Chilmark Research

Late this afternoon, Google Health Beta officially opened its doors for anyone to sign-up. While I did predict they would go live in the 2nd quarter, I was thinking end of the quarter, not the mid-point. Hat’s off to Google for moving so quickly.

As you know, I am at the TEPR conference trying to gather information and more importantly understand just why this conference is still in existence and more importantly, why it still attracts exhibitors as there is virtually no foot traffic, attendance is low and overall organization, well that is better left unsaid. Let’s just say that there is no WiFi and leave it at that.

But enough of TEPR, Google is the real story here (and far more interesting to tell). Following are some quick impressions and analysis.

What I really like:

Since I have a GMail account, sign-in to a Google Health Account was a breeze. Simply read the disclaimers (Terms of Service and Sharing Agreements), agree to them and you are on your way. - Loved It! And those disclaimers and privacy statement are similar to Microsoft HealthVault’s, forthright and easy to understand.

Out of the box connections with a number of data providers including Beth Israel Deaconess Medical Center, Cleveland Clinic, a lot of medication related services (Walgreens, Medco, Longs Drug, and Rx America). Somewhat surprising that CVS/Caremark link is not about medications, but clinicals from Minute Clinic. Likewise, you don’t get clinicals from Walgreens’ retail clinics, only meds. Odd.

They also provide ability to link to Quest Diagnostics so one can get their lab results imported into their Google Health account.

Google Health also provides an ability to link to a number of third party services, including PHR providers Medem, MyMedicalRecords and NoMoreClipboard (each of these vendors as well as Google Health is profiled in our PHR Market Report, that will be available for purchase later this week - drop an email to: info @ chilmarkresearch.com if interested), advocacy groups such as the American Heart Assoc. and LIVESTRONG.COM, Cleveland Clinic’s second opinion service MyConsult and several other services. Some charge a fee for services while others are free, all stated clearly on the Google Health site (though no actual pricing for services is provided).

The real beauty of both features above is that Google provides clear linkages to partner sites. When you click on those links, from within your Google Health account, you are taken to a secure page (https) on the partner’s site where you are clearly asked to sign-in to begin the authentication process and have your records transfered to your Google Health account, or sign-up for a service.

Unlike the less than stellar launch of Microsoft HealthVault, where you clicked on a partner link only to be sent into God knows where, Google has worked closely with this initial set of partners to make it very clear where you have landed and what to do next. Bravo Google.

The interface is clean, crisp and intuitive. Nothing to clutter the eyes/mind as you navigate around the site. This is so unlike most major PHR providers today who seem compelled to barrage you with a visually noisy website experience.

Working with partner SafeMed, the site provides medication interaction checking for the consumer to assist them with managing multiple medications and minimizing adverse drug events. Google Health is supporting such standards as SNOMED CT & ICD-9 (both used for diagnosis/condition coding), LOINC (lab data), and NDC & RxNorm (both used for medications). Google is also supporting a slightly modified form of the CCR standard (which is quickly becoming the defacto standard for PHRs), that they call CCR/G.

What still needs work:

While they have partnered with a number of pharmacy companies and a couple of providers, that is far from capturing the broader market and really making life easier for the average consumer (i.e., a PHR that can self-populate and stay updated without a lot of consumer feeding). An obvious choice is data from health insurers (payers). Payers, arguably, have the largest trove of consumer health data, data that often includes lab results, medications and treatments. Granted, claims data is not as rich as clinical data, but there are very few practices today with as sophisticated digital clinical record keeping practices as Cleveland Clinic and Beth Israel. Google will have to get payers on board to make this work.

Retail clinics, who most often are already using CCR are an obvious link/partner for Google. CVS’s Minute Clinic is a good start, but where is Walgreens’ own clinics and will Google extend out to those corporate campus clinics that Walgreens just purchased? I really can’t criticize Google for this last point as Walgreens did just acquire these clinics, but would have like to have seen Google at least, in some fashion address the employer market for these solutions.

Missing any place to put advanced directives.

No capabilities yet to assist a consumer in managing their health savings account. Be a nice opportunity for Google and Intuit to partner.

Site would hang-up on me occasionally, but that may be more of a function of this terrible hotel Internet connection, than Google.

Was not all that impressed with the search engine for finding a doctor. When I entered my doctor’s last name and city, got back a number of hits but they were all peripheral - not a single one giving me contact details or for that matter even identifying my doctor. Wasted effort for me.

Lastly, an odd thing happened in testing the link to Quest Diagnostics. When I landed on the Quest site, it requested a PIN to sign-in to begin transfer process. Well, I don’t think I even have a PIN with Quest so I backed out of the site. Yet, later, noticed on the landing page of my Google Health, the Quest banner for finding a Quest location or scheduling an appointment. Really looked more like an advertisement to me as I certainly didn’t request the banner and now have to figure out how to remove it.

Bottom Line:

While I am sure I’ll find other small quibbles regarding Google Health, all in all, it is difficult to find anything really major to dislike about this offering. My biggest gripe would be that it is too thin, both from a tools /functionality provided perspective and partners from which to import data. These are very important issues but they are also issues that Google should be readily able to address in the future if the have the mind to do so.

And is that really, at the end of the day what matters most?

Will Google and Microsoft stick it out and stay in the healthcare market long enough to see the tide change and the apathetic consumer turn into a proactive and engaged healthcare consumer. This sector is fraught with challenges which I have written about before and it is going to take time to address them. Let’s hope for everyone’s sake that these two companies have the patience to stick with it as I really do not see any other companies in the market that have the breadth of resources to make this happen.

The more I look at this market, the more I am convinced that needed change in the healthcare sector will come from the outside via greater direct engagement of the consumer in managing their health. And that will require giving the consumer the tools to do just that. Something which both Google and Microsoft are on track to provide.

Other Resources:

Google Health FAQ

Beth Israel’s CIO’s Impressions (Note: As he was part of Google’s Advisory team, you won’t find a critical, unbiased view).

Berkman

Was at the Berkman Center Conference, an event focused on the future of the Internet.  It being at Harvard, and Berkman traditionally being associated with the Law School, more than enough policy and political discourse for my tastes.  Not to say it wasn’t interesting, actually quite thought provoking, just not along the lines of what I was looking for, e.g., the business of the Internet, new modalities of delivering software, services and the like.  No, discussion focused more on broad consumer issues and a lot on such things as content copyrights, the future of publishing (books, magazines and newspapers), libraries, even the future of academic institutions like Harvard - you get the idea.

In fact, there was almost an elitists disdain for business.  Didn’t take it personally,  just chalked it up to academics.  Having worked at MIT for 7 years, did learn a bit about what makes them tick.

Big Take Away: Young hotshot, Jonathan Zittrain, who is currently at Oxford and being aggressively recruited by both Harvard and Stanford is quite amazing.  Don’t miss the chance to hear him speak if he is in your area or at an event you are attending.  His just finished book: The Future of the Internet - And How to Stop It is excellent.

TEPR

Next week, it’s off to the TEPR conference, attending for the first time, where I’ll be giving a “State of the PHR Market” presentation based on our research which has culminated in a comprehensive 104 page report that includes profiles on 20 vendors, some you have heard of and some interesting ones that you may have missed.  If you are attending TEPR, I’ll be presenting on Tuesday afternoon at 4:30, Rm 209, title of presentation: Evolving PHR Market, New Actors, New Directions

Speaking of report…
had hoped to have the “store” up for interested readers to buy the report today, but alas, putting together one of those online stores was more challenging than planned.  The report, however, is completed and the ability to purchase the report will be available next week.  If you have already requested being notified, I have your email on file and will inform you when you can pick-up a copy.  For other interested parties, just send an email to: info @ chilmarkresearch.com and I’ll put you on the list.

I got religion.

At least religion that part of the savior to today’s, and more importantly, tomorrow’s healthcare crisis lies on the Internet.

With the abysmal adoption of IT to date within the healthcare sector, I am a strong believer that this industry will simply leap-frog the traditional, three-tiered IT architectural model and move directly to an SaaS-type model (ala athenahealth or Salesforce.com) coupled with cloud computing.  Granted, this will not occur over night and most large hospitals and IDNs will be loathed to give up on their server farms and internally developed apps, but there is a very large percentage of care (some estimate it at 80%) which takes place outside these large healthcare facilities, and it is here where adoption of healthcare IT (HIT) is lowest and where we will see the Interent play the biggest role.

We are still very early in the game here and there are numerous issues to contend with from privacy and security to uptime, to control - not insurmountable, but issues that must be addressed nonetheless.  So to get up to speed on how some of these issues may be tackled, I’m of to Harvard University for the next couple of days to get some schooling on the topic.  The Berkman Center for Internet & Society is having a 10th anniversary conference and have put together a very interesting agenda.  Will report back any insights I garner.

Read in the WSJ this morning an interesting article on new approaches that are being taken to introduce/solicit consumers to participate in clinical trials. The problem seems to be that consumers actually have little reluctance to participate in such trials. The problem is, they just don’t know what trials are occurring that may be pertinent to their profile (needs, condition, physical attributes, etc.). This is one area where start-ups such as PatientsLikeMe are looking to leverage their communities.

In the article, the reporter goes into some depth explaining how the company, EmergingMed works to match a consumer’s profile to the enrollment criteria of a clinical trial for cancer. The company uses online and call-in technicians to provide an appropriate match based on cancer, stage, and other factors. Company has been in business since 2000 and claims to have placed over 115,000 people into clinical trials. Decent story overall and a great example of where PHRs can play an important role in the future - provided of course that the consumer chooses whether or not to opt-in and having their records used in this manner.

But what really got to me was later today I was alerted to this press release. Now was it just coincidence that the WSJ would publish a story on EmergingMed the exact same day that this press release was released, or is there something else going on?

Smells awfully fishy to me and not unlike payola for DJs (or for that matter doctors) - just wonder how much the WSJ got paid for this placement?

Really a shame as I have been a subscriber to the WSJ for years. Now under new ownership, I have seen a number of changes at the WSJ, none of which I am fond of. Hmmm, maybe time to switch to the NYT.

We’re down to the final proofs, the final edits and the PHR Market Report will be ready by the end of the week.  A long process, but well worthwhile - the end result being a comprehensive report of roughly 100 pages in length and 20 in-depth vendor profiles.

My deep thanks and appreciation go out to so many who have provided advice, assistance and encouragement.  While there are far too many to list all contributors, special thanks go out to Rick Benoit at Intel, Ken Mandl and Will Crawford at Children’s Hospital Boston, Sean Nolan at Microsoft, Jerry Lin at Google, David Dobrin of B2B Analysts, and all the PHR vendors who showed such patience in answering my many questions.

As a lead-in, following is the Preface to the Report.  Again, to be notified when report is released, simply send an email to info-at-chilmarkresearch.com

Quite suddenly, the Personal Health Record (PHR) market has taken on renewed interest.  Countless press articles extol both the virtues and risks of PHRs. Government institutions are dedicating resources to understand how PHRs may affect the healthcare sector – driving needed change. Employers and health plans seek new ways of using PHRs to engage their constituents, encouraging them to adopt healthy behaviors. Providers are adopting PHR solutions to deliver added value to their customers and increase customer retention.

Against this back-drop, within the last year the PHR market has seen the entrance of two of the largest and arguably most significant consumer-driven software companies in the world, Google and Microsoft, who are each pursuing their own consumer-focused, personal healthcare strategies. Even the employer-led consortium, Dossia is back on track developing a personal healthcare platform with Children’s Hospital of Boston that when complete may serve upwards of 8 million consumers.

Further, it is becoming increasingly clear that the U.S. healthcare market is in need of some serious restructuring. While PHRs are no panacea for the healthcare challenges this country faces, they have the potential to initiate change that is long overdue, change that will be consumer led and consumer driven.

Yet, despite this interest, a clear, pressing need, and the entrance of major players, the PHR market remains an elusive, challenging market to understand and predict its future outcome. A multitude of companies, large and small, have developed an equally broad array of PHR solutions. Some solutions reside on a consumer’s desktop, others come on a USB and still others are offered over the Web. Beyond modalities, the capabilities of these solutions are even more wide ranging, from simplistic systems for filing of electronic records to sophisticated solutions with personalization tools that guide the user on not only how to manage their health and the health of loved ones, but may for example provide advice on who may be the best physician in their area for a given aliment and the costs of treatment.

Over the last several months, Chilmark Research has interviewed a wide range of PHR vendors, users, employers, proponents, detractors and observers. One observation became readily apparent in these discussions, the future of the PHR market lies on the Web. Therefore, unlike other reports on this market, the focus of this report is strictly on Web-based PHR applications, that are referred to as iPHR solutions.

First in a series of reports, this report is designed to bring clarity to the reader on where the iPHR market is today, where it is headed and the adoption challenges that need to be overcome. Most importantly, the report will assist the reader in understanding who are the leading iPHR vendors today, what is their unique value proposition and areas they need to improve. Armed with this information the reader will have the knowledge necessary to initiate their own evaluation and selection of an iPHR solution that meets their personal needs or the needs of the organization they represent.

Earlier today had a post on the HDM online quick survey showing early results that PHRs are definitely coming - at least that is what those in the healthcare IT (HIT) sector believe.

Further adding validation to the HDM quick poll are the results of an online survey that the Healthcare Information Management Systems Society (HIMSS) sponsored in April, which were just released. Like the HDM survey, one can assume that the vast majority of respondents to the HIMSS survey also came from the HIT community.

Results from this survey of 675 respondents include:

• Nearly 50% believe Privacy/Security issues are the biggest hurdle to adoption. This may be an issue but as I have said before, personally believe this is a red herring. The big issue is for PHR vendors to actually deliver a solution that is more valuable than a simple online repository for my records.
• A whopping 92% believe that the consumer should own the PHR. Hmm, wonder if that also includes controlling access and portability?
• Not too surprising, over three quarters believe that a PHR should be integrated to an EMR to deliver higher value in treatment. Something I’m in full agreement with and early studies on PHR adoption have borne-out.
• Nearly 50% see the entry of Google and Microsoft giving a big lift to PHR adoption. Just look at all the press these two have generated already! At the recent WHCC event that I attended, this was one of the top subjects being discussed in the hallways.

Yes, people are talking.  Yes, this will raise visibility on the whole PHR topic. Now what we need to see are some real results in strong user growth and adoption of PHRs.  WebMD’s modest forecast last week during their 1st Qtr call of 10% growth is nothing to write home about so we’ll have to look to other PHR vendors. Will Google Health light the fire?

Over on the online publication Health Data Management (HDM), they have an online poll today addressing the future of PHRs.  While the question is pretty black & white by using the word “never”, the overall results are telling (results as of 4:45pm ET).  Looks like among the HIT elite, PHRs will definitely happen.

The use of personal health records software will never become widespread.

107 Responses

Looks like among the HIT elite, PHRs will definitely happen.  Now the question is how and when?

Last week, I wrote a post addressing the risks of digital medical records and referenced the EMR platform that was developed by John Halamka and his team over at Beth Israel Deaconess Medical Center (BIDMC) here in Boston. In that post I stated that I was dismayed that when Halamka talked about this new EMR they are rolling out, and in some detail, nowhere did he make reference to the security features that would be built into the system to prevent, or at least minimize the kinds of breaches we’ve seen recently at any number of institutions. (I’ve written plenty on this in the past, do a search on the site to find more references.)

Halamka stated in a comment on his blog last week that he would address the security access issue this week. Halamka kept his promise. He has done a good job of articulating how access is controlled via some 500 rules that define access rights based on your role within the organization/IDN. Some very good lessons to be learned here that most other healthcare institutions would be wise to emulate.

Of course, I could not let Halamka completely off the hook. I have now asked if he will go a step further to articulate how BIDMC will reconcile access and opt-in rules a consumer may defined in their own personal PHR platform/system (e.g., Dossia, Google Health or HealthVault) that resides outside of BIDMC’s IDN, with the rules established within BIDMC.

Any Quarterly Announcement press release that leads off with anything but the financial numbers usually signals trouble. WebMD is no exception.

Just got off the WebMD first quarter conference call. Knew it was going to be one of those calls that did not have cheering from financial analysts as they began their questioning with something to the effect of: ” Great results, you really are hitting your numbers, yada, yada, yada…”

No, this was going to be subdued as the company gave everyone fair warning with a pre-announcement that advertising revenue is expected to not grow as fast through 2008 as originally forecasted.

In the call today, WebMD honchos were quite pleased with the number of unique visitors in Q1, now at 51.9M/month, nearly a 25% increase over last year. They were so please with these numbers, they used them as th title for their Q1′08 press release. This translated into overall revenue up 17%, with advertising up 23% while what they call “private portals” (which is really their PHR solution) growing at 9% year over year.

Looking Closer at WebMD PHR Performance in Q1′08

Digging a little deeper into what was said on the call regarding the PHR solution, WebMD saw the number of clients grow from 103 to 122, an 18% growth rate. But if client growth is 18% and they are only experiencing 9% revenue growth, it would appear that they are seeing some significant pricing pressure in the market. And that 18% growth in new clients is substantially below most of their much smaller competitors. Granted, it doesn’t take many clients to boost the growth of small competitors, but when I hear from one PHR vendor that they have had a doubling in the number of clients in each of the preceding two years and now have nearly triple the number of clients as WebMD, it makes me begin to wonder if WebMD is really capitalizing on the growth that is occurring in this sector.

Another thing I found disturbing in the call was the lack of discussion about WebMD’s initiatives in the PHR space. They discussed the competitive solution to Sermo, Physician Connect (now with 20k physicians registered), they talked about expansion overseas (not very informative and what they did divulge was not all that great), they talked about how popular their new magazine, WebMD is (even though the publishing group is still bleeding $$$) and they discussed Health Check, (they claim it is a success, but honestly, I don’t see it and they were not specific as to what metrics they were using to define success). And they spent a lot of time talking about a bunch of student loans they are holding and haven’t been able to sell at auction leading them to having to take a $27M impairment charge (geez, even these guys got caught up in the whole financial mess). The only mention of the PHR (private portal) business was a simple statement on growth, some new clients (Walt Disney and Newell Rubbermaid to name a couple), but no talk about how they are improving this platform, new initiatives, strategies to further penetrate the market. NOTHING!

Really makes me wonder if they are just milking this cash cow and looking for opportunities elsewhere that will be easier for them to defend in the future as the PHR market becomes increasingly more competitive.

There has been a lot of talk about extending current HIPAA regulations to address non-covered entities, particularly PHR vendors. Many believe that this is what is needed to preserve consumer privacy. There was even an article last month in the New England Journal of Medicine by the creators of the Dossia platform, Indivo that unfortunately was taken out of context by some, including the New York Times, (but not all) which continued to fan the flames for an extension of HIPAA. And of course, as long as those flames keep burning brightly, the traditional stakeholders in the healthcare market (especially providers, and health plans) who are loathed to have the consumer take more direct, personal control of their records, can sit back and continue to directly manage the consumer relationship without any pesky intermediaries (e.g., independent PHR vendors).

But HIPAA really doesn’t provide the protection that many of the press, privacy pundits and others claim. For example how many consumers know that under HIPAA…

Health care entities are allowed, for fundraising activities, to release to business associates - without explicit individual authorization - certain demographic information, such as names, addresses and dates of treatment, but not information about health or health care.

Sure, they are not sharing medical records, but they could be sharing information that I happened to be admitted to their psychiatric clinic, (e.g., I went to MGH and ended up at McLeans) which I’m sure most would rather not share.

This clause was responsible for the data breached at UCLA Medical Center when they hired an outside firm to do a fund raising program. While having over 6,300 records exposed on the Internet was bad enough, what is even worse is that the breach was discovered on Oct. 9th but it was not until mid-April that UCLA thought: Hmmm, maybe we should contact all those people effected.

Six months to let someone know that their privacy has been breached! What’s up with that?

As I have written several times before, I am a strong advocate of consumer privacy of virtually any information that is personal, including medical records. I have also taken to task the PHR industry for their extremely poor record, as an industry, to develop clear standards (shall we even suggest a certification process) that will bring some consistency on privacy policies across this industry sector. So far, it seems to having fallen on deaf ears as the research we conducted for our upcoming PHR Report found consistency across the industry to be nonexistent.

With no prompting of my own, at least that I am aware, Microsoft’s HealthVault Group has been very clear on its privacy policies. They even went so far as to extend these privacy policies to all partners of HealthVault via their Terms & Conditions sheet. With some prompting, I was able to get Microsoft to go public with these terms. Recently, Sean Nolan, chief architect for HealthVault put up a post further defining Microsoft’s perspective/policy as it pertains to HIPAA. He also provides a link to a very good overview of HIPAA and HealthVault that was put together by the HealthVault team and Microsoft’s legal team for the development community.  All, very good proactive moves. Now, if I could only start seeing Google making similar pronouncements/announcements, and while I’m at it, how about Dossia as well. Neither of these two has been as proactive as Microsoft on the issue of privacy and the market really needs more unity here.

Getting back to HIPAA.

First-off, I am not against some federal oversight and policy direction as it pertains to personal health records.  Right now, it is a bit of the Wild West as consumer’s take on more responsibility for managing their records and turn to PHR solutions.  What I fear though is that taking a simplistic aproach, “let’s extend HIPAA to cover PHRs” will not solve the problem and truly protect the consumer.  As the UCLA case above so clearly demonstrates, HIPAA does not provide the privacy that most consumers will want for their PHRs.  Also, numerous reports and surveys have shown, that while consumers are concerned with privacy, they believe that benefits of digital records outweigh the risks.

So we are left with a situation where first, HIPAA clearly does not provide the type of protection that most consumers believe they are receiving and secondly, consumers are not adverse to sharing information, but it is they who wish to choose who sees such information and not some third party entity that makes that choice for them.

Simply extended existing HIPAA regulations to non-covered entities will not provide consumers with a sufficient level of privacy protection.  In fact, it may have the perverse effect of giving a consumer a false sense of security.

Extending HIPAA is NOT the answer.

The answer will lie outside of HIPAA  in a new policy construct that puts the consumer in more direct control of how their information is used via an “opt-in” process, e.g., “I chose who I wish to see my data and to what degree of granularity that data is shared.”  Yes, it will make many in the healthcare sector nervous, but they are going to have to get used to it as this market will increasingly become consumer-driven and those consumer’s will want more control.

On last point (minor detail)…

While I may wish to chose to whom I share my records with and at what level of granularity - that granularity issue is a sticky one.  You see, most vendors’ PHR solutions do not have the data management capabilities built-in to allow data tagging for sharing or sequestering record information at a granular level.  For most, you either share all the data in your PHR, or none of it.   PHR vendors need to “get-on-the-ball” and start building this capability into their solution.  And consumers, you need to start asking PHR vendors if their platform supports such capabilities.