Posts Tagged ‘EMR’

hvdevicelabelIn an interesting twist, Cleveland Clinic and Microsoft’s HealthVault Grp announced a partnership this morning to address chronic disease management. The interesting twist is that Cleveland Clinic was the showcase beta customer for Google Health, which was announced by Google’s CEO Eric Schmidt earlier this year at HIMSS. Like their counterpart in Boston, Beth Israel Deaconess Medical Center, who was part of the initial Google Health public roll-out in May and who has since also established a link to HealthVault for their PatientSite users, Cleveland Clinic is taking an agnostic approach to the major platform plays with this agreement.

The Cleveland Clinic-HealthVault announcement is distinctive in that it focuses on chronic disease management, via telehealth, through use of HealthVault’s unique Connection Center. With some 50 devices from 9 vendors, the Connection Center allows the consumer to upload device data (e.g., glucose readings, heart rate, blood pressure, weight, peak flow, etc.) directly to their HealthVault account. In the Cleveland Clinic project, which began last week (Nov. 3rd), uploaded biometric data from HealthVault compliant devices will automatically be pushed to Cleveland Clinic’s EMR and subsequently exposed to the physician for patient tracking and follow-up.

Had a call this morning with Microsoft and one this afternoon with Cleveland Clinic who both shared further details on this announcement:

A target of 460 Cleveland Clinic patients will participate representing three distinct disease categories; hypertension, diabetes and heart failure. The roll-out is across the Cleveland Clinic Integrated Delivery Network (IDN) and not just hospital patients. Clearly, they are focusing on the big chronic disease categories that result in huge costs that many believe better telehealth monitoring can mitigate.

  • Hypertension patients, of which there are 400, will measure blood pressure only.
  • Diabetes patients, of which there will be 30, will use five devices to measure glucose, blood pressure, peakflow, pedometer and weight.
  • Heart Failure patients, the remaining 30, will use four devices to measure blood pressure, peakflow, pedometer and weight.

Pilot will initially be for an extremely short 90 days. Cleveland Clinic expects to have all patients active within 4-6 weeks. Not sure what they can accomplish in 90 days, maybe Cleveland is just hedging their bets to see if patients actually comply with the prescribed measurement and upload regime. Assuming that all goes well, one can guarantee that this pilot will be extended for at least a year, if not longer, as that is the only way they will be able to provide some demonstrable results that are publishable (something that Microsoft emphasized) and ultimately may influence future legislation (e.g., CMS funding), health plan reimbursement (P4P), and broader adoption among other Integrated Delivery Networks (IDNs).

Devices are being provided for free to trial participants. The only requirement, beyond the obvious willingness to diligently take their measurements, is that they have a Windows-based (XP SP2) computer and broadband access. Unfortunately, many heart disease patients are among the elderly and it is questionable as to how many have this capability. Still, the point here is to demonstrate, not solve all the problems and it is a good start.

Cleveland Clinic is training patients on the use of the devices(s), and data upload process to HealthVault, that is subsequently pushed to Cleveland Clinic’s EMR. Part of that training includes clearly notifying the patient when a particular reading should prompt a call to their doctor or even 911. Along with providing the device(s) and training, the physician will prescribe to the patient their measurement protocol (e.g., 2x/day, 3x/week, etc.) unique to that individual and the condition they are managing. Patients trust their doctors so receiving the package directly from their physician during an office visit makes a lot of sense and should encourage use and hopefully compliance. It will be interesting to see how compliant patients are to the prescribed compliance regiment as this is often a critical stumbling block. Will incentives be required?

Cleveland Clinic put in the upfront effort to understand how best to incorporate this new data stream into a physician’s workflow to minimize the burden. Specifically, the physician will receive a weekly notice notifying them that their patient(s) biometric data is ready for review. One click later and the physician is in the EMR reviewing their patient’s data for that past week. Prior to this pilot, Cleveland has experimented with other telehealth systems, but none were able to provide this level of integration with the core EMR system (always a stand-alone, silo’d operation) and thus saw little adoption among physicians. This is absolutely critical! Having spoken to many physicians about the success, and most often failure of telehealth initiatives, it nearly always circles back to lack of true integration to existing practices/workflow. Looks like this pilot tackles that issue head-on.

So what is the Business Case?

Wrapped up my conversation with Cleveland Clinic’s CIO, Dr. Martin Harris, (thanks again Martin for your time) by asking him: So what is the business case for this initiative? He outlined two areas where they see a benefit to Cleveland Clinic:

Service Case: In moving to this model of combining telehealth with traditional in-office visits they intend to completely re-design the office visit resulting in a better, more engaged and customer friendly process. This process will lead to higher customer service ratings, customer recruitment and higher customer retention – all important top-line metrics. They also see a service case for the physician as such a “system” will allow the physician to deliver a higher level of proactive care with their patients. Its all about market differentiation, distinguishing themselves in an increasingly crowded market – one that will only get more competitive.

Outcomes Case: One of the objectives of the pilot is to see if Cleveland Clinic can consistently improve the outcomes/health of its chronic care patients that will result in fewer hospital readmissions and/or complications. If all goes as planned, Cleveland Clinic believes that it will be able to use these positive results to request better reimbursement schedules (more income) from health plans. This certainly makes logical sense, but to date, health plans and CMS have been reluctant to support such programs – more of a wait and see approach. Hopefully, Cleveland Clinic will start showing some impressive results in a year or so and get those health plans on-board.

Final Note:

A couple of weeks ago I poked Microsoft about their lack of support for the telehealth consortium, the Continua Alliance. Sean Nolan responded stating a primary reason was Microsoft’s desire to move quickly (consortia always seem to move at a snail’s pace). Looks like that has paid-off as Google Health and Dossia cannot, today, support such capabilities as demonstrated above, though they are on the path having joined the Continua Alliance and Google demonstrated modest capabilities at the recent Connected for Health Symposium.

Looking ahead, we forecast 2009 to be a year of pilots which begin to demonstrate the utility of the platform model (Dossia, Google Health, & HealthVault) in support of telehealth and how telehealth technology and practices are best integrated into existing clinician workflow. Look to 2010 to see actual reimbursement models and P4P programs begin to take shape in support of promotion and adoption of telehealth.

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A Blog I frequently visit is that of John Halamka, the CIO at Boston based Beth Israel Deaconess Hospital.  Halamka is also one of those people that has seemingly unlimited amounts of energy, is on all sorts of committees and arguably, one of the sharper minds out there with a deep understanding of healthcare IT.

Halamka put up a very good post yesterday on what he foresees the ideal Electronic Health Record  (EHR) would look like.   Really a soup to nuts review going from clinical notes to images to labs to data  management and everything in between.  Well worth the read.

The only issue I had with the post was in the definition of EHR.  I go under the assumption that EHR=EMR + PHR.  So, while Halamka talks about a future EHR, looking more closely, he seems to be really talking about a clinician focused EMR system for there is no discussion of consumer input, or folding in of PHR information, (just pushing information out into a PHR).  This is a serious flaw, unless of course he replaces the EHR acronym with EMR in his post.

The future will have a consumer that is far more engaged in managing their health and probably a bit more demanding on the doctor.  The engaged consumer will want a greater say in the EHR, via their PHR.  Not accounting for such in the “Ideal EHR” results in an EHR that is paternal and will ultimately fail.

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Yesterday, Phillips announced that it will acquire Irish-based healthcare software provider TOMCAT Systems, Ltd. for an undisclosed sum. TOMCAT, based in Belfast with about 25 employees, offers a well-regarded cardiovascular information system (CVIS) software package that should fit nicely in the existing Philips cardiovascular portfolio. What I find particularly intriguing though is that TOMCAT is a specialty specific EMR/PM software package and to date, Philips has been reluctant to get into the EMR market. Could this signal a change at Philips? Will other EMR acquisitions by Philips be forthcoming?

tomcat.jpgWhen one looks at the TOMCAT model, it is easy to see why a cardiologist may like it, but why a hospital CIO may roll their eyes.

This is a cardio-specific EMR/PM platform. Such department specific solutions often are difficult to support over time and can become another information silo if they are not full integrated with the host EMR system that a hospital may be using. But today, it is the doctors and surgeons who rule the roost and most often a CIO must accept and adapt to the adoption of disparate solutions such as this. Philips undoubtedly understands this and may be looking to take this approach in doing an end run around large monolithic EMR solutions, such as those from their big competitors, Siemens and GE Medical. Time will tell.
As I looked at the TOMCAT model there was one big piece I found missing: Where is the connection to data coming from implantable devices once a patient is discharged? The first 60 days after discharged are the most critical to monitor. Boston Scientific realized that and developed of is telehealth remote monitoring solution, Latitude. In the fall of last year, GE partnered with Boston Scientific to have Latitude data feed directly into a patient’s record in their EMR solution Centricity. This partnership’s exclusivity is soon to expire. Maybe Philips should start a conversation with Boston Scientific.

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This week, the “Live Free or Die” state of New Hampshire’s House voted down House Bill 1587, a bill that would have strengthened the privacy rights of consumers.

The biggest objections to this bill came from the medical establishment itself claiming that passage of the bill would stall adoption of healthcare IT (HIT) systems. In one of the more bizarre statements Kathleen Bizarro (I’m not making that name up), EVP of the NH Hospital Association stated the bill would “essentially put a halt to the development of electronic medical records.” The medical establishment went on to state that the bill was too onerous, would restrict a physicians ability to provide good care, and that it would exceed existing federal laws (HIPAA).

All of these are pretty empty statements for the following reasons:

  • The bill was designed to simply provide the consumer more control over who gets to see their records. That it not a major burden for providers.  In fact, if a consumer requested an audit trail, the provider/hospital could charge the consumer a fee for providing such a report.
  • Adoption of HIT is not struggling due to privacy/record access issues, nor will it be in the future. HIT is struggling simply because for most physicians, the value proposition is not there.
  • In many states, laws have been passed to strengthen privacy above and beyond HIPAA as HIPAA certainly has its fair share of weaknesses. Unfortunately, most do not know this and hold up HIPAA as the be all to end all for privacy requirements.

Clearly there were other factors at play here as to why these organizations were against the bill. I have not read the bill itself and there may very well be some good reasons to oppose it, but based on the aforementioned arguments that were used, I have the feeling that this was a good bill and that special interests who have a vested interest in keeping firm control of consumers’ health records were at work here.

In a little touch of irony, legislators were granted privacy on this vote as they were able to cast their votes anonymously thereby not showing the public what side of the issue they were on. And it was a close one, defeated 166 to 150. The measure has gone back to committee for revision.

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The World Health Care Congress will have its 5th annual event this coming April 21-23 in Washington DC. Quite an impressive line-up of speakers (Toby Cosgrove will be there) with sessions targeting all healthcare stakeholders, from heath plans to employers to providers and everything in-between. It’s all there.

Heavy on the policy side (after all it is being held in Washington) with sessions targeted at addressing high, executive-level conversations regarding broader business issues practices, this is a excellent event to get a broader understanding of how these executives perceive the changes taking place in their industry and how they are responding to those changes.

For me personally, there are several sessions addressing consumer engagement issues that I’ll be sitting in on such as the one on Critical Health IT – Implementing PHRs and EMRs for Improved Transparency, which will be interesting for the simple fact of hearing the two sole presenters, each from Insurance companies (curious that a provider was left out of this session). Or this one: Impact of Disintermediaries and Building a New Value Proposition with both Microsoft’s Neupert and the CEO of The Regence Group presenting.

While this event may not have all the digerati that Health2.0 had this week or the deep dive into all things healthcare IT of HIMSS, it will provide good networking and perspective from the top.

If you are interested in attending, contact us: info@chilmarkresearch.com and we’ll bounce back an email with a special Chilmark Research discount.

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Late yesterday, the Cleveland Clinic announced that they have partnered with Google to do a pilot (beta) of the Google PHR. Cleveland Clinic intends to allow, by invitation, about 1-10% of its existing 100,000+ users of the Epic-based patient portal (a tethered PHR) called MyChart to participate in this trial.

Stated purpose is to test the ability to securely exchange medical records between the two platforms, one clinically-based (the Epic EMR system that Cleveland Clinc uses) and the new Google Health platform, which is consumer/patient focused.

Not all that surprising that Google is partnering with Cleveland and vis versa as the Cleveland Clinic’s CEO sits on the big Health Advisory Committee that Google formed last summer.


Google is taking a very slow and methodical approach to rolling out there PHR. This in stark contrast to Microsoft’s own HealthVault announcement back in early October, a premature announcement as HealthVault was clearly not yet ready for prime-time, or at least not the consumer. We can expect more of the same from Google, a cautious roll-out of the platform.  Look to their Advisory Board for where Google may turn next.

With HIMSS just around the corner and Google’s  CEO giving a keynote, expect more announcements in the coming week(s).

How Google is working with Cleveland Clinic, pulling patient clinical data out of a tethered PHR and populating a patient-controlled PHR, ala Google’s platform, points the way towards a future possibility for the dream of a National Health Information Network (NHIN). To date, NHIN initiatives are dominated by state and federal funding grants to create quasi-public Regional Health Information Organizations RHIOs), which by and large have failed to gain traction. Instead of a NHIN that is based on RHIOs and reliant on government support, we may very well see a NHIN that is built upon the large patient/consumer-centric Personal Health Systems (PHS), that are now entering the market from Microsoft, Google and Dossia.

If you thought the end of 2006 and all of 2007 were pretty exciting times for this market, just stay-tuned as 2008 will see a continued ramp-up in the excito-meter. Question, however, remains, once the dust settles and the last PR is written, will consumers actually use these platforms and thereby give these platforms a reason for being?

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Received an email this weekend from the organizers of the big healthcare IT conference, HIMSS, which will be held next week in Orlando. This is the BIG EVENT, where virtually all present and future players in the HIT market come to pontificate on HIT’s future (e.g., both Google’s and Revolution Health’s CEOs will be giving keynote presentations).

Now getting back to that email, which provided me a link to a “HIMSS Yellow Pages” online directory of exhibitors. Naturally clicked through to take a look at the directory and found a listing for PHR providers. Great, this will make my planning easier I thought and went to take a look at who will be exhibiting. Imagine my disappointment in finding just three companies listed (CareData, ICW and Greenway) none of which are significant players. Actually did a quick check on them, here’s what I found:

  • CareData is a small EMR supplier with a PHR called GlobalPatientRecord. Went to the PHR section and virtually all of the links associated with the tabs across the top (e.g., Company, Features, Testimonials, FAQ, etc.) are broken. Pretty clear that PHR is not a focal point for this company.
  • ICW is a PHR pure play with their solution Life Sensor. Life Sensor has seen some success in Germany, but after several years of trying to break into the North American market, they still have nothing to show for it. Give them an A for persistence but an F for execution.
  • Greenway Medical is another small EMR company who is pitching a PHR solution. This solution. however, is nothing more than a tethered portal to the Greenway EMR and not a true PHR.

Note, that Microsoft’s HealthVault was also listed, but as I have explained before, HealthVault is a Personal Health System, (PHS) and NOT a PHR.

So What’s Going On Here?

In my research on the PHR market, I have heard more than a few grumblings from PHR vendors that HIMSS is just giving lip-service to this sector, which seems quite evident based on what one sees here for this conference as well as what one may find on the HIMSS website (very little and dated) on PHRs. These PHR vendors have also reported that the HIMSS PHR task force has really gone nowhere, receiving little substantive support from HIMSS.

All of this is not that surprising seeing that HIMSS receives the vast majority of funding from those much larger hospital information system (HIS) providers such as Cerner, Eclipsys, Epic, GE Healthcare and Siemens to name a few. These HIS vendors have been anything but cooperative with PHR companies who are looking to develop APIs to these systems to facilitate interoperability and automate the updating of a consumer’s PHR. The HIS vendors have their own plans and would much rather have their customers (hospitals and larger physician practices) buy the patient portal solutions they are offering.  Could this lead to a jaundiced eye cast upon PHR vendors by HIMSS?

This leaves the independent PHR vendors out in the cold at an event such as HIMSS. But, this may change in time should the PHR market really begin to gain some traction. Question is though, where does one go to see that traction occurring? What even(s) will have a critical mass of PHR vendors where one can really begin to size up this market and its future? Unfortunately, no such event exists today that I am aware of.

In time, maybe (and that’s a big maybe), HIMSS will be the event. Then again, a number of PHR vendors will be at the big payers event, AHIP in June.

What is becoming clear is that today, the PHR market is splitting into three distinct markets, providers, payers and employers.  Therefore, if one is looking for such solutions, you’ll be looking at tethered EMR/PHR solutions from HIS vendors at HIMSS, payer-centric solutions that focus on disease management at AHIP and health & wellness with incentive management capabilities for those employer-centric PHR solutions.  Right now, most PHR vendors are using word-of-mouth for this last target opportunity.

Final Notes & FYI: 

What I can’t quite figure out is why, if HIMSS is giving so little visibility to PHRs, that the likes of CEO’s from Google, Microsoft and Revolution Health feel compelled to present at this event.  One can write-off Microsoft for they are targeting healthcare providers as well with Amalga, but the others?

Looking at the broader HIMSS agenda, one does finds a single session dedicated to PHRs titled PHR: An Industry Update from Various Perspectives to be held on Tuesday, Feb, 26th @ 1pm, room 203A for those interested.  I’ll be there, so please introduce yourself if you see me in the crowd.

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Amalga = Amalgamation

Earlier this week, Microsoft announced the release of its new product suite for the healthcare sector, Amalga. Almaga includes the Azyxxi solution, which they acquired from Medstory, and the Global 2000, hospital information management (HIS) solution being used at the medical tourism destination, Bumrungrad International Hospital.

A relatively minor announcement in the grand scheme of things, but a couple of points in the announcement are worth noting.

Once again, Microsoft made it clear that the Global 2000 HIS solution, (now called Amalga HIS) will not be sold in the US. Obviously, Microsoft doesn’t want to alienate existing HIT partners in the US, though not sure why Microsoft would be all that concerned as it is unlikely that other HIT vendors will run from Microsoft and into the arms of Red Hat/Linux or some other system.

I say this from experience.

Many moons ago, I made a prediction that ERP vendors would abandon their relationship with Microsoft when they acquired Great Plains and then Navision. I was not alone in this prediction. Sure, Microsoft’s ERP partners were all nervous and distanced themselves from Microsoft for a period of time. But within a relatively short period of time, these companies were back talking with MS and putting the MS certified sticker on their website. Why? Quite simple, their customers told them to. No customer was going to change their MS-based infrastructure just because Microsoft got into the market. So, expect Microsoft to initially target overseas markets for Amalga HIS, but in time, they will be selling it in the US if it makes business sense (i.e., their Amalga-Azyxxi customers ask for it).

As for Microsoft making a new category of software, ala Unified Intelligence System (which is the former Azyxxi) – well maybe it is new to the HIT space, but this is very old in other sectors, such as manufacturing where there have been such systems for years. Amalga (Azyxxi) will go GA sometime in the first half of 2008.

And where did they ever find that name Amalga – sounds like something out of a Bugs Bunny cartoon – short for amalgamation, but maybe that gives us some idea of their overall HIT strategy.

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Civic Duty?

If you get bored of walking the aisles of HIMSS and can’t bear to hear another vendor pitch, well you could always wander over to a session where people will gather to discuss and reach consensus on what are arguably the 5 most used acronyms in the industry. You can contribute to the discussion as part of your civic duty as there are some in the federal government that believe lack of clarity on these terms is holding back the adoption of healthcare IT (HIT).

But really, does anyone in the right mind truly believe this is the problem with HIT adoption? There are a myriad of issues that are stunting the adoption of HIT that range from poor software to poor implementation of good software, to lack of training and the list goes on and on. Consensus on the definitions of five acronyms (EHR, EMR, HIE, PHR, RHIO) will solve NOTHING as it pertains to actual adoption of IT in the healthcare sector!

Maybe its just sour grapes on my part for I did not win the contract. One of the Beltway Bandits did and for a princely sum of $500,000. Hey HHS, I would have done it for you for a tenth of that amount and you would have the report by now. Better yet, maybe HHS can get its money back and instead go out and buy a box-car load of Diffusion of Innovations by Everett Rogers, the undisputed Bible of how technology is adopted and diffused. Distribute the book to all HHS employees involve in HIT promotion efforts, study it closely and apply the concepts. Guarantee the results will be more productive than this definition effort which you are currently funding. (Note: Moore basically plagiarized Rogers’ work for his own Crossing the Chasm. Diffusion of Innovations is more academic and far more thorough than Chasing the Chasm).

But I digress.

This is one glaring example and quite possibly the most egregious of what is wrong with government efforts to date to drive adoption of HIT (actually gave it a “Golden Fleece Award” when I first heard about it). I have nothing against the many dedicated federal employees that are really trying to do the right thing, in fact, I have enormous respect for them for they really are taking on a herculean task. I just wish some of them would think more and do less.

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Wal-Mart, over the last few years has been aggressively moving into the healthcare market with one of its first big moves being the selling of some generics for $4/prescription. In an investor call last month, Wal-Mart went further hinting that it wishes to enter the pharmaceutical benefits management (PBM) market. A couple of good posts on the implications of this move can be found here, and here.

And more recently I reported the modest roll-out of the Dossia Personal Health System (PHS) among some 20 Wal-Mart employees.

Now, Wal-Mart has sent another signal to the market. It is common knowledge that Wal-Mart is establishing retail clinics in its stores. Wal-Mart is also forming partnerships with healthcare clinic operators for these in-store, retail clinics. What is new is that in this morning’s Wall Street Journal, in an ever so brief article, Wal-Mart stated that it will mandate that all retail clinics use the same electronic medical records (EMR) system from eClinicalWorks. With Wal-Mart projecting some 2,000 retail clinics by 2014, (currently according te the WSJ there are ~55 in operation) this is certainly a big win for eClinicalWorks. Hopefully, those projected new clinics won’t suffer the same fate as the 23 that recently shut-down within Wal-Mart.

But what will be even more interesting, at least from my vantage point, is to see how eClinicalWorks will inter-operate with the Dossia platform. It is virtually a foregone conclusion that these two systems will have to inter-operate at some level to serve Wal-Mart employees that are using Dossia and the convenience of Wal-Mart’s clinics.

And beyond Wal-Mart employees, might Dossia also become a platform for Wal-Mart retail clinic customers?

That is a tough question to answer for as of today, Dossia is being supported and built by a consortium of like-minded large employers that are looking to serve their employees. Beyond these employees, Dossia has made no commitments to serve the broader public, i.e., Wal-Mart’s clinic customers. This may provide an opportunity for Microsoft’s HealthVault or Google Health to enter. It will be important, therefore, to follow eClinicalWorks own PRs for any signals that may portend what PHR/PHS a Wal-Mart customer may be offered.

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