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