The concept of mobility in healthcare is nothing new to providers, vendors, and to Chilmark Research alike.  The current media and investor buzz surrounding mHealth stems from the belief that: 1) mobile technology has finally matured to a point where age-old healthcare processes can finally be revamped; and 2) mobile technology has not only matured but has actually been adopted en-mass by physicians and shows no signs of abating.

Doctors Love Smartphones, but are GaGa over the iPad
Recent reports from SpyGlass Consulting and Manhattan Research show that the vast majority of physicians already use smartphones. Pamela Dolan at the AMA has a nice commentary on these latest numbers. Chilmark Research’s recent talks with industry folks shows that the iPad is also gaining significant traction with physicians.  At a recent conference in Denver where Chilmark Research attended and spoke, the CIO of Catholic Health Initiative (CHI) sees providing their doctors with mobile apps (in CHI’s case on the iPad) as critical to the success of complying with meaningful use requirements.

mHealth Apps in Acute Care
Given that physicians have now ‘gone mobile’, does this imply that they will no longer be satisfied with computers-on-wheels (COWs), demanding mobile access to every piece of data buried in Health Information Systems (HIS)?   If yes, providing doctors with mobile access to patient and hospital data could be just the perk needed to attract more affiliated physicians, satisfy existing ones and ultimately drive the adoption and use of HIT by clinicians.

Here is a brief look at the mHealth acute care vendor landscape:

• Pure play inpatient mobile solutions companies like PatientKeeper and MedAptus have built their businesses on providing clinicians with mobile apps, each having started with charge capture and quality measures.  PatientKeeper expanded into CPOE with a limited roll-out that is scheduled to go GA in 2011. As the mHealth market continues to gain momentum, it will be interesting to follow the fate of these two companies.
• The big boys of HIS (Cerner, Eclipsys/Allscripts, Epic, GE Healthcare, McKesson, MEDITECH, Siemens) all have mHealth stories, albeit weak ones that revolve mostly around mobile browser access to their core EHR.  Early this year Epic released the Haiku app to Apple’s AppStore, resulting in some fanfare from the tech community.   Also, the Citrix Receiver app makes it possible to run Windows-based apps like McKesson and Cerner securely on the iPhone/iPad and Android, though with obvious usability issues associated with being a non-native app.
• Potential entrants/disruptors from outside the industry face a battle with the big boys, who seem to want to reduce mobility to an extra feature on their systems.  Diversinet is making a play in secure doctor-doctor and doctor-patient communications for the enterprise. The company has made extensive investments to the tune of some $80M spent over the last decade developing IP in encryption and identity management.

mHealth Apps in Ambulatory
There are a multitude of physician content and productivity apps in the AppStore, from anatomical diagrams to medical calculators to ICD-9 lookup and arguably the most successful category, medical content apps.

Mobile medical content companies such as Epocrates and Medscape have had a presence on physicians’ phones/PDAs for years.   We are closely following Epocrates’ expansion into the SaaS EHR market.  If mobile EHR access is a truly compelling value proposition for ambulatory physicians (we aren’t convinced it is), then Epocrates may be able to leverage the brand’s mobile association and large, existing installed base to stand out from the 400+ competing EHR vendors.

A number of ambulatory EHR vendors (AllScripts, eClinicalWorks, Greenway and NextGen) have recently introduced their own EHR mobile apps, most built for Apple’s mobile OS. Currently, it appears that little is on offer from EHR vendors for Google’s Android mobile OS, though that may change as Android becomes an increasingly compelling alternative to Apple.

Onward Ho!
Dipping our research fingers into the mHealth market, Chilmark Research is launching a new initiative that will culminate in the report: Enterprise Adoption of mHealth apps: Trends, Issues and Challenges. Over the course of the next couple of months (target release date is in advance of NIH’s mHealth Summit in DC) we will interview executives from the major HIS vendors, best-of-breed vendors, tech entrants, and leading Hospitals/IDNs. Through both primary and secondary research we will answer such questions as:

• What top mobile apps are currently being adopted in the enterprise?
• What are the priority unmet needs among leading Hospitals/IDNs?
• What challenges are currently hindering adoption of mHealth apps in the enterprise?

In the meantime we will be posting every other week specifically to give updates on our mHealth research.  Onward Ho!

This begs the question: Why did Ingenix pay so much for such a small HIT vendor?

Having interviewed a couple of Axolotl competitors about this deal and completing a briefing call this morning with Ingenix executives Bill Miller, EVP for Provider Solutions and Art Glasgow, CTO along with our broader analysis of the market, vis a vie the forthcoming HIE Market Report (yes, its coming, really it is), following are some thoughts and perspectives.

Ingenix is a company that grows by acquisition having acquired some 50+ companies since 1996. Since the beginning of 2010, the company has made 5 acquisitions already and based on the call with Ingenix today, there will be more. Miller stated on the call that Ingenix has primarily served the payer market but sees a convergence of administrative and clinical processes, thus has been making targeted acquisitions in the provider HIT market (e.g., CareTracker, a PM/EMR solution, Picis, an EMR for ED, QualityMetric for outcomes measurement) and now Axolotl. Miller inferred in the call that part of its provider acquisition strategy is to acquire companies with strong brand recognition in the provider market. Clearly, Axolotl has that in the HIE market, particularly among publicly-led HIEs, or RHIOs.

As one competitor put it: “Ingenix bought into the market.” And as another one stated, (Axolotl’s top competitor): “We are very happy.” Ingenix paid heavily for brand and for an established presence in the market (Axolotl has roughly 250 hospitals using their Elysium HIE platform and currently support four state-wide HIEs). As an independent company similar to Axolotl, the second vendor must be seeing the potential for a very large pay-out should they be acquired, thus not too surprising that they would be happy with this deal. But that second vendor may also be developing a slightly nervous twitch as very large players with deep pockets such as Carlyle Group (they own Carefx), GE, IBM, McKesson (owners of RelayHealth), Microsoft, Thomson-Reuters (partner with Care Evolution) and now Ingenix enter the HIE market. Let’s not count out the EHR vendors such as Cerner, Epic, and others who are also developing their own HIE solutions. The writing is on the wall: In five years time there will no longer be small, independent HIE vendors.  Those independent HIE vendors that survive will be a division of a far larger company.

During our call with Ingenix, Glasgow stated that Ingenix’s core competency is analytics and this is the focus of internal R&D expenditures. For all other HIT application areas, Ingenix would rather make an acquisition than organically build. Coupling Ingenix’s analytical capabilities with Axolotl’s Elysium platform creates some intriguing possibilities both from the perspective of Ingenix selling more of its portfolio in a larger more comprehensive HIE platform sale, but also creating the possibility for the HIE organization to create a sustainable model for future viability as articulated in an Ingenix White Paper (caution PDF). With forthcoming changes in healthcare via reform, new payment models etc., analytics will become an increasingly critical need for providers and HIE vendors are ideally positioned to provide such capabilities. Yet based on our research, virtually all HIE vendors have weak analytics capabilities. Microsoft is one of those at the forefront in this area with their Amalga platform, but their overall HIE solution is still a work in progress.

Glasgow also went on to state that Ingenix sees the HIE market moving to a PaaS model and Ingenix will continue to support Axolotl’s current development efforts to open up its APIs to third party vendors. The move to PaaS in the HIE market is still a nascent trend but one we believe will stick. Chilmark is planning to do a deeper dive on the subject in a future report. In the near-term we will be talking to Medicity later this week getting a deep-dive briefing on their forthcoming iNexx platform, which is at the forefront of among HIE vendors in creating a PaaS for the HIE market.

Some Challenges:
With any acquisition, there are always challenges, from alignment of staff (and even rationalization), to setting priorities for future R&D, to soothing customer and prospect fears as to what the acquisition means to their current or future investment. Challenges we foresee include:

Recouping their investment. Ingenix paid dearly for Axolotl, a company with a strong brand in the market, but also a company with an older platform that has proven difficult for some to implement and maintain. Axolotl clearly recognizes that Elysium needed to be re-architected and is well down the development path to address this need. Thus, Ingenix needs to continue to invest in Axolotl beyond the purchase price to insure Elysium transitions to a modern platform to support a PaaS model. This is not easy work, nor is it inexpensive and it is likely that there will be changes to Axolotl’s pricing structure to compensate for this investment.

Quelling market fears, part one. Ingenix has a mixed history with providers, having been sued by the NY Attorney General, and dragged before Congress last year for reportedly providing data to payers that shortchanged patients and providers. Ingenix has tried to come clean on the issue, but it has left a bad taste in the mouth of many. Now that Ingenix is jumping into  the very public arena of HIE, they will need to convince state agencies, providers and consumers that their intentions are noble, that data will be used to help improve care and ultimately outcomes while insuring that personal health information will remain secure and private.

Quelling market fears, part two. An acquisition nearly always generates some consternation on the part of existing customers and future prospects, with the number one issue being: Is their investment safe (i.e., the acquirer will not sunset the product and continue to invest in R&D)? With over 50 acquisitions in 14 years, Chilmark assumes that Ingenix is pretty savvy at how to acquire a company, leverage the assets, keep customers happy and build from there. But against that backdrop, Ingenix must address a market that has a lot of concerns over vendor/product viability. It is incumbent on Ingenix to educate the market that it indeed has a clear strategy for Axolotl and its Elysium platform. That the strategy aligns with market needs. that it includes continued support (R&D $$$ to modernize Elysium) and that they will continue to offer the level of support (if not better) that customers have come to expect from Axolotl.

Final Assessment:
Ingenix’s strategy for the HIE market is in very close alignment with what Chilmark Research is seeing as well: The move from simple messaging, i.e., pushing lab data around, to higher order capabilities such as analytics and the move to a PaaS model for HIEs.  While these are clearly the future trends for HIEs, the timing as to when these trends take hold is still very much in question.  The HIE market remains convoluted, messy and difficult, if not near impossible to make sense of.  Adding to the issue of complexity is market maturity wherein many buyers are often just looking for the most basic of capabilities.  Even Axolotl recognizes this releasing Elysium Express a few weeks back to address this basic market need.  Hopefully, Ingenix is a very patient company and fully understands the nature of the market it has just paid a princely sum to enter as it may be sometime before they recoup their investment in Axolotl.

Some observations from the road-trip:

This is a very big country that seems to have an endless appetite for corn.  The corn fields begin in Ohio, hit their stride in Indiana and don’t subside until you get to the western half of Nebraska.  Is it any wonder that we find high fructose corn syrup in just about anything we buy at the supermarket? I think not.

Iowa has what appears to be a wonderful, thoughtful culture best expressed through its rest-stops along I-80.  One rest stop focused on the art of the pen, another on good farming practices and the loss of top soil. A third had a mix of themes including an overview of the bicycling opportunities in Iowa.  And those rest-stops have free Wi-fi for those that need their Internet fix and some of the nicest people I met along the road.  I like this state a lot and if they only had the mountains of Colorado or the shores of Massachusetts, I’d pack my bags and be there in a heart beat.

Craigslist’s ride-share is a great way to find someone to share the drive with.  This was a suggestion of my son who had some concerns abut me driving west by myself.  Found someone on ride-share who wanted a ride to Boulder.  We met beforehand (don’t want to be stuck with someone for 3 days in a cocoon of a car driving cross country that you quickly tire of) and the chemistry was right.  We split gas, I paid tolls and she made the meals.  Since I was planning to camp at State Parks along the way, she was fine with tat and had her own tent.  Made the whole experience so much better.  Thanks Danielle.

This is a beautiful country.  I was simply blown-away with how beautiful this country is. Not just the Appalachian hills of Pennsylvania or the mountains of Colorado, but those plains of Nebraska, especially the fields of sunflowers stretching to the horizon.  The soaring whooping cranes I saw over the Interstate in Indiana, the rolling hills of Iowa and the pretty farms of Ohio.

Camping in State Parks is a far better deal and experience than staying in those concrete boxes they call hotels along the Interstate.  In a State Park not only do you see some wonderful sights (Lake Anita outside Des Moines is beautiful with its restored prairie grasses), you meet some really nice people from the local area.  And with an average price of $12/night (yes, they have showers, water etc.) one can travel very inexpensively all you need is a tent and sleeping bag.

It is damn near impossible to get a healthy meal on the road.  Fast food joints dominate the highways of America, be it the toll-road rest stops or what one may find immediately off an exit ramp.  If you want to eat healthy, i.e., fresh veggies, you best bring your own as you won’t find them along the highway.  And if you do stop to grab something to eat, go to the truck-stop cafe – a far better deal and better food than one will find at the fast food chains that litter this country.

Once the event in Denver was over, I headed straight up into the mountains.  After a couple of days acclimating to the higher altitude, it was time to head into the woods and completely disconnect with everything, bringing only what I needed in my pack for the next four days as I hiked up with a friend to the highest hot springs (11,300′ above sea level) in North America.  Some take aways from this hike and others through the Rockies…

I have too much stuff.  Nothing like carrying all you need for a few days to begin to appreciate how little we truly need to live.  Yes, its nice to have nice glasses to drink wine from, clothes that are comfortable with enough variety to fit one’s many moods; but really, how much do I really need to live?  Been trapped in the consumer mentality for a little too long and it is time to simplify.

Nature demands respect.  The day after reaching the hot springs I took a hike up to Triangle Pass, which tops out at ~13k feet.  Once there, saw a narrow trail head up to the top of a peak on my left and decided to ascend it.  The last 50′ or so of vertical gain that I made was on all fours as it was very steep and the rock was lose and “rotten” in sections.  As I was alone, the last thing I wanted to do was take a tumble, a tumble that would not likely end for 400-500 ft.  I made it to about 50′ from the top when I decided to turn back.  Yes, I was disappointed I didn’t “summit” but over the years and many close calls, I have learned to respect nature and this was a perfect example. But the views from where I stopped were so beautiful – I simply soaked them in before, again on all fours, making the descent.

Nature does not reveal herself readily.  There is so much beauty in this world that is right there in front of us to see. Yet similar to needing to be with someone for a period of time to see their inner beauty, one needs to take time with nature, sitting quietly and observing for only then does nature reveal a deeper, richer beauty.

As much as I love the ocean, (my major in college was Ocean Engineering and grad school was Physical Oceanography), the mountains bring to me a certain solace and comfort that I can not find elsewhere.  Not sure if it is their grandeur, the humility that they distill upon one or a combination, one thing I know is that I need to figure out a way to be in the mountains far more than I am today.

Health comes in many forms.  It is physical, it is mental. It is within us, it is without us.  As we embark on transforming the healthcare system in the US through HIT, (HITECH Act), Healthcare Reform, payment reform etc., I’m not convinced we are focusing on the right issues.  Ultimately, we need to focus on the individual and individual responsibility to take better care of themselves and their loved ones.

Traveling across the country one sees a broad cross-section of America and one thing that becomes so apparent is that in certain parts of this country, the local culture does not look at whole body health.  Far too many people are eating far too much, drinking far too much and simply not in a good mental space.  If we do not, as a nation address this issue soon, no amount of payment reform, technology or money that is currently earmarked to transform healthcare delivery in this country will keep us from driving over the proverbial financial cliff that will kill this country’s ability to compete in the global marketplace.

Over the next several days, I’ll be venturing forth into the proverbial wilderness of my home state of Colorado.  There is a particular wilderness hike/backpacking trip that I have not been on in over a decade. The hike takes one up to the highest hot springs in North America, elevation 11,200′ then over a pass at nearly 13,000′ then on down through a valley of wildflowers flanked by what are some of the most beautiful mountains I know, the Maroon Bells (see picture).

Hope all readers also have an opportunity to jump off the grid this summer to spend time with family, friends and themselves.  Such a break, at least for me, always give one perspective that can not be obtained when one is consistently, dare I say obsessively, connected to all things digital.

But this mad rush is creating some problems.

While the private HIEs seem to have their act together in putting together their Request for Proposals (RFPs), such is not the case for the state-driven initiatives.  Rather then formulating a long-term strategy for the HIE by performing a needs assessment for their state, setting priorities and laying out a phased, multi-year strategy to get there, far too many states are trying to “boil the ocean” with RFPs that list every imaginable capability that will all magically go live within a couple of years of contract reward.  Now it is hard to say who is at fault for these RFPs, is it the state or the consultants they have contracted with that formulated these lofty, unreachable goals, but this is a very real problem and unfortunately, the feds are providing extremely little guidance to the states on best practices.

While the above is more of a short-term concern, longer-term we may have a bigger problem on our hands.  The proliferation of private HIEs, coupled with state-driven initiatives with very little in the way of standards for data governance, sharing and use (this includes consent both within a state and across state lines) has the very real potential to create a ungodly, virtually intractable mess that will be impossible to manage.

So maybe it is time to rethink what we are doing before we get to far down this road.

What if we were to say, as a country, that much like Eisenhower did during his presidency to establish the Interstate Highway system, we made the decision that it is the public interest to lay down the network for an “interstate” system for the secure electronic transport of health information?  And rather than be cheap about it as we have done in the past dedicating only modest funding (e.g., NHIN CONNECT), let’s really make the investment necessary to make this work.

Yes, it won’t be cheap, but think of the alternative – 50 states, countless regions all with their own HIE.  Yes, states are required under HITECH to work collaboratively with neighboring states, but this will not lead to enough consistency to create a truly networked nation for the delivery of quality healthcare for all US citizens.

It is indeed time to take a stand for much like Eisenhower’s Interstate system, which I had the pleasure to enjoy as I traveled cross-country this week from Boston to my beloved mountains of Colorado, such an interstate system for the delivery of health information at the point of care will be something all citizens will benefit from. And taking a cue from the image above, rather than a “Symbol of Freedom” it would become a Symbol of Health.

I never liked the acquisition of Global 2000 for a few simple reasons:

1) Despite “low adoption of EMR” systems, the EMR market is actually a fairly mature market.  Most hospitals have an EMR already and it is not easy to dispace such – much like chipping out concrete. The “adoption problem” rests more with poor implementation and use, at least in the acute care market, which was the sweet spot for Amalga HIS.

2) Though Microsoft claimed that Amalga HIS would only be sold overseas, primarily in APAC, this acquisition put many an EMR company on alert to be careful working with Microsoft for Microsoft may change its mind at some future date and become a competitor in their backyard.  This hinders Microsoft’s ability to develop closer partnerships with these vendors, which Microsoft admitted was the case in a call with them earlier today.

3) The EMR market is a very messy, competitive market with far too many vendors.  The last thing it needs is another acute care EMR solution, even if it did come from a heavyweight such as Microsoft.  Also, one would have thought that Microsoft learned from its previous mis-steps in the Enterprise Resource Planning (ERP) market (very similar in many respects to EMR), where it made several acquisitions, but the return on that investment is less than stellar.

4) The EMR market, being messy, mature, etc., is not a market where one can truly be disruptive.  But once that data starts being collected and begins to have some structure, then the application of analytics and reporting to better understand operations and how to ultimately improve them, is a higher order of value that will be of high interest to healthcare organizations, both large and small. This is a disruptive opportunity. Now that we have a major push to drive adoption and use of EMRs/EHRs, that data will increasingly become available for solutions such as Microsoft’s Amalga UIS.  Microsoft can now focus its resources on this disruptive opportunity, rather than waste resources on an EHR.

It now appears that Microsoft has come to the same conclusion.  Thankfully, Microsoft is not leaving dozens of hospitals in the lurch.  Actually, Amalga HIS has only six customers today and those customers will receive support for the next five years.  After that they will be on their own, but Microsoft has assured me that they are working with third party vendors and service providers to insure that these customers will receive continued support in the future.

One take away from all of this:
Performing a viability assessment on a potential vendor may not reduce one’s risk. Even a big, viable company such as Microsoft may change its mind on occassion and chose to exit a market.

AT&T has Healthcare Community Online (HCO) as their primary HIE solution, which they often take to market with partner Covisint.  The lighthouse customer for these two was the now belly-up SharedHealth in the state of Tennessee. Despite AT&T’s claims to have a viable and competitive HIE solution, we have never heard anyone mention them, either within the context of an RFP, a competitive bake-off, mentioned as a competitor by other HIE vendors, etc.  Nothing. Nada.  It’s as if they don’t exist, and frankly, maybe they don’t in the HIE market. (Chilmark did not discount Covisint and there will be a detailed profile of this HIE vendor in our forthcoming report.)

Is Verizon doing anything more substantial in the HIE market?

Late last week, Verizon announced its own HIE product suite.  Let’s be polite, the press release didn’t have us in a panic wanting to call Verizon and immediately get a briefing.  Heck, writing this post several days after the release went out may give you another hint as to our level of interest and excitement.

What’s the problem?

1) Putting “Cloud” in the title of the press release.  Boring, and honestly not at all new as virtually all the leading HIE vendors having been providing cloud-based HIE solutions for years.

2) More importantly, Verizon’s chosen partners, MEDfx, MedVirginia and Oracle.  First MEDfx is but one of the countless and like its brethren, nameless, little HIT vendors out there in the market trying to survive, offering a wide range of solutions from EMR to PM, to HIE etc.  A mish-mash of products with little market traction.. Our bet is that 5 years from now, they’ll be gone.  One would have thought that with its size, brand and clout, Verizon would have been able to do better than this for an app partner. Second, picking a client as a partner? There may be some small value to that but to make that a key part of your announcement message, not so good and a clear sign of weakness.  Besides, it looks like what is really going on here is that MedVirginia is simply replacing its existing HIE vendor, Wellogic, an HIE vendor who, if field reports are correct, is on its last legs.  OK, we’ll give Verizon credit for partnering with Oracle for Oracle’s Master Patient Index solution, if it is indeed the one that Oracle built and not the poorer substitute built by one of Oracle’s most recent acquisition, Sun Microsystems.

It just puzzle’s us that these two very large companies, with clear established brands in the market are making such tepid plays in the HIE market.  They certainly have the resources to do something far bigger, say acquire one of the leading HIE vendors that has an established presence, good customer list and build from there.  In some of our more recent discussions with those assessing and looking to purchase an HIE solution, the issue of vendor viability is always a topic of discussion.  A large company like one of these telecoms could clearly remove that issue from discussion.

Maybe it is just a case of it’s not in their DNA.  Telecoms sell simple services that can be leverage across multiple markets.  Delving into the healthcare sector with an HIE play requires more than just a communication network, it requires secure messaging, deep domain knowledge of healthcare workflow and best practices and it requires a level of software expertise that is foreign to these companies.  No, it is Chilmark’s belief that announcements such as this simply cloud-up what is already a pretty murky market.

Our bottom-line advice to those assessing HIE solutions in this murky market:

1) Look to a vendor that has a proven track record, with good references from those you respect.

2) Seek a vendor (and not just their service partners) who has domain expertise and truly understands what is trying to be accomplished within the context of an HIE.  Look closely at their workflow templates as these will give you some idea as to how well they understand the business.

3) Delve deeply to understand a vendor’s true compettive differentiators.

4) Look closely at their list of partners, both software and service, and talk to the vendors customers about how well these partners’ solutions are integrated into the entire solution suite.

And dear readers, if you have a few suggestions of your own, please add them to the list in the comment section below.

1) ONC Chief, David Blumenthal’s article in the New England Journal of Medicine that was published on the same day wherein Blumenthal provides a clear abstract of the rules (the actual rules are 864 pgs in length and not a bad read if you have the time) in a easy to read and understand format.

2) Next, head over to the Dell website for a post by their own Dr. Kevin Fickenscher who gives an excellent background on the broader HITECH Act, the origination of the MU rules as well as taking a look at companion rules for Certification of EHRs and the new Privacy & Security rules that were also recently released.

3) Last, but certainly not least is a visit to John Halamka’s site where he provides a freely available, with no need to provide attribution, deck of slides that gives the big picture view of the final MU rules.

With such great resources out on the net, we at Chilmark Research see little need to write an in-depth review of these rules. That being said, we will provide some quick points of analysis.

1) Clearly, HHS listened to the market and the 2,000 comments it received and has relaxed the final MU rules significantly.  If any provider or hospital is still complaining, well they may be the type to complain no matter what.  These rules, while still challenging for some, are certainly doable.  Time to stop talking and get down to work.

2) Thankfully, probably to the chagrin of payers, the requirements to conduct administrative functions (eligibility checking and claims processing) from within the EHR has been removed.  This has always been a fairly silly requirement as today, much of this process is already done electronically through the Patient Management (PM) system. So no need to duplicate it within the EHR, besides which it would have been tough for many an EHR company to build out this functionality in such a relatively short timeframe.

3) The consumer engagement sections of the MU rules also saw some relaxation, but it was reasonable.  What may prove more interesting here is the new requirement within the certification rules for EHRs that they provide health education resources for consumers within the context of their platform.  This may prove to be a real money maker for the likes of health content providers such as A.D.A.M, Healthwise, WebMD, among others.

4) While understandable that there was some pull-back on health information exchange as we saw in the draft MU rules, we were quite surprised that it was completely eliminated in the final rules for Stage 1.  HHS claims that this was done due to the lack of maturity in the HIE market.  Well, yes and no.  There indeed may not be a lot of multi-stakeholder, publicly-led HIEs today that are actively exchanging data, whether regional or state level, but there is a robust market for private HIEs.  It is unfortunate that HHS pulled back on this one for “information sharing for care coordination” was one of the primary precepts of the original HITECH legislation.  Sure, will likely see something within Stage 2, but that does not get clinicians familiar with the concept today.

5) What really caught us by surprise is a reference in the MU rules (pg 39 to be exact) wherein HHS states that they will not discuss the future direction of Stage 3 at all.  Nothing. Nada.  Does this portend a complete pull-back from Stage 3?  Hard to say, but it is clear that HHS wants to see how well Stages 1 & 2 go over in the market before it makes any further demands on providers and the EHR vendors that serve them.

6) Along with the release of MU rules, HHS also released the final rules for EHR certification.  While having not delved into these deeply, yet, the whole concept of “certification” is fraught with challenges, primary among them, technology lock-in.  It is here where Chilmark believes we will see the greatest challenges to indeed create an environment that fosters innovation, providing clinicians with tools they will readily wish to use while at the same time providing some level of certification. Frankly, we do not believe it can be done. Congress really wrapped an albatross around the neck of HHS when they wrote that into the legislation.

What were they thinking?

A Couple of Thoughts on the Pending Release
A significant amount of effort by many a talented and dedicated individual has gone into providing the initial policy framework and ultimately the final language for these rules.  Hats-off to them for their service for what they may have done is defined much of the future core elements of healthcare IT systems in the decade to come.  Granted, this is only Stage One rules, we have only an inkling of an idea as to what to expect in Stages 2 & 3, but there is no doubt in our minds that these rules will have an impact on the HIT market, more broader technology adoption and use in healthcare and even more broadly, a fundamental change in healthcare delivery and the role of the citizen/patient.

While these rules will have a noticeable impact, we are less confident that they will have a lasting impact for two primary reasons:

1. It remains to be seen just how many physicians will take the bait (incentives) to buy a “certified EHR” and jump through all the hoops to demonstrate their meaningful use of said EHR.  Yes, $44k may seem like a lot initially, but when you start digging a little deeper into what the total cost of ownership is for an EHR and the number of hoops you must jump through to get that incentive payment, that attractive $44k starts looking less attractive in a hurry.
2. Looming on the horizon, just beyond the street noise that is meaningful use and the HITECH Act, is a far larger change agent, the Healthcare Reform Bill that was passed into law earlier this year.  Tucked into that legislation are a number of significant changes, primary among them, payment reform via CMS’s Innovation Center.  Following the old adage, “follow the money,” we at Chilmark foresee a restructuring of the healthcare delivery system that will necessitate the adoption of IT not for the aforementioned “meaningful use” but to more efficiently and effectively run operations.  (Over in the radiology world, an article on Aunt Minnie clearly directs radiologist to start thinking efficiency.) This is what organizations both large and small, and not just radiologists, need to be thinking about as meaningful use, in retrospect, may be seen as more of a distraction than anything else.

Therefore, do not be disillusioned at the lack of posts and/or the depth of analysis provided.  It is simply one of those cases where priorities must be set and right now, that priority is the forthcoming HIE Report.

A couple of quick tidbits from initial findings:

There is no agreed upon pricing structure in the HIE market.  Wide mix of pricing models from subscription to straight licensing and plenty in-between.

Most HIE vendors are focused on the basics of moving lab data with some order management and even referral management thrown-in.  Higher order functionality such as clinical decision support, care/case management and business intelligence/reporting are still immature.

Now to keep you busy, a couple of reports worth a scan/quick read are:

A Health Approach – Technology for Personalized, Preventative Healthcare: This report from the Europe (ICT Research) gives an overview of several technology initiatives in Europe.  While the report is not terribly focused (covers all forms of health technology) it does give one a sense of how those across the pond are thinking about personalized healthcare and where they are currently placing some bets with their research Euros.

Consumer Use of Computerized Applications to Address Health and Health Care Needs: This report was published last year by the US Dept of Health and Human Services.  Quite a comprehensive report and a good primer for those who are just beginning down this path.  For those who are more knowledgeable on the subject, the bibliography is the best I’ve seen on the subject.  Someone worked very hard on this report and it shows.

In closing, fear not, Chilmark Research continues to keep its ears to the ground and if anything earth-shattering (or at least HIT shattering) breaks, we will discussing it here, e.g. the drop of Meaningful Use rules, though frankly, those rules are getting far more attention than they deserve, same for certification of EHRs.  But we will discuss that in greater depth within a future post.

Oh, one last thing: the picture accompanying this post is a photo I took on the beach here in Chilmark MA. Basically, I like to take those nice rounded beach stones, balance them in odd ways and take a photo.  One of these days I may actually print and frame one of these pictures, but for now, they make nice wallpaper for the laptop.