The Global Initiative for COPD: Patient Guide

This PDF describes how lungs function in healthy individuals and contrasts that with illustrated content showing what happens to the lungs of a patient with COPD. The guide goes on to review the symptoms associated with COPD and explains how lung damage can affect quality of life. Information in “What you and your family can do to help slow the damage to your lungs” is divided into five sections, in numerical order, and focuses on quitting smoking, maintaining the correct medication regimen, the benefits of exercise, and more. The site also provides information about planning ahead if you will be traveling in order to keep COPD-related problems at bay.

Clinical Identification of Phenotypes in COPD (CLIP-COPD)

The phenotype estimation model available at this website allows physicians to enter data from a patient’s clinical history, physical exam, functional data, and chest radiography data. The site then provides physicians with the COPD phenotype that best fits that patient. This information can be used in the clinical setting to further tailor treatment options that are specific for that patient. The estimation model is derived from “Identification of a Predominant COPD Phenotype in Clinical Practice,” an article published in the March 2008 issue of 

COPD Foundation — Medical Professionals

The COPD Foundation gathers guidelines for diagnosis and management of COPD from the American Thoracic Society, European Respiratory Society, Global Initiative for Chronic Obstructive Lung Disease, and the American College of Physicians into one conveniently accessible place. The COPD Foundation has also developed “a concise Pocket Consultant with the most pertinent information about diagnosing and managing COPD,” which can be found by clicking on “COPD Guidelines” and following through to the “Publications” page. The “Testing and Diagnosis” section provides information about spirometry, patterns of COPD management in the primary care setting, and the link between comorbidities and COPD management.

Proteomic Expression Profiling of Haemophilus Influenzae Grown in Pooled Human Sputum from Adults with Chronic Obstructive Pulmonary Disease Reveal Antioxidant and Stress Responses

survives within the airways of adults with COPD.

The 1,402 proteins included eight anti-oxidant and five stress-related proteins, suggesting that expression of antioxidant activity and stress responses are important for survival in the airways. The researchers conclude: “These observations suggest that 

adapts to the oxidative and nutritionally limited conditions of the airways in adults with chronic obstructive pulmonary disease by increasing expression of molecules necessary for survival in these conditions.”

Coping Skills for Patients with Chronic Obstructive Pulmonary Disease (COPD) and their Caregivers

To examine “the effects of a telephone-based, caregiver assisted, coping skills training (CST) program” in patients and caregivers to determine if it helps patients and loved ones deal more effectively with the stress of the disease.

Randomized Trial of Physical Activity Selfmanagement Intervention for Patients with COPD

National Heart, Lung, and Blood Institute

To determine if a novel physical activity self-management (PASM) program will result in “clinically and statistically significant improvements in functional performance (ie, Chronic Respiratory Questionnaire [CRQ] dyspnea domain and 6-minute walk)”compared to the outcomes obtained by usual care (UC). The study will also address the cost-effectiveness of PASM compared to UC.

COPD — Enhancing Recognition and Improving Outcomes

Originally presented as a live webcast at the NACE Emerging Challenges in Primary Care Series: Update 2009, this activity is designed to provide physicians with the knowledge and tools to recognize cases of COPD earlier, a step that is aimed at improving care and treatment outcomes of patients. The program also discusses the diagnosis of COPD and the impact that lifestyle modification can have on COPD outcomes.

This activity is designed around the case study of a 56-year-old woman who presents with increased breathiness and a cough that has increased in frequency over the past week. The program guides participants through the patient’s introduction and history, provides the chance to order tests, explains the results, and discusses possible treatment options that are now available. The interactive design of the program allows physicians to increase their knowledge while working in a virtual practice setting.

Chronic Care Focus: Diagnosis and Treatment of COPD in Health Systems

This review article notes that “both chronic and acute COPD need to be differentiated from other similar respiratory diseases at diagnosis with the proper tools,” and that “health systems need to evaluate current regimens set aside for COPD alongside regimens for treating other respiratory diseases to ensure that overlaps can be made to avoid high cost.”

www.pharmacytimes.com/issue/pharmacy/2009/2009-04/2009-04-10206

Inhaled albuterol/Salbutamol and Ipratropium Bromide and their Combination in the Treatment of Chronic Obstructive Pulmonary Disease

 Expert Opinion on Drug Metabolism and Toxicology 

 To examine the efficacy of combined albuterol-ipratropium therapy for the treatment of stable COPD in comparison to more recently developed treatments.

 Although the combination was an innovative treatment at the time of its approval, and it does provide better improvement in airflow than either treatment alone. “The recent development and approval of longer acting and more potent agonists, anticholinergics and newer combination treatments have surpassed many of the advantages of combined albuterol-ipratropium for the treatment of patients with stable COPD.”

Patients can visit this website to find reliable answers to frequently asked questions about the use of Atrovent, including: “What are the possible side effects of ipratropium inhalation?” “What is the most important information I should know about ipratropium inhalation?” “What should I discuss with my healthcare provider before using ipratropium inhalation?” “How should I use ipratropium inhalation?” and “What happens if I miss a dose?”

Sensitivity of New Exercise Tests in Chronic Obstructive Pulmonary Disease

 This trial is designed to “develop simple exercise tests to assess the effects of pharmacological and rehabilitation interventions on exertional dyspnea in the primary care setting.” Patients will complete a total of four exercise tests: two 3-minute constant rate step tests and two 3-min constant rate shuttle walks. Each test will be preceded by the nebulization of either a placebo or 500μg of ipratropium bromide (Atrovent).

Articles

Feature Articles

We searched the Internet for COPD resources so you don't have to.

The Net Guide: COPD

This CDC-developed site features more than 10 tools for patients and their families. In addition to basic facts about diabetes, the site also covers diabetes in specific populations, such as women and some racial and ethnic groups. The sections on physical activity and staying healthy discuss how exercise and keeping up with various diabetes-related tests can give patients better quality of life. Loved ones who are concerned about their risk for diabetes will benefit from the pre-diabetes and prevention sections, designed to help individuals control their risk factors for diabete and avoid lifestyle choices that can contribute to the condition.

This site discusses the keys to effective blood sugar control, how to recognize when blood sugar is too high and what to do when that is the case, and how to recognize when blood sugar is too low and how to alleviate the symptoms of hypoglycemia. These important facts about blood sugar will provide patients with an easily accessible, basic resource to utilize at any time. Other topics covered here include the symptoms of type 1 diabetes, tips for healthy eating, and how to prevent complications commonly associated with diabetes.

DiabetesPro — Professional Resources Online

Check out the toolbars on each side of the Diabetes Pro homepage, which is the American Diabetes Association’s site for professionals, for helpful resources. On the left, the site highlights key topics for diabetes professionals: meetings and CME opportunities, scientific sessions, webcasts, books for professionals, and more. On the right, the “Breaking News” and “Meeting Reports” provide quick access to the latest news in diabetes research and treatment developments. This ADA site for professionals also offers information about upcoming conferences, clinical practice guidelines, and research grants.

Juvenile Diabetes Research Foundation International: For Scientists

In addition to research news, this site will also provide physicians with policy updates. Both sources of information will keep physicians updated about changes to clinical practice guidelines and provide the latest news to share with colleagues and patients and to use in research. The JDRF site for scientists also provides an extensive review of research and funding opportunities. Other areas of the JDRF site, such as “Life with Diabetes” and “Publications,” can be utilized by physicians to provide patients with information about diabetes management and treatment.

Exercise Training in Type 2 Diabetes and Hypertension

 National Institute of Diabetes and Digestive and Kidney Diseases

 To determine if the health of patients with both type 2 diabetes and hypertension improves with exercise training.

Study of Intensive, Homebased Family Therapy to Improve Illness Management in Youth with Diabetes

National Institute of Diabetes and Digestive and Kidney Diseases

 To determine if Multisystemic Therapy—home-based, family psychotherapy sessions 2-3 times a week&mdash;helps improve treatment adherence, metabolic control, and quality of life in children with diabetes.

Ability of Traditional Lipid Ratios and Apolipoprotein Ratios to Predict Cardiovascular Risk in People with Type 2 Diabetes

 To determine if the apolipoprotein B (ApoB):apolipoprotein A (ApoA)-I ratio should be used to indicate the need for lipid-lowering therapy.

 Lipid ratios and ApoB:ApoA-I performed better than any single lipid or apolipoprotein in predicting CVD risk, but these measurements were equally strong as predictors. The authors conclude that the data provided “little evidence for replacement of traditional lipids and their ratios with measures of ApoB, ApoA-I and their ratio.”

Multinational Study in Children and Adolescents with Newly Diagnosed Type 1 Diabetes: Association of Age, Ketoacidosis, HLA Status, and Autoantibodies on Residual Beta-cell Function and Glycemic Control 12 Months After Diagnosis

 To identify predictors of residual beta-cell function and glycemic control within a year of the diagnosis of type 1 diabetes (T1D).

 Residual beta-cell function at 12 months was best determined by younger age, ketoacidosis at diagnosis, and insulin antibodies and glutamic acid decarboxylase antibodies (GADA) 1 month after diagnosis, while glycemic control at 12 months “was influenced predominantly by ethnicity, HbA1c at diagnosis, and GADA at 1 month.”

This extensive guide to Victoza will provide physicians with important information about this injectable medication, designated specifically for adults with type 2 diabetes. More than 15 topics are discussed, including indications and usage, dosage forms and strengths, use in specific populations, and more. The extensive safety information covers contraindications, adverse reactions, overdose, and non-clinical toxicology. The final section of the guide is dedicated to patient counseling and includes information about proper handling of Victoza, laboratory tests, and possible side effects.

Switching to Once-daily Liraglutide from Twice-daily Exenatide Further Improves Glycemic Control in Patients with Type 2 Diabetes Using Oral Agents

 To determine the safety and efficacy of switching from twice-daily exenatide to once-daily

liraglutide or of 40 weeks of continuous liraglutide therapy.

 Switching medications “further and significantly reduced A1C (0.32%), fasting plasma glucose (0.9 mmol/l), body weight (0.9 kg), and systolic blood pressure (3.8 mmHg) with minimal minor hypoglycemia (1.30 episodes/patient-year) or nausea (3.2%).” Among patients continuing with liraglutide, “further significant decreases in body weight (0.4 kg) and systolic blood pressure (2.2 mmHg) occurred with 0.74 episodes/patient-year of minor hypoglycemia and 1.5% experiencing nausea.” The authors conclude that “conversion from exenatide to liraglutide is well tolerated and provides additional glycemic control and cardiometabolic benefits.”

Enterovirus Infection Linked to Type 1 Diabetes

Researchers at the University of Insubria in Varese, Italy have discovered a significant link between enterovirus infections and type 1, or juvenile, diabetes. More than four-fifths, 80%, of the 112 children included in the study, all of whom had type 1 diabetes, also had evidence of enterovirus infection in their blood. Though the study did not reveal a causal link between enteroviruses and diabetes, the results are “in tune” with earlier studies that have suggested enterovirus infections are associated with diabetes, according to the researchers.

www.hcplive.com/endocrinology/articles/diabetes_and_enteroviruses

Glucose-regulated Protein may Be Responsible for Mucormycosis Infection in Diabetics

Researchers at the University of California, Los Angeles, have discovered data in mice that may explain why patients with diabetes, particularly patients who also have diabetic ketoacidosis (DKA), are so susceptible to mucormyosis. The researchers aimed to determine “the endothelial cell receptor(s) for fungi of the order Mucorales, the fungi that cause mucormycosis,” according to the 

article on the study. The team discovered that the glucose-regulated protein 78 (GRP78) may be “a novel host receptor that mediates invasion and damage of human endothelial cells by 

, the most common etiologic species of Mucorales.”

www.hcplive.com/endocrinology/articles/mucormyosis_and_diabetes

This collection of recent news items about diabetes discusses a number of topics, including the role of the pharmacist in reducing the costs of treatment and improving health outcomes, how calories and salt intake can increase the risk of retinopathy for diabetic patients, clinical updates from the American Diabetes Association, and more.

www.pharmacytimes.com/issue/pharmacy/2010/April2010/DiabetesWatch-0410

Current and Emerging Antihyperglycemic Treatment Options for Type 2 Diabetes

This paper reviews the complex nature of diabetes and the reasons why, despite 11 classes of medications, the disease can be so difficult to treat. Treatment goals, challenges, and specific medications, including glucose-lowering agents and incretin-based therapies, are also discussed.

www.ajmc.com/supplement/managed-care/2010/A252_10marDiab/A252_10marDiab_Current

We searched the Internet for diabetes resources so you don't have to.

The Net Guide: Diabetes

Inflammation and the Pathogenesis of Atherothrombotic Disease

Lipids Online, a site that compiles online atherosclerosis resources, features this slide set, which discusses the changes that occur to the arteries as atherosclerosis develops. The program reviews the schematic time course of the disease in humans, macrophage colony-stimulating factor and its role in atherosclerosis, other health conditions that may arise as a result of atherosclerosis, and more.

Individualized Comprehensive Atherosclerosis Risk-reduction Evaluation Program

To determine if an individualized approach to diagnosing and/or treating atherosclerosis will improve health outcomes. The intervention group will be asked about genetic and lifestyle information and participant education, and given imaging tests to track diagnoses, therapies, and treatment, while the control group will receive standard care for atherosclerosis.

Contribution of Dietary Intakes of Antioxidants to Homocysteine-induced Low-density Lipoprotein (LDL) Oxidation in Atherosclerotic Patients

To determine the contribution of dietary intakes of antioxidants to Hcy-induced LDL oxidation.

Although plasma levels of homocysteine and LDL were higher in patients with atherosclerosis, plasma apo A-I in HDL and folate were lower. The researchers conclude that, although high intake of antioxidants seemed to be protective against atherosclerosis, “more evidence for the benefits of B vitamins as a homocysteine-lowering therapy is needed.”

Dysfunctional High-density Lipoprotein and Atherosclerosis

To examine practices that may reduce dysfunctional highdensity lipoprotein levels, previously identified as a negative risk factor for atherosclerosis.

Dysfunctional HDL “may be returned to normal by diet, exercise, degree of fat intake, and pharmacologic approaches,” the authors conclude. They also note that “orally active mimetic proteins are in development and have shown clinical promise.”

Increased Cardiovascular Disease Risk in Type 2 Diabetes: Pathophysiology

As cardiovascular disease is the major cause of death in patients with diabetes, the authors of this activity cite the importance of understanding “the pathophysiologic mechanisms that accelerate atherosclerosis in diabetes” and treating patients “early in the process of vascular injury.” This activity focuses on these topic areas, with the educational objectives of enabling physicians to “summarize the abundantevidence for increased cardiovascular disease in patients with type 2 diabetes; discuss the mechanisms of vascular injury in diabetes, emphasizing the visceral adipocyte and its role in causing the metabolic syndrome; and discuss and expand the concept of “global” risk management.”

Designed for patients, this video from the US Against Athero organization provides an interactive, narrated explanation of atherosclerosis, the risk factors, and how patients can help themselves fight the disease once they are diagnosed. It also reviews comorbid conditions, like high blood pressure and high

cholesterol, that can contribute to atherosclerosis.

Clinical Utility of CRP in Atherosclerosis

The Doctor’s Channel currently features a “Best Practice Series in Atherosclerosis” collection of videos, designed to provide visitors with interviews from “top physicians” as they discuss “the best ways to diagnose and treat atherosclerosis based on the most recent key findings.” Check out this video, which focuses on C-reactive protein testing and its value and prevalence in regard to atherosclerosis, and the other related videos in the series.

Direct your patients who have just started on Lipitor to this site for a wide range of information. The site discusses how Lipitor works, the proper way to take the medication, and potential side affects. The section on talking with a physician will remind your patients about important information to share with you and help them have an active role in their treatment. General overviews of heart disease and high cholesterol will help patients understand the importance of treatment and adherence to medication regimens.

Evaluation of Atorvastatin on Atherosclerosis Composition

 To examine the impact of atorvastatin on the coronary atherosclerosis plaque morphology.

Texture Analysis of Carotid Artery Atherosclerosis from Three-dimensional

To evaluate the impact of atorvastatin using multiclassifier image texture analysis tools.

 The researchers used a number of factors to evaluate images. Based on these factors, “the texture techniques that most differentiated between atorvastatin and placebo classes were Fourier power spectrum and Laws texture energy measures. The average classification accuracy between atorvastatin and placebo classes was improved from 57.22 +/- 12.11% using VWV to 97.87 +/- 3.93% using specific texture features.”

MRI May Enable Clinicians to Identify Dangerous Atherosclerotic Plaque in Coronary Arteries before they Rupture

Researchers at Boston University School of Medicine have shown that magnetic resonance imaging can non-invasively identify dangerous atherosclerotic plaques in the coronary artery and other vessels, a finding that would allow physicians and patients to initiate preventive measures “before thrombi begin to clog arteries and cause stroke or heart attack.”

www.hcplive.com/cardiology/articles/MRI_atherosclerotic_coronary_plaque

New Medication Reduces Leukotriene Production Following Acute Coronary Syndrome

Patients who suffer from acute coronary syndrome (ACS) are at an increased risk for another ACS attack. According to study results from the Montreal Heart Institute, a new medication, 5-Lipoxygenase Inhibitor VIA-2291 (Atreleuton), reduces leukotriene production following ACS. Leukotrienes have been linked to unstable atherosclerotic plaques and cardiovascular events, and the researchers hope that the new medication will reduce the rate of repeat cardiovascular events.

www.hcplive.com/cardiology/articles/leukotrienes_and_ACS

Your Patients May Be Asking about Aortic Valve Replacement—Top 10 Patient Education Sites

Barbara Walters’ recent surgery to replace a faulty aortic valve may lead some of your patients to ask about stenosis, aortic valve replacement surgery, mitral valve regurgitation, and other related topics. We’ve compiled a list of the top 10 online educational resources for patients who want to know more about these topics.

www.hcplive.com/cardiology/articles/top_10_aortic_valve

Medical Care Costs among Patients with Established Cardiovascular Disease

Researchers investigated the direct medical costs among patients with established cardiovascular disease through an observational longitudinal cohort study published in 

www.ajmc.com/issue/managed-care/2010/2010-03vol16-n03/AJMC_10marNicholsWebX_e86to93

We searched the Internet for atherosclerosis resources so you don't have to.

The Net Guide: Atherosclerosis

Before I launch into this month’s topic, I would be remiss if I failed to acknowledge the technological phenomenon sweeping the nation this spring. I am speaking, of course, about the “magical and revolutionary” iPad, which hit stores April 3 and almost immediately altered the course of history as we know it. Or so the hype would have us believe.

Don’t get me wrong: the iPad is a cool new device, but its applications to this point don’t seem as absolutely essential as its proponents would have us believe. So, while the rest of the world focuses on the iPad, I’m actually more interested in another recent development that might end up having just as great an impact on all our lives: flexible screen technology. I know, it’s not nearly as sexy as whatever the latest iThingy is, but trust me, if you haven’t heard about flexible screen technology yet, you will soon.

That’s because the latest research indicates that flexible and even “rollable” displays, a space-age concept touted for years in movies like 

series, are actually just around the corner. Imagine computers that can be folded up and put in your pocket, televisions that can be bent to view, and of course, cool new tools for your practice.

About two years ago, a company called Polymer Vision introduced e-Readius, an e-reader with a five-inch diagonal flexible screen, sporting a 320x240 resolution in 16 shades of gray. I haven’t used one myself, but the company claims its proprietary active-matrix electrophoretic display is as thin and light as paper, cannot be torn or broken, and can be rolled or folded into something as small as a finger.

Unlike the iPad, this product has not yet grabbed the public’s attention, which is interesting since it would be a boon to those who now get their daily news fix by scanning the headlines on an e-reader but miss the way they could roll up their old newspaper to swat a fly or smack their dog.

Looking further out into the future, Organic LED (OLED) may be the ultimate winner of this race. OLED is a light-emitting diode (LED) whose electroluminescent layer is composed of a film of organic compounds. The LED backlighting required by conventional liquid crystal displays (LCDs) is rigid, expensive, and complex to manufacture. On the other hand, OLED displays are easier to manufacture, more flexible and, as an added bonus, consume less energy.

That’s why industry giants like Sony, Samsung, and Kodak are all devoting significant time and money to the development of flexible OLED display screens. In October 2008, Samsung showcased the world’s thinnest OLED display, which was also the first to be bendable. It measured just 0.05 mm (thinner than a sheet of paper) and triggered a rumor that Apple would be using this OLED technology for their iPad.

The reality is that glitches, such as size and resolution limitations, and the difficulty of structuring the organic compounds so they won’t distort when bent, have kept designs from actually coming to market. But with the recent strides made with rollable displays (which, unlike the OLEDs, are enabled by plastic electronics rather than glass), we could be closer than ever to using these technologies in our everyday lives.

Practically speaking, the benefits of these flexible screens are boundless. Imagine, for instance, an EHR device as thin as paper, which can be as large as necessary, then completely rolled up or folded away when not in use. By closely mimicking paper, an EHR on this type of device might be more natural for many physicians to use during a patient encounter than a conventional PC or laptop. This may finally render obsolete the traditional paper chart, with its illegible writing, limited dynamic information, and all-round general unwieldiness.

I, for one, cannot wait for the day when I no longer have to lug my laptop around. And that is why I’m more excited about this developing story than the iPad which, frankly, is simply regurgitating existing technology (the iPhone) in a clever looking new package.

(Disclosure: I don’t have enough Apple stock.)

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Professorof Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Columns

Dr. Bertman discusses flexible screen computers.

Flexible Computer Screens May Soon Be Ready to Roll

spoke with Jay Parkinson, MD, back in May 2008 about the inadequacy of physician quality ratings, his high-tech practice management start-up Hello Health (

), and the importance of centering medical practice around the wants and needs of the patient. We spoke to Parkinson recently to catch up on developments with Hello Health, learn what new ventures he’s involved in, and discuss his ideas on how to effectively improve the healthcare system.

When we last spoke you said, “Much of the downfall of healthcare is that it’s been taken out of the community and made very impersonal.” What steps have you, and Hello Health, taken to remedy this issue, and are you seeing a change?

I left Hello Health full-time about five months ago; basically, I got it started and turned it over to my co-founder, Nat Findlay, and he and the team that we built it with are executing that right now. I pop in every once in a while, but other than that, they’re building up the company. The entire goal was to essentially give doctors the freedom to practice as they wish, so everything was designed to be fully customizable for doctors. They could go in and choose whether they offer videos or IM services, as well as how much they charge—if they wanted to charge $50 a visit or $1,000 a visit, they could do that. Even more importantly, it was designed for the patient to have their own health profile with people who can help solve their medical problems.

Did you leave Hello Health to pursue other ventures?

Yes, I started another company called The Future Well (

). It’s a really interesting company that’s just getting started. It is a company with three partners right now: myself and two others. [One is] Grant Harrison, a legend in the business world, because he built something called the Tesco Clubcard. Tesco is the second largest retailer in the world, behind Wal-Mart, and it’s based in the UK. We all go to Walgreen’s and we have our digitally tracked buying cards; he created that concept, and rolled it out in Tesco. I know the profit was about $300 million in the first year. He then thought that if you could engage loyalty in a retail space, you can engage consumer loyalty in a health space, and started Virgin Health Miles, which is a B2B company, part of the Virgin Richard Branson enterprises, but it rewards employees with Virgin mileage for good health behaviors. And then he left that and was the head of innovation at Humana. So, he and I found each other while I was working with Humana and just hit it off. Then Tim O’Reilly’s people hooked me up with Scott Switzer, who’s the third partner. He started a company called OpenX, which powers about 25% of the ads on the Internet. So, we take consumer loyalty and health innovation, and the creative doctor perspective, then add in some Open Source legendary data technology development, and that’s The Future Well.

We’re basically working with large brands, a few large companies, to sort of go for scale. Hello Health was a grassroots, ground-up revolution in the doctorpatient relationship, and now we’re working with large health players to help them create things that people love within the health space. For example, can we work with 180,000 people in New York to develop a healthcare system that changes how doctors are paid and how 180,000 people experience healthcare? We’re working with a group of 180,000 people to really design a healthcare system as if it were founded today with today’s causes and ways of doing business.

How has “Obama care” affected Hello Health, for better or worse?

Obama care is just health insurance reform. It’s not solving the access problem or the “let’s innovate how to pay doctors better” problem. So, when you add 35-50 million new people to the insurance pool without adding the same amount of doctors to cover them, you’re going to have huge access problems. Combine that with the fact that health insurance premiums double about every 7-8 years, and it’s easy to see they’re not fixing the cost problem. That’s going to push more and more highdeductible plans onto patients, and patients are going to be responsible for the first, say, $5,000.

Hello Health, I think, is the perfect key player in helping manage people’s first $5,000. In a sense, I think that Obama care, if you want to call it that, is sort of an ally with Hello Health, because if doctors can partner with their patients to let patients decide how they pay their doctors—do they pay them just for office visits or do they also pay them for communication&mdash;that’s an interesting problem to have. I think Hello Health enables that to happen. Doctors can get paid better not just for office visits but for e-mail and IM communication by the hour. And the doctor can get X amount of dollars per hour. If he can find the patients that are willing to pay that, then more power to that doctor.

What would Hello Health get out of that relationship from a physician that’s part of Hello Health?

Right now, it’s a certain percentage of the transaction.

Along with that, they get all of the support from Hello Health?

Right. That’s exactly what Hello Health is offering: customer support, like the technology support, as well as marketing support to help people market their practice.

Two years ago, you told us that success for you “would be that people start valuing healthcare and the doctor-patient relationship again.” Do you see that happening, or at least starting to happen?

I do. I think that doctors, fundamentally, need to change their offering away from just using pills and scalpels to more holistic care—things that actually help the real problems that people have. For example, when is the last time a doctor asked how much a patient makes for a living? That should very much influence whether that doctor prescribes a branded or generic medication and how he works with patients to help them create solutions that make sense for their lives. If you work with patients to create personalized solutions for their lives, rather than just say “here’s a pill” or “you need this procedure,” then the care is more about the relationship; it’s more of an understanding of the patient. If you understand the patient, then I think you can create better solutions for them.

Why not, even if a patient can afford the brand, give them the generic if it works just as well?

I 100% agree that that’s what should happen. Why is Lipitor the number-one drug in America, when there’s a perfectly good generic that’s $40 per month instead of $140 per month? It’s because doctors do not understand how much things cost. Within Hello Health, we’ve built it out so there’s a price tag next to every order, so doctors are knowledgeable about how much things cost.

The Hello Health model seems to be great for physicians who join, as well as the patients who accept the model. What happens to those patients who can’t afford, or are uncomfortable making the transition from a “regular” practice along with the doctor, thus compounding the primary care provider shortage? And what options does the physician have if he can’t keep or recruit enough patients who are willing and able to pay cash for their healthcare?

I think that we’re going to see, in the next few years, a large transition to more high-deductible plans, meaning that people are going to be forced to pay cash. You also have to look at how people use healthcare: 90% of Americans consume only 20% of healthcare resources. That means 10% of people consume 80% of healthcare. So, Hello Health is a perfect solution for 90% of Americans. If you combine those sort of services with the high-deductible plan—because the vast majority of Americans don’t meet their deductible&mdash;to me, it’s just an issue of creating a service that people love and engaging them with the brand and the concept. It’s not for every doctor and it’s not for every patient. That’s the end of the story, really. If you asked Apple to create a product that solved everyone’s problems, they’d fail pretty miserably. For Hello Health, it’s a matter of defining who their customers are in terms of doctors and patients and then creating something awesome.

How do you feel that the general doctor community has reacted to Hello Health?

I’m not really concerned with the general doctor community as much as I’m concerned with the doctors who get it. The doctors who get it embrace it and want to do it—how can we focus 100% on the product and how can Hello Health build something that they love? And they will serve as sort of the early adopters/evangelists. I was one of the first in line to get the iPhone, and it took about two or three years, but my parents now have an iPhone. It’s essentially a similar concept.

Is it too early to get a feel for the acceptance of The Future Well?

The Future Well, I think, is absolutely being accepted, but it’s a totally different concept. It’s a B2B sort of play. At the same time, Scott is working on an intelligent triage product, and that’s going to be our first product that we release. There are a ton of people out there who at 10:00 on a Friday night have belly pain and don’t know what to do. Well, there are triage lines that have existed for 30-40 years that have established protocols and evidence behind them. How can we bring that to the Internet, and how can we say, “These are some of the symptoms you’re describing, it sounds like an emergency, you need to go to the emergency room,” or, “You know what, you can wait 24 hours, here are four really amazing gastroenterologists that we know and love in New York City”? We don’t want to give them a list of 900 gastroenterologists, because that just overwhelms people.

The Future Well is also going to give patients some clues about how much things should cost, like “this is how much the average visit to the gastroenterologist should cost,” “this is how much the top 20 tests they offer cost,” and “this is how much the top 20 medications that they order cost.”

What makes Hello Health the model for salvaging our healthcare model, or do you not believe that it is?

No company can create a solution for poverty or the world’s problems. I think this can be a solution for access. I think it can also be a solution for stimulating or prodding the traditional healthcare community to innovate their services and offers. Apple, for example, came out with the iPhone, and now everyone has one. You wouldn’t buy a touchtone phone anymore; it would have to be touch-screen. There’s always going to be someone innovating what healthcare is, what it means, and how it’s paid for. I think that’s Hello Health’s role. I’d love to see it take off as essentially a secure Facebook for healthcare that gives doctors and patients the tools that they need to solve problems and get paid for them.

How would an interested physician get started with Hello Health, and what’s keeping him from going the direct-pay route on their own? What about becoming a member of another concierge/VIP medicine—type system?

It’s great that everyone has options. If they go to HelloHealth.com and poke around on the website, contact the guys there, talk to them, see what their offerings are, and choose Hello Health, that’s great. But, at the same time, I think it’s healthy that we all have options and competition. The most important thing is that doctors find what’s right for them.

What are you looking to tackle with The Future Well?

If you could view healthcare as a design problem, that’s sort of the problem that The Future Well is trying to solve. You look at healthcare over the past 100 years and you realize that it just sort of sprang up, and in the center of everything was the doctor’s time. But, nowadays, you can think of that process of healthcare delivery as a design problem. Apple sort of designed a whole ecosystem around their iPhone. That’s the kind of problem I’d like to look at with The Future Well. How do you design these processes, how do you design beautiful services that people love, and how do you design loyalty programs into healthcare, so that people have an incentive to embrace a healthy lifestyle?

We spoke to Parkinson recently to catch up on developments with Hello Health, learn what new ventures he's involved in, and discuss his ideas on how to effectively improve the healthcare system.

Jay Parkinson Says "Goodbye" to Hello Health

This month, our physician reviewers share their experiences with two apps they recently had the opportunity to review.

MedCalc is a free, physician-developed medical calculator featuring more than 100 calculations, support for US and SI units, “formulas within formulas,” and a unique translucent floating keypad for data entry. The “formulas within formulas” feature links to medical calculations that require results from another calculation (such as the APACHE II score requiring the results of the Glasgow coma score) in such a way that users do not have to copy and manually enter the results in the main calculation. The floating keypad is always on screen, but nearly transparent. The keypad becomes fully visible when tapped and will advance the data entry focus in the formula when swiped to the left or right. This floating keypad feature may be frustrating to some users.

MedCalc maintains a history of previous values entered for each calculation, which is helpful for repeat calculations on the same patient. The app also includes detailed information about each calculation, including links to primary source articles.

MedCalc is an excellent addition to the iPhone of any healthcare professional who uses scoring systems to assess the severity of illness or uses medical calculations.

One of the first apps I recommend to new iPhone purchasers is a replacement for the calendar app that comes with the iPhone, as most busy professionals find it to be too simple and inflexible for their needs. There are quite a few potential replacements out there, but I consider Informant to be the most feature-packed and flexible, and it’s well worth the $12.99 price tag for the full version (Pocket Informant Lite is available for free).

In terms of sheer aesthetics, Informant allows for multiple views, including Day, Week, Month, and also a unique List feature that allows for scrolling through upcoming appointments and tasks. The app also changes its view when the iPhone is rotated to landscape mode, providing an alternative way to look at the entire week. To-do tasks are integrated into the calendar, and there is great flexibility in how one can categorize and prioritize them; Informant also provides support for the Franklin-Covey ABC/123 method, which is what I use.

The To-Do feature allows for synchronization with Google Calendar, providing a cloud-based solution and the ability for multiple users to synchronize to a single calendar and coordinate schedules in real-time; the feature is a great way for work colleagues or even family members to synchronize appointments and events. Each user can select when he or she wants to view the ‘shared’ calendar, and can even create a local, ‘private’ calendar that others cannot see. This solution also allows one to pull up the same public calendar from a Web browser an make changes.

One of the major disadvantages is the lack of To-Do synchronization with Google’s To-Do. Informant uses a second application, Toodledo, for synchronization of tasks if one wishes for a cloud-based task solution. I opt to keep task synchronization off, which still allows for full functionality.

Settings are quite detailed and allow for an enormous amount of customization, and even the most demanding organizers will find satisfaction with this. Informant also takes advantage of push notification, allowing users to set alarms for to-dos and appointments without the application running. The integrated search function is robust, and necessary, since the iPhone’s innate search function cannot ‘see’ into Informant.

I highly recommend Informant for demanding and busy people who expect a lot from a calendar app. Outlook and previous BlackBerry users will feel at home with the high  degree of control provided with Informant.

From the HCPLive.com Network Partner iMedicalApps

The First Native iPad Electronic Health Record — An Interview with the Dr. Chronos EMR Development Team

The American healthcare system is finally on the road to a modern national IT infrastructure. Recently, the iMedicalApps team had the opportunity to speak to a small but ambitious group of IT professionals who aim to be at the forefront of this  modernization by targeting the physicians with the lowest penetration of electronic health records, those in smaller private practices.

Should Medical Professionals Get an iPhone, Blackberry, or Android Phone? It's

Lately, I’ve often been asked the question, “What type of smartphone should I get?” by my medical peers. I’ve been asked this by physicians, residents, medical students, and others. The answer to this question is not easy. Rather, as Facebook nomenclature would demand, “it’s complicated.”

App Wrap

Cloud computing—along with its close technology cousins, SaaS (Software-asa-Service) and ASP (Application Service Provider)&mdash;is all the rage. It seems like every healthcare software vendor is throwing around these buzzwords, as if they are the Holy Grail of healthcare technology. Typically, the advantages touted include the following:

• Eliminate all local computer software

• Reduce the risk of hardware and/or network outages

• Lower cost of installation and maintenance

• Easily scale to virtually unlimited computing horsepower and storage capacity

While all of those advantages are technically somewhat true, most of them are an oversimplification, and there are also significant risks and disadvantages associated with this technology.

Cloud computing has applicability in many, but certainly not all, business and technology settings. And for many healthcare organizations and physician practices, it’s the wrong solution.

It is IT outsourcing on steroids, and in many ways, it is merely a new name for technology that has been around for a long time. Back in the dot-com boom in the late ‘90s, there were many technology hosting companies that developed service offerings, and they coined the name Application Service Providers—or ASPs. But it goes back even further, to the early days of mainframe computers, where large companies like Boeing Computer Services and Computer Science Corporation had the means and resources to build large-scale computer centers, and smaller companies would purchase blocks of CPU time and other services. This was known as time sharing (not to be confused with vacation properties); so cloud computing is not really new.

What are the risks and disadvantages of SaaS/ cloud computing?

When faced with the one-time costs of a new server/ storage/networking platform, a smaller, pay-as-you-go monthly number might look appealing to a medical practice considering an EMR or new practice management system. But while cloud computing may offer users the advantage of quick start-up, some have found that investing in your own IT platform is a better value in the long term. Depending on your level of use, you can typically hit a break-even point between nine and 18 months; beyond that time frame, the monthly costs of the SaaS/Cloud model can be much higher. And even after paying the monthly fee for 24 months, you still don’t own anything and have to keep paying every month.

If monthly cashflow is an issue, a three-year, lease-to-own model provides roughly the same monthly payment amounts, and when the lease ends the payments also end, and you own the equipment free and clear for another 1-2 years of its useful life. Over time, investing in your own equipment costs far less—provided there are no major issues with the equipment.

There are still significant technology risks

In fact, in some ways SaaS/cloud computing risks are greater than having your own equipment. For example, with a typical client/server setup in your own office or clinic, if you lose your Internet connection you can still work, although you may lose some functionality. With SaaS/cloud, what happens if you lose your Internet connection? Are you able to save your work on a local hard drive if power is lost, then upload to the cloud when it is restored? This is the type of question you need to ask a provider if you’re considering going the cloud route.

That round blue cable in your clinic is called Ethernet, and it runs at 100 Megabits per second (Mbps). A T1 circuit, which is a fairly standard broadband Internet connection, runs at only 1.5 Mbps, or only 1/60th of that speed. Plus everyone in the office must share the T1, whereas every workstation gets 100 Mbps on your local Ethernet network. So the response time for your SaaS application may be very slow. This is particularly critical for EMR, PACS, and digital images, where a single patient study can easily be 100 Megabytes. The SaaS provider may show you fast response, but that is a demo. And they may tell you of the many happy clients who are using their service today, but since SaaS is relatively new, in our experience we’ve found that most of those customers are not fully using their applications across their whole clinic, and probably don’t have many years worth of business and clinical data loaded into the system yet.

When you ask this question of the provider, they might glibly reply that it’s “in the cloud.” Well, what, exactly, does that mean? They all say they have it secured in some kind of Fort Knox-type data center somewhere, but we have seen many of those so-called data centers, and some are just glorified offices with computers and other gear lying around literally on the floor. And what happens when you want to get your data back, either at the end of your contract, or earlier? Are you comfortable with not only putting your trust in the service provider’s software, but also irreversibly linking your vital business and clinical operations—and giving all your data&mdash;over to them? If not, this is something that needs to be ironed out before you agree to anything.

On top of that, you’re trusting not only your SaaS/Cloud provider, but also its choice of hardware and implementation vendors as well. Recently there was a case of a large national cloud provider losing the data of approximately 7,500 customers (

). The company sued its hardware storage vendor and its IT implementation vendor. But that did not do anything to get their clients’ data back. Is your data really safe? What if someone at your Cloud/SaaS provider —or an outside hacker&mdash;decides to get the data and sell it or use it inappropriately? There have been stories of internal IT staff stealing client data from an online service provider, and external hackers breaking into large corporate databases (4.2 Million Credit Card Numbers Stolen From Supermarket Chain; 

,and Heartland Data Breach Could Leave100 Million Accounts Exposed; 

). What’s to prevent that from happening to your data? No company can totally prevent data loss or theft, but by putting your data with your provider, you are assuming they are taking all the necessary steps to keep your data safe. Before you commit to a SaaS/Cloud service provider, you should investigate everything possible about their operations; obtain detailed information about the company’s security system, including how often tests are conducted.

You can only get the software that your provider gives you, and on their release/rollout schedule.

All software has updates and new releases. When you control your own IT destiny, you can decide when—and even if&mdash; you want to migrate to a new software release or do a technology upgrade. If someone else is providing IT as a service, you only get what they offer you, and the schedule is based on their timeframe. We know many clients who have developed their own report and interfaces based on a certain software platform (SQL Server 2005, for example). They had invested a lot of time and energy, and they did not want to automatically upgrade to SQL 2008 when it first came out, because their reports and interfaces would not work with SQL 2008. If they had been using a SaaS provider, they would have had no choice.

When there is an outage, where do you stand as far as restoration is concerned?

If you share an IT platform that is also used by United Airlines, the city of Los Angeles and Pfizer, who is the service provider going to get back up and running first? You may be much lower on the pecking order than you think. There may be service level agreements (SLAs) that give you some future credits for outages, but that doesn’t do much to help your with the operational costs of the outage and its impact on your clinic. And these outages are more common and more widespread than you might think. Some of the largest SaaS/Cloud providers have suffered multiple major outages, including Google’s Gmail (Gmail Outage Marks Sixth Downtime in Eight Months; 

) andBlackBerry (BlackBerry Outage Not Winning Any Fans for RIM; 

You May Already Be Using Cloud Computing!

These services, which you might already be using, take advantage of cloud computing:

): So, Google has quite a grasp on the cloud computing

market. Gmail allows for less spam, mobile access, and virtually endless storage.

More than one technology pundit has claimed that desktop software and computing that relies on local servers is on life support, soon to be replaced by an Internet-based approach that relies on a "cloud" of applications and virtual resources that are delivered over the Web
via your browser. Are proponents who want to apply this concept to EMRs correct when they say that this is the future of health IT, or do they have their head in the clouds?

June 2010

The Net Guide: COPD

The Net Guide: Diabetes

The Net Guide: Atherosclerosis

Flexible Computer Screens May Soon Be Ready to Roll

Jay Parkinson Says "Goodbye" to Hello Health

App Wrap

Cutting through the Fog of Cloud Computing

Check-Up

Digital Socialism and the Power of "No"

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