Like a dog on the scent of something interesting followed the trail to their idea factory, CrumpleItUp.  Very nicely done and gives one a sense of what may be possible, from a Web presentation stand point, if you start thinking beyond columns of text and smatterings of graphics.  Honestly, one of the best sites I’ve come across in sometime.

But I really fell in love with this little group and what they are trying to do when I learned that they are the brainchild behind Freewheel!n.  Freewheel!n is all about providing bicycles to consumers to encourage them to get around via bikes, thus contributing to health (big objective for Humana), goodwill (another Humana win – great PR), eco-friendly, (we all win) and the list goes on.

Freewheel!n made its grand intro at the Republican and Democratic conventions.  Following are some stats off of the Freewheel!n site (stats were cumulative over the 8 days of these conventions).
• 7,523 bike rides
• 41,724 miles ridden
• 1,293,429 calories burned
• 14.6 metric tons of carbon footprint reduction
What’s not to like?

Maybe that Freewheel!n is not in Boston yet, that is still in prototype mode, that we will have to wait to see it arrive in our own fair cities and towns.

Plenty has been written here and elsewhere about various initiatives of payers to encourage healthy behaviors.  Sorry Aetna, CIGNA, United Health, WellPoint, all of the BCBS plans, none of your initiatives have captured my imagination like CrumpleItUp. Humana has broken the mold in reaching out to consumers.

Take a look and learn.

Not any more.

Today’s Washington Post had a brief article on CIGNA’s introduction of the new website, itstimetofeelbetter. Along with the new website, which has a wide ranging and somewhat confusing mix of material, CIGNA is also leveraging social media, ala facebook, and the ubiquitous iPod via podcasts at “CIGNA University” on iTunes.

Checked out the site and it is worth a drive-by just to see how CIGNA perceives the market and what it seeks to offer the consumer.

What I liked:

• The interactive tools (most provided by Healthwise) are fun, though tough to read. Did a quick one on calories burned during my 2hr bike ride this morning (plenty, I get a big desert tonight – did I tell you I ride to eat?). Did another on heart health – looking good.
• Some informative, albeit common content, that one would find just about anywhere via Google search. Nicely presented.
• A “game” to test one’s health knowledge. Taking the test results in CIGNA contributing clean water to children in India.

What I was less impressed with:

• The content/information provided was all over the map. Sure, much of it was consumer facing, but if this is truly a site to educate the consumer, why have a white paper targeting employers?
• If one is going to do something on iTunes, why not get creative and develop a couple of innovative apps for the iPhone/iTouch. A podcast is just so 2002ish.
• Where is the information on PHRs? Absolutely nothing on the subject and a real missed opportunity to educate the consumer.
• How about quality and transparency in healthcare – nothing! How can CIGNA be promoting CDHP to employers while at the same time not educating the consumer on healthcare buying decisions is beyond me.

Bottomline:

Happy to see health plans get out there and try to educate the consumer and in time sites such as this should improve. Question is, will they actually dedicate the resources to do it?

Encourage CIGNA and others to rip a page out of the Google play-book and consider such activities as this as a continual work in progress – iterate, iterate, iterate – it will always be in Beta.

Cornerstone One: Standard Quality Measures

There has been a lot of quality metrics established, but agreement on the standards by which these will be measured is still a big challenge. Leavitt believes we are moving too slow. Currently, HHS is doing an inventory of the quality measurements they are currently using throughout HHS. They have identified 100 of them and will be going public with these measures this year.

Cornerstone Two: Standards for Cost of Care

Leavitt came down hard on healthcare costs and billing structure stating:

Our billing system in healthcare is insane.

He went on to draw an analogy between a consumer buying a car and a consumer buying knee replacement surgery going on to say we need to challenge the assumption that buying healthcare services is any different from other industries. Leavitt believes that current efforts striving for the perfect solution will never move us forward – he again stated we are moving to slow. We need to strive for good, not perfection. CMS is currently aggregating its cost for common procedures data and will make that publicly available to push the cost transparency issue forward. Getting back to that knee/car analogy, CMS covered the costs for 250.000 knee surgeries in 2007, the costs for those procedures will be made public this year.

Cornerstone Three: Interoperable EMR

Sees HHS steadily marching forward on interoperability. Quite proud of the establishment of CCHIT and the certification process used to insure EMR software is in compliance to interoperability standards. HHS, via it National Health Information Network (NHIN), will test flow of data among several systems by end of this year. Next year, he foresees this moving beyond test data to the flow of real data and scale-up.

While Leavitt recognizes the challenge of a broader NHIN and interoperability with fewer than 10% of small practices having an EMR system, he gave little concrete guidance on how to overcome this issue. They are looking to change the economic equation to promote adoption. What that equation will be remains to be seen, but I’d look to CMS as the prime leverage point.

One of his chief objectives this year is to see further adoption of eRx practices, which he will promote strongly. Currently looking to attach eRx requirements with physician reimbursement payment rule of he CMS bill before Congress.

Cornerstone Four: Incentives to Seek Value

He saved the fuzziest statements for this last cornerstone. Again, Leavitt promoted the need to establish standards for value metrics and incentives. Also emphasized the need for trust among all stakeholders to get this to work. The biggest challenge that HHS has uncovered here is that value and incentives are driven locally. Therefore, HHS’s role will be to establish the standards, and let the local community drive incentives. Chartered Value Exchanges, of which 14 have been awarded/funded to date, will be the mechanism to drive value and incentives at the local level. Goal is to have 50 opertational by 2010.

Leavitt closed his presentation by stating he sees the unbridled rise in healthcare costs as the biggest threat to our nation’s national economic security. Solving the healthcare puzzle is this generation’s challenge.

Analysis:

Yes, movement on Cornerstones One and Two has been glacial. Too many vested interests have very strong financial reasons to stall any progress on cost and quality transparency. While it appears that HHS will look to further leverage the clout of CMS, seems too little too late, unless of course the next administration picks up where Leavitt left off and pushes even harder to make this happen. In full agreement with Leavitt that we should strive for good enough and not perfection. Advocates for perfection are the ones truly stalling the process.

For Cornerstone Three, do believe that for all the complaining I have heard, all-in-all, CCHIT is moving the interoperability ball forward and EMR companies are structuring their solutions to comply. Now we just need to educate the physician. Here, HHS has fallen far short of the mark. For all the talk about wanting to drive adoption among physicians, adoption is still horribly low. Coupled with strong incentives to encourage adoption (CMS payment structure?) HHS could do more in educating physicians on what’s in it for them. The EMR market is still surprisingly fragmented, and even for me, an HIT analyst who covers this market for a living has a difficult time keeping up with all of them. Maybe CCHIT can provide some guidance here as well.

Corenerstone Four is my least favorite and was where Leavitt made the least clear statements. Defining value and structuring incentives around value is an extremely hard thing to do. The Chartered Value Exchange sounds like a re-branding of the failed RHIO concept and I don’t give these new exchanges any more chance of surviving than its predecessor. Secretary Leavitt, with all due respect, throw this one in the can and go with a three legged stool, afterall, a three legged stool is more stable anyway.

CIGNA & WellPoint to Make PHRs Portable in 2008

You heard it here first folks, CIGNA and WellPoint will make member data portable by end of 2008, following the lead of Aetna and UnitedHealth.

Sat in on the session, Critical Health IT, which had representatives of WellPoint and CIGNA talk about their consumer and broader health IT initiatives. During Q&A got a chance to ask both why have they not come forward with a public statement that they support the portability of a member’s PHR. (Note, during their own prepared remarks they gave somewhat dismal views of PHRs stating adoption has been a challenge). Both stated that they have every intent of making a member’s data portable. WellPoint and CIGNA are currently deploying the CCR standard internally to insure that the data will be portable and enable a member to populate a PHR of their choosing outside of their health plan. They also went on to state that this will be completed in 2008.

Towards the end of our exchange on this question, the WellPoint representative went on to state that they still have issues regarding privacy and releasing such data to a non-covered entity. GIGNA nodded in agreement. What a load of bull, particularly after WellPoint has had a few privacy/security breaches of their own.

Hey WellPoint, its my data, let me choose whether or not I wish to take the risk and stop being so damn paternal. Or is it, you just don’t want anyone between you and me? Watch out, you are about to be dis-intermediated.

The people who put on the WHCC have put together quite an impressive agenda with so many different and what look to be interesting tracks, the biggest challenge for me was just deciding which ones to attend.  In the end have chosen to focus on those tracks focused on consumer health including transparency, successful models for engagement, empowerment and the like.  Over the course of the next couple of days, I’ll provide a couple posts outlining some of the most critical issues raised and lessons learned from the various presenters and participants.  So stay tuned.

As an aside, had two interesting experiences yesterday, here in DC hainvg arrived a day early.  The first was meeting a man on the DC Metro who had flown in to attend a training session.  We got to talking and he asked me what I did for a living.  Told him healthcare and he immediately opened up with: “Healthcare costs and gas prices are going to drive us into the ground.”  As we continued talking he related his own, most recent experiences with the healthcare system.

He receives good coverage from his employer, though complained about his share of costs continuing to rise.  He has had a heart condition ever since he was a child.  Recently, he changed primary care physicians.  Despite a long record of a heart condition, his new doctor ordered a battery of tests that he estimates cost between $30-40,000.  Though he readily admitted that his costs were a few hundred dollars, he knew that in the end, we all will be paying higher prices to support such practices, that for him seemed at a sham.  He also found the multiple Explanation of Benefits (EOBs) forms that he received from the insurer during this whole process as to appear as though they were written in Greek – simply incomprehensible.

Now, I am not a doctor and certainly not one to judge whether or not these tests were unnecessary.  What this story does point out though are two important points:

1. Might this consumer, if he had control of his records that were safe-guarded in one of the online data repositories like HealthVault, or Google Health, or even Dossia (if his employer was a member), be able to provide a complete longitudinal health record, maybe the physician would have decided not to order these tests.
2. With all the talk from insurers about transparency, consumer empowerment and all the wonderful online tools that they want to provide to enable such, from this story it looks like they are getting a little ahead of themselves.  Rather than looking to the Internet and IT as the magic elixir to make all this happen, maybe insurers might want to start with something as simple and basic as making EOBs understandable.   Granted, not novel, nor sexy, but it may deliver better results.

The second little musing is that while heading over to the Hirshhorn Museum (my favorite here in DC, great sculpture garden and fabulous modern art) coming out of the Metro and what should I see plastered on the walls – at least 8 small billboard posters with that big smiling face of Magic Johnson saying something to the affect of “Together we will better manage our health.”

These are part of Aetna’s consumer advertising campaign to encourage greater consumer involvement in managing their health.  Really like this advertising campaign (seen full page ads in the WSJ as well).  As far as I can tell, they are the only major insurer being proactive on educating the consumer.  Now if we could just get the other big insurers (are you listening WellPoint, Cigna, UnitedHealth, etc.) to ramp-up their own consumer advertising to focus on a similar message, we may indeed begin to see consumers take a more proactive role.

One of the chief complaints I have heard from physicians (besides the issue of reimbursement) is the fear of being inundated with emails.  While this could become a problem, it doesn’t have to be that way.

At the recent HIMSS conference, I had the pleasure to get an in-depth demo of RelayHealth’s PHR solution.  As I stated in my write-up then, nice solution, though more physician centric than consumer.  The RelayHealth solution provides secure communication between the physician and consumer where in addition to an e-Consultation, a consumer can request a prescription refill, a referral or even schedule an appointment.   And for those e-Consultations, it prompts a consumer at the beginning of the inquiry to provide the co-pay via credit card before proceeding.  That step right there will limit the barrage of emails that physicians fear.  And if that payment step doesn’t do it, the lengthy questionnaire that follows may also limit those emails.

After the consumer processes the co-pay, they are taken through a thorough questionnaire with branching logic to describe their symptoms.  Not sure if it was the person doing the demo at HIMSS or not, but the number of questions he had to answer during  the demo was daunting.   Unfortunately for the consumer, the RelayHealth solution provides no feedback to the consumer as to how far along they are in the questionnaire process, which can get frustrating.

If you manage to survive this process, your physician will receive an in-depth profile of your current symptoms and likely provide you guidance via a return email, or if deemed necessary, schedule an appointment.   The complete e-Consultation is captured in the consumer’s RelayHealth PHR account, which is under the consumer’s control but sponsored by their physician.

While I have a couple of minor gripes with the RelayHealth platform, it is a powerful solution overall and something that I could see myself using to facilitate communcation with my physician(s).  During my meeting with RelayHealth  they also informed me that the PHR, though sponsored by the physician, is owned by the consumer.  Thus, if you move to another part of the country or just change doctors, your RelayHealth PHR is not tethered to the physician, but goes with you.

This sounds great in theory, but what happens if your new physician does not use RelayHealth?

Well, you are left with a PHR that does not connect.  This is one of the challenges with this solution and for that matter Medem and all tethered hospital-consumer portal solutions.  Their greatest value is in facilitating physician-consumer communication.  These companies have invested heavily in that capability at the expense of providing other features.  This is fine as long as you have that communication capability, (i.e., a physician using it) but value quickly evaporates without it.   RelayHealth, Medem and similar companies will need to form partnerships with other Web-based, health service providers to deliver sufficient value to the consumer while we await greater adoption among physician practices.

Malpractice insurer Northwest Physicians Insurance will be offering a rebate to physicians who adopt a PHR to facilitate patient-physician communication.  Looks like this insurer predicts that if they can get the patient and physician to communicate more effectively to improve patient safety (and have an audit trail to prove it), they will subsequently see a lower exposure to malpractice suits.

Physicians will be offered the Medem iHealth PHR to deploy in their practice.

While there are many a health plan (insurer) that offer PHRs to their covered members, this is the first time I’ve come across a malpractice insurer pushing physician adoption, and thereby consumer adoption of PHRs.  But will physicians adopt it?  Not so sure as reimbursement seems relatively low.  Then again, if a physician can tie this program to e-Consult reimbursements from Aetna or Cigna, well then, now we have something.

While I am no financial analyst, what I do know is that the past ownership structure of WebMD (84% owned by Healtheon) made WebMD a difficult acquisition target. Now that the two have combined WebMD may become much more attractive to a potential suitor.

WebMD is an attractive property for a number of reasons including:

Brand Recognition – They are the 800 pound gorilla in the personal health and wellness market, no one comes even close in numbers of page views and unique visitors.

Customers – WebMD has a long list of enterprise customers, both employers and health plans that is the envy of the industry.

Hot Market – Seems like everyone is clamoring for a piece of the action in the personal health and wellness space including the big boys Microsoft and Google.

Cash – A $700M war chest is nothing to sneeze at.

So who will come courting? Some likely suspects include:

RevolutionHealth could benefit with some added breadth and depth from WebMD and would love those WebMD customers. Also, WebMD had a relationship with AOL (discontinued last year) and RevolutionHealth is run by former AOL head, Steven Case. There will, however, be a lot of overlap that will need to be rationalized. Probability: High

Google may like the content and some of the tools WebMD would bring, but they are also pretty far along in their own plans/development and Brand, well Google has plenty of that. Probability: Low

Microsoft is much like Google, but has a greater propensity to make an acquisition to keep Google at bay. Microsoft might acquire WebMD as a defensive move. Also, Microsoft might like to have all those enterprise customers, not that they don’t have them already, but it could sure extend their presence in enterprise accounts. Probability: Medium

Intuit has taken a decidedly low profile approach to the PHR market. If they wanted to dramatically boost their visibility and further strengthen their product portfolio, this would be a good move for them. Unfortunately, it takes Intuit outside of its sweet spot/core competencies, thus they are unlikely to make a move. Probability: Low

Yahoo? Why not, though they seem to be ignoring the health & wellness market and have enough issues to deal with right now, primary among them the beast from Redmond. Probability: Low

Large insurers like WellPoint or Cigna could make a move similar to Aetna’s acquisition of ActiveHealth or UntiedHealth’s acquisition of HeathAtoZ and acquire WebMD. Thing is, the scale of a WebMD acquisition is massive in comparison and it could get quite messy as a lot of health plans (over 100) have some form of a relationship with WebMD and may bolt if WebMD goes to a competitor. Probability: Medium-low

Other HIT vendors such as McKesson, GE, Siemens, etc., are focused on business to business sales and in particular sales to hospitals. While WebMD gives them future paths for growth and could be leveraged in innovative ways (connecting clinicals to PHR and decision support tools), falls outside their current sales and distribution channels and is simply not in their DNA. Probability: Low

I’m sure their are other suitors out there, but this is just a quick hit list off the top of my head. And while I can give no definitive answer as to who the suitor will be, WebMD will have new ownership in 12-18 months. Probability: Very High

Employers are aggressively looking to reign in healthcare costs, which continue to grow faster than just about any other cost an employer may have. This has led to a dramatic up-tick in interest by employers for employee health and wellness solutions including among others, PHRs. Some forward-thinking employers, however, are looking beyond just healthcare insurance costs. For example, enabling an employee to meet with their doctor online from the comfort (I use that term loosely) of their office at work rather than having to spend an hour or more driving to and from a doctor’s office is a nice productivity boost for that employer.

Taking it to the next level of embedding such physician-patient communication/consultation within the context of an employee’s PHR just adds to the value proposition (of course the PHR is absolutely secure and the employer has absolutely no access to identifiable employee data contained therein). The value here is that not only does the employee/patient share their PHR with a physician online but together, they can go over such things as recent lab results, review images, discuss action plans and keep a record of all communications right there within the PHR.

Since its inception, PHR vendor Medem has always felt that physician-patient communication was critical to the success of PHR adoption by both patients and physicians and structured their solution around that fundamental belief. In a conversation with Medem’s Chief Medical Office, Henry DesPhillips, last week as part or our PHR Research Study, DePhillips’s stated that they are seeing increasing interest for their solution from payers.  Medem traditionally has  marketed and sold their solution almost exclusively to physicians, pitching it as a platform physicians could use to  improve patient services and retention.  In light of the rapid changes now occurring among payers such as reimbursing physicians for online consultations, Medem expanded its marketing efforts in early 2007 directly targeting payers.  They are getting some traction in the market having landed Medical Mutual of Ohio in 2007. If more payers follow Aetna and Cigna’s lead, Medem is in a good position to experience some healthy growth as they are one of the few independent PHRs now in the market with strong patient-physician communications capabilities.  While Medem certainly has an early jump on its competitors, many who I’ve spoken with are currently developing similar capabilities that they plan to release in 2008.

Another, slightly different example is Kaiser-Permanente. Awhile back I did a post on their big PHR roll-out, though I was not all that enthused at the time as I am not a big fan of tethered PHR solutions. Despite my own reservations, Kaiser is seeing very strong adoption among its membership, upwards of 50,000 new users/month. And what is one of the key features of this PHR that all those customers are most excited about? Yup, online consultations and appointment scheduling with their doctor(s).  (Note: At the top of that LA Times article in a picture of a Kaiser physician providing an online consultation.)

To date, I have not come across any independent studies (if you know of any please enlighten me) that point to the efficacy of online consultations, be it improved outcomes, better quality of care, lower total costs of care, etc. Regardless, intuitively I believe there are significant savings here. Unfortunately, as that LA Times article points out, the big payer elephant in the room is the federal government (Medicare) who are loathed to adopt anything new and have no plans to adopt online consultation at this time.

This is unfortunate as the most recent budget proposal by President Bush looks to simple, across the board cuts in Medicare reimbursements rather than how technologies such as this may contribute to lowering the total costs of care delivery but that is another story…

What is interesting about the Aetna announcement was that they not only agree to comply with New York state, but stated that it would reassess its program nationwide.  After the Aetna announcement, Cigna also stated that it to would also reassess its ranking system nationwide.  In their previous announcement, Cigna agreed to only look at how it assessed physicians in New York.

From this vantage point it looks like we may actually move towards some consistency in quality rankings, though it remains to be seen how consistent those rankings would be from one payer to the next.  Hopefully, a federal agency such as AHRQ will step in to assist payers in establishing clear, agreed to metrics across the industry by which all providers will be measured and reported.