Viewing entries tagged
health

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?

the email, the podcast and the simultaneous truths of genetic testing

The email Nearly six months ago, a physician friend sent me an email.

She wrote to me on the subject of genetic testing after I told anyone who would listen about 23andMe, Health Diagnostic Labs, and quantified self trends.

I can get kinda gung-ho about this stuff.

Her email stopped me in my tracks I’ve been paralyzed by it, unable to respond.

I have to respond to the queasy feeling in my stomach about untempered enthusiasm about commercially available genetic testing. I know you sat through statistics, and remember that in a low-risk population, the likelihood of a false positive test greatly outweighs a true positive test. I want you to add to that the uncertainty about what a positive genetic test means: “penetrance” means sometimes you have the genetic abnormality, but never get the disease, “mosaicism” means that not all your cells are 100% identical genetically, and finally there is the plain old uncertainty about how the environment affects gene expression. No wonder the USPSTF doesn’t recommend any genetic screening for the general population.

…Personally, I see patients who spent the $100 to get their ultrasound screen (read by someone who may or may not be qualified to do so) when they can’t afford their copay for necessary care. I think there is an ethical issue in that. That’s not even considering the counseling needed to negotiate the quagmire of heritable diseases. A recent conversation with a 40 year-old who just discovered she was BRAC2 (breast and ovarian cancer) positive around when and how to tell her adolescent daughters and how it would affect their decisions around marriage and children, brought this home. What if she did NOT have a family history and her test was a false positive?

The traditional argument against screening marketed to consumers is the added cost burden to the system of proving that those false positives are actually negative. (The statistical chance of having all normal tests on a 12 test panel is very close to zero.) Remember the classic article that 50% of care is unneeded? Isn’t this part of that 50%?

OK, I know there is also a lot of promise in this, and if we don’t explore and think about it it will never be ready for prime time. However it still gives me a queasy feeling when it is popularized. I was wondering if you thought about any of the issues above before you decided to be tested?

Boom. That put the breaks on the hamster wheel in my head.

I mean, I did think about a lot of those issues, at least as they pertained to me personally. But still her questions gave me pause.

Those who know me personally will attest I’m rarely at a loss for banter. (A middle school teacher once remarked: “Dawson would argue with a brick wall if it would talk back.”)

It’s not that I couldn’t think of responses. For instance: Some people would rather know than not know. Or, everyone has a right to chose for themselves. When it comes to cost, some argue, early detection through advanced diagnostics leads to less expensive treatment.

But I stalled, perplexed…

The Podcast

And then I listened to the latest Freaknomics podcast. Do You Really Want to Know Your Future? You can download/subscribe at iTunes, or listen via the media player below.

The podcast opens with Nancy Wexler discussing her mother’s diagnosis of Huntington’s, a genetically inherited, fatal neurological disorder. Wexler’s father founded the Hereditary Disease Foundation —an organization dedicated to finding a cure —which Wexler now runs.

Wexler speaks openly about the invention of a genetic test for Huntington’s:

DUBNER: If there had been a test available then, a test like the one that you helped develop later, do you think your mom would have taken it at a young age?

WEXLER: No.

DUBNER: Why?

WEXLER: Why should she have?

Later in the program, host Steven Dubner interviews Emily Oster, an economist trying to understand why some people simply don’t want to know what the future may hold:

OSTER: …I think what we come down to is the view that in fact largely the reason that people don’t want to get this test is because while they are untested they seem to be able to basically be able to basically pretend everything is fine and that that may be very valuable….I think what it tells us is that people care both about what they think will happen in the future and what actually happens. So you know, I enjoy going on a cruise, but I also value the time leading up to the cruise where I get to think about how great the cruise is going to be. I think often our normal, or standard economic models would basically say we only value the second thing, the only thing that’s beneficial of a cruise is the literal experience of being on the cruise. I think that what this says is in fact something that’s probably more comfortable for most non-economists, which is that there’s some value of, kind of, what you think is going to happen that that has like real benefits, or real costs for you.

 

The mantra

One of my favorite expressions is action conquers fear. We use it a lot in skiing. You can stand at the top of a mogul ridden black diamond and contemplate all the ways you'll fall and mangle your body. But the only way to settle the butterflies in your stomach is to make the first turn down the hill.

In the case of genetic testing, being able to take action on the results matters.

A friend and activist in BRCA testing and decision making suggests:

"...the key to all of this data is learning what's truly actionable. For something like BRCA, we have options. For Huntington's, we don't [yet]. But we need to build a model where we can find better preventative options for both diseases.  And I believe we can get there."

Knowing we can act on the results has a profound effect on the indifference curve (to borrow the economists' lingo), may impact our decision to test or not test. For instance, most of us don't shy away from taking our temperature to determine if we have a fever. We know how to treat a fever. But if we are contemplating something more serious and potentially life-changing, we may think differently about testing.

Each of us has to weigh the relative risk of knowing versus not knowing. 

The ah-ha

As simple, and even silly, as this may sound I found my ah-ha moment in the closing audio clips of the episode. It happened as I was walking out the door for an evening run.

Both things can co-exist: wanting to know and not wanting to know. And they can coexist in the same person.

The ah-ha is that there is no answer.

Whether we step through the looking glass or not, there will always be fear and rewards with both knowing and not knowing. They are simultaneous truths.

Will genetic testing bring some people peace? Yes. Might it incur unnecessary costs? Yes. Will knowing a propensity for a disease produce stress? Yes. Will not knowing have an effect? Yes.

I love the idea of two truths co-existing. Something can be reassuring and scary at the same time. Something cane be costly and cost-saving at the same time.

Absolutes, as it turns out, aren’t always absolute.

The podcast closes with recorded remarks from people who have a 50% chance of developing Huntington’s:

SHANA: My name is Shana Martin, I’m from Madison, Wisconsin, I’m 33 years old, I’m a world champion lumberjack athlete…I’m getting married in a few months, and we’re starting to explore having kids. And we chatted about it, I’m still quite firm that I don’t want to know.

 

 

>My name is Melinda Maher, I’m 25 years old and I’m living at risk for Huntington’s Disease…I hope to get a teaching job and I hope to move away from home and I hope to be able to move out and be on my own and have my own life and independence. And still right now I feel like if I were to test positive I would be afraid of that independence.

The Audio

The Prolog

 I asked my friend for permission to publish her email. She has again thrown down the gauntlet with more questions which challenge me to think deeper. But at the very least, we both agree that having these conversations is better than not having them.

What do you think, is it better to test, with the risks of knowing something you cannot un-know and may not be able to treat? Or, is it better to only test as needed?

next up: Patient Centered Technology 4/26

Next week, on Friday 4/26, I'll be speaking at RichTech's Health Forum. I'm talking about the rise of patient-centered technology. More info and registration here

Abstract

Title: Patient Centered Technology — how smart phones and the web are empowering patients and changing healthcare

In March 2013, Dr. Eric Topol gave Stephen Colbert a complete physical…with his iPhone. The web and connected devices have proven to be disruptive technologies and healthcare is no exception. Today, an increasing number of patients have access to some or all of their medical records through Electronic Health Record systems (EHRs). Smart devices, mobile apps and fitness gadgets also allow people to collect an unparalleled amount of self-generated health data. You can even get a DNA profile for less than than it costs to fill up an SUV.

What does all this mean for patients and the future of healthcare delivery? We’re already seeing a shift. Some call it consumerism, and sometimes it is referred to as mHealth (mobile health) or eHealth (electronic health). Often these terms are spoken about in conjunction with participatory medicine.

We'll will examine where we’ve been with patient-facing technology in healthcare, where we are today and where we are headed. It will include discussions around EHRs, the quantified self movement and the future of the doctor/patient relationship as influenced by technology.

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.

More on glycerin 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.

Book review: Thinking, Fast and Slow

I heard about Daniel Kahneman’s Thinking, Fast and Slow from friend and ePatient superstar e-Patient Dave. It’s the first, what I’ll call, real book I’ve dug into since finishing my MHA in January.

And, it has blown me away!

In Thinking, Kahneman outlines our brains’ two basic modes of thinking: system 1 and system 2. System 1 deals with instincts, gut reactions and heuristics. System 2 is the slower (Kahneman says lazy) part of our mind which is capable of more complicated reasoning.

We read, most often, through system 1 which recognizes words quickly, as patterns. System 1 is why we are open to suggestion (your left leg feels a little numb right now, doesn’t it?….see!).

System 2 is the part of our brain which can reason through fact and fiction. But only when we engage it. Kahneman demonstrates system 2 early in the book by having readers write a three digit number and mentally begin adding 1 to each digit. According to Kahneman we actually have a physiological response —our pupils dilate as we engage system 2 to work through the basic math.

Here’s what I’ve found most interesting:

System 1 works best with absolutes. Kahneman refers to this is WYSIATI, what you see is all there is. For example, we see a label reading 90% fat free as positive and forget there is also 10% which is fat. We see 90% fat free, that must be all that matters.

System 2 is more conscious and can hold multiple options at the same time.

This ties in to my growing understanding of pluralism —the concept of two or more truths coexisting. For instance, a patient can be both hopeful and scared at the same time. The challenge is, according to Kahneman, only system 2, the more lazy part of the mind, is capable of understanding that both emotions can coexist. Our tendency is to rely on system 1 which focuses on what is in front of us. In the case of the patient above, it may be a look of fear on their face. Boom, that’s it. System 1 identifies fear and that’s what we go with. The patient is scared and that’s what I’ll deal with.

Without engaging system 2, we might not also identify hopefulness, or optimism, or doubt, or any other coexisting emotions.

These two systems are not limited to how we process perceptions about emotions. We face the same challenges in examining facts, causation and data in general. In fact, that is what much of the book deals with.

Kahneman has a gifted ability, much like Malcolm Gladwell, to distill complex science into what almost feels like common sense. Despite its length, it is a quick, enjoyable read.

You can get it on Amazon here: Thinking, Fast and Slow

How a $4 internet cure saved me from chemotherapy and hundreds of dollars

No seriously. I know what you are thinking… Internet. cure. wack-job.

But I have pictures. I can prove it!

First, a little back story. I’ve had mild psoriasis for years. In my case, it presents as a few areas of dry, flaky skin. At first it was on my elbows and then a few other spots appeared on my legs. It’s annoying, but has been generally controlled with topical steroids.

The problem with topical steroids is they cause skin thinning. The generic ointment ran me about $10 a month.

This, in the grand scheme, is not a major health problem.

But for many, psoriasis can be both chronic and extremely embarrassing. It can form large, red, flaky patches all over one’s body and face. It itches, and can crack and bleed. It is often accompanied by inflammation in joints (which may be present and not felt). For many, P is a major health problem.

The [common treatments][1] for medium to severe P include:

  • Topical steroids
  • Anthralin (a med which affects DNA)
  • Topical retinoids
  • UV light therapy
  • Oral steroids or retinoids
  • Methotrexate - a form of chemotherapy and an autoimmune suppressant.

(You read the last one correctly, chemotherapy!)

Almost two years ago, I developed a persistent patch on my left wrist (interestingly, psoriasis usually presents bilaterally, although I never got any on my right wrist). When I wore a watch or long sleeves, it wasn’t bad. When I didn’t, people asked if I had poison ivy, got scratched by my cat or had otherwise managed to mangle myself.

Still, no big deal.

But I decided to finally go to the dermatologist. On the first visit, they injected several of the small patches on my arms and legs with steroids. For my legs, the injections served as a booster and did great work of clearing the more persistent patches.

When I asked about my arm, it was suggested I think seriously about chemotherapy (Methotrexate).

I told them my goal was to get away from systemic medications and would be interested in what the topical options were. I left with samples for a steroid foam, concentrated vitamin D foam and steroid tape. I was told to watch out for further thinning —my wrist was starting to show signs of long-term steroid contact (which leads to scaring).

The foams were messy and ineffective. The tape, which looks like clear packing tape, is impregnated with steroids and kept things in check. It was $60 a roll and a roll lasts a month.

Now, this is where some readers who know me are rolling their eyes. What about ePatients Nick? What about online communities? What about Dr. Google?!

I know… I know. Actually, I had checked into the P forums on Patients Like Me before. I’d done some basic searching and hadn’t found much of value. I found some people wrapped their affected areas in plastic kitchen wrap to seal the meds in. I tried that. Pain in the rear.

This time I decided to go deeper.

I started on Wikipedia’s psoriasis page where I learned there are several types of psoriasis. I had never been told there were different kinds before. should have looked sooner. Specifically, I learned most of mine was classified as plaque which responds quite well to steroids. Makes sense. I also learned about guttate psoriasis. Those pictures where more like my increasingly pink and nasty left wrist.

So I googled more, this time specifically on guttate P. I found the NIH site and a few others, none of which yielded new info.

Then I got a wild hair…guttate psoriasis home remedy. Nothing. But Google did suggest a similar search: guttate psoriasis treatment. That’s where I found this site. Its not without some challenges. First, it requires users to sign up. And despite the National Psoriasis Foundation branding, it is actually a for-profit organization which hosts sites for national foundations. Something wicked this way comes. But, if you look carefully, you can actually read some of the forum posts behind the sign-up banner.

I saw this post:

I read that a number of people had success applying glycerin USP grade from the drug store on their lesions. It is cheap and non-toxic. I figured, what do I have to lose. I started to apply the glycerin at the end of January …Five weeks after I started this she was 100% clear and she has stayed this way for almost 5 weeks now.

And there were more posts, all about glycerin. I typed guttate psoriasis glycerin into google. More posts, mostly from inspire.com.

I’ve suffered with the effects and treatments of psoriasis all over my body for 40 years and nothing helped. The steroids destroyed my skin and the pills and lotions did nothing at all. Now I finally found something that does what it says and it’s all Natural! The scars and marks from the steroids are vanishing, the red, raised bumps are are gone and all the itching has stopped, I can finally sleep!! I’m so thankful. I would recommend this to anyone who will listen!

Ok, let me get this straight? People on this special site, sponsored or owned or something’ed by the National Psoriasis Foundation have discovered a vegetable sweetener cures psoriasis? Beats chemotherapy!

I tried it.

Day 3:

day3

I didn’t think to take a picture on the first day, we’ll consider this the start. As you can see, my wrist was pretty splotchy and red. It was “in control” from two months of vitamin D foam and steroid tape.

Some of the posts on Inspire suggested they saw dramatic results in a week. After two weeks, I didn’t see much improvement, but decided not to give up. I applied a few drops of a $4 bottle of vegetable glycerin two times a day, diligently.

Day 30:

day30

This might be working.

Day 37:

day37

Virtually gone. In fact, if I hadn’t gotten sunburnt a few days ago, I doubt the photo would show any decreeable redness at all. Unbelievable.

Is this a scientific test? Not exactly, I’m a sample of one. But I did put some controls in place. I applied the glycerin two my left wrist and forearm, and right leg (which had some plaque legions). I did not apply anything to my left leg or right elbow.

Everywhere I applied the glycerin regularly, improved and in many cases disappeared completely. Legions where I did not apply anything stayed the same or worsened.

Cured, by the internet!

Tucked off in the western backwaters of the internet is this amazing resource. There is a whole forum of people who have discovered, somehow, cheap glycerin treats psoriasis better than topical meds, oral meds and chemotherapy.

Why was this information so hard to find? Why is it behind a walled garden?

Why doesn’t my doctor know about this? Or worse, did they know and not tell me?

I’m not sure how to connect these dots, but I am sure of one thing: I’ll search exhaustively from here on out and will be an even louder voice for others to do the same. To reiterate, my case wasn’t bad and I would have lived with it long before I tried chemotherapy. What concerns me is how information like this can be out there and not easily found by patients and, worse, be unknown to doctors.
_______

[1]: http://www.mayoclinic.com/health/psoriasis/DS00193/DSECTION=treatments%2Dand%2Ddrugs “Mayo Clinic Medical Library”

From elsewhere: Tracking health indicators hints towards disruptive innovation in doctor patient relationship

Pew Internet’s Susannah Fox, today, released the official report behind her amazing Stanford Medicine X talk. The report is a great read for data geeks, health wonks and ePatients alike. But there’s one part in particular I find especially indicative of an impending disruption in how we approach medical care as patients.

According to Pew:

Seven in ten (69%) U.S. adults track a health indicator for themselves or a loved one and many say this activity has changed their overall approach to health, according to a new survey by the Pew Research Center’s Internet & American Life Project.

This is the first national survey measuring health data tracking, which has been shown in clinical studies to be a tool for improving outcomes, particularly among people trying to lose weight or manage a chronic condition.

Of all the results, I find one in particular compelling:

40% of trackers say it has led them to ask a doctor new questions or to get a second opinion from another doctor.

I’m predicting 2013 and 2014 as the years we see a sea-change towards true consumer-driven health. In the past, wonks have spoken about high deductible plans and health spending accounts as the economic vehicle to compelling consumer behavior. The problem with that version is it assumes people will consume less healthcare services if they are footing the bill.

There is some truth regarding spending usage. But, largely sick people will seek care and people without access —via insurance or a government program —will delay care until the need is chronic and more costly.

What I’m excited about, based on the Pew results, is the potential of true consumer driven healthcare. Today, it’s increasingly easier to wear a gadget and get direct access to cutting edge lab tests. For $99, 23andMe will examine your DNA an report back some pretty amazing data.

So, if 40% of people report asking new questions based on following their own health indicators, how long before patients become the initiators of a care plan? Rather than rely on doctors to discover whats wrong with us, we’re moving a world where we might know more about ourselves before we seek a doctor than after seeing one.

That idea might challenge some people, including doctors. Rest assured, it doesn’t eliminate the need for doctors. We’re simply looking at a period of disruptive innovation which will change the role of physicians (in some circumstances). It’s a bit like coming to an architect with your own rough draft of blueprints.

For more about Susannah Fox, Pew and the report, check out the video interview from Medicine X:

Susannah Fox - Medicine X Conversation from Larry Chu on Vimeo.

From elsewhere: Participatory medicine to fight misconceptions about disease

Beryl Benderly, writing for Kaiser Health News and NPR’s Shots blog, tackles an important topic: misconceptions from providers about disease. In this case, Benderly writes about sickle cell.

There’s a lesson to be learned in this story for providers. And, is often the case, it is one of participatory medicine.

Patients suffering recurrent episodes know what works for their pain, but some doctors and nurses take that knowledge a sign of addiction. Patients with sickle cell pain wait an average of 30 minutes longer for pain medication than people with other extremely painful conditions, such as kidney stones, Tanabe’s research shows.

Patients know what works for their pain. That’s pretty simple. The painful part, aside from the actual pain, is the stigma so many patients have to battle to get the treatment they know to be effective.

One has to imagine, in a world where providers embrace patients as part of the care planning team, trust also increases.

Source: NPR Shots: Fighting Misconceptions About Sickle Cell Disease In The ER

From Elsewhere: Alec Baldwin and guest Robert Lustig on the sugar epidemic

This post is part of my From Elsewhere series.

A recent study reveals that 80 percent of the 600,000 food items in America are laced with added sugar. Lustig says, “There is not one biochemical reaction in your body, not one, that requires dietary fructose, not one that requires sugar. Dietary sugar is completely irrelevant to life.

Honestly, I didn’t expect that. Not considering the source. I mean, I’m not surprised by Dr. Lustig’s comments, but that’s not what I expected to hear when I downloaded Alec Baldwin’s podcast for the first time recently. Honestly, I’m not sure what I expected. Maybe a rating tirade about angry birds, airlines or one of Baldwin’s family members. But not a serious dialogue about the epidemic of noncommunicable disease owed to our increasingly flawed food system.

So, for those tempted to write off Baldwin’s show based on his many reported personal challenges, let me prothletise: This is a good show. This episode, in particular, is worth a listen.

Some my recognize Dr. Lustig from his popular YouTube video, Sugar: The Bitter Truth which has more than 2,600,000 views. Dr. Lustig breaks down the historical and socioeconomic events which have led to a food system full of processed, sweetened food. He goes on to discuss the toxic effect all this sugar has on our bodies and suggests sugar may be the underpinnings of the chronic diseases plaguing our society.

I’m not qualified to determine if Lustig is clinically accurate. But it doesn’t take a research scientist to know all the HFCS in our food supply can’t be helping the obesity problem.

Have a listen wither through the embedded player below or by downloading the podcast episode via iTunes.

Robert Lustig: We need a new food model. We need a new food growing model. By 2050, we’re gonna need four California Central Valleys in order to feed our population, we won’t even have one. Because of the runoff in the Sierra, the changes in soil erosion, we won’t even have one. So you know what the obesity epidemic might even take care of itself because we’ll have a famine because we are misusing our food system. Michael Pollan writes about this routinely. The bottom line is biochemically our current food environment does not work for us and until we fix it, we’ll continue to pour money down a rat hole. We will continue to be sick; we will continue to die of things like diabetes and heart disease. Medicare will be broke by 2024 because there won’t be any money to pay for it. You won’t be able to see a doctor because they’ll be too busy taking care of all the other fat people in the emergency room who are having their heart attacks and there won’t be enough food anyway.

via Here's The Thing: Robert Lustig Transcript - WNYC.

   

On bridges - connecting the real world and technology through emotional bridges

20120604-125607.jpg I saw a picture online the other day. “I love my computer because all my friends live in it.” It’s funny because it’s true. I’m also pretty sure there are magic, nearly microscopic elves who live in my iPhone. Think about it, how else can you explain how an iPhone works? Don’t give me that hokum about nanotechnology. It’s elves. Now get back inside my computer, friend.

Regrettably, sites like iFixIt and Wikipedia tell attest there are not, in fact, elves in my phone. As it turns out, you don’t live inside my computer either, though I’m still suspect. The bitter truth, is these things are just metal and silicone. It turns out, according to “experts”, Facebook isn’t really a place either. For that matter, the entire Internet doesn’t really exist anywhere. There go my plans to move there one day. Come to think of it, we’re spending more and more time with things that are really pretty cold and austere; void of any emotional connection.

The real world and what we see on a screen aren’t as connected as we might think. Sure, Facebook has changed how we keep in touch. But, there’s no way to reach out and touch something on someone’s wall. We can have an emotional experience via these sites and technologies, although it’s not the result of an interaction with something real. That’s exactly what an emerging big trend is all about.

Last week I came across two examples of things which connect the real world and the physical world with a particularly enormaring emotional appeal.

DearPhotograph is a site from the same team who did Post Secret. The premise is pretty simple, take a photo of yourself holding an older photo superimposed over the scene where it was originally taken. Then write a little note to that photo.

20120604-125849.jpg

I know what you are thinking. Hey Nick, get on board the USS Clue, it set sail long ago and left you on the dock. Don’t you know Facebook just bought instagram for like a gagallion bucks? Why are you so amped over another photo site? The difference is in how Dear Photograph bridges the real world, with a real object (a photo) and creates and emotional tie. The site, and technology, are just a vehicle to share the emotional thing created. That’s a pretty cool.

Dear Photograph is more than instagram or flickr or faceboo. It requires you to go and actually do something. You have to find an old picture, one with an emotional draw. Then you have to go to the spot it was taken - does that place still exist? Can you get there? Now align the photo in 3D space over that real place and take another picture. Still sound like just s photo website? The result is an emotional connection with a time and place, and the technology which made it happen.

Now that we’re getting settled in our temporary apparent, I had the opportunity to play with a technology I’ve been eyeing for a long time. The Nest thermostat is…well…a thermostat. But it’s like the iPhone of thermostats. And that’s by design. The Nest was created by Tony Fadell who, during his time at Apple, launched the iPod. The nest is part of a growing class of devices which connects the real world to the digital. For starters, it’s a real thing. You mount this gizmo on your wall (and, as a excellent example of experience design, even the install is well designed).

20120604-130025.jpg

Once hanging on your wall, the user experience melds between your physical interaction with the thermostat and it’s online features. You can check, set and monitor your temperature and energy usage from an app or the web. And if that sounds nerdy, it’s far from it. You really connect with this thing. It does something, it bridges the real, physical world of your home environment with the online world of data and numbers, and that creates a strange emotional bridge. It makes caring about energy use and savings a meaningful act.

I’m inspired by these two examples. They are bridges. They link our physical world with the intangible, elif-infested, silicone composed digital either. Think about a real bridge, it does more than get you from one side of a bank to another. It enables you to go someplace, to see someone, to touch something and to do something. That’s the next phase of technology - creating bridges.

In healthcare, we’ve known about technology bridges longer than many other industries. We’ve had medical wonder-gizmos for years. Considere the nearly ubiquitous heart rate monitor in every inpatient room. Beep, beep, beep… That rhythmic drone isn’t just a machine making nose, it is the heart beat of some we love. Each beep represents life, someone’s beating heart. Each beep also represents a data point inside the machine’s inner workings which will inform doctors and nurses. That’s a bridge.

We’ve also got a long way to go. While the inpatient room might be strewn with wires and beeps, funneling data into a black box, virtually none of those devices are designed with user experience or emotional consideration in mind. Neither are implantable medical devices. Just ask Hugo Campos who is crusading to get access to the data from a defribulator implanted in his chest.

The Internet is evolving to become an Internet of things, all connected to our real world, which is inherently tied to our feelings, hopes, needs, excitement, etc. Healthcare devices and services need to look towards sites like Dear Photograph and gadgets like Nest. What can we learn from things and services designed around creating emotional connections between the real world and the world of 1s and 0s. Now, more than ever, with health information growing by billions of dollars and health reform pushing much needed change on an already constrained system, we need user-centered design. We need bridges which connect us, real living things, with the beeps and wires, or our doctor’s avatar on a patient portal.

Socioeconomic factors and health outcomes in Virginia

  The quality of healthcare matters and it is one of the more difficult things for a consumer/patient to gauge. We can tell if a consumer product is cheaply made, or if a dining experience is sub par. It is harder to observe, research, quantify and compair the quality of healthcare. For most Americans, unless it is a major procedure, or requires services offered at a specialty location, we probably stick close to home. But what if the quality of care close to home is vastly different than even a few hours away?

Another very interesting angle is to consider is if variations in outcomes and quality are not simply in the hands of the provider, but also influenced by socioeconomic factors. Do you have access to high quality food and can you afford it? Do you have access to health education and do you have the means to follow the recommendations? Do work conditions in manufacturing-dominated areas contribute to health issues that aren't as prevalent in professional areas?

This week, the Robert Wood Johnson Foundation released an interactive tool for exploring health outcomes by geographic area. In Virginia, there are some pretty clear relationships between positive health outcomes and medican household income. I've not reviewed enough data to suggest any causalities. For instance, are better care facilities found in more populated areas and therefor those areas have better outcomes? Regardless, the relationship between low income and poor health outcomes is worthy of discussion; particularly as our country continues the debate over national health reform.

RWJF Map:

New York Times Economic Samples from 2005-2009:

In this case, the colors are inverse. The upper map shows positive health outcomes in white and light green. For instance, Nelson (NE) and Albemarle  (AE) counties. The lower map shows higher household incomes in dark green. For instance: Fredricksburg and Charlottesville metropolitan areas.

The relationship is a little more clear if we look at county by county:

Rank Health Income
1 Fairfax City of Calls Church
2 Arlington Arlington
3 Loudoun City of Alexandria
4 Albemarle Fairfax
5 York Loudoun
6 Alexandria City of Fairfax
7 James City James City County
8 Clarke Goochland County
9 Powhatan Albemarle
10 Mathews Fauquier

source: Health - RWJF, Income - Wikipedia

To be absolutely clear, this is not a scientific study. There are likely many other factors which should be considered including population density, density of qualified healthcare providers, etc. We need to also think about other things that go hand-in-hand with economic disparity. For instance, areas of low income are traditionally associated with fewer healthy options for food and are sometimes classified as food deserts. Areas of high income tend to also have better education, which has a well studied cause and effect relationship to positive health outcomes.

My point in sharing this comparison is simply to call attention to the large variation in health outcomes, even in a single state and to raise the question of socioeconomic factors, as well as variations in clinical quality, as a contributing factor. What do you think?

Quant Self gaining popularity in other circles

I'm continuing to see references to self quantification appear outside of the niche world of quantified self devotees. This week on the TWiT podcast network, two of Leo Laporte's shows featured conversations about capturing, measuring and analyzing data about our own health. Now, certainly these two shows represent niche communities and interests of their own. TWiG focuses on cloud computer, social networking and Google. Security Now is about, you guessed it, security. What I find particularly exciting is both shows feature discussions about using personal health devices without knowing the term quantified self, suggesting the ideas of self quantification are creeping into other areas; the long tail is beginning to widen.

On Episode 138 of This Week in Google, the hosts discussed the Nike Fuelband device. Nike's Fuelband wrist-worn gadget made a splashy debute at this year South By South West, selling out via their pop-up store. The Fuelband, which is often compaired to the defunct Jawbone Up, is very similar to the FitBit (which I still think is the best device in the space - love mine!).

Here is a link to the exact position of the discussion on the Fuelband.

Host Jeff Jarvis describes, these devices as "the internet of things, and things tend to be you..."  At last year's Stanford Med 2.0 event, Dr. Bryan Vartabedian  described personal health devices as "An API into the patient." An API - application programmer's interface - is a term in computer programming and hardware which references a programmer's ability to connect with another program or device. The point Dr. V and Mr. Jarvis are marking is that quantified self devices give users and providers access to retime data about health and actives, without needing a lagging lab test or resource-intensive diagnostic study.

On episode 344 of the wonderfully nerdy Security Now podcast, host Steve Gibson discusses his penchant for "conducting experiments on [himself]." In 2009, Mr. Gibson, usually focused on technology security, released a special hour long discussion on his studies of vitamin D. This week, he briefly mentions an expriment he conducted on eliminating most carbohydrates from his diet.

Editorial note - I've discovered in my own move to a mostly vegan diet, there many differing opinions on what constitutes the perfect diet and just as many studies to back them up. That said, I'm not sure I completely agree every part of his food-related discussion with host Leo Laporte. Nevertheless, Mr. Gibson has an almost obsessive habit of regular blood draws and lab tests.

You and watch their discussion on dietary changes and how they affected his lab results here.

Security Now 344: Your Questions, Steve's Answers #139 - YouTube.

Healthcare's digital divide: consumers vs providers

Last week, I wrote about embracing niche use cases, or what is known as the long tail. I referenced a William Gibson quote: The future is here…it’s just not evenly distributed.  If we are defining the future as processess, ideas, or technologies which sound far fetched to most, but in actuality exist in niche areas, then there is another way to consider their distribution. These processess, ideas or technologies can be widely accepted by some groups but still dismissed as "the future" by others. Consider mobile health technology.

According to the Pew American Life Project, nearly half of US adults have smart phones. Float Mobile Learning suggests there are 186 phones for every hospital bed in the US. They also suggest health apps is the 3rd fastest growing area on Apple's App Store. In 2011, South by South West, the popular interactive and music festival in Austin added a healthcare track. This year, the Health Track drew thousands, including big brand names like Qualcom, Cisco, and more.

But wait, there's more.

I created my own infographic... actually, it's part of a slide deck I use internally from which I've stripped the branding and strategy parts. Still, it shows how online and mobile health have tipped, and for consumers, are no longer niche areas.

See the trend here? If 80% of US Adults (including 56% of seniors) are going online for health information, can we really say the distribution is uneven?

The Digital Divide

There is a term, the digital divide which speaks to the rift between those with internet access and/or tech skills, and those without. Examples include the elderly and underserved communities, though there are certainly exceptions in those demographics.

There is another digital divide. When we consider the relatively wide adoption of online and mobile health ideas, processess and technologies, there is still a group for whom this is the future...it's out of reach, or not part of the plan: provider organizations.

Here, the future is evenly distributed among the general population, but very sporadically adopted by providers.

I'm not pointing fingers. This isn't easy stuff. 80% of doctors may have smart phones, according to Float, but how many are also advanced programers and IT gurus? And should we expect them to be? Nor should we expect them to expend their precious margins - believe me, they aren't as high as pop culture would suggest - on developing a state-of-the-art application.

Nevertheless, I suggest there are ways for providers and health systems to start embracing the future:

  • Use what is already available - if you have an EMR with a patient portal, then encourage patients to upload data from health apps. Likely, it will start as CSV attachments which will not immediately be discrete data. Nevertheless, it is engaging for patients, helpful to providers and forward thinking.
  • Share your expertise online - 80% of US adults want health information online, be part of filling the vacuum. When I give talks to clinical folks this is the point I stress the most. There is a powerful difference between hearing your local doctor's reaction to a new study and reading a national, disembodied by line on a national news site. Be the local expert!
  • Partner - if the idea of building your own app, accepting patient data, or starting a youtube channel is daunting, find someone who can help. This is part of a consumer's decision making process, how savvy, available and with it is my doc or health system? Would you fly an airline that didn't let you book online or bank with a bank that didn't have online banking?
  • Embrace cost reduction - If you are a primary care provider, do you really want to ask people to wait in your waiting room for 40 minutes to see you for 10 to get a refill on allergy meds? Building a process for reimbursable eVisits isn't nearly as hard as it sounds. Patients want them. We can FaceTime or Skype around the world, but not our doctors? How's that for uneven distribution?
  • Self-scheduling - finally, in the no-brainer category, nearly all airline tickets are booked online. OpenTable dominates dinner reservations via the web and mobile app. Why does it take a 10 minute call to get a doctor's appointment at a horrible time on a day that doesn't work for me?
One thing is clear, if we consider the uneven distribution of mHealth in terms of consumer vs provider, the idea is already mainstream for a huge segment of the market. With prospects like that, it doesn't take much to find gold. Embracing online tools and mHealth is going to be a major differentiator for providers and health systems who get on the band wagon early.

Mobile Medicine & Mobile Health Care: Float Mobile Learning.

 

The zombies are coming, are you fit enough to outrun them?

You are "Runner 5" set out on a mission to collect supplies and accomplish different objectives in a post-apocalyptic world... that involves the occasional zombie chase.

I think we all knew it would come to this one day. Zombies. Frankly, you can't say we haven't been warned. The CDC published the official Zombie Pandemic preparedness 101 guide in 2011. If you're    ready for a zombie apocalypse, then you're ready for any emergency.    emergency.cdc.gov

We don't know much about zombies. For instance, why do they want to eat brains? In my omnivore days, I did love sautéed calf's brains on toast with lemon caper butter. Are zombies just misguided gourmands? Possibly. However,I for one, am considerably less sympathetic to being the host of their locally sourced human offal delights.

What's to be done? Sure you can stock up on shotguns, barricade yourself in the hollow shell of a run down building and go all Mad Max on anything that moves. Me? I'm more of the out run and out last sort.

Admittedly, that raises the question: Can I outrun the zombies?

That's the premise of Zombies, RUN!, a new smartphone app designed to help encourage cardio fitness. Users fire up their phones and an audio story unfolds that starts with you, Runner 5, being chased by zombies. Along your mission, audio queues prompt you to zig down one street, or zag down another to collect supplies like water or toilet paper. Run too slowly, or not far enough and the zombies get your brains.

I haven't been this excited about a health related app in a long time. What a brilliant innovation on the gameification of health and behavior - add an interactive, fantasy layer.

For years, I've heard techies and entrepreneurs propose games where people with chronic conditions give away their health maintenance data in exchange for points, badges or real world stuff. Post your blood glucose readings and win an xbox... I find ideas like those condescending at best, teetering on malicious.

Zombies, RUN! is different. This is a way to trigger behavior change by upping one's motivation through a fictional, fun story. The end goal here, besides selling an app, is just fitness.

This also ushers in an entirely new concept for video games - ones where you actually work. This isn't pushing buttons, swiping your finger on a screen or flicking the Wimote around. You actually have to run. How interactive is that?!

Will Zombies, RUN live up to my expectations? We'll have to wait until February 27th to find out. But you can count on one thing... I'll be out there with my running shoes on collecting supplies for those of us who survive the zombie apocalypse! (And, assuming this blog is still running, I'll report back what I think of the app).

Here's the NPR storie with the game's creator:

via The New Running Game Where 'Zombies' Chase You : NPR.

Here is the creator's promo video:

Creepy, Malicious or Helpful - Google and Health related searches

Leo: "You search [Google] for psoriasis and you are telling the world..." Jeff: "So what if you have psoriasis.... what's the harm to [a patient who has type 2 diabetes] and google gives you ads.... we have to get down to [what is the real harm] and not have this discussion up here about creepyland"

That's the start of the conversation at towards the end of episode 132 of This Week in Google. Jeff Jarvis goes on to suggest Google has a vested interest in protecting people's data. He makes the point, if Google were to cross a line from what is perceived as creepy into actual malicious harm, their goose would be cooked. People would never use Google again. Jeff thinks the benefit we get from Google knowing more about us, coupled with their business interest, outweigh the risks.

Is he right? Do you think search engines know too much about us based on our search habits? What about this conversation in particular, around health related searches - a topic many hold as close to the vest as financial records?

I see both sides of the coin. I recognize the concern many have about not wishing to disclose sensitive health data for a various number of reasons - secrecy, perceived fear of insurance or employer reaction, data ownership, etc. I also see the value in a site like google knowing enough about me to return relevant results, based on a holistic picture of me. So what if they serve me related ads at the same time?

Curious what you think...

Here's a direct link to the conversation, starting at 1:03:30

This Week In Google 132: The Google Father - YouTube.

the one where Nick goes vegan...for a week

Dear pork, It's not you, its me.

 

Wait, let me start over.

 

Dear foie gras,

How do I say this, I've out grown you.

Literally.

 

Well, maybe that's all a little extreme. I mean, I'n not ready to give up meat whole hog.

I know what you are thinking: who hacked this blog and does Nick "Bacon" Dawson know? Rest assured, its me. Here's a picture of me holding today's news paper.

 

See! I am of sound mind and, perhaps more than ever, sound body. And really, thats what its about, this bloated extra large body I'm carrying around. Its getting old.

I'm not, on the whole, unhealthy. But I'm also not running a marathon any time soon either. My knees are crunchy, both have donor ligaments - parts in both of my knees came from some wonderful soul who donated their organs - they aren't mine. Hey, I fell hard, I defy any any ligament to take the falls I took and live to tell about it… but surely that extra 25lbs going into those 4 G ski turns wasn't helping.

He's how it went down.  For about three months now I've been kicking things into over drive. More cardio, less food. I got a FitBit, it tells me things..mostly it tells me when I'm lazy. So I've been running more. I've also been eating less.

 

I watched some movies too. I saw one about a guy who only had vegetable juice for 60 days. I watched one about the economics of corn. The best, the cream of the crop, so to speak, came with high praise. I heard about Forks over Knives from a colleague and friend. Dr. MK is a cardiac surgeon, he trained under one of the inventors of the heart transplant, he pretty much pioneered the use of surgical robotics in heart surgery… the man knows hearts. So, when he told me, over a year ago, that a vegan no-fat diet might prevent heart disease, my ears perked up.

Last week, Dr. MK and I were traveling together. I thought: what the hey, I've been working on calorie burn vs intake, lets see what this diet is like. And it wasn't bad… really!

 

At this point I feel compelled to tell you,  I'm still a man-card-carrying, Fred-Flintstone-steak-eating, sausage-making, bacon-loving carnivore. Let's just get that out there.

 

Still, eating a vegan no-fat diet really wasn't that bad. For starters, you taste everything. Try a salad without dressing, maybe just a little sea salt and lemon. It's alive, green, bitter, vibrant. If it is fresh and organic and well treated, there is a heck of a lot of flavor in them greens. Grains. Have you had really good quinoa or lentils?

Over the course of the week I tracked calorie intake versus burn. I have an awesome trainer at the gym who is helping me.  I'm trying to have a deficit of 3,500 - 4,500 calories a week. I get there through a mix of burning more and eating less. The trick is not to eat too few calories. So I monitored my intake. I used my FitBit to monitor burn and its online service for intake. At no point was I starving myself or in danger.

Here's the kicker, I lost 5 lbs (down 20 over all), feel great and have more energy than I've had in…I don't know when.

Will it last? Who knows. Have you seen the pork chops in my fridge? But I consider the week a crash course in what someone can do, how we can live. A vegan, fat-free diet can prevent heart disease and help turn off cancer genes. Surely a whole-foods-based diet is a long way towards the same goal. If (and by which I mean tomorrow) I eat pork fat, it will be from a farm I know, raising natural pigs in a healthy environment. Portions will be small. Veggies will be plentiful.

In what was perhaps a dose of karmic validation, on our last night on the road, I found myself - unplanned, I promise - sitting in the very seat piscitarian Steve Jobs had occupied a few months before. So I have that going for me.

someone build this: Foursquare for Doctors

The genesis of this idea came out of the Healthcare track of the C2C US/Russia Civil Summit that I participated in in June 2010. During a discussion around the use of social games, Dr. O Marion Burton had a lightbulb moment. He piped up with, "oh wow! how cool would it be to show off that I used a cheaper med and had better results!" I have been taken with the idea since that conversation. Since I am not a coder, here is my plea: someone help build this. Imagine a social site, a game of sorts, that rewards doctors and clinicians for improving outcomes, reducing costs and improving a patient's experience. Docs are a competitive lot, they worked hard to get where they are and that kind of drive doesn't end at graduation from medical school. "Dr. Smith just prescribed a less expensive alternative." Oh yeah? "Well, my patient just got out of the hospital a day under the national average length of stay." Can you see the peer pressure building?

Unfortunately this site doesn't exist...yet. Imitation is the sincerest form of flattery right?

Have you checked out the Foursquare social network? It is a social game, you (or rather your GPS equipped mobile phone) tells Foursquare where you are and Foursquare tells your friends. If you are out on the town and want everyone to get together at your favorite watering hole, you log into Foursquare, update your location and blast a note to your friends.

The game part comes into play in two ways. First, if you check into a place multiple times you may become its "Mayor". Savvy restaurants and businesses are rewarding mayors. In early 2010, Starbucks began offering Mayors a $1 discount off Frappuchinos. The second part of the game are the badges. You get badges for anything from checking in after 3:00AM (School Night) to checking in near the water (On a Boat). Think of them like Girl or Boy Scout merit badges, only, well, internetier.

Back to our medical example

Patient care is not a game and to create a social site that does not trivialize it takes tact. However, there is nothing wrong with a little healthy competition. The Federal Government's CMS website offers good data on how one hospital stacks up against another; and it is fairly easy to read….if you work in healthcare and spend your time digesting these kinds of things. I am not convinced that the average consumer wants to suss out the percentage difference between two providers (although the site does a nice job of using plain language).

What I am suggesting - no - begging someone to build is a site that is relevant to both clinicians and the public. Think: Foursquare for doctors. Write a script for a generic med three times, get a badge. Have a better than average outcome, get a badge. Become the mayor of wherever you attend CME courses. Doctors could follow each other and would see what their peers are up to. When Dr. Jones writes a generic script three times, Dr. Smith might ask him which med it was, what the differences are, why Dr. Jones prefers it, etc. The professional interaction does not have to happen on the site. The site is simply a way for docs to encourage each other to improve care. Patients can follow along too. You could visit your doctor's page and see what badges they have. Looking for the best surgeon? Find the one with the "10 complication free surgeries" badge.

I'm not much of a coder and don't have an ability to produce great design (although I did the fancy syringe badge for this post, pretty good huh?). So please… someone build this!

two knees, or not two knees

Editors note: yes, I went there on the title. Yes, I studied English in college and no I'm not ashamed of the cliche turn of phrase.... maybe a littleYou go in there My first reaction was to laugh, I think it caught my doctor off guard. "It's the ACL," he said shaking his head. The look on his face was earnest disappointment at the diagnosis. Maybe it was the eight weeks that had passed since the injury, or the fact that I skied out the rest of the season, but my only reaction was laughter. And, when you consider the circumstances, it is pretty funny.

Last April, we were out in Vail on the first day of a week long trip. My dad and I separated from my mother and my wife to go ski outer Mongolia in some soft but quite nice spring snow. Since he had the video camera, I had him go first with the intention of rocking through the bumps and getting some ego footage. I had a great run and took my time coming to a stop at the relatively flat bottom. As I was coasting slowly I lost my balance, the back of my ski dug in to some lose snow and I went over like a slinky. I heard a pop, shouted some choice words and lay there in pain for at least 10 minutes.I managed to ski down the front side of Vail, mostly on one ski (thanks years of race training for that useful trick!).

(I documented a lot of that process here and tagged posts as ACL) I had the reconstruction at home and this winter was back on the snow, skiing better than before the fall. It was a painful surgery and the rehab was hard - mostly because  it was boring and time consuming, not all together painful. On the one year anniversary, to the day, of that fall we were out in Steamboat. Same story- the old man and I hitting the back bowls. On our way back to the front, we came upon The Boat's section of double black diamonds. So I did the reasonable thing and sent my father ahead with the video camera. My thought was to get a video to send to my orthopedic doc to show him my full recovery. What would be a better testimonial than me flying down an impossably steep double black one year after my injury and reconstruction?

Right as I was taking off, Dire Straits' Espresso Love came on my iPod. For the whole year, I had avoided listening to that song. It was playing when I went down last year! But I was in mid turn, and off to a nice start and decided to ignore it. I skied a fairly iced out steep pitch nicely, although not as gracefully as I would I have liked. I took a pause and came to a gliding stop and thats when it happened.

The same, exact fall. Right knee this time. Same pop, but not nearly as much pain and no loss of range of motion (no swelling) I again skied off the mountain and even skied the rest of that week; followed by another two trips out west of some seriously hard skiing. In fact, I even bought two new pairs of skis this year because I was skiing so well. Unfortunately this right knee just has not changed. It is no worse, but no better either, there  is a constant dull pain. I've been in the gym pretty hard (squatting 360lbs often) and it feels stable when I run. Walking is another story, it does not totally slip out like my left did pre-surgery, but it locks up a bit with some significant pain at random times.

I broke down, had the MRI and consult. The diagnosis is a torn right ACL. Surgery seems imminent, and I am begining to make peace with that. My hope is, since I did not swell and do not have the resulting muscle loss, that I can do an abbreviated PT schedule and get back into the gym sooner. I'd rather not lose the ground on the weight loss and fitness while I convalesce for another 6 months.

So add this to the list of posts on this blog tagged with ACL... lets home this does not become an annual feature!