Future of Health IT: Trends and Scenarios

Red herrings swimming around Google and Microsoft PHRs

I spent three days last week at the American Medical Informatics Association (AMIA) Spring Congress. I was there to present lessons learned from Michigan's $3.2M NIH Roadmap contract funded under the 2003 "Re-Engineering the Clinical Research Enterprise" Broad Agency Announcement (BAA) in the Clinical Research Informatics track, but I spent a few of the sessions in the Personal Health Records (PHR) track.

Unsurprisingly, there was a lot of buzz in the PHR track about Google Health, and to a lesser degree, Microsoft HealthVault. Google Health was more prominent for several reasons, not all of which are enduringly pertinent: its public debut happened more recently; Google does not suffer from the Borg-like "Evil Empire" image from which Microsoft suffers; and Dr. Roni Zeiger, MD, Google Health Product Manager, was an eloquent and well-received speaker at one of the sessions.

That was Thursday. My presentations were on Friday right after lunch, so I was a bit distracted that morning and missed a couple of breakout sessions. After my time in the limelight, I spent a very inspiring hour talking with Bob DiLaura of Cleveland Clinic, during which we speculated about the future of PHRs. One assertion with which I believe we both agree is that the entry of these two major players is going to revolutionize the healthcare records "marketplace".

I put "marketplace" in quotes because in the USA a market implies exchange of value that can be represented in monetary terms. HealthVault and Google Health are free, and as FasterCures CEO Greg Simon said in one of the keynotes, "Free is the new money". Google and Microsoft will aim for volume, and monetization will come later. It's not terribly difficult to imagine a variety of ways huge volumes of consumer health records could be monetized without violating patient privacy. But there are a lot of red herrings in these waters. Let's look through the glass window in the bottom of the boat here and see what these red herrings look like.

Microsoft Explains HealthVault Strategy

I didn't get around to writing about this at the time, but a couple weeks ago I read in eWeek about how Microsoft Explains [its] HealthVault Strategy. There are a couple of analogies I wouldn't have made myself: MS compares HealthVault to XBox and PayPal.

The goal was to provide ways for consumers to better understand their health and health information and manage that information for themselves.

Conn [Grad Conn, Healthcare and Life Sciences senior director for global consumer strategy] explained that with consumers as the aggregators and the controllers of to whom, how and when their information can be shared, the traditional health information model is turned on its head.

"Right now, the mechanism for this is through HIPAA, which dictates how to control patient privacy when patients don't control the records," Conn said. HIPAA, he said, has very clear rules that patients can request to see, copy, add to or delete any piece of health information in their record, and HealthVault uses those same procedures, but in a digital format.

So far so good. This (when properly implemented, whether by Microsoft, Google, or some other "fourth party") will accomplish in nimble form what is already one of the clumsiest and least effective of the HIPAA provisions, the portability requirements. Your health records are indeed available to you as a patient, but the care provider has the option of charging you for the cost of making a copy, and in virtually all cases will only supply the records in hard-copy format, even when an underlying EMR or EHR is in use.

Now, on to the first of the startling analogies:

Web 2.0 Can Give Consumers More Control over Health Care

The closing keynote at Microsoft's Health & Life Sciences Developer and Solutions Conference, held April 22 through 24 in Atlantic City, N.J., got a write-up in eWeek: Web 2.0 Can Give Consumers More Control over Health Care.

Ben Flock, a Microsoft Healthcare & Life Sciences Industry advisor, told attendees during his closing keynote... that Web 2.0 technologies moved information out of isolated silos and into interlinked community computing platforms that function like software for users.

Flock said applying those same concepts to the health care industry would provide tools that would allow for better and more relevant information sharing, collaboration, and ultimately better care as consumers gained more control over their information and, ultimately, their health.

Web 2.0 features like product and service ratings, information search, social communities, and tools are a natural evolution of health care technology, Flock said, and represent a new business paradigm that companies and institutions will have to adopt in order to remain competitive and relevant.

"The social relevance factor is a moving target, especially in health care, because it's in such an early stage," Flock said. The key is successfully reaching out to partners, customers and consumers, he said, and Flock cited HealthVault as one way Microsoft was reaching health care consumers.

The clinical professions are ambivalent at best concerning online consumer health information. The message here is that the horse is out of the barn. It's too easy to create social networking applications that leverage Web 2.0 technologies like wikis, blogs, and podcasts, and exploit their synergies with Web 1.0 technologies like forums and mailing lists, and now with Web 3.0 technologies like Microsoft's HealthVault and the nascent Google Health. These applications will interconnect health information consumers with birds of a feather, but also with commercial entities bent on exploiting the opportunities the social media make possible.

Clinicians can either get on the speeding train now, or get run over. It's probably possible to do both, which is part of their hesitation in making the leap. But the inevitable is, to put it redundantly, inevitable.

The Wisdom of Patients: Health Care Meets Online Social Media - CHCF.org

You're wondering about the picture. I can tell. We'll get to that in a moment.

I read in the California Health Care Foundation's newsletter that Jane Sarasohn-Kahn MHSA of THINK-Health has written a report called The Wisdom of Patients: Health Care Meets Online Social Media.

Social media on the Internet are empowering, engaging, and educating health care consumers and providers. While consumers use social media -- including social networks, personal blogging, wikis, video-sharing, and other formats -- for emotional support, they also heavily rely on them to manage health conditions.

The Internet has evolved from the information-retrieval of “Web 1.0” to “Web 2.0,” which allows people who are not necessarily technologically savvy to generate and share content. The collective wisdom harnessed by social media can yield insights well beyond the knowledge of any single patient or physician, writes report author Jane Sarasohn-Kahn. The outcome of this development is “Health 2.0” -- a new movement that challenges the notion that health care happens only between a single patient and doctor in an exam room.

This dovetails nicely with what I learned in my thesis research on online consumer health search. People are taking control over their own health care, and using the Internet as a tool in that empowerment.  This is of course not new news; healthcare was a hot topic in forums on Compuserve and America Online before there was a World Wide Web. So what is new?

BBC NEWS: Developers question Mesh openness

This just in from BBC News' Technology facet, reporting from the Web 2.0 Conference: Developers question Mesh openness.

The company's new service, that will synch all of a user's devices and applications to produce a seamless framework, was unveiled at Web 2.0.

Microsoft has said the service will use open standards and be rolled out to Windows machines, Macs and mobiles.

But developers at the conference said they needed more detail about openness.

"I have just seen the cookie cutter slide show, " says start up entrepreneur Ola Agayi "and it has promise but I haven't had the chance to play around with it. It's certainly an interesting concept."

Microsoft Live Mesh is the realization of some work Microsoft Research has been doing on wireless mesh networks:

Researchers in Microsoft Research Redmond, Cambridge, and Silicon Valley are working to create wireless technologies that allow neighbors to connect  their home networks together. There are many advantages to enabling such connectivity and forming a community mesh network. For example, when enough neighbors cooperate and forward each others packets, they do not need to individually install an Internet "tap" (gateway) but instead can share faster, cost-effective Internet access via gateways that are distributed in their neighborhood.  Packets dynamically find a route, hopping from one neighbor's node to another to reach the Internet through one of these gateways. Another advantage is that neighbors can cooperatively deploy backup technology and never have to worry about losing information due to a catastrophic disk failure. A third advantage is that this technology allows bits created locally to be used locally without having to go through a service provider and the Internet. Neighborhood community networks allow faster and easier dissemination of cached information that is relevant to the local community.

Exciting stuff. Microsoft does nothing altruistically, surrendering that domain to the Gates Foundation. So the question is, is Live Mesh going to be as open as Microsoft says, or is it MS's latest attempt to own the Web? Stay tuned, more news at 11...

Eye Candy: Visualizing the Health Blogosphere

I've been working with network analysis and visualization tools now for two years, first in Lada Adamic's Network Theory course (which has evolved considerably in two years), then while working on my Master's thesis under the guidance of Lada and her colleague Suresh Bhavnani (who is now my colleague at the Michigan Institute for Clinical and Health Research).

Recently I've been working on a Python library for generating networks from the World Wide Web and Web-accessible RESTful services like the Technorati Cosmos API. As a test exercise that doubles as a tribute to Shahid Shah, proprietor of the Healthcare IT Guy blog, I have produced a network visualization of Shahid's Technorati cosmos. Click on the image to see it full-size in its own window. Apologies for the low resolution: Pajek only draws within the current display, and I did this on my HP 2710p.

This was produced using Pajek, a powerful, free, and sometimes maddening tool for network analysis.

Web 2.0 in Second Life: an expert hacks a Flickr interface

I came across a post in the hackdiary blog about how to integrate Flickr into Second Life (SL), in the form of a simple viewer for pictures from Flickr based on a given tag. hackdiary is the blog of Matt Biddulph, a Web designer who has done a number of interesting things in SL. The post isn't new, but that doesn't make it less interesting or valuable.

I've had quite a few requests for the source code of the Flickr screen for Second Life that I wrote about a few weeks ago. Here's the code, annotated with links to the Second Life coding wiki and a few notes.

I'm only publishing the LSL code, because the serverside code isn't very interesting and does pretty much exactly what it says in the previous post. If you want to run your own flickr screen, the URLs in the code below should work just as well for your objects as they do for mine. If you have problems, let me know. I reserve the right to switch off the code if the traffic gets too high, but I'll post here if I have to do that.

There's a neat little video built into the post demonstrating the Flickr screen.

Old is the New New: Health-related Social Networking & the Web 2.0 Bubble

Cross-posted from my Business Blogging for Health Professionals blog, with apologies to readers of both. I'm working on a longish post for FutureHIT that refers to the "Old is the New New" concept, so I wanted to get it introduced here.

Dmitriy Kruglyak covers the recent spate of Web 2.0 cover. age in the Wall Street Journal is a post called Health Social Networking & Web 2.0 Bubble. His take on Web 2.0 is cynical, but rings true in my ears. To me the real question is this: is there a Web 2.0 at all? If there is, its existence can be attributed to a curious characteristic of human culture: Old is the New New.

I am an avid fan of Web 2.0 technologies. AJAX, open APIs, mashups, and collaborative filtering mechanisms like tagging are much better building blocks for Web apps than earlier technologies like CGI and more proprietary technologies like Flash. I do wonder about the viability of Web 2.0 companies. Portals like Yahoo! buy up Web 2.0 companies; if you build a company that has no proprietary intellectual property and gives its products away for free, the only viable business model I can see is to sell out to a larger enterprise. In today's more realistic venture capital environment, it seems highly unlikely that VCs will give you big bucks and then wait around to see whether you are the next Amazon or the next Pets.com.

Peanut Butter Manifesto

This week the Economist ran an article about bureaucratic ossification at Yahoo! that became manifest in a memo leaked by the Wall Street Journal. From the Economist:

Panic may be creeping in at the edges, to judge from a leaked memo which is being called the "Peanut Butter Manifesto", and was penned by a Yahoo! executive who once shaved the letter Y on the back of his head.

The note complains that Yahoo! has become an underperforming bureaucracy with staff sequestered in silos scarcely talking to one other. It is said to combine a lack of accountability with an aversion to risk and a do-everything strategy that is like "spreading peanut butter across the myriad opportunities that continue to evolve in the online world. The result: a thin layer of investment spread across everything we do and thus we focus on nothing in particular". How are the mighty upstarts fallen!

Sounds a lot like most of the big organizations I have worked for or consulted in. There are exceptions, I'm sure. I can definitely think of organizational units within larger enterprises in which it was a joy to participate.

The Peanut Butter Manifesto summarizes the Yahoo! problem thus:

We have lost our passion to win. Far too many employees are "phoning" it in, lacking the passion and commitment to be a part of the solution. We sit idly by while -- at all levels -- employees are enabled to "hang around". Where is the accountability? ...

As a result, the employees that we really need to stay (leaders, risk-takers, innovators, passionate) become discouraged and leave. Unfortunately many who opt to stay are not the ones who will lead us through the dramatic change that is needed.

This makes me feel uneasy for two reasons. First, it sounds quite a bit like most academic health centers I know of. Second, I'm one of the ones who has opted to stay. I don't like the implications. Then again, I rebel against the judgment, even if it was self-imposed just now. I know a lot of people who have opted to stay in this kind of arcane, elaborate, medieval bureaucracy and yet are passionately committed to and very effective at what they do.

The Manifesto author offers an outline of a solution, too long to repeat here. What I can pass along are the two key principles upon which the solution rests:

Blow up the matrix. Empower a new generation and model of General Managers to be true general managers. Product, marketing, user experience & design, engineering, business development & operations all report into a small number of focused General Managers. Leave no doubt as to where accountability lies.

Kill the redundancies. Align a set of new BU's [business units] so that they are not competing against each other. Search focuses on search. Social media aligns with community and communications. No competing owners for Video, Photos, etc. And Front Page becomes Switzerland. This will be a delicate exercise -- decentralization can create inefficiencies, but I believe we can find the right balance.

Blow up the matrix: What a concept. Do we dare to try, in the world of academic health centers? How can we, unless the funding mechanisms change, whereby each faculty and staff is funded by fractions of multiple grants or contracts?

No answers here, folks. I'm just living the questions, for now.

Second Life and Institutions

Because I am interested in technology innovation per se, I read the blog of IBM Research executive Irving Wladawsky-Berger on a regular basis. He posted recently about Second Life, a phenomenon about which I have mixed feelings (see my posts Second Life and the Amish and Real Is Beautiful). A few things intrigued me. 

First, he agrees with my belief that Second Life exemplifies a new mode of human-computer interaction and interpersonal communication that will transform society at some point in the not-too-distant future. Second, his avatar looked a lot like he does in real life.  Third, he is looking closely at how this will affect the behavior of institutions, as opposed to the changes it will bring about in interpersonal psychology, which is what I have been observing. Finally, his view sounds a lot more positive than mine. Hmmm...