Is online healthcare at a tipping point in 2010?

Online healthcare is becoming more accepted by both patients and doctors, and is, I believe, at a tipping point in 2010. By 2015 online communication between patients and doctors and the routine use of multimedia information will be the norm.

Patients will still be seen in person but our improved capacity to communicate electronically is, as Clayton Christensen has put it, a "disruptive innovation" that will revolutionize healthcare delivery. Providers will be routinely using these new technologies, such as email, telemedicine, electronic records, social networks and wireless mobile applications with patients. This will make healthcare more affordable, accessible and efficient.

These changes will be supplemented and strengthened by the availability of multimedia data. Electronic clinical information will be more freely available than today for both patients and doctors to review, comment on, pass to others for second opinions, and compare with clinical databases and disease registries. This data will be in multiple electronic formats - numeric, text-based, audio, digitized still pictures, video, radiologic, genomic and 3D streams. It will include data emanating from multiple medical monitoring and diagnostic devices as well as from ubiquitously available consumer devices such as cell phones. Patients and physicians will have to learn to navigate a "sea" of data, using new techniques to evaluate and analyze the relative importance of specific data points and elements of clinical information.

These two changes will mean that by 2015 the relationship that many patients have with their doctors will have expanded beyond the in-person interaction of today, and will increasingly occur literally anytime, anywhere in both online and in-person environments.

Peter Yellowlees is the author of "Your health in the information age - how you and your doctor can use the internet to work together."

What is health informatics?

There is a lot of confusion about what exactly is health informatics - let me try and explain in a simplistic manner.

At the most basic level it is the discipline that creates a bridge between the clinical domains of knowledge and the domain of information technology.

It is sometimes hard to give a simple definition, but the American Medical Informatics Association has described it as follows:

"An emerging interdisciplinary and diverse field that:

• combines health sciences (such as medicine, dentistry, nursing, pharmacy and allied health) with computer science, management and decision science, biostatistics, engineering and information technology.
• solves problems in health care delivery, pharmaceutical, biomedical and health sciences research, health education and clinical decision making
• is essential in all aspects of health care and biomedicine"

The cornerstones of health informatics are the ability to:

• analyze data
• manage knowledge
• undertake data acquisition and representation
• manage change
• integrate information

Health informatics has a number of internal speciality areas, such as Medical/Clinical informatics, bioinformatics, nursing informatics, dental informatics, public health informatics and veterinary informatics.

Careers in health informatics exist in clinical care and research, personal health management for patients and consumers, public and population health, health policy and translational science. Informaticists help in the design, implementation, and use of systems that manage the increasingly complex and voluminous information in health care delivery and research.

There is an estimated need for 10,000 health informatics professionals in the next 5 years who will work in industry, academic institutinos, community based organizations, government agencies and the military, health care facilities, private practice, research organizations and private health practices.

This is an expanding and exciting field where high quality jobs are plentiful. It is not surprising that so many people are retraining and entering the profession of health informatics.

What is the truth about Health Reform?

Now that health reform is with us I thought it was worthwhile trying to summarize what I understand to be the truth about what it will mean. There are a number of pros and cons, and some areas that seem to be of equivocal benefit, depending on our personal views, so here is a brief summary...........

The positive aspects:

• 95% of legal US citizens will have health insurance, compared to 83% now - an increase of 32 million people
• Insurers cannot stop paying for people who are sick, even if they lose their jobs
• People with previously known medical conditions cannot be refused health insurance
• People who cannot afford health insurance will be able to obtain it relatively cheaply
• Medicaid will expand significantly, and children will be able to stay on their parents insurance until they are 26

The negative aspects:

• Most of the bill won't go into effect until 2014
• The costs will be about $94 billion per year for the first 10 years - but these will be more than covered by cost savings and tax increases
• Some states will have an increase in the cost of health insurance
• The Individual Mandate means that you either have to buy health insurance of have a $2.5% tax increase
• There is an extra tax on very expensive health insurance plans and for high income people

The equivocal issues:

• The public option is not an option
• More government involvement in healthcare, but remember that governments already pay for more than 65% of our healthcare, and hopefully this bill will reduce medical costs in the long run
• There is no federal money for abortion
• The extra regulation on insurance companies will probably increase costs, but will certainly increase quality, and will make sure that they spend at least 80% of their receipts on actual healthcare
• Doctors will have increased access to information about which treatments are most cost-effective
• Large employers have to offer insurance to all their employees or pay a fee

There are lots of other parts of health reform, but hopefully this very simple guide is helpful.

What is Macrowikinomics?

I am currently reading the book "Macrowikinomics" by Don Tapscott and include a quote from it below for interest and to stimulate some discussion about the relevance of these ideas in healthcare.............

"In our previous book, Wikinomics (Portfolio 2006), we called this new force "mass collaboration" and argued that it was reaching a tipping point where social networking was becoming a new mode of social production that would forever change the way products and services are designed, manufactured, and marketed on a global basis. But, in the four years since penning the idea, it's clear that wikinomics has gone beyond a business or a technology trend to become a more encompassing societal shift. It's a bit like going from micro- to macroeconomics. In which case, wikinomics, defined as the art and science of mass collaboration in business, becomes macrowikinomics:the application of wikinomics and its core principles to society and all of it institutions. Just as millions have contributed to Wikipedia—and thousands still make ongoing contributions to large-scale collaborations like Linux and the human genome project—there is now a historic opportunity to marshal human skill, ingenuity, and intelligence on a mass scale to reevaluate and reposition many of our institutions for the coming decades and for future generations. After all, the potential for new models of collaboration does not end with the production of software, media, entertainment, and culture. Why not open-source government, education, science, the production of energy, and even health care?"

What do you think of this? I am fascinated by these thoughts and by their possible implications for the healthcare industry. Especially in the public health arena, where tracking of all sorts of disasters, epidemics, wars and the like can be undertaken by those actually affected with posting on sites containing geographic information systems - just as an example. Tapscott quotes one of the more popular participatory medicine sites - www.patientslikeme.com. He says:

"PatientsLikeMe.com, is one of the Web's most vibrant health care communities, some 60,000 members believe that sharing their health care experiences and outcomes is good, and perhaps even integral, to speeding up the pace of research and fixing a broken health care system. Why? Because when patients share real-world data, collaboration on a global scale becomes possible. The health care system becomes more open and this in turn improves outcomes for patients, doctors and drug makers. New treatments can be evaluated and brought to market more quickly. Patients can learn about what's working for other patients like them and, in consultation with their doctors, make adjustments to their own treatment plans. All considered, communities such as PatientsLikeMe are leading the way toward a health care system that is cheaper, safer and better than what we have today."

I really like the idea of specialised social network sites, both open and closed, that are rapidly developing, where patients and doctors can mix and learn from each other - this seems especially helpful for those illnesses that are either common, like diabetes or heart disease, or rare, like Huntingdons Disease.

What does everyone else think? What sorts of health services are likely to be undertaken using the principles of "macrowikinomics"? It will be fascinating to see...............I look forward to comments and thoughts.

Asynchronous Telepsychiatry is Feasible

The following press release was published by UC Davis on August 5th 2010

A new study by researchers at the UC Davis School of Medicine has found that psychiatrists can accurately assess a patient's mental health by viewing videotaped interviews that are sent to them for consultation and treatment recommendations.

The approach, called asynchronous telepsychiatry, uses store-and-forward technology, in which medical information is retrieved, stored and transmitted for later review using e-mail or Web applications. It has been used extensively for specialties like dermatology, with photos of skin conditions sent to dermatologists, or x-rays sent to radiologists for assessment.

However, the current study is the first to examine store-and-forward technology for psychiatry, said Peter Yellowlees, professor of psychiatry and behavioral sciences and the study’s lead author. “A Feasibility Study of the Use of Asynchronous Telepsychiatry for Psychiatric Consultations” is published in the August issue of the journal Psychiatric Services.

“We’ve demonstrated that this approach is feasible and very efficient,” said Yellowlees, who is an internationally recognized expert in telepsychiatry. “Using store-and-forward technology allows us to provide opinions to primary-care doctors much more quickly than would usually be the case.”

The researchers conducted the study to determine the effectiveness of asynchronous telepsychiatry for patients in Tulare County, a rural county in California's San Joaquin Valley. Sixty male and female patients between the ages of 27 and 64 who had mostly mild-to-moderate mental-health disorders were included in the study.

Researcher Alberto Odor, associate adjunct professor of anesthesiology and pain medicine, conducted 20- to 30-minute structured videotaped interviews at a community-based primary-care clinic. The videos were then uploaded to UC Davis’ specially designed Web-based telepsychiatry consultation record. Yellowlees and Donald Hilty, professor of psychiatry and behavioral sciences, reviewed the videotapes and provided psychiatric evaluations to the patients' community-based primary-care physicians.

Fifty-one percent of patients received diagnoses of mood disorders, 19 percent received diagnoses of substance use disorders, 32 percent received diagnoses of anxiety disorders and 5 percent received other diagnoses — including kleptomania, schizophrenia and parasomnia. Five patients also were diagnosed with disorders such as borderline personality disorder, obsessive-compulsive disorder or personality disorder. Some of the individuals had multiple diagnoses.

One patient was referred for a face-to-face consultation with a psychiatrist because of the possibility of a diagnosis of early psychosis. The psychiatrists recommended additional laboratory evaluations for more than 80 percent of patients and made recommendations for medication changes in 95 percent of patients. In instances where medication changes were recommended, physicians also received long-term treatment plans. A variety of psychotherapies, such as individual and cognitive-behavioral therapy, were recommended for many of the patients. Community-based primary-care physicians said they found the practice worked well, the study says.

The consulting psychiatrists provided feedback to referring physicians within two weeks, but asynchronous telepsychiatry could occur within 24 hours if it were to become a regular service, Yellowlees said.

Asynchronous telepsychiatry should not take the place of face-to-face psychiatric evaluations and is not suitable for patients with urgent psychiatric conditions, he said. But there are a number of circumstances in which it would be helpful in providing more primary-care physicians greater access to psychiatric consultations.

“There is a substantial shortage of psychiatrists,” Yellowlees said. “Asynchronous telepsychiatry would allow us to have better access to information about patients being referred by primary providers and to provide more comprehensive opinions. This approach could be used by the military and in many different rural and metropolitan settings. It signals the beginning of the true multimedia electronic medical record with clinical video recordings becoming part of the data set.”

In addition to Yellowlees, Hilty and Odor, other study authors include Ana-Maria Iosif and Michelle Burke Parish, both of UC Davis, and Karen Haught of the Tulare County Department of Public Health.

Yellowlees is the author of "Information Age Health - how you and your doctor can use the Internet to work together" available on Amazon and at www.InformationAgeHealth.com

What is Meaningful Use?

$19.2 billion in Recovery Act funding has been designated to modernize the health care system by promoting and expanding the adoption of health information technology, but what is going to happen? Like it or not, all health professionals will be significantly impacted by the Health Information Technology for Economic and Clinical Health Act, or HITECH, and we will all have to change the way we work.

A carrot and stick approach has been taken with HITECH, with incentive payments for implementing electronic medical records (EMR) starting in 2011 averaging $44,000 per physician who achieves “meaningful use” of EMR’s, and reductions in patient payments from 2017 for those who don’t. It is not sufficient for EMR’s to be installed or available – they have to be in demonstrable routine “meaningful” use.

The Centers for Medicare and Medicaid Services has released a 555 page document that outlines the requirements for “meaningful use”. The proposal contains 25 measures for physicians and 23 measures for hospitals.

Let’s examine some of these.

At least 80% of all unique patients seen per provider must have demographics, an up-to-date problem list of current and active diagnoses and an active medication and allergy list recorded electronically, while clinical summaries must be provided to patients for at least 80% of office visits. Computerized Physician Order Entry must be used for at least 80% of all orders, the functionality for drug-drug, drug-allergy and drug-formulary checks must be implemented and at least 75% of all prescriptions written per provider are to be transmitted electronically.
The other measures, many of which require interoperability with other data systems for public health purposes, are detailed on the HITECH website.

It is evident that achieving “meaningful use” will significantly change the way much of American medicine is practiced. Dr David Blumenthal, National Coordinator for Health IT, has agreed that the proposed rules aim to “stretch” the health care community, but not “break” it. This is an exciting opportunity to radically improve patient care, underpinned by informatics expertise, and is one that we should welcome and support.

A video version of this post is available on www.youtube.com and at www.ucdmc.ucdavis/informatics

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.

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. http://www.atmeda.org

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.

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 www.InformationAgeHealth.com and most online bookstores.

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 www.InformationAgeHealth.com and most online bookstores.

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 www.InformationAgeHealth.com and most online bookstores.

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 www.InformationAgeHealth.com and most online bookstores.

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 http://informationagehealth.blogspot.com 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 www.InformationAgeHealth.com 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 http://informationagehealth.blogspot.com 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 www.InformationAgeHealth.com and most online

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 http://www.informationagehealth.com/ 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

Enjoy!

Mary Vasterling

http://www.into-healthcare.blogspot.com/

focus on human trafficking and health reform

Emily Norman

http://ehealthsecurity.blogspot.com/

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

http://geographyofmedicine.blogspot.com/

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

Jonathan Ware

http://packetgreen.blogspot.com/

the efficiency and organization of healthcare - 5 posts already

Rajiv Kairon

http://e-mednet.blogspot.com/

privacy and genetics

Esther Munoz

http://mhi214.blogspot.com/.

just started

Marie Goddard

http://healthinfoandpeople.blogspot.com/

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

http://ihealthinfo.blogspot.com//

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

Adrish Sannyasi

http://computingformedicine.blogspot.com/

just started

Nwamaka Dim

http://dimhealthinfo.blogspot.com/

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

http://ps377.blogspot.com/

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

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 www.InformationAgeHealth.com and most online bookstores.

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 www.InformationAgeHealth.com and most online bookstores.

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. informationagehealth.com 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.