2013
HIE
Market
Trends
Report
© 2013 CHILMARKRESEARCH
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ABOUT CHILMARKRESEARCH
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2013 HIE MARKET REPORT
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TABLE OF CONTENTS
Chapter 1: Executive Summary
Introduction
Barriers Remain
1-1
1-1
CHANGING HCO NEEDS MOVE MARKET TO HIE 2.0 SOLUTIONS
1-2
ON THE ROAD TO HIE 2.0
HIE or EHR
Analytics Still Lagging
Population Health Management Needs HIE
Public HIEs Struggle Towards Sustainability
Direct as Potential Spoiler
1-3
1-3
1-3
1-3
1-3
1-3
VENDORS AND SOLUTIONS COME AND GO
1-4
CONCLUSION
1-6
Chapter 2: Beyond First Generation HIEs
Introduction- MARKET HIGHLIGHTS2-1
HIE Definition
2-1
Long-Term Market Driver: Changing Reimbursement Models
2-3
Near-Term Challenge: Interoperability
2-4
Persistent Barriers
2-4
New Ideas For Stimulating Interoperability
2-5
PUBLIC AND ENTERPRISE HIE MARKET SEGMENTS
2-5
Public HIE Market, While Not Growing, is Not Going Away
2-5
Enterprise HIEs Grow Steadily
2-6
Query-Based Exchange Growing
2-6
THE TECHNOLOGY OF AN HIE
2-6
HIE AS CARE COORDINATOR
HIE 1.0 Shows You the Data
Standard HIE 1.0 Functionality
HIE 2.0 As Integrated Care Coordination
HIE 2.0 Expands Access and Delivers Patient-Centric
Care Coordination Cross-Enterprise Care Plans in HIE
Closed-Loop Referrals Management and HIE 2.0
LTPAC Providers and HIE 2.0
Medications Reconciliation and HIE 2.0
Clinical Decision Support and HIE 2.0
Patient Engagement and HIE 2.0
Immunization Registries and HIE 2.0
Notification Services and HIE 2.0
Analytics and HIE 2.0
Project Direct Muddies the Outlook for HIE 2.0
PaaS Progress Slow
2-8
2-8
2-8
2-10
CONCLUSIONS AND RECOMMENDATIONS
The HIE Market will Grow in 2013-2014
Vendors Will Come and Go
HCOs Will Demand More Innovation from HIE Vendors
More Query-Based Applications and Services
Clean Data is Not Enough
Be Cautious about Direct
Get Vendors to Get Serious about Population
Health Management
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2-17
2-17
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Payer-Provider Alignment Begins to Get the
Attention of HCO C-Suites
2-18
Chapter 3: HIE Vendor Profiles
Introduction3-1
Vendors Turn to Care Coordination
3-1
CORPORATE ACTIONS IN THE HIE MARKET
3-1
PROFILE GUIDE
Revenue
Product Overview
3-3
3-3
3-3
OVERALL RANKINGS
HIE Versus EHR
HIE Market Resists Classification
3-5
3-7
3-7
PRODUCT RANKINGS
3-9
ESSENTIAL HIE 2.0 APPLICATIONS
Medications Reconciliation
Referrals Management
Care Plans
Patient Engagement
Clinical Quality Reporting
Clinical Quality Reporting
Notification and Alert Services
3-9
3-9
3-10
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3-11
3-11
3-11
3-12
MARKETING RANKINGS
3-12
CONCLUSION
3-13
PROFILES
3-14
3-16
3-19
3-22
3-25
3-28
3-31
3-34
3-37
3-40
3-43
3-46
3-49
3-52
3-55
3-58
3-61
3-64
3-67
4medica
Alere Accountable Care Solutions
Caradigm
CareEvolution
Cerner
Certify Data Systems
Covisint
dbMotion
GSI Health
Harris Healthcare
HealthUnity
Informatics Corporation of America
InterSystems
Medicity
MobileMD
OptumInsight
Orion Health
RelayHealth
Surescripts Kryptiq
APPENDICES
APPENDIX A: Acronyms UsedA-1
APPENDIX B: Scope & MethodologyB-1
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TABLES & CHARTS
Chapter 1: Executive Summary
Table 1.1: Barriers to Interoperability
Table 1.2: The Chilmark HIE Maturity Model
Table 1.3: History of HIE-related Corporate Actions
Chart 1: HIE Vendors Migrate to HIE 2.0
1-1
1-2
1-5
1-6
Chapter 2: Beyond First Generation HIEs
Table 2.1: HIE Maturity Model
Table 2.2: Barriers to Interoperability
Table 2.3: New Ideas to Increase Interoperability
Table 2.4: Messaging Versus Query-Based HIE Advantages
Table 2.5: HIE 1.0 — Where We Are Today
Table 2.6: HIE 2.0 — Where We Are Going
Table 2.7: Referrals Process
Table 2.8: Representative List of HIE Vendors Offering Analytics
Table 2.9: Vendors Efforts to Build a PaaS HIE
2-3
2-5
2-5
2-7
2-9
2-10
2-12
2-15
2-16
Chapter 2: Vendor Profiles
Table 3.1: HIE-Related Corporate Actions
Table 3.2: Currently Available HIE Solutions by Ownership Status
Table 3.3: HIE Vendor Product Ranking Model
Table 3.4: HIE Vendor Market Ranking Model
Table 3.5: HIE Vendor Overall Ranking
Table 3.6: HIE Vendor Types
Table 3.7: HIE Vendor Classification Schema
Table 3.8: Leading Enterprise HIE Vendors Based on Market Presence
Table 3.9: HIE Vendor Product Capability Assessment
Table 3.10: Marketing Ranking
Table 3.11: Market Presence Ranking Criteria
Table 3.12: Market Presence Ranking
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EXECUTIVE
SUMMARY
CHAPTER 1: Executive Summary
INTRODUCTION
Health information exchange (HIE) remains a construct made of clinical interoperability products. Why is it
vaguely not working? If Google can present targeted advertisements to vast numbers of web surfers, why
can’t we serve up the records for Patient X? Admittedly, no one can fully answer this question but many are
trying. Information technology (IT) inevitably will make our healthcare system better than it is. Our belief
in IT stems from the commitment we see among the many vendors of HIE solutions reviewed in this report.
The past year has seen a pause in innovation in the HIE market as vendors focused on improving performance
and usability while decreasing deployment times of their offerings. The overall market for HIEs has grown.
The public HIE market has all but stalled; enterprise HIEs have accounted for nearly all growth. At the same
time, usage and transaction volumes for all HIEs have grown steadily. The seemingly simple ability to access
a patient’s medical records from a remote EHR is as distant as it ever was. Moreover, the ability for clinicians
in different healthcare organizations (HCOs) to collaborate on patient care using HIE-derived data and
applications is also not close to being a reality.
Innovation may be poised to rebound as vendors react to the market’s shift to value-based reimbursement
models. As HCOs begin to assume and share payment risk, their need to coordinate care is becoming more
pressing than ever. Disparate HCOs are forming tighter linkages in an effort to identify and manage common
risk across their patient panels. The hunt for tools that can help maximize payments, minimize penalties and
increase the quality of care is not new, but the fact that providers are now working in concert to do so is new.
Providers must also work with more than just other providers. Until now, relatively few HIE vendors have
regarded payers as potential consumers of HIE-derived patient data or providers as potential consumers of
HIE-derived payer data. This is changing as payment reform compels payers and providers to adjust their
relationships. The combination of complex benefit structures and new focus on care coordination will
require far more payer-provider collaboration than in the past. As HCOs begin to act more actuarial, they
will need to make use of payer data and payers will need more clinical data to support HCOs. Providers
and payers will have to move beyond just eligibility checking and claims presentment to a new level of
clinical, administrative and financial integration. For HIE vendors, this means renewed attention to payers
as potential participants in HIE networks.
Barriers Remain
The barriers to the effective movement of patient data from one HCO to another are still high, despite
many HIE vendors’ concerted efforts. These include technical obstacles, legal constraints and incentive
mismatches. (Table 1.1) HCOs, under traditional fee-for-service (FFS) payment models, had little reason
to share patient data with other HCOs for fear of losing patients. EHR vendors have feasted on incentive
dollars but have resisted opening their applications and databases to outside systems.
Barrier
Status
Matching patients to records
•N
ational patient identifier will not happen
•B
etter cross-enterprise MPIs a recognized need
Privacy and consent
• Tangle of state and federal rules can limit some providers’ access to patient data
EHR availability
•N
ot present in all care venues
•P
aper records still dominate in the community
•P
ost-acute, behavioral and other care providers lack access to EHRs
Standards
• Lots of standards and a lack of standards-adherent technology
Table 1.1: Barriers to Interoperability
The difficulty of matching patients to their records across multiple HCOs and applications, the challenge
of providers locating other providers for technology-supported referrals, and the lack of interoperable
EHRs combine to make interoperability complex and costly. Unless clinicians have faith that the data they
are looking at is complete and accurate (i.e. no missing or mismatched records), HIEs will never be more
than messaging systems. The CommonWell Health Alliance is taking a bull-by-the-horns approach to this
problem. This alliance of mostly EHR vendors is investing money and resources to better enable querybased information retrieval across member EHRs. Its first order of business will be better technology for
matching patients to their medical records in multiple HCOs.
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CHANGING HCO NEEDS MOVE MARKET TO HIE 2.0 SOLUTIONS
In this report, we differentiate between current- and future-generation HIEs as HIE 1.0 and HIE 2.0.
Traditional HIE 1.0 services based on messaging are starting to show their limitations as a way to support
better care coordination. It is now fairly clear that messaging systems alone will never meet provider’s
complex needs for cross-enterprise data and care collaboration support.
The next stage of evolution, what we are now calling HIE 2.0, captures the idea that multi-disciplinary care
teams working within and across different HCOs need technology-based workflows that allow them to create, modify and use cross-enterprise care plans for coordinated
care delivery. These care plans need to be patient-centric but also HIE 2.0 will provide richer information
adaptable to the population health management (PHM) needs of and more functionality to support
HCOs. While HIE 1.0 supplies provider-to-provider messages con- collaboration across care venues.
taining subsets of clinical data, HIE 2.0 will provide richer information and more functionality to support collaboration across care
venues and fill many of the gaps left by unconnected, incompatible and heterogeneous EHRs. HIE 2.0 will
still use messaging but will make far more significant use of query-based access to the longitudinal patient
record for advanced applications, workflow support and care coordination.
Based on the work completed for this report, we are proposing the following maturity model for HIEs. (Table
1.1). In this maturity model, we start with HIE 1.0 as a way of exchanging messages and end with HIE 2.0 as
an IT enabler of comprehensive, cross-enterprise care collaboration and coordination.
Overall
Maturity
HIE 1.0
Stage
Objectives
Characteristics
One
•P
rovide affiliated physicians basic
access to patient data
•P
lace orders, receive results
Portal-based access to patient data, orders
and results; simple messaging
functionality supports orders and results
Two
•P
rovide custom, role-based views to
facilitate care
• Secure messaging between clinicians
• Messaging-based referrals
Role-based patient data access and
secure messaging services with
provider directory through portal; referrals
message with patient
demographics and ADT data
Three
•D
rive MU Stage 1 compliance across institution, affiliates and community
EHR-lite and other services embedded in
HIE platform, reporting capabilities for some
clinical quality measures and MU attestation
Four
• E
mbed HIE derived patient data
directly into EHR workflow
• Facilitate care team management process
• Track and report usage metrics
Aggregate and normalize data for consumption by physician’s EHR, enable collaboration
across care team with data and provide HIE
usage data
Five
• D
rive MU Stage 2 compliance across enterprise boundaries
• Improve operational efficiency and
effectiveness of care
• Analytics begin to support for clinical pathways and risk-based care activities
Combine administrative, operational and
clinical data for analytics and
clinical quality reporting to improve care
quality and coordination
Six
• Robust support for care coordination
• Population health management
• CDS at point of care and for panels
Robust care planning application
accessible by cross-enterprise care teams;
integral notification services in HIE-EHR
ecosystem; better clinician alignment interand intra-enterprise
HIE 2.0
Table 1.2: The Chilmark HIE Maturity Model
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ON THE ROAD TO HIE 2.0
HIE or EHR
According to most progressive HIE vendors, many of the functions and information needed to deliver
coordinated care across HCOs can only be supplied by an HIE. Other HIE vendors are less than clear about
whether that functionality is better delivered in the HIE or in the EHR. Either way, providers managing risk
in value-based payment models need cross-enterprise patient data, wherever it may be. HIE 2.0 vendors
will be developing solutions that EHR vendors can’t or won’t by exploring the potential of data stored in
heterogeneous EHRs across the care continuum. HIE vendors can also provide key support in care settings
overlooked by EHR vendors, especially in long-term and post-acute care.
Analytics Still Lagging
HIE vendors, with a few exceptions, continue not to invest in analytics as a point-of-care tool that uses
HIE-derived data. Better analytics can serve multiple purposes at the point of care. It can help support care
decisions about individual patients for clinicians. In addition, analytics can serve as an important way for
HCOs to manage clinician alignment and ensure that clinical guidelines are being followed. Beyond just the
point of care, better analytics will be needed to address the onslaught of clinical quality and public health
reporting required of connected HCOs. Cross-enterprise data will be indispensable to the kinds of analytics
that will underpin these kinds of care-related activities. While the need for better analytics certainly raises
the question of whether EHRs should be providing it, HIE vendors are positioned to fill gaps left by EHR
vendors. More importantly, HIE vendors are in a position to provide market-leading solutions in this area,
but so far have not.
Population Health Management Needs HIE
Consistent with the goals of value-based care, HIE 2.0 must be both patient-centric and population-focused.
An HIE is invaluable for individual patients at the point of care but must also provide data that can be rolled
up to the panel level for PHM. An HIE 2.0 solution will become required infrastructure to support provider
PHM initiatives.
Public HIEs Struggle Toward Sustainability
Public HIEs deployed at a local, state or regional level continue to struggle with governance issues and
experiment with the combination of services that will lead to financial viability. Several public HIEs have
replaced their HIE vendors because of substandard executions in the last year. While a handful of public
HIEs have ceased operations, the public HIE market does not show signs of imploding. Over the course of
2012, growth in the overall number of public HIEs came to a virtual halt because direct government funding
of public HIEs stopped. Few HCOs are willing to pay a premium to use the messaging-based services on offer
in public HIEs, limiting their appeal for providers with more complex exchange requirements.
The expected addition of 30 million people to the healthcare system under the Patient Protection and
Affordable Care Act (PPACA), many of whom will be on Medicaid plans, could alter the dynamics of the
public HIE market. Many public HIEs seem to be on a path to providing services primarily for Medicaid
plans and populations, where investments in HIE technology and services will receive significant matching
reimbursement from the federal government. This surge in new patients could translate into new demand
for existing public HIE services.
Direct as Potential Spoiler
While providers will be adopting advanced HIE 2.0 applications, it is important to consider the impact of
a single regulatory provision. In 2012, the ONC established Direct-based messaging as the information
exchange standard in the Stage 2 meaningful use (MU) provisions related to care transitions and the view/
download/transmit to third parties core objective. Many HIE vendors are embracing this technology while
others correctly point out that Direct is not a great way to support clinical workflow. EHR vendors also have
plans to provide this support.
For HCOs committed to providing clinicians with the ability to query and retrieve a complete longitudinal
patient record from inside their EHR, Direct is not exactly progress. As secure email, Direct-based messages,
usually limited to a subset of patient data pushed to a specific clinician, render the transaction and the clinical
data invisible for most other purposes. Data that flows via Direct does not persist in the clinical record,
absent additional functionality and integration, and will most likely be siloed in email folders.
For good or ill, HCOs are likely to add Direct-based services for their clinicians and patients. The caution
for HCO leadership is that Direct could drive clinicians to rely on messaging so heavily that resources that
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could be used to deploy HIE 2.0 applications will instead be allocated to more messaging-based use cases.
Messaging will always have a place in coordinated care and Direct will be one way that HCOs can meet this
requirement in the long term. Messaging – Direct or proprietary – will only be able to meet a subset of the
complex care coordination needs of value-based care.
An additional caution for HIE vendors is that every EHR vendor will be likely begin to offer embedded
Direct services, driving margins down. This points to the significant downside for HIE vendors that do not
aggressively invest in the more advanced services embodied in HIE 2.0. For vendors, messaging-based
services – Direct or proprietary – could paint them into a low-margin corner.
VENDORS AND SOLUTIONS COME AND GO
The number of HIE vendors in the market continues to be a moving target; compared to 22 vendors profiled
in last year’s Chilmark Research HIE report, this year’s report includes 19 vendors. Since last year, several
vendors have dropped out of the HIE market as the opportunities for large state HIE projects disappeared.
However, some new vendors have also emerged and set their sights on the enterprise market.
On balance, we believe that the number of vendors focused on cross-enterprise interoperability
opportunities will continue to decline. The HIE market’s relatively short history has produced an unusually
high number of partnerships and corporate actions intended to exploit the opportunity. Table 1.3 plainly
shows a mixed record of success among participants.
HIE Vendor
Parent or
Partner
Date of
Action
Observations
Caradigm
GE and
Microsoft
May 2013
Refocus
•N
ow out of the HIE business in favor of analytics and PHM
• Parent Microsoft is out of the HIE business
Covisint
AT&T
2012
• AT&T partnership has run its course
Certify Data
Systems
Humana
Acquired
November
2012
• Potential that addressing needs of existing
customers and Humana’s internal needs will strain resources
• Long-term future of Cerner relationship is not certain
dbMotion
Allscripts
Acquired March • May become optimized for Allscripts and sold almost exclu2013
sively in Allscripts accounts
• The comeback kid of 2013
Initiate
IBM
Acquired March • Well regarded MPI still found across healthcare
2010
• IBM is out of the market as an HIE provider
Kryptiq
Surescripts
Acquired
September
2012
• National footprint and low cost for providers
• Market reaction to a pure messaging-based exchange solution remains to be seen
MobileMD
Siemens
Acquired
November
2011
• Lost momentum in the market
• Seen almost exclusively in Siemens accounts
• Long-term future uncertain
Medicity
Aetna
Acquired
January 2011
•R
emains the market leader
• Fits well with Aetna’s strategy to enable ACO models
MEDfx
Verizon
2012
• Verizon partnership now dead
Truven Health
Analytics
ThomsonReuters
Spun out April
2012
• Strategic retreat from healthcare by Thomson
• Effective partnership with CareEvolution
Carefx
Harris
Acquired
April 2011
• Positions Harris to compete for large contracts with the
DoD and VA
• Limited interested in non-government accounts
Axolotl
UnitedHealth
Group
Acquired
August 2010
• Mass exodus of Axolotl leadership
• Contraction in market footprint
• Future highly uncertain
Wellogic
Alere
Acquired
December
2011
• Market momentum building
• Extensive remote patient monitoring technology and
service capabilities
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Table 1.3: History of HIE-related Corporate Actions
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Chart 1: HIE Vendors Migrate to HIE 2.0
The relative sophistication of vendor solutions also continues to evolve, albeit slowly.
The majority of vendor scores and rankings in this report are lower than last year’s, not because vendors
are doing anything differently, but because so few vendors have made significant progress toward building
HIE 2.0 capabilities for better cross-enterprise care coordination. To be fair to the vendors, the majority of
the provider market is not close to being able to fully exploit HIE 2.0 solutions and today are simply using
elements of foundational HIEs. However, rapid change is occurring across the provider market with leading
innovators already seeking out solutions that will meet their strategic objectives to deliver more effective
and efficient care across care settings. Following a typical adoption S-curve, we forecast that the majority of
HCOs will be seeking some or all of the HIE 2.0 functionality we describe in the next 18-24 months.
Aetna’s Medicity maintains its hold on the top spot. While Medicity edged out OptumInsight for the top
spot last year, it has significantly widened that gap in the last 12 months. Medicity’s gain stems primarily
from OptumInsight’s continuing struggles with its product set and field execution rather than any significant
moves by Medicity. Orion Health is a clear second and has made good progress over the last year on all
fronts, including expansion into the enterprise market where it was previously weak.
Closely following Medicity and Orion Health are CareEvolution and Cerner. CareEvolution, a low-profile
vendor by any measure, has made more progress toward HIE 2.0 from a product standpoint than any other
vendor. Cerner, the “Steady Eddy” of the HIE business, has a comprehensive view of connectivity in the
community and vision for notification services that distinguishes it from other vendors.
Also putting in solid performances this year are Intersystems, McKesson’s RelayHeath, and Alere
Accountable Care Solutions (Alere ACS). Intersystems, has made progress in acquiring new customers with
a recent win at North Shore-LIJ Health System (NY). RelayHealth also has assumed a leadership position
in the industry trying to rally EHR vendors to a common view of cross-enterprise clinical interoperability.
The company also recently added a new HIE customer at the South Georgia Medical Center. Alere ACS
has had a number of new customer within the last few months and its wide view of device and software
interoperability is showing increasing traction in the market.
CONCLUSION
Regarding an HIE as simply messaging infrastructure underlying other HIT assets to help clinicians at the
point of care significantly underestimates its potential promise. Most HCOs are coming to the realization
that the HIE is a general-purpose tool that can serve new roles beyond sending orders and results from
one point to another. It can provide data-based evidence that an HCO is an effective and efficient referral
partner and collaborator. An HIE can also be used to see where patients are seeking care from other
providers, a need that will be increasingly important under accountable reimbursement models. There is
also growing and relatively new interest on the part of community physicians to connect to HIEs to facilitate
care coordination outside an acute care setting.
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The enterprise market will continue to be the dominant opportunity for all HIE vendors as the shift to valuebased care unfolds. At the same time, public HIEs will, as a group, build traffic and many will find a path
to sustainability, though that path may be one of extremely thin proportions, e.g., offering Direct secure
messaging services and not much else. We continue to believe that the HIE market is immature and that
there is significant room for growth and innovation.
HCOs of all sizes will increasingly be seeking solutions to more effectively and efficiently
manage population health. This will require a new level of care coordination that goes
well beyond the limited confines of today’s EHRs. These new requirements for care coordination will
ultimately determine the strategic objectives of HCOs and how they approach information exchange
with other HCOs. The constant change that has characterized the HIE vendor landscape in recent years will
continue unabated.
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CHAPTER 1: Notes
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BEYOND FIRST
GENERATION
HIES
CHAPTER 2: B
eyond First Generation HIEs
INTRODUCTION — MARKET HIGHLIGHTS
The past year has seen a continuation of several trends in the health information exchange (HIE) market that
we reported on last year. The market for enterprise HIEs has grown while the public HIE market has stalled.
HIE vendors have continued to slowly improve their product sets but the seemingly simple ability to access
and query medical records from a remote EHR is as distant as it ever was. The number of HIE vendors in the
market continues to be a moving target; compared to 22 vendors profiled in last year’s Chilmark Research
HIE report, this year’s report includes 19 vendors. Following are just a few of the factors that contributed to
the HIE landscape’s continued evolution:
The need for interoperable EHRs across a community is ever more pressing. The transition to risk-based
payment models is driving healthcare organizations (HCOs) large and small to scrutinize care patients
receive outside the HCO’s four walls. As quality-based payments proliferate over quantity-based payments,
every HCO will need visibility into other providers’ clinical and administrative data to coordinate care and
minimize financial risk.
Vendors are being acquired by larger companies or leaving the HIE business altogether. Caradigm recently
announced that it will resell Orion Health’s HIE and sunset its own offering. Early in 2013 Allscripts acquired
dbMotion. Humana’s purchase of Certify Data Systems demonstrates the former’s need for clinical data
interoperability but also casts some doubt on its long-term relationship with Cerner. IBM removed itself from
the HIE market and Verizon severed its relationship with MEDfx as lucrative state contratcs evaporated.
Some acquired HIE vendors have struggled. MobileMD has all but disappeared except in Siemens accounts
and a similar fate may befall dbMotion now that it is in the Allscripts stable. Axolotl is a shell of its former self
since its acquisition by OptumInsight. While Optum promises significant enhancements to Axolotl’s dated
technology as well as new functionality, it remains to be seen if Axolotl will return to its former market
prominence.
Others are thriving. Medicity continues to add new enterprise customers and evolve its product set under
Aetna. RelayHealth now leads McKesson’s efforts to develop and sell both HIE and population health
management solutions. Wellogic, which was acquired by Alere, appears to have finally turned the corner,
racking up a number of large, strategic wins in the first half of 2013.
New vendors enter or thrive as barrier-layer players. InterComponentWare has re-entered the market
as a supplier to its new and energetic U.S. partner, Sandlot Solutions. A host of vendors are doing well by
supplying components to HIE solution vendors and occasionally darting into the market with more complete
HIE solutions including Mirth, NextGate, Apenimed, and Health Language. Vendors with various electronic
data interchange (EDI)-based healthcare solutions have also found a promising niche in HIE componentry.
EHR vendors embrace interoperability anew. Several EHR vendors formed a new industry organization,
the CommonWell Health Alliance, with much fanfare. According to its mission, the alliance “plans to promote
and certify a national infrastructure with common standards and policies” that will help ensure interoperable
HIT. While many question its motives, its existence underscores the need for better interoperability and
serves to acknowledge that barriers to the electronic exchange of healthcare information continue to
impede progress.
Many vendors left after funds for public HIEs ran out. With the final federal funds for statewide HIEs
allocated, interest in public HIEs as prospects has vanished. Not only have federal funds dried up, public
HIEs present the never-ending issue of sustainability. Vendors attracted to the public HIE market by multimillion dollar engagements have either retreated altogether or have gone dormant in the HIE space. These
include Microsoft, Verizon, IBM and ACS.
Stage 2 meaningful use is here. The final rules for meaningful use (MU) Stage 2 were announced and will go
into effect in 2014. Stage 2 raises the interoperability stakes for EHR vendors. Representatives of the Office
of the National Coordinator (ONC) have repeatedly made the point that interoperability is the primary goal
of Stage 2 and if progress is not apparent, ONC is ready to revise the rules accordingly.
•U
nder Stage 2, eligible providers must use secure email based on Direct protocols for a variety of
purposes.
• The final rules include standards for summary of care records that include structured and coded
data to be formatted uniformly and sent securely during transitions of care, upon discharge, and to
patients.
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• Stage 2 establishes minimum thresholds for the proportion of encounters, patients and clinicians
using these functions.
For its part, the ONC plans to develop a testing platform for Stage 2 that will measure whether EHRs are
in fact interoperable and can send, receive, and incorporate patient data using the required standards and
protocols.
Stage 3 meaningful use is on its way. The MU Stage 3 Notice of Proposed Rulemaking (NPRM) will likely be
released in the latter half of 2013. While the focus of Stage 3 will be on delivering better outcomes, HIEs can
be used as tools to address several of the changes. For instance:
•T
he rule for medications reconciliation will likely be expanded to include reconciliations for
medications allergies and problem lists.
• The rule requiring a summary of care for transitions could be expanded to require that 65 percent of
transitions have a summary of care record and that 30 percent of these be transmitted electronically.
• Larger volumes of useful data will almost certainly need to move from EHR to EHR, at least for the
providers who accept the EHR incentives.
What is clear from 2012 is that building HIEs is tremendously difficult and requires a panoply of IT skills
and a maniacal healthcare focus. This market is not a place to find incremental revenues nor a way to get
a toehold in an account. Operating as a stand-alone HIE vendor is not for everyone. Large EHR vendors
and many payers continue to need HIE and interoperability solutions in their product portfolios or internal
operations.
Despite these challenges, the market continues to be quite lucrative for those with deep domain knowledge
and strong technology to take to market. Orion Health continues to expand its presence in the enterprise
market after being quite successful in the public HIE sector. Orion Health’s Rhapsody integration engine
remains one of the best in the market. CareEvolution, which keeps a very low profile in the market, continues
to rely on its strong independence and technical prowess to build an ever-more complete solution including
one of the better analytics solutions from an HIE vendor. InterSystems, which has had an on-again, off-again
affair with the HIE market has re-entered with renewed vigor in both the public and enterprise markets.
Medicity too has made progress selling into the enterprise market.
HIE Definition
An HIE aggregates or indexes patient data from multiple organizations and applications at the point of care
– push or pull. As a construct, HIE is assembled from the elements of clinical interoperability solutions from
vendors (many global but many not) in the U.S. The goal is to supply clinicians across the care continuum
with the information they need to support decision-making at the point of care. For the purposes of this
report, we use the following definition for both public and enterprise HIEs:
A health information exchange (HIE) provides secure access and exchange of relevant information
and workflow support across enterprise boundaries and among all stakeholders engaged in patient
care or population health. The ultimate goal of an HIE is to support collaborative care models,
improve the quality and value of care provided, and enhance care coordination.
We have modified last year’s definition to recognize the new focus on care coordination as providers
adjust to payment systems that reward quality rather than quantity. Clinicians across the care continuum –
primary care, specialty care, acute and post-acute care, long term care, pharmacies, and laboratories — are
now concerned with and need to monitor patient health information and care activities outside the four
walls of their facilities. With the advent of risk-based payment models and the emphasis on population
health management, HCOs need information on patient panels, not just individual patients. Clinical and
administrative data captured at any point in the care continuum can potentially be used anywhere in the
healthcare system.
In this report, we differentiate between existing and future HIEs as HIE 1.0 and HIE 2.0. Traditional HIE
1.0 services based on messaging are becoming more commoditized each year; to thrive HIE 1.0 vendors must offer more than HIE 2.0 will provide richer information
messaging. The next stage of evolution, what we are now call- and more functionality to support
ing HIE 2.0, captures the idea that multi-disciplinary care teams collaboration across care venues.
working within and across different HCOs need technologybased workflows that allow them to create, modify and use cross-enterprise care plans for coordinat2013 HIE MARKET REPORT
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ed care delivery. These patient-centric care plans need to be adaptable to the needs of care managers
concerned with patient panels. While HIE 1.0 supplied provider-to-provider messages with subsets of data, HIE 2.0 will provide richer information and more functionality to support collaboration across care venues and fill many of the gaps left by unconnected and incompatible EHRs.
An HCO’s progress from HIE 1.0 to HIE 2.0 can be considered based on the maturity of services offered to
clinicians. Virtually all HIEs start by providing simple web-based access to patient data via a secure portal.
In many environments web-based access is not possible for many clinicians. In the enterprise HIE market,
orders and results application are the common denominator. We refer to this as Stage 1 in our HIE maturity
model (Table 2.1). From this starting point, HCOs can add additional services and features that increase the
HIE’s value proposition but also increase the cost to operate and maintain the HIE. At Stage 6 in this maturity
model, an HCO is leveraging the capabilities of HIE 2.0 for connected clinicians – in and out of its four walls.
Overall
Maturity
HIE 1.0
Stage
Objectives
Characteristics
One
•P
rovide affiliated physicians basic
access to patient data
• Place orders, receive results
Portal-based access to patient data, orders
and results; simple messaging
functionality supports orders and results
Two
•P
rovide custom, role-based views to
facilitate care
•S
ecure messaging between clinicians
•M
essaging-based referrals
Role-based patient data access and
secure messaging services with provider
directory through portal; referrals message
with patient demographics and ADT data
Three
•D
rive MU Stage 1 compliance across
institution, affiliates and community
EHR-lite and other services embedded in
HIE platform, reporting capabilities for
some clinical quality measures and MU
attestation
Four
• E
mbed HIE derived patient data
directly into EHR workflow (EHR)
• Facilitate care team management process
• Track and report usage metrics
Aggregate and normalize data for
consumption by physician’s EHR, enable
collaboration across care team with data
and provide HIE usage data
Five
• D
rive MU Stage 2 compliance across enterprise boundaries
• Improve operational efficiency and
effectiveness of care
• Analytics begin to support for clinical pathways and risk-based care activities
Combine administrative, operational and
clinical data for analytics and quality
reporting to improve care quality and
coordination
Six
• Robust support for care coordination
• Population health management
• CDS at point of care and for panels
Robust care planning application
accessible by cross-enterprise care teams;
integral notification services in HIE-EHR
ecosystem; better clinician alignment interand intra-enterprise
HIE 2.0
Table 2.1: HIE Maturity Model
Long-Term Market Driver: Changing Reimbursement Models
Risk-based reimbursement drives the need for HIE 2.0 solutions. Disparate HCOs are forming tighter
linkages to identify and manage common risks. The hunt for tools that can help maximize payments,
minimize penalties and increase the quality of care is nothing new, but the fact that providers now align to
do so is new. Most will reorient their organizations and systems to ensure that the care a patient receives in
their facilities is consistent with the care a patient receives from other providers in the community.
One early example of the coordinated care challenge is the 30-day readmission penalty imposed by CMS on
hospitals. In response, many hospitals implemented high-touch risk identification programs with outreach
to patients and post-acute care providers. But the readmission penalty is the first of many such measures.
The challenge of better care coordination in a multi-risk environment will require more robust automated
tools to supplant the ad hoc staff-intensive programs that HCOs reach for reflexively.
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Near-Term Challenge: Interoperability
Private sector — The CommonWell Health Alliance is taking a bull-by-the-horns approach to the
challenges of interoperable EHRs. This alliance of mostly EHR vendors will invest money and resources to
enable query-based patient record retrieval across member EHRs. The first order of business will be matching
patients to their medical records in multiple HCOs. Historically, the inability to match patients to their
records has impeded the technical success of HIEs. Unless clinicians have faith that the data they are looking
at is complete and accurate (i.e. no missing or mismatched records), HIEs will never progress beyond elaborate messaging systems. CommonWell has taken this on, promising that patient records can be accessed and
processed between members’ EHRs. Unfortunately, most of the HIT industry has not joined CommonWell
nor signed on to its mission. While the threat of creating yet another silo lurks, CommonWell does represent
a significant effort within the private sector to overcome the obstacles to interoperability.
Public sector — Government initiatives at federal and state levels continue to directly fund efforts
to increase interoperability. Even though the federally-funded and state-administered State Health
Information Exchange Cooperative Agreement Program (SHIECAP) grants are allocated, the ONC is still
using its authority under the legislation to incent better interoperability. The ONC made grants in April
2013 under its Exemplar HIE Governance Program to the EHR/
Unless clinicians have faith that the
HIE Interoperability Workgroup (IWG) and DirectTrust. With this
data they are looking at is complete
grant, IWG will continue its efforts to develop implementation
and accurate, HIEs will never be more
specifications for plug-and-play interoperability. Over the last two
than messaging systems.
years, the IWG announced the HIE Certified program for EHR and
HIE vendors, hoping to make it simple for an HCO to know that
when it buys an IT system, that system will have all the components
required for plug-and-play interoperability. The IWG will use the grant funds to focus on the challenges of
patient matching and querying provider directories. The idea is to establish implementation specifications
and advance existing ONC efforts to improve the standards for Direct-based messaging and query-based
exchange. IWG is a New York eHealth Collaborative (NYeC)-led coalition of 19 States, 20 EHR vendors
(many of which are also members of the CommonWell Alliance), and 22 vendors of HIE solutions. With its
grant, DirectTrust will continue to establish security and rules of the road for Direct-based exchange and
expand its trusted-agent accreditation program.
At the federal level, the EHR Incentive Program will begin funding interoperability efforts in 2014 with Stage
2 MU. It will reward providers that exchange more health information and give patients secure online access
to their health information. The general thrust of Stage 2 MU is to make it easier for care teams to collaborate
by ensuring access to patient data from the full care continuum. Several of the Stage 2 objectives (e.g. care
coordination and electronic exchange of information) will require data and communications mechanisms
provided by an HIE. Many, but not all, currently certified EHRs will be able to meet these milestones
and objectives.
Persistent Barriers
The barriers to the effective movement of patient data from one HCO to another are still high, despite many
HIE vendors’ concerted efforts. They include technical obstacles, legal constraints and incentive mismatches.
(Table 2.2) HCOs, under traditional fee-for-service (FFS) payment models, had little reason to share patient
data with other HCOs for fear of losing referrals. EHR vendors have benefited handsomely from the flow of
EHR incentive dollars but have not yet taken the leap into opening their client applications or databases to
outside systems.
Matching patients to their records across HCOs continues to challenge vendors and HCOs. Master patient
indexes (MPIs) work passably inside an HCO but lose accuracy, speed and reliability when matching patients
to records in other HCOs. While a national patient identifier could theoretically address this problem, it
is politically unpalatable. Consent and privacy regulations vary by state and can make sharing data across
state boundaries cumbersome, to say the least.
Then there’s the challenge of providers locating other providers. Provider-to-provider messaging is on the
level of what mid-1980s technology never exceeded. Provider directories exist within HCOs but remain
invisible or difficult to use for clinicians in other organizations. A national provider directory accessible from
any EHR could could let providers discover other providers to give the network effect a chance to take hold
but no such capability is even remotely on the horizon.
The lack of interoperable EHRs is an increasingly visible barrier to better care coordination. Even in practices
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Barrier
Status
Matching patients to records
•N
ational patient identifier will not happen
• Better cross-enterprise MPIs are a recognized need
Privacy and consent
• Tangle of state and federal rules can limit some providers’ access to patient data
EHR availability
• Not present in all care venues
• Paper records still dominate in the community
• Post-acute, behavioral and other care providers lack access to EHRs
Standards
• Lots of standards and a lack of standards-adherent technology
Table 2.2: Barriers to Interoperability
that have attested for the EHR Incentive Program, paper records are commonplace. Many providers with
important roles in care coordination have not implemented EHRs, most notably long-term and post-acute
care (LTPAC) providers. Although both HIE and EHR vendors have lower-cost EHR-lite offerings, few LTPAC
providers have implemented or use them.
Medications management systems and laboratory systems are widely used but pharmacies and laboratories
remain siloed, unable to interoperate with HCOs and their EHRs. Some eligible professionals (EPs) and
eligible hospitals (EHs) that qualified for early round incentives with Stage 1-certified EHRs are at risk of
becoming stranded with non-interoperable EHRs that don’t meet the Stage 2 milestones and objectives for
interoperability.
New Ideas For Stimulating Interoperability
Ideas abound for stimulating investment in interoperability. (Table 2.3) In March 2013, the ONC and CMS
issued a joint request for information, called the Interoperability RFI. The RFI asked about measures the
agencies could take to strengthen the business case for “electronic exchange between providers to ensure
that patients’ health information will follow them seamlessly and securely wherever they access care.”
Idea
Status
Many of the 207 RFI respondents
suggested that no new regulations
(financial penalties or reporting
requirements) should be imposed
on HCOs or their vendors but most
Expand EHR incentive program • Good idea but politically unpalatable
believe that new subsidies (FFS
Nationwide provider directory • Surescripts most of the way there
payments or incentive payments)
Nationwide patient identifier
• Dead in the water
would be welcome. Many of those
Faster, better, cheaper MPI
• CommonWell working on it, though
who commented believe that the
likely over a year before first pilot
EHR Incentive Program should
be broadened to include nonincentivized providers, including
Table 2.3: New Ideas to Increase Interoperability
laboratories, LTPAC providers, and
behavioral health providers. Many favor adding fees to the Medicare FFS schedule to reimburse providers
for discrete activities like care coordination, medications and problem list reconciliation, and building
interfaces between EHRs and laboratory information systems (LIS).
New fees for medications
reconciliation and care
coordination
• Not likely under FFV or FFS
• New penalties for non-compliance
more likely
Another idea is to modify the MU criteria to incent clinical outcomes (i.e. actual interoperation between
different vendor systems) rather than specifying how those outcomes should be achieved – a vague but
interesting suggestion. The bottom line is that most respondents believe that the barriers to achieving
more interoperability can be reduced by a combination of changes to incentives, payment schemes, and
regulation. Between the continued product innovations of HIE vendors, broader vendor efforts like the
CommonWell Health Alliance, increased payer interest in clinical interoperability, and government tinkering
with incentives, the industry is evolving to make interoperability more of a reality, but it will take time.
PUBLIC AND ENTERPRISE HIE MARKET SEGMENTS
Public HIE Market, While Not Growing, is Not Going Away
Public HIEs deployed at a local, state or regional level continue to struggle with governance issues and
experiment with the combination of services that may lead to financial viability. While a handful of public
HIEs have ceased operations, the public HIE market shows no signs of imploding.
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Over the course of 2012, growth in the number of public HIEs
Public HIEs will benefit if CMS requires
came to a virtual halt. Public HIEs seem to be on a path to provida public HIE be the mechanism to
ing services primarily for Medicaid plans and populations. The
exchange clinical data for Medicare
trend varies by state, but is unmistakable. The expected addition
patients.
of 30 million people to the healthcare system under the Patient
Protection and Affordable Care Act (PPACA), many of whom will
be on Medicaid plans, could tip public HIEs toward sustainability by driving additional traffic. Public HIEs
could also benefit if CMS requires them to exchange clinical data for Medicare patients. An alternative read of
the role of public HIEs is that they could serve as Health Information Service Providers (HISPs) with a
provider directory.
One recurring issue for public HIEs is the reluctance of large HCOs to participate fully for fear of losing
referrals to other providers on the network. The counterpoint to this fear is the potential for public HIEs to
help identify patients who have leaked out of an HCO to a competitor. Querying a public HIE to see if there
are patients in an HCO’s risk-based panels who have sought care with other providers could be an important
and potentially profitable service offering for the public HIEs. Balancing the need to identify lost revenue
against the exposure to competitive losses will be a management challenge for large HCOs.
Enterprise HIEs Grow Steadily
The enterprise HIE market, privately funded and sponsored by hospitals and health systems, has continued
to grow, both in the number of HIEs and transactions during 2012. While relatively few HIE vendors were
the beneficiaries of the growth in the number of enterprise HIEs, all vendors report increased HIE use by
their customers. The prospects for continued growth for enterprise HIEs remains strong as payment reform
takes root. As payers and large providers acquire practices and impose care coordination requirements on
their new care partners, expect to see even more new enterprise HIEs and higher transaction volumes.
The enterprise HIE market remains the most active sector of the overall market for HIEs. Every vendor we
interviewed for this report sees enterprise HIEs, especially those formed by IDNs and large hospitals, as the
market with the greatest potential.
Hospitals and health systems originally established enterprise HIEs in order to generate more referrals
from affiliates and other community providers. More recently, enterprises are investing in HIEs as backbone
infrastructure to support new payment models and ultimately to drive better care coordination across their
connected communities.
But growth in enterprise HIEs poses its own challenges. While
HCOs that grow through acquisition
larger HCOs and payers continued to acquire smaller hospitals
have to support an ever-increasing
and independent practices in 2012, acquisition does not necessarnumber of EHRs.
ily lead to smooth integration. Many HCOs are facing stiff, often
implacable, resistance to EHR mandates from newly acquired providers. Only the most technologically challenged practices are submitting without complaint to “corporate”
standards, imposed by parent organizations, for EHR selection or conversion. As a consequence, HCOs that
grow through acquisition have to support an ever-increasing number of EHRs, generating yet more urgency
to the need for interoperability.
Query-Based Exchange Growing
The demand for query-based exchange will increase among enterprise HIEs in the next few years. While
message-based exchange still dominates in enterprise HIEs, query-based applications will see strong uptake
in response to payment reform and the need for better care coordination. Vendors that do not respond
with more robust support for query-based exchange risk being replaced by vendors that do. Messaging
and query-based applications will complement each other and both methods of using HIE data will grow.
(Table 2.4)
THE TECHNOLOGY OF AN HIE
Numerous HIT vendors offer interoperability solutions. An HIE composed of the following set of
components is a foundational HIE. Paradoxically, no two foundational HIEs are functionally equivalent; wide
discrepancies in HIE vendor offerings exist despite many common technology elements.
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Function
Messaging-Based Exchange
Query-Based Exchange
Data Storage
•V
endors have vague plans to “persist” data
stripped from messages and CCDs
•E
mail folders are not an easily
processed data source
•M
akes limited use of the longitudinal
patient record
• An HIE database for HIE-mediated workflow
• Longitudinal patient record serves care
coordination purposes
• Panels of longitudinal patient record serve
population health management purposes
Workflow
• Threaded messages are cumbersome but
usable
• Message exchange between multiple
clinicians makes care coordination more
complex
• Moderate support for one-way transactions
such as a discharge summary
• Workflow tool with access to HIE data
derived from cross-community EHRs
better supports care coordination and
a cross-community medical record
• Good support for complex transactions and
cross-community care teams
Notifications
and Alerts
•
•
•
•
• Notifications fire at time appropriate to
clinical circumstances
• Notifications configurable to privacy,
consent, clinician role(s), patient
condition, care venue, transition type
• Guaranteed delivery
• Can leverage CDS for evidence-based clinical
alerting
Patients
Engagement
•E
mail interactions with patients
•L
inks to content
•L
inks to permit patient-generated data
• Patient can access care coordination workflow
tool based on their level of adherence
Clinician
Alignment
•M
essage fatigue (alerts, emails, texts, etc.)
and proliferation of Direct email ids could
limit appeal
•L
imited ability to capture clinician
actions
• Workflow tool can record clinician actions
• Clinical protocols tracking
• One place for communications and care
coordination
M
essage-only option
N
otifications hard coded and one way
D
elivery not assured
G
ood support for one-way, non-time
sensitive transactions
Table 2.4: Messaging Versus Query-Based HIE Advantages
1. Master Patient Index (MPI): An HIE must be able to correctly match patients with their clinical
data. The MPI uses deterministic and/or probabilistic algorithms to identify and link patient data
from different providers for data exchange. While the majority of HIE vendors have developed
their own MPIs (typically a simple deterministic MPI), virtually all vendors have partnerships to
provide more advanced functionality.
2. Record Locator Service (RLS): Once the patient is identified with the MPI, the provider can use
the RLS to access patient records stored in decentralized provider systems. The RLS mediates the
exchange of documents, but does not store information from patient records.
3. Directory Services: Communication is the sine qua non of collaboration. Directory services
provide a list of all physicians and entities within a defined HIE network with their email addresses
to support referrals.
4. Cross-Enterprise Document Sharing (XDS): Integrating the Healthcare Enterprise (IHE) established XDS as a protocol for cross-enterprise document sharing. It enables query and retrieval of
stored documents across multiple healthcare enterprises.
5. Interface Engine: An interface engine listens for, extracts, transforms, and routes data and
messages to and from EHRs and administrative applications through the HIE. Relatively few HIE
vendors have developed an interface engine; most rely on third parties for this component.
6. Terminology Services: These services, which are most often provided via a partnership with a
third-party ISV, perform vocabulary mapping between disparate healthcare applications and
organizations. Widely adopted and used, particularly among public HIEs with multiple stakeholders, this capability normalizes data from various sources into a common vocabulary for all users
within a given HIE.
7. Messaging Services: Under the Stage 2 MU specifications, messaging services and infrastructure
will have to comply with Project Direct protocols and standards. Messaging services are processes
and software that facilitate the exchange of various types of messages through the HIE.
8. Transport and Content Standards: These are recognized specifications and protocols to enable
communication among different health data systems. Stage 2 MU specifies a number of standards
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9.
10.
11.
12.
including CCD, HL7, ICD-10, RxNorm, CVX, LOINC, and SNOMED CT, as well as detailed standards and implementation specifications for a number of other transactions. These include quality
reporting, laboratory results, electronic prescribing, immunizations, cancer registries, and
syndromic surveillance.
User Interface: HIE-sourced data can be presented to clinicians in a number of ways, including
through a clinician portal or embedded directly into the EHR. The user interface allows the clinician to enter orders, view results, and select clinical data for viewing and retransmission or to
initiate referrals.
Access and Authorization: HIEs provide role-based, and sometime clinical context-based mechanisms that specify the conditions under which a clinician can access and use the data.
Consent Management: Even as they collaborate around patient care, clinicians are obligated to
ensure patient privacy. This component helps providers manage patient consent to permit access
to their protected health information (PHI) within the HIE.
Auditing and Logging: This provides an audit trail and record of activity in the HIE as well as providing data for monitoring usage patterns.
Some HIE vendors augment their foundational HIE with the ability to store patient data in a clinical data
repository (CDR) in a single location or in distributed edge servers. All of the technologies described
above combine to produce the longitudinal patient record assembled from the data in connected EHRs
and administrative systems. In a directed exchange, data is assembled from the connected EHRs and
administrative systems and sent to a specific person or program for viewing or subsequent processing.
An HIE should also support exchange across heterogeneous EHR environments. For this reason, we do not
include EHR vendors that purport to have an HIE (e.g., athenahealth, eClinicalWorks, Epic, NextGen, etc.) if
those solutions do not support the complex kinds of exchange among heterogeneous EHRs that the wider
market needs.
HIE AS CARE COORDINATOR
HIE 1.0 Shows You the Data
HIE 1.0 has established a reasonable way for clinicians to send
HIE 1.0 has been a reasonable way for
messages containing clinical data and, in exceptional cases, support
clinicians to send clinical data and,
simple cross-enterprise queries. In most cases, clinicians only need
in exceptional cases, support simple
a subset of information from the longitudinal patient record. In
cross-enterprise queries.
messaging-based HIEs, a provider pushes a small subset of the
longitudinal patient record to another provider, generally for a
specific purpose, such as a referral or discharge. Query-based HIEs
generally rely on an index into the complete and distributed record and let clinicians pull relevant data into a
portal or their EHR.
HIE 1.0 has not proven a sufficient means to deliver coordinated care, nor has it improved clinician workflow generally. Most HIE 1.0 vendors conceptualize the HIE as a form of intelligent plumbing that delivers disparate patient records where they are needed. In this view, the HIE provides aggregated, normalized and summarized data for use by clinicians or consumption by their EHRs or other
applications.
We see a substantial number of messaging-based HIEs deployed, including public HIEs, but few that can
serve as models for the rest of the industry. There is a wide range of variability between HIE implementations
which paradoxically limits their ability to interoperate with other HCOs and HIEs. Nonetheless the following
overview of functionality that HIE 1.0 vendors have been delivering is an indication of where the industry
stands now.
Standard HIE 1.0 Functionality
1. Orders and Results: Almost all HIE 1.0 vendors provide a way to enter simple orders and view
results across enterprise boundaries. This usually involves laboratory orders and results that flow
between a community practice and a hospital or reference laboratory. Radiology and medications
orders (excluding e-prescribing, see below) may be supported, but are not nearly as common as
laboratory orders and results.
2. ePrescribing (eRx): Almost every HIE 1.0 vendor can now support medications order fulfillment,
although most do so in conjunction with a third party.
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3. Clinician Messaging: Most HIE 1.0 solutions provide a way for providers to communicate securely within the HIE network. The most common use case is to support one-way transmission of
referrals with clinical information about the patient.
4. Provider Portal or EHR Access: HIE 1.0 solutions provide a number of options for clinician access,
including stand-alone portals that support query functionality for the longitudinal patient record
and messaging clinicians can use to push clinical data where it is needed. HIE 1.0 solutions can
also integrate this functionality into the clinician’s EHR. This latter capability is a major cost driver
because interfacing to an EHR typically requires significant work. HCOs may need one or both of
these methods, depending on the needs of the clinicians.
5. Personal Health Record (PHR): Several vendors offer a patient portal so providers can offer PHR
access to their patients. The capabilities of these portals vary significantly. Many offer gateways to
services like Microsoft’s HealthVault, rather than provide a PHR directly. Most HIE vendors now
seem to regard PHRs specifically and patient engagement generally as a challenge best addressed
by other HIT industry participants. Blue Button and Blue Button+ are seeing increased support by
HIE vendors since Blue Button support often equates to support for the view/download/transmit
functional criteria in MU Stage 2.
6. Lightweight EHRs: Many HIE 1.0 vendors offer less expensive, less resource-intensive EHRs either
directly or through partnership(s). These EHRs or EHR modules, often certified under ONC’s 2011
rules, are particularly popular in public HIEs. They often provide the most frequently used clinical
functions, including lab orders and results, clinician messaging, imaging orders, a note writer and
viewer, and e-prescribing. Lightweight EHRs are typically adopted by organizations that have no
EHR or an EHR with limited functionality and are looking to qualify for the EHR Incentive Program.
7. Clinical Quality Reporting: A range of CMS and other payer programs, such as the Physician Quality Reporting System (PQRS) and Healthcare Effectiveness Data and Information Set (HEDIS),
have different but often overlapping measures that require HCOs to report clinical quality indicators. Some of these data can be gleaned from HIEs and most HIE vendors contribute data to these
often ad hoc reporting efforts. A few HIE vendors have built out-of-the-box solutions for some of
these programs.
Taken together, this functionality combines to provide the market with what we call an HIE 1.0 solution.
(Table 2.5)
Function
Progress
Notes
Orders and Results
Good for labs
Messaging and portal oriented
Clinician Messaging
Good
Used for referrals and increasingly for non-HIPAA compliant
patient communications
Notifications and Alerts
Poor
Usually not relevant to clinicians
Query Records in Remote
HCOs
Poor
Limited and portal-based
Portal Access
Good
Widespread usage but limited to clinicians in connected
communities
EHR Access
Limited
Some access to EHR data but limited integration to EHR
workflow
Personal Health Record
Fair
HIE vendor interest has flagged
Patient Engagement
Limited
Critical need for better care coordination but limited HIE vendor
actions
Lightweight EHR
Fair
HIE vendors stand ready to deploy for MU incentives
Clinical Quality Reporting
Limited
HIE vendors uninterested
Analytics
Limited
Many vendors ready to provide clean data from across
a community
Clinician Alignment
Poor
HIE vendors have no deliverable functionality
Table 2.5: HIE 1.0 — Where We Are Today
At this juncture, provider organizations are demanding more than just clean data from an HIE; HCOs want
workflow support and functionality to support collaborative care and tools to support population health
management. The challenge for HIE vendors is that these customers often lack a clear understanding of
what that functionality should be, whether it should reside in the EHR or the HIE, and how to integrate new
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functionality with existing care processes. In short, providers are searching for HIE 2.0 capabilities without
a clear idea of what it will mean to their organization. This lack of clarity points to abundant opportunities to
innovate for vendors seeking to build HIE 2.0 solutions with advanced functions and applications.
HIE 2.0 Will Move the Industry Toward Integrated Care Coordination
HIE 2.0 vendors are developing solutions that EHR vendors can’t or won’t develop, and are doing so by tapping
the potential of data stored in heterogeneous and multi-enterprise EHRs and other clinical applications as
a collaboration tool. Consistent with the goals of accountable care, the next generation of HIEs must be
both patient-centric and population-focused. The capabilities need to be deployed at the point of care for
individual patients but they must also provide data that can be rolled up to the panel level for population
health management (PHM). An HIE 2.0 solution will become required infrastructure to support PHM.
HIE 2.0 will integrate new capabilities to help streamline patient care and PHM. (Table 2.6) For example,
provider teams will need to know and communicate the status of a referral — via the cross-enterprise
care plan — as a care transition unfolds. Similarly, care navigators will need to communicate with groups
of care teams about gaps when a patient is included in multiple panels. Clinicians responsible for reducing
readmissions will need visibility into referrals and medications adherence as well as the ability to participate
in the development and execution of care plans.
The bottom line is that HIE 2.0 applications will not be stovepiped from the outset. To serve the integrated,
cross-enterprise nature of HIE 2.0, notification services will be integral to applications that support care
Capability
HIE 1.0
HIE 2.0
Exchange Mechanism
Message-based directed
exchange
Query-based exchange and directed exchange
Orders and Results
Orders to lab; results to
physician
Directed or query for results; results integrated into
source EHR
ePrescribing
Order and fulfillment
focused
Patient engagement
Cross-venue medications reconciliation
Query Records in Remote
HCOs
Minimal attention paid
here
More highly developed patient portals and Blue Button
capabilities
Lightweight EHR
Community extender
Community extender
Clinical Quality Reporting
Data only
Automated processes to create and submit reports to
public health agencies and payers
Metrics to encourage physician alignment
Clinician Messaging
Primary way to move
clinical data
One way to move clinical and administrative data
Notification and Alert
Services
U.S. Mail or messaging
push
Publish/subscribe with delivery to patient and provider
on device of choice or to patient’s repository of choice
Clinician Access
Mostly portal
Predominantly embedded in the EHR
Medications Reconciliation
Medications lists
Cross-enterprise integration and propagation of
medications-related changes
Referrals Management
Push of ADT data to
next provider
Closed-loop, cross-enterprise workflow support
Care Plans
Push of discharge
summary to post-acute
care
Cross-enterprise virtual team using a single care planning
workflow-based application with underlying clinical and
administrative data
Reporting and Registries
Data only with limited
reporting
Comprehensive automated reporting to payers and
public health agencies
Population Health
Management
Data only
Robust data and analysis tools for risk-based HCOs
Analytics
Data only
Cross-enterprise data models supporting population
health management and clinician alignment
Data Sources
Payer silos and provider
silos
Combined payer and provider data for risk management
and care coordination optimization
Table 2.6: HIE 2.0 — Where We Are Going
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plans and referrals. Similarly, referrals applications will need to talk to scheduling systems, which in turn
must be integrated with eligibility checking, revenue cycle management (RCM) and practice management
systems (PMS). This level of integration will underlie and reinforce the goals of better patient engagement
and clinician alignment for care quality and outcomes.
HIE 2.0 Expands Access and Delivers Patient-Centric Care Coordination
According to the most progressive HIE vendors, many of the functions and information needed to deliver
coordinated care across HCOs can only be supplied by an HIE. Other HIE vendors are less than clear about
whether functionality is better delivered in the HIE or in the EHR. Either way, providers managing risk
under value-based payment models need cross-enterprise patient data, wherever it may be.
The list of advanced, patient-centric applications that include aspects of HIE 2.0 is growing. So far, however,
no solutions can fully support cross-enterprise care planning — a core function for innovative HCOs. Some
of the vendors profiled in this report offer cross-enterprise
care planning on a small scale (see CareEvolution) or for limited
Cross-enterprise care plans will sit
communities of providers (see Medicity). But none can deliver
at the technological center of care
a general-purpose application geared to the needs and scale of
delivery so a clinician can access nearly
cross-enterprise information exchange. HCOs are also looking for
any data element or EHR function.
advanced applications such as closed-loop referrals management,
medications reconciliation, clinical quality reporting, and
immunization and disease reporting. In addition, HIE 2.0 will expand into areas where technology adoption
is low or non-existent such as LTPAC and behavioral health providers.
The value of HIE 2.0 is that it can help contribute to meeting the onerous care coordination challenges
in new value-based care models. The examples in the following sections illustrate how HIE 2.0 can fill the
functionality gaps left by unconnected, incompatible or features-challenged EHRs.
Cross-Enterprise Care Plans in HIE 2.0
Readmissions penalties and bundled payments require acute and post-acute providers to coordinate their
efforts before and after patients are discharged. As providers confront the challenges of risk-driven reimbursement, they are adopting some of the tools and techniques traditionally used by payers in disease and
care management. While some of the requisite risk mitigation functions can and will be built into provider
EHRs, HCOs will require cross-enterprise data for coordinated workflows and a complete picture of financial exposure.
HCOs are looking for solutions that enable multi-disciplinary, multi-enterprise care teams to build and
execute patient-centric care plans. These solutions should leverage the HIE as a data source and provide
tools for communication and collaboration. The tools need to be available to clinicians in all care settings
and for ancillary services like radiology, pharmacy and laboratory. In addition, each provider should be
able to access the tools through his or her preferred mechanism (portal, integrated in EHR, mobile device,
etc.) While the initial focus of these dynamic plans will be to support post-discharge care and reduce
readmissions, the potential uses are far ranging.
Cross-enterprise care plans will have a more clinical focus than traditional payer programs. They will sit at
the technological center of care delivery so clinicians can access nearly any data element or EHR function
at any time. For the foreseeable future, no HIE or EHR vendor will offer this capability. Some HIE vendors
market care or disease management offerings with both technology and services. For example, Aetna
and UnitedHealthCare offer services-based care management that use HIE technology from Medicity
or OptumInsight, respectively. The independent HIE vendor, CareEvolution, markets its technology in
conjunction with Molina Healthcare to deliver cross-HCO care plans. In the coming years, virtually all HIE
vendors will develop and market software to support this important HIE 2.0 capability. Until out-of-the-box
solutions for cross-enterprise care plans are available, services will play a prominent role in enabling such
functionality.
Closed-Loop Referrals Management and HIE 2.0
Messaging-centric HIE 1.0 applications have long supported referrals with one-way directed exchange.
These are generally proprietary in the sense that only providers within the same HIE network can exchange
information. Few remember the dark ages of the 1980s when different email systems were separate and
non-interoperable but that is the current state of messaging for clinicians. The advent of Direct secure
messaging could convert the one-way streets of communication into bustling plazas. Direct provides a
standards-based way to send referrals to connected providers and unconnected providers outside an HIE
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Function
Current Status
HIE 2.0 Future
Initiate referral
•D
octor tells patient to see a
specialist
• Doctor makes entry in EHR which gathers
relevant data and kicks off process
Data flow from
referring clinician
•P
hone, fax or HIE message with
patient demographics
• Often none of the above
• Embedded in care plan or pushed via message
Notifications and alerts
•M
inimal
• Messages or letters in U.S. mail
• All notifications are embedded in workflows if
non-critical
• Urgent notification flow directly to clinicians in
most expedient way
• Can be CDS- or evidence-based
Referral status
•D
ifficult or impossible to know
without asking patient
• Continuously updated care plan has most recent
interactions and care events
Scheduling
• Separate process
• Embedded in administrative workflow
Referral summary
• Mostly non-existent
• Results entered into care plan
• Referring physician gets appropriate notification
that referral is complete with relevant
recommendation
Table 2.7: Referrals Process
network with HISP-to-HISP services. It is also a simple and easy way to perform event-based notifications
and to deposit data into EHRs or HIEs with a CDR. Some HIE vendors enable Direct only for referrals to
providers outside the HIE network. Others will be using Direct for all referrals.
Most HCOs will want to satisfy the Stage 2 MU core objective and to that end will use Direct for referrals.
More forward-looking providers will seek a robust referrals solution using messaging and advanced
workflows with underlying HIE 2.0 functionality and query-based exchange. (Table 2.7) While these
providers are attracted to Direct for its lower cost and simplicity, they will eventually realize that it is not
a great way to support the continuous back and forth that referrals can generate. Nor is it a good way to
integrate with the host of EHRs, PMSs, eligibility checking and scheduling systems found in the community
setting. For these reasons, approaches to referrals that rely solely on messaging will be a technology
dead end.
With HIE 2.0, the referring and referred-to providers will expect to know the status of a referral (e.g.,
eligibility checking, appointment scheduled, not scheduled, completed, awaiting results) and then
collaborate through the cross-enterprise care plan for follow-up. Clinicians in cross-enterprise care teams
will insist on guaranteed delivery, something that Direct cannot support. Closed-loop referrals, another
important aspect of HIE 2.0, will provide a mechanism to ensure that referrals occur, and then, because data
will be available at a patient panel and organization level, the ability to monitor and manage the flow of
referrals and associated revenue.
Behavioral, Long-Term and Post-Acute Care Providers and HIE 2.0
To meet the demand for coordinated care, providers need tools that can be shared by hospitals, primary
care, specialty care, and LTPAC providers. Given that some 37 percent of Medicare patients discharged from hospitals require some
EHR and HIE vendors have been slow
form of LTPAC services, LTPAC organizations will play a key role in
to recognize the need for data outside
HIE 2.0. In order to compete for acute care referrals, LTPAC and
of hospitals and physician practices.
specialty providers will need to demonstrate they can work collabThis critical gap in the market spells
oratively to reduce avoidable readmissions. Bundled payments will
opportunity for HIE 2.0 vendors.
further compel LTPAC providers to raise the bar on their standards
of care delivery.
The EHR Incentive Program, with its focus on hospitals and physician practices, fails to reach the nursing
facilities and home healthcare providers that comprise the bulk of the LTPAC community. While some
providers in these venues have access to an EHR, most do not, and instead rely on paper-based systems
to collect clinical data. Under CMS rules for Medicare patients, nursing facilities use the Minimum Data
Set (MDS) assessment to collect clinical data. Home healthcare providers have a similar assessment tool
called the Outcome and Assessment Information Set (OASIS) and home health care plans use a tool called
CMS 485. Few HIE vendors currently market solutions for converting MDS, OASIS or CMS 485 forms to a
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continuity of care document (CCD) for directed messaging or any other form of exchange with specialists
or a hospital.
Some public HIEs have found ways to connect LTPAC providers to the wider healthcare community.
Technology developed by Pennsylvania’s public HIE, Keystone Beacon, allows skilled nursing facilities
without an EHR to convert an MDS to a CCD for transmittal to a hospital or other connected provider.
Geisinger Health System and BridgeGate International have commercialized this technology as a tool called
KeyHIE Transform that translates MDS or OASIS into CCDs for consumption by an HIE or EHR. KeyHIE
Transform fills a legitimate need for a clinically relevant subset of MDS and OASIS data in other care venues
in the wider health system.
LTPAC providers need inbound data but lack EHRs. These organizations will need timely access to discharge
summaries and medications. This includes access to the same collaborative cross-enterprise care planning
tools that hospital- and practice-based care teams use. To participate fully in these care plans, LTPAC
providers will need the ability to modify care plans and communicate with the wider care team about a
patient’s course of illness or recovery in their venues.
Both EHR and HIE vendors have been slow to recognize the need for data outside of hospitals and physician practices. While happy to provide connectivity with portal access or a lightweight EHR, the current
crop of vendors offer LTPAC providers little in the way of application functionality that supports care coordination with other provider organizations. This critical gap in the market spells opportunity for HIE 2.0
vendors and a few are responding. ICA recently announced that it is providing Direct-based messaging and
HISP services for Tennessee’s Health eShare Direct Project that will include home health providers, hospice providers and rehabilitation facilities. Cerner has partnered with the Norman Regional Health System
in Norman, Oklahoma, recipient of a 2011 ONC Challenge Grant, to deliver a lightweight EHR for LTPAC
sites that includes the use of directed exchange for managing transitions of care through the statewide HIE.
Medications Reconciliation and HIE 2.0
Formerly used only for shift changes and transfers within hospitals, medications reconciliations is slowly expanding to include
nearly every care transition. Medications reconciliation between
care venues is elemental to collaboration and meaningful use, but
potential difficulties abound. Unfortunately, most HIE vendors believe that medications reconciliation is the exclusive responsibility
of EHR vendors. Also unfortunately, most EHR vendors aren’t that
interested in reconciling medications from different care venues.
HCOs are under increasing pressure
to reconcile a patient’s medications
in the context of cross-enterprise
collaborative care.
There may or may not be an EHR at the first or second venue. The EHR in the first venue may not have
the capability to create or transmit an electronic medications list. The EHR in the second venue may not
have a medications reconciliation function or one that can ingest the medications list from the first venue.
In any of these instances, the HIE could step into the breach and provide not just data, but medications
reconciliation functionality. Few HIE vendors today offer medications reconciliation functionality even
though HCOs are under increasing pressure to reconcile a patient’s medications in the context of crossenterprise collaborative care.
Surescripts and its limits — Many of the HIE vendors profiled in this report rely on Surescripts to supply
the medications data for the longitudinal patient record. Surescripts delivers medications history to
hospital medications reconciliation applications and increasingly to HIEs and community EHRs. Surescripts
coverage is probably the broadest in the industry, but it is not universal. Oddly, some HIE vendors exaggerate
the scope of the information provided by Surescripts. While Surescripts is not the only aggregator of
medications data, its offerings exemplify both the value and the limitations of this kind of data. Clinicians
should understand the promise and limitation of such data.
Surescripts receives data on dispensed prescriptions from pharmacy benefits managers (PBMs) and from
retail pharmacies. Together, these sometimes-duplicative sources of information cover about 50 percent of
the prescriptions filled in 2012. The data includes the name of the drug, dose, quantity dispensed, days’ supply,
dispensing pharmacy with phone number, and the name of the prescribing physician from the previous 12
months. For a prescription to appear in the PBM claims data, the patient must have a prescription benefit
and the pharmacy has to be aware and record that the patient has the prescription benefit. If an uninsured
patient fills a prescription at a pharmacy, that data will appear in an HIE only if the pharmacy reports to the
Surescripts network. If an insured patient fills a prescription and pays with cash, that data will not appear in
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either the PBM claims or the Surescripts network. Surescripts cannot provide any information about overthe-counter medications unless they were filled for an insured patient and the pharmacy was aware that the
patient had the insurance benefit. Surescripts does not provide de-duped medications data. If a prescription
fill is in a PBM claims database and pharmacy database, both will appear in the data provided by Surescripts
to the HCO or HIE. In that case, the HIE, medications reconciliation application, or clinician will have to
resolve the duplication. Needless to say, Surescripts and other aggregator-sourced medications data come
with limitations that clinician users or application developers need to understand.
While most of the HIE vendors in this report believe that medications reconciliation should always be done
in the target EHR, we think that their HCO customers may not always agree. Just as most of these same HIE
vendors offered an EHR-lite capability to their customers seeking to receive the Stage 1 MU incentives, we
think it is likely that many of the same HCOs will be looking for a similar gap-filler to help them achieve the
Stage 2 MU incentives, specifically for the medications reconciliation care requirement. Over the longer
term, the HIE vendors that choose not to build a robust medication reconciliation functionality into their
solution suite may not regret that decision. However, getting technology-challenged customers ready for
Stage 2 until EHR vendors develop better cross-enterprise functionality will be a requirement.
Clinical Decision Support and HIE 2.0
The traditional use of clinical decision support (CDS) for generating evidence-based alerts is expanding to
include organization-specific treatment protocols, which can introduce and reinforce collaborative care for
individual clinicians. While CDS-specific languages like Arden or GEM have long been used to build medical
logic modules (MLM) to fire alerts in EHRs, they are neither universally deployed nor regarded as omniscient.
There is ongoing work to harmonize the various CDS standards to a single standard called Health eDecisions
(HeD). Consistent with the goals of value-based care, HIE 2.0 will provide cross-enterprise data to enhance
CDS to help HCOs identify wasteful practice variations. The opportunity to use CDS as an element of
notification services across care teams could be low-hanging fruit in the quest to coordinate care. This
will be especially important as HCOs try to increase physician alignment, mitigate risks, and optimize
reimbursement.
Patient Engagement and HIE 2.0
The dominant use case for Direct is provider-to-provider communications for referrals. Unfortunately
opportunities for patient-to-provider communications seems far off according to most HIE vendors.
Only one vendor reports doing a pilot that will use Direct protocols: GSI Health with the Avado PHR at
Maimonides Medical Center. In HIE 2.0, communications between patients and providers will be integral
to coordinated care. It is likely that Direct-based communications with patients will become a dominant
component of patient engagement efforts in the coming years.
With or without support for Direct — and often in violation of HIPAA rules — the number of provider-topatient emails is increasing rapidly.1 HIE vendors are going to have to step up their efforts to support Directbased services despite provider confusion about what it is and what kinds of use cases it should support.
Over the next 12 months, Chilmark Research will monitor the deployment of Direct-based services closely
to determine how it is affecting development of HIE 2.0 and enhancing patient-engagement efforts.
Immunization Registries and HIE 2.0
Immunization-registry functionality has a number of cross-HCO data implications since it always involves
communications outside the enterprise. In general, all 50 states have different reporting requirements for
immunizations, diseases, and reportable labs, despite the existence of several so-called standards in this
area. The bulk of this kind of reporting is still done on paper and transmitted through the mail. Though HIE
vendors report very little customer interest in this area to date, the MU requirement to report into registries
will drive providers to seek IT solutions to address this requirement. An HIE infrastructure platform may be
a logical place for this functionality to reside.
Notification Services and HIE 2.0
The backbone of HIE 2.0 will be notification services that go
much farther than letting providers know when a patient is admitted, discharged, fills or does not fill a prescription. Many
HIE vendors currently provide some limited forms of notification to PCPs for certain clinical events: usually hospital or ED admits and discharges or prescription fills. Many
technology vendors can generate a letter for delivery
1
With HIE 2.0, clinicians will have more
flexible ways to express preferences
for notification and patients will have
some control over which providers
receive notifications.
Reddy, Sumathi, "When Email Is Part of the Doctor’s Treatment,“ Wall Street Journal, March, 25, 2013
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by mail, fax, or, less frequently, HIE messaging. Clinicians have a limited variety of
options for subscribing to these alerts. With HIE 2.0, clinicians will have more flexible ways to
express preferences for notification types and for specific patients or patient panels and for a wide range
of clinical events. HIE 2.0 will provide the ability for clinicians to receive notifications based on highly
complex clinical fact patterns. Moreover, HIE 2.0 will also give patients control over which providers receive
which notifications and under what conditions.
The essential thrust of HIE 2.0 notification services will be to eliminate “noise” in the information that
clinicians and patients receive. For instance, we know that PCPs invariably disregard letters they receive
about patients having filled a prescription. That information may never make it into the patient’s record.
HIE 2.0 vendors will offer more than just push-based notification services to include more robust notices
embedded in clinician workflow delivered according to clinician and patient choice. This will allow better
integration and use of notifications in both EHRs and cross-enterprise care plan applications. Robust
notifications will make care coordination part of everyday care.
Analytics and HIE 2.0
Every HIE vendor claims to aggregate, normalize and stage data for use by analytics but few deliver more
than data. Some HIE vendors are now beginning to deliver analytics to support PHM. Some vendors
are producing analytics through partnership with a parent company (Aetna, Humana, OptumInsight,
RelayHealth). Some have built their own suite (CareEvolution). Others have partnered with another vendor
(Orion Health with Caradigm).
Vendor
Notes
Caradigm
Abandoned HIE market to become
an analytics and population health
management vendor
CareEvolution
Continued investment in analytics for
variety of purposes
InterSystems
HealthShare Active Analytics internally
developed
OptumInsight
Plans to leverage analytics as the base
for clinical quality reporting and public
health reporting
Orion Health
Partnering with Caradigm for
population health management
Table 2.8: Representative List of HIE Vendors Offering Analytics
The need for clinical quality reporting will
only increase and HIE vendors are in an ideal
position to enable advanced reporting and
analytics capabilities. Over time, incentives
such as PQRS, the e-Prescribing Incentive
Program and the EHR Incentive Program
will become penalties. This adds urgency
for all providers, risk-based and FFS-based,
to develop flexible and comprehensive
programs for reporting this information to
payers and other interested parties. A variety
of EHR and HIT vendors are selling analytics
tools based on clinical data. Vendors of HIE
2.0 are well positioned to drive understanding
of how to enhance collaborative care across
multiple enterprises sharing the same risk
because they can consolidate data from those
enterprises. Many HIE vendor’s analytics
offerings continue to evolve. (Table 2. 8)
Project Direct Muddies the Outlook for HIE 2.0
While providers will adopt advanced HIE 2.0 applications, it is important to consider the impact of a single
regulatory provision. In 2012, ONC established Direct-based messaging as the information exchange
standard in Stage 2 MU provisions related to care transitions and the view/download/transmit requirement
for transactions to third parties.
Signs point to strong adoption of Direct secure messaging in the coming years – a mixed blessing given its
significant shortcomings. For HCOs committed to providing clinicians a care plan based on the complete
longitudinal patient record from inside an EHR, Direct is not progress. As secure email, Direct-based
messages, usually limited to a subset of patient data pushed to
a specific clinician, render the transaction and the clinical data
Adoption of Direct protocols will
invisible for any other purposes in a foundational HIE. Data that
proceed despite significant provider
flows via Direct does not persist in the clinical record, absent
confusion about the limitations of the
additional functionality and integration, and will be siloed in email
technology.
folders. Direct is not a good workflow tool and could only supports
HIE 2.0 with significant additional development.
But Direct has blockbuster advantages. It is standard, universally available email technology. It is a cheap,
easy to deploy, and a resoundingly effective way to support a handful of use cases, most notably referrals.
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Use of Direct is required to qualify for the EHR incentives; EHRs certified under Stage 2 must be able to
support Direct within clinician workflow.
Direct is not widely deployed now but it will see rapid adoption in the coming year, particularly across public,
statewide HIEs as the ONC has made it a priority directive. We believe that adoption of Direct protocols will
proceed despite significant confusion among clinicians about the limitations of the technology and its uses.
Much of the current interest in Direct is attributable to the EHR Incentive Program and many HCOs have
not fully examined its limits.
Many messaging-centric HIE vendors argue that query-based
One open question is how EHR vendors
exchange has plateaued permanently because of the complexity
are going to integrate Direct into their
of cross-enterprise MPI technology and the lack of financially viproduct.
able use cases. A small but prominent minority believe that query-based exchange and the longitudinal patient record will never
flower. We disagree. Query-based exchange will inevitably grow
given the tableau of financial incentives and disincentives provided by the ONC, CMS and private payers.
If Google can serve up advertisements to anyone, the healthcare system can serve up patient records when
they are needed. As HCOs and clinician-users gain experience with query-based exchange, the use cases
around care coordination will become more apparent and volumes will build. The reality is that both query
and messaging exchange will see volume growth and each HCO will reach its own optimal mix based on its
patient population, case mix, affiliate community, and workflows. Whether the increased use of Direct will
depress demand for query-based services is still an open question.
Direct-based services are now a universal element of HIE vendor product plans in 2013. Every HIE vendor
is, or will soon be providing HISP services and Direct secure messaging. Direct will be important for enabling
cross-domain (or HISP-to-HISP) messages and notifications in that it won’t require providers to move
between different portals. Whether two different HCOs will be able to exchange Direct-based emails will
also depend on whether their respective HISPs have agreed to interconnect. Another open question is how
EHR vendors are going to integrate Direct into their product plans. EHR vendors are required under Stage
2 MU to support Direct. Although EHR vendors often announce offerings that purport to be standardsadherent, that adherence is always questionable. While HIE vendors are busy building a variety of Directbased services, the EHR vendors are no doubt waiting in the wings with offerings that could potentially
undercut the efforts of HIE vendors.
PaaS Progress Slow
HIE vendors have long aspired to offer an exchange solution based on a platform as a service (PaaS) model.
All have collided with the reality of building a robust HIE; no HIE vendor has anything that remotely
resembles a platform. Every HIE vendor has functioning partnerships that tend to provide component HIE
functionality or wider distribution. We continue to believe that vendors are not moving fast enough to
cultivate partnerships that will drive greater adoption from HCOs based on the attraction of third-party,
value-added applications. Given the coming care coordination challenges faced by HCOs, we are heartened
to see that vendors continue to plug away at making their solutions robust enough to serve as a PaaS.
(Table 2.9)
Vendor
Attributes
Observations
Aetna’s Medicity
•S
et of APIs for partners
•P
artners include Emdeon and LabCorp
Strongest HIE vendor could build critical mass
among providers and interest from payers
Covisint
•A
PIs link to core ExchangeLink
App Cloud has no support in healthcare
GSI Health
•D
evelopment environment for partners
•P
rovides core HIE technology stack based
on messaging
Company has had limited success recruiting
partners but the onslaught of new Direct email
addresses could change this
Orion Health
•R
EST-based APIs as a partner development
platform
Orion Health’s strong presence in public HIEs,
support for Direct and deep clinical workflow
expertise could attract partners
RelayHealth
•R
elayHealth HIE to serve as house HIE for
CommonWell EHR vendors
EHR vendors could add applications and drive
third parties to the RelayHealth HIE
Table 2.9: Vendors Efforts to Build a PaaS HIE
2013 HIE MARKET REPORT
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CONCLUSIONS AND RECOMMENDATIONS
The HIE Market will Grow in 2013-2014
As Stage 2 MU rules take effect, HCOs will be moving data around their communities at higher volumes.
Public and enterprise HIEs will see strong growth in transaction rates as HCOs first try to capture incentive
dollars and later try to reengineer processes to capture value in new payment systems. While the pace at
which this will happen is still unclear, growth is unavoidable.
Recommendation: HCOs that do not yet have an HIE or are not connected to an HIE will be soon.
Existing care processes will evolve as the need for better care coordination increases and HIEs will be
the key enabling technology.
Vendors Will Come and Go
Some of the vendors in this report are probably not going to build many of the advanced applications that
will be integral to HIE 2.0. Some have decided that functionality is best left to the EHR; some simply lack the
market momentum to make the requisite investments. For this reason, we expect that the vendor landscape
will continue to evolve with new entrants (eg., Sandlot) and exits (eg., Verizon). At the same time we expect
that all of the vendors in this report will continue to actively build and sell clinical interoperability solutions
for HCO internal operations.
Recommendation: It is more important than ever to choose an HIE vendor with a strategy for longterm viability. Look for vendors with the skills to meet your requirements and the resources to
weather the market’s ups and downs. But be aware, even the apparently most stable of HIE vendors
may see significant challenges after an acquisition event that could severely test your relationship.
HCOs Will Demand More Innovation from HIE Vendors
In the past year, most HIE vendors focused on improving the effectiveness and efficiency of existing
customer implementations. The few vendors that ended the year with more customers than they started
grew solely because of superior underlying service, not technology. These companies grew because they
made existing HIEs work more effectively for HCOs. New ideas from every vendor are the order of the
day. The HIE 2.0 applications and other care coordination applications described above are the first steps
toward building a better healthcare system.
Recommendation: Closely scrutinize vendor’s product roadmaps and measure them against the
vendor’s development capabilities. Discussion of vendor plans for functional enhancements should
not stop with the RFP but should become part of contract term sheets.
More Query-Based Applications and Services
Vendors that aspire to deliver HIE 2.0 solutions will need to significantly enhance their query-based
exchange applications and services. Messaging-based systems are simply not up to the task of delivering
clinical data when and where clinicians and patients need it. Healthcare information needs are complex and
the ways that patients and HCOs interact too varied. While messaging will always have a place in patient
care, the applications we highlight in this report are more sophisticated in their ability to find data across
enterprises and deliver it to the right person, at the right time, and in the right form.
Recommendation: Evaluate clinical use cases and user communities to determine whether
applications should be query- or message-based or both.
Clean Data is Not Enough
Regarding an HIE as basic plumbing that underlies EHRs or portals to help clinicians at the point of care
underestimates its significant promise. With payment reform and the demands of PHM, HIE 2.0 vendors
will need to deliver more than just clean data. HIE 2.0 will require concerted development efforts on the
analytics side of HIE and services that enhance care at the level of patient panels. HCOs will be looking to
HIE vendors for solutions that more closely resemble out-of-the-box functionality with predefined data
models and cubes that can support a range of reporting and clinical analysis.
Recommendation: Multi-enterprise care coordination introduces complexities that EHR vendors can
no longer ignore. Engage EHR vendors and HIE vendors about their joint support for care coordination
and interoperable clinical data. Many HIE vendors think that point-of-care applications are the EHR’s
responsibility — does the EHR vendor agree when multi-enterprise data is involved?
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Be Cautious about Direct
The low-hanging fruit of incentive dollars will drive HCOs to make Direct secure messaging available to
their clinicians. Although Direct is inevitable for most clinicians and is a reasonable way to support referrals,
it is not a good way to support care coordination more broadly.
Recommendation: Avoid making Direct the centerpiece of care coordination efforts because it
is not a platform. Instead, position Direct among clinician users as one way to support some care
coordination efforts.
Get Vendors to Get Serious about Population Health Management
After several years of half-hearted efforts to build and sell various analytical applications, HIE vendors will
have to fashion solutions that actually address the central problem for HCOs in the next few years: new
payment models. Reorganizing care processes will be difficult and HCOs will need to understand what is
working and what is not.
Recommendation: Insist that HIE vendors have specific plans to support population health
management efforts including details on how they intend to work with your combination of EHR
vendors. Seek similar explanations from your EHR vendors.
Payer-Provider Alignment Begins to Get the Attention of HCO C-Suites
Until now, relatively few HIE vendors have regarded payers as potential consumers of HIE-derived
patient data and providers as potential consumers of payer data. As HCOs begin to act more actuarial,
they will need to make use of payer data and payers will need more clinical data to support HCOs.
Recommendation: Approach HIE vendors about more specific plans to include payer-sourced data in
HIEs and in HIE-based applications.
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CHAPTER 2: Notes
2013 HIE MARKET REPORT
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VENDOR
PROFILES
CHAPTER 3: Vendor Profiles
INTRODUCTION
Vendors Turn to Care Coordination
For HIE vendors, product innovation took a back seat to improving
existing solutions during the last year. As innovation paused,
HCOs became more aware of the value and potential uses of HIEs,
namely, the role an HIE can play in coordinating care with other
HCOs. There has also been a dawning recognition — not universal
but pervasive — that better query-based exchange must become
more prominent in the HIE value proposition. Most vendors
in this report have product roadmaps that reflect this shift. A
countervailing trend is the rise of Direct secure messaging, which
could hamstring efforts to make HIEs a more responsive and
effective tool for a wider range of care coordination scenarios.
What has not changed in the last year is that building an HIE is
still a technically complex and politically fraught undertaking.
Today’s HIE market is vibrant and the solutions described in the
following profiles vary significantly. Where HIEs are working
effectively, orders and results continue to be the primary, if not
sole, information exchanged. On the demand side HCOs, driven
by payment reform, are searching for better ways to manage
and mitigate risk in concert with other providers. In one of the
biggest changes in the past 18 months, the need for solutions that
enhance care coordination rather than simply move data between
clinicians is reflected in a growing number of HCO IT agendas and
budgets.
But the difficulties of providing high-quality, high-performance,
cross-enterprise data remain daunting. We noted in the previous
chapter that Caradigm has effectively stopped marketing its
own HIE solution after several difficult years. We anticipate
that Caradigm will not be the last vendor to withdraw from this
market. At the same time, vendors with new, sometimes better
ideas will continue to enter the market.
Market Still Attracting
New Entrants
InterComponentWare AG (ICW) exited the HIE business in the U.S. However, it recently joined forces with Sandlot Solutions Partners of Fort Worth,
TX to tackle the U.S. HIE market once
again. Sandlot will be using ICW’s
MPI and RLS, as well as Mirth’s interface engine to deliver HIE solutions
for physician practices. Sandlot’s HIE
solution – Sandlot Connect – delivers
the longitudinal patient record from a
variety of clinical data sources to a
web-based portal. Sandlot has effectively become ICW’s channel partner for the U.S. market. Sandlot augments its HIE capabilities with a set of
analytics tools and a care management
application focused on the needs of
ACO-type providers.
While Sandlot is small by HIT vendor
standards, it has some traction in the
HIE market that belies its size. Most
recently, it added an ACO in Florida to
its roster of customers. In total, it has
provided HIE solutions to roughly 600
office-based physicians, as well as to
some physicians in hospitals and IDNs.
By any standard, this is a very small
market footprint but it points to the
continued attractiveness of the HIE
market and the opportunity presented
by risk-based provider organizations
such as the newly forming ACOs.
With this report, Chilmark Research has applied its methodology
(see Appendix B) to provide a clear picture of where this market
and the vendors who serve it are heading. The scores in this report
are, for the most part, lower than last year’s because HCOs’
standards are higher. They want solutions that include care coordination capabilities that HIE vendors are
only beginning to develop. The profiles that follow provide an overview of the leading HIE solutions in the
market today, their strengths and weaknesses, where they have enjoyed success and some insight as to
the future direction of each HIE vendor. These profiles are not an exhaustive analysis of each vendor’s
solution and business strategy. We emphasize that every vendor profiled in this report has the ability to
implement an effective and efficient HIE solution, albeit each with its own unique strengths and challenges.
Accordingly, an HCO would do well to understand the strengths of each vendor and how they align with the
organization’s own HIE strategy.
CORPORATE ACTIONS IN THE HIE MARKET
The ranks of the independent HIE vendor continued to thin since we published the Chilmark Research
2012 HIE Market Report. Certify and dbMotion were both acquired in the last year. (Table 3.1).
HCOs seeking an HIE solution from an unaffiliated vendor (Table 3.2) still have choices but we anticipate
further consolidation in the coming two years. Armed with the following information, HCO decision makers
can gain a clear picture of currently available solutions and shortlist vendors worth reviewing for their own
HIE initiatives.
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© 2013 CHILMARKRESEARCH
Acquisition
Date of
Acquisition
Parent
Corporate Impact/ Market Readiness
dbMotion
Allscripts
March
2013
• May become optimized for Allscripts environment
• Long-term future of Cerner relationship is not certain
• The comeback kid of 2013
Certify
Humana
November
2012
• Potential that addressing needs of existing customers and Humana’s internal needs will strain resources
Kryptiq
Surescripts
September
2012
• National footprint and low cost for providers
• Market reaction to a pure messaging-based exchange solution
remains to be seen
MobileMD
Siemens
November
2011
• Lost momentum in the market
• Long-term future uncertain
Medicity
Aetna
January
2011
• Remains the market leader
• Fits well with Aetna’s strategy to enable ACO models
Carefx
Harris
April 2011
• Positions Harris to compete for large contracts with the DoD and
VA
• Limited appeal to non-government customers
Axolotl
United
Health
August
2010
• Mass exodus of Axolotl leadership
• Contraction in market footprint
• Future highly uncertain
Wellogic
Alere
December
2011
• Market momentum building
• Comprehensive solution suite for population health management
not there yet
Table 3.1: HIE-Related Corporate Actions
Payer Owned
Acquiree
Company
Market Status
Certify Data Systems
Humana
Uncertain future outside of Humana
Medicity
Aetna
Remains market leader
OptumInsight
UnitedHealth Group
Continuing turmoil, strong product vision but
execution lacking
HIT or IT Vendor Owned
Acquiree
Company
Market Status
Cerner
Cerner
Captive to Cerner client base
Covisint Healthcare
Covisint
Healthcare secondary to automotive focus
dbMotion
Allscripts
Increasingly captive to Allscripts client base
Harris Healthcare
Harris
Good technology stack, governement focus
MobileMD
Siemens
Captive to Siemens client base
RelayHealth
McKesson
Partially captive to McKesson client
Table 3.2: Currently Available HIE Solutions by Ownership Status
2013 HIE MARKET REPORT
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Unaffiliated
Company
Market Status
4Medica
Deep laboratory orders and results experience
Alere ACS
Combining care management with domain expertise in devices and telehealth
Caradigm
Killed its eHealth HIE solution
CareEvolution
Good product suite, weak marketing - small market footprint
GSI Health
Start-up looking to become a platform
HealthUnity
Option for small HCOs
ICA
Mid-market player with roots in clinical research
InterSystems
HIE is one of many solutions in its strong suite of capabilities
Orion Health
Strongest independent HIE vendor in market
Surescripts - Kryptiq
Deep messaging functionality and expertise
Table 3.2: Currently Available HIE Solutions by Ownership Status
PROFILE GUIDE
Each HIE vendor profile is divided into three sections. The first section provides a concise company profile
including high-level rankings (Overall, Product & Marketing), company location, HIE-based revenue estimate,
target market, top three differentiators and lastly, the solution’s three most frequently used features.
Revenue
Revenue stated is our estimate of a vendor’s 2012 HIE-related revenue in the U.S. For example, although
McKesson had 2012 revenue of over $122 billion, its HIE revenue from RelayHealth and related businesses
is a fraction of that. We looked at factors such as the number of HIE clients, number of employees, and
customer mix to arrive at the estimates provided.
Product Overview
The second section provides a descriptive overview of the HIE vendor’s product offering. A top-level
ranking of the vendor’s product on innovation and execution is shown as well as information such as the
product’s name, latest version release, dominant architecture, and classification. The Product Innovation
ranking is based on several factors including: degree and ease of customization, ability to configure to
clinician workflow, architectural model, adoption of standards, use of open development tools, and the
vendor’s efforts to evolve their HIE solution to serve the market’s growing demand for HIE 2.0 solutions.
Product Execution ranking factors include: the vendor’s ability to deliver given functionality, the rate and
pace of releases, implementation capabilities, and speed of deployment.
We then provide further product specifics on each vendor’s HIE solution and rank each based on functional
categories critical for an HIE initiative. Because vendors can exhibit some form of competitive differentiation
in these product categories, some of the more common features that have become virtual commodities in
the market (messaging system, directory services, and privacy and security features) and are weighted less
heavily. Other features common in HIE solutions, such as MPIs are evaluated if differences remain based
on the vendor’s ability to support cross-enterprise features. Product categories are ranked using a Harvey
Ball indicator. Rankings range from an empty to full circle and are based on the completeness of a vendor’s
solution in meeting the functionality listed and how widely that feature is deployed among the vendor’s
client base (Table 3.3). After the Harvey Ball ranking of product features is a narrative that provides an
expanded assessment of the vendor’s product features and functionality as well as an overview of their
future product roadmap.
Following the product review section is an explanation of the vendor’s approach to marketing its solutions.
Similar to the product section, the marketing section uses several critical parameters to determine the
relative strength of a vendor’s marketing for its HIE solution. Without a robust marketing strategy, sales
capability, and support services, a product rarely succeeds in the market. This is especially true in the HIE
market, where customization and services are critical to success.
3-3 I July2013
© 2013 CHILMARKRESEARCH
Category
Data Access &
Presentation
External
Integration
Standards &
Terminology
Clinical
Coordination
Support
Medications
Reconciliation
Referrals
Management
Patient
Engagement
Platform
Support
Analytics &
Reporting
Product Ranking Schema
2
3
Portal view of incremental/departmental data
4
!
2
Role-level HIE integration platform with EHR-lite capabilities
3
4
!
2
3
4
!
1
2
3
4
!
1
2
3
16-25 EHRs
Hyper-developed portal, full longitudinal record access, customizable
HIE-sourced data integrated into EHR and clinician workflow
Integration with 1-15 distinct 3rd party EHRs
26-35 EHRs
More than 35 EHRs
Support HL7 messaging
Above with DICOM, LOINC, some IHE profiles supported (e.g., XDS)
Above with support extensive support for HIE stack & native terminology mapping
Above with semantic interoperability
No support
CCD to next provider
Above with PCP notification
Above with cross-enterprise workflow support for some care transitions
Above with cross-enterprise care team collaboration on multi-disciplinary care plans
No support
Medications list to next provider via DSM
Longitudinal record of medications across the community available to next provider
4
Concise record of episode-related medications queryable by next
provider
!
Full reconciliation process
1
2
3
4
!
2
3
4
!
1
2
3
4
!
1
2
No support
Simple push of patient demographics
Patient clinical information supplied to next provider
Closed-loop referrals management within the HIE
Closed-loop referrals management with other HIEs
None or via third party
Modest patient portal
Full-featured portal with educational content and administrative functions
Above with support for variety of patient-generated health data
Not supported
“Closed” APIs for select partners
Published APIs, easily accessible developer tools
Shared, integrated workflows across apps
Supports “Open” non-healthcare standards (e.g., OAuth, REST, etc.)
No native suport, some capabilities via partners
Modest native support, e.g. usage audits
3
More advanced reporting (quality measures, public health) and some pre-defined
analytics
4
All above with custom analytics & basic CDS
!
Previous and advanced analytics across numerous data types, both clinical and
administrative, customizable dashboards
2013 HIE MARKET REPORT
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Category
Clinical
Quality
Reporting
Public
Health
Reporting
Analytics for
Population
Health
Management
Product Ranking Schema
2
3
4
!
2
3
4
!
Provides cross-enterprise patient-level data only
Automated tool for collecting data and calculating quality measures
Automated tool for collecting data and calculating quality measures
Fully compliant reporting to all major clinical quality programs
Provides cross-enterprise patient data only
Supports some reporting for selected jurisdictions
Supports some reporting for many jurisdictions
Fully compliant reporting to all state and federal agencies
2
Provides cross-enterprise patient-level clinical and payer data only with third-party
analytics functionality
3
Cohort selection with data aggregation at population or episode level
4
Provides a hierarchy of views into a population with simple or few clinical and
financial KPIs
!
Above with many or complex clinical and financial KPIs
Table 3.3: HIE Vendor Product Ranking Model
Beginning with a high-level
ranking on Marketing Vision and
Marketing Execution, this section
provides further information
on a vendor’s go-to-market
strategy
including
target
market,
market
presence,
pricing
model,
flagship
customers, and partnerships.
As with the product section, a
vendor’s marketing prowess
is assessed with Harvey Balls.
(Table 3.4) The ranking section
is followed by a narrative
review
of
the
vendor’s
marketing strategy including
where that vendor seems to be
succeeding and where it may
face some challenges.
OVERALL RANKINGS
Most of the scores in this
report are lower than last
year’s because so few vendors
have made significant progress
toward building the HIE 2.0
applications that will support
better care coordination.
Aetna’s Medicity stands astride
the HIE business, maintaining
its hold on the top spot with
an overall ranking score of
B+. (Table 3.5) While Medicity
edged out OptumInsight for
the top spot last year, it has
3-5 I July2013
Category
Brand
Recognition
Market
Coverage
Geographical
Coverage
Partner
Strategy
Services
Vision
Market Ranking Schema
2
Not well known
3
Recognized in regional HIE markets or well known in
other HIT market
4
Well recognized brand in HIE market
!
Leading brand in HIE market
2
Small HIE presence
3
Presence in public or enterprise market
4
Some presence in both public and entperprise market or
strong presence in one of these markets
!
Strong presence in both public and enterprise market
2
Localized coverage
3
Several clients across region or in several states
4
Clients in all regions of the U.S.
!
Above plus international clients
2
One to two partners
3
Three to four partners with HIE relevance
4
More than four partners with HIE relevance
!
Broad, diverse ecosystem
2
Offered via third party
3
Limited services provided locally
4
Capable services organization providing regional
support
!
Complete, well-regarded services offering to address all
aspects of HIE deployment from strategy to go-live and
maintenance
2
In today, not looking to the future
3
Modest vision mapped to product strategy
4
Forward thinking vision that aligns well with near-term
market needs
!
Leading HIE market visionary that other vendors seek
to emulate
Table 3.4: HIE Vendor Market Ranking Model
© 2013 CHILMARKRESEARCH
Vendor
Product Market
Overall
4medica
C
C-
C
Alere ACS
B-
B-
B-
Caradigm
C-
C-
C-
CareEvolution
B+
B-
B
Cerner
C+
B
B
Certify Data Systems
B-
B
B-
Covisint
C-
C
C
dbMotion
C+
B-
B-
GSI Health
C
C
C
Harris
B-
C+
C+
HealthUnity
C-
C-
C-
ICA
B-
C
C+
InterSystems
B-
B
B-
Medicity
B+
B+
B+
MobileMD
C+
C
C+
OptumInsight
C
C+
C+
Orion Health
B+
B
B+
RelayHealth
B-
B
B-
Surescripts/Kryptiq
C+
B
B-
significantly widened that gap in the last 12
months. Medicity’s gain stems primarily from
OptumInsight’s continuing struggles with its
product set and field execution rather than
any significant moves by Medicity. We give
an unqualified edge to Medicity because it
continues to execute well in the field and made
inroads into the enterprise market.
Orion Health is a clear second and made good
progress over the last year on all fronts, including
expansion into the enterprise market where it
was previously weak. OptumInsight continues
to be a presence in the market but trails Medicity
and Orion Health because its products have not
kept pace and its field execution is ambiguous.
These three companies are the largest vendors
in terms of revenue. Moreover, they are the
most frequently mentioned competitors by all
other HIE vendors. But compared to all other
HIE vendors, Medicity and Orion Health have
done a superior job on the marketing front
and have performed better than their peers in
delivering HIE product functionality.
Orion Health is now a close second to Medicity,
the role formerly held by OptumInsight. Orion
Health continues to grow usage in its traditional public HIE and has made headway in the enterprise market.
It is now the second most frequently mentioned competitor by all other vendors. Right now, Orion Health is
probably the strongest unaffiliated vendor of HIE solutions in the market based on its broad product portfolio
and its ability to deliver for a range of HCOs and public entities. It is also moving aggressively to enhance its
analytics offerings with an expanded relationship with Caradigm.
Table 3.5: HIE Vendor Overall Ranking
Since its acquisition, OptumInsight (Axolotl) has clearly not had the focus it had in the past. OptumInsight’s
scores in most areas we evaluate have suffered dramatically in the last year. Many remember when Axolotl
was the leader of the HIE business, in spite of its Domino-based legacy platform. Its past success was rooted in
on-time go-lives which seemingly are no longer a priority. Company representatives claim that the company
intends to shore up and renew its position in the HIE market with new functionality that more closely meets
the needs of HCOs seeking HIE 2.0 solutions. Much of the contemplated functionality will be focused on
delivering robust notifications functionality. To its credit, OptumInsight’s view of market needs for notification
services is much broader than any other vendors profiled in this report. If the company can deliver on this
vision, clinicians will be able to subscribe to an extremely wide variety of clinical events for patients or panels
and receive notifications at the time and on the device they choose. Patients will also be able to control which
clinicians receive what information. Critical events will be pushed to the appropriate clinician or system for
more immediate action or intervention. It remains to be seen if OptumInsight will execute, but it has the
resources and appears to have the desire to right this listing ship.
Closely following Medicity and Orion Health are CareEvolution and Cerner who received solid Bs.
CareEvolution is not flashy and works with channel partners to take its products to market. From a
product standpoint only, CareEvolution has some of the most robust applications for multi-enterprise care
coordination. Today, its primary channel partner is Truven Health and together the companies have landed
several clients, including the states of Alabama and West Virginia. CareEvolution also works with Molina
Health in the managed care market.
Cerner is in many ways the “steady Eddy” of the HIE business. It was a strong advocate of Direct protocols
prior to their adoption by the ONC in the meaningful use (MU) rules. It is also the only major EHR vendor
with an HIE solution that truly embraces multi-vendor interoperability based on its partnership with
Certify Data Systems. It is also important to note that Cerner is one of the founding organizations of
the CommonWell Health Alliance which indicates its commitment to making query-based search across
disparate EHRs easier for HCOs.
While these rankings provide guidance about the relative strengths of HIE vendors, it is important to
2013 HIE MARKET REPORT
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remember that despite the pause in product innovation, the market is changing rapidly. For instance, one
vendor we talked to in December believed that the market was not rushing to adopt solutions that enable
value-based care. By March, the same vendor had completely reversed its position. More broadly, every
vendor in this report is well aware of the new market forces now at work on HCOs. All recognize that HCOs
are looking for HIE 2.0 solutions. Strengths and weaknesses in certain product categories are, in many
cases, a result of conscious choices made by individual vendors based on conditions in their customer sets.
Vendors that are strong in enterprise markets (e.g. Cerner, dbMotion, RelayHealth, or Surescripts) will be
responding to a subtly different set of requirements than vendors that have done well with public HIEs
(Medicity, OptumInsight, Orion Health). We think that vendors in the past year have spent considerable
resources responding to these requirement by making their existing solutions work more effectively. We
also expect the pace of innovation to increase in the next 1-2 years.
HIE Versus EHR
A continuing question for HCOs and their HIE vendors is whether the underlying HIE data and functionality
is best presented to clinicians in a portal or within the clinician’s EHR. Obviously, if a clinician has to tab
between a portal and the EHR, even with single sign-on and patient context, the clinical workflow suffers.
Most HCOs combine portals, EHRs and messages in different ways. For example, a physician could query a
complete longitudinal patient record in a portal and then pick certain lab results to attach to a message. The
lab results could be hospital- or reference lab-proprietary, in a PDF or an HL7 message. The recipient could
receive the results in either a portal or an EHR. The messaging system could be proprietary to the HIE vendor
or it could be secure email using Direct protocols. These few examples indicate how complex interactions and
combinations of technology make HIE implementations difficult and costly.
There is a spectrum of opinion among vendors about whether application functionality should be delivered in
the EHR or the HIE. Cerner and OptumInsight believe that clinician functionality should always be delivered
inside an EHR. Cerner thinks that medications reconciliation should be performed in the destination EHR — an
unsurprising position coming from an EHR vendor. Orion Health, on the other hand, thinks that functionality
should be delivered in the HIE when the EHR can’t or doesn’t. Orion Health is now in the process of defining
requirements for an HIE-based medications reconciliation function. In the middle, InterSystems strives to
deliver the functionality that customers ask for. We make this point only to emphasize that the assessments
we make in the product section of this report have to be considered in light of each vendor’s approach to
the market.
HIE Market Resists Classification
As indicated in Chapter 2, we have used different
classification schemas for HIE vendors based on their
general approach to providing functionality. HIE offerings
vary significantly and turnover adds to the complexity for
prospective buyers. For this reason, every HIE vendor
can fall into multiple categories. We provide several ways
to conceptualize these companies and their offerings. In
the broadest terms, three categories of companies sell
HIE solutions (Table 3.6):
CommonWell Health Alliance Standards
Patient Linking and Matching
Identify patients as they move across venues
Patient Access and Consent Management
Patient-controlled, simplified consents and
authorizations for sharing
Record Locator Service and Directed Query
Access patient data across venues
EHR Vendors: Nearly every EHR vendor claims to have an
HIE solution that supports multi-stakeholder and multiEHR interoperability, but evidence that this is happening
is scant. EHR vendors offering an internally developed HIE solution include Cerner, eClinicalWorks, Epic and
NextGen. Allscripts acquired HIE vendor dbMotion. Cerner also has a partnership with Certify Data Systems
for last-mile connectivity to community practices. Epic Everywhere is intended to interconnect Epic systems
Type
Vendors
Observations
EHR Vendors
Cerner, Epic, Allscripts, eClinicalWorks, NextGen,
dbMotion, Certify Data Systems, athenahealth,
MobileMD, RelayHealth
Focus on interoperability within their
install base, limited or no integration
with other EHRs
HIE Centric Vendors
Orion Health, InterSystems, Cerner, CareEvolution,
Alere ACS, 4medica, GSI Health, HealthUnity,
Kryptiq, Certify Data Systems
Strong support for clinical interoperability generally and committed to
HIE as a market opportunity
Others
Harris, Medicity, OptumInsight, Covisint,
Surescripts, Certify Data Systems, Alere ACS
Healthcare payer and provider focus
with wide range of results to date
Table 3.6: HIE Vendor Types
3-7 I July2013
© 2013 CHILMARKRESEARCH
for care coordination. Epic Elsewhere is intended to interconnect Epic and non-Epic EHRs. The reality is that
most of these solutions are best suited for homogeneous EHR environments.
HIE-Centric Vendors: This category contains HIT vendors that, through internal development and partnerships,
provide complete HIE solutions to serve this market. These vendors are also dedicating the necessary go-tomarket resources (sales, marketing, partnerships) to effectively capitalize on HIE market opportunities.
Others: This category contains vendors owned by payers or larger IT service organizations. While their
solutions resemble solutions from HIE-centric vendors, their market focus may be narrower.
This report focuses on the latter two categories: HIE-centric vendors and others.
An alternative way to view these vendors is based on the dominant way that they have deployed their HIE
solution. (Table 3.7) We have traditionally also used the following classification schema:
Type
Vendors
Observations
Portal-Centric
4medica, Harris, Certify Data Systems
Orders and results as the first cross-enterprise
HIE application; strong clinical vocabulary and
data standards capabilities
Messaging-Centric
Kryptiq Surescripts, RelayHealth,
Medicity, OptumInsight, MobileMD,
GSI Health, HealthUnity, Orion Health
Messaging focus and leading the charge to Direct
secure messaging; most need to broaden the
product portfolio to provide a true HIE platform
HIE Platform
Medicity, Cerner, CareEvolution, InterSystems, Covsisint, Orion Health, RelayHealth, Alere ACS
Leading the way to making HIEs a platform that
supports true clinical plug and play interoperability
Table 3.7: HIE Vendor Classification Schema
This points generally to each HIE vendor’s development focus. Both portal- and messaging-centric vendors
focus on their core competencies. Portal-centric vendors tend to focus on data aggregation and presentation
to produce the longitudinal patient record while messaging-centric vendors have focused on order and
results and referral management. But in each of these categories, the vendors are investing development
resources or establishing partnerships to become HIE platform vendors. Also note that some vendors appear
in multiple categories. For instance, Orion Health has a strong messaging solution but also is publishing its
RESTful APIs in order to attract partners and customers to build on its solution in an effort to become a true
HIE platform.
Tier
One
Two
Three
Vendor
Notes
Medicity
•L
arge gains in enterprise markets in 2012
•M
aintaining strong position in public markets
Orion Health
•S
trong presence in public market, growing in enterprise
• Small number of big-footprint clients
RelayHealth
• Large gains in enterprise market in 2012
• Commonwell may contribute to accelerated growth
Cerner/Certify
Data Systems
•C
lose partnership - strongest presence in enterprise market
•Q
uestions about Humana’s intent for Certify needs resolution
•A
lmost entirely contained to Cerner installed base
dbMotion
• Allscripts acquisition will drive further growth
• Likely to be less appealing outside Allscripts accounts
InterSystems
• Company re-committed to HIE market
• Very capable tech and strong brand in enterprise market
CareEvolution
• Good tech stack and best-in-market analytics
• Despite minimal marketing, gaining traction
OptumInsight
•S
ignificant struggles in market leading to market contraction
•V
ision is good, execution needs to improve
Surescripts/
Kryptiq
•N
ational footprint with e-prescribing network
• Partnership with Epic and others could accelerate growth
Table 3.8: Leading Enterprise HIE Vendors Based on Market Presence
2013 HIE MARKET REPORT
July2013
I 3-8
HIE vendors should all be moving toward building an HIE platform and delivering it with a Platform as a Service
(PaaS) model. The approach has proved challenging as it can lead to complex negotiations and agreements
among a multitude of vendors to deliver basic HIE functionality to a client. However, we believe vendors that
can assemble an HIE PaaS will be better positioned to solve a wider range of clinical interoperability challenges.
Yet another way to think about HIE vendors is based on the number of customers they have acquired.
(Table 3.8) We provide this table of vendors in the following profiles with 50 or more public and enterprise
customers in production.
Who will be the leading vendors in HIE five years from now? The question may be irrelevant. In five years
the HIE market may not even exist since solid clinical interoperability capabilities could become table stakes
for all HIT vendors. Many HIE vendors are no longer referring to themselves as HIE vendors and are using
language that evokes ideas related to clinical interoperability. The demand for better care coordination will
force changes that are at this point hard to predict.
This year, we think that an increasingly important distinction in the market is between message-based
exchange and query-based exchange. While each of these styles occurs in portals or embedded in EHRs,
message-based exchange still dominates in nearly all production HIEs. Every vendor profiled supports
message-based exchange, relatively few have strong support for query-based exchange, and fewer still have
live clients using query-based exchange for diverse use cases. As suggested in Chapter 2, we believe that over
the long term, each HCO will develop its optimal mix of message- and query-based transactions based on its
patient mix and approach to workflow. Efforts like the CommonWell Health Alliance are intended to foster
and promote query-based exchange.
As HCOs build experience with more HIE use cases, care coordination needs will determine whether
functions are message- or query-based or both. For example, notifications could be instant message-based
if the patient’s status or condition depends on a timely intervention. On the other hand, notifications could
also be query-based if the intervention is more appropriate for the next office visit when the PCP opens the
patient’s chart in the EHR. Whether functionality is deployed as message-based or query-based will depend
on the clinical context.
PRODUCT RANKINGS
Once again, as our research found last year, no vendor excels across all product capabilities. (See Table 3.9 on
following page). Most vendors are reasonably competent at integrating external sources of patient data, such
as EHRs and other HIS. Unfortunately, despite the efforts of HIE vendors to provide support for IHE-derived
standards, the same cannot be said for the EHR vendors. In our interviews with public and enterprise HIE
leaders and HIE vendors, we found a common and persistent problem: the vast majority of EHR systems in
use today still do not support IHE protocols, nor can they create or parse a usable CCD. True EHR-to-EHR
interoperability remains on the distant horizon. Most HIEs being deployed today must use HL7 messaging to
move data within a network.
ESSENTIAL HIE 2.0 APPLICATIONS
To deliver on the vision of coordinated care, an HCO needs an HIE with the following capabilities.
Medications Reconciliation
This new area of functionality is mostly not supported by any vendor in this report. As patients move from
one venue to another, medications discrepancies loom large as a potential problem for better coordinated
care. Most vendors are able to produce a medications lists from some combination of EHRs, aggregators or
discharge summaries. Many can also present these medications lists in the target EHR. However, most present
the lists through a portal or as an attachment to a message. What is missing is the ability to detect and correct
discrepancies in this list as well as to make changes as a patient moves to a different care venue or setting.
Some vendors have plans to provide medications reconciliations functionality. Some also plan to use the
reconciliation function for allergies and problem lists. We cannot say that there is a clear leader in this area.
From a product roadmap standpoint, Orion Health is gathering requirements for an HIE-based solution.
The bottom line is that a robust cross-enterprise medications reconciliation application is not currently
available from any vendor and future product actions will be heavily influenced by each vendor’s view where
functionality should be delivered.
3-9 I July2013
© 2013 CHILMARKRESEARCH
ICA
InterSystems
Medicity
MobileMD
OptumInsight
Orion Health
RelayHealth
Surescripts Kryptiq
Analytics for Polulation
Health Management
HealthUnity
Clinical Quality
Reporting
Harris
Platform Support
GSI Health
Referrals
Management
dbMotion
Clinical Coordination
Support
Covisint
External Integration
Certify Data Systems
Public Health
Reporting
Cerner
Analytics and
Reporting
CareEvolution
Pateint
Engagement
Caradigm
Medications
Reconciliation
Alere ACS
Standards and
Terminology
4medica
Data Access and
Presentation
Company
!
3
4
4
!
3
3
3
2
3
4
3
3
4
4
!
!
4
3
3
!
4
4
4
4
3
!
4
4
2
3
4
4
4
4
4
3
2
1
3
2
3
2
2
1
3
3
2
2
3
3
3
2
2
2
3
3
1
2
3
3
2
1
2
1
2
3
2
2
2
4
2
2
4
3
2
3
2
3
4
3
2
3
2
3
2
2
3
3
3
2
3
3
3
2
1
3
2
3
3
2
2
2
3
2
2
2
2
3
2
2
4
3
3
4
3
2
4
!
!
3
!
1
!
2
!
!
!
!
!
!
4
2
3
4
2
4
2
2
2
2
4
2
2
3
3
3
2
2
3
2
4
2
4
2
4
2
3
2
2
2
4
2
3
3
3
2
2
4
3
3
!
3
2
4
4
3
2
4
3
4
4
4
4
4
4
4
4
!
4
2
2
2
3
2
2
3
2
3
2
2
2
2
3
2
2
3
3
2
2
2
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
Table 3.9: HIE Vendor Product Capability Assessment
Referrals Management
The central interaction between providers coordinating care is the referral. HIEs have long supported referrals
with basic messages containing patient demographics sent to specialty or procedural providers. The market
is now looking for a referrals management capability that provides a full complement of targeted clinician
information exchange and the ability for providers to communicate and collaborate. In general, vendors are
making good progress toward delivering better support for referral management processes. Alere ACS, Harris,
CareEvolution, Orion Health and Medicity enjoy a slight advantage over other vendors since they provide a
basic closed-loop solution. No vendor currently links its referrals application to a cross-enterprise care plan
in a meaningful way. Similarly, no vendor can link a referral to a scheduling application. As we mentioned in
Chapter 2, the advent of Direct protocols will mean that all vendors will have to build Direct-based solutions
that match the functionality of their existing, mostly proprietary referrals applications.
Care Plans
Cross-enterprise care plans to support care coordination by multiple HCOs are not widely available in the
market. Several vendors provide more advanced functionality than others in this area including Alere ACS,
GSI Health, Surescripts and Harris. These solutions are either under development or have limited deployment
in fairly narrow clinical settings. For instance, CareEvolution and GSI Health have high-quality solutions that
are deployed for small patient populations. Orion Health has significant care plan expertise outside the U.S.
and is only now formulating plans to roll it out in the U.S.
HIE vendors with payer owners (OptumInsight, Medicity and Certify) or with strong roots in the care
management business (Alere ACS) were thought to have a natural advantage in care plans. The thinking was
that the combination of HIE-sourced payer and provider data combined with care management services and
expertise would contribute to the development of high-quality care plan solutions for a variety of conditions
and patient populations.
2013 HIE MARKET REPORT
July2013
I 3-10
So far, this promise remains unfulfilled for a variety of reasons. Some HCOs are still skittish about working
with a vendor owned by a payer. Alere ACS has had success in the last 6-9 months with HCOs that are leery
of payers. On the other hand, Medicity continues to grow – so not all HCOs share this concern. OptumInsight
appears to be treating payers as just another data source or data consumer. The ongoing confusion
within OptumInsight seems to be preventing it from effectively harnessing Axolotl’s technology to meet
broader UnitedHealth goals. Medicity can, and sometimes does, combine its technology with Aetna’s care
management services but has not gained significant market traction. Medicity is leading Aetna’s efforts to
provide IT enablement for ACO providers and we expect to see a more refined set of care plan solutions in
the future. Alere can provide care management services to supplement its technology but has had results to
date that mirror Medicity’s. Humana has made strong assertions about how it will use Certify’s technology
internally but we can only wait to see how this acquisition unfolds. The record of payer acquisitions suggests
that these acquisitions rarely proceed as planned and certainly do not bear fruit as quickly as envisioned.
For now, no vendor in this report provides robust care plan applications or services. In our discussions,
this area is regarded as relatively new and is expected to grow as HCOs assume more reimbursement risk.
Accordingly, the requirements are still vague and will undergo change as the market matures.
Patient Engagement
In the last year, we saw a sharp decline in interest in supporting patient engagement efforts by HIE vendors.
Many vendors have been providing simple, static patient portals that allow patients to view their personal
health information (PHI). While many of the vendors in this report did enhance their solutions’ ability to
support Blue Button this year, fewer have deployed that capability in production. While Aetna, Harris and
RelayHealth support Blue Button today, the majority of vendors stated that they intend to provide Blue
Button support in 2013. This support will likely do double duty since it will also support the view/download/
transmit requirement for Stage 2 MU. Orion Health and Medicity provide the most comprehensive support
for patient engagement followed by CareEvolution, Harris, and RelayHealth. Most recently ICA partnered
with NoMoreClipboard, a leader in patient engagement, to provide HIE and other healthcare data to patients.
HCOs will need more engaged patients in order to deliver more coordinated care and we expect that this
issue will receive heighted industry interest in the next 1-2 years, which in turn, will cause most of these
vendors to revisit their product plans.
Clinical Quality Reporting
Reporting requirements from payers are proliferating as the industry moves to value-based care. HIE
vendors are increasingly interested in providing functionality for clinical quality reporting. In addition,
public health agencies around the U.S. have long lists of reportable conditions. The dominant method for
HCOs, paper-based reporting, is becoming increasingly untenable. Most vendors are approaching this
challenge by combining the aggregation capabilities of their HIE with analytics and messaging functionality.
Broadly, they will use the HIE to collect the data needed, analytics to organize and format the data, and
messaging to present it to the payer or agency that requires it.
Every vendor has experience with some form of clinical quality reporting and most have enhanced their
offerings compared to last year. Medicity, Orion Health, RelayHealth, and CareEvolution have the most
robust offerings followed closely by Covisint and MobileMD. Most of these solutions involve significant
customization based on customer needs, which makes head-to-head comparisons difficult. OptumInsight’s
product roadmap has an interesting take on quality reporting. The company plans to use its notification
services to automate as much of this reporting as possible. For example, it plans to allow an HCO to enroll a
public health agency to its HIE, which will automatically generate and transmit reports based on a reportable
lab event. Ultimately, OptumInsight plans to generalize this capability for an array of quality- and eventreporting requirements.
Analytics
This year, as was the case last year, the majority of HIE vendors are concentrating on the first step in delivering
analytics: aggregating, normalizing, and presenting clean data to the analytics or importing engine of the
client’s choice. We noted last year that a complicating factor for analytics capabilities is that it is still extremely
difficult to aggregate patient data in a computable format across a community of HCOs. Much of the data
flowing through HIEs today is a mish-mash of formats from simple flat files, to PDFs, to HL7 messages, to
CCD or CCR files. In addition, many EHRs do not support healthcare data formats in a truly standard way. The
consequence is that effort required to normalize and standardize clinical data across a community can range
from difficult to Herculean.
Virtually every vendor is able to provide data to enable some basic reporting on traffic and utilization within
3-11 I July2013
© 2013 CHILMARKRESEARCH
an HIE. As we have said repeatedly, the reporting applications available today will not suffice. Most vendors
are still mulling how best to support population health management (PHM) efforts. Every company recognizes
that HIE-sourced data will be important for PHM since multi-enterprise data will be needed to manage risk.
Most vendors are also looking at analytics as one way to support the range of quality reporting and public
health reporting requirements their clients and prospects face. Vendors are actively looking at using analytics
to better support care coordination and help drive clinician alignment with HCO care goals.
The stand-out vendor in this area is CareEvolution. This company has a fairly robust set of analytics tools
within its Galileo application that enables an HCO to access, analyze, and present HIE data for a variety of
purposes. An important caveat is that while it is probably the best solution, Galileo has been deployed in a
fairly small number of HIEs to date. CareEvolution is trailed by a large number of vendors that have decided
that providing clean data is the best way to support analytics. Of these, Cerner and Intersystems may have a
slight edge. Cerner has a comprehensive approach to healthcare analytics based on Healthe Intent. Cerner’s
offering may be less functional at this point but it provides a solid base for future development and broad
market appeal. InterSystems has also invested in its HealthShare Active Analytics solution in the last year and
is in the process of rolling out applications that will deliver more advanced analytics.
Caradigm
CareEvolution
Cerner
Certify Data Systems
Covisint
dbMotion
GSI Health
While each of the criteria shown in Table 3.10
are critical for a vendor’s overall success in
the market, the clearest barometer of market
success is market presence (number of clients
and markets served). As discussed in Chapter
2, we divide the market into public HIEs (states
or multi-stakeholder) and enterprise HIEs.
Public HIEs had been a major area of focus for
a significant number of HIE vendors because
of the funding made available to states under
SHIECAP. While essentially all of that funding
has been allocated, some states are still
implementing their statewide HIE with some
Harris
2013 HIE MARKET REPORT
HealthUnity
ICA
InterSystems
Medicity
MobileMD
OptumInsight
Orion Health
RelayHealth
Surescripts Kryptiq
Vision
Alere ACS
Services
4medica
Partner Strategy
While we have provided a rating on Vision, do
not equate this rating with that of the Overall
Vision in the letter rankings, which is more
comprehensive in scope. The criteria we used to
analyze each vendor’s marketing capabilities is
described in Table 3.4.
Company
Geographical Coverage
This report assesses the marketing capabilities
across five critical parameters: Brand Recognition,
Market Acceptance, Geographical Coverage, Partner
Strategy, Services, and Vision. (Table 3.10)
Market Coverage
MARKETING RANKINGS
Brand Recognition
Notification and Alert Services
We did not rate notification services because no vendors have formalized offerings in their HIE solutions.
However, notification services did figure in nearly every vendor conversation and most believe that clinically
relevant information needs to be presented at the right point in the workflow to be effective. Notification
and alerts will plainly need to cross HCO borders in order to support care coordination under value-based
care. Most existing notification services are built on the messaging infrastructure of the HIE or with letters
in the mail. While notification services are really not on the radar for many HIE vendors, we expect that to
change soon. The two exceptions to this rule are Cerner and OptumInsight. Both have a vision of integral and
pervasive notification services in any EHR-HIE application ecosystem. For now we believe that Cerner leads in
terms of deliverable functionality while OptumInsight leads in terms of product vision. But, this is a nascent set
of services without a clear set of requirements.
As healthcare communities increase the amount
and complexity of their shared patient-care
efforts, more HIE vendors will need to respond
with robust notification services.
2
4
2
2
!
4
4
3
1
2
2
3
4
!
!
4
!
!
3
2
4
2
2
4
4
2
4
2
2
2
2
3
4
4
3
4
!
3
4
4
4
3
4
3
3
!
2
4
3
4
!
4
4
4
!
!
!
1
2
3
2
3
3
3
4
3
4
3
4
4
3
3
3
3
3
4
4
4
!
3
4
4
4
3
3
4
2
4
4
4
!
4
!
4
4
3
4
2
!
4
4
2
2
4
3
2
3
3
4
3
2
4
3
2
Table 3.10: Marketing Ranking
July2013
I 3-12
go-lives in 2012 (e.g. Massachusetts). Most HIE vendors are now focused most intently on the still-growing
enterprise market. Table 3.11 provides the ranking criteria used to assess a vendor’s market presence.
All vendors have a presence in the
State
Multi-Stakeholder
Enterprise
enterprise market. (Table 3.12).
Rating Number
Rating Number of
Rating Number of
Medicity and Cerner lead but
of States
Clients
Clients
are followed closely by 4medica,
None
None
1
1
1 None
dbMotion, Certify Data Systems,
InterSystems, RelayHealth and
2 1
2 1-3
2 1-8
Surescripts. We continue to
believe that the enterprise market
3 2-4
3 4-8
3 9-24
represents the best prospects
4 5-7
4 9-13
4 25-99
for growth overall. While most
physician practices have adopted
4 8+
4 13+
4 100+
some level of EHR technology, far
fewer are connected to an HIE. Over
Table 3.11: Market Presence Ranking Criteria
time and particularly as we approach
the deadlines for Stage 2 MU, more
practices will connect to HIEs, driving the need for more hospitals and health systems to build and support
HIE infrastructures.
Alere ACS
Caradigm
CareEvolution
Cerner
Certify Data Systems
Covisint
dbMotion
GSI Health
Harris
HealthUnity
ICA
InterSystems
Medicity
MobileMD
OptumInsight
Orion Health
RelayHealth
Surescripts Kryptiq
Enterprise
4medica
Multi-Stakeholder
Company
State
Many vendors could not resist the lure of the public market and have made various attempts to pursue
such accounts — with some success and some failures. Medicity, OptumInsight and Orion Health maintain
their lead in the public markets. While vendor activity in public markets ground to a standstill in 2012, this
could change as clinical interoperability becomes more of a focus for HCOs. Moreover, many HCOs are
eyeing public HIEs as a way to identify patient leakage to competing HCOs. Of the vendors with a strong
presence in public markets, OptumInsight, MobileMD and ICA
will be challenged to hold on to existing accounts over the next
1-2 years.
1
1
1
3
1
1
2
1
1
3
1
3
3
4
1
4
4
1
1
1
2
3
4
3
1
3
1
4
2
2
3
4
!
1
4
3
3
2
4
3
3
3
!
4
3
4
2
3
2
2
4
!
4
2
3
4
4
CONCLUSION
None of the vendors in the following profiles is pursuing
the same strategy as the others but many pursue the same
opportunities. The enterprise market will continue to be the
dominant opportunity for all as the shift to value-based care
unfolds. We continue to believe that the HIE market is immature
and that there is significant room for growth and innovation.
New requirements for care coordination will ultimately
determine the strategic objectives of HCOs and how they
approach information exchange with other HCOs. The following
companies can help these HCOs, together with their connected
communities and patients, to move to the new FFV world of
healthcare. The constant change that has characterized the HIE
vendor landscape will continue unabated.
Table 3.12: Market Presence Ranking
3-13 I July2013
© 2013 CHILMARKRESEARCH
4medica
C
C
C-
Overall
Product
Marketing
Company Headquarters: Culver City, CA
Year Founded: 1998
Website: www.4medica.com Ownership: Private
2012 HIE Revenue: $4-5 million (est.)
Ideal
Community, small or rural hospital
Customer
Top Three Differentiators:
1. Deep laboratory expertise
2. Web-based access for clinicians
3. Support for broad range of clinical data types
Product
P
roduct Innovation
Product Execution
Product: 4medica iEHR
Latest Version & Release Date: 4medica iEHR
Dominant Deployed Architecture: Hybrid
Classification: Portal-centric
B
C+
Top Three Most Used Features:
Product
Criteria
Rankings
1. Laboratory Orders and results
2. E-Prescribing
3. Interface engine and integration capabilities
!
03
1
1
3
1
4
3
2
!
2
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
4medica stands out among HIE vendors for its technology prowess and commitment to open source. The
company’s original client-server application from 1998 provided an orders and results portal that connected referring physicians to hospital laboratories. Since then the company added support for reference laboratories and built interfaces for a large number of practice and hospital EHRs. It also expanded its offerings
to support the exchange of pathology data and, to a lesser extent, imaging and medications data. 4medica
capitalized on this customer base by providing a certified EHR which now supports e-prescribing via Surescripts and a general purpose note writer for physicians. It currently uses a multi-tenant SaaS on a hybrid
architecture to provide an HIE solution with its own MPI, RLS and directory services. In addition, its EHR
offering is certified under both the ambulatory and inpatient rules.
During 2012, 4medica devoted significant development resources to making its MPI more accurate and less
costly than other MPI solutions in the market. Now called the 4medica Big Data MPI, it employs big data
storage and an inverted index that purports to deliver higher performance elimination of duplicates than
traditional approaches based on relational technology. It also began piloting Direct secure messaging. Their
soon-to-be-released analytics solution will be geared toward clinician alerting centered around lab results.
Accordingly, the company is leveraging its deep laboratory expertise to harmonize the often inconsistent
vocabularies used across multiple organizations in laboratory tests and results.
As the industry moves to HIE 2.0 solutions, 4medica’s product story is incomplete. While it has a truly
substantial catalog of EHR interfaces (580 and counting) and supports many IHE profiles, the company is
2013 HIE MARKET REPORT
July2013
I 3-14
challenged to provide more than just data for advanced HIE 2.0 application functionality. Other than the
functionality provided by its iEHR, the company’s offerings in this area consist of providing immunization
registries in some geographies. The company’s product plans in the area of care transition support, cross-enterprise team-based care plans are undefined. It provides the ability to perform medications reconciliation
with its ordering solution. Referrals management, readmissions reduction and clinical quality reporting are
slated to be delivered when its Big Data Analytics and Decision Support suite becomes available. From an
HIE 2.0 standpoint, some of these gaps may be reflective of the lack of demand from its laboratory-focused
customer set.
Until its product plans and positioning are better crystallized, 4medica will remain an enigma in the HIE
market with a solid technology story, but a lab-centric vision. This year, we wonder how 4medica will bring
more of a laboratorians perspective to HIE 2.0.
C
C
Marketing Market Vision Market Execution Primary Market: Small, rural and community hospitals, IPAs
Secondary Market: PCMH, payers
Estimated Number of Users (Private/Public): 40,000
• Statewide HIEs: 0
• Multi-stakeholder HIEs: 0
• Enterprise HIEs: 50
Provider Pricing Model: Subscription and perpetual
Flagship Customers: Adventist, Duke, Intermountain Healthcare, Sentara, Stanford
Partner: Surescripts, CenturyLink (Savvis), Kodak
Market
Criteria
Rankings
2
2
4
Brand Recognition
Market Coverage
Geographical Coverage
1
4
3
Partner Strategy
Services
Vision
4medica positions itself as a provider of clinical interoperability solutions, including HIE solutions. The company’s early products provided hospital lab results to community physicians and led naturally to this current focus. Its subsequent efforts support pathology orders and results and to a limited extent imaging. It
reports solid growth in the number of provider-users of its solution during 2012. Today, the company counts
some 100 organization as its customers, mostly laboratories who together support over 40,000 physicians
with 4medica solutions. 4medica provides their customers with connectivity to public HIEs including major
RHIOs and large public HIEs in the south and southwest. Despite this progress, the company is not visible in
the larger market as an HIE provider.
4medica often becomes involved in HIE engagements when a customer wants to connect to an immunization registry. As something of a hybrid HIE-EHR vendor, 4medica finds hospitals to be a slowly evolving
market. Its hospital engagements typically begin in a single department with either a need for clinical interoperability or to qualify for meaningful use incentives. 4medica can overlay iEHR on top of a legacy EHR.
This provides a single, cloud-based application and GUI to physicians for inpatient and ambulatory patient
lists as well as orders and results. The company claims to have found success at the lower end of the market
where resources are constrained.
Last year, we wondered whether 4medica was positioning itself to better enable accountable care with advanced analytics. We based this on its stated plans for 2012. To date, there is limited evidence that this is
happening. It appears that 4medica devoted most of its development resources in the last year to its Big
Data MPI offering and secondarily to its Big Data Analytics and Decision Support offering. This makes sense
for customers who need to sift through millions of laboratory records and match them to individual patients.
It is less clear how it will help the company become better known as an HIE vendor. Like last year, the company claims to be on the brink of delivering new analytics capabilities, mostly focused on lab results. 4medica
is trying to position itself as clinical interoperability vendor, but must be considered a provider of lab results
until it makes more progress toward providing a greater diversity of clinical data and stronger support for
HIE 2.0 workflows. We think it is unlikely that a technology story alone will accomplish this and the company
will need to make more concerted effort to find and develop partnerships with organizations that can bring
3-15 I July2013
© 2013 CHILMARKRESEARCH
Alere Accountable Care Solutions
BBB-
Overall
Product
Marketing
Company Headquarters: Waltham, MA
Year Founded: 1993
Website: www.alere.com Ownership: NYSE Listed
2012 HIE Revenue: $4-5 million (est.)
Ideal
Hospitals, large practices and PCMHs
Customer
Top Three Differentiators:
1. Semantic interoperability
2. Client options for clinician-users
3. Support for broad range of clinical data types
Product
B
C+
P
roduct Innovation
Product Execution
Product: Wellogic HIE
Latest Version & Release Date: Version 4.4, September 2012
Dominant Deployed Architecture: Hybrid
Classification: Foundational HIE
Top Three Most Used Features:
Product
Criteria
Rankings
1. Portal
2. Orders and results
3. View discharge summary
3
0!
3
2
2
3
Data Access & Presentation
3
External Integration
Standards & Terminology
4
4
Clinical Coordination Support
3
2
2
Platform Support
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
Referrals Management
Clinical Quality Reporting
Analytics for Population Health Management
The Alere Accountable Care Solutions’ (formerly Wellogic) HIE product provides a longitudinal patient
record that benefits from the company’s expertise with clinical vocabularies. It provides semantic interoperability in communities with any of the 23 EHRs it supports, as well as other clinical or administrative applications. Its customers use its HIE for access to a complete set of clinical data types. Much of Alere ACS’s HIE
application functionality is delivered to clinicians via its portal, although it can also be delivered to an EHR.
This functionality includes PCP notifications of hospital or ED admits and discharges, including a discharge
summary, care plan or patient-specific care gap identification, via secure messages delivered in the portal. It
also offers support for Direct and NwHIN services.
As a provider of HIE 2.0 solutions, Alere ACS presents a mixed picture. Its approach to medications reconciliation relies on Surescripts, claims data, and connected medications management applications. It collects
this data and reduces it to the list of active and dispensed medications for the clinician-user. The company believes that EHRs are the best place for the actual reconciliation of the lists. It also can include a fully
parsed list of discharge medications as part of a discharge summary.
Alere ACS will use CDS technology acquired as part of DiagnosisOne to better support value-based care for
HIE 2.0 providers. Now called Alere Analytics, this CDS implementation will be used to generate clinician
alerts at a patient and population level using data from HIE and non-HIE data sources. These alerts could be
related to readmissions risk management, care gap notification, simple physician notification, care recommendations, or treatment protocol monitoring. At this point, the integration between Alere Analytics and
the HIE is being piloted at Virtua Health System and scheduled for general release in July 2013.
2013 HIE MARKET REPORT
July2013
I 3-16
Alere’s disease management programs for customers implementing a readmission reduction program or
other collaboration-intensive, managed care programs is also part of the complete solution suite. This offering is traditional in the sense that it relies primarily on case managers in call centers working directly with
patients and their families. Wellogic also supports a messaging-based closed-loop referrals capability in the
HIE for connected clinicians. It can provide substantially the same functionality using Direct secure messaging for providers not connected to its HIE. Alere’s HIE has implemented a large number of disease registries
for its customers, including all of the major chronic diseases. It provides data for underlying cubes that can
support clinical quality reporting, disease registries and for population health management efforts.
The Alere ACS solution suite has many of the elements of an attractive product value proposition and the
vision to go with it, but few of these elements are live and in production today. While Alere ACS’ HIE can
certainly provide the data to support a collaborative, cross-enterprise care plan, the application functionality to enable it is not present. However, the combination of Alere’s disease management programs with the
HIE solution to build and use cross-enterprise, collaborative care plans could someday be a potent offering.
In addition, there are a host of other potential product synergies with Alere’s device-related businesses that
could improve the company’s position in telemedicine and remote monitoring. To be fair, Alere ACS’ work
with its customer Virtua includes the use of the HIE to ingest home-based biometric device data for patients
with chronic conditions and the development of a tool to support cross-enterprise care plans.
Certainly Alere has a vision aligned with market needs for a more complete and robust solution suite to
enable HIE 2.0 – and they have begun demonstrating it at lighthouse customer Virtua. But it remains to be
seen how this vision scales beyond this initial customer. We are cautiously optimistic that with the strong
financial support of Alere and the capabilities this company brings to the table that the former Wellogic will
turn the corner and begin to deliver .
B
C
Marketing Market Vision Market Execution Primary Market: Health systems, hospitals
Secondary Market: Medical homes, practices
Estimated Number of U.S.-based Users (Private/Public): 8,000
• Statewide HIEs : 0
• Multi-stakeholder HIEs: 2
• Enterprise HIEs: 12
Provider Pricing Model: License
Flagship Customers: Multi-Stakeholder: Northern Hawaii HIE, MedVirginia; Enterprise: Virtua
Health System, Atlanticare, Sparrow Health System, Triad Health Network, Children’s Care Alliance, Atlantic Medical Imaging
Partners: Oracle, Amazon, Surescripts
Market
Criteria
Rankings
4
4
4
Brand Recognition
Market Coverage
Geographical Coverage
2
4
4
Partner Strategy
Services
Vision
Alere ACS positions itself as a utility for healthcare data liquidity. Very modest growth in the number clinician-users in 2012 belies its claim that Alere’s deeper pockets have helped expand its product portfolio and
ability to support customers. Fast forward to the first half of 2013 and we are starting to see some glimmer
of hope for Alere ACS as they have racked up several large multi-stakeholder and enterprise wins that suggest the company has turned a corner.
During 2012, Alere took some steps to become more attractive in the market: it added support for Direct
secure messaging, became a certified HISP in several states and launched its certified ambulatory EHR offering. In addition, it added support for iOS and Windows Surface devices. Alere also acquired DiagnosisOne, a
vendor of order sets, clinical decision support, analytics and syndromic surveillance as well as MedApps to
provide a connectivity platform for biometric devices in support of remote patient monitoring. Combined
with existing Alere assets and Wellogic, the company has the potential to offer the market fairly comprehensive accountable care solutions portfolio.
3-17 I July2013
© 2013 CHILMARKRESEARCH
Alere ACS compares itself to HIE vendors with a payer parent because it offers Alere’s disease management
programs. But unlike payer-owned HIEs, Alere offer the advantage of payer-independence. This may make
it particularly attractive to multi-stakeholder HIEs that have payers as participants. While this claim makes
sense on its face, the advantage is so far theoretical since there have been no known deployments of the
complete suite, with the exception of the pilot at Virtua.
Acquisitions in healthcare IT generally deliver mixed results and in the case of Alere and Wellogic, the outcome remains unclear. Alere’s global focus and footprint has yet to deliver more opportunity for the former Wellogic HIE in the international market, though rumor has it that this will change in 2013. Although
Wellogic’s pre-existing customers have likely benefited from the more abundant resources of Alere, (and
long-term viability for their investment in Wellogic) the product actions taken to date are still very much at
the gestation stage. We hope that in 2013, Wellogic can turn this around and build on its work at Virtua to
deliver more care coordination functionality that could give Alere a disease and care management capability that distinguishes it in the market. Alere’s commanding presence in the device market and ability to offer
a full suite of services for remote care is something that sets this company apart from others.
At this point, we are cautiously optimistic for Alere ACS. It appears that the company has finally pulled a
number of key pieces together to support its vision of bringing to market a comprehensive solution suite.
However, Alere ACS is still very much in a visionary stage of development but it is a vision that is capturing
the imagination of some in the market leading to several large recent wins. Last year we expressed cautious
optimism that under new ownership Wellogic would finally be able to deliver on the promise of its impressive underlying technology. Early signs are pointing to this finally occurring and Alere ACS may become an
attractive alternative as one of the few unaffiliated solutions remaining in the market.
2013 HIE MARKET REPORT
July2013
I 3-18
Caradigm
CCC-
Overall
Product
Marketing
Company Headquarters: Bellevue, WA
Year Founded: 2011
Website: www.caradigm.com Ownership: Private
2012 HIE Revenue: $5 million (est.)
Ideal
Integrated delivery networks and hospitals
Customer
Top Three Differentiators:
1. HIE with strong support for content, transport and access standards
2. Standards-based analytics for cross-enterprise applications
3. Partner ecosystem
Product
C
P
roduct Innovation
D
Product Execution
Products and Version: Health Information Exchange 2.2, November 2012; Caradigm
Intelligence Platform (formerly marketed as Amalga) 3.0, March 2013
Dominant Deployed Architecture: Centralized
Classification: Portal-centric
Top Three Most Used Features:
1. Discharge summary
2. Labratory results
3. Medication lists
Product
Criteria
Rankings
4
04
2
3
3
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
2
2
2
2
2
3
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
NOTE: Shortly after this profile was prepared, Caradigm announced its intention to discontinue selling its own HIE
solution, eHealth, originally developed by GE. Customers will be put on maintenance with no future development
of the solution. Caradigm will become a distribution partner of Orion Health’s HIE solution. Since Caradigm will no
longer develop an HIE solution, this will be the last time that Chilmark covers Caradigm as an HIE vendor..
One year into this GE-Microsoft joint venture, the substance of Caradigm’s product lineup remains mostly
unchanged. However at HIMSS 2013, it announced some rebranding, additional partners and major changes to Amalga. Caradigm Health Information Exchange was the new brand for its eHealth offering and, as it
subsequently developed, is no longer being sold in the market. It integrates with the same EHRs it did this
time last year. It also relies on partner solutions for an MPI, messaging and directory services. Amalga is now
called the Caradigm Intelligence Platform. It now can aggregate and normalize data from EHRs, HIEs and
other sources of clinical and administrative data for a variety of purposes. Caradigm improved the odds of
market success for the Caradigm Intelligence Platform by offering it on its cloud infrastructure. This new
version provides better integration with Microsoft client software for visualization and presentation as well
as server-side enhancements for data staging and access. Its identity and access management solutions,
(the former Sentillion product suite) renamed Caradigm Single Sign-on, Caradigm Context Management
and Caradigm Provisioning, still provide a solid way to provision users and access rights as well as manage
patient context for all kinds of healthcare applications. This past fall, the company rolled out an update to its
readmissions management solution that relies primarily on ADT feeds. Customers can augment the readmissions prediction algorithm with medications, lab data and other clinical data.
3-19 I July2013
© 2013 CHILMARKRESEARCH
All of the partner applications announced at HIMSS 2013 use data from the Caradigm Health Information
Exchange, as well as EHR data, via its Caradigm Intelligence Platform offering. The Intelligence Platform
will be Caradigm’s flagship offering for supporting the advanced application functionality associated with
the delivery of accountable care.
A significant feature of the Caradigm Intelligence Platform is the recently announced Cohort Management
Designer. As the name implies, it allows essentially non-technical clinical users to configure subsets of patients based on clinical criteria. These subsets can then become the base for a handful of newly announced
applications from partners, including meaningful use clinical quality reporting, population health management and utilization management. Caradigm also intends to develop applications that rely on the Cohort
Management Designer.
For now, these applications are not all-encompassing. They leave a variety of unmet needs for cross-enterprise clinical information focused on population health, including care transition workflow tools, medications reconciliation tools, closed-loop referrals management, disease registries, multi-enterprise care team
planning support and a more information-based readmission avoidance capability. Some of these holes
could be plugged with Caradigm Care Management, a tool in development with partners Geisinger Health
Plan and Continuum Health Partners, for care managers slated for late 2013 release. Caradigm claims that
this offering will use the HIE to derive data from across the community to support a dynamic care plan con-
CC-
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, hospitals
Secondary Market: Independent practice associations, physician practices, payers
Estimated Number of U.S.-based Users (Private/Public): 2,500
• Statewide HIEs : 0
• Multi-stakeholder HIEs: 5
• Enterprise HIEs: 16
Provider Pricing Model: License
Flagship Customers: Keystone HIE, Central Florida RHIO, Metro Chicago Healthcare Council,
Boston Medical Center, Continuum Health Partners, St. Luke’s Health
System, Sturdy Hospital
Partners: InterComponentWare, NextGate, Kryptiq, Cognizant, Accenture
Market
Criteria
Rankings
2
2
4
Brand Recognition
3
Partner Strategy
Market Coverage
!
Services
Geographical Coverage
3
Vision
Given Caradigm’s size (some 600 employees) compared to nearly all of its competitors, together with the
extravagantly high profiles of its owners, it is mystifying that its HIE market footprint remains little changed
in one year. The announced partner applications for CIP coupled to its new relationship with Orion Health
are positive steps for a company that has struggled getting out of the starting block as an independent HIE
vendor. Caradigm, almost alone among HIE vendors, is aggressively pursuing a product partner strategy for
building the applications that will augment and complete its data delivery assets.
Caradigm’s patient engagement strategy includes partner applications such as Get Real Health’s Instant
PHR application. This application works natively on the Caradigm Intelligence Platform and provides an optional connection to Microsoft HealthVault. Caradigm will leverage the consent model of its Health Information Exchange and allow patients to manage their conditions and care. Few HIE vendors talk much about
patients portals and patient engagement is a problem that is not going away. This part of Caradigm’s strategy
is at least partially defined and could provide it with a market differentiator.
Caradigm has a highly professional and well-crafted story for HCOs seeking to transition into the fee-forvalue future but its days as an independent developer of HIE solutions have concluded. Instead, it will be
adding value to HIEs and HCOs in general with CIP. Soon and aggressively, the company will have to invest
in sales while at the same time adding functionality attractive to public and enterprise HIEs. Like last year in
this report, and given its most recent changes, its growth prospects remain a question mark.
2013 HIE MARKET REPORT
July2013
I 3-20
As we noted in the preamble of this profile, Caradigm’s participation in the HIE business will be derived from
Orion Health’s HIE. As for existing eHealth customers, Orion Health will begin the process of competing to
migrate its customers to Orion’s HIE.
3-21 I July2013
© 2013 CHILMARKRESEARCH
CareEvolution
B
B+
B-
Overall
Product
Marketing
Company Headquarters: Ann Arbor, MI
Year Founded: 2003
Website: www.careevolution.com Ownership: Private
2012 HIE Revenue: $7-10 million (est.)
Private: I ntegrated delivery network with hospitals, physician practices, and variety of post- Ideal
acute care providers and facilities
Customer
Public: States and statewide HIEs
Top Three Differentiators:
1. Integrated platform for care coordination
2. Continuity of care perspective
3. Increasingly competent analytics solution
Product
AB
P
roduct Innovation
Product Execution
Product: HIEBus
Latest Version & Release Date: 4.12 in fourth quarter 2012
Dominant Deployed Architecture: Hybrid
Classification: Foundational HIE
Top Three Most Used Features:
Product
Criteria
Rankings
1. Advanced visualization tools
2. Last mile drivers to legacy EHRs
3. Robust MPI
4
04
3
3
4
3
4
4
4
4
3
3
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
CareEvolution’s founders had significant experience implementing EHRs and noted that clinically important
patient data was not moving as fast as patients through the healthcare system. The company approaches
the HIE market with the goal of controlling its destiny and relies on internally-developed products. CareEvolution’s solution set consists of HIEBus, a foundational HIE with an MPI, RLS, an integration engine, an analytics engine, provider directory, security and consent, and portal infrastructure. It is built on a federated
SOAP-based model that can be hosted or self-hosted. While it can be implemented as either centralized,
federated or hybrid architectural models, the dominant architecture deployed today is hybrid.
HIEBus delivers the longitudinal patient record with most of CareEvolution’s public clients interested primarily in this part of its solution set. These public customers also tend to exchange a more limited range of
data types than its private clients. CareEvolution’s complete product set supports most of the advanced
HIE 2.0 applications needed by providers transitioning to value-based care delivery and payment models.
They implement custom-built applications that use cross-enterprise data provided by HIEBus, including an
MU-compliant patient portal, an EHR-integrated physician portal, medications reconciliation, ACO cost
monitoring, disease registries, care coordination or population health management. CareEvolution leverages HIEBus with three additional analytics products: Beacon Surveillance — a prospective clinical analytics
and alerting tool, Galileo — a retrospective analytics tool, and ThinEMR — a care coordination tool. These
work together to deliver clinical and financial value from cross-enterprise data.
2013 HIE MARKET REPORT
July2013
I 3-22
Beacon Surveillance is a rule-based clinical analytics and alerting engine used for individual or population
health management. It defines a patient subset based on complex demographic and clinical criteria. It then
generates alerts to clinicians or administrators monitoring that population based on data flowing through
HIEBus. It can also provide aggregated data from the longitudinal view for multiple potential uses. Alerts
can be presented as items in a work queue on the provider’s portal. The alerts can also be pushed to providers, care managers or administrators as an email — including Direct messages for those customers for whom
CareEvolution has built a HISP — or as real-time notification via text messaging.
A simple use case of Beacon Surveillance is to identify each patient in a primary care practice that has turned
50 and has had no colonoscopy. Its alerting function could make an entry on the work queue for the patient
so the physician could raise the issue during the next office visit. A slightly more complex use case is disease
registries. CareEvolution believes that a diabetes registry should not be different from a congestive heart
failure registry or a cancer registry. The different conditions are simply attributes of a patient, readily derived using the patient data aggregation capabilities of HIEBus. Using Beacon Surveillance, the organization
could define the disease condition using the appropriate criteria and populate the registry with the requisite
data from HIEBus.
Galileo, on the other hand, is retrospective and uses data supplied by HIEBus to support modeling and analytics. It provides a dashboard into historic clinical, financial or operational performance. Galileo also lets a
provider organization backtest a model it wants to implement in Beacon Surveillance. For example, using
historical data derived from HIEBus and Galileo analytics, a hospital could build a LACE-based scoring model of its discharges to see how accurately LACE would have predicted the readmissions risk of its patients.
By comparing the predicted risk to actual readmissions, it can refine the Galileo-based model to produce a
more accurate model of readmission risk scoring that can then be used in Beacon Surveillance. CareEvolution implemented this example with one if its clients by adding laboratory results to the traditional LACE
factors to generate the refined prediction. The resultant model is now implemented as an alert in Beacon
Surveillance to give a more accurate patient-level readmissions risk for use by discharge planners and care
managers.
B+
C
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, Medicaid managed care plans
Secondary Market: Public exchanges
Estimated Number of U.S.-based Users (Private/Public): 72,000
• Statewide HIEs : 4
• Multi-stakeholder HIEs: 12
• Enterprise HIEs: 13
Provider Pricing Model: License and/or Subscription
Flagship Customers: Public: State HIEs (SC, AL, WV, PA), Regional HIEs (East Alabama HIE,
Camden HIE); Enterprise: Providers (Catholic Health East, Parkview
Health, WVU Healthcare); Health Plans (Molina Healthcare, Amerigroup/
Wellpoint); ACO (QIP, Sisters of Providence, PPG)
Partners: Truven Health Analytics, Molina Healthcare
Market
Criteria
Rankings
2
2
3
Partner Strategy
Market Coverage
2
3
Geographical Coverage
!
Vision
Brand Recognition
Services
CareEvolution is an independent, technology-centric organization with an unusually clear understanding of
market needs as evidenced by its significant progress toward providing HIE 2.0 solutions and its slow and
steady addition of customers. Its approach to sales, marketing and partnerships is unconventional. It has no
direct sales force and most of its revenue and growth come from existing customers. This focus on keeping
its customers happy supports sustainability but makes the prospects for acquiring numbers of new customers murky. CareEvolution grew its install base of private HIT clients in 2012, including at least nine ACOs.
CareEvolution’s essentially exclusive (though in reality nonexclusive) external sales channel is Truven
Health Analytics (formerly the Healthcare Business of Thomson Reuters) which focuses exclusively on
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© 2013 CHILMARKRESEARCH
the public HIE market. To supplement this, it partners with its somewhat recently acquired customer, the
managed care payer Molina Healthcare, to seek more opportunities among Medicaid agencies in the state
government market. Whether the additional 30 million Medicaid enrollees expected as a result of PPACA
translates into additional opportunity for CareEvolution is an open question. The real opportunity and challenge for CareEvolution will be to acquire more enterprise customers more rapidly than it has in the past
few years. We think it is unlikely that the company can do this without finding a larger partner with sales
resources, organizational scale and a national reputation among healthcare providers.
CareEvolution invests in marketing strategically. Most HIT vendors stick closely to HIMSS and its regional
events. CareEvolution looks farther afield and seeks speaking opportunities for its clients at what it considers high visibility events frequented by thought leaders. For example, it participates in events sponsored
by the American Medical Informatics Association (AMIA) where it has exposure to CMIOs and a variety of
informaticists. CareEvolution characterizes its approach to sales and marketing as “being selective” and is
satisfied that it is getting a high yield from its sales and marketing efforts. While that may be true, we believe
that CareEvolution’s approach and organizational scale is limiting its growth.
CareEvolution is unconventional and under the leadership of its founder is likely to remain so. The company
is growing at a rate that is completely in alignment with the founder’s objective to emulate the success of
Epic. While other HIE vendors who remain independent may be beholden to VC firms and their goals, CareEvolution is self-funded and has no such pressures. This independence is refreshing in a market that has
seen significant consolidation.
2013 HIE MARKET REPORT
July2013
I 3-24
Cerner
B
C+
B
Overall
Product
Marketing
Company Headquarters: North Kansas City, MO
Year Founded: 1979
Website: www.cerner.com Ownership: NASDAQ Listed
2012 HIE Revenue: $18-21 million
Ideal
Integrated delivery networks, hospitals, large practices with installed Cerner clinical
Customer applications
Top Three Differentiators:
1. Multi-state consent management
2. Scale from small ambulatory setting to large delivery network
3. Ability to convert data streams from non-standard to standard-compliants
Product
P
roduct Innovation
Product Execution
Product: Cerner Network: HIE Service, Cerner Hub, Cerner HealthDock
Version: HIE Service 9.5 in November 2012; Cerner Hub 3.6.7.0 in November 2012
Dominant Deployed Architecture: Centralized
Classification: Portal-centric
BC+
Top Three Most Used Features:
Product
Criteria
Rankings
1. Results delivery
2. CCD exchange
3. Orders
!
04
2
2
3
3
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
!
2
2
4
2
2
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Cerner is the only major EHR vendor fully committed to supporting heterogeneous community EHRs with
HIE solutions. Its HIE solution – Cerner Network – consists of the Clinical Exchange Platform, Cerner Hub
and HealthDock, and Cerner Resonance. Cerner’s HIE solutions provides a foundational HIE built from a
combination of Cerner-developed, partner-developed and open source products. Much of the underlying software (e.g., MPI, RLS, IHE protocols, etc.) was built by Cerner’s close partner, Browsersoft. HealthDock, provided via a non-exclusive partnership with Certify Data Systems, delivers last-mile connectivity
for roughly 100 ambulatory EHRs. Taken together, Cerner provides an HIE solution that support clinicians
across enterprises for directed or query-based exchange and collaboration.
Cerner Hub, a general-purpose transaction routing service for providers and payers, provides HL7-based
connectivity between HIEs and clinical applications. HealthDock allows Cerner to provide HIE-derived
clinical data embedded into physician workflows for targeted EHRs. Cerner Resonance enables realtime, secure discovery and exchange of clinical information between health care providers using XCA
standards. It connects Cerner Millennium or non-Cerner EHRs to an HIE for query-based exchange. Cerner
often supplements its HIE offerings with products such as Cerner Direct, Cerner ePrescribe and Cerner
Patient Portal.
Broadly, Cerner provides services like results delivery for laboratory and radiology, and discharge summaries to practice-based EHRs. These transactions can also include connectivity to Surescripts for medications lists, bio surveillance, and state immunization registries. Cerner processes approximately 60 million
3-25 I July2013
© 2013 CHILMARKRESEARCH
directed exchange transactions per month. Cerner also provides the ability to query for data from within an
EHR. The queries return a summary of the data found in connected care venues from which the provider can
select for download. It processes roughly 1.5 million query-based transactions per month. All directed and
query transactions are based on XDS and relevant IHE profiles.
Cerner’s online referral management system will be released during the summer of 2013. This solution will
employ Direct secure messaging for care transitions and will also include various kinds of PCP notifications.
While Cerner will persist certain kinds of status information and provide notification to the referring provider when the referral is complete, this solution requires care teams to collaborate and share information
through messages rather than with a single tool. In this area, Cerner is more forward-thinking that most of
its EHR competitors but probably a little less nimble than some its HIE competitors.
In general, Cerner’s EHR-centricity causes it to develop advanced functionality in the EHR rather than in
the HIE. This translates into an abbreviated list of advanced HIE 2.0 solutions. Cerner believes that if functionality is not in the clinician’s workflow, then the clinician will not use it. Accordingly, Cerner believes that
functionality should be delivered within the EHR whenever possible, but it recognizes that there will always
be a need for a browser-based clinician portal. In either case, clinicians can see the full range of clinical data
available through Cerner HIE solutions and then perform a reconciliation process for any of the different
clinical data types. This approach necessarily implies that much of the advanced functionality for HIE 2.0
will be delivered in the clinicians’ EHR.
As we look ahead for some of the other applications that will support value-based care delivery and better
care coordination, Cerner’s HIE will be providing data, but not functionality. For example, it believes that
medications reconciliation is best performed within the EHR. Its HIE will present medications data to the
EHR but it is up to the EHR to normalize and standardize the data in the medications record. Cerner is now
doing a readmissions management proof-of-concept using algorithms jointly developed with Advocate to
identify patients at risk of readmission. So far, it has performed better than many current protocols.
Cerner’s laser-like focus on providing functionality in the EHRs in its own customer base is understandable
but different from other HIE vendors. Few vendors, EHR or HIE, understand clinician workflow as well as
Cerner. It is hard to square Cerner’s approach with the reality that in heterogeneous EHR environments,
HIEs can be a functional gap-filler.
B+
B
Marketing Market Vision Market Execution Primary Market: Cerner HCOs
Secondary Market: Public agencies, practice associations
Estimated Number of U.S.-based Users (Private/Public): 45,000
• Statewide HIEs : 0
• Multi-stakeholder HIEs: 6
• Enterprise HIEs: 193
Provider Pricing Model: License
Flagship Customers: Public: SMRTNet, LACIE, Tiger Institute Health Alliance; Enterprise:
Memorial Hermann, Adventist Health System, Emory Healthcare, UHS,
St. Barnabas, Albert Einstein
Partners: Certify Data Systems, Browsersoft
Market
Criteria
Rankings
!
Brand Recognition
4
4
Market Coverage
3
4
4
Geographical Coverage
Partner Strategy
Services
Vision
As we said at the outset, Cerner’s HIE efforts are unique in the EHR business. For its EHR customers who
want to connect to an HIE, it provides a significantly more “open” application environment than virtually all
other EHR vendors. Cerner was also a significant contributor to the development of the Direct protocols
and its eventual adoption by the ONC. It supports community EHRs via its Certify partnership and delivers
solutions that are based on standards it perceives to be widely adopted. Cerner is also a charter member of
the Commonwell Health Alliance.
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Cerner’s HIE efforts are part of its overarching Healthe Intent initiative to deliver comprehensive and coordinated functionality across the care continuum and become the population health OS (operating system)
for the industry. It is the cornerstone of its effort to move beyond the EHR vendor label to become what it
refers to as “A Health Company”. Cerner currently has nearly 193 live customers on its HIE solution, compared to 107 last year. The vast majority of these clients are enterprise clients but the company also has a
couple of public multi-stakeholder clients, including the Secure Medical Transfer Network in Oklahoma and
the Michiana Health Information Network. It reports that it has doubled the number of HIE-based transactions it processes over the last year. While the raw growth in the number of clients can be misleading given
size disparities between different kinds of providers, the transaction growth is impressive.
Cerner’s partner, Certify Data Systems, was acquired by Humana in 2012. Cerner believes it is protected
by the long-term nature of the original contract with Certify. Humana is bound by this contract and will
use Certify almost exclusively for internal purposes. Cerner sees this relationship as a good opportunity to
work closely with a big payer. For the foreseeable future, Certify will be the last mile solution for community
EHRs. Longer term, we see the Certify partnership as a significant potential risk for Cerner customers. If Humana changes its strategy – common for large payers – it could orphan or divest itself of what was formerly
Certify, leaving Cerner customers with more questions than interfaces.
Cerner has some tricky HIE marketing challenges in the coming years. It has positioned Healthe Intent as its
way to reach the entire care continuum to do population health management under fee-for-value care delivery. Cerner’s HIE solutions will play an indispensable role in providing the cross-enterprise data needed
to make Healthe Intent relevant and productive for customers. The good news is that Cerner’s HIE solutions
are well positioned to deliver on the promise of Healthe Intent. The bad news is that it is well positioned to
do so mostly for Cerner health systems and hospital customers.
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© 2013 CHILMARKRESEARCH
Certify Data Systems
BBB
Overall
Product
Marketing
Company Headquarters: San Jose, CA
Year Founded: 2004
Website: www.certifydatasystems.com Ownership: NYSE Listed
2012 HIE Revenue: $12-14 million (est.)
Integrated delivery networks and hospitals, medical homes
Ideal
Customer
Top Three Differentiators:
1. Hardware-based solution for turnkey installation
2. Distributed, configurable MPI
3. Full-feature system view of HIE
Product
C+
B-
P
roduct Innovation
Product Execution
Products and Version: HealthLogix HIE Platform 4.2, December 2012
Dominant Deployed Architecture: Federated with a hybrid query model
Classification: Messaging-centric
Top Three Most Used Features:
Product
Criteria
Rankings
1. Results distribution
2. Real-time CCD exchange
3. Orders workflow tools
3
04
2
1
2
2
!
2
3
3
2
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Certify Data Systems is the only successful HIE vendor with a hardware and cloud-based solution that
installs in ambulatory practices to provide “last mile” connectivity to EMRs. This has translated into comparatively rapid go-lives for connected practices. The company has also traditionally stood out among HIE
vendors for its consent management capabilities, network approach and its configurable MPI, the company
rebranded its product set in 2012. The HealthLogix HIE Platform now consists of the former Certify HealthDock, an edge server with an XDS registry and repository, and Certify Gateway, a server-side registry of
HealthDock nodes that constitute the connected community. It also launched real-time HIE query functionality this past year.
Certify believes Direct secure messaging is a viable solution for certain segments of the marketplace, but
is focusing its development efforts on more feature-rich capabilities that go beyond basic document exchange. While it acknowledges that the market in general is looking for this support, it claims that its customers are not. Certify echoes many in the HIE vendor community in its belief that Direct secure messaging
can provide a good way to perform referrals but is not a good way to support care coordination workflows
and information collection.
Looking ahead to the requirements embodied in HIE 2.0, Certify has a number of relevant plans but few
existing product capabilities. Certify’s HealthLogix value is the ability to query data from every node in a
community and present all CCDs or an aggregated CDA to an application, usually an EMR. HealthLogix also
gives healthcare providers without an EMR the ability to review CCDs or CDAs in real-time through the
Certify provider viewer. Certify suggests that these abilities will support a range of HIE 2.0 and population
2013 HIE MARKET REPORT
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health management applications like point of care CDS-based alerting or as input to care plans that operate
for an individual or a patient panel. HealthLogix can also provide the data needed for CMS clinical quality
reporting programs. Certify can use HealthLogix to deliver deduplicated, aggregated information based on
a unified clinical vocabulary. Certify has partnered with Anvita Health, a Humana subsidiary, and other clinical analytics companies, to provide healthcare analytics capabilities in the HealthLogix platform.
For referrals, Certify can push a message with an ADT-derived payload to a specialist. The specialist then
has the authority to query the network and receive the clinical information relevant to the referral. Certify
acknowledges that providers in general, and customers who need Direct secure messaging in particular, are
asking for a more definitive push of clinical data relevant to the referral at the outset. We have to note that
this is only the first step in delivering a more robust close-loop referrals management capability.
As part of Humana, Certify is better positioned to provide HIE 2.0 capabilities. Humana’s focus on medical homes could prod Certify to deliver more care coordination functionality at the practice level. Medical
homes will be full participants in cross-enterprise care coordination activities and will need workflow support. Certify has expanded its product capabilities to help identify gaps in care plans and could use Humana
to source this kind of data for propagation to workflows across the continuum. It also anticipates that Humana will be looking to Certify to better support condition-focused care planning activities that involve
clinicians from diverse organizations. Over the next year, we expect Certify to round out more HIE 2.0 capabilities as Humana increases its interactions with risk-based provider HCOs.
B
B
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, hospitals
Secondary Market: Independent practice associations, physician practices, payers
Estimated Number of U.S.-based Users (Private/Public): 10,000
• Statewide HIEs : 0
• Multi-stakeholder HIEs: 0
• Enterprise HIEs: 97
Provider Pricing Model: License or Subscription
Flagship Customers: Enterprise: Advocate Health Care, Adventist Health System, Baystate
Health Systems, Inc., Baptist Health, Emory, Legacy Health, MultiCare
Health System, Memorial Hermann Healthcare System, Sharp Healthcare,
UMass Memorial Health Care, Universal Health Services
Partners: Apelon, Oracle, Cerner
Market
Criteria
Rankings
4
4
3
Brand Recognition
3
Partner Strategy
Market Coverage
4
Services
Geographical Coverage
4
Vision
The most significant event in 2012 for Certify was its acquisition by Humana, a payer that operates in all 50
states. Humana’s strategy is to become the preferred provider to Medicare Advantage members and “dual
eligibles”. It has focused on acquiring primary care practices in an effort to build patient-centered medical
homes (PCMH). Humana will support this provider network with Certify and other IT acquisitions to ensure coordinated and informed care delivery. Certify anticipates that HealthLogix will be heavily deployed
around Humana for a variety of integration purposes in the coming years. At the same time, Certify must
reassure its existing HIE customers that it will continue to support them. We believe that Certify will meet
the needs of its existing customers but will devote development resources to Humana’s interoperability
solution as it rolls out its strategy for building medical homes. Humana reportedly intends to invest heavily
in Certify products which may result in better population health management applications that risk-based
providers will need. For that reason, Certify’s pre-existing HIE customers could benefit from this acquisition.
Certify has also provided “last mile” connectivity to EHRs for Cerner’s HIE offering. Both companies claim
that this relationship will endure in the short- and medium-term. Despite these assurances, the long term is
cloudy. In 2012 Certify finalized a similar relationship with Healthcare Management Systems, a provider of
EHR solutions to 700 community hospitals and specialty healthcare facilities. Like the Cerner relationship,
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© 2013 CHILMARKRESEARCH
Certify will provide connectivity for HMS’ EHR customers to a Certify or public HIE. This relationship was
finalized at about the same time as the acquisition by Humana. At this point it is difficult to rationalize this
relationship strictly in terms of Humana’s broader healthcare strategies.
Certify, as we described in the product section, is skeptical of the long-term value of Direct secure messaging and remains committed to a broader view of interoperability between clinical systems. It has an enviable
ability to support query-based exchange. As the HIE market makes its choice about the balance between
query- and message-based exchange, Certify will undoubtedly have to follow the lead of market, but also
pay heed to its Cerner customers. As noted in the Cerner section of this report, Cerner is an enthusiastic
supporter of Project Direct and will no doubt urge Certify to augment its offering to better support these
standards. Moreover, Certify’s non-Cerner customers (roughly 25% of its historic customer base) and its
HMS customers will also have a similar interest in supporting Direct protocols. Despite Certify’s misgivings
about these standards and directed exchange, we anticipate that it will broaden its offerings over the next
eighteen months.
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Covisint
C
CC
Overall
Product
Marketing
Company Headquarters: Detroit, MI
Year Founded: 1973(Compuware)
Website: www.covisint.com/healthcareOwnership: NASDAQ Listed
2012 HIE Revenue: $8-10 million
Integrated delivery networks and hospitals
Ideal
Customer
Top Three Differentiators:
1. Proven platform with strong identity management repurposed for healthcare
2. AppCloud for ExchangeLink customers offers third party applications
3. DocSite brings strong quality reporting tools
Product
P
roduct Innovation
Product Execution
Product and Version: Covisint ExchangeLink, ProviderLink and DocSite
Dominant Deployed Architecture: Hybrid
Classification: Platform-centric
CC-
Top Three Most Used Features:
Product
Criteria
Rankings
1. Identity and Access management
2. AppCloud services
3. Results distribution
3
03
1
2
3
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
3
2
2
2
3
2
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Covisint offers cloud-based information exchange services in multiple industries, including healthcare. The
company was formed by the big three automotive companies as an eProcurement and supply chain optimization solution. It investing about $500 million in 2000 to create a highly secure collaboration platform
allowing automotive companies to securely share intellectual property with their suppliers. Its HIE solution
– Covisint Healthcare – is built with J2EE, leverages an SOA and operates on an SaaS model.
In most HIE deployments Covisint Healthcare is a combination of three distinct modules: 1) HIE 2) registries/care coordination and 3) analytics. If desired, Covisint can also provide a hosted CDR to facilitate data
exchange. Covisint relies on two key partnerships to provide some of the functionality to power Covisint
Healthcare including NextGate for MPI, and Mirth for the CDR. While Covisint Healthcare can support
all three architectural models, the dominant architecture deployed in the field today is hybrid. Covisint’s
cloud identity services leverages what is arguably the company’s strongest technology competency: providing best-in-class security and authentication services. These capabilities were originally developed to support the automotive industry and are more than capable of meeting the most stringent requirements in the
healthcare sector. Cloud identity services provide administrators with the ability to provision tiered access
to health data from a central location that is readily federated across the exchange. It can also create record
access reports for auditing purposes.
In addition to the cloud identity services capabilities for workflow and data integration, Covisint Healthcare
also provides portal and data exchange services. Covisint’s portal services offer features common in most
portals including aggregated views of a patient’s record, user configurable dashboards and the ability for
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© 2013 CHILMARKRESEARCH
administrators to post bulletins (e.g., public health alert) to the portal for the provider community. For data
exchange, Covisint supports most common healthcare data standards for both administrative and clinical
requirements. Covisint has also been aggressive in support for both the national NwHIN as well as Direct. It
recently announced a Direct solution which offers HISP services with provider search, APIs for EHR access
and directory services.
Covisint was one of the first HIE vendors to offer “open APIs” under its AppCloud brand to selected third
party software vendors for use in a Covisint-based HIE network. The idea for AppCloud originated from
its partnership with the American Medical Association (AMA), which sought a way to provide a services to
its members. Today they are a number of partners providing applications for billing, clinical content, EHR,
PHR, e-prescribing, disease management, scheduling and referrals management on AppCloud. Covisint has
a similar arrangement with the BCBS Association which had promised payer-centric AppCloud services. It
recently announced a relationship with Milliman, Inc. that leverages the latter’s actuarial expertise in the
form of point-of-care analytics and seems to focus on predicting costs and identifying patients with chronic
diseases. Despite these efforts, Covisint has not had much success with AppCloud, which languishes in the
market. This is likely due more to the field execution than the AppCloud concept itself.
Covisint’s progress toward delivering HIE 2.0 functionality is spotty. It continues to have a relatively strong
clinical quality reporting offering, which it acquired via DocSite. It also recently announced a narrow notifications solution with support for some kinds of admits and discharges. While it can contribute data to crossenterprise workflows, it cannot deliver functionality, nor can any of its partners. Medications reconciliation
is not on the radar for Covisint. To support referrals, it does provide its internal messaging capability as well
as the new Direct-based messaging but neither offering supports closed-loop referrals management. The
company’s partnership with Milliman promises to deliver cost predictions at the point of care but this population health management offering is scheduled to go live in July, 2013. Currently, Covisint is very much a
work-in-progress in terms of its progress towards meeting the requirements of HIE 2.0 HCOs.
The impending spinout of Covisint raises genuine questions about whether the company will invest in further development of its platform or consider acquisitions to strengthen Covisint Healthcare. It seems more
likely that Covisint will focus its energy on revenue generating activities for the foreseeable future at the
expense of building out the platform to support HIE 2.0 functionality.
CC
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, hospitals
Secondary Market: Independent practice associations, physician practices, payers
Estimated Number of U.S.-based Users (Private/Public): 90,000
• Statewide HIEs : 1
• Multi-stakeholder HIEs: 8
• Enterprise HIEs: 20
Provider Pricing Model: Perpetual License
Flagship Customers: Indiana Health Information Exchange, BCBS Association, Vermont
Blueprint for Health
Partners: Mirth, AT&T, NextGate
Market
Criteria
Rankings
4
Brand Recognition
2
3
Market Coverage
3
4
2
Geographical Coverage
Partner Strategy
Services
Vision
In the last year, Covisint has sharpened its marketing focus on providing solutions that enable population
health at the point-of-care. It has rebranded it entire product line as Covisint Healthcare with a value proposition based on reducing costs and earning incentives. The company is concentrating on the data needs of
risk-based providers and payers. Overshadowing any conversation about Covisint is the persistent rumors
about the fate of its parent company, Compuware Corporation. There has been much recent discussion
about listed software companies being acquired by buyout groups and Compuware is often mentioned. Apparently in response, Compuware filed an S1 indicating its plan to sell Covisint in an IPO.
2013 HIE MARKET REPORT
July2013
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Covisint has successfully combined strategic partnerships with acquisitions to grow its presence in the
healthcare sector. The company’s first healthcare-related acquisition was ProviderLink closely followed by
Hilgraeve, which provided HIS integration tools. More recently, in 2010 Covisint acquired the quality reporting and CMS registry service DocSite and now positions this as a PQRS solution. As mentioned in the
product review, the company has also formed a number of technology partnerships to round out its HIE
offering.
In addition to technology partnerships, Covisint has been quite savvy in strategic channel partnerships. Its
partnership with the AMA gave Covisint credibility in healthcare, important if only because neither Compuware nor Covisint had established healthcare brands. Covisint also formed a partnership with AT&T to create the AT&T Healthcare Community Online. Despite having AT&T as their national go-to-market channel
partner, nothing has come of this partnership except the 2012 deal with the Indiana Health Information Exchange as the next generation platform for what is the nation’s oldest, most established statewide exchange.
Within the healthcare market, Covisint is targeting both private enterprise HIEs, ACOs and PCMHs as well
as public regional and state HIEs with an opportunistic strategy. The company is currently providing HIE
services in the southeast region of its home state of Michigan (My1HIE, now called Ingenium) and also has
a presence in a number of other states either at the regional level or in the case in Vermont and Montana,
providing a specific module (DocSite) statewide.
As we reported last year, the company remains a bit of an enigma in the HIE market. No other vendor identifies Covisint as a competitor in the HIE market. Others we have conferred with recognize the DocSite brand
only in the context of PQRS. The opportunistic strategy pursued in the past may have helped land some
clients but it has left Covisint without a clear brand identity. This continues to be one of Covisint’s chief
marketing challenges.
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© 2013 CHILMARKRESEARCH
dbMotion
BC+
B-
Overall
Product
Marketing
Company Headquarters: Pittsburgh, PA
Year Founded: 2004
Website: www.dbmotion.com Ownership: NASDAQ Listed
2012 HIE Revenue: $18-22 million (est.)
Integrated delivery networks, academic medical centers, hospitals, physician groups
Ideal
Customer
Top Three Differentiators:
1. Workflow integration
2. Semantic harmonization
3. Flexible platform
Product
C+
B-
P
roduct Innovation
Product Execution
Products and Version: dbMotion Solution 4.5, 2012
Dominant Deployed Architecture: Hybrid
Classification: Foundational HIE
Top Three Most Used Features:
Product
Criteria
Rankings
1. Clinical views application
2. Collaborate application
3. EHR Agent application
3
0!
3
1
2
2
!
2
2
4
2
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
In the past, dbMotion developed a reputation for selling tools rather than solutions with longer-than-average implementation times in complex environments. The company eventually solved these problems thanks
in part to its partnership with Allscripts. That partnership blossomed into the Allscripts Community Record
product and the acquisition this past March. Today, dbMotion Solution is a comprehensive HIE that provides
several ways for clinicians to connect to the clinical data they need. The company has made a strategic decision not to support imaging data and provides click integration with PACS systems rather than duplicating
images in a separate repository. Similarly, it decided not to develop a patient portal or MPI. It has always
provided very strong semantic interoperability. During 2012, dbMotion enhanced its offerings with the
continued rollout of EHR Agent, the Clinical Analytics Gateway and connectivity for several of its customers
with RHIOs based on Direct protocols.
dbMotion has flexibility in the way that clinicians access data available in the HIE. In addition to its provider
portal, clinicians can use EHR Agent, a window that floats over their EHR to display remote data not present
in the EHR. The clinician can select data and import it into their EHR if desired.
dbMotion’s current ability to support advanced applications for HIE 2.0 varies according to application
requirements. For care planning and care transitions, it has a rudimentary capability based on its
Collaborate product. It notes that using Collaborate will not count for the purposes of qualifying for the EHR
incentives since the messages exchanged are not based on the Direct protocols. It intends to remedy this in
the summer of 2013 with a MU-focused release. The company is working on the ability to leverage its data
to generate alerts, reminders and notifications to clinicians.
2013 HIE MARKET REPORT
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I 3-34
dbMotion has invested in medications reconciliation functionality for a number of its customers. Using
Clinical Views, it has created a consolidated medications list that allows a physician to continue or discontinue a particular medication as well as generate a summary of the reconciliation. The company notes that it
can be impossible, from a practical standpoint, to discontinue a medication in some remote EHRs. Its dominant and more broadly implemented approach is to present the medications lists from around the community for the target EHR to perform the reconciliation.
While it can support referrals with messaging it has yet to deliver a closed-loop referral application.
Similarly, it can support the distribution and receipt of a care plan but does not support the workflow for a
cross-enterprise care team working from a dynamic plan. For now, it uses its Collaborate product to support care transitions. With Collaborate, a hospital could generate a discharge CCD and send a Direct secure
message to a LTPAC provider with an attached Collaborate license. This license would allow the recipient
provider to click on a link to view the CCD. It also plans to roll out a readmissions avoidance application
sometime in 2013.
With reluctance, it has ramped up its ability to support Direct secure messaging. While it currently has customers who can send and receive Direct-based messages from a RHIO, it does not have a solution in general
availability. It plans to offer more HISP services to its customers in 2013, including XDS-based query.
Its Clinical Analytics Gateway underwent some changes since last year. This product can provide clean,
normalized data based on a single clinical vocabulary. It serves up the data for use by a variety of analytics front-ends, depending on its customer’s choice. The company did enhance this product to provide data
needed for some clinical quality reporting for chronic conditions. At the moment, dbMotion can provide
data for immunization registries but is formulating its plans for supporting disease registries and reportable
laboratory results. Like all vendors, progress in this area is slow because of the different requirements of the
50 states. In general, dbMotion needs to put forward better analytics functionality for HIE-derived data for
risk-based providers.
dbMotion’s HIE solution is fairly comprehensive as an HIE 1.0 offering. Over the next year, dbMotion Solution will need to more fully support the needs of HIE 2.0 providers including more robust notifications, better workflow for medications reconciliation, readmission avoidance, closed-loop referrals, patient engagement and cross-enterprise care planning.
C+
B
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, hospitals
Secondary Market: Independent practice associations, physician practices, payers
Estimated Number of U.S.-based Users (Private/Public): 200,000
• Statewide HIEs : 0
• Multi-stakeholder HIEs: 0
• Enterprise HIEs: 37
Provider Pricing Model: License
Flagship Customers: University of Pittsburgh Medical Center, UMass Memorial, Community
Memorial Health System, Sharp Healthcare
Partners: Allscripts, IMT, CapSTS
NOTE: The following ratings are based on the dbMotion brand not on Allscripts
Market
Criteria
Rankings
3
4
Brand Recognition
Partner Strategy
Market Coverage
3
3
Geographical Coverage
!
2
Vision
Services
Before dbMotion established its relationship with Allscripts, its future in the US was seriously in question.
Allscripts forced dbMotion to develop a solution that the market could readily adopt and use, and dbMotion
survived. In fact, the company is being mentioned by other HIE vendors as a competitor more often than it
has been in past years which points to its growing market muscle.
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© 2013 CHILMARKRESEARCH
Last year, we identified dbMotion as an acquisition candidate. Allscripts bought dbMotion in March 2013.
Publicly, Allscripts believes that dbMotion can advance Allscripts’ community strategy to offer better
physician-to-physician care coordination across diverse care settings. dbMotion had provided Allscript’s
HIE solution for some time and the bulk of dbMotion’s revenue came from Allscripts customers. From that
standpoint, the acquisition merely formalized an established and profitable business relationship. In the
general excitement surrounding this announcement, it is also important to remember that IBM had separate
relationships with dbMotion and Allscripts. Both dbMotion and Allscripts have tended to favor IBM Initiate
when they needed to sell an MPI solution. Outside the US, IBM is marketing dbMotion products to providers seeking a longitudinal patient record in heterogeneous EHR environments. How the new IBM-Allscripts
relationship will evolve is not clear.
dbMotion may be the poised to add a number of Allscripts customers in the coming few years. For dbMotion customers who are not Allscripts customers, the acquisition may become a concern. Allscripts shows
every intention of continuing to sell dbMotion technology and services as a stand-alone offering under the
assumption that it is a way to get a toehold in non-Allscripts accounts, as well as for incremental revenue.
Publicly, the company is saying that it intends to remain “above the EHR” and not beholden to Allscripts
requirements. However, we believe that the focus of its development investment will likely be on the needs
of its various Allscripts EHR customers.
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GSI Health
C
C
C
Overall
Product
Marketing
Company Headquarters: New York, NY
Year Founded: 2003
Website: www.gsihealth.com Ownership: Private
2012 HIE Revenue: $2-3 million (est.)
Care teams
Ideal
Customer
Top Three Differentiators:
1. Strong HISP offering
2. Care coordination platform with HIE connectivity
3. Cross-enterprise care planning
Product
C+
C-
P
roduct Innovation
Product Execution
Product and Version: GSIHealthCoordinator 3, November 2012
Dominant Deployed Architecture: Centralized
Classification: Platform-centric
Top Three Most Used Features:
Product
Criteria
Rankings
1. Coordinated care plans and assessments
2. Direct secure messaging for clinicians
3. Alerts
2
04
3
2
3
3
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
1
4
2
3
3
2
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
GSI Health, a consultant turned technology company, established its reputation by integrating technology
for a RHIO in greater New York City. Most of its core HIE product functionality is supplied by third parties, including Mirth’s interface engine and Oracle’s MPI. Its HIE offering, GSIHealthCoordinator, uses these
tools to build a longitudinal clinical record and deliver it to clinicians through a web-based dashboard. GSI
Health integrates these products and builds solutions for Direct secure messaging and community-based
care coordination. Sometime in 2013, it will augment this list of applications with better patient engagement
tools, a population health management solution and clinical decision support in selected clinical situations.
GSI Health’s care coordination functionality is impressive, considering its size and measured against its larger competitors. It supports workflow that allows clinicians from separate enterprises to form and modify
teams, collaborate to develop dynamic care plans, and track progress. It includes the ability to enroll individual patients into care programs based on their comorbidities, payer requirements and circumstances.
Clinicians can subscribe to a limited number of alerts (i.e ADT events, changes to a patient care plan). These
are implemented using its underlying consent schema. While the range of care coordination scenarios this
solution supports is still limited, it is being used for discharge planning for circumscribed populations.
GSI Health has embraced Project Direct and provides HISP services to many, if not all of its customers. It
implemented the Direct-based email technology that underlies New York state’s HIE. Also, care team members using its care coordination solution rely on Direct secure messaging as their primary communications
mechanism. Sometime in 2013, this will be enhanced to allow care team members to invite clinicians from
outside the network to participate.
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GSI Health is slightly farther along in its thinking about the needs of providers seeking HIE 2.0 solutions
than many other HIE vendors, but the company still is challenged to deliver on this thinking. For example,
its customer can send and receive referrals using some basic referral templates But closed-loop referrals
are only possible within a care team attached to the same HISP. This means that if a patient is referred to a
provider not found in their provider directory, there is no automatic way to see whether the appointment
occurred and any results of the referral.
While it has invested in Pentaho as an analytics front-end, it has yet to deliver significant application functionality to support the usage of its normalized clinical and financial data. During 2013, it is planning to roll
out applications that provide outcome and quality measure reporting and care gap analysis and reporting.
Also in 2013, the company will probably provide more support for mobile device access to its applications,
incorporating clinical decision support capabilities and supporting patient engagement efforts with the
Avado PHR.
GSI Health’s approach to medications reconciliation generally is that it should happen within an EHR. It has
the ability to provide community medications from connected EHRs and from CCDs via the HIE. From the
clinician’s perspective, medications can be imported into the patient summary on the GSIHealthCoordinator dashboard.
While GSI Health has developed some impressive but limited scale care coordination functionality for
cross-enterprise care teams, it is unclear how that technology could be more widely deployed in the market.
GSI Health uses mostly third-party software to build its solutions. Most other HIE vendors have at least
attempted to deliver technology–based value in at least one HIE technology component. The company is
also ahead of most HIE vendors in that it has gained a lot of experience developing Direct-based solutions.
Unfortunately, we expect that this kind of work will be rapidly commoditized in the next 12-18 months. GSI
Health’s value continues to be as a service provider for HIEs rather than as a technology-based solution
provider.
C+
C-
Marketing Market Vision Market Execution Primary Market: Medical homes
Secondary Market: Independent practice associations, physician practices, payers
Estimated Number of U.S.-based Users (Private/Public): 3,000
• Statewide HIEs : 0
• Multi-stakeholder HIEs: 3
• Enterprise HIEs: 1
Provider Pricing Model: Subscription
Flagship Customers: Enterprise: Spectrum Health Home, Multi-stakeholder: Maimonides
Medical Center, New York eHealth Collaborative, Texas Health Services
Authority
Partners: Pentaho, HINext, Secure eHealth, Avado, MedCPU
Market
Criteria
Rankings
1
Brand Recognition
2
2
Market Coverage
3
3
3
Geographical Coverage
Partner Strategy
Services
Vision
GSI Health describes itself as a provider of care coordination solutions that happens to have an HIE under
the covers. Without doubt, GSI Health has some care coordination capabilities that distinguish it from its
HIE competitors. Also without doubt, GSI Health has not transitioned from consultant to product-based
solution provider. For example, we recently heard from sources outside the company that GSI Health and its
partner HINext will be implementing a clinical assessments solution for its most prominent health system
client. As a consultant, it must embrace this and any opportunity. While this particular opportunity will likely
involve some cross-enterprise data, it is not reliant on an HIE. This inability to zero in on HIE as a market is
indicative of the company’s conflicted focus.
Its basic approach to the market is to position GSIHealthCoordinator as a care coordination platform and
to enlist partners to develop applications that add value to the platform. To date, the company has had no
2013 HIE MARKET REPORT
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I 3-38
success as a platform provider. To be fair, much larger competitors have had no success attracting partners
to build on an HIE platform. We believe that GSI Health does not have sufficiently large market footprint to
attract partners to its platform and might better serve itself with a partnership to a large healthcare systems
integrator seeking HIE and Direct expertise to deliver care coordination solutions.
GSI Health, despite its size, has vision to spare, compared to its much larger competitors. It has developed
impressive care coordination capabilities, albeit confined to specific providers and populations, that few HIE
vendors can match. The issue we have is how generalizable this functionality is to a larger market seeking
solutions to a much wider range of health needs for larger patient populations. GSI Health’s strong vision
of market needs is not reflected in its level of adoption by the market. It is unlikely that GSI Health has the
sales and marketing wherewithal to scale its market footprint enough to make it more visible as a supplier of
HIE 2.0 solutions. In addition, the company’s focus on consulting over product development will mean that
it will be difficult for it to break out and be seen as a strong and viable candidate for meeting an enterprise’s
HIE 2.0 needs.
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© 2013 CHILMARKRESEARCH
Harris Corporation
C+
BC+
Overall
Product
Marketing
Company Headquarters: Melbourne, FL
Year Founded: 1895
Website: healthcare.harris.com Ownership: NYSE Listed
2012 HIE Revenue: $12-15 million (est.)
Integrated delivery networks and hospitals
Ideal
Customer
Top Three Differentiators:
1. Portal customization
2. Open and extensible service-oriented architecture
3. Clinical workflow expertise
Product
C+
B-
P
roduct Innovation
Product Execution
Products and Version: Clinical Integration Platform 5, November 2012
Dominant Deployed Architecture: Federated
Classification: Portal-centric
Top Three Most Used Features:
Product
Criteria
Rankings
1. Provider portal
2. Longitudinal patient record
3. Referral management
3
04
2
3
2
2
!
2
4
4
2
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Harris Healthcare’s HIE solution provides a longitudinal patient record from a relatively large number of
EHRs to clinicians via a provider portal. Patients can access data and collaborate with clinicians via a patient
portal. Harris differs from most HIE vendors because of its strong orientation to delivering functionality
via portals rather than in the EHR but it does have the ability to embed their portal into EHRs and support
configurable workflow for physicians. It offers HL7 CCOW-based integration for workflow between portals
and EHRs.
Harris has demonstrated significant product prowess and flexibility as evidenced by its willingness to work
with a variety of technologies. For example, it uses open-source Mirth products for its integration engine,
MPI and CDR. Carefx’s products were almost entirely built using IBM Websphere but the company is now
using Google Web Tools to develop new functionality. Its technical expertise also complements its healthcare focus. Harris was deeply involved in architecting NwHIN Connect and provides NwHIN capabilities as
a part of its HIE solution.
Since Carefx became part of Harris, the company invested in moving from proprietary technologies to more
closely match governmental preferences for open technologies, and in the process distinguish itself from
IBM as a competitor. In particular, Harris is positioning itself to provide technology and services related to
coming integration of DoD’s AHLTA and the VA’s VistA EHRs. The company is committed to deploying the
best possible technology for its customers and adeptly partners with and uses technology of a variety of
software companies to deliver value to its customers.
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Harris Healthcare has some capabilities that support the industry’s evolution to HIE 2.0. It partners with
Telus Canada to provide a care management solution that it has not yet implemented in the U.S. With its
own technology, it can provide a basic care management capability for discharges in which a care navigator
can build a care plan, share it with a cross-enterprise care team and communicate with the patient, all occurring through portals. This solution was originally developed to help drive patient engagement rather than to
support better care coordination. It remains to be seen how effective it will be for supporting the somewhat
broader goal of better care transitions.
Harris is also starting to offer HISP services to its customers and is finding that requirements vary significantly from customer to customer. Like most HIE vendors, it reports that EHR vendors are reluctant to hew
to the published standards.
Harris provides a closed-loop referrals application for referring and specialty physicians. As patients complete referrals, their status is updated in the shared work queues and relevant results and notes are available to the referring physician. Many provider organizations will be looking for a referrals application based
on Direct protocols in order to qualify for the EHR incentives. Harris provides an arguably superior workflow solution that, ironically, might not qualify for the incentive. More broadly, its ability to provide care
plans for transitions into post-acute care will rely on this kind of workflow. As such, it is not yet a complete
solution for cross-enterprise care planning.
Harris works with a variety of vendors to support disease and immunization registries. It provides the clinical data needed to populate these products and has had experience with most of the major chronic diseases
in different customer engagements. Its approach to medications reconciliation is to gather, organize and
de-dupe medications data from the HIE and Surescripts and then to populate the medications management
function in the EHR for the actual reconciliation. It includes medications-related allergies in the reconciliation process. Similarly, it can provide data for functionality that implement CDS-based alerts.
Harris’ analytics offering consist largely of providing clean clinical and administrative data for consumption by any of the customer’s choice of front end analytics solutions. It supports a variety of usages of this
data from bed utilization to coding analysis. Like many HIE vendors, its offerings are specific to customer
needs. It also offers a set of business intelligence dashboards focused on utilization, protocol compliance
and clinical documentation. Many of these capabilities are based on technology jointly developed with the
Cleveland Clinic.
Harris’ progress toward supporting HIE 2.0 providers consists mostly of providing raw cross-enterprise
data and configurable workflow. As providers seek to improve care coordination with cross-enterprise
care plans, Harris will need to show that they can integrate advanced functions like medications reconciliation, closed-loop referrals and embed these into the clinician’s familiar workflow. A complicating factor for
Harris’ product development efforts will continue to be its parent’s focus on DoD and the VA – neither of
which are multi-payer providers. Most HIE vendors are building solutions for multi-payer HCOs with more
complex exchange patterns.
Marketing Market Vision Market Execution C
C+
Primary Market: Integrated delivery networks, hospitals
Secondary Market: Independent practice associations, public agencies
Estimated Number of U.S.-based Users (Private/Public): 150,000
• Statewide HIEs : 2
• Multi-stakeholder HIEs: 2
• Enterprise HIEs: 10
Provider Pricing Model: License or Subscription
Flagship Customers: Public: Veterans Administration, U.S. Department of Defense, State of
Oregon, State of Florida, LARHIX; Enterprise: Kaiser Permanente,
Scottsdale Healthcare, Presence Health
Partners: Mirth, Telus, Northgate
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Market
Criteria
Rankings
2
2
4
Brand Recognition
4
Partner Strategy
Market Coverage
4
Services
Geographical Coverage
3
Vision
Harris entered the HIE market as a result of acquiring Carefx. Harris Healthcare now positions itself as
a supplier of a clinical integration platform. Its solutions are intended to enhance care at both an episode
level and for chronic conditions with the data needed for care collaboration. It has traditionally focused on
portals for providers and patients. We think that an important qualification to this positioning is that Harris
is primarily interested in competing for and winning government contracts.
The Harris Clinical Integration Platform, developed originally by Carefx, is a central element of its overall
healthcare portfolio and has been deployed for more than just HIE purposes. Harris acquired Carefx in large
part because of its success with the Department of Defense. Harris has not ignored the requirments of commercial customers as evidenced by its NwHIN capabilities as a part of its HIE solution. But Carefx enjoyed
good success with private healthcare organizations. Last year, we questioned whether Harris would have a
genuine interest in a market outside its focus on governmental and public agencies. That concern remains
since Harris’s initial customer base from last year shrunk somewhat. While these losses were offset by the
addition of two or three enterprise customers in the last quarter of 2012, the company is not adding new
enterprise customers at a rapid pace.
On the sales and distribution side, Harris’ target market is becoming more apparent. The wider Harris Corporation does extensive business with various government agencies around the world. To date, there is little
evidence that Harris – as a government contractor – has brought any commercial business to the former
Carefx. Moreover, it is not clear how Carefx has enhanced Harris’ ability to sell more of its non-interoperability health care solutions. We believe that Harris’ current and future HIE marketing efforts will be almost
completely devoted to securing federal contracts such as the future effort to bridge the DoD’s ALTA and the
VA’s Vista EHRs.
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HealthUnity
CCC-
Overall
Product
Marketing
Company Headquarters: Bellevue, WA
Year Founded: 2004
Website: www.healthunity.com Ownership: Private
2012 HIE Revenue: $4-5 million (est.)
Integrated delivery networks and hospitals
Ideal
Customer
Top Three Differentiators:
1. Low cost HIE
2. Composite CCD Service
3. Option for smaller HCOs
Product
CC-
P
roduct Innovation
Product Execution
Product and Version: HealthUnity HIE 6, September 2012
Dominant Deployed Architecture: Hybrid
Classification: Portal-centric
Top Three Most Used Features:
Product
Criteria
Rankings
1. EHR-integrated portal with single sign-on
2. Direct secure messaging
3. Low-latency consolidated CCD
4
02
2
2
2
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
2
2
2
4
2
2
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
HealthUnity provides complete HIE solutions, built in-house on the Microsoft platform. It provides an MPI,
RLS and searching functionality, documentation exchange including the creation of a composite CCD from
multiple source documents, consent management services, Direct secure messaging as well as analytics and
a patient engagement solution. The company continues to struggle in the market with this technology in
part because the company lacks the scale needed to maintain effective partnerships and provide the service
levels needed by larger HCOs. On balance, this problem of scale seems to have contributed to the fact that
HealthUnity made less headway with its product set in 2012 than many other HIE vendors.
HealthUnity offers fully integrated, bi-directional interfaces to roughly 10 EHR software packages
including Siemens, Meditech, GE, Vitera and Cerner. This allows clinicians to pull a complete patient
longitudinal record from the HIE from within their EHR. The company can also offer a less complete level
of integration to about 50 other EHRs by supporting over 150 different HL7, CCD and C-CDA messages
and versions.
During 2012, the company has aggressively adopted federal initiatives, notably support for HealtheWay
connectivity, certification as an EHR module under the 2014 rules, and support for Direct protocols. The
company is also pursuing certification with CCHIT under its new HIE Certified Community, Direct and Network programs. HealthUnity also began offering BlueButton support in 2012 and is working with several of
its customers to move this solution into production.
HealthUnity has a mixed record when it comes to providing support for the care coordination applications of HIE 2.0 and tends to focus on supplying data rather than application functionality. It supports
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© 2013 CHILMARKRESEARCH
medications reconciliations by providing medications lists based on community-derived data, but has yet to
provide support for the cross-enterprise workflows for a reconciliation of the lists. It supports referrals with
pushed CCDs but has yet to support the workflow necessary for closed-loop referrals. It does provide the
underlying data for readmission prevention efforts. It can also provide the data needed to send reminders
to patients. While HealthUnity clearly understands the needs of clinicians in HIE 2.0, it has not yet moved
beyond the workflow requirements-gathering phase.
The company is planning to offer more support for care transitions and care plans in 2013. While it certainly can supply the data needed to enable cross-enterprise care plans and care gap identification, it is
working with its customers to define the specific functionality to better support this workflow. It also has
plans to further develop its analytics offerings by focusing on customer requirements for population health
management – as it did last year. At some point in 2013, the company also has plans to roll out a certified
patient engagement solution. In general, HealthUnity understands that provider organizations are looking
for stronger care coordination capabilities and will announce more specifics about its short-term direction
in Summer 2013.
HealthUnity provides a modular HIE solution that is closer to HIE 1.0 than to HIE 2.0. Its products are probably most suitable for smaller HCOs with Microsoft-based IT skills. The real question about HealthUnity’s products is whether and how long the market — and smaller HCOS more specifically — still favor this
Microsoft-centered approach.
CC-
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, Hospitals
Secondary Market: Independent practice associations, physician practices, payers
Estimated Number of U.S.-based Users (Private/Public): 14,000
• Statewide HIEs : 0
• Multi-stakeholder HIEs: 2
• Enterprise HIEs: 8
Provider Pricing Model: License
Flagship Customers: Multi-stakeholder: Metro Chicago Healthcare Council HIE, eHealth Network of Long Island HIE, Medical Information Network - North Sound HIE
Enterprise: Medstar Health HIE
Partners: Pentaho, Microsoft, Caradigm, NYeC, Cognosante
Market
Criteria
Rankings
2
Brand Recognition
2
3
Market Coverage
3
2
2
Geographical Coverage
Partner Strategy
Services
Vision
HealthUnity’s market approach is to focus on business needs and offer some of the most common use cases
for HIE. Broadly, these uses cases consist of a complete HIE with MPI, RLS, and consent management, a
stand-alone healthcare specific MPI, a PIX/PDQ Portal with consent management and data warehousing
services. At the same time, the company can offer their complete HIE solution in discrete modules. This allows customers to leverage what they might already have in the way of Microsoft technologies or existing
HIE services, eliminating the need to “rip and replace”. HealthUnity also believes that a completely .NETbased product set keeps the IT organization relevant to decision-making about healthcare interoperability
and care coordination support.
HealthUnity does offer a hosted solution but it appears not to be widely adopted right now. The company traditionally put great faith in the advantages of customer self-hosting with commodity hardware and
Microsoft software. Very recently, HealthUnity showed signs that it has heard the siren call of cloud-based
solutions for HCOs and will be taking steps to more aggressively enhance its cloud-based HIE offerings.
We think that this encouraging sign could help address reports from the field about difficult implementations with HealthUnity. A hosting or services partner with more significant resources could impact both
HealthUnity’s price to its customers and its ability to compete in larger HCOs with more complex clinical
environments and technical implementations.
2013 HIE MARKET REPORT
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I 3-44
HealthUnity formerly enjoyed a close relationship with Microsoft based on the latter’s Amalga UIS which
led to HealthUnity being selected, along with CSC, by the MetroChicago Healthcare Council to build its HIE.
Microsoft subsequently abandoned the Amalga suite to Caradigm. Since then, Caradigm has also exited the
HIE business and will rely in the future on Orion Health’s products to deliver HIE functionality, effectively
closing the doors to HealthUnity. In light of these actions and the company’s new found belief in the merits
of cloud-based offerings, we believe that HealthUnity’s partner strategy has taken a few steps backwards
in the last 18 months.
Since last year, HealthUnity’s market footprint is substantially unchanged. It still remains focused on providing HIE services to the enterprise market and has ambitious goals for 2013. On balance, we believe that
its general lack of progress over the last year is emblematic of HealthUnity’s difficulties with its partnerships. We continue to believe that the company can provide a low-cost and HIE suitable for small HCOs that
do not foresee a need to scale to large number of transactions.
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© 2013 CHILMARKRESEARCH
Informatics Corporation of America
C+
BC
Overall
Product
Marketing
Company Headquarters: Memphis, TN
Year Founded: 2005
Website: www.icainformatics.com Ownership: Private
2012 HIE Revenue: $7-9 million (est.)
Integrated delivery networks and hospitals
Ideal
Customer
Top Three Differentiators:
1. Optimized for smaller HCOs
2. Highly modular for targeted deployments
3. Supports HIE sustainability with flexible pricing
Product
C
B
P
roduct Innovation
Product Execution
Products and Version: CareAlign 3.2.2, October 2012
Dominant Deployed Architecture: Hybrid
Classification: Foundational HIE
Top Three Most Used Features:
Product
Criteria
Rankings
1. Direct-based messaging integrated in EHRs or via clinician portal
2. Clinician portal
3. Clinical data exchange
3
03
3
2
3
2
!
3
3
4
2
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Informatics Corporation of America (ICA) reorganized its product set in 2012 to reflect market demands.
ICA CareAlign provides the MPI, RLS, CDR with semantic tagging, directory services, security and authentication. It augmented its product lineup with a Direct-based offering that offers much of the functionality provided by its pre-existing clinical messaging solution. It also combined two separate analytics-based
products into an informatics platform that provides a number of population health management and clinical
quality reporting capabilities. ICA CareAlign is a reasonable match for smaller HCOs seeking a modular approach that can be broken down into digestible phases.
During 2012, the company rolled out its HISP services with a messaging application based on Direct protocols in 10 states and has seen rapid uptake. While its customers are using it for provider-to-provider messaging in support of referrals, discharges and consults, it has also seen some provider-to-patient use cases
in which patients send messages that authorize access to their records. ICA is a firm supporter of the idea
of Direct-enabled applications and sees it as a good way to provide last mile connectivity to wider provider
networks. The company was recently awarded one of the first DirectTrust Agent Accreditation Program
(DTAAP) certifications. One of its customers recently announced it had used its Direct-based services to
connect to several post-acute care providers in Tennessee.
Like all HIE vendors, ICA has had to balance the demands of providing aggregated data against the demands
for application functionality. Its origins as a data aggregation tool for medical informaticists at Vanderbilt
combined with customer demand helped it decide that its core competency is connecting clinicians and
leveraging data. It supports existing clinical workflow with the comprehensive longitudinal patient record to
2013 HIE MARKET REPORT
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I 3-46
the variety of clinical end-users who may access it via their EHR or through a clinician portal.
One consequence of this decision is that the company is focusing on providing data rather than functionality for the range of advanced applications needed in HIE 2.0. For instance, its customers can push messages
with discharge summaries or medications lists from a hospital to the next provider. In addition, clinicians
from different HCO can use CareAlign’s portal to access this data. While this data satisfies the immediate
needs associated with care transition for the EHR incentives, it is no substitute for the robust workflow
and functionality needed to support readmission reduction efforts, medications reconciliation or crossenterprise care plans. Its ability to support referrals is similarly limited to the exchange of messages with
attachments or portal access rather than a single tool used by multiple clinicians with status tracking and
communications support. The company also recently announced a partnership with NoMoreClipboard to
make HIE-derived data available to patients with the latter’s PHR applications.
Its analytics offering does provide the ability to stratify patient data into a variety of cohorts for many population health management efforts including utilization management. ICA can also provide data aggregated
from CCDs needed for clinical quality reporting. It announced a partnership with Futrix Health to offer
more functionality for payers and risk-based providers. In 2013, ICA will be investing in many of the more
advanced HIE 2.0 applications such as disease registries, and care planning support.
C
C-
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, hospitals, practice associations, medical homes
Secondary Market: Payers, post-acute care facilities
Estimated Number of U.S.-based Users (Private/Public): 10,000
•Statewide HIEs : 4
• Multi-stakeholder HIEs: 4
• Enterprise HIEs: 6
Provider Pricing Model: One-time license plus annual maintenance or annual subscription
Flagship Customers: Public: Kansas Health Information Exchange, Upper Peninsula Health
Information Exchange, Central Illinois Health Information Exchange;
Enterprise: Meridian Health
Partners: MarkLogic, Affiliated Computer Services, Emdeon, Design Clinicals, Clinical
Architecture, Futrix Health
Market
Criteria
Rankings
Partner Strategy
Market Coverage
4
4
Geographical Coverage
3
Vision
3
Brand Recognition
2
4
Services
Last year we noted ICA’s pragmatic approach to product development and marketing. The addition of
Direct-based services to its product portfolio will help it increase utilization in its customer base and add
new clinician-users. Unusually among HIE vendors, the company added a commercial customer that only
offers HISP services to physicians in a particular region. During 2012, ICA did not significantly grow its
customer base in either the public and enterprise markets but did significantly grow the number of go-lives
among these customers. The company also diversified its customer base in 2012 with the addition of its first
health plan which will give it experience using CareAlign to support care coordination between providers
and payers.
Like last year, we believe that ICA still struggles to compete in the national market and has not kept pace
with major competitors. Execution in the field, and to a lesser extent vision, remain constrained. In some
regions of the country, ICA has excelled in sales execution and follow-up, whereas in others it has faltered.
But the company is taking steps to project market leadership and vision. It opened an interoperability lab
for EHR vendors and recently became the first production deployment (Central Illinois HIE) of an Epic client with the XCA protocol and plans to go live with 7 other EHR vendors in 2013. The company has one of
the few live clients (Kansas Health Information Network) that supports real-time exchange across provider
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networks utilizing XDS.b, XCA, HL7v2 and Direct on a single platform. It is sending a signal to the market
that it can deliver query-based HIE applications.
The company has solid technology and we continue to find that it is a more than credible competitor in
small- to mid-size markets where the objective is to network clinics and providers with a comprehensive
longitudinal record. The company’s past relationship with ACS had helped it gain many of its public HIE
customers and it remains to be seen how the company can compete in larger HCO without a credible
replacement for this relationship. For the moment we believe that, despite its provenance at Vanderbilt, ICA
will find it difficult to compete for the largest HCOs seeking a vendor with a strong combined product and
services capability with a focus on the workflow-based care coordination requirements of HIE 2.0. ICA will
continue to be most competitive in smaller HIE venues where needs are modest and budgets tight.
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InterSystems
BBB
Overall
Product
Marketing
Company Headquarters: Cambridge, MA
Year Founded: 1978
Website: www.intersystems.com Ownership: Private
2012 HIE Revenue: $11-14 million
Integrated delivery networks and hospitals
Ideal
Customer
Top Three Differentiators:
1. Deep HIT expertise
2. Extracts and relates concepts from structured and unstructured data
3. Real-time active analytics based on healthcare data model
Product
BB
P
roduct Innovation
Product Execution
Product and Version: HealthShare 2012.1, July 2012
Dominant Deployed Architecture: Federated
Classification: Foundational HIE
Top Three Most Used Features:
Product
Criteria
Rankings
1. Aggregate and normalize data from multiple sources
2. Integrated workflow
3. Messaging for clinical users
3
04
3
2
3
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
!
3
3
4
2
2
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
InterSystems is a global provider of healthcare solutions based on its widely-adopted Caché object database and Ensemble interface engine. HealthShare is an informatics and interoperability platform for hospitals, IDNs, and public HIEs that provides analytics, access to structured and unstructured patient data via an
MPI, RLS and document registry, free text extraction, a clinician portal and clinical messaging. InterSystems
strives to provide clinicians with sub-second access to a patient’s longitudinal record. Broadly, InterSystems uses HealthShare to improve clinician engagement by providing only the relevant data for clinician
selection, rather than the total constellation of CCDs that exist for a patient. In some cases, InterSystems’
customers prefer to deliver it in the clinicians EHR while in others, a clinical viewer makes sense. In either
situation, InterSystems can leverage its considerable expertise with clinical integration. The company also
emphasizes that clinician needs will change over time and stresses that it can serve up data in ways that
reflects the changing preferences of individual users.
Last year, we noted that InterSystems’ focus on providing HIE-based functionality was not quite on par with
its ability to provide high-quality HIE-sourced data. This year, it has taken some important steps to help
providers with additional advanced HIE 2.0 functionality. For referrals, it added status information (i.e., past,
upcoming, missed) on follow-up appointments as well as an alerting capability as part of its messaging solution. It also enhanced its provider directory and added information about patient-provider relationships.
It can provide PCP notifications based on some ADT events. It does not provide these using Direct protocols but its customers can qualify for the EHR incentives via partner solutions. InterSystems approach to
medication reconciliation is to provide a composite list of medications that based on the EMR data sources.
We think that InterSystems will need to develop additional functionality to better support reconciliations
workflows across care venues.
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Its plans to support disease or immunization registries are in flux. The company plans to offer more Directbased services as well as support for BlueButton in 2013. While BlueButton support will contribute to satisfying the view/download/transmit provision in the EHR Incentive Program, it is only part of a more comprehensive patient engagement strategy. The company can provide data useful to readmissions reduction
efforts in the sense that it provides cross-enterprise teams the ability to view data and securely message
each other. But it has not developed extensive workflow that would support the creation, modification and
execution and multi-disciplinary, cross-enterprise care plans.
To support the needs of HIE 2.0 providers in their population health management efforts, HealthShare has a
mixed set of capabilities for the moment. Its HealthShare Active Analytics (HSAA) offering is a version of its
analytics solution DeepSee, customized for the HIE market. Active Analytics supports the creation of dashboards and condition-based patient cohorts for population health management purposes. The company has
used HSAA to detect care gaps for diabetes patients.
InterSystems’ incremental approach to evolving its HIE solution derives from its philosophy: healthcare
customers want to be enabled, rather than driven, by HIT vendors. HealthShare is an attractive offering for
larger, well-financed healthcare customers (public or enterprise) with clear ideas about what they want to
accomplish. While HealthShare does not provide the most advanced applications of HIE 2.0, InterSystems
can provide a proven and solid way for clinical data to move among disparate EHRs.
BB+
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, hospitals
Secondary Market: Public agencies, HIT vendors, payers
Estimated Number of U.S.-based Users (Private/Public): 17,000 (est.)
• Statewide HIEs : 5
• Multi-stakeholder HIEs: 9
• Enterprise HIEs: 36
Provider Pricing Model: License
Flagship Customers: Public: NY eHealth Collaborative, NYC Health & Hospital Corporation,
National Patient Summary in Sweden, NYC Office of Mental Health;
Enterprise: Spectrum Health, MemorialCare Health System, Rhode Island
Quality Institute
Partners: Latisys, Inpriva, Tieto, J2 Interactive, Orchestrate, CSC
Market
Criteria
Rankings
4
Brand Recognition
3
Market Coverage
!
Geographical Coverage
4
4
3
Partner Strategy
Services
Vision
InterSystems is one of the few HIE vendors with a truly global footprint and lessons learned around the
world are often used in the U.S. After fits and starts, the company decided to pursue HIE opportunities
among U.S. public entities where there is a clear governance model and the HIE strategy is “sensible.” It now
provides the statewide HIE in four states and recently announced that it will knit together 12 communitybased HIE networks for the Texas Health Services Authority. On the enterprise side of the market, it targets
larger HCOs with complex, heterogeneous clinical systems among its affiliates. This strategy is sound, based
on its progress to date. In addition, InterSystems appears to be targeting customers where it can provide a
solution that overlays and provides interconnectivity between separate HIE networks, public or enterprise.
InterSystems increased its market presence substantially in 2012, doubling the number of public HIEs globally and adding many new enterprise HIEs. A substantial proportion of these new customers were not preexisting Ensemble customers.
InterSystems is well known for its technical prowess and high price tag. Installations can be daunting for
organizations without strong IT skills or the resources to hire consultants. InterSystems’ deep roots in the
healthcare provider industry and its strong partnerships with the HIT vendors that build solutions with its
technology are longstanding. At the same time, the company’s effort to develop similar relationships based
on HSAA are relatively new. Given the growing HIE opportunity, we will watch with interest as InterSys2013 HIE MARKET REPORT
July2013
I 3-50
tems pursues growth through its traditional partnerships and among customers not already using any
InterSystems technology.
InterSystems is an engineering-driven organization with an abiding commitment to upward compatibility
and protecting its customer’s past IT investments. The company can deliver HIE solutions with HealthShare
for small and large HCOs and can support some extremely complex data exchange requirements. Rather
than dictate to its customers, it strives to put them in the best possible position for an uncertain future. As
such, InterSystems will remain a strong, but not bold, presence in the HIE market.
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© 2013 CHILMARKRESEARCH
Medicity/Aetna
B+
B+
B+
Overall
Product
Marketing
Company Headquarters: Memphis, TN
Year Founded: 2000
Website: www.medicity.com Ownership: NYSE Listed
2012 HIE Revenue: $68-72 million (est.)
Integrated delivery networks and hospitals
Ideal
Customer
Top Three Differentiators:
1. Support for wide range of data types
2. Good option for hospital-based exchange
3. Population health focus
Product
B+
P
roduct Innovation
B+
Product Execution
Products and Version: Formerly called Novo Grid and MediTrust, currently names in flux
Dominant Deployed Architecture: Hybrid
Classification: Foundational HIE
Top Three Most Used Features:
Product
Criteria
Rankings
1. Results or reports distribution to EMRs, inbox or public health agency
2. Referrals for care transitions with directed exchange
3. View of cross-community longitudinal patient record
4
04
3
4
3
3
!
3
4
4
3
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Medicity’s products are integral to Aetna’s overall strategy to support ACOs. Aetna consolidated its population health management solutions and health information technologies from ActiveHealth Management,
iTriage and Medicity under a single brand – Healthagen. Medicity will work closely with these other two
Aetna organizations to find product and service synergies. For example, Medicity intends to work with
ITriage to enhance its patient engagement strategy. More broadly, Aetna, as the parent company, can
complement technology-based offerings from Healthagen with a complete set of services-based care
management programs.
Medicity has the most comprehensive, if confusing, portfolio of HIE solutions of the vendors surveyed for
this report, a result of being a corporate rollup. Its product naming is in flux but the product set has four
parts. It has two foundational HIEs: Novo Grid and MediTrust. Novo Grid, its lightweight, entry-level messaging-based HIE for directed exchange is not being actively marketed. MediTrust provides the longitudinal
patient record for query-based exchange. Its collaboration product, yet unnamed, provides a closed-loop
referrals application, a clinical inbox application and an ONC-compliant Direct secure messaging application (all three based on the legacy iNexx product, a brand that it is now retired) as well as the longitudinal
community-wide patient record (based on the legacy ProAccess Community Health Record). Finally, it will
offer a notifications product that can generate notifications for clinical or non-clinical users or applications.
To supplement these HIE offerings, Insights is a new HIE-focused analytics offering that supplements the
more general-purpose ActiveHealth analytics offering from Aetna. Medicity promises a more straightforward branding and packaging scheme in late 2013.
2013 HIE MARKET REPORT
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The company has made some progress in providing the advanced functionality for HIE 2.0. It provides some
notification but cannot yet provide them based on multiple clinical events and according to combined clinician and patient preferences. Its closed-loop referrals applications is based on its internal messaging system.
It delivers a fairly robust feature set including guaranteed delivery, a greater variety of attachment types
and referral status information. It also offers a Direct-based referrals application that will let provider organizations meet the requirements for Stage 2 MU but does not yet provide a closed-loop referrals capability.
At the moment, most of its care planning functionality relies on pushed CCDs and care plans. It has not yet
developed cross-enterprise tools that will allow multiple clinicians to collaborate on care plan development
and execution with integrated communications. In the near term, it will expand the scope of its messagingbased applications to more fully leverage the longitudinal patient record and other Healthagen services.
For medications reconciliation, Medicity can provide a clinician with a side-by-side comparison of medications lists from two venues based on hospital and community-derived data from third party aggregators.
However, it believes that the actual reconciliation process is best left to the clinicians’ EHR. Medicity can
collect and organize data for immunization or disease registries and associated reporting and is seeing demand for more robust application functionality in this area driven by provider interest in Stage 2 MU. At
the moment, the company provides no specific functionality or services to support the inclusion of LTPAC
facilities in an HIE network. For care plans, Medicity can aggregate and deliver data to ActiveHealth where it
can be used to identify some care gaps and generate message-based notifications to the relevant clinicians.
Medicity Insights is new and intended to provide HIE-based insights into clinical operations rather than
at the point of care. The idea is to monitor data flowing through the HIE to help inform organizational or
operational strategy. It could be used to discover referral patterns in a community or to identify where
patients are “leaking” to other providers. Importantly, this offering presents a promising, but still undefined
and certainly unbuilt, vision for HIE-based analytics.
Medicity will be working with iTriage for patient engagement. Still in development, this offering uses clinical and HIE data sources to construct a clinical summary for delivery to a patient’s mobile device via secure
messaging. This functionality could be used to meet the view/download/transmit requirement of Stage 2
MU.
Medicity has an impressive array of HIE solutions for HCOs seeking directed and query-based exchange
across diverse communities. While still closer to HIE 1.0, the company is rapidly leveraging the technology
from its sister organizations to make full use of the longitudinal patient record for care coordination. While
it lacks a clear migration plan for its Novo Grid customers, it at least enjoys home field advantage as they
look for more functional HIE 2.0 solutions.
B
B+
Marketing Market Vision Market Execution Primary Market: Health systems, Practices
Secondary Market: Employers, Payers
Estimated Number of U.S.-based Users (Private/Public): 250,000
•Statewide HIEs : 6
• Multi-stakeholder HIEs: 14
• Enterprise HIEs: 127
Provider Pricing Model: License or Subscription
Flagship Customers: Public: Michigan Health Connect, Vermont Information Technology
Leaders, Wisconsin Health Information Network, Ohio Health Information Partnership, Texas Health Resources; Enterprise: Hoag Hospital, The
Methodist Health System
Partners: Other Aetna companies, Orchestrate Healthcare, Cognizant
Market
Criteria
Rankings
!
Brand Recognition
3
Partner Strategy
4
4
Market Coverage
4
Services
Geographical Coverage
4
Vision
3-53 I July2013
© 2013 CHILMARKRESEARCH
Medicity is the cornerstone of Aetna’s strategy to become the dominant IT supplier to ACOs. Medicity
pursues three primary market opportunities: hospitals and health systems seeking to better support
affiliates and other community providers with data, public collaboratives including multi-state entities,
state entities or regional entities, and opportunities presented by its parent Aetna. The company’s relatively large market presence has been driven by its ability to consolidate EHR data sources into a single feed
for consumption by the HIE and distribution to heterogeneous EHRs. The company also points to its track
record in delivering this functionality rapidly.
We noted last year that prospective provider customers might be skittish about working with a payer. This
seems not to be the case with Medicity which has grown, adding both several public and a number of enterprise customers in 2012 – in sharp contrast with other vendors with payer owners. This may be due to its
relative autonomy. Medicity’s involvement with wider Aetna opportunities are often collaborations
between Aetna business units. It has been able to participate more fully in state Medicaid opportunities
because of the work it has done with Aetna’s Schaller Anderson. The revenue effect of these Aetna relationships is unclear. Chilmark believes it is more likely than not that Medicity will contribute in a meaningful way
at Aetna and will fare better than other acquired HIE vendors. We must note that the majority of Medicity’s
senior staff, prior to the Aetna acquisition, have now left the company and Medicity will be grappling with
the challenges of transitioning to a new senior leadership team with unforeseeable consequences.
Medicity has always had strong and consistent marketing but its current branding and product lineup are
muddled. Its challenges are unique in that no other vendor has two foundational HIE offerings. Despite this
confusion the company is clear about what its solutions can accomplish for providers seeking ways to provide more coordinated care under risk-based payment models. It aligns well with the HIE 2.0 solutions that
provider organizations are now seeking.
Medicity stands astride the HIE business. Whether its remains on top will hinge on several factors. As its
customers become more deeply involved in new payment models, reliance on the former Novo Grid product
could become problematic. While the company is upgrading Novo Grid customers to MediTrust, it is not
clear what the optimal pace for those upgrades might be. Unless Novo Grid customers have a good reason to
switch to MediTrust, there is always a risk that a different HIE vendor could provide a good reason. Another
potentially limiting factor is the size and focus of its owner Aetna. Medicity represents a minute fraction
of Aetna’s revenues and profits and could have difficulty competing with other, larger business units for
resources. Medicity is also now unlikely to aggressively seek sales or technology partners outside of Aetna.
Finally, Medicity will probably focus only on U.S. opportunities despite the global nature of the market opportunity for clinical interoperability solutions.
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Siemens/MobileMD
C+
C+
C
Overall
Product
Marketing
Company Headquarters: Malvern, PA
Year Founded: 2006
Website: www.medical.siemens.com Ownership: XETRA Listed
2012 HIE Revenue: $13-15 million
Integrated delivery networks and hospitals
Ideal
Customer
Top Three Differentiators:
1. Rule-based clinical data routing
2. Supports clinician recruitment to HIE
3. Fully cloud-based
Product
C
P
roduct Innovation
C+
Product Execution
Product and Version: Siemens MobileMD 4D Health Information Exchange (4DX) 4.1.4; July 2012
Dominant Deployed Architecture: Hybrid
Classification: Messaging-centric
Top Three Most Used Features:
Product
Criteria
Rankings
1. Results pushed to clinician portal or EHR
2. Orders and scheduling
3. Records retrieval
4
04
2
2
2
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
!
2
2
4
2
2
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
NOTE: Siemens Healthcare did not respond to Chilmark’s request for the information used to prepare this profile. As
a result, we relied on a combination of publicly available information, its past submissions for this report and discussions with provider organizations, consultants and other HIE vendors to complete this vendor profile.
The Siemens MobileMD 4DX is a fully hosted HIE solution sold via a single upfront deployment fee and
monthly, per physician subscription thereafter. The solution is built on the Microsoft stack and implemented
as a .NET based SOA. MobileMD 4DX supports virtually all of the standards necessary for interoperability
across health systems, hospitals, clinics, as well as the affiliated practices that provide a referral base. The
company uses Corepoint’s Integration Engine to connect with roughly 40 EHRs, although direct consumption of patient data into the EHR is not possible for some of these EHRs. For physicians without an EHR,
the company offers either the MobileMD 4DX Clinical Portal or a certified EHR-lite offering. Its MobileMD
4DX eShare product provides a secure messaging system with templates to support referrals, consults and
authorizations. This product has some ability to populate a patient’s chart with data for downstream connected providers.
Siemens MobileMD’s progress toward delivering on HIE 2.0 is mixed. During 2012, it upgraded its product to
add support for Direct secure messaging as one way to support connectivity to non-Siemens HIE offerings.
It began to offer support for longitudinal views of patient information through aggregated, cross-enterprise
CCDs, an important enhancement for a vendor long known for its limited messaging-based functionality.
The company has yet to announce a more comprehensive set of offerings to support HIE 2.0 including care
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© 2013 CHILMARKRESEARCH
plans, medications reconciliation, closed-loop referrals management, complex publish/subscribe-based notifications and other advanced applications.
On a brighter note, Siemens MobileMD is the only HIE vendor to announce a way to integrate scheduling
into a patient portal. In a referrals situation, the patient or caregiver could theoretically schedule followup appointments at the same time that a discharge summary shows up the patient’s inbox. The limitation,
which is very significant considering Siemens’ tier two presence in the market, is that it works only with
facilities that use Soarian Scheduling.
While Siemens Healthcare – a €13 billion heavy hitter in the medical imaging business – would seem to be in
a good position to enhance care coordination, we have to question whether MobileMD 4DX is the product
that can deliver the advanced functionality of HIE 2.0 over the long term. Its success as a messaging-based
product that generates simple push-based referrals is only the first step to delivering cross-enterprise care
coordination. The common workflows required across the care continuum are going to need more robust
application functionality than messaging-based systems can deliver. Given the general lack of progress that
Siemens has seen with MobileMD, it increasingly looks like the acquisition, while executed with the best of
intentions, serves mostly to fill out Siemens Healthcare’s corporate-level powerpoint positioning.
CC+
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, Hospitals
Secondary Market: Independent practice associations, physician practices, payers
Estimated Number of U.S.-based Users (Private/Public): 6,400
• Statewide HIEs : 0
• Multi-stakeholder HIEs: 0
• Enterprise HIEs: 33
Provider Pricing Model: Installation fee and subscription based on number of clinicians
Flagship Customers: Enterprise: Dignity Health, Pinnacle Health, South Jersey Health
Partners: Latisys, Inpriva, Tieto, J2 Interactive, Orchestrate, CSC
Market
Criteria
Rankings
!
Brand Recognition
3
Partner Strategy
4
Market Coverage
!
Services
4
Geographical Coverage
3
Vision
Founded in 2005, MobileMD’s approach to HIE has been pragmatic and customer-focused. Its modest customer base has not grown significantly in the last year although its existing customers are generally satisfied. We have heard rumors, however, that some are reaching the limits of what MobileMD can provide and
are beginning to consider other options that will be more aggressively move them in the direction of HIE 2.0.
The company has focused solely on the enterprise market and mid-sized health systems. Its cloud-based
offering, strong commitment to customer service and affiliate recruitment have paid off for its customers.
This approach has helped the company overcome many of the functional gaps in MobileMD 4DX. The company has enjoyed past successes at Catholic Healthcare West, Pinnacle Health and Holy Redeemer. Most
recently, it landed East Texas Medical Center where it unseated an incumbent HIE vendor, OptumInsight. In
general, no other HIE vendor regards MobileMD as particularly competitive.
MobileMD, as a Siemens Healthcare business, is participating in Agenda 2013, Siemens’ two-year global
initiative to strengthen innovation and competitiveness of its healthcare solutions. Siemens will implement
this program in four areas: innovation, competitiveness, regional footprint, and people development. How
this will translate into increased HIE market activity for Siemens in unclear. As the example of integration
with Soarian Scheduling illustrates, it is likely that future development will remain focused on deeper integration with Siemens’ HIS portfolio.
What is clear is that Siemens is now positioning MobileMD 4DX is the centerpiece of Siemens’ care coordination strategy. The company claims to offer a heightened focus on driving patient engagement in addition
2013 HIE MARKET REPORT
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I 3-56
to enabling better connectivity between providers and provider organizations. It has seemingly embraced
the idea that patients and providers must be able to access any medical record, regardless of vendor. To
date, we have seen little evidence that this is actually happening outside of its collateral. While Siemens
is a dominating presence in global healthcare, particularly imaging, its lack of visibility as an HIE vendor is
becoming more obvious each year.
3-57 I July2013
© 2013 CHILMARKRESEARCH
OptumInsight
C+
C
C+
Overall
Product
Marketing
Company Headquarters: San Jose, CA
Year Founded: 1995
Website: www.optuminsight.com Ownership: NYSE Listed
2012 HIE Revenue: $50-55 million
State governments, multi-stakeholder HIEs
Ideal
Customer
Top Three Differentiators:
1. Complete technology stack
2. Push-based care collaboration
3. Visible in the HIE market
Product
BC-
P
roduct Innovation
Product Execution
Products and Version: Optum Health Information Exchange; Optum Care Suite
Dominant Deployed Architecture: Hybrid
Classification: Foundational HIE
Top Three Most Used Features:
Product
Criteria
Rankings
1. Results delivery (laboratory, pathology, radiology)
2. Community-wide patient record lookup
3. Electronic referral management
!
04
2
2
3
2
!
2
2
4
2
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Optum HIE was originally developed by Axolotl, a company subsequently acquired by OptumInsight. Optum
HIE provides a complete HIE solution consisting of an MPI, an RLS and provider directory services. It gives
clinicians access to the longitudinal patient record, referred to as the Virtual Health Record (VHR), provided
either through any of a number of ambulatory EHRs or a clinician portal (OptumInsight supplied or third
party). The VHR mimics a paper chart with tabs that display query results for data stored in Optum HIE’s
federated data sources and in applications outside of the Optum HIE. OptumInsight deploys Optum HIE as
hybrid-federated model in which source applications push data to individually configurable edge servers
that serve as entity-specific XDS repositories. This model has proven useful in OptumInsight’s public HIE
customer set where governance between and among separate public and private entities in a multi-stakeholder community has been difficult.
This once venerable product saw widespread adoption particularly among public HIEs but has seemingly
languished as OptumInsight tinkers with its wider value proposition. In OptumInsight’s defense, the original
Axolotl HIE platform was not known for its state-of-the-art architecture; it was and remains long overdue
for a significant upgrade. Axolotl has succeeded by sheer dint of excellent service. Under new ownership,
the dated product architecture combined with poor field execution has led to some significant challenges
for this once leading HIE vendor.
OptumInsight states that it is fully committed to Optum HIE and re-architecting the solution. The company
is taking measures over the next year to make its current product more robust in an effort to tide its customers over until it can deliver what it is now calling Optum HIE 2.0. It will be a cloud-based multi-tenant
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solution that promises to deliver HIE 2.0 functionality that blends messaging with clinician workflows.
Optum plans to deliver messaging-based and query-based functionality tied together with what could be
the most comprehensive notification services in the industry.
Every user of Optum HIE 2.0 – clinician and patient – will have a Direct email address as well as access to an
EHR or portal, respectively. Each user will be able to subscribe to events and receive notifications at the time
and in the format they choose. Similarly, they will be able to publish information and specify to whom it goes
and with what qualifications. This product promises to provide many advanced HIE 2.0 applications such as
support for cross-enterprise collaborative care plans and public health reporting. None of these capabilities
are currently available from OptumInsight but they are on their 12-24 month product roadmap. While the
company has articulated a comprehensive plan to deliver HIE 2.0 functionality, it is unlikely to roll it out until
mid-2014 at the earliest.
Optum Care Suite provides an analytics capability that uses data from Optum HIE and other data sources
defined by the customer. It is a general-purpose tool intended to extract and prepare clinical data for analytics-based applications. For reporting purposes, data can be pushed into the Optum HIE Reporting and Analytics (OHRA) central data warehouse, which loads data into subject-specific data marts for various reporting subject areas. OptumInsight offers the Pentaho business intelligence suite to its customers for building
application front-ends. Currently, this collection of offerings does not deliver pre-built functionality suitable
for clinical or financial users interested in population health management purposes using cross-enterprise
data. Further, it may require significant services to deliver that functionality to an end-user.
From a product standpoint, OptumInsight believes that robust notification services will be the backbone
of better care collaboration. This could give OptumInsight an edge in the market if these services are well
executed in the context of OptumInsight broader product portfolio. The next two years will be critical for
OptumInsight to deliver those services. In the near-term, the company needs to re-establish itself as a leading player in the market. A refocus on services combined with the ability to sell prospects on their product
vision will be critical. While general progress among HIE vendors toward HIE 2.0 is not yet impressive, this
once pioneering company is now in a position where it will have to push hard to catch up.
B
C-
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, public agencies
Secondary Market: Independent practice associations, physician practices
Estimated Number of U.S.-based Users (Private/Public): 110,000
•Statewide HIEs : 9
• Multi-stakeholder HIEs: 13
• Enterprise HIEs: 7
Provider Pricing Model: License
Flagship Customers: Multi-stakeholder: Santa Cruz HIE, Rochester RHIO, HealthBridge, Great
Lakes HIE; Enterprise: NYU Medical Center
Partners: Axesson, Pentaho
Market
Criteria
Rankings
4
3
4
Brand Recognition
3
Partner Strategy
Market Coverage
4
Services
Geographical Coverage
2
Vision
OptumInsight’s market footprint showed signs of erosion during 2012. It appears to have fewer private entities as customers than it did last year which is concerning because it had relatively few to start. The company has long been strong in the public sector but even here saw some defections as customers reconsidered
their decision and decided to go with another vendor. By contrast, its leading competitors experienced solid,
if not strong, growth. For the moment, OptumInsight is barely treading water in the market.
Despite these concerns, OptumInsight remains a highly visible presence in the HIE market. It is the second
most frequently mentioned competitor by all of the other vendors in the HIE market. From a sales stand-
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point, OptumInsight is engaging with prospective customers and responding to RFPs. But there just is not
strong evidence that company is closing deals based on these opportunities.
Axolotl had a long-established and well-deserved reputation for effectively connecting health systems
and hospitals to public HIEs. Last year, we raised concerns about OptumInsight’s ability to compete in the
enterprise market and its overall vision. This year, based on its presence in a large number of sales situations
and few wins, we have to question whether the company has the product portfolio to win new enterprise
customers and hold on to existing customers. Moreover, its traditional strength in public markets means
it will be exposed to the continuing challenges of a market whose long-term viability remains in question.
From a vision standpoint, the company squarely acknowledges the limits of its existing product and has a
plan to move forward.
While part of the plan for the Axolotl acquisition was to use the product more widely within United Health
Group, OptumInsight also recognizes the significant opportunity in the broader provider and payer
markets. The company is evolving its story to better serve the needs of ACOs. This outward focus could
serve it well assuming it can deliver a long overdue product upgrade and successfully deploy it at customer
sites. We have received reports of less than adequate service during deployments which combined with a
dated product portfolio points to a potential market tailspin.
It is conceivable that Optum HIE is suffering because it is one HIT product among many at OptumInsight where the fight for resources could be an issue. Whatever the internal dynamics may be at
OptumInsight, its long-term prospects as a dynamic and continuing participant in the HIE market are more
in doubt than they were one year ago. OptumInsight’s marketing advantage based on the Axolotl brand
reputation is dissipating. While we like OptumInsight’s vision for its HIE suite, we need to see demonstrable
improved services execution in the field and new products to restore confidence in this former stalwart of
the HIE market.
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Orion Health
B+
B+
B
Overall
Product
Marketing
Company Headquarters: Auckland, New Zealand
Year Founded: 1993
Website: www.orionhealth.com Ownership: Private
2012 HIE Revenue: $65 million (approximate and North America only)
IDNs, hospitals and public agencies
Ideal
Customer
Top Three Differentiators:
1. Highly scalable platform and global presence
2. Strong public HIE expertise
3. Integrated care management, case management, and disease management
Product
P
roduct Innovation
Product Execution
Product and Version: Orion Health Health Information Exchange 7.3, August 2012
Dominant Deployed Architecture: Hybrid
Classification: Foundational HIE
B+
B+
Top Three Most Used Features:
Product
Criteria
Rankings
1. Clinician portal
2. Clinician notifications
3. Direct secure messaging
!
04
2
4
3
4
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
!
3
4
4
3
2
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Orion Health’s HIE solution set consists of Orion Health Clinical Portal, Clinical Data Repository (CDR) and
Rhapsody, its well-regarded integration engine. These offerings, plus ancillary products, including Orion
Health Case Management, EMR Lite, Patient Portal, and Direct Secure Messaging, provide nearly all of the
functionality needed for a foundational HIE. Orion Health can offer public HIEs a consistent deployment
model that represents a low risk way to connect a community. The company’s support for patient engagement efforts is particularly strong measured against other HIE vendors. Orion Health relies on either NextGate or IBM for its MPI and provider directory. It also partners with Health Language for its clinical vocabulary services and normalization. Orion Health has sold its HIE solution in the past as licensed software but
currently urges its new customers to subscribe to their SaaS. During 2012, Orion enhanced its solutions
with support for Direct secure messaging, RESTful APIs for language-independent development of applications that use the HIE, some very basic analytics functionality, an ambulatory-certified EHR, and a new
version of its patient portal.
Orion Health’s Direct Secure Messaging solution now provides HISP services for its HIE and non-HIE clients. It supports secure exchange via a web-based interface or an EHR via XDR, S/MIME, IMAP and software device implementation. It manages the conversion between encrypted XDR messages and S/MIME
messages to provide connectivity for all it Direct provider participants.
Orion Health has long offered its Case Management product, which provides the ability to devise individualized care plans and track progress for disease management and wellness purposes. This offering is generally deployed for specific conditions for patient panels. Provider organizations can coordinate care tasks,
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using “best-practice” treatment protocols, among multiple providers. This solution has been used for many
chronic conditions, immunizations, well-child care and post-operative care management. Orion Health
Case Management, together with Rhapsody, provide what is probably the strongest solution for disease
registries and public health reporting in the HIE market. In addition, this solution will be the basis for Orion
Health’s efforts to support many of the advanced collaborative care plans needed for HIE 2.0.
While Orion Health Case Management is a strong offering, particularly from an HIE company, it currently lacks a good way to stratify patients prior to enrollment in risk-based clinical programs. Most patients
enrolled in a disease management program using their tools are individually flagged by a clinician. This is
an area that Orion Health plans to improve this year with analytics that can risk-stratify populations. This
points to an area of continuing challenge for Orion Health – analytics. The company has not been adept at
leveraging the wealth of clinical data it supplies beyond point-of-care information delivery. As its U.S. customers transition to value-based payment regimes, Orion Health will need to meet this evolving demand.
To be fair, it has partnered with MedeAnalytics and recently agreed to refer customers to Caradigm for its
Caradigm Intelligence Platform in the U.S. market.
Orion Health also still has work to do to support some of the other advanced applications needed for HIE
2.0. For now, its offering for medications reconciliation is limited to providing facility-specific medications
lists. It is working on a cross-enterprise medications reconciliation solution geared to the requirements of
post-acute care providers that is based on its Case Management offering. It has an established closed-loop
referrals management solution using the HIE and clinician portal. However, the referrals product does not
currently offer a solution that is Direct-compliant or which supports clinicians outside of the HIE, which will
be problematic for customers seeking to qualify for incentives under Stage 2 MU.
In the area of clinician notification, Orion Health has a number of deployable options for providers. Clinicians can configure the portal to subscribe to ADT events, new results, and referral completions and receive
notifications in their Direct inbox as well as other delivery channels. Orion Health is also looking closely at
customer needs for readmission management and anticipates releasing a solution sometime in 2013.
Orion Health has a strong product set that can meet the needs and budgets of HCOs large or small. Its continuing investment in its products and its global healthcare experience combine to meet the market where it
lives. It supports both directed and query-based exchange with many of the applications required by HIE 2.0
HCOs. Time will tell if it can round this out with better population health management capabilities.
B
B
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, hospitals
Secondary Market: Independent practice associations, physician practices, payers
Estimated Number of U.S.-based Users (Private/Public): 320,000
• Statewide HIEs : 6
• Multi-stakeholder HIEs: 5
• Enterprise HIEs: 14
Provider Pricing Model:Subscription
Flagship Customers: Public: Massachusetts HIway, Maine HealthInfoNet, Beacon Community
of Inland Northwest, LaHIE, NCHIE, New Mexico HIE Enterprise: Catholic
Health Initiatives, Walgreen’s, UNC Healthcare, Inland Empire HIE, Lahey
Clinic, Ochsner Health System, UCLA Medical Center
Partners: NextGate, Accenture, Caradigm, Health Language
Market
Criteria
Rankings
!
Brand Recognition
3
Partner Strategy
4
Market Coverage
!
Services
!
Geographical Coverage
4
Vision
Orion Health is arguably the most prominent provider of healthcare interoperability globally and a major
HIE vendor in the U.S. It can and does bring its lessons learned from other countries to the United States.
From its origins as the developer of New Zealand’s national HIE, Orion Health has built a comprehensive set
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of products and services that it has been selling to HIEs in the United States. Its integration engine, Rhapsody, has long been considered best-of-breed for EHR integration projects. Most of its revenue comes from
North America and the company has doubled its headcount there in the last year.
As an HIE provider, Orion Health can offer many things to many potential customers. For public HIEs or
smaller enterprise HIEs, Orion Health can supply a packaged offering that offers good basic functionality that can be enhanced over time. For larger enterprises with more complex exchange networks and the
need for scale, it offers a flexible and extensible platform. Orion Health is unambiguously a major supplier
to public HIEs. However, we believe that Orion Health has not yet established itself as a major supplier to
enterprise HIEs. While the company has sold into enterprise HIEs in the last year, we will look for further
progress over time.
Orion Health’s market footprint with its Direct Secure Messaging offering made strides over the last year.
From three live clients this time last year, the company now has eight organizations with just under 7,000
clinician mailboxes. This will be important for customers seeking to qualify for incentive payments. Based
on this successful experience in North America with SaaS, the company is rolling out this offering in other
parts of the world.
Orion Health’s partner strategy is a decidedly mixed story. The company established a relationship with
Agfa recently that gives Agfa’s radiologist-customers access to the rest of the medical record. For Orion
Health customers, it provides an image-enabled HIE or EHR. On the other hand, its recently enhanced
alliance with Caradigm provides it with a promising analytics offering. Orion Health could acquire
Caradigm’s small roster of customers -- assuming that other HIE vendors do not strike first. This could
effectively double Orion Health’s HIE footprint in the U.S. measured by the number of distinct entities.
This relationship continues to evolve but it is unclear whether Orion Health has a plan to capture these
customers. The bottom line is that Orion Health has functioning partnerships for some of its underlying
technology but few partnerships that will help it grow in the enterprise market.
We mentioned Orion Health Case Management as the basis for its offering for population health management. This product has been widely deployed in single-payer healthcare systems. Whether this solution will
be adaptable to the US market where multiple-payers are the norm is a looming unanswered question.
Despite the lack of a well-developed analytics strategy and its relative lack of success in enterprise markets,
the company is a steady and growing presence in the U.S. That Orion Health was able to provide Caradigm
with an exit strategy from the HIE business is a testament to its durability and reputation as a provider of
clinical interoperability solutions. We expect that Orion Health will more aggressively market and sell Orion
Health Case Management in the U.S. this year in an effort make itself more attractive to enterprise HIEs and
HCOs making the transition to risk-based reimbursement models.
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RelayHealth
BBB
Overall
Product
Marketing
Company Headquarters: Atlanta, GA
Year Founded: 1999
Website: www.relayhealth.com Ownership: NYSE Listed
2012 HIE Revenue: $39-43 million
Integrated delivery networks and hospitals
Ideal
Customer
Top Three Differentiators:
1. Strong solution in McKesson environments
2. Cross-enterprise patient identity management
3. Built-in patient engagement
Product
BB
P
roduct Innovation
Product Execution
Products and Version: RelayClinical Platform 12.11, October 2012
Dominant Deployed Architecture: Centralized
Classification: Foundational HIE
Top Three Most Used Features:
Product
Criteria
Rankings
1. Physician alignment solutions bundle
2. E-Prescribing
3. Care coordination solution bundle
4
03
3
3
3
3
4
2
3
!
3
2
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
RelayHealth provides clinical, financial, and pharmacy solutions for HCOs, payers and HIT vendors seeking
to better coordinate care and manage population health. Its HIE, RelayClinical Platform aggregates discrete
patient data into a single longitudinal record. As new information is received, a copy of each source document is made, matched to the patient identifier, and added to existing patient information to form an updated longitudinal record. Discrete data that arrives as a CCD, an order or result, can be mapped to specific
fields within the longitudinal record while unstructured data is maintained as an attached CCD. The longitudinal record can be shared electronically and is available for download in BlueButton format. This basic
mechanism underlies bundles for care coordination, physician alignment, and population management. This
ambitious set of capabilities uses internally developed, completely .NET-based software on a multi-tenant
SaaS platform.
For the more advanced applications needed for HIE 2.0, RelayHealth has a clear product vision, if not deliverable functionality. RelayHealth’s historic strength as a platform for patient-provider communications puts
it in the forefront of HIE vendors for patient engagement. For instance, it can send patients a variety of different reminder types. It is now in the process of making Direct secure messaging available for patients and
providers. It is currently offering HISP services for McKesson EHRs and is rolling out HISP services to other
EHRs that support the Direct protocols. With these services, it can deliver a variety of notifications to PCPs
for most of the major hospital-based events. It is important to emphasize that many of these Direct-based
services are being rolled out and are not necessarily live.
In other applications areas for HIE 2.0, RelayHealth has offerings that are works-in-progress. It has traditionally offered payers a disease management solution based on its VITAL Care Management platform. It is
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now formulating plans to make this available to risk-based providers in conjunction with technology from
McKesson Population Manager and Risk Manager (MedVentive) as a care management platform. While it
can provide basic data for immunizations and disease registries, the company points out that few of its customer are asking for these capabilities. It also points to the lack of standardization among the 50 states as
an obstacle to developing functionality that would deliver more than just raw data.
Its medication reconciliation functionality consists of the ability to deliver a current, normalized and deduped medications list using data supplied by third-party aggregators, its own eScripts e-prescribing solution, or by CCD received in an exchange transaction. It also provides data, in the form of CCDs, for the
purposes of cross-enterprise care plans and for care management. For instance, it can push a care plan as
an unstructured attachment to post-acute care providers and PCPs. Similarly, it supports collaboration with
consolidated CCDs. The company has yet to deliver functionality to support care plans and care team collaboration across the community that relies on applications other than simple messaging.
RelayHealth customers can perform some of the reporting needed for the EHR Incentive Program and for
other payer and governmental clinical quality reporting initiatives. The technology base for these reporting applications consists of data cubes that also support the ability to look at a patient’s data by disease
state, medication history, laboratory result and other clinical measures. The company believes that the data
captured in HIEs represent a much broader opportunity for more effective population health management,
especially when combined with technology from MedVentive and some McKesson care management capabilities. We agree that the vision and the potential is there and will watch with interest over the next year to
see whether the company begins to deliver something closer to out of the box functionality.
For McKesson customers, RelayHealth is farther along the road to HIE 2.0 than many HIE vendors. It has
made good progress in the last year in supporting query-based exchange and making better use of the longitudinal patient record in directed exchange. The company has a competitive offering for HCOs seeking to
offer Direct-based services for clinician and patients. As in the past, its patient engagement capabilities are
among the most competitive in the industry.
B
B+
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, public agencies.
Secondary Market: Department of Defense, HIT vendors
Estimated Number of U.S.-based Users (Private/Public): 41,000
•Statewide HIEs : 0
• Multi-stakeholder HIEs: 6
• Enterprise HIEs: 93
Provider Pricing Model: License
Flagship Customers: Public: Jersey Health Connect, Military Health System (Army, Navy and
Air Force Medical Service); Enterprise: Saint Luke’s Health System, Baptist
Health System Kentucky, Mississippi Health Partners, Atlantic Health, Hill
Physicians, St. Charles Health System
Partners: Other McKesson companies, Greenway, TransforMED, INteliChart
Market
Criteria
Rankings
!
!
!
Brand Recognition
3
Partner Strategy
Market Coverage
4
Services
Geographical Coverage
3
Vision
RelayHealth differs from most other HIE vendors because it focuses on a broader variety of clinical, financial and pharmacy solutions. RelayHealth can also support the exchange of data not typically found in HIEs,
usually eligibility and reimbursement data. While other HIE vendors can work with claims and revenue cycle
data, RelayHealth, again as part of McKesson, does offer significant expertise marrying this kind of data to
the clinical data found in HIEs and attached EHRs.
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After a review of its business, McKesson recently announced that RelayHealth would be expanded to
over 2,000 employees “with a concentrated focus on the capabilities needed for new care models, such as
coordinating care and managing populations.” RelayHealth has been given the mission and the resources to
become McKesson’s solution to enable population health management, a capability that will be integral to
the mission of any ACO.
RelayHealth Platform will serve as the unifying technology for the CommonWell Health Alliance – in theory.
The company has a singular commitment to advancing the cause of clinical interoperability in healthcare
within McKesson and across HIT. The initial services RelayHealth will provide to CommonWell members
will concern patient matching across HCOS, consent management, and clinical data routing. While the
possible impact of the CommonWell Health Alliance is uncertain, RelayHealth leadership role in this initiative is evidence of McKesson’s commitment to the full use of data across the continuum.
Last year, we noted that much of the demand that RelayHealth was experiencing came from McKesson
customers. It is heartening to see an acquisition in which the acquired company benefits from the captive
customers of the new parent. On the other hand, the company has had limited success outside of McKesson
marketing RelayClinical Platform. An important part of RelayHealth’s plans for meeting the needs of new
risk-based providers will depend on incorporating the technology and value proposition brought to McKesson by its newly acquired analytics vendor MedVentive. We think it will be important over the next year
for RelayHealth to involve MedVentive in the RelayClinical Platform, even if it does not enlist many third
parties in this effort.
On balance, RelayHealth has articulated a marketing vision for HIE 2.0 and population health management
for risk-based providers with MedVentive that is broader than other HIE vendors. However, it remains to be
seen, despite McKesson’s resources, if the company will deliver on this promise.
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Surescripts and Kryptiq
BC+
B
Overall
Product
Marketing
Company Headquarters: Arlington, VA
Year Founded: 2001
Website: www.surescripts.com Ownership: Private
2012 HIE Revenue: $11-15 million
EHR vendors, pharmacies, hospitals, large practices
Ideal
Customer
Top Three Differentiators:
1. National network
2. Ability for a physician or their delegate to send information to anyone with an email address
3. Integration with EHR workflow
C
B
Product P
roduct Innovation
Product Execution
Products: Surescripts Network for Clinical Interoperability
Version: Continuous subscription service
Dominant Deployed Architecture: Federated
Classification: Messaging-centric
Top Three Most Used Features:
Product
Criteria
Rankings
1. Send message
2. Directory services
3
02
3
2
2
3
Data Access & Presentation
Standards & Terminology
Medications Reconciliation
Patient Engagement
Analytics & Reporting
Public Health Reporting
2
4
3
4
2
1
External Integration
Clinical Coordination Support
Referrals Management
Platform Support
Clinical Quality Reporting
Analytics for Population Health Management
Surescripts acquired Kryptiq in 2012. Kryptiq was always atypical in the HIE market since it never delivered customary elements like an MPI or and RLS. It has focused on the movement of data around related
HCOs with a robust, collaborative messaging solution integrated into a relatively small number of ambulatory EHRs, but with an affinity for GE’s Centricity. Surescripts, a major provider of e-prescribing solutions
has also adopted a clinical messaging solution built largely on the value of its significant store of medications
data from its retail pharmacy parents.
The Surescripts Network for Clinical Interoperability (CI) is a general-purpose messaging solution for clinical communication and collaboration built in conjunction with the former Kryptiq’s technology on Surescripts’ network. It allows a clinician to send a secure message to another clinician with any kind of information payload. The payload could be, among other things, a CCD or a PDF and it could be coded in any
healthcare standard or in no standard. Moving aggressively to support Direct protocols, Surescripts is now a
HISP that supports the ability to connect anywhere on the Surescripts network and perform HISP-to-HISP,
Direct-compliant exchange outside that network. Clinicians gain access through their EHR or a clinician portal and the company has various ways to connect users based on whether they have a HISP already or will be
using Surescripts as their HISP. Surescripts’ current roster of integrated EHRs is thin (15) but contains some
of the major ambulatory products. For a company with a truly national footprint and broader ambitions, this
number is surprisingly low.
CI provides some distinct advantages over other Direct-compliant HISPs – guaranteed delivery of mes-
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sages and a discoverable directory of 480,000 physician-users of its e-prescribing solution. These advantages could be temporary so Surescripts is now starting to develop the workflow capabilities needed for
value-based care delivery. For example, it can generate letters to PCPs for some immunizations performed
in pharmacies. These notifications will have to be expanded to include many more kinds of events and recipients and, most obviously, leverage the CI network rather than the USPS. Although it can report immunizations to 31 states currently, it, like all other vendors, is working through the complexities of 50 different
standards for 50 different states.
The company is taking small steps toward increasing the range of clinical data that can be exchanged with
the CI. Under a CDC grant, it is working with some 600 hospital laboratories seeking to automate reporting
of results, using LOINC, to state public health agencies. The company is also doing some preliminary work
with Merge Healthcare to support information exchange between diagnostic imaging centers and providers
on the CI network.
For many of the more advanced HIE 2.0 applications, Surescripts has adopted a messaging-centric approach
to supporting clinician workflow. It suggests that an initial message from one provider to another can create
an expectation that the recipient will take an action and then respond to the originator. For example, it plans
to offer a referral message type that contains status data relevant to the referral (i.e. unscheduled, pending,
completed) that could provide the basis for a more functional, closed-loop referrals application and workflow. Building on this kind of back and forth exchange between clinicians, it hopes to support complex workflow in varied clinical contexts. This idiosyncratic view is understandable considering both Surescripts’ and
Kryptiq’s historic reliance on messaging, but possibly not realistic given market momentum toward more
query-based exchange and common cross-enterprise workflow automation.
Surescript’s general view is that clinicians want to be able to push high-quality data for medications reconciliation and it is up to the target EHR to perform the actual reconciliation. (see separate discussion in
Chapter 2 on Surescripts’ wider role in medications reconciliation for HIEs). This view is common among
HIE vendors and Surescripts can also support queries for the medications list. However, Surescripts is better positioned than any other HIE vendor to provide raw community-based data for medications reconciliations – pushed or pulled – we are not sure that its view of how that data can best be used by providers is in
step with HCO and clinician demand.
Kryptiq has long sold its CareManager application and, presumably, will now market it to more HCOs seeking to provide accountable care and support analytical applications. Broadly, this offering aggregates clinical
data in ways that are useful for risk management and care coordination and includes some CDS capabilities.
At this time, the company has not delivered much in the way of functionality that leverages this data. As with
the CI network broadly, Surescripts needs to make this offering more attractive to more different kinds of
EHR users.
CI is first and foremost a network for e-prescribing. Surescripts understands that adding services on this
network is key to its future. For now, the messaging approach is an effective way to deliver its existing services. The concern is that the inevitable increase in query-based exchange among HCOs is not being reflected in Surescripts current decisions about product development. While directed exchange will always be
used by clinicians in different HCOs, query-based services are a real and growing demand from Surescripts’
customers.
Marketing Market Vision Market Execution Primary Market: Integrated delivery networks, Hospitals
B
Secondary Market: Public agencies, practice associations
B
Estimated Number of U.S.-based Users (Private/Public): 300,000
•Statewide HIEs : 0
• Multi-stakeholder HIEs: 2
• Enterprise HIEs: 35
Provider Pricing Model: Set-up Fee and Subscription
Flagship Customers: Enterprise: CVS, Walgreens, Rite-Aid, Express Scripts, Inc., Epic, NextGen
Partners: GE Healthcare
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Market
Criteria
Rankings
3
Brand Recognition
4
Partner Strategy
3
Market Coverage
4
Services
!
Geographical Coverage
2
Vision
Last year, we said that the Surescripts-Kryptiq combination was a “viable, albeit lightweight HIE”, largely
because of its disinclination to generate the longitudinal patient record from across the community. Given
the heightened interest in Direct, it appears that the Surescripts-Kryptiq combination anticipated that the
technology future for the HIE market as a whole might be messaging-based. That said, Surescripts recognizes the urgent need to provide integrated access for many more EHRs than it currently does.
Surescripts acquired Kryptiq this past September and the marketing challenge now is to expand on the
established relationships with EHR vendors that came with Kryptiq. Surescripts and Epic announced that
Epic’s Care Everywhere interoperability platform will connect to the Surescripts CI. While this is an important step, integration with more community EHRs will be key if Surescripts hopes to replicate its success
with e-prescribing and attract more HCOs with Direct-based messaging to meet the Stage 2 MU criteria.
In addition, the company’s estimable value proposition in e-prescribing and medications history must also
be expanded to include other clinical data types. Its work with hospital laboratories in the Lab Interoperability Cooperative could be a first step. Since hospital laboratories are LOINC-challenged, this effort could
help them communicate to their communities in a more standard way.
At this point Surescripts’ embrace of query-based exchange is less than enthusiastic. We think this puts
it in a difficult position as a provider of HIE 2.0 solutions. Much of the workflow-based HIE 2.0 application functionality required by providers is not on the horizon for Surescripts. While it has a referrals value
proposition, it is seemingly not interested in developing workflow-based applications that will rely on access
to community-wide data. If market demand for referrals management applications stalls on a simple push
of clinical data to specialty providers, then Surescripts might be well positioned. However, we believe that
the market is moving in the direction of query-based exchange. Complex workflows that pull data from an
exchange community will only increase. For this reason, we believe that the Surescripts approach to the HIE
market will continue to be atypical.
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CHAPTER 3: Notes
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CHAPTER 3: Notes
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© 2013 CHILMARKRESEARCH
APPENDIX: A
ACRONYMS USED
Acronym
Definition
Acronym Definition
ACO
Accountable Care
Organization
DoD
ADT
Admit, Discharge or Transfer DSM
Direct Secure Messaging
AHLTA
Armed Forces Health
Longitudinal Technology
Architecture
DTAAP
DirectTrust Agent
Accreditation Program
AMIA
American Medical
Informatics Association
ED
Emergency Department
API
Application
Programming Interface
EDI
Electronic Data Interchange
ARRA
American Recovery &
Reinvestment Act
EH
Eligible Hospital
ASP
Application Service
Provider
EHR
Electronic Health Record
CA
Certificate Authority
eMAR
Electronic Medication
Administration Record
CAH
Critical Access Hospital
EP
Eligible Professional
CCD
Continuity-of-Care
Document
FFS
Fee-for-service
CCDA
Consolidated CDA
FFV
Fee-for-value
CCHIT
Certification Commission
for Health Information
Technology
GEM
Guideline Elements Model
CCOW
Clinical Context Object
Workgroup
HCO
Healthcare Organization
CCR
Continuity of Care Record
HeD
Health eDecisions
CDR
Clinical Data Repository
HEDIS
Healthcare Effectiveness Data
and Information Set
CDS
Clinical Decision Support
HHS
Department of Health and
Human Services
CIO
Chief Information Officer
HIE
Health Information Exchange
CMIO
Chief Medical Information
Officer
HIMSS
Health Information and
Management Systems Society
CMS
Center for Medicare and
Medicaid Services
HIO
Health Information Exchange
Organization
CPT
Common Procedural
Terminology
HIPAA
Health Insurance Portability
and Accountability Act
DICOM
Digital Imaging and
Communications in
Medicine
HIS
Health Information System
IaaS
Infrastructure as a Service
HISP
Health Information Service
Provider
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Department of Defense
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A-1
Acronym Definition
Acronym Definition
HIT
Healthcare Information
Technology
P4P
Pay for Performance
HITECH
Health Information
Technology for Economic
and Clinical Health
PaaS
Platform as a Service
HL7
Health Level 7
PACS
Picture Archiving and
Communications System
ICD
International Classification
of Disease
PBM
Pharmacy Benefits Manager
ICU
Integrated Delivery
Network
PCMH
Patient-centered Medical
Home
IDN
American Recovery &
Reinvestment Act
PCP
Primary Care Physician
IHE
Integrating the Healthcare
Enterprise
PDQ
Patient Demographics Query
IMAP
Internet Message Access
Protocol
PHI
Protected Health Information
IPA
Independent Practice
Association
PHM
Population Health
Management
ISV
Independent Software
Vendor
PHR
Personal Health Record
IT
Information Technology
PIX
Patient Identifier Crossreferencing
IWG
Interoperability Workgroup
PKI
Public Key Infrastructure
J2EE
Java 2 Enterprise Edition
PMS
Practice Management System
LIS
Laboratory Information
System
PPACA
Patient Protection and
Affordable Care Act
LOINC
Logical Observation
PQRS
Identifiers Names and Codes
MDS
Minimum Data Set
RCM
Revenue Cycle Management
MPI
Master Patient Index
RFI
Request for Information
MU
Meaningful Use
RFP
Request for Proposal
NDC
National Drug Code
RHIO
Regional Health Information
Organization
NPRM
Notice of Proposed
Rulemaking
RIS
Radiology Information System
NQF
National Quality Forum
RLS
Record Locator Service
NwHIN
Nationwide Health
Information Network
Saas
Software as a Service
OASIS
Outcome and Assessment
Information Set
S/MIME
Secure/Multipurpose Internet
Mail Extensions
ONC
Office of the National
Coordinator
SHIECAP
State Health Information
Exchange Cooperative
Agreement Program
OS
Operating System
SHIN-NY
Statewide Health Information
Network of New York
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Physician Quality Reporting
System
© 2013 CHILMARKRESEARCH
Acronym Definition
Acronym Definition
SNOMED
CT
Systematized Nomenclature
VLER
Of Medicine Clinical Terms
Virtual Lifetime Electronic
Record
SOA
Service-oriented
Architecture
XCA
Cross-Community Access
USPS
United States Postal Service
XDR
Cross-Enterprise Document
Reliable Interchange
VA
Veterans Administration
XDS
Cross-Enterprise Document
Sharing
VistA
Veterans Health Information
Systems and Technology
Architecture
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A-3
APPENDIX: B
SCOPE & METHODOLOGY
This report profiles 19 HIE vendors. Many more HIT suppliers claim to offer an HIE solution. Therefore, we
have established parameters as to what constitutes an HIE vendor for the purposes of this report:
• T
he vendor’s solution provides, at a minimum, clinical data viewing across multiple EHR and/or HIS
software platforms and messaging in support of clinician communication.
• T
he vendor has established a presence in the US market with several clients deploying or using its
solution today.
• T
he HIE solution is largely EHR agnostic. This rules out most EHR vendors (Epic, eClinicalWorks,
NextGen, etc.) who provide HIE capabilities to their captive clients with closed systems. Some
EHR vendors have partnered with HIE vendors such as Epic partnering with Surescripts. We have
profiled Surescripts, but not Epic. We also profile Cerner’s HIE solution because it pursues “open”
architectural model.
• T
he vendor’s core HIE capabilities are developed internally, i.e., this is not a solution built from just
partnerships — a practice common among telecoms & consulting firms (e.g. ACS, Verizon)
To compile this report, Chilmark Research combined extensive primary and secondary research techniques
to create a composite profile for each HIE vendor. Primary research was divided into two distinct steps
beginning with soliciting targeted HIE vendors for their involvement in the research project. Vendors were
asked to complete a detailed questionnaire to collect qualitative and quantitative information about the
company and the markets they pursue. Questions included among others: 2012 revenue and projected
2013 revenue, number of employees, primary market, number of healthcare entities currently using
their solution, and more in-depth questions regarding their solution’s features and functions. As this is
still a very immature market, many were reluctant to share some metrics regarding their business for
competitive reasons. In such situations, Chilmark Research provides estimates based on knowledge of the
market, common operational metrics and a vendor’s overall position in the market.
Upon receiving the completed questionnaire, a follow-up interview was conducted with each vendor.
These in-depth telephone interviews typically lasted one hour and were used to clarify their responses to
the questionnaire. This portion of the research effort also focused on topics that cannot easily be captured
within the context of a written questionnaire including competitive positioning, product roadmap,
partnership strategy, and which of their solution features are most attractive to prospective customers.
Chilmark Research performed a final analysis of the HIE vendors via secondary research and telephone
interviews with end users and consultants that have advised on, deployed or used an HIE system. This
information was compiled to provide the in-depth reviews and rankings of the vendors profiled in this
report. Prior to final publishing, all vendors were given an opportunity to review their profile narratives
(not rankings) for fact checking. Their comments and feedback were considered and where relevant,
incorporated into the final profile narratives.
Throughout the entire research process to compile this extensive report, Chilmark Research maintains
absolute objectivity (sometimes to a vendor’s chagrin) and it is our sincere hope that this report brings
greater clarity to this important market.
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© 2013 CHILMARKRESEARCH
Contact Information:
Chilmark Research LLC
Website: www.ChilmarkResearch.com
Email: info@chilmarkresearch.com
Phone: 617.615.9344
The information in this report is proprietary to and copyrighted by Chilmark Research.
No part of this report may be reproduced or distributed without prior permission of
Chilmark Research. The information contained within the report is not intended as
a solicitation of an offer to buy or sell any investment or other specific product. All
information and opinions expressed in this report were obtained from sources believed
to be reliable and in good faith. No representations or warranty expressed or implied is
made as to its accuracy or completeness.
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I July2013
© 2013 CHILMARKRESEARCH
CONTACT
Chilmark Research LLC
www.ChilmarkResearch.com
info@chilmarkresearch.com
617.615.9344
The information in this report is proprietary to and copyrighted by Chilmark Research. No part of this report may be reproduced or distributed
without prior permission of Chilmark Research. The information contained within the report is not intended as a solicitation of an offer
to buy or sell any investment or other specific product. All information and opinions expressed in this report were obtained from sources
believed to be reliable and in good faith. No representations or warranty expressed or implied is made as to its accuracy or completeness.