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MMI 401 American Health Care System Winter 2009 Instructor: Dr. M. Schulte

Chad Hodge Nadine Lewis Michael Lim Jennifer Linton

THE IMPACT OF GOOGLE HEALTH ON HEALTHCARE Google Health is an Internet based PHR which individuals can access via a web-browser. It helps users organize, gather, and communicate information about one’s health, in a centralized location. Google is an industry leader in organizing information in an easy to use format and brings together a group of leading health experts to bring Google Health to its users. This document summarizes the impact of Google Health and what it means to the healthcare industry.

Copyright © 2009 Chad Hodge, Nadine Lewis, Michael Lim, Jennifer Linton 2

Table of Contents

1 Introduction ............................................................................................................................. 4

2 PHR Background ...................................................................................................................... 4

Personal Health Record Architecture .......................................................................................... 6

3 Google Health .......................................................................................................................... 7

4 Google Health's Impact on IT .................................................................................................. 8

IT Introduction ............................................................................................................................. 8

IT Analysis .................................................................................................................................... 8

Personal Health Records - Requirements ................................................................................ 8

Data ......................................................................................................................................... 9

Security and Privacy .............................................................................................................. 10

API .......................................................................................................................................... 12

Services .................................................................................................................................. 13

IT Impact .................................................................................................................................... 14

5 Google Health's Impact on Users .......................................................................................... 15

User Introduction ...................................................................................................................... 15

User Analysis ............................................................................................................................. 15

User Background ................................................................................................................... 15

User Study Observations ....................................................................................................... 15

User Study Findings/Recommendations ............................................................................... 21

User Impact ............................................................................................................................... 22

6 Google Health's Impact on Clinicians .................................................................................... 23

Clinician Introduction ................................................................................................................ 23

Clinician Analysis ....................................................................................................................... 23

Google in a Clinical Environment........................................................................................... 23

7 Conclusion ............................................................................................................................. 25

8 Appendix A - Four Types of PHRs .......................................................................................... 28

Paper Based ........................................................................................................................... 28

Computer Based .................................................................................................................... 28

Internet Based ....................................................................................................................... 28


Portable Storage Based ......................................................................................................... 29

9 Appendix B – Google Flu Trends ............................................................................................ 29


1 Introduction Google is widely regarded as the world’s most successful Internet company and entered

the Healthcare market in 2006, when it began work on Google Health. Google brings its

strengths in ease of use, simplicity, organization, availability, and no cost philosophy to

the Personal Health Record (PHR) market. In May 2008, Google released Google Health

as a beta product to its users.

Google Health is currently one of many third-party providers that have entered the

Internet based PHR market place, and faces competition from companies such as

Microsoft and WebMD.

The full impact of Google Health is yet to be seen, as the product is still in its infancy but

the potential impact can have far reaching implications to patients, healthcare providers,

healthcare payers and government.

2 PHR Background

A Personal Health Record (PHR) is any device that allows users to store medical

information and history about themselves. This can be as simple as a file folder that

holds handwritten information and copies of prescriptions, to a more elaborate PHR

system that can include decision-support capabilities which can assist patients in

managing chronic conditions. There are 4 basic types of PHRs, paper based, computer

based, Internet based and portable storage based. Each type is differentiated by its

storage and communication method. (See Appendix A)

This broad definition has been transformed to a more modern version, and is now

commonly defined as an electronic application through which individuals are able to

access, manage, and share their health information, and that of others for whom they are

authorized, in a private, secure, and confidential environment.1 However, this should not

be confused with an Electronic Health Record (EHR). An EHR is an electronic version

of a patient’s medical record kept by doctors and hospitals. The data in the EHR are

controlled by and intended for use by medical providers.

The Center for Information Technology Leadership (CITL) estimated that widely adopted

use of personal health records could save the U.S. health care system more than $19

billion annually after expenses, with an initial start up cost of $3.7 billion and will

provide PHRs to 80% of the population.2 Comparatively, the cost to implement a

1 Paul C. Tang, Joan S. Ash, David W. Bates, J. Marc Overhage, and Daniel Z. Sands, (2006)

Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption,

Retrieved March 1, 2009 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1447551 2 David C. Kaelber, MD, PhD, Sapna Shah, MS, Adam Vincent, MPP, Eric Pan MD, MSc, Julie M.

Hook, MA, MPH, Doug Johnston, MTS, David W. Bates, MD, MSc, Blackford Middleton, MD, MPH,

MSc (2008) The Value of Personal Health Records, Retrieved March 1, 2009,

http://www.citl.org/_pdf/CITL_PHR_Report.pdf


nationwide EHR system is estimated by Rand Health at $28 billion per year during a ten-

year deployment and $16 billion per year thereafter with a potential fifteen year

cumulative savings of $142-$371 billion.3 If we extrapolate fifteen year costs versus

savings, PHR has a cost of $33.7 billion versus a savings of $315 billion and EHR has a

cost of $360 billion versus savings of $142-$371 billion.

Currently, less than 11% (2007) of American hospitals have fully implemented EHR

systems4, with 83% (2008) of American physicians still using paper based records

5. This

makes access to health information difficult. By establishing their own PHR, patients can

put often missing information directly in to their clinicians hands. This plays an important

role in helping to bridge an information gap that exists between patients and the health

professionals that serve them.6

By creating and managing a PHR, patients ensure that health care providers have the

most current and accurate information with which to provide proper care. A PHR

improves the quality of care received and reduces the number of unnecessary tests and

procedures at different providers, which ultimately reduces costs.

A PHR should contain information provided directly by the patient (or caregiver) as well

as information provided by healthcare professionals, such as clinicians, pharmacists, and

therapists. More prominent information you may expect to record in a PHR include: 7

Name and birth date

A list of emergency contacts

Contact information for all healthcare providers, such as your family’s dentist and

medical specialists

Health insurance information

Living wills, advance directives or medical power of attorney

Organ donor status

Dated list of significant illnesses, hospitalizations and surgical procedures

A list of your current medications and dosages

Dated list of immunizations for patient and patient’s family members

Lab test results

Plan for managing diseases/conditions over time

3 Richard Hillestad, James Bigeiow, Anthony Bower, Federico Girosi,

Robin Meiii, Richard Scoviile, and Roger Tayior (2005) Can Electronic Medical Record Systems

Transform Health Care? Potential Health Benefits, Savings, And Costs, Retrieved on March 1, 2009,

http://www.eecs.harvard.edu/cs199r/readings/RAND_benefits.pdf page 12 4 TIMOTHY F. KIRN, 2007, EMR adoption faces hurdles of time, cost, Retrieved on March 1,

2009, http://findarticles.com/p/articles/mi_hb4365/is_17_40/ai_n29397700?tag=content;col1 5 MARY ELLEN SCHNEIDER, (2008), Only 4% of physicians have comprehensive EHRs,

Retrieved on March 1, 2009,

http://findarticles.com/p/articles/mi_hb4393/is_9_39/ai_n29463244?tag=content;col1 6 Markle Foundation, (2004), CONNECTING AMERICANS TO THEIR HEALTHCARE,

Retrieved on March 1, 2009, http://www.connectingforhealth.org/resources/wg_eis_final_report_0704.pdf 7 American Heart Association, What should my PHR contain?, Retrieved on March 1, 2009,

http://www.americanheart.org/presenter.jhtml?identifier=3056166


A record of key health statistics like weight, blood pressure, cholesterol, glucose,

etc.

Allergies or sensitivities to drugs or materials such as latex

Important health and family events, dates and medical conditions in the patient’s

family history

Summaries of medical office visits

Specialists’ medical opinions

Vision, eye and dental records

Correspondence, such as letters and e-mails, between the patient and their

provider(s)

Educational materials or sources, relating to the patient’s health

Spiritual affiliation and considerations affecting the patient’s care

Lifestyle factors such as exercise, diet, supplements/herbal medications that the

patient takes and any counseling the patient may receive

A PHR can reduce medical errors, assist family members or others who may need to

make medical decisions on behalf of another family member. PHRs can also empower

users to:8

have educated discussions about their health with healthcare providers

securely share individual health information with someone who needs it, such as a

new caregiver

manage the health information of family members

effectively manage chronic disease(s)

better coordinate care with your various health care providers to improve

efficiency, quality and safety of the care received

access health information while traveling, or during events like a natural disaster

or another emergency situation

retrieve health information instantly and securely 24 hours a day

measure progress towards specific personal health goals

maintain healthcare providers’ instructions, summaries of medical visits, allergy

information, and status of insurance claims

track prescription medication dosages, instructions, and actual usage

track appointments, vaccinations and other wellness healthcare services

Personal Health Record Architecture In the Internet-based PHR industry, there are currently four emerging architecture types.

This can range from one provided by your insurer, to one that is fully integrated with

regional data sources with each type representing a different estimated savings as

indicated by the CITL.9

8 American Heart Association, Benefits of a PHR, Retrieved on March 1, 2009,

http://www.americanheart.org/presenter.jhtml?identifier=3056159 9

Chris Dimick, (2008), A Cost-Benefit Model for PHRs, Retrieved on March 1, 2009,

http://www.citl.org/news/2008%20ahima_PHR.pdf


Provider-tethered PHRs are tied to a healthcare organization’s internal record system.

This type of PHR architecture has an estimated annual savings to the healthcare industry

of $13 billion.

Payer-tethered systems are tied to a given payer’s system and this type of architecture has

an estimated annual savings to the healthcare industry of $14 billion.

Third-party PHRs are used by consumers to aggregate data from different, independent

sources. This type of PHR architecture can lead to great cost savings as user's are relied

on to enter information from all their care providers. This architecture has an estimated

annual savings to the healthcare industry of $16 billion.

Interoperable PHRs represents the future, with the ability to connect to and download

data from all regional data sources such as EHRs and other PHRs via standards-based

automated data exchange. This infrastructure leads to a record that is more complete than

any non-integrated repository. This architecture has the greatest estimated annual savings

to the healthcare industry of $21 billion.

It is important to know how Google Health is architected, so that one can better

understand how to interact with it, what niche it is trying to fill, and what users of the

system expect. Google Health currently falls between the third-party PHR and the

interoperable PHR. Currently, Google Health has limited ability to exchange data with

regional data sources, however, as more care providers, and payers integrate in to Google

Health, and the more standards-based automated data exchange is used, the more it will

move toward the interoperable model.

3 Google Health

Google Health provides 4 primary benefits to users including gathering, organizing,

informing, and communicating an individual’s medical information.

Currently, users of Google Health can:10

Build online health profiles

Users can enter health conditions, medications, allergies, and lab results into their

Google Health profile and they can name the profile anything they want. They can

even create multiple profiles for family members or others they care for.

Import medical records from hospitals and pharmacies

Users can choose from a list of Google Health partners to see if their hospitals or

pharmacies can send copies of their medical records or prescriptions to their

10

Google Health, (2009), About Google Health, Retrieved on March 11, 2009,

http://www.google.com/intl/en-US/health/about/index.html


Google Health profile. This way, they can save an accurate history of medical

conditions, medications, and test results all in one place.

Learn about health issues and find helpful resources

Users can review trusted information on diseases and conditions and learn about

possible medication interactions and other topics to talk to their doctors about.

Search for doctors and hospitals

Users can search for a doctor's name or location, find a doctor's website, get

directions to a doctor's office, and save a doctor's information to their medical

contacts list.

Connect to online health services

Users can browse the online health services directory to find services that are

integrated with Google Health that can help to better manage their health needs.

Currently, Google Health is a limited PHR product still in beta development. As Google

continues to develop this product, this product will add features, capabilities, and

ultimately improve the health care received by its users.

4 Google Health's Impact on IT

IT Introduction

During that past 6 months, Chad Hodge has had the opportunity to not only research

Google Health (as well as Microsoft Health), but has also had the opportunity to actually

implement this technology for a large reference lab system. The work done on this was to

enable PHR functionality for physicians who use the reference lab. Under HIPAA,

patients have a right to get a copy of the data that a company has about them. This

solution solved those issues for the company Chad was working with. From an IT

perspective, Chad provides vital knowledge of the PHR space and shares key points of

the knowledge gained during his implementation.

IT Analysis

Personal Health Records - Requirements

Google Health has several faces that a user can interact with. A technologist can do one

of two things; either be a data provider and send data into the Google Health system, or

be a service provider and utilize the data that it already has in its system. Both are equally

as important to the end-user of Google Health. Services cannot operate without data, and

data is not useful without services.


Data

To be a data provider to Google Health, there are several facts to know. First, understand

the data format and data elements that Google chooses to store in its system.

Technologists should be aware if the type of data they want to provide is not covered

under what Google Health is tracking. Google Health bases its data structure on the

Continuity of Care Record (CCR) format, but just a small subset of the overall standard.

The CCR format is a basic XML format, which allows for sections that describe each

aspect of a patient’s medical record. Specifically, Google Health supports the following

major sections:

Actors — which describe the medical professional who provided the care.

Patient — which describes the person receiving the care.

Descriptors about a patients care history — sections include functional

status, problems, social history, alerts (similar to allergies), medications,

immunizations, vital signs, results, and procedures.11

Each of the high level sections has more detail to it than can be listed here, but it is

important to note that the supporting detail fields of each of these sections accept coded

item data types. For example, if the healthcare provider sends in results of a patient’s

laboratory test, Google Health can handle it in one of several ways. First, the provider can

use free text to describe the test performed, or the provider can use one of the supported

coding types; in this case: LOINC, SNOMED, and CPT. Below is the list of all the

standard coding types that Google accepts for each major section:

Medications: RxNorm, NDC, FDB

Conditions and symptoms: SNOMEDCT, ICD9, FDB

Procedures: CPT, SNOMEDCT

Allergies: SNOMEDCT

Immunizations: CPT

Lab test: LOINC, CPT, SNOMED10

The implication of this is that it is very easy to send your data to Google Health using the

CCR format no matter what coding system you use. It is also likely that a technologist

may need to create a custom CCR data translator in order to be compliant with Google

Health’s own brand of CCR since it only uses a subset of the larger CCR format.

Once a data provider or service provider has access to Google Health there are strict rules

for how a provider can use the data. Each user of Google Health must give explicit

permission to any service to use or upload data on their behalf. Once access is given to

the provider, trust is extended to all aspects of the user’s data. That is to say that a

11

Google, Google Health Data API CCR Reference, Retrieved February 23, 2009.

http://code.google.com/apis/health/ccrg_reference.html#ccrgreference


technologist has access to all pieces of data that are in Google Health for that particular

user. Realizing the magnitude of this, Google Health has some requirements that must be

met in order to use their system. Some of the highlights include:

Explaining to the user up front how the service plans to use the data

Allowing the user to permanently delete any of their data you may have from the

system.

Allowing the user to break the link with the provider13

Google Health not only allows for you to link up with services that provide you data for

your profile, it also allows you to manually enter in data about yourself. Not just the

standard demographic or allergy information that you would expect, but it also allows

you to enter procedures and tests, along with their results. If you forward your medical

profile to another physician, how is he suppose to trust the data he is looking at if the user

can just add his own data whenever he wants? In essence, data sent by a service is

digitally signed, and allows it to be distinguished from manually entered data. If digitally

signed data is edited, the signature will be broken and will appear to be the same as

manually entered data.

Another item of interest is that Google Health does not allow users or technologists to

attach documents to a profile at the time this was written. This means that the user cannot

attach scans of records that a doctor has digitized, nor can the user add results from blood

work that is generated exclusively in PDF format, or even embed X-rays or other

radiological artifacts. Instead Google Health is expecting actual discrete values from all

results or procedures. Even then if the user does send Google Health discreet data, it pays

no attention to data format. Fixed width font results lose their format, which is what

makes them intelligible. According to the discussion boards Google is fixing this feature,

but it is obvious that their data model was not meant to support labs, or digitized paper

records.

What is nice about having Google Health manage the data is that it is no longer up to

each individual physician, or group. This insulates them from worries about data

corruption, or loss due to theft or fire. It is also convenient that they not only manage the

data, but that they also manage the security around the data.

Security and Privacy

Security in Google Health is accomplished with explicit access granted to each party one-

by-one according to the user. Once a user creates a Google Health profile, the only data

they can show in their profile is the data they enter by hand, unless they seek out data and

service providers. Once a user finds a data provider, say a pharmacy order feed, they

must explicitly give that feed access to their account. Once that link is established, the

pharmacy order feed can begin to send data to that profile until the user manually breaks

that link or until that user sets an expiration date for that data feed.


The initial request that the user makes to link to a data provider generates what Google

Health calls a short-lived token. That token can be used exactly one time, and then

expires. This one-time-use token is used by the data provider as a key to create a new

key that Google calls a long-lived token. That token will last as long as the user does not

deactivate the token by breaking the connection to that provider, or until the user sets

expiration on how long they want to receive data from that provider.

Once the provider has this long-lived token, they can begin sending data to a patient’s

profile immediately. All data that is sent to a profile must be digitally signed with an X-

509 certificate. This type of certificate has both a public and a private portion. The

private portion is kept by the data provider and they use it to digitally sign all the data it

sends to Google Health. They send the public portion to Google Health at the time it

registers its domain and service with Google. Then Google Health uses the public

portion to verify that the data was signed correctly, and not by some unauthorized person

trying to impersonate the data provider.

The data signed with the certificate also has a checksum created. This checksum is a sort

of digital trip-wire. If the data is edited anytime after Google Health receives it, the

checksum will not match, and the user will know that the data is not the original. This is

how Google is able to know the difference between authentic data sent to them by a data

provider, and the data that a user adds by hand to their own profile. Users cannot

digitally sign their data, and edited data loses its checksum.

Google Health also enforces security by requiring providers to register with them. Both

data and service providers must register with Google Health. When doing so, they give

them their public portion of the X-509 certificate as listed above, but Google Health also

requires service providers to register their domain which must be on a secure socket

protocol. Google Health uses this for redirection after linking to the user profile, as well

as establishing a connection on the backend to send or receive data from the profile. The

use of a secure socket protocol simply means that your web address is protected by a

SSL, and that all data sent back and forth on that channel is encrypted.

Another security aspect that Google Health, or any electronic PHR, provides is audit logs.

Users have the ability to see all the activity that has occurred on their account. Users can

see when they link to providers, the times and dates that they connected with the profile,

as well as all the user’s access to an individual account, in the case of a custodial setup.

Audit logs are explicitly required by HIPAA. However, because Google is not the

originator of medical data, and is considered a third-party, they are not required to

comply with HIPAA regulations.

One of the most common user concerns about security is unintended access to one’s data

on the public internet. People want to know if their data will show up on Google

searches, or by some other means. The specific concern is whether their data will show

up on the internet where their employers and insurance providers can view their personal

information. People fear discrimination and denial for employment due to past drug

issues, or denial for coverage because of pre-existing conditions or other indicators that


might suggest it will be expensive to insure that person. This is such a large concern that

Google itself has posed and answered that very question on their FAQ section, as noted

here:

“Will my employer or health insurance provider be able to see my Google

Health profile? You are in control of who views your Google Health profile. Remember, Google

will never sell your health information, and we will not share it with others unless

you explicitly authorize us to do so, or in the limited circumstances described in

the Google privacy policy, such as when we are required to do so by law.”

Overall, the security that Google provides for health data is commensurate with what one

would expect and what is considered reasonable. The security and data that Google

Health provides are of little value if there is no easy way for developers to utilize or

create services around this information. After all, Google does not generate or feed data

into Google Health as it stands. It depends wholly upon others to do that for them. That is

accomplished with the use of an Application Programming Interface (API).

API

An API is the set of functionality that developers can use to create new services around

existing platforms or programs; without it, no one could add new functionality other than

the original author, Google.

Google Health has an API in two languages: java and .NET. They both do the same

thing, just with different syntax. The API that Google provides for the .NET developers

has been unreliable at times, but overall is sufficient to perform the work necessary.

Because most all Google products are in a constant state of beta, their API’s change

frequently, often times breaking completely. Google Health queries the community and

finds out that their system completely overlooked some key piece of functionality, or is

not implementing some specific logic in the appropriate way, and they will change it.

This change requires the developers to download the new API, and find out if it broke

any of their existing code, and if so rewrite that piece. It is very troublesome for a

developer to have this happen to them frequently, which happens often with Google

Health.

Because the provided API for Google Health is specialized to a group’s own brand of

health profile, you cannot develop or test your software in isolation. Developers instead

need to use the sandbox that Google created for developers called H9. This sandbox is

simply a way to test out interactions and post and consume data in the way a user would

once the customized version of the program goes live, but without affecting anything in

their production environment. Developers are required to show their application work in

the sandbox before Google Health allows them to push the new application to the

production system.


With any sort of API, or programming language for that matter, one must be aware of

possible errors. In Google Health’s case, they will only ever throw one of three general

errors including:

Feed is empty

403 (unauthorized)

"Invalid Usage, Sharing denied: unregistered provider" Error

Finally, when one begins using any API, developers need to know where they can go for

help. Google Health does a fine job of making support information available. They have

a section setup that helps developers get started in the process. This section provides

developers code samples, links to download latest binaries, access to whitepapers, videos

to explain their vision of the product and more.12

Google Health provides a link to allow

a developer submit issues or new features into a queue, along with a discussion forum for

developers that allows them to ask questions and see solutions to problems they may be

facing. 13,14

Now that we understand what makes Google Health work, specifically the data, security,

and API, we can look at the services that companies and developers have actually

created.

Services

At the time this was written, Google Health did not provide any intrinsic services itself. It

simply aggregates data for others to use as the base for their services. The primary value

that a PHR offers is the ability to make an entire medical record portable, so

users/patients can take it with them to new doctors, or get second opinions quickly

without duplicating tests. This is a core feature to any PHR, and it is surprising that

Google Health does not offer that natively; instead users need to link up with a service

provider that offers that specific services.

As an example, sharing or copying medical records is a service that many companies

offer based on data in Google Health. There are some services that send records to

proprietary systems, such as ePocrates, but there are also more universal solutions such as

NoMoreClipBoard.com, and MyMedicalRecord.com, which are made for the masses.

There is even one service approved by the AMA, and which receives data from the

FDA.15

Clearly users have several choices.

12

Google, Google Health Data API, Retrieved February 23, 2009.

http://code.google.com/apis/health/ 13

Google, Google Health Developers, Retrieved February 19, 2009.

http://groups.google.com/group/googlehealthdevelopers 14

Google, Issues, Retrieved February 19, 2009.

http://code.google.com/p/gdata-issues/issues/list 15

Google, Google Health: copy and share your records, Retrieved March 3, 2009.

https://www.google.com/health/directory?cat=copyandsharerecords


There are services that take paper records, and translate them into electronic versions for

Google Health. That seems to be one of the more useful services for doctors thinking

about converting their records, or for patients who already have a paper copy of their

record and who want to join the system.

The largest service category found on Google Health is wellness centers. These are

services that read Google Health profiles, and then tailor their site to offer users pertinent

information about their health. These sites offer things like recommended checkup

schedules based on age or condition, how to understand some recent procedure the user

had, or ways to prevent or improve conditions.

The most obvious service that appears to be missing is that of simple analytics on top of

the Google Health data. Google itself is an authority on analytics, and this venue seems

ideal to do that again, yet there is nothing like that on Google Health. Perhaps they are in

development, or are hoping a service provider will develop this feature.

Google Health is clearly in its infancy, but has a lot of promise. Hopefully with a large

name player like Google getting into the game, PHRs will become more visible and more

popular. Many may benefit from the conveniences and savings expected from the PHR

(Google Health) model.

IT Impact It is clear that the introduction of third part PHR services such as what Google Health

offers, will impact not only the medical community, but also the patient’s involvement in

their own health affairs. With the amount of medical information at the patient’s

fingertip that Google Health offers, it is clear that patients will begin asking for, and

expect, this level of service from all their future physicians. This of course lays a burden

on those physicians.

To begin with, the physician will likely need to be on an electronic system in order to

even participate in this sort of system in a meaningful way. Once physicians meet this

requisite, they will need to convert their EMR data into the CCR format that Google

Health expects. CCR is a relatively new format that is analogous to HL7, and it is

gaining traction as a standard. Having a large player such as Google adopt that standard

shifts more importance to that format, and that effect cannot be discounted. There will of

course be hardware requirements as well, though the physician will likely use the existing

hardware their EMR is running on. Even so, processes in the office will need to change

in order to accommodate this new data point.

Perhaps at the conclusion of the exam, the patient can ask the office staff to release their

records to Google Health. There will also be the possibility that a new patient will ask to

have their records sent to the practice for their first visit. This requires a different set of

processes, as well as software to support that request. Keeping patient’s data will also

require data backup and retention policies, as well as ensure HIPAA compliance by

providing a log of users who have viewed a patient’s data. The amount of technological


skills needed at the physician office level is continually increasing. Hopefully, the benefit

to both parties will justify the added burden.

5 Google Health's Impact on Users

User Introduction As many individuals get older, health care gets progressively harder to track. Not to

mention, if these elderly individuals can’t keep track of their own health care, they need a

designated caretaker to keep track of it for them. They need to track information

including medications, health care visits at the doctor’s office and at the emergency

room, their health history information, medications, conditions, medical contacts, and

much more. In this user study Jennifer Linton was able to collect real data gathered from

a regularly seen scenario where a child (Jennifer’s mother) is the care taker for her

elderly parents and needs a way to log health information for future use.

The user study analyzes the current features of Google Health and identifies benefits and

potential improvements and opportunities for the tool from a user’s perspective. It

identifies the caretaker’s requirements for what information they need to track and the

expectations that the physician usually requires that a caretaker bring to the health care

visits, treatments, and emergencies.

User Analysis

User Background

To begin, we set up separate accounts for Harvey and Doreen. Harvey, who is 90 years

old, has a long history of depression and digestive issues and Doreen, 87 years old, has

dementia. They live together in an elderly care facility in an apartment and the caretakers

at the facility issue their daily medications and provide therapy. Kim, their daughter,

helps out on a weekly basis to provide transportation and knowledge for doctor’s visits,

finances, appointments, and shopping trips. She also assumed the role as power of

attorney for both Harvey and Doreen. When we began the user study, she brought her 4

three-ring binders that contained the medical history for Harvey and Doreen. There was

some organization to these binders, but it is a significant amount of unstructured

information to have to sift through if needed in a medical environment (i.e., emergency

room, doctor’s visit). Not only was it unstructured, it seemed burdensome to have to

carry around all of this information from place to place with the potential risk of the

records being destroyed.

User Study Observations

Kim began the user study by accessing the Google Health home page, which

conveniently presents a link to take a quick tour of the features available in the system.


As Kim skimmed through the tour, she began to mention some of the requirements she

would like to see in the tool. For example, she said, “I would like to compare the cost of

different medicines.” She also observed that, “Users of this system have to obviously be

somewhat computer literate,” hence the reason why she is recording and monitoring this

information rather than her parents.

She perused the features and then promptly logged on to begin transferring her

information from the binders into the Google Health system. She initially clicked on the

link Add to this Google Health profile, which sent her to a tabbed page where the first

tab allows the user to enter in conditions. She typed into the search box “Depression” and

selected the option “Depression” from the list that auto-populates. At first she didn’t

know what to do next, so she spent some time to click various links in the interface and

finally discovered that if she pressed the +Add button an item appeared in the right hand

side of the screen with a link to More info >> next to it. She clicked on the More info >>

link and it provided information about the symptoms, treatment, causes, test & diagnosis,

prognosis, prevention, complications, and when to contact a doctor. She was impressed

with this information, but navigated back to Google Health with the intention of reading

more about the condition at a later date.

Figure 1: Enter Conditions or Symptoms Screen

She then picked up each one of the 4 ring binders flipping through them all to find the

next piece of information she wanted to enter. She eventually found what she was

looking for, but it took a significant amount of time. She clicked on the link for

Medications in the left hand navigation next. She entered in the first of Harvey’s

medications and she commented, “Is there any way to identify and record the dosage and

instructions for the medication? … Where are you supposed to enter this information?”

She continued to enter the information into the same text field where she typed the name

of the medication. She added the dosage, strength, and frequency in the medication name

field because she didn’t know where else to put it, but did want to record this information

as it is vital to report to clinicians. She then quickly found that if you click on the

Medications link on the right hand side of the screen (the section title where the


medications are listed), she found that she could edit the details for the medication

including the dosage, strength, frequency, start date, end date, status, and any additional

notes.

Figure 2: Edit Medication Details Screen

Once Kim found the ability to edit the details, she found that there were nice usability

features available. Some of these features include the drop down selection menus to

indicate “How to take”, the dosage, and the frequency in which Harvey should take the

medication. She also liked the notes field. She noticed, in fact, that the dosage provided

only the options available for each independent type of medication. One feature that she

would like to have is the ability to edit the medication name. She found that after she

entered a medication name incorrectly, there was no way to revise the name without

having to delete the medication and start a new entry.

When she finished listing each medication for Harvey, including aspirin, Colace,

GlycoLax, Lexapro, and megastrol acetate, she commented that she appreciated the way

Google Health alphabetized the list of medications, and that the list provided “more info”

links to each medication providing additional information about each medication. Kim

decided then to move to the next curiosity of Google Health, that being, the Drug

interactions link in the left hand navigation. After clicking on the link, she noticed that

there were none listed for Harvey. She thought that it would be very helpful if Google

Health would flag or highlight the Drug interactions link to provide a visual indicator to

the user showing that drug interactions exist rather than the user having to actively click

the link to make sure there were no drug interactions. As a side note, Google Health does

in fact provide a visual indicator to the user if there are drug interactions.


Figure 3: Medication List Screen

Next, Kim decided to populate the profile details for Harvey’s Google Health PHR. She

effortlessly entered the Date of Birth, Sex, Race/Ethnicity, and Weight (as of the last

measurement). She did not know his Blood type, but intends to fill that in at a later time.

One suggested feature from Kim, as a user, is to provide a way to enter new weights after

each doctor’s visit and then be able to somehow graph the weight gain and loss

differences. She believes this is important information to communicate back to the

clinical personnel from one visit to the next.

Figure 4: Profile Details Screen

At this point, Kim continued filling out the conditions by clicking on the Conditions link

in the left hand navigation. She first tried to look up “digestion” but this was not listed as

a known disease. So, she instead typed it into the search box and added it to the list of

conditions list found on the right hand side of the screen by pressing the Enter key on the

keyboard. She also added Parkinson’s Disease, Cataract, and balance as other conditions

into Harvey’s current health issues list. For the Parkinson’s Disease record, Kim added

personal history notes and when she clicked the Save button, she mentioned that she

liked how Google Health formatted the notes so that you could easily see them under

each diagnosis. She then selected the Add record link in the Parkinson’s Disease section

and added another piece of information recording a more recent doctor visit.


Figure 5: Edit Condition Details Screens

When adding the record for balance, she noted that the need to use the calendar function

each time she had to enter the Start Date and End Date was not helpful. She wished she

could just type in the date or have the option to select it from the calendar. She also said

another possible improvement would be to structure the notes into multiple sections to

record the physician’s diagnosis and another to record the recommended treatment plan

for quicker look up rather than having to read through the notes each time to decipher the

treatment plan. She also observed that there was a column to indicate the name for the

“Treated by” healthcare provider, but there was nowhere to actually enter this

information into the condition details window.

Once she finished entering the conditions, she decided to enter the Medical contacts by

clicking on the Medical contacts link in the left hand navigation. She was able to add all

pertinent contact information except for the web site for which she would have liked to

have a separate section. She added the web site to the address area instead. She

mentioned that she liked the ability to click on the link for a map and that it took her to

Google Maps, but she was more interested in just seeing the location of the doctor rather

than having to enter more information to get directions.

Figure 6: Medical Contacts Screen

Other sections that Kim visited included the Import Medical Records link where she

observed that she could find resources to Import Medical Records, Explore medications

and treatments, Convert paper records, News and personalized content, and Copy and

share your records. She had no need to utilize these features at this time, but she did say


that she planned on setting up a Walgreens (one of the Google Health partners) account

to more easily monitor and order medications for Harvey through Google Health.

Features in which Kim vested some interest included the ability to create a new profile

that would contain some of the same information but maybe not as much as the extensive

profile she populated for Harvey’s personal reference. She thought it would be nice to use

the original profile as a template that could link directly to a new profile but with the

ability to hide and show the information needed for each specific profile. For example, if

she created a physician specific profile or an external family member specific profile, she

could display or hide content based on what she already entered but only for each specific

role.

She also thought it would be beneficial to create links and share profiles between

different individuals. For example, if a user wanted to keep track of their history using

information entered in other generations of family profiles. Then, they could keep track

of these pieces of pertinent information (i.e., cancer, Parkinson’s disease, dementia, etc.)

without having to enter this information in to their own profile separately.

Kim also tested the ability to create a PHR summary output from the information she

entered in the Google Health PHR. She said it is helpful to have a wallet sized card

indicating the Medications and Conditions for Harvey.

Figure 7: Example of the User’s Wallet-sized Card

She also printed out the full summary for Harvey which she thought would be useful in

the future to print out before each doctor’s visit.


Figure 8: Example of the User’s Full Summary Print Out

User Study Findings/Recommendations

The following features pertain to usability capabilities that the user liked:

drop down selection menus for medications to indicate “How to take,” the dosage,

and frequency

notes fields in the medication details and condition details

alphabetized medications list for easy reference

formatted the notes in the conditions and medications sections to easily see them

under each diagnosis

liked the ability to click on the link for a map to each medical contact’s office

location

ability to create a new profile

The following suggestions pertain to features the user would like to have available:

compare the cost of different medicines

edit the medication name after it has been entered

provide a way to enter new weights after each doctor’s visit and then be able to

somehow graph the weight differences


the need to use the calendar function each time she had to enter the Start Date and

End Date was not helpful

structure the notes in the conditions section into multiple sections to record the

physician’s diagnosis and another to record the recommended treatment plan for

quicker look up rather than having to read through the notes each time to decipher

the treatment plan

there was a column to indicate the name for the “Treated by” healthcare provider,

but there was nowhere to actually enter this information into the condition details

window

separate section in the medical contacts to add the web site for each contact

ability to create a new profile that links to an existing profile

create links and share profiles between different individuals

User Impact

Overall, the user found the ability to record all of this information in one single location

very helpful. However, she also believes it would take additional time to transfer the

information she receives from the doctor’s visits into the system rather than just saving

the paper copies of her notes in the binder. There is a significant change management

initiative/opportunity to make sure people use the electronic PHR system and not revert

back to storing their reference materials in three-ring binders.

As mentioned in the introduction, there are a number of items a PHR system should

provide to a user. Google Health does provide the majority of these capabilities.

However, there are some areas where Google Health can improve. For example, there

aren’t locations for recording health insurance information, living wills, and advance

directives or medial power of attorney. It does not have a location to store a user’s organ

donor status, medical images (i.e., PDF scan from doctor’s visits, or graphics or

radiologic images). Google Health could also provide spots to link family medical

histories, and include vision, eye, and dental records.

Also mentioned previously are a number of benefits users may identify with when using a

PHR. As of now, Google Health meets these needs on a low scale basis and is taking the

right step to help users become more educated and take ownership in keeping track of

their own health. Kim appreciated the opportunity to educate herself about specific

information regarding Harvey’s conditions and medications. And, she likes the ability to

have everything in one location to bring to the doctor. It helps to keep her more

organized.

Some users do feel a bit overwhelmed at this newfound responsibility of keeping track of

their personal information and they do have legitimate concerns about the privacy and

use of their electronic personal data. Google Health tries to address some of these

concerns in their FAQ.


For example, some concerns that individuals have regarding Google Health include,

whether Google Health protects the privacy of the health information, if any employer or

health insurance provider would be able to see Google Health profiles, and if Google

Health data is used for other Google products such as their search engine. Each of these

valid concerns is addressed in the FAQ16

. To summarize, they keep individual’s data

protected from outside parties unless the user want to share the information with these

people. They do not share the information unless the user authorizes them to do so. In

some litigation situations, Google may have the right to divulge information and this is

all describe in the Google privacy policy.

In response to the question, “How can Google Health help me,” Google Health provides

the best answer. “Google Health offers a single location to consolidate and store your

medical records and personal health information. Saving medical information in one

secure location helps you and your doctors have accurate and up-to-date information

about your health when you need it the most. This in turn means that your medical

treatments may be safer and more effective .You can also use Google Health to access a

host of online services and tools, from a variety of third-party companies, which can help

you better manage your care.”

6 Google Health's Impact on Clinicians

Clinician Introduction Google Health, in particular, does not have a great effect on clinicians as of date. More

and more clinician’s awareness continues to increase regarding PHRs. However, not

many have actually been provided access to patient’s accounts or seen patient

information printed from the Google Health system for clinical visits. The Google search

engine itself does provide an abundance of information that the clinicians utilize on a

regular basis and Nadine Lewis points out some of the key aspects that Google provides

to the clinical and healthcare environment. Eventually, Google could tie these pieces of

information into the Google Health tool to improve the system for clinicians and

education about public health.

Clinician Analysis

Google in a Clinical Environment

Google PHR will contribute to providing the clinician with valuable information in

preventing medical errors such as issuing medications which may have negative reaction

with currently issued medications. This is a medical error which can cause serious health

problems.

16

http://www.google.com/intl/en-US/health/faq.html


Google Health PHR may also decrease medical errors and prevent potential litigation

situations against MD’s since the Google Health PHR is in a readable, user friendly and

understandable format. Quite often physicians written orders and written prescriptions

are difficult for nursing, pharmacists, and other clinicians to read which increase chances

of errors. Google Health will reassure clinicians that correct orders are being carried out.

Google Health PHR will improve quality of clinical care since medical records, history,

medication records, allergy records, and lab records will be easily accessible. In addition

to improving quality of care Google Health PHR will empower patient with having

accurate knowledge of their own health status. For example, patients will be informed

regarding personal health issues and able to obtain valuable information on managing

such chronic health problems. Patient will have medication information at their

fingertips to be knowledgeable regarding adverse reactions and contraindications.

Likewise, a patient will be empowered having access to Physician databases which

include name, location, specialties, and doctor’s websites. High Profile health care

providers such as companies listed below are strong supporters of Google Health.

The Cleveland Clinic

Beth Israel Deaconess Medical Center

Longs Drug Stores

Walgreens Pharmacy

RX America

Quest Diagnostics

Many patients and providers have suggested that the introduction of information

technology can disrupt workflow and interfere with the patient and doctor dialogue.

However, many health records provide summary reports and print capabilities.

Therefore, patients and providers can use information to engage patients as collaborative

partners in their healthcare…

.During the 2007-2008 flu season, an early version of Google Flu Trends was used to

share results each week with the Epidemiology and Prevention Branch of the Influenza

Division at CDC. Each of the nine surveillance regions of the US, we were able to

accurately estimate current flu levels one to two weeks faster that published CDC reports.


This graph shows five years of query-based flu estimates for the Mid-Atlantic region of

the United States, compared against influenza surveillance data provided by CDC's U.S.

Influenza Sentinel Provider Surveillance Network. As you can see, estimates based on

Google search queries about flu are very closely matched to a flu activity indicator used

by CDC. Of course, past performance is no guarantee of future results. Our system is still

very experimental, so anything is possible, but we're hoping to see similar correlations in

the coming year.

7 Conclusion

In 2003, The Personal Health Working Group defined 7 attributes that a PHR system

should include.17

Each person has control of his or her own PHR. Individuals decide which parts of

their PHR can be accessed, by whom and for how long.

A PHR should contain information from one’s entire lifetime.

A PHR should contain information from healthcare providers.

A PHR should be accessible from any place at any time

A PHR should be private and secure

Information should be “transparent.” Individuals can see who entered each piece

of data, where it was transferred from and who has viewed it.

A PHR should permit each exchange of information with other health information

systems and health professionals.

Although currently limited in some aspects, Google Health does attempt to meet all 7

attributes for individual users and as features improve over time. As more and more

healthcare providers look to integrate in to Google Health, Google Health has the

potential to control a large portion of the internet PHR market.

As previously mentioned, Google Health is not the only large player in the internet PHR

market, but having Google Health in this product space, gives it more legitimacy,

competition, awareness and viability, than if Google was not a part of this market.

Currently, Google health has not heavily impacted the healthcare industry from a

technical or user perspective. However, as Google Health adds users to this product, we

can only guess what the potential impacts might be.

From a technical perspective, Google’s choice to use the newer, lighter weight standard

of CCR, instead of the more bulky HL7 may lead to a wider adoption of CCR. It also

places a bigger burden on provider adoption. The US care providers that are looking to

connect in to Google Health must use the CCR standard.

17

Markle Foundation, (2004), CONNECTING AMERICANS TO THEIR HEALTHCARE,

Retrieved on March 1, 2009, http://www.connectingforhealth.org/resources/wg_eis_final_report_0704.pdf

page 27


Google’s participation in the PHR market may also put additional pressures on providers

and hospitals to provide their patients who use Google Health access to download their

medical records. This in return may also speed up the digitization of care providers, as

they must be sufficiently digital in order to be able to upload patient information in to

patient’s PHRs. Providers may also need to provide the information in a different format

so that patients can easily understand the information presented.

Google Health also has the potential to alter the process where care providers handle

information. If patients are expecting their file to be updated in 24 hours, care providers,

must modify their internal and technical processes in order to meet these demands.

Ultimately, all these technical benefits should benefit Google Health users.

Currently, from a user’s perspective, Google Health is still limited, as the functionality it

provides, is not fully developed or explored. However, the potential benefits are great.

Google Health gives its users the ability to record their health information in one single

location accessible from anywhere in the world as well as allow them to share and

download information from their care providers. The greatest benefit Google Health can

provide is allowing patients to be more educated about their health as well as take

ownership in keeping track of their own health and records. It can empower and

encourage users to be more active in their medical care. Google Health also may have

the inadvertent benefit of increasing user’s internet and computer skills.

However, some Google Health users do have concerns that may need to be addressed.

Some users may feel overwhelmed, as our case study showed with this new found

responsibility of keeping track of their own health information, as it is not a responsibility

patients have had before. Users also have great concerns about privacy, and the use of

their electronic personal information.

Security and privacy are concerns many PHR users will have, and currently HIPAA

legislation does not apply to 3rd

Party PHRs, as they are not involved in the model of

patient care. Perhaps, this will lead to legislation changes to include 3rd

party PHRs.

Google in their privacy policy18

indicate that Google will only use user information in an

aggregate form in order to protect their users and will not release any identifiable

information with the user’s permission.

Google Health also has the potential to be one of the largest sources of patient health

information on earth and the impact of this is great. Recently, Google released its flu

tracking data showing that they were accurately able to determine flu activity across the

country two weeks before the CDC (centers for disease control)19

. This has the potential

to allow public health teams to react quickly and warn people about outbreaks to help

reduce the spread. If we expand this data analysis capability to the potential data that

Google Health could contain, the benefits to healthcare are immense, as you would be

able to study “live” data and not study data that may be several weeks or months old.

18

Google, 2009, retrieved on March 1, 2009, http://www.google.com/privacypolicy.html 19

http://www.google.org/flutrends/


In addition to all these benefits, Google health (along with other PHRs) has the ability to

provide $21 billion in cost savings. However there are obstacles to this savings. A 2008

study by Manhatten Research estimates only seven million Americans have accessed

PHRs20

, and 2003 census data shows, only 50 percent of households had internet access.

With these barriers, it will be difficult to achieve 80% usage. However, achieving 40%

usage is quite realistic, and if that can result in $10 billion in annual savings, it is still

extremely attractive in terms of a return on investment aspect.

As discussed, the potential impact of Google Health to healthcare is important to the

healthcare industry. Google Health can impact which data structure format becomes

more popular, and potentially become the single largest source of personal health

information, allowing researches access to “live” data. Use of Google Health as well as

other PHRs can empower users on their own health, resulting in better care, and

significant cost savings to the healthcare industry. The potential impact is too great to

ignore and the healthcare industry should be looking at expediting the use of PHRs for

the betterment of the healthcare industry.

20

Jon Hoeksma, 2009, Study finds US PHR use remains low, Retrieved on March 1, 2009,

http://www.ehealtheurope.net/News/4487/study_finds_us_phr_use_remains_low


8 Appendix A - Four Types of PHRs

A Personal Health Record (PHR) is broadly defined as any device that allows users to

store medical information and history about themselves. There are 4 basic types of PHRs

currently available, paper based, computer based, Internet based and portable storage

based. Each has their benefits and drawbacks. Types of PHR include:

Paper Based

Paper based PHRs have been in long before computers were invented. Paper based PHR

is any personal medical information that is printed on paper such as appointment

schedules, as well as copies of prescriptions, test results, clinical notes, and medical

histories. These can be handwritten or printed from any electronic PHR.

Paper based PHRs are the lowest cost as expensive computer equipment does not need to

be purchased, and they are accessible without a computer or electricity. However, they

can be difficult to share, and are susceptible to being miss placed, and damaged.

If you forget to bring your paper, information is not accessible

Computer Based

Computer based PHRs is any personal health information that is stored on a computer. It

can be as basic as a text document or a more sophisticated software application that

allows you to enter information in an easy to use format, which also downloads test

results, and provides encryption and user access restrictions. Computer based PHRs can

also allow for printing on paper, or copy to other electronic formats such as email,

CD/DVD, and personal storage device.

However Computer based PHRs are also susceptible to being hacked or lost due to failing

equipment, unauthorized access due to hacking or virus. It is also susceptible to user

error such as deleting the file.

Information is only accessible if printed, copied to Internet, or stored on a personal

storage device.

Internet Based

Internet based PHRs are any Personal Health information that is stored on a remote server

with the key benefit of being accessible via Internet. They may also have the ability to

print, back up, import and share information.

However, Internet based PHRs can be susceptible to physical damage to the server,

bankruptcy, unauthorized access via the Internet or other data connections.


Portable Storage Based

Portable storage based PHRs are any personal health information stored in portable

electronic format such as CD/DVD, USB memory card, smart card, or even Mobile

devices.

Often the information on these devices can be uploaded or downloaded from an Internet

based PHR, or can be printed as paper.

This type of PHR is susceptible to loss of the device, must have compatible hardware to

access the information, as well as a compatible software viewing application. There is

currently no standard to how information is stored in a portable storage device, so some

providers may not be able to view the information stored here.

If you forget to bring your device, information is not accessible

9 Appendix B – Google Flu Trends

As published by Miguel Heleft, in November 2008, In San Francisco there is a new

common symptom of the flu. A lot of ailing Americans enter their flu symptoms into

Google and other search engines before they call their doctors.

That simple task multiplied across millions of computers around the country, has

given early warning systems for fast spreading flu outbreaks, called Google Trends.

Tests of the new web tool from Google.org suggests that it is very possible to detect

outbreaks of the flu a week to 10 days before they are reported to by the Centers for

Disease Control and Prevention. For example, in February the C.D.C reported increasing

flu cases in Mid Atlantic states. Google.org analyzed those searches creating graphs and

maps which will predict where the flu is spreading.

There are reasons why the CDC’s reports are slower because they rely on data

collected from thousands of labs, and health care providers. Health experts are predicting

that Google data could help accelerate the response of the flu season and reducing the

spread of disease and potentially saving lives.

Presently, the service only covers the United States, but Google is hoping to use

the same procedures and techniques to track influenza and other diseases worldwide.

http://www.nytimes.com/2008/11/12/technology/internet/12flu.html

http://www.nytimes.com/2008/11/12/technology/internet/12flu.html

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