We live in an age in which patients have powerful tools for finding out more about their physicians. In the same way that friends now share online opinions about their favorite restaurants, the usual word-of-mouth recommendations about physicians has extended to online forums. Many physicians find this perturbing and go to great lengths in a futile effort to suppress these online opinions. Some even resort to litigation to remove negative opinions posted on websites and blogs, claiming that they’re libelous. I know many physicians who are struggling with the need to promote their practice while hiding online details about their private lives. Some physician friends of mine are even concerned about their physical safety, as they’ve attracted the attention of patients who have gone beyond being merely fans. These patients have devolved into stalkers that comb the Internet in the hopes of finding a nugget of information that can assist them in their obsession to connect with the object of their desire.

For every reader who is experiencing a similar nightmare or who is worried that they too might become the object of an obsessive patient’s attentions, I’d like to pass along some secrets that these physician friends of mine shared with me. I’ll explain how their “suitors” found out about them, how they fought further inadvertent disclosure, and how they have successfully continued an online private life with their loved ones. (To be clear, in this article, I am not referring to my own experience, to the experience of any of my professional partners, or to my place of employment, past or current.)

One struggle is that the practice of medicine is by necessity a public endeavor, since you have to let patients know when they can come to see you and list hours of operation on your practice website. Like many urgent care physicians, I don’t keep regular hours, so it’s harder to track me down, but most physicians have a regular schedule that establishes a pattern that’s easy to follow. Because of that, if they are leaving after dark at night, many of my friends ask for a security escort to their vehicle. It’s sad, but physicians are public servants and prime targets for stalkers. I’ve even heard of extreme cases in which the stalker hid inside the office, waiting for an opportunity when the physician was alone. Thank goodness none of my friends have been injured, and I hope it never gets to that. One measure of prevention is to not tempt stalkers by feeding their appetite with online details about your family and friends.

There is no privacy on the Internet. You need to be aware that anything you write online is public information. Even if you believe that you’re writing on a private website, there are many people who manage that site that have access to your writing. Unplanned lapses in online security have disclosed many writings to the public that were never intended to be on the open Internet. Even medical records, intended to be secured in private research databases, have been inadvertently exposed. You may feel safer by writing under a pseudonym, but the computer from which you write has a unique address, an “IP address,” that records the location and specific computer from where you’re writing. Even if you write from an Internet cafe, details of what you write can be used to triangulate your identity.

There are many unexpected ways in which folks can find out about you. Do three different Google searches: one on your name with “Dr” or “MD,” one on your home address, and one on your personal phone number, and you’ll be shocked at where these details can be found online. For references that list my home address and personal phone numbers, I e-mail the administrators of those Web pages and ask them to delete my personal information. You often find the e-mail address of the administrator at the bottom of the webpage.

When Googling, don’t stop at the first page of search results, keep going through all of the pages just to make sure. Although you can’t help having your state license registration on a public page, hopefully the only other details on that page are your practice address and contact information. The same goes if you’ve registered your business with your local Chamber of Commerce; make sure their website only provides information about your practice, not your personal details.

When searching, you may also find references and information dating back to medical school and residency. Using these dates, stalkers can approximate your age, so some of my friends have argued in favor of removing dates of med school graduation from public webpages. More recent search results may link to your house sale or purchase, or renovations listed by the local paper, uncomfortably disclosing your home address. If you have given any PowerPoint CME presentations at grand rounds or to trainees, you often put your contact information and e-mail address on the last slide, which will appear online if uploaded for medical residents to review later. You may have published articles in journals whose abstracts appear online and often include your e-mail address -- make sure it’s your professional e-mail address.

If you have registered your practice’s website URL, 

 shows the address and phone number of the person who registered that URL, which in small practices is often handled by the doctor. Some physicians put their contact information and e-mail in the comments sections of blogs and forums in order to hear back from their favorite physician bloggers, musical artists, or performing arts groups. Guess what? Those details are searchable online. Even if the comment is made in a supposedly private website like 

, it’s easy to find the necessary information to register (medical school and year of graduation) and read your comments.

How can putting more public information online help protect your private information?

One unfortunate place that your home address has to be listed is your local City Hall. If your stalker is determined enough, they can go digging for the record of the purchase of your home since it is a matter of public record. Some physician friends have been concerned enough to purchase their homes through trusts or use the name of their spouse to limit the chance that their home address could be ascertained. When friends of mine have had stalkers who were that persistent, it had unfortunately gotten to the point where sometimes they needed to go to court to get a restraining order.

The best way to combat inadvertent exposure is to flood the Web with information you want your patients to know about you: your professional practice information listed on your clinic’s website, your philanthropic interests, and your community affiliations. To increase the visibility of this information, there are two ways to make them come up higher in online searches. One is to submit the links to whatever sites you use to promote your practice, such as the local newspaper, online directories by Google and Yahoo, your IPA, county medical society, or even Yelp. You’ll find these by doing a search on your name, and they should already come up early in searches. Increase the page rank (popularity) of your own site by having more sites link to your practice website.

Whenever you do a local talk, use your practice website as the contact information, and they may thank you online by posting a link to your website. You should always link to your practice website when you leave comments on blogs and other websites. If you write in support of particular philanthropies or community organizations, link to your practice website within the article or endorsement. Consider giving health education talks, and in the ad promoting your talk, link to your practice website. Consider answering health education questions in your local paper and they’ll usually post it online, where you can ask them to link to your practice website. You can do the same at sites like 

, where I answer questions as well. Post many answers and that will quickly flood search results with the contact information you want people to know, as well as provide more links back to your site to increase page rank and thus searchability. 

One uniform response I’ve had from physician friends who have been stalked is anger and an unwillingness to give up their social life online. They still want to share their lives digitally with family and friends. There are a few ways to make things a little more private, other than flooding the public Internet with what you want the public to know about you. For starters, stop writing about your private life on public webpages; consider just e-mailing friends directly. Many people find e-mailing less useful than updating Facebook when trying to keep family and friends up-to-date, but are worried about inadvertent exposure. 

You can make your Facebook profile private

. I’ve set all of the privacy settings to make my information private to only those I friend request.

I can also block specific users, a feature that’s been helpful for friends who have been stalked. Some of them have had to ask Facebook multiple times to intervene to block the many different user IDs that a persistent stalker may set up to try to “friend” them, but it stops after they remove their profile from “Public Search Results” and 

make “only friends” able to see “Facebook Search Results."

 You may also want to remove your name from any “tags” of photos where your friends have identified you to limit more widespread exposure of your facial image. For my practice, I have a public Facebook page that is viewable to those who are not even signed into Facebook and that serves to redirect search results on my name to this public page. If you twitter about your private life, consider making your tweets 

 so that only friends you’ve granted access to can read your tweets.

Efforts at maintaining online connections are worthwhile given the power these tools have to deepen our friendships with those we care about. It’s important though that you realize just who you’re keeping up to date with and prevent prying eyes from seeing your private life. With a little care when sharing information online, and a lot of effort at increasing the popularity of your public practice site, you can do it!

Enoch Choi, MD, is an MDNG editorial board member and full-time family physician practicing urgent care as a partner at Palo Alto Medical Foundation in CA, where he sees patients in clinic, as well as online via PHR.

Articles

Cover Story

Although the adage that there is no privacy on the Internet is truer than ever, there are several steps that physicians can take to protect their private lives and information while still remaining active online.

My Patient Is Stalking Me Online

The healthcare insurance bill has finally been 

. Some feel this moment was “historic,” a true time to celebrate. Others feel this whole experience has revealed that our government clearly is not representing the will and the needs of its people. Still others are truly unsure what to believe. Are people reacting because they fear change or are they reacting to a flaw in the law itself? That’s the crux of the issue, isn’t it? Our citizenryâ€‘â€‘including healthcare professionalsâ€‘â€‘is basically divided right down the middle on this important issue.

The debate over the merits of this law began before the ink was dry on President Obama’s signature. People are not merely disagreeing with each other over this law, thoughâ€‘â€‘they are having all-out verbal wars. Too many people don’t want to discuss their views with each other; they just want to have the other people agree with their position. All of this harsh rhetoric, invective, and name calling are telltale cues that people are scared and uncertain about whether they are supporting the right team. Instead of engaging in such unhealthy discourse, I contend we should respect each others’ varying opinions and points of view and simply agree to disagree.

Our backgrounds as professionals and patients are what make us who we are, and if we learn to listen carefully to people who have different experiences, we’ll have more points of reference to use to judge not just the merits of this law, but also identify changes we should make—issues we can bring to the attention of our elected representatives.

Let me share with you my background as an example. As a pediatrician, I’m conceptually in favor of a plan that insures children and families in need. However, insuring those people without stipulations for who will care for them is a disaster in the making. We already have a shortage of primary care physicians, which includes pediatricians. Overloading the system with more insured patients without improving compensation plans for the already overwhelmed PCPs is going to hasten physician burnout until we can somehow increase the PCP work force.

Second, with more kids insured comes more ER visits. We all know the emergency rooms coast to coast are already overloaded with long wait times. More people per ER won’t improve that situation (in fact, it’s predicted to worsen the situation by 10%).

As a patient with a chronic condition, I’ve faced steep co-pays of over $200 per month, refusals to pay for needed medications and therapies, long waits for specialists, and even an inability to get in to see the specialist I needed to all, because of insurance. The current law doesn’t address any of these issues one bit. Shouldn’t a good law uphold the needs of all Americans? This law falls short for too many important groups in too many ways for my comfort level.

Open discourse is healthy, but debate with deaf ears is dangerous. It’s by learning to truly listen to one another free of judgment that true solutions for change will emerge. I’d love nothing more than to experience that day, because I have a hunch that will be the day we discover how to talk about real healthcare system reform without politicizing it. I’m game… how about you?

Columns

How can we have a real conversation about healthcare reform and other contentious issues without letting anger and frustration stop us from communicating?

Social Media Notebook - Let's Talk! Putting Aside the Animosity over the New Health Insurance Law

It appears that many members of Congress have bought in to several unrealistic healthcare reform ideas, one of which is to change the way we pay doctors to a system based on “quality” rather than on “quantity” measurements, such as the number of office visits or procedures performed. They hope to get the same amount of work for a more significant cost savings. The way to implement this is to increase the bureaucratic oversight of physician performance, all the while making doctors pay for the cost of this increased burden. Over the years, several 

 have been run in which physicians, after a lot of reporting and data gathering, generally ended up being paid poorly, if at all, for their efforts. None of these trials have demonstrated a significant improvement in 

. In some cases, the use of a “certified” EHR (c-EHR) actually was 

What exactly is this “quality” mantra currently being touted by politicians, including our President? Already, the US has one of the best healthcare systems in the world, albeit the costliest. 

 for US females has risen from 48 years in 1900 to 80 years in 2006; for males it’s risen from 46 years to 75 years. Our 

 are better than those in Europe and Canada, where waiting lines for crucial imaging tests can take months, time for cancer patients that can mean the difference between living and dying. “Quality” is now defined as the achievement of the best outcomes for the least amount of money. Sometimes, the best outcomes, if too costly, will not fall into this new definition of “quality.” Americans are beginning to realize this, which is partly why 

On February 12, 2009, President Obama signed the HITECH Act, which put into law a poorly funded, poorly thought-out mandate that forces physicians to not only buy a c-EHR, but to also “meaningfully use” it. In return, US taxpayers will reimburse complying physicians up to $44,000 over five years. No further payments are scheduled to be offered after 2015; in fact, penalties of up to 5% of a physician’s Medicare income will become reality starting in 2016. I calculated in my March 2009 column that the process would cost each physician a minimum of about $60,000 per year to see Medicare patients based on a typical medical practice like mine; this cost is due not only to the up-front purchase of the c-EHR, but to ongoing monthly maintenance costs, costs related to the need for increased staff, costs related to the increased time it takes to see a patient in a “meaningful” way, and 

 related to the cumbersome and slow electronic prescription mandate. If you multiply this cost by the number of 

 (~800,000), the yearly cost of “meaningfully” seeing Medicare patients would come out to $48 billion per year.

The federal government wants physicians to pay for all of this, which partially explains why the CDC published its biannual 

 in the US showing that only 6.3% of physicians are in a position to qualify for the HITECH reimbursement. Throughout the past 10 years, physician fees under Medicare have virtually been frozen, losing out to inflation to the point that it’s becoming harder for patients to find doctors who are willing to take on new Medicare patients. Asking physicians to perform costly “quality” pay-for-performance measures in this environment of decreasing reimbursement will doom the participation of physicians with Medicare.

Congress needs to repeal the HITECH Act, as well as any other similar costly bureaucratic mandates. Congress needs to offer physicians a free, open-source EHR, such as the 

. Whatever EHR is offered, its interface must be easy to use and actually helpful with patient care to the point that it will entice doctors into “significant use” without any costly mandates, penalties, or other forms of punishment. This free EHR would be easy to interconnect with health information exchanges because of the same underlying structure and standards.

Politicians need to realize and understand that the new, unproven concept of “quality” will be disastrous to our healthcare system and will be a massive burden on our economy if fully implemented.

It appears that many members of Congress have bought in to several unrealistic healthcare reform ideas, one of which is to change the way we pay doctors to a system based on Ã¢ï¿½ï¿½qualityÃ¢ï¿½ï¿½ rather than on quantityÃ¢ï¿½ï¿½ measurements, such as the number of office visits or procedures performed.

The HIT Realist - What Paying Doctors for "Quality, Not Quantity" Really Means

The recently completed 2010 HIMSS conference and exhibition in Atlanta was full of big tradeshow boothsâ€‘â€‘just one of many signs the health IT industry is being flooded with VC, M&A, and Wall Street money. And why is “smart money” gushing into health IT like it’s the next gold rush? Could it be that we physicians have a giant target on our backs that marks us unsuspecting dupes just waiting to be separated from our wallets? I’m starting to wonder…

During my three days at HIMSS, I visited many EHR vendor booths, as well as the informational booth set up by the Office of the National Coordinator for Health Information Technology (ONC), the organization responsible for coordinating and informing the public as to the actual details of ARRA and HITECH. I presented myself as a having a small family practice in Rhode Island collecting $16,000 per year from Medicareâ€‘â€‘all of which is 100% true. I asked vendors and the ONC how much money I would be able to collect for “meaningful” use of a “certified” EHR system. I asked them whether I would be able to collect the $44,000 that so many vendors promise. I also pressed for specific details, such as how the payments would be made, how often, etc.

What happened next literally blew my mind. I felt like Alice wandering though Wonderland as people said things to me that were not rooted in reality. The answers I got from vendors were all over the placeâ€‘â€‘ranging from promises that I will collect all $44,000 under the assumptions I gave them (not true!), to confessions that they were unsure. No two had the same answer, and only one company (GE) had the right answer. One vendor’s representative even confused the Medicare and Medicaid subsidies, promising me a whopping $65,000 pay day courtesy of the stimulus money. Five different federal officials at the ONC booth did no better than the vendors. Not one of the folks at that booth could answer my simple question.

The simple answer is that eligible providers will be able to collect the lesser of up to 75% of their total Medicare allowables (aka collections) in each of the five years beginning in 2010, or a maximum annual amount that changes year to year as shown at left.

This equals a total of $44,000 from Medicare (if you collect $24,000 or more from Medicare each year). So, while it is true that you could get up to $44,000, what many vendors fail to explain is that if you collect less than $24,000 from Medicare per year, you get less. In other words, the correct answer to my question is that my practice should be eligible to receive $38,000, which is a full $6,000 less than many physicians are banking on.

This would be laughable, until you think about the fact that thousands and thousands of overworked and underpaid small-practice physicians are going to pay outrageous sums for substandard solutions, all in the false expectation of some giant windfall at the end of the day. Shame on EHR vendors! Who do you think will get the short end of the stick when a physician, misled by unscrupulous EHR vendors, spends tens of thousands of dollars on an overpriced EHR?

For a more detailed report of my adventures at HIMSS, and the actual ludicrous answers I got to the questions posed to EHR vendors and the ONC, please see 

Big money is flooding the health IT industry, and that can mean only one thing: Doctors are about to get screwed.

April 2010

My Patient Is Stalking Me Online

Social Media Notebook - Let's Talk! Putting Aside the Animosity over the New Health Insurance Law

The HIT Realist - What Paying Doctors for "Quality, Not Quantity" Really Means

Tech Talk - HIMSS 2010: A State of Confusion

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