The military has always been on the front lines of technology, innovation, and medicine.

On the one hand, the demands are significant and the conditions are challenging. On the other hand, rewards for getting these things right can save lives and protect the country.

So when the military tests a brand new way of doing value-based care — I definitely pay attention.

Recently, the naval hospital in Jacksonville Florida launched an ambitious pilot project.

The goal, as Fierce Healthcare reports, was "to explore whether multidisciplinary care teams could improve the cost of care for active-duty personnel and their dependents."

The magnitude of the results of the pilot could be huge. As of 2019, the Navy spent $9.5 billion to deliver medical care to 2.8 million people (active duty personnel, retirees, and their dependents.)  And the initiative was ambitious -- pioneering a multidisciplinary way to take ultimate accountability for the results and the costs for complex conditions. 

The structure of the pilot was as follows: 

• Two project managers met weekly to guide the program.
• Medical conditions with high incidence and spending were chosen: back pain, osteoarthritis, diabetes, and high-risk pregnancy.
• Each condition had a physician and nurse co-champion with an interdisciplinary team working closely together to plan and execute care.

The results were very promising. Results showed that care was better, costs were lower, and active-duty personnel got back to work faster. 

Robert Kaplan, Harvard Business School co-author of the paper said that the results “demonstrated that no new medical advances or techniques are required to improve the health of these populations; just the need to better organize care around the patients’ conditions and treat them pro-actively with focused multi-disciplinary teams.”

What's fascinating to me about this project is that the military has an incentive to not only improve care and decrease costs -- but also to get personnel back to work as quickly as they can. In other words, it's a great demonstration truly considering all of the impacts of treatment -- care, costs, and the ultimate impact on the patient's life.

There were certainly challenges -- but the pilot showed the incredible value of working together, under an organized vision, and collaborating in multidisciplinary teams. These dramatic results could be transformative, certainly, for the military -- but it's possible they could be applied in many contexts with great results. “At a broader level, given the positive experience with this value-based health care pilot, the Navy’s implementation model could serve as a model for other organizations, including the Veterans Health Administration and those in the private sector, that are interested in new ways of organizing, measuring, and improving the care they deliver to patients,” the paper concluded.

To read more about the impact of medical collaboration, download our Quick Guide: 

In recent years, some of healthcare has become more of an industrial, technician-oriented, conveyor belt model. The “glory days” (many of which weren’t so glorious) of gentleman doctors and their code of honor are definitely a thing of the past.

In some ways, the new world order — more democratic, more distributed across a team — in medicine works well. It helps contain costs. More providers across the continuum of care are able to make decisions and care for patients. People are able to be great doctors and have a sane personal life.

But sometimes we are reminded that there is something timeless and sacred about the relationship between a doctor and a patient. And that may just be something we need to honor more in today’s healthcare environment.

There is something timeless and sacred about the relationship between a doctor and a patient. There is also a sacred and unique relationship between a nurse and his patient; and between a caregiver or aide and her patient. They are all equally valuable, but the nature of each relationship is different. And there is something unique about the quiet, hallowed space between a doctor and the patients they have the ultimate responsibility to care for.

But in the ever-growing pursuit of a more democratic but also more “factory-style” medical system, healthcare has tried to gloss over the importance and primacy of that relationship. It’s tempting to argue that you can spread care out between an aide, a nurse, a Nurse Practitioner, with little “star appearances” by a doctor — and that nothing is lost. Or, similarly, that you can have a doctor provide telehealth in 4-minute video calls with people across the country… and that nothing is lost.

I think that the real risks and downsides of this approach becomes brutally clear in the most extreme care situations. For instance, dramatic news stories have come up recently that, in one way or another, touch on the role of the doctor as ally, guide, leader, and healer — not just as a technician. For instance:

• Maine has become the eighth state in the country to legalize physician aid-in-dying, and although the AMA opposes the decision, they insist it could be ethical for a doctor to assist a patient in dying. 
• Doctors tend to feel responsible to go to more extreme treatment lengths at the end of life, if the patient leaves that decision entirely up to them. 
• The new ECMO "miracle machine" saves lives but leaves patients in limbo, prompting serious ethical quandaries for doctors and for their patients.
• The American Medical Association is now even suing states, insisting that abortions should be the result of a decision between a doctor and her patient.

These are all hot-button issues. And politically or ethically, you may have strong opinions about them. My point isn't which side you fall on each of these. My point is that in each situation, there is an extreme responsibility that the doctor has to collaborate with his/her patient and make a decision that is truly life or death. They're not situations where you can simply follow protocol. They're not situations where there's a single right answer. And they're not situations where a doctor can make a unilateral decision without truly understanding the patient and the patient's family. 

The truth is that, just as was true 200 years ago, doctors today have a grave responsibility to understand their patient — and act (as well as lead the patient to act) in a way that is truly in the patient's service. I believe that even as we keep an eye on costs, efficiencies, and teams — it's also fundamentally important that we honor the seriousness of the decisions that providers make with their patients. And that we support them — practically and emotionally -- in making them. That's where the role of medical collaboration comes in. It's not about 5-minute telemedicine videoconferencing. It's about helping doctors (and others across the continuum of care) in getting the collaboration and support they need to make the life-or-death decisions that they must make.

When a gun shot victim comes into the Emergency Room, so much has gone wrong.

An interaction between people has gone awry. Our social fabric that keeps violence at bay, has torn. And of course, our patient’s body is experiencing a cascade of things going seriously wrong.

So as doctors, it’s natural to do everything we can to fix the patient in front of us… but shrug our shoulders at all of the other things that have gone wrong to put that person in that position. Our job, it’s common to believe, starts when the stretcher enters the door. But a new program has me rethinking that — in ways that could save millions of lives.

Massachusetts General Hospital announced the launch of the Mass General Center for Gun Violence Prevention last week. The center was a collaboration of everyone from the Boston Police Department to doctors themselves. And it's envisioned to include programs ranging from providing education for providers on treating gun violence to sponsoring gun buyback programs. The center was founded by the pediatric surgeon Peter Masiakos, who says: 

"For as long as our profession has existed, our patients have depended on doctors to be sentinels against hidden societal dangers and advocates for policies that protect us against such dangers. On the front lines of patient care, we are routinely exposed to the faces affected by modern ills such as unemployment, food insecurity, substance use, racism and gun violence. We must stand front and center to better understand the determinants of gun violence and to develop the tools to impact this epidemic that is indiscriminate of race, age, creed, gender and sexual identity.”

The center itself challenges some of our implicit understandings of where healthcare providers start and end. It reminds me of the NRA's plea from last year for providers to "stay in their lane" and the heartfelt rejoinder by an ER doc that guns and violence prevention are very much a doctor's "lane."  This initiative goes even farther than advocacy and treatment — it positions doctors and the hospital as responsible for actually "treating" gun violence before it starts, in all of the social, economic, cultural, and educational ways that can happen.

The truth is that when I first read about Mass General's project, it seemed a surprising use of hospital time and resources. But the more I thought about it, the more the initiative made sense to me. This is a collaboration among multiple stakeholders. Just as we need collaboration across the continuum of care within medicine and for any given patient case, we need collaboration across diverse stakeholders outside of medicine to really change results for our patients.

It's one more reminder that, as doctors, we need to keep asking: 

• How can we be more collaborative to get better results for our patients?
• Who are the people we need to collaborate with for the best possible care?

Mass General's answers to these questions led them to a comprehensive new program. Your answers might just lead you to chatting with a colleague in the hallway. But all of us can ask the questions. 

For more stories of medical collaboration, download our free Quick Guide: 

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: 

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.

We've all been blindsided by technology taking the place of a human, when and where it shouldn't. 

It's the labyrinthine customer service switchboard when we just want to ask a simple question of a real person. It's the app that sends us in circles when we really just want to pay a bill. 

But a recent technology screw-up touched a serious nerve for one family -- and even called into question whether and how telemedicine should be used. 

Mr. Ernest Quintana was in the hospital for the third time in 15 days, as the New York Times recently recounted. His lung cancer was beginning to get the best of him and he was struggling. His family remained hopeful, though, and they were all with him throughout the hospital stay. 

One afternoon, though, Mr. Quintana was surprised to find a machine with a video screen on it being wheeled into his room. With his granddaughter by his bedside, Mr. Quintana listened as a doctor in an undisclosed location, and whom he had never met, began to discuss his care. His surprise turned to sadness and dismay when the doctor shared that Mr. Quintana was likely not going to survive this hospital stay and prepared him for end-of-life care.

A prognosis of death is never easy news for a person or a family. But hearing the news from a doctor you have a relationship with, who brings compassion, presence, and leadership, can decrease the suffering and ease the way forward. In Mr. Quintana's case, the terrible news and challenging decisions were worsened by the impersonal and jarring way that they were broached. No one wants to have a conversation about death with a stranger on a video screen. 

So is this a condemnation of telemedicine? Of technology?

I don't think so. I believe that this sad turn of events simply points to positive and negative uses of telemedicine and positive and negative uses of technology. 

So many people default to videoconferencing as the go-to (or even default) form for telemedicine to take. We believe videoconferencing has severe limitations because it requires expensive hardware and circuitous scheduling coordination. Those are some of the reasons that we believe hybrid Store-and-Forward telemedicine is significantly more powerful of a tool.

But this story brings into focus an even more important and powerful reason that we believe telemedicine should be about team-based collaboration -- not videoconferencing between a doctor and a patient. When telemedicine is used for healthcare providers to collaborate among each other, the patient can interact primarily or exclusively with the providers that they have a relationship with -- and the "other opinions" on the team can be shared among the medical team. That way, the providers can be leaders, healers, and human beings FIRST -- but use telemedicine to consult with other people on the team as necessary, and without disruption to the care for that patient.

For instance, in Mr. Quintana's case, perhaps an outside opinion was necessary regarding his end-of-life care. But rather than that opinion being piped in through a video screen, we believe it would have been far better for his provider, obviously, to consult with the outside doctor -- and then have a conversation with Mr. Quintana in person, within the context of their existing relationship. 

Don't risk this kind of technology screw-up. Prioritize human relationships and let technology -- and telemedicine -- serve them. 

My daughter has a particular pet peeve. She’s noticed that in so many movies, when there is a doctor in the story line, he or she (usually he) tends to be arrogant, insensitive, and uncaring — in so many ways, inhuman.

As doctors ourselves, we tend to see our colleagues — whether doctors, nurses, or aides — as very much human because we know them and interact with them every day. But it’s easy to see insurance carriers or drug companies or other parts of the healthcare system as faceless monsters that make our patients’ lives difficult.

Which is why I was really interested to read a series of articles that turned all of that on its head, and definitely warmed my heart.

A couple of weeks ago, Gina Kolata wrote an article in the New York Times about the new class of drugs, PCSK9 inhibitors, that slash cholesterol levels for patients that aren’t seeing results on statins, or with diet or exercise, but have serious risk of early heart attack or stroke.

She told the story of the hyper-expensive drugs, the $14,000 price tag that the drug manufacturers have set, and the insurance carriers that create a byzantine maze for any patients trying to access the drug.

It’s a well-known story — evil drug companies and evil insurers make it impossible for patients to access the care they need. When I read it, I didn’t think much of it.

Then, about a week later, another story came out.  In this one, the New York times reporter tells a story that pretty much upends all of my assumptions about the players in the story.

The evening her story was published, the founders of Regeneron — the manufacturer of the PCSK9 inhibitors — emailed her.  Dr. George D. Yancopoulos and Dr. Leonard S. Schleifer wrote:

“If you can, please put Mackenzie and Rodney in touch with us, and we will try and help them get covered, or we can arrange to give them the drug for free… While we can’t give everyone free drugs, we can help Mackenzie and Rodney, especially as they had the courage to step forward and share their experiences.”

He then gave his personal phone number and asked the journalist to give it to the patients in the story, “explaining that he can be slow answering emails.” 

In her story detailing her conversations with Dr. Yancopoulos, Kolata told the story of Regeneron. It was founded by the two doctors in 1988. 20 years after that, Regeneron got its first drug approved. 5 years after that, they made a profit. 25 years of a business isn’t exactly a “get rich quick” scheme. The total cost to develop the drug was $1.6 billion and last year they made just $195 million (a tiny fraction of the total investment.) In reading the article, it's clear that Dr. Yancopoulos has battled for decades to create a drug that he truly believes will save lives -- and that his heart is very much invested in making sure people have access to it.

Certainly, it's great that these two patients got access to the drug -- although that doesn't change the challenges that most patients will encounter in obtaining it. That said, it's a fascinating article and shows that even the most "inhuman" elements of the healthcare system -- for instance, drug manufacturers -- may have real people behind them who are doing their best to chart a course forward in a challenging system. 

The truth is that none of us are as smart as all of us, working together, are. (We say that a lot.) And for us all to work together, we must continue to see everyone in the healthcare system as human.