About a month ago, I posted a review of Safeway Foodflex , which intrigued me as a novel health management tool that uses data that is far more significant than that generated in medical care – what we eat. You can read the review here.  

I noted in the review that the site was down when I wrote my post – it was confirmed for me that this is because the site was in the midst of a major overhaul to improve its usability and focus. With that in mind I wanted to revisit to see what was different. I did get a little help understanding some of the features, but I have not spoken with the team at Safeway yet. They are of course welcome to comment/add information to what I write here!

The impact of transparent sharing

As the title of the post says, there is a really nice evolution happening here. First, its important to point out that the revolutionary concept that started with the last version is carried forward here – that your grocery will provide you (me) with the data we generate with our purchases and help us (me) leverage it for our health. Think about this for a minute – how much purchasing data do we generate in our daily lives, and how transparently is that shared with us?

A note about sharing personal data

In this blog review I struggled a bit regarding whether to share screenshots from my own account. Even though it’s perfectly legal, I have a rule in my professional life that I never demo my own medical record. My rationale behind this is that it’s poor form to use my account as a demo because it may unintentionally create an expectation for other employees/leaders that their personal medical information is sharable in public forums, even though there is no such expectation – my employer vigorously protects the privacy of its members/patients information. The better course is for organizations to create demonstration systems.

In this case, I decided that since I am a customer of Safeway and not an employee, that it’s okay since I’m not creating expectations for other customers or employees of Safeway. The application of the above is that I would not expect to see a Safeway employee demo this system using their own personal data.

I have blurred out my purchase details in any event.

Goal oriented: The case of sodium

I decided to focus on my intake of sodium, because I happen to dislike a lot of it in my diet, and as you can see from the screenshots below, I was able to go to household trend for sodium, zero in on a hidden source of it (fat free salad dressing, I really had no idea), find an alternative, and then see the impact on my trend. Slick.

What an improvement over conventional medical care today – in the doctor’s office we just don’t have time to review a person’s diet history, and usually just a few screening questions are possible, like “do you salt your food?” or “do you drink whole or nonfat milk?” I could imagine a nutritionist or a physician prescribing the use of this site with a goal to get sodium below a certain amount.

I think the site does a good job of not being prescriptive since it is not run by a health system – the focus is on USDA requirements without any valuation about whether there is “too much” of any nutrient. A health system involvement could make this a bit more relevant, by tying the results to clinical goals, however.

Future expansion

The site is not currently linked to Safeway.com for ordering of food. In addition, there still isn’t linkage to product images or food labels. I understand that this is a bit similar to the challenge in health care of putting drug labels and medication images together. It’s not an easy task.

Even more possibilities through integration of community and the health system

The site is a great example of Health 1.0 (and that’s a compliment, the competition is Health 0.0), through its liberation and simple management of the data. The power of this information included in a patient’s health record could be significant.

For example, in the future people could compare food choices with other patients who identify themselves with certain chronic conditions and maybe the quality of the management. You could ask, “Show me the shopping list of people with hemoglobin A1c’s under 7.0″

Or as Susannah Fox noted in a comment on the last post, “show me the shopping list of other families managing severe food allergies,” and “allow me to send a list of products (or evan a full shopping order) to family who we are visiting in preparation for a visit.”

In interactions with the health system, in a future world, maybe there could be a print format co-designed with a health system for reporting nutrient intake, and setting goals. In a world of HIT interoperability, I’d also be interested in standards for electronically conveying nutritional information into a personal health record, and ultimately into an electronic health record for use in medical care.

And of course let’s not forget even farther ranging applications, like Twitter integration (”Mother, I noticed on your Twitterfeed that your caloric intake is down over the past 2 weeks, are you feeling okay?”) and mobility.

A PHR for Food

I think Safeway’s work in this area should be watched and supported – I can imagine so many exam room conversations that could be impacted by a good discussion of what we eat. The foundation for those discussions is information – perhaps a discussion of Food 2.0 might be worthwhile at the upcoming Health 2.0 conference…..

Images: Click on any to see larger

• PHRs, Platforms & Consumer Trends – SlideShare – Nice overview of what it says in the title – slide presenation from John Chilmark.

I was at the unveiling of The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information and have since taken the time to read the documents posted on the HHS Website. This is not a point by point review of the documents, just the passages that were of interest to me as someone interested in patient empowerment.

I realize that there is ongoing discussion about this work, which I will link to here. I am still struck by Leavitt’s statement, which I tweeted here, which to me signaled the intent to overall to provide an environment where privacy is respected and patients have access to information that helps them be healthy.

So here goes.

1. The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information

The goal of this effort is to establish a policy framework for electronic health information exchange that can help guide the Nation’s adoption of health information technologies and help improve the availability of health information and health care quality.

(again, thinking about Leavitt’s statement above)

INDIVIDUAL ACCESS – Individuals should be provided with a simple and timely means to access and obtain their individually identifiable health information in a readable form and format.

(more on this in another document)

2. Privacy and Security Framework: Introduction

This guidance is limited to addressing common questions relating to electronic health information exchange in a networked environment, and, thus, is not intended to address electronic exchanges of health information occurring within an organization.

(some patients get care from federated medical groups as part of integrated care systems that securely share information between providers when there is a need to provide care)

3. Safeguards Principle and FAQs

Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients?

(this whole section is interesting, but just clipping the following part)

Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual. If the provider feels the patient may not be aware of the possible risks of using unencrypted e-mail, or has concerns about potential liability, the provider can alert the patient of those risks, and let the patient decide whether to continue e-mail communications.

4. The HIPAA Privacy Rule’s Right of Access and Health Information Technology

IMPLEMENTATION OF DENIAL The Privacy Rule further requires that denials of access be timely, written, provided to individuals in plain language, with a description of the basis for denial, and if applicable, contain statements of the individual’s rights to have the decision reviewed and how to request such a review. In addition, the notice of denial must inform the individual of how complaints may be filed with the covered entity or the Secretary of HHS. If access to some of the PHI is denied, the covered entity must, to the extent possible, give the individual access to any other PHI requested, after excluding the PHI to which the covered entity has a ground to deny access. See 45 C.F.R. § 164.524(d)(1).

However, where the covered entity provides individuals with electronic access to some or all of their health information, through a PHR or similar means, and the access is available to the individual at any time and without a request, it becomes more difficult to determine whether a denial of access has occurred and when notice to the individual is required. For example, the requirements in the Privacy Rule are flexible enough to permit a covered entity to notify the individual in advance of the types of PHI to which it intends to deny access and for which the Privacy Rule does not provide a right of review. See 45 C.F.R. § 164.524(a)(2).

(These appear to me to frame personal health records which show parts of a person’s medical record as implementing a form of denial of access which an organization should explain proactively, as opposed to “provision of limited access” which I think is what many organizations do today, without proactive explanation why some things are shown and some not)

There is a lot more in the documents that are relevant to someone like me and many people reading this post. I just wanted to highlight the ones that I noticed, again, with the intent I felt I heard in that conference room in Washington, DC. See what you think.

Mike Leavitt – Link Medical Funding to Interoperable Records – washingtonpost.com

The parenthesis in the title are mine:

Before lawmakers act, they need to think: If stimulus money supports a proliferation of systems that can’t exchange information, we will only be replacing paper-based silos of medical information with more expensive, computer-based silos that are barely more useful. Critical information will remain trapped in proprietary systems, unable to get to where it’s needed.

I would suggest that we be concerned also about the proliferation of systems that keep patients’ health information opaque to patients themselves. The new HHS Privacy Framework, in my opinion, seems to open the door to this possibility (I will quote on it in a post tomorrow) – if a stimulus money is given to a system, should the system also be interoperable with patients and their families by giving them access to it?

Juhan’s HealthCard, originally uploaded by juhansonin.

I serve with Juhan Sonin on the CCHIT Personal Health Records Workgroup. Juhan is an expert in usability and design of personal health services (compared to myself, for sure) and is helping the group understand the potential for certifying for usability of personal health record services.

Juhan notes that he uses his own personal health informaiton in his designs, so I wanted to confirm that it was okay to repost here. Confirmation is below. It can be easier than it is today to know the health status of a person, yes? See what you think.

Thanks; I use the HealthCard during EVERY nurse/doc/hospital/insurance transaction. Amazing reactions from ppl.

Anything I post = public and abusable.
All should be CC licensed.

HACK and ABUSE at will.

Thanks Ted,
Juhan

Nifty wallet card by the way. May I post to my blog (I assume yes, since it’s on Flickr..)?

Ted

• How Apple’s iPhone Reshaped the Industry – BusinessWeek – Discussion of "disintermediation risk". I wonder if there are analogies in health care?

After using Safeway’s Foodflex (and I think that’s the link, the site is down during this writing for scheduled maintenance. I think http://www.foodflex.com works as well) I realized that there’s an organization that has as much if not more data relevant to my health as my health system does – the grocery store.

It’s a good thing that Safeway is making this data available to consumers, I hope there are plans to support this data in achieving its potential as a powerful part of a personal health record system.

I learned about Safeway’s innovative work in health and health care from Scott Shreeve’s blog and some of the writing of Jen McCabe Gorman (more relevant links to Safeway-related work are here) so I decided to give Foodflex a try.

The sign-up was a little rocky, and my belief is that I was starting to use the site while it was having a series of outages. However, the customer service support team was very helpful, and the site appears to have stabilized since I began using it. It does take a few days to a week after signup for a nutrition report to be available after your first shopping trip.

Just like the first time seeing my own medical record on a personal health record, it was impressive to see a list of all the groceries I have purchased. The reality is this data is being collected on anyone who uses a food-club card, I think we forget that this is happening, so it is nice to get some return. The graphs are somewhat helpful, and there is an opportunity to look at alternatives to food items that I’ve purchased which have a different nutritional profile.

I think the power of this data is in the ability to self reflect on what we are actually buying – the occasional jar of peanut butter is sometimes more occasional than we think, for example. Before I get into some of the drawbacks of the site, I don’t want to underestimate this point. It’s a big deal to be presented with food choices in an automated system like this. Imagine the possibilities that could come from sharing this information with your family or other professionals that you might work with. They are big.

The challenges of Foodflex come from the navigation of the data, and the inability to do more than a few basic things with it. There is the ability to separate or remove certain food items from the calculations that do not belong to a specific person, but the controls are fairly crude. The site isn’t very AJAX-y and requires some paging around to see all of the information.

Before I would criticize the site, though, I would remember my own experience supporting patient access to their health care data – it’s not as easy as one would think, and relative to one’s peers, it’s incredibly innovative. Based on that idea, I think this is good work that should be encouraged.

And, this data should be made available as part of a personal health record (which would require a beefing up of security, since you only need to provide a phone number at a store to add data to an account).

As my colleague Paulanne Balch, MD, from Kaiser Permanente Colorado, informs me, the #1 thing a patient wants to know after a a doctor visit is, “What should I eat?” Our food record is as important and maybe more important than our biomedical record. In the future, an API could be made available for this data to be securely delivered to applications that could assist patients with specific dietary needs or goals. Just as with the personal health record, availability of data is a great first step. And the beginning of a revolution of rising expectations, which is good.

With thanks to Safeway for their innovation and for demonstrating the possibilities of this part of our health record. By the way, I did contact the very nice customer service folks and offered to talk to a program manager about the product and its plans, but did not get a response. If anyone out there wants to comment, or show me more in depth parts of the program, feel free to contact me or post in the comments, I’m available…..

Patient Accessible Electronic Health Records: Exploring Recommendations for Successful Implementation Strategies | Wiljer | Journal of Medical Internet Research –

Most participants agreed that access to the EHR is a fundamental patient right and that the implementation of PAEHRs should not be delayed.

There was also an important discussion and debate about when results should be provided—in real-time, after physician approval, or after a specified time delay. A balance must be struck between making the information available to patients in a timely fashion that supports self-managed care and patient safety so that patients are not unduly stressed by complex and ambiguous information. However, it is evident that the health care community is currently divided on this issue.

• Insurers Embrace Online Physician Visits, But Doctor Participation Slow To Catch On – iHealthBeat – “Aetna is agressively marketing the tool to its contracted providers” – some information about the support for patient-physician messaging in the fee for service sector. Also some information from Kaiser Permanente’s work. California Medical Association provides a distinctive perspective on change. See what you think. Why isn’t this catching on in the fee for service healthcare community? (Audiocast)

I received this query from fellow family physician, and now successful implementor of an enterprise-wide electronic health record, Matt Mulder, MD, who practices and works at The Everett Clinic, in Everett, Washington:

Hey, I am starting to toy with the idea of E Visits, and getting paid for them. I have heard of few other groups that are making these fly. From your travels, have you come across any fee for service group that is making these work. It appears some third party payors are paying for them – up to $35 per visit. Hope all is well, Matt

I had some ideas of people who I could refer this question to, but wanted to refer it to the readers here, for their ideas. Matt said OK to post here with his name and organizational affiliation. Do you know of groups who are providing reimbursed e-visits and how is it going? Patient, staff, doctor perspectives are welcome…

Let’s help Matt support a patient-centered, results-only patient experience. Please post your ideas in the comments.

Congratulations to the patients and staff at The Everett Clinic on completing their EHR implementation – I see that they now have a link to “My Medical Record” at The Everett Clinic. Great job! Let’s see if Matt can also tell us how that part of things is going…