Category Archives: e-health

Actually, there are clinical trials for health information technology

HIT research: Has to be in there somewhere!

HIT research: Has to be in there somewhere!

The New York Times Bits blog (The Lessons Thus Far From the Transition to Digital Patient Records) concludes its post on the ups and downs of health information technology by asserting the following:

In health information technology, there are no clinical trials or tests with randomized controls, as there are for drugs, for example. True, digital data does not go into the body, but it can increasingly guide what does.

Actually, high-quality studies of medical decision support tools are quite common. For example, here’s the abstract of a recent study (Evidence-Based Decision Support for Neurological Diagnosis Reduces Errors and Unnecessary Workup) published in the Journal of Child Neurology:

Using vignettes of real cases and the SimulConsult diagnostic decision support software, neurologists listed a differential diagnosis and workup before and after using the decision support. Using the software, there was a significant reduction in error, up to 75% for diagnosis and 56% for workup. This error reduction occurred despite the baseline being one in which testers were allowed to use narrative resources and Web searching. A key factor that improved performance was taking enough time (>2 minutes) to enter clinical findings into the software accurately. Under these conditions and for instances in which the diagnoses changed based on using the software, diagnostic accuracy improved in 96% of instances. There was a 6% decrease in the number of workup items accompanied by a 34% increase in relevance. The authors conclude that decision support for a neurological diagnosis can reduce errors and save on unnecessary testing.

The government and healthcare providers are investing a fortune in health information technology. A lot of time, effort and cash has been spent on installing EHRs and getting the initial data into them. But the real clinical and financial value will come from using the information in electronic health records for better communication and clinical decision making.

The Times does readers a disservice by asserting that high quality clinical trials aren’t and can’t be done.

photo credit: dullhunk via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group

eVisits: the 30 year march?

This guy moves faster than eVisit adoption

This fella moves faster than eVisit adoption

When I first started working in healthcare I was told that innovations can take a long, long time to be adopted. Now I’m old enough to have experienced it for myself.

The big news in the Seattle Times this week?

“To cut medical costs and diagnose minor ailments, WellPoint and Aetna, among other health insurers, are letting millions of patients get seen online first.”

“In a major expansion of telemedicine, WellPoint this month started offering 4 million patients the ability to have e-visits with doctors, while Aetna says it will boost online access to 8 million people next year from 3 million now.”

This has been a long time coming, and we’re still at the early stages of adoption, with plenty of naysayers remaining. I first worked on eVisits (or webVisits) in 2001, when Healinx (now RelayHealth) commercialized them. Researchers at Stanford and UC Berkeley studied the webVisit and concluded that their use cut total medical costs while improving patient and physician satisfaction. Here’s a press release from January 2003 on the study (Final Results: webVisit(SM) Study Finds RelayHealth Reduces Cost of Care While Satisfying Doctors and Patients).

Here’s what I said about it five years ago (eVisits continue their slow, steady rise) –before the iPad, Meaningful Use, or the Affordable Care Act:

It’s interesting to be in late 2009 and see e-visits described as a “disruptive innovation” that “the medical establishment is fighting.”  It’s a sensible concept, fairly straightforward to implement, efficient, and effective for certain situations. Yet growth has been slow. Part of the issue is that it’s health care we’re talking about, where innovation tends to be retarded when it involves changing physician practices. Another, related problem is that there’s no great financial incentive for the physician or patient to make a change. Health plans that do cover e-visits often charge the same co-pay for patients as for in-person visits, even though they often reimburse physicians at a lower rate.

My guess is that over the next decade we’ll see e-visits become common. Why?

  1. Adoption will follow the typical S-shaped curve, and we’ll soon get to the steep climb almost regardless of other changes
  2. More patients and physicians will simply expect to communicate online, as they do in every other area of their personal and professional lives
  3. Payment systems will evolve to support e-visits, rather than penalize them
  4. Adoption of electronic systems in physician offices in general will enable e-visits
  5. Supporting technologies will evolve and emerge. These include remote monitoring, higher bandwidth, personal health records, and mobile applications

Enjoy the next decade and don’t expect things to change too quickly.

Halfway into the decade these five factors are still playing out. Having said that I could probably have just reposted the article and changed the date and no one would have noticed.

Will things speed up dramatically over the next five years? In 2019 will we still be reading articles about this “novel” approach? I hope not but fear that we may.

photo credit: Nasitra via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group



First Opinion: Online doctor consults for the masses (interview transcript)

This is the transcript of my recent podcast with First Opinion COO, Dr. Vikram Bakhru.

Hey doc, let's chat

Hey doc, let’s chat

David E. Williams: This is David Williams from the Health Business Group. I’m speaking today with Dr. Vikram Bakhru, chief operating officer of First Opinion, an app that allows patients to text with doctors. Users get one free consult per month and keep the same doctor from visit to visit. Additional consults are as low as $2 per month and unlimited sessions are $25 a month.

Vik, do I have that right? And if so, how do you do it?

Vikram Bakhru: That’s exactly right. Our founder, McKay Thomas, basically set out to figure out a way to get people access to healthcare affordably and on their own schedule, as opposed to having to go and wait in stuffy waiting rooms.

In January 2013, he started First Opinion, and it’s come a long way since then. The app was officially launched in December 2013 and it’s been a wild ride over the last six months. Specifically, we enable families to text the doctor anytime, day or night, with simple and complex questions. We are there and able to get people answers quickly in under five minutes.  That is what we strive for.

The one free question a month is basically a way to get people oriented to the service and then if they like it, they can absolutely go ahead and get some more.

Williams: It’s obviously a broad market. You can go in any direction. However, I do notice on the app it focuses on families with kids. I noticed that all the doctors you advertise are moms, and when you get on the app it asks questions like how many kids do you have? Is it really focused on families? Tell me a little bit about the thinking on that positioning.

Bakhru: Right now, we are focused mainly on moms and moms-to-be. The idea there was that the mom is really the center of the household. They are the ones who are coordinating care and making sure everyone’s healthy and fed and doing a lot of the typical functions that we see in our country. What better way to support them than to provide them with easy access to a doctor anytime they feel they need to reach out and get information instead of having to jump on a video conference call or search the Web and sit for an hour trying to find the answer.

We want to provide accurate, credible information very quickly and we’re getting there. We’re off to a good start.

Williams: There are all sorts of permutations for telehealth or the telemedicine model. Some use physicians, others nurses, or nurse practitioners or PAs. Some are real-time, some asynchronous. Some are charging a large amount or a small amount, whether it’s incorporated with the insurance or not, whether it’s US practitioners or those that are overseas.

Can you help the listeners to understand where First Opinion fits in the overall eco-system of telehealth or however you define your broader universe?

Bakhru: Sure. We believe we provide the most accessible way to get in touch with the doctor. These doctors have graduated from some of the world’s top medical schools. They are not all based in the United States but they are all moms. As we discussed earlier, they really understand the people that are trying to get in touch with them and they’ll respond. They’re there to answer whatever is on the user’s mind and to actively go back and forth.

In our space many other companies are pursuing a limited model where users get access for ten minutes or get access to a follow-up with the company emailing them. What we really have strived to do is give direct access to the doctor. That’s really what it’s about. We have immense respect for other providers in our healthcare eco-system as you put it. We also believe that there’s value in just communicating to the doctor, just texting back and forth and getting information from the person users trust a great deal. And through our service, we’ll hopefully gain the trust as users get to know them better.

Williams: Another piece that I found interesting is that it seems that when somebody is assigned to a physician, they actually stick with the physician. So it’s not just an “on-demand, who’s available” model like most companies inside healthcare or outside of healthcare. Do I have that correct?

Bakhru: Yes, our clients, the moms and dads who use our service are constantly giving us the feedback that it is awesome to not have to explain what was going on three days ago, for example. The fact that we’re able to provide that consistent access to a doctor is really important to the people who use our service today.

We are really excited that we’ve been able to figure out a way to do that and most telehealth providers haven’t yet. Like you said, you get in touch with a different doctor each time you call in and it can be $40 or $50. On our platform, it is $25 a month, or $2 to $4 as you noted previously, which is very affordable for the majority of America.

Williams: If you look at what you’re doing, it seems to be in stark contrast to the way primary care is moving in general. If I look at the typical primary care practice, they’re focused on having the physician be the quarterback and then there’s all sorts of other professionals, whether they are nurse practitioners, physician assistants, nurses, administrative folks, or social workers for example, that are being leveraged, partly with big investments in electronic medical records, and other kinds of information technologies to get there.

On the other hand, it seems like what you have is more of an individual physician. From what I can tell anyway, it is light on the data side of things and more focused on responsiveness, accessibility and dealing directly with the doctor. Is that the approach?

Bakhru: That’s an accurate summary for the most part. We certainly have stayed away from big expensive electronic medical records that are so impersonal and don’t really allow you to connect to another human being, to a doctor who can provide the most immediate, accurate information.

We feel that we’ve taken on a different approach than what the trend is and I think we’ll find over time that the two actually are complementary. You do need a model that we’re moving in the direction of that allows you to connect with different providers based on the severity of what is going on. But when you’re at home, sitting on the couch, dealing with a child that has a 103 fever and wondering whether you need to go to the ER or whether you should call your pediatrician’s office a fourth time – because by the way you already called them three times and now you’re really wondering if you should reach out again – we’re there for you in those moments and we’re there to help provide clarity.

We don’t see ourselves as providing advanced cancer care. We certainly aren’t the company to call if you need in-depth analysis of a very complex illness. We are helping you get access to the primary care.  Seventy percent of office visits are informational, so let us be that provider of information for you and you can get that information by talking or texting to a real doctor instead of searching WebMD.

Williams: Let me follow up on that point about how what you do may be complementary to primary care practice. I know I’m not the only one who has good insurance, good relationship with the primary care physician and practice and still has situations like you described where you are wondering is it really worth the trouble to go and try to connect with the physician’s office? A minor or unexpected issue still involves a lot of activity in order to get it dealt with. And so, I and I think many others like me may have a physician or a nurse or somebody in their family that they turn to instead of an office visit.  I’m sure looking at your background, you probably have family members that do the same thing.

Are you positioned in a way that you can be complementary to a primary care practice and complement the activity with the patient’s physician’s office? In other words, might the doctor from First Opinion actually be in direct contact or help the patient be in contact with their primary care office?

Bakhru: We haven’t ruled that out from the realm of possibility. But today, we provide an accessible service directly to moms and dads who need access to a doctor right away. And over time, I would love to see us be able to insert ourselves into the normal flow of patient care. But today we’re a new company. We’re a year-and-a-half old and we’re doing a lot with a lot of different families.

Right now, we’re focused on making sure we provide a really great service and do it really well to the people who rely on us.

Williams: I’ll go back to my first introductory point about it seeming to be too good to be true in a sense. You’re offering quite a lot for not a lot of money. I want to delve into that a little bit more. One way that it could be done is this is a teaser rate and once people are used to the service, the price is going to go up. Another possibility is that you’ve got some other sort of business model, where you’re doing for example, some sort of data mining that’s going to be of use to marketers. Another way is certainly finding places where physicians are not as well-compensated as they are in the US.

Are some or all of these the case? I noticed that when I tried out the service, my physician was overseas in India. But what about those other pieces? Is it a teaser? Is there some business model above and beyond the actual just fee-for-service?

Bakhru: No. Today, our plan is not to increase the price that people are paying for chatting, texting, or consulting a doctor. And you’re right, many of our doctors are overseas, but they’ve gone to some of the best medical schools in the world. They go through a rigorous training and certification process that I, along with the rest of our team, has built. I’m fully confident that we’re offering good information to our users and I remain excited that we can actually do this at a very affordable price.

Our hope is that people come to us, try out the service and decide that they want to be able to purchase and actually continue the relationship with their doctor, and continue to have access to that same person day in and day out. Over the long term, it would be really great for these families to actually get to know the doctor on a level that you just wouldn’t’ be able to achieve, I think, in the current healthcare system, the way it’s set up right now.

To your earlier point, it is far too volume-focused. And the solution to that volume problem seems to be engaging different types of clinicians and practitioners. As I noted earlier, I think that’s appropriate. We are in an environment that allows great care to be delivered by a diverse group of people.  But it’s also nice to just have access to a doctor and be able to just ask a question. Just ask a question when it pops into your mind and reach for your phone and you’re able to get the information that you want.

Williams: Pure texting is a fairly narrow bandwidth communications medium. Is there a way that a doctor at First Opinion can send or receive things like links to other resources? What about reviewing an image of a rash or something like that? Would you expect or is there today the opportunity to go beyond the simple texting and would you see that as a potential place for expansion in the future if not?

Bakhru: Surprisingly, we have found that texting is actually one of the most convenient mediums to go back and forth with someone. I think we are in an environment where people are very accustomed to small bits of information and trying to go back and forth rather quickly. That has served us well so far. Today, we haven’t seen the need to expand that relationship to include a phone call or other media. I can envision that being an add-on service in the future or something that we look to develop based on feedback from our moms and dads that are on our platform.

But today, we are able to actually accomplish about 90 to 95 percent of what people need in a very simple, easy-to-use interface. It allows users to go back and forth with the doctor in just a handful of minutes each time. And there are consultations that people are purchasing, or receiving, one free per month and that doesn’t have a limit of characters or time, or number of questions that you can ask. It is really about convenience and access to a real doctor in real time. So far, that’s been meeting the needs of our users.

I wouldn’t take anything off the table in terms of what we want to do as a company. We’re out to change healthcare and truly allow people the access that they used to be able to receive relatively easy. But now, it just seems as you noted earlier too, a burden to call your doctor. Take a half day off from work, go sit in the waiting room and finally when you get seen you have ten or fifteen minutes of face time, which might be enough for one issue. But what if you have three issues on your mind? All of a sudden, it’s this very delicate dance on trying to respect the doctor’s time but also wanting to get your needs met.

We’re excited about the product that we have today and the simplicity that it offers for moms and dads to just reach out to a doctor about their own healthcare needs, about their kids’ needs, whether it’s a fever or a rash.

To your point, there may be a role for pictures through the platform, especially as we talk about rashes. But that’s also one in twenty questions. The other 19 are usually solved by the simple back and forth of just communicating information. It’s shocking how straightforward healthcare can actually be if you have the right mix of technology and access to doctors that are really, really good and willing to be innovative in how they approach patient care.

Williams: This service is focused on consumers today. Do you see a business-to-business model as well or would you expect it to always remain in the realm of the consumer?

Bakhru: We really like being able to interact directly with the moms and dads who come to us for their questions. But if our goal is to access moms and dads,  we can provide our service to them in a variety of ways. Today it is all about promoting the service and trying to get people to understand what we do and to give it a test run.

But there may be opportunities out there that allow us to bring online content live. To be the next step when someone reads an article and perhaps wants to chat about what they read. Or wants to see if what they have matches what the computer says they have, or the Internet article says they have.

So are there business-to-business opportunities out there? I imagine that there are and I’m excited when the time allows for us to pursue those. But right now, we are just inundated. I wouldn’t say overwhelmed because I think the team is doing a fantastic job managing everything that’s on our plate, but I would say that we’ve got our hands full. It’s been a wonderful six months since the application launched and we are so excited for what the future holds.

Williams: I’ve been speaking today with Dr. Vikram Bakhru. He is chief operating officer of First Opinion.

By healthcare business consultant David E. Williams of the Health Business Group


Health Business TV: Obamacare premiums, First Opinion, Healthcare Compass, and more

In the second edition of Health Business TV, I discuss Obamacare exchange premiums for 2015, the First Opinion app for inexpensive doctor/patient texting, the launch of Healthcare Compass for comparing primary care practices, and the results of last weekend’s Massachusetts Democratic party convention.

Please subscribe to the YouTube channel and tell your friends!

By healthcare business consultant David E. Williams of the Health Business Group

Healthcare Compass: Comparing primary care quality in Massachusetts

Massachusetts Health Quality Partners (MHQP) just launched Healthcare Compass, an informative and easy-to-navigate site for patients seeking comparative information on the quality of physician practices in the state. The site presents data on 19 elements of patient experience and clinical quality for adult practices and 14 for pediatric practices.

For example, patient experience includes feedback on how well doctors communicate with their patients and willingness to recommend the provider to family and friends. Clinical quality includes measures such as yearly follow-up to monitor patients on long-term medication and appropriate use of imaging for lower back pain.

I tested the site out and recommend it for those who are seeking a new primary care doctor or who are curious about how their current practice compares with others.

Local practice comparison

Local practice comparison

Here’s what I especially like:

  • The information presented is based on sound methodologies. Sample sizes are significant and where there is insufficient data (pretty rare for the practices I reviewed) no rating is given
  • The ratings are done on a three point scale (full circle, half circle, empty circle) and all three ratings are used, even for some of the top practices
  • It’s possible to compare multiple practices on one page
  • Each rating has a clickable link that provides four tabs: a summary of the measure and how it’s derived, what you can do, what your doctor can do, and helpful resources
  • Every comparison page can be emailed or printed
  • In general, the ratings are consistent with my perception of the strengths and weaknesses of the practices with which I am familiar
  • The organization behind the ratings (MHQP), is an independent, multi-stakeholder collaborative whose goal is to provide useful, unbiased information. You don’t see advertising on this site or some other business model that exploits the consumer

Of course, one website is not going to provide everything one could want. I do have a wish list of things I’d love to see, perhaps in future iterations of the site

  • Information is presented at the practice site level. There is no information on individual physicians. The practice site level does have real advantages: many of the measures are more reflective of the practice than the doctor, it helps with achieving statistical significance, and it keeps physicians from rebelling against the ratings. Still, some measures such as “how well doctors communicate with patients” are doctor specific and in my experience there is real variation within a practice
  • Users can compare specific practices that are close to a specific zip code or address. That’s useful but it prevents patients from generating a ranking of the top practices. I would be willing to travel if practices elsewhere were significantly better than those near my home
  • The measures are all interesting and useful on their own, but there’s no composite measure. The closest is “willingness to recommend,” which incidentally is the only measure expressed on a percentage basis. My practice gets a top rating on tests to monitor kidney disease and a poor rating on yearly follow-up to monitor patients on long-term medication. It’s hard to make a decision on that basis
  • The physician search functionality is somewhat weak. Put in a name like “Smith” and the site will bring up several practices but without revealing which Dr. Smith it is. (Joe Smith? Patti Smith? Smith Wesson?)
  • The information is limited to primary care. I don’t know that MHQP is in a position to do much about that in the near term but I put it out there because it’s important

All in all, Healthcare Compass is a great edition to the resources available to consumers.


By healthcare business consultant David E. Williams of the Health Business Group

First Opinion: Online doctor consults for the masses (podcast interview)

Hey doc, let's chat

Hey doc, let’s chat

The dominant trend in primary care is toward large group practices where more and more patient encounters are with NPs, PAs and other professionals rather than MDs. Co-pays are rising, and so-called patient-centered medical homes are leveraging electronic health records in the pursuit of “population health.”

Against this background, First Opinion, an iOS app, is going more or less in the opposite direction. The company allows users one free text-based consultation a month. Additional consults cost as little as $2, while unlimited sessions are $25 per month (the same as my primary care co-pay). What’s more, once a user is assigned to a physician they stay with that doctor –they don’t get switched every time they connect.

I tested out the service and think it has some potential. It’s a take on the concept of “virtual medical tourism” that I proposed years ago. My physician is in India –technology lets us bridge the long distance.

In this podcast interview, I discuss the company in depth with Dr. Vikram Bakhru, First Opinion’s Chief Operating Officer.

By healthcare business consultant David E. Williams of the Health Business Group


Castlight Enterprise Healthcare Summit: Magic and the President

Castlight Health is expanding beyond its origins in cost transparency, today announcing the Castlight Enterprise Cloud, which includes four “solution centers” — that encompass analytics, incentives, and personalization. The company made the announcement in a grand way, with an Enterprise Healthcare Summit featuring President Bill Clinton, Earvin “Magic” Johnson, Steve Forbes, Toby Cosgrove (Cleveland Clinic) and Castlight executives Giovanni Colella and Naomi Allen.

I had the opportunity to attend, learn more about the company’s latest, and mix and mingle with a high-powered crowd. Here’s my scrapbook:

Magic Johnson reflected on his basketball and business career, while dropping in a few words about price transparency in healthcare

Magic Johnson reflected on his basketball and business career, while dropping in a few words about price transparency in healthcare

Magic Johnson gave President  Clinton a rousing introduction

Magic Johnson gave President Clinton a rousing introduction

I expected Clinton to give a stump speech, but instead he personalized the speech to focus specifically on price transparency and Castlight's role

I expected Clinton to give a stump speech, but instead he personalized the speech to focus specifically on price transparency and Castlight’s role

CEO Giovanni Colella asked Clinton some follow-up questions, and the prez had plenty to say in reply

CEO Giovanni Colella asked Clinton some follow-up questions, and the prez had plenty to say in reply

Once Giovanni was done with the President he found some time for me

Once Giovanni was done with the President he found some time for me

The Cleveland Clinic's CEO Toby Cosgrove took part in a panel discussion. His fellow panelists were a little surprised when he called for provider monopolies

The Cleveland Clinic’s CEO Toby Cosgrove took part in a panel discussion. His fellow panelists were a little surprised when he called for provider monopolies

Steve Forbes never got to be president but he did get to speak in the same conference as one

Steve Forbes never got to be president but he did get to speak in the same conference as one

Castlight's Naomi Allen laid out the details of the new Castlight offerings

Castlight’s Naomi Allen laid out the details of the new Castlight offerings

American Social Club played some great crowd pleasers

American Social Club played some great crowd pleasers

82 Mercer might never be the same after Castlight's conference wraps

82 Mercer might never be the same after Castlight’s conference wraps

By healthcare business consultant David E. Williams of the Health Business Group