In the lead-up to HIMSS, Chilmark has been absolutely inundated with requests for meetings with vendors of all shapes and sizes.  How do we select who will meet with? Our selection criteria is pretty simple:

1) Is the HIT vendor providing a solution for which we are currently doing research (HIE market) or in the future (provider-based PHRs, mobile health apps, cloud computing in healthcare, clinical decision support, etc.).

2) Have we had fruitful, meaningful discussions with this vendor in the past?

This last point is particularly critical and played a major role in prompting this post (along with a meeting last week with an executive from PR firm Schwartz Communication, who also encouraged such a post).  There were numerous requests to meet with vendors we met with last year.  Those who gave horrific briefings last year were turned down. This post is dedicated to them in the hopes that they will change their analyst briefing strategy.

Top 5 Don’ts

1) Don’t give us a canned pitch. Not only is a canned pitch a waste of our precious time (and yours as well), canned pitches insult us, they insult our intelligence. Please save those for others less knowledgeable of the market.  Along with canned pitches, do not talk through Press Releases, ugh, we can read these on our flight home.

2) Don’t bother with PowerPoint. We only have at best 30min together, let’s not waste that time going through a series of PowerPoint slides – boring.  The other danger here is that analysts are bred to be cynics. When we see PowerPoint, first thing that comes into our heads – Vaporware! That is the last thing you want us thinking – Trust Me.

3) Don’t be obtrusive when we are talking to one of your customers. Let us have an unencumbered conversation with your customer which affords us the opportunity to drill down on the most critical issues/challenges as well as the significance of your solution in their organization.  Really quite annoying when a vendor is frequently interjecting themselves into a conversation. Please fade into background, you can clarify critical points later.

4) Don’t bad mouth your competition. Complete turn-off and also raises a red flag for that ever so cynical analyst leading him/her to think: Hmm, competition must be eating this company alive and they are struggling to remain relevant in the market.

5) Don’t forget to follow-up. Granted, not every briefing will be engaging, but that should not prevent you from following up after the show with analysts.  In that follow-up email, do reference specific conversation points and answering any questions that may have not been fully addressed during the show briefing.  Quite amazing how much this will assist you in your relationship(s) with analysts but also how infrequently it is done.  There were several briefing requests turned down this year due to lack of follow-up on their part after last year’s HIMSS.  Sloppy.

Top 5 Do’s

1) Do tell us about what you are seeing in the market. Sure, we”ll want to hear ever so briefly about your announcements at HIMSS, but more importantly, we want to hear about what YOU are seeing in the market and how your company is responding to market needs and challenges.  This puts your strategy in context for us. No you don’t have to be explicit, on your strategy that is, we can figure that out just fine on our own.  The more open and honest you are here will go a very long way to endearing your self in the analyst’s eyes.

2) Do have a couple of people involved in briefing from different disciplines (e.g., marketing, executive management, R&D). Too often, analyst briefings at events like HIMSS are seen as something similar to briefing the press with a press person and marketing executive present going through the motions.  Boring. Analysts want to understand your company at a far deeper level so leave the press bunny behind and bring in another senior exec from product development, management, etc.

3) Do keep conversation focused to one or two topics that are relevant to analyst and their research agenda. Remember, we only have about 20-25 minutes to work with once formal intros are done and we both want to get as much out of these briefing as humanly possible.  Focus discussion on one to two key points you want to get across as that is about all the time you’ll have.  Any more topics then that just get lost in the white noise of other activities.

4) Do introduce us to a customer or two. Analysts love talking to customers, ideally, not the ones that have been heavily coached by your marketing and sales team.  Do introduce us to a customer or two of yours that may also be attending HIMSS that we can talk to.  This need not take up our precious 30 minutes together, as an analyst can follow-up with customer.  And do take heed to Number 3 in the “Don’ts” above after making such an introduction.

5) Do ask us questions. Ideally, a briefing with an analyst is a conversation where both parties are asking questions of one another.  A good analyst (yes, there are many poor ones) has a unique perspective on the market that is actually a composite view of those conversations with numerous market players.  As I use to tell new analysts shortly after hiring: Think of yourself in the crow’s nest of a ship in the War of 1812.  You are not down on the deck in the heat of the action, you are removed from the intense excitement viewing the entire sea battle from your perch.  It is from that perch that you direct those below where to fire their cannons.  Use this time with the analyst to gain their perspective on the market and where you may need to point your cannons in the future.

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

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

The Certification workgroup presented their refined recommendations today (these were first announced at the July 16th meeting), which were subsequently approved by the broader HIT Policy Committee.  Marc Probst of InterMountain Healthcare and co-chair of the workgroup led discussions which began with a high level list of five recommendations, (see slide below).  For simplicity, we will focus on these five recommendations in our discussions as they encapsulate the entire meeting and what was ultimately approved.

In Recommendation 1 the workgroup emphasized that certification criteria must be kept at a high level, (e.g., not specify how an alert would be presented, simply that one would be presented) criteria must directly link back to supporting the meaningful use criteria that were approved on July 16th. Th workgroup also emphasized that the creation of certification criteria must be the responsibility of HHS/ONC and not a third party such as CCHIT. (Note: CMS is now converting MU criteria into actual rules – and based on some comments today, it is not an easy task.  Creating certification criteria will be easier, but still a lot to add on to the plate of HHS who already has its hands full.)

But where the workgroup wants a lot of specificity is with interoperability suggesting that HHS/CMS develop certification criteria that is quite specific to insure interoperability between systems. With such tight time-frames and deadlines in place, this issue of interoperability could become one of the most challenging aspects of the whole HITECH Act, for underlying all three workgroups (Meaningful Use, Certification and HIEs) is interoperability.  But what is interoperability anyway?  Is it computable data? Is it transmittal and sharing of PDFs? Is it order sets, med lists, labs?

Looking back, the Meaningful Use matrix does provide some guidance as to what data is to be shared for care coordination, but that still does not eliminate the challenge of creating specific criteria for interoperability that can be readily certified and put into the market.  Also, it is important to note that certification for vendors may have to occur every two years (2011, 2013, 2015) in lock-step with the ever increasing requirements for meaningful use which itself calls for ever more complex data sets to be shared.

Recommendation 2 was pretty much a no brainer as ARRA legislation specifically calls for certain enhancements to security and privacy of medical records (audit trails, consent, etc.).   Here again the workgroup emphasized the need for HHS to get aggressive on establishing clear certification guidance on interoperability as it pertains to addressing security and privacy.

It was in Recommendation 3 that the workgroup suggested that HHS allow multiple certification organizations (not just CCHIT), to conduct certifications of EHR systems stating that this will help create a competitive market for such services and increase transparency into the certification process.  The workgroup also recommended that NIST establish and execute an accreditation process for certifying organizations.

While CCHIT has certainly been marginalized, they will still play an important role in the interim.  Right now there are no other certifying organizations, the market is being quite cautious in making any large EMR purchases awaiting to see what comes out of DC and this whole certification/accreditation development and meaningful use rule-making is going to take time.  What was proposed today is that CCHIT take the lead until at least October (it will more likely end up being well into Q1’10) for mapping meaningful use criteria, as defined in the matrix, to high level certification criteria and provide an interim certification for EHR systems.  Remember, this role of CCHIT is on an interim basis and NOT permanent, though others may want you to think differently (Note, Government Health IT is owned by HIMSS a strong advocate of CCHIT.)

The workgroup also wanted to acknowledge the investments that HIT vendors have already made to get CCHIT certified.  Thus, for those vendors with 2008 CCHIT certification, they need not go through a whole re-certification once guidelines are released, but simply be certified for any gaps that may exist between these two certification processes, with the latter focused on meaningful use.

For Recommendation 4 it appears that like CCHIT, the workgroup received a lot of feedback from Open Source advocates, those that developed their own solutions and smaller software companies that have developed EHR enabling modules.  Therefore, the workgroup followed CCHIT’s lead wih a similar strategy recommending that all systems be tested equally with same high level criteria, regardless of the source of the software. They also encouraged a “flexible certification process” that will account for non-traditional software sources (eg, the RYO camp) and that there be a process to certify distinct, meaningful use enabling modules (eg, eRx).  Chilmark thought CCHIT did a good job here and it is equally good to see the workgroup recommend the same.

Recommendation 5 ties back into what we discussed earlier with regards to the future role of CCHIT – there needs to be a transition phase to account for the time-lag between the need to begin certifying EHRs for market and the lengthy rule-making process for meaningful use.  The workgroup recommends adopting what certification criteria that exists today (obviously from CCHIT) that supports meaningful use and where there are no existing criteria, work to converge criteria to meaningful use rules through close internal collaborations within HHS.

This is where it is going to get a little tricky as both the meaningful use matirx is a bit vague and well certification criteria, that is even more vague.  How do we bring convergence for all this in a timely fashion so that physicians and hospitals can begin installing certified EHRs that provide them the capability to demonstrate meaningful use in order to get their 2011 reimbursement?   We’re not sure how to get there from here, but one thing is for sure, it will be a rocky road ahead.

We’ll tell the world what meaningful use is on 6/16.

Referring to the next meeting of the ONC Policy Committee.If this indeed comes true, Chilmark will feel pretty good about this as it is something we predicted back on April 30th.

Many a vendor will also breath a sigh of relief as the delay in a meaningful use definition, which is required as part of the ARRA stimulus funding for EHRs, has stalled the market.  But that raises another question: Will the market continue to keep checkbooks in their drawers awaiting the definition of “certified EHRs?”

Hopefully, when it comes to certified EHRs, ONC will take a more measured and rational approach as advocated by the likes of the Markle Foundation, Adam Bosworth (former head of Google Health and one of the original developers of XML standard), Chilmark Research and many others rather than the approach that one legislator down in the Garden State of New Jersey has proposed in recent legislation that states, and I kid you not:

A prohibition on the sale or distribution in this State of HIT products that have not been certified by CCHIT…

Needless to say, it appears (thanks Mr. HIStalk) that this legislator has fans in Chicago (HIMSS), who, as we all know, is a big time supporter of all things CCHIT.

Is Leavitt’s post a desperate act from an organization who seems to be coming under increasing scrutiny for its close relationship to the HIT vendor advocacy organization, HIMSS? At first blush, the vitriol of his response comes off that way which is unfortunate and really misses the point.

Yes, there may be some questionable conflicts of interest between CCHIT and HIMSS, a relationship that remains extremely close. As an example, earlier this week Chilmark received a copy of an email that was sent by a HIMSS subcommittee to Mark Leavitt with an attached draft White Paper on “Defining & Testing EHR Usability” an area that CCHIT has made noises about certifying in the future.  Looks to us as if HIMSS is directly advising and guiding CCHIT. Is that really appropriate?

We’ll leave that for others to answer.

What Chilmark’s chief concern has been all along, and one that Dr. Kibbe shares as well as those who participated in the recent Markle Framework workshop and are signatories to the published report: Getting Health IT Right is that the potential for sole reliance on CCHIT for “certifying EHRs” under the ARRA is an extremely risky proposition, though this is exactly what HIMSS and CCHIT have been promoting all along. Reporter Dana Blackenhorn of ZDNet also has chimed in on the issue from the perspective of one who has seen more than a few similar efforts over the years covering IT.

Sole reliance on one organization such as CCHIT to certify EHRs will result in stagnation of innovation as they simply will not be able to keep up. Let’s also not forget that CCHIT certification is a fairly cumbersome and expensive process that has had little actual impact on EMR/EHR adoption, so why bother?  Maybe we need to look at self-certification models that support meaningful use of EHRs, thereby minimizing the burden on innovators and maximizing the options for providers.

Getting back to the beginning,

Leavitt may have been attempting to “set the record straight” but ultimately, his post does little to address primary concerns among many: CCHIT’s continued close relationship to a vendor advocacy organization HIMSS, nor how CCHIT will not stand in the way of innovation but promote such, nor how CCHIT can accelerate adoption and meaningful use of EHRs among clinicians.  Skipping over these critical questions and concerns does little to articulate the role that CCHIT may play in the future regarding the meaningful use of certified EHRs.

Now the question is: Will HIT vendors be the only beneficiaries of this federal windfall or will both clinicians and consumers also see value at the end of the day?  At this point, it is anybody’s guess.

But despite all of these well meaning (and certainly many self-serving) efforts, I enter my hotel room tonight and sit-down to write this post feeling depressed.

The depression comes from a disconcerting feeling that all that I have seen in the last few days are clear examples of exactly what is wrong with healthcare and that the $20B+ that we, as a nation, are preparing to spend on HIT will make little difference and may actually make things worse.

Though a strong believer in the transformative power of HIT in healthcare, after sitting in on a number of sessions and having conducted briefings with over 20 vendors (yes, I’ve been extremely busy here), it is clear that the mindset of this industry and many of its self-promoting pundits, needs to hit the reset button (or better yet, go into retirement). We are not, as an industry, focusing on the right things.  Rather than focusing on how to keep people out of the healthcare system, keep them from becoming patients, everything I have seen and heard here at HIMSS is about keeping people tied into the system.  A sad and depressing state of affairs that if I think about it too much, makes me angry.

After spending the last several days at HIMSS, I am convinced that the only way we are going to move the needle in a positive direction is to begin handing over the reins to the consumer.  For far too long this industry has kept the consumer in the dark and has not helped that consumer in directly managing their health.  It has taken a paternalistic view that must end immediately.  Nowhere at HIMSS did I see or hear people discuss the consumer (well, there was the occasional marketing education session on how to reach the consumer, but that is just marketing and doesn’t count).  The only perspective on display at HIMSS is that of consumer as patient.  Problem is, that view goes under the assumption that the only purpose of healthcare is to treat people that are already sick.

What about preventative health? What about the idea of keeping consumers out of the healthcare system?  What is the roll of this industry in providing the tools and capabilities that will enable consumers and care providers to work more closely together for mutual benefit?  Where are these discussions taking place? Where are these technologies on display?  Well, they are certainly not here at HIMSS, or at least I couldn’t find them.

A Bright Ray of Sunshine

As I prepare to head back to Boston I can take some small comfort in my dinner tonight with the founder and CEO of a small Chicago start-up.  Brilliant guy with an equally brilliant service that he is selling directly to large employers who sponsor the service to help keep their employees healthy.  A comprehensive offering that assists employees in managing their interactions with the healthcare system, but more importantly, assists those employees in staying out of the healthcare system. The company’s success is best represented by one of their first large customers, now nearly 2 years into it, who now has 96% of covered lives (that’s the employee and their covered family members) actively using the solution to manage their health.  I know of no other company in the market today that can demonstrate that level of adoption – simply an amazing number.  I’ll be doing a deeper dive on this company in the near future after I have had a chance to talk to their customers.

That bright ray of sunshine is what keeps me going.  Having heard that story, and I am sure there are others out there. I am more convinced than ever that the role of Chilmark Research is to search out and find those innovators who are working to take healthcare in a completely new direction.  This is why I started Chilmark Research – those stories need to be told, and we need solid analyst research to substantiate those claims and better understand the true adoption drivers.  This is where Chilmark Research will devote the majority of its efforts and hope that you will assist us by providing those stories, those proof points, that will, in a broader context, move the needle in a positive direction.

In our post on the subject, we were miffed that rather than countering Jablonski’s claims, HIMSS, through their lawyers, sought censorship. We did not comply.

What we countered with was what we thought a great idea:

HIMSS, we at Chilmark Research will gladly offer you the opportunity to guest post on Chilmark Research where, in full view of the public/readership you can provide a point-by-point response to Jablonski’s claims.

Seems sensible to us but for some odd reason, HIMSS has yet to respond to this offer.  Is there really something to hide here?  Does the cartoon above (simply substitute CCHIT for FDA) accurately portray what is really going on here?

Honestly, we tend to side with the belief that Jablonski is in some way a very disgruntled individual (former employee, contractor etc.) who has some ax to grind and was intimately familiar with some of the inner workings of both CCHIT and HIMSS.  But disgruntled or not, Jablonski does raise some broader issues that really need far closer review and scrutiny in light of the recently passed Stimulus Bill and the HITECH Act which will pour some $20B+ into the HIT market.

In today’s issue of Healthcare IT News, Neil Versel does a very good job of reporting on the controversy surrounding the Jablonski post and interviews others in the industry, including yours truly, on what many perceive as a strong potential for conflict of interests between an organization that is charged with certifying EMRs (CCHIT) and one responsible for promoting EMRs (HIMSS).

Many industry pundits, including John Glaser, CIO of Partners and senior member of NeHC (AHIC 2.0) believe that CCHIT will be the one responsible for making sure that all those EHRs that get adopted under HITECH Act, meet the “certified EHR” requirement.  But is CCHIT really in the best position to grant certification?  In one sense yes, as they have been doing just that for the last several years and claim over 160 products are now CCHIT certified.

But given their all to close relationship with the “HIT establishment” (HIMSS and the entrenched EMR vendors), are they really the best organization to oversee certification going forward?  Probably not in their current form.  Rather than contracting out to some third party, ala CCHIT, maybe a better solution would be to just let NIST do it themselves as they are truly neutral, have been given the authority (it’s in the legislation) and if they have sufficient staff, could certainly accomplish this task.

Ideally though, would not it be better to get the legislative body to go back and simply strike “certified” from the language of the HITECT Act?  To do so would leave us with providing incentives to physicians for “the meaningful use of EHR” by still promoting such behaviors as care coordination, quality, and eRx, without the burdensome requirement for “certified” EHR that will almost always be 3-5 years, at best, behind technology advances.

And by the way, just because it is “certified” does not, by any means, equate to interoperable.  One of the biggest fallacies in the market today.

Today, we received a letter from the law offices of Jackson Lewis LLP who are acting on behalf of HIMSS.  It appears that this website has gained a certain notoriety through comments left by a “Calvin Jablonski” (search and you’ll find them) on a number of posts. As it turns out, Jablonski has been busy not just commenting here but on other sites such as the Wall Street Journal’s Healthcare Blog, Neil Versel’s Healthcare IT Blog and even on Matthew Holt’s The Healthcare Blog (THCB).  However, it appears that Jablonski got his start here.  Lucky us.

Matthew did an admirable job of commenting on this little firestorm that Jablonski seems to have started and Matthew attempts to clear the air the “Jablonski comments issue.”  Chilmark Research, which has taken no stand, however, is now the proud owner of a letter from a legal firm representing HIMSS asking us to turn over any and all information we may have on Jablonski (contact details, etc.) as well as deleting all of his comments from the Chilmark Research website.

Now that puts us in a bit of a conundrum.  If we comply with the Jackson Lewis request we certainly would not have to worry about anymore letters, emails and maybe even calls.  Yes, it would make our life easier.

But there is a broader and far uglier precedence that would be set if we went along with their request.

First, is the violation of someone’s privacy. Requesting all information that Jablonski may have provided or left via his comments (IP address, email address, etc.) so the lawyers can track down Jablonski’s “true identity” is not something we are comfortable doing.  This site is designed to allow and encourage the free discourse of discussions on healthcare and technology’s role therein.  Would releasing such information to an offended party violate “free discourse”?

Second is the issue of censorship.  An important foundation of this country’s founding is free speech, to a point.  Yes, there are libel laws and the like but last we looked, the party taking offense must demonstrate clear damage. Are HIMSS and CCHIT, both receiving the wrath of Jablonski’s comments, truly damaged by what clearly appear to be the ravings of a disgruntled individual?  The bottom-line though is that we do not want to censor comments that add to a discussion are pertinent to the topic at hand – PERIOD!

Now in full disclosure, Chilmark Research did receive an email on Feb 19th from this HIMSS’s law firm, of which the letter today is but the same.  Upon receiving that email, we contacted HIMSS directly, spoke to the head of PR who immediately pushed us to HIMSS’s internal lawyer.  She told me that there was much internal discussion on their path forward to address the Jablonski issue.  Mentioned to her that we were not comfortable with their law firm’s requests and proposed a solution, which we thought was a damn good one.

HIMSS, we invite you to write a Guest Post that we would gladly post on the Chilmark Research site and highlight it to set the record straight.  Seems like a good solution to us but to date it has gone unanswered.

So HIMSS and the lawyers at Jackson Lewis, why the delay, this really is not all that complicated a problem to solve.

Note: Now we believe we have taken a prudent and thoughtful approach to resolving this issue in light of what our core operating beliefs.  However, we are open for suggestions and input from you dear readers on what path you deem most appropriate on this rather tricky issue.  Did Chilmark Research take the proper path through this potential minefield?  What would you have done if you were in a similar position, or better yet what have you done in similar situations?  Thanks in advance for any and all feedback.

Addendum:

It has been brought to our attention, via direct email, that there is actually a name for all of this and it even has an entry on Wikipedia: The Steisand Effect. Imagine that! Learn something new everyday.

Okay, so you have now joined the auto industry looking for government hand-outs.  Now why exactly does this industry believe it is any more deserving than others to receive this government largess.  If we, the government (tax payer), give you this $$$ how do we know you will spend it wisely as your track record to date isn’t all that great. And by the way, did you not recently refer to yourself as a industry trade organization receiving the majority of funding from encumbent HIT vendors?  Hmmm, this is beginning to smell funny.

Apply recognized standards and certified health IT products among all federally funded health programs by requiring that federal funding to assist providers and payers within these programs adopt health IT only be used for the purchase or upgrade of new health IT products that apply Healthcare Information Technology Standards Panel (HITSP) interoperability specifications and have Certification Commission for Health Information Technology (CCHIT) certification.

Time and again it has been shown that setting firm parameters around virtually any technology ultimately stifles innovation.  Now, don’t get us wrong, we are all for interoperability, but HITSP & CCHIT?  Why not ASTM, or NIST? Not a big fan of this approach, besides HITSP and CCHIT abound with vested interests (e.g., encumbent HIT vendors who already have a lock on the industry and big medical institutions that have huge sunk costs).

Expand Stark Exemptions and Anti-Kickback Safe Harbors for EMRs to cover additional healthcare software and related devices that apply HITSP interoperability specifications, are CCHIT-certified, and allow for better coordination of care and information sharing among related providers and their patients. In carrying-out out this recommendation, the Secretary should implement necessary measures and requirements to protect against conflict of interest and improper relationships among providers.

No problem with exemptions, big problem with HITSP and CCHIT (see above).

Codify HITSP as the National Standards Harmonization Body responsible for collaborating with the public and private sector to achieve a widely accepted and useful set of standards to enable the widespread interoperability among healthcare software applications. Adequate funding should be authorized and appropriated for HITSP from FY10 – FY14.

Don’t see a lot of value here.  So where is the value?  Using market-based incentives, ala CMS’s eRx program that is rolling out in ’09. Let’s leverage federal healthcare spending to encourage other changes.  No, you don’t need HITSP or CCHIT to do this, just use all that fed spending (DoD, federal employees, CMS, etc.)  and ask for records in CCR or CCD format to receive payment.

Codify a Senior Level Health IT Leader within the Administration to oversee a national health IT strategy.

Do we have such IT leaders in any other branch of government?  No, so why here?

Authorize a Federal Advisory and Coordinating Body for Health IT. Based on the experiences of the AHIC and its Successor organization, the US Congress should authorize a federal advisory committee – operating under the Federal Advisory Committee Act – responsible for advising the Administration on health IT initiatives throughout the US and coordinating standards harmonization through collaboration with HITSP and CCHIT.

Let’s go with Daschle’s proposal instead for a board similar to the one for the Federal Reserve.

Conduct a White House Summit on Healthcare Reform through Information Technology to develop consensus and propose solutions to critical, national health IT issues within the context of the larger national healthcare reform effort.

This industry has eventitis. Do we really need another one where all the pundits that make the conference rounds today have just one more event to put in their calendars?  Please, enough already.

For another view on how to spend federal largess, that is if there is any left after Wall Street and Main Street are done, Rick Peters did a fabulous post recently that deserves a full reading, including the comments. Now there is a blueprint worth reading Mr. President-elect Obama and Senator Daschle.