How big a network will the Health Internet (aka National Health Information Network) be?

My BOTE (back-of-the-envelope) calculation is that this network could consist of about 301 million nodes.  Here’s my math (pls. clarify or amplify):

• 300 million individuals in U.S.
• 700 K doctors
• 5 K hospitals
• 295 K — other B2B healthcare entities

Very rough…but I hope you get the point.

So let’s put into perspective press releases from Google or Microsoft announcing that they have developed new “partnerships” (i.e.nodes in the network) for Google Health or Microsoft HealthVault. As an example, today Google announced partnerships with APWU Health Plan and Harvard Pilgrim Health Plan.

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Two issues have rightfully surfaced front and center in the public’s understanding of HITECH Act implementation:

• ” definition of “Meaningful Use” of EHRs, and
• ” definition of “certification” process for EHRs

…and we applaud the progress of the workgroups and the HIT Policy Committee in addressing these issues constructively.

However…a THIRD issue lurks – “Data harmonization at the expense of data liquidity“, or put another way – “misplaced pursuit of one (and only one) language at the expense of practical communication.”

On August 20, the HIT Standards Committee approved recommendations to bring forward to the HIT Policy Committee meeting later this September. 

In this post, we will:

1. Summarize aspects of the HIT Standards Committee’s recommendations that are problematic
2. Develop an analogy to illustrate how the recommendations will limit innovation and increase barriers to communication.  Our analogy:

The Standards Committee recommendations are like mandating that everyone in the U.S. be required to speak Latin by 2013.

Dr. Blumenthal has wisely anticipated that there could be a situation where in his role as national coordinator that he should not follow a Committee’s advice:

“This committee does provide advice to the national coordinator, but it does not make policy,” Blumenthal said, with a noticeable emphasis on “not.” [iHealth Beat; August 18, 2009]

Dr. Blumenthal, this is exactly the situation you have anticipated. (more…)

This post is a foundational overview of characteristics of network industries.  Much of the terminology will deserve deeper discussion, but we have to start somewhere.

In his book The Economics of Network Industries, Professor Oz Shy lists four characteristics of network industries.

The main characteristics of these markets which distinguish them from the market for grain, dairy products, apples, and treasury bonds are:

1. Complementarity, compatibility and standards
2. Consumption externalities [network effects]
3. Switching costs and lock-in
4. Significant economies of scale in production

In this essay, I’ll quote from Dr. Shy in explaining each of these characteristics.  I’ll also offer a few thoughts as to how these characteristics apply to healthcare. More specifically, I’ll discuss physician adoption of EHRs (electronic health records) and patient adoption of PHRSs (personal health record systems).  

Why a PHRS instead of a plain old PHR?  Think of a PHRS as a PHR data repository platform bundled with multiple high-value applications. For a more detailed explanation, read here.   

Let’s look at the characteristics of network industries one at a time.

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There’s a double meaning to the title of this new series: Healthcare Crosses the Chasm to the Network Economy

At the level of technology, it’s a reference to Geoffrey Moore’s bestselling business/technology book — “Crossing the Chasm”. The Chasm here is the huge gap between early adopters of technology and mainstream users. The book describes the process of bringing specific technologies into mainstream usage.

At the level of clinical care, its a reference to the landmark 2001 report by the Institute of Medicine — “Crossing the Chasm”.  Here, the Chasm is a reference to the quality/safety gap existing in American healthcare, with major systemic recommendations for how to cross the chasm toward clinical improvement.

In this series, the “Crossing the Chasm” is a reference to both technology and clinical care — and to the interdependence between them. I believe we’re entering a new era in healthcare, marked by passage of the HITECH Act Federal stimulus legislation, but of which HITECH is only the beginning . While to a casual observer HITECH Act might seem focused on electronic health records (EHRs), it goes far beyond that.   

Over the past several years, I’ve had the privilege to work with many leading-edge clients who understand that health IT interoperability, networks, and platform/application technologies and business models will reshape health care over the coming years.  This has given me a chance to do a deep dive into understanding companies, business models and literature from outside health care, and then thinking through implications for health care companies (much blogging and book forthcoming).

This series will pull on concepts, terminology and lessons from two disciplines:

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Over the past few days, several of my respected colleagues have written excellent blog posts essentially asking “Does Google Health have life?”

• Scott Shreeve — CLEAR! Shocking Google Health Back to Life
• John Moore — Is Google Health Irrelevant?
• Will Crawford — Future of Google Health

I share their observations and sentiments.  I see Microsoft HealthVault as a serious business strategy while Google Health is more like a hobby (one of probably hundreds at Google).

Are there reasons Google should stick around healthcare? Absolutely!  Off the top of my head, I can think of five:

1. Google brings unique competencies to health care information seeking.
2. Google Health is doing a good job on a shoestring budget.
3. Healthcare is ripe for disruptive innovation.
4. Microsoft needs competition.
5. Microsoft HealthVault and Google Health are more complementary than competitive.

Let’s take these one at a time. (more…)

Economists call it “The Penguin Problem”  — No one moves unless everyone moves, so no one moves. 

The role of user expectations is crucial in getting penguins to move off of ice floes and in the successful adoption of new network technologies.  I’ll cover two main points in today’s essay:

• How “The Penguin Problem” Helps Explain Low EHR (electronic health record) Adoption To-Date
• How Recent Federal Actions Are Setting Higher Expectations for EHR Adoption

The Penguin Problem and Low EHR Adoption To-Date

While not the only factor, the role of user expectations is a crucial element in explaining the adoption of new network technologies. Harvard Business School Professor Tom Eisenmann explains:

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The last article in this series — Time for EHRs to Become Plug-and-Play — used words to describe a major industry shift underway in health IT.

Sometimes pictures help to make a point. Here are several diagrams that you can also download as PowerPoint slides.

 Computer Industry 1983 to 2002

  Source: Venkatraman, N. Winning in a Network Centric Era, 2006

Blueprint for Health IT Shift

From EMR 1.0 — 2008…

…to Clinical Groupware/EHR 2.0 — 2012 (more…)

by Vince Kuraitis and David C. Kibbe MD, MBA

Have you ever heard anyone tell a happy story of how easy it is to get a copy of their paper medical records?

Departing Health and Human Services Secretary Mike Leavitt is laying the groundwork for this same story to apply to access to YOUR electronic personal health information.

Here’s an overview to what evolved into a long posting:

1. Analysis: The Leavitt Framework Uses the HIPAA Privacy Rule as a Baseline for Electronic Access to Personal Health Information
2. Implication: Extending the HIPAA Privacy Rule Could Restrict Your Electronic Access to Your Personal Health Information
   • A.The HIPAA Privacy Rule Should Not Be the Baseline for Governing Access to Your Personal Health Information
   • B. Examples: Extending the HIPAA Privacy Rule Creates Barriers and Confusion
3. Implication: Extending the HIPAA Privacy Rule Protects Incumbents at the Expense of Innovators Like Microsoft and Google
4. Conclusion: The Leavitt Framework Creates Bad Public Policy (more…)

Yabut is a term coined by my esteemed colleague, the late Paul Fetrow.  It stands for “Yeah….but….”

Yabuts are the gotchas, the fine print, the details that affect the terms of any agreement.  For example, the telecom companies will tell you its easy to switch carriers now that we have number portability.  Yeah…but it will cost you $175 for an early termination fee.

Yesterday’s post ended with the optimistic observation that Google Health and Microsoft HealthVault have agreed in principle that the platforms will be open and interoperable. (Presumably) you’ll be able to either 1) move all your data from Google Health to HealthVault, or vice versa, and 2) be able to transfer data across networks, e.g., your doctor has signed up with HealthVault and the lab belongs to Google Health, but because the platforms are open and interoperable data will pass across the network and your doctor will get lab results seamlessly.

Again, the analogy here is the telephone network — where you know that you can pick up the phone and call anyone in the world, regardless of the technical networks required to pass your voice.

What are some of the yabuts to Google Health and Microsoft HealthVault exchanging data? In this case yabuts refers to customer lock-in tactics and switching costs that might be imposed. (more…)

What will the PHIN look like?  Will there be multiple, non-interoperable, competing networks or just one interoperable network?

This question is being answered with the best possible answer:  the PHIN is evolving as one, interoperable network.

Consider 3 scenarios:

• Scenario One: Status Quo — Your Personal Health Information Today
• Scenario Two: The PHIN — Multiple, non-interoperable platforms
• Scenario Three: The PHIN—Multiple, interoperable platforms

In this post, I’ll present  images of these scenarios as a foundation for a series of upcoming posts.  David and I will address questions such as “What’s really different about the PHIN? What elements create the transformative potential that has attracted Internet Titans to health care?”

Let’s take a look at these one at a time: (more…)

The current draft of the PHR Certification Criteria specifies use of the HL7 Continuity of Care Document (CCD) as the only endorsed standard for interoperable exchange of information to and from PHRs.  This is extremely short-sighted.

I wrote a comment to the PHR Work Group explaining why it’s important to adopt BOTH the HL7 CCD and the ASTM Continuity of Care Record (CCR) .  I suspect most professionals commenting on these criteria will be looking through the lenses of health information technology, so I thought it would be important to share a different view — one through the lenses of business strategy and public policy.  Here’s my commentary:

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"Re: UHG. Was at the Healthcare Quality Conference yesterday in Boston. Got to talking to a United Health exec who informed me that they have signed an agreement with Google Health and have a pending agreement with HealthVault. This backs up UHG’s previous statement that member records would be made portable. Individual made mention that the Google Health relationship extends beyond just claims records transfer and includes a technology partnership regarding UHG’s OMX."

Commentary: Among health care incumbents, health plans are experiencing the greatest heartburn over the emerging Personal Health Information Network (PHIN).

On the one hand, existing health plan IT and business models have been proprietary and closed. Here’s how a typical health plan might state their POV:

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By Vince Kuraitis and David C. Kibbe, MD, MBA

Once upon a time, there was a little girl named Goldilocks. Like most Americans, Goldilocks had concerns about achieving just the right amount of data liquidity for her personal health information (PHI).

Until today Goldilocks felt between a rock and a hard place:

"I want my PHI to be appropriately liquid — just the right viscosity. My PHI should be viscous enough to flow to my trusted health care providers to use to improve my health and health care.

“Today my PHI is frozen and inaccessible — it’s too cold.

“But I’m worried about the other extreme — the risks of using a personal health record (PHR). The privacy/security advocates tell me that I should be concerned about my PHI being too hot — like steam that’s vaporized and disperses uncontrollably into the atmosphere.

“How do I get it just right? …not too cold, not too hot?"

What happened today to resolve Goldilocks dilemma? The Markle Foundation’ released its Common Framework for Personal Health Information (PHI).

Dossia, Google, Intuit, Microsoft, and WebMD today joined prominent health care providers, health insurers, and consumer and privacy groups in endorsing a set of practices for new internet services that help consumers track and improve their health. The framework defines a set of practices that can help protect personal information and enhance consumer participation in online personal health records.

The Markle Foundation’s accomplishments in advancing this collaborative framework are nothing short of miraculous!

Let’s revisit Goldilocks and the bears to see exactly how the Framework resolves the PHI too hot/too cold dilemma. (more…)

The purpose of this post is to help a non-technical audience untangle some of the confusion regarding health data exchange standards, and particularly come to a better understanding of the similarities and  differences between the Continuity of Care Record (CCR) standard and the CDA Continuity of Care Document (CCD). But what I’m most interested in is getting beyond the technical, political, or economic positions and interests of the proponents of any particular standard to arrive at some principles that demonstrate in plain language what we are trying to achieve by using such standards in the first place.

Frankly, I don’t give a hoot about what standardized XML format for capturing clinical data and information about a person becomes the norm in the health care industry over the next several years. I do care that the decision is made by the people, institutions, and companies who use the standards, and not made by a quasi-governmental panel or a group of “industry experts” whose economic or political interests are served by the outcome, and dominated by a particular standards development organization with whom they are very cozy. 

In other words, I do want free and open market forces to be able to operate freely and openly as health information exchange evolves, in part because I believe market forces will work in the direction of continuously improving health IT, whereas in my experience top-down efforts are often protective of established interests and discouraging to innovation.

Herein lies the problem, in my opinion, with the standards adoption process that the Office of the National Coordinator of HIT (ONC) and HITSP have overseen during the past four years.

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We’re not.

From the Kansas City Business Journal :

Google Inc. has approached Cerner Corp. about a partnership, but Cerner officials don’t sound eager to entangle themselves with the Web-search Goliath.

That’s because the proposed partnership relates to Google Health, the personal health record site launched earlier in May in beta form.

The overture hasn’t led to substantive talks, Cerner President Trace Devanny said, because Cerner doesn’t see much value in Google Health or HealthVault, a similar site that Microsoft Corp. launched in October.

Cerner CEO Neal Patterson referred to the sites during a May 23 shareholders meeting as "electronic shoeboxes," requiring consumers to do much of the data importing and updating.

Why is Cerner dissing Google? Let’s take a look at Cerner’s current business model: (more…)

Drs. Mandl and Kohane begin their recent article in NEJM with the statement that “large corporations are seeking an integral and transformative role in the management of health care information,” and then warn that this “will profoundly affect the biomedical research enterprise.”   

At issue for the authors is who controls the information about you and me, our health and healthcare data. Without coming right out and saying it directly, they worry that data in the hands of consumers and patients made possible through PCHR service providers like Google and Microsoft could be dangerous to the nation’s health because of  “commercial interests”.  

So, they are warning us, too.

But, let’s examine the presumption that your personal health information is safest in the hands of the medical establishment (incumbent service and health care provider organizations and the biomedical research enterprise). The real question that their article in NEJM begs is:

how good a job of stewarding our health data is the medical establishment doing? (more…)

Tomorrow’s edition of the New England Journal of Medicine contains an article entitled “Tectonic Shifts in the Health Information Economy”.  While we have not yet fully digested this article, it’s clear that the authors’ description of the “Health Information Economy” closely parallels our initial description of the Personal Health Information Network (PHIN). 

The main thrust of the NEJM article is to discuss implications (good and bad) relating to clinical research. The NEJM article is also highlighted in a New York Times piece entitled “Warning on Storage of Health Records.”

In anticipation of our webinar tomorrow sponsored by Healthcare Informatics, we wanted to bring these articles to your attention ASAP. 

As a first pass at discussing these important articles, here are a few highlights from the NEJM article.  Whether you prefer the label the “Health Information Economy” or “Personal Health Information Network (PHIN)”, these excerpts describe the potential magnitude of the tectonic shifts: (more…)

I’ll take this a step further and ask “Could a linkage between HealthVault and Amalga become a centerpiece of Microsoft’s broader health care strategy?” (more…)

• What are companies like Google, Microsoft, and Dossia (sponsored by Intel, Wal-Mart, AT&T and others) hoping to accomplish in health care?
• What is the emerging Personal Health Information Network (PHIN) and why should you care?
• What’s the Continuity of Care Record (CCR) Standard, and how is it destined to become an initial focal point of data exchange initiatives?
• Why is the PHIN potentially disruptive to many business models? What types of companies or organizations could be affected the most?
• What are opportunities and threats to major health care players — hospitals, physicians, health plans, enterprise HIT vendors, ambulatory HIT vendors, and others?
• What specific actions can you take to be a leader in advancing the PHIN and positioning your company for success?

In a recent blog posting, David C. Kibbe, MD, MBA and I wrote an overview of our vision for the PHIN. 

Now, for the first time, we look forward to discussing our vision for the PHIN. This Healthcare Informatics webinar will be held:

Thursday, April 17, 1 PM Eastern, 10 AM Pacific.

Click here for details….read “Event Info” to see a more specific description of the webinar.  Get a 15% discount by using Promo Code VK15.

Here’s a diagram of the PHIN as we see it today:

(click on the picture for a larger version)

The Speakers

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Continua’s work-to-date is a necessary, but not yet sufficient effort to make RPM devices mainstream.

Knocking down the barrier of device-incompatibilty exposes the bigger barrier of lack of data interoperability among RPM technologies and between RPM devices and health care IT systems.  Jonathan Edwards, research VP and lead telemedicine analyst for Gartner, nails the issue:

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Who is the federal  government calling on to breathe life into the Nationwide Health Information Network (NHIN)? Google and Microsoft.

In our first article of this series describing the Personal Health Information Network (PHIN), we noted early entrants as Google Health, Microsoft HealthVault, and Dossia.  We also noted that the network could grow rapidly, and that others would want to join or link to the PHIN.

With Uncle Sam announcing plans to link to the PHIN, even we are surprised at the speed at which developments are occurring. 

Government Executive reports:

The federal office in charge of creating a national network of electronic health records plans to integrate the system with the health care databases that Google and Microsoft launched last year, on which individuals can store their health records, a top official with the Health and Human Services Department said….

(The HHS official) provided few details on how the office would incorporate personal health records….

Federal interfaces to the health network will be through an entity called NHIN Connect.

Here’s a simplified diagram of our current understanding of how NHIN Connect will link to the Personal Health Information Network (click on the diagram for a larger version):

Commentary (more…)

Two companies — Aetna and Microsoft — have come up with 180 degree different answers.

In this post, I will:

• Describe how Aetna’s and Microsoft’s approaches differ
• Speculate on why their approaches make strategic sense for the respective companies
• Explore how technology and expectations about using PHI for search are likely to change over time

Aetna’s SmartSource and Microsoft HealthVault 

Aetna has adopted a more aggressive strategy of using your PHI to improve search results. Microsoft HealthVault is employing a much more cautious strategy and (for now) has pledged NOT to use personalized health information to target health search.

Aetna is a health insurance plan with an existing member base of 17 million members.  Aetna’s recent press release announced a partnership with Healthline introducing

Aetna SmartSource, the first-ever personalized search engine that mines information from Aetna’s vast data resources to deliver meaningful, personalized health and health benefits information to Aetna members. 

Based on existing medical claims data that Aetna already has about members, your search term will be matched against your own medical history to provide the most relevant results.

Microsoft HealthVault search is different.  From the Microsoft HealthVault Fact Sheet:

Microsoft does not link users’ personal information with HealthVault search queries.

Why the Difference? (more…)

The Internet and digital technologies have transformed many aspects of our lives over the past twenty years.  We can get cash at ATMs all over the world; we can book our own airline reservations; we can shop and get best prices over the Internet.

Why hasn’t this happened in health care?  Something is missing.

Recently, major global information and communication companies have announced their intention to bring their technologies and business models to health care.  While the creation of Google Health (GH), Microsoft HealthVault (HV), and Dossia (sponsors include Intel, Wal-Mart, AT&T) are important news items by themselves, what’s more important is what they represent collectively — a new Personal Health Information Network (PHIN). The PHIN and applications developed around the PHIN will fill in many missing pieces and bring health care into the Information Age.

For example, suppose you just found out you have high blood pressure – that’s not uncommon.  Suppose you could easily submit information about your condition using the Google Health platform to receive a service that does the following:

• informs you whether there are clues in your medical history that point to a cause for your high blood pressure
• explains why being overweight can be a contributing factor
• tells you in easy-to understand language what the top number and the bottom number mean (”140 over 90″)
• explains which laboratory tests are necessary
• alerts you to the possibility that one of your prescription or over the counter  drugs could be making your high blood pressure worse
• advises you about the usefulness of using non-drug approaches to treatment
• tells you which treatment drugs have the greatest efficacy and safety for your specific circumstances
• tells you if any of those generics high blood pressure drugs are available at Walgreens for $4 a month
• offers to provide you a map with several Walgreens stores in your city that carry those $4 a month medications

…and many more possibilities we have not yet begun to imagine!

This essay:

• Is the first in a series of articles we’ll be writing to describe the PHIN and why it’s important — expect about a dozen follow-up posts.
• Is an overview of the basic idea — think executive summary or long abstract
• Introduces some new concepts, which we’ll try to simplify and define.  We understand that some of this is not easy reading. ….so we suggest you refill your cup of coffee and settle in. (more…)