Posts Tagged ‘RHIO’

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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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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With a poor track record to date getting Regional Health Information Organizations off the ground, the Office of the Coordinator of Health Information Technology within HHS is now looking to expand the National Health Information Network (NHIN) to exchange data with both Google Health and Microsoft’s HealthVault.

But first the Feds look to be scaling back their broad ambitions from a massive NHIN that incorporated (and funded) public and private entities with state and local RHIOs in a federated-type network. This is not working RHIOs seem to be collapsing about as fast as new ones are created as most do not have a sustainable business model. Now the Feds are focusing on what they can control forming a multi-agency initiative (includes such entities as the VA, Dept of Defense, Indian Health Services, CMS, CDC, etc.) to develop NHIN-Connect. The objective of NHIN-Connect is to create an information exchange gateway that these federal agengies can use to exchange electronic medical records. Couple of weeks ago, long-time Government contractor, Harris, won their first healthcare contract for $6.1M for the first phase NHIN-Connect. Please, don’t even get me started on why these contractors are allowed to keep feeding from the federal trough, even when show little experience – talk about a good ol’boy network.

Getting back to Google and Microsoft, this admission by the Feds to open and connect to these two consumer platforms clearly points the way as to how the future of NHIN will develop. It will not be in the control of the federal government, but consumers and those that serve them. But this does bring up a couple of questions as well. For example:

  • What about Dossia, will they be seen in the same light as Google and Microsoft by those leading NHIN initiatives?
  • When we start looking at privacy and security, how will Google and Microsoft address as the proxy for consumers in the broader context of population health studies that the CDC and NIH may want to do against aggregate data in the NHIN?

There are few easy answers and the questions are many. Ultimately, it may be Google and Microsoft (and Dossia) who end up calling the shots as they will be closest to the end consumer and those in Washington DC promoting NHIN will simply follow in their footsteps.

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

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

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


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

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

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

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

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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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In the recently passed 2008 Federal budget, Bush did not get his requested increase for the Office of the National Coordinator for Health Information Technology (ONC). Instead, Congress flat-lined ONC’s budget for 2008 holding it steady at $61.3M. Clearly, Congress is not all that impressed with the activities at ONC.

In an article in Government Health IT the head of ONC, Dr. Kolodner is quoted as saying that certain initiatives will be curtailed with the National Health Information Network (NHIN) taking the biggest hit. NHIN funding has been one of the primary sources of funds for Regional Health Information Organizations (RHIOs). With RHIOs struggling to become viable and most still highly dependent on such grants, it looks like one of my predictions for 2008 is closer to becoming reality, and we are only in the first week of the New Year!

Another casualty will be a planned effort to define a Personal Health Record (PHR) architecture. Thank goodness.

Really have a hard time understanding why the government wishes to get involved in such an activity and what meaningful contribution they could make. Organizations such as the Markle Foundation is promoting a Common Framework, the Robert Wood Johnson Foundation is sponsoring Project Health Design, CMS is working with HealthTrio and IBM on a PHR test case, and the list goes on and on.

Adding to that are what are arguably the most significant PHR architectural efforts today, those of Microsoft with HealthVault and Dossia. Both organizations are much more in-tune with the market and are aggressively moving ahead with a new architectural construct for the PHR market, that of a Personal Health System (PHS).  These systems will, if successful, become ecosystems for personal health applications (PHR a subset thereof) and will ultimately establish an architectural framework that is as much market-driven as it is needs-driven, rather than a perverse, government mandate-driven architecture.

This is something that ONC should not even think about attempting. Thankfully, Congress was thinking the same thing.

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A common practice in the analyst community is to take a look back at what has occurred and project forward as to what we might see in the coming year. I won’t spend anytime on what has occurred as you can always drift back to previous posts.

Following are the Top Ten predictions for 2008. Note, these predictions are primarily focused on our core research competency – Personal Healthcare Technology. And if these top ten differ from yours, by all means give us a comment providing your list.

1.) Election Year Puts Many Initiatives in Neutral
2.) Telehealth Continues to Gain Momentum Driving Consolidation
3.) Consumer Electronic Manufacturers Jump on Telehealth Bandwagon
4.) Legacy HIT Vendors Copycat AthenaHealth with Their Own SaaS Offerings
5.) PHRs Still in Headlines, While Adoption Stumbles Along
6.) Attention Turns to PHSs, but Vision Remains Well Ahead of Reality
7.) PDF – Healthcare Hits the Streets, Retail Clinics Love it, Physicians Less So
8.) Personal Identifier Initiatives on the Hill are DOA in ‘08
9.) Employers Expand High Deductible Plan Offerings, Consumers Challenged
10.) HIEs Hold Steady, RHIOs Fade Away – Major Re-thinking of NHIN

Election Year Puts Many Initiatives in Neutral
As the Bush administration continues to see high-ranking officials leave office, no new healthcare-centric initiatives are launched and those, such as the ill-fated National Health Information Network (NHIN), are put on life-support. Even pay for performance (P4P) activities are pulled back until a new administration is in place (mid 2009).

Telehealth Continues to Gain Momentum Driving Consolidation
2007 saw several reports touting the efficacy of telehealth practices, from interacting with a physician over the Internet to the migration of outpatient care and monitoring to the home via health sensor networks and the Web. This will be one of the strongest areas of growth in healthcare technology in 2008 with annual percentage rate growth in the mid-teens. Growth will drive consolidation, as large established players such as Philips, GE and Siemens acquire smaller device manufacturers with either unique technology platforms or specific vertical market presence.

Consumer Electronic Manufacturers Jump on Telehealth Bandwagon
The growth in telehealth and simple demographics (this market will only get bigger) will attract other electronic manufacturers with strong Brand and established consumer distribution channels. Think Sony, Toshiba, LG. Still too early for Nokia and Apple, but they are coming. These companies will also look to acquire, or partner with established players in the personal health technology market to gain domain knowledge and market presence. The upcoming CES confab in Las Vegas may shed some light on who will make the first move.

Legacy HIT Vendors Copycat AthenaHealth with Their Own SaaS Offerings
The success of AthenaHealth in the market and on Wall Street (10th best performing IPO in 2007) is certainly not lost on the traditional Healthcare IT (HIT) vendors. Like the software firms in the enterprise market who have all tried to replicate Salesforce.com with their own SaaS CRM solution, expect the legacy HIT vendors to do the same in their attempts to replicate AthenaHealth. Expect the same lack of success. To date, none of the traditional enterprise software vendors have been able to catch Salesforce.com, which still shows remarkable momentum in the market.

PHRs Still in Headlines, While Adoption Stumbles Along
With the impending release of Google Health in the first half of 2008, we will continue to see a lot of press dedicated to Personal Health Records (PHRs). Despite the press and employers who continue to adopt these solutions for their employees to foster better healthcare practices, there remain many significant challenges that will prevent the PHR market from really breaking out. Expect 2008 to be a build-out year for PHR vendors, thus tracking large customer wins, partnerships and alliances of these vendors will be critical to assess long-term viablity.

Attention Turns to PHSs, but Vision Remains Well Ahead of Reality
Microsoft has HealthVault, employers have Dossia and Google will have Google Health (or some other Brand name) by mid-2008. All of these are Personal Health Systems (PHSs). They are not a PHR, but a data repository and ultimately a utility that other applications, including PHRs can tap to serve the consumer. Each of these PHSs have enormous resources behind them, but their vision is far ahead of what they will be able to deliver in 2008. There is a lot of heavy lifting (standards, tagging, document management, security, etc.) that these entities will need to address, consuming most of 2008. Look to mid-2009 for these systems to be at a level of functionality that is useful to the broad market.

PDF-Healthcare Hits the Streets, Retail Clinics Love it, Physicians Less So
The “Best Practices Guide” for the use of PDF-Healthcare is making its way through the formal review process with expected release in the next month or so. Currently being used by one of the largest retail clinics, PDF-Healthcare has demonstrated its utility for this retail clinic that is now exchanging over 10,000 unique PDF-Healthcare documents a day throughout its organization.

While this retail clinic has reaped a number of advantages through the use of PDF-Healthcare, and larger healthcare providers will do so as well, smaller physician practices will be challenged by this format as most are ill equipped to accept such digital documentation. Thus, PDF-Healthcare will become another forcing function for physician adoption of EMR, something that most have been loathed to do.

Personal Identifier Initiatives on the Hill are DOA in ‘08

Several proposals surfaced in 2007 calling for the establishment of a personal identifier for American citizens to better track/tag their medical records. This is becoming increasingly relevant as use of digital records accelerates. Despite a very real need for personal identifiers, this issue exacerbates existing fears of privacy and government intrusion. Thus, this will not see the legislative light of day in 2008. A new administration may take it up in 2009 if they receive a strong mandate from the public (i.e., a landslide victory).

Employers Expand High Deductible Plan Offerings, Consumers Challenged
Building upon the growing trend we saw in 2007 of employers seeking new ways to lower their exposure to double digit growth in medical benefit costs, consumer-driven health plans, most often with high deductibles, are now in vogue. Young, healthy employees sign-on to such plans, chronic care sufferers reject them and middle-age employees with families struggle to determine what is best for them. Unfortunately, for this latter group few resources are available to assist them with making the best choice. And as for those young, healthy and very often Internet-savvy employees, they look to the Web to help them pick a doctor and control expenses. But they to will come up empty handed as cost transparency will remain elusive in 2008.

HIEs Hold Steady, RHIOs Fade Away – Major Re-thinking of NHIN
The reports released at the end of 2007, the first on the relatively dismal state of Regional Health Information Organizations (RHIOs) and the second on the modest success of Health Information Exchanges (HIEs) were simply a harbinger for 2008. Expect 2008 to deliver more of the same for RHIOs as they continue to struggle to establish a value proposition that will overcome competing entities participation in a RHIO. And there is the nagging issue of a revenue model for RHIOs to make them self-sustaining long-term – to date, this issue has not been solved. Both of these problems will lead to nearly a third of the remaining RHIOs closing their doors by the end of 2008 and another third will be best characterized as the walking dead.

While RHIOs fade, HIEs will continue to operate and see modest growth. Unlike RHIOs, HIEs are formed by entities that have a strong desire to share information, not withhold it. But HIEs will not be the panacea to the need for a NHIN as their reach will be limited and highly localized. This will limit the overall growth of HIEs and subsequently, their impact to the market.

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