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Health 2.0: Take a Lesson From the Web

by Wes Rishel  |  November 18, 2009  |  9 Comments

Believe it or not, this is about the Nationwide Health Information Network (NHIN) and maybe the Health Internet, whatever that turns out to be. But I’ll get back to that.

As discussed in Healthcare 2.0: Better Tweetment? I am on a mission to find concrete value propositions for Health 2.0. By this I mean not the “Wiffle Bat of hope” statements like “the Web changes everything” but the Louisville Slugger statements such as “modified primary care delivery models for self-pay professionals” or “Twittering from the operating room as a marketing tool.” Do I think that the hits that I identify will be the be the game changers? Of course not. Any day, in any park, the home runs may come from any batter.  But if we swing at every pitch, the odds of getting on base go down.

Let’s look at a home run from the Web. Did the Web revolutionize selling airline tickets? Well, for simple round trips and tours to major destinations it surely did. It is a simpler technology than the old one (calling a travel agent), more accessible and disintermediates some of the special knowledge of that agent. For complex itineraries, not so much. My company continues to use a major travel agency, that offers us its own version of Orbitz and offers real live people for the tricky bits.

What’s more, the Web experience didn’t revolutionize the entire travel industry. A great deal of the company to company and company to agency interchange is still enabled by computer-to-computer linkages among business application programs. Granted, the Internet helped with software compatibility but this was less the magic of new ways of dealing with consumers and more industry taking advantage of technologies originally driven by the consumer market.

Put it another way: woe be upon those who fail to aggressively improve their customer relationship through Web 2.0, but even more woe be on to those that think that they will sell boxcar lots of chemicals, oil drilling derricks or electronic subassemblies solely through consumer-friendly Web sites. More complex computer-to-computer interfaces are needed with a higher level of semantic interoperability than can be achieved by a person who is reading information from a screen and typing. Both accuracy and efficiency argue for getting people out of the loop.

We have the same issue with healthcare. We need to service both consumer engagement issues and the industrial-strength connections among healthcare providers, providers and other care delivery organizations. Better consumer engagement can profoundly impact people’s decisions on health maintenance and healthcare options, but the profound impacts depend on more than a social network and a snazzy Web experience. They depend on a long process of learning what actually changes behavior. To think otherwise is to ignore that the public had all the knowledge it needed to quit smoking thirty years ago.

We also need to connect the “industrial” healthcare organizations to those organizations and the agencies that are working to create transparency in quality and cost. Why, because we can avoid killing people in care transition. Every unnecessary death is precious, but talking only about deaths hides an equally important threat. By doing care transitions poorly and using 3 people to bill for every person who provides care we are denying care to many through the rationing that comes by limiting private and government coverage.

This is where the NHIN comes in. In the past it and health information exchanges (HIEs) have been focused on the “industrial” side, that is inter-HCO communications used in the course of giving care. We’ve had our share of Wiffle Bats in HIEs, but the 57 operational HIEs (according to eHI) and a number of self-sustaining HIEs show that it is possible to improve care transitions and even the gathering of quality data. The customer-facing channel (consumer engagement) was previously seen as the province of CDOs and PHRs. HIEs could be an enabler of interchange with the PHR but they were primarily about improving on the fax for gritty, back-room exchange of data.

The NHIN was seen to round off the edges of the HIE concept. It was to cover people who moved, overlapping catchment areas, and the providers and CDOs that operated where a local HIE was unlikely to occur and major organizations like the Veteran’s Health Administration and Kaiser that could not spare the resources to negotiate business and technology agreements with dozens or up to a hundred individual HIEs.

The NHIN also provided a work-around for the basic bug in U.S. healthcare IT: the lack of a singe person identifier.

Currently the NHIN work is on hold for a reevaluation of its direction and proposals abound for a Health Internet. Since the NHIN was designed to work over the Internet, what is different about the Health Internet? Apparently it is more consumer facing.

Consumer facing is good. It will achieve a measure of smarter use of healthcare and perhaps even smarter lifestyle choices. Reevaluation is good. There are plenty of opportunities to simplify the execution of the mission of the NHIN.

What would be bad would be to conflate the consumer-facing aspects of Web 2.0 and the “industrial” interchanges into a single solution that limited the “industrial interactions” to apply to those consumers that have proactively enabled it. We need to recognize that something akin to the HIPAA consent model is needed for some forms of information interchange.

We need to take the full lesson from the Web. It revolutionized consumer-facing business but is only a part of the solution for large-scale inter-business collaboration. We need to keep this distinction in mind during a reexamination of the NHIN. There is plenty of room to find a way to meet the NHIN mission better. The consumer-facing Web changes a lot in very important ways, but if we don’t recognize the rest of what healthcare needs we will face the possibility of reaching the year 2015 with the fax machine still being the primary interoperability technology among physicians and CDOs.

Category: healthcare-providers  interoperability  vertical-industries  

Tags: arra  health-20  health-it  healthcare-interoperability  healthcare-providers  nhin  universal-patient-id  

Wes Rishel
VP Distinguished Analyst
12 years at Gartner
45 years IT industry

Wes Rishel is a vice president and distinguished analyst in Gartner's healthcare provider research practice. He covers electronic medical records, interoperability, health information exchanges and the underlying technologies of healthcare IT, including application integration and standards. Read Full Bio

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  4. Dave Kirby says:

    Yes, where’s the beef! I’d offer two compact areas to search : RWJ’s Project HealthDesign ( and the Southen Piedmont HIE (SoPHIE) wiki at .

    SoPHIE is a project that is now through the planning stage. We started with collecting value propositions and proceeding with business/service outlines, business process defintion, and archtiecture to support it all. It is in an RFI stage now.

  5. Wes Rishel says:

    Dave, the RWJ link appears to be broken. In general, though, I am not sure that any design or study gets to the heart of my concern. I know that there are a lot of people and organizations that “get it” about supporting provider-to-provider communications, I am concerned that there may be a lot that don’t.

  6. Colin Evans says:

    Your segmentation of the health network into two channels, industrial and consumer, is very helpful.

    Many of my years at Intel were spent in leadership roles in the eBusiness Group and in Intel Labs driving the company onto the internet. I helped to create RosettaNet and chaired the Oasis Board during this epoch and this all sounds all too familiar. The web explosion was driven by the creation of value for individuals, not companies. It is also true that the path to successful adoption by consumers passed via a lot of experimentation and market failures – plenty of universally applauded good ideas that failed and a few completely crazy ideas that now we cannot live without.

    Today’s NHIN debate is rather like suggesting that Ford, Toyota, Smart, and Maserati should have agreed standards for displaying vehicle information before the consumer could possibly be allowed to visit any of their web sites – totally absurd.

    It is clear that the NHIN is not yet properly defined for industrial use but is totally over engineered for the needs of consumer access. If I didn’t know better, I’d say that the healthcare establishment was trying to erect barriers to disruption.

    Health 1.0 needs NHIN 2.0 – but Health 2.0 needs NHIN 0.1

  7. Wes Rishel says:

    Colin, nice summary, “Health 1.0 needs NHIN 2.0 – but Health 2.0 needs NHIN 0.1”

    As I mentioned in Health 2.0: Take a Lesson From the Web consumer-facing is important, but we cannot skimp “industrial side” and expect to make up for it on the consumer side. Both are important.

    We can move the industrial side much more quickly simply by taking a smaller bite at inter-provider interop than NHIN 1.0, particularly around the area of transitive trust.

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