I’m always on the lookout for new online communities around Healthcare IT. I test drive them for a little while and then decide how I’m going to incorporate them into my daily routine. I evaluate what benefits I get from participating. Sometimes the benefits of participating are just helping someone out. There’s something really satisfying about doing something for someone else.

My latest test drive has been the Healthcare IT Question and Answer site on Stack Exchange. I’ve used Stack Exchange a bunch before when I needed some programming help. However, I’m guessing that most people in healthcare IT (unless you’re a programmer) probably aren’t that familiar with Stack Exchange. Well, they created such an interesting community around question and answers that they got a whole bunch of VC funding and they’ve been growing their network into all sorts of new niches. Thus, the launch of the Healthcare IT Stack Exchange community.

You can go and check out my techguy profile on the HIT Stack Exchange site if you want to see what I’ve done. I’ve already got a reputation of 46 (whatever that means). I’ve already answered 9 questions on the site and a few people have been nice enough to vote up my answers.

For example, if you are a MUMPS lover, you can see my answers on this MUMPS replacement question and this NoSQL in Healthcare IT one. I couldn’t resist answering a question about CCHIT. I also took a swing at the PHR question, but I’m sure I could have dug a little more on that one to mention some other PHR software. Instead, I opted for the two most popular ones. I even hopped in the chat room, but it wasn’t that exciting since I was the only one there. You can check out the chat room, but you won’t be able to chat until you have enough reputation. Keeps out spammers, but makes for a boring chat room until you get some critical mass.

Of course, the real challenge with any site like this is the standard chicken and egg problem. You need a large number of people to ask and answer questions. However, in order to get a large number of people asking and answering questions, you need a lot of good questions and answers. I guess we’ll see how it evolves over time. The sidebar of the site says they’ve had 113 questions, 241 answers, 319 users and 147 visitors/day. A pretty small community, but a pretty good response rate considering the number of users. I just wish there was more discussion of EMR & EHR on the site since that’s what interests me most.

Let me know what you think and if you see any good questions or answers on the site that you think I should see. I’ll be keeping an eye on it to see how the community develops. I’d hate to have my 46 reputation points go to waste.

Patient Doctor Relationship
It seems like this topic keeps coming up in my online and social media reading. Basically, the discussion usually centers around the role the patient plays in healthcare. Many people like to discuss what has been called the ePatient. I instead want to talk about the motivations of patients and their ability to influence the healthcare system.

Patients in healthcare are unlike “customers” in many other industries. I can’t think of a single patient that wants to go and see a doctor. Ok, maybe they like the doctor and they want to get whatever’s ailing them fixed, but to a person I’m sure we’d say that going to the doctor is the last place we want to be. It’s not like going shopping for a new pair of shoes. There’s nothing you get to take home from the doctor. Well, at least nothing that you really want to take home.

Plus, healthcare is an interesting thing, because often it’s not clear if you should go to the doctor or not. If my A/C is broken, then it’s quite clear that I need to call an A/C repairman. Seeing a doctor is quite different since it’s a fine line between when you need to go and see the doctor versus when your body will heal on its own. I think we’ve all hated the doctor visit where they check you out and basically say there’s nothing they can do for you. Well, other than send you the bill for your visit. I guess that’s the cost of the peace of mind that you get from the visit (I know I’ve done that with my kids a few times).

Please don’t take this as me knocking doctors or the healthcare profession. They provide an absolutely essential and critical role in our lives. Without great doctors many of us wouldn’t be here today. My point in this post is that the patient doctor relationship is quite different than the customer business relationship that we’re use to seeing.

Online Patient Portals
Take for example the online patient portal. Many people love to go on Amazon.com (or insert your preferred shopping site) and browse through all the various things they could buy. We all know people who spend hours shopping. I don’t think I’ve ever heard someone say that they wanted to spend hours browsing through their patient portal. You know, someone who just couldn’t wait to see what great healthcare services their doctor could provide them.

The only partial exception to the above reasoning is possibly the chronic patient. If I’m a diabetic patient, then I am going to have an ongoing dialogue with my care provider and the services they provide. I’m going to be interested in monitoring and tracking my care in collaboration with the treatments that my doctor provides.

Is there a reason why we don’t want this kind of interaction for our general healthcare?

Regular Online Interaction with Doctors
Why shouldn’t I go online on a regular basis so that my doctor can assist me in total wellness even when I’m a healthy patient? The difference here of course lies in doctors treating symptoms and illness as opposed to a very different form of care: wellness. To be honest, I’m not sure I’ve seen any doctors who treat healthy patients. Sure, some doctors do provide some pro-active wellness information during a sick visit to the doctor. Regular physicals are the closest we come to doctors treating healthy patients, but how many health people get those? It feels counter intuitive that we would go and see a doctor when we’re healthy or appear to be healthy. However, maybe that’s the shift our healthcare system needs.

Reimbursement Model Challenge
One real challenge with what I just described is the reimbursement model we have in healthcare. We’ve incentivized treatment of sickness and illness. We haven’t (yet?) incentivized treatment of healthy patients and promotion of wellness. This sounds a bit like the ACO discussion that’s become so popular these days. I’ll be interested to see how these incentives play out. Word on the street is the train has left the building and reimbursement is going to be tied to healthcare outcomes in the future.

Healthy Patient Motivation
Unfortunately, another major challenge I see is that healthy patients aren’t really motivated by wellness initiatives. I’m sure that there are people that understand this phenomenon a lot better than I. Although, I think it’s abundantly illustrated when you talk to someone who’s getting older and starting to lose their health.

It seems particularly poignant for highly successful people that start to get older. How many times have we heard during Oprah or a Barbara Walters interview someone talk about being willing to give up all their riches and fame to just have their health (and they often throw family in there too)? All the time! The problem is that it takes old age or some other health incident for people to make healthy living and wellness an important part of their life. Which begs the question of whether even a change in the reimbursement model for healthcare will get unmotivated people to visit their doctors and be “treated” even when they’re a healthy patient.

Gamification of Healthcare
One idea that I find incredibly intriguing is the idea of gamification of healthcare and wellness. The basic concept behind gamification is to create incentives for people to do the behaviors you want them to do. I believe Foursquare was one of the first applications to do this. They would give you electronic badges and crown you as mayor as you did certain things on their mobile app. It was (and still is) amazing to see what people will do for a little electronic badge and the electronic title of mayor (Turns out this works in the offline world as well. There’s a reason boy scouts give out badges, beads and pins.). The question is how can we apply rewards systems to incentivize healthy behavior and wellness?

To be completely honest, I don’t think I’ve seen anyone crack the gamification code in healthcare. Although, I think the concept is just beginning. I predict in the next couple years that we’re going to see some amazing mobile and web applications that really drastically impact our motivation to healthy living.

The closest I’ve seen so far has been something like the Nike+ device and website. It’s a simple device that tracks your running habits either in a watch, iPod or even in your shoe. Then, that device uploads your running data to a website where you can create and track your running progress. It also provides a social experience, but that’s a topic for another day.

I actually find these tracking device/website combinations (see the FitBit and DigiFit as other examples) to be some of the most interesting things happening when it comes to pro active treating of healthy patients. A while back I predicted a whole plethora of medical tracking devices are going to hit the market. This is happening and will continue for many years to come. I heard one guy interviewed who talked about one day (many years from now) having little mini processors attached to every nerve or blood cell in our body. Ok, that’s kind of creepy to think about, but personal monitoring of our body is a burgeoning field in healthcare.

Crunching All the Personal Healthcare Device Data
The question once we’re monitoring all of these various vital signs and health information is what are we going to do with that information. Is it reasonable to think that we’ll be able to use computers to crunch through all the data and provide a self service analysis of all the data collected? Yes, Watson did some amazing things on Jeopardy, but I think we’re far away from the day when this type of self service crunching of all the medical data we collect will be possible.

Yes, that means we’re still going to need doctors and other healthcare professionals who help us analyze the data that we’re collecting and dealing with the health issues that are related to that data. In fact, I predict a whole new breed of doctor will come together that will be specialized at analyzing this data and treating even the healthy patients.

Future Healthy Patient Doctor Relationship
This all comes full circle when you go back to the start of this discussion: the doctor patient relationship. How are doctors going to see all this health information we’re collecting? Where are we going to have these healthy patient interactions with doctors? I predict that it will be through patient portals that are connected to a physician’s EHR.

I and every blogger I’ve ever known has been a stats junkie. We’re addicted to checking our stats. There’s no reason we wouldn’t be just as addicted to checking our health stats on a patient portal. The problem is that the patient portals I’ve seen aren’t there yet. Plus, most doctors aren’t yet ready for this type of healthy patient interaction around such a large set of data. Although, I predict we’ll get there and it will change the doctor patient relationship forever.

Let’s face it, I haven’t actually been nice to Google of late when it comes to healthcare (or maybe I have, just once). While I believe the criticisms are justified, I can see why some people might think I’m beating a dead horse, namely Google Health. But there are some unresolved questions in the area of privacy that Google really should answer.

Google’s ill-fated attempt at a PHR isn’t completely dead. The company won’t “retire” the online service until January, and will allow users to download their data through Jan. 1, 2013. Naturally, others have stepped up to try to fill the (tiny) void left by Google Health’s demise. To nobody’s surprise, Microsoft is helping the remarkably small number of Google Health users transition their accounts to HealthVault, Microsoft’s own overly hyped, underutilized PHR platform.

What concerns me is what will happen to data already on Google’s servers. Will records be archived? Will sensitive patient health data stay on Google’s servers in perpetuity? Nobody has said for sure.

Are records safe from Google’s data-mining juggernaut? Google has consistently said that it would not use health records for anything other than to steer traffic to its core search engine, but let’s face it, Google’s primary source of revenue is from algorithm-driven advertising.

But, you say, HIPAA protects patients from unauthorized uses of their data, right? Well, remember back to 2009, when the American Recovery and Reinvestment Act expressly made third-party data repositories, health information networks and, yes, personal health records, into HIPAA business associates, effectively holding them to the same rules as covered entities under HIPAA.

Wouldn’t you know, both Google and Microsoft came out and said they were not subject to this provision. No less an insider than former national health IT coordinator Dr. David Brailer, who was a part of the legislative negotiations, told me then that lawmakers had Google Health and HealthVault specifically in mind when they crafted the ARRA language. As far as I know, there haven’t been any reported data breaches involving either PHR platform, so there’s been no need to test whether ARRA actually does apply to them, but if I had my data on Google’s or Microsoft’s servers, I’d be concerned. I’d particularly want to know what Google plans on doing with the data it’s been holding once Google Health does shut down.

Perhaps it’s time for me to make some phone calls.

Meaningful Use Menu Measure: At least 10% of all unique patients seen by the eligible professional (EP) are provided timely (available to the patient within 4 business days) electronic access to their health information.

This is a third meaningful use measure related to providing patients with access to their health information. Meaningful Use Mondays has already addressed the two core measures—clinical summary and electronic copy of health information—“timely access” is a menu measure.

 The requirements are as follows:

• The measure includes a provision for EPs to claim an exclusion, but I don’t believe that many will qualify for this exclusion. They would have to attest that they “neither order nor create lab tests or information that would be contained in the problem list, medication list, medication allergy list, etc.”—a fact that would make meeting the core meaningful use measures quite unlikely.
• Access to patient information must be provided online, via a portal or a personal health record (PHR)—in contrast to the other two patient-related, access-to-information measures, which allow the use of various types of electronic media and/or paper.
• The denominator is “all unique patients seen during the reporting period.” Therefore, in order for that patient to be counted in the numerator, every time any piece of clinical information that can reside in the EHR is added to the patient’s chart, the portal must be updated within 4 days of the EP’s receipt of that information.
• This measure assesses the availability of timely access. It does not matter—for meaningful use purposes—whether patients request, or ever access, the information.

A challenge associated with this measure is securing patient consent to have clinical information posted on an online portal and then getting a sufficient number of patients to register. Because it is a menu measure, EPs can choose to omit this measure in Stage 1, and it appears—from my conversations with providers and with CMS—that many are planning to do just that!

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

The following is the fourth video in my inaugural run of EMR and Healthcare IT related videos. In this video I talk about some of the ways healthcare IT can help a patient be more active in their care. I’m sure there’s a number of e-Patients out there that can hop in and add a lot more to the discussion I start in this video. I must admit that as a relatively healthy individual I have a hard time really getting into the active patient (e-Patient if you like). However, I love the idea of patients being respectfully involved in their patient care.

The following video is in response to this question:
How can Healthcare IT help patients take a more active role in their care?

View the Healthcare IT and Active Patient Care Video Here

Last week I posted a poll asking how many readers of EMR and HIPAA used a PHR. Here’s the results of the PHR poll:

Pretty interesting to see that about 77% of those voting have not started a PHR or started one, but didn’t add much to their PHR. I guess I’m not all that surprised since I fall into that category as well. The scary thing is that this is coming from people who are in the healthcare and healthcare IT industry. If we’re not using a PHR, then I’d imagine that the number of PHR users outside of the industry is even smaller.

I’m still considering the compelling PHR use case since the results from this PHR poll says that one hasn’t shown its face yet. However, I must admit that the more I research and read about PHR and some of the possibilities, the more potential I can see in the PHR. Although, I also believe it won’t likely look like what most people call a PHR today.

Now for this week’s poll about reader’s approach to the EHR stimulus money. This should have some interesting results since I’ve added the time frame people plan to apply for the EHR incentive money as well.

I recently read an article (which I can’t find now) that said, We don’t log in to check our health data as much as we do our financial data. This was a pretty interesting statement considering a few days back I posted this tweet about PHR and being an active patient:

I want to spend some time thinking about the motivation for a healthy individual to become an active patient. #PHR #ePatient

February 25, 2011 10:15 pm via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

Figuring out the right motivation for someone to use a PHR has been something that’s been on my mind for quite a while. You may remember my post about requesting an appointment and sending your medical record using a PHR where I was asking some similar questions.

There’s certainly a place for software that connects patients with their doctors for things like scheduling an appointment, paying their bills, requesting prescription refills, and even doing e-visits. In fact, one of my advertisers recently launched an enterprise patient portal that has these types of features (check out this video which describes their feature set).

There’s no arguing that these types of connections to doctors are valued and something that patients would love to have. Many doctors are still on the fence about them, but I’m sure we’ll be seeing more and more of these types of services over time. However, while being really great features they still don’t solve the problem of a healthy patient wanting to log in to this portal regularly.

I think one game changer when it comes to PHR will likely be around an emerging set of devices which track our health. For example, over on Smart Phone Healthcare I recently wrote about Tracking Fitness and Activity Levels on Your Smartphone. These devices will track your steps, calories, heart rate, and sleep data and upload it to a centralized location where you can see all that data and watch your fitness and activity levels change over time. Plus, I believe we’re just getting started with collecting this type of data. You can easily see this moving to blood sugar levels, cholesterol, blood pressure, etc.

Now imagine that all of this data was available in your PHR. This type of data would be constantly updated and seeing the graphs of this health data over time is something that I’d login to check as much as I do my financial data.

Previously, I’d always been a bit down on these types of tracking devices. I’ve argued that we’re missing that link for doctors to be able to do something with the data that patients are collecting. I still think this is the case, but just because your doctor might not use the data a patient collects doesn’t mean it can’t be valuable to the patient to collect and see that data regularly. Plus, once EHR software and doctors are ready to digest the data, you’ll be ready as well.

As is often my Sunday tradition, I love to post some healthcare IT related polls. Today’s poll is prompted by this tweet I sent out earlier this weekend:

I want to spend some time thinking about the motivation for a healthy individual to become an active patient. #PHR #ePatient

February 25, 2011 10:15 pm via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

On that note, I’d love to see how many of my readers use a Personal Health Record (PHR) and more specifically if you update your PHR or not. Of course, this poll will be completely bias since it’s industry people right. Which is why if the results say that few people in the healthcare IT industry are updating their PHR info, then maybe PHR has some issues to be dealt with.

There’s a pretty fierce battle going on right now between all the various stakeholders interested in exchanging patient data. The stakeholders range from very large companies to government initiatives to startup companies. One of the major problems that I see is that it’s not completely clear which model of patient data exchange will win out. In fact, let’s not be surprised if a number of different options take hold.

With this said, I found it interesting that my favorite open source healthcare IT advocate, Fred Trotter, has chosen to get behind the Direct Project. In Fred’s post describing the challenges with the IHE-protocol HIE model approach is flawed and that the direct exchange of healthcare information is the way to go. In fact, he provides the following two illustrations in his post to show the difference:

HIE Model (click on the image to see it full size)

Direct Model (click on the image to see it full size)

Fred then offers this incredibly interesting conclusion:

At every level, organizations are deciding whether to invest in Direct or IHE-based exchange. At this point, I believe the only viable option is for a local exchange to either support Direct only, or both Direct and IHE. IHE is simply going to be too heavy weight for early adoption. Eventually, IHE may become dominate but for now Direct is much simpler, and puts the patient right in the center of everything. If you are a policy maker, you should be asking anyone involved with an HIE process to detail what their Direct-strategy is. If any effort is ignoring Direct and going with IHE-only I would lay odds that they will be broke and defunct before the decade is out.

Moreover, an IHE-only strategy is going to exclude direct participation from patients at this stage. If you care about patient empowerment, I recommend that you advocate for the Direct project at every level, including in your local HIE and REC.

Lots to consider with this complex challenge.

I guess you could say that the direct model is the patient centric model. Although, one could easily argue that the direct model doesn’t have the patient as the center of the model, but instead is a PHR centric model. So, the direct model will be a patient centered model only as much as the PHR software allows the patient to be involved.

Thus, it makes since why Microsoft HealthVault and Google Health are heavily involved in the Direct Project. Of course, they want to be involved in a project that puts them at the center of the communication.

The real question even with the direct model is what incentive do the various PHR vendors have to make this interaction happen? What will be the “cost” that PHR vendors pass on to consumers and/or doctors that use the PHR centric model? Basically, what’s the business model of the PHR vendors?

Unless we can find a PHR centric business model that works for the PHR vendor while still empowering the patient, even the direct model will fail or have adverse outcomes.

I was looking through the HIMSS session titles and saw one about the Usability of PHR, which prompted me sending out the following tweet:

Usability of PHR? First, shouldn’t we address the reason to use PHR?

January 14, 2011 12:53 pm via webReplyRetweetFavorite

@techguy

John Lynn

Then, a smart HIT journalist named Neil Versel sent his comment on my tweet:

Amen! #healthit #PHR RT @techguy: Usability of PHR? First, shouldn’t we address the reason to use PHR?

January 14, 2011 1:55 pm via ÜberSocialOrigReplyRetweetFavorite

@nversel

Neil Versel

Something to think about this weekend.