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Nov 11, 2015 · Live Doc Q&A's on Facebook & Twitter in Strategy, Policy & Best Practices

I can only share what I’ve learned from Twitter participating in a lot of chats. It can be really engaging and may make you prone to forget it’s in the pubic domain. For one of the chats, we developed a tweet chat disclosure . I wrote up a post for SMHN on it :

What I have seen that I’m not comfortable with is when chats ask people that are lurking to tweet that they’re there. That serves the interests of the chat moderators, not the silent participants. It’s fine to encourage DMs to help those on the fence, that may be a way to still expand the active participant base without risking a violation of trust.

I agree with the comments above. We’re in a funny place using social media in healthcare. The privacy requirements are increasingly stringent in clinical practice when it’s become easier to share things and more people want transparency. But it’s simple. Nothing is private if it’s digital, so your reputation is what you tweet/post in any forum.

Nov 11, 2015 · Live Doc Q&A's on Facebook & Twitter in Strategy, Policy & Best Practices

Hi Ann:
There are three active groups on Twitter that involve patients, advocates and physicians. They have organized chats at regular intervals:

#bcsm for breast cancer
#lcsm for lung cancer
#gyncsm for gynecologic cancer

The goals vary but generally fall under the education, support and advocacy themes. There are others, but these three and possibly #mmsm for myeloma are most consistently having patients and clinicians talking together.

Jul 1, 2015 · Viewpoint: 6 Trends Toward Higher Cost, Worse Health, Less Access


Editor’s Note: Moving right along with our series of viewpoints and predictions from thought leaders, here’s one from Platinum Fellow Matt Katz, M.D. (@subatomicdoc).  When I contacted him via DM (direct message) on Twitter about the somewhat dismal nature of his observations, Matt reminded me, “Correlation isn’t causation so we can hope I’m wrong.” And yes, he added a smiley face.

The Supreme Court just confirmed that Affordable Care Act (ACA) subsidies are constitutional.  But the jury is out on whether the ACA may help or hurt our health. Now that ACA can move ahead with more momentum, what other trends might drive us toward worse outcomes? Here are six big ones:

1) Hospital Consolidation
The ACA created incentives for Accountable Care Organizations to “give coordinated high quality care” with promised shared revenues for cost savings. The size of ACOs needed to achieve any savings favors hospital industry consolidation.

Dollars now spent on legal fees and costs of integrating different hospital systems mean less available for patient care, attracting quality physicians, or investing in new services. Hopefully all these resources will be a good investment for future cost savings, but don’t count on it.

Robert Wood Johnson’s Synthesis Project (2006) reported likely increases of 5% or more in health care costs with consolidation. The effect is worse in smaller geographic areas where oligopolies are created. In California, concerns were raised about higher costs occurring when hospitals and providers bargained together with payors.  In Massachusetts earlier this year, the Suffolk Superior Court stopped a merger for Partners Healthcare due to concerns of increased costs for the Commonwealth without proof of improved access or quality.

2) Meaningful Use
The HITECH Act passed in 2009 as part of a stimulus package designed to expand use of electronics health records (EHR). Up to $27 billion in incentives were authorized to promote EHR adoption with the goal of ‘meaningful use’ – improving the quality of care.

The cost of implementing EHRs is hundreds of billions more than the government incentives. Software purchase and maintenance, training staff, hiring medical scribes are more money diverted from helping patients. Again, There’s no good evidence to date that EHRs will improve outcomes .

Technology is no panacea but continues to drive healthcare costs up. And as stimulus funding dries up, EHR consolidation is next – forcing many professionals to relearn another system and hospitals to pay more for surviving systems.

Consolidating electronic health information makes it easier to raise costs through medical fraud and identity theft. A recent multinational report confirms healthcare data breaches are the most expensive, costing an average of $398 per exposed person in the U.S.  Anthem had a breach of 80 million customers earlier this year; do the math. EHRs make another potentially rewarding target. What will happen as Epic Systems, the largest EHR provider, becomes cloud-based?

EHRs are also designed for charge capture more than clinical use. So a lot of time is spent by providers learning a clunky system and less time focused on patients. This has spawned a new profession: medical scribes who document so the doctor or nurse can focus on patients. There may be some cost savings, but medical scribes are an unintended consequence that only increases the number of people needed to do the same job.

3) Physician Employment
Speaking of jobs: increasing numbers of doctors are employed by hospitals rather independent practice. There’s no strong evidence this trend improves outcomes, but recent data suggest physician employment increases the cost of healthcare.

Some doctors don’t want the increasingly complex challenges of private practice. With median debt levels of $180,000 for 2014 medical student graduates, some may not have a choice as non-profit hospital employment can provide benefits for debt relief.

Early data suggest buying practices is costly to hospitals – who pays those prices? Employment contracts may incentivize productivity (more patients, tests or procedures). With more time spend documenting, the only way for a doctor to maintain productivity is to spend less time talking to patients, and even less time listening to them.

4) Patient Satisfaction for Reimbursement
Be careful what you wish for – you might be treated like a V.I.P.

The ACA links hospital reimbursement to patient satisfaction with HCAHPS. The incentivized desire to please patients may result in excessive testing, medication or hospitalization.  Giving bad news about a poor prognosis could help curb excessive treatment but can make doctors appear less compassionate – so let someone else give it. Give the customer what s/he wants, you may get repeat customers but costs will go up.

An additional problem: patient satisfaction may not be linked to good outcomes.

One large study suggests satisfaction is linked to higher mortality and hospitalization. Another shows satisfaction is linked to less readmission rates but higher mortality rates. Better preventive health services use is actually linked to worse patient satisfaction.  While it’s important to be responsive to people’s needs, patient satisfaction is not a good measure of good care.

Using HCAHPS may also unfairly penalize hospitals with underserved populations. A recent study showed white, educated, English-speaking hospitals were more likely to have high HCAHPS scores. Ultimately this may limit access or growth of new programs where they are needed most.

5) Health Information Online
When people don’t have access to care, they’re more likely to go online for health information. There are some benefits, but there are also risks. It’s a great place to be exposed to a lot of direct-to-consumer marketing and anecdote. Social media are great resource for illicit online medications, and often what patients learn from DTCA and discuss with doctors may be problematic rather than helpful. Celebrities sharing opinions on health may also make it more difficult.

Younger, more educated people use the internet for health information, but they’re also more likely to be misled by anecdotes while feeling more empowered. Unfortunately There’s a tendency for sicker people to share experiences more online, risking misperception of the severity of illness or treatment side effects. This selection bias sharing bad stories may then excessively undermine public trust in health professionals and hospitals.

When used through a patient portal, online access may be linked to more office visits, telephone calls, ER visits and hospitalizations compared to patients who didn’t have online access. Effectively that means tilting clinical care toward patients who go online, meaning less time in clinic for patients who use the internet less.

6) Rising Deductibles and Underinsurance
The ACA provides access to insurance, but increasingly people have poorer coverage. A recent report suggests 31 million people are underinsured, increased to 23% of adults 19-64 in 2014 compared to 12% in 2013. The main cause is linked to higher deductibles. As a result, 44% of underinsured people have had at least one cost-related access problem.

There may be other unfavorable or favorable trends you have thought about. Many of the issues are complex and interrelated. Hopefully I’m wrong. But ignorance is not bliss. We need to question where we’re headed now that ACA and HITECH implementation move forward.

What do you see on the horizon for health care?

Feb 2, 2015 · Seeing Healing Relationships Helps Us Value Them

Recognizing the needs of patients as well as doctors is essential to healthcare. We may have ideas about what those needs are, but how do we include them in decisions about healthcare reform?

Both patients and healers (since this doesn’t apply only to doctors) have to combine strengths and recognize weaknesses for a trusting relationship to emerge. Pure autonomy doesn’t exist for either participant; it’s the caring connection itself that defines our ability to cope with adversity and begin the healing process.

Trust in the relationship and an ethics of caring are cornerstones of relational bioethics advocated by philosopher of science Alfred Tauber. Improving health requires trust on the part of patient and doctor. The relationship is part of them, and they are partly defined by that relationship as well.

This dual identity fits with Arthur Koestler in his book The Ghost in the Machine “ ‘wholes’ and ‘parts’ in [an] absolute sense just do not exist anywhere, either in the domain of living organisms or of social organisations.”

Koestler used the term holon to capture that duality of being a part and a whole at the same time. I suggest that we view the patient-healer relationship as a “healing holon”:

Katz Venn Diagram.Trust.700px

The therapeutic relationship is the core atom of healthcare; it’s what binds us together. If we want a better healthcare system, we need to start by strengthening that core, not eroding it. Strong healing relationships require that both patients and healers have their needs met.

One way to evaluate the value of institutional policies, technologies or legislation is to ask a simple question: Does this change improve or weaken patients, healers or their relationships?

If a proposed change does not have a net benefit on elements of the healing holon and promote trust, perhaps it’s not worth pursuing. This idea may give us a better way to evaluate new reforms.

What happens for someone with health issues? Multiple healing relationships have different value to a patient. For a woman with rheumatoid arthritis and some fractures as her main health issues, this is what it might look like:

 Katz Patient Holon.700 px

Doctors also experience multiple interactions. Here is what a busy day in clinic might look like:

Katz Dr Holon.700 px

I can’t quantify the value of each holon, but these examples show how some relationships will be more important or trusting than others.  The more overlap and trust, the better.

Seeing is believing, but you have to believe in something first to see a solution. What do you see? What do you believe?

 All images from Matthew Katz, M.D. Dr. Katz is a Platinum Fellow in the Social Media Health Network.



Dec 29, 2014 · E-Patients Deserve E-Doctors: Addressing the Needs of Both to Make Healthcare Better for Everyone

Everyone deserves a chance to be healthy. Physicians, of course, focus on helping patients. Unfortunately, I often see patients’ frustrations with the health care system itself directed toward doctors.

Meanwhile, doctors are under increasing pressures on multiple fronts. Yes, we’re imperfect, but making physicians the primary focus of patient anger will not solve problems we all face as humans who will, at some point, need health care. (Note: I’m using doctors as an example for this piece, but my observations apply to all health care professionals.)

Patients need doctors. Doctors need patients. Let’s find a way to value both.

Patients deserve to be empowered
Health is more than not being ill. The World Health Organization definition puts the full range of patients’ needs first: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

How can patients achieve the health they deserve? Only if they’re empowered. The “e” in e-patient can mean many things, but if health is a basic human right, then empowerment is the only “e” ensuring that right.

Being empowered means being able to meet certain fundamental needs, ones that need to be in place before we can make accurate, informed decisions about health. Here’s what we need for empowerment:

Patient's Hierarchy of Needs

Image: Matthew Katz

Autonomy is not absolute
Empowerment isn’t the same as autonomy. True autonomy is the ability to make an independent, free choice. Sometimes we don’t have the luxury of time; pain may color our perspective. Loved ones often can have strong influences upon our decisions. Humans are relational by nature, not truly independent.

Sometimes we disagree with health care professionals. Even when doctors or nurses want to help, their experience or ethical concerns may prevent them from giving us what we want or need. Patients are inherently vulnerable.

In addition, while more people may currently be involved with shared decision-making or perhaps even lead the process, not all patients want complete autonomy. Patient decision-making preferences may vary based upon many factors. It’s not reasonable to insist that patients lead decision-making if they want to receive guidance or direction from their physicians.

Patients deserve access, dignity, and a chance to be involved in decision-making, but that doesn’t automatically lead to satisfaction. In our desire for control, some of our choices may actually hurt us. Rather than being angry at doctors and taking our frustrations out on them, I suggest we recognize and explore common ground that may help patients and doctors alike.

Doctors are patients too
When we’re sick, we understand that others who suffer and need help will rightfully compete for doctors’ attention. What we often fail to remember is that those helping us may also struggle with health issues.

While data suggest doctors are becoming better than the general population about their health when it comes to smoking and obesity, physicians have higher rates of burnout and suicide. Multiple surveys show many medical students and doctors may have suicidal thoughts, with one study estimating that up to 24% of doctors have thought about taking their own life at some point in time.

Suicidal Ideation by Gender in Doctors


Doctors haven’t made it easier on themselves. Excessively high expectations of a different era and a tendency to internalize stresses rather than seek help may lead to burnout, hopelessness, and self-harm. Access to medication also makes substance abuse a particular problem in some specialties.

Multiple factors contribute to physician burnout, depression, and impairment. We can’t solve or eliminate them all, but e-patients should want doctors to be healthy and well. Healthy doctors are more accessible, better listeners, and more able to dedicate time to patients. As a small subset of patients, doctors deserve mental and physical health to ensure they can be there for us when we need them.

So what do doctors need for empowerment?

Doctors also have a hierarchy of needs
Healers need to be healthy first—just like patients. Then, they need the right personal characteristics, training and support to be better able to do their job—helping patients.

 Physician’s Hierarchy of NeedsPhysician's Hierarchy of Needs

Image: Matthew Katz

With health and virtuous characteristics as the foundation of success, doctors can earn the right to the trust of patients and their caregivers as well as society at large. This model affirms the patient-doctor relationship and aligns patients and doctors.

Making it better for everyone
We are all dissatisfied with an unhealthy health care system in a rapidly changing world. Empowering patients and doctors ensures they can work together. New technologies and tests are not solutions, they’re just tools. If patients and doctors don’t stand up for themselves, other stakeholders  (e.g. hospitals, insurers, industry)may unwittingly make things worse.

Thoughtful, vocal patients, caregivers and doctors should stand together. Even when we disagree, we can respect our differences while working toward solutions, both in clinic and for the health care system.

We both have a lot to bring to the table. Empowered patients are better able to collaborate. Empowered doctors are more able to adapt to each patients needs and communicate well to build trust. We need each other. And if we support each other, the entire health care system will be the better for it.

Matthew Katz, M.D., has served as a member of the External Advisory Board for the Mayo Clinic Center for Social Media and is a Platinum Fellow in the Social Media Health Network.

Nov 25, 2014 · Twitter Use at Three Annual Professional Meetings (2012-2014)

Thanks, Greg! I appreciate it. Let me starting brainstorming 🙂

Nov 24, 2014 · Twitter Use at Three Annual Professional Meetings (2012-2014)

Last year, I wrote about differences in how professional societies use social media during annual meetings. This year, the American Urological Association (AUA), American Society of Clinical Oncology (ASCO) and American Society for Radiation Oncology (ASTRO) have had their meetings, so it’s time to take another look. Looks like the growth trend continues for sharing research and specialty-specific information in cancer care via social media.

Using Symplur’s hashtag analytics, I reviewed Twitter data for ASCO and ASTRO annual meetings from 2012 through 2014. I chose to include one week before and two weeks after the meeting since discussion typically extends beyond face-to-face conferences.

Symplur had data for #AUA13 and #AUA14. #URO12 wasn’t in Symplur so I reviewed it manually on Twitter.

Figure 1

­Fig. 1. Tweets  for ASCO, AUA, and ASTRO
from week before to two weeks after annual meeting.

ASCO, which has been ahead of the pack for professional societies using social media, has shown continued strong growth in using Twitter. The increase in tweets mirror the increasing number of participants:

Figure 2

­Fig. 2. Participants tweeting from week before to two weeks after
annual meeting. ASCO, AUA and ASTRO

On an absolute scale, ASCO is the leader, but note that it has been strategically using social media longer than either AUA or ASTRO. And how are those organizations doing based upon growth rates? Pretty well.

Table 1

Table 1.   Social media metrics, 2012-2014.

AUA used #URO12 because a competing meeting was already using #AUA12, but #URO12 apparently wasn’t intuitive enough. Meanwhile, ASTRO appears to be lagging approximately one year behind AUA in most measures. Both organizations’ meetings had an increasing number of tweets per participant. ASCO’s Twitter use has been flat.

To what extent do the organizations themselves play a role in advocating Twitter activity?

ASCO, ASTRO and AUA have all grown their online presence with Twitter. But ASTRO hasn’t been as proactively tweeting at its own meeting as either ASCO or AUA.

In 2014, ASTRO had only 35 tweets using the meeting’s hashtag vs. 754 and 381 for ASCO and AUA, respectively. So far that doesn’t appear to be hurting ASTRO’s growth in using its annual meeting hashtag. But is organizational engagement needed to sustain that growth, or are people going to increasingly use Twitter on their own?

ASCO is a very large organization with over 34,000 members, so I wouldn’t expect either AUA or ASTRO to reach quite the same level of participation. But both urology and radiation oncology appear to be on the same path – sharing more cancer information online.

So, is sharing at academic meetings trending good, bad or meh? Should organizations proactively lead tweeting during meetings? Should organizations let this grassroots process be initiated by meeting participants? I’d love to know what you think.

Jul 10, 2014 · Start the Patient-Doctor Relationship with Questions about Gathering Health Information

Thanks Linda for your comment. It can be a challenge to address all the misinformation we find, and some of the content can become dated quickly. All the more reason it may be helpful in the clinic setting to consider asking about where our patients do their learning.