Being seasoned veterans of the HIE/CNM market, 2014 was not so much a year of surprises, but one in which HCOs finally coming to grips with reality. There was a tremendous level of exploration of the technical, organizational and incentives-based challenges facing healthcare. What was different this past year is that these struggles were being watched by people outside the healthcare sector as well.

Interoperability Issues Step Into Limelight
Surprise! HCOs slammed into the hard reality that enabling a population health strategy is basically impossible without the ability to effectively and efficiently communicate across care venues. A clamor arose from within and without the healthcare sector including:

• Congress added provisions to the recently passed “Cromnibus” funding bill to decertify EHRs that do not facilitate information exchange. This leaves ONC between the rock of widespread cries from providers and vendors for MU relief and the hard place of a Congress demanding progress toward interoperable health data.
• Last week, ONC announced its intent to make interoperability one of the keystones of their strategic plan.
• CommonWell Health’s first pilots went live and in November, Commonwell member athenahealth started offering the service for free to customers.
• The JASON Task Force released its report pointing out the many errors in the previous JASON Report but basically agreeing that interoperability is a core issue that needs to be a priority of future policy initiatives and mandates.
• Epic gets its own 15 minutes of shame (more like six months and counting) in the press on the Hill and in a Rand report due to its purported lack of interoperability. It gets so bad for Epic that they actually hire a lobbyist firm to fend off attacks.

SMART on FHIR Gains Visibility
Last summer’s work by the JASON Task Force is shaping up to be pivotal as it seems to have pushed the industry to embrace FHIR as a way out of the dead end of document-centric, messaging-based exchange moving towards discrete data exchange and SOA-based architecture with “open APIs”. The announcement of Project Argonaut by HL7 and many of the players on the JTF represents a commitment of resources to advance FHIR as a way to support API-based access to healthcare data. Argonaut’s ambitions are lofty and it is unclear whether committed resources will be sufficient to achieve its goals, but there is promise.

At the Cerner user conference in the fall, we had the opportunity to see what this may mean in the future with demos of SMART apps (e.g., Boston Children’s growth chart) that pulled discrete data from Millennium and presented in an Mpage frame within Cerner’s EHR – pretty cool.

But we have to pause and remind everyone that FHIR is not ready for prime time. Current pronouncements from FHIR standards mavens indicate that May 2015 will see the most complete (from a clinical standpoint) draft standard for FHIR since people first started talking about it. But we honestly can’t say that the transition from a draft standard to an “official” or “final” standard will be without some hiccups.

DSM Growth Rapidly Accelerates
2014 saw extremely rapid growth in Direct Secure Messaging (DSM) with some exchanges reporting 30-50% month over month growth in message volume. Granted, when you start from zero, such growth is not impressive, but it does at least show that once you have messaging embedded in physician workflow (EHR), it will get used. Whether it is used for actual patient care or to meet MU metrics is a separate question.

Unfortunately, this technological relic from the MU program will not have legs and 2015 will demonstrate conclusively the limits of the approach for day-to-day use by clinicians. For the most part, the recipients of a lot of this traffic, most notably PCPs and community-based nurses will soon decide that it does little to declutter patient information. For this reason, we believe that message volumes will continue to increase as provider attention decreases. This is not to say that every message will be ignored. Much like the fax machine, DSM will not go away readily, if ever. But clinicians will find that if they do not use it more or less at the same time that a message arrives or when a patient presents, they will never have the time to find and read the documents contained in this message stream.

Health Information Organizations (HIOs) Continue the Struggle
Not really anything new here as public HIOs were struggling to define their value proposition last year. What is different is that federal funding for such exchanges is all but over and now HIOs must subsist on their own revenue streams.

Maybe misery loves company, or maybe HIOs can really begin articulating a value proposition that will sustain them. Just this week, a set of HIOs formed an organization called the Strategic Health Information Exchange Collaborative (SHIEC). SHIEC represents yet another attempt by HIOs to collectively share best practices and lessons learned to extract value from past investments.

HIE is Dead-End, Time to Move to CNM
Finally, we completely restructured our approach to the HIE market and published the Clinician Network Management Market Trends Report 2014-15. This report is an outgrowth of two things: First, we had grown increasingly concerned with HIE as we felt the industry needed to think beyond simple information exchange to true network management to fully leverage the value of their investment(s). Secondly, our report early this year, Migration to CNM (which is free), validated these early concerns as numerous CIOs and CMIOs we interviewed concurred with the need for CNM.

The CNM Market Trends report finds genuine, if slow, progress by vendors in 2014 to meet the requirements for CNM. As a group, the vendors are bifurcating between those more focused on a range of finished applications and those more concerned with providing a data utility. The former group of vendors tend to be smaller, independent companies that are targeting the mid-market. The latter vendors are typically part of a larger organization and sell to large enterprise clients. Many of these larger data utility vendors supplement their core data provisioning with care management or analytics-based solutions from sister organizations.

Looking Ahead
No doubt will be hearing a lot more (tiresomely so) about the woes of the existing healthcare IT infrastructure that HITECH has wrought and the need to rectify to improve interoperability. ONC, once the vanguard here, is now but a paper tiger with no teeth – there budget is flat-lined and numerous senior executives have left. What will move the ball down the field is business need and on that, virtually every HCO can agree. Granted, it will not be inexpensive to accomplish, but the need for CNM far outweighs the costs and when there is a will, there is a way.