Amion stands for the question every physician asks at one point or other in their residency – “Am I on?”. As I’ve pointed out before, scheduling is one of the prime candidates for being done externalized – done right by a handful of players, and utilized by everyone else.
Unlike the recent upstarts though, Amion has been around for 15 years. You can read the full story here. And unlike vanity metrics thrown around by other start-ups, Amion probably is used by over 100,000 users, as the company claims. They have products aimed at three user categories -residents, attendings, and organizations. Individuals can schedule their blocks, clinics, shifts synchronized with their personal calendars on external services (like Google Calendar or iCloud). Nuances like shift swaps , didactic pairings are probably what makes it highly relevant product for physician scheduling. Organizations probably value features like the vacation request management, policy-based rules checks, vacation/duty-hour reports, managing last-minute coverage changes etc. Plus there are some logical overlays likes auto-scheduler and template-based scheduling. Last year, Amion announced that they were launching a mobile app in partnership with Doximity. It does make sense that Amion user profiles be powered by Doximity, but the tone of press release seems to suggest more intimacy (scope of which I can’t understand).
For those who dismiss scheduling as a calendering feature, not a product by itself, think again. Here is the rough categories of solutions aimed at the scheduling puzzle in healthcare:
Chances of consolidation? Sure. But more likely are acquisitions by incumbent EHR technology players. Either way, it’s fascinating to see the breed of solutions as evidence for the inherent complexity of delivering timely, coordinated care.
November 2013 Update: Stuart Karon from Amion was kind enough to reach out and explain the Doximity-Amion relationship. Seems like it started with Doximity pulling schedule data for it’s users from Amion. They ended up spinning that part off into an independent app (for Amion). That way Amion got a professional mobile app with minimal investment and Doximity got a channel for getting new users onto the network. Symbiotic…
Most of the time, Health IT spawns artificial concepts – born as a result of relentless media hype, each reaches a precocious peak of publicity and then quickly fades away. Buzzwords like RHIO, NHIN, PHR, Chronic Disease Management, etc. were all touted as game changing at one point or other in the past. Now it’s more about patient engagement, HIE, Analytics, Care Collaboration. One stands out in my mind though – Population Health Management (PHM). I think that even though it may be riding the hype cycle like all others, it has signs of legitimacy.
Think of it this way. For decades, we have endured and participated in a healthcare system that is geared towards encounter-based medicine. Patient comes in with complaint X, gets treated and billed for complaint X. Now with changing payment models though, it is important for the payers and providers to broaden their perspective. They need to keep track of patient (member) over a period of time, and keep them out of hospitals/ERs. As a result they need a “Longitudinal Health Record” that spans across encounters. This is what HIEs promise to provide and interoperability standards promise to enable.
From a Health IT vendor perspective, PHM means tools that help user do two things:
This is done by analyzing a population in a given care context. Like HbA1c tests for diabetics. PHM construct is based on the premise of looking beyond those who need immediate care (i.e. are having an encounter) and provide insights on the entire cohort under care.
This is where the analytics graduates into what it should be – Actionable Analytics. The ideal PHM tool will not only help find at-risk individuals, but also make it easy to do something about it. So if the PCP user has found the 50 at-risk diabetics in his/her 1000 patient panel, they now need to send reminder letters or queue them up for some kind of outreach. This workflow integration is what really legitimizes the emerging niche of PHM. Just analytics on it’s own doesn’t cut it.
But the devil is in the details, of course. One can argue why EHRs, the perennial stolid incumbents of health IT world, don’t have this as native capability. The answer is clear if you’ve ever used an EHR. They were (and are) built as transactional systems that focus on the current visit billing and documentation. Doing a parallel meta-analysis of how this patient fits into a population profile and what they need outside the context of this visit is a humungous leap for almost all EHRs. And that is why a new crop of startups have started to focus on this niche.
AmplifyHealth says all the right things on it’s website. They point out the need for finding patients that are going off-track. Like most startups, it avoids putting a live demo video on the site (so frustrating) so I’m going off of what the webpages claim as capabilities. The three areas they speak of:
- Patient Management: Seems like this provides ability to create custom lists, akin to registries. That is a valid value-add, aligned with actionable analytics as described above. But the website description veers off into “engage new patients, influence productive behavior, establish relationship” which is confusing. All those belong to the foundational practice management and EHR system.
- Measuring Outcomes: This would be the ‘meta-analysis’ that doesn’t come native with EHRs. Tracking outcomes based on measures is just starting to get engrained into the EHR DNA, thanks to the bullying by Meaningful Use regulation. But even that is a very regimented approach to this meta-analysis, and may not suffice for an ideal user. Hence the value-add opportunity.
- Client-Sales Support: Very interesting. This seems to be an administrative dashboard for provider groups, self-insured employer groups to analyze of potential savings for a population. So it goes beyond just the clinical aspect of Population Health Management. I can see that as a separate sell to administrative, non-clinical users.
Buoyed by the hype that usually accompanies anything new Health IT, PHM is ready to bask in media limelight. But this may be one of the rare occurrences where there is actual substance underlying the claim to fame. Of course, only time will tell. One thing is for sure – you will see this term splattered across a lot of vendor booths in HIMSS 2014.
Scheduling is starting to become a great example when I talk to others about what is wrong with the current mainstream healthcare IT market. In short, the mainstream vendors are trying to do everything, and ending up with sub-optimal solutions across the board. Luckily for them, most clients are either unaware or choose to overlook the grotesque in the IT solutions presented. Which is why, I think the future is niche. Focused solutions that do a fantastic job at a subset of the myriad jumble called healthcare will be the next generation. Scheduling, is one such focus.
Some good examples already exist, albeit with slight variations on how/what they approach in healthcare scheduling. MyHealthDirect, ZocDoc, Zeel, YourNurseIsOn, InQuicker come to mind. Add Lightning Bolt to the lineup (the complete list is here). Founded in 2002 by a scientist working on scheduling supercomputer tasks, Lightning Bolt provides medical staff scheduling solutions to create, manage, request, report and communicate staff schedules.
I’ve not used their solutions, so unable to do a deep examination. But two things stood out for me. First, they position tailored solutions to certain clinical domains like radiology, hospitalist, etc. That is nice, because I do believe that the challenges and complexities of scheduling in one clinical domain (like anesthesiology) may be different enough from another (say, something like Emergency Medicine) to warrant a different user experience. The underlying technical platform can of course be common. Second, I like the subscription-based pricing model. It’s common in the SaaS world, but most healthcare IT vendor ecosystem is still mired in license mentality.
It’s encouraging to see more entrants in the scheduling arena. What worries me is that niche solutions need to find enough scale to be viable long-term. Like it or not, the checks in enterprise healthcare IT are still written to stolid incumbents. Partly because these incumbents continuously claim to be a one-stop-shop (simpler for the client CIO, CFO)… which brings me to the point I started this post with (that they try to do a lot, and end up sucking at most of it).
So how does a new entrant, which does a singular-but-key workflow, find it’s place in the established ecosystem? I wish I knew. Regardless, an upstart like this will surely claim the crown for healthcare scheduling one day.
As I’ve pointed out before, referrals is a complicated workflow in healthcare. But it’s important nevertheless because it affects transition points in a patients care continuum, in turn affecting outcomes and cost.
Par8o was founded by the same guys who started Sermo (the online physician community that had the distinct honor of being the first review on Multiplyd 🙂 ). It’s a referral management platform for physicians and their staff. Basic participation features like send/receive referrals, adding staff is free. For $80.20/month, the premium account will enable prominent placement in search results, personalization (availability, insurance accepted, etc.).
The recent rise of startups focused on referrals indicates another failure point in the conventional EHR world. Why, one wonders, is this not just a feature of the EHR installed in the PCP and specialists’ office? Or a service provided by the regional Health Information Exchange (HIE)? Having yet another place to log in, figure out, and use is a detriment for the average physician who is time-strapped. Other headwinds exist. ONC‘s push for Direct Project based secure messaging may start creating a genuinely untethered (from EHRs) way for physicians to connect with each other. Competing with the current fax, phone system of referral is not easy either. They may be ugly and inefficient, but they are there. With established workflows and staff familiarity.
The gold at the end of referral management rainbow lies in two pots: Analytics and Provider Directory. The former provides overarching insight that has never truly existed thus far. Local referral patterns can be extremely useful for an organization (or an incoming independent provider) that is trying to grow roots in a given geographical region. Interesting side note: Fred Trotter is trying to figure this out by mining medicare data. Another example can be a referral leakage report that points out which kinds of patients are being referred out of the network and to whom are worth their virtual weight in gold for an aspiring ACO or an existing IDS.
Provider Directory is a comprehensive, up-to-date list of verified providers that includes, amongst other attributes, a secure digital way of reaching them. That may sound as simple as the yellow pages, but it’s not. The ideal Provider Directory that spans geographies is a great monetizable asset since any vendor who wants to sell something to those providers needs a valid, secure digital way to on-board and reach them. Not to mention the benefits to patient care when all providers can communicate with each other, irrespective of their bonding to the default EHR system.
Although referral management natively fits in EHRs functional spectrum, EHR vendors are most probably not going to get there fast enough or do a good enough job once they do. So there is definitely room for a dedicated referral management solution today. Since this is a network play, my money would be on a team that has created large viable physician networks before. Par8o (Sermo DNA) , Doximity (ePocrates DNA) both fit the bill.
In healthcare, ‘referral’ is used when a provider from one clinical domain directs a patient to a provider in another clinical domain. Most prominent use case is when a primary care physician (PCPs) refers a patient to a specialist or for services performed outside the PCP’s office (diagnostic tests, outpatient surgery, etc.). If a referral is deemed medically warranted, the PCP decides at minimum:
- In case of specialist: physician to whom the referral is made
- In case of services: what service, for how long (how many visits to authorize)
Most referral arrangements are based on mutually agreed referral guidelines between the referring and referred-to parties. These guidelines either developed by the medical groups or insurers themselves (sometimes in cooperation with their specialists) or bought from actuarial companies. In the majority of cases referrals result in a continuous back-and-forth communication between providers. Example: If a patient needs to be referred to a surgeon, what exactly should the PCP authorize as a part of the initial referral? The surgical procedure itself… Or simply authorize the patient’s initial consult and then issue any necessary additional referrals later (based on communication with the surgeon).
You get the picture. Referrals are not a simple in the real-world. And any software solution for referral management would need capability to effectively enable that back-and-forth workflow. Enter a new sub-species of Healthcare IT startups. EasyReferrals is an online system for facilitating and managing referrals between physicians. It’s not alone. See Trust.MD, DermLink.MD (dermatology-specific referrals). A more complete list is on Multiplyd Wiki.
The need seems to be there. My concern is around how these offerings fit in with the current healthcare IT ecosystem of EHRs and HIEs. If the daily workflow of participating provider is captured mostly by EHRs, isn’t referral management a candidate functionality within the EHR? Of course, EHRs are not good at everything (some would say, anything) so one can argue there is a need for a niche players. But referrals are not just a case of isolated messaging. To do them effectively, one would need to have some serious cross-over into patient information. E.g. sending clinical summaries or results or schedules back and forth between referrer and referee. Or communicating updates, results to the patient’s PHR. All of that requires information that is forte of an EHR. Standards or not, EHRs don’t have incentive to share that with other players.
It’s even more interesting for HIEs, since their whole value proposition is around connecting disparate providers in a geopolitical affinity group to enable such value-added workflows across participants. The whole HIE infrastructure, from Master Patient Index (MPI) to a Community-wide longitudinal health record, is created with the aim to facilitate business cases that are worth paying for. And referral management lends itself beautifully to the core of HIE and ACO viability. HIE vendors know it, and are busy in creating tools and governance that enable exactly that. Case in point – regional provider directories. Referral management is a non-starter without knowing what the end-points are. And HIEs/ACOs will own provider directories going forward. Integrating regional healthcare information is a political game (sadly) and I wouldn’t bet on untethered (with respect to EHR/HIE/ACO/IPA..) technology vendors for making a dent in that on their own.
Since I’m already at risk of being labeled doomsayer by few readers, I’ll bang the last nail in this coffin. DirectProject is
enabling forcing all incumbent Healthcare IT systems to have secure, point-to-point communication functionality that transcends data silos. Referrals are already the first use case being enabled by that uptake of DirectProject standard. So even the regulatory forces are creating headwinds for independent referral management solutions.
2017 Update: Seems like this company changed name to MedicalReferrals.com after 2012 and eventually got acquired by The Advisory Board, which seems to have lost interest in it.