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Healthcare Revisited

Consider how healthcare should be…

What’s the difference between healthcare and Cinderella?

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Glass slipper

Healthcare and Cinderella

The US healthcare system is facing an eminent change in its business model. Over the last several decades, through poorly aligned reimbursement systems and convoluted, market distorting subsidies, the business of our delivery system has become the filling of hospital beds. Sure, as a group, healthcare is filled with people who want to provide quality care, help patients, and improve outcomes, but that’s not what we get paid for. The vast majority of money in US healthcare is made by filing hospital beds, and by shortening length of stay.

In just the last decade, there’s been an increasing awareness of how broken our system is. We pay 2-3 times more than any other developed nation, and we have very little to show for it. In terms of performance, the World Health Organization ranked the US system 37th in the world; just above Cuba and Slovenia, and just behind Costa Rica and Dominica.

With the increasing visibility of how broken our system is, and the increasing industry awareness of the fact that the business models that have led to this travesty must change, you would think that more delivery systems would be seeking to shift to a more progressive solution. In an effort to help communicate part of why we’re moving so slowly, I wanted to share an analogy.

Let’s start by imagining a healthcare delivery system, all dressed up in a ball gown and glass slippers. Sould a little silly? Stick with me for just a minute more…

Read the rest of this entry »

It’s NOT the patients’ fault! Stop whining and fix it.

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Whining baby

Stop whining and make better tools!

Healthcare has to be among the whiniest of all industries. Can you imagine leaders in another industry blaming the consumer for not using their product? Can you imagine what would happen if a product director at GE, or Apple told his boss that the reason his product wasn’t successful was because of a problem with consumers? 

I can imagine it now, “Mr. Jobs, the product is perfect, just the way it is. The reason it’s not selling is because users are just too dumb to realize how good it is.”

It’s easy to see that response is whiny and lazy. They’d be lucky to get back to their desk before they were fired.

So why do we continue to put up with that mindset in healthcare? I recently read an Information Week article from Paul Cerrato titled, “Why Personal Health Records Have Flopped; It’s not a security, privacy, or data-sharing problem. It’s a patient problem“. In the article, he says that the problem with Personal Health Records is consumer apathy. That kind of thinking is no different than the ridiculous scenario we were imagining at Apple. Stop blaming patients, and put in the energy to figure out what they want and need!

Now Paul, just to clarify, I’m not endorsing Colin Evan’s belief that the problem is providers’ unwillingness to put patients in control of their medical data, either. What would a patient do with their medical data if they did have control of it? Medical data takes a lot of knowledge to understand and interpret, and the average healthcare consumer has about a 4th grade reading level (that means that half of them are actually reading below that).

What I am saying is that if we want to successfully improve the healthcare industry, we can’t be satisfied with blaming the patients. We have to take the time and energy to ask “why”. Why are people willing to spend twice the energy picking a TV that they’ll spend picking their doctor? Is it because they don’t care about their health? Personally, I have a much harder time believing that people don’t care about their health, and a much easier time believing that we’ve made crappy tools, that don’t adequately support consumers’ needs when it comes to the complex, confusing, and intimidating healthcare industry.

We need to know that we’re giving people access to good healthcare consumer engagement products that are functional, usable, and hopefully, even desirable. And to do that, we have to stop whining and recognize that it’s not the patients’ fault.

Why Epic myChart is NOT a Personal Health Record


Epic Systems MyChartI’ve spent most of the day today listening to  conversations about Epic myChart. As I’ve learned more, it’s become very clear that myChart is a good set of tools. But I have to suppress my urge to correct people every time they call it a Personal Health Record. It’s not. Why? Well, let’s start with a definition. One of the best definitions  of a Personal Health Record (and one of the most widely accepted and authoritative) that I’ve seen comes from HIMSS (Healthcare Information and Management Systems Society). They define a PHR as being:

“Universally accessible and layperson comprehensible, used as a lifelong tool for managing relevant health information…  Owned, managed and shared by the individual or his or her legal proxy(s), [allowing patients or proxies to] receive data from all constituents that participate in the individual’s healthcare…, enter their own data, and designate read-only access to the ePHR.”

If we break that definition apart, there are arguably four key components to this definition:

  1. Accessible and understandable
  2. Shareable, portable and lifelong
  3. Comprehensive (contains all relavent data)
  4. Owned and managed by the patient

Now myChart has done a reasonable (but not ideal) job with the first component. Presenting a patient’s medical information in an online format in an easy to navigate tool, using patient friendly terminology is a huge step forward; especially for an industry that’s known for its cryptic “medicalese” language and unwillingness to provide patients with access to information. I’ll post again soon about what I think is needed in order to make more meaningful strides towards truly understandable medical information. For now, I’m willing to concede that myChart meets this criteria.

On to the second point. This one is a little more dicey for several reasons. The myChart tools do allow patients to share their information with others, but for all intents and purposes, you either share it all, or you don’t. That may seem like a minor issue, but here’s a functional example of the problems that this creates. In many states, children between the ages of 13 and 18 have a right to receive particular types of medical care without parental permission (e.g. birth control, treatment of STD’s, and some behavioral health issues). Because myChart sharing is “all-or-nothing”, we’re expecting to have to completely turn off access to myChart for patients in this age range, since there is no way to only share “non-protected” information with parents. In addition, because the myChart web tools are “tethered” to the Epic EMR, the information in myChart isn’t really portable. I can’t really bring it with me to another healthcare system that isn’t using Epic. This also limits the “lifelong” nature of the tool. I’ll be generous and give them half-credit.

Considering the third point,  comprehensiveness, Epic seems to have made some good initial progress around this with their Lucy and myChart Central solutions. This allows information from other Epic systems to be seen within myChart, but most of the “Care Everywhere” functionality is provider-centric. It gives providers a reasonable way to see electronic data from outside of Epic, but I have yet to see a good way for patients to consolidate their medical information from multiple healthcare systems in a single place. Unless you’re part of an HMO like Kaiser (and you don’t ever travel or get emergency care), there’s a very high likelihood that you are getting care from multiple helathcare systems. Until all that information can come together in one place, I think that half-credit on this is generous as well.

In regards to the final point,  owned and managed by the patient, this is where myChart really starts to fall down as a PHR. Patients are extremely limited in their ability to enter their own information into myChart. Patients can submit information to their provider for review, but only the provider is able to actually add information. For example, if I started taking a non-prescription medication (e.g. aspirin, herbals, prilosec, antihistamines, etc), I could send my provider a note that tells them that I’ve started takign that med, but if they forget to add it to the chart, or decided not to, I have no ability to enter it into myChart myself. This is another place where the functionality from “Lucy” is helping them to move forward, but myChart is still a far cry from patient owned and managed. Under the best of circumstances, this is another half-credit area, and it’s probably closer to a “zero”.

If each of these criteria are weighted evenly,  myChart would score just above a 60% as a PHR.  Now make no mistake, I’m impressed with the work that Epic has done. Its created a nice set of tools to begin the process of modernizing the patient experience. It allows patients to schedule clinic appointments and send secure messages to their providers, request renewals of your prescriptions and pay medical bills. It also gives you a limited “patient friendly” view into your medical record. That’s pretty neat, but it’s not a Personal Health Record (PHR). It is a small window that allows patients a controlled and restricted view into information that is controlled and used by providers. It’s a Patient Chart View.  By calling it something that it is not, we risk lowering the bar on  one of the most important patient enagement tools available – a true Personal Health Record.

Defining telemedicine vs telehealth

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Why do we bother distinguishing between Electronic Medical Records (EMR’s) and Personal Health Records (PHR’s)? I mean both of them are, at their core, just healthcare content management systems. Why do we spend all this energy distinguishing between them?

The obvious answer is that while the two solutions are certainly related technologies, they are designed to meet two very different needs, and are pointed towards two very different audiences. EMR’s are tools used to help clinicians manage and share content with other clinicians. PHR’s are there to connect with patients. Since this is such an obvious difference to anyone familiar with healthcare, why is it that we don’t bother to make the same distinction in the case of telemedicine vs telehealth?

There are two very different uses, two totally different audiences that these two solutions are directed at. By lumping them together, we’re failing to use either of them as well as we should. That means we’re doing a disservice to both groups of users, the same way we would be doing if we tried to lump EMR’s and PHR’s together and use them interchangably.

There is certainly some similarity between telemedicine and telehealth. They both use technology to remove the geographic barriers to providng healthcare services. Sometimes, they even use similar technology, but that doesn’t really matter because the technolgy is just a channel. In the end, what healthcare consumers are “buying” when they use either telemedicine or telehealth is the service and expertise on the other end of the line.

In healthcare, there are two different kinds of clinical services that can be provided; care delivery and consultation. Each type of service has a different consumer. When a patient comes to a provider seeking care, and we respond with diagnosis or treatment, that’s care delivery. In that situation, the consumer is the patient themselves. But sometimes, the clinician doesn’t have the answer themselves. This is when consultative services come into play. Whether I’m looking to a radiologist for a read on a CT scan, or asking a stroke neurologist for their help in deciding to treat a stroke patient with TPA, If one clinician is asking another clinician to collaborate and share their expertise, that’s a consultation.

The same way that EMR’s are the right tool for clinicians and PHR’s are the right tool for patients, TeleMedicine lets clinicians connect with other clinicians to remove the geographic barriers to consultations, TeleHealth connects patients to clinicians, and makes it possible to deliver care regardless of distance.

Why telehealth is so scary…


I’ve been hearing quite a bit lately about how telemedicine (connecting providers to other providers for virtual consultations) and telehealth (connecting patients to providers for virtual care) are exciting new technologies, but that there just isn’t enough return on investment (ROI) to justify the cost of implementing them. The truth is, there’s massive ROI potential from this kind of care model, but existing providers simply don’t have much motivation to pursue it.

Telehealth is scary to existing healthcare systems, because it fundamentally changes the paradigm of how healthcare is delivered. In order to provide modern healthcare, we’ve always had to create massive “care factories” (also known as hospitals). Existing healthcare players have become pretty good at operating these care factories under the existing system’s rules. They are pretty happy with that situation, also, because the ridiculously high costs associated with building and running these factories protect established players by creating incredibly high barriers to entry into the healthcare industry. It’s also meant that the hospitals have become a vortex, sucking providers, services and patients into their field of influence.

Telemedicine and telehealth remove geography as a barrier to care. That means that suddenly, it’s possible to push out healthcare to the patients, rather than centralizing providers and pulling patients to our giant, expensive care factories. That’s incredibly disruptive! Read the rest of this entry »

We do NOT need more PCP’s

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The obvious fact is that despite the pending shortage of primary care providers (PCP’s)there’s no way to increase their numbers in a timely way. But that’s OK. Why? Because what we need isn’t more availability of PCP’s, it’s more availability of primary care services. That’s a subtle distinction, but an important one.

Another way to say this is that what we really need is not more providers, but a better way to meet healthcare consumer’s needs; and in order to do that well, the we’ve got to better understand what those needs are.

When a patient wants the healthcare system to manage a complex chronic disease like diabetes, their needs could probably be expressed as something like, “build a trusting relationship with me, know my medical history well, and create an effective long-term care plan”. Traditional primary care generally (well, maybe the better word is “hopefully”) does a pretty good job of meeting these kinds of needs.

Now imagine the same person who now wants the healthcare system to manage a itching, burning, uncomfortable (but clinically non-urgent) rash. Now their needs are different. What they want is more like, “Evaluate me ASAP, make sure I don’t have something more serious, get me the medication I need, and make it happen conveniently and cheaply”.

Our traditional primary care system is notoriously bad about meeting this second set of low acuity, high volume “On-Demand” consumer needs. The good news is that there are potential solutions that provide more availability of primary care services and better meet patient’s desires for on-demand care. Read the rest of this entry »