Check out this WSJ piece on the falloff of participation in Wikipedia: http://online.wsj.com/article/SB125893981183759969.html?mod=WSJ_hps_MIDDLESecondNews.

Since a medical- and health-oriented wiki would advance the democratization of care, the notion of such a crowd-sourced compendium of relevant knowledge is appealing, at least in principle.  But now I’m thinking the odds are stacked against the idea, for at least four reasons:

·         Lack of first-mover advantage.  The original Wikipedia benefitted enormously from sheer originality, which led to its having little or no competition in its formative years.  The situation of medical and healthcare wikis seems quite different.  Today, if you Google healthcare wiki, you get roughly 19 million hits.  Medical wiki delivers 6 million hits of its own, one of which — davidrothman.net — helpfully lists 67 different medical wikis.  67!  Yipes!  Rothman’s list, dated January 2009, doesn’t even include Medpedia, the high-profile but late-to-the-gate entrant supported, at least ostensibly, by Harvard, UMich and Stanford medical schools.  So far as I can tell, no one healthcare wiki — remember, all of them are mere derivations of the original idea — has managed to get out ahead of the pack.

·         Neither medical expertise nor ill health reside in the young.  According to the WSJ piece, the average age of Wikipedia editors — individuals, we can assume, who take an exhaulted interest in the project and give it quality time — is 26.8 years.  We know from marketing surveys that 27-somethings give little thought to questions of healthcare.  So if the original Wikipedia thrived on the peer-oriented values of Gen Y Millennials, medical and healthcare wikis cannot hope to benefit very much from the same labor source.

·         “Crowd-sourced” and “evidence-based” don’t play well together in the medical sandbox.  Let’s not be glib: In this field the gap between the argument for expertise and the case for user-generated content is highly-charged, and no panel discussion I’ve seen has made the tension go away.  Because the evidentiary base is weak for so much of what passes for best practice — and because newly-funded comparative effectiveness research can’t contribute much anytime soon — the experts can’t even reach consensus among themselves.  When it comes to the decline of the Holy Roman Empire or influences on the music of Bob Dylan, Wikipedia can get the state of current scholarship reasonably right — and, if it doesn’t, no one loses if we have to wait another six months.  In healthcare, disputes over who gets to write and edit articles, and about what they will say, will dwarf the disputes that rage around the content in Wikipedia at large — so much so that agreement on “one best wiki” will develop only after decades, if it happens at all.

·         Anyway, the golden age of wikis may be coming to an end.  That’s one way of reading the WSJ analysis.  My gut: Even if a medical wiki were to attain, for a brief moment in time, the blessed state of breadth and depth needed to help keep the rest of us as healthy as we can be, I see no reason whatsoever to suppose that stressed professionals would continue to take hours away from family and leisure pursuits in order to give the project the ongoing attention it would need.  And nothing’s as useless in medicine as yesterday’s state of the art.

On Feb. 2^nd and 3^rd I schlepped down to DC for the annual National Health Policy Conference sponsored by AcademyHealth and Health Affairs.  We 700-odd people in the audience (up a bit from 2008, organizers tell me) heard from Members of the House and Senate, their staff people, and Jeanne Lambrew, now Deputy Director of President Obama’s White House Office of Health Reform.  Much of the talk was guarded, even cryptic – some combination of hold-your-cards-close-to-the-vest and haven’t-a-clue-how-this-will-turn-out.  Still, the meeting was useful, not to mention just full – bigger than last year’s.  I came away with a better sense of the players and the likely nature and timing of some Obama Administration initiatives: 

·    Lambrew is a sophisticated thinker about health care policy with years of Clinton-era Executive Branch experience.  As a specialist on Medicare and Medicaid, she’s familiar with the ideas and controversies surrounding chronic care management, patient self-management, personal health records and the like.  In response to questions, she gave nods of approval to wellness and prevention, community-based rather than hospital-based services, and incentives to modify personal behavior.   

·    Judging from the sense of purpose and grasp of detail shown by Democratic Members of Congress and their staff, they spent much of last year preparing for the likelihood of one of their own occupying the White House.  For better or worse, they’ve already worked out a plan for 2009 and are putting it into play.  Dasche’s departure, announced midway through the meeting, won’t change the basic strategy, which seems to be a sequence of three major efforts…. 

·    First comes the Economic Stimulus bill.  The idea is to get it on the President’s desk this month (February 2009).  Health information technology and comparative effectiveness funds are part of the deal.  No question, little of the health-related money will actually get spent within the 18-month window during which the rest of the bill is supposed to have a stimulative effect.  But in Washington this is OK, because the reason for moving early on CE and HIT – at the moment this does mean mostly electronic medical records — is not job creation.  The EMR focus is all about accelerating collection of data – numbers on treatments and outcomes that can drive payment reform later.  The comparative effectiveness stuff is meant to set the stage for tough steps against unwarranted variations in care (Wennberg-style analysis is big here).  Both will take a while to unfold but both are seen as future sources of evidence.  So the thinking here is, Let’s get ‘em going.   

·    What comes second is — for the majority party in Congress — the heart of the matter: universal or near-universal health care coverage for the nation.  The deadline is the end of this year.  One unstated rationale for the tight timing is that Ted Kennedy needs to see this happen soon.  An explicit reason is that Democrats don’t want to see a good crisis go to waste – Rahm Emanuel’s principle.  And one idea guiding the process is said to derive from the successful Health Care for All campaign in Massachusetts: Do not condition universal coverage on reform of the financial arrangements underlying the entire system.  As heavy a lift as the former is, it’s lighter than the latter.  To try both at once is to risk achieving neither.   

·    What comes third, then, is what Lambrew called “fundamental change in health care costs.”  Montana Sen. Max Baucus, a key player, talked to us about a “bubble of excessive cost in health care” (and you know what happens, he hinted, when you don’t control bubbles).  We’re going to get to this, they both said (though they’re not sure when).  Give us time, they said.  Meanwhile, they added, consider the HIT and CE funding as “down payments” on a major overhaul, the substance of which is almost certain to be some form of episodic or case rate payment. 

No question, for the moment chronic care management, patient self-management, personal responsibility, and telehealth incentives are grouped with #3 in line, fundamental change.  Still, I am not pessimistic about the prospects of our getting to all of these items.  We are amid once-in-a-lifetime shifts in national finance.  Health care will not escape the tumult.  Much may happen (or, admittedly, not).  And if the early wave of HIT spending is envisioned as a way of generating numbers on which later fundamental change can be based, some of this spend can surely be peeled off — not without some pushing, I grant you – to test the financial and quality advantages of disruptive innovation around health at home, supported by information technology and consumer electronics. 

I liked joining six other observers of the scene to co-write Perspectives on the Future of Personal Health Records, a report published this month by the California HealthCare Foundation (CHCF).

Perspectives analyzes the potential of personal health records (PHRs) from different vantage points — consumer, physician, public health professional, large employer, and so on. I consult with Fortune 500 execs on uses of information technology in the realm of employee health benefits, which is why (I bet) CHCF asked me to present the large-employer perspective.

What do I see going on? For one thing, employers interested in the health and wellness of their people continue to believe, at least as a matter of principle, that any health information they help an employee to track should integrate with information kept by the employee’s doctor. On the other hand, their faith in the adoption of electronic health records by physicians is beginning to flag. So, principle schminzaple, they’re starting to think PHRs will evolve in ways less dependent on the information technology choices of finicky doctors.

What may happen in lieu of a desirable but elusive convergence? An explosion in consumer electronics, one that will carry over into healthcare and lead to a profusion of self-management tools and trackers — backed up, perhaps, by an omnibus record kept on the Web. Execs are betting that employees will store their data in more than one place and shift these preferences over time, depending on what needs doing and what tools seem useful and trustworthy.

The good news: If this view proves correct and a pluralistic market develops in PHRs, the door will stay open for continuous improvement in the product. I do think there’s an imperfect but useful precedent in the evolution of financial self-management tools like Quicken, which stand as reminders that millions of people will pay for software that helps them gain control over things that eat up time. Just as Quicken came along in response to the democratization of personal investing and an explosion in household financial data, so, too, PHRs seem positioned to thrive in an era of democratization for personal health management, one that is sure to produce its own informational surge.

The bad news: Less data integration, more data proliferation. And, at least for the time being, the very definition of health information — our sense of what’s good to know — will likely expand faster than the capacity of any electronic record system to gather it all up and feed it all back.

A number of esteemed colleagues have very interesting things to say about PHRs in the CHCF report. Patricia Flatley, RN, who’s long been involved with this stuff, opens with a general discussion. David Lansky offers a consumer perspective, Dr. Daniel Sands gives the physician vantage point, Dr. David Kibbe offers a technologist’s perspective, and my friend Dr. Jeremy Nobel takes the public health view. The results are available from CHCF at http://www.chcf.org/documents/chronicdisease/PHRPerspectives.pdf. If I knew enough about the blogging tool I’m using (Word Press) to make this URL live for you, I surely would.

Dropped in yesterday (May 31) on TCBI’s inaugural Summit on Behavioral Telehealth. Joe Kvedar, Director of the Center for Connected Health at Partners Healthcare (www.connected-health.org) remarked upon a convergence of “mental health, telehealth, and disease management,” which put the matter pretty well. What I saw, in a word:

… a new audience. The recipe for a typical healthcare IT gathering calls for two parts hungry entrepreneur to one part we-can-wait big company, one part we-may-cover-this-someday payer, one part where’s-my-place provider and one part I’ll-say-anything consultant. But this group was different. Thanks in part no doubt to the venue (Harvard Medical School) and the connections of the convenor (psychiatrist Steven Locke, after whose name follows one of those bewildering title trails found only in ancient royal lineages and American academic medical centers), the audience appeared to include substantial numbers of bona fide mental health professionals. People were intent on the subject matter — uses of technology and the Internet to engage those suffering from depression, anxiety, neurological conditions, substance abuse and a host of other things broadly viewed as behavioral. People were talkative, too — no sitting back and simply taking it in.

The Center for Business Innovation, the meeting organizer, seems to have found what our marketing friends call an “adjacency” — a new group, close to but also just beyond the current one — into which to expand its provision of informational and networking opportunities. Shrewd.