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Archive for the ‘Privacy’ Category

One guarantee in the healthcare sector is that when it comes to personal health information (PHI), there is no lack of issues and pundits to discuss security and privacy of such information/data. If one does not jump up and down bleating on about the sanctity of PHI and the need to protect it at all costs, well then you may be labeled a heretic and burned at the proverbial stake.

Now don’t get us wrong. Here at Chilmark Research we firmly believe that your PHI is arguably the most personal information you have and you do have a right to know exactly how it is used. Whether or not you own it remains to be seen for we have seen, read and heard on more than one occasion – some healthcare providers believe that it is their data, not yours, and may only begrudgingly give you access to some circumscribed portion of your PHI that they have stashed in their vast HIT fortress, or worse, scattered in a number of chart folders.

But where we do differ with many on the sanctity of PHI is that the collective use of our de-identified PHI on a community, regional, state or even national level can give us some amazing insights into what is working and what is not in this convoluted thing we call a healthcare system in the US. Using PHI for such purposes needs to be strongly supported. Unfortunately, we do a terrible job as a country in educating the populace on the collective value of their data to understand health trends, treatments and ultimately ascertain accurate comparative effectiveness. This leaves the door wide open for others to use the old FUD (fear uncertainty and doubt) factor to keep patients from actively sharing their de-identified PHI.

One of the more popular and edgy online dating sites, OK Cupid, has done some great things with the data they collect on their users. They take the vast amounts of data they collect and do some pretty fantastic and fun (fun is good, fun is engaging) analysis to understand their users and what makes them tick. For some reason, the healthcare industry just doesn’t do fun things with the data – always so morbid!

Imagine if we could collect similar data on health, or heck, even better, imagine taking some of OK Cupid’s findings on body image and sex drive, (see chart 7 & 8) and using that to educate the public on why it may be in their best interest to keep their weight in check. Sure doesn’t seem like the threat of diabetes, heart failure, etc. is doing the trick to lower obesity rates, maybe hitting them below the belt will work.

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A few years ago my daughter began developing asthma-like symptoms brought on by reactions to pollen, cat dander, and other triggers.  I can still remember the panic I felt in my chest the first time she ran to me wheezing and crying that she couldn’t breathe.  Thankfully, her wheezing episodes are mild, have decreased over time, and she never received the ‘Asthma’ diagnosis.

Serious health events such as a severe asthma attack produce such a strong, albeit negative demand for health care that the patient often winds up in the ER.  In this respect, asthma is unlike other chronic conditions with more deferred consequences (e.g. ‘diabesity’).

Clay Christensen wrote about this phenomenon in his book, “The Innovator’s Prescription”. Despite the significant behavioral change required (carrying inhalers, taking medication, tracking symptoms, following Asthma Action Plans), asthmatics and their caregivers have good reason to be engaged and compliant with treatment – immediate consequences (relief) to severe attack drive behavioral change (see figure).

A Growing Problem [a Growing Market]

In the US, the CDC reports that 1 in 12 people have asthma. There has also been an unexplained increase in rates among African American children – an almost 50% increase in the past decade.

[Note: Why are asthma rates soaring? Possible causes are not fully understood within the scientific community.  The ‘hygiene hypothesis’ blames ultra-clean western societies that suppress the natural development of the immune system. Other research refutes the hygiene hypothesis and points to western lifestyles/obesity as culprits. There have also been more Asthma diagnoses due to improvement in diagnostic methods over the last few decades.  Further reading on possible causes can be found at Scientific American.]

Given that asthma is a severe, chronic disease affecting a large percentage of the population, it is easy to make the case for investment in asthma-related products.  The American Academy of Allergy Asthma and Immunology (AAAAI) estimates 300 million people worldwide are currently affected – almost 5% of the population, with incidence rates on the rise.

Segmenting the US asthma market by age provides a model to understand key engagement models:

  • Asthma Moms are continually engaged in their child’s care.  They oftentimes take information, tips, and questions to the blogosphere.
  •  Adolescents manage their condition with Mom’s guidance, though they are not as vigilant in adhering to treatment plans.
  • Adult Asthmatics no longer have Mom looking over their shoulder, but are nonetheless motivated to keep symptoms at bay.

Devices to Monitor & Prevent Asthma Attacks

When my daughter was having frequent wheezing episodes, I would have found piece of mind in a technology that could detect and predict when she was going to have an attack… or at least warn of nearby environmental triggers.

Taking a quick look at the Apple App Store, there are almost 100 asthma-related Apps available.  These range from free educational Apps to diary-style Apps that require data entry to track peak flow and symptoms. Do Asthma Moms, especially those whose children have low-severity asthma, really have the time and motivation to write asthma diaries? Not to mention adolescents and adult asthmatics?

One company, iSonea, is building technologies to avoid this tedious (and possibly erroneous) data entry.  iSonea is currently making a big bet that consumer and provider appetite for asthma monitoring technologies will grow in the coming years.

iSonea

iSonea is a recently restructured and re-branded company that has been developing proprietary acoustic respiratory monitoring (ARM) devices for years. These devices are equipped with sensors and software that detect acoustic markers such as wheezes, rhonchi and cough.

Note: iSonea was formerly KarmelSonix, a medical device company consisting of a joint partnership between Israel and Australia.

I had the opportunity to speak with the new CEO of iSonea, Michael Thomas, who sees iSonea transitioning from a device-centric company to one that is software-based (guarding the castle with already-acquired IP).  In a future filled with Smartphones,   iSonea will try to reach those 300 million asthma patients through mobile Apps rather than through proprietary, expensive devices.

Imaging breathing into your Smartphone, which will analyze and quantify your wheezing in the audio.   Or, imagine your Smartphone setting off an alarm as it detects nearby environmental triggers, crowd-sourced in almost real time by nearby asthmatics.

iSonea is looking at the following revenue streams:

  • App downloads and upgrades. The first version of their AsthmaSense™ App will be released in 2012 with a subscription service.
  • Data. Anonymized patient data will be up for sale (iSonea is partnering with Qualcomm Life to get data out of devices and into the cloud). If a statistically significant number of asthmatics use the iSonea App, this data becomes valuable to a host of buyers.
  • Ads. Products and services could be marketed to the user based on usage patterns.  For example, coupons for therapy drugs could be displayed, etc. (This remains a sensitive area – iSonea needs to find the right amount and types of ads, if any)

Emerging Technologies to Engage Consumers

Another topic I discussed with Mr. Thomas and his VP of Marketing, Michael Cheney,  was the issue of how to make the Smartphone App ‘sticky’, or compelling to use.  All of us mobile-addicted folks know the feeling –  when out of the blue your brain sends you a signal to take your phone out of your pocket and start slinging angry birds.

Will the healthcare space tolerate consumer engagement strategies that have shown success elsewhere?   For example, can we social-ify and game-ify healthcare apps and expect higher user engagement?  I remain hopeful that, treading carefully, healthcare apps that use social media and gamification strategies can indeed achieve higher engagement rates, especially among  digital natives (youths).   App developers are already starting to wade into these waters. One interesting example is the DiaPETic App, where users are rewarded via their pet avatar for sticking to a glucose testing plan, much like the popular children’s online game, webkinz.

Who knows, maybe iSonea’s App will indeed spread virally as users encourage their friends to start “playing along” with them as they manage their symptoms and avoid attacks. Engaging adolescents in this manner would especially be appealing to Asthma Moms, who could do with a little less stress in their lives. But iSonea will need to take their existing mHealth App a bit farther than they have to date to enable such viral attraction among adolescents.

Anyone Else Out There?

There is a surprising dearth of competitors to iSonea, which means that either iSonea is particularly early and/or the space is an especially risky one – with no worn paths to tread.

One company that may morph into a company more like iSonea is Asthmapolis.

Asthmapolis is based out of Madison, Wisconsin and founded by Dr David Van Sickle, formerly of the CDC. They manufacture GPS-enabled devices that attach to inhalers, tracking when and where an asthma puff was needed. Recently, Asthmapolis announced a partnership with Dignity Health (formerly Catholic Healthcare West) where doctors will monitor patients’ inhaler use via a mobile App.

Like iSonea,  Asthmapolis will make asthma data available to patients and clinicians, and sell it to public health agencies and scientists.  Asthmapolis is also developing mobile Apps to receive and display this data, but is not currently (or publicly mentioning) any intent to move beyond GPS-inhalers and towards Smartphone-based asthma monitoring, which is a little surprising in this day and age when just about anyone that is considering a mobile App, typically ahas a smartphone strategy associated with it.

Market Analysis

How will iSonea (and Asthmapolis) defend their strategic positions if the market revs up and new competitors race to the honeypot? Will iSonea’s IP be strong enough? Will they have enough cash to hire good patent infringement lawyers?

Or, maybe this market will really be about the data and network effects.  The service to garner the most momentum early on will become exponentially more valuable until the market tips.  I wonder if Dr Van Sickle’s relationships with the CDC and medical researchers are strong enough so he has first dibs on selling data for population health management.

It will also be interesting to see when and where pharma will step in here (GlaxoSmithKline comes to mind).  Better daily monitoring leads to improved medication compliance, which will help fill pharma coffers.  I’m sure iSonea/Asthmapolis are already entertaining numerous solicitations for partnerships from Big Pharma.

Towards the Utopia of ACOs

The improved monitoring and prediction of asthma attacks definitely has a role to play in a post fee-for-service, ACO/PCMH world.  No doubt these technologies will help shift the patient’s perceived role from passive recipient of care to a more empowered consumer of health, resulting in less ER visits, less readmissions, and ultimately lowered healthcare costs. The social/crowd sourcing component may prove to be especially valuable – with asthma sufferers steering clear of various dangerous locales where several “attacks” occurred. There is, of course the whole privacy debate and clearly, patients should be given an option as to whether or not they wish to have their data shared. More than likely, most will choose to share their anonymized data, but that should be their choice and not that of the vendor of such solutions.

Of course there is no guarantee that consumers will adopt these technologies en masse. Will this be a technology that consumers ‘pull’ rather than it being pushed on them by providers? Will they adopt without a physician’s order or feedback and without FDA approval? One remaining issue is how to monitor children who can’t be trusted to carry a smartphone – either they need to wear some form of (expensive) proprietary device or then again mobile platforms such as the Apple iTouch with a simple data plan may fill this gap.

On a personal level, I would nevertheless like to see asthma monitoring stand out as a poster child for remote monitoring success.  If we can figure out a way to engage Asthma Moms, adolescents (with Social/Gamification strategies), and adult sufferers, then moving on to other chronic conditions on Dr. Christenson’s 2×2 matrix will begin to look more achievable.

Just this morning my daughter told me that she had trouble breathing last night. I look forward to the day when instead of me learning of her symptoms after-the-fact, a phone can wake me up in the middle of the night to warn me to check on her immediately.

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(Note: This is the second of a two-part post.)

Keeping it Local

This is most representative of the status quo and the most realistic path forward for the vast majority of payers who typically operate at the local level. In this scenario, one or more health plans in a regional market partner with other community stakeholders to co-fund and sustain a regional HIE. These stakeholders typically include large corporations with a large local employee base and/or provider organizations. Successful examples of such multi-stakeholder HIEs include the Louisville HIE (Humana, Anthem, Ford, Yum! and Kroger), and the Rochester RHIO, where payers (Aetna, BCBS, MVP) and hospitals share a 2/1 split of all operating expenses on a transaction model.

The benefit to payers in participating and most often funding the majority of such an HIE is three-fold. First, partnering with other organizations in the region contributes to a greater “fabric of trust” between the HIE and physicians within the region leading to greater physician participation. Secondly, by partnering with others, the payer is able to share HIE operating costs with other stakeholders. Third, physicians actively exchanging patient data can prevent some hospital readmissions and decrease duplicative lab and imaging tests, thereby lowering a payer’s total coverage cost in the region.

Conclusion: As HIE’s unfold at the community scale, local and regional stakeholders will share the operating costs and governance. As far as payer support for HIE’s goes, Chilmark predicts continued growth of these types of HIEs, particularly in less urban communities. We also predict that there will be significant growth in enterprise HIEs that are partially funded by payers, ultimately in support of a payer-provider partnership to establish an ACO. (Again, look to the recently announced NaviNet-Lumeris deal wherein three regional payers also played a role. For those payers, it’s all about making the provider transition to ACO/PCMH models as frictionless as possible.)

Real Challenges Remain

Despite a seemingly straightforward path for payers to get involved with HIE’s, there remain a number of challenges. These are two-fold in nature: Regulatory and Marketplace. On the regulatory front, the list of challenges is long and familiar: ICD-10 (while it seems like there will be another delay, much to the chagrin of the AMA this isn’t just going to go away) and HIPAA 5010, health insurance exchanges and other health reform mandates. (On the plus side, health information exchange-related spending counts favorably towards new medical loss ratio (MLR) rules).

However, the marketplace is where the true challenges lie, as there is hardly a guarantee that payers and provider groups will play nice with each other. Nowhere is this more evident than in the Western PA market, where a sort of fisticuffs have been going on between Highmark BCBS and UPMC.  Without going into the sordid details, Highmark (who just bought Pittsburgh’s second largest hospital network, West Penn Allegheny) and UPMC are now building competing HIEs in the same region because of a longstanding spat over contract negotiations. To hospitals who are now faced with participating in two separate HIE’s, this does not make much sense.

For the payers however, it does make sense when cast against the backdrop of rising competition. (Chilmark noted this challenge after attending the AHIP confab last summer.) Insurers are fighting with each other to keep their networks competitive. Providers are fighting with each other to secure preferred referral status, i.e. patient volume. Introducing an HIE in the middle of this environment has wide reaching implications for where patients are sent as well as who accrues and shares the savings. Throw in the variable of different reimbursement rates for commercial, Medicare and Medicare Advantage patients and you can see why partnering up to set up an information network is more than simply writing a check.

2012 and Beyond

So what does this all mean for a huge guest who’s seemingly unwanted at the party? Ultimately, payers’ involvement boils down into a few categories:

  • In the light of the tighter margins imposed by health reform, insurers who can afford it will diversify their business. The national health plans will be looking to acquire their own platform ala Aetna and UHG, with the additional hopes of squeezing cost savings out provider users and building a more favorable MLR. The main considerations in predicting this shift include vendor consolidation and the readiness of existing provider networks to collaborate.
  • Regional Insurers, such as the Blues and other statewide or multistate networks, have the wherewithal to setup and license their own platform for exchange either through payer-payer partnerships or on their own. The recent NaviNet deal seems to be more of an ACO play, but indicative of the business strategy of this class of payers who are willing and able to be flexible in how they approach their role as stakeholder in information networks.
  • Local Insurers who have fewer resources and who operate directly in the tides of market competition will opt for a ‘safer,’ multi-stakeholder approach in their communities. Partnerships will be heavily influenced by network dynamics, reimbursement channels and existing arrangements, such as burgeoning accountable care communities.

So, as rosy as information exchange seems on paper, it is permanently changing the way that provider and payer groups do business. From where Chilmark stands as an observer of the market’s evolution, it is all too clear that payers and providers ultimately have little choice but to work together. Payment reform and millions in IT incentives have already begun to influence the way that the delivery and payment markets work; the future of accountable care, proactive population health management and ‘smart’ health care delivery all depend on willing and trusting partnerships.

Unfortunately, as is too often the case, patients and other stakeholders get left out of the decision calculus. Pittsburgh residents will hardly benefit from the competitive business posturing there. We hope the folks deploying HIE’s over the coming years will put as much of an emphasis on leadership and governance as they do on technology and of course, the health of their business.

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Chilmark Research tends to shy away from the thorny, nearly intractable issues of privacy and security of Personal Health Information (PHI) (we’ll leave that to the lawyers and policy wonks to figure out). However one thing is very clear: As we continue to conduct more and more of our daily activities, both business and personal, via some form of digital device all those little messages, those bits and bytes of data we create are being collected by someone, somewhere to create a more accurate profile of us. In my own case, how else would my favorite site for weather (weatherunderground) know I’m an outdoor enthusiast and have a banner ad for backcountry?

Despite our reluctance to tread into this domain, it is one of extreme importance.  The healthcare industry is undergoing a digital transformation at roughly the same time as consumers increasingly use an ever wider set of digital tools from social media (twitter, facebook, etc.) to text messaging services (txt4baby) to various health & wellness apps on smartphones and even biometric sensors (Nike+, fitbit, Withings, etc.). We’re not sure where all this will lead but at the very least, the public needs to gain a better understanding of how their digital bits and bytes are being used and maybe begin to think twice as to how and where and with whom they share their PHI.

Today, we found one such educational tool, an animated video by Michael Rigley which is quite powerful using MMS as an example.

If this is what the telecoms can now do with a simple MMS, just imagine what they might do with some of that rich health-info you may be communicating.

As an aside, Dr. Searls is doing some interesting work at Harvard Law’s Berkman Center on the concept of VRM, (Vendor Relationship Management). Much of the principles he outlines could easily be transposed to the healthcare sector and the management of one’s PHI.

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Since its start in 2007, Chilmark Research has kept a fairly low profile as analyst firms go, focusing on a few discrete domains of healthcare IT (HIT). First there was patient and consumer engagement that led to the publication of our first report on Personal Health Records (PHRs). That first research effort led to a significant amount of consulting work and subsequently no reports published for broader market consumption until 2010. That year Chilmark research expanded into the mHealth domain, with the assistance of analyst Cora Sharma, and published the report: mHealth in the Enterprise.

In early 2011, Chilmark published what is arguably its most important, or certainly most popular body of research, a report on the Health Information Exchange (HIE) market. It was this report that clearly cemented Chilmark Research as a well-respected analyst firm providing unbiased, objective, and in-depth research on the domains it covers.

But there was a problem. By and large the vast majority of this work was done by one individual, myself, the founder of Chilmark Research. Over the course of 2011, particularly during the fall when a significant number of consulting assignments came in the door, I quickly came to the realization that I needed help. I was reaching burnout and the model needed to change.

What’s New:
In 2012, Chilmark Research is launching a subscription service called the Chilmark Advisory Service (CAS). This service will provide subscribers one of our annual market research reports (an updated HIE report is forthcoming, others in the works), a number of other content deliverables and direct access to Chilmark Research analysts for specific inquiries. More will be forthcoming regarding this service but encourage you to contact us directly (info @ chilmarkresearch dot com) if you wish to learn more immediately or schedule a meeting at HIMSS to discuss this service further.

Our research agenda for 2012 will look quite similar to our past work for we strongly believe these are the most important topics in healthcare IT today:

Patient & Consumer Engagement
Why it’s important: As the industry migrates to reimbursement models based on outcomes and providers take on more risk, it will become increasingly important to truly engage the patient and their loved ones as part of the care team. Also, in highly competitive markets, providers will be seeking new approaches to not only engage consumers, but build loyalty.

What we’ll be covering: Patient/consumer engagement and outreach strategies of both providers and payers including patient portals (Stage 2 meaningful use requirements are key market driver), telehealth, privacy & security (including consent management) and new models of care & outreach to not only improve consumer/patient satisfaction but improve outcomes.

mHealth
Why it’s important: No doubt about it, the growing ubiquity of smartphones and how they have become such an integral part of our lives (we store family pictures there, we record our expense reports on them, we answer emails, etc.) and an ever growing number of consumers are doing mobile searches to answer health-related questions. Couple this with near saturation of physician adoption of smartphones and the growing use of touchscreen tablets by providers, it is not too hard to imagine a future where mHealth becomes the touch-stone for provider-patient engagement.

What we’ll be covering: Primarily address consumer-centric and clinician-centric mHealth Apps, how the market is developing, what is being adopted and used and why, and lastly, what is the trajectory for this rapidly evolving, ever changing market.  Currently, we are in the midst of producing a report (ready by HIMSS’12) that takes a close look at mHealth Apps for provider-patient engagement.

Health Information Exchange
Why it’s important: The HIEs being put in place today are the fundamental infrastructure, “the pipes,” that will enable one, be it clinician or consumer, to create a true longitudinal, patient record which will lead to safer, more effective care (at least basic logic points to such). These pipes will also allow researchers, public health officials and others to perform advanced analytics on this clinical data that can lead to better, more effective and responsive care. Lastly, as we move to new outcomes-based reimbursement models, HIEs will become an absolute necessity for virtually all medium to large size healthcare organizations.

What we’ll be covering: As mentioned above, last year’s HIE Market Report put Chilmark Research firmly on the map as a firm providing unmatched coverage of this market. We have every intention of keeping that title. First off, we will be releasing an update of the HIE Market Report (target HIMSS’12 release date) with in-depth profiles of some 25 vendors. Second, we are launching a major research project in early February on end users’ experiences and future strategies for their HIE deployments. We have much more planned for this market, but that is a very good start!

How We’ll Do It:
As mentioned previously, I had some help, but not enough and certainly not enough to launch a major expansion of Chilmark Research. To address this issue I went out and found some incredibly bright young people (always believed in the adage, surround yourself with people smarter than you) to join Chilmark Research. They are:

The returning Cora Sharma who’s research use to be the mHealth domain but has now moved to Patient & Consumer Engagement Strategies & Tools.

The former Washingtonian who has returned to his New England roots, Naveen Rao. Naveen’s research focus will be HIE & analytics/BI domains.

And last but certainly not least, my son, John Moore III who in addition to leading an mHealth start-up of his own, will be focusing his research efforts at Chilmark on, you guessed it – mHealth.

Brief bios on these three stellar additions to the Chilmark Research team are over in the “About” section of this website.

I do not hire readily (learned my lessons there long ago) and have been very judicious in choosing only those who show significant promise. I have no doubt in my mind that with some mentoring, these three have the chops to become some of the finest analysts in the industry and the credibility that Chilmark has established in the market will continue to grow.

Speaking on behalf of the Chilmark Research team, we look forward to continuing to provide this vitally important industry that impacts us all with the critical research that is needed to help guide it forward in the successful adoption and use of IT to truly improve healthcare delivery. Each of us are very passionate about this issue, it is a mission for us and through our research we intend to make a positive impact.

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I recently had the opportunity to speak with Henry J. Feldman, M.D., instructor of medicine at Harvard Medical School at the Beth Israel Deaconess Medical Center (BIDMC).  Dr. Feldman also serves as Chief Information Architect in addition to practicing as a hospitalist at BIDMC.

Dr. Feldman discussed BIDMC’s platform-agnostic mobile strategy, whereby clinicians access all HIS data through the browser of whatever device they happen to be using.   Talking to Dr. Feldman was a far cry from talking with certain app-crazed technologists, who recoil at the thought of using the browser to deliver information into a busy doctor’s workflow.   At BIDMC there are no cool mobile apps, just web forms (Ajax is not welcome either).

This is not a story of antiquated technology.  I would consider BIDMC to be a lead user in the field of HIT and wireless health as they develop the majority of their systems in-house, have very large IT and informatics departments, and house the likes of globally recognized HIT leaders like John Halamka. (Full disclosure: I have been a fan of BIDMC since CEO Paul Levy co-taught my class ‘Economics of Health Care‘ at MIT.)

According to Dr. Feldman, BIDMC’s platform-agnostic architecture is working wonderfully well for them, and BIDMC has no need to jump on the app bandwagon.

Why Not the BrowserOne argument I have heard for shunning browser architecture is that the web-based user experience for a lot of clinical software is paltry – that the true potential of native UI is not realized.   Another argument centers around network connectivity, for example: “Wi-Fi doesn’t reach the basement of our hospital”, or “10 days of patient data has to be stored on the device – we can’t take chances with the network”.

Tackling the user experience argument: Most mobile browsers use the Webkit rendering engine, which renders UI widgets with the same look (but not always the same feel) as native widgets.  For a well designed webpage, this means consistency between the platform UI and the browser UI, something that nearly everyone prefers.

Now on to connectivity issues: BIDMC has invested heavily into its network infrastructure, creating a highly available, secure, very fast network. The result is that clinicians have high levels of confidence in accessing data through the browser anywhere at anytime within BIDMC.

It is a different story, however, when a doctor is out of range of the BIDMC network, where she doesn’t have the same talented networking team working for her.  Also, most hospitals don’t have a true medical grade wireless network like BIDMC.   What may help here is the FCC’s recent announcement on the use of white-space (vacant analog TV airwaves), leading to wi-fi on steroids in the not so distance future.

Headaches Avoided
Thinking of some of the headaches avoided by using a browser-based strategy:

  • No client to install and support on the end-device.  Lowered complexity and fewer points of failure.
  • No possible way to store data on the device.  This means no complex mobile device management because of privacy/security risks.
  • No worries about who will win the smartphone and tablet wars.  If a device has a browser it is supported.

Of course, everything is a trade-off and while BIDMC has thrived with a platform-agnostic philosophy, this may not be the best strategy for all hospitals seeking to roll-out mobility to their clinicians.   In Chilmark’s upcoming report, “Enterprise Adoption of mHealth Apps: Trends, Issues and Challenges, we’ll dive into the specific factors that would benefit a hospital to choose one architecture over the other, and highlight the trade-offs involved.

This week I look forward to visiting Kaiser Permanente Garfield Center for HealthCamp 2010, and Health 2.0 in San Francisco with John.  It is going to be a busy week!

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Everyone seems to have an opinion, or at least has written something, about the final Meaningful Use (MU) Rules that were released on July 13th.  Of the multitude of posts and articles out there on the net, there the top three to get you started are:

1) ONC Chief, David Blumenthal’s article in the New England Journal of Medicine that was published on the same day wherein Blumenthal provides a clear abstract of the rules (the actual rules are 864 pgs in length and not a bad read if you have the time) in a easy to read and understand format.

2) Next, head over to the Dell website for a post by their own Dr. Kevin Fickenscher who gives an excellent background on the broader HITECH Act, the origination of the MU rules as well as taking a look at companion rules for Certification of EHRs and the new Privacy & Security rules that were also recently released.

3) Last, but certainly not least is a visit to John Halamka’s site where he provides a freely available, with no need to provide attribution, deck of slides that gives the big picture view of the final MU rules.

With such great resources out on the net, we at Chilmark Research see little need to write an in-depth review of these rules. That being said, we will provide some quick points of analysis.

1) Clearly, HHS listened to the market and the 2,000 comments it received and has relaxed the final MU rules significantly.  If any provider or hospital is still complaining, well they may be the type to complain no matter what.  These rules, while still challenging for some, are certainly doable.  Time to stop talking and get down to work.

2) Thankfully, probably to the chagrin of payers, the requirements to conduct administrative functions (eligibility checking and claims processing) from within the EHR has been removed.  This has always been a fairly silly requirement as today, much of this process is already done electronically through the Patient Management (PM) system. So no need to duplicate it within the EHR, besides which it would have been tough for many an EHR company to build out this functionality in such a relatively short timeframe.

3) The consumer engagement sections of the MU rules also saw some relaxation, but it was reasonable.  What may prove more interesting here is the new requirement within the certification rules for EHRs that they provide health education resources for consumers within the context of their platform.  This may prove to be a real money maker for the likes of health content providers such as A.D.A.M, Healthwise, WebMD, among others.

4) While understandable that there was some pull-back on health information exchange as we saw in the draft MU rules, we were quite surprised that it was completely eliminated in the final rules for Stage 1.  HHS claims that this was done due to the lack of maturity in the HIE market.  Well, yes and no.  There indeed may not be a lot of multi-stakeholder, publicly-led HIEs today that are actively exchanging data, whether regional or state level, but there is a robust market for private HIEs.  It is unfortunate that HHS pulled back on this one for “information sharing for care coordination” was one of the primary precepts of the original HITECH legislation.  Sure, will likely see something within Stage 2, but that does not get clinicians familiar with the concept today.

5) What really caught us by surprise is a reference in the MU rules (pg 39 to be exact) wherein HHS states that they will not discuss the future direction of Stage 3 at all.  Nothing. Nada.  Does this portend a complete pull-back from Stage 3?  Hard to say, but it is clear that HHS wants to see how well Stages 1 & 2 go over in the market before it makes any further demands on providers and the EHR vendors that serve them.

6) Along with the release of MU rules, HHS also released the final rules for EHR certification.  While having not delved into these deeply, yet, the whole concept of “certification” is fraught with challenges, primary among them, technology lock-in.  It is here where Chilmark believes we will see the greatest challenges to indeed create an environment that fosters innovation, providing clinicians with tools they will readily wish to use while at the same time providing some level of certification. Frankly, we do not believe it can be done. Congress really wrapped an albatross around the neck of HHS when they wrote that into the legislation.

What were they thinking?

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