When health care research meets Trip Advisor

This is the time of year just after spring break when I enter the stress zone of planning the summer vacation.

I'm always on the quest of making everyone happy.

Finding some place that I can afford, where the kids will have fun and maybe get to experience something new, is always a challenge.

So, I search the internet far and wide for good deals and destinations.  One site that I always check out is Trip Advisor.

This travel website is populated with information on hotels, resorts, air fare, deals, and even food and restaurants.  But the heart of the site is the traveler reviews. These often number in the hundreds depending on the location and are many times candidly verbose.

Visitors can even give a score which is tallied at the top of the review to help you sort through the list.

So what does that have in common with health care research?

Well, frankly, if you relied completely on Trip Advisor you probably would never travel any where.

Let me show you what I mean.

Last year I thought I planned the perfect vacation (turned out, I did according to the family).  We used every (I mean, every) frequent flyer mile I had and the four of us traveled to Kona, Hawaii, one of the most beautiful and mysterious places on earth.

We stayed at the Fairmont Orchid in Kamuela which is on a  grand beach on the west side of the Big Island.  The grounds are impeccable, the staff is always at your beck and call, and virtually every room has a nice view.  I'm a member of the President's Club so the kids were able to get free internet as well as discounts on beach gear.

From the turtles that lounge on the beach to the prettiest sunset in the world, I could live there. 

Now to Trip Advisor:  here are the top reviews currently --

"I have to say that while we love the Fairmont, the level of service has become uneven, if not somewhat mundane."

"The service was average - long waits and average staff at breakfast. Room was nice, but dated. I saw three cockroaches in the hotel. The grounds were lovely but the overall experience was not worth the cost."

"For the price of this hotel, the room was a disappointment. First of all we were on the bottom floor, with people walking by constantly, so there was very little privacy. The bathroom had dust and dirt on the shelves, and the wall was filthy. There were 2 moldy pictures beside the bed..."

The take home message here is that each person has their own experience, and it is impossible to make everyone's stay perfect. 

We live in a society where expectations often exceed reality.  There is just no way to make everyone happy and provide perfection no matter how much you strive for this level. 

That brings me to health care. 

I recently had a lengthy discussion with someone regarding online treatments for a medical condition.  He had done considerable research, wanted to know the ins and outs of every perturbation of treatment, and why some people reported good results and some did not.

He finally wanted my opinion, and wanted me to weigh in on making a further review of these treatments and these patient experiences.

He just couldn't understand why some patients didn't report perfect results with at least one treatment.

I told him that unfortunately it doesn't work that way.  Every patient will have a different experience with virtually every treatment or procedure.

Sure, there is an "expected" outcome.  But we are dealing with a human body that is dissimilar from every other one on earth.  You just can't expect similarity.

But to even be more accurate, we are dealing with humans and their own expectations of what a successful outcome should be.  And that is even more challenging than the biophysics and physiology.  Humans rarely agree on anything.

So the take home message here is that research on medical procedures and treatments can be very valuable, but you should always take into context the individual nature of the reviews.

Otherwise, you would never travel anywhere, and you would never make a health care decision that could improve your life.

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

The Health Care Cold War: Will ACO's Bring Down The Wall?

Although there are no sounds of B-52's flying at low altitudes above the hospital, there are salvos nonetheless between the partners in health care as the positioning of providers in the ACO marketplace starts to crystallize.

ACO's, or accountable care organizations, are the product of one of the Obamacare beta solutions for controlling health care costs and improving outcomes.

My friend Dan Finch at the Texas Medical Association compared them to unicorns: no one's ever seen one but you'll recognize it when you do.

I'm not sure he's completely correct, there are a few of these organizations forming around the country. One in Chicago offers to produce great data on the utility of the delivery mechanism though the jury is still out on whether it will net positive results for patients.

These new entities can be formed really by anyone -- that is, anyone brave enough to pioneer the business model. The risks are great because of the capital requirements to protect the integrity of the captitated payment system which is really the heart of the organization.

Capitation is an ugly word in health care financing probably because of the almost unanimous negative consequences of the insurance models funded in this manner in the 90's.

Everyone then left with a bad taste in their mouth.

Insurance companies couldn't rein in physicians and hospitals to control costs and patients never bought into the model that prevented them from using a infinite amount of resources in their own health care.

So why would it be different now?

The argument is mostly supported not by the change in patient expectations or the robust IT infrastructure that we have in this century, but rather by the necessity to control costs. That argument unfortunately will drive the business principles that formulate these new organizations.

The definition of a "cold war" must include the word "protectionism." Certainly the world saw the escalation in missile batteries and nuclear warheads until Reagan was successful in "tearing down that wall."

But, pardon the reckless use of the 1988-presidential-debate line: Mr. Obama you are no Reagan.

Why am I so pessimistic these ACO's will find a place in this market space?

First is the lack of a unified national standard concerning our information technology infrastructure. There is currently no data sharing among providers outside of their own controlled groups (you can thank another federal stature for the difficulty here: read HIPPA).

And although a standard can be created and implemented, there is still the fact that many of the ground war health care practitioners (the primary care physicians) are still not active users of this technology. Current estimates put this at somewhere around 30% tops.

And with the cost of implementation of an electronic health record setup in a physician's office near $40K it will be some time before we see widespread adoption of EMR's.

Then there is the issue of exactly what we will measure to insure that quality care is being delivered. These so called "measures" of quality are still undergoing national debate and peer review. They're close to getting the numbers right. The question is whether physicians and patients will buy in.

And finally there is the nasty issue of "gain sharing." This is where you reward the parties for achieving the goals of delivering high quality care in an efficient manner.

Paying physicians is particularly difficult because of a myriad of other federal statues relating to anti-trust and kick back regulations.

Some groups, particularly hospitals, believe that the answer to this issue is direct employment of physicians. But this business model is challenging in that not only must a hospital control the diverse interests of a multi-specialty group of physicians, but it also has to morph the health care of individual patients to fit a cost savings model.

Both of these groups are not historically responsive to direction by a third party.

Then you have the difficult problem that hospitals are funded by actually admitting patients and providing care. In the ACO model the profits only come from keeping patient's healthy and OUT OF THE HOSPITAL.

Now sure, business models can change. But hospitals will have to recognize and be able to adapt to this change in a swift and controlled manner to insure that they remain profitable and can continue their mission.

Oh lest I forget one other very important party to the ACO equation: the people who pay for health care services.

Whether these ACO's are created as a hospital-based entity or along the traditional insurance model, at the end of the day both the government and American business expect to pay less for health care services in the future.

So for the ACO model to be successful it actually has to have a declining net revenue line.

It is this money line that has everyone so concerned and lining up to protect their own interests.

Hospitals are arguing for a hospital-centric model so they can control the dollar at the end of the day. Physicians are either jumping on board with the hospital groups or they are lobbying for measures to protect their private practice.

Patient groups are seeing that there could be limitations on both who they can see for care and where they can go. This loss of autonomy in the doctor-patient relationship will be very hard for most patients to swallow.

Insurance companies and business groups don't trust hospitals, physicians, or patients to work to control costs in the health care economy. So they are lobbying for strong protective measures to insure that ACO's don't get out of the normal reserve requirements to sell an insurance product.

ACO's hold the promise of ending the cold war.

If all of the parties could work together on a fair and balanced model that puts the patient first in the decision making process, it could offer an opportunity for success.

But for now all of the parties are building up their arms to protect their own interests, or they are being overwhelmed by a well funded adversary.

Virtually every hospital is "creating an ACO" and physician's practices are being gobbled up health care systems.

I applaud the idea of collaboration and use of IT to improve the health experience for patients. Today, though, I'm not too confident that the current attempt at tearing down the wall will work.


- Posted using BlogPress from my iPad

Location:Quito, Ecuador