Imprivata Cortext: Secure Communications Platform for Healthcare

WHITE PAPER Imprivata Cortext: Secure Communications Platform for Healthcare Sponsored by: Imprivata Lynne A. Dunbrack May 2014 INTRODUCTION At the heart of excellent patient care is good communication between care team members. However, a highly mobile workforce and multiple communications channels voice, landlines, mobile devices, email, and paging make it challenging for clinicians to communicate efficiently. Fragmented communication and information handoffs can result in suboptimal workflows that adversely affect patient care. In fact, The Joint Commission's Sentinel Event database reveals that poor communication is the root cause in nearly 70% of reported sentinel events. 1 Healthcare delivery and health management have always been communication intensive. Enabling the demand for real-time communication and collaboration is the growing use of personally owned mobile devices by healthcare professionals who have become accustomed to easy-to-use communication and collaboration tools in their personal lives and see the potential value of using these tools with colleagues and care teams to improve the quality, cost, and experience of care. As healthcare professionals become increasingly connected via their lightweight mobile devices (e.g., smartphones, tablets, and convertibles), real-time communication and collaboration is feasible. This IDC Health Insights white paper, sponsored by Imprivata, presents key findings of interviews with three healthcare IT executives regarding the deployment of Imprivata Cortext, a secure communications platform, and includes use cases and best practices. The three executives represent Atlantic Health System, Carolinas Pathology Group and Celligent Diagnostics, and Beaufort Memorial Hospital. Consistent findings across the three healthcare organizations are as follows: ease of use leads to quick clinician adoption, there is broad application of secure communication across various hospital workflows, and instant communication can save time for care team members and can improve collaboration. 1 Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert. Joint Commission on Accreditation of Healthcare Organizations, Issue No. 30, 2004. Oak Brook, Ill. May 2014, IDC Health Insights #HI248818

COMMUNICATION CHALLENGES AND OPPORTUNITIES Today, healthcare professionals use a number of different channels to communicate with each other; many of them are distracting and take healthcare professionals away from direct patient care, such as in-person meetings, telephone calls, and faxing. Some are secure, and others present vulnerabilities that could lead to violations of privacy and security policies. Each channel has its own challenges: Voice calls and paging without the awareness of presence (i.e., is the person available to take a call) are particularly prone to disrupt clinical workflows. This needlessly delays responses and frustrates senders and recipients as frequent multiple missed calls and callbacks are required to reach the parties who need to communicate and/or confirm for the sender that the recipient received the message. Overhead paging can be disruptive to patients and is often inefficient as it assumes the paged party is in the building. Also, many organizations use alphanumeric/text pagers, which are unencrypted and could also present a risk of violating HIPAA similar to SMS. Native mobile phone text messaging is fraught with potential security, documentation, and patient safety issues if used to communicate about patient care. Because native text messages are sent and stored as clear text to cell phones that may not be password protected or remotely erased in the event of reported loss or theft, personally identifiable health information may be visible to anyone who picks up or steals the device. To avoid violating privacy and security policies, some clinicians will try to communicate about a patient without divulging identifiers. This may lead to possible miscommunication between caregivers and the potential for patient safety issues such as misidentifying the patient being discussed and administering the wrong medication or dosage. Email can also be unsecure unless it is sent through secure channels such as a portal or encrypted, a step that can often be cumbersome because of third-party add-ons or a separate application or service, especially if the application is poorly designed or implemented. The asynchronous nature of email also presents communication delays because checking email throughout the day is not part of the regular workflow for many busy clinicians. The consumerization of technology is driving the adoption of mobile devices by clinicians who increasingly want to avail themselves of the full range of capabilities that mobile devices offer. Convenient communication is at the top of the list, specifically the ability to send text messages. Despite policies against texting PHI and the risk of steep HIPAA penalties, nearly one out of four physicians admitted to using the native text capabilities of his or her smartphone to send text messages to colleagues and patients (see Figure 1). 2014 IDC Health Insights #HI248818 2

FIGURE 1 Current Use of Text Messaging by Physicians: Native Versus Secure Q. Do you currently use any of the following technologies to communicate with your colleagues about patient care? Q. Do you currently use any of the following technologies to communicate with your patients? Native text capabilities of my mobile device 26.9 26.5 Third-party text messaging application to send text messages 7.3 11.5 0 10 20 30 (% of respondents) Colleagues Patients n = 234 Source: IDC Health Insights' Connected Health Physician Survey, 2013 No doubt, some physicians who are using a corporate-liable device assume that all applications and features of the smartphone, including native texting and instant messaging, have been secured by IT and approved for use in a clinical care setting. Only 11.5% of physicians use a secure texting solution to communicate with colleagues. The growth in accountable care organizations (ACOs) will underscore the need for better communication channels to support care coordination across the continuum of care to reduce healthcare costs and improve the patient experience and quality of care. New payment models and growing case mix complexity require health professionals and teams to communicate and collaborate more quickly and seamlessly with colleagues within the enterprise. For the first time, care teams must perform as tightly knit multidisciplinary teams that collectively prioritize their efforts and resources on delivering better outcomes in less time and at a lower cost. Since these multidisciplinary acute and post-acute care teams more often than not span multiple organizational boundaries, care professionals and teams also need to communicate and coordinate care beyond the enterprise walls, which requires collaborative communications technology. 2014 IDC Health Insights #HI248818 3

IMPRIVATA CORTEXT: A SECURE COMMUNICATIONS PLATFORM Imprivata delivers authentication management and secure communications solutions for healthcare to improve provider productivity for better focus on patient care. Imprivata OneSign, the company's integrated single sign-on, authentication management, and workflow automation platform, enables fast, secure, and more efficient access to clinical applications, roaming desktops, and other health information technology systems. Imprivata Cortext, a secure communications platform for healthcare, enables providers to securely send text, photo, and group messaging from their smartphone, tablet, or desktop to improve care coordination and communications. Imprivata has a robust ecosystem of technology partners that includes major electronic medical records vendors such as Epic, Cerner, MEDITECH, McKesson, and Siemens and a number of leading infrastructure providers such as VMware, Citrix, HP, and Dell as well as leading alerting and scheduling applications such as Connexall, Extension Healthcare, HIT Application Solutions, and Amion. Founded in 2001, Imprivata is based in Lexington, Massachusetts, and currently has more than 900 healthcare customers and 2 million licensed users globally. Imprivata Cortext enables providers to coordinate care easily from their smartphone, tablet, or workstation across multiple healthcare organizations. All messages, contacts, directories, and settings are synced in real time across all of the provider's devices. This ensures fast and accurate communication across a number of healthcare-specific workflows. Imprivata Cortext is designed to work inside and outside the hospital so that providers can communicate from anywhere using a WiFi or a cell connection. Through the Imprivata Developer program and partner APIs, Imprivata Cortext can integrate with the healthcare organization's existing alerting, scheduling, EMR, or other systems, enabling users to receive, acknowledge, or escalate clinical alerts, lab results, and other content securely to their mobile device or workstation. Imprivata provides a simple approach to onboarding large groups of new users into the system. Administrators can synchronize their Active Directory or import users directly into Imprivata Cortext via a CSV file or directly into the cloud. Once added, invitations are sent to users with a unique identifier to ensure that only authorized users can access Imprivata Cortext. Once the user has set up his or her account, he or she is able to send and access messages across any device, with a real-time sync across all devices (smartphone, tablet, or workstation). Imprivata provides services options for customers, which assist with end-user training, enrollment, and adoption. Text messages are sent securely using TLS or SSL connections with AES 256-bit and RSA 2,048-bit encryption. Data at rest is secured on mobile clients and on the server using AES 256-bit encryption. The communication infrastructure is hosted securely in the cloud via Amazon Web Services. Imprivata provides a Business Associate Agreement for every organization that uses Imprivata Cortext (whether the free version or a paid subscription) and has been verified for HIPAA compliance by an independent third party. For additional security, administrators can opt to protect the application with a personal identification number (PIN). 2014 IDC Health Insights #HI248818 4

A native desktop application is available for nurses and allied health professionals who may not be allowed to use their personal mobile devices for communicating with colleagues. The recently released native desktop application for PCs/Macs enables nurses to keep Imprivata Cortext running in the background with an icon in the systems tray and pop-up alerts that appear when people want to communicate with them. A secure texting solution is available for free to physician practices and clinics. Customers can enroll for free via the Imprivata Web site and then download Imprivata Cortext from the Apple App Store or the Google Play Store. The free version of the solution provides text, photo, and group messaging as well as multisite communication, standard support, and 30-day message archiving. The enterprise version, designed for hospitals, health systems, and accountable care organizations, is available on a subscription basis with tiered pricing based on the number of users. In addition to the core features of secure text, photo, and group messaging on the free version, the enterprise version adds features such as a native desktop application that is integrated with Imprivata OneSign; persistent alerts and custom sounds; multidevice support with real-time message synchronization; an API for interoperability with alerting, scheduling, EMR, and other applications; enterprise support; and extended message archiving. Imprivata Cortext is evolving from a secure texting solution to becoming a communications software platform that healthcare organizations can extend to meet their communications and collaboration needs. Through the Imprivata Development Partnership program and partner APIs, Imprivata Cortext can be integrated with a healthcare organization's existing paging, alerting, or on-call scheduling systems, enabling users to receive clinical alerts, lab results, and other content securely on their mobile device or workstation further embedding Imprivata Cortext into clinician workflows. IMPRIVATA CORTEXT USE CASES AND CUSTOMER PROFILES Atlantic Health System Atlantic Health System is one of the largest nonprofit healthcare organizations in New Jersey, with 1,339 licensed beds, 12,114 employees, and 3,168 physicians. The health system consists of 6 hospitals: 4 acute care hospitals, a children's hospital, and a rehabilitation hospital. Atlantic Health's ACO was formed in 2010 and was selected in 2012 to participate in the Medicare Shared Savings Program. Atlantic ACO is one of the largest ACOs in the nation, with more than 1,400 participating physicians and Atlantic Health's member hospitals in the provider network serving a seven-county area in New Jersey. The decision to go with Imprivata Cortext for secure texting was an easy one for Atlantic Health, as the healthcare organization is a long-standing user of Imprivata OneSign and has been an Imprivata customer since 2004. Like most healthcare organizations, Atlantic Health feared that health professionals were texting PHI to one another despite policies that prohibited native texting. Imprivata's launch of Imprivata Cortext provided Atlantic Health the opportunity to address this security issue with a vendor with which it was comfortable working. 2014 IDC Health Insights #HI248818 5

Atlantic Health does not have a formal BYOD policy. Physicians typically use their own devices (mostly iphones). However, 300 to 400 physicians employed by Atlantic Health are provided corporate-liable smartphones, as are the nurses. Nursing management was concerned about Atlantic Health's liability if a nurse's personal phone was broken while it was being used for work (e.g., it was dropped or infected with malware). Covering the costs associated with increased texting was also a factor; would Atlantic Health need to provide a monthly stipend or allowance for increased data and text plan fees? In early 2013, Atlantic Health rolled out Imprivata Cortext to 70 physicians participating in the pilot program. Rollout occurred department by department for physicians and unit by unit for nurses who used Imprivata Cortext from their desktop. Today, more than 1,100 users are communicating with Imprivata Cortext. The first use cases for Imprivata Cortext are related to the disposition of patients and communication between physicians and between physicians and their staff. Imprivata Cortext can accommodate multiple directories. Atlantic Health System has one directory across all four hospitals. The ACO manages a separate directory. Ambulatory clinics and physician practices may also set up their own directories using the free version to add users who are not part of the Atlantic Health System or ACO directories. These searchable directories enable PCPs to locate specialists within the network and refer patients to them, thus facilitating access to specialty care. An ER physician or hospitalist can use Imprivata Cortext to alert a patient's PCP that his or her patient is being seen in the ER; improved communication could reduce unnecessary hospital admissions. Atlantic Health System's pharmacists are also using Imprivata Cortext to communicate with hospitals to verify medication dosage, prescriptions, and therapeutic orders. While most nurses use Imprivata Cortext from their desktop computers, one of Atlantic Health's hospitals rolled out Imprivata Cortext for nurses to use from their corporateliable smartphones so that they could communicate with attending physicians, hospitalists, and other nurses. The technology enables them to expedite secure communications across clinicians and physicians within their required workflows and allows them to spend more time treating their patients. Before Imprivata Cortext was deployed, communication would have occurred in person, by phone, by pager, or, in the worst-case scenario, via native texting. Atlantic Health is also exploring how the ACO will use Imprivata Cortext. The first use case contemplated is referrals between PCPs and specialists. End users are also creating their own use cases as they gain experience using Imprivata Cortext and become familiar with its benefits. Frank McKenna, Atlantic Health System's Corporate Director of Customer Services & Information Security, Information Services & Support, commented, "From an organic standpoint, it starts the 'light bulb effect,' with a critical mass of users creating use cases at the operational level." The next rollout will target coordinators as well as home health and long-term care as the organization continues to expand the product to specialist groups. "From an organic standpoint, it starts the 'light bulb effect,' with a critical mass of users creating use cases at the operational level." Frank McKenna, Corporate Director of Customer Services & Information Security, Information Services & Support, Atlantic Health System 2014 IDC Health Insights #HI248818 6

Carolinas Pathology Group and Celligent Diagnostics Carolinas Pathology Group is a 30-physician anatomical pathology group that provides comprehensive anatomic, clinical, and molecular pathology services to 5 health systems, 2 large cancer centers, and 12 individual hospitals in the Carolinas as well as hundreds of group practices across the nation. Carolinas Pathology Group also owns its own independent lab, Celligent Diagnostics, that processes specimens for thousands of customers along the eastern seaboard. The primary objective for seeking a secure texting solution was to address the inherent challenges the pathologists faced communicating among themselves as well as with referring physicians located across the region. They wanted to facilitate point-of-care decision making. But the pathologists did not want email on their iphones, which were provided by the group. They did want the ability to send a video or an image of the specimen for a consult. (FDA regulations prohibit pathologists from making diagnoses from a digital image. However, they can provide a second opinion after reviewing one.) Thus the Carolinas Pathology Group began looking for a secure texting solution. Carolinas Pathology Group evaluated other secure texting solutions but turned to Imprivata, in part because one of Celligent's customers, Spartanburg Regional Healthcare System, uses Imprivata OneSign in its hospitals and ambulatory practices, and the pathologists knew people using Imprivata OneSign. Jared G. Block, M.D., Medical Director of Flow Cytometry for Carolinas Medical Center as well as the Laboratory Medical Director at Celligent Diagnostics, was a driving force in using Imprivata Cortext. Carolinas Pathology Group found that Imprivata provided an optimal balance of technical and clinical expertise. Carolinas Pathology Group uses a combination of BYOD and corporate-liable devices; the split is approximately 20% BYOD and 80% corporate liable. Smartphones provided by Carolinas Pathology Group are primarily iphones. IT appreciates that in addition to ensuring secure communication of PHI, Imprivata Cortext provides a single point of management from a dashboard console. For example, IT does not have to go around to every single phone to update Imprivata Cortext. Imprivata Cortext was rolled out as a pilot program starting with a couple of physicians that are heavy smartphone users. Through word of mouth by the power users, more users would download and begin to use Imprivata Cortext, including midlevel clinicians. Carolinas Pathology Group found the ability to support midlevels to be an important differentiator between Imprivata Cortext and other secure texting solutions. And because Imprivata Cortext is designed for communication between multiple organizations, inter-facility consults and referrals are simplified. To date, the core communication for the pathologists because they are removed from the patients is around consults, second opinions, and daily communication. The primary use cases are consults and referrals. The main benefits that Carolinas Pathology Group has achieved include the ability to reduce various communication barriers for both clinicians and administrators. "You can't put a price tag on transparency when it comes to communication." Jared Friends, Director of Marketing and Client Retention, Celligent Diagnostics Jared Friends, Director of Marketing and Client Retention for Celligent Diagnostics, commented that "you can't put a price tag on transparency when it comes to communication." 2014 IDC Health Insights #HI248818 7

Carolinas Pathology Group is also evaluating several future use cases: Consult cases: A potential referring physician will be able to go to the Carolinas Pathology Group Web site; search for a pathologist by specialty type, education, or location; and have the option to send the pathologist a text via "Cortext" asking his or her opinion on a potential consult case. Physicians could securely send the potential consult to the pathologist via Imprivata Cortext. Historical content: Imprivata Cortext allows the administrator to mine historical data in real time, presenting opportunities for analytics around cost and quality of care. An alternative to enterprise instant messaging applications: All 140 employees in the Carolinas Pathology Group, as well as the Celligent Diagnostics network, have use of the instant messaging application of a large software vendor. Clinical staff members who use both applications (especially the users with the mobile and desktop applications) prefer to use Imprivata Cortext for their private clinical conversations because of security and functionality. Beaufort Memorial Hospital Beaufort Memorial Hospital, based in Beaufort, South Carolina, is a 197-bed community hospital with over 200 physicians on staff. The largest hospital between Savannah and Charleston, South Carolina, Beaufort Memorial Hospital provides a wide range of medical services including emergency medical services. The hospital has been using Imprivata OneSign, an integrated access management solution for single sign-on and authentication, and Imprivata Cortext for over two years. The majority of Beaufort's physicians, even employed physicians, use their own smartphones. The hospital provides an annual stipend for the smartphone. Approximately half of the physicians use iphones; the remainder use mostly Android smartphones, with a modest number of physicians using Windows or other smartphones. Beaufort uses Imprivata Cortext to streamline the following workflows: Code STEMI. When a catheterization lab is activated, time is of the essence to alert the percutaneous coronary intervention (PCI) team that a patient is being sent from the emergency department and needs to be prepped for the cardiologist. Nurses in the ER can activate the code team for a STEMI in order to prepare for surgery. CMS requires that hospitals meet Code STEMI within 60 minutes. Prior to Imprivata Cortext, nurses paged numerous team members in order to reach them and waited for them to call back. Radiology. Radiologists use Imprivata Cortext to alert attending physicians that the requested radiology report is available or to send text and picture messages to specialists. Prior to using Imprivata Cortext, radiologists would call or page specialists who in turn would have to locate an available workstation to access the electronic health record to view the medical image and the corresponding radiology report. Anesthesiology. Anesthesiologists are highly mobile, moving between operating rooms and catheterization labs. Imprivata Cortext enables them to receive secure text messages that include not only current medications and recent lab results that could create a patient safety issue but also updates about when they can expect patients to be prepped for surgery and administration of anesthesia. 2014 IDC Health Insights #HI248818 8

Hospitalists. Nurses use the Cortext Desktop Application to send messages to the attending hospitalists' smartphones. Nurses can see at a glance whether the hospitalists received and opened the messages, while hospitalists could visually prioritize their messages within their "traffic" and clinical workflow. Prior to using Imprivata Cortext, clinicians and their staff relied on paging and telephoning to communicate with one another. This resulted in inevitable delays as clinicians waited for their colleagues to call them back and repeated paging when they did not respond in a timely fashion. Beaufort Memorial Hospital rolled out Imprivata Cortext en masse rather than by department or communication group as other Imprivata customers have elected to do. The hospital took this approach in part because Beaufort's physicians are technically savvy and would actively encourage their colleagues to use Imprivata Cortext so that they can securely text each other. Today, more than 100 physicians and 250 total healthcare professionals, including advanced licensed professionals, nurses, unit secretaries, and administrative staff, are using Imprivata Cortext to solve communication workflow issues between physicians, unit coordinators/secretaries and physicians, nurses, and physicians and nurses. Some of the call groups are using Cortext to respond to a patient situation quickly. For example, using Cortext has streamlined the ability to activate a call team for the catheter lab. A marketing campaign directed at nurses is under way. Office-based physicians are also using Cortext. The response from clinicians has been very positive, according to Ed Ricks, Vice President and CIO: "One of the satisfied physicians commented, 'Finally you're doing something for us instead of to us.'" "One of the satisfied physicians commented, 'Finally you're doing something for us instead of to us.'" Ed Ricks, Vice President and CIO, Beaufort Memorial Hospital Beaufort will continue to expand its use of Imprivata Cortext to take advantage of new features as the product evolves. ESSENTIAL GUIDANCE Rolling Cortext Out Across the Enterprise: Where to Start? When new technology is rolled out to clinicians, it can be tempting to target the more technically savvy clinicians who are willing to embrace new technology. There are advantages to this approach. Early adopters of technology understand that pilots of beta versions are intended to shake out issues and will provide constructive feedback for improving the technology. Power users will become clinician champions who will encourage their colleagues to use the new technology. But these power users are typically not representative of all users, so a pilot program that includes a combination of power users and novice, but enthusiastic, users will provide greater insights into how the new technology will be received and potential issues that need to be overcome for widespread user acceptance. 2014 IDC Health Insights #HI248818 9

Reaching clinicians to educate them about texting policies and new tools available to address security concerns related to mobile device use can be very challenging. Many physicians do not have email addresses or do not check their email frequently because they are focused on caring for their patients. Our research shows that beta and early customers used posters and flyers, in addition to email, to get the word out about Imprivata Cortext. IT staff attended clinical staff meetings and shift change meetings to bring communication groups on board together. They also made themselves available in lunch or break rooms to help clinicians who needed assistance installing Imprivata Cortext on their mobile devices. Best Practices and Lessons Learned The customers and executives interviewed for this document identified the following best practices and lessons learned as they rolled out Imprivata Cortext throughout their organization: Start with IT staff using Imprivata Cortext. Customers often started with the IT department to fine-tune their deployment approach and identify any usability or training issues that might need to be addressed before Imprivata Cortext was rolled out more widely. A unique byproduct of this approach is that customers discovered that Imprivata Cortext allows IT staff to communicate with clinicians or one another about IT support issues that require protected health information to be sent along to resolve the issue (e.g., the patient's name and medical record number to search for a problematic electronic health record). Roll out Imprivata Cortext by communication workgroups or department. A common approach to deploying clinical applications is to roll them out by department. For smaller healthcare organizations, such as ambulatory practices, this approach may be appropriate. However, in larger healthcare organizations, healthcare services are delivered by multidisciplinary teams that can consist of emergency physicians, radiologists, anesthesiologists, surgeons, nurses, and other allied health professionals. In these facilities, Imprivata Cortext should be rolled out to clinical teams or groups of clinicians that regularly communicate with each other. Therefore, one of the first steps toward a successful deployment of Imprivata Cortext is to understand the communication workgroups. Who are they? What do they need? What types of communications are not being served by notes in the EMR? With whom do care team members communicate? This team approach creates the necessary critical mass among clinicians who regularly communicate with each other, which in turn will increase the utilization of Imprivata Cortext. Clinical staff and shift change meetings are good venues for identifying communication groups. Develop a structured approach to deploying Imprivata Cortext along with a communication campaign. IT executives commented that because Imprivata Cortext was intuitive, the rollout was relatively informal, with invitations to enroll emailed to users. A more structured approach, including project management and a communication plan, would have been helpful to ensuring adoption and consistent use of Imprivata Cortext. Create brief videos to show users, particularly visual learners, how to download and use Imprivata Cortext. While Imprivata Cortext is intuitive because it works like native texting, some users are not that familiar with how to download mobile applications to their phones. For example, physicians would open the invitation email from their PCs rather than their mobile devices and then find they couldn't download Imprivata Cortext to their smartphones. 2014 IDC Health Insights #HI248818 10

Establish accepted use cases at the onset of the Imprivata Cortext rollout. Some early Imprivata Cortext customers relied on end users to identify use cases. Often, the use cases involved more integration with EMRs and clinical systems than IT was prepared to accommodate, given other IT initiatives that were under way. (It should be noted that through the Imprivata Development Partnership program and partner APIs, this integration is possible.) Customers should look to other Imprivata Cortext customers for examples of use cases and workflows that would benefit from secure texting as a communications channel. Parting Thoughts Secure texting is evolving from a niche point solution to a communications and collaboration platform to address the complexities of healthcare with its fragmented and, more often than not, inefficient communications channels. Communication and collaboration solutions, such as Imprivata Cortext, that include secure text messaging applications, enable clinicians to exchange PHI securely and communicate efficiently with their colleagues along multiple channels. IDC believes the effective use of mobile technology in healthcare will drive many process improvements, most notably improving patient safety and patient outcomes, and at the same time will reduce costs through productivity and efficiency gains. 2014 IDC Health Insights #HI248818 11

About IDC International Data Corporation (IDC) is the premier global provider of market intelligence, advisory services, and events for the information technology, telecommunications and consumer technology markets. IDC helps IT professionals, business executives, and the investment community make factbased decisions on technology purchases and business strategy. More than 1,100 IDC analysts provide global, regional, and local expertise on technology and industry opportunities and trends in over 110 countries worldwide. For 50 years, IDC has provided strategic insights to help our clients achieve their key business objectives. IDC is a subsidiary of IDG, the world's leading technology media, research, and events company. Global Headquarters 5 Speen Street Framingham, MA 01701 USA 508.935.4445 Twitter: @IDC idc-insights-community.com www.idc.com Copyright Notice Copyright 2014 IDC Health Insights. Reproduction without written permission is completely forbidden. External Publication of IDC Health Insights Information and Data: Any IDC Health Insights information that is to be used in advertising, press releases, or promotional materials requires prior written approval from the appropriate IDC Health Insights Vice President. A draft of the proposed document should accompany any such request. IDC Health Insights reserves the right to deny approval of external usage for any reason.