Project Health Design Blog

Openness in Healthcare

Posted by Lygeia Ricciardi on October 20, 2007

“With enough eyeballs, all bugs are shallow.” Roughly translated, a large enough number of minds can solve any technical problem. Such is the perspective of open-source advocate Eric S. Raymond.

If ever a morass of problems needed the input of many minds, it is the US health care system. In the next couple of months Elliot Maxwell, an author, lecturer, and IT strategy advisor, will publish a paper called “Openness in Healthcare” commissioned by the Committee for Economic Development, a non-profit economic and social policy research organization. 

The paper explores the concept of openness in health care from many angles, including biomedical research—like the collaborative process behind mapping the human genome; access to data from ongoing clinical trials for drugs and devices; and the implications of EHRs, PHRs, and the information-sharing culture they encourage. According to Maxwell’s Rule, “the team with the most smart people wins." Yet he does not argue that greater openness is a necessary or even positive condition in all circumstances.

The paper opens the reader’s mind to new ways of approaching old problems. It also includes policy recommendations regarding areas in which Maxwell believes greater openness is most likely to have a positive impact. He has offered to make “advance” copies of the paper available to readers of the Project HealthDesign blog upon request. If you want one, please submit a request to this blog via the “post” function (I won’t post your request unless you include a comment).

So how does openness apply to Project HealthDesign and its grantees? Steve Downs, the Robert Wood Johnson Foundation program officer overseeing the project, has several ideas. First, Project HealthDesign is built on the assumption of an (eventual) open flow of health data. Though HIPAA gives people the right to ask for their health records, the information is typically not available in digital form. At some point, if PHRs are going to be successful, we’ll need the ability to download our personal health data, in a standard format, from all of our providers. Clearly we have a ways to go.

Another relevant aspect of openness is the concept of open source. As the grantees know, any creation resulting from Project HealthDesign must be either placed in the public domain or licensed as open source, meaning that the software “source code” is publicly available with few (or no) intellectual property restrictions. As Downs says, “Some of the teams are solving problems that others will encounter in ways that are generalizable—making those solutions publicly available is the best way to leverage their impact.” His hope is that access to the inner workings of nine cutting-edge PHR applications will catalyze development within the broader PHR industry.

On a related point, Downs points out the desirability of providing access to application programming interfaces or APIs to PHR services. APIs are interfaces that enable developers to write software that can communicate with or draw on the resources of the service that offers the API. For example, Microsoft has an API that enables developers to write programs that work with Windows. Similarly, Google Maps has an API that developers use to integrate mapping interfaces in their web sites. If services that maintain PHRs offered APIs, then developers, such as the Project HealthDesign grantees, could build tools that draw on the data stored in the PHRs. That way, not everyone who wants to build a better medication reminder service needs to solve the problem of how to get access to the current meds list–they can simply write to the API of the PHR provider and request the meds list.

As Elliot Maxwell points out in his paper, openness is not an absolute value, but a spectrum of possibilities. A question for Project HealthDesign grantees and others developing PHRs: Are there ways in which openness has been a help or a hindrance in your work? Do you have ideas about how the status quo should be more—or less—open?

Is your state working on Health IT legislation?

Posted by Lygeia Ricciardi October 19, 2007

A couple of months ago I wrote about the federal Wired for Healthcare Quality Act of 2007. According to many experts, that bill is still probably the most important to watch if you care about Health IT, but it has been moving slowly. Among other things, in recent months Congress has instead been focused on reauthorizing the State Children's Health Insurance Program (SCHIP).

Perhaps in response to a slow rate of movement on the national front, states have been picking up the pace in passing their own health IT legislation. At the eHealth Initiative (eHI) national conference last week, Vice President Christine Bechtel reported that roughly 15 health IT bills have become law. Last year, 121 pieces of health IT legislation were introduced in 38 states. This year, already more than 200 have been introduced. The more recent bills place a greater emphasis than previous ones on tightly integrating health IT with the goals of increasing the quality, safety, and efficiency of health care.

Common themes of state health IT legislation include provision of funding for startup costs for RHIOs or healthcare providers, efforts to safeguard privacy, and encouraging consumer engagement in health through IT. This last theme is, of course, the most likely to impact developers of PHRs. To find out what your state is doing, have a look at eHI’s state legislation tracking center.

More on HealthVault: Profiling the Platform

Posted by Lygeia Ricciardi October 9, 2007

Thanks for your comments. While it seems that some users have run in to frustrations with the front-end features of HealthVault, what’s interesting about it from our perspective is Microsoft’s launch of a platform on which numerous PHRs and other applications can run. In other words, HealthVault is creating the “back end,” while Microsoft’s 40-plus partners and potential future partners are responsible for developing “front end” options that users can choose among. HealthVault (or any similar platform that may emerge) is laying the infrastructure to support a whole host of new products and services all using the same data created by you and your health care providers. For more on this, see Vince Kuraitis’ blog post.

Creating infrastructure tools is major undertaking, invisible to most users. In doing so with an open approach, HealthVault is making available to “front end” tool builders a stable, interoperable data source. This separation of the application from the information driving it makes the “front end” tool builder's job both easier and more sustainable—and more likely to result in applications that take us closer to the promised view of a suite of personalized interoperable health information tools. It frees patients or consumers to transfer their data from one application to another: that means you can take your PHR with you if you switch employers or health plans, or integrate your data from a glucose monitor (and other devices) into a PHR that helps you analyze it.

Early comments on this and other blogs may indicate that the front end utilities of HealthVault may not entirely hit the mark.  I have not had the chance to test drive most of the applications that “launched” with HealthVault last week. Some are bound to be more useful than others—but that judgment will vary based on the individual. Over the coming months and years I expect many more (and more sophisticated) tools that build on the HealthVault platform to become available. The value of the system as a whole will need to be judged over time.

What this development does, though, is to challenge the community of PHR visionaries to rethink the power and potential of personal health records—and to use platforms like this to create tools that can truly serve people as they engage in their health and health care.

Microsoft Launches HealthVault

Posted by Lygeia Ricciardi October 4, 2007

Today Microsoft launched its HealthVault service to help consumers access and manage their own health information. HealthVault is a free service that lets you aggregate your own data from different sources (for example, lab reports from your primary care doctor and X-rays from your chiropractor) and feed it into a PHR or a variety of other devices and services. It also includes a search function.

This type of platform could be a big enabler for PHRs, which will only meet their full potential if they can tap into a much freer flow of electronic health information than exists today. Of course HealthVault and services like it can’t magically dissolve the systemic barriers that have blocked electronic health information sharing for decades, but it’s built on the conviction that consumer demand will drive changes in the health system more efficiently than any other force.

This consumer-centric view is compatible with the Project HealthDesign vision. The healthcare system may be too mired by (and invested in) the status quo to transform itself, and government is not always the most effective or efficient instrument to do the job. Genuinely disruptive change will require consumer demand. The tools to cultivate and then unleash that demand may best be provided by a player or players totally outside of healthcare that is experienced in developing products and services for consumers—like Google, Intuit (maker of Quicken), Microsoft, or some other group yet to emerge on the scene.

This new system also employs an open-platform approach, which could significantly expand and diversify the PHR marketplace. At launch time there were more than 40 partners who have developed (or pledged to develop) PHRs or other applications that work with HealthVault. This open approach promotes innovation and also the customization of products to meet the needs of specific consumer groups (including those with a particular health condition, disability, or cultural background).

Much of this is in keeping with what Project HealthDesign teams have been working toward since last year. By creating specific applications that can be built upon an open platform, endless possibilities exist to support a patient’s individual needs and a caregiving team’s ability to provide optimal care. Individually and collectively, the grantees are building personal health information solutions to meet the needs of many types of consumers. Data contained in repositories such as HealthVault’s can form the bases of powerful tools that help individuals make good choices about health behaviors.

The open platform is likely to create economic opportunities for developers of PHRs and related applications. According to Peter Neupert, Corporate VP of Microsoft’s Health Solutions Group, for every $1 Microsoft earns from its existing products, applications that build on them earn $7. It would be great for PHR developers if that ratio were to extend into the health sector, too.

So how is Microsoft going to generate income on HealthVault—which is available to the public for free? Through advertising linked to Internet searches. Advertisers will pay Microsoft to post ads alongside of the search query results from an associated (but separate) HealthVault search engine. From a privacy perspective, however, it is very important to note that Microsoft will not use the health data you’ve stored in your HealthVault “account” to customize the ads, (at least not as of now). It will also destroy—not sell—any history of the searches you’ve made. All of which is appealing to privacy and consumer advocate groups, though it remains to be seen whether consumers will decide en mass to trust Microsoft with some of their most sensitive data.

Another question I have is whether ad revenues will really be enough to support this service. A (failed) assumption that advertising revenue would pay the bills of many startup web companies was a major factor in the dot com bust of the late 1990’s. Are things different now? Possibly. The Internet has become much more fully integrated into our lives. On the other hand, Microsoft is no startup. It doesn’t need to generate immediate cash or risk going out of business. As Mr. Neupert said at a dinner with a group of health leaders earlier this week, “We’re patient; we’re in this for the long haul.” It may indeed take years or decades to cultivate consumer trust and provider willingness to share data electronically—but Microsoft can afford to wait, and besides, I don’t think anyone believes we can transform the whole health system overnight.

We’d love to hear what you think of this new development and this new player. Any guess on whether HealthVault and services like it can really move PHRs and related technologies in a significant way? Will consumers bite?

See the official statement from Steve Downs of the Robert Wood Johnson Foundation regarding the Microsoft announcement.

Also note today’s New York Times article, "Microsoft Rolls Out Personal Health Records" by Steve Lohr.