Posts Tagged ‘HHS’

Now that NwHIN has been spun-out into the public-private entity Healtheway one has to wonder exactly what value they can deliver to market that will sustain them as they attempt to ween themselves from the federal spigot. Healtheway has no lack of challenges ahead but they intend to target one area that presents an interesting opportunity. Question is: Are they too early to market?

During a recent webinar, Healtheway’s interim executive director, Mariann Yeager, outlined the origin of Healtheway, the apparent traction Healtheway is gaining in the market and what their plan is going forward.

Healtheway got its start via funding from a variety of federal sources, all of whom who were looking for a solution to address their unique problems. For the Social Security Administration it was the need for a nationwide network to facilitate processing of disability claims. For the VA and lesser extent DoD it was the need to enable military personnel to receive care in the public sector and insure that their records were complete. Health & Human Services led most of the development effort leading to NHIN CONNECT, a less than stellar technology platform built by beltway bandits (who else), that hit the market with a thud.

One of the things the feds did get right though is a clear and comprehensive policy for data use sharing across disparate entities. The DURSA (data use and reciprocal support agreement) remains one of the key differentiators in Healtheway’s portfolio. Healtheway’s intent is to leverage the DURSA as the “unifying trust framework” and build upon that with a common set of technical exchange requirements (standards) to facilitate exchange with eHealth Exchange (this replaces the former NwHIN Exchange). Healtheway has also enlisted CCHIT to perform testing of technology vendors solutions to insure they comply with the technical exchange requirements that will allow for HIE-to-HIE connectivity.

That last sentence is the kicker. Healtheway and its eHealth Exchange is not intended to be an uber-national HIE but a set of policies and technical specs that will allow HIEs, be they public or private, to share information across institutional boundaries. Therefore, Healtheway will not get into the current rat’s nest of looking to on-board the multitude of ambulatory EHRs into an HIE but sit one level above that facilitating exchange across HIEs. This is something that many regional and state HIE programs are looking to facilitate, thus it is not surprising to see that a significant proportion of Healtheway members come from such organizations.

There will be a need for this functionality at some future point in time, but not today and likely not tomorrow either. Three key challenges stand in their way:

1) Getting buy-in from healthcare organizations and technology vendors. While membership has indeed grown, Healtheway is offering membership at a discount (likely a loss) to gain traction and unfortunately they still do not have significant traction as many brand names in healthcare are missing.

2) A tainted history with more than its share of missteps. Slowly coming out from under the wing of federal politics as a pseudo independent organization (Board still has plenty of government influence), Healtheway may begin to act more as an independent organization, more like a business. Unfortunately, due to a likely continual need for government funding that independence will likely be limited.

3) The HIE market, both from a technology, policy and implementation/deployment perspective is still primitive. The broad market is simply nowhere near the point of needing what Healtheway intends to offer for a few years to come, at least as it pertains to the exchange of clinical data. Good idea, too early to market. That being said, tehre will be value on the transaction side, e.g., SSA and disability claims processing.

Hopefully the future will prove us wrong on this one and Healtheway will indeed prosper and contribute to the maturity of the HIE market. But our advice, don’t bet on this horse just yet, give them six months than take a second look.

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Yesterday, I was in Washington DC to attend ONC’s Consumer Health IT Summit. While having high hopes for some breathtaking new developments, ultimately walked away disappointed as this event ultimately devolved into a Blue Button promotional event. Now I have nothing wrong with some promotion, after all my background is heavily steeped in marketing. What I do have a problem with, as an analyst, is major hype around any concept, technology, etc. that is not balanced with some serious, thoughtful critique.

There were times when I thought this event felt more like a channeling of a Health 2.0 event with the clarion call of “Give me my damn data” being chanted. At times like that I had to pinch myself to remember, no, I’m in the grand hall of the Hubert Humphrey Building. Of course the multiple, large portraits of past HHS Secretaries hanging from the walls was also a clear reminder of exactly where I was.

But despite some shortcomings, the event was focused around what may be the government’s (VA & CMS) finest contributions to promoting patient engagement – the Blue Button. The Blue Button was first released in 2010 by the VA to allow veterans to gain access and control of their personal health information (PHI). CMS later released their own version of Blue Button that allowed beneficiaries access to their claims data. The VA thought Blue Button would be a success if they saw 25K Vets use this capability. The VA passed that number long ago and now, two short years later, the doors have literally been blown off that original estimate with some one million patients now using Blue Button to gain access and control of their PHI.

That is a phenomenal rate of adoption especially when one considers what they actually have access to.

A Blue Button download does not give one a well formatted easy to read file of their PHI. No a Blue Button download is nothing more than a simple ASCII text file and when you look at such a file dump, it isn’t pretty. Thankfully, ASCII has been around since we were hunting the great wooly mammoth during the ice ages so just about any piece of software (e.g., legacy EHRs and claims data bases) can easily create an ASCII file and developers can likewise take an ASCII file and repurpose that text into something fairly legible.

One company doing just that is Humetrix who I first met at the HDI Forum in June. They were also present at this event where they gave me a quick demo of their latest version of iBlueButton – a nice piece of mHealth software that takes the ASCII file from a Blue Button download and reformats it into a very easy to read and decipher file that a consumer can share with their care team. There is even an iPad version designed specifically for physicians, which gets to my next point.

Whenever I am in the company of physicians, I often ask them how they are coping with the changes taking place and specifically adoption of HIT. Had one such conversation Sunday while I was doing the charity Jimmy Fund Marathon walk for cancer research. On this walk there are always quite a few oncologists and nurses and seeing as you’re walking for a good many miles, plenty of time to talk.

I asked one oncologist about HIT adoption at Dana Farber and meaningful use to which he quickly replied: “Meaningful use is the bane of our existence right now.” So I asked further: What problem could HIT really solve for him? He had a ready answer: “Rather than a new patient showing up with a mound of paper records that I must laboriously review, I want a digital version of a new patient’s record with labs, pathology, images, meds, etc. all readily laid out so I can make a more rapid assessment to define a treatment plan for that patient.”

Now we could wait until all the HIEs are in place, all DURSAs are signed resulting in frictionless data flows between healthcare institutions. We could wait until every certified EHR for Stage Two is deployed and physicians start using Direct messaging. We could also wait for patients to request under Stage Two that their provider transmit records to another (still not sure how complete those records need to be to meet Stage Two). Or we could enable Blue Button, educate the public and let them take direct control of their PHI and share it with whom they see fit. Plenty of options but if we really want to change healthcare, the last one is the most impactful, the most viable, but unfortunately like the others, it will take some time, though likely less than getting those DURSAs signed.

Getting back to yesterday’s event and my disappointment, following is what I would like to see in the future:

Honest and frank discussion on giving patients access to their records. The American Hospital Association was in vehement opposition to the Stage Two rules on patient access to their records. Let’s put them on stage to explain why, to give that contrarian viewpoint, to provide balance.

Enlist providers to discuss the benefits and challenges of giving patients access to their records. How does patient access to records change the conversation of care? How does it impact the workflow of a practice? What fears may physicians have and how do we address them?

Fewer panels of talking heads and more real world perspectives. The event had a wonderful moment when a Vietnam veteran talk about his healthcare challenges and how Blue Button contributed significantly to his self-management. Let see more of that, e.g. a Medicare patient using Blue Button.

And my biggest disappointment of all had nothing to do with this event – it had to do with Stage Two.

If indeed the feds really believe in the Blue Button the same way they believe in Direct then why the h*ll did they not directly put it into the certification criteria for EHRs. Clearly something went amiss and it is unfortunate.

Thankfully, many vendors have stated they will support Blue Button in a forthcoming release including Allscripts, athenahealth, Cerner, Greenway, and many others. Our last HIE report also found just over 25% of vendors profiled intend to support Blue Button in 2012. There is momentum here already, now we just need to on-board physicians to talk to their patients about the value of having access to and control of their PHI for as we move to more capitated models of care, the engaged patient may indeed be the miracle drug to rescue our healthcare system from financial collapse.

Addendum: Have received feedback regarding Stage Two and patient access to their records so let me clarify. Stage Two does indeed grant a patient the ability to access, view and transmit their records. This is incredibly powerful, especially with the push towards standards and the transmitted file being in a CDA standard format. As Keith Boone so clearly articulates, the content package that is transmitted under Stage Two is a fairly complete, summary document of care received and an individual’s health status. But Stage Two does not support an ability to transmit a full and complete longitudinal record. It is my understanding that the Blue Button, at least the instance at the VA, allows a patient to download their complete record thus why I took the argument down the path I did. 

In time it is my hope that the Blue Button becomes a symbol, as Keith puts it, “a verb,” that all will understand instinctively – click this, get your data and move on. Other services will take that data dump, transpose it the way you want it for the purposes you intend. The technology and standards behind it will simply become irrelevant to the user. It just works. Getting there will be the task of the S&I Framework workgroups. I wish them God’s speed in accomplishing that task for the benefit of all citizens.

Many in both the private and public sectors are working hard on that vision – keep up the good work!

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This week, the well regarded periodical, Health Affairs published its annual issue that focuses on Healthcare IT (HIT). One of the papers published was authored by ONC, with ONC head, Dr. David Blumenthal listed as a co-author. The paper, The Benefits of Health Information Technology: A Review of the Recent Literature Shows Predominantly Positive Results (think they could have made the title any longer?) ultimately took a close look at 154 studies conducted between July 2007 and February 2010 on the impact of HIT on a number of critical factors including quality and efficiency of care delivered and physician satisfaction.

There has been more than a few questions raised over the last couple of years as to the actual contribution HIT provides and whether or not we are on the right track with the substantial investment this country is making via incentives, grants and various programs to encourage the adoption and use of HIT among physicians and hospitals. Adding to those questions is the current fiscal crisis that this country and virtually all States are facing leading one to wonder, is this the best use of the taxpayers’ precious dollars. It appears that ONC’s sponsorship of this exhaustive study, which as the title states found overall positive contributions of HIT adoption, is an attempt to put those arguments to rest. It sure seems that way to this analyst as there was an unprecedented amount of “media push” coming out of ONC to get the story out including granting exclusive interviews for which Chilmark took advantage of yesterday in a ~15 minute interview with Blumenthal.

Prior to the interview, ONC requested the list of questions I would ask of Dr. Blumenthal. Thinking that 15 minutes was precious little time, I developed three questions that were open ended, but also did not tread into waters which I knew were verboten, e.g. what will be in Stage 2 MU…  The three questions and paraphrased responses based on my notes are provided below:

1) Many of the negative findings appear to involve challenges in adopting CPOE and workflow redesign. How will these findings/revelations influence future policy within ONC and more broadly across HHS?
Blumenthal: We always knew there would be challenges in adoption of HIT and for CPOE we significantly lowered the threshold in Stage One MU requirements. I can not speak to future MU requirements but do believe we are on the right track and it is important to remember that the intent of this law is not for everyone to meet MU requirements.
2) If indeed the “human element” is critical to successful HIT adoption, how will HHS seek to improve that metric in the adoption process?
Blumenthal: This is where the Regional Extension Centers (RECs) will play an important role in the future. RECs will be sharing best practices across the country amongst one another to insure that the human element in the adoption of HIT is minimized. Also, over time as more systems are installed, greater adoption occurs and physicians become more comfortable with their use we will see the human element become less of an issue.
3) What did you personally find as the most interesting/insightful finding of this publication review exercise?
Blumenthal: I was pleasantly surprised that the literature review supported positive outcomes as the result of the adoption of HIT across so many dimensions, particularly gains in efficiency.
Going through those questions actually went more quickly than I expected so I tossed in one more:
4) Usability of HIT solutions (EHR) remains an issue and Chuck Friedman of your office presented at HIMSS’11 that ONC, along with NIST were going to dig deeper into this issue. What will be ONC’s role?
Blumenthal: The challenge of usability is very real. I have head from many physicians, ‘I wish the computer worked for me and I didn’t work for the computer.’ Oftentimes, physicians do not do enough due diligence before buying a solution and do not know fully what they are getting until it is fully installed. EHRs are also very complicated products so determining what one might end up with is not always readily apparent in an initial review of a product. We hope to shed some sunshine on true usability. ONC itself will not ultimately be doing the testing, we will look to others (editor’s note: he’s likely certifying bodies such as CCHIT, Drummond, Surescripts, etc.).
In closing, I have a ton of respect for Dr. Blumenthal. The job he was given when he joined HHS two years ago was monumental. He has put in a Herculean effort to bring us to where we are today and I hope, I pray, that his successor will be able to carry the baton forward with such skill.

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Today, the Center for Medicare and Medicaid Services (CMS) launched a new site that is basically an everything you wanted to know about meaningful use, ARRA, the HITECH Act, certified EHRs, etc., but were afraid to ask.  This is a reasonable attempt by CMS to get as much information online, in one location, that addresses most of the nuances of the HITECH Act and its incentive programs for physician and hospital adoption of EHRs.  Unfortunately, like most government websites, or at least those that seem to emanate from HHS, it is a drab site that presents information in a way that your mid-90’s era web designer would be proud of.  (Note: inside sources state the problem rests with a chief web design honcho at HHS who is stuck on that old model much to the displeasure of others – oh well, that’s government.)

Needless to say, the site does provide a wealth of information, though you may have to dig to find what is most important to you.  The site may also become prone to being dated, so be careful and double check other sources for more current info.  For example, the section on certification of EHRs stated that certification rules will be released in “late spring/early summer” – well they are already out, having been released on June 18th.  Hopefully, HHS, CMS and ONC can work more closely going forward to insure that information on this new, and what may become an important site, is truly current.

In launching this site, CMS is trying to get ahead of the curve and likely onslaught of requests for information once the final meaningful use rules are released. While this website states that these rules will be released, again, “in late spring/early summer,” we are now placing our bets that these rules will be released at 4:55pm on July 3rd, unless of course someone in the administration decides to postpone such an announcement until the opportune moment comes along to generate some positive press for what is currently an embattled administration.

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The organization that Chilmark Research has had, at times, a trying relationship with, CCHIT, otherwise known as the Certification Commission for Health Information Technology has appointed a dear friend, Dr. Karen Bell as its new leader.

Dr. Bell, who I first met while doing research on the PHR market, was instrumental in having me present to then Sec. Leavitt on consumer-facing healthcare technology trends – still one of the highlights of my relatively short career as a healthcare industry analyst.  Since that presentation in 2008, my relationship with Dr. Bell has deepened and she has been one of several key mentors who have assisted me in understanding the healthcare IT market.

So, now that Dr. Bell has accepted this position to take over the reigns at CCHIT immediately, what might we expect:

Dr. Bell knows Washington DC and HHS quite well from her many years there.  She is effective in a highly politicized environment and will be able to effectively lead CCHIT through that political minefield.

She also knows the issues and is fairly competent on the technical side of the fence, though certainly not a coder.  Dr. Bell may be one of the better choices for CCHIT as she can advocate for this organization at a time when many still call into question its very existence.  Of course, that existence has been somewhat guaranteed by ARRA legislative language (was this put in by HIMSS/CCHIT lobbying efforts?) that states organizations will receive incentive reimbursement for “meaningful use of certified EHRs“.

Dr. Bell will put up a Chinese Wall between CCHIT and the HIT vendor organization, HIMSS.  She is fully aware of the perceived conflicts of interest between CCHIT and HIMSS and will seek to create some distance between these two organizations.

A strong advocate of consumer control of PHI, interoperability of EHRs, and the need for “open” HIE platforms/apps one can expect Dr. Bell to put extra emphasis on these issues at CCHIT within the context of certification requirements.  This actually works out just fine with HHS as that is just what they are looking to foster with ARRA funding.

But what is less clear about Dr. Bell’s future role at CCHIT is how she will lead this organization forward in bringing together those that truly know HIT (reaching beyond the vendor community), the challenges of adoption (e.g., workflow), the cumbersomeness of many apps (plenty of them already having been blessed in the past by CCHIT), the need to create a certification structure and pricing model that fosters innovation rather than stunts it (CCHIT certification is still too expensive for many young, innovative companies) and finally, insuring that CCHIT does not over-reach (as it was doing under Mark Leavitt’s leadership) and focus where it can make the most meaningful impact.

This is a very tall order for anyone and while I still question even the very existence of CCHIT (have yet to see any demonstrable proof that CCHIT certification has moved the EHR/EMR adoption needle in any statistically meaningful way), I do have faith in Dr. Bell.  If anyone can right this listing ship, it is her at the tiller.

Congratulations Dr. Bell and may you see smooth sailing in the not so distant future.


Anthony Guerra of HealthSystemCIO has a podcast interview with Dr. Bell now up on his website.

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One of the thornier issues regarding the establishment of public Health Information Exchanges (HIEs) is how to manage consumer consent of personal health information (PHI) sharing.  Today, there is no single standard approach across the US.  Some states have an opt-in process, others an opt-out.  Granularity of data shared, use cases for data sharing, etc. also vary widely from state to state.  These are just some of the findings of an extensive report (92 pgs) that was published this week by HHS’s Office of the National Coordinator (ONC), the ones responsible for funding the multitude of state-led HIEs under ARRA as well as the National Health Information Network (NHIN).

The report looks at the consumer consent policies (and challenges to implement) in eight states as well as three countries based on interviews and an extensive amount of secondary research.  While a tad long, there is some good information tucked inside the report if one spends the time to dig it out.  A good place to start is the Appendix that provides an overview of the consumer consent policies in the various states (HIEs) profiled.

Do not be too surprised if findings and conclusions of this report end up directing future policy, particularly as it pertains to the NHIN as it struggles to define an overarching common data use agreement and self governance model for the sharing of PHI.

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The first major distribution of HITECH Act funds occurred a couple of weeks ago when HHS awarded nearly $1 billion for HIT initiatives including $386 million to 40 states and territories to help establish public Health Information Exchanges (HIEs).  This represents the lion’s share of the original $564 million allocated for Statewide HIE development under ARRA.

Sixteen states did not receive funds including some of the largest states (by population) including Texas, Florida, and New Jersey.  Other states not receiving funding in this first round include: Alaska, Connecticut, Idaho, Indiana, Iowa, Louisiana, Maryland, Mississippi, Montana, Nebraska, North Dakota, South Carolina, and South Dakota.  These states will likely receive funding in the next round.  Additionally, there were a couple of awards that were bizarre including minor awards (~$700k) to some U.S. territories including Guam, American Samoa, and the Northern Marianas.  Almost kind of inevitable it seems when the federal government gets involved in handing out large amounts of cash.  Everybody wants to make sure to grab their respective piece of the pie however small it may be.

Funding Requirements (or how to get the $$$):

In its Funding Opportunity Announcement (FOA) last August 2009, the ONC identified 5 “Essential” Domains for HIE funding:

  • Governance
  • Finance
  • Technical Infrastructure
  • Business and Technical Operations
  • Legal/Policy

The ONC expectations were that states will define objectives, set goals, and measure progress within the context of these five domains.  This also includes the submission of a plan, approved by the Department of Human and Health Services, that describes the activities to facilitate and expand the electronic movement and use of HIE according to nationally recognized standards and implementation specifications.

To specifically get the funding, states had to submit an initial application by October 15th to the Department of Human and Health Services.  Additionally, states also have to submit a Strategic and Operational Plan.  The Strategic Plan contains the State’s vision, goals, objectives and strategies for statewide HIE including the plans to support provider adoption.  The Operational Plan contains a detailed explanation, targets, dates for execution of the Strategic Plan.  Basically, states applying for funding fell into 3 general groups:

  • States with no existing Strategic Plan – These states needed to provide a detailed description of activities to develop Strategic and Operational Plans by October 15th.  Subsequently, the state is expected to develop and submit their initial Strategic and Operational Plans within 6 –8 months of receiving their funding.  A limited number of states fell into this group including Arkansas, Illinois, Iowa, New Hamphsire, Nevada, North Dakota, Oklahoma, and South Carolina.
  • States with existing Strategic and/or Operational Plans that are not consistent with ONC criteria – These states submitted existing Plans with a detailed gap analysis compared to ONC’s criteria and a plan for revision by October 15th.  Subsequently, these states were to submit updated Strategic and Operational Plans in alignment with ONC criteria within 3 months of funding.  Almost all of the states fall into this category with about half needing to further align their Strategic/Operational Plans with ONC criteria required prior to the Implementation phase and the other half needing additional planning efforts required prior to the Implementation phase.
  • States with existing Strategic and/or Operational Plans that are consistent with ONC criteria – These states submitted their Plans for approval by ONC, including a description of health IT implementation to date and the plan for continued implementation. Only 4 states (Delaware, Idaho, New Mexico, Utah) submitted Operational Plans by October 15th.

Once the State’s Strategic and Operational Plans are approved, the State is free to begin to use the HIE funds for ‘Implementation purposes.’  From a Technical perspective, this means that the State can use these funds to select a vendor, sign a contract and begin actual development of the HIE infrastructure.

Impact on HIE Vendors

Several states, including Alaska, Maryland, and West Virginia, assumed future funding was in the bag and released RFPs in the later months of 2009.  Now that the awards are official, states across the country (and territories) will work with consultants to finalize their Strategic Plans and begin looking for an HIE vendor. In total, about 20-22 states are expected to issue RFPs for technical infrastructure over the next 6-12 months.

This is creating a giant land grab as vendors vie for position to tap this windfall of State HIE funding.  Some of the RFPs, such as the one from West Virginia in late November, elicited interest from dozens of various Health IT vendors.Officials from the West Virginia Health Information Network stated they received a ‘significant number’  of responses to their RFP although they refused to cite the exact number.

Confusion Abounds

All of this activity is creating a great deal of confusion in the market for those looking for an HIE solution.  HIT vendors of all strips are now claiming to be HIE vendors to tap into this new found source of funding.  One could even argue that IBM’s recent acquisition of Initiate was to some extent prompted by all this activity in the HIE market.  While numerous  HIT vendors  claim they have an HIE solution, only a handful have a solution that meets current and immediate future needs of the statewide HIEs.  Most others have specific HIE functionality elements, but not necessarily the full solution package.  Our forth-coming HIE Market Report (hope to have it on the streets by end of March) will seek to provide clarity by providing a market classification schema.

Vendors are also facing several challenges responding to these RFPs, primary among them, little commonality from one state to the next.  The most obvious one is that each state has their own unique approach to their technical architecture. They range from Idaho with its desire for a single statewide network (Idaho Health Data Exchange) to Indiana with multiple, independent, local HIEs, and no statewide architecture. Additionally, most states are issuing RFPs that include a number of use cases that go beyond just basic data exchange functions.  While the statewide HIEs obviously need to plan for the future, it is creating uncertainty among vendors in how they respond and price their solutions given that some of the use cases outlined in an RFP may never be implemented.

While being rewarded with a statewide HIE contract represents a significant win for a vendor, especially for smaller vendors, the real value (i.e., money to be made) is not from the initial contract of simply ‘connecting the pipes.’  The long-term value will come from deploying higher-value add applications and services such as analytics, quality reporting, transactional services which typically are 5x-7x more lucrative than basic data exchange services.  Data exchange is but the «tip of the iceberg» to far more lucrative opportunities and is why vendors are competing so hard for these contracts.

No Clear Leader

Our research has not identified any clear leader in the state HIE market today. Part of the reason for this is that few states have begun the process selecting an HIE vendor, let alone go live with a solution. If pressured, we would give the leadership crown to Axolotl who has had almost a singular focus on such public exchanges and now supports 4 statewide HIEs. Axolotl’s leadership, however is a tenuous one as there are several other vendors with at least one statewide HIE client including Medicity, Intersystems, and GE Healthcare. This market is clearly one that is wide open and we foresee significant activity in the coming 9-12 months.  Let the Great Land Grab of 2010 commence!

Note to Readers: In giving credit to where credit is due, Matt Guldin, who is leading Chilmark Research’s HIE research for our forthcoming report, authored this post.  Thank you Matt for a very informative post.

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As required by legislation in the American Reinvestment and Recovery Act (ARRA), HHS/CMS released rules for the meaningful use of certified EHRs before the end of 2009 (late the afternoon of Dec. 30th).  Others have already written plenty on what is actually stated in these rules, therefore, let’s take a look at the potential winners and losers of these new rules as well as those where it is still too early to tell.  This analysis will be laid out over the next few posts starting with Winners below.


Consultants: At 556 pages, very few physicians and hospitals will take the time to read the complete meaningful use rules, rather hiring consultants to guide them in mapping out a strategy to adopt and implement a certified EHR to meet these requirements in the tight time-frame allowed.  Hospitals and large private practices will have the resources to hire such consultants, small practices will not, instead relying on the yet to be formed statewide extension centers.

Payers: Demonstrating meaningful use will require electronic eligibility checking and claims submission for 80% of all patient visits.  This will greatly simplify payers cost burden for payers who must currently contend with eligibility checking by phone and mountains of paper claims submissions from providers.

Large, Established EHR/EMR Vendors: These vendors have the resources and political clout to insure their apps will meet certification requirements.  They will meet such requirements either through internal development or acquisitions.  In some cases, partnerships will also be used to meet smaller, niche requirements of meaningful use.  Big boys with an established presence include: AllScripts, Cerner, Eclipsys, Epic, GE, McKesson, NextGen, Siemens, etc.

Revenue Cycle Management (RCM) Vendors: Core to most RCM vendors solutions is the ability to perform electronic eligibility checking and e-claims submission.  As this is now a core requirement for incentive payment, these vendors will see a boom in business. Smaller, independent vendors such as MedAssets and SSI will likely be acquired.  Large vendors, such as Emdeon, may expand their offerings into core EMR functionality similar to what athenahealth has done with the introduction of athenaclinicals.  Companies such as RelayHealth should also see a bump up in business as providers look to address this requirement.

Medication Checking Reconciliation & eRx Apps: A significant amount of attention is being paid to addressing medication errors and e-Prescribing (eRx) in Stage 1 of the meaningful use rules.  The HITECH Act legislation specifically calls out eRx as part of meaningful use and CMS has been promoting/encouraging adoption as well so this is a no-brainer.  The big winner here is SureScripts.  Medication/formulary reconciliation is also called for in Stage 1, something that the Joint Commission has been advocating since 2005.  Several eRx and EMR apps have embedded this functionality in their solutions.  Lastly, physicians and hospitals will be required to do drug-drug, drug-allergy and drug-formulary checking.  Companies such as First Data and Thompson as well as Cerner’s Multum solution should do well in addressing this requirement.  There are also a plethora of smaller companies, such as enhancedMD, Epocrates, Medscape, etc. that may benefit, through partnerships with or acquisitions by larger HIT firms.

M&A Firms and Small, Innovative Software Companies:: Stage 1 is asking for a lot of functionality that simply does not exist in many EHR/EMR solutions.  Larger, more established EHR/EMR companies will not have enough time to build out all the functionality required and will either seek partnerships or acquire smaller, niche vendors such as those mentioned previously (our bet is we’ll see more acquisitions than partnerships).  Due to the strong demand for niche applications to fill gaps in their solution portfolios to meet Stage 1 requirements, these EHR/EMR vendors will likely pay premium dollars for the best-in-class apps.  Small, innovative software vendors and the M&A firms that represent them will do well over the next few years.

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The healthcare IT (HIT) industry waits with baited breath for the release of preliminary meaningful use (MU) rules, scheduled for later this month.  Why the baited breath?  Market has basically stalled as physicians & hospital CIOs hold off HIT purchases awaiting what will actually be asked of them to get those ARRA reimbursement checks.  Will the pain of adopting a “certified EHR” and demonstrating “meaningful use” be greater than the gain?  Will those meaningful use requirements be too onerous to encourage broad adoption, particularly among smaller ambulatory practices?

Looking across the market, following various HIT Policy and Standards Committee meetings, listening to HIT vendor pitches, private conversations with physicians and following various announcements coming out of HHS, be they press releases or Blog postings, Chilmark Research has come to several conclusions as to what one can expect in the near term:

1) HIT vendor pronouncements and promises that they will meet any and all MU criteria are extremely misleading.

Yes, HIT vendors may put in the minimum feature set to become a “certified EHR” (we still do not know what a certified EHR is yet) and they will likely have the capabilities embedded in their solution to meet MU criteria (especially in 2011), but the challenge is not so much the software, but how it is implemented.  Implement it poorly and physicians/hospitals will struggle mightily to demonstrate meaningful use of their EHR.

2) CMS will release MU rules with very low barriers to entry in 2011, but 2013 will have much higher barriers/hurdles to jump and same holds true for 2015.

HHS recognizes that the healthcare market is very immature in its adoption of HIT, that ARRA legislation has demanded certain criteria be met (MU) and that it is on a very tight time schedule.  A delicate balance is required to drive early adoption while concurrently meeting legislative intent.  Thus, for 2011 we can expect simple. basic MU criteria that does not require significant reporting, that is not burdensome to the practice and that HIT vendors can readily deliver upon today.  Chilmark Research also foresees 2011 data exchange requirements for care coordination to be extremely simple without a heavy reliance on HIEs.

3) The biggest challenge in 2011 and for that matter the entire HITECH Act is the successful implementation of certified EHRs that have a glide path leading the adopter on a clear upgrade and workflow optimization path for meeting MU criteria in 2013 and 2015.

That almost bears repeating (read it again folks). The successful implementation of certified EHRs is a huge challenge that unfortunately is largely being overlooked with most of the attention being paid to broader policy and standards issues.  Granted, HHS is expending a significant amount of energy and resources to address this issue with nearly $600M going to the establishment of regional extension centers, another $80M in grants for training IT professionals in community colleges and today’s announcement on the Beacon Community Cooperative Agreement Program. But again, we are dealing with a very aggressive adoption and reimbursement schedule.  Couple that with the rule that there is no partial reimbursement for partially meeting MU criteria and one has the makings of “Day the Earth Stood Still” scenario.

4) The infrastructure for data exchange in support of care coordination is simply not there.

ONC head, Dr. Blumenthal made it quite clear that exchanging data within a private HIE (IDN sponsored) will not meet MU criteria.  Problem is, of the 200 or so public HIEs that are now in existence, only 25% are actually moving data of any type (most of that data is very simple labs, med lists, etc. and not what HITECH/MU envision), another 25% are still in PowerPoint and the remaining 50% somewhere in between.  Again, HHS is putting significant resources behind this issue, but HIEs just don’t appear out of nowhere.  HIEs take time to develop, put in place data use and sharing agreements (DURSAs), define a business model, staff up, implement a vendor’s solution, tie the network together and finally begin moving data.  Chilmark still does not see a path on how to get from where we are today to what draft MU guidelines will require for data sharing in support of care coordination.  You can’t force a river folks.  Major rethink required.


Congress, in its infinite wisdom, gave HHS an albatross in the HITECH Act.  That is not to say we need to throw out the entire Act, far from it.  What is needed is a relaxation of the aggressive HIT adoption schedule that this legislation has written into law.

As proposed, we are looking at a coming train wreck of major proportions wherein by our estimates, over 35% of the estimated $44B that US taxpayers will be spending on the HITECH Act will be wasted.  Before we get any further down the road, it is time for HHS and administration leadership to go back to Congress to modify this Act, extending deadlines to insure adoption of HIT is thoughtful, effective and ultimately successful.

Note: This post was written during a flight delay.  Unfortunately, did not have the time to provide links to various supporting points in this post.  And thanks to Google for providing free Internet access at Logan airport over the holidays.

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blumenthalYesterday, David Blumenthal published a very thoughtful post on the HITECH Act as a foundation for information exchange in which he reflected on his own personal experience as a doctor.  That experience included the often frustrating realization that he could not obtain a complete longitudinal record of his patients (customers) due to either (or both) technical or business barriers.  In his post, Blumenthal goes on to elucidate on how the HITECH Act’s language is purposely worded to remove such barriers as the healthcare sector transitions from a provider-centric model to one that is patient (consumer) centric.

Following are our own reflections on Blumenthal’s post based on the reality of the market today and where Chilmark sees it heading in the future. Specifically, we’ll tackle each of Blumenthal’s bullet points in order.

HITECH Act squarely tackles the commercial barriers. Yes, HITECH funding is clearly earmarked in support of open and secure exchange of data, in fact it was one of the three core attributes of meaningful use (information exchange for care coordination) defined in the legislative language.  But HITECH Act and its provisions only pertain to those that accept the $$$ and it remains to be seen just how many entities sign-on.

Blumenthal closes his first bullet point with:

Consumers, patients and their caretakers should never feel locked into a single health system or exchange arrangement because it does not permit or encourage the sharing of information.

Ideally, this is the end result but not so sure how we get there from here.  In Boston, a very competitive healthcare market with some of the best healthcare informatists in the business, organizations and subsequently consumers are extremely challenged to get their data, let alone share it.  The video clip below from Microsoft on the deployment of Amalga for the Wisconsin HIE gives some idea as to how this might work, but even in this case, it is limited to ER, there is no consumer control.  We are in for a very, very long journey.

HITECH tackles economic barriers. Not really.  Sure, $36B is a heck of a lot of money for the HIT market and the potential follow-on penalties for not adopting an EHR may be significant for clinics and hospitals that derive a large proportion of revenue from CMS, but that is not necessarily the case for smaller, private practices where it is estimated that 80% of care actually occurs. For smaller practices that do not serve a large CMS population, the reimbursement of $44k/physician does not pay. The incentives, frankly, are not the powerful tool that Blumenthal claims they are for a significant portion of the market.

HITECH tackles the technical barriers. Huh?  Not sure how he came to that conclusion.  Maybe in time if the stars all align perfectly, such will come to pass but today we have a host of legacy systems that do not talk (inter-operate) with one another, strong disincentives for HIT vendors to actually create truly interoperable products (the more open and interoperable you are, the easier it is to be replaced with a competing solution) and then there is that whole issue of adoption mentioned under economic barriers above.

Yes, Blumenthal is correct in that the HITECH Act does instruct HHS to continue its investments in creating a nationwide electronic exchange for health information (the NHIN which will become the Health Internet).  But even here there have been challenges. The technology stack of the NHIN today, created by beltway bandits and not those deeply immersed in HIT, is crippled.  Hopefully, as was presented at the Harvard ITdotHealth Forum, the feds will open up and actively solicit the guidance and input of those that were present, and others to create an NHIN that is truly usable.

HITECH provides the building blocks for information exchange across jurisdictions. Yes and No. Certainly the HITECH Act will fund HIE initiatives in virtually all states with the $560M+ that was announced in early fall (States submitted their proposals earlier this month).  This will certainly accelerate activities at the state level for HIE build-out but the question remains: Will these state activities actually be able to devise a truly sustainable business model?  To date, it is rare indeed to find a public HIE that is self-sustaining.

Beyond the issue of funding these state HIE is the much thornier issue of the myriad of state laws and policies as it pertains to the distribution and sharing of medical records.  The only recourse may be a “super-DURSA” (caution PDF) passed by Congress to supersede state policies, which could prove quite challenging.

Despite outlining what are seen as some fairly significant challenges to Blumenthal’s upbeat and positive post, like him, we share in the desire to move the proverbial ball forward and more importantly (what we really, really liked about his post) focus on the patient, the consumer, the citizen.  In the end, it is they who are footing the bill for this massive initiative to get doctors, clinics and hospitals wired-up. Therefore, is it not they that should ultimately benefit from the HITECH Act through better care, greater flexibility in physician choice and who knows, maybe even receive lower cost of care.  A tall order in deed but certainly one worth working towards.

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