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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Why We Won’t See EHR Consolidation Anytime Soon

All too frequently I get the question:

When will we see the EHR market consolidate?

Not an unreasonable question considering just how many EHRs there are in the market today (north of 300) and all the buzz regarding growth in health IT adoption. There was even a recent post postulating that major EHR consolidation was “on the verge.” Even I have wondered at times why we have not seen any significant consolidation to date as there truly are far more vendors than this market can reasonably support.

But when we talk about EHR consolidation, let’s make sure we are all talking about the same thing. In the acute care market, significant consolidation has already occurred. Those companies that did not participate in consolidating this market (Cerner, Epic & Meditech) seem to have faired well. Those that pursued a roll-up, acquisition strategy (Allscripts, GE, McKesson) have had more mixed results.

It is the ambulatory sector where one finds a multitude of vendors all vying for a piece of the market and it is this market that has not seen any significant consolidation to date and likely will not see such for several years to come for two dominant reasons.

First, you need to be half crazy to do an acquisition. As nearly two-thirds of all acquisitions fail, the odds are stacked against you. Therefore, you need to be darn sure that this acquisition makes sound business sense before pulling the trigger.

Second, the ambulatory EHR market is simply not ripe for consolidation. The reason is simple. To remain viable in the market, EHR vendors must ensure that their products meet Meaningful Use (MU) requirements and meeting those requirements requires hefty investments.

Virtually all EHR vendors invested resources to get over the Stage One hurdle. In fact, the federal largesse of the HITECH Act attracted a number of new EHR entrants to market and likely kept a many EHR vendors afloat who would have otherwise gone under.

Stage Two’s certification hurdle has yet to be released but will assuredly require a continued and potentially significant investment in development resources by EHR vendors to comply. Same holds true for future Stage Three certification requirements.

At this juncture, it would be foolhardy to try and execute an EHR acquisition roll-up strategy. The technology has yet to stabilize, significant development investments are still required and most vendors do not have sufficient market penetration. Better to wait until the dust settles and clearer stratification of the market (who will remain viable, who will not) becomes apparent.

An Example from Manufacturing:
In my many years as an IT analyst I’ve seen few instances where acquisitions have actually worked out well for all parties concerned. When I led the manufacturing enterprise analyst group at a former employer I watched as two separate companies (Infor & SSA) executed roll-up acquisition strategies in the mature Enterprise Resource Planning (ERP) market.

Much like the ambulatory EHR market, these two companies targeted the low-end of the ERP market (small manufacturers). ERP companies acquired had two defining characteristics: stable platforms and reasonable penetration in their target markets.

Infor and SSA executed their strategies skillfully acquiring multiple companies; promising customers never to sunset a product; and meeting their investors’ goals by lowering operating costs (reduce duplicative administrative costs across acquired companies.

Post acquisition, Infor and SSA did not invest heavily in development, simply doing the minimum necessary to meet customers’ core requirements. Ultimately, Infor acquired SSA and Infor remains one of the dominant ERP companies in the market today.

A similar scenario will play-out in the ambulatory EHR market, it just will not be this year or next or even the one after that. Look to a couple of years post-Stage Three, for the long-awaited consolidation that so many have predicted to finally occur.

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At Last, It’s Here: 2012 HIE Market Report

This morning we announced the release of our latest report: 2012 HIE Market Report: Analysis and Trends of the Health information Exchange Market. As we found in last year’s report, the HIE Market and the vendors that serve it continues to be a very dynamic.

In little over a year we have seen several vendors exit the market, several others enter and the acquisitions of Carefx by Harris and MobileMD by Siemens. We also saw Microsoft pull completely out of the clinical market by turning over all its HIT assets (except HealthVault) to the new joint venture with GE, Caradigm.

Yet in spite of all this turmoil, the market continues to see spectacular growth in excess of 40% in 2011. The big news with all this growth is that only a small portion of it is coming via the HITECH Act and the various statewide HIE contracts that were awarded. No, the big market that literally all HIE vendors are now targeting is the private, “enterprise” market. Healthcare organizations (HCO) of all sizes are now looking to deploy HIE technology to not only meet Meaningful Use requirements, but respond to the pending changes in reimbursement, moving from a fee for service model to one that is based on outcomes.

To be successful under these new payment models, HCOs must better manage operations and the complete care cycle of a patient across care settings. In a community of heterogeneous EHRs, HCOs are adopting HIE technology at an accelerated rate to unlock the data silos of EHRs across the community to enable higher quality of care.

Arguably, the 2012 HIE Market Report’s most significant finding is…

The healthcare sector is rapidly moving to the post-EHR era. The value of patient data is not in the data silos of EHRs but in the network that an HIE supports.

The report provides the most comprehensive overview of the market and what are the significant trends that are driving this market forward. The report also provides a deep dive review of 22 leading HIE vendors, including product capability assessment and market presence. This information, compiled through in-depth research and countless interviews, provides all HIE stakeholders with the most accurate view of the market today.

It is our sincere hope that the information contained in this report will contribute to furthering the success of HIE deployments in the future as we strongly believe that only through health information exchange (the verb) can we improve the quality of health delivered within a community and ultimately, the nation.

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Predictions 2012: Not What You Think

Admittedly, our predictions for 2011 were modest. Most of those predictions were logical and did not take a whole lot of imagination to envision thus our success rate, 7 “hits”, 2 “toss-ups” and 2 “misses was quite high. And though are biggest accomplishment, predicting Blumenthal’s departure just a few short weeks before he actually announced such intentions is laudable, by and large these predictions just didn’t go far enough. So for 2012, rather than make simplistic predictions such as “analytics will be a high growth area” or “mHealth will create greater security concerns” or even “ACOs will begin to take hold” as none of these are all that thought provoking, we’ll go out on a limb with many of our predictions. Hopefully that limb won’t crack sending us crashing to the ground.

Without further adieu, here are our predictions:

Consumer/Patient Engagement – Not What it Seems
Despite the best efforts of the team at ONC to beat the consumer/patient engagement drum, providers by and large are still struggling with such basic issues of taking live their certified EHRs, making the transition to ICD-10, meeting physician demands to have everything served up on their new iPad and of course mapping out future strategies in anticipation of payment reform. Thus, we foresee consumer engagement remaining a tertiary issue in 2012. Just too many other pressing priorities at the moment. WebMD’s implosion on Jan. 10th may portend that this is not such a bad move – at least in the near term.

Bloom is Off the Rose, EHR Market Plateaus
Going out on a limb, we see 2012 as the year when we start talking of the post EHR-era. Yes, there will be plenty more EHR sales in the year to come but over 2012 we will also see EHR sales growth begin to plateau and level off by end of Q4’12. You heard it here first folks, it is time to collect your EHR winnings and seek new places to invest.

Finally, We’ll See Some Fairly Competent Tablet Apps from Legacy Vendors
Though physicians continue to adopt iPads at a rapid rate, they struggle to effectively use them in the hospitals to which they are affiliated simply because most hospital HIS cannot serve up an application effectively on an iPad. Sure, many have tried using Citrix as a stop-gap measure but this is just isn’t cutting it. In speaking to one CIO of a major IDN recently, he was so frustrated with his core EHR vendor’s slow pace of development that he is about ready to self-fund the development of an App for his physicians. Fear not CIOs and frustrated physicians, we have had the opportunity to see several alpha versions of iPad Apps that major EHR vendors are developing and they actually look pretty good. Look to Q2-Q3 ’12 for general availability release of these touch-screen native (mostly iPad-centric) Apps.

At Gunpoint, Direct Project Gains Traction
In 2011, the message came down from on high, or at least from the feds, that all State HIEs must include the use of Direct in their strategic plan. Pretty clear that this was politically motivated as to date, for the $500M plus we, as taxpayers are spending on these public HIEs, there is very little to show for it and we are now running headlong into an election year and this administration needs to show something, anything, in the way of success as it pertains to health information exchange. Sure Direct facilitates health information exchange (the verb), but so does a fax machine and frankly, Direct is only a modest step beyond faxing. Therefore, Direct will gain traction in these “forced” instances but we do not see it extending its reach into the much larger market of private, enterprise HIEs (does not sufficiently support care coordination, population health and analytics) and thus Direct’s overall impact in the market will be small and fade to nothing in three years time.

First CPT Codes for mHealth Apps Issued
mHealth Apps for care provisioning have not seen any significant adoption beyond pilot studies, studies which typically show some efficacy in their use. The big hang-up is a simple one, the risk to reward ratio for physicians to adopt and use mHealth Apps as part of the care process is too low. What might change that risk-reward ratio though is a CPT code whereby a physician actually gets paid to use, or have a patient use an App as part of the care process. WellDoc is one of the few mHealth App companies that is quite aggressive in moving the ball forward and we would not be too surprised if WellDoc did industry ground-breaking work to secure the first CPT codes for their diabetes management App.

Train has Left the Station as Supreme Court Rules on ACA
Though the Supreme Court will hear arguments for and against the constitutionality of the Affordable Care Act (ACA), it is unlikely that their subsequent ruling will throw out all of ACA (they may prune it). More importantly, the move to value-based reimbursement models is already in full swing, which is something that will not be reversed. Whatever the Supreme Court rules, its impact will be minimal and the numerous changes we are seeing take place today (move to accountable care models, patient centered medical home, etc.) will continue as the train has already left the station.

Changing of the Guard as Dynamic Duo Departs
Last year we predicted the departure of ONC head, Dr. David Blumenthal. This year is an election year and it is expected that there will be a significant changing of the guard across the administration. We predict that the dynamic duo that is Aneesh Chopra, White House CTO and Todd Park, HHS CTO will both be leaving their posts by end of the year.

M&A Continues, but at far more Reasonable Valuations
Okay, yes we have had this prediction for three years running, but we just can’t help ourselves as we see far too many vendors in this market (some 300+ EHR vendors alone!) and some rationalization must enter at some point. We are seeing rationalization on valuations (e.g., no one was willing to pay what Thomson Reuters wanted for their healthcare business unit despite there being a sizable number of bidders) and this will create an opportunity for acceleration in M&A activity in 2012.

Floundering HITECH Initiatives Attract Political Spotlight
Yes, we are seeing some modest success and adoption of EHRs as a result of the HITECH Act but the preponderance of such success is at hospitals that first have had some form of EHR already in place and also have a lot to lose if proposed reimbursement cuts from CMS come to fruition at the end this multi-year march to certified EHR adoption and meaningful use. Yet, under the covers we are still not seeing wide-spread EHR adoption at the ambulatory level, especially among smaller practices, State HIE initiatives struggle to define what they’ll actually be when the grow-up, the Beacon programs have not reached the promise land, and the RECs, well we were never a big fan of these for obvious reasons we outlined previously. As this is an election year, healthcare and anything with the stamp of the Obama administration on it, will become fair game and dragged into the limelight. Get ready for healthcare to become the political piñata of 2012

HIE Vendors Stumble
By the end of 2012, the final awards for State HIEs will conclude and with it the evaporation of the $500M plus honey-pot that attracted so many vendors into this space. What’s next for these vendors? Some will stumble out of the market with little to show for their efforts. Others will work with their public clients to stand-up these public HIEs in order that they provide value to their respective communities, which will not be easy and lead to more stumbling. And of course HIE vendors who have traditionally been focused on public markets will reposition themselves for the private, enterprise market. Some of these vendors are now stumbling in this transition to the enterprise market (requires different sales resources and tactics, technology requirements, etc.). This will result in yet another shakeout in this niche industry sector. (Our forthcoming HIE Market Report will provide further details)

The funny thing about doing these predictions is that as one actually goes through the process of thinking about this market, which is currently going through nearly unprecedented change, one ponders so many other predictions that just end up on the cutting room floor. Some of those include:

Payers continue to struggle with exactly what they’ll offer on the State Health Insurance Exchange.

Pharma companies look to insert themselves directly into physician workflow, via HIT.

Despite rising cost share, consumers still struggle to make intelligent, informed decisions.

Telehealth gets some wind under its wings as big telecoms start aggressive lobbying efforts.

You get the idea, plenty of turmoil, no lack of potential trajectories in technology adoption and use within the healthcare sector and we here at Chilmark Research look forward to continuing to provide thoughtful insight on this ever evolving market in 2012.

So now it’s your turn. Are we on the mark with our predictions? Did we reach too far? Is there a particular prediction that you have which we totally missed? It is you, the community of readers that make this site far richer than we ever could do on our own and we look forward to your feedback.

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A Tale of Two Medical Records

This is a tale of my nearly year-long attempt to integrate my family’s medical records from a small outpatient provider (MIT Medical) into my Kaiser Permanente HealthConnect EMR.

From 2008-2010 my family was living Boston where I was getting my MBA at MIT Sloan.  We had been long-time Kaiser members before we moved to Boston and I had all intentions of continuing with Kaiser when we moved back West.

It seemed only natural that Kaiser would be eager to receive and integrate my records from MIT Medical.  For example, I had assumed that Kaiser would be interested in the following:

  • The asthma symptoms that my kids had developed while in Boston, and the associated medications they had been prescribed.
  • The immunizations my kids had received.
  • The preventative tests and checkups that we had all received.

Retrieving Medical Records from MIT Medical

MIT Medical is a self-insured outpatient clinic and a long-time user of Allscripts EHR.  MIT Medical is no stranger to technology – they are part of MIT, after all.

However, gathering my family’s medical records was not a high-tech experience by any stretch.  In May of 2010 I descended into the basement of MIT Medical into their small medical records office, where I signed the necessary HIPAA forms.  There was no mention of CCD/CCR, though in all fairness I was hesitant to ask – this looked more like a paper shuffling office than anything else.

I elected to have the medical records sent to me (not Kaiser).  I was told that I would be charged a fixed amount for every page of my record, but there was no way of knowing how many pages would eventually be sent.   This struck me as odd, but I still agreed to pay the unknown bill when it came.

After moving back to California, I wondered how long it would take for my medical records to arrive.  I received them within 2 months, which I assume, is the time it takes for a carrier pigeon to make its way from the east to the west coast.  During this time period my daughter began to have problems with asthma symptoms and I had to take her to the Kaiser ER, where her doctors had no past information on her asthma symptoms other than what I could remember.

Nevertheless, with the precious records finally in my hands, I was ready for the next step.

Getting External Medical Records into Kaiser HealthConnect

Still hopeful of achieving interoperable-EHR nirvana, I contacted KP member services and was given the address of their medical records office.  I mailed in the MIT medical records, and presto!  I assumed I was done.  However, in the back of my mind I knew it wasn’t going to be that easy… I never received a confirmation from KP that my medical records had been received, which made me doubt the whole process. However, I had other things in life to attend to besides this medical record integration project, and so I did nothing further and continued to hope for the best (the ‘best’ being that some individual or algorithm was turning the unstructured data from my MIT medical records into structured data and inputting this data into KP HealthConnect).

It turns out that I should have been a bit more pessimistic.  It soon became clear that my doctors and KP in general had no idea that I had sent in the records.  My pediatrician was asking me for my kids’ immunization records for the 2 years we were in Boston, and I kept getting automated reminders from Kaiser to schedule preventative tests and checkups that had already been done.

I then called the KP medical records office and had a very unsatisfying conversation where I was told that my records had never been received.  With a feeling of defeat, I knew I would have to begin the process of secure-emailing KP member services to get to the bottom of this.  The following is an account of those interactions:

  1. After contacting KP member services, I was told to call the medical records office (again).
  2. I called the medical records office twice but my messages were not returned.
  3. I secure-emailed member services again and asked how they were going to resolve this issue.  They never got back to me.
  4. After a few weeks I secure-emailed KP member services again.  Finally something got put into motion.
  5. I was called by someone from the medical records office.  She told me that my medical records had never been received.  She suggested that they had gotten lost in the mail?  She advised that it was probably best to physically drive to the medical records office and submit the records in person.
  6. 10 minutes later I was called by yet another person from the medical records office who sounded a lot more authoritative than the previous person (she had no idea that someone had called me previously and had told me to drive to the office).  She then informed me that my MIT medical records had been in HealthConnect since August 2010!  I asked her why my doctors, member services, medical records personnel, and seemingly all of KP had no idea that the MIT medical records existed.  Her response was along the lines of “They probably didn’t check HealthConnect”. Speaking to her further, I learned that the MIT records were stored as various PDFs within some content management section of HealthConnect (that apparently that clinicians don’t pay much attention to).

I secure-emailed my pediatrician and told him to check HealthConnect for the PDF.  Luckily he was able to find the kids’ immunizations, reconcile them with what was in HealthConnect proper, and then prescribe the immunizations they were lacking. Total time it took to get this information to him?  10 months.

At this point I was more than a little disgruntled.  Going through this process has shown me just how far away we still are from EHR-interoperability nirvana.  I have been trained however.  Whenever my doctors/nurses seem to be lacking information, I know now to remind them to please “check out that huge PDF file in your content management section of HealthConnect”. To my surprise, my clinicians are really only interested in the immunization data, ignoring the rest – even if that means that care and tests are duplicated.

The Big Picture

I realize that in this personal story of EMR integration gone wrong, the stakes for my family were relatively low.  We do not suffer from complicated co-morbidities, deadly allergic reactions, or the like. There was never really any danger of life-threatening circumstances arising due to lack of EMR integration.   For other less fortunate families who change healthcare providers, the stakes are obviously higher.

All in all, this experience has clearly demonstrated the general lack of interest in EHR interoperability among two very tech-savvy providers.   There was absolutely no process in place at MIT Medical or Kaiser that made it known to me, the healthcare consumer, that I should take steps to integrate my medical records.  Why didn’t MIT Medical suggest to that I might want to take my medical records with me when I left Boston?  Why didn’t Kaiser ping me for my medical records as soon as I arrived back in California?  Every step of the process was lengthy and painful, and required great initiative on my part.

There are some obvious reasons for this lack of interest in EHR interoperability in that the competitive advantages around not sharing patient data are just too powerful (but this is another post).

Looking forward to Stages 2/3 of Meaningful Use, I am left pondering how various parts of MU will break down if we do not accomplish data sharing.  For example, how are we going to engage patients by giving them access to their clinical data if this data isn’t portable in a computable format?  I remain reluctantly hopeful, and look forward to the day when the data in that PDF file residing within HealthConnect is finally fully integrated.

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SureScripts, A Defacto NHIN

Yesterday in New Orleans, SureScripts announced a new line of business: Clinical Interoperability. Leveraging their existing ePrescribing solution platform, currently serving over 200K physicians nationwide, and combining it with the technology stack of messaging solution provider Kryptiq, SureScripts will offer providers, EHR vendors, HIEs and other stakeholders the opportunity to securely share clinical information across town, the state, a region and the country. In this combination, SureScripts will provide the rails and Kryptiq will address the last mile of connectivity. This announcement has some pretty big implications for the HIE market.  Chilmark was briefed prior to this announcement by both SureScripts and Kryptiq, following is what we learned.

Details:
SureScripts primary focus has been to provide the network that would support physicians transition to ePrescribing. Therefore, SureScripts has been focused on transmitting NDP data and not clinical notes. SureScripts got into the transmission of clinical summaries from one of its larger customers, MinuteClinic wanted to send clinical summaries of patient visits directly to primary care providers. In the past year SureScripts has facilitated the movement of over 0ne million patient summaries for MinuteClinic to primary care physicians using CCR. Seeing an opportunity, SureScripts sought a partner that could take this capability to the next level.

Kryptiq, a company profiled in Chilmark’s forthcoming HIE Market Trends Report due out next month, can be characterized as vendor of HIE capabilities that allow for the organic growth of an HIE without the overhead. Kryptiq has worked behind the scenes for a number of EHR companies to provide secure, structured messaging services within these EHRss ecosystems of customers connecting them to one another as well as to other systems, including SureScripts to facilitate care coordination.

SureScripts has made an equity investment in Kryptiq (undisclosed but likely in the range $7-9M over the next few years) to build-out Kryptiq’s technology stack for SureScripts. The Clinical Interoperability solution will combine SureScripts foundational technology (provider directory, security, authentication, master patient index, etc.) with Kryptiq’s connectivity toolset (interface technology to various EHRs), secure messaging framework and clinical portal.

SureScripts will release the first wave of Clinical Interoperability products in early December. Pricing will be subscription-based (monthly) and depend on the level of service a given practice desires.

Implications:
SureScripts is the closest thing the US has to a de facto National Health Information Network (NHIN). With the rapid growth in ePrescribing (181% in 2009) representing over 600M prescriptions and now over 200K physicians connected to SureScripts, SureScripts has a network in place, particularly in the ambulatory sector, that few if any can boast of. Sure, Epic has its walled garden of Epic Everywhere and its future release of Epic Elsewhere will attempt to connect physicians using other EHRs, but the walled garden has not proven itself to be sustainable over time. Just look at AOL’s walled garden: fine in the early days of the Internet but was simply unable to innovate fast enough to satisfy market needs and wants.

As an EHR vendor neutral platform that actually puts EHR vendors through a rigorous process to provide them with SureScripts certification, SureScripts is not a threat. If anything, and this is highly dependent on what SureScripts may do in expanding its Clinical Interoperability product and services suite, SureScripts may provide a common foundational and commercial NHIN framework that will allow others, including EHR vendors to provide innovative solutions upon. This may lead to a Platform as a Service (PaaS) model facilitating the adoption of distinct modules that sit upon the SureScripts/Kryptiq communication network.

While both SureScripts and Kryptiq stated that they did not see themselves competing directly with HIE vendors, Chilmark sees quite the opposite. Through its ePrescribing services, SureScripts already has established data connections and relationships with a number of EHR vendors. Kryptiq, through its services, has the technology that provides the interfaces to a wide range of EHRs, many of them in the ambulatory sector where SureScripts is also strong. The combined SureScripts-Kryptiq solution suite will impact many an HIE vendor’s bottom-line for these HIE vendors generate a significant portion of revenue on EHR interfaces and their portal solutions. The SureScripts announcement is likely generating a significant number of internal meetings among HIE vendors as they assess what their game plan will be moving forward. If they are wise, they will seek out SureScripts and look at opportunities to collaborate, offering distinct value-added services on the SureScripts network.

While Chilmark was briefed prior to this announcement by both SureScripts and Kryptiq the briefing was short and details few. A more in-depth briefing will occur in the next week or two, including a deep dive into the technology stack. We’ll keep you posted.

Addendum:
John Halamka, CIO at BIDMC, was on the SureScripts panel yesterday at MGMA when this announcement was made. He provides his own perspective from the vantage point of one who is deeply involved in the Massachusetts HIE initiative.

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