Posts Tagged ‘cloud computing’

The big health IT industry confab HIMSS kicks off one week from today.  With some 28 briefings scheduled over 2.5 days, the Chilmark Research team will be extremely busy to say the least.  It is with that in mind that Chilmark has prepared the top 5 do’s and don’ts that all vendors need to keep in mind when briefing analysts to insure that these briefings are fruitful for both parties. (This post is as much for self-preservation as it is a public service.)

In the lead-up to HIMSS, Chilmark has been absolutely inundated with requests for meetings with vendors of all shapes and sizes.  How do we select who will meet with? Our selection criteria is pretty simple:

1) Is the HIT vendor providing a solution for which we are currently doing research (HIE market) or in the future (provider-based PHRs, mobile health apps, cloud computing in healthcare, clinical decision support, etc.).

2) Have we had fruitful, meaningful discussions with this vendor in the past?

This last point is particularly critical and played a major role in prompting this post (along with a meeting last week with an executive from PR firm Schwartz Communication, who also encouraged such a post).  There were numerous requests to meet with vendors we met with last year.  Those who gave horrific briefings last year were turned down. This post is dedicated to them in the hopes that they will change their analyst briefing strategy.

Top 5 Don’ts

1) Don’t give us a canned pitch. Not only is a canned pitch a waste of our precious time (and yours as well), canned pitches insult us, they insult our intelligence. Please save those for others less knowledgeable of the market.  Along with canned pitches, do not talk through Press Releases, ugh, we can read these on our flight home.

2) Don’t bother with PowerPoint. We only have at best 30min together, let’s not waste that time going through a series of PowerPoint slides – boring.  The other danger here is that analysts are bred to be cynics. When we see PowerPoint, first thing that comes into our heads – Vaporware! That is the last thing you want us thinking – Trust Me.

3) Don’t be obtrusive when we are talking to one of your customers. Let us have an unencumbered conversation with your customer which affords us the opportunity to drill down on the most critical issues/challenges as well as the significance of your solution in their organization.  Really quite annoying when a vendor is frequently interjecting themselves into a conversation. Please fade into background, you can clarify critical points later.

4) Don’t bad mouth your competition. Complete turn-off and also raises a red flag for that ever so cynical analyst leading him/her to think: Hmm, competition must be eating this company alive and they are struggling to remain relevant in the market.

5) Don’t forget to follow-up. Granted, not every briefing will be engaging, but that should not prevent you from following up after the show with analysts.  In that follow-up email, do reference specific conversation points and answering any questions that may have not been fully addressed during the show briefing.  Quite amazing how much this will assist you in your relationship(s) with analysts but also how infrequently it is done.  There were several briefing requests turned down this year due to lack of follow-up on their part after last year’s HIMSS.  Sloppy.

Top 5 Do’s

1) Do tell us about what you are seeing in the market. Sure, we”ll want to hear ever so briefly about your announcements at HIMSS, but more importantly, we want to hear about what YOU are seeing in the market and how your company is responding to market needs and challenges.  This puts your strategy in context for us. No you don’t have to be explicit, on your strategy that is, we can figure that out just fine on our own.  The more open and honest you are here will go a very long way to endearing your self in the analyst’s eyes.

2) Do have a couple of people involved in briefing from different disciplines (e.g., marketing, executive management, R&D). Too often, analyst briefings at events like HIMSS are seen as something similar to briefing the press with a press person and marketing executive present going through the motions.  Boring. Analysts want to understand your company at a far deeper level so leave the press bunny behind and bring in another senior exec from product development, management, etc.

3) Do keep conversation focused to one or two topics that are relevant to analyst and their research agenda. Remember, we only have about 20-25 minutes to work with once formal intros are done and we both want to get as much out of these briefing as humanly possible.  Focus discussion on one to two key points you want to get across as that is about all the time you’ll have.  Any more topics then that just get lost in the white noise of other activities.

4) Do introduce us to a customer or two. Analysts love talking to customers, ideally, not the ones that have been heavily coached by your marketing and sales team.  Do introduce us to a customer or two of yours that may also be attending HIMSS that we can talk to.  This need not take up our precious 30 minutes together, as an analyst can follow-up with customer.  And do take heed to Number 3 in the “Don’ts” above after making such an introduction.

5) Do ask us questions. Ideally, a briefing with an analyst is a conversation where both parties are asking questions of one another.  A good analyst (yes, there are many poor ones) has a unique perspective on the market that is actually a composite view of those conversations with numerous market players.  As I use to tell new analysts shortly after hiring: Think of yourself in the crow’s nest of a ship in the War of 1812.  You are not down on the deck in the heat of the action, you are removed from the intense excitement viewing the entire sea battle from your perch.  It is from that perch that you direct those below where to fire their cannons.  Use this time with the analyst to gain their perspective on the market and where you may need to point your cannons in the future.

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While conducting research for the long overdue and nearly completed report on Personal Health Clouds (Dossia, Google Health and HealthVault) came across a recently published report by the European Network and Information Security Agency (ENISA) addressing cloud computing security.  Though quite long (over 120 pages) the report provides a very comprehensive overview of cloud computing, its benefits, risks and some very good risk assessment tools to assist one in evaluating a cloud solution offering including segmentation by SaaS, IaaS and PaaS.

With the rapid migration to the “cloud computing” paradigm in the healthcare sector, be it personal health clouds, HIE vendors transitioning to PaaS vendors (note: Medicity made their own PaaS announcement yesterday – more to follow in near future), EMR vendors offering hosted solutions, to move to manage and store images in the cloud, and various niche vendors such as Medcommons, who uses Amazon to host its service, a report such as this is quite valuable and instructive both for potential users of cloud services as well as those offering them.

If you have even a remote interest in this subject, trust me, just get the report as it is one of the best I’ve come across to date.

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PaaS Challenges for HIE Vendors

Yesterday’s post took a look at the future for the Health Information Exchange (HIE) market putting forth the projection that successful HIEs will move towards a platform as a service (PaaS) cloud computing model. Market forces (meaningful use) and simple logic are driving this transition.

Since putting up the post, Chilmark has received several emails from HIE vendors; without exception, all state that they are now moving in this direction.

But what yesterday’s post failed to mention were some of the likely challenges HIE vendors will face in making this transition.  The figure below outlines the top three we foresee.

PaaS challenge

What do you foresee as the top three challenges for incumbents? Will new entrants simply leapfrog over incumbents or as in the past, will these new entrants simply burn up a lot of cash/resources and walk away from this market (this seems to have repeated itself in the HIT sector numerous times) with little to show for all their efforts?

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ibm_cloud_copyJust stumbled across this article, during the course of research for upcoming Health Cloud report.  IBM is sponsoring research at a number of universities around the globe all looking at specific Cloud Computing applications in specific industry sectors.

What we found of particular interest in the article is the research in health cloud computing that IBM is sponsoring at the Univ. of Pretoria in South Africa. The ultimate goal of this research is to expand the health cloud across the seven universities that comprise the HEALTH Alliance in East Africa to provide a “Center of Excellence” for medical services in sub-Saharan Africa.

When one thinks of coupling this health cloud with mHealth (mobile health apps), there are all sorts interesting service models that can be created to finally deliver much needed and better care in this corner of the world.

Well done IBM.

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I’m here today at my alma mater, MIT to attend Technology Review’s annual conference, EmTech (short for emerging technologies). And why am I attending an event that appears to have little relevance to healthcare? Well, there is one session this afternoon addressing EMRs and another tomorrow on personalized medicine, but those are periphery to my real reason to attend.

Simply, I am a firm believer that in any industry sector, the Black Swans will almost always come from outside the industry. In healthcare, this will be particularly true as this industry is calcified with countless special interests unwilling to give ground to improve the overall system. Healthcare will see some pretty serious tectonic shifts over the coming years and innovations (black swans) will be a key contributor to those shifts.

I’ll be reporting sporadically from the event throughout the day. Warning – usually I take notes at an event, digest them and publish a summary a couple of days later. Today, I’ll report live the distillation process that usully occurs will not be present today.

10:15am First keynote was giving by V. Khosla, founder of Khosla Ventures. Very interesting and engaging talk on the principles that Khosla uses to assess innovations to invest in. Though the company focuses on “Green Technology”, here are some takeaways for healthcare innovators and investors. (Khosla’a presentation was so much better than Clayton Christensen’s that I heard last April at the WHCC. If you ever get a chance to hear Khosla speak, do it!)

Rules of Investing
Attack manageable, but material problems
Technology that achieves unsubsidized competitiveness
Technology that scales, scales at a competitive cost structure
Manageable start-up cost & short innovation cycles

Forecasts are almost always horribly wrong. Don’t trust them.

Always look at the total relevancy of an innovation. Understanding potential impact of technology requires one to look at what is relevant scale, without this, you do not/will not be able to capture the full opportunity if full relevancy is not considered.

When considering innovation scenarios, consider true total costs. Gave a very good example of photovoltaics and the current policies/push for low cost/low efficiency. The big costs in solar farms are, according o their calculations, infrastructure and construction costs – both of which scales dramatically in costs when pursuing low cost photovoltaics. Makes me wonder what in the healthcare sector has strong support today but total costs of adoption will negate its true long-term value.

11:00 Second morning keynote by Ning founder & CEO Gina Bianchini. Ning is a Web 2.0 type of social networking platform and not a “Walled Garden” which Gina called other social network sites such as Facebook, mySpace & YouTube. Gina demonstrated, through static screenshots, ala PowerPoint, a wide array of current Ning social community sites.

Honestly, not all that impressed with what I saw or her presentation. Static presentation that focused on only the big success stories and not the challenges/market needs that they are really trying to solve – the interesting problems today that Ning may facilitate in getting answers to.

Became quickly bored with her talk and went to the Ning site. Did a search on healthcare to see what kind of communities have been created. Search turned up loads of communities addressing a whole wide range of issues from job postings, to HIT, to consumer drected health and healthcare marketing. There are now over 400 different healthcare communities on Ning. Sounds like a lot doesn’t it.

Dig a little deeper and what I find is that most of these communities are very sparsely populated (e.g., almost all the ones I visited had less than 10 members) and not exactly dynamic (most “discussions” in these communities I visited were several months old). Looks like another emperor has no clothes story to me.

Hot Technology Tip: Most recent highpoint: great little demo by one of the TR35, an incredibly slick application for managing your Outlook email called Xobni (inbox spelled backwards). Technology was developed by an MIT grad while he was in the undergraduate program. Though I run on the Mac (Xobni is lost on me), person sitting next to me whispered he uses Xobni and absolutely loves it.

Panel on Mobile Technology of the Future:

Motorola rep just stated that Google’s Android does not have much of a future. Requires too much computing resources for the low cost mobile phones that make up the majority of the market.

Google responded that yes, Android is targeted at more full-featured phones but due to Moore’s Law, within 18 months, mid and even some low tier phones will be able to run Android. Claims that they have already run Android on phones at the $100 price point.

Adobe rep (Kevin Lynch, CTO) stated that most apps are still developed with the PC in mind, that developers have yet to fully re-think how apps might be used, displayed and leverage within the context of mobile platforms. Went on to say that there are far too many OSs for mobile platforms which makes it difficult for developers to create apps, becomes too expensive. Holy grail – develop once, use on any platform.

Ques: When will be see SDKs for mobile platforms based on Web technology? Web app development environments for mobile apps is still not there yet. Must use native apps today. Google stated that they are quickly moving in that direction and fuly believe in Web app development environments. Adobe also stated that their development of “Air” is targeted at creating a Web-based development environment for mobile apps, but it is still at least a year to two out.

Ques: How big and how fast will this market grow:

  • Google response: Android has had 100M downloads so far. It is moving very fast and changing very quickly.
  • Motorola: Yes, calling is still the primary function and will remain so until some really interesting apps arrive on the market and shift consumer perspectives
  • Adobe: We need break-throughs in battery technology for today, Moore’s Law does not apply to mobile until this problem is solved.

12:30 Lunch talk by Amazon CTO: Spoke of Amazon’s hosting services (Elastic Compute Cloud), how they came into being, how they leverage Amazon’s existing infrastructure, etc. More of a techie sales pitch. Gave some examples of those using the Amazon services. Focused on multi-media companies that are targeting consumers. Not exactly barn burner/difficult, services to provide. Definitely not “mission critical” examples. Will have to talk with him at one of the breaks to see if Amazon hosted services are being used in more challenging applications that may give some perspective as to how it might be used in healthcare.

Big selling point for something like Amazon services is that it is nearly infinitely scalable and can be tapped, as needed at a fairly reasonable cost. Such a service could be of value to PHR vendors (note, most are already using hosted services/data farms for their PHR). More broadly, HIEs and RHIOs als appear to be ideal applications for Amazon’s services. Though Amazon is not a “covered entity” I’d place my bet on them on keeping my health records secure and private than any hospital or IDN in the country today.

Do know one HIT company using Amazon today, MedCommons, who turned to Amazon due to Amazon’s proven ability to handle very rich data, for MedCommons, that means medical imaging. Spoken with one of the founders of MedCommons who has been quite impressed/happy with Amazon’s services.

1:30, Session on Cloud Computing: Nice panel representation that includes senior exec from Salesforce.com, Google exec, the Amazon CTO and one of the founders of VMWare (MIT has always done an excellent job of attracting some very talented, high-level speakers).

Overall theme – Internet as the platform, the operating system with applications sitting on top, this is what cloud computing is all about. Thus, not too surprising that there is a land-rush on right now by just about everyone in the computing industry (and even those you would not associate with hi-tech e.g., Amazon).

Comment by Salesforce.com – Right now the current regulatory structure and policies, on an international level are far-beyond where the technology is today. This could create some serious issues, potentially, in the future. Not unlike the current challenges and issues that have been raised regarding industry storage of medical records by non-covered entities.

Pricing for cloud computing services and apps are moving from user-based pricing to usage (pay as you go) pricing. In healthcare sector we’ll see a mixed model with a low subscription price supplemented with usage/transactional fees.

For software developers, start thinking about just the application and not worrying about the OS and underlying technologies so much. For example, it is now pretty easy to put together a service that combines Amazon data services, with Salesforce and Google to create an interesting offering for the market. Not much different than what Google and Microsoft are proposing with their healthcare plays. Will be interesting to see what someone like RelayHealth develops as they have a fairly high level strategic relationship with HealthVault.

3:15, Session on EHRs (note, I’ll use EMR acronym): Panel includes John Halamka (Beth Israel’s CIO), Karen Bell (HHS), Craig Feied, (Chief Strategy Officer, Microsoft Health Solutions, he developed Azzyxi at MedStar) and Girish Kumar Navani, (President, eClinicalWorks). Karen started off basically setting the stage giving a broad landscape overview of the challenges in healthcare and subsequently HIT, for the audience with the HIT Hierarchy of Needs slide (pyramid, privacy at the base up to public good at the pinnacle).

Decent size audience, easily a third of the total attendees at EmTech (there are currently 3 concurrent sessions).

Halamka followed with the common statement regarding lack of EMR adoption. Claims EMR is still too expensive at $40-60K per practice with a corresponding drop in productivity for first 6 months of 25%. Beth Israel s requiring all affiliated physicians to adopt and use an EMR. They are offering a hosted eClinicalWorks for these affiliated practices at a big discount to encourage adoption. Hopes that better P4P metrics will result in higher payments from CMS and other payers to augment the cost of hosting the EMR. Halamka also talked of consumer’s abilty to move PHR data from BI’s PatientSite to either Google Health or HealthVault. Today, the only thing you can move into either repository is medications and allergies. Not much value there!

Kumar was next. eClinicalWorks is now in over 20k physician offices. Talk in broad terms, not terribly specific. Does believe that “patient-center healthcare” is the next major change in healthcare that will be a forcing function for EMR adoption. Not to surprising to hear from an EMR vendor. He does not like the term of EMR, sees it more as a technology that helps patients get better care and allows a doctor to deliver better, more informed care. Hmm, like this statement – he is absolutely right, EMR is a dead term, we need something new.

They just did a quick survey of audience, Managing Personal Health Information: 14% would trust lab or pharmacy, 32% would trust a company such as Google or Microsoft and 54% would trust only themselves or a doctor.

Craig talked about the development of Azzyxi and how what all he wanted to do was try to provide the most information possible at the point of care, in this case the ER. Believe that errors/failures in medicine are not about Execution, but in Planning. Unfortunately, he claims all the effort now is on Execution (meds, wrong patient, wrong procedure, etc.), rather than upfront Planning. Talked of the “Spectrum of Wellness” as core to MS’s health sector strategy – a rethinking of what healthcare is and how it is delivered, not only when you are sick, but when you are well. Good speaker, a bit heavy on the sales pitch.

Q&A Session: What’s the value to a primary care physician in adopting EMR. Halamka claims that P4P and quality reporting is becoming an ever bigger issue for physicians and that these systems can actually help doctors ultimately earn more and earn it easier (HT can greatly facilitate all sorts of transactional processes). Kumar also followed up stating that it will help physicians better understand what they are doing as well as help doctors prepare more effectively for patient visits. Supported Halamka’s view that quality and P4P will also push adoption going forward. These programs start to really put some cost justification behind EMR adoption. Craig thought that it is up to software vendors to create sufficient value in their solutions that will lead to adoption.

Status oF PHRs: Halamka – we have 40K users of Patientsite and believe in patient control, thus opening up to Google Health and HealthVault. Karen, still informative stages but right now pretty wide open as the apps are simple today and maybe not what consumer will use tomorrow.

Addendum to EMR Session – picked-up through conversations after formal session:

  • According to recent HHS calculations, there is over $700M in incentives, via payers, through various P4P and quality improvement programs that can be used to subsidize EMR adoption by practicing physicians. Clearly, there is money to be had, not sure though that most physicians know how to capitalize on it. EMR vendors need to start educating the market on these opportunties and not leave it up to the physicians to learn about them.
  • Today, Beth Israel is allowing their customer to export their PatientSite PHR data to either Google Health or HealthVault. Problem is, they are only exporting medications (includes immunizations) and allergies. Ask Halamka why they are not exporting the full record and he told me that neither Google nor Microsoft’s offerings can handle anymore than that – the data model is just not there yet. So, all you consumers waiting with baited breadth for a full feature service from either of these companies will be waiting a little longer.
  • eClinicalWorks is seeing no issue with reluctance in adoption of EMR solutions, Kumar told me they have plenty of business and are still on a very rapid growth path. Early problems precipitated by a couple of huge orders (e.g., NYC) are behind them now. Also, despite all the rumors, and the fact that Kumar is originally from India, over 80% of all employees are based right here in the US. Kumar does use resources in India, but on a flex model to address pressing, unexpected customer needs – not an every day occurrence.

As I mentioned earlier, this is the first time that I have just reported directly from the event. Let me know, via comments, if you found this useful or prefer my former approach of distillation then reporting within a couple of days of actual event.

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The latest issue of HIStalk mentioned a recent post by noted Harvard Professor Nick Carr (he wrote the controversial book, Does IT Matter).

The post addresses the rapidly evolving trend towards “Cloud Computing” and raises a number of issues/implications that cloud computing may present.

As all Personal Health System (PHS) platforms (Dossia, Google and HealthVault) are built upon the cloud computing concept, this post by Nick Carr is a must read for anyone trying to understand what cloud computing means to personal health information.

Is that “Stormy Weather” I hear in the background?

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I got religion.

At least religion that part of the savior to today’s, and more importantly, tomorrow’s healthcare crisis lies on the Internet.

With the abysmal adoption of IT to date within the healthcare sector, I am a strong believer that this industry will simply leap-frog the traditional, three-tiered IT architectural model and move directly to an SaaS-type model (ala athenahealth or Salesforce.com) coupled with cloud computing.  Granted, this will not occur over night and most large hospitals and IDNs will be loathed to give up on their server farms and internally developed apps, but there is a very large percentage of care (some estimate it at 80%) which takes place outside these large healthcare facilities, and it is here where adoption of healthcare IT (HIT) is lowest and where we will see the Interent play the biggest role.

We are still very early in the game here and there are numerous issues to contend with from privacy and security to uptime, to control – not insurmountable, but issues that must be addressed nonetheless.  So to get up to speed on how some of these issues may be tackled, I’m of to Harvard University for the next couple of days to get some schooling on the topic.  The Berkman Center for Internet & Society is having a 10th anniversary conference and have put together a very interesting agenda.  Will report back any insights I garner.

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