Posts Tagged ‘PHR’

The market is abuzz about all things mHealth. Press coverage on provider-patient mHealth solutions is ramping up with a recent example being the pointcounterpoint piece in Forbes following the press waterfall about Happtique’s app-prescribing platform. We even wrote a piece recently about a personal experience using the iTriage app to self-diagnose E. Coli poisoning.

Here at Chilmark Research we have been following the adoption of mHealth solutions for some time and in addition to several private contracted studies for clients, published the report, mHealth in the Enterprise in late 2010.

We are now releasing our newest report, mHealth Adoption for Patient Engagement, Status, Trends and Forecast. This report takes a close look at adoption trends for mHealth apps that will facilitate provider-patient engagement. Our research uncovered a market with an enormous future ahead, (market will exceed $1.1B by 2017) but significant hurdles continue to stand in its way, at least for the near-term.

The report is both heartening and saddening. Heartening for the market will accelerate quickly in about three years time, a fairly short window for the healthcare sector. Saddened, because it means a lot of the current hype will overinflate expectations of impatient technology investors foraying into this unfamiliar space, greatly increasing the potential for high rates of failure as these investors pull the plug on their young prospects.

For the report, we started with the definition of mHealth from the WHO report mHealth, New Horizons for Health Through Mobile Technologies, published in 2011:

“…mHealth or mobile health is medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants and other wireless devices.

We then narrowed the scope to those offerings that went beyond mere monitoring and are truly engaging care providers in more continuous, patient-centered care. What we found should surprise no one that follows this market: there is almost no current market demand for such solutions, and offerings today remain in perpetual pilot stage.

The market won’t really be one to speak of until 2014 comes around. This is when CMS begins basing quality payments on a competitive scale. The advantage for these payments will go to provider groups that have already starting internal testing of first line innovations such as two-way patient messaging services.

The current mobile priority for progressive healthcare organizations (HCOs) is simple transactional systems that allow a patient to view their records via a mobile optimized PHR portal, and perform simple transactions such as appointment scheduling and prescription refill requests. These initiatives are largely being driven by the marketing department of HCOs to increase member/patient loyalty.

Adoption of these services is still incentivized by current payment models, where fee-for-service reigns supreme. Scheduling tools have repeatedly been shown to decrease patient no-shows and are hugely popular among users. Increasing the opportunity to provide billable services in the short term will equate to greater access to care in the long term as patients have the opportunity to adjust appointments according to their schedule, reducing issues around last minute cancellations, which happen with approximately half of all primary care visits.

The true revolution is in its earliest stages as more innovative organizations start to adopt patient-physician messaging tools. Over the past few years, a number of doctors were already starting to do this to improve their connection with patients, but standard email is often not secure enough to meet the requirements of HIPAA compliance. This has led to a number of companies developing solutions specifically for the sake of enabling more secure communication, some of which are just starting to be worked into the mPHRs previously discussed.

These ad hoc messaging systems are the first generation of what will later become true patient engagement solutions that focus on specific chronic diseases driven in part with patient-derived data. This will result in fundamentally different models of care provision, as patient-generated data factors into proactive, near real-time decision-making.

Over the ensuing years we predict convergence of disease specific care provisioning mHealth apps with an mPHR, secure messaging and various transactional tools. Today, no HIT vendor, whether from the mHealth, PHR, EHR or other has publically articulated such a solution suite though many look to be heading in that direction. The recent announcement by Aetna of its win at Banner Healthcare may be a very early indicator of what is to come.

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WebMD announced first quarter earnings today that showed continued lackluster results for their “Private Portal” division, slipping roughly 5% year over year from $23M to $21.8M.

Now one could argue that the overall decline in employment due to the recession is to blame for the drop in clients from 134 to 131 in Q1-2010, but we see something else at play: high pricing for low value delivered.

Having spoken to a number of existing and former customers of WebMD, one gets the clear sense that the private portal business is no longer core to WebMD’s corporate strategy and frankly why should they as they reported overall growth of an impressive 20%.

Its pretty clear to us that the private portal business of WebMD is a business they intend to milk for all it’s worth. This may create opportunities for newer companies to capitalize on. The challenge for them will be to provide a full suite of solution capabilities as few employers or payers today are seeking niche solutions.

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infoexInformation Exchange in support of care coordination is one of the three meaningful use criteria cited in the ARRA (Stimulus) legislation, with the other two being demonstrated use of eRx and ablity to provide quality reporting metrics.

In many conversations and presentations though, it appears that the consensus view is that “Information Exchange” is that which occurs between clinicians.  Funny thing though, the legislation never states that this is indeed the requirement.  Within the Recovery Bill, Division B, Subtitle A, Section 4101 that legislation states:

(ii) INFORMATION EXCHANGE.-The eligible professional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (CHi), that during such period such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination.

Thus, is HHS chooses to go down this path, Information Exchange for care coordination could be defined very broadly to include an entity that has a stake in coordinating care, including the patient/consumer.  Therefore, might a clinician that agrees to provide a consumer with open access to their records be construed to meet this particular requirement for “meaningful use”? If yes, portal providers such as EMR agnostic MEDSEEK or EMR vendors such as NextGen or Epic who offer a portal may see an uptick in their patient portal business.

But what might happen if HHS tied Information Exchange for care coordination together with the language of Division A, Part 1, Section 13405 (don’t you just love government docs!) which states:

(1) the individual shall have a right to obtain from such covered entity a copy of such information in an electronic format and, if the individual chooses, to direct the covered entity to transmit such copy directly to an entity or person designated by the individual, provided that any such choice is clear, conspicuous, and specific;

In such a scenario, we see portability of medical records in support of information exchange come to the forefront.  Might such an incentive encourage recalcitrant organizations to begin opening up and allowing patients/consumers to not only have a digital copy of their records, but request that it be sent to the PHR or personal health cloud of their choosing and then using their PHR as the locus for care coordination?

If such does come to pass, PHR providers may have a unique opportunity to assist physicians in addressing what will be one of the more difficult meaningful use criteria.  What Chilmark also likes about this scenario is that it gives the patient/consumer direct control of their records and in some respects puts them on more equal footing with the clinician>  This could become one of the few areas where consumers directly benefit from all the billions being spent on HIT.

One area that might trip this up completely though is demonstrating “care coordination.” It is here that the PHR vendor will need to focus their energies demonstrating that their solution provides the tools and capabilities in support of such among all stakeholders in this web of information exchange.

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Sitting in on the webcast by Google today, most discussions is focusing on Google Health. Doing “live tweets” via twitter which you’ll find at john_chilmark

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

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

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

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

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Here I am at the World Health Care Congress with what appears to be all the major movers and shakers in the healthcare sector, Chairmans, CEOs, Presidents, EVPs – some really big names, some very powerful players. Now I will never claim to be as brilliant as these people, after all, I’m writing this sitting in the audience and not up on the stage giving the presentation. But with all this cranium here at the conference, why do I hear so much dis-information?

For example, the session on PHRs and Consumer Engagement had panelists who could not accurately define the offerings of Dossia, Google, and Microsoft’s HealthVault and in some respects, had it completely wrong. These are the biggest players in this space, or at least will be soon, easily eclipsing WebMD, RevolutionHealth or any other PHR-like entity in the market today. Do they do this on purpose, or do they really just not know? Very disturbing when one thinks that these panelists were chosen due to their purported wealth of knowledge on the subject.

Another one is that red herring that I have ranted on in the past and is certainly a pet peeve, Privacy.  This issue still gets thrown out there by vested interests (and there are plenty of them here) who have little desire to release the records they control to some third party (or only reluctantly release them) that will stand between them and their relationship with the consumer.  Therefore, they throw out the Privacy Bogeyman to scare the consumer and it is really getting quite old.  I have yet to hear of one privacy breach at a PHR vendor, but weekly I hear of one breach after another at both payers and providers. So who is more secure?
The whining that physicians can not go digital because of costs. As I related in my notes from the first day, this should be viewed as an investment in the business.  Granted, there will not be an immediate ROI, but it will come in time, that I am sure of and ultimately, it will allow providers to participate in the future as more and more consumers look to engage their providers over the Web and desiring greater access and control over their records.  Again, a lot of dis-information on the topic that needs to stop.

Well, enough of my own whining.

There really are some great sessions here today including the keynote this morning from Safeway’s Chairman and CEO, Steve Burd. Safeway is doing some interesting things regarding promotion of health and wellness within their family of employees their families and even their customers.

Also intriguing story at EMC where to gain credibility for their PHR initiative, they brought in various medical research institutions to promote their ongoing clinical trials within the PHR and solicit employee participation.  Involving these research institutionsgave the PHR instant credibility and  was very instrumental in EMC’s internal push for PHR adoption. After about four years, adoption of the PHR at EMC stands at 50% of all EMC employees worldwide with adoption still growing.

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I’ll be attending the World Health Care Congress (WHCC) here in Washington DC getting my fill of all things healthcare and most likely an overdose on policy – after all, this is Washington.

The people who put on the WHCC have put together quite an impressive agenda with so many different and what look to be interesting tracks, the biggest challenge for me was just deciding which ones to attend.  In the end have chosen to focus on those tracks focused on consumer health including transparency, successful models for engagement, empowerment and the like.  Over the course of the next couple of days, I’ll provide a couple posts outlining some of the most critical issues raised and lessons learned from the various presenters and participants.  So stay tuned.

As an aside, had two interesting experiences yesterday, here in DC hainvg arrived a day early.  The first was meeting a man on the DC Metro who had flown in to attend a training session.  We got to talking and he asked me what I did for a living.  Told him healthcare and he immediately opened up with: “Healthcare costs and gas prices are going to drive us into the ground.”  As we continued talking he related his own, most recent experiences with the healthcare system.

He receives good coverage from his employer, though complained about his share of costs continuing to rise.  He has had a heart condition ever since he was a child.  Recently, he changed primary care physicians.  Despite a long record of a heart condition, his new doctor ordered a battery of tests that he estimates cost between $30-40,000.  Though he readily admitted that his costs were a few hundred dollars, he knew that in the end, we all will be paying higher prices to support such practices, that for him seemed at a sham.  He also found the multiple Explanation of Benefits (EOBs) forms that he received from the insurer during this whole process as to appear as though they were written in Greek – simply incomprehensible.

Now, I am not a doctor and certainly not one to judge whether or not these tests were unnecessary.  What this story does point out though are two important points:

  1. Might this consumer, if he had control of his records that were safe-guarded in one of the online data repositories like HealthVault, or Google Health, or even Dossia (if his employer was a member), be able to provide a complete longitudinal health record, maybe the physician would have decided not to order these tests.
  2. With all the talk from insurers about transparency, consumer empowerment and all the wonderful online tools that they want to provide to enable such, from this story it looks like they are getting a little ahead of themselves.  Rather than looking to the Internet and IT as the magic elixir to make all this happen, maybe insurers might want to start with something as simple and basic as making EOBs understandable.   Granted, not novel, nor sexy, but it may deliver better results.

The second little musing is that while heading over to the Hirshhorn Museum (my favorite here in DC, great sculpture garden and fabulous modern art) coming out of the Metro and what should I see plastered on the walls – at least 8 small billboard posters with that big smiling face of Magic Johnson saying something to the affect of “Together we will better manage our health.”

These are part of Aetna’s consumer advertising campaign to encourage greater consumer involvement in managing their health.  Really like this advertising campaign (seen full page ads in the WSJ as well).  As far as I can tell, they are the only major insurer being proactive on educating the consumer.  Now if we could just get the other big insurers (are you listening WellPoint, Cigna, UnitedHealth, etc.) to ramp-up their own consumer advertising to focus on a similar message, we may indeed begin to see consumers take a more proactive role.

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As many who read here know, one of the biggest challenges I’ve discussed regarding consumer adoption of PHRs is making these systems simple and automated.

Simple – as in the example of what Google has done to create a great, yet simple to use  interface.

Automated – to automatically populate a consumer’s PHR with pertinent health data, regardless of data source, be it pharmacy, doctor, hospital, lab, you name it.

While I do not mean to discount the fine work Google has done to create a simple intuitive user interface, honestly, this is not all that hard to do.

What is extremely hard and will remain a challenge for PHRs, the vendors who create them and subsequently consumers for the foreseeable future is getting that data into a PHR automatically, rather than having to do self-entry.  But how does one get their hands on that data?

Yes, there are issues with standards adoption and more broadly, healthcare IT adoption among providers.  But it is also an issue of control.  Whoever controls the data, controls the relationship.  Thus, many a healthcare stakeholder will be reluctant to fully release such data to the care of the consumer for their PHR, even though by right, it belongs to the consumer.

Like myself, Dana Blankenhorn over at ZDNet has been in the IT industry for a number of years and like me, not just healthcare.  Dana posted a great piece on the issue of data control this morning that is well worth the read for he really hits the nail on the head as to what the real issue is and the Teutonic struggles that lie ahead between all the various stakeholders that are fighting for the mind-share and ultimately control of the consumer relationship.

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While there has been plenty of press on privacy and security as it relates to PHR vendors, especially now that Google and Microsoft have jumped into the arena, it is absolutely critical that the press, various “privacy pundits” and the consumer realize that this issue is not just limited to PHR vendors.

Sure, it’s easy to pick on these companies, but honestly, it does not paint an accurate picture as to what the true risks are in the market today as we increasingly move to an environment where our medical records, and for that matter any information about us, will be in digital form. Yes, there are risks, but there are benefits as well, benefits which the majority of Americans are willing to accept in the pursuit of better care.

Now back to those PHR vendors. As I have stated before, the industry as a whole has not done a very good job of policing itself and insuring that the average consumer easily understands the privacy and security afforded to them in a given PHR.

But moving beyond PHR vendors, there are a number of others who also have information on your medical history. Earlier this week, one of the nation’s largest health plans, WellPoint, announced that it had a breach in security that exposed information on roughly 128,000 members. What is particularly disturbing in this case was that these records were exposed on the Internet for over a year and that this was far from an isolated incident at WellPoint.

And WellPoint is not alone. There was the stolen laptop in January that contained records of some 300,000 members of Horizon Blue Cross Blue Shield of New Jersey and the stolen laptop in late February of an NIH researcher with some 3,000 records. And there are many more such incidents you will find by simply doing a Google search.

And who said hospitals were safe? A report just released from the healthcare IT group, HIMSS (Health Information Management Systems Society) found in their survey of 263 HIT professionals that more work needs to be done to better protect and secure patients’ medical records.

This is, dare I say it, a universal issue that will affect any organization regardless of size and where they are in the broad supply chain of medical records, be they payers, providers, researchers, consumers and of course PHR vendors. There are no easy answers here and we may need to simply accept the fact that with the digitization of some of our most important and sensitive information, our medical records and history, that there will be risks which we will all share. Hopefully, the benefits that we will accrue through the adoption ad use of such digital records will outweigh those risks.

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Over the past couple of weeks I’ve uncovered a couple of recent reports that add to the growing body of evidence that employers will be one of the key markets for Web-based PHR vendors in the future. Going beyond the simple visibility that efforts such as the employer consortium Dossia platform will bring to the PHR market, employers are increasingly taking a long-term view towards employee health and wellness programs. Employers will increasingly rely on PHRs as a foundational element of their strategy.

Human Resources consulting firm Hewitt released late last week the results of a study it conducted among 500 U.S. employers. One of the most significant findings was that 88% of employers responded that they intend to invest in long-term solutions to keep employees healthy. This was up a whopping 25% over last year’s 63%. Within the report it is also noted:

…more than 85 percent of companies say they invest or plan to invest significant resources in long-term health and productivity initiatives over the next three-to-five years. In addition, almost two-thirds (63 percent) plan to offer incentives to motivate sustained health care behavior change, and 67 percent will utilize health care data and measurements to drive their organization’s health care strategy.

Clearly, based on the Hewitt survey it appears that a properly structured employer-sponsored PHR that provides employees with health and wellness information (and action plans) along with incentives as well as delivering employers key de-identified population health metrics, will go long ways towards helping employers meet their long-term objectives.

Another interesting, and in my view more comprehensive study, is the recent report from another HR consulting firm, Towers-Perrin. Their report, 2008 Health Care Costs Survey, (warning PDF) surveyed 500 large U.S. employers representing some 10 million employees. What is particularly attractive about this report are the comparisons made between employers that are high-performing, versus those that are low-performing. In a nutshell, high-performing companies will pay on average 16% less in 2008 ($8,532. vs $10,200/employee) for healthcare insurance costs versus low-performing companies.

High-performing companies take a very pro-active approach to managing healthcare costs in comparison to their lower-performing brethren by focusing at a nearly 2:1 margin on the following:

  • Motivating employees to manage healthcare purchases responsibly.
  • Support employees capability to make sound healthcare decisions.
  • Focusing on employee health management (e.g., population health analysis, pro-active management of high risks, disease and chronic care management, etc.).

Each of these three can be supported to some degree by the better PHR solutions in the market today

The challenge for employers, however, is still a mixture of gaining employee trust and the need to provide appropriate incentives. Sponsoring a PHR for employees may certainly be a step in the right direction, but how that PHR is presented to employees will make a world of difference as to its ultimate adoption and success. As the Hewit study points out, a significant percentage of employees are still hesitant to trust the motivations of their employers and often do not follow-up on health recommendations without incentives. How employers address these issues will ultimately decide the fate of their internal efforts to control healthcare cost increases.

The California Healthcare Foundation has provided some initial guidance, for employers looking to adopt a PHR platform for their employees. While somewhat perfunctory, this will be of some value to those employers just getting started.

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