OpenGraph is a data model, and through your interactions with web sites enabled for OpenGraph – a meta model is built around your interactions with those sites.  So for example, IMDB (the Internet Movie Database) is OpenGraph enabled, providing other OpenGraph enabled sites (like Facebook) to leverage your interaction with it to learn about a semantic relationship between you and a movie or TV show.  In it’s simplest form, it’s simply IMDB putting a “Like” button on every movie profile page that when clicked, sends that information to Facebook which in turn, realizes you clicked the “Like” button and adds that action to your Facebook profile.  Facebook may also see that the object that you’ve liked is a movie, and add it to your favorite movies.  It may also look at a list of the actors in that movie and add that, too, quietly to your profile.  All of this allows Facebook to learn more about you and improve your Facebook experience.  For IMDB, it allows them to gain traffic from the largest social networking site in the world.

But OpenGraph is indeed largely only going to communicate information you WANT to share with Facebook.  The expense of someone integrating their site in such a way that allows the user to drive that interaction is almost 0.  For a price (coding effort for the site developer) they can too PUSH that data to Facebook based on an interaction and nominally with little action from the Facebook user (they would only be asked once if it was okay for that site to access your data, as Facebook connect works today).  And it’s not limited to Facebook – it just so happens that Facebook is at the moment the greatest consumer and producer of information about individuals that the world has ever seen.

But why would OpenGraph ever be limited to creating this semantic model of the web and the metamodel of how we interact with it to movie databases and newspaper sites?  In theory, there is nothing preventing a user’s interactions with AllRecipes.com for instance being modeled against a weight management tool, so that as a dieter, I can tell Weight Watchers for instance that “I ate this” – akin to Facebook’s “Like” button.  As I accrued these interactions, the OpenGraph consumer of this information – the Facebook analogue – could hum in the background understanding things like when I had cravings, or when I was most likely to skip a meal, or when I was going entirely off track.  Just like with Facebook, the value realized by sharing this information is only as much as a participant in the metamodel is willing to share.  But Facebook has proven time and again that if you provide enough value to someone looking to share something about themselves, they are willing to give up a modicum of privacy to get it.

Today, the user experience for tracking health information is simply arduous, and thus no one has succeeded in creating this portable record of my health and wellness.  Google Health is gone, HealthVault is living in obscurity.  Can OpenGraph – or a close cousin, provide the integral and simple experience that leverages the daily interactions people have with the world around them to maintain a timeline of health and wellness events?  If it can, then there is the opportunity for someone to build a destination that leverages that stream of information like Facebook does to improve outcomes, automate coaching, and engage people where barriers currently prevent adoption today.

1.       get the population to act like health care consumers via transparency on cost and quality and disintermediation of the cost of health insurance [1]

2.       make all patient data patient owned and patient centric via secure patient health record

3.       break the ‘3-foot rule’ so that care can be delivered (and relationships strengthened) beyond the 4 walls of the provider

4.       give the consumer immediate financial skin in the game so that they understand how taking better care of them self will lead to financial savings as well as improved health[2]

5.       ensure all people have access to free (meaning ‘paid for through taxes’) preventative care

6.       ensure all people have access to safety net insurance for catastrophic care

7.       require that all providers of care use an electronic health record and be connected to a health information exchange [3]

8.       remove perverse incentives in the system that encourage duplication of tests or defensive medicine and instead let the system pay the best doctors for the best performance

9.       reduce fraud in the system

[2] because the negative impact of poor health decisions take so long to manifest themselves from the negative behavior e.g. getting cancer from smoking, heart disease or diabetes from being overweight

[2] so that information can be received about the patient to provide coordinated care, and so that information can be sent to the patient’s ‘medical home’ (their primary care provider)

It’s no secret that a critical success factor in wellness programs of any substance from weight loss to smoking cessation to fitness has been in the power of groups. Group aerobics programs, community outreach, and weekly Weight Watchers meetings not only offer economies of scale for the organizers but have the benefit of connecting people with a common goal to a guidance and support system that is the first line of defense against lapses in willpower and judgement. The advent of social networking has expanded the frontier of the effectiveness of community support networks.

Additionally, competition has also been long used as the incentive for personal improvement. Sport by it’s nature is the challenge of individuals engaging in a comparison of performance between one another to determine the victor. To win, the participants attempt to out-train one another and gain insight into the methods and routines of their competition.

Each of these basic natures of our being are being employed through technology today to propel technology solutions for wellness.

The state of health in America is in crisis.  Obesity rates, diabetes rates, depression – all one needs to do is turn on the TV or surf the web to understand that we’re on a razor’s edge.  It can seem overwhelming because of the sheer scale of the problem.  What are the most fundamental problems that need to be solved to solve the state of health in America?  Over the past few months, I’ve been reading a lot and taking time here and there to think about this question and what some possible answers might be.  So far, it seems like the simplest areas would be the most impactful.  I propose therefore that four fundamental hurdles that need to be overcome to improve the state of health in America are as follows:

• People’s ability/motivation to make good decisions on nutrition
• People’s ability/motivation to be active and to build strength
• People’s ability/motivation to reduce destructive behaviors (e.g. smoking, drinking excessively)
• People’s ability to access primary care via someone with whom they have a relationship and who knows them well (the ideal vision for this is based largely in the concept of the medical home)

If you agree that these four are significant contributors to the poor state of health in America, then we can ask ourselves the following question:  How do we get people to *want* to make the behavior change around the items above?  Today I will focus on the first item (I’ll cover the others in later posts)

Why don’t people make good nutritional decisions? Like any complex social issue, there is no one simple answer.  There are multiple contributing factors, but in my opinion two significant contributors are that we are addicted to convenience and our educational/family system has done a horrible job at educating people how to properly feed their body.

1. The extinction of the family dinner time It used to be that most families sat down together for at least one home cooked meal every day.  Food wasn’t about convenience, but about togetherness and family.  Over time, single-parent households became much more common, working hours got longer, people’s schedules got busier, and home cooked dinners became a luxury.  “Food on the run” became the norm.   Businesses in the US are incredibly smart when it comes to optimizing around what the customer wants.  When it became evident that Americans by and large placed higher value in food that could be quickly prepared, in large quantities for the least amount of cash – businesses took notice and the food industry simply gave us what we wanted.  The result is an incredible selection of foods that are nutritional ‘question marks’.
2. Lack of education/food awareness When one creates a home-cooked meal from scratch, it’s evident what the ingredients are.  When one lets someone else essentially cook for them, then the ingredients become obfuscated.  When one compares the marketing and advertising dollars that are spent to encourage us to consume mass produced, ‘engineered foods’ against the amount of time, money and effort into educating the population how to cook for themselves in a way that will meet their body’s nutritional needs, is the state of health in America really a surprise?  The lack of education around how easy it is to cook nutritious meals at home, combined with misguided attempts to vilify fat (or carbs or sugar, or dairy, or eggs, or… well, you get the idea), added to the abundance of quick, easy, readymade meals is a recipe for disaster.  The result is a society that has become seriously uneducated about how much and what types of nutrition our bodies really need and how to meet those needs.

So back to the question:  how do we increase people’s motivation to make good decisions about nutrition?  One answer is through a combination of focused education and focused reward.  “Education” would focus on ensuring that people know what is a ‘good’ nutrition decision and what is a ‘bad’ nutrition decision.  “Reward” would measure the results of those good decisions and would literally reward improvement on those metrics.  One way of doing this is via value based benefit programs where consumers get cash for completing certain activities and meeting certain goals.

The good news is that there is no shortage of educational content on which foods are nutritious and which are not.  The better news is that employers and health plans are demonstrating the willingness to implement value-based benefit plans and wellness plans that provide real incentive to behavior change.

What are your thoughts on how to encourage behavior change?

This fragmentation is certainly the least appealing facet of the mobile application market.  The investment in the construction of a mobile application is staggering.  Tomi Ahonen (author of Communities Dominate Brands) did a recent breakdown of the economics of the iTunes App Store and concluded that on average it costs over $35,000 USD to build the typical iPhone application.  But that same average application will only net $682 USD in revenues per year.  Compare that with the cost of developing a web application targeted at mobile devices – about 1/10th that cost.

Now think about developing an Android, Windows, Blackberry, and iPhone port of your mobile application.  The numbers are as prohibitive as they come.

The high stakes here are incentivizing bad behavior: Apple’s license agreement for iOS development being the prime example of defensive maneuvering in the fragmented market.  Not only are we being cornered into repetitive development for multiple platforms – but now extra steps are being taken to ensure that we have to.  Adobe’s model to metacompile flash applications for iPhone deployment became a lightning rod for Apple this past spring.  PhoneGap skirts metacompilation by providing a development toolkit more akin to a scaffold, but consistently lags behind in support for more recent device features.

Fragmentation of desktop platforms has always been a far less limiting problem. Virtualization and tools for cross-platform compilation has enabled developers to target a ubiquitous number of platforms or more often than not, simply disregard the problem.  Furthermore, the development of rich internet applications delivered by the browser has provided a natural cross-platform channel.  With the evolution of the HTML5 standard and it’s continued support by big players like Google and Apple – the ability to take a “write once, run anywhere” mentality to application development via the web browser will continue to be the disruptive force in software delivery as deployment costs continue to be pushed down.

The most ubiquitous mobile browsers – Safari and Chrome, both support much of HTML5 for their host devices.  So why haven’t developers turned to the browser to solve the problem of mobile deployment in the same way they have for desktop applications?  As big as the promise that have been delivered by RIA development has been, there have always been significant limitations – ones that mobile environments exacerbate:

• Connectivity:  Browser-based applications have long required that internet access be reliable.  Browser security prevents access to a users local storage (with Google Gears innovating around this limitation, though at the cost of a plug-in), and thus a lack of connectivity meant a lack of access.  In mobile development, this is a consistent concern.  HTML5’s native features for controlled local storage will solve this;
• Access to native environment:  Likewise with connectivity, the browser has always been severely restrictive (in fact, entirely restrictive) of access to local hardware like built-in cameras, microphones, or external peripherals.  The compact and feature rich accessories in the modern smart phone are a particularly high-value draw to mobile application developers who can only access these features through the native APIs.  Not having access to this from the web environment is certainly secure, but it completely removes some of the value of developing mobile web applications;
• Performance:  While this has improved, web applications are powered by inherently slow JavaScript.  Google’s Joel Weber compared noted in 2008 that the web application is to a native desktop app as a Commodore 64 is to today’s PC.  And while the processing power of the smartphone is leaps and bounds better today than it even was 3 years ago, it still is extremely limited;
• Commercial viability: The most important limitation is also the business problem – how do you monetize web applications?  It’s certainly something that has been done – otherwise the growth of web applications targeted at desktop users would not have exploded as it has.  But it has proven tricky in the mobile space.  The various App stores have proven effective in creating a marketplace for native applications by providing a simple deployment and distribution model.  This channel has allowed mobile devices to put apps at the user’s fingertips, something unmatched by web applications.

Until these limitations are addressed, mobile applications will continue to be loss centers or complimentary pieces of larger application ecosystems.  If mobile deployment is ever to replace or even rival the ubiquity of desktops, they will need to take the human factors learning’s of the past years that have enabled such rich mobile applications and apply them to a deployment and commercial model that enables platforms solely targeted at mobile to exist profitably on their own

Yet for all its promise, the adoption of healthcare technology by providers has been impeded by other factors. One such factor is the generally acknowledged resistance by care providers to information technology changes. To a degree, this resistance is due to two main challenges: the loss of productivity when changes are implemented and the often high capital costs for some enterprise information technology solutions that smaller or mid-sized practices are unable to shoulder or stomach. SaaS solutions have met the latter challenge by lowering the costs that have been one barrier to entry by not requiring separate and costly individual installations of solutions for each care provider or practice. Some reports suggest that such SaaS solutions are already reducing this provider resistance to technology adoption. The former challenge is being addressed more gradually by improved workflow and user experience design. These growing disciplines are delivering better solutions whose improved design minimizes the inevitable loss of productivity experienced while care providers, like adopters, are learning to use a new workflow or tool.

Atop these shifts in healthcare empowered by information technology, mobile health applications promise to be great catalysts for increased adoption and impact. With people being increasingly comfortable using smartphones for data applications and not just voice, it makes the adoption of information technology in general and mobile technology in particular easier in the healthcare industry. Mobile technology is particularly applicable to healthcare due to the significant cost, time, and inconvenience that are incurred in just transporting patients to doctors for those consultations that do not need to be in-person. Research by TripleTree presents a good analysis of the market and opportunities in mHealth. Technology and wireless phone companies also see the posibilities for healthcare and are now beginning to move to deliver solutions. For those whom might resist adopting health information technology, mHealth promises to bring health information technology to them.

Along the way we are seeing a dramatic change in the channels through which these offerings can be delivered:  It started out via face to face interactions between consumers and health providers.  Next was the capability for phone interactions with wellness coaches or clinicians.  Soon, there was access to tools and content at the job site through personal computers or kiosks.  Before long, access to these tools was extended to the home through laptops and high-speed internet.  Remote monitoring has long been a staple for the sickest among us, but at long last we are seeing a massive upsurge in the ability for mobile telephones to deliver high quality data and user experiences on the go for ALL healthcare consumers.

Combined with the relentless focus on moderating the healthcare cost trend, the incredible growth in the capability of mobile devices – devices which have permeated the population much more extensively than computers, and which users tend to carry with them everywhere – will certainly improve the business case for the next generation of innovative mobile products and services to help people manage their own health and – overall – to be healthier.  Early adopters have been using commercially available mobile activity tracking applications and nutrition tracking applications for over a year.  As these investments start to show a return – either by helping people stay fit and thereby gaining credibility and creating customer loyalty (not to mention winning more customers through word of mouth), or by demonstrating a return on investment to health plans or employers – more innovations will come.

The key to creating products and services that will provide the biggest return on investment is not to simply create a mobile app for the iPhone in a “me too” strategy.  Rather, businesses must take a step back and understand what tasks your customers really want to be able to conduct via a mobile platform.

The end result is a win-win for customers and health providers – more choice of tools to help customers to manage their health (with more access through more channels), and more engaged and loyal customers.

The key to creating products and services that will provide the biggest return on investment is not to simply create a mobile app for the iPhone in a “me too” strategy.  Rather, businesses must take a step back and understand what tasks your customers really want to be able to conduct via a mobile platform, to understand how those needs reflect your business’ current capabilities, and what existing capabilities can be extended (or what new capabilities can be created) to the mobile channel.

For those who do this well, the mobile channel will open opportunities to capture large numbers of new customers.

Given the relationship between obesity and other chronic health conditions like diabetes, high blood pressure, and heart failure, these rates are indeed frightening to consider.  It’s been widely acknowledged that today’s generation of children are poised to be the first in a long time to have a shorter average lifespan than their parents.

Clearly, there’s a lot of bad press about obesity.  So much so that it’s not even ‘news’ anymore.  However, there is good news: there’s no shortage of attention being paid to the subject.  Many people and many organizations have taken it upon themselves to address the rising tide of obesity.  Consumer empowerment is on the rise; for example there have been laws passed to make caloric information available to consumers at the point of decision-making.  Attention to the fact that people aren’t getting the proper level of activity is also on the rise.  As just one example, the First Lady has made it a personal mission to address obesity by getting kids moving.  After decades of budget cuts to school sports programs, physical education, the elimination of school recess, even things like unsafe neighborhoods for kids – we have a lot of ground to make up.  But at least there are signs of progress.   This must continue to accelerate – otherwise our notoriously short attention span as Americans will be a death knell for the little process that has been made.

Where I personally would like to see more attention paid to address the obesity epidemic is on the topic of nutrition.  After all, we ‘are what we eat’, and getting people to be less sedentary is only addressing half of the problem.  The other half of the problem is that the food industry has realized that there is a large portion of the population who will gladly spend their money on nutritionally deficient, yet calorie (and sodium!) dense “convenience foods” in lieu of fresh, nutritious, natural foods.  As a society, we have become dependent upon convenience in all areas, and our food has become no exception.  Our ‘nutrition/value’ barometer is all out of whack.  After all, how can we honestly expect to pay $1 for a nutritious hamburger?

We need to re-educate people that good nutrition doesn’t necessarily have to come at the expense of convenience.  Until we break the trend of reliance upon convenience foods, obesity will continue to be a problem that we address after it has arrived.  We need to stop treating the symptom and treat the cause.

Based upon the various amalgamations of the data, the conclusion I have reached is that the health reform bill focuses largely on “access” through things such as:

• covering the currently uninsured by requiring (and where necessary, subsidizing) all Americans to purchase insurance,
• removing the ability of insurers to deny coverage based upon pre-existing conditions,
• removing the limits that insurers can place on members through ‘lifetime maximums’ that limit the total amount of money the insurance company spends on any member’s care
• extending the age limit for children to remain on their parents’ policy

I applaud these actions, and recognize that they are an important element of reforming the way we deliver healthcare by ensuring that people have access to care. That said, increasing access alone will not only fail to moderate the cost trend – it is likely to exacerbate it. So what’s missing?

1. Payment reform – much has already been said about the perverse incentives created by the fee-for-service reimbursement model. True health reform must include payment reform that puts the incentive on delivering better outcomes, not simply delivering more care.
2. Limits on litigation – another incentive that doctors have to prescribe care that doesn’t directly correlate to better outcomes is the fear of litigation. True health reform needs to address our litigious nature as a society, and protect doctors from frivolous lawsuits.
3. Patient behavior reform – despite plenty of evidence to the contrary, the predominant mindset among patients is that more care is better care, and that more expensive care is better care. In order to moderate the healthcare cost trend, there will need to be less consumption of healthcare and a shift from late stage medical care to more preventative medicine. Increased access to care will certainly help, but more will need to be done than to simply provide people with the ability to see a doctor – they will need incentives that actually change behavior.
4. Eliminating waste due to fraud and overuse – an obvious way to reduce healthcare spending is by eliminating the 30% that is estimated to go to waste or fraud. Advantages of health IT are that it can limit duplication of healthcare (waste), increase efficiency of the care currently being applied (efficiency) and apply controls to prevent or detect outliers (fraud protection).
5. Reforming the system itself – largely overlooked is the idea of reforming entirely the system of how insurers, patients and providers work together. True Healthcare reform would enable more disruptive innovation in the market – such as allowing members to select whatever combination of wellness and health insurance they like (even across state lines) rather than limiting to 2 or 3 choices by their employer, or allowing members to carry their plan with them for as long as they like, even if they change employers. There are limitless possibilities for new and unique business models that will provide better value at lower cost.

The reform bill that was signed into law this week is a start, but to really change the healthcare landscape in America, we will need to address many (if not all) of the items above as well.

What do you think?

iGetBetter is an advanced web application built primarily using 3 key technologies – Microsoft .NET 3.5, Entity Framework with MySQL and JQuery coupled with Windows Communication Foundation. From Microsoft the .NET 3.5 development framework allowed the development team to leverage several prepackaged tools allowing for a fast development cycle. Whenever client input led to design changes the .NET framework allowed us to quickly change direction and respond.

Another key technology used on iGetBetter is Entity Framework; it allows iGetBetter to have a pluggable tool to access iGetBetter’s database. To lower overall project cost the less expensive MySQL database platform was used during the alpha and beta phases of the project however, iGetBetter has the flexibility to transition to a full enterprise-grade database platform when needed.

iGetBetter is a dynamic application, in iGetBetter patient recuperation plans are modeled and are shown in many different views such as in a calendar, in a stack and on a timeline. Being web based but having native application type gestures such as ‘drag and drop’ and ’stacking’ required iGetBetter to use a JavaScript and user interface framework. Based on maturity and ease to learn we chose JQuery. iGetBetter is pushing the limits of modern browsers, JQuery coupled with the Windows Communication Foundation proved invaluable in representing an easy to use and advanced user interface while providing a stable and flexible application architecture.

Windows Communication Foundation provides a separation between the iGetBetter application and its user interface. What this means is if iGetBetter should need to work as a windows application or on a mobile device such as the iPhone, the time it takes to develop it will be significantly reduced.

Altogether these various technologies Microsoft .NET 3.5, Entity Framework, JQuery, Windows Communication Foundation and MySQL work together to provide a stable and flexible foundation for iGetBetter toadapt to new requirements and to meet application goals.