Mike Magee

In 2007, our organization, Positive Medicine Inc., advanced 7 visions which together, we predicted, would radically reshape health care as we knew it.(1)  One of those visions was titled Collapsing Databases. Results published this week in the Journal of the American Medical Informatics Association show that we were right on the concept but somewhat off on the methodology.(2,3) More on that study in a moment.

First the theory. Collapsing Databases states that there are three enormous health databases that are in the process of going virtual or electronic. The first of these is the Clinical Research Database or CRD. On the back end of the Vioxx withdrawal, conflict of interest concerns, and legitimate health consumer desires for early access to discovery information, major research databases are moving toward open transparency. For better or worse, the public is gaining ready access to the vast majority of positive and negative results of studies at the time of completion. These results will be increasingly transparent, electronic and readily transferable, far and wide. (4,5)

The second database is the Continuing Medical Education or CME database. It, too, is going electronic. In fact, projections are that 50% of all U.S. CME will be electronic by 2016, and eCME has been demonstrated to be effective. It is likely that within ten years, the vast majority of CME will be virtual and will be applied in real time rather than in episodic segments. Handheld devices are increasingly standard medical equipment in caring encounters, providing immediate database support to the patient/physician relationship during the evaluative and joint decision making process. This allows experts to quite confidently predict that in a preventive health care system where information is overwhelmingly the dominant health care product, CME will be inter-changeable and indecipherable from the care itself. (6)

The third database is  CCE or Continuing Consumer Education. The consumer movement continues to evolve from educational empowerment to active engagement and inclusion in the health care team. 80% of Internet users in 2010 accessed health information on the web. (7) We therefore predicted that patients and their families would increasingly demand access to the same hand-held hardware and information software that the other care team members are using. Such access would: 1) help avoid any confusion that might arise from multi-tracked information,  2)accelerate demand for simple and well designed educational products in the marketplace, and 3) advance convergence and address electronic incompatibility which otherwise  might compromise the primary “home to care team to home” care continuity loop.

Now five years later, nothing has occurred that would alter the end points predicted above. However the process or means to accomplish this transformation, and the speed with which this will occur,  is now clearer and less obstacle prone than we had predicted. The reason? Public access to search engine databases combined with sophisticated, algorithm driven analysis.

In 2007, we said, “If CRD and CME will collapse upon each other, CME and CCE will in many ways become one and the same… Are these not, after all, one and the same? Does not all clinical data originate with the people? Do they not loan this data to the people in whom they have the greatest trust and confidence – their physicians, nurses, and other caregivers? And if our records are one and the same, should we not also use the same informational resources to support our joint decision-making? Wouldn’t this be the best way to help us stay on the same page and avoid any chance of miscalculation, misinformation, or mistake?”(1)

In the JAMIA study reported out this week, scientists at Microsoft, Stanford and Columbia University analyzed data drawn from search engines of Google, Microsoft and Yahoo. The approach taken was similar to what had been successfully used to publicly track flu trends by Google search results. What they uncovered clearly demonstrated the well known deficiencies that have long existed in the FDA’s post-market drug side effect system which relies on the voluntary physician reporting through the Adverse Event Reporting System.(2,3)

The independent third party analysis of 82 million de-identified public search results from 6 million Internet users for drug, symptom and condition information uncovered that the combination of cholesterol lowering pravastatin with the anti-depressant paroxetine was associated with high blood sugar. Specifically, if you took one of these drugs, you subsequently searched for “high blood sugar” in 4 or 5% of the cases; but if you took both, you searched in 10% of the cases.(2,3)

In 2008, the FDA launched the Sentinel Initiative which they hope will eventually monitor, through health care professional reporting, the drug use and associated complications of 100 million citizens.(3) The expansion of electronic medical records, and national insurer and pharmacy databases could in the future make this feasible. But what this week’s study reveals is that, at least for a reactive health care system, it is possible to access this information, perhaps more easily, through a “consumer direct” channel.

In 2007, we stated, “As we move from intervention to prevention, health care will be an information dominated product or service, and this product will be anchored by three massive, collapsing databases – discovery (CRD), medical (CME) and consumer (CCE) – with primary ownership residing where the data originated, with the people, and provided primarily to the people caring for the people. Killer applications that allow health care to move from intervention to prevention to strategic health planning will emerge on the consumer side with health care professionals moving toward the people to support confidence, trust and relationship building. By utilizing the same software, information will double connect the people to the people caring for the people, rather then serving as a double check on each other.”(1)

Largely correct. And yet, one could argue that existing search engines are short-circuiting the need for “killer applications”. Patients, represented in this case by 3rd party researchers using their de-identified data, have already figured out how to access patients “double-checks” on the health delivery system; and that a “double-check” is quicker and more reliable than a “double-connect” approach. Health databases are “collapsing”, and with greater ease than we had predicted.

For Health Commentary, I’m Mike Magee

References:

1. Visions. Positive Medicine Inc. http://positivemedicine.info/?page_id=54

2, White RW,  Tatonetti NP, Shah NH, Altman RB, Horvitz E. Web-scale Pharmacovigelence: Listening To Signales From The Crowd. JAMIA doi:10.1136/amiajnl-2012-001482. http://jamia.bmj.com/content/early/2013/02/05/amiajnl-2012-001482.abstract

3. Markoff J. Unreported Side Effects of Drugs Are Found Using Internet Search Data, Study Finds. NYT. March 7, 2013. A12. http://www.nytimes.com/2013/03/07/science/unreported-side-effects-of-drugs-found-using-internet-data-study-finds.html?ref=drugspharmaceuticals&_r=0

4. Greener M. Drug Safety On Trial. EMBO Reports. 2005.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1299263/

5. PhRMA Statement Supporting Enhanced Transparency. Aug. 2, 2010http://www.phrma.org/media/releases/phrma-statement-supporting-enhanced-transparency

6. Harris JM. The growth, characteristics, and future of online CME. The Journal of Continuing Education in The Health Professions http://onlinelibrary.wiley.com/doi/10.1002/chp.20050/abstract

7. Fox S. Health Digital Divide. Pew Research Center. Feb. 1, 2011.http://pewinternet.org/Reports/2011/HealthTopics.aspx

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