Proceedings

Slide Presentation Handouts

Paper

Session 122
Technologies for E-Healthcare
AUTHOR/PRESENTER

Kenneth A. Kleinberg
Vice President and Research Director
Gartner
Stamford, CT

2002 ANNUAL HIMSS CONFERENCE & EXHIBITION

COPYRIGHT 2002 BY THE HEALTHCARE INFORMATION AND MANAGEMENT SYSTEMS SOCIETY. 1

INTRODUCTION
E-business and e-healthcare applications and technologies will have a greater impact on healthcare
than any other IT development since the 1980s. The business risks of not adopting them now exceeds
the technology risk of implementation failure. Despite the dot.com implosion, e-healthcare continues
to advancein many cases via the established healthcare vendors that have benefited from the les-
sons learned from the failed dot.coms. In addition, Healthcare organizations (HCOs) that have been
cautious about the use of Internet technologies can now find numerous examples in other industries of
Internet technology adoption and success, as well as many healthcare pilot examples and early suc-
cesses. Some of the technologies and approaches that enable e-health are evolutionary and some are
revolutionary. This paper focuses on a number of the most exciting and valuable technologies and
approaches.
Overall, we believe that HCOS should invest in e-health now! In particular, vendors and users that do
not embrace the new wave of delivery and integration technologies including Web integration servers,
browsers, integration brokers, Service-oriented architectures (SOAs), Extensible Markup Language
(XML), Application Service Providers (ASPs), wireless application gateways (WAGs) and Web serv-
ices will find it increasingly difficult to compete. Vendors and users that do not take advantage of new
communication technology advances such as broadband and wireless computing, and that do not use
business process management technologies such as workflow and rule-based processing, will only
get a fraction of the value of e-health applications and technologies. We also believe that collabora-
tive, application-focused technologies including supply chain management, e-forms, e-procurement
and customer self service will provide near immediate return on investment (ROI), but only if they are
done well. We also warn organizations that E-health applications must be supported by a comprehen-
sive security strategy that may include Public Key Infrastructure (PKI), firewalls, biometrics, smart
cards and intrusion detection systems, but its all too easy to overspend and under-protect.
Here, then, are our more detailed opinions about a number of e-healthcare technologies and
approaches, including some strategic planning assumptions, and our recommended advice:

IS THE INTERNET TRULY A DIFFERENT PARADIGM?

Many IT professionals prefer to believe the Internet is just a reshuffling of the same old computing
paradigm that has been going on for decadescentralized server systems accessed by simpler end-
user devices. What these folks are missing, however, is what makes all the difference; the Internet
provides a nearly universal and open way to connect computer systems to communicate with each
other using a set of agreed-upon technology and protocolsthe brittleness and restrictions of most
point-to-point (e.g., B2B) interfaces are overcome. The use of browser technology, in particular, frees
the IS organization from having to write their applications to many specific end-user platforms, and
greatly simplifies the task of rolling out applications to users (e.g., B2C), whether they are within the
organization, a partner to it or totally outside it (e.g., patients and consumers). As bandwidth contin-
ues to increase and as communications go increasingly wireless, the Internet becomes even more
ubiquitous and valuabletruly a new era in computing (the Supranet). It serves as an open window
that enables healthcare to finally connect its stakeholders in ways that have the potential to decrease
delays, increase accuracy and improve the overall healthcare environment.
Action Item: HCOs should view the Internet as a new window of opportunity to succeed on commu-
nications and connectivity applications that were difficult, if not impossible, to succeed on in the past.

APPLICATION HOSTING TECHNOLOGY: NEW AND OLD APPROACHES

In the last dozen years, there have been many advances in application hosting. Monolithic legacy sys-
tems with green screen terminals serving a limited user audience have given way to two-tier and now
multitier client/server architectures. The Web provides even greater flexibility for hosting, requiring
only a browser at the client site. ASPsa remote hosting Web-based approachhave high potential
to reduce the upstart and maintenance costs of healthcare applications. As such, many vendors of
monolithic, host-based applications and two-tier client/server applications are positioning themselves
as ASPs by remotely hosting their applications and charging on a usage basis. These vendors are
nominally correct in claiming to be ASPs. However, fronting a two-tier, client/server application with
Citrix Metaframe or replacing the 3270 screens of a monolithic, host-based application with HTML
pages, will not improve the flexibility, portability or openness of these legacy applications, necessary
to support e-health initiatives. More modern approaches that use Java clients, XML, and service-ori-
ented architectures, and that support the principals of network computing (write once run anywhere,
network context storage, dynamic cached propagation, automated platform adjustment) will be
needed to more fully bring the value of the Web to healthcare. To leverage legacy assets in the Internet
era, vendors are beginning to include application and Web servers in the middle tiersconnected to

2002 HIMSS Proceedings: Educational Sessions Session 122 / Page 2

the back-end systems and to each other by integration broker technology, and to end users over Web
protocols (see the discussion on Healthcare Vertical Portals below). Eventually, we expect application
functionality will be offered as e-services, where the coding techniques and hosting are transparent to
the end user, and services are delivered to a variety of device types (e.g., PC or PDA or wristwatch).
Strategic Planning Assumption: After 2003, 80 percent of the most successful healthcare ASP offer-
ings will be built on n-tier, network computing platforms and support XML-enabled, service-oriented
architectures (0.7 probability).
Action Item: HCOs should pursue more modern hosting strategies including service-oriented archi-
tecture (SOA), ASP and Web services.

EVOLVING TO E-FORMS
As the majority of healthcare forms are still paper-based, the ability to accurately capture (not to men-
tion efficiently store it and rapidly retrieve it) information is severely limited. Paper-based forms are
inherently inflexible to changing needs (e.g., new or different fields), are limited in the amount of
directions that they can provide (e.g., you often have to turn the paper over to see the instructions) and
dont provide any feedback. Users are often only aware the forms were filled out incorrectly when the
form is returned to them with the errors markedoften days or weeks later. Faxing, imaging and
optical and intelligent character recognition (OCR/ICR) still does not catch the problems at the
source. Client/server-based forms, while providing sophisticated edits and pop-up instructions, are
difficult to deploy and maintain, but they can maintain state. New e-forms, especially those based on
XML forms definition in combination with various browser-enabled devices, can bring new relief and
flexibility to healthcare data entry. However, until challenges such as bandwidth, maintaining state,
and the adding of workflow and business rules are addressed (business process automation and man-
agement), the use of Internet browser and ASP technology for e-forms, while lowering the costs of
implementing and maintaining the application, may be too slow for intensive data entry. For the next
year or two, we expect such e-forms solutions will be limited to occasional data entry and will need
to be deployed with a batch/synchronization approach.
Strategic Planning Assumption: By 2005, 80 percent of data capture in healthcare will be via elec-
tronic means (0.7 probability).
Action Item: HCOs should look for opportunities to deploy e-forms with an eye on maintaining state
and bandwidth constraints.

HEALTHCARE STANDARDS
Healthcare has historically been an entity unto itselfonly partially electronically connected to other
industries (e.g., EDI to payer organizations). As such, it has therefore been less influenced by outside
standards. Within healthcare, however, the need for the use of standards has been higherespecially
in such areas as need to connect multiple departments together and provide a common language for
exchanging information. Some of these standards efforts have been more successful than others. HL7
version 2 is, by most accounts, the biggest standards success in healthcare, but it is not plug-and-play.
CORBAmed, on the other hand, has aimed high for a more tightly coupled integration and coopera-
tion approach, and has been struggling. Efforts to advance HL7 to a less ambiguous and more power-
ful object-focused v.3 (and the XML-based clinical document architecture) remain mostly on track,
but they are no longer alone on center stage. Today, as healthcare enters the Internet Era, its need to
communicate with a wider range of industries and stakeholders has increased in importance. A new
and emerging world of standards and consortia, mostly focused on XML and B2B e-commerce, will
increasingly become important for healthcare to adopt or adapt. We believe XML will not be effective
on a large scale until a rich set of application-specific B2B standards exists. Several groups are vying
to provide those standards for healthcare. The ebXML framework (or whatever more evolved forms
supercede it) could make their work synergistic.
Strategic Planning Assumption: Through 2003, more than half of all new HL7 interfaces worldwide
will be based on HL7 v.2 (0.8 probability)by 2006, 90 percent of all new U.S. standards-based
healthcare interfaces will be based on HL7 v.3 (0.7 probability).
Action Item: HCOs should contact their standards development organizations urging ebXML partici-
pation, and give the same message to vendors through requests for proposals and user-group meetings.

2002 HIMSS Proceedings: Educational Sessions Session 122 / Page 3

HEALTHCARE VERTICAL PORTALS: ALL THINGS TO ALL STAKEHOLDERS?
A healthcare vertical portal (HVP) provides a foundation for creating e-business/e-health functions
by providing one or more of the following: organized access to focused aggregate healthcare content,
connectivity solutions for linking business partners and healthcare stakeholders, e-commerce func-
tions for managing business transactions, and linkages to improve supply chain management (SCM)
operations using the Internet as the communications and transaction medium. Most HVPs attempt to
offer a broad range of these capabilities and serve multiple stakeholders (e.g., consumers, physicians
and payer organizations). For some, this HVP approach is the only reasonable means for tying their
disparate products and suites together. To provide such integrated functionality, these vendors must
address multiple technical challenges, such as providing robust search and navigation, high perform-
ance/scalability and minimal requirements on the part of the client (browser). Linking the HVP to
multiple legacy systems and providing users with an integrated, stateful portal experience is key.
Since it will be difficult for any one HVP to meet all these business and technical requirements, most
HCOs will choose more than one HVP vendor to achieve their desired business goals. Examples of
HVPs include WebMD, Medscape and HealthVision.
Strategic Planning Assumption: Hybrid HVP models that provide content and transactions will be the
winning approach in healthcare during the next three years (0.8 probability).
Action Item: Care delivery organizations (CDOs) must strive to standardize their user interfaces and
to align their HVP and business strategies when working with different vendors to extend their
Web capabilities.

PERSONAL HEALTH RECORDS EVOLVE

Personal health records (PHRs) are Internet-accessible repositories for storing information (both
structured/coded and unstructured) that helps describe an individuals health status and are optimized
primarily for consumer use. A major differentiator of PHRs from other healthcare information sys-
tems is that they are not necessarily CDO-based, the data contained within a PHR can and should be
aggregated from multiple CDOs while the data contained within a PHR is owned and controlled by
the individual consumer (or designee). PHRs may become a consumers single digital point of con-
tact with HCOs. Despite the immaturity of current products, PHRs have the potential to solve two of
the problems plaguing healthcare consumers: accessibility and transportability of their medical
records. Accessibility for patients can be improved by the use of a dejargonzier or some sort of
translator/CMV. Additional capabilities that consumers will want/expect include a scheduler and var-
ious wellness tools. For example, patients may wish to use the PHR to monitor their health condition
and provide alerts and notifications to selected others (e.g., physicians and relatives). Security and
need to know access will be paramount to the success of PHRs (emergency information should be
relatively easy to access by any health professional).
Strategic Planning Assumption: By year-end 2005, at least 25 percent of consumers who get health-
care services from multiple CDOs will use a PHR to facilitate those interactions (0.7 probability).
Action Item: CDOs must begin planning for the eventuality that their patients will insist that CDOs
have the ability to interact with a PHR that services the consumer.

PHYSICIAN-PATIENT WEB-BASED MESSAGING

Although e-mail is a common method of communications today among private and commercial
users, it is still rare between patients and physicians. The reasons for this are many, but the primary
ones are physicians being concerned aboutbeing overwhelmed with too much e-mail, security/pri-
vacy issues and not being able to charge for the consultation. To address these concerns, a number of
vendors are now offering physician/patient communications systems that are similar to e-mail in
capabilities, yet use browser-based Internet technologies in combination with workflow, routing and
Internet security technologiese.g., Healinx had created a number of templates for common physi-
cian/patient communications such as a consultation about a medical condition, prescription refill
requests, appointment requests and referrals. Using these forms and workflow, e-mails can be
securely routed to the appropriate personnel so that only those communications that require physician
input or authorization reach the physician. To date, some desired capabilities are not yet provided
(e.g., the patient has no way of knowing if the physicians office has read the request, and overall
group queue management is not yet sophisticated). In any case, capabilities such as these (as well as
more common e-mail response management systems and emerging e-mail staging server approaches)
are more likely to be incorporated in more comprehensive suites of products or as part of healthcare
vertical portals as opposed to stand-alone products.

2002 HIMSS Proceedings: Educational Sessions Session 122 / Page 4

Strategic Planning Assumption: Through 2003, in most situations, staging-server-based e-mail prod-
ucts will remain the most cost-effective approach for HCOs to comply with the HIPAA security reg-
ulations authentication and encryption requirements pertaining to e-mail communication with
patients and members (0.8 probability)
Action Item: HCOs should look beyond simple e-mail solutions that are prone to basic problems that
inhibit processes, and should search for systems that use workflow and rules-based routing.

BUSINESS PROCESS MANAGEMENT

Only a handful of healthcare vendors have begun to deliver on a true, process-centric workflow-
enabled approach to e-health. Using XML-based process automation is a winning strategy. In such an
approach, processes and applications are defined using a graphical process modeling tool where rout-
ing rules can be defined. Forms and reports are created and adopted from template starting points.
After process initiation, knowledge workers and patients have tasks pushed to them over the Web (it
should be possible to dynamically create forms and screens presented to the user based on where
users are in the process, the current environment and other factors). Users should also be able to
access process status and reports. Therefore, status is no longer a mystery and parties are no longer
confused as to who is required to take the next action. Although simple in concept, such user-accessi-
ble viewing and driving of process has been mostly missing in healthcare applications. XML and the
Internets digital dial tone are key enablers of this Web-based process-driven workflow approach.
Strategic Planning Assumption: Although true, process-centric, workflow-driven e-health vendor
offerings began to emerge in 2000, the majority of e-health vendors will not provide such capabilities
until 2003 (0.7 probability).
Action Item: HCOs should look to adopt true, workflow-enabled, process-driven applications that
support business process management.

WIRELESS INFRASTRUCTURE
There are three distinct requirements for wireless access in healthcare: high bandwidth LAN connec-
tivity, wide-area connectivity, and cable replacement. In terms of a building or campus infrastructure,
the 802.11b standard should give HCOs the confidence to invest in it as an enterprise infrastructure,
however, there are still some issues of bandwidth (WLANs can operate at close to Ethernet speed of
11 Mbps, but not close to wired fast Ethernet speed of 100 Mbps); cost (which continues to drop);
compatibility (there are still many proprietary solutions); and scalability (e.g., fast, seamless roam-
ing). The situation is far less clear for wide area data access. The dream of a single technology solu-
tion for third-generation mobile is lost in a jumble of standards, and it will be 2005 before high speed,
packet-based wireless data services are generally available.
Bluetooth networking can help to negotiate some compromises associated with PDAs and smart
phones, allowing these devices to access to headsets, keyboards, and printers, as well as, synchronize
with desktop PCs and servers, all without wires. As such, we recommend that HCOs view Bluetooth
along the lines of a wireless USB replacement. We do not believe that Bluetooth will serve as a
replacement for WLAN technology.
Tactical Guideline: Wireless LANs will become a critical access type as third-generation wide-area
wireless fails to meet the market requirements for bandwidth, coverage and compatibility before 2005.
Action Item: HCOs should establish IEEE 802.11b as the enterprises standard for a wireless LAN
infrastructure, and Bluetooth as their standard for cable replacement and synchronization applications.

MOBILE HEALTHCARE COMPUTING: FUNCTIONS AND TIMEFRAMES

Numerous vendors are entering, or have already entered, the mobile clinician application spacetar-
geting Palm, Windows CE (Pocket PC) or lightweight laptop devices. The usual strategy is to offer
one or more functions as a starting point, with the intention to add more capabilities later as the user
base size increases. Typical starting functions offered are prescription writing, medical coding/charge
capture and ordering/viewing lab reports. Additional applications include viewing other reports,
receiving alerts, links to scheduling systems, and even clinical decision support capabilities. In each
of these areas, there are multiple levels of sophisticatione.g., a prescription writer might also
include online drug-drug interaction checking, formulary compliance and links to pharmacy benefits
management systems. The degree of linkage to the CPRif it existsis obviously a major factor in
increasing application value as well.

2002 HIMSS Proceedings: Educational Sessions Session 122 / Page 5

Technologies that will further enable the adoption of handheld healthcare in the next few years
include Bluetooth (to remove the cables between devices), PKI (and other security technologies),
microbrowser capabilities and the maturation of PDA software development tools.
Looking further ahead, additional technologies that will help the adoption of handheld healthcare
include speech and handwriting recognition, glasses-mounted visual displays, and increased use of
biometrics for user identification. We expect the most common providers of clinical handheld tech-
nology will shift from the healthcare-PDA-specific vendors of today to the leading HIS and PM ven-
dors, to eventually just about all HIS/PM vendors (some PDA-focused vendors have already faltered).
The HIS/PM vendors will have the option to provide this capability either through direct device inter-
faces (a poor approach), via the tools available in healthcare vertical portals (a fair approach), through
wireless application gateways (a better approach), or via WAG functionality that has been combined
with HVPs (the best approach).
Strategic Planning Assumption: By 2005, PDAs that support continuous speech recognition with
editing functions that include handwriting recognition will be routinely used as the primary method
of healthcare input data capture at the point-of-care (0.7 probability).
Action Item: CDOs should pilot point solutions with PDA-focused vendors, but should press their
more established PM and CPR vendors to offer their more robust applications in a PDA form factor.

TELEMEDICINE: SEE ME, FEEL ME, OPERATE ON ME?

Telemedicine has the tremendous potential to return users to a patient-centric model of healthcare
where care comes to the patient, not vice versa. Teleconferencing has been with us for some time, but
bandwidth and equipment costs have been high. However, these issues are already beginning to fade.
Bigger problemssuch as the political and financial aspects of telemedicinewill prevent wide-
spread adoption with some exceptions, such as the military, progressive HCOs and meeting the needs
of remote communities or outposts. In the short-term, CDOs should look for telemedicine applica-
tions that require minimal physical point-of-care supporte.g., holding telemedicine psychological
exams where only having a view of the patient is needed as opposed to applications that require
action physical contact, such as remote drug administration. The use of digital cameras and new com-
pression algorithms are already facilitating more detailed diagnoses to be accomplishedsuch as
providing a detailed picture of a rash. Eventually, the pioneering robotic surgeries that are already
taking place will begin to become routine.
Tactical Guideline: Telemedicine will continue to be held back more by political and financial factors
than by technical factorswith some exceptions such as the military, large progressive health plans
and where special needs must be met, such as the servicing of remote communities or outposts.
Action Item: Telemedicine should be pursued as a joint effort between local and remote physicians,
not as a means of displacing existing doctors.

HOME MONITORING AND INTERNET APPLIANCES

The use of the Internet and Internet appliances to connect care delivery professionals to their patients
at the home are on the increase. Such devices are designed to be simple enough to be used by patients
and to transmit their readings over the Internetusually by automatically dialing out via a phone line
(the use of wireless technology will become common in the next few years). By reducing the need for
care delivery professionals to make house calls, such devices can dramatically reduce overall costs
and increase quality through more frequent monitoring. For example, VivoMetrics LifeShirt embeds
sensors in a special shirt that measure more than 40 physiological signs. Sensatexs Smart Shirt per-
forms similar capabilities. It uses a special fabric and wearable motherboard, and is designed to trans-
mit information via a satellite connection. Aleres AlereNet DayLink Monitor combines a biometric
measuring device with an interactive display and communications unitpatients can transmit infor-
mation such as their weight to their care professionals. Health Heros Health Buddy Internet appli-
ance is about the size of a large alarm clock and features four buttons for interaction with the patient.
It connects via a toll-free call to the Health Hero Network, which can be accessed by care providers.
Other potential home health monitoring devices include motion detectors, video camseven sensors
in the toilet.
Strategic Planning Assumption: By 2006, 25 percent of senior citizens (older than 65) in the United
States will have some aspects of their health remotely monitored via the Internet from their homes
(0.8 probability).
Action Item: HCOs should prepare themselves to take advantage of the upcoming proliferation of
home Internet health appliances.

2002 HIMSS Proceedings: Educational Sessions Session 122 / Page 6

MEDICATION MANGEMENT USING BAR CODING, PDAS AND WIRELESS
Incorrect medication administration (as highlighted by recent reports from the Institute of Medicine)
and inefficiencies in healthcare materials management and the supply chain are real problems IT can
address. Proper identification of physician, patient, medication and dose at the point of care are essen-
tial, and they can be enabled with bar-code technology, PDAs and wireless technology. For example,
the linkage between the PDA, and computer-based patient record system (CPR) and drug dispensing
device can provide drug-drug interaction checking and clinical decision support system (CDSS) for
the particular patient. Linkages between the PDA, the drug dispensing system and back-end
Enterprise Resource Planning (ERP) systems can ensure proper charge capture and billing. Supply
chain linkages from ERP and material management systems back to the suppliers, manufactures and
distributors can help ensure that the right drugs are manufactured, delivered and available when
needed, and can help determine which drugs are most effective for which conditions (evidence-based
medicine). The use of Internet technologies, including workflow, integration brokers and others will
all be helpful.
Strategic Planning Assumption: By 2005, 75 percent of CDOs will have Web-based SCM-enabling
applications integrated with ERP back-office functions in place (0.8 probability).
Action Item: CDOs should take immediate and strong action to avail themselves of technologies that
reduce the risk of medication errors or suffer the wrath of the media and of community outcry.

E-PROCUREMENT AND E-SCM CHALLENGES

Many HCOs are becoming familiar with e-procurement through such marketplaces as the Global
Healthcare Exchange, distributor alliances such as HealthNexis (formerly The New Health
Exchange) and major partnerships between healthcare e-procurement vendors and GPOs (e.g.,
Neoforma with Novation and Medibuy with Premier). Being able to comparison shop or take advan-
tage of GPO contracts online are just a few possibilities. The emergence of cross-industry XML-
based standards and the bodies that promote them is both enabling and confusing this space (e.g.,
ebXML, Oasis, RosettaNet). In addition, e-procurement is just part of a much larger puzzle in the
quest for efficiencies and savings e.g., being able to combine e-procurement with contract manage-
ment helps an organization understand what contracts and purchasing patterns it already has so it can
make intelligent decisions about purchasing on- or off-contract. Another area of synergy is to link e-
procurement to the supply chain (with vendors like I2) so that not only are HCOs buying the right
products from the right placesthey are helping to ensure that they buy them at the right time and
that they know when they are going to arrive. Integration between e-procurement systems and legacy
ERP systems also needs to occur to limit data entry duplication. HCOs should become familiar with
healthcare standard efforts in this space, such as the Coalition for Healthcare eStandards (CHeS
www.chestandards.com) and its support of the Electronic Commerce Code Management Association
(ECCMAwww.eccma.org).
Action Item: HCOs should begin to pilot (e.g., no long-term contracts yet) e-procurementfirst via
established relationships, but if these are not sufficient, they should look beyond to other options, par-
ticularly for off-contract items.

CONTACT CENTER CHALLENGES: APLOGIZE OR ADDRESS?

As consumers/patients become more demanding and technology-savvy, HCOs will need to step up their
call center functionality to offer more comprehensive contact centers. The advantages are many, espe-
cially given that an increasing number of contacts can be of the self-service variety (e.g., via phone-based
IVR, ERMS, or browser access to patient data). Such self service can decrease costs per requests from
dollars to pennies and, when multiplied by the millions of members and multiple requests received, can
offer a return on investment (ROI) in the millions of dollars per year. However, not all contact center tech-
nologies are ready for prime time, and the integration of these technologies can be even more problem-
atic. For example, it is still typical these days, even in more technology-savvy industries, to find
disconnects and discrepancies between what an enterprise offers on the Web and what its sales and sup-
port people are familiar with (this is often due to Internet initiatives being launched by separate or spun-
off business units). Although the hype is still high, HCOs should begin to pursue Customer Relationship
Management (CRM) strategies that at least take advantage of some of the mature contact center tech-
nologies such as IVR and CTI, with increasing use of the Web being a strong focus of future investment.
Strategic Planning Assumption: By 2002, HCOs that have integrated live Web contacts or e-mail with
their telephone-based agents will experience greater than 25 percent performance improvements in
targeted interactions (0.7 probability).
Action Item: HCOs should upgrade their call centers to contact centers.

2002 HIMSS Proceedings: Educational Sessions Session 122 / Page 7

SECURITY TECHNOLOGIES AND CHALLENGES:
As healthcare moves toward the CPR, as the size of the integrated delivery system (IDS) continues to
increase and as the number of lives under a particular HCO continues to increase, issues of who you
are become even more important from an IT point of view. Identification/authentication can be bro-
ken down into what you are, what you know and what you have. What you are technology (bio-
metrics) offers some of the more robust ID solutions, but it also has limitations (e.g., for a retinal
scan, the patients eyes might be closed). What you know technology (passwords) has numerous
limitations (e.g., capture and replay tactics). What you have technology (e.g., a smart card or some
other type of device) places a burden on the user (i.e., you have to carry the card). A combination of
two or more of these techniques can be used to offer the highest authentication and security. HCOs
should recognize that they do not have an either/or decision to make about biometrics vs. digital sig-
naturesthere is opportunity for both approaches. Biometric identification offers a low-annoyance,
high-security mechanism to protect the private keys that underlie the PKI-based digital signature and
encrypted-channel infrastructure that will be required for physicians to review patient clinical infor-
mation and remotely write electronic orders.
Strategic Planning Assumption: By 2003, PKI will be the only cost-effective technology available for
authentication, integrity and non-repudiation of healthcare users and systems for e-health and privacy
(0.8 probability).
Strategic Planning Assumption: Through 2004, biometric identification and proximity detection will
be the only technologies unobtrusive enough to elicit the cooperation of physicians and nurses to ade-
quately protect the PKI-based private keys supporting digital signatures in busy clinical environments
(0.8 probability).
Action Item: HCOs should pursue multifactored identification starting with care-givers, and eventu-
ally to enable patients and members.

E-HEALTHCARE VENDOR SELECTION

In the Internet Era, there are no shortage of vendors and hype. HCOs facing these choices should pay
particular attention to the overall strategy of large vendors (the vendors strategy should be aligned
with the users strategy) and these large vendors willingness to be open, integrate with and partner
(and, of course, to embrace the Internet). HCOs considering smaller vendors, particular the dot-com
vendors should look for realistic time lines, perform extra due diligence (particularly regarding finan-
cials) and look for those vendors that have partnerships with the HCOs core vendor, because the dan-
gers of smaller vendors being acquired or going out of business are not only real, but likely (even
some larger players have had tough times during the recent dot.com fallout). Although public compa-
nies offer a higher window of visibility to an HCO, such public disclosures are no guarantee that
the vendor has not become a house of cards (deterioration in customer service is an early warning
sign). For all HCO vendor decisions, the quality and philosophy of a vendors senior management
team remains the most important consideration.
Examples of vendors offering e-healthcare products and solutions include:
Mobile Healthcare Applications: ePhysician, iScribe, AllScripts, PatientKeeper, ePocrates
Healthcare Web-Development: Medseek, Doghouse, Citrix/Sequoia, Wellogic
Integration Brokers: Sybase/Neon, Quovadx/Xcare.net/Healthcare.com, Meractor, SeeBeyond
e-Procurement: Neoforma, MediBuy, Veranto, Ventro, Omnicell
Healthcare Vertical Portals: McKesson, WebMD, Healthvision, Medscape
Healthcare Internet Appliances: Vivometrics, HealthHero
Strategic Planning Assumption: By year-end 2002, 90 percent of dot-com e-health vendors that
have not achieved gross profits will fail (0.8 probability).
Action Item: HCOs should choose vendors with an eye on the capabilities of the management team,
the vendors willingness to partner, and the vendors understanding of and use of Internet technologies.

2002 HIMSS Proceedings: Educational Sessions Session 122 / Page 8

SUMMARY OF RECOMMENDATIONS
Here is a summary of our recommendations for HCO adoption of e-healthcare:
Start now to develop and execute on an e-health strategy.
Press vendors to comply with leading healthcare standards bodies.
Aim for hybrid HVP approaches of bricks and clicks.
Aim for PHRs with structured data feeds from CPRs.
Look for opportunities to apply e-forms, workflow, rules and BPA.
Apply ASPs only where appropriate, with an eye on bandwidth.
View handheld healthcare devices as extensions of existing applications.
Consider telehealth applications where touch is not needed.
Support or start deployment of home Internet appliances.
Participate in B2B marketplacesdont burn your bridges.
Upgrade call centers to contact centers.
Deploy security technologies commensurate with risks.

AUTHOR BIOGRAPHY
Mr. Kleinberg is a VP/Research Director in Gartners Healthcare group with more than 21 years of
experience in IT. He covers underlying, enabling and emerging technologies in healthcare with a
focus on e-health. Prior companies that Mr. Kleinberg has worked for include New Science
Associates, Coopers & Lybrand and Unisys Corp.

2002 HIMSS Proceedings: Educational Sessions Session 122 / Page 9