For many people, getting started with Total Recall means taking charge of their personal health information. Here are a few options for you to check out:

• Google Health lets your store your health data online. You can import data from some partner hospitals and pharmacies.
• Microsoft HealthVault also lets you store your health data online. A number of devices can upload data to your account. Some third party sites and applications use HealthVault for storage.
• Minerva Health Manager stores your health records on your PC, and also on a USB stick to share with a hospital, new doctor, etc.
• Polka’s My Health has a web-based interface that synchronizes with SmartPhones

From Total Recall blog

An interesting, and somewhat overlooked press release came out last week from the health information exchange (HIE) vendor Axolotl wherein they announced that a third party independent software vendor (ISV), eHealth Global Technologies, would be available on top of the core Axolotl HIE application, Elysium Exchange.  The new app, Elysium Image Exchange allows for secure image exchange among HIE participants.  Though the new application may appear like nothing more than Axolotl contracting out the building of an app desired by its HIE customers, there is a more here than meets the eye.

HIE Vendors as Future PaaS for Clinical Needs

Independent HIE vendors (not part of a larger EMR vendor) such as Axolotl, Covisint, dbMotion, InterSystems, Medicity and RelayHealth are in a unique position to become more than just an HIE focusing on the exchange of clinical records but could become Platform as a Service (PaaS) vendors providing a wide range of services and apps on top of their core infrastructure, OS and App Server stack.  The following two figures illustrate what is possible should these vendors open up their application programming interface (APIs) to allow other ISVs to build apps on top of their HIE platform.

HIE vendors are in an ideal position to become a PaaS for they already have the key features necessary.  As aggregators and distributors of clinical data in a secure fashion, these vendors have the core infrastructure already in place.  They have the data repository, they have the master patient index (MPI) and they understand what is required to address privacy and security requirements of data exchange within a network.  What these vendors, by and large have not done is open their APIs to third party ISVs to truly create a PaaS.

In speaking with Axolotl’s president Glenn Keet he stated that they came to the realization that they alone could not move fast enough to meet the needs of the market.  While they currently offer an CCHIT certified “EMR lite” for small physician practices there are a multitude of other services that they foresee.  For example, within the “meaningful use” criteria that physicians will need to demonstrate to receive reimbursement for EHR adoption, there are a number of quality reports that must be created and filed with CMS.  Keet envisions ISVs leveraging Axolotl’s APIs to create services to automate such reporting.  Meaningful use criteria also will require physicians to sponsor a PHR for their customers.  Again, with an open API, PHR ISVs could sit on top of the Axolotl (or other HIE vendor) platform and provide such capabilities. Clinical decision support (CDS) tools are another app/service that would be ideally suited to sitting on top of an HIE PaaS.

Microsoft is another vendor who is now venturing in to the HIE market with its Amalga platform, which is the foundation for the Wisconsin HIE (WHIE).  Using its core Amalga UIS along with HealthVault, Microsoft could also create a clinical PaaS with a multitude of ISVs providing services to the physician market. To date and to our knowledge, this has not occurred but we’re pretty sure Microsoft is looking into providing such capabilities as it would be in alignment with other actions that they have done to date in the healthcare sector.

What this may portend is the creation of PaaS that support the concept of substitutable apps as laid out by Ken Mandle and Issac Kohane of Children’s Hospital Informatics Program (CHIP) Boston. Another proponent is David Kibbe with what he refers to as Clinical Groupware a concept he first described back in Febuary 2009.  In each of these examples, the dominant theme is the move away from monolithic EMR/EHR apps to small, lightweight apps that are invoked when needed.  More information on this concept can be found at the recently created site: ITdotHealth.  (Note: Unfortunately, at the recent meeting at Harvard Medical School, Health Information as a Platform, which was organized by Mandl and Kohane, outside of Microsoft, there did not appear to be any representation from HIE vendors.)

An Opportunity for RHIOs to Become Viable?

A lot of effort and money is now being poured into the build-out of public Health Information Exchanges (HIEs) that are commonly referred to as Regional Health Information Organizations (RHIOs).  While many see it crucial to build out this information exchange infrastructure to support care coordination (a key criteria for stimulus funding reimbursement for EHR adoption), the challenge for RHIOs has been to create a business plan that insures long-term viability of a RHIO once grant funding drys up.  The market is littered with failed, failing and simply struggling RHIOs.  Recently, while sitting in on a conference call where a State RHIO discussed their go-live plans a question was asked: Do you have a model for sustaining the RHIO long-term?  To which the Executive Director of the RHIO replied, No.

But might not a RHIO that is actually a PaaS for a given region or State, become a provider of Clinical Groupware including a range of services and applications such as multiple lightweight EMRs to choose from, say one for pediatrics, another for orthopedists, a third for general practioners, quality reporting services, a range of CDS apps, etc. charging a small transaction fee for the use of such services and thereby begin to create viable service-based business? We think so and see this as the next evolution in the HIE market.

This has been a year that I will not be sad when it is laid to rest.

In June I fractured my right heel while hiking in Tevas. (Note to self, if you are hiking, where hiking boots!). July rolls around, a number of stressful events occur and I end up with some sort of stress related, intestinal nightmare. Been on Prilosec for last couple of months, saw GI last week, endo scheduled for mid-December.  Then, in a charitable act I do the local benefit ride, Hub on Wheels, only to go down in a wet corner, fracturing right wrist and receiving a nasty laceration above right eye.

How many separate institutions have been involved in my care over the last six or so months (physicians, clinics, lab and hospitals)?

Heel, 2: Radiologist and podiatrist, each separate practices.

Intestinal problem, 2: Primary care doctor (clinic), lab work, (clinic), specialist (Boston Medical Center).

Bike crash, 2: Trauma/ER (Brigham & Women’s), plastic surgeon (Faulkner Hosp.), orthopedist (brigham & Women’s).

Six separate institutions, each with their own separate systems, distinct policies and procedures for gaining access to/copies of one’s records.  And in my initial inquiries, I’ve yet to find any of these institutions that will provide my records neatly packaged in a common CCD or CCR format on a CD or USB that I could then easily upload into my personal health platform (PHP).  All institutions stated I can certainly get a copy, but it will require going to separate offices, facilities, filling out release forms what have you to get those records, and they will be, rum roll please…

on paper.

Since none of the institutions mentioned above have a relationship with either Google Health or HealthVault, if I want my information stored in one of these accounts, I will have to enter the information myself or use one of the services on these platforms (Health Postbox Express or yourHealth), which you can send your records to (or automatically retrieved from your clinician) and they’ll upload your personal health records for a small fee.

My God that seems like a lot of work. I work in this industry and find this task of collecting my records daunting.  Is it any wonder that consumer adoption of these platforms and PHRs in general is so lackluster?

There is a sliver of hope in that the meaningful use requirements for HIT adoption under ARRA do support consumer access to their records and better yet that physicians provide their customers a PHR in 2013 (still don’t know what that PHR might be, could be a disaster if it is nothing more than a tethered, portal view into EMR), but that still does not overcome the basic challenge for just about anyone:

• How do I get copies of my records?
• How do I know my records are complete and accurate?
• If the records are incomplete or inaccurate, how do I rectify?
• What format (standard) should I ask for if I have a choice?
• How do I get these records into my personal health record account?

These may seem like basic questions, but they are very real and there is no clear and compelling document out there today (if you find one please provide a link in comments section) that lays it out in plain English (or other language of your choice).

Google Health, HealthVault, WebMD, Dossia and PHR vendors are you listening?

What the market needs, heck what I need is a clear and concise QuickStart Guide that addresses the questions above. Any takers?

Another Health 2.0 Conference has come to pass and with broken wrist limiting typing fluidity, going to keep this synopsis short and sweet.

Not sure who said first impressions are lasting impressions, but coming up on the facilities that were to house this year’s Health 2.0 conference, I had a moment of trepidation upon seeing the signage for Health 2.0 (yes, the picture to right is real) with a back-drop of a funky auto parts and repair store across the street.  Once in the cavernous hall (note to self – cavernous halls should not concurrently house exhibits and stage) all went smoothly until one opened up the laptop and alas, no Wi-fi (actually there ended up being sporadic service but it was so bad as to be almost worthless).  An event focusing on Internet tools for health and no Wi-fi – am I in some sort of perverse David Lynch movie?

On to the event itself…

Highlights:

The Health 2.0 Accelerator demonstration was pretty impressive.  In the demonstration, nine different applications were used in a fairly seamless fashion to facilitate a consumer’s interaction with the healthcare system. A simple, yet powerful demonstration of what is possible when independent software vendors (ISVs) agree on some basic open standards, in this case OAuth and CCR to securely move data around a network. This example, while still a little too cumbersome or most consumers, points us in the right direction and might make an ideal case for the Health Internet.

Ability to meet many innovators in one place.  Health 2.0 is really the only game in town today that draws a wide range of innovators to one location.  J.D. Kleinke wrote a very good post on the event where he thought maybe the event was becoming a little too corporate.  I really do not see much problem with that, in fact, would like to see more realism demonstrated by these innovators through their articulation of clear and compelling business models, but I digress.

Best Demo: A tie, HealthVault & Quicken Health are the hands-down winners for best demos (outside of the Accelerator mentioned above).  HealthVault demonstrated their new “widget store” that is available within one’s personal MSN Health & Wellness account.  Leveraging data that one has in their HealthVault account, the MSN health widgets make that data truly actionable.  Over time, one can envision a health “AppStore” in MSN Health quite similar to Apple’s AppStore for the iPhone where ISVs build a wide range of health apps for the consumer that can be readily accessed all in one place.

While I have always had reservations about Quicken Health (too limited, only addresses one problem, financial) was very impressed with the architecture of the application.  Beautiful user interface, very nice tools built right in (e.g. hover over a given lab and you get a brief abstract of the lab test and its purpose). Another nice feature was the ability to contest claims, electronically, right from within Quicken.  Having dealt with many a mis-labeled/assessed claim before, that feature alone (no more voicemail hell) practically sold me on getting this app when it is released later this year.  Upon further thought though, better check with my payer first to see if they even would allow me to contest a claim electronically.

Excellent briefings with several companies including an update with Google Health, a deep and thoughtful dive with Within3 (keep track of them, they may have something if they move fast enough), a good update from Allviant (product CarePass is in beta), a great conversation, as always, with the folks of Polka and a surprising interview (amazed at how far they have come, more in near future) with MedHelp (another one to watch).

Disappointments:

While the Health 2.0 Accelerator succeeded, the Clinical Groupware session failed.  First off, I am not sure those in the audience fully understood what the term “clinical groupware” means and why it is important to consider.  Second, there was almost no discussion on what type of underlying architecture is required to make apps run in a clinical groupware environment.  So what we were left with was some very broad statements that clinical groupware is good for you, good for the industry, etc. but nothing about how it would actually work. Then there were the vendors in this session that did little to further the discussion.  Instead of demonstrating data sharing and substitutability of their apps, key tenets for clinical groupware to work, we were shown apps working in isolation.

Payers certainly have a voice in the healthcare discussion but do they really have a voice in the Health 2.0 discussion.  Certainly the organizers of this event think so but I differ.  Ultimately, it is employers that are footing the bill and have the most to potentially gain in offering their employees such tools.  And if not employers, how about the benefits consultants who advise them?  Getting quite tired of sessions composed of payers talking about how they always want to do good for their members.  Let’s be real, they want to maintain and/or improve margins and few consumers trust them.

The apparent fawning over the latest Health 2.0 rock star(s).  At the Spring event it was Jay Parkinson and Hello Health.  This fall it appeared that we had two: Roy Schoenberg of American Well and Adam Bosworth of Keas.  I’ll give credit to American Well to at least having a product/service in the market, but do they really need to be placed on a pedestal as the poster child for telemedicine? Roy is extremely polished and presents well, but hey, they are far from being the only game in town and not sure why they had two separate stage apearances, one on each day.  As for Adam and Keas, Adam certainly has a great publicist (gets an article on Keas in the NY Times on the first day of Health 2.0, coincidence, I doubt it) and is well known in IT circles, but he has also been extremely slow in introducing his product – suppose to go GA sometime this month.  So here we have a company founder without a live product in the market again being invited up on stage on two separate occasions.  Why, I can’t figure it out as my initial assessment of Keas is that it is a fairly simple product with low barriers for competing products (e.g., if Google put their mind to it, they could do the same with their search features and Google Health pretty easily).

The venue was just a disaster, enuf said.

Where are the established HIT companies, where are the intersections between these traditional ISVs that ultimately hold the data and these Health 2.0 ISVs looking to get their hands on it to power their services.  Bridges need to be built as today, Health 2.0 sits like an island, isolated in a very broad sea.

Wrap-up:

Health 2.0 is a great networking event.  Just about everyone in this particularly market is there and its always good to connect with people face-to-face as phone calls, emails, etc. only go so far.  Content of sessions though is a very mixed bag and appears highly slanted to those vendors who pay to play (sponsors, exhibitors, etc.) and not as expansive as it could be.  Hopefully, like many things in life, the organizers of this Fall’s Health 2.0 will learn from the many mistakes made and the next one will bring more value to attendees.

Over the past month or so on travel to a number of events, was a bit shocked to see all the attention being paid to the upcoming flu season and in particular, the H1N1 virus, commonly referred to as the Swine Flu.  It first caught my attention at MIT’s emTech’09 conference where everywhere you turned there was some poster encouraging you to wash your hands, or cover your mouth while coughing or simply defining symptoms of the flu and if you have those symptoms, isolate yourself.  Along with those signs and posters, were the little dispensers of disinfectants, again, seemingly everywhere.

Next up were the airports. Again, posters everywhere encouraging those with the symptoms to NOT get on the plane but go into isolation.  Luckily, I’m not a hypochondriac or else I doubt if I would do any travel this flu season.

But what really caught my eye at the San Francisco airport was the small booth set-up by Harmony Pharmacy, right there in the airport concourse giving out flu shots.  The two young nurses working there said they have been very busy giving flu shots, even though these shots are only for the broad-base seasonal flu and not H1N1, which is the nasty one we all need to be concerned about.

And how concerned you ask?

At the Health2.0 Conference held this week in San Francisco during a panel discussion, Google talked about their recently released FluTrends app, which they claim provides results on the spread of the flu about 1.5-2 weeks faster than what the Center for Disease Control (CDC) can provide.  Applying advanced analytics/algorthims to Google search inquiries, Google is able to put together not only a graph of how quickly the virus is spreading in the US (and numerous other countries) but more specifically where it is most concentrated.  With a virus as virulent as the H1N1, literally everyday counts and this service by Google may help providers in say Texas, or better yet a state neighboring Texas to prepare for the worst.

Not to be outdone on the panel, Microsoft made its own announcement (Press Release went out yesterday) on the panel of an on-line, flu self-assessment tool called the H1N1 Flu Response Center. The Response Center a flu self-assessment tool developed at Emory University that Microsoft has licensed. A very quick and easy self-assessment tool that concludes with stating either you may or may not have the flu and providing a list of next steps to take.

It is good to see both Google and Microsoft take a lead here and it certainly will not hurt their broader marketing health & wellness ambitions.  Personally, my only regret is not seeing the signs early enough to capitalize on this growing national issue, which if Google’s FluTrends is correct, it will be one nasty flu season.

Addendum:

Sean Nolan, chief architect has a new post that goes into far greater detail as to the background development of their flu assessment tool (built on the MSFT cloud service Azure) and the background analytics, using Amalga UIS for real-time tracking and trending data for research use.

Chilmark has not been a big fan of the National Health Information Network (NHIN) concept. It was, and in large part still is, a top heavy federal government effort to create a nationwide infrastructure to facilitate the exchange of clinical information. A high, lofty and admirable goal, but one that is far too in front of where the market is today.  The NHIN is like putting in an interstate highway system (something that did not happen until Eisenhower came to office) when we are still traveling by horse and buggy. Chilmark has argued for a more measured approach beginning locally via HIEs established by IDNs (our favorite as there is a clear and compelling business case) and RHIOs in regions where competitors willingly chose not to compete on data, rather seeing value in sharing data.

But what might happen if the folks in DC stopped talking about the NHIN as some uber-Health Exchange, but instead positioned it as a consumer-focused platform?

That is basically what happened yesterday at the ITdotHealth event where the new federal CTO, Aneesh Chopra and new HHS CTO Todd Park presented their conceptual idea to a pretty select group who had gathered together to discuss the idea of platforms in HIT to support discrete, substitutable, modular apps. (John Halamka gave a nice write-up of the event in which he participated on the first day).  Chopra and Park were seeking to float this idea among the movers and shakers of new models for HIT, gauge the interest and ultimately solicit support for the concept.

In somewhat of a re-branding exercise. Chopra and Park are proposing that the NHIN now be viewed not so much as solely a clinician to clinician care coordination exchange platform but rather one that also will focus on the consumer, creating a secure Health Internet to facilitate consumer access to and ultimately control of their personal health information (PHI). The basic NHIN, let’s now refer to it the Health Internet, is still composed of the same technology stack: platform independent, open source, freely available with published standards, etc. that support an independent software vendor’s (ISV) ability to build apps upon the Health Internet stack for consumer consumption (e.g., health & wellness services, PHRs, etc.). In June, we attended the NHIN CONNECT conference and our write-up provides a few more specifics on the Health Internet.

At the ITdotHealth event many of the participants (Google Health, HealthVault, MinuteClinic, etc.) stated that they “are in” and are willing to work with the feds to insure that their respective platforms/services will be able to readily connect to and exchange PHI upon a consumer’s request over the Health Internet.  Even EMR giant Cerner voted tentative support for the idea if the Health Internet would assist them in helping their customers (clinicians, clinics, hospitals) meet some of the forthcoming meaningful use criteria that is now being formulated by CMS – Chopra at the June CONNECT event and Park at this one basically inferred that providing the capability for an EHR to connect to the Health Internet would address some aspects of meaningful use.

Chopra also stated that he has the support of numerous federal agencies (DoD, CMS, and other agencies) who are now working together with HHS to define how the Health Internet might serve their respective constituents.  These agencies have not yet formally committed to allowing PHI to migrate to the Health Internet, but today are addressing the critical process issues of consumer access, control, and consent as it pertains to on-ramping PHI to the Health Internet. Chilmark believes that these issues will be resolved within the year.  When that happens, we can expect some pretty significant movement of PHI across the Health Internet.  For example, the DoD alone has nearly 4M active duty members (multiply that by 2.2 for dependents and the number skyrockets to over 8M) whose PHI may begin to flow on the Health Internet.

And it is not just Google Health, HealthVault or others that may be beneficiaries of the Health Internet.  In speaking with a representative of the VA (yes, VA is a supporter as well) he related that this will allow veterans an opportunity to choose the best services out there in the market to assist them in managing their health.  No longer will the VA have to try and create such apps themselves, or find partners to create the apps to sit on top of the VA PHR HealtheVet. Instead, the VA can simply direct a veteran to the Health Internet where such services will reside and instruct a vet as to how to access those services.

This is exactly what Chopra and Park envision with Chopra adamantly stating at the beginning of his talk that they seek, through the Health Internet, the creation of a fertile environment where innovation can flourish and ultimately consumers will benefit.

Finally, HHS & the Feds are Talking About the Consumer

Chilmark has been quite disheartened as of late with the lack of attention paid to the consumer, the citizen who is footing the bill to get doctors and hospitals wired.  We chided the HIT Policy workgroup for HIEs for their complete lack of acknowledging the consumer’s role and ownership of PHI.  We came back from DC recently disillusioned at the nearly myopic focus of ONC on clinicians.  Chilmark is concerned that the $44k allotted to a physician to adopt an EHR is not enough, another forcing function is required and what better forcing function than the citizen, the customer of the physician to drive adoption of EHRs.

Low and behold others at HHS and elsewhere had similar feelings and are now moving aggressively forward with a concept that directly addresses the consumer. Hallelujah!

The Plan:

At the ITdotHealth meeting, Park and Chopra stated that if interest is high (sure seemed to be at this meeting), they wanted to take that feedback back to DC and work with the federal team to start laying the groundwork to get started ASAP.  Hypothesized goals and objectives include:

The federal team will begin by working with industry stakeholders (PHR providers, EMR providers, services, hospitals, fed agencies, etc.) to identify the gaps, determine if the existing protocols are adequate and lay-out a roadmap to rectify. They also stress that they will seek involvement of consumer representatives and privacy advocates to insure their input is included early on in the process.

By February 2010, begin filling the gaps and modify protocols and standards where necessary.

Launch beta in early Q2′10 moving mock PHI over the Health Internet to test the system, make modifications and hardened the network.

Though they did not go so far as to say when the Health Internet will move live PHI, our estimate, assuming all goes relatively smoothly, is that the Health Internet will be open for business by late Q2-early Q3′10.  This is a very fast track for the Health Internet, but certainly doable as the core infrastructure is already in place and this exercise is more of a fine tuning effort, than building from scratch.

Putting on the Pragmatist Hat:

Chilmark is very encouraged by the idea of the Health Internet and the new direction it is taking, creating a consumer directed and controlled interstate for the secure transfer of PHI. Not only does it finally acknowledge that at the end of the day, all the HIT spending in the world will make little difference if we do not get the one who has the most to gain, the consumer, involved, but this initiative may also create a fertile environment for innovation to occur.

But there are some challenges ahead for the Health Internet, which include:

The DURSA (Data Use & Reciprocal Support Agreement), which all NHIN (Health Internet) users (data providers, services, ISVs, etc) must sign to participate, stipulates that participants must abide by HIPAA requirements. Now HealthVault is on record stating that they have no problem with HIPAA, but Google is another story where they have been fairly adamant that HIPAA does not apply to them.  Will Google now agree to HIPAA?  And what about other ISVs and service providers, will they adhere to the requirements in the DURSA?

Beyond the feds and HIPAA requirements, there is a morass of state-specific laws as it pertains to the release of PHI, many of which go far beyond HIPAA in  their requirements.  As the Health Internet looks to create one common “health interstate” for the movement of PHI, how will these state laws be reconciled to allow this to occur?

Lastly, there is the issue of bringing awareness to the public.  While the vast majority of consumers use Google for a second opinion, very few use the Internet to store, access and share their records.  Very few even know what a PHR is.  Whenever the topic is raised in conversations with lay people, maybe one person might have heard of Google Health or HealthVault, but it is a rare person indeed that has any understanding what these services are for and why they might be interested in using such a service. This may ultimately be one of the biggest challenges for Chopra and Park, but to their credit, they are making the right moves now, garnering industry backing who can assist them in “getting the message out.”

Chilmark Research will assist as best it can from its vantage point.

Aneesh and Todd, we are in!

On September 14th, Children’s Hospital of Boston made a joint announcement with eClinicalWorks (eCW) whereby ambulatory practices affiliated with Children’s using eCW will be able to export patient data into “MyChildren’s.” MyChildren’s is the personal health platform (PHP) that Children’s Hospital provides for its customers and is based on Indivo, the open source PHP that was developed at Children’s and is the foundation for Dossia.  On Friday, Sept 18th, Chilmark Research had the opportunity to speak with the key people at Children’s who are behind this initiative (Dan Nigrin, CIO, Greg Young, heads up PPOC (affiliated practices) and Ken Mandl, Harvard Prof and key person behind Indivo) to gain a better understanding of what they are doing and its significance. Here’s what we learned.

Some background:

Children’s Hospital, which is affiliated with Harvard has the Children’s Hospital Informatics Program (CHIP) which developed the Indivo platform and has always been a very strong advocate of the concept of the “patient-controlled medical record.”  Their initial work, both technology and policy, led to Microsoft’s HealthVault, Google Health and Dossia, all of whom have adopted similar platform models and policies regarding consumer access and control of their personal health information (PHI).

About 3 years ago, Children’s group of affiliated ambulatory practices, PPOC, (about 75 in all) made the joint decision to go digital and adopt an EMR solution, in this case eCW in a hosted delivery model (ASP).  Today, the majority are now live with eCW and the balance, with exception of ~5 practices who have chosen not to adopt, will be live by Sept 2010.  Children’s Hospital uses Cerner as its EMR.

Children’s did a “soft” release of MyChildren’s in mid-April’09.  Little promotion to date and currently about 1200 users.  Soft launch was intentional to understand user needs and desires as well as await a larger, more aggressive launch in late 2009.  In early 2010, MyChildren’s will transition to the latest Indivo release, IndivoX.  It is also in early 2010, that data will begin flowing from eCW EMRs in affiliated practices into a patient’s MyChildren’s account.

The Offering: eCW, Cerner and MyChildren’s:

By connecting the affiliate practice EMRs to MyChildren’s a parent will be able have a more complete longitudinal record of their child.  The data elements that will flow into a MyChildre’sn record include immunization records, allergies, ambulatory lab data, meds, basic physical measurements (height, weight, BP, etc.) and problem lists. An interesting tidbit we learned during the call is that growth data is absolutely critical in evaluating the health of a child.  Thus, getting this data from the ambulatory setting is an important objective for Children’s in monitoring the long-term health of its patients.

MyChildren’s will support the creation of specific care plans based on specific diseases/conditions, e.g. asthma, that are a combination of template and physician input drawing data from the MyChildren’s platform that is specific to the patient/child.  MyChildren’s will also enable a parent to automatically create school and camp health forms.  Like the care plans, the school/camp forms will draw upon the data MyChildren’s collects from both ambulatory (eCW) and inpatient (Cerner) encounters to populate the forms which can then be printed and submitted to the requesting body.

Inpatient lab data will not be imported into MyChildren’s, which we found odd.  Children’s explained that in the inpatient setting a significant amount of lab data is generated and they did not want to overload a given patient’s account.  This may indeed be true, but can they not at least provide a subset of that data, that which is most critical to both a parent and possibly an affiliated practice?  This has come up in internal discussions and is being evaluated.

In the future, they will also be importing pathology results, images and clinical notes into a MyChildren’s account.  When asked about after visit summaries (AVSs), Children’s stated that this is another element they are considering but do not have specific plans today. They have purposely decided not to import genetic data into MyChildren’s.

One of the more interesting aspects of this announcement is their intention to use Indivo (MyChildren’s) in an HIE capacity.  Specifically, inpatient Cerner data will pass through Indivo and on out to affiliated practices and vice versa.  EMR users in either setting, inpatient or outpatient will be able to readily pull-up data within their native EMR (that is parsed through MyChildren’S) thereby minimizing disruption to existing work-flow practices.   Granted, this is not as high-powered as say a native HIE solution from someone like Axolotl or Medicity, but it does solve the immediate needs of Children’s for a very nominal cost.

The Wrap:

Besides walking the talk by supporting consumer access to and control of their PHI, Children’s Hospital is putting these processes and practices in place via MyChildren’s to support the patient-centric medical home concept which they believe will continue to gain acceptance and support among policy makers. Here in Massachusetts where healthcare costs have continued to escalate at an alarming rate, payment reform is now a top discussion topic with the medical home concept receiving significant consideration.  Children’s sees the writing on the wall and is taking a proactive approach.  Hat’s off to them.

It is also good to see how a PHP (MyChildren’ in this case) can become the nexus for care, a nexus where the patient is truly at the center, where they are in control of their PHI.  Supporting this patient-centric care model is rare.  Sure, many healthcare providers will state that they support the concept, but it is hard to find many that actually put it into practice.  Children’s Hospital of Boston, along with others such as Kaiser-Permanente, Beth Israel, Cleveland Clinic, Mayo, and even more recently New York Presbyterian are leading the way.  Question now is: How far back are the followers and how quickly will they come and join this growing and inevitable trend with more than words, but actions?

This year was Chilmark Research’s third AHRQ’09 event. The previous two we attend in 2007 and 2008 left us, how shall we say it… underwhelmed and really did not have much intention of attending this year.  But that was before ARRA, before meaningful use, before certified EHRs, and certainly before we were asked if we would be interested in presenting and moderating a session entitled: PHRs, What are they good for?

Of course we accepted the invitation to present and moderate the PHR session and well, with so much else happening in DC right now, probably would have attended regardless to get a read on the market from the rarefied air of AHRQ grant recipients.

Unlike past events that were composed strictly of AHRQ grant recipients, AHRQ employees, and numerous beltway bandits (they prefer to be called govt. contractors), this event took quite a different tack casting a much broader net bringing in all sorts of presenters from government, academia, numerous NGOs, private sector, some patients, etc., all who have never received an AHRQ grant.  While I did not have a chance to interview the countless AHRQ grant recipients in attendance (still the majority) on this new format, those I did talk to found this new approach refreshing and enlightening.

From our perspective, this is now the best bang for the buck healthcare event today in the US (it is free after all), something we would not have said last year.  Congratulations to the AHRQ Team that pulled this together – you did a fabulous job in bringing a wide range of viewpoints and perspectives to this event and we are quite positive that all attendees came away with something of value.  Now, if we could just do something about that Godawful website of yours.  Suggest you pick up a copy of Don’t Make Me Think and give it to your Web development team – in fact, by a case of that book and distribute it throughout HHS as we find virtually all properties to hurt our feeble minds.

Key takeaways from the event:

Our concept to push beyond the PHR term and start talking about PHPs was very well received by many in the audience of the session we moderated.  Several came up to us afterwards and talked about their own “platform” initiatives.  Also, was surprised (probably shouldn’t have been) that Kaiser-Permanente is now looking beyond their successful Health Manager to a “Web Presence Platform” for their members.

Patient safety improves by leaps and bounds when transparency is applied and patients are provided a mechanism to report errors that are taken seriously.  Twenty-five percent of errors are easy to understand, report and rectify, its the other 75% that are extremely challenging. The best approach to address that 75% is through close collaboration between the patient and their care team. Unfortunately, there are few examples and mechanisms in place today as to how to facilitate this process.

University of Illinois – Chicago has done some absolutely amazing work on patient safety front with some very novel approaches, e.g. residents have to report at least five mistakes in a given period to move on and applying analytics/reporting to weed-out the physicians with the highest number of complaints and errors..  And guess what, their liability insurance coverage costs have plummeted.

Regarding patient safety, results of a large consumer survey found that consumers seek five key things:

• An explanation & recognition of responsibility,
• Accountability,
• Evidence of action taken to insure future risk in minimized,
• An apology,
• Personalized response to their specific case, no form letters!

Pretty commonsensical to us, but that is the funny thing about commonsense, it is rarely common.

HHS has some great people doing great things but HHS marketing S*ucks (don’t believe us, go back and just look at their websites and take it from there).  This results in few knowing of the good work and initiatives occurring within HHS.  For example, the creator of healthfinder.gov spoke about how they looked closely at user interactions to improve the site and also how they rebuilt it to address prevention rather than disease.  Healthfinder.gov has a wealth of information that has been fully vetted, really a great resource, and even better, its for free.  At AHRQ’09, Healthfinder told us they are now developing a widget that can be freely installed on any website, which will allow a user to enter very basic demographic info and get preventative health content that is relevant to them.  So all you small start-ups, you don’t need to begin paying for content via third parties such as Healthwise but instead could begin by installing the new healthfinder widget for fully vetted health prevention content.

GE launched a global initiative across all sites with 100 or more employees entitled “Healthy Worksite”.  Currently 95% of sites are participating.  In the future, GE will “certify” sites if they meet certain metrics such as:

• Insuring that 70% of food served at the onsite cafeteria are healthy and providing a 20% discount to employees for purchasing “healthy food.”
• Site has an active smoking cessation program in place.
• Site provides incentives for employees to participate in fitness programs.

In return for being certify, not only will the worksite be a good corporate citizen of GE, but will receive worksite bonuses/paybacks in the form of lower healthcare costs (premiums) they’ll have to pay.

An interesting aspect of the GE program is no support for an employee sponsored PHR.  Rather, GE will simply provide employees links to various sites (both payer-centric, e.g. Optum or independent e.g. WebMD or provider, e.g., Mayo or Cleveland Clinic) and let the employee chose whether or not to participate.  And in a change from the norm, GE plans to measure net employee participation in prevention programs rather than more specific health information to avoid the nasty tangle of PHI.  Not sure how they’ll do this as in 2010, they’ll be launching a company-wide health risk assessment (HRA) program.

Lastly, coming out of the PHR session we moderated was the finding from Group Health that After Visit Summaries (AVSs) provided to patients after a visit have been transformative to care. Maybe, just maybe there may be a tie-in between what the Univ. of Chicago has done on the patient safety reporting front and what GHC has done with AVS.  The parallels are there. Both rely on close, collaborative and honest communication, both are transformative to the practice and delivery of care. Both need the patient and at times, the family involved – they need their input, their voice. Both lead to the opportunity to lower errors and improve outcomes and in doing so provide the opportunity to lower healthcare costs.

Yesterday, we outlined why the PHR term has the potential to stunt future advances in consumer health and engagement via HIT.  Our thesis is that the PHR term is rooted in a dated concept of simply providing the user/citizen a virtual file cabinet for their health records.  Since the initial introduction of Internet-based PHRs nearly a decade ago, adoption has been by and large abysmal.  Our belief is that adoption, or lack thereof, is symptomatic of PHRs not having a sufficient value proposition for the vast majority of potential users.

But where we really get concerned with the PHR term is that in the meaningful use recommendations that were accepted in July.   Under meaningful use guidelines, those obtaining Stimulus (ARRA) funding for adoption of a certified EHR must provide a PHR to their patients by 2013.  Trouble here is how will HHS define what that PHR is?  Last year, HHS paid a princely sum to have the PHR term defined (see below).  This term, we have been told, is what will be used within the context of meaningful use rule making.  If this is indeed true, adoption of PHRs will continue to be lackluster.

PHR, Personal Health Record: “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.”

To move beyond the limitations of this definition (and the baggage that goes with it) Chilmark proposes a new term, Personal Health Platforms (PHPs) with the hope that others will pick up the banner moving us beyond where we are today and hopefully get HHS to look beyond the narrow confines of the PHR definition that they have before them.

What is a Personal Health Platform?

Our proposed definition is as follows:

A Personal Health Platform (PHP) is an Internet-based platform that securely stores and manages a citizen’s personal health data, data that may be derived from multiple sources including among others clinical systems, payer systems, self-enter data, and biometric.  The PHP also provides the framework and capabilities to support applications, services and/or tools that a citizen may invoke to leverage their personal health data enabling the citizen to make better, more well-informed decisions regarding their health or the health of a loved one.

The second sentence of that definition is the key differentiator. A PHP does more than simply store the data, it makes that data actionable.

While the acronym may be new, at least in the context of healthcare, the concept is not.  There are a number of examples of PHPs in the market today with WebMD arguably one of the most well-known.  Microsoft’s HealthVault, Google Health and Dossia are other examples of PHPs.  One could even argue that tethered systems such as Kaiser-Permenante’s MyChart is a PHP for MyChart provides a wide range of services to K-P members.  In each of these examples, the PHP is not just a repository for health data but provides users various tools, apps and services that leverage that data to enable a deeper level of engagement, something a PHR, as defined above, cannot do.

As an example, Sean Nolan, Chief Architect for HealthVault recently talked about how one might leverage HealthVault ecosystem partners medLAB and Keas leveraging lab data to create personalized care plans.  Another example is the recent partnership between Medikeeper and change:healthcare wherein change:healthcare will become a widget on a citizen’s Medikeeper dashboard enabling the citizen to make wiser, more cost effective health decisions that are based on health data stored in a Medikeeper account.

Now that we have introduced the term PHP, and the justification for the need of this term in future policy discussions, our next step is to create an ontology for the PHP market.  You’ll have to stay tuned for that one which we hope to get out next week between our trip to the AHRQ conference and the Health Data Management event in Boston.

Michael J. Astrue, Commissioner of Social Security, announced today that the agency has entered into an agreement with Microsoft to test the use of Microsoft’s HealthVault application in the disability process. HealthVault is a free online service that enables people to gather, store and manage their families’ health information, and share that information with their physicians and healthcare providers. These “personal health records” contain the same types of information that Social Security generally obtains from people applying for disability benefits.

“The use of personal health records holds great promise for ensuring that the medical information we collect from someone applying for disability benefits is accurate and complete,” Commissioner Astrue said. “Combined with other advancements in health information technology, our use of HealthVault should result in faster decisions for disability applicants. I look forward to working closely with Microsoft, a world-wide leader in information technology.”

Social Security and Microsoft are developing a technical prototype connecting the two organizations that will be available later this year. The agency also will collaborate with Microsoft to study current personal health record standards, gaps in those standards, and options for filling those gaps.

Social Security is a recognized leader in the use of health information technology. It is the first government agency to use the Nationwide Health Information Network (NHIN), a safe and secure method for receiving instantaneous access to electronic medical records. The NHIN is an initiative of the Department of Health and Human Services and is supported by multiple government agencies and private sector entities.

source

Scott Shreve, formerly of Medsphere, wrote a good post imploring Google to get back into the Personal Health Cloud game, a game where Microsoft HealthVault now appears to be the only game in town.  Everything Scott says in his post Chilmark Research agrees with and we would even go so far as to say that Google Health has been nothing more than a distraction to the broader market.  A distraction in that Google Health has really done very little to create a truly compelling platform, yet due to its size, market presence and media and market pundits belief that Google is the be all to end all, Google Health gets far more press and attention than it rightfully deserves.

As Scott points out, it is not as if the Google Health team does not have a lot of good people working for them.  All who I have met have a passion for what they do.  No, the problem is not with them, it sits higher-up in the corner office where senior Google execs have yet to dedicate the resources to truly make the Google Health platform a viable alternative to HealthVault.  Yes, Google has made a some announcements, most recently with regards to Advance Directives, over the last several months that demonstrate that the team continues to build functionality into the platform, but none of this functionality is new, none of it novel, none of it that goes beyond what HealthVault had at least a year or more prior. (Note, the Advance Directives feature is pretty significant as it signals a change to the core data model of Google Health allowing it to store unstructured data – something that Google Health did not support previously.  This does open numerous opportunities for expansion of services within this platform.)

And don’t even get us started on Google Health’s abysmal efforts in attracting new partners to the platform to create a truly viable ecosystem…

The sad thing is that innovation is driven as much by competition as it is by shear creative inspiration.  Without a viable competitor, HealthVault may become complacent and we, the consumer of such services will ultimately pay the price.  Please Google, for the sake of all, at least quintuple the size of Google Health’s team so that it is at least a tenth the size of HealthVault’s.  Maybe then we will begin to see some sign of a viable competitor, a viable platform and a viable choice for the consumer and Google Health will once again become relevant to the market.

On July 16th, the Office of the National Coordinator for Health IT (ONC) held a lengthy meeting of the HIT Policy Committee where a wide range of topics were addressed by various workgroups.  As we reported earlier, the Meaningful Use (MU) Workgroup presented the second draft of recommendations, that were approved.  Over the course of the day, the Policy Committee also heard from the Health Information Exchange (HIE) Workgroup and the EHR Certification and Adoption Workgroup.

Now there has been a lot of fussing about just what constitutes an HIE as well as the bigger issue of how do the feds insure that HIEs of one form or another are in place to support the MU criteria for information exchange.  Looking at the slides that the HIE Workgroup used for this meeting, it appears that they were attempting to first educate the broader committee on just what an HIE may be, what types of data may flow through an HIE in support of MU criteria and finally some recommendations to consider for HIEs to support overarching HHS objectives.

In reviewing these slides Chilmark was struck by the four models used to represent HIEs today (see below).  First thing we thought of upon looking at these models is: These models only represent what is being built today and more importantly, completely ignore the consumer/citizen and their future control of personal health information (PHI)? Where is citizen’s PHR or personal health cloud account (Dossia, Google Health or HealthVault)?  Are these PHRs or health clouds not HIEs in their own right, albeit truly citizen/patient-centric?  The HIE Workgroup appears stuck in old models, models that have struggled to prove themselves relevant and viable to the market.

Roughly a week after this meeting, on July 22nd the eHealth Initiative (eHI) released the results of its annual survey of HIEs, the sixth year they have done so.  Through the generous sponsorship of HIE vendor Axolotl, one can get the full report for free and on Aug 4th, eHI will host a free webcast to go over the results.  While the report had many positive things to say about the current state of HIEs, claiming that more are operational, more are showing some form of return on investment (either soft or hard) and that more data is being exchanged, Chilmark found it interesting that the primary issue facing HIEs today is “Privacy and Confidentiality.”  With stricter HIPAA consumer consent criteria forthcoming as the result of the passage of ARRA legislation, this will only become more difficult.

Another small bit of information tucked into the eHI report are some numbers regarding consumer access to their PHI within an HIE.  Of those 67 operational HIEs today, a paltry 12% have some form of consumer access to their PHI.  Might not greater engagement of consumers by these HIEs lend not only public support for HIEs, (and future funding as well as relevancy- both still a nagging issues) but also address the biggest issue HIEs are confronting today, privacy and confidentiality?

Then one goes back to look at the models presented by the HIE Workgroup, models that have no place for the citizen. These are not models that the public can readily support for the public has been completely left out of the equation.  And ARRA legislation has given $300M in taxpayer/public money earmarked for HIE development over the next two years…

Hold on here, we need a major rethink on what an HIE is, who an HIE serves and the relevancy of HIEs to the public interest.

Granted, Chilmark will cut the Workgroup some slack as they are, we believe, making these recommendations with the best of intentions.  What is troubling though is that this Workgroup has failed to create a vision for HIEs that not only supports MU criteria, but more importantly, supports the citizen’s need (and possible desire) to take greater stewardship of their health records.  What the HIE Workgroup has proposed instead is a continuation of the status quo, which is truly unfortunate at a time when we as a nation are looking for new approaches to better engage citizens in self-managing their health, fostering healthy behaviors and empowering them to make wiser healthcare decisions for themselves and their loved ones.

It is time to move away from such paternalistic models so prevalent in healthcare today and represented in what the HIE Workgroup presented on July 16th. Let us create a new vision for HIEs that puts the citizen in the center.  Thankfully, there are some thoughtleaders adopting this model, best represented by the efforts in Washington State, which now has three healthbanks, two using HealthVault the third using Google Health.

July 6th, 2009

Posted by Dana Blankenhorn @ 5:06 am

It’s hard to argue with Microsoft HealthVault’s market momentum.

Every week seems to bring another release in which HealthVault is partnering with some other major industry player. Walgreens. HealthPartners. CitiusTech. The American Medical Association. Etc. Etc. Etc.

David Cerino general manager for the consumer health group at Microsoft, which includes HealthVault, credits the product’s tight integration with Microsoft’s Amalga software system, coupled with the fact this is not required, with helping HealthVault gain traction.

I really believe the way we’ve architected and built HealthVault, and the open platform, has excited a lot of partners.

It’s not only going to be consumers managing their health care on their own, but a lot of core data is sitting in source systems in hospitals, medical offices, pharmacies…a lot of people see we look at the ecosystem from the point of view of source data as well as consumers.

Translation. Google may be LeBron James but Microsoft is Dwight Howard, and you don’t pull on Superman’s cape.

The key to success in building a Personal Health Record (PHR) business, it turns out, is accessing the Electronic Health Record (EHR) data that hospitals, pharmacies, insurers and others have in their online silos. Microsoft and Cerino have done their homework.

That is now paying off, as Microsoft moves from hospitals and pharmacies to insurers, the big dogs in the health data business. “We have a partnership with Aetna that moves data into HealthVault. We’ve announced Health Partners and a couple of the Blues.”

Fort those companies, “The value proposition can’t be that if you leave we hold your data.” Not with health reform on the way. But since Microsoft has proven it’s a player in health care data, the insurers turn to it first.

Cerino compares what is happening with PHRs with what happened earlier this decade with online banking, which is the territory he covered before this.

So far, however, most of what has been happening in the PHR world is market “push,” owners of data pushing patients to take possession of it online. What seems to be lacking is market “pull,” which could come from social networks devoted to specific diseases and conditions.

” We’re always talking about it and looking at it. We look at a site like Diabetic Connect expanding and putting an application online, which we could integrate with. It could integrate healthcare devices and allow a different type of health management, and connect that to the provider.”

So Cerino not only has success and momentum, but a definite strategy. Eventually, push meets pull and HealthVault is at the center of it.

“Social networks are the consumer swell. If they demanded physicians deliver data electronically it would have happened. Then there’s the professionals’ side.  What’s the value for them? The two will start to converge.”

Microsoft is putting itself in the position to be the only answer to that question of convergence, once it is asked by enough people.

The feds are beating the CONNECT drum. This week, ONC sponsored a two-day event in DC to begin educating the market as to what CONNECT is and how it may be leveraged to support information exchange.  At least that is the impression one had in signing up for this event.  In actuality, the event was somewhat schizophrenic in gyrating back and forth between the National Health Information Network (NHIN) and CONNECT, the software platform upon which the National Health Information Exchange (NHIE) and intra-agency network.

In terms of attendance, probably close to 700, with a huge contingent of consultants (beltway bandits) such as Harris, Northrup, MITRE, IBM, SAIC and of course Sun (soon to be Oracle).  Event also attracted high level visibility with ONC head David Blumenthal kicking off the event, followed by Obama’s new CTO, Aneesh Chopra.  (Note, for all of you developers out there, Aneesh talked about government transparency and the new data.gov site. Though in its infancy, released just over a month ago, data.gov may provide some interesting mash-up opportunities but unfortunately lacking healthcare data.)

So what is CONNECT?

In simplest terms, CONNECT is a technology stack built with Open Source software (Sun-derived) to support the development of the NHIE and more broadly a NHIN.  Thus, from the onset CONNECT has had broad participation from the likes of CMS, the VA, DoD, Bureau of Indian Affairs and the first true test case user, the Social Security Administration (SSA) who recently completed a successful beta test of the platform with RHIO MedVirginia.  In March 2009, V1.0 of CONNECT was released to the market.  On July 9th, V2.1 will be released.  While CONNECT was developed to create an NHIE, it longer-term goals are to become the backbone to the NHN.

CONNECT was built on Open Standards, mostly the Sun open source stack.  The underlying database today is Sun Solaris, on top which sits a common 3-tiered architecture built with Java tools.  Directly above the database is the secure, NHIN messaging layer for secure transport.  A Services layer for query, search, patient identification and exchange sits above messaging. The final layer is the “Profile” layer for specific domain functionality and the building of novel apps such as those for biosurveillance, population health, quality reporting, etc.

In building the core CONNECT platform, developers paid special attention to keeping functionality to a minimum to insure flexibility and enable innovation as the NHIN gains traction.  Naturally, Web Services are supported within the context of CONNECT’s core SOA.  For the consumer preference profile, CONNECT developers adopted the OASIS standard, XACML.  The CONNECT services directory uses UDDI V3.0.

And Current Thinking on the NHIN?

John Glaser, who was also on the agenda listed five key activities of the NHIN development:

1. Create and demonstrate a series of standards and protocols for defining data exchange at State & National level.
2. Establish DURSA (Data Use & Reciprocal Support Agreement) & legal agreements for data exchange.
3. Establish governance mechanism to set path for future development direction of the Open platform.
4. Conduct a series of demos to test functionality, usability and value.
5. Promote development of “interstitial technology” for NHIN platform to make it actually functional and useful (e.g. patient identifier).

And in grand style, Glaser went on to conclude that the NHIN sets the “framework, the structure and foundation” for broader future exchange in support of “meaningful use.”  In fact, throughout the first day numerous speakers would keep circling back to meaningful use, the HITECH ACT, ARRA etc. and how CONNECT fits in.  Many of these connections between CONNECT and ARRA legislative language were quite a stretch of the imagination making one wonder why the need for such over-reaching justification? Does CONNECT really need to be so heavily pitched to the market to justify its existence and promote its adoption?

Business Model Anyone?

Maybe one of the biggest red flags was a complete lack of discussion over the course of this two-day event on viable business models for Exchanges, a notorious issue that most public-sponsored Exchanges have struggled to address. That’s not to say the money is not there, it just seems as though the policy wonks in DC and the multitude of beltway bandit contractors that the feds (HHS) hires just don’t think about this issue, or just do not know how to address it.

For example, currently, the SSA spends $500M/year (yes a half billion dollars a year folks) on converting medical records to a digital format, and that has nothing to do with the huge back-load of disability claims that SSA is trying to address which has its own hidden costs to both providers and the SSA.  Now there is a business here, we’re sure of it and CONNECT might play an important role if one were to develop a novel “interstitial app” on the platform that would facilitate the SSA in addressing this problem.

Addressing Data Ownership: The Bane of Most Exchanges

In Chilmark’s past research on Exchanges, beyond establishing a viable business model, data ownership within the Exchange is an extremely difficult challenge where it appears only the lawyers come out ahead.  For the CONNECT NHIN, the initial consortium has drafted a DURSA that addresses virtually all aspects of data exchange and use, from consent, to obligations to permitted purposes for using data and ultimately data ownership.  The DURSA is currently undergoing internal agency review and likely to be released by end of year.

Key components of the DURSA include:

• Extension of HIPAA to all participants on the NHIN.
• HIPAA is the floor for all activities on NHIN but local and State laws that go beyond HIPAA are not preempted.
• Limited permitted uses of data (e.g., neither use for research or legal/enforcement is allowed).
• All participants must respond to a data request from an NHIN member. One is not required to share data, but must, at a minimum, acknowledge request for data.
• Once data is transferred to recipient, data is now owned by recipient and they can share/exchange data anyway they see fit that is in conformance to their policies.

Clearly, the fed consortium that put together this DURSA is looking to maximize data liquidity.  Despite their good intentions, it is unlikely that this will be readily adopted in the market for despite assurances, risks to the consumer, the patient appear greater than the value derived.  In speaking with one doctor after the DURSA session, he just shook his head saying that very few practicing physicians that he knows would accept these DURSA terms.

Where is the Consumer Voice in All of This?

One the morning of the first day, Sarah Wade, the wife of a retired soldier wounded in Iraq spoke to the challenges of caring for her husband in this convoluted healthcare system that we all, as citizens, must contend with.  Her talk was real, it was heartfelt and something that many of us can relate to within some aspect of our own lives.  Yes, the secure exchange and sharing of personal health information (PHI) has far more benefits than many of the purported risks.  But that does not mean that citizens do not have a voice in these discussions as ultimately, these discussions involve the most personal aspects of their lives, their PHI.

Unfortunately, there seems to be little here within the hallowed walls of those developing the NHIN that pertains to the US citizen.  Yes, they have insured that at a minimum, HIPAA is there to protect PHI, and yes, there are provisions to gain consent for exchange of PHI among certain participant types and maybe most importantly, one of the six permitted data uses is allowing the consumer to request that their data be exported to a PHR – all well and good, but simply not enough.

First, when data is exchanged on the NHIN there is no capability to discretely tag data to share only that data which is pertinent to specific care and treatment.  A spokesperson stated that data tagging was simply too complicated an issue to address, thus taken off the table.  Weak excuse – Microsoft HealthVault has that capability today.

When asked about the role of consumer data ownership and the PHR within the context of the NHIN, ONC stated that they have had internal discussions, yet have reached no conclusions, apparently, no clear policies.  For now, it looks like they have put this on the far back-burner.

As mentioned previously, the DURSA allows for the transmittal of PHI from one participant to another and once the requester receives the data, the requester becomes the data owner as well and may share/distribute the data in anyway they desire in accordance with their own policies and guidelines.  Big question here is how will the NHIN provide a citizen with a clear audit trail of all who have viewed their PHI? No answer to date.

Based on what was presented this week, it appears that these critical issues were by and large side-stepped as the agenda for CONNECT and NHIN is all about the enterprise, be it a government agency or a hospital.  Certainly understandable that someone like the SSA would have such a view but it is unfortunate that HHS/ONC has not been more inclusive of the citizen in its deliberations and development of core policies.

Looking Ahead

At first blush, Chilmark saw CONNECT competing with existing Exchange vendors such as Axolotl, InterSystems, Medicity and Wellogic. Conversations with a couple of these vendors, however, gave a different view – they see little threat today. CONNECT is simply too immature and despite it being open source, adoption of the CONNECT platform will still need a full team to configure and implement the solution and support it, no small task.  As one vendor told me: “…technology is only 20% of the problem in setting up an Exchange.” For the foreseeable future, it is unlikely that CONNECT will impact these vendors.  Of course, a large service provider with a strong healthcare IT practice (e.g., CSC, IBM, Perot, etc.) could make a play here successfully leveraging CONNECT into a full-service offering competing directly with these vendors. Yet even this scenario is still a few years out due to CONNECT’s immaturity as a full-fledge Exchange platform.

Where CONNECT will see the greatest traction is within the federal and possibily state governments that are looking to take waste out of the system, such as the SSA example cited previously.  In that context we will see service providers capitalize on this service opportunity to government agencies.  We will also see vendors create CONNECT gateways allowing others outside of government to participate in the NHIN in support of anything from meaningful use (quality reporting and information exchange) to facilitating care transition (military to private practice – RelayHealth did a nice demo of this), to supporting transactional processes.

But CONNECT and the NHIN have a long road ahead of them.  For CONNECT it will be about the creation of a community of developers that look to build apps and ultimately businesses that leverage the core technology stack that is CONNECT.  Unfortunately, at this event organizers did not have anyone address the business opportunity of building for CONNECT.  Without that ecosystem of apps, CONNECT may ultimately fade into a small, relatively irrelevant platform.

On the NHIN-side, it is hard to see a massive groundswell of support. Within the context of the NHIE, yes there is value, but when one extends the model beyond those confines it becomes increasingly difficult to define a sustainable model and some of the DURSA language will be met with strong resistance outside the cloistered government view.

In addition to sustainability, there are some serious issues regarding citizens’ PHI rights to control the sharing of their data.  Without clearer, more defensible answers to some of the questions outlined above regarding PHI, NHIN could face some siginifcant hurdles on the public stage.  HHS leadership would be wise to go back and rethink their strategy to engage citizens in promoting NHIN beginning with giving the citizens a greater say in just how there PHI will be shared and used. Ultimately, HHS/ONC is going to need that strong citizen support to induce change in the healthcare sector, including adoption and use of the NHIN.

An area of great debate and some controversy in the realm of privacy is health related information being maintained online via PHRs. PHRs, or personal health records, are the ultimate manifestation of increasingly sophisticated online health management tools. Though presently in a nascent stage of development, PHRs have an encouraging capacity to improve patient health care if more stringent privacy regulation is implemented.

The following presentation 1) offers a rudimentary understanding of HIPAA (current legislation regulating patient privacy in some PHRs) 2) highlights key aspects of PHR privacy policies provided by non-covered entities (Microsoft and Google) and 3) argues that HIPAA should be significantly amended before it is nominated as the vehicle to expand the patient protections for those who choose to utilize the benefits afforded by PHRs currently offered by non-covered entities.

One of the more intriguing sessions at the recent Microsoft Connected Health Conference was that hosted by Mark Johnston, International Business Development Lead for Microsoft Health Solutions Group (HSG).  During this session and follow-on conversations, Chilmark Research received a pretty clear picture of the HealthVault International strategy. Following is an overview of what we learned and our assessment.

Overview

Currently, Microsoft has had discussions with some 28 countries to date on how the HealthVault platform might be used to serve their citizens.  Of these 28, Microsoft has had more detailed,”scenario-based” discussions (specific use case scenarios, e.g. chronic care mgmt) with 11 countries and is in deep “contract-like” discussions with 6 countries.  Microsoft is seeing the greatest interest from European and some Asian countries.  In addition to these 28, Canadian telecom, Telus, will be the “Go to Market” (GTM) partner for HealthVault in Canada and Thai medical tourism destination, Bumrungrad Hospital will use HealthVault as part of a continuity of care process (see figure – DOPU stands for Drop-off, Pick-up) for US citizens. (Today, Bumrungrad serves roughly 60,000 US citizens/yr.  Technically, Bumrungrad is not an international instance of HealthVault, although they did present in the International session. Bumrungrad is simply creating a HealthVault account for the US citizen on the US instance of HealthVault – there is no separate instance of HealthVault in Thailand.)

The key driver for all countries is not much different than what we are experiencing in the US.  All are looking to reduce their medical risk profile by providing citizens and physicians better tools to manage health.  Primary objectives include:

• Support telemedicine with device connectivity (HealthVault Connection Center).
• Provide mechanisms/systems/tools, via HealthVault, to allow citizens to better self-manage and where possible minimize chronic diseases.
• Proactively engage citizens in their health by providing them with access to their personal health information leading to better, healthier and more knowledgeable decisions and subsequently, behaviors.

For example, Finland currently has 90% of its physicians using an EMR, but like most countries Finland continues to see healthcare costs rise.  Therefore, Finland is now looking at HealthVault as a critical component to take their national healthcare system to another level with deeper, direct engagement of their citizens and thereby mitigate cost increases. (In theory this makes sense, but there is no conclusive evidence that indeed this will work. Today, most are going on faith.)

The Business Model

As in the case of Telus, Microsoft intends to sell the HealthVault stack to a GTM partner in a given country.  The GTM partner will typically be a private entity, such as Telus, but Microsoft does not rule out the possibility that a government entity may also take on this responsibility (likely rare). It will then be the GTM partner’s responsibility to build the localization of HealthVault substantiation in their country that is in compliance with the country’s (and sponsor’s) policies, laws (privacy, security, consent, etc.), standards, language, culture and other requirements that are pertinent.  Obviously, it will also be the responsibility of the GTM partner to “sell” the platform to the sponsor (most often a government entity) and maintain the platform over time (maintenance upgrades, etc.).

Microsoft envisions the sponsor being directly responsible for defining the objectives of the HealthVault platform instance in their country.  Therefore, the sponsor will identify what specific attributes of the platform to emphasize and identify the partners (software & biometric devices) that will comprise the ecosystem of services to be offered to their citizenship.

Actual pricing model for HealthVault appears to be in a state of flux as Microsoft seeks to better understand what is most acceptable in what is still an extremely immature market.

Some Technical Challenges

There are a couple of key challenges for Microsoft and its GTM partners as it looks to propagate multiple instances of HealthVault around the globe.  They are:

1. How to build in localization features without altering the core functionality (data model, authentication, APIs) that comprise the HealthVault platform?
2. How to insure that all instances of the HealthVault platform are maintained as new features and functions are added to the core?

Sean Nolan, chief architect for HealthVault, outlined their strategy as follows: First, HealthVault’s architecture has two levels, one operational, the other policy.  The operational level includes the core features (APIs, SDK, data model, etc.) that will remain common to all HealthVault instances – these are not altered in anyway by the GTM partner or the HealthVault sponsor in a given country.  (Chilmark is assuming that within the “operational level” Microsoft will also enable support for various standards used in other countries.) It is at the policy level that HealthVault provides flexibility for country-specific modifications to be made (e.g., consent, record sharing, etc.).  Sean did go on to say that to date, the HealthVault model for authorization is globally acceptable.

To address the second challenge, Microsoft has language in its contract(s) with the GTM partner that their instance of the HealthVault platform must be updated every 6 months.  Currently, Microsoft updates HealthVault with new features/functions/fixes every 6 weeks or so.  Going forward, it will be releasing to clients platform upgrades on a quarterly basis.  Therefore, a given GTM partner and their sponsor can skip no more than one upgrade cycle.  This insures that all instances of HealthVault fall no farther than six months behind, thus staying current with new releases, fixes, API enhancements, etc.  This is extremely important as all these scattered instances of HealthVault could become nearly impossible to support.  Maybe even more importantly though is that multiple instances at varying levels of version cycles could endanger the attractiveness of HealthVault as a development platform for third party software developers and device manufacturers who add value, via the ecosystem effects of this cloud-based platform.

Assessment

As we have outlined in previous posts, Microsoft is developing a number of models to monetize the HealthVault platform, going international being one of them.  This is not too surprising as no one has figured out a direct to consumer model for a healthcare platform.  The only who has come close is WebMD, who is heavily dependent on pharma for advertising revenue, and WebMD is a closed platform, not the more open ecosystem that HealthVault is becoming.  Microsoft’s international strategy appears well-thought through and the architecture is in place to go abroad. It also appears that there is a ready market for this solution as virtually every country is struggling with some aspect of trying to control healthcare costs by lowering the medical risk profile of their population.

In moving into the international market, Microsoft is also creating far more opportunities for its ecosystem partners.  Among its software and device partners, we project that device partners will be the biggest beneficiaries in the near-term as most are already international companies and have the distribution network in place to take their products to market.  Software partners, of which most are small, typically build solutions to serve their markets of origin.  Some of these companies will successfully move into international instances of HealthVault, but most will not.

But there may be some potential problems ahead.

First, it is not clear whether or not Microsoft will GTM in a given country with only one partner.  For example, if the larger Infoway in Canada where to approach Microsoft tomorrow, would Microsoft also establish a relationship with them and let Telus and Infoway fight it out in Canada for garnering sponsor(s)? Certainly plausible but may also create conflicts that will come back to haunt Microsoft. (Received feedback from MSFT-HSG on this issue, their answer: in this scenario, they would allow Telus to sub-license HealthVault within Canada.)

Secondly, in all likelihood, GTM partners, acting on behalf of sponsors will make requests for platform features to add to core HealthVault functionality (operational level).  Question is, how will these requests be prioritized and acted upon?  The likely prioritization path will be similar to any large enterprise platform; poll other clients, assessed internal development goals and resources and make a go/no go decision. That is fine, but there will always be some clients who will want some level of customization/flexibility but it does not appear that such will be supported.

Another area where there may be an issue is on the policy front. Microsoft is a strong supporter of consumer rights to gain access and control their personal health information (PHI) and was one of the lead endorsers to the Declaration of Health Data Rights released Monday night.  But what if some country does not share these views, e.g., Google’s struggles with China? What if a country does not support this basic tenet of HealthVault, consumer access and control?  Will Microsoft refuse to do business with such a country/partner?  Also, what fail-safes are in place to insure that GTM partners do not abuse/compromise the rich PHI data that they are collecting in a given country?  Will that issue be left to the country where the instance is in place to address or will Microsoft exert some level of policy control via its contractural language?  A slippery slope indeed.

Lastly, we still do not have clear evidence that giving consumers access to their PHI actually modifies behaviors leading to lower medical risk profiles.  Yes, there have been a few studies of modest size that provide some andectotal evidence that such is the case, but honestly, the data is still pretty sparse.  We are operating more on faith here than clinical evidence and while Microsoft appears to be off to a good start, it remains to be seen just how much traction they will get longer-term.

In Star Trek, the Next Generation, the virtually insurmountable evil force in the Universe is the Borg, whose famous line to all who resist is:

Resistance is futile, you will be assimilated.

To some extent, that is the impression I walk away with from my attendance at the Microsoft Connected Health Conference.  That indeed, Microsoft and its Health Solutions Group (HSG) has indeed been assimilated by the healthcare sector.

Now this is not necessarily a bad thing for Microsoft or the broader market but it does signal some important changes within the organization and more broadly confirms the strategy implied in recent announcements.  Primary among them is Microsoft HSG’s migration from an early consumer-centric strategy to an enterprise strategy.  Yes, HSG will continue to stand behind the consumer’s right to their health data and the consumer’s right to share that data with whom the consumer deems appropriate, but no longer is Microsoft interested in drawing the consumer to HealthVault, rather, Microsoft will go to market directly targeting large enterprises, currently providers, ideally selling them a combination package of Amalga UIS and HealthVault as in the case of the recent New York Presbyterian announcement.

This makes a whole lot of sense for a few reasons:

First, there is a compelling business model and money to be made selling this solution suite to large provider networks and on the international level, countries with a national eHealth infrastructure (e.g., Australia or Finland where EMR adoption is over 90%).  Note: Chilmark will write a separate, follow-on post addressing HealthVault in the international market.

Second, signing on providers facilitates getting data flowing through the healthcare system (data liquidity) and into consumer HealthVault accounts thereby creating value for consumers and secondary traction in the consumer market.

Third, signing on big names in the healthcare space such as Cleveland Clinic, K-P, Mayo Clinic, MedStar, NY Presbyterian and Partners Healthcare (their Connected for Health Grp) establishes credibility in the provider market and by extension may increase physician acceptance and adoption of consumer-controlled health record accounts.

But by assimilation, HSG may also become vulnerable to becoming staid and dare I say boring, which may result in not attracting the best and the brightest developers out there in the market to create new, elegant apps.

Sitting in the audience of some 600 people at this event I was struck by the average age that looked to be approaching 40yrs old.  Looking around I wondered where are all the young, hot shot developers that are really pushing the envelop with exciting, new and dynamic apps?  Where is the buzz? Where is the excitement? Where is that effusive energy of hope and change?  Unfortunately I did not see much of that here.

Making matters worse were some of the presentations I sat in on that were given by various provider partners.  In one session that discussed leveraging HealthVault’s Connection Center for biometric remote monitoring, I was struck by just how horrid the user interfaces (UIs) were that these healthcare providers developed for their patients.  Seriously, these were b*tt ugly.  Is this really representative of what HealthVault is capable of? Of course not, but one walks out of such a session just shaking their head wondering how can we move away from dated presentation constructs to new models of engagement.

From what was on display at this event, it does not look like we’ll find those new constructs blossoming forth from the existing healthcare borg.

Wrap-up:

HSG has done an amazing job in their relative short history in the healthcare sector and Peter and his team have much to be proud of.  Clearly, they will be a growing, influential force in the health and life sciences sector.

But as their presence and influence grows, it is Chilmark’s hope that HSG does not lose sight of the disruptors that will enter the healthcare sector.  As Mark Smith, head of the California Health Care Foundation stated earlier today in his keynote:

…travel agents did not push for Expedia, tellers did not push for ATMs…

Microsoft would be wise to keep that lesson front of mind and in future event(s) foster an opportunity for those disruptors to take center stage.

Addendum:

Couple of posts from others you may find interesting:

Will Crawford, Children’s Hospital who attended Day One.

David Harlow who spoke with Peter Neupert on conference call from event.

Doing some more reading about HealthVault, I came across a few links of value:

- Cleveland Clinic makes electronic medical records personal, more accessible [another example of HealthVault in action]

- The Future of Personal Health Records [Susannah Fox's take, focusing on access methods]

- National Committee on Vital Health Statistics (NCVHS) [an American advisory body on health data, statistic, and health IT policy - their site is jam-packed with resources]

- Medical Problems Could Include Identity Theft [sometimes I'm too quick to dismiss the privacy issues associated with electronic personal health records; here is an example that illustrates why people have cause to worry]

AND speaking of identity:

Today, I registered with my provincial College of Physicians and Surgeons. I’d sent in the paperwork weeks ago, so today was about verifying my degree and my identity. I brought my passport and my degree in the folder we got at graduation, but I was charmed to see a fellow new-resident show up with her degree – already in a gigantic frame. The process was very quick, with the clerk announcing to me that “basically, [the College] is just a big bureaucracy.” They photocopied my degree, gave me a receipt for the fee for registration + criminal record-check, and I was on my way. It made me wonder if any forged MD certificates every passed through that office. But I didn’t think about what they would do with my personal information. I just always assume it’s secure. Hmmm.

I was invited by an Account Supervisor from a PR firm to participate in a small component of Microsoft’s Connected Health Conference. Since I’m not in Washington state, the way people like me could participate was via Twitter chat. Basically, we read and write tweets using a hash tag (#datalib) for discussions on the subject.

Said rep. suggested TweetChat.com as a way of easily joining in. So, at Thursday at noon, I prayed that the wireless connection would hold up and jumped in.

I wanted to try it out a) to try my hand at this new form of chatting, b) to see what the whole thing was about, and c) to meet some other relevant Twitterers. And I satisfied all three of those interests.

a) The twitter chat:

• It was a bit disjointed. The moderator started asking questions; then we decided to introduce ourselves. So we did, and got rolling right away.
• There were multiple threads of conversation going on at the same time, just like in a regular chat. Only, they were all sort of about the same topic, so it was pretty hard to follow who was replying to what.
• That said, the kind of discussion we had would probably be better suited to threads on a message board.
• I was afraid the whole time that all the things I was posting in #datalib would be confusing to any of my Twitter Followers who didn’t know I was in the middle of a ‘chat’ session
• It promptly ended, with no summary or conclusion; more questions than answers; and a someone better understanding of why Twitter is not a chat program!
• Here’s the transcript, dynamic though it may be: #datalib
• Overall, not bad for a first go! Kudos to the moderators who were handling a barrage of questions from all angles.

b) the Topic

• We started trying to define data liberation; I threw in terms like ‘transparency,’ and ‘accessibility’
• Specifically I was curious about HealthVault form the health-care provider’s perspective, and what I and my patients could get out of it
• From what I gather, HealthVault is a Microsoft construct that will allow patients (or their designated care-givers) access to a universal, digital health record; it will be accessible from any number of portals, where patients can enter and review their data; it’s not entirely clear to me  how the records will be accessible to healthcare providers, but there will be some form of permission needed to be granted by the patient to do so

• There were some tech/integration/compatibility questions, but they were deferred to the website
• One chatter suggested an ID card that could be swiped at ‘Health Kiosks,’ that would bring up a patient’s file; the moderators mentioned access from mobile phones and other options
• We voiced praise for Health Vault: reducing redundancy, empowering patients, patient safety
• And we voiced concerns: patients having direct access to data without an interpreter (doctor) could be dangerous, physicians might be reluctant without incentives/compensation, user-fees would deter patients, those not tech-inclined or without caregivers who are may fall through the cracks
• It’s already happening in Hawaii, and it looks good (mind you, this IS an advertisement): see Microsoft Health Stories
• @HealthVault asked us what benchmarks should be used, I replied the “only benchmark that matters would be chronic care outcomes; morbidity & mortality improvements in HV vs. non-users.”
• Lots of unanswered and new questions…
  

I’ve seen Microsoft and eHealth in the news lately. There has been talk of Telus and Microsoft being involved in managing patient-centered eHealth records for Canada. I might add, they are planning to use Health Vault. I hope they ask us, first!

and finally:

c) New people

• Managed to ‘meet’ a good handful of relevant Twits (!), including @SusannahFox, @cindythroop, @donshep, @iChrisBarnes, @connectologist, @PatrickMann, @pondisci, @ThroopCat, for anyone reading this who wants to find some professionals/patients with similar interests

It worked out well enough and certainly piqued my interest in the HealthVault or similar constructs. I’ve wanted something as integrative as this for as long as I can remember, I’m just  going to have to think a lot more about this patient- (as opposed to provider-) centred model.

http://www.cnn.com/2009/TECH/biztech/05/19/cnet.google.microsoft.health/index.html

So honestly – how many of you banders do it? You know what I mean…eating a no-no lap-band food … such as pizza, pasta, nachos….oooh my! And then after you’ve chewed to your hearts content, spit the food out because you know if you swallow it, it will just come back up? I’ve been doing that – but only in the safety of my home. I want to know if this is just a weird thing that just I’m doing or if there are other banders that can relate.

In other news, I’m getting LASIK eye surgery to correct my vision today at 11am PST! Eeek. I’m going to Pacific Cataract and Lasik Institute in Bellevue, WA. Very nervous. Extremely nervous. I’ve had to wear glasses for the past 2 weeks v. contacts so my eyes will “go back to their normal shape”. See photo below.

Lise with glasses

Also have been tracking my steps via this cool pedometer that the folks from HealthVault sent me after reading my blog post about their cool weight tracking application – which rocks and is totally free. I realized that I’m not walking as much as I should be – only about 4,000 steps a day v. the recommended 8-10,000. But it sure was a nice gift from the HealthVault folks!

Provider PHRs currently have the largest number of actual users, with Chilmark Research estimating that nearly 70% of all PHR use occurs on a provider-sponsored PHR.  While this is certainly significant, one must remember that the PHR market is very immature, adoption is low and at about at the same level of EMR usage in ambulatory settings (>5%) and there has been little traction beyond some well-known and publicized examples, e.g, Kaiser-Permanente (KP), Veterans Affairs, Cleveland Clinic, etc.

Several factors contribute to provider PHRs succeeding where others struggle:

Trust: Consumers trust their physicians more than employers and payers to look out for the best interests.  If a provider suggests to a consumer that using their PHR would be advantageous, the consumer will take the suggestion more seriously and with less fear that data within the PHR will be used against them (denial of coverage, stigmatized, etc.) at some future point in time.

Value: Most of the better provider sponsored PHRs provide transactional tools that facilitate a consumer’s interaction with their provider including appointment scheduling, eConsults, viewing lab results and Rx refill requests.  Independent PHRs  or those sponsored by employers or payers simply do not have transaction capabilities with provider networks, end of story.

Data: While there has been some recent publicity on bad data that may exist in even a provider sponsored PHR, by and large the data therein is better and certainly more useful than what you’ll find in an employer or payer sponsored PHR, which is almost solely claims and PBM data.

But provider PHRs also have their fair share of challenges and shortcomings:

Tethered: Virtually all provider PHRs, for that matter virtually any sponsored PHR that a consumer may use is tethered to the sponsor and th consumer can not readily take records with them should they change plans/providers/location, etc.  This is slowly beginning to change as leading providers such as Beth Israel Deaconess, Cleveland Clinic, KP and New York Presbyterian allow their customers to export their records to one of the Health Clouds (Google Health or HealthVault), but we still have a very, very long ways to go.

Siloed: Provider sponsored PHRs give only one facet of a consumer’s record, those notes, labs, meds, etc. that were provided through that specific provider/network.  If the consumer has a several providers, both in and outside a given network, the consumer may well end up with more than one provider PHR but no aggregate PHR, unless of course they get all their records up into a Health Cloud.

Poor User Interface: Chilmark Research has seen many a provider sponsored PHR and by and large, they could use some good User Interface (UI) engineering, some nasty stuff out there.  This may simply be an end result of the lack of attention  paid to this aspect of the services a provider offers its community.  Another reason may be the clinician perspective that most provider sponsored PHRs pursue, rather than considering consumer needs first.

Lack of Control: Yes, consumers trust their providers more than just about anyone else, but increasingly, consumers want more direct control of information (records) that is theirs.  No, this does not mean that they can edit clinician notes, but it does give the option to choose who to share their records with, e.g., does a dermatologist need to know about an STD in college, 20 years prior?

As was discussed yesterday, Chilmark Research is seeing an uptick in provider interest to deploy and use PHRs that go beyond marketing and customer service.  But to be successful long-term, providers must look at their PHR strategy more broadly and more inclusive of the full spectrum of the consumers’ needs, which will more than likely extend beyond the confines of what the provider can offer in their PHR deployment.

What New York Presbyterian (NYP) is doing with HealthVault is a good example.  NYP wants to reduce re-admissions of cardiac patients upon discharge but fully realizes (as most hospitals have experienced) once a patient is discharged, they basically fall into a black hole and the hospital has little idea or means to track  how the patient is doing in the ambulatory setting.  By providing the patient with a portable, HealthVault account within the context of MyNYP.org, the patient is able to share their discharge notes with their primary care physician (PCP) and likewise, the PCP can upload progress reports to the account as well. This is taking care beyond the confines of NYP and its network, by putting the consumer in control, something that is rarely done today.

To some extent, the arguments put forth by Drs. Tang and Lee a month ago in the New England Journal of Medicine are true: Provider sponsored PHRs will be the true successors in the PHR market. But if providers continue their practices of keeping data siloed, tethered, in their control and offer a poor user experience, provider PHRs will be but a small step along the path to consumer-centric, consumer-controlled personal health record management.  Now the million dollar question is: Is the consumer ready to take on this responsibility?