I am really passionate about my work with patients, but stress still creeps in. And when I get overwhelmed, the first thing I think about is time off. I think ahead to dinnertime, gardening on Saturday, or Christmas with the family. Judging by the numbers on healthcare provider burnout, I'm not alone. 

So it would be logical to assume that cutting work hours would also cut dissatisfaction, stress, and healthcare provider burnout. But a new study out of South Korea shows just the opposite. When the work week was slashed by 10%, job and life satisfaction didn't shift, even over a 10-year period.

It seems that working less didn't help people feel a great sense of well-being. 

Over here at ClickCare, this really resonated with us. While we're certainly no proponents of "workaholism", we believe that it is better, more collaborative, more satisfying work environments that we need as healthcare providers -- not just fewer hours. We've found that the keys to lessening burnout are simple but fundamental: more medical collaboration, good relationships with our colleagues, and real connections with patients. 

Robert Rudolf, an assistant professor of economics at Korea University in Seoul, summarized his thoughts on the findings in this way: "[Having a sense of] higher personal freedom about their work ... will make workers both happier and more productive.” And we've found just the same -- when we're free to do our best work, we also end up doing our happiest work. 

Curious whether medical collaboration could help with burnout? Get our quick-guide here:

Something happened in the last couple of decades of practicing medicine. On one hand, it's become increasingly difficult to care for our patients: we see 5 patients in the time we used to see 1; it's impossible to navigate insurance companies' rules; and hospital regulations seem to tie our feet and ask us to jump.

At the same time, medical administrators use "patient satisfaction" as the metric of success, and so regulate provider actions in service of that metric: sit down when you're speaking with patients; talk about feelings; talk about facts; thank the patient for choosing our hospital. Oh, and see more patients.

Somehow these formulaic demands feel both overwhelming and insufficient. We agree that patient satisfaction is fundamentally important. But we disagree that the route to patient satisfaction -- when up to half of physicians show signs of burnout -- is more rules, more sticks, and more carrots.

We'd like to propose something revolutionary: that patient satisfaction starts with provider satisfaction. Our experience is proof, the studies back it up, and our patients seem to echo the sentiment. So, in service of that… 

5 reasons that patient satisfaction starts with happy, satisfied providers:  

1. Compassion fatigue can disable us. Compassion fatigue (sometimes called Secondary Traumatic Stress) is a documented condition, common in caregivers and healthcare providers. When compassion fatigue occurs, disconnection, negativity, and even inefficacy in regular work is the result. A lack of support, pervasive stress and pressure, and isolation are all causes -- the exact things that inspired us to start ClickCare -- and are things that persist in so much of healthcare. 
2. Happy providers communicate better. We all know that providers that communicate well have happier patients. But you might be surprised to find out that if we're happier, we'll communicate better. In fact, a study from the University of Arizona showed that happy people have deeper, more substantive conversations, something that patients seem to crave. 
3. Burned-out providers become unable to do even the basics. One recent study shows that providers with burnout are detached, have a low sense of empathy, and even lie and cheat.  So while sometimes we think of self-care or avoiding burnout as a selfish thing, it's very clear that getting what we need as providers is the most altruistic thing we can do. 
4. Will power and good decision-making plummet when exhausted. There is a really fascinating set of research that shows that will power and good decision-making are linked. And the more decisions we are required to make (or the more will power we use), the more that "muscle" becomes exhausted. Once exhausted, our will power and decision-making become very poor -- until we recharge, rest the muscle, and are ready to use it again. As every healthcare provider knows, a day in the office is an endless series of complex decisions. And when we're not given the space or support to rest from that complexity, the evidence shows that we'll perform poorly.
5. Finally, providers actually need the same things patients need. So often, providers and patients are pitted against each other in a "zero sum" model of medicine: it is assumed that if the provider is getting what she needs then the patient won't, and vice versa. In fact, however, as elaborated in this New York Times article, providers need many of the same things that lead to patient satisfaction. Both patients and providers need more time in the exam room, better communication, simpler regulations, less rush, and more authentic interaction with each other. So it's actually a win-win.

He called, we answered, and he asked us some interesting questions. We did our best to bring some insight about ClickCare and iClickCare. Here is a link: Expert Interviews, For any of you who would like some more background about why we do what we do, we answered these questions:

• After long careers as physicians, why did you start?
• Give me an example of how a patient would benefit?
• If the internet is involved, how can privacy be assured?
• Everything’s expensive in medicine, how does ClickCare save?
• How does iClickCare fit into other healthcare IT initiatives?
• How soon will I see this in my doctor’s office?

These questions are very commonly asked of us. Is there anything that we left out? Do you agree? We welcome your comments.

TNTC
Some of us will remember the old urinalysis report of Too Numerous To Count.

Certainly, the same report could be given for smart phone medical apps. We and our patients can track our blood sugar, exercise, blood pressure, weight, well being, stress and sleep. We have diet apps and women’s apps. We have medical references, and even physiologic monitoring.

Useful and concise reviews can be found at Medical iPhone. They reviewed ClickCare on Wednesday, April 20, 2011. A search in the Apple App store reveals nearly 6000 apps.

The buzz in the media, and the great majority of apps, center on those that are for the patient and consumer (B2C). There are many exciting (and some say futuristic) apps which help the owner of the smart phone to diagnose and care for herself. We do not demean these efforts, but have to ask the question: “What next?”

What does the provider do when the patient comes into the office hunched over, concerned, and holding a beautiful graphic display, delineating a consistently elevated blood sugar. She switches apps and the display shows blood pressure, high, as well. She has documented her intermittent headaches on her headache app. She brings in a Google search.

Google search for diabetes, hypertension, headache

She has not shown you an app for observation, but you observe acne and increased facial hair and think it unusual for a 43 year old.

So what next? Have you made the diagnosis? With which specialist should you confer? Do you call the renal person for her hypertension, a diabetologist, a neurologist? What studies would each like before seeing the patient? Since you know each of these as individuals in your community, and they are part of your natural network, who, indeed, could diagnose and comfort the patient best?

You have two choices:

1. You could pick up the phone or walk down the hall, wait until the CNA gets done with her break and ask her to dial. Or, you could wait on hold, ask the receptionist to ask the nurse to ask the doctor to “get him out of the room.”  Or, you could tell the patient that she might have a brain tumor, a lung tumor, an obesity problem, a new onset of diabetes, a normal expectation of hypertension, and to go see one of the specialists and tell him what you think. Maybe you want to dictate a letter, and wait for one to be returned. Expect the patient to wait for appointments for a long time because these folks are really busy.

2. You could take a picture with your iPhone, distill the history, and with three clicks of the mouse, ask each specialist for his thoughts, preferred tests, and concurrence with your presumed diagnosis. Did you make yours yet?  Each specialist gets back to you with a simple reply button, you call the patient, you share the diagnosis and the coordinated, collaborative treatment plan.

Someday, ClickCare will help each patient with her own care, but right now, today, it can help you, her trusted advisor, advocate, and experienced provider to care for her and yourself – quickly, securely, and with great satisfaction.

You just experienced (B2B). As the consumer wave rushes towards the medical professional’s office, help is available for those providers who care for them. Patients and consumers alike, still need help, and their providers need to help each other.

That’s what’s next.

Here is the Answer.

Or if you are really cool, take out your smartphone and read this bar code.

Use your barcode reader for the answer

We meet all kinds of people as we spread the word about how collaboration can help your patients.

Here is a recent post, and notable quote:
“The iPad could change things. If you think in terms of, ‘Is that a form factor that works better so a visiting nurse can go out to a patient’s home, and say, ‘Gee, this wound doesn’t look so good. Let me pop a picture and send it to the surgeon, who can then access it on his iPad or anything else,’ I think that’s possible.”
Thomas J. Handler M.D., a research director in Gartner’s Healthcare Provider analyst group, tells the News Alert. 1

A safe prediction I would say: iClickCare is already on the iPhone and compatible with iPad. As soon as we have time to stand in a long line, we will be putting the iPad 2 through its paces and see how the camera works. We are pretty sure that it does, but after all, we were talking about the future weren’t we?

That is so then, and we are so now.

And finally, this response from a rather large organization that runs nursing homes:
“Photographs are prohibited at our facilities” 2

What things can you share that you are doing and seem like the future?

Footnotes:
1. Telemedicine and eHealth Newsletter, March 11, 2011,Mary Ann Liebert, Inc.

2. Anonymous, we would not want to embarrass them in front of our extensive readership.

3. Full disclosure: a different Gartner analyst has interviewed us.

There is a lot to talk about. Year end is for reflection. Year beginning is for looking forward. We are reticent to predict (as in Doctor, “how long does she have to live?”), but it seems as if all the buzz of stimulus monies, of EMRs, of personal health, of debate over health care, some fundamentals have been forgotten. Forget fundamentals, disregard principles, abandon commitments, but if you do so, you will be reminded that you “Can’t Fool Mother Nature”.

So we want to look forward to where ClickCare will fit in.

Three diverse concepts relate to each other: EMRs, Twitter with information overload, and the Cloud.

Many of us have made large, very large, investments in licensing, infrastructure and workflow for EMR/EHRs. We have spent a lot of human capital to be sure that we get on the wagon with meaningful use. We have kept a very close eye on stimulus money. Why would we want to challenge ourselves even more? Why, then, are we unsure of ourselves?. Perhaps, we feel that the fable of the Emperor’s New Clothes might come true. Perhaps, we can see no end in sight.

The Emperor's New Clothes

First, we should feel satisfied and confident that the EMR is already advancing. Electronic subscribing and fewer scattered repositories of patient information are most valuable. So while we worry that the “truth might come out”, all is not lost. The team at ClickCare is very committed to being sure that the EMR becomes an even more valuable resource because ClickCare and iClickCare can magnify it and fill the gaps that most fear to mention. There are limits to the EMR. Dr. Alok A. Khorana eloquently and wisely describes them in his brief essay, Physician as Typist, in the Journal of Clinical Oncology.

One point is the lack of focus on communication–his EMR author with him as the typist:

“I stare at the primary care physician’s note in front of me. I have been concerned about our mutual patient’s hypertension. I believe it has been exacerbated by the use of bevacizumab, and I have referred her back for additional management. All I need is an acknowledgment of the problem and a treatment plan. The note that I have received is three pages long and is filled with unrelated laboratory values, scan results, and jumbled-up text.”

In contrast were other notes, generated “by hand”:

I get other notes, too, from providers that haven’t yet adopted an EMR system. I made a recent referral for a patient with hematuria to a urologist. In a day or two, I received a one-page summary of the problem, including a differential diagnosis, the findings on cystoscopy, and the plan for additional surveillance. It was, really, all I needed. Another oncologic surgeon with whom I share patients always mentions the patient’s profession in the first sentence of the letter. It tells me something about the care that a surgeon who cares to find out such details will provide. However, as our institution transforms from a hybrid to a completely EMR system, these unique styles are likely to disappear.

What is the reason there is a difference between man and machine? Dr. Khorana perceptively notes:

“Recall that there are two major narratives associated with the physician-patient encounter. The first is the narrative told by the patient to the physician. The starting point of this narrative is relatively uniform: the complaint that brought the patient in. From here onward, however, the narrative can be remarkably free flowing and often tangential. To make sense of this free-flowing story, we as providers resort to a second narrative. The physician’s narrative repackages the patient’s tale, but in a format that serves the scientific goal of the note, which is to reach a diagnosis and treatment plan. Of necessity, it requires the act of listening closely and mindfully to the patient first.”

This article is clearly and cogently written. Reading it is highly recommended.

The reaction

What we would add is that ClickCare takes that very “act of listening closely and mindfully to the patient first”, and allows the listener to act upon it subsequently and cooperatively with other colleagues. Not with every patient, not with every visit, but when necessary and appropriate, to do so easily and quickly. Indeed, ClickCare offers the patient an audience of more than just one.

Another way of looking at this, is that there is too much information, and that communication is not taking place. Here are excerpts from an interview on the blog GIGAOM.

Om Malik, the blogger is interviewing Evan Williams, the cofounder of Twitter:

Om Malik: Ev, when you look at the web of today, say compared to the days of Blogger, what do you see? You feel there is just too much stuff on the web these days?,

Evan Williams:I totally agree. There’s too much stuff. It seems to me that almost all tools we rely on to manage information weren’t designed for a world of infinite info. They were designed as if you could consume whatever was out there that you were interested in.

Om Malik:Do you think that the future of the Internet will involve machines thinking on our behalf?

Evan WIlliams: Yes, they’ll have to. But it’s a combination of machines and the crowd. Data collected from the crowd that is analyzed by machines. For us, at least, that’s the future. Facebook is already like that. YouTube is like that. Anything that has a lot of information has to be like that. People are obsessed with social but it’s not really “social.” It’s making better decisions because of decisions of other people. It’s algorithms based on other people to help direct your attention another way.

They also discuss immediacy and relevancy.

Om If you were starting Twitter today – same service, but in a world that is very mobile, very multi-touch driven and a very portable web – what would it look like?

Ev: I’d have to think about that for a while but i don’t think it looks that different than what we have today. Twitter is a natural fit for mobile – it has the immediacy. There is nothing significantly missing, but (we) need to really boost relevancy. If you can’t read everything, then (what is that) you really do need to know right now.

Immediacy creates a need for mobility. Mobility creates a need for immediacy. Again, ClickCare supports and enables the EMR by enabling both immediacy and mobility regardless of which EMR was purchased.

Which brings us to the Cloud, and our last prediction about where ClickCare fits in. Many will become comfortable with the Cloud, immediacy and access. There are some who already expect it. The last mile of internet access not with standing (ClickCare can use 3G and Edge), communication with pictures and words can be the norm. We will expand more on this in another post.

In the meantime our prediction is that the patients will begin to get better care this year. We just need to look ahead and beyond.

A lot of people seem to think so.  The most recent report, abstracted by research2guidance entitled “Global Mobile Health Market Report 2010-2015” was reported at mHealth Summit last week.  We also heard the same theme when we presented at mHealth in San Diego, last month.

The statistics are amazing, and all point to the same message:  we are all mobile creatures and would rather not be on a leash.  Research2guidance estimates that 500 million people will be using smartphones in various ways for health care.  These range from continuing medical education to unique monitoring devices.

We at ClickCare would caution, however, that the right tool, at the right time, at the right price should be used.  We could not be more enthusiastic about iClickCare and the iPhone, we also know that sitting quietly at a large, easy to read computer screen can be as valuable as taking and sending a secure message and photo/video with the iPhone.  That is why we have both available and included with each subscription.

Similarly, one can subscribe either via download from the App Store, or from our website ClickCare.com .  A free two week trial lets you start collaborating with your colleagues immediately–with an iPhone, with a desktop, with a laptop or iPad.

Use a needle to sew a laceration or a shirt.  Use a sledgehammer to crush a rock.

Use your ClickCare subscription in the way that is best for you at a particular time and in a particular place.

We look forward to your comments.

Rite Aid to pay $1M to settle HIPAA privacy case

The regulators mean business. This is not the first enforcement of HIPAA by any means, but it is a significant one both in scope and in penalty.

We often hear busy doctors say I just use email. The patient says it is OK.

It may be OK with the patient, but it is not OK with regulators. In this case, both the Federal Trade Commission and the Office of Civil Rights of Health and Human Services have accused Rite Aid of improperly disposing of records in an unauthorized trash container.

Occasionally, it seems best to have the end justify the means – it more likely will not be the right thing to do. In matters such as HIPAA, it is a high risk maneuver. Since ClickCare can get to the same end in a legal way, why not use it? Further, all collaborations are saved and available for reference and teaching.

The HITECH act (which provides loans for EMR adoption) added teeth to the HIPAA regulations:

The Health Information Technology for Economic and Clinical Health (HITECH) Act provides a tiered system for assessing the level of each HIPAA privacy violation and, therefore, its penalty:
Tier A is for violations in which the offender didn’t realize he or she violated the Act and would have handled the matter differently if he or she had. This results in a $100 fine for each violation, and the total imposed for such violations cannot exceed $25,000 for the calendar year.
Tier B is for violations due to reasonable cause, but not “willful neglect.” The result is a $1,000 fine for each violation, and the fines cannot exceed $100,000 for the calendar year.
Tier C is for violations due to willful neglect that the organization ultimately corrected. The result is a $10,000 fine for each violation, and the fines cannot exceed $250,000 for the calendar year.
Tier D is for violations of willful neglect that the organization did not correct. The result is a $50,000 fine for each violation, and the fines cannot exceed $1,500,000 for the calendar year.
The HITECH Act also allows states’ attorneys general to levy fines and seek attorneys fees from covered entities on behalf of victims. Courts now have the ability to award costs, which they were previously unable to do.

Collaborate legally.

Comments based on http://www.healthcarefinancenews.com/news/rite-aid-pay-1m-settle-hipaa-privacy-case,  quoting Editor’s note: This is an excerpt from the April 2009 edition of the HCPro, Inc. newsletter, Briefings on HIPAA.

As medical professionals, we really don’t sit down much.  We walk from exam room to exam room, floor to floor, department to department, home to work, work to home, hospital to hospital, and even to our patients homes.

So the challenge, as a reconstructive surgeon building a software solution for collaboration among providers, was this: How can we make this solution organic, flexible, and easy-to-access? In other words, how can we make it reflect our lives, not the life of the average IBM worker?

The answer was to build a network not with concrete, paper, and disks, but with computer-to-computer connections that function like neurons in the brain. The answer? The cloud. And how do we access the cloud? Via Software as a Service (SaaS.)

Instead of requiring a concrete program on your individual computer, the cloud means that you subscribe to a service (SaaS again) that connects you with the “cloud” (a network of computers) to store and manage data, and to process that data as a partner with your computer.

To completely mix the metaphor, it’s like an apartment building where the furnace is shared by all of its tenants.  The apartment owner sets the thermostat in his apartment, while his neighbor sets a thermostat to a different setting.  Neither runs down to the basement and puts water in the boiler and coal on the fire.  Each of the multiple tenants has his own keys and locks.  But, the cost of the furnace and its maintenance is shared. Each tenant pays less for the heat than if each had bought his own furnace (needless to say a “green” use of our resources.)

Cloud services have five essential characteristics:

1. On-demand self-service: no IT guy needs to supply you with access or passwords. No disks; no servers; no installers. It’s there when you need it.
2. Broad network access: you can use the service from wherever you want, whenever you want. Your mother-in-law’s PC after dinner? Check. Your iPhone from a Hawaiian beach? Double-check.
3. Resource pooling: This is where the furnace example comes in. You don’t need a computing center or even a very good laptop. You just need to connect to computers that do these functions for you.
4. Rapid elasticity: It grows as you grow. No need to estimate usage 18 months later. Also, because changes can be made instantly, there is no “your computer is worthless now” obsolescence.
5. Measured service: Like the pay-per-pound buffet, you don’t have to pay for what you’re not going to use.

We use information continually, want updates, and want help. However, unlike office dwellers with their fingers glued to their keyboard, we flow, and we need our information to flow with us. The cloud does, and that’s why ClickCare is all about the cloud.