Beyond a Thousand Clicks

On March 18th, Kaiser Health News (KHN) and Fortune published https://khn.org/news/death-by-a-thousand-clicks/, a deep expose into all that has gone wrong with the adoption of Electronic Health Records (EHR) across the physician landscape in the U.S. The article was well researched – it is a good piece of journalism.

But are the findings in this article all that surprising?

Frankly, no.

Prior to the signing of the HITECH Act in 2007, which incentivized physicians to adopt EHRs, EHR adoption nationwide stood at a paltry 12-14% for hospitals and about half that for physician practices. Within a decade, however, EHR adoption soared to over 95% for hospitals. That is a massive uptake of a technology that most healthcare organizations were loathed to adopt in the first place.

What could go wrong? Plenty.

As the KHN article points out, we are still working our way through the muck of what became a false market created by the HITECH Act for EHR software adoption and use. The market became flooded overnight with EHR solutions. Despite the government’s best efforts to certify that these solutions met certain criteria – a lot of questionable software ended up in the market.

Yet, even some of the most popular, widely adopted EHR software deployed across the industry is not meeting the needs of end users. In two separate conversations I have had with physicians on my care team, one likened the EHR his large academic medical center is using to just a glorified billing system that does nothing for him in actually caring for his patients. The second physician turned to me after painfully clicking over and over again to make an appointment stated: “If anything is going to make me lose my love of medicine, it is this EHR software.” And note, this was a freshly installed EHR replacing this health system’s internally developed EHR.

Deploying a complex enterprise software solution, be it EHR, supply chain, enterprise resource planning (ERP), etc. is an extremely challenging endeavor regardless of industry sector. I watched first-hand as some of the largest manufacturers in the world did massive rollouts of SAP, Oracle and other systems and it was never, ever easy. Cost overruns, delays and extremely dissatisfied end users were par for the course. And this was an industry sector that willingly made the choice to invest and adopt such systems.

So yes, there is plenty to write about on how the digitization of healthcare has delivered results far, far less than first imagined when HITECH was passed. We still have a long road ahead in optimizing the technology for end users – a technology that was so hastily adopted in a market not fully sold on its intrinsic value. But that is a relatively easy story to tell, albeit limited in vision and scope

What tends to get lost in these discussions is that what we are doing today is laying the foundation for an entirely new change in how we will deliver care, change that will occur along the entire care delivery chain.

Keeping an Eye on the Prize

However, what tends to get lost in these discussions is that what we are doing today is laying the foundation for an entirely new, dare I say radical, change in how we will deliver care, change that will occur along the entire care delivery chain.

The field of medicine has never had such vast troves of computational medical data available to it as we are beginning to see today. The potential opportunity to do deep analysis on such data will open completely new discoveries on everything from the efficacy of therapeutics and clinical pathways, to advances in artificial intelligence for more accurate diagnosis, to discovering new treatment modalities to other advances that are only limited by one’s imagination. One need only look at some of the work Dr. Atul Butte is doing at UCSF to have an appreciation for what we are beginning to unravel today and what the future may hold.

This deeper, broader view of what the adoption and use of EHRs and other enterprise software to support the delivery of care – including new analytics solutions such as those profiled in our recent report – is truly the prize, as a society we are after. Let’s keep our eye on the prize.

Stay up to the minute.

Did You Know?

HIMSS’19: Maturing Market Drives Pragmatism

Even the exhibit hall was calmer with vendors focused on solving specific problems instead of the latest buzzword

Frankly, I was dreading attending HIMSS this year. I’ve grown tired of the hype, the noise and just how little we have accomplished as an industry in the past few years. We have not contained costs, but have increased clinician burnout. We have made only a modest impact on quality, but the lack of interoperability has hampered care coordination. I had become increasingly cynical every year as we approached the big event, dreading more of the same, which is never a good thing.

Yet at the outset, while waiting to board my flight to Orlando, I started meeting many a compatriot in healthcare IT. This did not stop until I landed back in Boston five days later. Those brief meetings always included a hug, checking in with how each other is doing personally and then proceeding to talk about the industry – in that order. I have worked in a wide range of industries over the course of my career, only in healthcare have I experienced such genuine warmth and caring. These brief encounters renew my spirit pushing that cynicism back for this industry is more than just a business, it is about health, and it is about life.

HIMSS’19 Reflections

For the last eleven HIMSS conferences I have attended, there has always been one buzzword or acronym that virtually all vendors on the exhibit floor would latch onto, whether they could deliver those capabilities or not. There was no such word or acronym this year. The hype, the buzz may be behind us, which is welcomed by this analyst and I’m sure most in attendance.

I also noticed that conversations were less about whiz-bang features. Instead, conversations focused on specific problems that can be solved and value delivered to an organization. The industry is quickly moving beyond being strictly regulatory-driven (albeit CMS’s NPRM dropped Monday at HIMSS goes against that) to a more pragmatic market, which is a healthy sign of a maturing industry.

It was clear this year that the EHR war for buyers is over. Those EHR vendors offering a fairly limited, EHR-centric product with few extensions (e.g. analytics, RCM, PHM, etc.) were eerily quiet. EHR vendors with broad capabilities had their fair share of visitors, but the discussions focused on the extension apps and equally important, how to extract value from those significant EHR investments.

In speaking to one of the largest EHR vendors, they were surprised by the interest in PHM among their clients, which has been tepid in recent years. Clearly, CMS’s recent moves to get provider organizations to get serious and start taking on downside risk are being felt. But this vendor went on to say that most prospects simply want someone to tell them what to do to be successful. For companies like Aledade and Evolent this must sound like mana from heaven.

Some quick outtakes from HIMSS’19

  • Acute and ambulatory have been by and large taken care of, yet we still do a very poor job as an industry addressing the “community of health.” Good opportunity for a truly visual, intuitive platform.
  • Ada Health, a Berlin-based small company using AI for self-triage is just entering the US market and has landed Sutter Health as its lighthouse customer. Keep an eye on them – they are interesting.
  • Significant shift among provider-centric vendors who are now signing large deals with payers. Still plenty of mistrust between providers and payers, but if incentives are aligned – it can work.
  • Collective Medical out of Utah has been operating in stealth mode and racked up several payer and provider clients. Compelling value-prop but they will have to move fast as several much larger vendors are looking to do something similar.
  • Many a large health IT vendor does a poor job at data aggregation and digestion (normalization) and are seeking partnerships with a number of small innovative companies that focus on this problem.
  • Apervita, a company that has been around for several years with a business model I never was fond of has completely changed direction. I like what I saw at HIMSS this year. Their work with NCQA is pretty impressive.

The Wrap

HIMSS this year reflects a maturing market. With any maturing market, conferences like HIMSS begin to lose their luster, despite their own self-promotional hype. But what HIMSS does well is to bring together a broad cross-section of the industry and remains a fabulous place to reconnect and network. Does it need to be three and a half days (plus!), I do not believe so. In five years, HIMSS will still be here, but the high water mark was likely last year (barring any major federal incentives a la HITECH). The tide is going out.

HIMSS’19: What to Expect, What I Hope to Find

Next week, most of the healthcare IT industry will descend on Orlando to attend HIMSS’19. This is my 12th year attending HIMSS, an event for me that is more about networking and confirming assumptions than actually learning anything new.

For years now, HIMSS and the multitude of vendors exhibiting there have feasted at the trough of federal largesse ($35B plus), via the HITECH Act passed in 2008 to foster adoption of EHRs. The HITECH Act was successful, driving EHR adoption from the low teens to over 90% today. Though some may question the value of that investment, I personally believe that over time (another 7-10 years) we will reap benefits that far exceed that initial investment.

However, now that we’ve reached that level of adoption, the market has plateaued. Sure, there were hopes of a robust EHR replacement market, but that never materialized. Then there was the hope for huge gains (profits) to be made on the shift from volume to value through the sale of PHM solution suites. That didn’t pan out too well either as the fate of the ACA was left in the lurch with a change in administrations. Also, quite frankly, PHM is a complex sell, requiring significant change management that few healthcare organizations were ready to commit to and few vendors had the services to support.

The provider health IT market is going through a significant transition and it’s not going to be pretty. Clearly, the party is over and one has to wonder: Why does HIMSS continue to exist? Why are all these vendors here? Are we on the Titanic, seemingly blind to the economic icebergs that surround us?

But I digress.

What is important is that the EHR has become the central nervous system to provider organizations. Secondly, this market will continue to consolidate rapidly with few independent EHRs surviving the shakeout. Those left standing will attempt a number of different strategies to drive continued growth in a plateauing market.

  • Acquire other EHR vendors to gain market share (Allscripts, Cerner, CPSI, Harris)
  • All major EHR vendors are pursuing an extension strategy moving from EHR to supporting PHM, RCM, analytics, etc, though their capabilities in these adjacent areas vary wildly.
  • Expansion into new markets. Epic is looking to dentistry and insurance. Allscripts, life sciences and payers with Veradigm. Cerner, government and payers. All large acute/ambulatory EHR vendors are actively pursuing overseas markets, with Meditech particularly strong in Canada.

It remains to be seen how successful these strategies will be but rest assured, even if successful, no EHR vendor is completely safe from a future acquisition.

This sets the stage for what to expect at HIMSS’19:

  • All vendors will continue to tout the momentum they have in the market as if this market will remain forever on a hockey stick trajectory, but very few can back it up.
  • AI/ML will be just as pervasive this year as last, permeating all aspects of health IT, but likely very little demonstrable proof of scale.
  • A multitude of disease-specific, chronic management solutions but no vendor with a true portfolio of best-in-class solutions on a single platform. Resmed appears close to enabling such a platform for respiratory ailments.
  • More FHIR use cases.
  • Plenty of patient-centric this, consumer-centric that but all a head fake as it is really about capturing patient revenue via online bill pay and filling vacant appointment slots.

And what I hope to find at HIMSS’19:

  • An AI/ML company that has truly scaled its solution across an enterprise in at least two customer deployments.
  • Clear metrics from EHR vendors on the level of adoption and use of FHIR across their client base.
  • An engagement solution that is looking beyond the near-term volume/revenue needs of a healthcare organization to how to truly engage patients/consumers in their health e.g. Aetna/Apple’s Attain app.
  • How vendors are assisting their customers in achieving demonstrable, defendable ROI from their solutions. Health Catalyst stands out here.

May your trip to HIMSS’19 be a success, however you define it. And if you see us in the halls, do not hesitate to stop and say hello – maybe we’ll have a few quick on-the-fly notes to share.

Health IT for Behavioral and Mental Healthcare

Coaching Technology

While the landmark health reform laws enacted in 2009 (HITECH Act) and 2010 (Affordable Care Act, or ACA) have begun transforming certain aspects of the US healthcare system, they have not had a meaningful impact on behavioral and mental health care delivery. Patients in need of these services already face an uphill battle in terms of social stigma and making a decision to seek out care, yet our system compounds such challenges through poor benefit design, uneven IT adoption, and lack of care coordination. An emerging fleet of technology solutions focused on behavioral health care has the potential to improve care, though they are not without their own set of challenges.

> Providers lack adequate incentives to adopt patient-facing digital mental health care tools. This is due both to omission of non-psychiatric mental health specialists in the Meaningful Use program as well as the slow adoption of value-based contracts.
> Vendors of new technology have not placed a premium on making their platforms interoperable with legacy software. New startups have focused most of their efforts on developing self-contained tools geared towards the employer market rather than emphasizing document exchange, shared care plans, or tools for the population health manager to manage mental health needs.
> Given the fragmented nature of the delivery system for mental health care, the market for mental health care IT is quite immature. While there are ample opportunities for one-off improvements (primary care, substance abuse facilities, Veterans Affairs, higher education, employee programs, etc) – only those health systems who can underwrite their own reforms will be the ones taking action.

To read the full article, please submit your information below:

eCQMs: Beginning of a Long and Rocky Road

A New Necessity

Payment-based upon quality measurement is at the center of a wide range of efforts to improve health care performance by various payers including the federal government. Historically, quality measurement either had to rely upon either administrative data (e.g., claims) and/or a combination of manual chart abstraction.

Electronic clinical quality measures (eCQMs) derived from EHRs have been touted as a way to effectively scale the growing requirements for quality management program. Starting in CY/FY 2014, eligible providers in the EHR Incentive program beyond their first year of MU participation will have to submit a select number of eCQMs to CMS in order to successfully attest. Providers who fail to successfully attest will be subject to payment reductions of one percent in 2015, two percent in 2016, and three percent in 2017. eCQMs are also being utilized as a method for providers to submit quality data for other federal programs including the Hospital Inpatient Reporting Program and the Physician Quality Reporting System.

The Office of the National Coordinator for Health Information Technology (ONC) certifies that EHR technologies are capable of accurately calculating the eCQM results for the EHR incentive program. Initial findings though have found several issues with abstracting, calculating, and submitting eCQMs.

To read the full article, please submit your information below:

The Waning Influence of ONC

Market Challenges

Many are beginning to question ONC’s role in the further promotion of EHR adoption and use. Healthcare organizations of all sizes are struggling with a rapidly shifting landscape that is increasingly pushing such initiatives as compliance to ONC’s meaningful use program further back on their list of priorities. Despite the efforts of new ONC director, Dr. Karen DeSalvo, to redirect ONC’s current programs, many factors are working against her office and ONC’s influence in the market will continue to wane.

To read the full article, please submit your information below:

Hunkered Down on HIE

Been pretty quiet here on the Chilmark Research site for the simple reason – we are doing one heck of a lot of research which you’ll be seeing the results of in the not so distant future.

Primary among those research efforts is the update to the 2010 HIE Market Report. The last report was extremely successful and highly regarded among those in the know. For example, a CEO from one of the top HIE vendors told us:

By far, Chilmark Research has done the best research on the increasingly critical HIE market – no one else has come close to providing the in-depth research that is contained in the 2010 HIE Market Report.

And it is not just the HIE vendors who appreciated the report as we sold quite a few to healthcare organizations who have been using the report to assist them in their strategic decisions and ultimately vendor selection process.

But the HIE market is evolving quite quickly and thus the need to provide a refresh of the report. For example, of the 21 vendors profiled in the last report, 7 will not show up in the next edition. Even with that change, there are more entrants into what has become a lucrative market (albeit still relatively small) and in the 2012 report we will have in-depth profiles of 22 HIE vendors.

To give you some brief insight into the report, following is the intro to Chapter 3.

“The more things change, the more they stay the same.”

This French proverb accurately characterizes the state of the HIE market and the vendors who serve it. In last year’s report we commented on how the market was becoming increasingly crowded and competitive. We profiled 21 vendors in that report and a third of them did not make it into this report. Some exited the market (ICW, MedPlus, MEDSEEK, Misys, PatientKeeper, Telus), others acquired (Carefx and MobileMD) and then there is the folding of the HIE assets of GE and Microsoft into the new entity Caradigm. This year we have 22 vendors profiled including: Caradigm and Microsoft (still difficult to know what will become of their joint assets, but we provide some guidance), Harris, who had acquired Carefx, Siemens, who picked up MobileMD and some new entrants including 4medica, Certify Data Systems, the young start-up GSI Health and HealthUnity. We even broke from tradition, if you can call one year a tradition, and profiled one of the leading EHR vendors, Cerner, who contrary to prevailing EHR vendor wisdom, or at least strategy, is creating an open HIE platform.

The market is as competitive as ever with a monumental shift towards the enterprise market. Some vendors have been serving this market all along, others, whose focus has been the public market are to varying degrees of success making the transition to the enterprise market. But despite this overwhelming shift to the enterprise market, the HIE market remains no less mature than it was last year. The solutions on offer vary significantly and in our interviews with vendors, consultants and end users we found a market that really has not defined a clear set of requirements for the HIE. There is always the ubiquitous desire to facilitate orders, referrals and distribution of results but beyond that, the needs of a given HCO can vary greatly, which has subsequently led to continued market confusion as to what an HIE is and is not.

With this report, Chilmark Research once again has applied its deep research methodology (see Appendix B) to provide a clearer picture of where this market and the vendors who serve it are today and where it is heading. The profiles contained in this report are not meant to provide an exhaustive analysis of each vendor’s solution and business strategy. Rather, their purpose is to provide a concise overview of leading HIE solutions in the market today, their strengths and weaknesses, what sector(s) of the market that the vendor has had particular success in and provide insight as to an HIE vendor’s future direction. Armed with this information, the reader will gain a clear picture of currently available solutions enabling one to create a short-list of those worthy of more in-depth internal review and follow-up for their own HIE initiatives.

In our opinion, we are slowly but surely beginning to enter the post-EHR era. The U.S., federal government’s push for physician and hospital adoption of EHRs, via the HITECH Act, appears to be having the intended affect. The recent Robert Wood Johnson Foundation study published in the April 2012 edition of Health Affairs has physician adoption and use of EHRs now at 57 percent. But the value of those electronic patient records is not in the data silo of a given EHR, but in how patient data can be aggregated and used to facilitate care coordination across care settings and subsequently improve the quality of care a patient receives. This is the province of the HIE and where the real value of electronically recording a patient’s health will reside, not in the silo of the EHR, but in the network of the HIE.

Please bear with us and our lack of frequent posts. We are working hard here at Chilmark Research, which can make it a challenge to find that extra bit of time to write for the public. Once the HIE Report is released (next week), we should be getting back to a more regular schedule of posts to this website. Stay Tuned.

Rational Thought Infects HITECH

Couple of weeks back the HIT Policy Committee began to seriously consider what a delay of Stage Two meaningful use (MU) might look like. This push for a delay is being driven in large part by EHR vendors. The problem is one of timing. While Stage Two rules are to be released on June 8, 2011, there is growing concern among these software companies that they simply will not have enough time to build, test and deploy the required functionality in time for their customers to demonstrate meaningful use and pick-up their incentive check at the Medicare window.

This does not come as a surprise. When the HITECH Act was first passed as part of the broader Stimulus Bill (ARRA), the primary objective, at least for ARRA and subsequently HITECH, was getting people back to work. The HITECH legislative language was purposely vague highlighting such key objectives as getting physicians to “meaningfully use” a “certified EHR” to promote “care coordination.” Since this was a jobs’ bill, the legislative language also pushed for the billions of dollars in HITECH funding to be doled out expeditiously.

Problem is, installing software into an existing operation is just a tad more difficult than say resurfacing a roadway. When you layer into that software installation issues such as changes in workflow, training clinicians, insuring patient safety is maintained (and ideally improved) you end up with a very challenging situation. In the case of HITECH, this challenge is further compounded by the desire to continuously improve, via the proposed three stages of MU requirements, the quality of care delivered. These are the challenges providers and hospitals are facing but as mentioned previously, the EHR vendors are struggling as well to deliver the functionality required to meet future meaningful use requirements.

Last week at the Massachusetts Governor’s Healthcare IT Conference both Dr. Blumenthal and Dr. Halamka gave their perspectives on this conundrum of whether or not to delay Stage Two MU. Blumenthal was quite cautious in his statements that basically inferred that such a delay could have some repercussions on the entire HITECH Act wherein some of the funding may be retracted if it was not spent in the timeframe allotted to it under this legislative act. In today’s acrimonious federal budget wrangling on the Hill this is a very real possibility.

Halamka proposed another scenario wherein Stage Two would be split into a Stage 2A and 2B. Meeting Stage 2A would not entail new software functionality, but simply attestation that the provider/hospital was meeting the stepped up implementation of their EHR. For example, in Stage One, the CPOE requirement is for 30% of patients to have at least one order via CPOE. In proposed Stage 2, the requirement is 60% of patients. No new software functionality is required, just more physicians trained on how to use CPOE. Stage 2B would address those MU requirements that are new and requiring additional EHR functionality (e.g., record a longitudinal care plan for 20% of all patients).

What is likely to happen?

Looking into its analyst’s crystal ball, Chilmark foresees the following:

  1. Stage Two will be delayed in some form or fashion as there has been a lot of grumbling by healthcare providers who have struggled to meet Stage One (and even Stage One was significantly water-downed from what was first proposed).
  2. Halamka’s scenario of Stage Two being broken up into two makes sense as it addresses both legislative issues (keeps ball rolling) but also allows the industry time to add new functionality and subsequent training to ensure safety.
  3. The delay in full Stage Two MU requirements will put significant pressure on Stage Three with Stage Three subsequently pulled. Those requirements outlined in Stage Three will be achieved through other approaches that HHS has at its disposal, e.g., payment reform.
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