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PHAT: Mash-Up on Healthcare IT

November 19, 2009 by John

On Monday, I participated in the Harvard School of Public Health event, Public Health and Technology (PHAT) which brought together a diverse views of healthcare, reform and the role that IT will play.  The morning session focused on the status quo so to speak addressing the challenges of HIT in the clinical setting and the fed’s initiatives regarding the HITECH Act to get clinicians wired.  The afternoon session, which began with a keynote by Keas founder Adam Bosworth on consumer access and use of IT to self-manage their health and health of loved ones.  A lot of ground was covered over the course of this day long event with highlights provided in a mash-up below.

Current State, Clinicians, ARRA and HITECH Act:

Harvard professor Asish Jha gave a fairly disheartening current state of HIT adoption by clinicians and hospitals in the US.  His presentation was based on research he has been doing to understand current adoption of EHR in ambulatory and acute settings.

Over 90% of hospitals have no functional comprehensive EHR today.  Those that do tend to be large hospitals and teaching hospitals. Inadequate capital (73%), maintenance costs (44%) and physician resistance (36%) are cited as the top three barriers to adoption.

In the ambulatory setting, 83% do not have a functional EHR today, though 17% of those stated that they have purchased such but have not implemented and another 26% plan to purchase such within the next two years.  Top three barriers to adoption: lack of capital (67%), finding a system that meets their needs (54%) and uncertainty of ROI (51%).  Interestingly, in fourth at 45% was the fear that the EHR would become obsolete. This particular fear may be one that EHR vendors with an SaaS solution could easily defend against.

In both the acute and ambulatory settings, the number one hurdle, access to capital, may be rectified through the HITECH Act, that is if those expecting reimbursement meet meaningful use criteria.  And therein may be a challenge for John Halamka, in his keynote stated that there will be no partial reimbursement for meeting just part of meaningful use.  Its all or nothing folks.

In comparing US adoption rates of HIT with other countries, the US is in good company regarding acute care setting adoption but in ambulatory settings, we are far behind our peers.

Halamka gave a great overview of HITECH Act, its many nuances and what the future may portend.  His slide on the ARRA business model was particularly enlightening.

During the morning panel discussion we heard such things as:

David Cutler, Harvard economist and adviser to Obama administration stating: “Anyone wonder where all the middle managers have gone since the start of the recession? They are now in healthcare. There are now more mid-level administrators in the healthcare sector than nurses.“  Sobering statistic!

Prof. Jha has found no conclusive evidence that shows EHR adoption contributes to lowering costs or improving quality.  Steve Lohr, reporter for the NY Times wrote an article on Ja’s findings just prior to this event.

Karen Bell, formerly of ONC and now with MassPro was quick to point out that one should not despair that no conclusive evidence has been found as to the efficacy of EHRs for it takes several years for IT to make its impact known and measurable.  She’s correct, just look at the productivity paradox that occurred in manufacturing which began adopting IT in earnest in the 80’s and true productivity gains do not begin to present themselves until a full decade later.  We can expect similar results in healthcare.

Bell: “Doctors starting from scratch today in adopting an EHR will not likely meet meaningful use criteria for reimbursement in 24 months, hurdle is too high, experience in effectively using these systems too low.  More likely to meet criteria in 36 months.” Hmmm, might the regional extension centers provide assistance here? Oh, that’s right, these are not in place yet either. Train wreck coming?

Cutler: “Underwhelmed by the healthcare industry’s adoption of best practices from other industries.” I share this belief despite all the calls from healthcare stating, but we are different.  Complete BS and there are some forward thinking individuals in healthcare who are, for example, adopting lean and six sigma – hat’s off to them.

Jha and Halamka: Both see tremendous value in HIT as it relates to quality and comparative effectiveness research.  Big issue here is that few if any EHRs in the market today are structured to collect, analyze and report on such metrics.

Bell: “There has been plenty of talk on HIT standards but woefully little on implementation guidance, i.e., how to bring data in, incorporate it into workflow, make it actionable and facilitate efficiencies in care.” Amen.

Consumer Empowerment through HIT:

While I would love nothing more than to provide a complete report on this portion of the event, unfortunately I was moderating the panel and thus, did not take notes.  But I will report on what Adam Bosworth had to say as well as some results of a quick survey I did of the audience.

Adam Bosworth, formerly head of Google Health’s initiative and now launching his start-up, Keas gave the afternoon keynote. Drawing from personal experience (health), IT knowledge (one of the original developers of XML), and the healthcare sector, Bosworth gave a wide ranging talk about the challenges this country faces (declining number of primary care docs, tripling of obesity in 20yrs, healthcare costs projected to hit $3.4T by 2013, etc.).  A couple of key points Bosworth’s made:

There is no demand for EHRs, demand today is artificially derived through incentives. Today’s EHRs are not easy to use, are not intuitive and there has yet to be a proven and repeatable model for ROI.

In every industry there are methods for direct data transfer between entities.  There are no “regional exchanges” to assist with data transfer so why are we focusing on building regional HIEs? In healthcare if doctors could only have access to two things, they would choose labs and meds. Bosworth claims that between SureScripts, LabCore and Quest, we have those basic needs met.  Not so sure about that as hospitals still perform a lot of tests themselves and I don’t believe SureScripts handles all classes of medications.

Before the afternoon panel formerly began, I asked the audience of about 100 a few questions, here are the responses:

Q: How many have used the Internet to conduct a health related search in the last year?

A: 99% answered yes.

Q: How many have a smartphone?

A: About 50% of audience use a smartphone.

Q: Of those with a smartphone, how many have a health related app on their phone?

A: About 65% have a health-related app installed.

Q: How many found their current doctor online?

A: About 25% of the audience.

This last question and answer was the most shocking to me.  Yes, it was a self-selected crowd. Yes, the audience had a significant number of young people (~50%)  as many grad students were in attendance.  But still, nearly 50% of this demographic finding their doctor online – WOW!  Get a clue doctors, this is the next generation of highly educated digital natives.  This is the future and it won’t be too long until this generation will begin raising families and they have very high expectations as to how they expect you to interact with them.  I’ll give you a hint, it ain’t paper, it ain’t a fax and it ain’t a phone call.

The Wrap:

The organizers of this event did a fabulous job of bringing together some very diverse views and perspectives on healthcare IT, not an easy thing to do and the results were thought-provoking, enlightening but also showed the large riff between what are two nearly diametrically opposing views on healthcare IT policy.  On one side you have the status quo, or at least that is how it appears, of driving physician adoption of HIT, a model that can be argued is based on a premise of the provider remains in the driver’s seat. It represents the legacy, provider-centric model of care.

On the other side, you have those arguing that where we really need to invest is in consumer engagement insuring that the consumer is the end beneficiary of healthcare IT investments, thus a consumer/patient-centric model of care. In this vein, investment needs to be directed at new tools that allow for more proactive and productive engagement and communication between physician, patient and community in support of care.

Ultimately, the market will decide but in the meantime, we taxpayers may end up wasting a lot of Stimulus dollars on a program that is forcing systems on clinicians rather than letting the market push from the ground up.  It is quite clear from that little survey I did of this audience that change is occurring and this change will accelerate with or without Stimulus dollars.

Posted in EHR, EMR, HIE, HIT, PHR, RHIO, consumer health, policy | Tagged , , | 6 Comments »

Covisint Jumps onto PaaS Bandwagon

November 15, 2009 by John

A couple of weeks ago Chilmark Research did a small piece on the need for HIE vendors to move beyond silo’d standalone exchanges to a Platform as a Service (PaaS) model.  In the write-up, the HIE vendor Axolotl was mentioned for their recent announcement of a third party image viewing app that was now available on their platform.  In speaking with Axolotl’s President, Glenn Keet, he stated that this was the first app of many that would eventually be hosted on the platform. As Keet rightly put it; there are far too many needs in healthcare for any one vendor to satisfy and that partnershps wil be critical moving forward.

As a result of that post, Chilmark received several private emails from HIE vendors all stating that they were on a similar track to Axolotl’s.  One of those who contacted us was Covisint, who announced their AppCloud last week.  (for more background on Covisint, see the piece we wrote over a year ago) written We had a briefing with Covisint late last week and Covisint was kind enough to send us their slide deck from the Healthcare IT Summit where they announced AppCloud.

appcloud1In this first slide, Covisint lays out the key attributes of a PaaS model, both for independent software vendors (ISVs) and end-users (clinicians). Nothing wrong with those value propositions but I would add one for end users, ability to easily switch among various apps, say from one EMR solution to another.  Covisint also left out one potential beneficiary, those hosting the HIE.  As we mentioned in the previous PaaS post, far too many RHIOs do not have sustainable business models.  Offering access to apps, conducting simple transaction services (reporting for meaningful use) etc. could provide these RHIOs with a steady revenue stream.

appcloud2Now this is a great slide for it clearly shows how bringing together multiple solutions and services into one PaaS can facilitate a physician’s need to meet the multitude of “meaningful use” requirements.  Another key benefit of the PaaS model is that a physician need only do a single sign-on to access all the apps and services on Covisint.  This is both more secure and a lot easier to deal with then having to log-in separately to a multiple apps.

appcloud3The AMA is Covisint’s lighthouse customer (early adopter) of the AppCloud concept and has been working closely with Covisint to build out these capabilities to serve their membership. The AMA has some pretty big plans for this service, including offering an EMR from AllScripts, but it remains to be seen just how extensive this service will ultimately be and more important, whether or not its membership will find value in it.  AMA’s track record in the software arena is hardly stellar (Medem) and not convinced their venture here will succeed but wil give them credit for at least being creative and pushing the envelop.

Looking Ahead:

While Chilmark Research may have been one of the first analyst firms to write on the topic of HIE vendors morphing into healthcare-centric PaaS, it appears that the vendors themselves have been spending some time thinking about this issue and how they can structure themselves to capitalize on this evolution in the market.  The future battleground will likely be the fight for partners.

There are only so many stellar ISVs with broad brand recognition in the market.  The Axolotls, Covisints, etc. will be out in the market courting the best-of-breed ISVs to build to their platform first and not a competitors. The skill and speed at which these HIE vendors can land those relationships will be a key metric to watch as this market, with $560M coming down the pike, shifts into high gear.

 

 

Posted in EMR, HIE, Health Cloud, Privacy, RHIO, Security | Tagged , , | 3 Comments »

Blumenthal Beats HITECH Drum

November 13, 2009 by John

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

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

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

Blumenthal closes his first bullet point with:

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

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

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

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

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

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

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

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

Posted in EHR, EMR, HIE, RHIO, policy, standards | Tagged , , , , | 3 Comments »

Harvard Health Forum to Tackle Consumer HIT

November 10, 2009 by John

hsph_logoNext Monday I’ll be participating in the Public Health & Technology (PHAT) Forum at the Harvard School of Public Health, an event by and large organized by Harvard’s Public Health grad students.  I feel honored to be moderating the afternoon panel that will address “Patient Empowerment Through HIT.”  Last I heard, there were still a few openings left so if you are in the area, encourage you to attend this event.

Organizers have put together a top notch panel that includes:

Esther Dyson, well known in consumer health IT circles and now on the Advisory Panel of the new e-Journal, the Journal for Participatory Medicine.

Steve Munini, COO of the employer led health platform Dossia.  Steve hosed Chilmark’s recent visit to Dossia for an in-depth briefing resulting in the post, “Round Two: A Dossia Update”

Fred Smith, from Centers for Disease Control and Prevention (CDC) where he leads the interactive media team within CDC’s National Center for Health Marketing.

George Willock, CEO and co-founder of the employee health & wellness service HealthString.  Had the pleasure to be briefed by George at their offices in Chicago, which was quite uplifting after a pretty depressing visit to the HIMSS annual conference.

While I have not prepared any specific questions for the panelists, yet, I have broken down my ideas into three thematic areas (Note: as roughly 50% of the audience will be grad students, I have tried to target thoughts and questions towards exposing and reflecting on what the future may hold and less on yesterday and today):

Innovation: An ever increasing array of consumer-facing, healthcare apps, devices and services are entering the market enabling a citizen to take on more direct responsibility for managing their health and/or the health of a loved one. Such innovation empowers the citizen and making them less dependent on a healthcare provider. How will this change the role of healthcare providers in the future?

ARRA, Meaningful Use & Digital Records: The federal government is investing some $36B+ into digitizing the healthcare sector.  Unfortunately, virtually all of this is going directly to hospitals and healthcare providers and little has been discussed or earmarked directly towards citizens, with the exception of “meaningful use,” and even that remains fuzzy.  What will the impact be to care, citizen empowerment, and more broadly healthcare reform through the digitization and distribution of medical records?  What are the risks and are we adequately prepared to meet them?  In five years time will we see a much deeper engagement between citizens and clinicians as a result of this investment?

Provider-centric vs. Patient/Citizen-centric Care: As citizens are being asked to take on an ever increasing responsibility for their care (insurance co-pays, health incentives, disease mgmt, etc.) and are given the tools (HIT) for greater empowerment, we ill see a shift from a provider-centric care model (and IT architecture that goes with it) to one that is patient/citizen-centric. What does this shift mean to current HIT architectural models?  How will this shift impact future care delivery models?

Posted in Dossia, EHR, consumer health, policy | Tagged | 2 Comments »

PaaS Challenges for HIE Vendors

November 3, 2009 by John

Yesterday’s post took a look at the future for the Health Information Exchange (HIE) market putting forth the projection that successful HIEs will move towards a platform as a service (PaaS) cloud computing model. Market forces (meaningful use) and simple logic are driving this transition.

Since putting up the post, Chilmark has received several emails from HIE vendors; without exception, all state that they are now moving in this direction.

But what yesterday’s post failed to mention were some of the likely challenges HIE vendors will face in making this transition.  The figure below outlines the top three we foresee.

PaaS challenge

What do you foresee as the top three challenges for incumbents? Will new entrants simply leapfrog over incumbents or as in the past, will these new entrants simply burn up a lot of cash/resources and walk away from this market (this seems to have repeated itself in the HIT sector numerous times) with little to show for all their efforts?

Posted in HIE | Tagged , | 3 Comments »

Rant: Huffington Post No Friend to Small Business

November 3, 2009 by John

A bit miffed right now with the Huffington Post.

A couple of weeks ago I was interviewed by one of their reporters regarding the proposal to rename and refocus the federal government’s National Health Information Network (NHIN) the Health Internet.  The reporter did a fine job on the article, well researched, well written and I was quoted.

Problem was my attribution.  Initially, the article read John Moore, healthcare blogger.  No, that is incorrect I told the reporter on Monday.  I am an industry analyst and founder of the analyst firm Chilmark Research LLC.  I requested that they change the attribution to reference my affiliation to Chilmark Research.  No go. The best they said they could do was to reference me as an analyst.

Now if it were an analyst firm like Gartner, Forrester, heck even IDC, they would likely reference these firms along with the analyst quote.  So why not a small firm such as Chilmark Research that is relatively new to the market?  No answer.

I even argued that numerous publications including InformationWeek, Health Data Management, HealthIT News, the AMA, and many others recognize Chilmark Research as a viable firm. And certainly my clients, including several Fortune 500 firms also recognize Chilmark Research.

So what gives Huffington Post?  Why do you choose not to acknowledge a small firm?  Again, no answer.

And to think, I once thought Huffington Post was a truly reputable eZine.  They have certainly slipped a few notches in my book.

Posted in PHR | Tagged | 1 Comment »

HIEs, Future PaaS for Healthcare?

November 2, 2009 by John

iaas-paas-saasAn interesting, and somewhat overlooked press release came out last week from the health information exchange (HIE) vendor Axolotl wherein they announced that a third party independent software vendor (ISV), eHealth Global Technologies, would be available on top of the core Axolotl HIE application, Elysium Exchange.  The new app, Elysium Image Exchange allows for secure image exchange among HIE participants.  Though the new application may appear like nothing more than Axolotl contracting out the building of an app desired by its HIE customers, there is a more here than meets the eye.

HIE Vendors as Future PaaS for Clinical Needs

Independent HIE vendors (not part of a larger EMR vendor) such as Axolotl, Covisint, dbMotion, InterSystems, Medicity and RelayHealth are in a unique position to become more than just an HIE focusing on the exchange of clinical records but could become Platform as a Service (PaaS) vendors providing a wide range of services and apps on top of their core infrastructure, OS and App Server stack.  The following two figures illustrate what is possible should these vendors open up their application programming interface (APIs) to allow other ISVs to build apps on top of their HIE platform.

HIE1

HIE2

HIE vendors are in an ideal position to become a PaaS for they already have the key features necessary.  As aggregators and distributors of clinical data in a secure fashion, these vendors have the core infrastructure already in place.  They have the data repository, they have the master patient index (MPI) and they understand what is required to address privacy and security requirements of data exchange within a network.  What these vendors, by and large have not done is open their APIs to third party ISVs to truly create a PaaS.

In speaking with Axolotl’s president Glenn Keet he stated that they came to the realization that they alone could not move fast enough to meet the needs of the market.  While they currently offer an CCHIT certified “EMR lite” for small physician practices there are a multitude of other services that they foresee.  For example, within the “meaningful use” criteria that physicians will need to demonstrate to receive reimbursement for EHR adoption, there are a number of quality reports that must be created and filed with CMS.  Keet envisions ISVs leveraging Axolotl’s APIs to create services to automate such reporting.  Meaningful use criteria also will require physicians to sponsor a PHR for their customers.  Again, with an open API, PHR ISVs could sit on top of the Axolotl (or other HIE vendor) platform and provide such capabilities. Clinical decision support (CDS) tools are another app/service that would be ideally suited to sitting on top of an HIE PaaS.

Microsoft is another vendor who is now venturing in to the HIE market with its Amalga platform, which is the foundation for the Wisconsin HIE (WHIE).  Using its core Amalga UIS along with HealthVault, Microsoft could also create a clinical PaaS with a multitude of ISVs providing services to the physician market. To date and to our knowledge, this has not occurred but we’re pretty sure Microsoft is looking into providing such capabilities as it would be in alignment with other actions that they have done to date in the healthcare sector.

What this may portend is the creation of PaaS that support the concept of substitutable apps as laid out by Ken Mandle and Issac Kohane of Children’s Hospital Informatics Program (CHIP) Boston. Another proponent is David Kibbe with what he refers to as Clinical Groupware a concept he first described back in Febuary 2009.  In each of these examples, the dominant theme is the move away from monolithic EMR/EHR apps to small, lightweight apps that are invoked when needed.  More information on this concept can be found at the recently created site: ITdotHealth.  (Note: Unfortunately, at the recent meeting at Harvard Medical School, Health Information as a Platform, which was organized by Mandl and Kohane, outside of Microsoft, there did not appear to be any representation from HIE vendors.)

An Opportunity for RHIOs to Become Viable?

A lot of effort and money is now being poured into the build-out of public Health Information Exchanges (HIEs) that are commonly referred to as Regional Health Information Organizations (RHIOs).  While many see it crucial to build out this information exchange infrastructure to support care coordination (a key criteria for stimulus funding reimbursement for EHR adoption), the challenge for RHIOs has been to create a business plan that insures long-term viability of a RHIO once grant funding drys up.  The market is littered with failed, failing and simply struggling RHIOs.  Recently, while sitting in on a conference call where a State RHIO discussed their go-live plans a question was asked: Do you have a model for sustaining the RHIO long-term?  To which the Executive Director of the RHIO replied, No.

But might not a RHIO that is actually a PaaS for a given region or State, become a provider of Clinical Groupware including a range of services and applications such as multiple lightweight EMRs to choose from, say one for pediatrics, another for orthopedists, a third for general practioners, quality reporting services, a range of CDS apps, etc. charging a small transaction fee for the use of such services and thereby begin to create viable service-based business? We think so and see this as the next evolution in the HIE market.

Posted in EHR, EMR, HIE, HealthVault, Microsoft, PHR, policy | Tagged , , , , , | 1 Comment »

Halloween Treat in DC

October 30, 2009 by John

halloween

On my way to the Metro to attend the mHealth Summit came across this Halloween-themed protest against payers and in support of healthcare reform.  They had the haunted music blaring, the megaphone manned by a Zombie.  How fitting in these times of great controversy regrading reform and just a tad ironic as I headed to a healthcare event where the technology being discussed may lower health disparities and in its own small way contribute to healthcare reform.

Posted in PHR | Tagged | 1 Comment »

Learnings from mHealth Summit

October 30, 2009 by John

mHealthOver the last two days, been attending the Foundation for the NIH’s event, the mHealth Summit.  This being its inaugural year, the event has been covering a wide gambit of issues, but the majority of panel sessions, keynotes and what not have focused on the use of mHealth tech for addressing public health needs in developing countries.

Key Take-Aways:

mHealth is clearly a top priority of the Obama Administration. Rare that an inaugural event would attract HHS Secretary Kathleen Sebelius as keynote speaker when so much is happening on the Hill regarding healthcare reform. In addition to the Secretary, day two had a keynote by US Ambassador Elizabeth Fawley Bagley.  Brian Dolan of mobihealthnews.com did a nice write-up on the Secretary’s keynote.

mHealth initiatives in developing countries do not have a sustainable business model, all are grant funded. Big problem here as the researchers are not structuring their research to collect the data needed to justify the investment(s) and subsequently define sustainable business models for the mHealth technology they have deployed. Crazy!  This is not basic research folks and those funding these initiatives need to be more diligent in reviewing proposals to insure that such data types (hard and soft savings metrics) are collected. (For a counter view on this issue read ICTworks post on the topic. FYI, ICTworks is part of inveceo, a small company formed out of Josh Nesbitt’s, who is a Stanford student, work in Africa. Josh gave one of th better presentations at this event, very inspiring.)

African countries want a platform that allows them to build mHealth apps that address the priorities they chose in a manner that reflects their culture. Consultants and pre-packaged, shrink-wrap solutions need not apply. (Note: OpenMRS appears to be gaining wide popularity in developing countries.)

Most mHealth efforts/research & roll-out, at least expressed at this event, are very narrowly focused on one disease state. Research has borne out time and again that the vast majority of those with a chronic condition and many with an episodic condition suffer from some other co-morbidity, particularly in the realm of mood disorders.  More work is required to build out these mHealth apps to be still simple to use, but also multi-faceted to address whole health.

There are some really outstanding results in the use of mHealth. One of many examples presented: A public health texting service in South Africa addressing AIDs and TB awareness, encouraging those at risk to call public health clinic, resulted in call volume increase of over 300% to public health clinics that has not subsided.

Iterative user interface design is critical. Those deploying mHealth solutions in the field have found that designing the user interface (UI) is not trivial by any means (is it ever?) requiring an iterative process as one is dealing with very small real-estate inherent in mobile devices.  End users often get icons wrong, mis-enter info, do not complete sections if too lengthy, etc. But even in designing that UI, take user inputs with a grain of salt as users often prefer UIs that they use incorrectly.

Mobile tech may well be the silver bullet to address healthcare disparities. While there has been a significant amount of attention/discussion on health disparities that may arise via Internet-based consumer-facing healthcare services, mHealth apps may provide a balance as both African-American and Hispanic communities in the US are far more heavier users of mobile tech than Caucasians.

This was a good event, but like any inaugural event, there are always a few bugs to work-out.  Hopefully next year’s event (November 9-10) will more effectively address new technologies and modalities that will support mHealth initiatives (most tech on display here is re-purposed tech from 10yrs ago) and expand to include discussions on real outcomes, sustainable business models and consumer-facing mHealth apps with real consumers talking about their personal experiences.

As we’ve said many times in our writings:

Health is Mobile

Health does not occur when you are in front of your computer, it is a part of your every day life and actions. There is tremendous promise in mHealth apps but this market is still extremely young, nascent and immature.  A lot of experimentation occurring today but in a 2-4 years this experimentation will convert into vibrant business models.  Mobile apps will be the future of much of health, wellness, and care.  Any company/software vendor worth their salt in the healthcare space better damn well have a mobile strategy on their white board or they may well become irrelevant.

Posted in consumer health, mHealth, telehealth, telemedicine | Tagged , | 7 Comments »

Round Two: A Dossia Update

October 26, 2009 by John

dossialogoLast Friday had the chance to meet up with the folks at Dossia, the personal health platform (PHP) formed by a consortium of employers. Purpose of the meeting was to get a deep dive update on Dossia and learn more about what they have done in the last year or so since they went live with Wal-Mart in fall 2008.

Since that go-live, Dossia has been fairly quiet, though they did announce two new “founding members” and released the open API this past summer. But frankly, not much to write home about.

Despite being the first “out the door” PHP, several months ahead of Microsoft’s formal announcement of HealthVault in early October 2007, Dossia has floundered.  First was the break-up with their first development partner, Omnimedix which led to Dossia forming a relationship with Children’s Hospital, Boston to use the open source Indivo PHP.  After nearly a year of work with the Indivo team, Dossia finally had WebMD linked into Dossia.  This integration between WebMD and the core Indivo-based Dossia platform was done under some pretty tight deadlines to meet Wal-Mart’s aggressive roll-out schedule – as part of their annual fall health fairs for employees across the country.  The push led to a less than ideal integration with the WebMD, an integration that could not be readily duplicated with any other third party independent software vendors (ISVs).  Thus, Dossia’s desire to build an ecosystem of apps on top of their PHP was put into stasis as the Dossia team focused on the Wal-Mart roll-out.

A year later much has been learned.

Dossia discovered that Indivo V3.2 was not fully scalable to meet large enterprise needs.

The Indivo platform was developed by Harvard Med School academics to test the concepts and policies associated with a patient-controlled health record system.  Prior to Dossia’s adoption of Indivo, the platform had seen small scale implementations at Children’s Hospital, MIT’s on-campus hospital and at Hewlett-Packard in association with a flu vaccination study. In each of these implementations, no ecosystem of apps was deployed via a common and open application programming interface (API).  This is understandable as Indivo was structured to test concepts, not necessarily structured for large scale commercial roll-out.

Since last fall, the Dossia team hired a completely new team of developers (size of Dossia team on par with Google Health ~15-18 FTEs), completely re-architected their platform to meet scalability requirements, addressed user interface (UI) issues (Indivo lacked a modern, intuitive interface), and developed a stable API that ISVs could use.  On October 15th, the new platform/UI went live.

The new API was released at the end of June and there are now 20 ISVs modifying their apps to sit on the Dossia platform.  As of today, in addition to WebMD, Dossia has eClinicalWorks (eCW is used in Wal-Mart’s retail & corporate clinics – don’t forget that eCW is also being sold through Sam’s Club), Healthtrio, Medikeeper and Metavante, who had acquired CapMed, live on the platform.

Indivo platform did not adequately address the myriad of state laws relating to record consent and sharing for teenagers.

Last year’s Wal-Mart roll-out was targeted at just employees. No incentives were provided, it was completely left up to the employee as to whether or not they wished to participate.  While Wal-Mart obtained “favorable” adoption, a key desire of employees was to have a Dossia account not only for themselves but also for their dependents. This desire led to some fairly significant challenges for Dossia in providing the appropriate consent structure for teenage dependents where State laws vary significantly.  These new consent requirements were built into the new platform as well.

Employers wanted support for dental records.

Another request from employer consortium members was the ability to support dental record data.  As part of the platform rebuild, Dossia has also embedded a dental data schema.  To the best of our knowledge, Dossia is the only PHP who has this capability today.

User interface needed to be simpler, more intuitive to provide easy access to personal health information (PHI).

During the meeting, Dossia provided a demo of its new interface, which was very simple to navigate, ranking on par with Google’s and a more intuitive experience than that of HealthVault.  Dossia has a slight advantage here in that employers define which apps employees have access to and upon sign-up populate an employee’s account with their claims and pharmacy benefits management (PBM) data.  For either Google Health or HealthVault, most consumers must go through the actions of loading their own data, choosing their own apps, etc., to establish a viable and personally value producing account.  This is similar to the adage “with freedom comes responsibility.”

Challenges Remain:

Dossia has made impressive progress since its initial launch last fall.  They have addressed the scalability issue, they have finally released an open API for ISVs to create an ecosystem of future apps and several other consortium members will be going live on the platform in the near future.  Despite these gains, challenges remain.

Where’s the lab data?

While Dossia has the ability to support clinical data in either CCR or CCD formats, today they are only importing claims and medication data from PBM firms.  Dossia, like Google Health and HealthVault does not support images today.  In somewhat of a surprise, Dossia also does not currently support lab data imports from either Quest or LabCorp.  This is a surprise for two reasons: First, viewing labs online has been found to be one of the most desired attributes of a a personal health account and secondly, both Google and Microsoft can import lab data from either of these national testing labs that represent some 80%+ of all labs done in the US.  If Google and Microsoft can do it, why not Dossia?

What’s the value proposition for employers?

Chilmark still struggles to understand what the value proposition is an employer to adopt the Dossia platform for their employees. Yes, Dossia may be a non-profit looking to provide a common platform that will provide employers more flexibility in the health-related tools (PHRs, HRAs, wellness apps, etc.) they can offer their employees to better manage employee health and wellness, but is that enough? Today, few employers see the strategic advantage of providing even the simplest of such tools (e.g. a WebMD account, an online wellness program, a disease management program that actually works, etc.) to their employees. If it is difficult for them to see value here, how can they realistically make the leap to considering a health platform with an ecosystem of apps?

And the value prop for employees is…?

Yes, the interface is much improved and yes, PHI data is automatically imported into an account and an employee’s Dossia account is fully their own, but beyond that, why would an employee sign-up to have an account? What other attributes and services does Dossia provide that are attractive to a consumer? According to Kaiser-Permanente and others, those who adopt and use such system use them to look at their lab data and conduct simple transactions such as Rx refills and appointment scheduling, all features that Dossia does not support.  So again, the value for a consumer in using Dossia is?

A couple of suggestions:

Rev up the marketing engine

If Dossia’s claims are indeed true, that the platform is stable, scalable and open to third party ISVs to build-out the ecosystem, then it is time for Dossia to become more aggressive on the marketing front.  Who better to market Dossia than its consortium members?

To date, Dossia’s consortium members have been extremely quiet and they are arguably, Dossia’s strongest marketing partner.  But if Dossia’s founding members are not out there promoting the platform, clearly stating the value proposition they see in being a member and even, as in the case of Wal-Mart, begin talking about the successes they have seen since launching Dossia, then how is any other employer suppose to buy-in to the concept?

And a concept it is for there are few in the industry today, including health benefits management firms and consultants, that fully understand what the ecosystem/PHP model represents and the value it may deliver to employers over the long-term.  The best advocates, the best marketing Dossia can receive at this critical juncture, is the vocal support of its members. So where are they?

Get the labs

Ability to access, view and share lab data is one of the top features that early adopters of PHRs and PHPs appreciate.  Dossia needs to get this issue addressed immediately. End of story.

Delivery a value proposition that employees will appreciate and use

Critical to the success of the most popular personal health systems in the market today are their ability to support transactional processes.  While it would be extremely difficult, if not impossible for Dossia to support such functions as appointment scheduling, Rx refills, eVisits with one’s primary care doctor, there is one transaction area where they could excel: providing health-related financial decision support tools.  Such tools would provide support for health savings accounts, plan deductables and balances, pricing transparency for common procedures, medications, etc., special employee health discounts, and the list goes on.   There are a number of interesting apps now entering the market that provide such capabilities and Dossia would be wise to focus on these ISVs providing an added level of assistance to get them on-board quickly.

Wrap-up:

Walking into the briefing, expectations were quite low for what we might hear from Dossia. Their quiet, reclusive nature, lack of partners, and seemingly little progress being demonstrated to the market left one thinking that Dossia will fade over the next couple of years.  The briefing put many fears to rest.  Dossia is proceeding ahead at a careful measured pace and has accomplished much over the last year.  It is far too early to count them out.

But will Dossia ultimately succeed, will they be a force to be reckoned with will they become a key market influencer?

Still too early to tell.  The platform is stable, the API is there for third party ISVs and with Dossia representing over 8 million potential users (employees) this is a market nearly 3x the size of the most popular PHR today, that of Kaiser-Permanente – a very sizable and attractive market for most any ISV.  But without strong vocal support (marketing) by executives of its consortium members, Dossia will struggle to make its presence known, struggle to clearly articulate its value proposition and struggle to influence the market and subsequently drive market adoption among employers on behalf of their employees.

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