Ingenix is a wholly-owned subsidiary of UnitedHealth Group, an $87 billion (2009 revenue) company with approximately 80,000 employees in its four major divisions:  health benefits, benefits management, data and information services, and pharmacy benefits management (PBM).   The health benefits (insurance) segment is the largest by far with 2009 revenue of $81.3 billion, and Ingenix (the data and information services segment) is the smallest with 2009 revenue of $1.8 billion.

However, Ingenix has an operating margin of 13.5% vs. the health benefits margin of 5.9% and Ingenix’s recent top line growth is stronger than the other segments.  Considering the number of acquisitions made by Ingenix, it’s not a surprise that revenue is growing.  According to Ingenix’s careers page, the group has acquired over 50 companies in the past 10 years.  See Alacra’s headlines and timeline of the Ingenix acquisitions since 1998 (as well as their offer to sell you more information).

A few notable acquisitions include The Lewin Group, a healthcare consulting company, QualityMetric, a health outcomes measurement company, and PICIS, a clinical workflow IT vendor to hospital emergency departments.  I find these deals of note because they clearly extend Ingenix’s purview beyond the payer and pharma analytics segment into the clinical analytics segment. 

The Lewin Group, for instance, received a contract from HHS last year to develop the framework for comparative effectiveness research.

Lewin describes how the resources of its sister companies within Ingenix position it well to develop the framework that will be used to determine the relative effectiveness of treatments on its own site as follows (emphasis mine):

The Lewin Group Center for Comparative Effectiveness Research has unique capabilities for conducting and supporting CER, combining The Lewin Group’s broad and widely recognized record of independent analysis of health information technology, evidence-based medicine, health care policy and other issues; affiliate company i3’s expertise in clinical trials and study design, drug safety, health economics and outcomes research; and Ingenix data.  Through Ingenix, the Center will have access to robust longitudinal de-identified patient data sets including integrated medical, disability, laboratory results and pharmacy claims data.  The staff available to the Center includes more than 1200 health services researchers, clinicians, clinical trial design experts, epidemiologists, biostatisticians, health data experts, health economists, and others.

In John Moore’s post, Ingenix’s EVP for provider solutions states that he “sees a convergence of administrative and clinical processes”.  I agree that analytic processes and platforms that have been developed for the payer market are being adapted for use in clinical settings, and I’d add that the same type of convergence is occurring between life science research analytic platforms and clinical platforms.  In fact, I’ve drawn a 3 circle Venn diagram illustrating the convergence in healthcare data analytics between these three domains in recent client reports.  

Should we be concerned that a large payer analytics company (Ingenix), owned by one of the largest health insurance providers, is on a path toward becoming a dominant clinical data analytics company?  I think so.  There are so many reasons to be optimistic about the benefits of data analytics in healthcare applications that can lead to improved personalized care and drug treatments.  But, like Levy, I have concerns about the concentration of power in large organizations and the implications of such market power on the future of clinical decision support systems.

Three talks at TEDxBoston that held the most for publishers were those by César Hidalgo, Seth Priebatsch, and Eric Mongeon.  Hidalgo spoke of the benefits of incorporating more complex relationships in predictive modeling.   He used the example from his studies of development economics, but on his website he also describes his collaborative research project related to predictive modeling of human diseases: HuDiNe.   Advances in computer technology and analytics have enabled his work that models complex relationships between a large number of variables.   Underlying his research are cross-discipline data sets, a trend that data publishers in all industry should take note of. 

Priebatsch, who is founder of SCVNGR, a game platform for completing place-based challenges, addressed how engaging users through interactive learning experiences that offer tangible or virtual rewards can guide behavior.  He referred to the medication compliance problem in healthcare where patients don’t take their prescriptions as directed and mentioned Cambridge-based Vitality that has a partial solution with its smart device GlowCaps.  Too bad he wasn’t aware of HealthPrize, [1]  another start-up that is targeting the same medication compliance issue with a solution that embraces the gaming mentality and rewards positive behavior.

Eric Mongeon, who includes the line “Denier of the death of print” in his Twitter profile, underscored how design can transform a publication into a multi-dimensional experience.   In his 4 by Poe series, design isn’t an afterthought, it’s an integral part of the publication.  The same thinking should hold for digital publishers that want to rise above commodity status.  Another lesson from Mongeon’s talk: publishers won’t enhance the lifetime of their print publications by scrimping on design and quality. 

TEDxBoston included an imaginative collection of speakers from academia, industry, non-profits, start-ups, students, musicians, artists, and journalists.  Every talk and performance was inspiring and passionate.   Filtering it for to B2B and healthcare publishers, the message was: always consider the three TED elements when planning content products and services.  Think beyond the informational value of your content to consider how to optimize the experience of consuming your content—that is, if you want to rise above commodity status. 

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1 HealthPrize’s  CMO, Dr. Katrina Firlik, will be speaking. at our upcoming Data Content 2010 conference.

I’m pleased to see that objectives related to patient access to information from his/her record are emphasized in the final rule. Offering incentives for doctors to provide patients with a clinical summary at each visit will improve doctor-patient relationships and help patients become more involved in their own health care and almost certainly will improve patient compliance with care instructions. But what really caught my attention is the rule that relates to using “certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate” [i.] This objective wasn’t included in the interim certification criteria, so its addition to Stage 1 of the final rule was a pleasant surprise.

The rule only requires that >10% of patients receive patient-specific education resources. Still, it is a start and will provide encouragement to more healthcare publishers to invest in creating high quality timely information for patients that can be incorporated into EHRs.

Already, clinical information publishers including EBSCO, Thomson Reuters Healthcare, Elsevier and Wolters Kluwer are in various stages of customizing patient education information for use within electronic records via Infobuttons.[ii]  The new meaningful use rule will be a boost to all publishers of evidence-based medicine to continue to fund expansion of their information sources and clinical decision tools for patients. And, once consumers get a taste for the personally relevant education materials that help them understand their conditions and their care plans, I predict that demand for more patient education resources will skyrocket.

i Full text of the patient education section from the final rule is appended below.

ii For more on Infobuttons, see: http://www.informatics-review.com/wiki/index.php/Infobuttons .
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Full text of the section of the meaningful use final rule from the CFR.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 412, 413, 422, and 495

NPRM EP/Eligible Hospital Objective: “Provide access to patient-specific education resources upon request.”

In the proposed rule, we discussed this objective, but did not propose it. We stated that there was a paucity of knowledge resources that are integrated with EHR, and that also are widely available. We also noted that the ability to provide education resources in multiple languages CMS-0033-F 182 might be limited. We stated our intent to further explore the objective in subsequent stages of meaningful use.

Comment: We received many comments, including comments from both the HIT Policy Committee and MedPAC, to include this measure in the final rule. These commenters disagreed with our assertion in the proposed rule that “there is currently a paucity of knowledge resources that are integrated within EHRs, that are widely available, and that meet these criteria, particularly in multiple languages.” Specific examples of the availability of knowledge resources integrated with current EHRs were provided. The HIT Policy Committee amended their recommendation in their comments on the proposed rule to:

- EPs and hospitals should report on the percentage of patients for whom they use the EHR to suggest patient-specific education resources.

Other recommended language for the objective includes

- Provide patients educational information that is specific to their health needs as identified by information contained in their EHR technology such as diagnoses and demographic data, and

- The original HIT Policy Committee objective of “Provide access to patient-specific education resources upon request.”

Response: We are convinced by commenters that the availability of education resources linked to EHRs is more widely available than we had indicated in the proposed rule. Therefore, for the final rule we will include this objective for the Stage 1 of meaningful use.

We note that the new recommendation of the HIT Policy Committee is a hybrid of a measure and an objective, whereas in developing the meaningful use criteria we consistently identify both an objective and associated measure. However, we agree with the HIT Policy Committee and others CMS-0033-F 183 that the objective and associated measure should make clear that the EP, eligible hospital or CAH should utilize certified EHR technology in a manner where the technology suggests patient-specific educational resources based on the information stored in the certified EHR technology. Therefore, we are including a revised version of this objective in the final rule for Stage 1 of meaningful use.

We also believe it is necessary to state what level of EP, eligible hospital and CAH discretion is available when deciding whether to provide education resources identified by certified EHR technology to the patient. Therefore, we include the phrase “if appropriate”, which allows the EP or the authorized provider in the eligible hospital or CAH final decision on whether the education resource is useful and relevant to a specific patient.

After consideration of the public comments received, we are including this meaningful use objective for EPs at §495.6(e)(6)(i) and eligible hospitals and CAHs at §495.6(g)(5)(i) of our regulations as “Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate”.

NPRM EP/Eligible Hospital Measure: Not applicable

Comment: CMS received a comment requesting an 80 percent threshold of appropriate patients and/or caregivers receiving patient-specific educational materials. In addition, the HIT Policy Committee’s revised objective suggests a patient based percentage.

Response: As with the addition of the recording of advance directives, we are able to relate this measure to one that is based on patients and can be accomplished solely using certified EHR technology. As this objective requires more than just the recording of information in certified EHR technology, we adopt a lower threshold of 10 percent.

CMS-0033-F 184

After consideration of the public comments received, we are including this meaningful use measure for EPs at §495.6(e)(6)(ii) and eligible hospitals at §495.6(g)(5)(ii) of our regulations as “More than 10 percent of all unique patients seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) are provided patient-specific education resources”.

We further specify that in order to meet this objective and measure, an EP, eligible hospital, or CAH must use the capabilities Certified EHR Technology includes as specified and standards at 45 CFR 170.302(m). The ability to calculate the measure is included in certified EHR technology.

To calculate the percentage, CMS and ONC have worked together to define the following for this objective:

* Denominator: Number of unique patients seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period. A unique patient is discussed under the CPOE objective.

* Numerator: Number of patients in the denominator who are provided patient education specific resources

* Threshold: The resulting percentage must be more than 10 percent in order for an EP, eligible hospital, or CAH to meet this measure.

We do not believe that any EP, eligible hospital, or CAH will not have more than 10 percent of their patients eligible to receive patient specific education resources and therefore do not believe an exclusion is necessary for this objective.

“Marketers have to be content creators.”

“Content first, then transactions.”

“The Web is becoming more mobile, more emotive, more experiential.”

Weber set the stage perfectly for our panel that followed: How Content Marketing is Shifting the Role of Publishers. In the changing landscape he described [1], all marketers are becoming publishers, and the content they produce creates new opportunities for publishers to aggregate information. Our panel of three digital publishing leaders provided great examples of how to this can be done.  For most B2B publishers, the ultimate goal of their digital environment (or community) is to bring together the buyers and sellers in their market segment to inform buying decisions and facilitate transactions.  The markets represented on the panel ranged from medical products, non-alcoholic beverages, commercial marine professionals, integrative practitioners , to even brides-to-be.

Some key recommendations for creating digital environments from our session:

• Listen to your customers. This may seem obvious, but most B2B publishers aren’t using social media and the interactive nature of the Web to its full extent to gain understanding of the characteristics and needs of their buyer and seller audiences.

• Facilitate communications between audience members to create a community. Prospects and buyers are more likely to exchange views on a neutral publisher’s site than on an individual vendor company’s website.

• Once you have an engaged community, consider live events that enable the community members to interact in person. The quality of the event is enhanced when attendees have already interacted online.

• Try including video interviews on your site. The shelf-life of video interviews is much longer than that of current news, and video has become much easier to produce. Put them on YouTube and they may go viral!

• Final practical tip: check your company’s profile on LinkedIn. It’s there whether you know it or not; you may as well take control of it.

The many other ideas presented and discussed in the Q&A reflected two mindsets. 1) New media tools are to be feared because they turn marketers into competitors; or 2) content produced by marketers creates new opportunities for publishers to aggregate and add value. However, this session underscored that, instead of fearing and resisting new technologies, publishers should seize the day and use them to improve relationships with customers, suppliers, advertisers, and sponsors.

Note, although this post is written for a general B2B audience, the pharmaceutical sector where pharma-sponsored content is growing at the expense of pharma advertising, would make an excellent case study on how content marketing is affecting publishers.

[1] See Roger Wilson’s summary of the ABM event  for additional perspectives on the program. 

I would like to thank the panelists who participated in the session: Melissa Chang, President, Pure Incubation; John Craven, President, BevNet.com; and Brian Randall, VP, e-media, Diversified Business Communications. 

Last week, I attended Patient-Centered IT ‘10 produced by the health and wellness team of Capstone Partners, an investment bank that serves middle market companies.  The quality of speakers and the interesting mix of health IT and health content start-ups combined to make it one of the better healthcare conferences I’ve attended in a while.

Among the highlights:

Jim Champy-of Reenginering the Corporation fame–opened the meeting with a preview of his new book, Reengineering Health Care, co-authored by Harry Greenspun, MD, CMO of Dell. Available in June, it is targeted to clinicians and exhorts them to take a stronger role in calling for improvements in our healthcare delivery system.   In Champy’s words, we “need proof to convince clinicians” of the benefits of changing and automating processes in healthcare provider institutions. 

Toward of the end of his talk, Champy expressed surprise that more consumers are not clamoring for change in our healthcare delivery system.   Why aren’t they?  I think it’s because they don’t have enough information about the often dangerous flaws in our current system or enough knowledge of how much better the system could be with improvements that are eminently doable with existing information sources and IT resources. 

Another speaker, Katrina Firlik, MD, CMO of HealthPrize, brought up the point that “data can drive better behavior“.    Her company uses techniques from human behavior studies to create engaging programs to improve patient adherence to prescription drug treatments.   

Both speakers emphasized the role of “evidence-based narratives” in changing human behavior.  We are producing and collecting increasing amounts of health-related data, and we’re making good progress in introducing standards and improving the interoperability between currently fragmented data sets, though the need for aggregators and consolidators will remain strong for the foreseeable future.

What is needed are compelling stories based on the data-stories that link back to the source data and exhibit a solid understanding of it. But Rosling warns that misrepresentations will be rampant as access to data becomes more open.  I recommend watching Rosling’s presentation that is referenced below–especially the first 20 minutes–for an entertaining and inspiring view of the power of data to change the healthcare story.

I’ll reveal my bias upfront. My background is in digital information services, and I’ve always viewed information management systems as tools for increasing the utility of the content that flows through these systems. An information system that doesn’t optimize the utility of the content in a way that adds efficiency to a process or leads to better outcomes is not all that compelling to a user.

With EHR systems, it has been long apparent to me that their value would be far higher to the clinicians who use them if the knowledge embedded in medical textbooks, scholarly research publications, and other reference sources were incorporated into the EHR systems at or near the point of care. Over the past 10-15 years, we’ve witnessed the gradual migration of information that had been stored in separate online reference systems to systems that physicians and other clinicians can access on their handheld devices or EHR/EMR screens. Epocrates for drug reference information on early PDA devices was a pioneer. Now, nearly all the reference and research content is digitized, but most of it hasn’t been incorporated into EHRs in a manner that maximizes its utility for clinicians. 

At this year’s HIMSS conference, there were myriad signs of accelerating convergence of EHR systems and health content. EHR vendors are eager to embed clinical information into their systems to demonstrate the value of incorporating accepted clinical guidelines, procedures, lab values, drug dosing suggestions, regulatory benchmarks and any other useful clinical reference content that would save the clinician’s time and lead to improved outcomes. Embedding the accepted rules and guidelines into an EHR system also provides the ability to customize recommendations based on the patient’s characteristics (sex, weight, other drugs being taken, allergies, and increasingly personal genome). The advantages of having the appropriate rules and guidelines embedded in the software are obvious. Just think TurboTax. [Note, I am focusing on clinical content in this post; benefits for administrative/performance improvement applications are equally compelling.]

Granted, medicine is more complex than the tax code. (It may be hard to believe anything is more complex than the tax code, even taking into account the state-wide variations, but it’s true!). Hospitals will continue to follow different procedures, guidelines will remain suggested guidelines to allow for individual variations, and new medical knowledge will be acquired daily. Nonetheless, the value of automating the practice of applying widely accepted medical rules and guidelines is immense-for practitioners and patients.

Medical publishers have been slow to adapt their content for usage in EHR/EMRs. Zynx Health, a Hearst Business company, was a leader in providing order set workflow systems that incorporate content. Their sister company, First DataBank, also proved the ground for transforming drug information to medication management systems. Based on my discussions at HIMSS, other medical publishers are accelerating their efforts to create clinical decision support systems from their collections of content that can be embedded in EHR/EMR systems. Elsevier, Thomson Reuters, and Wolters Kluwer, the big 3, have made great strides.

HIMSS is still a very technology-centric event with limited focus on health content and relatively few publishers exhibiting. Along with the big 3, a handful of other publishers, including EBSCO/DynaMed, Lexi-Comp, PEPID, and several patient education publishers (ExitCare, Healthwise, Patientedu.com) were present. And, of course, MedTech, the publisher of Healthcare IT New and Healthcare Finance News, which also publishes the Exhibit Guide and the daily HIMSS10 Guide, was there. BNA, a publisher of regulatory information, had a booth, too.

However, I see 2010 as a turning point for health content publishers. They have to learn to adapt their information for inclusion in EHRs. A digital version of a reference work is no longer good enough. The content has to become an “app” that can be incorporated into electronic systems.[2] Standalone content that doesn’t plug in to a user’s system or get embedded into clinical decision support systems will be left on the sidelines. By the time HIMSS11 rolls around next year, expect to see more health content publishers among the exhibitors and more clinical decision applications that can be integrated into healthcare information systems on display. Soon it will be difficult to identify where the content ends and the technology begins.

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1 Health Information Technology for Economic and Clinical Health Act (HITECH Act) is part of the American Recovery and Reinvestment Act (ARRA) bill of 2009 (aka, the Stimulus Bill). For details see: http://healthit.hhs.gov/.
2 Official standards for Meaningful Use that include use of evidence-based order sets and other clinical decision support systems by 2012-2015 will fuel this trend. 

RT @HealthVault: Register today for the Microsoft Connected Health Conf May 19-20. https://www.msconnectedhealth.com/SiteLogin.aspx

GE’s press release for HIMSS. Includes debut of clinical knowledge platform that helps providers with quality improvement initiatives, expanded HIE services, a clinical portal and a patient health management system.

PatientFinder, which estimates # of insured patients in region that have specific diseases but are untreated, to be offered by HealthLeaders Interstudy.