Posts Tagged ‘adoption’

There have been a lot of discussions on the Net regarding the potential impact of the iPad in the healthcare sector.  At this point, there is very little agreement with some pointing to the ubiquitous nature of the iPhone in healthcare as a foreshadowing of the iPad’s future impact, while others point to the modest uptake of tablet computing platforms as a precursor for minimal impact.

Our 2 cents worth…

We believe the iPad will see the biggest impact in two areas: medical education and patient-clinician communication.

The iPad’s rich user interface, native support for eReading, strong graphics (color) capabilities, ability to use various medical calculators (there are a slew of them already in the AppStore) and numerous other medical apps (most of these are iPhone apps and will need to be updated to take full advantage of the iPad’s larger 9″ screen) provides an incredibly rich ecosystem/learning environment for medical students.  Nothing else comes close – a slam-dunk for Apple.

That rich, graphical user interface, it’s inherent e-reader capabilities and portability also lends itself as possibly the best patient education platform yet created to foster patient-clinician interaction.  At bedside, a clinician has the ability to review with a patient a given treatment, say a surgical procedure, prior to the operation showing rich anatomical details (e.g., a patient’s 64 slice color enhanced 3D CAT scan), potential risks, etc. Heck, one could even show a video clip of the procedure right there on the iPad.  Now that is cool and sure beats the common approach today, some long lecture that oft-times is difficult to follow.

Beyond those two compelling use cases, other uses in healthcare for the iPad include its use by nurses and hospitalists to provide bedside care, tap multiple apps (hopefully multi-tasking will come in OS v4.0 to be announced on April 8th), in an intuitive environment.  As to how the iPad may extend beyond these limited boundaries for support of say charge capture and CPOE remains to be seen but in the immortal words of many an Apple iPhone advertisement:

There is an app for that.

And based on some of our initial conversations with mHealth app developers, many are already working on just these types of applications for the iPad, which they hope to bring to market within next several months.

One thing is certain, from at least one data point we received this past weekend, there is strong, initial interest in the medical community as to what the iPad may facilitate.  Speaking to one of the technical folks at the local Apple store this past weekend we learned the following: Of the 1,000 iPads sold on Saturday (this store did sell-out), 700 were sold off the floor and 300 were reserved for business customers.  Of those “business customers” a significant share of those 300 iPads (north of 30%) were sold to local medical institutions.

One of those local healthcare institutions appears to be Beth Israel Deaconess Medical Center (BIDMC) where an ER doc has provided his own iPad review, based on actual use during a shift.  Particularly like his comment about using it for patient education.  Might the iPad truly bridge the information gap between patient and clinician?  One thing is for certain, it will make it much easier for patient and clinician to confer over a given diagnosis, results and creation of a treatment plan with supporting documentation/graphics.

Read into that what you may but one thing is for certain, there is significant interest in the healthcare sector to at least understand how the iPad may be used within the context of care delivery in a hospital.  It remains to be seen as to how end users will actually use these devices and what apps will be developed to serve this market (might Epocrates see stronger uptake for their EMR on the iPad vs. the iPhone?) that take advantage of the larger, 9″ screen, but based on what we have experienced with the iPhone, there are likely more than a few developers right now working on novel applications that clinicians will find valuable. Question is: Will they be valuable enough to augment the extra weight and volume of lugging the iPad versus a smartphone?

Only time will tell.

That being said, based on initial impressions of physicians, such as the one from BIDMC (see above) and our own limited experience in using the iPad this week, the iPad is pretty incredible and could usher in a whole new approach to healthcare IT (interfacing to and interacting with an EMR/EHR system) that may result in physicians adopting and using such technology, willingly.  Could we even go so far as to say that the iPad will be a bigger contributor to HIT adoption and use than the $40B in ARRA funding that the feds will spend over the next several years as part of the HITECH Act?

Again, only time will tell.


Some other perspectives on the iPad in healthcare:

Article in HealthLeaders with some interviews with med professionals buying an iPad at Apple store in SanDiego.

ComputerWorld article looking at various business sector (including healthcare) uses of iPad.

Post by iPhone iMedicalApps on some of the current challenges for those adopting an iPad for medical use (virtually all the problems listed will be resolved within next few months)

Another post, this time at iPhoneCTO looks at the iPad in the med space for workforce mgmt.

Well look at this!  Children’s Hospital here in Boston announced today (4/8/10) that it has received one of the recent HHS innovation grants to “…investigate, evaluate, and prototype approaches to achieving an “iPhone-like” health information technology platform model…”

Another ER doc writes a review of the iPad.

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With the impending comment deadline for Meaningful Use (MU) fast approaching, many organizations, from CHIME to AHA to AAFP and others are asking for some form of relaxation of MU criteria in the final version.  Now it is not to say these concerns are not justified, it just may be that they are misplaced for the vast majority of those who currently do not use an EHR, small physician practices and clinics.  It is within these small practices, which are really just small businesses, that the majority of patient care occurs and where possibly the biggest benefit may be derived in the use of EHRs. It is also here where we may find the highest adoption hurdles, and those adoption hurdles are not so much about MU criteria, but more about productivity losses in adopting an EHR.

This past weekend I spent some time with a nurse who works in a primary care/pediatrics clinic in Vermont.  There facility, part of a network of several clinics, recently adopted and went live with a new EHR system (about 18 months ago). According to the nurse, this EHR, from one of the big names in ambulatory systems, has been a complete disaster for the clinic.  Productivity is way down, countless glitches have occurred, whole system crashed during a recent upgrade and the list goes on.  For 2009, this clinic, which has been in operation for a few decades, had its first ever loss last year, the year they went live with this EHR. The clinic puts the blame squarely on the EHR, which has severely constricted their ability to see patients and as all readers know, clinicians get paid for seeing patients, not trying to use a complex and difficult to use EHR.

It is stories like this that concern me.

This is a clinic trying to do the right thing, trying to use an EHR in a meaningful way (note, did not say meaningful use) and they are struggling. Yes, they do want to deliver the best patient care, but at the end of the day, they, like any business have bills to pay.  They are losing money far in excess of what HITECH Act incentives will provide. This story is, unfortunately, not unique, though few EHR vendors will come clean on the productivity hit to a practice.  Maybe instead of guaranteeing that their application(s) will meet MU criteria, EHR vendors should guarantee that the productivity hit of using their solution will not exceed HITECH incentive payments.  Now that would be an interesting value proposition.

Thanks to Michael Jahn of Jahn & Associates for the MU cartoon.


This post was picked up by The Health Care Blog (THCB) and there is quite a lively discussion occurring in the comments area.

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stimulus_bill_cartoonWith the HITECH Act passed and the Dept. of HHS feverishly working to draft a clear definition of what “meaningful use” and “certified EHR” actually mean for reimbursement purposes, a far bigger question looms: Is the promise of $19B dollars dedicated to reimbursing those hospitals and physicians who adopt and meaningfully use an EHR enough?

Let’s take a quick look at the numbers. (For sake of simplicity, this post will look at physician reimbursement.)

For adopting and meaningfully using a certified EHR a physician may be reimbursed between $44K (Medicare) to $65K (Medicaid).  This will not be a lump sum payment, but is parsed out over 5 years as the physician continues to demonstrate meaningful use of an EHR.  Important points here, the physician pays up-front costs (sunk capital) and is reimbursed over time if he/she can demonstrate meaningful use and the solution adopted is “certified.”

As the latest Wal-Mart, Dell and eClincalWorks partnership shows, vendors looking to sell into this market opportunity are pricing their solutions at or near reimbursement levels, e.g., $25K year one and $4-6.5K for follow-on years in the Wal-Mart offering.

According to athenahealth CEO, Jonathan Bush, their customer, a physician, grosses $400k/yr.

Virtually every report we have seen and physicians we have spoken to who use an EMR/EHR today, readily admit that the upfont pain of implementation, training and becoming adept at using the solution was significant.  The significance is most often felt in an average 30% productivity hit for the first 6 months that is compensated through longer hours or seeing less patients.  The proactice does not return to pre-implementation state of operation till a year after go-live.

Combining the above and keeping calculations simple: (Note: we’ll assume productivity returns to previous state within first year and use a sliding scale for productivity hit in year one of,  first 6 months 30% hit, second 3 months, 20% and and last 3 months 10%)

Year One Cost: ($25K) for EHR purchase + (0.30($400K/2) + .2($400K/4) + .1($400K/4)) = ($115K)

Year One Reimbursement: $25K (more generous Medicaid)

Total Cost to Physician: ($115K) + $25K = ($90K)

After Year One, the physician is already down $90K.  Assuming practice returns to normal operations/productivity in years 2-5 and the physician is successful in getting full reimbursement from Medicaid, at the end of five years, that physician is still down $50K. Depending on how much business the physician derives from Medicaid, it will take many more years of avoiding the “stick,” the sliding decrease of Medicaid payments, before a physician recoups this initial, year one loss.

Bottom-line: Adopting an EHR to tap that $19B dollar Stimulus package does not make economic sense for the average physician.

Solving the Physician Adoption Problem

To drive EHR adoption we will need three things:

1) Low “meaningful use” thresholds to ease the pain that a physician has to go through to demonstrate that indeed they are meaningfully using an EHR.  As a starting pointing, let’s target electronic exchange of labs, meds and vitals (including allergies) for care coordination combined with eRx.  That should address care coordination, quality and eRx outlined in HITECH Act.

2) Very simple certification process for HIT. Do not burden the system with complex certification processes, ala CCHIT.  Don’t get me wrong, CCHIT has done some good things in the past, but to apply CCHIT certification for “certified EHR” will create far too complex and onerous a process for truly new and innovation approaches to provide solutions that assist physicians in meeting meaningful use criteria.

3) Leverage the consumer to create an additional forcing function to drive physician adoption as reimbursement under the HITECH Act is insufficient.  Getting the consumer engaged may prove challenging, but engage we must for at the end of the day, the value in a physician adopting and using an EHR must return to the end consumer/taxpayer as they are the one footing the bill.

Over the next few years we, as a nation will be extremely challenged to drive true healthcare reform, healthcare reform as President Obama stated that is “evidence-based.”  A common refrain in the manufacturing industry is:  “You can not improve what you do not measure.”  Today, our healthcare system has absolutely no systematic way of measuring its performance.  It truly is a travesty.  Healthcare IT can, if effectively deployed and used, can play a critical role in collecting those measurements that we can begin to use to conduct true, evidence-based reform.

We need to articulate to the Joe the Plumbers of this country, what HIT adoption and use means to them.  To date, the healthcare industry and government has done an extremely poor job of helping Joe understand that value.  Without his/her support, no amount of money thrown at this problem will suffice.

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macarthurLate last week, the MacArthur Foundation released the results of a seminal, 3-year ethnographic study that looked closely at how youth are using new media in their everyday lives.  For the report, Living & Learning with New Media, some 800 youth were studied which included over 5,000 hours of observations of online activity.

Researchers were looking to answer two primary questions:

How are new media being integrated into youth practices and agendas? How do these practices change the dynamics of youth-adult negotiations over literacy, learning, and authoritative knowledge?

In our quick scan of the report which you can pick-up at the MacArthur Foundation, one of the most interesting comments the authors made in the Executive Summary (caution PDF) was the following:

Capitalizing on peer-based learning. Youth using new media often learn from their peers, not teachers or adults, and notions of expertise and authority have been turned on their heads. Such learning differs fundamentally from traditional instruction and is often framed negatively by adults as a means of “peer pressure.” Yet adults can still have tremendous influence in setting “learning goals,” particularly on the interest-driven side, where adult hobbyists function as role models and more experienced peers.

Why was this interesting?  Let’s substitute a few words.

Capitalizing on peer-based learning. Youth Consumers using new media often learn from their peers, not teachers doctors or adults other caregivers, and notions of expertise and authority have been turned on their heads. Such learning differs fundamentally from traditional instruction and is often framed negatively by adults doctors as a means of “peer pressure.” ill-informed and inaccurate advice. Yet adults doctors can still have tremendous influence in setting “learning goals,” particularly on the interest-driven side, where adult hobbyists doctors and caregivers function as role models health coaches and more experienced peers.

Thus, in addition to simply learning about how “Digital Natives” (children) are using new media in their lives, some of the results of this research can be extrapolated to the early adopters of consumer-facing HIT solutions.

Though long on text and short on metrics, the report provides some insightful analysis and is worth the read for anyone targeting the digital native market or more broadly, early adopters of Internet-based solutions.  Based on our feelings last week, maybe we should send a few copies of the report to the HIMSS conferenece board.  Then again, have the strong feeling that anything so subtle as that would be completely lost on them.

For another perspective on the report, the NY Times article generated a flurry of comments, most appearing quite negative and from the more elderly, digital naive.

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CCHIT is Looking for $$$

A significant portion of CCHIT’s funding has come from the government, though they have been able to shrink that reliance to roughly 50% or so of operating costs through the fees they charge EMR vendors to “certify” their products.  But federal funds run out in March 2009 and CCHIT may not have a guarantee for future funding, particularly in today’s dismal financial climate.  Also, we at Chilmark Research are not terribly convinced that CCHIT has had all that much impact on HIT adoption to date, which still stands at appaulingly low rates.

So what might CCHIT do?

Well, they are now seeking your input to help them define what other ripe market opportunties there are for them to exploit…

Opps, we meant to say that CCHIT is now seeking communty input on other areas in the HIT sector that are in need of certification that will promote interoperability and HIT adoption.

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The Partners Healthcare pseudo-analyst firm, CITL has just released a monster report on the potential value of PHRs. At 144 pages, it is imposing, but don’t let the page count fool you as the Executive Summary will serve just fine for the majority of readers. Report was sponsored by Google, ICW, Kaiser-Permanente and Microsoft.

Did a summary review of the report and walk away with the following impressions.

What I Liked:

Some interesting financial models on the potential benefits of fairly common transactional activities (e.g., appointment scheduling, Rx refills, eVsits, medication mgmt, etc.) that PHR usage supports. Look for these in the next PowerPoint presentation from a PHR vendor or other like pundit like myself.

Good overview on what a PHR is and potential value to providers and payers.

Excellent literature review & references.

What I had Trouble With:

For the cost/benefit analysis, CITL proposed a scenario of 80% user adoption within 10 years that will generate $19B in annual savings. 80% adoption? $19B is savings? What are they smoking over there? PHR adoption today sits at 3-6% nationwide and with the current state of broader HIT adoption, will remain low until we get some data liquidity – an extremely tough nut to crack. Even if we get good data liquidity as represented in such examples as Kaiser where they have done a fabulous job rolling-out their PHR to customers, adoption is still only at 30% by the end of 2008. Simply put, we are unlikely to ever see 80%, unless of course there is a complete overhaul of the US healthcare system. But, hey, if we scale it back to 40% adoption, will that equate to $9.5B in savings? That is still a very respectable number and 40% is obtainable.

While report appears comprehensive a deeper look reveals a pretty big hole, no analysis on value proposition for employers. The employer market is one of the biggest markets for PHRs and was completely ignored in this report. This omission calls the complete report into question.

Report has an odd perspective that almost always references the “patient” and not the “consumer”. Get a clue folks, it is becoming a consumer-driven market (whether healthcare providers like it or not) and the reference to patients is outdated and frankly, paternal.

Another oddity was the reference to four distinct PHR architectures; provider-tethered, payer-tethered, third party and interoperable PHRs. What tripped me up here was the reference to interoperable PHRs which I initially, and wrongly assumed to mean those PHRs in the market today that use common standards such as CCR & CCD. No, couldn’t have been more wrong – they do not see those PHRs or even the platforms from Google, Microsoft and Dossia as interoperable. Huh? For CITL, interoperable PHRs, for which they lay the biggest beneficiaries of wide-spread adoption upon are in fact RHIOs. So how did they get there (all the big benefit numbers) when time and again we are seeing RHIOs fail left and right and most still are living hand-to-mouth from government grants? And why leave third party PHRs that support standards out of the interoperable category? A serious misstep here.


Good to see some of the major players in the market support a study of this magnitude. Also good to see some serious attention paid to the potential benefits of PHRs. It is just unfortunate that the net result is a report with some fairly large omissions, questionable assumptions and subsequently some grossly inflated benefit projections. Reminds me of the all too common market reports I would read during the dot-com days. Big projections, outstanding growth, huge numbers, everyone on the bandwagon that ultimately went over the cliff of reality.

Yes, there are (or can be) some major benefits from the adoption and use of PHRs but those benefits need to be tempered with a healthcare system that has a multitude of issues to address and frankly a consumer that rarely does anything with regard to their health until they need to.

A broader view needs to be taken, something that Microsoft has already hit upon, and in some respects consumers downloading health & fitness apps off the iPhone AppStore are already doing. It’s about whole health & wellness management, not episodic healthcare management. That is where the long-term growth, adoption and value is, not in the limited payer/provider perspective represented in this report.

Maybe it’s time we get rid of the PHR acronym and indeed take a broader view that supports what the consumer ultimately wants.


Rich Elmore has a more positive vew of the report with a some report figures thrown in which you will find over on his blog.

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8:00am, Keynote Regina Herzlinger, Professor @ Harvard and author of Who Killed Healthcare: Very good, thought provoking and at times funny presentation. If you ever get a chance to hear her present, do it!

Key points made:

  • Need to move to Consumer-Driven Health Plans (CDHP).
  • CDHP’s are crippled until we, as a country are able to provide cost and quality transparency.
  • Sees the role of government as similar to that of the SEC – set the guidelines and a clear regulatory structure and then get out of the way.
  • She’s a big fan of Switzerland’s healthcare program.

8:50am Panel Session: Giving Out Grades, Online Ratings of Physicians: Consumer’s Union, Angie’s List nd HealthGrades up on the stage. Some initial statements by the panelists, nothing really new out of Consumer’s Union or HealthGrades. Angie, of Angie’s List fame, the company recently rolled-out a physician rating service (hmm, wonder how doctors feel about being rated along side the Joe the Plumbers of the US), Angie readily admits that they are very much in beta for developing the physician rating service but already are seeing a tremendous amount of interest among their members.

Moving into Q&A with the panelists, hoping for something insightful.

HealthGrades, when they first started, had a lot of push-back from hospitals. That has completely changed as CMS is now doing hospital ratings and hospitals themselves are doing self-reporting of quality metrics, even publishing such ratings in local papers. Goes on to state that a the physician level, we are still very early in the rating game but foresees that like hospitals, physician ratings will become pervasive.

Based on the discussions, we are much farther along in rating hospitals than rating physicians. Pitched a question at HealthGrades based on personal experience and they did admit that it is still early (they introduced the physician service about 1yr ago). HealthGrades now has ~600K consumer provided physician ratings and are getting nearly 1,000 new ratings/day.

Consumer Union does not rate physicians at this tme and is looking for free consulting device on how they might provide such a service. As mentioned earlier, Angie’s List is in start-up, beta mode. Some of the safeguards that Angie’s provides is that no comments can be made anonymously, that they do have systems in place to insure that someone does not “game the system” and they send an email to a provider when a new rating/comment has been posted.

10:30am Clay Shirky Presenting: Basically an extended version of what Clay presented last week at Health 2.0 conference. Difference here is that he is presented to a much different and smaller crowd (plenty of physicians and academics at this event). Not quite as warm, on the edge of their seats, receptive audience as last week.

Argues that technology spreads socially. Thus one needs to observe social communities and what is being adopted then develop the capabiltiies for information flow that leverage what is popular for a population subset. Clay stated this in response to a question on addressing the digital divide. Simply, populations where use of computers/Internet is not prevalent, the cell phone is pervasive. Thus, we need to rethink ways to delver health information to these mobile systems (e.g., lab results, appt. scheduling, etc.).

3:00pm, Panel Session on the Consumer as Payer: Discussion is all over the map, which may be partially due to the panel make-up (Findlay from Myca Health, CEO at Dovetail, Dr. Gruber from J&J and CEO of Consult-a-Doctor).

Consult-a-Doctor: Pricing, $100/yr/member(consumer) for direct access to a doctor for second opinions. Go to market is primarily through payers and employers. Forecast they will reach 1M covered lives within the year.

J&J representative on the stage is very pragmatic. It’s all about making the consumer’s life easier. Believes all the big talk about changing healthcare is mis-directed. Need to look at the individual and what we can do to help them. Right on!

Question on regulatory environment, does it hinder expansion. Wolf Shalgman from Consult-a-Doctor sees a big problem with the disparate regulatory structure, at the state level. Other panelists did not bother to respond, though I know from talking directly to Dovetail, that it is a significant issue that hinders their growth.

3:50pm Panel Session on Getting Past 3% (basically how do we drive broader adoption of PHR-type services): Carol Diamond from Markle is moderating and we have Bosworth from Keas, Jamie Heywood, co-founder of PatientsLikeMe (PLM) and Craig Froude from WebMD.

Ask Craig what makes employer health platforms work. Craig stated that if you build it, they may or may not come, but if you offer incentives, they will show-up. Need to communicate very clearly to employees why you are doing it, what’s in it for the employee and most importantly, what will the employer do with your data. Transparency s absolutely critical to establish trust. Some mployers do it well, others less so. Employees typically like the reduce co-pays, versus straight cash-card like reimbursements.

Bosworth stating that technology is not the problem with regards to adoption. We have plenty of technology currently available to address privacy, security and interoperability.  Went on to state that Dept of HHS, Kolodner’s statement last week at Health 2.0 comparing the software interoperability issue to VHS vs. Betamax as a poor analogy (actually said it was simply wrong) as software is not a “hardened” product, but quite malleable to the need(s) of the end user/application.

PLM design requirement, all information that a consumer and a physician would need to collaborate wth regards to care must be able to be delivered in 2 web pages.  Another design concpet: assume that te consumers that use PLM are altruistic, that they do wat to contribute to the broader community and make the world a better place.  Jamie believe that in healthcare today, far too many companies ignore this very important factor, too myopically focused.

Craig just announced that beginning in Q1’09 any employee that leaves an employer who has been sponsoring their WebMD PHR will have the ability to port their employer-based PHR data to the direct to consumer WebMD portal, thus supporting full portability of the record, albeit within WebMD properties.  Craig considers this a big move for them.

Now the question is: Will they let me port that data out of WebMD in some come standard (CCD or CCR) to a Google Health or HealthVault.  Don’t hold your breath as yesterday during the panel I moderated, Craig stated that such would not occur until there was a business case and right now, they don’t see one.

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