Upon hearing news of the proposed merger between satellite radio companies XM and Sirius (for an interesting take on whether this will happen, check out this 

), I couldn’t help but think of my own experience with satellite radio and how much I love it. Before I explain, here’s how I see it…

There are two camps of satellite radio listeners: those who love Howard Stern (Sirius) and those who don’t (XM). I fall into the latter category, and I’m glad I made the choice all those years ago when satellite radio was just as misunderstood as Sanjaya Malakar. Over the years, XM has added a 24-hour hockey station (XM 204 — Home Ice) and Major League Baseball to its channel lineup, giving me something to look forward to besides the great uninterrupted music during my 70-minute ride to and from work every day.

Currently, I have two XM subscriptions/radios: one for my car complete with the sports ticker, 30-minute replay, and the “Favorites” feature that tells me when one of my favorite songs/artists is currently playing on another station. My second unit is hooked up to my home theater system, which allows me to listen to the XM feed outside on my “B” speakers (outdoor speakers and the summer…sounds like a future “Downtime” topic…) and turn on contemporary jazz (Channel 71, “Watercolors”), light pop/romance songs for the lady (Channel 23, “The Heart”), or “later” classic rock (Channel 49, “Big Tracks”) and enjoy a fine cigar and a glass of Rosemount Shiraz on my deck (hmmm…cigars and wine…another “Downtime” column!). And sometimes, when I want to bother my annoying neighbor, I throw on Channel 42 (“Liquid Metal”) and crank up the volume. Good times.

The thing is, I’m a gadget hound who was never interested in satellite radio until my dad got it and told me how awesome it was. Now, you have to know that my dad is not the most technologically savvy individual by any stretch of the imagination, but he’s a damn smart fellow and the best Jeopardy! player I’ve ever seen; so, his advice is usually sound. A day later, I had my fi rst XM radio, and I haven’t looked back since.

Simply put, you don’t know how good satellite radio is until you have it. To test myself, I tried listening to the clowns on New York’s 95.5 WPLJ morning show one Friday, and it was like I was back in 2002: They were doing the exact same shtick (“The Friday Morning Blast Off , complete with in-studio audience!”) as they did back then, with the same musical preludes, the same gags, the

same commercials, the same personalities, the same jokes…everything. Th e formula was identical, and the result was also the same: LAME. Hearing the show just confi rmed what I already knew: never again would I go back to free radio. I will gladly pay 12

bucks a month to keep my ears free from the debacle that is AM/FM.

Which brings me to my next “can’t-live-without-it” gadget: 

. Much like satellite radio, TiVo is only appreciated if you have it. If you don’t, well, I’m sorry.

Anyway, TiVo brings something to the table that other digital video recorders (DVRs) simply can’t: personality. With everything from the little “TiVo guy,” to the ergonomic and perfectly situated “peanut” remote, to the unmistakable audible “boops” (they’re not beeps, they’re boops) that greet every keypress, TiVo is a welcome part of our home, both upstairs as a hacked 120-hour original Series 1 DirecTiVo unit that integrates with my DirecTV satellite television, and downstairs as the HD TiVo unit, which can record HD broadcasts. Nirvana indeed!

With innovative features like the “Season Pass,” “Wishlists,” and “Suggestions,” my TiVo has become the go-to gadget in my home. Honestly, if I could only keep one piece of tech, TiVo would be it. With three kids, television watching comes at a premium, and with top-notch shows (see my list) only a click away, when an hour can be had on my schedule, the TiVo is my life—and time&mdash;saver.

Recoding television through a hard drive is such a simple idea, but I never thought it could be this cool or literally impact my “downtime” as much as it has. When I first brought it home, my wife thought it was just another piece of electronics that I would soon abandon for the next big thing. It wasn’t long before she became even more of a television junkie than she already was, setting up 

Season Passes for our kids or recording stellar programs like 

So even if I have to sort through countless “Oxygen” shows or Noggin entertainment, it’s all been worth it. The power of TiVo, indeed. 

Articles

Feature Articles

Upon hearing news of the new merger between satellite radio companies XM
and Sirius, I couldnï¿½t help but think of my own experience with satellite radio and how much I love it. 

Downtime: Don't Know What You've Got Till It's Gone (...or You've Never Had It)

"Telemedicine,” one of the latest buzzwords in the medical technology industry, is a concept that represents a paradigm

shift in information management processes. Telemedicine makes it easy to manage patient data across different platforms nationally and quickly. Some of the same technology employed in telemedicine can also enable virtual communication between practices and their patients. The missing link to this point has been the availability of an intelligent medical practice patient communication system that goes far beyond traditional client/server-based “reminder” solutions. 

fills this void, allowing even practices that still use older scheduling and patient management systems to upgrade their one-way patient communications to include the functions of automatic routine reminders, recall/recare, wellness communications, and contacting patients who desire earlier appointments following late cancellations. Cellminder takes virtual communications to the next level by reducing the time needed to manage routine one-way conversations, increasing profi tability, enhancing patient

satisfaction, and improving quality and continuity of care.

Most commercial solutions for reminding patients of their appointments are based on telemarketing-type servers that use offi ce phone lines to deliver messages—mostly to home answering machines. They do help to reduce the many hours required for practices to manually call their patients, and they help to reduce revenue losses due to no-show patients. However, these systems are often slow and ineffective, relying on a transactional methodology that is based on communicating with patients one at a time.

To achieve true and complete one-way communication management status, the IT department at Cellminder rethought the entire

methodology and process of patient communication management.

Advanced Methodology and Software Platform

The virtual communications software platform deployed by Cellminder was built based on extensive interviews with practice administrators, front desk personnel, and doctors dissatisfi ed with their current patient communications and desiring

a system that was user-friendly for even the least sophisticated practice staff . The value in using this form of technology stems from the diff erence between “oneway” and “two-way” practice-to-patient communications. Virtual communications technology is far more effective and effi cient for one-way messaging, saving medical practices many thousands of dollars per month, as well as helping to generate revenue when dealing with the roughly 80% of practice-to-patient communications that are one-way in nature.

Clients access the virtual communications management toolset online, similar to other software as a service (SAS) models like 

. Double entry of patient contact and appointment information is eliminated through data integrations that synchronize easily with any practice management system that can export a text-delimited file.

Unlike most “reminder” systems, Cellminder requires little or no end-of-day export activity, as all future appointments, new patients, and changes to existing appointments are automatically updated each day. The virtual communications platform also relies on specific patient preferences to enable practices to communicate more effectively.

Virtual communications eliminates using practices’ phone lines completely, although the Caller ID reveals the practice’s name and phone number. This means that patients are contacted nearly concurrently rather than consecutively, as with manual or even server-based systems, plus, with Cellminder the practice’s phone lines remain available for inbound and outbound two-way communication calls.

Virtual communication technology allows practices to customize their own patient communications based on their patients’ demographics, communications preferences, and personal schedules, plus additional content that can be delivered by various means.

Through synchronization with practice management and EMR software, practices only need to access the virtual communications website directly for less than two hours per month, mostly to view and print reports on all their one-way communications activity or to contact any number of patients immediately for any sudden schedule change. Virtual communication is the perfect partner for practices upgrading their practice management system to an EMR with telemedicine capabilities, and Cellminder is the only communications solution marketing this technology.

Gary Szasz is Founder and Senior Vice President of Cellminder, Inc.

"Telemedicine," one of the latest buzzwords in the medical technology industry, is a concept that represents a paradigm shift in information management processes.

TechSector: Virtual Communication Technology Saves Time and Money

As early as November 2001, the increasing popularity of Internet consultations without a previous relationship between physician and patient was well recognized, enough that Swedish researchers conducted a study that lasted through January 2002 to “investigate how an Internet-based 

 service without any preexisting doctor—patient relationship was used and evaluated by the enquirers.” Their findings, published in April 2006, show that such services are appreciated for their convenience and flexibility and the ability for users to reflect upon diagnoses, second opinions, and advice from a physician as opposed to attempting to remember conversations during a face-to-face meeting with a doctor.

Dozens of sites have popped up during the past six or seven years, and even earlier, offering advice (see O

 below), diagnoses, second opinions, and even prescriptions from doctors who never physically meet the person with whom they are consulting. Dale C. Alverson, MD, Medical Director of the Center for Telehealth and Cybermedicine Research at the 

University of New Mexico Health Sciences Center

that the popularity of such sites has risen “because of the gaps in access to services and the limited resources that we have to provide services. The tools of telehealth— the information communication technologies&mdash;offer opportunities to reach out to people who need services they can’t receive easily and also provide a way for healthcare professionals to virtually extend themselves to those people.” Further, the anonymity such sites offer to patients has also spurred their interest. “If you want Viagra or whatever it may be, and you don’t want to go to the doctor, that’s one way to get it. It’s a huge marketplace,” adds Rob Sprang, MD, Center for Telehealth & E-Health Law board of directors, and director of 

, University of Kentucky College of Medicine. 

, where individuals seeking health information provide answers to a comprehensive set of questions regarding weight, diet and other habits (smoking, alcohol intake, exercise, etc), immunizations, current medications and health supplements, current and previous family and personal health issues, presenting symptoms, and other factors. The information provided is aggregated to produce a thorough report that displays all replies entered, suggestions regarding what to do based on them, and the probability of certain diagnoses and their urgency.

Patients can then save their summary and, for $50, obtain comments on all aspects from a physician and ask a medical question to be answered by that physician. Users can also conveniently link right to the sister site 

, where questions can be asked of a general physician for $60. Similarly, 

 “a diagnosis and treatment program that uses medical specialists to accurately diagnose symptoms…with a program created by 1,500 specialist physicians”— and its sister site 

—“a treatment program that uses medical specialists to accurately select the best and newest treatment for each patient, based on individual patient’s characteristics”&mdash;offer their services through a one-year subscription of $9.99.

Without regard to safety, it’s clear why patients would want to take advantage of the services provided by the above sites, but we can only speculate as to why a US oncologist would participate (please e-mail us at 

 if you participate, know someone who does, or have thoughts on the matter). Although Online Medical Diagnosis lists its associated physicians, no contact or affiliation information is provided, and when we searched for the individuals using Google and Yahoo, either no actual physician turned up or the name was so common that it would be difficult to determine who was the physician in question. Further, e-mail messages sent to the only site listing direct contact information for its doctor(s) and other staff were immediately bounced back, and calls to corporate numbers lead to unreturned voice mail messages and/or a bunch of “I don’t know, let me transfer you to…”

Given how difficult it is to actually contact any of the doctors working with these sites or look up the names of those that may be listed, it’s nearly—and likely purposely&mdash;impossible to confirm their legitimacy. “I can’t imagine that they are legitimate physicians,” said Sprang. “I realize there are doctors that may use the Internet for existing patients to help them renew prescriptions or make modifications to prescriptions, but anyone who associates with these blind Internet operations should have their medical license revoked. It’s unquestionably inappropriate.”

So, with a clear negative stigma surrounding them, why would an oncologist get involved with an online consulting or prescribing service? Aside from providing an easy way to make a buck without having to deal with coding, reimbursement, or typical office hours, oncologists who offer consultations and prescriptions online can take as long as they want to provide answers or information to patients, and can do so from the comforts of their own home should they so chose.

However, “Any physician who gets involved with this, I really have to question,” added Sprang. “There are a lot of legitimate physicians who are turning to the Internet to facilitate contact with physicians. It’s a brilliant application of the technology.” Sprang stresses the importance of differentiating between the legitimate practice of telemedicine—treating a patient who is actually viewed and heard via video teleconferencing technology&mdash;and the consultations and prescriptions provided by the services listed in the above sidebar.

Other online physicians and oncologists include those who are using video teleconferencing to establish a relationship with a patient— just as they would with a patient who comes to their office, clinic, or hospital&mdash;and using secure e-mail messaging services and further video conferencing for follow-up (see our feature story from the American Telemedicine Association and our Day in the Life item in the Pulse section for more on this technology). “The premise is that if you use telehealth to provide service,” stated Dr. Alverson, “you should be able to provide that service in the same way you would establish a relationship with the patient face-to-face; that is, you do an adequate history, you make sure that an adequate physical is done&mdash;and that may require a third party. You should perform the examination in a way very similar to how you would if you were seeing the patient physically face-to-face. And that’s actually been a general policy that’s been developed through various national organizations, such as the Center for Telehealth & E-Health Law.”

Sprang feels such practice will “unquestionably” become preferred in the not-too-distant future. “Very few of us are able to live in a community that has access to all of the medical services that you could ever need,” he explained. Telemedicine “is the only way that I can see that we can make sure that you are not penalized for living in a medically underserved area, whether a rural area or in downtown urban areas because of financial constraints.” He notes that the idea of medically underserved populations is often mistakenly only associated with rural areas (see our feature on remote health for more on this). “If you live in downtown Lexington and don’t have a car, you’re medically underserved,” he added. “You’d have to walk all the way across town to get to a doctor’s office; a young mom with a young baby for instance just can’t do that.”

In either case, rural or urban, Dr. Alverson explained to 

that because many people can’t actually make the trip to the office or clinic—regardless of how close it may be&mdash;“many healthcare professionals are beginning to adopt and integrate telehealth, because it allows them to more effectively and consistently provide service to patients.” Primary care providers can now use telehealth to “allow their patients to more easily get oncology services; a primary care provider in a rural community can now offer the ability for the patient to get that service more quickly, more easily when they need it. Oncologists can follow-up with their patients more effectively as well. There’s more and more evidence, particularly in areas of chronic disease and the aging population, that more expedient access to care can be offered through these tools of telehealth, which is improving the health of the people served. There are some good examples of that, even in the home environment, with diseases like cancer and congestive heart failure, in which it’s being shown that problems are being picked up sooner.” He added that because patient management can be rearranged with telehealth, patients are able to remain out of the hospital, improving quality of life and saving the healthcare system money, because the patients aren’t requiring more extensive critical care services.

However convenient and cost-effective providing medical services via telehealth may be, oncologists who do so are faced with additional legal and ethical issues that may hamper their ability to “contend” with the “traditional” oncologist who sees patients only physically, face-to-face. “Modern medical concerns with telemedicine and robotics practiced across national and other jurisdictional boundaries engage the historical, complex area of law called conflict of laws,” wrote Dickens BM and Cook RJ in the July 2005 issue of the 

. Does a practitioner licensed in one jurisdiction and treating a patient in another violate the laws in that other jurisdiction? If that practitioner violates a contract or treats the patient negligently, does the practitioner incur liability in his jurisdiction, the patient’s, or both? What if treatment that is lawful in the practitioner’s jurisdiction isn’t lawful in the patient’s? Is that a crime? These questions have yet to be answered definitively, according to a June 2006 

article. However, the author writes that “it is also the case that health-care professionals who undertake telemedicine in a prudent manner will minimize the possibility of medicolegal complications.”

Although our above-described “pretenders” are a minority in the world of healthcare providers, “there certainly can be the threat that we’ll see more of [them,] because of the difficulty in trying to track these types of people,” explained Dr. Alverson. “There is a legitimate concern about unqualified, unauthorized people creating online services that ask patients to fill out a questionnaire on a Web page and then they send them a prescription. That’s a problem that needs to be monitored. These people and the sites they run can have a fairly large impact because the Internet reaches so many people.” He added that improvements in ways to police such activity and track down what he calls the “Viagra doctors” can help in weeding out the “bad actors.” Dr. Alverson also thinks “we have an obligation to educate the general public about the potential harm that can be done by obtaining your healthcare virtually from someone you don’t know who may not be qualified to provide that service. That gets into the area of authentication who is really on the other end? Are they really qualified to provide this service? That goes for video conferencing as well a person can get on a camera in a live monitor and say he’s a psychiatrist, and patients just have to trust that he is. Now there are some very interesting ways of authentication with biometrics, using fingerprints, retinal scans, and so on. I think we’ll see more of that because of these concerns.” Why haven’t ideas and proposals like Dr. Alverson’s come to fruition? Some states are implementing laws to crack down on care provided across borders via the Internet to patients who are never met by the doctor (see 

 below). Dr. Sprang noted that “Congress has proposed multiple laws, but I don’t know of any that have passed yet.” He added that in the current Kentucky legislative session, Senate bill 88—meant to address these issues&mdash;was introduced and passed in the Senate, sent to the House, amended, and then sent back to the Senate. “I don’t know whether anything is going to happen with this either.”

So, talk to your congressperson, tell him or her about the importance of passing bills like Kentucky’s bill 88. But, when you do, make sure to explain the importance of the bill’s language, warns Sprang. “I’ve been talking to the attorney general of the state, because the attorney general in Kentucky—a very aggressive guy&mdash;decided he had enough and that he was going to push the state legislature to clamp down on this.” In that legislation, “the language said to prescribe medication, you had to have a face-to-face encounter. I’m OK with that, unless you interpret it as we have to be in the same room together, which is possible with a strict interpretation. So, I called him and said ‘look, nobody is more supportive of what you’re trying to do than I am, but you need to make sure you qualify that term as including an interactive videoconference encounter.’ His office said, ‘Oh, we would never want to do anything that would damage telehealth. We value that technology.’ So, they came back and wrote in the legislation also including an encounter as defined in my telehealth legislation. It protected us. That’s my only concern with being too zealous about going after this legislatively. If you don’t carefully craft the language, you could put the telehealth industry out of business. Nobody is more supportive of fighting the Internet pharmacies than the telehealth industry, just be careful when you write the legislation that you don’t throw the baby out with the bathwater.”

When it comes to legitimate telemedicine, unless you plan on retiring anytime soon, it’s certainly worth your while to at least check out the technology. Telemedicine is here to stay and growing in numbers and popularity. After all, if you can’t beat ’em, join ’em.

Sites Offering Cancer-Specific Consultation Services

Dozens of websites have popped up over the past few years offering
advice, diagnoses, second opinions, and even prescriptions from
physicians who never physically meet the patient.

Online MDs: Contenders or Pretenders

Information technology plays an important role in many aspects of our society and is an emerging force in the healthcare industry. One area of health IT that shows great promise is remote health monitoring, which during the past 10 years has risen from humble beginnings to become a significant player in healthcare.

 spoke with Joseph Kvedar, MD, director of the 

 in Boston, MA, who explained that “remote health monitoring involves the use of sensor technologies, primarily to gather physiologic information about patients that allows care providers, as well as patients, to make decisions about the care without actually being in the same room.” 

Remote health monitoring is designed to help empower patients in becoming more actively involved with their personal health management. Patients with a chronic illness, such as diabetes, asthma, or chronic heart failure, need to be motivated to follow management plans and make necessary lifestyle modifications in order to minimize the chances that they’ll develop additional complications that could further jeopardize their health, thus requiring expensive treatment. The feedback provided by constant monitoring can help reinforce adherence and good health practices. 

 in remote health monitoring have even found that patients who use the technology make fewer unnecessary doctor visits and are less likely to require hospitalization. Remote health monitoring can also help 

. “If an organization plans patient visits every three days at a cost of $100 per visit, for example, over a 60-day period, the cost is $2,000 for 20 visits”. Mark VanderWerf, president of American Medical Development (AMD) Telemedicine, said that incorporating remote health monitoring into such a patient’s care may mean that patient “might only visit [the doctor’s office] seven to nine times in the 60-day period, so for each 60 days, you save in excess of $1,000.” 

Remote health monitoring systems also provide tools for patients that enable them to learn about and understand their illness, so they can walk into a doctor’s office feeling more confident. Companies like 

 have worked hard to incorporate educational modules into their products as a way to encourage self-management. 

 spoke about the advantages of incorporating remote health monitoring tools into patient care with R. William Vandivier, MD, clinical director of the Chronic Obstructive Pulmonary Disease (COPD) Center at the University of Colorado Hospital. “I think ultimately they [the patients] get better care,” he said. 

Self-management and education are essential parts of the treatment plan for patients who have a chronic illness, according to Health Hero Network, Inc., which has incorporated tools into its monitoring systems to enable patients to take a more active role in their own care. The Health Buddy System®, a user-friendly four-button device with a large screen, is the company’s flagship program. It “integrates home health monitoring technology with clinical information databases, Internet-enabled decision support tools, health management programs, and content development tools.” With the ability to support 130 programs—10 with 

 certification—that remotely monitor 30 different conditions (eg, cardiovascular, endocrine, psychiatry), the Health Buddy can be used by practitioners in just about any medical specialty. Its educational content “can be combined into programs that address a single disease state or comorbid conditions or even trimorbid conditions,” says Suneel Ratan, Vice President of Business Development at Health Hero. “That’s the first degree of personalization for the patient&mdash;it’s personalized to their condition.”

The Health Buddy also sends a daily transmission of specified patient data based on a set of rules established by the healthcare professional depending on what illness is being monitored. Patients will spend about 10 minutes with the Health Buddy answering questions (eg, “How are you feeling today?”) and connecting other devices that measure vital signs so the information can be uploaded into the system. “It will assess [the patient’s] behavior and [give them] coaching about their behavior,” said Ratan. “They’ll be assessed about their knowledge of their condition and given feedback and [further] education about their condition.” The device dials into a set 1-800 number overnight and uploads data and results to a physician interface—which can manage up to 200 or 300 patients&mdash;for care managers and care providers to view the following morning. Patients whose vital signs and symptoms show an adverse change will be automatically placed at the top of a contact list, making it easier for a care provider to follow up with those patients at a higher risk, reducing the amount of time spent on the phone. This way, they’re “only managing the 5-7% who are showing up as high-risk for signs and symptoms on a given day,” said Ratan.

Health Hero is currently conducting a study in the Pacific Northwest with Medicare patients. Although quantitative results have yet to be analyzed and released, Ratan told 

 that “physicians in that program are really amazed that they now have patients who have struggled with their conditions for years and got into a place where they were really sick, who are now doing a lot of the things that they need to do everyday to keep themselves relatively healthier.”

With a focus on providing user-friendly capabilities to upload realtime patient data from biometric devices into personal health records (PHR), 

 is “a pioneer in Internet-based remote health monitoring systems [and] serves those managing asthma, diabetes, pulmonary disease, hypertension, cardiovascular disease, congestive heart failure [CHF], and HIV/AIDS.” Although MediCompass Connect®, which “enables the collection of data that can be shared by members with their care team between provider visits,” is iMetrikus’ main focus, it’s the 

 that may be the more interesting health monitoring resource, due to its ability to connect to more than 30 monitoring devices from different companies. MetrikLink transmits information through a telephone line or over the Internet, enabling authorized members of the healthcare team to easily review patients’ data. As part of MediCompass, it serves as a “universal communication gateway that securely transfers data from health monitoring and point-of-care devices.” Robert Murphy, Senior Vice President of Marketing, told 

, that “MetrikLink is really where our core development is and where our unique place in the marketplace is.” 

Medtronic offers a similar product called the 

. It is “the leading Internet-based system to help physicians and patients better manage chronic cardiovascular disease treated by implantable device therapy.” Participating patients need only turn on the monitor, place a small, computer mouseshaped antenna over their implanted Medtronic device (a variety of the company’s implantable cardioverter defibrillators and cardiac resynchronization therapy-defibrillators are currently supported; Medtronic plans to provide support for additional devices in the future), and connect it to a telephone line anywhere within the US. The CareLink Network enables physicians to review a patient’s signs and symptoms and determine if any changes have occurred since the last office visit. Molly McMillen, Public Relations Manager for Medtronic Cardiac Disease Rhythm Management, says that not only are the implanted devices convenient for the patients (100,000+ currently enrolled), but they “cut the time for routine follow-up by 65 percent.”

The companies that create and distribute remote health monitoring products are understandably enthusiastic about the technology’s potential to help improve healthcare outcomes in a variety of disease states and patient populations. But what do some of the healthcare professionals who have studied remote health monitoring and incorporated it into practice have to say?

One benefit of remote health monitoring technology touted by supporters is its ability to increase access to care for geographically underserved areas. Because patients in rural areas often have a much harder time than their urban and suburban counterparts when it comes to accessing medical care, a study is being conducted at the 

, under the direction of Dr. Vandivier, to measure the effectiveness of remote health monitoring in patients with COPD who live in urban and rural regions of Colorado. “Urban medicine is kind of different than rural medicine, so we’ve partnered with 

, and we’re enrolling patients from both of our sites,” Dr. Vandivier told 

. “We’re also doing rural medicine, which we’re maybe even more excited about because a lot of patients out in these counties in Colorado that are rural or even frontier— which have even fewer people&mdash;have a lot harder time getting their medical care.” 

The study, known as the Advanced eHealth for COPD in Colorado Program, is designed to “evaluate the impact of the eHealth approach on reducing healthcare costs and improving quality of life for participants.” The study will provide up to 400 patients with a pulse oximeter, a handheld spirometer (for exhaled breath monitoring), a pedometer, and an electronic communication device, which they will use to make daily reports of their self-monitored health information to healthcare professionals at Kaiser and the University of Colorado, who will in turn provide patients with educational information about COPD and “contact any participant who has a monitored parameter in a questionable range and determine what interventions may be needed.” The study is also looking at the economic impact of remote health monitoring. 

 from a pilot program showed that remote monitoring saved “nearly $3,200 per patient over just a 12-week period, largely by alerting healthcare providers to signs of developing problems before they ballooned into larger complications.” 

, “Initially, I actually was skeptical of this sort of mechanism to teach patients about their disease and to administer care to them, but I am a true believer in it now. I think for our patients, it’s really made a huge difference.”

Another remote health monitoring program, conducted by the 

, is focusing on “extending the care community beyond the traditional walls of healthcare institutions by bringing healthcare to the everyday surrounding of the health consumer and their families.” Dr. Kvedar told 

 that the Center runs many programs and initiatives to measure the effectiveness of remote monitoring of patients with chronic diseases. The Center has analyzed “the latest data on years of patients going through that kind of a process” and found that “the hospitalization rate for patients on the intervention is reduced from a former rate of 22% to 5%.” The 

 is also looking at how “new models of care that extend and enhance the physician—patient relationship are emerging through innovation of technology and process.”

We had a bit to say on the topic of the patient—physician relationship in our 

, “The 21st Century Patient—Physician Relationship.”

With regard to his personal experience with remote health monitoring technology, Dr. Kvedar said, “Remote monitoring means that I can take care of almost all of the aspects that I would normally rely on the physical examination in the offi ce to give me without being in the office with the patient.” 

Even the government has recognized the importance of using remote health monitoring for patients with chronic illnesses. In fact, on February 15, US Senator Norm Coleman (R-MN) introduced the 

, which would “provide for coverage of remote patient management services for chronic health care conditions under the Medicare Program.” The text of the bill included nine statements (or “findings”), including: “Remote patient monitoring can make chronic disease management more effective and efficient for patients and the health care system” and “Utilization of these technologies not only improves the quality of care given to patients, it also reduces the need for frequent physician office appointments, costly emergency room visits, and unnecessary hospitalizations.”

In this month’s Cover Story we discuss the possible effects of the decline in the number of primary care physicians on the healthcare system. When asked if remote health monitoring could help to lessen the impact of this particular problem, Kvedar says, “It should empower the primary care doctor. There are several advantages to having a connective health view of the healthcare system. One of those is that individuals that can make informed decisions about patient care, including patients themselves, do not have to be doctors all the time.” Kvedar further discussed how remote health monitoring may make it easier for the physician to “take more of an oversight role in care. The technology allows for a complete physiologic picture to be in front of a doctor, and perhaps a care provider that’s closer to the action, say a home care nurse, can make decisions about that care much more effectively because of the richness of the information.”

Do You Think Remote Health Monitoring Will Revolutionize the Healthcare Industry?

“I do, because right now we have these very significant pressures on us. One of course is cost pressure, to do more with less. Another is that we aren’t training more primary care doctors—fewer people are going into primary care, whereas the number of patients with chronic illnesses is growing quite rapidly. If we don’t change our model of caring for those patients, something will have to give because primary care doctors are seeing a patient on average every seven minutes.”

“I think that it’s more a question of technology has evolved and how it continues to evolve, how people market it to consumers, and individuals becoming more accustomed and acclimated to using the technology in their everyday lives. That’s where it becomes revolutionary.”

Senior Vice President of Marketing, iMetrikus

“We believe it has the power. We believe it’s going to take a lot of work to do it, but that in the next three to five years, you’ll see a significant increase in the number and types of remote monitoring that are occurring in our healthcare system.”

Vice President of Business Development, Health Hero

“I do think it will revolutionize healthcare simply because it will help us get proper care to people in all sorts of situations. People are so much more electronically savvy these days that for the first time, they’re going to be able to actually use these kinds of systems. I definitely think it is important, but I also don’t think remote health monitoring is a substitute for real people.”

Council on Aging — The Health Hero® Technology Platform

Medtronic CareLink Network for Heart Failure Patients

Remote Monitoring for Implantable Cardioverter Defibrillator (ICD)Patients

Remote health monitoring empowers patients and physicians, increases access to healthcare services, and helps reduce healthcare costs.

Long Distance Dedication: Remote Health Monitoring

Unless changes are made, and soon, the looming shortage of primary care physicians we've been hearing about for so long will become a reality as older doctors retire and new medical school graduates opt to enter subspecialty practices that promise more money, shorter hours, and fewer headaches. A substantial decline in the numbers of primary care physicians will produce effects that ripple throughout the healthcare system--those physicians who do elect to practice primary care medicine will be forced to see more patients than ever before, yet patients will find it increasingly difficult to obtain treatment. 

What can be done to avert this crisis? Some in the industry have proposed substantive changes to the primary care reimbursement model that would place less emphasis on procedures performed and instead base compensation in part on time spent with patients. Advances in healthcare information technology may also help alleviate some of the financial pressures on harried primary care practices by increasing efficiency and streamlining workflow. 

 entering family practice residencies dropped by 50% between 1997 and 2005. Half of internal medicine residents chose to go into primary care in 1998; nowadays nearly 80% of internal medicine residents choose to become subspecialists or hospitalists. 

The American Academy of Family Physicians

 documents a similar crisis in family medicine. In an effort to alleviate some of the financial pressures associated with primary care practice (higher overhead costs and lower levels of compensation on average compared to other specialties), some primary care physicians are converting to a "high-tech, low-overhead" practice model, a trend that, if it catches on, could help off set the decline in primary care medicine, according to a 

. Such a move would also theoretically enable PCPs to exercise greater control over their time; instead of rushing through visits or overbooking in an attempt to maximize the number of patient visits, PCPs could schedule fewer appointments and spend more time with each patient. 

"PCPs are really getting the squeeze, which means they either have to see more patients, schedule shorter visits, or work longer hours," says 

 editorial board member Gary Stephen Nace, MD, Associate Professor of Clinical Medicine at the University of Illinois College of Medicine. "In terms of lifestyle, you really don't have nearly as much control as you would in a subspecialty, particularly something that's more associated with shifts, like anesthesia or radiology." 

On average, primary care physicians see approximately 15-20 patients per day in an eight-hour day. Add to that the 30 minutes spent on paperwork, charting, and handling referrals per individual, and you end up with rushed patient encounters. 

Increased access to information technology is enabling patients to take a more active role in their healthcare and more effectively manage their health. More informed patients tend to adhere better to treatment plans and require fewer explanations from their physicians regarding their care. This can be especially beneficial to the solo practitioner, whose already limited time is spread even thinner by rising demands. 

Healthcare technology (in the form of the Internet) not only can give patients the freedom to learn all they can about their conditions and treatment, when applied to practice in the form of telemedicine (visit mdng.com for more on this subject from the American Telemedicine Association), it can also alleviate the need for an in-person visit in some cases, relieving some of the stress on the physician's schedule. Healthcare technology can also be used to streamline medical practice, making it more efficient. 

One example of tech's contribution to this process: practice management software programs for physicians. "Traditionally, physicians are not doing very well when it comes to applying modern business solutions, and certainly not in more innovative practice management concepts, so I think it's going to take the rare entrepreneurial physician to implement that successfully," says Dr. Nace, about PCPs' implementation of technology. John Wasson, MD, Professor of Medicine and Community and Family Medicine at Dartmouth Medical School, spoke to MDNG about "How's Your Health?" (

) an online tool for healthcare improvement intended for use in the primary care setting and funded by 

 that "lets people assess their health and receive information tailored to their particular needs." Used by thousands of patients, the survey, which takes about 10 minutes to complete, is designed to better engage physicians and patients through a series of multiple-choice questions about symptoms, medications, diet, emotional issues, and other topics. "HYH is designed as a non-commercial service," says Dr. Wasson. "It has organically grown from more than 25 years of research and development," he says. "For these reasons, it really works well. As Don Berwick, MD, of the Institute for Health Care Improvement said, "[HYH] is a national resource." 

Wasson mentioned in a recent report by the Institute for Healthcare Improvement (

) that he "realized that physicians and their patients just weren't on the same page." And as technology advanced, physicians had even less time to devote to quality patient care. "Healthcare produces jargon," says Dr. Wasson. "The term patient-centered care seems to have originated as a reaction to paternalistic 

. Collaborative care [self-management] results when doctors and members of the healthcare team actively engage patients in evidence-based decision-making and management based on what matters to the patients. Patients should become better "self-care managers" as a result of collaborative care," taking the burden off PCPs. "Collaborative care is associated with improved patient outcomes." 

On October 3, 2006, the Centers for Disease Control (

) and the National Business Coalition on Health (

) convened an expert panel to discuss HYH and other health risk assessments (HRAs). The final report is pending, but it was recommended that the content for these assessments address "what is the matter" (eg, bioclinical information) and "what matters" (eg, the functional and psychological behavior orientation that leads to behavior change). HYH is clearly linked to well-accepted, noncommercial HRAs. "[Solo docs] who use HYH checklists find that it greatly augments their ability to be on the same page with their patients," says Dr. Wasson. 

"The term patient-centered care seems to have originated as a reaction to paternalistic "doctor-centered" health services. Collaborative care [selfmanagement] results when doctors and members of the healthcare team actively engage patients in evidence-based decision making and management based on what matters to the patients." 

Dr. Wasson lists the following steps physicians should take in order to most effectively access/navigate the HYH survey online: 

Go to the "For Businesses/Physicians" section to review all components of HYH and read strategies and approaches adopted by other physicians who have used this resource. 

Ask all members of the staff to complete HYH once truthfully, and then a second time as a "sick patient." In this way, they will more completely see how HYH customizes inquiry and information. 

Discuss how the office would fit HYH into everyday work. As pointed out in "For Businesses/Physicians," an office usually staggers implementation in some way until everyone is comfortable with their role and what to do with HYH results. 

The physician orders HYH and considers also having the information feed into a Docsite registry so that the office can generate a list of patients by categories such as confi dence and pain. 

The physician customizes the website and sets up a new e-mail dropbox into which the patient e-mail will be received. 

The physician tests the system as though he or she were a patient. 

Medical blogs also provide a helpful forum for physicians to exchange information and gain insight on working with their patients, courtesy of the Internet. Robert M. Centor, MD, Professor and Director, Division of General Internal Medicine at Huntsville Regional Medical Campus in Birmingham, AL, started his own medical blog in May 2002, called "DB's Med Rants." He told MDNG that about four or five months before starting 

 (the "DB" stands for "Dr. Bob's") he stumbled upon related blogger sites. "I found 

 and said "that's pretty cool, and I think I could blog about that, because I know medicine. I decided to start a medical blog because there were only two or three at the time. I started Med Rants, and over the first couple years, I was trying to find my voice, like anywriter." 

Since its inception, Dr. Centor's blog has had more than one million visits, with approximately 10,000 hits per week. Clearly, blogging could ease some of the burden on solo docs, who feel not only strained for time, but pressured to be "in the know." They are "trying to harness technology to make family practices more manageable and profitable," according to the WSJ article cited in the iHealthBeat piece mentioned previously. At the same time, trying to sign up new patients while retaining current ones and managing costs can prove difficult without the cushion of a larger practice environment. 

Increased patient loads and the lack of control over scheduling are often cited among the chief reasons that students select specialty practice over primary care medicine. "PCPs are the first point of contact, so it's really not surprising that folks are migrating away from primary care,” says Dr. Nace. "We see it in internal medicine all the time in our training programs." The American College of Physicians (

) claims that internal medicine physicians are still trying to figure out how to reverse the trend of students electing to enter subspecialty practice instead of primary care medicine. The decrease in PCPs' salaries over the past eight years is certainly another contributing factor in this 

The "high-tech, low overhead" model of solo practice--often referred to as a "micropractice"--is a developing trend that could help partially off set the decline in primary care. New technologies are making it easier to efficiently run a profi table solo practice, which may make the prospect of doing so more appealing to students who are attracted to the freedom of solo practice but not to the difficulties of doing so as a PCP. That being said, a 

 conducted by The Commonwealth Fund (CWF) of 1,837 physicians across the US found that, despite the advantages greater use of health IT could provide to solo practitioners, physicians who practice in large medical groups are more likely to adopt and use IT than solo practitioners. 

The survey also found that only one-quarter of solo physicians practice in a high-tech offi ce where technology is used routinely to improve operational effi ciency and clinical care. Among the 13% of solo practice physicians polled in the CWF survey was Dr. Greg Hinson, a MA-based family physician who once relied on handwritten notes and has since moved to practice management software programs to accommodate his patients' needs. He told 

 in November 2005 that when researching EMR (electronic medical record) companies, he found that the market was less than friendly to small practices. 

When he described his small staff to prospective vendors, they "would stop Hinson midsentence and say, "You can't afford us." After a year of doing his homework, he settled on 

 which, according to Dr. Hinson, "provides everything from health maintenance alerts to pediatric features like growth charts." 

A May 2006 article in USA Today profiled a like-minded solo physician, Dr. L. Gordon Moore, who runs his office with the aid of one nurse and a computer loaded with state-of-the-art 

. His two-room "micropractice" based in Rochester, NY seeks to increase quality of care and time spent with patients (look for our article on micropractices in the August issue). He attributes part of his efficiency to 

, a "not-forprofit practice redesign initiative of the American Academy of Family Physicians (

) focused on studying and implementing transformed models of high-performance practices that meet the needs of both patients and practices." 

In a nutshell, the initiative helped him streamline his workflow management with the aid of technology. Dr. Centor supports the use of Internet-based programs to more efficiently manage his practice. "I use 

 all the time if I'm a bit confused about a medical problem and need to get some information," he says. "It's the easiest thing, and it's great because it means that physicians don't have to go to a library. It's a lot easier to search things online." 

Easy access to the Internet and the vast and increasing amount of information, Web-based software applications, and other online resources have been immensely beneficial to physicians, especially to those in solo practice. Whether improved information technology and other tools can help stem the decline in the numbers of PCPs by mitigating some of the less attractive features of primary care medicine remains to be seen. 

Perhaps the decline of primary care medicine can be addressed in part through better terminology and semantics? Which leads to the next question: Are PCPs actually specialists, or "jacks of all trades" The 

 touched on this debate, citing PCPs' ability to function as managers, educators, and counselors as one reason why they should be more appropriately labeled primary care 

When we examine the differences between primary care and specialty practice, career satisfaction certainly becomes a factor. In fact, the Journal of the American Medical Association (

) claims overall physician satisfaction levels between 1997 and 2001 did not change dramatically. However, "declining income, threats to physicians' ability to manage their day-to-day patient interactions and their time, and [obstacles] to their ability to provide high-quality care," are mostly associated with decreases in 

A Community Tracking Study (CTS) Physician Survey was conducted in which physicians indicated how changes in their practice environments affect their general career satisfaction. "The strongest and most consistent predictors of change in satisfaction were changes in measures of clinical autonomy, including increases in hours worked and physicians' ability to obtain services for their patients." Changes in exposure to managed care were loosely related to changes in satisfaction. The study suggests that changes in physician career satisfaction may be influenced by three general factors: changes in the physician's practice environment (eg, solo practice vs. large practice), including the income derived from practice and hours worked, changes in physicians" perceptions of their ability to provide high-quality care to their patients, and changes in the economy. 

When it comes to career satisfaction, physicians' main concern frequently seems to be over one fairly obvious issue: reimbursement. "Our reimbursement system is as irrational as a reimbursement system can be," says Centor, about primary care. "What it means is we see patients faster than we should. You really should never feel like you have to rush a patient visit. Patients should get the right amount of time. We don't attend all the issues; we cannot attend all the prevention because we're not getting paid for it. But the incentives are much greater for doing than for thinking." 

Would a reimbursement model that focuses more on the "specialized" aspects of primary care--diagnostic acumen, continuity of care, etc--and more accurately takes into account the increased time primary care physicians must spend with patients be a fairer system, and thus improve the reimbursement climate for PCPs vis a vie their colleagues in specialty practice? Dr. Nace agrees that PCPs are poorly reimbursed relative to the time they must devote to patients, as compared to reimbursement for performing procedures. "And so the [PCPs] are really underreimbursed," he says. This is exacerbated by the fact that "primary care practices are also traditionally expensive, with overhead expenses of 50-60%." 

The average income of specialists has remained about the same, according to a series of surveys conducted by the Center for Studying Health System Change (

). The HSC surveys also reported that the incomes of primary care physicians have remained about one-third less than those of most specialist physicians. "The tendency is clearly toward sub-specialization," says Nace. 

Is there light at the end of the tunnel? Perhaps improvements in technology coupled with a seriously revamped reimbursement model will help stanch the bleeding in primary care and avert the shortage in family medicine, general internal medicine, and other areas of primary care practice that have long been predicted. It's probably still too early to tell what the final outcome will be, but most every expert we spoke with agrees that something must be done, and soon. And what about the solo practitioner? Will this type of practice, traditionally associated with primary care, flourish in the face of advances in technology? 

Dr. Centor actually sees a movement away from solo practice, down the road. "Solo practice will continue to decrease in our society, for different reasons," he says. "If you're a solo doc in a small town, you're always the doctor--every hour of the day. And a lot of people don't want to do that. You want people to cover you at night. You want to be able to take vacations. And it's just a different expectation. There will be less and less docs in solo practice" over time. And so evolution continues its steady march. 

Oncologists Also Falling Short: Patient Demands, Diagnoses Increase

 stated that during the next decade, it will become increasingly more difficult for patients to find new oncologists. This gradual decline may be attributed to an explosion in the number of cancer patients, creating an increased demand on the already limited supply of oncologists. The main reason for this is the baby boomer generation. As this group passes age 65 years--the age at which cancer rates rise significantly--oncologists may be slow to keep up with the demand. 

During the next 10 years, it's predicted there will be a 48% climb in cancer incidence and an 81% hike in cancer survivors, making the ability to schedule appointments with an oncologist. The anticipated shortage is due not only to rising demand, but also to the limited rate at which new oncologists are entering the field (approximately 10,400 medical oncologists are currently employed in the US, with only 500 new physicians entering the field each year). Adding to the impending shortage is the fact that nearly half of currently practicing oncologists are nearing retirement themselves. 

Unless changes are made, and soon, the looming shortage of primary care physicians we've been hearing about for so long will become a reality as older doctors retire and new medical school ...

The Incredible Shrinking PCP: Growing Pains in Primary Care

If the AMA’s attention is any measure of importance, blogging has hit the physician mainstream. A January 15 feature in AMA Health News (

) highlighted “Grand Rounds,” which is a weekly review of the best blog posts by healthcare bloggers across the blogosphere. Consumers are trying desperately to fi nd more authoritative and less pharmaceutically biased health information, and blogging is garnering some of this focus. 

In 1999, Jacob Reider, a family physician and medical informatician, was the second physician to write regularly and post publicly on the Internet (

). His writing highlighted technologies helpful to physicians in small practices, and commented on topics of interest to generalists (immunizations, guidelines). In the years since 1999, a few dozen physicians have started their own blogs. Most have followed a diarist’s style—a personal journal that focuses on topics of interest to physicians like them. Bloggers generally stick to writing about issues within their specialty but make it more personal by including day-in-the-life details that give their writing a friendlier, more informal feel than a medical journal. For example, Reider produced the first physician’s podcast, reviewing what he did in his day of practice. 

In early years, medical blogging was an insular community; bloggers read and commented on each other’s posts. In the last three years, when reviewing comments on medical blogs, you can see that the general public has discovered medblogs and are eager readers. Consumers see blogs as authentic, first-person testimonials regarding timely information on particular treatments, medications, and diseases. Consumers can read blogs for distilled opinions and information, rather than rely on sites like PubMed (

), with their often incomprehensible (to consumers) clinical information. Consumers may even begin to stray from Google, unable to confi dently choose from an unqualified list of links to information of varying quality as they see nutraceutical (nutritional supplements for sale in health food stores) advertorial content encroach. Consumers have fl ocked to more qualifi ed content, such as the physicians answering questions at blogs like About.com’s Guides. Such guides include Vincent Ianelli’s Pediatrician Guide (

), where his face is prominently displayed, and his physician credentials are “googleable” for verifi cation. Others seek to pay physicians—such as Kevin Pho, Internist and popular medblogger of “Straight from the Doc” (

)— specifi cally for private replies at sites like MedHelp (

) have attempted to attract readers by hiring celebrities, physicians, and nurses as bloggers, with questionable success. They’ve failed to provide stylish writing and technologies that allow readers to continue the conversation. Readers want short, witty blog postings combined with an open community that enables them to comment on the site’s content, rate that content, write about it on their own blogs, and e-mail content to friends. They want to see authoritative content, as well as the user-generated commentary surrounding the topic. Consider the popularity of Howard Dean’s blog that drew thousands of commenters a day to his presidential candidacy forum four years ago. Political controversy drove involvement. Consider the popularity of social networking sites like MySpace (

), where readers can review the products and services they consume; LinkedIn (www.linkedin.com) and FaceBook (

), where users can provide testimonials for friends; and Flickr (

,) which enable visitors to post photos, video fi les, and other content and send it to friends. 

The popularity of these kinds of sites is rapidly spreading, leading to the development of online destinations where like-minded folks can communicate through public patient-to-patient forums—popular sites include DailyStrength (

), Everyday Health (www. everydayhealth.com), The HealthCentral Network (

). The question is whether the growth of these public forums will match the private interactions in places like CarePages (

), or at sites such as MedHelp, where questions posed by patients are answered by physicians. 

Another question remains to be answered: How long will all of the venture-backed companies survive? Just as with Web 1.0, startup funds come with big expectations attached, and investors won’t wait forever (as seen during the dotcom bust a few years back). I’m glad that some of these companies are non-profi ts, but I am concerned about those that are designed to burn through all of their funding, expecting to get a bigger round of funding in the next pass. I’m expecting some spectacular fl ame-outs in the coming year or two and am saddened that many consumers will lose resources that they’ve come to rely on. 

Dr. Choi is an urgent care medical informatician for PAMF, MedHelp, Epic, Misys, and Google, and the author of the blogs at 

www.socialtext.net/speakers/index. cgi?enoch_choi

Medical blogging is becoming more and more popular. Learn the history of the latest phenomenon and how you can get started with your own blog.

April 2007

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The Incredible Shrinking PCP: Growing Pains in Primary Care

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