Book Review: The Digital Doctor

If you have ever had a negative experience with technology in a medical office, everDigital Doctor felt so upset at the intellectual speed bumps of an EMR, frazzled by the dozens of mouse clicks required for even the simplest task or  felt isolated as a patient when your doctor spends your whole appointment looking at their computer, you may be wondering “how did we get here?”  What happened that caused medicine to value the input of data more than any other aspect of a medical encounter?  To find those answers and many more, I recommend reading “The Digital Doctor” by Dr Robert Wachter.

I just recently finished reading this book and can’t stop thinking about it.  This book is not the love letter to healthcare technology that I thought it would be.  Originally published in 2015 with the latest edition published in 2017, “The Digital Doctor” tells the story of healthcare technology, with specific focus on electronic medical records, has taken over modern American Medicine.  Dr Wachter interviewed 100 individuals and weaves their personal stories of the impact of changing healthcare policy on how patients receive and physicians provide care.

While technology and electronic medical records have the potential for improving medical care, Dr Wachter paints the picture that too much dependence on technology that is not quite good enough is a recipe for disaster.  Several chapters of the book are explains, from numerous points of view, how a long patient could receive a dose of medicine that was 39 times too high.  How could the electronic medical record have led a physician to the wrong dose calculation, how could the pharmacist not realize the error and how could the nurse give a patient 39 tablets when one was what was required?  The story is fascinating and the subtle role that technology played in this mistake at every single phase is almost terrifying.

Dr Wachter goes into a lot of detail about other components of healthcare technology like Personal Health Records, Patient Portals, Open Notes and Social Connectivity.  For anyone out there who uses EPIC for their EMR, like I do, there is a whole chapter dedicated to the behemoth Wisconsin company.  If nothing else, you will appreciate the story of Charm the horse and probably think of nothing else the next time you log into EPIC.

You can find the book on Amazon here and you will not be disappointed.   I do not participate in any affiliate marketing, this is just my opinion.  I do feel that any one who wants to change the future must understand the past.  For those like me who want to impact positively our digital and connected healthcare future, The Digital Doctor is a must read.

Hoping To See Your Doctor Via Telemedicine? Here’s A Quick Guide From Kaiser Health News

Hoping To See Your Doctor Via Telemedicine? Here’s A Quick Guide

by: Steven Findlay, Kaiser Health Newskhn_logo_3000x3000

Tucked into the federal budget law Congress passed in February was a provision that significantly expands the use of telemedicine — long a hyped health care reform, and now poised to go mainstream within five to 10 years.

“There’s much broader recognition of the benefits,” said Mei Wa Kwong, executive director of the Center for Connected Health Policy, a research group that promotes telemedicine in Sacramento, Calif. “The law is the latest to make telemedicine more accessible. But we still have a ways to go before most consumers are aware of the option.”

The new law allows Medicare to cover telemedicine services for people who have had a stroke and those who get kidney dialysis, either at home or at a dialysis facility. It also permits Medicare Advantage Plans — private plans that enroll a third of Medicare beneficiaries — to offer telemedicine as a covered benefit.

Separately, as of Jan. 1, Medicare began allowing doctors to bill the government for monitoring certain patients remotely using telemedicine tools — for example, tracking heartbeat and rhythm, blood pressure and blood glucose levels.

Telemedicine, also referred to as telehealth, uses computers — and their display monitors, software and capacity for data analysis — to deliver virtual health services.
In the easiest-to-understand example, a patient is in one location and has an e-visit with the doctor in another location. They are connected via a secure video link. Proponents say that more sophisticated monitoring is on the horizon and that virtual encounters will become more commonplace.

As acceptance and adoption of telemedicine expands, so does coverage. All private health plans, Medicare, state Medicaid programs and the Department of Veterans Affairs now cover some e-visits — albeit with restrictions. More health centers and hospitals are launching virtual health centers. And websites offering virtual “doctor-on-demand” services are proliferating.

Concerns exist, however. Doctors worry that they may get paid less if insurance reimbursement is lower for e-visits than in-person appointments, or that e-visits could undermine the doctor-patient relationship by reducing valuable face time. They point out that for some ailments, like strep throat, it’s best if doctors or other health providers see the patient.

Health economists, meanwhile, are concerned that e-visits could add to costs rather than constrain them — if, for example, doctors and patients abuse e-visits by scheduling them unnecessarily because they are quick and easy. Also, insurers may be motivated to push doctors to do more e-visits instead of in-person visits to save money. And for some people, access to proper equipment or internet access can be difficult.

“The potential for abuse is there,” says Dr. Robert Berenson, a Medicare expert at the Urban Institute. “We will need to prevent gaming and misuse of the system. But, generally, helping people avoid unnecessary doctor’s office and hospital visits is a good thing, if we do it right.”

Here’s a briefing on telemedicine basics:

Q: Are e-visits available from most hospitals and doctors?

Not yet. But access is increasing. Ask your doctor, clinic or hospital.

In some cities, medical centers are setting up telehealth “hubs” to handle patients. For example, Penn Medicine in Philadelphia launched its  Connected Care center in February with 50 full-time employees, 24/7 access to care and a program to treat chronically ill patients at home. Some of the center’s e-visit services are open only to Penn Medicine employees, but other services are available to anyone, with a focus on residents of Pennsylvania, New Jersey, Delaware and Maryland, said Bill Hanson, vice president and chief medical information officer at Penn Medicine.

Similarly, Mercy Virtual in Chesterfield, Mo., a St. Louis suburb, serves patients throughout the Midwest, and those treated at Mercy Health’s network of 44 hospitals in five states. Launched in 2015, Mercy Virtual provided care to 750,000 people in 2017 with a team of 700 doctors, nurses and support staff.

Other medical centers with virtual health programs include Avera Health based in South Dakota; Cleveland Clinic in Ohio; Dignity Health in San Francisco; Intermountain Healthcare in Utah; and Kaiser Permanente, a managed-care health system in California and elsewhere.

Kaiser Permanente reported last year that 21 percent of its 110 million patient interactions in 2015 were e-visits. Officials there predict that by 2020 e-visits will exceed in-person visits. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

Q: What restrictions do health plans, Medicare and Medicaid put on e-visits?

Health plan coverage varies, but most private insurers cover e-visits, and 34 states and the District of Columbia require that they do. A few states still require that a patient relationship be established with an in-person visit before the provider can bill for an e-visit. Check with your insurer about its policies.

Medicare’s coverage of e-visits is more restrictive. First, e-visits must take the place of an in-person visit. Second, with exceptions allowed under February’s budget law, Medicare largely restricts e-visits to those that occur in rural areas that have a shortage of doctors and/or hospitals. And third, most e-visits can’t occur when the patient is at home. They can be done from a variety of other locations, such as a rural health clinic, a dialysis center or skilled nursing facility. A bill in Congress would loosen that restriction.

In contrast, almost all state Medicaid programs cover e-visits in the home. But restrictions still apply. For example, only 22 states cover remote patient monitoring for Medicaid enrollees.

The Telehealth Resource Centers, a federally funded organization promoting telemedicine and providing consumer information, has detailed explanations of e-visit restrictions and limitations.

Q: Do I need special computer equipment?

No. E-visits and other forms of telemedicine are done over commonly available computers, laptops, tablets and smartphones — and are typically encrypted to protect privacy. Specialized equipment is usually needed for remote monitoring, such as blood pressure or heart rate. One vexing barrier: broadband availability in rural areas. Also, millions of low-income and older Americans still lack Wi-Fi in their homes.

Q: What services can I get through telemedicine?

Most e-visits are for primary care or follow-up services, such as assessing symptoms or checking on people who have had a medical procedure. But a growing number — no one keeps national statistics — cater to people with chronic conditions who are being monitored at home, said Kwong.

Dermatology e-visits are becoming especially common. You can send a close-up photo of a skin rash, mole or other problem for an immediate assessment. Psychotherapy by e-visit is also expanding.

Sometimes an e-visit may provide an initial medical assessment for an injury, wound or illness that is clearly not life-threatening. Some cities are testing ambulance services that use telemedicine to triage whether people need a trip to the hospital.

Q: Will I save money if I do an e-visit instead of going into the doctor’s office?

E-visits are generally less expensive than a trip to the doctor, but you may not see the difference if your insurance covers both with only a small copay or no copay. If you have a large deductible, however, an e-visit may mean you pay less out-of-pocket for that encounter.

Some states require insurers to make equal reimbursements for in-office and telemedicine consultations on simple matters.

Q: Are there downsides or risks with telemedicine and e-visits?

There’s no evidence so far that your risk of being diagnosed wrongly or treated inappropriately is any greater with an e-visit compared to an in-person visit.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

MySugr at ATA18

While attending the annual conference for the American Telemedicine Association last week, I had a chance to catch up with one of my previous Health Apps of the Month.  MySugr is now offering a package with a connected blood glucose meter and needed testing supplies to get started with their App.  You can check them out at mysugr.com and read my article on them from last year.

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Telemedicine and the Patient Experience

       Video-based telemedicine is being adopted by healthcare institutions, physicians andsmartphone-2471545_1920 advanced practitioners at a significant pace.  This is driven by the ease and convenience of use as well as opportunities to improve access and decrease cost.  There are new useful tools that improve the telemedicine experience that allow physicians to listen to a patient heart and lunge, check blood pressure and even look inside someone’s ear from a great distance away connected electronically.  No one can predict what might be on the horizon for telemedicine.
       As we focus on the technology that allows us as physicians and advanced practitioners to provide telemedicine we must not forget the patient experience.  With attribution to Amazon’s Jeff Bezos, we should focus less on what will change and ask what will not change?  What will not change about the patient experience in a video-based telemedicine encounter compared to an in-office encounter?  What will be true about a patient wants today and in the future, regardless of whether that visit takes place in real-space or cyber-space?  There are several key points about the patient experience to remember.

 

Distracted Doctoring: Patients want to be the center of their physicians attention when they seek medical care.  They want to know that their provider is there for them and allowing them to tell their story.  My own patients will let me know, sometimes subtly and sometimes not, when they think I am looking at my computer more than them.  All healthcare providers can fall into that trap of reviewing the chart and starting their documentation while trying to listen to their patient.  This is no different for telemedicine video visits.  Focusing on the “second-screen” with an EMR, a telemedicine provider can seem just as distracted.  Multitasking with your patient lessens the patient experience online and in person
Quality Medicine: No matter the venue – a medical practice office, hospital or virtually from home, all patients seeking care just want to feel better.  They need a physicians or advanced practitioner with excellent clinical acumen.  One can not expect that telehealth will always be low-acuity, easy diagnoses.  High quality medical care also incorporates education and motivation that provides patients with the tools to reach their health goals.
Relationships Matter: Trust is the foundational reason that patients continue to visit a specific provider.  They trust that they will be seen, trust that appropriate tests will be done, trust that their physician will place their best interests first and trust that they will feel better.  It takes time to develop that trust and in a field like telemedicine where a patient may never see the same provider on a regular basis, the relationship is developed with the brand itself.  Standardized operations providing consistently good service will help reinforce positive experiences and create a repeat customer.  Just like in regular clinical practice, that trust is communicated to family and friends who can promote the use of the brand.
Cost: Patients are increasingly bearing the costs of healthcare.  Insurance companies are shifting that burden to patients who are having to become experts in their own insurance plans and cost-conscious consumers.  Price transparency is an important factor for patients making decisions.  They are looking for cheaper and more cost effective ways to seek healthcare.  The allure up-front pricing of telemedicine options allows patients to make more informed decisions.  Price transparency will continue to change patient consumer behaviors virtually as well as in clinical practice.
Time:  In medicine, it seems there is always too little or too much time.  The benefits of telemedicine will be diminished if it falls down the same path as outpatient medicine.  If the wait time to obtain an appointment it too long, if appoints are delayed by physicians and advanced practitioners running behind or if there is a delay in the next step in diagnostic testing then the patient really was no better on virtually.  If the patient is feeling rushed by a distracted physician, if they can not discuss all the medical issues they have and have no time to tell their story then the convenience of telemedicine is diminished.
       Focusing on the patient experience through the virtual healthcare landscape can sharpen the focus for any telemedicine provider.  Successful integration of the technological advances we will encounter depend on continuing to provide the the patient what they need first.
(This post was originally published on for the ATA18 Connectors Blog.)

Digital Springtime

       Spring is here and that brings thoughts of blooming plants and warmth, growth and

Spring Monet

Spring by Claude Monet

regeneration.  Everyone tends to revere spring, things are new and the cold dark winter is ending.  For me the winter coincided with a a rather trying period of time in my real day job.  While I love writing and blogging and learning everything I can about Digital and Connected Health, my day job doesn’t really involve a significant amount of that field.  Recently there have been numerous work priorities that involved a significant amount of my time and what time was left I dedicated to my family.  So my site here has been sitting fallow for a little while.

       By thinking about what topics to cover next, I found myself asking the question, Do I really even care about Digital and Connected Health?  Is it that Digital Health can fundamentally change the landscape of healthcare or am I seduced by the luster of technology?  Am I sucker taken in by the shiniest new objects in medicine?
       The truth is I don’t think there is a technological solution to every problem and that is especially true for medicine.  Technology in medicine does circumvent the modern behemoth that the American healthcare system is can speak directly to the people seeking care, our patients.  What I am most passionate about is Access to Medical Care and Patient Empowerment.  That is where our current system has failed and where Digital and Connected Health can lead.
       We now work as Physicians and Advanced Practitioners and we are patients in a system that is built on the infallibility of Physician.  It is a “Just Trust Me” model.  Do what I say and things will be fine.  For a myriad of factors that system is just not tolerated any longer but most people still have to seek care from his system.  Patients have to navigate this system as best they can.  Right now though patients want more control, more information and to take charge of their healthcare journey.  They want to make their own choices.
       The burden of paying for healthcare has been shifting towards the patient as well.  They are shouldering the cost of the care they receive and want a greater voice in how they use it.  Some people choose to exert control by not seeking care at all, eliminating interaction with a system that bypasses their wishes and is often unaffordable.  Others may seek alternative healers than the traditional modern doctor, who offer simpler options for patients to take more control.
       What limits patient access and empowerment today?  What about just asking your physician a question without an appointment?  Most people would laugh even at the thought.  It is not that as physicians we do not want to discuss important matters with you but often times we just can not find the time.  After a long day in my practice, a full day being 20-24 patients, reviewing lab results, refills medications and then actually charting and billing for visits there just isn’t a spare moment to eat lunch, let alone have conversations over the phone.  It may have a huge impact on a patient to talk through a medical issue, but spending 10-15 minutes of uncompensated time just isn’t viable for most physicians on a daily basis.
       What about being able to actually come into the office to have an appointment?  Most Physicians are booked out for weeks.  Many doctors wear that as a badge of honor and their administrators like to see that demand.  What happens to that patient that needs to be seen today, who needs advice and care and the biggest impact for positive change is today?  Will the impact of the message about their health be the same in 3 weeks?  Where else will they turn for information and care?  What about refills for chronic conditions that are vital for longevity but as a healthcare system we determine that you need to come into our office, our space, follow our rules just to keep you blood pressure in good range?  Hard to take a day off from work? Sorry we don’t see patients after 4pm.  We don’t open on Saturday.  Holidays?  You must be joking.
       Digital and Connected Health can be the flexible solution patients need.  They can take charge of their own health with newer tools that empower them and work outside the current unofficial rules just discussed.  Can’t get into your physicians office for weeks?  Well there is a telemedicine group ready to take your video call right now.  You can choose the time and you can do it from your desk at work over lunch or at home on your couch after your shift at work.
       Do you need a refill on birth control but it has been a year since your last PCP visit?  Well, you could wait another couple weeks or use an app on your phone to connect with clinicians who can review your history and prescribe the medication you need.  On your time and your direction.
       Those medical questions you have, the resources are endless.  It is almost cliche to refer to “Dr Google” but who doesn’t use a search engine to find necessary information before making any decision?  You can spend hours researching the car you want to buy before ever having to set foot in a dealership.  Between WebMD, Mayo Clinic, Patients Like Me and numerous other medical sites, finding detailed and relevant information has never been easier.  (Check out this post.)  No one has to wait for their physicians medical assistant to call back and relay a generic message.  No waiting for an appointment.
       Our current Healthcare System does not have the needed incentives for all parties and enough inertia to provide the broad access to care and empowerment of patients that we need to have an impact.  Digital and Connected Health provides everyone with an option that can empower everyone to access the care they need when they need it.

January 2018 7 Cups app

7 Cups

7 cups logo

What it is:  App designed to provide on-demand emotional support
What devices: Apple IOS devices and Android Devices
Cost: Free to download and use but does have costs associated with certain features
Who should use it: Anyone looking to improve their mental health 
Why use it: There are times when everyone struggles to maintain a positive outlook,
doptionseal with negative stress or are just looking to vent about recent events in their lives.  For those who wish to reach out and receive support they may not have access through traditional medical models.  They may feel they need more immediate help, avoid feeling like a burden to family and friends or just wish to stay anonymous.  The digital health app 7 Cups can provide necessary help.
 
7 Cups has several ways to receive mental health support.  7 Cups uses volunteers who are trained to provide emotional support via text.  This is completely anonymous.  The app asks several questions to guide what kind of support someone might need and connects them with a live volunteer.  In testing this out, the wait time to be connected to a volunteer was between 2-5 minutes.  The app has the appearance of any chat service and in intuitive to use.  
 
Within the app are many options for guided imagery  and mindfulness exercises.  These can be complete on-demand any time.  The app also serves as a way to participate in a community.  There are message boards from groups within the 7 Cups app, usually themed.  For example there is an Addiction Support Community and an Eating Disorder group.  
 
Many counselors and therapists can be contacted through the app to provide more intense treatment options.  
Chat Options

November 2017 Sworkit App

Sworkit

What it is: Sworkit is a fitness app that provides stretching, cardio and yoga workouts on demandsworkit-update.png

What devices: Iphone, Ipads and Android devices

Cost: Free or for a fee a premium version that is ad-free and has access to a broader range of exercise plans

Who should use it: Patients, caretakers and physicians, pretty much anyone and everyone

Why use it:  Sworkit limits excuses.  This the best most portable exercise program around.  Every exercise program in the Sworkit app requires no equipment.  All you need for good work out is your phone and a little space.  If you have 5 minutes at the office, you can use Sworkit.  If you have 15 minutes in your hotel room while traveling, you can use Sworkit.  Sworkit eliminates the barriers you have to the cardiovascular exercise we need for optimal health.

When you download the Sworkit app, you have access to a guided set of exercises.  Sworkit will take you through set of exercises based on your preferences for yoga, strength training, cardio or stretching.  The programs can last as long as 60 minutes or can be done in as little as 5 minutes.  Each exercise movement can be seen on your device screen as a video which shows you exactly what to do.  There is a voice overlay prompt and a timer to tell you when to move on to the next movement.  The benefit of being able to tap an app and then have a guided exercise program is unparalleled.

The Premium features are included for $7.99 monthly fee or $59.99 for the year and include access to several extra exercise routines and the ability to use guided workout plans or customize workouts the way you want.  The Premium version is ad-free but the ads in the Free version are not that distracting at all.

Download Sworkit today and you can have a digital personal trainer lead you in a great exercise routine anytime and anywhere you and your phone can go.

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