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Can Social Media Really Influence Health Behaviors? A Small Clinical Trial Argues The Answer Is Yes.

Sep 14, 2013• 4

By Jaan Sidorov, MD

Thanks to the technologic allure of iPhones replacing stethoscopes, apps substituting for doctors and electronic information substituting for having to actually talk to patients, this thoroughly modern correspondent is all about medical-social media.

Think Facebook for the flu. Twitter for tinnitus. Egads, listen to the typical consultant, pundit or futurist and it’s easy to believe that we’re on the verge of a silicon-based health care revolution.

But then reality intrudes and some skeptic somewhere always asks about the bang for the buck, the juice for the squeeze, the return for the investment. It’s a good question.

For something of an answer, consider the results appearing in a recently published randomized clinical trial by researchers at UCLA. Over a 4 month period, “at risk persons” were recruited for a clinical research trial with on-line ads (Facebook banners, Craigslist, for example) as well as announcements in community settings and venues. Once subjects met the inclusion criteria and had a unique Facebook account, they were randomly assigned to one of two treatment arms.

One treatment arm used a closed Facebook group to coach persons about their at risk condition. The other treatment arm similarly used Facebook to coach persons about general health improvement. Lay “Peer Leaders,” who were given a three hour training session on “epidemiology of the condition or general health subjects and ways of using Facebook to discuss health and stigmatizing topics,” were assigned to lead the groups.

Peer Leaders attempted to reach out to their assigned group persons with messaging, chats and wall posts. Once the link was established, the relationship in the intervention group included communication about prevention and treatment of the condition. At the end of 1, 2 and three months of the study, participants completed a variety of surveys.

Results?

57 individuals were in the control general health group and 55 were in the condition coaching group. According to the surveys, intervention patients were ultimately statistically significantly more likely to agree to condition testing (44%) than the control patients (20%). Because there were few participants, the modest decrease in actual tests or risk behaviors were not statistically meaningful.

This correspondent’s take:

While this was a small study, this is the first time that I have seen reasonable proof that social media by itself can move the behavior needle. On the other hand, this did not result in a patient engagement stampede toward better care or hard clinical outcomes. A majority of participants (56%) did not appear to benefit. Nonetheless, the results do support the inclusion of Facebook-style closed group social media in the suite of population health management services.

Patient Engagement: On Metrics and Meaning

Sep 12, 2013• 28

By Leslie Kernisan, MD

What is patient engagement?

Everyone agrees that it’s a good thing, and that we healthcare providers should be fostering it.

How to do so, however, depends on just what you believe patient engagement means.

As Dan Munro recently pointed out, the term “patient engagement” is a hot buzz phrase, and – in the best tradition of such phrases – it’s amorphous enough and appealing enough to mean…just about anything.

Provided that it that makes us feel good about healthcare, of course. Better yet, provided that it casts our favorite healthcare approaches in a favorable light. (Rob Lamberts nicely summarizes some angles of the term here.)

I actually rather liked Munro’s post, titled “Patient engagement: Blockbuster Drug or Snake Oil?” until he got to this part: “We now have some very real metrics around what constitutes real patient engagement and Leonard highlighted two impressive examples.” He goes on to point to two studies of care coordination for chronic illness — one at Kaiser and the other at the VA – and summarizes some key improvements in outcomes.

At Kaiser, they included things like decreased mortality rates and fewer emergencies, as well as improved cholesterol screenings and more people meeting cholesterol goals. With the VA’s Telehealth program, hospital days were reduced and patient satisfaction was 86%. (BTW, I had a VA primary care clinic from 2006-2010, and several of my patients were in Telehealth.)

These are indeed nice results. Still, somehow they didn’t impress me as constituting “real patient engagement.” They seemed more like “real population health management, facilitated by teams, care coordination, communication infrastructure, and organized protocols.”

Shouldn’t real patient engagement mean more than this?

Defining patient engagement

Here’s my current take:

Supporting patient engagement means fostering a fruitful collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.

When Your Doctor Dies

Sep 12, 2013• 14

By Abraar Karan

Several studies have explored the experience of grief that physicians feel when they lose a patient.

But what about when the patient loses a physician—when the doctor dies?

Dr. K was a well-known child psychiatrist, a loving husband, a father of two, and an irreplaceable support and friend for a number of children suffering from trauma, schizophrenia, bipolar disorder, autism and other challenging psychiatric conditions. Earlier this year, Dr. K passed away in a tragic accident while vacationing with his family. His loss was nearly unbearable for most of us.

Days after the funeral, a colleague of Dr. K inquired into whose care his patients would be transferred. She was shocked to hear that one of his patients, a young teenager suffering from Asperger’s syndrome, anxiety, and depression, had overdosed on his medication and committed suicide the day he heard of Dr. K’s death. It was no coincidence.

Behind the family members, close friends, colleagues, and acquaintances are the physician’s patients. They are part of a separate, almost secret life that the physician leads. And yet, the patient is whom the physician spends more time with than anyone else—they are in some ways the truest reflection of the doctor. While family and others grieve together in collective remembrance, patients often do so isolated, alone, confidential.

Death of a Porn Star

Sep 12, 2013• 6

By Tim Lahey, MD

Porn stars all across San Fernando were told to put their clothes back on and go home a couple of weeks ago on the news that a 29 year-old adult actress named Cameron Bay tested positive for HIV.

Shortly thereafter, the Internet lit up. News, judgments, and jokes shot left and right in newsrooms as freely as bodily fluids fly on set. Countless reporters and pundits surely worked overtime to do the deep background: who were Ms. Bay’s co-actors, who did what to whom, and inquiring minds want to know: were condoms used? Imagine the frenzied speculation, all those sticky keystrokes.

Don’t get me wrong: the details of the whodunit have medical import. Public health workers need to find who is at risk. Those who are at risk need testing and education including reminders that early tests can be falsely negative and must be repeated. Since this isn’t the first case of HIV among the scantily clad actors of San Fernando, CA, Ms. Bay’s diagnosis demands we try again to get porn stars to practice safer sex. My guess is legal maneuvers will never do much to affect the sex lives of the nude and infamous, but if porn viewers could learn to have fun even with a condom on set there might be a hope.

Twitter captured all this and more. It showed the diversity of our reactions to Ms. Bay and people like her. Some tweets expressed a sense of inevitability:

Some were judgmental:

Reforming Health Reform

Sep 11, 2013• 16

By ROGER COLLIER

It may say something about expectations for the Affordable Care Act that the simplistic “just repeal Obamacare” cries of Congressional Republicans are starting to be supplemented by proposals for its replacement.

The most detailed so far is from the conservative American Enterprise Institute, which has published an unexpectedly non-doctrinaire study authored by Harvard professor Michael Chernew and seven other respected academics.

It’s far from perfect, but it’s worth reading.

Structural details of the AEI proposal, modestly titled “Best of Both Worlds,” aren’t always clear (page 1 lists four “principles,” page 5 lists five “priorities”, and page 16 lists three “major planks”), but it does attempt a bipartisan approach, combining ideas from left and right.

Some of these ideas have been contained in other proposals, such as those of Wyden and Bennett and Fuchs and Emanuel (which may damn the AEI proposal in right-wing eyes), and most recently in a THCB piece by Martin Gaynor. They include the elimination of the employer coverage tax preference, the provision of “premium support” subsidies for most individuals, and the establishment of a national insurance exchange. Together, they are designed to encourage individual choice and responsibility and to maximize competition between insurers, while removing some of the inequities of the present system (and of the ACA).

The AEI proposal assumes that eliminating the employer coverage tax preference will result in most individuals obtaining coverage through a national exchange, with national regulation of insurance plans. Current Medicaid eligibles will be included, with the replacement of acute care Medicaid funding by subsidies for conventional coverage. All individuals will be able to choose between fully-subsidized “basic plans” and more generous partially-subsidized options, typically with substantial deductibles tied to income and health status. Insurers will be encouraged to offer multi-year coverage and, unlike in the ACA, medical underwriting will be allowed. The only government financing will be for premium subsidies, to be funded by the additional income and payroll tax revenues resulting from elimination of the employer tax preference and by redirecting federal and state Medicaid payments.

Health Exchange Confusion: Why We’re Getting the IBM Story Wrong

Sep 10, 2013• 13

By David Williams

I was a bit surprised by the front-page headline and accompanying article in the weekend Wall Street Journal (IBM to Move Retirees Off Its Health Rolls). The headline and subtext of the article are that IBM is ending health benefits for retirees, leaving them to fend for themselves. But as I read through the specifics that doesn’t appear to be at all what’s happening. Unfortunately, the article’s main impact is to leave an unduly negative impression of private health insurance exchanges.

Retiree health benefits are a big deal, especially for employees who retire before they reach the Medicare eligibility age of 65. A typical early retiree in his or her 50s will face high premiums in the individual market compared to a younger, and typically healthier, person. If they are among the few whose company provides generous coverage they are very lucky.

[On a side note, life is about to get easier for early retirees who have to buy their own insurance, thanks to Obamacare’s banning of medical underwriting and limits on the ratio of premiums charged to older people versus younger ones.]

When a person turns 65 life gets a lot easier on the health insurance front as the federal government takes over the vast majority of costs. As a result, a retiree on Medicare is much cheaper for an employer to provide health care benefits to, since they are essentially just paying for supplemental coverage.

Obesity and the AMA, Part Two

Sep 10, 2013• 11

By Vik Khanna & Al Lewis

A likely unanticipated consequence of the AMA’s decision to label obesity a disease, even though their own scientific council said not to, is that this might serve as the macguffin leading to furtherance of a protected class of people. This has serious implications not only for employment discrimination, but also for wellness programs, which often hinge vastly overblown claims of being able to help the obese who they almost universally label as “high risk” people.

Well, what if people who are obese, who are no doubt tired of being condescended to, first by wellness companies, and now by the AMA, decide that they are going to seek medical approval to opt out of wellness programs? A study recently published in the journal Translational Behavioral Medicine reports on a highly coercive, electronically monitored walking program for obese people: 17% opted not to participate and another 5% actually got their physician’s approval to opt out. The physician approval to opt out is key to any resistance strategy.

Under the final wellness rules issued by the federal government earlier this year, physician certification that it is medically unadvisable for an employee to participate in a wellness program creates a burden for the employer and wellness vendor. They must provide reasonable alternatives that do not disadvantage the employee in terms of either time or cost and that address the physician’s concerns.

Further, if the employee’s physician disagrees with offered alternative, the employer and wellness vendor must provide a second alternative. The coup de grace is that “adverse benefit determinations based on whether a participant or beneficiary is entitled to a reasonable alternative standard for a reward under a wellness program are considered to involve medical judgment and therefore are eligible for Federal external review.”

Targeting people based on body mass index (BMI) is an intellectually, morally, scientifically, and mathematically bankrupt approach. The AMA’s decision will actually help obese people and advocates for their dignified treatment in the workplace and society start to understand that they can refuse to opt in to these insulting programs and, simultaneously, be protected from penalties. Clearly, this is the opposite of what unsuspecting employers expect when vendors (and their own brokers) sell them these programs: more useless doctor visits, less leverage with penalties…and more employee disgruntlement. Not just the obese will be disgruntled, but also those who have to pay the penalties because their BMI is too high to get the reward but not high enough to get a doctor’s note.

Regulating Health IT: When, Who, and How?

Sep 10, 2013• 7

By Rebecca L. Jewell, Esq. & Dan Haley

Health care providers and consumers are increasingly using mobile technology to exchange information. Many health IT providers readily acknowledge that some level of oversight is required to ensure patient safety and privacy protections, but many providers question whether the FDA is the right agency for the job and want to see the FDASIA recommendations.

Can the FDA, with its already limited resources and lengthy review cycles, regulate the fast-moving health IT industry? Should it? Health IT is fundamentally different from a medical device in many ways. For oversight purposes, the key differentiator between the two is the opportunity for clinical intervention in the use of health IT. Many medical devices interact directly with the patient (such as an infusion pump or pacemaker). Most health IT, on the other hand, merely provides information to clinicians, who ultimately make independent, experienced care decisions. Physicians are informed, but not controlled, by the information. This leads to a vast difference in the patient risk proposition and rigid regulatory oversight is not appropriate.

Advocates of a broad health IT oversight framework – which encompasses mobile health IT – are urging the FDA to delay release of its final guidance, particularly in light of a July 2012 Congressional mandate for the creation of a comprehensive oversight framework that avoids regulatory duplication.

But some mobile medical application developers are pressing the FDA to move forward immediately, believing its guidance will reduce the regulatory uncertainty that they believe is stifling innovation and investment in some aspects of mHealth.

The Not Normals Break Through — An Update From the Khan Academy

Sep 9, 2013• 2

By MICHAEL PAINTER, MD

If you’re going to get ambitious about your next task, don’t go and talk to normal people about it. You’ll only get normal answers. Get out of your comfortable little world and step into a completely alien one. As we say round here, when worlds collide, transformation happens.

Love that passage from Brian Millar’s 2012 Fast Company piece. (Plus, it gives me the awesome chance to nod to the eccentrics and outliers—like Millar’s dominatrix and tattooed hipster set—and their unlikely importance to pioneering, breakthrough ideas).

Recently RWJF extended another grant to the Khan Academy; this one for $1.25 million. I say another as we started this health education journey with Sal, Rishi and the Khan team—right after Sal’s outstanding 2011 TED/Long Beach talk. That discussion resulted in a preliminary 2012 $350,000 bet on this great team. We were intrigued by their big idea—and we thought the world might be too.

What’s that big idea again? Just this: an entirely free, utterly fantastic health education for anyone in the world with a computer and an Internet connection.

Potentially crazy? Perhaps. Ambitious? No kidding. But for RWJF’s pioneering work, that’s right where we like to be. We thought there just might be something there. One year later, we are even more convinced. In that time, the Khan team has pushed intensely and hard—creating its new Healthcare and Medicine Initiative basically from scratch.

For instance, with our support, Khan staff have developed about 200 videos now posted on that Healthcare and Medicine Initiative site—as well as their YouTube medical channel. These videos have received about 800,000 views, and the site has over 10,000 new subscribers. Khan continues to work with Stanford Medical School. That collaboration includes developing and posting Stanford Medical School content on the Khan site as well as integrating the online format into traditional medical school courses.Continue reading…

The Shocking Truth About Medication Errors

Sep 9, 2013• 8

By Leah Binder

Let’s say a physician writes a prescription for Colchicine and accidentally orders “10.0 mg,” when he should have ordered “1.0 mg.” That’s a tiny decimal error, a mistake even the best doctor could make. But it can be catastrophic for the patient. The higher dose could cause Colchicine poisoning, similar to arsenic poisoning: burning in the mouth and throat, excruciating abdominal pain. Internal organs would melt away and death would likely occur within 24 to 72 hours.

The ease with which even the best doctors can make gruesome errors is why hospitals set up elaborate systems to check and double check orders before drugs are given to patients. Some hospitals are better at this checking than others. Medication errors happen all the time, an estimated one million each year, contributing to 7,000 deaths. On average there is one medication error every day for every inpatient. Let’s take a closer look at what’s contributing to these preventable errors.

Hospitals Are In The Technological Dark Ages

According to recent research, the best known way for hospitals to protect patients from errors is by adopting technology called computerized physician order entry (CPOE). The physician (or other authorized prescriber) enters orders for a patient on a computer that contains patient information such as key lab values, clinical condition, allergies, etc. The computer checks the safety and appropriateness of the order and sends it electronically to the pharmacy. In the Colchicine example, a good CPOE system would alert the physician to the misplaced decimal in the order, and the best systems would prevent the order from being written in the first place. In my mind, one of the greatest advances of CPOE is that it eliminates the need for pharmacists to decipher physician handwriting. I’ve often wondered how they do that.

The research suggests errors decline by as much as 85 percent when hospitals implement CPOE, yet the pace of adoption in the hospital industry is agonizingly slow. To jump start progress, the federal government used economic stimulus funds starting back in 2009 to incentivize hospital investment in CPOE and electronic medical records (EMRs). That improved the pace of change, but still, most hospitals are in the Dark Ages when compared to other industries like airlines or retail.

My nonprofit, Leapfrog, finds that only about a third of the hospitals that voluntarily report to our survey meet our standard for full implementation of CPOE. Even for that minority of hospitals that adopt CPOE, the system doesn’t always work as advertised. Like all technology, CPOE must be continually tested and modified. That’s not always happening.