If you are an avid follower of the advancement of health informatics, you have undoubtedly noticed the buzzing excitement at the shear immensity of the task at hand. At this stage, we’re only “getting the lay of the land”, so to speak, as we determine what our future e-health infrastructure should look like as we gear up for the single largest IT reform in history. While we in the health informatics community sort out the acronyms we will be using to realize this task, I’d like to stop for a minute and talk about what a brave new world with a global e-health infrastructure could look like. 

Let’s follow Jane Smith during a regular day in the future:

Jane wakes up early. It’s going to be a busy day. She has an appointment with her doctor in the afternoon to get some vaccinations against Typhoid and Hepatitis A as she will be flying to India in a couple of week. But first she has to get ready for her morning run. She will meet with her personal trainer for a 1½-hour high impact cardio workout before work.

1 in 20 have diabetes in the U.S. and Jane is one of them. As part of her routine, she takes her first shot in the morning using her DiaVox 2000. The DiaVox is a telemetry device that takes her blood and uploads all the sample data to her RHIO . The DiaVox then computes and administers the insulin shot based on the results of the blood sample. Meanwhile, the RHIO saves the data to her profile and makes parts of it available for data mining for researchers working on more efficient treatments and others who run geographical analyses on the impact the environment has on Type I diabetics. The RHIO gives scientists and researchers access to millions of samples that used to be numbered in the 1000s.

Jane meets her personal trainer and they go for a 45-minute run followed by 45 minutes of yoga. Jane’s monitor tracks her activities throughout the day and alerts her if she is working out too much. Diabetics need to be careful when exercising and want to avoid excessive strain on the body. Her monitor uploads the details of her workout to her RHIO when she gets home and compares it with her previous exercises and those of others and recommends a diet that fits her level of activity.

During lunch, Jane has an appointment with her doctor. She needs to get two vaccination shots for her trip to India. Her doctor retrieves her medical record from the RHIO and is able to get a complete overview of her health including her own private entries, past visits to all the doctors she has visited before [in the world] and notes from her acupuncturist and homeopath. Based on her past blood samples and that of others with a similar gene code, there is a high likelihood that she will experience adverse reactions to the most common Typhoid vaccine and suggest she use a different one. At the end of her appointment her doctor enters in her new vaccination records into the system; making it available to everyone with access to her records.

Let’s quickly fast forward to when Jane is in India.

Jane caught a nasty stomach virus while she was trying out the local cuisine. She stops by the local hospital to ask for advice. The doctor in India has access to all the same information about Jane as Jane’s own doctor back home. He was going to recommend Gatorade and dry crackers, but since Jane is a diabetic, he puts her on a plasma drip overnight without question as the system indicates that her travel insurance covers it.

This was a simple example of how seamless medical information could flow and benefit all in the process. Thanks to the system, Jane gets the best treatment medicine can offer based on her personal data and that of millions of others. Jane also contributes to the system as scientists have anonymous access to her data and can run 1000s of different tests with data taken from any region of the world they want. That information can help track down outbreaks of Ebola and predict the probability of future outbreaks. It can run vast simulations on the human populace to help improve lives. The opportunities are endless.

Next time I will cover a slightly touchier subject about how health insurance will play its part and why a hybrid socialized model of healthcare can be a really good solution because it fits the system.

There is a lot of discussion around e-health and how it will re-invent the health care sector. The question that gets asked the most is “Eh, so what do we do? How much is this going to cost? How are we dealing with interoperability?”

Let’s take a big breath and get some distance from the entangled forest we call “health IT”.  We’ll get a nice overview from 100 000 feet up, away from the wires and the cobwebs. Now, as technologists we are trying to solve the problem of securely sharing patient sensitive data and other medical related information across systems, companies and borders, while conforming to regulations and standards. This is not rocket science… and even if it were, rocket science today is done by small start-up companies consisting of some very persistent college drop-outs ;-) The obstacle to a clean shiny new system such as this is the systems we have already created for the last two decades. It’s the red tape that prohibits greater levels of transparency, and it’s the user and company adoption rates of e-health systems. I want to be cautious with stating the latter as there is no true e-health system to adopt just yet.

What would I do then if I was the newly appointed head of Health Reform, the NIH or HHS and my task was to save healthcare; knowing that the previous administration made it quite clear it couldn’t be done and that they would let “someone else” try to come up with a solution?

I would be trying to solve:

• Cutting cost – as the system we have now is not sustainable
• Improving healthcare – leveraging technology to help lower medical miss-management
• Interoperability – building systems that can talk to each other but also by creating greater transparency

As it stands now, states and municipalities are trying to find solutions that work for them, while hospitals are concerned with EMR adoption. As the new head of HHS, I know this does not solve anything. It’s more like a temporary, and very costly, alleviation than anything else; held together by wooden sticks and some thread. It would be like having a few dozen “internets” instead of one. What we need is a national [and if possible a global] solution.

If I know this to be the best and really only solution that can last and grow for generations to come, like a gambler, the next step would be for me to place my bets. The first thing that comes to mind in order to make this work is to create a national identifier initiative. The national identifier would be unique enough to avoid accidental duplication within states and countries. I would look at similar initiatives made by other countries to see if we could gain some insight there. The system would be used, first and foremost, for user discovery. Any health provider wishing to create a record for one of their patients would associate their own data with the national identifier of the patient. When queries to retrieve patient data where executed, the common identifier would be there to reconcile the information.

This would already be a great accomplishment. Privacy activists will of course have a field day with this kind of legislature; stating that Homeland Security and insurance companies will have access to all their medical information. To say it bluntly, they already do, and who cares if your blood pressure was 120/80 five years ago? The intention behind this system is to make healthcare viable and whole again. The price we have to pay is sometimes more transparency. So instead of your paper-based medical record being stashed away somewhere in your doctor’s filing cabinet, it is now available online at the click of a button. All in all, I consider that to be an improvement over the present situation.

Now that providers are using the national identifiers, the next step would be accessibility. In other words, System X wants to retrieve all information for a patient. Where does it go to do that? Is someone keeping a list of every available application in every hospital and insurance company that System X can dial into and ask for information? If so, the latency would be ridiculously slow and “the system” still couldn’t guarantee a unified patient record. And this is really the raison d'être of e-health today. Regardless of whether every e-health application in the world can speak the same language, they first need to find one another and then query each other for information. If that happens to be 1000+ applications, it wouldn’t be feasible. So refactoring existing systems is not worth the effort. They served a purpose but are not suitable for retrofitting in an environment such as this.

Making all existing hospital software talk the same language is not worth investing government money in. As the head of HHS, what do I do? My next step would be to look at the new breed of Web 2.0 patient-empowering applications created by Microsoft, Google, and Revolution Health. It is impressive how much money they have already invested in e-health and the model for the two giants is simple: search! Microsoft and Google are about investing money in the ability to team up with an extensive list of companies, such as Google’s partnership with Allscripts, Beth Israel Deaconess and CVS, and be able to import their records about you and index them for searching. They’re also giving users the ability to enter personal data about themselves.

This is the best that’s out there right now and they have done a really good job. The question is are these applications suitable for a global populace and as a replacement for existing hospital applications that house millions of user records? If I look critically at their business model, it entails that for this to work you have to have an account with Google and maybe accounts with up to 4 different providers that Google has partnered to be able to access your records. Many of these providers charge a subscription fee or one-time price based on the nature of the service, which can get rather costly for the average user. The main reason you’d want Google to store your records is so that you can share them with other providers. What if Google doesn’t have a direct link to your provider? In that case, you or your practitioner, or both, need to sign up for another set of services to be able to share records which most likely is going to cost you more money. When you start working with these services you get the feeling that it’s glued together with wire and string, it’s impractical and costly. What if you are not online and you wish to share your hospital record with another hospital? Better yet, a hospital wants to share records directly with another hospital. In this case these services are no good at all. They don’t work. As a Web 2.0 company, you are also relying on your partner sites to be up and running which doesn’t solve the 99.99% uptime requirement such a system needs to have. It becomes too sketchy and it doesn’t matter if you have a thousand man support team when the problem is not with you but with your partner.

However, this is definitely a good start going in the right direction. I think they all focus on the patient and offer their services accordingly. But my goal is to save our healthcare, as we know it. Can it be accomplished through these companies or are the aforementioned just dabbling in business models while spending million of dollars to be the first in the e-health space? I personally do not think they offer the solution necessary.

Which leaves me with the last, ultra-risky, option of placing my bets on building a centralized system that can do everything. It would have to cater to hospitals, small providers, patients, insurance companies, countries and any other entity involved with the e-health life-cycle; effectively creating a cradle-2-grave solution that can be exported and used by other countries. France and Great Britain has spent a lot of money creating centralized solutions. However, they are not where they want to be as far as keeping the promise of a true e-health system.

Past administrations have clearly said they would not venture into creating such a system because of the price tag and a 60% failure rate. Is the time for such a system now? The prospect of universal healthcare, both as far as coverage is concerned and the infrastructure that goes with it to make it a reality is very titillating. If I were to commit the HHS to such a grand plan, I’d first want the greatest minds in healthcare and software design to come together to establish viability.  Then I’d want the best entrepreneurs to divvy up the project into doable chunks of work. One would focus on creating an e-health platform. Another would focus on the services that get put on the platform. A third would focus on creating an integration API so other e-health vendors can also start creating these services. A fourth would focus on regulatory requirements and how to implement it across services and across national borders. In effect, the model would be very similar to that of salesforce.com.

This is exactly what we have been doing for the last 4 years. It’s been a slow and time-consuming process as we’ve been waiting for the right technical and medical standards and policies to get solidified. It’s a work in progress but we have found this model to work very well. It’s very scalable as you can put the whole system up on the cloud. Services can talk to each other using a variety of APIs, protocols and standards. We have a federated security strategy for every entity registered with the system and we are teaming up with domain experts to write declarative security policies that can be exported across borders. It’s really a handful to think about all the different pieces that need to come together for such a system to function. However, I do believe our model is superior and I also believe it will become evident in the years to come. Stay tuned!

John Lynn keeps an interesting e-health blog at www.emrandhipaa.com. I posted an entry on the role of HIEs and RHIOs in the years to come on his blog here. 

CCHIT published a HIE compliance specification on October 1st, 2008. Check it out here. This is really great news for integrators. It all comes down to "standards, standards, standard".

 We'll be giving a presentation at "XML In Practice 2008" in Arlington, Virginia on December 8 - 10. Check out the details here. We'll put a focus on data interchange using XML in the health care arena."How to make old systems start talking to each other and how to build new system that facilitate portability, security and, of course, comply to the latest standards. Come see us!

I am excited to be a part of the e-health revolution. So many new innovations and online tools are on the way or has already been released for hospitals, patients, at-home health and insurance companies to help them do their work faster, with fewer mistakes and with the patient as the focal point. Municipalities are embracing e-health networks and empowering their citizens with better control and improved care. It's really uplifting to see all the movement towards a common goal of e-health for the nation and e-health for all countries.

Now let's do better!

The U.S. has calculated it will cost approximately $150 billion to reform our health care infrastructure.  That's a lot of money but it's an investment costing less than 1% GDP with a reward that is, unmistakably, priceless; the well being of a nation. If you are interested in staying up-to-date with news in the e-health arena, you should go to SmartBrief and sign up here.

See, we (as in all of us) have the technology. We know what needs to get done; TO BUILD AN INTEROPERABLE SYSTEM THAT CAN SECURELY STORE AND EXCHANGE MEDICAL RELATED DATA FOR THE ENTIRE POPULACE. Easy! We don't have that yet. Everyone, including Health XCEL, are working hard at building a system that is tough enough, secure enough, yet "open" enough to be usable. We're building systems while waiting for the critical answers to technical questions, such as what protocols and standards to support, and political questions, such as what does an application need to conform to before it can safely be put into use. Many countries, right now, don't even allow for medical data to be on the same computer that has access to the internet. That's why there's a lot of work to be done on many different levels. Many applications have already been built for this purpose, but they will go obsolete quickly as a more solid direction is marked out and end-users are demanding more control, more features and, above all, a solid doctor-patient relationship that can be managed in the 21st century.

I am not going to say too much here, but I will say that I am very very excited about the application we have been working on. It is not done yet... but the hardest part is complete. 

More to come very soon. Stay tuned!

If you follow developments in the e-health arena, you can see that there is A LOT going on. There have been standards meetings, such as Interop 2008 , where major players in health IT have been discussing how to have their systems talk to each other. Sun Microsystems just created a new group called the open ehealth foundation; promoting best practices for commercial implementations of e-health initiatives. Politicians all have health care on their lips these days and they know e-health is the solution to the problem. Both the U.S. and the E.U. are talking about changing legislation so that it will be easier to pass sensitive patient information from one point to the other via the Internet.

What does that mean for the average user? It means that within a decade you will be interacting with all your doctors in a completely different way than you have before. It will be easier. It will be better. But users also have a learning curve to climb. It's educating yourself about the privacy concerns you have about allowing your medical records to go online. Many are afraid that their data will be easily accessible by anyone or for anyone to break in and get them. Find out about how safe your records really are. Read up on the security seals and accreditations sites have received and what they mean. There will never be 100% security on anything. The problem is a human one. If someone really wants your information, they will get it. If that information was locked in a doctor's office it would actually be easier to steal than were it online. Another reality check to ask yourself is, what don't I wish people to see and why? I am not suggesting less security. Not at all. I am saying to take a worst case scenario and look at the repercussions. What would an intruder be interested in? Most likely, they will want your social security number and credit card information so they can commit identity fraud. Credit card companies face the same security issues every day but that hasn't stopped them or their customers from embracing the Internet. I am advocating that we take the lessons learned and apply them to e-health.

There is a lot of work to be done before e-health is an actual reality. Systems need to be built. Laws need to be passed. Educating yourself and taking charge of your health is the best thing you can do. Let's get going!

After many years of work, hxcel.com goes online. We have only one, but rather large, goal... to revolutionize health care as we know it. They key factors of success are helping large institutions and countries lower the rising cost of health care by instituting e-health with a global perspective and by offering superior services to every tier; making it a pleasurable experience and not a daunting one. Just because the term has e- in front of it doesn't mean it should be harder than making coffee. And not losing track of the "local is global" mindset.

We want to make the world a better, healthier and happier place, and that starts with the next door neighbor. That means working with our users on the local level; finding out about their needs, their hopes and their desires. This sounds obviously cliché... it's meant to be ;-) It does, of course, mean working with and conforming to the rules and regulations of a specific country or locale and making sure they are properly implemented. It means finding out what can be done better. It means offering our services to non-profit organizations such as Red-Cross or UNICEF so they can use them for people that many times go neglected. It means going the extra step to see if we can make people's lives better. It's about giving back to the planet that gave us all life. How beautiful is that. Life!

This is a small beginning compared to what's to come. A friend of mine once said, "Well, at least you have your target market firmly in place.... the planet. What's next… Mars?" If you ask anyone in the know about instituting global health care reform, they would most assuredly say you are bonkers and that it cannot be done. I believe in the "if you build it, they will come" attitude.

What it all comes down to is that proper health care services make people healthy and happy. When people are healthy and happy they perform better in their lives, make other people healthy and happy (attitudes are contagious) and contribute to a positive cycle that adds to the universal balance of life on the planet. It's that important.