I think that’s happened recently with the iPhone, as I just received a note from Richard Baron, MD, from the great ABIM Foundation, who said he heard the words “have to” from my mouth echoing in his head about whether he should get one. The “have to” part is about using what are patients are using, and learning about it with them, rather than telling them not to use what we don’t understand.

So, he got one, and maybe a few other people I recommended the iPhone to did, as well. I thought I’d post which iPhone Applications I’m using on my iPhone to give people a head start. Try them out, see what you think. And kudos to all the health care professionals out there who say “yes” to trying new things so they can perform better for their patients.

A little info:

• DC Weather is a hyperlink to the hour-by-hour of Washington, DC. You can customize for your city.
• Tipr is also a hyperlink to a web-based Tipping application. It gives you the results in palindromes, so you can check for manipulation. Nifty.
• Remote is Apple’s iTunes and iTV controller. Very cool.
• RSS is a hyperlink to Google Reader. It’s what I use for RSS now. Well optimized for iPhone and the Web (sorry NetNewsWire, I had to switch…)
• Where is a helpful assist for my Starbucks-dar. Maybe also useful for Zipcar (when I have to drive, Metro is really my automobile)
• Loopt and Twinkle are my preferred location aware friendfinders/lifestreamers. Just testing them now.
• Twitterific is where I post to my Twitterfeed. Give it a try. Follow me.
• Urban Spoon, Restaurants, and Yelp are my food finders, except I am not much of a foodie, so I am mostly interested in these for their health promotion potential.
• Mobile News is as it says. I am really not much of a news junkie (Andrew Weil, MD recommended awhile back that too much news is unhealthy, I’d rather just make my own news)
• Cuberunner is just a game to demonstrate the accelerometer functions - for the “Isn’t this device cool” factor. Thanks to Jody Pettit, MD, fellow i-enthusiast for the tip.
• 1Password is useful for storing Web passwords securely. It has a built in web browser so will enter them for you.
• Epocrates is just a cool medical application that shows the promise of the device. Imagine using this as a tool for medication reconciliation and adherence - like how about a patient version, a pharmacist version, a nursing version, that delivers the med list graphically to the patient?
• AOL Radio and Last.fm are experiments in finding music online.
• MyLite is the electronic flashlight. I like the rock concert effect. Works really well in a power outage.
• Google is google. I should use this app more - it does really nice searches of contacts on the phone.

You can get a sense of how I do things from this list, I realized. I don’t have an electronic to-do list, task manager, etc. I’ll post separately about what I do for that. Paper is really good for a lot of things.

What apps am I missing? What do you think of these?

Click on the image to see it larger size

Patient Story (Frydman)

For today’s post, I am going to paste a dialog I had with Gilles, which contains some follow up questions I had about a new process for managing blood pressure

Ted: Ok, very helpful -

Gilles: I’d say amazingly helpful! See remark at bottom.

Ted: So what if the doctor said, “Your blood pressure in the office is high today. I don’t know if you really have high blood pressure though. Can I show you how to check it at home and will you check it twice a day, in the morning and at night, and then we’ll take the average and decide if you have high blood pressure?”

Would this make you anxious?

Gilles: I don;t think you can answer this question in a unidimensional fashion. It would probably be anxiolytic if this is the first time I heard of HBP. If this is what I hear at a repeat visit I almost certainly will be ready to hear 10 times more details about HBP. But if during the first interaction the doc would say “I don’t know if you really have high blood pressure though. Just in case maybe you could read the following information about HBP” and then give me some URLs like the Medline Plus entry or this one: http://www.ash-us.org/about_hypertension/index.htm. I think it would definitely prepare for a much better interaction the next time I saw the doc. In fact in case of diagnosis of HBP or changes of BP, I would definitely advocate for this method followed by a second visit not too long after. That is basically what my PCP does with me, whenever there is a change in BP. Follow-up in 1 week/10 days.

Ted: [It turns out that checking throughout the day isn't really helpful, twice a day is best]

Gilles: That’s good to know. I didn’t know. This is not trivial info and is not easy to find if you are actively looking for it. But it should definitely be part of BP home monitoring guidelines. If you check http://www.medicinenet.com/script/main/art.asp?articlekey=89718 you will notice no mention of what you just told me.

Ted: Let’s say your blood pressure was high this way. If the doctor said, “I would like to have you be in charge of checking your blood pressure, once every 3 months, for just one 7 day period, twice a day.”

Is this a routine you would be willing to follow?

I do not understand. You mean choose randomly a week during this 3 months window and get 14 basic readings as a result?

I would probably freak out, wanting to get feedback about the results ASAP.

Ted: What if the blood pressure cuff didn’t come from your doctor - what if your employer came to you and said, “For our employees who have high blood pressure, we are going to give them free cuffs to allow them to connect to their doctor.” Do you think this would or would not be a good way to change the ideas about measuring blood pressure, from a privacy perspective?

What if the messages about blood pressure being harmful came from your employer too - would this be welcomed, or would you think, “this is really something I should only get from my doctor?”

Gilles: I am certainly not an example for this. I would certainly distrust any involvement of my employer in health matters.

Ted: Last question - is this discovery, that BP was important to you, something you needed time to make, or do you think you would have made a change sooner if the initial conversation was different?

I think the conversation was not optimal at all. He is a real friend and a great doctor but evidently not the greatest communicator. But the conversation about learning about HBP and developing knowledge about it could very well be done by a trained nurse assistant. I strongly believe that instead of immediately treating it would have been much better to give me a solid dose of info RX. I am sure that I would have been early on a much more compliant patient.

Ted: I looked up what I know about time of day for blood pressure for you - I don’t have an accurate answer about apnea, but it appears that “morning” and “evening” have been selected because they correlate best with the possibility of stroke in the future, actually better than what your doctor would measure during the day.

I found this as well

“In persons successfully treated with CPAP, cessation of treatment causes blood pressure levels to increase, while restarting treatment causes blood pressure levels to fall again.”

from here:

http://www.aafp.org/afp/20020115/229.html

I think your presence will be very helpful next week.

Gilles: I don’t think I would have found this great article. So here is a clear example of how a 2 minutes interaction between a somewhat informed patient and a physician can produce real results. My family has a real history of apnea and I am convinced that there is a real connection. The input from a physician becomes more and more important as one starts to ask precise questions about the potential reasons for the HBP. Yes the internet is great but we all know there is a limit to the benefits. At some point the filtering done by an expert becomes fundamental. Maybe the internet has just shifted the level at which the filtering does occur.

Clinical and Public Health pearls (Houston-Miller and Eytan)

• Patients are at risk for non-persistence and poor control if they have less than 1 health care visit per year or do not have blood pressure in the last 6 months.
• The overall US control rate is 36.8%; The Healthy People 2010 goal is 50%.
• This translates into 10.7 million Californians, with 3.3 million with controlled hypertension, a gap of 7.4 million people. (source)

Comment

Where is the data? and What’s Missing? From the conversation above, it appears that there isn’t good understanding about how to monitor blood pressure from home, either on the part of patients, or on the part of the medical profession. Prior to reading the AHA position paper, I did not know that a protocol existed for doing this accurately, and I would gather that most physicians that recommend home monitoring do not provide the guidance that is recommended by the American Heart Association, or desired by our patient.

The impact of this is that a patient may not monitor at the right times or with the right technique, resulting in changes to therapy that are inaccurate. In terms of what’s missing, without clear guidance from a physician besides, “Come in to see me and we’ll check it in my office,” the guideline or protocol is implicitly stated that blood pressure measurement is a physician-centric activity, even if the physician recommends home monitoring.

I of course welcome counter arguments to this hypothesis!

To close things out on the current state of affairs, here’s a slide show of all the pieces put together. Go through them as a group and notice where the data is in each case. Is it localized to the patient? Is the patient supported in engaging in the management of their condition outside of the medical office visit? And what about the stakeholders that are represented but not participating - the connectivity providers, the social networks. Can or should they be involved?

Final question: Should this current state continue? (Loaded question. Hint: Look at the results we’re getting with this approach)

This is a nice video from Consumer Reports Health of a patient who is unable to get health insurance coverage, because her physician has coded a diagnosis of “chronic obstructive pulmonary disease,” instead of “asthma.”

From time to time, I get asked, “what’s the business case for patients accessing their medical records online?” In this case, it might allow them to keep bringing business because they could alert their doctor to inaccuracies in their medical record which would allow them to keep their coverage. There might not be an inaccuracy in the first place - when we know our patients will see what we do, it changes our behavior.

In this case, the patient’s business case is clear.

From time to time, I also get asked, “will I get calls/e-mails from patients with questions about what’s in their medical record?” After seeing the impact to this patient and her family, I think this is the kind of e-mail or phone call a physician would be happy to receive.

Kudos to Consumer Reports Health for making their content embedable (is that a word?).

JAMA — Web Searching for Information About Physicians, July 9, 2008, Gorrindo and Groves 300 (2): 213

The medical community is experiencing the same GenX, GenY, Baby Boomer challenge that everyone else is. I’ve written about it on this blog (See these posts, and these posts) quite a bit, as it took me awhile in my own professional work to realize what was going on - many of the discussions I was having seemed to be themed to the generation of the person I was talking to rather than the specific person. This turned out to be really helpful in creating understanding and collaboration.

I think we need each other, and if anything, my discovery (glass half-full) is that many baby boomers have the desire and ability to have their creativity unleashed. GenX-Y can and will help with that by stimulating the conversation (See my most recent read for a great example). I enjoy being sandwich guy (Gen X), it’s kind of like being a family physician, coordinating with all of the other medical and surgical specialists, all of whom add value to everything I do and (hopefully) vice versa.

Acknowledging the tension, and creating some more

I’m glad to see the authors call out that the tension exists, at the same time they create the tension they speak of in their advice, which is centered around the concept of being “aggressive” about “protecting” the physician:

Talking to Patients About How They Are Using the Internet. If a physician suspects that an Internet-savvy patient is engaged in seeking personal information about him or her, we recommend that the physician talk with the patient about the garnered information. This is particularly relevant when treating young adults or adolescents who commonly use the Internet. Physicians should clearly inform patients that the Internet is not a substitute for face-to-face conversation.

It’s not? Patients need to be talked to? We need to clearly inform them about how to use the Internet?

There’s a very cool alternative paradigm where we protect the patient, by clearly informing them about everything we are doing for and to them, and listen to them about how they use the Internet, so we can use it with them. It’s completely possible. The best part is that I’ve seen many a baby boomer embrace it. The future’s bright for our profession and those we serve….

“Why Work Sucks and How to Fix It: No Schedules, No Meetings, No Joke–the Simple Change That Can Make Your Job Terrific” (Cali Ressler, Jody Thompson)

As a leader in an organization, imagine reading this description of an employee’s workday:

A typical day for me includes waking up when my room is too bright from the sun and I can no longer sleep. I check my e-mail to make sure there are no pressing issues and respond to anyone who needs my input. I will typically watch an episode of South Park on the Internet, then walk to my local grocery store and buy some breakfast, even though it’s closer to lunch at this point. After eating I will work in front of my television with ESPN on in the background. At this point I will choose to go into the office or continue to work from home, or maybe not even work at all and go for a bike ride or jog. If there is still work to do later that night, I’ll do it then and it’s no big deal.

I’ll admit it - it kind of made me gulp when I read it.

At the same time, though, I have been in a lot of conversations with a lot of personal and professional colleagues over the past 3-4 years or so, where the question we’re asking ourselves is, “Is this how work life is supposed to be?” Spoken or unspoken, the answer is “we don’t think so.” Various companies’ data also show a trend toward less vacancy in their physical locations.

In the middle of that self-discovery, I read about BestBuy, Inc., (see “Smashing the Clock“). This is the book about their journey.

It’s time to let go and see what our employees can really do - BestBuy Manager

A Results Only Work Environment (ROWE) is as it says - one where results are measured, not time spent. There are no timeclocks, no discussion of time, and no “Sludge” as the authors refer to it. “Sludge” are the comments people make to each other about time, whether it’s about being late to a meeting, or working late at night. Simply put, the authors state, an employer is trading work for money. Why not give them what they pay for?

Reading beyond the BusinessWeek article was very useful - this is not flextime, it’s not “working from home,” it’s a different philosophy altogether. That includes the vignette above. Totally allowed, if you have the results to show for it. The concept can appear challenging; however, it makes sense, in the context of strong leadership committed to respecting employees and customers. That’s where I found similarities to the work I have done.

About respect

When I first read about this work, I asked about how this was similar or different from the LEAN transformation I participated in, in the area of health information technology. Some of the things were consistent, some seemed less so, like having technology teams physically present alongside doctors and nurses, guiding care and feeding of an electronic health record system.

My reconciliation of all of this rests with not comparing individual tools/approaches between ROWE and LEAN. What they both have in common is respect for the customer and staff, and strong leaders. It’s impressive that at the heart of the ROWE movement was (at the time) a 24 year old employee of BestBuy (Cali Ressler), who was dissatisfied with the status quo. The authors also explicitly reject war analogies in business as I have. In my own situation, there was not just a desire to change the way we worked, it was clear that not changing would be unsafe. Healthcare organizations across the country are now learning this, thankfully, but it’s a slow transformation, and the transformations that are happening are nowhere near as radical as ROWE, which is why I am interested in the movement (not because I want to be radical, but because the threats to our patients and their families’ health are so significant).

Just because you can no longer be late doesn’t mean you can be lame

Preliminary data from the University of Minnesota’s Flexible Work and Well-Being Center are showing that voluntary terminations are down, involuntary terminations are up.

Mea culpa and, as usual, I see analogies to health care

I liked the concepts in the book a lot, and have done a self-inventory of my own sludge and the sludge that’s been directed my way. The kind of sludge I get nowadays is really from people who want to understand better how technology can be used to help patients stay healthy. I welcome it as an opportunity to teach and learn. As the authors discussed, people can learn to live sludge-free, and they really want to live sludge-free. It starts with us.

I could see myself promoting ROWE in health care settings, and I think physicians, primary care ones especially, would benefit. The work I do to change health care is completely connected to the idea that health is a means, not an end, and people who go into health care want to support our patients where support is needed, mostly where they live, work, and play. I don’t believe people in health care are any more attached to time than Cali and Jody’s (former?) colleagues at BestBuy are. When I read the stories of BestBuy employees before and after, I reflected on some of the conversations I have had with health professionals (at all levels) who have really been challenged to juggle their passion for helping people and their ability to provide for themselves and their families, physically and emotionally. What would it be like for a family medicine or internal medicine specialist to provide their cognitive services to patients and families using a combination of virtual tools and office (or even home presence) when the situation called for it? Look at what HelloHealth is doing. It’s possible.

A Results Only Patient Experience (ROPE)?

A came upon this table in the book, and curiously, I found it extensible to our health care system. I hope I won’t get in trouble for using it to think about what our health care system were like if our patients experienced it the way a BestBuy employee experienced their work life. The edits are mine.

Hilary Worthen, MD, visited us in person in Oakland, when we had this discussion , to describe Harvard-Affiliated Cambridge Health Alliance’s patient portal. CHA is using the MyChart patient access system, produced by Epic Systems, Inc. Here are his slides. Comments welcome.

I photographed this advertisement while riding on BART in San Francisco recently - it struck me as a creative way to engage Generation Y, and in 2008, a reminder that for some people, online connections are becoming dominant to in-person ones (that and the fact that no one is advertising to Generation X, we’re the generation lost to marketers…). I liked it also because it supports my occasional motto, “in person is the new online.” On a more basic level, though, it speaks to the revolution that Web2.0 is creating around community - as I learned in the patient portal work I have done, these online connections can actually strengthen rather than weaken the offline ones.

You can see the rest of Dentyne’s innovative campaign on their site - they missed one crucial detail in their appeal to the Web 2.0 generation, though, by not making this content embeddable, which should be the case for a campaign like this. From my own experience, I know that big companies are often not of one personality, so there can be some disconnects as large organizations move into the future. In the meantime, enjoy the images.

Thoughtful quasi-blogpost* from Mark Leavitt, MD, who is also the Chair of the Certification Commission for Health Information Technology (CCHIT). In the post, Mark very nicely acknolwedges the number of dedicated volunteers in the CCHIT process - I know from experience that this group is working hard and is very talented (way more than I am).

*the quasi part is that I notice that the Health Affairs blog appears (to me anyway) as more of a Web 1.0 publication with comments, than a blog in the spirit of blogs. It might be nice to tweak the HTML title tags a bit for easier embedding into other blogs, and maybe shorter, more personal posts, in the spirit of blogging. I think Health Affairs has been on the leading edge to adopt the blog format in the first place to be sure, now perhaps they could go a little farther to support interaction with the people in health policy in a more behind the curtain way…

Update: Incidentally, depending on the reviewer, I am either congratulated or questioned about my presentation style. I just ran across this very nice slideshare : Death by Powerpoint . See if the slides below are more similar to that ideal (I hope they are)

This photograph is from a session using Tapulous’ Twinkle software, which is a location-aware version of Twitter. This exchange is evidence that the iPhone’s most powerful innovation is not 3G, it’s GPS, which Apple, Inc., has now seeded into the mainstream, just as it did with a host of other technologies, like Wi-Fi.

What is shown here is community being created with complete strangers based on location - this exchange happened when my tweet was broadcast to everyone within a 1 mile radius of the San Francisco airport.

Some of you out there have been expressing your reservations about Twitter, Friendfeed, and the like. Here’s a nice article about both. Don’t be reserved, these are important technologies that will have applications in healthcare. Get your Twitter accounts now. Post your ideas in the comments, as well, please!

And San Francisco, thanks for being nice. You never disappoint.

The most recent time was yesterday, when Veenu Aulakh, MPH, and I brought together Safety Net health care organizations, and national experts in patient online access and social impact of the Internet to talk about (you can guess…) “Patient Online Access in the Safety Net.”

These being the first convenings I have co-led, rather than participated in, I have learned a ton, and have gotten a good understanding of doing this for a purpose, which both situations have had. In the event we hosted yesterday, in Oakland, I put together an A3 document before we invited anyone, which included the background, the goals, and most importantly, the “why?” we were doing this in the first place. It was really helpful to have created agreement around the “why?” - I referred to this many times in the planning.

At the event itself, I got a new perspective that I had not had as a participant previously. It was one of listener/observer - even when I was doing the talking, I was interested to see reactions and learn what people and organizations are capable of. It made me think that when I have been a participant in convenings in the past, this is what my hosts were doing - learning what myself or my organization was capable of doing to solve a problem, as much as they might have tapped me as an expert. Interesting to have this happening in my brain.

Sharing information happened, too, courtesy of some of the most innovative organizations in the U.S., including Cambridge Health Alliance, University of California, San Francisco’s Positive Health Program , New York’s Primary Care Information Project, Institute for Family Health, and Kaiser Permanente.

In addition to all of this, there were a few nice moments of recognition for people’s work, such as when Jim Kahn, MD, thanked Kate Christensen, MD, and her team at Kaiser Permanente for their support and assistance in the launch of the myHERO patient portal for HIV patients cared for at San Francisco General Hospital.

…and a little something for me, a follow-up conversation with Hilary Worthen, MD, from Cambridge Health Alliance, about his study and pathway to discover and implement LEAN in primary care at CHA. He told me that for him, this is a transition from thinking about exam rooms and staff to “work that you need to get done, defined by doctor and patient.” I love hearing about how people apply their creativity and copy the thinking of LEAN to do exceptional things for their patients.

This being the second time I have done this, I don’t know if it was perfect. We tried a lot of things I’ve not done in meetings before, and I am still working to integrate social media before, during, and after. I am definitely sold on my philosophy of supporting any and all technology use (”if you need or want to use your device, use it”) - I have not, in my conveningness, come around to the “turn your devices off” philosophy, as I have written about previously.

Oh, and I learned that a 60″ table seats 8 people.

Here are a few images from yesterday. I’ll follow up with my slides in a separate post. Click on any to see larger size.

Livingston, Gretchen, Susan Minushkin, and D’Vera Cohn. Pew Hispanic Center Report: Hispanics and Health Care in the United States: Access, Information and Knowledge. Pew Hispanic Center.

Tomorrow I will be in Oakland, California, along with health care leaders from the California Heatlhcare Foundation, California Safety Net Organizations, National Leaders in Patient Online Access in the Safety Net, and other national leaders in the social aspect of the Internet for Americans to talk about patient online access in the health safety net. It promises to be a very interesting day, which I’ll post about here.

The referenced report is one of two recent studies on the impact of the Internet among Latinos in the United States, and among all Californians (next post). They are both timely and useful as we answer the question that I was asked many times while visiting Safety Net medical centers: “Are our patients online?”

Pew Hispanic Center Report: Hispanics and Health Care in the United States: Access, Information and Knowledge

This report describes research performed jointly by the Pew Hispanic Center and Robert Wood Johnson Foundation, and consisted of a bilingual telephone survey of a nationally represented samle of 4,013 Hispanic adults conducted from July - September, 2007.

Highlights from my review

• 27 % of Latinos report having no usual care provider, the rate is 42 % for those without insurance.According to the CDC, the proportion among Hispanics is more than double that of non-Hispanic whites and non-Hispanic blacks.
• Language differences are significant: 24 % are English dominant, 35 % are bilingual, 41 % are Spanish-dominant. This has significance with regard to the Internet….only 17% of Spanish-dominant Latinos receive health information from the Internet, compared to 53 % of their English-dominant peers. Interestingly, those of South American descent report a 51 % figure, higher than the figure for Puerto Rican (49%) and Mexico (31%).
• Fleshing the language issue a bit more: 40 percent of those who get health information from the television get it from Spanish-language stations. For those getting information from radio, 47 % rely on Spanish language radio stations
• Youth is a factor: 42 % of those aged 18-29 get health information from the Internet.
• Overall, 35% of Hispanics get their health information from the Internet, far behind television (68%), radio (40%), or a doctor (72%)
• Also of interest to me is in the demographics of this population, younger than their non-Hispanic cohorts, and with lower rates of chronic disease today (20 % with high blood pressure, compared to 22.4 % Non-Hispanic White, 31.6 % Non-Hispanic Black)
• And….in terms of health seeking, 41% said the reason they did not have a regular health provider was because they are seldom sick. The impact? Only 62 % of these individuals have had their blood pressure checked in the last 2 years.

What impressed me overall was the impact of language - it reinforces what I saw from my observations way back in November 2007:

Key health care leaders are saying the time for PHRs are now. Based on the Boston visit, I am saying the time for multilingual and culturally relevant PHRs is now.

Obviously, I still believe that, and this is why I am especially excited that one of the organizations presenting to us today is Cambridge Health Alliance (see information about my visits with CHA here), who have launched their personal health record to a population that is predominanly portuguese-speaking.

Without parity in access to quality health information, the concern is that the dependence on the in-person interaction with the health provider is greater for Spanish-dominant individuals than for English-dominant, and therefore the risk is greater that needed preventive care will not happen if they do not have a usual health care provider. The data appear to bear this out. It is worth thinking - if you did not have your blood pressure checked in the last 2 years, how would you be able to reassure your family about your ability to provide for them with a healthy heart? Should these individuals wait for their organs to be damaged, or should they have an equal chance at providing for themselves and their families with healthy hearts, brains, and kidneys? Thank you to the Pew Hispanic Center and Robert Wood Johnson Foundation for informing these questions.