Jared Kaltwasser

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 earlier this summer that it would partner with the National Health Service in Britain to provide vetted health information to Alexa users, the deal prompted a mix of reactions. Under the arrangement, Amazon agreed to use NHS resources to answer health-related queries asked of the artificial intelligence platform.

Some in the U.K. praised the deal as a positive step toward ensuring consumers receive accurate information when they search through a smart speaker. Others were quick to raise privacy concerns, worrying about the implications of giving Amazon access to the health data of millions of Britons.

If the prospect of “Paging Dr. Alexa” raises concerns overseas, for customers in the U.S., the questions are equally -- perhaps even more -- complex.

A tech company that receives healthcare information based on a consumer’s internet search generally is not bound by the Health Insurance Portability and Accountability Act (HIPAA), the main privacy law governing healthcare data in the U.S., said Natasha Duarte, a policy analyst at the Center for Democracy and Technology.

“HIPAA does not cover that information, and it’s something that I’m not sure everyone realizes,” Duarte told 

HIPAA covers entities that directly provide care to consumers, such as hospitals and clinics, she said. And it applies to business associates of those providers who might come into contact with patient health data, she added.

However, when a patient discloses health information online or through a search query, neither the search engine nor the source of the resulting health information is bound by HIPAA unless they happen to fit into the provider or business associate categories, Duarte explained.

As in the U.K., Amazon has been looking for ways to expand its healthcare offerings in the U.S. In April, the company 

 with insurers, providers, and digital health companies to create six new healthcare “skills.” The skills -- sets of concrete tasks like checking on the status of a prescription or providing a hospital with post-surgical status updates -- are HIPAA-compliant, Amazon says. That means the data users disclose when using the specific skills is protected in the same way hospitals and insurers protect other health data. Amazon said it plans to expand the AI platform’s HIPAA-compliant skills.

Still, Alexa’s new skillset covers just a fraction of health-related uses for smart speakers, and Amazon is just one of a number of companies moving into the space.

That means the large majority of health-related information or queries sent through smart speakers are not protected by HIPAA, nor is the information dispensed by the AI platforms necessarily accurate.

If an AI platform by the likes of Amazon, Google, and Apple were to create information partnerships with exclusive trusted providers of health advice (as in the U.K.), Duarte said it would raise questions about how much control users have over the sources of their healthcare information.

Such an arrangement would need to be highly transparent, she said.

“So if whenever you make a health query your information is all coming from one source or at least one source that’s aggregating information, that should be transparent to people because it’s a departure from the way that a search engine would normally work,” she said.

Determining exactly what counts as a health question is another issue, Duarte said.

“If someone is looking for information on diet, is that a query about a health issue or health condition that should go to NHS or is it more of a lifestyle issue if people are interested in a particular diet?” she said.

The answer to that question could have implications for where an artificial intelligence platform directs the question, as well as for the privacy of the person asking it, experts told 

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Outside of the AI ecosystem, computer and smartphone users access a wide range of health information without any protection from HIPAA. Some of that online health information is provided directly by healthcare providers, a growing number of whom have created customer-facing health information sites.

Abner Weintraub, a consultant who advises healthcare and technology companies on HIPAA compliance, said when a provider creates a health information website, they are obliged to abide by HIPAA regulations.

“In general, the answer is yes they do have to be more careful [with patient data],” he said.

Healthcare providers provide care to patients, and thus, unlike media companies, they fall under HIPAA’s umbrella.

But that doesn’t always happen in reality, Weintraub said. In most of those cases, providers evade HIPAA requirements by asking users to accept lengthy user agreements that waive the user’s right to health data protections.

“They’re basically getting out from under HIPAA to a large degree by putting in the fine print sections that essentially waive the patient’s rights to privacy,” he said.

Weintraub believes this is exploitative and deceptive.

That workaround could theoretically transfer to an AI environment, further complicating the transparency issues raised by Duarte.

If there’s a fix for the problem, regulators in the U.S. have yet to find it. Weintraub said only two jurisdictions, California and New York, have passed strict state-level data protections. California’s is the tougher of the two, but both require a broader spectrum of entities to keep private the sensitive personal information of residents of the states.

If regulators tackle the issue at a federal level, they will need to confront a handful of key questions. One question, Duarte said, is whether information should be treated differently when it comes through a smart speaker as opposed to a search query on a computer or tablet. She noted that some technology companies have different privacy policies for the different platforms.

Weintraub said he thinks regulators should consider information from smart speakers as even more sensitive than laptop of mobile phone searches, given that the queries take place in the user’s home and given the technical capability of these devices to record audio and obtain information even when the user isn’t asking a question. The so-called “Castle Doctrine” gives homeowners additional rights to self-defense when they are subject to a crime in their own home as opposed to out in public, Weintraub noted.

“The Castle Doctrine doesn’t apply to health information, but I bring it up as an example because state and federal laws all acknowledge in one way or another that you have special rights within your home that don’t exist outside the home,” he said.

Duarte said the swiftest action will likely come at the state level, where states like Washington and Maine have been working on legislation that would bolster privacy protections.

“So there’s momentum in the states,” she said. “Federally there’s momentum, it’s just a little bit less clear how quickly things can or will move.”

In the meantime, Duarte said it’s not practical to ask users not to use the internet to look up health information, particularly in an era where patients increasingly are being asked to act as consumers and comparison shop.

Weintraub said users should consider using privacy-focused search engines like Startpage and Duck Duck Go, and also close their browsers and clear their caches often. Aside from privacy-protected search engines, he said, people need to use the internet with the realization that their data might not be kept private.

“Treat all searches that don’t happen [through a privacy-focused browser] as public information,” he said. “That’s not going to be easy for people to digest or hear. That’s not what the people want to hear. That’s disturbing information.”

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As major retailers push their way into healthcare, some big names continue to turn their attention to care coordination. Both Walgreens and Walmart recently announced moves related to the organizational process, which is aimed at boosting patient adherence and disease maintenance.

Care coordination, of course, is a key component of the move to value-based care. The process could be critical in a future that no longer relies on the fee-for-service healthcare model.

In this new world, the steps taken by Walmart and Walgreens could position the retailers to boost revenues and perhaps increase competition with traditional healthcare providers — all by helping patients organize the healthcare services they receive.

“Our research shows that Walgreens customers are looking for new, convenient and affordable ways to understand and manage their healthcare needs,” said Giovanni Monti, MBA, MIA, vice president and director of healthcare innovation at Walgreens Boots Alliance, Inc., in a press release.

Walgreens said it would expand its Find Care platform, which helps patients connect with providers, to include chronic disease management tools. Specifically, the company plans to add services geared toward patients with asthma, chronic obstructive pulmonary disease (COPD) and diabetes.

“We believe that by integrating connected care devices, digital therapeutics and the pharmacy experience, we’ll help individuals better manage their chronic conditions while also lowering the overall cost of care,” Monti added.

Walmart, meanwhile, acquired an Indian startup called FloCare. That company created a care coordination platform for the “aging-at-home” population. The deal folds FloCare into Walmart’s technology subsidiary, WalmartLabs, which is based in Mountain View, California. The acquisition took the form of an acqui-hire, with FloCare’s executives joining Walmart Lab’s customer-technology team. The company did not respond to questions seeking comment on its plans for the FloCare platform.

Walgreens said it will partner with Dexcom to provide patients with diabetes with access to the Dexcom G6 continuous glucose monitoring system. The system involves a subdermal monitor that can be worn for up to 10 days to track glucose levels and wirelessly issue alerts when patients reach high or low benchmarks.

For asthma and COPD, Walgreens will incorporate the 

, a small device that attaches to a patient’s inhaler, allowing patients and physicians to better track medication use. The Propeller app also generates personalized insights such as reminders and air quality alerts.

Just one year old, the Find Care platform is available to patients through partnerships between Walgreens and more than two dozen health systems and providers.

Propeller co-founder and CEO David Van Sickle said retailers are logical partners for companies that aim to improve patient management of chronic diseases.

“Simplifying the self-management of chronic diseases is essential to improving outcomes and reducing the burden on patients and their families,” he told 

™. “Reputable retailers like Walgreens make it easier to get digital health tools into the hands of people that need them.”

Patients can sign up for Propeller through the Find Care platform at no cost thanks to sponsorships from pharma companies.

Propeller encourages physician involvement but said it’s possible for patients to access the program even without their doctor’s involvement. Van Sickle said he hopes to expand Propeller’s reach through further deals with other retailers.

But as digital health innovators team up with retail players that are new to healthcare, a question emerges: What role will health systems play in these new relationships? And if the answer is “none,” then what does that mean for health systems and how can C-suites act to avoid harm?

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The premise of clinical decision support (CDS) software is clear: Use technology to leverage the power of big data to improve patient care and, theoretically, drive down costs. But the technology is, in many ways, still at the starting gate, in part due to technical and bureaucratic hurdles and a lack of scientific data surrounding its use.

Now, a major academic medical center, the University of Virginia Health System, is launching a concerted effort to find ways to integrate CDS into its organization. The evaluation is part of a larger effort at the health system to boost value-based care. It could prove to be a model to help other medical centers take the leap.

Joseph Wiencek, Ph.D., an assistant professor of pathology at UVA, said the health system is looking at products developed in house and elsewhere.

“We have several rules built from our internal analytics/informatics teams but would like to see if there is any value in external support that is becoming more widely available,” he told 

“These decision support tools would likely target high-volume, low-cost tests as well as high cost, low volume.”

The team remains in the evaluation and “data-crunching” phase, but he said one important element of the evaluation will be to get buy-in from the health system stakeholders.

“Since we are an academic teaching hospital, it is important to research and strategically partner with service lines and department leads to make sure we achieve lateral buy-in from our colleagues,” he said.

He and teammate Andrew Parsons, M.D., MPH, an assistant professor of medicine at UVA, recently wrote about how reduce laboratory costs, noting that “low-value care” — care that could be eliminated without harming patient safety &mdash; costs the U.S. healthcare system an estimated $800 billion each year.

 that integrating decision support tools into electronic health record software could help reduce unnecessary costs. However, given the relative novelty of these types of products, health systems should evaluate them carefully before integration.

™ that there simply isn’t much in the way of scientific literature when it comes to the effects of CDS.

“I think the lack of peer-reviewed literature is an enormous impact,” he said.

While the technical work that’s required to implement the systems can be difficult, Wiencek said scientific evaluation will also be key.

“It truly is a multi-modal approach, and support from your colleagues and evidence-based literature will really be the only way these tools will succeed,” he said.

Ultimately, the success of any decision support technology will be about more than just cost. For some institutions, that could be the benchmark. But for others, victory might resemble patients receiving the right test at the right time, he said.

In fact, a recent study by researchers at the Massachusetts Institute of Technology 

 that CDS helped providers make more appropriate decisions but didn’t result in cost savings, in part because sometimes the most appropriate decision was a high-cost test.

Wiencek said while cost is a major issue in healthcare generally, he doesn’t think people should overemphasize its importance. Besides, he said, the cost implications of better decisions might not appear in the short term.

“Doing the right test for the right patient will lead to better clinical decisions, and patients will get the care that they need or be diagnosed faster,” he said. “If this happens, costs will fall, too. I’d like to see these types of tools lead us in that direction.”

Wiencek offered no timeline as to when UVA will complete its evaluations, though he said the team is proceeding at a “steady pace.” The health system is currently working with a single external vendor, though he said they have been approached by several others.

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Patients enrolled in Anthem’s health insurance plans might soon have a new way to connect with their physicians: through text message. The company this month said it is 

 to develop a co-branded app that will enable patients to chat with their providers for less than the cost of a typical office visit copay.

The deal is just the latest in a wave of partnerships and 

 launches that aim to facilitate text-based communication between providers and their patients. The moves could increase convenience for patients. However, it might represent a significant shift in the way physicians “see” patients.

James Ellzy, M.D., a family physician in Washington, D.C., told 

™ that text-message communication can be a win-win for patients and physicians, but it’s important that patients understand that text-based communication has its limits.

“I can’t tell you that you’re having a heart attack via a chat,” he said.

But text and chat can offer a meaningful way to provide advice and care, particularly when the physician already has a relationship with the patient or their family.

“I think that relationship between patient and provider being established ahead of time expands what we can do,” he said.

In some ways, text communication isn’t new for physicians. Ellzy said many family doctors already provide their cellphone numbers to patients with whom they have an established relationship, particularly if they are concerned about the patient. He said patients tend not to abuse the privilege.

“In general, most patients are very respectful because they say you are a physician and they’re not going to call you about every little thing,” he said.

However, Ellzy noted that providers aren’t compensated for such interactions. Thus, in case a tool like the Anthem/K Health app increases the number of doctor-patient text interactions, physicians need to know whether and how they will be paid for the consultations.

“I think one of the questions always is, ‘Am I getting reimbursed for that time?’ — especially if it’s part of the health plan,” he said. “Is the health plan going to reimburse me for that or not?”

If text visits are compensated — and if practices can reallocate resources to align overhead with a shift from 100% in-person visits to some mix of in-person and text “visits” &mdash; the change could work out well, he said.

In addition to allowing for text interactions with physicians, the K Health app will also allow Anthem patients to schedule appointments and ssee common diagnoses when patients present with similar symptoms.

Aside from the technological implications, the expansion of healthcare-by-text could affect the workflow of providers and continuity of care. Many patients who want quick answers turn to telemedicine providers or retail walk-in clinics.

“What I have seen over the years is that patients who are healthier and younger tend to want convenience over continuity (with their regular provider),” Ellzy said. “Older patients or patients with chronic conditions like to have that continuity because they have so much history to tell that they don’t want to tell that entire history every time they go in.”

When patients choose convenience, though, the records of those interactions often don’t make it back to the patient’s primary care physician.

Apps and services that make it easier to contact the patient’s regular provider might dissuade patients from going elsewhere, thereby keeping the records in house.

At larger practices like Ellzy’s, providers typically rotate “cellphone duty” in which they handle off-hours calls from patients. Such a system could be converted to “text message duty,” Ellzy said. But even if the patient interacts with a different provider at the same clinic, at least those records would still be in house, and the provider who chatted with the patient could personally communicate any pertinent information to the patient’s regular primary care doctor.

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A deal between Anthem and an app developer could make it easier for patients to access care via text.
 

Jared Kaltwasser

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