“I found my diagnosis on the Internet”

Raise your hand if you’ve ever gone online in search of a diagnosis that fits your symptoms or to read everything you can find about a condition you’re dealing with or a new medication you’re taking. Now raise your hand if you’ve ever talked to your doctor about what you’re reading on the Internet.

The Internet has made a bottomless well of information readily accessible to anyone with an online connection. But it seems we’re still figuring out how to incorporate this fact into the doctor-patient relationship in ways that allow everyone to feel comfortable with it.

Doctors tend to cringe when patients show up for an appointment with a stack of printouts from the Internet.

Patients tend to resent it when the doctor ignores or dismisses their personal research.

Doctors may not mind their patients’ efforts to become more informed but they don’t always trust the patient’s ability to recognize whether a source is reputable.

Patients want to know how to evaluate a source’s credibility but they don’t know where to start.

These are some of the impressions I gathered earlier this week from a health care social media chat on Twitter that focused on, among other things, that pesky pile of printouts in the exam room. (For those who haven’t discovered the weekly tweetchat, it takes place every Sunday from 8 to 9 p.m. central time; follow along at #hcsm and brace yourself for an hour of free-wheeling, fun and insightful discussion.)







So what are we to glean from all of this? Although there doesn’t seem to be a single right way for patients to share health information they’ve found online, some approaches may be more helpful than others.

Most doctors don’t have time to wade through large stacks of printouts, so patients will probably have more success if they stick to summaries and as few pages as possible.

How the topic is introduced seems to matter. Is it an open-minded exchange or is it an argument? Is it respectful of each other’s perspective? Doctors have greater medical knowledge and hands-on experience but patients are the experts when it comes to their own experiences.

One of the conundrums is how to sort the wheat from the chaff. There’s a lot of questionable health information floating around online, but if patients haven’t learned to critically evaluate what they’re reading for accuracy and credibility, they can easily be led astray by misinformation. On the other hand, it’s hard for patients to develop these skills if their doctor is dismissive of their efforts and unwilling to provide coaching or guidance.

Frankly, the train has already left the station on this issue. A 2009 study by the Pew Research Internet Project found that looking for health information online has become a “mainstream activity.” Sixty-one percent of the adults who were surveyed said they used online sources for health information, and one in 10 said that what they learned had a major impact on either their own health care or how they cared for someone else.

But here’s another interesting finding: Patients whose doctors encourage them to search out health information online are, on average, more engaged in their care and more satisfied, regardless of whether they and the doctor agree on the information. In other words, it’s the participation and the open dialogue that really matter.

Quibbles over whether patients should talk to their doctor about health information they’ve found online are no longer the point. It’s time to move on to the bigger issue of how to have these conversations in the most beneficial way possible.

Making friends with the patient portal

I’ll disclose this up front: I’m a big fan of the concept of allowing patients online access to their medical information through a patient portal. Family members who live in the metro area have been using portals for a few years, and now this feature is available locally too.

Patient portals are promoted as a tool to help patients become more involved and engaged in their care. It’s still a little early to know whether this actually is the outcome; portals just haven’t been around long enough to build up a strong body of evidence in their favor.

At the very least, though, they make it easier for people to find out their lab results, double-check their prescription medication list, etc., by simply logging into their personal account. No need to make phone calls or leave messages. No waiting for results to arrive by snail mail. And seriously, is there anything more annoying than to be told only that your lab results or X-ray were “normal”? Show me the numbers, please.

Not that there aren’t naysayers. Many folks haven’t been very impressed by their experience with patient portals – for example, health communication guru Steve Wilkins, who recently was introduced to the portal offered by his doctor’s practice and was underwhelmed. He can send messages to the staff and request appointments and prescription refills but apparently not much else. “Asking is certainly different than doing in my book,” he reflected. “How the heck is this supposed to make me feel engaged?”

I’ve heard other complaints that some portals are very restrictive in how patients are allowed to use them, thereby limiting the benefits.

A couple of thoughts: First, patient portals won’t instantly remove all the obstacles in doctor-patient communication. They’re a tool, and their success will partly depend on people’s willingness and ability to use them as intended. I think there’s going to be a learning curve before the benefits become apparent. In the meantime, everyone needs to be somewhat patient and not demand results like, right now.

Second, simply offering a patient portal doesn’t automatically mean it has value, as Wilkins points out. Practices that only allow a handful of non-interactive features on their portal will probably be disappointed when few patients sign up or actively use the portal… but they really shouldn’t be surprised.

My prediction is that engagement will be highest when the portal 1) has multiple features that appeal to patients and create a useful tool for health care self-management; and 2) is actively promoted by medical practices as something their patients ought to try.

Patient portals might sound like nothing more than a new technological spin on the exchange of information that has always taken place between doctors and patients. But the reality is that they’re helping shift the fulcrum of engagement toward the patient. Our medical information was always available to us but it was often presumed that it didn’t have to be shared unless we asked to see it. Now the presumption is that of course our information will be shared without first having to ask for it. See the difference?

There’s a health app for that… but will it help?

If you’re someone like Jared Sieling, you’ll track everything you eat for weeks and then pore over the data to uncover your nutritional shortcomings. Other self-trackers monitor their heart rate during workouts, log how many steps they take each day or chart how far and how fast they perform on their daily run.

Are these “elite livers”, as some of them call themselves, a standout example of highly engaged health consumers or are they just, well, obsessed? And where does the average person fit into this?

The rising popularity of self-tracking was explored recently by the Star Tribune of Minneapolis, where a Twin Cities Quantified Self meetup took place this month. Sieling told the newspaper that self-tracking has helped him zero in on where his health habits could improve – more protein in his diet, for instance.

Most Americans track their personal health in some way or another. We weigh ourselves on the bathroom scale, check our blood pressure with a home monitor or wear a pedometer to count how many steps we take each day. As athlete Erin Klegstad told the Star Tribune, “I just like to see the numbers and [it’s] fun to watch it all. It’s taught me what my body can do and makes me push harder.”

But with the growth of hundreds of new apps, monitors and gadgets, self-tracking has reached a whole new level of data collection and analysis. Many people are starting to wonder: Are health apps really as beneficial as they’re cracked up to be?

Heart attack survivor and Heart Sisters blogger Carolyn Thomas attended a conference last fall in Silicon Valley, where she encountered a whole passel of mobile health app designers. All of them were convinced that technology is the answer to healthier living, but Thomas couldn’t help wondering if any of them knew what it’s like to be a real patient.

She writes:

It struck me that the imaginary patient using this technology wasn’t anything like me, or my readers, or most of the heart patients I meet or hear from or talk to on any given day. Instead, the patient that the hypemeisters talked about seemed to be some kind of fairy tale fantasy patient: tech-savvy, highly motivated, compliant, eager to track every possible health indicator 24/7, and most of all – oh, did I mention? – NOT SICK.

In other words, an apparent case of “healthy privilege,” or the tendency of the healthy to assume everyone else is like them, Thomas wrote.

Jessie Gruman, president and founder of the Center for Advancing Health in Washington, D.C., is recovering from stomach cancer and needs to eat something every hour, a task that takes time, planning and mental energy every single day. But when she downloaded a popular app to help keep a food diary, she found it was more time-consuming to use the app than to actually eat the food.

“I used the app for three days before I resorted to pen and paper,” she wrote a few months ago in an “Open Letter to Mobile Health App Developers and Their Funders.”

Gruman offers this real-life advice to the app people: 1. We will not use mobile apps that add to the time we spend caring for ourselves. 2. We do not respond well to nagging. 3. We favor apps that are linked to (or associated with) our clinicians.

There’s a big difference between those who use technology to track every aspect of their daily health and those who are living with chronic conditions and may not have the energy or commitment to use the technology in a meaningful way, Thomas writes.

“I do consider myself an engaged patient, but I do not own a smartphone, a 7-inch tablet, or an iPad – nor, as a person with a chronic illness living on a modest disability pension, could I afford them,” she writes.

Even the medical community is struggling to figure out the role that self-tracking can, or should, play in personal health.

Dr. Michael Joyner, a physiologist and professor of anesthesiology at the Mayo Clinic, told the Star Tribune of Minneapolis that the proliferation of health apps offers some hope for improving the management of chronic diseases. But at the same time, it’s possible to go overboard with detailed self-tracking, he acknowledges. “Are they living life or are they tracking life?”

Dr. Leslie Kernisan, who provides care for geriatric patients, recently pondered whether she should be prescribing apps – and if so, which ones?

Apps can be useful if they help patients meet their medical goals or provide information that’s clinically useful in some way, she wrote. “But I worry that we’ll end up making the same mistakes with apps as we’ve often made with the prescription of medications: recommendations based on marketing rather than thoughtful assessment of expected value, and prescription of apps for every little medical condition rather than choosing a few high-yield apps based on a whole-person approach to managing healthcare.”

Here’s some final food for thought: A 2011 consumer survey of smartphone users found that one in four health-related apps were used only once, and nearly three out of four were abandoned by the 10th use.

Are health apps mostly a niche technology for the worried well and the data junkies? Or do they hold some promise for real, live, actual patients in need of tools to help them manage their health in ways that are constructive rather than burdensome? At the moment, the answer isn’t at all clear.

The EHR: Love it, hate it; here to stay

In a world where information technology is inextricably entwined in how we live (when was the last time you spent more than 24 hours without online access?), it’s often baffling to see how slowly health care has embraced all things digital.

To be sure, most hospitals and medical groups are making progress. A majority of physicians now have the ability to e-prescribe, and it would be hard to find a health care organization that doesn’t use or store at least some patient information electronically. On the whole, however, there’s a long road ahead for many organizations to reach the nirvana of a fully integrated electronic health record that incorporates both clinical and billing information, allows information to be exchanged between providers and organizations, and makes the fullest use of technology to enhance care.

It prompts the question: Why?

Because adoption of an electronic health record system is neither simple, straightforward nor cheap, that’s why. It demands a major commitment from health care organizations – a commitment, moreover, that tends to be mostly invisible to patients and the public and may not offer an immediate payback.

The challenges of EHR implementation emerged in the details I learned while talking to staff at Rice Memorial Hospital here in Willmar about the hospital’s conversion to Epic last year.

Going live with the new system, which replaced six disparate health information systems across the hospital, involved a $4 million investment, a full year of planning and countless hours of training before flipping the switch on Feb. 1, 2012. One year later, Rice still has lots of work ahead to optimize the system and reach additional milestones that will qualify the hospital for the next stage in federal meaningful use criteria.

The hospital is starting to see some of the benefits – no more chasing down of paper charts, for one. But it’s not hard to realize why many health care organizations would hesitate to dive into EHR adoption when they know how time-consuming and resource-intensive it’s going to be.

Indeed, clinicians and health care leaders are often ambivalent over whether the EHR is an enhancement to patient care or an invention of Satan.

Consider the responses to a recent blog entry by Dr. Robert Wachter, one of the leading voices in the U.S. for patient safety, about the federal HITECH program to promote the use of information technology in health care.

Doctors used words such as “tedious” and “akin to torture” to describe their experiences with the EHR.

“My role anymore is about 50% practicing medicine and the rest being a data entry clerk,” one commenter complained. “It has overall decreased my efficiency rather than increased it. I really like some aspects of it such as drug interaction warnings and clinical reminders. There’s a lot I don’t like.”

From someone else: “Most of American medicine is not done in large clinics or hospitals with their own in-house IT staff and the burden on the rest of us has been near intolerable.”

Earlier this year the American Medical Association sounded an alarm over the federal push toward higher and higher levels of meaningful use, warning that it may be too much, too fast for many providers, especially in view of issues with software design and usability that haven’t been fully resolved yet.

There’s emerging evidence that although some aspects of the EHR are safer, such as replacing handwritten physician orders with computerized physician order entry, the technology also has introduced new potential for other types of errors. Although patient portals are part of the meaningful use requirements and are meant to encourage more engagement by patients, they tend to contain limited information, and organizations are beginning to find that the mere presence of an online portal does not mean patients will actually use it.

So what’s the good side?

A growing body of research confirms the benefits of information technology in making health care safer and creating new opportunities for mining health data to improve care. A survey last year of physicians found that the majority had few complaints about using an EHR and most also felt it helped make their practice more efficient.

Here’s what Dr. Wachter has to say to the critics:

Let’s pause to ask a few questions: Does anyone honestly believe that computerizing American healthcare is wrongheaded? Or that the correct strategy was to continue toe-tapping, waiting for “the market” to promote IT adoption when, in 2009, only 16 percent of US hospitals and doctors’ offices had functioning clinical IT systems? Or that they would like to be a patient, or a clinician, in a paper-and-pencil hospital?

I didn’t think so.

Love it or hate it, the electronic health record is clearly on its way to becoming a permanent part of the health care landscape. The challenge, it would seem, lies in constructively addressing the vulnerabilities of the EHR, supporting organizations through the transition, using feedback from clinicians to make EHR systems better, and trying to eliminate some of the pain inherent in the process so the electronic health record can begin to deliver all that its supporters have promised.

Does online patient access = better care?

When patients have online access to their medical record and the ability to email their doctor, does it lead to better care?

In theory, patient portals are supposed to improve communication between patients and clinicians and encourage patients to become more engaged in their care, thereby producing better outcomes. There has also been a belief that if patients can view test results online and have non-urgent concerns resolved via email, it would help cut down on in-person use of health care services and allow the system to function more efficiently.

But a new study, carried out by Kaiser Permanente and published last month in the Journal of the American Medical Association, has found that the case for efficiency might be wishful thinking.

Previous studies that have examined patient use of health information technology have mostly been small. This study was a large one, involving about 44,000 Kaiser Colorado members who had online access to their medical record and 44,000 who did not. Both groups were followed before and after the introduction of an online patient portal.

The results were surprising. Contrary to what the researchers expected, patient use of the portal was associated with more, rather than fewer, office visits and telephone calls. The researchers found an 8 percent increase in the volume of phone calls from these patients and a 16 percent increase in office visits.

Patients who had access to the online portal also made more visits to the clinic after hours, went to the emergency room more often and were hospitalized more often than those who weren’t signed up for the portal.

Is there a connection between online access to medical information and care-seeking behavior by patients? The study wasn’t designed to explore this, although Dr. Ted Palen, the lead author, speculated in an accompanying audio interview that patients who anticipated needing more care may have been more likely to sign up for the portal in the first place.

It’s an intriguing study because there’s still much that isn’t clear about how health information technology is shaping patient behavior and the impact this has on the delivery of health care. Which patients are more likely to use online access to their doctor and their medical record? Do patient portals foster more engagement? Are outcomes better for these patients? When a medical practice decides to offer an online patient portal, does it promote more efficient communication or does it create an extra burden?

This last point is important. An 8 percent increase in phone calls or a 16 percent increase in office visits might not sound like much, but when it’s applied across a system  with thousands of patients, it can add up to a significant impact, Dr. Palen points out.

Health systems considering the use of patient portals need to ask themselves whether they have the capacity to absorb a potential increase in utilization, he said. “You’d better plan for that.”

The findings from the study could further dampen the enthusiasm for online patient portals, which the health care system has been slow to adopt anyway. What we don’t know, however, is whether the additional office visits and phone calls were actually beneficial in some way to patient health, or whether there was a fundamental difference between the patients who signed up for the portal and those who didn’t.

The increased utilization may in fact have been “a good thing” if it led to better outcomes and health status in the long run, Dr. Palen said. But it seems far more study and analysis are needed to truly sort out the impact of patient-centered information technology and how to use it wisely, appropriately and effectively.

Demolishing assumptions about patients and the PHR

When a medical practice in Florida decided to survey its patients about whether they’d be willing to use a personal health record offered by the practice, the doctors figured those most likely to say yes would be younger, well-educated and higher-income. They also hypothesized that the likely users would be more health-literate.

As it turned out, they were right – but only by half.

Income and schooling made no difference and neither did age. What seemed to matter most was the patient’s health literacy (or, to be more accurate, the patient’s perception of his or her level of health literacy). Among the patients in the survey who said they were willing to use a personal health record, 65 percent self-reported high health literacy. For those who weren’t willing to use a PHR, only 38 percent estimated their health literacy as high.

Overall, three out of four who responded to the survey said they’d be willing to adopt a personal health record if the medical practice made this service available to them.

The results of the survey appear in a recent edition of the Perspectives in Health Information Management journal, and they raise some interesting questions about the assumptions that often are made regarding patients and information technology – e.g. that older adults don’t go online or less-educated individuals aren’t very interested in a personal health record.

Even the researchers were a bit taken aback by their findings. Alice Noblin, Ph.D., an assistant professor and program director for the Health Informatics and Information Management Program at the University of Central Florida, told the AMA’s Medical News Today, “I knew going in that it was a high Medicaid population, so the demographics didn’t surprise me. But how they felt about the PHRs, yes, I thought they would be a lot more unwilling to get involved with it, but definitely, most of them were interested.”

To be sure, this was a small survey, involving only 562 patients at just one medical practice. Nor was it able to predict whether these patients would translate their willingness into action if an online personal health record became available to them.

One of the lessons, however, seems to be that the medical community shouldn’t take for granted that most of their patients are indifferent to technology – and they shouldn’t underestimate patient interest in PHRs either.

A couple of the more intriguing findings from the survey: More than half of the patients who participated in the survey had a high school education or less, yet 71 percent in this group said they were willing to use a personal health record. And although nearly 60 percent of the respondents were in the lowest income category ($20,000 a year or less), three-fourths of them were interested in using a PHR. Most of the survey participants also were middle-aged and older.

Now for another statistic: Nationally, use of personal health records has been placed at around 7 percent of the total patient population – a very low figure when you consider the extent to which people are using information technology in other areas of their lives.

It’s not clear why there hasn’t been more uptake. Some of this can be traced to people’s concerns about privacy and security; unlike the electronic medical records maintained by hospitals and medical practices, the personal health record is maintained by patients themselves. Some of it could be due to the amount of hunting and gathering often required for consumers to create a PHR that’s complete and accurate. Actual use also somewhat depends on the PHR’s design and whether it’s easy or cumbersome.

But much of it simply might be a result of a general lack of awareness and patient education. Would it help if medical practices took a greater lead in discussing and promoting the PHR with their patients?

This particular survey was commissioned by a medical practice that wanted to offer a PHR and wanted to gather some data before making a final decision. Although many health care professionals remain ambivalent about how much information should be placed in the hands of patients, this small study suggests patients are more receptive than providers might think – and furthermore, that patient interest cuts across the demographics of age, income and education. It remains to be seen how the gap between what patients say they want and what providers assume they want can somehow be narrowed.

A (flu) shot in the arm

When I rolled up my sleeve last week for my annual flu shot, I was given a new option: an intradermal injection, using a microneedle to deliver the vaccine into the skin instead of the traditional intramuscular stab in the arm.

Who knew the choices for receiving a flu shot could multiply so quickly in just the past 10 years? First there was the introduction in 2003 of FluMist, an inhaled version of the flu vaccine that does away with shots altogether. Now there’s the microinjection – still a shot, technically speaking, but with considerably less of the ouch factor; it involves an ultrafine needle that’s 90 percent smaller than the usual flu vaccine needle and penetrates no deeper than the top few layers of skin.

Many of us could use a guide to what’s available in the world of flu shots these days, and who’s eligible for what. Here’s a quick rundown, courtesy of the U.S. Centers for Disease Control and Prevention:

Regular flu shot: Suitable for most people; not approved for infants younger than 6 months. The regular vaccine accounts for most of the flu vaccine administered in the United States each year. It is given as an intramuscular injection, usually in the upper arm. The vaccine contains inactivated, or killed, influenza viruses. Side effects can include soreness, redness or swelling where the injection was given, muscle aches and low-grade fever.

Nasal spray flu vaccine: An aerosol form of the vaccine that’s given as a spray into the nose. Because it’s made with a weakened form of the flu virus, it’s recommended only for healthy individuals between the ages of 2 and 49. Anyone older or younger than this or who has a chronic condition or other risk factor should not receive the inhaled version of the influenza vaccine. The most common side effects among children include runny nose, headache, wheezing, vomiting, muscle aches and fever. Typical side effects for adults include runny nose, headache, sore throat and cough.

Intradermal flu shot: Administered with a prefilled microneedle into the top layers of the skin. This version of the influenza vaccine was introduced in the 2011-12 flu season. It was offered on a limited basis last year but has become more widely available this year. Besides being somewhat gentler than the traditional flu shot, it contains 40 percent less antigen, meaning it requires a lower amount of active ingredients to deliver the same flu protection as the traditional vaccine. Otherwise, the intradermal flu shot works in the body the same way as a regular flu shot and protects against the same three strains of flu as other yearly versions of the flu vaccine.

Intradermal flu shots are FDA-approved for adults ages 18 through 64. Side effects include redness, swelling, pain, toughness and itching at the injection site. These side effects seem to be somewhat more common with this form of the flu vaccine than with regular flu shots. Other side effects that have been noted include headache, muscle aches and fatigue.

High-dose flu vaccine: Designed for adults 65 and older. The high-dose vaccine contains four times the amount of antigen as a regular vaccine and is intended to provide greater protection for older adults whose immune systems have waned with age. It’s given as an intramuscular shot, the same as the regular flu vaccine.

High-dose flu vaccine is not recommended for older adults who have had a previous severe reaction to a flu shot. As with the intradermal vaccine, side effects seem to be reported more frequently; they include pain, redness and swelling at the injection site, headache, muscle aches, fever and overall malaise.

Although it’s a welcome development to have more options, it puts more burden on the consumer to make an appropriate choice. Aside from eligibility, one of the key questions is this: Regardless of which form of the flu vaccine you choose, will it be effective?

By now, the nasal spray has accumulated a substantial 10-year track record of safety and reliability, especially among children. Some research suggests it’s less effective in adults, however, and the recommendations for who can receive it remain limited to healthy individuals ages 2 to 49.

Because the intradermal vaccine is newer, there are fewer studies that have examined its effectiveness. But most of the researchers’ conclusions are positive, and one study even found that this form of the flu vaccine worked better in older adults. As intradermal flu shots gain wider use, stay tuned for more information evaluating their safety and effectiveness.

One thing on which there’s a clear consensus among the researchers: Whether it’s a shot in the arm, a spray up the nostrils or an injection into the skin, the flu vaccine only works in those who actually receive it.

Worrying ourselves sick

You have a headache that won’t go away. In search of more information, you Google your symptoms and discover you might have eyestrain or tension. Or food allergies. Or meningitis. Possibly even a brain tumor.

How can the average person make sense of all the health information available on the Internet?

Often they can’t, and it may be to their detriment, suggests an American Medical News article outlining the increased anxiety some doctors are seeing among patients who research their symptoms online.

From the article:

The increase in using the Internet to self-diagnose comes at a time when many physicians are encouraging patients to be more involved in their medical care to help improve health outcomes, particularly for chronic illnesses. Some health professionals say researching medical concerns on reputable websites can be a positive step for patients, because it helps them become more educated about their health. In doing so, patients sometimes accurately diagnose themselves, particularly when it involves common illnesses, such as appendicitis and strep throat, doctors said.

More often, though, the large number of health websites, some of which are unreliable, mislead patients into thinking they have a medical problem, say health professionals. They say the outcome frequently is heightened patient anxiety and unnecessary screening tests that can result in medical complications. Cyberchondria also demands that physicians spend more time in office visits as they discuss why the individual thinks he or she has a particular disease, educate the patient on why that diagnosis is unlikely and then determine the true cause of the symptoms.

I can attest to some of this firsthand. For the past decade I’ve belonged to an online lymphoma discussion group. Lymphoma is one of those cancers whose symptoms are often vague. It isn’t easy for the layperson to distinguish between fevers and enlarged lymph nodes that might be a sign of lymphoma vs. fevers and enlarged lymph nodes that are a sign of something more benign, such as an infection.

On a regular basis, people join the group who haven’t been diagnosed with lymphoma (often they haven’t even had a biopsy yet) but are worried sick they might have it because of what they read on the Internet. Most of the time their fears turn out to be unfounded. In fact, some of the staunch old-timers in the group have started issuing a standard line of advice to these folks: Get off the Internet until you’ve had a chance to talk to your doctor and/or have a formal diagnosis. Some are reassured by this but others aren’t, and their distress can be painful to see.

A little bit of worried-well behavior is not necessarily bad. Sometimes it can prompt people to take necessary action. Sometimes the patient even turns out to be right. At what point, however, does it cross the line?

A question worth asking is whether cyberchondria is just another form of the classic hypochondria, amplified by easy access to online health information. Academic studies on cyberchondria seem to be few and far between. (When I conducted a search via the U.S. National Library of Medicine and National Institutes of Health, I found exactly five published reports.)

The most recent study appeared last month in the Journal of Anxiety Disorders. It explored whether health anxiety is linked to the online use of health information and concluded that yes, there’s an association and that individuals who already have underlying anxiety about their health can become worse the more time they spend researching health information online.

Perhaps this is at least partly a matter of degree. It’s one thing to worry; it’s quite another for the anxiety to escalate into full-blown hypochondria, which can become so obsessive as to interfere with careers, relationships and quality of life.

Among those interviewed by American Medical News was Dr. Rahul Khare, an assistant professor in the Department of Emergency Medicine at Northwestern University Feinberg School of Medicine in Chicago. Dr. Khare said he’s seeing an increase in cyberchondria, especially among young adults who show up in the emergency room after researching their symptoms online.

Patients are “way more knowledgeable” than they used to be, he noted. “But too much information without proper guidance can cause anxiety or fear.”

I don’t think we’d want to return to an era when patients were told a minimum of information and paternally advised not to worry. The challenge these days is just the opposite: learning how to sift through vast amounts of data and figuring out which pieces are relevant and which aren’t. It gives me a whole new respect for what it takes to learn how to think like a doctor.

Distracted at the bedside

The patient was seriously sick and in the hospital. The doctors had doubled the dose he was taking of a blood-thinning medication to reduce his risk of stroke. But after evaluating his case a couple of days later, they decided to temporarily discontinue the medication and obtain an echocardiogram to make sure the drug was still needed.

A doctor-in-training took the order. As she began entering it in her smartphone, she was distracted by a text message about an upcoming party. She texted a response, the medical team moved on to the next patient… and the order to stop the medication was never completed.

Four days later the patient was rushed into emergency open-heart surgery to stem internal bleeding caused by too high a dose of blood thinner.

This real-life case appears in the online Morbidity and Mortality Rounds of the U.S. Agency for Healthcare Research and Quality and offers an alarming example of an issue that’s becoming increasingly prevalent in health care: the distractions and multitasking associated with information technology.

If the news coverage lately is any indication, there’s reason for growing concern.

The AHRQ case report is but one instance. Although the patient fortunately survived, it was at the cost of a potentially risky emergency surgery and lengthier hospital stay.

A recent article in the New York Times cited several other examples. In one case, a neurosurgeon apparently got distracted while using a wireless headset to make personal calls in the OR, and the patient wound up partially paralyzed. Other examples included a nurse checking airfare prices online during spinal surgery, intensive care unit staffers using hospital computers to visit eBay and Amazon, and technicians texting or talking on their cell phones during surgery.

It had to happen, I suppose. Smartphones, texting, tablets, Twitter and the like are such a common part of everyday life that it’s inevitable they would spill over into the health care setting. What’s concerning are the implications for patient care, where the stakes are so high.

From the New York Times article:

“You walk around the hospital, and what you see is not funny,” said Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center in upstate New York, who added that he had seen nurses, doctors and other staff members glued to their phones, computers and iPads.

“You justify carrying devices around the hospital to do medical records,” he said. “But you can surf the Internet or do Facebook, and sometimes, for whatever reason, Facebook is more tempting.”

“My gut feeling is lives are in danger,” said Dr. Papadakos, who recently published an article on “electronic distraction” in Anesthesiology News, a journal. “We’re not educating people about the problem, and it’s getting worse.”

Patient safety is clearly the most critical issue, but technology may also be exacting a toll on the human connection so essential in health care. Josephine Ensign, a nurse practitioner and blogger in Seattle, last week described an encounter outside a hospital elevator with three employees absorbed in their smartphones.

“Their smartphones collided, and they looked up dazedly, sheepishly apologizing as they stepped on to the elevator,” she wrote. “Then all three resumed communing with their smartphones.”

She writes:

When my father was in the hospital last year, I noticed that his nurses spent much more time on the mobile computer stations outside of his room than they did in direct patient care. He had some terrific nurses, and they told me that they hated how much time they had to spend in checking and entering patient data in the computers. The legitimate use of technology in health care is all in the name of patient safety. But at what cost does it come in terms of the human interaction necessary as the core of all healing?

I’m not sure what the answer should be. Outlawing mobile devices and computers is simply not going to happen; after all, there’s a worthwhile place for technology in health care. And when technology is done well, it can enhance care and increase safety, observes Dr. John Halamka, chief information officer at Beth Israel Deaconess Hospital in Boston and chief information officer and dean for technology at Harvard Medical School.

The real issue seems to lie in the day-to-day details, Halamka writes in a commentary accompanying the AHRQ case study. “Mobile devices are becoming an increasingly important part of the clinical workday. Leveraging the benefits while applying technology and policy risk mitigations will result in their optimal use.”

Read more about it here and here.

Photo: Wikimedia Commons

Trend-spotting in health care

We’re still a few weeks away from 2012, but apparently it’s not too soon to take a look at some of the trends shaping what happens in health care next year.

Pricewaterhouse Cooper LLC issued a report last week on the top 12 trends to watch in 2012. Their summary of the findings:

In 2012, health industry organizations will connect in new ways with each other and their consumers as they wade through economic, regulatory, and political uncertainty. Some are stepping forward in cooperation; others are rewriting the rules of competition.

Among the key issues, we’ll see value move from theory to reality, investments ramp up in informatics, the effects of drug shortages, insurers gear up to compete in a new insurance exchange marketplace, pharma companies slim down and healthcare increasing its social media presence.

That’s the view from 90,000 feet. But what does it all mean for the ordinary person? Here’s how some of these trends might show up at the level of the patient/consumer experience:

– Expect to see information technology, i.e. computers, become much more widespread, from the hospital room to the exam room.

– Out-of-pocket costs for health care will continue to rise, forcing many people to think harder about whether to seek care at the doctor’s office or the emergency room. In a survey by Pricewaterhouse Cooper, nearly half of the respondents said they had decided to skip a doctor visit or prescription drug in the past year because of the cost, and one in 10 had done so at least five times.

– Value will be important. Health organizations are under growing pressure to deliver quality, affordable care that keeps their patients satisfied; those that fall short could wind up being financially penalized. Patients can expect to see more surveys asking them for their opinion.The real test, of course, will be whether patient preferences lead to meaningful changes in how care is provided.

– Look for care delivery systems to become more integrated. There are many incentives to do so: efficiency, savings and better coordination of care. According to Pricewaterhouse Cooper, health insurers invested $2 billion last year to acquire or align with physician groups, clinics and hospitals. For patients, there could be more confusion in the short run as the players reposition themselves on the chessboard. In the long run, though, it’s believed that care will be better when it’s less fragmented. Whether this actually will become the case remains debatable; the concept of “accountable care organizations,” contained within the 2010 health care reform bill, has plenty of critics.

– A retail spin is coming to the health insurance market. States are expected to start certifying health plans in October 2012 for participation in health insurance exchanges, allowing consumers to shop for their own health care coverage. This could be a real benefit for people who aren’t otherwise able to obtain affordable health insurance. But the option could be underutilized if consumers don’t have enough information or education to compare plans and make good decisions.

– Is your hospital or clinic on Facebook? If not, they risk getting left behind. The social media are emerging as an important way of reaching out to patients and the community. One-third of the respondents in the Pricewaterhouse Cooper survey – and half of the respondents under age 35 – said they had used social media channels to connect with health care organizations or with other people with shared health interests.

Euro RSCG, a global marketing and communications agency (and the same company that forecast the concepts we now know as corporate social responsibility and helicopter parenting), last week issued its own trend outlook.

The top five trends identified: a rising use of medical tourism, telemedicine and personalized medicine; an increasing worldwide incidence of diabetes; and a rise in cyberchondria, or the tendency of people to Google their symptoms and misdiagnose themselves. According to Euro RSCG, all five of these trends signal a cultural shift in the attitudes, beliefs and values that shape how we think and talk about health care.

Photo: Wikimedia Commons