Navigating Healthcare – Patient Safety and Personal Healthcare Management

Saving Healthcare Quality

Saving Healthcare Quality

The Incrementalist Graphic Fred Trotter

This week I am talking to Fred Trotter (@fredtrotter), CTO CareSet Systems – the first commercial Medicare Data company. Fred has a long and fascinating background that unlike many healthcare Cybersecurity experts started in the security field and transitioned to healthcare and healthcare data. You can read his musings on Hacking Healthcare here.

We talked about Fred’s coordination of the Save the Agency for Healthcare Research and Quality (AHRQ) data project that took off online using twitter and other social channels as an unofficial mechanism. The AHRQ and the National Guideline Clearinghouse (NGC) was expected to be taken offline earlier this year as part of budget cuts and there was a significant concern that the 1,500+ clinical guideline summaries currently available would disappear forever. Some of us might think its a simple thing to copy content thus preserving the material but as Fred explains it was not that simple


In fact he contributes to the Internet Archive project (aka the Way back Machine) on a regular basis as one fo the important community projects that is workmen to preserve the digital history fo the web. Listen in to find out why the internet archive copy that was stored on this site was not enough and how Fred and the others used the insights and data from the Archive site to improve their data capture and storage. You can access the data on Guidelines here and the Quality Measures here – all sourced from this GitHub Project

We also talk about his history and involvement in the Health Care Industry Cybersecurity Task Force that was convened under President Obama’s administration by the DHS in March 2016. They issued their report to congress June 2017:  Report on Improving Cybersecurity in the Health Care Industry. Listen in to hear about the experience of bringing this diverse group together as they attempted to predict future attacks (Hint – many of the things they predicted came true that same year!)

Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.

Listen along on HealthcareNowRadio or on SoundCloud

Saving Healthcare Quality was originally published on Dr Nick – The Incrementalist


New Horizons for me at Dell

Posted in #hcsm, Dell, Healthcare Technology, HealthIT, HIT, HITsm, Innovation, Technology by drnic on July 20, 2015

I am excited to announce I am joining Dell Healthcare and Life Sciences 

as their Chief Medical Officer. Dell has been ranked number one in Healthcare Provider Services for six consecutive years by Gartner and continue to expand their presence in healthcare space with an incredible range of solutions and services that are combined with extensive experience offerings of hardware and infrastructure.

This was such an exciting opportunity with a dynamic company with a focus on healthcare that is driven by a guiding principle from Michael Dell:

Technology has always been about enabling human potential

The opportunity to apply this principle with the assembled first class talented team that have a wide range of skills and deep industry knowledge is empowering and exciting. Healthcare is personal and struggling to deal with technology that has in many cases hindered the personal realtionship between the doctor and the patient. Clinicians want to focus on the patient and not the technology and while patients like technology to be used to improve the quality and safety of care while helping to reduce the costs they also want to doctor to pay attention to them not the device(s) as I have said on many occasions – here in this AMDIS presentation on documentation:

and Healthcare Technology need to include Patients

When I looked at the breadth of what Dell already offers its customers, the range of amazing talent, and some of their innovation projects that included

  • An impressive healthcare cloud and a focus on Interoperability
  • Patient engagement, predictive analytics, population health management
  • Social Media and mobile solutions
  • Working on Genomics Cloud Storage and analysis that included the recent announcement of the Dell and Translational Genomics Research Institute that is supporting the fight against Pediatric Cancer and helping clinical researchers and doctors globally expand the reach and impact of the world’s first Food and Drug Administration (FDA)-approved personalized medicine trial for pediatric cancer.
  • This all felt like a perfect match and one that offered me personally an incredible opportunity to have a positive impact on healthcare delivery system here in the US but also around the world.

Amongst the many bonuses of this opportunity was my friend becoming a new work colleague – I am excited to be joining Mandi Bishop (@MandBPro) – social media guru, #HealthITChick and innovator in data management and analysis.

The big draw for me was that Dell already has a vast amount of products, solutions and data along with insights that they are already integrating across multiple platforms, facilities and technologies. I can’t wait to share more on some of the projects the Dell team are working on soon.



New Horizons for me at Dell was originally published on Dr Nick – The Incrementalist

MasterChef in Healthcare: Integrating Social Media

Posted in #hcsm, #mHealth, Healthcare Technology, HealthIT, HIT, HITsm by drnic on April 15, 2015

Social Media is rapidly becoming an integral part of our lives. Despite the pervasive nature of the communication channel healthcare remains a technology laggard. This presentation from HIMSS15 Wednesday Apr 15) will offer insights to help understand why healthcare professionals should join the community, participate in the discussion and how can do so successfully.


I presented this topic at HIMSS15 on Wednesday Apr 15 – you can find the listing here. As promised I am posting a summary of the points as well as a link to the Slideshare for that presentation

You can find the presentation on my slideshare (nvt) here

Master chef in healthcare- integrating social media – @DrNic1 from Nick van Terheyden




Technology is all pervasive in our lives and Social media is everywhere – in fact in a recent survey of 3,000 people conducted in the US, UK and Germany to help counter the limited time with their physicians, patients are seeking information and embracing technology outside of the doctor’s office to come to appointments prepared. Approximately 80 percent of patients feel engaged in their own health:

  • 68 percent of patients bring a list of questions to each doctor’s consult;
  • 39 percent have checked WebMD or another online source in advance; and
  • 20 percent bring personal health data from outside monitors.



You can see some 87%o f US adults are online in this Pew internet research so if you are not on board you are missing a huge opportunity but more importantly your patients are forming an opinion about you before they meet you




 What is Social Media

  • It’s a conversation, not a lecture
  • It’s an extension of everyday interactionCollaboration
  • It’s group driven, not top-down
  • It’s messy, disorganized & hard to control
  • It’s a tool, not an end-point
  • But most of all…



If you have not already – go to twitter and sign up for an account

What to Tweet

  • What you have read that you want to share with others
  • When and where you are speaking
  • Something you post on your blog
  • A link to a Web site that you find interesting
  • Listen to conversations happening online using keywords (hashtags, lists and searches) – learn from your colleagues, friends and patients
  • Befriend people – and then earn their trust by solve problems, answering queries, helping and providing useful information
  • Share information, valuable content with them
  • Questions and Requests for information and help – crowdsourcing answers
  • At a minimum – Lurk, Listen and Learn

There are many HashTags to follow and starting by assign friends and colleagues what they follow is a a good start but then get involved – join an online chat and community and take a look at the listing of healthcare hash tags from symplur. Listed below are a few of the healthcare hash tags I follow:

#hcsm (h/c social media)
#HCLDR (healthcare leaders)
#HITsm (health IT social media)#MedEd (medical education)
#eolchat (end of life/elder chat)
#BCSM (breast-cancer social media)
#LCSM (lung-cancer social media)
#BTSM (brain tumor social media)
#S4PM (Society for participatory medicine)

But I received a aggregated list when I polled my followed that included all these:


#POWHIT – People & Organizations improving Workflow w/HIT


#JACR 4th Thurs 12pm EST
#LCSM Every other Thurs 8pm EST
#BCSM Mon 9pm ET
#HCLDR Tues 8:30pm EST
#MedEd Thurs 9pm EST


@twubs @hashtracking or @tweetreachapp


My thanks to all my twitter friends who contributed

@HealthcareWen @HIMSS @lsaldanamd @sjdmd @HealthcareWen @DrJosephKim @dirkstanley @dlschermd @Docweighsin @RossMartin @CraigJoseph @RobertWahMD @ishakir @SteltsMD @JenniferJoeMD @StevenChanMD @CIBR_News @Jim_Rawson_MD @aussiclydesdale @ACRselect @AdamFuhriman @Gregmogel @ruthcarlosmd @techguy @MandiBPro @HITshrink @ahier @RandaPerkinsMD @motorcycle_guy @wareflo @susannahfox @Lygeia @ePatientDave @CMichaelGibson @Colin_Hung @annelizhannan @MelSmithJones @Paul_Sonnier @JennDennard @HIStalk @JohnNosta @2healthguru @lsaldanamd @lisagualtieri @EricTopol @ShahidNShah @DanMunro @Daniel_Kraft


Put yourself somewhere on the Social Media Adoption Curve



Add LinkedIn and Facebook – they offer a different channel and voice – Facebook tends to be more social and LinkedIn tends to be more professional/business orientated

There are some good examples already out there

The Mayo Clinic has several properties and their own published guide book to social media and the University of Maryland Medical Center that has blended many channels

What Not to Do

The JAMA 2012 report Online posting of unprofessional content by medical students highlighted a high proportion of violations and problems and there are plenty of examples of people who failed use basic common sense – I personally like the 12 word Simple Social Media Policy from the Mayo

Don’t Lie
Don’t Pry
Don’t Cheat
Can’t Delete
Don’t Steal
Don’t Reveal



  • Social Media for Physicians is a Game Changer
  • Social media, when effective, will establish a physician’s brand and connect him/her with those in need of their services
  • With increased deductibles, more consumers will “shop” using social media sites.
  • Social Media will Expand the Physician’s Role with Patients
  • Social media is shaping patient encounters with physicians and that impact is expected to increase significantly
  • Extending the patient experience will foster existing patient relationships and improve patient outcomes, especially for long-term chronic conditions.


Where are you on the social media ladder and are you going to climb higher?




MasterChef in Healthcare: Integrating Social Media was originally published on Dr Nick – The Incrementalist

Connected Health and Accelerating the Adoption of #mHealth

Posted in #hcsm, #mHealth, bigdata, EMR, Health Reform, HealthIT, HITsm, Medical Devices by drnic on November 7, 2014

I attended the Connected Healthcare Conference in San Diego yesterday Accelerate mHealth Adoption: Deliver Results through Data Driven Business Models for End-User Engagement

Never has there been so much to play for in the mobile health landscape, a revolution is just round the corner with key players from the health care and consumer markets coming together to develop the mHealth industry. This Connected Health Summit will create a bridge bringing together hospitals, clinicians, providers, payers, software and hardware innovators, consumer groups and the wireless industry.

You can find the agenda here and the organizers will be publishing the presentations – there were many interesting insights

Andrew Litt, MD (@DrAndyLitt) (Principal at Cornice Health Ventures, LLC) opened the conference with a great overview of the industry and a slew of challenges and opportunities.

He sees our industry in Phase 1 – the Capture and Digitization of records and we have yet to really move and explore Phase 2:

Move and Exchnage Data AND Analyze and Manage Data that is linked to Information Driven decision Making

And Phase 3:

Managing Patient Health

In our need to move from data to analysis and information he cited a statistic from a white paper: Analytics: The Nervous System of IT-Enabled Healthcare that sadly puts 80% of data in the EMR unstructured. This is a fixable problem today with Clinical Language Understandingand we are seeing some results and a change in the industry to stop looking to doctors to be data entry clerks He also cited Hospitals:

Technology offers tremendous scope to not only fix these problems but get ahead of the problem (as is done in other industries like the Airline industry that has rebooked your flights before you even land and miss your connection). As he suggested could we use data to understand who is likely to develop a heart attack in the next 2 hours and try and change this outcome

But integrating mHealth into our workflow requires an mHealth Ecosystem:

mHealth needs an ecosystem that improves workflow and integrates data to reduce clinicians workload. This is why doctors and clinicians are resisting mHealth – they don’t like the change to the workflow that has little if any positive effect (for the doctor – they may have a positive effect for the individuals health) of reducing clinicians workload

Interesting comment on wearables and the perspective of doctors on these devices:

What bothers the doctor – mostly the people who are buying and using wearable fitness/activity trackers are the people that are young healthy fit and want to prove to (themselves/others) that they are young fit and healthy?

His graphic on Security and privacy was on the money:

Essential to balance Privacy of Health with interoperability but trust is the imperative The stats he presented were troubling (at best)

  • 96% – Percentage of all healthcare providers that had at least one data breach in the past two years
  • 18 Million – Number of patients whose protected health information was breached between 2009 and 2011
  • 60% – Proportion of healthcare providers that have had 2 or more breaches in the past 2 years
  • 65% – Proportion of breaches reported involving mobile devices
  • $50 – Black market value of a health record

The healthcare industry is under attack and is the most attacked industry today:

You might find these figures of the value of Healthcare data as it is valued on the black-market

Another interesting data point:

HIMSS records a total of 11,000 Healthcare Technology companies – less than 100 are large size and the balance of 10,900 are small business that are essentially capturing and scattering your data across many systems and data repositories…

Multiple other presentations and panelists that were all insightful. As always Jack Young (@youngjhmb) from Qualcomm Life Venture fund had some great insights – impossible to capture all of them but here are some:

Healthcare is moving out of the hospital into the home for many reasons but cost is a big driver:

and he suggested there was at least $1.5 Trillion in economic value as the industry shifts (shifting vs replacement?)


Many were surprised by his stat that users check their smart phone at least 150 times per day (just looking around my world this seems low) – in fact a quick check online suggests this is no longer valid and it is probably 221 times per day. Given this device is the one thing we will not leave home without and it now contains a range of sensors including:

  • Accelerometer
  • Gyroscope
  • Magnetometers
  • GPS
  • Cameras
  • Infrared
  • Touchscreen
  • Finger print
  • Force
  • NFC
  • WiFi/Bluetooth/Cellular

We have the potential for more passive compliance with our patients (and as many stated in their presentations likely more accurate as self reported data is notoriously inaccurate) He predicted a a 10x growth in wearables from 2014 – 2018 with 26% of this growth attributable to smart watches (I know hard to believe at this point but I think if you looked back 4 years ago the iPad had nothing like the level of penetration it does today) iPad Growth Rate

I liked his assessment of the werable market place by researching the eBay Discount against the price of the new device:

and even worse for Smart Watches

I also presented “mHealth Reimbursement – Who Will Pay: You can see it here at Slideshare or below:

mHealth Reimbursement : Who Will Pay? from Nick van Terheyden

Comments Off on Connected Health and Accelerating the Adoption of #mHealth

Getting Value from the EHR – Yes it is Possible

Posted in #hcr, #hcsm, Art of Medicine, EHR, EMR, Healthcare Technology, HealthIT, HIT, HITsm by drnic on July 18, 2014

I have the privilege of spending a lot of time on the road interacting with clinicians around the country (and world). I hear with too much frequency many doctors complaining about the Electronic Medical Record and how it fails to help them and in many cases makes their work harder. Some of this is a hangover from the past and the inadequate technology and in some cases hardware at the time In fact I’ve told this story a number of times that I can date to around 1995/6 and in this piece: Clinical documentation in the EHR

Many years ago, an excited friend who worked for one of the electronic health record (EHR) vendors at that time — it was really more of a billing and patient tracking and management system than an EHR — was desperate to show me some of their latest applications. In particular, a new module they had developed to capture clinical data. My friend pulled out his laptop, fired up the application, selected a patient and proceeded to enter blood pressure (BP). Some 20-plus clicks later, he had entered a BP of 120/80. While he was excited, I was dumbfounded. When it comes to patient care, doctors didn’t have time for 20 clicks to record BP years ago and they definitely don’t have that luxury in today’s demanding medical environment.

There is still some of that going on and not enough focus on the User Interface design and turning the technology into a barrier – this is the focus of the Art of Medicine campaign we launched some weeks ago

This article on Government HealthIT Are electronic health records already too cluttered? highlights a rising problem and one I hear about frequently. This is not just a healthcare problem and it is the focus of the work by Edward Tufte an American statistician and professor emeritus of political science, statistics, and computer science at Yale University who is well known for his books on information design which are bets acquired by attending one of his frequent courses on data visualization Here is a recent overview of visualization on the iPhone

He has a section on healthcare but many of his principles apply

For Brian Jacobs the problem was even more acute working in a Pediatric ICU:

The ICU is a very toxic and tech-laden environment….because of that, it offers the opportunity to make a lot of mistakes

As he points out much of the cutter derives form the multiple notes entered into the EHR every day. “It’s not uncommon in teaching hospitals to have six to seven notes per day on one patient, by the time the attending physician, residents, consultants, other doctors and fellows check on the patient.” So they instituted a policy of One Note per day

Actually its

It’s actually one note per team per patient per day; one giant multi-contributor note. They still may be all writing their components, but it’s one note

With a template to hold the content generated each morning by the resident and then everyone contributing to that one note, adding and amending as necessary

So in addressing the issue clutter they also addressed usability and design turning the note into a living breathing document that is updated and maintained by the team that now takes care of patients But he addressed some other important issues – especially when it comes to quality of care and the quality of the medical note

Copy Forward is subject to some warranted scrutinyfrom a billing and audit standpoint. Much of the repetitive and “clutter” in the note comes form the copying forward of past information. But:

These notes should never be the same

And as part of that message they moved to an “End-of-day note” that was a fresh summary of the patient. Add to that an updated and well maintained Problem List and integration with the billing system to allow doctors to select their code for the work carried out that day and they moved to a valuable addition to the healthcare team in delivering quality healthcare with their EHR

EHRs are: more complete, legible, accessible and can be auto-populated and searched. They can provide diagnosis codes and they’re good for billing. On the other hand, they can sometimes lack quality information and are by far, too cluttered.

I said this back in 2003 (yikes!) – The Future of Technology is already here – Who’s on Board the train and who’s left at the station. I still believe it and understand that the technology does need to get better and be more integrated into the existing workflow

The next generation of health care technology is here, with visionaries and futurists pushing the envelope to enhance, create and generate the newest cutting edge in health care delivery. Advances in technology, like advances in medicine, are a shared entity that enhances life expectancy and the quality of life.

Comments Off on Getting Value from the EHR – Yes it is Possible

Interview from #Health2Con with @DocWeighsIn on #speechrecognition #HealthIT #NLP and beyond

Loved spending time with Dr Pat Salber (@DocWeighsIn) from the Health 2.0 conference that took place a couple of weeks ago

I had the privilege of watching her in action as she blended social media with the sessions at Health 2.0 and tweeted a picture of her in action

We spent some time afterwards talking about innovation in HealthIT and documentation on subjects as wide and varied as Florence and INtelligent assistants through Speech Recognition and Natural Language Processing (NLP) or Clinical Language Understanding (CLU):

21 Bow Tie Salute to Farzad Mostashari

Like many in the healthcare IT industry, I was saddened by the announcement that Dr Farzad Mostashari (@Farzad_ONC) would be retiring. I would suggest as famed football legend Vince Lombardi said

“The strength of the group is the strength of the leaders”

And, for healthcare technology, Dr. Mostashari has been a great leader. I’ve outlined below some of the many contributions he has made to healthcare.

Dr. Mostashari joined the Office of the National Coordinator (ONC) in 2009, and has had a huge and positive impact on the implementation, development and overall perception of healthcare IT.  Personally impacted by the state of healthcare when his mother was admitted for arrhythmias, after having asked for the paper chart, he admitted;

I couldn’t even read the cardiology consult’s name
Perhaps this is one of the reasons he like me is a proud member of Regina Holliday (@ReginaHolliday) “Walking Gallery“. This difficult, and highly personal, situation likely galvanized his vision as he took on the daunting tasks demanded by the role of the ONC. He inherited a department that had, in effect, been pushed over the edge of the luge and, whilst speeding wildly along this track, was expected steer a course that would deliver on a range of programs in record time:

  • Meaningful Use of Electronic Health Records (EHR)
  • Certification program for EHRs
  • National Standards
  • Grant programs
  • Regional Extension Centers
And that was just what he knew about coming in. The team endured the challenges, weathered the storm in the “Office of No Christmas”

He rapidly earned a reputation as a leader who listened and was engaged.  He made many appearances and, although he may not have been the first, he was certainly an early adopter of social media and online engagement – clear indicators of his heartfelt passion to be part of the solution. As a customer service representative I recently encountered very astutely pointed out:
I can’t do anything about the past, but I can help improve the future

It is hard to pick individual highlights from such an impressive record, but here’s my list of Dr. Mostashari’s top 13 achievements and quotable/notable moments from his time in office:

  1. Successfully delivering on the Stage 1 Meaningful Use, despite frustrations and the challenges of a fickle and change-resistant healthcare profession.  He gracefully offered a personal hand to help steer his colleagues:
    “Meaningful use is the best-we-could-make-it roadmap to prepare for delivery of higher quality care and mitigating some of the costs toward getting there, if it’s a distraction we need to change it, and I want to hear from you personally.”
  2. Creating a viable technical assistance program that has touched many providers and hospitals through regional extension centers (REC).
  3. Driving the successful adoption of electronic health records (EHRs) and electronic medical records (EMRs).
  4. Interoperability (see note below on focus for the future)
  5. Pushing for patient empowerment (He, like me, is a proud owner and runway model for the Regina Holliday Healthcare Collection).
  6. As he said: “We’re on the right track to make meaningful use of meaningful use” 
  7. ePrescribing
  8. And as if to prove the point about his use of social media, this from his twitter feed: “We’ve made more progress with EHRs in the past 2 years then we have in 20”   
  9. Championing the patient engagement he stated: “We cannot have it be profitable to hoard patient information
  10. Nailing the coffin shut on paper he said: “Once you close a paper file it’s dead. You’re not able to move it or learn from it
  11. While this may not be his own personal quote but he applied cyberpunk science fiction, William F. Gibson famous quote to healthcare: “The future is already here – it’s just not evenly distributed.” by pointing out that we do have the technology – its just not being applied
  12. Piloting Meaningful Use stage 2 criteria, which built on the success of stage 1, and pushed towards interoperability including standards for data sharing data, quality improvement, and quality measures that foster  patent engagement. As he put it: “We are using every lever at our disposal to increase the sharing of information” and “Patients need to care for themselves and become partners in their care
  13. Successfully weathering the storm of the controversial (or as he put it “headline grabbing“) Health Affairs article based on data from 2008 that suggested that EHR technology was increasing the costs of healthcare.
The Future:
To the lucky individual taking the reins, I offer five suggested  areas of focus:
2. A friend once said to me: “You’ve put us on the horse, you might as well give us the ride.” The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari’s play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.

  1. Continue the engaged and inclusive discussion with all the constituents and make social media a central part of that strategy both for ONC but also for the healthcare industry.
  2. A friend once said to me: “You’ve put us on the horse, you might as well give us the ride” The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari’s play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.
  3. I must include a shout out for patient engagement. Nowhere else in the industry will you find such a large and untapped resource that is ready, willing – but perhaps not yet able to participate in the change. As I have stated many times:  when a doctor and patient are in a room, there is nobody, I repeat nobody, more interested in successful outcomes than the patient. Give them the tools and make them part of the solution.
  4. Occasionally, the issue of Tort and Medical Negligence is raised, but it appears to have the “third rail” syndrome. Unless this is addressed, we will continue to see “defensive medicine” practiced. As I recently blogged in Science, Evidence and Clinical Practice, despite clear data that shows intensive monitoring causes more harm in normal care deliveries, we continue to see almost universal rates of this high-level monitoring.  While some may be attributable to the payment system, I believe a large part of this volume stems from the general inertia of and fear of litigation.
  5. Above all – have fun. I made this point at every soccer practice when I was a coach. If you aren’t having fun, there is little incentive to do well or, for that matter, to do at all. I know I am constantly amazed at the great fortune that finds me at this intersection of medicine and technology. I constantly have that feeling as if I paddled for the wave just at the right time:
“Surf’s Up dude – ten foot waves of the Pier”

The Making of the 21 Bow Tie Salute

Dr Farzad Mostashari has been an incredible role model, a source of inspiration and a true visionary who has helped others see what the future of healthcare can look like. And so, in extreme appreciation of all that he has accomplished, I offer this 21 Bow Tie Salute.  

I was fortunate enough to have another wonderful role model, my father, take the time to teach me how to tie a bow tie, but for those of you wanting to learn the fine craft of tying a bow tie, instructions are included below (The 21 Bow Tie Salute was made with Real Bow Ties). 
Thanks Dad!

Here are some basic instructions:

News and sources include:
Healthcare IT News

Four Reasons Doctors Worry About Social Media – #GetOverIt

Posted in #hcsm, HealthIT, HITsm, social media by drnic on April 17, 2013

I’m fortunate enough to spend a lot of time interacting with physicians, entrepreneurs, and investors on the bleeding edge of digital health – and it’s a consistently thrilling experience.

At the same time, the continuous exposure to the imaginative and the extraordinary can also be a bit deceptive.  Self-associating groups, as Sunstein has discussed, tend to adopt relatively extreme views, and it’s easy to envision this happening in Silicon Valley in general, and to digital health innovators in particular.

Consequently, it was probably healthy, and certainly arresting, to attend a breakout session on social media at recent a medical conference; the audience members were mostly practicing physicians, seemed passionate about patient care, and were explicitly interested in learning about social media.  Yet, most of the clinicians were not prepared to embrace it, and many were poignantly struggling to come to terms with a phenomenon they recognized as important, yet which viscerally troubled them.

Their concerns seem to fall into four categories, two involving patients, and two involving physicians.

1. Patients Receiving “Bad” Information

Many physicians described the challenges of dealing with patients who had retrieved wrong or incomplete information from the internet.  This turns out to be a remarkably common problem; doctors reported spending a lot of time undoing bad information.

The challenge was highlighted by the observation that 25% of Google searches for headache reportedly discuss brain tumors, even though such a diagnosis would be exceptionally uncommon.  The thought was that while physicians have learned during their training to appropriately weigh pre-test probabilities, patients have not, and are likely to fixate on extreme diagnoses rather than those that are most likely.

It seemed to me that “Dr. Google” upset many doctors not only because it complicated office visits, but also because it fundamentally altered the traditional doctor/patient relationship; as one physician said – verbatim – “I’ve lost my authority.”  It’s hard not to see this as a profound shift in perspective many experienced physicians understandably struggle to manage.

2. Patients Transmitting “Bad” Information

Many doctors in the audience were also visibly troubled by the ease with which patients could share “misleading” information, whether about medicine or the doctors themselves.

Despite the clear repudiation of a link between vaccines and autism, for instance, many patients continue to worry, a concern reportedly spurred on by an active internet anti-vaccine community.

Doctors were also fretting about the ease with which disgruntled patients could use the internet to besmirch reputations — one physician complained that when he Googled himself, the first links that came up were bad reviews he said represented a small number of extremely vocal patients.

3. Physicians Receiving Information Badly

While some senior physicians worried that young doctors might start to rely on tweets rather than peer-reviewed articles, it seemed that the most significant concern raised was the impact that the “internet culture” was having on the practice of medicine.  “We need to teach students that traditional values are still important,” one audience member said (again, verbatim), suggesting that students have become progressively less reflective.

The use of mobile devices – what consultants call “phone hygiene” – emerged as a particular source of physician aggravation.  Rounding residents would routinely look at the cell phones rather than pay attention to either the patients or the senior doctors, leading at least one doctor to prohibit the use of mobile devices on rounds – except for a 5’ phone break he built into the schedule, to accommodate what he described as the young doctors’ obvious addiction.

Another senior doctor, in a complaint evocative of this recent, much-discussed NYT article, noted that residents would routinely update her by text, rather than by phone.  She suggested this reflected a more general trend of young physician disengagement, evidently preferring to interact with devices rather than with other people.

4. Physicians Transmitting Information Badly

The ability afforded by social media to share information rapidly and broadly was another source of concern.  Many senior physicians worried young doctors might use social media in unprofessional ways – sharing things they shouldn’t, saying things they shouldn’t – potentially placing themselves and their institutions at risk.

In some cases, even seemingly innocent activities might be deemed inappropriate.  One young physician offered as an example a (medically-related) internet survey research project he wanted to do.  He said that while he could do this very easily, nearly instantly, and essentially for nothing using Google, he learned from his department this would violate institutional policy, and to conduct the research with the required protections in place would cost at least $25,000; naturally, the research has not progressed.

Moving Forward

Great post by David on why clinicians should jump with both feet into the world of Social Media

A shift in how healthcare is paid for

Posted in #hcsm, Health Care Costs, Healthcare Insurance, HealthIT, HITsm, Meaningful Use by drnic on December 17, 2012

CHELMSFORD, Mass. — It’s hard work being one of Dr. Damian Folch’s diabetic patients.

If a lab test shows high cholesterol, Folch is quick to call or email. No patient can leave the office without scheduling an annual eye exam, a key preventive test. A missed exam or an appointment leads to another call.

“We are a real pain in their necks,” joked Folch, a primary care physician in suburban Boston. “We track them down.”

That kind of attention has always been good medicine. For Folch, 59, it’s now good business. He is among thousands of physicians in Massachusetts whose pay depends on how their patients fare, not just on how many times they see them. If patients stay healthy and avoid costly medical care, he gets more money.

This simple shift in how healthcare is paid for — long seen as key to taming costs — has been occurring in pockets of the country. But nowhere is it happening more systematically than in Massachusetts, the state that blazed a trail in 2006 by guaranteeing its residents health insurance. Now Massachusetts, a model for President Obama‘s 2010 national healthcare law, may offer another template for national leaders looking to control health spending.

“There have been few greater periods of change in American medical history … and this is the epicenter,” said Dr. Kevin Tabb, a former chief medical officer at Stanford Hospital and Clinics in Northern California who now heads Beth Israel Deaconess Medical Center, one of Boston’s leading hospitals. “It is striking how different Massachusetts is from the rest of the nation.”

In the last three years, commercial insurers in the state have moved nearly 1 million patients into health plans that reward doctors and hospitals that control costs while improving quality.

About 180,000 Massachusetts seniors are on track to get care from physicians paid this way by Medicare through a new initiative included in the national health law. And this summer, state lawmakers passed legislation aimed at moving 1.7 million government employees and Medicaid recipients into similar health plans.

Within a few years, close to half of the state’s 6.5 million residents could be in a health plan that pays for medical care in a fundamentally different way.

Massachusetts’ move to reshape how healthcare is financed is still in its infancy. And the state continues to have the nation’s highest medical costs, spending nearly 50% more per person than the national average.

That has fueled skepticism from conservatives who see too much government involvement and from liberals who say the state should more aggressively set medical prices. “I don’t see how we can rely on market forces,” said Nancy Turnbull, associate dean of the Harvard School of Public Health.

But early research in Massachusetts suggests the approach may be slowing health spending. And medical providers, business leaders and elected officials are increasingly hopeful they are making headway.

“Whether this is sustainable remains to be seen,” said James Roosevelt Jr., president of Tufts Health Plan, one of the state’s largest insurers. “But there is a broad consensus that it makes more sense to pay for healthcare this way.”

The building block of the Massachusetts experiment is a contract between insurers and groups of doctors known as a global payment. In such contracts, physicians receive a budget to care for a cohort of patients. If doctors can care for their patients more economically, they keep a portion of the savings. If patient care exceeds the budget, they pay a penalty.

That is supposed to encourage physicians to keep their patients healthier and direct them to lower-cost hospitals and specialists.

If poorly designed, the arrangement can create a financial incentive to skimp on care. That perceived problem undermined earlier experiments with global payments and provoked a backlash against managed care in the 1990s.

“The most widespread attempts to do this failed,” acknowledged Andrew Dreyfus, president of Blue Cross Blue Shield of Massachusetts, the state’s largest health plan and a leading proponent of the new generation of global payment contracts. “There was no quality measurement…. It was really just about dollars.”

In a key change, Blue Cross now links its contracts to dozens of quality metrics that track whether patients get the right screenings and exams, whether doctors and hospitals prescribe the correct drugs — even whether patients are satisfied with their care. That means a doctor who withholds care in hopes of saving money faces a penalty if patients suffer or are unhappy.

In Folch’s suite outside Boston, these measurements have been transformational.

On a shelf in his tidy office are reams of spreadsheets, updated constantly, that outline how each of his patients is faring, which tests they have taken and which are due. With bonus payments from Blue Cross, he has hired new aides and installed a new computer system to better track his patients.

“We had to change the way we practiced,” Folch said.

Folch also had to explain to patients why he wants them to get X-rays, eye exams and other routine care at the community hospital rather than at one of Boston’s famous teaching hospitals, where an MRI that normally runs about $1,100 can cost as much as $1,650.

That wasn’t easy.

“I try to explain that I’m not throwing them to the lions. I am referring them to people that I go to,” Folch said. “If you have some rare form of cancer, then of course we’re going to, say, get a second opinion…. But I had a lot of difficult conversations at first.”

Some patients quit his practice.

Change has not come easily around the state, particularly for hospitals that depend on filling beds, not on keeping patients healthy enough to prevent hospitalizations.

“It’s a dramatic reorientation,” said Dr. Tom Lee, an executive with Partners HealthCare, the state’s dominant hospital group.

Medical practices like Folch’s are already making significant strides, however.

Between 2008 and 2011, the percentage of Folch’s patients getting recommended colorectal cancer screenings increased from 61% to 82%. The share of patients with cardiovascular conditions managing their cholesterol jumped from 75% to 89%. And last year, all of Folch’s diabetic patients successfully managed their cholesterol and had their yearly diabetic eye exams.

“If he sees something he doesn’t like, he contacts me right away,” said Bill Wooster, a 59-year-old sales representative who began seeing Folch after having a stroke four years ago. “I’m his patient, but I feel like more of a friend.”

Those results are mirrored elsewhere. Statewide, the quality of care provided by physicians in a Blue Cross contract like Folch’s — known as an Alternative Quality Contract — outpaced that of other medical providers, according to an analysis by Harvard Medical School researchers published in the journal Health Affairs.

Although the cost savings were modest, healthcare spending increased more slowly for the Blue Cross medical practices compared with others. Patients were hospitalized less and used fewer expensive services like advanced imaging. “These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care,” the researchers concluded.

It’s unclear whether other states, especially those where political resistance to the national health law remains fervent, will follow Massachusetts’ lead on cost control. “Much of the rest of the country is still battling over the merits of covering everybody,” said Alan Weil, president of the National Academy for State Health Policy.

In Massachusetts, however, the reforms remain very popular. “This has allowed me to be a better doctor,” Folch said. “And it’s better for my patients.”

A simple idea that is not news as I have pointed out on several occasions
Universal Health Care – Pay While You are Healthy and Reassessing Primary Care.
The Chinese principle of paying the local doctor while you are well may seem like an oversimplification but as Einstein said

Everything should be made as simple as possible, but not simpler

This seems like a really simple and a great strategy – it would help to capture data in sufficient detail to be able to demonstrate value and quality in the population. The capture of this data would be secondary to the actual health management and delivery of care that is keeping patients well. Unlike the current system which focuses on the documentation as verification of clinical activity and consumes much of the doctors time. I’m willing to bet most clinicians would be supportive of any system that focuses on the care and generates sufficient information to demonstrate the health improvement rather than burdening the care providers with data entry tasks.


Voice of the Doctor – July Part 2

July Voice of the Doctor Guests

Jul 13
Talking to Don Rosenthal (You can follow him on twitter @DonRosenthal) part of the original team that developed the scheduling system for the Hubble Space Telescope and ran the artificial intelligence group at NASA. HE is also the founder and CTO of Allocade and publishes a blog THITSE A Mashup of Tech, Healthcare IT, and Space Exploration
He published a two part blog on HiTech answer on Medical Records Interoperability: My medical data should move with me as easily as my music or photo library and Part 2 where he threw down the “latex” gauntlet to the #HealthIT industry in creating interoperability that was as easy as sharing my music and photos libraries <–I could not agree more with his points and these articles are worth digesting to get a good understating of the barriers we all face to sharing medical data effectively and creating truly interoperable healthcare.

We will be talking about Artificial Intelligence in Healthcare and how we can bring this technology to the complex world of medicine.

Will AI really make a difference to healthcare or is it still a mirage on the horizon of innovation
Can AI replace the clinicians consultation and review and should it
What can we learn from AI implantation from NASA and space exploration where time and distance have significant impact on the need for autonomous intelligence.

Jul 20
Monthly news round up – more opportunity to dive into the latest news and activities. THere has been lots of follow up commentary and discussion on the ruling and we will cover this as well as the most recent #HealthIT #HITsm #hcsm #HIT #EMR #CMIO #doctors #mHealth news

Jul 27
I am looking forward to talking with Gregg Masters (You can follow him on twitter @2healthguru). He is the CEO of Xantamedia and a well recognized voice and Top Players in the Social Media world. I had the privilege of meeting Gregg a while back in person and have enjoyed reading his posts and thoughts.

He and I exchanged tweets shortly after the #SCOTUS #ACA ruling was announced after I posted a link to this: Health-care leaders: Ruling no cure for spiraling costs which for me was an interesting take on the challenges that talked about the fragmented nature of the healthcare system and a general agreement that it’s broken:

“We all agree, I think, that the current fee-for-service model has all the wrong incentives in it,” said Swedish Medical Center CEO Kevin Brown. “The health-care system has been really fragmented, with independent entities all working for their own best interests.”

I liked the concept they talked about where:

Insurers and providers have worked together, rejiggering the typical payment model to shift incentives toward keeping people healthy instead of just running up bills when they’re sick.

Which reminded me of the ancient practice of paying the doctor in your village while you were healthy, only stopping paying him when you fell ill (I know simplistic but quite compelling). They did say that

The Affordable Care Act, which relies on private insurance, for the most part doesn’t directly address costs.

And while it represents a start (every journey begins with a step) there are still holes (tort and medical liability to mention a couple). Gregg responded and suggested that:

innovation will come via margins aka CMMI. Private market ACOs & direct practice models galloping ahead

We had a series of exchanges and I suggested that instead of the 140 character exchange he come on my radio show to discuss and he graciously agreed. Much as I did pre the release of the ruling, when I had the pleasure of talking with Sam Bierstock on March 30, we started with tentatively opposing views but in reality our opinions were not widely different. You can hear download that show here

I’m looking forward to a lively and informative discussion and by then will have had an extra 2 weeks to diets more of the details of the ruling and its potential effects.

Hope you can join me on #Voice of the Doctor

Join me on Friday at 2:30 ET on VoiceoftheDoctor There are three ways to tune in:
• Stream the show live – click the Listen Live Now to launch our Internet radio player.

• You can also call in. A few minutes before our show starts, call in the following number: Call: 1-559-546-1880; Enter participant code: 840521#
• is now on iTunes Radio! Stream the show live – you’ll find this station listed under News/Talk