HIMSS or Bust

CA or bustNext week is that proverbial event we all, in the HIT industry, look forward to with some trepidation - HIMSS’14. For an analyst firm such as ours HIMSS provides us a great opportunity to talk with end users, vendors of all stripes and just reconnect with like-minded folks. HIMSS is probably the only annual event that is a must attend to get a good perspective on where we are, as an industry, in advancing the adoption, deployment and use of HIT in the provider setting. That’s the upside.

There is a downside to HIMSS as well. Like most conferences of its type, HIMSS is a huge cheerleading event for all things HIT. In many ways, HIMSS is like the town of Lake Wobegon, where all of the children are above average. You will almost never hear anything called into question – no negativity here folks. Everything looks rosy and as one cruises the exhibit hall vendors pitch what they believe is the next big thing in healthcare.

HIMSS is the epitome of buzz-card bingo. Be forewarned ye vendors for which meetings between us have been scheduled for every time I hear “Big Data” I will yell out, BINGO! 

As Naveen pointed out in his recent post, HIMSS and the vendors therein must be approached with a healthy bit of skepticism. But as analysts, we must do our best to not let that skepticism slip into cynicism, for a cynic often paints a broad negative brush, losing their objectivity in the process and not see the good things that are happening as well.

HIMSS is also a fairly large event and I know that no matter how comfortable my shoes, no matter how much rest I get beforehand, by the time I take that flight back to Boston, I will be absolutely spent.

Despite these downsides, I am actually really excited about HIMSS this year and can’t wait to get there.

First and most importantly, this year’s event will be the first time that we have our entire team attending. Not only has this lessened my own meeting burden (last I counted, this year I only have 24 meetings in 3 days vs last year’s 35), it also gives us a great opportunity to interact with a far broader range of stakeholders in the HIT market with analysts focused on analytics, patient engagement, HIE, EHR and the biggest buzzword from last year, population health management (PHM).

I have always returned from HIMSS with new, invaluable contacts and an updated perspective on where the industry is truly at – not the picture the vendors paint, but the composite, the collage that is created from countless conversations over those three to four days of attendance. In having the Chilmark team there, I hope they will also walk away from HIMSS with a similarly refreshed rolodex and some nuanced thoughts on how their respective research domains will evolved in the years to come.

Secondly, we are seeing some interesting trends in the market as of late that need further validation. For example, today PHM is whatever a vendor decides it to be based on their own core competencies. Our conversations with healthcare organizations (HCOs) has not been all that insightful either as their PHM definitions are as disparate as the vendors. Where there is convergence though is on the need for strong analytics to drive PHM initiatives. So if analytics is the engine, what is the steering wheel, what are the tires, is HIE the gas tank, or the fueling station?

Looking to HIE, as we mentioned in late 2013, we see a need to redefine this sector. Where is the next opportunity for value realization for a provider once their HIE is live? Yes, we are looking beyond referrals! We have our own ideas, but we want to bounce those ideas off of others – HIMSS is a fabulously opportunity to do just that.

These are just a couple of my own thoughts. Our analysts; Cora for analytics, Naveen for patient engagement, Rob for EHR and Brian on HIE, all have their own questions they seek answers to. Hopefully, HIMSS will prove fruitful for us all in finding some of the answers we seek on the future trajectory of HIT, where the value is to be found and how together, we can all work towards a healthcare system that delivers ever higher quality care to all.

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Three Big Questions for Stage 3 & Patient Engagement

big waveFor many, the delay of Stage 3 of the Meaningful Use program evoked a collective sigh of relief, providing a much-needed extra year to focus on the challenging requirements for patient engagement and interoperability. As distant as 2017 may seem however, the preparation for Stage 3 is already underway in Washington; the vendor community and providers will soon be scrambling to follow suit.

Barring further delays, the timeline is as follows: This fall CMS will release the notice of proposed rulemaking (NPRM) for Stage 3 and the corresponding NPRM for the Standards and Certification Criteria. The former is the programmatic framework for what to expect – measures, percentages, reporting requirements, etc., while the latter is the technical product guidelines for software vendors to follow in order to receive ONC certification as a Stage 3 compliant solution that will enable their customers, if properly implemented and used, to collect those sought-after incentive dollars. The final rule is expected to drop sometime in Q1-Q2 of 2015 – just one year away.

But that doesn’t mean there’s a year to put off thinking about it. In a few short weeks, the Health IT Policy Committee (HITPC) is set to deliver an official recommendation on the topic of Stage 3’s patient engagement requirements to the ONC. From all indications, it appears this super-group of wonks will press for inclusion of patient-generated health data (PGHD – yet another #ONCronym for your twitter streams) into electronic health record systems. The technical experts have defined PGHD as follows:

“health-related data—including health history, symptoms, biometric data, treatment history, lifestyle choices, and other information—created, recorded, gathered, or inferred by or from patients or their designees (i.e., care partners or those who assist them) to help address a health concern.”

At first glance, this is a no-brainer, as we’ve been hearing the clarion calls for such inputs for the better part of the last decade. 60 percent of US adults claim to track their weight, diet, or exercise routine, according to the Pew Research Center’s data. Evidence for the positive impact of this data on quality, satisfaction, and in some cases cost is thin but growing.

But as we are learning through the first two stages of this program as well as the early headaches of ACA rollout, reams of sophisticated studies floated down from the ivory tower do not effective policies make. Despite the need for PGHD, when it is wonkified, ONCified, and held to the temple of the nation’s delivery system, there may be a small disaster in waiting. Below are three questions Chilmark is keenly tracking throughout the remainder of 2014:

What Constitutes PGHD?
The language used thus far raises much speculation about what exactly this inclusion will mean when it hits the front lines. The definition provides only a general description, leaving a lot of possibility for interpretation and application down the road. For many, PGHD evokes the notion of datastreams from the vast array of health and wellness devices such as fitbits and jawbones, Bluetooth medical devices, and of course, tracking apps. Yet the definition above makes PGHD seem to carry more of an health risk assessment (HRA)-like utility, where patients fill out a survey and have it sent to their doctors in advance. Yet another angle is the notion of patient-reported outcomes: clinically oriented inputs from patients with regard to their physical and psychosocial health status. Outfits like ATA, HIMSS and others are lobbying for full inclusion of patient-monitoring and home-health data.

Each of these use cases brings with it a unique set of programmatic and technical components. A popular example as of late is with biometric data: If a panel of diabetic patients are all given Bluetooth glucometers that input into respective EHRs, then what – Will someone monitor each of them? Or are HCOs expected to fit those data into an algorithm that alerts and ultimately predicts any aberrance? This has been referred to as providing doctors with ‘insight’ rather than raw data. That sounds snazzy, but can we realistically mandate the creation of insight?

Collecting data such as patient allergies or side effects appears a simpler use case on paper. Yet HITPC is appearing to use everyone’s favorite A+ students – IDN’s like Geisinger, Kaiser Permanente, and Group Health Cooperative among others as the basis for their recommendation. As one example, the report lauds GHC’s eHRA model, which is based on a shared EHR and shared clinical staff for data review. As nicely as that may work, Chilmark is skeptical that it’s reproducible in an average clinical setting. Generally, the innovators in the digital engagement space have been the insurers, not the providers. We understand the need to look at innovators in order to prescribe a path for the rest of the country, but in talking to regular folks at urban hospitals, community clinics, mid-sized IPAs –it’s more likely that fluid data is a byproduct of integrated systems, not the other way around.

How Will the Market Respond?
Despite its unpopularity in the C-suite, meaningful use has forced EHR vendors to pull their heads out of the sand and advance their product features. In addition to giving providers a break, part of the reason behind the Stage 3 delay was for vendors’ benefit: “[to provide] ample time for developers to create and distribute certified EHR technology…and incorporate lessons learned about usability and customization.” The Standards and Certification Criteria 2017 edition will play a big role in the next lurch forward, and one can be sure that those new mandated features will be all the rage at HIMSS 2015.

Yet at the broadest level, the evolution of EHRs (billing >> administration >> clinical) appears to be stalling. In exploring the patient engagement market and the to-date limited functionality of tethered patient portals despite Stage 2’s requirements one thing has become clear: EHR vendors will simply not just add new features for the sake of their customers (forget about patients). With new PGHD functionality emerging, we expect new companies to step up to the plate and seek modular ONC-ATCB certification

An example already underway is 3rd party data integration. Over the last few years, device manufacturers, startups, and third parties started seeing the value in injecting their data into EHRs. The emergence of middleware companies who provide integration as a service, such as Nanthealth, Corepoint, and Validic, will continue as PGHD requirements develop over the coming months. Similar companies will start (and already are) filling the void for HRA functionality, portal requirements, patient communication, and so on. We expect that this will only exacerbate the headache faced by CIOs & CMIOs with a long list of purchasing options. Startups take note: It should also set off a shopping spree by EHR companies and other enterprise vendors looking to buy rather than build. Allscripts acquisition last year of Jardogs is one such example.

Will Providers be Ready?
In a word, no. The inclusion of PGHD brings with it an avalanche of procedural and programmatic preparation: data review and quality assurance, governance models and new workflows, the prickly issue of data ownership, staff time and training, liability concerns, HIPAA extension of coverage, ever-increasing insurer coordination, clinician accountability, and of course, patient consent, onboarding, and marketing. With the last one, keep in mind that we now live in the post-Snowden era…

Of course, without details of the required measures, further hand-wringing is unwarranted at this point. But suffice to say there’s a small storm-a-comin.’ As the definitions, rules, and standards of patient-generated health data emerge, we look forward to what promises to be a rich commentary and response to the NPRM amidst the broader discussion in the health IT community throughout 2014.

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Whose Data is it Anyway?

privacyA common and somewhat unique aspect to EHR vendor contracts is that the EHR vendor lays claim to the data entered into their system. Rob and I, who co-authored this post have worked in many industries as analysts. Nowhere, in our collective experience, have we seen such a thing. Manufacturers, retailers, financial institutions, etc. would never think of relinquishing their data to their enterprise software vendor of choice.

It confounds us as to why healthcare organizations let their vendors of choice get away with this and frankly, in this day of increasing concerns about patient privacy, why is this practice allowed in the first place?

The Office of the National Coordinator for Health Information Technology (ONC) released a report this summer defining EHR contract terms and lending some advice on what should and should not be in your EHR vendor’s contract.

The ONC recommendations are good but incomplete and come from a legal perspective.

As we approach the 3-5 year anniversary of the beginning of the upsurge in EHR purchasing via the HITECH Act, cracks are beginning to show. Roughly a third of healthcare organizations are now looking to replace their EHR. To assist HCO clients we wrote an article published in our recent October Monthly Update for CAS clients expanding on some of the points made by the ONC, and adding a few more critical considerations for HCOs trying to lower EHR costs and reduce risk.

The one item in many EHR contracts that is most troubling is the notion the patient data HCOs enter into their EHR is becomes the property in whole, or in-part, of the EHR vendor.

It’s Your Data Act Like it
Prior to the internet-age the concept that any data input into software either on the desktop, on-premise or in the cloud (AKA hosted or time sharing) was not owned entirely by the users was unheard of. But with the emergence of search engines and social media, the rights to data have slowly eroded away from the user in favor of the software/service provider. Facebook is notorious for making subtle changes to its data privacy agreements that raise the ire of privacy rights advocates.

Of course this is not a good situation when we are talking about healthcare, a sector that collects the most personal data one may own. EHR purchasers need to take a hard detailed look at their software agreements to get a clear picture of what rights to data are being transferred to the software vendors and whether or not that is in the best interests of the HCO and the community it serves..

Our recommendation: Do not let EHR vendor have any rights to the data – Period!

The second data ownership challenge to be very careful of is the increasing incorporation of patient generated health data into the healthcare delivery system. We project an explosion in the use of biometric devices, be it consumer purchased or HCO supplied, to monitor the health of patients outside of the exam room. Much of this data will find its way into the EHR. Exactly who owns this data and what rights each party has is still debatable. It is critical that before HCOs accept user data they work out user data ownership processes, procedures, and rights.

If the EHR vendor has retained some rights to data the patients need to be informed and have consented to this sharing agreement. In our experience this is rarely if ever explicitly stated. HCOs need to be careful here as this could become a public relations disaster.

We are not lawyers, we are offering our advice and experience to HCO CEOs, CFOs and CIOs, from the perspective of business risk and economics. At Chilmark we have deep experience in best practices used in other industries with regards to data use and sharing agreements. We have also spent significant time reviewing the entire software purchasing lifecycle and culture, and are here to help HCOs in reviewing these contracts.

Addendum: Rob and I worked together on this post but our WordPress backend doesn’t like to do co-authored posts.

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Wellness Market: Too Many Chasing Too Little

CrowdHaving taken a hiatus from last year’s Health 2.0 event, was looking forward to this year’s event to see what may be new and upcoming among those looking to disrupt the status quo. Unfortunately, surprisingly little.

Health 2.0 a couple of weeks back had your usually cheery crowd of those who are looking to transform healthcare. As with past Health 2.0 events we have attended, hype was far out in front of market reality but that does not seem to deter the cheerleaders, which were again present with abundance among the some 1,700+ attendees.

Show Me Your Big Data – That’s what I thought, not so big after all
There was plenty (i.e., too much) talk about Big Data when in reality, presentations focused on relatively small datasets with little thematic similarity in any one session. For example, the Risk Assessment & Big Data session had Dell talking about genomics, Sutter Health talking predictive analytics for CHF, another about mashing up claims and clinical data and the last looking at risk assessment. At the conclusion of this session, nary a question was asked – audience confused. Another session on Big Data tools for Population Health Management (PHM) was cut short, thankfully, when the power died. Hard to say if it is the industry drinking the hype, this particular event (though experienced similar at HIMSS’13), or what but this silliness has to stop – we really need clarity, not smoke n’mirrors =- and don’t even get me started on PHM…

Track Me – Track You and no, I probably don’t want your data, at least not yet
In addition to riding the Big Data hype, the event also jumped on the hype surrounding the rapid proliferation of self-tracking, biometric devices now entering the market and all the great things that will come as a result of consumer adoption and use of such devices to monitor health. Not all are jumping on this band-wagon and for good reasons. There is no doubt that in time, such devices will be used by clinicians and patients together which will be the focus of a forthcoming Insight Report from Chilmark but our early research points to a number of challenges in the adoption and use of such devices in the context healthcare delivery.

There was again a plethora of solutions for price transparency. Some odd partnerships that are more opportunistic, for the partners, than providing value for the end users, e.g., the Dr Chrono-Box.net demo was so laborious I can’t imagine any clinician actually doing it. On the patient engagement front, plenty of new solutions on display and was particularly impressed with what Mana Health had build for the NYeHC patient portal contest. Simple, clean, straight-forward and intuitive to use refreshing.

Of course no Health 2.0 event would be complete without one of the large commercial payers taking the stage to announce their latest and greatest member outreach initiative. Two years ago it was Aetna with CarePass. This year it looked like it would be Humana until they were a no show – but Cigna was there with GO YOU Hub. First impressions of GO YOU: a fairly shallow pool in the health & wellness domain with lots of catchy phrases and colors – something your pre-pubescent daughter may like – but this adult quickly lost interest after four clicks

Health & Wellness Redux, Redux, Redux
And again, no Health 2.0 event would be complete without a gaggle of health & wellness solutions, the majority of which won’t be around by 2016.

There are now far more health and wellness solutions in the market than what the market can absorb. This situation is not likely to get better anytime soon as the numerous incubator/start-up accelerators continue to spew more of these solutions into the market every year. The only thing I can think of is that the barriers to entry must be exceedingly low, yet few of these companies realize that the barriers to adoption are exceedingly high and the market is on the verge of contraction.

The Big Squeeze
We are now projecting a significant level of contraction in the health and wellness arena as the broader market comes to grips with a shift in risk from payers to providers with providers ill prepared to accept that responsibility and the migration of many employees off of their employer plans and onto Health Insurance Exchanges (HIX).

This will create two challenges:

Providers are not accustomed to providing such solutions to their patients. While risk may shift to providers, provider adoption and use of such solutions to manage their patient populations is limited. When one adds in self-tracking devices, well…

…providers are struggling with the data dumps from their recently install EHR. The last thing they are seeking is another data source. Healthrageous is one example. A self-tracking wellness solution that was developed by provider Partners Healthcare, adopted in pilots by some big providers, failed to gain traction and was quietly sold to Humana. Not a pleasant outcome. If a provider organization can’t make a go of it through a spin-out, to the multitude of these health & wellness solutions think they can?

Second, we are at the very beginning of a massive shift of employers directing employees to HIX. Despite a fitful start, the use of HIX will grow overtime as a wide range of employers, but especially those in the retail and hospitality industries, direct their employees to these exchanges. Shifting employees to HIX reduces employer exposure (risk shifting) and will lead to decreasing interest and adoption of health and wellness solutions by employers.

Yet despite these challenges, the cheerleading at all Health 2.0 events and a questionable future, one thing that comes through every year is that there are a significant number of people that truly want to do something good, something meaningful to improve the sorry state that is our dysfunctional healthcare system, which we all struggle with at times. These are the people that attend Health 2.0, the ones willing to talk about the “Unmentionables”, the ones to project a vision of a better future for us all, the ones willing to take a risk. For that they should be applauded. But be wary as most will not be around three years hence.

But next time, can we actually have some front line providers in greater abundance to give us their take on all of this. Unfortunately, this event was sorely lacking in such, though it did have its fair share of various healthcare representatives – they just weren’t the ones from the front lines which is who we all need to be hearing from today.

Special thanks to Graham Watson for the image. Graham is easily the best cycling photographer in the world today.

And an extra special thanks to Cora who was there with me and provided a few tidbits of her own to this post.

 

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Crashes, Bugs, and Major Usability Issues at Covered California

I have spent the past few days struggling to apply for insurance on California’s HIX, CoveredCA. Early on in the application process I tried to withhold judgment, but have since learned that coveredca.com has a price tag of $360M, awarded to Accenture. And so I am feeling decidedly less generous and have penned this short note. I hope that details of my experience can be of benefit to CoveredCA, Accenture, and anyone in the state considering applying for insurance.

System Slows to a Halt (Oct 9th)
I started out by checking a few news and twitter sources, which reported that the initial kinks with CoveredCA had been worked out. However when I began the application process the system was unbearably slow. I waited easily 30 seconds for every form submit. Eventually, I was presented with a cryptic error message when the system finally crashed: Oracle Access Manager Operation Error”.

The (very nice) woman I spoke with at the CoveredCA call center confirmed that the site was down. However, this news was absolutely under-reported. There were a few tweets that noted the system failure, but that was it. Notably, @CoveredCA remained silent on the issue.

I gave up staring at the Oracle error message, and the next morning (Oct 10), logged back in at 5am thinking I would beat peak web traffic. At 5am the site was still down, this time for “scheduled maintenance”.

I eventually completed my application later in the day… overcoming several usability hurdles and bugs along the way… as detailed below:

Major Usability Issues Encountered

  • Lack of login link. Why is their no login link on the landing page? It is completely non-intuitive to click “start” when I really want to just login and continue my application.
  • Security questions gone wild. These were so bizarre. There were 5 different security questions with 5+ question dropdowns each. One example: “What is your funniest friend’s last name?”
  • Children…are not adults. If a person has been identified as a child why am I still bombarded with adult-centric questions about that child, e.g. “has this person submitted a tax return.” Why should I ever be given the option to assign a child to be the parent of another child?
  • Family relationships. There has to be a better way to identify family relationships than the all-permutations-approach used. I’m sure this problem has been long solved — what does TurboTax do here? CoveredCA and its partner Accenture seems to have completely ignored industry best practices.
  • Going back and forward through application. It is absolutely unclear how to go “back and forth” in the application workflow easily.
  • Family member health status. Absolutely weird UI for specifying how many family members have high healthcare/high medication needs — need to click plus (+) and minus (–) boxes.
  • How do I verify my income? At one point in the application workflow, it was specified that I had to verify my income before I could fully qualify for health insurance. I still do not how I am supposed to do this — no instructions given and no email follow up.

Major Bugs Encountered

  • Bug #1: editing previously entered data. After I was nearly done with the application process, I tried to edit some of my husband’s citizenship details.  When I clicked the ‘edit’ button next to his name I was taken back to the wrong family member’s form. I could find no other way to edit my husband’s contact information.
  • Bug #2: going “back” in application. After I was unsuccessful at editing my husband’s information, I was taken back several screens in the application and had to click “continue, continue, continue,… ” many times to get back to where I was.  At this point I became resolute to never try to “go back” in the application process ever again.
  • Bug #3: health plans search. When shopping for health plans I tried to search for health plans by both physician and hospital. I typed in “Kaiser”… and… no results found! Pretty shocking considering that Kaiser-Permanente is the largest, fully integrated insurer-provider in the country with headquarters in California. How could they miss this is beyond my imagination.

I am not one who wants to see CoveredCA fail, and I appreciated @CoveredCA responding to my tweets — albeit giving general assurances that the web team is “working on” the problems. I hope these problems can be resolved quickly (but doubt it).

Unfortunately, by spending $360 million of taxpayer dollars for Accenture consulting services and producing this kind of product, CoveredCA is giving plenty fodder to those that want HIX, and general healthcare reform, to fail. One really has to wonder, were those dollars well spent, and if there is any clause in the contract to hold Accenture’s feet to the fire until they get this fixed. Lastly, If anyone can tell me how I am supposed to verify my income then I would be much obliged.

 

 

 

 

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Moving to HIE 2.0

This week I had the pleasure to be the keynote speaker at Orion Health’s HIE User Conference in the beautiful state of my youth, Colorado. In preparing for this conference I was struck again by just how quickly this market continues to evolve and just how messy evolution can be. By the time my slide deck was completed, I came to the conclusion that the health information exchange (HIE) industry is moving from HIE 1.0 to HIE 2.0. While no trend happens over night, certainly the release of Stage 2 meaningful use  (MU) requirements had a significant impact.

HIE 1.0: All About the Message
Within the realm of HIE 1.0 the primary focus is on fairly simple, message-based, transactional processes. Large healthcare organizations (HCOs) adopted HIEs to facilitate orders and referrals with the hope that by making it easier for an ambulatory provider to place an order and receive timely access to lab results, that the provider would be more inclined to push business to that HCO, rather than a competing HCO in the community. It was all about physician alignment. Countless HCOs installed such HIEs, which are typically based on a lightweight, federated model. It was simple, inexpensive and relatively quick to deploy.

In the public sector, most HIE’s were meant to serve public health reporting functions and facilitate physician access to records to minimize duplicate tests and deliver better care. The objectives of public HIEs are far harder to reach, the value far harder to articulate and have contributed to a lack of sustainability and ultimately failure of may a public HIE. In a somewhat bizarre twist, last summer Health and Human Services (HHS) sent forth new mandates to all statewide HIEs to focus first and foremost on Direct Secure Messaging (DSM). DSM is little more than secure email, thus the original grand plans of public HIEs have been whittled down to much more modest goals.

With the release of Stage 2 meaningful use, which will require EHR vendors to embed DSM functionality within their EHR to become certified, messaging solutions provided by HIE vendors have now become commoditized. Messaging in the context of HIE is now passe.

HIE 2.0: All About Delivering Care
It has always been Chilmark Research’s opinion that the enterprise market will lead the public market in adoption and use of new, innovative HIE technology. With the move towards value-based contracting and associated reimbursement models, accountable delivery systems (ADS) (note: we don’t like to use the term ACO unless we are specifically talking about CMS), of all sizes are now looking to adopt an HIE platform and those that adopted a messaging-based HIE are looking to replace it. This will result in a high level of turnover in the HIE market, which we began seeing during middle half of last year.

The move to an ADS model requires a HCO to manage a given patient across all care settings. To meet these objectives, HIE 2.0 solutions will have such common attributes as data normalization services, patient disease registries, care management tools (care plans, templates and workflow) and some form of patient engagement capabilities. In adopting and deploying an HIE that goes beyond simple federated messaging, the HCO hopes to insure that appropriate care is delivered to a patient across all care settings and that all individuals (patient, loved one, case manager, nurse, doctor, etc.) that are a part of a given care team have the most current and relevant information associated with that patient, at their finger tips.

This is the goal of an HIE 2.0 but we are still quite a ways from getting there. Our latest end user research finds a market that is full of frustration. Despite all those Stage 1 certified EHRs that have been deployed, very few of them can actually create and/or parse a CCD. We are still in the land of simplistic and cumbersome HL 7 messaging. Some pretty big steps forward were made by the feds in Stage 2 to rectify this now well-known, but also fairly well-kept secret that HIEs today simply cannot readily support care management processes across care settings in a heterogeneous EHR environment. This week’s announcement to further push the envelop, via certification of HIE/EHR in conjunction with efforts that are being led by NYeHC are also a welcomed sign.

Ultimately, though, it will be market need that presses this issue forward, not the efforts of HHS, NYeHC and others. As HCOs continue their acquisition spree to build a robust ADS to serve their communities, these organizations will begin to have the marketing clout to force vendors to change their ways. For example, while Stage 2 may have had some impact on Epic’s decision to finally admit Care Elsewhere would forever be vaporware and have them strike a partnership with Surescripts, it is our belief that Epic’s customers were the ones that really forced Epic’s hand. Now if we could only apply similar clout to those ambulatory EHR vendors who hold their clients hostage with exorbitant interface fees – maybe this is where the feds can play their greatest role and Stage 2 is a strong step in the right direction.

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