Emerging Standards and the Disruption of HIE 1.0
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Emerging standards in health information exchange, driven by the ONC and others, are going to change what health IT customers (hospitals, physicians, labs, etc) are going to pay for. This is an overview of those new standards, and my perspective on the implications for health technology companies, particularly EHR and HIE vendors.
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Emerging Standards and the Disruption of HIE 1.0
- 1. Emerging Standards and the Disruption of HIE 1.0 Jitin Asnaani, ONC
- 2. Agenda What is HIE? How does HIE create value today? What are the emerging standards for HIE? How will these standards affect HIE business models? What does this mean for vendors? Perspectives – What do you think? Acknowledgements 1
- 3. What is HIE? Since the 1970s patient care has accelerated away from the “one provider” model physicians live in silos Health information exchange (HIE) services have emerged with the aim of re-connecting physicians with their patients With adoption of HIE projected to accelerate in the near-term, new and incumbent vendors of HIE services are searching for viable business models: How will value be created? What will customers pay for? What’s the best strategy to capture this value? 2
- 4. Creating Value: A Different Perspective Traditional product management and marketing strategy focuses on “Who is the customer?” Segmentation based on attributes Geography, local demographics, level of urbanization, distribution of physicians, presence of academic medical centers, etc. But successful entrepreneurs first ask the question “What is the customer trying to get done?” This is how customers experience life – whether the customer is a patient, physician, hospital, government agency, etc. They “hire” a product to do a “job” for them For physicians, Health IT is about solving valuable hard jobs in patient care!* * Physicians also have hard jobs in reimbursement – while we chose to focus on the clinical hard jobs here, the implications for HIE described in this document will similarly apply 3
- 7. EHRs with Unstructured Data
- 8. EHRs with Structured Data
- 10. Phone / Fax
- 11. HIEs/RHIOs/HISPs
- 14. Privacy, Security, Consent mgmt.4
- 16. ONC and others are establishing standards for the content and transport mechanisms for exchange
- 19. EHRs with Unstructured Data
- 20. EHRs with Structured Data
- 22. Phone / Fax
- 23. HIEs/RHIOs/HISPs
- 25. Privacy, Security, Consent mgmt.5
- 26. Emerging Standards: Content S&I Framework: Community of 350+ participants: HIT vendors, SDOs, government agencies, IDNs, academic centers, physician practices, etc. Transitions of Care (ToC) Initiative: focused on defining a common modular set of clinical data for exchange during a care transition Lab Results Interfaces (LRI) Initiative:focused on standardizing lab results reporting to ambulatory primary care settings Numerous initiatives elsewhere across the industry to standardize public health reporting, lab orders, etc. 6
- 27. Emerging Standards: Transport v1 of Nationwide Health Information Network: Standardizes transport, security and queries for scalable patient and document discovery across communities of care Implemented by 8 substantial IDNs/Federal Agencies, with several more onboarding over the year Evolving models for certification and governance Direct Project*: Standardizes transport and security mechanisms for secure directed messages between healthcare participants Commitment to implement by 50+ vendors and 25+ states S&I Framework: New initiatives focused on Provider Directories and Certificate Interoperability 7 * To be merged into the Nationwide Health Information Network in the near future
- 28. What happens when functionality like “connectivity” gets commoditized?* A commoditized product is in “overshoot” Functionality provided exceeds value customers can utilize Customers not willing to pay more for added functionality on the existing performance basis Disruption! Once requirements for functionality and reliability have been met, customers redefine what is not “good enough” Customers become willing to pay premium prices for improved performance along new trajectories of innovation, such as convenience or customization 8
- 29. Disrupting HIE 1.0 HIE 1.0 required fully-integrated bespoke architectures, because “connecting” was hard As emerging standards simplify and commoditize connectivity, the nature of firms involved in HIE changes HIE & EHR vendors that compete on “being able to do it” will be disrupted Commoditization will enable modular interfaces, driving down cost to deploy basic connectivity – and consequently, low price points* HIE 2.0 will be all about seamless clinical workflows, regardless of where the data resides Basis of competition shifts towards providing clinical value: seamless clinical workflows & quality management Good businesses are going to couple technology and service for workflow integration and change management 9
- 32. EHRs with Unstructured Data
- 33. EHRs with Structured Data
- 35. Phone / Fax
- 36. HIEs/RHIOs/HISPs
- 37. Connected EHRsProducts “hired” for this job time time Performance Basis: Today Integrated Workflows within hospital/practice Connectivity to relevant external data sources HIE 2.0: Seamless Clinical Workflows, regardless of where data resides Performance Basis: Future 10
- 38. What does this mean for EHR vendors? EHR vendors can embrace one of two strategic paradigms: Apple Model – integrated lifestyle/computing platform Provide high-performing, fully-integrated solution for health information exchange and clinical workflows Attract demanding/high-end customers who are willing to pay for it PC Model – modular components with standard interfaces Optimize performance on key functionality, i.e., clinical workflows Create modular interfaces to standardized or third-party plug-ins for connectivity Appeal to broad customer base 11
- 39. What does this mean for HIE vendors? Incumbent HIE vendors must move up-market, race to scale, or embrace disruption: March Upmarket: Provide high-performing connectivity solutions that high-end/demanding customers will pay for (the Apple model again) Race to Scale: Try to become super-regional or even nationwide providers of low-margin connectivity solutions (the Utility Company model) Embrace Disruption – very hard: Partnerships/M&A with the disruptors who will provide clinical value in the future (AOL/Time Warner, Cisco/Flip, etc.) 12
- 40. Your perspective This is our hypothesis: what’s your view? What do you think will be the impact of standardization? Where do you see HIE business models heading in the next 3-5 years? How will this affect hospitals, IDNs, physician practices, labs, IT vendors, and other healthcare participants? What role and impact will payment reform have in terms of HIE capabilities and business models? 13
- 41. Acknowledgements This discussion utilizes theories and terminology articulated by Clayton M. Christensen and Michael E. Raynorin my academic and professional engagements with each, and described in detail in their excellent book “Innovator’s Solution” The storyline is built on the vision and real-world experiences first shared with me by Arien Malec, Coordinator of the Direct Project and the S&I Framework Much thanks to the edits and suggestions provided by ONC colleagues and contractors Brian Ahier, Erica Galvez and Sachin Jain 14
- 42. Thank You!
Notas do Editor
- Example: Why connectivity is hardI recall that, at my last startup, we had to deal with the challenge of enabling connectivity first-hand: - Our first client - an 800+ bed hospital with 150K emergency department visits annually - faced a constant barrage of complaints from community physicians, whose patients would enter the clinic expecting post-discharge care after visiting the hospital ER - and the physicians would be caught completely flat-footed, with no knowledge of the ED visit and limited access (if any) to the hospital data.To solve this problem, we built a solution that simply alerts community physicians when their patients were discharged from the hospital ED, and provided a link to a read-only web-based discharge summary. Just to create this simple solution, we had to connect to 5 different Hospital Information Systems (HISs) and translate between a half-dozen protocols and document formats. We had to do all that for a read-only discharge summary displayed on a flat web page!So for good reason, “connectivity” has been the name of the game for HIE vendors
- Layman definition of “content”: includes the actual clinical information, such as diagnoses, medication lists, lab test results, etc.
- Layman definition of “transport”: includes the mechanism for ensuring that a message gets from Point A to Point B. This includes a bunch of underlying technology for packaging, routing, encrypting, and other components that ensure that a message is successfully conveyed from sender to receiver securely and privately.
- Examples of commoditized products:Paperclip – vanishingly small number of people who desire premium paper clips – as much a commodity as the metal that they are made ofArithmetic calculators – can buy one for 2 bucks or lessWordprocessingsoftware – described more belowExample of commoditization resulting in change in basis of competition, leading to disruption: - WordPerfect: did the job just fine! But it got commoditized – the raw “wordprocessing” capability was more than good enough for most people. - People now needed software that performed along a different dimension: integration with other business apps. And so Microsoft Word came in and won, even though it was not a markedly better “wordprocessor” than WordPerfect (in fact, it likely had fewer features). - Now that integration with other software is becoming easier – particularly with the standardization of document formats and content types - the basis may be shifting again, to “ease of collaboration”. So new products like GoogleDocs and Wikispaces (and consequently Office Live) are starting to disrupt the usage of plain old MS Word.
- Real-world Example of HIE 2.0:The Direct Project MedAllies Pilot is connecting a variety of healthcare participants throughout the Hudson Valley area of NY - focused on the physician clinical workflow. From the moment a referred patient has entered a provider’s office to the moment he leaves, the clinician uses only his EHR to retrieve, store, update, and transmit data to a referred specialist. A clean, elegant, seamless clinical experience, enabled through EHR vendors today.
- Example of Apple Approach:In-house solutions at the nation’s leading IDNs and academic centersExample of PC Approach:Cloud-based EHRs, and the growing list of EHRs that are implementing Direct functionality, such as Greenway, eClinicalWorks, etc.
- Example of March Upmarket Approach:Some highly localized HIEs might do this, though even they won’t afford to be insular to standardized exchange beyond the community’s boundariesExamples of Race to Scale Approach:-Rhode Island Quality Institute, which is the State HIE for Rhode Island. RIQI recognized that this game was a race to scale, and so they got out of the business altogether - outsourcing it to major vendors (who could more realistically achieve the race to scale than RIQI could), facilitated by appropriate state-wide policies. RIQI itself focused on providing other services along the value chain.- Another HIE, Nebraska Health Information Exchange (NeHIE - pronounced “Nee-high”) did exactly the opposite: not only are they building a standards-based connectivity HIE solution in Nebraska, they’re actively selling the service to surrounding states too