For those of you interested in this idea – of electronic health records working as platforms that support substitutable applications (see earlier posts here and here ) – Ken Mandl and Zak Kohane convened a small working group to come up with principles for fostering the development of an “iPhone-like” platform for healthcare information technology. Check it out and come back here for discussion.
A bunch of things caught my eye today that may be of interest. First, given that the Games for Health conference kicks off today and I have to sit it out this year, I was especially glad to see this article in the Syracuse Post-Standard. It profiles one of our Health Games Research grantees, Cornell University, which has given middle-schoolers iPhones loaded with a game designed to encourage healthier eating choices. The way they do it is pretty clever, though...the kids take care of their own virtual pet and snap photos of their food selections, which are sent to the Cornell research team. When indicated, the virtual pet will prompt the kids to consider, say, trading in their chips for a yogurt next time. It's more of a fun interaction than preaching, as the article points out, and it goes wherever the kids go. I like that it shows how health is playing out apart from health care settings and encounters, and how games and game technologies may provide ways to deliver health messages to kids in ways that are so much more up their alley, and potentially so much more effective.
Second, Steve Downs and John Lumpkin blogged on June 1 on "Catalyzing an App Store for EHRs," which our friends at the Health Care Blog were kind enough to re-post. A great conversation has kicked up around this - read the comments and add your own thoughts.
Finally, Project HealthDesign received 145 new proposals last week in response to its Round 2 CFP. National Program Director Patti Brennan talks about the breadth of ideas and wide range of observations of daily living that teams proposed - they'll be working together with patients managing multiple chronic diseases to capture and analyze health data generated in the course of daily life and test how it can be integrated in to clinical care workflows.
Posted by Steve Downs and John Lumpkin, Senior Vice President, Health Care Group
Recently, Steve posted about the idea, floated by Ken Mandl and Zak Kohane, that EHRs (or health IT more broadly) could move to a model of competitive, substitutable applications running off a platform that would provide secure medical record storage. In other words, the iPhone app model, but, for example, you could have an e-prescribing app that runs over an EHR instead of the Yelp restaurant review app on your iPhone. We’re thinking about the provider side of the market here, as Google Health and Microsoft HealthVault are already doing this on the consumer side.
It’s nice to ponder these “what ifs,” but we’re a bit more action-oriented here and we’ve turned our attention to asking what it would take to make this happen. It seems that there are two things that are needed. First, we need the platform. Some of the most notable platforms started out as proprietary that were then opened up. The IBM PC comes to mind as an example. Some were designed from the beginning to be open platforms with limited functionality until the market started developing applications. A recent example is the development of iGoogle and the tons of applications that are available for free. Finally, there was the purely public domain development from the beginning to end that we've seen in the Linux world. Or perhaps we don’t need a common platform and maybe what is needed is to stimulate the market for health IT products that have open application programming interfaces (APIs) that allow for third-party application development? Several ideas come to mind.
I just read Professor Pentland’s post here and have been learning a bit about what Dr. Richard Katz at George Washington University has been doing in the District of Columbia to use cell phones to assist patients in city clinics to monitor their diabetes. The new round of funding for Project Health Design, focusing on how information about patterns of everyday living can be collected and interpreted, can add to a field that helps empower people to better manage their health.
While all of this is exciting, frankly, I’m a bit frustrated that what seems so intuitively logical and necessary to improve health and health care has not evolved more rapidly. There are lots of independent researchers doing independent work, cell phone manufacturers seem engaged and some consumer-oriented businesses are selling product. But it doesn’t seem to me that a “field” is emerging. Part of the reason for this may be that the government has yet to acknowledge that this is field that is worth a major investment. The traditional structures at NIH are such that this field isn’t a natural “fit” and that there isn’t enough “evidence.” Of course, part of the reason there isn’t an evidence base is that funding for its development has been lacking. Private funders – corporate and philanthropic – tend to operate independently, making the development of an evidence base difficult.
We are at a point in time when there is unprecedented opportunity. Health reform and the economic stimulus funding can help make tremendous inroads here. The only question is how to align the need, the technology, the science and the funding. I’d like to hear how others think we can bring it all together.
Professor Alex (Sandy) Pentland is the co-director of the Digital Life Consortium at the Massachusetts Institute of Technology and was co-founder of the Center for Future Health at the University of Rochester, which we write about often here on the blog. Pentland has a grant from Pioneer to explore the potential role of reality mining technology - a concept that he helped develop - in medicine and in public health. We asked him to tell us about this work, and he responded:
We live our lives in digital networks. We wake up in the morning, check our e-mail, make a quick phone call, commute to work, buy lunch. Many of these transactions leave digital breadcrumbs – tiny records of our daily experiences. Reality mining, which pulls together these crumbs using statistical analysis and machine learning methods, offers an increasingly comprehensive picture of our lives, both individually and collectively, with the potential of transforming our understanding of ourselves, our organizations, and our society in a fashion that was barely conceivable just a few years ago. It is for this reason that reality mining was recently identified by Technology Review as one of “10 emerging technologies that could change the world.”
As pointed out in a recent Nature article, the single most important source of reality mining data is the ubiquitous mobile phone. Every time a person uses a mobile phone, a few bits of information can be collected. The phone pings the nearest mobile-phone towers, revealing its location. Accelerometers already in some phones can record patterns of physical activity, and the phone’s signal processing hardware can analyze the user’s speaking patterns. With the aid of data-mining algorithms, these data could shed light on the user’s health behaviors, creating new ways of improving their health.
To illustrate, consider two examples of how reality mining may benefit individual health care. By taking advantage of special sensors in mobile phones, such as the microphone or the accelerometers built into newer devices like Apple’s iPhone, important diagnostic data can be captured. Commercial trials by start-up Cogito Health are demonstrating that we can accurately screen for depression from the way a person talks -- depressed people tend to speak more slowly, a change that speech analysis software on a phone might recognize more readily than friends or family do. Similarly, experiments in my laboratory have shown that monitoring a phone’s motion sensors can also reveal small changes in gait, which could be an early indicator of ailments such as Parkinson’s disease.
Perhaps the greatest potential of reality mining of mobile phone data is to create a personalized health system (as opposed to a heathcare system): a set of information tools that helps people thrive, staying healthy and happy during their entire lives. Such a system would be owned by the individuals themselves, not by hospitals or clinics.
Best Buy, CVS, and Wal-Mart are already queuing up to sell and service the tools such as these that allow people to manage their health. The vision is that is emerging is of a health system built around mobile phones with special sensing capabilities to record your daily and weekly patterns, smart bathrooms that keep track of new types of vital signs, smart exercise equipment that knows your personal patterns, and more…all provided by consumer electronics and similar industries. By building a health system that supports lifelong health, we can make sure our healthcare system is used in the most efficient way. And, even more importantly, we can help citizens of the United States of America achieve far more healthy, happy, and even thriving lives.
photo credit: Julien Pacaud.
As Paul Tarini just discussed, we had a thought-provoking discussion with Clayton Christensen about disruptive innovations and health IT. One idea that interested me in particular was the potential for electronic health record (EHR) systems that are offered on the Software as a Service (SaaS) model to serve as a disruptive innovation.
Let me back up for a minute. Christensen talked about looking at the pre-conditions for disruptive innovations. One of them is when companies “overshoot” the market in terms of performance. For example, their product adds more and more features (each of which adds value to fewer and fewer customers) and becomes very expensive. They target the high-end of the market, where they make the highest margins, and as a result, they offer more than the lower end needs at a price that the lower end can’t afford. They’re “overshooting” that part of the market. This then creates opportunities for new entrants, with a new approach – that gives them a cost advantage – to make inroads at the low end of the market. The dynamic that follows is what ultimately transforms the market: the incumbent happily cedes the low end of the market because they make higher margins at the upper levels, giving the new entrant some traction. The new entrant then seeks the next rung up in the market, which the incumbent again, gladly cedes so they can focus on their most profitable customers, and so on, until Toyota, which started with cheap subcompacts in the 70s, introduces Lexus and starts taking on Mercedes.
So that got us thinking about the EHR marketplace and especially small practices. A lot of people experience real cognitive dissonance when they think of a three-doc practice installing a traditional EHR where they install and maintain the hardware and software on site. Systems designed for larger practices (with dedicated IT support) can be cost-prohibitive for small practices. Sounds like overshoot to me. Enter SaaS-based EHRs, which, by offering a very different technical and business model and (presumably) a real cost advantage, ought to be primed to take on the low end of the market, away from which the incumbents might happily walk.
What am I missing here? Is anyone seeing signs of this happening? Are there SaaS EHR vendors that look particularly promising?
The other key Christensen concept that came into the discussion is the idea Paul mentioned that customers have “jobs” to do, as opposed to systems they need. In my mind, “job” relates quite directly to “app,” as in “there’s an app for that.” (There I go quoting Apple ads again.) This gets back to my earlier post on EHRs and apps, which I won’t rehash other than to say that adoption of EHRs would likely be enhanced if they offered the apps that help providers do the many jobs they need to get done and that the best way to ensure that is to open up app development to 3rd parties.
Several themes and memes emerged from the Health 2.0/Information Therapy conference over the last several days. One theme is the need to re-imagine the relationship between patient and doctor in order to prepare for a Health 2.0 world. In the past, doctors were the primary, if not the only, source of health information. Doctors defined what was relevant to patients' health (e.g. blood pressure, blood tests, height and weight), and they were responsible for collecting it whenever the patient came to their office. In the Health 2.0 world, patients seek information that is relevant to them ("given the pollen count today, do I need to take an extra dose of my allergy medication?"). This new dynamic views patients as sources of health-relevant information, much of which is collected outside of the clinical setting. Patients are no longer passive subjects, but "info-mediaries," as some attendees called them, in their own right.
Paul Wallace of Kaiser Permanente and the Center for Information Therapy and Jamie Heywood of PatientsLikeMe debated the question during the session entitled "What is the Future Role of the Doctor?". Certain ideas and phrases -- in other words, "memes" -- filtered throughout the discussion, shaping the participants' efforts to rethink the relationship between patient, doctor and data. In order to get their minds around what this new relationship might look like, the panelists and members of the audience employed a few metaphors. These analogies quickly morphed into memes, and conference attendees referred back to them to summarize and simplify their perspective on the future relationship between doctor and patient. Here's a sampling:
Football: The doctor is the quarterback. She is the leader of a team, calling the shots. Perhaps she gets direction from the care coordinator (the coach). Where is the patient in this model? The patient is the all-important ball -- the object of coordination among different health care providers as they move it up the field. Banking: The health care system is the banking system. Patients can access and control their health data via an online health management portfolio. The portfolio includes myriad tools, geared to different types of patients. In this model, the doctor is like a financial planner - she helps patients navigate the system. Organization: The patient is the CEO of her body, and her doctor is a hired consultant.
While similar in that they place increased importance on the patient, these metaphors also reveal very different visions for the future role of the doctor.
Continue reading "From Health 2.0: Re-Imagining the Doctor-Patient Relationship " »
I arrived at the Health 2.0 Conference bright and early this morning. At the urging of this very tech-savvy community, I joined Twitter and issued my first-ever Tweet. (For complete coverage of the conference, check out the 600 + following at #heatlh2con). Next, I popped into the Health2.0 Accelerator pre-conference meeting, where (among other things), we learned about how the Accelerator and Project HealthDesign will collaborate going forward. Afterwards, I spent some time fielding questions about the next round of Project HealthDesign at our expo booth. All before the conference officially kicked off at 1:30pm! The first session initiated the debate over whether Health 2.0 and Information Therapy (Ix) are in tension or in synergy. We heard from Don Kemper, CEO of Healthwise, that Health 2.0 and Ix are the yin and the yang of translating data into information, information into knowledge, and knowledge in to behavior change. Matthew Holt, founder of Health 2.0, countered that a “shared understanding is not necessarily enough to support a marriage between Health 2.0 and Ix.” Given the candid format and the diversity of the crowd here, we can expect more “great debates” to follow. Check back for reflections on tomorrow’s sessions, including “The Future Role of the Doctor,” and “User-Generated content vs. Expert: What’s the best approach to Knowledge Creation?”
In the afternoon session of Day 1 at TED, Tim Berners-Lee, credited as inventor of the World Wide Web, made a simple request, one he’s trying to build a movement around: put your data on the web. In Berners-Lee’s view, data held in the hands of the few is a lost opportunity. It’s like the complaint leveled against the researchers who held on to the Dead Sea Scrolls for so long and wouldn’t let other researchers work with them or analyze them…only we’re talking about digitized data, not papyrus-based data.
Putting data on the web in a format that allows linking would open it up to all manner of exploration and analysis. “When you connect data together, you get power,” he said. This spirit is what’s behind our support of Rapid Learning, which is being championed by Lynn Etheridge. Rapid Learning proposes to link patient data bases from various provider organizations for research purposes. It’s also embedded in our support for ARCHeS, the effort to build a user interface for the Archimedes model that would enable more people to harness its power to answer questions.
Berners-Lee pushed the idea of putting data on the web to its limits, leading the audience in a chant of “Raw Data Now, Raw Data Now.” For some people, looking at some kinds of data, the idea of just posting it on the web is disconcerting. Assuming one takes proper steps to assure privacy and confidentiality, should all data be open for mining and analysis, or are there limits to what should be shared in its raw form?
It doesn’t take much insight to know that the current method of delivering (and paying for) health is broken and not sustainable. Making changes at the margins won’t work. Aside from current (and obvious) inefficiencies, we have a population that’s living longer, has more medical conditions and more methods for treating them. Even if you believe your personal health care support is doing OK, you have to know that there’s a crisis in the future. If you believe we’re already in a crisis, you know we’re heading for a catastrophe. There is a school of thought that crises have a way of solving themselves. There’s a great story about how at the start of the 20th century, with the growth of the telephone, there was a fear that the number of switchboard operators needed for manual switching systems would soon exceed supply, and that the problem was solved (just in time) by the invention of automated switching systems. This story was repeated as recently as 1998 in a letter to the NY Times. Unfortunately, this story is not true. The first automatic switch was invented in 1889 by Almon B. Strowger who developed it because he believed the operator was deliberately routing calls to his competition. In fact, as late as 1920 Bell in Atlanta continued to use operators and only changed when there was an operator strike.
Recognizing, therefore, that most crises are not self-resolving, and at our request, the Center for Future Health at the University of Rochester convened a diverse group of thought leaders interested in real-time personalized health monitoring. They came to discuss how people might benefit from personalized self-care systems, how such systems might enable people to take more responsibility for their own health and what RWJF might do to advance the field. What we learned is that there are amazing things taking shape that hold the promise of technologies that are both useful (in terms of their ability to improve our health) and unobtrusive, that there are lots of single point experiments and that there are major obstacles to coherent development. The challenge remains finding activities that can be transformational in accelerating the field while avoiding, or at least mitigating, some of the costly dead ends.
