subtitled: foreseeing a day when we will shop for and buy medical services without leaving the house.

Google  - (n.) first stop on the information superhighway.
“I went to google to find the answer”

Google – (v.) to look for anything online
“He wanted to know more about diphtheria, so he googled it”

Google – (n.) medical instrument used to aid in diagnosis and treatment
“Sally wondered about the bump on her arm, so she went to google and googled the symptoms of spider bites”

Sometimes a topic is like a cloud full of metaphors waiting to rain down. The trains coming and you better get onboard. That ship has sailed. Know thy enemy. A few weeks ago I had the privilege to speak (along with a group of infinitely more qualified other folks) at a healthcare conference in Chicago. During one of the panel discussions, someone made a comment which I’ve been chewing on for a week. ”The competition, for attention online, is sites like RatedMd and WebMD.”The only thing I could think of was those Loony Tunes where the Abominable Snowman always got confused and said: “Which way did he go George, Which way did he go?”. He was cutely befuddled by misdirection as abominable snowman are apparently wont to be. (The catch phrase, by the way, comes from Of Mice and Men.)

The context of that comment was in regards to reputation control and public perception. The concern is healthcare providers are being valued and rated online and without some presence of their own, their “brand” has potential to be devalued. While that point deserves some consideration, it wasn’t what got me thinking.

What set the hamster on my mental wheel gasping for breath was the idea of online sites competing for patient attention in general.  This isn’t a new idea and likely won’t strike you as terribly profound. People go online, they google, and now they talk to each other via social media sites. Now think about this: how does that play out when those searches, sites and conversations reduce the overall need for your system’s healthcare services? What happens when a patient goes online and gets a diagnosis and even a treatment rather than coming through your doors?

Think it won’t happen?

I’ve been looking for pickle crocks. I like to pickle things. You probably know that about me. Here’s the thing about pickling, when you let natural bacteria do the work, its a delicate process. Two things will kill the bacteria and render salty but unpicked veggies every time: sunlight and chlorine in municipal water. The later is easy, you buy spring water from the store. The best solution against sunlight is an earthenware ceramic pickle crock. You’ve seen them in your grandmother’s kitchen, probably holding the wooden spoons and whisk in the corner near the stove. Once upon a time, they served a real purpose. The problem is that they are increasingly more rare. It seems no one else shares my interest in pickling – shame. So try this: go to google, type in “pickle crock”.

If your results are similar to mine (and remember, a google search is in the fingers of the beholder), then the top 5 or 6 results for pickle crock are online stores or sales sites. You may even get some Google Shopping results at the top. Think I even checked a local store first? (I know, I know, its good to shop locally).

Now, google “allergies”. This time the top several sites are informational sites: WebMD, MedicineNet, eMedicineHealth, and even a few nationally known hospitals.

I know what you are thinking. Yeah, you can buy a pickle crock online but its not like you can buy an allergy diagnosis on WebMD. …. yet.

Last week CMS, the Center for Medicare Services, announced it is loosening the regulations around telemedince certifications. That is a big step. The process for credentialing practitioners to treat people via Skype just got a lot easier.

Lets talk fee-for-service

This one is simple. The average net reimbursement for a family physician visit is about $60. The average patient co-pay is $25. If a patient can stay in their own home, avoid the hour wait in the waiting room, not to mention the germs and two year old copy of Highlights magazine, and see a doctor or nurse via Skype for $15, which path do you think they’ll pick? You’re out $60 and the patient saved $10. There is, of course, the huge downstream impact on referrals and patient loyalty as well.

Enter the ACO

With the hullabaloo around Accountable Care Organizations, there is an increased interest in technologies like telemedcine. They can save money. Here’s the rundown incase you missed it. In an ACO model, a provider is given a pool of patients, lets say 5,000. They are then allotted a fixed amount of money to keep those patients well for a year. Lets say $1,000,000. If no patients come in the door at all and all of those patients are perfectly healthy you effectively pocket the cool million. However, when they do come in, you need to use your resources wisely. The healthier they are, the more you keep. So you have a mixed bag – don’t order expensive tests, thats money out of your pocket. But you do need to ensure they get better. Now what happens when those patients start going online and getting treated by eVisits from other providers? The current CMS regulations do not prevent patients from seeing other doctors. However, you are still on the hook for the outcomes. If that eVisit doesn’t work out, or worse, has an adverse outcome, guess who’s pocket is being reached into?

Now, I’m the last one to spread FUD and start fear mongering. I’m also a big fan of the interwebz and the potential these technologies hold for patients (after all, we are all patients). What I would suggest is that health systems and providers need to be ahead of this curve, not behind it (that one counts double for buzz word bingo). We need to offer these services to our communities and patients ourselves and not let large, profit driven websites own this space. eVisits, telemedicine, social media, text messages, email, EMR … these are all doable today. There are already patient populations where this makes sense and there are revenue models which work. In a fee for service environment, what does the pro forma look like? Can you staff a nurse in a role to interact with patients and charge them just a little less than an office visit co-pay? What about doctor to doctor telemedince as a start? Lets not be the Abominable Snowman with our arms crossed and fingers pointed in opposite directions asking: “which way did he go George, which way did he go?”

Update: From the “great minds think alike department”, Jen Riggle wrote a great post on the same day talking about, of all things, skyping doctors. Her research and links suggest reality is closer than we may think. In particular, take a look at Dr. Brian Goldman’s advice. He suggests starting with established patients. If you already know, because you have meaningfully implemented an EMR, that someone has seasonal allergies every spring, that is one more check box in feeling secure about making that diagnosis next April via Skype.

By the way, Leeners sells great stoneware pickling crocks at a good price.

I have been thinking a lot lately about the relative importance of social media. Actually, I have been thinking about history. Really, what we know about history is what was recorded by the people who thought those particular details were favorable or important. What’s the old saying? History is written by the victors. In a sense, the same thing is true for recent history; take family for example. What do we really know about what our parents were like in high school?  I am inclined to believe my parents were pretty cool cats. I have seen pictures of them before prom, football uniforms and signed yearbooks. But the truth is that I was not there. The truth is that I am seeing their history as told by the victors.

Now think about this – think about all the kids growing up in the socially networked generation. What happens when they grow up and have families of their own? Who gets to tell the history when it was already been documented live in real time? Its a mind-bender isn’t it? The children of the next generation, maybe even my kids, will have a digital history of our entire lives. Everything we posted, tweeted, flickred, youtubed, regretted, liked, friended, faned…. it will all be there. That embarrassing night in college, videos from our wedding, tweets about the first job. Imagine the internet as the scrapbook of the future. What will our kids find when they google us?

As I started thinking more about the idea – and indeed the importance of the concept itself – it made more sense (at least to my twisted brain) to explore it graphically:

To that end, you’ll probably enjoy this presentation in full screen here