Posts Tagged ‘Dossia’

Since its initial launch to much fanfare, Google Health has struggled to be relevant.  Since its formal launch in May 2008, Google Health has not dedicated the resources to build out this platform into a truly engaging ecosystem of applications to assist the consumer in managing their health or the health of a loved one.  Rather than build out new features, support a broadening array of standards, focus on the necessary business development that is required to establish partnerships, Google has taken a laissez-faire attitude to this product/service never dedicating more than a handful of engineers to the effort and most often flexing in outside vendors, such as IBM who built the module to bring in biometric from Continua compliant devices.

Rumors are now floating about that this lack of relevancy, this lack of a true commitment to Google Health has led to that oh so fateful executive decision – pulling the plug on Google Health and either letting the team go or reassigning them to other divisions within the organization.  With maybe 25 employees max at any one time working on Google Health, this will not have major implications internally, but it may have some broad repercussions in the industry that include:

Without a viable competitor, will HealthVault languish in its efforts to provide a truly clean, easy to engage and use platform?
Google Health’s interface and ease of interaction has always been one of its key features. Unlike Microsoft’s HealthVault, which initially was a beast to try and use, Google Health from the start was simple, intuitive and dare one say it, almost fun to use.  Though HealthVault has come a long way in improving the user experience, it remains a more trying experience. With Google Health put on the proverbial shelf, will HealthVault no longer be pushed as hard to continuously improve the user experience.

Perception that Personal Health Platform (PHP) market is dead.
Markets do not exist if there are no competitors. If the rumors are true, what we have left are Dossia, the private, employer-based platform and HealthVault.  These two alone do not constitute a market, therefore, can we now boldly state that there is no market for consumer-based PHPs?  Market would seem to say yes, though Chilmark has a hard-time admitting as much as we have been strong proponents of the PHP concept.  It may simply be that this market is still extremely immature as the consumer is not well-educated in the value in managing their own personal health information (PHI), nor is such information in easy to access and use digital form factors.  History is littered with great inventions by great inventors who ended up in the poor-house simply because the timing was off, This may indeed be the case for PHP.

Lack of options for small, consumer-focused independent software vendors (ISVs).
Dossia takes a very cautious approach to adding ISVs to its ecosystem, basically choosing those that their employer members wish to have available for their employees.  Microsoft has been quite aggressive in adding an increasingly wide array of ISV partners to create a fairly rich ecosystem.  Problem is, some ISVs are reluctant to work with Microsoft for whatever reason.  Without Google as an option, they are left with few options.

Could stall innovation.
Similar to the first point wherein Google Health’s attractive and easy to engage interface was a welcome relief to our experiences with HealthVault which subsequently put the pressure on Microsoft to improve the user experience, without Google pushing the innovation envelop in directions that Microsoft or to a lesser extent Dossia may not have pushed, we are now left with the very real possibility of not seeing truly new, innovative models for how consumers can gain access to, use and leverage their PHI to improve their health as well as their interactions with the healthcare system.  This may ultimately prove to be the biggest repercussion in this nascent market of consumer health IT.

It is critical to state that though, if rumors prove true – Google has disbanded its Google Health team, that does not mean Google Health is dead.  What it does mean is that Google Health has been put into stasis, that we will not see any new innovations, we will not see an expansion of its support of standards beyond the bastardized version of CCR that Google Health currently uses and the number of new partners, be it those providing data (payers, providers, etc.) or using it (ISVs), joining the Google Health ecosystem will trend to zero.  Sure, one can still store their PHI on Google Health and one will be able to able to use one of the existing ISVs, just don’t expect much more than what we have today going forward.

So without Google Health to keep the boys and girls in Redmond on their toes, might we continue to use the metaphor in Microsoft’s efforts to package the iPod as the metaphor for the user experience at HealthVault.  We sure hope not and many of the most senior executives at Microsoft have assured us that this will not be the case. In fact, to their credit, it was one of these executives that first guided us to the Microsoft exercise in repackaging the iPod video, so we remain optimistically hopeful.

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Round Two: A Dossia Update

dossialogoLast Friday had the chance to meet up with the folks at Dossia, the personal health platform (PHP) formed by a consortium of employers. Purpose of the meeting was to get a deep dive update on Dossia and learn more about what they have done in the last year or so since they went live with Wal-Mart in fall 2008.

Since that go-live, Dossia has been fairly quiet, though they did announce two new “founding members” and released the open API this past summer. But frankly, not much to write home about.

Despite being the first “out the door” PHP, several months ahead of Microsoft’s formal announcement of HealthVault in early October 2007, Dossia has floundered.  First was the break-up with their first development partner, Omnimedix which led to Dossia forming a relationship with Children’s Hospital, Boston to use the open source Indivo PHP.  After nearly a year of work with the Indivo team, Dossia finally had WebMD linked into Dossia.  This integration between WebMD and the core Indivo-based Dossia platform was done under some pretty tight deadlines to meet Wal-Mart’s aggressive roll-out schedule – as part of their annual fall health fairs for employees across the country.  The push led to a less than ideal integration with the WebMD, an integration that could not be readily duplicated with any other third party independent software vendors (ISVs).  Thus, Dossia’s desire to build an ecosystem of apps on top of their PHP was put into stasis as the Dossia team focused on the Wal-Mart roll-out.

A year later much has been learned.

Dossia discovered that Indivo V3.2 was not fully scalable to meet large enterprise needs.

The Indivo platform was developed by Harvard Med School academics to test the concepts and policies associated with a patient-controlled health record system.  Prior to Dossia’s adoption of Indivo, the platform had seen small scale implementations at Children’s Hospital, MIT’s on-campus hospital and at Hewlett-Packard in association with a flu vaccination study. In each of these implementations, no ecosystem of apps was deployed via a common and open application programming interface (API).  This is understandable as Indivo was structured to test concepts, not necessarily structured for large scale commercial roll-out.

Since last fall, the Dossia team hired a completely new team of developers (size of Dossia team on par with Google Health ~15-18 FTEs), completely re-architected their platform to meet scalability requirements, addressed user interface (UI) issues (Indivo lacked a modern, intuitive interface), and developed a stable API that ISVs could use.  On October 15th, the new platform/UI went live.

The new API was released at the end of June and there are now 20 ISVs modifying their apps to sit on the Dossia platform.  As of today, in addition to WebMD, Dossia has eClinicalWorks (eCW is used in Wal-Mart’s retail & corporate clinics – don’t forget that eCW is also being sold through Sam’s Club), Healthtrio, Medikeeper and Metavante, who had acquired CapMed, live on the platform.

Indivo platform did not adequately address the myriad of state laws relating to record consent and sharing for teenagers.

Last year’s Wal-Mart roll-out was targeted at just employees. No incentives were provided, it was completely left up to the employee as to whether or not they wished to participate.  While Wal-Mart obtained “favorable” adoption, a key desire of employees was to have a Dossia account not only for themselves but also for their dependents. This desire led to some fairly significant challenges for Dossia in providing the appropriate consent structure for teenage dependents where State laws vary significantly.  These new consent requirements were built into the new platform as well.

Employers wanted support for dental records.

Another request from employer consortium members was the ability to support dental record data.  As part of the platform rebuild, Dossia has also embedded a dental data schema.  To the best of our knowledge, Dossia is the only PHP who has this capability today.

User interface needed to be simpler, more intuitive to provide easy access to personal health information (PHI).

During the meeting, Dossia provided a demo of its new interface, which was very simple to navigate, ranking on par with Google’s and a more intuitive experience than that of HealthVault.  Dossia has a slight advantage here in that employers define which apps employees have access to and upon sign-up populate an employee’s account with their claims and pharmacy benefits management (PBM) data.  For either Google Health or HealthVault, most consumers must go through the actions of loading their own data, choosing their own apps, etc., to establish a viable and personally value producing account.  This is similar to the adage “with freedom comes responsibility.”

Challenges Remain:

Dossia has made impressive progress since its initial launch last fall.  They have addressed the scalability issue, they have finally released an open API for ISVs to create an ecosystem of future apps and several other consortium members will be going live on the platform in the near future.  Despite these gains, challenges remain.

Where’s the lab data?

While Dossia has the ability to support clinical data in either CCR or CCD formats, today they are only importing claims and medication data from PBM firms.  Dossia, like Google Health and HealthVault does not support images today.  In somewhat of a surprise, Dossia also does not currently support lab data imports from either Quest or LabCorp.  This is a surprise for two reasons: First, viewing labs online has been found to be one of the most desired attributes of a a personal health account and secondly, both Google and Microsoft can import lab data from either of these national testing labs that represent some 80%+ of all labs done in the US.  If Google and Microsoft can do it, why not Dossia?

What’s the value proposition for employers?

Chilmark still struggles to understand what the value proposition is an employer to adopt the Dossia platform for their employees. Yes, Dossia may be a non-profit looking to provide a common platform that will provide employers more flexibility in the health-related tools (PHRs, HRAs, wellness apps, etc.) they can offer their employees to better manage employee health and wellness, but is that enough? Today, few employers see the strategic advantage of providing even the simplest of such tools (e.g. a WebMD account, an online wellness program, a disease management program that actually works, etc.) to their employees. If it is difficult for them to see value here, how can they realistically make the leap to considering a health platform with an ecosystem of apps?

And the value prop for employees is…?

Yes, the interface is much improved and yes, PHI data is automatically imported into an account and an employee’s Dossia account is fully their own, but beyond that, why would an employee sign-up to have an account? What other attributes and services does Dossia provide that are attractive to a consumer? According to Kaiser-Permanente and others, those who adopt and use such system use them to look at their lab data and conduct simple transactions such as Rx refills and appointment scheduling, all features that Dossia does not support.  So again, the value for a consumer in using Dossia is?

A couple of suggestions:

Rev up the marketing engine

If Dossia’s claims are indeed true, that the platform is stable, scalable and open to third party ISVs to build-out the ecosystem, then it is time for Dossia to become more aggressive on the marketing front.  Who better to market Dossia than its consortium members?

To date, Dossia’s consortium members have been extremely quiet and they are arguably, Dossia’s strongest marketing partner.  But if Dossia’s founding members are not out there promoting the platform, clearly stating the value proposition they see in being a member and even, as in the case of Wal-Mart, begin talking about the successes they have seen since launching Dossia, then how is any other employer suppose to buy-in to the concept?

And a concept it is for there are few in the industry today, including health benefits management firms and consultants, that fully understand what the ecosystem/PHP model represents and the value it may deliver to employers over the long-term.  The best advocates, the best marketing Dossia can receive at this critical juncture, is the vocal support of its members. So where are they?

Get the labs

Ability to access, view and share lab data is one of the top features that early adopters of PHRs and PHPs appreciate.  Dossia needs to get this issue addressed immediately. End of story.

Delivery a value proposition that employees will appreciate and use

Critical to the success of the most popular personal health systems in the market today are their ability to support transactional processes.  While it would be extremely difficult, if not impossible for Dossia to support such functions as appointment scheduling, Rx refills, eVisits with one’s primary care doctor, there is one transaction area where they could excel: providing health-related financial decision support tools.  Such tools would provide support for health savings accounts, plan deductables and balances, pricing transparency for common procedures, medications, etc., special employee health discounts, and the list goes on.   There are a number of interesting apps now entering the market that provide such capabilities and Dossia would be wise to focus on these ISVs providing an added level of assistance to get them on-board quickly.


Walking into the briefing, expectations were quite low for what we might hear from Dossia. Their quiet, reclusive nature, lack of partners, and seemingly little progress being demonstrated to the market left one thinking that Dossia will fade over the next couple of years.  The briefing put many fears to rest.  Dossia is proceeding ahead at a careful measured pace and has accomplished much over the last year.  It is far too early to count them out.

But will Dossia ultimately succeed, will they be a force to be reckoned with will they become a key market influencer?

Still too early to tell.  The platform is stable, the API is there for third party ISVs and with Dossia representing over 8 million potential users (employees) this is a market nearly 3x the size of the most popular PHR today, that of Kaiser-Permanente – a very sizable and attractive market for most any ISV.  But without strong vocal support (marketing) by executives of its consortium members, Dossia will struggle to make its presence known, struggle to clearly articulate its value proposition and struggle to influence the market and subsequently drive market adoption among employers on behalf of their employees.

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Gave the Keynote presentation this morning at the Lab InfoTech Summit here in Las Vegas.  The organizer, Bruce Friedman, Professor Emeritus in Pathology at University of Michigan, asked me to update the audience on what is happening in the PHR market and more broadly, what are the implications, either implied or explicit are trends in PHRs to pathology labs.

Took me some time to think this one through, but finally a light-bulb went off in my head!  What are KP members most enthralled with in using the KP PHR – its getting their lab results quickly, online and with background information on what those results mean to take appropriate action(s).  Then, if one were to look at RHIOs & HIEs, what types of data are the first to move within these Exchanges, lab data and meds.  Stepping into ER, what does an ER doc most want to see when a patient presents in ER; labs, meds, and allergies.  The need to make lab data “liquid” was everywhere.

This “aha moment” led to the creation of a presentation, see below, that folds in our previous research on PHRs, more recent research on Cloud Computing in healthcare, some even more recent work on RHIOs and HIEs with what all this means to the lab market.

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wii-fitThe extremely popular Wii gaming system will begin connecting directly to health professionals in April.  It appears that this will be first offered in Japan combining the existing Wii Fit and Wii Balance devices with bi-directional online communication capabilities.  Moving beyond just providing the gaming devices and platform, Nintendo is partnering with NEC, Hitatci and Panasonic to provide a service whereby users of Wii Fit or Balance will be able to send their work-outs to “health professionals” and receive feedback, via email, regarding these workouts with suggestions (e.g. only 10 push-ups? do 20 next time).

Interesting concept but half-baked.  Sure, it may be nice to get some feedback on a given workout but is it really all that useful if you do not have any biometric data to go with it?  And what is a “health professional” anyway, a recent graduate of We Are Physical Therapy University?

We’ll have to wait and see what ultimately arises from this initial trial balloon.

In a broader sense, it really is a brilliant idea that may quickly move beyond the shores of Japan to North America.  We can readily foresee employers and payers adopting a Wii Health-type of service combining the Wii, with the bi-directional communication capabilities to health coaches and maybe even to a consumer’s PHR.  HealthString is one such PHR that has a heavy focus on health coaching and sells their product/services almost exclusively to employers. One can easily imagine an employer who offers HealthString to its employees combining their health coaching service and PHR with an incentive/rebate on the purchase of Wii Fit to foster healthy behaviors among its employees to improve overall population health.

Or maybe, again via a rebate program, an employer can set-up an internal team challenge using something like Limeade (another health solution targeting employers), combining their solutions with the bi-directional communication and logging of work-outs capabilities of Wii Fit to promote peer-based fitness.  Clearly, there are all sorts of permutations and scenarios of services that one can build upon with the Wii Fit and this future bi-directional communication capability.

Makes us wonder if Nintendo has had any discussions with the folks at HealthVault and their Connection Center.

Oops, HealthVault is owned by Microsoft with its competing Xbox.  Nintendo, better look to Google Health and Dossia, both would be receptive to their overtures.

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gh1Chilmark Research is furiously working on its next report that will take an in-depth look at the three major platform plays, Dossia, Google Health and Microsoft’s HealthVault.  Shaping up to be an excellent report (in our humble opinion) with a target release date of mid-December.

One of the challenges in writing this report is taking what is a fairly new concept in IT, “Cloud Computing” and even newer, “Platform as a Service” (PaaS) and convey its implications to the healthcare sector.   Hard to do in a space that is changing so fast.

We foresee that this trend holds a lot of promise for the healthcare sector greatly accelerating the use of HIT, across the continuum (consumers, physicians, caregivers, etc.) for the simple reason that it removes the burden of infrastructure (hardware & much software) support and will likely be a hell of a lot easier to use then many of the client-server systems of today.

But we digress.

In looking at the three platform plays, we have a section in the report that addresses their operating models.  While doing research on the subject we stumbled across an excellent analysis of Google’s strategy by Nick Carr.  This is the clearest, most cogent analysis we have seen and is spot-on.

If you are even remotely interested in Google, we highly recommend reading Carr’s piece.

After reading one will quickly realize exactly why Google may be able to offer Google Health free forgoing the need for sponsored ads or selling data (even if it’s anonymized) to third parties, both fears that are frequently bantered about in the healthcare sector.  These fears appear to be ill-informed and many times are simply fear mongering by those either wanting to make a name for themselves or simply do not want to give up the data.

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hvdevicelabelIn an interesting twist, Cleveland Clinic and Microsoft’s HealthVault Grp announced a partnership this morning to address chronic disease management. The interesting twist is that Cleveland Clinic was the showcase beta customer for Google Health, which was announced by Google’s CEO Eric Schmidt earlier this year at HIMSS. Like their counterpart in Boston, Beth Israel Deaconess Medical Center, who was part of the initial Google Health public roll-out in May and who has since also established a link to HealthVault for their PatientSite users, Cleveland Clinic is taking an agnostic approach to the major platform plays with this agreement.

The Cleveland Clinic-HealthVault announcement is distinctive in that it focuses on chronic disease management, via telehealth, through use of HealthVault’s unique Connection Center. With some 50 devices from 9 vendors, the Connection Center allows the consumer to upload device data (e.g., glucose readings, heart rate, blood pressure, weight, peak flow, etc.) directly to their HealthVault account. In the Cleveland Clinic project, which began last week (Nov. 3rd), uploaded biometric data from HealthVault compliant devices will automatically be pushed to Cleveland Clinic’s EMR and subsequently exposed to the physician for patient tracking and follow-up.

Had a call this morning with Microsoft and one this afternoon with Cleveland Clinic who both shared further details on this announcement:

A target of 460 Cleveland Clinic patients will participate representing three distinct disease categories; hypertension, diabetes and heart failure. The roll-out is across the Cleveland Clinic Integrated Delivery Network (IDN) and not just hospital patients. Clearly, they are focusing on the big chronic disease categories that result in huge costs that many believe better telehealth monitoring can mitigate.

  • Hypertension patients, of which there are 400, will measure blood pressure only.
  • Diabetes patients, of which there will be 30, will use five devices to measure glucose, blood pressure, peakflow, pedometer and weight.
  • Heart Failure patients, the remaining 30, will use four devices to measure blood pressure, peakflow, pedometer and weight.

Pilot will initially be for an extremely short 90 days. Cleveland Clinic expects to have all patients active within 4-6 weeks. Not sure what they can accomplish in 90 days, maybe Cleveland is just hedging their bets to see if patients actually comply with the prescribed measurement and upload regime. Assuming that all goes well, one can guarantee that this pilot will be extended for at least a year, if not longer, as that is the only way they will be able to provide some demonstrable results that are publishable (something that Microsoft emphasized) and ultimately may influence future legislation (e.g., CMS funding), health plan reimbursement (P4P), and broader adoption among other Integrated Delivery Networks (IDNs).

Devices are being provided for free to trial participants. The only requirement, beyond the obvious willingness to diligently take their measurements, is that they have a Windows-based (XP SP2) computer and broadband access. Unfortunately, many heart disease patients are among the elderly and it is questionable as to how many have this capability. Still, the point here is to demonstrate, not solve all the problems and it is a good start.

Cleveland Clinic is training patients on the use of the devices(s), and data upload process to HealthVault, that is subsequently pushed to Cleveland Clinic’s EMR. Part of that training includes clearly notifying the patient when a particular reading should prompt a call to their doctor or even 911. Along with providing the device(s) and training, the physician will prescribe to the patient their measurement protocol (e.g., 2x/day, 3x/week, etc.) unique to that individual and the condition they are managing. Patients trust their doctors so receiving the package directly from their physician during an office visit makes a lot of sense and should encourage use and hopefully compliance. It will be interesting to see how compliant patients are to the prescribed compliance regiment as this is often a critical stumbling block. Will incentives be required?

Cleveland Clinic put in the upfront effort to understand how best to incorporate this new data stream into a physician’s workflow to minimize the burden. Specifically, the physician will receive a weekly notice notifying them that their patient(s) biometric data is ready for review. One click later and the physician is in the EMR reviewing their patient’s data for that past week. Prior to this pilot, Cleveland has experimented with other telehealth systems, but none were able to provide this level of integration with the core EMR system (always a stand-alone, silo’d operation) and thus saw little adoption among physicians. This is absolutely critical! Having spoken to many physicians about the success, and most often failure of telehealth initiatives, it nearly always circles back to lack of true integration to existing practices/workflow. Looks like this pilot tackles that issue head-on.

So what is the Business Case?

Wrapped up my conversation with Cleveland Clinic’s CIO, Dr. Martin Harris, (thanks again Martin for your time) by asking him: So what is the business case for this initiative? He outlined two areas where they see a benefit to Cleveland Clinic:

Service Case: In moving to this model of combining telehealth with traditional in-office visits they intend to completely re-design the office visit resulting in a better, more engaged and customer friendly process. This process will lead to higher customer service ratings, customer recruitment and higher customer retention – all important top-line metrics. They also see a service case for the physician as such a “system” will allow the physician to deliver a higher level of proactive care with their patients. Its all about market differentiation, distinguishing themselves in an increasingly crowded market – one that will only get more competitive.

Outcomes Case: One of the objectives of the pilot is to see if Cleveland Clinic can consistently improve the outcomes/health of its chronic care patients that will result in fewer hospital readmissions and/or complications. If all goes as planned, Cleveland Clinic believes that it will be able to use these positive results to request better reimbursement schedules (more income) from health plans. This certainly makes logical sense, but to date, health plans and CMS have been reluctant to support such programs – more of a wait and see approach. Hopefully, Cleveland Clinic will start showing some impressive results in a year or so and get those health plans on-board.

Final Note:

A couple of weeks ago I poked Microsoft about their lack of support for the telehealth consortium, the Continua Alliance. Sean Nolan responded stating a primary reason was Microsoft’s desire to move quickly (consortia always seem to move at a snail’s pace). Looks like that has paid-off as Google Health and Dossia cannot, today, support such capabilities as demonstrated above, though they are on the path having joined the Continua Alliance and Google demonstrated modest capabilities at the recent Connected for Health Symposium.

Looking ahead, we forecast 2009 to be a year of pilots which begin to demonstrate the utility of the platform model (Dossia, Google Health, & HealthVault) in support of telehealth and how telehealth technology and practices are best integrated into existing clinician workflow. Look to 2010 to see actual reimbursement models and P4P programs begin to take shape in support of promotion and adoption of telehealth.

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One of the treats of this week’s Connected for Health Symposium was the opportunity to moderate a panel entitled: Personal Health Information Platforms and Records: What’s the Nitty-Gritty Situation on the Ground?

Obviously, I could not provide notes on this session while concurrently moderating it, but did find the following article at Healthcare IT News that provides some flavor as to what was discussed.

I began the session with broad questions targeted at all panelists and concluded my questioning with pointed questions to each of the participants. Following are the questions and their answers:

Google Health:

Ques: You currently only support a modified version of the CCR standard and do not allow for unstructured data in Google Health. Will you support other standards and unstructured data?

Ans: Yes, we do intend to support other standards including CCD in the near future. We are also building out the capabilities to support unstructured data.

Assessment: Good to hear that Google intends to support other standards and quite pleased to hear that they will be offering users the capability to store unstructured data (important for journaling, loading up advanced directives, etc.)


Ques: How will you support portability of the record should an employee leave their employer?

Ans: We intend to support portability of the employee’s record. As of today, we have not worked out a pricing model should an employee wish to maintain their data on Dossia.

Assessment: This is the same answer they gave me last year – obviously a back burner issue that Dossia has not spent much time on.


Ques: You are currently working with Dossia and now being rolled-out to Wal-mart employees. Do you intend to become a part of either the Google Health or HealthVault platforms?

Ans: We will become a part of these other platforms when there is a business case for doing so. (In other words: Only when a client asks us to do so and basically pays for it.)

Assessment: Seems logical and why commit to something that to date is still unproven and none of your large enterprise clients have asked for.

Microsoft HealthVault:

Ques: Recently, both Google Health and Dossia became members of the Continua Alliance supporting Continua’s open standard for medical device connectivity. Since biometrics is an important part of HealthVault (and its proprietary Connection Center), why are you not a supporting member of Continua?

Ans: Microsoft wanted to move faster then Continua to deliver a solution to market. We continue to follow what Continua is doing and will reconsider joining Continua at a later date.

Assessment: Yes, Microsoft is correct in that Continua has been moving slowly and understand that they may not have wanted to be hindered, after all, Microsoft now has over 50 devices that can feed data through Connection Center into an individual’s HealthVault account while Continua has yet to bring a single certified product to market.

That being said, Continua standard compliant products will start rolling into the market, en mass, in 2009. Continua gave a very impressive demo (at least for the audience as I was bored having seen similar device connectivity over ten years ago in the manufacturing space, but that is another story), including numerous devices, as well as an upload of device data directly into a Google Health account. Also, Continua is not expensive to join – it is only $5K/yr to become a “contributor” member, chump change for Microsoft.

Just can’t figure out why Microsoft won’t pony up a measly $5K to at least show support for the concept of Continua, unless of course they have every intention to make the Connection Center a lock-in solution. Do not believe this is Microsoft’s intent, but their position on Continua naturally raises suspicion as to their intentions. Hopefully, they will reconsider this stance and join Continua in the near future.

On another note – Microsoft did announce, while up thereon the panel that they have an iPhone app in the works that will be released shortly.  Can’t wait to see what that may be – stay tuned as we plan to dig deeper.

After my questioning I opened up questioning to the audience. The highlight was when someone asked when will we see interoperability between the platforms. This generated some lively discussion between Google and Microsoft with Google’s Jerry Lin finally saying to Microsoft’s Grad Conn that Google was ready when they are. To which Grad responded positively and said let’s talk after the session.

Don’t know what came of those discussions and regret not holding their feet to the fire in front of the audience and asking them when, specifically, will we see such interoperability. Guess that will have to wait for the next such opportunity.

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Bouncing from the Health 2.0 event last week to Connected for Health Symposium here in Boston, organized by Partners Healthcare, I’ll be reporting on some of the key presentations. Will also be moderating the afternoon session on the major platform plays, Dossia, Google Health, HealthVault and WebMD who is not exactly a platform but certainly the 800 lbs. gorilla in the PHR market.

8:15am, Keynote: MA Senator and former presidential nominee John Kerry has taken the stage. Kerry wastes n time in hitting McCain hard on his healthcare policies. Under current administration, healthcare premiums have gone up 78%, Starbucks spends more on healthcare than coffee, GM spends more on healthcare than steel. Not exactly the fault of the current administration, but Kerry wants to put it on their doorstep though it really needs to be put on the doorstep of all branches of government.

Kerry now talking about the lack of effort in promoting prevention. Reflected on his own cancer story, prostrate, which was caught early. “Healthcare system is overburdened due to the stupid choices we make.” We do not focus on prevention where the real savings are.

Kerry went on to claim that the recently passed legislation to promote adoption of eRx as the most significant healthcare legislation passed in recent history. Even mentions the good work of Newt Gingrich claiming he was instrumental in getting the eRx legislation through Congress.

Moving on to Q&A with Kerry. Asked about physician rating services. Believes it is necessary that accountability is needed in medicine and would like to see the medical profession do a better job of policing itself. Does not want to see the government step in to do this as they will not do it well. Sees healthcare as not under-regulated, just poorly regulated. Takes a shot at CMS claiming it is extremely opaque and not terribly effective. Lays partial blame on OMB, which sets a number of the rules. Does not want the government to take a heavy hand in regulating healthcare as he is concerned that this will stifle innovation.

Question: With the current economic crisis unfolding, will this put healthcare legislation and change via a new administration on the back-burner? Kerry: we are in a deep financial crisis that will led to the next president’s primary task being the establishment of confidence in the market. That must be addressed first before we can move to other important issues. Sees the need for government to invest directly in the economy, e.g., healthcare, infrastructure, etc.

Ques: How can government foster EMR adoption? Kerry rattles of some statistics on Partners’ HIT adoption. Kerry then goes on to give the bromide of we need interoperability.

Ques: How can we get some of the senators holding back HIT legislation to move forward? Kerry stated that security and privacy are a key issue that is hindering movement on this legislation but points to examples in other markets that privacy and security can be adequately addressed.

Kerry closed by expressing great frustration wit the OMB scoring of legislation process – a process by which proposed legislation is evaluated by OMB as to its potential impact. Kerry strongly stated that OMB looks at just costs but does not give a fair shake to potential savings.

Note: Kerry, with Gingrich and Billy Beane had an Op-Ed in the Sunday NYTimes.

8:45am Next up: Susannah Fox from Pew Charitable Trust: “Participatory Medicine” Starts off with a PR from 2001 where the AMA cautioned consumers from going online to get healthcare information. Obviously, consumers have ignored this AMA, protect our turf, statement. 12% of Internet users participate in online health communities and nearly 25% of those between ages of 18-39 use one of these communities.

Pew research has found that about one third of those who go online for health information have been helped in a significant way. Only about 3% have actually been harmed. Order of magnitude difference. There research has also found that the first line of information inquiry by a consumer is a physician (roughly 80%).

Argues that healthcare is stuck in the broadcast world – information targeted at you and not include you is a dated model that healthcare sector is still using and will not work in the future. Consumers will look elsewhere to the risk of healthcare incumbents. Encourages the healthcare sector to open up and share information more aggressively, actively engaging the consumer. Get the consumers to participate, not just observe.

Pew breaks out population by: Elite tech users (31%), mid-range (20%) and low tech (49%). Online cancer forums are 96% white and over 75% with a college education (UNC study). Argues Web 2.0 is not being used by the vast majority o Americans today (clearly, if those stats are to be believed). Engaging the low tech community (particularly Latinos and African Americans) are highly connected via their cell phones. mHealth is where it is at to engage these communities.

Her seven word challenge/closing:

Recruit Doctors, Let e-Patients Lead, Go Mobile

Do not listen to AMA from 2001, do not take a closed aproach and do not end up in the same boat that the recording industry was left in when consumers went online for music. Get out there and actively engage consumers wth regards to their health. Make it participatory medicine.

10:00am Panel Session on Primary Care and Coordinating Chronic Care: Panelists include George Chadraoui, IBM Healthcare Benefits Leader, David Hom, formerly of Pitney Bowes (he played a leading role getting Pitnet Bowes to sign on to Dossia), Edwina Rogers, Dir. Patient0centered Primary Care Collaborative and Vince Kuratis, of Better Health Technologies and blogger – e-CareManagement.

Main focus seems to be on the concept o the “Medical Home” Rogers sees a very large growth opportuntiy fr “disease management” companies to tap into the Medical Home concept delivering services to primary care physicians to enable them to do better chronic care mgmt. Hom, sees 24/7 telemedicine coupled to incentives and the PCP (primary care physicians). to make this all work. Unfortunately, what Hom is seeing today is proliferation of a multitude of messages being sent to the consumer and simply overwhelming and confusing them. Vince makes an astute observation that CMS (Medicare) is putting the onus on the PCP for chronic care mgmt whereas in the broader market health plans are delivering /handling much of the load.

Medicare is looking at reimbursement models of $30 to over $100 chronic care mgmt. Rogers sees this as providing some significant funding to chronic care mgmt concepts and innovators. Hom counters that there is still high degree of fragmentation, most often created by health plans. Hom sees PHRs as having the potential to bridge many of the gaps and fragmentation today. But Hom goes on to state that the proliferation of solutions arriving in the market is making the decision process as to what solution to chose far more difficult which may stunt overall adoption.

Issue raised, the continuing and growing problem of shortage of PCPs to actually implement the medical home concept. Rogers comments that if we can realign incentives and make it worthwhile for med students to pursue a PCP occupation, we will not have a shortage.

11:00am Panel on Wireless and Mobile Services for Connected Health: Check the agenda at the Symposium website for panelists (Verizon, Qualcomm, WellDoc and Sensei represented). How is the iPhone & smart phone technology facilitate care. 200M iPhone apps have been downloaded to date, per Jobs Q3 call last week. Represents nearly $1M/day in spend on iPhone apps. Cell phones tend to be very personal, portable devices that have become extremely pervasive. Cell phone operators are finding that children’s use of SMS is forcing parents/older generation t use this technology.

Interesting question by the moderator: When will large sophisticated health organizations such as Partners will automatically update your PHR via a cell phone/wireless when you pay a visit to a Partners’ physician. One respondent, the financial services industry is moving forward on this type of concept, but the healthcare industry is not. That being said, healthcare has many of the similar concerns as the financial market. Another counters that we need to walk before we can run and unlike financial sector, healthcare is very fragmented and HIT adoption is likewise fragmented at the physician practice level.

Sure is and market forces may start to push the envelop, though it will be excruciatingly slow, thus most likely to occur outside of the traditional healthcare sector/practice and bubble up via consumers just moving ahead leaving many physicians behind. Believe this was also the message that Susannah Fox was trying to convey to this audience.

Panelist just confirmed what I put in italics above.

Metric: $100B/yr in revenue generated worldwide for cell phone operators from SMS/texting.

The business model or mHealth: A value proposition needs to be created for the consumer that will actively engage them. Needs to be a highly personalized interaction thus needs strong intelligence to identify what is imortant to a given user and delivering only what is of interest to that specific consumer. SPAM, adverts, etc. will not work on a mobile device – something that consumers will not tolerate. Regarding the scaling of mHealth, one panelists sees Wal-Mart, India and new health gaming-type apps as driving future growth. Another panelist encouraged developers to go directly after payers, they are the ones with deep pockets and need (No Duh!).

Keep waiting for something interesting, nothing out of this panel, just more substantiation of what has been said before in other venues. But hey, I’ll cut them some slack as maybe for this audience its all new.

2:15pm, Panel Session, VCs Talk About Who will Make $$$ in Connected Health & Why: Pack house for this session, standing room only.

In New England region about 20 investor (angel) groups. They meet monthly to consider investment options. They are finding that the VCs have really pulled back on investing in the last month or so. Encouraging companies to have a Plan A & B Plan A we come out of the financial crisis in a year or so. Plan B, financial crisis and tight credit markets continue for 2-3 years. Finding it very difficult for new start-ups to get money, slightly easier to get $$$ to scale-up.

VCs looking for cash efficient companies and models that will quickly get them to cash-flow positive in a far shorter period of time than in the past. Contraction – looking to place fewer rounds in any given entity. Nationally, VCs raised $30B in capital in 2007, for ’08 looking at $20B and for ’09 roughly $16B (half of what was available in ’07). Project high mortality rate for many existing VCs. Advising companies that they need to significantly decrease burn rate to survive the next 12-18 months. There will be very little new money to go around. Don’t over-engineer the product, focus on only those features that are absolutely needed for a product to gain traction.

Start-ups need not show near-term profitability but do need to articulate a clear commercialization model that shows a path to break-even in 3-4 years. So it is not so much an issue of profitability now, but demonstrating a good model to get you there.

Warning, next 12-24 months will be very hostile.

Business models that seem to be working…

Recurring revenue models focused on a B2B2C model. The B2C model is not attractive to VCs. This is not unlike what I observed and commented upon last week at the Health 2.0 event.

One of the VCs is seeing too many companies that say: “Hey we have a great product/service for payers, providers, employers, etc.” This actually turns this VC guy off as he is looking for companies that demonstrate focus and are not trying to tackle numerous markets and subsequently, trying to develop numerous channels. Just won’t get to profitability fast enouh in his tight credit market.

Big problem for VC firms today is liquidity in the market to provide them an exit strategy. Right now, VCs have very few exit options which severely constrains their model and thus cascades into their ability to fund new ideas/strat-ups. About the only exit strategy today is mergers or acquisitions.

None of the VCs on ths panel are terribly interested in Health 2.0 apps. More interested in new diagnostics that can be used by small practices and remote monitoring/sensor apps. See good opportunities here. Another is also looking at genetic testing, genomics & personalized medicine.

5:45pm Continua Alliance Demonstration: Currently, they are running through all the various companies that are a part of the demo, a literal who’s who including IBM, Oracle, Google Health (they along with Dossia recently signed on to Continua, Microsoft HealthVault is now the odd man out here), a number of mostly small device vendors with exception of Philips who will demo their new Mtiva platform for remote chronic care monitoring.

First demo has an “elderly woman”, Natasha, taking simple vital sign measurements. Very simplistic GUI. Next, a remote caregiver, using Motiva, clearly shows Natasha’s trending data for evaluation. Caregiver sees a disturbing trend (weight gain) and pushes data to a physician. Physician now takes the stage, logs in and sees a new report has arrived (Natasha’s) for review. Shows simple data fields in columns – surprisingly does not appear to demonstrate any analytic capabilities to pick out what may be outliers in the data set to quickly flag data/areas of concern. Yes, this may not b an area that Continua is focused on – they focus on remote device data interoperability. Still would expect more in such a demo. Odd.

Demo 2 has a consumer with type 2 diabetes and obesity. He takes various vital measurements (weight, glucose), records them and data is automatically pushed to caregiver. Caregiver reviews data and using Continua format (its a combination of IHE & HL7 CCD standards), pushes data to the consumer dietitian and the consumer’s Google Health account (hmm, Google doesn’t support CCD yet, so how did they do that?)

Both pretty simplistic demos that came across as more of a stage for all the various Continua Alliance partners than really doing something interesting. Continua is now about 2 years old so they have made some good progress on device interoperability and I’m sure there will be more interesting applications next year.

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In what seems like ages since the first announcement of the formation of Dossia, the third platform play for personal health information (the other two being Google Health and Microsoft HealthVault), Dossia has moved from a an extremely limited pilot of ~20 Wal-Mart employees (guinea pigs) to now become a part of Wal-Mart’s 2009 health benefits package for all employees. Employees will be provided a personal WebMD PHR with WebMD sitting on top of the Dossia utility data service. Wal-Mart issued a tepid PR yesterday announcing a number of health & wellnesses programs for their employees with the Dossia announcement showing up at the bottom of the list.

Dossia issued its own announcement (caution PDF), but again, thin on the details.

Today’s Health Data Management article does contain the most complete information I have found as they did talk directly to Dossia CEO, Colin Evans about the Wal-Mart roll-out.

Looking over this material, a few questions immediately come to mind:

Is the data in the PHR fully portable should I leave Wal-Mart? If yes, how would I go about exporting it to say a Google Health account?

If I leave Wal-Mart, can I still maintain my Dossia/Wal-Mart PHR? If yes, is there a cost to maintain the service?

What access will my employer have to the PHR? How is my privacy assured? What safeguards are in place?

Why only Wal-Mart, after all there are several more employers involved with Dossia? When will the other employer sponsors roll-out a Dossia/PHR service to their employees? What really puzzles me here is that Wal-Mart is rolling this out before Intel, one of the original founders (Wal-Mart came later). Intel has been a very strong and vocal proponent and actually has a number of Intel staffers on loan to Dossia, including Colin Evans. Logically, I would have predicted Intel to be the first to provide a Dossia service to their employees.

The big $100,000. question though is:

Can Dossia move fast enough to create a compelling platform that delivers sufficient value to the rest of the consortium members (and future members)?

Since its initial announcement in late 2006, it has taken Dossia nearly 2 years to get to this point and from what I have read, about the only difference between Dossia and a health plan-sponsored PHR is that with Dossia, employees get portability of their claims and medication data if they should switch heath plans. (Note: health plans claim they can now do this via the AHIP tech standards released last summer, but to date, none have actually done it.) Beyond that though, don’t see much else and this is after nearly two years of development. Granted they did have a false start with Omnimedix, but still this seems like an awfully long time to deliver such basic functionality.

Which leads to a broader question:

Will Dossia be sustainable?

Dossia was announced nearly a year before HealthVault. Back then, this was new, this was novel. Now, it looks like an also ran. With payers beginning to show a willingness to allow a member to export claims data to either HealthVault or Google Health, thereby giving them complete control over the record without potential for any employer interference, what added value does Dossia bring? Will an employee be willing to pay the small subscription fee for a PHR like CapMed, Medikeeper, Medem or NoMoreClipboard, which can be found on Google Health or HealthVault rather than going with the one their employer is offering that sits atop Dossia?

Right now, in its current version, Dossia isn’t offering much to differentiate itself in the market. That’s not to say they can’t, nor that they will not be sustainable. They have an excellent platform in Indivo Health, and they have some excellent personnel on-board, but they are going to have to hit the after-burners to be more competitive and provide a more compelling value proposition (offering/ecosystem) to their consortium members and ultimately consortium employees. If the value proposition is indeed compelling, only then will Dossia begin to create a self-sustaining, virtuous cycle that will lead to more consortium members and subsequently more software developers/vendor offerings within Dossia that further enrich the ecosystem.

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Last week, the Robert Wood Johnson Foundation (RWJ) hosted a one day event in Washington DC. Purpose of the event was to showcase the nine PHR-type solutions that have been developed under the multi-year, $5M Project HealthDesign (PHD) umbrella. Seven projects were funded at academic institutions the other two, beltway bandit consulting firms.

Though I was unable to attend due to previous commitments, here is what I have been able to put together based on my conversations with several who did attend and my knowledge of PHD and the projects supported.

  • Over 200 in attendance with strong representation from policy folks (after all it was held in DC), institutions that were being funded, advocacy groups (again, mostly those from DC area), some health plan reps and an ever so small smattering of business entities, i.e., those who are already developing or offer a PHR solutions today.
  • Wide ranging agenda that had a Who’s Who of policy folks (e.g., Karen Bell of HHS, Carol Diamond of Markle and of course several from RWJ), Amy Tenderich of DiabetesMine (she did her own post on the event), and of course the researchers who presented their concepts/prototypes. There was also a panel on the platform plays with representatives from Dossia, Google & Microsoft. (Note: I’ll be moderating a similar panel at the end of October at the Connected for Health Symposium.)
  • Good discussions and novel approach to providing demonstrations of the PHR prototypes. Demonstration consisted of a slick video (professionally done with actors, scripts, common props (the PHR/PDA-like, hand-held device, etc.) produced by RWJ for each of the nine projects. You’ll find them here.
  • Provided a good opportunity to network with a certain segment of the industry, policy wonks, advocacy reps and academic researchers.
  • Some interesting concepts and prototypes presented of what may be possible in the future. Many of the researchers spent significant time working directly with consumers, observing how they manage their health today as part of the development process, which was followed by a design process that focused strongly on usability. (Many PHR vendors today could learn a thing or two here!)

Assessment from afar

From this vantage point, here is my assessment of PHD to date.

  • When initially conceived, in late 2005/early 2006, probably looked like a great idea with PHD leadership thinking along the lines of: “let’s sponsor some innovative ideas/technology around the concept of enabling consumers to more effectively manage their health that goes beyond a simple, static health record account (PHR).” But a lot has happened in the intervening years and now the results of this funding appears more quaint than thought-provoking.
  • RWJ’s underlying mantra for PHD is:

It’s not the record…

It’s what you do with it!

Couldn’t agree more. As I wrote recently when profiling the new CapMed notification feature. Static PHRs are dead in the water.

  • Choosing to go solely with academic researchers and beltway bandits without any conditions for commercialization was a huge blunder. Yes, I know the whole argument for letting researchers think out of the box in the creation of new solutions, but let’s bring at least a modicum of reality to the table. Having worked in academia with arguably the top university when it comes to commercialization of research, MIT, I know personally just how tough an issue this is and how many great ideas end up on the shelf (yes, even at an esteemed institution such as MIT). It appears that RWJ’s PHD and those it has funded have no plans to commercialize any of this work. Spoke to one businessman in attendance who actually approached some of the researchers and ask about commercialization – each and everyone gave him blank stares. Really a shame.
  • PHD has also funded development of an open platform. This began awhile back when they published “functional requirements for PHRs” which ironically, was the same terminology that HL7 was using and announced at roughly the same time, so here was one small confusing step made, at least confusing for me making me wonder if they RWJ was out-of-touch. Now they created a Common Platform construct that is quite familiar to another “Open” platform, that from Children’s Hospital in Boston, Indivo Health. Indivo Health has been around for several years also will be the underlying technology for the employer-led consortium Dossia.

This all leads me to thinking. What is PHD (and more broadly RWJ) trying to do that is truly different and will move the industry forward and ultimately enable consumers to more actively participate and manage their health? When I sum it all up, I do not get much more than bringing more visibility to the consumer on the concept of self-care management.

Which leads me to the follow-on question: was this the best use of that $5M?

Maybe yes, maybe no.

Yes, in that when they started this initiative, RWJ was looking to expand the concept of what a PHR is and what it might be capable of. From their vantage point, PHD may have appeared to be striking out in a whole new way as to how a consumer may leverage IT to better manage their health. And of course, there is the publicity angle. Getting the word out and educating consumers about what may be possible is indeed needed and this initiative by RWJ has generated pockets of publicity.

However, I lean more towards no. Their decision to go almost solely with academics and consultants resulted in a program that appears out of touch with what is occurring in the market. Numerous examples support this including: the slight mis-step with the Functional Model announcement, funding the development of an open platform when one already exists (see Indivo Health), and supporting development of apps without any discussion of what is the business case (i.e., is there commercialization potential). Let it be known, I have no beef with academic researchers and am actually a very strong supporter of academic research, but I lean more towards supporting basic research, not applied. In this case it was even worse, supporting applied research without a technology transfer strategy. As mentioned previously, this may have been purposeful to encourage out-of-box thinking, but I find this most often results in nothing more than mental gymnastics if you do not attach fundamental market principles to the process. Unfortunately, the results of mental gymnastics almost always end up on the shelf, not in the market.


RWJ receives a round of applause for bringing together some of the leaders, albeit more from non-profits than for profits, to discuss how consumers may leverage such IT tools in near future to better manage their health. Their support has resulted in some very good work (some of those demos are excellent and I really liked the Sujansky & Associates Report – PHD Platforms and Standards Analysis) and trust more is forthcoming. In the future, however, I do hope that RWJ looks more broadly soliciting greater involvement of those directly in the business of creating new and novel consumer-facing healthcare apps. Such involvement in RWJ’s deliberations and programs will result in even more fruitful research with even greater impact.

And is that not what we all are striving for?

For views from others who attended the event see:

Post by RWJ

Post by Vince Kuratis, moderator of the platform panel session

Amy’s post – she gave the luncheon keynote

Ted Etyan’s views (slim content with pictures)

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