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

In response to a column in The New York Times last week (http://www.nytimes.com/2007/05/24/fashion/24Cyber.html), I wrote the following letter to the editor (for which they apparently aren’t publishing any letters):

Regarding “Visits to Doctors Who Are Not in, Ever” (May 24), democratization of information has made health content widely available—some would describe this a blessing and others a curse. The question is how do we steer people to information that is accurate, comprehensive, relevant, understandable, and useful?

Empirical research we’ve conducted on diabetes Web sites suggests that the guidance offered by most “experts”—such as a “trustworthy” sponsor, the currency of the content, or the process for updating it—provides little insight into the content’s actual accuracy or comprehensiveness.

Innovative collaborative filtering approaches can be effective, but they also have limitations—in part due to the complexity of medical science and its pace of change. Objective, systematic instruments now exist that could be scaled to provide critical guidance to consumers. These two approaches can complement each other and help people navigate life-and-death matters for themselves and their loved ones.

Since I get more than 150 words here, I’ll expand a bit…. First some quick background: The research I refer to is summarized in a white paper on “The Mysterious Maze of the World Wide Web” on the www.ixcenter.org Web site and the more scientific papers are available from the peer-reviewed Journal of Medical Internet Research (www.jmir.org).

It’s reasonable to approach the evaluation of Web site information quality like many other scientific questions where the answers (to “what is high-quality content?”) are not always straightforward. We can triangulate by using multiple methods to answer the question.

Specifically–and as I proposed in the original research–we can combine three kinds of measurement: structural measures of quality to give a generic content threshold test; performance measures of accuracy and comprehensiveness for specific conditions; and assessment of consumers’ perspectives on content in terms of functionality, understandability and overall utility.

In my original work (before the “Health 2.0″ space existed) , I had envisioned this being done more though random consumer survey methods, but the collective filtering approach is considerably more efficient, even if less scientific.

Bringing these different strategies together will provide everybody with a lot more guidance about health information quality, the first ingredient for good information therapy.

–Josh

Looking at how young people use the Web for virtually everything from commerce to social networking, it’s not hard to imagine an increasingly virtual future health care world. If Don Berwick is right that at least half of current in-person clinical encounters don’t require a visit, this generation likely will change the character of US health care delivery.

But what about the other end of the chronological spectrum? One of the common questions I get is how we make information therapy (Ix) relevant for seniors–the population that consumes the greatest amount of health care.

Although part of the answer is that Ix need not be delivered electronically, the more compelling notion from my perspective is that we have a magnificent and mostly untapped opportunity to extend patient-centered health information technology (HIT) applications to people who really need them.

The potential of the innovative applications that comprise patient-centered HIT (e.g., personal health records (PHRs), secure messaging, online tools, etc.) can be maximized if we successfully integrate them into patient-clinician relationships. Ideally, they should be viewed as tools within that context.

More than anybody else, seniors are likely to have ongoing and frequent relationships with their clinicians. In fact, in many cases, seniors concurrently interact with multiple providers, making the need for coordinated relationship management tools all the more important. Without them, we wind up with considerable redundancy, poor communication (not just between patient and doctor but among providers involved in that person’s care), and the possibility for dangerous medical errors.

Furthermore, other characteristics more common as people age (e.g., limited mobility, cognitive functioning issues) increase the importance of having patient-centered HIT applications. They can allow for communication without patient and clinician needing to be in the same place and for communication to be trianglulated–for example, to include the child or spouse of a senior with cognitive impairment.

Many seniors are already accessing considerable health care information online (to some, a surprising percentage), and there’s no doubt that the aging baby boomer population will vastly expand the online senior population in the near future. However, there’s no reason why we can’t do more to help more seniors capitalize on this golden opportunity now.

Community efforts involving librarians, hospital community outreach staff, senior centers, and others can effectively break down barriers limiting seniors’ adoption of e-health resources. Although I haven’t seen a lot of empirical data, anecdotal evidence suggests that, once obstacles are removed, seniors become active Internet users.

Who do you think the next generation of PHR users will be?

–Josh

(Visit www.ixcenter.org for more about PHRs and related issues.)

What do consumers really want? To answer that question in health care, we might want to look at leaders in other industries that have developed great reputations with consumers.

This past Sunday’s New York Times Magazine had a cover story about Toyota and how that company–now with a market capitalization of $240 billion, which is greater than GM, Ford, Daimler-Chrysler, Honda and Nissan combined–has created the most profitable car company in the world. Toyota goes to extraordinary lengths to understand consumers’ needs.

In the NYT piece, Jon Gertner writes, “Toyota’s chief engineers consider it their responsibility to begin a design (or redesign) by going out and seeing for themselves–the term within Toyota is genchi genbutsu–what customers want in a car or a truck and how any current versions come up short.” Although Toyota’s Sienna minivan already was a remarkably successful product line, Gertner proceeds to tell his readers how the lead North American engineer took on the task of redesigning it by driving “the Sienna (and other minivans) in every American state, every Canadian province, and most of Mexico.” He ultimately logged 53,000 miles over 3 years in order to understand how conditions and consumers’ needs varied across the entire continent.

Likewise, Intuit–the maker of the wildly popular financial software Quicken and TurboTax–also believes that effective consumer research and development requires what they call “follow-me-home research.” In order to understand consumer needs, Intuit insists that you have to observe people directly in their everyday settings rather than just trusting self-reported survey data. Intuit is now taking this approach in developing their health care consumer finance software tools.

At our 5th annual information thearpy (Ix) conference last fall, the Robert Wood Johnson Foundation provided the IxCenter with a grant that allowed us to bring consumers to present directly to our audience of health care professionals. By every account, their perspectives were invaluable to the diverse group of attendees, because it helped these professionals to tune in to what consumers really need as health care organizations design innovative Ix initiatives.

I’m hopeful that we’ll continue to be able to bring real-world patients, members, and consumers to our annual Ix conference. Over time, I also hope that we’ll have more opportunities to spend time observing and learning from people in their homes and doctors’ offices.

The more we do that, the more we’ll learn. The more we learn, the more we can help.

–Josh

Following up on Tuesday’s posting, another question that came up a few times in our webcast, “MyHealth, Circa 2007: Consumer Needs and Market Responses in eHealth,” related to consumer privacy concerns.

I believe three things about privacy and security related to online personal health information (PHI).

1. Every provider, system, Web site or other entity that collects consumers’ PHI must invest time and resources to protect PHI and make a firm commitment to ensuring its privacy and security.
2. It can be done effectively–if done right, these electronic entitites should be able to protect PHI better than more traditional mechanisms for storing PHI. Many successful examples already exist in health care, but we can see even more examples in other industries. After all, it wasn’t long ago that experts said that people would never transmit credit card information online in order to buy books–yet Amazon seems to have a few customers.
3. Ultimately, what will make the difference for consumers is the value of the online tools. Most people who use online banking and shopping cannot imagine ever going back to the old way of doing business even though there always exists some risk for identity theft, etc. If online health tools provide consumers with clear, understandable, useful information that meets their particular needs, they will be willing to assume the minimal risk associated with online tools that make a strong commitment to protecting their PHI.

Let me be clear: I absolutely believe that consumers’ privacy and security concerns are real and critically important issues. We should and can address them fully.

–Josh

Although the New York Times took a pass on my letter in response to a Jane Brody column January 30 (http://www.nytimes.com/2007/01/30/health/30brody.html?ex=1170910800&en=c1237335b6037a06&ei=5070), I thought others might be interested…

To complement the expert suggestions in “The Importance of Knowing What the Doctor Is Talking About” (January 30, 2007), keep in mind that most people are “patients” in the traditional clinical environment far less than 1% of any year’s 8,760 hours.

Therefore, we should maximize the value of that in-person clinical encounter with information targeted to the individual’s moment in care and tailored to their individual needs.

More specifically, a “visit prep” information prescription preceding every encounter will better prepare both patient and clinician for their 15 minutes (give or take) together. Also, research that tells us that patients forget 50% to 80% of everything a doctor says by the time they get home, so an after-visit summary reinforces key issues they discussed.

Implementing these two strategies brings us closer to the Institute of Medicine’s first recommendation from its landmark “Crossing the Quality Chasm” report for care based on “continuous healing relationships.”

–Josh

With Revolution Health launching its new consumer portal, a newspaper reporter called me earlier this week to ask what I thought about new efforts such as this….

It’s clear to me that—even though they generally don’t express it this way—consumers are clamoring for information therapy (Ix). And just to be clear, Ix is not simply a shorthand for health information. Ix involves delivering information targeted to a person’s specific moment in care and tailored to the individual’s particular needs.

A wide variety of consumer research makes it clear that consumers are hungry for health information. For example, Susannah Fox from the Pew Internet & American Life Project (www.pewinternet.org) has previously described a “Dr. Google phenomenon” in that, in a typical day, more people go online to get health information than visit doctors to get answers to their health questions.

I fully support the democratization of information ushered in by the Internet and other forces, but I also realize that it’s not fulfilling the needs of many consumers. Most consumers aren’t interested in generic health information. They want answers to specific questions at a particular moment in care that relate to people in their specific circumstances.

To date, the Internet hasn’t delivered that. It’s akin to having a garden with plants, flowers and vegetables that need varying amounts of water and the weather gods delivering a monsoon.

Part of the reason that the term “information therapy” has value is because of the corollaries between it and medication therapy. Information overload can result in an “overdose.” Consumers reading the wrong information can experience negative “side effects.” The right kind and amount of information depends on the specific individual, which means that we often need to “titrate the dosage,” much the same way doctors might adjust the dose of warfarin (Coumadin) for patients with atrial fibrillation (an irregular heartbeat).

Going online for health information generally involves (at least) four challenges. First, can you find the information you need? Again, it’s not hard to find information, but it’s another thing to find it highly specific to your need at a particular time. Once you find it, do you understand it? Has it been provided to you in a way that you can make sense of it? Third, there’s the issue of whether you can remember it.

Finally, even if you can find, understand and remember the information you need, you still may need help in contextualizing it for your own situation. That’s why there often is value in having your personal health library as part of bidirectional communication system with your clinician (of multidirectional to the extent that it involves multiple care professionals). With all that in place, then you’re ready to act on the information to improve your health, decision making and healthy behaviors.

The answer I had to give to the reporter is “I don’t know.” It’s far too early to tell whether Revolution or Google Health will create the kind of navigational support that will guide consumers to the Ix they need. At the very least, however, the fact that people with the resources of Steve Case and Google are pouring money into finding answers tells us that there’s a lot of interest in figuring this out.

There’s no doubt that much research remains to better understand what the optimal dose, frequency, and duration of information prescribing is for people in different circumstances. We are beginning to pursue this as part of our Ix research agenda and, when we figure it out, we’ll be sure to let you know.

–Josh

The Center for Information Therapy (IxCenter) holds periodic public webinars in addition to our monthly IxInsights webinars for IxAction Alliance members. Typically, we get 20-40 participants for these sessions. Yesterday, we sent out a notice about a webinar we’re holding on January 23 on “Personal Health Records (PHRs) and Information Therapy: Transforming Health Care.” Less than 24 hours later, more than 100 people have signed up.

I’m certainly not the first person to suggest that PHRs have the potential to be a major disruptive force in health care, but there are many reasons to believe that the hype behind this “next thing” actually has some legs. Although the focus of many health information technology (HIT) advocates over the last few years has been on the provider or system-oriented electronic health record (EHR), it’s the PHR that actually has the potential to dramatically change the organization of health care delivery.

Direct access to, and control over, one’s personal health information (PHI) could be another catalyst in the democratization of health care, similar to the way that the Internet has democratized information flow (regarding health and everything else).

However, also like the Internet, the PHR’s potential may be limited in health care if we don’t find ways to make PHI more than a series of data points swirling around some consumer portal. The PHI must be conveyed so that it is understandable, usable and meaningful to the average consumer. If it exists in a vacuum, it will have limited utility.

One of the critical aspects of information therapy (Ix) is figuring out how to contextualize the PHI by connecting it to content. Moreover, those who have a stake in consumers using PHRs to better manage their health need to think about how to deliver proactive streams of information targeted to consumers’ specific moments in care and tailored to their individual needs. This dual functionality–contextualization and bidirectional communication–is critical to enabling PHRs to fulfill their promise.

It would be valuable for the audience of this blog to hear some stories from consumers and clinicians about how this has played out.

–Josh