The Health 2.0 Blog

New NRC Report Finds "Health Care IT Chasm," Seeks New Course Toward Quality Improvement and Cost Savings

By DAVID C. KIBBE, MD MBA

Like the Institute of Medicine's (IOM) 2001 counterpart report, "Crossing the Quality Chasm," a new report from the National Research Council of the National Academies is complex, full of new ideas assembled from multiple disciplines, and is likely to have seminal importance in framing public policy from now on. "Computational Technology for Effective Health Care:  Immediate Steps and Strategic Directions" was released last Friday, January 9, 2009 in draft, but there is so much to comment on that I think it's wise to begin with a quote from the committee that sums up the central conclusion:

In short, the nation faces a health care IT chasm that is analogous to the quality chasm highlighted by the IOM over the past decade. In the quality domain, various improvement efforts have failed to improve health care outcomes, and sometimes even done more harm than good. Similarly, based on an examination of the multiple sources of evidence described above and viewing them through the lens of the committee’s judgment, the committee believes that the nation faces the same risk with health care IT—that current efforts aimed at the nationwide deployment of health care IT will not be sufficient to achieve the vision of 21st century health care, and may even set back the cause if these efforts continue wholly without change from their present course. Success in this regard will require greater emphasis on the goal of improving health care by providing cognitive support for health care providers and even for patients and family caregivers on the part of computer science and health/biomedical informatics researchers. Vendors, health care organizations, and government, too, will also have to pay greater attention to cognitive support. This point is the central conclusion articulated in this report. (emphasis added)

It would be difficult to find a more sober indictment of US health care IT policy and implementation over the past decade than what is contained here. The report is the result of many meetings and site visits beginning in April 2007. It was written by a committee chaired by William W. Stead, MD, Director of the prestigious Informatics Center at Vanderbilt University Medical Center, and includes not only some of the nation's top academic computer scientists and health IT engineers, but representatives from the private sector (Google and Intel) as well.

The report recommends that governmental institutions - especially the federal government - should explicitly embrace measurable health care quality improvement as the driving rationale for its health care IT adoption efforts, and should shun programs that promote specific clinical applications or products.

Although the report's language is sometimes almost impenetrable, the Committee's major criticism of today's health IT is that the systems in use do not support the clinical decision making processes that are foundational to the practice of quality medicine, lacking what the authors refer to as "cognitive support." Nor do they adequately support the data collection and aggregation necessary to analyze, report, and improve care.  Again, in the words of the report:

The committee also saw little cognitive support for data interpretation, planning, or collaboration. For example, even in situations where different members of the care team were physically gathered at the entrance to a patient’s room and looking at different aspects of a patient’s case on their individual computers, collaborative interactions took place via verbal discussion, not directly supported in any way by the computer systems, and the discussions were not captured back into the system or record (i.e., the valuable high-level abstractions and integration were neither supported nor retained for future use).
 
Instead, committee members repeatedly observed health care IT focused on individual transactions (e.g., medication X is given to the patient at 9:42 p.m., laboratory result Y is returned to the physician, and so on) and virtually no attention being paid to helping the clinician understand how the voluminous data collected could relate to the overall health care status of any individual patient. Care providers spent a great deal of time in electronically documenting what they did for patients, but these providers often said that they were entering the information to comply with regulations or to defend against lawsuits, rather than because they expected someone to use it to improve clinical care.

And I found it refreshingly honest that the report compares the human interfacing of health care software with software used in other information-intense environments, and not favorably:

A reviewer of this report in draft form noted the non-intuitive behavior of most health care IT systems and the training requirements that result from that behavior. Hospitals often require 3- or 4-hour training sessions for physicians before they can get the user names and passwords for access to new clinical systems. Yet much of the computing software that these people use in other settings (e.g., office software) adopts a consistent interface metaphor across applications and adheres to prevailing design/interface norms. As a result, there is much less need for training, and the user manual need only be consulted when special questions arise. In contrast, health care IT lacks these characteristics of conventional software packages—a fact that reflects the failure of these systems to address some basic human interface considerations.

Not all criticism
But the new "Health Care IT Chasm" report is not just criticism.  It suggests a number of ways to think about the challenges going forward, posits principles that can achieve a vision of patient-centered decision support, and makes clear cut recommendations aimed at the government, health care provider organizations, the IT vendor community, and researchers.    Here are a few highlights that caught my immediate attention:

• Motivated by a presentation from Intermountain Healthcare’s Marc Probst, the Committee found it useful to categorize health care information technology (IT) into four domains: automation; connectivity; decision support; and data-mining. 
  
  The report comments that there is currently an "imbalance" in which most IT efforts have been focused on automation, and not enough on the other three domains.
  
  
• The report suggests two sets of principles to guide governmental policy on health care IT, one for making progress in the near term, and one for the longer term.
  • Making progress in the near term, “Principles for evolutionary change":
    •    Focus on improvements in care - technology is secondary.
    •    Seek incremental gain from incremental effort.
    •    Record available data so that today’s biomedical knowledge can be used to interpret the data to drive care, process improvement, and research. 
    •    Design for human and organizational factors so that social and institutional processes will not pose barriers to appropriately taking advantage of technology.
    •    Support the cognitive functions of all caregivers, including health professionals, patients, and their families.
    
    
  • While preparing for the long term, “Principles for radical change":
    •    Architect information and workflow systems to accommodate disruptive change.
    •    Archive data for subsequent re-interpretation, that is, in anticipation of future advances in biomedical knowledge that may change today’s interpretation of data and advances in computer science that may provide new ways extracting meaningful and useful knowledge from existing data stores.
    •    Seek and develop technologies that identify and eliminate ineffective work processes.
    •    Seek and develop technologies that clarify the context of data.
    

• The report calls for increasing the development of IT tools for patients and consumers, not just doctors and nurses:
  

A final and significant benefit for the committee’s vision of patient-centered cognitive support is that patients themselves should be able to make use of tools designed with such support in mind. That is, entirely apart from being useful for clinicians, tools and technologies for patient-centered cognitive support should also be able to provide value for patients who wish to understand their own medical conditions more completely and thoroughly. Obviously, different interfaces would be required (e.g., interfaces that translate medical jargon into lay language)—but the underlying tools for medical data integration, modeling, and abstraction designed for patient-centered cognitive support are likely to be the same in any system for lay end users (i.e., patients).

• The report recommends that health care organizations and their leaders:

Insist that vendors supply IT that permits the separation of data from applications and facilitates data transfers to and from other non-vendor applications in shareable and generally useful formats.

Notice the wording here doesn't mention standards, but only shareable and generally useful formats. To discuss the separation of data from software applications de-mystifies that awful term interoperability, and gets more directly at the heart of the matter of sharing data.

• The section of the report on Research Challenges provides readers with a high level diagram of what the committee calls the "virtual patient" -- which they define as "a conceptual model of the patient reflecting their [the clinician's] understanding of interacting physiological, psychological, societal, and other dimensions."  The diagram illustrates where they believe health IT is currently, and where it needs to go in the future.
  

Bound to spark controversy
As readers of this review will certainly know, there is currently an on-going debate occasioned by President-elect Obama's pledge to spend $50 billion on health IT as part of the economic recovery package, about how the new administration should parse these investments in health IT over the next few years.  One group favors massive expenditure on existing products and services, such as EHRs, and the other recommends an approach that would also support incremental and less disruptive IT adoption while re-designing clinical software and communications technology to be more affordable and directly contributory to better care outcomes.  The timing of the Health Care IT Chasm report, therefore, could not be, well, more timely. 

There is probably something in this report to help reinforce the arguments of both the "EHRs are good enough" camp as well as the "don't spend bad money after good" group. But I find it predominantly a cautionary tale, told by a group of scientists who have carefully considered the present course of IT investment and have found it needing a re-direction.  Because many of the committee members are or have been leaders of the present course, the report is by definition courageously self-critical. It is also commendable that this committee took the time and effort to actually survey health care institutions, talk with doctors, nurses, and patients, and examine first hand the social, organizational, and technical interactions of the IT systems they criticize in this report.  This is not just a report by the experts.  It is a report by experts who are also stewards and witnesses.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

   

Let's Reboot America's HIT Conversation Part 1: Putting EHRs in Context

by DAVID C. KIBBE and BRIAN KLEPPER

On December 19th, we published an Open Letter to the Obama Health Team, cautioning the incoming Administration against limiting its Health Information Technology (IT) investments to Electronic Health Records (EHRs). Instead, we recommended that their health IT plan be rethought to favor a large array of innovative applications that can be easily adopted to result in more effective, less expensive care.

The response to that post was vigorous - we received many comments and inquiries from the health care vendor,  professional and policy communities - urging us to provide more clarity. One prominent commentator called to ask whether we, in fact, supported the use of EHRs. We both have been active EMR and health IT supporters for many years. Dr. Kibbe was a developer of the Continuity of Care Record (CCR), a de facto standard format for Electronic Medical Records (EMRs), and has assisted hundreds of medical practices to adopt EHRs. Dr. Klepper has been involved in EMR projects for the last 15 years, and the onsite clinic firm he works with provides every clinician with a range of health IT tools, including EMRs.

That said, we are realistic about the problems that exist with health information technologies as they are currently constituted. As we described in our previous post (and contrary to some recent claims), most products are NOT interoperable, meaning licensees of different commercial systems - each using different proprietary formats - often find it difficult to exchange even basic health care information.

Most EHRs are bloated with functions that often are turned off by practitioners, that are promoted politically through the current CCHIT certification process, and that drive up costs of purchase, implementation and maintenance. Despite moving toward Web-based delivery models that have MUCH lower transactional costs than old-fashioned client/server approaches, most commercial offerings are still extremely expensive, especially compared to the revenue flows of the relatively small operations they support. (John Halamka MD's recent recommendation that the Fed invest $50,000 per clinician for rapid implementation of "interoperable CCHIT certified electronic records with built in decision support, clinical data exchange, and quality reporting" provides an idea of the resource allocations that are on the table.) The very wide range of choices in the market currently raises the question of whether the implementation of a national EHR infrastructure MUST be so costly.

Many health care professionals still think of health IT as a compartmentalized function within health care organizations. But health IT has increasingly become the glue between and across all health care supply chain, care delivery and financing enterprises. In the past, it was enough for health IT to facilitate information exchange inside organizations - in which case a proprietary system would do - but we now expect information to be sent and received seamlessly, independent of platform, including over the Internet. Most of the currently dominant EHR technologies don't even begin to get us there.

Nor, despite the rampant optimism about its potential, can a focus on health IT alone - or even more emphatically, EHRs - resolve health care's deeper problems. As the noted health care economist Alain Enthoven wrote in a December 28 New York Times editorial:

[President-elect Obama]... has suggested, for example, that electronic medical records could save Americans nearly $80 billion per year. But information technology cannot bring meaningful savings if it is used in a health care system that regularly rewards waste and punishes efficiency, as ours does.

In other words, as the recent reports from the Congressional Budget Office and the Dartmouth Atlas point out (yet again), real reforms will require an array of significant changes, many of which will face withering opposition from entrenched interests. One of those interests is the established health care information technology sector, which stands to finally win handsomely from huge Federal investment in their current products.

The good news is that this is the position held by Peter Orszag, the incoming Director of the Office of Management and Budget, the current Director of the Congressional Budget Office, an astute student of health care dynamics, and a key member of the Obama health team.  In July 18, 2008 testimony before the Senate Finance Committee, he said:

The bottom line is that research does indicate that, in certain settings, health IT appears to facilitate reductions in health spending if other steps in the broader healthcare system are also taken to alter incentives to promote savings. By itself, however, the adoption of more health IT is generally not sufficient to produce significant cost savings.

In other words, it is fair to be skeptical about how we should proceed with a national health IT build-out effort. The health IT industry's current product/service offerings are analogous to the auto industry's obsession with SUVs, as much the problem as the solution. Just as the auto industry can be re-purposed to build lower-energy, less wasteful vehicles, so too should the health IT industry be encouraged to offer smarter products that serve the interests of an affordable, convenient, and evidence-based health care system.

A smorgasbord of Health Information Technologies is available to help us build a far better health system. Part 2 will describe some functions that a national health IT infrastructure renewal effort might consider.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc.

Let's Reboot America's Health IT Conversation Part 2: Beyond EHRs

DAVID C. KIBBE and BRIAN KLEPPER

Yesterday we tried to put EHRs into perspective. They're important, and we can't effectively move health care forward without them. But they're only one of many important health IT functions. EHRs and health IT alone won't fix health care. So developing a comprehensive but effective national health IT plan is a huge undertaking that requires broad, non-ideological thinking.

As we've learned so painfully elsewhere in the economy, the danger we face now in developing health care solutions is throwing good money after bad. We don't merely need a readjustment of how health IT dollars are spent. We need to reboot the entire conversation about how health IT relates to health, health care, and health care reform. To get there, we need to take a deep breath and start from well-established and agreed-upon principles.

Most of us want a health system that, whenever possible, bases care on knowledge of what does and doesn't work - i.e., evidence. We want care that is coordinated, not fragmented, across the continuum of settings, visits and events. And we want care that is personal, affordable and increasingly convenient.

Most of us also agree that, so far, we have not achieved these ideals. In fact, health care continues to become costlier, quality is spotty, and the gap between the health care we believe possible and the current system is widening.

We believe that most health care professionals are acutely aware that more health IT alone cannot resolve these problems. Despite billions of dollars in health IT investments by health care professionals and organizations, the gap persists and is widening. Many physician practices have expanded their health IT functions, moving beyond electronic billing systems - a necessary asset to be paid by Medicare - toward EMRs and from paper to software systems.  About a quarter of US physicians use EHRs from commercial vendors. Hospitals and health plans - larger, corporate organizations with more dedicated capital resources - have implemented health IT more quickly. Even so, the tools implemented have typically been focused on record-keeping and transactional processing, not decision-support. Health care clinical and administrative decisions have not yet become more rational, less tolerant of waste and duplication, or more congruent with evidence.

We don't need simply more health health IT; instead, we need an array of specific health IT functions and capabilities that can facilitate better care at lower cost, and the adherence to evidence-based rules.

What would those empowering health IT products look like, and what would they do?

Focusing on Decision Support
Most important, new health IT would help patients, clinicians, managers and purchasers make the best possible clinical and administrative decisions. This includes identifying risks and following the best path to lowering them whenever possible. Health IT should help people stay healthy and avoid illness through active clinical decision support, and make sure that the system recognizes value. Which patients, according to past data, have acute or chronic conditions that need care? Which, do the data show, are the most effective (or high value) doctors, hospital services, treatments and interventions - so that the market can work to drive efficiency.  Given a particular set of signs or symptoms, lab test results, or genetic test, what is the best next step in care?

Technology and information engineering is readily available to do this. Car technologies now help drivers understand when a problem is occurring, or is likely to occur, monitoring and communicating fluid levels, tire pressure, maintenance appointments, and location in case of emergency. Banking technologies can flag suspicious credit card purchases and can instantly invalidate charge cards. Recently, Google trended flu searches to help estimate regional flu activity; their estimates have been consistent with the CDC's weekly provider surveillance network reports.

By comparison, most health IT is relatively unsophisticated. In general, the prevailing front line tools do not yet help clinicians identify individual- or population-level health risks. They do not yet provide guidance with evidence-based approaches that can best mitigate those risks, create alerts and reminders, or help monitor adherence to care plans, even though the data are now clear that most Americans die and we pay the most money due to easily preventable and managed conditions.

In short, we monitor our cars and bank accounts better than we do our health. We can change this.

Untethering Patients with Easily Accessible Personal Health Information
High value health IT would improve care by making summary personal health information available to providers and patients, increasingly independent of location and time. Most health records are still tied to a health care organization's data center, supporting an outdated business model in which the patient must come to a centralized, expensive location for even the most routine tasks, like history-taking or lab testing. Most current EHRs don't change this, in large part because they aren't connected to the Internet yet. Web-enabled patient information would untether the patient, and make increasingly standardized care more readily available anywhere. De-coupling health information from health care providers is the first step in the development of new business models that will offer team-based care services wherever one is located, saving money and increasing convenience.

Empowering Patients Through Online Linkages with Clinicians and Other Patients
High value health IT will link patients with clinicians, will match problems with the most appropriate solutions, and will use social networking to increase access to patient- and condition-specific information, knowledge, and guidance. This class of health IT applications and services will be particularly useful with chronic illness, shifting more of the condition's monitoring and management to the patient and his/her family and peers, with diminished reliance on the office-based physician and the single visit model of care. Bringing advances like these to fruition will require much broader implementation and access to broadband and mobile technologies, as well as standardized health record formats that use XML, like the Continuity of Care Record (CCR).

Supporting Participatory Medicine: Bridging the Medical Home and Web-Based Care
As Kibbe and Kvedar recently wrote, much of the health IT we're describing here bridges the divide between two powerful trends: Health 2.0 (or user-generated health care ), and "the medical home." It is now clear that, while most health care consumers want to be more actively engaged in their own care management - e.g., using Web-based search and joining patient communities - they also want to be connected to their physicians for questions and care when appropriate. The way forward here is Participatory Medicine that combines and remixes health information and knowledge - some from experts and some from the crowd - in the interest of helping us live healthier lives.  Here is a very good description from Neal Kaufman, MD, a practicing pediatrician and the CEO of DPS Health, about how this will work:

...organized medicine needs to provide the day-to-day support patients need to prevent disease and to self-manage their conditions if they are ill. In the connected era that means just in time delivery of the personalized and up-to-date data and information a person needs to have the knowledge to make wise choices. It means supporting patients to easily and accurately keep track of their performance. It means providing tailored messages and experience that speak to each person based on their unique characteristics, their performance on key behaviors and their needs at that moment in time. It means helping patients link directly to family and friends for critical support, and link to their many providers to help integrate medical care with everyday life.

Making Data and Accountability the Routine By-Product of the Use of Health IT
Health IT can help make all health care professionals and organizations - physicians, hospitals, other providers, health plans, drug firms, device firms - more accountable stewards for quality, safety and cost results, and for the engineering required for continuous improvement. We can learn from our current supply, care delivery and finance processes in the same ways that Toyota and Wal-Mart monitor their internal business processes. 

But we need to design data aggregation into the products from the start, not as an afterthought. The problem is not just that we lack some important data elements to carry out these analyses now. More to the point, we have not committed nationally to aggregating, analyzing, and reporting the massive amounts of health data that we already have. Similarly, due to a lack of incentives and competing interests, most professional and organizational health care players have resisted using data to improve the quality, safety and cost of American care. 

Interoperabilitiy of various EHRs is absolutely critical to the ability to cost-effectively collect, manage, and report outcomes data.  All health IT products used in the care of diabetic patients, for example, ought to be required to export performance data relevant to care of diabetes in standardized formats.  All research of any kind depends on this capability.

Removing the Complexity and Cost Associated with Multi-Payer Claims Administration
Health IT ought to make claims payment, eligibility look-up, co-pay verification, and other administrative processes simpler, easier, and faster for providers, patients, and family members.  There is no good reason why we don't currently have an all-payer clearinghouse for patient administrative and financial information that is standards- and web-based. There also is no good reason why, in the era of PayPal, physicians and hospitals experience Days in Accounts Receivable of 36 and 55, respectively. As Rick Peters has written recently, it is time for us to build a scalable, XML, and cloud-based claims adjudication, public health, and quality reporting system to replace the entire archaic mainframe systems at CMS and their fiscal intermediaries. "Make the winning solution open source, implement it for Medicare and the CDC, and offer it free to every state Medicaid program and all the commercial payers," he says, and we agree it is time to use updated technology to resolve the inexcusable claims administration mess.

Closing the Collaboration Gap
Finally, a new generation of health IT platforms and services will close the "collaboration gap" that exists between the system's many sequestered players, who as a result perform so much less effectively and efficiently than they otherwise might. Clinicians, for example, diagnose disease and set up treatment plans but often are isolated from helping patients cope, manage, or adhere to these plans. Patients, once diagnosed, are motivated to manage their illnesses but often have few tools or methods to assist them. Purchasers and payers want to see clinicians use the most efficacious resources, but typically do not have a way to inform and reward evidence-based purchasing processes. In every case, health IT can facilitate a more collaborative experience that is tailored to the user's purpose, no matter what role that user plays in vast health care space.

Health IT presents enormous, unprecedented opportunities to improve the quality of care, to dramatically reduce the waste and cost inherent in our current approach, and to culturally transform physicians and patients so both become more actively engaged in improving health and health care. Bringing the fluidity of health information and knowledge that is just starting to fruition will allow us to leverage the true power of information engineering, and that can take many forms.  We think the name "clinical groupware" is more appropriate to this new class of health IT products and services than is the term "EHRs."  In any case,  the real health IT challenge to the Obama health care team is to step back, take stock of the kinds of applications that are emerging in the domain of health IT, including EHRs, and create an expansive, open policy structure that can leap beyond the status quo and really change the way American health care, in all its facets, works.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc.

Health 2.0 Road Trip Vroom! Vroom!

By David Kibbe

This country is simply meant to be seen from a motorcycle. It's big, it's wide open, and all sorts of Health 2.0 activity is happening.

Unless, of course, you're in downtown New York City, where you'd have to be crazy to drive anything. I kicked off the Great American Motorcycle Tour for Health 2.0 in Manhattan, in hot pursuit of the real people of Health 2.0, including Tara Parker Pope of the New York Times, and a host of folks who came to the HelloHealth opening party in Williamsburg, Brooklyn. Jay Parkinson was the master of ceremonies, but I also interview Nat Findlay of Myca and Howard Krein, MD of Organized Wisdom. Sans Honda Goldwing. So, I took the subway, did a lot of walking, and shot a lot of film.

I'm asking all the interviewees the same question:  Are YOU Health 2.0? And you will be surprised at some of the answers I'm getting. Who are these people, and why are they blogging, starting medical practices with videoconference capability built in, creating new kinds of health search and knowledge engines, and generally finding new and exciting ways to use Web 2.0 technologies? The stories behind the obvious are what I'm after, in a Zen sort of way, of course.

Next stop: Chattanooga, Tennessee. And, yes, this time I'm going to be traveling by motorcycle all the way. Vroom!

Health 2.0 Community Present and Vocal as Markle Foundation Policy Meeting Discusses "Consumer Access Practices for Networked Health Information" by David Kibbe

This meeting held by the Markle Foundation near San Diego  over two days  last week may turn out to be the most important health information and technology policy meeting of the past 5 years.  So I'll try to choose my words for this post very carefully.  If this increases the length somewhat, I apologize for that in advance.

Why was this meeting significant?  Simply put, the Health 2.0 community was involved. With Microsoft's Peter Neupert, Google's Missy Krasner, Esther Dyson, Adam Bosworth from Keas.com, Jamie Heywood from PatientsLIkeMe.com, Karen and Richard from Sophia's Garden, and representatives from MinuteClinic, Wal-Mart, Intuit,  Dell, eClinicalWorks, and Intel  present and vocal, this meeting had a different, and to my mind more open atmosphere than any other policy meeting I've attended.  It was not dominated by entrenched large health care enterprises, such as the  academic hospitals, Kaiser, health plans,  the large IT vendors, and the AMA.  In fact, those organizations were often on the defensive in the conversation, because they are perceived by some as not making it easy for consumers to get to the information they want and need.  In fairness to these and other incumbent groups who were present, I witnessed a new and a very welcome openness to discuss ways to get the data into the hands of the consumer.

Another reason concerns the excellent job done by the Markle Foundation, and David Lansky in particular, crafting a framework for the discussion, one that captures what is really going on with respect to health data and information storage, exchange, and use, and not just a theoretical construct of how it should be working.  Too many of these policy meetings over the years have represented merely a top-down view of incremental change favored by the entrenched big interests in health care.  This was a real breakthrough that should help connect Health 2.0 with public health policy.

Health 2.0, Computable Data Exchange, and The Sparse Information Model, by David C. Kibbe, MD MBA

One of the processes that Health 2.0 will certainly come to depend upon for its growth and utility is that of computable data exchange.  What I mean is this:  how do we help our customers/users get their basic health information; how do they upload it to our applications; and how do we store it for them in such a way that it can be re-used, re-connected, and re-purposed?  An important corollary of such a process specification involves answering this question: what do we mean by "basic health information" ?  I'm going to suggest that we employ what I'll call a Sparse Information Model to help solve these problems. The purpose of this blog is to get a discussion going about this process.

After all, we don't want to re-create the experience of the frustratingly infamous clip board and its paper forms, which must be filled out over and over again at the doctor's office or hospital. Health 2.0 applications and web sites don't want to force users to type in their own health information repeatedly, do they?  No, much better would  to collect the important health data and information one time,  and store it in a manner that can be used many times. To do this all Health 2.0 applications must know precisely how to import, read, and interpret the data when presented with them. This might be the "glue" that holds numerous Health 2.0 partners together, allowing many different kinds of sites and applications  -- search, social media, decision support tools, pricing sites, etc. -- to make the user's experience of sharing his or her health data seamless and easy, across those domains.