• The Health 2.0 Blog: Google Health beta — What’s really new and different? - Nice commentary from David Kibbe - looking at the advantage to all of health care (and health) that come from moving to standardized movement of data. I agree.

• Cerner Disses Google Health. Surprised? | e-CareManagement - From Vince Kuratis, who I learned about CCR with.

• Bioethics Forum - Google Health: Organizing Your Medical Information - Comment on this blog about a method to display drug/device ads to physicians reviewing a patient's medical record. Is this sort of thing different than a physician reviewing a medical record while writing with a branded pen on branded paper that sits in their office in front of their computer, next to their drug sample cabinet (if they allow these things in their practice). Shouldn’t the conversation be about being an unbranded doctor instead of Google’s implementation?

• McCain Makes Health Records Public - Could he do it using CCR? - Without commenting on the content of Senator McCain's health care record, wouldn't it be cool (if he approves) to release it in CCR format to show the promise of the standard? Same for all the candidates?

A3 (Project Plan). Click here to learn more about what an A3 is

This post contains the A3 Document, or the Project Plan, for Connectivity for California Consumers. I have been posting some of the data that supports this plan on this blog (click here to see them all). In addition, I have been working with staff at California Healthcare Foundation and potential stakeholders to improve the plan.

For those of you unfamiliar with the A3 format, it is designed to (a) tell a story and (b) incrementally improved to the point that the actions are clear at the time a project is launched. It may be revised once a day or even more often. The process of discussing the project and making improvements is called “nemawashi.” I am using this blog for extended nemawashi, so please post your comments.

Since an A3 tells a story, starting on the left, going down, and then on the right, I will summarize the story here. Feel free to print out the A3 and follow along (A3 means “11 x 17″ paper. You may have to shrink to fit on letter size).

Issue & Focus

1. The California Healthcare Foundation is dedicated to the improvement of the lives of Californians managing chronic illnesses.
2. There are many community stakeholders involved in supporting this goal; their work could be improved by making connections to each other that are meaningful for patients.
3. This is part of a broader strategic plan to support the objective of involving patients and families in all aspects of their care. This is the identified gap to be closed through this work.
4. California Healthcare Foundation is seen as catalyst and partner for patient engagement in California

Current Condition

1. There are well known gaps the care of people with high blood pressure
2. The impact of these gaps is distributed across stakeholders differently compared to other chronic illnesses, which includes a strong productivity-loss component, due to the high prevalence of the condition in employed populations (see charts).
3. There are examples of employers and technology companies approaching these gaps in hypertension and other chronic illnesses that can be studied.

Problem Analysis

1. Lack of access to care accounts for only 10% of poor blood pressure control; there is a physician component in setting goals, and a patient component in operationalizing those goals, that may not be accomplished in physician visits alone.
2. Patients who are not seen at least every 12 months are at greater risk for non-adherence
3. The societal costs of inadequate management are spread diffusely; few organizations are able to to see the total harm from this perspective
4. There are few models outside of integrated care systems of using non-visit-based approaches to managing chronic illness.
5. We are just entering an era of interoperability, with many solutions not yet integrated into the value chain of patients and payers

Target Condition

This pilot seeks to create a functioning ecosystem that supports chronic disease management across the lifecycle, with the best candidate being hypertension

Action Plan

We began by interviewing example employers, health care providers, and technology providers to understand which approaches and components appeared most promising. At this time, it seems most reasonable to approach this first from the employer perspective.

Next step will be to convene a group of potential partners in June or July, 2008, at California Healthcare Foundation, to discuss how pieces would fit together.

A presentation would be made to the CHCF Board in the fall, with funding and activity to begin in 2009.

Cost / Cost-Benefit / Waste Recognition

There are recognized wastes, which include unnecessary visits for blood pressure monitoring, inadequate medication therapy, and inadequate use of the health system, for patients who have not been seen in the past 12 months.

There are costs including, technology costs (although the goal is not to build anything new), and realignment of incentives to support non-visit-based care.

Followup / Unresolved Issues

Points of concern and planned countermeasures

1. What is the metric for patient access? (Pacific Business Group on Health is working on an employee engagement survey; metrics for patient access to their health data may need to be developed)
2. How can this complement the launch of both a P4P measure for blood pressure management, and a HEDIS “Relative Resource Use for Uncomplicated Hypertension” measure for 2008?
3. Data for presenteeism and productivity loss does not seem intuitive (I have reviewed this in depth and we can bring in clinical champions to verify)
4. Partners and aligned interests (will do due diligence to support cooperative business models of partners)
5. How to engage patients in things like biometric monitoring and blood pressure control (will look at plan design options, but most importantly will go to the factory floor, and will bring an employee/patient advisor on to the team)

So that’s the script that goes with the story, more or less. Comment away, and keep in mind that each comment will change the A3 a little every time.

Colleague in patient empowerment Susannah Fox e-mailed me this question and so we thought we’d start one.

Jay Parkinson, MD, linked to a discussion happening on Digg in his blog. E-patients is also hosting an informed discussion on their blog.

Is it cliche to say that this is evolutionary, not revolutionary? I think it’s of benefit to patients and our profession that a dialogue has started around moving health care data in a standardized way to a place where people can aggregate and do things with it to improve their health. A year or two ago, it was hard to think about a standardized extract of a medical record that you could send from an EHR system except in very specialized situations. Now you can do with several partners, Google being the most recently announced option.

I didn’t even think about writing a special post about it, even though I thought, “Cool, this work will support the ideas I am exploring with the California Healthcare Foundation, that patients can be involved and active in their care, across health environments (health system, work, play).” So rather than writing about it, I just incorporated the possibility into the work we’re already doing, which is great.

I think of privacy as a state of being that allows a person to feel comfortable seeking health care regardless of the issue. This is a good place to be, and when that state of being doesn’t exist, people will seek it out, even if it means not seeking needed care, which could be devastating both to patient and health system. At the same time they seek comfort, they also want to build confidence in their ability to manage their health by having as much information their care as possible. In systems where patients have good access and trust, the care is better, and it feels great (and is great) to provide and receive care in that setting. Both things are important, we should not sacrifice one for the other; every patient deserves to achieve their life goals through optimal health.

May 15th through May 18th:

• CCR Product Compatibility List — AAFP Center for Health Information Technology - Adoption list of CCR - not up to date, but gives a glimpse of who has been involved.
• Montana Healthshare - Montana organization to use CCR to improve population health
• Solventus CEND/PHR - A reference implementation of a PHR using CCD, developed by Stephen Waldren, MD and David Kibbe, MD
• PDF Healthcare - A technology platform for enclosing historical documents - can contain a CCR
• SourceForge.net: CCR Acceleration Resources Project - The XSLT transofrm from XML -> HTML for CCR
• www.ccrstandard.com - Continuity of Care Record (CCR)Standard — Resource Site _uacct = “UA-2242673-1″; urchinTracker(); - Home base for CCR
• “I hope that some day you get your wish” - "Medicine has a 100% failure rate" - a discussion of physicians in information technology.
• The WETA Guide to Fine Dining | WETA TV 26 - A nice series on DC treasures
• The Health Care Blog: PODCAST/CONSUMERS/TECH: Interview with Joseph Kvedar, Partners’ Connected Health guru - Information about ConnectedHealth and the EMC pilot they are doing

April 1st through April 2nd:

• Pattern Recognition » Blog Archive » I really hate Zotero - Like the concept, wants to improve the implementation
• Medical Home | Solution to Chronic Care Management? | Health Care | Disruptive Innovation for a New Primary Care Model | Center for Health Solutions - Deloitte LLP - Very nice overview of Medical Home, particularly with the rundown of stakeholders in the back, plus the medical home cost model.
• WordPress ? Support » Tags Import As Numbers, Not Words - Importing issues Wordpress
• Web 2.0 Expo San Francisco 2008 ? Co-produced by TechWeb & O’Reilly Conferences, April 22 - 25, 2008, San Francisco, CA -
• Compare Accounts | YouSendIt - Store and forward service for the times when e-mail isn’t so efficient. I use XDrive.
• Convert Your Paper to iPaper | Scribd - An ambitious project to convert paper , no extra charge
• John Furrier Says Google?s CIO is Leaving for EMI - Interesting change of employer, could the same thing happen if a Google employee was recruited to run a health care organization?
• Twitter - A Teaching and Learning Tool | ICT in my Classroom - Nice discussion of the uses of Twitter in education
• VoiceThread - Group conversations around images, docs and videos - An interesting image, video, voice annotating service. What are the applicaitons in medical group training and patient involvement

March 18th through March 19th:

• The ‘World Wide Computer’?Another HAL? - Businessweek’s Review of “The Big Switch” - I used it for comparison
• NPR: Doctor Blogs Raise Concerns About Patient Privacy - I agree with points raised - a patient should never seek care and then discover that they have been written about on a blog. Instead, they should receive a copy of the medical record that has been created about them. At the same time, physician bloggers are doing something very important - they are testing the boundaries of transparency, to support a more accountable health care system. If anyone saw the 60 minutes story about Dennis Quaid and his family, the rationale for this become very clear.
• What Every Physician Should Know About the RUC - January 2008 - Family Practice Management - The information is useful. As primary care providers I think we need to be careful to include our specialty colleagues in the conversation, not distance themselves from it. As a member of a large multispecialty medical group, I know that there is interest across the physician community in supporting community health and the best experience for patients.
• MindBlizzard blog: Virtual Healthcare 2: Palomar Pomerado Health - All right - More news about the utility of Second Life - testing a hospital before it launches
• What is the ROI on employee suggestion systems? - A nice example from the toothpaste industry. But not necessarily one that supports the evidence, that far less toothpaste than people think is needed to protect teeth…..Maybe a customer suggestion system might be in order.

The Big Switch: Rewiring the World, from Edison to Google

This book was recommended to me by another Health Information Technology professional, and I really got a lot out of … the first half of it. I was so on the fence about what I thought about it as a whole that I looked up both the review of the book on BusinessWeek.com, and I read Nicholas Carr’s article “IT Doesn’t Matter,” from the Harvard Business Review to check on my thinking.

I’ll start with the first half, which was very engaging and engrossing, comparing the rise of the electrical industry to the commoditization of information technology. I have read about the electrical industry before, but not so well laid out. There are many parallels worthy of drawing, such as the way our culture was deliberately and unintentionally changed as a result of electrification. Fascinating, especially around the way that managing a household changed - the same number of hours doing house work, just higher expectations and more technical skill required. This is where the HBR article also helped a little bit, because the concepts are important for health information technology. In the article, he says

In the earliest phases of its buildout, however, an infrastructural technology can take the form of a proprietary technology. As long as access to the technology is restricted - through physical limitations, intellectual property rights, high costs, or a lack of standards - a company can use it to gain advantages over rivals.

That sort of sums up the state of Health Information Technology, and a nice analysis done of this recently also alluded to the idea that there’s an inertia present among vendors that’s keeping HIT in this phase.

That’s unfortunate.

That HIT though. What about the rest of IT within a health care company - the storage servers, the document creators, e-mail, etc. He says

In the long run, the IT department is unlikely to survive, at least not in its familiar form. It will have little left to do once the bulk of business computing shifts out of private data centers and into “the cloud.”

The HBR article helps here as well, where he says that the IT buildout in most companies is complete, and “Commodities can be essential to business without being essential to strategy.”

The second half of the book is about the “World Wide Computer” and the implications that it has for privacy and the general threatening of industries as we know them today. I think the data about the publishing industry is compelling and of note - 13 percent, or 150,000 jobs lost since 2001. This potentially awaits any industry that is disintermediated.

I thought, though, that this section was written for a different generation of reader, though, one who has not grown up with computers. It’s a nice overview and a lot of the truths make sense, but they didn’t seem like revelations to me in my GenX state. I was really hoping for more detail on how the new IT department would be like and how companies were moving to things like employee asset management and software as a service.

So, maybe worthy of a read, at least the first half, from your local library or book rental service (more on this in a future post).

There are some provocative ideas and I would be interested in learning about companies that are moving to software as services across the enterprise, so reduce the waste of excess storage and maintenance of data centers. If anyone knows of companies doing this, let me know either in the comments or by contacting me directly.