In late March, I headed down to Belize with a bunch of high school students to do some service work. Joining the crew was a parent, Harry (not his real name), who happened to be a urologist sharing a private practice with five other urologists. We got to talking about the industry, the rapid changes that are occurring and of course HIT, where the conversation quickly turned to health information exchanges (HIE).

This urologist’s practice has been using eClinicalWorks (eCW) for several years now and despite their proficiency with using this EHR, the practice has never fully recovered the productivity it once had. Regardless, they have come to accept this hit on productivity as just the cost of doing business. (Note: In Massachusetts all physicians must adopt and use an EHR to be credentialed, regardless of meaningful use or any other programs.)

Harry spends two days a week in surgery with most operations taking place in one of four facilities: local, unaffiliated hospital Winchester (who uses Meditech), Beth Israel Deanconess (has a home-grown EHR but encourages affiliate practices to adopt eCW), Childrens’ Hospital (a Cerner shop that also promotes eCW in ambulatory) and Partners which is now moving from its homegrown EHR solution to Epic (BTW, in a recent conversation with a contact at Partners learned that they are spending $1M/day for next five years on Epic switch - ouch!).

All of these hospital organizations want a closer affiliation with these urologists in support of future value-based payments and of course just getting these physicians to do more surgeries at their respective institutions. Thus, all of them want the urologist practice to adopt their interoperability model. Harry stated that Partners, the biggest healthcare organization in metro-Boston and arguably New England, is pushing particularly hard for them to switch to Epic as Epic does not have an HIE offering (Epic Everywhere is not an HIE in our definition nor apparently in ONC’s) and encourages its customers to put all ambulatory affiliates on Epic instead. In addition to these organizations, the Commonwealth is also encouraging this practice to join the statewide HIE.

After the pain and suffering Harry’s practice went through to become proficient on eCW, they are loathed to switch to Epic. Besides, switching to Epic would limit their ability to connect with other healthcare organizations they work with as Epic does not play well with others.

Harry’s situation is not unique and is likely being played out across the country, especially in urban areas where there may be a number of competing healthcare systems each trying to establish their own HIE. In such a situation what is an independent physician practice to do?

Certainly they could sell the practice, as many physicians have already done, to the highest bidder. Not an option for Harry and his physician partners as they like their independence and plan to keep it that way.

They could turn to the statewide HIE and hope that it will provide the depth of services (interoperability) to enable them to connect and share records in support of care coordination with all hospital systems they work with. Ideally, this may be the best approach but unfortunately they’ll be waiting a very long time for this to happen, if it happens at all. Today, most statewide HIEs, including Massachusetts are focused on enabling Direct secure messaging, a simple, political expediency that those in D.C. can point to as a shiny example of information exchange for the nearly half billion dollars spent on statewide HIEs. It is unlikely that most statewide HIEs will evolve beyond Direct providing the type of deep connectivity between a practice and an healthcare system to coordinate care effectively. That’s not to say we are throwing out the baby with the bathwater as there are some states that are doing exemplary work e.g., NY, IN

Then there is the option of just staying the course and hoping that lightweight connectivity directly into eCW will miraculously occur. For Harry and his partners, both Childrens and Beth Israel currently support eCW and interoperability with the acute care EHR will be supported. Partners may be left with no other option then to purchase a third party HIE solution to connect affiliate practices in the highly competitive, metro-Boston market. As for community hospital, Winchester, this hospital is unlikely to survive as an independent and will either be acquired or eventually be forced to shut its doors.

Still Waiting…
While the vast majority of ambulatory practices will ultimately be acquired, there will be a significant number of specialists who will continue to operate independently and with a number of healthcare institutions. The current hodgepodge of HIEs being stood up in various communities and the multitude in a given urban area will put increasing strain on physician practices such as Harry’s, who like any of us, given too much choice will simply forgo a decision.

Maybe, just maybe the efforts of the Interop Workgroup will take practices such as Harry’s to the promise land that will allow them to support coordinated care, in a simple streamlined fashion, amongst a wide range of healthcare organizations in their community irrespective of underlying HIT infrastructures. We have not heard of any such examples to date, but we remain hopeful as the current model being deployed today, while likely addressing the all too familiar 80% of the problem, still leaves a very critical 20% unresolved.

Arguably, the biggest news story coming out of HIMSS last month was the announcement of the CommonWell Health Alliance – a vendor-led initiative to enable query-based, clinical data sharing. So much has been written about CommonWell that there is little need to rehash what has been said before.

What has not been said, or at least has been sensationalized nearly to the point irrelevance is the whole controversy surrounding Epic and how they were not invited to join the CommonWell Alliance until after the announcement. None other than Epic’s own founder and CEO, Judy Faulkner, has gone on record stating the Epic was unaware of CommonWell prior to the announcement. Faulkner has gone on to question the motives of CommonWell, in an effort to subvert it, in her highly influential role on the Dept of Health & Human Services HIT workgroup committee.

That was the last straw.

It is one thing to moan and groan at the HIT love fest that is HIMSS, where vendors commonly discount the announcements of competitors. But it is quite another thing to be a part of a highly influential body that is defining nationwide HIT policy and make the same claims over again, especially when they are frankly not true.

Is there some truth to Faulkner’s claims that the vendors who have created CommonWell may have had an additional motive, stopping the steamroller that is Epic? More than likely.

But it is also true that founding members of the CommonWell Alliance do wish to lay down the swords of hoarding data to allow higher order services to be developed on top of the CommonWell platform. They all see the market changing rapidly. They know that they, on their own, cannot move fast enough to meet all the needs of the market. They understand that the next iteration in HIT is to move to a platform-based services model – that is where the value will be. As to whether or not CommonWell will ultimately be successful, that is far from certain as there are many rivers to cross before we see the query-based health information sharing that these alliance members envision take hold, if at all, in this industry.

From our vantage point, Epic, with its monolithic strategy that is more akin to Wang Laboratories than it is to Apple’s iOS, is operating on a model that while providing a seamless environment from ambulatory to acute (something other EHR vendors have totally messed up on), will ultimately hinder healthcare organizations’ ability to rapidly innovate and respond to market changes. Epic simply will not be able to move fast enough and their customers will struggle as a result.

As to whether or not Epic was invited to the CommonWell party; we have received confirmation from several sources that indeed Epic was invited to join a couple of weeks prior to the announcement. What likely occurred is that Epic saw that CommonWell’s goals, objectives, and operating structure were already formalized when the invite arrived. Thus, Epic would not have an ability to make substantive contributions to this initiative and rejected the invitation.

It is disingenuous for Epic to state otherwise and if they were a public company, they may have been subjected to an SEC inquiry. But alas, Epic is not a public company and Faulkner can say what she wishes with few, if any, repercussions. Her quite vocal denouncements of CommonWell though do show that she clearly does feel threatened by this alliance.

But a core mission of Chilmark is to cut through the BS to ensure that this industry is informed. In keeping with that mission, we felt it important to let you know what is really happening behind the scenes at CommonWell. Hopefully, we have set the story straight on the CommonWell Health Alliance and Epic saga.

We came back from HIMSS and got right to work on the March Monthly Update for Chilmark Advisory Services subscribers. As we’ve reported in a previous post, HIMSS13 afforded enormous buzz and less enlightenment regarding the state of health IT, particularly the four key areas we see as essential to this industry making a true difference in patient care. In our March update, and the reports currently underway, Chilmark Research does the opposite: provide insight without buzz. Below are abstracts from this month’s update. To find out how you can receive the full update, send an email to: info at chilmarkresearch dot com

Public vs. Private Oversight of Mobile Health
John Moore III

mHealth, known for rapid innovation and iteration, has a tendency to buck at the snail’s pace of FDA regulation. Last month, during a series of hearings considering whether smartphones and tablets with medical apps qualify as medical devices and thus require FDA approval, many charged the FDA with stifling innovation. After all, how many developers or investors want to sink resources into an industry that will be regulated in ways that have yet to be determined?

Enter Happtique and its Health App Certification Program. Happtique intends to complement the work of the FDA, and has introduced a set of standards for health apps that fall into the grey area between apps that are clearly medical and those with a clear consumer focus. This could herald a new age of credibility for mHealth. However, as both regulator and marketplace for many of the apps that it regulates, Happtique could end up in a very sticky situation. They will need to tread carefully to maintain their objectivity in both certifying apps while at the same time providing a marketplace for mHealth apps.

The March Toward Better Patient Engagement
Naveen Rao

The open question in health IT these days is whether patient engagement will gain traction or if it will suffer the same fate as PHRs. One thing is certain; healthcare needs far better patient engagement methods, processes and techniques than what one finds today as most current efforts in engagement have very little to do with helping a patient manage a condition. Time and again in our discussions with healthcare institutions of all sizes we find the same scenario being played out – engagement today is focused on building patient/customer loyalty to the institution – they are simply no more than marketing efforts.

Stage 2 meaningful use is requiring a deeper level of patient access to their records via view, download and transmit requirements and there is even a requirement for some email messaging between provider and patient. But there is a bigger issue at play, payment reform wherein providers will be taking on more risk for the patient populations they manage. Without deeper engagement with the patient regarding a chronic disease, providers will struggle with these new payment risk models.

Several related markets, such as telemonitoring and wearable tech are taking off. Chilmark analyst Naveen Rao spent near-exclusive attention to the patient-engagement tracks, vendors, and sessions at HIMSS13. In his article for the March update, Naveen identifies three factors that will define if and how well the patient-engagement market will stay afloat in the coming years.

CommonWell Alliance Intends to Tackle Interop
John Moore

The announcement of CommonWell Health Alliance was likely the biggest story to come out of HIMSS (Allscripts acquiring longtime HIE partner dbMotion may have been a close second). The group’s stated purpose is to enable interoperability across the five founding members’ EHRs. For starters at least, this includes: Allscripts, athenahealth, Cerner, Greenway, and McKesson’s RelayHealth division. In its simplest form, CommonWell will establish a set of standards and services that enable query-based health information sharing in a heterogeneous EHR environment.

Part of the challenge with interoperability within a community of heterogeneous EHRs is that standards are useless when it comes to things like patient matching, consent management, or locating records, all of which are fundamental to interoperability and all of which require standardized services model. CommonWell founders know this and have plans to address it. The greatest challenge facing CommonWell, however, may be the market itself as adoption of HIE tech within the ambulatory sector remains a challenge.

Each month, subscribers to the Chilmark Advisory Services (CAS) receive an update of our research on the most transformative trends in the healthcare IT sector. Exclusive to CAS subscribers, monthly updates are part of the continuous feed of information and analysis we generate to keep subscribers on top of the rapid-fire changes in this market.

Today, Caradigm and Orion Health announced their partnership wherein Caradigm will go to market with Orion Health’s HIE solution suite and likewise Orion Health will take  Caradigm’s analytics solution, Caradigm Intelligence Platform (CIP) to market to its existing and future customers. Existing Caradigm customers (~20) who are now on the eHealth platform will be put on life-support and encouraged to make the transition to Orion’s solution in the coming year.

Orion Health has had a long relationship with Microsoft, including acquiring Microsoft’s Amalga HIS solution and partnering with Orion to combine the then Amalga UIS with Orion’s HIE solution. Shortly after this announcement was made though, Microsoft threw in the towel on the clinical market combining its assets with a collection of those from GE which resulted in the NewCo, Caradigm.

As part of the establishment of Caradigm, GE contributed eHealth, its HIE solution suite that was co-developed with Geisinger and Qualibria, a quality management platform developed in conjunction with InterMountain. With the death of eHealth and a product which has yet to see the light of day (Qualibria) its beginning to look like GE brought very little to the Caradigm relationship.

Back to the Orion-Caradigm partnership…

As we have written in the past the core services that HIE vendors offered in the past are quickly being commoditized by such things as Direct secure messaging being embedded in future certified EHRs for stage two meaningful use requirements. With the recent announcement of CommonWell Health Alliance, even query type services may also become commoditized.

Clearly, to stay competitive and relevant, HIE vendors need to move to what we term as HIE 2.0, providing more advanced services that leverage the data flowing through the “pipes” of an HIE to more effectively manage the health of a given community the HIE serves. This is particularly important for enterprise clients ( a market Orion is now targeting) and can also assist public HIEs (Orion’s traditional market) in providing value-add services that may help them reach nirvana (sustainability). With CIP, Orion can provide a more compelling offering. The big challenge here for Orion will be in effectively pricing and deploying CIP, (Amalga UIS was notoriously expensive and difficult to deploy. Caradigm has rebranded Amalga Version 3, a much improved version architecturally, as CIP to distance themselves from the stigma of the Amalga brand).

While the relationship provides value to Orion, it may provide even greater value to Caradigm, a company that has stumbled to gain traction in the market. Orion provides a ready channel to market via Orion’s existing broad HIE customer base – one of the world’s largest. Orion also provides Caradigm an effective exit from directly participating in the HIE market with a solution that frankly was not up to the task. The announcement also claims that Orion has agreed to develop applications for the CIP which contributes to Caradigm’s goal of being perceived as a platform play in the market. What those apps may be is still an open question. Based on the language in the PR, it looks like not a lot of thought has gone into that aspect of the relationship yet.

Now we’ll just have to wait and see how this plays out in the market.

What to watch:

1. Joint customer wins – who and where.
2. How many existing eHealth clients transition directly to Orion or jettison for another HIE vendor entirely.
3. Apps that Orion builds for CIP.
4. Existing Orion clients that purchase CIP and whether or not we see accelerated growth in such purchases or an initial surge followed by stagnation.