Recently, Google announce that the Google Health PHR will be retiring.
I posted the announcement to the Society for Participatory Medicine mailing list, and there has been alot of discussion about this, there. There are several issues that lots of people do not seem to understand, and some implications of this that have been missed.
Losers: Google Health Users
Let me be perfectly clear. If you trusted Google Health with your healthcare data you are screwed, unless the Microsoft HealthVault team rescues you. Even then, you are likely screwed anyways.
The whole point of Google Health was that it was more than a mere store of your XML patient data. It was a network of providers, like pharmacies, drug companies, non-profits and countless other service providers who added value to your health record.
I love the Direct Project but it only makes health data mobile, it is another matter altogether to make your health data semantically useful again. There is no way that the HealthVault team will be able to replicate 100% of the value that Google Health was providing based merely on the XML output from Google Health. As service providers and patients themselves added to their Google Health record, it made those records more complex than HealthVault, or any other PHR system, can easily understand. This is called Lossy Data Conversion.
The patients who will lose the most useful data, are those patients who leveraged Google Health the most. The more you invested in Google Health, the more screwed you are now. Of course, the other group who is going to be really screwed are the people who do not pay attention to announcements like this at all, (and ignore or filter email warnings) who will try to find data they stored in Google Health four years from now, only to discover that the deadline for data download had passed, and their data is gone. Ironically, the people who this is most likely to happen to are older people, who are not terribly tech savvy -and- who might have stored data in Google Health precisely so that they could ensure it would be available as they aged. Again the more they invested, (seemed like a good idea at the time), the more screwed they are today. Not good.
Probably the most important lesson to take away from all of this is that trusting proprietary health software vendors or services with critical health data is a bad idea. But sadly, that will not likely be a lesson learned here.
Losers: PHR vendors
Second, there is the implications for PHR vendors. It does not look good for you. Google is in a unique position as a company. It is capable of making money giving away very valuable services, because it makes more money on advertising when someone merely uses the site. The business plan on Google Health was, essentially
“Lets spend a few 10’s of millions on this, and then make it back because a few million people will click on ads, after leaving Google Health to do a web search of some kind.”
Your average PHR company cannot make that kind of play. Most companies do not have a way to translate mass visitors into dollars. That is what makes the gmail service work for Google. Enough people click on ads through the service to pay for the entire thing for everyone. Google specifically admitted this problem in the post above with:
But we haven’t found a way to translate that limited usage into widespread adoption in the daily health routines of millions of people. That’s why we’ve made the difficult decision to discontinue the Google Health service
So if you are trying to start a PHR business and you cannot afford to give away a product you spent millions developing for years… this spells trouble. Google Health and Microsoft Healthvault together spelled the end of the still languishing dot-com bubble PHR services. I cannot imagine an investor in their right mind who would touch this space with a business model anything like Google Health.
Here is the basic takeaway from Google Health PHR:
People are not willing to use a good stand-alone PHR, even if it is free.
That word “stand-alone” is critical.
Losers: Me
I have been wondering, as a right this, if I should be a winner or a loser on this one. I get to say “I told you so” to everyone I warned not to invest in a proprietary platform… which is fun. But I also now have to almost entirely re-write a chapter in my new book.
I (along with intrepid David Uhlman) am writing the first book on Health IT for O’Reilly media, called “Getting to Meaningful Use and Beyond“. I wrote the chapter on patient-facing software, and I featured Google Health extensively. After all, it was relevant, last week. I felt reassured after I asked Roni Zeiger a month or two ago if Google Health would survive? After all, I had heard rumors. He told me not to listen to gossip and I left feeling like my chapter would be published intact.
So much for meeting my deadline.
Winners: Direct Project
As Google Health dies it is giving a ringing endorsement to the Direct Project (of which I am a contributor). Hopefully this will raise some awareness regarding Direct as the foundation for the first generation of the Health Internet.
Winners: Microsoft HealthVault
Most of the industry pundits, like myself, have recognized for years that the “build the platform” business model that worked for Facebook and Itunes, was not going to work for Personal Health Records. Why? No “killer app”. Itunes+Ipod was the killer app for the Iphone platform, for Xbox it was the original Halo. For Facebook it was your ‘wall’, or perhaps (shudder) FarmVille.
The killer app for a PHR is dead simple: Healthcare. The two most widely used and successful PHR deployments in the country are the Kaiser Permanente and the VA’s My Healthevet. Why? You can get a message to your doctor through them, and receive replies back. They are a component of your actual healthcare. You do not have to type data into them, its just there. If you want to schedule an appointment or view your lab results you can do that. If you want to renew a prescription, the PHR can help. In short, the PHR is a workhorse in your actual healthcare process.
The Microsoft Healthvault team gets this. That is why they have been working on the Direct Project for months. They know that the Direct Project is the only way that they can have their PHR connect to -all- doctors the same way that Kaiser and the VA connect to their doctors.
Moreover, HealthVault has the only working mass-scale Direct beta in deployment: It is very likely that the only place you will be able to transfer Google Health records will be directly into HealthVault, for the foreseeable future.
HealthVault just became the 800 gorilla in the space.
My only question is why didn’t the Google leadership see the strategic significance of the Direct Project? They were obviously aware of it technically, and they usually do a good job translating technical understanding into strategic understanding.
Seems pretty simple to me. PHR usage is high -only- in systems where you can communicate with your healthcare provider in various ways. Google was disappointed by how few people were using their PHR. Direct is the only chance in hell that you have to reach every healthcare provider in the United States in the next five years. When you put it like that, Microsoft’s strategy seems pretty obvious… why didn’t the Google leadership catch on? Probably the Direct opportunity was too little too late for the internal political process at Google.
Winners: Indivo X
Indivo X has almost all of the same benefits as HealthVault (they are little behind on the Direct implementation and beta deployment), but if you actually want to avoid a repeat of the Google Health fiasco, this is the way to go. If you import your Google Health record into an Indivo X instance, you are not locked-in again.
Indivo X is Open Source, you can run your own instance if you want..
From now on, people will regard Indivo X as the safe option for PHR deployment, and rightly so, it is the only safe option. Until I can convince Sean and the rest of the HealthVault team to go full kimono, Indivo X is by far the most mature Open Source option available.
Why I do not think Google Health will, or should go Open Source
If Google drops code for Google Health, thats cool and I would take a look… but I am not going to hold my breath.
Its pretty simple; Indivo was Open Source and available before Google Health launched. Some people believe that Google Health, like Dossia, is actually a long-ago fork of Indivo.
Indivo has moved on to bigger and better things. Indivo X, the current version of Indivo already has substantial functionality that Google Health is missing. It is already a mature codebase, with a community, and is generally operating openly as an Open Source project should. The Indivo project is not perfect, but they have steam.
Steam, motion, community, these are the things that make the Open Source garden grow.
Google Health would not actually help the Open Source community that much. We already have a better PHR project, and anything coming out of Google would compete for developers and attention with Indivo X.
Even if they wanted to, I am not sure that Google could usefully Open Source the whole Google Health codebase. Google projects often run on Googles custom, and proprietary database and network services. It is entirely possible that Google Health would be useless without that back end.
What -would- help is for Google Health to release any components that Indivo X is missing. If they have an interesting Blue Button parser (which I happen to know they do) for instance, or some generalizable code for managing CCRs (that CCR-in-a-feed thing was a nice trick for instance…) then those components would be very useful.
Moreover, any components that would help people to parse their own Google Health data would be very welcome.
Probably the most important thing that they can do is license their API under several Open Source licenses. This way, Indivo X and HealthVault would be able to write a bridge that would allow currently existing Google partners to interface with Indivo X, without re-writing code. That would be pretty cool.
Here’s a link to Google’s step-by-step instructions on how to transfer all your data from Google Health to Microsoft HealthVault: http://www.google.com/support/health/bin/answer.py?hl=en&answer=1347995
I doubt Google Health was ever a clone of Indivo, as I believe it is built using Google Web Toolkit (Java). I also suspect the code depends heavily on Google infrastructure, so I doubt a code release would be immediately useful to the rest of the world.
Indeed a sad passing Google Health’s folding but not entirely unexpected. My surprise, why they didn’t just put Google Health into stasis and await the broader healthcare IT market to mature. But if you look at Google’s history with other “sandbox” initiatives – if they don’t gain significant traction, they get the ax and no looking back.
As to Indivo X, really don’t see this going anywhere as it does not have the “ecosystem” of apps/services that make it actually useful for the average consumer. HealthVault has done this to the point of confusion (23 PHRs that one can choose from) but hopefully MSFT will begin offering a rating service allowing users to rate such services similar to iTunes.
hi Fred —
Feel free to reach out, if you need to re-tune your patient-facing software chapter to HealthVault.
cheers,
Vaibhav
Lot’s of angst over this – and I’m struggling as to why. Revolution Health folded theirs in Jan 2010 – and no one really blinked. Steve Case managed to pivot/sell the assets – so I don’t think he lost too much – but it definitely wasn’t the success he was targeting (for himself or the PHR category). Google’s failure – and the PHR category more generally is pretty basic/easy. There is/was no compelling consumer value – at scale. That’s hard to get to when a product (any product) is free. Because of their size – GOOG was able to keep the cost of delivery low – but that’s never zero – even for them. So – how long do you run a business unit in the red before saying enough? I guess it’s about 16 quarters.
Some of this is also true with Healthvault (which I’ve heard has 6-figure adoption #’s – but conveniently avoids any press or discussion around actual numbers). Where MSFT’s PHR is different – and they as a company are different – is that they can (and do) sell Healthvault to other countries (where a single payer model supports a CAL). Here in the U.S. – it’s more of a channel strategy that helps support a broader focus (and revenue stream) around provider-centric healthcare solutions (Amalga, expreSSO, etc…). MSFT also has a very rich history and strong commitment to the healthcare industry – going back to the days when MS-HUG was a standalone entity (Bill would often keynote the annual event). I was at one of those where he demo’d our software. At the time – we were pioneering the use of XML (the smaller offspring of SGML) specifically in healthcare (Baylor Health).
The VA’s solution is impressive at scale – but let’s not compare public consumer needs with a military demographic that get’s fully subsidized healthcare. All that really says is that a centralized EHR (with individual access) has value at scale (assuming it’s free). Same with KP – which can also dictate use as a very large IDN (basically walled-garden). KP’s adoption % are impressive – but probably closer to 50% – not 100%.
Dossia is struggling for cash (currently in fundraising mode) because they’re not profitable after 5 years of development/deployment. And that’s with 10 really big member companies that include Intel (with their own Venture arm) and WalMart. Only 6 of the 10 member companies are running with it.
Open Source may well be the solution here – but it too has a cost – even if the software itself is free. Servers, bandwidth, consumer support, engineering integration support – are all very real $’s (and big ones at consumer scale).
The value of a PHR has not been proven – in spite of multiple large attempts. Where it has succeeded – MSFT, KP, VA – it is because the underlying healthcare costs are significantly lower or fully subsidized (or with MSFT – revenue is available in many other directions – direct and indirectly).
Google’s failure – and Revolution Health before it – highlight the biggest consumer deterrent of all – personal risk. That risk has always included interoperability (read Chilmark’s post – The Tale of Two Medical Records from March of this year: http://bit.ly/gRAN7X ). It just needs to include vendor commitment. When the vendor is also the healthcare delivery network – voila! Just don’t move out of that network!
My health information is in Google Health. I would love to migrate it, but probably don’t want to put it with Health Vault either, because I thought Health Vault had no user interface/front end.
It’s not about the current data, it’s about the partnerships that allowed my pharmacy and labs to keep inputting and updating data to keep the record up to date. What happens to all that now? If I migrate, will the next PHR automatically update from CMS?
Hi Fred who is “coding for social change”. Some disturbing mistakes on the part of Google, but I’d stay away from Microsoft traps and particularly from praising their traps.
PHRs make intuitive sense as a technology that we all need for societal health to advance. They will enable personal health empowerment, accountability and “self help” to take place. However, what Google Health and conversely, Patients Like Me show, is that people are interested in maintaining their own records, mainly when their health is compromised or the current health system isn’t perceived as meeting their needs.
This is the big challenge of personal health. Most people, for better or for worse, aren’t concerned with their health in a consistent way when we largely live in a feeling of good health. Google Health was a mass PHR model that didn’t have practical relevance to the majority of the population. Why keep a record for yourself when you won’t use it for anything?
PHRs will have their day in time once our cultures around health responsibility change. Rather than PHRs altering the culture, the culture will make PHRs second nature. This is why the Indivo platform-like model is where the work needs to occur at this point, because the fundamental idea embedded in PHRs is still a bit culturally “green”.
Just my $0.02.
Great article Fred,
I can’t comment on the platforms that remain, but I can comment on why Google dropped it. I speculate here: I’m pretty certain that the mandate that came as a result of the recent leadership change. Basically, it came down that focus was key. As much as this is a tired, overused and ultimately dangerous way to shake up a business that is moving sideways, it is one of the default strategies. I’m pretty certain that Google has decreed something like, “we need to focus on X things, with Social right at the top”. It is very possible that Google Health is X+1. In other words, a good idea, but (for the reasons you mentioned re: Google’s scale) it is a rounding error for this particular sideways moving behemoth. And, yes, Google is decidedly moving sideways with its crushing dependence on Adwords/AdSense for something north of 90% of its revenues. Ouch.
Also, I’m going to challenge you on what generally causes Google to be interested in something as I think it changes the lense a bit when you assess the merit of whatever they did or what they do next. Google is about signals. Gmail’s business value to Google isn’t really about showing you ads within Gmail. Its about profiling you based on signals that the content of your mail generates. I haven’t even bothered to dig up any claims that Google makes about privacy and targeting, but I’m pretty sure that processing signals so that they can target you better, through AdSense and other advertising products, is what they are about. AdSense and upcoming DoubleClick products run across the web (i.e. they follow you). While PHRs ought to worry, I think competing ad networks need to worry a whole lot more.
This might seem like a minor distinction from the point you are making, but I think it helps when you look at Google and why they invest (and divest). The net outcome is the same: Gmail delivers huge, useful volumes of signals to profile and target you while Google Health did not. It would seem that health information would be very useful as a signal, but I suspect (without knowing for sure) that they would be breaking some existing or pending law in any number of countries by using that data to round out your Google profile. If privacy wasn’t the issue, it may have been scale: there simply wasn’t enough volume to justify the development and maintenance of algorithms that profile you based on your Google Health data.
While Google may never manufacture their own car, the Google car prototype is, in my opinion, all about signals to navigate and signals to target you.