Data-Driven Patient Outreach: Financially Efficient or Morally Compromised?

I recently spoke with a clinical analytics vendor about one of their provider customer’s bizarre decisions – to no longer encourage a subset of their diabetic population to take the HbA1C test. The reason? These diabetics were covered under a new P4P payment contract, which no longer rewarded such testing.

I am not naïve to the fact that, since the beginning of the practice of medicine, patients have been treated according to different care standards…with payment to blame more often than not.

Now our payment models are evolving and population health management (PHM) has become a word du jour. In addition, the payer-provider line is blurring, and data is flowing more freely than ever between the two former adversaries. From a PHM-centric standpoint, new incentives now present themselves to treat similar patients differently based on these newly acquired datasets.

Different Payment, Different Data, Different Outreach

Take for example, massive healthcare systems such as Intermountain and Geisinger. These HCOs own their own health plans, but unlike Kaiser Permanente, also accept outside insurance. Patients can therefore be covered be under FFS, P4P contracts, risk-based contracts, as well as the HCO-specific payer plan. In addition, these HCOs have developed their own advanced care models that should, in theory, override the influences of payment on care. However, things soon get tricky with regards to PHM outreach:

  • If Debbie the Diabetic is covered under FFS, she will get zero outreach or, if she is lucky, outreach based on her sophisticated HCO’s advanced care models — with the HCO acting against its own short term financial interests.
  • If Debbie is covered under an all-upside P4P contract, she will get reminders in order for the HCO to tick off certain boxes in her payer’s P4P contract (process or outcomes-based), for example, to encourage her to come in for HbA1C testing, foot exams, etc. Perhaps there will be minimal effort invested in helping her control her blood glucose better.
  • If Debbie is covered under an at-risk contract that incentivizes global cost reduction (MSSP ACO, ACO with potential downside, capitation), someone will be trying to figure out how to get her cost utilization down. Her claims data will be run through a risk assessment model, and her costs will be projected. If Debbie is sufficiently out of control and really racking up the costs, she will be assigned a high touch case manager.

Note: the important enabler within these different outreach models is different datasets and the analytics software that runs on top. P4P Registries run on top of billing or EHR data. Risk-based analytics runs on top of adjudicated claims data. Within each analytics system, care gaps and associated outreach are tailored toward entirely different payment models.

Giving up on “Hopeless” patients (because the data says so)

There are many more usecases ahead in which data can be leveraged to perform unequal PHM-outreach. Take, for example, the ability of a risk-bearing HCO to predict which patients will actually comply with outreach, and which can be assigned to the “Hopeless” bucket.

Every medical professional can recount various patient horror stories. The mentally ill woman who visits the ED every weekend even though there is nothing wrong with her physically. The morbidly obese diabetic who has just lost a foot but continues to eat himself into oblivion. Despite the repeated pleas of multiple case managers, these patients are unable or unwilling to modify their respective trajectories.

If there is absolutely nothing the HCO can do to change certain patients’ behavior (within a given budget), should the HCO cut its losses, ignore the Hopeless, and focus resources on other patients?

Shiny new predictive models could be used to this end. Think of the growing number of variables with predictive power beyond ICD, CPT, and charges: BMI, race, zipcode, past outreach responses, self-generated fitness data. Let’s enter morally shady territory and include variables sold by data scrapers: real estate transactions, courthouse documents, credit worthiness of facebook friends, etc.

Running Debbie the Diabetic through this predictive model, we might learn that there is a 1% chance that she will respond to automated outreach, and a 15% change that she will respond to high touch outreach. It may be financially efficient to focus care management resources on other patients, but what would Debbie’s doctor say about this?

The medical establishment isn’t exactly in love with unfamiliar predictive models that use sensitive data sources to tell them which patients will respond to outreach. Clinicians usually already know who these patients are within their panels — and believe in a more equal approach to outreach.

As providers continue to disrupt themselves via value-based reimbursement, PHM-outreach inequalities will be just one of the many contentious problem areas going forward…and the desires of risk managers and clinicians will continue to collide. In my conversations with vendors and end-users for the Clinical Analytics Market Report research, I for one was surprised at how nonchalant my interviewees were in discussing this morally ambiguous territory — and I have yet to hear the patient’s voice.




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.



Clinical Data Has Arrived. Now What?

Last year it became clear that the term ACO-enablement was going out of fad, and a new buzzword — population health management (PHM) — was surfacing. After interviews with several industry stakeholders, it soon became clear to us at Chilmark Research that there were high levels of interest in:

  1. Just how new sources of clinical data (EHR, HIE, user-generated), were going to be ingested into analytics systems, and:
  2. How providers were going to adopt analytics for PHM as they began to take on patient health risk in value-based reimbursement contracts.

As we continued interviewing vendors and talking to people in the field, our first Analytics research endeavor, Clinical Analytics for Population Health Management (CAPH) Market Trends Report, (expected publication: week of Aug 19th – stay tuned) began to take shape. As an analyst I was both excited to dive right in, and at the same time daunted by the level of technical, clinical, and business-model complexity that would be involved.

A large, thorny, elephant was in the room that no one seemed to want to talk about — were providers the right parties to take on patient health risk? Would they fail like payers before them? Regardless, providers were starting to march down the risk continuum, and I was going to follow them.

As we began talking to more vendors, it soon became clear that an incredible number of them were pivoting, purporting to serve the CAPH market. Some were positioning offerings along the ACO lines, others were talking about Big Data, and others preferred a Population Health Management marketing message. In the end we selected 14 vendors to profile across several different categories:

Top Level Classification Vendors
Clinical Best of Breed: Infrastructure-Centric Caradigm, Explorys, Health Catalyst, InterSystems
Clinical Best of Breed: App-Centric Humedica, Wellcentive
Claims-Based Best-of-Breed App & Pivoting The Advisory Board Company, Aetna/ActiveHealth Management, Truven
HIT Vendor with Secondary Analytics Solution athenahealth, CareEvolution, Cerner, MedVentive
Generic Horizontal Analytics/Services IBM

The process of interviewing these vendors and their end-users was initially tedious, as vendors often had radically different architectural approaches and stances on the market. A common language had not (and has not) developed for talking about CAPH, and I soon learned to speak claims-centric and clinical-centric dialects.

Over the coming month I will be writing a series of posts on some of the more interesting findings from the report. Please feel free to leave comments below or get in touch with me directly if you are interested in clinical analytics/population health management — I will enjoy any and all feedback and as I continue to follow the CAPH space closely over the coming year.





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


Implementing Analytics for PHM and Accountable Care.

In order to implement population health management and accountable care, healthcare provider organizations (HCOs) will have to deploy dozens of analytic applications, including clinical, operational and financial applications. With demand for applications outstripping the ability of IT to develop these applications in-house, many of the required applications will be purchased — frequently by end-users with little or no input from IT.

Consequently, most HCOs will end up with a mishmash of analytical applications with different software components. Short-term gains for end-users could cause long-term pain for IT if too many of these standalone applications get installed, all requiring different overlapping infrastructure technology, data, and support. For example, one application may use Microsoft’s data integration, database, or end-user Business Intelligence (BI) software, another could use IBM’s, even though IT has chosen a third vendor as the preferred standard for data integration, end-user tools, and database.

Our report, Building an Infrastructure to Drive Healthcare Analytics, examines this challenge and documents how to create a flexible infrastructure framework to support analytic applications. And how to weave all the technology together into a consistent and manageable platform

The bottom line is building an analytics infrastructure is a design and construction process pulling together and assembling a handful of mature and capable software components — typically from different vendors. The overall architecture and technical requirements of each of the components, as we outline in the report, are well known and tested. It is not rocket science

What makes analytics hard is that the outcomes, particularly organizational impacts, are not known with certainty at the beginning of the project, and the economics are merely uncertain projections until the project moves towards production. The biggest challenge is managing and integrating each analytic project into the platform using the IT best practices we outline.

One other challenge that we discuss in-depth within this report is the need to look at IT analytics projects as different from virtually any other IT project. Analytics projects have an exceptionally high rate of failure. Therefore, rather than using a common project management approach with set deadlines and milestones for analytics projects, we encourage users to use a portfolio management approach that will be flexible and anticipate potential failure, allowing for quick resource alignment once fate of a given analytics initiative is known.


HIEs Experience Growing Pains, EHRs Stumble with Population Health

May at Chilmark Research saw us compiling the results of extensive research for two major market reports one on Health Information Exchange (HIE) and the other on Analytics for Population Health Management. Both will be released shortly. In our May update, we preview the HIE report and also look at what it will take for electronic health records (EHRs) to truly support population health management. You can read abstracts of each below.

Subscribers to the Chilmark Advisory Service (CAS) receive among other services, research content that includes: Monthly Updates, quarterly Insight Reports, and one major Market Trends report a year as part of their membership. To find out how you can receive the full update, send an email to:

HIE Market in Transition, Requires New Vocabulary
John Moore

The HIE market has always had trouble defining itself. In the early days, vendor marketing messages painted a rosy picture of what an HIE could do, but when one pulled back the curtains, few products on the market could actually exchange health information across a heterogeneous EHR environment. Fast forward to 2013 and the market is redefining itself once again and vendor messages have become more vague.

In the HIE of the future, HIEs will be the interstitial layer that connects all the various IT systems across a community to present patient data in a coherent manner in support of collaborative care processes. Unfortunately, the nascent state of interoperability still makes actual execution a challenge. The industry is moving in the right direction, but it is a slow and often expensive move.

In this month’s update and the upcoming 2013 HIE Market Report, we define a future state for health information exchange: HIE 2.0. Frankly, we are not fans of the trendy 2.0 language, though it comes in handy to describe a technology in transition. In our report and over the coming year, Chilmark Research will begin defining a new HIE vocabulary, one with more staying power and specificity that incorporates the important challenges ahead for this critical infrastructure technology.

Building Towards Population Health Management
Rob Tholemeier and John Moore

Core to any technology platform that supports population health management (PHM) is the ability to effectively and accurately capture, store, and allow for ready retrieval of a patient’s health history and current condition. Today, healthcare providers of all sizes are looking to EHRs to accomplish much of this task. We doubt that today’s crop of EHRs are up to the challenge.

Early EHRs were not designed first and foremost to facilitate and improve the delivery of care; they were designed to facilitate billing. The focus on billing led to the creation of solutions that have zapped physician productivity and generated widespread reports of physician productivity dropping 25-30% during the first year of go-live.

The next generation of EHRs will require significant enhancements to support provider effectiveness and efficiency in the delivery of care within a PHM construct. In this research note, we look at four of the necessary enhancements: embedded analytics; intelligent rules engines; situational awareness; and standardized interfaces. A future research note will examine three more: human-centered design; natural language processing; and biometric and patient-generated health data (PGHD). Without these core capabilities, built directly into the EHR and not a bolt-on, the industry will continue to struggle in its attempts to truly manage the health of the population they serve.

Each month, subscribers to the Chilmark Advisory Services (CAS) receive an update of our research on the most transformative trends in the healthcare IT sector. Exclusive to CAS subscribers, Monthly Updates are part of the continuous feed of information and analysis we generate to keep subscribers on top of the rapid-fire changes in this market.