4 simple steps to better health - an insiders look
Peter Yellowlees MD
Pmyellowlees@ucdavis.edu
www.informationagehealth.com
http://informationagehealth.blogspot.com
The authors expertise
Peter Yellowlees MD is Director of the Health Informatics Program and Professor of Psychiatry at the University of California Davis. He undertakes clinical work at the University of California Davis Health System in Sacramento and is an internationally recognized expert in health information technology. He teaches both psychiatry and informatics to medical students, residents and graduate students from a number of disciplines, and runs an online graduate course in telemedicine through the University of California Davis Extension at www.extension.ucdavis.edu. He is in regular demand as an international conference speaker giving more than 100 presentations world-wide over the past five years. He has published more than 150 scientific articles and book chapters, including many on eHealth, has co-authored three books and received well over $7m in research grants. His full academic Curriculum Vitae is available at the web site for the Department of Psychiatry at the University of California Davis at www.ucdmc.ucdavis.edu/psychiatry.
Dr Yellowlees is on the editorial boards of the Journal of Telemedicine and Telecare, and Telemedicine and eHealth. He is a regular reviewer for many journals and has featured in several educational videos and films. He is involved in a series of exciting and leading-edge research programs involving telemedicine, virtual reality and data mining. He is a strong philosophical believer in patients having ubiquitous access to information any time
Introduction
Everyone talks about how expensive healthcare is, yet few people have started to really look at how it could be cheaper for patients. Many of the costs of healthcare are the result of inefficient practices that arise from a system that has not been focused on patients, and has just assumed that patients will travel from one clinic to the next, from one lab to another, and from home to hospital. Most doctors practices and health systems try and save money for themselves, but not for patients, and often they actually make more money by being inefficient because patients end up having more consultations and repeat tests than are really necessary, and paying for them. There are now many ways that the internet can be used to improve your health, and at the same time to save both time and money, and to therefore ultimately make healthcare cheaper for everyone.
The goal of this book is to describe how you, as a patient, can best use the Internet to improve your own healthcare, and how you can do that by working with your usual doctor, and any of your other healthcare providers.
So what are these four simple steps that I describe. In brief they are:
1. Learn about how to use the internet for your healthcare.
2. Check out your doctor, and any other health providers, to make sure that they are appropriately expert and qualified to provide your care - and that they can do this using the internet
3. Learn to work collaboratively with your doctor using internet based healthcare
4. Check out your current treatment, and compare it with best practices and health guidelines that you can find on the internet. Then consult with your doctor, and discuss any areas where you think improvements can be made.
These are very straightforward simple and logical steps to take - but relatively few people actually take them and follow through to make sure that their overall healthcare is improved. This is despite the fact that almost every patient that I see nowadays has already been on the Internet before my consultation with them. This is especially so if they have a chronic illness – and we know that more than 10% of the population at any one time have chronic illnesses like diabetes, heart failure, cancer, depression or substance abuse. Whether they have been on the Internet or not before I see them, I almost always recommend that patients look at specific websites to get more information about their health as part of their treatment plan. A small number of them have checked out my expertise - you can find my resume at www.informationagehealth.com - but very few go through the logical sequence of steps I describe above, and which are detailed in this book.
When was the last time you visited your doctor? What was it like? What happened? Who else was part of the consultation? Was your doctor using a computer during the consultation? And if so, for what purpose?
Think about 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.
The fact that we are now living in the Information Age is recognized widely. 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. The same policies are being implemented in Britain and Australia. Large health systems like Kaiser Permanente are forming partnerships with commercial companies such as Microsoft 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.
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? This is what this book is about. It is about how you, as a patient, can make the best use of this amazing new resource, the Internet, and the information available online, to work with your doctor, or any health care provider, 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. And to save you time and money.
Chapter 1. Learn how to use the internet for your healthcare.
I recently put the word “health” into the Google search engine. The search returned 1.32 billion web pages where the word “health” was mentioned. I do really mean the number 1,330,000,000 – more than a billion mentions. I followed up with other words. “Money” found 1.2 billion pages, “sex” 819 million, and “Microsoft” 868 million. What an amazing statement about the popularity of health on the net – more mentions than sex, money and Microsoft! And numbers of references now in the billions. When I did this same search in 2000, there were 27 million “health” references so this is more than a forty fold increase in the past 8 years. What an expansion of interest and use.
The business of eHealth on the Internet is expanding rapidly. Two recent reports from the Pew Foundation (www.pewinternet.org) and Harris Interactive (www.harrisinteractive.com) have confirmed that 75-80 per cent of United States Internet users utilize the Internet for health information and healthcare – that is around 140 million people. This is over 65% of the entire adult population of the USA – an average of 8 million people every day!. Not surprisingly those individuals with chronic illnesses, who have recently been diagnosed with a medical condition or who have broadband Internet connections use the Internet for healthcare more commonly than other Internet users, and their searches for health information is becoming a regular habit, often several times per month.
Business sees the healthcare sector as a particularly attractive industry that will benefit from web-based technologies because of its enormous size, inefficiency and information intensity. Moreover, the healthcare industry is particularly fragmented with a large number of participants, including general practitioners and primary care clinicians, specialists, institutions (public and private hospitals and diagnostic companies), health funds, pharmaceutical companies, retail pharmacies and, of course, patients.
John Chambers, from Cisco Systems, has been quoted many times as saying that “the Internet waits for no-one”, and now that we have the rise of what is being called the second Internet revolution, with the influence of social networking and sites like facebook and youtube, the importance of the Internet has increased dramatically as it has entered the social fabric of our lives. We know that the radio took 30 years, and the TV 15 years, to build an audience of 60 million people around the world. The Web won 90 million people in its first three years and hasn’t looked back so that there are now well over a billion Internet users around the world. If you want to get the latest numbers go to the Internet page on wikipedia.com, where continuous worldwide numbers of Internet users are constantly updated.
Countries like China, and regions like South America and the Indian subcontinent, with their large populations and economic bases, are becoming significant powers in the Internet world. I visited India in 2003 and while driving along the main road from Agra to Delhi was astonished to see broadband fiber being laid in hand dug trenches alongside the roadway, and to learn from my driver that this was now commonly seen as the whole of India was being rapidly wired. There are many different languages on the Internet, and while English is most certainly the most common language, every country has its own language based websites. It is a fascinating exercise to search for similar organizations or national interests around the world, and see how they are presented. I recently looked for all the organizations around the world interested in health informatics, as many are listed on the international medical informatics organization website (www.imia.org) and was fascinated to see how informatics was presented so differently in so many different countries, cultures and languages.
Many forces enable the practice of Internet healthcare - or as it is often called, eHealth – to advance rapidly, including the following:
consumers are spending more of their own income on health, with an estimated increase in cost of 2.5% to 3.5% per year as the population ages.
consumers are being encouraged to take more responsibility for their health, and to know more about treatments offered for them, their effectiveness and the track record of the individual provider or medical team offering the treatment.
it is known that conventional health services are associated with many unintended injuries or complications, and government task forces in the United States, Europe and Australia have all strongly recommended more information technology involvement in the healthcare system to reduce errors and mistakes.
health practitioners are now generally highly computer literate, and the medical students of today have grown up in a world where they have never known of life without the Internet. Many doctors have their own homepages, and the culture of health is changing whereby it is now well understood by both patients and doctors that patients can drive their care through accessing good quality information.
the spread and increasing access to fast internet connections via broadband, which has led the whole internet to become so much more accessible than was the case when most people connected by dial up. Think how rapidly it is now possible to download video – films, TV shows, clips on www.youtube.com, family movies – and remember how long this used to take before the advent of broadband connections. I can certainly remember downloads a few years ago literally taking hours, whereas now most download times are measured in seconds, or minutes at the most.
there were a series of highly publicized and funded Internet health portals developed before the “dot com bust” of 2001-2 that have survived and developed, with WebMD, Medscape and e-Medicine being probably the three most influential sites at a professional level. Major publishing companies have developed substantial healthcare Internet programs, and Google and Microsoft have recently entered the health industry with a bang, both focusing on building personal health records for patients, and working with premier health organizations, such as the Cleveland Clinic.
the Internet itself is a major force, as it has literally become part of our daily lives. For example we now see kitchens routinely designed to include a computer area so that the cook can access the Internet while working there. Just look at the number of recipes and cooking websites available on the Internet. I wonder if you do what I sometimes do, which is to put a selection of the foods that I have available in the fridge into Google, and see what recipes come up using them. This is a great “decision support” tool for cooking, and is now starting to occur in the health area. A number of papers have been written where symptoms have been put into Google to see if the search engine can correctly identify the diagnosis – and it does so in about 50% of cases.
Today eHealth mainly involves the Internet and email, although videoconferencing (often called telemedicine) is also expanding rapidly, and is the technology that was mainly used to deliver online health in the past, and which I have used since 1992. In fact telemedicine is now being defined frequently as including videoconferencing, email, messaging and telephony – as all types of online technologies rapidly converge. The capabilities of the phone and video are being continuously merged on the Internet, with the use of Voice over Internet Protocol (VOIP) in audio or video environments through providers such as skype. Undoubtedly what used to be simply a telephone will emerge as a major health tool over the next few years, with the iPhone and Blackberry among leading products available everywhere. I certainly answer a high proportion of my emails with my blackberry, and access my schedule as well as make most of my telephone calls with the same device. Recently it also became the device that I attach to my laptop so that I can have continuous broadband access to my laptop wherever I am. We will eventually most likely move to a single digital platform for most distant health communications, but right now we still undertake our communications using relatively few approaches, as instant messaging and texting, while commonly used in daily life, especially by teenagers, have not had much impact in the health arena yet. This recent wave of interactive technology has already dramatically improved the ability of patients and their clinicians to communicate in more ways, and with more effectiveness, than could have been imagined even ten years ago. And the pace of change is escalating. It is estimated that the speed and power of computer technology is doubling every 18 months.
There are three main types of clinical interactions on the Internet; therapist/patient; therapist/therapist; and particularly patient/patient. Patients are using the Internet to help each other. Widespread access to the Internet and email has enabled great improvements in clinical and teaching services worldwide.
All clinicians at UC Davis have email so that patients can contact us easily if we wish that to happen, as I do. And patients do. And there are many websites where patients can access doctors who are prepared to prescribe and offer advice. I am deliberately not going to mention the names of any of these companies in this book because this is an evolving market, and they change constantly, but what you will discover is how to find and assess the sites for yourself. The largest of these web-based consulting companies in the USA supposedly has doctors available and registered in most states, and has over 4 million patients as subscribers.
The Internet is not a place for the unwary. Sir Robert Baden-Powell, when he dreamed up the Boy Scout motto “Be prepared” many years ago wasn’t thinking of the Internet, but he might have been, because his warning is so appropriate. If you are looking for a doctor through the Internet, be wary, suspicious, hesitant. Thoroughly check out their websites to ensure they meet good professional standards and are not money making “fly by night” operations because there are still relatively few health professionals practicing fully online. It’s always interesting to make regular checks on suspicious looking sites, say every two weeks or so. It is amazing how frequently they suddenly shut down or move – not the sign of a reputable operation. As long as you are careful, the Internet is a great place to find information and advice, although not yet a great place to connect with individual counselors or have an ongoing relationship with a doctor unless it is combined with a conventional face to face relationship. Talk with your doctor about how you may be able to communicate better with him or her via the Internet in preference to trying to find a primarily web-based doctor. And, as with any new adventure, go cautiously!
The changing face of healthcare
A new millennium - a revolution in health care. Within ten years visiting most doctors over the Internet will be commonplace. Within the safety and convenience of our own homes we'll be able to speak to health professionals, access information on our health and receive support from groups of people with similar problems. Wireless videophones will be commonplace and we will be able to live in a virtual environment if we wish – able to contact our doctor, order groceries from the supermarket or set the security system in our home from wherever we are.
Most of the technical problems associated with going online have been overcome. What we have to do now is to change the way we interact and communicate as patients and doctors gradually get used to the capabilities provided by today’s multi-media 24 by 7 environments.
As we spend more time online we must remember two core principles. The first is the complementarity principle - computers do well, what humans do badly, and vice versa. Computers never forget appointments or test results, while doctors are better at working out the meaning of an abnormal set of symptoms. The second principle is the importance of redesigning business processes before building new software environments – that one should not design new software to support an old inefficient business process. Many of our historical healthcare programs have assumed that a patient and a doctor have to physically meet to undertake a transaction, but of course that is no longer true in many instances.
We need to think differently, for example, about the doctor-patient consultation, which is what this book is about. At a basic level this consultation can be described as consisting of three information processes – data capture ( the history and examination), data analysis (the diagnosis), and business planning (the creation of a treatment plan). Using the principles mentioned above we can now start to identify which components are best undertaken by the various humans involved, and which are best undertaken automatically or supported by technology. This is where the multi-media Internet has untapped resources and possibilities for patients and doctors.
Our population is ageing with "baby-boomers" demanding better quality healthcare. They are also determined to have home-based health care, and will pay to avoid going into nursing homes. At the same time governments are trying to reduce the escalating cost of health care by cutting back services as much as possible and closing down hospitals. Everyone recognizes that the use of electronic medical records is a way of improving the quality of care and making patient information more available where it counts, at the time of the doctor-patient consultation. We need to shift the center of gravity of care away from expensive hospitals and clinics, and back to the home.
It is not only cheaper to treat people at home and online, with less hospital bills at thousands of dollars per day, but patients can also become more involved in their own care. With a single keystroke patient, primary physician, specialist and home health nurse can be brought together. Many homes in the US have broadband Internet, or cable TV, both of which can be used to deliver electronic home care in future. Companies such as Intel are already developing technologies to be used in the home for the elderly in particular – for the baby boomers. These involve multiple health monitoring options – not only to collect obvious health data such as blood pressure, weight or pulse rates for patients with heart conditions, but to monitor patients with Alzheimer’s as they move throughout their home, undertake survey responses from family members via television, and as alarm systems for any medical emergency. Telecommunications and cable television companies are the likely future infrastructure providers of tomorrow’s health environment as they replace hospital beds with homecare accessibility. Care will be more available, better quality. Heath professionals more accountable and patients better informed.
The net is widening
Already 60-70% of American homes contain a computer, and according to the Pew Foundation, more than 80% of American adults use the Internet regularly. Most hospitals are moving towards introducing electronic medical record systems, and now have videoconferencing facilities that allows them to have high quality video conversations and interviews with experts or patients at other places, just as undertaken on news programs and seen on television every night. In countries like the Netherlands (88%), Norway (88%) and Sweden (77%) Internet access is higher than in the US (69%), which is currently only the 14th “most wired” country in the world, although the US is working hard to catch up. Billions of people around the world use the Internet regularly, many of them exclusively for email, although in Africa in particular the cell phone is the method of choice to access the Internet, and for online communication. The 69% of adults in the USA who have access to the Internet, has increased enormously compared with the figure of 23% in 1997. The Internet as a health care center, accessible to millions of people all around the world, is already with us. We now have younger generations, such as the current “millenials” generation, aged 18-25, who have never known life without the Internet, among the 1.2 billion users worldwide. This is approximately 17% of the worlds total population accessing a “place” that has only been in existence for about 15 years. What an incredible speed of take up.
The call from patients for more input into health matters continues to grow. The last decade has seen an enormous rise in the number and power of self-help and patient driven health interest groups, and they are all very aware of the need to have an online presence, and to communicate with their members via the Internet. These groups are using the Internet to provide information to their members and gather support for their causes through user groups, listservs, bulletin boards and online advertising.
At the same time computers are becoming more affordable. You can now buy a good quality home computer for less than $600 and the cost is falling nearly as fast as online technologies are improving. Several companies have developed $100 - $200 computers especially designed for the underdeveloped world in an effort to help developing nations rapidly catch up with the West, and to reduce what has been called the social digital divide.
E for Expectations
The Web offers an amazing combination of immediacy, global reach, personalization and specialization. This means you can be the center of a world of information that is relevant to you, and which you have engineered. It has led to our expectations changing for basic service and product delivery. We now expect 24 hour global access, speed, do it yourself resources, personalization and customization, a large range of services and products, as well as the ability to pay online. In short, more choice and access, more empowerment. The convergence of technologies such as the phone, wireless, broadband Internet access, and digital TV is rapidly increasing the power and availability of information. The excitement caused by this convergence is reflected in the exponential growth of use of the Web, where uptake indicators are defying gravity.
If you want to discover details about the background, history and development of the Internet, look at wikipedia ( www.wikipedia.org) , the multi-lingual web based free open source encyclopedia, which is a very widely used reference site, and which has essentially replaced the Encyclopedia Britannica, as the ultimate reference source.
Go there for almost any imaginable information you want. Here you can find that there were 93 users of the Internet from the Vatican City in 2007, and that this was 12% of the local population, compared with 210 million users in the USA, or 69% of the population in the same year. You can also read about Internet terminology, history, protocols, structure, common uses, social impact and access by region - all superbly well presented with links via the world wide web to multiple sources of information. Just remember that with wikipedia, while the great majority of information is carefully checked and is accurate, the core components of the encyclopedia are written by volunteers such as you and I, and we all make occasional mistakes. If you find mistakes on wikipedia, do please correct them.
For some time, Internet traffic has been doubling every hundred days, and the recent broadband shifts are increasing the speed of the Web by 50 to 100 times. Apart from the massive numbers of people predicted to connect to the Web worldwide, there are certain sections of the world where access is particularly common. Even Europe, which was relatively slow in the race to join the Internet era, now has widespread access and as we have moved away from not only having .com, .org and .net as the only domain names with the opening up of multiple other names such as .tv and .biz. The introduction of 24 hour streamed television, films and audio files on demand through a number of services such as iTunes, has led to us thinking quite differently of the mind-bending overall effect of the Web on global society. Many people, including myself, now use their computer like a TV or radio – we access podcasts (audio) and vodcasts (video) of the news and current affairs, download music and films, and watch sports from around the world on commercial streaming websites. We are certainly able to live and communicate in very different ways, and all from our home.
Feeling the byte
In the USA in 2005 17,700 health care professionals provided care for 7.6 million patients in their homes, making over 80 million home visits that year. Most of these patients are elderly or chronically ill and by the year 2010 it's expected this number will have swelled even further. More dramatically, the home health care market in the USA, which was estimated to cost $34 billion in 1996, cost $53 billion in 2005.
But while home care is expensive, it's still less expensive than in-patient care where the average 2005 hospital admission lasting 5.8 days cost $28,000. The current annual cost of healthcare in the US is $2.3 trillion, or $7,600 per person per year. This is 16% of the gross domestic product (GDP), and these figures are predicted to rise to $4.2 trillion, and 20% of GDP by 2016. Inpatient accommodation alone in the US costs well over $1000 million a day; that's before any treatment costs are added. $3 for every American every day! Yet if just one person in every 200 could be treated outside an institution there would be an annual saving of $2 billion. Similarly another $1 billion could be saved by reducing the number of people in nursing homes by just 5%, one person in twenty. Obviously, it will be less expensive for patients to be properly cared for in their own homes using eHealth. We need to learn to spend less on health in the US generally as other western countries only spend about 10% of their gross domestic product compared with our 16% on health, and seem to have better health outcomes.
The move toward home-based eHealthcare will not, however, be driven solely by the need to cut costs. The rapidly aging generation of "baby boomers" will insist on more and better quality homecare and community services. As a member of the so-called “indulgent” and “demanding” generation, I have no intention of being hospitalized except under the most serious circumstances! When I am old I want to be cared for in my home, with my family around me, as much as possible, and I am very comfortable using technology to assist in that process.
It's your health chart
How often have you wanted to read what your health professionals have written about you? Through a shared electronic medical record you'll not only be able to read what your doctor has written. You'll also be able to check it is accurate and even contribute to it yourself!
For many years whenever I have had blood tests done by my doctor he has sent me the results at my request. However from 2005 onwards, when my healthcare providers implemented a full electronic medical record, I. have been able to log in to see the results online. It is so good being able to thoroughly check what is happening with my tests immediately after I have had them, and to track the results over time. Actually seeing my cholesterol results, and being able to link them with my weight and eating habits, makes a great difference, and has me much more involved in my own care.
The health homepage of the future will contain all your health records – it will be like your own health website. You will be able to make notes in it and collaborate with all types of health care professionals. Because it is on the Internet it will be accessible to you wherever you are in the world. It will be linked to health information, videomail, email and a range of related technologies that will allow you to see your own X-rays, pathology results, even your surgeons operating notes. Within a few years the following scenario will be commonplace:
“I've had a night of terrifying palpitations so, before going to work, I decide to seek reassurance from my doctor. I go to my home communications system and, via the individualized touch screen, press the videophone icon to speak to my doctor's receptionist, Mary.
Almost immediately she comes on screen via a secure high-speed video Internet connection. She compares my online diary with my doctor's and asks if I would prefer an appointment in person, either at the clinic or at my home…or by video, either to my home or via my laptop at work.
I decide to leave a note describing my symptoms in my shared electronic medical record for my doctor to look at when she comes in from her early morning home visits. She will either email or videomail me back if she thinks I should see her sooner than my scheduled consultation.
Keying in my password, I access my own record via the secure directories and write a short note about my symptoms. When I use the word “palpitation” it is highlighted as hypertext. I hit the hotlink and download a patient information sheet on “palpitation,” developed by a university in England and recommended by my doctor. While I have my electronic medical record open I scan back and check what my doctor wrote the last time we met. I am pleased to see that her treatment plan is based on the clinical guidelines developed for my heart condition recommended by the physician I saw some months before.