Monday, June 30, 2008

The Patient as the Platform | Linux Journal

The Patient as the Platform | Linux Journal: "I believe that having a data store for health records is a necessary but insufficient condition for the true independence and control required for each of us to be the point of integration for the health care we get, and the point of origination for controlling that care — for getting second and third opinions, for summoning data across bureaucratic boundaries, for actually relating to the systems that serve us, rather than serving as dependent variables within them.

For patients to become platforms, we need more tools and capabilities that are native to the patient. All of us need to be able to walk around the world with the ability to jack into any health care system and drive it. How? I don't know yet. I'm still new to this. But I do know that these are capabilities we need to add to ourselves, as independent drivers of health care services. And that these must be based on free and open standards and code.

The new health care infrastructure must be built on independent and autonomous patients, not on systems that surround and subordinate patients. Once it is, the systems will be vastly improved, and far more profitable for all."

Healthcare should be about the patient !

Sunday, June 29, 2008

Doctor's Day !

Working Towards Wellness - the role of corporates

In the past, the relationship between employers and employees was simple. Employees came to work at the factory and the factory owner paid them for their labour. Working conditions were often poor, and no one complained.

Today, enlightened corporates realize that employees are their most valuable asset and just like they need to invest in training them in order to hone their professional skills, they also need to invest in improving their health. After all, only a healthy employee can be productive !

Corporates have a unique and vital role in improving the wellness, health and physical fitness of employees . After all, most of us spend most of our waking hours at work ; and if our workplace provides us with a healthy working environment, this will help us to remain healthy.

CSR or corporate social responsibility has become a buzzword , but charity begins at home and employers need to address what they can do to help their employees remain well. This is basic business common sense – the first rule of marketing states that you should treat your employees the same way you treat your best customers.

Shouldn’t a company focus on its core competence rather than worry about their employee’s health ? Isn’t remaining healthy the employee’s responsibility ? Or his doctor’s ? Why should the company care ? They should, for purely selfish reasons ! There is a sound business case for companies investing in keeping their employees healthy, because sick leave is a major loss of productive resources.

All employees deal with common health problems daily. “ What can you do to manage your back ache at home ? Is there a safe and simple home remedy for your nagging cough ? Is your child's fever serious ? When should you take him to your doctor ? Your husband has chest pain. Should you panic ? Is this heartburn ? Or a heart-attack ? Should you take the day off ? Or go in to work ? “ Each day absent from work for dealing with medical problems in the employee’s family damages the company’s bottom line ! This is especially true when the problem could easily have been managed without going to a doctor ! Can we afford to lose this precious asset by ignoring it ?

Workplace health promotion (WHP) programmes which target physical inactivity , smoking, alcoholism and unhealthy dietary habits are effective in improving lifestyle related diseases such as obesity, diabetes and cardiovascular disease - major risk factors for noncommunicable diseases (NCDs), which are becoming a leading cause of death in developing countries like India. In fact, the World Economic Forum and World Health Organisation released an important report titled "Preventing Non-communicable Diseases in the Workplace", in Geneva in 19 May 2008 and this important issue is going be discussed in the India Economic Summit, New Delhi, India, 15-16 November 2008.

Progressive companies in the USA recognize that unhealthy employees are a financial burden and that wellness programs can provide an effective solution. Instituting wellness programs that help employees adopt healthier behaviors can be an important way to decrease illness, absenteeism, turnover, medical claims; and increase productivity and create a healthier bottom line.

How can Corporate India help to improve the health of Indians ? Traditionally, most companies just pay for their employees’ medical insurance policies, which means they provide financial cover in case of illness. I feel they need to take a more proactive approach and prevent illness ! At present, HR ( Human Resources ) departments think of themselves simply as dispensers of health care entitlements . If an employee falls ill and submits a claim, they feel that their job is to process the claim so that the costs of the medical care are reimbursed. This is very short-sighted !

In the US, employee health management (EHM) programs have been around since the 1970s. However, when employers simply offer free EHM programs and do not offer incentives for participation in them, the uptake of such wellness programs is poor. They attract only those employees who already committed to personal health and fitness, while those most needing to improve these dimensions ignored the opportunity. However, by providing incentives, participation rates of as high as 95% have become possible.

Instead of focusing solely on healthcare and disability claims costs, these programs look at absenteeism reductionism and presenteeism as desired outcomes. They look at employees who have “productivity impairment” behaviors and conditions, including emotional/behavioral problems, inadequate sleep, stress, and similar debilitating factors, many of which are epidemic in call centers and BPOs today, and provide holistic solutions.

Results have been far more positive than earlier EHM investments that focused just on healthcare cost reduction. Productivity “recovery” often increases total economic benefit to employers by two to five times, compared to healthcare cost reduction alone. Progressive companies allow employees to design their own EHM goals, and this has been very helpful since it is the employees’ own personal efforts that make EHM successful.

The good news is that progressive companies in India are now following the US trend. Many companies provide gymnasiums and fitness centers in their campuses; technology companies use the internet to provide their employees with online counseling programs; others offer their employees a free PHR ( Personal Health Record) to help them manage their own health; while others are gifting free copies of the Healthwise Handbook to help their employees to remain healthy.

What’s your company doing to improve the health of its employees ?

NB I wrote this article for Times Wellness, where it was first published.

Friday, June 27, 2008

Why is premature ejaculation so common ?

Premature ejaculation is one of the commonest sexual problems affecting men - and maybe far commoner than it's much-hyped cousin, ED ( erectile dysfunction). I was having a fascinating conversation at dinner with my friend, Dr Hemant Morparia and he was explaining his theory for why premature ejaculation is so common in men ( doctors have weird dinner-table
conversations - this is an occupational hazard !)

He used evolutionary psychology ( aka sociobiology) to explain his thesis. When man first started having sex, " quickies " were far safer than prolonged intercourse, which meant evolution favoured premature ejaculators for many reasons.

1. They could have sex with more women, this winning the "sperm wars".
2. Having sex in the open left the couple vulnerable to dangers from predators. Men who completed intercourse faster reduced their exposure to danger.
3. There was little privacy in primitive times, and having sex in front of other men meant that they would get sexually aroused by watching the act , and would want to have sex with his partner . Premature ejaculators could have sex more quickly and quietly, and thus were less likely to create competition with the other males.

Does this make sense ?

Wednesday, June 25, 2008

Why I don't want my daughter to become a doctor

I am in the prime of my professional career as an IVF specialist and have been very pleased with the way life has treated me. However, I have major misgivings about what the next generation of Indian doctors are going to have to deal with.

Here’s a sampling of some of the woes medical students and residents in India have to battle with today.

There’s an apparently never-ending series of examinations to clear before you can get a license to practice . For some specialties, it can take upto 10 years before you get a degree which means that doctors are over 30 years old by the time they start seeing patients independently.

The government changes the medical college rules when it so fancies. When some politician decides that doctors need to do more for the poor, medical colleges make new rules and decide that rural service is compulsory , so that hapless medical students are stuck for another year in a village, in a hopeless job where they learn nothing, and have no facilities or supplies to be able to do any good to anyone.

There are limited seats and openings for certain specialties which means that many young doctors never get a chance to practice the specialty they want to. Not only are there very few seats, but most of these are blocked as a result of the pernicious reservation policy. Imagine the heartburn a bright young doctor who has set his mind on becoming a heart surgeon goes through when the only seat available for MCh cardiothoracic surgery goes to a candidate who has only 50% of his marks, just because he belongs to a backward class.

Doctors are a soft target and easy to beat up on. The Indian press enjoys doctor-bashing and does it with predictable regularity. A few black sheep tar the image of the entire profession so that hard working upright doctors who have devoted their lives to taking care of patients are treated with disrespect. Doctors are considered to be dishonest money-hungry professionals – and the law ( PNDT Act) now forces ultrasound clinics to put up signs which effectively
say – “ We will not perform illegal activities” ! Society no longer trusts doctors - it's that simple !

The government has failed miserably at providing primary health care to citizens , but does its best to interfere with the running of efficient corporate hospitals , just because they make a profit.

Individually, we all respect our personal doctor and go running to him when we fall ill . However, we tend to view the medical profession as a whole with a jaundiced eye ! Why is there such a major discrepancy in the way most of view the medical profession vis-a-vis our own doctor ?

Doctors are usually excellent in the clinic. They are very good at helping their patients, one at a time, because this is what they have been trained to do , and they do this very well. Ironically, this is what hurts them ! They are not very good as a group because they have poor political skills and cannot band together . They often end up fighting with each other because of petty personal rivalry and compete with each other for patients and prestige. They are so focussed on trying to get more of the slice of the patient population for themselves that they don't realise that their cake is fast shrinking ! There is strength in unity, but the Medical Associations do not stand up for individual doctors who are helpless and vulnerable. The profession has lost its autonomy, and is regulated by bureaucrats and outsiders, who have little understanding of the realities of providing medical care.

The role which doctors used to play in guiding society to provide health care for the community has been usurped by health activists , who are supposed to represent the interests of patients. Unfortunately, many of these live in ivory towers and have never taken care of a patient in their lives. They provide excellent solutions on paper which never get implemented because they are unrealistic and impractical.

What can we do to redress the problem ?

Doctors have a lot of individual clout and they should learn to use it for the sake of the profession. This is difficult to do in the hurly-burly of daily medical practice, but senior doctors who have retired can perform this role very efficiently. Doctors are meant to be patient advocates – and senior retired doctors should be invited to represent the interests of patients and doctors . They have spent a lifetime studying medicine and healthcare and are aware of ground realities.

It’s a fact that the medical profession has lost its charm and the future looks even gloomier. Doctors have lost their moral authority and their professional prestige. We seem to be headed the US route, where the doctor-patient relationship has been tarnished because of commercialism.

If this negative vicious cycle continues, not only is it going be sad for the next generation of doctors but it’s going to be even worse for the next generation of patients ! Angry, unhappy and frustrated doctors provide poor quality care – and it is their patients who will suffer !

The Ultimate Guide to Taking Control of Your Health Records | NOEDb

The Ultimate Guide to Taking Control of Your Health Records | NOEDb: "Managing your personal health records has become the latest buzz. By utilizing an online service, you can record, store, update, and share all your information. Having all of your information in one place promises to provide better treatment for routine medical care, and in cases of chronic illness or emergencies, having the most up-to-date information on your health can make the difference between life and death. The following resources will help you learn about managing your health records, tell you where to go for the best services to help you, and offers a peek into what medical providers can implement."

Understanding Evidence-based Healthcare

Understanding Evidence-based Healthcare: This free web course has been created by the United States Cochrane Center as part of a project undertaken by Consumers United for Evidence-based Healthcare (CUE), and is designed to help consumer advocates understand the fundamentals of evidence-based healthcare concepts and skills. Registration is open and free of charge.

"# Module 1. INTRO: What is evidence-based healthcare and why is it important? (45 minutes)
# Module 2. ASK: The importance of research questions in evidence based healthcare. (40 minutes)
# Module 3. ALIGN: Research design, bias and levels of evidence. (1 hour)
# Module 4. ACQUIRE: Searching for healthcare information. Assessing harms and benefits. (1 hour 10 minutes)
# Module 5. APPRAISE: Behind the numbers: Understanding healthcare statistics. Science, speed and the search for best evidence. (1 hour 20 minutes)
# Module 6: APPLY: Critical appraisal and making better decisions for evidence-based healthcare, Determining causality. (1 hour)"

Patients rarely use online ratings to pick physicians ... American Medical News

Patients rarely use online ratings to pick physicians ... American Medical News: " But experts say online word-of-mouth is still considered a powerful tool, as people look for personal stories when learning about a new doctor."

Tuesday, June 24, 2008

Personal Health Record (PHR) Systems: An Evolving Challenge to EHR Systems

Personal Health Record (PHR) Systems: An Evolving Challenge to EHR Systems: "The current healthcare system must evolve from the doctor-centered production system of today to a more holistic, integrated person-centered system of the future. We must better understand that each of us is the primary healthcare provider for ourselves. In many ways, people are becoming their own 'ConsumerMD', supported by advanced information systems, technologies, and processes that enable self-care. The rise of Personal Health Record (PHR) systems will play a key role in this impending change."

Concierge Medicine - The Future or the Past? | Brain Blogger

Concierge Medicine - The Future or the Past? | Brain Blogger: "An increasing number of physicians are turning to something known as “concierge medicine,” or “boutique medicine.” Under this system, patients are required to pay a yearly fee to the physician above and beyond the cost of their healthcare, which can range from $1,000 to $20,000. In return for this fee, they are granted a much higher level of access to their physician than one would expect. Doctors who participate in concierge medicine spend an hour with their patients on visits. They give out their personal cell phone numbers to be reached at all times. Many make house calls at no additional fee. Physicians guarantee that if you are sick and need to be seen, you can do so within 2 hours. Those long waits in the doctor’s office? Gone. Concierge physicians guarantee no wait in the waiting room."

Going Solo: One Doc, One Room, One Year Later - March 2002 - Family Practice Management

Going Solo: One Doc, One Room, One Year Later - March 2002 - Family Practice Management: "Interaction between the patient and care team is deep and personal. The care team has 'memory' of the patient. Interaction is not the price we pay to submit a claim. It is the very essence of what we do. It is the vehicle for all that occurs in health care. Productivity-based compensation models and thin operating margins put severe pressure on time, thereby robbing patients and physicians of the meaningful interaction that is the core ingredient in good care. But an ideal practice has the time for patients to speak uninterrupted, for shared decision making, for sensitivity to cultural and community context, and for listening to patients' stories."

Going Solo: Making the Leap - February 2002 - Family Practice Management

Going Solo: Making the Leap - February 2002 - Family Practice Management: "To create this, I had to focus on what was essential. Health care is at its core a very local, personal process. When we function at our peak, we are available to patients when they need us. We treat each patient interaction as if it is the only one. We translate our understanding of the latest medical knowledge to the individual."

Very inspiring story of a doctor who has used technology cleverly to help him to take better care of his patients ! It's a model which has stood the test of time !

Sunday, June 22, 2008

Empowering patients to be co-producers of their own health

Empowering patients to be co-producers of their own health: " Empowering patients to be co-producers of their own health is a great thing and one way to make our “system” more understandable. Much of the current web innovation in the health care arena is trying to do this. There are great possibilities for one percent of patients to become more involved co-producers of health care. But it is very important (for everyone that is able) to become a co-producer of their own health. Empowering the patient will make significant changes in our system…and it doesn’t require policy change or money."

NetDoc - Competition, innovation and the Sorceror's Apprentice

NetDoc - Competition, innovation and the Sorceror's Apprentice: "The “wisdom of the market” is comprised of a sum of the decisions of rational consumers. In the example of computers, that wisdom determined what the cost of a computer should be in order that a significant number of consumers would buy one.

There is no “wisdom of the market” with regard to health care. Consumers, i.e. patients, are not wise. They are frightened, sick, and confused. That’s what happens to human beings when they are sick or injured. Patients are irrational consumers, and no amount of arm bending, medical websites, or cajoling on the behalf of medical economists is going to change that.

I would suggest that the medical economists who are also parents are just as irrational when their children are ill as any other human being.

Great Britain’s NHS lacks the competition that drives innovation. As a consequence it is greatly inefficient.

America’s unfettered free market lacks the rational “market wisdom” necessary for a demand side to direct the competition of the supply side. Patients are by definition irrational. There is no market wisdom in a health care system run according to the tenets of an unfettered free market. The supply side competes for profit alone, unfettered by any restraints."

eMedTV - Health Information Brought to Life™

eMedTV - Health Information Brought to Life™: "eMedTV offers over 100 health channels, each serving as a portal to an extensive library of medical information. Our articles explore subjects ranging from symptoms and diseases to tests and procedures to drugs and supplements. Each topic contains a series of articles carefully designed to answer your questions and provide detailed health information. Links to related articles are found on each page, streamlining your search for the exact medical information you need."

What Medicine Can Learn From Business - Comarow on Quality (

What Medicine Can Learn From Business - Comarow on Quality ( "The Best Practice—How the New Quality Movement Is Transforming Medicine, to be published next month, is in part an account of the shock wave the 1999 IOM report sent through hospital boardrooms and clinics and in part a recitation of remedies that enlightened healthcare organizations are putting in place. The book, by journalist Charles Kenney, isn't nearly as wonkish as its title suggests. It's a great read, as exemplified by a passage describing a visit to Japan a few years ago by top administrators at Virginia Mason Medical Center in Seattle, to see if Toyota's vaunted management and production techniques could work at the hospital.

During the visit, a team led by Virginia Mason's chief of medicine met with a Toyota guru, a sensei who had absorbed the Toyota approach into his very marrow. Examining a layout of the hospital, the sensei learned that there were waiting rooms scattered across the campus.

'Who waits there?' the sensei asked.

'Patients,' said the chief of medicine.

'What are they waiting for?'

'The doctor.'

The sensei was told there might be a hundred or so such waiting rooms and that patients wait about 45 minutes on average.

"You have a hundred waiting areas where patients wait an average of 45 minutes for a doctor?" He paused and let the question hang in the air. "Aren't you ashamed?"

Many doctors seem to take perverse pride in how full their waiting rooms are; and how many weeks in advance their appointments are booked. To me, this just spells poor time management ! But as long as patients feel they are helpless and need to be patient, doctors will continue ill-treating patients.

Safe Medical Care – We Can Wish It or We Can Design It | Health Commentary

Safe Medical Care – We Can Wish It or We Can Design It | Health Commentary: "Relying on doctors to do the right thing out of a sense of duty or through fear (malpractice suits) totally ignores the fact that to err is human. People will make serious mistakes because of misinterpretations, knowledge deficits or persistent habits of thought, even when they try to avoid them. Only systems that:

1. Avoid Reliance on Memory
2. Simplify Tasks
3. Standardize Procedures and Equipment
4. Use Constraints and Forcing Functions
5. Use Protocols and Checklists Wisely

will move medicine out of its cottage industry practices into the modern world of systems design."

Millennial Patients: How Your Practice Will Change as You Prepare to Care for the Next Generation of Patients

Millennial Patients: How Your Practice Will Change as You Prepare to Care for the Next Generation of Patients: "Millennial patients can best be defined by their behavior, rather than their age, sex, or demographic. Millennial patients are the first generation of Americans to grow up with the Internet as a pervasive part of their lives. They use the Internet in their everyday life to research information, purchase tickets, pay bills, and meet their personal, social, and professional needs. They are amazed, bewildered, and ultimately angry with the inability to access their healthcare services in this way. They cannot understand, and they will not tolerate, this disparity in the ability to manage healthcare transactions as simply as they manage their financial transactions. They are knowledgeable, intelligent, are typically prepared for their appointments, and inherently expect and demand a far higher level of service from their healthcare provider."

Patients as healthcare providers?

Patients as healthcare providers?: " Enabling new technologies works both ways in allowing patients and physicians to interact in new ways. For physicians, that means the ability to empower patients by helping them become more informed, involved, and in-tune with their own health. Just as the use of mid-level providers served as an eff ective extension of the physician, many of these new technologies can push outsourcing of care all the way down to the patient. In this paradigm, the patient becomes another provider, perhaps a much more accurate and appropriate description of the term primary provider.

David S. Sobel, MD, MPH, Medical Director of Patient Education and Health Promotion for The Permanente Medical Group at Kaiser Permanente, is responsible for 3.3 million members who interact with the Kaiser system and has a simple mantra for success: “Keep the patients healthy, happy, and at home.” Beyond the trite saying is a powerful philosophy about patient empowerment. Namely, Sobel considers his patients as providers and collaborators in the care process. “Patients are most often viewed as consumers of healthcare, and health professionals are seen as the primary healthcare providers” Sobel says. “In fact, 70 to 90% of all symptoms are self-diagnosed and self-treated".

The Columbus Dispatch : Touch-screen helps young patients talk to doctors

The Columbus Dispatch : Touch-screen helps young patients talk to doctors: " Turning a doctor's waiting room into an electronic chat room might be a key to getting teens help for risky behavior, according to a study by Nationwide Children's Hospital.

Health eTouch Pad is a 10-inch touch-screen computer that asks questions about health and behavior while patients are waiting to see a doctor.

The gadget, developed by Children's researchers, serves as a screening device, allowing doctors to ask questions that might be rushed or forgotten in an exam. The information is sent to a control site, where it is summarized and flagged to indicate concerns. Doctors could receive reports right away, to discuss in the exam, or days later."

Going off the Grid - The Rise of “Direct Practice” Medicine « Crossover Healthcare

Going off the Grid - The Rise of “Direct Practice” Medicine « Crossover Healthcare: "Physicians and the patients who are entering into these “direct practice” (the PC way to say Concierge Medicine) relationships is one of liberation, of freedom, and of doing things the way that they should be done. The providers get to provide a much higher level of care, to truly get to know their patients as they are incented to spend appropriate time with them, and over time get to know them within their unique social/cultural context as well (hence the house calls become important). The patients love the access, the attentiveness, and are willing to spend cash to have the type of unhurried, contemplative time with their physicians that is required to develop a trusted relationship and deliver high quality care."

Am I a good candidate for medical travel/medical tourism? Take the quiz! | MedTripInfo

Am I a good candidate for medical travel/medical tourism? Take the quiz! | MedTripInfo: " Many factors go into deciding whether you are a good candidate for international medical travel (also called medical tourism). Reducing these into a single quiz runs the risk of over-simplification. The scores and conclusions from it are not a substitute for common sense and are certainly not medical advice! But they can give some idea about your suitability for the particular procedure and the destination you have in mind."

Most IVF patients are excellent candidates, which is why we see so many of them in our clinic.

We Need Free Trade in Health Care -

We Need Free Trade in Health Care - " Consider the four modes of service transactions distinguished by the WTO's 1995 General Agreement on Trade in Services.

Mode 1 refers to 'arm's length' services that are typically found online: The provider and the user of services do not have to be in physical proximity. Mode 2 relates to patients going to doctors elsewhere. Mode 3 refers mainly to creating and staffing hospitals in other countries. Mode 4 encompasses doctors and other medical personnel going to where the patients are. All modes promise varying, and substantial, cost savings."


Trusera: "We believe there’s power in sharing personal experience and knowledge to help others in their health journey. We are more than just the sum of our conditions. We're people first, parents, caregivers, husbands and wives, and, on some occasions, patients.

That's why we created Trusera, an online health network where you can find and share real-world experiences. By connecting with others, you can find valuable insights that help you take control of your health. At Trusera, you get relevant, credible and useful health information and insight from others who’ve been there."

Reasons Not To Become A Doctor

Reasons Not To Become A Doctor : " No one ever said being a doctor was easy. School and training go on seemingly forever; once graduation arrives, doctors work long hours and are faced with life-and-death decisions daily.

But there were rewards. For decades, doctors earned hefty paychecks, had autonomy and respect. But those benefits are fading, and as a result, so is the number of doctors. Within the next 15 years, the United States will experience a shortage of between 90,000 to 200,000 physicians, according to the recently published Will the Last Physician in America Please Turn Off the Lights: A Look at America's Looming Doctor Shortage.

The American Medical Association recognizes there are shortages in certain geographic areas and in certain specialties. Part of that is due to the aging population and a stagnant number of medical-school applicants.

But there are other significant reasons. They include the increasing costs of medical malpractice coverage, higher practice costs, lower insurance reimbursement rates and insurance-company restrictions resulting in less autonomy over how patients are cared for."

The Health Care Blog: Mckinsey smells opportunity in explaining health care

The Health Care Blog: Mckinsey smells opportunity in explaining health care: "
McKinsey Quarterly released an interesting study this week under the moniker, “What Consumers Want in Health Care.' The central theme of the publication was the large and growing opportunity for a new type of health care “infomediaries” (who traffic in the flow, enhancement, and interconnectivity of information) to have a large and sustained impact in the transformation of our current system to a next-generation system required to meet the health needs of the future.

A few relevant quotes:

* Retail health consumers constitute a market worth hundreds of billions of dollars annually.
* Currently 116 million consumers have a choice of health insurance (expected to be 151M by 2011).
* Most consumers still do not “shop” for insurance -- 74 percent will like purchase from current health insurer.
* People who do “shop” do so during moments of considerable change -- and a full 41 percent either considered or changed insurance.
* Most people need additional guidance, education, and advice to make decisions."

Looks like people will pay for Information Therapy !

Health Blog : The Doctor Will See You on the Webcam Now

Health Blog : The Doctor Will See You on the Webcam Now: "American Well sounds like a company that’s selling doctor visits via webcam. But Roy Schoenberg, the CEO, tells us we don’t get it.

“The fact that you can engage in a Web video chat with a provider is a nice exercise, but it’s not the fundamental offering of the system,” is how he put it in a recent conversation.

The company’s big idea is more ambitious: A patient who wants an online doctor consult can log on and get something approaching a complete doctor visit, often without waiting. The doc can review the patient’s record, make a diagnosis, write a prescription and make a referral, all online. Patients without a webcam can talk to the doctor on the phone.

The company’s business model is to partner with insurers, who agree to reimburse in-network doctors for patient e-visits. Docs who choose to work with American Well can sign on whenever they want and see patients who are looking for an online visit

The visits are reimbursed through relatively new standardized billing codes that allow docs to get paid for electronic visits. The insurer pays the doc, and American Well takes a cut. The company also charges an up-front licensing fee.

Doctors make about $40 for a 10 minute consult. The rate can vary — specialists may cost more, and the price may rise after hours or if a patient wants an immediate consult rather than wait a few hours. It’s up to the insurer to set the parameters on what’s reimbursed and what the patient pays out of pocket, but the basic idea is for patients to be on the hook for their regular co-pay."

Saturday, June 21, 2008

The new doctor-patient paradigm

The new doctor-patient paradigm - Medical Economics: "Wesley J. Sugai, a solo pediatrician in Kailua-Kona, HI, thinks the rapid growth of large group practices has fueled the move to more impersonal care. 'The patient belongs to the group rather than to an individual physician,' he says. 'Hence the erosion of the classic doctor-patient relationship. It's now shallow, impersonal, and unsatisfying for both doctor and patient.'"

Thursday, June 19, 2008

Essay - Fed Up With the Frustrations, More Doctors Change Course -

Essay - Fed Up With the Frustrations, More Doctors Change Course - "Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said.

And it is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors’ lounges. Malpractice worries also remain at the forefront of many physicians’ minds, compounded by increasing liability premiums that have forced many into early retirement.

In surveys, increasing numbers of doctors attest to diminishing enthusiasm for medicine and say they would discourage a friend or family member from going into the profession."

Unhappy doctors will lead to unhappy patients - leading to a negative vicious cycle.

Medical Practice Management Software - Made in India - for Indian doctors !

We keep on hearing that India is an Information Technology powerhouse; Indian doctors are extremely technology savvy; and that Indians in general are very clever. Yet, no Indian company so far has developed a program to help Indian doctors take better care of their patients.

Fortunately, this has now changed thanks to the efforts of Girish Mohata, a bright entrepreneur who has developed and released a medical practice management software designed for Indian doctors , called EasyClinic.

I requested Girish to write about EasyClinic - and here's his guest entry.

" We have spent over 3 years in designing and developing Easy Clinic to seamlessly fit with an Indian doctor’s workflow. Most clinical software focuses around better patient care as the primary objective. We consider that to be a by-product. Easy Clinic focuses on the doctor. It is designed to assist the doctor and automatically leads to delivery of better patient care by the doctor. This makes a huge difference in the adoption and usability of Easy Clinic. It enables a doctor to maintain electronic medical records and manage his practice better without being slowed down as a result of using a computer program.

Each aspect of a doctor’s workflow has been thoroughly researched and there are many customisation options in Easy Clinic. For example , ordering investigations and prescribing drugs can be done in less than 10 seconds; clinical notes can be written quickly using self defined shortcuts; and bills to patients can be recorded with a single click .

The drugs database in Easy Clinic has been licensed through CIMS India and is updated quarterly. This provides the doctor with the latest drug information at the click of a mouse. It also reduces medical errors by automatically warning about drug interactions and allergies

Practice management features such as accounting have been designed to suit a doctor rather than an accountant. They are extremely simple and intuitive. For example a doctor can bill a patient with a single click and record expenses using simple voucher entries. Easy Clinic automatically generates their day book, form 3C and other financial reports.

Easy Clinic records and presents data intelligently which enables informed decision making; automates routine tasks; provides prompts on clinical activities ; and provides quick hassle-free accounting , thus making the doctor’s day much more organised . The doctor will be able to see a substantial improvement in the management of patient medical records ; and will be able to run the practice more efficiently as a business. Patients will also be much happier, as a result of the sense of professionalism EasyClinic provides to the practice ."

What some patients want - fulfilling reprouctive desires

I sometimes get some very unusual requests from prospective parents !

Here's a request I got by email

" I am interested in the following:

  1. Egg donation from a young Caucasian woman (in her 20’s) who is has both intelligence and beautiful with the following physical characteristics:
    1. Caucasian (white) race
    2. Light skin complexion
    3. Light colored hair
    4. Blue eyes
    5. Height: 5 feet 5 inches to 5 feet 8 inches
    6. Slender build
    7. Very attractive (beauty)

This may not be available in India so I have some questions and ask your advice:

    1. If I obtain the egg donor, is it best to bring her to India?
    2. Is it possible for her to donate here in the US and have the cells transported to your facility?
    3. Would freezing be utilized?
    4. What do you advise as the best approach for success?
  1. IVF at your facility using all donated egg cells and my sperm cells making me the genetic father.
  2. Three of the fertilized cell would then be split and re-split to produce 3 sets of up to 6 identical fertilized cells. This is a step seldom used. The purpose is this step is to create the potential for identical twins (3 to 5 identical individuals). All eggs cell might be frozen at this step. But I will discuss and ask for your technical advice.
  3. Surrogate mothers: I wish to have you arrange up to 4 surrogate mothers who will each have 2 to 3 of the fertilized cells implanted (or a number you may recommend). I will look to you for your advice and technical knowledge on the best approach for this aspect.
  4. Prenatal care of the mothers and related medical care at birth. "
Technically, it's possible to do all this, but I am uncomfortable with this request !

Is this a reasonable wish list ? Who is to decide ? Is it something doctors should agree to do ? Are doctors just technicians ? Are there limits to respecting patient autonomy and fulfilling patient's personal desires ? If a patients understands and is willing to pay, when should doctors say No ? And why ?

Patient-Centered Health Information Technology (PCHIT) Blog » Patient AND Family Centered, using the PHR to connect with everyone

Patient-Centered Health Information Technology (PCHIT) Blog » Patient AND Family Centered, using the PHR to connect with everyone: "One of the things I have noticed in the era of the EHR/PHR is that there is always someone else or others supporting patients that are not with them physically. This part isn’t new, but my ability to support that vital group (families and community) is.

What I do, then, is use the After Visit Summary to compose a letter to that person or people, with the patient helping me write it. The “letter” is printed out on the hard copy, and then permanently stored for viewing on the PHR of course."

This is a great idea - write a summary letter not just to the family physician, but to the caregiver as well !

How to talk to a doctor -

How to talk to a doctor - "You are an empowered, assertive and knowledgeable patient. You can Google like nobody's business. But if you lack one crucial skill, you still may get lousy medical care.

That skill: talking to doctors.

'The old technique of having a conversation is 99% of what a successful doctor's visit is about,' says Peter Salgo, a professor of medicine and anesthesiology at Columbia University in New York and host of the PBS medical series Second Opinion.

We hear a lot, of course, about doctors who don't listen, don't answer questions or don't remember their manners.

But communication is a two-way endeavor. And sometimes it's patients who fail Communication 101."

Patient-Centered Health Information Technology (PCHIT) Blog » Meeting Consumers Where They Are

Patient-Centered Health Information Technology (PCHIT) Blog » Meeting Consumers Where They Are: "people designing health care behavior change interventions need to “meet people where they are” (my words) and they need to be “fun” (Joe’s words).

I particularly liked Joe’s closing slide on the disconnect between chronic care management today and consumers’ values (particularly the values of baby boomer women–who Joe says make on the order of 90% of the health care decisions in the US…that seems a little bit high to me, but his point is well taken). I think I’ve gotten most of this right–if I’ve mistaken anything, I hope Joe can correct me. The today is first and the consumer values are second in each dichotomy below.

* Data intensive vs. Useful knowledge
* Empower physicians vs. Empower consumers
* Trust authority vs. Trust experience
* Populations based vs. Personalized services
* Physician-patient-centric vs. Social networks
* Hospital & home focus vs. Ubiquitous
* Deliberate speed vs. Internet time
* Disease & illness care vs. Proactive vitality (wellness)"

Tuesday, June 17, 2008

Funny film on having sex

A sense of humour can make coping with infertility much easier ! This video , by Woody Allen, is guaranteed to make you laugh !

Monday, June 16, 2008

What consumers want in health care - The McKinsey Quarterly

What consumers want in health care- The McKinsey Quarterly: " * Faced with health care decisions, consumers are concerned, confused, and unprepared. They rely heavily on personal recommendations and brand recognition, according to a recent McKinsey study.
* As the industry shifts from a wholesale to a retail model, a new market of consumers is demanding clearer information and personalized support. A company that pays careful attention to their needs, desires, and habits stands to gain a significant advantage over its competitors in this quickly burgeoning market."

New generation PHRs which help patients manage their own health

Through applications that gather health information from everyday life, next- generation personal health records provide individuals with new tools to help them engage in and manage their health.

Collection and use of ODL ( observations of daily living) information – which includes information on such activities and experiences as sleep, diet, exercise, mood and adherence to medication regimens – is one area that is genuinely user-directed, both in the kind of information that is contained in the record and the health-related activities that stem from it.

How to pay your bill when you fall ill

No one wants to fall ill , but when you do, the last thing you want to worry about is the doctor’s bills. This is why it’s a good idea to take a health insurance policy to protect yourself against the financial losses caused by a medical problem. Medical care can be expensive and a health insurance policy can provide financial protection and ensure you can afford the best medical care.

The traditional form of health insurance is called indemnity insurance (also known as fee-for-service ) , in which the insurer pays for the cost of covered health care services after they have been provided. In most indemnity insurance plans the patient is free to choose his own doctor or hospital.

In the past, the health insurance business was a monopoly, so the only medical insurance policy available for most of us was MediClaim, through the subsidiaries of the General Insurance Corporation (GIC). Today, with increasing liberalization, the insurance business in India has been opened to the private sector, and there are now many more options to choose from. While this extra choice is great, because companies are competing with one another to offer customers the best deal, having so many options can be confusing ! Also, not all the changes are for the best , and you need to use your judgment when deciding which policy to select for your family. Since the cost of medical treatment is rising faster than the rate of inflation, premiums are likely to increase sharply each year. Also, as you get older, the likelihood of your making a claim increases, which means premiums may jump even more dramatically.

What do customers want from a health insurance policy ? Your basic needs are: protection from financial loss because of hospital bills ; free access to doctors and hospitals you want to go to; no fine print for exclusions; reasonable costs; convenience at the time of hospitalization so you don’t have to pay first and then claim the money from the company ( what is called a “ cashless” transaction);prompt payment of medical claims; quick processing of claims; minimal paperwork; and friendly customer service.

Today, because there are so many companies competing for your business, they all have great marketing campaigns and are happy to sign you up because they want to increase their market share and they know that once signed up, most customers usually stay for life. However, most Indian health insurance companies are still stuck in the past when their only role was limited to paying the hospital bills. All they seem to do collect your premium every year and pay your medical bills in case you fall sick and need hospitalization.

This is shortsighted. Remember that this is a health insurance policy , which should not just provide illness care , but also help us to remain well ! In the USA, which has the most evolved health insurance market, things are different. Insurance companies have realized that spending on medical care after a person falls ill is expensive for them . It’s much more cost-effective to invest money in educating, counseling and motivating people to remain well, so they do not fall ill in the first place - after all, prevention is better than cure ! In fact, in ancient India, this was a well-accepted principle and the doctor ( whose job was to keep the family in good health) was paid only as long as everyone was healthy. If anyone fell ill, the payments stopped, until they recovered. It would be interesting to see if an innovative health insurance company could come up with a modern version of this model !

There are many options now available to insurance companies which they can use to help their customers remain healthy. These include tools for counseling; lifestyle improvement; weight loss; and smoking cessation programs. Many of these can be provided online on the web, which makes them inexpensive to deliver. They can also offer discounted memberships to gyms , spas, yoga classes, meditation retreats and counseling sessions, to help their customers take a proactive approach in managing stress and fighting off disease.

Similar tools can be used to help patients with a chronic illness manage their disease better so they don’t need hospitalization. Hospital care becomes very expensive – and teaching patients to take care of themselves is a powerful therapeutic intervention. This is called “disease management” – and has been applied abroad for a wide range of diseases, ranging from asthma to hypertension to diabetes.

These programs are cost-effective for the insurance company to offer – and don’t need them to spend too much either . An excellent example is the recent study from Partners Health Initiative (PHI) in Anderson, South Carolina which showed they saved an estimated $34.5 million in 30 months—thanks to simply gifting a copy of the world’s largest selling patient education book, the Healthwise Handbook, to all their customers !

The lesson is clear - not only is there a business case for health insurance companies to be investing in patient education , it’s also a great way of helping them win more customers and keeping their customers happy. Enlightened customers should ask health insurance companies for tools to promote their health !

Sunday, June 15, 2008

Medical emergency ! What should I do ? A guide for Indians

Medical care during emergencies in India leaves a lot to be desired. Those of us who watch medical shows on TV ( such as ER) are very impressed with the high quality of care Emergency Rooms in the US provide. If there is an accident, someone phones 911, and within a few minutes an ambulance is promptly dispatched and succor provided. In India, unfortunately, the reality is far grimmer. If there is an accident, most of us prefer not to get involved and turn a blind eye. What’s worse, is that if we do try to help the victim by rushing them to the nearest local hospital, the doctor there may refuse to treat the patient – and tell us to transfer them to a government hospital. What is tragic is that many victims die because of simple medical problems ( such as bleeding) which could have been treated and their lives saved if medical care was provided to them promptly during the emergency.

Doctors know that during a medical emergency ( for example, a traffic accident or a heart attack), there is a “golden hour” which can literally spell the difference between life and death. If effective medical care is promptly delivered efficiently during this critical period, many lives could be saved. However, traffic accidents remain a distressingly common cause of preventable death in India. Given the state of our roads and our civic sense, this problem is going to keep on increasing unless we tackle it efficiently.

What should you do if you see an accident and the driver is bleeding profusely ? The first human instinct is to rush the patient to the local hospital for emergency medical care; or call for an ambulance. However, the nearest medical facility could be your local nursing home or hospital, many of which will refuse to admit these patients. Patients are then shunted off from pillar to post – losing valuable time – and possibly their lives, in the process. Not that large private hospitals are much better. Many do not even have a well-equipped Casualty ( ER): and even if they do, they refuse to take on the patient, until payment is made first.

It’s true that doctors have an ethical obligation to treat any patient – especially during an emergency. However, many refuse to do so. This is not because they are wicked or uncaring , but the sad truth is that many often don’t have the expertise or equipment to do so. What makes a bad situation worse, is that others refuse to do so because they are worried about the police hassles . Accident and emergency cases are often medicolegal cases , and these entail the burden of a lot of paperwork. While some are worried about who will pay for this medical care ( which can be expensive), others are fearful that if they try to help and the patient dies, the mob will vent their anger on the doctor and beat him up. It’s often much easier for the doctor not to do nothing, because they do not want to stick their neck out.

This is a sad situation , but it’s really no different from the approach most of us take when we see an accident. We prefer turning a blind eye and carrying on with our lives and are quite happy to let “someone else” provide succor because it’s not really our problem. Unfortunately, it is our problem. Ask not for whom the bell tolls – it tolls for thee ! Tomorrow , it could be your turn – or mine .

Shouldn’t doctors be held to a higher standard ? Haven’t they sworn a Hippocratic Oath to save lives ? Isn’t there a law which compels them to provide emergency assistance ? How can they refuse to help and transfer the patient ? Isn’t this illegal ?

The truth is that it’s impossible to compel doctors to provide emergency medical care. While most good doctors will do this on moral ground, they cannot be forced to do so – and in any case, this is hardly an effective solution. There are observations made by Supreme Court judges about the importance of doctors providing medical care expeditiously, but these are unlikely to be legally binding – and are very hard to implement in the absence of the needed infrastructure.

Following the Supreme Court Judgement in 1989 ( Pt. Parmanand Katara vs Union of India AIR 1989) , the Motor Vehicles Act was amended in 1994 and under section 134, it was made mandatory for the driver and the owner of the vehicle to take the accident victim to the nearest doctor and for the doctor to treat the victim without waiting for any formality. But, even after all this, the situation has not improved.

I think we cannot fix this problem on an individual basis – and passing a law is unlikely to help. “ Good samaritan” guidelines from the Mumbai Police encourage bystanders to provide assistance in an emergency by reassuring people that the police will not harass them. What can we do to improve the medical care provided during emergencies. ?

This is a societal problem , which needs to be addressed by the government. Unfortunately, there is no 911 service in Bombay – India’s prima urbis ! Most leading Mumbaikars are more focused on earning more money, rather than trying to improve these basic services. This is very short-sighted, as emergencies and accidents can strike anyone at any time !

The good news is that the EMRI ( Emergency Management and Research Institute,, a non-profit organization started by Mr.B.Ramalinga Raju (founder and Chairman, Satyam Computers) in Hyderabad, has implemented a very effective free medical emergency service in Andhra Pradesh called 108. This is a public-private partnership ; and is a shining example of what socially responsible Indians are capable of doing, when they put their mind to it.

We need similar services in Bombay and Maharashtra – and all over the country ! I do hope citizens will put pressure on the government to make this a reality. Once this happens, then we will no longer need to worry about proving effective emergency medical care !


JAY PARKINSON + MD + MPH: "Hello Health is the consumer brand of healthcare delivery from your neighborhood doctor powered by the Myca platform. As a member of Hello Health, you log in, tell us what’s wrong in your own words, then schedule an appointment just as easily as making an appointment at the Apple Genius Bar — and then a doctor shows up at your house at your requested time. And it costs about $50 cheaper than your typical office-based physician. Hello Health is a consumer brand — not a healthcare brand, but a consumer brand much like Zipcar, Netflix, or FedEx — it’s the “consumer experience” of having your own accessible neighborhood doctor who communicates the way we all communicate these days via email, IM, video chat, and text messaging. Hello Health is a “Geek Squad” of doctors for a Netflix-priced, monthly subscription fee. We’re modeling ourselves on consumer brands that have changed established industries much like FedEx, Toyota, Whole Foods, Zipcar, Netflix, and Apple. But we’re using our technology and the power of our consumer-focused brand, hello health, to change healthcare — to rescue both patients and doctors."

Thursday, June 12, 2008

ABCDE of Angina and Coronary Artery Disease Treatment

ABCDE of Angina and Coronary Artery Disease Treatment - : "Drug therapy is effective for the treatment of stable angina and for slowing progression of coronary artery disease. Unstable angina may require surgical intervention in addition to the therapies given for stable angina. Lifestyle changes are essential for improving outcome in anyone with heart disease. Experts have come up with a mnemonic device (ABCDE) for remembering ten factors that are fundamental for angina management:

A. Aspirin and antianginal drugs

B. Blood pressure and beta-blockers

C. Cholesterol and cigarettes;

D. Diet and diabetes;

E. Exercise and education."

I love clever acronyms !

Video with Techniques for Effective Patient Self-Management -

Video with Techniques for Effective Patient Self-Management - "Evidence is growing that indicates as much as 90% of the care needed to manage a chronic disease must come directly from the patient. These important self-management interventions, such as self-monitoring and healthy lifestyle changes, lead not only to improved health, but also to increased patient satisfaction and reductions in hospital and emergency room costs.

From physicians to nursing assistants, health care providers play a critical role in supporting patient self-management. However, this can be difficult for primary care practices, particularly if providers are unfamiliar with behavior change strategies. Patient self-management also fundamentally challenges the traditional authority of providers and transforms the patient-provider relationship into a collaborative partnership.

To support health care providers in promoting patient self-management, CHCF has produced a short training video called 'Techniques for Effective Patient Self-Management.' The 33-minute presentation provides strategies and tools that busy clinicians can use to help patients adopt healthy behaviors."

The Wisdom of Patients: Health Care Meets Online Social Media -

The Wisdom of Patients: Health Care Meets Online Social Media - "Social media on the Internet are empowering, engaging, and educating health care consumers and providers. While consumers use social media -- including social networks, personal blogging, wikis, video-sharing, and other formats -- for emotional support, they also heavily rely on them to manage health conditions.

The Internet has evolved from the information-retrieval of “Web 1.0” to “Web 2.0,” which allows people who are not necessarily technologically savvy to generate and share content. The collective wisdom harnessed by social media can yield insights well beyond the knowledge of any single patient or physician, writes report author Jane Sarasohn-Kahn. The outcome of this development is “Health 2.0” -- a new movement that challenges the notion that health care happens only between a single patient and doctor in an exam room.

Using examples, this report describes how the Web is becoming a platform for convening people with shared concerns and creating health information that is more relevant to consumers. Social networks, ranging from MySpace to specific disease-oriented sites, are proliferating so rapidly that new services are already under development to help health consumers navigate through the networks."

How much does free cost ?

I have just been reading a great book, called Predictably Irrational by Dan Ariely.

A chapter titled The Cost of Zero Cost, seems to imply that if anything is offered free, then people will flock to get it.

This is what I felt too when we setup HELP 10 years ago. HELP, the Health Education Library for People is India's first Consumer Health Education Resource Center. We kept entry to HELP free with the hope that more people would make use of our services because there were being provided at no cost.

However, even though we provide unique services which are useful and which are not available anywhere else in the city ( which has a population of over 15 million people) we only get about 50 visitors per day, even though we are located in the heart of the city.

An alternative point of view is that people do not use our services because they are free. The belief is that people do not value anything which is given away free because they perceive that it has no value.

Who is right ? What should we do ? Should we charge a nominal amount for our services ( so that people will realise the value we provide) ? Or should we continue to give them away free ?

Wednesday, June 11, 2008

A HELPing Hand

This article appeared in India's leading healthcare magazine, Express Healthcare !

Sunday, June 08, 2008

SafeMed Solutions

SafeMed Solutions: "SafeMed is an analytical software company dedicated to transforming healthcare decision-making by providing information that is trusted, understandable, personalized, and useful by doctors and patients. Leading healthcare Web sites, insurers, doctors and electronic medical records use SafeMed for next-generation Clinical Decision Support (CDS).


* Empowering Consumers with actionable, real-time health information that is personalized and not generic
* Intelligently identifying recommended preventions, followup, and therapies for existing conditions
* Detecting potentially harmful drug therapies, and medications to avoid
* Identifying safety-checked medication alternatives which are covered by a specific insurer with real-time financial comparison capabilities
* Delivering physician-labeled internet search queries using the highest-quality sources

How You Can Get Better Medical Care - Part II | Brain Blogger

How You Can Get Better Medical Care - Part II | Brain Blogger: "As a patient, you cannot control whether your doctor is intellectually or financially compelled to help you. You can’t control what disease or problem you are having. You could try and find a doctor who specializes in your problem, but that might be difficult if you don’t have a complex problem. You could try and find a doctor who makes most of his living on fixing your problem, but that might be difficult as well unless you have some inside connections or lots of patient feedback to know what the doctor’s bread and butter practice is all about.

The one thing that you can control is getting your physician to be emotionally compelled to help you. This may come in the form of that special connection you have to him. Or perhaps because you have a mutual friend or colleague. Or perhaps because you brought him a gift and he remembers you as the patient who brings gifts.

Whatever your method, I do recommend that patients try and do something to curry favor with their physician. If you are in a position of influence, don’t be shy to let your doctor know that you can refer other patients to him."

This is good advise - and is true when dealing with any professional . You need to try to stand out from the crowd, so you get more personalised attention and care !

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