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Date: Tuesday, 22 Dec 2009 05:31

This is a direct quote. James May, chief executive of the Air Transport Association, the industry’s largest trade group, said Monday that its members would comply with the new rule “even though we believe it will lead to unintended consequences — more canceled flights and greater passenger inconvenience.” He added that “the requirement of having planes return to the gates within a three-hour window or face significant fines is inconsistent with our goal of completing as many flights as possible. In  other words the Air Transport Association representing the airlines doesn’t care about us being stuck on the ground in a plane for more than 3 hours if they can fly more planes. They might as well tell us that they don’t care about us at all. Hello. We pay your bills. We are your customers.

It is always amazing to hear such organizations admit that the comfort and service to the customer is simply not a goal.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Wednesday, 09 Dec 2009 21:40

What is the future of health care? How will we actually lower the number of people who suffer or die needlessly?  How will we deliver care more effectively? Today, two ideas are competing for attention in this space:

  1. Personalized Medicine
  2. Personalized Wellness

Let’s talk first about Personalized Medicine. There is a lot of talk about the future of medicine being personalized medications. What is usually meant by this is that the blood and DNA of the patient is analyzed and then, using data gleaned from the EMR, a medicine precisely tailored to meet that patient’s need and their metabolism is prescribed. This is of course a wonderful vision—one that I would have loved to see realized a few years earlier. My mother was given several medicines for her recurrent ovarian cancer that were more or less ineffective.

Now it isn’t a pipe dream. There are blood and DNA tests run today for medicines like Warfarin or treatments for breast cancer. The best example is AIDS/HIV where DNA of the virus is used to determine which retrovirals will work. But in general, this is turning out to be very hard and very slow to do. It is hard just to figure out which medicines work for who based on their blood, DNA, and other phenotypic data. It works in some cases but fails in many. And even when a drug targeting a specific genetic profile is engineered, it is difficult and expensive to deliver to the right place in the body at the right time, in the right amount, and for the right duration. For example, we’ve known a lot about the genetics of cystic fibrosis —i.e., which proteins aren’t being generated properly in the lung cells due to mutations in a specific gene. Presently there are viruses that have been engineered that can generate the correct, functioning proteins, but the means to deploy an effective treatment has yet to be solved. Still there are clear examples of personalized therapies based on an individual’s DNA which help prolong life and have sufficient sales to warrant biotechnology/ pharmaceutical interest.  The clearest example of this is the drug from Genentech called trastuzumab (brand name Herceptin).  All in all, it is likely that it will be expensive and hard to change the DNA, but that the ability to produce solutions based on one’s DNA will be more viable.

Another issue is cost effectiveness in producing personalized medicines when such treatments serve a small market; the more specialized the medicine, the less likely it is to be developed. Thus, will we see a slew of highly personalized drugs targeting unique genomes or disease organisms? As was said in the movie “The Princess Bride,” when two magicians tried to bring the hero back to life and one magician asked another “think it will work?”, the reply was “it would take a miracle.” Of course in the movie he did come back to life, but life isn’t a movie.

Now let’s talk about Personalized Wellness. The leading causes of death relate to life style, lack of routine medical examination, and basic outages in care.  Put differently, it doesn’t require medical miracles to prevent far more disease and avoid far more suffering and deaths than all those caused by cancer (outside of lung cancer) each year. It requires personalized wellness and “good health incentives.” What is personalized wellness? It is personal advice to individuals about their health that takes into account their health data, their personalities, their goals, and their activities and what is the appropriate standard of care for them. It involves tracking their progress or lack thereof—what the Robert Wood Johnson Foundation has called ODLs or observations of daily living.

It’s possible for people who are at risk for diabetes or heart disease to avoid these diseases.  And for those who already suffer from them, it’s possible to cure them by clearing up their arteries or at least stop complications like blindness and renal failure. If they are living with asthma, get them the personalized help they need to minimize attacks and shorten episodes. If they are living with depression, give them support and tools like breathing calmly, meditation, regular exercise, and smart diets. This isn’t magic.  There is much scientific evidence about what works, and translations for healthy living are plentiful on the Web.  Think mint.com, a site that balances your budget, for health. The cost of building a site that empowers patients to manage their health is a tiny fraction of the cost of a single medicine being brought to market. Will DNA count in this space? Certainly. Some people have lower risks based on their genetic makeup, and others have higher risks. Certain nutritional interventions will benefit some people and may harm other.  But DNA testing can also inform intelligent prevention.

We want both personalized medicine and personalized wellness. But we can have the latter much sooner and it will probably do more good, at least in the next decade or two.

There is one thing making it very hard to deliver on this vision today. Much of personalized wellness advice depends on basic lab results like the lipid panel. The person with a total cholesterol of 150 may need different advice than the person with a total cholesterol of 250, for example. Today, if I go into a lab to get my blood drawn, say for my checkup, I cannot download the data into my personalized wellness tool of choice unless my doctor electronically approves it.  Not because the lab cannot support this—90% of labs performed outside hospitals are covered by Quest Diagnostics or LabCorp and both support electronic data transfer.  Rather, a doctor’s electronic approval is required to release the lab data to the patient, even when the patient wants this data. Well, most of the doctors aren’t using electronic systems and most of the ones who are don’t have the ability to approve these transfers, while some of the ones who do have the ability choose not to. The notable exception is Kaiser, which delivers labs to all of its patients online at the same time that the patients’ doctors get them. Three million patients use Kaiser’s PHR and the number one use is for viewing labs. Kudos, Kaiser!

But if you aren’t lucky enough to be a Kaiser member or want to use a different tool for this purpose, you are out of luck. (Actually, Kaiser may be integrating with Microsoft HealthVault and then one could use one’s own tools, but the timetable for rollout is unclear.) This is like not being able to use mint.com because your bank won’t allow the transfer of financial data to your account at that site.  It makes no sense, and is one more example of how the system foils patients’ attempts to take responsibility for their own health.  It clearly stifles innovation in an area that has the most potential to solve economic and personal health care issues in the U.S.

I call on DC and the State Legislatures to change these laws.  Learn from Kaiser.  Pass laws that specifically give the lab companies the obligation to deliver our data electronically directly to us – the people, if we want it. If you desire true health care reform that actually will lower costs and curb illness, unleash the power of the innovators to help consumers with personal wellness as mint.com does with financial wellness. Release our health data.

Author: "adambosworth" Tags: "health, Uncategorized"
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Date: Saturday, 28 Nov 2009 23:02

Alexandra Drane started a wonderful movement called Engage with Grace over a year ago and she asked me to join a Thanksgiving rally supporting this movement. I’m happy and proud to do so. As I wrote in one of my most contentious posts, once my mother was diagnosed as being terminal after a valiant 4 year battle with Ovarian cancer, the system totally failed us. Support turned to indifference. Every attempt was made to have my mother end her days in the hospital rather than spending her last 2 months at home. It was only because of my connections and resources that she was even able to end her days with dignity surrounded by those who loved her. Indeed just days before the end, she was able to be taken in a wheelchair to the library she had presided over for over 40 years at Saint Ann’s School and see it officially renamed to the Anne Bosworth library and hear the tributes of all who have known her and learned from her. All this would have been denied if the current “health system” had had its way. It is this indifference to the needs of those at this stage of life that the movement is dedicated to combating and I enthusiastically endorse it. Engage with Grace has 5 basic questions everyone should know.

We are supposed to ask more lighthearted questions on this Thanksgiving weekend, but I’ve been unable to get WordPress to accept this questionnaire and I think it is a sign. We need to change the system profoundly to take human needs into account first. We need a system that works to meet these needs, not to try every possible futile procedure leaving those poor souls to suffer their last weeks or days in pain and indignity against their will. This is a serious business for those of us who have lived through this, seen the suffering first hand. We give thanks for many things this weekend but we look forward to the day when we can give thanks for a caring health care system.

To learn more please go to www.engagewithgrace.org.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Tuesday, 17 Nov 2009 18:19

Keas has launched.  Keas is a place consumers come to when they want to take charge of their health or that of someone they love. They come to get the personalized advice and content that they need to understand their health and to know what they need to do and to be reminded/helped to do it. Keas delivers this personalized advice via Keas Care Plans. Think of each Care Plan as a set of great health experts giving you personalized interpretation and advice about your health and what you need to do based on your health data, your goals, and your progress to date. Not just once, but on an ongoing basis. But we at Keas don’t write these Care Plans in general. Great experts in health, whether in pediatric Asthma or dealing with H1N1 or with Diabetes do so.  You don’t need to be a programmer or have an IT department to build Keas Care Plans, but you do need to have great health experts,  great content people and usually (at least for your first one) help from what we have come to call Keas Producers.

We at Keas have been overwhelmed with astonishing potential partners in the health field who want to build great Keas Care Plans. We are humbled and gratified, but we are also urgently in need of someone to lead this effort for us. What sort of person do we need? We need someone with passion for the customer who will work with every partner to ensure that their care plans are engaging,  personalized, helpful and responsive and hire/manage the Keas producers we need to help the partners in this effort. We need someone who will be able to understand the health issues involved, but also the consumer passion and who can help our partners not just to deliver content personalized to the need, but video, twitter, great links, living discussions, polls, and everything else required to actually help the users of their Keas Care Plan to get the most out of it.

So, in short you need to be a leader, tireless,willing to get your fingernails dirty and lead by doing, passionate, unafraid of risk (this is a start up!), excited and knowledgeable about health, great at working with partners, with good business sense, experienced in building and leading teams that partner with others, and with an understanding of how the web is changing from a text world to an interactive and video world. If this is you and you want to help our partners produce the 100′s of care plans they now want to build, then let us know please at careers@keas.com.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Tuesday, 10 Nov 2009 16:11

John Halamka put up a thoughtful piece today which I for one heartily endorse. I’ve worked with John off and on since starting Google Health and we have really traversed down this road together.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Thursday, 29 Oct 2009 14:47

Warning. This is a rare nerdy technical post more for. It is about Healthcare XML standards.

I’ve was kindly asked to testify at a meeting in DC this week about standards at an hour when I’m normally not awake. But despite a deep aversion to not getting enough sleep, I was up and on the phone. What made me do such a thing? Well, the discussion was about what actually will work in terms of making health data liquid. What standards should be used for the integration of such data?

Somewhat to my surprise and usually to my pain, I’ve been involved in several successful standards. One was used to exchange data between databases and consumer applications like spreadsheets and Access. It was called ODBC and worked surprisingly well after some initial hiccups. Another was the standard for what today is called AJAX, namely building complex interactive web pages like gmail’s. Perhaps most importantly there was XML. These are the successes. There were also some failures. One that stands in my memory is one called OLE DB which was an attempt to supplant/replace ODBC. One that comes close to being a failure was/is the XML Schema specification. From all these efforts, there were a few lessons learned and it is these that I shared with DC this Thursday. What are they?

  1. Keep the standard as simple and stupid as possible. The odds of failure are at least the square of the degrees of complexity of the standard. It may also be the square of the size of the committee writing the standard. Successful standards are generally simple and focused and easy to read. In the health care world, this means just focus first on that data which can be encoded unambiguously such as demographics, test results, medicines. Don’t focus on all types of health data for all types of health. Don’t focus on how to know if your partner should have access to what (see points 2,3, and 4 below).
  2. The data being exchanged should be human readable and easy to understand. Standards are adopted by engineers building code to implement them. They can only build if they can easily understand the standard (see above) and easily test it. This is why, in the last 15 years, text standards like HTTP, HTML, XML, and so on have won. The developers can open any edit editor, look at the data being sent/received, and see if it looks right. When Tim Berners Lee first did this on the internet, most of the “serious” networking people out there thought using text for HTTP was crazy. But it worked incredibly well. Obviously this worked well for XML too. This has implications. It isn’t enough to just say XML. The average engineer (who has to implement these standards) should be able to eyeball the format and understand it. When you see XML grammars that only a computer can understand, they tend not to get widespread adoption. There are several so-called XML grammars that layer an abstract knowledge model on top of XML like RDF and in my experience, they are much harder to read/understand and they don’t get used much.  In my opinion Hl7 suffers from this.
  3. Standards work best when they are focused. Don’t build an 18 wheeler to drive a city block. Standards often fail because committees with very different complex goals come together without actual working implementations to sanity check both the complexity (see point 1 above) and the intelligibility (see point 2 above). Part of the genius of the web was that Tim Berners-Lee correctly separated the protocol (HTTP) from the stuff the browser should display (HTML). It is like separating an envelope from the letter inside. It is basic. And necessary. Standards which include levels or layers all jammed into one big thing tend to fail because the poor engineers have to understand everything when all they need to understand is one thing. So they boycott it. In health care, this means don’t include in one standard how to encode health data and how to decide who gets it and how to manage security. If all I, as an engineer, want is to put together a list of medicines about a patient and send that to someone who needs it, then that’s all I should have to do. The resulting XML should look like a list of medicines to the me. Then, if it doesn’t work, I can get on the phone with my opposite number and usually figure out in 5 minutes what’s wrong. Also I can usually author this in a day or two because I don’t have to read/learn/understand a spec like a telephone book. I don’t have to have to understand the “abstract data model”. The heart of the initial XML spec was tiny. Intentionally so. I heard someone say indignantly about the push to simplify Health IT standards that we should be “raising the bar on standards” not lowering them. This is like arguing that we should insist that kids learn to drive an airplane to walk to the next door neighbor’s house. All successful standards are as simple as possible, not as hard as possible.
  4. Standards should have precise encodings. ODBC was precise about data types. Basic XML is a tiny standard except for the precise encodings about the characters of the text, Unicode. That is most of the spec, properly so, because it ensures that the encodings are precise. In health care this means that the standard should be precise about the encodings for medicines, test results, demographics, and conditions and make sure that the encodings can be used legally and without royalties by all parties. The government could play a role here by requiring NPI’s for all doctor related activities, SNOMED CT for all conditions, LOINC for all labs, and some encoding for all medicines (be it NDC, rxNorm, or FDB) and guaranteeing that use of these encodings is free for all use.
  5. Always have real implementations that are actually being used as part of design of any standard. It is hard to know whether something actually works or can be engineered in a practical sense until you actually do it. ODBC for example was built by many of us actually building it as we went along. In the health care world, a lot of us have built and used CCR as we go, learning what works and what doesn’t very practically and that has made it a good easy to use standard for bundling health data. And the real implementations should be supportable by a single engineer in a few weeks.
  6. Put in hysteresis for the unexpected. This is something that the net formats do particularly well. If there is something in HTTP that the receiver doesn’t understand it ignores it. It doesn’t break. If there is something in HTML that the browser doesn’t understand, it ignores it. It doesn’t break. See Postel’s law.  Assume the unexpected. False precision is the graveyard of successful standards. XML Schema did very badly in this regard. Again, CCR does fairly well here.
  7. Make the spec itself free, public on the web, and include lots of simple examples on the web site. Engineers are just humans. They learn best by example and if the standard adheres to the points above, then the examples will be clear and obvious. Usually you can tell if a standard is going to work if you go to a web site by the group and there is a clear definition and there are clear examples of the standard that anyone can understand. When you go to the HL7 site the generality and abstraction and complexity are totally daunting to the average joe. It certainly confuses me. And make no mistakes. Engineers are average joes with tight time deadlines. They are mostly not PhD’s.

Let’s be honest, a lot of standards are written for purposes other than promoting interoperability. Some exist to protect legacy advantages or to create an opportunity to profit from proprietary intellectual property. Others seem to take on a life of their own and seem to exist solely to justify the continued existence of the standards body itself or to create an opportunity for the authors to collect on juicy consultant fees explaining how the standard is meant to work to the poor saps who have to implement it. I think we can agree that,  whatever they are, those are usually not good standards. Health data interoperability is far too important an issue to let fall victim to such an approach.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Tuesday, 13 Oct 2009 23:15

We have been truly blessed here at Keas. We have amazing partners in Quest Diagnostics, Healthwise, CVS MinuteClinic, Dr. Alan Greene and the DiabetesMine/Joslyn team of Amy Tenderich and Dr. Rich Jackson. We have a great team within Keas. And we received some extraordinarily supportive news reporting about Keas during the last week including The New York Times and Fox Business as we opened up a public beta for everybody. We are truly grateful.

For those of you who missed this news, Keas now has an open, free public beta at www.keas.com.

What is Keas? Keas brings you the best medical minds to deliver personalized help so that you can start to take charge of your health. These health experts build personalized expertise into a Keas Care Plan, based on the very same questions and feedback that occurs in person, during an office visit. In other words, these Care Plans look at or ask for your data just as health experts would. Given that data, Keas Care Plans can help you understand your health by charting the results that matter, indicating whether you are where you should be (in the green), have some risks (in the yellow), or clearly need serious attention (in the red). And because they are developed by health professionals who understand the nuances of health issues, Care Plans deliver “to-dos” for you to see at a glance what steps to take to get in the green and stay in the green.

We also announced a wonderful strategic alliance with Quest Diagnostics. If your doctor orders a blood test to be taken at a Quest Diagnostics Patient Service Center, when the results come in Quest and your doctor will help get your data into Keas. In addition, as part of the strategic alliance, Quest Diagnostics has worked with Keas to help interpret your data, based on your personal health status, as falling in the red, the yellow, or the green. It is another layer of expertise that offers you the best advice for taking charge of your health.

Thanks to the news coverage and our partnership with Quest Diagnostics, we are now getting large numbers of users each day. And that brings us yet another layer of expertise – you, the user.  As we develop communities based on individual Care Plans, your knowledge and wisdom will be invaluable to those who share your specific health concerns, and we’ll provide the tools for peer-to-peer support. In addition, we at Keas need your smart observations: we can only make our services great and truly useful with your help. We want to know from you what Keas Care Plans you need that we haven’t built. We want to know which Care Plans can be better and how. We want to know which “to-dos” need to be improved and expanded, and your preferred modes and frequency of messaging. We want to know what Keas should be doing for you that it isn’t already doing in order to provide the best personalized help from the best medical minds. So please keep your feedback coming.

Our commitment to you is that we will learn and work hard and steadily to fix the things that need fixing and add the things that need adding. Working together over the next few months, we can make Keas the tool you need to understand your health and take charge of it, with help from the best health experts and from each other. It is an exciting time.

If you are a health expert and want to join us in building Care Plans for your patients, please email us here.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Monday, 05 Oct 2009 17:00

In most fields of human endeavor, there has been a sea-change, a revolution in technology, over the last decade which has gone largely unrecognized or acknowledged outside of the IT industry. It has been in the area of what is known either a machine-learning or data-mining. These are different tactics for accomplishing the same goal – learning from data.

What makes Google such a formidable competitor in the ads space is machine learning. What makes my bank now able to do such a good job of warning me about possible fraud is machine learning. What makes travel companies so good at pricing is data mining and machine learning. If I were giving any aspiring student going to a university to study computer engineering advice, it would be to focus on this area. It is almost like magic. We see it in subtle ways like NetFlix movie recommendations, but this is just the tip of the iceberg. Beneath the waves, almost every field is moving in this direction. And, these systems are dynamic and rapid. They are constantly learning and constantly improving.

There has been one notable exception. Health care. Machine learning and data mining do require a lot of data. Since you aren’t able to do controlled double blind randomized experiments, you need enough data to make the conclusions statistically significant in a messy data world. But given enough data, learning can and does happen. We are poised at the beginning of a similar sea-change in health care. As vast amounts of personal health care data start to get collected we will start to learn what is actually effective and what isn’t for whom. This is really a prerequisite for personalized health. The term is used loosely to mean giving people the personalized advice/treatment that they need based on their data. But the only way to personalize is to know what’s effective for whom. Some of this will doubtless be based on genomic information. But far more will just be based on looking at what is working for whom based on their conditions, ongoing test results, and treatments.  And this is key. The human body varies tremendously based both on environment and on inheritance. One size doesn’t fit all.

Until recently, a lot of machine learning from health data has been still-born for 3 reasons:

  1. It has been too hard to translate what is known about personalized medicine from research into clinical practice. This is known as the “translation” problem. But online tools that do know these things are going to rapidly change this failure in translation in the decade to come.
  2. There hasn’t been nearly enough data because almost no data was automated and, even when it was, it wasn’t tracking the data over the individual and their treatment plan. Instead, it was tracking the order over the insurance number and the practice because that’s where the money was. Between ARRA’s meaningful use mandates which are going to force tracking against the patient and the burgeoning consumer movement to take charge of their own health as the system increasingly limits their access to continuous care from physicians, this lack of data is going to change at least as profoundly in the decade to come.
  3. There was no money in giving consumers personalized treatment and indeed movements against it, both the population studies (witness the debates right now about diabetics being told to lower their blood sugar) and because the doctor’s weren’t paid for outcomes. But consumers are going to demand the treatment for the best outcome. Also we’re learning that often, it will cost less. Often the standard care given is too much treatment, so brilliantly called out in the book “Overtreated” and, paradoxically, your outcomes are better as the cost goes down, not up.  Back surgery tends to be a post-child for this, also called out well in the book “Flatlined“. We are going to be forced to figure out how to be more cost-effective, and more effective in general in treating illness.

All the systems emerging to help consumers get personalized advice and information about their health are going to be incredible treasure troves of data about what works. And this will be a virtuous cycle. As the systems learn, they will encourage consumers to increasingly flow data into them for better more personalized advice and encourage physicians to do the same and then this data will help these systems to learn even more rapidly. I predict now that within a decade, no practicing physician will consider treating their patients without the support/advice of the expertise embodied in the machine learning that will have taken place. And finally, we will truly move to an evidence based health care system.

Author: "adambosworth" Tags: "health, Uncategorized"
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Date: Sunday, 30 Aug 2009 17:10

What the Republicans are doing now with regard to the health bill is a classic tactic used by scum everywhere through history. It is the big lie and the vicious lie. Hitler used this tactic over and over again in gaining power in the third Reich. And the real truth is beautifully described by NICHOLAS D. KRISTOF in the New York Times.

This is a personal issue to me and thus makes me particularly angry. When my poor mother finally turned the tide for the worse in her battle with Ovarian cancer, she was diagnosed at the Hutch in Seattle. I had to fight, almost physically, to get her out of a hospital 3,000 miles from her beloved apartment in NYC and back home to the apartment where she wanted to end her days. I almost had to medivac her before she recovered just enough to get her discharged and onto a wheelchair and thus onto a plane back to NYC. Once in NYC, I brought her into Sloan Kettering Memorial Hospital which had treated her well while treatment worked, but once it was clear that all options had ended and she only had a couple of months left, they and the current medical system left her and us terribly adrift. They basically sent an old lady away to die and confront fear and pain without any offer whatsoever of home help. They gave her a complicated regime for the painkillers and other meds that even the visiting nurses of NY (who were saints) couldn’t administer and Sloan offered no help in finding the “High Tech” nurses we required for my mothers care. We went through fear, pain and panic for the next couple of days trying to help her follow the meds regime they had given us on discharge which it turned out, even the visiting nurses of NY (saints!) couldn’t follow. I finally found some along with the help of an extraordinary friend of my mothers who had been an ICU nurse and we managed for the next 2 months until her last few days when she chose to go into a hospice. But the modern health care system tried hard to have her die in the hospital at a cost of 1,000′s of dollars a day when all she wanted was to be at home, pain-free, among friends. For that, not a penny. Her hospital never even called to see how she was doing.  And this is what the Republicans are trying to protect – this soulless cruel heartless vicious system. They should be ashamed. I am ashamed of them.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Monday, 10 Aug 2009 23:44

I was at the Aspen Health Forum last week listening to a really diverse crowd talk about health care in the US and doing a bit of talking of my own.  I was talking about the importance of giving us all the right to our health data online, a topic I’ve posted about with many others on healthdatarights.org and my talk fit right into the larger topic of how personalization can help to transform medicine which can be found if you scroll down to the “Big Idea – the body”.

The theme of the conference was a more holistic one and included a truly wonderful talk by Mehmet Oz about overall health and wellness as well sessions on play, food, and sex. People forget how much of illness is caused by stress and how important it is to find ways in your life to just enjoy the world you live in.  None of us can completely avoid stress, but all of us should strive to balance our drive to succeed with the need to stop and smell the roses. Of course the conference on all this started every day at 7:45 AM and finished at 10:00 PM and this was a weekend, but the intentions were good.

If you want to know what I said there and would prefer to read than listen, here is the text of the talk I gave at the Aspen Health Forum.


There is a lot of talk about improving health care. And there is a lot to improve.

Inadequate Evidence: We don’t know enough about what works. We should require sharing of population statistics across practices and hospitals in order to better determine what works for whom. We should reward practices and hospitals that are delivering the best most cost-effective long-term outcomes and penalize those that deliver the worst.

Overtreated: Doctors often don’t know what the evidence suggests that they should do. Often even when they do they don’t do it not because of careful clinical thought but habit. The book Overtreated makes this painfully clear. We need to reward/encourage doctors based on long-term outcomes, not pills and procedures.

Flatlined: Payment is skewed away from the people who should be the coaches for consumers, the primary care physicians, because of a model that pays for the complexity of a procedure rather than for the cost-effectiveness of it. This model has encouraged countless unnecessary spinal fusions, stents, and other expensive procedures and discouraged any form of preventive medicine, patient jawboning or oversight. We need to reward/encourage doctors based on cost-effective long-term outcomes, not on difficultly of procedure. The book Flatlined makes this point incredibly clear.

No PCP <-> Patient time: Doctors can’t jawbone their patients anyway. In the old days, primary care physicians jaw-boned their patients. But that took time and energy, neither of which they have today when they have 30% increased patient loads. So they don’t. And people who should be healthy end up with joint replacements, depression, stress, heart disease, diabetes, gestational diabetes, and increased risks of cancer. And in so doing, the life-style related diseases cost us over $3 Billion a day.

: And the patients need jawboning badly. A key reason that our health care costs are out of control are consumer’s life styles and ignorance and lack of skin in the game. Patients literally do not know how to be healthy, have no sense of the implicit costs of being unhealthy, and have no incentives to be healthier short of chronic pain. up to 70% of our costs are due to life-style related diseases with obesity and inactivity and poor eating choices being key ones. 23 years ago, only 7 states had an obesity rate over 15%. Today only one state is under 20% and that majority are 25% or over. We have a wave of diabetics who don’t really take care of themselves leading to amputations, blindness, renal failure, heart disease, and other terrible consequences and costs.

They need more than jawboning. They need tools.

I dream of a day when everyone has online access to their health and wellness plan – Not their sickness plan, but their health & wellness Care Plan, personalized and tailored to their specific health data, their needs, their goals and  their realities.
I dream of a day when we don’t publish books about how to stay healthy, we publish personalized health & wellness Care Plans written by the best in the business, experts in their fields, but augmented by the feedback and realities of online engagement with their customers as the authors and experts determine what works for whom.
I dream of a day when we truly know which Care Plans work for whom because we have been able to measure which do.
I dream of a day when consumers talk about their health score as today, they might talk about their handicap or FICO score and work with trainers to lower it as they do their handicap
I dream of a day when their doctors are partners in these Care Plans, not people patients visit when they are sick

We can and will fuel the engine and drive the innovation and payments that will slowly but surely reverse most of these problems.
This dream requires only one thing to make it a reality. One thing that can unblock this logjam. Here is the “big idea”.


A Declaration of Health Data Rights

In an era when technology allows personal health information to be more easily stored, updated, accessed and exchanged, the following rights should be self-evident and inalienable. We the people:

  1. Have the right to our own health data
  2. Have the right to know the source of each health data element
  3. Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; if data exist in computable form, they must be made available in that form
  4. Have the right to share our health data with others as we see fit

These principles express basic human rights as well as essential elements of health care that is participatory, appropriate and in the interests of each patient. No law or policy should abridge these rights.
When we endorse and support these rights, the rest will follow slowly but surely.

Those of us, all over the world, who can innovate online will deliver to humans the tools that take their data into account and help them best understand and manage their health. We will connect them with your expertise. You will be able to advise, based on their detailed data, not 100′s of patients, but 100′s of thousands. We can and will team up with you to make this happen.

IF we provide incentives for being healthy (e.g. compliant with a regime, not obese, not a smoker, routine exercise, regular preventative care) the rest will follow very quickly.

Why the Declaration of Health Data Rights
Shockingly most doctors don’t even have the patient’s data electronically. But the organizations at the source do. Labs and the pharmacies and insurers and the imaging labs do. We empower the consumers to get their health data electronically, rapidly and online. This is the fuel that will fire the engine of consumer health-care because it enables the rise of online tools to help consumers manage their health and work in a participatory manner with others best equipped to help them driven by data and expertise specific to their needs. As human beings, we all have this right. To deny it is to deny healthy living to all. We are in the business of increasing health and this is the tap that must be turned on.

What will this enable.

Revolution Deferred: Next we move the routine and the information out of the doctors hands and into the consumers through these online Care Plans, whether it is getting ready for a visit, discharge, or managing a chronic disease. The internet has profoundly revolutionized every other business moving all routine work into the consumers hands, but giving them choices, flexibility, and transparent information. Travel. Banking. Books. Movies. Eating. Only in health care is this revolution deferred. We must move health care out of the 19th century and into the 21st. Then we will harness the creative talents of tens of thousands all across the world. What’s more, it will enable us to measure what works for whom in a computable fashion. It is unacceptable that this hasn’t already happened.

Health Coaches anywhere: We allow people anywhere to provide expertise online to consumers. What sense does it make that only a cardiologist in NY state who may well be out of date and has no incentives to help someone go on a diet/exercise regime is the only one who can treat a patient in NY state? Why can’t anyone with expertise in heart disease, anywhere in the world, help that patient? They will become the online partners in these health plans.

Patient Engagement
: The most important of these tools will be Care Plans. They will be the online tools consumers use to know what it means for them to be healthy and how to be healthy. People need the tools and training and support to know what to do, why they should do it, and the encouragement to do it. This is called patient engagement. This is called participatory medicine. Once people have online control over their health data, their medicines and their labs and their images, a myriad of online Care Plans will emerge to help them understand how to be healthy

Incentives: Lastly, we provide some incentives, even small ones, in the form of lower health care costs, to individuals who are managing their health well as measured/defined by these computable protocols. To anyone who has tried it, a reward of a few $100 / year has a dramatic effect on compliance. Let’s say that 70MM people aren’t managing their health well or the health of their children. At $300 / year in incentives (e.g. decreased premiums) that’s $21 Billion a year or less than 1% of our health care costs IF they in fact become as healthy as they can in which case they save far more than that. We spend that on avoidable life-style related health-care each week right now. The return on that investment would be almost 100:1. It’s effect will be vastly greater than putting the current behemoth EMR’s into doctor’s offices which will often be like giving giant combines to the suburbanite who wants to mow the lawn.  Giving physicians the wrong tool and the wrong incentives will still lead to the wrong result. Giving the consumers the right incentives will drive consumerism throughout the healthcare system and drive the right results, by definition.

All this stems from an incredibly simple idea.

Give consumers the right to a copy of their own health data, without impediment or delay, online in the place of their choice.
We will see the rise of online Health Plans targeted at helping consumers to understand their health and to learn how to be healthy or stay healthy.
We will see the rise of money flowing to consumers, doctors, nutritionists, fitness experts, and health coaches to support the consumers in their efforts.
We will see the system evolve from a sick care system to a health care system, driven by consumer demand.

Why will this work? Because it harnesses the power of the world’s intelligence, the world’s online delivery and the worlds innovators – you – and rewards you for doing the right thing.
It isn’t bottle-necked by how many people in medical school become PCP’s because the online tools massively leverage expertise and remove rote work from physician’s lives and transcend national borders.

It funnels the money and the talent to what works.

When we all support the declaration of Health Data Rights in deed, not in words, we will change health-care.

Join me in making Health Data Rights a reality, not a dream

Author: "adambosworth" Tags: "Uncategorized"
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Date: Monday, 27 Jul 2009 02:30

We are beginning to see the end of the beginning in health news. People are starting to realize that the system is broken. But we are in the cusp period and the news reminds me of watching a tide change right as you go from the ebb to the flood. The following articles caught my eye in this regard.

Best new post I’ve seen this year is about how we can really lower costs.If you read nothing else, read this please.

In their tirades against Obama’s attempts to fix a tragically broken health care system, the Wall Street Journal has descended to the ludicrous. See their article on Big Pharma gets played. They are shocked, shocked that US citizens may actually have the legal right to pay less for drugs by buying them from Canada.  The WSJ concludes by saying dramatically, that “the real victims of government health care will be American patients”. Because we pay less for drugs? When did the WSJ decide that price competition was bad for the consumer?

The WSJ editorials have consistantly ignored the elephant in the room, namely that US citizens are significantly sicker than most other civilized countries (we tend to rank between 25th and 37th) despite the US spending almost twice as much per capita  asthose countries and that our costs of health care – $2.5 Trillion on track to reach $4 Trillion within a decade as the baby boomers age – are unsupportable anyway. Something has to change. Also, consider that as the babyboomers age, the health care costs will be mainly in Medicare.

Strange things happen in Texas. Imagine if your broker was mismanaging your money and people in the organization spoke up and warned the SEC that this was happening. You might not know because you’re no expert on investing. Heck you might like the broker. But the people in the organization would know. They are the experts. What should happen? You would hope that the broker would be disciplined. But in Texas, when it is the vastly more important area of your health without which no real happiness is possible, if people speak up, they are indicted and threatened with 10 years in jail. Here’s hoping that the health care providers in Texas speak up loudly against  this  abuse of power.

A lot of doctors express skepticism out there about online support for health on the part of the doctors. A common comment is that my patients are older and aren’t on the net or aren’t willing to use the net to manage their health. Doctors should learn from Kaiser who reports that 87% of their Medicare patients are happy users of Kaiser’s My Health Manager.

It is interesting to watch some health care providers start to scream as it dawns on them that the meaningful use bill might actually require them to have proof that they are improving their patients health in some basic measurable ways in two and a half years. Incredibly, they claim that that isn’t enough time. In the world of online computing it’s an eternity.

Author: "adambosworth" Tags: "Uncategorized, health"
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Date: Tuesday, 23 Jun 2009 00:59

In this post I want to talk about an overdue revolution – a revolution in health care. It is a revolution which can greatly transform health care for the better and one where an acknowledgment of some simple basic human rights is key.

In almost every field today, the power of online communities, online tools, and online data has been revolutionary, whether it be finance, travel, purchasing goods, books, getting the news, or entertainment. If, for example, we want to plan a trip, we can search online, book online, print out our boarding pass online, and see what others have thought online. Our schedule is clearly there and usually, if the site is well designed, it is there in a form where we can effortlessly digitally update our online calendars as well.

This revolution has led to far better information, far more freedom to plan and organize things and usually a far better experience. No more waiting in line at the counter at the airport or at the bank or at the store. No more wondering if we’re getting the right thing or going to the right place. No more (and you have to be my age to appreciate this) trying to get to the bank before 3:00 PM so that we’ll have money for the weekend or the vacation. Along with this convenience came the idea that the data is the consumer’s data and we deserve to know it. We have the right to it.

Yet, in the area where it matters most, our health, virtually none of this is true. It is as though the revolution never occurred.  We cannot easily see what our data is online (e.g. our labs, our prescriptions, our problem list, our images) unless we are lucky enough to be at Kaiser; let alone if, like almost all Americans, we have dealt with innumerable different clinics, hospitals, doctors, labs, and pharmacies during our life. Further, we cannot easily take the time online to understand what this data means for us and harness the online power of experts or the opinion of others to best understand our health and where we stand.

Let me give the simplest example. Many people in this country are given medicines by multiple doctors which may be dangerous in combination or have harmful effects if we have some specific condition. No fault of the doctors. They don’t have the holistic view of our health data either. They can’t even access our data online most of the time. Now the  American Recovery and Reinvestment Act of 2009 or ARRA aims to fix this for the physicians. But we, as the affected consumer, can’t easily go online, load in all our medicines and test results and problem lists in computable form and and with a mouse click learn if there’s an issue, as, for example, we might use an online flight tracker to see if there was a travel issue.  Thus our health and well-being take a back seat to our travel ease and comfort with potentially serious consequences.

Sometimes there are laws on the books that actually prevent us from getting our health data. If we have a risk of heart disease and really should keep an eye on our cholesterol, there is a simple lab test, a lipid panel, that we could use to make sure that our exercise, diet, and medicine programs were working. But in many states we cannot order this online. Even if it is ordered for us, in many states we cannot just ask the lab to directly download the results to us at the time the test is taken. It is as though they’ve made it illegal to find out how much we have in the bank or where our trip will take us.

Only our health is more important than anything else. Without good health, life is greatly compromised. If there is one place where we must have the right to the best information, advice, care, online support, and planning possible it is  our health.

Today I proudly join together with a group of  leaders across health care working to establish a Declaration of Health Data Rights. The text of the declaration is clear, appropriate and extraordinarily important to us all.

A Declaration of Health Data Rights

In an era when technology allows personal health information to be more easily stored, updated, accessed and exchanged, the following rights should be self-evident and inalienable. We the people:

1. Have the right to our own health data

2. Have the right to know the source of each health data element

3. Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; If data exist in computable form, they must be made available in that form

4. Have the right to share our health data with others as we see fit

These principles express basic human rights as well as essential elements of health care that is participatory, appropriate and in the interests of each patient. No law or policy should abridge these rights.

My company Keas and I wholeheartedly endorse this declaration and are proud to be part of a growing community that recognizes its importance.

If you would like to add your voice to ours, you can get started by visiting http://www.HealthDataRights.org and see who else is endorsing this declaration and spread the word. Support and defend our rights to our health data and start the revolution.

Author: "adambosworth" Tags: "Uncategorized, health"
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Date: Thursday, 18 Jun 2009 17:37

Obama’s administration took the first important step in health care reform this week. They put up a proposed definition of meaningful use for ARRA (The American Recovery and Reinvestment Act of 2009). There are two key documents to review: a preamble which is excellent and calls out all the key issues that need to be addressed; and a matrix which reviews the planned requirements for meaningful use for the key areas identified for improvement. These are:

  1. Improve Quality, safety, efficiency, and reduce health disparities. – Read Overtreated to learn why this is key
  2. Engage patients and families – Without this, we cannot solve the fundamental cost problems we face
  3. Improve Care Coordination – It will be amazing to see care coordination come into the 21st century
  4. Improve population and public health – They are correctly focusing on measuring what works and who is doing it
  5. Ensure adequate privacy and security protections for personal health data – I believe consumers should control who sees what of their personal health data and am excited to see this supported.

I’m really delighted. This document isn’t perfect in my opinion. In particular, it calls for EHR’s to “provide patients with electronic copy of – or electronic access to – clinical information (including lab results, problem list, medication list, allergies) per patient preference (e.g through PHR). This allows the bad “old days” of tethered PHR’s to continue where as you switch doctors because of changes in your location, insurer, job, or just need a better doctor, or you want to include other doctors in complex care, or want outside or second opinions about your data, you cannot get it because not everyone is using the same EHR. It is key that the patients control their PHR’s and that they can transfer or download or copy this data in as computable a form as is available in the EHR into their PHR of choice.

But overall the committee that produced this document is to be congratulated. Kudo’s and congratulations to the members of the HIT Policy Committee and a special thanks to David Blumenthal. And while there are features in the matrix that aren’t called for until 2013 that I’d like to see in 2011, again, it is an excellent document.

The preamble does an excellent job calling out why we need this and what we need to improve. Don’t change a word of it please!!

Author: "adambosworth" Tags: "Uncategorized, health"
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Date: Sunday, 14 Jun 2009 16:26

Not only are tempers rising. There is a feeling across the board in health care that it is time to speak up.

Doctors are speaking up. Brian Klepper and David Kibbe just put up an interesting post. Bob Wachter, who I knew when at Google Health, referred to an excellent article by one of my heroes, Atul Gwande in his latest post pointing out that the current system has no discernible efforts to actually manage overall outcomes and costs.  Contrary to the inane platitudes one hears from certain Senators blandly assuring us that the health care system needs no repair, people across the board are pointing out that the system is broken. The center cannot hold. But we will not bow to the prediction in Yeat’s magnificent poem in which the best lack all conviction and the worst are filled with passionate intensity.The system can and must and will be fixed. It is time to speak up.

Watching legislature meet health care is like watching a slow motion train wreck. Witness the bill in contention in NJ right now. Essentially it will prohibit or drastically slow down the sale of innovative products that actually help consumers understand or manage their health. For example a product that prints out a medical history for the consumer to help him/her have a better doctor visit or a product that uses the FDA guidelines to warn about med/med interactions as Google does or a product that helps users collaborate on improving their health will all be prohibited if they actually used “health data” unless the CCHIT specifically licensed them. Imagine if every product to help you budget, plan a vacation and the finances, plan to save for your kids college education or retirement planning all had to be licensed by an agency let alone one that was never intended to do this. That is essentially what the NJ bill does. It is time to speak up.

Author: "adambosworth" Tags: "Uncategorized, health"
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Date: Friday, 29 May 2009 19:15

Mark Leavitt has written an angry post in the Health Care Blog about some concerns David Kibbe has with the current administration health plans. (Full disclosure – David Kibbe is an adviser to Keas and a friend).  I understand Dr. Leavitt’s annoyance, but what is really happening here is a result of a deep fear among many of us that the new ARRA health bill will miss out on an incredible opportunity to actually make a difference in how health care is practiced. This fear can be paraphrased as a fear that only the incumbents will be allowed to be “certified EHR’s” and arguably the incumbents haven’t really made as big a difference in how health care is practiced as one would hope.

Let me explain.

The simplest way to describe what the administration seems to want is to be able to insure more people (a LOT more) at a lower cost (since otherwise the total costs go up a lot). Many of us have a strong belief that we can only lower costs and/or improve health-care if we make the consumer part of the solution, what is often called “patient engagement”. At the end of the day, episodic care treating people only when they get seriously sick, enough to go to their doctor or the ER isn’t ideal. What we believe is ideal is teaching people to keep a constant eye on their health and keep them out of the doctor’s office and especially out of the ER.  One might think that the forthcoming funding for Electronic Health Records (EHR’s) would support systems that deliver this sort of patient engagement and long-term patient wellness and thus help lead to better support for patient engagement. But in fact, many of the  traditional EHR’s have not focused on this at all, hence our fear about giving them a de-facto monopoly.Secondly, most small practices can’t really afford to use big iron EHR’s. Even if it is free, they can’t really afford to do it because it will still require training, more time per patient potentially, and so on. Lastly, more EHR’s don’t work with other EHR’s so that coordinated care across practices isn’t supported and most people who are elderly or who have serious illnesses have more than one physician treating them.

The way around this is to build systems that don’t just duplicate what physicians do today during their face to face meetings with their patients, but rather provide new capabilities that will help with continuous and coordinated care and can generate additive revenues for physicians and then evolve by adding those features that automate the current physician activities as demanded by the physicians. What would such systems support? They would support having a way to chat with or exchange messages with a patient for a fee so that unnecessary office visits can be removed and the patient is more likely to reach out for help. Think eVisit-lite. They would support a simple way to monitor the health of a patient who either has a chronic disease or is on path to developing one again for a fee so that physicians are actually getting paid for keeping their patients healthier as opposed to being punished for it since, ideally, it will result in fewer visits/procedures over time. In short these systems will support physicians  managing an ongoing paid relationship with the patient rather than an episodic one measured only by in-office visits.  What should be done about helping physicians who are afraid of losing time to retraining? These systems should be as easy to use as a Southwest airlines reservation page. These systems should have a cost is so low that physicians don’t care. Most of these points aren’t typical of most of the big EHR’s currently being sold. Again, hence our fear that a de-facto monopoly of the incumbents will lose this opportunity to let 100 disruptive innovations flower.

It is my opinion that the bar for “meaningful use” and a “certified EHR” should be limited to the following:

  • Easy way to share electronically computable data about medicines and labs with the patient’s URL’s of choice. These URL’s would point to the services that are helping/advising/monitoring the patient in a patient controlled way. This alone should be enough to declare a tool certified because it empowers consumers to take charge of their own health. This is also the backbone of cooperative care since then multiple physicians, regardless of vendor or practice, can exchange and share computable health data about a patient.
  • Easy standardized way to support an inbox both between physicians using different EHR’s (think email today) and between patients and their physician/nurse/physician’s assistant. This should be optional, but Medicare and insurers should be encouraged to pay for such support. Kaiser has found that the burden isn’t high and it cuts in-office visits significantly. This should certainly be sufficient for meaningful use because this, in conjunction with the first point ensures that physicians can coordinate care for a patient. It also frees up the patient to pick the best other doctors who provide the best care, regardless of practice because the collaboration can occur across practices.
  • Support for ePrescribing, largely, to be honest, so that the prescription information can flow to the patient.
  • Easy way to put patients on ongoing fee-based computable care programs and monitor how they are doing sending alerts to the physician where necessary so that physicians know when their patients are trending in the wrong direction. Something as simple as monitoring blood pressure and weight and ankle swelling can prevent repeat heart attacks. Something as simple as monitoring total steps taken a day and blood sugar and meals can prevent serious diabetic complications. But physicians aren’t paid to put patients on such plans or for the time to monitor them. Instead we wait for catastrophe and pay for that.

Not one of these except for ePrescribe duplicates existing physician work flow . These are new services that should generate new revenues for physicians all focused on continuous and coordinated care. Most people don’t get these services from their doctors (Kaiser is always a notable exception precisely because, I believe,  they are actually paid to keep people well).  And these are the services that will truly drive patient engagement with their health and with their physicians. Ultimately, it is my premise that patient engagement with their physician is the key to unlocking our health system, driving true innovation and converting it from a sick care system to a true health care system. There is an excellent post by David Brailer, the former National Health Information Technology Coordinator, supporting the urgent need for innovation and patient engagement in health care.

I ask Dr Leavitt and CCHIT to help ensure that the funds unlocked by ARRA be used to support these capabilities in as open and easy a way as possible and to avoid, at all costs, a de-facto monopoly in the physicians’ offices by the current EHR vendors by defining meaningful use of certified EHR’s to meet only the few and simple requirements listed above.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Monday, 11 May 2009 20:24

Best two books I’ve read on health in the US this year were:

Flatlined and Overtreated

Both make it so clear that we have to fix the system that you wonder how some Senators can continue to blithly insist that there is no problem and that we have a “pretty good system”.  We have good doctors and technology. The system itself, as these books make clear, isn’t good at all.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Thursday, 09 Apr 2009 02:09

When I was running Google Health I would constantly hear how it was impossible to download health data because of the doctors notes and conditions and lots of fancy stuff that wouldn’t be interoperable. And I agreed. I focused entirely on getting labs and meds to be generally available because these seemed to be the only two things that were computable and not dependent on the vagueries of the hospitals and EHR’s. There is a wonderful post up on on ePatients.net by e-Patient Dave detailing what happens when you try to get more and actually get less. The post is a constant reminder to start small and make sure that what you’re doing works. It is also a reminder that the big systems because they aren’t paid for by the consumers or reviewed by the consumers or ever see the light of day are a terrible mess. Like everything else hidden in the dark, health data is crawling with mistakes. Let’s let the light in!!

Author: "adambosworth" Tags: "Uncategorized"
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Date: Wednesday, 01 Apr 2009 01:54

The New York Times has a dire warning that the $19 Billion that ARRA calls to spend on electronic health records (EHR’s) could be wasted.  They bring up two valid concerns. The first is that physicians will not use EHR’s to improve the quality of healthcare, but primarily just for record keeping. The second is that the government will not require simple open standards that all comers can easily use to drive innovation and new cheaper solutions.”

It is certainly a risk and some of the answers aren’t intuitive. The ARRA act calls for meaningful use of the EHR’s and the NY Times article assumes that meaningful use is determined by improving care and curbing costs. This is of course the goal and if the EHR does a good job of real-time clinical decision support, it will undoubtedly improve care.

But it is an error to conflate physicians using EHR’s with curbing costs. To curb costs it is essential to create more ways and more choices for patients to own their computable health data thus enabling patients to use their data to get help and advice. This is usually called Data Liquidity and it empowers patients by adding choice into the equation. Put simply, EHR’s should, at the patient’s request, send the patient’s data (and it is the patient’s data after all) to their PHR (personal health record) of choice. Then, instead of being reliant on a single overworked physician to understand and interpret their data, they can have access to many tools and many people to help them stay healthy and on their own dime. History has shown that choice and competition lead to far better and more cost-effective results.

Some object to this model of patient controlled PHR’s. In the current issue of NEJM there is an article by Drs Paul  Tang and Thomas Lees suggesting that the best PHR is one tethered to the EHR. They argue that only this way can there be a shared patient record and only this way is the patient’s security and privacy be assured thanks to HIPAA. The article further contrasts the untethered PHR to the one run/managed by the doctor by suggesting that only the latter will help the patient to easily manage and understand their blood pressure and glucometer readings with intelligent doctor oversight.,This is very much a false dichotomy.

First, HIPAA does not give patients the ability to control who can see what of their data. It simply makes sure that only a doctor treating them can have access to it. But the patient has no fine grained control. Microsoft’s HealthVault, by contrast, does provide such protection. Clearly no one would use a PHR that leaked their health data so the business imperative for PHR’s to be secure is actually far greater than provider imperative.

Secondly, as the article points out, many patients see many doctors. The odds that all one’s doctors work for the same institution with the same EMR are both slim and presuppose, again, a lack of choice for the patient.

There is a much simpler solution. First, require the newly “certified” EHR’s that ARRA will pay for to share the patients Labs and Med’s and Conditions in a standard computable way with the patient’s PHR on patient request. Many countries  have long since figured out how to do this using SNOMED codes. Surely we can do the same using standard encoding’s for the Meds, Conditions, and Labs and standard XML formats like CCR and CCD to describe the patient data. Indeed many health organizations have have already done just this with Google Health such as Beth Israel Deaconess, Cleveland Clinic, Quest Diagnostics, CVS and Walgreens.

Second, provide extra rewards to EHR’s that support interoperable secure messaging using a standard way to exchange messages. Then patients can own their data, have a wide range of choices and still have an efficient way to communicate with their doctors. And a huge side benefit will be that doctors can now see the bigger picture of what is happening with their patients outside of their own practice.

All this will lead to truly collaborative medicine with a payoff that can only come from informed decision making and feedom of choice by the patients.

Author: "adambosworth" Tags: "Uncategorized"
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Date: Friday, 27 Feb 2009 19:49

On Tuesday night President Obama laid down both a problem and a promise. He said, “we must also address the crushing cost of health care. This is a cost that now causes a bankruptcy in America every thirty seconds…and in each of these years, one million more Americans have lost their health insurance. It is one of the major reasons why small businesses close their doors and corporations ship jobs overseas.”  And then he said the new budget would make “the largest investment ever in preventive care, because that is one of the best ways to keep our people healthy and our costs under control.”

Folks, keeping our costs under control and our people healthy will require a new era of collaborative medicine.  What is collaborative medicine? It is a health-care system in which consumers and their physicians work together on an ongoing basis to avoid unnecessary illness and suffering. Imagine doctors who had the time to really help you or those you care about to stay healthy and well.  Imagine if every person who needed help with their health had not only a dedicated online tool to help them manage their health, but also their primary care physician looking over their shoulder to help them follow their personal plan. In general, data shows that mindful and aware people manage their health better. The point of this post is that not only can we afford collaborative medicine — we can afford it with the funds already promised in the stimulus bill.  Best of all, it will save us far more than it will cost us in the long run.

This is a simple proposal for how to get us there.

First I want to make a startling point. As I pointed out in my TEPR talk, out of the $2.3 trillion we spend on health care, incredibly less than 1% of it actually goes to the  primary care physicians. Put differently folks, what we think of as medicine — which is seeing our doctor — leaves only about $20 billion in our doctor’s pocket (not counting specialists) out of the total of $2.3 trillion spent. Think what a small percentage of our total health care costs that means are going to our doctors. If you subtract $20 Billion from $2.3 trillion, you get $2.28 trillion. All the rest of that $2.28 trillion is going to insurance filing, insurance processing, hospitals, labs, medicines, imaging, and specialists.

If you want to think about this more personally, our national health care costs average about $7500 for each man, woman, and child and more than $15,000 for people who actually have, or are at risk of having, serious illnesses (probably only 100 million but I figured 150 million here just to be safe). Of that $15,000, less than $100 is going to the primary care physicians to treat you. Because of this, there is a shortage of primary care physicians which is why, when Massachusetts insured all of its citizens, the biggest problem became just getting an appointment.   And, even if you can get an appointment, most doctors have no tools or time to really help you manage your health on an ongoing basis.

Really it seems that there are about 100 million people who need much more active management and care. These are the people who will cost us or are costing us so much money today. How can we help them? We can offer each primary care physician $100 for each at-risk or ill patient each year to provide collaborative online support to their patients and offer a monetary award to each patient who actually reduces his/her risk factors by even one risk factor. What will this cost and could it come out of the $20 Billion just approved for Health IT in DC?

At $100 per at-risk or ill patient, primary care physicians will earn $10 billion more, out of the $20 billion allocated to online innovation. That’s a tiny fraction of the $2.3 Trillion we spend today but it is a windfall for these doctors, like getting a 50% raise This will help attract some desperately needed freshly-minted doctors to primary care medicine. And because at least half of that $2.3 trillion is spent on treating preventable lifestyle diseases, it will not take much for our much-happier primary care docs to have profound impact on their patients lives:  reducing just ONE one risk factor triggers enormous reductions in health care costs.

How much will it cost to deliver the required IT to support collaborative medicine between doctor and patient?  As I pointed out in my talk at TEPR , you will find that those of us creating health IT online would have no problem delivering the tools to the doctors and consumers alike for collaborative medicine for a tiny fraction of $20 billion currently proposed by the legislation. I suggest that $3.6 billion is plenty to pay for systems will enable 100 million people to be helped by doctors, therapists, and coaches alike.

Data consistently shows that offering people a reward, even a modest one, for improving their health increases compliance. We have money left over for this. If $20 billion is being spent, and $10 billion goes to the doctors and $3.6 billion goes to the IT systems to support this,  that leaves $6.4 billion for the 100 million Americans who have lifestyle issues that have led or are leading to disease. Figure that we’re shooting for 15% of them to remove a risk factor. That’s 15 million Americans. With $6.4 billion, we can reward each of them with several hundred dollars each. Even if, optimistically, 30% of them improve we can  still provide about $200 per person as a reward. And the savings to the US of 15 million people dropping even one risk factor will be vastly greater than this. Dropping even one risk factor typically will cut someone’s expected annual health costs by $1000-$2000 – more when they’re older. Not to mention the reward to them of actually feeling better, being more mobile, and the peace of mind to those who love them.  As tax payers we are going to be paying this bill anyway — we should try to cut it now.

My proposal benefits consumers and doctors alike. The doctors are getting paid more to deliver better care that is actually targeted, with the help of IT, at providing ongoing coaching and support for patients to encourage them to improve their lifestyles. Doctors are being paid more to do a better and enjoyable job. The consumers finally have tools to manage their health but with the added value of having the person they most trust in this matter, their primary care physician oversee their progress and plan.  More doctors will become primary care physicians because the pay is better and the job is more fun, which will address the shortage issue we’ve seen in Massachusetts. It will mean fewer patients going to specialists and having lots of expensive treatments and stays in hospitals as they start to make the changes that help them avoid diabetes, heart disease, and the complications thereof.

We’re prepared to spend $20 billion on trying to improve Health IT anyway. Let’s spend it correctly.

Author: "adambosworth" Tags: "health"
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Date: Thursday, 05 Feb 2009 23:14

Building Keas has been more than a full time job for the last 9 months; exciting, rewarding, occasionally difficult, and overall enormously fun. Mostly, as we have hunkered down to build Keas, I have avoided giving speeches or anything else not required to get the product launched.

But I did agree to give a talk at TEPR and I gave it this week. I gave it because we’re at an extraordinary point in our history. We have a new administration who actually wants change and can see that the current health care system needs to change.  The basic thesis of the speech is that our health care system is broken and on track to get worse, and that the only way to fix this is to get truly participatory health care between the doctors and the patients and their other health coaches. Surprisingly, as I point out in the talk, we can make a major dent in our current $2.3 Trillion of costs by covering every single American who has health issues for $50 Billion or just over 2% of the cost. Of this money, only $3.6 billion would actually go to the people building the Health IT systems. The rest, as is called out in the talk, would go to provide incentives to consumers and health providers alike to work collaboratively on their health and, in particular, for consumers to be able to be the stewards of their own health with online and ongoing support from the health care community.

Other than that, this is an exciting moment at Keas. We raised a bunch of money in December so we’re well funded (although we’re carefully husbanding our cash). We are just about to launch our first pilots. We have an amazing team but we are still looking for 2 good programmers including one who is really gifted at user interface, Javascript, CSS, HTML, etc. In addition, we’re looking for one totally can-do doctor, passionate about improving the health system, collaborative health care, and online patient support and willing to do whatever it takes to make that happen at a startup’s salary.

Author: "adambosworth" Tags: "Uncategorized"
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