Resilient Ambassadors of Change

e-healthcare may cure many ills

Healthcare costs too much.  Patients are dissatisfied.  Physicians are dissatisfied.  Insurance companies have too much control--patients and doctors too little.  Medical records are scattered.  Too little information is available.  Too much information is available.  The physician workforce is shrinking.  So, what's the good news?  Internet savvy patients, doctors, and other innovative stakeholders are making strides in addressing some of these problems in ways that may become the basis for how healthcare is practiced in the future.

Many clinicians have overestimated the risks of online health resources to their patients and underestimated the benefits.   E-healthcare may be one of the most important cultural medical revolutions of this century, and the majority of physicians are not savvy enough to operate in this emerging culture.   Our future physicians will likely have the benefit of growing up immersed in the internet social and electronic culture, and hopefully with the skills to follow in the footsteps of the pioneers

The e-patient.  More and more, people are seeking healthcare online.  They research their medical problems on a variety of web-based medical sites (e.g., WebMD); they blog and use social networks to share with and learn from others with similar health conditions or interests.   Patients in force are abandoning traditional methods for obtaining medical advice and even treatment plans (i.e., physicians office) in favor of the more on-demand options that the internet offers.  The e-patient has a personal health record.  The e-patient requires a non-traditional approach to healthcare.  The e-patient is extremely active in their own medical care and requires a collaborative relationship with their physicians.  E-patients are blogging and using social networks to share with and learn from others who have similar conditions or interests, and have been for several years.  Our current base of healthcare professionals seem blissfully unaware of the impact that the e-patient might have on the skills they will need to best serve their patients in the near and far future.  The general population seems to be light years ahead in taking advantage of the benefits of the burgeoning social and collaborative electronic culture and tools than our medical professionals.  The net friendliness of clinicians and provider organizations is becoming an important new aspect of healthcare quality. 

The e-doctor.  Unfortunately, the e-doctor is a much more rare species that the e-patient, as the medical community is often slower to adopt changes that the general population readily embrace.  There are some pioneers and early adopters who are empowering and enabling their patients and themselves by embracing trends and adopting technologies to provide a higher quality of patient care and experience.   In addition to encouraging the e-patient as a collaborator and an informed partner in their own healthcare, the e-doctor is a pioneer, often abandoning traditional structures that act as barriers (e.g., insurance reimbursements, traditional office visits, overhead, etc.).  In his practice, the e-doctor is in direct contact with patients, taking advantage of text messaging, email, and social media in order to facilitate treatment and education of their patients.  The e-doctor utilizes cost effective options when running his practice and provides cost effective choices for patients.

Hey I think I've spotted one!  Have a look and listen to Jay Parkinson of Hello Health describe his innovative approach to healthcare. 

Jay Parkinson, Hello Health from Health 2.0 on Vimeo.

Pay for performance (P4P)--How's my driving?

The first time I heard about P4P, I thought what a great old idea!  Didn't they call it "piecework" back in the day?  Why shouldn't I be paid more if I could churn out 60 widgets in an hour compared to the guy next to me making only 43?  Well for one, maybe his widgets were better than mine.  Maybe I was working with inferior widget parts.  Maybe someone on the widget part line slowed him down.  There may be reasons why we are no longer paid by the "piece." 

Surely churning out patients was not what health insurance companies had in mind, so P4P must be tied to patient outcomes or satisfaction or some other measure that the physician is performing at his best.  So what's the fuss?  As a patient, I certainly would like to know that my physician is a top performer.  Why wouldn't they want data about their patient outcomes and satisfaction collected, analyzed and shared with insurance companies and patients?  Maybe their patients are sicker, poorer, and unable to afford to comply or follow up.  Maybe they have no control over the interactions between staff and patients. Maybe they are powerless to fix system problems within a hospital. There may be reasons why physicians are leery of embracing P4P sponsored by insurance companies. 

Today, buried in an otherwise engaging post on The Medical Quack, I found a reference to a kind of P4P that could affect me more directly in the not so distant future. On it's face,like piecework and physician P4P it seemslike a great idea. I drive carefully and I pay less money for car insurance. I have a spotless driving record--no accidents or tickets (except the parking tickets my sons get when they borrow my car).  I should be paying less for car insurance. It seems Progressive Insurance has a device that tracks your driving habits, coupled with a program called My Rate promising lower rates. You can even log on to the website and track your projected renewal rate based on your driving. What if my rates go up? What if I can't get insurance anywhere?  Maybe the device was faulty. Maybe I lent my car to my son (the one who gets the parking tickets).  Maybe I was driving erratically while dodging the other nuts on the road. Maybe there are reasons to suspect the motives of insurance companies.

I'm not sure money is the best motive for improving your widget making, driving, or patient care. I'm pretty sure insurance companies and other third parties that stand to gain while we lose are NOT the best choice to drive improvement. 

So what is a medical home anyway?

Given numerous recent news headlines, blog posts, and Google alerts, the concept of the medical home is gaining momentum and you may be in the minority if you admit to not knowing what the fuss is all about.  I knew it was probably something I should pay attention to, but I just could not drum up much interest in reliving those months when mom-mom's living room was transformed into a makeshift hospital ward complete with the bed that cranked up and down, a portable potty, food tray, bedpans, and the nurses and aids who were "helping" mom-mom die. Why would anyone want a medical home? 

I wasn't even close!  I should have followed my instincts and boned up on my medical home knowledge so that I wasn't just shaking my head up and down when the phrase came up in a recent advisory committee meeting.  So, for those of you who were nodding right along with me, here's the scoop.

According to the Patient-Centered Primary Care Collaborative,

The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care to adults, youth and children.  The PCMH will broaden access to primary care, while enhancing care coordination. Primary care physicians practicing in the highest level medical home will:

• Take personal responsibility and accountability for the ongoing care of patients;
• Be accessible to their patients on short notice, for expanded hours, and open scheduling;
• Be able to conduct consultations through email and telephone;
• Utilize the latest health information technology and evidence-based medical approaches, as well as maintain updated electronic personal health records

...and much much more.  Click here to read the PCPCC Brochure 

The Patient Centered Primary Care Collaborative was created to change a health care system that does not work for anyone--patients, providers, and those purchasing health care.  Its members include representation from employers, primary care physician associations, health benefits companies, trade and professional groups, and health care quality improvement associations. 

I've also read that pediatricians are credited with developing this concept and that the American Academy of Pediatrics, the Americal College of Physicians, the American Academy of Family Physicians, and the American Osteopathic Association teamed up to develop the medical home principles.

Now that we're up to date on the what and the who, I'll keep a lookout for any buzz on this trend toward a more cost effective and efficient, patient-centered model of health care.

Finding Doctor Right

In a special section Decoding your health, the New York Times provides some solid information and advice to consumers in a variety of articles around topics like Googling your health, popular medical websites, FDA approval for medications, alternative medicine, and more. 

One of the articles, You can find Dr. Right, with some effort, gives consumers some direction for selecting a physician, using what little objective data is currenty available, as most consumers continue to rely largely on word-of-mouth referrals from family and friends.

The article suggests contacting the usual suspects like your State Medical Board for licensing information, your health plan (as some are beginning to provide some quality measures) and the American Board of Medical Specialties for specialty certification information, as well as some of the emerging services offering physician ratings.  Still, this is precious little information as the basis for a most intimate doctor/patient relationship--no quality measures of physician performance or even descriptive data about physicians' practices.

No surprises here, good objective data is hard to get, and volumes of subjective physician rating data will likely not provide the basis for good decision making.  The relevance and timliness of our discussions around physician matching, performance measures of physians in practice, physician practice profiles, and data compilation and report out continues to be supported by the increasing public demand for quality measures for physicians.

"...patients cannot get their hands on a wealth of information about physicians that is compiled by government agencies....  The Medicare program recently started a physician quality reporting iniative,...information is not yet public."

In an attempt to obtain data about procedures done by physicians (e.g., knee replacements, prostate surgery, etc.), last year the nonprofit group Consumers' Checkbook won a lawsuit granting access to Medicare's physician records.  The government is appealing the decision--there goes that big, publicly-available data set that we've been dreaming about.

Physician communication skills -- predicting and preventing future woes

Many thanks to a local scouter in our tech services unit who passed along an article from Science Daily that he thought would interest us.  The article Physician's 'dashboard' takes a measure of communication skills reports on a study that utilizes a new system to instantaneousy report patients' perceptions of recent encounters. 

The system, developed by researchers at the Medical College of Georgia School of Medicine, uses a touch screen kiosk where patients respond to six communication-related questions immediately following their encounter with the physician.  The other part of the system is a 12-inch screen that displays near real-time results of ongoing patient surveys in a colorful, easily interpretable visual display.  Additionally, the system provides private feedback to individual physicians in the form of a weekly email.  The purposes of the study are to 1. determine whether or not patients will complete the survey immediately following their visit, and 2. how physicians will respond when they actually have data.

The article quotes Dr. Pamela Wagner, who teaches communication skills to first year medical students, as saying, "The number one predictor of malpractice is poor communication, not that something bad has happened." Dr. Wagner goes on to say, "The innate desire to do well may help physicians modify their habits when they see vivid evidence that they are not."

While reading this first article, another one caught my eye.  Doctors' 'bedside manner' test predicts patient complaints reports on the results of  McGill University study of 3000+ practicing physicians who took the MCC clinical skills examination and the relationship between low scorers and the likelihood of patient complaints.

"Low scores on the exam were quite predictive," said  RobinTamblyn, scientific director of McGill University's Clinical and Health Informatics research unit. "It was really like a dose-response relationship. The higher your score, the less likely you would get complaints.

Both of these articles indicate the importance of good physician communication skills in optimizing patient care and satisfaction and/or preventing malpractice.  I sure hope the MCG is successful in providing practicing physians with data that will enable them to recognize a need for improved communication skills.  As for all of those low scorers on the clinical skills exam--maybe the bar should be set higher...

Project health design and next generation PHRs

Project Health Design is a $5 million national program funded by the Robert Wood Johnson Foundation.  It's goal is to design a suite of Personal Health Applications (the next generation of Personal Health Records) that are integrated to support people in achieving their varied yet specific health goals. 

With that said, on Wednesday I attended A 'Report Out' from Project Health Design and Forum on Next-Generation PHRs where nine multidisciplinary teams showcased their prototypes of user-centered PHR applications.  It was noted early on that calling these applications PHRs does not do them justice, as they are not merely records nor are they simply a means of collecting and storing data for doctors or researches to review and manipulate.  They are interactive applications that collect information, provide customized feedback, and empower people to take control of their health decisions.

Each team worked on prototyping one application and had to work across teams as interoperability is key to the future of PHRs.  Patients use these web applications with either their desktop, laptop or tablet computers and/or internet-enabled mobile device.  Focus groups with patients and providers featured heavily in the design phase.  For example, from older adults, who may not be technologically savvy or manually dexterous, they learned that a touch screen tablet device worked better than a smaller mobile device when using an application designed to guide self-care post heart surgery.  Younger adults and teens preferred mobile devices over being tied to a computer when managing their chronic illnesses. 

Each team began their morning session with a video showcasing their application prototype followed by discussion and Q&A.  Be sure to check out one or two of the video links below:

• managing diabetetes
• assisting older adults with transitions of care
• breast cancer treatment planning
• medication management for children
• chronic heart failure self-care and management
• chronic disease medication management between office visits
• pain management
• helping sedentary adults become more physically active
• assisting chronically ill adolescents in transitioning from pediatric to adult care settings

These applications emphasize action.  While they do collect data for review by providers, they also  provide a communication link betweent the patient and provider, and most importantly empower the patient to make more independent day-to-day decisions about their health care.

The afternoon started off with two breakout sessions.  I was drawn to Session A Open Platform and Core Components, because my of my sometimes unbalanced interest in the technology.  However, I forced myself to broaden my scope and attended Session B Policy Implications, where discussion centered around the need for very strong foundations for protection and privacy and the need to address PHR issues that might hamper widespread adoption. Privacy policies should not prevent people from sharing their medical data; rather they should promote choice, as many of the development teams found that people were more than willing to share their private data when they received benefits that empower them to be more involved and take more control over their health decisions.

Breakouts were followed by a session highlighting the successes of health systems that have implemented comprehensive EHR programs from Kaiser Permanente, Partners HealthCare System, Markle Foundation, and University Hopitals and Health Systems. 

The final panel consisted of some of the biggies in the tech industry.  Colin Evans of Dossia Consortium; Neil Ramshaw from Google Health Team; and Keith Toussaint from Microsoft Health Vault.  There were no fisticuffs!  Both Neil and Keith indicated that it was too early for a battle to the death, as there are still too many barriers to widespread adoption.  While not agreeing on collaborating with one another, all agreed that interoperability between platforms was important.

A day well spent, an excellent conference, an awesome project. 

Surgical skill--it's not just in the hands

Last week, we hosted Mark Smith, MD and Kanav Kahol, PhD for an in-house seminar.  Mark is the System Director of Simulation and Innovation at Banner Good Samaritan Hospital, and Kanav is an Assistant Professor in the Department of Biomedical Informatics at Arizona State University.  We first met them at the Medicine Meets Virtual Reality Conference earlier this year, where they were demonstrating an innovative approach to preparing surgical residents to do procedures by practicing with the Nintendo Wii.  They modified a Wiimote controller by connecting a laparoscopic probe and had surgical residents warm up with Marble Mania, a simple maze game, prior to doing a procedure on a surgical simulator.  Their study showed that residents who practiced with the Wii and Marble Mania did significantly better than those who did not.  But that was only the hook to get our attention.  Mark and Kanav's presentation whetted our appetites with the range and direction of their research activities around skills and performance training and assessment.

For example

• Cognitive surgical simulators -- adding a layer of cognitive exercises (neuropsychological tasks) to basic simulators to provide more challenging exercises over and above psychomotor skills training
• Dynamic simulations -- an intelligent tutoring system that uses EEG to gage a surgeon's current proficiency and provides tasks and scenarios relevant to their skill level, enabling them to hone skills and focus on areas of weakness
• Visualizing surgical skill -- using real-time analysis to capture hand movement patterns of surgeons while completing a standardized task; comparing with database of novice to expert hand movements; and providing real-time feedback using a graphical hand display driven by a real-time data stream.
• Measuring movement expertise -- a promising approach to objectively evaluating surgical skills based on hand movement analysis instead of tool movement
• Fatigue effects -- focuses on effect of fatigue on surgical residents' cognitive skills during simulated surgical exercises

Some found discussion around cognitive capacity and introducing noise into the simulated environment to be particularly interesting as it related to some of our own BS topics around professional burnout and novice/expert performance.  Others were interested in social networking experiments using smart cards.  All were interested in further discussions around potential collaborations.

Healthcare Facts

While scouting, I happened upon the Healthcare Facts website.  According to the website, through a collaborative effort among Blue Cross and Blue Shield plans, they deliver "health care information as easy to understand as a nutrition label."  Well, it's not exactly what I was thinking of as "health care information," but rather health care provider information in a format that I found much more useful than what is available to me through my own healthcare provider's website. 

To enter the site you must select your state (currently only Minnesota and Louisianna) from a drop down list, which directs you to the "Shopping for Care" page, where you are able to shop for a hospital or a health care provider.  Membership in BC/BS is not required to use the service.  You can select by region, county or city.  Once you've selected your provider or hospital, you are presented with a factsheet that looks very much like the typical nutrition label found on all food products. 

I was able to do a side-by-side comparison of two healthcare providers of interest to me.  It was very similar to comparing digital camera features on circuity.com or bestbuy.com.  Features were categorized by Accessibility, Safety and Quality, Services and Technology.  Have a peek at the output from my comparison.  I would have liked the opportunity to compare more than two at a time, and the data is a bit skimpy right now, but objective information about features offered by each practitioner is a good start. 

Searching for medical information

For some reason, I got interested in Wiki's again.  I probably saw a post about medical wiki's which led to a search of resources available for consumers and medical professionals.  While searching, I came across a couple of "compilations" of medicine-related wikis, and pretty soon I became engrossed in scanning these resources for their relative value to me, as a consumer, and wondering about how useful they are for medical professionals.  Instead of trying to commit some of the information to memory, I decided to compile our very own Medical Wiki List. 

This wiki list is organized by intended audience. If the website did not explicitly state the target audience, some judgments were made about whether the intended audience was the medical professional or the general public/health care consumer. All wikis on this list are accessible to everyone. Some of them allow anonymous contributors/editors. Many require registration prior to contributing to articles, and some do not allow contributions from "non-professionals." 

For future reference, a link was added to the sidebar under the heading "Wikis."

Dreams of an electronic doctor-patient relationship dashed

My primary care physician has always been fond of telling jokes; I never leave an appointment without  hearing one or two or three or four.  He gets particularly punchy toward the end of a long day, so when I have an appointment near 8 pm, I can always count on his best rendition of the ones he’s tried out over the course of the day.  About 12 years ago, when he partnered with a major university hospital in Philadelphia, he finally discovered email.   I had been using email for years before, but it was very new to him.  We chatted about the benefits of email, particularly about what seemed to be the major function of email at the time—to spread jokes.  Since I was never good at remembering jokes, I never had any comebacks for him, but he enjoyed jokes so much that I offered to forward my best picks to his email address.  He was delighted. 

For several years, I kept him supplied with jokes.   The benefits of this electronic relationship were one-sided; he got new material, I got zip.  Many times I was tempted to email him with a quick question, but refrained from crossing that boundary—we never talked about practicing medicine via email.  Oh but how much easier it would have been to send him a quick question than it would have been to battle the office sentinels who guarded his time as if it were gold.  How much less intrusive I thought it would be, since he could respond at his leisure—I would not be just one more name and phone number in a long list of patients clamoring for his phone time.   How much easier it would have been for me, a typist, to frame my question in text, as opposed to getting tongue tied on the phone.  How nice to forward my list of issues in anticipation of my next visit.  I wonder how easy it would have been to engage in an electronic doctor-patient relationship.  Was it selfish of me to expect my physician to consult with me electronically, as it would probably be light years before any insurance company would offer reimbursement.  It could become another medium, like the telephone, through which patients acquire additional care and physicians additional overhead.

For the past few years, it has been an important focus of my work to explore trends and technologies that are likely to impact how physicians practice medicine in the future.  I read a lot about how the medical industry is light years behind others in this digital age.  It seems like a thousand years ago, or was it two paragraphs ago, that I had visions of receiving healthcare via email.  Some medical institutions provide a host of electronic options for your healthcare needs, and the occasional technology savvy physician is blazing new trails in innovative medical practices.   Even as far back as 2002, according to a Harris poll, 90% of patients surveyed wanted to exchange email with their physicians, and although email has the potential to strengthen the physician-patient relationship and improve both patient education and the quality of care, it is still nowhere near main stream.

It seems there are issues—privacy issues, discoverability and liability issues, reimbursement (or lack of) issues.  There are also ground rules, at least guidelines, to be established around what medical matters should be addressed via email or what turnaround time people should expect. 

It is not likely that I will enjoy an electronic relationship with my physician now or in the near future.  In fact, email as I know it (sent from a desktop computer in my home or business office) will probably not be the medium of choice for tomorrow’s patients anyway.  After all, how efficient is it to use 10 digits to get a message to your physician?  What the heck do you think thumbs are for?  Who has eight fingers anymore anyway?  For that matter, why wouldn’t you just queue up your avatar in your physician’s virtual office, while continuing your real-life activities, then teleport to as soon as your number’s called? 

I really was born too late…