Prenatal care in the United States is a bit of a crucible for issues related to rising health costs, telemedicine, and medical collaboration. 

Maternity and prenatal care are at the nexus of high-pressure healthcare, patients with often-routine but occasionally hyper-sophisticated care, and the high cost of care. For instance, OB-Gyn providers consistently have the highest rates of malpractice law suits in all of medicine. 

As the leading edge of healthcare, prenatal care is an interesting lens through which to see common dynamics in the rest of medicine. So two new articles are relevant to all of us, even though they're focused on prenatal medicine. 

First, UnitedHealthcare is launching bundled payments for maternity care. It will roll out the program to 20 provider groups by the end of the year. Under this program, providers will be paid a lump sum for prenatal, delivery and postpartum care. 

While a small percentage of all maternity care in this country, I believe that the impact of this program will be outsized. As a huge cost center within healthcare, insurers have a keen interest in shaving prenatal costs in any way they can. And a bundled payments system is, potentially, a way to do that. In a hypothetical kind of way, this program makes a lot of sense for everyone involved. In practice, the onus of doing the care coordination and medical collaboration that is demanded by a bundled payments system is huge. It requires that providers manage the diversity of providers across the continuum of care, and across the length and breadth of prenatal scenarios -- from the most simple to the most complex. 

I do think that eventually, this kind of integrated payment system is what we need for healthcare. But in the short and medium term, I think it's unwise to just pay in  a bundle without giving providers the appropriate tools to make sure the requisite care coordination happens. It's a "sink or swim" model, without giving providers the tools they need to swim.

Related to this is a study done to see whether a prenatal app could complement in-person visits effectively. Prenatal care has a notoriously intensive visit schedule -- which can be burdensome on both the patient and on the providers. But, as Fierce Healthcare reports, “providers say visits are hard to cut back on due to decreased patient satisfaction, the need for weight and blood pressure monitoring as well as the importance of providing educational information around pregnancy health.” So a new study looked at whether an app providing weight and blood pressure monitoring, as well as timed education for expectant moms, could be as effective as in-person visits for lower risk patients. The results? Patients were able to use the app to decrease their number of prenatal visits by about 20% without a decrease in patient or provider satisfaction. That said, it was a very small study size of less than 100 patients and perhaps more investigation is needed.

On one hand, I was excited to see the study of the use of the prenatal app -- as it's an example of actually providing a tool, rather than just changing how payments happen. On the other hand, I wonder whether it's the best tool we can come up with. I'd like to see more communication and coordination, and a more holistic approach -- rather than simply remote monitoring and one-size-fits-all education. 

I applaud any effort to improve healthcare and to use technology to evolve how we communicate and care for our patients. That said, I also think that it's important that we continue finding ways to care for our patients better -- not just less or more cheaply. 

In theory, none of us SHOULD need to do medical collaboration. In an ideal world, each healthcare provider has perfect knowledge of every disease and impeccably up-to-date information on their patient, at all times.

The reality? Each healthcare provider has a rich, powerful, and incomplete perspective. That means that the super-specialist and the aide both have a crucial role to play. And that the more we communicate with each other about our patients, the more fully we can help them.

It’s not often you have precise confirmation of this reality. But a recent article in JAMA put a spotlight on it for me.

One of the more routine things we do as doctors is recommend cancer screenings. It’s not the most sophisticated analysis; it’s not the most intense moment. But it is important and absolutely does save lives.

As routine as this may be, however, it is still powerfully impacted by the real limitations we have as busy, human people who are acting within a context of too-short visits and too-hectic care contexts. In fact, this recent study by the University of Pennsylvania, and published by JAMA, shows that "As the overall clinic day progresses, clinicians may face decision fatigue, defined as the depletion of self-control and active initiative that results from the cumulative burden of decision making"' and that "Relative to 8 am, the adjusted odds ratios (OR) of clinician ordering and patient completion of breast cancer screening was significantly lower for each hour from 10 am to 5 pm."

In other words, even the most fundamental aspects of the care we provide are impacted by our own energy levels and the context in which we see the patient. 

This isn't shocking; it is completely natural and human. But — it’s our responsibility to support ourselves so that every patient we see gets the same standard of care. Just as it is our responsibility to wash our hands, it is our responsibility to get the collaboration and support we need from colleagues through telemedicine-based medical collaboration. We can't fix the healthcare system. But we can make sure that we have the tools we need to work effectively within it — every hour of the day. 

Get the support you need with iClickCare. Try it for free: 

When we became doctors, we did so because we wanted to help patients live longer, healthier lives. Not because we wanted to "provide healthcare."

That said, as days get more hectic, as visits with patients get shorter, and as demands on us get more intense, it's not easy to keep our sights on that vision of health. 

But a recent study reminded me of the very real difference between healthcare and true health -- and I bet it's a reminder that most of you need, too. 

A recent article in Fierce Healthcare looks at a study by The Stanford University School of Medicine's Clinical Excellence Research Center in California, which explored what role healthcare plays in avoiding premature death.

This question about the role of healthcare almost feels like a contradiction in terms -- our knee-jerk reaction is to say, "Of course healthcare plays the primary role in preventing premature death!"  But the results of the study contradicts that intuitive response. In fact, although healthcare plays a role in longevity, behavioral and social factors have much more influence on the longevity of people in the United States

Healthcare is estimated to prevent 5-15% of premature deaths. Behavioral and social factors, on the other hand, account for between 16% and 65% of premature deaths in the United States. As Robert Kaplan, research director of the Clinical Excellence Research Center (CERC) said, “in order to bring the U.S. health back in line with other rich countries, we need more than medicine.”

So what is that "more than medicine" that our patients need?

Dr. Steven Woolf, MD, Virginia Commonwealth University explains, “Healthcare systems need to do their part, such as paying attention to the social needs of their patients in order to help lower emergency department visits and hospital admissions.”  In other words, we need to: 

• Take a holistic view of our patients' health, including their social, environmental, financial, and behavioral realities. 
• Coordinate care and do medical collaboration so that we can actually attend to the full picture of our patients' health, rather than just "providing care."

That might mean realizing that a patient can't take time off work -- so using iClickCare to collaborate with a colleague on the case, rather than sending the patient for a consult. It might mean coordinating with a patient's care team across the continuum of care, including all of the aides and nurses that will care for that patient when they are discharged. It might mean doing medical collaboration with our young patient's teachers, social worker, pediatrician, and family -- rather than performing a procedure in isolation. 

We've said it before and we'll say it again: medical collaboration is not an optional flourish -- it's the foundation of caring for our patients in a truly effective way. 

Get our Quick Guide to Medical Collaboration for free, here: 

Some things in medicine come and go.

Many trends — demands on our time or our practice — start off as the trend du jour but eventually get abandoned for new trends on the horizon.

But there is one trend in medicine that appears to be here to stay— and it’s coming to your state and town, whether you are ready or not.

That trend that’s here to stay?  Value-based payment in medicine.

As Fierce Healthcare summarizes, in just 5 years, 700% more states have adopted value-based payment (VBP) systems. Currently, only 4 states have yet to launch a value-based model.

What does that mean for most healthcare providers?  It means that it's not enough to simply put our heads down and provide good care for the patient in front of us. In a value-based model, it becomes very much "our problem" whether care coordination happens, whether we need to do medical collaboration, and what "non-medical" things are affecting our patients.

For instance, in a value-based model, there are concrete consequences to referring a patient to a doctor 3 hours away and hoping the patient gets an appointment and that they actually go. The patient may not make it to the appointment, end up with a bad outcome, and ultimately — in addition to the subpar care — it becomes a financial hit for the doctor and her organization.  Far better?  Use a system like iClickCare to get a 2-minute consult from that provider, while the patient is in front of you. 

For a long time, healthcare providers felt that medical collaboration and care coordination were altruistic things they would do "when they had time."  In a VBP world, collaboration and coordination are the most practical, incentivized activities in healthcare. Coordinating a medical team means that followup care happens and readmissions drop. Medical collaboration means that you can efficiently pull in providers across the continuum of care to determine the best possible course of treatment — decreasing length of stay.

It's not always the case that the right thing to do and the selfish thing to do are the same. But in a VBP world, the right thing and the selfish thing are the same — use medical collaboration, telemedicine, and care coordination to care for our patients. 

You can try iClickCare for free. Get started in 5 minutes or less here: 

It’s one of the conundrums of modern life that time-saving technology sometimes takes more time than it saves us.

For instance, email is quicker than a phone call, and yet office workers spend an average of 4 hours a day checking their email. We're somehow spending so much time managing the technology of connection that we have less time to actually... connect.

And medicine is no different — healthcare providers are spending dramatically increased times interacting with EHRs/EMRs and plummeting hours with patients. 

It’s disturbing but true: a study of first-year residents shows that 43% of their time is spent interacting with electronic medical records — that’s 3 times more than they spend interacting with patients. In fact, according to JAMA, they spend nearly 90% of their time away from patients.

The problem with this time split isn't so much that it's not efficient. The problem is that healthcare's most valuable assets — the human beings who are our healthcare providers — aren't being used to their "highest and best" potential. That matters for the output that we see from them (in terms of quality of care and innovation) as well as for the long-term sustainability of healthcare (considering the sky-high rates of healthcare provider burnout.) 

It's easy to look at this and bemoan the use of technology in medicine. Perhaps technology is inherently distracting, alienating, and time-consuming?

Personally, I don't think so. Technology can detract from our time with patients or it can add to it. What makes the difference is whether the technology we are using has been thoughtfully designed, intuitively structured, and whether it integrates into our workflow. The answer to all three of those questions for most Electronic Health Records is a resounding "no," which is why EHRs have become such a time-sink and distraction for doctors.

The truth is that we can’t go backward to an era of black doctors’ bags and paper medical records. But we can go forward to an era of holistic, integrated technology. And I think that as leaders in medicine, it's our responsibility to demand technology that supports human engagement, the art of medicine, connection and collaboration with our colleagues, and the highest and best use of our time. This demand of our technology is far from frivolous; it's key to our ability to uphold our commitment to our patients.

Thankfully, I think that there are subtle signs that healthcare is beginning to swing its huge pendulum back toward human interaction and human-scale healthcare. As Dr. Zimlichman wrote recently, even hospitals themselves are becoming a "technology" that is unwieldy and shows signs of shrinking in significance: 

“The hospital as we know it—a medical center crammed full of patients, beds, equipment, medical staff and service workers, and much more—is an expense society can't really afford anymore... Other industries—retail, banking, finance and others—have long used digital tools to enable clients and businesses to collaborate and connect, anytime and anywhere. Those tools are now available to the medical industry—and given the constantly ballooning costs of care, the hospital is a perfect candidate for its own digital revolution.”

In other words, its possible that we are actually at the peak of technology's negative impact on medicine. And that as technologies mature and healthcare evolves, technology may actually begin to bring medicine back into a more sane, human-centered way of working. As healthcare providers, we can usher that new way of working into reality — or we can resist it by holding tight to "the devil we know."  I suggest the latter.

Curious how a simple technology like iClickCare actually works? Watch a 1-minute video to learn more: 

Those of us who live in the US tend to think of our medical system as the most cutting-edge in the world.

And there is a lot of truth to that — medical innovation is certainly an area of strength for us and we can be proud of our contributions. 

That said, a recent New York Times article put a spotlight on the ways developing countries can show a special kind of rapid innovation with technology that sometimes leapfrogs our slow, deeply challenged adoption patterns.

Any new technology presented to the US medical community has to beat a gauntlet of obstacles to be adopted. Between regulatory issues, compatibility troubles, concerns about compensation, and political drama, the adoption of any new technology is a minefield.

Sometimes the needs of developing countries make technological adoption quicker and more focused than it would ever be in the US. For instance, a new ultrasound scanner has been invented that can do ultrasounds anywhere in the world, with a device the size of an electric shaver, connected to an iPhone.

As the New York times reports, “Two-thirds of the world’s population gets no imaging at all,” so the allure of an ultrasound wand that can provide even rudimentary imaging is compelling for medical providers and NGOs in developing countries. Many times, the stance is one of finding innovative ways to use technology, rather than having the immediate reaction be one of resistance. Further, experimentation seems to come at less of a perceived cost, as downsides of failures may not be as dramatic in terms of repercussions.

So within a short period of time, providers in Uganda used their new ultrasound wand to scan everyone from babies to nonagenarians. And their approach to using it in service of diagnoses was deeply creative.

My challenge as the founder of a medical technology company is to support US medical providers in approaching innovation in this same way — but of course in combination with all of the advantages that we have in our medical system. How is that possible?  I believe that when providers in the US make an effort to try new technologies as quickly and cheaply as possible, it lends us the type of speed and innovation sometimes only found in a country like Uganda when experimenting with an ultrasound wand. The smaller and faster our experiments are, the less investment we have in every single one succeeding. That's what I'm so passionate about iClickCare as a medical collaboration tool — it doesn't require expensive hardware, even one doctor can start using it on his/her own, and it's so intuitive to use that you can do your first consult within minutes. That means that it's inexpensive and fast for medical providers to experiment with its optimal usage in their unique medical setting — making innovation much faster and more expansive than it is with huge, expensive, and years-to-implement videoconferencing hardware. 

We can certainly learn something from the resilience and creativity of other countries — and innovation around medical technology may be one place to start. 

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I’ve always said that it’s better to stay out of the hospital.

When confronted with risks of infection, error, or complications — it’s of course better to stay healthy and stay home.

But sometimes an elective surgery is wise or an emergency hospital stay is necessary. And in those cases, all of us want to be sure that our patients are safe.

But recent data and evidence has begged the question — are hospitals incentivized to hide infections when they occur?

I have to believe that almost all hospitals across the country prioritize patient well-being above any concerns about reputation or profitability.

But when antibiotic resistance combines with age-old concerns about infection and sickness in hospitals, things get serious. And even good intentions — for instance, to thoroughly investigate an outbreak without alarming people — can end up hiding data and information that could keep people safe. 

And the reality is that we all depend on hospitals sharing this information on their own behalf because there aren't agencies that will do so for them. In fact, as the New York Times reports, "under its agreement with states, the CDC is barred from publicly identifying hospitals that are battling to contain the spread of dangerous pathogens."  For instance in 2016, there was an outbreak of a drug-resistant pathogen in a Kentucky hospital — but it was not until 2018 that the CDC issued a report on the outbreak. And, of course, hospitals themselves have often "circled the wagons" when an outbreak occurs, looking into the infections themselves rather than sharing information more broadly. 

I completely understand wanting to limit public disclosure, especially in cases when public perception could be misinformed and reactive. Infection is complex and hospitals are often so big, they're like miniature cities, with outbreaks affecting a small minority of people.

But I do wonder whether the instinct to limit information about drug resistant infectious outbreaks within the medical community make sense. In fact, the tendency to limit information in this way is common in medicine, both at the level of the institution and at the level of the individual provider. We're under such immense pressure and scrutiny in the medical community — with such devastating consequences if mistakes are made — that many providers and organizations learn that it's better to keep information to yourself. The medical community often notices that "silos" keep excellent care, medical collaboration, and greater efficiency from happening — but the reality is that many of us have incentives to maintain those silos. So when an outbreak of an infection occurs, hospitals try to limit misinformation or panic — and in so doing, may limit information that could help other providers do care coordination or support them in solving the problem. 

I hope that hospitals are doing the best they possibly can to prevent outbreaks, as well as sharing information when the outbreaks occur. But I also know that all of us in medicine should learn to share information more freely, collaborate more effectively, and put our patients' care well above our own instinct to hide missteps or needs for support. And we hope that iClickCare can play a role in helping providers share information securely, safely, and without risking negative consequences. 

Try iClickCare for sharing information among the medical community members and within your medical team — safely and securely:  

For the older people at Long Term Care facilities, nursing homes, and assisted living facilities, even small issues — like a simple fall — end up with a transfer to the emergency room. Those visits to the ER can often mean a hospital stay as well. And of course, hospital stays can cause backtracking for overall strength, wellness, dementia, and disease. The best case scenario — a visit to a doctor instead of a visit to an ER — can still mean bouncing from provider to provider, with a lot of stress and physical challenges along the way. 

But aren't these ER visits, hospital stays, and doctors' visits simply the necessary realities of life. New insights and ways of working point to innovative solutions to this Business As Usual problem. 

There are 30,000 assisted living facilities in the US. As the New York Times reports, “most assisted living facilities have no doctors on site or on call; only about half have nurses on staff or on call.”

That means that if an event happens — a virus, a fall, a concern about a worsening condition — it results in a transfer, doctor's appointment, or ER visit, the vast majority of the time. Of course, coordination of medical transfers, tests, appointments, and the like can be a huge challenge for any person — but throw in significant physical challenges and perhaps cognitive impairment and the challenges compound.

“The assisted living industry has to recognize that the model of residents going out to see their own doctors hasn’t worked for a long time,” said Christopher Laxton, executive director of The Society for Post-Acute and Long-Term Care Medicine. “It’s an expensive, disruptive response to problems that often could be handled in the building, if health care professionals were more available to assess residents and provide treatment when needed.”

It's a way of caring for people that hurts the patient, the provider, the Long Term Care facility, and even the hospitals. Hospitals will stay away from sending their patients back to the community if they are afraid they’ll be readmitted within 30 days of discharge. And Long Term Care organizations may shy away from getting the right care for their residents if it often results in backsliding in their care. 

So what is the solution?

One solution has been to have a geriatrician on staff. But realistically, that doesn’t solve the problem. There will be myriad medical problems that fall outside of the expertise or time of that provider. 

There are two key things that need to happen:

• Hospitals should partner with assisted living and nursing home facilities that have the means to do medical collaboration and prevent readmissions.
• Long Term Care facilities must find ways to get the medical consults they need without putting their residents through the stress and danger of ER visits and bouncing among doctors’ appointments.

To facilitate those goals, though, hospitals, doctors, nurses, aides, and care providers at Long Term Care facilities need a platform to collaborate. The ideal scenario is that if a resident has a fall that isn't actually worrisome but could use "an extra pair of eyes,"  an aide can take a photo or video, consult with a trusted provider at a practice or hospital in the community, and keep the patient at home base until or unless a transfer is needed. It's good care in every way: it saves money, decreases readmissions, and ultimately supports the best possible health, wellness, and quality of life for the patient. It's a classic example, too, of why email or text messaging — in addition to not being HIPAA compliant — aren't nearly sufficient. In cases like this, whole teams are involved and cases need to by asynchronously collaborated on, over the span of time. A one-off question won't fit the bill. 

Care coordination and healthcare collaboration aren't a panacea. But I do believe that when it comes to Long Term Care, the impact of collaboration and coordination can be dramatic. 

If you're involved in Long Term Care, get our ebook on using telemedicine to improve care and make workflows more efficient:

By the end of their career, nearly half of all doctors will be sued.

Any suit is gut-wrenching for a doctor. It means that not only was there an undesired patient outcome, but the relationship with the patient has broken down to such an extent, that a lawsuit has become the chosen path forward.

That said, medical malpractice lawsuits involving children are especially disturbing and concerning. No doctor wants a child to have less than perfect care — and the litigation process itself can be deeply painful for all involved. So I was really interested to notice a recent study that seems to point to a commonsense way of decreasing your risk of being involved in a malpractice suit involving a child.

A recent study, by The Doctors Company, looked at 1,215 malpractice claims filed on behalf of pediatric patients, from 2008 through 2017. These claims spanned 52 specialities and subspecialties.

What’s fascinating isn’t so much the claims themselves, but rather the root causes, allegations, and factors of the malpractice suits. Many of the most common factors in the lawsuits actually boil down to poor communication and poor medical collaboration among providers.

3 crucial highlights of the medical malpractice study that boil down to bad medical collaboration:

• Missed, failed, or wrong diagnoses were the main reason for lawsuits.
• Poor communication between the physician and the patient or family was a factor in up to 22% of claims, depending on the age of the child.
• System and collaboration failures, such as not notifying treating physicians of critical test results, was also a primary cause of patient injuries. 

No doctor wants to put their patients at risk. And no doctor wants to be sued. But the sad truth is that many doctors think they're "too busy" for medical collaboration -- even though in all three of the determinants of medical malpractice above, medical collaboration could have been preventative. 

It's easy to say "an ounce of prevention is worth a pound of cure" for our patients. But the ounce of prevention created by medical collaboration is worth far more than trying to "cure" a bad outcome or lawsuit once it has already occurred. 

Learn more about how easy and fast medical collaboration can be:

For many decades, we’ve thought about vaccines as a battle of science catching up with disease.

Conquering polio or measles was about finding the vaccine that would protect human bodies from those diseases, and then distributing those vaccines broadly enough to create immunity across the population.

However, there have been recent outbreaks of diseases that call into question this understanding. In places like the US and Europe, where the vaccines are established and the distribution is strong, we’ve seen a recent backsliding, with outbreaks of diseases like measles affecting communities. For instance, Washington State has had 71 cases of measles, just in the last few months.

So what are we to learn, as healthcare providers and leaders? And is there any way to win?

These outbreaks are of such concern, in fact, that there was a congressional hearing recently to explore the causes and potential fixes for these outbreaks.

Saad Omer, MBBS, MPH, PhD, from the Emory Vaccine Center, told the U.S. Senate Committee on Health, Education, Labor and Pensions that to battle new outbreaks, funding is needed not just for vaccines and research — but also for communication with the public about vaccines.

The biggest chink in the armor of our protection against these diseases is actually misinformation about vaccines, not limitations of the vaccines themselves. We all know about the concerns that boiled up in recent years about the supposed link between vaccines and autism. As Fierce Healthcare summarizes, “A paper published in The Lancet more than 20 years ago was long ago retracted after the author admitted to falsifying the information, but the concerns among many parents have persisted.”

This context shows clearly that in this case, protection against disease is about more than just science and treatment -- it's about the emotions, fears, and ideals of human beings. Whatever the science shows, if a mom believes the vaccine will cause autism, her child won't receive it. John Wiesman, DrPH, MPH, who is Washington's secretary of health said, “We need to be looking at how it is we get to the hearts and minds of people around vaccines and to not put science on the shelf."

Healthcare can't be distilled to a procedure, a recommendation, a scientific finding, or a single intervention. It's a messy, complex art that involves the hearts, minds, bodies, and social context. Which is exactly why healthcare collaboration can't just be secure text messages between two providers. It needs to allow the complex, long-term interactions of a whole medical team, across the continuum of care, and over time.

Hybrid store-and-forward telemedicine is a technology that supports this very human way of caring. And when the human context is respected -- it means that the science can succeed.