[By Joe Flower, from the May 17, 2010, issue of H&HN Weekly]

The country seems to have shifted in less than 18 months from a
slogan of “Yes We Can!” to “Oh, well…” and a shrug, then back to “Cool!
I think. What was that, really?” Hopes for a true rebirth of health
care turned into the Year of Screaming Inanely, then took that long
slide from what we might hope for to what we might settle for. Yet
suddenly it seems like things are popping up all over the place, like
mushrooms on a forest floor in springtime. New projects and initiatives
are emerging from little companies, big companies, garage startups,
info-giants and mega-industrial combines.

It looks just as if, frustrated by a glacial and refractory
legislative process, Americans and American companies have taken
matters into their own hands, not with torches and pitchforks, but
devices and codes and business models, all trying to figure out some
way they can help make health care better, faster and cheaper. It is as
if Rosie the Riveter of the World War II poster were once again flexing
a muscle and saying, “We can do it!”

Better for Less

“Better, faster and cheaper?” The glib management saw is: “Quality,
cost and speed—choose two.” The received wisdom is that you can do
things at high quality and low cost, but it will take a long time. If
you want high quality at high speed, it will cost a bundle. If you want
low cost and high speed, you can’t have quality.

But health care does not fit that wisdom at all. In health care
“speed” translates to “accessibility,” in terms of coverage,
availability of services and convenience, as well as sheer rapid
response.

And uniquely in health care, the management saw is wrong: You can
have all three. The Dartmouth Center studies repeatedly show that
efficiency and effectiveness go together in health care. There is no
clinical advantage to making the process more clunky, difficult and
expensive. And more is not better in health care—doing more tests and
more procedures actually correlates not just with added cost, but with
worse outcomes. Efficiency, convenience and low cost are
therapeutically effective.

This is the giant prize at the center of the labyrinth of changing
health care: We could do it better for less. Much better, for much
less. And more and more companies are heading straight for that prize.

Retail Clinics

Let me give you a few examples. They sometimes are big, bold
actions, and sometimes are things that seem like details from the
outside, but could turn out to be very large.

CVS/Caremark, for instance. The CVS pharmacy chain has been growing
very quickly over the last 15 years, swallowing up Revco, Arbor,
Eckard, Sav-On, Osco and Longs, ballooning from 1,400 stores to over
7,000. In 2006, it bought MinuteClinic, a chain of retail clinics, and
began expanding it to almost 600 locations today. In 2007, CVS merged
with the massive pharmacy benefit manager Caremark, with some 64,000
participating pharmacies, to become CVS/Caremark. The combined
organization is now the largest provider of prescription medicines in
the nation.

The interesting detail? CVS/Caremark has decided to use its massive
market footprint to do something about chronic disease, starting with
diabetes. It goes beyond the more usual passive education programs to
aggressively get out and work with patients by, for instance, sending a
nurse to your house to show you how to test your glucose level, how to
use insulin and how to regulate your diet to keep the disease in check.

And the PBM side of the company is working with the pharmacy part so
you can walk into any MinuteClinic to get the same advice, or get your
A1c score tested, any time that is convenient, instead of having to
make an appointment at a doctor’s office. There is likely a convincing
business model to such services, but these kinds of direct patient
services are much harder to pull off than another PBM deal or opening
another store. They are the kind of thing a company has to want to do.

A Leader in Efficiency

GE Healthcare, with 46,000 employees, headquartered in the United
Kingdom, is one of the largest vendors of medical equipment in the
world, owning (to take one example) 80 percent of all the anesthesia
machines in the United States and 60 percent of the machines in the
world. Like all of General Electric, the world’s largest corporation,
GE Healthcare is highly focused on quality, and the processes by which
it continually hones its products and abilities.

But GE Healthcare has come to realize that this mindset, so natural
within GE, is not shared by its customers, who often think quite
differently, and have quite different concerns and incentives. Within
the past year, it set out on a major program involving all its major
executives, down to the manager level, especially in the service
division, which interacts with the customers on-site every day for
years on end, to better understand the customer—how the industry works,
how it makes its money, how it gets things done, why quality and
efficiency in processes are only beginning to be understood across much
of health care.

They are doing this, GE executives tell me, not only to work with
their customers better, but also partly to influence their customers,
to educate them to the way GE thinks about quality and efficiency. I
asked one GE Healthcare executive how this would help sales. If it were
really able to help its customers be more efficient, wouldn’t they be
more efficient, among other things, in using GE machines—and so
actually buy fewer units?

“That may happen,” he told me, “but we see that health care simply
has to change, and it will change, to be more lean and efficient. If we
help lead that charge, we will be identified in the customers’ minds
with a whole new way of working more efficiently, with less variation,
and better quality.”

New Approaches to Storing Health Records

Personal health records make up one big mushroom patch. Google
Health, for instance, provides a place where patients can keep their
health records. But here again, the revolutionary force is down in the
details. Besides plain old record storage, Google Health also provides
what may become a de facto standard for personal health records, making the CCR standard it has adopted into the MP3 of health records.

Equally important, both Microsoft’s HealthVault and Google Health
work like Apple’s iPhone: They provide an open platform with an API—an
application programming interface—for which anyone can design apps.
MDLiveCare, the see-a-real-doctor-online-right-now site I mentioned in
a previous column, is an app integrated with Google Health, as
OnlineCare is with HealthVault.

Similarly, SalesForce.com has invested in (and provided its
Force.com platform for) PracticeFusion, a free medical practice suite.
Its ChartShare allows any authorized provider to view and interact with
the patient’s chart—and its sibling, PatientFusion, gives the patient a
look at the chart arranged in one convenient interface. All of this
software is free.

The business models are all over the map. Like many things Google
does, Google Health does not really have a business model, except
Google’s belief (so far well-founded) that the more it can provide
storage and search and interface for every bit of information on the
planet, the more it will prosper. Google Health does not plop
advertising on your chart, and does not sell your information to
anyone. PracticeFusion supports itself through advertising and through
selling impersonal, statistical information about disease trends.
MDLiveCare asks for your credit card information.

Mostly, these companies seem to be in a kind of land rush. They see
health information as a nowhere-near-mature field, and they are staking
out the territory with little or no focus on profit for now.

New Platforms

If we want to imagine the true power of these patient interfaces, we
have to look even beyond today’s Internet browser-driven information
world to the new platforms arising right now: the smart phone and the
whatever we will call the generic version of the iPad. The iPhone is
not just a product, it is a platform. Though Apple is suing its
imitators, the platform will be imitated, copied, expanded and made
cheaper. The core of it is not the device, it is the combination of
cheap or free apps on a relatively open platform for which anyone can
design.

The growth of this model has been explosive: More than 140,000 apps
are now available for the iPhone alone; people have downloaded more
than 3 billion of them. There is already a website dedicated just to
reviewing medical apps (iMedicalApp.com, of course), including patient
scheduler apps, charge capture apps, medical calculators and patient
trackers.

The recently launched iPad will likely be another platform—similar,
but bigger and even easier to use, big enough to share, intuitive
enough for the non-tech-savvy, on which anyone can build any app,
especially including patient health care interfaces of every flavor.
Like the iPhone, it will launch a flood of imitators as well, and
manufacturers are already developing medical applications and
accessories for it.

Real Value

None of these things will “fix” health care. But collectively they
route around its problems and head more directly toward the real value
we are looking for—the health of the patient, at the highest possible
quality and the least possible cost. Insurance reform can make health
care more available for more people. But collectively, these
innovations do what insurance reform could never do—actually make
health care better, faster, cheaper.

Cartoonist Walt Kelley’s character Pogo famously pronounced: “We
have met the enemy and he is us.” But Buddhist teacher Pema Chodron
much less famously pointed out that there is a corollary to Pogo’s
pronouncement: “I have met the friend and he is me.” In health care we
have for a long time been our own worst enemies, each defending our own
turf and way of doing things, often caught in a welter of mixed
incentives that would cross an investment banker’s eyes. In these
disruptive innovations, we can see the million ways we have of becoming
our own best friends.

By Joe Flower, from Hospitals and Health Networks Weekly, 1/19/10

Below the fold and off the radar, way out of the range of town-hall screamers, talk show ranters and headline writers, and even largely outside the awareness of most policy wonks and health care executives, a growing ferment, a yeasty mix of new technologies, relationships, expectations and business models has been maturing. Health care is changing in ways we may have difficulty picturing, let alone adapting to, or using.

Some things remain, some seem hard to budge. Revenues have rebounded, but hospitals are still suffering. We may have a recovery, but it is still a hollow and jobless recovery. The free clinics of America treated twice as many people in 2009 as in 2008, and the trend still is up. Whatever happens about reform, millions will remain uninsured, and tens of millions will not be able to afford the insurance available to them, or even to use the insurance they have. Costs—what it costs providers to do business and what it costs consumers to buy the product—are likely to rise even faster over the next few years than over the last few years.  

But for all that remains, much is breaking up, changing, sending out new shoots. The year of reform debate, though little of it was well-informed and much of it was frankly addlepated, has destabilized the market, the public’s expectations, and the explicit and implicit underlying rules by which we operate. At the same time, the stimulus money in the ARRA has begun to create new markets and new opportunities—and the market is responding in surprising ways.

New Hospital Thinking

The retail clinic and urgent care movements, both created to fill the vast market hole of inconvenience and expense in the primary care market, are both maturing. The over 8,000 urgent care clinics remained invisible to the reform agenda (probably good news for them), and have slowly been consolidating into larger groups. The growth in retail clinics, on the other hand, slowed dramatically in 2008 and 2009, with increasing numbers of hospitals opting to open their own clinics in joint ventures with physicians (but taking more time at it than venture capitalists would), and many retail clinic chains opting to partner with hospitals for their brand, expertise and orientation to quality.

Both movements have continued their challenge to conventional hospital thinking and have immersed hospital executives in the severe market discipline inherent in delivering directly to the market: the speed, the tight processes, the implied or expressed warranties, and the price consciousness that a casual, walk-in and more often self-pay market demands.
Increasing numbers of hospitals are kicking out their traditional strategic walls, seeking ways to “Mayo up,” to become more comprehensive, to embody multiple business models for the multiple businesses, customers and products of health care.

Hospitals are questioning assumptions right and left, rocking the boat with wild actions:

• Increasing numbers of hospitals are voluntarily publishing price lists and such policies as the automatic discount for uninsured cash payers
• Northwest Hospital in Seattle established a chain of free clinics because it’s the right thing to do
• North Shore/Long Island Jewish offered to pay doctors 50 percent of the cost to digitize their offices—or 85 percent if they allow their data (shorn of personal identifiers) to be mined for information on what works and what doesn’t in treating, for instance, diabetes or COPD.

Across health care, the same forces are pushing health care toward rising employment of physicians by hospitals and health networks, and what some are seeing as the impending collapse of private practice, especially in primary care. Jeff Goldsmith, in his October 2009 article in H&HN Weekly, compared the rush to employment to the desperate lines of refugees trying to get onto the last helicopter out of Saigon.

Here as elsewhere, the forces and technologies that will have the greatest impact on health care, both in the United States and around the world, are not the shiny big things like robotics, blockbuster drugs and the latest scanners, but the ubiquitous, the commonplace, the rising tide of the unremarkable—the technologies, business relationships and processes that change the mundane.

Cell Phones

A plethora of phenomena are efflorescing under the rubrics of “Health 2.0” and “Medicine 2.0,” a concatenation of new tech—or, often, existing tech mashed up in new ways to route around the problems of the mess that is the health care system of 2010. Many of these are distintermediative information technologies, ways of bringing health care information, and the power to source it, manage it, and put it to use, directly to the clinician, the caretaker or the patient.

For instance: cell phones. How many in the world? As of now, about 4.5 billion, in a world with about 6.7 billion people. On the margin, many of those cell phones represent a business—one cell phone serving, for a few rupees or pesetas per call, a whole village, or a whole neighborhood of a favela. This is far more connectivity than the estimated 1.5 billion Internet accounts.

Today’s average smart phone has more computing power than the average desktop computer did on Sept. 11. And Moore’s Law is applying with more than usual vigor to these devices: The downward price pressure seems both rapid and inexorable, along with the downward drift of features to the cheaper and cheaper models. So we are at the tipping point where the whole world is becoming connected by a network of devices that increasingly have voice and data connection, computing power, often imaging ability, and especially the ability to run third-party applications.

Cell phones are emerging not only as information distributors, but as clinical management tools. Clinicians are already using apps on smart phones to run workflows and checklists, to check formularies, and access EMRs and PAX. Public health workers, particularly in the less developed parts of the world, are using apps for remote data collection, remote monitoring, communication with workers in the field, tracking epidemics, and actual remote diagnostics and treatment.

And the diagnostics will not for long be limited to simply collecting information, or even a snapshot of the patient. Microsoft, for instance, is working with a number of startups that are busy adapting existing technologies to cell phones—inexpensive microscopes that snap onto the cell phone’s camera to e-mail a micro-photo to a consulting physician or lab; a $50 hand-held sonogram device that snaps into a smart phone’s USB port and delivers the image to the phone’s screen; even a tiny, cheap oximeter that straps around your pinky and accumulates oxygen readings to be sent remotely to your doctor.

There are hundreds of such emerging devices and applications that we could group under the motto “Fast, cheap, and out of control”—out of control in the sense that these disruptive technologies tend to route around the existing medical infrastructure and value chain, linking up in alternative value chains and business models.

Websites

Similarly, in a phenomenon that has been accelerating since the mid-1990s, “apomediaries” are coming to the fore, sources of aggregate medical information (websites or individuals, clinical professionals or not) who bring expertise straight to the customer, cutting out the middleman. Scores of single-disease sites arise, some of them becoming the top source of information for particular diseases, especially less common ones; one of these sites is the Trigeminal Neuralgia Association (http://www.fpa-support.org/).

Think Facebook for medicine and you get the picture: A number of sites aggregate thousands of users tracking hundreds of particular syndromes or physical concerns and package them with “apomediaries” or physicians to help guide the conversation and provide information. The largest, 16-year-old MedHelp.com, still operating out of a bare-bones garage-like space south of Market in San Francisco, gets 8 million unique visitors a month, and has over a million registered users focused on over 300 conditions. It is focused not only on giving the patient information, but also on putting together information that is useful to doctors.

Doctors are getting new help, as well. The American College of Gastrointerologists just signed up as the newest organization to join Within3 (https://within3.com), a HIPAA-ready, physicians-only social media site linking doctors with peers and mentors. Some hospitals, like North Shore/LIJ, are reaching out to their physicians with digitization programs. Some are using Doctors Partner from RedPaladin.com, a virtualized system that requires no new hardware. Some doctors are picking up free electronic health record software from Practice Fusion (http://www.practicefusion.com/).

Doctors who think “free” is not their favorite price point, who don’t like their Practice Fusion’s ASP (advertising, sponsorship, partnership) business model, might go to Doctations (http://www.doctations.com/), where a comprehensive advertising-free medical practice software suite, from pre-qualifying claims to EHR to formularies, designed by doctors around doctors’ practice needs, goes for $187 a month—with all the patient data kept in a perpetual trust, unavailable to the company.

Health Care through the Web

Patients themselves have an array of new choices not only for information, but for actual health care. Take a look at MDLiveCare (https://www.mdlivecare.com/). You want to talk to a doctor or a shrink? It’s $59.95 for the call, by phone, chat or webcam. Become a regular customer, and the price drops: $9.95 a month, $99.95 a year, $149.95 for a family: Board-certified physicians, licensed therapists, their own pharmacy and labs. The price is so low that, in a world in which face time with a real physician is still a precious commodity, even for the insured, many patients may sign up for it just as a backup.

And when they need to go in for the big stuff, they may well turn to the Healthcare Blue Book (http://healthcarebluebook.com/), type in their ZIP code and the procedure they are considering, and find the prices for physician, anesthesia and hospital services, along with instructions on how to locate the highest quality, the lowest cost and the real discounts. Such applications will, fairly rapidly, increase their breadth and quality of information, putting each enterprise you run into direct price competition with your rivals across town or across the country.

Rating sites for both physicians and hospitals are growing apace. Most of them lack sufficient information. They are largely unfair, easily manipulated, and uninformed by any true medical judgment. But they are not going away. They are part of the new ecology of information and opinion, and health care institutions can fight back only by getting better at what they do, finding ways to measure how much better they are, and putting the information out there as transparently as possible.

The tide is turning to flood. New methods of linking people and the help and information they need, of linking doctors to each other and to health care institutions, of organizing their practices and informing their decisions, of rating quality and cost and ferreting out value, are rising around us so fast no
one can keep track. It will take great attention to even parse out what new disruptive technology, value chain or business model could disrupt your business models—and what you could use to bring your customers the care they need better, faster and cheaper. This is the path of the future: ubiquitous, cheap and spectacularly ordinary.

Howard Rheingold has a pain in the butt – a big one – but how he is handling that fact is one snapshot of the rising power of social media in health care.

Howard is a veteran futurist. Onetime editor of the Whole Earth Catalog, one of the founding figures of the Well (the Ur of online communities), founder of ElectricMinds.com and Brainstorms.com, author of Smart Mobs, a number of other books and an avalanche of article, posts, Tweets, podcasts, and videoblogs, lecturer at Stanford and Berkeley, popular speaker, Howard is known and loved not only for his insight and provocative thoughts, but for his sense of fun, his lime-green and canary yellow suits, and his shoes painted with Van Gogh’s “Starry Night.”

And now he has butt cancer.

At 62, he has just been diagnosed with squamous cell carcinoma of the rectum. What did he do about it, once he had talked to all the specialists, gotten his pain meds, and scheduled his radiation therapy and chemo? He posted on Facebook about his butt, then immediately gave his butt its own blog (howardsbutt.tumblr.com) and Twitter feed (twitter.com/rheingoldsbutt) – all of which were promptly inundated with responses, taking up the motto, “Howard’s butt is our butt!”

A silly diversion? Not at all. A smart way to handle the inevitable swarm of questions, expressions of sympathy, and offers to help. More than that, even: A stream of studies have strongly correlated people’s resilience in health crises to the size and strength of their social network. Your friends provide you not only with warmth and encouragement, they can also help out. Howard is lucky to have been married to Judy for 42 years, but she will need help as well, friends to cook meals, run errands, and drive him to therapy – and Howard has already arranged an online calendar on Doodle.com where friends can simply click the box to sign up for particular tasks.

Howard has always been a pioneer of the ways in which new technologies are re-shaping our connections to one another. And in this crisis, he is doing it again, patterning what will increasingly become a normal part of health care – using new technologies not only to track our situation, get lab results, and make appointments, but to organize our networks of support.

There are many of us in Howard's many communities linked across cyberspace who have appreciated his vision and his enthusiasms for the better natures of the future over the years, and who wish him well, and offer him our best hope and help in this struggle. We're with you, Howard.

At this week’s Health 2.0 conference in San Francisco, we interviewed innovators in healthcare IT.  Here’s the first interview, Dr. Lou Cornacchia, a neurosurgeon who has spent 5 years developing a fully integrated electronic medical record system for physicians in private practice.  He talks about his product, the business model, and some lessons learned along the way.

Wonks and geeks – that's who we need to build the next health care. Wonks (policy types) are in the forefront right now. But the geeks (tech types) are working away, like lemurs in the final age of the dinosaurs, filling the ecological niches that are opening up, building not just disruptive devices and applications, but entire disruptive value chains, just outside of the spotlight, just under the radar. We're 10 days away from the Health 2.0 San Francisco 09 conference, the big confab of the Matthew Holt/The Health Care Blog crowd (THCB.com). Thursday night a little pre-conference cocktail party featured brand-new companies doing sharp things like putting workflows and checklists on iPhones and Blackberries, or using cheap sensors for constant real-time monitoring of children with asthma, bed-ridden adults in danger of bed sores, and other vulnerable people. The party overflowed the mean and lean offices (about big enough for a 4-car garage) of MedHelp.com, a massive online health community claiming 8 million unique visitors a month, and a million registered users tracking their health in over 300 different conditions. If you're looking for the future of health care, Health 2.0 confabs are not bad places to hang out.