Finding Few Answers at HIMSS’13

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.

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.



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.


Looking Back on 2011 – What A Strange Year It’s Been

It is almost becoming the norm to say that it has been another tumultuous year in the healthcare IT market. Market consolidation, pushback on timelines, growing chorus from IT departments that enough is enough against the backdrop of the political circus in Washington and across the land as we prepare for the 2012 election year. If 2011, was a bit bumpy, believe we will see craters in the road to HIT enlightenment in 2012. But we’ll save that discussion for our future predictions for 2012 post, which we hope to get to next week. (Editor’s Note: Don’t hold your breath though, if the snow flakes are flying, we’ll be on the slopes next week.)

Today’s post takes a look back on 2011 by reviewing our predictions earlier in the year and assessing where we hit the mark, where we missed and if there is such a thing, where we came close. So without further adieu…

1. MU Initiatives Move to Tactical 
Hit This did come true as meaningful use, while still top of mind for the CIO, is not top of mind for others in the executive suite who are now looking at how to compete in the future as reimbursement models shift from fee-for-service to value-based contracts.

2. C-Suite Strategy Focuses on New Payment Models 
Hit An admittedly “softball” prediction, this was a natural fall-out of prediction numero uno. And yes, the consultants are making out like bandits as we predicted they would helping senior execs figure out their future competitive strategy.

3. RCM & Charge Capture Systems Require Overhaul 
Miss By and large, most vendors in this sector have not done a whole lot yet as they await to see how the market develops. With most healthcare organizations struggling to get the basics done (e.g., meet MU requirements, ICD-9 -> ICD-10, apply analytics, etc.) we are not seeing big demand from customers and subsequently, not a big push by vendors.

4. Mergers & Acquisitions Continue Unabated
Hit Another “gimme” of sorts for we had this prediction in 2010 and it was a “hit” and need only look at this market with its some odd 300+ EHRs to choose from, everyone wanting to call themselves at HIE vendor (last we checked, HIMSS listed some 189 HIE vendors alone), countless other HIT solutions to see that this market is far from mature. But arguably the biggest news in 2011 was Microsoft’s capitulation that despite the billion dollar plus investment, it wasn’t cut out or the clinical market and dumping its HIT assets into a new joint venture with GE. What we are also seeing is some rationality return as valuations have moderated. This may have led to Thomson Reuters’ recent decision to not sell-off its healthcare division – no one was willing to pay the high price tag they had on this property.

5. Federally Funded State Initiatives Struggle
Toss-up There has been some progress and there are those that would vehemently argue that Beacon Communities, RECs and state HIEs are moving ahead briskly. But then again, we do get some disturbing reports that all is not progressing as once envisioned, one might even go so far as to say some of these programs are beyond just struggling, but clearly going off the tracks. We’ll reserve judgment until we see clear evidence of such pending disasters, which will likely be prevalent, but highly distributed.

6. Changing of the Guard at ONC
Hit Not long after we posted our 2011 predictions, Blumenthal announced his resignation from ONC. We could not have been more prophetic if we tried.

7. Physicians will continue to go Ga-Ga over the iPad and the fast-following touchscreen tablets much to the chagrin of CIOs.
Hit Enabling physicians access to health information systems via their hand-held mobile devices, including touch-screen tablets is still a struggle for most organizations. At first, IT departments turned to Citrix as stop-gap measure, but the UX was far from ideal. In our recent research we found many an IT department still struggling to address this issue. mobile enablement of physicians is a top priority.

8. Apps Proliferate: Consumer-facing First, Private Practice Second, Enterprises Dead Last
Hit In hindsight, another admittedly easy prediction to make. What may be a more interesting prediction is when will mHealth Apps really become a truly viable market? Does the profitable exit of iTriage/Healthagen, which was picked up by Aetna portend such? By our standards, no. Go back to our recent post from the mHealth Summit for more in-depth analysis.

9. The Poor Man’s (doctor’s) HIE Takes Hold
Miss We thought that the Direct Project would quickly take hold and see rapid adoption among smaller physician practices and those organizations looking to “connect the last mile” to small affiliated practices in their network. Not happening yet though the current administration is doing its best to push this technology by requiring all state designated entities that are standing up statewide HIEs to include Direct in the strategic operating plan.

10. Analytics & Business Intelligence Perceived as Nirvana 
Hit, kind of… 
In retrospect, not even sure this was really a prediction but simply more of a statement as to where healthcare organizations are headed with their HIT investments. We have a long ways to go, though there is certainly no lack of vendors that now are touting some form of analytics capabilities. Our advice, tread carefully as most solutions today are half-baked.

11) The Buzz at HIMSS’11? Everything ACO! 
While some vendors were discussing ACO enablement at the 2011 HIMSS, the vast majority were not with the key focus continuing to be meeting Meaningful Use requirements. As mentioned in previous prediction, we see MU as a tactical issue with the strategic issue being: How do we leverage IT infrastructure to support communities of care? Maybe at HIMSS’12 we’ll see more discussion of this issue, but we’re not holding our breath.

This may have been our best year yet with our predictions having only 3 clear misses out of 11 predictions made. Granted, some of those predictions were not exactly the most profound or shall we say big stretches, but we do take some satisfaction in really nailing a few.

And while we intend to provide our own 2012 predictions, no time like the present to begin the process. So we ask you dear reader, what is your 2-3 top predictions for 2012? Will Todd Park stay on at HHS? Will forced budget cuts decimate HITECH? Will the Supreme Court’s ruling on ACA have any impact on HIT spend by either payers or providers? Will mHealth Apps such as WellDoc’s for diabetic care finally receive a CBT code thereby accelerating adoption of such tools?  We look forward to your input.

And of course we wish everyone a Joyous holiday season and wish you and yours continued good health in the new year to come.

Home for Christmas by Thomas Kinkade


Trickle Down Health or Health 2.0 Impressions

Another year, another Health 2.0 under the belt. This being the fourth time attending it is interesting to see how this event and its participants have evolved. Like many things in life, some things at Health 2.0 have changed, some have not, most for the better, but there remain some troubling aspects to this event that cannot be ignored.

When thinking back on the demos of countless vendors of years’ past, this year’s Health 2.0 had two distinguishing characteristics:

Demos are cleaner, with better user interfaces (UI). The companies demoing at Health 2.0 are spending a lot more time and resources on creating inviting, clean and engaging interfaces that are a welcome change from the cluttered messes of demos past. As with Mark Twain’s famous quote: “I would have written you a shorter letter if I had the time.” reducing an application to its core elements takes time. Clearly, the majority of Health 2.0 vendors this year have spent the time and resources necessary to create a simple and engaging environment for the end user.

Business models are more sophisticated. At the first Health 2.0 event, just about every single vendor there stated that their business model was going to be based on some mix of Freemium and advertising revenue. Needless to say, just about every Health 2.0 start-up from that conference has either gone out of business, is among the walking dead (takes a lot to completely kill a company – trust me, I’ve been there) or has changed their model to survive. This year, the business models presented are more creative and for some, likely to see success in the market.

The contributing factor to these two changes is the amount of money now flowing into the health IT sector. Investors smell opportunity and are placing some pretty big bets as represented by the investments in Castlight (~$80M), ZocDoc ($50M) and CareCloud, who announced a $20M round at the event. That’s some serious cash and with all the investors that were present at this event, quite sure there are more investments in the wings.

Snap-shot impressions of demos:

  • Mobile remains hot but no one seems to have figured out a way to rise above the noise.
  • Big data is the new hot phrase but few understand its implications. Most demos simply demonstrated even more fractionation of data into distinct silos with no clear path towards aggregation.
  • Many see the key to success as becoming the facebook of healthcare with a Zynga Farmville thrown in for good measure. By the end of two days, just about ready to strangle the next demo that started with some reference to facebook and/or gamification.
  • Pricing transparency is a big area of focus for many but seriously doubt most will get past their first round of angel funding as this is already a competitive market. Speaking of which, almost as frustrating as short vacuous demos is the lack of clear arguments by those giving these demos as to why they’ll succeed.
  • Demos never get into details, thus rarely instructive.
  • Many platform plays, ala PaaS, but like big data, few truly understand what that means and how to get there.

While Health 2.0 can get overwhelming with the number of rapid fire, albeit  shallow demos from the multitudes of vendors who are all trying to make their mark in a market that has experienced a significant amount of churn, the event is invigorating for the passion that is shown. Sure, everyone is hoping to make a living on their next greatest innovation, but unlike virtually any other health IT related conference, those at Health 2.0 have passion. They are on a mission. They want to truly change healthcare. They want to make a difference. That passion is contagious. Unfortunately, that passion appears to be confined to the digerati.

Looking around at the Health 2.0 audience one sees a sea of almost exclusively upper, middle class professionals that are tapping away on their iPad, smartphone or laptop. When one sits back and thinks about the many demos seen, virtually all of them seem to be designed for this audience. Maybe the most disturbing part of the event was the on-stage interview with a mother of eight kids (she was white, middle age and clearly upper middle class) showing how her family is tapped into the quantified self movement with the various Apps they use to track their health and fitness. This is not representative of the broad swath of the American populace who are the ones that will drive our healthcare system off the proverbial cliff. It is that grandmother in Indiana who is caring for her diabetic, overweight husband, two grandchildren, a daughter suffering from an addiction and a son-in-law who is unemployed and has no health insurance that we need to talk to, have up on stage to tell us what they need to better manage their health and interaction with the healthcare system. And we need not go to that extreme, how about just having someone from a safety-net clinic talk about their needs? Sadly, no such representatives were to be found at Health 2.0.

It is this detachment that has Chilmark most concern with this passionate movement. Yes, virtually all Health 2.0 participants are passionate about helping all healthcare stakeholders but if we do not start talking to a broader cross-section of the populace, this movement may be much like the barricade scene in Les Miserables wherein the students leading the call for a revolution end up dead and with little to show for they had not engaged the populace-at-large. Some may argue that like this technology will indeed trickle down to the masses in much the same way that smartphones are now replacing feature phones in the mobile market. This “trickle-down theory may indeed come to pass but then again, we could just as easily end up with something very similar toPresident Reagan’s trickle-down theory for wealth distribution and we all know what the end result of that has been.




HIE Market Snippets

In January, we released our HIE Market Report: Analysis & Trends which was extremely well-received. Sales have exceeded our rather optimistic projections – great for us. But what we are most proud of and honestly what keeps us going is that others are also gaining value from this report, especially those looking to purchase an HIE solution. As one large healthcare organization recently told us:

Your report has been invaluable in not only our vendor assessment process, but how our organization needs to think about our long-term HIE strategy.

We have also heard on numerous occasions the need to update the report as the market is changing so quickly and indeed it has. Several HIE vendors have been acquired, others have withdrawn from the market and there continues to be an influx of new entrants hoping to capitalize on what remains an immature market.

There are also a number of underlying trends that have disrupted the market to varying degrees. Thus, we have begun putting together our research plan for an update of the HIE report. As part of that process we have been contacting and interviewing those who purchased the first report to get their feedback on what they would like to see in the next edition. Several interviews have been conducted so far and we even had a briefing with one HIE vendor that we had given up for dead, but no, looks they are very much alive and may (emphasis on may) become a strong player in the future provided their new parent invests in them at the level required to build market share.

Following are a few snippets of what we have learned through these interviews so far:

Workflow, workflow, workflow: Embedding information exchange processes into the workflow of a clinician is becoming a very big issue. Now the question is: What are the top priority workflows that users wish to enable and what are the HIE vendors offering in this regard and how easy is it to configure workflows to meet specific needs?

Analytics & reporting: Everyone continues to talk about this issue, which has been a dominant issue for enterprise HIEs. What has changed though is that even public HIEs are now looking to enable analytics & reporting capabilities as one approach for creating a sustainable business model. HIE vendors are dedicating significant resources to address this need but there is very little understanding as to the actual maturity of these offerings.

Fragmentation in enterprise HIE market: In the last report we split the market into two large classifications, Public and Enterprise. Several we have interviewed suggested we ignore the public market and focus the next report solely on the enterprise market further breaking it down by the healthcare organization’s business strategy justification for deploying an HIE.

Dominant HIE business models: The HIE market continues to evolve rapidly and a key question posed to us is: How do we see this market evolving, where will it be in five years? Quite the loaded question but sure as hell fun to ponder. Currently, we see the market bifurcating into one group of companies that are providing solutions to facilitate care management and another group looking to provide solutions that facilitate operations management.

Clarify closed, EHR-driven HIE solutions versus standalone, open HIE solutions: Several EHR vendors are offering their own HIE solutions but these solutions do not readily connect to other EHRs thus mostly a closed system. Then we have the open HIEs, including some offered by EHR vendors that have the ability to connect to multitude of EHRs via interface engines. In the enterprise HIE market, there is considerable confusion among end users as to which path is optimal for their organization and this is a topic worthy of deeper discussion. (In our last report we simply ignored these closed systems as they were outside the scope of the report.)

Future impact of NHIN Direct: There has been a big push by those controlling the purse strings in Washington DC (election year coming up, need to show some successes with that $564M that went to States for HIEs) to drive adoption and use of NHIN Direct. Any vendor wishing to land a publicly funded project must now have the ability to enable NHIN Direct on their HIE platform. NHIN Direct, as we pointed out input last report, will commoditize basic messaging services of an HIE. Now the question is: How will NHIN Direct impact the broader healthcare sector and will it find its way into enterprise HIEs or remain an confined to public HIEs?

Plenty to chew on here and a lot of research will be required to tease out the answers to these questions. But that is exactly what analysts thrive upon and we are more than ready for the challenge, in fact we welcome it with open arms.

Now you may be wondering; who was that HIE vendor given up for dead? None other than the Boston-based firm Wellogic, a company that made a number of strategic, go-to-market blunders but has now been acquired by Alere. Alere, a seemingly successful and very acquisitive company, certainly has the resources to bring Wellogic back from the dead and make them a serious competitor going forward provided, as we stated earlier, they invest for the long-term as this market, though still relatively immature, is seeing ever larger players enter with deep pockets and far greater resources at their disposal.


Likely Suitors as Thomson Reuters Exits Healthcare

Earlier this week, Thomson Reuters (TR) announced that it intends to sell off its healthcare unit. A logical first response is: What they heck, why would they sell right now when the healthcare market is so hot and shows no signs of letting up? Thomson Reuters is a well-respected brand in healthcare and as healthcare organizations (providers and payers) of all sizes look to more effectively run their operations, TR’s portfolio of healthcare solutions are well positioned.

This isn’t the first time they have tried to sell-off their healthcare unit (tried once before back in late 90’s), but it may be the most opportune one.

Looking more broadly at the entire TR portfolio, the healthcare unit sticks out like a sore thumb. Thomson Reuters is an international company and the vertical market services (legal, financial, etc.) they provide are leveraged horizontally around the world. The Thomson Reuter’s healthcare unit, however, is structured to serve the unique characteristics (3rd party payer system) of the US market a characteristic not commonly found elsewhere. There is not an international leverage opportunity for TR with their healthcare operations, thus from a strictly business is business point of view, selling off the unit when the market is hot makes a lot of sense.

In 2010, revenue for this unit was roughly ~$450M with good margins approaching 20%, so the potential sale price won’t be cheap (in excess of $1B is not out of the question) and this naturally limits the field of possible suitors. Following are a few likely suitors, a probability ranking, why they might make such a move as well as why they may sit this one out.

Aetna: 80%
Why: As healthcare reform restricts the margins that payers can make on their insurance business, publicly-owned health insurance companies such as Aetna need to look elsewhere for growth opportunities to increase shareholder value. Aetna has ActiveHealth that combined with their recent acquisition of Medicity makes for a nice potential play in the ACO market. Key pieces missing in their portfolio are analytics and content, both core attributes of TR Healthcare. Nice synergies, nice fit and Aetna is not shy about making software acquisitions and is one of the more forward thinking, software savvy payers in the market.

Why Not: The Medicity acquisition was significant at some $500M and taking on another significant acquisition may be more than they can handle right now. Is the company prepared to double up on its HIT bet and pick-up TR Healthcare? Hard for us to think of any reasons why not and see Aetna as a leading contender.

Dell: 65%
Why: Dell is making a pretty big push into the healthcare sector having acquired services firm, Perot, cloud imaging archive service InSite One and forming a partnership with Microsoft to deliver the Amalga platform in the “cloud” for their customers, who are primarily community hospitals running Meditech. Adding the TR portfolio, and serving it up in the cloud could be a very attractive proposition for this company, which is almost entirely focused on the US market.

Why Not: It will take some significant work on Dell’s part to get the TR healthcare portfolio into a package that can be delivered from the cloud. There is also the small issue that much of the TR portfolio is built on Oracle database technology and Dell is pretty much wedded to the MSFT stack, including SQL.

GE: 75%
Why: GE Healthcare and TR having been working together for over a year on combining clinical datasets and analytics for comparative effectiveness research and announced the results of that collaboration the end of last month. GE is also looking to expand beyond its present confines of Centricity and combining TR Healthcare with its existing eHealth activities could boost its presence and provide a gateway into numerous TR accounts.

Why Not: GE has its hands full trying to right the ship of Centricity and making a major acquisition may be seen as a distraction. Also, GE and its Healthimagination effort is global in scope and TR Healthcare’s US focus does not align with that broader vision.

Now there are certainly a number of other potential acquirers but for a number of reasons we just don’t see them pulling the trigger on this acquisition, but then again… They include:

Large service firms (Accenture, CSC, Deloitte, etc.):
These companies by and large get paid on billable hours and not software, unless of course they are building some custom solution like Harris did for the feds (the less than stellar NHIN CONNECT) and even in that case it was more a billable hours exercise. No, TR’s healthcare business is too far afield from the traditional business model of these firms.

Large, multi-state healthcare organizations (HCA, VHA, Premier, etc.):
Sure, some of what TR owns was developed by such large healthcare organizations but the value in this acquisition, which will be factored into the price, is the ability to leverage this portfolio of solutions across the entire US healthcare market. Numbers likely do not work for one of these entities as the scope of deployment is too limited.

Large multi-state Payers (Cigna, Humana, WellPoint, etc.):
Aetna and United Health Group (UHG) are placing bets on healthcare IT, the rest of the payers are looking elsewhere (e.g., WellPoint’s acquisition of CareMore). Too much overlap with existing products in UHG’s OptumInsight portfolio so they are out as well.

Large EHR companies (AllScripts, Cerner, Epic, etc.):
Each EHR vendor has their own reasons for not making a bid. It would require either a visionary, or absolutely crazy move (but honestly not much separation between visionary and crazy) on their part for this to happen. Loads of risk, chances extremely slim.

IBM: Don’t see the synergies with acquisitions they have made to date. Besides, much of TR’s portfolio runs on top of Oracle.

Microsoft: See IBM

Oracle: This may be the dark horse. Oracle has been on the periphery of healthcare, is trying to make in-roads in HIE (less than successful) and is a very acquisitive company (basically their entire enterprise software application group was acquired). Also, as mentioned before, TR’s solution portfolio is built on Oracle.

There is also the possibility that Thomson Reuters corporate will find that the market may not be willing to pay what they think this division is worth and as they did in 1997, simply hang on to it for after all, it is generating positive cashflow.