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Earlier this year, the popular social network Facebook introduced a new initiative designed to help corporations advertise to its users. 

allowed members to “share information [about their actions on]... other websites for distribution to their friends.” Facebook allowed advertisers to select the type of content that would be shared via the social network, including purchase information.

Facebook promised its users they would be able to “decide whether to distribute specific actions from participating sites with their friends.” Unfortunately, reality did not match Facebook’s promises. A few weeks after Beacon launched, influential Forrester analyst and blogger Charlene Li wrote a post, “

,” in which she related her disturbing experience with the new advertising service. She said: Earlier this week, I bought a coffee table on 

. When I next logged into Facebook... [I] saw [information about my purchase on my newsfeed]. I was pretty surprised to see this, because I received no notification while I was on Overstock.com that they had the Facebook Beacon installed on the site. If they had, I would have turned it off.

I used my personal e-mail address to buy the coffee table, so I was puzzled why and how this ‘personal’ activity was being associated with my ‘public’ Facebook profile. Li went on to note that her biggest problem with Facebook Beacon was that she didn’t have control over the information that would be shared with her network. She said “I need to be in control and not get blindsided... I was seriously wigged out, but wouldn’t have been if Overstock had simply told me that they were inserting a Facebook Beacon and given me the opportunity at that time to opt-in to Beacon.”

Although purchasing a coffee table is an innocent activity, in a healthcare context, the situation could potentially carry serious repercussions. For example, what if a Facebook member with bipolar disorder purchases a book about this condition on Amazon.com? Here’s the catch: no one in their immediate network knows that they have this condition and the user does not want to share this information. All of a sudden, because of Beacon, everyone knows. This potentially serious privacy breach could have serious personal and professional repercussions.

Facebook Quenches Beacon Firestorm, but Privacy Concerns Remain

After weeks of user protest and negative press, 

. The company promised that “users will have clear options... to either delete or publish [information about their purchases].” Facebook’s move is welcome; however, the Beacon flap indicates that user privacy can sometimes take a back seat when Web 2.0 companies are racing to maximize their advertising revenue. This should be a major concern for healthcare social media advocates. Many companies are taking privacy concerns very seriously; however, there is a real possibility a company will someday inadvertently release or share private medical information. After all, it has happened before.

In 2002, Eli Lilly and Company agreed to settle Federal Trade Commission (FTC) charges that it had failed to protect information patients submitted on its Prozac.com website. According to the FTC, “A Lilly employee created a new computer program to access Medi-messenger subscribers’ e-mail addresses and sent them an e-mail message announcing the termination of the Medi-messenger service. The 

 included all of the recipients’ e-mail addresses within the ‘To:’ line of the message, thereby unintentionally disclosing to each individual subscriber the e-mail addresses of all 669 Medi-messenger subscribers.” The FTC argued that Lilly violated its own privacy policies and failed to take appropriate steps to protect users’ sensitive information.

Another concern is that many Internet users are not worried that their personal information is floating around in cyberspace. According to a report released in December 2007 by the Pew Internet & American Life Project, 60% of Internet users are “unconcerned about the extent of data available about them online.” However, there are signs this blasé attitude may be partly fueled by ignorance. Privacy advocates say that information Internet users do not believe is online (such as their e-mail addresses, phone numbers, and names of employers) can be found via a simple search engine query.

As social media applications become more ubiquitous and powerful, it is very likely that Americans will continue to use them for health-related purposes. However, a major privacy breach could significantly set back efforts to empower patients, providers, and others using Web 2.0 technologies.

Fard Johnmar is the founder of Envision Solutions, LLC, a full-service healthcare marketing communications consulting firm. Visit 

 to learn more about the company and the services it offers.

Articles

Earlier this year, the popular social network Facebook introduced a new initiative designed to help corporations advertise to its users.

Social Media Notebook: Will Privacy Be the Achilles' Heel of the Healthcare Social Media Revolution?

In case you hadn’t noticed, CompUSA, the largest computer specialty retailer in the country, closed more than half of its domestic stores back in February. I wasn’t that surprised, given how empty my local CompUSA always seems to be, how they never seem to have the computer I want in stock, and how the salespeople push extended warranties (on which they make commission). In fact, I would say that nearly all brick-and-mortar computer retailers fail at providing that truly excellent customer experience for which we always hope, but which is oh-so-elusive. For me, the ultimate customer experience is to walk into a clean, large, well-lighted store with lots of hardware and software on display and in stock; speak to someone knowledgeable; and then walk out the door with my new purchase. Unfortunately, I have rarely had that experience and you probably haven’t, either.

Mom-and-pop computer shops are great if you want a custom-built computer. But they tend to have quirky store hours (and occasionally quirky staff ), and you may have to wait a week or two to take delivery of your (often non-brand-name) computer. These stores also tend to be limited in their display items and available stock of merchandise.

At the other end of the spectrum are the big-box electronics stores (like Best Buy and Circuit City), which have taken over as the principal merchants of computers in malls and stand-alone stores across America. Because they tend to have large product demonstration and display areas, they are ideal for browsing computer equipment. However, there are several factors that often detract from the overall shopping experience at these stores.

- You can often save 10% or more off the brick-and-mortar store price by shopping online, assuming you know exactly what you want—just type the product name into a shopping-specific search engine like 

. Always do your homework and ensure the merchant you are buying from has a good customer satisfaction rating.

 - Let’s face it, your average salesperson doesn’t know much about computers. Even worse are the salespeople who think they do, but provide only incorrect information. It’s hard to be confident about your purchase when you realize you know more about the product than the person from whom you are about to buy it.

 - Is there anything worse than really wanting something, driving 20 minutes to the store, spending another 10 minutes waiting for someone to help you, only to find out that the item is out of stock?

 - One of the biggest scams in retail. In November 2006, Consumer Reports launched a public awareness campaign to educate shoppers about the often misleading information surrounding extended warranties. According to this trusted watchdog, stores are pushing extended warranties like never before because they are revenue drivers. But the dirty little secret retailers don’t want you to know is that most products don’t break down often enough to make warranties worthwhile. When repairs are necessary, they are usually affordable, and, in many cases, cost less than the warranty. Besides, many electronics retailers don’t even provide technical service or support themselves—they just ship the goods back to the manufacturer.

I still visit the big-name computer stores, but only to play with products in their demonstration areas and figure out what I really want. Then I go home and order it online. This not only saves me money, it also lets me avoid the dreaded extended warranty sales pitch.

Apple Stores are the exception to the rule, a model for what the computer retail experience should be for everyone. Although they also try to push extended warranties, unlike other tech stores, the Apple “genius” staff is usually quite knowledgeable, and the range of products on display and in stock is often impressive.

Dr. Bertman is Physician Editor-in-Chief of 

. He is also a Clinical Assistant Professor of Family Medicine at Brown University and president of 

, a leading developer of Electronic Health Record (EHR) software. He also is the founder and president of 

, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI

In case you hadn't noticed, CompUSA, the largest computer specialty retailer in the country, closed more than half of its domestic stores back in February. I wasn't that surprised, given how empty...

Thinking Outside the (Big) Box When Buying a Computer

Healthcare is undergoing a transformation that is placing more responsibility and decision-making in the hands of patients. In this new healthcare world, physicians need tools that improve the patient experience and office efficiency. These tools make communicating with a doctor as easy as sending an e—mail; enable test results to be available almost instantly; and eliminate redundant paperwork through secure electronic sharing. The solutions needed are readily available, cost-effective, and easy-to-use, allowing anyone with an e–mail address and Internet access to participate.

Secure Connectivity Tools Improve Patient Service

Connectivity tools allow medical providers to improve the patient-provider relationship by giving patients timely access to practice services. These tools, including secure messaging, patient portals, and document management solutions, allow patients to avoid redundant paperwork and build stronger bonds with their physicians, while maintaining the strictest levels of privacy.

As connectivity tools are adopted, patient expectations are changing. Dr. Tom Landholt of PatientCare Family Practice in Springfield, MO and Medical Director of HIT for MassPro, one of the leading performance improvement organizations in the United States, sends 70 percent of his lab results via secure messaging. Under the old workflow, patients would not be notifi ed for days. Now, his patients expect to have the results available to them the day after they are tested.

Connectivity solutions also increase information accuracy and replace the waiting room experience with convenient online services. Brian Williams, president of Springfield Neurological and Spine Institute in Missouri, is experiencing firsthand the growing confidence patients have in securely sharing health information online. When given the choice of paper forms or completing forms online, 50 percent of his patients elect to provide their information

online before arriving for their appointment.

Reducing Costs by Improving Office Efficiency

Improving the patient—doctor relationship through connectivity tools also improves the operational efficiency of the office. These tools enable doctors’ offices to overcome the inefficient manual processes associated with managing traditional mailings and faxes. At Westchester Medical Group, a multi-specialty practice based in White Plains, NY, 20 percent of each medical assistant’s time has been saved by implementing secure messaging to replace slow and error-prone phone and paper-based processes. The practice anticipates reducing costs an additional 30 percent over five years, as further improvements in productivity are realized through the implementation of more online services.

Many practices are building their entire organizations around this new way of doing business. Dr. Christopher Crow and his colleagues at Dallas-based Village Health Partners, the 2007 HIMSS Ambulatory Davies Award winner, believe connectivity solutions are central to providing exceptional levels of service to their patients. These tools place their practice on the cutting edge of innovation and are allowing the practice to expand its off erings in a brand new facility wired specifically for a paperless practice.

Patients of GreenField Health in Portland, OR, experience a clinical relationship fundamentally different from the typical practice experience. There is no waiting room at GreenField because patients never have to wait for their appointments. Every patient has their physician’s e—mail address and is invited to contact them with questions. These revolutionary changes are largely possible because GreenField has embraced modern information technologies, such as secure messaging and a patient portal, to facilitate more efficient and effective care.

As healthcare transforms, new competitors, including retail clinics and consumer companies, are altering patient expectations. These players understand the importance of connectivity. For example, the launch of Microsoft’s HealthVault platform prominently featured patient—physician communication. To succeed, providers must adopt solutions that dramatically improve the availability and efficiency of service and care, and ultimately democratize the healthcare system.

, the leading provider of next generation healthcare connectivity solutions.

Healthcare is undergoing a transformation that is placing more responsibility and decision-making in the hands of patients. In this new healthcare world, physicians need tools that improve the...

The Benefits of Next-Generation Health Care Connectivity: January 4, 2008

Pay-for-performance programs, in which providers are reimbursed at a higher rate if they can demonstrate that they deliver high-quality services, are being introduced in most states as part of an aggressive attempt at controlling healthcare costs without adversely affecting the quality of care. Indeed, many of these programs promise better quality as a result of being able to measure key indicators that are thought to drive clinical outcomes, as well as patients’ perception of the level of care.

At issue, however, is whether these programs can be effectively put in place ahead of the installation of complete electronic health records (EHRs). Many in the industry argue that, without an EHR, it will be impossible to establish controlled processes for the measurement of these indicators in a reliable manner, such that the measurements are truly comparable across providers, because the data necessary for these calculations will only be available after the problem of EHR

interoperability has been addressed. Others argue that P4P programs can be established, but they would consist of weak indicators with all the bureaucratic limitations of HEDIS-like calculations, citing similar data-availability issues.

This article will argue that a robust P4P program—with meaningful indicators and an affordable mechanism for auditing and verifying the measurements&mdash;can indeed be established in advance of universal availability of EHR technology. In fact, the greatest barriers to such a program are not rooted in the availability of data, but rather in the adoption of regional data-sharing agreements among all the industry players.

The healthcare industry, which accounts for approximately 15% of the US gross national product, is poised for a radical transformation aimed at reducing the rate of growth of its costs and at increasing the quality and reliability of its services. The industry is universally perceived to have high costs, and the traditional view that high costs correlate with high medical quality are being challenged by a crude but effective first pass at the measurement of healthcare outcomes—which suggests otherwise. Driving this transformation is the work of a coalition of large payers (including the employers and the government), insurers, and providers, and its primary vehicle will be an overhauled payment system for healthcare services.

In order to complete the transformation, the industry must be able to measure the “value” and the cost of the healthcare delivered. These measures must be objectively derived from information in the medical record, and must be comparable across providers. The cost of obtaining the information used in the measures would, ideally, not significantly exceed the costs already incurred in documentation of the medical record, or else the measurement process will itself make

We will start our argument by debunking the idea that the EHR will make the task of creating a robust P4P program much easier. Everyone involved in the measurement of healthcare agrees that coordinating the efforts necessary to create such a program is a difficult task. But how would an EHR simplify this?

Claim #1: EHRs make available all the data that is needed to calculate the P4P measures.

This is patently untrue. Most of the data elements necessary to calculate clinical P4P measures are already available in other electronic systems that are much more common than EHRs. Lab values are available from lab systems and lab vendors. Demographics, procedures, and diagnoses are available from billing and registration systems. Pharmacy data is available within the dispensing industry and from the payers (insurance companies and the government).

Visit-utilization information is available from scheduling and billing systems. While the EHR contains additional clinical information, much of it is in text form (progress notes, for example) and is not readily of use in refining a P4P program.

Claim #2: EHRs will make the data available from a single source

, rather than from disparate systems, therefore making the task easier because all the data for a single individual is tied together under a single ID, whereas separate systems might not share the same identifier for a unique patient. At first glance, this seems to make sense—after all, no one wants to manage the difficult task of matching a lab value to a patient record without an identifier. However, let us remember how the data in the EHR was brought together under a single identifier to begin with: by tackling the difficult question of providing a unique ID to each patient and requiring your lab vendor, for example, to include that identifier in the HL7 transaction that brings back the result. Therefore, an EHR is not necessary in order to ensure a common identifier across data systems of the same provider organization. By contrast, external data that does not carry the unique identifier of a provider organization is equally difficult to integrate, whether one is working with an EHR system or with separate systems. In other words, the industry must solve this problem whether or not we fi rst install EHRs everywhere. Master Patient Index functionality is available in most commercial registration systems, and can also be utilized at the level of Regional Health Information Organizations (RHIOs) in order to overcome this problem.

Claim #3: EHRs contain additional clinical information

 that allows the calculation of measures that are more accurate than those calculated using only “administrative” data. For example, EHRs contain “problem lists” populated by the physicians, which may be a more accurate way of identifying a diabetic than by using the ICD9 diagnosis code in an encounter, which may actually be indicating a “rule-out” of the disease. Additionally, a provider can indicate valid reasons that disqualify a patient from a particular protocol that is used in a measure (for example, allergy to a medication or a “not-medically-necessary” situation such as that of a 95-year-old diabetic with terminal cancer of whom the provider probably won’t require bi-annual glyco-hemoglobin testing).

This is the most valid claim. It appeals to our distrust of early HEDIS-type measures that inaccurately identified diabetics, or the possible individual contraindications to receiving aspirin post myocardial infarction. However, the first concern has been demonstrated to be false by the local successes involving RHIOs or other community registries that collectively pool data from multiple providers and correctly maintain accurate diabetic registries without relying on a problem list. Instead, these systems identify possible diabetics by looking at multiple possible indicators (ICD9, lab values, insulin-type medications) with greater accuracy and then making those lists available to the providers for verification—a process we at Palo Alto Medical Foundation have discovered to be much more accurate than relying on the provider to add the diagnosis to the problem list of an EHR, which shows greater variability across providers who are comfortable or facile with the complexity of a full EHR. The second concern, contraindications or allergies, is real, but hardly a reason to wait years for EHRs to be available universally rather than adding this capability to regional integrators of data.

Having asserted that the EHR does not add much that is not already available, we must propose an alternative mechanism for the support of P4P programs. This approach must maximize the use of available information and leapfrog some of the challenges presented by the lack of a universal patient identifier. It must then perform two distinctly separate but complementary tasks. First, it must gather the data from every available electronic source and perform systematic cleanup functions. Second, it must be able to calculate hundreds of clinical, operational, and financial (efficiency) indicators in a transparent and easily auditable manner. We have been using the term “tactical warehouse” to refer to such systems. Many versions of such systems have arisen from local efforts of large integrated systems, medical groups, RHIOs, or other large collaborative efforts. Although some lack flexibility or a robust architecture, others represent the birth of a new class of healthcare IT that promises to address not only P4P needs, but also the portability of essential elements of our medical records.

The Palo Alto Medical Foundation tactical data warehouse, called Solutions, consists of three engines:

 gathers data from any available source system. It contains data cleansing software that was designed based on the premise that most important measures in healthcare come from relatively few fields (see the “Pareto rule”). It uses extraction technology (not the more complicated live interface) to access data regardless of system brand. It draws data from systems including EHRs, lab systems, registration, billing, general ledger and payroll, etc. And it houses a simple Master Patient Index tool that facilitates the creation of a tree of patient identifi ers that ties a unique patient across source systems. Its output is a clean, simplified EHR-like set of tables containing the fields that are required for most P4P calculations. Lab tests and other elements have been merged such that, for example, all fasting glucose tests are identified by a single code.

 applies the definition of each measure to create “metric tables,” which are refreshed weekly, monthly, or quarterly as required by each metric. In the process, this engine generates useful “value-added” tables such as disease rosters and patient activity tables that create a rich, standardized

environment ripe for the easy generation of ad hoc queries.

 catalogs the measures and makes them available to the users singly (for use in products such as dashboards and scorecards), in data series that represent the value of a metric over a period (used in run charts), or in series representing value ranges (for histograms). We maintain more than 150 metrics and their 1,100 variants in a catalog that includes clinical (eg, percent of diabetics with HgA1C <7, by provider), operational (eg, panel size or see-your-own ratios, by provider), and financial (eg, direct cost per practice RVU, by department measures, along with their “roll-ups”) to departmental, site, and organization levels.

The industry would do well to embrace local and regional efforts toward the creation of such systems by pressuring all players (providers, insurers, pharmacies, lab vendors, etc) to enter into HIPAA-compliant data-sharing agreements that would feed these clearinghouse and data aggregation services. Agencies such as AHRQ, NQF, and others, backed by HRSA and CMS, should initiate aggressive certification services that would enable successful tactical warehouse efforts to offer these calculation services, along with data portability services, with a stamp that guarantees that the calculations conform to registered measure defi nition standards.

If we follow that path, we will enable robust P4P programs which, if aggressively funded to motivate change, just might prevent an explosion of costs that are looming once the “Baby Boom” generation hits the Medicare rolls. And by bypassing the EHR, we will get there five years sooner.

Tomas Moran, MS, is Senior Director of Quality and Planning for the Palo Alto Medical Foundation for Health Care, Research and Education, a not-for-profit pioneer in both multispecialty group practice of medicine and outpatient medicine. The foundation is an affiliate of Sutter Health. To learn more about the organization, visit their website at 

Pay-for-performance programs, in which providers are reimbursed at a higher rate if they can demonstrate that they deliver high-quality services, are being introduced in most states as part of an...

January 2008 | Oncology Live®

Social Media Notebook: Will Privacy Be the Achilles' Heel of the Healthcare Social Media Revolution?

Thinking Outside the (Big) Box When Buying a Computer

The Benefits of Next-Generation Health Care Connectivity: January 4, 2008

Is P4P Possible Without an EHR?