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Health 2.1 By Esther Dyson

Of all the participants at Health 2.0, Esther Dyson may be the best known outside the world of healthcare.  Esther was one of the earliest backers of Health 2.0 and it is far from an exaggeration to say that the conference would not have been possible without her support and encouragement. Together with Steve Brown of Health Hero, David Kibbe of AAFP, Lee Shapiro of Allscripts, Jay Silverstein of Revolution Health and CommerceNet’s Marty Tenenbaum, she anchored the day’s closing reactor panel: "Health 2.0: Looking Ahead."  Today she offers her reactions to what she saw and experienced on September 20th. This post first appeared on Esther’s blog at the Huffington Post, from where it has been repotted, as Esther might put it. 

Last week I participated in Matthew Holt’s and Indu Subaiya’s Health 2.0 conference,
which attracted more than twice the number of people they had
anticipated (about 500) and left many more turned away. So, clearly,
something’s in the air.

    People
    are excited. There were two drug-interaction companies – DoubleCheckMD
    onstage and PharmaSurveyor at a booth – that allow individuals (and
    doctors) to mine huge amounts of information to assess heir own drug
    combinations. There were countless social networks, self-monitoring
    services and other harbingers of the new, user-controlled world of
    health online. [Disclosure at the end.]

    My role was as an end-of-day panelist, reacting to what I had seen, and
    here is what I said (somewhat cleaned up, of course). It brought me
    back to New Year’s of 2004/2005, when I attended a
    health-care panel at Renaissance Weekend. In Renaissance fashion
    (everyone’s an expert), there were about 25 panelists and three of us
    in the audience. The experts were indeed experts: head of a health
    insurance company, a longtime ER doctor, a couple of execs from a
    variety of health 1.0 providers (i.e. hospitals and clinics), some
    government officials, and so on. They were intelligent, lucid, sincere
    and well-meaning. Each of them gave a little talk he or she had clearly
    given a hundred times, and each of the panelists had probably heard at
    least some of the other panelists ten or twenty times. They explained
    the problems with the system eloquently: mis-aligned incentives,
    stalled information flows, undereducated consumers, overworked doctors,
    prohibitive liability insurance and excessive CYA testing, and on and
    on. It was clear nothing could be done.

    If this session had been held in my industry, I thought,
    there would have been five ex-doctors with perpetual-motion-like
    schemes to predict the onset of cancer, realign incentives, re-train
    consumers and avoid the extra testing through better information
    management. And there would have been ten VCs waiting to fund them.
    Where was the energy, naivete – and funding – that could foster change?

    Two years ago at CNET I managed to get 100 participants to such an
    event (on "Personal Health Information"). It was tremendously exciting,
    but not really the critical mass that Matt and Indu collected last
    week.

    A calcified heart

    Yet I’m not sure it is a critical mass yet. The folks
    assembled will certainly create something new. In a way, they are like
    the mobile phone companies, routing around the dying landline
    companies… but now that all the incumbents have bought most of the
    mobile companies, it’s not clear what we have achieved.

    In the same way, the companies here are empowering consumers (or
    patients) giving them the tools to talk to one another, to question
    their doctors, to monitor their own conditions…

    But they can’t simply dissolve a hairball, as someone described the
    health care system earlier in the day. They need to take on the
    calcified mess at the bottom of the drain – or to be more anatomical
    about it, they are clearing the capillaries and buffing the nerve
    endings, but at the center of everything there’s a calcified heart
    pumping blood/information/money in the wrong direction through a
    tangled mass of arteries that misdirects resources to tumors and
    useless vestigial organs.

    That will take serious staying power and serious money. Many of
    these companies have no business model at all – except perhaps for
    being bought by Google or Revolution Health or some wealthy eyeball
    aggregator.


    Routing around the damage and eroding the center

    Yet I’m optimistic. These start-ups will tug at the system. Instead
    of relying on blood from the heart, they’ll start to generate their own
    – whether it’s genetic information supplied for their own purposes by
    individuals and also contributed (or sold) to research; user-generated
    monitoring data; or user payments from people with large deductibles or
    no insurance at all.

    Things start to change when the institutions don’t control all the
    information. Even though the largest flow of money will still be
    centralized and often mis-directed, the new user tools will make all
    the tangles more visible.

    At that point, the Health 3.0 conference will have to include folks
    from the establishment – government, large software vendors and
    entrenched health-care institutions.

    Information won’t make you free, but it will force you to address the questions

    One way or another, we’ll start to face the questions we used to
    bury in obscurity: Who pays? Who costs money? and most compellingly:
    What outcomes should we expect for any given population and what
    outcomes do we actually get? That’s when we’ll be able to see the
    impact of the institutions: I.e., we’ll be able to say which
    institutions do a good job, after adjustments for the population they
    serve (wiping out the excuse of "well, you see, we have a unique
    population of patients so it’s unfair to compare us to any other
    institution.")

    Once that happens, we’ll have to start facing the basic question:
    How much of each person’s health care costs should be a public
    responsibility, and how much should be borne by individuals?

    Let me leave that question hanging, and move on to the second point.

    With all thy getting, get understanding

    Yes, it’s true that at the center of our health care system there’s
    a giant fibrillating mass of heart and arterial tissue. But at the
    center of each of the putatively empowered users we celebrate, there’s
    a hardened, irrational human soul, greedy for short-term gratification,
    terrified or oblivious of consequences, and innumerate to boot.

    Much of the conversation centered around getting information to
    users, but what about getting them to act on it? Probably the strongest
    candidate in that field is RealAge.com,  which Hearst is acquiring for a reported $100 million. They weren’t there, unfortunately; they were probably busy talking to the new owners.

    RealAge is a slightly cheesy site that relies a little too much on ads
    for vitamin supplements, but it is focused on behavior modification.
    You fill out a fairly lengthy questionnaire – but it asks you things
    you are likely to know, such as your number of friends or *whether* you
    take your meds, not which ones they are…. Then it calculates your
    RealAge, which is either lower or higher than your calendar age
    depending on your answers. It’s pretty easy to figure out how changing
    your answers will change your RealAge. Drive slower – or report that you drive slower – and voila!  minus quite a few months!

    Sure, people may lie, but they’d prefer to tell the truth and
    RealAge motivates them. I bet that RealAge has changed more behavior,
    more cost-effectively, than any entity other than Alcoholics Anonymous
    (and perhaps some churches).

    Social networks may come close, and they are a wonderful
    development. A large number of them showed up at Health 2.0, including
    both disease-centered patients’ groups and doctors’ and clinicians’
    communities, each with its own approach.

    But most of these are for care-givers or for the ill. The trick is
    to reach the healthy as well as the ill. In the end, the cheapest way
    to foster health is to maintain it, reducing the need for health care
    in the first place.

    Disclosure:  I’m on the board of (and an investor in) 23andMe, an investor in PatientsLikeMe, Ovusoft , and a likely investor in ReliefInsite. I was an investor in Medstory,
    now happily repotted at Microsoft. And I’m a research subject in George
    Church’s Personal Genome Project – more about that soon.

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