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Posts Tagged ‘HIE’

Today, IBM announced that it has signed-on eHealth Initiative (eHI) CEO, Janet Marchibroda as their new chief healthcare officer.  A somewhat odd title as she is not a doctor, but that is ibm-in-second-lifereally not the issue here.

To date, IBM has been somewhat missing from action in all the HIT buzz with most of the limelight being showered upon traditional EMR vendors and of course the big, yet still nascent initiatives of Google Health and Microsoft’s HealthVault.  With the appointment of Marchibroda, is IBM signalling a renewed interest in HIT?

Our guess is yes and IBM will be targeting its efforts in one sector of the market that has no major competitor, the “Exchange” (HIE & RHIO) markets.

Why “Exchanges”?

  1. Leverages IBM’s core technology strengths in middleware.
  2. Plenty of services revenue in the Exchange market for IBM to tap into.
  3. No competition of note as market is dominated by vendors with less than $30M in annual sales.  IBM may make a play for one of these vendors to gain added expertise and credibility that goes beyond their acquisition of Healthlink in 2005, which was a services play.
  4. Initial HITECH Act funding of $300M with certainly more to follow.

What does Marchibroda bring to the table?

  1. Knows the political landscape on the Hill quite well.
  2. Intimately familiar with the Exchange market through leading eHI and knows both where the skeletons are hidden and where the money will flow.

Note that IBM has played a small, exploratory role in Exchanges in the past, particularly with the North Carolina RHIO, (NCHICA) and Taconic RHIO (THINC), but given their size, nothing really of significance – maybe they decided the market just was not mature enough.  With significant HITECH $$$ now flowing in though, IBM may be getting ready to re-enter the market.

Keep an eye on IBM, as more is likely forthcoming in the next few months as they set themselves up to capitalize on the HITECH Act.

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8:15am After the formal introductions, Karen Davis, head of The Commonwealth Fund has taken the stage.  She’s beginning with the slides we have all seen (that is those of us who attend these events), unsustainable growth in spending, not getting what we paid for, etc.  Their “National Scoreboard” has found quality slipping 1n 2008 from last survey in 2006.

Think we’re bad?  Canadian adoption of HIT in primary practice is half that of the US (8% vs 19% in US).  At least according to their survey.

Commonwealth has found in their surveys that physicians who adopt HIT and get comfortable using, actually find, or at least believe, that they can provide better care than before.

Karen has now begun talking about the Danish national HIT system (she was just there).  Fascinating what Denmark has done.

  • 98% adoption of physician use of HIT & eRx
  • Physicians are reimbursed $7 (probably 5 euros) for each email thy respond to.
  • Have established a master HIE for the country where every bit of health documentation related to a consumer is put and can be accessed via a Master Patient Index (MPI), via the Web.  All information is digital, fully searchable and get this, Controlled by the Consumer!  The consumer can see who has reviewed their records (audit trail) and determine who has access to their records.  As an added privacy feature, physicians must always (except in break the glass emergency) click a check-off box stating that the consumer has granted them access prior to viewing a record.  Sounds like a pretty sweet set-up.
  • To close the loop on eRx, the system also connects to pharmacies for them to upload when scripts were actually filled.
  • Took Denmark 10 years to put this together.

Now circling back to what we might see in terms of healthcare reform with the new administration.  Nothing new here.

9:45am We now have a panel of various legislative aides who will talk about what they see coming in the future. First aide, for Enzi?, stated that they have put up all sorts of HIT bills, all to go up in flames.  Hopefully for the future. One aide stated that their boss, Congressman Barton (R-TX) has had his records breached twice, so he is extremely concerned about the privacy issue.  Big challenge for him is how do we privacy for health records and who ultimately has control of the records.  In this case, the Congressman believes the consumer should have ultimate control.

Odd all this talk about privacy – amounts to nothing without enforcement.

Rep. Sheldon (D-RI) is a freshman and very keen on HIT issues.  Surprisingly, not a big fan of P4P programs to fund HIT adoption, at least P4P that focuses on individual docs, would rather see P4P focus on communities of care.  Likes the old Land Grant funding model.  This was used oh about a century ago for supporting agricultural sciences and led to all those state universities that have an A and or M in them, e.g, Texas A&M.  Honestly, don’t see this going anywhere, but good to see some new thinking.

So far, about a third of the aides have made statements, no one has mentioned the consumer (other than the privacy statement) and what their interest is in HIT.  All about the physician – extremely myopic.

Attendee composition is almost the antithesis to Health 2.0.  Few computers are open (or even here), lots of “suits”, mid-forty and up, stiff.  About 100 in attendance.

Kennedy aide’s comments quite short and sweet, their focus is on three main areas, coverage, quality and prevention, putting together legislative teams to address them: .  Kennedy aide went on to state that the challenge of healthcare reform will be in containing all the add-ons which various legislators will add to any major legislative act.

During the Q&A, one of the aides stated that ~60% of residencies are done in VA hospitals where they get to use the “state-of-the-art” EMR, VistA and how we need to extend such tools in the general healthcare space.  A physician got up and asked the aide: “Have you ever used VistA?” infering that it was hardly state-of-the-art, and aide admitted “No” and audience got a good chuckle.

Really exposes a key issue:  Those that are creating the legislation just skim across the top of the issues/challenges without digging deeper.

10:00am Next panel has a Who’s Who of HIT folks such as John Glasser (AHIC and Partners’ CIO) Marc Overhage (Indiana HIE), J&J rep, AMA rep, etc.  Panel is to get their views on healthcare reform and role of HIT.  Hopefully better than the last panel.

Beyond no free WiFi at this event – just don’t see how any conference organizer worth their salt would not provide such – can’t find a power plug and begining to run low.  Frustrating. May have to come back later, revert to pen and paper.  Possibly twitter, john-chilmark

Panel agreement that HIT now has strong visibility on the hill and that we have come a long way – it is being discussed.  Big challenge though is how do we get value out of HIT. Currently, there is no solid evidence that HIT lowers costs (CIGNA’s CMO asked Jon White of AHRQ if there was such evidence, Jon responded no, not today).  Belief is that such benefits will accumulate and be realized in 7-10 years time.

Key imperatives of panelists:

  • Glasser – Continue to fund CCHIT, ONC and AHRQ (and although he didn;t say it, AHIC 2.0).  Figure out how do we use CMS to set examples and motivate change.
  • Weber – (Business Coalition rep) No single national solution.  Medicare needs to harmonize at the local level, which they do not see occuring today. Medicare needs to open up, join payment reform strateiges, open up their data, become more flexible.  CMS is so huge, really can’t get anywhere without their involvement.
  • Overhage – Whatever is done needs to be incremental (you mean it isn’t already?).  90% of healthcare costs are spent directly on wages, thus any savings may directly affect jobs, thus move slowly, methodically to minimize transition. Think through how you will leverage existing infrastructure.
  • Steven (from AMA) – Get DEA on-board to let physicians eRx and let’s be honest with adoption as in 2005, one third of states did not allow eRx and now in 2008 it has all of the sudden become a mandate.
  • Richardson (J&J) – Find regions where things are moving quickly ahead and devote energies/resources there to develop best practices.
  • Kang (CIGNA) – Address the patient privacy issue.  Sees it as a “process” issue and that is unlikely to be solved through legislation. Get HHS/CMS to push for a move from payment based on visits to payment based on outcomes.

12:00pm Luncheon Speaker, John Tooker who spoke about AHIC Successor, or AHIC 2.0.  Pretty poor presentation, incredibly boring and text heavy slides, no real value pointed to as a result of AHIC work to date – just a lot of hand waving.  Yikes, if this is representative of what AHIC 2.0 will be, time to close up shop NOW!

1:00 pm Engaging Consumers Session:
American Heart Assoc (AHA) – Courtney gave overview of all that AHA is doing.  Go Red initiative, targets women to take better care of themselves.  Partnered with Revolution Health for Go Red, online community for women, 600+/day interacting.  They see 2M views/month at main AHA site. Recently launched a consumer education on PHRs, how to select, etc. only 15K visitors to date, still pretty crude.  Also have a section on main website dedicated to educating public on broader Health IT issues.

For youth they’ve created http://www.healthiergeneration.org

Doing a lot of outreach via churches, which has been extremely successful in the South.

Second presenter is from Healthwise, one of their SVPs, Leslie Kelly Hall.  Healthwise has seen very healthy, rapid growth, now at 220 employees, 400K+ pages of content.

Healthwise works closely with Information Therapy and jointly filed comments to CCHIT regarding certification standards for PHRs stating that content must be a part of a PHR and thus a part of certification. They believe this will provide sense of context and future care – prevention.  Sounds self-serving to me.

Gave a nice demo of a diabetes eduction piece they developed that folded education, survey questions etc to create a specific plan for a given consumer.

2:30pm, BCBS Assoc, CEO to talk about comparative effectiveness, at least that is how they introduced him.  Began by stating what we need is clear leadership on where we want healthcare to go as a country.  Oh boy, I bet this is said with each new administration and I bet each new administration believes they bringing clear leadership but get completely bogged down in the political morass that is healthcare today, a morass that payers like BCBS help to create and sustain.

BCBS has a new initiative across all plans called Blue Health Intelligence (bhi).  Claim employers are already using it to help structure plans that are appropriate for their specific populations.  Sounds more like a way to keep employers tied to BCBS plans vs competing plans ala UNH, Aetna, etc.  Not necessarily a bad thing, but question how objective they can truly be.

In strong support of Comparative Effectiveness Institute (CEI).  BCBS believes that roughly 30% of healthcare spend is wasted an areas that this Institute would address.  See it as public-private entity.  Estimate cost: $500M/yr.  Savings $338B/yr (number from The Commonwealth Fund).  Not just about lowering costs but also about improving quality.  Baucus proposal has the CEI concept within it.  Could Obama get behind this?

Want 100% of all BCBS members to have access to a PHR by 2010.  Claim that they are currently at 75% of BCBS plans now offering a PHR to their members.  Gave an example of Anthem and their PHR.  Funny he should use Anthem.  As a member of Anthem, Anthem has never, in my several years of coverage mentioned that I have a PHR.  Doesn’t do a whole lot of good if you don’t tell anyone.  Anthem is not alone, pretty common situation across all payers, most do an absolutely terrible job of consumer education as it pertains to PHRs.

Out of power, reverted to twitter.

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This morning’s Wall Street Journal has an article, first page – Section B, highlighting the growing impact of the financial crisis on the IT industry. The enterprise software powerhouse, SAP, shocked investors earlier this week when it warned that it would not meet its 3rd Qtr target, citing slowness in the mid-market. Another tech company, RightNow Technologies (provides an SaaS CRM solution) also announced that they are seeing delays on invoice payments. And getting back to the WSJ article, VC firms are having a tough time raising capital and are have begun telling start-ups to batten-down-the-hatches for a long slow period. Some have even gone on to say to their start-ups that if you have a bank credit line, draw it down now as it may not be there tomorrow.

Impact on Healthcare IT (HIT) Spending

Adding to the tight money situation for businesses of all sizes, regardless of market sector, decreasing consumer spending and the increasing burden of healthcare costs shouldered by consumers will directly impact healthcare. Small to mid-size physician practices will be particularly hard hit as consumers forgo visits. This will, in-turn, slow technology adoption for the foreseeable future and result in drastic consolidation among HIT vendors.

And for those of you holding out for one of the presidential candidates to drop a boat-load of money into HIT, don’t hold your breath. During a debate last week at Harvard, two noted healthcare economists each representing one of the candidates (they were both senior advisors to teh candidates) were quite clear in stating that any promises of large investments in HIT will have to wait while other priorities take precedent.

Despite all the doom and gloom, occasionally one sees a glimmer of brightness. IBM this week pre-announced earnings (to quell market concerns) that were positive. And this morning, I received a similar announcement from WebMD, wherein they state that advertising revenue for the third quarter is up substantially, year over year. Like IBM, clearly WebMD wants to get out in front with positive news to quell investor fears rather than wait till their scheduled 3rd Qtr conference call on Oct. 30th.

Quick Assessment:

  • Mid-market HIT vendors targeting physician practices will suffer. Expect consolidation, bankruptcy filings and even shuttered doors. Vendors targeting large practices and hospitals will rely heavily on maintenance and service revenues as customers look to control spend by canceling or delaying large projects.
  • There are far to many integration platform vendors targeting the RHIO/HIE market. Most of these will fail. Those that succeed will have a strong, existing client-base (not heavily reliant on RHIOs) with a clear annuity stream to carry them through what will be a tight market for the next 2-4 years. Those with a clear technological advantage will likely be acquired.
  • The consumer-facing HIT vendors will have little success going directly to the end consumer. Thus, their go to market strategy must migrate to a B2B2C (business>business>consumer) model. In pursuing such a strategy, they must show clear and demonstrable savings to the business sponsor. Creative financing and cost sharing approaches will increase to fund such deployments.
  • Internet-based, consumer-facing health solutions, particularly anyone claiming to be “Health 2.0” company must go beyond the hype and focus on delivering some real value that they can monetize. PatientsLikeMe appears to be on the road to success, far too many others to list do not. A real shake-out will occur here as these start-ups struggle to raise cash.
  • Whether one likes it or not, clearly, there is money in advertising but tapping that source will require a company to show that they have the visitors and are growing in number of impressions. That growth should exceed overall growth in health-related search. WebMD is one clear example, Waterfront Media another and eMarketer lists a few more.

Quick Note:  Just found this article over on CNET that takes  hard look at Web 2.0 companies with the potential to blow-up.  Hmmm, if one were to make a similar one for the Health 2.0 apps sector, who would You put on the list?

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Last year, I attended one of my first healthcare conferences, that sponsored by the federal agency, Agency for Healthcare Research and Quality (AHRQ). While I had mixed feelings about that inaugural event (at least inaugural for me), I returned this year to see what progress has been made on the quality front and whether or not the growing trend of consumerism in healthcare is having any impact.

I may have been expecting too much as it seemed more like a step back in time, a deja vu event.

First off, this is by and large an academic research crowd, not a group prone to uttering such phrases as “the business case of quality” or “consumerism”. No, this is a crowd that talks of patients, patient safety, research methodologies, and the like. Nothing wrong with that, from a strict research sense, but I see big problems with this if AHRQ wants to transition funded research to something beyond an academic exercise, something AHRQ has stated some intention to do with their new Innovations initiative.

But maybe it is not entirely AHRQ’s fault. The lack of innovation in healthcare, as it relates to quality, may be systemic. AHRQ Director Clancey, basically inferred such in her keynote stating that there is a lack of linkage among healthcare institutes between quality and profitability that needs to change, that today, focus is on short-term results and not long-term impacts.

In all the presentations I heard thereafter, however, never was profitability/business case for quality mentioned again. No talk of quality and cost savings, no mention of quality metrics and customer retention – Nothing. Maybe AHRQ needs to begin rethinking its grant proposal process and prompt researchers to consider such factors, develop metrics to measure such, and deliver such results as part of a researcher’s final report.

As for quality, Clancey stated that AHRQ analysis of quality metrics has found no significant change in the last several years. In fact, in some cases quality is actually decreasing, particularly disparities in care for at risk populations. The proverbial ball is not moving forward – it is in stasis or worse, like Sisyphus, rolling backwards.

Makes me begin to wonder: If quality is not improving then why exactly is AHRQ in business and why are they funding all these various research projects at institutions, that honestly, should be paying for this research themselves – that is of course if these institutions see the business value of quality?

Some quick impressions and highlights:

  • Attendees are a tight knit group of researchers (~85% from academia), AHRQ employees and a smattering of government contractors. Incestuous
  • Lots and lots of “Quality” templates being created to overlay on top of EMR systems to report on quality metrics. Seems as though everyone is building their own set of templates unique to their organization – a lot of reinventing the wheel here. Is this a business opportunity???
  • Universal number one factor hindering adoption of quality initiatives is time. Does the reporting of quality metrics/actions put a time burden on clinicians, if yes, forget about it, it will not be adopted. Strategies to overcome include: deploying speech recognition. streamlining process as much as possible through pre-populating data fields (pull from existing EMR/PM data stores), and/or look more broadly at clinician workflow to find opportunities to “save time”.
  • Clinicians prefer unstructured text entry versus pick lists as pick lists often do not adequately capture an encounter. This has led to design of multiple micro templates with branching logic for quality reporting to minimize unstructured text inputs, but provide needed flexibility.
  • Majority of quality research efforts have no tie-in at the institution level to P4P programs. Again, getting back to the business case – where is it? Did ask one presenter if there was any tie-in to P4P. She stated that they are thinking about P4P, see it coming and what they are doing today should set them up to capitalize on this opportunity once it is presented to them by payers.
  • According to one researcher/presentation, there are no metrics to measure quality improvements resulting from HIE/RHIO programs. Wow, that was a shocker! If true, quite embarrassing seeing as how much money federal, state and other organizations have invested in such programs to date.
  • In a telehealth demonstration project, the lead investigator spoke of the numerous issues they had while working with the HIT/telehealth service vendor. This researcher stated that the market is full of telehealth service providers with such a wide range of capabilities, service level agreements, privacy policies etc., that it really needs some form of oversight, be it certification or regulation. This industry needs to get its act together and start self-policing, or else they’ll have regulators on their back in the very near future which could become a very big problem for this extremely young and rapidly evolving sector.

That’s all for now as I need to run into the next session. Will provide a brief recap, some notes on AHRQ’s Innovation Initiative, etc. in a follow-on post.

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Back at the beginning of the year, I did a Top Ten Predictions post where one of the predictions was the continued struggles of Regional Health Information Organizations (RHIOs) and the steady rise of Health Information Exchanges (HIEs).  Since much of the ballyhooed National Health Information Network (NHIN) is built upon the premise of RHIOs and their success, the NHIN is basically dead in the water.

Sure, NHIN supported by RHIOs is a great and grand vision, but that is about it – a great and grand vision created by policy folks in government (and their academic counterparts) that has little basis in reality.  That divorce from reality stems from a lack of a true, justifiable business case.  There is simply no compelling business reason for the vast majority of health industry stakeholders to invest in RHIOs. (Note: those that have invested in RHIOs are most often doing it for political reasons, not business ones.)

This is not the case for HIEs. These networks are created by entities, typically large hospitals, that do have a compelling business reason (one reason: encourages referrals to their hospital) to share health information within a network of business partners (their provider network).  This is quite similar to a supply chain network within the manufacturing sector.  In manufacturing its about sharing bills of materials, design drawings and the like to accelerate time to market.  For hospitals its about delivering value to smaller practices, most often giving a physician a window into the HIE host’s EMR to facilitate care and insure referrals.  The August cover story of the publication Health Data Management has an excellent story that goes into greater details on why HIEs are growing in popularity.

It is an expensive and time consuming endeavor to build these HIEs.  RHIOs, well, there are another order of magnitude more difficult to accomplish and likewise costly to support.  And let’s not even begin thinking about NHIN – that is one vision that is at least a decade away, if not longer.

How might we move the proverbial ball forward?

First, discontinue investing federal/state funds into RHIOs.

Second, redirect energies (not necessarily funding) towards supporting HIEs.

Support for HIEs can come in multiple forms, but maybe a tax break or rebate to the sponsoring entity of an HIE is possible with some caveat to the effect that th HIE will support open, interoperable standards.  This will insure that the HIE will be capable of participating in a broader entity e.g. RHIO and further down the road the NHIN.  Taking this approach will provide a logical, stepwise strategy to growing the connections towards a nationwide network that begins at a very local level delivering incremental value every step along the way.

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This just in, Microsoft’s HealthVault announced a partnership with AT&T and Covisint to enable healthcare data exchange across a highly distributed network.  While I have not had a chance to really dig into this announcement, it does appear, at least on the surface, to be quite an interesting partnership.

One of the most interesting aspects to this announcement is Covisint.  For those who may not remember the  dot-com hey-days of the late nineties, Covisint  was originally formed by the Big Three automakers with the purpose of creating a common architecture for e-Procurement and other supply chain enhancing functions.  Covisint never really did take-off, despite massive spending by the Big Three and Tier One suppliers.  Big problem came up when the automakers discovered that many of their pricing, contracts, and materials information were actually very proprietary and thus not suited for Covisint.  That left Covisint with commodity type products to attend to and there were simply not enough at sufficient margins to sustain the model.

Maybe their venture into healthcare will be more promising.  Covisint certainly has the secure data exchange angle well-covered.  Look to the AT&T/Covisint deal in Tennessee to understand more of where this may be going.

Will look into it further and possibly do a more in-depth report if warranted.  For

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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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