Health 2.0 - Medicine 2.0: Videos, Blogs, and Doctors

Medicine 2.0: Videos, Blogs, and Doctors


Brian Klepper, a health care analysis with a new blog, www.brianklepper.net, just sent me a newspaper piece from the Silicon Valley/San Jose Journal, dated Nov. 2. Brian’s blog is worth visiting – it shows energy, insight, and passion. Besides, it contains a dedication to him from me in my book Voices of Health Reform.


But back to the newspaper article. It reports,



• A deal between Medem, Inc, a San Francisco firm headed by Ed Fotsch, MD and backed by multiple medical societies, offering web-based services to 70,000 doctors, and YouTube.



• The fact that doctors use email more than other profession, after engineers, are moving online fast and furiously, using social networking programs, blogs, wikis, podcasts. Videos, an specialized search engines – anything floating out there in cyberspace – to talk to patients and to each other.


• The realization that doctors are lonely. It cites Daniel Pallestrant, MD, Sermo CEO, who says, “What Sermo seems to have tapped into is a longing by physicians to regain peer collaboration..”



As a consequence, a wave of online deals aimed squarely at doctors is sweeping over the Web.



• In May, Sermo signed a deal with the AMA, to foster doctor collaboration, and in October, another deal with Pfizer, allowing the drug firm to listen into anonymous conversations with doctors.



• Fligz, Inc, struck a deal with HealthGrade, permitting its 3 million visitors to tour medical facilities and to view doctors at work.



More and more, doctors are using online videos, “click and view,” to substitute for text and to show visually who they are and what they do.



Dmetri Kruglyyak, of Trusted MD, a medical blogging network, says Medicine 2.0 is all about doctors showing their human side by creating an image of themselves as persons.



Bloggers have become the thought leaders of medicine. Johnson & Johnson, Inc has organized blogger events, and Humana, Inc., has created a website for bloggers (ChangeNow4helath.com). Med Gadget, a blog created by a San Francisco anesthesiologist, Michael Ostorwsky, has attracted drug firms, device makers, and software companies.



Opines Ed. Fotsch, MD, “ There are a lot of market forces behind this. It’s an obvious next step. A third of office visits aren’t about the physical exam. They’re about getting information. A one-on-one visti is really not very efficient. What we’re trying to do is make medicine more consumer friendly.”



Summary



Hold onto your hats, you practitioner doctors,
Web videos are becoming your patients’ proctors.
The new videos are really all about you.
And facts about you patients can view.
Through videos you’re becoming patient advisors.

Effect of complexity - Advice on Dealing with Complexity

“The best advice is to give no advice.”

Piet Hein, Grooks


Experts say the health system and medical practice itself are so complex nobody can understand them (or by implication) do anything about them.


When I hear this line, I think of Edgeware: Insights from Complexity Science for Health Care Leaders, VHA, Inc 1998). The book lays out nine pieces of advice. You may find them useful, even they come from a hospital organization and are being delivered by a blogger who has deputized himself as American physicians’ defender-in-chief.


The Nine Advice Principles on Dealing with Complexity



1) View your system as human interactions rather than as a machine or military organization with rigid rules. Be flexible. Adapt on the edge of human experience. In other words, it’s the patients, not the rules stupid.



2) Build a good-enough vision and provide minimal specifications rather than planning every detail. Don’t sweat the small stuff. When dealing with individual patients, it’s the small human gestures that count, not the overarching strategies.


3) Combine rationality (measurement , standards, and controls) with experiments (trial and error, risk taking and autonomy). Balance data and intuition. Data shouldn’t dictate what you do, nor should it be used to indicate your overall performance.


4) Pay attention to your practice’s edges where most information flows, differences, outside influences, control, and disputes occur. Deal with situations there one at a time. Listen to what your patients did before entering your practice and what they do after.


5) Uncover and work with paradox and tension. Don’t shy away from them as if they were unnatural. People disagree. Deal with it. Act incrementally. Between your patients and you, there are no miracles. There will always be uncertainties and differences of opinion.


6) Go with multiple actions at the fringes. Let your direction arise from what works. Don’t try to be “sure” before you proceed with anything. In an individualistic society like America, there is no single path to Nirvana.



7) Listen to the shadow system. Realize informal relationships, gossip, and hallway conversations echo how people actually think and what they do. Listen to your patients. They are telling you their diagnosis, their concerns, and their bias.


8) Grow by “chunking.” Allow your judgments to emerge out of simple solutions that work and are capable of being done independently. Always remember. Seek simplicity but distrust it in a complicated health system.


9) Mix cooperation with competition. It’s not one or the other. Let people compete with ideas and experiment. Dealing with patients is a dialogue not a dictatorship.



To this, I would add, cultivate “wild ideas” flowing from the frontlines. Don’t snigger. Listen, savor, and cogitate.



Summary


When coping with complexity, go to the edge of your practice. Go to the convexity. .For it’s there real things happen, where reality isn’t misshapen. Being there will help resolve your perplexity.

U.S. health care system - Beyond Those Health Care Numbers

In today’s NYT (Nov. 4), N. Gregory Mankiw, a Harvard economics professor advising the Romney campaign, puts three scare-mongering health statistics in context.


STATEMENT 1 – The U.S. has lower life expectancies and higher infant mortalities than Canada, which has national health insurance. True. Canadian men and women live 2.6 and 2.3 years more respectively. But the cause may be larger social forces beyond the control of the health system. Americans are 50% more likely to die from accidents and homicide. Americans are more obese – our men (31%) and women (33%) have a body mass index of 30 or more compared to 17% of Canadian men and 19% of Canadian women. Our high infant mortality rates are directly related to our rate of teenage motherhood out of wedlock. National health insurance is unlikely to change homicide or accident rates, obesity, or sexual mores.


STATEMENT 2 – Some 47 million Americans have no health insurance. True again. But of the 47 million 10 million aren’t American citizens. The 47 million also includes million who are eligible for Medicaid but don’t apply, and it includes 18 million who make $50,000 or more who choose to spend their money elsewhere. Comments the good professor, “We should be wary of sweeping reforms of our health system if they motivated by the fact that a small percentage of the population is uninsured.”


STATEMENT 3 – Health costs are eating up an every increasing share of Americans’ income. In 1950, the percent was 5%, in 2006, 16%. But the reasons may be symptoms of success – better medical technologies, more economic prosperity, and longer, better, more productive lives... “As we look at reform plans, concludes professor Mankiw, “we should be careful not to be fooled by statistics into thinking that the problems are worse than they really are.”

Clinical Innovation - Low Tech Innovations and Simple Steps

I saw on television the other day how Doctors without Borders had come up with a low tech answer to save Africa’s starving children. The doctors created a peanut butter paste laced with essential vitamin and minerals that doesn’t need to be refrigerated. Mothers from the bush pick up the paste at distribution points, carry it home, and feed it to the children . The results are magical and are turning around rampant malnutrition in Africa.


Genuine innovations are often simple, human, and commonsensical. For example, in her book, Managing Patient Expectations: The Art of Finding and Keeping Loyal Patients, Susan Keane Baker, says one simple office innovation boils down to anticipating “moments of truth” in patient encounters with your office.


These include: calling your practice, making an appointment, receiving directions, meeting the receptionist, waiting in the reception or exam room, meeting the clinicians, giving a history, having an exam or an invasive procedures, giving a lab specimen, receiving discharge instructions, leaving the practice, obtaining lab results, and receiving a bill. Here the innovation is low tech: training yourself and your staff to make each of these moments as pleasant as possible.


Also on the low tech side (innovation is too lofty a term), one can protect patients’ against infection, by simply washing hands, avoiding shaving procedural sites, discarding items in rooms of infected patients, changing catheters often, elevating the head of the bed and cleaning the mouths of respirator patients, listening to distress calls from nurses and relatives, and rechecking orders when patients are transferred from one hospital site to another.


A Low Tech Tribute


Effective innovations aren’t always rocket science,
You don’t automatically need a high tech appliance.
You don’t have to google.
Just rev-up the old noodle.
And rely on old fashioned self-reliance.

Costs - The Health Care Cost Challenge

I have coffee each morning with a group of eight men of Medicare age. Each considers himself “healthy,” yet,

• one has had both knees replaced,
• another is scheduled soon for surgery for a bulging abdominal aneurysm,
• another has had open heart surgery ,
• another has had a stent placed to bypass an iliac aneurysm,
• another has had rotator cuff surgery,
• another has a vertebral column festooned with metallic devices,
• two have had surgery for intractable disc-induced sacroiliac pain,
• three have had cataracts extracted,
• four have had skin cancers excised,
• most of them are on statins or antihypertensive agents,
• all have had a CT or MRI scan during their medical episodes.

To the man, all thought doctors did the right thing for the right reasons at the right time. And I have not told their wives’ tales. All, and here is the kicker, are functioning, active members of the community.

You do the math. Now tell me – in human and politically feasible terms – how do you put the health care genie back in the bottle and close the lid?

When I think of my coffee mates, I’m bemused and sympathetic when federal officials talk of heading off the impending health care cost apocalypse. They would impress me more if they offered concrete solutions – such as overt rationing or high deductibles --to decrease demand by dampening routine expectations of my coffee friends.

The talk of those who would tamp down exploding costs generally seems to be: we could only rein in those greedy doctors with their expensive technologies; all would be well, to wit:

“The bulk of the spending growth appears not to result from increasing disease prevalence but from the development and diffusion of new medical technologies and therapies ( Orszag, Peter, and Ellis, Philip, “The Challenge of Rising Health Costs – A View from the Congressional Budget Office, November 1, 2007, NEJM). With full knowledge of my limited sample size, I challenge the notion about disease prevalence, especially in an aging population.

My small group would disagree with the cost critics’ secondary argument: those U.S. citizens don’t show any health or quality gains from these technologies,

“There might be less concern about increasing costs if they yielded commensurate gains in health. Instead substantial evidence exists that more expensive care doesn’t always mean higher quality care.” (Nov.1, NEJM).

What do federal budget officials mean by “quality” – adherence to guidelines, meeting quality standards, or disease outcomes? Or are they referring to longevity, which is beyond the reach or control of most doctors most of the time, since longevity

Depends mostly on social and cultural factors outside physician offices
Or hospital wards --genetics, personal behavior, and social factors, such as violence or other forms of mayhem.

The underlying implication is that American doctors are foisting technologies on Americans who don’t need high tech care. Mention is rarely made that the current system promotes such care by having third parties pay for it, that Americans expect and even demand such care because it enhances their life style and keeps them functional well into old age, and that many, including doctors, citizens, and lawyers, consider it indefensible to deny such care to Americans who consider it their God-given entitlement right to have access to such care (as long as someone else is paying for it).

Furthermore, no American politician has the guts to say that either overt or covert rationing will be necessary to stem this access to high tech care to cut costs. Neither will they say that if citizens have to pay more out of pocket, demand will decrease.

Besides, who is to say what percent of GNP, now 16%, should be devoted to health care in an aging population who wants to remain as young and healthy and fuctioning as as long as they can.

Interview, Sermo - A Conversation With the Founder of Sermo

Prelude: This conversation with Daniel Pallestant, MD, founder and CEO of Sermo.com, appeared on HealthLeaders News on Oct.31. 2007. The conversation runs 1500 words, a length for which I apologize. But as a wise editor once explained, “Some articles are too long at 200 words, some are too short at 2000 words. I trust this is just about right. I recently had a far-reaching conversation with Dr. Daniel Palestrant, who founded Sermo.com and launched it in September 2006. I use the word “conversation” in the title because Palestrant, trained as a general surgeon, and now full-time as Sermo.com’s CEO, believes passionately in the value of conversation between doctors.

Sermo, he indicated to me, is Latin for “conversation” He espouses easy-to-access Internet-based conversation as a powerful means for transforming and empowering doctors, understanding the health system, and making doctors principle agents for promoting socially responsible health care that works to everyone’s best interest.


Palestrant, who has a BS in the history of science from Johns Hopkins and an MD from Duke, was in his third year as a surgical resident at Beth Israel Deaconess when an L4-L5 herniated disc laid him low. While recuperating he wrote the business plan for Sermo.com, an idea that had been gestating in mind for several years.

Palestrant oversees Sermo’s vision. He concentrates on ensuring Sermo as a valuable resource to physicians. Daniel’s first experiences with health care information technologies came when he conceived, designed, proposed and managed deployment of CIBUR (CIGNA Internet Based Universal Resource), one of the first commercial Web-based health care resources for physicians and allied health professionals.

He founded his first company, Azygos, Inc., in 1998. He successfully raised $2.2 million for Azygos. He sold the company to BioNetrix in May of 2001. After selling Azygos, he joined BioNetrix (Now BNX Systems) as director of health care. At BNX Systems, he helped health care-focused businesses increase network security, improve patient privacy safeguards, and comply with HIPAA.

By nature an entrepreneur, Palestrant thought a place existed for an Internet-based free-wheeling conversational forum for licensed practitioners to talk to each other without interference by outside parties, and to feel free, frank, and uninhibited about their opinions. Access to the site is limited to physicians licensed in the U.S., a model he plans to retain.

Before writing his business plan, he had observed doctors had become “too busy.” They were so preoccupied by dealing with managed care hassles, pressures to install electronic record systems, coping with ever-lowering reimbursements, making a living, and meeting the bottom line. Many, he felt, no longer had time to talk to one another in staff rooms, hospital corridors, and other settings where physicians consult meet, kibitz, and exchange views.

Yet he knew full well physicians are the driving force in the health system, initiating in one way or another 80 percent of health costs. He knew business leaders, health care executives, marketing experts, and venture capitalists, aware that health care was consuming 1/6 of the gross national product, were vitally interested, indeed obsessed, with what doctors thought about the system and their responses to innovative products that we’re being introduced into the market.

Palestrant, in short, intuitively sensed business executives and venture capitalists were vitally interested in what doctors thought. Financial institutions, health care organizations, and government were hungry for information on physician trends and opinions.

While on his back, incapacitated by his herniated disc, Palestrant wrote his business plan, approached venture capitalists, learned from his past experiences in founding another Internet-based company, Azygos.com, in 1998 which he sold, and began to assemble a management team. In retrospect, he regards his herniated disc as an act of serendipity, for it gave him the opportunity to think through and formulate his business plan.

The rest is history. Sermo.com has garnered a total of $39 million in venture capital funds, attracted 35,000 practicing physicians into contributing, commenting, and seeking information from its site; succeeded in growing its readership by 1000 doctors a week; struck an alliance with the American Medical Association in May 2007, and caught the attention of the media world.

His site has been called MyFace.com for doctors, and has been cited by the Wall Street Journal as the leading example of “social networking sites” among professionals ( Jessica Vascular, “Social Networking
Goes Professional: Doctors, Salesmen, Executives Turn to New Sites to Consult, Commiserate With Peers; Weeding Out Impostors”). Sermo.com is now featured in Wikipedia, a dubious honor, and has withstood a security probe from critics, who claimed the site was an invitation for hackers to steal doctor identities

None of these happenings seem to faze Dr. Palestrant. He is following his passions – empowering doctors through frank exchanges between peers, identifying physician problems, seeking solutions, and learning what works.

Among his observations, gathered from his web site and his own insights, are these.

• The deck is stacked against doctors – by government, health plans, policy makers, lawyers, general hospitals, the U.S Congress, and elites- through rules and regulations, restrictions against independent pricing, collaboration with each other, and innovations to improve the system. As I was speaking to him, he had started to read Regina Herzlinger’s book Who Killed Health Care? America’s $2 Trillion Medical Problem – and the Consumer-Driven Cure (McGraw Hill, 2007), which outlines the forces “killing” doctors and the health system and restricting innovation.

• A genuine and deep physician “supply and demand” dysequalibrium exists for American physicians. Because of low reimbursement, loss of autonomy, bureaucratic red tape, patient overload and loss of respect, American medicine is no longer attracting the best and the brightest of young Americans. Palestrant fears U.S. health care may sink into mediocrity.

• We live in a world that rewards “perfect information, ” i.e., the better and more sophisticated your information the greater your market dominance. What particularly disturbs Palestrant is health plans’ storehouses of claims information. Through predictive modeling and data mining models techniques , the plans have knowledge of transactions across the entire system – information individual physicians do not possess. Plans can use this information to control physicians and, in essence, to tell doctors how to practice the health plans brand of medicine. He believes one solution for improving the system may be removing the middlemen.

• Ultimately he sees cost shifts to consumers, making them conscious of what they’re paying for, market transparency of prices, and personal responsibility as the outcome of current trends. He says the recent GM-UAW pact, which set up an independent trust run by the union, and giving members a lump sum of money to spend rather open ended benefits as evidence of this trend. He believes the pact will have a catalytic effect inducing other industries to follow suit to be globally competitive.

• He doesn’t think the way doctors are paid will remain static, under the strict control of third parties. Given the diminishing supply of doctors and the accelerating demand of their services, he foresees many practitioners charging extra fees to patients who want to be seen. This is already happening on a significant scale in New York City. And he believes other business models – concierge and retainer or cash only practices – will proliferate.

• Despite the success of Sermo.com in facilitating conversations among doctors (“Physicians spent 3000 hours on Sermo yesterday”). Palestrant is not an unabashed enthusiast of information technologies and their application to medical practice. He believes pen and paper will retain their power because they are a more human means of expression. He isn’t surprised electronic medical records have failed to catch on a big way. “Once you put a computer in a room with a doctor and a patient, something is lost. It just isn’t the same as a doctor with pen and paper, with the doctors setting down thoughts with pen on paper in a patient’s presence.” He feels the same about the limited success of e-prescribing.

• The information generated and contained on sermo.com is much sought after, as well as Pelestrant’s opinions, by Wall Street firms, the AMA, and venture capitalists. Through Sermo, for perhaps the first time on a large scale, analysts and health care marketers have solid data, enabling to discern how doctors feel and act, and what they’re likely to invest in. A good example is doctors’ attitudes towards electronic medical records. If you read the Sermo site, you quickly realize economically hard pressed practitioners simply don’t see either the clinical usefulness or the return on investment of these new wondrous information technology systems.


Has anything about Sermo surprised Palestrant? Yes, he says, the biggest surprise has been the age of physicians participating. Three fourths of physicians joining the site are over 45. This flies in the face of the stereotype that young doctors are the first to embrace information technologies. The high participation rate could reflect several things; pent-up frustrations of dealing with a dysfunctional system, desire for informal consultation among others encountering similar problems. He has also been surprised by the length of time and the frequency of physician visits to Sermo. Some physicians visit Sermo.com, four or five times a day.

Finally, Palestrant has been impressed by the spirit of camaraderie among physicians. There’s a brotherhood and sisterhood out there, and doctors are eagerly embracing the opportunity to help each other and to make sense out of a sometime nonsensical system.