Stop Thief!

A Harris Interactive poll suggests that public awareness of health privacy concerns is on the rise, according to a report in Modern Healthcare.  The poll is described as an “online interactive” survey, however, which raises concerns about sampling validity.  That caveat aside, it’s interesting to note that there appears to be increasing public awareness of health data theft and data security issues - which, as we have written here before, are rampant.  (We’ve been following health privacy concerns for some time now.)

The poll also suggests that data thefts could be undermining public support for Electronic Health Records (EHR), which is another reason to get this problem under control before it escalates any further.

The Modern Healthcare article also reports that Booz Allen Hamilton was awarded a $450,000 grant in order to

…do an “environmental scan” to get its arms around the problem, then convene a meeting to gather ideas on how medical identity theft should be addressed, and then to write up an action plan recommending ways to deal with the problem.

I would’ve liked to have that contract, and I could’ve done it for a lot less.  We haven’t begun to explore the full implications of rampant health data theft - and we shouldn’t, at least in a public forum.

Still, I suspect the real solution to this problem is going to come from an imaginative entrepreneur, not a Federally-funded study.

(via CHCF’s iHealthBeat; image courtesy Medical Informatics Insider)

Health Information Online: New & Interesting Developments

People keep trying to provide comparative cost information that health “consumers” can use to make their treatment decisions. Many of us have predicted that someone would try to be the Travelocity of health purchasing, and Carol.com says it wants to be exactly that (as reported in the Minneapolis Star Tribune).

I tried the site. It’s ambitious, and in its own way it’s also overtly political. “Competition has changed every market but health care,” the Flash introduction says. “That’s about to change.” Some would argue that there are many reasons why health care can never fit simple market models, including confusion about what exactly is being bought and sold. (Is it “wellness”? A fix for your specific health problem? Or just a set of individual treatments, none of which can be predicted in advance?)

I had some difficulty following the process for acid reflux, the condition I’d selected as a test. It came up with only one “price” of $213, from one provider - but what was it for? Diagnosis? Treatment? End-to-end cure? How much will I need to pay for pharmaceuticals? Will I need to return quarterly? Annually? Ever? If it’s just one office visit, it should say so. If it’s a treatment plan, it should say that.

This is not to knock Carol.com’s creators unfairly. They have an interesting take on this often-discussed idea, and according to the Star Tribune they’ve already affected some unit pricing in the area. And I love their attempt to use decision trees to help people figure out what they need. (Try it - it’s interesting.)

But they need to be cautious about over-promising, and they need to recognize that most of their users will be insured - which will make their pricing information misleading, if not irrelevant. Most of all, they need to define the commodity that’s truly being bought and sold in the health market. That’s the hard part.

Meanwhile, Kaiser Permanente seems to be pioneering an different model for Internet interaction with the health process. iHealthBeat summarizes the features of Kaiser’s new member portal (free registration required), as originally reported in the Sacramento Business Journal. Features include appointment scheduling, prescription refills, viewing lab results, and e-mailing doctors (who will presumably write back).

A staff model HMO like Kaiser is the obvious place to develop a successful service of this kind. All the needed information is present under one roof. Since doctors are employees and not independent businesses, they can take time to answer emails without losing income.

The logical next step is to develop a similar service for the majority of Americans who don’t belong to group or staff model HMOs. That will require some leg work and some cooperation, especially among physicians, laboratories, and other diagnostic providers. And it will require financial incentives for providers to participate, including a payment schedule for answering emails and a system for transferring medical information securely.

(Carol.com, on the other hand, charges providers to participate. That may alter the blend of participants away from the lowest-cost providers, especially on the physician side. And who makes sure data is updated?)

What else will it take to succeed? A thorough knowledge of the inner workings of our so-called health “system,” and a clear-eyed look at the motivation of the participants.

In related news, California is posting a list of hospitals willing to provide discounts to uninsured patients, along with a comparison-shopping tool. Two Michigan health systems are posting their prices for common procedures (but note - these are charges, not the payments they typically receive for these services. Caveat emptor and all that.)

Prediction: Not very many people will use these California or Michigan portals. There will be one or more sites that do become popular someday, but they’ll look like a cross between Carol.com, secure email, and a supercharged search engine.

The goal is to create the classic “knowledge pyramid”: Data needs to be organized into information, and information needs to be organized to become knowledge. If somebody builds it, they will come.

Are ‘Medical Googlers’ Really A Problem?

After dozens of ventures to create health sites for health consumers, most people still seek medical information through Google. That surprises some tech investors. What’s more, the very act of searching ticks off at least one doctor, and probably many more.

Dr. Scott Haig is aggravated by “Susan,” a patient he considers a “medical Googler” (as he writes in TIME Magazine and as covered in the New York Times). ” We had never met,” he begins, “but as we talked on the phone I knew she was Googling me.” Sounds a little defensive to me. That clackety-clack typing sound he heard could have been her making notes on the conversation, or Googling her health condition, or any number of other less personal activities. (Presumably she Googled him before she placed the call.)

It is rude to surf the Net while you’re on the phone - I’ve been busted for it myself. But no need to jump to conclusions.

Dr. Haig goes on to describe Susan’s irritating personality and seemingly inept parenting - as if those two were inevitable and inseparable characteristics of the “medical Googler.” But guess what? Studies indicate more than 130 million Americans sought medical information online last year. Are they all obnoxious jerks?

Dr. Haig’s reaction is indicative of a deeper trend that troubles many doctors: Patients are arming themselves with medical information and making their own decisions. In the abstract, that’s what they should do. But in practice, it results in a shift away from the doctor-centric model - physician as priest - that many practitioners understandably find more comfortable. And there are risks, which technology has been slow to address.

But here’s the bottom line: They’re here, they’re search-engine is near, get used to it.

If Dr. Haig’s description is accurate, Susan sounds like the kind of annoying patient doctors have had to tolerate since the dawn of the profession. Her ‘Googling’ doesn’t make her who she is - and she won’t change.

But physicians like Dr. Haig will have to adapt - or spend the rest of their careers in a state of heightened aggravation. The ‘Medical Googler’ (and her descendents on newer platforms) are the wave of a future that’s already here.

Health Privacy Creates Policy and Technology Challenges

Last summer the Wall Street Journal ran a piece about inaccurate data on medical records, which is a common problem. That led WSJ blogger Jacob Goldstein to observe that, when it comes to obtaining health coverage, medical records are the new “credit score.”

He’s absolutely right - although you can argue that, as reporters say, he “buried the lede.” Most people don’t even realize that insurance companies ever see their personal medical records. That’s a significant story. In fact, most people have no idea who sees their medical information or where it goes. I’m not aware of any comprehensive study on the collection and distribution of medical information.

I do recall seeing a research paper on insurance information in the 1980’s that said that the typical medical bill is handled by 25 different people before it is paid or denied. (No citation available, though I’ve tried to track it down - so consider it apocryphal if you must.)

Policy Need #1: Public awareness, debate, and accountability for the sharing of medical information in the claims administration process.

The digitization of medical information is the new “bipartisan” issue of the 21st Century, uniting politicians from Hillary Clinton and John Edwards to Newt Gingrich. And there are compelling reasons for it, whatever shape health care reform eventually takes. But there are risks.

There have been many security breaches of health data involving hundreds of thousands of patients and their medical records, as we’ve discussed before. (The total number of people involved in any type of data breach over a three-year period? 159 million.)

Technology Need #1: A health security coding system for providers and payers that really works. A number of people are working on it, and there’s a university study group tackling the issue, but nobody’s cracked the code yet in a way that these various markets can embrace.

Then there’s the growing area of health data mining. This can be a very good thing, encouraging both research and better services for individuals. Yet the political state of the art lags behind the technology, which keeps developing. Esther Dyson has an attractive solution: informed consent. Answer those online questionnaires and search for medical information all night if you like, she suggests, but insist that your digital content providers allow you to control what is and isn’t shared.

Policy Need #2: Extend informed consent to health technologies of the future, too, such as telemedicine. It’s an elegant, simple solution to a growing problem - a solution that arose in the private sector. But it doesn’t cover all possibilities. That’s why the American Medical Informatics Association offered some suggested guidelines for the secondary uses of medical data that includes public debate and consensus; a health data taxonomy; and a redirection of the debate away from the ownership of data and toward the the topics of access, use, and control.

We’ll have even bigger problems in the future, including the collection and use of genome data. Dyson understands the implications of genomic information on the insurance industry better than the Economist does, but neither addresses the possibility of genomic data being used for, say, pre-employment examinations.

Would Abraham Lincoln ever have become President if the country knew in advance that he had a tendency toward severe depression? And if he hadn’t been, would the country have been better off?

Technology Need #2: A genomic “reader” that is sophisticated enough to categorize an individual’s enhanced abilities as well as their vulnerability to disease.

Policy Need #3: A national debate on the proper uses of genomic data.

So, when do we begin the public discussion of health data and privacy? And who’s going to meet those tech challenges and reap the economic rewards that will follow?

(Image of secure public health data center licensed under Creative Commons from HMS, Inc.)

Santa Barbara Data Initiative: The Lessons of Failure

The California Health Care Foundation (CHCF) has published the results of a study to determine why its pilot program to develop a RHIO (Regional Health Information Organization) failed in Santa Barbara. The report is clear, well-written, and instructive.

The goal was admirable: CHCF wanted to create a centralized database of patient information that was readily available to hospitals, physicians, and other providers as they delivered medical services to area residents. It was hoped that this RHIO would become a model for similar efforts around the country.

In its summary, CHCF cites “lack of a compelling business case, distorted economic incentives, passive leadership among participants, vendor limitations, software delays, and privacy and security issues as factors that played a significant role in the project’s eventual closure.”

But the report itself (caution: pdf) is even more interesting. Dr. David Brailer, who led the software company engaged for the project, later went on to head President Bush’s technology initiative. One report described him as the man whose “job was to sell Bush’s rewiring of American medicine.”

Dr. Brailer is a brilliant and innovative man, and the authors say that the project suffered from the loss of his charismatic leadership after he went to Washington. But they also suggest that either he or his organization (CareScience) oversold their own capabilities and the available technology, and undersold the difficulties involved - no doubt unintentionally.

The authors also say that Dr. Brailer differed other stakeholders in CareScience over the extent to which the company should supplement CHCF’s initial investment as a form of R&D for its own products - which CHCF had hoped would result from this project.

Reading the report, a couple of other possible reasons for its failure come to mind - reasons that help explain that “passive leadership” and some of the other problems:

Failure to understand participants’ motives

Each of the participants in the health economy have reasons for participating in it. These are primarily, but not exclusively, economic. They also have well-ingrained behaviors. This extends from physicians and senior hospital administrators to ward clerks and front desk staff. Failure to examine the motives of each of the players led to an unwillingness to either assume new expense, which the authors note.

What they don’t note, but is also significant, is that these participants won’t change their behavior unless they are given reasons to do so that make sense to them - and speak to their economic, social, and personal motivations.

More research into these motivations is needed, and practical suggestions for changing them need to be developed.

The behavioral dynamics of medical care

It’s very difficult to persuade physicians - or patients - to change long-standing methods of interacting with one another. For the RHIO concept to be fully successful, physicians need to become comfortable with pausing to retrieve information from a computer. That may mean teaching them new behavior - or, emphasizing PDAs and other less-intrusive handheld technologies. As an alternative, office staff might be trained to retrieve the information and give it to the doctor before the patient arrives.

Further research in the sociology and anthropology of physician/patient behavior could help solve this problem.

Forgetting to heed the “cui bono” principle

Because the U.S. healthcare system is economically decentralized, changes in one area may result in financial benefits elsewhere. In this case, the theory behind the CHCF initiative was that care would improve and operating efficiencies would increase under a working RHIO.

But, as the lawyers ask, “Cui bono?” Who benefits? In this case, a broad array of private insurers could save money from better efficiencies and outcomes. But these payers weren’t brought in as stakeholders in the process. To complicate matters further, additional investment today may save future insurers money - and we can’t know who those future insurers might be. This is one of the reasons why wellness programs have taken so long to find a foothold.

Additional research should be conducted into alternative funding models for RHIOs that involve private and public payers.

One large-scale payer was involved as a stakeholder: The Santa Barbara County Health Care Initiative, which pays Medi-Cal claims in the area. The report’s authors don’t provide much detail on the Initiative’s role in this effort.*

The report’s authors do a fine job of detailing many other problems with the project, but these two areas might deserve further study at some point.

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* Conflict-of-interest alert: I worked as a Systems Analyst for the vendor that set up the Santa Barbara County Health Initiative under an HMO-like data model - way back in 1982.

Tomorrow Calling: News From the IT Front

There’s a flood of interesting news in the Health IT world.  Each item deserves its own extended entry.  Hopefully someday …

EHRs

A recent study suggests that electronic health records don’t improve ambulatory health care - at least not unless they’re designed to take advantage of the things IT can do better than paper records can. As one of the study’s leaders, Dr. Jeffrey Linder, observed:

“There’s nothing magical about electronic health records. You need to have tools in place that take advantage of technology to show improvements in quality. You need to do additional work instead of just turning on the computer.”

EHRs must be joined to other knowledge-driven technology in order to enhance medical care. First, however, we need to catch up with Europe. Primary care doctors there have better access to IT than do their counterparts in North America.

Web-Based Messaging

A pilot project at Kaiser Permanente indicates that linking doctors and patients with web-based messaging reduces the number of office visits. While project leaders expected younger, more tech-savvy enrollees to be the primary users, they were surprised to discover that older patients were enthusiastic users of the system. Their health needs, especially regarding chronic care, led them to make the most use of messaging. That’s good news for a country with an aging population.

Now the nation’s economic model has to catch up with the technology. Reducing office visits is fine for Kaiser, where doctors are on salary. Fee-for-service medicine will be a hostile environment for messaging as long as doctors are giving up their time to message and losing income in return. As I’ve said for a long time, insurers will need to come up with a fee schedule for online consultation - a nominal fee of, say $5 with no patient copay - in order for programs like this to succeed.

Technology With a Human Touch

Dr. Thomas Lee has written an interesting piece about the human/technology interface and its relevance to health IT. We’re of like mind. IT won’t change or enhance human behavior in the health care system (using “system” in the global, socio-economic sense) until its easier to use.

Speaking of which, I thought I had weathered the iPhone craze without sparking my own techno-lust. But I saw one at a friend’s house this weekend. I’m trying to fight the phenomenon of craving that it triggered.

Rapid Learning

And speaking of health as a system - a dynamic organization with inputs, outputs, and behaviors that are observable, predictable, and changeable - there’s an exciting (to me, anyway) special edition of Health Affairs on“Rapid Learning”: using information from current and future electronic sources to monitor the changing epidemiological and behavior picture in order to respond rapidly to changing patterns of disease and treatment.

I hope to write more about this in the future. In a related effort, the DHS recently joined with bloggers from across the political spectrum in a very smart attempt to mobilize blogs and other web-based resources to help in case a pandemic strikes. Their first effort was Pandemic Flu Awareness Week. Hopefully there will be more such enlightened efforts in the future.

And it’s nice to be able to praise the Feds for a change.

Bipartisan Support for More Provider Health IT

There’s a place for healthy partisan differences, and a place for bipartisanship. This initiative goes into the latter category. Whether you’re a free-market radical, a single-payer advocate, or something in between, better collection and analysis of information will help the delivery of medical care.

(Single-marketers take note: Primary physicians in Europe and the UK are well ahead of their U.S. and Canadian counterparts in the adoption of IT.)

A group of Senators that includes Ted Kennedy, Hillary Clinton, and Orrin Hatch has sponsored  a bill called The Wired for Health Care Quality Act of 2007. It provides $163 million over a four-year period (that’s not very much) to help providers who don’t make very much money adopt news IT strategies. It would also help states create low-interest loan programs for them, and provide funding for local and regional initiatives to collect and share health data.

The bill would also require that HHS designate an organization to create health care performance measures, which is an important step forward. If adopted, this bill will help create the electronic infrastructure for a better health system - whatever you imagine that system to be.

I don’t think there’s enough money in the bill.  It provides $40 million and change per year for four years.  That’s less than a few dozen costly medical cases will cost in each of those years.  But it’s a start, and that’s a good thing.

Will PHPs Succeed or Fail? It’s All About Execution … Which Means Investment

Highmark (Blue Cross Blue Shield of PA) is offering an online Personal Health Record portal, or PHR. As HealthDataManagement.com reports:

Available through a secure page at highmarkbcbs.com, the Pittsburgh-based insurer will automatically populate PHRs with relevant claims and administrative data that includes dates of service, diagnoses and treatments, medications and other information.

The PHR includes tracking technology that enables users to keep records on certain health status measures, such as blood glucose, blood pressure, cholesterol level and weight. Other recordkeeping functions include medication tracking, immunizations, physician information, treatment history and allergies. Members also can enter additional information in their PHR, which is printable to share with clinicians.

Highmark further will offer PHR users personalized plans for improving their health. The PHR includes links to educational materials.

There are a lot of factors to consider in good web portal design - including variations in literacy rates, ease of access, generational/cultural differences in how people interact with a screen, identifying the “teachability moment” in health education, and much more. That doesn’t even touch the issue of content. Execution will determine the success or failure of the PHP concept.

There’s a good opportunity for the right team to build the content and develop design templates for PHPs. The question is: Where is that team? There’s an investment opportunity out there for the right partners …

(courtesy iHealthBeat - California HealthCare Foundation)

Free IT For Doctors, Updated - New York’s Using It For Those Who Treat the Poor

I’ve written about the potential market for IT in the primary care physician arena before (here and here, for example). There is a substantial need for solutions in this arena, and for those that can serve other physician specialties too.

That’s apparently part of the thinking behind New York City’s $19.8 million grant for physician systems that integrate clinical and billing/administrative functions. They’re starting with docs who treat Medicaid patients and the uninsured. That’s a good place to start.

Washington DC has decided to do something similar, starting with eight community health clinics and moving into local hospitals.

I haven’t looked at these particular apps, and I worry about ongoing R&D and support under this model - but I’ll keep watching. And I’m betting there are creative ways to enhance an app of this kind that these programs haven’t yet considered.

The Trouble With IT Innovation - People Get Dependent on Tech Too Soon

The California HealthCare Foundation’s iHealthBeat summarizes several recent articles on problems with the massive IT/connectivity project now underway in the UK.  This is the next-generation version of a “PC’s for PCP’s” (primary care doctor) we managed in Hungary as part of a World Bank/USAID initiative in the early 90’s.

People have the tendency to become dependent on these new systems too soon and drop redundant processes (like paper calendars).   Apparently that’s happened in the UK, where some children reportedly missed scheduled vaccinations as a result of tech problems.

There also appears to be a healthy dose of classic government-contracting problems:  delays, slowdowns, failure to adequately manage the project.

Reformers, beware.