A Tale of Rails and Ramps

ACH (bank transfer) is pretty sweet, but underutilized/less well known to consumers. Source
  • Twilio: In their own “What does Twilio Do” page, they immediately hit on the format of acting as an easy on-ramp to the legacy (but ubiquitous) telephony networks — SMS, voice, Whatapp, etc — simplifying the experience and buffering the developer from having to interact with the complexity of legacy standards — (SIP, XMPP, RTP, GSM, etc)
  • Mailgun (and SendGrid and Mailchimp and many others): Their products page has verbiage articulating how they act as an API on-ramp to the ubiquitous legacy technology of email — simplifying the experience and buffering the developer from having to deal with the pain of SMTP servers and MIME formats.
  • Lob: Less well-known, but very well regarded, they act as an API on-ramp to the (very) legacy, ubiquitous postal network to allow the sending of mail nationwide, simplifying the experience and buffering the developer from having to deal with the complexity of the analog world (buying paper, printing, postage, sending).
  1. Amass profits as first-mover or (better) the simplest/least frictionful on-ramp (see red offerings in the screenshot below)
  2. Use market presence and weight from 1 to build differentiated or at least supplementary services to lock in the customer base (see blue offerings), commonly analytics or insights only realizable via that market weight
  3. Use brand and partnerships from 1 to start to build an adjacent unique function/network and upsell to captive audience locked in from 2 (see green offerings)

2021 Healthcare Infrastructure Awards™

1. Imperfect but Actually Kinda Useful Award

  • Positives: ☝️. It’s no surprise that where the money flows, ubiquity goes. These are the payment rails of healthcare, so the incentives are there to have full connectivity.
  • Negatives: Like most ubiquitous networks, the technology is old and decrepit. X12, like its clinical EDI brother from another mother HL7, fundamentally sucks (and is unfortunately enshrined into law via HIPAA as the standard to be used for the foreseeable future).
  • Competition: There are plenty of clearinghouses such as Availity, Optum, Change, and Waystar. The interchange has made broad payer integration a commodity, forcing the various clearinghouses into the difficult competition of constantly decreasing prices. As the pure-play clearinghouse has become less viable, we’ve seen consolidation in the space between various players, as well as differentiation by virtue of non-traditional offerings, such as telehealth (which is not exactly the first complementary offering I’d naturally think of alongside eligibility and claims).
  • On-ramps: Pokitdok was the torchbearer in this area, offering eligibility, claims, and associated master data APIs backended to payers with X12. It actually acts less as an on-ramp and more as its own network, a modern clearinghouse directly connecting to insurance partners often. Its success in doing so led to an acquisition in 2018 by one of those legacy clearinghouses, Change Healthcare. Eligible and pVerify are the remaining independents of this mold. Some interesting discussion of those companies on Reddit (one of the few sources of semi-honest dialogue on the Internet, second only to Twitter) here.
  • Positives: Thanks to copious regulation and the fact that e-prescribing saves providers money / makes pharmacies money, there was massive adoption of Surescripts in the 2000s and early 2010s, so you can reliably count on a doctor being able to send your prescription to a pharmacy without printing it out or faxing 99% of the time.
  • Negatives: It’s not perfect, though. Transfers between pharmacies still occur out of band if a patient changes their mind about where they want to pick something up. Providers don’t yet get updates about the dispense status sent back to them commonly. And upgrades to the network are slow (the 2017 updates to the core NCPDP SCRIPT standard have only just been adopted, despite regulation mandating such)
  • Competition: It’s a single ubiquitous network (there’s no Mastercard to Surescripts’s Visa), possibly because of antitrust, but at least it works reliably. Truepill offers an alternative, in that providers can have their prescriptions fulfilled reliably, but it’s always by the Truepill pharmacy (not any pharmacy nationwide).
  • On-ramps: Lackluster, as Surescripts has guarded against that to some degree to prevent competition (see antitrust case). Bravado Health comes up first in a quick “e-prescribing API” search and is clearly angling for reducing onboarding friction with their “Accelerate your development. No Surescripts certification required” pitch. DoseSpot was grandfathered in and is a common choice for new digital health organizations looking to simplify onboarding and not have to deal with NCPDP XML (although anecdotally they’re supposedly a bit lackluster in features and support). Change has an API listed (but not really documented). DrFirst gets some buzz there but I think their solution is more a portal/UI to jump to, not a developer-friendly API. GiftHEALTH is also doing some really interesting stuff to fill in the gaps and enable transfers of medications between pharmacies, while also aiming to reduce the administrative burden on pharmacists.

2. Pirate Hugh Grant Award

Ubiquitous but regionally fragmented solutions don’t piece together into a cohesive national utlity
  • Positives: The Carequality trust framework has woven together a number of regional and competitive players (Commonwell, eHealth Exchange, state HIEs, EHR specific networks) into a fairly cohesive national network for querying/pulling a patient’s record. Likewise, DirectTrust reaches 1.5 million or so providers (at least on paper), allowing the push of a patient’s record to a specific organization or doctor. Lastly, vendors like PatientPing, Collective Medical, and Audacious Inquiry (primarily through state HIEs) have made event notification for subscribed patients (understanding when a patient is admitted into another healthcare organization) fairly widespread.
  • Negatives: “Wait, Brendan, why isn’t this in the top tier?” you might ask. While each individual network has wide deployment, the whole is significantly greater than the sum of its parts. Event notification is fragmented geographically between PatientPing, Collective Medical, and Audacious Inquiry, meaning none can be fully counted on at a national scale. As a query only arrangement, Carequality is filled with extraneous traffic. DirectTrust suffers from data quality issues in regards to its organizational/provider directory (as entries are often out-of-date or invalid). A complete and comprehensive strategy at a minimum needs to be national in scope and ideally would combine or overlay the three functions. Proper and reliable event notification would reduce Carequality’s traffic problem, where the clean directory of Carequality would be hugely beneficial for DirectTrust when pushing data.
  • Competition: For clinical data retrieval and push, Carequality and DirectTrust are well-established, but event notification is still a bit of a land grab, with no interchange or exchange between the three vendors. Beyond that, Patient Centered Data Home (PCDH) by SHIEC (a consortium of the state HIEs) has similar event notification and clinical data retrieval functions. Together, it adds up to an incomplete strategy.
  • On-ramps: Various vendors, such as Redox (disclosure: the company I work for), Kno2, Particle Health, or Health Gorilla, offer easier onboarding and access to the Carequality framework. Health Information Service Providers are the certified on-ramps for DirectTrust, although not all have modernized with an API-driven approach.
  • Positives: As a result of Meaningful Use and other regulation, public health agencies have (for the most part) programs in place to receive syndromic surveillance, lab reports, and vaccinations. So there’s a nice illusion of ubiquity, at least.
  • Negatives: Everything else. Each state has different processes for enrolling and connecting and often different transport standards. There’s a distinct lack of interoperability between them. Many do not pass the sniff test of “do they even actually work”. We saw massive failures in regards to lab reporting throughout the pandemic and we’re seeing similar issues with vaccination registries. I did a write-up on immunization registries, if you’re looking for a deeper dive.
  • Competition: Ultimately, national problems need national solutions. The spiderweb patchwork of state registries with legacy technology is in sore need of modernization. At a minimum, this is an opportunity for the federal government to decide between CDC and HHS ownership of national lab reporting and to complete the Immunization Gateway project. But we should go further — if state registries are the bottlenecks, they need to be functional and funded. They also need modern provider onboarding (the Carequality trust agreements would be well-suited for this) and patient data access.
  • On-ramps: APHL AIMS and Redox both offer national lab reporting, having aggregated the state and local ELR registries. Ironbridge and Redox do the same for vaccination reporting.

3. Gru’s Master Plan Award

  • Patient Identity is so fundamentally core to all other problems, but we still have no overarching, national path to getting to a better place. India has shown (in a non-health specific way) the tremendous benefits that starting with identity can have on national rails — solve identity first and suddenly tons of friction and wasted effort for every point solution is alleviated. Most existing networks/rails delegate out matching to individual participants or utilize some probabilistic matching if they are more centralized. Private solutions like Experian Health, Verato, or Clear really only help in limited capacities, sold and customized enterprise by enterprise. Ambitious proposals range all over the spectrum from centralized federal service à la India down to decentralized ledgers (hello, blockchain enthusiasts) but for any to be successful, a prescriptive path needs to be chosen. Otherwise, we can continue to pretend that credit companies are the best stewards of identity with knowledge-based questions like this:
Squeakycat and 3–5 knowledge based questions: a stalwart bastion protecting America against malevolent fraudsters nationwide
  • Reference Lab Ordering and Resulting is still in network formation mode. Even if a large healthcare organization has built out their own clinical, pathology, or genetics lab, they often have niche tests that they do not have the right equipment for. Reference labs exist to service this need and provide convenience to the patient, in that the location to draw blood or other specimens may be closer to their home. Labcorp and Quest are the most prominent, so many health systems built point-to-point integrations with them, which has been the status quo solution. There has recently been an explosion of new reference labs, especially in the genetics space, so several players have attempted to aggregate them into a network and sell that access/connectivity to providers via API or simple portals, such as Rupa Health, ORDRS, Health Gorilla, Change Healthcare, or Redox.
  • Prior authorizations (approval for procedures or admissions by a patient’s insurance company) are exceedingly manual in most cases, with the occasional point-to-point integration. We have seen regulatory progress as the CMS has mandated payers expose this through APIs, but the capability is not yet widely deployed nor exposed via an on-ramp aggregating those endpoints.
  • Diagnostic image exchange (exchange radiology, cardiology, and other clinical imaging) is limited and balkanized in the US, with various vendors like LifeImage, Ambra Health, and Nuance having extensive proprietary networks. Carequality has advanced an implementation guide to unify the networks and other players, but there has been limited adoption.
  • Study subject recruitment (enrolling enough patients with the diagnoses intended to be studied in clinical trials) is incredibly difficult in today’s system. 37 percent of sites selected for clinical trial studies under-enroll Healthcare in the US has...some problems. It’s an industry where incentives are misaligned, where the patient/provider/payer triangle is heavily tilted against the patient, and where the debt-fueled arms race for expansion and growth forces an unparalleled upward trajectory of prices.

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Healthcare integration and interoperability advocate. Language learner. Fierce and unrelenting friend of dogs.

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Brendan Keeler

Brendan Keeler

Healthcare integration and interoperability advocate. Language learner. Fierce and unrelenting friend of dogs.

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