FHIR and the Future of Interoperability

There is growing interest in the health care information technology community in an emerging data exchange technology known as FHIR (pronounced “fire”). Last year we held a webinar on the topic with Dr. John Halamka, CIO of Beth Israel Deaconess Medical Center; Keith Boone, Standards Geek at GE Healthcare; Janet Campbell, Software Developer at Epic; and Arien Malec, VP, Data Platform and Acquisition Tools at RelayHealth. Now I am following up with another great webinar (register for free HERE) with a great panel including Dr. Michael Hodgkins, CMIO of American Medical Association (AMA); Dr. Doug Fridsma, MD, CEO American Medical Informatics Association (AMIA); Dr. Charles Jaffe, CEO Health Level Seven (HL7); Jeffery Smith, Senior Director of Federal Affairs, College of Healthcare Information Management Executives (CHIME); and Mario Hyland, Senior Vice President AEGIS.net, Inc. You won't want to miss this...

Health IT Sections in Proposed Rule to Update the Medicare Shared Savings Program

On December 1, 2014, CMS released an NPRM updating policies under the Medicare Shared Savings Program (MSSP). The proposed rule outlines proposed changes and seeks feedback in key program areas, including some health IT components. Comments are due February 6, 2015. The proposed rule is available here. The sections dealing with health IT are below.

8. Required Process to Coordinate Care

a. Overview

Section 1899(b)(2)(G) of the Act requires an ACO to "define processes to … coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies." In the November 2011 final rule (76 FR 67829 through 67830), we established requirements under § 425.112(b)(4) that ACOs define their care coordination processes across and among primary care physicians, specialists, and acute and postacute providers. As part of this requirement, an ACO must define its methods and processes to coordinate care throughout an episode of care and during its transitions. In its application to participate in the Shared Savings Program, the ACO must submit a description of its individualized care program, along with a sample care plan, and explain how this program is used to promote improved outcomes for, at a minimum, its high-risk and multiple chronic condition patients. In addition, an ACO’s application must describe target populations that would benefit from individualized care plans.

In developing these policies for the November 2011 final rule (76 FR 67819), we received comments acknowledging that requiring ACOs to define processes to promote coordination of care is vital to the success of the Shared Savings Program. Commenters stressed the importance of health information exchanges in coordination of care activities and recommended that CMS allow ACOs the flexibility to use any standards-based electronic care coordination tools that meet their needs. Other commenters suggested that the proposed rule anticipated a level of functional health information exchange and technology adoption that may be too aggressive.

As stated in § 425.204(c)(1)(ii), applicants to the Shared Savings Program must provide a description, or documents sufficient to describe, how the ACO will implement the required processes and patient-centeredness criteria under § 425.112, including descriptions of the remedial processes and penalties (including the potential for expulsion) that will apply if an ACO participant or an ACO provider/supplier fails to comply with and implement these processes. Under § 425.112(b), an ACO must establish processes to accomplish the following: promote evidence-based medicine; promote patient engagement; develop an infrastructure to internally report on quality and cost metrics required for monitoring and feedback; and coordinate care across and among primary care physicians, specialists and acute and postacute providers and suppliers.

In addition to the processes described previously, we believe it is important for applicants to explain how they will develop the health information technology tools and infrastructure to accomplish care coordination across and among physicians and providers Adoption of health information technology is important for supporting care coordination by ACO participants and other providers outside the ACO in the following ways: secure, private sharing of patient information; reporting on quality data and aggregating data across providers and sites to track quality measures; and deploying clinical decision support tools that provide access to alerts and evidence based-guidelines. As ACOs establish more mature processes for risk management, information technology infrastructure allows ACOs and providers to conduct robust financial management of beneficiary populations, deliver cost and quality feedback reporting to individual providers, and streamline the administration of risk based contracts across multiple payers. We believe that requiring ACOs to address health information technology infrastructure in their application to the Shared Savings program would support more careful planning and increased focus on this issue.

b. Accelerating Health Information Technology

HHS believes all patients, their families, and their healthcare providers should have consistent and timely access to their health information in a standardized format that can be securely exchanged between the patient, providers, and others involved in the patient’s care. (HHS August 2013 Statement, “Principles and Strategies for Accelerating Health Information Exchange”) HHS is committed to accelerating health information exchange (HIE) through the use of EHRs and other types of health information technology (HIT) across the broader care continuum through a number of initiatives including: (1) alignment of incentives and payment adjustments to encourage provider adoption and optimization of HIT and HIE services through Medicare and Medicaid payment policies; (2) adoption of common standards and certification requirements for interoperable HIT; (3) support for privacy and security of patient information across all HIE-focused initiatives; and (4) governance of health information networks. These initiatives are designed to encourage HIE among health care providers, including professionals and hospitals eligible for the Medicare and Medicaid EHR Incentive Programs and those who are not eligible for the EHR Incentive programs as well as those providers that are participating in the Medicare Shared Savings Program as an ACO and those that are not, and are designed to improve care delivery and coordination across the entire care continuum. For example, the Transition of Care Measure #2 in Stage 2 of the Medicare and Medicaid EHR Incentive Programs requires HIE to share summary records for at least 10 percent of care transitions.

We believe that HIE and the use of certified EHRs can effectively and efficiently help ACOs and participating providers improve internal care delivery practices, support management of patient care across the continuum, and support the reporting of electronically specified clinical quality measures (eCQMs).

c. Proposed Revisions

We continue to believe that ACOs should coordinate care between all types of providers and across all services, and that the secure, electronic exchange of health information across all providers in a community is of the utmost importance for both effective care coordination activities and the success of the Shared Savings Program. We understand that ACOs will differ in their ability to adopt the appropriate health information exchange technologies, but we continue to underscore the importance of robust health information exchange tools in effective care coordination.

ACOs have reported how important access to real time data is for providers to improve care coordination across all sites of care, including outpatient, acute, and postacute sites of care. We believe that providers across the continuum of care are essential partners to physicians in the management of patient care. ACOs participating in the program indicate that they are actively developing the necessary infrastructure and have been encouraging the use of technologies that enable real time data sharing among and between sites of care. We believe having a process and plan in place to coordinate a beneficiary’s care by electronically sharing health information improves care, and that this helps all clinicians involved in the care of a patient to securely access the necessary health information in a timely manner. It also can also be used to engage beneficiaries in their own care. We further believe that Shared Savings Program applicants should provide, as part of the application, their plans for improving care coordination by developing, encouraging, and using enabling technologies and electronic health records to make health information electronically available to all practitioners involved in a beneficiary’s care.

Therefore, we propose to add a new requirement to the eligibility requirements under §425.112(b)(4)(ii)(C) which would require an ACO to describe in its application how it will encourage and promote the use of enabling technologies for improving care coordination for beneficiaries. Such enabling technologies and services may include electronic health records and other health IT tools (such as population health management and data aggregation and analytic tools), telehealth services (including remote patient monitoring), health information exchange services, or other electronic tools to engage patients in their care. We also propose to add a new provision at § 425.112(b)(4)(ii)(D) to require the applicant to describe how the ACO intends to partner with long-term and postacute care providers to improve care coordination for the ACO’s assigned beneficiaries.

Finally, we propose to add a provision under § 425.112(b)(4)(ii)(E) to require that an ACO define and submit major milestones or performance targets it will use in each performance year to assess the progress of its ACO participants in implementing the elements required under § 425.112(b)(4). For instance, providers would be required to submit milestones and targets such as: projected dates for implementation of an electronic quality reporting infrastructure for participants; the number of providers expected to be connected to health information exchange services by year; or the projected dates for implementing elements of their care coordination approach, such as alert notifications on emergency department and hospital visits or e-care plan tools for virtual care teams. We believe this information would allow us to better understand and support ACOs’ plans to put into place the systems and processes needed to deliver high quality care to beneficiaries.

We also note that ACOs have flexibility to use telehealth services as they deem appropriate for their efforts to improve care and avoid unnecessary costs. Some ACOs have already reported that they are actively using telehealth services to improve care for their beneficiaries. We welcome information from ACOs and other stakeholders about the use of such technologies. We seek comment on the specific services and functions of this technology that might be appropriately adopted by ACOs. For example, does the use of telehealth services and other technologies necessitate any additional protections for beneficiaries? Are these technologies necessary for care coordination or could other methods be used for care coordination? If a particular technology is necessary, under what circumstances?

HHS Publishes FDASIA Health IT Report

HHS released a draft report that includes a proposed strategy and recommendations for a health information technology (health IT) framework, which promotes product innovation while maintaining appropriate patient protections and avoiding regulatory duplication. The congressionally mandated report was developed in consultation with health IT experts and consumer representatives and proposes to clarify oversight of health IT products based on a product’s function and the potential risk to patients who use it.

The report was developed by the U.S. Food and Drug Administration (FDA) in consultation with two other federal agencies that oversee health IT: HHS’ Office of the National Coordinator for Health IT (ONC) and the Federal Communications Commission (FCC). The FDA seeks public comment on the draft document. Comments can be submitted HERE on regulations.gov

The agencies are also holding a three day public workshop on May 13, 14, and 15 2014 at the National Institute of Standards and Technology to discuss the framework and its components. I would encourage anyone interested in health IT including consumers, providers, and healthcare organizations to register for the workshop HERE. It will be available via webcast or in person, but registration is required.

“The diverse and rapidly developing industry of health information technology requires a thoughtful, flexible approach,” said HHS Secretary Kathleen Sebelius. “This proposed strategy is designed to promote innovation and provide technology to consumers and health care providers while maintaining patient safety.”

"ONC welcomes comment on the draft report and stands ready to collaborate with stakeholders to ensure that health IT is designed and used with both innovation and patient safety in mind," National Coordinator for Health IT Karen DeSalvo said.

“This proposed strategy will facilitate innovation, protect patients and support FDA’s focused oversight on higher risk technology, similar to medical devices that are currently regulated,” said Jeffrey Shuren, M.D., director of the FDA’s Center for Devices and Radiological Health. “FDA looks forward to additional stakeholder feedback on the proposed framework in this draft report.”

Included in the framework is a proposal for ONC to create a public-private Health IT Safety Center in collaboration with the FDA, the FCC, HHS’ Agency for Healthcare Research and Quality (AHRQ) and other stakeholders. The Health IT Safety Center would work on best practices and provide a forum for the exchange of ideas and information focused on patient safety.

In the FDASIA legislation Congress required the FDA, ONC, and FCC to develop “a report that contains a proposed strategy and recommendations on an appropriate, risk-based regulatory framework pertaining to health information technology, including mobile medical applications, that promotes innovation, protects patient safety, and avoids regulatory duplication.” This report fulfills that requirement. The report proposes a risk-based regulatory framework for health IT which focuses on the functionality of health IT products not the platform themselves. The report suggests there will be few changes to most regulatory policies, and although they touch on mobile health applications, they don’t provide any new details on how the FDA will regulate mobile health apps deemed to be regulated medical devices or accessories to medical devices.

The proposed strategy identifies three categories of health IT:

• Administrative health IT functions (requiring no additional oversight),
• Health management health IT functions (no FDA oversight), and
• Medical device health IT functions (FDA oversight continues).

Medical device health IT functionality is where FDA will focus its oversight. Oversight of health management health IT will be through the enforcement of standards and through testing and certification, primarily overseen by the ONC. Conformance to standards will be used to meet some regulatory requirements. This is the area that will have the broadest impact on the health information exchange market. The report concludes that product testing, certification and accreditation can provide assurance that certain products, services, systems, or organizations meet specified standards or fulfill certain requirements. They recommend that these tools should be used and applied in a risk- based manner to distinguish high quality products, developers, vendors and organizations from those that fail to meet a specified level of quality, safety, or performance. They also recommend that non- governmental, independent programs to perform conformity assessments should be developed to fill current gaps.

As I mentioned, they have also proposed the creation of a Health IT Safety Center (funding has already been included in the President's budget request to Congress). This public-private entity would be created by ONC, in collaboration with FDA, FCC, and the Agency for Healthcare Research and Quality (AHRQ), with involvement of other Federal agencies, and other health IT stakeholders. They are seeking comment on how to best implement the creation of this entity. Instead of regulation, they will rely mainly on stakeholders reaching a consensus and voluntarily abiding by agreed-on industry standards.

Health management HIT functions (clinical software), includes but is not limited to: health information and data management, data capture and encounter documentation, electronic access to clinical results, most clinical decision support, medication management (eMAR), electronic communication and coordination among providers and patients, provider order entry, knowledge (clinical evidence) management, and patient identification and matching. “The agencies believe the potential safety risks posed by health management IT functionality are generally low compared to the potential benefits and must be addressed by looking at the entire health IT ecosystem rather than single, targeted solutions,” the report says. The report identifies the following four key priority areas for health management health IT functionality and then outlines some potential next steps that could be taken to help more fully realize the benefits of health IT:

1. Promote the Use of Quality Management Principles;
2. Identify, Develop, and Adopt Standards and Best Practices; They identified the following specific focus areas for standards and best practices implementation:
• Health IT design and development, including usability;
• Local implementation, customization and maintenance of health IT;
• Interoperability;
• Quality management, including quality systems;
• Risk management.
3. Leverage Conformity Assessment Tools; and
4. Create an Environment of Learning and Continual Improvement.

The report recommends that entities be identified to develop tests to validate interoperability, test product conformance with standards, and transparently share results of product performance to promote broader adoption of interoperable solutions. It will be very important to engage with the agencies during the comment period and the public meetings that will be scheduled over the next 90 days. It is also very likely that there will be hearings on Capitol Hill to review the report and it is possible that additional legislative action could be taken

There was a teleconference held on Thursday April 3, 2014 at 4:00 pm by the FDA, ONC and FCC to discuss the report and respond to questions. The panel was moderated by Stephanie Joseph, MPH, Health Programs Coordinator, Office of Health and Constituent Affairs, Office of External Affairs, FDA

Panelists included:

• Jeffrey Shuren, M.D., J.D., Director, Center for Devices and Radiological Health, FDA
• Jodi Daniel, Director of the Office of Policy Planning,  ONC
• Matthew Quinn, Director, Healthcare Initiatives, FCC

Audio of the panel is below

New Interoperability Initiative "CareQuality" Launched at HIMSS Conference

Healtheway Calls for Industry to Band Together to Transform Dream of Nationwide Health Data Sharing into a Reality

Carequality, a new initiative dedicated to accelerating progress in health data exchange among multi-platform networks, healthcare providers, electronic health record (EHR) and health information exchange (HIE) vendors was announced Monday February 24, 2014 at the HIMSS COnference in Orlando, Florida. Carequality is an open, transparent and inclusive industry-driven effort that will convene stakeholders and facilitate industry consensus to develop and maintain a standards-based interoperability framework that enables information exchange between and among networks. Carequality’s goal is to facilitate agreement on a common national-level set of requirements that will enable providers to access patient data from other groups as easily and securely as today’s bank customers connect to disparate banks and user accounts on the ATM network. Once achieved, this level of health data interoperability will represent a quantum leap in the quality of healthcare available and reduce the cost to support interoperability.

"The new frontier in achieving nationwide, secure health data exchange involves building upon all of the existing great work across various consortia and networks and tying it all together into a unified approach for the industry," said Mariann Yeager, Healtheway’s Executive Director. "A group of organizations – including many of those most active today in achieving nationwide interoperability – approached Healtheway about serving as the neutral convener for industry stakeholders to come together and work through implementation-level issues to enable exchange between and among networks. Today, we are presenting a call for action to participate in CareQuality and join this effort."

CareQuality is just beginning its activities and is open to all stakeholders who wish to participate. Healtheway is issuing a call for all interested parties to join the effort and engage in CareQuality. A wide range of organizations have pledged to join CareQuality as founders, including:

• California Association of Health Information Exchanges
• Community Health Information Collaborative
• eClinicalWorks
• Epic
• Greenway
• ICA
• Kaiser Permanente
• lifeIMAGE
• MDI Achieve
• Medfusion
• Medicity
• MedVirginia
• Mirth
• Netsmart
• New York eHealth Collaborative
• Optum HIE
• Orion Health
• Santa Cruz Health Information Exchange
• Surescripts
• Walgreens

Interoperability is a key component of the meaningful use program and is critical to building out an IT infrastructure to supporting a transformed healthcare system. CareQuality's work will be available to all industry stakeholders regardless of membership so that any provider group, electronic health record vendor, or exchange network can see how the group’s participants are accelerating exchange connections by using a single, non-proprietary interoperability framework.

At last year's HIMSS conference a group of EHR vendors, headed up by McKesson, Athenahealth and Cerner, started the CommonWell Health Alliance to promote interoperability. Epic, which was left of the effort, said this was more of a competitive play, and declined to join. Epic has questioned the purpose of Commonwell, claiming it is unnecessary since national interoperability standards already exist. Now Epic, along with many leading HIE vendors are anchors in the CareQuality Initiative.

“We are pleased to support Healtheway’s Carequality initiative. We strongly believe in the democratization of data exchange under the guidance of an independent national convener like Healtheway. We have a successful track record of cross-EHR interoperability conforming to the NwHIN and newer Direct standards and welcome the opportunity to work with this broad group of well-respected industry stakeholders to help accelerate record exchange under free and open standards," said Carl Dvorak the President at Epic.

HIE vendors like Medicity, ICA, Orion and Optum to name a few, are on board with the new initiative, and having it under the auspices of Healtheway as a neutral third party convener seems to give it some degree of transparency. "The Carequality initiative aligns strategically with Medicity’s commitment to interoperability and integrated workflow solutions for network-enabled population health. We are excited to join with key industry stakeholders to foster a more effective, connected health care ecosystem. Collectively, we embrace the value of continually improving patient outcomes, and this collaboration demonstrates great strides toward that goal," said Nancy Ham, CEO of Medicity.

Health IT State of the Union

I appeared on the Fed Tech Talk radio program on Federal News Radio which aired on WFED 1500 AM in Washington, DC on January 28, 2014. It was a fun discussion with host John Gilroy (check out his blog here) where we discussed the Office of the National Coordinator for Health Information Technology (ONC) Annual Meeting, the historic signing of an MOU between the United States and Great Britain on sharing health IT tools, health information exchange, EHR adoption, the Direct Project, mobile health, and the current state of health IT in the nation.

I gave some background on my involvement in health information technology and an overview of the landscape in health IT and how we are building out an infrastructure to improve our healthcare system. This was a lot of fun, and hopefully helped get the word out that the state of health IT in this country is strong, and we are looking at the best year ever ahead. The bottom line is that it is time to drag the US healthcare system (albeit kicking and screaming) into the 21st century of technology.

Analytics: Realizing the Value of Health IT

This is my post on the value of health information technology for National Health IT week. So far we have not yet fully been able to realise the value of health IT. While great efforts at adopting electronic health records and interoperability and  we are beginning to see some results from the billions of taxpayer dollars invested, we still have a long way to go before we see the true value of health IT.

Healthcare has been slowly moving through three waves of digitization and health data management: data collection, data sharing, and data analytics. While the data collection and sharing waves have been having some success, spurred on by the HITECH Act and implementation of electronic health records and health information exchanges, they have not yet significantly impacted costs or quality in healthcare, the third wave is ready to crash on our shores and I believe we will actually begin to see an IT infrastructure than support the new payment and care delivery models which are emerging.

This third wave of analytics will enable large numbers of healthcare organizations to realize some significant returns on their IT investments and thrive in the healthcare marketplace of the future. Developing a consensus model for adoption of analytics capabilities could help healthcare leaders and vendors succeed by providing a common roadmap for the deployment of these capabilities. But much of the success of these analytics platforms will depend on the underlying architecture and I think the "late-binding" data warehouse model holds the most promise.

The term late-binding dates back to at least the 1960s, where it can be found in Communications of the ACM. The term was widely used to describe languages such as LISP, though usually with negative connotations about performance. In the 1980s Smalltalk popularized object-oriented programming (OOP) and with it late binding. Alan Kay in History Of Programming Languages 2 laid out the fundamentals of OOP and late-binding architecture in The Early History of Smalltalk section. In the early to mid-1990s, Microsoft heavily promoted its COM standard as a binary interface between different OOP programming languages. COM programming equally promoted early and late binding, with many languages supporting both at the syntax level.

The late-binding data warehouse model is a just in time method and is more adaptable to new analytics use cases and data content than those that make use of early binding and tightly coupled enterprise data models. Late-binding is a method of assembling data from disparate sources just in time for particular analytic use cases, known as the late-binding model of data warehousing, is starting to gain traction in healthcare as many provider organizations gear up for population health management. The advantage of this approach is that it allows users to combine disparate data very quickly for targeted analyses without locking data warehouses into a predetermined data model.

This late-binding model for use in healthcare analytics was developed by Dale Sanders who after witnessing and reflecting upon the failure of several multimillion-dollar data warehousing projects during his work in the US military, saw the same patterns in data engineering as those in software engineering prior to OOP. In the late 1990s, while employed by TRW Inc., he was sponsored by the Pentagon to study advanced decision support in nuclear warfare operations, a project called the Stratgic Execution Decision Aid. He turned to the healthcare industry for what he expected to be role-model examples of computer-aided analytics to drive better decisions in time-critical, life-critical situations but instead found almost no examples, with the notable exception of a scattered few such as at Intermountain Healthcare in Salt Lake City.

Last month I was able to get a peek behind the curtain at the Health Catalyst analytics solution, which Dale has been helping develop. Health Catalyst is a data warehousing company that recently has gained a number of customers and investors among large healthcare organizations. For example Partners HealthCare System has joined with the investment arms of Kaiser Permanente and Indiana University in an $8 million equity investment in Health Catalyst. Health Catalyst uses a late-binding data warehouse model. There is a very good Slideshare on Late Binding in Data Warehouses that helps to illustrate some of the concepts.

Last year The Advisory Board Company acquired clinical analytics vendor 360Fresh. 360Fresh offers two products. Pulse360 uses text and data mining to extract information from EHRs and other systems to provide answers to clinical and quality questions. They also have Track360, which is a clinician care coordination and workflow tool designed to streamline provider handoffs, provide alerts, and improves patient communications. Both of these products are targeted for use by academic medical centers, independent community hospitals, and large-scale ambulatory providers. 360Fresh will augment The Advisory Board Company's Crimson offering which provides retrospective data review, by adding real time analytics capabilities.

Dale Sanders, along with colleagues Jim Adams, Ernie Hood and Meg Aranow of The Advisory Board Company; Denis Protti of the University of Victoria, British Columbia; Dr. Dick Gibson, Providence Health and Services; Mike Davis of Mountain Summit Partners; along with Dr. David and Tom Burton, both of Healthcare Catalyst, worked to develop an eight-stage Analytic Adoption Model similar to the seven-stage EMR Adoption Model (EMRAM) from HIMSS Analytics. This model was initially described in ElectronicHealthcare in September 2012. The hope is that this model will enable healthcare organizations to fully understand and leverage the capabilities of analytics so that we can begin to see the real value of health IT in laying a technology foundation to achieve the triple aim.

This model borrows lessons learned from the HIMSS EMRAM, and describes a similar approach for assessing the adoption of analytics in healthcare. The Healthcare Analytics Adoption Model provides:

• A framework for evaluating the industry’s adoption of analytics
• A roadmap for organizations to measure their own progress toward analytic adoption
• A framework for evaluating vendor products

HIMSS Analytics has also partnered with the International Institute for Analytics (IIA) to create a benchmarking survey designed to measure and score clinical & business intelligence and analytics maturity in healthcare organizations. They will use the DELTA model (data, enterprise-focus, leadership, targets and analysts) to assess analytic capabilities. I expect we will see a lot more about the Healthcare Analytics Adoption Model as the work continues to progress. This will lead us into the future of health IT where value will ultimately be realized.

Here is a good Slideshare on the Healthcare Analytics Adoption Model being developed:

Turn the page

After eleven years working at Mid-Columbia Medical Center (MCMC) in The Dalles, Oregon, I have decided to take advantage of some new opportunities and move on from the organization. This was a very difficult decision to make because I truly love MCMC. In 1992 MCMC was the first hospital in the world to implement the Planetree concept of patient-centered care facility wide, and in 2007 MCMC was recognized as a "Designated Patient-Centered Hospital", only one of five such hospitals in the country.

I've written about Planetree before and have always been incredibly impressed with the organization. It is with great gratitude that I leave both MCMC and Planetree since my life life has been dramatically changed by being a part of these fine institutions, but I am sure that at some point in the future we will cross paths again. The heart of the organization is patient-centered and I will always support these principles.

I am leaving MCMC, but fortunately I don't have to leave The Dalles, and will continue work both locally, statewide, and nationally on healthcare transformation. I live in one of the most beautiful places in the country: the gorgeous Columbia River Gorge! I am very grateful that my new opportunities are not requiring me to relocate.

I am also very grateful to people at MCMC who have been instrumental in my success. Of course some of the most important are: my boss, the CIO Erick Larson, the Medical Director Judy Richardson, and also the CFO Don Arbon, as well as the CEO Duane Francis (who actually invented the position Health IT Evangelist and the article in Government Health IT magazine was subsequently cited on the ONC website Health IT Journey's page... it makes for an interesting read :). But most of all I am in debt to Elise Bailey, one of the many unsung heroes of our healthcare system, for her faith in me and her unwavering faith in the power of Jesus Christ to transform lives. She gave me the chance I needed and believed in me eleven years ago when few others would. I will always be very grateful.

But like all great chapters in life, it is time to turn the page and move into the next phase of the journey. I have created Advanced Health Information Exchange Resources (AHIER) and will be working on Outreach and Business Development for DirectTrust (among other things) under a cooperative agreement with the ONC to participate in the Exemplar HIE Governance Program. DirectTrust is partnering with ONC and other participants to develop and adopt policies, interoperability requirements and business practices that align with national priorities. The goal is to overcome some of the EHR interoperability challenges, reduce implementation costs, and assure the privacy and security of health information exchange. Much of this effort has sprung from the Scalable Trust Forum.

I also have some other consulting engagements lined up, and I will continue to tweet, blog, and write about health IT and the technology infrastructure that supports new payment and care delivery models. One of the first things I am going to do is slowly transform this blog into more of hybrid blog/website. I will continue with somewhat of a focus and EHR and HIE, but also begin moving into the area of analytics. I once said "Big data is the next big thing in health IT," and now that we have begun aggregating this massive data set, the next wave beginning to crest is analytics. So watch for some posts focused on business intelligence and analytics capabilities, as I continue to cover the digitization of healthcare.

EHR Vendor Market Share

The latest SK&A "Physician Office Usage of Electronic Health Records Software" report shows continued growth in EHR software adoption, with 50% adoption in medical offices. In addition to reported trends by specialty, office size, application and ownership, this latest edition ranks EHR vendors by market share (see table below). You can register for a number of their reports for free here: http://www.skainfo.com/reports

SK&A was awarded a contract by the U.S. Department of Health and Human Services (HHS), Office of the National Coordinator for Health IT (ONC), to provide ongoing survey information about the adoption, usage and planned usage of electronic health records (EHR) by physicians in U.S. medical offices. The SK&;A OneKey database of 251,000 medical offices and over 700,000 physicians is delivered to ONC quarterly.

SK&A's Research Center in Irvine, Calif., conducts telephone interviews with office managers and physicians in all 50 states and the District of Columbia. Every month, the researchers survey and verify information at more than 40,000 sites. Medical offices are asked about their intent to purchase an EHR and about their timeframe, decision factors (such as price and functionality), and awareness of government incentives for adopting EHR technology.

EHR Vendor Market Share by Practice Size Rank Vendor Name Number of Physicians in Practice 1 to 3 4 to 10 11 to 25 26 to 40 41+ Overall 1 Allscripts 10.0% 13.2% 11.6% 10.7% 7.1% 10.6% 2 eClinicalworks Logan Solutions 11.0% 8.6% 5.5% 3.4% 0.0% 10.5% 3 Epic Systems Corporation 8.1% 17.0% 30.1% 33.5% 51.0% 10.3% 4 NextGen Healthcare 5.3% 9.3% 9.9% 5.3% 6.1% 6.1% 5 Practice Fusion 7.1% 1.0% 0.1% 0.0% 0.0% 5.8% 6 General Electric Healthcare IT 3.3% 7.2% 8.0% 11.2% 10.2% 4.1% 7 McKesson Provider Technologies 3.8% 2.7% 3.0% 5.8% 4.1% 3.6% 8 Cerner Corporation 3.1% 4.6% 8.0% 11.2% 10.2% 3.5% 9 AmazingCharts.com, Inc. 3.2% 0.5% 0.0% 0.0% 0.0% 2.7% 10 athenahealth, Inc 2.5% 1.6% 0.4% 0.0% 0.0% 2.3% 11 Greenway Medical Technologies, Inc. 1.7% 3.9% 2.3% 0.0% 2.0% 2.0% 12 MedPlus, A Quest Diagnostics Co. 2.3% 0.5% 0.1% 0.0% 0.0% 1.9% 13 e-MDs, Inc. 2.1% 1.5% 0.4% 1.0% 0.0% 1.9% 14 MEDITECH, Inc. 1.5% 2.8% 4.6% 6.3% 1.0% 1.8% 15 Vitera Healthcare Solutions 1.4% 2.1% 1.1% 0.5% 0.0% 1.6% 16 Community Computer Service Inc. 1.1% 1.9% 0.9% 0.0% 0.0% 1.2% 17 BioMedix Vascular Solutions 1.3% 0.3% 0.0% 0.0% 0.0% 1.1% 18 Office Ally 1.3% 0.2% 0.0% 0.0% 0.0% 1.1% 19 SOAPware, Inc. 1.1% 0.2% 0.0% 0.0% 0.0% 0.9% 20 NexTech Systems, Inc. 0.9% 0.3% 0.1% 0.0% 0.0% 0.8% 21 All Others Vendors (422) 27.8% 20.7% 14.0% 11.2% 8.2% 26.3% Grand Total 100% 100% 100% 100% 100% 100%

Source: SK&A, A Cegedim Company, May 2013.