Category Archives: EHR

Here an HIE, There an HIE, Everywhere an HIE

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In late March, I headed down to Belize with a bunch of high school students to do some service work. Joining the crew was a parent, Harry (not his real name), who happened to be a urologist sharing a private practice with five other urologists. We got to talking about the industry, the rapid changes that are occurring and of course HIT, where the conversation quickly turned to health information exchanges (HIE).

This urologist’s practice has been using eClinicalWorks (eCW) for several years now and despite their proficiency with using this EHR, the practice has never fully recovered the productivity it once had. Regardless, they have come to accept this hit on productivity as just the cost of doing business. (Note: In Massachusetts all physicians must adopt and use an EHR to be credentialed, regardless of meaningful use or any other programs.)

Harry spends two days a week in surgery with most operations taking place in one of four facilities: local, unaffiliated hospital Winchester (who uses Meditech), Beth Israel Deanconess (has a home-grown EHR but encourages affiliate practices to adopt eCW), Childrens’ Hospital (a Cerner shop that also promotes eCW in ambulatory) and Partners which is now moving from its homegrown EHR solution to Epic (BTW, in a recent conversation with a contact at Partners learned that they are spending $1M/day for next five years on Epic switch - ouch!).

All of these hospital organizations want a closer affiliation with these urologists in support of future value-based payments and of course just getting these physicians to do more surgeries at their respective institutions. Thus, all of them want the urologist practice to adopt their interoperability model. Harry stated that Partners, the biggest healthcare organization in metro-Boston and arguably New England, is pushing particularly hard for them to switch to Epic as Epic does not have an HIE offering (Epic Everywhere is not an HIE in our definition nor apparently in ONC’s) and encourages its customers to put all ambulatory affiliates on Epic instead. In addition to these organizations, the Commonwealth is also encouraging this practice to join the statewide HIE.

After the pain and suffering Harry’s practice went through to become proficient on eCW, they are loathed to switch to Epic. Besides, switching to Epic would limit their ability to connect with other healthcare organizations they work with as Epic does not play well with others.

Harry’s situation is not unique and is likely being played out across the country, especially in urban areas where there may be a number of competing healthcare systems each trying to establish their own HIE. In such a situation what is an independent physician practice to do?

Certainly they could sell the practice, as many physicians have already done, to the highest bidder. Not an option for Harry and his physician partners as they like their independence and plan to keep it that way.

They could turn to the statewide HIE and hope that it will provide the depth of services (interoperability) to enable them to connect and share records in support of care coordination with all hospital systems they work with. Ideally, this may be the best approach but unfortunately they’ll be waiting a very long time for this to happen, if it happens at all. Today, most statewide HIEs, including Massachusetts are focused on enabling Direct secure messaging, a simple, political expediency that those in D.C. can point to as a shiny example of information exchange for the nearly half billion dollars spent on statewide HIEs. It is unlikely that most statewide HIEs will evolve beyond Direct providing the type of deep connectivity between a practice and an healthcare system to coordinate care effectively. That’s not to say we are throwing out the baby with the bathwater as there are some states that are doing exemplary work e.g., NY, IN

Then there is the option of just staying the course and hoping that lightweight connectivity directly into eCW will miraculously occur. For Harry and his partners, both Childrens and Beth Israel currently support eCW and interoperability with the acute care EHR will be supported. Partners may be left with no other option then to purchase a third party HIE solution to connect affiliate practices in the highly competitive, metro-Boston market. As for community hospital, Winchester, this hospital is unlikely to survive as an independent and will either be acquired or eventually be forced to shut its doors.

Still Waiting…
While the vast majority of ambulatory practices will ultimately be acquired, there will be a significant number of specialists who will continue to operate independently and with a number of healthcare institutions. The current hodgepodge of HIEs being stood up in various communities and the multitude in a given urban area will put increasing strain on physician practices such as Harry’s, who like any of us, given too much choice will simply forgo a decision.

Maybe, just maybe the efforts of the Interop Workgroup will take practices such as Harry’s to the promise land that will allow them to support coordinated care, in a simple streamlined fashion, amongst a wide range of healthcare organizations in their community irrespective of underlying HIT infrastructures. We have not heard of any such examples to date, but we remain hopeful as the current model being deployed today, while likely addressing the all too familiar 80% of the problem, still leaves a very critical 20% unresolved.

 

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Finding Few Answers at HIMSS’13

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Last week was yet another HIMSS, this time in the Big Easy – one of my favorite cities, despite the unfortunate decay occurring on Bourbon St. As with the many HIMSS I have attended before, this is the seminal event of the year where one has the opportunity to reconnect with friends, acquitances and countless others all in the hope of gaining a pulse on the healthcare IT (HIT) industry.

Having been barraged with countless invites in advance of the show to meet with this or that vendor, I winnowed down the number of meetings to a select few and even then, had far more on my plate then I could reasonably consume over the three plus days that I was there. And of course, there were the countless press releases I received during the week of HIMSS, nearly all of them barely worth the digital type and bandwidth used to create and distribute.

So easy to get lost in all this noise. I just can’t fathom how a healthcare executive is suppose to wade through it on their own, let alone the staff that reports up into them.

This year’s HIMSS pilgrimage was to seek knowledge within four core areas:

  1. State of innovation in HIT,
  2. Greater understanding on the state of analytics adoption,
  3. Market maturity with regards to population health management and
  4. Is the industry finally taking true patient engagement seriously?

Following are findings and musings on these four.

Innovation – Where is it?
For all the talk of innovation in this sector, it is astonishing just how little there truly is. I searched high and low for real innovation and came up dry. Even went to the Venture Fair on Sunday to see what a number of young companies are bringing to market and found little to capture my imagination. Either this is a sign that I have been in this market too long or maybe a sign of just how challenging this market can be for those who wish to truly be innovative, to be disruptive. Walking the halls of HIMSS, one certainly gets the feeling that this is a show that is not about leveraging HIT for disruptive purposes, but to maintain the status quo.

One of the few glimmers of hope for future innovation may come from an unlikely source; the consortium of five EHR vendors that have committed to the CommonWell Health Alliance. While one must be cautious in throwing one’s support behind such an initiative, I threw caution to the wind in a brief interview after the announcement.

Why the enthusiasm?

If CommonWell succeeds in its mission to create an information sharing platform across these five vendors – and others should they join – we’ll finally, as an industry, move beyond competing on data silos ultimately providing a higher level of functionality to the end user. On top of this sharing platform, we may then begin to see true innovation occur – innovation that taps the data that flows across the CommonWell network. Of course this is all dependent on just how “open” CommonWell will be and that is something we will not know for at least a year. – Yes, healthcare moves slow.

Analytics – Why is it?
The market for healthcare analytics has been hyped beyond imagination but beyond the hype is what appears to be a complete lack of why this industry is even pursuing analytics. There appears to be very little underlying justifications as to why a healthcare organization should be doing analytics in the first place.

Time and again, in one discussion after another, we found a very immature buyers’ market for analytics solutions. Most buyers cannot answer, with any degree of specificity, the simple questions: Why do we want an analytics solution? – What is the business case? And its not just the buyers as many vendors complained of the horrible RFPs that they are receiving which were drafted by some big name consulting firms. One vendor told us point-blank:

“We are no longer responding to RFPs as they are such garbage and a waste of time. If we can’t connect at the most senior strategic level of the organization, then we know that they do not have the maturity of thought to begin the conversation, let alone the journey.”

As most of you already know, Cora is working on the report: Analytics for Population Risk Management that will be released in April. It is our goal to help clear the air and educate this market and if anyone can do it, it is Cora.

Population Health – What is it?
And to think, I though analytics was an over-hyped market. Analytics has nothing on the next big market buzzword, population health management (PHM). Much like the fable of the blind men and the elephant, population health is whatever you wish to make of it or whatever part of the healthcare elephant you happen to be attached to.

What a mess. Despite all the hype on PHM, which comes under many guises including Accountable Care Solutions, Systems or Suite, I did not come across a single vendor that had a complete solution suite. Even those vendors that have significant pieces of a PHM solution, still have not knitted their portfolio together to be a seamless offering. Buyers of such solutions will be spending a lot of money on services to stich these things together for the next 2-3 years.

In the second half of the year, Chilmark Research intends to devote a significant amount of resources to fully flesh-out what is meant by PHM, what are the critical components to enable such and where one might go to find them. Stay tuned.

Patient Engagement – How is it?
Anyone who has followed Chilmark Research and my ramblings for more than a couple of years knows that I have a soft spot for patient engagement. It was within this broad category that I got my start with the publication of the iPHR Market Trends Report in 2008. While that market has not developed sufficiently to support a full-time analyst, it is still an area we track closely and in addition to myself, both Cora and Naveen keep tabs on this market. Naveen will give some of his HIMSS impressions next week wherein he’ll focus specifically on patient engagement.

Waiting with bated breath for this market to take off is fraught with futility. Despite the quite vocal efforts of ONC to push patient engagement to the forefront, I still see most programs at healthcare institutions being funded by marketing departments. It is not about engagement, its about loyalty. Even HIMSS seems to recognize this as they had a number of screens scattered throughout the convention center that flashed four screens: 1) Healthy Patient, 2) Connected Patient, 3) Informed Patient, 4) Stronger Patient which left me wondering…

Where is the engaged patient?

Without engagement folks we are dead in the water for only an engaged patient will take the necessary steps to actively managed their health.

Wrap-up
HIMSS is what it is, a large conference that gathers just about everyone interested in the HIT market in one place. But in such a gathering, a significant amount of noise is created leaving one wondering: Does this conference provide real enlightenment and clarity to the market and the solutions therein, or does it just create greater confusion?

Reflecting on the conference and reviewing my notes for this post I find it is some of both, with a weighting towards noise and confusion. In the coming months, as we release our reports on HIEs, Analytics and later this year, those on population health and patient engagement, we intend to provide the clarity that all stakeholders need to have informed discussions and ultimately make informed decisions. That in a nutshell is the purpose of Chilmark and what guides us our research agenda.

 

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ACO Here, ACO There, ACO, ACO Everywhere & Vendor Response

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In less than two years we have gone from Accountable Care Organization (ACO) as a concept, to ACO as a new model of care delivery. With the January announcement that there were 106 more added to the Medicare ACO program, we now have 254 ACOs nationwide. David Muhlestein of Leavitt Partners has done some of his own research and puts the total number of ACO-like entities at over 400. And let’s not forget that commercial insurers are putting forth their own contracts with providers to set-up similar accountable delivery systems where there is some element of gain and risk sharing with providers.

Now it is one thing to say you have signed on to become an ACO and quite another to actually execute on the contract. Among the numerous challenges that an ACO model presents, is the need for more sophisticated IT systems that will support distributed care management across a diverse care team that extends from the primary care physician, to the specialists, to the care manager, the patient and others. EHRs today will simply not get you there.

Today, there is no such out of the box solution from any one vendor that will enable an ACO model. But there are several vendors positioning themselves to be that one stop shop to enable your ACO strategy.

Following are some vignettes of several vendors looking to enable an ACO strategy and what they have on offer. (Note: This is our proverbial toe-in-the-water as we’ll be doing a comprehensive report on this market later this year)

Aetna: A commercial payer, Aetna is looking for new high-growth revenue opportunities and has targeted healthcare IT. Shortly after acquiring leading HIE vendor Medicity, and soon after leading mHealth App iTriage the company announced its ACO-enablement suite that combines the two above with analytics/managed care solution Active Health.
Strengths: Strong HIE brand, good consumer/patient engagement tools
Weakness: Predictive analytics and care management tools are not as competitive

CareEvolution: A privately owned HIE targeting the private, enterprise market, the company has built its own analytics engine, Galileo. Galileo provides deep dive capabilities into clinical, operational and claims data contained within a given network of providers.
Strengths: State of art HIE solution, good analytics capabilities
Weaknesses: Consumer/patient engagement tools are almost non-existent, low recognition in market

Cerner: Cerner’s HealtheIntent is part of the company’s broader strategy to move beyond being an IT company to becoming a health company. Like most EHR companies, ability to move as fast as market requirements is a challenge.
Strengths: Leading EHR, strong brand, leading visionary among EHR companies, has a good HIE solution, has broad suite of consumer engagement tools
Weaknesses: Analytics is lagging, resources to respond quickly is a challenge, distributed care management tools still work in progress

Epic: Company has one objective, rule all and do so through a highly proprietary and closed model. With Epic Everywhere, their HIE solution for Epic sites, company is able to provide exchange across entities as long as they are using Epic. Recently signed deal with Surescripts to allow exchange with other EHRs. Epic’s MyChart is the leading patient portal in the market.
Strengths: Growing dominance in market, solution suite is tightly integrated from ambulatory to acute care settings, patient portal is widely adopted
Weaknesses: Epic continues to follow a dated model of highly controlled, closed system that while providing high integrity, will ultimately yield a lumbering dinosaur – think Wang circa 1983

RelayHealth: Part of McKesson, RelayHealth has always been a catchall for various acquisitions that McKesson could not find an appropriate home for. A major reorg occurred a couple of weeks ago that will reposition RelayHealth as McKesson’s ACO-enablement suite.
Strengths: Strong consumer/patient engagement tools, a leading HIE solution in the enterprise market and with the reorg, the addition of new assets including the recently acquired analytics solution, MedVentive
Weaknesses: Still does not have a good story to tell around distributed care management, how MedVentive will be folded in remains to be seen.

This is by no means an exhaustive list of those HIT companies looking to offer an ACO-enablement solution suite, but simply meant to provide some perspective on what is currently on offer in the market.

As we prepare to head to HIMSS a week from Saturday, on the top of our list of things we wish to learn more about is exactly how companies such as those listed above and others not listed are meeting the current and future needs of the 400+ ACOs across the country and more importantly, how they intend to become the leaders in this rapidly developing field.

Thanks to KramesStayWell.com for the image

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Four Diverse Research Notes in Jan Monthly Update

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As Chilmark has grown, so has our areas of research which is best represented in the following four research notes that our analysts put together for Chilmark Advisory Service (CAS) clients. The following four abstracts provide you perspective on some of the most critical and pertinent developments int his market sector.

We will be at HIMSS this year and likely have a few copies of this Monthly Update in our bags. If you want to get together to discuss the CAS service, just let us know, but be quick as our calendars for this event are rapidly filling up.

Fair Warning For Healthcare CFOs
The office, duties, and functions of healthcare CFOs will begin a major upgrade this year. Such changes have been a long time coming, but with only three years to take on Risk Assumption ACOs (RAAs), time is short. The difference between what is coming in, in fees for service, or capitation fees, has become dangerously close to what it costs to “keep the lights on.” Something has to be done. Fortunately there is plenty of mature software and a number of best practices CFOs can borrow from other industries to insure the solvency of our healthcare system. The four primary domains where CFOs should begin are:

  1. Formalized Budget & Planning
  2. Activity-based Costing
  3. Performance Monitoring and Measurement
  4. Contract Management

EHR Data is More Untrustworthy Than You Think
The healthcare industry, in its rush to adopt medical records and fervor to keep medical records HIPAA-compliant, has completely underinvested in ensuring the quality of the data that is entered into those medical records. Poor data quality stemming from human error and a pervasive lack of validation has enormous consequences for treatment decisions at the point of care and for secondary uses of patient data, particularly analytics. This research note takes a close look at the problem of data quality and what other industries have done to address it.

Keeping Track of Wearable Health Tech
Up until now, the $2 billion wearable tech market has focused primarily on wellness and fitness, and barely skittered around the edges of the broader healthcare market. In the past, devices such as quantified-self tools, fitness peripherals, movement trackers, and the like were not up to the task of tracking complex healthcare data but this is rapidly changing. Thanks to a confluence of growing interest, increasing market maturity, more robust, multi-dimensional devices and good timing, Chilmark Research believes wearable tech stands ready to make significant inroads into a value-driven healthcare market.

Learning to Like Direct
Despite a strong market and federal incentives, this is an uneasy time for HIE vendors, and Direct (Direct Secure Messaging) tops the list of HIE headaches. Direct doesn’t just sequester data in silos. In many HIE vendors’ view, it sends clinical information to some bunker underneath the silos of healthcare data. Add to this the fact that the legion of EHR-enabled providers is growing and these providers want information from their HIEs, including secure messages sent through Direct, integrated into existing EHRs. From a workflow perspective, this makes sense, but established EHR vendors have little to no incentive to make things easy for the new HIE kids. This article looks at Direct and what its rise portends for the future of HIE vendors and their product development and go to market strategies.

 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.

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2013 – A Year of Surprises

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In the blink of an eye, a New Year has appeared and with it the need to look into our crystal ball (or is it a magic 8 ball) to make our annual predictions for the healthcare IT sector. Personally, I find this to be one of the more interesting and seriously fun parts of being an analyst.

Be forewarned, we’ve seen enough mealy-mouth, water-downed predictions as of late that simply state the obvious to last a lifetime. So let’s crack a few eggs and make some stretch predictions shall we. (Note: each analyst has contributed a prediction or two, which is noted).

1) Structured Data will Remain Gold Standard in 2013 – Cora
Despite Watson and all the buzz about mining unstructured data, the only data that will be analyzed in volume in 2013 will remain structured data. Forget about the 80% of health data that is unstructured. Simple key-value matching will continue but robust, rigorous pattern matching, NLP, etc, will have to wait.

2) The Need to Address Data Quality Moves to Forefront - Cora
Data quality issues (DQ) will become increasingly visible as more providers wonder why their clinical data is such garbage. Providers will be shocked they need to invest in DQ specialists/departments/processes (along with the security to support them).

3) Many ACOs Come to an “OMG, What Have We Done” Moment - Rob
For the first half of the year healthcare organizations (HCOs) will be all buzzy implementing, on paper, gain-sharing ACOs. By Independence Day these same HCOs will begin figuring out it is hard and expensive to set up an ACO and that their back office financial management tools are inadequate. By the end of 2013, just two years away from Risk Assumption ACOs (RAACOs) HCOs will take one of three paths: 1) realize ACOs carry all the risk and more of HMOs and bow-out; or 2) scramble to purchase and implement complex financial management software; or 3) cash-out and sell themselves to a payer.

4) Several HIE Vendors Pack Bags & Leave – John
Virtually all of the federal funds distributed to States to stand-up their statewide HIEs has been allocated. Without that federal largess we will begin seeing some vendors exit the HIE market. Who will they be? Think large companies with lots of brand equity and close ties to lobbyists but with only modest healthcare experience. Those vendors that remain must now contend with upping their value proposition beyond simple information  exchange (Direct Secure Messaging will take over that task). Some of the weaker HIE players with limited resources will be looking for a buyer.

5) HIE Market Growth Begins to Slow -John
Over the last several years the HIE market has been growing at a blistering pace well in excess of 30%. That growth will begin to taper off ever so slightly in 2013, say 18-22% CAGR as all who have adopted a solution continue down the arduous path deployment and on-ramping ambulatory providers to extract value from their HIE platform.

6) Despite Strong Growth in Direct Secure Messaging (DSM), Fax Isn’t Dead Yet - Brian
Volume growth in use of DSM sent via health information service providers (HISPs) in 2013 will exceed 100% driven primarily by integrated delivery networks (IDNs) seeking efficiencies and referrals. Despite this impressive sounding growth, far less than 5% of all care transitions will use DSM by end of 2013. And don’t forget, numbers lie. Much will be reported in 2013 on the growth in absolute number of secure email IDs issued by HISPs, but the majority of those accounts will remain inactive.

7) EHR Source Code Subpoenaed -Rob
We will see our first EHR software source code subpoenaed in a malpractice lawsuit this year – the developer will be named as a co-defendant.

8) Chorus Grows Louder, Politicians Weigh-in and MU Program is Put in Stasis – John
HITECH & meaningful use (MU) have done their job, by and large as EHR adoption and use has swelled dramatically throughout the healthcare sector. But there is also a dark-side. Deploying software so that it is effectively used takes time. Unfortunately, the provisions of ARRA do not allow for time to be taken, which is leading to a rapid cram-down of EHRs and associated MU requirements on clinicians. Early signs of a backlash began appearing in 2012. That backlash will come into full bloom in 2013 leading to Congressional hearings and ultimately someone in the White House being forced to hit the pause button on MU requirements.

9) Quantified Self (QS) Crosses Over into Healthcare – Naveen
The peripheral, biometric, consumer market is starting to bloom. In addition to completely new products and companies, we will see development of more flexible platforms driven by a focus on open APIs. Employers will start to incentivize the QS movement as part of their benefits programs. There will also be a shift from wellness-only into light medical use of these devices for such things as physical therapy/rehabilitation programs, mood tracking, sleep tracking and simple pain reporting.

10) Providers Take Interest in Health & Wellness Solutions – John 3
Payers and employers are the traditional markets for health and wellness solutions. But in 2013, those healthcare organizations (HCOs) that are moving towards capitated care models will markedly step up their interest in and adoption of these solutions. This will also result in new hires (health coaches, nutritionists, etc.) as clinicians balk at taking on added responsibility.

11) Emerging Conflicts Over Patient Generated Health Data - Cora
Conflicts will emerge between EHR data and user-generated health data.  Early adopting QS-type patients (see prediction 10) will be bringing in their mobile-app-generated data to their doctors. Majority of doctor(s) will declare that the data doesn’t match up to their records and will not accept it. Resulting conflicts over how/if to get this data into the medical record will ensue.

12) Patient Experience Begins Being Factored In to Treatment – John 3
With increasing attention on patient/customer satisfaction and need to improve adherence to treatment plans, innovative HCOs will begin adopting mHealth solutions that enable patients to track, in real-time, their treatment experience. Treatment plans will be modified “on-the-fly” based on these “experiences” to improve adherence.

Of course there were many other predictions that we mulled over that ultimately landed on the cutting room floor. What remains are predictions that we felt will create the greatest disturbances or ripples in the industry. Predictions that are generally not all that obvious or maybe it is just that there are not many who wish to state such in writing (we’re not shy).

Whatever the case may be, these are our predictions. we’ll stick by them unless someone has some incredibly brilliant argument as to why we have it completely wrong (that’s what comments are for).

So have at it everyone, are we on target, or will we completely miss the mark in 2013?

 

 

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Humana Jumps into HIE Market, Claims Analytics Turn Sights of Clinical, Med Adherence

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CR_brandWebNovember saw the acquisition of yet another HIE vendor by a payer (Humana). An in-depth analysis of this acquisition and its implications was provided to Chilmark Advisory Service (CAS) clients at the end of November. Following are abstracts of the three research notes in our latest Monthly Update.

Humana Leaps Into the HIE Market
The health insurance industry is undergoing massive upheaval. Payers don’t need a crystal ball to see that in the near future, providers will sell services directly to employers, and that insurers need to get creative in order to stay competitive. With its acquisition of HIE vendor, Certify Data Systems, Humana joined two other payers in the HIE market: Aetna and UnitedHealth Group. Yet Humana’s strategy sets it apart from the other payers. On a single day in November, Humana announced not one but three acquisitions: Certify plus two Florida-based managed care service organizations. Humana has clearly articulated its plan to become the preferred Integrated Delivery Provider to Medicare Advantage members and dual eligibles. By adding Certify’s strong HIE capabilities to its bag of tricks, along with the ability to deliver primary care directly to a large Medicare population, Humana has positioned itself to do just that. Continue reading →

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