Tag Archives: ePatient

Obamacare Delays and Rearranging Deck Chairs on the Titanic: Old People Can’t Surf

This week the White House announced yet another Obamacare delay–actually, to be precise, they termed it an “accommodation”.  The reason given for the delay was that there were concerns voiced by the Obama administration that the “rush” to sign up during the final days may cause delays and result in a website crash.  Therefore, it was proclaimed that those who were “trying to sign up” would be given an extension to mid April to complete the process.  Overall there have been more than 20 unilateral changes/delays/exceptions made by the President without Congressional approval or oversight.  Exceptions have been provided for businesses and those who serve and work in our Congress BUT the individual mandate remains in place.   In the meantime, many that have been counted as “signing up” have no insurance and a large number have not yet paid their premiums.  However, the biggest problem with the manipulation of the Affordable Care Act (ACA) may actually be the commentary of one of its greatest supporters–Senator Harry Reid.

With the 2014 Midterm elections looming, many of those in Congress who are facing reelection have commented on the latest delays in an effort to positively spin the news.  As you might expect, those in leadership roles such as Senator Harry Reid have tried to minimize the impact of repeated Obamacare failures and fixes on his part (a desperate attempt to cling to a majority). In an effort to explain the need for the latest delay Senator Reid has shown his complete lack of connection with the nation.  He publicly proclaimed and was quoted in the Washington Times as saying that “some [old people] may not be educated about [or understand] the internet”.  In reality, more seniors than ever before are utilizing the internet in order to maintain medical information.  Pew Research Center data indicates that as of 2013, nearly 60% of all Americans in the 50-65 year old age group are actively engaged in internet based social media.  Even more telling is the fact that 50% of those over the age of 65 are involved in AT LEAST one internet based social media outlet.  It is clear that the internet and medicine will be intimately connected in the future.  Twitter, a popular site for micro-blogging in 140 characters or less has seen a 79% increase in utilization by users in the 50-65 year old age group.  When you carefully examine the Senator’s comments he is clearly referring to those in the 50-65 year old range–those over 65 will be enrolled in Medicare and have no need to go to the exchanges.  The younger populations-such as the millennials–are assumed to be web savvy from birth.

The delivery of healthcare is already evolving digitally–particularly in the areas of the electronic patient and in mobile health applications.  For Senator Reid to make such a statement concerning the inability of older Americans to “understand” the internet not only is insulting but  shows a complete lack of connection to and respect for the very people he claims to want to protect.  Seniors are more web savvy now and are able to access the web in a variety of ways–there is data from non biased scientific surveys (such as those conducted last year by Pew) to substantiate my statement.  In reality, his comments are a sad attempt to explain the inexplicable–why do the Democrats in Congress continue to hang on to a system that is clearly failing?

The ACA continues to suffer setbacks–most of them at the hands of the President who has dedicated his legacy to its success.  The latest delay (or accommodation, as the Obama Administration prefers to call it) is more about the lack of enrollees and less about the ability of older Americans to successfully interact with the internet.  Many seniors are surfing on a daily basis.  The internet is not the problem with the ACA and healthcare reform–rather it is the legislation that is broken and badly in need of a fix.

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Home monitoring to improve health outcomes: Holy grail or Rabbit Hole?

Technology in medicine advances at a rapid pace.  In the US today most patients have access to mobile phones, smartphones and tablets.  Medical device makers continue to innovate and create ways in which these technologies can be used by patients and physicians to monitor complex biologic machinery such as implantable cardiac defibrillators (ICDs) and Pacemakers at home–without the need for routine office visits.  These technologies create large masses of DATA.  These home-generated data can be instrumental in managing chronic disease  but can also create logistical as well as legal issues for physicians and their staff.

For the longest time, physicians have relied on patients to bring in a log of their blood pressures or blood sugars from home (often scribbled on a notepad, and often not accurately recorded) in order to determine when medication adjustments are needed.  In patients with congestive heart failure, physicians rely on a log of daily weights in order to make changes in the patients daily diuretic regimen in an effort to prevent hospital admissions for decompensation.  Now, device makers have created insulin pumps and glucometers that can be downloaded to a laptop and the information emailed to the physician for analysis.  ICD makers such as Biotronik actually have created cell phones that interact with the implanted device and transmits regular data to the physician 24 hours a day.

The big question is:  Does home monitoring really make a difference in outcomes and does it impact cost of care?

This week in the Annals of Internal Medicine, an important meta analysis was published evaluating the effectiveness of home monitoring technology on outcomes in patients with high blood pressure.  In the study, 52 different comparative trials were analysed.  Each of these trials evaluated the effectiveness of home monitoring of blood pressure and compared outcomes to patients who received home monitoring plus additional online or in-person support.  The study showed that all patients who had remote home monitoring of blood pressure had lower readings at 6 months but only those with home monitoring plus additional infrastructure and support from their physician’s office had more long term benefits.  Moreover, those patients with the added support experienced a more substantial reduction in blood pressure when compared to standard care or to remote monitoring without additional support.

As reported in the Wall Street Journal this week, the economic impact of home monitoring and data management on physicians and physician practices may be significantly negative.  Currently, physicians are not reimbursed for much of the home monitoring data management (with the exception of ICDs and Pacemakers which are reimbursed by medicare).  Many practices are hiring complete departments of highly skilled nurses and staff to deal with the enormous amount of incoming patient data from remote sources.  The additional staffing required to process and react to home monitoring data creates additional overhead–all in a practice setting where reimbursement continues to decline.  At some point, something has to give.

Don’t get me wrong, I am a huge proponent of the ePatient and of mHealth.  Using technology to help patients manage chronic  illnesses at home is the way medicine will be practiced in the future–and this practice will ultimately improve outcomes.  However, as technology advances, we must also find a way to advance the way in which physicians and their staff are able to process and utilize data in a cost effective and meaningful way for the patient.  If the government intends to successfully overhaul healthcare and institute a fully electronic universal electronic medical record, then some consideration must be given to practice workflow, data management and the costs associated with the challenges that these new frontiers will present.

The Annals of Internal Medicine study is clear–home monitoring and data collection helps patients manage their chronic disease–BUT, the largest benefit is seen when home monitoring is combined with additional support from the patient’s healthcare team.

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The Blogging Patient and Cyberspace: Unlimited Possibilities for Improving Health and Battling Disease

Social media has opened a whole new world for patients.  Now, information about disease is readily accessible and available to everyone.  Certainly, there are issues with reliability and accuracy of internet sources and this can create uneasiness and misunderstanding for both physician and patient.  However, the internet can also provide many new therapeutic possibilities.  In particular, online support groups, twitter chats and blogging can provide a positive outlet for patients suffering with disease.  Today, I want to focus on one of these internet opportunities–the patient blog.  Recently, a online article on iHealth Beat explored this concept  of patient blogging and its benefits.

Just as commonly experienced in the climax and resolution phase of Greek tragedy, writing a blog about one’s experience as a patient can be cathartic.  Patients with chronic illnesses or with a new diagnosis are often confused, frightened and angry.  Numerous studies in the psychiatry literature have demonstrated that journaling or writing about one’s feelings and experiences can have a very positive effect on emotional health.  Journaling has been shown to have several other unexpected benefits as well.  In the age of the internet and social media, journaling is now called blogging.  Blogging can be a private posting (where only you  or those you approve can see) or can be made public for anyone to see.

Blogging can have many benefits that are very similar to journaling.   From a pure neuro-biological standpoint, while you are occupied with writing, the analytical left brain is engaged in the writing process.  This allows the right brain to be free to feel, emote and create.  In this setting, you are able to better understand yourself and the world around you.  Specifically, there are four distinct benefits that patients can receive from blogging that I believe are worth mentioning:

1. Blogging helps to clarify thoughts and feelings:  Often writing down our feelings provides a way for us to better organize our thoughts.  Blogging can help patients with terminal illnesses better understand their disease and how they are reacting or adjusting to the challenges of the diagnosis and/or therapy.

2. Blogging helps you to get to know yourself better:  Writing routinely will help you better understand what makes you happy and content.  Conversely, writing will also help you better understand what people and situations upset you.  This can be incredibly important when battling chronic disease.  It is important that you are able to spend more time doing the things that make you happy and are able to identify and avoid things that are upsetting.

3. Blogging helps you to reduce stress:  Patients who receive a diagnosis of a major illness or who suffer daily with the challenges of chronic disease often have a great deal of anger and resentment.  It is human nature to ask questions such as “why me?”.  Blogging about angry feelings can be a positive and therapeutic release of emotion.  It allows for the writer to return from the blog more centered and better equipped to deal with negative emotion

4. Blogging helps unlock your creativity:  Often we approach problem solving from a purely left brain analytical perspective.  This is how we are taught throughout our education to attack problems in math and science in school.  However, some problems are only solved through creativity and through the use of a more right brain approach.  Writing allows the right brain to creatively attack problems while the analytical side of the brain is occupied with the mechanics of the writing process.

I believe that blogging can be just as important as medication compliance in patients with chronic disease.  The diagnosis of a chronic disease can produce a great deal of stress and emotional angst.  Patients who are able to deal with negative feelings and emotions in a more positive way are better suited to tackling their health problems.  As mentioned above, blogging has many benefits on our emotional health.  By dealing with negative emotions and unlocking creativity, we are better able to deal with the realities of chronic disease and more effectively interact with friends and loved ones.  I encourage everyone–patient, physician, family member or friend–to begin to blog.  I expect that the health benefits of writing will be well worth the time in front of the computer screen and the insights that you may discover about yourself may be be life changing.


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Policing The Internet: Physician Behavior In Cyberspace

In the last few weeks there have been several articles published examining the behavior of physicians and other healthcare providers on social media outlets.  Certainly, professionals must take care as to what is posted online–as I tell my 11 year old daughter–the internet is forever.  Social media is now commonplace and smartphones and tablet computers make for almost unlimited access.  Because of the ease of use and ubiquitous access to social media, these outlets can be a powerful tool for interacting with patients.  As you might imagine because of visibility, the internet and social media outlets in particular, are another enormous area for potential regulation.  Physicians are held to high standards for behavior both in and outside of the hospital (as they should be) and the cyberspace is no exception.

In spite of the potential pitfalls of social media, I believe that reaching out to patients and colleagues via cyberspace is the future of medicine and will positively impact our ability to provide healthcare in the future.A recent study published in Archives of Internal Medicine in January identified high risk online physician behaviors to be avoided.  As the authors state, there are no formal policies in place  to address physician online behavior in most state medical boards.  However, the intent of the Archives article was to identify behaviors that are likely to be considered violations of online professionalism.  Many of the behaviors identified are just simply common sense–Physicians should not post pictures of drunken debauchery or make inappropriate, sexist or racist comments on social media outlets.  In addition, physicians should never inaccurately present outcomes data, present false credentials, or post pictures without patient permission.  Most certainly, physicians should not engage in non professional relationships with patients in cyberspace.  A recent article on the NPR website published examples of tweets that are likely to get a physician in trouble with professional governing bodies.

Yesterday in the Wall Street Journal, author Anna Mathews explores the controversy associated with physician-patient relationships on Facebook.    In the world of social media, Facebook is the number one viewed website in the world.  It facilitates connections between old friends and fosters new interactions.  However, when physicians become active on Facebook, there is potential for both positive and negative impact.  In a survey in the Journal of General Internal Medicine, researchers found that nearly 85% of all medical students are involved in social media sites–this suggests that the next generation of physicians will become increasingly more active and engaged with each other and with patients via sites like Twitter and Facebook in the future.  Another survey found that while more than 80% of physicians who are active on Twitter and Facebook are likely to engage and interact with one another, less than 8% interact with patients via social media.  However, for those that do use Facebook and Twitter to interact with patients, there are significant legal and ethical questions that arise.  In an extreme example discussed in the WSJ article, one physician actually returns calls when contacted via his Facebook account.  I worry that universal and unrestricted access to healthcare providers may blur the line between one’s personal and professional lives.  In order to provide the highest quality care, physicians and other healthcare providers must also have some downtime–everyone needs to recharge and relax.  Moreover, once a provider sets a precedent for interacting via social media with active patients (and establishes a doctor-patient relationship) a legal obligation to continue to respond in the same manner may be created.  Just how deep does the rabbit hole go?

I am an active social media user.  I enjoy engaging other physicians and patients in cyberspace.  I believe that social media is a powerful tool that medicine and physicians must embrace.  However, I am careful in how I interact with patients and colleagues in the social media world.

Here are my thoughts:

Things to AVOID in Medical Social Media

1. Never share privileged information
2. Never identify patients or provide information that could be used to identify patients
3. Never, ever give specific medical advice to a patient (never ever engage in patient care and create a doctor-patient relationship)
4. Never misrepresent my credentials or my training and expertise
5. Never provide inaccurate outcomes data
6. Never post pictures or make statements that reflect poorly on my professional reputation

Things to DO EVERY DAY in Medical Social Media

1. Engage your audience with interesting posts–provide commentary on timely medical information as it is released in the press
2. Promote yourself and your abilities–let potential patients and other providers know what you do and how to reach you
3. Become a Key Opinion Leader–engage colleagues in discussions about current therapies, emerging technologies, etc4. Educate–Twitter, Facebook and Blogging are great ways to teach patients about health related topics of interest WITHOUT developing a doctor-patient relationship and giving patient specific device.  Patients frequently turn to the internet for medical information.

Social Media is the final frontier for the doctor-patient relationship.  As physicians and healthcare providers we are held to high behavioral standards.  In addition, legal considerations abound in medicine today and will continue to be an issue until our country addresses tort reform.  As a profession, we must develop standards for online behavior based on good judgement and common sense.  In addition, we must learn to embrace the power of social media and maximize its potential positive impacts on our patients and our profession.

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Tracking Health Indicators: The Role of mHealth Technologies in Improving Outcomes

Smartphones, tablets such as the iPad and other mobile technologies are becoming commonplace in the US today.  These devices are nimble, efficient and able to process large amounts of data while conveniently sized.  In a recent survey in 2012, it was found that nearly 95% of all Americans have mobile phones and 60% have smartphone devices.  The numbers are a bit higher in the younger age groups but the devices are prevalent even in the over 65 set.  Tablet computer sales are expected to overtake laptops in 2013–one estimate predicts that 240 million tablets and 204 million laptops will be purchased this year.  With technology at everyone’s fingertips, it is not surprising that more and more patients are using technology to track their medical conditions.

The New York Times recently reported on a survey published by the Pew Research Center on American’s health tracking behaviors.  Fortunately, as a society, it appears that we are becoming much more health conscious.  In the survey, Pew researchers found that 70% of all adults track some health indicator for themselves or a loved one.  However, much of the tracking is classified as informal and 49% say that they track “in [their] head”.  Of those who track health indicators, 35% use a paper journal and now 21% use technology such as a smartphone or tablet application.  As mentioned in the Pew report, this is the first survey conducted to examine health tracking behaviors in the US–Importantly, the survey found that 46% of those with tracking behaviors changed their approach to healthcare and have become much more engaged.  Specifically, the engagement prompted them to ask more questions of their physician and to often seek more that one opinion.

Mobile technology is a powerful tool.  Last year alone over 500 companies made healthcare related applications and there are now almost 15,000 applications for health indicator tracking on the market.  By tracking health indicators such as blood pressure, heart rate, daily weights and blood sugars (among others) patients can see the impact of interventions such as diet, exercise and drug therapy.  Seeing results in real time can be very motivating.  The ill effects of chronic diseases such as hypertension and obesity are not always readily apparent to patients until end organ damage occurs.  With tracking applications, the patient is able to see the day to day variation and is engaged in the control of his or her health indicators.  As I have mentioned in a previous blog, I believe that the time is near when physicians will begin prescribing mobile health tracking applications for their patients during routine office visits.  Healthcare in the US has to change in order to be successful.  No longer can patients passively sit back and accept the fact that physicians will be able to take care of all of their healthcare needs.  Now, more than ever, patient engagement and participation is key to success.  Under the new healthcare system, physicians will face increased pressure to see more patients in less time.  Documentation challenges with electronic medical records (EMR) and other paperwork will further diminish the time spent with patients.  Patient participation in health maintenance through health indicator tracking via mobile applications will prove to be a critically important part of our healthcare system.  I foresee a doctor’s visit where a patient can download their smartphone data directly into their EMR file in their physicians office.  This ability to sync data will not only save time but will improve accuracy of the record.  Ultimately, I expect that mobile applications will be able to transmit data messages to physician offices when certain health indicators have risen to dangerous levels.

Technology to improve the health of Americans is here.  How and when we incorporate these technologies into the healthcare system is still developing.  As with most things in medicine in the US, the FDA will most likely begin to play a larger role in the evaluation of health tracking applications.  Ultimately, I expect the same level of regulation that we see with new prescription drugs or medical devices.  (However, that could be  subject of a blog all its own).  For now, I encourage patients and physicians to consider using medical applications in their practices.   Certainly, tracking indicators can benefit patient outcomes–patient access to data increases awareness, increases engagement and will ultimately save healthcare dollars.

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