Digital Dermatologist

Take a look at this app for evaluating skin lesions. How long does it take to see a dermatologist in your city? This is the beginning. Medicine will be become more mechanized in order to become more personalized.



Disease Care Management Blog Link

Social Media and the Road to Patient Empowerment (and why stop there: disaster preparedness, Google and governance…)

More Than Just A Techie
Communication Tool?

The Disease Management Care Blog has two kin who recently went through major surgery. After being surprised by significant post-operative symptoms, they were told by their providers that the side-effects they were describing were “common.”  In retrospect, there was little in the informed consent, the peri-operative discussions, documentation, education materials or discharge instructions that provided adequate warning.  In both instances, the response of the well-meaning, harried and overworked nurses and surgeons was the same….  gawrsh, we should include your insight in our education materials, so we can warn other patients!

Knowing how hospitals, nurses, doctors and educators compile these materials, the DMCB thinks the likelihood that actual patient feedback will be used is about as high as their VP-Administrator agreeing to forgo this year’s bonus so the hospital can afford to give the case managers a raise.

Everyone is just too busy.

The DMCB appreciates that NCQA, Consumer Reports and CMS are doing their part for post-op patients with the HCAHPS survey (morehere).  There is also a large body of science on the topic that helps us understand the need for patient input, includes other more detailed surveys, shows it’s possible to clutter patient awareness with too much information and confirms that many hospital workers know there is a problem.  What’s more, poorly prepared patients appear tobe part of a much bigger problem in a clinical domain that’s been dubbed “transitions of care“: after all, if the doctors can’t get things straight with each other, where does that leave the patients?

Figuring the issue isn’t going away, the DMCB wonders if “social media” and, in particular, patient-authored education wikis that usesonline collaboration to taps into the wisdom of crowds is an answer. After a quick Google search, it appears to the DMCB that there aren’t many of these kind of hosted wikis out there. Given the hospitals’ overall performance in this field to date, maybe that’s not surprising.  This may be something that, like Like Patients Like Me, will ultimately be up to health care consumers themselves.

This may be an area ripe for the leadership of the population health and disease management companies.  Maybe this will be the next step in the evolution toward greater patient empowerment.  Or maybe someone should develop it and sell it to a company. [Note to self]

But the DMCB Isn’t Stopping There: Disaster Preparedness and a Looming Disaster for Google? 

And speaking of social media, the DMCB continues wonder where its potential will end.  For example, Japanese earthquake victims relied Twitter, Facebook and texting in the days following the disaster to get information on escape routes and shelter.  And by the way, which would you believe about radiation exposure risk: “tweets” from your trusted circle of known contacts or announcements from a government spokesman?

And if disaster preparedness isn’t enough, how about the threat to that multi-billion company called “Google?”  Check out this (lightly edited) quote from an NPR report (with DMCB bolding)

But the story’s not over yet. Daniel Roth from says what if people just start searching the web without Google. That kind of messes up the game for all the players. 

Mr. ROTH: I know, speaking personally, I read a lot from what I see from my friends on twitter.

CHACE: Roth says your social network might be the next search engine. And it’s still pretty hard to game the system of hearing directly from your friends. 

Mr. ROTH: When they suggest a story, I’m way more likely to click on it, because it’s already been vetted. So I spend less time on aggregation sites, and I spend more time looking to see what my friends are aggregating for me. And how do you win in that game? I think you win in that game by writing stories that people really want to read.

And Governance?

And if social media can be a threat to multi-billion dollar companies, how about being a threat to governments?  National security experts are undoubtedly sorting out its role in the fall of Egypt, the threat to Iran and China and the continuing turmoil in Syria.  Yet, it remains to be seen if Western-style governance will also remain immune. While 24-7 global access to multiple information streams isn’t necessarily the basis of our economic and political discontent, we also don’t know if old-fashioned representative democracy is the fix for the Middle East’s turmoil. The Internet in general and social media in particular seem to be making any kind of governance anywhere on the globe difficult for both tyrants and elected officials alike.

Post Mortem


While doing some research the other day on personal health records (PHRs), I came acrossthis article, describing Revolution Health’s announcement — without much media attention — about dropping its PHR at the beginning of 2010. (Disclosure: I worked for Revolution Health in 2005-2006, and now have a business relationship with the company that acquired them, Everyday Health.)

The most interesting statement I found in this brief news article was, “The e-mail did not indicate why the company decided to terminate its PHR service. The company advised users to download their PHR as a .pdf file and save the document for their records.”

Ah, a PDF. Yes, that’ll make it extremely easy to get that data into some other PHR(sarcasm alert).

And that led me to understand the underlying problem with all PHRs today, and the problem PHRs have always had — nobody trusts the companies who offer them, and few people understand what they are or why they should care.

And that led me to understand the underlying problem with all PHRs today, and the problem PHRs have always had — nobody trusts the companies who offer them, and few people understand what they are or why they should care.

I kind of chuckle when I hear a company describe that a part of its business strategy is the personal health record. I first heard of a PHR back in 1999, when I worked for, at that time competing for the #1 spot as the leading consumer health website with WebMD ( lost).’s management had this brilliant idea that everybody would want — and pay for — a personal health record online. In fact, this was the founding principle of the company that eventually became (as seen in one of their SEC 10k filings from that time):

To say that the idea of a personal health record (or personal medical record, as they called it) has been kicking around the Internet for a long time would be an understatement. ( dropped the idea altogether after a falling out with their PHR development partner, HealthMagic.)

Our company was founded in July 1997 as Personal Medical Records, Inc. During 1997 our primary operating activities related to the development of software for Dr. Koop’s Personal Medical Record System.

But nobody pays much attention to history on the Internet. One of the most frustrating components of consulting for companies today is their inability and unwillingness to listen and to learn from the companies who’ve come before.

Had the folks who were running Revolution Health at the time really dug into the market for personal health records, they would’ve seen exactly what we’ve seen now for well over a decade — nobody’s clamoring for them. Nobody is going to their doctor and saying,

“Gee doc, if only I had some way where I could manually enter in all of this data and try and keep it updated on a regular basis, and ensure that the company I choose to enter all this data in with is (a) going to be around 5 years from now and (b) is going to allow me to export it in a way that is actually helpful, I would be so much happier and healthier!”

Of course, let’s assume that I’m wrong. Let’s assume the 2011 IDC Health Insights’ survey of 1,200 consumers done earlier this year showing only 7 percent of respondents ever having used a PHR, and less than half still using one — which is virtually unchanged from when they conducted the same survey 5 years ago. Let’s say consumers are chomping at the bit for this kind of personal tracking ability.

What will they find?

Poor quality systems that haven’t undergone real-world testing with real-world data. As we discussed back in April 2009, PHRs simply don’t work as intended with real-world data. If one of the largest companies in the technology world with some of the brightest engineering talent on Earth can’t get this right — Google Health, in this case — what hope do we have?

Well, it seems, not a whole lot.

A March 30 article over at eWeek describes how Google is unlikely to move forward with Google Health. Instead, it’s likely to be relegated to the backburner, along with all of its other failed experiments. Of course, Google won’t comment on this, and they never will. Every company trumpets to every media outlet possible when they release a product, but mum’s the word when it comes time to acknowledge the product was unsuccessful and they’re shutting it down (or worse, putting it into a static state with little future development).

This is exactly the lack of transparency and openness consumers are fed up with, and one of the primary reasons patients are leery of trusting their personal health data with a single company. You don’t know whether it’s going to go under, sell your health data (even in aggregate form), or simply decide to quietly stop supporting its service in any meaningful way (without actually shutting it down). You may get your data out, but it may only be as a PDF. Today, there are still no widely-implemented standards for sharing health data records (although that is changing, slowly).

There are some notable exceptions, which I should call out here so that we can end on a positive note. — which just opened up to everyone for any health condition — is quite transparent about what they do with your data. They aggregate it, they sell it, that’s how they make their money. And apparently it’s working, since they’ve been around now for many years.

Electronic medical records, like Microsoft’s HealthVault, are also a different animal, because they have tended to focus on addressing more of the needs of the provider, health care systems and hospitals, rather than just consumers. Paying attention to both sides of the equation — how data enters the system and how data gets out — is so important, yet something a lot of products in this space underestimate or pay nothing but lip service to.

I think it’s time to finally put the idea of a global personal health record to bed, permanently. We already have lots of individual personal health records floating around out there, tied directly to our personal health interests. And while it would be nice and more convenient to have them all somehow communicate with one another, companies who own all these individual records seem reluctant to explore the possibilities of enabling such communication. There are a lot of reasons — some valid, some not — for this reluctance.

Perhaps this will change in a more open and transparent future. But I won’t be holding my breath.

Also check out Denise Amrich RN’s article on the Google Health rumor mill, Have rumors of Google Health’s death been greatly exaggerated?

John M. Grohol, Psy.D, is one of the pioneers in online mental health education and support, getting his start on the Internet in 1992 with depression support groups and advocacy efforts. He founded and is the publisher of the Internet’s leading mental health and psychology network, Psych Central.




The New York Times recently published an article titled the Family Can’t Give Away Solo Practicewistfully noting that doctors like Dr. Ronald Sroka and “doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat…larger practices tend to be less intimate”

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service.  How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing.  Of course, there was a price.  His life was focused solely around medicine which was the norm of his generation.  Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner.  Not surprising.  In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient.  This is bedside manner.  The last two items relate to whether a patient can be seen quickly and easily when care is needed.

But beyond bedside manner and ease of getting care, both which are very important, does the public care about getting the right care or just assume that it is a given?  My suspicion is that they assume all medical care provided by doctors is the same, yet research demonstrates the contrary.  One study found that 75 percent of primary care doctors provided the wrong type of colon cancer screening. Those most likely to do the wrong test after a positive stool screening test?  Those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice.

Personal relationships between doctors and patients are important, but that should not be the only criteria regarding high quality care.

I love primary care.  I’ve worked at Kaiser Permanente (KP) in Northern California since 2000, a “larger practice”.  The number of patients a full-time doctor cares for is about half of the 4000 patients of Dr. Sroka’s.  Doctors have access to a comprehensive electronic medical record that provides real-time information about a patient’s lab work, imaging studies, and medications 24/7.  Primary care doctors and specialists can collaborate working off a common database and eliminating the uncertainty that exists in a paper based medical system and when doctors work in isolated solo practices.  Our primary care doctors are supported with a call center which is open all year round day and night to provide patients advice on symptoms and advice on when problems can be safely cared at home, when a doctor’s appointment is needed, or when medical care is more emergent.

In other words, doctors can be doctors.

Let’s not assume or confuse the rising trend of large group practices or the implementation of more electronic medical records and technology in doctors’ offices as automatically dooming doctor-patient relationships to becoming more impersonal.  The rise of social media like Twitter and Facebook have increasingly made society more connected than ever.

If Americans and doctors want solo practices, then they will demand them.  Certainly there are successful solo practice models like the Ideal Medical Practice, which also supported by information technology, that can provide patients with a doctor who is a sole proprietor.  To say all primary care doctors should join large group practices should be absurd because doctors like patients are individuals and one type of practice does not fit all.

Yet, the fundamental problem with this New York Times piece is the implication that solo practices provide doctor-patient relationships that are more intimate and where patients have a level of trust and confidence in doctors that perhaps exceeds that of thoughtfully designed larger practices.  It offers no evidence if the quality of care delivered is as good.  Let’s not use a practice model which was prevalent in the 1960s and assume its passing is a bad thing.  It may not be up to the challenges of the 21st century.

Davis Liu, MD, is a practicing board-certified family physician and author of the book, “Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.” Follow him at his blog, Saving Money and Surviving the Healthcare Crisis or on Twitter, davisliumd.

Before We Save the World, We Need to Know How to Pay for it.


The United States, of course.

Oh, no, wait, it’s Canada.

Actually, I think it could be Germany.

Geez, now I think it might be the UK.

You could go on and on like this.  But you know what?

No matter how good or bad your system is, there are certain universal truths.

Here are four of them that might make you look at global health care a little differently.

First, health care is getting more expensive, all over the world.  A new study by the global consultant, Towers Watson (disclosure: Towers Watson is a Best Doctors client) found that the average medical cost trend around the world will be 10.5% in 2011.  In the advanced economies costs will rise by an average of 9.3%.  While Americans tend to think of rising medical costs as a uniquely American problem (they’ll rise by 9.9% here), it’s just not true.  Canadian costs will rise by 13.3%.  In the UK and Switzerland, they will increase by 9.5%, and in France by 8.4%.

Why is it happening?  As ever, the main drivers are the increasing availability of new medical therapies – and inappropriate use of care.  We see the same phenomenon at Best Doctors in our global experience.  Across the world, our data for 2010 showed that just over 20% of patients had an incorrect diagnosis, and about half were pursuing inappropriate treatment plans.

Second, consumers are increasingly dissatisfied with their health care experience.  The Commonwealth Fund’s 2010 survey on views of health care found that 68% of Americans think their health care system needs to be fundamentally changed or completely rebuilt.  But 61% of Canadians thought the same thing, as did 58% of French people, 52% of Swiss, 48% of the Dutch, and 75% of Australians.  All of these places have remarkably different systems, and yet none of them are very well-liked at all.

Third, time spent dealing with insurance restrictions is a major barrier to quality care in the United States – but it’s becoming a problem elsewhere, too.  According to the Commonwealth Fund, 48% of American doctors said that coverage restrictions were a “major problem” getting in the way of delivering needed care.  While it’s less of a problem outside the U.S., nearly 20% of Canadian doctors reported the same problem.  As other countries adopt U.S.-style cost controls to deal with the rising cost of care, it’s likely that doctors in those countries, too, will start to report the same trouble.

Fourth, some employers, insurers and governments are looking for a better way.  The Towers Watson study reflected something we found in our own study.  Payers are increasingly implementing programs to get people to take better care of themselves and be more involved in their health care decisions.  Programs like wellness and prevention and higher deductible plans are part of an overall approach to getting consumers more engaged in their health.  But one of the fastest growth areas is still what some call “second opinion” – programs like what Best Doctors provides – where the goal is to help make sure that every person gets the right diagnosis and treatment.  Towers Watson found that 25% of health care payers across the globe have implemented these programs.  They help make sure each person is dealt with as a patient, regardless of how good or how bad their health care system might be.

So, who really has the worst health care system?

I don’t think there’s an answer to that question, except for this: don’t get sick.

Evan Falchuk is President and Chief Strategy Officer of Best Doctors, Inc. Prior to joining Best Doctors, Inc., in 1999, he was an attorney at the Washington, DC, office of Fried, Frank, Harris, Shriver and Jacobson, where he worked on SEC enforcement cases.

Non-Consumers: Why American Well Will Do Well (via Crossover Healthcare)

An interesting model of care. Is this the breakthrough we are looking for? There are many barriers to entry with regards to revenue streams, technology limitations and patient acceptance. However, all of these barriers are likely to become smaller over time. This is a serious contender for a groundbreaking sea change in the practice of medicine.

Non-Consumers: Why American Well Will Do Well Consumer (kən-sū'mər) n. . Ultimate user of a product or service. One that consumes, especially one that acquires goods or services for direct use or ownership rather than for resale or use in production and manufacturing. HI consumers set to say HI! to physicians online January 15. I have been following American Well for the last year and have spoken at several conferences with CEO Roy Schoenberg. American Well is Act II for the Schoenberg broth … Read More

via Crossover Healthcare

A Call to Action

We are living today through the age of disruption. You can’t do big things if you’re content with just doing things a little better than everyone else or a little differently from how you’ve done them in the past. In an era of intense competition and non-stop reinvention, the only way to stand out from the crowd is to stand for something special. Originality has become the acid test of strategy.

For so long, organizations and leaders were content operating in the middle of the road. But today, with so much pressure, so much change, so many new ways to do everything, the middle of the road has become the road to nowhere.

—William C. Taylor, Fortune Magazine, March 2, 2011