1. Healthcare Mobile Information Flow Victor Camlek VP Market Intelligence Thomson Reuters Healthcare & Science March 2011

2. ©2011 Thomson Reuters 1 A WORLD OF DATA. DELIVERED. HEALTHCARE & SCIENCE SOLUTIONS Providers Payers Pharma Researchers Operations & Finance Planning & Marketing Regulatory Reporting Clinical Performance Improvement Clinical Workflow Clinical Decision Support Research EvaluationAuthoring & PublishingResearch & Discovery Action OI ® crmView ® CareDiscovery ® 100 Top Hospitals ® Clinical Strategic Services Clinical Xpert ® Micromedex ® 2.0 Thomson Reuters Research Analytics InCites, Journal Citation Reports, ScienceWire EndNote ® Web of Knowledge sm ScholarOne Web of Science Research & Discovery Clinical TrialsCommercializationPost-Launch Comparative Effectiveness Research Thomson Reuters Pharma Integrity Thomson Reuters Pharma Regulations IDRACMedical Literature Analyzer Health Plan Management Pharmacy Xpert ® Cost Containment Care Management Consumer Engagement Consumer Health Solutions HEDIS Fraud & Abuse Advantage Suite Medical Episode Grouper Advantage Suite DataProbe Physician Performance Assessment

3. Headline News: The capabilities of mobile technology are greatly influencing the practice of medicine TODAY! As the technology matures there is potential that a huge amount of workflow content may become available for use over mobile devices. What will this continue to mean for STM Publishers and their customers?

4. Healthcare: Converging Mobile Markets Mobile Solutions for Interactive Data Management Telemedicine mHealth Mobile Devices Mobile Content 3

5. mHealth Definition mHealth –The practice of medical and public health supported by mobile devices –Sub-segment of e-Health –The use of mobile devices in collecting community and clinical health data; delivery of healthcare information to practitioners, researchers, and patients; and, real-time monitoring of patient vital signs, and direct provision of care (Telemedicine) mHealth gets into the actual practice of medicine, which is one of the reasons that it has been embraced by the World Health Organization as a way to manage healthcare in third-world countries. 4

6. Telemedicine Definition Telemedicine –An application of clinical medicine where medical information is transferred through interactive audiovisual media for the purpose of consulting, and sometimes remote medical procedures or examinations –Includes two concepts Real time (synchronous) and store-and-forward Home Health (asynchronous) –Mobile devices may or may not be used Mobile telehealth: provision of medicine via a mobile unit Services may involve mobile technology used by a mobile vehicle associated to a medical facility Telemedicine includes some mobility and is often mentioned within the context of the mobile market. However it involves the connection of at least two points to either perform or monitor patient care. 5

7. Mobile Content Definition Referential healthcare-related content May include: –Disease monographs –Drug-related content –Order sets –Protocols –Social networking content Electronic Medical Record(EMR)/Electronic Health Record(EHR) The ability to combine referential and patient-related data creates a mobile solution The capability for content to be delivered over a mobile device combined with interaction with patient-related data represents a current market in which various companies participate. 6

8. Mobile Solutions for Interactive Data Management Definition Mobile Solutions for Interactive Data Management –Solutions that permit users to achieve mobile access to data from Hospital Information Systems (HIS) using at least one data presentation format –Solutions must possess a data access layer that obtains and deconstructs information from disparate HIS systems, and repackages the information around a patient object –Provides a mobility platform for interactive data retrieval and transmission This is the core space where STM content providers may be interested in serving. 7

9. ContentWorkflowPlatformDevicesmHealthTelemedicine Referential Drug Data Clinical Journals News Guidelines EHR Charge Capture Patient Index CPOE Order Sets Rounding Scheduling Patient Alerts Lab Data Financial/ Billing Mgmt Performance Mgmt Software Diagnostic Imaging Ability to stage, re-configure and message data from an HIS or source system to a variety of devices Handheld PDA’s Smartphones iPod Touch iPad iPhone Android Windows Mobile Net books Mobile Carts Mobile Diagnostic tools Workstations Patient Monitoring devices Mobile telemedicine/ telecare devices MP3 players for mLearning Laptop computers and desktops Data collection software The use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care. Telemedicine includes consultative, diagnostic, and treatment services 8 STM Content Space + Workflow Data Healthcare Mobility and STM Publishers STM Opportunity Content Enablers Adjacent Areas

10. ContentWorkflowPlatformDevicesmHealthTelemedicine Referential Drug Data Clinical Journals News Guidelines EHR/EMR Charge Capture Patient Index CPOE Order Sets Rounding Scheduling Patient Alerts Lab Data Financial/ Billing Mgmt Performance Mgmt Software Diagnostic Imaging Ability to stage, re-configure and message data from an HIS or source system to a variety of devices Handheld PDA’s Smartphones iPod Touch iPad iPhone Android Windows Mobile Net books Mobile Carts Mobile Diagnostic tools Workstations Patient Monitoring devices Mobile telemedicine/ telecare devices MP3 players for mLearning Laptop computers and desktops Data collection software The use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care. Telemedicine includes consultative, diagnostic, and treatment services 9 STM Content Space + Workflow Data Healthcare Mobility and STM Publishers STM Opportunity Content enablers Adjacent Areas This market is in an early stage

11. Mobile Devices Definition Mobile Devices –Traditionally “Pocket-sized computing devices,” typically having a display screen with touch input or a miniature keyboard –The definition is evolving as larger mobile devices appear (iPad, Net-books) –Not all of these devices can access all public or proprietary mobile networks, however, as they develop more will be able to include direct mobile access Mobile Devices may include: –Smartphone –Mobile computer/Mobile cart/Mobile monitor –Personal digital assistant/enterprise digital assistant including the Blackberry –Digital still camera (DSC)/Digital video camera (DVC or digital camcorder) –Portable media player –e-book reader –Pager –Personal navigation devices –iPad (as of 2010) Advances in mobile device technology are fueling mobility as a growing medical application 10 Confidential – Do Not Distribute

12. Relevant Handheld Devices BlackBerryPalmNokia Windows Phone Android Phone iPod Touch iPhone 4G iPad Motion computing, mobile computer and mobile cart NetBook 11 Confidential – Do Not Distribute

13. Market Dynamics: Worldwide mobile device sales to end users equaled 1.6 billion units in 2010, a 31.8 percent increase from 2009 Smartphone sales to end users were up 72.1 percent from 2009 and accounted for 19 percent of total mobile communications device sales in 2010 Worldwide mobile phone sales to end users reached 32.7 percent growth in the fourth quarter of 2010, with sales of 452 million units Gartner forecasts worldwide mobile application store downloads to reach 17.7 billion downloads in 2011, a 117 percent increase from an estimated 8.2 billion downloads in 2010 According to the MDsearch Smartphone Survey, 53% of physician respondents own a smartphone and 63% of those physicians are using mobile medical applications EMR vendors have begun to offer remote access to EMRs via smartphone applications (Example: Epic Systems partnership with Apple announced in 2009 for a mobile EHR pilot) 12 Source: Gartner Research; 'Forecast: Mobile Application Stores, Worldwide, 2008-2014' Mdsearch: and Mobile Health Q1 2010 State of the Industry. Mobilehealthnews, 2010 report

14. STM Participants: Early Signs of Differentiation “Large healthcare publishers such as Hearst Business Media, Reed Elsevier, Thomson Reuters, and Wolters Kluwer have a portfolio of products that support clinicians, healthcare providers, and payers along the healthcare workflow. These products are still evolving as the technologies mature.” “The main components include traditional reference and journal content; teaching and training applications (particularly for nursing).” “The most highly competitive area is in clinical decision support tools, where order sets and drug reference databases are the most common product.” “There will be increased focus on content integration with work-flow needs and just-in-time delivery driving competitive features and pricing. As much of the evidence as possible should be embedded in content-based software.” 13 Source: Outsell, Inc., Growth Trends in the Market for Clinical Decision Support Tools, June 2010

15. HC Mobility: Notable Service Providers 14 Clinical Workflow Sources TR Clinical Expert Patientkeeper Global Care Quest Dr. First IQMax Theradoc Expert Systems Pharmacy OneSource (Sentri7) MedMind (CareFusion) Premier Safety Surveillor Cogon Systems CureMD Referential Content and Analysis UnBound Medicine Medicine Central Evidence Central ePocrates Lexi-Comp Dynamed Diagnosaurus Skyscape Up-to-date Tarascon Pocket Pharmacopia TR Micromedex products MedAptus Zynx, First DataBank Elsevier – First Consult 14 Confidential – Do Not Distribute

16. ©2008 Thomson Reuters The Concept and The Potential Today: –All relevant information derived from a patient encounter may be documented and transmitted to a mobile device –However, previous information documented in various medical records will not be readily available until there is additional progress creating EHRs (Electronic Health Records) –The available data may be combined with value-added referential content delivered to a mobile device at the point of care Tomorrow: –Even more information will become consistently available at the point of care and for use during ongoing treatment 15

17. 16 Thomson Reuters CLINICAL XPERT AGGREGATES PATIENT DATA FROM THE HOSPITAL AND DELIVERS IT DIRECTLY TO CLINICAINS

18. 17 CLINICAL XPERT ADDRESSES HOSPITALS’ CLINICAL AND BUSINESS CHALLENGES… Enhances clinician efficiency Champions informed decision at the point-of-care Address CMS and Joint Commission initiatives Identifies high-risk patients quickly via clinical surveillance Promotes patient safety and reduces medical errors Reduces lost or inaccurate charges (CX Billing) Facilitates clinician communication Improves physician satisfaction and relationship with the hospital Creates competitive advantage for recruiting clinicians Serves as an HIS downtime solution, providing uninterrupted access to patient information when the HIS is not available

19. ©2008 Thomson Reuters Clinical Xpert Solutions SolutionAttributes CareFocusGeneric surveillance tool capable of supporting any clinical area Clinical Xpert NavigatorRounding, Mobility and Tracking to support clinicians across locations when managing patients Pharmacy XpertIntelligent dashboard, pharmacy specific surveillance, quality drug/disease content, department management reporting 18

20. Pharmacy Xpert Product Description Pharmacy Application Micromedex Content Clinical Xpert Foundation Xpert design to support pharmacy decision support Links to HIS systems Patient specific drug interaction checking, IV Index and calculators Drugdex Diseasedex GM Drug REAX IV Index Pre-built pharmacy profiles Patient data Real-time surveillance Mobility Integration with any HIS Pharmacy Xpert consists of three primary components 19

21. ©2008 Thomson Reuters Clinical Xpert: Value Proposition Patient Safety/Improved Outcomes: –Real time patient surveillance to: Manage patient specific drug therapy effectively Identify patients at risk Improved cost management –IV to PO proactive conversion –Antimicrobial therapy management –ADE (Adverse Drug Events) prevention XPert software: –‘Just what I need to know’ – targeted, relevant information needed to make optimal decisions –Evidence-based surveillance and recommendations –Intelligent user design anticipates information needs Technology ROI –Works with any HIS system –CCOW (Clinical Context Object Workgroup)(context management) compliant –Implementation resource requirements minimal –Infrastructure designed to support multiple Xpert systems 20

22. ©2008 Thomson Reuters Business Model Issues Solutions include two components: –Software needed to access, manage and transmit the data –Content, including referential content available via subscriptions, tailored to meet the needs of the mobile device customer 21

23. Business Model Issues Costs associated with HIMS data conversation Technology challenges –Data access layer capabilities –Messaging layer to devices –Mobile device platform strategy End-User issues –Who is the actual customer (Institutional Providers, Physicians, Pharmacists, others) –Willingness-to-pay –Quality assurance Regulatory issues –Privacy –Data Integrity 22

24. Business Model Options Software model: –Perpetual lease –Maintenance –Updates Subscription-based Transaction-based Sponsorship Advertising App Store for download Capital investment –Requires institutional participation –Includes subscription to content Suitable for content Less likely Provides service to organizations Less likely Shells are available to enable usage by those with institutional access or “skinny” versions of content 23

25. ©2008 Thomson Reuters Technical Issues Technical Options –Web-based approach Quickest approach Not a complete solution (no off-line capability; can use various device features) –Vendor Specific (You pick the winner or sink the cost) Works within capabilities of specific device/platform Some platforms have limitations (Apple does not permit Flash and 3G usage; it avoids apps that impact network resources) –Hybrid Digital Platform Permits service to multiple device platforms The issue is choosing the right platform Recommended Reading: “Building Applications for the Mobile Web, Best Practices,” at Thomson Reuters Legal, 10/28/10 24

26. Challenges Moving Forward The path to the highest quality solution sets will require additional progress in electronic health records (EHRs) –Interoperability challenges –Data standardization challenges –Adoption challenges (perhaps overcome in the US by Meaningful Use requirements) We are at an early phase that could be the beginning of a path to even greater benefits based upon the ability to access and utilize a very high volume of existing data that will become available as EHRs are fully adapted for use in mobile devices.

27. U.S. Hospital EHR Adoption Forecasts *Hospitals in this instance are considered to be acute care, non-federal hospitals; baseline penetration rates are derived from an analysis by Jha, et al in Health Affairs (October 2010) based on the March-September 2009 AHA health IT survey (N=3101); forecasts modeled based on primary and secondary research with health care CIOs Source: Frost & Sullivan

28. U.S. Physician EHR Adoption Forecasts *EHR = any EHR with basic or advanced capabilities

29. Conclusion Mobility is already providing important services to healthcare professionals Moving forward, there should be increasing adoption of EHRs by 2016 The combination of widespread EHRs plus more advanced wireless device features should have a profound effect on the level of information that will be available and useful at the point of care Future business models will need to account for higher amounts of data available at the point of care, along with the software investment required to access data from various systems 28