Last week was the massive Salesforce.com user conference Dreamforce (massive in that there were more attendees at Dreamforce then this year’s HIMSS!). We’ve been reviewing more than a few articles and writings written by those who attended the event. In the few short years of its existence (~13yrs) Salesforce.com has become one of the leading Customer Relationship Management (CRM) vendors in the market and basically pushed the previous leader Siebel to the brink and into the arms of Oracle. Salesforce is arguably the leader in the Software as a Service (SaaS) market and thus someone to pay close attention to on all things “Cloud Computing.”
So what makes Salesforce.com so compelling and what are some parallels to the healthcare sector?
Similar Market Demographics: From the beginning Salesforce has always been structured as a SaaS and targeted the hard to reach and highly distributed sales forces of companies of all sizes. Actually, they first targeted the small to medium business (SMB) market and once successful there, went after Siebel in big enterprises. In healthcare, the vast majority of care is provided by small, 1-3 physician practices that are highly distributed across the country – perfect target for a hosted SaaS offering.
According to the latest count, there are 255 Health Information Exchange (HIE) organizations across the country, which amounts to an average of 5 in each State. If you are a practicing physician and have an EHR, chances are someone already knocked on your door offering to connect your practice to the local HIE for a small fee. If you don’t have an EHR, you may have had offers to access an HIE web portal, or maybe an HIE supplied EHR Lite, allowing you to at the very least view clinical data from other sources. Perhaps for free. If you are the proud owner of one of the full-featured EHRs, you may wonder what an HIE can do for you that your EHR is not already doing, and whether that service is worth your hard earned money.
In theory, a top-shelf EHR should be able to connect your practice to multiple facilities and allow you to exchange information to the best of all participants’ abilities. Granted most EHRs are still working on some of the connections, particularly to local facilities, but all in all, an EHR should be able to eventually provide for all your connectivity needs as shown in Figure 1. Note that for some types of connections, your EHR vendor can use a clearinghouse or portal approach to simplify and reduce costs of connectivity. For example, you don’t need a separate interface for each pharmacy – you use Surescripts as the clearinghouse and let them worry about it. You also don’t need an individual connection to each patient’s home – you communicate with all of them through one portal. With the exception of Surescripts pharmacy connectivity and a small number of reference labs, each connection, or interface, is costing you a pretty penny, and the more local the connection, the longer it takes to build.
The idea behind a network is that it grows stronger as more participants join it. A basic example is a cell phone provider that allows its members to make free calls to other members – the policy becomes more valuable as more people join the network.
Health Information Exchanges (HIEs) work on the same principle – networks connecting electronic health record (EHR) systems, pharmacies, Medicaid Management Information Systems, etc. The idea is sound, but the information shared is only as valuable as the number of participants and the quality of the data and resources.
Interconnectivity and interaction among providers can potentially do so much to raise the standard of patient care that it’s important we do all we can to facilitate participation in HIEs. With that said, we must recognize that it takes time to build quality and we want to make sure we’re getting it right.Continue reading…
I was recently asked by an Institute of Medicine committee to comment about the impact of healthcare information technologies (HIT) on patient safety and how to maximize the safety of HIT-assisted care.
“HIT-assisted care” means health care and services that incorporate and take advantage of health information technologies and health information exchange for the purpose of improving the processes and outcomes of health care services. HIT-assisted care includes care supported by and involving: EHRs, clinical decision support, computerized provider order entry, health information exchange, patient engagement technologies, and other health information technology used in clinical care.
There are two separate questions:
1. What technologies, properly used, improve safety?
2. Given that automation can introduce new types of errors, what can be done to ensure that HIT itself is safe?
To explore these topics, let’s take a look at Health Information Exchange (HIE). What HIE technologies improve safety and how can we ensure the technologies are safe to use?
I’ve written previously about Healthcare Information Exchange Sustainability and the need for Healthcare Information Services Providers (HISPs) to serve as gateways connecting individual EHRs.
How should HISPs be funded and how can we encourage HISP vendors to connect every little guy in the country?
We’ve started to think about this in Massachusetts.
There are numerous vendors promising HISP services – Medicity (Aenta), Axolotl (Ingenix), Surescripts, Verizon, and Covisint.
An HIE needs to include at least one common approach to data transport, a routing directory, and a certificate management process that creates a trust fabric. Existing HISP vendors have heterogeneous approaches to each of these functions. In the future, the Direct Project may provide a single approach, but for now HISP vendors will need to be motivated to adhere to State HIE requirements.
An idea that has been embraced by some State HIEs, such as New Hampshire, is to pay HISP vendors a modest fee (under 100K) to support State requirements. This “connectivity” incentive results in interoperable HISPs, creating a statewide network of networks.
Once a standardized HISP approach is supported by multiple vendors, then individual practices need to be connected. Some practices will be aggregated into hubs by EHR software vendors as has been done in cities such as North Adams (Massachusetts), projects such as the New York City PCIP project, and physicians organizations such as the Beth Israel Deaconess Physicians Organization. However, it’s not likely to be cost effective for a vendor to connect every isolated practice to a HISP for the $50/month the practice is willing to pay.
First it was United Health Group’s (UHG) Ingenix Division’s acquisition of leading HIE vendor (and top competitor to Medicity) Axolotl. Then this morning Aetna counters by acquiring Medicity. In just a few short months these two payers have completely changed the landscape of the HIE market by acquiring the two leading HIE vendors in the market today. Now that both of these vendors are in the hands of payers what are the implications both to the HIE market and more broadly the healthcare sector? Following is our assessment based on our continuing research of the HIE market and a number of interviews today, not only with the Aetna and Medicity, but also several other active participants in the HIE market.
Aetna acquired Medicity for a King’s ransom of $500M, a handsome multiple of Medicity’s 2010 gross revenue. Medicity will operate as a separate entity under the Aetna brand maintaining its current headquarters in Utah. According to Medicity, initial conversations began in late October/early November and quickly accelerated to the deal announced today. Aetna plans to close the deal before the end of year. As part of the deal, the senior management team of Medicity has agreed to stay in place for the next few years.
While some may argue that Aetna was simply looking to counter the move by UHG or Aetna’s new CEO was looking to make a mark, Chilmark sees a more thoughtful and strategic move at play here which in the end may justify the price paid.
This is a summary of the HIT Trends Report for October 2010. You can get the current issue or subscribe here.
The evolving health information exchange market. The HIE segment was center-stage this month with a game-changing announcement by Surescripts. It will combine its national physician directory and EMR connectivity with apps from its strategic investment in Kryptiq to offer physician-to-physician clinical messaging beginning in December, extending its dominant market position. As first to market with these functions, it will likely cement its standing as the country’s premiere neutral national network. It also enables a platform for additional web services from collaborating partners in the future. We are also reminded this month in Healthcare IT News of the relative dominance of Epic in the IDN and large practice market with the startling statistic that 75% of Wisconsin residents are in the databases of its state user group. Using Epic tools and with patient consent physicians in the state can see patient information across institutions. And there’s a story this month that Verizon is expanding its vision as an HIE by adding clinical lab and imaging results to its networking services with leading transcription companies. These three lenses: (1) Surescripts as the leading national network; (2) Epic as the leading national EMR; and (3) Verizon as the leading national telecom, exemplify the rapidly changing dynamics in this segment.
EHRs and HIT have become central to transformation of clinical practice. One large driver is the announcement by the insurance commission of the inclusion of HIT as well as wellness and care management as medical expenses for insurers under PPACA. In the past these areas were generally allocated to the administrative budget of health plans which limited participation. This will increase payer investment. A CMS exec, Anthony Rogers, reported to Healthcare IT News on early results of CMS accountable care organization (ACO) pilots. He noted that practices with EMRs were getting most of the $36M in incentives and said, “If that’s not a business case [for EHRs], I don’t know what is.” The Patient-Centered Primary Care Collaborative, the organization driving medical homes released two reports this month also highlighting HIT’s role in transformation. One report looks at best practices to engage patients in a medical home project using HIT. It’s a compendium of 15 essays by a diverse set of experts on different perspectives about using health IT to engage patients, plus snapshots of two dozen case examples. The other report focuses on five ways to implement HIT effectively to enable clinical decision support. And CSC released a roadmap for HIT in ACOs with an elegant six factor model: member engagement; medical management; clinical information exchange; quality reporting; business intelligence; and risk and revenue management.