I thought I would use my column this month to discuss RevolutionHealth.com.  After spending some time surfi ng around the site, I’ve concluded that it just might be the most over-hyped health information website ever launched. It’s an all-around healthcare information portal, with a few interesting features, but there’s nothing revolutionary at all.

Large health information portals for consumers have been around for quite some time, going back to the launch of Drkoop.com and 

 in the 1990s. Th ese websites were also media darlings at a time when interest and investment in the Internet was exploding. Like RevolutionHealth.  com, these companies were also founded by larger-than-life personalities who lent credibility and gravitas to the endeavors.  Drkoop.com, founded by former Surgeon General C. Everett Koop, netted $88.5 million from its July 1999 IPO. Th e stock subsequently rose from $9 to as high as $45.75 per share, giving this not-yet-profi table company a market capitalization of nearly half a billion dollars! We all know what happened since 2000.  Th e stock went to zero, and today Drkoop.com is just another health information website that makes money from advertising.  WebMD.com, on the other hand, suff ered a less ignoble fate.  Technology industry luminary James Clark, who also founded Netscape, started a company called Healtheon, which merged with WebMD.com in 1999, just as the dot.com bubble was about to burst. Th e idea was that WebMD would be the front end and Healtheon the back end of an integrated company. Clark’s original dream of creating an overarching Web-based system to make healthcare transactions more effi cient is long gone. Instead, WebMD has evolved into a company with related product lines and some successful, albeit not interconnected, Internet portals.  In many ways, RevolutionHealth.com and WebMD.com are remarkably similar. Both off er a wealth of healthcare information and make it easy to fi nd a specific topic. I have no problem recommending them to patients who ask for a good health information website. Both sites also allow them to find a doctor or hospital, as well as look up drugs and medications.  

RevolutionHealth.com goes a step further by allowing patients to search for an insurance provider. But this is not at all revolutionary, as there are many websites that already allow patients to easily research, compare, and purchase health insurance plans.  RevolutionHealth.com also touts that its users can create a PHR. Many healthcare portals off er this feature, including WebMD.com. I railed about the issue of PHRs in my last column, but I think it’s worth reiterating the point. It’s all well and good for patients to enter their own information into a PHR for their own records. But these websites encourage consumers to ask their doctors to review the PHR data as well as provide actual medical records, which the patient can fax to the website company for data entry into their online health record.

Who is going to pay for the time and eff ort that my office must spend to fulfi ll the patient’s request, not to mention the legal risk involved with “reviewing” the patient’s PHR? Once I have agreed to look at my patent’s PHR, I am sure a plaintiff attorney would argue that I should be responsible for knowing and addressing all the data within the PHR. And it won’t be long before a well-intentioned physician gets sued for not adequately addressing some issue alluded to in the PHR. Of course, third-party payers aren’t currently reimbursing us to review the PHR, and when they do, I’m certain receiving the payment will be mired in the painful claims submission and denial process with which we are all too familiar.  In the end, RevolutionHealth.com is no revolution. It is simply another healthcare portal that is long on hype but short on solutions to the most critical challenges facing doctor—patient communication.  An Internet portal that facilitates data fl ows between doctor and patient, while providing physicians real revenue for this exchange, all while not having to fear malpractice attorneys or deal with thirdparty payers—now that would be a real revolution.

Dr. Bertman is Physician Editor-in-Chief of

. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of 

, a leading developer of EHR software. He is also the founder and president of 

, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Articles

Feature Articles

I thought I would use my column this month to discuss RevolutionHealth.com.  After spending some time surfi ng around the site, I've concluded that it just might be the most over-hyped health information website ever launched. It's an all-around healthcare information portal, with a few interesting features, but there's nothing revolutionary at all.

Tech Talk: The Revolution That Wasn't

Tired and typing. Not clinic notes or even a personal e-mail. No, I was typing an answer to a question posted on MedHelp.com, where I was the “expert” on the adult type 2 diabetes forum. I started serving in this capacity in the fall of 2007, and it was now the spring of 2008. On some days, it was quite enjoyable and interesting. Other days, it dragged, and I asked myself where these questions were coming from and why I was doing this.

 and my other blogs was certainly not something I envisioned a few years ago, but there I was in the Internet trenches and, for the most part, loving it. My friends and family found it amusing and surprising that I was so engaged on the computer, given that I am not the most techsavvy person in the world. My approach to computers is that I want them to work when I press keys. If they do not, I get frustrated, and the help desk is next on my speed dial.  I have always prided myself on being a great clinician, and integral to that was seeing my patients face to face. So, the idea of communicating via the Web in some ways was a bit alien to me.

But then a few things changed. The first was my decision to leave work for a while. I had been in clinical practice for almost a year and was not very happy. My twin daughters were very young, and I missed being with them during the day. Plus, being a “parttime” physician was not as part-time as I had planned. Even when I was not physically in my clinic, I was spending a lot of time writing notes and answering pages. So, I stepped out for a while to be at home with my daughters, but I was concerned about losing touch with medicine during this time away from clinic. The second major turn of events was the stroke suffered by an aunt who I am very close with. She had diabetes for many years, but was adamant that she did not. She had both a stroke and a MI, which thankfully left her with few defi cits. But the scare reminded me of a promise I had made to myself but that had been somewhat forgotten under the pile of adult-life duties: I wanted to contribute something to my island home of St. Vincent and the Grenadines, where diabetes was rampant. Moving there was not much of an option given my husband’s career in research and need to be at a major academic center.

So, I brainstormed about alternatives and stumbled on a little idea based on my love of writing. I contacted the editors of a national newspaper and off ered to write a free diabetes education column. After reviewing two writing samples, they agreed, and I became the author of a regular “Sugar Matters” column in the 

newspaper of St. Vincent and the Grenadines.

The third development was my decision to start an online practice, the 

. This one, more than any other idea we had, took the most gumption and also garnered quizzical looks from family and friends. A medical practice entirely online? How is that possible?  Unknown to us at that time, there was a whole burgeoning industry of telemedicine, and we have since learned a great deal about the viability of an online practice. But at the start, we felt like we were all alone in this quest. We also felt that we needed legitimacy.  While we were searching for advertising venues for our company, I happened upon MedHelp.  I was impressed by their scope of services and noticed there was neither an adult diabetes expert on staff nor an adrenal disease expert.  So, I off ered to become involved, and within two weeks, the “Adult Diabetes” forum was born.  Life became very busy very quickly, even without physically being in my endocrine clinic.  Between being a fulltime mom, moonlighting at a local hospital, and being a journalist and blogger, I was always doing something and meeting a self-imposed deadline. But I found that I was enjoying it a great deal. Both of my pro bono contributions were personally satisfying, even accounting for those days when I was so tired that I did not relish the thought of doing anything for free for anyone.

I started receiving e-mails from readers living in St. Vincent and the Grenadines talking about the articles and how they enjoyed reading them and learning more about diabetes in a way they understood. Although the idea initially seemed novel, in retrospect it made great sense to me; I have always enjoyed writing and talking in general, so what better way to include both than with this column? “Sugar Matters” has been a labor of love for me, and I plan to continue writing for the paper as long as they will have me. It’s a small thing, but it’s my way of giving something back to my home that gave me so much when I was growing up. I hope my aunt continues reading it!

MedHelp was something else entirely, requiring more work and with diff erent rewards. With my stepping out of clinical practice for the year, I missed “talking” with my patients about all things endocrine—diabetes and otherwise. And MedHelp gave that back to some extent. It was not “live,” but I still had my communication with others who had endocrine concerns. There were three to fi ve questions posted daily, with some quite spare (“I feel tired, could this be diabetes?”), others quite complicated and accompanied by two pages of data transcribed by individuals wanting essentially free consultation, and others that were totally inappropriate for the forum (“I have this lesion on my fill-in-the-blank”). Some questions were troubling (illicit drug use in diabetes, parents forbidding marriage because of a diabetic fi ancé), and others gave themselves away from the get-go (“Don’t think I am strange, but…”). Although answering some questions was fairly easy, I also learned a great deal when I had to search for answers myself, especially with questions regarding herbal remedies for diabetes. For me, though, the most fun thing about MedHelp was continuing some form of a physician—patient interaction while I was at home. Th ere were many people who had some repeat postings with follow-up questions, so a conversation of sorts happened naturally after the initial posting.

Now, I am officially gone from MedHelp, having stepped down when it all became much too busy for me as I juggled many responsibilities. I do miss it, so I may step back in to some degree. But further blogging fun is on the horizon: I recently teamed up with 

 to become their senior endocrinologist and will be participating in some live chats and also contributing to their blog. I am especially looking forward to the live chats as I continue my foray into cyber social circles.

You may be wondering how all this affected my secondary goal of improving visibility for my online practice? It has helped a great deal, as good as any newspaper advertising we placed. So, at least for now while our practice grows slowly, I am no longer some obscure, potentially crazy doctor with a Web office. My blogging has allowed people to get to know me a bit more than my bio allows and to see if they like me or not, as well as if they agree with my approach to medicine. Not many folks get that chance when referred in person, so that is a major advantage for patients.

For those of you thinking about heading to Web-based interactions of some sort, opportunities of all kinds are available. The number of medicine-based websites where professionals contribute seems to have exploded during the last 10 years, and it continues to grow. Many doctors and offi ces have amazing websites that provide opportunities for patients to ask questions. Plus, I have found that more and more patients are doing Web searches on their doctors or potential doctors before seeing them, and if nothing comes up, they can become worried. Without us knowing it, the Internet has become the new CV and the new “word-of-mouth” for many people.  One year ago, a search of my name brought up some articles I had written in the past and my fellowship grand rounds presentation. Now, there are pages and pages of sites where I can be found, and as daunting as it is for me to see (I certainly don’t feel nearly as popular as the search makes me out to be!), I have already had several patients say that seeing my name associated with other medical articles/sites encouraged them to contact me directly.  Whatever your interest, there is a Web opportunity for you, and it has become a fantastic resource for professionals in many ways. Still wondering where you can fi t? Ask yourself what your goal is: Help out on an advice site? Check. Flex those writing fi ngers again? Check. Voice your opinion in a public forum? Check. Increase your visibility, as a person or practice? Check.

Or simply wade into the Internet waters and see if you like it. It’s a great pool party out here, and I think it will only get bigger, so jump on in.  And BYOB (bring your own blog).

Dr. Anita Ramsetty is Board Certifi ed in Endocrinology and Internal Medicine, and is the founder of the 

, an online medical practice devoted to diabetes care and second opinion consulting. She is also a faculty member at the Medical University of South Carolina, and the “Sugar Matters” columnist for Caribbean and US newspapers.

My blogging has allowed people to get to know me a bit more than my bio allows and to see if they like me or not, as well as if they agree with my approach to medicine. 

Special Feature: Why I'm a Medical Blogger

Nearly 29% of Americans discontinue their medication before it runs out, 22% take less than prescribed on the label, 12% don’t take their medication after they fill a prescription, and another 12% don’t bother to fi ll the prescription at all, according to the 

. What’s more, 10% of hospital admissions and 23% of nursing home admissions are due to the failure of a patient to take a prescription medication correctly, and as many as 59% of those taking fi ve or more medications are taking them improperly. The numbers don’t lie; medication compliance is a huge issue faced by healthcare professionals.

So, imagine if a device existed that monitored when a pill was taken—not to mention its effects on the body&mdash;and transmitted that data to a physician, family member, or other caregiver. “That would be the ultimate compliance system,” says Leslie Saxon, a cardiologist at the University of Southern California and a consultant for 

, a company currently developing such a system. “One of the surefire ways to track a pill is to track it after it’s ingested. If you can do that harmlessly and transmit that data somewhere, it’s a maximum use of enabling technologies.” Proteus’ new Raisin system features a pill containing an ingestible event marker (IEM)—consisting of a microchip the size of a grain of sand and a nontoxic, thin-film battery activated

upon ingestion when exposed to water—that when swallowed, sends a high-frequency electrical current using the body’s conductive tissues to conduct a signal with a modulation that provides a unique marker for the pill and which is confi ned within the body. 

A receiver built into a skin patch or subcutaneous insert picks up the signal and logs it, and also senses physiological parameters like heart rate, respiration, and bodily movement. The data is then uploaded to a server via a cell phone or a computer and sent to a family member’s or physician’s mobile device or computer to be scrutinized.  Doses and administration times can then be altered based on how many pills the patient is taking, what medications those pills contain, and when they are taken. “If you had a technology that for each person you could know what their heart pressure did—which is a big predictor for how heart failure patients are doing&mdash;and you also knew when they took their drug, you could really get down to creating a tailored prescription for each person,” says Saxon. “You’d know for Mrs. Jones that after she eats, she needs this or that. You could not only dose it right, but time it better.” Patients’ relatives could also be alerted when a dose was missed. “It enables that person to call up and say, ‘Mum, you forgot to take your pill today,’” said Proteus CEO Andrew Thompson.

Direct observation of patients with a contagious condition that requires constant medication monitoring, like tuberculosis, can also be drastically reduced or eliminated with the system, which achieves the same goal, but without the intrusion or potential contamination.  Patients and caregivers needn’t worry about privacy issues. “The data we’ve developed inside you stays inside you unless you give permission to have it go outside you,” noted Thompson. And because the system’s signals are transmitted electrically through skin tissues, they can’t be picked up remotely, even by the receiver of another patient using the same system (even if they came into skin-toskin contact). Data that is transmitted to a caregiver, is protected by security safeguards.

Though not available yet, clinical trials in human users have begun to test functionality of the IEM and sensors, with Proteus hoping to bring the system to the market in 2011.  Costs should be reasonable; when manufactured in volume, the IEMs could cost less than a penny each, according to Proteus CTO Mark Zdeblick.

“It’s a really novel, incremental, interesting technology that’s going to be tested and could be a real addition to enforcing compliance,” concludes Saxon.

10% of hospital admissions and 23% of nursing home admissions are due to the failure of a patient to take a prescription medication correctly, and as many as 59% of those taking fi ve or more medications are taking them improperly.

TechSectors: Medical Device - The Networked Pill

Matthew Holt is a ubiquitous presence in the online world of Health 2.0. He is the proprietor of 

, essential reading that promises to tell you “everything you always wanted to know about the health care system. But were afraid to ask;” he is an in-demand healthcare strategist, consultant, and 

; and he is one of the organizers of the Health 2.0 — User-generated 

. We spoke with him about the ideas underlying Health 2.0 and where he sees this movement continuing.

My simple definition is that Health 2.0 is the use of Web 2.0 technologies in healthcare. Typically, Web 2.0 technologies include blogs, wikis, discussion and community sites, and those that make it very easy for technology users, rather than publishers, to generate content and share it with each other.

2 How are Health 2.0 applications currently being used in healthcare?

There’s a fantastic patient community called 

, where patients keep a kind of diary that’s like an electronic medical record for themselves, including detailed information about what is going on in their lives and all they are doing to cope with their diseases. A huge amount of information gets shared. Th ere have been online communities in diff erent formats since the early ‘90s, and now Health 2.0 off ers tools and technologies that make it easier to use them. By using forums like PatientsLikeMe and with the increased ability to search these forums, people can fi nd useful information more easily. Usually, a doctor sees a patient, sees what their symptoms are, and usually has one to three diagnoses in their mind at the time. But many times, there is a wrong diagnosis or incomplete diagnosis, or there is a rare disease that is showing up like a more common disease.  Th e impact of the ability to search into other people’s experiences and match with cases online in these communities is going to be substantial. A doctor may see one or two of these cases in a lifetime, but there may be 20 or 30 or 1,000 of these people, and if you can put them all together in one group, it makes the information much easier to find.

3 How long will the Health 2.0 movement continue?

I would argue that the incorporation of these applications into all kinds of business and activity online is going to keep going, because it’s another wave of technology. People are not going to stop caring about their patient community or their disease.  Companies are going to fi gure out what tools and technologies people are fi nding useful and adapt their business processes accordingly. In healthcare, there’s also non-commercial interest, so things will be supported by foundations and patient groups, with or without the actual success of individual Health 2.0-type companies. Even if Revolution Health or PatientsLikeMe goes away, I think these tools will continue to be used, both by healthcare organizations as part of their Web eff orts, and by nonprofit groups and patient communities.

4 What are your views on Revolution Health?

I like RevolutionHealth.com as a website. I think they’re trying to do basically everything across the board in terms of Health 2.0, putting together all these diff erent tools for consumers to use to interact with each other around their health. I think they’ve done quite a nice job. But the problem with Revolution Health is if you call yourself “Revolution” and you start off by making a huge splash, you’re going to be disappointed whatever you do. So, I think if you ignore what Steve Case said when he started it and ignore the name, it’s a nice website. It’s building traffic—mostly by acquisition&mdash;and they’ve now got a lot of good pieces in place and some traction in terms of the market place. The problem from a business perspective is, if you start off spending a huge amount of money the way they did, and take on huge numbers of people, it’s very hard to understand how they are going to make a huge amount of money doing it. But time will tell on that one. It took 

 a long time to fi gure out their business, but they are doing well these days.

5 Do you see a lot of misconceptions regarding Health 2.0?

I think any time you’re talking about something as complicated and with as many vested interests as the healthcare system, saying that we’re going to change the healthcare system using Health 2.0 is over-ambitious. Some people are at the risk of grafting other things like the concept of transparency of data too.  Health 2.0 is going to help with that, but it’s not going to completely force that on the market. I think if you say Health 2.0 is going to change healthcare as we know it in every aspect and immediately, you’re going to be disappointed. But if you say we expect to see Health 2.0 adopted by more and more patients, physicians, and healthcare organizations, I’d agree; I’m sure it could slowly change the way healthcare is delivered and the way people manage their health.

Matthew Holt is a ubiquitous presence in the online world of Health 2.0. He is the proprietor of The Health Care Blog, essential reading that promises to tell you "everything you always wanted to know about the health care system.

5 Questions... with Matthew Holt, Health 2.0 Conference Founder

Convenient, remote information access; interconnectivity; and a host of other key features has led the healthcare industry to embrace the Internet, as evidenced by the proliferation and success of for-profit sites like 

Neuroleptic Malignant Syndrome Information Service

However, the Internet has evolved beyond its origins as a collection of interconnected websites with static information. It has become a medium through which relationships are established, information is shared and aggregated, and communities are developed. 

, a virtual online world, has become a popular destination not just for recreation, but business as well. Blog authors now have a large readership base on par with some newspaper columnists. User-generated content is fast becoming the dominant online business model. The healthcare industry has embraced this trend, utilizing the Internet to do everything from publishing electronic versions of clinical journals to conducting business online with Web-based forms for prior authorization of medications and enabling patients to fi nd the right healthcare provider in an insurance network. This trend has been referred to as 

, and many new healthcare companies have adopted this paradigm, calling it Health 2.0.

, an advocate for free and open source software and the author of many “gold standard” technical manuals, is widely acknowledged as the originator of the Web 2.0 concept. Th ere are several signifi cant principles of Web 2.0, the first being the idea of the “Web as a platform.” An analogy is that 

 is a document platform company but not a publisher of electronic texts.

Another important principle of Web 2.0 is that “the service automatically gets better the more people use it.” This is how the additive eff ect of more computers increases not only the number of websites, but actually provides a service. For example, the 

 project of Stanford University harnesses the idle computing power of computers and powerful gaming systems such as the PlayStation 3 on the Internet to study protein folding and misfolding via a distributed computing system. Participants can check on how much they have contributed and see how they rank against other contributors. In the spirit of competition, the hardware site 

 is hosting a competition to see which group reaches 5 million points first.

In a similar vein, another principle of Web 2.0 is that the Internet as a medium has created the opportunity to harness the collective intelligence of the entire online community. 

 is a prime example of this concept. The name comes from “Wiki,” a Hawaiian word for “quick,” and “pedia,” as in encyclopedia. In Web terms, a wiki is a collection of pages designed to enable anyone to contribute or modify content. Users can add pictures, video, and create links to information on other sites in addition to adding explanations, definitions, and other content. Wikipedia is a popular destination because it provides information on an unbelievably wide range of topics. Sharing resources online in large virtual communities is another key feature of Web 2.0, as exemplified by sites such as 

. At Del.icio.us, after users create an account, they can bookmark favorite sites and “tag” them with keywords, enabling other users on Del.icio.us to search for and discover these sites.

Del.icio.us keeps track of how many other people save these sites as well, which provides another measure of which websites and content the community deems most relevant. In addition, Del.icio.us users can join up with one another to create networks and alert others in their network of new sites. Digg takes a similar approach, in that users tag and submit interesting and useful sites for appraisal and comment by other Digg members, who rate them either as digg (positive) or bury (negative). Digg users can search based on most popular story, least popular story, newest story, oldest story, and most-commented-on story.

 is a healthcare-based sharing tool that works in the same way as Del.icio.us and Digg but it is restricted to physicians, nurse practitioners, and physician assistants only. RSS, or “really simple syndication,” is another popular method of sharing content.  Easy to download and use, RSS readers enable users to subscribe to “feeds” that deliver news and other information from their favorite websites and other information sources. In essence, RSS feeds enable the user to have multiple sources of information pulled into the reader program, which also tracks which content is new and which has been read. For example, 

 offers the option of sending search results as an RSS feed, so that any new journal that meets the user-generated search terms will appear in that person’s RSS reader.

Depends on who you ask. A variety of healthcare thinkers and pundits have off ered competing defi nitions of Health 2.0.  Matthew Holt, founder of the 

, sees Health 2.0 as a user-generated phenomenon. Scott Shreeve of 

 says that Health 2.0 companies provide the venue to transform healthcare, whereas Jos Bakker of Philips Medical Systems sees Health 2.0 as the next evolution in the Web space for the 

. Perhaps the best way to understand the Health 2.0 trend is to review some of its leading companies.

One of the new trends in Health 2.0 is improved healthcare information searching.  Health-specific search engines, such as 

, improve on existing search engines like 

 by searching not only the Internet, but specific sites, including ClinicalTrials.gov and PubMed, with specific health-related terms from medical taxonomies. These taxonomies likely include Medline’s 

Systematized Nomenclature of Medicine-Clinical Terms

 (NCI) Thesarus.  These search engines also search specific sites that have earned 

Utilization Review Accreditation Commission

 (URAC) certification. The health search engines employ specific algorithms to implement the medical taxonomies, as well as utilize health experts, to refine the search terms (especially consumer-focused terms). 

 takes a slightly different approach. Instead of relying on algorithms and semantic analysis, it adds the wisdom of trained expert search guides and physician reviewers.

 are among the most wellknown social networking sites on the Internet.  Many patients have gravitated to these sites to create a presence on the Internet for themselves, as well as to establish links to their friends and business colleagues. In the Health 2.0 world, social networking among patients has taken on new meaning.  At 

, patients can create an online journal, join an online support community, and invite family and friends to join. Activities are communicated via e-mail alerts to community news and friends. Members give virtual “hugs” to help support one another, providing support almost 24/7. At 

, the social context takes the sharing of patient experiences further; although it focuses right now on Parkinson’s disease, multiple sclerosis, HIV/AIDS, and amyotropic lateral sclerosis, patients on the site not only share their symptoms, but also data on their treatment, which are tracked. Th is information is then plotted graphically over time, which helps others see the outcome of treatment on specifi c symptoms. 

also provides support communities for patients but adds topic-based forums featuring physician experts.

 is the largest professional network online, with more than 20 million members. It offers a variety of services, including job postings, the ability to post questions to one’s network or the larger community, and discussion forums. One of the key features is the ability to see network updates, such as the new connections of your primary connections, as well as any changes to their profi les. The site is extremely popular with recruiters, who typically have over 500+ connections. But the medical community represents less than 4% of total users.  In the Health 2.0 space, 

 is the largest online healthcare community, with more than 60,000 members.

At this site, physicians pose questions and answers so that clinical findings and unusual events can be shared, with the collective knowledge advancing patient care in a peer-review manner. Physicians are verified when they join but can maintain a relatively anonymous profile. Pharmaceutical companies and other groups can pay to access the observations and clinical insights posted on Sermo. 

 also pools and shares clinical pearls similar to Sermo, but its revenue comes from medical technology companies that sponsor forums seeking user experiences.

 also allows members to share clinical pearls but adds sections for business practice and personal interests. 

 has a more professional focus compared to the sites above. Its goal is simply networking, and not collective information aggregation. Within3 has both research and clinical communities, as well as individual and institutional members, national and international members, and groups with the idea of facilitating information exchange, whether it’s a clinical trial or referral for care.

Although the definition of Health 2.0 may be a moving target, the essence is that the “Internet as a platform” concept creates opportunities for both patients and providers—the whole is greater than the sum of its parts. It has become a dynamic entity, with many similar sites that are also diff erent in subtle ways. Which sites will prevail and dominate is too difficult to predict in the post-dot-com era, but certainly the time to try is now, instead of waiting.

Dr. Luo is the Physician Editor-in-Chief of

, and chief of consultation and liaison psychiatry in the department of psychiatry at the UCLA Semel Institute for Neuroscience and Human Behavior.

The Internet has evolved beyond its origins as a collection of interconnected websites with static information. 

Taking the Wheel: The People and Companies Driving Health 2.0

His advantage? He’s a personally motivated billionaire with plenty of Internet experience—you may recognize his name from the America Online (AOL) days, when he piloted the fledgling Internet company he co-founded with two other entrepreneurs into one of the greatest success stories in American business history, only to see it fade away following a merger with 

 that Case has referred to as a “failure in timing and execution.”

Although the 2001 merger was the beginning of the end for AOL—and the beginning of millions of dollars in losses for Case and other shareholders&mdash;at the time, Case was worrying about a much more important issue; 2001 was also the year his brother, Dan, was diagnosed with a brain tumor. Sadly, Dan passed away in June of 2002. Case attributes part of his motivation for starting Revolution Health to his family’s exhausting and frustrating experiences with the healthcare industry as a result of his brother’s illness. Visitors to Case’s blog on 

 will find a post titled “Why I Started Revolution Health,” that explains this personal motivation. He writes about his brother, who “was fighting for his life, but had to divert much of his already-sapped energy to deal with bureaucracies, fi lling out forms, waiting in lines, trying to keep track of his medications, all the while seeking out other patients, and exchanging perspectives on treatment options.” Case also says that, “even though the United States has many of the world’s best doctors, hospitals, and technologies, the ‘system’ continues to make things diffi cult, cumbersome, and frustrating.” This is why he founded Revolution Health, to catalyze a much-needed revolution, “led by the people, for the people.”

The Revolution Health Network, which comprises RevolutionHealth.com, several other companies and online properties acquired over the past couple of years (Case has poured more than $100 million into the Network), and an array of partnerships, was named the number one health property on the Internet in February, according to 

 rankings. Case explains that RevolutionHealth.com was able to achieve this ranking because it successfully implemented a multi-brand strategy that included the acquisitions of HealthTalk—which provides information to patients suffering from chronic illnesses&mdash;and CarePages, a MySpace.com-type website designed to “connect family and friends during illness and injury.” Revolution Health

has also partnered with SparkPeople—a leading diet and fi tness website&mdash;and DrugStore.com, where visitors can purchase a variety of products they would fi nd in their local pharmacy or vitamins and supplements store. Case maintains that RevolutionHealth.com is and will remain the cornerstone of his strategy, but he has always believed that “the healthcare industry is a multi-faceted marketplace and that there isn’t a one-size-fits-all solution.” He says that RevolutionHealth.com will continue to pursue strategic alliances with affi liates that focus on specific niches within healthcare in order to provide a well-rounded consumer experience.

Case has worked from the start to ensure that RevolutionHealth.com is anchored with trusted content from reliable sources such as the Mayo Clinic, the Cleveland Clinic, and Harvard Medical School, and that it provides a user-friendly, interactive experience for members who want to discuss their health and share resources. You might then expect that the site would be crowded with visitors eager to chat about the information they’ve read on the site, share opinions, offer support, and seek advice. However, one thing that stands out when you visit RevolutionHealth.com is the scarcity of comments and user input on the blog postings, forums, doctor and hospital ratings, and every other resource that depends on extensive consumer interaction to be successful.

Case is the first to admit that uptake has been slow, but he explains that it has only been a year since RevolutionHealth.com launched and that the most important step was to get the site up and running. Now, he is shifting focus and working to build a level of comfort and trust with consumers, something that he says will take time. He likens the experience to his early AOL days.  “We’ve always viewed this as a process,” he says. “I think it will take a number of years before we really have the kind of traction that we think we’ll ultimately have. What we’ve been able to accomplish over the past year is impressive, and we acknowledge that there’s still a lot of work to be done. The first year after we launched our first service in the ‘80s, I think we had less than 50,000 customers, and they were using it something like only an hour a week. Now, tens of millions of customers are using it multiple hours each day. These things take time.”

A major obstacle to Revolution’s social networking approach is that healthcare presents unique challenges to efforts to promote consumer interaction and empowerment. For example, until very recently, much of the information that would be most useful in making an informed healthcare decision (price, outcomes and other quality measures, etc) was simply not available. Another challenge stems from the mindset of patients used to a healthcare system that often removes choices from them and masks in a variety of ways the true cost of care. Scott Shreeve, MD, author of the healthcare IT blog 

, thinks this is an especially critical challenge, and questions whether consumers can really be encouraged to take personal and fi nancial responsibility of their health when they don’t think twice about spending $2,000 on a home entertainment system, but balk at paying $75 to see a trained healthcare professional.

Case agrees that it will be difficult to get people to change their habits and expectations when it comes to healthcare. “There’s no question that over the last half a century, we’ve trained consumers to really abdicate health decisions,” he says. “The basic thought process for the consumer was ‘if I partially pay, or if the government is paying, then I guess it’s not unreasonable if they have a strong say in how this plays out.’” Ever the optimist, however, Case believes that he can help change this and is encouraged because “consumers actually do have a fair say and are demonstrating the ability to recognize and pay for value in the whole business of staying healthy and feeling good and looking good. It’s only when you get sick that you move into what we call the ‘healthcare system.’ But the industry of staying healthy—whether it be the fi tness club, or the vitamin supplements, or massage&mdash;is already predominantly a ‘consumer chooses, consumer pays’ retail marketplace. It’s only the business of sickness that is the complex institution we characterize as ‘healthcare.’ We now need to turn our attention to the ‘dealing with sickness’ industry, which has many of the challenges and problems we have been talking about.” Whether Case’s estimation of consumers being more involved with “staying healthy” than the “business of sickness” is accurate may be irrelevant. The real question is whether he will be able to catalyze a “revolution” with the Revolution Health Network and social networking strategy. It’s like the old saying: “you can lead a horse to water, but you can’t make it drink.” Consumers may understand the benefi ts of taking a more active role in their health, but in the end it is up to them to make that effort. So far on RevolutionHealth.com, there’s been minimal consumer engagement.

John Moore, a managing partner at the healthcare industry analyst firm 

 and an experienced IT analyst in the healthcare sector, believes that, right now, Revolution Health isn’t much more than a lot of hype. He openly agrees with Steve Case that healthcare is in need of a “revolution” that will be driven in large part by the consumer. However, Moore also believes that Revolution Health is “a company looking for a problem to solve,” and that “it hasn’t quite fi gured out where it fits.” He thinks that Case and company do not fully understand what needs to be done to catalyze a consumer-driven revolution in healthcare, and refers to their methods as a “strategy du jour.”

Right now, according to Moore, “They are at the roulette table placing bets on black, red, odds and evens, and then they are waiting to see where the marble is going to drop. They have the RediClinic brand; they have the CarePages; they have the basic health content; they have a personal health record on their site. They have all these different things, but I haven’t seen a very good synergy across the diff erent products they have. They haven’t really thought through how they should knit those things together.” A couple months ago, Moore posted an entry on his Chilmark Research website titled “

Odd, Facts Don’t Support Revolution Health’s Claim

.” In it, he draws some attention to the confusing numbers used to promote Revolution Health as the number one health property on the Internet.  When Case purchased the online properties HealthTalk and SparkPeople in late 2007, the Revolution Health Network was catapulted up the rankings in terms of page views. Th ese strategic acquisitions by Case garnered some positive press for the “Revolu-tion Health” brand. However, the acquisitions were even more eff ective in diverting attention away from the tiny role RevolutionHealth.com’s traffic played in these rankings.

 chart showing the traffic rankings of RevolutionHealth.com and 

 from September 2007 to the time of his posting (February 2008). The graph clearly shows WebMD with a commanding lead in traffic, with little or no gain by RevolutionHealth.com. If Revolution Health (not RevolutionHealth.com) is the number one health property on the Internet, it’s not through traffic organically built by the site. WebMD has been able to foster significant consumer interaction on its site, perhaps in part because of the robust results returned by any healthcare-related search on WebMD. Searching for the same information on RevolutionHealth.com often does not yield similar results, something Moore is quick to point out. “I just don’t think Revolution has done a very good job of articulating their value proposition for the end user,” he says. “I go there and I use some common search terms to look for content, and usually I can fi nd better content just doing a Google search.”

The surprisingly shallow pool of information, and other site deficiencies, can make it seem as though Revolution Health jumped into the market before it was fully prepared. Many of the site’s resources and features, like the “Find a Doctor” and “Compare Health Insurance” sections, are clunky and can be confusing to navigate. The website would be more useful if it had fewer, more intuitive features instead of trying to do too much at once and throwing resources up there just for the sake of having them. Has Revolution Health squandered a valuable opportunity to capture the public’s attention?  Moore doesn’t think so, explaining that there’s still plenty of time and that, with some adjustments, the company should be able to get on track. He believes that at this point the only thing Revolution Health has really done is waste some money. Establishing a viable presence will take time, he says, because “going direct-to-consumer is a diffi cult nut to crack. At this stage of maturity in the market, the Revolution Health Network would be wise to develop some strong partnerships on the provider side.”

Case agrees that it is important for Revolution to establish relationships with physician groups in order to get a greater physician presence on the site. He says that, “We are absolutely interested; we’re having discussions with lots of different people and lots of diff erent organizations.” Case stresses that only time will tell, but that although his focus so far has been to get consumers more engaged in their healthcare, he also believes that physicians are just as frustrated as patients with the healthcare system, if not more so. He thinks that if he successfully convinces patients to be more active in their healthcare, they will put pressure on the system and allow physicians more time to “focus on the health issues and spend less time focusing on the bureaucratic issues.”

There is no questioning Case’s sincerity; his personal experiences have motivated him to push for major changes in American healthcare, and he deserves some credit for recognizing that he can (literally) afford to try and shake up the system. Streamlining the many features on the website into a more cohesive portfolio of resources might enable Case to gain the trust of the consumer. Revolution’s wisdomof-the-crowds approach would also be enhanced by adding an important element—physicians&mdash;who have had plenty of their own frustrating experiences with the healthcare industry.  If there is going to be a revolution, it’s going to require the eff orts of stakeholders at every level of the healthcare system. And although RevolutionHealth.com has not been able to capture the attention of the public yet, Case is in it for the long haul. “RevolutionHealth.com has come a long way in a relatively short, 12-month period, but we’ll be at this for 10, 15, 20 years,” Case says. “I think of this as the top of the first inning and there’s still many more innings to play.”

Steve Case is on a mission to save healthcare, and he intends to do it by harnessing the consumer-empowering capabilities of the Internet.

June 2008

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