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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Here an HIE, There an HIE, Everywhere an HIE

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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Innovation: What is it?

innovationIf it is one thing that the healthcare IT industry doesn’t lack, it is innovation – or it least innovation on the edges. A quick search on Google for health IT innovation challenges will serve you up over 23K hits. From Sanofi, to HHS, to Cigna and other stakeholders, there seems to be no lack of challenges, code-a-thons and the like but one has to wonder, do the results of any of these challenges actually end up in the hands of consumers and/or clinicians? If yes, and I have my doubts, the number that actually make it over that last threshold is exceedingly small.

That’s not to say these challenge grants do not serve a purpose. Such challenges do attract young developers into the healthcare sector where they can apply their well-honed skills to solve a problem. Maybe it will never be a commercial success, but it does expose them to the market, the needs therein and maybe they’ll stick around by joining one of the many HIT companies. Continue reading

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A Layer Above it All: Healtheway’s Value Prop

Now that NwHIN has been spun-out into the public-private entity Healtheway one has to wonder exactly what value they can deliver to market that will sustain them as they attempt to ween themselves from the federal spigot. Healtheway has no lack of challenges ahead but they intend to target one area that presents an interesting opportunity. Question is: Are they too early to market?

During a recent webinar, Healtheway’s interim executive director, Mariann Yeager, outlined the origin of Healtheway, the apparent traction Healtheway is gaining in the market and what their plan is going forward.

Healtheway got its start via funding from a variety of federal sources, all of whom who were looking for a solution to address their unique problems. For the Social Security Administration it was the need for a nationwide network to facilitate processing of disability claims. For the VA and lesser extent DoD it was the need to enable military personnel to receive care in the public sector and insure that their records were complete. Health & Human Services led most of the development effort leading to NHIN CONNECT, a less than stellar technology platform built by beltway bandits (who else), that hit the market with a thud.

One of the things the feds did get right though is a clear and comprehensive policy for data use sharing across disparate entities. The DURSA (data use and reciprocal support agreement) remains one of the key differentiators in Healtheway’s portfolio. Healtheway’s intent is to leverage the DURSA as the “unifying trust framework” and build upon that with a common set of technical exchange requirements (standards) to facilitate exchange with eHealth Exchange (this replaces the former NwHIN Exchange). Healtheway has also enlisted CCHIT to perform testing of technology vendors solutions to insure they comply with the technical exchange requirements that will allow for HIE-to-HIE connectivity.

That last sentence is the kicker. Healtheway and its eHealth Exchange is not intended to be an uber-national HIE but a set of policies and technical specs that will allow HIEs, be they public or private, to share information across institutional boundaries. Therefore, Healtheway will not get into the current rat’s nest of looking to on-board the multitude of ambulatory EHRs into an HIE but sit one level above that facilitating exchange across HIEs. This is something that many regional and state HIE programs are looking to facilitate, thus it is not surprising to see that a significant proportion of Healtheway members come from such organizations.

There will be a need for this functionality at some future point in time, but not today and likely not tomorrow either. Three key challenges stand in their way:

1) Getting buy-in from healthcare organizations and technology vendors. While membership has indeed grown, Healtheway is offering membership at a discount (likely a loss) to gain traction and unfortunately they still do not have significant traction as many brand names in healthcare are missing.

2) A tainted history with more than its share of missteps. Slowly coming out from under the wing of federal politics as a pseudo independent organization (Board still has plenty of government influence), Healtheway may begin to act more as an independent organization, more like a business. Unfortunately, due to a likely continual need for government funding that independence will likely be limited.

3) The HIE market, both from a technology, policy and implementation/deployment perspective is still primitive. The broad market is simply nowhere near the point of needing what Healtheway intends to offer for a few years to come, at least as it pertains to the exchange of clinical data. Good idea, too early to market. That being said, tehre will be value on the transaction side, e.g., SSA and disability claims processing.

Hopefully the future will prove us wrong on this one and Healtheway will indeed prosper and contribute to the maturity of the HIE market. But our advice, don’t bet on this horse just yet, give them six months than take a second look.

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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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Limits and Lags in Healthcare Productivity

In a recent Health Affairs blog, Alex Goldsmith does a back-of-the-envelope analysis of the peculiar economics of healthcare. According to the Bureau of Labor Statistics, employment in healthcare increased by 1.149 million people from 2007-2011. He contrasts this increase in employment (read increased cost) with declining hospital admissions, low single-digit growth in hospital outpatient volumes and declining physician office visit volume (read declining economic output). A New England Journal of Medicine article published in Oct. 2011 also showed a net percentage decrease in productivity growth (see figure below).

Over this same time period there has been steadily increasing investment in IT for hospitals and doctor’s offices much of it as a result of the HITECH Act that was passed in 2009. Compared to ten years ago, more healthcare workers are doing less healthcare with more information technology. And little over a week ago a Wall Street Journal op-ed by Stephen Soumerai and Ross Koppel pulled no punches, calling the savings to be gained from IT in healthcare “chimerical.” We have known for a long time that providers themselves insist that productivity drops after installing an EHR and there is little evidence to refute such claims and plenty of evidence to support them.

The absence of productivity improvements or cost savings after big IT investments is neither new nor unique to healthcare. Way back in 1987, Nobel laureate and MIT professor Robert Solow famously said, “We see computers everywhere but in the productivity statistics.”  For the next ten years, economists leveled forests (this was a pre-internet time after all) trying to explain away the Solow productivity paradox. While the dotcom boom rendered productivity paradoxes as interesting as bell-bottom pants, few would now contest that increased use of IT drives productivity improvements. It is just a long journey to get there with some successfully surviving the journey and others not. There are plenty of examples in other industry sectors of companies that did not effectively adopt and use IT, ultimately contributing to their downfall.

The EHR Incentive Program and all of the other IT-related ONC and CMS programs have a host of now familiar policy objectives. The fact that IT is at their center says loudly that CMS is trying to coax incremental productivity improvements from a reluctant system.

So where are the productivity improvements in healthcare? While we are only one year into the meaningful use (MU) saga, we would argue that we are seeing three things: 1) the limits to IT as a productivity-boosting panacea, 2) a lag between the investment in IT and a productivity payoff and 3) an existing reimbursement model that does not effectively support IT adoption that is in alignment with meaningful use objectives.

Providers that invest: Most of the current incentives for IT adoption are aimed at the point of the healthcare spear: CMS is willing to pay most frontline clinicians in private practices, clinics and hospitals to adopt IT. These same frontline clinicians, however, are increasingly frustrated and burned-out by the fee-for-service treadmill. Simply getting a primary care physician (PCP) to meaningfully use an EHR will not allow her to suddenly double her patient load. If anything, it will likely decrease office productivity for at least a year as all staff members become familiar with and effective in using an EHR.

Measures like the Stage 2 MU objectives build on that basic EHR to let that same PCP leverage work done in other parts of the healthcare system to deliver more coordinated care. The PCP still can’t double her workload but she might be able to accomplish more in each encounter. In this instance, we see the lag between the investment in a basic EHR and the enhanced productivity of a more interoperable EHR, a time lag measured in years.

Providers that do not invest or under-invest: These incentives are not available to some segments of the provider community (e.g. skilled nursing facilities, behavioral health facilities). The limit is that non-incented providers presumably will invest modestly or not at all in EHRs, interoperable or otherwise. In this instance, the lag may well be a very long time.

Further, incentives are voluntary. Eligible providers can IT-up and take the money — or not. Nearly half of eligible hospitals have collected something under the EHR Incentive Program. The ranks of qualifying EPs, while still low, continue to grow and we will likely see a majority of EPs sign-on to this program.

The Wall Street Journal op-ed claims that ONC and providers are captives of the healthcare IT vendors.  The authors suggest that vendors, presumably in an effort to protect their markets, blocked efforts to make EHRs more interoperable, effectively blunting cost or productivity improvements. This is a fair criticism, probably true, and a clear limit to what we could expect from Stage 1 MU.

However, providers in a pure fee-for-service world have rarely found sufficient value in adoption of EHRs to justify the investment, thus the need for incentives. As the market slowly shifts reimbursement to value-based metrics, the justification to invest in an EHR begins to look more attractive to a PCP. Coupling this with future, MU Stage 2, certified EHR solutions that will better support care coordination across a heterogenous EHR landscape in a given community, the potential for true improvements in productivity appear promising. There is even a potential silver lining for providers that do not invest or under-invest as even the left-behinds have at least have a fax machine and a browser and may begin to enjoy some of the productivity gains of a reformed, networked system.

The network effect that kicks-in over time may like a rising tide, lift all boats. But this is a very slow tide that will rise over many years. Now the question is: How many of those boats have holes in them and will forever rest on the ocean’s bottom or does the tide simply rise too slow and others just pull their boats out of the water?

Note: This post has been authored by our newest analyst, Brian Murphy a former employee of Eclipsys, IBM and others as well as a former analyst for Yankee Group. Find out more about Brian on our About page.

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