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.
After many long months of discussion and debate, the first draft of Meaningful Use has come out. 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.
It’s important that we keep this in mind -- that we’re not just trying to implement technology. We’re trying to improve the performance of the health system. And our willingness to succeed should only be exceeded by our willingness to prepare, and as part of that preparation, we must ensure that flexibility, scalability, and interoperability are inherent traits in the system. Why? Because, health is fundamentally data-driven. Nobody -- physicians, consumers, hospitals, insurance companies, governments -- can make good decisions without good data.
So driving data liquidity -- that is the ability for data to flow throughout the system -- has to be the critical focus. For years, we’ve been building systems in a “top-down” way to reach information, but what we need to do is build from the information up. One thing Carol Diamond said at a Health Affairs event that I attended with her really struck me -- the idea of bringing the question to the data -- leaving the data where it is and bringing the question/problem/issue to it. For a long time, what we did as an industry was use expensive research grants and complex tools to cull and compile data that was intended to answer one specific question, and by the time we’d sorted through the data enough to answer that question, it was either out of date or ten other, more pressing questions had popped up in the meantime. What we need is a system that unlocks all of the data that exists already in the health care sphere, and allows it to flow between silos so that when questions arise, we can bring those questions to the data for quick, evidence based answers -- rather than the other way around.
Given this, as discussions/refinements continue around meaningful use, I believe it’s critical for the following to be a part of the final definition:
· We can’t just capture data, it must be available in “real-time” in order make the right decisions and improve outcomes -- whether we’re talking about patients or populations.
· We have to enable data to become liquid -- specifically, doing this by separating data from applications. This is one of the recommendations from a study by the National Research Council of the National Academies that takes a look at what types of computational technology and investments are best for improving health outcomes. Let the excuse not be that the data is trapped in systems that we built, that we have to wait for standards.
· We’ve got to give consumers access to their data -- not just in static form -- but empower them with an electronic copy so they can easily share it, use it, add to it–creating a lifelong health data asset.
· We should accelerate the objective of having PHR access to EHR data to the 2011 Objectives and Measures. There is no need to wait until 2015. These technologies are available today and will bring real, sustainable benefits, not just for consumers, but for the overall health care system.
· We must ensure that we do not have an overly-prescriptive certification regime that focuses on certifying features and functions every-other-year. This will produce the unintended consequence of stifling innovation. Software vendors will be forced to develop towards a certified feature list rather than look for new and better ways to improve clinical processes and health outcomes,
The foundation of success is based upon data liquidity, and so it must be central to our thinking as we prepare for the future.
We’re just wrapping up our annual Connected Health Conference. I wanted to share some insights and observations from the past three days. We had 925 attendees representing 409 organizations -- attendance more than doubled from last year, which is pretty amazing given that conference attendance is down all over the US… At this year’s conference, our Amalga and HealthVault customers and partners all came together for the first time. The most frequent comment I heard from attendees was excitement about the breadth of work we are doing and the new opportunities they see as a result. The main issue that came up over and over again was the importance of driving and aligning innovation in health IT, health policy (e.g. reimbursement strategies), and business.
This topic first came up during our opening keynote panel on Thursday with Professor Uwe E. Reinhard, Dr. David Kibbe and former HHS Secretary Mike Leavitt. Secretary Leavitt introduced the notion that advancements in reimbursement reform are needed as much as stimulus for technology adoption. According to Leavitt, health IT will become ubiquitous when consumers demand it from their healthcare providers. While I agree with Levitt about informed, engaged consumers being key drivers of change, I also think that physicians, industry and other partners must demand a smarter approach to reimbursement from policymakers. One place to begin innovating and experimenting with a better reimbursement system is at the state level. During this morning’s keynote, Dr. Mark Smith of the California Health Care Foundation, made several insightful observations about factors affecting HIT adoption such as; better, simpler solutions for physicians, a stronger voice for government as purchaser in mandating effective standards and a reimbursement policy that rewards outcomes vs. volume. However, as David Harlow pointed out during a conversation today, our tough economic climate makes it difficult for states to take the lead.
Dr. Kibbe emphasized the need for web-based tools that could be assembled in a modular way to qualify for stimulus dollars. Both Kibbe and Smith made the strong point that physicians haven’t adopted existing technology solutions for a reason and that any stimulus/policy reform needs to be flexible enough to allow innovation in solutions vs. trying to “jam” solutions that don’t meet current needs or practical market requirements. In speaking with our Amalga partners, they too are interested in understanding how meaningful use and certification will be defined and applied. Our customers shared many examples with each other of liberating and unifying data which makes measuring quality and proving effectiveness easier and automatic. As much as health IT has the potential to help cut inefficiency and improve operational throughput, we still need the right policy solutions to bring greater transparency to what patients are purchasing from their providers and that quality of those services…as Leavitt demonstrated humorously with his story about colonoscopy pricing.
You can see some of the highlights of the panel discussion as well as Mark Smith's keynote below.
Our commitment to connecting technology, policy and business innovations is central to our vision of unifying a fragmented health ecosystem. In his remarks, Microsoft Chief Research & Strategy Officer Craig Mundie highlighted the major role health plays in economies around the world and the huge opportunity for software to improve peoples’ lives. Our Connected Health Conference this week brought together many different "perspectives" from across the fragmented health ecosystem -- what really struck me was everyone's energy and desire to let innovation reengineer the health system. I hope that the public and private sectors can work together to drive real change. We all know that that it's not going to be easy, but it will -- and must -- happen.
I think we’d all agree that the healthcare debate continues to intensify. Many say it has entered a new stage as conversations move to proposals -- with Senate Democrats recommending a bill that will amplify the debate even more -- to decide if the US will adopt universal coverage.
Access seems to have replaced change as the word of the day. Everyone seems to be focused on it -- including Peter Orszag and Virginia Postrel. There’s no doubt that access is important -- but addressing access prior to reengineering the system is like adding passengers to a sinking ship. And in this case, the ship is going down in a sea of red -- the growing debt that will be incurred.
What we really need to do is what I highlighted in my contribution to the Washington Post’s new Daily Dose Panel Blog, Diagnosing and Treating the Health Non-System.
It’s not just about access. There are multiple symptoms and ailments that interact with one another. The three principal "diseases" are:
· Access (too many uninsured people)
· Value (too much spending for the health results delivered)
· Ignorance (at every level - who really pays for health, misaligned incentives, true costs, quality measures, transparency and more)
The most important to fix is value -- how do we improve health outcomes for the same or lower economic cost? Why is this most important? Everyone acknowledges that health spending is already in an economic crisis -- both in the near term and certainly in the long term (Medicare's unfunded liability exceeds $36 trillion!). Even if everyone in the country woke up tomorrow morning with health insurance coverage, it still would not address the hard economic truth -- we must get more value, as measured by better health outcomes, for every dollar we spend on health. The recent article in the New Yorker illustrates this particularly well.
The whole operating framework surrounding the health delivery system requires re-engineering to realize value. We need a system that supports and rewards innovation in health around new drugs, new devices or new procedures. Today, this innovation happens on a small scale, at times producing great results. But what we need is broad-scale innovation around health delivery for chronic disease management (which accounts for 70% or more of total spending) as well as prevention and wellness.
The reason this innovation and re-engineering isn't happening right now in the delivery of health services is because of the inflexibility in the payment system and misaligned incentives -- largely the result of Medicare rules and regulations driven by Congress today.
Each of us pays for health care (taxes, lower incomes, cash) whether we realize it or not, but as consumers, we’re rarely informed and engaged with our own health. We can’t get the basic data we need to make the right daily decisions.
I believe that Congress must focus on building an operating framework of rules and regulations that aligns physician and hospital payment with health outcomes and encourages innovation on how best to deliver it. This is evidenced by an amazing statistic I read this week. In June 2008, the Congressional Budget Office estimated that up to one-third of 2006 spending – roughly $700 billon or nearly 5% of our GDP – did not improve health outcomes. And we want to add more people into this system?
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 don't know about you -- but trying to keep track of and make sense of the company announcements, the many awareness events designed by politicians and the folks hoping to influence the policy makers, the work being done by folks at HHS and the Hill to create new rules and policies and the press and punditry all commenting on all these activities -- makes my head feel like it is going to explode!
Just look at the past two weeks. IBM said they were going to finance $2B of HIT spend to enable health systems to bridge the 'donut hole' in the stimulus package, complementing their earlier announcements this year of health ‘innovations’ through their partnership with Google and Continua. GE followed with an announcement of $6B of investment, financing and 'innovations' that will lead to even more billions of savings in the U.S. health sector...and they will help underserved health markets globally at the same time! At a White House event this past Monday, a group of health industry stakeholders promised trillions in future savings by restraining price increases and 'doing better’. And Tuesday, there was another White House event on health -- featuring the role of employers. Cecily Hall, a colleague of mine at Microsoft, attended and explained some of Microsoft's innovative health benefits around clinically driven weight loss and mobile medicine. I don't know how many billions of savings this event will lead to -- since I'm still on yet another plane, but given I have a 'healthy imagination' -- I am confident the projected savings will be significant.
The choices we make about the future of our health system matter a lot for the future welfare of our country -- so I hope we have an informed and fact based debate that goes beyond the sound bite outline that seems to be shaping up in both the media and the political arena. Health touches everyone. We have all been to the doctor and had our own or extended family based experiences, and so we all have our opinions about what works and what is broken in our healthcare system. Consequently there is a lot of 'noise' about both the challenges and the ways to fix the healthcare system -- some that ignore basic laws of economics.
For whatever reason -- a generation of employer sponsored health insurance, government programs, no checkout lines in the doctor’s office – has caused people to make a fundamental mistake, to think of health care as something 'unique' and to suspend the principles of economics when they conceptualize and think about the problem. The price of healthcare is not your co-pay...no matter what the public perception is. Providing universal insurance and covering everyone will not fix the health system by itself...and in fact may exacerbate critical flaws that exist. No matter HOW it is funded (cash at checkout, employer payroll costs or taxes); individuals are paying for their health care...just like they are paying for their retirement income or car insurance. There is no economic free lunch here -- that a government run, single payer system or other construct makes it either free or creates 'more healthcare' for folks to consume. It doesn't. Yes, the societal question of income re-distribution remains (namely am I paying for my health care AND your health care or just mine). But we should not confuse how to organize a sixth of our economy around income re-distribution goals...think of how clear, fair and effective our income tax system is.
Educating the public around the principles that health is an economic good and that individuals are indeed paying for their own health care, albeit in hidden ways, would go a long way to improving the probabilities for a more efficient, intelligent health system coming out of the reform debate.
If we acknowledge that health, that is the delivery of health care services and the prevention of illness, are economic activities -- then we can ask the question about what is the best way to organize that economic activity to create value -- value for producers (doctors, hospitals), value for consumers (patients, employers, payers), and value for society (more quality life years). It is not a zero sum game. In most of our economy, we expect market mechanisms -- things like prices, product or service innovations, or profits -- to allocate resources, improve productivity, lower costs and improve quality over time. In health, many of these important factors are constrained or hidden given the structure of the payment system and the role of the government in setting the rules of the game.
In applying the principles of economics to the health reform debate, it is important to be consistent and not selective. There are many stakeholders in the dialog who believe that the problems are the result of for-profit companies (insurance, pharma) and that non-profits and government are a priori better (better use of resources and results). This perspective is simply wrong and not supportable with an analysis of the facts. Participants are optimizing given the rules/framework they understand -- and here the government is setting the rules (taxes, reimbursement, CMS) and must take accountability for the consequences -- intended and unintended just like in the housing boom and financial crisis. One of the really hard challenges in health is measuring the right outcomes/results. Does pay for performance mean the physician ‘checked all the boxes’ for documentation or that we got more health for a given set of inputs? In the end, not-for-profits are economic actors too -- no margin, no mission -- they have to pay market prices for inputs and charge market/regulated prices for outputs. They raise money in the capital markets (debt) and mostly try to optimize like for-profit enterprises.
Today's health system in the U.S. is a regulated system....and it many ways it doesn't work so well...but perhaps better than our 'facts' acknowledge. Everyone acknowledges that we need to get more 'value' out of the resources we have put into providing health care. Everyone acknowledges that there is no 'silver bullet' or no easy fix to the multiple challenges that exist in delivering and paying for health. Nearly everyone acknowledges that 'cash based' segments of the health system (cosmetic surgery, corrective eye surgery, dentistry, veterinary) have done a better job innovating and delivering better quality and lower costs than the more heavily regulated segments of the system. Unlike other industries -- a lot of the challenge in health is we don't know enough -- about disease, about what treatments really work, about what to do when -- and so on. Consequently, we need a system and framework that allows and incents systematic learning and improvement, discovery of new diagnostics and therapeutics and the best systems to deliver them.
So let's have a real conversation about how to build a framework for a health system that works.
It has been an interesting week for me, participating in three different events in the last seven days. With HIMSS at the beginning of the April -- it has been a real opportunity to get a snapshot of what folks are thinking, planning and worrying about in these hyper-active times of HiTech and health reform.
Thursday, I was on a panel at the Markle Foundation’s Connecting for Health event -- talking about ARRA, meaningful use and certification. I have to give a lot of credit to the Markle folks and participants for driving a very well thought out set of principles and priorities for ONC to consider in defining both meaningful use and certification, and more importantly reminding everyone of what the goals of HIT are all about -- better health outcomes. They had an impressive crowd of thought leaders at the event (which shows the interest in getting meaningful use defined right) and they have a broad and growing group who are supporting their consensus position. You can read more about it here -- and Microsoft is supporting the recommendations, along with many others.
Last Friday and Saturday, I participated in Innovation 2009, hosted by Health Evolution Partners, led by David Brailer. The participants and speakers were fabulous (and I'm not generally a fan of conferences). The discussion centered around new business ideas, how to innovate, the challenges facing large companies and the policy frameworks required to get the U.S. to the promised land of better health outcomes at the same or lower costs. I am an entrepreneur at heart (this being my 5th start up), so it was really exciting and a bit unexpected to hear from the many companies doing innovative and very focused things in the broad health ecosystem. I won't enumerate them here -- but suffice it to say the number of follow up actions I left with from this conference exceeded HIMSS -- which had a 1000 times the attendance. (Perhaps this is an indication of where innovation is happening). We had lots of discussion about the need for health reform -- that it should encourage innovation in multiple directions (care delivery, payment, new entrants). And a very real fear was raised -- that reform could actually stifle innovation. One discussion point was the 'public plan' option being floated by the administration and a prominent spokesperson said implementation of that "would be a catastrophe!"
On Monday and Tuesday, I participated in the Milken Institute Global Conference. They also do a great job of getting world class speakers, but given there are over 3k participants, it was a very different feel than Innovation 2009 with less than 200. The Milken conference is broad -- finance, credit, energy, international, education and health. What really strikes me is the number of folks that go to the conference that are really interested in the challenges and opportunities in health. I was fortunate enough to participate in a great conversation between Elias Zerhouni (former head of NIH), Jamie Heywood (founder of patientslikeme.com and super smart guy), Anne Wojcicki (founder of 23andme.com and super smart gal), and others about the critical challenges in the current paradigm of clinical trials and therapeutic discovery. Increasing the rate of discovering what works in health (precisely identifying the disease, finding targeted cures, providing feedback loops) is critical to addressing the cost crisis, the quality challenges and improving health outcomes. Here again, the system is failing (FDA, large drug companies) because the framework, institutional infrastructure and information platforms aren't flexible and adaptive enough to deal with the real needs of today. As a result, new groups are forming to find ways to innovate either around or completely alongside the existing institutions to accelerate knowledge -- like Alpha 1, patientslikeme.com, collabrx and many others. It is interesting to note the role of philanthropy and foundations in changing how the science and infrastructure is being driven -- groups like the Canary foundation and FasterCures and of course the Bill and Melinda Gates Foundation.
The flu pandemic has been the center of the news and was certainly a topic in all of the conferences above. From helping to prevent pandemics, to accelerating knowledge and understanding, to improving health outcomes and increasing access to quality health care -- information technology and platforms -- are critical.
(cross-posted on Microsoft on the Issues)
My family and I just got back from a vacation in Mexico, so the news that’s on everyone’s mind—the spread of H1N1 Influenza A—is weighing even more heavily on me. With the media hype machine driving minute by minute coverage, it’s hard not to think about devastating epidemics and pandemics of the past—typhoid fever, smallpox, bubonic plague, cholera, Spanish Flu, typhus, tuberculosis, malaria, HIV/AIDs—illnesses that spread uncontrollably and killed millions.
While we should be concerned, we should also remember just how far we’ve come in facing these challenges. Today, the Internet, blogs, instant messaging, and other technologies can disseminate information about new threats and new medical knowledge faster than ever before. Technology gives us the opportunity to face these crises better than we have in the past.
Yet we still have a long way to go. The identification of threats and the transmission of basic information remains a fundamental challenge. News of the recent outbreak broke on April 24th—18 days after public health officials started investigating unusual cases of respiratory illness in Mexico. Eighteen days doesn’t sound like a long time, but in the world of infectious diseases, it can be the different between life and death. According to The Rapid Syndrome Validation Project, a delay of even one day in detecting certain diseases like smallpox could mean the "…difference between the loss and salvage of as much as 90 percent of an exposed population.” I think we all can agree that we can do better than 18 days.
And now as the disease progresses, do we have the right information platforms in place to enable front line workers and public health folks to gather, transmit, analyze data, and ultimately act? We have a highly fragmented health system in the US, and it is much more complex when you look globally, where we have language barriers and in many regions, no infrastructure in place. Since SARS and the anthrax attacks, there have been a lot of pilot projects and investment in infrastructure – but perhaps not yet enough. More importantly, I believe that a “separate” infrastructure for public health (or the buzz word ‘bio-surveillance’) isn’t the best approach because systems that aren’t used every day are never up to date. Just look at the challenges and barriers to the CDC’s BioSense National Program—a program with admirable goals, but limited results in terms of hospitals actually reporting data. A better approach is to have flexible enterprise data systems that allow for the re-use and re-purposing of data quickly and easily, because these are the types of systems that enable us to prepare and respond to these by definition unknowable future issues.
I do what I do because I believe that technology, if employed correctly, can be a transformative force. It can act as a key enabler to improve surveillance, diagnosis, treatment monitoring and prevention. The people on the front lines managing this crisis are doing an incredible job, under intense pressure. I have to say how impressed I am with the professionalism and commitment of these public health officials—internationally and in the US. I’m proud of the work that Microsoft is doing to support them –working closely with local and international authorities to provide technologies and products to support the effort to combat this threat. One example is the work the Internet Explorer team has done to enable people to put Centers for Disease Control health tips and news updates at the top of their browsers through a new swine flu “Web slice” for Internet Explorer 8, now available at www.ieaddons.com.
We have great people. Great technology exists from Microsoft and many other companies. The threats aren’t going away. Time to build a platform to ‘really’ deal with them.
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.
(cross-posted on Microsoft on the Issues)
In 1987, President Ronald Reagan gave one of his most well remembered speeches. Few of us could forget his words to Mikhail Gorbachev to “tear down this wall”—proving to be prophetic when the German Democratic Republic announced the re-opening of the border in 1989, and the subsequent destruction of the Berlin Wall. What followed? A new flow of people, ideas, commerce, and capital—creating the groundwork for unification and a better way of life in Germany and Eastern Europe, benefiting all of us economically and politically in unanticipated ways.
A similar type of disruptive change needs to happen in the health ecosystem today. Just as the free flow of ideas and capital were the foundation for dramatic improvements in society, so should the free flow of health data be the foundation for realizing a future of secure, personalized, data driven medicine in health.
Yet many outdated ideas and mechanisms stand in the way of change; the most important of which are the now impractical walls that were erected and still exist around patient-data. And all of us—IT vendors, providers, payers, pharmacy benefit managers, policy makers and others in the health ecosystem have enabled the walls to exist in spite of the obvious benefits to patient safety and the overall health economy.
Real-time, accessible, meaningful and comprehensive data is fundamental to health care as a whole–to make a diagnosis, provide quality care, pay the right bill, discover new therapies, and so on. What’s of paramount importance is liberating the data and making it available for re-use in different contexts. This is critical for improving outcomes, paying for value, creating a learning healthcare system, enabling discoveries and fundamentally changing the dynamics of the ecosystem. We should be treating health data as a vital asset—health enterprises and consumers—to drive an efficient, high-quality, value-based, evidence-focused future for medicine.
So why isn’t there data liquidity or the appropriate flow of data in the ecosystem? There are two major walls preventing the liberation of data and each is starting to have some cracks.
First, there is the “it’s-my-data” wall put up by hospitals, insurance plans, pharmacy benefit managers, and others. They believe there is some competitive advantage by keeping the data inside their walls. And there are lots of excuses supporting their position–patients don’t want it, they can’t understand it, it might do them harm blah, blah, blah. This wall is starting to crack. Many institutions recognize that the consumer has a right to a copy of their data and are making the appropriate connections to personally controlled health data repositories like HealthVault or Google Health. Many others are writing about it too—John Moore asserted in a recent post, “Personal health data belongs to the consumer and the consumer should decide how it is shared. This is a very radical concept that still has most providers, payers and other data holders shaking in their boots.”
The second wall is the “waiting-for-the-right-standards-set-by-government” wall. There are multiple excuses buttressing this wall; the core of which come down to technology, standards or policy excuses. Without debating each point–one inexcusable barrier is the IT enterprise system vendors who make it difficult or expensive to get access to the data, to separate it from the application. They believe that proprietary “lock-in” provides them with a strategic advantage. We’re all in business and need to create strategic value for our products, but let’s do it in the application layer—rules, workflow, user experience, price, or services—not by trapping patient data in a proprietary database structure.
Our customers and partners and their customers need to be able to re-use their health data, and in ways they haven’t always thought of or anticipated. They have to be able to build cross-vendor systems to improve care. If information can be made liquid—flowing from where it is generated to where it is needed, and combining it with other bits of information to provide a comprehensive view—it can be tremendously powerful.
We, in the IT industry, can step up and be a driving force in enabling data to become liquid—specifically, doing this by separating data from applications. This is one of the recommendations from a study by the National Research Council of the National Academies that takes a look at what types of computational technology and investments are best for improving health outcomes. Let the excuse not be that the data is trapped in systems that we built, that we have to wait for standards.
We need to enable this, and we can start to do it today. Just look at the Health Information Exchange in Wisconsin and CVS MinuteClinic. In the former, value is being added immediately to users in the ED, without requiring all the participating EDs to change their systems or to be standards compliant (or CCHIT certified). At MinuteClinics, summary after-visit health data are made available to customers online using the Continuity of Care Record standard.
There’s a proven model for extracting and transforming data in many ways—HL7 feeds, non-HL7 feeds, web services, database replication, XML and XSLT, and more—and along the way we can create value by interpreting the data and adding metadata. At Microsoft, we’re doing it today both in the enterprise with Amalga and across enterprises to the consumer with HealthVault. We hope other vendors follow this lead to drive better outcomes for patients, and we expect buyers of IT systems to demand vendors to meet this standard (excuse the pun). Where standards are available, we should leverage them, and where standards do not yet exist, we should output the information in a consistent consumable format for the install base.
I understand that there are many, many complicated aspects of this problem, including the need to reform our payment system. But we don’t have to work out everything first to begin building a better, more data enabled, data rich and accessible health delivery system now. David Kibbe did a nice job simplifying and laying out some core recommendations in his post, Five Shovel-Ready Health Care Reforms.
I have argued previously that HiTech should focus on investments which leverage existing digital data sources and drive better health outcomes. With the dollars that are being allocated to EMRs, it’s critical that the data is liquid and that the consumer is connected to the data in a meaningful way
I understand that this kind of disruptive change can be uncomfortable because the forces unleashed can lead to unpredictable results for specific stakeholders. But like the fall of the Berlin Wall, it is clear that the most important stakeholder—the citizen or patient—will be better off, and the other key stakeholders—providers, payers, policy makers, etc.—will participate in a healthier ecosystem. There will be profound, new opportunities for everyone in this future.
The time for excuses is over. Let’s tear down the walls and get the data flowing. We can do it now.
The current hot, behind-the-scenes, debate in HIT is around how “meaningful use” of HIT will be defined for purposes of the incentive payments provided in the HiTech portion of ARRA. Since there is a lot of money at stake and a lot of interested stakeholders, I am sure it will be an energetic debate.
Hopefully the definition of “meaningful use” will include some concept of improved health outcomes (Message to Washington - Its all about the Outcomes ). I know this presents many challenges, and I don’t pretend to have the complete answer on how to best define “meaningful use”.
As Zeke Emanuel remarked at our IOM meeting this week, specific suggestions are much more effective than general principles in rule-making – so I’m taking to heart his recommendation.
My simple, concrete, critically important and specific suggestion for incorporation into the definition of “meaningful use”? Make sharing data and actionable information with consumers a required condition of “meaningful use.” Specific and simple. I can add lots of characteristics to it – near real time, two-way sharing, portable, and so on – but the essential point is that consumer access to their own data has to be DEFINED as part of “meaningful use.” Consumers are the ones ultimately accountable for their health. If we don’t include them, we will miss this historic opportunity to create a new ‘platform’ for transforming care in innovative ways.
We need to think bigger. Folks in Washington talk about HiTech portion of ARRA as being a down payment on the future of health delivery. I am not sure what that means myself. But if it means we are building a platform for transforming care or creating a learning health care system – I know it must include connecting the last mile, which means incorporating the consumer and the home into the platform – by design.
The formal definition of meaningful is: full of meaning, significance, purpose, or value.
The key word for me in this definition is value. Unless the definition of meaningful use is extended to include the consumer, real value in way of improved health outcomes or return on this huge investment will never be realized.
Today I spoke at a very well attended Health Affairs event in Washington DC -- originally designed (months ago in a different time warp in HIT light years) to discuss lessons learned by folks leveraging HIT in effective ways, along with the usual challenges, issues and opportunities. Naturally the discussion was hijacked by the implications, potential consequences and opportunities raised by the ARRA stimulus act and the HITech portion of it in particular.
There is much to report from the event -- because there were a lot of smart and thoughtful panelists -- and because the issues are at the same time complicated, familiar and not super well understood. I don't have time to cover them all in this post.
There is a strong consensus (it showed up in comments from many panelists) around the theme I care most about -- which is we must focus on the outcomes one wants to achieve (better health outcomes at the same or lower cost) and then encourage innovation between providers and technology suppliers to deliver those outcomes. Said another way -- technology is a tool (a means) and not an end in itself. This is why health reform and the health stimulus have to be intertwined and self-reinforcing. Just spending money on HIT is not going to lead to the 'down payment' (i.e. future savings) that Obama believes it is.
Mark Smith brought this to life most effectively in his remarks -- that by adding a computer to Kramer's bookstore you don't end up turning it into Amazon.com. Kaiser reported in the article summarizing the experience in Hawaii with KP Healthconnect (EMR) -- that family practice office visits went down by 25+%. For Kaiser, an integrated delivery network and health plan -- that is a benefit to their bottom line. (I should note patient satisfaction went up in this period because needs were met by phone/email -- a totally win/win situation for Kaiser and consumer alike). For a more typical, small office family physician -- that is a disaster...because revenues are tied to visits. To succeed, we have to change the paradigm of healthcare away from the tyranny of the visit based payment system (Kramer's bookstore) and reward longitudinal care systems (future amazon.com). If we spend a bunch of money automating existing systems of care -- and not enabling new platforms -- we have missed the huge opportunity to make a difference.
Carol Diamond made the subtle, but I think hugely important point that has not fully sunk in to the folks waiting at the starting line of the HIT land rush -- that the public is going to expect accountability for improved outcomes with the stimulus spend. Health touches everyone -- and if the country spends $30+Billion dollars on 'investment' and the average citizen experience with the health delivery network is no different and costs continue to rise -- there is going to be accountability for where did the money go. She is rightly trying to focus the minds of the folks with the wagons -- better pick your spots wisely -- just getting a homestead isn't good enough -- it had better be productive land.
My biggest ah-ha moment came a few hours after the event in a conversation with the CEO of a large player in the healthcare supply chain. I realized that a significant portion of the Health Affairs event, the broader conversation about overall HIT investments and the specific conversation I was having ALL ACKNOWLEDGED and CONCLUDED that individuals (people, patients, consumers, whatever label we want to use) have a right to a personally controlled health record and that the personally controlled health data management platform is a critical component (perhaps a necessary component) of ANY FUTURE HEALTH IT SYSTEM and probably any payment reform system.
The ah-ha point is -- Microsoft has made a difference -- a huge difference -- by taking the leadership role it did 3 years ago by investing in building, defining, evangelizing, shipping and refining a personally controlled health data management system, HealthVault. We have a long way to go to make it easy, ubiquitous and fully connected -- and to deliver the value I know it will to consumers/patients in their everyday health lives. But I know it is a good and innovative idea and one that has changed and framed the debate in a positive way. While I have always believed that -- to see the effect and reality of the impact -- made my day.
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.
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
David C. Kibbe and Peter Neupert
Now that the Obama administration and Congress have committed to spending billions of tax payers’ money on health IT as part of the economic stimulus package, it’s important to be clear about what consumers and patients ought to expect in return—better decision-making by doctors and patients.
The thing is, nobody can make good decisions without good data. Unfortunately, too many in our industry use data “lock-in” as a tactic to keep their customers captive. Policy makers’ myopic focus on standards and certification does little but provide good air cover for this status quo. Our fundamental first step has to be to ensure data liquidity – making it easy for the data to move around and do some good for us all.
We suggest the following three goals ought to be achieved by end of 2009:
- Patients’ clinical data (diagnoses, medications, allergies, lab results, immunization history, etc.) are available to doctors in 75% of emergency rooms, clinic offices, and hospitals within their region.
- Patients’ doctors or medical practices have a “face sheet” that lets any staff member see an all-up view of their relevant health data, including visit status, meds, labs, images, all of which is also viewable to patients via the Web.
- Every time patients see providers, they are given an electronic after-visit report that includes what was done and what the next steps for care will be according to best practices and evidence-based protocols, whenever these are applicable.
Some who view this seemingly humble list of achievements will say that we can’t do it, because the standards aren’t ready, or the data is too complex. They’ll say that delays are necessary, due to worries about privacy or because too much data is still on paper.
We disagree. We believe that where there’s a will, there is going to be a way. And we already know most of what we need to know to achieve these goals. We know that:
- huge amounts of digital data exist, already formatted electronically, but scattered across many proprietary systems (meds, labs, images).
- software and the Internet makes it possible—in a low cost, lightweight way—to get data out of these databases to the point of decision making (to the ER doctor, the patient/consumer, or the primary care physician).
- people are hungry for information in whatever form they can get it:
- Getting it on paper is better than nothing
- Getting it quickly is better than getting it late
- Getting it in non-standard digital format is better than paper (software is pretty good at transforming non-standard to standard formats)
- Getting it in a standard format is better
- Getting it in a structured, standard format is best
- An integration “big bang” -- getting everybody all of a sudden onto one, single, structured and standard format—can’t and won’t happen.
We don’t have to wait for new standards to make data accessible—we can do a ton now without standards. What we need more than anything else is for people to demand that their personal health data are separated from the software applications that are used to collect and store the data.
This idea of separating health data from the applications is very important, and a better way to frame the discussion about how to achieve data liquidity than is the term “interoperability,” which we find cumbersome and opaque. Smart people, armed with software, can do incredible things with data in any format – so long as they can get to it.
Customers of health information systems want to re-use their health data, and in ways they haven’t always thought of or anticipated. However, many enterprise system vendors make it difficult or expensive to get access to the data—to separate it from the application. They believe that proprietary “lock-in” allows them some form of strategic advantage.
We understand that IT vendors are in business, and need to create strategic value for their products. And we are very much in favor of that—in rules, in workflow, in user experience, price and flexibility, and so on. However, vendors should not be able to “lock” the patient or enterprise data into their applications, and thereby inhibit the ability of customers and partners to build cross-vendor systems that improve care.
It’s possible for vendors to provide value without the need for lock-in. There are lots of examples of this, for example, the Health Information Exchange in Wisconsin and CVS MinuteClinic. In the former, value is clearly being added immediately to users in the ED, without requiring all the participating EDs to change their systems or to be standards compliant (or CCHIT certified). At MinuteClinics, summary after-visit health data are made available to customers online using the Continuity of Care Record standard. This is where the low hanging fruit is.
There’s already a proven model for extracting and transforming data in many ways – HL7 feeds, non-HL7 feeds, web services, database replication, XML and XSLT, and more – and along the way wecan create value by interpreting the data and adding metadata. Microsoft is doing it today– both in the enterprise with Amalga and and across enterprises to the consumer with HealthVault. We hope other vendors follow this lead to drive better outcomes for patients.
Unlike the physical world where there is a need for dejure standards—think railroad tracks—in the software world, there is much more flexibility and the standards that work are the ones that evolve from USAGE and market acceptance. The certification and standards road equals conferences, press releases, “connectathons”, caregivers-turned-bureaucrats. The outcomes road equals immediate benefits to actual caregivers AND learning we can apply to the next round, and the next, and the next.
We have given the industry decades to make this happen --- and just in the last 1-2 years have people finally gotten fed up and just started moving. Our great risk here is that the people lobbying for dollars and certification today are the people who are invested in the old road. With the amount of money we are talking about, we run the risk of just giving them another decade to delay and plan. Instead, let’s put the dollars into rewarding behavior and outcomes, and let the people who live with the problems every day figure out how to solve them.
When we set out to go to the moon in the 1960’s we didn’t say “let’s build a great rocket.” So, too, in this case we shouldn’t say “let’s buy a great IT system.” Our measurements should be tied to what we want – better care, informed by the data that is just out there waiting for us to use it.
David C Kibbe MD MBA is a Family Physician and Senior Adviser to the American Academy of Family Physicians who consults on health care professional and consumer technologies. Peter Neupert is Health Solutions Group Corporate Vice President at Microsoft.
