Monday, June 27, 2011

Yet Another Google Health Memorial Blog

Me Too! Me Too!

I wanted to wait at least a few days to let everyone else pile on Google Health before I threw in my two cents from the peanut gallery. Of course there has been plenty of I told you so, should have listened, and here's where we went wrong, all rightfully so. If you want to hear that, buy me a drink sometime. Right now I don't want to repeat what's already been said, except for what deserves to be repeated: I will trust my doctor and primary care facility to store my medical records, and no one else. That is the only way it will work.

Now, let me add this: Google Health was too generic.

Specialization is Your Friend

The comparison has been made between "tethered" and "untethered" PHRs. It would seem logical that providers want to keep patients - more treatment means more revenue - and that makes people tend to build patient portals which drive patients into their own institutions (and profit centers) and not to their competitors. I don't look at it this way. I think each provider facility is so specialized that they look at a general-purpose PHR and think, "This isn't exactly what my patients need." If it's not exactly what the patient needs, it's useless, possibly harmful. Even among the few large makers of traditional EHR systems, every single installation is different and highly customized. Why wouldn't patient systems be just as specialized?

Every hospital has its specialties, its centers of excellence, and a patient population more or less centered around what it does well. Let's say, for example, a referral hospital specializes in transplants. They are in the best position to design a PHR-type system with the features that transplant patients need, and transplant patients will flock there for treatment with or without a PHR.

Say another hospital treats a lot of cystic fibrosis patients. They, too, have an idea of a different set of features that will serve their patient population best, and if they are very good, it is entirely possible that nearly every cystic fibrosis patient in the country will have an account on their patient portal. One only needs to look at primary care facilities such as Kaiser, the VA, and Palo Alto Medical Foundation to see the first hints of how this can work.

If you start out by defining your patient population as "everyone," how are you going to even think about what features are needed most? Most common denominator? Most efficacious numerator? It's a recipe for stasis and mediocrity.

Precisely what problem were they trying to solve? It's easier from an engineering standpoint to define the problem in terms of data. After all, Google's stock and trade as a company is moving and analyzing data in large amounts, so naturally they tackled the health record head-on by building a nearly exact replica of a standard patient summary document and not much else.

What we have here is not a health record problem, it's a health visualization problem.

Physician, Heal Thy Computer

It's going to be up to the clinicians to figure out what patients need, and can use, from web technology. If you are a physician and have a great idea, you will have no trouble finding talented engineers to build it for you. Even if you have a lousy idea - like Google Health proved to be - you can see there's no shortage of talent, dedication, and know-how to make it happen.

What we need is something that lets clinicians with good ideas implement them, on their own EHR systems, in small pieces. Up to this point, if you wanted something as simple as a glucose monitoring chart for your diabetes patients, it took a lot of work just to build infrastructure around getting the data from its various sources and loading it into a web application. What if you could devote 90% of development time to data visualization, instead of data plumbing? Then we can let a thousand flowers bloom.

What if, eventually, patient records could aggregate from diverse sources into your system, making your patient portal a place to store, view, and analyze a personal health record for as long as you have patient consent to keep it within your facility? What if the PHR was an entity of pure data, and followed the patient from system to system? As long as you have a primary care facility, would you even need a Google Health?

Engineering is a marvelous and noble profession, but clinicians are coming from the more important - and complicated - side of the equation. I've been programming since I was 12 years old and the most difficult, complicated, incomprehensible system I've ever come across is health care, only to hear a respected, practicing physician look at computer diagrams and say, "I don't know that technical stuff." Yes you do. Healthcare is all technical stuff. Anyone who can understand medicine enough to practice it, can go on to say, "I know what these particular patients need from a medical record." That's who will be driving the technology forward.

Google Health is dead. The PHR is just getting started.

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