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charges, costs and reimbursement - a difference WITH distinction

  We need to stop confusing charges with costs. If we want to affect what we pay for healthcare, relative to value, we need to talk about costs.  If we are talking about consumers' ability to price compare, average reimbursement is more relevant. Charges are made up numbers.

 

CMS is touting this:

 

But are charges the right thing to focus on?

What each provider gets paid, their reimbursement, may be more relevant to most healthcare consumers. As a country, concerned about healthcare's rising costs and its total percent of GDP, perhaps we should be asking providers to get clear and open about true costs.

what if corporate personality tools were used in medicine?

Treat me how I want to be treated at that moment without knowing me or how I feel. Seems like a reasonable request, right? Maybe not so much. And still, it’s what our modern —indeed overdue —conversation about patient-centered care demands. Patients and providers are clamoring for better partnerships; they desire to communicate effectively, to understand one another. But we don’t really have great tools and processes in place to support fast, low-effort assessments of learning styles and communication preferences.

Are you visual or aural? Do you need control or want to be directed? Does the nature of a situation affect how you might answer that question? Do you want reenforcement, an opportunity to teach back, an opportunity to question? Do you need time to reflect, or do you make quick decisions? And how many of even clearly know these things about ourselves in our daily lives, let alone when we are dealing with our health and wellbeing.

Imagine this scene: you arrive at your annual physical. Except for the occasional cold, you really only see your physician once a year. How well do you really know each other? You are highly visual and prefer diagrams to lengthy documents. You also like to have all the facts and tend to worry when you feel under informed. You are ok to let someone else plan things, so long as you know the plan. Your physician, in her spare time, is an amature writer. She would much prefer writing to talking, and is often reserved during your interactions. She is of a generation where her training reinforced a paternalistic, I know best style of practice.

You have 25–30 minutes together for your visit. Most of that time is spent doing a physical exam and updating your history. But your physician finds something unexpected, a lump. “Get an MRI and I’ll call you soon when we know more…”

Do things break down?

Do you leave feeling informed or terrified or somewhere in between? Could you describe to your spouse what happened, where the lump is and what it might be?

The challenge with treat me how I want to be treated at that moment without knowing me or how I feel is the unfair burden it places on both parties. How, in a time-restricted environment are two parties supposed to quickly get to know one another’s styles and preferences in a way some spouses even spend years working towards? And, for patients and physicians who have a long-standing relationship, wouldn’t an aid at least help remind you of the other person’s prefernces, so you don’t have to rely on memory or assumptions?

When I worked for a large multi-state health system, we used a commercial tool called Personalsys. Everyone in a management role took an online personality preference test. The computer spit out a brief narrative and color-coded chart. As will not be a surprise to those who have worked with me, I tend to be highly energized by ideas and creative brainstorming and am less driven by deadlines than others (something I’ve had to build systems to help support). Many of my healthcare finance coworkers, at the risk of generalizing, were, conversely, highly structured. They like plans and deadlines and clear objectives. If we had a meeting, someone would see my chart and the spikes in my green creative areas, where they might have spikes in their red structure areas. “Ohhh you’re one of those aren’t you? All creative and loosey-goosey…” And we’d laugh and poke fun at each other’s personality traits and preferences. “yeah, well I bet you’re all tightly wound and obsessed with numbers…”

Personalysis

In reality, the framed charts behind everyone’s desks became a bit of an inside gag. The insecure among the lot would cast their doubts on the efficacy of the hippie tools and new age management practices. But even the doubters knew there was some benefit to understanding how their colleagues work and think. You could walk into someone’s office, and know within seconds how they like to interact and work with other people, and in turn what you might expect from them.

There are other examples of these types of tools which are being deployed increasingly in large corporate settings. The DISC assessment, for instance, looks at how a person feels about control using the vernacular of dominance, inducement, submission and compliance. And what discussion of personality inventories would be complete without a mention of my personal favorite, the Myers-Briggs Type Indicator (I’m an ENFP for the inquiring minds out there)?

DISC

Visual and narrative aids like Personalysis or the DISC assessment, are not commonly a part of patient-provider interactions. But why shouldn’t they be used? Imagine if every patient had a card with a visual indicator on one side, in a short narrative about their preferences and styles on the other. What if every doctor had a similar tool framed on the wall of their exam room and office? Patient styles and preferences would be stored in medical records and patients could learn about their physicians’ styles online before visits.

Now imagine this scene: you arrive at the emergency room with chest pains and shortness of breath. You are scared, but not in dire straits. You are taken back, immediately, into an exam bay. A physician comes in, sees your chart and knows right away that you like to be in control of situations. You are aural and work better with big pictures than minutia. How might their communication style change to meet your needs, where you are, at that exact moment? Perhaps, in stead of patting you on the shoulder and saying “you are going to be fine dear…” they might instead offer “Ok, we’re going to move quickly, my concern is a blockage, so we’re going to get you to the cath lab, you’ll remain conscious, this is a great team who has done more of these than anyone else in town, after the cath, we’ll know more. Is that plan ok with you?”

To be fair, I suspect the later example is more typical of modern physician communication styles than my patronizing former example. But there is still room for a tool to help aid the process.

We need something quick, easy to understand and effective. It should be a two-way tool, allowing both patients and providers to quickly understand each other and meet in the middle. If this idea of participatory shared decision making is to work, it’s going to need some aids. The good news is some examples already exist. The folks at Diagram Office, a New York-based design firm have created some fantastic conversation aids around shared decision making.

Diagrams OpenIDEO submission

I’m still looking for a solution which fits upstream of decision making. I’m suggesting something which exists as the very first step between a patient and provider, before a word is ever spoken.

Anyone have a prototype?

What if there was an EMR built on Wikipedia?

WikiEMRI’ve been thinking about EMRs, electronic medical records, lately. It’s a subject, despite some professional experience, I don’t feel particularly close to. In fact, if anything, they are a source of consternation. As an industry insider, I see them as an expensive albatross around our collective neck. As a human centered design advisor, I see them as an encumbrance for both providers and patients. And, as a patient I see them largely as an opaque blob of data about me with a placating window in the form of a portal.

Which makes me wonder, am I obsessed with EMRs lately?

One of the reasons is certainly my personal interest in technology. And, while I don’t work in health IT, it’s natural to draw some connections. For instance, Wikipedia is consistently in among the top 10 most visited internet sites ( it is currently number 6 ). And, say what you will about citing Wikipedia, but a 2010 study found it as accurate as Britanica. Google trusts Wikipedia enough to use it as the primary source for its knowledge graph cards; and we’ve all settled a bar bet by finding some fact where a Wikipedia article is the canonical answer.

The secret sauce for Wikipedia is in it’s roots. Literally, the root of its name, wiki, describes the underlying structure. Wikis were the internet’a solution to knowledge bases – large repositories of information about a process or thing. Companies had been using knowledge base software for years. Traditionally, a central maintainer, often a sort of corporate librarian, curated information, such as common answers to customer questions, so customer service reps could find it quickly.

Wikis democratize the knowledge base by allowing anyone to edit an entry. If you work for a company which sells widgets and you discover a new way to service the widget, you simply amend or append to the record in the corporate wiki. But what about the corporate librarian, they all cried. Except, no body cried.

It turns out, the network effect and the wisdom of crowds produce richer, more accurate databases of knowledge when the literal barrier to entity is removed. Make it easy for anyone to input knowledge, and the database and its accuracy grow. And so it came to be, since anyone can edit almost any entry in the largest encyclopedia the world has ever known, Wikipedia is remarkably current and accurate.

So I wonder…what if medical records worked like Wikipedia?

What if, my record lived on some commonly accessible platform; not open to anyone, but accessible by my providers and I? Maybe we have to do some kind of online handshake to mutually access it.

What if we could both edit the record, at the same time? My doctors could put in their notes and I could add my own. Or I could edit theirs. And they could edit mine.

Some readers may have concerns about the records’ integrity but as patient advocacy expert Trisha Torrey points out reviewing our own medical records can help spot and fix errors. And, as we know from Wikipedia, more eyes and contributors on a record increase its accuracy and reliability.

Another important lesson from Wikipedia is the idea of revision log, which Wikipedia calls page history. Any registered user can make edits to almost any record in Wikipedia’s vast online encyclopedia. Every time an edit is made the changes are logged, including the name of the user who made them. Anyone can review the changes and roll back some or all of them, or make additional changes of their own.

Imagine a medical record platform where patients can review the entries made by a doctor, and if appropriate make additions at it or even changes. For instance, after reviewing notes from my last physical, I discovered a small unimportant inaccuracy in my record. I take Vitamin D supplements, and in the record, it was noted that I take Vitamin E. Big deal? Probably not, but what if it was related to a prescription medicine? Providers are human and, as we know, to err is human, but by allowing patients to review and edit their own records, they would be able to fix errors.

A Wikipedia-style EMR would also better allow for patient-contributed data. There are often symptoms, observations or measurements which patients observe outside of the timeframe of a visit with their doctor: a week of poor sleep, a month of improving blood pressure measurements, an off-again, on-again skin rash. These kinds of things may not even warrant a phone call, but wouldn’t it be nice to log them directly?

Finally, and this may perhaps be my strongest argument for a Wikipedia-style EMR, we’ve got to do something about data exchange. Color me cynical, but I’m not convinced the health information exchanges (HIEs), offered by the major EMR vendors as well as technology giants such as Oracle, are the answer. Each EMR vendor has a financial incentive to keep their data in a proprietary format. Further, their customers are, by definition, the providers, not patients.

No, what we need instead is a common, centrally accessible platform where patients and providers have parity, equal footing. No one party’s observations, notes, measurements, or data trumps the other. A common platform would make it easier for different providers to openly collaborate, in front of the patient, virtually, in a common record. Your specialist could be literally updating the same records which you, the patient, are adding to while your primary care doctor is also reviewing and making edits. Dogs and cats, living together. Mass hysteria!

GB

And there’s an extra credit reason we need a Wikipedia-style EMR. It doesn’t just promote or enable patient empowerment, it demands it. Owning our own data requires responsibility. It becomes the patient’s garden to tend. And its our right to tend those gardens.  Stephen Ross and Chen-Tan Lin, writing in JAMIA, concur:

Overall, studies suggest the potential for modest benefits (for instance, in enhancing doctor-patient communication). Risks (for instance, increasing patient worry or confusion) appear to be minimal in medical patients.

This doesn’t have to be a pie-in-the-sky dream either. Someone could build a WikiEMR today. The platform which runs Wikipedia is called Wikimedia. In fact, it would likely meet all of the Meaingful Use Stage 1 requirements…except one, and could be regarded as HITECH-compliant:

  • Anyone can download it, or install it on a hosted server. It can use the same strong SSL encryption which protects Epic, Allscripts, Athena and McKesson platforms.
  • It is free (a substantial discount off the price tags stuck to the EMR giants).
  • It provides user access audits and record edit history.
  • It is accessible via mobile and desktop
  • It can use multi-factor authentication
  • Wikimarkup, the simple language used on Wikimedia sites, supports mathmatical calculations so a WikiEMR could do unit conversions, Boolean checks, and data aggregation and reporting (including graphing).
  • It can generate reports for the MU core measures including abstracting 14 core objectives, 5 out of 10 of the menu objectives, etc.

What one, small, requirement is missing? As far as I know, Wikimedia is not a certified EMR. Anyone want to start a fund drive?

Amazon.com as a delivery model for population health

There’s that line about art, “good artists copy, great artists steal.” There’s some debate about if Picasso said it first, but most of us geeks know it from Steve Jobs.

Often, I see things from companies and industries outside of healthcare —processes, products, best practices —which inspire me. I like these little inspirations because they often aren’t rocket science, but nonetheless fuel some creative thoughts about their applicability in healthcare.

The other night, around 9:00 PM on a holiday Monday, I ordered some obscure aviation stuff from Amazon. I needed a new headset, a leg-mounted chart holder, a paper calculating tool called an E6B computer and a portable canister of oxygen. I have Amazon Prime, their subscription service which provides expedited 2 day shipping, so I expectd to see my stuff on Wednesday afternoon. I was blown away when there was an Amazon box outside my door by 9:00 AM the next morning, Tuesday.

Amazon

A box showed up early, big deal, right?

Here’s what I think happened and why I’m so impressed. I had been browsing for some aviation stuff for a few days. Amazon clearly knows and tracks my window shopping. It’s how they suggest items when you come back to the site. I believe they preemptivly moved some of those obscure aviation items to the closest distribution center in anticipation of my purchase. In fact, Amazon was awarded a patient for exactly that process last week.

By predicting my purchasing behavior, Amazon was able to beat my expectations for delivery – a known threat to their model is the instant gratification of local retail – and get my package to me in 12 hours.

We’ve got a lot of data in healthcare. That’s to the lagging but persistent implementation of electronic medical records, doctors and health systems are beginning to apply some big data science to their patient populations. For instance, any credible EMR can tell a physician how many of her patients have asthma. More advanced systems, including bolt on solutions can look at disease panels and cross sample against last visit date. Mr. Smith, we see it’s been a year since your last visit, how’s your arthritis? Can we schedule you and appointment with Dr. Jones?

While those types of systems are starting to gain traction, the Amazon solution, despite its apparent simplicaty, is far more advanced. Amazon is thinking ahead, they are predicting behavior. And with the tools we have in healthcare today, there’s no reason health systems and providers cannot do the same thing.

For instance, Google’s Flu Tracker looks at searches for things like flu symptoms, remedies and clinics and can accurately determine and even predict outbreaks. Providers would follow suit and move flu shots into communities before outbreaks hit. Retailers call this just in time inventory. And we don’t have to stop there. What about actual behavior modeling? Mr. Dawson, we see from Twitter you are training for another marathon and have been skiing a lot. Studies show that preemptive sports massages can help prevent more serious injuries, can we make an appointment for you to see our physical therapist? Yeah, ok, a secretly really want that one. But it doesn’t have to be based on leasure activities.

The point is, we have the tools and data to do some pretty impressive predictions for both populations and individuals and we’d be wise to start prototyping some of these approaches right away.

So, why aren’t we?

It’s easy to point the finger at our payment system, or internal red tape. And, I’m certain those things are a factor. But I think there’s a greater inirtia at work, a sense of overwhelming change and uncertainty weighting down the industry. We’ve become cautious to the point of immobilization. If it’s not evidence based and tested by Hopkins, Mass Gen or Mayo, then we aren’t trying it. And that’s a shame, because once Amazon figures out how to deliver a self-administering flu shot, or Asthma inhaler I’m 12 hours, it will be too late for healthcare’s traditional players to catch up.

Evernote Is My EMR And Its Better Than The Rest

EvernoteEMRSpoiler alert: I’m not dying and there doesn’t appear to be anything major wrong with me.

I know, you hate spoilers. But I thought I’d get that one out of there way. It makes the rest of this considerably more pleasant for us both.

I’ve got a new personal electronic medical record. I’m able to store and track my health history. I can add and edit my own notes. I can pull in data from external sources like my quantified self gadgets. I can share data with my provider, or family members. It’s secure, it’s cloud-based, it’s mobile and it’s on all major platforms.

Evernote is my personal EMR.

For the uninitiated, Evernote is a cloud-based, free service with apps on every major desktop and mobile platform. It’s general purpose is to store, sort and help you find anything you throw at it. You can upload a PDF, email a note, clip an image from a website. You name it, and Evernote can probably store it. Take a picture of a wine label, and Evernote will transcribe the text in the image using optical character recognition, so when you search for Zinfendel, you’ll find the image of the wine bottle. But wait there’s more. Since you took the picture with your phone, Evernote also has the gps data, time and date attached to the image. You can add some tags such as “California”, “zin”, and “jammy” to make the note even more specic and personal.

Evernote has a widely supported API (applications programmers’ interface), so many other apps can read and write data into Evernote. For instance, the web-based automation service if this then that, IFTT as it’s known, will, for instance, append a line to an Evernote note every time you get a tweet; creating an effective backup solution.

I personally throw everything I can into Evernote. When I book travel, and the print window pops up over the itenary confirmation, it select PDF to evernote rather than print. When an online store emails me a receipt, I forward the email into Evernote. I have more IFTT rules logging things to Evernote than I can feasibly recount, but a few stand out. When I step on my Withings wifi-enabled scale, IFTT adds a line to an Evernote note with the date, time, my weight and body mass data. I can do the same thing with my Withings blood pressure cuff. And, it turns out, Evernote is pretty much perfect as a personal EMR.

In short, I get a lot of meaningful use out of Evernote.

Recently I was asked to get an MRI (see above re spoiler). I had the MRI done at a health system an hour away from my home. The system uses Epic and has the MyChart patient portal available. My primary care doctor also works for a system which uses Epic and has MyChart. But these two Epic installations might as well be separated by led walls. My PCP ordered some labs, that the other doctor needed and my PCP, in turn, wanted a copy of my MRI results. So one doctor calls me and says can you please print a fax to us the lab results. Mummmm, ok. It’s 2014 and I, the patient, am transmitting my own clinical data between two systems via analogue fax? Then my PCP wants a copy of the MRI results. Same problem. I am again reduced to data mule. I am Jacks health information edchange

title

So now we have two identical multi-million dollar EMR installations, each with some data about me, but neither having a complete picture or seamless interchange. Again, I’ll point out that this is 2014 and I can FaceTime someone around the world on my phone. And we’re using faxes?!?

But there is one place where I have a complete record of my health and health-related behavior. You guessed it, Evernote. Everytime I have a test done, I get an email from which ever isolated multi-million dollar Epic system at which I’m seen. I log in, and click a button on my web browser tool bar which instantly clips the entire page as both text and image and stores it in an Evernote notebook called Health.

The images from my MRI? They are in Evernote.

Last year, before my annual physical, I decided to eat my own dog food. I started a new note in my Health notebook called health observations. I captured the little things I wanted to remember throughout the year: an ache here, a reminder that I saw a physical therapist, a picture of the vitamin D supplement I started taking… Before my physical, I typed out an agenda in an Evernote note:

  • Review observations note
  • show picture of all supplements and capture into med reconciliation list
  • review journal article on psoriasis and glycerine and why I’m not using prescription steroids anymore
  • ask for opinions on nutritionalists

When I went into the physical, I let my physician do his HPI and med rec and then mentioned my agenda. He knows me well enough to find the humor in my proposal - hey, it’s pretty nerdy - but he graciously went along with it. He did his physical exam and then tuned control of the visit over to me. I asked if I could record the audio and did so using Evernote’s built in audio recording feature.

I also scan, or import PDFs of all my insurance data including EOBs (explanation of benefits). I scan medical receipts and co-pays. So I effective also have a rudimentary revenue cycle system.

I am nearly certain, today, Evernote has a more complete, more personalized view of my health and medical history than any other system on the planet. I can share entire notes, or their contents, via secure links to anyone I chose. I can automate data intake, or enter it manually. I can capture fitness and behavior data. I can trend, search, snapshot, and review my own medical records. I can add to them any time I want, from any device.

Please tell me why a multi-million dollar system is more patient-centered?

Could Google's HelpOuts be a market place for expert patients?

This week, Google introduced a new product, HelpOuts. The idea is pretty simple: experts make their time available, at reasonable rates. Anyone can sign up for time with an expert. Google touts using HelpOuts for things like learning a language, doing yoga, getting help with computer programing and…wait for it… healthcare services.

On this week’s TWiG {This Week in Google} podcast, the hosts very quickly see the healthcare applications. In fact, they even postulate about using HelpOuts for assistance navigating [Healthcare.Gov](http://www.healthcare.gov] and the insurance marketplace.

You are thinking what I’m thinking, right?

For starters, this throws the doors wide open for the idea of telehealth. For the price of a co-pay, you could dial up a doctor for a quick consult via Google Hangouts.

But, wait, there’s more!

What happens when patients are the experts? What if hospitals, doctors, and health systems could buy time with patients? Hey, we want to do this new service, would that be valuable for you? Or perhaps, could you help us review our new patient portal and offer suggestions for improvements?

I love these marketplaces which disintermediate the whole concept of expertise and time. We’re increasingly accepting of the idea of patients as experts. But, to date, there hasn’t been a great way to find the best patient experts by area of expertise and availability. Might HelpOuts prove to be the Match.com for pairing patient experts with provider organizations, other patients and the healthcare industry at large?

I bet, collectively, we can grow a list of some pretty clever healthcare uses for HelpOuts. For instance:

  • Employee health services
  • Dietary and wellness counseling
  • Billing and insurance form review - this one has huge potential, in my mind!
  • Rural healthcare delivery
  • Midwife and doula coaching
  • Second opinion
  • Medical librarian service for patients - someone who helps find articles and interpret them for patients

What thoughts come to your mind? Anyone thinking about signing up as an expert?

This Week in Google 223

The one where I get all soapboxy about the term Obamacare

Tidal Basin

Dear Friends, Pundits, and Politicians,

Can we please stop calling health reform Obamacare?

Opponents began calling the health reform law and its associated components Obamacare as a way to both detract from the law and the President. Those who are not in favor of the PPACA report on Obamacare’s problems and challenges; linking the bill and the President hand in hand with some scary story about how Americans will somehow be less well off if more people have access to healthcare. Let’s defund Obamacare sounds a little to me like taking your toys and going home.

[And, correct me if I’m wrong, I don’t remember calling anything the Bushwar, Clintonbudget or Kennedymoonmission - when did taking liberties with the President’s name become acceptable?]

Those in favor of the the PPACA have co-opted the term; adopting in as a rally cry for the Act’s benefits. Do you like Obamacare, I think it’s a good thing… people will confide in me during meetings and events. Even CMS and policy wonks promoting the Act use the term frequently. Remember the kid in school with an unkind nickname who eventually started referring him-or-herself by the nickname? I bet they didn’t love it, deep down inside.

But here’s the thing…

We’re talking about healthcare. We’re talking about the difference between someone being able to see a doctor or not, to get medications or not, to have better, more fulfilling lives… or not. Making healthcare about politics —and I understand, the two have been an odd couple well before Jack Lemmon and Walter Matthau —does our humanity a disservice.

It’s not Obamacare, it’s the PPACA, health reform, Medicaid expansion, health insurance exchanges, accountable and population health, wellness visits and more.

And besides, spellcheck doesn’t even think Obamacare is a word.

Now, would someone help me down from this soap box, my knees aren’t what they used to be.

When Giants Stumble

When giants stumbleHDR Sunset

Local Cleveland channel News 5 reporter Cassandra Nist posted today:

The Cleveland Clinic announced Wednesday morning that they will be cutting $330 million from their 2014 budget.

“This is a process and the Cleveland Clinic is focused on driving a more efficient healthcare system. The goal is to make healthcare more affordable [and] efficient to patients,” Cleveland Clinic spokeswoman Eileen Sheil said.

The Cleveland Clinic acknowledges that there will be a reduction in the workforce, however the numbers are unknown at this time.

Shiel said this is “not unique to the Cleveland Clinic“ and that it is ”happening to hospitals across the nation.”

Our large healthcare providers —health systems and big hospitals —are in trouble. Public and political concern about hight costs are putting pressure on providers to lean out their organizations. (The true source of much of that cost may be out of their control, by the way). Simultaneously, we are living through a sea change in how care is being delivered. We’re not as far away from the smart phone physical as one may think.

Let’s also not forget population health. Forget concerns about about bridging the gap between the payment models. Do we really know how to take our existing large, complex healthcare ecosystem and turn it 180 degrees towards prevention and wellness?

Recently, while speaking to a group of hospital leaders, I shared an analogy I’ve been kicking around in my brain: these systems are giants and they won’t suddenly fall over. Instead, like Atlas, they will become increasingly unable to bear their the weight and will begin to stumble. Some, from time to time, might even drop to a knee to catch their breath.

Is Cleveland Clinic the first giant to stumble?

I’m all for cutting the fat and being more efficient. But how much of that is spin and how much reflects concerns around constrained reembursement and a changing care model?

Not to be all grey clouds and Andy Rooney here… These giants are giants for a reason. I have great faith in their sophistication, leadership and clinical abilities. Unlike small community hospitals, I doubt we’ll see any of them fall down outright. The smart ones, like Cleveland Clinic, are already thinking about:

  • Population health - Cleveland Clinic’s lauded bundled payment program for Lowes and Walmart is a clever example.
  • Patient engagement - Cleveland Clinic’s highly regarded Empathy video shows a serious commitment to the human side of healthcare.
  • Integrated model - The clinic model, with its employed physicians and team-based care, continues to make a lot of sense. I think we’ll see large health plans follow Lowes and Walmart, with renowned clinics like Cleveland Clinic, Mayo Clinic, Stanford, and Johns Hopkins, become preferred centers of excellence for these plans (further challenging community systems and hospitals).

Could the new iPhone improve patient-centeredness?

Estimote

On episode 423 of This Week in Tech, Robert Scoble discusses Apple’s new iBeacon protocol.

iBeacon uses bluetooth low energy to both identify devices to one another and allow smart phones to hone in on a signal.

Scoble, at roughly 1:01:00 (no direct link, sorry), discusses his secret plan to place iBeacon-like technology around his local Ritz Carlton hotel. The idea is to allow the door man, bartender and others to recognize Scoble and others by their phone and greet them accordingly. The usual Mr. Scoble?

What if hospitals and clinics used iBeacon technology? What if that meant never having to get lost inside the maze of a hospital, because your phone could follow beacons? What if the doctor’s office knew you were there in time for your appointment just by walking in the door? No more sign in sheet.

And, given Apple’s new fingerprint security features, how long before we never have to fill out a stack of forms on a clipboard? Maybe taping our phone, watch or other device on a special “registration” spot would take care of everything.

And maybe, just maybe, our medical records would live in our personal clouds, following us, rather than scattered between each different healthcare provider we see.

Fast forward to 1:01:00 for the discussion on iBeacons.

I wrote elsewhere: Making the most of your next doctor’s visit — Better Humans — Medium

Making the most of your next doctor’s visit Learn tips from ePatients about ways to hack you visit for better healthcare and a better relationship with your doctor.If you are lucky enough to be fairly healthy, then you may only go to the doctor once a year. Making the most out of your annual physical, or a trip to the doctor can be challenging. There is an emerging trend, known as ePatients, who are empowered, engaged and experts. By learning some of ePatient techniques, you too can improve your help and your relationship with your healthcare providers. Even if your health needs require more frequent visits, there are still some tips and tricks to make sure your questions are answered and your needs met.

via Making the most of your next doctor’s visit — Better Humans — Medium.

Well, friends, they may think it's a movement

woodstock

I often think I was meant to be a hippie and was born at the wrong time. A bow tie and navy blazer wearing hippie. That could be a thing, right? Anyway, growing up we listened to a lot of folk music. I remember the first time I saw Arlo Guthrie in concert and he played Alice’s Restaurant. Wow!

There’s a spoken verse in the nearly 20 minute long song* where Guthrie says:

You know, if one person, just one person does it they may think he’s really sick and they won’t take him. And if three people do it, three, can you imagine, three people walking in singin a bar of Alice’s Restaurant and walking out. They may think it’s an organization. And can you, can you imagine fifty people a day, I said fifty people a day walking in singin a bar of Alice’s Restaurant and walking out. And friends they may thinks it’s a movement.

Well, friends, let’s start a movement!

I’m asking for people (hint: if you are reading this, you qualify) to record short videos about their desires for the ideal patient/provider relationship.

These videos will be a cacophony of voices. I suspect we’ll hear some common themes. And I also hope we’ll hear some individualism. After all, no two people are alike and no two patient/provider relationships will be exactly alike.

I’ll take the videos and compile them into one big video project. It will end up on youtube, so you’ll need to be comfortable with it being shown online if you submit something.

I’ll license the video as Creative Commons Attribution-ShareALike 3.0 So we can all make use of the video, provided it is properly attributed.

Creative Commons License

How might this get used?

My first plan is to create one large video with portions or entire clips from individual submissions. I’ll upload it. We can all use it.

It’ll be a movement! Imagine all our engaged, empowered voices! A movement!

I also have immediate plans to share some of the snippets with hospital executives and physicians who desire to more fully embrace patient engagement, shared decision making and patient-centered care.

If you are also interested in directly working with hospitals who may be interested in patient advisors, please let me know and I’ll make your contact info available when I share the clips during talks, etc.

Deadline - 8/31/2013

Format: 30–60 second videos

Setting Super informal, just using your webcam. Office or home settings perfectly fine. Just make sure you can be heard clearly.

Rundown:

  • Intro - name
  • About you (non clinical info, hobbies, age, etc)
  • About your DX or concern
  • What you want in a provider - how you want to be treated and how you want that relationship to function
  • How people can find you online?

Might be best to avoid naming providers or organizations, or citing particularly negative experiences in detail. Remember, we want to inspire, not shame.

How

  • Mac: Launch iMovie. Chose Import from Camera from the File Menu. Record your video. Chose Export from the Share Menu.
  • iPhone: Launch your camera. Set it to video mode. Hold at arm’s length or have someone else record you.
  • Windows: Wave a rubber chicken in front of the computer? Seriously, I have no idea.

Send * Email me the file * Upload to youtube and send me the link via email or twitter * Upload to dropbox and share with me * Upload to my file inbox here, no dropbox account required

_________ * note I’m not linking to the song. Guthrie says some lines —I believe as ironic humor from a different era —which are ugly and disrespectful. I believe he was mocking what he perceived to be the attitudes of military recruiters of the time, but not reflecting his individual beliefs. Don’t buy the song. Just enjoy the reference here.

the ROI of social media in healthcare - a case study

Its 2013. And we’re still talking about social media in healthcare like its a thing. I know, right?

Here’s the deal if you are still on the fence: Social media isn’t marketing. It’s not a strategic focus. It doesn’t require special guidelines. It’s just a different way to talk to someone.

You don’t do social media right…or wrong, for that matter.

What you do, is care about people the same way you would if they were in front of you.

In his latest Just Talking podcast Chris Snider speaks with Carly Medosch.

Self-Referential alert. (missing the old blink tags from the web circa 1998)

Around minute 8:30 Carly begins telling the story of how we met via a tweet.

Her experience from a few years ago —the first time I’ve heard her speak about it —is one of the most meaningful moments of in my career to date.

I took a few seconds to respond to Carly's tweet, via the hospital's account. I asked a colleague to check in on her —a sign of a great culture is a team who has each others' backs, no questions asked. Did we bend the cost curve or reduce readmissions? No. But we brought just a little more humanity to her visit.

It wasn't about social media. It didn't require a strategy and it wasn't part of a campaign.

Wonder what the ROI on that tweet was?

What if… patients had ID badges too?

Doctors, nurses and administrators all get badges. You can tell a lot from someone’s badge. I prefer to be called Bob instead of Robert… Smile or no smile, our photos say a lot too.

And what about all those degrees and certifications? They are indicators of accomplishments and knowledge and often serve to endear trust. A brain surgeon with alphabet soup after their name is probably a pretty smart cookie.

What if patients had ID badges of their own? What might we convey in a small 4x3 square of plastic? And, for starters, how do we ensure they increase trust, empathy and dignity?

Erin Keeley Moore chimed in:

Another ePatient friend, who’s account is private and thus will remain anonymous here, suggests:

it would be nice to earn an honorary doctorate for my “field work” as a patient since age 13

What would your patient badge look like?

Would it have a playful photo, or a serious one?

Would you list your given name, or a nickname?

What areas are you an expert in?

What's missing or would make this better?

badge

explained

reading list: getting real about socioeconomics and policy

Following the lead of the great Susannah Fox, I want to share a few articles which have the hamster wheel in my brain spinning in double time. We’re starting to seriously wrestle with some of the real socioeconomic and policy  challenges of health and providing healthcare. Two of these articles appear in popular press rather than journals.

Sabrina Tavernise in the New York Times writes about The Health Toll of Immigration to America.

A growing body of mortality research on immigrants has shown that the longer they live in this country, the worse their rates of heart disease, high blood pressure and diabetes. And while their American-born children may have more money, they tend to live shorter lives than the parents. “There’s something about life in the United States that is not conducive to good health across generations,” said Robert A. Hummer, a social demographer at the University of Texas at Austin.

Thanks to Dennis Boyle for sharing the article.

 

The New York times, H. Gilbert Welch writes Diagnosis: Insufficient Outrage

Consider another recent shift in health care: hospitals have been aggressively buying up physician practices. This could be desirable, a way to get doctors to use the same medical record so that your primary care practitioner knows what your cardiologist did.

But that may not be the primary motivation for these consolidations. For years Medicare has paid hospitals more than independent physician practices for outpatient care, even when they are providing the same things. The extra payment is called the facility fee, and is meant to compensate hospitals for their public service — taking on the sickest patients and providing the most complex care.

Hat tip to Doctor_V and DrNancyGlass1 for finding the article:

 

In the New England Journal of Medicine, Michael Rawlins, MD publishes: NICE: Moving Onward

There is now wide acceptance that no country seeking to provide universal health care has the resources necessary to achieve the highest possible standards of care for everyone. …

This part is important:

However, priority setting in health care must encompass more than the technical and scientific demands of health technology assessment. It must also take account of the social values of the relevant communities. NICE therefore established a Citizens Council, with members drawn from the general public, to examine, deliberate over, and report on the social principles on which the Institute’s guidance should be based.

Grateful for Pritpal Tamber, MD for the oignal quote and link:

 

HIPAA: The greatest red herring the world has ever seen

In 60s FERPA law opened up access for students to see their records. Why do we still not have same in healthcare #tedmed

Ryan Panschadsaram at TEDMED 2013

At TEDMED this year, White House advisor Ryan Panchadsaram spoke about patient rights. He spoke about how all of us have the right to view our health records and take control of the content. Specifically he called out our rights to:

  • View our records
  • Correct mistakes
  • Decide who sees them
  • Request a copy

Panchadsaram said we’re all already afforded these rights under HIPAA.

scccrrrrreeeeecccchhhhh

HIPAA? The Dread Pirate Roberts of laws? The none shall pass of policies? The Great Wall of HCSM?

Yes, that HIPAA.

The Health Insurance Portability and Accountability Act has been manifest into the greatest red herring the world has ever seen.

For years we’ve all —me included —blamed HIPAA for various reasons our eHealth, mHealth, and HCSM dreams have failed to take flight. Oh, doctors can’t engage with patients online because if HIPAA (Actually, to fairly represent most of the objections, I should probably misspell it HIPPA).

Panchadsaram’s point is spot on. HIPAA is not a limiter, it’s an empowerment tool.

And if we, as digital and social health advocates, are going to make headway, we’re going to have to reframe our arguments, or drop them all together.

If we stop thinking about HIPAA as the the barrier, what then? We might also think differently about the whole problem.

How might we reframe our thinking?

Maybe it’s not about getting your doctor to tweet with you. Maybe instead its about helping the traditional medical establishment (ah-hum, I count myself in that lot) understand that these tools exist, and patients use them to discover expertise and new connections.

Maybe we shouldn’t expect hospital Facebook pages to reply to every patient by saying: thank you, come see us again soon. Instead we should be driving them to post how someone who sees Panchadsaram’s video can get easy online access to their own records.

Wherever we do, let’s stop blaming and start solving. Action conquers fear!

You can watch Ryan Panchadsaram’s talk below or on the TEDMED site. Ryan is also on Twitter. Here is the Office of Civial Rights letter he mentions in the talk.

study how teens use the web to solve #HCSM challenges

On Sunday I got plugged back into one of my favorite things - the #HCSM tweet chat. Somewhere between graduate school, career demands and whatever else life throws at us, I hadn’t spent much time with the HCSM crowd. It was great to get plugged back in to the latest in healthcare and social media thinking.

This week’s chat was full of fresh ideas, new faces and progressive thinking.

But elsewhere - blogs, articles, random tweets - I’m still seeing a lot of concerns around two specific areas: adoption and privacy.

Maybe we should take a hint from how teens think about social networking.

On this week’s episode of This Week in Tech, the panel discusses Vine, Instagram and online messaging in general. They talk about critical mass and the network effect - terms us techie types use to adoption of social media.

Host Leo Laporte points out that teens have no allegiance to one particular platform. Facebook’s done for kids," he says.

It turns out, what teens value is privacy and features, not a particular platform. They move quickly as the landscape changes, with little or no loyalty for a technology brand. What they chase are easier access to friends on a platform their parents haven’t discovered yet.

They flock to apps like Snap Chat for two reasons:

1) It lets them send pictures quickly and easily

2) The app promises the pictures will disappear in a matter of seconds. IE no record exists.

Am I suggesting Snap is HIPAA compliant? Not at all. But maybe studying teen behavior around social media, networking and mobile apps could provide some valuable insight into adoption and privacy challenges with HCSM.

Takeaways: 

  1. Try new things quickly and follow the trends. You may not send a Vine video to your doctor, but testing new apps and networks may lead to fresh thinking.  You'll at least be ready if there's a ground swell. 
  2. Be agile in your thinking. Being locked in to Facebook and Twitter narrows our thinking. A Facebook page probably won't cure cancer.
  3. Picture a different enemy. Pretend HIPAA isn't the problem, instead its a parent looking over your shoulder. Pretend we aren't worried about law suits, but instead making sure so-and-so's girlfriend shouldn't know so-and-so took whatshisface to a movie last weekend. Would that change how you think about privacy? What solutions shake out that can be applied to healthcare?

Here’s a link to the specific spot in the TWiT conversation. It starts around 0:58:00.

You can watch the full episode here:

notes on registration

Notes on registration:

Blame it on the availability heuristic, but I feel like every conversation I’ve had in the last 24 hours has been about registration and waiting. You won’t be surprised to learn, I have feelings and opinions about this.

It started with last night’s #PXchat where we chatted about waiting rooms. Think about that term waiting rooms.

Waiting is a basic fundamental of today’s healthcare environment. We generally accept it as a given, at some, probably many, points in a healthcare visit we will wait. We’ll sit and look at our shoes, or phone, or a three month old copy of Road and Track.

Why do we have to wait? It’s rhetorical, I know why we wait. But maybe we really should ask: should we have waits? Starbucks is one of my favorite service industry examples —they use just-in-time fulfillment. We rarely wait more than a minute or two for our triple mocha frappa half caf soy Americanos.

Don’t do it. I know you are reaching for your skeptical hat. But healthcare isn’t a coffee shop, Nick… Don’t put the hat on. Don’t say those words. Just think for a minute, what if there were no waits? Woah!

Then, today a lunch, I had an inspiring chat with a colleague about identity and mindset. She shared an experiment she participated in during graduate school. Would people be more or less confident if they were made conscious of their ethnic identity?

Think about the thing we do after we wait. We go give a complete stranger a list of the little buckets we fit into, parts of our identity. We willfully give up: * Age * Gender * Home address * Ethnic background * Even some socioeconomic info

By sitting, uncomfortably, across from someone and sharing these things, we are also reminded of them. At least subconsciously, they are now at the top of our minds. Do we bring them as badges or baggage into the visit with the doctor? What impact, does that identity recall have?

I’m willing to bet, at least the initial act of registration puts us in a bit of a subservient mindset.

We don’t, in my experience, have the same feelings about hotel check in. Is that because we fill out most of our identifying information online, prior to arrival? (That one isn’t rhetorical - really, is that why?)

This afternoon, I had the chance to visit a really cool space. You know those kinds of places you see in movies or commercials and you think but no one really gets to work in places like that… Well these people do. Think modular walls, mixed soft and hard surfaces, smart screens, cool chairs and funky colors. Cool stuff!

This is what I saw when I walked in Welcome, me

Hello ego!

But it’s actually a lot neater than an ego play. Their welcome area is designed around the psychology of greating the person coming into the space for the first time. It’s insanely welcoming to see yourself on a screen. The entry area is also perched a few steps higher than the work space. So you enter with a commanding view which, in turn, puts you in the position of power, rather than feeling swallowed by a new space. You can surveil everything.

Why not have personalized welcome screens?

It’s as if a million risk manager voices just cried out at once. Stick with me.

If a doctor’s office knows you, really knows you, they’ll know your interests. Surely there’s some field in most current EMRs which would allow someone to capture that I’m into skiing. So when it’s time for my appointment, why not cycle up a clip from a Warren Miller ski film? It would be intermixed with a shot of wild flowers, representing some other patient’s passion. Neither visual gives away our personal information or identity. But both visuals would make us feel personally cared for and welcomed.

Just some notes on registration….

What do you think - what glaring opportunities for improvement do you see? What things should we be thinking about from the staff perspective to improve their work experience?

notes on registration

Notes on registration:

Blame it on the availability heuristic, but I feel like every conversation I’ve had in the last 24 hours has been about registration and waiting. You won’t be surprised to learn, I have feelings and opinions about this.

It started with last night’s #PXchat where we chatted about waiting rooms. Think about that term waiting rooms.

Waiting is a basic fundamental of today’s healthcare environment. We generally accept it as a given, at some, probably many, points in a healthcare visit we will wait. We’ll sit and look at our shoes, or phone, or a three month old copy of Road and Track.

Why do we have to wait? It’s rhetorical, I know why we wait. But maybe we really should ask: should we have waits? Starbucks is one of my favorite service industry examples —they use just-in-time fulfillment. We rarely wait more than a minute or two for our triple mocha frappa half caf soy Americanos.

Don’t do it. I know you are reaching for your skeptical hat. But healthcare isn’t a coffee shop, Nick… Don’t put the hat on. Don’t say those words. Just think for a minute, what if there were no waits? Woah!

Then, today a lunch, I had an inspiring chat with a colleague about identity and mindset. She shared an experiment she participated in during graduate school. Would people be more or less confident if they were made conscious of their ethnic identity?

Think about the thing we do after we wait. We go give a complete stranger a list of the little buckets we fit into, parts of our identity. We willfully give up: * Age * Gender * Home address * Ethnic background * Even some socioeconomic info

By sitting, uncomfortably, across from someone and sharing these things, we are also reminded of them. At least subconsciously, they are now at the top of our minds. Do we bring them as badges or baggage into the visit with the doctor? What impact, does that identity recall have?

I’m willing to bet, at least the initial act of registration puts us in a bit of a subservient mindset.

We don’t, in my experience, have the same feelings about hotel check in. Is that because we fill out most of our identifying information online, prior to arrival? (That one isn’t rhetorical - really, is that why?)

This afternoon, I had the chance to visit a really cool space. You know those kinds of places you see in movies or commercials and you think but no one really gets to work in places like that… Well these people do. Think modular walls, mixed soft and hard surfaces, smart screens, cool chairs and funky colors. Cool stuff!

This is what I saw when I walked in Welcome, me

Hello ego!

But it’s actually a lot neater than an ego play. Their welcome area is designed around the psychology of greating the person coming into the space for the first time. It’s insanely welcoming to see yourself on a screen. The entry area is also perched a few steps higher than the work space. So you enter with a commanding view which, in turn, puts you in the position of power, rather than feeling swallowed by a new space. You can surveil everything.

Why not have personalized welcome screens?

It’s as if a million risk manager voices just cried out at once. Stick with me.

If a doctor’s office knows you, really knows you, they’ll know your interests. Surely there’s some field in most current EMRs which would allow someone to capture that I’m into skiing. So when it’s time for my appointment, why not cycle up a clip from a Warren Miller ski film? It would be intermixed with a shot of wild flowers, representing some other patient’s passion. Neither visual gives away our personal information or identity. But both visuals would make us feel personally cared for and welcomed.

Just some notes on registration….

What do you think - what glaring opportunities for improvement do you see? What things should we be thinking about from the staff perspective to improve their work experience?

Articles on hospital charges raise eyebrows, but they miss the mark —charges mean very little

There’s been a lot of talk this week about the data CMS released. It shows hospital charges and Medicare payment.

Articles like this raise eyebrows:

In one hospital in Dallas, the average bill for treating simple pneumonia was $14,610, while another there charged over $38,000.

via Hospital Billing Varies Wildly, U.S. Data Shows - NYTimes.com.

And they are missing the big picture.

The reason prices vary so greatly is the result of how commercial insurance contracts are negotiated and paid.

Hospitals want an annual margin - about 4% on average. To get there, they have to look at what the contracts pay well on and what they don’t. Medicare is irrelevant because it pays on a fee schedule. So they focus on commercial contracts. If one hospital’s contracts pay well on pneumonia, then the price gets raised.

I’m not assigning a value judgement to how or why this is done. But it is worth pointing out.

I also think it’s misleading to suggest those without insurance foot the full bill. While there are tragic examples, that’s rarely the case. Again, not suggesting its right or wrong, just saying there’s more to the story.

What can we learn from hospital charges? Very little. They are the ghosts of an ever changing industry based on a third party payment system.

NPR plays it safer:

…the numbers only tell us part of the story. “Charges are list prices,” he says. “They’re sticker prices.”

The Washington Post addressess uninsured programs:

“The chargemaster can be confusing because it’s highly variable and generally not what a consumer would pay,” said Carol Steinberg, vice president at the American Hospital Association. “Even an uninsured person isn’t always paying the chargemaster rate.”

Paul Levy nails it on his blog, (although he and I may disagree on the role of commercial insurance):

This is a case where the release of bad data is worse than having no data at all. A hospital’s chargemaster is an archaic fiction, a way previously used to allocate the joint and common costs of the hospital to particular services. It does not serve as the basis for how much a hospital is paid by Medicare. It does not serve as the basis for how much a hospital is paid by Medicaid. It does not serve as the basis for how much a hospital is paid by private insurers.

Updated to add:

David Lazarus asks if we are ok with the end result - high bills, in the his LA Times coverage:

Medical costs are often inexplicably high and are almost always kept hidden from patients until the bill arrives. Health insurance, meanwhile, is frequently coverage in name only.

What do you think? Does the charge data tell you anything meaningful?

More on glycerine and psoriasis

\Last week, I wrote about my experience treating psoriasis with inexpensive vegetable glycerine. I want to briefly follow up on things I’ve since learned, some comments and some questions.

The Research

The folks on the Inspire forum are amazingly helpful (a hallmark of any ePatient community!). I’ve was pointed to BrianFH who is believed to be the progenitor on the topic.

In this post, BrianFH lays forth his hypothesis on why glycerin is effective in treating psoriasis.

Many of the early posts on Inspire related to glycerin point to a few key journal articles and news sources.

News Sources

Academic Articles

Most of the research in the field seems to come from Wendy Bollag, PhD, a cell physicist at the University of Georgia.

Dr. Bollag has published several articles on glycerin and skin, including a few in which she speculates on its success in treating psoriasis.

  • Qin H, Zheng X, Zhong X, Shetty AK, Elias PM, Bollag WB. Aquaporin–3 in keratinocytes and skin: Its role and interaction with phospholipase D2. Arch Biochem Biophys. 2011 Jan 26.
  • A potential role for the phospholipase D2-aquaporin–3 signaling module in early keratinocyte differentiation: production of a phosphatidylglycerol signaling lipid. Bollag WB, Xie D, Zheng X, Zhong X. J Invest Dermatol. 2007 Dec;127(12):2823–31. Epub 2007 Jun 28.

Why is this information so hard to find?

This is still the most disconcerting part for me. In fact, I’m writing these posts largely as an attempt to increase awareness for others who may be searching for low-cost, low-risk, effective psorasis treatments.

The lack of a real, reputable study on the use of glycerin to treat psoriasis was discussed on Inspire. The thread’s author reports on an email exchange with Dr. Bollag.

“We are in the process of preparing a manuscript for submission on some additional research on this project but it probably won’t be out for many months still (depending on how kind or unkind the reviewers are). In the meantime, we published a review article discussing the evidence for the importance of glycerol, and more particularly its transporter aquaporin–3, in healthy and diseased skin. Anecdotally, I have heard from several individuals of the benefits of glycerol, which can be obtained from a pharmacy or from a crafts store like Michael’s (glycerol, otherwise known as glycerin, is an ingredient in cake icing). Thank you for letting me know about this thread–I will go take a look. Interestingly, I have applied several times to NPF to study this idea and have always been declined for funding.”

That last sentence gives many, including me, heartburn.

Placebo Effect

Without a reputable, reproducible study in a peer-reviewed journal, any success with glycerine and psoriasis is simply a placebo effect. Or at least that’s how it will be received by naysayers and skeptics. Even worse, it will not make its way in front of doctors.

In healthcare, physicians and wonky administrative types (like me) tend to favor evidence based medicine —doing what reproducible, peer-reviewed literature shows to be effective. That’s why we need a study for this $4 internet cure.

Follow the funding?

I’m pretty cynical. But I’m not sure I totally buy the notion research goes unfunded because there’s no money in the cure. Regardless, I wonder if this is a case where the community should crowdsource the trial.