Lab Soft News

The Other Real Threat to Intel; Better Utilization of its Chips

I, like many other people with an IT interest, have been closely following the decline in PC sales (see: The Shift from PCs to Tablets; Most iPads Stay in the Living Room). On the face of it, this shift would seem not to bode well for chip manufacturers like Intel. However and simultaneously, the server business is booming with the proliferation of web users and more attention to cloud computing. Christopher Mims addressed this scenmario in a recent article (see: The (other) real threat to Intel’s business: You’re making better use of its products), Below is an excerpt from it:

...Well, the PC is dying, and that’s been devastating to [Intel's] revenue. But that misses an important point: Intel’s server business is doing well. It’s the only part of the company that’s both growing and contributing materially to the bottom line. Intel estimates that, for example, for every 120 tablets sold, someone has to buy a new server to deliver content and apps to those devices....So even though people are buying fewer PCs with Intel chips in them, they’re buying devices that require more servers, most of which have Intel chips in them. Why, then, isn’t the explosion of mobile offsetting the contraction in Intel’s business?

Multiplexing is a term from electronics and signal processing, and it describes, for example, the process of carrying several phone conversations on a single telephone wire. In general, multiplexing is applied to situations in which, with a little ingenuity, an expensive resource can be shared. In 2011, economists applied the term multiplexing to the business model of Netflix, which at the time was still sending out a lot of DVDs by mail. The obvious secret to Netflix’s business model at the time was that a single shared resource—a DVD of a hot new Hollywood blockbuster, for example—could be re-used again and again as it rotated between customers.

Zipcar, Netflix, AirBnB and several other companies all have essentially the same business model: Use the internet and information technology to squeeze as much use as possible out of an expensive, previously under-utilized resource....And now consider the “cloud.” Cloud computing is just a way to put as many microprocessors as possible into a single building, where they are fed computing tasks that use as much of their capacity as possible. That’s multiplexing. What the cloud is gradually doing is replacing all those expensive chips in people’s personal computers, where they spend most of the time switched off or idling, with a smaller number of chips in data centers that can be used at full blast pretty much all the time. When we stream videos or edit online documents, most of the processing it requires isn’t being done on the devices we’re using, but in the cloud.

This is great for consumers—more efficiency leads to lower costs and increased capabilities—and bad for Intel. Every transistor it rolls out is being used more effectively than ever. We have found a way to take the expensive resource the company produces and share it as much as possible. And the less powerful chips that still reside in our mobile devices? For the most part, Intel isn’t in that business, even though it very much wants to be. This, as much as the “death of the PC,” is the horns of Intel’s dilemma.

In essence, Mims presents some of the consequences as multiplexing meets the cloud. Here is the story in truncated form: (1) pack as many microprocessors as possible into a room; (2) rent out the computing power of that room to other businesses; and (3) the cost of a previously expensive resource like microprocessors and even demand for them ratchets down. There is decreased demand for Intel's microprocessors because each one of them is being used by these new technologies (multiplexing and the cloud) to its maximum capability by customers. The use of tablets and mobile phones is growing but Intel missed our on most of this less-powerful-chip business, perhaps because of its lack of understanding of disruptive innovation.

GAO Issues Report about the Potential to Hack Embedded Medical Devices

The array of implantable medical devices that store and download data continues to grow. Examples include three types of cardiac devices: pacemakers , implantable cardioverter defibrillators (ICD), and biventricular pacemakers (see: UNC Electrophysiology Services). All of these devices contain chips that store data that can be downloaded for subsequent review and analysis. I posted a previous note discussing whether patients with such devices are legally entitled to access this data (see: Should Patients Have Access to Data from Their Implanted Medical Devices?). I recently came across an interesting article recently about a possible hacking threat of implanted medical devices (see: Hacking medical devices – movie plot or realistic threat?), Below is an excerpt from it:

As providers work to update their HIPAA policies and procedures, there’s another area of concern to consider: the hacking of implantable medical devices. In August of last year, the Government Accountability Office, the “congressional watchdog,” released a report ...identifying information security issues associated with medical devices and advising the FDA to ramp-up its efforts to address these issues. These devices include implantable defibrillators, insulin pumps, pacemakers, and other devices used to monitor and transmit a patient’s medical status. Specifically, the GAO considered intentional threats to such devices, including hackers obtaining unauthorized access, or using malware, viruses, or worms to interfere with the functioning of the device.  Although there have been no documented incidents thus far, the GAO cited several demonstrations in controlled settings showing that hacking of these devices is a real threat. In one demonstration, the researchers were able to remotely deliver commands to a defibrillator. Other demonstrations revealed that hackers could prevent insulin pumps from operating properly or manipulate the amount of insulin to be dispensed. Unfortunately, the GAO report also acknowledged that efforts to address the security issues associated with these devices could adversely affect the performance of the devices. For one, pacemakers cannot be made immune to all electrical signals because the device must be able to detect the signals naturally generated by the patient’s heart to determine irregularity in pulse. Further, adding encryption – a security feature of which most providers are aware – could drain a device’s battery, which can only be replaced by surgery. The FDA has stated that, in the future, the agency will consider information security risks resulting from intentional threats when reviewing new devices submitted by manufacturers. 

For now, much of this discussion probably relates to the potential to hack life-critical devices rather than any real and immediate threat. Nevertheless, it also highlights how dependent many of us are on our high-tech devices, some putting their very lives under the control of them. Unfortunately, even the potential to hack these devices could serve as an impetus for some to attempt to do so. I am glad that the GAO issued its report. It will cause the manufacturers of these devices to endeavor to make them unhackable. Unfortunately, this probably is impossible given the history of hacking any device controlled by software and with the ability to communicate externally. As noted above, battery life is critical for these devices and making them more complex may impair this function. It's one thing to have an intelligent device on your wrist or in your pocket. It's another to have it embedded in your chest and in control of your destiny.

Most Web Site Internal Search Engines Are Inadequate

I have been frustrated for years by the inadequacy of many web site internal search engines. I will use the search engine of the New York Times as one example of my point. After I have read a story in the print edition of the newspaper, I will then often try to access the same story on-line using the NYT internal search feature in preparation for writing a blog note. For search terms, I may use two or three of the exact words from the newspaper headline and then fail to retrieve the article most of the time. I often then include in the search the last name of the reporter. This usually works for me.

By way of contrast, my Google searchs on almost any topic, even with what may be inadequate search terms, almost always satisfy me. Keep in mind that Google, of course, covers all of the information on the web and the NYT search engine covers only what's printed in the newspaper and perhaps some of their on-line information. 

How can you explain how one of the premiere information-gathering companies in the world, the New York Times, fares so poorly in searches on its own web site? I think that the explanation is that it is engaged primarily in the print information business and began to publish on the web relatively late. Google has always been in the web search business.

Why doesn't the NYT simply use Google as its internal search engine? That's how I provide an internal search of this blog. I think that the answer is that the NYT sees e-information companies like Google and Craigslist as competitors (see: Search Neutrality and Why the Cure May Be Worse Than the Disease; NYT Complains that Innovation Being Snuffed Out by Craig's List). Better to do a job poorly then admit that a competitor does it better. 

For the rest of us who may be interested in retrieving information from the NYT web site, there is an easy solution. Simply use Google whenever you want to perform such a search. As one of your search terms, include the following: site:nyt.com. No frustration and you can easily get the story you are looking for. Here's a link to the Google advanced search page that includes this site option.

Google Strikes Deal with French Government Regarding Online Content

I have posted previous notes about the question of whether Google is a search engine and news consolidator or a publisher of content (see: When Does Sophisticated Web Search Result in the Creation of New Content?; Google as an Enabler and Protector of Global Information Exchange; Is Google a Publisher or a Search Engine? Can Google Have It Both Ways?; Google's Deal with Publishers; Broad Current Acceptance of E-Books). According to a recent article, this question has been sorted out, for the time being, in France (see: French Publishers Forge Deal With Google, Breaking Ranks With Europe). Below is an excerpt from the article:

Publishers in France say they have struck an innovative agreement with Google on the use of their content online. Their counterparts elsewhere in Europe, however, say the French gave in too easily to the Internet giant.The deal was signed this month by President François Hollande of France and Eric E. Schmidt, the executive chairman of Google, who called it a breakthrough in the tense relationship between publishers and Google, and as a possible model for other countries to follow. Under the deal, Google agreed to set up a fund, worth 60 million euroes, or $80 million, over three years, to help publishers develop their digital units. The two sides also pledged to deepen business ties, using Google’s online tools, in an effort to generate more online revenue for the publishers, who have struggled to counteract dwindling print revenue. But the French group, representing newspaper and magazine publishers with an online presence, as well as a variety of other news-oriented Web sites, yielded on its most important demand: that Google and other search engines and “aggregators” of news should start paying for links to their content. Google, which insists that its links provide a service to publishers by directing traffic to their sites, had fiercely resisted any change in the principle of free linking. The agreement dismayed members of the European Publishers Council, a lobbying group in Brussels, which has been pushing for a fundamental change in the relationship between publishers and Google. The group criticized the French publishers for breaking ranks and striking a separate business agreement that has no statutory standing. The deal “does not address the continuing problem of unauthorized reuse and monetization of content, and so does not provide the online press with the financial certainty or mechanisms for legal redress which it needs to build sustainable business models and ensure its continued investment in high-quality content,” Angela Mills Wade, executive director of the publishers council, said in a statement. German publishers were also scornful, with Anja Pasquay, a spokeswoman for the German Newspaper Publishers’ Association, saying: “Obviously the French position isn’t one that we would favor. This is not the solution for Germany.”

A few comments about this article. First of all, $80 million dollars over three years to keep the French publishers relatively satisfied strikes me as very good news for Google. The amount is trivial for Google and serves to drive a wedge into the European publishing industry on the basis of the French accommodation. I am not surprised that the European Publishers Council and the Germans expressed regret about the deal. So much for European unity. Every country will be trying to strike the best perceived deal for itself.

Secondly, how likely do any of you readers think that Google will be able to help the French publishers in any substantive way to "develop their digital units." I suspect that much of the European book and newspaper industry is either not knowledgeable about the web or resistant to learning any new tricks from the "Silicon Valley" types. Google is buying a temporary hiatus from the French until digital publishing is even more entrenched. Most content publishing will soon be digital. The European newspaper, magazine, and book publishers need to understand this reality and come to view Google as an ally, not an enemy, in the process of monetizing their content going forward. They are swimming upstream.

Pathology Informatics Conference Moved to May 13-16, 2014

The Association of Pathology Informatics (API) has decided to change the date of its signature pathology conference, Pathology Informatics 2014, to May 13-16, 2014. The usual 2013 Fall conference will be skipped over as a consequence of this date change. The 2014 conference will be held at the Wyndham Grand Pittsburgh Downtown. This follows three previous, and successful, Fall conferences in Boston, Pittsburgh, and Chicago in 2010-2012. The rationale behind this decision was based on the following considerations:

• The Fall CME calendar has become extremely crowded with a large number of other pathology conferences and LIS user groups.
• One of the two predecessor conferences to Pathology Informatics 201X, AIMCL/Lab InfoTech Summit, always took place in the Spring and met with considerable success at this time of the year.

For 2013, the API Education Committee is planning numerous pathology informatics offerings including a series of webinars and lectures/panels in collaboration with other pathology societies including ASCP, CAP, AMP, and USCAP. There will thus be no gap in informatics educational offering due to the repositioning of this major conference. The overarching goal for the API is to continue to position Pathology Informatics 2014 as the premier pathology informatics conference of the year.

Google Dominates Global Search Even More than Desktop Search

I find myself searching the web much more frequently with my smartphone these days because the screen is relatively large, the response is quick, and there are some features available such as verbal search that I find useful. I had not thought about it, but it turns out that Google dominates mobile search even more than desktop search. This fact was highlighted in a recent news article (see: Mobile Apps Drive Rapid Change in Searches):

When the Federal Trade Commission decided last week to close its antitrust investigation of Google without charges, one important factor, though hardly mentioned, was just beneath the surface: the mobile revolution. Google has 96 percent of the global market for mobile Web searches. Google has repeatedly made the argument — and the commission agreed — that the speed of change in the technology industry made it impossible for regulators to impose restrictions without stalling future innovations. Exhibit A is the mobile device. Nowhere has technology changed as rapidly and consumer behavior as broadly. As people abandon desktop computers for mobile ones, existing tech companies’ business models are being upended and new companies are blooming....Google had new [mobile] competitors on all sides trying to chip away at its hold on the mobile search and advertising market. Still, Google is even more dominant on mobile phones than on desktop computers. It has 96 percent of the world’s mobile search market....It collects 57 percent of mobile ad revenue in the United States, while Facebook, its nearest competitor, gets just 9 percent....But, analysts say, as people change their search habits on mobile devices — bypassing Google to go straight to apps like Yelp’s, for example — that dominance could wane, or a competitor could swoop in and knock Google off its perch....On cellphones or tablets, for instance, people increasingly skip Google altogether in favor of apps like Flixster for movie times or Kayak for flights. Apple is taking on mobile search with Siri on the iPhone, which can answer questions about the weather or search for nearby restaurants. With its new mapping service, Apple has also entered local search.....The latest Google search apps for Android and Apple devices let people search by talking, and then offer spoken answers. And Google now shows its so-called knowledge cards — with answers to trivia questions or photos and details about people and places — on mobile devices.

I have been involved with information technology for about three decades. When I first started following the field, I thought the pace of development was dizzying and measured in months. Now change is measured in mere weeks. It had never occurred to me that an "app" could be designed in a way to supplant Google search but this article convinced me otherwise. When I am interested in finding a restaurant, I go straight to Yelp, bypassing the "standard" browser search. My reason for doing this is that Yelp provides me with better information more quickly about restaurants. The article also discussed a new search app called Izik where, according to the company home page, you "type less and get more." Retrieval results are simpler and includes images. A recent article discussed how an Izik search is optimized for tablets: Meet Izik: Tablet-Friendly Search From Blekko. 

Should Patients Have Access to Data from Their Implanted Medical Devices?

Here's an interesting topic that I had never considered before: should patients have unfettered access to the data captured by their implanted medical devices (see: Should You Have Unfettered Access to Your Implanted Medical Device Data?; IMPLANT DEVICES COLLECT PATIENT DATA, BUT PATIENTS DENIED ACCESS). Below is an excerpt from the first article that introduces the topic:

There was a very interesting story in the Wall Street Journal [see: Heart Gadgets Test Privacy-Law Limits] that looked at the inability of patients who have implanted medical devices such as defibrillator implants to gain access to the raw information the devices are sending out. According to the story, the device manufacturers say that rules by the U.S. Food and Drug Administration (FDA) require that the information be only sent to the patients’ hospitals or doctors, who are in fact the device manufacturers’ end-item customers. If a patient want’s to get access to the raw device data, they are told that they have to get it from their healthcare provider...The device manufacturers argue that the data from a medical device like a defibrillator isn’t in a “useful format” that patients could understand anyway, and that if they were to try make it so, it would (a) require FDA approval and (b) cost the manufactures a lot of money, which they don’t want to spend. They also argue that they haven't seen any customer demand for such information.The FDA...generally “supports patient access” to medical device information, but only if it is in a format that is presented in a way that provides “proper interpretation and explanation,” like that delivered by a doctor. In other words, don’t count on the FDA to approve broad patient access to medical device information in “useful format” or not.

Many doctors support the FDA’s position, arguing that getting access to device information – especially raw information - might cause “cause anxiety or even harm if a patient misunderstood the signals.” However, there are other incentives also at work keeping patients from accessing raw or even interpreted medical device information.......If a patient wants their implanted device information, the patient is likely going to have get an appointment and pay whatever fee the doctor or hospital charges....Furthermore, a doctor or hospital usually doesn’t get the devices' raw data themselves anyway: device manufacturers only send output summaries to them....Device manufacturers typically make doctors and hospitals sign contracts that restrict use of the devices’ raw data. The manufacturers can do that because raw data from an implanted device is not considered to be medical record information under the 1996 Health Insurance Portability and Accountability Act (HIPAA) which gives a patient the right to access their medical information held by their healthcare provider.

It also turns out that the device manufacturers are exploring business opportunities to sell “the data to health systems or insurers that could use it to predict diseases and possibly lower their costs.”....The WSJ says that Medtronic , for example, “is developing a matchstick-size monitor, implantable without surgery, that could track measures such as heart rate and arrhythmia that can predict heart disease.” With such a device, Medtronic “envision(s) a future where employers might require insured workers with a family history of heart disease to have the device implanted or face higher insurance premiums.” Of course, if that "vision" became the norm, I wouldn’t doubt that the next step would be for employers to start insisting that all of their insured employees have non-surgically implantable devices to check on a whole host of health factors, such as drug and alcohol use...., the amount of sleep they are getting.

It becames rapidly apparent that this discussion has very little to do with access to the raw data being captured by defibrillator implants. Neither patients nor even cardiologists would be able to make sense of such data. However, fast-forward to the idea that patients at risk for acute cardiac problems in the near future may have implanted devices that would monitor their cardiac status in real-time and predict imminent problems. I could envision a scenario, as described in the excerpt above, in which employers or health insurance companies would be eager to tap into such data streams. In this way, they could avoid the high costs of acute care episodes by requiring early medical intervention. I Googled the search term "health monitoring device" and got 695,000 hits so there is lots of interest in this topic. I predict that this will be one of the hottest topics in healthcare in the next year or two, particularly in relationship to smart phones supplemented by additional hardware and software that will be more common than implanted devices (see: "Check Engine Light" for Health Surveillance on Our Smart Phones). 

Some Hospitals Can't Get Past the Final Epic Deployment Step: the "Judy Check"

Here's an interesting item courtesy of Mr. HIStalk that relates to the final step in the deployment of an Epic EHR in a hospital -- the "Judy check" (see: News 12/5/12). 

From Diminutive Avian: Re: Epic. Most people don’t know that Epic has one final implementation check. Judy has to personally give the go-ahead. If she doesn’t like what she sees, she tells the customer she’s pulling out and gives them their money back. That’s another reason why the company has only successful implementations.

Mr. HIStalk response: Unlike publicly traded vendors, Epic is more than willing to walk away if the client is botching the install and ignoring Epic’s recommendations.” I’ve been told that at least two big academic medical centers are in precisely this predicament as we speak. From what I’ve heard, Judy gives the client two choices: (a) agree to let Epic send in a SWAT team to take over the project, or (b) find themselves another vendor.

I was prompted to ask myself to ask the following question upon reading this item: why do some hospital executives need to give the keys to the place to Epic, an IT vendor? I don't think that this happens in other industries. Are we dealing with massive in-house IT incompetence in hospitals or some other factor? I suspect that there may be two forces at work here.

The first is that there is a poor record of complex, large system installs across the world, particularly in large organizations. Too many moving pieces and too many affected users resulting in political chaos and technical complexity. I discussed this idea in a previous note (see: Modeling the Costs of IT System Failures Globally). Here is a quote from it:

Researchers often attempt to quantify the number of failed IT projects, usually reporting statistics that discuss failures as a percentage of the overall number of IT projects. These failure stats are primarily useful to the extent they illustrate that IT failure is a common and serious problem. In a recent white paper, Roger Sessions defined a model (Cost of IT Failure) that quantifies the dollar cost of IT failure worldwide. Roger concludes that global IT failure costs the world economy a staggering $6.2 trillion per year, or $500 billion each month.

The second force at work is that hospital executives have been conned into thinking that their only solution to support clinical computing is the deployment of a single, large EHR. The fallacy of this thinking was pointed out by Dr. Paul Chang in a lecture at Pathology Informatics 2012 (see: The Internet as the New Industrial Revolution: Implications for Healthcare). Here is an excerpt from that note:

[W]e have hospitals today spending hundreds of millions of dollars installing EHRs running on local servers that are the rough equivalent of "mainframe computers" in a former era. Dr. Paul Chang commented in his lecture at PI-2012 that healthcare is the only industry in the U.S. that "solves" its computer problems by using a single, monolithic, inflexible EHR system rather than a set of specialized servers connected on a network (see: Digital Revolution in Radiology). With this more advanced computer architecture, the user submits a query to the network and the response is assembled using information from the most appropriate, specialized systems.

The irony of Epic and its EHR is that the company provides both the most widely accepted EHR solution for hospital executives and then evolves into the hospital's worst nightmare. It sells a monolithic product that only the company can install in some settings. The reasons that only its SWAT team can finish the install are: (1) the members of the SWAT team understand the product in-depth; and (2) the SWAT team can ride roughshod over hospitals employees who don't favor the system and may be sabotaging its deployment. It would be interesting to find out how short a leash Epic puts these errant clients after the install.

"Check Engine Light" for Health Surveillance on Our Smart Phones

Smart phones are beginning to supplant PCs as our most important and versatile digital devices (see: Differences Increasingly Blurred Between PCs and Smartphones). One piece of evidence for this change is the use of smart phones as health monitoring devices including the presence of personal "check engine" light. In this latter case, smart phones are being used to continuously collect real time passive (mobile sensor) and active (patient-reported outcomes) data. Here's an excerpt from an article about this topic (see: MIT Media Lab Spin-Out Ginger.io Raises $6.5 Million Series A Round):

MIT Media Lab spin-out and TechStars alum Ginger.io has announced it has raised $6.5 million in Series A funding, bringing their total financing to $8.2 million.The round was led by Khosla Ventures and will help the behavioral health analytics startup continue to grow....“We are at a time of great disruption in healthcare,” said Vinod Khosla, founding partner of Khosla Ventures, in a release. “Ginger.io is at the forefront of data-driven technology and healthcare, with the potential to transform the way we manage chronic disease populations, and we’re excited to help the Ginger.io team drive this transition.”

Mr. HIStalk has also informed us about a similar approach by Scanadu (see: Monday Morning Update 12/3/12). Another player in this same market is Healthrageous. Here is an excerpt from the HIStalk recent note:

Scanadu, the 20-employee company whose tagline is “Sending your Smartphone to Med School,” announces that it will release three consumer tools by the end of 2013. The $150 Scanadu Scout is held to the temple and in less than 10 seconds, checks pulse, heart activity, temperature, and pulse oximetry and sends the results via Bluetooth to its smartphone app. Project ScanaFlo is a disposable cartridge that turns a smartphone into a urine analysis reader (pregnancy complications, gestational diabetes, kidney failure, or UTI). Project ScanaFlu is a saliva tester that detects cold symptoms by checking for strep, influenza, adenovirus,and RSV. Scanadu is best known for working on a tricorder-like health assessment device and these modules are the first components of it.

So what do we make of all of this? I have suggested in a previous note that nurse practitioners (NPs) may replace many primary care physicians (PCPs) as the first health care professional we will visit with a complaint. Such individuals may then provide treatment or refer us to another health professional (see: A Solution to the PCP Shortage: Nurse Practitioners). It is also in the realm of possible that some of these same initial diagnostic and triaging function may be taken over by our smart phones that will provide both active and passive surveillance of our health status.

Humana Acquires HIE Vendor Certify Data Systems

Health information exchanges (HIEs) have been around for a while with a spotty history of success (see: Sharing Medical Records across Hospitals with Epic's Care Everywhere; Health Insurance Companies Jump into Healthcare Network (HIE) Business). The problem with some of the earlier non-profit, community-based HIEs is that they lacked an adequate business model. There are several organizational models for HIEs (see: HIE Toolkit). We now learn that yet another health insurance company is acquiring an HIE (see: Humana Acquires Certify Data Systems Company a pioneer and leader in health information exchange technology). My sense is that the HIE business model pursued by these health insurance companies does make sense for them but perhaps not for me. In addition, these companies also have very deep pockets. Below is an excerpt from this latter article:

Humana..., one of the nation’s leading health and well-being companies, announced today it has acquired Certify Data Systems, a pioneer in health information exchange (HIE) technology. Terms of the transaction were not disclosed.“Humana remains focused on leveraging the power of technology to provide a more coordinated patient experience for our members that will enable quality, affordable health care”. Hospitals, physicians and laboratories across the nation have adopted the HealthLogix Enterprise HIE platform from Certify. The platform provides two-way sharing of clinical information across disparate electronic health record systems (EHRs), connecting healthcare providers and allowing them to share relevant patient health information in real-time. 

John, who blogs over at Chilmark Research had this to say about the CDS purchase by Humana (see: Another HIE Purchase by a Payer):

Today, national health insurer, Humana, announced that it has acquired Certify Data Systems (CDS). This marks the third HIE vendor (UHG acquired Axolotl & Aetna acquired Medicity) that has been acquired by a payer in the last couple of years. Not that surprising when one looks at how aggressively payers are moving into the accountable care arena and seeking to form tighter links with physicians in their network, particularly those in the ambulatory sector, where CDS has done particularly well. A key part of CDS’s success in the market was through its partnership with Cerner where it provided the technology stack for connecting ambulatory practices. The Certify HealthLogix is a well architected platform that has seen strong adoption. While terms of the deal were not disclosed, it is our guess that Humana paid a pretty penny for CDS, likely all cash deal at about 6-8x estimated 2012 sales.

Here's as press release from 2009 documenting the relationship between Cerner and Certify Data Systems (see: Cerner Offers Enhanced Solution to Enable Information Sharing between Hospitals and Physician Practices).

I think that John is definitely right when he says that "payers are moving into the accountable care arena and seeking to form tighter [communication] links with physicians in their network, particularly those in the ambulatory sector." However, it's not clear to me that independent, physician owned, ambulatory practices will be enthusiastic about having a health insurance company provide them with networking services. How ethical will they be in terms of providing these services. UnitedHealth, for one, has not shown any qualms about taking liberties with the information that it manages and ignoring conflicts of interest (see: UnitedHealth to Develop Telehealth Network with Cisco; UnitedHealth Settles Suit with New York Attorney General Cuomo; UnitedHealth deal draws concern).