urine that detects the presence or absence of a specified drug. Although it is not a diagnosis, UDT results are generally a reliable indicator of what is present (and what is not) in the injured body worker’s system. The knowledge gained through the testing helps to minimize risks for undesired consequences including misuse, abuse, and diversion of opioids. With this information in hand, adjustments to the medication therapy regimen or other intervention activities can occur. UDT can also be an agent of positive change, as monitoring often leads to behavior modification, whether in direct response to an unexpected testing result or from the sentinel effect of knowing that medication use is being monitored.
- Medication Agreements or “Pain Contracts” signed by the injured worker and their prescribing doctor serve as a detailed and well-documented informed consent describing the risks and benefits associated with the use of prescription pain medications. Medication agreements help the prescribing doctor set expectations regarding the patient’s adherence to the prescribed medication therapy regimen. They serve as a means to facilitate care and provide for a way to document mutual understanding by clearly delineating the roles, responsibilities, and expectations of each party. Research also suggests that medication agreements promote safety and education as injured workers learn more about their therapy regimen, its risks, and benefits.
- Pill Counts quantify adherence by comparing the number of doses remaining in a pill bottle with the number of doses that should remain based on prescription instructions. Most often, physicians request pill counts at random intervals or the physician may ask the injured worker to bring their medication to all appointments. As a monitoring tool, pill counts can be useful in confirming proper use, or conversely, diversion activities.
On a stand-alone basis, these tools rank high on individual merit. When used together as part of a consolidated medication management approach, their impact escalates quite favorably. The collective use of UDT, Medication Agreements, and pill counts enhance decision-making, eliminating gaps in understanding. Their use raises awareness of potential high-risk, high-cost situations. Moreover, when used in concert with a collaborative effort on the part of the payer, PBM, physician, and injured worker, they can improve communication and align objectives to mitigate misuse or abuse situations throughout the life of a claim.
Medication monitoring can achieve better outcomes
The vast majority of injured workers use medications as directed. Unfortunately, situations of misuse and abuse are far too common. Studies show a growing trend of discrepancies between the medication prescription and actual medication-regimen adherence when it comes to claimants on opioid therapy (Health Trends: Prescription Drug Monitoring Report, 2012). In response, payers, working alongside with their PBM and other stakeholders, are deploying medication monitoring tools with greater frequency to verify the injured worker is appropriately using their medications, particularly opioid analgesics. The good news is these efforts are working. Forty-five percent of patients with previously demonstrated aberrant drug-related behaviors were able to adhere to their medication regimens after management with drug testing or in combination with signed treatment agreements and multispecialty care (Laffer Associates and Millennium Research Institute, October 2011).
In our own studies, we have similarly found that clinical interventions performed in conjunction with medication monitoring tools such as UDT reduces utilization of high-risk medications in injured workers on chronic opioid therapy. Results showed there was a decrease in all measures of utilization, driven primarily by opioids (32% decrease) and benzodiazepines (51% decrease), as well as a 26% reduction in total utilization of all medications, regardless of drug class. This is proof positive that medication monitoring can be useful in achieving better outcomes.