This week, Apple released their latest disruptive innovation, iBooks 2 and iBooks Author. iBooks 2 is a free update to the iBooks app for iPads. iBooks Author is a free mac desktop application which enables anyone with some basic typing and drag-and-drop skills to create pretty amazing eBooks. eBooks can contain pictures, links, audio, video, rotating graphics, self study questions and more. This is the future of patient education, shared decision aids and pre and post visit care.

On the outset, the idea of combining text and video and pictures isn’t really that new. It’s been around since…well… the start of the web. But in the context of a book, there is something really strangely compelling about seeing a moving video in the middle of static text. I can’t quite describe it. After about an hour of tinkering with the app and pasting some images and text in from a keynote presentation, I had a nice little proof of concept. You can download it and see for yourself here.

There is something which draws you in when you see live action video playing within a frame of text. Adult education experts call this blended learning. We absorb more when we engage more of our senses.

So imagine this, your doctor tells you that you are going to need surgery. What’s that process going to be like? What do I do before hand to prep? What should I do when I get home, you ask?

“Well, you can just download my free eBook,” he says.

The book walks you through the pros and cons of surgery. It plays a video of the doctor outlining the procedure. A moving picture gallery shows you where to arrive, and what to expect the day of surgery. Another video shows you how to use the pre-surgical antimicrobial wash the doctor sent you home with. There are links to online communities from other patients who have been through the same process. There is even an embedded twitter search showing a real time discussion about your condition. Wow!

A few days after the procedure, you fire up chapter two. It shows a diagram of some basic stretching. The next page talks about nutrition. To make sure you understand the concepts, there is a short self test, don’t worry, it’s open book.

These tools are simple to create. They are easy to publish (for free). And, they are a tremendous value-add to patients. Apple has done it again. By disintermediating author from the publisher, they’ve given us all the ability to make robust patient aids. For that matter, patients could make them for other patients, and publish them on their blogs, or via the iTunes book store.

What are you waiting for, go publish your first eBook!

You can download my demo/work-in-progress book, Innovation in Healthcare: A Requirement For Success here. I’ll continue to update it after this post is live, however the point is not to provide a serious book about health reform and innovation tactics. Rather, the point is to demonstrate how the technology can be used in a healthcare setting (this book is more geared to the administrative types than patients).

The gallery below includes images and descriptions of features in eBooks. 

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 had the privilege recently of being asked to write a short reflection on the use of social media in healthcare. I suggested many of us are moving from our freshman year – getting familiar with campus, determining which is the cooler spot to hang out at, facebook or twitter… you get the idea – towards our sophomore and junior years. For many providers, this year is about figuring out what to do next. What will actually bring value and make using social media in healthcare, well, meaningful. What are the meaningful use guidelines for #HCSM?

In late 2010, the federal government released a much anticipated set of guidelines around how healthcare providers should use electronic medical records. The guidelines, know as Meaningful Use, specifically spell out what features an EMR must contain and how doctors must use those features in order to qualify for federal stimulus dollars. For instance, the guidelines suggest providers council every smoker on smoking cessation. The software must be able to prompt doctors when someone has identified as a smoker and it must be able to capture that the physician has spoken to them about quitting.

Meaningful Use says it is not enough to simply have an electronic record. Meaningful Use says the EMR’s feature set and how it is put into practice determine the impact it has on care. Today, we can say the same thing about social media in healthcare. With heartfelt thanks to the pioneers who fought the HIPAA and ROI battles, it is no longer enough to simply have a facebook page or twitter account. There are expectations around engagement, user experience, quality and value which users have come to expect through interactions with other individuals and organizations.

The good news is that there is no single correct way to use social media and digital communications as a provider. There are, however, a few basic ideas which I boldly offer as guidelines for using social media as a healthcare provider:

• Be available – Phil Baumann said it well. You do not need to be famous online, you just need to be available. In fact, the rest breaks down if when this guideline is not followed. It has been said many times by many people, social media is less about pushing and more about pulling. If you are not open to conversations with the public, patients, other providers, etc then social media may not be for you.  As guidelines go, this one may be the most significant for meaningfully using social media. Being available is more than just replying to tweets. Availability means knowing who within the organization can answer the question authoritatively; It means having a team of on call experts. I know at least one healthcare thought leader who envisions call centers giving way to tweeting centers. Have the capacity and expertese to follow up with your tweets, comments and facebook wall.
• Bring Value – There is an easy litmus test for this one. Think: “why would I follow or fan a company?” Most people get enough spam email and junk mail. Can you honestly say you would want to get the message you are pushing out if you didn’t work for the provider pushing it out? If not, then it is probably spam. So what kinds of things bring value? Think about curation, sharing expertise, answering questions, helping someone find what they are looking for. Here is a simple way to bring value: go to search.twitter.com and select advanced search. For the search string, enter something like “doctor” and then put your zip code in the location field. Chances are someone in your area is looking for a good doctor. Reply and offer to set them up with a same day appointment. Now that’s value! Another example includes hosting diagnosis specific communities and wikis with clinician participation. Imagine an online community of folks who have been and are about to go through an orthopedic joint replacement. What kind of value would they get from connecting with each other and sharing experiences in a forum moderated by a clinical expert?
• Liberate your expertise – Most physicians go through at least 4 years of medical school and post graduate education. Many pursue fellowships and residencies. There is a significant amount of intellect and scholarship trapped in those brains of theirs. Here is the problem, until there is something wrong with me, I have no way of tapping into that knowledge. We often mistake holding onto our ideas and knowledge as power. The reality is the opposite. Those who are willing to share their expertise often find the rewards to be considerable. If you are a physician, you are a trusted expert in your field (the same can be said of provider organizations). Your use of social media must consist of sharing that expertise. Provide your opinion on the health news of the day. People would much rather get that expertise from someone local and trusted than an etherial disembodied name on the byline of a major news paper. Here are two great examples: Dr. Howard Luks and Piedmont’s HealthWatchMD site.
• Be collaborative – engage publicly with other physicians and experts (and can’t patients be experts in their own conditions?). If you are an expert individually, and there is indeed benefit to liberating that expertise, imagine what happens when you team up with other experts? In medicine there is the concept of grand rounds – opportunities for physicians to present complex cases as learning experiences to other providers. Today’s social tools are perfect platforms for grand rounds. The more providers are willing to interact and share, the more we all benefit. This collective knowledge becomes searchable, accessible by anyone – patient or provider – who wants to learn more about a condition or treatment. Dr. Gayle Smith does a fantastic job of collaborating with patients and colleagues.
• Be Innovative - Innovations come in many forms; not everyone has to be the next iPod. Think about how social and digital tools are being used outside of healthcare. What applications might they have in improving health and patient experience? Over 500 million people are using facebook. According to their statistics, 250 million access the site from a mobile platform and mobile users access the site at least two times a day. What does that tell us about the role mobile platforms play in what has become the most significant communication tool of our age? Do you have a way to interact with patients via a mobile device? What about text messaging? There is an innovation which is easy to adopt. Solve problems, don’t get hung up on them.

There you have it. How is that for a start? As we start to go beyond simply being online it is time to think about how to have an impact in what we are doing. What other guidelines would you propose? What about from a patient’s perspective, what makes social media meaningful?

Elsewhere: Remember me? Yeah, me either. This whole graduate school thing is hard – who knew!?! Elsewhere is my series of posts highlighting content from sources I find interesting, inspiring and supportive.

My world got a little bit smaller the other day. When I walk the dog I usually listen to podcasts, downloadable audio and video shows. Think TiVo for your iPhone. You already knew that didn’t you?

So I’m listening to American Public Media’s The Splendid Table. If you are at all inclined towards the culinary arts, by which I mean eating, then it is well worth a listen. You can dial it in on most NPR stations, although I suggest you download it to you portable gizmo as a podcast, either through iTunes or their website directly.

Anyway. Host Lynne Rossetto Kasper kicks off each week with a mini-monolog about some food trend or observation.

This week, Lynne discussed an employer which is offering to help subsidize community sponsored agriculture (CSA) memberships for employees. CSAs are like gym memberships for famers markets. Usually you pre-pay to “join” a farm and get regular deliveries of fresh veggies, meats, dairy, etc. You help fund the operations and get a share of the lauder in return.

Think about that for a second – an employer that was willing to sponsor a food lifestyle choice for employees.

Some employers, although I anecdotally suspect the number is low, sponsor gym memberships for employees. The idea is when you workout you are healthier and thus avoid disease and illness which, in turn, saves the company money on healthcare costs.

If that logic holds true (and aren’t we told we are what we eat?) then doesn’t sponsoring healthy food choices also make sense?

There is a lot of talk in the healthcare industry about “accountable care.” Without going into details on the pros and cons and esoteric points, suffice it to say it means healthcare provides partner with the people paying for care to reduce the cost and innovate the care model. Most people who get insurance in the US, outside of Medicare, get it through their employers. Many of those employers are self-insured; meaning they pay for care out of the company’s coffers, even if administered through a third-party commercial plan. You may have blue cross, but your employer is likely footing most if not all of the bill.

Given that, doesn’t it make sense for employers to support employees who make healthy food choices?

Paying for CSA memberships is admittedly not the norm. It is a little on the hippie, 2000s-dot-com-days side of out there. But it may offer similar benefits as paying for gym membership, or perhaps it is even better. Nonetheless, it is as least accountable, forwarding thinking and socially responsible.

In my growing elsewhere series, I’ve been highlighting content from other sources online. You know, curating, as the hip social media types say.

Last week, the LA Times reported that ‘hospitals are looking more like luxury hotels’. The article says that a report found that, to patients, the non clinical experience mattered twice as much as the clinical experience. I call it patient experience. In healthcare, it means how we care for someone’s complete needs – emotional, clinical, spiritual, etc. Sometimes it is as simple as spotting the guest who needs directions and walking them to the right place. Sometimes it means giving a hug, or sitting and listening. In the end, it is about people taking care of people.

So what do a bar and a hospital have in common? How you treat people is how people will think of you. I’m proud to call An Bui, “Chief Beer Officer” at Mekong in Richmond a friend. I’m proud to call him a friend because he treats me like a friend. An’s special gift is treating everyone he meets like someone special, getting to know them and providing the best service he can, every time. This week, Richmond.com is profiling An — the quote below typifies An and his approach to service. It also shows his affinity for and success with extending his style of service outside the four walls of Mekong using social media.

It’s people. You have to get to know people. Relationships. Take care of them. We’re not perfect. We know we can always improve. But people who come back to us, we always try to take care of. For me, I’m happy. I like people to be happy. At bar, I do my best to keep people happy. Pour good beer, talk to people like family or at least very good friend.

I’m a beer lover. I say Mekong is for beer lovers. We welcome beer lovers and create new beer lovers by focusing on great beer. That’s why I have a lot of friends on Facebook. I love Facebook. Anyone can friend me who has come into Mekong. I enjoy happy friend. Make good recommendations, too. Also, good customers and friends who tell other people about our food and beer and how we get to know you. We have great customers out there who visit us all the time and tell others and post on Facebook and Twitter.

So, let me get this out in the open. I’m not a social media advocate. I’m not a social media guru, expert, thought leader, or zealot. I am not pro-twitter. I’m not really that into Facebook (please don’t unfriend me!). You might be surprised to read that I’m not always looking down at my phone. Maybe I am. But still.

I am an advocate for care. I am an aspiring healthcare guru, a wanna be expert, a hopeful thought leader and unabashed zealot for improving the patient experience. I am a pro human. I am really into making someone’s care experience a holistic one. You might be surprised to read that I like to spend part of my day greeting people at the door of our ER.

When did social media become about, well, social media? When we we decide that talking about what we are talking on was more important than what we should really be talking about? I’m not an angry blogger, I promise. And I’m not singling out anyone or any post either. In fact, there have been some important online discussions recently about the validity of social media in healthcare.

But, isn’t it really about healthcare, about care. I mean, if its not, why are we interested? I’m guilty of getting wrapped up in frenzy; and suspect we all are. This is my call to action, my reminder to myself and my sincere wish – lets keep it about advancing how we care for others. We do that in many unique ways. Doctors do it differently from nurses, who do it differently from patient advocates, who do it differently from mental health professionals who do it differently from us admin types, who …. well, you get it. Still, we are all focused on improving the experiences and outcomes of those we care for. When we start talking about the 1s and 0s that our bully pulpit is made of, we’ve lost some of our effectiveness.

Be health champions first. Let’s be champions of care first. Let’s focus on using early adopter, expert, and guru status to champion what it is we are really doing – elevating the art of healthcare.

epilogue: Now, I know what you are thinking. Wasn’t my last post on this blog a hubristic, aggrandizing, self-promotional link to an article where I was quoted as being some kind form of thought leader? I see where you are going with that though and I agree. I’m talking to myself in this post. In fact, when I forget about this altruistic nonsense, I expect you (my two readers, hi mom!) to call me out. I’ll also add that those kinds of articles and posts are important. They are ammo in our arsenal to promote the use of social media – we just need to remember why we are so keen to promote it in the first place.

The November issue of the Catholic Health Association’s Health Progress Magazine includes an article on social media and healthcare. Social Media: New tools boost marketing, education, community, by William Sweetland and Susan Thomson is available on the CHA website as a pdf.

I had the privilege of being interviewed for the piece. I find being asked certain questions prompts me to think about my own work in a different way. That was abolutely the experience I had when Bill Sweetland asked me about the intersection of Catholic healthcare and social media. I am not catholic and have only worked in catholic healthcare for a little over 3 years. When I made my transition from the consulting world back to the provider side, joining a not-for-profit with an emphasis on customer experience and community health was a no-brainer. When we formed our social media program, the same tenants that govern our mission and values went into guiding our social media program. It was a fun exercise to see just how much overlap there is between social media and mission-driven, community focused healthcare.

At Bon Secours Richmond Health System in Richmond, Va., Nick Dawson, administrative director for community engagement, has so far figured out that his goals for social media include “improving the patient’s experience” and “giving away” the hospital’s “vast scientific medical knowledge to promote holistic healing and wellness.”

Wait, give away core expertise? Isn’t that counter-intuitive?

“Isn’t there a saying that tells us that if you give away your riches, your core competence, it will come back to you many times over? It’s a funda- mental truth when you think about it,” Dawson said. “And social media can help us do that” — educate patients and the public, in other words — “in a big way.”

And… for a little light humor regarding accountable care:

A few weeks ago I had the privilege of being asked to write a guest blog post for Odom Lewis, a healthcare communications staffing and recruiting firm. Angelia from Odom asked me to comment on Dr. Bridget Duffy’s ever-inspiring presentation from the 2009 Gel Conference. Some may recall that I wrote about Dr. Duffy’s talk here on this blog in June 2010.

In short, since most of us are not doctors, or may not even be conscious while we are being attended to, it is very hard to gauge the quality of the clinical attention we are receiving. However, every person has the ability to gauge their healthcare experience. When providers make the patient experience a strategic goal, everything else will follow: clinical outcomes, revenue, market share, etc.

For most of us, auto mechanics are a bit of a mystery. The oil light comes on, we drive to the dealership, they work some voodoo and we drive away under the impression that things are running smoothly under the hood. Unless you have the know-how, there isn’t a way to verify the quality of the work that is done. That is probably why savvy dealerships started offering fancy waiting areas – coffee, danishes, flat screen TVs and high speed Internet. If we can’t judge the craftsmanship, maybe we’ll make our service decisions based on the waiting experience. The interesting thing is that medicine is not much different.

Want to read the rest? Head over to the Odom Lewis blog.

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!