Archive | September, 2008

Ranting: Do We Know What We Want?

This is a little bit of a rant set off by the current market / political situation.  First, I know we all think of this as a bailout…apparently the messaging is 20:1 in DC from their constituents.  I wonder how many of those people are the same people that wanted loose credit standards so that more people could afford houses and people could get bigger houses.

Blaming the banks is like blaming the auto companies for making SUVs.  They are giving the consumers what they want.  If consumers are willing to buy it, someone is going to make it.

But, this has lots of application in healthcare.  We are critical of the fast food companies for contributing to our obesity epidemic, but we don’t want government regulation and we don’t self-regulate.  We want to stay compliant with our medications, but we forget and don’t want to be told what to do.  We want to have unlimited access to care, but we don’t take preventative steps…we wait until it’s an emergency.  We don’t want prices to go up, but we want to have every possible test done using the latest technology.

So…why do we shift blame around?  We need to understand the long-term implications of our decisions from wanting the bigger house to driving the SUV to eating whatever we want.

How Are You Classified?

One of the typical models used by consumer marketers is the Prizm model by Claritas.  If you’re interested in whether you’re a “Pools & Patios”, “Home Sweet Home” or “Empty Nest”, go here and put in your zipcode.  In my case, it gave me five possible classifications – Blue Blood Estates, Exec Suites, Kids & Cul-de-Sacs, Movers & Shakers, and Winner’s Circle.  After looking at them, I could quickly see myself being classified as the Kids & Cul-de-Sacs one (see below).

They start with 66 different categories which can be used.  Of course, this is primarily driven by zipcode and a few other attributes and misses things around your attitude towards health that you might find in other health segmentation models, but it is an important marketing fundamental to understand.

Retail Healthcare Blog

Just a quick note on a new blog someone sent me on the Retail Healthcare Market.

Drug Not Covered – What To Do?

As I was doing this for my son, I realized that most people probably don’t know that the option exists.  It’s something called a Formulary Override.  If you are prescribed a medication that is not covered (meaning you pay full price), you can get it covered at a 3rd tier copay (less than full cost) if your physician requests it and has a legitimate medical reason for it.

So…what do you do:

  1. Call your health plan and select the IVR option for pharmacy.
  2. When you talk to a call center agent, ask them about your drug.  They will confirm that it isn’t covered.
  3. Ask them what you need to do to get it covered (or ask them specifically for a formulary override form that your physician can fill out).
  4. Get the form (or download it from their website).
  5. Ask your physician to fax it into their prior authorization department.
  6. They should quickly run on it for you and have you set up in the system within a few days (if approved).

Just a quick inside hint for you.

Win Detergent – For Athletes

Not really a product promotion, but I have been so impressed that I thought I would post a more light-hearted entry.  I just started using this Win Detergent for my running clothes.  Much better.  For those of you that are athletes and have trouble getting that sweat smell out of your workout clothes.  Give this a try.  (I get it at the local Dicks Sporting Goods.)

WOW – They Didn’t Approve the Bailout!

I honestly are very surprised.  I don’t think anyone of us wants there to be a bailout, but I have to talk about the fact that I am shocked that it didn’t get approved.  In healthcare, we have already seen an impact in terms of less preventative care, less compliance / adherence, and this will only make things worse.

Ideally, the government shouldn’t be involved in private enterprise, but I also hope that the government can stop the bleeding across all markets.  Job losses and loss in savings or retirement accounts will be a massively depressing one-two punch to many people. Not to mention the tax it will be on the government in terms of unemployment and the tax on the healthcare system in terms of uninsured.

And, with little liquidity in the credit markets, people can’t be as entrepreneurial to start their own businesses, and they don’t have a lot of access to credit to move or live paycheck to paycheck.

I know it’s not a healthcare issue, but without a stable economy, it’s going to be hard to take on healthcare reform.

Flu Shots Coming

With the recommendation that 86% of the population needs a flu shot this year, will you get one? I will. So the question is what will employers and insurers do to encourage this.

It seems like a great opportunity for them to communicate a positive message. Wouldn’t you like to receive a call telling you that you need to get a shot and where to go? It will be even more important as supplies get limited.

This is one of those low cost opportunities to build good will and potentially avoid some real costs of urgent car and ER visits as the elderly and kids get the flu.

I Get A Different Conclusion

In the same Express Scripts’ investor deck, I have to disagree with the slide below which is supposedly proof that the Consumerology efforts are working.

Showing me that the trend for a client who was above their norm last year (see drug trend comparisons), went down to 3% (year-over-year) increase (which is over both Medco’s and Prime Therapeutics’ average trend) doesn’t seem that impressive.  In the years when I worked on the drug trend publication, we showed that the average client with two or more plan design changes had negative trend, on average.

And, further complicating this example is the fact that this shows a client implementing mandatory mail, mandatory generics, and step therapy.  These are a series of proven, reject oriented solutions that force the member to make changes or pay much more.  Anyone can drive trend with these.  If you show me that non-reject oriented programs work to the same degree due to targeting and personalization using consumerology, then I am impressed.  Obviously, I am not there anymore, but I don’t think this is a compelling case study for consumerology.  Maybe there is more to the story like no impact on the call center or no impact on member satisfaction or less members hitting a reject at the point-of-sale (POS).

Express Scripts Patient Segmentation

In a recent investor deck, Express Scripts laid out some of their segmentation from their Consumerology program.  This is similar to some of the work we do with clients at Silverlink Communications to help them develop segmentation models through a test and control approach.

What they have come up with are 5 segments of their members – “Movers and Shakers”, “Rock Solid”, “Getting By”, “Rising Stars”, and “Here and Now”. They describe some of the attributes of each segment on the first slide below and then show how messaging on driving mail order utilization was applied for each segment over the web.  The final slide below shows the results when the targeted messaging is used on the web.

It will be interesting to see how that messaging plays out via other channels (i.e., letter or outbound call) and when pushed to the member versus a situation where the member is on the portal and looking for information (a fairly engaged member).

Drug Trend Comparisons

Here are a few comparisons from the Drug Trend Reports published by some of the largest PBMs. There is no industry standard on definitions and what is included so I did my best to pick a couple of comparative metrics. (Note: In case you are unfamiliar with these reports, they are summaries of 2007.)

Overall Trend

Specialty Trend

Managed Trend

Generic Dispensing Rate

Mail Order (90-day)

CVS / Caremark






Express Scripts










Prime Therapeutics









    • They break out their best in class as having a 3.4% trend and say that clients who used proactive trend management were at 2.1% on average.
    • Best in class generic dispensing rate was 65.6% (employers) and 66.7% (health plans).
    • Mail order rate as reported in press release for close of 2007. (Not sure how to compare this to the 12.8% reported in their TrendsRx report.)
    • Overall trend was 5.5% when specialty drugs are included.
    • Had to find the generic fill rate in their 4th quarter financial press release. Either I missed it in the trend report or it was strangely missing.
    • Mail order rate was derived from the same 4th quarter release which showed 40.8M mail Rxs and 507M adjusted Rxs. Multiplying 40.8 by 3 to adjust from 90-days to 30-days and dividing that by 507 gave me the 24.1%.
    • Deriving the mail order rate from the 2007 full year press release gave me 94.8M mail order Rxs which I multiplied by 3 to get to adjusted Rxs and then divided by 748.3M to get 38.0%.
  • Prime Therapeutics trend report (Drug Trend Insights)
    • Their trend was 2.9% if specialty drugs are included. Trend ranged from (1.3%) to 7.5% across their blues clients/owners.
    • Overall trend was 5.66%. The 4.8% excludes specialty trend.
    • GDR was 69.6% if you include Medicare.
    • The 35.9% mail order rate includes their Advantage90 offering for 90-days at retail.

Revolution Health For Sale

I was a little surprised to find out that Revolution Health is up for sale.  On the one hand, they pursued a WebMD type strategy when we all know tons of companies have died going down this path.  But, they had lots of money and lots of smart people.  Does that mean success?  Not necessarily?  We have all seen the teams full of stars that can’t outperform the true team of average players.

On the flip side, it seems so early to go up in a space that is obviously destined to grow.  It just goes to show how undefined it is and how hard it is to make money.

Individual Insurance Premiums

Citibank put out a report about the individual market for health insurance.  I found the following chart from eHealthinsurnace to be interesting.  It shows the family premiums broken out by age and gender.

Uninsured Segments

I thought this graph from Aetna was interesting on how it segmented out the uninsured and pulled out some of the high level groupings.

Ipsos Obesity Study

Ipsos, a research group, just published an obesity study which looks at attitudes and perceptions around obesity around the world.  Here is one chart that shows the level of worry about obesity versus the level of obesity within the country.

78% of people surveyed supported education as a tool and 22% supported government intervention.  The government intervention options were interesting:

As you might imagine, Americans were the least interested in the government prohibiting the sale of unhealthy foods to minors.

Broken Processes

Sometimes the best processes just don’t work…typically because of human error.  When I returned my rental car today, they told me that it wasn’t my car.  Apparently, I had somehow left the lot with the wrong car.  Which means they parked the car in the wrong spot or told me the wrong spot to go to.  On the way off the lot, they checked my paperwork across the barcode so I don’t see how that happens.

That made me think about an incident the other day at my pharmacy.  When I was tracking down my paper receipts for my old prescriptions, I went to my pharmacy and asked for a prescription history.  The pharmacy technician printed out all my prescriptions from the past 18 months after asking my name.  But, he never checked my identification.  I am not sure, but that seemed a little too easy especially since it was a tech at a chain pharmacy that had never seen me before and where I hadn’t been for months.  Given privacy issues, that can’t be the official process.

Still Want to be an MD

In the letters to the editor section of today’s (9/16/08) USA Today, there was a grim quote that I thought worth repeating. It was in response to their article on “Boomers May See Doctor Shortage” and is by a Dr. JA McErlean.

“Imagine how many applicants would apply for this job description: ‘Idealistic Generation X/Y overachievers with low- to mid-six-figure student loans to work in imploding health care system currently subject to runaway entitlement spending. Future salary to be subject to government whim and guaranteed not to keep up with inflation. Will be subject to unreasonable expectations of patients and held responsible for less-than-perfect outcomes by consumer advocates and trial lawyers. Must be able to work 70-80 hours per week, not including on-call duties, and place family obligations a distant second to career pursuits.'”

This points out so many issues that I am not sure how to respond:

  • Student loans and college tuition – a runaway issue that seems to be getting better as colleges are more willing to allocate their funds to support students with grants.
  • Imploding system – clearly a system in turmoil, but aren’t most. Just look at our financial system here in the US with Lehman Brothers filing for bankruptcy.
  • Entitlement spending – not my best area of knowledge so I won’t comment.
  • Payment schedule – definitely an issue. How to compensate physicians and motivate physicians to drive outcomes is a complex problem which has to be fixed. What is appropriate compensation for an hour of work is a complex problem looking across how teachers, doctors, CEOs, line auto workers, and others get paid.
  • Patient expectations – not sure on this one. I think I could find people in every line of business from professional athlete to landscaping that would complain about customer expectations. I think some of this gets back to a better system (technology) and the right incentives. No more limiting the interaction to 15 minutes.
  • Perfect outcomes and litigation – obvious physicians aren’t the only one responsible for outcomes. Medicine isn’t an exact science (yet). Patients have a lot of responsibility for adherence and diet among other things. Litigation is and has been an issue for years.
  • Working long hours – I think lots of people suffer from this. I agree that generally physicians work more hours than lots of people which seems risky to me since that has to increase to probability of an error.
  • Balance – anyone pursuing a career with a family has this tradeoff and balance issue to deal with.

I guess it all depends on what you want out of life and your career. We would all like to find the well paid job with average hours which allowed us to control our schedule had understanding customers and where we are doing work that we are passionate about. I think physicians do have it hard, but I would expect that many hard-working Americans who can’t even make ends meet working two jobs won’t be real empathetic.

CVS Comes To St. Louis

St. Louis is pretty well dominated in the chain pharmacy space by Walgreens. After that, I would bet market share is pretty well divided across independents and the primary grocery stores of Schnucks and Dierbergs. I remember years ago when we looked at narrowing retail networks at Express Scripts we looked at a lot of markets and different chains. I think for our members over 50% of the pharmacy claims in St. Louis were filled at Walgreen’s stores. Eliminating them from the network would be a major disruption and a competitive disadvantage for those employers and health insurers.

I had heard the rumor that CVS was building its first St. Louis store about 2 miles from my house, and I saw an article in the paper about it a few weeks ago. They will definitely be in the middle of Walgreen’s territory. I have about 5 Walgreen’s stores within 5 miles of my house. And, four of them were built in the past 3 years.

I find that competitive strategy very interesting. It’s like Home Depot and Lowes. They are usually located near one another. In that case, you might grow the market slightly, but I don’t think the same is true for pharmacy and convenience store items.

Lose Weight Without Dieting

Isn’t that a great teaser! My wife was reading an article to me the other day from some magazine. Some famous person was claiming that they lost 30 pounds without dieting. Of course, that sounds promising (and probably sold a lot of magazines).

In the end, the person talked about working out 6 days a week for at least an hour and changing all the foods they ate to be healthy. Maybe not a “diet” technically (just like we are technically not in a “recession”), but I think most people can lose weight if they work out 6 hours per week and eat healthy food.

Ultimately, it is a very basic equation. Calories in versus calories burned.

Battle to Buy Long’s Drugs

Not a big surprise for CVS Caremark to make a play for Long’s.  They have been a much more acquisition oriented company.  But, Friday, Walgreens came out with a slightly larger bid which is much more unusual.  Walgreens until a few years ago had grown almost entirely through organic growth.  (WSJ Blog on this)

With Long’s, either company will get 500 stores in the West – CA, AZ, HI, and NV.  They will also get RxAmerica which is a PBM with 8 million lives.  This would be a big jump for Walgreen’s PBM, and a nice bump for the CVS Caremark PBM.

The CVS Caremark deal was essentially done at $2.7B before Friday’s public bid of $2.8B by Walgreens.

Tom Ryan, Chairman, President and CEO of CVS Caremark, commented, “Our offer represents a full and fair price for Longs shares, and we stand firm on our price. Furthermore, the CVS Caremark’s offer has cleared all regulatory hurdles and provides certainty of completion to Longs shareholders.”

So far, it doesn’t seem like CVS Caremark is going to up their bid.  Tom Ryan should be used to this.  When they bought Caremark, Express Scripts made a late bid in the process.  I am not sure what will happen here, but I would expect that seeing Walgreens as the bigger will certainly make them think hard about how to get this deal done.

Texting for Deductibles and Copays

I often get a lot of ideas from financial services.  I was watching a banking advertisement yesterday where the customer could text their bank to get a real-time balance.  It made me think what a great service that would be in healthcare.

Imagine texting your plan for an immediate response on:

  • Your deductible
  • Your FSA balance
  • Your copay on a specific drug
  • Whether a provider is in network
  • The status of your prior authorization
  • A list of formulary alternatives

Since a lot of the logic exists, the question becomes one of using this medium and designing a secure mechanism for accessing the system and providing information.  Patients would have to register their mobile phone and approve it for PHI.  (There may be more to this, but it seems like it must be doable.)

Predicting Sickness

Wouldn’t it make the job of wellness a lot easier if we could predict who will get sick. There might be some indicators, but then you need to act and convinve them to take action. A little bit of the Holy Grail.

“We know that 59% of individuals [who seek services] are newly sick, and would have fallen into the ‘healthy’ category 12 or 18 months ago. We want to find these people before they get sick to see if we can reduce the risk or help them retain their health and vitality.”

— Jodi Prohofsky, senior VP of operations for CIGNA Corp.’s Health Solutions unit, telling AIS’s Health Plan Week about CIGNA’s new “It’s Time to Feel Better” outreach program.

WSJ on Personal Home Pages

An article that I found of interest was in the Wall Street Journal back on the 14th of July…it is about whether people have or will have their own personal website – Facebook, LinkedIn, blog, etc.  I think it’s a good discussion topic especially given all the discussions around Health 2.0 and doctors and patients blogging about events.

Disease Management Evaluation – Care Scientific

My former boss, Brenda Motheral, from Express Scripts spent a year at Healthways running their research group and has now decided to go out and do some consulting (new company is Care Scientific).  Her evaluation of the Disease Management industry was just published in the Journal of Managed Care Pharmacy.  It is a pretty critical view of the state of the industry.  Here are a few highlights:

  • There have been several articles published questioning the value of these programs this year.
  • There are five reasons for dissatisfaction:
    • Desire for better alignment of vendor and client interests
    • Desire for greater transparency in business arrangements
    • Desire for improved plausibility in reports of financial and clinical outcomes
    • Desire for more rigorous evaluation methodology
    • Desire for more convincing evidence of outcomes improvement
  • There is misalignment today…For example, if I get paid per member, how hard should I try to contact them when all that will do is drive up my costs.
  • Lack of alignment can be addressed through contractual requirements and pay per engagement.
  • There is a lack of data available on how many members are contacted.  [Not for companies that use Silverlink for their automated outreach who have real-time data available with detailed call information.]
  • There are calculation questions in comparing vendors.  [Something I have talked about several times here.]
  • She compares the move to transparency in this industry to what happened to the PBM industry earlier this decade which created new competition and changed several business models.
  • She advocates for really looking critically at the ROIs claimed by these vendors and talks about NND (number needed to decrease) which is the model that the DMAA (Disease Management Association of America) adopted as part of their outcomes guidelines.
  • She also raises concern about DM companies moving into wellness which is another area “fraught with numerous new methodological issues that warrant close attention”.
  • She talks about an industry push (from buyers) to demand new expectations from vendors.
  • She talks about the fact that the focus on ROI may not make sense since “literature suggests that less than 20% of treatments for existing conditions are cost-saving.”

“Plan sponsors also bear responsibility for the current situation.  As long as they demand a short-term ROI in the current model and inconsistently require comparison groups, they are more likely to promote methodological creativity than they are to inspire true innovation.”

As with the dozens of publications she has had over the years, this one is well written with a well referenced set of facts.  She presents a challenge to the industry in how to approach.

The challenges are interesting to reflect on given the overall industry focus on improving healthy behavior, being more proactive, more actively managing patients, and other activities that a DM company should be well positioned to do.  But, a high touch model is certainly challenged given lower cost options.  Creative solutions that leverage technology to identify gaps in care, create data segments, personalize interactions based on preferences, and use motivational interviewing to drive behavior exist and should be able to create value.  It will be an interesting 12-18 months for the industry.

Managing Antibiotics in Hospitals

I got this story from PharmacyOneSource the other day and thought I would share it.

“Between one-third and a half of all hospital patients receive antimicrobial drugs, and antibiotic prescriptions can account for 30-50 percent of many hospitals’ total drug budgets. Researchers estimate up to half of these are unnecessary, and this excess also contributes to the problem of drug-resistant bacteria.”

They gave two case examples:

  • Johns Hopkins implemented a web-based approval system for more than 30 antimicrobial drugs on a “restricted” list. The system forces orders to be approved by an infectious disease specialist before they are sent to the pharmacy. They found it saved $370,000 in the first year of its use.
  • University of Virginia found that switching between two antibiotics, linezolid and vancomycin, every three months in the surgical ICU decreased the MRSA infection rate from 1.9 to 1.4 patients per 100 admissions.

Medco’s CEO on National Healthcare Reform

David Snow, the Medco CEO, presented his blueprint for healthcare reform today. You can read it here. My notes from reviewing it are:

  • We’re paying twice as much per person (~$7,000) as other countries with little incremental value. To get back in balance, we need to reduce costs by 50% or $1 trillion per year.
  • 3 rules for reform:
    • “First, keep it simple – in business, complex solutions always fail.” [good advice…difficult to do with politics and government involved]
    • Incremental, evolutionary change is more accepted than revolutionary change. [yes…but it will take a lot longer]
    • Government and private sector’s roles have to be clear:
      • Government – promulgate and regulate.
      • Private – operate and innovate.
  • “Setting policy around life-and-death decisions is, and should remain, the province of the public sector.” [what politician or elected official wants to determine the value of a life]
  • Five suggestions (which create $1 trillion in savings per year):
    • Wiring healthcare
    • Fixing Medicare’s financial fundamentals
    • Eliminating medical liability and defensive medicine
    • Increasing compliance and reducing errors
    • Promoting healthy lifestyles
  • “In an era when preschoolers use the Internet to chat with friends half a world away, it is inexcusable that doctors write prescriptions – in Latin – that patients need to take to another professional in a process fraught with countless opportunities for error.”
  • “30% of Medicare spending today, roughly $130 billion, relates to healthcare costs incurred by patients in their last year of life – often where there is no hope for recovery or improvement in quality of life.”
  • He makes some good points about the need for government involvement in changing attitudes around wellness comparing it to the changes around forest fires and seatbelt safety.
  • “When our political discourse is limited to ‘who pays the bill’ instead of ‘the bill is too high,’ and fails to address root-cause problems, that isn’t health care reform.”

S.A.D., ADD, OCD – Are we all affected?

A friend from Europe pinged me a few months ago to see if I wanted to connect him with someone who could distribute SAD lighting here in the US.  (SAD apparently means Seasonal Affective Disorder.)  Before even responding, I talked to a chief medical officer I know to validate the condition and the effect of lighting.

But, it made me wonder…are there some diseases that many people have to a lesser degree that we rationalize in different ways.  If people with SAD are depressed and have less energy in the winter due to lack of lighting, is this what many others simply refer to as the winter blues and just take for granted?  I can think of lots of people who are different in the dark winter months when they are inside.

For that matter, for people with ADD (Attention Deficit Disorder), focus is a challenge, but many of our most creative and innovative people are people who thrive in some chaotic form and come up with new ideas (e.g., story about CEO with ADD).  Do they all have ADD or some mild form of ADD?  (CBS article)

I could go on, but let’s look at one more – OCD (Obsessive Compulsive Disorder).  People with this condition can’t help themselves with certain actions – e.g., washing their hands until they bleed.  But, there are lots of people who are considered meticulous or anal retentive who get rewarded for their focus on detail and ability to do mundane tasks repeditively with little error.  Do these people have a mild form of OCD?

Don’t You Want To Live

Apparently, the Walgreen‘s CEO told the WSJ that not only is this a tough year, but they are taking a tough love approach with their patients.  In their blog earlier today, they said that Jeffrey Rein said “Walgreen pharmacists try to persuade patients to take their pills by asking them whether they want to be alive to see their children grow up.”

As they talk about, there have been several studies showing that patients are skipping pills and doing other things to stretch their prescriptions.  But based on what I saw in the Lehman Brothers research yesterday about Walgreens, I wouldn’t have thought things were that desparate.  They reported August same-store stales of 3% which is low compared to their historical results but still positive in this economy.

Interestingly, the report commented that they were increasing promotional activity which would negatively impact front end margins while CVS had recently said that it’s promotional spending (as a percentage of sales) was lower.

[In full disclosure, I do not own any of these stocks as individual stocks.  They may be held in mutual funds that I own.]

Prescription Price Elasticity Explained

If interested, Emily Cox who runs the research group at Express Scripts recently put up a post on some research on this topic on their blog.  This is a relevant target based on the discussions around compliance and value based insurance design.

60.7 miles a day for 51 consecutive days!!

Amazing is all I can say.  I can’t even believe that there is a 3,100 mile race in existence.  Obviously a very small number of annual participants – looks like 14 this year.

I thought it was impressive when Dean Karnazes did 50 marathons in 50 days a few years ago.  But, to have to do 2 marathons a day for the same period seems inconceivable.

Probably one thing (like running barefoot) that I am unlikely to try.

Payers Spending On BI and Information Delivery

“Healthcare payer spending on business intelligence, information delivery and transparency is the fastest growing spending category in 2008 for healthcare payers,” said Janice Young, IDC Program Director, Payer IT Strategies.

This quote was in our press release this morning around the growth at Silverlink.  You can read about the company in the release, but I wanted to focus on this quote from IDC.

On the one hand, I think consumers should be saying “Amen!” that payers are focusing on business intelligence (BI) although that can mean a lot of things.  On the other hand, they would shocked to know how new this is to the healthcare space compared with the consumer packaged goods industry.  BI can help identify gaps in care and identify how to help patients become better.  BI can help personalize the messaging that you receive from your health plan so you don’t have these huge legal caveats about all savings and other specifics being based on your exact plan design and deductible.

Information delivery can also mean a lot of things.  Is this reporting to the employer?  Is this online analysis for the consumer?  Is this communications?

And, I am not sure what transparency means, but I hope it means things like letting consumers actually understand the price of goods and services and how to make tradeoffs between different options with all the data (e.g., quality, price, outcomes, patient experience).

Overall, for those of us in the healthcare communications space, this is a rising tide that helps.  It means the payers who support all of you consumers are raising the bar and looking at how to use their information to improve the experience and outcomes (ideally).  It could also allow them to better focus their efforts on the riskiest patients and discover the best way to drive behavior.

The data is there and has been there so figuring out how to use it and what to use it for is critical.  Mapping this against the patient expectations and desired activities can be a great positive for the consumerism movement.  Integrated data.  Accessible data.  Digestible data. Sounds great.

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