Open Source, Open Licensing, P2P Production in Healthcare

Building the Nexthealth application, I'm having to continuously fight the urge to pull back brutally on the reins of altruism.

Users will sign up, login, and be prompted through a 4-step healthcare decision making process using visuals Maarten den Braber and I developed when trying to describe the evolution of Health 2.0.

The site will have zero ads. We won't charge users a subscription fee. We've committed to making this a free-range, public good, and that type of business model is still VERY unique, particularly in healthcare tech.

Because we're committed to making Nexthealth an open-source, easily customizable tool for individuals and communities struggling with healthcare decision-making, we're giving away the code.

Why are we doing this for free?

This isn't the first app the Nexthealth crew will build. In fact, it's just the introductory handshake. We're already working on a business plan for the next thing. So in essence, building the Nexthealth app and releasing it is building the ultimate business card. It says who we are and what we're capable of producing, with very limited time and resources.

Some more info from our FAQs about releasing the code:

Code - Fried or Broiled: We're actually giving you the code for the Nexthealth tool 2 ways. First, you can use the code open-source, delinked from the database our web guru has designed. Or, you can choose to use the code that's 'connected' to the values linked to our mySQL database on the back end - choose option number 1 to use the graph arbitrarily, or paste it over your own database - choose option number 2 to use the graph with functionality just like that on the Nexthealth site (data from the database populates the graph, so what we're really saying is you can copy and paste our values and options or lift the graph and insert your own).

Open API Means Have it Your Way: Build a bar graph, a line chart, a pie chart. The database we've developed can be modified to display your data values in multiple visualizations (especially useful for team logins and public health research applications).


But Nexthealth isn't the only group to milk the power of creative collaboration to create a 'public good.'

Although still a rare bird, peer-2-peer production for NFP output is not entirely new to healthcare.

Exhibit A: The Open Source Prosthetics Project.

The project is "an open source collaboration between users, designers and funders with the goal of making our creations available for anyone to use and build upon. Our hope is to use this and our complementary sites to create a core group of lead users and to speed up and amplify the impact of their innovations in the industry."

Here's the wiki for the project; sign up to volunteer here.

The Open Source Prosthetics Project is an initiative of the Shared Design Alliance. There's a good overview of how shared design contributes to industry advancements (especially in tech) here.

For a more general overview of peer governance in collaborative software communities, as well as other great P2P resources, check out the P2P Foundation here..

If you're interested in open-source healthcare, I'll be posting additional examples and Nexthealth info in the next few weeks. Stick around. Collaborative health innovation is the only way to reach warp speed before we self-destruct.

What's Next After Health 2.0: Content+Community Online?

Bloggers' Note:

This is just a primer to get the cerebral juices flowing on this subject.

Hands down the best discussions about where things are moving will happen at Health 2.0 (in case any Health Management Rx readers don't use Twitter, full disclosure: I'm helping Matthew and Indu manage speakers and volunteers for this event). Matthew Holt will give far more interesting and complex thoughts on the subject, along with an all-star lineup of firms figuring this out during DBAs.

This post is the result of some incendiary conversations that occurred yesterday as I was hanging out with the HealthCentral crowd in Arlington, Va, learning how they manage 35 online communities covering areas of consumer interest ranging from sexual health to ADHD (full disclosure: I write about health, policy, and politics for HealthCentral).

Managing the flow of health-related information, both subjective (user posts) and objective (news links, etc). is an amazingly complex job. The backend content management system that runs this thing is a behemoth.

I don't know why I found discovering the sheer computational muscle that runs the HC works surprising - lets chalk it up to lack of sleep after some crazy Nexthealth design days and nights.

I'm not usually so slow in making these connections, but I also don't usually do this type of synthesis-storming alone - the Nexthealth hive is an excellent supportive group where many of us work together to connect the dots...I don't like going solo.

If the Nexthealth crew was hashing this out over wine, cookies, and whiteboard scribblings, we might describe it this way: If Health 1.0 was content online, and Health 2.0 is content+community online, then what we're looking at with long-tail firms like HealthCentral is an organization similar to libraries with a bunch of book groups...some information, or value, is composed by expert authors and the rest is user or community generated.

But online, the proportions of who generates the majority of content, and thus who defines the 'value' of information, is flip-flopping. And therein arises the credibility of sources issue that has Health 2.0 execs beating their heads against the wall trying to solve.

It's a simpler issue than most of us think - more of the tools, companies, and content we design must allow users to bring subjective values to bear. The tools themselves MUST be objective. Neutral. Search terms shouldn't be the only way to judge 'value' or 'credibility' of information.

Why? Because the subjectivity of healthcare decisions is infinite, variable, and thus indefinable.

Or, I should say, it has been. It's like we're trying to make the evolutionary leap from single-celled to mammalian life without interim stages.

We need to be gathering more data about NOT what healthcare consumers are searching for, or who they're talking to, but what they're trying to USE our tools to DO...what decisions are being driven by online health content? online health communities?

Content is great. Community is fantastic. Commerce, which happens online in Health 2.0 and offline via care in the 'real world', is even better. But we need coherence between all of these for consumers' actual choices and decisions to be impacted. Why?

Because the health content and communities we're pasting up all over the cloud don't actually exist in a vacuum.

How do consumers USE this content? What do/buy decisions do we make as a result of participating in online health communities? A prime example - I might be a DiabetesMine user and buy a new pump after reading about it on Amy's site.

Ok, so, if Amy's site has the coherence factor down, then I don't have to leave that online interaction to buy the thing, unless I CHOOSE to do so...I should have access to that healthcare good online or offline, and the choice to buy at either point according to my preferences and values.

And as a healthcare consumer, it's impossible for anyone else to define how my preferences and values impact my do/buy decisions.

But it is NOT impossible for them to provide tools that help me clarify how I make do/buy decisions in health using Health 2.0 content+community companies. Nexthealth is working on one that we'll release as a public good very soon (we'll even give you the code so you can modify it to be more relevant to your healthcare planning at the 'point of service'). And it's this type of data gathering that should have Health 2.0 companies lifting up the couch cushions digging for coins.

Without knowing how consumers value our services based on THEIR end game, what they want out of wellness, what's next for THEIR individual health, we can't build companies that provide anything of value.

It's no coincidence that the majority of Health 2.0 firms are living on VC vapor, or ad revenues. Freemium models come the closest to helping health consumers reach the end game; they're providing an application, a decision support tool like those SugarStats offers to people living with diabetes.

Again, the system isn't providing people with these tools; it's users, recognizing what's next for them and building an offering that lets them articulate and discuss value to make decisions for health, who are changing the system.

An i for an i model is changing healthcare ("i" need/want this, so "i" will build it and then "you" and "we" can use it) now, but we'll start to see more "i" to "you" built for "us" models. We are most definitely still building out the long tail, which has to happen before we can get to semantic interoperability (dipping in and out of healthcare buying online and offline).

Again, complete semantic interoperability for health means consumers should be able to access healthcare goods and services, online and offline, at will.

We need companies built around data-gathering and ear to door functions that let us hear what consumers want, and what decisions they're trying to make with all our wonderful "Expedias of Health 2.0."

It's no coincidence that you can still build a B2B and B2C software applications company that solves a niche need for people and make millions of dollars. Applications help people DO stuff with what they learn and what they're talking about, based on what they want to accomplish.

What does your Health 2.0 site/service help users accomplish? Where is the "do/buy" intersection? How many clicks does it take me to get there? You damn well better be able to answer a question this simple, in less than 15 seconds. Otherwise, what value IS it you're providing?

But let's go back to where Health 2.0 is right now for a hot second....how can we possibly define a singular health content and community site or service has value for every user at any given point in time?

The answer is simple: We can't.

We have to let THEM tell US what they find valuable in making healthcare decisions - what kind of information? What kinds of people? How do they want to pay? WHAT moves them to the make/do/buy decision point for health?

This means massive amounts of data, and also increased data transparency and transference.

But here's another problem with Health 2.0 companies; we're still feeling verrry proprietary about our users' data and our customer bases, as well we should.

But it is possible to anonymize data, and then explain to consumers in a passionate, engaged manner, why they should consider allowing your firm to release some randomized information for public health research purposes. 23andme is doing this sort of thing already; in essence consumer-direct genetics companies are the first giving us the option to make our genome 'open source.'

But they're still giving us bits and pieces, right?

They're not literally copying and pasting our entire individual genome into a Google doc and letting us share it, compose Wordles from our chromosomes, or lock it up in a vault and throw away the key. It's like getting a hard film copy of our X-rays and having to tote that around - it's literally a disconnected snapshot of one part of our body where something is wrong. We don't have any way to connect that back to our larger wellness picture.

The trick here is for companies to build machines, tools, interfaces, services, and goods that let us just use the hell out of them, however we want, when we want. This means we should be able to access them on our phones. In our homes. In our cars. At stores. At banks. On our laptops. Go mobile. Go web-based. Then build an interesting brick and mortar access point.

Think of the banking industry, which is a tired metaphor for where healthcare is going but will be even more applicable in the next 2-3 years.

Via online banking, physical banking locations, and ATMs, we can access our bank accounts any which way we choose. It's completely up to us, the consumers.

And here's the beauty - I don't have to look at my bank balance the same way every time. If I'm on the road, I make a phone call. If I'm online, I chat and check via the bank's web interface. If I'm traveling and need cash, which I hate to carry, I sniff out an ATM.

Again, the CHOICE is up to me, the consumer, and the really interesting part is that I make that DECISION based not on my 'knowledge' of the financial industry, or my level of education or banking literacy.

I just know I need money, and I need to know how much money I have. Why do we assume it will be any different for consumers of health goods/services once we make data and tools to access it available to them in brain dead simple interfaces, both online and offline?

Look. We trust people to elect a President. To pay taxes. To go to school. To buy a car. To buy or rent a house. To take care of kids. To enlist in the military. To pick a college, or a job, which impacts your earning power, lifestyle, and all manner of complex interconnected factors.

In Africa, despite disease, poverty, and war, cell phones are a booming industry. I may not have indoor plumbing, but I can text someone. We're making all the wrong assumptions about consumers and healthcare, health information, just like we used to do regarding technology.

Can you imagine what would have happened in the consumer electronics industry if Steve Jobs had seen a prototype of the iPod and said, "um, nope, that's not how users listen to music now. We'll pass." The end goal there: consumers will be able to access music and movies, online and offline, at will. We'll build the online piece.

So why don't we trust consumers to make choices in healthcare? They don't all have to be super-consumers; most will not be...go back to the 10-80-10 rule. Most, the Middle 80, will use these services on a limited basis. Some people check their bank balance every day; some check it when they pay bills, some never check it and get into trouble.

If we can't check our healthcare data out when and where we want, and get as little or as much complex info about it as we want, we're all going to be bouncing checks with our health.

To Health 2.0 companies - build the tools. Make em sweet. Make em simple. At Nexthealth we're all about figuring out ways to do that; connecting people online and offline. The decision-support model we'll release is just a handshake- our way of introducing ourselves and getting involved in an ongoing conversation.

Health 3.0 and 4.0 companies will let us do this with our healthcare information. Check out the backend EHR built by Myca for Jay Parkinson's Hello Health...that baby is absolute beauty in pure software form.

So the tools we design from here on out have to be objective, neutral, and allow each user to access them, harness them to make decisions for health and wellness that have PERSONAL relevance, in real time. So, when and where they need to make a decision.

How do we drive population-based healthcare change? Start at the grassroots level, with each individual. Teach each consumer that they have healthcare choices to make. It's that simple, and that blindingly complex. For instance, people my age, and those with open minds (thanks Jacqueline!) are more likely to search for health information online, and much more likely to use online social networking sites. So who's building health decision-support apps that call to the Guitar Hero Healthcare generation? So far, only sites like I'm Too Young for This, etc.


Here's the problem, still, with online health content: In libraries, newspapers, etc. the vast majority of the content was 'expert' generated - authors who go through an academic or 'traditional' publishing process, etc. - they've passed the barriers to entry. Sure, a bit of library and academic content was generated by rank amateurs, but it was much more difficult to gain entry into that rarified atmosphere.

Online health content sites remove many of those barriers to entry. Health 2.0 sites (content+community) break down the walls even more - community members act as peer experts. The rise of the amateur, or here comes everybody according to Clay Shirky.

Libraries needed their Dewey Decimal system for years, and online repositories of content are still struggling over 'logical' organization and creating ever-evolving ways for users to get our hands on the information we need.

Bill Allman and I talked about my helping out with some content management or filling more of a community manager role...after touring the software, and then spending some time in the community pages, guess which one I picked?

In essence, I find it very difficult to remain interested in/invested in business models in the Health 2.0 world that continue to populate the evolving landscape with older barriers to entry.

Everything I'm investing in now breaks those barriers down. I don't want to be an 'expert' writer, or journalist. I don't want to spend time uploading expert content. I want to be exactly what I am; an e-patient. A blogger. A speaker liaison for Health 2.0. A policy op-ed writer for HealthCentral. A Nexthealth initiator, co-founder, and firestarter.

This is the reason we're building the Nexthealth model open-source. Why we'll release the API as a public good. Blow barriers to entry right to bits.

I'm not going to say anything foolish or arrogant like this thing will raise the bar for Health 2.0 firms. It's not even about raising the bar. Instead it's about creating tools that lower the bar, get closer to the ground, where the people are...we don't need more pie in the sky killer apps no one actually uses...we need to build things that get closer to what people want and need, when they want and need to make a decision.

The problem is the gulf that exists between where we are now: Health 2.0, content+community, and where people and companies like Virgin Health are trying to go - incentivizing behaviors so consumers make healthier choices, which saves us money and the system time and resources.

But here's the kicker: You can't incentivize how consumers make healthier decisions if you don't have a consumer-centric system that gathers a hell of a lot of data about how consumers are using your content and community to make decisions. To buy things. To do things. What great hubris to believe we can convince people to do things differently and take responsibility for their own health when we repeatedly lock them out of making choices in the system.

To get from here to there, people have to be able to take that wonderful health content and those wonderful friends they met in health 2.0 social networks and USE THEM TO MAKE DECISIONS.

How will consumers ACT based on the health information they're finding online? WHO will they go see in the real world based on recommendations they gained online?

And once you can figure this out, how to motivate consumers to move to the do/buy stage, THEN we'll start seeing viable, revenue-producing business models for Health 2.0 firms.

Note to the larger Health 2.0 community - banner ads suck. I don't want to look at them. If you alienate me with your ads, I leave your wonderful site. Those things don't tell me what I want. They don't offer things I want to buy. I'm more likely to click on a link for a product from someone I follow on Twitter. If you slam me with ads, I think you lack credibility. Take a harder look at where you're putting your ads and how often you're putting them in my face. Ok. Rant over.

In addition to "how do I make money" we need to be asking ourselves the following about our user bases....

How do they figure out how to navigate in a system that does its best to dictate care?

How do we build and support a consumer-centric system, where the patient realizes "hey, I'm smack dab in the middle of this tangled web, and I've got a hell of a lot of choices to make that 1. I don't understand yet and 2. didn't even know I had the ability to choose."

But oh. Once we can choose to buy health goods and services, online and offline, lookout.

I'll wrap up this break from Nexthealth work with a final question every Health 2.0 firm should be able to answer: How are you helping healthcare consumers (and who are your consumers? patients? docs?) figure out what's next?

And by the way, if you're a poor broke student, analyst, or startup entrepreneur, leave a comment or get in touch - we're looking for 20 more Health 2.0 volunteers (free admission to panels, demos, and events).

Healthcare for the "Middle 80"

“Head for where the puck is headed, not where it is...” - Hugh McLeod

“I think the internet could revolutionize health care just like it has revolutionized the music industry, the travel industry, and the newspaper industry. And with all due respect to this beautiful shrine of a Newseum, those industries got run over by the clue train instead of jumping onto it.”
- e-patient Dave (Center for Information Therapy's 7th Annual
Wired Conference, June 12-13, 2008 @ the Newseum, Washington, DC)

“You say you want a revolution, well.....you ask me for a contribution, well, we all do what we can...” - The Beatles

Ain't this America...

It's 10:22 am on a sunny Saturday morning.

My baby sister and her husband stand outside greeting a new neighbor. My sister is 38 weeks pregnant with their first child, my niece. The new neighbor just got out of nursing school, recently finished her OB/GYN rotation. She wants to be an L&D nurse.

My sister's house in Blacksburg, VA, is part of a unique green development for working-class families. My sister, her husband, the new neighbors – they are the “Middle 80.”

And our current healthcare delivery system is failing to seize new opportunities to communicate with them.

They are the part of the pie American economy presidential candidates salivate over, the part of the American economy aware of outsourcing to the Pacific Rim, engaged in green behaviors if they want to be, banking online, trying to make a living in an economy taking a head dive.

The Middle 80; our new lower, hard-working, sometimes college-educated, lifestyle oriented middle class. And more than half of them think our next Commander In Chief should make HIT a top priority.

They read and write poetry, watch DVDs on friend's laptops, choose not to have a microwave, attend wine tastings at local shops on Fridays, and last night hosted a campfire-party for 50 to bon voyage church friends moving to Richmond, complete with bay-blue and white pennants and coordinated wrapped plasticware.

The Middle 80 is, far more than we give them credit for, resourceful.

My sister created “We'll Miss You” penants from green, blue and cream calico fabric after she didn't find any to her liking. When likeable solutions are not presented in the marketplace, the Middle 80 craft them from bits of knowledge gained via experience and the references of friends, family, and yes, neighbors.

I've written before about the 10-80-10 rule in healthcare, where 10 percent of consumers will be unwilling/unable to be engaged, participatory partners in care, 10 percent of consumers will be 'hyperhealth' hyperengaged, tech savvy, and all over Health 2.0 services like white on rice.

And then there's the Middle 80.

When I translated the 10-80-10 rule from sales to healthcare, there wasn't much hard supporting evidence that the same percentages would hold true for consumer behavior in healthcare. Turns out, consumers are consumers.

Lately though, there's been some pretty substantial research to support it; Susannah Fox of the Pew Internet and American Life Research project reported more than 80% of the American public uses the web for healthcare related search (and Google uses that study to sell health advertising here).

And the Kaiser Permanente study hyperlinked here and above tells us 65% have gone online to get information about a medical condition. 73% think the benefits of being able to access healthcare records online outweigh privacy risks.

And that study is a year old. Think of how the world has changed in a year. Think of how the healthcare delivery system has not.

Let's look for a moment at how American healthcare is missing the boat for the Middle 80, like my sister, and what she chose to do about it.

Memorial day weekend. My sister and cousin were traveling back to Virginia from Southern Maryland.

A curve, a wobble, and the van carrying my baby sister, her baby, and my baby cousin flipped to the right side. After admittance and constant monitoring, all were released from the hospital with clean bills of health, except for one little thing; my future niece was now in breech presentation.

Her doc suggested a c-section and put it on the OR schedule for June 18^{th -} 39 weeks.

We're bustling around the house getting ready for the day, headed to Wal-Mart to pick up groceries and cook up a freezer-full of food for the first weeks after the baby is born. My sister's alto voice is strong as she tells me the latest chapter in her personal health narrative. She is determined to convey how and why she chose to become a proactive participant in her care.

My sister: “I had never asked them why they scheduled it for 39 weeks rather than 40 weeks.”

Many more patients than we believe, even those who trust their physicians, literally, with their lives, are scared.

Scared of what may happen, yes, but also scared to ask questions of care-providers.

When she learned she was pregnant, my sister read quite a bit about natural childbirth, explored homebirthing options, accounts by midwives, doulas, etc. when she learned she was pregnant. However, she'd read almost nothing about cesarean sections.

My sister does not own a television. She does not own a microwave. She does not have a computer or internet access at home, which is why I'm sitting in Bollo's coffee shop in downtown Blacksburg, sipping a skinny mocha, typing this story.

But my baby sister – she wasn't satisfied with not knowing why her doc had scheduled the c-section for 39 weeks. She wasn't satisfied with not knowing the risks. She wasn't satisfied with feeling scared.

So what did she do about it? What just about anyone in their 20s does now. She went online.

She used the computer at work to search for information on Google using the search terms: “c-section,” “when should I have a c-section,” “external version” “how should I flip my baby.”

Based on what she read online, after asking her doc if this particular potential solution was appropriate, she went to the gym and laid upside down on the incline bench with her butt higher than her head for 10 minutes. She stopped when she got dizzy, and felt “embarrassed and discouraged.”

I asked my sister why she looked online for this information. Her response? “Fear.”

My sister: “My perception of what happens if you're not willing to educate yourself is that the doctors will make decisions for you and it'll happen. They'll just tell you that this is the way it's gonna be and that'll happen. I felt safe, don't get me wrong. I felt like I would have been taken care of and that they would have made healthy decisions for me, but maybe not my optimal decision.”

My sister's OB does 5-10 versions a year. 3-4% of babies have some kind of breech presentation. 65% of external versions are successful at around 37 weeks (Blogger's note: Revised after original posting; if I've still got this wrong please let me know in the comments). About 4% of originally successful external versions fail -the baby flips back around. Sometimes this is natural – the stubborn babies don't want to turn, some can't due to neuro-muscular defects.

Question to my sister: “Why didn't you ask your doc or schedule an appointment to talk about your fear first?”

Even though she trusts her physician absolutely to do what's best for herself and her baby, my sister said she went online due to a variety of complicated, interrelated factors including time and a desire to learn for herself what options were available, and hear what other moms thought. “I can tell he's rushed. I feel like he's always been frank with me, has not sugarcoated anything.”

For instance, early in her pregnancy, she prepared a list of questions. One of the first she asked her doc: “What do you see as the risks and benefits of natural childbirth?”

His response: "First let me tell you about my experience with pain. People experience pain differently. Some women can come in at 2cm and are writhing on the table, and some women come in at 8cms and think they're having indigestion.

I think it's really sad when I see a woman dead-set on natural childbirth and she's in pain, or the labor doesn't progress, or the baby goes into distress and she requires an epidural or a C-section (or other intervention) and “it ruins the birthing experience.” They lose the focus of the miracle that their baby is being born."

"On the other hand, women come in planning to have an epidural and it's the middle of the night and they're waiting on the anesthesiologist, or you get it and it's not effective, again, the focus is taken away from the miracle that's happening."

Me: “This was a great answer."

My sister: "More than the risk and benefits of natural childbirth, I think he was speaking more to the mindset of either, the experience.”

She's the part of the consumer healthcare experience no one thinks is happening, but it's out there happening, 80 percent of the time. At least.

I'm wondering how she and her doc have managed to fit so much conversation and cooperation in determining her optimal care plan into 2-4 minute windows. Me: “How long are these visits with your doc?”

My sister: “There have been visits that have been half an hour long, there have been 5 minute visits. It depends on whether or not I have questions. I have to be prepared to make the visit that long. They're not gonna stay in there. Why would they? They have a whole waiting room full of people.”

“When I was at the hospital and he was flipping the baby, he also had 3 ladies in labor, two dilated at 9cms and 1 pushing, and he was still responsible for taking calls at the hospital.”

Literally and figuratively, docs have their hands full. And they're not getting paid to juggle the optimization of care for every patient who wishes to participate.

Our payment and incentivization system is turning docs into mechanics, but we're not giving them the tools they need to keep us running at the levels we want. It's like an experienced, certified, knowledgeable mechanic being confronted with a next-generation hybrid car, and trying to fix the thing's engine with the only tool she's got - a sledgehammer.

The Middle 80 percent of today's medical consumers are the hybrids, and the bulky, imprecise tools we're giving our docs to operate with are the sledgehammers.

This is the other part of the 'consumer' experience in medicine we're all forgetting. Patients aren't the only consumers in the coming “consumer-centric” system. Physicians are consumers of goods and services that increase their ability to treat patients efficiently and empathically, or they would be if better options were out there.

But that's a blog post for another time; let's go back to the 'patients as consumers' thing for a bit.

Part of the problem with the current state of consumer-centric care is that we have problems accepting that simplifying offerings for patients doesn't necessarily mean creating products for the “lowest common denominator” as one Center for Information Therapy's Wired attendee put it yesterday morning during a roundtable discussion.

In one sense, it doesn't matter that the average health literacy level is the equivalent of a 5^th grade reading level. Though the average reading level in the US as whole hovers around a shameful 8^th grade level, this hasn't stopped our economy from moving past the industrial age, to the service age, and finally to a knowledge and innovation economy, driven by supply and demand market forces. US healthcare, however, is still stuck in the 'industrial age' model of care delivery.

The “industrial age” approach to healthcare assumes that the same model will work for everyone in the Middle 80. And you know what they say about assuming.

This completely misses microsegmentation which has swept the global consumer economy. If we aimed for the “lowest common denominator,” we'd aim all offerings at the lower 10 percent, and miss the Middle 80 entirely, both here and abroad.

But in many ways, we already are missing them.

EMR and PHR platforms marketed today are consumer-centric, proprietary, closed-end systems that are bulky, clumsy, and slow-moving. Several tech and web players have semi-decent models, but their organizations lack the coherence needed to make confluent applications palatable to the Middle 80.

When this coherence factor arrives, it will herald the arrival of 'nexthealth' (remember from this post that nexthealth = content + community + commerce + coherence, when healthcare consumers, all of them, can 'dip' online and offline for access to healthcare/wellness goods and services).

An application (or 20) that meet the Middle 80 where we live, play, work, love has yet to arrive, but it's on its way. It'll be here sooner than you think.

Someday soon this post will seem unusually prescient. It's not.

All it predicts is that some few healthcare and HIT entrepreneurs are aiming where the puck is going, and this approach will bear fruit. They will succeed in changing how patients and physicians, two underrated, underrepresented healthcare consumer segments, view healthcare planning and delivery, as both an art and a business.

The Middle 80 is out there, actively searching for 'what's next.' The question is, are you building some part of it for them, or will you watch, bewildered, as the evolution of consumer-centric care passes you by?

Startup in a Hospital - the Transcript

Jen: Ok so Maarten den Braber and I are on the train, after a Nexthealth meeting on Wednesday, the fourth of June - it's 11:33, we're just about to arrive in Utrecht.

Jen: Um, we decided that when we present our paper on the semantic web sparking health 2.0 in Vegas - ah - since we're bootstrapping Nexthealth NL, we need to find a way to get into town and get involved in the healthcare scene there...so - we wanna do "Startup in a Hospital."

Jen: The idea is to stay in a hospital in Vegas for 3 or 4 days, before the conference, to find a hospital contact who'd be willing to let us videoblog from the room - and present possibly some portions of our talk, since what we're talking about is 'nexthealth.'

Jen: Kind of action items to get that going is to contact...Dorrit at InterimIC, see if she knows anybody in Vegas, email Paul Levy, to see if he knows any hospital executives out there, to put out an all post bulletin to our networks via LinkedIn and Twitter, to also talk to some of the docs and med students that we know in the blogosphere to try to find somebody in Vegas...

Jen: Again, we're thinking "Next Hospital," (nexthospital.com), "Startup in a Hospital" (startupinahospital.com), live videoblogging...if we had any kind of video capability on the train we would be doing this, but instead we're just hitting you with the really really low-tech option of an actual tape recorder. Thank you GE for our - circa 1985 recording of the birth of this startup. One of many to come.

Maarten: Startuphospital.com? So...
Jen: Startupinahospital.com?
Maarten: Startupinahospital?
Jen: Yeah...

Maarten: So we should ask - maybe for The Netherlands we should find a sponsor....we need to get our tech gear sponsored - so we'll need videophones, we'll need webcams, we'll need to be able to stream live from the hospital...for the conference...
Jen: Nokia, Apple...(laughs)

Maarten: We'll have to get the, uhm, oh! We'll, we'll try to pitch it to Vodafone. We'll ask Vodafone. They sponsored something at MoMo - we'll get them to sponsor videophone - so Startup in Hospitals...
Jen: Nokia, Vodafone, we're the bloggers you really wanted to meet but didn't have time to at MOMO 6 in Amsterdam, so we'll be in touch.
Maarten: Oh...
Jen: By the way, we need all this equipment in, umm, 4 weeks time because the International Conference on the Semantic Web is happening in Vegas from the 14th to the 17th of July, so, yeah, get back to us quick on this.

Maarten: Ahhh, what else do we need? What else do we need?
Jen: Branded scrubs!
Maarten: ?
Jen: Anybody want to sponsor us while we are videoblogging from our Startupinahospital.com? What are we calling it? Hospitalstartup.com? We should be wearing branded scrubs! With nexthealth.nl and our sponsors, so Vodafone, if you want to sponsor us, that would be really great and we'll wear scrubs...

Maarten: We'll call Scoble and get on Fastcompany.tv...
Jen: laughs.
Maarten: laughs!
Jen: Also, um Jason Calacanis (nice middle name) at Maholo, ah, yeah, we'll be calling you too, Andrew Hyde, Brad Feld at Foundry Group and TechStars, we'll be calling you guys. We're the people who keep annoying you with healthcare and entrepreneur startup slogans for VCwear.com...


Maarten: Hospitalwear.com, Hospitalstartupwear.com - we'll have to launch here, we'll have to launch our own version online!
Jen: Right so if you guys don't help us we'll compete with you.
Maarten: (laughing) - So...

****Train noise - conductor (in Dutch) - Maarten needs to transfer at this station - great flurry of activity ensues as we pack stuff away****.

Maarten: Yeah see you in Vegas. Next time I think in scrubs. Inside a hospital. Doing a startup. Maarten: Oh! We can get Madonna to sponsor also.
Jen: Celine Dion, the Luxor hotel, this list goes on and on.
Maarten: And, and, and we get a free room at the MGM Grand. If we're not comfortable enough.
Jen: Yeah and some high stakes chips, that, that would be really nice too...PS- we are crazy!



As if you needed our help in figuring that last part out...

Defining Health 2.0 - Debate Rages On

Call it Health 2.0, definition v2.0: A fresh round of chatter last week surrounding the semantic debate.

• Last week e-patient Dave asked the blogosphere to contribute definitions of Health 2.0.

• Dr. Ted Eytan kicked off an additional thread here.
  

• Lodewijk Bos of ICMCC in Holland has an excellent response here.
  

• Dr. Reece at MedInnovationBlog weighs in with his customary panache here.
  

While I've posted at length about portions of the topic before, formulating a response to Dave and Ted puts the broader puzzle pieces together - I'm reposting my response below.

Why the continued harping on Health 2.0?

My greatest fear is that continuing noise about cementing a single concrete definition will prevent early innovators from moving forward.

This is why much of my recent research, with co-collaborator Maarten den Braber and the neXthealth team here in Holland, is focused on the evolution of Health 2.0 towards the penultimate end-goal - completely realized consumer centric care that adds transactional value for companies, caregivers, and consumers.

Are we too enchanted with defining Health 2.0 to look ahead and refocus on what's most important, namely:

• What Health 2.0 allows us to do?
  
• Why it's necessary?
  
• Whom it allows us to involve?
  
• How it allows us to connect?
  
• When and where it provides new access points to a traditionally hierarchical, closed delivery system?
  

Do you agree that Health 2.0 is a transitional phase, a stop on the roadmap towards consumer-centric care, or do you think it's an endpoint where we've realized the full benefit of tossing patients, HIT, PHAs, and providers in the proverbial blender and hitting 'pulse'?

I'm worried we're holding our fingers on the button a bit too long.

Let's pour out the blended mix and see who likes the taste, then worry about refining the recipe.

As a result of our concern about roadblocks to implementation, Maarten and I begun work on a concrete model current providers will be able to use to plot the route to consumer-centric care.

After hashing out the concept in a paper last week, Maarten remarked: "If you can see it you can hit it, if you can hit it you can kill it."

We won't be able to 'see it' ladies and gents, much less 'kill it,' if we can't move from discussing to doing.

Below are my thoughts on how to get it done.

*************************************************************************************

Hi Dave -

Crossposted a portion of the response below over at Ted Eytan's blog...seems like the debate surrounding a universal Health 2.0 definition, like the EHR/PHR debacle, will hang around for awhile while early innovators and interrogators hash out the lexicon.

Then once we've dotted our i's and crossed our t's we'll need to reach out at a more systemic level and get implementors involved (then we'll see hospital execs attending Health 2.0 conferences) - one patient's voice can be powerful but the wisdom of crowds multiplies the effect and amplifies the volume.

So the vital question becomes not JUST how to define Health 2.0, but how to get innovators, interrogators, and implementors to all have a seat at the table and connect concepts, current service lines, and create future partnerships that offer maximum value on both the personal and population levels.

A group of us here in Holland are wrestling with the same conceptual questions.

After participating in the first Health 2.0 Unconference here in Holland in April, we've come up with the following tentative stab at defining not only the 2.0 portion, but the evolution towards complete consumer-centric care, which Maarten and I inelegantly define as a consumer being able to 'dip' in and out of the healthcare system (virtual AND brick and mortar) "at will."

"At will" means consumers who want to be active partners in care have the tools (provided by innovative entrepreneurial startups and offerings that connect virtual services and real-world systems) to help them do so...but we must also remember not all are capable/willing to become proactive partners in care.

Before we get into the definitions of Health 2.0, etc. and how the movement will help us arrive at consumer-centric care, we need to have realistic expectations of end-consumer engagement numbers - let's add a dose of pragmatism to our idealism.

Consumer engagement in healthcare will follow a sort of 10-80-10 rule (gross oversimplification but helps illustrate the point)...10 percent will be hyperengaged 'superpatients' and 'superproviders' who are early adopters. These people, including e-patients, medical bloggers, etc. (i.e. us) are already pushing the system towards the next phase by defining Health 2.0.

But another 10 percent of consumers are incapable (physically incapacitated)/unwilling (selectively incapacitated) to become primary, proactive, participatory partners in care.

That leaves the gulf in the middle for Health 2.0 to ignite - 80 percent or so of consumers who are waiting to see what value will be offered.

To get those middle 80 percent involved though, there are a few more progressive evolutionary stages we'll have to define and nurture.

At it’s simplest, Health 2.0 = content (what many have mentioned, Scott et. al.) and community (Amy Tenderich at DiabetesMine, etc).

The end goal, of course, is better, safer, consumer-centric care.

This can only be realized by combining currently disparate groups of initiatives, which can be loosely clustered according to 2 motivating factors: efficiency (quality, safety, transparency), and empathy (Jacqueline Fackeldey’s theory of “human-to-human” hotealthcare @ Fackeldey Finds, Dr. Reece’s “Human 2.0″ @ Med Innovation Blog).

If we use web-evolutionary terms to define the current position, then we can predict where Health 2.0, consumer-centric care - enabled by HIT but also ‘brick and mortar’ integration of wellness tech- will go…

*Health 1.0 (1C) = content

*Health 2.0 (2Cs) = content + community

*Health 3.0 (3Cs) = content + community + commerce (transactions that create value for both company and consumer)

*Health 4.0 (4Cs) = content + community + commerce + what we’re currently missing - coherence

Then we arrive, eventually (hopefully) at fully realized consumer centric care - something we're calling "neXthealth" (more info on this definition available).

At this phase, consumers (patients, providers, payors) can dip in and out of the system at will (online, offline, virtual and brick and mortar services).

In an ideal world, we’ll all come the realization, sooner or later, that consumers in the healthcare system are not just patients, not only providers, but ANYONE who generates, purchases, provides, recommends, or reviews healthcare and wellness goods, sites, and services.

We’re starting to see firms that realize Health 3.0 goals now - Organized Wisdom, Carol.com, SugarStats.com, American Well…but what they’re missing is the 4th C - coherence - a connection platform that bridges their services to other online and offline organizations in an 'open source' fashion.

Services and sites will begin to offer ways for consumers, probably patients and providers first, to connect current care delivery platforms (hospitals, retail clinics) and web-based services (physician chat, PHAs, online scheduling, etc).

More here…http://healthmgmtrx.blogspot.com/2008/04/defining-health-30-and-40.html

Also, for those interested, many of us are tweeting about Health 2.0, 3.0, etc. on Twitter.com - for interesting developments, blog posts, and links search and follow:

jenmccabegorman (Jen McCabe Gorman - Health Management Rx, neXthealth)
mdbraber (Maarten den Braber - neXthealth)
martijnhulst (Martijn Hulst - neXthealth)
shakingtree (Niels Schuddeboom - neXthealth)
fackeldeyfinds (Jacqueline Fackeldey - Fackeldey Finds, neXthealth)
Jeroen Kuipers (Building Better Care, neXthealth)
icmcc (Lodewijk Bos)
NCurse (Berci Mesko - ScienceRoll)
Marston (Marston - SugarStats.com)

And Dave, I'm hoping you'll be attending Health 2.0 in San Francisco in the fall?

Best -
JMG