When my oldest daughter was in third grade, she and a friend decided to attempt to determine the sex of her friend’s pet gerbil, Fluffy. This was a complicated task for two eager 7-year-olds, literate for their age but still new to the game of Internet searches. Determined, these two young biologists sat at a computer with Fluffy in one young hand and a book called “Gerbil: Your Guide to Care” in the hands of the other while both stared at the computer screen awaiting the results of the recently typed in query: “finding the sex of a gerbil.”

After a few minutes searching online, my daughter emerged with a question: “What does elongated mean?”

If she had been a true “tween” or teen, this question could have been alarming, but we took it at face value given her age and the task at hand and answered it with a simple definition: “it means to become long.” Since boy gerbils do have a long line near their genitalia, the kids deemed Fluffy must be a boy. Us adults were not so sure given the description but were so impressed by their determination to confirm Fluffy’s gender and their use of the Internet, we decided Fluffy, the boy gerbil, would be happiest as a bachelor… just in case!

Fast forward nine years; these kids are now almost 16 and much more online with more complicated searches, heavy social media involvement, and cell phones basically glued to their hands. They use peers for information, including about health issues, and their interests and life experiences drive their searches. But they don’t search like we do. They do quick searches and basically stop after the first page or so. Remember, these are teens, and they are about the here and now. They want information quickly, and once they find answers that read ok, they move on. They don’t think about issues of reliability like we do. Actually, adults don’t think much about issues of online reliability either, but teens think about it even less!

The Pew Internet and American Life Project documented the teen e-patient experience in 

 and reported that 1/3 of teens age 12-17 years are hunting for health information online, with 17% seeking information about “sensitive topics,” such as drug use, depression, and sexual health. In 

, Pew Internet and American Life Project noted that only 15% of health information seekers check the source of their information online!

Why is this important? Teens are very likely to find misinformation online and more likely to buy into that information than adults because of how they are wired. Because a participation gap still exists with many parents, parents may not know that their teens are searching for health information online, or what they are doing online to begin with.

While our job isn’t to teach our families the technologies themselves, it is our job to be sure they become e-health savvy, because that directly impacts their health and wellbeing. The younger our patients are, the higher the stakes if faulty online health information leads to a poor offline health decision, so we truly can’t ignore this responsibility or assume someone else will pick up the slack.

Before you panic and start to worry that adding any more to the visit will shortchange other important areas, what I’m suggesting won’t add more time at all, but save you time. By asking your patients about their “Dr. Google” experiences, you’ll become more efficient and have more effective conversations about what is really on your patients’ and their parents’ minds. You’ll be better able to address the true health issues and debunk the myths, as well as dispense a few pearls about where to get more reliable health information next time they embark on an online health hunt.

For a more in-depth e-health discussion, you can use your online health venues, social media platforms, blogs, websites, and newsletters to post tips, articles, and lists of links to help guide your families to healthy online search practices. When  you do, be sure to address the following points:

1. Finding accurate information online: Websites and blogs you recommend.

3. What makes an author reputable and an expert? Patients don’t often look at credentials or realize that some sites use MD authors, whereas others are writers quoting MDs or other experts.

4. When should a parent or teen call you instead of searching Dr. Google?

We tell parents to model good behavior for their kids. If we model good online health literacy behavior for our families, we’ll be providing a service that will go a long way to ensuring they have a safe and healthy future.

Articles

Columns

Dr. Gwenn examines the impact of the Internet on teenagers' understanding of health issues pertinent to them and how a teenager's use of the Internet for information differs from a physician's.

Social Media Notebook - Mining for eHealth Information and Striking Gold: How Do Teens Fare?

My kids might not believe this, but I’ve never been a particular fan of the phrase “I told you so.” Probably because it’s used mostly by people who are more concerned with thumping their own chests than with imparting any valuable wisdom that could be gained from the fact that they were actually proven right over the course of time. But in the wake of the recent announcement that 

 is “discontinuing (its PHR) service," and the continued struggles of Microsoft and Google to launch their own PHR products, all I can say is... sorry... I told you so.

Back in the spring of 2008, when Revolution Health, along with Microsoft and Google, was ramping up its efforts to jump into the PHR game, I greeted 

 with a gigantic raised eyebrow. While much of the media were fawning over the new services, I was, as it turns out, justifiably skeptical.

Part of the problem is that consumers (aka, our patients) have simply not shown much interest in using PHRs. Google and Microsoft may point to surveys that say 78% of US adults want PHRs, and even 26% are willing to pay for them, but wanting them and spending the time it takes to actually create them are two entirely different things. If you don’t believe me, just ask the folks over at Revolution Health, whose “revolution” has gone belly up thanks to the disinterest of the public at large.

In fairness, Microsoft has made strides recently toward making 

 more accessible and user-friendly, but even this progress doesn’t address my biggest concern with the current state of PHRs: the real cost in time, energy, and legal risk to physicians who would be responsible for knowing what’s inside the patient’s PHR.

My feelings today remain as strong on the subject as they were two years ago. It’s not that I don’t see a future for people having and keeping their own health records; I just refuse to be a part of it until a reasonable compensation plan is determined that makes it worth my time, energy, and medico-legal liability.

My fear is that physicians who know of the existence of a patient’s PHR will be liable if information appears within it that the physician didn’t recognize and/or act on. Let’s say, for example, the PHR notes a complaint of chest pressure (perhaps related to congestion from a recent cold), or some history of a potential cardiac issue that the patient has never  spent time discussing during an actual visit. Simply put, the physician will end up screwed if that patient happens to have a heart attack at some point in the future. Of course,  the patient is screwed too, but a malpractice lawyer will make this appear to be the physician’s faultâ€‘â€‘ something that could have been avoided had the physician followed up or adequately addressed the information “clearly provided within the PHR.”

Without adequate compensation for this very real risk, let alone reasonable compensation for whatever time is spent evaluating the issue, physicians will be placed in a very precarious position where PHRs are concerned. Don’t forget we’re already forced to squeeze in more patients in less time just to pay our ever-expanding overhead. Imagine if we now have to start reviewing PHRs in the course of our day? Insurance companies will do what they have done time and time again: consider it “standard care” and say this is part of what they already pay through reimbursements of E&M codes. Spending the appropriate amount of time to adequately review and understand a patient’s PHR requires adequate compensation beyond current office visit codes.

So, while I firmly believe that healthcare will someday certainly include PHRs, for the time being, physicians should adamantly refuse to be cajoled or drawn into being involved with any part of them without a clear understanding of how our time and energy will be compensated. If we do start  working with PHRs before the system is fixed, I may be forced to utter another “I told you so” somewhere down the line.

Trust me, that would bring me no pleasure.

The recent announcement that Revolution Health was discontinuing its  PHR service should not have surprise anybody who has been paying attention to this market. Patients have been apathetic at best to this technology, and physicians have wisely steered clear out of concerns over time, reimbursement, and liability issues.

Tech Talk: Personal Health Records: A Failed Revolution

The healthcare reform laws will increase the overall cost to our economy by much more than the Congressional Budget Office (CBO) projection of $1 trillion over 10 years. The CBO numbers do not take the big picture into account. For one, counting on the proposed half-billion-dollar cuts to Medicare to actually gain political support is unrealistic, because if history is any indicator, this will never happen. Just two years ago, President 

 was unable to push through cuts of $78 billion from Medicare over five years due to opposition from the very Democrats who now say we need a five-fold larger cut. Also, adding a large group of new Medicaid patients will overwhelm state budgets, which already cannot afford the current cost of providing care for the poor.

The ranks of physicians will diminish at the same time that the aging baby boomer population will produce an upsurge in the number of older patients who require care. It is projected that nearly half of currently practicing primary care physicians will reduce their patient workloads drastically or retire due to large cutbacks in their reimbursements, increased government bureaucracy, and the mandated use of costly unproven EMR technologies. The poorly funded 

 that have been proposed will further add to physicians’ business overhead costs and interfere with the physician-patient relationship.

The new healthcare system will place more power in the hands of non-physician bureaucrats who will decide what care will be offered to patients. The dark realities that age and cost will be the deciding factors in the new healthcare system will come to pass, with a loss of autonomy in deciding our own healthcare choices. The belief that “more care is better care” will clash with the typical European/Canadian style of rationing (http://bit.ly/9DQ0Xd). Those who have the means to do so will have to pay for “extra” care out-ofpocket, while those in the middle class will have to comply with the “

,” which is an apt phrase to describe the coming system in which denials of care will be even more frequent than they are now.

Tort reform and lobbying — follow the money

Under the recently passed healthcare reform laws, illegal immigrants are not explicitly entitled to healthcare, but since there is no method to reliably document a patient’s legal status, the number of illegal immigrants that end up being covered is expected to increase dramatically. Also, according to the 

, under immigration reform as much as $300 billion could be added to the new healthcare bill, rendering obsolete 

 to keep the cost at $970 billion over 10 years.

Tort reform, which is a politically polarizing topic, was virtually ignored during the run-up to healthcare reform. Without controlling the costs that physicians have to endure due to out-of-control lawsuitsâ€‘â€‘which inevitably leads to high-cost malpractice insurance premiumsâ€‘â€‘and without controlling the high cost of “defensive medicine,” the cost of healthcare will continue its rapid rise. The 

 last October estimated that tort reform alone can save our healthcare system upwards of $54 billion over 10 years.

The cost of medications will continue to soar; the pharmaceutical industry spent millions of dollars on lobbying Congress in an effort 

to avoid a Canadian-style pharmaceutical program

 that would see many medications cost up to 90% less than their American counterparts. In the second quarter of 2009 alone, pharma spent 

Don’t get me wrong—there are many good aspects of the newly enacted healthcare reform laws, but there are far more troublesome aspects that need to be improved if we want reform to be truly successful.

There are numerous reasons why the new healthcare reform laws will fail to improve our healthcare system.

The HIT Realist: What Effect Will Healthcare Reform Have on the Healthcare Crisis?

A prospective client (we’ll call him “Richard”) asked for my help with a difficult legal and financial problem. Richard is a physician. He earns a solid living, and a few years ago he purchased an office building that was leased by the state in which he practices. The lease had five years to run, but the broker assured him that the state had been a tenant there for 20 years and wasn’t likely to move. He bought the property for $2.5 million with an 80% loan. However, the state has now given notice that it will be moving out in a few months, and with no rental income from the property Richard won’t be able to carry the $15,000 monthly negative. What should he do? If he stops making the payments, the lender is likely to foreclose on the property, and obtain a substantial deficiency judgment. Richard’s personal savings and the equity in his home are subject to a collection action on the judgment and his 25 years of savings and hard work are certainly at risk.

This scenario is not unusual these days; I get several similar calls each week. In every case, the caller has purchased a business or a rental property and the income has dropped substantially over the last two years. The choice is whether to keep dipping into dwindling savings to make the payments, hoping to forestall a collection action for some time, or to give the property back now. In either case, substantial losses will be incurred, far beyond the initial investment.

In my experience, the failure to properly measure and plan for business risk often represents a greater and more realistic financial threat than any other source, including possible malpractice claims. These lapses in judgment are caused by a  combination of factors. When everyone is caught up in a rising market, the question of what happens if things don’t work out is rarely considered. Over-enthusiasm and optimism about a new deal seems to suppress some degree of critical, cautious thinking. It may also be true that the real legal and financial risks of a particular deal are not always completely understood, even by those who consider themselves experts in the field. For example, analyzing a real estate purchase requires a sophisticated understanding of financing, comparable rents, the quality of the location, and the credit risk of the tenants. A buyer without a thorough knowledge of this information is open to the wider risk of unexpected developments.

I’ve heard many people justify risk taking with the standard mantra that “big risks often produce big rewards.” Nothing could be further from the truth. In fact, those who are the most financially successful usually get that way by taking the least amount of risk, not the most. These financially gifted individuals are able to resist market exuberance and develop a high level of knowledge about each facet of a particular deal. It’s true that sometimes big risk-takers get rich. Luck can be a good short-term substitute for skill, but as a rule the big risk-takers end up broke (unless the government bails them out).

I’m certainly not suggesting that no one should ever go forward with a business deal simply because there are risks of financial failure. What I do believe is that whenever a new venture is planned, the degree of risk should be objectively analyzed. What is my risk of loss? How much can I lose if things go wrong or unexpected events materialize? Will I lose just my initial  down-payment or do I have liability for the full loan? Richard certainly would not have purchased the property if he had known that he could lose all of his accumulated savings.

Once the amount at risk is calculated, the question becomes “How well can I limit this potential loss through proper business structuring and asset protection?” Sometimes the purchase can be structured through the use of certain business entities to limit potential losses. In addition, it is usually possible to protect personal assets from the liability associated with a particular deal if the planning is completed at an early stage. Once the total amount at risk of loss is known, the issue of whether the deal is worthwhile from an economic standpoint can be intelligently addressed.

Big risks do not always produce big rewards, a fact that physicians and other high-risk business owners should always keep in mind when making financial decisions.

Covering Your Assets: Advance Planning Can Cut Liability Risks

With the ongoing uncertainty in the medical community over healthcare reform and reimbursement methodologies, many physicians are exploring other practice models, including a return to cash-only (in-part or in-whole), a full-service concierge  model, and the increasingly popluar hybrid model of concierge care.

These models are alternatives to generating revenue from third-party payers or volume-based care. Each is distinct in its approach and each utilizes technology to a different extent to enhance practice management and patient communication.

In addition to analyzing the pros and cons of new practice models, physicians must also examine their current approach and the technology requirements for practice alternatives. Many new models emphasize a more patient-centric approach to care. In these models, the technology needs to go beyond practice management systems designed to manage billing, electronic health records, scheduling, and reports to payers. In order for physicians to be successful under a patient-centric model of care, technology must help to better connect patients to physicians through channels such as e-mail and cell phone communications.

When considering new practice models, physicians must bear in mind several key issues:

• How much time will I need to allocate to communicate with patients under a new practice model? How will that impact other areas of the practice?

• How will technology help me deliver a better level of service to my patients?

• Will I need to invest money for new technologies?

• Will my patients utilize new technologies I offer, or are they more comfortable with traditional forms of communication?

Over the past decade, full concierge practices — in which physicians charge patients a fee in exchange for greater access and convenience &mdash; have become both popular and controversial. Full-model concierge practices require physicians to limit practice size to a few hundred patients who desire and can afford concierge medical care. Typical costs to patients range from $1,500 to more than $10,000 annually. Such practices provide benefits to physicians and participating patients. For physicians, they offer the revenue needed to survive, as well as a more manageable and enjoyable practice. For patients, concierge practices

offer convenience, and the chance for a more meaningful relationship with a trusted physician.

Technology plays an important role in full-model concierge practices. Patients want to be able to communicate with physicians by phone or e-mail, and they want that connection to be direct and almost instantaneous. Because of the limited number of patients

(or in some cases, the limited number of patients who utilize these technologies), cell phone and Internet communications are manageable for physicians, and often help facilitate a more meaningful dialogue. Conversely, most traditional physician practices, with thousands of patients on their roster, often do not have the time for this level of direct connectivity.

The full concierge model works well for physicians and for patients who are willing and able to invest more money in their health. Yet this model has raised considerable concern among many physicians, patients, and even legislators. Downsizing practices can result in thousands of disenfranchised patients. While such models do have a place in an open market, they limit the number of physicians available to care for patients who can’t afford treatment.

A number of traditional practices are using information technology to more effectively share and manage information. There are obvious benefits to having readily available, shareable, and accurate information; however, employing technology to manage data can build a barrier between the patient and physician. To that end, many traditional practices do not employ advanced communication strategies to enhance physician-patient contact, as despite the potential gains, the use of e-mail and cell phone communication with patients can interfere with handling large numbers of visits, some have found.

Cash-only primary care practices that do not participate in government and private plans are very few in number, but interest is growing. Although they often are more easily able to afford and implement electronic medical records (EMRs) and enhanced communications, they also have fewer active patients than regular practices and are not compelled to employ information management solutions. In this type of environment, the use of technology is a decision made purely on what works best for the practice.

A rapidly growing model, hybrid concierge, offers the benefits of a privately funded practice model with the ability to provide patients with choices regarding the style of care they wish to receive. Under this model, for an annual fee, concierge patients receive comprehensive preventive care and an annual physical, 24/7 availability to their physicians, and little or no waiting time for same or next-day appointments. Many physicians also provide cell phone numbers and make occasional house calls.

Physicians note that they appreciate the hybrid model because it addresses their professional and personal needs while keeping their patient panels and payor relationships intact. The balance of traditional volume care with a portion of the day at a much less hurried pace allows the physician an opportunity to deliver care in a more ideal environment, while still treating a wide variety of patients.

The most important difference between hybrid and full-model concierge practices is that the hybrid model enables physicians to continue to see all of their patients. Unlike full concierge and cash-only practices, the hybrid model does not detract volume from the physician. It encourages the continuation of participation in plans and the continuation of a relationship with traditional patients. Physicians remain in the system, accessible to all their patients, and patients are able to choose the model that best meets their needs.

As with the full concierge models, a hybrid practice features a membership structure where patients pay an annual fee for defined services and are part of a smaller pool of the physician’s total practice. Hybrid programs are typically a non-covered benefit under most traditional health plans and Medicare. However, many patients with flexible spending accounts and health savings accounts use that portion of their benefit to cover the fees as, with proper structuring, it is a qualifying expense. Concierge programs are attractive to Medicare patients or those with chronic and or complex illnesses, as the advocacy, advice, and enhanced services are often worth the out-of-pocket expense.

In a hybrid model, technology can be used both to enhance communication between the patient and physician, and to manage the huge volume of information efficiently through the use of EMRs. The primary role of technology is to properly manage the connectivity to allow physicians sufficient time to care for a reasonable number of patients. Concierge members in a hybrid program are generally given the physician’s cell phone numbers, a dedicated phone line at the office, and often, the email address of the physician, to enhance individual communication and service levels at the practice.

Physicians are encouraged to use smart phones that are updated with basic patient demographic information and connected to their EMR. When patients call, physicians can readily access their basic information, and make entries into the patient’s record if needed. In the hybrid program, patients average less than one cell phone call per day; which is manageable for most physicians.

The hybrid model also enables patients to utilize a portable device that houses their health information. While many patients are concerned about having their medical history on the Internet, most recognize that the ability to access basic information — particularly when traveling or in the event of an emergency &mdash; is an important benefit. It contains information such as name, age, health insurance, current medications, allergies, copies of the annual physical report, etc. Practices can add to or update their personal medical stick as needed when patients visit; it can become as robust as the physician and the patients desire.

Physicians considering adopting new practice models need to identify the goals for their practice and evaluate their own comfort level with technology and the needs of their patients. The key questions facing physicians considering new practice models are which one is best for their practice and their patients, and what role technology should play. Specific issues to examine include the following:

• What are my practice goals? (To see more patients; limit my practice patient load; spend more time with family; gradually transition to retirement; better manage current patients, etc.)

• Which of the practice models currently available help me reach my goals? A hybrid model could help a physician better manage existing patients and could also be used as a strategy to either grow or slowly decrease practice size over time.

• What technologies does our office currently use? If the practice has a practice management and EMR system, explore carefully the impact a new practice model will have on existing technologies. If not, look to see what new technologies would need to be acquired — from smart phones to software &mdash; to meet the model’s basic design.

• What do my patients want/need? Some older patients may have no interest in e-mail or Internet connectivity. If so, bringing on a program that forces them into that model could be detrimental. Look for programs that meet both your needs and the needs of your patients.

The goal for any medical practice today is to provide quality care to patients and maintain a financially stable practice. In today’s market, with reimbursements declining, overhead increasing and uncertainty over reform, reaching this goal seems elusive for many dedicated physicians. Looking at available successful practice model options — especially those that provide a private source of funding &mdash; and ensuring that technologies meet the needs of the practice and patients, will help physicians meet their goals and build a successful and enjoyable practice.

Cover Story

With a physician shortage looming and patients seeking more access to caregivers and a higher level of service, is a hybrid concierge model the answer?

May 2010

Social Media Notebook - Mining for eHealth Information and Striking Gold: How Do Teens Fare?

Tech Talk: Personal Health Records: A Failed Revolution

The HIT Realist: What Effect Will Healthcare Reform Have on the Healthcare Crisis?

Covering Your Assets: Advance Planning Can Cut Liability Risks

The Right Technology Is Essential for Physicians Adopting New Patient-centric Practice Models

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