Category Archives: Optimizing Patient Care

Quit Beating A Dead Horse (and wasting money): The Day of the Pharma Rep is Done

As I sit behind a computer in my office today at the Physician’s “workstation”, I am baffled at the steady flow of Pharmaceutical representatives that flow into our office on a daily basis. Each rep comes in with a fancy glossy print detailing the data concerning their particular drug. My office is busy—patients are coming in and out and medical assistants are busy checking vitals and verifying medications (and of course, entering data into the computer system EMR). Yet the reps come in and stand at the workstation until someone acknowledges them. They stand, and stand—often distracting clinical staff. These reps are given a quota of “visits” they must make by their superiors. Many times they will arrive with their direct supervisor in tow—they are evaluated by the relationship they may (or may not have) with a group of physicians. But my time with each and every patient I see is limited due to the increased electronic medical record work that I must do—I feel bad for the reps (it is not their fault that they are placed in this role)—but Do I really have time to stop the endless flow of clinical work to speak to them? Does a Pharma rep actually provide any real value to me or to my patients? Would a “detail” presentation by any rep change my practice?

The Days of Yore

In the past, pharma reps were a source of “samples” that I could provide to my poorer patients who could not afford their meds. This was a real value—I depended on reps to provide these medications for my patients. In the days of print only access to journals, I may not have been as current with the medical literature. Reps would often come in and discuss breaking trial news that I had not yet had time to read about. Often they would discuss upcoming trials and plans for the future. We would have spirited “academic” debates over drugs, trial design and outcomes or endpoints. When you were unable to attend scientific meetings, the pharma rep would often be able to summarize the latest trials after they were released.

Now, my institution no longer allows “samples” to be left, and honestly, if I need a drug rep to share the latest data with me then I am not doing my job as a physician. Online access to immediate data from trials upon their release makes “keeping current” much easier. Social Media and other digital tools make it possible to attend national academic meetings such as the American Heart Association annual scientific session or the American College of Cardiology meetings allow everyone to be virtually present for ground breaking presentations of Late Breaking Clinical Trials.

Don’t get me wrong, there is nothing wrong with the people who choose to be pharma reps—many are smart, classy, well-meaning folks. However, there is a lot wrong with the antiquated pharma rep sales model in today’s world. Modern technology and easy access to data allows physicians to keep up with the latest clinical trials. Pharmaceutical detailing by reps is not very helpful—it is scripted and based solely on what the FDA allows them to say (think on label vs off label). Reps are not allowed to talk about upcoming trials or discuss any off label applications.

What’s the Answer?

Drug prices in the United States are far too high. Pharma will argue (rightfully so) that the costs of research and development (as well as marketing) drive those costs. However, I think that there are ways to lower costs without sacrificing R and D. I would argue that a restructuring of the pharma “sales force” would save significant dollars. I would also argue that making the FDA approval process more streamlined, faster and more agile would also lower costs. The current Congress is working on the “Cures Act” that will address some of the issues associated with the FDA process. Ultimately, I think that pharma must adjust to the way medicine is now practiced. There is no role for the pharmaceutical representative in the office or hospital. These individuals have absolutely no bearing on my choice to prescribe a particular drug and do not contribute to my continuing medical education. Nearly 75% of all Americans go to the internet after a doctor’s visit. Almost all physicians can access the internet immediately from a smartphone or tablet. Pharma should move their marketing and sales efforts to the digital space exclusively. There is no role for in person physician-pharma rep interaction in medicine today. Use these dollars in better ways—fund patient assistance programs, improve treatments and fund clinical trials. Stop spending money on lunches for the office staff and on fancy packaging. Glossy detail cards are simply tossed in the trash as soon as the representative leaves the building. Focus more on patients. The days of the drug rep have come to an end.

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Sharing Bad News or Keeping Secrets—How Physician Communication Impacts Patients and Families

Doctors and Patients bond over time. Information exchange, education and sharing of expertise are critical activities that add to the effective practice of medicine. Delivering bad news is unfortunately an unpleasant part of a physician’s job. Honesty, empathy and clear communication are essential to delivering news to patients and their families—even when the news is unpleasant or unexpected. While communication is an integral part of the practice of medicine, not all healthcare providers are able to relay information or test results in a way that is easily digested and processed by patients. Some physicians may avoid delivering bad news altogether—often keeping patients in the dark. While a paternalistic approach to medicine was accepted as the status quo for physician behavior in the 1950s, patients now expect to play a more active role in their own care. Patients have a right to demand data and understand why their healthcare providers make particular diagnostic and treatment decisions.

Recently, a disturbing report indicated that in a database of Medicare patients who were newly diagnosed with Alzheimer’s disease, only 45% were informed of their diagnosis by their physician. While shocking, these statistics mirror the way in which cancer diagnoses were handled in the 1950s with many doctors choosing not to tell patients about a devastating health problem. With the advent of better cancer therapies and improved outcomes, now we see than nearly 95% of all patients are informed of their cancer diagnosis by their physician.

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How can this be? Why would a physician NOT tell a patient about a potentially life changing diagnosis?

I think that there are many reasons for this finding in Alzheimer’s disease and that we must address these issues in order to provide ethical and timely care to our patients.

  1. Time constraints: Electronic documentation requirements and non-clinical duties allow for less time spent with each patient. In order to deliver bad news such as a terminal diagnosis, a responsible physician must not only spend time carefully delivering a clear message but must also be available to handle the reaction and questions that will inevitably follow. Many physicians may avoid discussing difficult issues due to the lack of time available to help the patient and family process a diagnosis. We must create ways to diminish the administrative burden on physicians and free them up to do more of what they do best—care for patients. More reasonable and meaningful documentation requirements must be brought forward. Currently, many physicians spend far more time typing on a computer rather than interacting in a meaningful way with patients during their office visits. Eye contact, human interaction and empathy are becoming more of a rarity in the exam room. This certainly limits the effective delivery of bad (or good) news to patients. Priority MUST be placed on actual care rather than the computer mandated documentation of said “care”.
  2. Dwindling Long-Term Doctor Patient Relationships: Networks of hospitals, providers and healthcare systems have significantly disrupted traditional referral patterns and long-term care plans. Many patients who have been enrolled in the ACA exchanges are now being told that they cannot see their previous providers. Many physicians (even in states such as California) are opting out of the Obamacare insurances due to extremely low reimbursement rates. Patients may be diagnosed with a significant life changing illness such as Alzheimer’s disease early in their relationship with a brand new healthcare provider. When a new physician provides a patient with bad news—of a life-changing diagnosis that will severely limit their life expectancy as well as quality of life—patients often have difficulty interpreting these results. Healthcare providers that have no relationship with a patient or family are at an extreme disadvantage when delivering negative healthcare news. Long-term doctor patient relationships allow physicians to have a better understanding of the patient, their values and their family dynamics. This “insider knowledge” can help facilitate difficult discussions in the exam room.
  3. Lack of effective therapies to treat the disease: No physician likes to deliver bad news. No doctor wants to admit “defeat” at the hands of disease. It is often the case where some healthcare providers will not disclose some aspects of a diagnosis if there are no effective treatments. I firmly disagree with this practice of withholding relevant information as I believe that every patient has the right to know what they may be facing—many will make significant life choices if they know they have a progressively debilitating disease such as Alzheimer’s disease. In the 1950s, many patients were not told about terminal cancer diagnoses due to the lack of effective treatments. However, medicine is no longer paternalistic—we must engage and involve our patients in every decision.
  4. Lack of Physician communication education: As Medical Students we are often overwhelmed with facts to memorize and little attention is given to teaching students how to effectively interact with patients as well as colleagues. Mock interviews with post interview feedback should be a part of pre clinical training for physicians. We must incorporate lectures on grief and the grieving process into the first year of medical school. Making connections with patients must be a priority for physicians in the future—we must equip trainees with the tools they need for success.  Leaders distinguish themselves by the way in which they share bad news.  According to Forbes magazine the critical components of sharing bad news include–accuracy of communication, taking responsibility for the situation, listening, and telling people what you will do next.

What’s next?

As with most things in medicine, change often occurs “around” healthcare providers without direct physician input. Physicians are appropriately focused on providing excellent care and connecting with patients while politicians and economists craft the future of medicine. The issues with lack of communication of negative findings with patients MUST be addressed. Patients have a right to their own data and have a right to know both significant and insignificant findings. In order to avoid situations where patients are not fully informed about their medical condition, we must continue to remain focused on the patient—even if it means that other clerical obligations are left unattended.

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Reflecting on Medicine in 2014: Sailing Rough Seas and Finding Uncharted Waters Ahead

As we close out on a tumultuous 2014 in healthcare, many physicians are looking forward to a better and more stable 2015. For most of us, 2014 has been marked by significant change. Many healthcare providers have seen their jobs and their patient care roles transform completely. Physician autonomy has diminished and regulation and mandated electronic paperwork has more than doubled. Many physicians find that they are spending far less time caring for patients and a greater proportion of their available clinical time is now being spent interfacing with a computer—both at work and at home on personal time.

During the last year, we have all been affected by the rollout of the Affordable Care Act (ACA), changes in reimbursement, as well as the implementation of a new billing and coding system (ICD-10). For many of us, it also marked a year of transition to system wide electronic medical record systems such as Epic and the growing pains associated with such a major upheaval in the way in which medicine is practiced.   Many practices have continued the trend of “integration” with larger healthcare systems in order to remain financially viable. The American College of Cardiology estimates that by the end of 2014, nearly 60% of all physician members have integrated with hospital systems and this number is expected to rise even further in 2015—ultimately defining the death of private practice as we know it.

Why have these changes occurred?

Ultimately, I believe that the changes to the way in which healthcare is delivered has come about due to 3 distinct reasons:

 1. Declining Reimbursement

Currently reimbursement continues to fall. Multiple government budgetary “fixes” have led to much uncertainty and instability in medical practices (much like seen in any small business with financial and market instability). In addition, the implementation of the ACA has resulted in the expansion of the Medicaid population in the US—now nearly 1 in 5 Americans is covered under a Medicaid plan. Traditionally, Medicaid plans reimburse at levels 45% less than Medicare (which is already much lower than private insurance payments). While the Obama administration did provide a payment incentive for physicians to accept Medicaid, this incentive expires this week. Many practices are becoming financially non viable as overhead costs are risking to more than 60%. As for the ACA, many exchanges have set prices and negotiated contracts with hospital systems—leaving many practices out of network. Both patients and doctors suffer—longtime relationships are severed due to lack of access to particular physicians.

2. Increasing Administrative/Regulatory Demands

With the implementation of the ICD-10 coding system, now physicians are confronted with more than 85, 000 codes (previously the number of codes was approximately 15,000). In addition, “meaningful use” mandates for payment have resulted in increasing documentation requirements and even more electronic paperwork. In addition, the implementation of new billing and coding systems has required increasing staff (more overhead) as well as intensive physician training. Sadly, the new coding system that has been mandated by the Federal government includes thousands of absurdities such as a code for an “Orca bite” as well as a code for an “injury suffered while water skiing with skis on fire”.

3. Electronic Medical Record Mandates

Federal requirements for the implementation of Electronic Medical Records and electronic prescribing have resulted in several negative impacts on practices. While in theory, the idea of a universal medical record that is portable and accessible to all providers is a noble goal, the current reality in of EMR in the US is troubling. There are several different EMR systems and none of them are standardized—none of them allow for cross talk and communication. Many small practices cannot afford the up front expenditures associated with the purchase and implementation of the EMR (often in the hundreds of thousands of dollars).   In addition, the EMR has slowed productivity for many providers and resulted in more work that must be taken home to complete—not a good thing for physician morale. Finally, and most importantly, the EMR often serves to separate doctor and patient and hinders the development of a doctor-patient relationship. Rather than focusing on the patient and having a conversation during an office visit, many physicians are glued to a computer screen during the encounter.

So, What is next in 2015?

While I have probably painted a bleak picture for Medicine in 2014, it is my hope that we are able to move forward in a more positive way in 2015. I think that there are several very exciting developments that are gaining momentum within medicine and healthcare in general.  Innovation and medical entrepreneurship will be critical in moving healthcare forward in 2015.  Physicians must continue to lobby for the tools and freedoms to provide better patient care experiences for all stakeholders in the healthcare space.

2015 begins with much promise. I am excited to see what we as healthcare professionals will be able to accomplish in the coming year. We must continue to put patients first and strive to provide outstanding care in spite of the obstacles put before us. While 2014 provided challenges, we must rise above the fray and continue to advocate for a better healthcare system in the US today and in the future.

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Obama’s Latest Bait and Switch for Docs: Medicaid Payments to be Cut by 40%

As we enter year two of the Affordable Care Act, we have seen many issues arise during implementation.  Through both executive order and executive memorandum, President Obama has unilaterally changed the law more than 100 times in order to advance his own political agenda.  When it became important to publicize enrollment and increased coverage of the uninsured, the President and the ACA provided for an increased payment scale for patients with Medicaid.  With the rapid increase of Medicaid insured patients due to the implementation of the ACA, the administration utilized the increased payments as an incentive to attract more physicians to participate in Medicaid programs.  According to the New York Times, the ACA has resulted in the largest increase in Medicaid covered patients in history–now nearly 20% of all Americans are covered under this plan.  Attracting physicians to cover Medicare patients has been critical in order to meet the demand for access to care and  to adequately cover the newly insured.  Now, unless changes are made this week, Medicaid reimbursements will be cut once again leaving many physicians to wonder if they can continue to treat the increasing numbers of Americans covered thru these programs.

Traditionally, Medicaid has reimbursed physicians at rates significantly lower than Medicare–making practices with large numbers of Medicaid patients financially non viable.  As the ACA was rolled out, a provision provided for significantly better Medicaid payment rates to physicians in order to help provide larger networks of care for the newly insured.  Now, there looms an automatic payment rate cut of nearly 43% for Medicaid payments to primary care physicians–many of these are the same physicians who agreed to expand Medicaid within their practices in order to meet demand.  According to Forbes, traditional Medicaid reimbursement averages just 61% of Medicare reimbursement rates (which is often significantly lower than private insurance rates).  In addition, many Medicaid patients require a disproportionate amount of time and resources from the office–doctors are caught between a “rock and a hard place”–between a moral obligation to treat these patients and a desire to avoid financial ruin.  These patients tend to be sicker, have multiple medical problems and have suffered from a long time lack of preventive care.

Finances are not the only piece of the Medicaid puzzle. Government regulation and paperwork and processing often delays payments to physicians and impacts their ability to run a financially sound business.   Interestingly, a study from 2013 published in Health Affairs suggested that while physicians welcomed an increase in reimbursement rates as incentive to treat Medicaid patients that quicker payment times, reduced paperwork and simplified administrative processes would also need to be a part of any type of reform.  (of course, none of these items were included in the incentive package).

Many primary care physicians stepped up to answer the call for increasing coverage of Medicare patients when the ACA was initially rolled out.  Now, these same physicians are contemplating the need to drop these patients from their clinics with the pending change in reimbursement.  As mentioned above, in addition to lower reimbursement rates, the Medicaid program requires an enormous amount of administrative work in order to file claims and these claims are often paid very late–those running a small practice are forced with more work for less pay and often have to make difficult budgetary decisions in order to  payroll for their staff each week.   While the administration touts the swelling numbers of Medicaid covered patients–nearly 68 million currently–I suspect access to quality care will soon become an issue.  Just as with every other manipulation of the ACA over the last two years, legacy and political agendas have taken precedent over what really should matter–providing quality medical care AND prompt, easy access to care for the formerly uninsured.  In an effort to tout swelling numbers of “covered” Americans, the Obama administration has failed to anticipate the impact of short term financial incentives for primary care physicians to accept increasing numbers of Medicare patients.  Even in states such as California, officials are bracing for a large number of physicians who have announced that they will likely drop out of Medicaid plans if the planned cuts are implemented as scheduled.

It is time for the Obama administration to stop playing political games with our healthcare.  If the mission of the ACA is to provide affordable quality healthcare for all Americans, then we need to ensure that there are quality, dedicated physicians available to provide that care.  The Medicaid “bait and switch” is just one example of our President’s shortsightedness and lack of connection to those dedicated physicians who work tirelessly to ensure that ALL patients have access to care (regardless of insurance type).  It is my hope that the new Congress will engage with the physician community and find real solutions to the US healthcare crisis–and no longer allow the President to place his perceived legacy over the healthcare of those Americans who are in need.

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Image adapted from The Peanuts comic strip by Charles Shultz

The Land of Oz: Engaging Viewers or Selling Snake Oil?

Dr Mehmet Oz, also known by many as America’s Doctor, is a very influential face within American medicine.  An accomplished cardiac surgeon and Columbia University faculty member, Dr Oz has impressive academic credentials.  However, in the last year, Dr Oz has received significant criticism for claims he has made about non traditional medical treatments on his nationally syndicated television show where he has called many of them “revolutionary” or “miracle cures”–many of his statements are without scientific merit and have no basis in traditional evidence based medicine.  Much of this culminated with his voluntary testimony in front of the US Congress this past summer.  During the hearing, Dr Oz was blasted for making sensationalized, misleading statements.  While I believe Dr Oz genuinely cares about helping others improve their health, I do think that he used poor judgement when speaking about these non traditional treatments.

This week, a study in the British Medical Journal (BMJ) examined the claims that have been made by Dr Oz and The Doctors syndicated television shows.  In the study, investigators randomly chose 40 episodes of each program and then attempted to find medical evidence for claims made about 80 separate treatments.  What they found was astonishing–only 50% of the therapies had either a study or case report to support the claims that were made by the television doctors.  More concerning was the fact that of the 80 recommendations from the Dr Oz Show, the data supported the claims only 46%.  In fact, nearly 15% of the time the best available evidence actually contradicted the claims that were made by Dr Oz on his show.  The Doctors television program did slightly better with evidence supporting their recommendations 64% of the time.   The investigators concluded that most recommendations from medical talk shows lacked adequate evidence to support their use and that television doctors do not provide adequate information on each treatment and do not disclose any potential conflict of interest.

This particular study has significant implications for both patients and physicians.  As physicians we are constantly confronted by patients who come into to the office to discuss treatments that they may have heard about on television.  We must not only be aware of these therapies but we also have to better educate patients and help them decide if any of the “Dr Oz treatments” are right for them and their disease process. Patients are bombarded with medical recommendations from television which are commonly sensationalized and oversold by television doctors and other well known personalities.  We must caution patients that when phrases such as “miracle cure” and “revolutionary treatment” are used on television when a particular disease or medical problem is discussed that the advice given is more than likely too good to be true.

As a physician that regularly appears on television to provide insight and commentary for medical stories and new medical developments, I am always careful to provide information that is based in fact.  Media personalities have a responsibility to report the truth–when giving opinion, we must be clear that we are in fact, making a statement of opinion that is based on fact and the best available medical evidence.  As physician journalist, I have an even greater responsibility to choose my words carefully–it is part of the American culture that TV appearances give on camera experts increased credibility and believability. While I believe that Dr Oz as well as the physicians who appear on The Doctors syndicated shows have the best of intentions, I do think that their zeal for ratings and viewers may lead to making less than accurate claims.  These shows have great potential–they bring medical issues to the forefront and actually help to engage patients in their own medical care.  We know that patient engagement is critical to improving outcomes–and these types of shows can play an important role.  Rather than reporting on non traditional therapies that have not been studied by randomized controlled clinical trials, television doctors such as Mehmet Oz could make a much larger impact by focusing on ways to prevent disease and reduce obesity among his viewers.  For now, viewers must continue to question medical claims made by Dr Oz and other television doctors.  And physicians who play prominent roles in the media must choose their words carefully and ensure that accurate, data driven information is provided to viewers–leave the snake oil at home.

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Controlling the Costs of Innovation: Let’s Refocus and Remember The Patient

In a controversial study released this week, Tufts University’s Center for the Study of Drug Development estimates that the cost to bring a new drug to market exceeds nearly 2.6 billion dollars.  The study, which was 40% funded by industry has been criticized for over estimating these costs in favor of industry and misrepresenting some cost estimates.  While we will not know fully the extent of the methodology of the study until later in 2015 when it is published in a peer reviewed journal, these preliminary findings were released in advance and have already begun to spur debate.

However, irrespective of these criticisms, I believe that the study does have merit and brings an important issue forward—is the FDA stifling innovation with excessive fees and paperwork?  Are smaller, less well funded researchers/corporations unable to significantly contribute without partnering with big pharma? Who will ultimately bear the increased cost of drug development?

Innovation is what has always made healthcare in the US great–it is what separates us from the rest of the world.  For decades, the US has been able to attract talent from throughout the world and this has resulted in numerous “game changing” breakthroughs in medicine.  Through continued development of new drugs, new technologies and new ways to better treat disease, we are able to improve outcomes and reduce death from preventable disease.  The US has always been a place where others from around the world have come to incubate and grow ideas.  Now, it appears that innovation must come at a substantial cost–the increasing capital required for drug development as well as taxes on medical device companies only serve to squeeze out the “small guys with big ideas” and limit our ability to continue to produce new, more effective therapies and cures.  In addition, these additional costs to the pharmaceutical industry are not simply added to their bottom line–they are pushed on to the healthcare consumer as well as Federally funded healthcare plans.  Ultimately, the taxpayer bears the brunt of the increased cost.

The process of drug development is long and arduous.  Government regulation, politics and greed have served to make it even more difficult.  Physicians in academic medicine, scientists, pharmacologists and leaders in industry have learned to partner and share ideas in order to bring basic science principles from the bench to the bedside—ultimately translating ideas into cures.  Certainly, big pharma is in place to make profits and increase market share.  But as costs increase, many drug makers are putting less and less profit back into research and development.  Growth can become stagnant and new ideas may never reach the bench or bedside.  Federally funded research–such as NIH grants–face big cuts and budgets are often embroiled in political battles.  Legislators use research dollars as bargaining chips and fund projects that appeal only to a particular interest group or a group of favored donors.  We must find a better way to promote medical innovation and reward research.  We must find better ways to choose the most promising projects for funding.  We must be good stewards of the R & D dollar and make every single investment count.

As with most things in medicine, we must always pause and remember to focus on the patient.  Advocating for the patient suffering with disease is the reason most of us became involved in medicine in the first place.  Whether the study from Tufts over-estimates the cost of development or not, it should still serve as a wake up call to us all.  We must work to control the cost of developing new therapies—we must limit excessive taxation, we must promote entrepreneurship and begin to fix the current system of FDA approval for new therapies.  We must separate politics from medicine and streamline processes—eliminate paperwork and promote efficiency–if we are to continue to lead the world in medical innovation.  We must continue to make room for the “small guy with the big ideas”–If we do not–ultimately it will be our patients that suffer in the end.

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An Apple A Day—Changing Medicine Through Technology and Engagement

The practice of medicine and healthcare in general has become an electronic and increasingly mobile interaction. Patients are better informed, more engaged, more connected and have a much greater virtual presence. In fact, according to Pew Research data, the fastest growing demographic on Twitter are those who are in the 45-65 age bracket.   Nearly 50% of all seniors engage online on a daily basis through at least one social media platform and many of these interactions and online engagements occur via mobile devices. Almost 75% of all adults go online within hours of attending a visit with their physician in order to gather more information about their particular medical problem. For healthcare providers—and for patients—the internet and mobile technology presents us all with wonderful opportunities to interact, engage, support and ultimately improve outcomes.

New connected devices and medical applications for mobile devices are on growing exponentially.   The world responded favorably to the latest release of the iPhone 6 and the iOS8 operating system recently released by Apple. The new device has many interesting features but one in particular caught my eye early on. Apple has created a standard package for all iOS 8 devices that is called the Health Kit. This particular application allows a user to track calories, steps taken (similar to a pedometer), flights of stairs climbed and other customizable health related data points. These data can be organized into graphs and charts that allow users to track progress and adjust activity levels to achieve particular goals. More impressively, the device will allow other health related applications to organize data in the Health Kit as well. One of the biggest problems with medial applications in the past is that there has never been an easy place to organize, store, collect and view all of the data together. Moreover, this data is not easily shared with healthcare providers. The Health Kit and Apple may revolutionize this entire process of data collection, retrieval and sharing—Apple has partnered with a major electronic medical record service known as EPIC. Work is underway to allow the Health Kit data and applications to easily interact with the EPIC medical record. This would allow for easy downloads of health data during a face-to-face encounter with healthcare providers. Currently, most major hospitals and healthcare systems are moving to the EPIC platform. The data collected and downloaded at one location would subsequently be available to all providers in the system—portability of data allows for better care and less duplication of effort.

Much has been written about patient engagement and improved outcomes in the medical literature. I can think of no better way to improve engagement than through the use of real time health applications –these allow patients to receive real time feedback—both good and bad—and respond quickly in order to improve their overall health status. I think that this type of technology will only continue to grow. Apple plans to release the Apple Watch in early 2015. I expect that this will also be integrated with Health Kit and allow for the measurement of respiratory rate, heart rate, body temperature and other biologic measurements. As these tools continue to develop and applications grow, healthcare providers as well as patients must be receptive to their use. These technologies have the potential to allow clinicians to better assess patients between office visits and provide more directed and timely changes in therapy. Ultimately I believe these technologies will transform healthcare. As we continue to struggle with healthcare cost containment in the era of healthcare reform, the ability to shift care and routine interaction to mobile platforms may very well prove to be a critical piece of the puzzle.

This is an exciting time in medicine as well as in healthcare technology. Moving forward, I look to a day where biologic sensors collect data, relay data to mobile devices and then transmit information seamlessly to healthcare systems. The healthcare providers are alerted to any abnormalities and electronic responses are generated—those patients requiring timely in person visits can be identified and scheduled, while those that can be handled virtually can be managed quickly and effectively as well. Ultimately, our goal is to better manage disease and improve outcomes. I think that technologies such as the Health Kit and the Apple Watch are giant leaps forward and are just the beginning of a new age of virtual healthcare.

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