For more than a decade, the financial services industry and retail merchants have been creating and perfecting an intricate weave of interoperable Web-based applications and data sources. Consumers can invest in markets worldwide, transfer assets from bank to bank, pay credit card and utility bills, and search for deals on their favorite products without ever leaving their living room.
But give healthcare consumers a home blood pressure monitor or glucometer and see if they can send their measurements to a primary care physician or specialist; or how far physicians get in integrating a patient's data from different offices in the same city, within the same medical group or IPA, sometimes the same building.
Should tech-savvy consumers broach the subject with their doctor, it's likely they'd hear some pretty stock responses — healthcare is complicated; EHRs are expensive and there's no ROI for the doc (just the insurance company); there are too many formats and terminologies to integrate smoothly. Sorry.
Nonsense, says one industry analyst.
“You know, if the industry had really wanted to solve this problem, we would have a long time ago,” says Lynne Dunbrack, program director for Framingham, Mass.-based IDC's Health Industry Insights.
Google, Mountain View, Calif., and Microsoft, Redmond, Wash., are promising to do just what the established healthcare IT community has failed to do — create portable and interoperable health records, available to consumers and caregivers alike, accessible anywhere via Web browser. Their technological architectures differ slightly, but the principle is the same, and expert consensus says it is absolutely revolutionary: The consumers control their own data. And, given the reluctance that entrenched vendors have shown to enable interoperability and accessibility, and the reluctance of clinicians and insurers to adopt the retail attitude of “the customer is always right,” it might fall to acute care CIOs to lead the charge.
Will Weider, CIO of Ministry Healthcare and Affinity Health Systems, Milwaukee, says he has not had good experiences in “multiple” attempts to foster a compelling PHR/patient portal with traditional healthcare IT vendors. He thinks the Google and Microsoft efforts are far better attuned to the needs of both healthcare professionals and patients than existing offerings. “I truly see what they're doing here as something that's going to change healthcare,” he adds.
Larry Stofko, CIO of St. Joseph's Health System, Orange, Calif., says the Google and Microsoft platforms are harbingers of a wider phenomenon. “If I step back just a little bit from this specific PHR, it's even broader, to social networking to instant messaging. It's the consumerization of the enterprise. That's going to be increasingly important in the next three to five years.”
Both technologies are just out of the starting gate, though HealthVault officially launched six months prior to Google Health (which launched publicly May 19 after pilot testing at Cleveland Clinic). While the two have yet to agree on a common API, there is consensus on using the Continuity of Care Record and Document (CCR/CCD) standards. Pioneering CIOs are optimistic there will be no insurmountable integration hurdles.
“On the transport side, it's SOAP, XML and HTTPS,” says John Halamka, M.D., CIO at Boston's Beth Israel Deaconess Medical Center, and Harvard Medical School, and chairman of the American National Standards Institute's Healthcare IT Standards Panel. “On the data side, the Continuity of Care Document is really a synthesis of HL7 and ASTM's CCR, and a really nice convergence. It really does everything folks need — structured data, problems, medications and labs and narrative data, history, physicals, summaries, etc. That, to me, is the tipping point,” he says. “That's done.”
Intangibles and a ‘sea change’
One of the more interesting aspects of the Google and Microsoft entries is the introduction of the intangible into the economic equation for hospitals. That is, while they will not be shouldering the cost of creating or storing these applications and databases, they will have to find some way to integrate them with their existing or proposed EHR/PHR plan. And, because direct marketing via these platforms is being strongly discouraged to protect patient privacy, it can be hard to discern a quantifiable ROI. But Halamka (who served on the Google Health advisory panel prior to the pilot's launch), Cleveland Clinic CIO C. Martin Harris, M.D., Stofko, and Weider all say there is enough upside to the Google and Microsoft platforms to bore ahead.
“The patients who use PHRs love them, and have basically said it is the one thing that has kept them a devoted patient of Beth Israel Deaconess,” Halamka says. “So, if I can attract and retain patients based on PHR integration, it's pretty important.”
In fact, he says a recent Beth Israel random phone survey of 2,000 adults in eastern Massachusetts revealed 19 percent of respondents would change to an e-enabled doctor if they had the choice. “That's a major forcing mechanism,” says Halamka.
Harris offers a more bottom-line example of how these PHRs are a boon to hospitals. He estimates that 2,000 of the 8,000 patients a day the hospital treats have no electronic record with the Clinic in any form. Should the technologies become as popular as their advocates hope, Harris says even those patients whose physicians do not use EMRs could still have critical data stored on a Google or Microsoft-type PHR and available to hospital staff on their first encounter.
“Even a physician who's still using a pen and paper in their office sends their patient to a retail pharmacy or commercial lab or hospital where that information is available in electronic form,” Harris says. “So I can know their basics; their allergies, their medication list, and diagnostic testing, which is an enormous step forward for us when we're seeing one of those 2,000 patients.”
The possibilities of patient-controlled PHRs have also reached hospital directors. Weider, who also thinks the Dossia effort led by some large employers (including Wal-Mart) could be a major player in PHRs, says the Ministry board recently asked him if patients' records could be easily portable, even if they switched physicians with the new technologies.
“I said that, for the first time in my life, I have optimism about that,” Weider says. “We've been stuck with a lack of standards and no one organization big enough to drive it, but now I see these three and, in the next few years, there's going to be a major sea change.”
Uncertainties and imperatives
Even the most optimistic backer of the Google and Microsoft model concedes that sea change will be slow, however. Near-term, both concepts have to work through the pilot stage. Harris, for instance, says the Google Health UI had to be tweaked early on in the pilot to make it more user-friendly; and Dunbrack says the HealthVault setup is also quite complex.
In fact, in order for a prospective user to see how it works, they are first asked to set up an account — which might be off-putting for consumers wary of Microsoft's no-holds-barred competitive philosophy. In fact, even a technology veteran like Stofko still has some “show me” attitude toward Microsoft, which has seen another central Web-wide repository idea (its Passport identity architecture) fall flat.
“Over the years, we've seen Microsoft in and out of healthcare,” he says. “I think before, the perception was they created a healthcare division — at least this was my perception — because a hospital is typically in the top five employers in any city, and that's a huge number of individual desktop licenses. I think they're past that, and with the people they've brought in from the healthcare industry, they've put some meat and teeth behind it. Now, they have to prove the longevity of their commitment, so I'm not past that hurdle, but I am past the, ‘We're just in it for software seats’ skepticism.”
There are perhaps two factors that might determine the ultimate success of the two platforms. The first is patient acceptance. Dunbrack, for instance, says that in the last survey Health Industry Insights did on PHRs, more than half the respondents had no idea what the concept was. Some patients might also hesitate to post data online, as early critics of the technologies warn neither Google nor Microsoft is subject to HIPAA regulations. Both Halamka and Dunbrack, however, say both companies are well aware of the commercial ramifications of a data breach or even a whiff of unbidden commercialization in either platform, and are sanguine, because safeguards are in place.
“Obviously, Google and Microsoft are selling trust,” Halamka says. “That's really all they're selling in their PHRs. If they abrogate that, they will have lost their business model.”
The technological factor that might affect adoption is the platforms' ability to make all the data posted relevant to everyone who looks at it, without making it too simplistic for clinicians or forcing patients to learn ICD coding. Both Halamka and Dunbrack see great opportunities for developers of translation middleware and natural language processing applications. Halamka and Harris say early ambiguities around terminologies will also be offset by the platforms' abilities to receive dynamically “pushed” data from hospital systems, and that there will be enough overlap so clinician and layman will find the platforms useful.
“It's not true for everything, but for basics like medications coming from a pharmacy and lab results it's already in the coded formats I need,” Harris says. “What's not going to be there Day One, and may not be there for a long time, is structured notes and other things where you would have to have some adoptive structured approach to documentation, which is a challenge I don't think we're quite ready for.”
Harris also says unstructured data supplied by patients will be valuable. “I still want to see it, I just won't post it. I'll do that interpretation and put it in my EMR, which is precisely what's happening in the office today.”
St. Joseph's Stofko sees a great market opportunity for health systems in facilitating this eco-system of applications, especially as more enterprise computing is transferred to utility grids and cloud models. More companies, he says, might begin to develop Web-based “light” EMRs that would greatly lower the barriers to physician adoption. The health systems themselves, he says, could look ahead to providing a comprehensive dashboard of applications via the new platforms.
“We could potentially private label them — ‘Brought to you by St. Joseph Health System.’ Some could be integrated within our consumer Web site or patient portal, developed by third parties with just some branding,” he says. And such branding could lead to a loyal patient base that is confident the local hospital is going a long way to ensure that any clinician they see will have access to up-to-date and accurate information on them, Stofko adds.
“It's not a short-term ROI, but what it does is lead towards that affinity because, most likely, people will need hospital or acute care at some point in their life,” he says. “Our contribution to making their life better for an extended period of time will keep their affinity with our hospitals and our mission when they need a period of acute care.”