Claims Data is NOT a Trojan Horse

dataTrustProbably the most notable development apparent at HIMSS14 was how much HIE and interoperability vendors are now talking about including claims data in their solution sets. Last year at this time, most of these vendors questioned the clinical value and utility of claims data at the point of care. In contrast, this year HIE vendors are now talking as if claims data were as liquid as orders and results between provider organizations. This is a positive, if somewhat overstated, development on the part of the vendors.

In mid-2013 we did see quite an uptick in interest on the part of payers to become more directly involved in HIE initiatives. This interest continued to accelerate through the remainder of 2013 as payers felt that they did have valuable information to contribute, such as eligibility checks when patient is being admitted to ER or information on patient follow-up post discharge and prescription refills (medication compliance). Some of this information, e.g. eligibility check can be provided in near real-time to a patient’s primary care physician.

While vendor support for claims data exchange points to the general increasing level of support for the evolution to value-based reimbursement (VBR), the problem with claims from the provider perspective is history.

Payers until now have been the gatekeepers-to-money translating in the minds of doctors, nurses and patients as gatekeepers-to-care. Payers have wanted better access to clinical data for decades but provider organizations do not want payers poking around in their clinical data. This is not the opinion of most providers, it is still the opinion of every provider we’ve spoken to. This stems from simple distrust of payer motives and the fear of ultimately having their data used against them, which regrettably has happened in the past.

Another challenge has been payers unwillingness to share data outside of a specific VBR contract. In numerous calls we have had with clinical executives, a common refrain has been that payers hold-out on sharing data unless there is something in it for them. Not exactly altruistic or in the best interests of providing quality care across a community.

Most provider organizations are only too happy to get specific about the limitations of claims data and further entanglements with payers through claims or other kinds of data:

Claims data is not that current
Most of the provider organizations we talk to maintain that the payers can only provide accurate data for things that happened six months ago. Anything of a shorter time horizon than that is subject to revision and therefore of very limited value. The exception to this is the aforementioned eligibility checks wherein a provider organization can receive near real-time visibility into network leakage.

Claims data is hard to work with
Providers correctly point out that most payer data sits in 1960s- and 1970s-era mainframe databases and file systems and is processed nightly by COBOL batch applications. While payers use this data to send lots of paper reports to providers, few providers have figured out how to use this data to improve patient care. Instead, this kind of payer data mostly just adds to the fog of data surrounding patient care and is by and large ignored.

Payers motives are suspect
Payers like to create the impression that they make healthcare happen for patients even though they do not provide the full suite of healthcare services nor do they appear to serve patients/members in a manner to truly help them with their healthcare issues. On this point, members share provider views and have strong distrust of payer motives.

Challenges Using Payer Data
Provider organizations will have challenges using claims data in the here and now. Looked at from what happens at the point of care, providing physicians with tools that somehow integrate financial relevance into the practice of delivering quality care is not something that most organizations are really prepared to do. From a more narrow technical perspective, the EHR’s ability to accept this data and make it relevant and actionable for front-line clinicians in their workflows is also something that providers (and by extension their HIE and EHR vendors) will need to address.

Benefits to Providers
But VBR is coming and payers are in a position to help solve some of the soon-to-be or already vexing problems for many provider organizations: revenue leakage, patient risk scoring, care gap identification, medications adherence, clinician performance management, care management or population health.

Solutions to these problems will provide a range of different benefits to provider organizations but genuinely hard to incorporate gracefully into clinician workflows. In addition, solving these problems will require more than just the payer claims data. A range of payer-derived data types will be needed to help provider organizations.

Changing Dynamics of the Payer-Provider Relationship
The use of payer-derived data is inevitable and providers need to look at potential silver lining. Some providers are actively talking about using payer data to evaluate and compare health plan benefit design. The thinking is that by comparing similarly situated patients from different payers from an outcomes standpoint, they may be able to link specific features of a benefit plan (e.g. free annual physical exam by PCP) to better outcomes. If the outcome variance from payer to payer is not minimal then maybe there is a member-benefit design problem that they need to raise with the payer. More importantly, it might put the provider in a better position to recommend to their patients the most effective health plan based on the patients’ overall health history. Using the same logic, providers could compare the performance of partner provider organizations as an aide to negotiation with those partners.

The point is that provider organizations need not view the use of payer-provided claims and other data as all downside. Claims data is as good a place as any to start building trust between traditional adversaries.

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Time to Move Beyond HIE

CNMOur ongoing coverage of the HIE industry leads us to the question of what clinicians do after getting connected to an HIE?

To this end, we are conducting a 10-minute web survey on clinician’s experiences using HIEs for care coordination. We want to understand how clinicians are using HIEs today in their daly activities. If you are a credentialed clinician with any experience using an HIE of any kind, we invite you to take the survey by clicking on this link.

In appreciation for completing the survey, we will provide a $50.00 Amazon gift certificate for the first 50 completed surveys we receive from verifiable clinicians (i.e. a working email address at the end of the survey). We are particularly looking for clinicians working in large group practices or in post-acute care but any care venue is appropriate. Just remember, you must be a credentialed clinician, have a good sense of how your HCO is or should be using an HIE, complete the entire survey and provide us with an email address to qualify (and also so we know where to send that Amazon GC). Don’t worry, we promise to never to disclose your name or the name of your organization and your contact details to anyone, for any reason.

Why are we doing this?
Simple. The days of thinking about HIE as basic plumbing are over. Enabling HIE remains complex and expensive due to the lack of interoperability across the heterogeneous EHR landscape found in most communities. At a recent conference, David Kibbe of DirectTrust gave a presentation with the following data points.

In one Arizona County there are…

Specific Data Points

  • ~6400 physicians
  • ~70 EHR vendor products
  • 58 of these vendors have fewer than 100 physician customers each
  • 104 Walgreens locations
  • 64 CVS locations
  • 8 HIEs
  • 1 Immunization Registry

Unspecific Data Points

  • Some number of reference labs
  • Some number of imaging centers
  • Some number of long term care providers and facilities
  • Some number of home care provider organizations with some number of nurses, home health aides, assorted other clinicians and social workers
  • One state ELR system and disease surveillance system

While we certainly recognize why many still speak of HIE in the context of just stitching together communities of practice and their disparate EHRs; to truly move forward, healthcare leaders need to stop thinking that they are enabling HIE. Thinking within the construct of HIE is a natural, self-limiting proposition that does not focus on value realization.

Follow the Money – Network Management Critical
As the industry makes the massive transition from fee-for-service to value-based reimbursement models, the long-term success (or ultimate failure) of a healthcare organization will be highly dependent on their ability to effectively manage their clinician network, both owned and affiliated. And when we say manage, we are not talking about heavy-handed management, but more about ensuring that all in-network clinicians are aligned along the same goals and objectives to maximize reimbursement. Network of clinicians need to work together to accomplish such goals as:

  • Successful care transitions that minimize readmits
  • Managing care gaps
  • Define, distribute and track clinical pathways
  • Keeping those at risk of chronic disease from contracting the disease
  • Effectively manage patients with chronic disease(s)
  • Practice score-carding to identify outliers and take corrective action
  • Assign attribution based on contract terms and clinician involvement

Virtually all ambulatory practices do not have the resources to address the above and their EHRs certainly won’t get them there either. Only the parent HCO has the resources and expertise to enable this advance functionality and it is their job to insure such is distributed to their network and owned and affiliated physicians.

Our hypothesis is that large HCOs are searching for ways to influence clinical processes and workflow outside their walls and will leverage their HIE infrastructure to do so. At the same time, community-based clinicians need better access to better information so they know what is expected of them when treating shared risk patients. In the next year, we will be looking at the ways that HCOs are building alignment within their networks of physicians – owned or affiliated – to establish common care goals and objectives that also maximize contract opportunities for everyone.

This survey is the first step in our research on the necessary transition from HIE to Clinician Network Management (CNM). Time to roil the industry and think beyond the limited confines of HIE to the value that can be delivered within a clinician network.

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Can Mirth Revive NextGen?

Last week, NextGen’s parent company, QSI, acquired open-source tools vendor Mirth for $59M. While a relatively small acquisition, it nonetheless will have an impact on the broader HIE market. Mirth’s toolset has an array of HIE components, notably its well-regarded Mirth Connect integration engine, the cornerstone of its commercial and open-source success to date.

The acquisition confirmed two critical points we made in our 2013 HIE Market Trends Report:

1) EHR vendors need new and better ways to support clinical interoperability in an increasingly heterogeneous EHR world and
2) that consolidation in the HIE market will continue unabated.

Mirth, was never a full-bodied HIE vendor, but has been a steady presence in the market as a component supplier to HIEs and HIE vendors, notably Harris and Covisint among others. Its open-source tools get potential customers in the door who can then convert to a commercial license. In a call with Mirth executives, post acquisition, they stated that today, there are nearly 650 commercial licensees of Mirth Connect – for clinical interoperability projects.

Mirth’s integration engine, Mirth Connect, is not as widely deployed in production environments as most of its competitors (i.e., Orion Health, Corepoint, InterSystems or Infor). However,, Mirth Connect has found its way into a variety of prototyping and testing environments for HL7 messaging and EHR integrations. For many developers and healthcare systems, its no-cost, initial cost has been irresistible to desperate HL7 developers around the industry with Mirth claiming some 25,000 active open source licenses out of the 100,000 plus downloads of Mirth Connect.

While Mirth Connect is the cornerstone of Mirth’s product suite, the company does offer other tools that are commonly found in HIE deployments including a data warehouse and master patient index (MPI).

Like other open source vendors, Mirth has grown by selling wrap-around services to healthcare organizations (HCOs) that use its solutions for more extensive and complex deployments. Accordingly, Mirth pops up on our radar screen in discussions with public and enterprise HIEs. Mirth has also been very active in the efforts of the EHR Vendor Affinity Group for the Beacon Community, convened by ONC. But despite its well-received tools and commitment to better clinical interoperability, Mirth has always been somewhat hamstrung by its organizational reach, resources and delivery capabilities.

With this acquisition, NextGen will now use Mirth products for the 90,000 physician users of its community EHR offerings. In speaking with a senior executive at NextGen, she informed us that NextGen plans to preserve Mirth’s independence, retaining the Mirth brand, staff, offices and existing partner relationships and software licensing terms.

We see this acquisition of Mirth as a relatively low cost way for NextGen to accomplish two goals:

1) Do what it could not accomplish internally; develop a cross-enterprise interoperability platform for its current and future customers.
2) Reinvigorate the company and its market luster.

Main Street Realities and Wall Street Expectations
Quality Systems is under pressure to change for two sets of reasons: the dynamics of the community EHR market and the requirements of Wall Street.

These are unsettled times in the community EHR market as physicians gain more day-to-day experience with EHRs, leading inexorably to heightened expectations for EHRs. While the giants of the community EHR market boast like Roman emperors about their offerings, single-digit market shares and rumors of mass EHR replacements have vendors looking over their shoulders. NextGen, like all community EHR vendors, has customer retention concerns and must take product actions so its customers can participate in new models of care at both the patient and population level.

The acquisition of Mirth is also a tacit admission that NextGen’s EHR Connect has not been entirely equal to the complex task of providing cross-enterprise EHR interoperability for its customers. NextGen EHR Connect, like similar offerings from most EHR vendors, does not readily support interoperability in a heterogeneous EHR environment.

While the company is making all the right noises about how Mirth can help provide more interoperable data to support new payment models and population health management, it is unclear why NextGen took this specific product action: buying – rather than partnering with – a company to achieve this goal. After all, plenty of HIE vendors, EHR vendors and HIT integrators thrive using partnerships to get any or all of the tools that Mirth sells.

The explanation probably lies in Quality Systems, Inc.’s (QSI) relationship to Wall Street. The company is now “dead money” in Wall Street lingo. It certainly has fared less well than some its competitors (see chart for an unflattering 1-year comparison with Cerner, athenahealth and even down on its luck Allscripts). A hedge fund owner forced QSI to take on three new board members this summer and reevaluate the company’s “strategy”.

This acquisition could be more related to how the company is perceived by Wall Street than Main Street HIT customers and partners. Buying Mirth was relatively cheap – $59 million reportedly – and, in the Wall Street worldview, a way to burnish NextGen, with its roster of captive physician customers, thereby making it a more attractive target to the usual roster of larger, acquisitive HIT and private equity companies.

Licensing Caution for Mirth Customers and Partners
For existing Mirth customers, product licensing could become problematic over the long term. While NextGen is committed to preserving Mirth’s existing open-source and commercial licenses, the pressure to deliver better revenue results is on at NextGen and the company will eventually turn its attention to increasing the revenue yield of solutions built with Mirth tools that are now spread across many HCOs.

For Mirth’s open-source customers, the transition to some kind of NextGen master license from Mirth’s Mozilla-derived license could introduce unwelcome changes in the form of decreased deployment flexibility or increased direct or indirect costs. These customers could experience higher than expected costs and contractual complexity as they expand their deployments to support new needs or more users. All Mirth customers risk being stranded on existing software as NextGen evolves the software and licensing terms of future versions of Mirth tools to suit its needs. NextGen’s commitment to or interest in preserving the licensing rights or upward compatibility of existing customers is a question mark over the long term. If QSI itself is acquired, that uncertainty multiplies.

For Mirth partners, the foregoing concerns could be more significant. We know that HIE vendors Harris and Covisint have relationships with Mirth under which they use a variety of Mirth tools. We can only hope that these and other partners contemplated that Mirth could be acquired – and its new parent could in turn be acquired – when negotiating the terms of their partnership agreements and licenses. If not, they and their HCO customers could be surprised as Mirth’s licensing terms change to meet the business needs of its new owners.

Granted, all Mirth customers have the current source code should NextGen indeed change terms and conditions in unacceptable ways, this may put some of these companies in the position of directly supporting the code base going forward.

Consolidation Continues and EHR Vendors Interoperate

The bottom line is that this acquisition is more evidence of consolidation in the market for clinical interoperability and for the technology stack found within HIE solutions suites. NextGen is not the only EHR company to acquire HIE technology with Allscripts having acquired dbMotion earlier this year and Siemens acquired MobileMD nearly two years ago. It is also evidence of EHR vendors’ need for better interoperability technology and the inadequacy of existing EHR vendor solutions for connecting care communities in the new world of payment reform.

If history is any guide though, HIE-related acquisitions by EHR vendors do not bode well for this acquisition of Mirth. Over the last several years several HIE vendors have been acquired by EHR vendors. In all cases, these acquisitions have led to the former independent HIE vendor to be but a shadow of its former self.

 

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Pushing the Envelope to HIE 2.0

Innovation driven by the effective use of IT has long catalyzed industry transformations – except in healthcare.

We all know people who have never waited in a teller line to cash a check. In the now unlikely event that systems fail, it would be a new experience for many to actually go to a teller to conduct a transaction with a bank.

Patients still get diagnosed and treated with or without electronic health records (EHRs), health information exchanges (HIEs), or any of the panoply of IT-based tools used by clinicians and their organizations. Goose quills wielded by the credentialed are the universal backup plan in healthcare. IT has thus far not been mission-critical the way it is now for other industries. We find this somewhat surprising as healthcare is such a knowledge intensive industry. Logic and reason would argue for wide-spread adoption and use of IT, but such has not been the case, that is until recently.

Inexorably, the healthcare industry is undergoing massive transformation and IT is seen as playing an absolutely pivotal role in the future effective and efficient delivery of healthcare. Among the multitude of IT vendors targeting healthcare, HIE vendors are pushing hard to make IT truly mission-critical.

We saw this trend coming several years ago when we initially launched our unparalleled, in-depth research on the HIE market, which continues with the release of the 2013 HIE Market Trends Report next week. In the last several years, HIE developers’ brainpower, as well as that of their customers, has focused on getting existing installations to function at adequate levels. in the last year or so, vendors have zeroed in on improving deployment timeframes to decrease time to value. While this is a laudable goal, its end result has been an actual decline in innovation in the HIE market – a key finding in our 2013 HIE report. It shows that 2012 was most notable for a pause in innovation, even among the strongest vendors.

Future of HIE Hinges on Reimbursement, Which Remains Uncertain
The healthcare market is shifting faster than HIE vendors, partially because two things are happening at once. Stage 2 meaningful use will go into effect in 2014, causing (healthcare organizations) HCOs to seek interoperability solutions in large numbers. An even more significant driver for interoperability solutions is the ongoing conversion to value-based reimbursement across the healthcare sector. This transformation, with its ever-mutating timetable, radiates uncertainty.

For example, in December, one HIE vendor executive told us he believed the strategic imperative for larger HCOs to connect to their affiliates had been overstated. He and his colleagues saw the shift to value-based care as a process that would unfold over many years and the company planned to help its customers connect to affiliates as fee-for-value slowly became a reality. By late May, the same vendor had executed an about-face and – like every vendor in the report – had gone all-in on supporting new models of care delivery and reimbursement – right now.

Fast forward to two weeks ago and we see data indicating that providers are considering bailing out of the Pioneer ACO program for reasons that are still obscure. Last week UnitedHealth Group predicted its accountable care business will more than double in the next few years from its current $20 billion base. You can’t blame HIE vendors for feeling whipsawed.

Vendors Embrace Care Coordination, Or Exit Stage Left
While the pace of transformation to value-based reimbursement keeps everyone guessing, the momentum is clearly away from fee-for-service. Every vendor interviewed and profiled in the HIE report has plans to provide better support for care coordination so that HCOs and clinicians can band together to maximize payments and care quality while minimizing penalties. Yet, nearly all vendors have a slightly different take on how to enable such capabilities.

Some are focusing on specific clinical processes like referrals or cross-enterprise medications reconciliation. Others are focusing on knitting together HCOs, clinicians, and patients with robust notification services embedded in the diverse EHRs and devices found in connected care communities. But the key word here is “plans.” No HIE vendor is currently able to meet the demands of this transformation in the industry – whatever its eventual pace. We dispute the naysayers who insist you can’t get there from here, and believe the HIE vendors profiled in this report are pushing hard to get in front of this transformation, a transformation in HIE capabilities to a future state we have termed HIE 2.0.

Outlook for HIE 2.0
The main theme of this report is the evolution to what we call HIE 2.0. We introduce a revised maturity model that starts at messaging-based HIE 1.0 and ends at HIE 2.0 where multidisciplinary care teams working across organizations collaborate to care for patients and patient panels using HIE-enabled care planning tools and applications. While some will undoubtedly quibble with the specifics of this maturity model, it sets forth a clear path to an endpoint where HIE technology will begin to assume a more mission-critical role in care delivery.

To support this new maturity model, we have in-turn defined the capabilities that HIE vendors will need to enable in an HIE 2.0 solution suite. THis capabilities are outlined in the table below.

Messaging Rises to the Level of Its Incompetence
While messaging will be an integral part of HIEs until time itself wears out, messaging-based HIEs have gone as far as they will go from a use-case standpoint. There are still a lot of faxes, phones calls, and letters that messaging could replace, but the limitations of messaging as a way to support complex, multi-enterprise clinical workflows are obvious to nearly everyone in the industry. Messaging diehards persist but their numbers continue to dwindle.

In the future, messaging will be supplemented with more robust notification services built into HIE-enabled collaborative care plans that deliver the right information, in the right context, to the right clinicians at the right times, on the devices or in the clinical applications of their choice. Moreover, many of the advanced applications of HIE 2.0 will be built using query-based services that take more fulsome advantage of the longitudinal patient record. A caution here is that Stage 2 meaningful use requires the use of Direct Secure Messaging protocols for certain transactions. This is not only driving strong demand from HCOs but also causing HIE and EHR vendors to include Direct-based services in their product plans. For reasons detailed in the report, this technological detour into messaging is a dead-end.

Lower Rankings Yet Reason for Optimism
For readers familiar with our past HIE Reports, we must mention that all vendor rankings are lower this year. This reflects the need to adjust the ranking criteria to reflect increasing expectations of HCOs and changing market requirements. HCOs need more from their HIEs than ever before – more functionality, more use cases and better reliability, availability and servicability. No vendor is remotely close to being able to assemble an HIE 2.0 solution right now. But many vendors are pushing hard and we expect the best to begin rolling out HIE 2.0 products by the middle of 2014

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Limits and Lags in Healthcare Productivity

In a recent Health Affairs blog, Alex Goldsmith does a back-of-the-envelope analysis of the peculiar economics of healthcare. According to the Bureau of Labor Statistics, employment in healthcare increased by 1.149 million people from 2007-2011. He contrasts this increase in employment (read increased cost) with declining hospital admissions, low single-digit growth in hospital outpatient volumes and declining physician office visit volume (read declining economic output). A New England Journal of Medicine article published in Oct. 2011 also showed a net percentage decrease in productivity growth (see figure below).

Over this same time period there has been steadily increasing investment in IT for hospitals and doctor’s offices much of it as a result of the HITECH Act that was passed in 2009. Compared to ten years ago, more healthcare workers are doing less healthcare with more information technology. And little over a week ago a Wall Street Journal op-ed by Stephen Soumerai and Ross Koppel pulled no punches, calling the savings to be gained from IT in healthcare “chimerical.” We have known for a long time that providers themselves insist that productivity drops after installing an EHR and there is little evidence to refute such claims and plenty of evidence to support them.

The absence of productivity improvements or cost savings after big IT investments is neither new nor unique to healthcare. Way back in 1987, Nobel laureate and MIT professor Robert Solow famously said, “We see computers everywhere but in the productivity statistics.”  For the next ten years, economists leveled forests (this was a pre-internet time after all) trying to explain away the Solow productivity paradox. While the dotcom boom rendered productivity paradoxes as interesting as bell-bottom pants, few would now contest that increased use of IT drives productivity improvements. It is just a long journey to get there with some successfully surviving the journey and others not. There are plenty of examples in other industry sectors of companies that did not effectively adopt and use IT, ultimately contributing to their downfall.

The EHR Incentive Program and all of the other IT-related ONC and CMS programs have a host of now familiar policy objectives. The fact that IT is at their center says loudly that CMS is trying to coax incremental productivity improvements from a reluctant system.

So where are the productivity improvements in healthcare? While we are only one year into the meaningful use (MU) saga, we would argue that we are seeing three things: 1) the limits to IT as a productivity-boosting panacea, 2) a lag between the investment in IT and a productivity payoff and 3) an existing reimbursement model that does not effectively support IT adoption that is in alignment with meaningful use objectives.

Providers that invest: Most of the current incentives for IT adoption are aimed at the point of the healthcare spear: CMS is willing to pay most frontline clinicians in private practices, clinics and hospitals to adopt IT. These same frontline clinicians, however, are increasingly frustrated and burned-out by the fee-for-service treadmill. Simply getting a primary care physician (PCP) to meaningfully use an EHR will not allow her to suddenly double her patient load. If anything, it will likely decrease office productivity for at least a year as all staff members become familiar with and effective in using an EHR.

Measures like the Stage 2 MU objectives build on that basic EHR to let that same PCP leverage work done in other parts of the healthcare system to deliver more coordinated care. The PCP still can’t double her workload but she might be able to accomplish more in each encounter. In this instance, we see the lag between the investment in a basic EHR and the enhanced productivity of a more interoperable EHR, a time lag measured in years.

Providers that do not invest or under-invest: These incentives are not available to some segments of the provider community (e.g. skilled nursing facilities, behavioral health facilities). The limit is that non-incented providers presumably will invest modestly or not at all in EHRs, interoperable or otherwise. In this instance, the lag may well be a very long time.

Further, incentives are voluntary. Eligible providers can IT-up and take the money — or not. Nearly half of eligible hospitals have collected something under the EHR Incentive Program. The ranks of qualifying EPs, while still low, continue to grow and we will likely see a majority of EPs sign-on to this program.

The Wall Street Journal op-ed claims that ONC and providers are captives of the healthcare IT vendors.  The authors suggest that vendors, presumably in an effort to protect their markets, blocked efforts to make EHRs more interoperable, effectively blunting cost or productivity improvements. This is a fair criticism, probably true, and a clear limit to what we could expect from Stage 1 MU.

However, providers in a pure fee-for-service world have rarely found sufficient value in adoption of EHRs to justify the investment, thus the need for incentives. As the market slowly shifts reimbursement to value-based metrics, the justification to invest in an EHR begins to look more attractive to a PCP. Coupling this with future, MU Stage 2, certified EHR solutions that will better support care coordination across a heterogenous EHR landscape in a given community, the potential for true improvements in productivity appear promising. There is even a potential silver lining for providers that do not invest or under-invest as even the left-behinds have at least have a fax machine and a browser and may begin to enjoy some of the productivity gains of a reformed, networked system.

The network effect that kicks-in over time may like a rising tide, lift all boats. But this is a very slow tide that will rise over many years. Now the question is: How many of those boats have holes in them and will forever rest on the ocean’s bottom or does the tide simply rise too slow and others just pull their boats out of the water?

Note: This post has been authored by our newest analyst, Brian Murphy a former employee of Eclipsys, IBM and others as well as a former analyst for Yankee Group. Find out more about Brian on our About page.

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