1. Opening Keynote A Manifesto for Healthcare’s Disruptive Innovation of the Decade: Open EHR Technology Platform(s) and Ecosystem Vince Kuraitis JD, MBA Better Health Technologies, LLC http://e-CareManagement.comhttp://e-CareManagement.com blog (208) 395-1197

2. 2 Overview I.A Case Study in Disruptive Innovation: Apple iPhone & Google Android II.A Manifesto for Healthcare: Open EHR Tech Platform(s) and Ecosystem Yesterday -- Closed Today -- Walled Garden Tomorrow -- Open III.Implications for the Healthcare Unbound Community Note: Graphics referencing articles/reports contain hyperlinks to the original source.

3. 3 Is your company a platform? an application? both? Simple view of apps –Apps need access to data about patient –Perform process/intervention –Deliver data back to health record Provocative assertion: Almost every healthcare service or product can function as an “app” “Chances are you’re an app”

4. 4 I. A Case Study in Disruptive Innovation: Apple iPhone & Google Android 2 Success Stories Growth Value Competitive Ecosystem

5. 5

6. 6 iPhone + Android Share of Smartphone Internet Usage April 08: 6% February 10: 86%

7. 7 Walled Garden

8. 8 What’s a Walled Garden (WG)? Controls users’ access to content and services Restricts the user’s navigation within particular areas (applications) Not all alike: differing heights and levels of permeability to the walls.

9. 9 Walled Garden (WG): Apple iPhone Chronology –March 7, 2007: Apple introduces iPhone “product” –March 2, 2008: Apple opens API to developers –March 6, 2008: 100,000 downloads of SDK Kleiner, Perkins announces $100 M investment fund –November 4, 2009: 100 K apps –July 2010: 225 K apps

10. 10 Business model –Open API –Virtually every other aspect closed Integrated hardware/software platform Non-swappable applications Exclusive distribution of apps. Restriction on carrier choice Restrictions and controls on developers –Multiple revenue sources -- HW $$, developer $$, app store –Highly controlled user experience

11. 11 iPhone Revenue Q2:07 $5M Q1:10 $5.5B

12. 12

13. 13 Google Android Operating System-- Open Platform Open Handset Alliance: 30+ companies –Google Android open source SW –Multiple handset developers bring hardware Open API 20+ smartphones on the market use Android OS 70+ K Android apps Google maintains “control points”, e.g., see http://www.visionmobile.com/blog/2010/04/is- android-evil/ http://www.visionmobile.com/blog/2010/04/is- android-evil/

14. 14 Google can give away Android because... “...we make money, and lots of it, it turns out, from advertising on mobile phones.” Eric Schmidt, CEO, Google

15. 15

16. 16 Result: A Vibrant, Competitive Ecosystem

17. 17 II. A Manifesto for Healthcare: Open EHR Tech Platform(s) and Ecosystem

18. 18 Modularity: Dis-Integration of the Computer Industry Source: Venkatraman, N. Winning in a Network Centric Era, 2006

19. 19 From EMR 1.0...

20. 20.... EHR 2.0/ Clinical Groupware v1.1, June 2009

21. 21 Evolution of EMR/EHR Technology 1)Yesterday: Closed/Monolithic 2)Today: Walled Garden EHR Platforms 3)Tomorrow?: Open EHR Technology Platform(s) with Plug- and-Play Modular Apps

22. 22 From 1) Closed to 2) Walled Gardens to 3) Open Platform(s) 1 2 3

23. 23

24. 24 Open Disagreement about terminology Openness not synonymous with –Free –Open source –open not same as "good"; closed not "bad" Will WG platforms be innovative? Some. –Acknowledge -- Many benefits of closed system Control over user experience Security, privacy –But, best case scenario is competition between WG and Open EHR platforms Many misc examples of platform control, e.g., –iPhone battery not user replaceable –Proprietary 30 PIN cable vs. USB Customer POV of interoperability, modularity, plug-and- play: "It just works"

25. 25 A taxonomy of “open” (one example) 1) Open source – and especially it’s impact on devices – Android 2) Open standards – W3C standards 3) Open APIs i.e. Application Programming Interfaces – for instance access to Location APIs 4) Open access (freedom to contact anyone on the network), 5) Open choice of enablers (for example – the ability to choose your billing system), 6) Data portability (ownership of your data) 7) The ability to access any application (i.e. not just the provider’s application) a.k.a the classic ‘Walled Garden’ debate – On deck/ Off deck ‘Open’ in relationship to the Cloud 9) Impact on developers and a shift in value to the edge of the network 10) Low barriers of entry for third party developers

26. 26 Maximizing vs. Optimizing Openness?

27. 27 2) TODAY: “Walled Garden” EHR Platforms 1)AMA/Dell AMA to team with Dell for EHR info platform 3/10 AMA to team with Dell for EHR info platform 2)AT&T AT&T Expands Healthcare Community Online to Improve Patient Care 2/10 AT&T Expands Healthcare Community Online to Improve Patient Care 3)Axolotl Axolotl Corp Showcases New SOA Technology at HIMSS 2010 3/10 Axolotl Corp Showcases New SOA Technology at HIMSS 2010 4)Covisint Covisint Jumps onto PaaS Bandwagon 11/09 Covisint Jumps onto PaaS Bandwagon 5)Eclipsys Eclipsys Introduces Open Platform to Transform Health IT and Drive Electronic Health Record Adoption 3/10 Eclipsys Introduces Open Platform to Transform Health IT and Drive Electronic Health Record Adoption 6)GE GE IT CEO touts debut of next-gen clinical knowledge platform, eHealth Platform 3/10 GE IT CEO touts debut of next-gen clinical knowledge platform, eHealth Platform 7)Henry Schein Henry Schein Announces the Launch of Innovative Henry Schein ConnectHealth (TM) Collaborative 3/10 Henry Schein Announces the Launch of Innovative Henry Schein ConnectHealth (TM) Collaborative 8)Medecision MEDecision Webinar Will Introduce New InFrame Collaborative Health Information Service Technology 3/10 MEDecision Webinar Will Introduce New InFrame Collaborative Health Information Service Technology 9)Medicity Medicity Opens Its Health Information Exchange Platform to Third-party Application Development 11/09 Medicity Opens Its Health Information Exchange Platform to Third-party Application Development 10)Microsoft/Eclipsys Microsoft and Eclipsys Announce Health Care IT Alliance 2/10 Microsoft and Eclipsys Announce Health Care IT Alliance 11)Navinet NaviNet Offers End-to-End Healthcare Communications Platform 2/10 NaviNet Offers End-to-End Healthcare Communications Platform 12)Quest Diagnostics Quest Diagnostics Unveils Care360 EHR 3/10 Quest Diagnostics Unveils Care360 EHR 13)Verizon Verizon Launches IT Platform to Help Accelerate Adoption of Electronic Health Care Records 3/10 Verizon Launches IT Platform to Help Accelerate Adoption of Electronic Health Care Records

28. 28 Will WG platforms result in innovation? 13+ platforms! –Cost/time to get up learning curve with each platform? –How easy is the API to learn/use? –How are revenues split? –Which platform(s) have market viability? Likely winners unclear High transaction costs of exploring options Wait and see? How will app vendors view WG platforms?

29. 29 From 1) Closed to 2) Walled Gardens to 3) Open Platform(s) 1 2 3

30. 30 3) Tomorrow?: Open EHR Technology Platforms with Plug-and-Play Modular Apps Open at many levels (not necessarily all) –API –Patient ownership of data –Data portability –Open standards –Open source –Cross-platform apps –Low barriers to entry/restrictions for developers –etc.

31. 31 1)Technology platforms that support substitutable applications should be promoted. 2)Messages and protocols for data exchange should be allowed to emerge on demand in a market-driven approach, and specified transparently at every level. 3)Protocols and application programming interfaces should allow the possibility of multiple platforms co-existing. 4)Application programming interfaces should be open. 5)Substitutable application or platform vendors should not have control over what is installed on the platform 6)Application installation should be turnkey. 7)The intellectual property of platforms and applications should be kept separate. 8)All applications should be removable and none should be required to run a platform. 9)The platform should have a highly efficient delivery mechanism for applications. 10)Certification requirements for platforms and applications should be kept minimal to maximize substitutability. Android-like

32. 32 3 Elements for Disruptive Innovation 1)Technological enabler. Typically, sophisticated technology whose purpose is to simplify, it routinizes the solution to problems that previously required unstructured processes of intuitive experimentation to resolve. 2)Business model innovation. Can profitably deliver these simplified solutions to customers in ways that make them affordable and conveniently accessible. 3)Value network. A commercial infrastructure whose constituent companies have consistently disruptive, mutually reinforcing economic models. MIA

33. 33...early spring flowers ready to burst forth in a blossom of innovation

34. 34 Drivers Toward an Open EHR Technology Platform The Office of the National Coordinator for Health IT (ONC).Office of the National Coordinator for Health IT –…we believe that it will be common in the near future for Certified EHR Technology to be assembled from several replaceable and swappable EHR Modules. Health & Human Services, Interim Final Rule on Standards, December 2009 p.41Interim Final Rule on Standards Google Health and Microsoft HealthVaultGoogle Health Microsoft HealthVault The Clinical Groupware CollaborativeClinical Groupware Collaborative Free or freemium EHR offerings such as Practice FusionPractice Fusion Free and open source software (FOSS) e.g., Mirth, VISTAMirth VISTA openEHR NHIN-Direct ONC SHARP Grant for Childrens Hospital Boston and Harvard Medical SchoolONC SHARP Grant Application vendors WG platforms (...migration toward openness)

35. 35 III. Implications for the Healthcare Unbound Community

36. 36 Value Creation vs. Value Capture Platform or App?

37. 37 What’s the disruptive opportunity in an open EHR technology platform? Value creation/capture battle between platforms & apps –Platform owners (e.g., Apple iPhone) want to capture the value by maintaining tight control over their platforms –Application vendors are incentivized to commoditize the platform so that value creation and value capture can migrate to the applications themselves

38. 38 1) Yesterday: HU Companies (Apps with no platform)

39. 39 2) Today: Walled Garden EHR Platform/Apps Platform A Size = Value capture opportunity

40. 40 3) Tomorrow: Open EHR Technology Platform/Apps Platform A Size = Value capture opportunity

41. 41 Beneficiaries of Open EHR Technology Platform(s) Patients Doctors & hospitals: competition, lower prices, no lock-in Payers –Government –Commercial –Employers 1000s of app vendors Other care providers

42. 42 The Value of the Clinical Groupware Collaborative http://clinicalgroupwarecollaborative.org

43. 43 Stages 2 & 3 of HITECH “Meaningful Use” will be a bonanza for the HU community

44. 44 A Thousand Flowers of Innovation In Full Blossom

45. 45 END