Convergence and the Three Rules for Data Governance

Across the industry novel provider-payer collaborations have arisen – something we refer to as Convergence. The macro-factor driving this push to convergence is simple; the migration to newer value-based care (VBC) reimbursement models and the rise of consumerism in healthcare.

Convergence comes in many forms ranging from Accountable Care Organizations (ACOs) to provider-owned health plans (payvider) to payer-owned provider networks and the most interesting of all – deep strategic partnerships, including joint ventures (JV), that have arisen between a provider and payer. And we are only just getting started.

Anthem refers to their initial foray in convergence – Vivity Health, the seven-system provider network partnership with California Blue Cross as Convergence 1.0. One of their more recent partnerships with Aurora Health in Wisconsin is referred to as Convergence 2.0.

Aetna has also been an early proponent of convergence with its first JV, Innovation Health, which was established a few years back with Virginia’s Inova Health. Since then, Aetna has announced four additional JVs, (Allina, Banner, Sutter and Texas Health Resources). In each of these instances, Aetna is seeking to partner with a healthcare organization to provide a more seamless and complete healthcare service that will be highly attractive to self-insured employers and individuals buying insurance via an exchange. Aetna EVP, Gary Loveman, who is leading this effort, will be one of our keynote speakers at our Convergence conference next month.

Regardless of whether or not it is Convergence 1.0, 2.0, a deeply binding JV or some other form of convergence, core to the success of any of these strategies rests on the need to have a clear data sharing strategy. The deeper the level of convergence – moving from transactional processes to strategic – the greater the need for data transparency. If the convergence strategy is deep, the sharing of data must likewise be comprehensive to ensure that all parties are working from a “single version of the truth.”

Data sharing will be critical to support the applications and workflows that extend across the converged entity. The shared data asset will also be paramount for establishing mutually agreed to key performance indicators (KPIs) such as quality and costs of delivery care, care variability and administrative actions/burden, etc. These KPIs will help to optimize processes and drive alignment across the converged entity’s health service chain.

But this is where the true challenge to convergence arises.

Much of the data that may be necessary for success, is highly sensitive to one party or the other. If there is a lack of trust between partners a converged strategy will most likely fail. This gets to the core of any convergence strategy – mutual respect and trust is the starting point, followed by a strong desire or need to partner. That need to partner, to collaborate deeply must be shared by all parties.

But well meaning intent and a strong desire to share data in support of a convergence strategy is only the beginning of the process. The hardest step will be to define the rules of data usage requiring a strong, mutually agreed to data governance policy.

In our conversations with countless healthcare organizations, we find time and time again that data governance is one of the most oft overlooked aspects of their data curation and analytics strategy. Therefore, it is not too surprising for us to see the struggles that many an organization is facing today with governance that extends beyond their four walls to include a partner, who may at one time have been a competitor.

There are three simple rules to data governance in a converged strategy.

  1. Ensure parity between the two partnering organizations. If one has the upper hand, data sharing will likely be problematic compromising convergence goals and objectives.
  2. Define upfront what datasets will be required and for what purposes. In addition to what types of data and who is responsible for it, address issues such as latency, usage, quality and purposes for which data will be used.
  3. Place a skilled diplomat in charge of your data governance strategy. Governance tackles “soft issues” such as policies, people, privacy, security and trust, all key skills of one with strong diplomatic skills.

Be you a provider or payer, follow these rules to data governance will go a long way to establishing the trusted foundational framework for your own convergence efforts.

Stay up to the minute.

“As biometric data becomes cheaper and easier to collect through smart sensors, devices, and mobile apps, expect to see more innovations in consumer health.”

-Alicia Vergaras

HIMSS’15 Pilgrimage: Impressions and Takeaways

CRinMoroccoAnother year, another HIMSS conference. While I often may gripe about this event; the seemingly endless parroting of buzzword(s) de jour, the countless press releases that really are much ado about nothing and highly questionable surveys and research results, that have little founding in reality, there is a silver lining to all of this…

HIMSS affords me the opportunity to meet with so many people I’ve come to know in this sector. Some are my mentors, others clients or partners and all have become friends. That friendship extends from a shared desire and dedication to improve healthcare delivery through the effective adoption and use of IT.

While HIMSS is utterly exhausting it is also incredibly invigorating – kind of a Yin/Yang thing.  I always return from the event with a ton of ideas as to where Chilmark can further assist this industry, because frankly, finding good objective research and insights in this sector sure seems tough to come by.

Key Takeaways:

The “Big Data” hype cools to a simmer. Thankfully, the number of companies quoting, referencing or inferring how they address big data has subsided. This sector needs to get the little data right before it can step-up in any meaningful way to big data.

PHM is a too vague a term. The challenge with population health management (PHM), as a term, is that it is so broad. This results in virtually any vendor laying claim to it – though they may only be solving a very small piece of the PHM puzzle. No vendor at HIMSS’15 has a solution that can fully enable a PHM strategy. Met with many a CIO who has come to same conclusion, but every CIO struggled with same problem: Where best to start and with who?

Everyone does Care Management. In his post prior to HIMSS, our analyst Matt predicted that care management/care coordination would be the new buzzword term de jour. He was spot on. Countless vendors had banners promoting their ability to address care management processes. Unfortunately for users, when one takes a deeper look at these care management apps, one typically finds a glorified spreadsheet. Surely we can do better than this!

Clinical analytics is cool, but financial and clinical analytics together insures long-term survival. Saw plenty of vendors promoting their latest analytic wares and virtually all the demos focused on clinical analytics. Only a few vendors have taken the next step and are co-mingling clinical and financial analytics – which will be absolutely critical for HCOs. Unfortunately, most of these solutions make it far too difficult to perform such a simple task as: At the patient level, identify the most costly patients, what is driving the high costs of care for these patient(s) (visits to specialists, procedures, labs, meds, etc.) in order to determine what may be done to reign in costs.

Notes & Observations

A couple of companies I spoke with, Arcadia and Health Catalyst, did talk about the co-mingling of clinical and financial data, but as mentioned previously, they were in the minority.

ICW was back after a five year hiatus from HIMSS. They’ve gone through a major restructuring to refocus their development efforts on HIE and care management. They’ve always had some pretty decent technology under the hood – their challenge has been channel(s) to market. Not easy for a company from abroad.

Humana announced Transcend Insights (combo of Certify Data Systems, Anvita and nliven), yet another payer-led solution suite. They’ll be challenged to compete with Aetna’s Healthagen and UHG’s Optum. Humana’s deep expertise in Medicare may be key differentiator.

Caradigm looks to be finally gaining some traction and their booth was very busy. They are beginning to get some wins for their Care Management suite, which they co-developed with Geisinger Health.

Orion Health has the most visionary architecture for CNM that I have witnessed to date. Now they have to execute on that vision.

RelayHealth now has both performance analytics (HBOC) and MedVentive under its wing. They will be combining RelayHealth’s data aggregation capabilities, these analytics solutions and hosting in Microsoft’s Azure Cloud. Going beta this summer at ten sites and G.A., by end of summer.

Apervita was one of the more interesting briefings, as they are a company trying to create a marketplace for analytic algorithms that an HCO can source and apply to their EDW. Recently landed Series A round – one to watch.

Aetna’s Healthagen is targeting self-insured employers as well. In North Carolina, the PHM program Healthagen rolled-out across the 680K state employees realized a savings to the state of some $450M over three years. Not sure how those savings were calculated, but a number even half that is impressive.

Kryptiq, which recently spun-out from Surescripts, is taking to market Care Manager, an app originally developed at Providence Health in Portland. Solution automates many of the tasks required for CCM reimbursement under Medicare.

The EHR bubble is over but big question is: Will bolt-on sales of PHM-enabling modules be enough to sustain this market? Cerner is seeing very good traction for its Healthe Registries product, but a contract sale of that product likely pales in comparison to a Millennium sale.

The EHR vendors with the biggest, most elaborate booths are also the ones that are struggling the most in today’s increasingly competitive market.


Athenahealth had by far some of the best marketing booth panels I’ve ever seen at HIMSS.

InterSystems is jumping into the patient portal business. We’ve never been fans of EHR-tethered portals and Intersystems’ move is welcomed.

Health Catalyst continues its momentum, both in raising funds and landing new clients. They are moving fast knowing that the likes of Epic, Cerner and other best of breed vendors are in pursuit.

Lumira, management buy-out of Wellogic from Alere, is building out a solution suite combining engagement, data exchange, biometrics and analytics. Lumira sees itself as a becoming an “Outcomes Company”. How that differs from a traditional MCO is hard to gauge right now.

Everyone wanted to know the implications of IBM’s big announcements at HIMSS. Certainly thought provoking, but IBM has a ways to go to convince the market, especially providers, of what value they can deliver.

The record winning CCD file that Medicity has seen fly over its network was 100MB – that’s HUGE! By way of comparison, one of our 100+pg market trends reports averages about 1.3MB. Is it any wonder that this industry struggles with interoperability.

Plenty of talk and wringing of hands over issue of interoperability, but saw nothing at HIMSS that gave me hope that this issue will be solved across the country in the next 12-18months. Think 3-5yrs at best.

Box had a small booth at HIMSS and unbeknownst to me, acquired a start-up that has a pretty slick DICOM image viewing and medical grade mark-up application that now resides on Box.

BluePrint Healthcare IT’s Care Navigator is a nicely packaged app for care coordination. Children’s Specialized Hospital in NJ have been able to derive some high value from its use in caring for its pediatrics patients.


Of course, with 42K+ attendees, some 1.2K+ exhibitors there is no way any one person can take it all in. One needs a plan and a highly targeted one at that to be able to really get any value out of this event. As they say, practice makes perfect and this being my eighth or so HIMSS, I am getting a little more practiced at how to navigate this event. Never easy, always exhausting, at times depressing, but also never boring. See you in Las Vegas – the site of next year’s HIMSS.

Can Apple Keep the Doctor Away?

health“His treatment was fragmented rather than integrated. Each of his myriad maladies was being treated by different specialists – oncologists, pain specialists, nutritionists, hepatologists, and hematologists – but they were not being coordinated in a cohesive approach.”

Steve Jobs, by Walter Isaacson (p. 549)

As you’ve undoubtedly heard, Apple made a big splash last week by announcing “official” involvement in healthcare through a new app and accompanying SDK. In the past week much fanfare has been made and many speculations have been raised. As an industry that is built on the notion of looking forward, the obvious question right now is, “Will Apple Succeed?” An important precursor however is, “What is Apple trying to do?”

The announcement at WWDC was scant on details, comprising just three minutes of the broader two-hour session. More detail is available elsewhere, but the basics are that this fall, Apple will release an app called “Health” to track and store multiple health data, mostly from devices, of around 60 parameters upon release with iOS 8. The app will enable selective sharing of data, across other apps or with other individuals. The app’s release coincides with the pre-release of an SDK called “HealthKit”, designed to allow third party apps built with HealthKit to be able to have common data structures for data management, sharing, and privacy control. Two early partners were announced in Mayo Clinic and Epic, though details of those partnerships are still TBD.

So the vision here appears to be that patients and healthcare providers can use multiple apps written on Healthkit, all through a consumer-controlled, portable hub (that also makes calls!) to help fill the healthcare void when patients are away from a health facility.  Sound familiar? So much for “Think Different” – Apple is not trying out anything new here. Rather, they are betting that this particular formula of consumer-friendly hardware, new software, brand strength and market clout can result in a win. But they are also, finally, addressing a problem that has plagued health apps for years: an inability to aggregate data into one spot for a more complete view of one’s health.

Over the long term, the web-dominant approach to the above vision is slowly dying; the notion of sitting down at a computer to upload workouts or blood sugar readings into a website already seems antiquated compared to automated tracking on a device. So if mobile truly is the future, then Apple seems better positioned then others to capitalize on that trend, save Samsung.

With Samsung’s recent announcement of the SAMI platform, their S-Health app on the S4 and S5, and other recent activity in health IT, they too have arrived to the party. We will cover both tech titans’ varying approaches more deeply as part of the CAS as details around them emerge. For now, looking at ghosts of PHRs past as well as the current mHealth environment, we can point to several issues that will define the success or failure of Apple and their contemporaries.

Timing: Compared to predecessors, Apple has the benefit of timing on their side. Consumer-friendly hardware is now ubiquitous in the market (much of it Apple’s) and growing in sophistication. Healthcare software has decidedly shifted in a mobile-friendly direction, from a wellspring of APIs from major HIT vendors to emergence of standards like HL7’s FHIR. With the MU3 PGHD provision set to roll out this fall, the timing here could work out in Apple’s favor.

Wellness vs. Health: Many from Aetna to Microsoft have struggled trying to straddle the fence between wellness and medical care. We suspect Apple will be no different. Despite the umbrella of “health”, fitness tracking and condition management are two different marketplaces. Apple’s best bet for success may be to drive Wellness growth through B2C efforts, and drive clinical adoption through healthcare partnerships and clinical evangelists. For now, it is Apple’s best interest (and the broader industry’s collectively) to keep these lines blurred.

Quality and Curation:  With regards to adoption, the biggest healthcare complaint about mHealth is that there is too much going on. With over 43,000 apps available in some flavor of health, Healthkit adding more may not necessarily be better. It remains unclear what Apple’s involvement at this level will look like, but if they really want to get a foothold in the marketplace, they are best served by addressing this issue on some level.

Data: Apple is essentially the Epic of their industry: They’re big and well-fed and they don’t play well with their peers. Apple may take the same approach that Epic took before being regulated into interoperability by the ONC; they are big enough and far enough outside of healthcare that the NPRM for Stage 3 PGHD might not matter to them.

Closing Thoughts: Potential vs. Reality

At this early stage, questions can go on forever. Speculation aside, one thing we can safely say is that Apple is not all of a sudden a healthcare company. With this recent announcement they have simply provided some new tools to a broken industry, tools that appear to be arriving at the right place, at the right time.

Hopes seem to be higher within the healthcare industry and across the blogosphere that this is just a first step for Apple. With its beloved brand, vast resources, design-driven thinking, and technological expertise, many are rooting for Apple to be the one to rewrite the chapter on enterprise mHealth strategy. Realistically however, Apple’s goals here are likely more simple: to sell more phones, tap directly into a booming mHealth market (Remember, Apple keeps 30% of all app revenue), and grease the wheels of their widely rumored iWatch rollout.

Payers Refocus Efforts on ROI for Member Engagement

cvrWhat a difference a year has made to the payer market. In late 2012 Chilmark Research published the first version of our Payer Benchmark report — detailing how leading payers were beginning to adopt emerging consumer technologies. We found a market where significant experimentation was occurring, but little if any broad, member wide deployments and a market still trying to understand social media.

This week we are releasing the next iteration of this report – Benchmark Report 2013: Payer Adoption of Emerging Consumer Tech – Payers Continue their Pursuit of the Digital Consumer. Based on the research I conducted for this report, I find it simply amazing to see how this market has shifted over the course of a single year.

For one thing, the traditional health insurance business model continues to erode, as the Affordable Care Act (ACA) has capped medical loss ratios (MLRs) and has completely stripped payers of their ability to underwrite based on health risk.

Meanwhile, payer-provider realignment is ongoing. Hospitals are partnering directly with employers or launching health plans that might compete with payers in the employer market. Likewise, some payers are acquiring providers to more closely align financial interests with healthcare services delivered.  All this bodes well for rising interest in payer-provider-aligned population health management and patient engagement technologies.

In addition, the ACA/Obamacare has come to be seen as inevitable, and Health Insurance Exchanges (HIX) are forcing payers to seek out new places in the minds of consumers and within the broader healthcare ecosystem —  with an increasing focus on engaging and retaining consumers.

Outside of healthcare, the consumer tech space continues to defy our expectations.  It is easy to see how in the past year that emerging, low-cost activity tracking technologies have spread far beyond early adopters.

These and other macro forces are pushing payers toward the digital consumer in ever more multi-faceted ways.  For example, payers have drastically pulled back from their flurry of experimentation in 2012, and are now focusing their efforts into fewer, more precise areas where they foresee strong potential for ROI.

One change from 2012 is the pull-back in creating mobile app versions of member service portals, as have health & wellness app launches. (This makes sense: in general, very few payer-launched or payer-owned mobile apps have gained any kind of significant traction, with iTriage as a notable outlier, and they already had good traction prior to acquisition by Aetna).


While payers may have pulled back from rapid experimentation along certain lines, this does not mean that they have given up on the digital consumer. To the contrary, we continue to see growing investment in payer-owned consumer platforms, biometric tracking initiatives, the next generation of social media, and more… all detailed in the report.

This report profiles an expanded set of payers as compared to the first edition, across commercial, Blues, and provider-aligned categories. These innovative payers are exploring the wild west of digital consumer engagement and learning as they go. The report describes their experimentation in detail, what initiatives are working and why, and where promising new territory might lie. Any organization that is looking to build-out a strategy that leverages consumer tech for member/patient engagement will find this report invaluable.

We hope our subscribers enjoy the read…as much as we enjoyed the research.

Breaking New Ground

Today is a great day for Chilmark Research and hopefully the world of healthcare IT.

At long last, the much anticipated Market Trends report Clinical Analytics for Population Health (CAPH) has been published. Coming in at slightly more than 100 pages with in-depth profiles on 14 vendors, it is our hope that this report will be instrumental in advancing the discussion of how analytics can be effectively used to drive strategic population health management initiatives.

Our research philosophy at Chilmark Research is relatively simple relying on three dominant criteria:

  • First, target sub-sectors of healthcare IT that have the potential to be truly transformative to the delivery of care.
    Clinical analytics certainly fits that criteria.
  • Second, look for areas where there is a significant amount of turmoil and rapid evolution that thereby make it exceedingly difficult for end users/adopters to make sense of.
    And I thought HIE market was a confusing mess, analytics even more so!
  • Third, is the market potentially large enough (will we be able to sell enough studies to recoup our investment) that it is worth our effort.
    We have been receiving a slew of inquiries from healthcare organizations of all sizes on state of clinical analytics, who is doing good work, who less so. 

If all the above are in alignment, we dig in and dig deep for ultimately we wish to produce a report that will lead to a better, more educated market.

As is the case in this particular report, Cora and I began first mapping out a strategy to address healthcare analytics last summer. Over the ensuing months we continued to refine our thoughts (well it was really Cora refining the thoughts and passing it by me and Rob). Ultimately, we narrowed down the research effort to focus on CAPH as this was the one sector of analytics that best met the criteria above. In the months following, Cora did a tremendous amount of research that has resulted in an excellent report that is on par with our well-respected research on the HIE market and may readily become the defining report on this subject area.

Like the HIE Market Trends Report that we first started publishing several years ago, the CAPH report creates a vendor neutral framework and vocabulary for the industry to adopt and use in their internal discussions and decisions. The report also provides a close look at a number of influential vendors in the market, sizing up their relative strengths and challenges. Lastly, we plan to update this report on an annual basis to insure that the market stays well-informed on the trajectory of the market, the advances taking place and ultimately insure that the market is well-educated on the topic prior to making critical, strategic purchasing decisions.

A big thanks to all organizations and individuals we interviewed over the last year who assisted in developing our thoughts and perspectives on the clinical analytics sector – we couldn’t have done it without your valued inputs.

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

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

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

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

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

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

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

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

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

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

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

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

Thanks to for the image

At the Intersection of Obesity and HIT

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.

One Step Forward, Two Steps Back

mHealth12Be careful what you wish for sure did apply to this year’s mHealth Summit, which was held last week in Washington D.C. Of the some 4,000 in attendance, I was one of the 10% or was it even 1% of those present that have attended all four events in succession. It is with that perspective that I came away from this year’s mHealth Summit more disappointed than ever.

At previous mHealth Summits, I often bemoaned the lack of organization of the conference, the often bizarre exhibitors one would find (couple of years back one exhibitor, and I kid you not, was marketing herbal aphrodisiacs) and basic necessities one would find at virtually any event, breaks with coffee, maybe a snack here and there. This disorganized, but charming event was mHealth Alliance Summits of years past. (more…)

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

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

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

Benchmarking Payers Adoption of Consumer Tech

Awhile back, a large health insurer (payer) commissioned Chilmark Research to do a market scan on how payers across the country were using emerging consumer technologies to engage their members. We found this project to be quite interesting and rather than have much of that research sit on the shelves forevermore, we decided to build upon it.

Today we are releasing the results of that effort.

Our latest report: Benchmark Report: Payer Adoption of Emerging Consumer Technologies takes a close look at over 40 payer (health insurers) initiatives that are using a wide variety of consumer technologies (apps, social media, games, etc.) for member engagement. Here’s the PR announcing the report’s release.

Now it is well-known that payers have had a very mixed record in engaging their members. Part of the problem has been trust as members are justified in taking a cautious approach when sharing their health information with payers for fear of future denials. Secondly, many payer initiatives have been half-baked wherein payers have not been fully engaged themselves in the concept of member engagement.

But as we pointed out in a post earlier this summer, this is all beginning to change. Numerous market forces are now pressing down upon payers and payers are increasingly coming to the realization that they need to deploy member engagement solutions that work. Payers are now going to where consumers already are seeking to engage their members via a variety of consumer-based technologies. This report is our initial effort to gain a greater understanding of what payers are doing today and provide some guidance as to how their efforts will evolve overtime.

One thing we have learned in the course of our research is that despite all the talk, the majority of these efforts are in their infancy and that the vast majority of payers have not even begun to venture down this path. Therefore, we intend to update this report on a periodic basis to benchmark payer adoption of consumer tech in support of member engagement and gain an even deeper understanding of what works and just as importantly, what does not.

Thanks to the many that we have interviewed over the course of the last several months to compile this report as your inputs have been invaluable.

Payers Take Another Stab at Engagement with Consumer-based Tools

It is now nail-biting time, as we here at Chilmark Research brace ourselves for the upcoming Supreme Court decision on the legitimacy of the Affordable Care Act.  We as a nation are indeed living in very interesting times and I am again reminded why I find healthcare markets endlessly fascinating (and perplexing). (Editor’s note: This post was written by senior analyst Cora Sharma and highlights some of her latest research that looks at payer strategies for patient/member engagement.)

Of interest is just how many of the ~30 million uninsured US citizens will land on insurers’ doorsteps in 2014. Even if the Individual Mandate is upheld, it is still uncertain just how many of these uninsured individuals will opt to pay penalties rather than purchase health insurance.

For my patient engagement research, I have spent the past several months speaking with executives at large payers about their consumer-focused strategies.  Just how are payers planning on using relevant consumer technologies to keep new individual customers engaged and healthy?  After such a dismal track record over the years around health/wellness/DM initiatives, is it worth another go-around? (Cora’s research will culminate in a forthcoming report to be released within the next couple of weeks.)

Payer Initiatives in Consumer Technologies
Kaiser Permanente and Humana actually began experimenting in this area circa 2008, creating flash-based, online health games for children. In 2010, UHG released the first version of the OptumizeMe social game App, Anthem released its Grocery Guide App (now EOL), and Aetna partnered with to provide a social network for members in recovery.

Now all of the major payers have ongoing products, partnerships, and pilots around consumer-focused health and wellness and disease management — though with varying respective strategies (the upcoming report explores these 35 ongoing payer initiatives in detail).

The figure below shows an interesting slice of data around social games, in that the majority of these initiatives are becoming social and ‘gamified’:

Note: Data point positions do not represent degree of gamification/ social-ification. These are just meant to illustrate number of initiatives in each category

Another trend our research has found is the willingness of payers to look beyond health and wellness and towards the complex FDA-regulated space of chronic disease management solutions (partnering with Healthrageous and Welldoc), as well as seeking to improve member ‘Wellbeing’.  Aetna’s partnership with Mindbloom to offer members the premium version of the Life Game™ is one of the few efforts we found among payers that looks to engage the full spectrum of health of a member with a focus on Wellbeing.

Growing market in payers that can transition to a post-FFS world.
In the future, we predict that this market will continue growing along two distinct tracks:

  1. In payers that successfully transition their businesses to risk-sharing, care coordinating models (ACO/PCMH) looking to proactively engage members/patients in self-managing their health; and
  2. As pure marketing-plays, e.g. releasing cool mobile Apps that generate a nice press release, some market buzz, but little else.

As many readers may know, the health insurance industry is going through a period of rapid transformation.  Payers with the means and the wherewithal to innovate their business models are purchasing providers, as well as partnering with them for data-sharing agreements and ACO-like payment contracts.  Some large payers are also getting into the ACO-enablement business through acquisition of software companies.

Insurers who do not innovate their business models towards a post-FFS (fee for service) world (be they pure insurance providers or mostly claims processors) will find little incentive to experiment heavily with emerging consumer technologies.  The crux of the matter is that they will never have the long-term incentives (nor the culture) to shift gears away from their actuarial focus and will remain low margin businesses, if they manage to survive at all.

Affecting behavior change towards health and wellness has proven incredibly difficult over the long haul. There is scant evidence that these new payer initiatives that seek to adopt common consumer engagement technologies and strategies are meeting objectives. As the entire healthcare industry pivots towards new bundled care reimbursement models though, there may be a glimmer of hope. I remain cautiously optimistic to see payers experimenting with and adopting emerging consumer technologies, knowing that there is still a long road to travel.

Some Areas We Covered in May Monthly

Earlier this year Chilmark Research launched its latest service, the Chilmark Advisory Service (CAS). One of the benefits of CAS is that subscribers receive a continuous feed of our research, from major annual reports such as the recently released 2012 HIE Market Report, to Quarterly Reports (e.g., mHealth Adoption for Patient Engagement) and exclusive to subscribers, the Monthly Update. Of course, subscribers also get unfettered access to our analysts to answer any specific questions they may have.

For the merry month of May, the Monthly Report touched upon four topics that are abstracted below:

Social Games for Wellbeing, Courtesy of Your Health Insurer
Much of this story was pulled from the forthcoming report that Cora is authoring that takes a close look at how payers are adopting consumer technologies (social media, gamification, mobile apps, etc.) to more effectively engage their members in healthy behaviors. This story looked at the current initiatives of Aetna, Blue Cross of California, Cigna, and Humana, each of which is taking a slightly different approach to more actively engage their members.

When Behavioral Health Goes Mainstream Will Technology be Ready?
This year, five states received grants of $600K each to explore how they would integrate behavioral health data into their statewide HIEs.  Analyst Naveen interviewed several stakeholders about how they would actually address the technology and policy hurdles to incorporate such data into an HIE. One of his findings, which he details in this story, is that current technology offerings from HIE vendors are ill-prepared to address this growing need to fold in behavioral health data into the HIE. Secondly, there remain significant policy issues that need to be addressed as behavioral health data is some of the most sensitive and protected health data.

Filling Gaps Separating Behavioral Health from the Healthcare Continuum
We had another story on the relative state of technology adoption within the behavioral health community. Our interviews with several stakeholders uncovered a market that is even further behind (at least 10-15 years) the rest of the medical community in IT adoption and use. As public health officials, healthcare organizations and others come to the realization that a significant proportion of chronic disease patients have a co-morbidity with a behavioral health issue, they are also coming to the realization that more effective care coordination must also occur with behavioral health specialists. John (the younger) takes a close look at what may develop in this market to fill the current gap.

Feds Look to Tighten Privacy & Security of HIEs
This last story took provided subscribers an assessment of the current Request for Information (RFI) for the Nationwide Health Information Network (NwHIN). The RFI was released on May 10, 2012 and is the an attempt by the U.S. government to establish a clear set of governance rules for the sharing and use of patient data within an HIE, and of course more broadly across the U.S., via the NwHIN. While the objectives are noble and to some extent needed, our assessment is that in several areas the RFI goes too far and will significantly hinder HIE innovation, deployment and adoption.

If you wish to learn more about CAS, please head on over to the Research Services page and towards the bottom there is a slide deck that provides a prospectus on CAS. If that piques your interest, drop us a line and we’ll be more than happy to answer any further questions you may have regarding the service.

Trash Talk vs. Reality

Spreading FUD (fear, uncertainty and doubt) is one of the most common sales tactics used against a competitor. I’m never surprised to hear some FUD being thrown around at a major trade show like HIMSS, but this year it seemed to be particularly virulent among the many vendors I spoke to, which did surprise me. In a market that seemingly has nearly unprecedented money flowing into it, why all the trash talk? The only rational I can come up with is that all that money flowing into healthcare IT is also attracting far more competition from ever bigger players with greater resources.

For example, a little over a year ago the HIE market was comprised of very small vendors, the majority with sales in the $15-25M range. Today we have IBM, who acquired Initiate, Ingenix, who acquired Axolotl, Aetna who acquired Medicity, GE who is partnered with ICW, Surescripts, who partnered with Kryptiq, Thomson Reuters who is partnered with Care Evolution, Microsoft with their Amalga platform, Emdeon, who rolled out their HIE solution at HIMSS’11, and Harris Corp. who announced they will acquire Carefx. This is clearly a white hot market and one that will only see more consolidation in the coming year.

Getting back to the point of this post…

One rumor I heard over and over again was that Medicity was seeing a major push-back by clients and prospects as a result of their acquisition by Aetna. Several vendors told me that the Pennsylvania HIE contract (PHIX) that was going to Medicity had been torn up due to Medicity’s new ownership structure. I was also told that several other Medicity contracts were also in jeopardy. (Note: heard nearly an equal amount of similar rumors for Axolotl, who’s parent is United Health Group.) Now this may all have some truth to it, but it is important that anyone listening to these rumors must consider the source and do their own background check.

It appears that Vermont has done just that for today they awarded the State HIE contract to Medicity. Vermont Information Technology Leaders Inc., (VITL) has been operating a pilot HIE in the State for nearly five years, using technology from GE Healthcare (it was a relatively simple document management solution) so it is with some surprise that the incumbent, GE, who has been investing heavily in updating their HIE solution suite did not get the win.  Another company that was likely bidding for this contract is Covisint, who recently won the contract for Vermont’s Blueprint for Health. Since there will be a direct link between VITL and Blueprint, again a bit of surprise that Covisint did not win this contract either.

So what does this tell us?

1) Despite all the rumors and trash talk not everyone is listening.

2) The fear that payer ownership of an HIE vendor will result in a sales slide for the HIE vendor may be misplaced.

3) Decent, proven technology (and likely very aggressive pricing) can overcome a lot of FUD.

Another HUGE Acquisition in HIE Market

Just as we are trying to put the final touches to the forthcoming HIE Market Report, another major HIE vendor gets acquired and again it is a very big fish swallowing a small and very pricey little fish. Geez, they are making our life difficult here at Chilmark.

This morning, Aetna announced that it will acquire Medicity for some $500M.  With United Health Group’s Ingenix acquiring Medicity’s top competitor, Axolotl earlier this year and now Medicity being picked up, the HIE market is going through a major upheaval with few, (one could even argue none) strong, independent HIE vendors left.

Chilmark Research will reach-out to both Medicity and Aetna to get their take on this acquisition as well as competing vendors as this really is a pretty big deal for all players in the HIE market.

HealthVault Adds Another Arrow to its Quiver

optum1Seemingly on a roll, OptumHealth, the consumer facing health and wellness division of United Health Group (UHG), the nation’s largest health insurer, announced yesterday that it will support health record portability by allowing members to export their Optum PHR data to HealthVault.  Basically, what this means is that any user of the Optum PHR (formerly know as Health AtoZ which is free to any and all, not just UHG members – it is ad supported) will be able to move their health data out of the Optum PHR and into HealthVault, with HealthVault serving as a long-term, independent data repository that is controlled by the consumer.  This action follows on the footsteps of a similar announcement by Aetna in October.

While the press release states that this is being offered to all 25M+ members of UHG, it raises all sorts of questions.  A few which we hope to have answers for next week when we speak to Optum are:

  • Just how many UHG members are actively using the OptumHealth PHR today?
  • Exactly what types of data will be portable?  Is it everything that resides in a member’s PHR (e.g., claims, maybe PBM, HRA data) or some subset thereof?
  • When will this be made available, is it live today or will it be phased in?
  • What is the business case for making this happen?  Is this something that employers are asking for or are there other justifications?
  • Will you be making similar announcements in support of Google Health and Dossia (Dossia is a bit of a no-brainer)?
  • How will data flow between the two systems (publish/subscribe model – RSS, Atom, etc.) and what will be the data standard used?
  • How will you be positioning and advertising this capability to Optum PHR members?

We’ll put up a more in-depth post next week, provided OptumHealth is forthcoming with answering our questions.

Humana Breaks the Mold

freeSlowly getting the hang of Twitter and while cruising around the TwitterSphere yesterday looking for updates from the WHIT’08 conference in DC came across a guy providing live tweets from the event.  Looking more closely at his profile, it turns out he works in a “skunk-like” innovations group at Humana, called Humana Innovations.

Like a dog on the scent of something interesting followed the trail to their idea factory, CrumpleItUp.  Very nicely done and gives one a sense of what may be possible, from a Web presentation stand point, if you start thinking beyond columns of text and smatterings of graphics.  Honestly, one of the best sites I’ve come across in sometime.

But I really fell in love with this little group and what they are trying to do when I learned that they are the brainchild behind Freewheel!n.  Freewheel!n is all about providing bicycles to consumers to encourage them to get around via bikes, thus contributing to health (big objective for Humana), goodwill (another Humana win – great PR), eco-friendly, (we all win) and the list goes on.

Freewheel!n made its grand intro at the Republican and Democratic conventions.  Following are some stats off of the Freewheel!n site (stats were cumulative over the 8 days of these conventions).
• 7,523 bike rides
• 41,724 miles ridden
• 1,293,429 calories burned
• 14.6 metric tons of carbon footprint reduction
What’s not to like?

Maybe that Freewheel!n is not in Boston yet, that is still in prototype mode, that we will have to wait to see it arrive in our own fair cities and towns.

Plenty has been written here and elsewhere about various initiatives of payers to encourage healthy behaviors.  Sorry Aetna, CIGNA, United Health, WellPoint, all of the BCBS plans, none of your initiatives have captured my imagination like CrumpleItUp. Humana has broken the mold in reaching out to consumers.

Take a look and learn.

Avoiding the Tough Issues (Like Healthcare Reform)

Typically, we do not cover political policy issues regarding healthcare (at least we don’t write about them anymore than we absolutely have to) as there are plenty of others to turn to for such analysis (hint: search on, “health wonk review”).  That being said, did read a good article this morning by the folks at Univ of Penn’s Wharton School.

The article takes a broad look at “entitlement reform” beginning with Social Security and quickly moving to healthcare with some comparison/contrast analysis by Wharton professors of the two competing candidates proposals.  Found the most insightful comments coming towards the end from Wharton Health Care Mgmt & professor of medicine, David Asch who stated:

“Though it is not a perfect system, it is what we have right now, and I worry that getting rid of it in one fell swoop would be extremely dangerous,” (editor’s note: he’s referring to McCain’s plan) Asch says. He acknowledges that making consumers more responsible for health care spending might work to reduce costs and target medical resources more effectively. But the system is not yet equipped to give consumers the information about health care quality or pricing they would need to make the right decisions. “It’s not like when you go into a store to buy a TV and you know what the TV will cost,” he says. “Allowing patients to have skin in the game only works if they have the information [with] which a reasonable person could make a decision.”

And therein lies the problem, visibility to healthcare pricing is extremely opaque despite such efforts as Aetna’s SmartSource and various state and federal agency initiatives.

It is still extremely difficult for a consumer to know exactly what the price will be for a given procedure and even if they see that price, say posted on a hospital’s website, it is likely to be far higher than what an insurer would pay for the exact same procedure.  Insurers negotiate steep discounts with providers and since this is considered proprietary and a competitive advantage by insurers, they sure won’t be sharing the information with others anytime soon.

Even employers can be challenged to get to the bottom of true pricing.  At the WHCC conference last April, Safeway CEO Steve Burd stated that they did a quick survey for a common diagnostic procedure and in a ten mile radius of their corporate campus found a 10x difference in pricing ($600 to $6000. for the exact same procedure).

So where does IT and Internet-based services come into all of this?

As employers increasingly push ever higher deductible plans, HSAs and consumer-directed health plans (CDHP) on their employees, employers will seek tools that they can offer their employees to assist them in making wise and economical choices, thus lessening some of the pain.  Based on our cursory review of solutions targeting the employer market, it is difficult to find any that provide this type of capability outside of an existing insurer.

If you know of such a solution, we sure would like to hear about it.

Come to think of it, this could actually evolve into an interesting research project that looks at the various ways employers are tackling this problem. Thoughts?

CIGNA Playing Catch-up Introduces New Site

CIGNA has appeared asleep at the wheel for sometime now as competitors Wellpoint and the more aggressive Aetna look to engage the end consumer.

Not any more.

Today’s Washington Post had a brief article on CIGNA’s introduction of the new website, itstimetofeelbetter. Along with the new website, which has a wide ranging and somewhat confusing mix of material, CIGNA is also leveraging social media, ala facebook, and the ubiquitous iPod via podcasts at “CIGNA University” on iTunes.

Checked out the site and it is worth a drive-by just to see how CIGNA perceives the market and what it seeks to offer the consumer.

What I liked:

  • The interactive tools (most provided by Healthwise) are fun, though tough to read. Did a quick one on calories burned during my 2hr bike ride this morning (plenty, I get a big desert tonight – did I tell you I ride to eat?). Did another on heart health – looking good.
  • Some informative, albeit common content, that one would find just about anywhere via Google search. Nicely presented.
  • A “game” to test one’s health knowledge. Taking the test results in CIGNA contributing clean water to children in India.

What I was less impressed with:

  • The content/information provided was all over the map. Sure, much of it was consumer facing, but if this is truly a site to educate the consumer, why have a white paper targeting employers?
  • If one is going to do something on iTunes, why not get creative and develop a couple of innovative apps for the iPhone/iTouch. A podcast is just so 2002ish.
  • Where is the information on PHRs? Absolutely nothing on the subject and a real missed opportunity to educate the consumer.
  • How about quality and transparency in healthcare – nothing! How can CIGNA be promoting CDHP to employers while at the same time not educating the consumer on healthcare buying decisions is beyond me.


Happy to see health plans get out there and try to educate the consumer and in time sites such as this should improve. Question is, will they actually dedicate the resources to do it?

Encourage CIGNA and others to rip a page out of the Google play-book and consider such activities as this as a continual work in progress – iterate, iterate, iterate – it will always be in Beta.

Is Medical Tourism Set to Explode?

The merry month of May brought two interesting articles on medical tourism, the first from the Tier One strategy consulting firm McKinsey entitled Mapping the Market for Medical Travel. The second, an excellent article in the May issue of Fast Company. Both reports were very well-researched and written providing unique perspectives on medical tourism.

McKinsey Highlights:

  • Market today is only 60-85,000 consumers worldwide. McKinsey uses a very strict definition for medical tourist including only those that travel some distance for care.
  • 40% seek the most advanced treatment, often traveling to the US. Roughly 75% of these medical tourists come from two regions, Middle East and Latin America.
  • 32% are looking for better quality of care and typically travel from developing countries.
  • 15% seek faster care for medically necessary procedures.
  • 9% seek lower costs for medically necessary procedures. In this category, 99% of the medical tourists originate from the US.


  • Incorporating medical tourism options as part of payer network.
  • Establishing common, universal metrics to assess quality of outcomes.
  • Addressing continuity of care/follow-on treatment.
  • Overcoming inconvenience of travel

Market Potential:

  • $10,000. differential in cost is the tipping point. An aortic valve replacement in the US costs in excess of $100,000. In Asia, average cost at an international hospital is $12,000, providing plenty of opportunity for shared savings.
  • If payers jump onto bandwagon (and it appears they are), potential number of US medical tourists could jump 100x to over 500,000 consumers/year.

Fast Company Highlights:
Less focused on metrics, article looked closely at the success of Thailand’s Bumrungrad Hospital, expanding upon its interview with the hospital’s former marketing director, Ruben Toral. Toral, a North Carolina native joined Bumrungrad in 2001 and was instrumental in helping this hospital double patient flow to 430,000 by 2006. Toral has gone on to start MedNet Asia, a software start-up to assist payers doing business with Asian hospitals.

What was particularly interesting about this article was the number of quotes from various corners, including payers (UnitedHealth Group), large providers (former head of Harvard Medical International), employer (Blue Ridge Paper Products) and a union (AFL-CIO rep.) to name a few. This provided a more qualitative view of the market, its potential, where it may be headed, what we might see in the future, e.g., payers sharing cost savings with consumers should the consumer elect to go overseas for treatment, and of course barriers.

Closing Comments:

Though there is a lot of talk about medical tourism, it is still just talk. Until it becomes far easier for the average US consumer to evaluate, choose and engage with an offshore medical institution, the market will not take-off. Sure, there are plenty of intermediaries in the market today willing to help arrange your travel to some foreign destination for that surgery you need, but trying to determine who is reputable and can be trusted is not all that easy. (Do what I did – Google “medical tourism”. You’ll get some 2.3M hits – not an easy ask wading through that list, even with the paid ads to find a reputable firm to go with!).

From the Fast Company article, though, it certainly appears that payers (and their employer customers) are looking very closely at medical tourism to control costs and may well lead the effort to provide consumers with these tools for evaluating options, including providing a list of pre-screened facilities and assisting them with their travel arrangements.

There is also the significant issue regarding continuity of care. I have yet to see any clear, established models that insure such continuity after discharge from an offshore hospital. Is there a role here for a consumer’s PHR? Maybe so.

Using their PHR, a consumer could share their US-based records with an offshore surgeon in advance, use the PHR (if the capabilities exist) for secure communication with that physician and likewise, upon discharge, the offshore hospital could then upload directly to the consumer’s PHR their complete digital records from the procedure for sharing with their care providers back home. (Note, many of these offshore facilities use state-of-the-art HIT. For example, Bumrungrad Hospital in Thailand, one of the leaders in medical tourism deployed their home-grown EMR, Global 2000, seven years ago. Microsoft purchased Global 2000 last year and its now part of Amalga.)

On thing in clear, change will come. It is now more a matter of where (which procedures), when (just how fast it will take-off) and what will be the broader ramifications to the traditional healthcare market in the US. As a doctor recently wrote in an editorial about New England grocer Hannaford’s move (with Aetna’s assistance) to provide employees incentives to have knee and hip surgeries done in Singapore, this is but a canary in the coal mine.

Aetna’s CEO Again Attacks 3rd Party PHRs

You may recall that during an interview last October with the fine folks who manage the WSJ’s Health Blog that Aetna’s CEO, Ron Williams called Microsoft’s personal health platform, HealthVault and Google Health “vaporware”.

Well, he’s at it again, this time taking another pot-shot at Google Health.

Yesterday, while speaking at the MIT CIO Symposium Williams stated that the likes of Microsoft and Google do not have an “interest in improving the system or looking for gaps in care. When the data goes there, it is really static and stored.” He then went on to promote their own “Care Engine” a technology platform that came with their acquisition of ActiveHealth in 2006. Sounds to me like another desperate attempt of the old guard in the healthcare sector simply trying to protect their turf.

With all due respect Mr. Williams, you are about to be dis-intermediated. I know it, and it appears you know it as well, though you’ll fight like hell to spin it otherwise.

Reasons Why:

First, data going into anything will always be static and stored until someone decides to do something with it. Before purchasing ActiveHealth, your claims data was as static as the next entity’s data. ActiveHealth has some excellent analytics under the hood to do analysis, but you are not alone here. Google is a master at data search, retrieval and of course analytics. Microsoft is no slouch here either. Both are just starting down this path and will quickly catch-up and surpass what Aetna provides today.  In Google’s case, for example, they will be able to tap clinical data, a much richer source of data than the claims data you currently tap with the Care Engine.

Second, the Aetna PHR, built on top of the ActiveHealth technology stack, is still new to the market (introduced in June 2007) and is still pretty thin in consumer functionality. (ActiveHealth is profiled in the just released iPHR Report by Chilmark Research). At the rate that Google is moving (and for that matter Microsoft’s HealthVault), they will quickly eclipse your offering. Is that not why ActiveHealth is already a partner of HealthVault?  Are you not hedging your bets?

Third, privacy and security issues are certainly there but honestly, you and your brethren in the payer market, despite HIPAA statues, don’t exactly have a stellar record in keeping records safe. Microsoft and Google have far more at stake here regarding breach of privacy/security (it could potentially bring down everything they’ve built to date all in one fell swoop) and will be strict guardians of a consumer’s records.

Lastly, Aetna you and other payers still struggle with the consumer trust issue as well as portability of records. Despite numerous statements by the payer community to not use a consumer’s PHR data against them, consumers remain extremely cautious and reluctant to adopt a payer sponsored PHR. Outside entities such as Google and Microsoft have no vested interests in lowering medical loss ratios (MLRs) to improve margins, like you do. Thus, they are rightly perceived as neutral and trusted to protect their (the consumer’s) best interests.

Rather than fight this tsunami of consumer-led healthcare Mr. Williams, I encourage you to embrace it as a more engaged consumer is one who will be more knowledgeable and involved in caring for themselves and their loved ones. And in the end, will that not lower your MLRs anyway?

WHCC & Reports from the Field

I’ll be attending the World Health Care Congress (WHCC) here in Washington DC getting my fill of all things healthcare and most likely an overdose on policy – after all, this is Washington.

The people who put on the WHCC have put together quite an impressive agenda with so many different and what look to be interesting tracks, the biggest challenge for me was just deciding which ones to attend.  In the end have chosen to focus on those tracks focused on consumer health including transparency, successful models for engagement, empowerment and the like.  Over the course of the next couple of days, I’ll provide a couple posts outlining some of the most critical issues raised and lessons learned from the various presenters and participants.  So stay tuned.

As an aside, had two interesting experiences yesterday, here in DC hainvg arrived a day early.  The first was meeting a man on the DC Metro who had flown in to attend a training session.  We got to talking and he asked me what I did for a living.  Told him healthcare and he immediately opened up with: “Healthcare costs and gas prices are going to drive us into the ground.”  As we continued talking he related his own, most recent experiences with the healthcare system.

He receives good coverage from his employer, though complained about his share of costs continuing to rise.  He has had a heart condition ever since he was a child.  Recently, he changed primary care physicians.  Despite a long record of a heart condition, his new doctor ordered a battery of tests that he estimates cost between $30-40,000.  Though he readily admitted that his costs were a few hundred dollars, he knew that in the end, we all will be paying higher prices to support such practices, that for him seemed at a sham.  He also found the multiple Explanation of Benefits (EOBs) forms that he received from the insurer during this whole process as to appear as though they were written in Greek – simply incomprehensible.

Now, I am not a doctor and certainly not one to judge whether or not these tests were unnecessary.  What this story does point out though are two important points:

  1. Might this consumer, if he had control of his records that were safe-guarded in one of the online data repositories like HealthVault, or Google Health, or even Dossia (if his employer was a member), be able to provide a complete longitudinal health record, maybe the physician would have decided not to order these tests.
  2. With all the talk from insurers about transparency, consumer empowerment and all the wonderful online tools that they want to provide to enable such, from this story it looks like they are getting a little ahead of themselves.  Rather than looking to the Internet and IT as the magic elixir to make all this happen, maybe insurers might want to start with something as simple and basic as making EOBs understandable.   Granted, not novel, nor sexy, but it may deliver better results.

The second little musing is that while heading over to the Hirshhorn Museum (my favorite here in DC, great sculpture garden and fabulous modern art) coming out of the Metro and what should I see plastered on the walls – at least 8 small billboard posters with that big smiling face of Magic Johnson saying something to the affect of “Together we will better manage our health.”

These are part of Aetna’s consumer advertising campaign to encourage greater consumer involvement in managing their health.  Really like this advertising campaign (seen full page ads in the WSJ as well).  As far as I can tell, they are the only major insurer being proactive on educating the consumer.  Now if we could just get the other big insurers (are you listening WellPoint, Cigna, UnitedHealth, etc.) to ramp-up their own consumer advertising to focus on a similar message, we may indeed begin to see consumers take a more proactive role.

Web Visits Gets Air Time

This morning, on National Public Radio’s (NPR) Morning Edition, there was a nice 5 minute segment on  e-Consultations.  With the two big insurers Aetna and Cigna now reimbursing physicians for conducting such e-Consultations, we will be seeing much more of this in the future.  During the NPR spot they interviewed an internist who actively performs e-Consultations, via physician-consumer communication and PHR platform RelayHealth.

One of the chief complaints I have heard from physicians (besides the issue of reimbursement) is the fear of being inundated with emails.  While this could become a problem, it doesn’t have to be that way.

At the recent HIMSS conference, I had the pleasure to get an in-depth demo of RelayHealth’s PHR solution.  As I stated in my write-up then, nice solution, though more physician centric than consumer.  The RelayHealth solution provides secure communication between the physician and consumer where in addition to an e-Consultation, a consumer can request a prescription refill, a referral or even schedule an appointment.   And for those e-Consultations, it prompts a consumer at the beginning of the inquiry to provide the co-pay via credit card before proceeding.  That step right there will limit the barrage of emails that physicians fear.  And if that payment step doesn’t do it, the lengthy questionnaire that follows may also limit those emails.

After the consumer processes the co-pay, they are taken through a thorough questionnaire with branching logic to describe their symptoms.  Not sure if it was the person doing the demo at HIMSS or not, but the number of questions he had to answer during  the demo was daunting.   Unfortunately for the consumer, the RelayHealth solution provides no feedback to the consumer as to how far along they are in the questionnaire process, which can get frustrating.

If you manage to survive this process, your physician will receive an in-depth profile of your current symptoms and likely provide you guidance via a return email, or if deemed necessary, schedule an appointment.   The complete e-Consultation is captured in the consumer’s RelayHealth PHR account, which is under the consumer’s control but sponsored by their physician.

While I have a couple of minor gripes with the RelayHealth platform, it is a powerful solution overall and something that I could see myself using to facilitate communcation with my physician(s).  During my meeting with RelayHealth  they also informed me that the PHR, though sponsored by the physician, is owned by the consumer.  Thus, if you move to another part of the country or just change doctors, your RelayHealth PHR is not tethered to the physician, but goes with you.

This sounds great in theory, but what happens if your new physician does not use RelayHealth?

Well, you are left with a PHR that does not connect.  This is one of the challenges with this solution and for that matter Medem and all tethered hospital-consumer portal solutions.  Their greatest value is in facilitating physician-consumer communication.  These companies have invested heavily in that capability at the expense of providing other features.  This is fine as long as you have that communication capability, (i.e., a physician using it) but value quickly evaporates without it.   RelayHealth, Medem and similar companies will need to form partnerships with other Web-based, health service providers to deliver sufficient value to the consumer while we await greater adoption among physician practices.

An Interesting Marriage: Malpractice and PHRs

Now here’s an interesting spin…

Malpractice insurer Northwest Physicians Insurance will be offering a rebate to physicians who adopt a PHR to facilitate patient-physician communication.  Looks like this insurer predicts that if they can get the patient and physician to communicate more effectively to improve patient safety (and have an audit trail to prove it), they will subsequently see a lower exposure to malpractice suits.

Physicians will be offered the Medem iHealth PHR to deploy in their practice.

While there are many a health plan (insurer) that offer PHRs to their covered members, this is the first time I’ve come across a malpractice insurer pushing physician adoption, and thereby consumer adoption of PHRs.  But will physicians adopt it?  Not so sure as reimbursement seems relatively low.  Then again, if a physician can tie this program to e-Consult reimbursements from Aetna or Cigna, well then, now we have something.

The Business Case for Aetna’s SmartSource

Pondering the previous post on Aetna’s announcement today regarding SmartSource, have come up with the following business arguments as to why Aetna is aggressively pursuing a consumer health engagement path.
1) Bring more value to the consumer/customer to get them to actually use their PHR. This is arguably the top reason as they have invested quite a bit in the PHR and my guess is that they are still struggling to gain traction among those 16.8M lives covered.

2) Aetna wants to be perceived in the market, particularly among investors, that they are out in front of their competitors in pushing/encouraging consumer engagement in their health with the perceived (and hoped for) benefit being lower medical loss ratios (MLRs) leading to better margins.

3) Changing perception also extends to their big customers, employers.  Aetna can point to announcements such as this to make a compelling argument to employer benefit managers that Aetna is taking proactive steps to help them control their healthcare coverage costs as well.

Aetna Keeps Pushing the Envelope

Aetna is pretty aggressive on the personal healthcare front.

First they buy ActiveHealth Management.  Granted, ActiveHealth’s main target is not the consumer (disease management is their core competency), but they did introduce an online PHR early last year.

Secondly, Aetna has partnered with all the major personal health systems (PHS) plays which include Dossia, Google and Microsoft’s HealthVault.  A key part of these partnerships what often goes unnoticed is that Aetna is providing their customers data portability with the ability to store their Aetna-sourced health record data (claims data, and possibly medication and lab data) on any of these platforms.  The consumer is not tethered to Aetna.

And today they announced SmartSource, an embedded health search tool that leverages Healthline.  There is a quick little video within the Aetna PR that demonstrates what SmartSource actually does that is well worth viewing, at least once you get past the tacky beginning.

What I like about SmartSource:

Nice integration of medical search functional within a consumer’s PHR.

Clean interface for the consumer, at least according to the demo.  Maybe Healthline could learn something here.

Highly targeted search information that directly leverages a customer’s PHR .  Particularly slick was the ability to search on a condition, then look at cost of treatment based on location (your zip code), followed by list of physicians in one’s locale and their fees for treatment.  Now that’s a very nice feature that I would readily use, if needed.

Where I have some concerns:

Though Aetna claims that information that they may be able to gleam from your searches and PHR will not be used against you in future premiums, claims, etc., how will they assure such from occurring?  Is there an outside advisory or audit board that will insure such will not occur?

How much utility will this provide to the consumer versus comparable solutions from Google Health or HealthVault.  Even if the previous trust concern is addressed, Aetna may well struggle to assure their customers that they are safe using this tool, when other options exist.


Aetna is making some bold, aggressive moves to provide the consumer both flexibility and tools to better manage their health  While bold, they are quite necessary as to date, adoption of health plan sponsored PHRs has been quite weak.

And Aetna is not alone.  WellPoint has a number of initiatives as well, including the partnership with Zagat for physician ranking.  UnitedHealth, has been almost as aggressive as Aetna, having acquired PHR provider HealthAtoZ, formed the Optum Health Division and like Aetna, announced that consumer health data would be in their control, thereby supporting portability.

The PHR market, as predicted, is getting a lot of press this year.  Are these health plans now coming to market with compelling enough PHR offerings that will result in a ground swell of consumer adoption?  That really is the bottom-line.

If you seek more info on this story, NY Times has an article today and The Health Blog has a podcast interview with Healthline’s CEO, West Shell.

HIMSS – Part Deux

Back home from my two day whirlwind tour of HIMSS. Here’s what I have for you from Day Two.

Significantly slower on Tuesday, though it did pick up later in the afternoon. So was everyone out playing golf or hanging out by the pool before the rain set in, or were they at one of the educational sessions? Hard to tell, but there sure were a lot vendors just sitting around not even trying to look busy.


Had a good briefing with Microsoft. Couple of quick stats for you:

  • Over 4,700 downloads of the HealthVault SDK to date.
  • Have some 100 signed partners that intend to provide a personal health application leveraging HealthVault. Big focus in 2008 is getting these providers live. Sure hope so as so called demos in exhibit area were weak.

As a follow-up to yesterday’s announcement on the $3M Be Well Fund that Microsoft is sponsoring, Microsoft is putting some pretty tight guidelines on it. First, they are really looking to fund innovative ideas coming out of academia and other non-profits such as health advocacy groups. Second, proposals have to be in by May 9th, awards announced July 1st and product ready for demo in October. Will be extremely interesting to see what this produces.

And just in case someone did not see the PR, Microsoft had a HUGE one page ad announcing the Be Well Fund in both yesterday’s and today’s WSJ. Prime spots as well.

I’ll provide a longer post addressing the Microsoft briefing later this week.


In just another example of HIMSS’s seeming indifference to patients as consumers, went to the HIMSS session (sponsored by the HIMSS PHR sub-committee), Personal Health Records: An Industry Update from Various Perspectives. It was awful. Information presented was superficial and dated and seeing as only one person presented, hardly from various perspectives. Really a shame as there was quite a large audience (over 200) in attendance who deserved better than this for their time spent.

Hey HIMSS, take a look at the aforementioned Microsoft ad wherein Microsoft states, and I quote, “..innovative health applications that accelerate connections between consumers (my emphasis) and physicians and the information they need to make informed decisions.” and get a clue. This is where the train is headed so get on board or be left at the station.

More RelayHealth

Yesterday, I mentioned the physician centric PHR company RelayHealth (parent McKesson). Went back there for continuing discussion with their VP of Consumer Solutions, Ken Tarkoff who informed me that they have nearly 1M consumers using this PHR. That may very well put RelayHealth at the top, in terms of users, and ahead of the likes of WebMD. It is a compelling solution, though not sure how RelayHealth customer Aetna will combine it with their own ActiveHealth Management PHR solution.


Learned more about ICW and their LifeSensor PHR. Interesting company that has seen success in Europe, but despite being in the US for a few years now, as seen very little traction. They did win Memorial Hospital in Rhode Island late last year, and another small hospital on the West coast – so maybe they are finally getting serious, we’ll have to wait and see.

Seeing as ICW has had such little success with LifeSensor in the States, I wrote them off. After visiting their booth and getting an initial briefing, my judgment may have been hasty. Quick review:

  • Their motto Don’t reject, connect. Big into promoting interoperability and announced the eHealth Foundation with founding partners Sun and Agfa. Was told that several others intend to join. Might one of them be Siemens?
  • ICW has over 650 employees worldwide.
  • They have established numerous partnerships many of which are with medical device suppliers for device connectivity to automatically populate one’s PHR.
  • Multi-lingual capability (English, German, French, Russian and Bulgarian).
  • Deep domain expertise in the use of Smartcards. Great platform for a “911 card” but little adoption in US. If that changes, (don’t hold your breadth) ICW is well positioned.
  • They offer their SDK to anyone interested in developing apps for the LifeSensor platform and have established an ICW Developers’ Network, (IDN) to support such development efforts. For the IDN, ICW hosts an annual developers conference to share best practices, learn about ICW’s product roadmap, etc. and hosts an online forum for continuing interaction.

Despite all of this, I still have some reservations about ICW as they have yet to prove themselves here in the States and this market is not getting easier to enter, particularly with Google now joining the ranks of PHR providers. ICW is staffing up operations in the US and indeed they could begin making a mark, but their execution in the field will need to be near perfect. Certainly a company worth watching and tracking as they do have quite a nice solution with some distinct differentiation.

Coolest Demo of the Day

Last but not least on the cool technology front was getting a demo of the MiCard from founder and president Tracy Evans. MiCard is this little credit card sized storage device (1GB) with a small screen that one can scroll through. MiCard has partnered with PHR provider NoMoreClipboard who together will sell this prepackaged solution at your local pharmacy or online for ~$130. BTW, NoMoreClipboard – nice PHR solution, too bad their marketing doesn’t quite match-up. Regardless, another PHR vendor worth watching closely, interesting technology under the hood.

Here’s how it works. Consumer gets a subscription to the online NoMoreClipboard where they can create a PHR and simply download information (emergency info or everything) through the mini USB port into MiCard. Once on MiCard, information is in read-only mode and one can quickly scroll through the record with simply up/down arrows on MiCard.

Great idea for emergency situations as it provides PHR info, without allowing direct access to one’s online PHR. And unlike the common USB solutions of today, EMTs and doctors don’t have to take the risk of pluging a USB into their network to see critical information. It is all easily accessible and viewable on MiCard. In addition to direct to consumer sales via pharamcies and the like, Tracy stated that physician practices are also buying MiCard to give to their customers for free as an added value service.

Busiest Booth

Google continues to attract quite a crowd, which can either be a boom or a bust to their neighbors.  Boom for it brings foot traffic.  Bust for it is difficult for someone to even get past the Google crowd and to your booth.  Pretty savvy on Google’s part to go with a small booth.  Having a bustling crowd always attracts attention from afar with passers by wondering, hmm, wondering what’s happening down that aisle – think I’ll go take a look, which of curse just brings more on-lookers.

Lesson Learned

Lastly, number one lesson learned, stay for at least three days as there is no way to sufficiently see everything at HIMSS in any less than that.

With Merger, Is WebMD Now in Play?

This morning, along with announcing very good 4th qtr growth at WebMD, a concurrent announcement was made that Healtheon and WebMD have agreed to merge, putting the value of the combined entity at about $2.3B. Due to the structure of the deal, WebMD will also end up with a hefty war chest estimated at $700M.

While I am no financial analyst, what I do know is that the past ownership structure of WebMD (84% owned by Healtheon) made WebMD a difficult acquisition target. Now that the two have combined WebMD may become much more attractive to a potential suitor.

WebMD is an attractive property for a number of reasons including:

Brand Recognition – They are the 800 pound gorilla in the personal health and wellness market, no one comes even close in numbers of page views and unique visitors.

Customers – WebMD has a long list of enterprise customers, both employers and health plans that is the envy of the industry.

Hot Market – Seems like everyone is clamoring for a piece of the action in the personal health and wellness space including the big boys Microsoft and Google.

Cash – A $700M war chest is nothing to sneeze at.

So who will come courting? Some likely suspects include:

RevolutionHealth could benefit with some added breadth and depth from WebMD and would love those WebMD customers. Also, WebMD had a relationship with AOL (discontinued last year) and RevolutionHealth is run by former AOL head, Steven Case. There will, however, be a lot of overlap that will need to be rationalized. Probability: High

Google may like the content and some of the tools WebMD would bring, but they are also pretty far along in their own plans/development and Brand, well Google has plenty of that. Probability: Low

Microsoft is much like Google, but has a greater propensity to make an acquisition to keep Google at bay. Microsoft might acquire WebMD as a defensive move. Also, Microsoft might like to have all those enterprise customers, not that they don’t have them already, but it could sure extend their presence in enterprise accounts. Probability: Medium

Intuit has taken a decidedly low profile approach to the PHR market. If they wanted to dramatically boost their visibility and further strengthen their product portfolio, this would be a good move for them. Unfortunately, it takes Intuit outside of its sweet spot/core competencies, thus they are unlikely to make a move. Probability: Low

Yahoo? Why not, though they seem to be ignoring the health & wellness market and have enough issues to deal with right now, primary among them the beast from Redmond. Probability: Low

Large insurers like WellPoint or Cigna could make a move similar to Aetna’s acquisition of ActiveHealth or UntiedHealth’s acquisition of HeathAtoZ and acquire WebMD. Thing is, the scale of a WebMD acquisition is massive in comparison and it could get quite messy as a lot of health plans (over 100) have some form of a relationship with WebMD and may bolt if WebMD goes to a competitor. Probability: Medium-low

Other HIT vendors such as McKesson, GE, Siemens, etc., are focused on business to business sales and in particular sales to hospitals. While WebMD gives them future paths for growth and could be leveraged in innovative ways (connecting clinicals to PHR and decision support tools), falls outside their current sales and distribution channels and is simply not in their DNA. Probability: Low

I’m sure their are other suitors out there, but this is just a quick hit list off the top of my head. And while I can give no definitive answer as to who the suitor will be, WebMD will have new ownership in 12-18 months. Probability: Very High

The Painfully Slow Move to Online Services

This week, the LA Times has an interesting article on how major insurers Cigna and Aetna will be reimbursing physicians for providing online consultations.  It is encouraging to see these major payers step-up and support such practices. Other payers will likely follow as this could become a key service differentiator that would be attractive not only to just patients and physicians, but more importantly to these payer’s customers – employers.

Employers are aggressively looking to reign in healthcare costs, which continue to grow faster than just about any other cost an employer may have. This has led to a dramatic up-tick in interest by employers for employee health and wellness solutions including among others, PHRs. Some forward-thinking employers, however, are looking beyond just healthcare insurance costs. For example, enabling an employee to meet with their doctor online from the comfort (I use that term loosely) of their office at work rather than having to spend an hour or more driving to and from a doctor’s office is a nice productivity boost for that employer.

Taking it to the next level of embedding such physician-patient communication/consultation within the context of an employee’s PHR just adds to the value proposition (of course the PHR is absolutely secure and the employer has absolutely no access to identifiable employee data contained therein). The value here is that not only does the employee/patient share their PHR with a physician online but together, they can go over such things as recent lab results, review images, discuss action plans and keep a record of all communications right there within the PHR.

Since its inception, PHR vendor Medem has always felt that physician-patient communication was critical to the success of PHR adoption by both patients and physicians and structured their solution around that fundamental belief. In a conversation with Medem’s Chief Medical Office, Henry DesPhillips, last week as part or our PHR Research Study, DePhillips’s stated that they are seeing increasing interest for their solution from payers.  Medem traditionally has  marketed and sold their solution almost exclusively to physicians, pitching it as a platform physicians could use to  improve patient services and retention.  In light of the rapid changes now occurring among payers such as reimbursing physicians for online consultations, Medem expanded its marketing efforts in early 2007 directly targeting payers.  They are getting some traction in the market having landed Medical Mutual of Ohio in 2007. If more payers follow Aetna and Cigna’s lead, Medem is in a good position to experience some healthy growth as they are one of the few independent PHRs now in the market with strong patient-physician communications capabilities.  While Medem certainly has an early jump on its competitors, many who I’ve spoken with are currently developing similar capabilities that they plan to release in 2008.

Another, slightly different example is Kaiser-Permanente. Awhile back I did a post on their big PHR roll-out, though I was not all that enthused at the time as I am not a big fan of tethered PHR solutions. Despite my own reservations, Kaiser is seeing very strong adoption among its membership, upwards of 50,000 new users/month. And what is one of the key features of this PHR that all those customers are most excited about? Yup, online consultations and appointment scheduling with their doctor(s).  (Note: At the top of that LA Times article in a picture of a Kaiser physician providing an online consultation.)

To date, I have not come across any independent studies (if you know of any please enlighten me) that point to the efficacy of online consultations, be it improved outcomes, better quality of care, lower total costs of care, etc. Regardless, intuitively I believe there are significant savings here. Unfortunately, as that LA Times article points out, the big payer elephant in the room is the federal government (Medicare) who are loathed to adopt anything new and have no plans to adopt online consultation at this time.

This is unfortunate as the most recent budget proposal by President Bush looks to simple, across the board cuts in Medicare reimbursements rather than how technologies such as this may contribute to lowering the total costs of care delivery but that is another story…

Marriott’s PHR Goes Live for 50,000

Hotel chain, Marriott, announced that they are now offering a PHR for their 50,000 employees.  IT publication InformationWeek  wrote a pretty good article covering Marriott’s plans and the Aetna owned ActiveHealth PHR that is being used.  Article also provides a couple of interesting quotes from a physician.

ActiveHealth CEO, Lonny Reisman is quoted claiming that they have some 18 million plus users of ActiveHealth.  Unfortunately, the reporter failed to ask Reisman if these users were using the ActiveHealth PHR, or one of the many other ActiveHealth offerings.

To set the record straight, my estimate is that ActiveHealth has less than 10,000 active PHR users outside of parent Aetna.  Even among the multitudes of consumers that have healthcare coverage through Aetna, the number is far south of 300,000 for active users of ActiveHealth’s PHR.

ActiveHealth is not alone.

Among the many PHR vendors I have interviewed, a universal challenge is the missionary work required to educate the market.  This is still a very new technology, a very new approach to healthcare for consumers, physicians and even employers.   We have a ways to go to get to 18 million as an industry, let alone one single PHR vendor.

Correction: AMA Article on PHRs

As physicians will play an extremely important role in the future adoption and use of personal health records (PHRs), educating physicians on this technology platform, where it is today and where it is heading, is critical. Unfortunately, it appeared that the AMA was not stepping up to play such an important educational role as a recent PHR article posted on their website gave only a cursory overview.

Last week, in a brief post, I chided the AMA for this poor article which caught the attention of the article’s author. She was kind enough to send me the complete article, all 5 pages of it. Apparently, the AMA only provides brief abstracts of articles for public viewing on their website. For the complete article you need to be a card carrying member of the AMA.

The complete article is far more comprehensive than alluded to previously and for that I stand corrected. What is disconcerting though is that the article takes a relatively dim view of PHRs, beginning with the title – PHR: Pretty Half-Hearted Reception.

Now granted, PHR vendors have struggled over the years to make themselves meaningful to the broader public. In a cursory review of many of them, a significant portion are nothing more than a series of simple template forms which the consumer must fill-out – not much value there. Was also astonished at just how bad some of these solutions are – really some are God-awful. But this is all changing, and fairly rapidly, which the article does not address.

Moves by Microsoft, Dossia-Indivo and Google in the future will significantly alter the landscape bringing more investment, skills and reach, which will raise the overall quality of PHRs are lesser solutions will not survive. Efforts such as Kaiser-Permanente’s My Health Record is seeing adoption at the rate of 50,000 new users a month. Aetna’s own PHR, which has seen only limited roll-out to date has signed-on over 800,000 users since it was introduced 10 short months ago. Clearly, PHRs are gaining momentum, something that this article seems to miss.

So, in the best interests of its constituency, the AMA needs to take a broader and more proactive view of PHRs. This would include: interviewing physicians who have found value in PHRs, (not just the one who has negative feelings about them as was the case in this article), interviewing employers who have established PHRs for their employees, talking to payers such as Aetna about their experiences, reaching out to the big, new entrants Microsoft and Dossia who are creating personal health platforms (PHPs) and most important of all, consumers who are using these solutions.

Only then, will AMA’s constituency be able to make a an educated judgment on PHRs and what it will mean to their practice. And isn’t that really the point of these articles?

Moving the Ball Forward: PCHRI 2007

The Children’s Hospital Informatics Program (CHIP), developers of Indivo, hosted PCHRI 2007, an invitation only conference over the last two days. The event brought together about 100 leading players in the Personal Health Record (PHR) market to discuss where the market is today, what challenges lie ahead, and what we might see in the future.

Over the past year the PHR market has certainly seen a significant pick-up in activity. Microsoft rolled out HealthVault, the big employer-led Dossia initiative adopted the Indivo platform, Kaiser-Permanente released their PHR to its 8.5 million members, Aetna released a hosted PHR and let us not forget Google, who has yet to release anything but continues to generate a lot of buzz in the market. Given this backdrop, the PCHRI conference was full of updates, announcements, outlines of strategies (Dossia in particular which I’ll do a separate post on), and discussions on what is needed to move the PHR ball further forward in 2008. Following are some highlights.

Personal Health System
Discussion is moving beyond just what a PHR is to what a Personal Health System (PHS) may look like. This is being driven in large part by the actions of Microsoft and Dossia who are both looking to provide a personal health platform (PHP) upon which a wide variety of applications may sit, including PHRs. As a corollary to this, Aetna said it will allow users of its PHR to move their records/data into HealthVault or Dossia and New York Presbyterian and CapMed are currently working with Microsoft to insure interoperability between their PHRs and HealthVault.

Role of Standards
Standards are not perceived as a problem for PHRs. There are plenty out there in the market today, the PHR community simply needs to agree on one and move forward. Ah, but therein lies the trick – getting them all to agree. This point will become irrelevant as the PHP players define the standards for their platforms. And for those platforms, Open Source is not important, but Open Standards and Open APIs (application programming interfaces) are critical.

Regulations & Policies
Virtually unanimous agreement that this market is too immature for any strict, prescriptive policies or regulations. Rather, participants saw a need for a light policy framework to provide the market with the flexibility needed to try new approaches and value propositions to meet consumer needs while still providing some government oversight.

A couple of elephants remain in the room, one quite visible, the second less so. The visible elephant is privacy as this remains the number one issue for consumers. What Aetna found, however, in their focus groups is that once consumers started using the PHR, their privacy concerns diminished. Another interesting revelation is that consumers are quite willing to relinquish privacy concerns, via voluntary disclosure, if they thought that it would contribute to a greater common good. This finding came from the folks at PatientsLikeMe who stated that among their members, over 70% have volunteered information about themselves on the site that is index-able and searchable by Google. (Today’s WSJ Health Blog also released some interesting survey findings on this issue.)

Despite these positive privacy trends it was clear that the PHR industry as a whole has not done a thing to allay consumer privacy concerns and current privacy policies remain confusing, fragmented and all too often misleading. As with the comment above on standards, hopefully the future platform/system plays in the personal health market will drive a higher level of privacy policy standardization and compliance.

The invisible elephant is the lack of digital data and when it is available, delivering it to consumers in a format and context that they can readily understand and take action upon. Widespread agreement that a model that relies on the consumer to manually populate a PHR with data will not see broad adoption (ironically, this is what is most commonly found today among untethered PHRs). Therefore, automating this process is critical. SharedHealth, the Tennessee Health Information Exchange (HIE) did a demonstration project for CMS earlier this year moving large EMR data sets to a PHR. The biggest challenge (manually intensive and expensive) was converting EMR data into terms the consumer will understand within their PHR. This elephant will be in the room for quite some time as there were no easy answers presented at this conference as to how to address this issue.

Data Usage
There are quite a few stakeholders circling the PHR market hoping to get access to this potentially rich treasure trove of data. The pharmaceutical industry is looking to access this data to perform a wide variety of research tasks from identifying potential candidates for clinical trials to finding genetic markers for diseases in new drug development. Amgen stated that they have been attempting to use de-identified EMR data for oncology research but are finding it arduous and expensive. Amgen reflected on a breast cancer research program where they found that the critical data fields of interest in the EMR data sets were filled out only 20% of the time and that does not account for “dirty” data. Ultimately this was a worthless endeavor for them. Amgen sees strong potential in the PHR market for providing such data and openly stated it is willing to invest to make it happen.

And it is not only the private sector looking to get its hands on PHR data – Uncle Sam wants it as well. The Center for Disease Control (CDC) for example is interested in gaining access to provide them with a better picture of population health and bio-surveillance.

As this event was focused on Personally Controlled Health Record, there was general agreement that such data sharing was acceptable provided that the PHR solution offered sufficient granularity to allow the consumer to selectively share data (most PHRs today do not) and that it was up to the consumer to decide whether or not to share such data, not the PHR provider.

Going in the opposite direction was PatientsLikeMe. They stated that they have every intention of sharing their customers’ data with pharmaceutical companies – as it is core to their revenue/business model. They believe that pharmaceutical companies are in the best position to help those on PatientsLikeMe with new drug therapies and thus should be welcomed, not spurned. Of course, many at the event who come from the physician side of the fence looked at this idea with a jaundiced eye.

Some Final Data Points

  • Aetna’s PHR, which was released on Feb 14, 2007 now has over 800,000 users. Strongest adoption is among chronic care patients.
  • The Veteran’s Administration’s PHR now has over 500,000 users.
  • CapMed has over 600,000 of its PHR in the market today.
  • WebMD is supporting over 200 private PHR portals for payers and employers.
  • Dossia is on track with roll-out to early adopters by end of 2007.
  • Of the 39 BC/BS plans nationwide, 67% have gone live with a PHR or will do so in the near future.

There is always an afterglow coming from one of these conferences and this one is no different. Beyond the glow though, it is hard to argue that PHRs are still a technology not yet ready for prime time. This is clearly changing and quite rapidly. No longer does this market resemble Sisyphus slowly rolling a ball up a hill. This ball is starting to roll down and is picking up momentum. That’s not to say it won’t hit some speed bumps along the way, but if 2007 is any harbinger, 2008 will be an even more dynamic year for the PHR market.

Aetna Joins Cigna and Goes One Step Further

Aetna, under pressure from the New York Attorney General’s office, has agreed to change its physician quality ranking system.  This follows a similar move by Cigna about two weeks ago.  Both UnitedHealth and WellPoint BS/BC are the remaining hold-outs, but I expect them to follow suit in the near future.

What is interesting about the Aetna announcement was that they not only agree to comply with New York state, but stated that it would reassess its program nationwide.  After the Aetna announcement, Cigna also stated that it to would also reassess its ranking system nationwide.  In their previous announcement, Cigna agreed to only look at how it assessed physicians in New York.

From this vantage point it looks like we may actually move towards some consistency in quality rankings, though it remains to be seen how consistent those rankings would be from one payer to the next.  Hopefully, a federal agency such as AHRQ will step in to assist payers in establishing clear, agreed to metrics across the industry by which all providers will be measured and reported.

Is Aetna Janus with Two Faces?

Just saw over on the WSJ Healthcare Blog that Aetna’s CEO, Ronald Williams is claiming that Microsoft is just pushing “Vaporware” with its launch of HealthVault. Having already done some cursory analysis of the HealthVault site, I can confidently say that it is not vaporware, though it may be a bit thin in places.

Hope to have a more thorough review tomorrow. However, I have banged on the search engine feature – initial impressions are favorable. Microsoft has done a nice job of restructuring MedStory to be more consumer friendly and their partnership with others for content, e.g., Mayo Clinic is welcomed.

Getting back to Aetna…

What I find so ironic about Williams’ comments is that while Willliams is blasting Microsoft and its HealthVault platform, a subsidiary of Aetna, ActiveHealth which was acquired by Aetna to provide Aetna customers with their own PHR announced today that they are partnering with Microsoft’s HealthVault.

Looks like Ronald Williams needs to look a little more closely at the Microsoft HealthVault platform, for if I’m reading the the ActiveHealth PR correctly, it would appear that the ActivePHR is an integral part of HealthVault. So does that mean Williams is claiming that his own company’s ActiveHealth platform is vaporware as well?

Apparently not, for if you read the ActiveHealth PR closely you’ll see at the bottom this quote from Williams:
“Microsoft HealthVault provides ActiveHealth with a powerful platform to directly reach consumers with the CareEngine,” said Ronald A. Williams, Chairman and CEO of Aetna, parent of ActiveHealth Management.

Now I have to wonder, did Williams really say that? If yes, it sure runs counter to what he is reported to have said to the folks that run the WSJ Healthcare blog.