Category Archives: Conferences

The next 15%: The Software Enabled Services Concept

Software Enabled Services

  1. Professional service offerings that leverage software to synergistically deliver higher levels of performance than obtainable from either alone.
  2. A next generation construct which builds upon the concept of Software as a Service (SaaS) but involves the actual human delivery of the services.

I am here in Las Vegas at the athenahealth user conference. Jonathan Bush is on the MIC regaling the crowd with his usual unique style of charismatic evangelism (“um…this is a pie chart, lots of lines, lots of things, yada yada yada”). The crowd is a typical demographic of office management set as seen across America – a middle aged office staff crew, mostly women, and mostly worried about the day to day activities of running a practice. They are here, I assume, because they want to learn how to leverage a very powerful practice management and electronic health record software. However, I wonder how many of them understand that what they really have is the most powerful software enabled service (SeS) offering in the industry.

We implemented athenaHealth (both Collector and Clinicals) in December 2009 at a traditional medical practice that Crossover Health manages.  We noted an immediate 5% bump in our revenue through better documentation, we accelerated our collections 5%, and because of new capabilities we were able to modify our staffing which reduced our costs by another 5%. This 15% uptick in revenue is real, noticeable, and has had an immediate impact on our practice.

All these advantages could be had by implementing probably most any reasonable EHR/PM software system. However, the reason I am attending the conference isn’t for this first 15% efficiency gain, its the next 15%. This next 15% is much harder and where I believe our partnership with athena will pay big dividends.  I am attending the conference not to optimize “points and clicks”, but rather to better understand the “nodes and grids”. I am here to learn how to plug in and play up the network effect and power grid that is athenahealth.

Think about it. Our little practice is one outpost in a networked grid of practices “fighting the man” every day. We are all working off the same software, sharing our collective knowledge we gain every day, wearing down the inefficiencies of each practice, measuring and monitoring our improvements, and taking advantage of nearly 2,000 athenistas who work around the clock to ensure that my practice gets Paid More, Paid Faster and with Less Work every single day. I get a monthly Practice Performance Report which compares my little clinic to the best benchmarking in the network, that clearly delineates areas of improvement, and provides a support infrastructure to help me get there. The financial controls on my practice are unprecedented; and only made possible through the network effect of my colleague clinics and the centralized efficiencies inherent in athena’s business model.

The software enabled service approach is well on its way to closing the second 15% gap, and best positioned to initiate the hunt for the third 15%  – the uncharted and untapped area of clinical process and outcome improvement. I can’t wait to see athena apply their patented approach to the measurement, monitoring, and continual improvement of the clinical side of medicine. This will only happen as financial incentives become aligned with excellent clinical outcomes, and no one is in a better position to do that than athenahealth.

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CLEAR! Shocking Google Health Back to Life

* This is the second part of my commentary on the June HealthVault Connected Care Conference in Seattle. I hope to use this post to motivate my good friends at Google Health into taking a much more public, visible, and proactive role in the health conversation. More importantly, it is a call to Google HQ to wake up to the opportunity within health care to leverage their current tools and technology to create a platform that others can use to enable the creation of a next generation health system.

The scene was familiar, but it didn’t take away the tragedy. A young motor vehicle accident victim was involved in a head on collision with a drunk driver. The blunt trauma to the chest had created a literal mish-mash of complex internal injuries. The ambulance crew had attempted multiple times enroute to obtain a pulse and the monitors were all flatlined from the field. They intubated the patient in the field, performed CPR enroute, and initiated a ATLS protocol which included shocking the patient en route. In the face of asystole (lack of heart movement) after blunt trauma to the chest, the indication is to literally crack the chest open (called a anterolateral thoracotomy), a serious medieval last ditch rescue effort to save a life.

My perception is that the Mack truck called Microsoft HealthVault has just run over a young upstart, Google Health, who had such a promising future. The blunt trauma has put the patient in a precarious fight for survival, and the only way out that this ER doctor can see is to crack the chest open.

I really like Missy, Roni, and crew and believe they are smart, capable, and well connected individuals who have really done some great work to get the product launched. However, I cannot for the life of me understand why Google as an organization cannot get serious about the Health care vertical. A couple of stats:

My most recent assessment of the Google Health vs. Microsoft Health Here is my most recent assessment of the Microsoft Health vs. Google Health

It is not like Google couldn’t do some amazing things very fast. I am not just talking about Google Wave style innovation, I mean just their current assets themselves could be reassembled in short order to produce a very useful health care communication platform. They already have gmail, calendering, photos, search, documents, video, chat, and a framework from which to store/retrieve their health information. I think you could build out a mashup in no time that is immediately competitive and would be the leading “groupware” tool available. They also have all their current relationships and the interest of any health care CEO in the country.

Ironically, the reference to iGoogle (platform w/ widgets of functionality) was mentioned more than once at the Microsoft HealthVault conference. I don’t remember hearing about this at the Google conference – oh, oops – Google doesn’t have a conference.

I guess my point is that I love the innovation machine that is Google. I am just profoundly disappointed at what appears to be a lack of commitment by the organization to truly invest and innovate in the health care space. Is it a strategy question? An opportunity cost situation? Why the paralysis?

Google! The patient is dying on the table. The only thing I can see doing at this point is getting out the rib cutters.

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Microsoft Vaults Ahead into the Personal Health Information Space

* I am out at the Eli Lilly Health 2.0 Summit and just finished a presentation by Microsoft Health Services team. It was an interesting presentation, if but for nothing else to show their worldwide commitment to health. It reminded me of the June Health Vault Summit I attended where I wrote but forgot to post a summary from the meeting.

I am flying home from the HealthVault Connected Care Conference in Seattle. I left with two big takeaways which will be addressed in two separate posts. It was a great trip, in fact refreshing in many ways, coming on the heels of a wonderful but intellectually strenuous series of meetings for the X PRIZE. In fact, I have never been to Seattle when it was so beautiful – perfectly warm and sunny days with intermittent cumulus clouds and light breezes whose temperature was nearly imperceptible. My favorite evening in town was spent watching sailboats glide effortlessly around the Sound in the fading sunlight of a perfect day. Magic.

Perhaps the setting got me in a good mood, but I walked away very clearly impressed with what Microsoft is attempting to do with their health care strategy. I have to be clear – as an ardent and passionate open source advocate (recovering zealot) – I was very ambivalent about stepping clearly into and over “enemy” lines during my sojourn in Redmond. I was quickly put at ease by the West Coast flavor of the meeting (ie, casual business dress with a young-ish crowd, high energy music, and overall good karma) and the impressive lineup of speakers and attendees. Furthermore, this was the first time I was actually able to figure out what the heck HealthVault really is and how all these various partnerships I keep reading about even begin to make sense.

Let me explain.

The big debate in the media has been positioned as a HealthVault versus Google for domination in the PHR space. In fact, I have written about this contest as a no contest as it so clearly favors Google. The Google I know and love is fast evolving, agile, and no-nonsense developer of web-based tools that make my life easier. In fact, they have become my personal computing platform of choice (Gmail, Calendar, documents, chat, video, etc). This contrasts starkly to Microsoft’s traditional proprietary platform lock in approach. I figured that their approach to health management would be the same.

Actually, 18 months later, I was surprised when I peeled back the onion. From my perspective, HealthVault has chosen to address one of the thorniest issues in healthcare by taking on the hard job of trying to integrate the personal health information mess that exists for consumers (affectionately called the “Healthcare Hairball” by Esther Dyson). Essentially, HealthVault can be considered a “translational” database – what I mean by that is it takes variable health care information inputs (from devices, EMR’s, labs, images, documents) and then stashes them away in your health “vault”. This information is then available to be retrieved and accessed (or translated) by a variety of “viewers” or output tools suited to the individuals needs and wants.

So, if you are willing to conform to HealthVault’s database standards, you can become a contributor to an individuals lifetime record; conversely, if you are willing to subscribe to HealthVault’s UI rules, you can then retrieve any information that is stored in the same database. As such, HealthVault becomes this centralized repository for all information and the source from which information can populate innumerable other applications. Given Microsofts vast resources, and their strong commitment to developing out the their health care business, they become a safe bet to invest time and resources for the storing and translation of personal health care information to and from nearly any device. As a result, a very robust community of data and device partners have begun to aggregate around the platform.

This obviously plays well into Microsofts strategy wherein they can give away HealthVault for free to consumers (who aren’t going to pay for this anyway) in an effort to bring other Microsoft products and partners to the consumer who has invested in the platform. I was able to see this in Amalgam, which functions as a sophisticated HealthVault of sorts for hosptials and large health care organizations in managing their disparate data sources, types, and translation needs. It also plays well into a platform / widget strategy which has far reaching potential. I got to see this in some private demonstrations regarding their new BING search engine (since HealthVault literally knows your health profile, they are able to contextualize search in an unbelievably personal way). The possibilities for the community of data and device companies as well as new and interesting widgets of functionality to grow seems palpable based on current progress and projected growth.

So kudos to Peter Neupert and crew for the progress to date. I was impressed.

But I was also puzzled at the same time – Where (on earth ) Is Google Health?

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Death to Innovators – The Tragedy of Healthcare Innovation

Tragedy (trăj’ĭ-dē) n.

  1. A disastrous event, especially one involving distressing loss or injury to life
  2. A tragic aspect or element.
  3. A drama or literary work in which the main character is brought to ruin or suffers extreme sorrow, especially as a consequence of a tragic flaw, moral weakness, or inability to cope with unfavorable circumstances.

The Advisory Board to the Health 2.0 Conference have been rehashing the recent conference in preparation for the fall program. We are continuing to try to push the boundaries of how to highlight bleeding edge innovations (dessert) and the new tools and technologies (eye-candy), but trying to be disciplined in challenging the community to put up their hard core case studies (nutritious tofo in the words of Esther Dyson) that demonstrate why this movement actually matters. This latter one requires thoughtful discipline, and hard data, from people trying to do very hard things (like obtain accurate personal health data from disparate sources, help consumers understand and optimize health value, and show how these new models of care actually lower cost). We look forward to producing a great program and I will keep you posted on these conversations.

The reason it is so hard to “do the right thing” in health care is that the current environment is a conspiracy of connundrums – no accountabilty, no transparency, rules/regulations, culture, binding contracts, third party payments, behavioral choices, lack of evidence, etc ad nauseaum. A real world example of how this plays out can be seen in the Vicious Cycle of Healthcare Innovation. This article highlights what happens when health care providers “do the right thing” but are rewarded with less money, which then kills off not only their desire but also their capability to do the right thing. Its a beautiful mechanism to ensure that the status quo never changes. This “Death to Innovators” concept has been highlighted by Intermountain Healthcare (pneumonia), Virginia Mason (back pain), and health innovators like Rushika Fernandopulle , MD at Reinnassance Health.

These tragedies have to be overcome. Given the grip of the medico-industrial complex, and their lobbying minions in DC, the only hope I have is that an entirely new system of health can begin to develop and emerge “off the grid” for the current non-consumers of healthcare. From this toehold, and from early and small efforts of the myriad groups seeking to change the financing of healthcare, I am hopeful that innovation can emerge that will align incentives, coordinate care delivery, improve outcomes, and be rewarded appropriately for these results.  That is why I am involved in the various efforts to not only bring innovation to light but also demonstrate that these models can flourish.

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Recap: Building Health 2.0 Into The Delivery System

Recap (rē-kăp) n.

  1. To replace a cap or caplike covering on: recapped the bottle.
  2. To restore (a used tire of a motor vehicle) to usable condition by bonding new rubber onto the worn tread and lateral surface.

We had a busy session yesterday during my panel. Besides the irritating AV problems (in/out sound, survey probs, etc), we had a pretty good conversation on stage with 4 innovative provider types who are making a real difference in health care. The slides that we used to set the stage:

KEY POINTS:

  1. Integrated Delivery Systems rock. The integrated systems deliver the best results. Period. But what about the other 85% – what can they learn from them? How can we distributed thier lessons learned to others who are trying to create “systems”. Both Group Health and the Dartmouth Clinics have acheived amazing results. Of interest, audience selected by 55% integrated delivery system, and 35% chose a small group practice.
  2. Transparency Rules. We opened up our second discussion going just right to the heart of the matter – What the heck happened with ePatient Dave, BIDMC, and Google Health? While much media has been generated regarding the ptifalls and perils, I think Roni Zieger (rhymes with “Tiger” as he unfortunately had to correct me) hit the nail on the head by essentially saying “don’t throw out the baby with the bathwater”. Essentially ePatient Dave has a very complex history – 92 ICD9 codes during the course of his illness – and essentially the entire data stream was released to his PHR. This was flawlessly execute by BIDMC to Google but exploded as ePatient Dave actually looked at what was sent over. The signal to noise ratio was impercetible (so much noise!). While there was no harm done, ePatient Dave appropriately called FOUL! regarding the potential for error, problem, and pain. This created a juicy story for the media which created a potential crisis for both BIDMC and Google. In Zen-like Fashion, John Halamka immediately diffused the situation by calling a meeting with all the players, openly discussed the concerns, made both a short and long term fix, and then putting together a strategy on how to deal with this issues in the future.  While the media story was the problem with the administrative claims data being shared, the real story was how – in a health 2.0 world – being transparent allows troubles to be trumped tersely. We heard directly from Roni, from John Halmka, and also ePatient Dave who spoke out as well. It was a great session, great conversation, and great example of the brave new world of health 2.0.
  3. Death to Innovators. Rushika had alot of great comments regarding both the opportunity and the challeng faced by innovators within the system. He was shunned, excluded, cursed, vilified, and all but tarred and feathered in Boston as he chose to focus on optimizing health of individuals to the exclusion of feeding the rapacious “system” as now constituted. He has pushed the boundaries in terms of adopting and expanding on the notion of the medical home, customer service, payment mechanism, etc. But serious challenges exist to reform the regulatory, the payment, and the entire culture. Rushika mentioned that health 2.0 will allow the patients to “vote with their feet” as they move to practices who deliver in this way.
  4. No Money, No Change! The bottom line was that all the good, bad, and ugly of our health care system has some roots in the financial incentives that are created. We need to fundamentally need to get to the root of this in order to create/reform the next generation system. If the actual financing of health care does not change, there is little hope that the delivery can change. An interesting insight into this was Group Health – which financially aligns the physicians payment to quality outcomes. According to James, “listen, changing the culture toward quality outcomes is hard enough – trying to do it when its against your self interest to do it is impossible”.  Even for innovators like Myca, there rate limiting step is potentially the payment mechanism as well (although they have a very juicy $250B cash payment market to go after!).

We did not have enough time to discuss, or take questions, but I believe we were able to accomplish our stated objective:

  1. Sense of realism of the challenges, but more importantly an optimism for the potential of Health 2.0; 2
  2. A realization that not only are new entrants creating systems from scratch based on this new paradigm but large, established players are leveraging these tools/technology as well; and finally,
  3. The possibility to transform our health system will happen both inside and outside the current system to ultimately result in a high performing, value-based, next generation health system to increases individual vitality and improves community health.

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Building Health 2.0 Into the Delivery System

Delivery (dĭ-lĭv‘ə-rē) n.

  1. The act of conveying or delivering, the act of transferring to another.
  2. Something delivered, as a shipment or package.

I am enroute to Boston for the Health 2.0 conference. I look forward to moderating a great session in the afternoon – “Great Debate #2 – Building Health 2.0 Into The Delivery System”. I have an awesome group of panelist as well as presentors (see below) and look forward to a lively session.

The original debates about Health 2.0 framed the definition as either Web 2.0 tools being adopted by health care or a much larger vision of how those enabling technologies would transform the delivery system itself. This session is the next installment in the quest to answer the question about the role, opportunity, and the ultimate impact Health 2.0 will have on health – and how this new paradigm alters relationships between patients, providers, payers, and the system itself.

Health 2.0 has already changed the landscape of health by delivering tools and technology that empowers patient communities, results in connected physicians, forces transparency to the system, and restores the patient to the center of the health experience. However, much of this has happened at the margins, outside the traditionally paternalistic medical-industrial system. While this has populists and even revolutionary appeal, the quest for far broader adoption of these concepts must penetrate deeper into the underbelly, into the very heart of the plumbing, to attack the calcified hairball where a thousand health revolutions have died before.

During my session we will explore the current state of the movement, to assess how Health 2.0 is now changing the actual delivery of health care. The previous Great Debate #1 will have discussed the role of information therapy, essentially curated content from a trusted heath advisor, as the first beach head from which to continue to infiltrate the health delivery system. We will discuss the current state of the art with the thought leaders actually implementing Health 2.0 – from small independent clinics to large integrated delivery systems – who are adopting and adapting these enabling technologies as part of a larger transformation to a next generation health system.

My aim for the session is that you will leave with three memes for further exploration:

  1. A sense of realism for the challenges, but more importantly an optimism for the potential impact of Health 2.0 in this health reform cycle;
  2. An awareness that new entrants are creating systems from scratch outside the current health care paradigm, but that established players are innovating inside with using similar tools/technology; and finally
  3. An appreciation that the traditional paternalism (structural, cultural, regulatory, and political) inherent in medicine is giving way to the participatory nature of Health 2.0

Together, these trends will serve as catalyst to transform the finance, delivery, and incentives our current system into manner that creates a patient-centered, high performance, value-based, next generation health system (“Health 2.0”) that  increase individual vitality and the health of communities.

As part of the session, we will also see presentations from three different platforms, who based on their collective recent media blitz, are clearly at the bleeding edge of a brave new world full of possibilities. The focus will be on transactional capabilities and overall utility for real patients trying to manage real health information in the real world. We look forward to learning from Googles forays into data sharing, Myca’s new paradigm shifting EHR/PHR, and how Kaiser Permanent continues to extend, deepen, and broaden their relationship with their patients using KPConnect.

The Bios from our presentors is found below:

Roni Zieger, MD
Project Manager
Google Health

Dr. Zeiger is a Product Manager at Google where he helps lead Google Health and also works on improving the quality of health-related search.  He has worked as a primary care physician, in urgent care, and has served as a Clinical Instructor of Medicine at Stanford University School of Medicine. Dr. Zeiger received his MD from Stanford and completed an internal medicine residency at the University of California, San Francisco.  He was a fellow in medical informatics at Veterans Affairs in Palo Alto, California, and received a masters degree in biomedical informatics from Stanford University.

Sean Khoizon, MD, MPH
Medical Director
Hello Health / Myca

Dr. Khozin is a founding member and practicing physician at Hello Health, a technology-enabled medical care delivery system that makes healthcare more accessible for patients and practicing medicine more streamlined for physicians. By using the Hello Health platform, patients can schedule an appointment online to see their physicians in the office or communicate with them by email, text messaging, and video chat. For doctors, the platform reduces overhead and creates new channels of communication with patients. Hello Health has developed a web-based platform that creates a patient-centric environment powered by social networking tools to connect and share information with healthcare providers. The technology is also a fully integrated electronic medical record and practice management system.
Ted Eytan, MD
Clinical Innovation
Kaiser Permanente

Dr. Eytan currently works as a Medical Director for Delivery Systems Operations Improvement for the Permanente Federation, LLC. His experience is in working with large medical groups, patients, and technologists to bring health care consumers useful information and decision-making health tools, to ensure that patients have an active role in their own health care.  Dr. Eytan is board certified in family practice. He has relocated to Washington, DC, from Seattle, working in the area of patient-centered health care enabled by technology, with organizations including the California Healthcare Foundation.  He attended medical school at the University of Arizona. He received his master’s of public health degree from the University of California, Berkeley, and his master’s of science, health services degree from the University of Washington. He completed his residency training at Group Health and his fellowship training in the Robert Wood Johnson Clinical Scholars Program at the University of Washington in 2000. His particular interests are patient and family involvement in care, health information technology, and supporting the health and diversity of communities.

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Cathedral and the Bazaar in Healthcare

Bazaar (bə-zär’) n.

  1. A market consisting of a street lined with shops and stalls, especially one in the Middle East.
  2. A shop or a part of a store in which miscellaneous articles are sold.

Eric Raymond is a famous open source advocate who published a seminal book on the fundamental philosophic basis for the movement. He used the analogy of the Cathedral as contrasted to the Bazaar as the metaphor to compare very top down, overly ornate approaches to software development versus the much more chaotic, decentralized, but ever more vibrant approach of open source.

The Cathedral and The Bazaar

The Cathedral and The Bazaar

Having lived that world for several years, I understand the powerful metaphor, and appreciate its appeal to my natural revolutionary streak.

I see the same thing evolving in healthcare – we are beginning to see the big, monolithic systems like Kaiser, Intermountain, Geisinger, Group Health, and even the VA begin to demonstrate impressive outcomes in terms of cost, quality, IT, and patient experience. This might lead one to think that this is the best way to go and we should all begin to worship within the whited walls of a an integrated, fixed fee provider group (“The Cathedral”).

But while the Cathedral has its place and has its appeal, there is much to be found within the ever more vibrant, chaotic, and pleuripotent Bazaar. In fact, I believe that the bottoms up Bazaar holds far more promise to bring me products and services to meet my personalized needs than could be provided by the Cathedral model. Unfortunately, the very nature of the Bazaar makes it difficult to harness, coordinate, and distribute those services in a scalable way.

My contention, however, is that the tools and technology are arriving that will allow the Bazaar to compete head on with the Cathedral. In my “Bazedral” model, there is a layer of software and services that serves as the virtualization layer to abstract out the current challenges of coordination, mixability, and modularity. This integration layer would enable providers to come together in ways to deliver  analogous if not superior results (given the enhanced competitive nature of trying to be one of the “care modules” that gets plugged into the overall solution). Thus all the component parts of a right hip repair (pre-op workup, surgeon, anesthesia, recovery, rehab, etc) could be put out to bid but brought together in delivery by the virtual integrator to provide a seamless, integrated service experience This could be huge.

Bottom line for me . . . Cathedral Care is superior (for now). However, I believe there are “virtual integration” companies coming that will allow the Bazaar Care model to self organize in ways that will not only challenge but beat the outcomes results we have seen to date from the Cathedral. This would actually be good for the overall health care system, would challenge Cathedral players to continue to improve and adapt, and ensure competitive market alternatives.

Let us pray for the hastening of this day – Amen!

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