Obligatory Post on Google Health

Not that anybody needs another post on the seemingly shattering news of Google Health’s recent entrance into palliative care hospice, but I think we may be missing something. Opinions out there range from Mr. Histalk’s summary of how Google Health is not offering anything of value to consumers, to the passionate cry for how the Google Health model is vital to health care, from Matthew Holt, and everything in between, including Jon Mertz’s view that Google Health’s Personal Health Record (PHR) was ahead of its time and should, or will be resurrected someday, with the usual comparisons to online banking and its one aggregator Mint. So which one is right? Perhaps all…..

Online banking’s main attraction is online bill pay. Online banking, which commenced in its current form in the mid ninties, would have probably languished without electronic bill pay. Paying bills is something people had to do since the days when this activity entailed hunting down a buffalo and carrying its various parts across one’s shoulder to pay for those cool moccasins with the lovely colored stitching. It continued to the day when you had to pull out a few banknotes and coins from the secret jar and run them over to the corner store to pay your tab, culminating with writing a check, placing it in an envelope, turning your house upside down to find a stamp and running it over to the mailbox, and of course you had to order checks and buy envelops and stamps in advance. Online banking allows you to pay for life’s necessities and its pleasures without moving an inch from your couch. It’s all in the wrist, and it takes 5 seconds at the most. What required a few thousands calories in the buffalo days and at least a hundred or so in the paper checks days, only takes about 5 calories of your energy today. The contribution of online banking and online shopping in general, to the obesity epidemic must be quite substantial.

The point here is that online banking is an evolution in the process of transacting business between human beings, which is as old as humanity itself. Online banking is just one more stepping stone between bartering for goods and the eventual disappearance of the archaic Gold calibrated valuation of human effort ant output. Online banking did not need to create a new market and did not need to convince customers to buy something they didn’t know they needed. As a byproduct, online banking took the intellectual effort out of balancing a checkbook. Not everybody was balancing their checkbooks, but those that didn’t were acutely aware that they should and that dire consequences are inevitable, and you could see the victims everywhere. Would people lineup to sign on to an electronic check balancer? Perhaps, but they would not log in very often, if at all. Enter the online banking aggregator. Mint was launched in 2007, well over a decade after online banking was introduced, to solve the unique problems of those with too many accounts, at too many banks, to keep track of. It’s a nice problem to have and obviously this aggregate service did appeal to a niche market. Mint says that they have 4 million registered users, but no numbers on how many registered users actually use the system. Either way, this is a rather small fraction of online banking users.

Patient Portals are to the health care sector, what online banking is to the financial industry. These are web utilities made available by the institution providing you with services (health care or banking), that allow you to efficiently perform transactions from your couch, transactions which you are forced to perform anyway. Patient Portals are rather new, certainly not a decade old just yet, and are slowly being adopted by consumers. As health services are being consolidated into larger and more comprehensive systems, just like banks historically were, Patient Portals are becoming more capable of providing efficiency and actually solving consumer problems. And just like online banking did not require interoperability between banks to become useful, Patient Portals have no such requirement either. You don’t need interoperability to make an appointment or pay a bill to Kaiser. You just need to log into Epic’s MyChart. And the same is true for many other large health systems running on Epic or Cerner or smaller technology platforms. In a few short years, most people will have accounts on Patient Portals (some more than one), and gone will be the days when you had to call the office for an appointment, call for a copy of your immunization record for school, or look for a tattered stamp to send your doctor payment in.

Google Health is not like direct online banking. Google Health is like Mint, and just like Mint had to wait over a decade after the introduction of online banking to be born, Google Health would have to wait until online health becomes a reality, examine its shortcomings and see if aggregation can solve problems for those who have too many health accounts at too many health facilities, and are wanting to balance their healthbooks. Most people don’t have enough ongoing financial concerns to actually need a Mint, just like most people don’t have enough health concerns to see value in an aggregated PHR. Sure, there are those who want to keep track of self-generated measurements of their health, just like some folks need to use Quick Books to keep financial records independent from, and comingled with, banking records. Most folks don’t feel compelled to use Quick Books in addition to bank accounts and most folks don’t have the urge to keep records of their health status outside a medical facility. Unless these market drivers change, either by popular culture shift or by regulation, Google’s business model will not be a good fit with aggregating health records any more than it is for aggregating financial records. Since Intuit, who makes Quick Books, was interested enough to acquire Mint, perhaps Apple, who has more self-measuring gadgets on its platform than any other vendor, may find an interest in health data aggregation. Call it Coconut, which is also a fruit and goes fabulously well with Mint.

Data - Free At Last!

Next time you visit a doctor’s office, try to peek beyond the front desk and you will usually get a glimpse of dozens of metal shelves loaded with thousands of paper charts neatly stacked in conventional library stacks. If you have a chance to walk into the medical records department of a hospital, you will see the same, multiplied by many orders of magnitude, including folks walking around with carts full of paper charts busily putting stuff into the shelves and taking more stuff out, just like librarians do. If you close your eyes and try to imagine what health information technology is doing now, you can almost hear a huge sucking sound pulling all those pieces of paper off the shelves in a big tornado-like swirl, and into the lone computer at the front desk. Play the Walt Disney music score for Fantasia in the background while the steel shelves are swiped clean and medical records are transformed into zeros and ones and swiftly pulled into cyberspace as Data. Then an eerie silence sets upon the room and all you can hear are keyboards clicking away. No more shelves, no more carts, no more paper and very few people remaining. Somehow the computer, which has morphed into dozens of terminals scattered across the rooms, looks a lot bigger now. This is how Data becomes free.

If you stick around a bit longer, a faint trickling sound will start appearing here and there. It will grow stronger and more ominous very quickly. The Fantasia movie score has music for that too. It now sounds like a raging torrent, a waterfall of sorts, and it is coming from the computer. You can practically see the deluge of zeros and ones furiously exploding out of computer screens faster and faster until the rooms are filled with free Data. Free Data comes and goes as it pleases, and for every Byte you released into cyberspace, trillions of other Bytes have been released by others, and they are all coming your way now. In computer parlance, you are experiencing a “stack overflow” – too many zeros and ones to process correctly. As computer folks know all too well, in order to fix the problem, you must first identify its source. So where is newly freed Data coming from and why is it coming your way at all?

The first source of free Data should be very familiar to any health care provider. It consists of previously paper-bound clinical information from other facilities of care. These are the old lab reports, imaging results, prescription renewal requests and the occasional consult note, referral or discharge note. These used to make their way into an office via fax, telephone, regular mail or hand delivery by patients. Instead of being stacked on your desk for review and sign-off, the Data is now neatly arranged in to-do lists or dashboards on your computer, marked with colored icons for Abnormal, Panic or Must See, depending on your software and its particular configuration. Not to worry, the lab will still call in critical/panic results. This is one of the nicest features in EHR software and a true time saver, since you can quickly go through all results, sign-off, forward to staff and release to patients. Electronic prescription renewals, if done right, are also a big improvement on the old fax requests and endless phone calls. Various progress and consult notes travelling uninhibited into your charts can be regarded as a positive development. True, these notes are currently bloated and consist of stilted, computer generated prose, but they should get better given enough time. All in all, having professionally generated clinical Data flowing freely between medical facilities has the potential to be a huge improvement on the status quo.

And then there is patient generated Data, either the manually created trickle, or the automatically created and released flood building up behind millions of mobile devices. No one can argue that obtaining as much information as possible from a patient is a bad thing. The carefully honed art of taking histories and the thorough examination that usually follows, are both aimed at collecting as much information as possible about the patient as a whole person to facilitate diagnosis and treatment. When medical records were chained down by their paper existence, patients’ access to their own records was always mediated by a staff member and required physical proximity to the chart location. As the Data in medical records becomes free, the Data currently stored in patients’ heads becomes free as well, and the two are yearning to be joined.

Several leading EHRs are already allowing patients to access their electronic records and add their own Data, such as histories, and many more will do so in the very near future. The most obvious use of such access is the replacement of the endless intake forms before checking patients in, but patients could also update their Data at will, when things change or when they remember something new. For example, Jane Doe working with the care team on weight loss and fitness could go update the frequency of workouts or note her new all grapefruit diet plan. Someone should check Jane’s long medications list and call her right away. The grapefruit is now part of your chart and part of your responsibilities. So should you have a clinician monitor patient entries into their records on a daily basis and take necessary action? It may save a life here and there, and it may also prevent a lawsuit here and there. [Note to EHR developers: when you provide patients with write access to the chart, you should also provide the clinic with an assignable task list of all updates made in the last 24 hours, with an option to accept, deny or pend the change based on further actions.]

But the most ominous deluge of patient originated data is still gearing up for its ultimate release into the land of the free Data. There are iPhone glucometers, and iPhone blood pressure cuffs and an iPhone EKG device is almost ready to enter the market. There is even an Android application that compiles and analyzes such mundane Data as where you go and who you call or text to figure out if you may be on the verge of becoming sick. All this Data, and probably much more from a variety of sensors and labs-on-a-chip developing faster than mushrooms after the rain, will eventually be set free and find its way into your chart. We are not talking about a few hundred entries a day here, which could be monitored, albeit at major cost, by a human staffer. We are looking at terabytes of data continuously streaming up into the cloud and down into your medical records. It gives new meaning to the term “ambulatory”, since you would be presiding over an entire patient panel connected to FDA approved, ICU-like machinery wherever they go. How many EKGs can you look at every day? What if you miss one and that’s “the one”? What is the value of looking at 10 EKGs from the same “worried well” person every single day? [Note to gadget developers: without a mechanism to review and analyze gadget generated data, and without accepting legal responsibility for generating medically correct credible alerts, you will have a very hard time convincing any medical facility to open their charts to your free Data.]

It is very rarely that when a problem presents itself, it comes with a solution standing right behind it, but this is exactly the case for free Data. If iPhone apps and sensors are about to create a flood of Data, the next generation of gadgets is waiting in the wings to use this Data and divert all headaches from practicing physicians to their patients. The X-Prize Foundation is developing two new challenges. The bigger one is the famous Tricorder X PRIZE which “will award $10 million to the team that develops a mobile solution that can inexpensively diagnose patients by combining expert systems and medical point-of-care data—such as lab-on-a-chip or wireless sensors, provide a recommended course of treatment, and upload all relevant data to the cloud”. The second one is the Digital Doctor X CHALLENGE which “will award $1 million to the team that builds a low-cost, point-of-care expert diagnostics and treatment system based on a computer platform that can be operated by a minimally-trained person to accurately diagnose a range of common, regional diseases”. A combination of IBM Watson software wired to a bunch of the newest iPhone gadgets should pretty much do it. Not only patients will be able to measure everything, but for $9.99 or $99.99, they could purchase a shiny “doc-in-a-box” to take home. I assume that pharmacies will have to honor prescriptions from those devices eventually, and I assume that there will be plenty legal disclaimers to make patients fully responsible for any mishaps.

And if that’s not enough to alleviate your concerns regarding terabytes of free Data floating out there, please know that the X Prize folks have it all planned out. They are considering an X Prize for a Brain Computer Interface, which should make all the difference on how Data is set free and how free Data is processed: “The winner of the Brain Computer Interface competition will be the team that successfully demonstrates a bi-directional non-verbal brain-computer communication. Teams may use an invasive or non-invasive brain transmission device, and may train the human participant in any way they desire.” The future is here.

Excelling at Average Results

Fee-for-service (FFS) is the method by which you pay your lawyer, your barber, your waiter, your cleaning lady, your airline, your plumber,  your dry-cleaner, and your mechanic, to just name a few. If you expand services to include tangible products, then you pay fee-for-product (FFP) at your grocery store, bookstore, hardware store, car dealer, farmer market and any other purveyor of goods. Sometimes, you don’t pay FFS or FFP. When you purchase a subscription service like cable TV or New York Times online news, or a membership for a gym or a professional society, you pay a capitated rate for a predefined package of services that you have unlimited access to for a certain period of time, usually a year or more. A third way of paying for services is through extended warranty contracts. Here you pay a fixed fee, in advance, and the seller is committing to keep your product in functioning order, or replace it, no matter how much labor goes into this task. Warranties usually have exclusions, in very small print, spelling out exactly what repairs will not be made and usually if you are negligent in your care for the covered product, they won’t fix it under the warranty contract. You’ll have to pay extra if you want it fixed. It is easy to buy warranties for shiny new products and almost impossible to obtain coverage for older items that are more likely to break and may not be worth much anyway.

When you go to a doctor or a hospital, and you have no insurance, you will pay on a FFS basis for each encounter. You will receive an itemized bill for all services and materials used in your treatment, with the obligatory shock inducing grand total at the bottom. This is very similar to taking your car to a mechanic, except that nobody will give you an estimate before doing the work. Many times you will get separate bills from several physicians involved in your care, if they are not employed by the same facility, which is very confusing. If you have insurance, which is similar to having purchased an extended warranty on your persona, they will still send you the same bills “for your records”. If all services fall under the contractual terms of your warranty, your insurer will pay the bills, and worst case scenario, you will have to pay a small percentage of the total, which is much lower than the original asking price. If you happen to be insured by an HMO, your doctor won’t get payment for the particular bill. Instead your HMO has a fixed price contract with your doctor, which in effect means that your HMO is purchasing a third party warranty from your doctor to cover the warranty they sold you in the form of insurance. For services that are outside the warranty terms, you will have to pay full price.  If you visit a subscription based concierge practice, it’s pretty much like going to the gym. You won’t have to pay anything unless you order one of those high energy smoothies at the bar.

The current common wisdom is that the FFS model in medical care is not working as well as it does in every other part of the economy mainly because most consumers are covered by those pesky warranties and therefore completely desensitized to price of services. People that buy those extended warranties at the electronics store, somehow don’t exhibit the same levels of gluttony for repair services and those warranties prove to be very good business for the seller as evident in the incessant and sometimes downright aggressive efforts to make you buy one before you leave the store. So why is it that folks don’t regularly throw their iPhones down the toilet, and don’t send their notebooks back to Dell on a weekly basis, but seem to constantly be seeking more “free” medical services? The most common explanation is that those doctors, who are not selling third party warranties to insurers and are therefore paid under the FFS model, are using their professional status to encourage the superfluous usage of their medical services for the sole purpose of personal financial gain. On the other hand, those physicians who do provide warranties on their patients under an HMO model have been often accused of withholding necessary services with the exact same purpose in mind.

The proposed solution to this quandary is to require physicians and the entities they work for to sell third party warranties augmented by Service Level Agreements (SLA) to ensure adequate quality of service. Since, if you run a small shop, it is rather hard, and very risky, to sell comprehensive warranties for something as complex as a person, most care providers are consolidating to create large shops and networks capable of providing soup to nuts services in-house. SLAs are not a new concept. In the computer industry, for example, maintenance and support agreements usually include specified uptimes, first response times and resolution times based on problem severity. They also include financial penalties for all of the above. If humans could be kept on locked racks in temperature controlled rooms, connected to adequate energy supplies and be equipped with diagnostic monitoring devices (like in the Matrix), we could easily apply very good SLAs to capitation contracts. Since this is not yet the case, and since we are talking about many millions of units, the best we can do is formulate medical care SLAs mostly in terms of percentages of evidence-based processes leading to good enough outcomes at a reasonable cost per head. So for example, if 80% of diabetics can be controlled at a cost not to exceed an average of, say $10,000 per diabetic per year, the care provider will be considered to provide good value for the dollar and therefore rewarded with some sort of performance bonus. If you can maintain 99% of diabetics controlled at an average cost of $15,000 per diabetic per year, you’re out of luck, and the same goes for achieving only 50% control regardless of the price. This is called Value Based Purchasing (VBP) and this is how insurers will be contracting with increasingly larger provider organizations to supply medical care to increasingly larger populations.

This model of paying for services is not necessarily bad, since we probably have a long way to go before most providers are able to meet the currently proposed SLAs. We can also keep pushing the SLAs up incrementally, and by tightening controls on both consumers and providers, we should be able to reduce variability of processes and standardize enough to achieve Six Sigma on measures shown to best contain overall costs of care. Of course, in this zero sum system, there is no room for outliers. Just like spending all day trying to fix one stubborn server can derail maintenance on a farm of thousands of machines, and may even get you fired, providing heroic and very expensive medical care to one individual is directly detrimental to assigned population needs and may cause serious financial loss to the provider. Every rookie computer engineer knows that in large enough server farms, it is best to ditch a malfunctioning server. You won’t even feel it. That’s the whole point of having server farms. Now if you work for a small business and all you have is one lonely rack of servers, and they all have names (the Oracle box, the NAS, the web server, etc.), you’ll work all day and all night to keep each and single one alive. You’ll get fired if you don’t.