Last week, I continued my round the world itinerary visiting customers, partners, and governmental agencies.  I took an overnight flight from London to Bangkok on a Saturday—the plane was full, primarily of tourists taking advantage of what Thailand has to offer, despite the political turmoil.  My day started with a random act of kindness—receiving a text message from someone who picked up documents I left on the train to London and offering to send them to me—remarkable!  What many folks don’t recognize when looking at maps is how large, spread out and diverse Asia Pacific is.  After arriving early Sunday morning, I caught up with my team on the ground, many of whom just came from Arab Health—a huge HIT conference.  I then spent Monday in Bangkok with customers, Tuesday in Kuala Lumpur departing on an overnight flight to Sydney, and Wednesday to Friday in Sydney departing on an overnight/day flight to U.S. for a brief, but important meeting in Scottsdale, AZ on Friday afternoon before the last leg getting home to Seattle that evening.  Amazingly throughout the 13 days, there were no big logistical problems (no lost bags, no delays over an hour, no lines over 30 minutes)—made it much easier to survive! 

Here are a few of my observations from Asia Pacific—with more specifics this week to provide context:

Monday morning started with a visit to a large public hospital in Bangkok.  They are at the same time very sophisticated from a diagnostic/therapeutic perspective (research lab, surgery center) and very antiquated from a work process perspective.  They see a huge number of patients—both with appointments and not.  Their “system” is primarily paper-based—the amount of forms and paper they have is overwhelming.  Their whole system is based on queues—throughout the hospital, there are people waiting and standing in line.  To get a pharmacy or lab item, a patient might go through three separate queues or tellers with an indeterminate wait time at each—identify/submit order, make payment, and draw or receive lab or Rx.  I was struck by the incredible opportunity for the use of technology to improve the entire system—in terms of throughput and satisfaction, and ultimately patient care.  Hospital management also sees the need and the opportunity— to invest in the information infrastructure as they have invested in the medical equipment infrastructure—but the implementation task seems daunting to all.

I spent the afternoon at Bumrungrad Hospital in Thailand where I have a development organization and key strategic partner.  Bumrungrad is an amazing example of excellence—using technology to support clear outcomes—quality, efficiency, and customer satisfaction.  Each time I’m there, they show me advances in infrastructure, workflow processes and facilities.  It is great to have strategic partners who push the agenda for our products forward.  Now they’re moving on to Bumrungrad Version 3.0—a whole new level of service and are again looking to IT to help.  While they serve the local population, they serve an even greater number of foreigners—thousands and thousands of “medical tourists” from the US, Middle East, Europe, and Asia.  Interestingly one of the key topics was how to leverage HealthVault in supporting the medical tourist and expatriate part of their business…something we have talked about internally but now have prioritized.

In Kuala Lumpur, I visited two private hospital groups, each of which is part of a larger conglomerate.  They view healthcare as a growth portion of their portfolio and they have money.  I enjoyed learning from them about their goals and approach, and explaining our strategy to them.  The perceptions of what Microsoft is as a brand are so prevalent and ingrained—consequently, I have learned my most important objective is to communicate with folks that HSG is a serious and thoughtful player in health information technology.  These private hospitals want technology partners to help them do a lot; —streamline their clinical and business processes, use clinical workflow tools to put guardrails on clinical processes, provide sophisticated BI tools and to stay on the leading edge.  While they are focused on their enterprise needs first—our Health connected strategy—of connecting consumers to physicians to facilities—really resonated with them for their future business needs.

In Sydney, I met a very diverse group of folks—shadow ministers, MDs, CEOs of hospitals, members of the Clinical Excellence Commission, and members of the NSW health service.  Australia has been pursuing leveraging HIT for several years.  Some states are pursuing standardized Cerner implementations for hospitals and there is an institution named NEHTA that has been exploring the policy issues/standards around community or personal ehealth records.  As I’ve noted before, the challenges in Australia are similar to the U.S. and Europe—leveraging information across the continuum of care, getting more out of their existing departmental systems, improving performance at the enterprise and system level and engaging consumers.  The health of the healthcare system is a hot media and political topic—everyone is talking about the Garling report and what it means, physician concerns about the Cerner implementation in emergency departments and other specific bad ED incidents the media have publicized.  While I get the scale benefits of standard software and standard rollouts by centralized and skilled service organizations—they frequently run into challenges in the healthcare domain.

I concluded my trip in Scottsdale, AZ, where I had the opportunity to address a small group of CEOs at the Health Management Academy.  It was a great interaction about how technology has changed many industries. I had the opportunity to use my personal history to tell the story of how connecting vision, technology folks and domain experts has powered positive and sustainable change—which I have had the good fortune of doing at Microsoft, at MSNBC and at drugstore.com.   It was fitting to conclude the trip back in the U.S with leaders dealing with the challenges in their organizations and the economic climate.  Increasingly I see the local market separating into two segments—while all are focused on cost containment—some are primarily hunkering down and others are seeing the current climate as an opportunity to invest in transformation.  Obviously I believe the right technology is critical to both groups.

Let me wrap with a side comment.  I’m over 50 years old and have been traveling internationally for nearly 40 years.  Even though there have been many articles and books written about how the world is flat, it is remarkable to me how much the world has changed in this relatively short period of time...and yet, in some respects I believe the change is just starting.  From the ease of staying in touch (my kids could call/text me anytime—didn’t need to know where I was at all)—to the ability to stay connected to important events in the U.S. (Superbowl started at 6am local time in Bangkok with Thai announcers and a pre-game show)—to physically getting from place to place—it is all steadily improving and becoming part of the norm.  In the same 13 day time frame, I worked out on four separate continents—ran in the cold in London’s Hyde Park and in the heat around the Sydney Opera House—and collected all the workout information on my HealthVault compatible Polar heart rate monitor and watch.

Over three years ago, we started on a journey -- to empower consumers with tools to help make better health decisions and drive better health outcomes.  We believed that the simplest, easiest way to start was to give consumers their data in a secure and private way, and allow them to share it from provider to provider, keep it in one place over time, and learn about it in order to make better daily health decisions.  That simple idea was the beginning of HealthVault. 

Back then, there were a lot of objections.  Consumers don’t want their data.  Consumers can’t understand their data.  Their data might actually do them harm…blah…blah…blah…

But fortunately, things have shifted.  Consumers have made it pretty clear that they want to be involved in their health – as evidenced by looking at social networking sites like PatientsLikeMe, the raw numbers of health Internet Searches, or research reports like The American Public on Health Care:  The Missing Perspective, released by the CEG, Accenture and IOM:

·       78% of American favor giving doctors the ability to share access to their medical records if done with their permission.

·       66% said that they see the value in including their own information anonymously in a large database to help researchers.

 

And I’m happy to say for a number of reasons that consumer products like HealthVault and GoogleHealth continue to gain market traction. 

Today marks another milestone – the first Industry-wide initiative to establish a “Declaration of Health Data rights” to support patients’ rights to access and share their own health information – https://healthdatarights.org will go live tonight, along with blog posts and endorsements from thought leaders and organizations across the country.

While we’re making change, and it's great to see so many organizations and thought leaders coming together, it’s important that we not stop here…that we continue to move forward—specifically by ensuring that consumer access to their data is included in the definition of “meaningful use.”  While I’m optimistic about what I see -- what’s been laid out seems to focus on driving real outcomes improvement in the health care system -- we will not be successful without further refinements.  Consumers cannot just be given access to data in static form, but must be provided with an electronic copy of their data so they can easily share it, use it, add to it -- creating a lifelong health data asset.  In the end, consumers are the ones accountable for their own health.

I have spent some time over the past several weeks to read and get educated about various health reform proposals.   As can be expected - there is a lot of dialog on this topic given the political season.    Health Affairs has some good articles up if you want to get informed about the Presidential candidates proposals.    Maggie Mahar has a great post up at The Health Care Blog detailing some current thoughts of one of my favorite economists on the topic,  Prof. Uwe Reinhardt.

However, the more I consider and read about the topic, the more skeptical I get about the prospects that we will have meaningful reform anytime soon...which is a real problem.    I am concerned by both the lack of understanding and by the politics!   I guess I am an naive idiot for being surprised.

I am generally biased towards market based capitalism and individual rights and accountabilities.   But as we all know -- markets have and require rules to properly function in setting prices and allocating resources (prime reasons why they are more effective than alternative economic forms).    Look at Russia today -- without the rule of law -- they can't sustain their autocratic economy.

In the U.S. Health 'system' - we sometimes have the worst of both worlds.   As Prof. Reinhardt points out -- there is no legitimate reason to tie one's health insurance to employment -- it has perverse consequences.   We have rigid rules on the supply side (what Medicare will pay for, how Medicaid reimburses and so on) -- which contribute to a lack of innovation on supplying economically cost effective services (tele-medicine for example).    Consumers are also legitimately confused on the demand side -- neither knowing what things cost or why they need to think about providing for their future health like they have to provide for their future retirement income.

The political debate is often framed around covering the un-insured.   While an important consideration -- it is not the most important issue.   The most important problem is how to create a framework where we get more value out of the current spend on health.    This is the key economic and policy question.    If we can improve the value delivered (health outcomes/economic inputs consumed) -- then there will be more dollars available to cover the disadvantaged (social, economics, genetics).    If we can't improve the former (value delivered) there is little chance we can afford the latter (more coverage).

Many smart folks realize this -- but they have not figured out how to make this argument effective with political soundbites (neither have I).   So the current political dialog is shallow and does not help frame the real debate we will have to have in the coming years.

The meltdown of the U.S. financial markets is instructive to health IMHO.   Not that hospitals or doctors are using leverage inappropriately, as in the financial sector.   But rather that the rules and incentives matter, that transparency matters (does anybody really understand pricing in hospitals?) and that a system out of whack (imbalances -- such as docs leaving private practice) ultimately leads to a systemic problem.     Many recognize the 'system' is sick, many even understand how the trends are getting worse not better - but there is not a clear path forward because of the incredibly gargantuan, yet fragmented nature of the 'system'.    Hence my current skepticism towards progress.

So this week’s question from the Washington Post RX Blog was:

What's Your Take On Obama's Speech?  What did you think of President Barack Obama's Sept. 9 speech to a joint session of Congress? Was it effective? Did it "move the needle?"

My response is below.

 

I applaud the administration for shining a bright light on health reform. The government -- as buyer, regulator and leader -- must be a part of any solution. The political calculus has created a real sense of urgency to do something about this complex system which touches everyone and accounts for one sixth of our economy. The consequence however, through a lack of transparency and understanding, has reduced the public dialogue to be between "public insurance options" vs. "death panels." Framing the debate this way and consuming available public attention on "wedge" issues won't lead to a sustainable future system.

My attendance at an Institute of Medicine workshop this week in the midst of the buzz about the speech served as a stark reminder about the depth and breadth of the hard problems:

• Access (too many uninsured)
• Costs (growing faster than inflation)
• Demographics (aging populations driving up systemic costs)
• Quality (not enough -- as measured by comparative outcomes, disparity in care geographically)
• Worsening health (people dying because of a lack of focus on improving the care delivery process).

I was struck by the number of smart, passionate people representing the major stakeholders working together to drive change. Veterans of the process recognize that change is imperative but hard -- because the details matter. We are in this predicament because incentives, tax policies, government reimbursement schemes and increasing specialization and capability of medicine have led us here.

The president delivered an inspirational speech, laying out basic principles: everyone should have access, nobody with insurance will have to change it and cost growth must be slowed. Voters know there is no free lunch, and health is no different.

We can't achieve reform without educating the public. A sustainable system is not as simple as providing more access. Consumers are ultimately responsible for their health and their daily choices cost the system. We need to help them engage in their health differently, be wiser purchasers, and understand trade-offs. As long as they believe the price of care is their co-pay and continue to engage as they have, there won't be sustainable reform.

There are best practices at organizations like Geisinger that have re-invented care delivery and consumer engagement models. These leaders will tell you that success is about aligning incentives, understanding the details and making trade-offs.

The difficult work of figuring out the details and making hard choices is still ahead.

I don't normally blog about our products per se, but today marks an important milestone for Microsoft shipping solutions that are important signposts toward the future -- the transformation of healthcare.

The first is the launch of the Mayo Clinic Health Manager powered by HealthVault -- the focus of this solution is to enable the 'family health manager' to organize her information in one place and receive customized recommendations.  The second is New York Presbyterian’s realization of a ‘connected health environment’ that brings together information on the clinic or hospital side using Amalga and extends it to patients through the introduction of mynyp.org via HealthVault.  Each of these solutions concretely demonstrates how collaboratively we can move health systems forward today -- connecting users with their clinical information and providing interactive, personalized tools to empower them further. 

The HiTech stimulus and health reform policy debates acknowledge the importance of information technology in transforming the health system...however questions remain about the how and shape of that transformation.  Last week, I finished the Innovator's Prescription by Clay Christensen et al., which I strongly recommend to folks trying to understand the types of disruptive innovation that can and should occur in the health ecosystem to improve outcomes and change the cost dynamic.  The books brings a new vocabulary that can help advance the discussion -- and highlights the importance of new business models in creating innovation.  We need a different business model to deal with chronic care and prevention.  I am confident that technology in general and the type of technology we are building and deploying with these innovative leaders in particular is critical to enabling these new business models.

It is exciting to go from ideas -- to plans -- to prototypes -- to actually shipping solutions that tear down the walls of data silos and begin the journey of using liberated data to deliver new solutions for consumers/patients.  We are still early in this journey, and I look forward to getting feedback from users -- consumers, clinical users and IT professionals -- on how to improve the capability and usefulness of our solutions.

I love the fresh debate about standards and the evolution of Health IT raised by the three Health Affairs articles.    I agree wholeheartedly with the perspectives of Carol and Clay - and frequently reinforce these comments to customers, policy makers and audiences alike. 

1. It's about the patient - not about the standards. Value in the form of patient care and business results can be improved by moving/reusing the data already in the system! There is no need to wait for 'standards'.  Ultimately we need to be focused on solutions that provide value to patients….better quality of care.
    
2. If it's about the patient, we need to empower consumers to be active and engaged participants in the system and they will demand 'connected' care and more health and wellness choices.  They will increasingly make physician choices based on the ability and willingness of physicians to leverage communications/connected care to improve patient convenience and outcomes.  In order to have more choice, consumers need to be able to access and leverage health IT solutions: the same ones that are being used by their physicians and other stakeholders across the spectrum of care.
    
3. Health IT is a great enabler for many things (outcomes, safety, results, employee productivity, employee satisfaction) but not an end in itself. System design matters a lot - metadata is the answer to enabling exchange of info today to evolve to standard exchange tomorrow.  Health IT is only one piece of the puzzle, but we can't wait for all the pieces to be in place; We need to start improving outcomes today. These beliefs have informed the design principles of the software products we introduced in the marketplace - both HealthVault and Amalga.

In addition to consumers as a change agent, I remain hopeful that the buyers of large health IT systems will wake up and demand more from their vendors; Not in terms of custom features, but in terms of a real commitment to interoperability and to unlocking the data that exists in systems already.   Health IT buyers are critical stakeholders/components of the ecosystem and need to demonstrate leadership in getting us to real solutions that extract the value from HIT - and not let themselves be positioned as victims controlled by the vendors. Unlocking the data that providers and patients need to make the right decisions should be the priority, with the goal of improving patient outcomes.

After my visit to Washington D.C. and the U.S. Senate, I thought it might be instructive to visit other parts of the world to gain additional perspective on the challenges the global economic crisis is posing to health systems.  For the last five days, I have been in Western Europe visiting four different countries and interacting with health system CEOs and CIOs, ministers of health, leading social service bureaucrats and members of the Microsoft health ecosystem.

Here are some observations worth sharing:

• Everywhere there is a deep interest in personally controlled health records - more than I anticipated, and despite the fact that some early projects in the category have performed poorly and have low adoption.  Stakeholders recognize that citizens/consumers need to be actively engaged in their health in order to improve the results and economics of the health system.  They view personally controlled health records as an important tool to motivate and engage them.  They don't see other options that can accomplish this goal.
• Privacy is a major issue surrounding the sharing of health data -- either in the professional arena (insurance, provider to provider, provider to pharma) or in the case of professional to consumer.  Many have concluded (as we have in the design of HealthVault) that personally controlled health records are the best solution (but not the only one).
• Health systems and their funders are looking for ways to connect the health delivery system across institutional boundaries -- from GP systems to hospitals and specialists.  No one is doing it well yet.  They see it as critical to delivering better outcomes and containing costs, and they acknowledge that seamless data sharing is critical to enable new work flows.  Unfortunately there remain many barriers to this seamless data sharing -- some technical, but mostly economic fear of existing stakeholders around loss of revenue or the implications of transparency on business practice/quality of delivery.
• The payment systems inhibit innovation in many cases or drive it in others.  In some markets, governments are pinning their hopes on private insurance as a vehicle for innovation and focus on wellness/prevention while in other markets the government is directly trying to tinker with the payment schemes to encourage new behaviors by the provider organizations.  From an economics perspective -- what strikes me as the real problem and challenge with these approaches is that the feedback loops are long and indirect, and consequently the cycle time of improvement will be incredibly slow.  This is why price mechanisms in the capitalist system are so important - real time feedback mechanisms with the ability to self adjust.
• The people with whom I met had an informed interest in what was going on in the U.S., particularly around the stimulus bill for health IT and about the prospects for health reform.   They are watching to see the impact.  What surprised me was the low esteem in which most regarded the U.S. health system...based on the statistics around health spend as a % of total GDP spend and reported health outcomes.  I acknowledge that the U.S. system has many flaws, is broken in many ways, and has lots of waste that should be eliminated.  But I have always been a bit of a skeptic that the statistics on outcomes really tell the full and complete story around quality of care delivered across different societies.  I am not sure that the perception of others really matters in this case in terms of the U.S. needing to fix the problems regardless -- but it bothered me enough to flag it and put in my "think about it later" list.

Some I visited are surprised to learn that Microsoft is investing in health specific software and services solutions.  Others are challenging us to do even more to bring ease of use, effective application integration and user interface innovation to the health worker desktop today!  Most are hopeful that the next round of technology and software investments really help improve the working environment on the front lines of health delivery and health outcomes.

Next stop -- Asia Pacific.  Given our ambitious goals, I often tell my team that time is our enemy when it comes to success.  Ironically, I have turned the motivational saying into a concrete reality as my itinerary has three of the next six nights aboard planes.  whoops

 

The NYT editorial yesterday chastising physicians and the U.S. health system for not adopting electronic medical records adds a new MSM voice to the debate regarding technology as the no-brainer foundation of health reform.    Naturally this is a frequent topic in the trade mags/blogs in my inbox.   The chief implication in the MSM editorial however is that "public financing" is the key factor that would accelerate EMR adoption in this country, as it seemingly has in other countries.    Not surprisingly, there is also an active number of bills in Congress looking to increase the government spend on health information technology -- with varying formulas and priorities.

There is no doubt that if the government provides a lot of financing for EMR adoption by physicians that there will be more computers in doctor's offices and hospitals.   The real question however is will the right technology investments be made that generate the most value - for the physician, for the citizen/patient and for health outcomes.    Unfortunately, the health IT landscape is littered with large, often government sponsored projects, that consume resources but fail to deliver the expected outcomes for a variety of reasons -- poor design, lack of adoption by users, too slow, automate the wrong things and so on.    Just spending more money on information technology -- without looking at all the factors driving behavior in our health ecosystem (payment reform in terms of what we pay for and who pays it and consumer expectations) is unlikely to achieve the expected outcomes.

Clearly, I believe information technology is a critical component of improving health outcomes...or I wouldn't be investing time and resources in building solutions.   Further, I believe that payers need to work with providers to finance investments in improving health outcomes -- of which information technology is a key factor.  At an early stage, some good work is going on with good early results, such as in Massachusetts.   Given that the Federal government is involved as a payer in a significant portion of health spend (nearly 40% by some accounts) - it needs to participate in the solution or other payers won't.

So what is my main point?  We (our government) has scarce resources...they should use them wisely and carefully.    I want to make sure that investments in information technology have a high return to users, payers, citizens and health outcomes.   There is lots of electronic data out there today -- medication histories, lab results, diagnostic images -- and just making these available to physicians and patients alike at the point of decision making -- may generate desired outcomes (lower cost and better care) at a much lower technology spend level.    Yes, paper charts are archaic and sub-optimal and will ultimately be replaced by digital systems.    We can achieve our shared goals of better "value" from our health system (better outcomes for the spend) -- faster and cheaper -- by unlocking the digital data that already exists (Esther Dyson made this call for data liquidity several years ago) and incentivizing physicians and consumers to use the data.    Let's not be satisfied with waiting for EMR adoption to happen.

Last week, we hosted around 20 physicians from one of our Amalga early adopters for a two day, two-way conversation around what the most important challenges in health delivery are and how software can help address them.    It was a very instructive conversation -- from which I learned a lot and met some talented, accomplished and interesting individuals.

Part of our objective was to imagine a future where software technology enabled new types of workflows and an extended delivery network beyond the hospital.    There was a lot of energy and discussion about the shape of such a future (increase the focus on prevention - inside the hospital and as a core to the delivery network goals).   As the discussion went on there was spirited debate about where to start, how to measure and how to pick goals that would really be transformational.

I am not prepared to go into the details of the conversation here -- but there were a few non-proprietary insights for me -- that are worth sharing:

First -- I have a much deeper understanding of the diversity of perspective, understanding and challenges -- of the various specialities and practice groups within a large delivery system.    Given this beginning point -- and other factors such as physician model -- I appreciate the need for (and challenge) of leadership to enable change to really happen.

Next the dynamics of an "enterprise" health system seems more like a conglomerate than a traditional product focused enterprise -- even though they are serving a common customer and market.    This makes goal setting, prioritization of metrics for performance and resource allocation much harder -- if you want to drive to a common vision.

We started the session listening to Dr. David Pryor from Ascension Health.   Pryor described how Ascension set themselves an audacious 5 year goal (zero preventable medical errors) and then went about a series of process improvements to get there.    It was fascinating to listen to him describe the steps, the challenges, what worked and most impressively the results they achieved in a relatively short timeframe in multiple different institutions.    It truly is a remarkable story -- and given the organizational comments above -- even more impressive.    It is great that he was willing to share their best practices openly.

All health delivery organizations face big challenges on multiple fronts.    Everyone knows, that quality (outcomes) needs to improve and would reap large economic and social benefits.   And clearly -- as Ascension has demonstrated - real progress is possible.    In a truly competitive sector -- like banking -- the advancements of the certain organizations would ripple reasonably quickly through the sector (improve or lose share).   This dynamic doesn't appear to be at work in the health sector.    So it is going to be up to the leaders of our health delivery institutions -- to set audacious goals and drive to achieve them.

Today is Election Day in the United States -- I hope eligible citizens perform their civic duty and vote!   The headlines and pundits are calling this an historic election and many of us are wondering what the election results will mean for the future of health care.   Will there actually be 'real' efforts at broad based health reform?    Will the government get behind substantial investments in health IT?   Is that a good thing or a bad thing?    There are an endless number of topical questions.

Typically I believe the headlines and pundits way over exaggerate and over dramatize the current events -- to drum up interest and viewers.    This time, I am not so sure.    I have been learning about the History of Freedom -- from J. Rufus Fears -- a course I strongly recommend for all who value their liberty.   I am not quite halfway through -- having just gotten through Luther and the Protestant Reformation.    There are a number of important lessons from the past -- particularly about the interconnectedness of prosperity and freedom and even of 'empire' and individual freedom's.   Fears draws great analogies from Rome and Greece that are relevant to today's challenges.   One thing I found interesting was how the growth in government in Roman times -- led to increased bureaucracy which necessitated increasing taxes which sowed the groundwork for the decline of the empire.   There is no way to simply summarize -- so I won't attempt to -- those with interest can explore further on their own.  Suffice it to say -- we are not the first society (or dominant power) to be dealing with these issues.

The salient point for today -- is the immense role specific, individual leaders have played in the journey of history.   Fears draws parallels between Socrates and Jesus (both teachers, both taking on conventional wisdom, both needling the elites of their time, both refusing to recant at their trials, both seeking fundamental truths etc.).   These individual leaders advanced both the understanding of freedom and the cause over time.  He then reminds us how Constantine nearly single handedly enabled Christianity to go from a tiny, persecuted minority to the dominant religion (and in some periods, power) for over a thousand years.  Bottom line -- specific individuals make history.

We are lucky in this country to be able to 'choose' our leaders.    I just hope we have the collective wisdom to preserve our liberties and prosperity, at the same time.   We can learn from the past and hopefully avoid making the same mistakes as earlier societies.    I am less confident we have the will or the desire to do so.

You might ask - how does this (freedom, leaders) relate to the topic of health reform?   It does in two important ways - first by setting the overall context of society in which health is just a part (role of government vs. role of individual) and secondly by encouraging (or not) a comprehensive debate on reform based on core principles/value or a political one based on temporary advantage.

As a "software guy," I believe health is fundamentally a data problem…in fact, it may be the most important data management problem in the world. I also firmly believe that breakthroughs in health data technologies are the foundation upon which new business models, innovations, and disruptions can happen in health care and economics. Data technologies will transform healthcare… for the Consumer…for the Physician…for the Hospital…for Public Health

In that vein, I’ve asked Dr. Mike Gallagher, the Director of Business Intelligence and Outcomes Analysis at El Camino Hospital in Mountain View, CA., to do a guest post today. He spends a lot of time thinking about the application of data technologies to preventive medicine, and he and his team did some amazing work during the recent events surrounding the H1N1 Influenza A virus.

As a "public health " physician, when an outbreak like H1N1 Influenza A occurs, you typically have several key concerns. You want to know what started the outbreak. You want to know who’s infected. And you want to know who has been exposed (think about health care workers in particular). Knowing the answers to these questions as quickly as possible is critical to understanding and effectively managing the situation. Most of our past challenges occurred because we weren't able to get answers quickly - months for complete answers. This is really where IT can play a major role, improving surveillance, diagnosis, treatment monitoring and prevention.

With the recent outbreak, we quickly realized that we had to have an easy way to keep track of incoming patients, and coordinate team efforts internally. In the not-so-distant past, we might have used an excel spreadsheet to manually crunch the numbers every three hours, and then faxed the results to the Public Health Dept. Our team coordination might have been a central bulletin board. But by leveraging our data management technology, it took us three hours to create an easy to use "tracker" to be filled in at our Emergency Dept. to collect data real-time, and respond quickly. This might sound really simple to the average person, but to front line physicians and nurses, having an easy-to-use tool like this is invaluable.

By capturing this data, we had the ability to do further analysis and take action. For example, we could see the number of patients who came into the Emergency Department from a particular zip code. While none of them were actually infected, we could deduce that there was a great deal of "worry" in a particular area. We could let officials know this information, so they could issue alerts or send letters home with children in schools versus taking drastic action like closing schools which could have much broader implications. With simple mapping technologies, we could have taken this a step further to create a visual of cases by area. And we leveraged other simple technologies – a share site - to capture RSS feeds from the CDC, post our key numbers in real-time, etc, - allowing everyone from everywhere to know what was going on.

As we think about the future – in preparing for the next crisis, I think it’s critical that those in the public and private sectors go beyond today’s dialogue which seems to focus on EHRs or what I call "a local hospital or institutional" view to a more "patient-centric lifetime view"—the ability to easily collect and share comprehensive data throughout the course of the patients life. Imagine if we could pool all that data – of course, in an ethically, secure, private, "right way" – what we could learn about people, and how we could use the intelligence to improve the overall health system. I believe that the definition of "meaningful use" has to include the consumer and has to include some notion of "business intelligence".

For those of us on the front lines, we can’t make good decisions without good data.

 

Dr. Gallagher is the Director of Business Intelligence and Outcomes Analysis at El Camino Hospital in Mountain View, CA. He holds an MBA in Healthcare Finance and Management of Technology & Innovation from UC Davis. During his UCSF medical fellowship he received his MPH from UC Berkeley. He has many years of experience as an informaticist in medicine, retail and high volume manufacturing. Application of statistics and epidemiology to population health topics is integral to his medical practice of preventive medicine.  Dr. Gallagher remains a practicing physician at UC Berkeley.

I haven't blogged recently, because I took my family to Moscow and St. Petersburg to learn and experience more about this fascinating country with a rich and proud history – a trip that I highly recommend.

While I was there -- I decided to learn a bit about their health system and its challenges.   As is well known, Russia has substantial long-term challenges related to a projected decline in population and a relatively low mortality age.  The country is using its new wealth to address health infrastructure needs -- but as in most countries, the health system is big; it sits under different sets of jurisdictions (fragmented); and is largely operated at the local level.

I had the opportunity to visit a leading oncology hospital outside Moscow (#62).    It is set in a tranquil, park-like setting outside the suburbs and has multiple buildings on this relatively small campus.   Its new surgery center (less than 3 years old) is outfitted with modern equipment and a local vendor-driven, HIS-like system of which they are very proud.   Parts of the long-term bed facility were under construction.

The HIS system was built on Windows and uses Citrix terminal servers.   They demoed it and its broad feature set to me for over an hour, putting up with my incessant questions about how things worked.   They showed it to me in a small auditorium setting, which is used every morning by the head of surgery to go over the previous day’s results and today’s planned surgeries.  The system was pretty complete -- managing the obvious things like patient registration and patient data, up to and including identification of which patients should be prepped for discharged that day or the next day.  Reducing the length of a patient stay (the Russian average is much longer than in US) is one of the priorities of the administration, in order to reduce service wait times.

More interesting than the HIS system, was speaking with the deputy director of the hospital, who is still a practicing physician.   We had a very engaging discussion, which made it clear that he was quite proud of his facility, of the improved results he had been able to accomplish over the last few years, and the fact that an executive from Microsoft was interested in learning from him.  He opened a fresh bottle of a Russian brandy drink (it was late in the day) to share over our conversation.   He was proud that their HIS implementation had enabled him to operate the facility more effectively: manage drug costs better (major expense), manage his resourcing better, be able to tell which docs were doing well and which ones weren't (to intervene), and to improve overall capacity…the key basic things he needed to improve results.  

His main point was that he needed to get more done, (i.e. see more people, get wait lists down and so on), without any additional funding.   It was about managing priorities and resources to get the most out of them.  Now maybe that shouldn't be surprising -- but it was striking to me nearly 8000 miles away from home, in a dramatically different environment and economic/payment system -- that the needs were similar and that IT was being used effectively by pioneers to improve their results in meaningful ways.

Last week was the HealthVault Solutions conference held by my team.   The metrics were great -- lots of new applications launched and partners signed, attendance oversold, 600 people, 285 different organizations etc. -- but the story is not in the numbers.   What excited me was the energy in the room -- the passion of the people who work in health and want to be part of doing better for consumers.   Many participants came up to me at the end of the first day (after 2 hour demo session) and said they were really starting to get it -- the benefits of a personal health data platform -- with multiple applications sharing data as determined by the user.   Getting it is a good sign.   Dr. Mehmet Oz, who was the keynote speaker the next morning, took the energy level up a notch and raised the stakes.    Dr. Oz shared his sweeping vision of empowering consumers (YOU) to improve health -- but the key learning for me was -- to truly engage consumers you must connect with them emotionally.   Reason by itself -- don't smoke you will get cancer, don't eat too much you will get fat -- simply is not enough to change behavior.    Personalization, connectivity are key -- but we have to be able to connect at the emotional level with users - -this is a new set of challenges.    We also announced the winners of our innovation fund - the HealthVault Be Well Fund.    We were astonished by the diversity and quality of responses -- and excited to inform the winners, so we can get started on the 15 exciting projects.

Yesterday, Microsoft hosted the Center for Health Transformation (CHT) meeting on our campus.   CHT is led by Newt Gingrich -- he is a tireless champion for change and for raising our expectations for results from the health delivery system.    CHT does good work stimulating ideas, motivating policy makers to learn and be thoughtful when approaching health and creating connections between their members who are doing good work.    Newt was a judge on the HealthVault Be Well Fund panel.  Many U.S. ecosystem players participated and exchanged ideas -- sharing ways that IT plus leadership can improve overall results in the health delivery system -- like Gary Kaplan CEO at Virginia Mason, an integrated delivery system in Seattle that has utilized the "Toyota Lean" for system improvement.  Given the fragmented nature of the health ecosystem -- these stories of best practices and improved results -- need to be told and retold and retold -- to motivate additional champions how to change and give practical examples of how to make progress.

The last two days I have been participating in the 4th annual Pacific Health Summit.   The mission of the PHS is to bring leading scientists together with policy makers and industry to tackle hard problems in Global Health.   It is a fascinating conference because of the mix of people (scientists, ministers, NGOs, industrialists) -- all of whom bring a real passion to helping "improve" Global Health -- but start from very different perspectives and world views.   This years theme (selected a year ago) was around nutrition and the twin challenges of under nutrition (hunger, nutrient deficiencies and their impact on health status) and over nutrition (obesity, diabetes and the impact on health status and costs).    The timeliness of the topic -- given current events -- only raised the level of urgency and passion behind the conversation.     I won't even attempt to do justice to the theme in a brief blog -- given the complexity and interdependencies of the key threads -- I'm sure a final report will be published.    I can report a few surprising data points for the benefit of others:

• despite the lowest incidence of obesity -- Japan implemented a national policy in April to focus on prevention because of current costs and the need to change trend lines. This means that all people in Japan ages 40-74 are required to get an annual checkup.    One panelist -- Takemi-san a former vice-minister of health -- described how he had made a public promise to lose 10 kilos - -and this became a big and frequent media event (waist measurement and weigh in).   But he achieved the goal!
• China too has started a new program to prevent obesity -- as part of an overall approach to public health.   The program's essence is its simplicity -- healthy weight and healthy blood pressure.    They determined that if they could motivate everyone to eat 40kcals less/day -- they could dramatically change future trend lines.  So they ask people to eat 2 less bites off of their dinner plate.  
• India -- while being a food exporting nation -- has roughly 40% of children under 5 being under-weight.   This data point was used to demonstrate that "point solutions" or "simple programs" don't work -- that behavior change at either the national or individual level require comprehensive approaches (education, training, incentives, etc) that also take into account culture and traditions.

The role of nutrition in Global Health is clearly important -- and impacts costs and outcomes throughout the system -- from childhood development through to the management or prevention of chronic conditions.    One key takeaway for me is that it will require leadership (at multiple levels) and new forms of collaboration between the private sector and the public sector to sustainability address this issue.

Today the MSM had a good article from one of the premier journalists covering health, Milt Freudenheim about a CMS pilot project around the "medical home" -- which is simply a vehicle to motivate primary care doctors to provide 'better' care to patients with chronic or complex diseases.    The basic premise is that physicians can provide care that is both more effective (better outcomes) and costs less over the long run (prevents unnecessary acute problems) by 'monitoring' consumers during their every day life and not just when they visit the doctor with a problem.    Microsoft has actually designed HealthVault to enable this kind of 'connected care' using the Internet to enable communications and by enabling personal health devices to make it brain dead easy to get objective information from consumers on a regular basis.

The real question in my mind -- is why there has been so little innovation around how doctors figure out how to 'package' a bundle of services for consumers and charge them for it?

My wife likes to remind me of lots of examples where 'bundles of services' are both performed better than in traditional health delivery and consumers willingly pay for them.   The most obvious example is with veterinarians.   We have three dogs (just exiting the puppy stage -- all at 2 years old -- it is a long story).   We have a vet that makes house calls, has an electronic medical record for each of them, calls to make sure the Bella is taking her pills and that Mac's ear infection is clearing up -- makes sure that the routine vaccinations are done on time and so on.   She always calls to follow up on any given problem.    It is easy to connect with her by email or phone - -very unlike most folks experience with primary care.   Why is that?    It is not that we value pet health more than human health?    My hypothesis is that the vet business is largely a cash business -- and as a result it invests in technology and services (bundles) to attract customers in ways that a fixed price, reimbursement driven business does not.

John Goodman at NCPA has written extensively on this topic, you can learn more here.   The main point is there is not enough innovation on the supply side -- and one sees a lot more innovation (better outcomes at declining vs. rising prices in health) in the cash based businesses like cosmetic surgery and LASIK.   In general I think he is right -- and it has deep implications for future policy.

I also give credit to Chuck Kilo at Greenfield Health - who first convinced me (after beating me up in an argument) that true reform in health care had to start with how physicians were paid -- perhaps an obvious insight but one that is often missing in the debate of how to get to a better 'system' than where we are today.

The Freudenheim article points to the problem of a declining population of primary care docs -- and one of the reasons is the 'system' puts them in a box where they don't make enough money, they can't do a good job and to make more money actually means doing a worse job, not better.   How is that motivating or attractive?      I gave a speech a year ago -- to the American Society of Clinical Endocrinologists -- and foreshadowed the benefits of connected care through HealthVault (though it wasn't launched yet).   Many, many docs came up to me afterwards and said yes, they were using Excel or forms or other systems to get data from patients remotely - -but they were making less money while delivering better care -- how does this scale?    

There are other innovations going on outside of retail clinics and cosmetic surgery...but they don't get a lot of attention - perhaps they should.   I learned quite a bit about the economics of a physician practice from a real innovator on the delivery side (also in Seattle -- where concierge medicine got started); his name is Garrison Bliss and his latest venture is Qliance.    There is a whole society for folks trying to innovate on the supply side - -and they deserve support...because it may be innovations on the supply side -- some that will work and some that won't -- that will help us find the real answers to the dilemmas of improving health delivery and outcomes. 

So this week’s question from the Washington Post RX Blog was:

Do you think that a government-sponsored health insurance option is needed to help control rising costs and "keep insurers honest," as President Obama says?

 

My response is now live:  Lessons from Medicare and Medicaid.

My main points:

·         How will another government-managed option be better at building a health system that works for the 21st Century than the one we already have (Medicare and Medicaid)?

·         While these programs began with admiral goals and are politically popular, in reality, over the past 40 years, they have done little to control costs or drive innovation.

·         What's needed is a new framework to drive innovation, better value, improved outcomes and increased access.

Please feel free to comment with your own thoughts on the public option. 

Today Tara Parker-Pope had a thought provoking column about the strains in the doctor/patient relationship -- and there are some good additional anecdotes and discussion on her blog, Well.

I have maintained for a couple of years that doctors are missing an opportunity to leverage their "trusted brand" (a.k.a the trusted relationship) by embracing basic Internet technologies to communicate more effectively, consistently with their patients.    The simplest example is think of all the information a doctor's office has and needs to distribute to patients -- info about their disease (pamphlet anyone), info about the drugs they prescribe, info about what to do before the procedure,  info about post-visit instructions and so on.    The doctor could "push" this information to the right patients easily -- using a basic CRM type system.   It may not be "personalized" -- but it would be relevant, timely, delivered in a form that patients could use/reuse the information and perhaps learn more, if they chose to in a self-directed way. 

I first learned about "information therapy" and the key role it played in improving outcomes from the founders of Healthwise -- and they are still pursuing this mission, with an expanded set of services.   When you think about -- you want information from the doctor -- and we know from our consumer market research -- the consumers want "trusted information" -- but they also want a lot more than the 2 minutes, shorthand version today's economic model supports in the typical office visit or phone call.

The opportunity is physicians could differentiate their services, extend their reach beyond the office visit and improve the value of their services (and customer satisfaction measures) -- if they could figure out how to deliver "information therapy" or other content they believe in -- to their patients.     If physician offices were like other small/medium sized businesses -- they would have figured out how to do this -- like many successful businesses in other industries have done.

I am sure lots of docs have done some really great things - but why isn't it more widespread?    My hypothesis is -- the economic motivation is not there.   Because of the fee for service, bureaucratic nature of physician reimbursement -- the innovative doc can't capture the incremental value being delivered.    See my previous post on the need for supply side flexibility to stimulate innovation -- this (information therapy, relationship management, brand extension) is precisely the type of service obviously being demanded by consumers -- but is not being 'supplied' by physicians - because they don't have the tools/flexibility to capture the value (or even experiment to find out).

I recently traveled for two weeks in the Asia Pacific region on Microsoft Health related business.   I was fortunate to meet with a broad diversity of folks -- from Minister's of Health, to CEO's of leading private and public hospitals, to GP's interested in how technology can help them and even to citizens with concerns about the capacity and capability of their health delivery systems.    Interacting with these passionate, dedicated and talented folks is one of the great parts of my job.

I returned with the following observations:

• while everyone I talked with sees the potential for health information technology to improve health delivery and outcomes -- the real challenge each of them faces is what practical steps to take to realize this potential for their institution or system.    Another way to say this -- is how to spend money most effectively to get results.
• the need and desire for a "citizen-centered" health data platform was clear in nearly every country and type of system...which was a bit of a surprise to me.   In Australia the buzz was about how at the recent 2020 summit held by the new prime minister folks had talked about a "healthbook" like service to facilitate better care and outcomes -- but patient controlled.   In Singapore, they currently have a tender around a patient-centered PHR platform pilot.   In emerging market countries -- they recognize the need for an online portal -- to help with both education and data sharing.   In China -- they have several pilots ongoing.
• that managing chronic conditions across the hospital and physician boundary is a problem and priority in most places
• that every country -- whether developed or emerging -- whether publicly well funded or mostly private pay -- has a difficult time figuring out how to prioritize and to incent prevention -- those behaviors that would prevent bad health events or outcomes.

So I see many similarities regarding the challenges and opportunities of health delivery systems in the U.S. and in other parts of the world.   However, I had a wonderful philosophy professor in college that taught me the true insight comes not from seeing the similarities but in understanding the differences (which apparently is true with regard to our DNA as well).    The differences are real and vary by country and system type.   A quick trip is too short a time to fully digest these differences.   The good news is there are many who believe that software can help the health delivery system do a better job in terms of outcomes, satisfaction and capacity and want to work with Microsoft to figure out how best to do it for them.

We are hosting the second HealthVault Solutions conference June 9 &10 in Bellevue.   The amount of effort and activity on our part -- and on the part of our partners who will showcase their web applications at the event is truly remarkable.    As a startup guy most of my career -- this infectious enthusiasm and passion by all the folks involved -- generates the endorphins that make startups and innovation so much fun.

For those that know me -- my primary focus is always on the next problem, on identifying and working on the things we can and must do better and not looking back at the accomplishments or progress.    As I prepare for this event however -- what really strikes me is the progress we, along with our partners (and others) are making towards the vision of empowering consumers and physicians to use the Internet effectively as a tool to improve health.   

A year ago -- we had working code and a beta environment for our very early partners.    Nothing available to the public.  Lots of talk and ideas here and in the industry at large - but not much tangible.   Today we have over 30 web health applications that copy data to/from HealthVault and enable users to reuse their health information in new ways without the burden of re-entering it all the time.    We also have 50 personal health devices from weight scales to glucometers to peak flow meters and more that connect directly to HealthVault -- which makes it so much easier for people to use this information to understand how to stay well or to use it in communicating with their physician.    In addition to our efforts -- Google Health is also now available to consumers.

Because of how HUGE the health eco-system is -- trillions of dollars, hundreds of millions of consumers/patients, hundreds of thousands of physicians, thousands of hospitals, hundreds of insurance plans and so on -- progress can be hard to notice in the early phases.   First -- we can celebrate the many partners that saw the vision early and have already built connections with HealthVault and we love them.    But I can also see a big difference in the conversation we are having with stakeholders in the eco-system and it is evolving from the tire-kicking phase to the "how can I get involved to help my business or my customers" phase....which to me indicates momentum is building and building fast.

Every once in a while it is nice to look back and recognize that the vision we have around HealthVault -- of building a consumer-centered health platform -- which lots of stakeholders will use to help consumers and themselves -- is really working!   Now, back to working on the things we can do better.

I had the good fortune of participating in an Allen and Co. health 'event' last week.   They brought together a small number of entrepreneurs and big company folk such as myself (and spouses) for an intimate few days of conversation, networking and recreation.    Their formula really works for forming relationships and developing deeper understanding of others' perspectives.  They also do an outstanding job with the execution -- so I found it well worth the investment in time.

Given the mix and high quality of folks -- we had engaging and wide ranging conversations with the following tidbits worth sharing:

• what is the future (and right) business model for diagnostics?    how (and when) will diagnostics dramatically change the health delivery system?
• how the existing policy framework encourages (forces) entrepreneurs to exploit the mis-alignment of incentives (find the gaps with new middleware type solutions) vs. creating end-to-end value improvement.
• what will it take to get supply-side innovation and payment reform?  is this even on the agenda of the presidential campaigns?   why not?
• does the increased use of information technology lead to consolidation of the fragmented health delivery system -- or does it enable 'virtual' consolidation through information networks vs. business organization?    or does it do both over time -- in phases?
• what form of evolution will emerging markets go through -- as they build both capacity and insurance systems?    what would we advise them to do?  and are there business opportunities for entrepreneurs or big companies only or both?

A funny incongruity, is I learned a lot about the development of a two-sided health specific market in today's connected Internet driven world -- while riding on horseback!