This proposal submission from clinicalMessage responds to the Matchmaking Innovation request to help connect patients and researchers differently. The clinicalMessage platform can engage providers, patients, and researchers to collaboratively develop research questions, share data according to consent, and disseminate results to improve population health outcomes. clinicalMessage currently provides capabilities for patient engagement, provider decision support, and outcomes registries. Partnering with Matchmaking could help clinicalMessage expand these capabilities to more populations and research areas. The proposal demonstrates how clinicalMessage meets the criteria of connecting diverse groups, developing usable models, and maximizing patient-centeredness while ensuring scientific rigor in potential collaborations.

1. This proposal submission is a
response to Matchmaking Innovation
request to help “do research
differently”. The proposal highlights
our understanding of the opportunity
and how clinicalMessage , an award
winning IT capability, can help
providers, researchers, and patients
to engage in collaborative research
that positively affects the health of the
population within United States and
globally.
Patient-Research
Challenge
and
clinicalMessage
Solution
Proposal Submisson
clinicalMessage Team, 2013
To: Matchmaking Selection Committee
Please accept this proposal as a formal submission by clinicalMessage Inc. Team. The undersigned has the authority to
submit this proposal. Should you have any further questions, please feel free to reach us at any time.
clinicalMessage authorized personal:
______________________________________________
Jason Uppal, MA, P.Eng. Chief Architect ClinicalMessage
Email: Jason.Uppal@clinicalMessage.Org
Tel: 610 732 8500

2. Table of Contents
I. clinicalMessage Submission ................................................................................................................... 2
Requirements ...................................................................................................................................... 2
Matchmaking 2013 Challenge ............................................................................................................ 2
Our Understanding of the Challenge ................................................................................................... 2
Matchmaker Concept Proposal ............................................................................................................... 3
Matchmaker Required Capabilities ...................................................................................................... 3
clinicalMessage Architecture and Capabilities ....................................................................................... 3
Scope of Matchmaking Project ............................................................................................................... 4
clinicalMessage Gaps ........................................................................................................................ 4
Plan to Close the Gaps ...................................................................................................................... 4
About clinicalMessage Inc. .................................................................................................................... 5
clinicalMessage Corporation ............................................................................................................... 5
Business Model ................................................................................................................................ 5
clinicalMessage: Patient Centered Capabilities ......................................................................................... 6
clinicalMessage: Provider Centered Capabilities .................................................................................... 6
II. clinicalMessage Response Summary ...................................................................................................... 7
III. Plan Forward ..................................................................................................................................... 9
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3. I. clinicalMessage Submission
clinicalMessage IT program was initiated as a cooperative effort by a medical research facility and an engineering
firm with deep expertise in business transformation across multiple industries. Initially, the scope of the program was
to develop information management capabilities to reduce variability in care processes and reduce the impact of gaps
in care. In 2012, clinicalMessage received a bronze medal by the Edison Awards Foundation for innovative healthcare
transformation solution. Currently, clinicalMessage capability has been extended to enable critical real-time
information flow to the providers and patients in order to improve the overall health of the population measured
through IHI Triple Aim performance measures.
We believe the vision of patient-research matchmaking and clinicalMessage is in complete alignment and through
cooperation, both organizations can help realize their vision and help improve the health of the population not only
within United States, but also globally.
Requirements
Matchmaking 2013 Challenge
“This challenge, which we’re launching in collaboration with Health 2.0, offers an opportunity for innovators to help
PCORI pursue our commitment to “research done differently” by bringing the voice of patients, caregivers and other
stakeholders clearly and fully to the research process. We believe this means having patients and caregivers serve as
collaborators with researchers in such critical activities as formulating research questions, developing research
materials, determining research protocols, and helping to review and disseminate study results.”
Our Understanding of the Challenge
• Enable researchers, providers and population to jointly develop
research hypothesis in the context of population health
improvement
• Develop a closed loop system that allows for collaboration of
data/research amongst PCORI stakeholders
• PCORI will fund these research projects and measure their
impact on overall population health
• Facilitate the dissemination of research findings and study data
to providers and population health in a timely fashion
• Accomplish this through cost effective and secure information
management and sharing portal with particular focus on hard to
Figure 1: Collaborative Integrated IT Platform
reach population
• Advance PCORI’s vision to impact and improve population health management across care continuum
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4. Matchmaker Concept Proposal
Matchmaker Required Capabilities
We believe the scope outlined in Matchmaker Vision, cannot be addressed by a single point solution, rather it will
need to be an integrated capability that will :
• Engage Providers, Population and Patients
• Manage necessary health (PHI and non-PHI) information in most non intrusive way as part of natural care
delivery workflow
• Maintain explicitly consented relationship between providers, population and patients
• Enable broad researchers to access non phi outcomes registries to develop hypothesise
• Facilitate local intervention and monitor progress through most rigorous research methods
• Disseminate results locally and globally
• Through overall health of the population metrics - Measure the impact of PCORI investment/cost on local
and global population level
• Capture research specific ideas, topics of study, and areas of interest by patients, providers & researchers
clinicalMessage Architecture and Capabilities
• Engage Population – self-
help, engagement in care
management process and
identify research questions
• Engage Providers – PCMH
enabling capability
• Population Health Measures
at practice level
• Outcomes database –
accessible by consenting
patients and providers
• Orthopedic outcomes
registry
• Learning-research platform
for idea generation on both
provider & patient portal
Figure 2: clinicalMessage and eHealth Capability
(Note: These capabilities listed above already exist in clinicalMessage, or they are within our business scope in 2013)
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5. Scope of Matchmaking Project
clinicalMessage Gaps
The following gaps are within our clinicalMessage business plan. However, we believe these care gaps can be closed
more effectively through partnership with the patient-researcher matchmaking team.
• Design to extract data from clinicalMessage to build non-PHI outcomes registry data-warehouse
• Orthopedic Outcomes registry project is currently being developed
• Adoption of all registries as a source of data to establish initial research hypothesise and partner with care
providers “ to do research differently ”
Figure 3: Required Resources
Plan to Close the Gaps
clinicalMessage team has developed
following resource and project plan.
Figure 4: Partial Project Plan
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6. About clinicalMessage Inc.
clinicalMessage Corporation
clinicalMessage is a social corporation and registered in state of Delaware with following ownership structure :
• 40% allocated to future Research & Development in Population Health, managed as a trust
• 20% allocated to Founders
• 40% to Equity Market
We believe this structures will enable us to build a self- sustaining healthcare improvement business model.
Business Model
Revenue Opportunities
• Outcomes registry (non-PHI) will be made available to all researchers and physicians at nominal cost
• Providers will get real-time access to decision support and streamlined way to manage care management
workflow at roughly $1 dollar per patient per year
• No cost is incurred to population for being part of clinicalMessage
Figure 5: clinicalMessage Business Model
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7. clinicalMessage: Patient Centered Capabilities
• eHealthBook: manage my own health information and interact real-time with (read only) my information, and
designated family members
• Biometrics: record my specific body information as often as required. Actively engage me via reminders and alerts
to check and record my biometrics (BP, weight, sugar levels, heart rate, etc)
• Health Challenge: self or with the help from family, friends and physician, establish my health goals and record daily
progress towards them. Share my health goal related information with my family and care team members.
• Engaged Care: be part of the hospital care team if I get sick. Allow doctors and care team to have immediate access
to my medical history, medication, allergies and current health plan. Communicate with my care team members
important information via secure
messaging.
• My Community: connect globally with
people who have the same diseases as
me; connect locally to what is happening
in my own community. Get involved with
community support groups or club to build
health network.
• Health Games: use awards, games and
recognition to stay healthy. Save and
build “my health” credit bank so I can
redeem my bonus points for special items
at corporate "health partner" stores.
• Health Index: be counted in global
population health performance as a US
citizen, so I can compare my health status
with other countries.
• Health Study Idea: initiate and submit health
study ideas or topics for doctors and research centers to help
me and my family stay healthy.
clinicalMessage: Provider Centered Capabilities
@ Hospital: Hospitalist
• Process Variability to Reduce Errors and Gaps in Care Delivery:
Implementing Care Team Coordination, Best Practice and Standards, Real-time Team Based Communication, Hand-
off/Sign-Out, Patient Goals and Care Plan, Patient and Family Engagement, Discharge, Consult, Real-Time handoff to
Family Physicians
• Tools to Improve Clinical Care Process:
Real-Time clinical audits using lean six sigma methodology. Support a learning organization culture, with professional
development, peer review, and process improvement.
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8. • Measurement Capability of Organization and Staff Outcome Performance Data:
Real-Time scorecard – measure the impact of provider actions on care delivery for the patient, specifically shows
capability performance as well as Patient Outcomes, For example – LOS, Readmission, Unaddressed alerts,
Compliance, Team Based Care etc.
@Home: Community Health Worker
• Portfolio: Group or Assign patients by profile – culture/language, geographic, chronic sickness, type of care required
• Clinical Information: Case Worker can access critical patient health information real-time
• Decision Support : Immediate access to best practice to support care delivery anytime, anywhere
• Team Collaboration: Real-time, secure communication to collaborate with care team members, patients and family
@ Primary Care Office: PCMH
• Care Coordination: Coordinate care across the entire continuum, implement patient centered medical home,
improve process to manage EHR
• Decision Support : Decision support based on Evidence Based Practice
• Simplified EHR: Manage clinical information as part of natural care process and generate all necessary regulatory
reports automatically
II. clinicalMessage Response Summary
This section summarizes clinicalMessage response, in terms of prescribed evaluation criteria previously set forth:
[Matchmaking Evaluation Criteria 1] The entry’s actual or described technical capacity to efficiently and effectively
connect patients and researchers, across multiple platforms and levels of complexity.
[clinicalMessage Response 1] Currently all HIT capabilities place Electronic Health Record in the center.
As a result, the entire healthcare ecosystem suffers from lack of inter-operability among disparate systems
that are complex and work under different incentive schemes.
clinicalMessage on the other hand starts with Population needs in the center, streamlines care delivery
processes regardless of care delivery channel and only then starts to automate the flow of essential health
related information. As result, clinicalMessage IT platform can capture essential information as natural part
of care delivery process and through secure channel, deliver real time information to the point of action be
that the provider, researchers, and/or the population.
[Matchmaking Evaluation Criteria 2] Usability, scalability and sustainability across diverse populations with
differing levels of access to, understanding of, and experience with technology and health/health care information.
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9. [clinicalMessage Response 2] clinicalMessage employs "user centric design" to ensure the system
workflow matches the “natural workflow” and system thinking approach ensure the problem is solved form all
stakeholders point of view. Social media design principle – one button one action enables us to build an IT
system that enables the end user to complete their task with no system training.
For Example:
• Patient, provider can submit an improvement opportunity and other members can join in to help
improve the idea. The idea is then evaluated by the lean six sigma team and the system provides
prescribed ways to bring idea to fruition.
[Matchmaking Evaluation Criteria 3] Degree of development of the model or prototype
[clinicalMessage Response 3] Basic system to engage provider and patient already exist in
clinicalMessage capability. We are currently an outcome spine registry that will allow providers and patients
to leverage latest information and incorporate it in their care plan including best practice.
Matchmaking Innovation program will enable clinicalMessage to extend the outcome registry to other
domains and make data accessible to broader researchers in the community.
[Matchmaking Evaluation Criteria 4] Differences in the ways that patients, caregivers and researchers understand,
describe and seek answers to the problems they face or the issues they’re trying to address (ex, different terms for
similar concepts, general levels of health literacy, etc.).
[clinicalMessage Response 4] clinicalMessage architecture incorporates the system thinking approach.
Instead of starting with EHR in the middle, this approach analyzes the needs of each stakeholder, their skills
and what is important to them. We wrote a blog (http://qrs3e.com/architecture-of-healthcare-systems/) that
describes the challenges and how to overcome them.
[Matchmaking Evaluation Criteria 5] Maximizing “patient-centeredness” – the submission’s ability to account for
and effectively focus on and address patients’ needs – while also emphasizing and facilitating researchers’ need to
emphasize the scientific rigor of any resulting collaboration.
[clinicalMessage Response 5] Patient Centeredness is central to clinicalMessage architecture. We ensure
patient-centeredness by using the following outcome and capability performance measures:
1. Population Health Outcome Measures:
a. Total cost of care
 Cost of care in episodic care centers
 Cost of medications
 Cost of care through primary care setting
b. Quality of Care
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10.  Health Index (measure the inability to do what is important )
2. Capability Performance Measures:
a. Dashboards - clinicalMessage provides real-time performance dashboards to each
stakeholder that allows them to assess the impact of their action on the patient care.
b . Population:
 Engagement index
 Real-time survey – how am I feeling now
 Automatically collected Biometric feeds
c. Providers
 Team based care
[Matchmaking Evaluation Criteria 6] The particular challenges of serving "hard-to-reach" audiences, including, but
not limited to, ethnic and racial minorities, rural populations, the elderly, the disabled/physically challenged (ex,
Section 508 compliance) and those for whom English is a second language.
[clinicalMessage Response 6] clinicalMessage architecture supports multiple languages. The system
layout is based on the providers preferred language. The open architecture can be extended to support user
provided data into the preferred language of the receiver. There are several challenges that need to be
overcome including real-time translation of user provided data.
III. Plan Forward
We, at clinicalMessage, have a shared vision with The 2013 Matchmaking Challenge. Furthermore, we believe that by
partnering together, we can support the community at large to advance “research done differently.” The goal of
clinicalMessage is to improve population health and engage all stakeholders in the care delivery process.
clinicalMessage is the ideal platform to bring the voice of patients, providers, and caregivers together in the
research process. Collectively we can advance population health and drive improvements. Research done differently
means having patients and caregivers serve as collaborators on study teams using clinicalMessage platform. Together
we can share data, formulate research questions, develop research protocols, and help to disseminate important study
findings.
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