Health IT 100: Leaders in Healthcare Social Media

Just a quick note to thank everyone who voted for me in the HIT100 poll. I was delighted to be ranked #8 among an elite group of health IT specialists and industry leaders.

For more detail and information on the follow-on poll to name the top 5 health IT social media influencers, see Keith Boone’s post.

A special thanks to Michael Planchart (@theEHRguy) who conceived of the poll. The results are very helpful in steering people to the highest quality disseminators of health IT information.  I’m truly honored to be in the company of everyone who is on the list.

Google Health Post-Mortem

Last Friday, June 24, Google announced that it will shut down Google Health, which had become a much-hyped platform within the health IT community for storing one’s personal health and wellness data. Outside of the health IT community, Google Health made little impact.  I have read at least a dozen other articles that dissect the technical reasons and health IT insider viewpoints on why Google Health failed.  I’d like to discuss the reasons why Google Health never gained traction within Google.

I’ve followed Google from the very early days when they burst on the scene as a new search engine when nobody thought we needed a new search engine.  Google transformed search by using an algorithmic approach to identify the most relevant results.  Among the three key factors that differentiated Google from the pack were 1) algorithms that ranked pages based on popularity (Page Rank) and 2) scale: the larger the collection of sites that were crawled, the better the results (at the time circa 2000).  Since its introduction, Google’s algorithms have changed many times, but the fundamental fact that Google prefers to depend on programmable solutions that don’t require human intervention remains constant.  And, Google continues to chase large-scale opportunities where it can become an essential layer of the infrastructure.

Factor 3) is the business model. Remember the early 2000s when we all wondered how Google would make money?  After Yahoo acquired Overture in 2003, the revenue model was decided.  Keyword-driven advertising became the preferred method to monetize traffic on the popular search engine sites and scale matters in this model.    

With these three key factors in mind: algorithms not people, scale, and an advertising-driven revenue model, let’s consider why Google Health was destined for failure.

Google has done an excellent job of staying ahead in the “scale” category.  Google loves large repositories of data that it can monetize via advertising.  Google Books is an example. Once the legal hurdles have been worked out, Google Books will run without much human intervention –and has the bonus of providing an e-commerce revenue stream along with an advertising revenue stream.

Where Google got into some early trouble with Google Books was they wanted to side-step the hard work involved in working out agreements with publishers, so they did a deal with AAP and the Writers Guild that required authors and publishers to opt-out and take action if they wanted to set their own pricing terms.  When it came to orphan works, Google would be the presumptive copyright owner if the rightful owner couldn’t be located. So far, Google Books fits with the scale and business model elements. But, Google Books required a heavy initial investment in scanning books.  That certainly requires significant human effort, but Google was able to hire inexpensive labor and only older books needed to be scanned.  Newer books are available in electronic form, so once the initial investment is completed, the humans that place the books on the scanners will no longer be necessary. 

With Google Health I have to agree with Kent Bottles who wrote that Google found the degree of complexity in healthcare too great because it required too much specialized conversion programming and relationship-building with multiple stakeholders.  This variability that cannot be easily managed algorithmically is beyond Google’s chosen core competencies.

With respect to revenue models, Google said they would never put ads around PHR data in Google Health.  I think I still have a copy of the initial terms and conditions that stated that Google planned to monetize Google Health through data-mining aggregated patient data and then presumably selling the results to interested parties, with Pharma undoubtedly at the top of the list. In order for the mined data to be useful, scale and consistency of content types and formats would be necessary.  The revenue models could include keyword and display ads or content sales.

So, in effect, Google Health fell short on all three factors: scale, ability to use an algorithmic approach to content management and search, and revenue model.  Yes, health represents over 17% of our economy, so scale was still a possibility, but rate of adoption was slow—and was named as the primary reason for discontinuing the service.  Google will continue to reap benefits of health care searches via its advertising programs on its existing online and mobile search engines, but a Google Health product that was defined as a personal health data repository just doesn’t represent a big enough opportunity for Google. 

Like most of the healthcare publishing and health IT community, I was excited when I first heard that Google was establishing a health group.  Note, I first wrote about Google Health in 2006 when Google Health was envisioned as part of the Google Co-op program that had a crowdsourced model that encouraged publishers and subject matter experts to tag healthcare information.  Google Health took several turns during its short lifetime and who knows, it could come back in five or ten years once the healthcare industry grows up to resemble the financial services industry where the majority of customers log on to their computers to manage their accounts.  But, even then, its business model will have to measure up to Google’s broad business objectives for it to have any chance of succeeding.

Look to Payers for Innovation in Health Information

So much attention has been focused on the adoption of EHRs by provider organizations—largely because of ARRA HITECH funding—that one could be led to believe that most health IT advances are occurring on the clinical side of healthcare.  In reality, the business side has been quicker to adopt IT systems that add efficiency to the workflow of the participants. Practice management software and revenue cycle management solutions are two examples.

However, the exchange of data between stakeholder groups remains the stumbling block in improving the efficiency of our healthcare system.  On the provider side, it has been evident from the start that one of the most “meaningful” uses of a patient’s electronic record is the ability to make the information available where, when and to whom it is needed.  But, the pathway to meaningful health information exchange (HIE) is a bumpy one—not just because of technical issues, rather because of the regional nature of healthcare laws and regulations that has led to a very fragmented healthcare market.  I overheard someone from a hospital system in Florida at HIMSS say that a Florida-wide exchange may be a good thing, but it doesn’t solve his real problem of the snowbirds who come to Florida in winter but whose primary healthcare providers are in the Northeast. 

But once again, payers are leading the way in “meaningful” exchange of patient data between providers and payers.  The infrastructure created for revenue cycle management applications—eligibility checks, claims submissions, etc.—already exists, so why not build upon it?

In March, I attended the grand opening of NaviNet’s new headquarters in Boston.  I knew that NaviNet provided a communications platform for payers to exchange information with providers and that they were actively expanding their portfolio of services, so I wanted to know more about them.  I left that evening thinking that NaviNet’s existing platform that already connects 470,000 physicians in 128,000 offices to a growing number of large health care plans could be leveraged for exchanging clinical data. 

This week I had a follow-on conversation with Kimberly Labow, Chief Marketing Officer at NaviNet.  Kim confirmed that NaviNet recognizes the opportunity to leverage their existing network to become a single point of contact for business and clinical communications. 

At this point, NaviNet has already expanded to offer practice management and EMR applications to provider clients and has recently launched a mobile eprescribing application in Florida in conjunction with Aetna.  It’s interesting to note that Availity is also part of this strategic partnership because they were working with Aetna and Prematics prior to NaviNet’s involvement.  NaviNet subsequently acquired Prematics, which led to this multi-factorial “coopetition”.  [Note: Aetna has recently acquired Medicity, a health information exchange vendor, which makes the level of coopetition even more multi-dimensional.] However, this level of cooperation is not an anomaly; I see it is a sign of things to come as our healthcare system undergoes periods of consolidation within and across stakeholder groups. 

Given the existing structure of our healthcare system, the payer segment— unlike the providers—has clear incentives to use information to increase efficiency in business and clinical areas.  Payers recognize the benefits of working with patients to encourage more healthful behavior and are taking an active role in creating care plans and follow-on communication with patients.   At the recent Patient-Centered Computing and eHealth: Transforming Healthcare Quality course, Blackford Middleton suggested that in an alternate future, if providers don’t respond to the challenges of adopting health IT and learning how to use and analyze data, they will be disrupted and the insurers will become our healthcare coaches. 

I doubt that many patients, physicians or hospital groups want health insurance plans to become the primary source of health advice and care management.  However, we are moving toward a more integrated payer-provider model with ACOs and we have witnessed the success of integrated delivery networks like Kaiser Permanente. Convergence is occurring from all directions: providers are merging with physician groups, providers are consolidating, payers are consolidating, and payers are also diversifying into healthcare delivery.  A recent Wall St. Journal article described the payer diversification efforts as including: “acquisitions and partnerships that will allow the [health insurers] to employ doctors directly, delivery health information technologies, and participate in new hospital-doctor groups known and accountable-care organizations”. 

With alliances and acquisitions occurring within and across stakeholder lines, it is becoming a challenge to coordinate standards efforts and for analysts like me to try to diagram an industry that’s in flux.

NaviNet is trying to make a contribution toward coordinating efforts with the Unified Patient Information Management (UPIM) platform they are supporting. For my part, I rely on variations of the convergence diagram below that I created some time ago, which attempts to illustrate the clinical information market in an EHR-centric world. The initial version had payers outside of the inner circle. After writing this post, I think it’s time for another updated illustration that more closely aligns providers and payers!

 

Clinical Information Flows in an EHR-Centric World

Patient-Centered Computing and eHealth

In early May, I had the opportunity to attend the Harvard Medical School CME course, Patient Centered Computing and eHealth: Transforming Healthcare Quality. The 2 1/2 day course is directed by  Blackford Middleton,MD, MPH, MSc Corporate Director Clinical Informatics Research and Development Partners HealthCare and co-directed by Patricia C.Dykes, DNSc, MA, RN Senior Nurse Scientist Nursing Research Program Director Center for Nursing Excellence Brigham and Women’s Hospital.  The outstanding faculty of experts included Brent James, Paul Tang, Patti Brennan, John Halamka, Fabienne Bourgeois, Josh Seidman, Victor Strecher, Judy Murphy, and many others.  The full list of the faculty and their affiliations is included on the site linked to above.   I served as the “official tweeter” for the course and want to share with my readers some of the highlights of this practical course designed for the physicians who are responsible for adopting EHRs and applying health IT in “meaningful” ways to improve healthcare quality.

The full transcript can be found at: http://hashtags.foxepractice.com/healthcare-hashtag-transcript.php?hashtag=PCeHealth11.  For smaller doses, you can read the daily summaries here:

Day 1 Summary

Day 2 Summary

Day 3 Summary

The course included workshops, panel discussions and plenary presentations. To give a taste of the topics covered and insights shared, I’m posting a few outtakes from the Twitter stream for #PCeHealth11 below:

dahern1

Brent James opening keynote sobering view of healthcare crisis but making case of HIT as one key factor for positive change Clinicians are poor at “rate estimation” and need technology tools to support decision making - James

bfm

Brent James — more important to standardize care than anything else to control costs and improve quality. Great opening talk!

Sobko: 25% of Medicare recipients had a complication during care transition within 30 days post-discharge

janicemccallum

Sobko on care transition: setting goals helps engage patients with care plans; also teach them when there is a red-flag.

bfm

Vic #Strecher #UMich to achieve behavior change don’t always need Health Coach, often eHeatlh tools sufficient, or combo

janicemccallum

Common theme for engaging #patients : establish a mission or goal to drive behavior change. Tools alone aren’t sufficient.

#MU incentives have to be aligned so that efficiency gains aren’t viewed as income reduction by some: @jhalamka.

#NHIN isn’t a “thing”; it’s a set of data usage agreements and standards: @jhalamka #HIE

Micky Tripathi: think of #HIE as a verb, the act of exchanging information.

Common theme here: secure provider-patient communication saves time b/c it replaces phone calls that typically take more time.

Recap from @bfm for day 1: healthcare system is in crisis (Brent James) & has severely negative effect on US financial health.

Need to train physicians to be effective knowledge managers; simply too much to know everything. @bfm #KM #CDS #pcehealth11

bgaustin

Paul Tang keynote: cannot change issues like obesity one person at a time. Change must be community-driven.

janicemccallum

Jon Wald—biggest driver of usage of patient journals in study: marketing of the patient portal by the practice. #PHR

bgaustin

“Any doctor who can be replaced by a computer deserves to be replaced.” -Dr Warner Slack

janicemccallum

Who sponsors #PHRs? 50% health insurers; 25% providers. J. Wald, RTI.org

Not much focus on #patient-reported data yet in #EHRs; Wald calls it “patient-entered data” or P-E-D. #PHR

BI-like dashboards w/ trend data in #EHRs help provide early warning signs to physicians. #analytics

Too many facts to remember & the right information is often not available at point of need. #CDS #EBM #POC @bfm

Referral is weak link in continuum of care: Zuccotti’s team developed clinical referral management system. Patient role was key.

Jonathan Teich def of #CDS: makes the right thing to do the easy thing to do. #EBM

Teich refers to #AHRQ’s eRecommendations project: http://bit.ly/jMMS3G #CDS

Cool: @jjseidman describing new program #pophealth: http://projectpophealth.org/ Open-sourced qual measures prog. #CDS #MU

AF4Q works with #ONC #REC (regional ext. centers) to help them w/ #quality measures; also trying to harmonize the many meaures.

janicemccallum

Alt. future: If providers don’t respond to challenges they will be disrupted & insurers & payers will become coaches @bfm

#ARRA #HITECH: the $27B tail wagging the $2.5T dog (Paul Tang). #HCR

#EHR and #CDS adoption isn’t so much a function of fear of techology; rather physicians need to be convinced of added value. @bfm

#ACOs will shine light on importance of handoffs btwn providers & reduce missed communication. Luke Sato

bgaustin

Powerful keynote by Brent James: “Today’s problems are nearly always yesterday’s solutions.” #EBM

Amplifying Your Content via Twitter

If I offered you a highly targeted opt-in list of potential customers and key opinion leaders who would promote the content in your publications, what would you be willing to pay per name in the list?  What if I told you there was no cost and furthermore, I’ll include metrics on who promoted your content along with a profile of that individual?  Sounds pretty interesting, right?  

This is one of the benefits of Twitter, as well as other social networks.  But, wait a minute, didn’t a report commissioned by Yahoo! just find that Twitter is a media platform and not a social network?  Well, some of the headlines I read made it sound that way, but the actual report, Who Says What to Whom on Twitter, confirms earlier research that found that “Twitter more closely resembled an information sharing network than a social network”.  That’s not the same as saying it’s not a social network.

Twitter is of course a social network: the platform is interactive and users decide whom to follow.  That’s enough to make it a social network.  Granted, Twitter differs from FaceBook in that following does not have to be reciprocal.  So, I may choose to follow the feed of a publication that interests me, say for example, @TheEconomist, but the Economist may not find value in following me.  In this respect, Twitter resembles a media platform, since a large part of the population uses Twitter to receive information, not publish information. 

It should be noted that a key finding of the Who Says What report is that infomediaries play an important role on Twitter. [The authors use the terms ‘intermediaries’ and ‘opinion leaders’, but I prefer infomediary.]  For example, I may chose not to follow @NYTimes because I know my friend @KentBottles will provide tweets that cover stories of interest to me from the Times.  Kent becomes the infomediary –or curator—for content from The New York Times for me. 

Okay, we’ve established that Twitter is a social networking and media platform.  Now consider that it is particularly well-suited for mobile and local applications. Let’s see, if I spell out the benefits and features I’ve mentioned above, we can say that Twitter is:

“a social local mobile real-time amplifier and audience building curation tool that offers detailed usage metrics and is available at no cost”.

So why have publishers been so slow to apply Twitter? The problem is that Twitter is many things to many people, which makes it very difficult to classify.  Trying to classify it as either a social network or media platform doesn’t make sense.  It’s both and more.  My advice to publishers is to focus on its amplification capabilities for existing content.  I recommend this podcast with David Meerman Scott, Ian Condry, Michael Bird and Gary Halliwell to get some other expert opinions on this topic.  And note that I commented on the podcast page, which NetProspex’s marketing team then posted as a separate blog and tweeted it.   Amplification, indeed!

Most of the Twitter presentations I see are targeted to marketers and advertisers, not publishers, and I’m considering preparing a seminar on the value of Twitter to healthcare and B2B publishers from my perspective as a consultant who focuses on effective business models for data producers/publishers. Please contact me to let me know if you would be interested.  If there’s enough interest, I’ll develop a seminar that can be presented onsite or offsite.