BLOG on IT/IS in Healthcare & Life Sciences Joerg Schwarz on Healthcare [Health + Care]

As usual, google did a good job. Their hype started before and at the Health 2.0 conference last year in San Francisco, then Dr. Eric Schmidt announced google health in February at HIMSS08 in Orlando, and earlier this week the beta version of the actual service opened its service to users. The hype worked, and google gets lots of attention. This entry discusses Sun's position on PHR in general and google Health specifically.

google did IMHO a good job with their approach for two reasons. First, they addressed what I, along with others who attended the Health 2.0 conference in San Francisco last year, perceived to be the essential flaw of many start ups in the health 2.0 space. One startup offered health search, another a community of patients, and yet another search and rating of care providers. The unison feedback after the Health 2.0 conference was that Health 2.0 was too fragmented to be attractive. And what do you know – google health offers all these services in one place! Good job listening, folks! The second thing google did well was integrating at least one representative of good old health 1.0, Cleveland Clinic. Including a hospital chain, and promising to populate records from professional data, instead of relying solely on patient input, is a good move. Yes, this time Microsoft was the pioneer, but the pioneers are not always the successful ones.

Let's flash back for a minute or so. Dr. Stephen T. Parente, then assistant Professor for Management at the Carlson School of Management in Minneapolis (coincidentally the place where I will talk tomorrow about medical image archive architectures) published in the November/December 2000 issue of Health Affairs an article titled “Beyond the hype: a taxonomy of e-health business models”. In this article, he already defined the different electronic commerce models for e-health as (a) Health e-commerce portals, (b) Health e-commerce connectivity, (c) business-to-business e-commerce and (d) business to consumer e-commerce. Using this taxonomy, google ehealth is primarily a portal, and like OnHealth at the time of his publication, offers services to consumers. Parente identified data standardization as a major obstacle to the success of e-commerce in health care a the time – and I would say this statement is today as much true as eight years ago. google promises that customers will be able to download medical records from care providers. That's a huge promise.

First of all, only 27% of primary care care physicians do use electronic medical records (EMR). Chances are that most doctors couldn't upload patient data, even if they wanted to, unless google plans to offer a fax interface. Secondly, many hospitals have EMR, but its a big question if they would want to open them to consumers. They are actually using them, among other things, to gain competitive advantage with their referring physicians, instead. And if they did, who would pay for, and implement connectivity? google will have to define an interface, but since most hospitals (and the practice management systems of physicians) use proprietary EMR solutions, they would have to depend on their vendors for implementing connectivity - see discussion with HC CIOs on standards. Would google pay for that? If they expect doctors to pay for the opportunity of sharing their records, there are a bunch of RHIO's in line first, desperately hoping for that to happen for years. Or will we be able to use this as another argument for open source and open standards in health care?

Even if google will solve these problems, they'd have to be aware of another threat Parente mentioned already in 2000: he calls it "free riders". If google indeed solved the problems associated with hospital and doctor participation and integration, the next challenge will be guarding their database from other interested parties, like payers. Payers are sitting on mountains of data from claims. If they structured their data properly, they'd have a led up on both google and Microsoft in populating PHRs. Would they want to populate google's PHR? I don't think so. If they are smart, they will understand this as a competitive tool and offer PHR services to their subscribers, free riding on standards set by someone else, just as Parente said. And then there is the government as the potential custodian of health records - some legislative efforts are already under way, like H.R. 2991. The innovative moves of google and Microsoft, based on questionable business models by for-profit companies, could encourage a new federal government to put a legislative framework for PHRs in place - one way or another.

Last but not least - cui bono? Does google invest in it's PHR just for the good of mankind? Right now they say they will not use their PHRs for advertising. Oh boy - my blue eyes want to believe this! But then again, I'm not really blond, either. What is the main source of revenue for google? "Advertising revenues made up 98% of our revenues for the three months ended March 31, 2008 and 99% for the three months ended March 31, 2007" said google, inc.'s most recent SEC filing.

Let's speculate for a second. Imagine YOU were a commercial, for profit enterprise. Let's further imagine YOU somehow manged to get 100 million Americans or so to open personal health care accounts with you. As a result, YOU as the custodian of the data (did we talk about database encryption and PGP? No, I didn't think so) knew everything about your customer's medical condition(s). Let's further imagine 99% of your revenue was advertising, similar to google. Now, a maker of a ethical drugs for people with congestive heart disease approaches you with the attempt to target patients with congestive heart disease. I mean, seriously, would you be tempted or not? Be honest! Well, google, of course, wouldn't. But wait until Carl Icahn gets wind of this. Will he say: "nonne pecunia olet".  Let's get serious, people. Are we in pre-glasnost USSR or in the U.S. of A? See, that's what I mean.

Nobody likes to spoil a party, so let's all be happy with google for jumping in a pool of cold water full of sharks, and raise a glass to them: cheers!

Now you ask yourself, and me, possibly, where is Sun in this picture?

Well, I'd say, we used to be the dot in dot com, and in this context we're now the hyphen in e-Health (Ambre: I'm talking figuratively here, this is not our new slogan for Sun in health care!)  

Dr. Greg Papadoupoulos, our CTO, thinks the world only needs five computers. Greg is much smarter than me, MIT Ph.D. and all, so lets assume he is right.  One of those five "computers" will be google, he says. It's about time we get one of those five computers for health care! Seriously - what Greg discusses in this blog entry is the movement towards web centric services, and we see this development in health care already. I'm not sure I buy the number five- but that's not the point here. In any case, Sun's role is to be the plumber - we provide the infrastructure for web based services such as google's; we'd be the guys to supply middleware and infrastructure to make things happen, such as glassfish and open ESB. We are working bottoms up, while Microsoft and google work top down. Meaning, we are working on connecting traditional health care providers to each other, so we can deliver a coherent single patient view - like we do with PLIS in British Columbia or Geissinger. 

Once we can deliver a single patient view based on professional, high quality data, we can structure the information and use it both for patients or consumers, and for medical professionals. And, we could of course populate the google health PHR or Microsoft's Health Vault, or both, because these are just two more interfaces to the hundreds we already are building in the conventional health care space. Welcome to the real world. So while google is doing their task, we do ours. Of course, building SOA infrastructures that connect health care provider applications is not as sexy and media prone as the glorious PHR, but somebody's got to do it. And yes, that's us, Sun, the dot in dot com and the hyphen in e-Health. We're the unsung worker in Brecht's "Questions from a worker who reads" (my favorite poem, by the way). In all seriousness, we are working on open source based infrastructure to enable PHRs like google's or ICW's or Tolven's.

Let me close these remarks with a reflexion on a recent conversation with Wes Rishel from Gartner. Wes said in our chat about PHRs that "if information alone was the solution, smokers wouldn't smoke and overweight people wouldn't eat unhealthy". Well, and right he is! Here I am, overweight, drinking a beer and eating a steak in Minneapolis. I know I should have had just a salad. But no PHR would have made me eat another salad and drink just water. The point is that the jury is still out on how much difference PHRs will make. I'm convinced they will lead to better decision making in the medical profession (it would help doctors to know pre-conditions and medications, for example), but the people who will go through the effort of maintaining their personal health record are maybe not the people we want to reach - like my 84 year old mother (who doesn't even have a computer, let alone a PHR). But how effective PHRs are going to be is a whole other story. And yes, at least I don't smoke cigars anymore, talking about learning to live healthy.
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References:

Parente, T. (2000), Beyond the hype: a taxonomy of e-health business models, Health Affairs, 2000, 19, 6, 89-102

Grossman, J.M., Bodenheimer, T.S. (2006), Hospital-Physician Portals: The role of competition in driving clinical data exchange, Health Affairs, 2006, 25, 6, 1629-1636