Setting the Stage: The Health Care Information Breakthrough

Of all the massive and abrupt changes sparked by the global Covid-19 pandemic, healthcare has
been center stage. Whether tracking incidence, aggregating test results, coordinating delivery of
care and prevention, or developing vaccines and medicines, health agencies and institutions have
been literal lifelines, and have been pushed to their limits under urgent expectations.

And as a patient, how did you have to pivot? Starting in 2020, you had to adjust suddenly as your
healthcare went increasingly digital. Telehealth appointments became standard. “Patient portals”
popped up to transport you to your provider’s space. You could report symptoms on a
smartphone app. Your vaccination record resided in the cloud, and a screen on your smartphone
could tell you and the world whether you were okay to fly on a plane, eat in a restaurant, take
that courtside seat, or attend classes.

As these digital solutions have burgeoned, so has the importance of electronic health records
(EHR). Access to that information is, strictly speaking, nothing new. U.S. patients have had the
right to see their own health information since 1996, when the federal government put in place
the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.1 Whether your
health records are a doctor’s scribbles on a piece of paper, an x-ray, a lab’s blood-test results, a
complicated digital report–no matter what form they’re in–you legally have rights over your own
health information.

But having those rights hasn’t meant that most patients possess their records. And their records
aren’t consistently in an accessible or centralized form online. Yes, providers must turn over
records when patients ask for them. Until late last year, however, those patient
requests–when they happened at all, which was not often–were frequently met with delays and
even fees. And if you didn’t have a fax machine, which was the preferred medium of delivery for
lots of providers, you might not get them at all. Despite HIPAA, up until October 2022, patients
had little control over their electronic health records.

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Who then was in control? Health systems, data networks, and the companies that sell electronic
medical records. They were the ones who determined how much data patients could access,
when, and under what circumstances. Along the way, private data brokers made huge profits by
amassing hundreds of millions of medical records (stripped of information that would identify
the individual patient) and selling rights to drug companies, device makers, and insurers without
patients’ knowledge or consent.2

Two smart business reasons were behind healthcare organizations’ reluctance to relinquish
information: “It makes it easier to retain patients in their care, and it keeps them in control of
information with high commercial and research value.”3

Why was October 6, 2022, a game-changing date? It finally gave teeth to the 21st Century Cures
Act (Cures Act), which for six years prior had been steadily attempting to turn the ship around
and force hospitals, clinics, and other providers to make it easy and free for patients to get their
electronic health records. That timeline included an April 2021 regulation smoothing the path for
patients to access and download their health records with third-party apps and barring providers
from making it difficult for patients. (See Exhibit 1 for a snapshot of the main U.S. government
agency in charge of electronic health information, HealthIT.gov.)

Now the balance of power has shifted by law: Patients can get unfettered access to their data, and
they can choose who else to share it with. We’re now at a “jumping-off point for a patient-
mediated data economy,” writes a health IT journalist, “that lets consumers in health care benefit
from the fluidity they’ve had for decades in banking: they can move their information easily and
electronically, and link their accounts to new services and software applications.”4

What’s in it for patients? If they can get their data, “they can better understand their care, shop
for services, and participate in research without waiting for a clinician, or drug company, to
present them with an opportunity.”5

The loosening of the institutional grip on records has been hailed as a win for patients. It’s also
sparked a burst of activity by both start-ups and established companies. Getting in the EHR game
with a service, a product, or a data platform is an alluring business opportunity. Will this seismic
shift in access be a win too for tech companies? The prognosis: It remains to be seen.

Oracle and Oracle Health

The basic facts
Founded in 1977 by Larry Ellison, who serves today as chairman of the board and chief
technology officer, Oracle has excelled at developing database management systems. Having
gone public in 1986, the company is one of the top providers of software, hardware systems, and
services and is valued at $299.5 billion. (See Exhibit 2 for Gartner’s July 2022 report
highlighting Oracle’s leadership in “completeness of Vision and Ability to Execute for ERP and
financial solutions,” as well as this link for other analysts’ ratings and observations.) It has
offices around the world and has 143,000 full-time employees. It is ranked no. 91 on the 2022

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Fortune 500 list. Catalyzed by Ellison’s latest mission—announced last summer—the company
has a bold vision of “making the world a better place.”6 And just what is that mission?

Ellison announces bold vision: “It’s about saving lives”

In June 2022 Oracle closed its biggest acquisition ever, paying $28.3 billion for electronic health
record company Cerner. The move has positioned Oracle to positively disrupt the healthcare
industry by leveraging its deep expertise in technology and databases to address some of the
most profound challenges plaguing healthcare delivery.

The new direction for Oracle has emerged from Ellison’s concerns about the fragmentation of
EHR and its inherent barrier to what the healthcare community calls “interoperability”—the
ability of health organizations to share information and thereby streamline care, medical
innovation, and public health trends. That objective is essentially what the provisions of the
Cures Act aim for. “Better information is the key to transforming healthcare,” Ellison declared at
a briefing a few days after the Cerner acquisition. “Better information will allow doctors to
deliver better patient outcomes. Better information will allow public health officials to develop
much better public health policy and it will fundamentally lower healthcare costs overall."7
(Read Oracle’s Oct. 2022 blog post summarizing Ellison’s vision.)

If Oracle’s teams and clients weren’t already mobilizing to expand and deepen cloud-based
approaches to healthcare—and many certainly were—the Covid-19 pandemic hurled them into
urgent action. Within weeks and months Oracle racked up several success stories, including

• electronically prescreening more than 600,000 individuals who signed

up for vaccine clinical trials (working with the U.S. Centers for
Disease Control and Prevention and the National Institutes of Health)
• developing v-Safe, a smartphone app individuals could use to report
how they were feeling after being vaccinated, and

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 • helping Oxford University deploy—in just 68 days—the Global
Pathogen Analysis System to help research organizations, public
health agencies, and diagnostic companies better understand the
makeup and spread of Covid-19 and its variants.

The underlying key to all of these is the ability to use data to drive insights, a problem that
Oracle is committed to addressing through human-centric experiences for patients, providers,
payers, and the public.

“While Oracle has been a bit of a hidden brand throughout the first
45 years of the company, Oracle is now going to be at the center of
the next generation of healthcare in what we call patient
engagement where patients interact with and share information with
caregivers and doctors. So people are going to be carrying around
Oracle in their pockets. And it’s not iTunes, with 1,000 songs in your
pocket, but the interface with caregivers will be through the Oracle
smartphone application. Longitudinal health records will be
available to you. And you the patient will be controlling access to
health records, and sharing those with doctors electronically on a
smartphone.”

Oracle CEO Larry Ellison, June 2022

(quoted in Bob Evans, Cloud Wars, Nov. 21, 2022)

Empowering Patients: The Challenge for the Marshall International Case

Competition

The problem
Where are your healthcare records? Typically they’re siloed off—perhaps at your primary care
provider’s office (including a dentist’s), or your university’s student health center, a Walmart or
CVS (they’re now running their own health clinics with their own records), or that out-of-town
clinic where you went when you crashed your bike on vacation, to name just a few.

If you’re a tech-savvy patient, you may also have uploaded some records to Apple’s Health
Records on iOS.

And where isn’t the only question. Who uses your records? For what purpose? Are institutions
making money from patients’ records—profit that the patient never shares?

Patient advocates say that too many people are unaware of the volume of information recorded
about them or its value. And they’re unaware that they may have new, direct opportunities to

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participate in clinical studies and digital health services all from the convenience of their homes
or local communities.

Building a Business Case for Incentivizing Individuals to Share Their Health Data
As the healthcare ecosystem continues to digitize and transform, Oracle wants to understand how
future generations of consumers, citizens, and leaders think about their health data and how they
want to shape the future of healthcare.

Here are some questions for you to consider:

Why should individuals share their health data?

So much of who we are, what we do, what we like and dislike, and where we’ve been and might
be going is already out there with or without our consent. Given the “personally identifiable data
that dribbles from our computer hardware and from our networks,” as Professor Charles Seife
put it in a critique of 23andMe, “and with the amazing volumes of information that we always
seem willing to share with perfect strangers—even corporate ones,” why should individuals
share their health data? What motivations might appeal to them?

Key reasons why individuals might share their health data include:
• better understanding their care,
• shopping for services,
• participating in research without waiting for a clinician, or drug company, to present
them with an opportunity,8 and
• benefiting monetarily, personally, or ethically.

They might also be motivated by

• playing a part in the bigger picture and
• strengthening public health through data for researchers and public agencies like the CDC
or local public health departments

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Covid-19 breakthroughs, for instance, were often propelled by patients who volunteered their
health data. Same with the recent outbreak of mpox, whose spread in the U.S. was contained due
in part to the LGBTQ community’s efforts to track and share information. Researchers are also
relying on big data to understand and follow mental health issues like depression, isolation, and
addictions so that patients can get personalized medicine.9

There is also now another incentive for individuals: They can potentially make money from their
health data. (More on this below.)

Researchers have found that consumers think that all data is not equal. Certain kinds of
information are regarded as highly sensitive (e.g. Social Security numbers); other kinds of data
are less sensitive (e.g., the media you like). See Exhibits 3 and 4 for insights into consumers’
willingness to share data—what kind and when.

As you consider incentives for patients to share their health data, you may want to think about
how different demographics should be approached differently. Why and how might Gen Zs and
Millennials, for instance, respond to incentives that are distinctive from how older generations
are motivated to participate?

Consider whether ranking the incentives you come up with would be useful.

What about socioeconomic disparities?

Patients and healthcare professionals, especially those in the public health arena and
organizations concerned with underserved populations, want to close the gaps in inequality.
There is a clear healthcare divide. Health companies too are mounting outreach campaigns to
populations that have been long underrepresented, like Pfizer’s new clinical trial platform and its
ads to recruit Black and Latinx participants, as well as the Harvard Personal Genomic Project.

Some analysts say the barriers that constitute the divide are patients’ limited digital or health
literacy (or both), limited access to high-speed internet or up-to-date equipment, and
misinformation or lack of information.

Regardless of the precise causes of healthcare inequity, it’s clear that having access to one’s own
records and visibility into how they’re being used offer benefits to patients. In a study exploring

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patient empowerment through online access to health records, researchers found that U.S.
patients in lower socioeconomic tiers were less likely to read their records. But those who did
reported higher benefits, according to this team of researchers. Why is it even more important for
these patients to have EHR? “Perhaps these patients are offered less information initially in
person, have more difficulty processing the information, or ask fewer questions, making the
written information in the record all the more important. . . . As surveys show, patients who are
more vulnerable to communication breakdowns in face-to-face visits might have the most to gain
from access. In short, not offering patients access might also incur negative consequences for
care that must be balanced against access.” 10

Is there a role for educating patients?

According to Liz Salmi, a brain-cancer patient who is now communications and patient
initiatives director at OpenNotes, to have a real impact data sharing must be accompanied by an
education campaign to help patients understand their rights and the benefits of getting their
data.11
Consider whether a consumer education campaign should be part of the business model for a
National Medical Database.

What about security concerns?

How can a company, like Oracle, assure customers that their information is safe? This includes
protection from unauthorized users and sharing. And if the individual wants anonymity, how can
that be guaranteed? Are individual customers even aware of security risks? Are they able to
distinguish reputable data users from swindlers?

Concerns will vary from person to person. “For people who have to manage a lot of information
about their health,” says Prof. Wanda Pratt, of the Information School at the University of
Washington, “making [access] easier is so valuable. Even if there are privacy concerns, it’s
worth it. Others feel the exact opposite. We need to be able to support both.”12

Note: See Oracle’s robust database security solutions on the company’s website, which
highlights its being named the overall leader in the 2021 KuppingerCole Leadership Compass for
Database and Big Data Security.

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Commodifying your personal health data: It’s legal, but is it ethical?

Another incentive for sharing data is the potential for individuals to make money from their own
health data. Centralized health database providers, like Oracle, are grappling with the advantages
and disadvantages to patients of a transactional model. Researchers worldwide are exploring the
ethical and market implications too.

“Selling your own health data is completely legal—if you wanted to, you could request a
copy of your electronic health record from your doctor and post an ad on eBay,
Craigslist, or even Facebook Marketplace. But unlike a used car or a work of art or a
cherished family heirloom, your personal data isn’t something of value that you give up
forever once it leaves your home. It’s something else entirely—it belongs to you, long
after you sell it, until the day you die. It’s an asset that can be sold over and over,
without depletion, until the demand diminishes.”(Jeanette Beebe, Fast Company)13

“If you look at the people who’ve made money from data in the
hundreds of millions or billions, it’s white males. Look around. This
[personal data] is the new natural resource. This is actually the
opportunity to level the playing field.”

Richie Etwaru, Co-CEO

Hu-manity.co, five-year-old tech company offering individuals and organizations digital-privacy solutions

Naturally, there are questions of secure monetization. Various solutions have been floated. Notes
a health-data-marketplace article in Fast Company, “The pricing and valuation of this sensitive
health data should be handled carefully and securely, and a blockchain-based system with a
health-specific cryptocurrency is one way to go.”14

But even with practical transaction measures in place, not all experts are on board with
monetization of individual records. These voices advocate for protection of the consumer by
collective agencies. “Although individuals should have direct control over their data wherever
this helps to protect their privacy and dignity (including individual consent to data use in the
context of medicine or insurance), data property rights should be a collective, not an individual,
right,” asserts a team of scholars in their recent article “Why Paying Individual People for Their
Health Data Is a Bad Idea.” “Individual-level monetization is likely to lead to a situation in
which the rich pay with money, whereas people on low incomes pay with data,” they warn. (See
Exhibit 5.) Instead, “communities and nations should decide how data should be used and for
whose benefits. In contrast to open-access regimes, in which data can be taken by anyone and is
often used most profitably by those with the deepest pockets, collective property rights would
enable communities to exclude certain types of user, such as large technology companies, or
impose conditions of use.” 15

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In your recommendations, you will want to keep cautions and alternatives like this in mind.

Other tasks for your case study team

As you ponder the important questions listed above, you will want to integrate your insights into
the following two specific business model explorations. You may come up with other ways to
frame these.

1. What KPIs might be used to measure successful transactions between consumers

and healthcare systems?

A company or a project relies on KPIs to help them (1) align with strategic goals, (2) track the
right data, and (3) offer smart insights about whether things are on track. Oracle itself, through
its Netsuite, has created popular guides about KPIs, especially for chief financial officers,
including, recently, The Data-Driven CFO: Refocusing on the KPIs That Matter. (See Exhibit 6
for an Oracle visual of five reasons why KPIs matter and the online program notes for this case
competition for the Data-Driven CFO PDF.)

What measures would you suggest to gauge, for instance, consumer interest in using a
centralized, human-centric health data system, the actual number of users, ease of use, churn
rate, attrition rate, staffing, and profitability. How could these KPIs be SMART—specific,
measurable, achievable, relevant, and time-bound?

Your model might also answer, “What is a reasonable time frame for return on investment?”

2. What Marketing Strategies Might Be Effective?

Capitalizing on transformations in healthcare access, technology, public policy, and patient

awareness can legitimately be called an innovation. Any marketing 101 course would suggest the
7P formula: product, price, promotion, place, people, packaging, and positioning. In
brainstorming a marketing strategy, however, in addition to those standard considerations, you
may want to keep in mind a marketing philosophy famously articulated by Slack’s founder,
Stewart Butterfield: “Sell the transformation.” Slack was selling a software product, to be sure.
But what it marketed was an innovation that promised to change a whole system, change human
behavior. (See Butterfield’s memo “We don’t sell saddles here.”)

As you formulate a marketing plan, keep in mind the questions posed earlier about
socioeconomics, privacy, individual motivations, consumer preferences and demographics,
ethics.

Oracle is excited to learn of your recommendations tomorrow and to better understand what
tomorrow’s generation wants for the future of healthcare.

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Exhibits

Exhibit 1.
HealthIT.gov
“Our vision is better health enabled by data”

What We Do

The Office of the National Coordinator for Health Information Technology (ONC) is at the forefront of the
administration’s health IT efforts and is a resource to the entire health system to support the adoption of health
information technology and the promotion of nationwide, standards-based health information exchange to
improve health care. ONC is organizationally located within the Office of the Secretary for the U.S.
Department of Health and Human Services (HHS).

ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the
most advanced health information technology and the electronic exchange of health information. The position
of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the
Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009.

Through its work, ONC remains focused on two strategic objectives:

○ Advancing the development and use of health IT capabilities; and

○ Establishing expectations for data sharing

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Exhibit 2.
Gartner Vendor Rating excerpt 2022

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Exhibit 3.
Jan. 24, 2022, results of survey of 3543 US adults, published in Journal of the American Medical
Assn. Network Open. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788307

Findings

In this survey study of 3543 US adults, consumer willingness to share digital data was associated
with a range of factors, most importantly the source and type of data. Certain data (eg, financial,
social media, public cameras) were viewed as more sensitive than electronic health record data,
but underlying views on digital health privacy were strongly associated with consumer views on
sharing any digital information.

Implications

The proliferation of digital health data from a wide range of sources creates many opportunities
to develop programs and tools to improve health. Our study shows that many consumers—when
given a choice—are reluctant to share their digital health information. Rather than context
driving preferences, many consumers seemed to have strong views about sharing or not sharing
information regardless of the specific use case scenario. The key question is whether enhanced
privacy protections would increase trust and support for socially beneficial uses. Prior research
suggests that when protections are perceived to be stronger (ie, consumers have greater control),
consumers have fewer privacy concerns.34 The current lack of protections may hinder consumer
support for health programs powered by consumer digital data and data science.

Journal of Medical Internet Research, Grande D, Luna Marti X, Merchant R, Asch D, Dolan A,
Sharma M, Cannuscio C
Consumer Views on Health Applications of Consumer Digital Data and Health Privacy Among
US Adults: Qualitative Interview Study
J Med Internet Res 2021;23(6):e29395
URL: https://www.jmir.org/2021/6/e29395
DOI: 10.2196/29395

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Exhibit 4.
Nov. 12, 2014, Pew Research Center study, by Mary Madden
Americans Consider Certain Kinds of Data to Be More Sensitive Than Others
A majority also consider health information to be very sensitive
More than half (55%) of adults consider the state of their health and the medicines they take to
be “very sensitive” information while 26% view that kind of information to be “somewhat
sensitive.” Another 12% say that health information is “not too sensitive,” and 5% say it is “not
at all sensitive.”

Men and women rank the sensitivity of health information equally. And adults of all ages are just
as likely to say that their health data is “very sensitive.” In general, those who have higher levels
of education and income report a greater level of sensitivity with regard to the details of their
health information.

Those who have heard a lot about government surveillance programs are especially likely to say
their health information is “very sensitive” (65%), along with those who check up on their digital
footprints online (61%)

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Exhibit 5.

Exhibit 6.

Graphic from The Data-Driven CFO, Oracle Netsuite, 2023

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1
This case study focuses on the situation in the United States in order to ensure that the scope is
manageable in the brief timeframe of the Marshall International Case Competition. Data sharing and
electronic health records are topics being vigorously discussed and explored worldwide by policymakers,
researchers, health organizations, and advocates.

2
Ross, Casey. “Call it data liberation day: Patients can now access all their health records digitally.” Stat
News, Oct. 6, 2022. https://www.statnews.com/2022/10/06/health-data-information-blocking-records/
3
Ibid.
4
Landi, Heather. ”ONC data shows 77% of information blocking complaints involve providers.” Fierce
Healthcare. March 1, 2022. ttps://www.fiercehealthcare.com/health-tech/onc-data-shows-77-information-
blocking-complaints-point-finger-providers
5
Ibid.
6
Evans, Bob. “Larry Ellison: ‘Healthcare Mission’ Transformation Oracle, Culture.” Cloud Wars. Nov. 21,
2022. https://accelerationeconomy.com/cloud-wars/larry-ellison-healthcare-mission-transforming-oracle-
culture/
7
Landi, Heather. “Oracle, Cerner plan to build national medical records database as Larry Ellison pitches
bold vision for healthcare. Fierce Healthcare. June 10, 2022. https://www.fiercehealthcare.com/health-
tech/oracle-cerner-plan-build-national-medical-records-database-ellison-pitches-bold-vision
8
Landi, op cit.
9
Mouadda, Nidal, et al. “Turning data into better mental health: Past, present, and future.” Frontiers in
Digital Health, Aug. 17, 2022. https://www.frontiersin.org/articles/10.3389/fdgth.2022.916810/full
10
Hägglund, Maria, et al. “Patient empowerment through online access to health records.” BMJ, Sept. 29,
2022. https://www.bmj.com/content/bmj/378/bmj-2022-071531.full.pdf
11
Ross, op. cit.
12
Quoted in Nicole Wetsman, “Accessing health records on your iPhone is a dream and a nightmare.”
Popular Science. Jan. 23, 2019. https://www.popsci.com/apple-iphone-personal-health-record/
13
Beebe, Jeanette, “You can now make money selling your own health data, but should you?” Fast
Company, Sept. 27, 2019. https://www.fastcompany.com/90409942/would-you-sell-your-own-health-data-
theres-a-market-for-it-but-ethical-concerns-remain
14
Ibid.

15
Prainsack, B., Forgó, N. “Why paying individual people for their health data is a bad idea.” Nat Med 28,
1989–1991 (2022). https://rdcu.be/c3uda https://doi.org/10.1038/s41591-022-01955-4. “Open access
regimes” comprise countries and public agencies whose policies allow—and in fact encourage—complete
accessibility of digital repositories of data and scientific and medical research results. For more
information, see D’Agostino, M., et al., “Open data and public health.” Rev. Panam Salud Publica. 2018
June. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386141/

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