Thursday, October 30, 2008

Optimizing Healthcare Delivery in INDIA: A Patient Centric Approach'

Optimizing Healthcare Delivery in INDIA: A Patient Centric Approach': " The Indian Healthcare sector is undergoing a radical transformation, with the initial steps taken forward more than a decade back. Healthcare, which is a US$ 40 billion industry, is growing at 15% every year. We stand at the threshold of an exciting opportunity to design and engineer sustainable delivery systems, develop numerous commercially viable & customizable delivery formats for the growing, demanding and health conscious Indian populace.

The 5th India Health Summit will focus on 'Optimizing Healthcare Delivery in INDIA: A Patient Centric Approach'.

SmartCards for Digital HealthCare

SmartCards for Digital HealthCare: "The Medical Group Management Association (MGMA) will push the health insurance industry to standardize patient identification cards with magnetic stripes, bar codes, or embedded chips and has commissioned a study to quantify the potential savings for payers and providers alike.

MGMA wants to go after the perceived low-hanging fruit of administrative waste, specifically in standardizing physician credentialing and patient eligibility and benefits verification. The organization will study the cost to medical practices of making copies of patient insurance cards, manual entry of data—and related transcription errors—telephone calls to check benefits, and delayed collection of co-payments from not having accurate information at the time of service."

This makes so much sense ! We all carry over 2-10 types of credit cards already, to manage our money ! Why not a card to manage our health ?

HealthVault, Aetna Offer New Service - WSJ.com

HealthVault, Aetna Offer New Service - WSJ.com: "In another step toward making patients' health records portable, a new partnership between Aetna Inc. and Microsoft Corp. will allow patients covered by the national insurer to transfer medical records to Microsoft's year-old health-record Web site, HealthVault. Starting next month, many enrollees in the insurer's plans will be able to move information from their Aetna 'personal health record' -- an online repository of data that includes claims, diagnoses, test results and prescriptions -- to HealthVault. Patients can pick and choose what they would like to transfer between Aetna's and Microsoft's sites.

The program will be available to people who have access to Aetna's personal health record, which the insurer has so far rolled out to some six million people. It will be available next year to many more Aetna customers. Aetna has a total of 17 million members.

A variety of technology companies, insurers and health providers are pushing to give patients the ability to access all of their health information in one place and to transfer it easily to doctors or hospitals, among others. Sites such as HealthVault and Google Inc.'s Google Health, which launched earlier this year, are trying to become central points where patients' data are available to them, for instance, when they switch from one insurer to another."

Will this be an inflection point in the way consumers manage their health on the web ?

Wednesday, October 29, 2008

Criminal checks for IVF women?

Criminal checks for IVF women?: "Women seeking IVF treatment could be forced to undergo a police check if new laws are passed. The Victorian legislation would mean more than 14,000 women who sought out fertility treatment each year were forced to undergo the test.

News Limited newspapers reports the legislation is before the Victorian Parliament. Under the laws, a patient would need to undergo a checks for history of sexual convictions, violent offences or any child protection orders taken out against them. The laws would mean some potential patients were unable to receive treatment."

Another great example of the way infertile women are discriminated against ! If you are fertile and a drug addict , no one stops you from having as many babies as you want. However, if you are infertile, and are willing to put yourself through an IVF cycle in order to have a deeply loved baby, then you need to undergo a security check ! Talk about unfair double standards...

Monday, October 27, 2008

Consumers Key to Health Care Reform Efforts

Consumers Key to Health Care Reform Efforts: " There is a growing consensus that activating and engaging consumers is an essential component to health care reform in the United States. The health care choices of individual consumers and daily management of their own health can profoundly affect health care utilization, costs and outcomes. While there are sharp differences between advocates of a strong government role in health care reform and those who believe reform should be achieved primarily through the private sector, most health care reformers at least acknowledge that improvements in quality, cost containment and reductions in low-value care will not occur without more informed and engaged consumers and patients. Payment reform and structural changes to care delivery only address one side of the equation. The other side is consumers and patients becoming more informed decision-makers and managers of their health."

Friday, October 24, 2008

Asking questions - a guide for patients

We expect our doctors to provide us with the information we need about our medical problems, so that we can get the right medical care. The only way we learn about our options is by asking questions , but unortunately, most patients are not very good at asking questions - and if you don't ask the right questions, you'll never get the right answers !

1. What to ask ?

Which questions to ask is the first skill you need to master. In general, it's quite easy to find answers to medical FAQs easily online - and if you can find the answers to your questions on the web or from books, then it's not usually a good idea to ask your doctor these questions, unless you need confirmation or validation.

Since doctors have a limited time, the best questions to ask are those which will have an impact on your treatment options. Make a list of all your questions - and try answering those you can by doing your own homework yourself. With the remaining questions, try prioritising them, and start by asking the important ones first; leaving the unimportant ones to the end, so you can skip them if you run out of time

2. Whom to ask ?

The doctor is not always the best person. If it's questions about billing or costs, often the clinic staff will be much better informed - and much more helpful too !

3. When to ask ?

This is an art you need to learn. Unfortunately, many patients only seem to remember all their important questions right at the end of the consultation - at which time the doctor is trying to wind up and move on to the next patient. Not only is he unlikely to provide good answers , he will also resent your questions.

4. How to ask ?

This is an important skill to master. You don't need to be aggressive - but you do need to learn to be assertive. There's a fine balance between the two and you can hone your abilities so you know how to do this. You can learn from your children - when they want something, they know exactly which questions to ask , and how to ask them, so you are much more likely to say yes, rather than no !

Also, remember that not all questions need to be asked face to face. Email is a great way to ask questions and receive answers - and many doctors prefer this option.

What US doctors can learn from Indian doctors

With the looming global economic recession, doctors and hospitals are going to have to learn to provide medical care more efficiently. This is not something most doctors in the US are good at, unfortunately. Since they live in the lap of luxury, they are often very wasteful about using scarce resources - and often overuse tests and treatments, even though they are not useful or effective. While HMOs and evidence based medicine guidelines have tried to curtail this , they have not been very successful so far.

I think rather than try to restrain doctors and not allow them to do what they want to do ( an approach most doctors resent, because they feel this encroaches on their autonomy) , if we can show them how other doctors manage to provide great medical results under the same resource constraints, then they can learn from these positive role models, and stop their wasteful practises. We need to use a carrot approach, rather than a stick approach !

Doctors have always been happy to learn from centers of excellence. In the 1920s, US doctors would do to Europe to learn from European doctors. In the 1980s, many doctors from all over the world would travel to the US to learn from US doctors. While US doctors and hospitals are still great at treating zebras, they don't do a very good job at managing basic medical problems cost effectively or efficiently.

I think they can learn a lot from Indian doctors and hospitals, who have mastered this art. Indian doctors are used to working frugally with limited resources, and still achieve great clinical results. We can be world leaders in teaching other doctors how to do this !

A.D.A.M., Inc. | Mobile Applications for the iPhone

A.D.A.M., Inc. | Mobile Applications for the iPhone: " A vast knowledgebase of health symptoms at your fingertips! The A.D.A.M. Symptom Navigator for the iPhone will let you quickly and easily identify
what to do about any health symptoms, right at your fingertips, all within just a couple of taps!

You never know when or where a symptom will occur. Whether you’re on a business trip, on vacation with family, or at the baseball park, you have access to important health information from your iPhone, allowing you to make informed health decisions even when you are away from your home computer.
From chest pain to fever, sprain, and upset stomach, you can access up-to-date, expert-reviewed
medical content. The tool will help you determine what your symptoms mean, whether to self-treat,
and when to seek professional medical attention."

The Health Care Blog: Liveblog Health 2.0: Health-Management Tools for Consumers

The Health Care Blog: Liveblog Health 2.0: Health-Management Tools for Consumers: "What sort of digital tools are available to health consumers to help them manage the healthinfosphere–and [not to put too fine a point on it]–their health?"

Breaking bad news - how much to tell ?

Breaking bad news is one of the most difficult tasks a doctor has to perform. It's also one of the most difficult ones to do well - and many doctors never manage to do a good job with this. There are many reasons for this and the most important is that every patient is different - and every patient's needs as regards being told unpalatable news are different . Some would rather hear all the gory details, so they can arm themselves with the information they need, and then find the right solution. Others would rather shield themselves from hard reality - and let the doctor make all the decisions. For most of us, we'd prefer a balanced mix between these two extremes - Gautam Buddha's middle path !

The trouble is that the doctor has no way of divining which our preferred coping style is. This is why most develop their own preferred style, depending upon their own personality. Many take a paternalistic approach, where "the doctor knows best" and routinely censor all information, because they do not want the "shock" of the "bad news" to unduly distress the patient. Others, who believe that "honesty is the best policy", spill all the beans dispassionately and heartlessly, which is why many patients now believe that doctors are uncaring and unfeeling.

Many doctors tell the unvarnished truth to a relative of the patient, who acts as the patient's advocate. This person can then present the truth to the patient in a style which the patient is comfortable with. While this is a great model in theory, in real life it often fails miserably, especially in Indian society, where we take great pains to not use words like cancer in the deluded belief that hearing the truth will cause the patient to hasten her way to an early death.

Sometimes , hiding the truth from the patient is the unkindest cut of all - even though it is done with the kindest of intentions !

Tuesday, October 21, 2008

Communicating With Patients

Communicating With Patients: "THE RESPECT MODEL

Rapport

* Connect on a social level.
* See the patient’s point of view.
* Consciously suspend judgment.
* Recognize and avoid making assumptions.

Empathy

* Remember that the patient has come to you for help.
* Seek out and understand the patient’s rational for his/her behaviors or illness.
* Verbally acknowledge and legitimize the patient’s feelings.

Support

* Ask about and understand the barriers to care and compliance.
* Help the patient overcome barriers.
* Involve family members if appropriate.
* Reassure the patient you are and will be available to help.

Partnership

* Be flexible with regard to control issues.
* Negotiate roles when necessary.
* Stress that you are working together to address health problems.

Explanations

* Check often for understanding.
* Use verbal clarification techniques.

Cultural competence

* Respect the patient’s cultural beliefs.
* Understand that the patient’s view of you may be defined by ethnic or cultural stereotypes.
* Be aware of your own cultural biases and preconceptions.
* Know your limits"

The Ideal Doctor Revealed - Greater Case Acceptance and Referrals in the Voice of the Customer

The Ideal Doctor Revealed - Greater Case Acceptance and Referrals in the Voice of the Customer: "Interestingly, the Mayo 'traits of the ideal doctor' study that's been widely seen in the past few years, involved 192 patents—a smaller number of patients perhaps than your office sees in a few days. According to the Mayo survey, the seven things that patents most appreciate (with patient descriptions) in doctors are:

* Confident: 'The doctor's confidence gives me confidence.'
* Empathetic: 'The doctor tries to understand what I am feeling & experiencing, physically and emotionally, and communicates that understanding to me.'
* Humane: 'The doctor is caring, compassionate, and kind.'
* Personal: 'The doctor is interested in me more than just as a patient; he/she interacts with me, and remembers me as an individual.'
* Forthright: 'The doctor tells me what I need to know in plain language.'
* Respectful: 'The doctor takes my input seriously and works with me.'
* Thorough: 'The doctor is conscientious and persistent.'"

Monday, October 13, 2008

How the global financial crisis is going to be good for Indian doctors

Everyone is hurting from the global financial crisis. I think this is actually a great opportunity for Indian healthcare. US companies and US health insurance players are going to need to tighten their purse strings - and they are now going to be forced to look for more cost effective healthcare services. Since these are not available in the US, they will start looking for options overseas - and India will be high on their list.

Uptil now, most medical tourists came to India of their own accord - either because they were not happy with their own healthcare system; or they could not afford US medical care, and needed to save money. They were paying from their own pockets for their medical care.

Now, as the entire country needs to save money, lots of corporates and health insurance players are going to be forced to look for inexpensive alternatives. While many US doctors and hospitals will have to shape up and provide more cost effective services, they will find it hard to compete with Indian healthcare providers.

Money talks - and it's going to talk very loudly in the next few months. Uptil now, doctors and hospitals i the US only had to compete with each other, which means they could set their own rates ( which were often exorbitant, and about 10 times as much as Indian doctors charged , for no very good reason, other than - " This is the US market rate". This is going to change very quickly, as payers are going to demand efficiency and cost savings . Just like remuneration rates for cataract surgery dropped dramatically in the US when Medicare cracked the whip, we are going to see a similar impact across the entire medical ecosystem.

We live in interesting times !

Sunday, October 12, 2008

For Some Doctors, Empathy Is in Short Supply - US News and World Report

For Some Doctors, Empathy Is in Short Supply - US News and World Report: "'It would be helpful for physicians to think about having a response ready,' Morse added. 'The bulk of patients' concerns are existential and physicians don't necessarily have to do something to fix it. Just acknowledging it, in and of itself, can be very helpful and it doesn't take a lot of time.'

Added Frankel: 'The most important job of a physician is also the most important job for a minister or for a lawyer or anyone else: To try and help people cope with the uncertainties of life.'"

This is the challenge - and the opportunity. Patients don't expect doctors to work miracles - but a kind word can be very healing !

An Overview of Empathy

An Overview of Empathy: "Empathy is a powerful communication skill that is often misunderstood and underused. Initially, empathy was referred to as 'bedside manner'; now, however, authors and educators consider empathetic communication a teachable, learnable skill that has tangible benefits for both clinician and patient: Effective empathetic communication enhances the therapeutic effectiveness of the clinician-patient relationship. Appropriate use of empathy as a communication tool facilitates the clinical interview, increases the efficiency of gathering information, and honors the patient."

Empathetic doctors have patients who often become "raving fans" ! It's also important for patients to be empathetic, so they can get the best care from their doctor. Smart patients can sense when doctors have time to sit and chat - and when they don't !

Doctors as learned infomediaries - a better option ?

Doctors are medical knowledge experts, and patients go to doctors so that they can use their specialised knowledge to get the correct diagnosis and the right treatment. The trouble with this traditional model is that there are too few doctors, with the result that doctors often act as bottlenecks. It takes time to get an appointment - and waiting lists can extend for months. Also, doctors tend to guard their specialised knowledge and often refuse to share it. Finally, while good doctors will provide good care, often bad doctors will overtreat for financial reasons. This means that patients are often unhappy with the medial care they receive from their doctors.

Is there a better alternative ?

I think the trick is to use learned infomediaries to provide medical triage, so that simple problems can be handled with self-care; and doctors only need to see patients with complex problems, who require more advanced expertise.

This has many advantages. Access to medical information will be much faster; less expensive; and doctors will not get bored handling mundane "routine " problems.

This is not a new idea, and has been tried before in different avatars. For example, computer scientists have tried to use artificial intelligence to develop expert systems which allow computers to make a diagnosis; and countries have used "primary health care" village workers to reach out to many more people, to provide them with basic healthcare.

The good news is that the internet allows us to reach many more people much more efficiently. Most people will now routinely use the net to research their medical problem - both before going to the doctor; and after wards, to check on his recommendations.

The trouble is that many people are not sophisticated enough to be able to use the net efficiently. They often get lost - or even worse, misled by unreliable websites.

Can we provide a better model ? I think the missing element we need to add is a human being, who will help the patient find the right information. This person could be a nurse; a physician assistant; a medical student; an expert patient; or a retired doctor - all of whom are much less expensive than a doctor !

This expert can help the patient find the correct information - and help them to make sense of it. It also adds an element of humanism to the net, something which can be vitally important when you are ill !

This sort of blending click and mortar model will allow us to provide patients with the best of both worlds - online and offline !

We can use a stepped care approach, in which simple problems can be resolved with the help of these learned infomediaries; and more complex problems can be referred to the doctor.

This approach can help to save time , money and energy. Call centers and medical helplines staffed by nurses already provide such a service in many cities - can't we do a better job and scale this up ?

Saturday, October 11, 2008

Linking employee benefits to talent management

Linking employee benefits to talent management : "One heavily unionized manufacturer, for example, is marketing its benefits with the theme “empowering you to better manage your health” through new nurse hotlines and increased preventive-care coverage. Its marketing campaign appeals to that large segment of employees who value broad health care services above all other benefits."

This is why corporates need to invest in health education for their employees. It's good for their employees - which means its good for them !

A better hospital experience - The McKinsey Quarterly

A better hospital experience - The McKinsey Quarterly : "What really matters to patients.

To understand which factors patients value, we tested their interest in 11 nonclinical aspects of a hospital visit, such as a simple sign-in process and extensive in-room entertainment options. We found that patients might switch hospitals for many reasons, but two stand out. First, patients will consider switching if they think that a specific hospital will keep them better informed (for example, by providing counselors who can help them understand medical terms). "

So why don't more hospitals have a patient education resource center on their premises, like the Mayo Clinic does ? Investing in patient education will help them attract many more patients - and create a great positive buzz as well !

Indian pharma companies start using the web for patient education - finally !

Indian pharma companies start using the web for patient education - finally ! : "Welcome to the world of Hair Awareness. We at ASSIST - a patient awareness initiative in skin and hair care by Dr.Reddy’s, are keen to provide you with information on why a person loses hair. It also aims to guide you to the best available treatment."

I am glad pharma companies in India are finally waking up and realising the potential of using the web for patient education. I am sure we will see the good, bad and the ugly - but this is a start !

How to make medical decisions

As a doctor, I often receive calls from friends who want to know more about their treatment options.

Here's an example.

Dear Dr. Malpani,

Many thanks for your offer to help us at this crucial juncture as we could really use some dispassionate advice.

My mother (Mrs.DF ), age 61 years, is a diabetic and high blood pressure patient for the past 14 years and her condition has largely been under control. She has been taking daily walks (2 Kms) and regular yoga exercises. Last November, she took a pilgrimage to South India and fell ill during that period. She was found to have high blood pressure (190/105) consistently and was rushed back to Mumbai.

I took her to Dr. AB (MD – Cardiologist & Diabetologist) at Chembur and she has been under his treatment since. She visited Dr. AB for her regular check-up on 6th Oct and her Doctor found small variations in her ECG and recommended that we do an Echo Cardiogram, Chest X-Ray, USG of Abdomen and Angiography. However, she experienced chest pain, sweating and pain in her left hand on 8th Oct and was rushed to a critical cardiac care hospital nearby (Dr. XZ Hospital, Chembur) within one hour.

Subsequent ECG revealed that she had experienced a mild Heart attack. Her condition is now stable and Dr. AB is very happy with her overall progress (pressure normal, kidney creatinine level normal, cholesterol levels normal both LDL and HDL. Only ESR, WBC are slightly elevated). Her Chest X-Ray reveals slight enlargement of the heart. She has now been shifted out of the ICCU and into the special room.

As next steps, I have been advised by Dr. AB to go for an Angiography at any leading hospital. But as you can imagine, I have numerous opinions from friends and well-wishers on everything from Angioplasty to Bypass surgery and am fairly confused.

I have also got an introduction to Dr. MN and Dr. OP ( from Chennai but operating at Lilavati).

I seek your advise on what I should really evaluate at this point as the various options are bewildering to a lay man. Sincere thanks for your offer to help.

Best regards


This was my advice.

I agree this is a hard call.

I'd suggest the following course of action:

1. Use your head. Read about the problem ( ischemic heart disease and its treatment options) and learn about your possible options. HELP is a good place to go to, if you want to find out the right information. Not every abnormality needs to be treated – and sometimes treatment can be harmful !
2. Get at least 2 opinions from consultants. The fist consultation will teach you what questions to ask – and how to make sense of the answers
3. Listen to your heart ( gut feelings)
4. Work out the logistics.

Outcomes are always uncertain, but if you follow the right process, you can take the path of least regret, so you have peace of mind you did your best !

Dr Malpani

IVF - The comic book !

I am an ardent believer in patient education, and find it quit frustrating when patients do not make the effort to learn about their treatment options. Leaving everything upto the doctor can be quite dangerous !

This is why I experiment with different approaches to make medical information more accessible to the layperson. I have always been fascinated by comic books - and find they are a great way of getting uninterested students to read.

We have now put up a new comic book which teaches patients about IVF. It's online and it's free ! Comments and feedback are welcome !

Sunday, October 05, 2008

iRADix.in is an exclusive Radiology portal bringing all Imaging professionals

iRADix.in is an exclusive Radiology portal bringing all Imaging professionals together : " When we're all connected, great things happen. Join us and see how the life on this network is changing Radiology.

Iradix is the Largest online network of Radiologists -- created, maintained & promoted by Radiologists.

This network is getting Better, Bigger & Larger connecting thousands of Radiologists from more than 100 different countries.

It's great to see doctors using technology so enthusiastically to help doctors help themselves ! This is an initiative Indian doctors can be proud of. I am so happy to see senior physicians participating in this venture.
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Wednesday, October 01, 2008

The Secret Code of the Bhagavad Gita

One of the people I admire a lot is my e-friend, Dr Kamath, a psychiatrist in the USA. He has kindly given me permission to upload his newest book, The Secret Code of the Bhagavad Gita to the web ! Please read this - it will change your life !

Adoption in India - a friendly guide from NAAF

Here's a user friendly guide to the adoption process in India, from NAAF - the National Association of Adoptive Families !

Heartwarming story from one of our patients

Here's a heartwarming story from one of our patients, and her quest to complete her family. This is what makes being a doctor such fun ! All the heartburn and stress are worth it !

The ART bill to regulate IVF in India - doctors, patients and bureaucrats

The Draft of the proposed ART bill to regulate IVF clinics in India has now been published online; and the public is being invited to offer feedback.

While regulation maybe needed to improve the quality of IVF services, and one of the good things about the bill is that it legalises surrogacy, I have major concerns about certain clauses in the bill. For example, it does not allow altruistic egg donation between sisters - and I cannot understand why this is being banned. Nowhere else in the world is egg donation between sisters disallowed - and in fact, sisters usually make very good egg donors, for obvious reasons.

The purported reason for this ban is to ensure anonymity - but I cannot understand what benefit this provides. While altruistic surrogacy is allowed, altruistic egg donation ( which is encouraged in most countries) is not ! If a woman can donate one of her kidneys to her sister, why can't she donate her eggs ? What amazes me is that Indian women are keeping quiet about this infringement on their autonomy !

The ban is based on talking to sociologists; and a few bad experiences, where family members were "coerced" into donating their eggs. However, I think it's unfair to generalise based on a few bad cases and to ban this option outright for everyone !

I think it all boils down to the worldview of lawyers versus doctors. Lawyers and bureaucrats look at the world through a lens of problems because that's all they deal with . They try to think up means to prevent these problems. Their major tools are laws and rules to prevent and prohibit . While this can be a good approach, when carried to extremes, it results in bad outcomes for many helpless individuals. Doctors , on the other hand, usually take an empowering and enabling approach, to try to help patients who come to them in their hour of need. They will try to look for means to help people, rather than to limit their rights.

Thus, if the Bill had been drafted by a doctor, it would have laid out under what conditions egg donation between sisters is allowed , so that everyone's interests are protected. The Bill has taken an enabling approach towards surrogacy, by clearly defining under what conditions it is allowed, thus protecting everyone's interests - the infertile couples, the doctor and the surrogate. Why can't they take the same approach to egg donation as well ?

By allowing lawyers to set limits on what doctors can do, patients are going to pay a price in the long run, because their doctor's hands are tied.

The reason doctors and bureaucrats think about things so differently is because of a top-down versus bottom up approach.

Bureaucrats and regulators take a top-down approach. They pride themselves on their ability to look at the "big picture". They trouble shoot, based on problems which have already been encountered; or potential problems which may arise - and think of ways and means to prevent such problems. If, in the process, they prevent some individuals from doing certain things, they feel that this is the price which needs to be paid - and justify it by saying that you may need to crack a few eggs to make an omelette; and that individuals should be willing to sacrifice for the sake of the "greater good". They try to fit square pegs into round holes - and if a few pegs get hurt in the process, then so be it. Since this is private pain, individual patients suffer in silence, and the harm caused to them is never made obvious, so everyone feels that this is a good law which provides an effective solution.

Doctors, on the other hand, take a bottom up approach. They deal with individual patients, one at a time, and try to help them resolve their problems. They look for solutions, so their patients can get what they desire.

Such a difference in opinions is likely to lead to clashes - which doctors invariably lose, because they do not have the political skills ( or time) to follow the process required to provide useful inputs.

Unfortunately, the biggest losers in this process are patients, who find that their rights are curtailed for no fault of theirs.
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