Healthcare IT

Rating websites are all the rage on the internet. From RateMyTeachers.com to RateMyCop.com, you can rate practically anything nowadays.

A new website called Vitals.com allows you now to rate your doctor as well. In addition to being able to read reviews from other patients, there are also other physician statistics. For instance, Vitals.com informs you whether or not the doctor is board certified, where the physician graduated from medical school, and also the rating of the medical school where they graduated.

For me, the more information available for patients, the better.

According to Insurance and Technology, health insurer WellPoint has partnered with Zagat’s Survey to allow WellPoint’s members to rate their doctors.  Zagat’s will use its 30 point rating system to evaluate all doctors.  According to Spirit magazine, patients can grade doctors based on “including doctor availability, office environment, trustworthiness, and communication.”

Other websites, such as RateMDs.com, already offer patients the ability to rate doctors, but WellPoint is the first health insurer to offer this service to its members.

TechCrunch reports on a Facebook application that alerts potential donors to donate blood in times of shortage.  Take all Types (TAT) is the name of the innovative non-profit which invented this application.  The TAT website wisely states:

“There are always shortages of blood throughout the nation, even though there are plenty of potential donors out there. After All, we all have blood we can share. The main issue is communication!“

VentureBeat (”…Health 2.0…“) profiles six innovative Health 2.0 firms which were at the 2008 Health 2.0 Conference in San Diego.  Each firm on the list aims to reinvent the doctor patient relationship.

Included on the list is Carol.com which allows patients to do medical shopping.  PharmaSurveyor allows users to enter the medications they are on and see if there are any harmful drug interactions.

There are lots of innovative ideas coming down the Health 2.0 pipeline.

Electronic medical records (EMR) hold the promise of vastly improving the quality of medical care received in the U.S. today. One of the major issues with EMR is privacy however. Patients generally want their doctors to know as much about their health as possible in order to make the best possible medical diagnoses and treatment decisions.

Yet who should you trust with your EMR? Physician groups are generally too small to efficiently implement EMR. Further, if you switch doctors, most patients want their EMR to follow them. What if the health insurers are put in charge of the EMR? This may make the most sense, but some health insurers can use the EMR to learn more about the health of their enrollees. While this seems like a good thing, when a certain enrollee gets sicker, they may decide either to increase their premiums or to try to drop their coverage. A clear conflict of interest exists here.

What about a third party EMR vendor? Google and Microsoft both are offering EMR services. But do you really want one of these enormous corporations selling your most personal medical information to other companies?

One solution to this problem is Keyose.com. Created by Dr. Julio Bonis, Keyose is a completely anonymous EMR service. Here’s how it works:

1. Users sign up and enter their personal health information.
2. A username code is generated along with a public and private password. The public password is printed on an ID card that doctors can use to access medical information. The private password enables users to update their medical information. Further, Keyose allows patients to use their private password to enter confidential medical information that people with the public password (e.g.: physicians) will not be able to view. This allows patients to manage their own health care information.
3. You do not enter personal data (e.g.: not your name or an e-mail) when you sign up in Keyose. Thus, you will not receive any marketing materials. Even if a hacker breaks into the system, they will not be able to match your medical information to your name or email.
4. Finally, it is free to sign up.

As you know, there is nothing in life that is free. How does Keyose plan to fund this project? According to their “Help” section:

In the future we could include information about sponsors (including private health insurance companies, pharmaceutical or biomedical industries) mainly intended for doctors who access the personal health records. We could also charge for premium services (for instance translating the personal health record for international patients or providing contextual information about a patient’s diseases).

There are drawbacks to this patient-based EMR. Patients do not use the same jargon as physicians and, thus, much important information could be lost in translation between the physician and the patient. Also, the information is uploaded by the patient, and not physicians, nurses, or trained staff.

I tried out Keyose myself. It was pretty basic and could have used more pre-defined fields (currently there is only DOB, gender, blood type, allergies, and personal and family history). Specific fields detailing whether or not you have certain allergies, or whether you have received certain vaccines would be helpful. Also, I could view the confidential information section even when I logged in using the public password.

Nevertheless, Keyose does seem like an step in the right direction.

Google’s blog gives a preview of its Google Health application.  TechCrunch provides some analysis.

Google is everywhere. CNN reports that Google is venturing into health records biz.

“Google Inc. will begin storing the medical records of a few thousand people as it tests a long-awaited health service that’s likely to raise more concerns about the volume of sensitive information entrusted to the Internet search leader.

The pilot project to be announced Thursday will involve 1,500 to 10,000 patients at the Cleveland Clinic who volunteered to an electronic transfer of their personal health records so they can be retrieved through Google’s new service, which won’t be open to the general public…

The third-party services are troublesome because they aren’t covered by the Health Insurance Portability and Accountability Act, or HIPAA, said Pam Dixon, executive director of the World Privacy Forum, which just issued a cautionary report on the topic.

Passed in 1996, HIPAA established strict standards that classify medical information as a privileged communication between a doctor and patient. Among other things, the law requires a doctor to notify a patient when subpoenaed for a medical record.

That means a patient who agrees to transfer medical records to an external health service run by Google or Microsoft could be unwittingly making it easier for the government or some other legal adversary to obtain the information, Dixon said.”

The New York Times blog BITS also has a post about Google Health as well.

The Sacramento Business Journal has an interesting article (”Better communication…“) on Kaiser Permanente’s online system for patients called “KP HealthConnect.”  The system allows patients to schedule appointments, refill prescriptions, view lab results and email doctors.

Implementing electronic medical records (EMR) have been elevated to a top priority by healthcare policymakers. Using EMR, medical providers may be able to improve quality and better detect adverse events.

One way to improve quality with EMR is chart abstraction. After a physician-patient encounter, the doctor can review the medical chart to see if he or she prescribed the correct treatments or advice to the patient. This quality improvement methodology is certainly feasible without EMR, but is made much easier and inexpensive when patient records are held electronically. A paper by Luck et al. (2000) claims that chart abstraction may not capture all quality measures. In fact, chart abstraction typically underestimates the quality of care provided. This is likely due to the fact that physicians do not write down every minute detail of the visit and thus quality may be underestimated. Another issue is recording bias. “Busier practitioners may do more than they write down or good recorders may not be careful history takers (or physical examiners).” Plus, one must realize that a patients medical record serves multiple purposes. It is not only a medical document, but a legal record and a source of billing information. These facts may compromise the integrity of the EMR (e.g.: DRG creep).

A paper by Bates et al. (JAMIA 2003) claims that chart review or chart abstraction is overall a good technique, but may be too expensive for routine use and may fail to detect may adverse events. The Bates paper reviews a number of studies looking at electronic tools such as “event monitoring” and “natural language processing” which can help to detect problems before they occur.

EMR are only useful if physicians actually use them. A study by Miller and Sim (Health Affairs 2004) find that “the path to quality improvement and financial benefits lies in getting the greatest number of physicians to use the EMR (and not paper) for as many of their daily activities as possible. The key obstacle in this path to quality is the extra time it takes physicians to learn to use the EMR effectively for their daily tasks.” EMRs are only useful if all relevant data are included in the EMR. If most information is documented, but a physician records a patient’s allergies in the paper, but not electronic chart, there could be serious adverse medical affects. The Miller and Sim paper also proposes some solutions of how to best implement EMR.

Another unforeseen side-effect of using EMR that physicians will spend more time typing and gazing at a computer screen and less time interacting with the patient. A study by Margalit et al. (2006) finds that in Israel, “physicians spent close to one-quarter of visit time gazing at the computer screen.” The computer may enhance record keeping, but it also may diminish dialogue.

Finally, whenever EMR are implemented, they must be integrated in to the current systems in use. The new EMR must be integrated with the technology currently in use and well as the social system in place. One must also take into account the technical and physical infrastructure in place. For instance, Harrison, Koppel and Bar-Lev (JAMIA 2007) document that implementing computerized physician order entry at one children’s hospital “reduced beside nurse-physician interaction about critically ill infants. Nurses had fewer opportunities to provide feedback that sometimes led to beneficial medication changes.

• David W. Bates, MD, MSc, R. Scott Evans, MS, PhD, Harvey Murff, MD, Peter D. Stetson, MD, Lisa Pizziferri and George Hripcsak, MD. 2003. “Detecting Adverse Events Using Information Technology” JAMIA. 10:115-128.
• Harrison HI, Koppel R, Bar-Lev S. 2007. “Unintended Consequences of Information Technologies in Health Care–An Interactive Sociotechnical Analysis” J Am Medical Informatics Assoc. 14(5): 542-549.
• Jeff Luck, John W. Peabody, Timothy R. Dresselhaus, Martin Lee and Peter Glassman. 2000. “How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record” The American Journal of Medicine. 108(8): 642-649.
• Margalit RS, Roter D, Dunevant MA, Larson S, Reis S. 2006. “Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters.” Patient Educ Couns. 61(1):134-41.
• Miller RH, Sim I. 2004. “Physicians’ Use of Electronic Medical Records: Barriers and Solutions” Health Affairs. 23(2): 116-126.

I recently received an email from the Patient Privacy Rights organization. They are conducting a campaign to protect the privacy of individual’s prescription drug information. According to their website, a Newsday article reports the following:

Randee Lonergan filled her prescriptions at the same pharmacy for years. But a month ago she was shocked to find the pharmacy closed and all her family’s medical records sold to a nearby Target store in Levittown. Her information was sold legally because of a loophole in medical privacy law that allows pharmacies to “auction off” customer records - including prescriptions, information about medical conditions, Social Security numbers and insurance records - “to the highest bidder,” Sen. Charles Schumer said yesterday. The practice of selling off records, Schumer said, is a nationwide problem. Federal law requires doctors to let patients know when their medical history is being shared. But the law allows pharmacies to sell patient information to other pharmacies, Schumer said.

This sounds horrible. Patients should have a right to keep their medical information private. No one should be able to buy information that would tell them whether I take Zoloff for depression, Flomax for frequent urination, AZT to treat HIV or Viagra for erectile disfunction (see video).

I was about to sign the petition when I realized that sometimes I do want people to know what medications I am taking. One of the major benefits of electronic health records (EHR) is that emergency room doctors who I have never seem before can have instant access to my current medications and my allergies. EHR can help to provide a patient’s network of doctors with standardized information which can help in the treat of medical ailments.

How can we limit patient medical data to only the people and organizations that we want to have it? Would providing strict patient privacy protection make a standardized EHR impossible? Is it feasible to restrict access to medical records in a manner which protects patient privacy, but enhances medical care? These are complicated questions of which we need to find an answer.

GigaOM reports on some new Health 2.0 developments in Germany in its article “Health 2.0 Gaining Traction in Germany.”  Websites such as Helpster and Imedo are among a number of website which are now rating German physicians.  In order to take into account established medical institutions, Imedo is including the physician certification status as part of its rating.  This certification status is decided by the German Kassenärztliche Vereinigung, “a public organization in charge of distributing the lion’s share of physicians’ income.”

Will German physicians even engage in price competition for patients?  Two German websites believe so:

In the transactional domain, 2te-Zahnarztmeinung and Arzt-Preisvergleich have gained significant traction by running reverse auctions — primarily for dentists’ treatments — which allow for a high degree of comparability. Navigating closely on the edge of what German law allows, a potential patient does not have to automatically contract with the cheapest offering. Instead, she can compare all anonymously quoted prices and take into account the ratings given by patients who have undergone a similar treatment. The physician she chooses then awards 15 to 20 percent of his fee back to the platform.

Is this the wave of the future?  The Healthcare Economist says yes and no.

Yes because for medical procedures which are 1) fairly routine, 2) of relatively low risk and 3) where the patient has a high quality of information regarding the cost and benefits of the procedure, the internet can provide an important means of disseminating information and driving down price.  Dentist visits are predictable and quality is relatively easy to measure.  Thus using these websites will be a boon to consumers.

No because for more complicated procedures these website’s information will likely not be helpful.  Using outcome measures for complicated procedures must make risk adjustments to take into account patient case mix.  Process measures may be to simple to take into account factors such as disease interactions.  And structural measures (e.g.: nurse-patient ratio, the use of electronic medical records) may only be peripherally related to the quality of care.  I doubt that cardiothorasic surgeons will start bidding for patients any time in the near future.  Patients, whose cost for these expensive procedures will generally be covered by insurance, will choose a doctor likely based on their primary care doc’s referral or the opinions of their peers.

Thus, the Health 2.0 movement is likely to be a significant development for the low-cost, predictable sector of medical care.  Specialist and hospital care is much more difficult to measure and price and I believe will likely be hardly affected by these new developments.

Many people believe that better information technology (IT) can help improve the quality of medical care in the U.S. and around the world. For instance, if a doctor prescribes a drug which interacts harmfully with a drug the patient is already taking, a computer program could notify the doctor of this problem. If a patient has a certain disease, a computer program could help to narrow down the physician’s treatment options.

The problem with this top-down, one-size-fits-all doctoring is that every patient is unique. Of course, there are medical standards which should generally be followed, but often these standardized treatments have to be altered slightly or completely depending on patient wishes, the prevalence of multiple diseases, or economic constraints. Further, the physician typically has superior information regarding the patient’s condition than a standardized computer algorithm.

An NBER working paper by Javitt, Rebitzer and Reisman investigates a randomized trial of the implementation of a new IT system at a commercial HMO plan. The program was ‘turned on’ for some patients for each physician in the HMO and ‘turned off’ for other patients. The program would give three care consideration (CC) alerts: stop a drug, do a test, or add a drug. Each of these warnings had 3 severity levels.

The authors compare data on the CC alerts which occurred for the ’switched on’ patients with the hypothetical CC alerts which would have occurred if the software had been running. The authors found that the IT program lead to 6% lower charges in the turned on group compared to the control. The authors interpret this to be due to lower hospitalization rates and medication complications in the treatment group.

One key aspect of the program is that the CC alerts could be ignored by doctors.

“Physicians often have better information about their patients than does the error detecting software. Actions that look like a misstep to the computer may in fact be the result of informed physician choice, informed patient choice and/or patient non-compliance. For this reason, the HMO and the software company viewed CCs as recommendations that physicians were free to ignore if they disagreed.”

Physicians seemed to heed these CC alerts more than other studies had previously thought they would. Why?

Our results, however, suggest something more: the messages in the CCs seem to have had a bigger effect on physicians than the conventional medical channels used to promote the HOPE trial findings. It seems plausible that the CCs were influential because they linked a general recommendation (“take ACE inhibitorsâ€?) to a specific patient [my italics] and a specific cite to the medical literature.”

To me, this seems to be the most appropriate way to implement medical IT.

• Javitt JC, Rebitzer JB, Reisman L, (2007) “Information Technology and Medical Missteps: Evidence from a Randomized Trial ” NBER WP #13493.

Yesterday, Microsoft announced the introduction of the online medical records system titled Health Vault. Online medical records would greatly increase productivity in the health care industry since:

1. Patients would be able to have all their health care information in one spot.
2. Moving from one state or country to another would not entail losing your medical records.
3. Physicians would have a standardized way of recording patient data
4. There would be no confusion with respect to messy physician hand writing.

The N.Y. Times states:

“The value of what we’re doing will go up rapidly as we get more partners,â€? said Peter Neupert, the vice president in charge of Microsoft’s health group…

The company hopes that individuals will give doctors, clinics and hospitals permission to submit information like medicines prescribed and data on blood pressure and cholesterol levels.  Mr. Neupert said such data transfers would then be automatic, over the Internet, which is why the partnerships are so important.

Microsoft wisely decided to name to online medical system Health Vault. This is a shrewd strategic move because the major impediment to online medical records is patient privacy and information security.

This is where a paradox occurs. According to the Economist:

Sean Nolan of Microsoft explains that the business model depends on one thing: targeted search. Microsoft is betting that people will use its Health Vault Search to find out about their ailments. This service relies on an approach known as “vertical searchâ€? which attempts to provide more relevant results than generalist search engines like Google and Yahoo! by specialising in a particular field. The firm’s recent acquisition of Medstory, a vertical-search engine focusing on health care, has given it a boost in this area.

Health Vault’s search engine would definitely work better than those of rival sites if it could examine users’ health records and past queries, and thus provide the responses that are most relevant to each individual’s situation. But in order to attract any users in the first place, Microsoft has promised to enforce strict privacy rules. These, says Mr Nolan, would preclude such data-mining.

More coverage is available here:

• The Economist
• N.Y. Times
• Read/Write Web
• NPR’s Marketplace

TechDirt has an interesting article (”The Doctr Is In“) about Dr. Jay Parkinson.  Dr. Parkinson started a boutique clinic in which patients pay for services out of pocket.  Unlike most boutique practices, patients can email or instant message the doctor about any medical questions from 8am to 5pm, or in the case of medical emergencies Parkinson is available 24/7.  Techdirt claims that “studies confirm that online chat with your doctor is nearly as effective as an in-person visit.”  Further, if the patient is sufficiently ill, Parkinson will make house visits (two are included in the $500 annual retainer fee).  Another interesting aspect of the Parkinson practice is the following:

“…since all of his clients are very price conscious (since they’re paying out of pocket), he actively shops around for the best value specialists to send his clients to. In the age of copayments and insurance, you very rarely see much price comparison shopping in health care .”

You can visit Dr. Parkinson’s website here.

A new website is available to help patients and physicians find information regarding various diseases.  The site is called CureHunter.  The site not only has a ton of information on different diseases, therapies, drugs, and bio-agents, but shows the relationship between each of these in a very appealing visual interface.  Since I am not a physician, I am not qualified to assess the quality of the information on the site, but the concept does seems appealing–especially for patients who require inter-specialty care.

You walk into your doctors office hoping for a diagnosis to your most recent ailment.  The doctor runs some tests and leaves the room telling you he will return.  Ten minutes later, the doctor tells you that you have diabetes.  What was the doctor doing during the ten minutes?  Most likely, he was reviewing the tests, thinking about your particular case, and checking the internet for more information.  What technical website did the doctor use for your diagnosis?  The most likely answer is Google. 

At least this is what an article on the Alt Search Engine website states.  The article continues:

We surveyed 6,000 physicians and learned that Google and other consumer search engines were frequently used by physicians to get clinical information. Among physicians 45 and under, more than 90 percent said they used the Internet and search engines frequently, and Google was the preferred search engine among all specialties surveyed. When asked why, the answer was simple. Forty-three percent offered the top response, “it seemed like a good place to start.�

Google may be popular among physicians, but they also expressed a certain degree of dissatisfaction, with 65 percent of primary care physicians (PCPs) saying Google searches returned too many irrelevant results.

Despite the primacy of Google, new search engines are coming into the market specifically targeted to physicians, researchers and patients.  PubMed is a search tool most often used by researchers (like myself) to review scholarly journal articles.  There is also another tool called GoPubMed which also helps physicians and researchers stay abreast of the latest medical research.

SearchMedica is a site which I found to be more practical in that it links to government and physician authorities on different diseases.  For instance, searching for ‘diabetes,’ the first four results were the National Diabetes Information Clearinghouse (NDIC), the CDC’s Diabetes Public Health Resource, an article from the journal Diabetes Care, and the CDC’s Diabetes Frequently Asked Questions.

Other health search engines include: Healthline, GoPubMed, RevolutionHealth, Kosmix, CognitionSearch, GenieKnows (Health), MEDgle, Helia, ReleMed, MedWhat, MedicineNet, Diagnosaurus, WebMD, and HealthExcite.

The internet has an abundance of healthcare information available; the only problem left to solve is how to organize and access all of it.

Why is it taking so long for the medical industry to adopt information and communication technology?  Is it a good thing that it is taking so long?  This is the question addressed by an interesting and non-technical NBER working paper by Michael Christensen and Dahlia Remler (”ICT in Chronic Disease Care“)

What is Information and Communication Technology (ICT)

Christensen and Remler divide ICT into 4 categories:

1. Technologies that support patient self care and education: These include  websites (such as Medco Health) to help people with chronic conditions.
2. Patient-provider and provider-provider communication: Email, targeted educational emails, etc.
3. Electronic data storage and sharing: EMR
4. Technologies that combine all of the above: Examples of this include clinical algorithm engines such as Aetna’s MedQuery.

Will ICT increase health costs?

The answer to this question is not clear.  The authors note “In general, while technological improvement can allow us to provide the same level of health at a lower cost, it can potentially also make it worthwhile to spend even more resources on health care to greatly improve health.”  Thus, ICT can result in significant efficiency gains to the health care sector without reducing the overall cost.

Why is it so difficult to adopt ICT?

There are many reasons why ICT adoption has been so slow:

1. Network Externalities:  Items such as EMR have this issue.  An investment in EMR increases in value as the number of users increases.  Since EMR usage is so fragmented at this point, the positive network externalities in this market are not yet accruing to those who have invested.
2. Switching Costs: If a provider (or health plan) chooses a EMR system, and they choose one that becomes a non-dominant system, they may be forced to switch to a new network.  Thus, all the fixed costs invested in the original EMR system will have been wasted.  A provider can instead decide to wait before purchasing an EMR system in order to see which system emerges as the market leader.  Thus, while not adopting EMR early on may cause short term losses, in the long run, it may be a wise decision in the presence of switching costs and thus slow adoption may be an optimal strategy. This issue is treated more thoroughly in the real option pricing theory.
3. Consumer Responses Blunted: In regular markets, consumers receive higher quality at lower prices by ‘voting with their feet’ and purchasing only high value items.  In the health care sector things are not so simple.  There are 4 interlinked markets: health care services, health care insurance, the labor market and political economy.  “economy). The result of all these complicated linkages is that market forces from consumers to the health care providers are far more indirect and blunter than are the market forces in most industries. The forces must be transmitted through each stage and each stage brings its own transaction costs.”  One example the authors use is trying to persuade doctors to use email.  Employers have motivation to demand that doctors supply this service to their employees to make their employees happier.  Employees, however, value their job much more than whether their doctor has email or not, so direct employee pressure, while it exists, is likely a weak agent of change in the health care market.

The authors conclude the paper making the following wise pronouncement: “A tradeoff therefore exists between seeking more standardization to allow for greater adoption and less standardization to allow for greater product differentiation.”

Last month’s Wall Street Journal (”Faltering Family MDs get Technology Lifeline“) has an interesting article about how small-practice physicians are using technology as a weapon against the economies of scale which physicians working for large-scale practices enjoy. The article tells the story of Dr. Gordon Moore. When he worked at a large, hospital-owned medical practice, Dr. Moore soon became fed up with the time pressure to see over 30 patients per day and decided to start his own solo practice.

Patients at [Dr. Moore's] “micropractice” can call or email to get appointments the same day. Visits last 30 minutes. Dr. Moore can be reached day or night on his cellphone. To refill a prescription, he walks “zero feet,” he says, and taps a few keys on his laptop. “I was able to build a Norman Rockwell practice with a 21st-century information-technology backbone,” he says…

In the summer of 1998, Dr. Moore attended a talk on how technology could be used to improve medical “work flow,” and another by a Massachusetts Institute of Technology professor who talked about how a local bike shop got lean by cutting its area by 75% and still thrived. The professor suggested similar stripping of overhead would work in other fields.

In early 2001, after considerable anxiety about the decision, Dr. Moore opened a solo practice in an airless 150-square-foot room in a small office building. By keeping a tight lid on overhead costs, he hoped to see fewer patients — no more than about a dozen a day — and provide them better care, and still earn a decent wage for a doctor.”

The American Academy of Family Physicians has an interesting chart demonstrating that fewer U.S. medical School graduates are filling family-medicine residency programs.

According to the Economist magazine (”Bit by bit“), firms such as Wal-Mart, Pitney Bowes, and Intel are announcing plans to launch an online patient-information service next year with the non-profit firm Omnimedix Institute. The consortium aims to develop Dossia, which—according to the institute—is “a secure, private, independent network for capturing medical information and delivering it to patients and their families.”

Why are firms willing to incur such high costs on behalf of their employees without any compensation in return? According to the Dossia group “with employers paying almost half of all US healthcare costs, Dossia will be an important component in making the healthcare system more efficient and effective, eliminating waste and duplication.” In other words, not only will the patients benefit, but the firms will be able to cut costs. The Economist is not entirely convinced that the consortium’s plans will work since the health care market is so fragmented on the supply-side. In fact, the greatest advances in healthcare IT have occurred within consolidated entities such as Kaiser-Permanente and the VA.

Capitalism certainly creates the best incentives for innovation, but government mandates—while often putting a damper on technological advancement—are able institute important standardization measures. Some national standard of electronic patient medical records would certainly be Pareto-improving for society. Government controlled patient health information would create to significant privacy issues and lack of flexibility on the part of providers; however, a government mandate to standardize patient records using input from insurance companies, physicians, and patients should lead to a superior outcome for all of society.

The Health Care Blog has a very interesting post (”Healthcare and the Long Tail“) by Jim Walker.  Mr. Walker is a lifelong Philadelphia resident who is the Director of Business Development for the social networking site called MyMedwork.  He uses concepts developed in Chris Anderson’s book The Long Tail and applies them to the healthcare field.  Here is an excerpt:

“For those not familiar with the Long Tail, Anderson describes how Amazon, Netflix, and other online retailers sell lots of the usual blockbusters, but actually derive more total volume from 100s of thousands of niche products.  In healthcare, it is the left side of this distribution curve which inspires (for better or worse) Wal-Mart, Target, and others to offer “Doc In A Boxâ€? services -  Allergies, Bladder Infections, Bronchitis, Ear Infections, Pink Eye, Sinus Infections, and a full battery of vaccines – all served up for a fixed price while you wait.

On the right hand end of the curve though, the NIH Office of Rare Disease classifies over 6,000 conditions, each afflicting fewer than 200,000 Americans.  Along this part of the curve, things do indeed get very ambiguous in a hurry – both for patients and physicians. Specialization is a response to this range of ailments (“nichefication� in Anderson’s terms), and brings physicians repeated cases of a particular nature – giving them the confidence that they can routinely diagnose and treat a high percentage of these patients. However, even within a particular specialty area, cases will naturally follow a distribution curve from typical to atypical. Unto themselves – atypical cases are just that – one of a kind aberrations that force physicians to go outside their typical “comfort zone� of diagnosis and treatment.  For each individual physician, these atypical cases feel like the exception rather than the rule. What the Long Tail suggests though, is that taken in their entirety, these rare cases actually compromise a large percentage of all medical cases. In fact, over 25 million Americans suffer from a “rare� condition.

This is problematic, because in general, physicians – and the healthcare system as a whole - are not well prepared for dealing with the many and inevitable rare cases. In fact, statistics show that the median time to diagnosis of a rare condition is six months, and the average is almost three years!”

You may be used to calling your doctor and being told by the staff that you must wait weeks to see your family practice physician.  Now imagine calling your doctor and hearing, “I can see you this afternoon…or tomorrow if you like…which one is best for you Mr. Shafrin?”  How can a practice be able to do this while increasing the number of patients the physicians see?  The answer is open access scheduling; let’s see how it works.

With open access scheduling, only 25-50% of appointments are booked more than a few days ahead of time.  The remaining appointment slots are left open for same-day or prior-day appointments.  A common slogan heard with this type of scheduling is to “do today’s work today.”  Patient satisfaction increases with these shorter wait times.  Physicians find there are fewer no-shows.  Also, with fewer appointments made in advance, there are also fewer reschedulings if a doctor has an academic meeting or a family issue and must cancel appointments. 

An article in Family Practice Management (March 2006) describes how Baylor Family Medicine implemented this style of schedule.  The practice did the following:

1. Setting a ‘go live’ date to eliminate backlog
2. Establishing a 5 day appointment window (which was later extended to 15 days).  Those who request procedures, instead of just appointments, did have to make an appointment as usual.
3. Patients received access to the physician’s schedule through the practice’s website as well as through printed handouts distributed in the office.
4. Staffing levels were maintained.

The article continues:

“After switching to open-access scheduling, the period for the third available appointment changed from an average of 17 days to 1 day. We have been able to maintain this average for more than 2.5 years despite unexpected faculty leave and the usual variations in provider availability that are inherent to an academic practice. While some days are extensively pre-booked, overall we have avoided a backlog.”

I would appreciate any comments from physicians or patients who have had experience with open access scheduling to see if these claims do truly hold.

We are now in the information age. Let’s take a look at the following numbers:

• Internet World Stats reports that approximately 70% of Americans now have access to the Internet. (This puts it 7th in the world in terms of Internet penetration).
• Over 85% of physicians have access to high speed internet in their offices. Sixty-three percent of physicians use email to communicate with friends/family, other doctors, or other business.
• Among individuals with Internet access, 90% want to communicate with their physician over email. In fact, 56% of patients claim that having the ability to email their doctor would influence their choice of doctor.

One would expect that the physician-patient web messaging would be increasing at a rapid pace; however, this is not the case. In a study conducted in 2005, only 16.6% of physicians had used email to communicate with their patients. Less than 3% of physicians use email “frequently” as a means to exchange information with their patients. This is relatively shocking. Let’s now look at some pros and cons of web consulting.

Pros

• Ends the problem of telephone tag
• Is convenient for consumers. For instance, prescription drug refills, appointments and diagnosis of simple diseases can all occur over email.
• Allows patients a more impersonal forum to discuss sensitive topics.
• Email provides an easier means for documentation than the telephone.
• Receiving information regarding a patient’s condition before a patient comes to the office, can lead to a more efficient visit.

Cons (and some fixes)

• Doctors fear that they will be overwhelmed with emails. Most studies have shown that this is not the case. Doctors also fear that the emails will be extremely long (”please answer the following 18 questions…”). An integrated web system in which emails are limited to a certain number of characters could prevent this.
• Responding in a timely manner is important. For instance

“Sometimes [the nurses] filter questions [received by phone] appropriately but sometimes they don’t. With e-mail, when patients mail me a concern I get it.I had a patient e-mail me with questions about whether he needed a tetanus shot [after an acute event] and I got the message [several days later]“

• English only? Limiting email to English only, may cause problems for ESL (english as a second language) patients.
• Payment. Few doctors charge for consults via email. Having a charge per email or a monthly ‘retainer’ to be able to email the doctor would make email communication worthwhile for the physician.
• Malpractice Liability. There have not been any suits (yet) over doctor-patient email consultations, but doctors predict this will soon occur.
• Confidentiality. If everyone in one household has the same email, there could be problems of confidentiality.

“The biggest snafu that I committed was with a patient’s husband, who was having an affair, I breeched patient confidentiality, by sending information to one spouse who I thought was then giving it to the other spouse.”