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Managing Emerging Technology In Healthcare Moderator: Pamela Labaj, Senior Counsel, Panasonic Panelists - Thomas Managing Emerging Technology In Healthcare Moderator: Pamela Labaj, Senior Counsel, Panasonic Panelists - Thomas Strachan: VP, Legal, Compliance, Payor Relations, Preventice Solutions Group - Brandy Canady: Assoc. General Counsel, Contracts & Transactions, Presence Health - Jerry Kolosky: Senior Healthcare Advisor, Panasonic - Beni Surpin: Partner, Foley & Lardner LLP

Managing Emerging Technology in Healthcare SUMMARY • INTRO • Medicine is a science and Managing Emerging Technology in Healthcare SUMMARY • INTRO • Medicine is a science and thus is data driven • • Collection, analysis and use of data is essential to enabling appropriate diagnosis, treatment, prevention and cure of disease for patient and populations Emerging technology is enabling unprecedented changes at a record pace in all aspects of healthcare: • • • delivery of healthcare improvements in patient outcomes with reduced costs introduction of incentives and penalties to effectuate desired migration from a fee for service model to a value based reimbursement solution involvement of patients with their own data collection accelerated communication of increased quantities and quality of healthrelated data between patient and physician, physicians (EMR/EHR), providers, payers, across the ocean(s), etc. expanded and multi-locational storage of and access to health-related data

Managing Emerging Technology in Healthcare SUMMARY (continued) • • • Data privacy and security Managing Emerging Technology in Healthcare SUMMARY (continued) • • • Data privacy and security is a critical concern to providers, payers, patients and regulators (U. S. and OUS) Ever increasing need for international expansion vs. conflicting or varying data privacy, IP and related individual country regulations Rapidly Emerging Technology in Healthcare • Telemedicine • • • technology option designed to improve patient health, throughput and patient satisfaction includes two-way, real-time and near real-time interactive communication between patient and physician decreases costs associated with traditional F 2 F provision of medical care requires appropriate hardware, software, workflow and clinical/practitioner integration Medical Devices – hardware (FDA, CE, FCC, etc. ) • • • Remote diagnostic cardiac monitor (safety, functionality, design control) External (Holter, cardiac event, mobile cardiac telemetry) Internal (implantable)

Managing Emerging Technology in Healthcare SUMMARY (continued) • Software • • • device (algorithms) Managing Emerging Technology in Healthcare SUMMARY (continued) • Software • • • device (algorithms) client or cloud-hosted applications (location of server/data access points) services (remote cardiac monitoring services) mobile applications (end-user centric) sharing of patient data (across-borders)

Managing Emerging Technology in Healthcare CHALLENGES • • • No workable plan to migrate Managing Emerging Technology in Healthcare CHALLENGES • • • No workable plan to migrate from emerging technology to consistently useful, cost-efficient output for patients, physicians Limited and reactionary collaboration between interested parties Danger of short-term thinking in a healthcare world currently evolving around emerging and inherently limited life technology • • • Healthcare system currently lacks workable/scalable legal and compliance best practices • • • rapid obsolescence of devices (hardware) and software creates obstacles to long-term planning and risk management system does not yet cause or enable medical device manufacturers, software developers, providers, sub-providers, payers, regulators, etc. to be on the same page about emerging technology, costs, value-based reimbursement (codes, payment, etc. ), use and related guidelines Limitation of laws, regulations (FDA, FCC, CMS, HIPAA, etc. ) Gaps and inconsistencies in varying medical reimbursement policies creating obstacles and confusion

Managing Emerging Technology in Healthcare CHALLENGES (continued) • Increasing threat of data breaches, hackers, Managing Emerging Technology in Healthcare CHALLENGES (continued) • Increasing threat of data breaches, hackers, phishing, ransomware • • • Reimbursement/Payment Data Disconnects • • • Technology has sped past reimbursement structure Medicare/private payer prohibitions related to patient data access/use need for increased education of payers by certain technology/services providers (investigational/experimental) inadequate direct involvement of practitioners with payers Limited Workable/Scalable Guidelines • • need for privacy and security of patient data (e. g. medical devices, software, international implications) create potential roadblocks Varying and inconsistent regulations, policies and organizational expectations related to necessary and required protection for patient data for technology, data security, reimbursement/payment, etc. Intellectual Property Obstacles • • sole/joint ownership challenges (i. e. cloud-based platforms deliverables when dealing with source code) international implications for use of emerging technology OUS

Managing Emerging Technology in Healthcare SOLUTIONS (macro: system-wide) • Foster pro-active communication, education, collaboration Managing Emerging Technology in Healthcare SOLUTIONS (macro: system-wide) • Foster pro-active communication, education, collaboration between all interested parties despite varying motivations • • • create mutually beneficial environment for consistent development and application of clinical guidelines, protocols, medical policies, reimbursement standards Enable greater data predictability to allow for improved day to day analysis/response Redirect focus towards “big picture” data collection solutions • • • data collected should be most relevant, most reliable – for proper diagnosis, treatment and for predictability analysis include viable, measurable data points – reduce admissions and readmissions for patients and populations push for review/revision of existing federal, state, international regulations – accommodate existing data privacy concerns and allow for expansion to predictable future environments

Managing Emerging Technology in Healthcare SOLUTIONS (micro: organizational/enterprise-level) • Design appropriate processes to consistently Managing Emerging Technology in Healthcare SOLUTIONS (micro: organizational/enterprise-level) • Design appropriate processes to consistently identify, mitigate risk • • Create environment of collaboration between Legal and IT • • include Legal/Compliance Groups early and often at front end of business discussions/decisions related to uses of technology foster continued open lines of communication between groups ensure appropriate data integrity, privacy, security Require collaboration between varying providers and partners • • • create and communicate appropriate risk assessment and incident response guideline train, test, retrain, ensure compliance facilitate expedited means to make necessary changes to policy review existing EMR/EHR systems create workable, scalable standards Be prepared to have difficult discussion about privacy, security, data liability (OUS), shared IP rights, costs, reimbursement

Managing Emerging Technology in Healthcare SOLUTIONS (micro: organizational) • Understand monitor IT and network Managing Emerging Technology in Healthcare SOLUTIONS (micro: organizational) • Understand monitor IT and network risks AND review insurance coverage • • • Communicate and educate Board of Directors to relevant technology changes in healthcare, regulatory landscape, applicable risks, proactive solutions, mitigation, etc. • • be proactive, fiduciary duties, director liability Revise contract forms as necessary to include reasonable T&Cs • • ensure insurance policy includes adequate “cyber insurance” to protect organization from data breaches, network security failures, etc. – beware of exclusions! conduct cyber risk assessments, incident response planning Expedites negotiations Seek and engage knowledgeable and experienced business partners • outside counsel, IT/security, audit, experts

DIGITAL HEALTH & CONSUMPTION TECHNOLOGY • Expanded access to information • Increased engagement PATIENT DIGITAL HEALTH & CONSUMPTION TECHNOLOGY • Expanded access to information • Increased engagement PATIENT VS. CONSUMER • Patient empowerment • Curated health and wellness experience NEXT GENERATION HEALTHCARE • Heightened provider accountability • Data-driven fluidity

EMERGING CARE DELIVERY MODEL TELEMEDICIN E CART/ROBOT PATIENT PORTAL & APP WEARABLE/ MONITORING DEVICE EMERGING CARE DELIVERY MODEL TELEMEDICIN E CART/ROBOT PATIENT PORTAL & APP WEARABLE/ MONITORING DEVICE

PROVIDER LIABILITY FOR MOBILE & EMERGING HEALTH TECHNOLOGY DATA, PRIVACY, & SECURITY § HIPAA PROVIDER LIABILITY FOR MOBILE & EMERGING HEALTH TECHNOLOGY DATA, PRIVACY, & SECURITY § HIPAA regulatory enforcement § increasing FTC activity in assuring privacy/security of health care services § private right of action under state law § interactions with other systems & products § right to data § limited FDA regulation encourages innovation § Degree to which developer(s) can shift liability § accuracy/reliability of warranties regarding effectiveness/efficacy; evidence-based representations § liability may extend outside stream of commerce § institution’s vicarious liability for a provider’s actions § nexus between patient and provider § provider’s engagement with a specific patient’s case § Prevailing standards of care for prescription/recommendation (or lack thereof) of apps/devices PRODUCT REGULATION & LIABILITY PROFESSIONAL MALPRACTICE LIABILITY

INTEGRATION OF NEW TECHNOLOGY COLLABORATION • Legal – IT – clinical/operational departments cooperate during INTEGRATION OF NEW TECHNOLOGY COLLABORATION • Legal – IT – clinical/operational departments cooperate during selection/RFP and negotiations/contracting ADAPTABILITY • Ongoing analysis of evolving regulatory & clinical environments • Flexibility in contracts (e. g. , term/termination, right to amend) PROCESS • Vet new technology for compatibility • Establish workflow for intake and assessment

CONTRACTING FOR SECURITY* PRODUCT EXPLORATION NEGOTIATION • Understand product deployment • Privacy-by-design • Product’s CONTRACTING FOR SECURITY* PRODUCT EXPLORATION NEGOTIATION • Understand product deployment • Privacy-by-design • Product’s effect on organization’s risk profile • Vendor’s information security program (commercially reasonable; FTC & FDA guidance) • Address cybersecurity incident responses • Downstream compliance • Audit rights • Representations/warranties and related consequences *See “Buying Io. T Technology: How to Contract Securely, Merker, Nicholas R. , Law 360, June 17, 2016 (available at: http: //www. law 360. com/articles/808010/buying-iot-technology-how-to-contract-securely)

An Opportunity for Transformation • An unsustainable system must either change, or break down An Opportunity for Transformation • An unsustainable system must either change, or break down • Aging societies & the “Tectonics of Demography” • Example: Retirement of Baby Boomers • 80% of age 65+ suffer from one or more chronic conditions – as do many of the poor • CCM 75% of the US healthcare spend.

World Population, 60 & Older World Population, 60 & Older

Ratio of Workers / Medicare Beneficiaries Ratio of Workers / Medicare Beneficiaries

Within 25 Years, In Japan. . . • Seniors will outnumber children age 15 Within 25 Years, In Japan. . . • Seniors will outnumber children age 15 and under by more than 4 to 1 • 40% of Japanese will be 65 or older • Younger generations of Japanese face significant decline in standard of living due to the "Parent Care Tsunami"

The Inevitability of Change • Pressing need for innovative models of care delivery supported The Inevitability of Change • Pressing need for innovative models of care delivery supported by contemporary technologies • Emergence of value-based reimbursement, payerprovider alliances, & patient self-management • Healthcare transformation will require secure, networked technologies, a flexible legal & policy framework, user experience optimization & technical / workflow interoperability across the continuum-of-care

A Population Health Framework • Imperatives of the “Triple AIM” – Per-Capita Cost Reduction A Population Health Framework • Imperatives of the “Triple AIM” – Per-Capita Cost Reduction – Improved Outcomes – Enhanced Patient Satisfaction • Chronic Care Management • Informed Care Transitions • Health & Wellness – Fusion of Clinical, Behavioral, & Social Factors

State Level Policy Initiatives • Medicaid Innovation • Private Payor Telehealth Reimbursement Parity • State Level Policy Initiatives • Medicaid Innovation • Private Payor Telehealth Reimbursement Parity • Subsidies for Rural & Urban Broadband • State Boards of Medicine Licensing • Health Information Exchange • Community Service Organizations • Innovation Partnerships

Federal Policy Initiatives • Medicare – Increased support for remote patient monitoring services in Federal Policy Initiatives • Medicare – Increased support for remote patient monitoring services in conjunction with accountable care, bundled payments and other coordinated care models • • • Telehealth Reimbursement for Critical Access Lift Restrictions for “Originating Sites” (e. g. Home) FCC Support for Broadband Expansion Veterans Health Initiatives Standards for HIE and Interoperability

Data Monetization and Privacy/Cybersecurity Agenda § Data Monetization – Extracting Value from Connectivity – Data Monetization and Privacy/Cybersecurity Agenda § Data Monetization – Extracting Value from Connectivity – Monetizing Device Health Data – Data Ownership and PHI Restrictions § Privacy and Cybersecurity – Legislative and Regulatory Overview – FDA & FTC Regulations – Privacy Requirements and FDA Guidance – Cost of Data Breach – Guidance for Businesses

Data Monetization: Extracting Value from Connectivity § Use of Io. T in healthcare expected Data Monetization: Extracting Value from Connectivity § Use of Io. T in healthcare expected to grow to $117 B revenue by 2020 § “Big Data” analytics from health care information could be worth $9 billion to U. S. public health surveillance (by improving detection of and response to infectious disease outbreaks) and $300 billion to American health care in general (Mc. Kinsey & Company Data Valuations) § BUT most organizations have yet to derive significant commercial value § More than 200 businesses created since 2010 developing innovative tools to make use of available health care analytics § Companies offer platforms to connect disparate data from across Io. T devices for actionable insights (patterns, diagnoses), and turn these into revenue through productized services for external business partners and clients § Hospitals are able to run more efficiently and improve quality of care

Data Monetization: Monetizing Device Health Data Areas in which health care data can be Data Monetization: Monetizing Device Health Data Areas in which health care data can be monetized: • Mobile Applications • Web Based Technologies • Technology/infrastructure – Data storage, Security and access • Expanding Data Access and Scaling Data Use • Marketing and Sales • Research • Data Analytics

Data Monetization: Data Ownership and PHI Restrictions § HIPAA only applies to medical devices Data Monetization: Data Ownership and PHI Restrictions § HIPAA only applies to medical devices (as defined by the FDA) that send data directly to a covered entity: – Patients own their own Health Information – State law may assign ownership to records that contain Health Information § HIPAA does not apply for most other wearables, personal “medical” devices, and other health related platforms used by consumers: – Consumers generally own this data, but may be modified by the manufacturer’s Terms of Use – Most emerging technology Terms of Use have broad use rights for the vendor, even if they don’t change the ownership. Vendors own derivative works created from the exploitation of the licensed data – May include “social media” applications like Fit. Bit, Jawbone, etc. § HIPAA Final Omnibus Rule (2013) restricts covered entity from selling identifiable PHI or using PHI for marketing communications without permission from the individual § But if PHI is properly sold to a third party not covered by HIPAA (e. g. data analytics company), third party may use, disclose or sell the data § Sale of de-identified PHI is permissible

Privacy and Cybersecurity: Legislative and Regulatory Overview § FTC Act § FDA (FDA Guidance Privacy and Cybersecurity: Legislative and Regulatory Overview § FTC Act § FDA (FDA Guidance on Mobile Medical Applications) § HIPAA & HITECH § Children’s Online Privacy Protection Rule (COPPA) § European GDPR

Privacy and Cybersecurity: FDA & FTC Regulations § FDA has power to dictate cybersecurity Privacy and Cybersecurity: FDA & FTC Regulations § FDA has power to dictate cybersecurity and privacy requirements of regulated medical devices (subject to pre-marketing and post-marketing regulatory controls) – Many devices sold directly to consumers explicitly disclaim their device is a medical device § FTC has power to hold organizations responsible for their cybersecurity and privacy practices under Section 5 “unfair and deceptive practices”

Privacy and Cybersecurity: Privacy Requirements and FDA Guidance § HIPAA Privacy Rule (for Protected Privacy and Cybersecurity: Privacy Requirements and FDA Guidance § HIPAA Privacy Rule (for Protected Health Information) – If device is a “Medical Device, ” information collected is likely governed by HIPAA as PHI § FTC Section 5 (for other types of information not regulated by HIPAA) § European GDPR and restrictions on data transfer § FDA recommends medical device manufacturers proactively plan for and assess cybersecurity vulnerabilities consistent with the FDA’s Quality System Regulation – Implement core principles of identify, protect, detect, respond, and recover from NIST’s Framework for Improving Critical Infrastructure Cybersecurity – Understanding, assessing and detecting presence and impact of a cybersecurity vulnerability – Define essential performance and develop mitigations to protect, respond and recover from cybersecurity risk

Privacy and Cybersecurity: Costs of Data Breach § Healthcare industry has highest cost per Privacy and Cybersecurity: Costs of Data Breach § Healthcare industry has highest cost per capita in event of a data breach – $402 compared to overall mean of $221 § However, for “consumer” wearable industry, costs are more in line with average – $218 per record § 2/3 of these costs may be “indirect” costs, including abnormal churn

Privacy and Cybersecurity: Guidance for Business Privacy and Cybersecurity: Guidance for Business

Contact Information Pamela Labaj Senior Counsel Panasonic (908) 377 -5525 plabaj@verizon. net Brandy Canady Contact Information Pamela Labaj Senior Counsel Panasonic (908) 377 -5525 [email protected] net Brandy Canady Associate General Counsel, Contracts and Transactions Presence Health 312. 308. 3267 brandy. [email protected] org Thomas Strachan Vice President - Legal, Compliance & Payer Relations Preventice Solutions Group (281) 760 -0500 [email protected] com Beni Surpin Partner Foley & Lardner LLP 858. 847. 6736 [email protected] com Jerry Kolosky Senior Healthcare Advisor, Office of the CTO Panasonic 914. 260. 2001 [email protected] com

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