Posts Tagged ‘HIT’

HIMSS or Bust

Two extremely short weeks from today will be the official start of that annual healthcare IT (HIT) confab called HIMSS. Tens of thousands will gather to hear the latest and greatest on how HIT will deliver unfathomable rewards to all who adopt. Of course there will also be those discussions that if you aren’t on the EHR, HIE, CDS, RCM or any other HIT acronym bandwagon then surely you will fail to meet the high goals and aspirations of the policy wonks in DC and State-houses across the country. Your days are surely numbered.

Don’t get us wrong. Chilmark Research is actually a strong proponent of HIT, if it is judiciously deployed, clinicians have a voice and training is truly training (A friend who is a nurse told me the horror story of sitting in two full days of training where the trainer from a very well-known ambulatory vendor refused to allow those in the class to actually use the EHR – they had to sit and watch endless demos). Problem is, as the training example points out, this is rarely done and the aggressive timelines of ARRA for EHR incentive payments sure doesn’t help.

But we digress. If nothing else, HIMSS affords one the opportunity to get a pulse on the industry if one just ignores most of the loud pronouncements plastered all over the front of the various booths and in those all too common theaters. Having been to countless events such as this in numerous market sectors, the pulse is found behind the scenes, behind the posters, in the hallways in casual conversations, in the questions that you overhear being asked, in private conversations with key people in the industry.

In my own case, I look to HIMSS as partly educational, partly business development. Over the last few weeks I have received countless invitations to meet with various companies of all shapes and sizes. I just wish those sending these invitations would actually take the time to get to know Chilmark Research first as the vast majority are of very little interest – I mean really, do I want to sit-down and learn about the latest COW?

I do a lot of planning upfront and select who I want to meet with and rarely entertain unsolicited invitations. At this point, my three days of HIMSS are completely packed and if I were wise I’d spend the next two weeks taking it easy and resting up for what will be a three day marathon that begins with breakfast meetings and ends sometime late after the last reception. The most exhausting part of it all, simply that as an analyst you are always “On”. In almost any conversation you are asked for an opinion, a forecast, a prediction and if they don’t like it, you then need to defend it with logic. I love the challenge, I love the intellectual stimulus but by the time I board that flight home I’m totally spent.

To help you prepare for HIMSS, here are a few suggestions:

Attend the mobihealthnews webinar this Thursday, February 10th at 2pm ET. I’ll be presenting alongside mobihealthnews editor Brian Dolan and Diversinet executive Mark Trigsted. We’ll be talking about mHealth Trends in 2011 and what to expect at HIMSS on the mHealth front. Registration is free and last I heard, they have nearly 800 registrants.

Register for the FierceHealthIT HIMSS Executive Breakfast which will be held Tuesday morning. I will be part of a great panel that includes Lynn Vogel from MD Anderson, Joe Kvedar of Partner’s Center for Connected Health and Capt. Robert Marshall, CMIO of the Navy.  Our topic: mHealth’s Evolving Role in Achieving Meaningful Use, should make for a lively conversation.

Keep your meetings with vendors short. There is so much going on for your typical vendor that it will be difficult for them to truly remember details of an in-depth discussion.  So much is happening at a big event like this that the best one can hope for is a meet n’greet type of meeting where one meets with some key executives of the vendor, gains a quick read on their direction, what the vendor sees as important. With this information, you can determine whether or not a more in-depth follow-up meeting is warranted.

Be sure to leave yourself a good 15-30 minutes of space between meetings. This time will prove invaluable for a number of reasons including:

  • Gives you a breather to go over your notes and add any details you may not have written down during the meeting itself.
  • Provides some cushion should a meeting be going very well allowing you to carry a conversation to a successful conclusion.
  • Allows you time to get to your next meeting without being late. (Last year was a nightmare for me with the exhibit hall split in two – took forever for me to get from one side to the next. Thankfully I had some cushion time built into schedule.)

In closing, while I find HIMSS to be depressing at times and the hype of vendors far out-strips their ability to execute, this is a valuable conference to attend as it does bring all the key industry players in HIT under one roof. Despite all the wonderful communication tools we now have at our disposal from Facebook to Twitter to webcasts, emails and good old fashion phone calls, we are still social creatures and we do need face-time with one another to strengthen relationships, form new ones and assess ones we are unsure of. This can only be done in-person and HIMSS provides that opportunity.

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Reading through the headlines, the press releases and checking in on today’s HIT Policy Committee meeting, it appears that the over-riding theme of comments regarding Meaningful Use (MU) rules (these were due by COB on 3/15) is to relax the rules, particularly regarding reimbursement and clarify other requirements of MU to ease the burden on providers seeking to comply.

This is not too surprising.

The policy to make incentive payments for EHR adoption and all or nothing deal (either you comply 100% to MU criteria to get reimbursement or nothing) is just plain silly.  Sure, flexibility will put a greater administrative burden on the Center for Medicare and Medicaid Services (CMS), but the risk of low adoption due to lack of flexibility is a real issue that CMS needs to address.

Another problem is that some of the reporting requirements are not terribly specific and will likely create an overhead reporting burden for providers.  In this case, the call is for more specificity to simplify and potentially even automate this process.

One area that Chilmark is seeing a wide range of comments is with regards to patient access to their medical records.  While there does not seem to be any major organization calling for a relaxation of this requirement, the MU rules are also not terribly specific on what access to one’s records actually means. Is it just a portal view, is it interactive, can one’s records be readily downloaded and transferred to another site (e.g., Google Health, HealthVault or other)?

Also, Stage One MU is pretty weak on the issue of providers delivering health content to a patient/citizen following a diagnosis.  This is such an easy thing to do, just don’t see why MU rules are not more forceful on this count. The tools/technologies/services are readily available, it is just a matter of making it happen. Speaking from personal experience, providing such health content after a diagnosis would go a long way towards a truly engaged and educated patient (and their support network) than what we have today.

The most thoughtful comments seen are those from the Markle Foundation.  Granted, Chilmark Research did play a small role and is a signatory, but really, they are quite good and are the result of Markle’s stellar outreach to the community (56 organizations were involved) in drafting these comments and suggested recommendations for MU rules.  Markle’s recommendations are a likely bellweather of what is to come in the final rules for unlike the multitudes of others who submitted comments, all with some sort of vested interest (AHA, AMA, HIMSS, etc.) Markle is neutral and the comments were developed by consensus from across the healthcare community.  To simplify your ability to review these comments, they have been uploaded to Scribd for easy viewing.

Early word is that the final rules for Stage One MU will be released late Spring.

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Doing some quick analysis of the healthcare IT market and have uncovered some 17 HIT software acquisitions since beginning of year.

Is this but a lead up to the big industry confab, HIMSS that begins in a few short weeks?

Certainly, the market is in desperate need of consolidation. Recent actions are likely but a small example of a trend that will accelerate over the next 12-18 months.

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HCcostcutCartoonAfter the $36B+ has been spent on what is hoped is the digitization of the healthcare sector via adoption of EHRs, what will be the consumer role?  That was the question put to four speakers yesterday as part of the eHealth Initiative webcast that Chilmark Research participated in yesterday. Other speakers included: Phil Marshall of WebMD, Eva Powell of the National Partnership for Women & Families, and George Scriban of Microsoft.

With only 10 minutes allotted to each speaker, it is not like we had sufficient time to dive deeply into the issues, but simply to give some flavor as to what might be expected in the future, post-Stimulus.  Currently, the legislation as well as all discussion to date regarding the ARRA funding for EHR adoption has been eerily silent on what will all of this funding mean to the average consumer/tax-payer.  How will they directly benefit?  Will it be through lower costs and subsequently insurance premiums? Will it be through better quality of care? Might it be convenience?  Hard to say but one thing can be said at this point: Sadly, HHS, has spent very little effort in articulating the value proposition of the planned HIT Stimulus spending for the tax-payer.  If HHS is not careful, this may come back to haunt them and more broadly, the Obama Administration further down the road.

Following is the slide presentation that Chilmark Research used yesterday where we gave our own views on the role the consumer will play post-stimulus.  Not exactly the most far-reaching of projections, simply too many variables at this early date.

During the Q&A, what struck me was the relative simplicity of the questions and to some extent the lack of in-depth knowledge on some of the critical consumer issues,  particularly with regards to PHRs.  Following is a set of questions that came through from one of the Blue Plans.  If they have these types of questions, quite sure many others do as well.

Ques: What types of metrics are available to track PHR usage?

Ans: Currently, there is no consistency on what metrics are tracked in a PHR.  Most often, metrics used are defined by the sponsor and may include accessing record, taking an action, responding to an alert, etc.  Ill-defined as market is still immature.

· Ques: What are the most used features in the PHR?

Ans: Depends on who is sponsoring the PHR. Employer/payer sponsored PHRs often have an HRA with incentives tied to it to encourage completion.  Increasingly, these PHRs have tie-ins to HSAs and pricing data to assist in purchasing decisions. Provider PHRs depend on level of transactional services provided. The most successful PHR today in North America is the one at Kaiser-Permanente and consumers use the following: Access Labs, Schedule Appointments, Request Rx Refills and have eConsults.  Consumer sponsored PHRs are minuscule part of market, less than 2% by our estimates.

· Ques: What percentage of today’s PHRs are pre-populated with data?

Ans: Data comes in many forms, claims, PBM, clinical, admin, images, labs, etc. Most sponsored PHRs have some pre-populated data. Thus Chilmark’s guess is ~90% but warning, amount & type of data is HIGHLY variable.

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doctorsnhspubdombigOver the last week we have not been as diligent in providing posts on happenings in the HIT market (we try to do at least 4/wk) as we prepared for the big industry confab, HIMSS09.  Are dance card for HIMSS is completely packed with briefings across a wide expanse of the market, from some of the smaller HIE/RHIO companies such as Axolotl and Medicity, to the big consumer plays of Google and Microsoft (note, MS also has a growing clinical initiative in Amalga – will be briefed on that as well), to EMR plays Eclipsys, McKesson and SaaS darling athenahealth to those companies developing mHealth apps for consumers and clinicians.

Over the course of the next four days we will provide updates on what we see and hear, being your eyes and ears at the show.  Of course, with any large show of this type there is always a number of announcements as vendors stand-up and pound their chests in front o their competitors.  Those announcements may truly shake-up the market will be covered, all the other nonsense, ignored.

Note: Chilmark Research was privy and pre-briefed on a big announcement by a large IDN of a technology stack that has consumer and clinician facing aspects to it.  Stay tuned, analysis forthcoming regarding.

In addition to periodic updates on the Chilmark Research site, there will also be live “tweets” ia Twitter.  On the left is the Twitter feed that you can check.  You may also follow directly on Twitter by following: @john_chilmark  If you want an even Bigger view of all things HIMSS09, via Twitter, their are a number of others at the event who will be tweeting their impresssions.  Best way to get the big picture view is using the hashtag #himss09.  And for that hashtag, Twitterfall is the best.

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congressWe are heading down the wrong path.

Despite the rounds of applause from virtually all sectors of the healthcare establishment (AHA, HIMSS, AllScripts’ customers, etc.) the HITECH Act, as currently drafted in the Stimulus Bill (both House and Senate versions of HITECH are quite similar), will ossify healthcare IT (HIT) completely stagnating innovation in HIT.  It is also questionable as to how much the HITECH Act will actually contribute to the ulitmate objective; simply delivering better, more cost effective care.

That is not to say that the use of HIT can not improve outcomes, that it cannot improve health, far from it.  What we argue is that this legislation is extremely problematic for it has created an incentive structure that is not conducive to innovation.

Where did the legislature make a wrong turn?

As we mentioned in our previous post on the passage of HR 1, HITECH legislation is providing incentives for physicians to be reimbursed for the adoption of “certified EHRs”.  Certification, by its very nature, is a time consuming (some might say time wasting) exercise. Certification to standards is even worse (ever been a part of a Standards making body – they move at a glacial pace).  Stating that physicians will only be reimbursed for adopting certified EMRs basically puts the death nail into any innovative ideas that break from the cumbersome certification process or don’t adhere to some archaic standard like CCD.

Let us not also forget that the very word “certified” strikes fear into the heart of any Venture Capitalist (VC).  Honestly, who in their right mind would ever invest in a start-up that need to go through some arduous certification process to enter a market, a certification process established by players in a given market?  No, certification is good at creating moats and castle walls and not greenfields that foster opportunities for innovation.

A second key point and maybe even more important one is that if the purpose of HITECH is to deliver better, more effective healthcare than the incentives are completely misaligned.  Just because we reimburse a physician for purchasing a certified EHR, doesn’t automatically equate to their using the solution to deliver effective care. We are providing incentives for actions, not behaviors.

And what’s the alternative?

To truly foster an open market, open innovation and subsequently open adoption of HIT, it is necessary to create a legislative framework of incentives that focus on what behaviors we wish to see adopted by physicians and not which technologies we wish to see them use.

For example, if we were to develop an incentive program that simply asks physicians to do a quick review of a patient’s current medication list prior to writing a prescription for a new medication and include checking for possible interactions, (prof that they checked might be easily monitored through the major eRx clearing house SureScripts) we would see a likely decrease in adverse drug events (ADE).  This could easily be tied to the current eRx push by CMS.

In this example, we are not incenting the physician to use a certain technology, but adopt a certain behavior (check before prescribing).  Imagine the impact if we saw but a 15% drop in ADEs as a result in such change in behavior. Now that’s savings, that’s better healthcare and it is a greenfield of opportunity.  Similar behavioral incentives can be created in numerous other areas.

It is clear that the legislature took the easy path as it is far simpler (and politically more expedient) to create incentives for the adoption of a technology, certified EHRs, rather than the more strenuous task of creating incentives to encourage behavioral change.  Unfortunately, if the current legislation ends up with Obama’s signature, we will be pouring wet concrete into a market with woefully low HIT adoption.  When that concrete sets, it will be nearly impossible to chip-out and we will be left with an edifice of good intentions gone horribly wrong.

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cashJust finished reading/scanning HR 1, the House Stimulus bill focusing on the HIT section, to which some $20B greenbacks will flow. This Bill just went just the Appropriations Committee and will likely pass the full house later this week. The HITECH Act (HIT for Economic and Clinical Health), is massive at some 190 pages, beginning on page 395 covering everything from codifying the Office of the National Coordinator (ONCHIT), to the numerous reports that ONCHIT has been instructed to fund, to how that $20B will be spent.

HITECH Act also carries with it a legacy of the Bush era: “The utilization of a certified EHR for each person in the US by 2014.”

Following are some quick, interesting highlights:

ONCHIT budget to soar over 4x to $250M for FY09 from the $61M it received in FY08.  Guess they’ll need all that money to fund those research reports, as well as support the new version of HITSP and AHIC, which is now called NeHC.

Both HITSP and NeHC become key advising entities to ONCHIT, HITSP on standards and NeHC on HIT policy.  Quite sure the folks in both groups are happy to hear this, especially NeHC as there was some question as to their survival if the feds did not dump $$$ in their coffers.

National Institute of Standards & Technology (NIST) to take a leadership role in testing standards and implementation specifications.

Substantial amount of writing on privacy, particularly consumer notification process should their health information be compromised.  Even had a special section on notification process for PHR vendors going so far as to reference third part data repositories (e.g, Dossia, GHealth and HealthVault).  Good to see formal procedures put in place, at the federal level to guide notification process – it’s about time!

Continuing on privacy, Bill also instructs ONC chief to appoint a CPO, Chief Privacy Officer.  This individual will have the uneviable task of attempting to coordinate helth data privacy policies across this great land of ours where it seems as though every State has their own unique twist.  Without some reconciliation on these privacy policies, the whole NHIN is nothing but a pipe dream.

A whooping $300M or RHIOs.  All those small RHIO software vendors must be licking their chops as this is a significant amount of money (about double the market size in 2008).  Expect to see consolidation and acquisitions as bigger HIT players look to get into this lucrative market.

Establishing an Extension Program for HIT.  Much like the existing Land Grant and Sea Grant programs and their extension services for agriculture and marine industries, the Bill proposes the establishment of a similar program for  HIT.  At one point in my career, I actually worked for Sea Grant, thus I know the model intimately and have mixed feelings.  Yes, it can be a very good model to reach out to small business and assist them in adopting best practices in the adoption and use of HIT, but often these programs, while well-intended, are not terribly efficient.  There is a universal benefit, however, in that often these extension services are located in academic institutions and thus can foster undergraduates and graduates to pursue research/careers in this field and right now, we can’t have too many.

trainFor the most part, we are comfortable with the above, but where the Bill really flies off the tracks is with the term:

“Certified EHR”

This term is used throughout the HITECH Act and refers to an EHR that is “certified” as:

‘‘(A) IN GENERAL.—The National Coordinator, in consultation with the Director of the  National Institute of Standards and Technology, shall develop a program (either directly or by contract) for the voluntary certification of health information technology as being in compliance with applicable certification criteria adopted under this subtitle… (want to dig deeper – go to page 407)

Basically what this states is that any reimbursements, payments, anything coming out of that $20B largess towards the support for adoption of HIT will only go to those instances where a “certified” EHR has been adopted or used.  And what it implies is that funding/reimbursements/incentives will onlygo to those who adopt nd use a CCHIT certified EHR.

This is a MASSIVE MISTAKE for the simple reason that it results in technology lock – technology locked to specific, “certified” criteria/standards resulting not in new innovative products, but actually retarding their introduction.

Need evidence?

Turn to the EPA and the Clean Air Act (CAA) (I did quite a bit of research at MIT for EPA on technology adoption in regulated markets, hmm, is healthcare much different, surprisingly no). The CAA when first promulgated specified specific technologies to be used to control and measure stack gases.

Benefit: Clear articulation of what technologies industry needed to adopt to comply to the CAA.

Outcome: Rapid adoption and use of these technologies leading to dramatic reductions in air pollutants.

Unintended consequence: When new and better technologies arrived on the scene, the EPA had no ready approach to get industry to adopt better technologies (without an Act of Congress) and as for diagnostic techniques for measuring stack gases, they were stuck as well.

Result: This stifled the US market for technology developers and subsequently, new technologies, once the regs were changed to incentives (trading emission credits) came from overseas, where the market was structured to advance their development and use.

Unfortunately, it does not appear that today’s legislature, nor those in HHS remember what happened at EPA with the CAA and have created an incentive program within this Bill that will result in exactly the same outcome as we saw in the environmental sector, rapid adoption, widely deployed HIT, technology lock-in with archaic standards such as HL7’s CCD and ultimately a technology frozen wasteland with other countries beginning to take the lead in HIT development, deployment and use.

Rather than follow this path, the Senate, in negotiation with the House, can strike the term certified from this legislation and instead encourage the adoption of HIT in support of scenarios that are based on information sharing and not just within an IDN but across a more expansive network.  For example, information sharing could be demonstrated by a physician being able to export of a health record, at a customer’s request, to that consumer’s personally-controlled online health account using CCR, CCD or other standard. Is that not in support of the objectives of data portability?  Of course, there is also the example of sharing health information within the context of an HIE or RHIO or other, more loosely formed network.

Therefore, it is not so much requiring that an EHR comply to specific criteria to be certified and thereby, the adoption of only certified EHRs will be reimbursed, rather it is to provide incentives that encourage what is our ultimate goal, putting health information into a digital form factor that can be securely shared among all relevant stakeholders in support of a healthier public.  After all, at the end of the day, is this not what we are all trying to accomplish?

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