Stakeholder’s Progress report for FHIR

The following blog entry is a guest post from Grahame Grieve, creator of Fast Healthcare Interoperability Resources (FHIR):

"During the week of Sept 14th to 19th, HL7 held a working meeting during which the organization worked on further developing the FHIR specification.

FHIR is an important new standard, not just because it does what the existing specifications do in a simpler fashion, but because it does entirely new things as well.  Because of this, market interest and hype concerning FHIR is astonishing (see Wes Rishel’s comments ) . The FHIR project team is aware that there is a duality here: expectations and excitement about FHIR are high, but what we have published is still an early beta, and FHIR is not yet ready to meet the expectations that people have about it.  We intend and expect to get there, but it there is still a lot of work to be done.

One of the key gaps the project team has identified is that the clinical content parts of the specification are not as solid as the underlying technical framework. We know that the strength of FHIR isn’t because we’re clever, but because we keep testing it through implementation experience, particularly connectathons – a relentless cycle of test, refine, test…. Our regular developer connectathons are continuing to grow in participation, depth and sophistication, but they don’t test of FHIR’s clinical features well. So this meeting, we did something new: we held a clinical connectathon – a group of clinicians using the FHIR specification to communicate with each other about some prepared clinical scenarios. Like our first technical connectathon, the potential of the specification was clear, but we identified a number of areas where we need additional development before FHIR is ready for real world usage. We plan to make clinical connectathons a regular feature in the future.

During this meeting, we started preparing the next full release of FHIR – DSTU (Draft Standard) 2. We anticipate publishing this in the middle of 2015. It will feature new functionality for clinical records, assessments, claiming, consent management, and more, and we agreed to a number of significant changes to the specification in response to implementer experience. Several organizations (including ONC and HSPC ) and countries are working on implementation guides for FHIR, and their experiences are starting to drive the specification and the development of additional implementation tooling.

Up to now, FHIR has primarily been a standards project: a group of people with a core task of producing a standard. But now, the FHIR project and management teams are going to start placing increasing focus on engaging with the wider implementation community. Connectathons are effective forums for validating the specification, building an active implementer community and seeding specific exchanges. One important part of this will be ever closer cooperation between HL7 and IHE as IHE starts adopting FHIR in the future."

For a more detailed technical progress report, see Grahame's Website.
.

Unity Farm Journal - Fourth Week of September 2014

As we prepare for winter, we’re busy splitting wood, preparing the winter garlic beds, and finishing the building maintenance tasks for the cold and wet months ahead.

We burn about 3 cords of wood each winter, all split from fallen trees on the farm.   We use small amounts of cedar as hot, fast burning kindling.   We use Oak, Maple, Ash, Hickory and Black Bird for hot, slow burning sustained warmth.   We do not use poplar, which burns cool/quickly, instead saving it for mushroom production.

Last week I created a system for labeling all our half-cord wood racks (21 of them).   I painted galvanized strips of metal which now hang from hooks on each rack, coded as follows

Cedar - Red (Red Cedar)
Oak -  White  (White Oak)
Maple - Gold (Golden Maple)
Ash - Green  (Green Ash)
Hickory -  Unpainted  (Hickory has no color names)
Black Birch - Black  (Black Birch)

This winter we’ll have fully cured wood of all types, so we’re ready for whatever Mother Nature throw our way.

We’ve found good homes for many of our Summer guinea offspring and the total count is now down from 88 to 68.  Ideally we’d like to overwinter about 50.

We’ve picked McIntosh and Roxbury Russet Apples.   Our Empires will be ready in a week or two.   We’re looking forward to 3 more weekends of cider pressing in October/November.    The fermentation of our first batch is going well and we’ll likely rack it this weekend and then start malolactic fermentation, turning the sharp malic acid into rounded, complex lactic acid.

We continue to harvest tomatoes, turnips, and greens from the hoop house.   Peppers and eggplants are nearly done producing.   We’ll replace those raised beds with winter lettuces soon.

We'll plant the garlic in mid October, but the outdoor raised beds for overwintering garlic are ready.

The big project over the weekend will be building our room sized refrigerator for storing all the mushrooms of Fall between picking and delivery to farmstands/farmers markets.    Our Italian and Grey Dove Oysters are fruiting.  Our Native Harvest Shitake are pinning and we’ll pick them soon.    We’ve optimized our mushroom workflow by using plastic picking boxes from an agricultural supplier in Canada.   We use one container from log to refrigerator to market.

The bee preparation for winter continues as we feed them, optimize the hive configuration to reduce moisture/cold, and ensure pests/diseases are minimized.

One of the ducks aspirated some water (caused by rough underwater mating behavior) and we’re treating her with antibiotics for pneumonia.  Her breathing is labored but she’s eating/drinking, and alert.

I look forward to a weekend of crisp Fall weather, harvesting, hauling, and preparing for the months ahead.

You know Meaningful Use is Real When...

My 83 year old father-in-law returned from a recent outpatient visit to his primary care provider with two customized handouts  - a transition of care summary detailing problems/meds/allergies and an opt-in consent for the exchange of that care summary over the state Healthcare Information Exchange, the MassHIWay.

We discussed them over dinner.

A photo is shown below (with his consent)

As I’ve written about several times, the Meaningful Use Stage 2 Transition of Care and Patient Access requirements are hard since they require environmental and cultural changes.   There’s no magic bullet to implement them, it just takes time and diligent effort, one patient at a time.

His opt in consent is signed and his data is viewable throughout Massachusetts for care coordination, population health and quality measurement.   The numerators for Stage 2 are being incremented every day.

As I watch the rollout in Massachusetts I see an amazing trajectory - over 150 healthcare organizations are on the MassHIWay, using the standards required by Meaningful Use Stage 2 certification.  The key to our success has been low cost, a flexible on boarding approach, and common patient/provider educational materials shared by all.  

Here are the actual statistics of what BIDMC has sent over the past year using Meaningful Use Stage 2 standards.  

As I described in a previous post, this is more evidence of interoperability that’s real.

How do we ensure that extends across the industry?

When I meet with many vendors, they measure success when the sale is made or when the go live occurs rather than when adoption achieves the outcomes desired.    Today I’m at KLAS in Salt Lake City with several EHR vendors discussing “magical thinking”.    Over the course of the day we all concluded that we need to redefine success based on outcomes - mutually aligned self interest that pays vendors for achieving commonly agreed upon goals.   The CIO wants improved quality/efficiency, fewer emails, and great communication.   The vendor wants to make a sale, achieve customer success/reputation, and grow market share.    Some vendors have recast their business as a process delivery rather than product delivery.    We can all learn from that.

My father in law has demonstrated the Meaningful Use policy outcome - an understanding of his care and respect for his privacy preferences.  As we think about the next steps to enhance interoperability, industry stakeholders should forge collaborative relationships outside of regulation that align incentives to achieve the results we all want.

Early Experiences with the iPhone 6

I’m truly not an “Apple fanboy”.   I’m a believer in “do-acracy”, rewarding people and companies that create useful products which save me time.

I stay objective about every company.  I recently emailed one of my favorite companies which has slowed its innovation, “we need products not powerpoint”.

So what about the iPhone 6?

Although I’m an early adopter of many technology ideas - social media, mobile, analytics and cloud, I tend to be a laggard when purchasing devices for myself.   I do not drive a Tesla, I drive the simplest, most cost effective Prius.   I used an iPhone 4S from 2011 to 2014, skipping the entire iPhone 5/5S generation.

After thousands of charges, my 4S started to falter so replacement with a 6 seemed reasonable.   Also, since BIDMC will be developing several Healthkit applications, it’s reasonable to have an iPhone 6 for testing.

On Friday, I copied all my iPhone 4S data (not patient information) to the iCloud and then activated the iPhone 6 using my iCloud resources.

Everything worked flawlessly, although I did need to call Verizon because the volume of new iPhone activations caused delays in cellular account transitions.     Verizon re-pushed my account transition and the iPhone 6 activated with my existing cell number.

I left the office on Friday afternoon to join a conference call while driving home and forgot the iPhone 6 charger.    This would have been a major mistake for the iPhone 4S, but after 48 hours, the iPhone 6 still has an 80% charge.

The game changer for me has been the use of fingerprint ID rather than PIN code to access the encrypted device and the optimization of the hardware/software for one handed operation.

Also, as I’m composing email, I’m offered word suggestions that reduce my typing about 50%

Finally, the accessibility features work very well for me.   I have glaucoma with a somewhat narrowed field of vision, nearsightedness (-7 diopters) and the presbyopia of age that reduces my reading focus.   I use the iPhone 6 in Zoom mode which creates a very easy to read screen for all functions.

One last thought - given that the iPhone 6 is a bit larger than my iPhone 4S, I have yet to master how to carry it.  I’m using a shirt or pants pocket until my holster arrives next week.    Since my early Blackberry days, I’ve used a holster.    It may be time to use a simple silicone case and carry the device with me in my messenger bag.     I'll test the holster verses messenger bag for usability and report back.

Thus far, the iPhone 6 is a usability winner.

A Tale of Two Companies

The Apple Store on September 19th at 7:00am  - the line on Boylston Street is over 1000 people long to purchase an iPhone 6.

The Microsoft Store on September 19th at 10:30am  - two employees are surfing the web on a Surface RT.   The poster outside explains how Microsoft improves your iPhone.

Unity Farm Journal - Third Week of September 2014

Gluten free and Paleo diets seem to be the rage these days.    I prefer Michael Pollan’s advice - eat food, not so much, mostly vegetables.   It’s impossible for us to say if the real Paleo diet was raw wooly mammoth or the roots/berries found near the cave, but from living at Unity Farm, my version of the Paleo diet is based on what I can gather every day from the environment around me.

Every night after caring for the animals (living things come first), I walk the mushroom laying yards and pick the available Shitake, Oyster, Agaricus, Wine Cap, and Lion’s Mane mushrooms.    Dinner last night included a stir fry of Unity Farm mushrooms, peppers, and onions.

I spend 30 minutes in the hoop house every night weeding the raised beds, picking vegetables, and planting successive rounds of greens so that we have a continuous supply of chard, spinach, lettuce, cress, and mibuna (a Japanese green).    Here’s a typical night’s picking basket of chinese long beans, german striped tomatoes, and roma tomatoes.

On the way back to the barn yard I walk along the raspberry bush brambles and forest edge picking berries and wild Concord grapes.

The end result is food that is high fiber, low calorie, locally grown, and sustainable.  You won’t find Hot Pockets in our pantry.

The Apple crush began this weekend and we pressed 150 pounds of apples (Macs, Rhode Island Greening, Golden Delicious, and Granny Smith, trying to balance tart, sweet, astringent, and aromatic components.   I added 30ppm of sulfite to the a 20 liter fermenter and 24 hours later inoculated with Pasteur Champagne yeast.     Here’s what the pressing looks like as all the equipment is washed/sterilized prior to pressing.

The 99 guineas continue to be happy and healthy.   The only side effect is that Unity Farm now looks like a scene from Alfred Hitchcock's "The Birds".    Here’s a typical scene from the front porch.

Still no baby alpaca.   Mom can hardly walk and we’re thinking she’s setting a new record for gestation time.

We removed all the honey supers from the bee hives last weekend and fed the bees a combination of sugar water, bee tea, and fumigillin B, to strengthen the hive for winter/reduce nosema infection.    All 12 hives are strong and have generous honey/nectar stores.  Last winter was brutal and per the 2015 Farmer’s Almanac, we’re in for another cold, snowy winter in New England.    The bees have every preparation possible for them to be strong and healthy.

Next weekend will be devoted to alpaca health, building new roosts in the coop for the guineas, and splitting firewood for next year, anticipating the three cords we will burn this year.

The Path Forward for Query/Retrieve

In 2009, I wrote about The Genius of the AND  in thinking about the different standards requirements of “Blue Button” versus "transitions of care".    We accepted CCR and CCD for the first stage of Meaningful Use as a means of buying time to allow the CCDA to be more fully defined.

In 2014, we’re faced with a similar issue as we specify query/retrieve standards to “pull” healthcare data from various sources for care coordination, care management, and population health.

At present, the industry has implemented several functional approaches to query/retrieve, each incorporating both open standards and proprietary implementations:

CommonWell
Epic Care Everywhere
Cerner Resonance
eClinicalWorks P2P and eHX
eHealth Exchange/Healtheway
Surescripts
Regional HIEs such as the MassHIWay

Differing standards and architectures are used based on workflow, use cases, and policy constraints.  Some are synchronous and some are asynchronous.  It's too early in the process to declare any of the enabling open standards as either winners or losers.    Rather than regulate an answer (i.e. XCA must be used, FHIR must be used), it is better at this point to embrace functional criteria for query/retrieve capabilities that will enable an ecosystem to develop as the market  evolves.    Adoption will be our metric for success, and we'll be able to reduce optionality over time by evaluating implementation experience.

Interoperability in other industries, taking examples from Google, Amazon, Facebook, Apple, and Alibaba, is based entirely on RESTful, JSON/XML, and OAuth approaches for open APIs that enable and authorize data-level and document-level exchanges.    We are in a transitional period between an older standards profile (IHE XCA) that is complex (particularly for today's agile, multi-platform environment)/does not support data-level open APIs and an emerging standard (FHIR resource definitions & profiles) which is based on currently prevailing architectural and design principles/does support both document- and data-level access.  The dilemma is that this emerging standard requires some focused development attention before it's ready for prime time.  Although healthcare is indeed a bit delayed in its adoption of information technology, its needs are quite similar to those of other industries, so it is not an edge case that requires a different approach.  To help align healthcare with current technology trends, it is critical that we not lock ourselves into an older healthcare-specific standard -- else we will suffer the consequences of higher costs, longer development cycles, and less compatibility with current enterprise and consumer technologies.      Based on everything we know about the work to date in HITSP, HITSC, S&I, SDOs, and HIEs,  the best approach for the future seems to be:

Vocabulary - centralize all vocabulary resources for download/real time retrieval at the value-set level -- curated and provisioned by the NLM's Value Set Authority Center.

Content - both profile-constrained document and discrete data approaches should be supported.  A constrained CCDA based on a small number of templates that limit vocabulary and metadata optionality and are focused on a small number of high value use cases is a reasonable document format for the next 5 years.   An entry-level set of FHIR resource definitions and profiles can be developed in the next 12-24 months as an open API that supports both document-level access to static CCDAs and data-level access.  That is a reasonable discrete data approach for the next 5 years that will serve high-value clinical use cases for the near-term but, more importantly, build a gateway to rich interoperability founded on JSON/XML approaches for the future.

Transport/Security - We should accept both SOAP/SAML and REST(HTTP)/OAuth 2.0 as reasonable approaches for the next 5 years -- though we anticipate a continuing and accelerating decline in support for SOAP/SAML, with a corresponding increase in adoption of HTTP/OAuth, across all IT environments.

Thus, we should allow multiple approaches to enable the marketplace for the next 2 years, while working to constrain CCDA and complete FHIR resource definitions and profile specifications.       in 2017, we'll have enough experience with query/retrieve and adequate standards maturity to begin convergence to fewer standards in a way that still supports the older standards for those who don't want to "rip-and-replace" but also provides a pathway for those who would like to start building on newer standards to carry them further into the future.

We believe that incentives for cross-boundary sharing (e.g. MU incentives, as well as emerging market incentives) will work better to move the industry forward than forcing technical compliance to complex standards.   We should focus on the outcome rather than the process.

Networks require considerable additional work beyond the implementation of particular standards.  With this recommendation, we are encouraging the evolution of multiple robust networks that enable and facilitate query/retrieve, with the expectation that these networks will create appropriate bridging techniques to other networks, in response to incentives and market demands.

What about HIE governance?

HIE is still largely a highly heterogeneous and locally-dispersed regional activity based on local policies, technologies, and use cases.   Forcing a single governance approach in the next 2 years will quash innovation, limit adoption, and negatively misalign incentives.

ONC should have a role in defining outcomes, but not prescribing standards yet, at this critical juncture where some are maturing and fading but the successors haven’t fully emerged yet.  There are active communities effectively developing solutions.  That includes SDOs, broad industry groups, and the actual networks created by CommonWell / HealtheWay / Surescripts.  This is more than some kind of vague “invisible hand of the market”, there is real work happening with responsible players with whom ONC can collaborate.

The Affordable Care Act and new economic incentives are aligning payers, providers, and patients to share data.   These economic incentives are more powerful than meaningful use regulation and should be allowed to shape the standards and governance of HIE for the next 2 years.    In 2017, as the standards have matured, and the marketplace has made implementation choices, the notion of a single national standard for query/retrieve should be revisited.

Unity Farm Journal - Second Week of September 2014

As readers of my blog may have noticed from my infrequent posts, the past two weeks have been truly chaotic, filled with harvest and Fall planting activities during the transition from the dog days of Summer to the traffic filled first days of school.   (And there were a few red-eye flights  as the conference/lecture season begins).

Fall is my favorite time of year.   We’ve had nights in the low 50’s, days in the 70’s, and all our summer plantings are at the peak of their ripeness.    We’ve picked Asia pairs, McIntosh apples, late summer greens, carrots, tomatoes, and eggplant.   Every weekend night has been filled with grill- roasted vegetables and mushrooms.    Every weekend day has been busy canning blueberries (Unity Blue Jam), pickles, and tomato sauce. The hoop house is overflowing with newly planted growth - turnips, daikon radish, broccoli, spinach, and chard.   The cabbage butterflies are laying eggs on several of the “cabbage-like” greens, so I’ve applied an organic soap to the leaves in an effort to avoid too much crop loss.  

We learned last year that garlic and squash are best grown outside of the hoop house, so I’ve laid down a foundation of alpaca manure, moss, vermiculite, and compost for overwinter planting.

Still no alpaca baby - there are reports of 435 day gestations in first time alpaca moms, so our cria watch continues.

The dogs provided an interesting challenge this week.  Somewhere within a mile of the farm, a female dog was in heat (our female Great Pyrenees is neutered).   Our 120 pound male Great Pyrenees, Shiro, lost his mind.   He stopped eating.  He mated (or tried) 24 hours a day.  Our female, Bundle, tried to remove his face multiple times, but it did not discourage him.  After 4 days, it was as if a switch turned off.  He suddenly started playing, eating, and sleeping.   We (and Bundle) were relieved.

The major event of the week was that our 27th guinea, missing for 4 weeks, returned from the forest.  Unfortunately, she brought 16 babies back with her.   I say unfortunately, because our total guinea count is now

27 adults
11 teens
17 tweens
17 toddlers
16 babies
————
88 guineas

Combined with our 11 chickens, we now have 99 birds to overwinter in the coop.   At best, the coop will fit 66 birds comfortably.   We need to find a good home for our toddlers and babies - two groups of guineas we never planned.   We’ve put up signs at every feed/seed supply in Metrowest.    If you have a few acres, a coop/poultry housing, and an interest in wonderful tick eating guineas, please let me know!

The mushrooms continue to be prolific and we’re continuing to harvest oysters and shitake every day.   2014 is a year of learning for us - when different subtypes of mushrooms will fruit, which are the best tasting, which are the most insect resistant etc.    For now, our sales of mushrooms are limited until we are completely satisfied with the product.

We’re planning for our Fall cider pressing, tasting our fermentations from last year and evaluating how our mixtures of aromatic, tart, sweet, and astringent apple ciders have aged.   We’ll also prepare enough cider to make fresh cider vinegar, using the “mother of vinegar” from last year as a culture.

Over the next few weeks we’ll finish  freezing, drying, pickling, and canning the produce from the 2014 season, such as the sun-dried tomatoes below.    Soon, the leaves will start to fall, and our activities will gradually change to wood splitting and preparing all the citizens of Unity Farm for 6 months of cold ahead.

The September HIT Standards Committee

The September HIT Standards Committee was one of the most important meetings in the history of the group.   We heard pivotal reports from the NWIN Power Team about Query/Response standards as well as from the JASON Task Force.   Together they gave us important guidance to accelerate FHIR, REST, and OAuth, aligning healthcare query/response standards with the technology approaches used in every other industry.  We were also advised to polish existing CCDA standards in the short term while working on the longer term FHIR initiatives.

Dixie Baker and David McCallie presented Query/Response recommendations suggesting that use cases for 2017 certification be limited to:

*Query a named external health care organization for a document containing a specific patient’s data
* Respond to query with requested document, list of documents, or non-availability of
document
* Allow both synchronous and asynchronous queries

They proposed that certification be based on functional requirements that

* Move the industry in the direction of broad use of RESTful, FHIR-based services, including services to support query for both documents and discrete data elements
* Simple query of a known external entity for a document containing an identified patient’s information

They also recommended that short term efforts should focus on specific improvements  to facilitate query for, and selective retrieval of, a range of clinically useful CCDA documents, including but not limited to implementation specifications to support “on demand” retrieval of a simple current summary (problems, allergies/intolerances, current medications, recent labs, etc.), and specifications for a complete longitudinal summary, in addition to the current encounter-by-encounter documents.

Finally, they voiced strong support of efforts to accelerate development of FHIR-based services and FHIR profiles, consistent with recommendations of the JASON Task Force

Next, Steve Posnack and Mike Lipinski presented the early work on defining the use cases for the data provenance initiative.  They emphasized that no standards have been chosen or evaluated for maturity.   We’re currently in a requirements gather phase.

Next Steve and Mike presented an overview of the 2014 Edition Release 2 EHR Certification Criteria Final Rule.

The press has widely reported that ONC abandoned the 2015 rule, when in fact, they simply changed the nomenclature to name rules based on the year they are finalized.   This new rule offers a very reasonable balance of optional criteria that fix previous certification problems such as the inability for HIEs to certify transport only capabilities.

The NCPDP Real Time Benefit Check Analysis Task Group provided an overview of their efforts to bring cost and benefits information for pharmaceuticals to all stakeholders - payers, providers, and patients - based on the use of common data elements and data sources.

Finally, David McCallie presented a brilliant overview of the JASON Task Force review of the JASON Report.

The key takeaway - the general conclusions of the JASON report, which lack operational workflow details, was turned into a set of concrete recommendations very similar to those of the NwHIN Power Team - FHIR query/response for discrete data elements using RESTful transport and OAuth.

I look forward to the October 15 joint meeting of the Policy and Standards Committees in which we will try to move forward the agenda for the next year, hopefully embracing some of the principles discussed today.

The Apple Platform for Wellness Arrives

Today I’m sitting at the Flint Center in Cupertino where Steve Jobs introduced the first MacIntosh 30 years ago.  Who can forget the iconic commercial “why 1984 won’t be like 1984”?   It was the year I graduated from college and the year I married my wife Kathy.

Now, 30 years later, we’re on the cusp of a different kind of revolution - the consumerization of healthcare middleware that gathers data about your body/activity from multiple sensors and consolidates it into a secure container on your personal smartphone.  No cloud storage is used.  In fact, Apple has specifically changed its policies so that health data is never replicated to iCloud.   Data remains on your device under your control.  Apple does not specifically provide a function to transmit data off the device.  The intent of Healthkit is that it serves as middleware, consolidating data and providing a container to share data with other apps that you specifically trust.

For example, Beth Israel Deaconess, could create a Patientsite application that you trust to access healthcare data on your phone.   Your care team could monitor this data for meaningful variations and intervene via a home care visit or telemedicine connection when appropriate.

If Congestive Health Failure patients have significant short term weight gain, a visiting caregiver could evaluate the situation and adjust the patient’s diuretic dose.

Recently, a donor committed significant funds to the development on an app that will do just that.    We hope to have a running prototype in 2015.

Not only did Apple introduce the iPhone 6/iPhone 6 Plus (pictured below) as highly capable mobile computers, they also introduced secure e-commerce features (Apple Pay) and the Apple Watch.

The Apple Watch includes motion sensors (accelerometer, gyroscope), barometric pressure (for elevation change), and heart rate.  It includes a touch screen that can discern a swipe from a press.  It includes haptics that can provide tactile feedback such as reminders to take medication or change course while running a pre-determined route.    The Apple Watch communicates with the iPhone for GPS data and LTE (4G wireless).   Here's my arm, my heartbeat, and my black Kevlar shirt.

Although Apple has introduced fitness applications with the Watch and iOS8, the greatest potential for the suite of products introduced today is the development ecosystem, enabling academia, industry, and government to innovate.   Now that all the devices in your home can consolidate data about you into one secure container under your control, developers can focus on creative analytics, visualizations and alerts/reminders, not struggling to interface heterogeneous devices.

U2/Bono arrived on stage to play a new single.   A few minutes afterwards, the entire album was released to 500 million iTunes users for free.   What is the significance for healthcare?  The fact that Apple can reach 500 million consumers in a moment is faster dissemination of innovation than any change management program that healthcare IT stakeholders could conceive.

It’s an exciting time, the Perfect Storm for Innovation, that I’ve written about in the past.    Apple created an enormous white pavilion next to the Flint Center for the demonstration of these products.  I spent the afternoon using the technology they announced.

Now the fun begins, changing the face of healthcare with new tools available to payers, providers, and patients over the next year.