Sharing healthcare data

John Wilbanks makes an eloquent case for why medical privacy rules, created more than 70 years ago, are now standing in the way of innovation. This blog previously explored the tension between privacy and innovation (see for example this or this) and it's great to see the emergence of a well crafted argument that recognizes the risks of not addressing this tension.

In his talk, John says:

I'm proposing … that we reach into our bodies and we grab the genotype, and we reach into the medical system and we grab our records, and we use it to build something together.

See the full talk here:

Revival

I'm pleased to report that, after a year-long hiatus, I will be reviving HCDMS. The blog will be revamped to focus on network-enabled business models in healthcare.

Stay tuned.

RIP Google Health

The announced demise of Google Health was greeted by industry observers as a long overdue termination of a service that had simply failed to catch on with the general public. That Google Health was lagging Microsoft's HealthVault is no surprise: commentators had consistently ranked Microsoft's offering above Google's service.

Whether this is simply a failure of Google to develop a viable business model or a larger failure of the PHR world  is a more interesting question and one that will be debated endlessly in the weeks to come.

Here are two perspectives: the first from John D. Halamka recognizing the role Google Health played in raising public awareness of PHRs. Halamka writes:

Google Health is truly innovative and broke new ground when it created interfaces to hospitals, labs, and pharmacies in 2008. I was there at the beginning and can definitively state that it was Google's reputation and vision that broke down the political barriers keeping data from patients

The counter view is from HISTalk that claims Google Health's failure was due to the lack of appreciation of unique requirements of Healthcare.The author states:

Google predictably did what its know-it-all technology company predecessors have done over the years: dipped an arrogant and half-assed toe into the health IT waters; roused a loud rabble of shrieking fanboy bloggers and reporters (many of them as light on healthcare IT experience as Google) who instantly declared it to be the Second Coming that would make all decades-old boring vendors instantly obsolete or subservient to the Googleplex

 My own reaction to this is that no matter what view you take on the merits of Google's strategy, PHRs play a critical role in getting consumers to own their own healthcare choices. This is in a limited way comparable to how consumers must own their financial choices and can benefit from tools (such as www.mint.com) to manage their decisions. From that perspective, the demise of Google Health is a step backwards for Healthcare 2.0.

Where are we headed?

As Stage 2 of Meaningful Use takes shape, I've been wondering whether the Healthcare IT revolution will indeed achieve its main objective: improving patient care while keeping costs in check. The answer that seems to emerge, based on many conversations and much reading, is "not yet." There's little doubt that the Healthcare IT revolution, driven by Federal funding, is driving IT adoption. What is less clear is whether this is on a trajectory that leads to better patient care and lower costs.

What seems more likely, like we've seen in other technological phase shifts, is that the first revolution will create something of a bubble that will eventually pop. Based on the infrastructure work done during the first bubble, a new revolution will rise and eventually deliver the goods. We saw it with the internet. It happened with ATMs (until ATMs started accepting checks, they didn't have as much of impact on costs). It seems the likely path for Healthcare.

Bubbles aren't inherently bad. They provide an opportunity to break old barriers, develop new innovations, test business models. But bubbles pop and cause a lot of collateral damage along the way.

Agree? Disagree?

Meaningful Use Update

Late last year, a College of Health Information Management Executives (CHIME) survey indicated that confidence in meeting meaningful use deadlines had dropped in the months following the launch of the program. Previous reports were a lot more optimistic putting the number of first year adopters at 28%.

It is important to note that the overall results have not changed: even with the new survey, almost 90% respondents expect to meet Stage 1 criteria by 2012. In a large change management exercise, it is common to see early optimism shift as the realities of implementation take hold. That said, the report is likely to spur additional debate on the extent of the impact of HITECH funding.

Observers generally agree that Meaningful Use will drive the Healthcare IT agenda for the next few years; whether it makes a meaningful impact on the quality of care is another matter.

PCAST

The Healthcare IT world is abuzz with the report by the President's Council of Advisors on Science and Technology (PCAST) on realizing the full potential from HIT. Here is a link to the full report:
http://www.whitehouse.gov/sites/default/files/microsites/ostp/pcast-health-it-report.pdf

In John Halamka's review of the PCAST report, he writes:

"In the spirit of my recent blog about The Glass Half Full, I believe the PCAST report is a positive set of recommendations that builds on the Meaningful Use Stage 1 effort to date.   ONC should be congratulated for creating a foundation that is so consistent with the PCAST vision for the future"

Do you agree that the work on HIT thus far (via ONCHIT, Meaningful Use, etc) is consistent with the PCAST recommendations?

Privacy safeguards

For the past few months, the Wall Street Journal has run a great series on the use of electronic personal information by commercial entities. The series is titled "What They Know." While the emphasis of this series has mostly been on the tracking of web browsing behavior, the latest article in this series discusses the "scraping" of personal data from a patient support network called PatientsLikeMe.

This is a troubling development.

Like the electronic commerce IT revolution before it, the anticipated healthcare IT revolution depends upon the proper security (and associated trust) of private data. I have covered Privacy in healthcare before (see this, for example) and my summary conclusion remains that this topic will receive a disproportionate amount of attention in the coming months.

I don't agree with alarmists like Deb Peel who advocate against use of any patient data (and consequently put a number of patients at risk). The right answer is to put well understood safeguards in place and use de-identified data in a manner that promotes innovation in outcomes based treatment. This is an opportunity for companies to innovate in this space.

What products/innovations do you think we need?

The Art of Product Management

As a product manager, I think a lot about how I can better understand my customers. A funny incident made me realize that one can't ever assume to know customers well enough: it's always a work in progress.

During the last week of September, I joined several other colleagues at the annual AHIMA conference in Orlando, Florida. The conference is a gathering of Health Information Management (HIM) professionals. Topics cover transcription, coding, release of information (or as the healthcare industry calls it, simply, 'ROI'), audits, and compliance. My company's booth was organized around our themes of connecting the patient record, EMR enablement, and compliance.

Emily, our Manager of Experiential Marketing, had developed a booth activity around building a bracelet as a metaphor for what we do: link the discrete elements in the physical and digital worlds and create a complete, valuable, patient record. For each bracelet that visitors made, we would donate money to a good cause. To obtain charms needed to build this bracelet, visitors would have to visit various stations and learn about our solutions. I didn't think this was a practical idea because I wasn't sure our customers would want to build bracelets at a conference. I thought an Apple iPad giveaway might have been more appealing.

It turned out--I was totally wrong and our booth visitors LOVED the activity! Emily knew this audience a lot better than I did. We ended up oversubscribed (mobbed?) and many customers told me that this was one of the most active booths at the show. Mission accomplished! Well done Emily and the team!

Ingenix acquires coding company

HISTalk reports that Ingenix is acquiring A-Life Medical. I have speculated on the grand strategy behind Ingenix's acquisition spree (see for example, this, this, this, or this) and it's getting more clear now: Ingenix wants to have a presence in multiple touchpoints in the healthcare IT value chain. They are assembling data collection and analytical components that used together will provide a powerful analytics-driven (outcomes driven?) healthcare delivery model.

This has been a busy week at work with our planning projects in full swing. I'm looking forward to AHIMA later this week and I plan to resuming a more predictable posting schedule after that. Much to report on based on what I've learnt in these past few weeks!

Blumenthal Vs. O'Neil

ONCHIT chief David Blumenthal and former Treasury Secretary, Paul O'Neill debated EMRs and national standards: see related story from Mass Device.

I'm back from several field visits this week to hospitals in North Carolina. I'll summarize observations in a future post; and then from Sept 26 through Sept 29th, I'm back on the road for AHIMA. I look forward to further conversations with healthcare executives and I'll report findings soon thereafter.

Meaningful Use for 90% hospitals in the next two years

The Wall Street Journal today reports that 28% hospitals expect to qualify for incentives in 2011 and 62% in 2012. This is consistent with my expectation from a few weeks ago that Meaningful Use will be item #1 on the agenda for healthcare IT. The Gold Rush is about to begin, even though questions remain on whether true adoption can be achieved in this time frame.

I'm visiting a number of hospital CIOs this week (and posting will be light as a result) but I'll report back on first-hand impressions from the field.

Eric Dishman on taking health care off the mainframe

Eric Dishman has a wonderful TED Talk on moving our healthcare system "off the mainframe." This talk was part of TED MED 2009. Mr. Dishman makes a compelling case for why we need a shift in mentality away from crisis-driven (or event-driven) institutional healthcare model to a more proactive personal-driven model of care.

Don't miss it! (you may need to click the direct link above: RSS readers may not show the video below)

Healthcare Costs and the American Dream

The New America Blog has a story on rising healthcare costs: Good news: increases are more modest compared to previous years; bad news: cost increases are now almost entirely being passed on to consumers.

I was speaking to a friend recently who works for a major life insurance company. That company has recently moved to a high-deductible plan, meaning employees are now responsible for several thousand dollars of medical expenses before any insurance kicks in. For younger healthier people, skipping healthcare is an option but for young families or older employees this is effectively a 5%+ pay cut.

I'm not one to argue against patients taking more responsibility, and consequently more costs, for their health and well being. However, the issue here is less about individual responsibility and more about the social contract we have with our employers. The contract that if we do our jobs well and if we work hard there are certain measures of security that accrue. See this article from the Financial Times from a few weeks ago on the crisis in Middle America.

How does one reverse this decline?

How Long Will It Take to Adopt EMRs?

One story that got a lot of press last week was Prof. Aashish Jha's research update on the adoption of Electronic Medical Records. Prof. Jha has observed that only about 12% of US hospitals have a fully operational EMR at the end of 2009 and only 2% would have complied with Meaningful Use guidelines release this July that determine whether Providers can receive Federal incentives starting next year. 


Common sense suggests that electronic medical records should have much wider adoption, particularly since most sides agree that a properly implemented EMR improves patient care. After all, as one advertisement by United Healthcare recently noted, "your Pizza delivery guy stores your orders electronically. Why can't your doctor do the same?" The reality is that EMRs have not been widely adopted because there are many counter forces:

• Medical information like health status is not as determininistic as, say, financial data. There is no unique score, or set of scores that can uniquely pin point the state of your health in a way that two reasonable, independent observers would always agree. In banking, there is no ambiguity on your bank balance when it is viewed by two separate observers. Similarly, your Pizza preferences are, in general, mostly deterministic and can be described in a way that is interpreted in the same way. I buy this argument, but it doesn't explain it all.
• Some commentators have suggested that medicine is viewed as an art by an older generation of physicians and as long as that group makes decisions for the medical community, EMRs and other metrics-driven tools are likely to remain on the backburner. This is an artful argument, but again, it cannot explain the widespread inability of Providers to adopt EMRs. Some (more cynical?) observers have even claimed that the Providers don't want EMRs because it allows them to preserve inefficiencies and make more money.
• The most compelling reason for the lack of adoption is simply that the benefits of EMR accure to those that don't pay for it. Put in other words, those that have to pay for EMRs aren't the ones that benefit the most. So, cash strapped hospitals are not very likely to want to make a huge IT investment if they don't see direct returns of some form. The Federal goverment has recognized this misalignment of incentives and much of the HITECH funding through Meaningful Use attempts to address this deficiency.

So, if you believe this logic, it would stand to reason that EMRs will see a much more rapid pace of adoption as Federal incentives kick in. Prof. Jha's paper seems to make a similar conclusion.

For more on the topic, Prof. Eric Ford and others published a bass diffusion analysis applied to EMRs. This study was published in 2006 and concluded that EMR adoption would take a decade longer than the 2014 target set by the Bush Administration as part of E.O. 13335 that established the ONCHIT. I have yet to see an update on this study, post Meaningful Use incentive payments, but the paper is still worth a read for its analysis of buying behavior in the medical community. Specifically, the paper examines the similarity in buysing behavior between healthcare IT and consumer goods, given that both are influenced by the coefficient of imitation (doing what key opinion leaders do) than coefficient of innovation (buying the latest and greatest). Heady stuff.

Ingenix...yet again

In several recent posts, I have tried to determine the grand strategy behind Ingenix's recent acquisition spree.

For a much more comprehensive analysis, see today's HISTalk Investor's Chair briefing.

So, what's your take on the real story behind all this momentum? What is Ingenix (and United Healthcare by extension) trying to do?

Using Crowdsourcing Principles for CDS

One of the emerging challenges for Clinical Decision Support systems is the problem of how to describe the data that is input into the rules engine. For a detailed description of this problem, see Keith Boone's Standards Activity Around Clinical Decision Support.

Of course, with Meaningful Use still in Stage 1, the emphasis is currently on data capture rather than clinical decision support. Healthcare IT has an article on how Google's IP from its failed Wave product may be of help in digitizing hard-to-read physician notes.  Most providers today perform some form of scanning of physical files; the approach proposed in the article essentially involves principles of "crowdsourcing" where a complex translation is farmed out to a large number of people that work on tiny bits of the problem, usually only for a few seconds each.

When the focus shifts towards CDS in Stage 2 of Meaningful Use, a similar crowdsourced approach could be used to create CDS rules databases. Hosted EMR vendors like athenahealth are most likely to be in a position to mine their databases for such an effort.

Best Care Anywhere Reviewed by Andy Oram

For those of you that read my review of Best Care Anywhere, please see Andy Oram's comprehensive and insightful read: The Software Behind the VA's health care transformation.

Andy ends the post with a call for help:

If you'd like to learn more about VistA, help to add features so it can become the nation's electronic health record system, or just meet the fascinating people who work with it, check out the WorldVistA community..... doctors are moving quickly to install electronic record systems ..... To play in this space, VistA needs both more promotion and.... changes to simplify deployment and configuration.

Ingenix Continued

I've reported on this blog that Ingenix bought Executive Health Resources not too long after picking up Picis. Well, they've done it again: Ingenix announced yet another acquisition at close of business today: Axolotl, an HIE Services provider. Ingenix was rumored to be entering the HIE space and HISTalk reaffirmed it this morning. This acquisition confirms it.

With a string of recent acquisitions, UnitedHealthcare is inching closer to its vision of becoming a Kaiser-like end-to-end provider with a focus on outcomes. This also appears to be a pragmatic shift away from some of the more fancy predictive modeling approaches that hold promise but do not deliver near-term results.

Organizational Models Behind Healthcare Delivery

In a review of the China Study, I wrote about how Healthcare discussions often revolve around insurance, treatments, technology, operational excellence, etc. but not as often on driving factors like lifestyles, choices, etc. As a product manager, I'm often confronted by similar questions on strategy; for example, can organizational culture be a source of sustainable advantage? Are we overly focused on business models, technology leadership, incumbency  when we should also think about how are teams operate and how members relate with each other?

Today's HISTalk mentions how Epic, the leader of the EMR vendor market if you measure momentum, focuses not on hiring candidates with the best experience but instead selects those with the right traits, qualities, and skills. HISTalk states:

"Epic emphasizes that many hospitals can staff their projects internally, choosing people who know the organization. However, they emphasize choosing the best and brightest, not those with time to spare. Epic advocates the same approach it takes in its own hiring: don’t worry about relevant experience, choose people with the right traits, qualities, and skills, they say."

Top-tier management consulting firms like BCG, Bain, and McKinsey have always known this. As a result, these firms test candidates on scenarios (or "cases") to evaluate how a candidate would think in a particular situation rather than evaluating the candidate on behavioral questions (that can generally be memorized). Other companies in other industries are catching on. Netflix famously released it's Freedom and Responsibility Culture reference guide that emphasizes context over control.

How much time do you spend on your organization's team dynamics? What methods do you use to select candidates?

Data Classification

John Moehrke has a comprehensive post on Data Classification. As privacy and security considerations are codified within electronic medical records, standards are essential. There are three areas that I see these standards playing a transformative role, but I'm sure there are others:

1. HIE Consent Management: There are seven services needed for the creation of HIEs. Many are still under development but the least developed area amongst these is most likely patient consent. See Private Access--one of the potential technology providers in this space.
2. Release of Information: Much of the business of release-of-information, estimated to be a $1B market [1], depends upon the proper redaction of sensitive information from medical records. Codifying privacy preferences will eventually allow automated release-of-information processing. Mature data classification techniques may enable a disruptive technology to upend this market, which is currently dominated by HealthPort with a $250M annual revenue stream.
3. Data De-Identification: De-identification is currently a somewhat manual process if you want data that retains some degree of usefulness. HIPAA requires a person with knowledge of general statistical principals to certify that reverse engineering of identity is not easily possible or it requires the removal of 18 fields that remove personally identifiable information. Data classification takes us one step closer to automated de-identification.

While on this subject, see Keith Boone's contention that redacted documents should not be considered the same as the original document and hence should not retain signatures that were used to sign the original.

[1] market sizing from HealthPort, Inc. S-1 filing with the SEC, 2009