Monday, December 21, 2009

Can your doctor read your mind?

There is considerable research being undertaken on new ways of communicating. And I don't just mean communicating with each other as we talk, sing, shout or cry. I mean ways of communicating with other objects, such as cars, computers and other electronic devices. I also mean communicating with people who are in other parts of the world, and who we may or may not know. And I also mean communicating with animals, with people who are deaf and blind, or who are profoundly physically or mentally disabled.

We all know of many examples of our unconscious mind seemingly taking over and informing us of events occurring before they do actually happen - we call it "déjà vue." I will never forget my first memory of this. I was watching a soccer game on television, and I suddenly "knew" that a goal was about to be scored in a certain way, by a particular player, and within a couple of minutes exactly what I "knew" happened.

There are many other examples of the unconscious mind influencing us, our behavior, or our decisions over the ages, and books have been written, societies and religions formed and history influenced on multiple occasions by the strength of our unconscious and the many unconscious or inexplicable communications that occur in our world.

But how will the power of our unconscious mind be influential in healthcare? And will it be somehow linked with the research on communication that is occurring around the world at this time? Will it occur in tandem with research that is trying to define our moods, and which uses electrical currents through our bodies to predict, for instance, suicidal intent?

Let's move to a more mundane form of communication. This article was written with the aid of a voice recognition system. I spoke into a microphone and words appeared on the screen, mostly accurate, but needing some corrections. I also now write my patients notes using a similar system - straight into their electronic records, which I can also control with the voice system. So we are certainly starting to use voice control systems in everyday life, even if they are not yet perfect. But what is the natural extension of these sorts of activities, and how might they be used in the field of healthcare?

We all know that we can communicate just by looking at people. We also know that we can tell what another person is thinking, particularly if that person is very close or important to us. I know that I and my wife often realize that we are thinking the same thing at the same time - and much more frequently than should occur just by coincidence, or because we are in the same environment.

So will be able to eventually use these extra powers of communication with our doctors? Will it be possible for our doctors to literally "read" our minds - to download our thoughts straight into our electronic medical records? It is certainly possible for humans to use their minds to control other objects, without even needing to talk. A number of experiments have shown that our electrical brainwaves can be trained and used to control other objects, be they an artificial limb, or a computer joystick, and these experiments offer substantial hope to severely disabled people.

I think the answer is certainly "yes". But with a caveat. This will not occur soon. And we will have to have considerable ethical debates before any such programs are introduced into clinical practice. But it should be possible. After all, a doctors primary diagnostic skill is pattern recognition - we see simple, and often unusual patterns in massive amounts of data collected from patients, and equate these patterns with a diagnosis. So why should we not be able to extend this often unconscious skill in pattern recognition to include the power to "read" our patients more accurately. All doctors know certain colleagues who are frequently regarded as superior diagnosticians who already almost seem able to do this. So I suspect that in future, as we discover more about the interaction between the mind, the brain and the environment, that we will develop physical means of "mindreading". I wonder how that will affect the doctor-patient relationship?

Peter Yellowlees MD has recently published "Your health in the Information Age - how you and your doctor can use the Internet to work together" - available at most online bookstores.

Thursday, December 3, 2009

Guidelines for videoconferencing in mental health

I am very pleased that the guidelines on videoconferencing in mental health published by the American Telemedicine Association are finally available. A large number of people contributed to these guidelines, but the core writing group for them was myself, Jay Shore MD, Lisa Roberts PhD, with a lot of input from a number of others, including Barb Johnston, who had worked with me on an earlier version published by the California Telemedicine and eHealth Center, and Brian Grady MD, Eve-Lynn Nelson PhD and Kathleen Myers MD.

Writing guidelines is an exhaustive process. It is not the sort of thing an individual can do, and requires input from large numbers of people, especially people with different perspectives. Unfortunately in medicine, it is rare to find a single view on a clinical process, and this was as true for these guidelines as it is for the many other sets of guidelines available in other areas.
I know that all the authors are pleased with the result here - for several reasons. First of all the guidelines are relatively short, usable and practical. They do not have the failing of many other guidelines that are 50 pages or more long, or only apply to a very specific group of patients or settings. These guidelines are really generic, and can be used by any mental health provider with any type of patient. They also have a lot of overlap with non-mental health areas, and would be usable, for instance, by providers in primary care, geriatrics and many areas of internal medicine. They also apply to adults, children and the elderly, as well as to emergency and non-emergency situations. And they have information about clinical, educational and technical issues and approaches - all in just a few pages. They are designed to be downloaded and could easily be taped to videoconferencing machines so that they are easily available for use "stat" by any provider undertaking consultations using videoconferencing. So let's hope that that is how they are used, and that they are helpful. It would be good if a number of the American specialist colleges, such as the American Psychiatric Association, and the the American Psychological Association, could adopt these guidelines for their own use, rather than attempting to rewrite them completely. Let's see if that happens.

In the meantime, I strongly suggest that, if you are a provider of mental health services, that you download a copy and go through it, so that you can undertake telepsychiatry consultations in the best possible way. The guidelines are available at the American Telemedicine Association.

Monday, November 2, 2009

Health Informatics specialists are essential to reform and transform our health system

Much of the American health system is outdated, inefficient and excessively expensive. Many have written about what is wrong with our system, and how important is the process of health reform. But relatively little has been written about what is required to improve the care of all Americans, and how we are to arrive at comprehensive solutions that both disrupt our current system of care, and replace it with improved approaches. One thing we can be certain about is that any changes that we make will be dependent on our capacity to harness information technology, and to use computerized systems intelligently to reform and transform our patient care environments and processes.

Clayton Christensen, in a recent ground breaking book, has argued that disruptive innovation is now necessary in our health industry and that this consists of three elements. The first requirement is for sophisticated technologies to simplify healthcare processes, the second is for business models that deliver more affordable and patient focused solutions, and the third is a commercial and information infrastructure to act as a value-added network.

For this vision to be implemented at a practical level, his model requires strong leadership and the training of substantial numbers of health informatics and change implementation specialists to take up transformative roles within our healthcare system.

Let's look at how this model might work for the average American academic medical center currently trying to provide a full range of sophisticated medical services while using our antiquated and exponentially increasing fee-for-service cost model, and running a series of regional primary care clinics.

The first element is to implement sophisticated technologies to simplify healthcare processes. This includes a full electronic medical record, accessed by patients and clinical staff, available anytime anywhere, sharing data with competitors systems, fully available for research and clinical trials and including a sophisticated set of decision rules to assist all users. This academic center would have extensive telemedicine and internal and external communications systems, online platforms for all types of continuing education, and an active virtual community profile and social networking program. All of the technologies would be continuously improved and evaluated by a team of health informatics specialists, part of whose role is to train their colleagues and the next generation of change implementation specialists.

The second element is to transform the clinical and cost-approach taken by the medical center which will need to focus on specialized areas of internally acknowledged strength to become, as Christensen notes, a "solution shop" in its areas of strength, while no longer providing a full range of all types of medical and surgical services. This may mean dropping certain types of care completely, and negotiating for such specialist services to be delivered at another hospital instead. It may mean creating specialist community clinics with capitated payment models. It will certainly mean doing more of what it does well, and less of what it does not see as core clinical activities. It means taking on services that are already efficient and technologically supported, and adding value to these services through technological and clinical innovation. This second element requires both business and technological expertise.

The third element in the model is developing what Christensen calls "facilitated networks" which he defines as enterprises in which people exchange things with each other. This is where the academic center might decide to partner with previous competitors, promote pre-paid preventative health approaches, support health savings accounts linked to employer groups and encourage all patients to have personally controlled health records. All of these activities are underpinned by the need to have extensive expertise in health informatics - the discipline that is, above all others, required to transform American healthcare.

So the question is, can a modern academic medical center in the USA afford to be without a strong health informatics program as it moves forward in this era of health reform?

And the answer?

A resounding "No".

Peter Yellowlees MD has recently published "Your health in the Information Age - how you and your doctor can use the Internet to work together" - available at most online bookstores.

Wednesday, October 28, 2009

A scary story - the public option?

Why is Congress so afraid of the public option? Why are politicians getting so worked up about a system that every other Western country already has, and which works so well in all of them? Why do they not want to extend Medicare, a widely supported and valuable system that even the most ardent republicans are now praising? Why are they afraid of a competitive system that will force insurance companies to be more honest and keep their premiums reasonable? Why do they want to seemingly continue with our current broken expensive inefficient health system?

Is the public option really that scary?

Of course not.

So let's look at this question? What are the reasons?

Doubtless some politicians have strong philosophical views that preclude them supporting the public option - that is fair enough, and at least they can tell their constituents without any health insurance in perfect honesty that they would like them to remain in the same uninsured state for the foreseeable future.

Others are clearly in the pockets of the insurance companies, and have listened to too many industry lobbyists giving positive presentations containing inaccurate data. They have taken contributions from the companies, and feel a sense of alignment as a consequence. They may even have some of these companies based in their states, allowing them the self-deception that they are helping retain jobs in their own states by opposing the public option.

But most of them are scared. They are scared of making decisions. They are scared of change. They are scared of losing their seats, and their power and influence. They are scared of upsetting their current position. They would prefer to retain the status quo, and are afraid of a different world.

We need to examine why this is the case. What will make them less scared. What will give them the courage to stand up and promote change, when it is so patently needed?

Members of Congress need to understand that if they can identify this fear, as fear of change, that they will be able to conquer it and move forward. Congress is well known as a slow moving place, where change happens at a glacial pace, so it is hardly surprising that our representatives are suddenly scared of the rapid pace of potential change, and are frightened.

And it is true that some of them have much to lose. They may be up for re-election and feel considerable pressure from advocacy groups and funders. But they have to make a decision. Do they stand up for themselves, and do something right? Do they make a vote to save lives? Do they try and help save the life of the many people currently dying needlessly in our wonderful land of plenty? Do they take the advice of 70% of doctors, like myself, who support the need for a public option to help keep the health system more honest?

Fear of change can be overcome. Remember that a life without change is often boring and monotonous. Think how much more fulfilled our Congressmen will feel for having done the "right thing" and voted to implement change, and a public option in healthcare. Change is essential in our lives. It opens up new vistas and opportunities. When you face change, and overcome it, you can then go on and face more changes in your life and successfully overcome them. And enjoy your life more.

Our politicians need to overcome their fear. The public option is not really a scary story. Change must be embraced. They need to do the right thing for themselves, for their constituents, and for their country. This way they will grow, and will become bigger and better people. For that is what happens when you embrace change and move on and overcome your fear.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Saturday, October 17, 2009

Questions for your doctor?

I had a rewarding experience last week when one of my patients asked me a range of excellent questions about their condition. I had just diagnosed them as having an anxiety disorder. This patient was clearly concerned about possible medication side effects, having had difficulties with these in the past, and wanted to know in detail about the type of psychotherapy that would be most likely to help them. I recommended that they read about the illness on the handouts that I printed out for them, and on a number of websites I suggested, before coming back to see me again to decide on a course of treatment. It was pleasing to have a good open discussion about their best therapeutic options, to not need to simply prescribe and undertake a treatment program immediately, and to be able to take the time for the patient to do their own research, and then come back and make a joint decision on the best therapy together. This is the way medicine, in non-emergency situations, should be practiced.

Unfortunately this is not the usual way that physicians practice, partly because it takes more time to communicate and arrive at a mutually agreed treatment plan, but also because most patients still do not really plan in advance what questions they should ask. This leads to doctors still having to second guess what patients want to know when they give them an opinion, and of course they therefore often omit telling patients key information of particular importance to that individual.

Most doctors like patients to ask appropriate relevant questions about their health condition. Two way information flow is a key component in any doctor-patient relationship. It is just as essential that patients ask questions of doctors about their diagnosis and treatment, as it is for doctors to ask patients questions to help them decide what tests are necessary, and what treatments are best.

Think about the last time you bought a major consumer item, such as a television, computer or an expensive piece of furniture, or even something cheaper, such as a cell phone or new clothing. What research did you do? Did you go online and compare all sorts of products? Did you go to various stores and compare prices, availability and replacement guarantees? How much time did you spend on your research before making your purchase?

What about when you last went to see your accountant or your lawyer? Did you think through what issues might come up beforehand and plan some possible questions? Did you think of several potential scenarios that might occur, and try and work out what your response would be to those?

Now compare this with the last time you went to see your doctor. Did you check out various different hospitals if you needed surgery? Did you read up on a variety of possible medications if you needed drug therapy? Did you confirm your diagnosis by reading about your disorder and all possible treatment modalities? Did your doctor tell you what he or she thought was wrong, and then offer information to help you make a decision on what to do next?

The Agency for Healthcare Research and Quality has been running an excellent public campaign called "Questions are the Answers". This campaign encourages patients to create their own list of questions whenever they visit the doctor, or need to have any sort of medical procedure. The campaign consists of both print and internet resources, as well as television advertisements. The Agency has created all sorts of lists of questions which I would encourage any patient to use, and has sorted them by a number of differing situations and encounters that commonly occur in the health field. Examples of some of the core questions are "What is this test for?", "How many times have you done this?", "Are there any alternatives to surgery?" and "How do you spell the name of that drug?" These may all sound like very simple questions but it is astonishing how often patients, when confronted with a potentially life changing or serious diagnosis, have very few questions at the time of the doctor's consultation. Of course people often think of questions afterwards, and will then hopefully read up on their condition and arrange another appointment to ask their doctor about these issues, but not all do, leading to people receiving all sorts of medications and surgeries for reasons that they simply do not understand.

So do help your doctor, and plan your questions as much in advance as much as you can. Most doctors will be appreciative of your questions, and will be happy to answer them so that your treatment can progress with your full understanding.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Tuesday, October 6, 2009

Jobs in health informatics are becoming plentiful

The way most doctors and health care professionals do their jobs has hardly changed over the past thirty to forty years. Contrast this with the enormous changes in, say, transport, manufacturing and telecommunications!

But hang on to your stethoscopes! Despite the fact that some doctors still have their heads buried firmly in the sand, the winds of change are blowing and most doctors are now using electronic communication technologies, if not enthusiastically, then at least regularly. The combination of technological change, the demands of business and the rise of consumerism are causing radical changes in the way healthcare is practiced around the world. Health Informatics experts are poised to revolutionize health practices by implementing the enormous changes needed in the health system, that have already occurred in other industries. These professionals typically have backgrounds in either healthcare, such as nurses and doctors, or information technology, and then receive cross-training so as to be able to work across both areas in the newly emerging electronic health systems of today and tomorrow.

The changes in healthcare will be the 21st century’s equivalent of the public health initiatives of sanitation and nutrition which revolutionized health care in the twentieth century. Integration of online technologies will see doctors and patients working together on electronic health records with patients having much more say in their treatments. The development of widely available broadband networks and video mail will bring electronic health into everyone’s home. Patients and doctors will work collaboratively on the internet as parters with the agreed mutual objective of health improvement.

Look at how fast the average adolescent can send messages on their phone – gone are the days when a telephone was just an audio device. The way we interact with communication systems is radically changing the way we behave and think in ways that are impossible to predict. And the computer literate children of today - the millenials and succeeding generations - will drive these changes. How many doctors want to interact with patients using instant messaging? Not many today, but the doctors of the millennial generation will probably think nothing of this approach. And these sorts of systems will be developed by experts who have been trained in health informatics, and who understand how to apply information technologies of all sorts to change and improve the way that we deliver patient care.

Knowledge has never been as important - and as accessible - as it is today.

Technology, and in particular, Internet technology, is transforming the academic medical landscape. A large number of institutions are moving to digital-only radiography and full electronic medical records. I no longer write any notes on paper – all my clinical work is electronically recorded. Residents now come to rounds armed with a vast array of reference information stored in hand-held personal digital assistants. The iPod is now a platform for lectures presented either as "podcasts" and “videocasts” and is also used as a mobile x-ray image viewer. Continuing medical education is increasingly available through the Internet. The digital revolution has greatly altered how academic health systems pursue education, research, and clinical care, and this is spreading through the rest of the health system.

The provision of clinical care is changing rapidly as health informatics technologies become increasingly used and accepted, with a move away from episodic care to concentrating on continuity of care, especially for patients with chronic disease who will create the greatest disease burden in the future. Care is gradually moving away from a focus on the service provider to that of the informed patient and from an individual approach to treatment to a team approach. Increasingly, less focus is placed on treating the illness and more is placed on wellness promotion and illness prevention: the model of the”Information Age care” first described by Dr Tom Ferguson MD. To move to this future of information age healthcare, the availability and use of information must be strengthened to facilitate changes in health service delivery, and a much greater focus must be placed on developing and refining the information technology infrastructure, and on training experts in health informatics who can create and develop the electronic clinical environments needed by both patients and doctors.

This is all occurring at a time of difficulty in our economy, but America is known for its capacity to thrive on challenges, and to rapidly change its industrial practices in the face of adversity. The health system needs large numbers of experts in health informatics, and training programs are being rapidly expanded. The University of California Davis Health Informatics graduate program, for instance, has doubled the number of Masters Health Informatics students in one year, and has enrolled 76 new students in a fully online Health Informatics certificate program within the last three months. The Obama Administration is putting billions of dollars into health informatics implementation and training with funds from the American Recovery and Reinvestment Act and increasing numbers of jobs in health informatics are already appearing. The jobs website, CareerBuilder has just marked health informatics as it's number one emerging industry job opportunity, and is highlighting a number of jobs in areas as diverse as telemedicine, nursing information officers, clinical information technology liaisons, programmers, analysts, data integration experts and health service managers.

So, as healthcare continues to change and become more electronically enabled, watch out for this whole new generation of professionals trained in Health Informatics, and how they will facilitate the changes in healthcare, and eventually contribute to improving the health of all of us.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Wednesday, September 30, 2009

How to talk back to your doctor?

When was the last time you visited your doctor? What was it like? What happened? How did you communicate? Were you listened to? Were you able to develop, or deepen, your therapeutic relationship with them? Who else was part of the consultation? Was your doctor using a computer during the consultation? And if so, for what purpose?

There are a number of factors that are known to strengthen the therapeutic relationship that you have with your doctor, and they all fall under the broad heading of “patient empowerment”. There is a truism in healthcare that “knowledge is power” and that this is a key component of any good relationship. The capacity to make choices based on correct information, whether it is from your doctor, or the Internet, or elsewhere, is crucial. Another factor is responsibility – patients have to be aware of what is expected of them in the relationship, just as is the case for doctors – with any treatment program being designed to make the patient independent and able to take charge of their own lives and any future treatment programs. Finally patients need to know what are the expectations of their treatment program, who else might need to be involved (such as family, interpreters or other doctors), how can second opinions be arranged.

All of these matters are related to knowledge and information, and all can be improved by working with your doctor and the Internet to help yourself better. 38% of patients in a recent study from the Pew Foundation reported being able to email their doctors in 2008, compared with only 6% of patients in 2003, but over 80% of patients said they would like this ability. The same study estimated that over 8 million Americans use the Internet to search for health information every single day. This works out at over 140 million Americans each year. We all know the importance of communication, and doctors and patients are now increasingly communicating by using the Internet and email.

Think about all these questions. Have you, like many others, seen your doctor in the presence of a third “person” – a computer linked to the Internet? Most doctors have rapidly computerized their practices over the past decade. They are very aware of the extraordinary amount of health information on the Internet, and most are fluent users of email, and many other software packages. Doctors have taken to the Internet like ducks to water, and use many aspects of the Internet for their own lives just like most other people in the USA. They use it to manage their practices, and many now also communicate regularly with patients on email. This is not surprising. Most doctors will use any useful innovation or new technology that presents itself to allow them to provide better care. They are very aware that this is the Information Age, and that they and their patients can greatly benefit from the amazing amount of healthcare information that is now at their finger tips, and from the astonishing access that they have to this information.

It is national US health policy for all patients to have an electronic health record within a few years time, so many doctors and hospitals are implementing such records to hold patient information. Large health systems are forming partnerships with commercial companies such as Microsoft and Google to make health information more available to patients in the form of personal health records – another way for patients to see, and contribute to, their own health information. And another way for patients to learn more about themselves, and hence communicate better with their doctors.

So what happened when you saw your doctor? How did he or she then involve this “third person” in the consultation? How did you feel about it, and did it help you? Were you able to find and use the amazing amount of health information available online, to work with your doctor, to collaboratively become the winning team that is necessary to keep you healthy, happy, and fully productive in as many aspects of your life as possible. To teach you how to talk back to your doctor, to be heard, and to be empowered to improve your health.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Monday, September 14, 2009

Virtual Reality in Medicine - many evolving uses and advantages

Virtual reality techniques, involving three-dimensional imaging and surround sound, are increasingly being used in diagnosis, treatment, and medical education. Initial applications of virtual reality in medicine involved visualization of the complex data sets generated by computed tomography (CT) and magnetic resonance imaging (MRI) scans. A recent application of these techniques for diagnostic purposes has been the “virtual colonoscopy,” in which data from a contrast-enhanced abdominal CT scan is used to make a “fly-through” of the colon. Radiologists then use this fly-through for colon cancer screening. Recent improvements in methodology have brought the sensitivity and specificity of this technique closer to the levels of optical colonoscopy, and patients prefer the technique to the traditional method.

Virtual reality has also been used extensively to treat phobias (such as a fear of heights, flying and spiders) and post-traumatic stress disorder. This type of therapy has been shown to be effective in the academic setting, and several commercial entities now offer it to patients. In one of my projects using the multi-user virtual reality environment offered by Second Life, one of several easily available online virtual reality environments, we have used a virtual psychosis environment to teach medical students about the auditory and visual hallucinations suffered by patients with schizophrenia.

Virtual reality has been used to provide medical education about healthcare responses to emergencies such as earthquakes, plane crashes and fires. While the primary advantage in phobia treatment is a “safe environment” which patients can explore, the primary advantage in emergency preparedness is simulation of events that are either too rare or too dangerous for effective real-world training. The immersive nature of the virtual reality experience helps to recreate the sense of urgency or panic associated with these events.

Virtual reality programs have also been used for a variety of medical emergency, mass casualty, and disaster response training sessions for medical and public health professionals. One study developed a protocol for training physicians to treat victims of chemical-origin mass casualties as well as victims of biological agents using simulated patients. Although it was found that using standardized patients for such training was more realistic, the computer-based simulations afforded a number of advantages over the live training. These included increased cost effectiveness, the opportunity to conduct the same training sessions over and over to improve skills, and the ability to use “just-in-time” learning techniques and experience the training session at any time and location, while adjusting the type and level of expertise required to use the training for various emergency response professionals. Others have explored the potential for training emergency responders for major health emergencies using virtual reality. Their objective was to increase exposure to life-like emergency situations to improve decision-making and performance and reduce psychological distress in a real health emergency.

Experience with recent natural disasters and terrorist acts has shown that good communication and coordination between responders is vital to an effective response. In my work using Second Life to develop a virtual mass disaster emergency clinic to hand out antibiotics to the population following a massive anthrax bioterrorism attack, we have found a number of important advantages of the virtual world, over the real world, for training first responders.

Responders to such events come from many different organizations, including fire, police, military, and hospital personnel. There are three major difficulties in training and evaluating these first responders in the real world:
They have little or no chance to train together before the event occurs and hence lack teamwork skills.
What training they may have had comes at great cost, in large part due to the effort and need to transport so many people to a specific training site at a specific time.
The training sites frequently cannot be the most common targets – for example, one cannot shut down the Golden Gate Bridge during rush hour to train for an earthquake or terror scenario.

Virtual reality offers some intriguing advantages over the real world for these aspects of first responder training, as all of the above difficulties can be overcome. Virtual reality systems can support multiple simultaneous users, each connecting to the system using standard office personal computers and broadband Internet access. Lifelike models of buildings, roads, bridges, and other natural and man-made structures where the users can interact can be constructed. Finally, the whole scenario can be digitally preserved and a full workflow analysis can be performed retrospectively. Public health officials and first-responders can work through the scenarios as many times as they like to familiarize themselves with the workflow and emergency protocols, without encumbering the time and expense of organizing a mock emergency in real life.

Virtual Reality treatments are rapidly becoming more available. They are currently being used to treat post-traumatic stress disorders caused by wartime experiences, and US servicemen are now increasingly being offered such programs. Rather than the traditional method of confronting old nightmares, online technology is able to deliver treatment in a far more therapeutic and humane way. Patients are “transported” to the battlefront and fears and traumas are resolved in virtual place and real time. Virtual Reality is here to stay, and will increasingly be used widely in a number of areas of healthcare.

Peter Yellowlees MD blogs at and has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Virtual Reality Medical Education in Second Life

Increasing numbers of people are using the Internet for the provision of all sorts of health services, from prescribing, through consulting to setting up automated self-treatment programs. But what about using it for education and therapy? After all, in theory, the ultimate form of cognitive behavioral therapy should be “virtual reality therapy.” By simply wearing your wrap-around sound and vision multimedia headset you can be instantly transported to a cliff edge, soar in a plane thousands of feet above the ground or be surrounded by a gathering of thousands of spiders - depending on your phobia. And the ultimate form of online education should be fully interactive, case based and student driven, all of which I now use in my teaching in Second Life.

The phrase “virtual reality” was coined by Jaron Lanier in 1989 to describe computer simulations of physical environments. Since the mid-1990s, the video game industry and 3D graphics card manufacturers have driven forward the state of personal computer graphics, advancing it far beyond the needs of most business users. These systems range in capability from simple displays of 3D objects to entire virtual cities. Virtual reality systems are now being routinely implemented on personal computers for a variety of activities. One of the most popular virtual reality programs is Second Life, produced by Linden Lab, Inc. Second Life is a general-purpose virtual world accessible through any Internet-connected personal computer. In order to interact in Second Life, users create “avatars”, or animated characters, to represent themselves. Individuals use these avatars to maneuver through various “worlds”, complete with buildings, geographical features, and other avatars. While the system borrows heavily from video game technology, it is not a game – there are no points, no levels, no missions, and nothing to win. It is simply a platform by which people can create virtual communities, model geological, meteorological, or behavioral phenomena, or rehearse events. I have been working in Second Life for several years now.

Users of Second Life include a variety of education organizations, from Harvard Law School to the American Cancer Society. There are currently areas of the virtual world that provide such disparate services as teaching heart sounds and auscultation technique, providing social support for individuals with Asperger's Syndrome, and modeling the effects of tsunami on coastal towns. The system has over 10 million account holders from all over the world, most of them with free basic accounts. Approximately 800,000 of those users are active, with over 80,000 of them connected to the system at any time. Virtual reality programs such as Second Life are increasingly being used for educational purposes in a variety of fields, including medical training and disaster preparedness. Linden Lab currently operates the Second Life Education Wiki which functions as a source of information for educators and trainers in a variety of fields who wish to use Second Life for distance learning or large-scale training purposes. A number of government agencies, including the Department of Homeland Security, the Centers for Disease Control, the National Institutes of Health, and the National Science Foundation, have begun using Second Life to hold meetings, conduct training sessions, and explore ways to make access to information more readily available around the world. A recent comprehensive survey intended to gather information on the activities, attitudes, and interests of educators active in Second Life conducted by New Media Consortium reported that the majority used it for educational purposes such as teaching and taking classes as well as for faculty training and development.

I have been using Second Life as a teaching and learning environment for several years now. With colleagues I have created a "virtual hallucinations" environment, which demonstrates the lived experience of psychosis and allows participants who travel through the environment to experience both visual and auditory hallucinations; visions and voices. We used this environment to teach this experience to our medical and psychology students. With the California Department of Health and other colleagues I have created a virtual bioterrorism crisis clinic to train health workers, and more recently, as part of our Health Informatics Certificate Program, with University of California Davis Extension, we have taught informatics students in a virtual conference center on our own private island; Davis Island. Students find the environment straightforward to learn to navigate, and within a week of our informatics students being introduced to the environment they were able to travel and tour around Second Life with the rest of us with ease.

Second Life and similar multi-user environments offer enormous possibilities in the medical educational world, where such applications are now called "serious games" rather than social or fun software. Students of the future will adapt to them very easily, and it is clear that applications such as Second Life have a great educational future before them. I look forward to continuing to teach classes of medical and graduate students "inworld".

Peter Yellowlees MD blogs at and has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online

Sunday, August 16, 2009

Should we measure the quality of blogs?

Blogs have now become ubiquitously available. Just as the Internet is widespread and accessible, becoming cheaper, better understood and more user-friendly and flexible, so are blogs becoming more common and important. Access to blogs is increasingly via phones and multiple devices which can be read or viewed anywhere, anytime. The recent emergence of the i-Phone and Blackberry generation of devices, with their extraordinary capacity to download and play music and movies, to act as a phone and messaging system, to use email and scheduling software, and to fully access the Internet for maps, search tools and the like, has simply made the Internet a more accessible and useful tool for use in everyday life. And blogs have flourished with this easy accessibility.

Blogs are all about opinion. They are now massively used, promoted, discussed and quoted. Some have become mainstream news outlets, checked every day. Blogging has become a new form of work for both trained and untrained "journalists". I, as an educator, have even started using them as an educational tool in an online course I am teaching, and have all the students creating and maintaining their own blogs as part of their assignments.

But who is attempting to evaluate blogs for quality, accuracy, truth, consistency and all of the other components that are typically focused on by, for instance, editors of published journals or newspapers, or directors of television shows. Blogs are, in reality, a mix of all sorts of different media types, often presented in a multi-media fashion with video clips and a number of other enhancements.

And should we be trying to measure the quality of blogs anyway? After all, a blog is a derivation of literally a web-log. Early blogs were simply a series of postings in the form of a diary of activities posted on the internet for all to see. They have certainly rapidly developed as an information source since those first examples, and now often used to promote views held by individuals or organizations on almost any subject under the sun.

We do measure and evaluate most written communications, and most media publications, and for many different reasons. We may want to demonstrate certain levels of quality and accuracy, to see if they have changed views of the subjects who read or watched them, to count what they have sold or promoted and demonstrate their effectiveness or to judge how to improve them for future editions. Alternatively we may want to measure usability or readability. But do we do this with blogs? Blogs are different from many other publications on the Internet, and are even less permanent than many other types of website environments. While most blogs do have an archiving process for past postings, all such archived postings can be changed, deleted, and otherwise altered retrospectively, so that the sense of permanency that the internet has with some content, simply doesn't exist with blogs.

I have searched the web briefly for articles about blog evaluation, or blog measurement, and cannot find many that have made a serious attempt at this. Does this mean that this is not worthwhile doing? I doubt it. Does it mean that no-one is doing it. Again a negative answer, as I am sure they are. Does it mean that it is a hard and perhaps thankless task? Most certainly. Can any readers of this article find some good examples of blog evaluations? I hope they can.

The only form of "measurement" of blogs seems to be a popularity index, and there are many groups now focused on identifying the "top 10" or the "top 100" blogs in a certain area. But popularity is very different from quality, and it would be good to see some structured quality measures combined with the popularity counts. Some blogs do get widely quoted, and are "fact checked" by a range of groups, but this fact checking is really only about core content quoted on the blogs, and not about the quality of the blog more generally.

It does seem odd that blogs, which are now becoming a mainstream news source for many of us, and which we know are notoriously unreliable, are not being evaluated and are not being treated in the same way that other important new sources are treated.

My own area of interest is internet healthcare. It would not be too difficult to set up a measuring and evaluation process to use with blogs in that area, and this would seem to be a well worthwhile task. This is particularly important with respect to our current debate on healthcare reform, as blogs are taking a front row seat in the efforts of all sides to promote their views, yet there is little attempt to evaluate their quality or accuracy, and this leads to the potential for the rapid spread of misinformation.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Health Informatics Student blog url's

I am currently running a course through UC Davis Extension called "The Internet and the future of patient care". As part of that course all my students have to write a blog - they have just started and I attach a list of the name of the students and the url's for those blogs that are currently active, and will update it with a few more over time.

It is interesting to see the types of topics they are choosing - a lot of interest on how social environments and attitudes mix with technology - fascinating


Mary Vasterling

focus on human trafficking and health reform

Emily Norman

challenges in the E-Health Record system from the perspectives of IT software, hardware development and support that I leanred from my professional experience.

Brian Paciotti

to focus attention to the human ecology of health and medicine by looking at medical outcomes on a map.

Jonathan Ware

the efficiency and organization of healthcare - 5 posts already

Rajiv Kairon

privacy and genetics

Esther Munoz

just started

Marie Goddard

I want to start discussions about how we can get people, both health care professionals and the lay public, including patients to feel more comfortable and confident with using computer technology in managing personal health, the health care of patients and of our population

Mohammed Morshed

how internet changes the fundamental dynamics of health care, the way people think about health care.

Adrish Sannyasi

just started

Nwamaka Dim

I discovered certain inefficiencies in the handling of medical records in healthcare organization. How the organization lose a lot of money and lack of follow-up of their patients due to improper record keeping.

Jermy Wong

This is going to be my healthcare informatics journal, I would like to share my thoughts and what I learn via this blog

Monday, July 27, 2009

Why public health insurance is essential to save American lives

The current debate on health reform is getting lost in the numbers and dollars game in Congress. The arguments have become about price. What is the cheaper option? How can we pay for it? What is the best value? It is about the health insurance industry defending its ground, and attempting to maintain the current status quo. It is about how this industry may continue to make substantial profits out of the misery of all those patients who are sick, while maintaining a system that encourages them to avoid making payments as much as possible, to either patients or doctors. It is about a system where large special interests are able to negotiate low payments to doctors who have little bargaining power or strength, and which leads doctors to increasingly insist that patients pay them directly, rather than go through their insurers, hence letting the insurers completely off the financial hook.

Let's put a real human face on what is happening in American healthcare at present.

As a physician working in a major academic medical center in California, let me tell a few stories of some of the horrors that I have seen that are directly caused by the appalling way that American healthcare is organized and paid for. These stories are clear evidence that we cannot continue with our current system of insurance funding, and simply have to have a public insurance option available to offer choice to all Americans, and to create competition for private insurance companies which they just don't have at present.

Firstly let me say that I am extremely proud to be working in this medical center, which last year provided over $160 million of uncompensated care to the uninsured. This is about double the year before, a fact that is directly the consequence of the recession, increased numbers of uninsured patients, and an increased level of social poverty.

Think of the middle-aged homeless woman with diabetes who was admitted yet again with pneumonia. She has been sleeping rough, and in great personal danger having been assaulted numerous times. She cannot get out of a cycle of poverty, homelessness, illness and peril, and every time she recovers in hospital, it is sickening for the medical and nursing staff to know that she is being discharged to the street, where the cycle will continue. She has no insurance, no family, no future and no hope. Her medical prognosis is dreadful, she is unable to receive any regular follow up care for her diabetes, and she will probably not live for more than a few years unless there are major changes in her situation. She desperately needs good medical and social care, but there is little for her to receive, and she ends up costing society a huge amount because of her multiple expensive hospital admissions, occurring because she has no regular outpatient care. She would be so much better off with regular public health insurance, and would at least have a chance of breaking this cycle.

Think of the recently unemployed father of three young children whose wife died a year ago. He lost his company sponsored health insurance when he lost his job, and is unable to afford to pay the quoted premiums from other insurance companies because of his possible prior history of high blood pressure, found on two medical exams in the past, andwhich is seen as a risk factor for possible cardiac problems in the future.

Think of the patient with chronic schizophrenia who has suddenly had his treatment program closed by a county mental health department desperate to save money and faced with the decision to close either their firefighting or mental health services to meet their budget. This patient has nowhere to go for treatment, eventually runs out of medication, becomes psychotic again, tries to kill himself because of his delusions, and is re-admitted to an inpatient facility for several weeks at great public expense.

These are the faces of the health reform debate. These are the people that President Obama is fighting for, and which the insurance industry will not help, which they prefer to ignore. This is why we have to have a public health insurance option. And this is why we have to have true health reform in this country.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Sunday, July 19, 2009

Health care reform - will Dr Obama be able to cure the US Health System?

Let’s pretend that President Obama is actually Dr Obama, and that his job is to diagnose and treat the US Health System. What will he find, how will he go about it, and what will be the outcome?

The process of diagnosis is relatively straight forward. Everyone acknowledges that the system is broken and that there are a number of agreed on symptoms of this disorder. Firstly the system is far too costly, consuming almost twice as many dollars per capita as health systems in other Western countries. And this expense is also poorly focused, with over thirty per cent being spent on administrative non-patient care costs (such as insurance companies costs and profits, and excessive administrative costs for providers), almost twice as much being spent on medications as other countries, and reimbursement inappropriately targeting piece rate medicine and rewarding doctors who perform interventions, (such as surgeons and radiologists) instead of prevention and the treatment of chronic illness (such as primary care physicians). Of course the existence of 47 million uninsured is a disgrace and a huge problem, as is the relatively poor quality of overall care provided nationally for the money spent. And finally the whole system is very patchy, with excellence provided relatively cheaply in some areas, and the opposite in many others, and this occurring in the setting of relatively little investment in electronic medical records and modern information technology, which could certainly improve the system.

So what should Dr Obama do? If he addresses some of the problems above, then the task becomes clearer. It is absolutely necessary to introduce some form of national public insurance program, both to insure the currently uninsured, and to provide competition for the excessive number of health insurance companies to make them reduce their rates, increase their cover, and provide better value services. It is likely that this process will lead to many of the insurance companies going out of business, and that is fine, because there are way to many at present, and it would be more rational for us to have fewer larger health insurance operations. At the same time the cost of pharmaceuticals has to be addressed – there needs to be a nationally negotiated formulary for core essential drugs that are paid out of the public purse. At the same time the payment structure for providers needs to be changed, and more emphasis paid for services for chronic illness and prevention, and less for interventional medicine, while also encouraging, as is happening, the use of electronic medical record systems and other health information technology initiatives. A single dramatic enhancement would come if he insisted on the introduction of a national health identifier number as this would greatly enhance the ability of providers to exchange health information when necessary, and would greatly simplify billing and administrative processes.

Many other things have to happen, of course, but will Dr Obama and his team be up to this task? We currently have a bloated and inefficient health system, and in any such system there are winners and losers. The winners in today’s health system are insurance companies, the pharmaceutical industry, and large numbers of providers who are used to receiving excessively high incomes for interventional services. The losers are patients, and the country. When looked at broadly, the diagnosis and treatment of our health system are actually relatively straightforward, but it has to be accepted that today’s “winners” will not necessarily remain in that position long term, and that there will be a number of losers as we change the system. Let’s just hope that Dr Obama, and his multidisciplinary team in Congress, are able to push through the reforms the US health system needs so that the patient is no longer the loser.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Monday, July 6, 2009

Jama reviews "Your health in the Information Age" very positively

I am pleased to say that a very positive review of my book, "your health in the information age" has been published in the Journal of the American Medical Association, the most prestigious general medical journal in the world. The reviewer introduced his review in the following way:

"If you have heard the joke" What kind of physician uses the Internet? A URLologist" then Your Health in the Information Age" may be just the ticket for you and your patients. This 188 page book takes on the monumental task of offering an excellent exploration of the exponentially expanding world of e-health for readers already searching for health information on the Internet, as well as for relative newbies".

And finishes with the following:

"Your Health in the information age" is not an "e-health for dummies". It is an academic and insightful look into the exciting and nascent world of online health care. Whatever your views on the flaws and failures of the US healthcare system, you have to admit that things are changing. Make no mistake: online care is a game changer."

It is very pleasing to read such a positive review, which also includes some very reasonable criticisms that I will be delighted to confront when I write the next version of the book. You can all read the full review by going to my website at www. and following the links. I hope you do, and I hope that this review encourages you to tell your friends and colleagues about the book, and to continue to think critically about all aspects of e-health on the Internet.

Online healthcare is a game changer

Dr Stanley Borg, in the Journal of the American Medical Association, recently wrote that "whatever your views on the flaws and failures of the US health care system, you have to admit that things are changing. Make no mistake: online care is a game changer."

I agree, but what did he mean by that?

Could he be talking about how technology is going to radically improve the way we deliver and receive our healthcare? Does he see new technologies as being around the corner, and about to envelop us and help us improve our health? What does he really mean by "online care"? Is it enough for us to communicate with our doctor on the Internet, or should we be becoming involved in online groups and counseling fellow patients? Should we have all of our medical records stored online, and be able to access them ourselves to make sure that they are correct. Should we be wearing electronic monitors of our heart, our breathing, our temperature, all of which constantly transmit our vital signs in real time to the database of our choosing? Or should we be undertaking robotic surgery using automated machines controlled by a surgeon hundreds of miles away?

Does this sound scary, or is it a form of "techno-utopia" that we should all be seeking? I can easily answer that one at least. Techno-utopia, as defined by Wikipedia, is “a hypothetical ideal society, in which laws, government, and social conditions are solely operating for the benefit and well-being of all its citizens, set in the near- or far-future, when advanced science and technology will allow these ideal living standards to exist; for example, post scarcity, changes in human nature and the human condition, the absence of suffering and even the end of death.” We are certainly not close to this.

In place of the static perfection of a utopia, others have envisioned online health as occuring in an "extropia," an evolving open society allowing individuals and voluntary groupings to form the institutions and social forms they prefer. Perhaps the web 2.0 is the beginning of this extropia?
We have to be careful not to be “techno-Utopians” - excessively, uncritically accepting of technologies. People like this don’t tend to use new technologies as effectively as they could because they view the technologies as ends in themselves, not as tools. It is commonly held that using new technologies uncritically implies bad habits of the mind. Taking television as an example, one could argue that this technology has led us to concentrate on superficial, rapid acquisition of knowledge rather than on deep thinking and careful consideration. Look at all the “news bites” prepared for TV – and how if you are trained in media skills, you are almost always taught to literally speak in short “bites” that are easily reportable but often meaningless.

Healthcare on the Internet, in partnership with your doctor, does promise huge benefits not only for us all, patients, clinicians and society in general, and is, to quote Dr Borg, a "game changer". But in embracing technology, the human factor must not be forgotten. It is not the cleverness of the technology that is important but how we use it to derive most benefit for us, for our children, and for society. We have to learn to improve, to control, and to effectively use the tools and techniques now available to deliver online healthcare to improve our health and, in doing this, to enrich the quality of our lives.

If we look at the future direction that online healthcare is moving in, and which is being supported by the Obama Administration, the following themes are evident:

§ Our future isn’t what it used to be, as we move to the era of virtual hospitals and global clinicians
§ Our health system is gradually changing and becoming electronic and distributed, with less dependency on buildings, and more on communication networks from the patients home to the operating theater
§ Research is opening up whole new ways of delivering healthcare, using all our senses, and in a much more personalized manner
§ Patients are demanding better and more accessible healthcare, and will obtain it from all around the world in future
§ The doctor-patient relationship is changing, and will become increasingly open and driven by empowered patients living in an information rich environment – where the Internet is increasingly influential and important in clinical consultations.

Online care is a game changer, and we should all embrace it and learn to use it to our best advantage.

Peter Yellowlees MD has recently published "Your Health in the Information Age - how you and your doctor can use the Internet to work together." The book is available at Amazon, iUniverse, and most online bookstores.

Monday, June 22, 2009

Telemedicine is an essential component of healthcare reform

It is clear that most stakeholders in the health industry now support President Obama's view that it is essential that we have substantial healthcare reform, and soon. The arguments around the issue are not whether this should happen, but how and when it will occur. An excellent white paper has just been written on how national telemedicine initiatives are essential to that reform. The whole paper, primarily authored by Rashid Bashshur PhD and Gary Shannon PhD, is available for free download at I strongly suggest that you read it.

In brief the paper makes the case that the need for reform stems from long-standing problems in our health system, and demonstrates that the central role of telemedicine derives from an ever-expanding body of research-and experience that attests to its merit in addressing these problems.

The paper notes that "despite the fact that the United States spends more on health care than any other country, both in absolute numbers and on a per capita basis, the health status of Americans ranks relatively low when compared with that of people in other developed nations. Moreover, the general discrepancy between expenditures and health status indicators in the U.S. masks significant differentials among segments of the population, based on socio-economic, geographic, cultural, ethnic and other factors."

The consequence of these factors is that we continue to suffer from inequities in access to health care, inefficiencies in the delivery of care, escalating costs and the prevalence of adverse life styles that exacerbate these problems.

I have just spent been on call over the last weekend working in a major Academic Medical Center Emergency Department managing acutely psychotic patients transferred there as a place of last resort because the only local locked inpatient psychiatric facility was closed to admissions because it was full as a result of major financially driven cuts to local outpatient mental health services. This is the sort of concrete evidence that the American healthcare system is broken, inefficient, disorganized and inequitable.

Why is this relevant? Simply because we must improve our system of care, make it more integrated, and start using electronic healthcare more intelligently and more frequently. Electronic health records represent a means to improving the health care system but are only a partial solution to the problems we face. The practice of telemedicine, where patients are treated by videoconferencing or email in real or asynchronous time, incorporating electronic medical records, is a much better way of working, and allows many of the geographical and cultural inequities we face in health care access to be overcome. The white paper argues effectively and strongly for those involved in planning healthcare reform to take a broad view of the use of health information technology, and to think beyond electronic health records to a time where we will be using telemedicine incorporating electronic health records.

Peter Yellowlees MD has recently published "Your Health in the Information Age - how you and your doctor can use the Internet to work together." The book is available at and most online bookstores. An e-Book called "4 simple steps to better health - an insiders look" is available at Smashwords at

Thursday, June 4, 2009

Public Health Insurance - a lifesaver for the American Health System

There is much debate around the type of insurance proposals that will be required in the new health system currently being negotiated in Congress. President Obama has just come out in support of a public health plan, which is opposed by private insurers who say that they could not compete with a public health plan that didn't have to make a profit. Supporters of the public plan proposal correctly say that it would give people more choices and create more competition. Opponents argue that private health plans would go out of business, leaving only an entirely government-run health care system.

Of course all sides are exaggerating and taking up extreme positions. They will all in time compromise and hopefully reach some form of agreement. The sad part is that at present they don't seem to be thinking of the person at the center of all this - the patient. It is widely acknowledged that healthcare costs far too much in this country, while at the same time at least 47 million Americans are uninsured. So, from a patients perspective, if you do have health insurance, you are paying way too much for it, and getting poor value, and if you don't have it, then you just continue to suffer. What a dreadful choice.

The goal of overhauling the health care system is to lower costs and extend care to the uninsured. Obama wants a bill on his desk in October. Where can Congress begin to compromise, and why is it that Republicans in particular, believe that public health plans are likely to be so dreadful. They regularly bring up the ogre of "socialized medicine" whenever public plans are discussed, but there is no evidence whatsoever that countries with more federal control over their health systems, especially in Europe, have worse health outcomes that the USA. In fact the contrary is true, health outcomes are much better overall, for a lot less money per capita.
As a physician who has lived and worked in the USA, Australia and Britain, and who has an interest in how health services are organized, I think we could move forward in a relatively simple way as long as we always keep the patient at the center, and don't try and design a health system primarily to protect profit levels for various constituents, whether they be providers, health insurers or pharmaceutical companies.

Firstly we need a public-private partnership philosophy. That means public and private, not just private. America is founded on capitalist principals, where the profit motive is central, and any new approach to healthcare must combine this with the need to develop core public services that may be less likely to ever achieve a profit. Funding for care needs to be provided on the basis of annual or episodic whole of person care, rather than on individual piece rates as at present. The primary importance of this approach is that it will force more resources into the prevention of illness - to wellness promotion - rather than into the treatment of illness that has already commenced. This is an approach that Kaiser Permanente is well known for.

The public component of the healthcare system would include universal basic health insurance (including catastrophic care insurance) and many emergency and isolated health services, as well as much more public health focus on prevention and health promotion. Public programs should also pick up much of pre/post natal and early child care to ensure all mothers and babies are properly looked after, and probably care of some special populations who cannot afford private health insurance such as the unemployed, some seniors and certain impoverished or geographically isolated groups. These are areas where there will be less competition with private insurers who have typically kept away from them.

The private component would be funded with the aid of tax incentives to encourage most people (or companies) to take out private insurance with aim that at least 80-90% of the population should have private insurance. It is crucial to reach this level of insurance to be confident that we all have "skin in the game" and are financially responsible for at least a good proportion of our healthcare costs, and do not see healthcare as something that is provided by the government for free. The private sector should offer a full range of services from birth to death - with the ability to charge extra for certain "non-essential" services such as cosmetic surgery and other niche areas - but with regulation to prevent people being excluded on grounds of pre-existing conditions.

These ideas are taken from what I consider to be the best parts of the American, British and Australian health systems. No country has a perfect health system. America is the Land of the Free and can afford to choose the best of what other countries have attempted as it debates how to improve its healthcare system. Lets hope that Congress can be creative and not get bogged down in political dogma.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores. A shortened version of the book, available as an e-Book for download to iPhones, Blackberry's, PDA's and other mobile devices called "4 Simple steps to Better Health - an Insiders Look" is available at Smashwords at

Ready to Launch? Swine Flu phase 2?

When will swine flu reappear in the Northern Hemisphere? Next September of October is the most likely time.

Most pandemics go through a well described series of three peaks of infection rate. There is an initial outbreak, that we have just had, followed by several months of relatively little activity as the flu literally travels south to the traditional flu season in the Southern Hemisphere. The flu then returns with its largest peak of activity with the next Northern Hemisphere flu season, traditionally around September and October, before dropping away again. There is usually then a final relatively small outbreak the following flu season during the next spring.

Pandemic flu literally spreads around the world, from north to south, and currently continues to be a threat south of the equator, where countries are entering the winter months and their traditional flu season, according to Dr Christian Sandrock, a UC Davis infectious diseases expert on the effect of this virus.

According to the CDC South America has had more than 600 cases, including one death in Chile, while Australia has reported more than 500.

Overall swine flu has hit more than 60 countries, with the United States reporting the most cases — more than 11,400, including at least 19 deaths, according to the CDC, compared with just over 5,700 in Mexico.

The good news is that the swine flu does not seem to be particularly dangerous to humans, although it spreads easily, it kills in relatively small numbers and is not a very potent form of flu. This does not mean that it can be ignored because with the likely impending outbreak next autumn many patients with chronic diseases, and young children, will be at increased risk of infection and potentially fatal consequences.

What should we be doing? Apart from all the obvious things like good hygiene, avoiding contamination and reducing infection spread by self-isolation of those who are infected, this is a classic example of how we can use health informatics and information technology for the greater public good.

If we had universal electronic records, and good public health reporting systems, we would be able to both identify outbreaks earlier, and treat those with infections more rapidly, as well as possibly follow up clusters of outbreaks to prevent further spread. Have a look at the CDC home page and study their swine flu influenza surveillance systems and see the large amount of data that is able to be collected now, without universal electronic records. The data is already impressive but to collect it is difficult because it involves amalgamating so many different data sources, few of which are complete, so the data itself is still not as good as it could be. And it is not available in real time.

The Obama administration is planning a comprehensive implementation of electronic medical records nationwide within the next five years. A very positive added value effect of this important initiative will be the production of more data, much of it in real time, to combat major pandemics such as swine flu, as well as a number of other substantial public health threats such as bioterrorism. The secondary use of electronic health record data for these sorts of purposes should greatly encourage all doctors and health systems to implement electronic health records, and to make sure that they are able to exchange key health information with important national bodies like the CDC.

This article is based on excerpts from the recently published book "Your Health in the Information Age - how you and your doctor can use the Internet to work together," by Peter Yellowlees MD. Available at and most online bookstores. An e-Book called "4 simple steps to better health - an insiders look" is available at Smashwords at

Wednesday, May 27, 2009

ATM Healthcare? The way of the future?

Doctors are starting to redesign the way they work to link better with patients and to use the newly available multi-media technologies. This is an important process that will undoubtedly accelerate over the next 20 years. There is a need to substantially redesign many of the traditional processes used to practice medicine - and move to new ways of delivering health services, using what I call ATM Healthcare.

What, then, is ATM Healthcare?

When we think of the term ATM, most of us think of banks. The acronym ATM has entered our language so completely that many people don't even know what the letters stand for - they just know that undertaking an ATM transaction allows money to be drawn direct from their bank account, not from a credit account, and that they can do this at a special ATM machine usually in the street, or at a store checkout. ATM stands for Automated Teller Machine and is simply a direct electronic entry to your bank and your accounts. And it is very simple, convenient and consumer friendly. ATM has made banks and bank accounts much more accessible to customers, wherever and whenever they want. At the same time they have made the work of banks more efficient while dramatically cutting the cost of bank transactions to a few cents from an average of $10-15 per face to face transaction with a teller. This has happened because ATM machines now manage most of the simple bank transactions that used to take up a lot of the time of tellers. This frees up bank staff to spend more time on complicated transactions where human expertise is required. Who can now imagine a bank without widespread ATM facilities? And all this has happened in just a few years.

Computer scientists think of ATM in a very different way. For them ATM is a technical term describing how data can be passed across an electronic network. Here ATM stands for a protocol called Asynchronous Transfer Mode. This protocol was designed as a way of merging old telephone networks with more modern packet-switched computer networks in order to deliver data, voice, and video over the same channel. In other words it allows all sorts of differing data, from varying data sources, to be delivered at the same time.

So what have these two types of ATM have to do with healthcare?

Think of the obvious parallels.

The doctor-patient consultation is in many ways similar to the traditional bank interaction with a teller. It is confidential, about 80% of consultations are relatively simple, and if complications arise, a second person can be called in to give specialist advice. There are also parallels with the computer scientist ATM, because this consultation nowadays involves typically several different types of data - voice, lab results, paper and electronic documents (health records), and increasingly video and digital images. The consultation itself can be described in both computer language and clinical terms as consisting of three information processes – data capture (history and examination), data analysis (diagnosis), and business planning (treatment).
What we in healthcare need to do is start thinking like bankers, and focus on providing our services in a more consumer friendly way. As we do this, doctors need to follow two core principles. The first is the complementarity principle - computers do well, what humans do badly, and vice versa. Computers never forget, and are great at scheduling, remembering and reminding, but humans are much better at data analysis and decision making. So computers should be able to do many simple health transactions, remember and order prescriptions and lab tests, schedule appointments, and provide preventative health information. The second principle is the importance of redesigning business processes before introducing new technologies. There are a lot of similarities between banking and the practice of medicine. And doctors can learn from bankers in this area. There is no reason why we should not introduce ATM Healthcare, in just the same way as bankers have introduced ATM Banking.

What would ATM Healthcare look like?

Firstly, lets assume that, like banking, ATM Healthcare is going to be used for relatively straightforward consultations in many specialities, and will not replace the complicated face to face consultation or intervention that makes up about 20% of overall medical consultations, and will always remain the health "gold standard" consultation. We already have most of the tools of ATM Healthcare at our disposal. Electronic Medical Records, lab results and x-ray images are the health equivalent of bank statements. Telemedicine - video consulting either in real time (synchronous), or delayed time (asynchronous) - is now a proven technology, is already available in some supermarket clinics, and is the equivalent of the teller machine. Email and wireless telephony provide more mobile access to providers, and the whole internet is an amazing educational and clinical communication platform that is already delivering all sorts of ATM Healthcare. We have lots of systems to combine different types of data and present them simultaneously to doctors and patients, just as per the computer scientists version of ATM.

Patients need to encourage doctors to think of ways of redesigning their practice processes to make better use of available multimedia technologies so that they can continue to provide better and more available care. I am sure this will happen, especially as more of the “millennial” generation start receiving care. They will demand that doctors use these technologies, and increasingly change their ways, and hopefully use the example of banking as we move increasingly to ATM Healthcare.

This article is based on excerpts from the recently published book “Your Health in the Information Age – how you and your doctor can use the Internet to work together” by Peter Yellowlees MD. Available at and most online bookstores. A shortened version of the book, available as an e-Book for download to iPhones, Blackberry's, PDA's and other mobile devices called "4 simple steps to better health - an insiders look" is available at Smashwords at

Thursday, May 21, 2009

Can social networking on the internet improve your health?

We have all heard the term Web 2.0. It refers to a second generation of websites and activities mainly involving social networking websites like MySpace and FaceBook. A related recent term is Health 2.0 which is the use of Web 2.0 methods for healthcare. There has already been one excellent Health 2.0 conference that was widely attended by industry, health providers and some patients, and another such conference is occurring soon in San Francisco. The whole concept of Health 2.0 and the use of social networking sites in healthcare is starting to gain momentum, and the increase in interest in what is being called "participatory medicine", where patients and health providers collaborate more equally than in the past, is likely to give it more of a boost.

Much of the history of these types of initiatives can be traced back to Dr Tom Ferguson, who was one of the giants of the early years of the Internet. He urged patients to educate themselves and share knowledge with one another, and encouraged doctors to collaborate with patients rather than command them. Predicting the Internet's potential for disseminating medical information long before it became a familiar conduit, he was an early proponent of its use, terming laymen who did so "e-patients." He classified doctor’s consultation styles on the net into two types. He talked about Type 1 doctors who are "advisors, coaches and information providers" but who specifically do not attempt to diagnose or treat. These doctors, or other health professionals, are typically available through their own sites, or through the many commercial sites. They generally don't advise the same patient twice, usually don't even give their name, although the commercial sites "guarantee" that they are fully qualified, and will often refer you to a local face to face doctor or hospital. Interestingly, I understand, this is how many of them receive payment for their services - the sites get a "spotters fee" from local services that they refer to.

Ferguson also defined type 2 doctors, the majority of medical providers on the net. These are doctors like me who provide normal face to face care, and who encourage their patients to also use email to contact them directly - a rational and sensible use of new technologies which, as long as guidelines for Internet consultations are followed, is a great way of working for both patient and doctor.

Full time Internet health services and providers will become much more common in the next few years, however, as we move to being able to use secure video systems over the Internet. I predict that eventually as many as 10-20% of all health consultations will take place in cyberspace within 10 years or so. This will be a real revolution in healthcare.

I do think that the emergence of online doctors who are prepared to treat their patients in a collaborative manner, both face to face and online, is the way of the future. The question is, how will this happen, and can it happen via social networking sites on the internet? I think this will be perfectly possible. There is no reason, for example, why groups of patients, along with their doctors, could not sign up for a "closed" social networking site that focused on their particular chronic disease, say diabetes, heart disease or depression. The social networking site could allow all patients to access many different doctors for advice and health education, and could be supplemented by educational information recommended by both doctors and patients who are members of the site. This is effectively the same as facebook, where "friends" are accepted into a social networking group, and not just anyone can join. The disease focused networking site, and all its activities, would occur as an adjunct to the patients having their own individual continuing doctor-patient relationships with their usual doctor, whether this relationship be face to face and/or online. I think it is time for some research in this area to see if this combination of conventional care, and social networking support, can actually improve patient outcomes in the long term. My bet is that it would.

This article is based on excerpts from the recently published book “Your Health in the Information Age – how you and your doctor can use the Internet to work together” by Peter Yellowlees MD. Available at and most online bookstores. A shortened version of the book, available as an e-Book for download to iPhones, Blackberry's, PDA's and other mobile devices called "4 simple steps to better health - an insiders look" is available at Smashwords at

Tuesday, May 12, 2009

e-patients and participatory medicine

Dr Tom Ferguson, who tragically died aged 62 in 2006, was one of the giants of the early years of the Internet. He urged patients to educate themselves and share knowledge with one another, and encouraged doctors to collaborate with patients rather than command them. Predicting the Internet's potential for disseminating medical information long before it became a familiar conduit, he was an early proponent of its use, terming laymen who did so "e-patients." He classified doctor’s consultation styles on the net into two types. He talked about Type 1 doctors who are "advisors, coaches and information providers" but who specifically do not attempt to diagnose or treat. These doctors, or other health professionals, are typically available through their own sites, or through the many commercial sites. They generally don't advise the same patient twice, usually don't even give their name, although the commercial sites "guarantee" that they are fully qualified, and will often refer you to a local face to face doctor or hospital. Interestingly, I understand, this is how many of them receive payment for their services - the sites get a "spotters fee" from local services that they refer to.
Ferguson also defined type 2 doctors, the majority of medical providers on the net. These are doctors like me who provide normal face to face care, and who encourage their patients to also use email to contact them directly - a rational and sensible use of new technologies which, as long as guidelines for Internet consultations are followed, is a great way of working for both patient and doctor.

I deliberately don't recommend any online doctors from any particular sites because it is really impossible to tell how good they are, although there are many such sites easily accessible via Google. Interestingly a recent study undertaken by ABC’s “Good Morning America” found that, while consultations from three major web sites could be useful for routine problems, the sites doctors made misleading diagnoses in more difficult cases. The program concluded that patients should avoid online consults for problems that couldn’t wait more than 24 hours, but that it would be reasonable to consult with their regular physician online about routine problems that they had had before.

There is another group of health care providers, however, who attempt to provide full health services only on the Internet. Many of these provide counseling or therapy services for mental health problems, or alternative therapies of an often bizarre and inappropriate nature. At the present time my advice is generally to stay away from many of these, unless you can be sure who they are, and ideally can also see them face to face. Full time Internet health services and providers will become much more common in the next few years, however, as we move to being able to use secure video systems over the Internet. I predict that eventually as many as 10-20% of all health consultations will take place in cyberspace within 10 years or so. This will be a real revolution in healthcare.

I do think that the emergence of online doctors who are prepared to treat their patients in a collaborative manner, both face to face and online, is the way of the future. This approach to care has been termed "participatory medicine" and features the empowered "e-patients" that Ferguson also described, communicating with their online providers. A fascinating example of a website devoted to participatory medicine, and which includes an excellent white paper written by Ferguson, is

This article is based on excerpts from the recently published book “Your Health in the Information Age – how you and your doctor can use the Internet to work together” by Peter Yellowlees MD. Available at and most online bookstores. A shortened version of the book, available as an e-Book for download to iPhones, Blackberry's, PDA's and other mobile devices called "4 simple steps to better health - an insiders look" is available at Smashwords at

Thursday, May 7, 2009

Narcissistic America? Do computers have feelings too?

Narcissism seems to be the word "du jour" on health sites on the internet right now. Articles and blogs on the topic of narcissism abound. Doubtless this is partly because the pieces easily find a very interested audience - narcissists themselves. Not surprisingly narcissists love reading about themselves, and there are a lot of narcissists in our culture, so this topic is always bound to be popular in cyberspace. But is it only us physical humans who are narcissistic? Is this a trait held by virtual people, such as avatars, or even by inanimate objects such as computers and cell phones?

Our faces show our emotions. They are the window of our feelings. Physicians are trained to both consciously and unconsciously pick up diagnostic cues from patients’ faces. We know what someone physically looks like when they are depressed but we can’t physiologically describe it. We know their brow is furrowed, their mouth drawn, their skin looks dry and pasty and that they are tearful and their face moves slowly. Soon we will be able to mathematically measure and model our facial features by converting a video to digital data. So if we can digitally measure depression, and other moods, using facial recognition software, why not measure narcissism in the same way? Then we could more easily pick a narcissist in the real-life world, as well as in the virtual environment.

How would we do this? If we were to model syntax and language content in sentences, we would likely find narcissists using terms like "me" and "I" much more frequently than others. Equally they would be dismissive of others, patronizing and self-centered, and this could be modeled in their speech. We could examine the facial features and physical attributes given to avatars in virtual worlds like Second Life and would expect to find, for instance, that avatars owned by narcissists were consistently more handsome, taller, more powerful and more dramatic than avatars owned by others. These avatars might be more destructive and bullying, engaging in harmful and power-hungry behaviors. Interestingly the existence of the "Cyber Narcissist" has been postulated and described on a number of websites and blogs - an extension of the real world narcissist who can easily promote themselves and fend off criticism by adopting any number of nicknames and aliases in anonymous sections of the internet. So maybe we can start to identify narcissists in the online world - even though they are all likely to be extensions of their real-life narcissistic alter egos.

But what about narcissistic inanimate objects?

Far fetched as it sounds it is already possible for information to be electrically passed along a line of people holding hands with terminals attached to the legs of the person at each end of the line! This sounds weird but we all know we transmit electricity and must wear rubber shoes when repairing electrical equipment. It is therefore logical, even if it seems unreal right now, that we could literally be a part of the information system! This is called “affective computing” - computing with feelings. Researchers are looking at how to transmit smells, or signals identifying smells, over the Internet – this is perhaps somewhat easier as it is possible to have digital signals transmitted that encode for specific smells, and release them, from one end of a line to another. The term “natural interfacing” is used by scientists who are studying the mechanics of how to allow humans to interact via computers in a way similar to talking to each other – without a need for a keyboard, pad or stylus. The ultimate goal for these researchers is to design systems that can interact directly with our minds – allowing sounds and ideas to be transmitted straight into our brains, allowing us to merge seamlessly with machines. In this view of the future people will have wearable mini-computers that understand the rhythm, inflection, tone and emphasis of speech, and that can respond in a human sounding manner – very different from the mechanical sounding computer speech we have now.

So maybe it will one day be possible to have a narcissistic computer. Or a narcissistic cell phone. Perhaps the iPhone of today, already the trendy attachment of many narcissists who proudly demonstrate their latest software application with only the slightest encouragement, is a forerunner of the narcissistic electrical device of the future. Will it eventually show its feelings by changing color, automatically turn on music to drown out people it doesn't want to hear, and constantly remind its owner how clever, skillful and attractive they are by reinforcing their most intimate thoughts and feelings

Such technology is not in the realms of fantasy. Suicidal depression is as much an emergency as heart failure and hopefully in the future it will be monitored just like diabetes, heart disease and asthma. Undoubtedly lives will be saved. But will this also apply to narcissism, and will there really be narcissistic machines that mirror their owners thoughts and feelings. For that we will have to wait a while, and in the meantime we must read about real-live narcissism, and try to remain modest about any possible upcoming scientific breakthroughs in this field.

This article is based on excerpts from the recently published book “Your Health in the Information Age – how you and your doctor can use the Internet to work together” by Peter Yellowlees MD. Available at and most online bookstores. A shortened version of the book, available as an e-Book for download to iPhones, Blackberry's, PDA's and other mobile devices called "4 simple steps to better health - an insiders look" is available at Smashwords at