Personally Controlled Health Records and the App Store for Health
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Intelligent Health Lab
Personally Controlled Health Records and the
App Store for Health
Kenneth D. Mandl, MD, MPH
Director, Intelligent Health LaboratoryChildren’s Hospital Informatics Program
Harvard Medical School Center for Biomedical Informatics
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Intelligent Health Lab
$2.5 Trillion17% GDP
Low return on investment 24th Life expectancy at birth 29th Infant mortality 37th System performance 1/3 spent on activities that do not improve
patient outcomes Inconsistent use of effective interventions
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Intelligent Health Lab
US Spending per capita vs. Life Expectancy
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Intelligent Health Lab
Biased Evidence—two examples
Publication bias Negative studies aren’t published
Industry funded trials
Are less likely published within 2 years of completion
Are more likely to publish reported favorable outcomes
Annals of Internal Medicine 2010
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Intelligent Health Lab
As per the National Coordinator . . .
New England Journal of Med 2008: Low uptake of HIT in ambulatory setting
New England Journal of Med 2009 Low uptake in of HIT in hospitals
Conclusion: $48B investment, pushing the technology
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Intelligent Health Lab
Cap applies for any eligible professional with at least $24,000 in Medicare Part B allowable charges in each payment year
Medicare Meaningful Use Incentive Payment Schedule
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Intelligent Health Lab
The Goal:
A Learning Health System
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Intelligent Health Lab
But investment is in current stage technologies:
No data in or out, no communication, terrible UIs
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Intelligent Health Lab
March 1, 2009
“There’s no way small practices can effectively implement electronic health records on their own.”
“This is not the iPhone.”
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Intelligent Health Lab
Later in March
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Intelligent Health Lab
$15M ONC-FUNDED RESEARCH PROJECT
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Intelligent Health Lab
Clinical use case 1
Med-tastic is a well-funded NewCo which has developed an elegant medication list application that has physician and consumer facing functionality
To work, Med-tastic needs Prescribing history Dispensed medication history Allergies Problem list diagnoses
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Intelligent Health Lab
Use case 2
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Intelligent Health Lab
Domestic Abuse
British Medical Journal 2009
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Intelligent Health Lab
Use case 2 (cont)
The application would require Comprehensive diagnostic data from primary
site of care for each patient (to work well) Comprehensive diagnostic data from all sites of
care (to work very well)
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Intelligent Health Lab
MedTastic may be able to develop apps adapted to several APIs (Cerner’s Mpages etc)
Academic group cannot. THEREFORE, focus is on an API that enables a
single apps store for Cerner Install Hospital with homegrown system Physician practice Open source EMR
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Intelligent Health Lab
We imagine EMRs as an iPhone-like platform where Medtastic
could create and widely distribute an app across many
disparate EMRs
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Intelligent Health Lab
EHR as an “iPhone-like” Platform
There is a common application programming interface that enables Software developers to build SUSTITUTABLE
applications Push innovation to the edges Nimbly evolve functionality Avoid vendor lock Shrink switching costs Enable disruption
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Intelligent Health Lab
Our vocabulary:
Data Sources (managed by containers)Containers (present data from data sources to
apps in a uniform fashion)Apps (completely substitutable)
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Intelligent Health Lab
Substitutabilityworks both ways—
the containers can also be swapped out
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Intelligent Health Lab
Governance
code: open-source, open formats,led by SMArt team
app store: one app exchange to start, but others can be built. Installations manage their app gallery. Users manage their dashboards.
brand: compliance test to ensure that “SMArt” is meaningful
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Intelligent Health Lab
“App Store”
The SMArt App Exchange will feature appsapproved by the SMArt committee
Other organizations can operateand vouch for alternate app exchanges
Each SMArt container installationwill decide which apps it wants to featurein its App Gallery
Each user may select his preferred apps placed in his App Dashboard
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Intelligent Health Lab
It is not the wild west
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Intelligent Health Lab
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Intelligent Health Lab
SMArtPlatforms.org
SMArt Health App $5,000 Challenge Announced by Aneesh Chopra during keynote with Bill Gates
at mHealth last week Opens in March and allows innovation in MODULAR
functionality Imposes discipline on us to create version 1.0 of the API Judges:
Regina Herzlinger (Harvard Business School) David Kibbe (AFP) Doug Solomon (IDEO) Edward Tufte (Yale) Jim Walker (Geisenger)
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Intelligent Health Lab
NEJM 2008
Ecosystem
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Intelligent Health Lab
“We cannot overstate how important PHRs are to the efficient functioning of a low-cost, high quality health-care system . . . . We think that the INDIVO system, or something like it is a good place to start.”
--Clayton Christensen Harvard Business School
2009
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Intelligent Health Lab
Will disruptive innovation be or fostered in healthcare
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Intelligent Health Lab
Looping in the Patient
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Intelligent Health Lab
In 1994 we observed that institutions rarely share data
H1 H2 H3 x xProprietaryPerceived competitionPrivacyHealth Insurance Portability and Accountability ActNo dedicated resources to do so
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Intelligent Health Lab
What if we gave patients a tool to request their records electronically?
H1 H2 H3 x x
Indivo Server
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Intelligent Health Lab
And create a personal health record
H1 H2 H3 x x
Indivo ServerComprehensive record
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Intelligent Health Lab
The collection of these records is a population health database
H1 H2 H3 x x
Indivo Records Indivo Server
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Intelligent Health Lab
Intelligent Health Lab | Children’s Hospital Informatics Program
Our original statement on personal control
A PCHR stored all of an individual’s medical history in a container with: patient control interoperability open standards rules to protect patients
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Intelligent Health Lab
Patient role
Patients can access the record grant access to others
specific to their role of selected portions of the record
store their record in a location of their choice annotate in the record (but not delete) grant access to “apps” and to devices
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Intelligent Health Lab
NEJM 2008
Ecosystem
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Intelligent Health Lab
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Intelligent Health Lab
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Intelligent Health Lab
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Intelligent Health Lab
“We cannot overstate how important PHRs are to the efficient functioning of a low-cost, high quality health-care system . . . . We think that the INDIVO system, or something like it is a good place to start.”
--Clayton Christensen Harvard Business School
2009
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Intelligent Health Lab
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Intelligent Health Lab
New England Journal of Medicine 2008
Tectonic shifts: PCHR vendors and users create large
accessible populations for public health study and intervention
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Intelligent Health Lab
Individual contributions are accurate
JAMIA 2007
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Intelligent Health Lab
JAMIA 2007
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Intelligent Health Lab
Patient vs. Doc Reports
Basch The Missing Voice of Patients in Drug-Safety Reporting
NEJM 2010
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Intelligent Health Lab
Individual contributions to drug safety data
Patient reported outcomes Adverse effects Efficacy endpoints Adherence Satisfaction Quality of life
Patient reported data Over the counter meds Complimentary/alternative meds
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Intelligent Health Lab
THE GENOMICS APP
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Intelligent Health Lab
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Intelligent Health Lab
“What ever will we think about now that the genome project is complete?”
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Intelligent Health Lab
• Genes• Environment
• Microbiome• Phenotype• Healthcare
NEED LARGE NNEED data capture
at home and in clinics
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Intelligent Health Lab
Phenome-Genome Database (PGD)
Standard Biorepository 1. Static phenotype2. No return of
research results to patients
3. No patient engagement
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Intelligent Health Lab
Disintermediation (MD’s not required)
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Intelligent Health Lab
Dangers of Large N and small p(D)
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Intelligent Health Lab
Why consent?
Without consent:Tend to be stuck with anonymized
datasets which are often cross-sectional and single purpose
Impedes study of phenotype over timeTend to lose the opportunity to follow-
up with the patient (public health imperatives are an exception)
Risk privacy backlash
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Intelligent Health Lab
Tectonic shifts in the health information economy:Enabling inference across the data of PCHR users
Population Database
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Intelligent Health Lab
The Gene Partnership
Science 2007
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Intelligent Health Lab
The necessary compact entails complexity
WSJ 2010
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Intelligent Health Lab
www.smartplatforms.org
www.genepartnership.org
www.indivohealth.org