Tag Archives: Google Health

Future of Google Health

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John Moore at Chilmark Research asks today if Google Health is irrelevant. I’m re-blogging it because I agree with him. Microsoft is easily the leading player in broad audience Personal Health Record platforms. That doesn’t mean their product is ideal – it’s certainly not – but they’ve been improving it steadily and have integrated it with a very cohesive strategy aimed at engaging with the healthcare industry as a whole. Google hasn’t done that.

One take-away I had from the Microsoft Health Solutions Group conference in June (besides one heck of an airplane-acquired infection) was how tightly Microsoft is linking Amalga UIS – its hospital intelligence/data warehousing offering – with HealthVault. Amalga is the back-door – hospitals will make the data integration investments because of bottom-line and quality improvement benefits that are realized by UIS. But once that work is done, integrating with HealthVault is just flipping a switch. Microsoft has allocated its R&D money accordingly.

Google, on the other hand, still strikes me as simply dallying in healthcare. They’ve done some good work in focused healthcare search, but that’s pretty much where it ends. I completely agree with John’s statement that Google has gotten disproportionate attention simply because it’s Google. I’m not really inclined to start trying to take down the myth of Google here, but it’s safe to say that the company isn’t omnicompetent. From very personal experience, it was quite difficult to get projects in PHR off the ground during the six months after Google Health leaked but before it launched. There was a huge chilling effect – everybody wanted to wait and see what Google would do.

Chrome OS has nothing to do with PHRs

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I usually don’t bother picking on other people’s editorials. But this one, from FierceHealth IT (which I usually like, incidentally – it’s a nice roundup of daily HIT stories) just struck me as trying to fill space:

Google’s Chrome OS may heat up PHR competition with Microsoft – FierceHealthIT.

Google’s Chrome OS has nothing to do with healthcare. This is not a signal of the shift to cloud computing – that signal flare went up several years ago. Google won’t “tightly couple” Google Health to Chrome OS. HealthVault is just as web based and interactive as Google Health (admittedly, a little more complex to use, but you get more out of it).  Both systems have all kinds of big, enterprise-class integrations behind them.  Chrome OS is about Netbooks – they’ll ship a few million units on cheap hardware, and it will be easier for us to sit in front of the TV at night checking email. I won’t say it will never be a competitive desktop operating system, but that would be many years and several paradigm shifts down the road. A new version of Google Calendar would be more significant – at least you could integrate that with appointment reminders somehow.

The last sentence kind of sums it up:

I don’t pretend to have any kind of crystal ball here. But I do think it’s hard to argue that the PHR world is a lot more interesting with the Chrome OS in it.

That’s verbatim. And I agree – it is VERY hard to argue the proposition that Chrome OS makes any kind of difference whatsoever.

Android, by the way, is a different story – while it’s also too early to say, Google’s OTHER OS project, intended at the moment for cell phones, could enable a range of interesting healthcare applications. Since it doesn’t require always-on connectivity, Android could form the base of a handheld computing ecosystem in healthcare. Apple’s iPhone OS could do the same thing, and if Apple brings out a tablet, as they’re now expected to, I’d look for a wave of innovation coming off that platform. Local storage coupled with intuitive interfaces and great performance? That matters.

How the codes versus clinical story ended up…

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The big topic on the Health IT blogosphere was Dave deBronkart’s misleading administrative data in Google Health.  One of the really nice things about Web 2.0 – and responsive organizations – is that learning can be rapid, and lessons quickly applied. Here’s a post by John Halamka, the CIO of Beth Israel Deaconess, Dave’s hospital, outlining the changes they’ve made to their Google Health integration:

Life as a Healthcare CIO: Lessons Learned from e-Patient Dave.

Should some of this stuff have been figured out earlier? Probably yes, but virtually everybody in the PHR industry has been using claims data for years, since it’s all that most organizations have access to. So there’s not much point in singling out Beth Israel for having included it.

The upshot is that there’s been a change in how at least one hospital is dealing with this data, and there’s been some useful discussion about how difficult this whole data liquidity project actually is. More broadly, the use of claims data for consumer-level health records has taken a hit, although not a fatal one. Claims are often very useful for broad, population level analysis – not in the least because inaccuracies and inconsistencies tend to come out in the wash. As various commentators have noted, they were never intended as an instrument to actually provide healthcare.

The FTC and PHR Breach Disclosure

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The Federal Trade Commission has issued a draft rule that outlines how PHR providers must notify consumers in the event of security breaches (warning, PDF!). The rule includes platforms like HealthVault and Google Health along with individual PHR vendors like WebMD and ActiveHealth.  Comments can be submitted here, and are due by June 1st. This does NOT affect HIPAA covered entities such as hospitals and insurance companies, although the Department of Health and Human Services will be issuing one soon, and the content is expected to be quite similar.

The Recovery Act contained temporary requirements, which will remain in effect until Congress passes new legislation based on a report currently in development by HHS and the FTC. The report is due in a year, and legislation takes a long time, so these “interim” requirements will almost certainly be in force until 2010, and possibly longer. Interim rules that hang around long enough tend to be the basis of permanent rules.

Here’s a summary of who is affected and under what circumstances:

  • A “breach of security” is defined as the acquisition of identifiable health information of an individual, from a PHR, without authorization.
  • The rule also contains the word “unsecured.” This means encryption – if a laptop containing appropriately encrypted data is stolen, that doesn’t count as a breach for notification purposes.  HHS is responsible for issuing a guidance on acceptable security policies, to be updated annually.
  • Access is not the same as acquisition. Employees looking up records about friends and celebrities is a breach. An employee inadvertently loading the wrong record in the EHR is not.
  • The “fact of having an account with a vendor of personal health records” is itself considered sensitive information. The obvious example (used in the notice) would be releasing a list of names by a company that provides PHR services for AIDS patients.
  • De-identified information, according to the existing HIPAA de-identification rules, fall outside the scope of the rule.
  • “PHR related entities”  are what the platform vendors call “Personal Health Applications”. It’s a broad net, and the examples include websites offering medication management applications and bricks-and-mortar companies advertising dietary supplements online, as long as the interaction with these companies is through a PHR or PHR platform.  The definition also includes organizations that “access information in a personal health record or send information to a personal health record.”

The breach notification requirement itself has a few components:

  • Third party service providers must notify their customers (vendors of PHRs and PHAs) following the discovery of a breach. The individuals affected must be explicitly identified.
  • Notice must be received by a “senior official” of the PHR vendor or PHR related entity.
  • There is a “reasonably should have known” clause that sets an expectation of reasonable security measures. You can be in violation of the rule if you didn’t detect the breach in time. But since some breaches are hard to detect, you’re not always in violation if you discover something belatedly.
  • Notifications to individuals must be made “without unreasonable delay” and always within 60 days.
  • Notice must be by first-class mail, or by email if the individual consents (which must be “affirmative” consent, not something buried in an end user license agreement).  There is no obligation to provide notification by mail (although if the customer doesn’t consent to email notifications, you can’t provide them with service otherwise).
  • If ten or more individuals can’t be reached, a substitute notice must be posted – a large link on the home page for six months, or through a media campaign.
  • The FTC must be notified in five business days if 500 or more people are involved. If fewer than 500 people are involved, reports may be submitted annually.

That’s not all there is to it – the rule also describes the content of breach notices and the supporting document includes an economic impact assessment. I wrote some similar impact analysis documents when I was at CMS – it’s always a challenge to get it right.

My quick reaction: it’s not bad. We’ll see every PHR vendor race to add that “email notification” permission to their products. The cost of compliance shouldn’t be that burdensome, although it’s certainly non-zero, and that’s really the point – organizations need to take security seriously, and making breaches costly and embarrassing is a good way to do that.

Claims Data and PHRs

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The Boston Globe ran a piece this morning about the challenges of using insurance claims data to populate PHRs. It’s nicely done, and highlights what a shame it is that the Boston Globe is teetering on the verge of bankruptcy.

Electronic health records raise doubt – The Boston Globe.

Dave deBronkart, the patient involved, has been an active blogger for several years at e-Patient Dave.

Claims data is very challenging – it’s messy and not particularly precise.  I always envisioned claims information as being useful primarily as a directory, rather than a source of actual content for PHRs. The insurance company knows where you’ve gotten treatment, and that information can be used by a PHR platform to seek out information from clinical systems. Of course, that requires a lot more interoperability in the entire system than we have today.

Another approach is to work backwards – rather than including every claim from an insurance company in the PHR, only include the unambigous subset. A flu shot is a flu shot. But some data is just ambigous – like the cancer in the story, which seems tohave used a broad billing code. And some, of course, is intentional – physicians who file a misleading diagnosis so that a patient can be reimbursed for an off-label use of an expensive drug.  So for these cases – give the user an interface that allows them to review potentially problematic data, and explain clearly that some of it might not be entirely accurate, and there’s a good reason for that.

Finally, consumer controlled health records require very clear statements of data provenance. This was something our group paid a lot of attention to back when we were working on active development in the area, and Microsoft does a pretty nice job in HealthVault as well. I don’t know what Google’s design rationale was in not choosing to surface this information more prominently, but to my mind it was a mistake. Ten years from now we may have clinical data flowing so effortlessly that we can simply sit back and trust in the validity of any automatically sourced data. But that day is not today.

Google Health integrates with CVS

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Ok, back to Health IT and PHRs. This is something I’d hoped to see:

CVS-Google Health pact now includes drugstores – BusinessWeek.

Medication lists are the most important part of a Personal Health Record. Over the last four years I’ve spent a lot of time talking with physicians about this, and it’s almost the only point of complete unanimity. “Give me the medication list,” they say, “and all else is forgiven.” A physician can infer quite a bit of very useful information from a the drugs a patient is taking.

I’m looking forward to trying this out. Unfortunately (for this very specific task) I’m not on any chronic medications. But I do fill all my prescriptions at CVS, since I’ve spent the last five years in Boston and Washington, both cities with extreme CVS penetration. So they have data on me – we’ll see how easy it is to get it out without having a new prescription filled.

The next step is for other pharmacy chains to follow suit (I think they’ll have to – WalMart and Walgreens, in particular). The CVS announcement demonstrates that the security and identity issues are manageable. This is a lot simpler than building a Health Information Exchange, where you have to identify patients at one or more degrees of remove. Determining that Patient A, visiting Hospital B, is the same Patient A that visited Hospital C three weeks ago is a hard problem, particular when Patient A isn’t involved in the determination. Figuring out how to release pharmacy data to Patient A is a lot simpler – because all that CVS really has to do is prove that they’re turning over the data to the Google Health account associated with the person who physically walked into the store and picked up the pills. All the necessary identity proofing is already in place, and if the patient used a fake name and paid cash – so what? It’s still not a HIPAA violation.

Widespread pharmacy adoption is going to blow PHR adoption wide open, and Google just took the high ground. I expect to see a similar announcement around integration with HealthVault shortly. CVS Caremark and Microsoft did a webinar together a few weeks ago, and Dr. Troy Brennan, CVS’ Executive Vice President and Chief Medical Officer, was previously at Aetna where he was a major supporter of the ActiveHealth PHR platform. He gets it – and CVS certainly understands that a single PHR platform partner is not in their best interest. My prediction for the future is that we’ll see all of the major chains linked up with both Google Health and HealthVault within the next year.