During my travels I’ve had conversations with countless people from a CMIO in New York, to the head of HR for a major semiconductor manufacturer, to CEOs of numerous HIT companies to the CEO of national commercial payer. Reflecting upon these conversations, common themes arise.

There is a clear recognition that the delivery of care must change but there is little agreement as to what that change should be. All have said it will require a major restructuring of the healthcare industrial complex and that the patient/member/consumer/employee must be engaged to take personal responsibility for the management of their health. Fine. But when one asks more probing questions as to how that will actually be accomplished  – what will it take – the opinions diverge.

• For the CMIO, it is about the “Cloud” where patients and clinicians will meet with their mobile apps and Bluetooth-enabled sensors to manage care.

• For the head of HR, it is about creating a corporate culture of wellness within the work environment and then taking steps to extend that culture into the home.

• For HIT executives, it is developing a solution suite that extends beyond the confines of their current offerings to enable community health. Within that context many expressed a need to redefine the vocabulary we use as the current vocabulary limits a more expansive, strategic discussion of what it means to engage the patient, the populace, in self management.

• And for the CEO of the payer organization, it is about the need for internal transformation to create a trusted relationship between them and their members.

While one cannot quibble with any of these views, each being reflective of the vantage and leverage point these executives have at their disposal, the problem remains: Getting the average citizen to engage in their health will remain a significant challenge, and frankly, “the system” is not helping much to overcome this challenge.

The top five hurdles are:

1. The pedagogy of medical school education does not encourage proactive, collaborative engagement between patient and clinician.
2. The lack of trust that payers carry around the neck like an albatross is due to business practices that are not in the best interests of a member, or potential member with a health condition, but the financial interests of a payer. Yes, there is a delicate balance, but denying someone due to a pre-existing condition (a practice now outlawed) does not instill a warm and fuzzy feeling among the general populace.
3. Employers’ inability to instill healthy behaviors among their employee base, including top ranking executives. If they can’t get that senior executive to stop smoking, you think an underling will?
4. Bridging the disconnect between the rich tools that a consumer can use to manage numerous aspects of their life including the proliferation of health and wellness apps and devices with the rather paltry patient engagement tools that most healthcare providers currently offer.
5. Overcoming a culture of entitlement to healthcare regardless of cost. Consumers do not truly know what they are buying with their healthcare dollars and didn’t have to as employer benefit plans covered costs. We now have an adult population that has grown accustomed to simply not worry about the consequences of their behaviors till it is typically too late.

My attendance at these numerous events gave me good perspective on these challenges and how they may be addressed. But I walked away slowly from each conversation thinking:

Yes, these are all good ideas but systemic change will take time. It took us awhile to get into this current mess and likely will take a similar amount of time to dig out.

Question is: Do we even have the luxury of such time?

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.

What has not been said, or at least has been sensationalized nearly to the point irrelevance is the whole controversy surrounding Epic and how they were not invited to join the CommonWell Alliance until after the announcement. None other than Epic’s own founder and CEO, Judy Faulkner, has gone on record stating the Epic was unaware of CommonWell prior to the announcement. Faulkner has gone on to question the motives of CommonWell, in an effort to subvert it, in her highly influential role on the Dept of Health & Human Services HIT workgroup committee.

That was the last straw.

It is one thing to moan and groan at the HIT love fest that is HIMSS, where vendors commonly discount the announcements of competitors. But it is quite another thing to be a part of a highly influential body that is defining nationwide HIT policy and make the same claims over again, especially when they are frankly not true.

Is there some truth to Faulkner’s claims that the vendors who have created CommonWell may have had an additional motive, stopping the steamroller that is Epic? More than likely.

But it is also true that founding members of the CommonWell Alliance do wish to lay down the swords of hoarding data to allow higher order services to be developed on top of the CommonWell platform. They all see the market changing rapidly. They know that they, on their own, cannot move fast enough to meet all the needs of the market. They understand that the next iteration in HIT is to move to a platform-based services model – that is where the value will be. As to whether or not CommonWell will ultimately be successful, that is far from certain as there are many rivers to cross before we see the query-based health information sharing that these alliance members envision take hold, if at all, in this industry.

From our vantage point, Epic, with its monolithic strategy that is more akin to Wang Laboratories than it is to Apple’s iOS, is operating on a model that while providing a seamless environment from ambulatory to acute (something other EHR vendors have totally messed up on), will ultimately hinder healthcare organizations’ ability to rapidly innovate and respond to market changes. Epic simply will not be able to move fast enough and their customers will struggle as a result.

As to whether or not Epic was invited to the CommonWell party; we have received confirmation from several sources that indeed Epic was invited to join a couple of weeks prior to the announcement. What likely occurred is that Epic saw that CommonWell’s goals, objectives, and operating structure were already formalized when the invite arrived. Thus, Epic would not have an ability to make substantive contributions to this initiative and rejected the invitation.

It is disingenuous for Epic to state otherwise and if they were a public company, they may have been subjected to an SEC inquiry. But alas, Epic is not a public company and Faulkner can say what she wishes with few, if any, repercussions. Her quite vocal denouncements of CommonWell though do show that she clearly does feel threatened by this alliance.

But a core mission of Chilmark is to cut through the BS to ensure that this industry is informed. In keeping with that mission, we felt it important to let you know what is really happening behind the scenes at CommonWell. Hopefully, we have set the story straight on the CommonWell Health Alliance and Epic saga.

Public vs. Private Oversight of Mobile Health
John Moore III

mHealth, known for rapid innovation and iteration, has a tendency to buck at the snail’s pace of FDA regulation. Last month, during a series of hearings considering whether smartphones and tablets with medical apps qualify as medical devices and thus require FDA approval, many charged the FDA with stifling innovation. After all, how many developers or investors want to sink resources into an industry that will be regulated in ways that have yet to be determined?

Enter Happtique and its Health App Certification Program. Happtique intends to complement the work of the FDA, and has introduced a set of standards for health apps that fall into the grey area between apps that are clearly medical and those with a clear consumer focus. This could herald a new age of credibility for mHealth. However, as both regulator and marketplace for many of the apps that it regulates, Happtique could end up in a very sticky situation. They will need to tread carefully to maintain their objectivity in both certifying apps while at the same time providing a marketplace for mHealth apps.

The March Toward Better Patient Engagement
Naveen Rao

The open question in health IT these days is whether patient engagement will gain traction or if it will suffer the same fate as PHRs. One thing is certain; healthcare needs far better patient engagement methods, processes and techniques than what one finds today as most current efforts in engagement have very little to do with helping a patient manage a condition. Time and again in our discussions with healthcare institutions of all sizes we find the same scenario being played out – engagement today is focused on building patient/customer loyalty to the institution – they are simply no more than marketing efforts.

Stage 2 meaningful use is requiring a deeper level of patient access to their records via view, download and transmit requirements and there is even a requirement for some email messaging between provider and patient. But there is a bigger issue at play, payment reform wherein providers will be taking on more risk for the patient populations they manage. Without deeper engagement with the patient regarding a chronic disease, providers will struggle with these new payment risk models.

Several related markets, such as telemonitoring and wearable tech are taking off. Chilmark analyst Naveen Rao spent near-exclusive attention to the patient-engagement tracks, vendors, and sessions at HIMSS13. In his article for the March update, Naveen identifies three factors that will define if and how well the patient-engagement market will stay afloat in the coming years.

CommonWell Alliance Intends to Tackle Interop
John Moore

The announcement of CommonWell Health Alliance was likely the biggest story to come out of HIMSS (Allscripts acquiring longtime HIE partner dbMotion may have been a close second). The group’s stated purpose is to enable interoperability across the five founding members’ EHRs. For starters at least, this includes: Allscripts, athenahealth, Cerner, Greenway, and McKesson’s RelayHealth division. In its simplest form, CommonWell will establish a set of standards and services that enable query-based health information sharing in a heterogeneous EHR environment.

Part of the challenge with interoperability within a community of heterogeneous EHRs is that standards are useless when it comes to things like patient matching, consent management, or locating records, all of which are fundamental to interoperability and all of which require standardized services model. CommonWell founders know this and have plans to address it. The greatest challenge facing CommonWell, however, may be the market itself as adoption of HIE tech within the ambulatory sector remains a challenge.

Each month, subscribers to the Chilmark Advisory Services (CAS) receive an update of our research on the most transformative trends in the healthcare IT sector. Exclusive to CAS subscribers, monthly updates are part of the continuous feed of information and analysis we generate to keep subscribers on top of the rapid-fire changes in this market.

Orion Health has had a long relationship with Microsoft, including acquiring Microsoft’s Amalga HIS solution and partnering with Orion to combine the then Amalga UIS with Orion’s HIE solution. Shortly after this announcement was made though, Microsoft threw in the towel on the clinical market combining its assets with a collection of those from GE which resulted in the NewCo, Caradigm.

As part of the establishment of Caradigm, GE contributed eHealth, its HIE solution suite that was co-developed with Geisinger and Qualibria, a quality management platform developed in conjunction with InterMountain. With the death of eHealth and a product which has yet to see the light of day (Qualibria) its beginning to look like GE brought very little to the Caradigm relationship.

Back to the Orion-Caradigm partnership…

As we have written in the past the core services that HIE vendors offered in the past are quickly being commoditized by such things as Direct secure messaging being embedded in future certified EHRs for stage two meaningful use requirements. With the recent announcement of CommonWell Health Alliance, even query type services may also become commoditized.

Clearly, to stay competitive and relevant, HIE vendors need to move to what we term as HIE 2.0, providing more advanced services that leverage the data flowing through the “pipes” of an HIE to more effectively manage the health of a given community the HIE serves. This is particularly important for enterprise clients ( a market Orion is now targeting) and can also assist public HIEs (Orion’s traditional market) in providing value-add services that may help them reach nirvana (sustainability). With CIP, Orion can provide a more compelling offering. The big challenge here for Orion will be in effectively pricing and deploying CIP, (Amalga UIS was notoriously expensive and difficult to deploy. Caradigm has rebranded Amalga Version 3, a much improved version architecturally, as CIP to distance themselves from the stigma of the Amalga brand).

While the relationship provides value to Orion, it may provide even greater value to Caradigm, a company that has stumbled to gain traction in the market. Orion provides a ready channel to market via Orion’s existing broad HIE customer base – one of the world’s largest. Orion also provides Caradigm an effective exit from directly participating in the HIE market with a solution that frankly was not up to the task. The announcement also claims that Orion has agreed to develop applications for the CIP which contributes to Caradigm’s goal of being perceived as a platform play in the market. What those apps may be is still an open question. Based on the language in the PR, it looks like not a lot of thought has gone into that aspect of the relationship yet.

Now we’ll just have to wait and see how this plays out in the market.

What to watch:

1. Joint customer wins – who and where.
2. How many existing eHealth clients transition directly to Orion or jettison for another HIE vendor entirely.
3. Apps that Orion builds for CIP.
4. Existing Orion clients that purchase CIP and whether or not we see accelerated growth in such purchases or an initial surge followed by stagnation.

Easy to claim, but is it true? Only time will tell which organizations are getting it right, and which are little more than hype.

“Patient Engagement” has built up increasing buzz over the last few years through dedicated lip service from government, corporations, public leaders, entrepreneurs, and patient advocates. As John alluded to last week, however, patient engagement may be entering a Catch-22: Most everyone agrees it plays a vital role in the modern health care system we purport progress towards – yet the immense hype it’s developed has already begun prompting eye-rolling among health care executives who are skeptical of all the talk.

HIMSS provided a perfect backdrop to explore both the ballooning expectations in this area as well as showcase some of the budding signs of progress. While I agree with John’s central thesis (to date, mostly a heavy marketing push geared towards loyalty rather than engagement), there are some early signs of progress that indicate we are in the early stages of a shift from the ‘talking’ phase to the ‘showing’ phase.

At a presentation by University of Miami Children’s Hospital, we got a peek at what this could look like when done well (PDF). They have designed a complete view of the hospital’s workflow as it involves any ‘patient touches.’ First they break down the various stages of a patient’s interaction with the health care system into five major buckets:

1. Pre-Arrival
2. Pre-Treatment
3. Point of Care
4. Discharge
5. Follow-up

Inside each of these intervals of the patient journey through UMiami’s system, there are corresponding “engagement” protocols, tools, and processes deployed. For example, while a patient is in the waiting room, there is a digital check-in system that also addresses medication adherence inquiries, assesses gaps in care, and occupies patients (in this case, children and parents) with interactive waiting room programs. A mirroring process is in place at check-out to follow up on reported gaps or issues, administer a quick experience survey, and recruit for enrollment into any relevant support programs or follow-on visits.

The thesis claims that building this baseline connection to the patient using a set of tools pulls them into a workflow that is subsequently easier to maintain through a continuum of online messaging, reminder systems, and follow-up care. A central tenet of this approach is consistency: use the same format and the same branding in these efforts to ensure patients feel they are a part of something, rather than a widget.

If a personal episode of care I endured last fall in Austin is a barometer of progress, we are very far from the ideal: Typically, patients are directed to some half-baked portal to pick a doctor, usually through their insurer, which has no effect on the amount of paperwork that needs to be filled in at the doctor’s office or the subspecialty referral clinic. Once the care is delivered in the silo (team of one), the payment vultures descend, with the referring doctor’s office, the specialists’ billing department, and insurance companies snail-mailing multiple paper documents in the following weeks and months. To wit, none of that pile of papers inquires about the patient’s current health status – it just scares them away from making an appointment the next time if it’s at all avoidable.

So in our eyes, patient engagement is about more than a turnkey solution, or a whiz-bang app. It is an approach. In our fragmented payment and delivery system, seamless experiences are the exception, not the norm. It follows then that meaningful, comprehensive engagement platforms won’t emerge until HCOs change the way they operate.

We are realists here at Chilmark Research, so while we won’t offer a take on how much water has been poured into the glass, we are working on a more detailed analysis for this month’s CAS subscribers about the drivers and trends that might produce a more comprehensive approach to patient engagement by next year’s HIMSS conference.

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

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

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

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

Following are findings and musings on these four.

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

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

Why the enthusiasm?

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

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

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

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

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

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

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

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

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

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

Where is the engaged patient?

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

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

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

But we’ll get to HIMSS next week – I promise.

In the meantime, below are just a few of the topics that we covered in our most recent Chilmark Advisory Service (CAS) Monthly Update. The research notes contained within this monthly provide you with a glimmer of some of our current areas of research interest. For example, the reorg at McKesson is but one example of the massive trend (which was readily apparent at HIMSS) of companies repositioning themselves for population health management in support of financially-linked communities of care (e.g., ACOs). Cora’s research in analytics has brought to light some of the challenges that well-meaning executives may face when trying to get clinicians to adopt and use predictive analytics. While Brian’s story delves into the vexing problem of medication reconciliation within a distributed healthcare community.

The abstracts below provide provide a few more details. But far better than abstracts is of course – drum roll please – becoming a subscriber to CAS where you not only receive a wide range of research content from us over the course of a year, but also direct access to our top-notch team of analysts. Want more information? Just drop us a line to info@ChilmarkResearch.com and we’ll be in touch.

Reorg at McKesson Points to Broader Repositioning
In early February, McKesson Technology Solutions went through a major reorganization and the primary beneficiary appears to be RelayHealth. Historically, RelayHealth has seemed little more than a staging area for McKesson-acquired HIT assets that did not fit logically into any other area of the broader McKesson Technology Solutions Group. With the reorg, RelayHealth not only grows in size, it finally appears to have been given a clear and overarching mission: to become McKesson’s solution to enable population health management. ACOs would be wise to take note.

Will Providers Ever Trust Predictive Analytics
Analytics vendors are approaching the clinical market with predictive models as end-alls for population health risk management. However, doctors, nurses, and case managers have their own ideas about what clinical variables really matter, and they can identify their highest-risk patients practically from memory — no fancy models needed. While there are reasons to be optimistic about PA adoption, vendors should brace themselves for a tough market in which clinical intuition will clash with statistics. One option will be to integrate provider-identified variables into vendor models, an approach that will likely infuri­ate the statisticians but could go a long way in overcoming clinician misgivings.

Medications Reconciliation Continues to Challenge HIE Vendors
In best-case scenarios, medications reconciliation can help avoid adverse drug events by pointing out discrepancies such as missing medications, unneeded medications or incorrect doses at patient discharge. Yet even now that HIT solutions built to support safe hand-offs have been widely deployed, the AHRQ attributes 770,000 deaths per year to ADEs. Meaningful use gives PCPs the responsibility for post-discharge medications reconciliation and as of yet, insufficient tools to do so. Thanks to inconsistent process and technologies across providers, the medications lists PCPs have to work with are riddles with irrelevant medication data, (e.g. a three-year old prescription to treat foot fungus) and missing information (e.g. medications paid for out of pocket). Before medications reconciliation lives up to its promise, serious gaps like this will need to be addressed.

Each month, subscribers to the Chilmark Advisory Services (CAS) receive an update of our research on the most transformative trends in the healthcare IT sector. Exclusive to CAS subscribers, monthly updates are part of the continuous feed of information and analysis we generate to keep subscribers on top of the rapid-fire changes in this 

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

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

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

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

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

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

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

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

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

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

Thanks to KramesStayWell.com for the image

We Americans are on a very terrifying path, health-wise, based on the latest obesity projections from RWJF.

Medical “innovations” around the obesity epidemic are unsettling, to say the least. Most recently, Dean Kamen (of Segway fame) filed a patent for a self-serve Stomach-Pumping Machine.

Disturbing medical devices aside, what does the obesity crisis mean to healthcare IT (HIT)?  Yes, increasing obesity rates means more metabolic syndrome, more intervention, more biometric data,more data stored in EHRs, more HIE to share that data, more clinical analytics and care coordination software, …

Does this sound interesting to you?  In my research I am more focused on how technological innovation can function as a solution to the obesity crisis. First let’s consider the payers — the large, innovative ones who continue to rally for behavior change.

Payer-Sponsored Wellness & Patient Engagement Soldier On

Payer-sponsored behavior change programs have never sustained results in the long term, but this doesn’t stop the early adopters from soldiering on.   For our 2012 Payer Benchmark Report, we profiled several large, innovative payers working to engage their members and the public through low-cost consumer technologies.

Some interesting new developments in this space include:

• Aetna is looking to make running on a treadmill bearable. Its new ‘Passage’ app (storing data in CarePass), promises to make exercisers feel as if they are travelling within a city of their choosing.
• Cigna has just released a ‘Healthy Living App Pack’, bundling the extremely popular FoodEducate app with 3 less-popular ones.  (Cigna didn’t develop FoodEducate, but licensed it from founder Hemi Weingarten).
• Humana has begun offering the HumanaVitality rewards system to a group of Medicare Advantage members. Let’s hope that seniors will take more kindly to this program than to HumanaVille, Humana’s failed attempt at creating an online senior health education community.

Consumer Health Companies Need to Move Beyond Fanatics

If payer apps can’t motivate widespread weight loss, then maybe the consumer space can? Consumer companies are currently busy developing software and testing out motivational models on the fly.  This is not exactly the scientific method but it works for small agile environments…and is definitely something that large payers are less adept at.

There is a belief among many of the quantified-self set that just the act of presenting health data to the consumer affects behavior change.  I seriously doubt this, and believe that consumer health startups have played a miniscule role in affecting real behavior change.  So far, they have provided diet and exercise fanatics better tools to fuel their obsession.

In order to reach the ‘bottom of the pyramid’, must we then dole out dollars for weight loss? I recently spoke with Gregory Coleman, one of the founders of nExercise, which offers a gamified “rewards program” where users randomly accumulate points, similar to a lottery, which can be applied towards real world discounts.

(nExercise is also the driving force behind the recently formed FITco, or ‘Founders In Technology Combating Obesity’. FITco functions as a place for founders to form data sharing/interoperability partnerships, and aggregate marketing dollars).

Talking with Gregory, I found myself better understanding the challenges these consumer companies are up against as they seek to move beyond their core base.  In offering financial incentives, they must spark interest without destroying intrinsic motivation. Framing financial incentives in term of ‘rewards’ and ‘discounts’ helps, but the real goal is to wean users off of them.

Cash, Friends, and Coaching: A Pipe Dream?

Several academic studies have shown that a combination of financial incentives, social support, and coaching from a trusted ally, produced significant behavior change, at least in the short term.

I can imagine a day when I seamlessly upload exercise and diet related data into a CarePass-type platform, where:

• my insurance carrier’s app notices that I have been working out, maintaining my BMI, and applies discounts to my premium.
• my doctor’s app (motivated by value-based reimbursement), suggests that I keep my maximum heart rate below 160 BPM
• I display achievement badges to my friends, and make my data available to health companies in order to receive discounts/free samples

Hmmm, what is that distant feeling of unease, the feeling like I am a pawn in someone else’s Grand Plan?  It might have something to do with the complete loss of privacy around my data.  However, if those premium discounts are steep enough, I can live with that.

Whether we get people sharing their health data or tempt them with financial incentives for weight loss, the systematic nature of the obesity problem remains a force to contend with. In the end it will be up to all of us to push back against the institutions that make us fat. Seeking out motivational consumer solutions is a low cost place to start.