Thursday, February 24, 2011

The new pandemic: Will viral social media lead a health care revolution?

As we watch events unfold around the world with social media orchestrated revolution you can see the power that this new media can play in change.

First in Egypt, and now in Libya, millions of people are hearing about democracy and demanding change via smart phones and iPads over the internet.

What started as merely a march toppled a world leader.

So can social media create these same kind of changes in health care?

Today the ability to stay connected almost anywhere in the world has made being "off the grid" almost impossible. Which means that patients and health care providers are almost always able to communicate.

And, effective communication is the key to any health care message.

For years the internet has provided and almost encyclopedic reference for any illness, ailment, treatment, or medication. It is a rare patient that comes into my office that hasn't Googled their problem first.

Our office has free WiFi for patients, so even in the exam room patients can look up our recommendations and interact about conflicting discussions on the internet.

With the advent of online images, patients often compare tumors and rashes with jpegs they find on Flickr. This is their first opinion.

I am their second.

But what we see now going in the world is much deeper. And it offers the opportunity for a revolution in how we interact and disseminate health care information.

And ultimately care for patients.

Though smart phones and iPads, with WiFi and 3G, people can now be connected virtually anywhere in the world. It has made being "off the grid" a dream weekend away for many techno-nerds.

This technology is fascinating in its ability to behave almost like a living creature.

The word "viral" has always been used to describe how messages and content can spread so quickly around the globe. We've all seen those videos that reach a million or so downloads days after they are posted.

Viruses though by nature are not truly "living and breathing." They are merely protein products that rely on transmission from one host to another.

Certainly they can morph and evolve, becoming resistant to treatments and more easily spread, but they never replicate alone and they eventually die with their host.

I would argue that our social media revolution is more than viral. It is becoming living and breathing.

It is becoming alive.

With 500 million or so folks on Facebook, new groups and pages are made every second.

Instantaneous social networks can be created on autism, HIV, depression, and on and on.

Testimonials, treatments, and even tears can be shed together over a continuous interactive stream of discussion.

And it takes on a life of its own.

Never was this more clear than in Egypt. Once the message commenced and the social debate was started, the government shut down the internet, wireless phones, cable television, and even the power to some satellite relay stations.

Yet the revolution continued. It was spread via rumor and from person to person.

Even to people who never participated in Facebook, Twitter, or any internet discussion.

So will we see this in health care communications? I think we will. Is it too far fetched to believe that patients will move beyond just Googling a treatment suggestion in an exam room, to rather posting the idea on Facebook and immediately being able to discuss the concept with friends and family for feedback and suggestions?

Physicians already post diagnostic dilemmas sans personal information on the internet for assistance. So as treatments and plans are discussed will the confluence of information become the new "standard of care" against which we are all measured.

That would mean that the "standard" will be constantly evolving and changing as millions of patients and physicians provide continuous feedback and input.

And will this impact spread beyond the electronic world to effect patients and physicians who have steadfastly refused to participate in social media?

There are certainly dangers involved here. Aside from the privacy concerns, it is clear that without physicians and other health care providers being involved in the process that this standard could evolve into bad medicine and harm for patients.

Imagine if you will that a viral video on antiperspirants causing Alzheimer's creates a national outrage against personal hygiene, Congressional inquiry, and a ban on your favorite roll-on.

Funny? Just Google "phthalates" and "small penis." I think you can see how science and medicine can be influenced by social media. Sometimes with junk science.

So, the take home message here? Social media communication is here, and it will continue to grow and influence how we treat and take care of patients.

It will become alive and self perpetuating regardless if you participate or not.

It's essential that all the parties embrace and participate in the technology. We should welcome patients to examine their care on the internet, and we should encourage physicians to become involved in internet based discussions, groups, blogs, Facebook, and Twitter.

There is an evolution in the doctor-patient relationship and it will revolve around social media interactions.

And it's not a bad thing.

I guess if you are reading this blog you are already participating in social media to some extent. So will these words become viral?

Self interestingly I hope so.

- Posted using BlogPress from my iPad

Location:Dallas, Texas

Tuesday, February 22, 2011

Re-bamacare: Is health care reform now a problem for Republicans?

The public relations nightmare for the Obama administration's health care plan last year now seems to be a problem for the Republicans.

Republican lawmakers have long wanted more intense reforms of insurance laws that purport to stream line the system, lower cost, and cut out redundancy.

Of course the concern for patients is that the only sure fire way to lower health care costs is to restrict access and therefore lower utilization.

Patient advocates have long been skeptical of Republican promoted health care (read: insurance reforms) because below the surface the bills seem to be reminiscent of old war style cronyism: pandering to the insurance companies and corporate medicine.

True or not, that's not the purpose of my discussion today. This is more about the table turning anti-Obamacare public sentiment that is now being carefully redirected toward these Republican proposals.

Particularly in state legislatures where lawmakers are now struggling to balance state budges with escalating deficits, every possible revenue source or cost cutting move is being critically examined.

On the surface many of these ideas seem plausible -- directly employee physicians so that their prescribing and ordering habits can be controlled.

Given that the most expensive piece of medical equipment in America right now is the pen, this would seem to be on target.

Limit tests or procedures, force the use of quality guidelines and metrics, cross share lab to prevent redundancy, and put physicians smack in the middle of a care management team to increase quality and value for patients.

And to make more money for the corporate entities involved.

The problem is not whether something like these rules need to be implemented -- they do -- the problem is that absent proper oversight and restraint the slippery slope of profits and revenue would suggest that patients might get the short end of the stick.

Just imagine if your physician was told to use a certain drug, a certain provider for a procedure or diagnostic test, a particular institution for your surgery -- your choice would be gone as would that of the physician.

Now certainly we are all going to have give up some health care decision freedom as we move to limit the exponential rise in health care expenditures.

But patients and physicians need the opportunity for some autonomy in the doctor-patient relationship.

Whether it is contractural protections against wrongful termination, protections against adverse hospital decisions, prohibitions against forced admissions, or whistleblower protections, physicians need to maintain some degree of separation from the unintended consequences of corporate America.

Patients need this as well.

What's been fascinating to watch is that in multiple states where Republicans are using the budget shortfall as a steam roller to clear a path for any proposal that seems to save money, the health care changes related to employment and insurance reform seem to be hitting a snag.

Dubbed "____-bamacare" depending on the lawmaker in question, use of this phrase immediately conjures up negative sentiment not only among the public but also among fellow Republicans who might not be so forward educated on the benefits at stake.

This is particularly evident in Texas where Lieutenant Governor David Dewhurst is seeing push back on his proposals to expand corporate control of health care.

From visiting with hundreds of patients its clear that monkeying with anything to do with a patient's health care choices, particularly now in this post-Obamacare sensitivity, is a risky move.

It is likely that good proposals will also potentially fall on the sword with our President's plan.

Patients seem to be tired of government intervention in health care. They recognize the need for changes in the cost, but they are still not convinced that government or big business is in the best position to make these decisions.

They are probably right.

- Posted using BlogPress from my iPad

Location:Jacksonville, Florida

Monday, February 21, 2011

Your private health information: Could it end up on YouTube?

Ok, imagine this.

You take a video of your little girl's soccer practice with your iPhone. Within moments it's posted on YouTube for the grandparents to see.

Minutes later search engines called spiders begin to crawl across the data set of images on your upload. Face recognition technology identifies a face on the video and, with some assistance from the geo-tagging of the built in GPS metadata that accompanied the upload, gets a general location of where the video was made.

It determines that your child has other photos posted on Flickr and also a photo in the local newspaper. Now it associates a name with the face. The name might be associated with a Facebook account.

Maybe there's an article that mentions a parent. The data discovery evolution continues continually attributing identifying information. The parent's information is exhaustive, but most importantly it contains an address.

From a face on a cell phone video, a sexual predator might discover the home and contact information for your child.

All searchable by keyword: soccer, girl, Facebook, my home town.


Its easy to see the danger the internet can pose to children. We all know that. From Net Nanny to Web Watcher there are software and web packages that purport to protect our children.

They are good. But not perfect.

Health information interconnectivity is considered the holy grail of disease management.

In fact, most experts, including me, feel that without a robust means of health care providers sharing information we can never achieve the cost and quality metrics required for optimal health care delivery.

Especially as we enter the world of the ACO - accountable care organizations - where multiple providers may very well be paid to manage the health care of an individual patient, it will be essential to share information.

Cost savings will be dependent on reducing duplicated tests, encouraging patients to fill needed prescriptions for their diabetes or hypertension, or reminding and scheduling patients for preventative health measures like mammograms or a colonoscopy.

And patients will like it.

Can you imagine a doctor visit for an elderly patient where medicines are continually updated including whether they were even filled at the pharmacy?

We have that now in our office and many physicians subscribe to pharmacy data information that can help us know what medications patients are using.

In addition many offices and emergency rooms have access to claims data for some insured patients.

What does this tell you? Well, for one thing, it can report what you have filed on your health insurance as a recent claim including diagnosis codes for illnesses, visits to other emergency rooms or health providers, and procedures you may have had.

It certainly isn't perfect - the coding has to be right and it's stale (often not being updated for months) - but it provides a snapshot of the health care services that you received which in a pinch can provide a physician with some idea of your medical background.

Some insurers will also report medical allergies to round out the picture.

But the problem here is that all the information is fragmented. There are multiple sources, many that are not up-to-date or recent, and they are on many different databases.

The word thrown out a lot by governments and policy gurus is "data warehousing." This would be a central repository of all the available information that could be accessed securely and updated.

The benefits could be great: better managed health care for individuals and populations. Maybe less visits to the emergency rooms for diabetics, fewer readmissions to the hospital for patients with congestive heart failure, and less unnecessary tests for patients with chronic diseases.

The concept of disease case management might be able to lower cost and improve quality. A value statement that would be hard for anyone to argue with.

But are our privacy rules robust enough to protect our patients?

That's really the question.

So imagine these scenarios.

A school district during a new hire review of a teacher discover that she's taken antidepressants in the past. Would this be a good employee to hire?

A drug company does a database query for men with erectile dysfunction as a diagnosis code and who have been prescribed Viagra. They are sent emails and junk mail advertising a new little blue pill.

Your company hires a consultant to lower health insurance costs for your employees. They sell a product that searches the web and ranks future applicants on past health care costs and usage and provides a score. With a high score an applicant doesn't get an interview.

You file a disability claim on your short term disability plan. Your insurance company, by finding your face on a YouTube video and attributing a name, sees that you can play on a YMCA flag football team. See the problem here?

You could write hundreds of these scenarios. Does it mean that we have to shut down interconnectivity and data sharing of sensitive health information?

No. We can't afford too.

We must continue to move the ball forward to achieve quality and cost improvement.

We have no other option.

But it does raise the concern that as we get more and more data on the web, and more and more sophisticated in our processing power, there will be big problems with patient's privacy.

The best thing that could happen would be a systematic process -- where everyone works together -- to create a unified secure database with strong patient protection rules, including who can access the data and how it can be used.

For now we are left with a fragmented system where companies and governments are creating their own plan and their own data warehouses. All of these will have their own rules, security, data, and problems.

So am I scared of posting something on Facebook?

Absolutely not.

Do I think someday someone will be posting the status of my high blood pressure?


- Posted using BlogPress from my iPad

Location:Dallas, Texas

Thursday, February 17, 2011

Stark Contrast: How the Democrats are missing again on healthcare

Recently Pete Stark told a group that the Republicans were trying to shove a massive bill to repeal the Obamacare Bill down the throats of the Democrats.

The Republicans two-page bill stands in sharp contrast to the 2000-plus page bill pushed through by the Democrats last spring. So Mr. Stark, what's different now?

I had the pleasure of spending an hour with Congressman Stark last March right before the historic vote that changed the way healthcare is financed and delivered in this country. He was adamant at that time that he would never "support" the Senate version of the healthcare bill.

Well he did.

Now this isn't the first time or probably the last that a member of Congress has changed their mind.

But fundamentally the reason he voted for the bill as did most of the Democrats was political: legislation had to be passed regardless if it was good or not. Nancy Pelosi's health care chief told me in a meeting the same day that "we know its not a good bill but we can always fix it later."

The Republicans have taken the position that repeal is the best choice, followed by not funding key elements of the legislation, and probably hoping that the Supreme Court will rule that the Democrats overstepped their interpretation of the commerce clause. The latter is the ruse that allowed them to pass the bill in the first place.

So now the Democrats believe they have to defend the bill they created. And reforming the legislation would be tantamount to failure.

The American Medical Association adopted a recent slogan from their Texan brethren when they started preaching the "Keep what's good. Fix what's broken" mantra. But this lobby tactic would assume that either side would want to fix anything in the first place.

Neither the Democrats nor the Republicans are really motivated to reform the legislation. These polar opposite positions place American patients right in the middle of a stand off -- most likely to be killed by "friendly" fire.

Democrats are missing the boat here by not learning from prior mistakes and following the advice that we talked with Pete Stark about a year ago. Give patients some protections from preexisting illness and right of recision rules from the insurance companies and allow them to keep their doctor.

That's really what patients and taxpayers want.

And, tank the rest of the 2000 pages of the bill.

The 18 thousand new IRS agents, the Independent Medicare Advisory Panel, the criminalization of billing issues, the mandate on individual coverage, the expansion of a broken Medicaid system -- all of this needs to go away. None of it will improve the health of America.

But sadly it is doubtful that anything good will happen in Congress this term related to healthcare.

Yes, the House can refuse to fund key elements of the legislation...they can vote to repeal the bill. But the Democratically controlled Senate and the sitting President will not allow the bill go away.

In the meantime Washington bureaucrats will be turning out millions of pages of rules and regulations that will immortalize Obamacare for millions of patients.

- Posted using BlogPress from my iPad