Category Archives: Health 2.0

Getting Real: Can Health 2.0 Stay Relevant?

Relevant (rĕl’ə-vənt)

1. Having to do with the matter at hand; to the point

I read with amusement Susanna Fox’s redux review about the relevance of Health 2.0 in general and in changing patient’s behavior specifically.  Here questions reveals her bias in a very limited definition of Health 2.0 that I attempted to abolish originally in some of my bantering with Matthew Holt. I always saw Health 2.0 as a “movement” that would not be defined so much by its technology but rather enabled by it. As an “enabler”, the technology can help people do new things in new ways but I never believed technology in and of itself  had the power to truly change health, health behaviors, or health care delivery in and of itself.

That is why my definition of health 2.0 was always more expansive and contemplated an entire “movement” to the next generation health care “system”. This new system must include new delivery models, new financing mechanism, and the new tools and technology that bring all of this together in a simple, efficient, and affordable way.  Clearly this next generation of care would include technology, the new tools, but until we had a new delivery system that is financed in a new way we are going to continue to have the same behaviors across the patient, physician, provider, and payor continuum.

So Susanna, I don’t think your version of Health 2.0 (Tools and Technology) do much to get us to the behavior change you seek. In fact, getting to the root of behavior change requires almost a religious experience. Interestingly enough, the health care industry provides plenty of “religious” experiences including passing close to death, unbelievably poor customer experiences that invoke deep passions (ie, the birth of ePatient Dave), and promise of a far better world than we currently enjoy. So while the tools and technology show us what is possible, health care delivery and health finance are the catechismal doctrines we must reform first that actually incent the behavioral change we all seek.

So is Health 2.0 Relevant?  I think it depends on your definition!

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Filed under Health 2.0, Innovation, Irony

Crossover Piquant: Check this out!

Piquant (pē-känt’) adj.

  1. Appealingly provocative
  2. Charming, interesting, or attractive

One of the great promises of technology is to make things simpler, easier, and more affordable for end users. In the medical practice, we have so much complexity, difficulty, and cost in most of our processes that when we find something that actually works as advertised we fall in love.

I had one such “appealingly provocative” experience this weekend. While attending a high school football game in support of one of my member patients (leading passer in Orange County by the way!), the player was injured. I initially thought it was a concussive injury but the reason he remained down was the he knew he had severely rolled his ankle. His father called me from the field (I was in the stands) and I followed along by text messaging as he was treated initially by the trainer and later by the team orthopedic surgeon. He was unable to continue playing due to the injury and it was iced and wrapped overnight.

The next morning I met him at our clinic, fired up our new TRX GP-5 machine (all digital x-ray machine), and took some beautiful images. These were captured on our PC based OmniView rendering software (proprietary and expensive) and fed to our OsiriX viewing software (open source and free!). I was able to manipulate the image at will, contrast and enlarge as needed to highlight all the structures, and automatically send the image to a remote radiologist for reading. No films to carry, no chemicals to purchase, and no storage required – ever. Simple, Efficient, and Affordable.

But I was just warming up.

The process we are using at Crossover Health to acquire an x-ray image to the iPad

The piquant was my ability to wirelessly transmit the image from my MacBook (serving as a server) to the iPad. This process is made possible by the fact that I have can move the standards based DICOM image from a PC to a MAC (using OsiriX), and then push it out to my iPad. While I thoroughly enjoy technology, I often get frustrated because I lack the technical expertise and patients to work out all the kinks. I was pleased to see that I was able to point and direct all the connections where they needed to go and the images appeared neatly onto my iPad without any problems.

From the patient experience, all they knew was that the image was shot, its being read by a board certified radiologist, and they are seeing, touching, and experience the iPad as a new device in our patient-physician relationship.  The patient was intrigued, impressed, and engaged (entertained?) by the whole process. I dare say it was a “fun” visit (why does the typical health care experience have to be so lame anyway?) for them to participate in this process, see their physician pushing the technology barriers, and engaging in the diagnostic process in a way they never have before.

The piquant experience certainly piqued the interest of their family who had the family.

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Filed under Design, Health 2.0, Innovation, Open Source, Uncategorized, Value

Day 49: “Magically” raising the Bar in Primary Care

Magic (măj’ĭk) adj.

  1. Possessing distinctive qualities that produce unaccountable or baffling effects.
  2. Of, relating to, or invoking the supernatural

The California Health Care Foundation does some really good work. I listened to their President Mark Smith give a speech at the Microsoft conference last June and came away really impressed with him and what the organization is all about.  They also generate quite a few solid reports on issues affecting Californians but also as representative of what the rest of the nation can look forward to as well.

An interesting report that was recently issued related to the supply of California physicians.  The report is basically a powerpoint, which is really smart, because in our world of information overload a powerpoint is about all the detail you can swallow on a quick scan through. Four of the slides really caught my attention as they told a compelling story of what has happened to primary care.

We begin our review by noting that general physician supply has been flat for the last 15 years. There are a variety of reasons for this including economic alternatives, fixed number of medical schools, and the length of training versus the end payoff during the career.

Medical Graduates has remained flat in the CA for last 15 years while population has grown 40% during that time.

The flat physician supply is bad enough, but coupled with more than a decade of medical school graduates choosing specialties (less than 10% remain in primary care), we see a growing disparity in the numbers going into these safety net fields. The multifactorial reasons why graduates don’t pursue care in primary medicine relates to revenue model, business model, intensity of work, and job satisfaction among others.

California barely meets the nationally recognized standard for numbers of primary care physicians.

This is demonstrated in the attached slide showing the payment disparities between specialties. While primary care has enjoyed a recent increase it salary it has only moved from a running joke to a one liner. the 20% increase still puts it dead last in compensation and ~$15K lower than the next closest specialty.

While primary care has enjoyed a 20% increase, it is still $15K lower than the next lowest paid specialty.

To add insult to injury, California Primary Care Physicians are not just economically under appreciated as a specialty, they are also under appreciated geographically when compared to their peers. In one of the most expensive places in the country, they only make about 88% of what their peers make in other states.

When comparing CA PCP's against their peers in other states, they earned about 90% of national average.

Putting this all together paints a pretty tough picture for primary care – flat physician supply, only 5-8% of grads going in primary care, as a result of low pay, and for those choosing to stay in California they are rewarded with even less relative pay comparing to their PCP peers in other states.  These are all big macroeconomic trends that will take a long time to correct.

However, in the short run, at Crossover Health we believe that we give PCP’s HOPE that there is a better way, HOPE that there is a brighter day, and HOPE that they can either once again return to the medicine they loved to practice or forge ahead in creating an entirely new type of health care based on membership business model, using a powerful technology platform, and creating a new value network of specialist and ancillary providers. We believe we can raise the bar through each of these innovation singly, but when synergistically applied, we think we have something magic. 

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Filed under Crossover, Health 2.0, Primary Care

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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Filed under Conferences, Health 2.0, Health Finance, Innovation

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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Filed under Conferences, Health 2.0, Innovation, Value