This year, for the second time in my life, I had the opportunity to choose between several health insurance providers.  I opted for a provider that has a good reputation for embracing the latest information technology and also being patient-centered.  I chose my doctor online, scheduled an appointment online, and received communication - prior to my initial appointment - online.

Several days before my appointment, as instructed, I went to my assigned one-stop shopping center (a.k.a. medical center) to have my blood drawn.  Later that day, I received my cholesterol levels online (cool!).  The day before the appointment, I received the results of the remaining blood tests.  I don’t know much about white cells and red cells and what is supposed to be high or low, but my results were reported alongside desirable ranges.  At my appointment, my doctor walked me through the blood test results, reviewed my medical history, and asked about my medical concerns. 

The grand finale of my visit was receiving my first “after-visit summary.”  In addition to my vital signs (I could have lived without the inclusion of my alleged weight!), the summary included follow-up instructions for various issues we discussed.  For example, since I am a new patient, the summary tells me where to go in the one-stop shopping center to request the transfer of my previous medical records.

I feel like a kid again, like a child who has just learned a new and exciting skill.  I feel a sense of ownership over this experience because I was able to do things like choose a health plan and view my test results online…all without the “supervision” of an adult!  Obviously, I was happy to have an in-person interaction with a real doctor to explain my test results and address my medical concerns.  I feel like a big kid, though, because I feel I am being treated like a capable and welcome participant in my own health care.  Maybe it’s not really me “growing up,” but the health care system.  Either way, it’s a good thing.

I was on a panel today at the Chronic Care & Prevention Congress put on by the World Congress. The session’s title was “Innovative Technologies Showcasing Results in the Management of Chronic Care Shaping Future Policy to Drive Innovations in Healthcare.”

The lead presenter for our panel was the always insightful Joe Coughlin, PhD, of the MIT Age Lab. Joe has a lot of thoughtful and out-of-the-box things to say, but I think they boil down to the basic message that people designing health care behavior change interventions need to “meet people where they are” (my words) and they need to be “fun” (Joe’s words).

I particularly liked Joe’s closing slide on the disconnect between chronic care management today and consumers’ values (particularly the values of baby boomer women–who Joe says make on the order of 90% of the health care decisions in the US…that seems a little bit high to me, but his point is well taken). I think I’ve gotten most of this right–if I’ve mistaken anything, I hope Joe can correct me. The today is first and the consumer values are second in each dichotomy below.

• Data intensive vs. Useful knowledge
• Empower physicians vs. Empower consumers
• Trust authority vs. Trust experience
• Populations based vs. Personalized services
• Physician-patient-centric vs. Social networks
• Hospital & home focus vs. Ubiquitous
• Deliberate speed vs. Internet time
• Disease & illness care vs. Proactive vitality (wellness)

I fundamentally agree with Joe on his insights, although–as with many things–the current state of the chronic care management world has probably begun to move away from the left side a little bit already. What will be interesting to see is how many progressive provider organizations and other health care institutions proactively move toward the right side of these dichotomies. If not, consumers likely will eventually get fed up with providers and turn elsewhere (e.g., the Internet, Wal-Mart, Health 2.0 companies, etc.) to get what they need.

After a long build-up, Google finally launched its personal health record (PHR) for public consumption. There has been great anticipation that Google’s entry into the health care space could be the most disruptive innovation to a delivery system nearing a state of disarray. After all, before Google had invested even one dime in health care, each day more people were going to Google to answer their health questions than were going to a doctor.

The amazing economic and information transformation that Google has achieved in less than a decade coupled with the delays in launching Google Health led to perhaps unrealistic expectations. A quick review of what it has to offer leaves me with several questions…

• (The biggest question) Given that there is nothing in my Google Health profile right now and none of the links to Google’s partners provide any personal health data for me, what benefit is there for me to using Google versus a spreadsheet on my own laptop?
• Will consumers who have experienced auto-populated PHRs (e.g., via providers that have transferred EHR data to a secure patient portal) be interested in starting all over again (even if they can import that data–such as with Cleveland Clinic patients)?
• How big of a challenge will it be for Google to get consumers to trust the corporate behemoth with their personal data?
• Why does a search for “diabetes” in the Google Health search engine generate completely different content for me than looking under “diabetes” in Google’s “Health topics”?

This last question is particularly perplexing to me. Google Health tells me that one of the things it allows me to do is “Review trusted information on diseases and conditions and learn about possible medication interactions and other topics to talk your doctors about.” But I don’t know how they decide what is trusted information and why they direct me to different content depending on which way I decide to enter Google searching.

Part of the aforementioned unrealistic expectations is because health care is more complicated than many other information industries. There’s no doubt the health care delivery system is in dire need of dramatic change and that Google’s sheer power as an information broker has tremendous potential to shape any field that is so dependent on finding good information. I hope this is just the beginning.

At the 7th Annual Information Therapy (Ix) Conference, “WIxRED: Next-Generation Patient-Centered Care,” participants will hear from national leaders in implementing much of what Google Health is trying to do: Deliver the right information to the right person at the right time. Take a look at the agenda and register today.

Last week, the California HealthCare Foundation released a new “Snapshot” report titled, “Just Looking: Consumer Use of the Internet to Manage Care.” It’s a great title–not only clever but descriptive of what seems to be going on in California right now.

Although a majority of Californians are using the Internet to search for answers to their health questions, only between 1 in 10 and 1 in 8 are using it to fill a prescription, communicate with a clinician, or make an appointment. Between one quarter and one third of Californians are using the Web to find a physician, assess clinicians, or review benefits or claims information.

These data are hardly a surprise and are very much in keeping with what is going on around the country. Why is the Internet still mostly being used this way?

Certainly, much of it is due to the inadequate connection between consumers’ lives of on the Web and their lives in their doctors’ offices. We know from the Pew Internet Project that–when clinicians ignore consumers’ queries generated by Internet searching–frustrated consumers don’t stop searching, they just keep what they’re doing from their doctors.

The moment in care when a consumer is searching for information is the perfect time to connect him or her to some other health care management resource–whether human or electronic. We need to figure out how to weave those connections into the care delivery process. We also need to figure out that we can make sure that the content they find is understandable, meaningful and actionable to consumers.

That’s part of what makes an information therapy (Ix) “killer app”–which is one of the highlights of the 7th Annual Ix Conference, “WIxRED: Next-Generation Patient-Centered Care.” In the Killer Apps session, James Hereford (EVP of Strategic Services & Quality at Group Health Cooperative in Seattle) and Susan Edgman-Levitan (who runs Mass General’s Stoeckle Center for Primary Care Innovation in Boston) will share both their visions and their experiences with implementing such Ix initiatives in very different real-world settings.

The Center for Children and Families at the Georgetown Health Policy Institute has just released a series of issue briefs on “Strengthening Medicaid.” I authored one of these papers, “Health Information Technology: Innovative Applications for Medicaid,” which discusses strategies that states can use to improve the quality and efficiency of Medicaid programs. The paper addresses how HIT relates to health disparities, health literacy, and the digital divide.

To see more about these issues, see the robust Ix discussion on the patient-centered health information technology (PCHIT) blog.

I will be doing a considerable amount of my blogging about information therapy (Ix) at the now-live Patient Centered Health Information Technology (PCHIT) blog. The Center for Information Therapy’s (IxCenter’s) new PCHIT Initiative will have an active learning community of clinicians hosted by me and Ted Eytan, MD, the IxCenter’s Senior Visiting Fellow, who is currently on sabbatical from Group Health Cooperative in Seattle, where he serves as Medical Director for Health Informatics & Web Services.

–Josh

A colleague out in Seattle posted a great story, Information Therapy on the Go, about his experience in despensing information therapy (Ix) in taxis. The end of his post raised some questions: What is an information therapist? Who can be an information therapist? How can we train people to be information therapists in order to meet the great need that’s out there for them?

I, too, get asked to prescribe Ix to family, friends and randome people with considerable frequency (and I’m more than happy to help if I can). Even though I’m not a physician like Ted, as my at-the-time, 3-year-old Ben said, I am a “question doctor,” perhaps a colloquial version of information therapist.

The colleague I mention above is Ted Eytan, MD (Medical Director, Health Informatics & Web Services, Group Health Cooperative), who is on his way to Washington next week for a sabbatical. He’ll be spending quite a bit of his time serving as a Visiting Senior Fellow here at the Center for Information Therapy (IxCenter), and we’re thrilled to have him working with us more closely. Since he’s been one of the greatest Ix champions in the country, we’ve been working with him ad hoc since the birth of the IxCenter six years ago, but having a greater mindshare is going to be a fantastic opportunity for the IxCenter.

Stay tuned for much more on this in the near future…

–Josh

Will the biggest disruption in health care be an Internet-based health care industry? We already know that more consumers get answers to their health care questions on a daily basis from the Internet than from their doctors. But do we think that online tools will evolve enough to allow consumers to organize and make sense of that information without trained professionals?

Will the trend toward “convenience care” (pharmacy- or mall-based walk-in clinics) have the greatest impact on how providers organize care delivery? Will they need to re-think the way they practice medicine to meet new consumer expectations?

Maybe CMS’s requirement that hospitals begin publicly reporting patient experience data in 2008 will forever change how hospital view patient-centered care. Will hospitals finally find that being truly patient-centered has a business ROI?

Will consumer control over their own health information via personal health records (PHRs) alter the historical information asymmetry and allow them to control their own health care lives? What needs to be done to make sure that PHRs actually fulfill their potential as a disruptive force given that personal health data availability by itself will have a marginal impact?

Will the evolution of electronic health records (EHRs) and a robust interoperable health information exchange dramatically change health care by increasing connectivity among systems, providers, and others? Or, will we just create a process for transferring 1’s and 0’s on top of poor models of health care delivery?

Will the boom in biomonitoring/wireless devices (the so-called “healthcare unbound” space) revolutionize health care by allowing consumers to access the health care they need anytime, anywhere, and any way they want it?

Maybe the answer lies in more ubiquitous technologies. Could expanded use of cell phones and the application of tailored automated telephony allow us to reach a broader audience more conveniently, thus increasing the likelihood that average consumers will be more activated about their health care needs?

Can we more effectively engage consumers in better managing their own health by learning from Hollywood or video games about how to draw people in through entertainment? By doing so, can we make health care “fun” or at least truly engaging?

Can we find new payment structures to eliminate the perverse incentives that plague our current health care delivery system? Or, will people find ways to game any new system we design…or will entrenched interests simply prevent new systems from coming into fruition?

Is there any hope at all for finding a way to cover the growing number of uninsured in the country given the politically changed environment in Washington?

What is the role of information therapy (Ix) in each of these potentially disruptive forces?

Which of these developments will have the biggest impact on health care? Beyond that, will any of them actually change a system that has so many challenges and problems?

Many of these questions will be tackled at our upcoming Ix conference October 8-10 in Park City (see http://guest.cvent.com/EVENTS/Info/Agenda.aspx?e=f586de48-3d6e-4064-8543-1c7037b58890 for the full conference agenda). I hope you’ll join us.

–Josh

The IxCenter published a white paper a few years ago entitled, “The Ix Evidence Base: Using Information Therapy to Cross the Quality Chasm” (available at http://www.ixcenter.org/publications/whitepapers.cfm). In it, we detailed the emprical evidence that supports the Ix role in addressing each of the 10 rules that Institute of Medicine (IOM) laid out for health care delivery system redesign.

As Ix has matured, we have found new ways that Ix has directly addressed the IOM/Quality Chasm call to action. Perhaps most importantly, the IOM’s first rule for system redesign was to have “Care based on continuous healing relationships.” Rather than just interacting with health care professionals in traditional visits specific to a particular acute issue, people should have mechanisms for ongoing contact wherever and whever they need it.

In this graphic, iom-rule-1-continuous-cycle-w-20.ppt, I offer one way to think about how Ix can advance continuous healing relationships. Specifically, Ix for visit preparation can be used to better prepare patient and clinician for an in-person clinical encounter. Since we know that 50% to 80% of everything a doctor tells a patient is completely forgotten by the time the patient gets home, the Ix after-visit summary is critically important for reinforcing the key pieces of information that transpired during the visit. Through PHRs and other patient-centered HIT tools, Ix can then be delivered for health promotion, risk reduction and ongoing care management to help maintain a continous cycle of care.

It raises some questions worthy of discussion…

Efficacy of the Model: Does you think this model works? Can it move us from episodic, disjointed encounters with the delivery system to continuous healing relationships?

Reimbursement and Infrastructure: Does an infrastructure exist to support this cycle of care? Does the current reimbursement system create too many perverse incentives to prevent this model from flourishing? Can the patient-centered medical home model (being advocated by the primary care medical societies and others) provide an effective mechanism for encouraging this kind of care delivery?

Fit with Health 2.0 Innovations: What do you think about the potential role of the various Health 2.0 activities (e.g., targeted search, content tagging, social networks, etc.) that I have laid on top of this model? Are there new tools that exist (or will soon) that will help to get us there more quickly than working through the traditional care delivery system?

I’ll be interested in your thoughts.

–Josh

We are eager to identify new strategies for helping practicing clinicians to make it easier to integrate information therapy (Ix) into their clinical workflow. One model that we have conceptualized is collaborating with leading local and regional quality leaders to stimulate Ix advancement in their own communities.

We are aware that this “Ix Across America” concept requires not only a combination of a lot of intense work and patience on our part, but also strong leadership from respected champions in each partnering community. I’m happy to report that our first test of this concept is off to a great start, thanks to the leadership of Helen Riehle, Executive Director of the Vermont Program for Quality in Health Care (VPQ), and several other committed innovators in the small but creative state of Vermont.

The report below summarizes the first phase of our “Ix Across America” best test in Vermont.

VPQ devoted its 2007 Spring Learning Forum to information therapy (Ix^®). VPQ has helped diverse medical practices across the state to implement learning collaboratives, particularly around Ed Wagner’s Chronic Care Model (CCM).

After some introductory comments from the VPQ Executive Director and Vermont’s Lt. Governor, I set the context by explaining Ix in detail and contextualizing it vis-à-vis the CCM and related quality improvement (QI) strategies. Ted Eytan, MD, MPH (family practice physician and Medical Director, Health Informatics, Group Health Cooperative), presented many specific Ix initiatives Group Health has implemented in the context of its broader patient-centered informatics strategy.
Rushika Fernandopulle, MD, MPP (Internist and Co-Founder, Renaissance Health), described how he has used Ix in a small practice. In both cases, these practicing physicians provided considerable detail regarding the challenges and solutions for integrating Ix into the clinical workflow.

Forum attendees separated for breakout sessions. Practicing clinicians, practice managers, hospital administrators, and others affiliated with specific clinical practices discussed opportunities for applying these Ix approaches to their own settings. Attendees representing state government agencies, quality organizations, and those representing Vermont Information Technology Leaders (VITL, the state’s regional health information organization or RHIO) engaged in a policy-oriented discussion of how the state could facilitate greater Ix adoption.

When the breakout groups reported back to the full audience after lunch, these robust discussions resulted in several concrete next steps for Ix advancement including: implementation of multiple specific Ix initiatives in different practices; incorporation of Ix and consumer-focused activities into VITL’s pilot projects; integration of Ix components into the Vermont Department of Health’s Blueprint for Health project; and other statewide collaboration opportunities. The most popular specific Ix initiative that
Vermont practices plan to implement is the after-visit summary, but clinicians and administrators plan to pursue several other initiatives as well and there is broad interest in personal health record implementation. With respect to VITL and the Blueprint for Health, leaders believe that the architecture that is created can be used to make Ix a more explicit goal. In addition, VITL’s first implementation project related to medication history could involve components that more directly support consumer engagement in their health.

In the afternoon, Bob Corrigan (Vice President, Product Management, Emmi Solutions) discussed the “power of conversation” and demonstrated an interactive, engaging approach to Ix via text, audio, video and other graphics. All of the day’s speakers and state health care leaders involved in VITL and the Blueprint for Health (Cy Jordan, MD, MPH, Medical Director, VPQ; Andrea Lott, CIO, Northeastern Vermont Regional Hospital; and Jeremiah Sable, MD, Public Health Physician, Health IT, Vermont Department of Health) participated in a panel discussion to identify the greatest opportunities for integrating Ix and consumer-facing HIT applications into Vermont’s critical statewide health care initiatives.

Both Ted and I were able to frame all the day’s discussions after spending the day before in individual practices in
Vermont and with leaders from VITL and VPQ. These visits provided context for the specific challenges unique to
Vermont clinicians and HIT leaders.

We look forward to following up with Vermont practices, hospitals, HIT leaders, and government agencies through several concrete next steps to ensure that HIT implementation involves consumer-focused initiatives. Other quality leaders who think their communities would be good Ix laboratories should let me know.

–Josh