Archive for the ‘CDA’ Category

All too frequently I get the question:

When will we see the EHR market consolidate?

Not an unreasonable question considering just how many EHRs there are in the market today (north of 300) and all the buzz regarding growth in health IT adoption. There was even a recent post postulating that major EHR consolidation was “on the verge.” Even I have wondered at times why we have not seen any significant consolidation to date as there truly are far more vendors than this market can reasonably support.

But when we talk about EHR consolidation, let’s make sure we are all talking about the same thing. In the acute care market, significant consolidation has already occurred. Those companies that did not participate in consolidating this market (Cerner, Epic & Meditech) seem to have faired well. Those that pursued a roll-up, acquisition strategy (Allscripts, GE, McKesson) have had more mixed results.

It is the ambulatory sector where one finds a multitude of vendors all vying for a piece of the market and it is this market that has not seen any significant consolidation to date and likely will not see such for several years to come for two dominant reasons.

First, you need to be half crazy to do an acquisition. As nearly two-thirds of all acquisitions fail, the odds are stacked against you. Therefore, you need to be darn sure that this acquisition makes sound business sense before pulling the trigger.

Second, the ambulatory EHR market is simply not ripe for consolidation. The reason is simple. To remain viable in the market, EHR vendors must ensure that their products meet Meaningful Use (MU) requirements and meeting those requirements requires hefty investments.

Virtually all EHR vendors invested resources to get over the Stage One hurdle. In fact, the federal largesse of the HITECH Act attracted a number of new EHR entrants to market and likely kept a many EHR vendors afloat who would have otherwise gone under.

Stage Two’s certification hurdle has yet to be released but will assuredly require a continued and potentially significant investment in development resources by EHR vendors to comply. Same holds true for future Stage Three certification requirements.

At this juncture, it would be foolhardy to try and execute an EHR acquisition roll-up strategy. The technology has yet to stabilize, significant development investments are still required and most vendors do not have sufficient market penetration. Better to wait until the dust settles and clearer stratification of the market (who will remain viable, who will not) becomes apparent.

An Example from Manufacturing:
In my many years as an IT analyst I’ve seen few instances where acquisitions have actually worked out well for all parties concerned. When I led the manufacturing enterprise analyst group at a former employer I watched as two separate companies (Infor & SSA) executed roll-up acquisition strategies in the mature Enterprise Resource Planning (ERP) market.

Much like the ambulatory EHR market, these two companies targeted the low-end of the ERP market (small manufacturers). ERP companies acquired had two defining characteristics: stable platforms and reasonable penetration in their target markets.

Infor and SSA executed their strategies skillfully acquiring multiple companies; promising customers never to sunset a product; and meeting their investors’ goals by lowering operating costs (reduce duplicative administrative costs across acquired companies.

Post acquisition, Infor and SSA did not invest heavily in development, simply doing the minimum necessary to meet customers’ core requirements. Ultimately, Infor acquired SSA and Infor remains one of the dominant ERP companies in the market today.

A similar scenario will play-out in the ambulatory EHR market, it just will not be this year or next or even the one after that. Look to a couple of years post-Stage Three, for the long-awaited consolidation that so many have predicted to finally occur.

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This morning we announced the release of our latest report: 2012 HIE Market Report: Analysis and Trends of the Health information Exchange Market. As we found in last year’s report, the HIE Market and the vendors that serve it continues to be a very dynamic.

In little over a year we have seen several vendors exit the market, several others enter and the acquisitions of Carefx by Harris and MobileMD by Siemens. We also saw Microsoft pull completely out of the clinical market by turning over all its HIT assets (except HealthVault) to the new joint venture with GE, Caradigm.

Yet in spite of all this turmoil, the market continues to see spectacular growth in excess of 40% in 2011. The big news with all this growth is that only a small portion of it is coming via the HITECH Act and the various statewide HIE contracts that were awarded. No, the big market that literally all HIE vendors are now targeting is the private, “enterprise” market. Healthcare organizations (HCO) of all sizes are now looking to deploy HIE technology to not only meet Meaningful Use requirements, but respond to the pending changes in reimbursement, moving from a fee for service model to one that is based on outcomes.

To be successful under these new payment models, HCOs must better manage operations and the complete care cycle of a patient across care settings. In a community of heterogeneous EHRs, HCOs are adopting HIE technology at an accelerated rate to unlock the data silos of EHRs across the community to enable higher quality of care.

Arguably, the 2012 HIE Market Report’s most significant finding is…

The healthcare sector is rapidly moving to the post-EHR era. The value of patient data is not in the data silos of EHRs but in the network that an HIE supports.

The report provides the most comprehensive overview of the market and what are the significant trends that are driving this market forward. The report also provides a deep dive review of 22 leading HIE vendors, including product capability assessment and market presence. This information, compiled through in-depth research and countless interviews, provides all HIE stakeholders with the most accurate view of the market today.

It is our sincere hope that the information contained in this report will contribute to furthering the success of HIE deployments in the future as we strongly believe that only through health information exchange (the verb) can we improve the quality of health delivered within a community and ultimately, the nation.

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Admittedly, our predictions for 2011 were modest. Most of those predictions were logical and did not take a whole lot of imagination to envision thus our success rate, 7 “hits”, 2 “toss-ups” and 2 “misses was quite high. And though are biggest accomplishment, predicting Blumenthal’s departure just a few short weeks before he actually announced such intentions is laudable, by and large these predictions just didn’t go far enough. So for 2012, rather than make simplistic predictions such as “analytics will be a high growth area” or “mHealth will create greater security concerns” or even “ACOs will begin to take hold” as none of these are all that thought provoking, we’ll go out on a limb with many of our predictions. Hopefully that limb won’t crack sending us crashing to the ground.

Without further adieu, here are our predictions:

Consumer/Patient Engagement – Not What it Seems
Despite the best efforts of the team at ONC to beat the consumer/patient engagement drum, providers by and large are still struggling with such basic issues of taking live their certified EHRs, making the transition to ICD-10, meeting physician demands to have everything served up on their new iPad and of course mapping out future strategies in anticipation of payment reform. Thus, we foresee consumer engagement remaining a tertiary issue in 2012. Just too many other pressing priorities at the moment. WebMD’s implosion on Jan. 10th may portend that this is not such a bad move – at least in the near term.

Bloom is Off the Rose, EHR Market Plateaus
Going out on a limb, we see 2012 as the year when we start talking of the post EHR-era. Yes, there will be plenty more EHR sales in the year to come but over 2012 we will also see EHR sales growth begin to plateau and level off by end of Q4’12. You heard it here first folks, it is time to collect your EHR winnings and seek new places to invest.

Finally, We’ll See Some Fairly Competent Tablet Apps from Legacy Vendors
Though physicians continue to adopt iPads at a rapid rate, they struggle to effectively use them in the hospitals to which they are affiliated simply because most hospital HIS cannot serve up an application effectively on an iPad. Sure, many have tried using Citrix as a stop-gap measure but this is just isn’t cutting it. In speaking to one CIO of a major IDN recently, he was so frustrated with his core EHR vendor’s slow pace of development that he is about ready to self-fund the development of an App for his physicians. Fear not CIOs and frustrated physicians, we have had the opportunity to see several alpha versions of iPad Apps that major EHR vendors are developing and they actually look pretty good. Look to Q2-Q3 ’12 for general availability release of these touch-screen native (mostly iPad-centric) Apps.

At Gunpoint, Direct Project Gains Traction
In 2011, the message came down from on high, or at least from the feds, that all State HIEs must include the use of Direct in their strategic plan. Pretty clear that this was politically motivated as to date, for the $500M plus we, as taxpayers are spending on these public HIEs, there is very little to show for it and we are now running headlong into an election year and this administration needs to show something, anything, in the way of success as it pertains to health information exchange. Sure Direct facilitates health information exchange (the verb), but so does a fax machine and frankly, Direct is only a modest step beyond faxing. Therefore, Direct will gain traction in these “forced” instances but we do not see it extending its reach into the much larger market of private, enterprise HIEs (does not sufficiently support care coordination, population health and analytics) and thus Direct’s overall impact in the market will be small and fade to nothing in three years time.

First CPT Codes for mHealth Apps Issued
mHealth Apps for care provisioning have not seen any significant adoption beyond pilot studies, studies which typically show some efficacy in their use. The big hang-up is a simple one, the risk to reward ratio for physicians to adopt and use mHealth Apps as part of the care process is too low. What might change that risk-reward ratio though is a CPT code whereby a physician actually gets paid to use, or have a patient use an App as part of the care process. WellDoc is one of the few mHealth App companies that is quite aggressive in moving the ball forward and we would not be too surprised if WellDoc did industry ground-breaking work to secure the first CPT codes for their diabetes management App.

Train has Left the Station as Supreme Court Rules on ACA
Though the Supreme Court will hear arguments for and against the constitutionality of the Affordable Care Act (ACA), it is unlikely that their subsequent ruling will throw out all of ACA (they may prune it). More importantly, the move to value-based reimbursement models is already in full swing, which is something that will not be reversed. Whatever the Supreme Court rules, its impact will be minimal and the numerous changes we are seeing take place today (move to accountable care models, patient centered medical home, etc.) will continue as the train has already left the station.

Changing of the Guard as Dynamic Duo Departs
Last year we predicted the departure of ONC head, Dr. David Blumenthal. This year is an election year and it is expected that there will be a significant changing of the guard across the administration. We predict that the dynamic duo that is Aneesh Chopra, White House CTO and Todd Park, HHS CTO will both be leaving their posts by end of the year.

M&A Continues, but at far more Reasonable Valuations
Okay, yes we have had this prediction for three years running, but we just can’t help ourselves as we see far too many vendors in this market (some 300+ EHR vendors alone!) and some rationalization must enter at some point. We are seeing rationalization on valuations (e.g., no one was willing to pay what Thomson Reuters wanted for their healthcare business unit despite there being a sizable number of bidders) and this will create an opportunity for acceleration in M&A activity in 2012.

Floundering HITECH Initiatives Attract Political Spotlight
Yes, we are seeing some modest success and adoption of EHRs as a result of the HITECH Act but the preponderance of such success is at hospitals that first have had some form of EHR already in place and also have a lot to lose if proposed reimbursement cuts from CMS come to fruition at the end this multi-year march to certified EHR adoption and meaningful use. Yet, under the covers we are still not seeing wide-spread EHR adoption at the ambulatory level, especially among smaller practices, State HIE initiatives struggle to define what they’ll actually be when the grow-up, the Beacon programs have not reached the promise land, and the RECs, well we were never a big fan of these for obvious reasons we outlined previously. As this is an election year, healthcare and anything with the stamp of the Obama administration on it, will become fair game and dragged into the limelight. Get ready for healthcare to become the political piñata of 2012

HIE Vendors Stumble
By the end of 2012, the final awards for State HIEs will conclude and with it the evaporation of the $500M plus honey-pot that attracted so many vendors into this space. What’s next for these vendors? Some will stumble out of the market with little to show for their efforts. Others will work with their public clients to stand-up these public HIEs in order that they provide value to their respective communities, which will not be easy and lead to more stumbling. And of course HIE vendors who have traditionally been focused on public markets will reposition themselves for the private, enterprise market. Some of these vendors are now stumbling in this transition to the enterprise market (requires different sales resources and tactics, technology requirements, etc.). This will result in yet another shakeout in this niche industry sector. (Our forthcoming HIE Market Report will provide further details)

The funny thing about doing these predictions is that as one actually goes through the process of thinking about this market, which is currently going through nearly unprecedented change, one ponders so many other predictions that just end up on the cutting room floor. Some of those include:

Payers continue to struggle with exactly what they’ll offer on the State Health Insurance Exchange.

Pharma companies look to insert themselves directly into physician workflow, via HIT.

Despite rising cost share, consumers still struggle to make intelligent, informed decisions.

Telehealth gets some wind under its wings as big telecoms start aggressive lobbying efforts.

You get the idea, plenty of turmoil, no lack of potential trajectories in technology adoption and use within the healthcare sector and we here at Chilmark Research look forward to continuing to provide thoughtful insight on this ever evolving market in 2012.

So now it’s your turn. Are we on the mark with our predictions? Did we reach too far? Is there a particular prediction that you have which we totally missed? It is you, the community of readers that make this site far richer than we ever could do on our own and we look forward to your feedback.

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Making Sense of the NHIN

The National Health Information Network (NHIN), which was the previous ONC head’s (Kolodner) top priority, or at least seemed that way is a concept that has its advocates and detractors.  To date, we have been more of a detractor as the original NHIN was a very heavy, top down approach by the federal government to establish a national Health Information Exchange (HIE).  Certain federal agencies loved the idea (e.g., Social Security Administration which has an embarrassing 18 month backlog of disability claims), but those in the field (local hospitals, RHIOs, HIEs, etc.) were not such a big fan of the concept.  Heck, we can’t even get RHIOs established, let alone an NHIN.  Adding to NHIN woes was its platform, built by beltway bandits with technology ill-suited to create a flexible, lightweight transport mechanism for the exchange of health information.

Thankfully, a new administration has come on board, new people have joined ONC and the bloated NHIN of recent history is getting a major rework – actually being split with NHIN referring more to the policy constructs that will define information exchange (the DURSA – Data Use and Reciprocal Support Agreement) and NHIN Direct, a much lighter weight technology stack to enable point to point communication.

Unfortunately, Chilmark has not had the time as of late (see previous post) to do a deep dive but while at the recent Governor’s Conference here in Boston, we bumped into Keith who works for GE and has represented GE in many of the discussions/meetings that ONC has held recently on NHIN and NHIN Direct.  Therefore, I asked him if he would be willing to write something on this topic, which follows below.  (Note, in conversations with some State Reps at the Governor’s conference, there is some significant consternation among many regarding the NHIN and NHIN Direct so this is far from a slam dunk for the feds – time will tell as to how this will actually be adopted and used.)

And if this topic of standards evolution, healthcare, information exchange interests you, encourage you to follow Keith’s Blog as he has some good stuff there.

What is the NHIN

John Moore of Chillmark Research asked for this one:

What is the NHIN, NHIN Connect and NHIN Direct, and the differences between them?

NHIN stands for the National Health Information Network.  But NHIN is not really a network, rather, it is a concept describing the infrastructure needed to connect healthcare providers from Maine to California to Alaska to Hawaii to Alabama to …

A better name for NHIN would be the National Health Information Infrastructure, or NHII.  At least that’s what we called it in 2004.  Some of this is covered in a post I did on the history behind ARRA.

The NHIN has been described as the backbone for exchange, much like the Interstate Highway infrastructure.  We really already have the necessary infrastructure needed: that is the Internet.  What NHIN really did was specify the rules of the road for traveling on the healthcare interstate.

In 2006, the newly create Office of the National Coordinator issued an RFP to test (pilot) technologies that would be used to connect heatlhcare providers across the states of this country.  I’m not sure why, but they used the name NHIN for this program, rather that show continuity with the NHII work that had gone on before.  Four organizations were awarded contracts for this NHIN Pilot project.

Subsequently in 2007-2008, a new RFP was issued and awarded by ONC across 11 different healthcare organizations to support NHIN Implementations.  The Federal Health architects across the federal agencies realized that they needed a platform to help agencies and organizations to connect to these NHIN implementations.  This project was an Open Source software project that became NHIN Connect.  NHIN Connect provides the software you need to get on the highway and follow the rules of the road.  It’s been called the onramp to the NHIN.

Finally, we have NHIN Direct.  To get from my home to my doctor’s office, I never go near the highway.  To get from my doctor’s office to one of my specialists,  I still need to travel from the office parking lot, to the interstate.  I drive differently on these back streets and local highways than I do on the Interstate.  The rules are different there.  The same is true for the small practice.  In order to connect to their collegues and to their paitients, they need a different infrastructure.  That infrastructure needs to be sommething that they can purchase from Best Buy, or sign up for over the web, using the stuff they already have, to allow them to connect up to the NHIN.  NHIN Direct is the way that providers can connect to others without having to be aware of the gravel, concrete and steel that they are driving over.  They just want to get into their car and go.

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CBR002836Just about anything you hear coming out of HHS’s ONC office is with regards to digitizing the doctor’s office.  This is somewhat understandable as there is some $36B in ARRA funding just waiting for the rules on “meaningful use” (MU) to come out of CMS sometime in December. Until those rules are released, the EMR market will continue to be in stasis.

Unfortunately, this nearly myopic focus of the physician and their adoption of a “certified EHR” has completely left the consumer/citizen out of the equation. We fear that this could come back to haunt ONC as our back of the envelop calculations show that ARRA funding comes up about $80K short of reimbursing a physician for adoption of an EHR.  Another forcing function is needed to bring these doctors into the 21st century.  Citizens can be that forcing function, but to date, HHS/ONC has completely ignored them.

We will give credit to the HIT Policy Committee MU workgroup and their MU matrix which states that physicians will provide citizens a PHR by 2013.  Question is, what will that PHR be?  Just an electronic file cabinet (nothing but records) bolted to the floor (not portable)?  If that did occur it would be an unmitigated disaster, with extremely low adoption and use.

Stepping into this fray is Rep. Patrick Kennedy of Rhode Island who’s office is now creating a Bill (caution PDF of draft Bill) likely to be introduced int he near future, entitled the Personal Health Information Act, to amend the ARRA/HITECH Act by establishing clearly defined guidelines (at least clearer that what has been defined to date) for “Personal Health Record systems.”  We won’t quibble that Kennedy’s office does not use the term Personal Health Platforms, but take satisfaction in seeing the term “systems.”

This 8pg draft Bill is a quick read, but below is out outline of it with commentary.

The Bill defines a PHR System (PHRS) as one which:

  • Provides a medical history that includes all major diagnosis and procedures with updates.  This is a no-brainer.
  • Provides recent lab results if available in electronic form.  Not sure why they state that this is limited to electronic lab results only.  Don’t most doctor’s offices have scanners? Concern here is that it may become a loophole.  Also, are all lab results to be fed into PHRS?  If yes, this could create some challenges as their is a significantly wide range of views in the medical community as to what labs should be shared with their customers via a PHR.  And if those labs are provided, they are basically useless to your average consumer if they are not provided in context.
  • List medications and prescriptions, both current and historical.  Again, a no brainer on providing the lists, but what about providing the capability to request prescription refills?
  • Online secure communication with provider practices.  Many a provider is not too keen on this if there is no corresponding reimbursement model. CMS, why don’t you take the lead here, the rest of the payers will follow.
  • Automated appointment and care reminders as well as educational and self management tools.  Now appointment reminders, heck even scheduling an appointment online is pretty straight forward and it does facilitate front-office operations, but what do they mean by self management tools?  What about educational tools?  Will a simply link-out to some website suffice or are these tools to be embedded within the PHRS itself.  This could get tricky and expensive.
  • Provide privacy, security and consent tools.  While it does not mention it in the Bill, assume such will be HIPAA compliant.  Not really sure why they do not mention HIPAA in the Bill itself.  Also, consent may prove challenging, especially for parents of teenagers as the laws vary from state to state.
  • Provide CCD & related CDA documents as well as clinical and administrative messages necessary to exchange information between providers.  Please, do we really want to force CCD/CDA onto the PHRS market where CCR is perfectly adequate and by the way, generally viewed by most IT folks as a far superior standard to work with for exchanging information.  Bad move here by Rep. Kennedy and hope this will be modified as this Bill makes its way through the House.
  • Support full portability between providers.  Good to see portability supported, but should this not be portability between systems/other PHPS or PHRS in this case?
  • PHRS delivers the functionality to serve the intake process and thereby minimize use of or eliminate the ubiquitous clipboard.  Great to see this in the Bill and any physician worth his or her salt will support this capability as it again reduces front office workloads.
  • Access to the PHRS is controlled by the patient or an authorized representative of the patient.  WHOA, expect big time push-back on this one from the physician community.  The Bill asks them to support some pretty rich functionality within the PHRS and then goes and states that the physician can be completely shut out of the PHRS a the whim of the patient?  While we do support citizen control of their health records, believe this provision is a political mistake that could completely sink the whole Bill.  This may be a bridge too far for the medical community to cross.

What’s Missing?

While this Bill is a good first step, we did find a couple of areas where the Bill is lacking.

  • First off is the whole concept of Provenance. By this we mean who create a given record entry, who has seen the record, has the record been altered in any way.  Basically, an audit trail for one’s PHI within the PHRS.  Which leads to the next omission:
  • Providing the citizen the ability to annotate the notes to provide feedback to the provider/care team.  Which leads to another omission:
  • Provide journal capabilities within the PHRS that allows the citizen to record their health/health events that occur outside of the practice.
  • Another area we were surprised to not see addressed was the ability to incorporate biometric data into the PHRS.  Biometric data will become increasingly important in the years to come to support care outside the confines of the doctor’s office or hospital.  Ability to import biometric data needs to be a fundamental capability of a PHRS.
  • One other key attribute that is missing from the PHRS is the ability for the citizen to selectively tag and share data elements within their PHRS account.  For example, one may want their primary care physician to know that they had an STD in college, but not necessarily their dermatologist.


This draft Bill shows promise and may finally get ONC to start talking about the value taxpayers will receive from the HITECH Act, rather than what they have done to date, simply messaging to physicians.

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Earlier this year, Dossia established a partnership with the Children’s Hospital Informatics Program (CHIP) at Children’s Hospital Boston to use the Indivo platform that CHIP developed. Indivo has been used in a couple of trial personal health record (PHR) applications, including one at HP for an employee flu immunization program and more recently at MIT for students using MIT’s healthcare facilities. It is also being made available to all patients at Children’s Hospital Boston. With Dossia, the Indivo team will look to expand the capabilities of this open source application to evolve beyond a PHR to becoming a personally-controlled health record infrastructure (PCHRI) system that will be the foundation for a potentially wide range of personal health applications (PHAs). Therefore, like Microsoft’s HealthVault, Dossia will not be a PHR, but a personal health platform (PHP).

At last week’s PCHRI 2007 event, Colin Evans, President of Dossia and Omid Moghadam, Strategy Director, outlined Dossia’s strategy and plans. There will be two posts on this subject. This first one which follows addresses Dossia’s “Utility Model”, architecture and governance. The second will look more broadly at Dossia’s strategy and its implications in the broader personal health market.

Employing a Utility Model
Dossia will structure itself on a utility model, providing foundational, personal health record services for the broader community, which in this case are the employers, and the employees they represent, who will participate in Dossia. As a utility, Dossia will provide a single, common infrastructure for the collection and storage of personal health information. In addition, Dossia will establish a common set of application programming interfaces (APIs) to allow various PHAs to access data for presentation to the consumer. Lastly, Dossia will create a single set of certification standards for PHAs to insure that they conform to policies and protocols regarding data use and distribution,

To become self-sustaining in the future, (currently Dossia is funded by significant sponsor contributions) one can imagine Dossia using a similar revenue model as that of a utility assessing various service fees for such activities as data collection and reconciliation (claims, labs, EMR, prescriptions, etc.), application hosting, and benchmark reporting (e.g., employer comparing their wellness incentives against the success of others within the Dossia community). This revenue model differs significantly from others in that it will not rely on advertising revenue, which is a model used by many including Microsoft and safe to assume it will be Google’s as well. Nor does the model rely on data mining, an approach used by a small fraction of PHAs, or subscription/service fees which is a more common model among PHAs.

An interesting aspect of the Dossia utility model is that the personal health data residing within the repository will not be owned by Dossia, nor will Dossia control how that data is shared – that decision will be left to the rightful data owner, the consumer, which in this case is the employee of one of the employer sponsors. The consumer will decide whom they will share their personal health information with and Dossia further states that the data will be portable, allowing the consumer to take the data with them, should they leave their employer or wish to leave the Dossia platform for any other reason. The specifics as to how this will all work remain unclear (e.g., level of granularity for data sharing or how one would receive their health data to transfer to another platform), but these are Dossia’s intentions.

Extending the personal, consumer ownership of data, the Dossia entity will not sell any of the personal health data contained within it, including de-identified data. They will leave the decision entirely up to the consumer letting them decide as to whether or not they wish to participate in any program/application (e.g., clinical trials, health surveys, medication side effect studies) that would require use of their personal health data residing within the Dossia repository.

Dossia’s Architecture
The architecture envisioned for Dossia (see figure, warning PDF) is a three-tiered model. It begins with a foundational data services layer followed by a data repository on top of which will sit a the final layer which will consist of a collection of open, standards-based APIs. These APIs will allow third party PHAs, which comprise the Dossia ecosystem, to access the data repository for subsequent retrieval and display of consumer-specific data within their application.

What is important to note here is that as a utility, Dossia’s desire is to remain a neutral provider of common services that provides current and future Dossia members the ability to choose from a wide range of PHAs depending on their specific needs. Dossia will not dictate which PHR or for that matter any other PHA to use leaving that choice to the Dossia employer sponsor. What Dossia may dictate, however, is that the PHA be Dossia certified. What that certification will look like has yet to be defined but one can reasonably assume that certification will include strict guidelines on privacy and security of health record data.

In addition to the developing a common set of APIs for PHAs at the upper layer, as a utility Dossia will also establish a single clear gateway for personal health data to be piped into the data repository. This may prove to be just as critical to the broader personal healthcare market as the APIs mentioned previously.

Providing a single data gateway to providers of data (pharmacies, physicians, payers, laboratory services, etc.) will greatly simplify the data collection process, which to date as been the bane of most PHR initiatives. The PHRs that are currently available in the market simply don’t have the scale/consumers to entice a data provider to deliver the data in a standard format that is readably usable by a PHR provider. This prevents automation of data collection and population of a consumer’s PHR leaving the consumer to input such data manually. Dossia instantly brings scale to the market through its representation of some 8.5 million consumers. This number will likely grow, clearly providing the scale that justifies a data provider’s conformance to Dossia’s data gateway standards.

Dossia Governance
Dossia’s leadership team is comprised of senior executives from a number of its founding member employers. Both Colin and Omid are on “loan” from Intel to lead the Dossia initiative and a number of other employees from Cardinal Health, Intel, Pitney Bowes and Wal-Mart play key roles as well.

Working with the Indivo team at CHIP, Dossia.org will define the services and protocols to collect personal health data from a wide range of pertinent sources and the mechanisms by which that data will be stored within the data repository. Although Dossia has yet to make any firm commitments it will likely adopt such emerging standards as the clinical document architecture (CDA) and continuity of care record (CCR) as well as future adoption of PDF Healthcare (currently being balloted by ASTM with expected release in early 2008) as Intel played a significant role in the development of PDF Healthcare.

At the API layer, Dossia intends to create a special interest group (SIG) that will define this, the most critical layer in the Dossia architecture. In a brief call I had yesterday with the Dossia representative who is leading the SIG effort, I was told that this group is still very much in the formative stages, but future representation will include Dossia employer sponsors and PHA representatives. One of the key charters for this group will be to define exactly how data will be securely and seamlessly accessed from the data repository. Dossia did state at PCHRI 2007 that they intend to use “open” APIs, with published specifications.

A utility model for Dossia makes a lot of sense. It establishes Dossia as a neutral aggregator and distributor of personal health information with no secondary agenda, unlike Microsoft and in the future Google. This will make Dossia attractive to both data providers and PHAs that may have a conflict of interest issue with other aggregator/platform providers. This also makes Dossia attractive to future employers for as a utility, it will not dictate which PHA to use, that choice is left to the employer and/or employee based on their specific needs. Finally, as a utility Dossia should be able to create a self-sustaining revenue model based on utility like services for employer participants. Similar to your electric bill being billed out at kilowatt hours, one can envision Dossia billing employers on a similar usage fee, say number of employees accessing the system per year.

There is not too much to say about the architecture. Indivo uses a common architectural model that is not too dissimilar to the one Microsoft has deployed for HealthVault. Its a widely accepted architectural model and it works. But as everyone knows, the devil is always in the details and such models, this early in development are purposely vague.

As for governance, the chief concern I have here is regarding the API layer and the SIG that will be formed to guide its development. Yes, Dossia is still in the early stages of development having only recently chosen Indivo after a falling out with its previous partner Omnimedix, but this is the most critical layer in their architectural stack and the lack of a clear charter and membership combined with the planned limited roll-out of Dossia by year-end and broader roll-out in 2008 gives one pause for concern as this has the potential to stall this roll-out do to a potential lack of functionality at the API layer.

Within the next week or so there will be a follow-on post addressing the implications of Dossia in the broader personal healthcare market including its impact on providers, payers and least we forget, the multitude of PHA providers in the market today.

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