Recently, I’ve met with several internet startups, web thought leaders, and venture capitalists.

There’s one word that’s come up in every conversation and it’s not Plastics.  It’s Gamification.

Gamification, described by Wikipedia is applying gaming principles to non-gaming applications and processes,

“in order to encourage people to adopt them, or to influence how they are used. Gamification works by making technology more engaging, by encouraging users to engage in desired behaviors, by showing a path to mastery and autonomy, by helping to solve problems and not being a distraction, and by taking advantage of humans’ psychological predisposition to engage in gaming.”

Whenever technologists create a cool new application, they often focus on the innovation necessary to solve a hard engineering problem rather than the user experience or how to ensure the ongoing use of the software.

Many internet companies have tried and failed (such as Google Health) to create highly usable healthcare sites, but failed to engage customers over the long term.

Although the biology behind gamification is controversial, the claim is that the human brain inherently enjoys problem solving and the dopamine-mediated emotional rewards that come with it.   Sticky platforms like Facebook implement many gamification features to keep users coming back.   Group competitions, customer loyalty programs, and goal achievement are all examples of gamification strategies.

We’re in the midst of a redesign of the BIDMC Personal Health Record, Patientsite.  Not only do we want to make it easier to use and more visually appealing, we want to ensure it adds value and becomes a destination that patients want to revisit.   We’ll certainly keep Gamification principles in mind.

So next time you’re faced with a software redesign, think about its use more than its engineering.  Replace Plastics with Gamification in your lexicon.   There’s a great future in it.

John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chief Information Officer at Harvard Medical School, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician. He’s also the author of the popular Life as a Healthcare CIO blog.

Reviewing “The Myth of The Paperless Office” for the New Yorker in 2002, Malcolm Gladwell argued that if the computer had come first, and paper didn’t exist, someone would have had to invent it.  Paper, it turns out, is a lot more useful than we typically appreciate.

It occurred to me that perhaps the same might be said of another product we seem to take for granted in the digital age – medicines.  (Disclosure: I work at a company that makes them.)

Medicines – you know, those little white pills that everyone loves to critique – are in many cases remarkably effective solutions to very difficult problems; it’s actually kind of amazing how useful some of these products can be.  What an incredibly powerful idea – addressing a difficult and complex health problem with a simple pill you can pop before breakfast.

I read a tweet recently asserting that physicians may soon prescribe health apps as an alternative to medications; my initial reaction: good luck with that one.  It’s certainly easy enough to envision how magical thinking about the power of health apps will soon be replaced by disappointment as app developers realize something drug makers have known for years: it’s hard to improve health, and it can be very difficult to get patients to stick with a treatment long enough to make a difference.

At the same time, it’s clear there are profound opportunities in digital health; I imagine the most effective applications will find a way to complement and enhance traditional therapeutics, rather than position themselves as “alt apps” – the alternative medicines of the digital age (you can just see the eBook now: “Health Apps ‘They’ Don’t Want You To Know About”).

There are at least two major areas where digital medicine might be expected to play a significant role.  The first opportunity is in helping to motivate behavior change by spurring patient engagement, whether in something as basic as completing a full course of antibiotics (I could easily imagine a motivational app being useful here) to a task as monumental as achieving sustained weight loss (a goal of many apps, of course, though it’s not clear any have proved to be broadly game-changing).

The second key area is in measurement, a topic I’ve discussed extensively (see here, here, and here), and around which I’ve co-founded a new academic initiative, the Center for Assessment Technology and Continuous Health (CATCH), together with MGH Chief of Medicine Dennis Ausiello and several Boston-area colleagues.  The basic idea is that improved phenotypic measurement – measurement of relevant parameters in a fashion more comprehensive and more continuous than typical patient data – could immediately improve care while also advancing future science.

An interesting underlying challenge associated with both of these areas that we must confront is the need to figure out how to do more than preach to the choir – see this characteristically elegant discussion of this phenomenon by Duke University’s Mark DeLong.

The specific issue for digital health is that the costs and burdens of healthcare are not evenly distributed, and a relatively small number of people drive most of the costs and also bear most of the suffering.  I’m not sure these patients are always the ones who are eagerly sampling the new health apps or at the leading edge of the quantified self movement (although the participants in PatientsLikeMe and similar communities may represent important exceptions).  Finding a way to bridge this gap will be important to demonstrate a meaningful impact on health – and also to provide a sustainable business model in this cost-focused era.

The flip side is that the need for improved measurement of real people is so pronounced that if you embarked on a serious effort here – as CATCH plans to initiate – and could achieve more comprehensive measurements in a broader selection of people and patients, there’s a good chance it could generate results that might improve health delivery almost immediately. The key hurdles will be the logistical obstacles associated with actually collecting these data, as highlighted in Chapter Two of this recent Kauffman Foundation report, and discussed extensively at the recent Sage Commons Congress.  But if acquired, these data are likely to render healthcare more efficient and effective, and can help us ensure we do a better job of understanding current practices and getting a better sense of what works best – acknowledging, importantly, that there’s usually not going to be a single best approach that should be applied reflexively to every patient, as discussed here and here.

Less certain, however, is how these digital approaches can help us improve care in a revolutionary, not just evolutionary, way (as I’ve previously discussed in context of Steve Jobs).  It’s terrific to understand what sorts of approaches to antibiotics and physical therapy work best for cystic fibrosis patients (see here), but how much better would it be for patients to have a new medicine that fixes the underlying problem completely and permanently?

To put it crudely, the development of an effective vaccine did a lot more for the treatment of polio than applying the best design thinking to the construction of an iron lung ever could.  I worry a bit that in our fascination with technology and design – which matter a lot for patients in the here and now – we’re neglecting the need figure out some way to get at the difficult biological questions that remain at the root of disease.  I really don’t believe a clever app is going to cure cancer – though one might improve and help optimize the experience of patients now suffering from the disease.

What I can imagine, however, is that the focus on patient measurement will highlight the importance of understanding disease in the context of person, rather than in a petri dish or a model organism, and beyond that, will lead to the development of technologies that make the study of human physiology, and pathophysiogy, increasingly robust.  Perhaps the ability to characterize cancer cells more precisely in a living patient could help identify more effective treatments, for example.

The good news is that there seems to be a lot of interest now in balancing classic reductionism with a more physiologic perspective; this includes a renewed emphasis on phenotypic screening (see here and here), and an interest more generally in understanding diseases though patients rather than model organisms.   For example, a scientist responding to a previous piece noted that the development of the recently-approved Vertex drug for a variant of CF reflected a more patient-based approach than was typical for industry.

A final point to contemplate is how big pharma should view the nascent efforts in digital health; I think Avado’s Dave Chase (who certainly gets my vote as contributing the most consistently insightful writing about the evolving digital health landscape) nails it in this recent piece, in which he describes the pharmaceutical industry as essentially watching with bemused interest and applauding politely from the sidelines.  On the one hand, they’ve more than a sneaking suspicion they need to change their business model, but on the other hand, they’re sitting on a ton of cash, and seemed inured by this point to the endless invocations of a burning platform – it’s almost as if they’ve decided this is more of a PR problem than a core business issue.

The thing is, biopharma companies may be positioned better than almost anyone to take advantage of the opportunities in digital health; as I’ve suggested, they have a unique understanding of the complexities of the healthcare system, and have a deeper familiarity with the many stakeholders.  They also would be operating in a space where many potential competitors fear to tread.

Bottom line:

1. Digital health is not a magic answer but an important part of an integrated solution
2. Key opportunities for digital health are behavior modification (patient engagement) and phenotypic measurement, and both activities must involve more than just self-selected early adopters
3. We still need to focus on understanding the biological basis of dreadful diseases; hopefully, improved patient-focused technologies will help.
4. Big pharmas could evolve to become leading players in digital health, but are likely to continue to observe from the sidelines — in their luxury boxes — at least for the foreseeable future

David Shaywitz is co-founder of the Harvard PASTEUR program, a research initiative at Harvard Medical School. His a strategist at a biopharmaceutical company in South San Francisco. You can follow him at his personal website. This post originally appeared on Forbes.

When most of us think about Facebook, the first phrase that comes to mind probably isn’t “good Samaritan.”  Facebook is an easy way to keep in touch with friends, and it can be a gigantic time-suck, for sure, but last week the site did something that could truly benefit a lot of people. On May 1, Facebook launched an initiative to encourage users to become organ donors, and within 24 hours there had been a spike in the number of people volunteering their body parts for the good of others.

California’s registry saw almost two months’ worth of people sign up within the first day after the Facebook put up the feature.

Organ transplantation is one of the miracles of modern medicine, but there simply aren’t enough organs to go around for all the patients who need them. According to the United Network for Organ Sharing (UNOS), there are 72,900 people on active lists waiting for an organ. Compare that number to the 2,263 transplants that took place between January 2011 – 2012. Last year, more than 6,000 people died waiting for an organ.Obviously, increasing the number of organ donors could have a huge impact on the number of transplants – and on the lives of thousands of people.

Why don’t more people become donors? Some object on religious grounds, but the biggest obstacle is inertia. Most of us who sign up to be organ donors (I’m one of them) do so when we renew our driver’s license, by checking a box on a form saying we want to donate our organs. If you don’t mark the form, it’s assumed you don’t want to donate. Most people only encounter this choice every few years, when their driver’s license is up for renewal, and it’s hard to think about such a decision while standing at a Department of Motor Vehicles counter.

Some countries, such as Spain, Australia and Germany, have opt-out systems. It’s assumed that you are willing to donate unless you’ve said you prefer not to. Rates of donation in those countries are sometimes higher than in the US, although some presumed-consent countries have much lower rates. (Factors other than the number of donors, like the availability of surgical facilities and transplant surgeons, can affect the number of actual transplants in different countries.)

Another way to get more people to donate would be a “mandated choice.” This idea was proposed by behavioral economist Richard Thaler, in his book Nudge: Improving Decisions About Health, Wealth, and Happiness (with Cass Sunstein). Instead of a form that you can simply leave empty if you don’t know whether you want to donate, you have to choose between “yes” and “no.” There’s psychological evidence that even having to make that choice could get more people to think about their preferences and choose to donate. Israel has yet another incentive to get people to donate: those who are registered as donors get priority if they later need an organ themselves. Facebook’s effort depends on another psychological effect, the power of social persuasion. If your friends are all donors, maybe you should sign up, too.

Whether or not Facebook’s initiative will have a sustained effect on the number of available organs remains to be seen, but there’s a side to this issue that deserves at least a mention. Organ transplants are expensive. The surgery itself can cost as much as a million dollars, and that’s not including the drugs and other care transplant patients require for the rest of their lives. Granted, that’s money well spent in terms of lives saved. But imagine if there were enough organs for every person who needed one. We’d have to find more than $100 billion a year in addition to what we’re already paying for health care.

I’m not suggesting more organ donation is a bad idea, or that we shouldn’t do more transplants. Just the opposite. It would be money well spent. It’s also yet another reason to weed out the trillions of dollars we are on track to waste over the next decade on health care that doesn’t help patients or improve lives.

Joe Colucci is a research associate at the Health Policy Program of the New America Foundation. Shannon Brownlee, MS, is a nationally recognized award-winning journalist and author who has written for the New York Times Magazine, The New Republic, British Medical Journal and The Huffington Post, among many others. The post first appeared on the New America Foundation’s blog.

Are the House and Senate giving us a false choice for how to control health care costs in Massachusetts? Aren’t there other options?

A few major themes have emerged from the two payment reform proposals and highlight the fact that they fail to align incentives for patients to be more involved in the purchase of their health insurance and their health care.

For example, even with full transparency of cost and quality (which is a huge lift on its own) for many patients, high-cost still correlates with higher quality in medicine. A recent report from Attorney General Coakley proved this theory wrong, but simply providing patients with cost data without placing the right incentives in their health plan to choose the low-cost high-quality provider will result in many selecting the most expensive care. As a result, these proposals will fall short of sustainably bending the cost curve.

There is another way for the Commonwealth- patient-centered health plans, see Health Affairs($) for national savings estimates. The impact would be significant in Massachusetts as less than 3% of residents are on a form of these plans, compared to 13% nationally.

Any reform of payment methods must be aware of limits on the state’s power to regulate the 53% of Massachusetts companies that are self-insured (and are therefore regulated by the federal government), and of course Medicare beneficiaries in the state. The bills do not touch long term care, prescription drugs, hospital fixed costs, health plan reserves, medical devices or insurance overhead. So what does that leave us, an awfully small pool out of the roughly $60B to cut from. From a practical standpoint, are we looking to “fix” our health care problems by laying off workers or severely reducing their pay? That is one of the few options left. Is that a long-term sustainable and innovative approach?

The media and most stakeholders have missed this point completely. Instead of debating what arbitrary reduction in growth we would like to see (if we are just making up numbers I propose GSP minus 10%).  We need to be realistic and have a debate about how these proposals will play out in implementation, the unintended consequences,  and how stakeholders will react to the incentives in the bill. (For example, how do we deal with those living in Massachusetts but receiving their care in another state. Or the other way around.)

My concern is that both houses of the legislature will pass their versions with some minor tweaks, and then in conference committee, behind closed doors and with lots of industry lobbying, a “compromise” will be struck taxing both insurers and providers.

From a consumer and long-term health sector perspective, this will be a raw deal.

It is built on two flawed assumptions. First that new taxes, assessments, and surcharges will not be passed onto consumers in some form. Second, that the answer to our health care problem is chasing previous flawed government intervention with more flawed government intervention. These two assumptions should not be the terms of debate for payment reform in Massachusetts. Is there a third pill to consider?

Joshua Archambault is director of health care policy at the Pioneer Institute where this post first appeared. He is also the co-author of The Great Experiment.

When I entered the VC business 10 years ago, I tried to keep thinking about venture capital as a business, where the key focus area was on meeting the needs of our target customers — entrepreneurs and limited partner investors.

In the case of entrepreneurs, those needs have changed radically in these last 10 years.  The surge in seed investing over the last few years has been well-reported and analyzed.  With advances in cloud computing, open source infrastructure, development tools and general “Lean Start-Up” techniques, entrepreneurs need less capital than ever before.  And when entrepreneurs’ needs change (i.e., requiring less capital), smart investors adjust to meet those new needs.  Hence, the rise of angels, super-angels, incubators, accelerators, micro-VCs and VC-led seed programs.

But as the “Great Seed Experiment” (as my partner, Michael Greeley, calls it) matures, a new trend is emerging.  Entrepreneurs are beginning to learn the difference between what I’ll call Passive Seeds and Activist Seeds.  And entrepreneurs are learning that the difference between the two, although somewhat subtle, matters greatly.

Passive Seeds are when a VC invests a small amount of money (for a $200-500M mid-sized fund, typically $250k or less, for a large $1B fund, perhaps $500k or less), to achieve a very small amount of ownership (typically less than 5%) to simply create an option to participate as a more meaningful investor in the future.  Passive seed programs get most of the press attention because of their sheer volume.

When you ask venture capitalists about their seed programs, many will brag about how many seed investments they have made (20-40 per year is not uncommon) and how wonderful it is that so few of them “graduate” to become series A investments (perhaps 10-20%) because it shows how discriminating they are.  Other characteristics of passive seeds is that one or two of the partners can make the decision to invest, rather than requiring the entire partnership to approve, and the due diligence is very light.  Additionally, in a passive seed round, VCs don’t mind if 3-5 firms participate, as opposed to more tyically 1-2, and each VC partner can juggle a dozen passive seeds at any given time.  Sometimes there are more VC investors than employees in a passive seed!

But entrepreneurs are starting to wise up.  The conventional wisdom has emerged that Passive Seeds from VC investors are bad for start-ups and entrepreneurs.  VCs who make passive seeds are not typically engaged enough in the business to add meaningful value.  Further, they send a bad signal to the funding market when they don’t invest in the Series A, thus creating inappropriate leverage on the entrepreneur at the time of the Series A decision.

Seed investor/venture capitalist/entrepreneur Chris Dixon has written extensively about this issue, and I couldn’t agree with him more when he declares, based on his discussions with experienced founders, “there is no room for debate” on the issue.

Activist Seeds VC investors are a different story (which Chris acknowledges, although uses different language).  From the VCs perspective, an activist seed is when the firm commits the full time, resources, and energy into the investment that they would do with a Series A.  From the entrepreneur’s perspective, they truly wants to raise less capital because of all the positive Lean Start-Up trends noted below, but wants the active involvement of a value-added VC firm.

An activist seed from a VC is typically more like $250K-$1 million and the ownership is closer to 8-10%.  The full partnership approves an activist seed and the due diligence, although abbreviated, is thoughtful and serious.  The firm gets to know the business and the entrepreneur better and thus makes a deeper commitment in making the investment.

The conversion rate of an activist seed into a larger Series A is more like 50-75% and each VC partner dedicates as much time to an activist seed as they do a larger Series A.  In short, an activist seed is nearly identical to a Series A, just smaller, slightly more streamlined, and informal – all appropriate for the stage of the business and the requirements ahead.

So next time you are discussing a seed round with a VC firm, figure out if their firm’s philosophy is activist or passive.  At Flybridge, we firmly believe in activist seeds (two nice examples recently in the news are Crashlytics and ZestCash).  Different firms have different approaches.  Make sure you find out which is which, and make sure it’s a fit for your needs.  Here are a few questions you can ask yourself to distinguish between the two:

• Was the entire partnership engaged in the investment decision process?  Did I meet with and pitch to the entire firm?  This results in a greater sense of commitment and shared ownership.
• Did the VC open up her network and make a few value-added introductions to prospective talent, customers and business development partners?  Again, this is an indication that the VC is willing to add value along the way and be more active than passive.
• Was the due diligence process rigorous? Do they seem to really understand my business and the subtelties around what it takes to win?  Did they ask tough questions, check my personal references to get to know me better, put me in front of prospective customers?

Absent these elements, you are at risk of taking money from a VC that views you as “an option” rather than “an investment” – not a place a hard-charging entrepreneur who needs as many friends on their side as possible wants to be!

Jeff Bussgang is a general partner at Flybridge Capital Partners. He is the author of Mastering the VC Game, is an insider’s guide for entrepreneurs on financing and company-building. Follow him at his blog Seeing Both Sides where this post first appeared.

Reading Barbara Ehrenreich’s “Bright-Sided” has been liberating in that is has given me permission to let my pessimistic nature out of the closet.

Well, it’s not exactly that I am pessimistic, but certainly I am not given over to brightness and cheer all the time. My poison is worry. Yes, I am a worrier, in case you had not noticed. So, imagine how satisfying it is for me to find new things to worry about. As if climate change were not enough, lately I started to worry about science.

No, my anxiety about how we do clinical science overall is not new; this blog is overrun with it. However, the new branch of that anxiety relates to something I have termed “fast science.” Like fast food it fills us up, but the calories are at best empty and at worst detrimental. What I mean is that science is a process more than it is a result, and this process cannot and should not be microwaved. Don’t believe me? Let me give you a couple of instances where slow science may be the answer to our woes.

1. Lies and damned lies

Remember this story in the Atlantic that rattled us with its incendiary message? Researcher John Ioannidis has been making headlines with his assertion that most, if not all, of what we know in medicine is in doubt, given how we do and publish research. And how we do and publish research has everything to do with the speed of “progress.” Academic careers are made with positive results, to sell news the media demand positive results, and to respond to this demand academic journals prefer only to publish positive results (this last phenomenon is referred to as “publication bias,” and is something Ben Goldacre rails against at length). A further manifestation of this fast science is that “no replicators need apply.” I am, of course, referring to an extension of the publications bias, whereby journals are not interested in publishing even a positive study that replicates a previous finding — this is simply not sexy. Thus, results have to be quick and positive to grab a share of our attention and sell academic prestige, journals and news.

2. Science output to drive business profits

In his book Supercapitalism, Robert Reich describes the growing demand by investors over the last several decades to squeeze ever-growing profits. It is clear that this chase after short-term profits has resulted in job loss in the US through outsourcing, the widening of the economic gap, and even the crash of the world economy following the collapse of the mortgage-backed securities house of cards. Much of the profit can be counted on to come through scientific innovations which may or may not improve our quality of life.

In medicine, where scientific progress is applied to our fragile being, being reasonably sure of our findings seems pretty important. Yet speed is once again the order of the day. I will grant you that speed is of importance in such diseases as advanced cancer, for example, where we may and should accept a level of uncertainty that we would ordinarily run away from in other circumstances. But doesn’t it make sense to be much more cautious before broadly accepting an intervention that happens before one gets sick, one that is meant to diagnose either early disease or a precursor to one? Should we not demand slower science before we allow anyone to medicalize such normal events in life as menopause and aging? Should this caution also not apply to screening for diseases that may or may not impact us in the long term, yet the chase could hurt us substantially in the immediate future?

But this is not the way to stimulate the economy or to make a profit. The half-life of a medical device, for example, is less than 1 year. After that a new “improved” version of the device is expected, whether it does or does not improve outcomes. For decades we were told to get screening mammography after the age of 40, only to find out now that the risks of this may well outweigh its benefits for many. The American Lung Association has just endorsed CT screening for lung cancer among current or former heavy smokers, yet the jury on its risk-benefit-uncertainty equation should still be in the thick of deliberations.

3. Science denialism

We hear a lot about how people are turning away from science. The state of Tennessee is about to descend back into the dark ages when superstitions instead of scientific theories dominated the classroom. A strong and largely anti-scientific lobby wants to bury any mention of human-driven climate change; fortunately, it looks like they are not succeeding. The anti-vaccination groups are getting more instead of less vocal following repeated debunking of any link between vaccination and autism. Science denialism is so rampant that there was even a need for a conference on how to address it. What gives?

While blaming everything on fast science alone may be reductionist, fast science in the setting of our growing societal innumeracy is a recipe for disaster, as we are seeing unfold. Our schools have failed spectacularly in their duty to educate kids about the process of science, while at the same time arming them with the “single-right-answer-to-every-question” attitude toward knowledge. This pernicious combination, along with the publication and reporting of sexy science at the expense of the more thorough analytic and introspective approach, seals the impression that the roller coaster of scientific knowledge represents not the very essence of how science should be done, but that science (and scientists) has failed.

Is slow science the answer to this fiasco? Only in part, I am afraid. Without altering fundamentally how we teach science at all levels, it would not be the cure, even if it were possible to execute. No, I am afraid that without teaching what science is, it is not even possible to get it to slow down.

Let me reiterate: the pace of scientific discovery is slow. This does not mean that we need to hide every step of it from view until we get the results that we deem worthy of sharing. On the contrary, I agree with those who think that sharing at the more interim steps can only improve what we do. Yet the innumeracy, fame and fortune are forces that put such free sharing in peril by misrepresenting it as the final answer to everything. And when the answer is changed, which is not only expected, but indeed desired in scientific pursuits, the public opinion punishes science.

Let me end with a quote I read on one of my favorite web sites, Brain Pickings, in a review of the book boldly entitled Ignorance: How It Drives Science:

Are we too enthralled with the answers these days? Are we afraid of questions, especially those that linger too long? We seem to have come to a phase in civilization marked by a voracious appetite for knowledge, in which the growth of information is exponential and, perhaps more important, its availability easier and faster than ever.

[...]There are a lot of facts to be known in order to be a professional anything — lawyer, doctor, engineer, accountant, teacher. But with science there is one important difference. The facts serve mainly to access the ignorance… Scientists don’t concentrate on what they know, which is considerable but minuscule, but rather on what they don’t know…. Science traffics in ignorance, cultivates it, and is driven by it. Mucking about in the unknown is an adventure; doing it for a living is something most scientists consider a privilege.

So, let’s celebrate uncertainty. Let’s take time to question, answer and question again. Slow down, take a deep breath, cook a slow meal and think.

Marya Zilberberg, MD, MPH, is a physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is the Founder and President of EviMed Research Group, LLC, a consultancy specializing in epidemiology, health services and outcomes research. She is also a professor of Epidemiology at the University of Massachusetts, Amherst. Dr. Zilberberg blogs at Healthcare, etc.

As physicians, our primary concern is ensuring the health and safety of our patients. The Food and Drug Administration has offered a new concept to make more prescription drugs available over the counter (OTC). Proponents claim it could improve patient health and outcomes, reduce patient costs and promote proper medication use. We are skeptical that it would achieve any of these goals.

The American Medical Association is concerned about patients taking certain drugs without physician involvement — especially patients with chronic diseases. No evidence has been offered that the innovative technologies underpinning this concept would actually allow patients with high blood pressure, high cholesterol, asthma or migraine headaches to self-diagnose and manage these serious chronic medical conditions safely on their own.

As a chronic condition evolves, treatment changes are often needed from a physician. Without physician involvement, patients might take the wrong medication or dose for their needs, potentially causing harm. Self-diagnosis and treatment conflict with the care coordination and disease management that new health care payment and delivery models are trying to achieve.

Contrary to claims that this will save patients money, out-of-pocket costs for insured individuals, including those under Medicare, would increase for drugs switched from prescription to OTC status because patients would need to cover the entire cost themselves. Higher costs would make it harder for patients to afford the medication they need.

Patients are more likely to take the medicine they need when they need it while under a doctor’s care. Physicians are one of the most important motivators in getting patients to take medication as directed. Any proposed expansion of OTC medications needs to preserve, not undermine, the patient-physician relationship.

Patients rely on physicians to provide sound diagnosis and treatment information and to help them meet their unique health needs. Expanding many prescription medications to OTC interferes with that important relationship without offering any real benefits to improve patients’ health or reduce their costs.

Peter W. Carmel is president of the American Medical Association. This post first appeared in USA Today.

Privacy policies are long legalese documents that obfuscate meaning. Nobody reads them because they are indecipherable and obtuse. Yet, these are the documents that tell you what’s going on with your data — how, when, and by whom your information will used. To put it another way, the privacy policy lets you know if some company can make money from information (like selling you email to a spammer).

Creative Commons did an amazing thing for copyright law. It made it understandable.

Creative commons reduced the complexity of letting others use your work with a set of combinable, modular icons.

In order for privacy policies to have meaning for actual people, we need to follow in Creative Commons footsteps. We need to reduce the complexity of privacy policies to an indicator scannable in seconds. At the same time, we need a visual language for delving deeper into how our data is used—a set of icons may not be enough to paint the rich picture of where you data is going.

Understanding Data Flows

With the rise of web services, your information can end up in unexpected places. To get a better understanding of some of the complexities of data flow, we sketch out how Anti-phishing works in Firefox (with help from Oliver Reichenstein).

Here’s what that looks like as a wall of text, which is the typical privacy policy mode.

The difference in understandability is huge between the text and the schematic. In fact, while we were working on creating this infographic we found a hole in our legalese and updated it accordingly.

The idea here is that by creating a visual schematic language, it is relatively painless way for a company to convert their wall-of-text into something a bit more approachable. And that the more visualization actually shines a light into the dense tangle of words, possibly highlighting flaws or trouble spots that would have otherwise remained hidden.

The simple form

The visual schematic language is a descriptive way of explaining a privacy policy and helps us to understand what’s going on underneath the hood. It doesn’t solve the problem of being able to quickly figure out the guarantees a privacy policy is making on your data.

For that, we want to move from the descriptive to the proscriptive, to a set of legally-bindings icons like Creative Commons.

As an experiment, we tried a schematic form of icons. The feedback that we’ve got so far is that the schematic is over-kill and that a set of icons more similar to Creative Commons’s would be easier to scan and understand. The next step is for us to come up with a set of orthogonal decisions about what compromises the most important aspects of a privacy policy. In the end, we probably shouldn’t have more than 5 icons in the interest of simplicity.

For now here are a set of axis we’ve come up with that need to be whittled down:

Is your information…

Shared with a 3rd Party? Shared internally within the company?

Anonymized/Aggregated before being stored or used?

Personally Identifiable?

Stored for more than x number of days?

Encrypted on the server?

Monetized (sold) in some way?

Usable to contact you?

Update: Based on the feedback, we’ve decided the set of attributes people should care about.

Aza Raskin, former head of user experience at Mozilla Labs and creative lead for Firefox, now runs Massive Health, a startup that aims to help people take control of their health. This post originally appeared at his blog.

Don’t assume anything.

Assumptions can kill.  Assuming something regarding your own health care can cost you money, cause you pain, and yes, even kill you.  Here’s my list of potentially harmful assumptions:

1.  No news is good news

If you have a test done and don’t hear anything about the result, do not assume it is fine.  This assumption kills people.  I have too many patients with too much information flying at me every day for me to catch every important detail.  Sometimes things are missed, but sometimes the results don’t come to our office.   We have trained our patients to expect an email or letter with their results within a certain amount of time, so they sometimes call when the test results don’t come in.  I tell them to do so in the clinical summary sheet I hand out at the end of each visit, but the assumption remains.

Always know what tests are being run, and always get the results of those tests (in writing, if possible).

2.  The doctor will think I am stupid

I often have patients apologizing to me.  They apologize when they have a “weird” symptom, when they “ask too many questions,” when they stop taking a medication due to side-effects, and when they are really, really worried about something.  They seem afraid that I am going to roll my eyes and think of them as “one of those patients” – the kind that I complain about to my office staff.

I hate it when people apologize.  Apologies assume there is some standard or expectation that a person is not meeting, and the only expectations that I have of my patients is:
a. they have or want to prevent medical problems
b. They want my help.

Why should I get mad at people for either of these things, as it is the job of a doctor to help people who need them.  I know there are doctors out there who treat patients like bad kids or like they are morons, but those doctors are out of step with reality.  They are the morons.  I don’t apologize to the barber that my hair grew.  I don’t apologize to my accountant for having tax questions.  Understand your position as the paying customer; get what you paid for.

One warning on this one: viewing yourself as a customer cuts both ways.  If you have the right to get what you pay for, the doctor has the right to be paid for what they give you.  People often think docs should do what they do out of pure charity and kindness, which is wrong.  I may expect the mechanic to be kind and charitable, but I should also expect to pay them for what they do.  This means that expecting your doctor to spend 30 minutes with you and only charge you for a 5-minute visit is not fair to the doctor (or his wife and kids).

3.  Doctors don’t want to be questioned

I hope I am not unusual in this, but I would rather have patients question what I do than to accept everything I say.

Patients’ questions help me in several ways.  First, they let me know what I am not explaining well enough.  I think people follow instructions better when they understand them, so if you don’t understand what I said, ask.  Second, questions build my credibility.  If I can explain the reason for my recommendations, I am more trusted.  If I fear questions, then it looks like I am hiding something.  Third, and most importantly, questions sometimes lead to better care.  Sometimes patients ask me about something I haven’t considered.  Sometimes the questions make me think things through and see my faulty logic.  Sometimes questions make me look for information and learn something.

Good doctoring has a whole lot of teaching in it.  Teaching is not a goal in itself, however; the goal is to get the person being taught to understand.  If you don’t understand what’s being done, why you got a prescription, or what your diagnosis is, ask.  If you wonder about another possible diagnosis, ask.  If your doctor doesn’t like you asking questions, ask for a copy of your records and find another doctor.

4.  Standard care is the right care.

Much of what doctors do is based on, or at least consistent with science; but a lot of care goes on despite that science says otherwise.  A group of physician organizations recently banded together and published the Choosing Wisely Campaign, a set of “things patients and physicians should question.”  The groups urge doctors and patients to choose care that is:

• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary

Here’s a sample of things done frequently that the Choosing Wisely campaign suggests questioning:

• Getting an x-ray for people with uncomplicated back pain
• Using antibiotics for sinusitis lasting less than 7 days
• Routine EKG’s on average (lower-risk) people
• Routine screening stress-tests
• Use of anti-inflammatory drugs (NSAID’s) in people with high blood pressure, heart disease, kidney problems, or diabetes.

There are many more recommendations on the site, but the reason this campaign was launched was because of how often these rules are broken.  I must admit, I have had to change my habits in the light of some of these recommendations.

5.  My doctors talk to each other

I am a primary care doctor, so I am supposed to be the hub of a patient’s care.  If a patient of mine goes in the hospital, has surgery, sees a specialist, or goes to the emergency room, I am supposed to be notified.  Unfortunately, this is probably not even true in of 50% of these situations.  Even when patients ask specifically to have records sent to me, they often aren’t there.

Specialists also have this problem, often getting consults without a clear reason.  Often this is a problem at the referring physician’s end, but we have had numerous specialists turn down offers to access our records.  We have also offered access to our records by hospitalists and ER doctors, only to be been turned down.  Many doctors prefer to give care with only information they gather.  It is rare that any doctor has all of the information that may be helpful.

An exception to this is the integrated care system run by a hospital (usually), in which doctors all share medical records.  Clearly the sharing of information in that setting is better than in my world, but being under the care of a hospital gives other disadvantages I will discuss later.

6.  My doctor has accurate records

Not only do I not have much of the information that comes from other doctors, but the information I do have in my records are not always accurate.  The biggest culprit in our office is old information that doesn’t get taken off.  It takes a large amount of time to make sure a person’s records are accurate, and there are no insurance companies willing to pay for improved accuracy.  So accuracy only happens when doctors take time away from reimbursed patient care and work to organize the records.  Again, our office makes a valiant effort at keeping things accurate, but I have found that it takes a huge amount of time, planning, and energy to keep records updated.

I personally don’t think this will change until the patient becomes responsible to keep their own records.  Nobody will ever care about a patient’s records as much as the patient does.  In the mean-time, I recommend that you keep an updated list of your medications, surgeries, problems, and even your family/home situation and bring it with you to visits.

7.  I will be notified when things are due

Are you due for a colonoscopy, thyroid lab tests, a follow-up CT scan, or a diabetic eye exam?  Most people don’t know exactly when things are due, and many assume they will be notified when this is the case.  Gastroenterologists do often call when the follow-up colonoscopy is due, and mammography facilities sometimes call for a follow-up, but these are exceptions to this rule.  Doctors often say “repeat test in six months,” and then expect the patient to call to schedule after six months.  Even patients coming into the office may not be reminded of overdue tests, mainly due to the disorganization of medical records (#3 above).  If you think you might be due for something, ask.  Even asking the question, “are there any tests or labs I am due to get done?” can help remind providers to check for these things.  Remember, it is incredibly hard to keep records organize, so don’t assume your doctor’s office will act anything like Jiffy-Lube.

8.  Hospitals care

The commercials boast of how local hospitals are “there for you when you need them most,” and “your advocate for your health.”  This is horse hockey.  The people in the hospital may be caring and kind.  The doctors, nurses, and even administrators may want you to be healthy.  But the hospital is a business which requires people to be sick and have lots of procedures done to be profitable.  Most health care dollars are spent in hospitals, and many times those dollars do no good to the patient.  I’ve seen end-stage cancer patients get heart catheterization, people with dementia spend weeks in the ICU, and countless other procedures are done with no benefit (other than income to the hospital).

Don’t be fooled.  Your goal is to stay healthy and stay out of the hospital;  your doing so is bad for the business of hospitals.

9.  More is better

I have patients frequently asking for tests they don’t need.  Shouldn’t people get yearly lab panels?  Shouldn’t kids get their cholesterol checked?  What about those screening mobile tests for carotid artery plaques or PAD?  It’s hard to make my patients understand that in saying “no” to tests, I am being a better doctor.  I talked about this in an earlier post, but it bears repeating.  If someone has a high chance of having a condition, screening for it is useless (doing a strep test on someone with an obvious strep throat).  If someone has a very low chance of having a condition, screening for it won’t reduce the risk (CA-125 screening for ovarian cancer, for example).  Having more information is often not helpful, can lead to unnecessary worry or further testing, and costs a lot of money for no gain.  I don’t want more information, I want the right information.

10.  New is better

What about that new drug advertised on TV?  What about the surgery done by robots?  Should I take that antidepressant for pain?  Do I have low-T?  Should I go to the hospital with the brand new 200 gazillion dollar heart pavilion? Always look at advertising with a skeptical eye.  The main reason businesses spend money on advertising is that they want to make more money when you use the thing they advertised.  The 200 gazillion dollars for the heart pavilion has to come from somewhere.  There’s a reason why you first heard of “low T” on television and not from your doctor: the company who wants to fix your T wants your money.  Robotic surgery is surely cool, but it is also really expensive to buy that machine, and hospitals need you to want the “cool” surgery so they can pay for those machines.

Sometimes “new and improved” is a truthful boast, but usually it is a means into your wallet.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind). Where this post first appeared.

I’ve been saying it for years (and in 3D and Technicolor in my new book Healthcare Beyond Reform): The Standard Model of Healthcare (the traditional unmodified fee-for-service, commodified, defined-benefit payment system) is broken and doomed. It’s fascinating to hear that even the CEO of Aetna, Mark Bertolini, said exactly that recently at a major healthcare technology conference — and that Forbes, a bastion of business and the private approach to everything, would publish an article on his remarks.

At Health 2.0 last fall, Bertolini said that he no longer thinks of Aetna as an insurance company, but primarily as an information company. This time, he made these main points:

• The end of medical underwriting in the ACA, combined with other demographic, regulatory, and economic factors, made health insurers’ business model increasingly untenable.
• These changes will not go away, one way or another, no matter what the Supreme Court does, no matter who is elected in November. These changes are directly tied not just to legislation but to underlying demographic and economic realities
• This is not a terrible thing. “We got pulled through the crucible against our will and have been reshaped because of it,” he said. “For most of what has already been implemented, it has been a pretty good thing.”
• Health insurers are unlikely to disappear. But their primary role in the future will be using new technologies to help accountable health systems serve their customers and drive out costs — and the health systems, not the health insurers, will increasingly be the face, the brand, of that improvement. “We can use technology to make it easier for the consumer. Convenience is the new word for quality.”

He is right on every count, and that is not news. What is news is who is saying it. When the CEOs of companies like Aetna and Cigna, and the CEOs of the many Blues that I have been working with in recent months, show that they understand the size, shape, and power of the changes we are all surfing together, that to me is one more clear sign that this change is happening. There will be no going back.

With nearly 30 years’ experience, Joe Flower has emerged as a premier observer on the deep forces changing healthcare in the United States and around the world. As a healthcare speaker, writer, and consultant, he has explored the future of healthcare with clients ranging from the World Health Organization, the Global Business Network, and the U.K. National Health Service, to the majority of state hospital associations in the U.S. You can find more of Joe’s work at his website, imaginewhatif.