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What’s next for health reform after the House passed their bill, H.R. 3962?

Kevin — Sun, 08 Nov 2009 07:00:49 PST

Originally published in MedPage Today

by Emily P. Walker, MedPage Today Washington Correspondent

The House of Representatives voted 220 to 215 to pass historic healthcare reform legislation late Saturday night, after 11 hours of debate before a packed gallery of spectators.

H.R. 3962 passed by a narrow margin: Democrats needed 218 votes to pass the bill and wound up with just two more than that, after 39 Democrats jumped ship and voted “Nay.” Only one Republican — Anh “Joseph” Cao from Louisiana voted for the measure.

Once the vote count hit 218, Democrats cheered loudly. Applause continued as the final votes trickled in during the few minutes that remained of the 15 allotted for the vote. When the clock ran down, the chamber erupted in elated applause, the hugging, kissing, and cheering abating only for the few minutes it took for Speaker of the House Nancy Pelosi to declare “The bill is passed!”

The $1.1 trillion bill would expand insurance coverage to an additional 38 million people over the next decade by requiring that almost all citizens have insurance and providing subsidies to those who can’t afford it. The measure also contains a public option that would allow doctors and hospitals to negotiate with the government over reimbursement rates for treating patients enrolled in the public plan.

The unusual Saturday session was characterized by hours of theatrically partisan debate, and crowds of spectators waited hours in line to get five-minute glimpses of the floor proceedings.

Democrats called attention to the historic nature of the vote.

“Leaders of every party and political philosophy as far back as Teddy Roosevelt have called for healthcare for the American people,” Pelosi said. “Today the call will be answered.”

Republicans repeatedly called the measure a “freedom-killing, job-killing bill” that would bankrupt the government for future generations and criminalize people who do not have insurance. Speakers used a number of props — including a baby and a pair of handcuffs — to drive home their points.

The final vote came just minutes after approval of a controversial abortion amendment. Sponsored by anti-abortion Democrats Bart Stupak of Michigan and Brad Ellsworth of Indiana, the amendment would bar the government from offering abortion in its public plan, and make it illegal for private insurers that participate in the exchange from providing abortion coverage, except in the case of rape, incest or when the woman’s health is in danger.

The amendment passed by a vote of 240 to 194, with support from 64 Democrats and all but one Republican — John Shadegg of Arizona, who cast a vote of “present.”

A 1977 law, known as the Hyde Amendment, already prevents use of federal money to fund abortions. Stupak said his amendment simply applied the Hyde amendment to H.R. 3962, but opponents said it would go much further. Not only would it mean the new public plan can’t pay for abortions, opponents charged, but none of the private insurance plans that participate in the exchange could provide abortions either because government money would pay for the creation of the exchange.

Low- and moderate-income women who receive government subsidies to purchase health insurance would not have coverage for elective abortions because they would be required to purchase insurance from the exchange.

“The amendment has no impact on individuals with a private plan who do not receive a subsidy,” Stupak explained.

Women in the public plan, or who have a plan through the exchange, could choose to buy a separate abortion-coverage plan using their own money, which Rep. Jan Schakowsky called “a ridiculous and unworkable approach since no woman plans an unplanned pregnancy.”

There was language in H.R. 3962 — authored by Rep. Lois Capps (D-Calif.), a nurse — that specified that if plans in the exchange wanted to provide abortion coverage, it would have to be funded through premiums paid by the individual, not government money. That language was an effort to placate anti-abortion members of Congress, but they said it didn’t go far enough.

Capps spoke out against the Stupak/Pitts amendment.

“It will be the only language in the entire legislation that restricts coverage of a legal medical procedure,” she said.

Stupak maintained that his amendment is just cementing current law.

“I am not writing a new federal abortion policy,” he said.

Abortion rights groups like NARAL and Planned Parenthood blasted the amendment, while the United States Conference of Catholic Bishop’s Organization (USCCBO) praised it.

The amendment would have to be approved in the Senate, and then survive conference before it becomes law.

The final version of the House bill lacked a doctor payment fix, but a separate bill that would replace the sustainable growth rate (SGR) formula is expected to come to a vote next week.

The bill passed by the House on Saturday would require businesses with payrolls above $500,000 to offer health insurance to their employees.

It would also make a number of changes to insurance company practices, including a prohibition against denying coverage because of pre-existing conditions, outlawing lifetime caps on coverage, and requiring governmental review of rate increases.

The measure would also:

* Establish an “Innovation Center” within CMS to “pursue additional payment and delivery systems reforms”
* Begin to close the Medicare “doughnut hole” for drug costs immediately, and eliminates it completely by 2019
* Establish grant programs to test alternatives to the tort system in medical malpractice cases
* Immediately create a high-risk insurance program for those who haven’t had insurance for several months, or who were denied a policy based on pre-existing conditions
* End the antitrust exemption afforded to insurance companies
* Allow young people to continue to receive coverage on their parents’ insurance through age 27

Republicans attempted to have their own version of a healthcare bill adopted as an amendment, but that measure failed by a vote of 176 to 258, with Rep. Timothy Johnson (R-Ill.), casting the lone Republican vote against the GOP plan.

During a procedural vote known as a “motion to recommit,” Republicans attempted to have the bill sent back to committee for members to add medical liability reform language to the legislation, but that motion was rejected.

The Senate has yet to vote on its version of a healthcare reform bill.

Visit MedPageToday.com for more health policy news.

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Ten top medical blog posts, October 2009

Kevin — Sun, 08 Nov 2009 03:00:46 PST

Here are the top posts from the past month, based on the number of times they were viewed.

1. Two nurses face jail time for reporting a doctor to the Texas Medical Board

2. Why pregnant women should get the H1N1 flu vaccine

3. Why doctors should choose Google Android over the iPhone for medical apps

4. What having the H1N1 flu feels like

5. Flu and H1N1 influenza vaccine recommendations for doctors and health care workers

6. Has the ban on doctors accepting drug company gifts gone too far?

7. Are surgical masks as effective as N95 respirators to prevent influenza?

8. How House, M.D. is affecting patients’ expectations of medical care

9. How should doctors handle the difficult patient?

10. Doctor makes more money on eBay than practicing medicine

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How the health care system is corrupting doctors

Kevin — Sat, 07 Nov 2009 12:00:03 PST

Originally published in HCPLive.com

by Jeff Brown, MD

I had the same reaction . . . shock at seeing an almost obscene claim about our profession in a national newspaper. But it got me thinking, which no doubt was its intended purpose. While we are thinking and feeling our way through this wide-ranging debate on health care, we might as well examine everything. And as we have painfully learned, no part of life is immune from money issues, especially medicine.

Corruption, for our purposes here, is the bending or abrogating of our integrity, putting forth what is “best” for our patient as a result of venal or other outside influences. We may not think about it much but we are assaulted on a daily basis in many ways, some obvious, some subtle.

The poster child for lobbying physicians is the drug rep. Before Congress began reining in Big Pharma’s largesse over the last 20 years, there was a time of thinly veiled bribes—trips, cash for “consulting,” speaking and research—and my office was once booked over a month in advance for catered lunches for the staff. “Any restaurant you want and anything on the menu,” we were told. We thought it was just a nice perk for the staff and kept them around the office.

And don’t forget the endless supply of company-name-stamped tchotchkes, of course, or the embarrassing feeding frenzy at national medical meetings where presumably ethical and well-paid docs and their wives rushed to fill bulging goody bags with “free” junk in the extensive exhibitor’s hall.

We should ruefully admit that these companies weren’t blindly spending billions on these programs and couldn’t document that these things worked. In spite of our righteous protestations, they did. Did you know that drug companies still pay a monthly fee to pharmacies to see a specific read-out on what and how much each doc prescribes? They know that we too are human and our prescribing habits change, admit it or not, when the companies pay personal attention to us.

Good riddance to the drug companies’ more flagrant gifts: it’s been a long time coming.

Now let’s revisit the biggest corrupter of all, the fee-for-service structure. With all the economic pressure of student loans, high overhead, family needs and on and on, it takes a steel will to stay on point. Not to yield in those extensive gray areas of decision-making and perform extra procedures, schedule extra visits, order tests through facilities in which we have an economic interest, or change our prescribing habits all require a major effort to keep ones eyes on the horizon. And worse, in addition to our personal rationalizations, our patients often demand that we do these things! So we acquiesce, knowing that we are often just buying time for problems that will get better anyway . . . and really, what’s the harm?

Ironically, the knock we’ve had against HMOs/managed care—that being paid for doing too little is a bad idea for our patients—also applies for fee-for-service which pays us too-often for doing too much. That’s why I have written in the past that putting docs on salary would mitigate the cost of health care considerably. Yes, there are other issues that arise with docs on salary, like maintaining activity and quality levels, but that discussion is for another day.

Corruption is also engendered by the insurance companies being inefficient and just plain difficult. It is axiomatic that when you are dealing with a dysfunctional system, the only way you can get your work done is to game the system. So you or your staff manipulate things like CPT, ICD-9s, and other forms without end. You say it’s only “fair” and that you are just trying to help your patient get what they need by doing whatever it takes. This is too often true and we’ve all done it. But it is not “clean” and diminishes us each time we do it. The ends certainly do not justify the means.

Even putting ethics aside, all of this costs time, which in our trade is money. Because time is all we have, besides our good names, we are corrupted and bent away from our primary mission. I’m reminded of the old saw that says, “We all know what we are, we’re just dickering about the price.”

But I’d like to think that our profession still aspires to set a standard for others to be better than that.

Jeff Brown is a family physician who blogs at Take As Needed.

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Op-ed: Injured patients deserve medical malpractice reform

Kevin — Sat, 07 Nov 2009 03:00:23 PST

A version of this op-ed was published on October 26th, 2009 in the USA Today.

President Obama has acknowledged that changes in the medical malpractice system must be considered with other health reforms, and recently ordered that pilot projects to improve the way we compensate injured patients be implemented.

Reforming medical liability has historically been a source of major contention. Physicians argue that the system is expensive, promotes multi-million dollar awards disproportionate to the injuries suffered, and encourages “defensive medicine” – the practice of ordering tests to avoid being sued.

Lawyers, on the other hand, say that suing doctors provides the only way for patients harmed by medical errors to seek financial redress, and dismiss the notion that malpractice costs and defensive medicine contribute substantially to health care spending.

But what’s overlooked in this argument is that the current liability system often does injured patients a disservice. And that’s the most important reason why medical malpractice reform is needed.

A study from The New England Journal of Medicine provides stark insight. Researchers found that nearly one in six cases involving patients injured from medical errors received no payment. For patients who did receive compensation, they waited an average of five years before their case was decided, with one-third of claims requiring six years or more to resolve. These are long waits for patients and their families, who are forced to endure the uncertainty of whether they will be compensated or not.

And with 54 cents of every dollar injured patients receive used to pay legal and administrative fees, the overhead costs clearly do not justify this level of inefficiency.

Furthermore, medical malpractice does little to promote patient safety. Although it’s been cited that medical errors account for close to 100,000 patient deaths annually, the majority are caused by failed systems or procedures, not physician negligence. Doctors and hospitals ideally should learn from mistakes in order to improve patient care, but that’s difficult to do when liability cases are resolved in an adversarial, often acrimonious, manner.

Indeed, in 2006, then Senator Barack Obama, alongside Hillary Rodham Clinton, wrote that the current system “does not promote open communication to improve patient safety,” and, “jeopardizes patient safety by creating an intimidating liability environment.”

There are many who advocate caps on malpractice awards as a solution, but this does little to fairly compensate patients more expediently, nor will it make the necessary improvements to patient safety. In Texas, for instance, a $250,000 cap on non-economic damages has made it more difficult for injured patients to seek compensation because lawyers find most claims too unprofitable to pursue.

Perhaps we should look abroad for other ideas.

The United States is one of the few countries in the world that uses a jury to decide instances of medical malpractice. Liability cases in the United Kingdom, Germany, and most of Canada use specially trained judges instead, who can not only decide cases more quickly, but also in a manner more reliable and consistent than a jury. These “health courts” will speed up the time it takes for injured patients to receive compensation. Additionally, according to Philip Howard, the chairman of the legal reform coalition Common Good, by implementing health courts, “information about each [malpractice] incident, would be compiled and disseminated so that doctors and hospitals could learn from their errors.”

Another consideration is a “no-fault” approach to deciding malpractice claims, used in countries like Sweden and New Zealand. Under such a system, legitimately injured patients are quickly compensated using payments based on the severity of injury without assigning blame to doctors. In fact, physicians in Sweden often work together with patients filling out the necessary forms, making them allies rather than adversaries. Such an initiative can also sharply reduce legal costs, with the money compensating more patients instead, while sparing physicians the ordeal of a malpractice trial.

Despite the disagreements surrounding the health reform debate, most feel that our health care system cannot continue to function under the status quo. If we care at all about the plight of injured patients, neither can our medical malpractice system.

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Support for the patient centered medical home in the House health reform bill

Kevin — Fri, 06 Nov 2009 11:00:02 PST

by Thomas C. Bent, MD

As the House of Representatives prepares to vote on its historic health care reform bill on Saturday, family physicians are heartened to see the support it gives to the emerging new model of care, the patient centered medical home.

The House bill is good news on many fronts. It would provide health insurance coverage for some 96 percent of Americans and would reduce the federal deficit by $30 billion. The Congressional Budget Office estimates this bill would lower health care costs in part by improving health care delivery and relying on the medical home model with its greater focus on primary and preventive care.

Debate about this bill has been exceedingly contentious. In fact, thousands of people are demonstrating in the streets of Washington, D.C. as I write this. Yet at a deeper level, health care reform isn’t a Democratic or Republican political issue – it’s a non-partisan moral issue. Researchers at Harvard reported recently that 45,000 people die in the U.S. every year because they lack health care coverage and so cannot afford appropriate care. Many more die each year from entirely preventable chronic illnesses.

Three out of every four health care dollars – $1.5 trillion of $2 trillion spent on health care year in the U.S. – go toward treating chronic illnesses, most of them preventable. An estimated 133 million Americans have at least one chronic disease, such as diabetes, heart disease, cancer, stroke, or lung disease. In Los Angeles, public health experts have documented that 80% of preventable disability and death in that county is associated with chronic disease.

Our current health care system is failing our patients by focusing more on treating acute conditions – like heart attacks – than on preventing the causes, such as obesity that leads to heart disease. As a result, patients suffer unnecessarily and health care costs are spiraling out of control. We need a better model, with more emphasis on prevention, backed up by the excellent care our subspecialist colleagues provide.

Patient centered medical home efforts in North Carolina, Pennsylvania, Colorado and elsewhere have delivered improved patient outcomes and multi-million-dollar cost savings in recent years. Key elements include identifying patients who need preventive and chronic disease care and ensuring they regularly receive such care; providing extended office hours and 24/7 access to primary care physicians to prevent unnecessary emergency room visits; using evidence-based medicine to provide clinically effective and cost-effective care; delivering care with a physician-led team of providers working to the full scope of their respective positions; and coordinating patients’ care throughout the health care system.

We know what needs to be done – we just need the political will to align payment and medical education systems accordingly. That’s in part what the House bill would do.

The California Academy of Family Physicians believes that ensuring Americans can afford to seek care that focuses on keeping them well, managing chronic illnesses, and coordinating their care throughout the entire health care system is not a government takeover – it’s a humanitarian response to the crises faced by the millions of uninsured and underserved in our nation.

Thomas C. Bent is President of the California Academy of Family Physicians.

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What is the best insulin regimen for patients with diabetes?

Kevin — Fri, 06 Nov 2009 09:00:00 PST

Originally published in Insidermedicine

The best method for taking insulin among individuals with type 2 diabetes has been identified in research published in the latest issue of the New England Journal of Medicine.

Here is some information about type 2 diabetes:

• It is a condition in which your body does not produce enough insulin and/or does not use available insulin properly

• Insulin is needed to convert sugar in the blood into energy; without it , sugar builds up in the blood

• Treatments include antidiabetic medicines that help the body produce and use insulin as well insulin replacement therapy

Researchers from the University of Oxford randomly assigned over 700 individuals with type 2 diabetes whose blood sugar levels were not adequately controlled despite taking two types of antidiabetic medicine to receive one of three insulin regimens. These regimens were basal, or long-acting insulin once daily; prandial, or short-acting insulin three times daily at mealtime; or biphasic, or short- and long-acting insulin twice daily. After one year, if blood sugar levels were not adequately controlled, one of the antidiabetic medicines would be replaced with a second type of insulin.

Most patients in all three groups eventually needed to take two types of insulin, but fewer patients in the biphasic insulin group were able to maintain adequate control of their blood sugar levels than those in either of the other two insulin groups. The risk of hypoglycemia, or dangerously low blood sugar, was highest in those taking prandial insulin, and patients taking this type of insulin also gained the most weight.

Today’s research demonstrates that individuals with type 2 diabetes who need to start taking insulin should begin with basal insulin and then add prandial insulin, as needed.

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Vaccines do not cause autism in children, whether or not they have inborn errors of metabolism

Kevin — Fri, 06 Nov 2009 07:00:12 PST

Originally published in MedPage Today

by Michael Smith, MedPage Today North American Correspondent

Vaccination does not appear to cause autism or other health problems in children with inborn errors of metabolism, a researcher said here.

In a retrospective analysis, children with such conditions were not more likely than normal children to visit emergency rooms or need hospital care after vaccination, according to Nicola Klein, MD, PhD, of the Kaiser Permanente Vaccine Study Center in Oakland, Calif.

While the data are preliminary and the sample size is small, Klein said at the annual meeting of the Infectious Diseases Society of America, there doesn’t seem to be an association between vaccination and adverse events in children with inborn errors of metabolism.

The issue is important because of a 2007 ruling under the Vaccine Injury Compensation Program that the family of Georgia girl was entitled to compensation.

Hannah Poling was diagnosed with encephalopathy caused by a mitochondrial enzyme deficit and her family successfully argued that a series of vaccinations had led to the condition. (See Despite ‘Sad’ Case of Georgia Girl, CDC Reiterates ‘Life-Saving’ Value of Vaccines)

The girl’s disorder is one of about 90 inherited diseases collectively known as inborn errors of metabolism.

After the ruling, “there was some concern that vaccination may place some children with genetic disorders at increased risk for autism or other adverse effects,” Klein told reporters.

To investigate the issue, she and colleagues combed Northern California Kaiser Permanente’s electronic medical records, looking for children who were diagnosed with an inborn error of metabolism from 1990 to 2007 and remained in the company’s system until they were at least 3 years old.

All told, they found 79 children with such defects and compared their immunization and health records to those of 1,580 matched controls, Klein said.

During the first three years of life, she said, there was no difference in the proportion of children whose vaccinations were up to date at age two. Also, they were not more likely than the healthy children to have any recommended vaccine delays.

The researchers also analyzed emergency room visits and inpatient stays among all children up to age 18 with an inborn error of metabolism who received at least one vaccine at any time.

For each of the 322 children they identified, Klein said, she and colleagues compared events during the first 30 days after a vaccination with the following 30 days.

“If the vaccine was causing any problems, we would expect to see them emerge right around the time of vaccination, not a month later,” she said.

But, for the 30 days immediately after vaccination, compared to postvaccine days 31 to 60, they found:

* For emergency room visits, the rate ratio was 0.83, which was not significant with a 95% confidence interval from 0.60 to 1.14.
* For inpatient stays, the rate ratio was 1.1, also not significant with a 95% confidence interval from 0.9 to 1.4.

“We found no increase in emergency room visits or serious side effects,” Klein said. Interestingly, seven of the larger group of children had a mitochondrial disorder.

The findings are preliminary but “very reassuring,” according to Larry Pickering, MD, of Emory University in Atlanta, who was not part of the study but moderated the session at which it was presented.

“Most of us who take care of kids with inborn errors of metabolism think vaccination is one of the best interventions we can offer them,” Pickering told reporters.

“They are at increased risk for devastating complications, even death, from the diseases that the vaccines prevent,” he said after the session.

Interestingly, the so-called “vaccine court” has sharply rejected recent claims that the MMR vaccine – against measles, mumps, and rubella — led to autism in thee children.

Visit MedPageToday.com for more vaccine news.

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Did Nidal Malik Hasan suffer from compassion fatigue or vicarious traumatization?

Kevin — Thu, 05 Nov 2009 20:54:10 PST

There are many tragic questions emerging from today’s massacre at Fort Hood. The one I’m interested in is why a reportedly mild-mannered psychiatrist, a specialist in disaster and preventive psychiatry no less, would make the decision to open fire on his fellow soldiers.

One reason may be so-called compassion fatigue, also known as vicarious traumatization or secondary traumatization.

According to the Psychiatric Times, the condition is defined as “indirect exposure to trauma through a firsthand account or narrative of a traumatic event. The vivid recounting of trauma by the survivor and the clinician’s subsequent cognitive or emotional representation of that event may result in a set of symptoms and reactions that parallel PTSD (e.g., re-experiencing, avoidance and hyperarousal). Secondary traumatization is also referred to as compassion fatigue and vicarious traumatization.”

It’s certainly possible. Todd Essig, over at True/Slant, paints a vivid, plausible scenario:

Imagine every day trying to help young men and women somehow put their lives back together despite their night terrors, flashbacks, and chronic sleeplessness. While you reach out to help, they mistrust your every move and respond with hair-trigger tempers, not to mention all the physical symptoms, alienation, and hopelessness. Surrounded by thoughts of suicide–and homicide–you try and keep faith with the honor and challenge of providing care.

But soon the line between their experience and yours starts to blur until, well, something like what happened at Fort Hood today becomes an all too real possibility.

Combined with the fact that he was due to be deployed to Iraq, extremely reluctantly if reports are to be believed, we can surmise that his thought process was compounded an already fragile mental state.

But wait. That explanation may too simplistic, according to Mindy B. Mechanic, an associate professor of psychology at California State University, Fullerton. She says that such an extreme reaction, even in the setting of vicarious traumatization, is unlikely: “They might get depressed or have some emotional fallout from it, but to go on a shooting spree is not part of what happens to people from having to deal with trauma survivors all the time.”

It’s obviously too early to come up with anything conclusive. More will almost certainly come out in the ensuing days.

But if anything, this event brings much needed light to the mental health issues plaguing both soldiers, and apparently, their doctors.

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Are nurse unions using the H1N1 flu pandemic as a bargaining ploy?

Kevin — Thu, 05 Nov 2009 11:00:41 PST

by Toni Brayer, MD

Only in the United States could a virus like H1N1 bring out the worst in medical politics and greed. We are facing a pandemic that requires coordination, communication and the best of medical practice. But what are we getting? Strikes, lawsuits and anything but putting patients first.

The California Nurse Association (CNA), is taking this opportunity to call a strike on three large Catholic hospital chains (which comprise a total of 34 hospitals) throughout California and Nevada. The union bosses say the chief concerns are a lack of protective gear, improper isolation techniques and staffing that requires nurses to work 12-hour shifts during the flu crisis.

Although the nurses seem to want to walk out during a pandemic to “protect patients,” nurses in New York and Washington also filed a lawsuit over the idea that they should be required to get the flu vaccine.

You can’t have it both ways, nurses. You either want protection or you don’t.

This is an obvious smokescreen for contract negotiations, not H1N1 preparedness. Coincidentally, the CNA is in negotiations now with Catholic Healthcare West. Since nurses in California already earn more than many physicians, this type of bargaining rhetoric exposes an somewhat unseemly side of nursing.

Most nurses in California hospitals work part time and receive full benefits. At a time when unemployment is at an all time high, nurses are receiving up to six percent pay raises due to union bargaining.

I respect nurses and believe in true collaboration for patient care, but as we prepare for flu season, this type of unprofessional, opportunistic behavior needs to be called out for what it is.

Tony Brayer is an internal medicine physician who blogs at EverythingHealth.

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Health care social networking basics for doctors

Kevin — Thu, 05 Nov 2009 09:00:17 PST

Originally published in HCPLive.com

by Enoch Choi, MD

Patients have embraced social networking tools that allow them to share information, offer support, and compare healthcare experiences. Physicians should also use these tools to connect with their patients and local communities and provide general medical information.

Healthcare social networking has made impressive inroads into the mainstream, as like-minded folks find each other online and chat about their passions. From politics to personal, from professionals to patients, the Internet has exploded with people talking about their health and healthcare. Perhaps the economic downturn has rekindled peoples’ appreciation for those things that make life worthwhile—our families and communities—and refocused their interest in improving their health. I know from personal experience that a great shock can help you value what you have more—I recently successfully resuscitated an acquaintance’s child from near drowning and have been hugging my children every chance I get. I see friends reacting to the economic downturn in a similar fashion, reinvesting in their health as they watch their 401(k) and housing values shrink. Many of them are participating in online discussions as part of their investigations into how to improve their health.

President Obama’s proposal to overhaul the healthcare system unleashed a torrent of activity on e-mail lists, blogs, Facebook, and Twitter as citizens think that this time, something may really change. What’s amazing is that this energy has not been unique to the online space. You know that people are really worked up when they vote in record numbers and when large numbers of citizens show up to support or heckle in town hall meetings. This shows how effective online organizing can be; we’ve crossed the chasm from silly flash-mobs to impacting politics-as-usual. Maybe healthcare social networking isn’t just all talk.

Connecting online
Social media and social networking are not only about politics; they can also be about actual medical care. As people use social networks to ask about health, they find others with the same conditions, and at the same stage of treatment. Most folks are asking about what they can expect in terms of prognosis and possible complications. People tend to talk about common illnesses in public spaces like blogs and Facebook, but for more complex conditions, some patients often prefer private e-mail lists such as Yahoo Groups, where they feel more secure to reveal details. Others get very specific in public forums about how a particular treatment or medication could help them with their symptoms. Some patients choose to record online diaries that contain detailed data about their treatment and response, through online resources such as Google Health, Microsoft HealthVault, PatientsLikeMe, and personal health applications at MedHelp. With the latter two, records can only be viewed with the user’s consent; information stored in Microsoft HealthVault and Google Health is completely private.

The healthcare social networking format that I see used most often is quick updates from friends on their Facebook or Twitter pages announcing that they’re sick, which prompts other friends to offer comfort and suggest remedies. I’ve taken to commenting as well, offering suggestions on what friends can do at home to help with colds and other minor injuries. This is the same kind of health education you can find from books like the , or iPhone resources such as Medzio, but tailored specifically to what my friend has said online. I don’t practice medicine online—I don’t diagnose or prescribe or tell them what to do. I offer options based on their symptoms and point out things they should be more concerned about. It’s like what I imagine happened when our communities were much smaller and folks knew their local doc and asked quick questions at the grocery store or at church. Now, it happens online with more depth in places like the “Expert Forums” at MedHelp.org and at Yahoo Answers, where you can ask physicians these kinds of questions, sometimes for a fee. The great thing is that all of these conversations are archived publicly, enabling anyone with these conditions to benefit from reading about them.

I see the most questions of this sort in private e-mail lists, such as the Palo Alto Menlo Park Parents Club, where more than 4,000 parents with children up to age five ask each other about local providers and how they care for certain illnesses. These parents with kids younger than elementary school age don’t yet have PTA networks on which to rely, and many of them have recently moved to the area and are looking for testimonials from like-minded parents. As providers realize that their reputation can be made or broken online, they’re starting to engage and respond to questions and complaints in these online venues. My own experience is that parents come and seek me out for urgent care since they know that I’ve been open online and am trusted by that community.

Spread the word
Healthcare social networking can be particularly effective in getting the word out about hot-button public health topics. Information about H1N1 (the artist previously known as “swine flu” before being hog-tied), has flowed so much more freely than information about SARS did seven years ago. This time, the CDC updated its website regularly and provided webinars and conference calls for physicians and the public. Even local health departments started using Twitter to tell folks about the rapidly changing response. From this information, local schools and parents could understand the real risks involved (not terrible to date, thank God) and avoid further school closures and panic. I tweeted and used my Facebook updates to share guidelines for when it is appropriate to come in to be seen for urgent care, since so many people were coming in with very mild symptoms without fever, or with no symptoms at all, just because they’d recently traveled to Mexico.

Using social media to spread the word about public service announcements is particularly potent. I recently posted a shocking video depicting a gruesome accident due to texting while driving. In just a few minutes, hundreds of my friends viewed it, and a dozen commented and reposted it to their own friends. I connected with a fraction of the millions that have viewed it on Fox TV, but in a much more personal way. A fellow physician commented that the video was “so 20th century. Nowadays, we should say ‘Don’t tweet and drive!’”

Nonprofit engagement
Health nonprofit organizations are also engaging the social networking enthusiasm of their members. Though applications like Facebook Causes and Kiva allow for direct cash donations, you can make a greater impact by getting the word out about an organization’s message through online handouts, photos, YouTube videos, and invitations to events and fundraisers. The Leukemia & Lymphoma Society’s Team In Training program has been especially effective in engaging supporters through social networks.

A day doesn’t go by without a local chapter of a nonprofit inviting me to a meeting, training, or fundraiser. To prepare for a debrief for the families who witnessed my resuscitation of a child from near drowning, I’m relying on online materials from Johnson & Johnson and Kidpower in order to encourage parents to watch their kids more safely and empower their kids to stay safe in the water. I haven’t even moderated the discussion yet, and parents are commenting enthusiastically online in anticipation of our meeting.

Have some fun
Exercise video games are a really fun way to use healthcare social networking. I may not have time to hit the gym most days, but I always seem to find time to play my Nintendo Wii, whether it be Wii Fit, EA Sports Active, Punch-Out, or just to compete to be the biggest loser with Jillian Michaels Fitness Ultimatum (God knows I need to lose a few…). Even if no one else at home wants to join me, by becoming online “buddies” with other Wii-owning friends, I can feel like I’m part of a larger exercise community. It’s more fun working out with EA Sports Active with one of my kids, but seeing friends working out seems to kick my butt into gear more effectively. Wii Fit, which focuses on improving balance rather than increasing aerobic endurance, can help elders who are at risk of developing balance issues resulting in falls and possible hip fractures. I dream of a future where elders not only chat about their golf handicap or how well their doubles game went, but also become Wii buddies and brag about their low “Wii Fit Age.”

New iPhone applications also offer an easy way to track your fitness goals and show your friends how fit you’re getting. I’d like to see iPhone apps that use the accelerometer in the iPhone to track your exercise.

Academics, however, are expressing some caution with regard to social networking and personal health information. In an e-mail to students and faculty of Harvard Medical School, Dean for Medical Education Jules Dienstag wrote: “Caution is recommended . . . in using social networking sites such as Facebook or MySpace. Items that represent unprofessional behavior that are posted by you on such networking sites reflect poorly on you and the medical profession. Such items may become public and could subject you to unintended exposure and consequences.” For physicians, it’s clear that you should only practice medicine online through HIPAA-compliant private and secure portals that allow you to e-prescribe and provide care that is linked to your EMR, like we do at Palo Alto Medical Foundation. What’s not clear is how your other public expressions, health-related or not, reflect on you. I only post things online that I’d be happy for anyone to know about, even when posting in a purportedly private place like a closed e-mail list or with Facebook friends. You never know who could copy some incriminating photo to send to your boss. (Not that I participate in any activities I want to hide, of course!)

With the anticipation of increased competition in the wake of healthcare reform, I believe physicians will have to engage online and become more transparent. An excellent example of what I believe to be the future is www.askdrwu.com, the website of surgeons Drs. Calvin Lee and Tammy Wu, who publish their statistics so you can see their experience and success rates. Educated patients will increasingly demand to know complication rates, and will spread the word about great surgeons who embrace transparency like these two old college friends of mine. The future looks bright for patients in terms of learning about safety and quality, and healthcare social networking will be a central part of that future.

Enoch Choi is an MDNG editorial board member, partner at Palo Alto Medical Foundation Urgent Care, and adjunct clinical instructor in internal medicine at Stanford Medical School. Connect with Dr. Choi at Facebook, Twitter, and LinkedIn.

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