“At best, technology supports and improves human life; at its worst, it alienates, isolates, distorts and destroys.” — John Naisbitt, author of High Tech, High Touch

We live and practice in an increasingly technology-driven society. Email and texting are default methods of communication, and our patients request that we friend them on Facebook and follow health advice delivered in brief 140-character bursts on Twitter. In a 2008 survey conducted by the Commonwealth Fund, nearly 90 percent of respondents indicated they wanted their physicians to communicate electronically. Patients want high-tech doctors. But they also want more face-to-face time, more personal connections; let’s call it “high-touch” care. The 21st century buzzword is patient-centered care (PCC), defined by the Institute of Medicine as “care that is respectful of and responsive to individual patient preferences, needs and values.” PCC reaffirms the doctor-patient relationship as a key to improving both clinical outcomes and cost-efficiency. There exists a common perception, dating back at least as far back as the Industrial Revolution, that the increasing reliance of society on technology necessarily furthers human disconnection. In the evermore complex world we inhabit, how do we reconcile our high-touch values with our high-tech realities?

I am convinced we can have it both ways, but only if we heed Naisbitt’s warning. Technology is neither bad nor good. It is how we use the tools we develop that determine this outcome. In no industry is this more evident than medicine. Preliminary research suggests a high-touch, patient-centered medical home model leads to better health at lower cost. More encouraging data is in the pipeline, too, as the Patient-Centered Outcomes Research Institute (PCORI, funded through the Patient Protection and Affordable Care Act of 2010) is actively supporting work to elucidate which models are most promising. Can technology enhance patient-centered care? Yes, by facilitating communication and connection, the keys to promoting healing relationships. Let’s examine several innovative high-tech/high-touch initiatives.

1. Patient portal: athenaCommunicator (athenahealth)

I’ve been a huge fan of athenahealth since 2008, when I decided to go with their cloud-based practice management/EHR solution for my new practice, the Whole Child Center. At the time, I was really impressed by athenahealth’s ability to improve my clinical and administrative efficiency so I could spend more time doing what matters: being with patients. But with the subsequent addition of athenaCommunicator, their superb web portal product, patient-centered care took center stage. Patients can now update health and demographic information, request appointments and prescriptions, receive test results, and communicate via secure messaging. Greater access has led to more efficient communication and more satisfied patients. I find emails preferable to phone calls; the conversation is more fluid and continuous. Office visits are much more enjoyable, as I can simply be present, not feeling pressured. We review what is happening now as opposed to everything that’s happened since the last visit. My relationships with my patients are enhanced by the ability to communicate more efficiently.

2. Clinical tool: emWave2 (Heartmath)

In primary care medicine, most of the tools we have at our disposal are for diagnostic purposes. I’ve got some cool stuff to check eyes and ears and even a new-fangled electronic stethoscope. But my favorite gadget by far is about the size of an iPod and more powerful therapeutically than most pharmaceuticals I prescribe. It’s called the emWave2, and it’s a handheld biofeedback device that monitors heart rate variability (HRV) simply by placing your thumb on the device or by attaching an earlobe probe. HRV is a biological reflection of how our heart rate changes from beat to beat in sync with our breathing. The more in sync, the more “coherent” our HRV. Higher coherence is associated with more effective stress coping. I use the emWave2 to teach patients with conditions like irritable bowel syndrome and chronic headaches how to be aware of when they’re stressed (different colored lights reflect better or worse HRV) and learn tools (e.g., yoga, meditation) to improve HRV. One of the central tenets of PCC is empowering patients to make sustainable changes in behavior, leading to better health outcomes. Mind-body strategies like biofeedback are among the safest and most effective methods to give back patients control over their health.

3. Social Media: Facebook and Twitter

The rise of social networks like Facebook and Twitter highlights our society’s desire to reconnect and share stories and information in new and interesting ways. A 2011 QuantiaMD survey found that 87 percent of physicians use social media personally, while 67 percent use it professionally. Practitioners who have embraced this technology are now able to address not only the individual information needs of a single patient but can deliver messages instantaneously to an entire community. I maintain an active Facebook page linked to my Twitter account. Recent posts/tweets include notices of interviews/articles related to my book, health news about vitamin D, a video on how to make a DIY natural hand sanitizer, and a request for baby supplies for victims of Hurricane Sandy. The opportunities for connection — and for action — are endless in this new world of doctor-patient communication. Social media should be interactive and participatory. While I do not give specific health advice publicly, I welcome posts by patients wishing to share information, resources and events. We’ve created a virtual community with far greater reach than my brick-and-mortar practice ever could.

“The new media have caught on for a reason. Knowledge is increasing exponentially; human brainpower and waking hours are not. Fortunately, the Internet and information technologies are helping us manage, search and retrieve our collective intellectual output at different scales, from Twitter and previews to e-books and online encyclopedias. Far from making us stupid, these technologies are the only things that will keep us smart.” — Dr. Steven Pinker, Professor of Psychology at Harvard University

Lucky for me, Dr. Pinker was my undergrad advisor at MIT. I learned from him and my other mentors there that technological advances must be tempered by humanism. With this in mind, I have chosen to profile scientific solutions that facilitate, not hinder, connection between doctors and patients. As we are challenged to make the most of the time we spend together, our relationships — powerful healing tools in and of themselves — can be deepened through the selective use of high-tech solutions to support PCC initiatives. The Agency for Healthcare Research and Quality June 2012 report, “Enabling Patient-Centered Care Through Health Information Technology,” found that “significant evidence exists confirming the positive impact of PCC-related health IT applications on health care outcomes.” The future of health care is in fact dependent on reemphasizing time-tested, old-school values inherent in PCC through the use of modern communication tools. If we are to move forward, it must towards a hybrid high-tech, high-touch system that does not shun the use of technology but instead embraces the challenge of mindfully utilizing our best new technologies to optimize health care.

Dr. Rosen is an integrative pediatrician based in Oradell, N.J. and an athenahealth client. This article previously appeared in The Huffington Post.

The AP alert flashed over my phone, its words chilling: gun, shooter, elementary school. Then the report: 27 killed, 20 of them young children. Killed by a young adult not old enough to legally buy a drink, but able to get his hands on a fearsome amount of firepower, and old enough to have developed a hatred of others that nobody will ever comprehend.

Struggling with this since, I have realized a few truths. These children and this shooter are no different than my patients in my pediatric practice. We see children from first day of life through-22 years of age. We see innocent little ones and difficult adolescents. We see children, some happy and well-adjusted, while others are clearly lonely, anxious, depressed and oppositional.

Our technological advances, those that we hail as great improvements in many of our careers and lives have not benefited us in managing mental health problems. In fact, technology may have played a role in exacerbating the problem.

Kids can bully on the Internet 24/7 without ever seeing the emotional impact on the face of their victim. The power of social media allows them infinite resources to torture from behind a seemingly impenetrable wall. Video games abound with violence; these, I refuse to view myself. Movies are now accessible at the tap of a finger and sadly, many of the most popular of them illustrate in blood and gore the power and lethality of guns. These films rarely show the emotional endpoint of the deaths of their countless characters. Video games are available even for free across a countless sea of electronic devices; many glorify the power of killing. Television?  You can’t even count the channels. Shows depicting crime and guns, as well as an unending library of on-demand, violent content are enormously popular and available all day and all night in the family living room through to the borderless possibilities of our teens’ tablet computers.

In my office, I run late sometimes. OK, I run late frequently. When I open the door to the room, there are the patients – four-year-olds watching movies, teenagers texting or playing shoot ’em-up video games. Then there are the parents who are forever texting, gaming on iPhones, or reading on Kindles. I used to joke with parents and say “I am sorry I am running late, but happy I was able to provide them some quality time with your children.” These days, I am not so sure. Is there such a thing as quality human time or are we all so attached to our electronic devices that we don’t know how to be with our children? With each other?

As pediatricians we are supposed to talk about everything in our 15 minute slots. In addition to the medical basics, we are expected to address parental concerns about management of complex psychological issues. There are barely enough mental health professionals in this country to staff the acute care facilities and crisis centers. Resources for patients with problems like the shooter, or for other children with less serious, but still significant behavioral concerns are scarce. Is it possible to prevent another Newtown slaughter? We have many discussions to have about gun control, mental health, culture and education. What can we do as we race through our day? 

Don’t get me wrong, I am one big-time technology fan and I sure appreciate the benefits, but I think I will be trying much harder to encourage my patients to spend more time with people and less time in front of a screen, not only because it will help prevent obesity, but because it will help foster humanity in what seems to be an increasingly inhuman world.

Dr. Sally Ginsburg is an athenahealth client and a pediatrician at Pioneer Valley Pediatrics in western Massachusetts.

So, if you are reading this, you probably understand that this Internet thing is going to be big. In fact, maybe you used this “Internet” to do all your Christmas shopping this year.

Like me, you may even think that NO isolated instances of software will hold any active health information within the decade. But you may not be all the way with me when I tell you that it isn’t just cloud-based software that will hold it, but a cloud-based marketplace for service.

Remember that blog post a few years back where I showed the software evolution exhibit from some future museum of ancient computing history? We need the service company in that diagram, not just the cloud computing company that precedes it, and, for that to work, we need permission to monetize the whole supply chain.

For example, the person who best knows what electronic information is needed by Cardiac, Vascular & Thoracic Surgeons (CVTS) of Greater Cincinnati (new client…woo hoo!) is someone who does not live in Washington D.C. In fact, even if someone in D.C. told them what to need, CVTS wouldn’t receive it. It would be a tiny bit off—since no one is incented to provide accurate and complete referral information—and no one would return CVTS’s call when the primary care group got it wrong. And CVTS wouldn’t hassle too much about it because they don’t want that primary care group to get pissed and start using another surgery group. Is this a hard thing to understand?

Maybe everyone buys it but they don’t see an alternative? Is there an alternative? I thought you’d never ask!

What if CVTS could design and then re-design over time what data they wanted? What if they could do it online in a little portal? Every time they piloted and adjusted a care pathway for a procedure, they would adjust the data they require in their portal. Then everyone who refers to them would start pulling the required data from their medical records. Why? Because these data would be pulled automatically by the network of cloud-based information services that sits behind all the area practices…and because CVTS would be paying for the information if and only if the data arrived electronically and complete.

The cloud-based players would be expert at pulling said data and at prompting the staff of referral-sending practices (in 6th grade English because that’s how everyone rolls except in health care)…if they weren’t, they would have lost to athenahealth, which is already expert at this.

Now pull the camera back from CVTS, and you see a social movement that would make even Arlo Guthrie cry an “Alice’s Restaurant” tear.

That is, you can get anything you want…if you make it easy and pay for it.

So why is it not happening?

Is the world really just waiting for athenahealth to get big enough to do it for everyone? I’m flattered, but I think not.

No, it isn’t happening primarily because it is illegal under the Stark and anti-kickback laws.

We need to change this.

The voters of California’s 13th congressional district already changed out Pete Stark (my first Christmas present).

Now we need to adjust his law and others so that the single most important health reform of the 21st century—the emergence of a sustainable market for the exchange of health information—can finally rise.

Happy holidays, everyone!

‘Tis the season for KLAS rankings, fa la la la la, la la la la…and here at athenahealth we are very merry! In fact, our CEO Jonathan Bush could hardly contain himself when he read the 2012 Best in KLAS Awards: Software & Services annual report, especially when he got to the EHR rankings. 

We finally were able to catch up with Jonathan during one of his many victory laps…

Yes, we stood out in both the EHR and practice management categories. In fact, we scored #1 rankings for athenaClinicals, athenahealth’s cloud-based EHR, for physician practices with 1-10 physicians, and for athenaCollector, athenahealth’s cloud-based practice management offering, within two market segments, practices with 1-10 and 11-75 physicians.

We like to think these rankings reveal a broader trend in health care that moves away from traditional software and the staid way of doing things and focuses on the values of cloud-based software and services. And this, of course, leads us to run a few celebratory laps…

Welcome to our second installment of Cloud Analytics! Today, we’re delving into patient responsibility with regard to deductibles, co-pay and co-insurance – for patients with private insurance.

Across the country, total patient responsibility is on the rise, increasing financial stress not only for patients, but also for practices that now have to collect more money from patients.

How much has the patient payment burden been increasing? Calculated as a percentage of allowables (the contracted amount that insurers agree to pay providers, rather than the amount the providers charge), patient responsibility has increased in each of the last two years, rising from 18.6% in 2009 to 19.9% in 2011:

This points to patient responsibility increasing at an even higher rate than annual increases in total allowables.
What’s driving this increase? Deductibles, a fact that becomes apparent when we break out the data by types of patient responsibility. Between 2009 and 2011, deductibles have increased considerably, while co-pays have actually decreased and co-insurance has stayed flat:

Some believe that increasing deductibles are a good thing, acting as an incentive for consumers to take greater personal responsibility. Some think it’s a negative, penalizing those who are chronically ill and/or have lower incomes. Either way, rising deductibles affect both patients and practices.
Over the last three years, unpaid deductibles (deductibles not paid within a year), as a percentage of allowables, have increased. In contrast, unpaid co-pays have stayed constant:

In other words, practices are having more difficulty collecting what they are owed by the patient. This is hardly news; the more money patients owe, the harder it is to collect. A struggling economy does not help either. What is new, however, are the trends toward greater participation in high deductible plans, whether by experimentation or employer fiat.

As for co-pays, why are they decreasing? We’re not policy or plan design experts (if you are, we’d love to hear from you!), but we think the Affordable Care Act (ACA) may be an influencing factor. A key part of the ACA is a provision that brings the co-pay for preventative care visits to $0 for new plans, starting in September of 2010. And with the ACA extending subsidies to many new patients and allowing them to get lower-end individual plans from private insurance, many of these patients will end up in high-deductible plans over the next few years. Measuring the impact of the ACA is new territory for us so we’ll explore related issues in future posts.

In the meantime, let’s look at the most recent data we have: Is 2012 offering a reprieve from the rise in patient responsibility? It doesn’t appear so. Looking at the first three quarters, for 2009 through 2012, we see similar patterns (increasing deductibles, decreasing co-pays):

Note that percentages for deductibles in Figure 4 (Q1-Q3) are higher than in Figure 2 (full year), because payments towards deductibles are higher towards the beginning of the year. This is due to deductibles becoming reset every year, usually at the beginning of the calendar year, meaning practices have an uneven revenue stream beyond other seasonal variations:

If we break these numbers down by region and specialty, we also see rising deductibles. If you’re interested in drilling down further, you can see these numbers in our recent infographic, also published in Medscape. It appears this trend in rising patient responsibility is real, across regions and specialties.

The bottom line is that this is an extra burden for medical practices. Can patient collection be added to what’s needed to meet Meaningful Use requirements, as well as the additional responsibilities of being a Patient-Centered Medical Home (PCMH) or part of an Accountable Care Organization (ACO)? How will things change by region or specialty?

While we think about these questions, let us know what you think!

In our next installment, we’ll explore reimbursement differences between specialties. Thanks for reading!