However, there are for-profit firms who aggregate, and dispense this information in an expedient way. This has allowed a great deal of efficiency and speed in the retail banking world. Consumers must consent to the collection, and ultimate dissemination of their financial info before it can be shared.

I don’t see how google health is much different. nothing happens that the patient does not ultimately allow.

Frankly, I’m all for it because in the end, it is the choice of the consumer, and the consumer has complete control.

At CureHunter we are patient activist oriented too, but rather than asking for their data we stick with analyzing peer-reviewed research. Disease research is complicated enough without adding more human data-entry error into the mix.

I think we need a national/global initiative to standardize the exchange of anonymous data between hospitals… first. The hospitals still have the best data.

Adam seems to have been the driving force behind Google Health to date. Anything I said about the future would be totally speculative, so I’ll just say that I hope his vision has been ingrained with the remaining members of the team.

Vince

How, in fact, does this change anything, aside from improving the records of a majority-elite and sorta-kinda-not-really control costs? Not that there’s anything wrong with that, but I can’t help but feel this will be just another reason to discriminate against the poor – no EHR? Sorry. I don’t see patients without them.

One, there are a couple of bills floating around Congress to support the establishment of Independent Health Record Banks (also sometimes called Independent Health Record Trusts). A key facet of these banks is that the persons whose data are in the bank are the only members of the bank and have ultimate say over policy for the bank. While this puts the “patients” individually and collectively in a position of control that appears to me to be stronger than others models that I’ve seen, I’d be interested in comments on how such a bank seen as a variant of a PHR’s database, would work in practice to accomplish this sort of patient-centric result without seriously denting the interests in a business model to fund the operations. Would this level of control encourage more patients to use/support useful health data sharing?

Two, most privacy laws/regulations today govern the sharing of data between health enterprises and support the right of patients to obtain their health information and use it as they wish. By one theory, if the data that might usefully flow between health enterprises used the patient (or patient-controlled agent) as an intermediary, then the patient would have control over his/her health information flow in a way that would seem to eliminate the typically complex decision about whether sharing the data was permitted under law. Generally, it seems that the question for a health enterprise would turn from “Can I release this data without risking violation of a privacy law/regulation?” to “Is there a solid rationale for me to resist releasing this data?”. While such a model would move some power from health care enterprises to their customers (and so they may resist), it seems to be consistent with the idea of a patient-centric model generally and seems to solve the sharing problem to most customer’s satisfaction. How do you see the future of this idea?

Creating “de facto” standards might get the ball rolling if “de jure” standards didn’t already exist, but now the best course is for “de facto” and “de jure” to be one and the same.

So Vince, my main man, you need to bump your analysis up a level. Who or what is bigger even than Google? The self-same US of A, that’s who! Take your terrific essay, Find every mention of “Google” and “GH,” hit Replace and substitute the words “federal government,” and you got yourself a plan!

Yessirree bob, I propose that e-CareManagement convene a serious discussion of the only truly scalable solution to the woes of US health care — national government mandates. If they’re good enough for Social Security and good enough for Medicare, they’re dang-tootin’ good enough for PHRs! A lot of Democrats know I’m right but aren’t ready to say so yet, know what I mean? But it’ll come! The Kuraitis plan for national PHRs, right-sized, federalized, and deGoogle-ized!

Electronic health reords aren’t the magic bullet after all.

Stanford shows no improvement in patient care due to electronic health records:

http://news.yahoo.com/s/nm/records_dc;_ylt=AlxlcRLgG13iGzBvV1SoWIPq188F

They recently acquired Azyxxi(an aggregator of hospital-wide EMR data) and Medstory(a content provider now linked with MSN).

Wildcat will follow shortly https://www.microsofthealthbeta.com/shell/help.aspx?topicid=faq

I think they will take a more pragmatic approach to solving the need for standardization and pulling together scattered data for a PHR given their entry into the EMR alrady.

In terms of the business model – I think the % of the population that will actually use a PHR is limited. Most people don’t want to be reminded of their mortality and a record of your health is a nasty reminder. Checking the value of your stocks and social networking is a far nicer way to spend time online for most people.

Google make money by taking other people’s data and selling it to advertizers. Do you trust them with your PHI and do you want them selling your deidentified data to the health care providers and drug companies (and government?) to make money.

There is also a community model where people engage in a discussion about health topics. PHI sharing comes as trust is established – which can be monetized also through advertizing – the sort of MySpace for health care. Perhaps the bootstrap will involve “Dr. Google” or his agents providing expert, trusted advice. The agents should be associated with trusted real-world health care brands until the conversation floats into the virtual world and on-line reputations take over.

If tusted health care brands got a clue and they’d enter the market themselves and compete with Google. They (badly) understand HIPAA and protect patient data like it was their own. And their buiness models are at least based on delivering something or real value – care. But it probably won’t happen since they neither have the technology skills nor the vision.

If Google are only partially successful it will still be a boon to consumerism by getting outcome information into the hands of the consumer to support personal choice. It will also put pressure on the medical profession who seem to want to make “doctoring” a secret secience of the well-qualified, with the patient positioned as too ignorant to know what’s best for themselves.

I can not agree more that GH is one of the best positioned players to embark on the great IT and technological challenge to seamlessly syndicate and integrate scattered and non-standardized healthcare information for each individual.

One question, though, I have is, can “patient centric” be really feasible? The poor medical education level of general population tends to be blamed for the challenge, but more importantly, I am not convinced if the lifestyle modification and health management of an individual would require a whole depository of personal health information. Hence, I am not sure to what extent and exactly how GH would be able to leverage patients as a force to syndicate the scattered health data.

I would appreciate your insight.

Let’s see..consumers already have a big trust issue when it comes to their personal health info. I wonder how they would feel if they thought their genetic profile could one day come up for sale in an AdSense text ad?

The only way that I’d differ from Vince (other than I was too lazy to write my GH conclusions out fully) is that that I’d add in the one interesting VC investment Google has made. It’s in 23andme.

Aside from the fact that the CEO is Larry or Sergey (I can’t tell those two apart)’s wife—bet that made the pitch easier!— and that Esther Dyson has her hooks into it as well, the other interesting thing about 23andme is that it’s a genetic testing company. And it seems pretty logical that genetic information is going to be mixed into PHRs in the near future….so it doesn’t take a rocket genome scientist to make the link between 23andme and the not yet unveiled Google PHR/personal health URL.

They key question is whether Google (and more importantly American consumers using Google as a vehicle) has the clout to make the health care system willingly and easily give up its data….

We shall see.

>>>>Simon put it very well…personally i find it bizarre to think patients will entrust Google.
It’s Google or Nothing ! Currently the patients don’t really have a seat at the Health Table.

>>>>Medical records aren’t the answer to everything
So true, exercise and clean drinking water saves more lives than any silly EMR.

Health plan sponsored PHRs are useless.
They have no content.

>>>>”Like all new things in today’s evolving consumer/retail healthcare industry, it will be the consumer and not the pundits like me who will eventually decide how successful Google’s strategy will be.”
If you believe this statement, you believe that Google will be very successful. Right now patients have little to no access to their health information. Google is going to MAKE THEM a part of the loop.

>>>>”Perhaps the ‘best’ or most useful PHR/EHR structure will not be a single EHR stored on a removeable memory stick (although wouldn’t that be handy???),”
PHRs on a memory stick will never work. I find it odd that someone could even think that they might.

>>>>”Simon and Paul raise the inevitable questions about TRUST. My point here is not to defend GH, but I will share how I think about this.”
Actually, over the long term, patients may feel there is *MORE* security having 1 place for all the health information vs. it being scattered ALL over the place ! Not to mention, a wee “theoretical security risk” seems small when the promise is of more organized, affordable healthcare.

>>>>”With health plans already beginning to become under some pressure from banks on their one flank (financial transactions), I find it highly unlikely that they would agree to partner/share any data with Google and goes to great lengths to hinder Google’s efforts.”
89% of the financial benefit of what I call exchangeable health information goes to the payors (health plans). read Markle.org

>>>>”I just don’t know if they (Google) will be committed to going down the rabbit hole into the health care industry.”
Good point. The healthcare pie *IS* big :)

Great post and comments on the potentials of Google Health. One other fact that might be useful is most EMRs are terrible and are unlikely to ever be able to exchange health information. So …. GH’s competition is weak, for the forseeable future !

Google, Inc certainly has the industrial and IT clout to put something like this together, but the issue of PHR as a stand alone is inefficient….they need to develop a PHR that integrates into the system on separate servers which are secure (I am sure they thought about that one already)

We just presented our type 2 diabetes clinical trial results at ADA Scientific Sessions. I remember reading a comment about how there was no good data available yet in the world of wireless medical device enabled patient management. Well, here it is for type 2 diabetes.

As to GH, all of us who have been around this industry and have seen numerous failures of “the next great thing” delivered by the non-healthcare IT world that promises to finally bring healthcare into this century. Nonetheless, we will root for the effort. While institional resistance to change will be a huge barrier to the GOOG, we may find that consumer apathy and fear (of loss of privacy) may be even more important. GOOGLE’s business success has been founded on fast consumer uptake and that source of energy will not drive this effort. GH will indeed have to demonstrate persistence until payors mandate electronically accessible records as a condition of participation and payment, and then the world will change.

I was particularly interested in your outlook on the disruptive potential of Google’s PHI model on health plans. I just got done attending the AHIP Conference in Vegas and Google Health came up in alot of conversations with both the vendors/health plans.

If health plans truly do follow through on the buzzword of the conference (“B2C”), then Google’s PHI model poses a potential threat to health plans strategic initiatives to become “health care advocates” to their members on several fronts (primarily by negating the value of the large repositories of claims history data that the plans are sitting on).

With health plans already beginning to become under some pressure from banks on their one flank (financial transactions), I find it highly unlikely that they would agree to partner/share any data with Google and goes to great lengths to hinder Google’s efforts.

It would force Google to negotiate with a myriad of alternative partners (clearinghouses, PBMs, labs, etc) to supply them with personal health information. This would require a substantial strategic investment by Google in time, staff, and effort. I just don’t know if they will be committed to going down the rabbit hole into the health care industry.

I’ll take a whack at some of your comments.

1) Randy and Steve raise questions about EXECUTION for GH — certainly a big challenge. You both wonder whether GH is Healtheon reincarnated.

What’s NOT different since Healtheon went public (around 1998)? Special interests are no less entrenched today, and I expect that there will be a lot of pushback. I’ve quoted Jim Clark before as pointing out that what many see as waste and excess spending in health care is what others see as food on the table. For every disrupter there is an disruptee.

Several things are different:

a) GH’s approach strikes me as far more collaborative and calculated. Healtheon was an Internet bubble company (IPO at $8, trading closes at $32 on day 1, height of the roller coaster at $120, then crashing down below original IPO price). The plan wasn’t there.
b) Healtheon’s model was primarily B2B, whereas GH seems to be banking much more on support from patients themselves, as well probably from employers, government, and others.
c) HIT developments in general, and the CCR standard in particular, have advanced significantly

These factors don’t guarantee success, but they raise the odds.

2) Simon and Paul raise the inevitable questions about TRUST.

My point here is not to defend GH, but I will share how I think about this. First, I’ll acknoweldge the validity of concerns about trust; this is a real issue.

For me it’s a risk/benefit analysis. The benefits of GH — both individually and for the health care system — are tremendous. The IOM pointed to 98,000 deaths per year in hospitals because of lack of quality and IT. Lack of IT in health care is a really big problem

On the risk side, I’ll pose back “Who would you trust” (In God we trust is not an option). While Google has baggage, so does everybody else on the trust issue — employers, health plans, pharma, others all have trust issues. Providers do better on trust, but they have little economic incentive to create interoperable, transportable PHRs.

3) Steve talks about Project HealthDesign’s evolving thinking about next generation PHRs. These guys have some great work around next generation PHRs — check out http://www.projecthealthdesign.org/ and http://rwjfblogs.typepad.com/pioneer/health_it/index.html . Steve correctly points out that an ecosystem is beginning to form around anticipated evolutions in PHRs.

4) Jen discussed SOAP and asks about the optimal EHR/PHR structure.

Think of the CCR standard as a foundation for PHI. In current form, the CCR standard covers free text, structured text, or coded data for 17 modules:

Patient demographics, Insurance information, Advance directives, Problems/diagnoses, Allergies and alerts, Medication list, Immunizations, Family history, Social history, Vital signs Results, Procedures, Encounters, Medical equipment, Plan of care, Health care providers, Functional status

As the MP3 of PHI, the current CCR standard is a great start…but there’s always MP4 for the future.

Vince

These sheets have list space for subjective information (patient states greater pain after walking 30 mins yesterday), objective (patient able to perform 10 additional quad reps at level 2), assessment (patient progressing toward goals but not completely satisfied with speed of recovery – revise goals), and protocol (exercise program revisions, etc.).

Perhaps the ‘best’ or most useful PHR/EHR structure will not be a single EHR stored on a removeable memory stick (although wouldn’t that be handy???), but rather a combination of approaches dogpiled together using web-based applications.

This would allow the partnership of patients and caregivers in ensuring accuracy and utility of personal health as well as official medical record data, and the added bonus is that patients who are just not interested in being very involved can still leave the bulk of the work up to the medical professionals.

For example, using the SOAP analogy, I envision the subjective being a memory stick, CD-Rom, or Personal Health URL (or any/all of the above), ‘owned’ by the patient and accessible at the docs office/hospital.

The objective portion would be an EMR that nurses, docs etc. would pull up on laptops, or small flatscreens on moveable trays, stored within the hospital system/server but ‘reviewable’ by the patient either with a special access code, with an email address to the MR staff or the docs office/AA to contact if they see or suspect a mistake.

Likewise, patients could download information from their own hospital EM record (after the legal eagles have looked at HIPAA and laid down multiple forms a patient would have to sign prior to posting their own information on the web, especially if it’s a publicly available page).

Caregivers could then utilize the subjective portion while charting the objective portion online in the patient’s room during the visit.

Assessment and protocol could also be under the umbrella of caregiver management, as they currently are handled in the paper system.

It will also be interesting to see how health plans in particular will respond if at all. After all this will not be the first time we have seen high tech companies (Healtheon, WebMD and Revolution Health) take a “veni, vedi, vici” approach to healthcare…only to have them die a slow death “trying to cross the Alps” – an allusion to the healthcare industry.

Like all new things in today’s evolving consumer/retail healthcare industry, it will be the consumer and not the pundits like me who will eventually decide how successful Google’s strategy will be. I wonder if Google brought any elephants along for the journey?

Congrats on a very timely and well thought out posting. It will be very interesting to see if a Google PHR will experience any greater consumer adoption that have health plan sponsored PHRs -

Some points to consider: Do you exist in an information silo? Can you get out? Simon put it very well…personally i find it bizarre to think patients will entrust Google.

What if your Doctor has a problem with Google and will not use its service. Such problems can arise from unfair competition, fear of American big business culture or just plain old “they don’t pay me enough”.

Medical records aren’t the answer to everything and there are widespread misunderstandings from tech people of their value or a patients ability to create/manage a useful one. The consumer orientation of the google health record will mean it is so padded out that it will ineffectively consume vast amounts of individual physician time and it will be hard to find an acceptable way to reimburse for this.

Terrific piece and thanks for the mentions of Project HealthDesign. In the discussion of next generation PHRs, we’re thinking of an architecture that has three levels: 1) the data typically held by a provider or other health care institution (i.e. your medical record); 2) the collection of these data, as well other user generated data (i.e. what you expect Google or other intermediaries to do); and then 3) the applications or tools that are developed to help people act on their data to improve their health. In my mind, each of these ought to have open (secure, of course) interfaces so that as a user, you can ask your provider to send your data to the service that you use to store your data (perhaps Google, perhaps others) and then, ideally, there’s a marketplace of developers building applications that both draw on the data your service holds and populate that service with data generated outside the care system (e.g. a pain diary, data on meds taken). I’ve fleshed out some of these ideas more on the Pioneering Ideas blog.