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Tag: Patients

A Cross-Party Win: Empowering Consumers Through Digital Health

By LYGEIA RICCIARDI

These days Americans are more politically divided than ever, disagreeing vehemently about everything from guns to the role of the press. Despite the distrust and inflammatory rhetoric, there are examples of cross-party, trans-Administration collaboration and success. Let’s celebrate them and be motivated by what happens we put differences aside and focus on shared long-term goals.

Using digital technology to empower healthcare consumers is one example of a cross-party win, a still-developing success story that has been cultivated for more than a decade by the efforts of public and private sector leaders from a wide variety of affiliations and political perspectives.

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The Solution Never Works If You Haven’t Identified the Problem

I have a bias, I admit it. I am sensitive to studies with a subtext of “those stupid patients, what are we going to do about them?” Read the following rant with that in mind.

A pharmacy benefits manager a/k/a PBM funds a study of patients nonadherent to chronic prescription medication. The premise of the study, Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial (hiding behind a paywall, by the way), is that “forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices.” Thus, the intervention consisted of sending a population which included folks taking meds for schizophrenia and bipolar disorder either “a pill bottle strip with toggles, digital timer cap or standard pillbox” along with their mail order meds. There was of course a control group who received neither notification or a device. Surprise, surprise! Getting a prize in your Crackerjack box from your PBM does not improve medication adherence. Those stupid patients! Why won’t they do what’s good for them?

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Lifetime Health Records For Patients?

flying cadeucii Leonard Kish and Eric Topol recently argued eloquently for patient control of a lifetime health record, adding their voices to the calls for patient ownership of health records, building on the foundational notion that ownership is necessary in order to assert control because “possession is nine-tenths of the law.”

I certainly agree that patient control of data is of paramount importance, but I am not convinced that we need to take the leap to patient “ownership” of data, and I am not quite sure what that even means in this day and age — or how it really differs from the status quo.

I’m less worried about the name we use for the bundle of rights a patient has with respect to his or her health data than I am about the vehicle available to exercise those rights.Continue reading…

Opening the Care Conversation Through Open Notes

Susan DentzerIt’s a memory aid.

It’s truth serum.

Using it can transform relationships forever.

These may sound like come-ons for the type of product typically hawked on late-night television.  But in fact, they’re some of the things people are saying about OpenNotes.

OpenNotes isn’t a product, but an idea: That the notes doctors and other clinicians write about visits with patients should be available to the patients themselves. Although federal law  gives patients that right, longstanding medical practice has been to reserve those visit notes for clinicians’ eyes only.

But Tom Delbanco and Jan Walker, a physician and nurse at Beth Israel Deaconess Medical Center in Boston, have long seen things differently.

Their personal experiences with patients, and inability to access care records for their own family members, persuaded them that the traditional practice of “closed” visit notes had to change.  So, with primary support from the Robert Wood Johnson Foundation, they launched what has now become a movement.

In 2010, Delbanco, Walker and colleagues led a study in which more than 100 primary care doctors from three health systems began sharing notes online with patients. Patients got secure messages prompting them that the notes were available, and reminders to read notes before their next appointments.

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Patients are NOT Customers

Screen Shot 2015-03-21 at 4.26.26 PMRecently I wrote about the problems with Maintenance of Certification requirements.  One of the phrases I read repeatedly when I was researching the piece was “the patient as customer.”  Here’s a quote from the online journal produced by Accenture, the management consulting company:

Patients are less forgiving of poor service than they once were, and the bar keeps being raised higher because of the continually improving service quality offered by other kinds of companies with whom patients interact—overnight delivery services, online retailers, luxury auto dealerships and more. With these kinds of cross-sector comparisons now the norm, hospitals will have to venture beyond the traditional realm of merely providing world-class medical care. They must put in place the operations and processes to satisfy patients through differentiated experiences that engender greater loyalty. The key is to approach patients as customers, and to design the end-to-end patient experience accordingly.

Except for one thing.  Patients are NOT customers.

The definition of a “customer” is a person or entity that obtains a service or product from another person or entity in exchange for money.  Customers can buy either goods or services.  Health care is classified by the government as a service industry because it provides an intangible thing rather than an actual thing.  If you buy a good, like a car, you voluntarily decide to shop around and get the best car you can for the price.  Even a vacation, especially a vacation package or a cruise, is a good.  A nice dinner, while a good in the sense of the food, is also a service.  You buy the services of the cook and servers.

Here is why the patient shouldn’t be considered a customer, at least not in the business sense.

1. Patients are not on vacation.  They are not in the mindset that they are sitting in the doctors office or the hospital to have a good time.  They are not relaxed, they have not left their troubles temporarily behind them.  They have not bought room service and a massage. They are not in the mood to be happy.  They would rather not be requiring the service they are requesting.  Which leads to number 2:

2. Patients have not chosen to buy the service.  Patients have been forced to seek the service, in most cases.

3. Patients are not paying for the service.  At least not directly.  And they have no idea what the price is anyway.

4. Patients are not buying a product from which they can demand a positive outcome.  Sometimes the result of the service is still illness and/or death.  This does not mean the service provided was not a good one.

5. The patient is not always right.  A patient cannot, or should not, go to a doctor demanding certain things.  They should demand good care, but that care might mean denying the patient what the patient thinks he or she needs.  The doctor is not a servant; she does not have to do everything the patient wants.  She is obligated to do everything the patient needs.

6. Patient satisfaction does not always correlate with the quality of the product.A patient who is given antibiotics for a cold is very satisfied but has gotten poor quality care.  A patient who gets a knee scope for knee pain might also be very satisfied, despite the fact that such surgery has been shown to have little actual benefit in many types of knee pain.

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What Do Women Know About Obamacare That Men Don’t?

Susan DentzerFor the second year running, more women than men have signed up for coverage in health insurance marketplaces during open enrollment under the Affordable Care Act. According to the Department of Health and Human Services, enrollment ran 56 percent female, 44 percent male, during last year’s open enrollment season; preliminary data from this year shows enrollment at 55 percent female, 45 percent male – a 10 percentage point difference.

What gives? An HHS spokeswoman says the department can’t explain most of the differential. Females make up about 51 percent of the U.S. population, but there is no real evidence that, prior to ACA implementation, they were disproportionately more likely to be uninsured than men – and in fact, some evidence indicates that they were less likely to be uninsured than males .

What is clear that many women were highly motivated to obtain coverage under the health reform law – most likely because they want it, and need it.

It’s widely accepted that women tend to be highly concerned about health and health care; they use more of it than men, in part due to reproductive services, and make 80 percent of health care decisions for their families . The early evidence also suggests that women who obtained coverage during open enrollment season last year actively used it.  Continue reading…

How Technology Will Disrupt Your Doctor’s Monopoly

flying cadeuciiAlthough you may not realize it, your doctor is a monopoly. Yes, you can see someone else, but not without difficulty. And if you wanted a second opinion, how far would you go? In part, through insurance coverage, in part based on a desire for convenience, healthcare is generally a local monopoly. However, that may be about to change.

I’m a radiologist, an expert in medical imaging. When I started my career in 1997, I’d show up for work and it was just me and my films. The exams presented to me were a mix of imaging- CT, MRI, ultrasound, plain X-Rays- all captured, presented and stored on film. By 2000, the film was gone. Just about everything I did was done on a computer.

I was an early proponent for this technology (also know as PACS for Picture Archiving and Communications Systems). It allowed my group to work faster and smarter. However through a series of steps (consolidation, specialization and finally commoditization/globalization) technology broke up the local monopoly many radiology groups enjoyed. Similar to Instagram, PACS allowed medical images to be seen instantly by anyone anywhere. And now, based on improvements in technology, I’m expecting similar changes for the rest of healthcare.

Consolidation

Tele-radiology first emerged in hospitals when computers began to be used to optimize the daily workload. At the beginning of my career, several doctors divided work for the day into piles. Each person did his or her allotment with no real help from peers. With the transition to digital, work became a common pile that was shared among physicians in the same hospital. Faster doctors filled downtime gaps reading more cases, resulting in improved overall efficiency.

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The Therapeutic Paradox: What’s Right for the Population May Not Be Right for the Patient

flying cadeuciiAn article in this week’s New York Times called Will This Treatment Help Me?  There’s a Statistic for that highlights the disconnect between the risks (and risk reductions) that epidemiologists, researchers, guideline writers, the pharmaceutical industry, and policy wonks think are significant and the risks (and risk reductions) patients intuitively think are significant enough to warrant treatment.

The authors, bloggers at The Incidental Economist, begin the article with a sobering look at the number needed to treat (NNT).  For the primary prevention of myocardial infarction (MI), if 2000 people with a 10% or higher risk of MI in the next 10 years take aspirin for 2 years, one MI will be prevented.  1999 people will have gotten no benefit from aspirin, and four will have an MI in spite of taking aspirin.  Aspirin, a very good drug on all accounts, is far from a panacea, and this from a man (me) who takes it in spite of falling far below the risk threshold at which it is recommended.

One problem with NNT is that for patients it is a gratuitous numerical transformation of a simple number that anybody could understand (the absolute risk reduction  – “your risk of stroke is reduced 3% by taking coumadin“), into a more abstract one (the NNT – “if we treat 33 people with coumadin, we prevent one stroke among them”) that requires retransformation into examples that people can understand, as shown in pictograms in the NYT article.  A person trying to understand stroke prevention with coumadin could care less about the other 32 people his doctor is treating with coumadin, he is interested in himself.  And his risk is reduced 3%.  So why do we even use the NNT, why not just use ARR?

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A Tale of Two Sore Throats: On Retail Clinics and Urgent Care

Leslie Kernisan new headshotSix years ago, just after arriving in Baltimore for a winter conference, I fell sick with fever and a bad sore throat.

After a night of feeling awful, I went looking for help. I found it at a Minute Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did a rapid strep test, and prescribed me medication. I picked up my medication at the pharmacy there. The visit cost something like $85, and took maybe 30 minutes. They gave me forms to submit to my California insurance. And I was well enough to present my research as planned by day 3 of the conference.

Fast forward to this year. After feeling a bit blah on a Monday evening, I developed a sore throat, headache, and fever overnight.

I figured it was a winter viral pharyngitis, rearranged my schedule, and planned to make it an “easy day.” Usually a low-key day plus a good night’s sleep does the trick for me.

But not with this bug.

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