Mark Dimor

Mad Men Circa 1977

Prime Burger on 5 East 51st across from Staint Patrick’s is closing after 74 years. My first non-sales job was in the building around the corner on Madison Ave. I was doing medical advertising. It was just down the street from DDB. (Those famous VW ads). It was amazing to be in advertising in the heart of mid town surrounded by ad agencies and everything we see on Mad Men. It was where I met Donna.

Prime Burger had the best EVER burgers and fries perfect just perfect. Life is organic it lives and dies one big cycle. This article reminded me of what has been in my life not what is gone.

ED, PCP and Medicaid: A Knowledge Translation Solution

The NEJM published ‘Emergency Departments, Medicaid Costs, and Access to Primary Care-Understanding the Link’. The article examined Washington State’s Health Care Authority effort to curb non-emergency care delivered in ED. ‘By July 1, hospitals accounting for at least 75% of ED utilization by Medicaid fee-for-service clients must submit legal attestations that they are complying with the plan. If they fail to do so, the Authority may proceed with implementing its policy of nonpayment for ED visits it determines to be nonemergency visits.’

We all know to well the reasons, since 2008 9.8 million Americans have lost employer-sponsored health insurance. Subsequently Medicaid rolls have burgeoned by 7.5 million. States are looking for ways to cut spending on Medicaid and the low hanging fruit is overuse of EDs.

A 1996 study researchers posted in 56 ED nationwide interviewed 6,187 walk-in patients in a 24 hour period. The majority cited clinical reasons or preferences, while 45% identified a medical emergency and finally 19% said they sent by an HCP.

Will this type of action help Medicaid beneficiaries to not seek nonemergency ED visits and hit the primary care physicians office? Two well made points: most ill patients can’t differentiate a sprain from a break and 3% to 5% patients identified as nonurgent at the ED by a trained triage nurse needed immediate hospitalization.

For the low income Americans the ED is the only reasonable choice. If they are turned away because of state policies we may be facing a larger crisis of critically ill patients needing greater care at greater cost. The primary care physician is key here. But it is not the only part that needs to be changed.

This is a complex system of patients, ED, primary care physicians, nurses, and state government all looking at aspects of this issue differently. Trying to change behavior one audience or system at a time with brochures, letters, email, etc. will largely go unnoticed because as you shore of one part of the system the other falters. Healthcare whack a mole.

This is the perfect example of where Knowledge Translation can bring behavioral change on a large scale.

Knowledge Translation is defined as:

“the exchange, synthesis, and ethically-sound application of knowledge—within a complex set of interactions among researchers and users—to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system (CIHR, 2004).”

Knowledge Translation is the coordination and active manipulation of new knowledge (e.g how to teach patients to not rely on the ED) and it application to all parts of the system through prior research. KT relies on process improvement within these complex systems, not simply a laying of pamphlets on learners. Or forced economic changes. It is a system wide approach.

In my estimation we need to step beyond Draconian responses to a single aspect of a problem (i.e. overuse of the ED) and look at the entire system. Attack it as a systemic problem including fixing the primary care mess in America. I have not seen a better example of where KT can be applied to change behavior.

The Office Visit: A Learning Experience?

Digital Tonto’s fourth paradigm shift is ‘From Transactions to Experiences’. This captures the essences of the three previous shifts and I believe has the greatest application in healthcare.

Greg states, previously the brand and the consumer had a one-time value exchange based on feature benefit attributes. Consumers expected x and received x. This mimics the brand (physician) and consumer (patient) historically and in many instances today. The physician offers a value: care and management of your health on an as needed basis. The features are apparent, knowledge, expertise, experience, prescription, etc. The benefits are equally apparent, wellness. It was a simple value exchange. I need a checkup, I saw my HCP, I had a cold, I saw my HCP, I have a chronic illness, I see my HCP. In between these moments of interaction with my HCP there is healthcare inactivity unless there is chronic or terminal illness. Or I am one of the growing numbers of patients who are going online or engaging in social media to improve my healthcare knowledge. Largely this occurs outside the office visit.

The simple value exchange is morphing before our eyes. Brands are partnering with consumers in order to achieve ‘maximum utility and enjoyment from their purchase’. Brands want to create experiences for consumers. Remember, adult learners and all adults learn from experiences and upon reflection adults will integrate experiences into their lives.

As I’ve stated previously the office visit is not a drive by. It can be the place to begin life long learning. Physicians must engage in life long learning. It seems simple to have patients do the same? There are a huge number of patients engaging in learning about their own a loved ones healthcare. It is where, with little work, a HCP and patient can maximize the effect of simple check-up to the management of chronic illness. The smallest functional environment of learning in healthcare is the patient physician office visit. It does not have to end there. Both physician and patient can change that transaction to an experience and create a learning narrative. Make it a learning experience for both parties.

I will present ways to begin this healthcare learning experience in future posts.

Fighting the Drug War is Killing the Terminally Ill

Is this the lasting impression America has on pain management: it’s a criminal conspiracy?

Here

And those who should know how to treat pain don’t do it very well.

Here

How much of the former is driving the later because it gets the headlines, coverage, and sells? America hates junkies.

I would say we are trying to look taller fighting pain medication drug abuse by standing on the terminally ill. Somehow we need to find a way to do both AND not do one at the expense of the other.

The Office Visit is Not a Drive By

In Digital Tonto’s post ‘4 New Marketing Paradigms’ Greg’s second paradigm is titled ‘From Campaigns to Platforms’. http://tiny.cc/srj2dw His premise is that marketers can no longer just run ads till they wear out; they need to build campaigns that integrate social media, e-commerce, and interaction with the reader/viewer. Marketers are now ‘tailoring the message to past behavior’. I am very found of his closing sentence ‘Brands need to become authors whose stories unfold over time.’ www.digitaltonto.com The brand becomes the connection to reader/viewer not just a feature or benefit.

How does this relate to healthcare? The physician is the brand. The patient is the consumer of that brand. The office visit for a check-up or care for an acute or chronic condition is the ad/commercial. It is where the consumer (patient) interacts with the brand (physician). And historically it is a flat moment where the patient is passive and the physician active. With all the changes occurring in healthcare etc. more patients are becoming active in their health and care. Many physicians are stepping up to meet that half way. But that is not enough and it misses key inflection points. Engagement between physician and patient is becoming the new black and it is up to the physician to lead the way. To in a sense create that learning narrative with the patient.

The physician as a brand should look at that visit not as a one time event in a string of events. It is a way to build a brand platform based on patient needs and goals. It is the moment where the physician can determine not just blood pressure but pressure points for knowledge uptake and begin that healthcare narrative. What are the problems/goals/needs the patient wants? How can the physician become the author of a patient narrative? Does the patient leave with an Rx? Or do they leave with a continuum of care based on integration into the brand platform? ‘My physician is a great doctor but he is also doing more then caring for me, he hears me.’

Yes, yes I know, not all patients want to be part of a platform or need to be. The 20 year old patient in excellent health who comes in for a check up is not looking to solve a healthcare problem. And frankly many older patients with chronic HTN are not interested either. What exists is the opportunity to for HCP to take the pulse of each patients’ needs and goals regarding their health and learning styles and to change the office visit from a drive by to an engagement for life. Why can’t patients move from grade school to graduate school in their relationship with their physician over time? Physicians need life long learning. So do patients. I’m getting all misty here http://tiny.cc/93j2dw

And yes dear readers (all three) you re correct, how does a busy HCP achieve this? Stick with me and it shall be shown.

Making The Office Visit a Value Exchange

Sunday night at 9pm EDT the #HCSM chat happens. It is one of the best online healthcare chats that I’ve participated in. It is fast, smart, well facilitated, and with some of the best and the brightest minds I have the pleasure of interacting with. The topics are well considered and examined in great detail. Each discussion drives me to think more and consider the changes occurring in healthcare. If you haven’t participated or lurked and you are interested in healthcare check it out, ” …as the dormouse said, ‘Feed your head’.”

I’m sure I am the most annoying participant with my continuous hocking about SM being a tactic and we need to identify strategies/goals and then overlay a tactic. Can’t help myself Donna and Alan beat me about the head for years to learn what a strategy is and how to use it. Sunday night #hcsm takes me back to sitting in the agency and having account people talk about tactics before they identify a strategy. Backing a tactic into a strategy is putting your shoes on and then your socks.

Sunday morning along with the NY Times I get my mailing from Digital Tonto (www.digitaltonto.com). One of his posts was 4 New Marketing Paradigms: here

Within that post were nuggets that clarified my thinking about those HCSM chats.

Greg the 4 new marketing paradigms:

From Making Contacts to Building Assets

From Campaigns to Platforms

From Awareness to Activation

From Transactions to Experiences

Yes, his post is about consumer media and marketing but let’s get real. We have to think in terms of marketing, communications, and strategies if we are going to meet the needs of patients in this evolving digital world.

It is the patient who is driving a need to know and learn because the www is allowing them in real time to seek solutions to problems they have, classic adult learning. To assume physicians who are struggling to keep up with an ever increasing work load and diminishing returns will jump into social media as a solution without first understanding what is happening is as likely as Mitt Romney is to have a cup of coffee.So we must look at strategies that engage both physician and patients and make that amazing unit of learning (patient & physician) work harder and produce better results. In a word use a strategy to show the physician what’s in it for them.

In the section: From Making Contacts to Building Assets Greg states ‘What’s emerging is the concept of value exchange in the form of owned media assets.’ This is not about using apps and content (tactics) to capture ‘eyeballs’ (think patient office visits). It’s about building assets and creating engagement.

The asset is the physicians knowledge and skill at delivering care. Creating engagement is helping patients replace or complement what they’ve learned at WebMD. Physicians should become MyMD to patients seeking knowledge. Make no mistake, patients trust their physician more then WebMD or they want to. Talk about a ready made gap to close, this is one that can be done.

Take away: The office visit is greater then the sum of its parts. It is a place to begin the ‘value exchange’.

I will examine how Greg’s other models relate to health communications and social media over the next few days. And I will show an example of how to begin that value exchange.

NYMC Seminar on Social Media and What I Learned

I attended the April 24th New York Medical College day of presentations on iMedicine- The Influence of Social Media on Medicine. This was an informative and forward thinking event on social media and healthcare. There were 10+ presenters including: Howard Luks, MD, Mark Ryan, MD, Brian McGowan, PhD, Ryan Madanick, MD, Lawrence Sherman, Kent Bottles, MD, and others:

The site is here: http://tiny.cc/wjbndw

Watching and listening I was struck by the depth of knowledge and experience each speaker had specific to SM and how well SM has served each one. As the day progressed I was filled with an overwhelming sense that SM in HC has the power to change, no improve, patient outcomes. Then Kent Bottles, MD spoke and shared the Gartner Hype Cycle. http://tiny.cc/mlbndw and http://www.shockoe.com/blog/trends-in-tech-truth-or-noise/ As he gently put it we may be drinking the Kool-Aid.

The consistent thread throughout all the presentations was the value social media has for physicians, patients, and outcomes. Each presentation spoke to social media not just an important new technology bringing physicians, patients, and healthcare together but showed executing it in new and more productive ways. Five presenters highlight key take away messages:

Mark Ryan, MD @richmonddoc spoke about the long history of personal one to one care delivered by the family physician and how social media can return us to that model and what it means for care.

Natash Burgert, MD www.kckidsdoc.com demonstrated how Tweeter, her web site, and other social media tools changed her practice and improved the care for her patients. She showed how a small investment in time produces durable and important outcomes with parents and patients. She is part of her local community and the community is part of her practice.

Ryan Madanick, MD @ryanmadanickmd presented was how his seeming late adoption of social media was not a barrier. In fact his coming into it as he did provided greater benefits for not just his patients but for his colleagues on both a national and global level.

Howard Luks, MD @hjluks presented the way he integrates a blog, Facebook Page, YouTube Channel, and personal site to educate and engage with patients.

Loring Day a patient spoke about how she was able to improve her care through social media and her physicians (Luks, MD) online presence.

I am highlighting these presenters among the many equally excellent and illustrative ones because they connect the dots in social media and healthcare. Social media in healthcare is about learning. It is shared decision making at a macro level. Patients are adult learners. They want to find solutions to problems they are having. Each of these HCP is offering their patients and colleagues not just places but knowledge. They are providing solution’s patients are seeking directly and indirectly. The physician and the patient is the smallest functional environment of learning and what was shown are ways to extend that beyond and back into the office visit, and ultimately to outcomes. These are communities of practice for the 21^st century built around technology and basic learning.

Kent Bottles, MD www.kentbottles.com is correct, in a way we are drinking the Kool-Aid believing social media is the answer to all out healthcare problems. We will see a period of dissolution with social media in healthcare and the plateau. We will NEVER reach 100% of patients.

My observations:

Social media in healthcare works. It extends what once was to what is and will be, care delivered not top down but together.

Are the audiences seen above a self-selecting small cohort? What can we do to move beyond self-selecting participants? Can we create a push pull?

Can we demonstrate outcomes? What are they?

Performing needs assessments to determine what problems patients are seeking solutions to and where on their continuum of knowledge/learning they reside? This will help to identify others outside the current users of social media. It will also give insight into learning needs that may differ between demographics with the same issue.

Social media is only a tactic, a mere toy. These presenters use social media as part of a strategy that educates, engages, and motivates. This is how a tactic work best, as part of an integrated strategy.

Whether each presenter deliberately identified a strategy or simple found where social media worked best is not up for debate. Social media works in healthcare. The question becomes how do we take these successes and extend it? How do we smooth out the Gartner Hype Cycle?

It is time to approach social media and healthcare in a deliberate fashion, as educators seeking to understand learner needs and problems. In every practice there are 20 year olds in perfect health who have no problems they are seeking solutions to. For them thier physicians social media is about as useful as breasts on a bull.

At the same time there are a slew of 50 something patients with problems who are seeking solutions. With a little planning and work we can improve the percent of 50 year olds who engage with HCP to solve their healthcare problems. It is not WebMD but MyMD. That is where the future of social media and healthcare will meet and improve outcomes.

Pain Management not Just a Global Issue

It is well documented that patients with terminal illness in general do not receive what experts would consider appropriate and continuous pain relief. This is an issue even more acute globally. And the reasons are equally well documented: no access to morphine, HCP attitude, family concerns, lack of knowledge on how to treat.

On a very small scale and in many regards unrelated I witnessed this. Thursday I had to go to have a dental implant removed. It went from a scheduled procedure to an emergency one. I was able to contact my previous DDS who referred to a very good oral surgeon. Prior to him beginning I played 21 questions just to make sure I knew what was what. I asked about postoperative pain. “Do you have any ibuprofen at home?’ was his answer. After my WTF look and saying “you’ve got to be kidding me” he relented and said he would write a script.

The procedure was quick. I left the office with a ton of lidocaine on board. Not so bad. I got home laid down and within 30 minutes my face felt like I was hit with a brick. Acute, sharp, and relentless is how I would characterize the pain. Ibuprofen? In a pig’s eye? It would not even begin to touch this. Filled the Rx and found some relief behind the pain, not in front of it.

I will confess that within 24 hours the pain was resolved. Still, to feel like I needed to beg to get a strong analgesic that was in fact needed was a bit of an issue. This does not compare to chronic pain associated with terminal illness. I witnessed this with my wife in hospice and how well and professionally the pain management team kept ahead of her pain and was able, even when Donna could not communicate, to read her body language to know when they needed to change or increase medication. This was not the same. I do not expect an HCP who is board certified as a dental anesthesiologist and oral surgeon to understand pain and terminal illness. But he should know about pain and its effective management. Really now he should.

His first reaction was to not offer an analgesic unless asked. I was put into the role of a drug seeker. If I did not have that Rx I would’ve been on the phone demanding he call it in. Wasting his time and mine. At the very least he should describe the level of pain for how long and ask me what I thought I wanted. Not think he knew me better then he did at our first meeting. In some small small way this is the state of pain management.

A Surprise From the NY Times

The NY Times has an article on chefs and what they listen to in the kitchen. The NYT selected a dozen or so chefs from around the US and asked them to share what they listened to and created a sample page with everyones suggestions. Nicely done NY Times. You can find it here.