In the last few weeks and especially after I was featured in the New York Times and Crain’s New York Business about how I use social media to communicate with patients, I’ve received a lot of inquiries from an intrigued group of colleagues and journalists about the issues surrounding the use of Twitter to communicate with patients. My thoughts on this topic are as follows:

• Twitter is a great tool for physicians to disseminate information and their expertise on relevant and timely medical topics
• Twitter is not a secure platform where patients’ protected health information (PHI) can be discussed freely. This seems obvious but based on some of the questions I’ve been asked lately it appears that some people think they may soon be able to interact with doctors on Twitter for their medical issues. This is not a realistic, or even legal, expectation. Doctor-patient interactions should ideally be confined to highly secure online platforms and the doctor’s office.

I use social media, as embedded into my practice’s secure EMR/PHR platform, for 2 main reasons:

1. Chronic disease management. I’m actively pursuing the use of secure email, video conferencing, and instant messaging to ensure continuity of care between office visits and help my patients better manage their chronic diseases. Getting patients engaged in the process of care can make them become active and empowered participants in their own care.
2. Care coordination. I’m exploring the uses of social media for care coordination. In this context, the patient is placed at the center with their care team around them. All members of the care team, being on the same platform, have access to the same information with seamless (and structured) streams of patient-to-provider and provider-to-provider health information exchange.

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As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. Atul Gawande

As Gawande puts it, we are now witnessing a “battle for the soul of American Medicine.” There is a lot of blame going around but there is a trend that is starting to emerge: we need a redesign how care is delivered. Gawande likes the idea of having integrated healthcare delivery systems, like the Mayo Clinic, where salaried physicians work in multidisciplinary teams and there is a fair amount of collective thinking. As the CEO of the Mayo Clinic told him, “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing.”

If we conclude that the Mayo Clinic model is applicable to other parts of the country, replicating it requires reforming the system in such a way that it does not financially threaten physicians (less than 10% of healthcare dollars go to physicians) but changes the incentives from doing more to thinking more. Most physicians would find getting paid for their time this way more fulfilling but are currently burdened by a payment and malpractice environment that promotes doing more that’s needed and disregards the cognitive aspects of medicine (Although the issue of malpractice is downplayed by some, physicians of all specialties and creed practice defensively).

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

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In recent years, doctor-bashing has become a popular hobby. Physicians seem to blamed for everything. A friend and retired pathologist, Dr. Richard Reece, recently described this phenomenon on his blog as follows (excerpt):

For a number of years, physicians, as the most visible symbol of health care delivery, have been criticized, chastised, and blamed for everything — as the primary source of exploding health costs, practicing poor quality care, to being computer troglodytes for failing to accept money-losing electronic health records designed to document their every act.

You can tax doctors all you want, reduce their fees, regulate them, blame them for system dysfunction, but these actions taken collectively, are likely to reduce the number of existing doctors, discourage young people from entering the profession, and cause mobile doctors to adopt other options. One of the most common options is not seeing new Medicare and Medicaid patients because of low rates of payments and high burdens of paperwork.

The moral of this tale: without more doctors, health care reform measures promising greater access is meaningless, and more regulations, more information technology, more cuts in reimbursement, even more token rewards for installing EHRs and meeting quality indicators, are not likely to produce more doctors.

Marginalizing and blaming doctors is, at best, counterproductive to realizing meaningful healthcare reform. Let’s all come together and engage in constructive dialogue. The stakes are too high and affect everyone in the country.

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There are no one step solutions for managing complex change such as healthcare reform at the national level. Many factors have to come together in perfect harmony.

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Consumers shopping for health insurance today face more choice, complexity, and financial exposure than ever before. In an increasingly uncertain world, what they are really seeking is peace of mind in their choices. Insurers that address the emotional needs and biases embedded in the typical consumer’s behavior will be successful in creating and distributing effective products, earning the consumers’ trust, providing a more satisfying shopping experience, and, ultimately, helping consumers better manage their health. The McKinsey Quarterly

Insurance companies continue to be profitable not because they have extraordinary products but because of how they’ve positioned themselves. Unrivaled as an industry, they’ve enjoyed a comfortable share of a very large market but consumers today are more sophisticated and have evolving needs that must be met. Ignoring these needs can make the health insurance industry unstable and irrelevant as providers begin to come up with innovative ways of connecting directly with patients and the new administration increases efforts to expand its control over the flow of healthcare dollars.

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For Margalit Gur-Arie, writing for the Health Care blog, the future of primary care is a barren landscape:

I fear that the independent family doctor is going to go the way the corner bookstore went, and be replaced by the cold, impersonal, shiny mega-clinic chain in the city. It won’t be long after that before Wal-Mart sets up the Wal-Health clinics in rural America. Any young kids out there planning on going to medical school and hoping for an illustrious career with Wal-Mart?

The Institute of Medicine defines continuity of care, the core attribute of primary care, to have 3 dimensions: continuity in information, continuity in management, and continuity in the patient-physician relationship.

Margalit Gur-Arie’s vision of the future of primary care will at best lack one essential element of continuity: the patient-physician relationship. But does this really matter? The person who commented on her story certainly thinks so:

I’m going to look for an internist who will agree to be my ombudsman if my health indicates a need for any kind of specialist (heart, circulatory, ortho, etc.). I understand being referred to a specialist, but I don’t want to be sent off on my own. I really want a medical pro to guide me among several options… and if possible, I want his second opinion about anything a specialist would do if it is anything other than trivial or an emergency.

I don’t know if I will succeed in finding the PCP of my dreams, but I know I can’t put it off forever. … In my case expertise is less important than a personal willingness on the part of a professional to advise me on matters I can’t learn on my own.

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Despite the state’s move towards universal health insurance, visits to Massachusetts emergency rooms went up 7% between 2005 and 2007. This is consistent with a 2008 study in the Annals of Emergency Medicine showing that the primarily driver behind an increase in emergency room utilization from 1996 to 2004 was lack of access to convenient care, not lack of health insurance. In this study, uninsured individuals accounted for less than 16% of emergency room visits.

The moral of the story: health insurance coverage does not equal access to care, at least not as long as we have a shortage of primary care physicians. Ensuring access to care requires transforming our payment system, addressing the structural defects in healthcare delivery, and revitalizing primary care.

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The arrival of digital medicine promises to shake the medical establishment to its roots, not least because it will hand so much more information over to patients themselves. But the biggest savings will not come through exotic pills or “patient empowerment”, but from the application of basic economics. Realign the incentives in health care so that innovation focuses on making patients better and health care cheaper…

Economist

I agree and our challenge remains reforming the payment system so that it can support the uptake of innovations that bring true value to the healthcare system.

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Jay and I will be speaking to the medical students at Mount Sinai in NYC about Hello Health and the future of our beloved profession, replete with beer and snacks! We often speak in these settings and it’s always a pleasure to connect with the curious doctors and leaders of tomorrow.

Here’s the official invitation:

THE FUTURE OF MEDICINE!

HELLO HEALTH is revolutionizing health care using our familiar procrastination technology.

Frustrated with the bureaucracy of health care, a group of Brooklyn physicians created Hello Health: a system of affordable, efficient, user-friendly health care using facebook, video g-chat, and text messaging. Hear them speak about their vision…

WHERE: Annenberg Student Lounge
WHEN: Thursday April 16th at 6pm
BEER AND SNACKS WILL BE SERVED!

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In the latest issue of the New England Journal of Medicine, Eric G. Campbell, Ph.D., writes about “The Future of Research Funding in Academic Medicine.”

The premise:

Medical schools and teaching hospitals in the United States are essential producers of basic scientific and clinical knowledge that drives our supply of new medicines, devices, and other health care innovations. Today, the funding for this work is dwindling, rendering the current structure of the biomedical research enterprise unsustainable. Given the economic crisis, the fiscal and operational models of this enterprise must be restructured if the stability of academic institutions is to be maintained and our growing health care needs are to be met.

Financial support for biomedical research in the United States comes from 3 main sources:

• Government (federal and state)
• Pharma/biotech industry
• Nonprofit foundations

The problem:

For the near future, the outlook for research funding from any of these sources is rather bleak. States are expected to reach a combined budget shortfall exceeding $200 billion…  Industry is spending more on research and development, but fewer drugs and medical devices are being approved for the market, and tightened regulation may be hurting profits… Evidence of a downturn in foundation support is already emerging. Since last October, unprecedented declines in the stock market have reduced foundations’ endowments by an average of 30%.

The solution (this one is a lot more difficult to predict and articulate):

If U.S. science is to continue playing a key role in global progress, some major belt tightening will be required. …major reform, with an eye toward long-term sustainability and management of research-enterprise growth, is essential. Although academic institutions face great challenges, our country’s unprecedented hardships may provide them with a long overdue stimulus to make needed changes. A failure to seize this opportunity could have dramatic consequences for the health of the research enterprise.

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