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HarpoonLogo2CDue to a tremendous workload at Chilmark Research, creating cogent, free content is expensive, at least to us.  Therefore, to provide value to you dear reader without taxing our synapses to the breaking point this post will give you a few highlights from te week that caught our attention.

How much is too much?

The recommendations for meaningful use paid a fair amount of attention to the issue of consumer/patient access to their medical records.  The big question, however, is just how much access is appropriate?  Does one let the consumer see absolutely everything within the record including all notes despite how esoteric they may be, challenging to understand and potential for mis-interpretation?  For some perspective:

A very thoughtful, extremely funny and intelligent physician who goes by the twitter handle of @doc-rob wrote about his own practice’s deliberations on the subject and the comments are just as insightful as his.

The Boston Globe had an article in today’s edition on Beth Israel’s decision to let their customers/patients have full access to the complete record.

And the Wall Street Journal’s own Health Care Blog also drew attention to the Boston Globe article with again, some great comments.

Outside of mental health, where there are some extremely valid reasons for not sharing clinician notes, the consumer should indeed have full access for as we have seen in countless other industry sectors, information liberation solves far more problems that it creates.

CCHIT looking to become contortionist?

This week, CCHIT’s Mark Leavitt hosted two townhall meetings to present changes that CCHIT is considering in its certification process.  Prompting these changes is CCHIT’s clear desire to be the go-to certification entity for all “certified EHRs” which is the only technology that will receive reimburse under the HITECH Act.  Going through the slidedeck our quick conclusion was that CCHIT is bending over backwards to try and address concerns in the market about their certification process.

What Chilmark likes about the proposed changes:

A three tiered process that acknowledges different technologies and architectures for EHRs (e.g. modular apps and roll-your-own) that fall outside of the common EMR vendor model upon which CCHIT was founded.

A pricing model that is fair and reasonable.

What Chilmark is not so crazy about:

Like anything, the devil is always in the details and what CCHIT presented is still pretty thin on details.  At first glance, we see a growing complexity in the certification process as often times, software does not abide by strict boundaries.  This is especially true from EMR-Comprehensive vs. EMR-Modular.

Not convinced that CCHIT has the resources available to keep up with technology developments and changes to insure innovative products reach the market quickly.  More complexity is typically a time sink of major proportions.

The HIPAA and EMR blog’s author, John did sit in on both CCHIT townhall meetings and has a good write-up/analysis that is worth the read.

Mark Leavitt also wrote a piece for California Health Care Foundation’s iHealthBeat providing his perspective on the monumental changes coming to healthcare and of course the great role his organization plans to serve in those changes.  My advice to Mark, don’t count your chickens before they hatch.

Get a Life

Last Friday, the Pew Charitable Trust released their latest study on consumer use of the Internet for health.  Chilmark has a lot of respect for their work which is always thoughtful, well-reasoned, applies good methodology and results always have a few surprises.  Unfortunately, have yet to read the full report, only the post that the lead reseacher, Suzannah Fox, wrote on the report.  Do know this though, if you are even remotely interested in understanding how the public is using the Internet to address their health issues and also want to understand underlying demographic differences, just go read the report.  I’ll be doing that myself on Sunday as I recover from the infamous Harpoon Brewery to Brewery ride tomorrow.

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Just dropped by the iPhone AppStore to see if any new health & wellness applications have been added to the site since the post I did on July 23rd.

Imagine my surprise in seeing some 64 separate iPhone apps – a doubling of the number of apps in 2 short weeks.

Now the question is: Will we see continued exponential growth and if so, for how long?  Or will it quickly plateau once it reaches a critical mass of the main apps consumers seek?

One thing is for sure, if it continues at this rate, Apple will have to re-categorize apps to make them easier to find and select.

The coolest app I saw today BTW was Stride, an app that leverages the accelerometers in the iPhone (they are mainly used for gaming) to turn the iPhone into a pedometer. Slick

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There has been a tremendous amount of buzz regarding the latest iPhone release with most of the attention focusing on the 3G and GPS capabilities of the new iPhone. But one of the biggest features may turn out to be the AppStore, providing you health specific apps to take with you on your iPhone.

The AppStore leverages Apple’s existing iTunes and similar to selecting and downloading music, the AppStore allows one to select from some 800 or so applications to download to their iPhone. Most applications are free and probably 95% cost less than $10. When one clicks on an App icon a brief description of the application is provided along with screen shots highlighting features of the app. Along with the description, there is also a “star” rating system with user reviews.

In addition to games, business apps, restaurant guides and the like, as of today there are 32 apps dedicated to health. About a third of the apps are for nutrition, diet and weight. Another third are dedicated to fitness. The remaining apps are split between PHR-light apps (ICE-type apps of which there were 3) a real, mobile PHR platform called MyLifeRecord (a personal version for $10 or a family version for $50), 3 apps targeting physicians, including iChart EMR from CareTools which was the most expensive app at $140. and the popular Epocrates. Another interesting app for the physician was MIM for medical imaging – looked pretty slick. Surprisingly, did not find the A.D.A.M. app at the store nor anything from Dr. Jay Parkinson’s new company Myca, despite his well-known use of the iPhone. (Note, it does appear that an iPhone app, HelloHealth is forthcoming from Myca).

Nice start but what I would like to see in the future are:

  • An app that provides the ability to locate a highly rated physician in close proximity to me and make an appointment if something comes up while on travel. Something like ZocDoc, but with countrywide coverage.
  • A medication reminder telling me which medication I may need to take at a certain time of day.
  • Universal, biometric reading and charting app pulling data from virtually any biometric device, via Bluetooth, loading, it up to the iPhone and a hosted app. Currently there is one for glucose monitoring, but would like to see a single platform for numerous measurement types.
  • Tie in my Garmin 305, which I use for my cycling training, with other apps like MapMyRide or training software such as TrainingPeaks.
  • Enable an e-Consult or second opinion through a service like American Well.

Obviously, I could go on and on and I’m sure you have ideas of your own. Better yet, why not put an idea or two down in the comments field at the end of this post.

Ramifications:
While we talk of consumer-facing HIT solutions e.g., PHRs, and Personal Health Systems (PHSs), these are virtually all tied to a computer, be it desktop or laptop. Having a BlackBerry myself, which handles email brilliantly, its ability to allow me to easily navigate the web is abysmal and I would never use it to access my hosted PHR or perform most of the wish list tasks above.

The iPhone was built for the Web and the graphics display is impressive. Combining its ability to easily access and navigate the Web and present information (or take in user generated info) in a tight, portable package has the potential to liberate a PHR and for that matter any number of health and wellness apps to travel with the consumer.

Sure, there are already some biometric devices that, via Bluetooth, can transmit data to a repository for later viewing and tracking. And yes, there are some PHR applications that provide rudimentary access via a cell phone or smart phone. The iPhone, however takes all of this to a new level that I have yet to see on any other platform and that AppStore makes it extremely easy to find and choose an app that is most appropriate to your needs (where else will you find PHR type applications listed with actual user reviews?)

Health does not take place in the hospital or in your doctor’s office. It occurs every moment of the day, in the foods you choose to eat, the biometric device you may be using to monitor some aspect of your health or that exercise regime that you are just beginning. Health goes where you go, this is why the future of consumer-driven health will increasingly rely on mobile technologies like the iPhone coupled with apps designed for such a platform. This is what I refer to as the 4th generation of Personal Health Apps, which includes PHRs: apps that are highly personal, always with you, providing actionable information when needed or as programmed.

What remains to be seen is how will the iPhone and the health apps delivered therein become a part of the broad ecosystem plays of Dossia, Google and Microsoft. Really should not be too big a bridge to cross as all of these ecosystems are supporting various Open Standards and putting the consumer firmly in control of their data, its only a matter of connecting the dots.

While I projected in a recent presentation to AHIC that the 4th generation mentioned above is still several years away, it looks like I may have to refine that projection as this train appears to be moving faster than I originally thought.

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As you know, I commute by bike to work. Been doing this for some 20+ years despite Boston ranking as one of the least bike friendly cities (according to Bicycle magazine) in the country.

Yesterday, one of the Boston Globe columnist wrote a piece on her own cycling experiences in and around Boston. I actually ride frequently in the town of Milton which she references and unfortunately know the two riders that were hit (I’ve raced against them, they are both excellent, very experienced riders). While the article is a reasonable one for the average Globe reader, what shocked me in reading it today was the huge number of reader comments to the article, which now number over 370.

Clearly, as more cyclist take to the road to do their part for the environment, or improve their health or just save money (gas averages $4.00/gal in Boston) we are seeing a growing tension between those on the road in cars and those on bikes. No easy resolution on this one as a quick scan of the comments showed more ignorance on the part of drivers as to bicycling in general and more specifically, bike commuting. Maybe it is time for some PSAs (public service announcements) to educate both sides.

In full disclosure, here are my own cycling/commuting habits:

  • I will roll through red lights after stopping and making sure there are no approaching cars. This happens about 30% of the time, the other 70% I wait for the light to turn green.
  • At a light, I will ride up to the front if it is red to get in good position when the light turns green. I’ll typically do a quick sprint start to get across the intersection and in front of the traffic behind me. The main reason I do this is to get out in front of cars when they are starting off to insure that they see me. It is also to insure that I don’t get hit by some car turning right who has not signaled (yes, this has happened to me).
  • I do signal when I am turning, though less so when turning right as compared to turning left.
  • I virtually never ride in the wrong direction down a one-way street.
  • I do “take a lane” in rotaries as I want to insure that I am clearly visible to drivers. I also go extremely quick though rotaries (typically 25mph+) so as not to be an impediment to traffic.
  • I ride about 3 ft out from parked cars. I have been “doored” twice. It hurts and I don’t want to experience it again. Sometimes on the narrow streets of Boston drivers get upset with me as this 3 ft rule results in me taking a lane but when an opportunity opens up (e.g., no parked cars 30 yds or more) I pull right over.
  • I don’t ride on MUT (multi-use trails) and most bike paths (they usually become MUTs anyway) as they are simply too dangerous with people on roller blades, folks walking their dogs on retractable leashes, (which always seem stretched to the limit), Moms with strollers and barely walking toddlers, etc. etc. Its the road for me.
  • I always wear a helmet. I’ve cracked three due to crashes.

If you ride, be safe out there and use all of your senses to be aware of your surroundings (people riding on city streets with iPods plugged in their ears are idiots). If you are new to commuting, in time you will develop almost a 6th sense. Use it, it will keep you out of a lot of trouble down the road.

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Vince, over on his e-Care Management blog has a good post up today where he compares the respective consumer healthcare platforms from Microsoft (HealthVault) and Google Health.  Bottom line for Vince is that there are more similarities than differences between these two initiatives and that consumer engagement will be their collective top challenge.

Certainly agree with him on that last point.  In conversations I have had with many friends, family and associates outside of the healthcare industry, virtually everyone sees the utility of having control and access to their medical records via the Internet, but almost without exception, no one really knows how to get started.

To their credit, the AHIMA has launched a major campaign to educate the consumer on PHRs, but it will take a lot more than this to move up the adoption curve beyond early innovators.

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Though Google announced the formal unveiling of their PHR last week, via the deal with Cleveland Clinic, today was the true coming out event when Google CEO Eric Schmidt formally introduced Google Health to the throngs at HIMSS during his keynote.

Google Health

Based on the demo I received at HIMSS, conversations I have had and comments Schmidt made during his presentation here’s what we are looking at.

What it is…

  • A basic PHR that relies heavily on Google’s core competency, search, to provide unique features rarely found in other PHRs.
  • Search features include finding a doctor that begins with a pull-down pick list of specialists to choose from, and of course the obvious ability to search on conditions, diseases, medications, etc.
  • Delivers that wonderful, clean user interface that Google is known for. Just can’t understand why others in this market (are you listening WebMD and RevolutionHealth) feel compelled to bombard us with such messy, confusing, mind-numbing user experiences. Get a clue.
  • Auto-complete feature when entering your medications. This also includes an intelligent agent running in the background that will automatically notify you if there are any possible adverse drug interactions.
  • Service is offered free to the consumer and will not be ad supported. Google is looking to simply drive traffic and does not want to risk the wrath of privacy advocates if it went down that slippery slope of targeted ads based on your health profile.
  • Cleveland Clinic trial is with approximately 1370 consumers.
  • Expect broader, public roll-out in 6-12 weeks, unless of course they run into some major problems at Cleveland.

What it is not…

  • It is not a utility service like Microsoft’s HealthVault or the employer-led Dossia initiative. This is a full-fledge PHR, or at least the beginnings of one.
  • It is not a best-in-class full-featured PHR. In its current form, Google Health is pretty simplistic. Sure, there are some nice search features and they do have a very talented team so I’m sure will see more, but in its current state, it provides far less functionality than other solutions currently in the market.
  • It is not a secure communication platform as it does not provide any means of secure communication between a consumer and their physician. An important feature that consumers want and increasingly physicians as both Aetna and Cigna have agreed to reimburse physicians for e-Consults.
  • It is not ready for the overseas markets. Schmidt stated that they are focused on the US market today as a number of key overseas markets health programs are government run. This creates regulatory hurdles that will take time to overcome.

Final Analysis

Good first steps by Google Health, but they are just that, first steps. The solution is thin, both in breadth and depth, though I am confident that will see a pretty rapid succession of features being rolled-out over the course of the year.

There are some significant challenges ahead, chief among them developing the mechanisms (APIs) to allow the ready exchange of clinical, claims, lab results, etc., between a consumer’s PHR on Google Health and their care providers. Today, the Google solution is far too dependent on the consumer to fill-out the PHR, which even with the search and auto-fill features is still too cumbersome for the vast majority of consumers.

Google is fully aware of this and the trial with Cleveland Clinic is to test the ability to securely transfer a consumer’s record and automatically populate a Google Health account. Problem is, Cleveland Clinic is but one hospital system, running one type of EMR, Epic. What about all those other hospitals running competing EMR solutions from Cerner, GE, Eclipsys and the list goes on? Does Google plan to develop APIs for each of them? And who will pay for all this development work? When I asked one of the Google representatives at HIMSS about this, he clearly understood the problem, shrugged his shoulders and said something to the effect of: We plan to develop an open API for others to adopt and use to connect into Google Health. Hmmm, not much of an answer there.

Google is not alone here as most PHR vendors are struggling with this issue as well. Microsoft is one of them. When I met with Microsoft they actually told me that they would love for Google to start using the tools which they recently released to the development community so together they would have greater clout. For obvious reasons, Google is not likely take Microsoft up on their offer.

When behemoths like Google and Microsoft enter a market, it brings a lot of visibility and interest, which in-turn brings visibility to numerous smaller players as well. It also raises expectations. Subsequently, the stronger, niche PHR companies that provide something unique will see a nice bump-up in interest and sales. Unfortunately, the vast majority of PHR companies (including some of the biggest ones) do not have such differentiation and will become increasingly irrelevant.

And if you want the official spin from Google, here is the post from Marissa Mayer of Google which went up on their site this morning.

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Looks like payola in the healthcare sector extends beyond pharma. Late yesterday, the Wall Street Journal health blog posted an article on consultant fees paid by implant manufacturers. In a settlement agreement with the government, leading implant manufacturers (Zimmer, J&J, Smith & Nephew, Biomet and Stryker) agreed to post on-line, fees they have paid to consultants (orthopedic surgeons) with some of those fees exceeding $1M for over 40 of those “consultants.” Now that is an impressive kick-back that I don’t think any DJs saw during the height of the payola scheme in the early ’60’s.

So what is the healthcare IT (HIT) angle on this you ask?

Information such as this will be quite beneficial to employers, payers and consumers, who actually pay for these surgeries and may begin taking into account such consultant fees when they consider provider choices. Thus, it is quite easy to imagine such information being re-purposed in the future to populate on-line, doctor search and referral or personal health record (PHR) services such as Xoova, Medem, Zebra Health to name a few.

or even Just another step along the long, long path to transparency in this industry.

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