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The Healthcare Problem

Patient Centered Care

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Patient Centered Care

The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.  

This should be a silly question, like asking if car-repair is car-centered.  But it is clear that much of the high cost of care in our country is due to the huge number of unnecessary procedures, medications, hospitalizations, and services given to/done on people.  Unnecessary care is, almost always, not patient-centered.  

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Patient Centered (Part 1)

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Patient Centered (Part 1)

Rather than dwelling on the malfunction of the system, however, I want to turn my eyes toward what most people don't see: what real patient-centered care could and should be. It's not that I am suddenly wiser than my colleagues in the sick-care system.  Despite 18 years in practice, I was not able to see what true patient-centered care looked like until I left the system. 

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ICD-10 and Inflation of Codes

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ICD-10 and Inflation of Codes

For those still unaware (perhaps looking through catalogs for gigantic inflatables for president's day), ICD-10 is the 10th iteration of the coding taxonomy used for diagnosis in our lovely health care system.  This system replaces ICD-9, which one would expect from a numerological standpoint (although the folks at Microsoft jumped from Windows 8 to Windows 10, so anything is possible).  This change should be cause for great celebration, as  ICD-9 was miserably inconsistent and idiosyncratic, having no codes describing weakness of the arms, while having several for being in a horse-drawn vehicle that was struck by a streetcar.  Really.

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The Impending Revolution

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The Impending Revolution

Like my practice, membership medicine is still in its early phases.  Like my practice, the future of membership medicine depends on a lot of things beyond our control.  But the excitement I hear regularly from physicians, residents, medical students, patients, business owners, and even politicians about its potential is quite remarkable.  Both of these conferences were full of something that I once thought no longer existed: doctors who were excited about medicine and cautiously optimistic about the future.

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Gaia and Snake Oil

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Gaia and Snake Oil

The idea of a 'balance' to be disturbed flies in the face of the reality easily seen in this world: few people get through the year without getting sick, and none ultimately avoid getting some terminal condition.  In short, fighting sickness is always a losing game.

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My Deadly Reality

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My Deadly Reality

It looked so easy....  What could be so hard about catching crab in the Bering Sea?  Surely I am tough enough for that.

It looked so easy.... What could be so hard about building a practice compatible with the Affordable Care Act?  Surely I am smart enough for that. 

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Washington, We Have a Problem

“Daddy?”

“Yes, Jonathan?”

“Sometimes my leg hurts.”

“Yes?”

“Why does it hurt?”

“Uh, that’s a tough question.  Does it hurt a lot?”

“No, just every once in a while.”

“OK, and where does it hurt.”

He gives an expression of disbelief at the stupidity of the question.  ”My leg!”

“Where on your leg?”

“I don’t know,” patience now growing thin.  ”I just want to know what’s causing it.”

“Well, Jonathan, it doesn’t work that way.  My main job is to make sure there is nothing bad going on, and then to make a person feel better.  If the problem a person has is not a danger to them or is not causing trouble, we usually don’t know the cause.  It’s certainly nothing serious.”

By this point I had lost.  I had lost his interest in the subject, and, more significantly, I had lost his faith in me as a doctor.  He is our concrete thinker; presently about to graduate from Georgia Tech with a degree in industrial engineering (and looking for a job, I might add).  He didn’t have desire to understand the subtleties of practicing medicine; he just wanted answers.  My lack of answers was a big mark against me.

It turns out that Jonathan is not alone in this. People come to me for answers, and my profession pitches doctors as the ones with answers.  We fix problems.

This, of course, is not true – a fact that I have come to see as a core problem in the practice of medicine in America, and a reality that (as everything seems to do) comes largely from the way we pay for medicine.  We are paid to fix problems.  How do we fix problems?  With procedures.

The best evidence for this are the things at the heart of health care: codes.   There are three types of codes that dominate the financial and clinical lives of anyone in health care:

  • ICD codes – Codes for medical problems
  • CPT codes – Codes for medical procedures
  • E/M codes – Codes used by doctors who don’t do procedures so they can get paid for office visits.

What this encourages from the medical profession is predictable: lots of problems treated by lots of procedures.  This is good for doctors who do procedures, especially ones that are cutting-edge (like robotic surgery) or ones that seem particularly dramatic and/or heroic (open heart surgery, heart stents).  These are the things the headline consuming public is most hungry for.  Just like it grabs more headlines to catch a terrorist plot just before it has its horrible effect than to prevent it early in the process, it’s a lot sexier to do a procedure to treat heart disease than to simply prevent the disease in the first place.  Which is the better outcome?  Preventing heart disease.  Which is paid more?  Not even close.

The Problem with Problems

A more subtle (and perhaps more significant) effect of this mindset is the way in which everything is labeled as “problems” or “diseases.”  A recent ruling of the AMA that obesity is a “disease” stirred up quite a bit of controversy. The AMA ruling does nothing to change the nature of Obesity, and clearly is more a discussion of semantics, politics, and funding, than it is a true medical question.  In reality, I used to not be able to bill the ICD-9 code for obesity and get paid, but now I guess I could (if I did that kind of thing any more).  I suspect this opens the door for more procedures to be paid for by insurers, as the response to any problem is always a procedure in our system.

There is pressure now to respond to each “problem” with a procedure, or at least a thing to eliminate it as a problem.  Examples:

  • Sinus infections are routinely treated with antibiotics despite no evidence that it actually helps.  Having marketed our profession as problem-fixers, we are met with patients expecting a fix to their problem.  They are disappointed (and even angry) when we don’t “do something” for a “problem” that will resolve on its own, even if the intervention probably causes more harm than benefit.  Problem: sinusitis.  Procedure: antibiotic.  Check.
  • Cholesterol treatment is another example of this.  High cholesterol, be it LDL, Total, or Triglyceride is seen as a “problem,” even in people who are not at risk for heart disease.  I’ve seen many low-risk patients come to my practice on cholesterol medication that does little more than improve their numbers.  The evidence shows that certain high-risk people benefit from being on certain medications which lower the cholesterol.  For folks outside of those high-risk groups, the medications simply make numbers look better (at best) and potentially harm them (at worst).  Problem: High Cholesterol.  Procedure: Cholesterol drug.  Check.
  • Depression and anxiety are normal emotions.  Life is painful and unsure.  There only are two ways to avoid these emotions: die or get stoned.  My personal experience (some fairly recent) is that the times of life most marked by anxiety and depression are accompanied by significant personal growth.  Before everyone gets mad at me for saying these aren’t diseases, I must add that there are cases of both of these emotions that are terribly destructive and potentially fatal if not treated.  But we physicians have lowered the price of admission to treatment, including people going through hard times as those who have clinical depression.  Responding to TV ads about “that pill that will make me happy,” we are met with patients expecting us to “fix their problem” – a problem that is not really a problem; it’s life.  Problem: Anxious and Depressed People.  Procedure: Medication.  Check.

A Better Way

I think there’s a better way to look at things.  I’ve said this before, but I am coming to grasp just how radical this approach is and just how much it undermines our health care system.  There is something far more important than problems:

Risk.

When someone comes to my office with chest pain, my thoughts do not go to the question: “what is going on?”  A more important problem comes first: “is this a dangerous situation?”  I want to know if the person is ready to die from a heart attack or other serious problem.  This is true in nearly every decision I make as a doctor when faced with a condition.  Could that cough be latent lung cancer?  Could that headache be a brain tumor?  Could the depressed man kill himself?

Risk-reduction also rules how I approach disease.  I treat cholesterol and hypertension, not because they themselves are problems, but because they can lead to heart disease, stroke, and other problems.  High cholesterol is not, in my opinion, a “disease” for most people; it is a risk factor.  I treat diabetes mainly to prevent the complications.  Do I care if a 90 year-old has an A1c of 8?  No way.  It doesn’t increase their risk enough to matter.

This does not mean we approach “prevention” like the system presently does: throwing procedures at it.  The health care system doesn’t reward having healthy patients, it rewards doing procedures reported to prevent problems.  Yet the system is not addressing the true goal of prevention: risk reduction. We are “rewarded” by ordering tests, whether or not they reduce risk.  PSA testing is a perfect example of this, as are many other misguided attempts to treat prevention as another problem to  fix with a procedure.

The problem with this, of course, is that it far more to the financial benefit of doctors (and drug companies) for us to address every problem and show we are giving “good care” by checking off the box next to each problem.  In the bigger picture, risk-reduction makes the jobs of future cardiovascular surgeons (and drug companies) much less secure.  It attacks the revenue stream of most doctors and hospitals (and drug companies) right where it counts: you can’t make nearly as much money off of healthy people as you can people with “problems.”

This is why, I believe, any system that profits more from people with “problems” than those without is destined to collapse.  Our system is opposed to the goal of every person I see: to stay healthy and stay on as few drugs, have as few procedures, and avoid as many doctors (and drug companies) as possible.

What would happen if we prevented disease?  What would happen if people didn’t have medical problems?  For society it would be great.  For the health care industry it would be a huge problem.

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Adventures in Medicine, Part 1

While hard at work at building a new practice and (in the eyes of some) on my insanely misguided effort to build a medical record, I've been thinking.  Dangerous thing to do, you know.  It can lead to scary things like ideas, creativity, and change.  I know, I should be satisfied with the usual mental vacuum state, but I've found it a very hard habit to kick.  Perhaps there's a 12-step group for folks with ideas they can't suppress. Anyway, my thoughts have centered around explaining what I am doing with all of the my time and energy, and, more importantly, why I am doing all that stuff that keeps me from writing about important things like body odor, accordions, and toddlers with flame-throwers.  I've really strayed from the good ol' days, haven't I?  The problem is, I've grown so accustomed to my nerd persona that I end up giving explanations that are harder to understand.  To combat this, I've decided to employ a technique I learned from my formative years: stories with pictures.  My hope is that, through the use of my incredible drawing talent I will not only explain things faster (saving 1000 words per picture), but prevent my readers from falling, as they often do, into a confused slumber.

So, here goes.

Adventures in Health Care: Part 1 - The Participants

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This is a patient.  Let's call him "Chuck."  Chuck is not really a "patient," he's a person.  Many doctors believe that people like Chuck don't exist outside of their role as "patients," but this has been proven false (thanks to the tireless work of Oprah and ePatient Dave). But since this story is about Chuck's wacky adventures in health care, we will mainly think of Chuck in his role of "patient."

Why are people like Chuck called "patients?"  Some people think it's to put them in their necessary subservient place in the system.  I think it's just to be ironic.

Chuck is a generally healthy guy, but occasionally he does get sick.  He also worries about getting sick in the future, and want's to keep himself as healthy as possible.  This is when he uses the health care system, and when he is forced to be "patient."

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This is Chuck's Family.  It's the main reason he wants to stay healthy and avoid being a "patient."  He has a lovely wife, two adorable children, and a cat that likes to ride around the house on a Roomba.  I suspect you've heard about the cat; he's gotten pretty famous.  Chuck's family wants him to stay around for a long time so he can pay bills, share his expert opinion on whether an outfit makes his wife's butt look fat, lecture the kids about the dangers of drugs and Cartoon Network, and answer his cat's voluminous fan mail.  He would also like to live to be able to see his grandchildren (although he's not sure his kids will survive that long).

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This is Chuck's doctor, Dr. Ron.  Dr. Ron is a "primary care provider," or PCP.  Ron never particularly liked being called a "provider," but the peer pressure from the insurance companies and the other "cooler" doctors (specialists) have made Ron accept this name without thinking any more.  Primary care doctors are also called "generalists," but are known to hospital administrators, insurance company barons, and the "cool" specialists as:

  1. Referral sources
  2. The ones to blame
  3. Cannon fodder for insurance contracts
  4. The guys who can't afford the cars we drive.

Like most primary care doctors, Ron is very, very busy.  He doesn't feel like he's got much of a choice, as it's the only way he can make enough to pay his student loans and still have enough for his loan on his Kia. This causes the following deadly consequences:

  • Spending all day seeing patients in the office gives him little time for anything else.
  • He doesn't answer questions over the phone, instead making patients come in for anything that takes more than three words to answer.
  • This makes his office visit workload even heavier, and makes the average visit be about less "exciting" problems.
  • Ron then wonders why his patients come to him for such small problems.

Last week, Chuck hurt his back (while trying to avoid his cat) and wasn't sure what to do about it.  He didn't initially go to the doctor, but did what most people do when they have a question: checked the Internet.  He doesn't like doing this, though, as it usually confuses him more.  Besides, he's heard that doctors get mad if you look things up on the Internet.

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He gave up trying to find answers on his own, called Dr. Ron's office, and was set-up with an appointment.  This meant that he had to take time off of work, wait in the office for a long time, and then fit all of his questions into the brief time Dr. Ron is in the exam room and not focused on documentation. This usually is about 30 seconds.  But this is what Chuck, and everyone else in the country is used to, so Chuck puts up with the inconvenience this causes, dutifully paying his copay for those precious 30 seconds of attention.

In truth, Dr. Ron is not too happy with this arrangement. He went into medicine because he thought it would be cool to help people, have awesome knowledge nobody else knew, and to make his mom proud. He likes taking care of people, but is finding less and less of what he went into medicine for. Each year it seems like he spends less time with his patients, and more time with his computer.

This got much worse in the past few years as the government decided all doctors should be using computers in a “meaningful and useful” way. Unfortunately, “meaningful” and “useful are defined by the government, not doctors and patients, and Ron is not quite sure if the government wasn't just being ironic when they decided on these definitions.

Despite the difficulties, Chuck likes Dr. Ron, who seems to spend more time with him and listen to his problems more than other doctors he’s had. A few times Dr. Ron spent a whopping 5 minutes talking with Chuck and answering his questions. This made Chuck feel a bit guilty, as Dr. Ron seemed pretty tired and stressed out.

(To Be Continued....)

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Trickle Up Economics

It's been a month since I started my new practice.  We are up to nearly 150 patients now, and aside from the cost to renovate my building, our revenue has already surpassed our spending.  The reason this is possible is that a cash-pay practice in which 100% of income is paid up front has an incredibly low overhead.  My admitted ineptitude at financial complexity has forced me to simplify our finances as much as possible.  This means that the accounting is "so simple even a doctor can do it," which means I don't need any front-office support staff.  I don't send out bills because nobody owes me anything.  It's just me and my nurse, focusing our energy on jury-rigging a computerized record so we can give good care. Our attention to care has not gone unnoticed.  Yesterday I got a call from a local TV news reporter who wanted to do a story on what I am doing.  Apparently she heard rumor "from someone who was in the hospital."  I was the talk of the newsroom, yet I've hardly done any marketing; in fact, I am trying to limit the rate of our growth so I can focus on building a system that won't collapse under a higher patient volume.  I explained this to the disappointed reporter why I was not interested in the interview by telling her that I left my old practice because I needed to get off of the hamster wheel of healthcare; the last thing I want to do now is to build my own hamster wheel.

hamster-wheel

I've also gotten interest from a place I didn't expect: local specialists.  I always thought what I am doing applies only to primary care, as it is hard to do a monthly fee for the procedure-oriented specialties.  But as the enthusiasm for my new type of practice grows in the community, it may spur a boom in cash-paying patients.  Why?  One of the provisions in the Accountable Care Act (ACA) is that small businesses (with over 50 employees) who want to avoid the penalty for not having insurance can opt to contract with a direct-care physician like myself in conjunction with a high-deductible health care plan.  Even though I have made no effort to attract such interest, I've already been approached by 2 businesses of 100 employees to make such an arrangement.  Again, I turned the offer down for now, saying I am quite interested, but would only do so when my practice was ready.  But the fact that this happened while I am doing my to best avoid attracting such attention suggests to me that the desire for this is very intense in the small business community.  This makes sense, as they don't want to pay the fines, but also don't want to pay the exorbitant cost of standard insurance, and so would jump at any other option.

The end result is a potentially large influx of patients who are basically self-pay.  The specialists, who see me lowering my overhead significantly by taking cash payment up-front, see the same opportunity for their practices.  The hitch for them is that they are not allowed to give discounts to self-pay patients that they are not also giving to Medicare patients.  Yes, it is illegal for a Medicare provider to give a discount to non-Medicare patients who cannot afford the cost.  There are ways around this rule, and I hope to work out something for my specialist colleagues so they can give significant discounts in exchange for cash up front (which is, by the way, the same logic that the labs use to give the enormous discounts I am offering to my patients on lab services).  I have had multiple specialists show very high interest in such an arrangement.  I'll fill you in as this develops.

This seems quite ironic to me - a sort of "trickle-up economics," where I am spreading the benefit of offering discounted care in exchange for cash to the higher-paid specialists.  It is a win-win-win arrangement, though, as the specialists benefit from reducing their overhead while getting guaranteed payment, I benefit by increasing the value of my type of practice even more to my patients, and the patient benefits by getting cheaper care.  This, of course, raises the likelihood that more businesses will opt for this payment model, and the movement gains momentum. Who loses?  The "increased overhead" comes in the form of the front-office staff doing billing, coding, and collections.  This is the staff my simple-minded approach to finances has heretofore avoided, and hopes to continue avoiding.

trickle-up

I may be completely wrong in this, as it may not consider other factors (which wouldn't surprise me), but I am not wrong about the intense interest I see in what I am doing.  It is palpable.  When I spoke at HIMSS over the weekend (ironically as keynote for a pre-conference targeted at large health systems building ACO's), the reception was remarkably positive.  My message of simplicity is falling, apparently, on very fertile soil.  Did they realize the implication of "cost savings" being the need for less employees and the to downsize their business?  I took great pains to emphasize the point, yet the reception was vigorously positive.

I suppose little should surprise me, in a world where the have-less's could have their abundance trickle up to the have-mores.  Who knows, maybe people will even pay attention to the economic wisdom of a doctor with an accounting impediment.

Nah.  That's ridiculous.

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For the Record

For the record: I am a geek.  I love technology.  I adopted EMR when all the cool kids were using paper.  Instead of loitering in the "in" doctors lounge making eyes at the nurses, I was writing clinical content and making my care more efficient.  I was getting "meaningful use" out of my EMR even when nobody paid me to do it.   But now who's laughing?  While they are slaving away trying to get their "meaningful use" checks, I've moved on to greener pastures, laughing at their sorry butts!  It's just like my mom promised it would be.  Thanks mom.

Really, for the record, I am not so much a technology fan as a "systems" guy.  I like finding the right tool for the job, building systems that make it easier to do what I want, and technology is perfect for that job.  I am not so much a fan of technology, but what technology can do.  Technology is not the goal, it is the best tool to reach many of my goals.  There are two things that measure the effectiveness of a tool:

  1. Is the tool the right one for the job?
  2. Is the person using the tool properly?

So, when answering the question I posed at the end of my last post, what constitutes a "good" EMR, I have to use these criteria.

How is technology the right tool for the job?  The job I seek to do is not what EMR's are designed for: documenting health care.  I want a tool to help me give care.  I can afford to focus on giving better care since I am no longer paid to document, which is what the health care system demands of doctors.  I spent the past 16 years using a documentation tool for care, which is definitely a mismatch.

What then would a care tool look like?  Here are the things I think are most important for good care:

1.  Communication over Documentation

While data gets all the attention of IT vendors, health executives, and government drones, it is the communication of that data that constitutes good care.  One of my first goals in my new practice is to use whatever tools possible to enable that communication.  Standard health care only allows communication in the exam room (although many patients would say that doctors are so focused on documentation that they don't listen there either).  Between office visits there is virtual silence from the patient, as if their life is not happening during that time.

I've considered making bumper stickers that say: "My doctor answers my email" or "My doctor answers the phone," with my logo and web address underneath.  This is effective because of the insinuated truth that most doctors don't do either.  The system dictates this, but good care says otherwise.  My patients have been delighted when I answer questions, view the spreadsheets they fill out, and interact with them on a daily basis.  It's communication, and tech makes it much easier.

Documentation is OK, as long as that documentation centers on the communication of data, not just the data itself.

Yet even I use the term "medical record," which refers to a static collection of data rather than a tool to allow that data to be used well.  Any good health IT system must not simply document the communication, but must enable that communication as to happen easily as possible.  This means both getting information from my patients and putting it into their hands.  This is why another central goal of my practice is to give patients access to their records.  Too much of patient care is done blindly, not knowing what care has been done, relying on the patient to re-recite their medical history.  With the proliferation of mobile technology, my patients can bring their medical record with them wherever they go.  This, in turn, enables better communication with other providers.

2.  Organization of Data

Walking around with a computerized stack of paper, however, is not all that my patients need; they need the information to be organized.  This is another of the strengths of IT.  An astute commenter on my last post gave a link to a TED talk on the beauty of data visualization, which shows how organizing and presenting data in the right way can make dry data tell rich stories.  I want an EMR that shows me a timeline of the patient tagged with their symptoms, medications, lab results, vital signs, and any other pertinent data I want to see.  What is the relationship of exercise to your depression?  Did that back pain start after you added that medication?

The point of organization is to see through the extraneous to see the meaningful.  It is, in essence, another part of communication.  As I listen to a patient's story, I ask questions and bring out important details they may have missed, and ignoring that which I know is not significant.  This is what makes a good diagnostician, and the ability to this with the volumes of patient data is what would allow IT to improve care.

3.  Collaboration, not Ownership

The world of health IT is obsessed with something called "data ownership."  This is kind of crazy, as data is information, and information is fluid.  How do you "own" information?  If I learn a fact, do I "own it?"  If I possess a book, does that make me the owner of its ideas?  The wonderful world of HIPAA and the threat of identity theft has bolstered the cause of "ownership."  Unfortunately, communication of ideas is diametrically opposed to this concept.  IT must not be about building walled gardens of data, but about collaborating with that data for the sake of patient care.

I first heard of the term, collaborative health record from Dave Chase (the guy who first told me about my kind of practice), and I really like the concept.  The idea is that the ideal patient record is a collaboration between the patient and the caretakers.  Patients know things I don't: what meds they've been taking, how they feel, whether they are married, are smoking, or if they had measles as a child.  In fact, if you look at a typical note in a patient chart, the majority of the information is originally "owned" by the patient.  So why not let them take care of those parts of the record?  Why not let them update when they've been to a specialist and had their medication changed?  Better yet, why not have the specialist take part in this too, collaborating to make sure the patient got the message correctly?

Why, in fact, do I need to re-create what the patient could do better than me?  Why not just look at what they've done instead of transcribing it into "my" record?

This sounds suspiciously like a wiki.  What resource on the internet gives useful (albeit sometimes inaccurate) information in a format that elementary school students understand?  Wikipedia.  Isn't this a better way to organize patient data than a typical EMR?

4. Easy Does It

In considering what I need from IT to give patient care, there is one more thing I need - something that is clearly lacking in most EMR systems: ease of use.  I should have seen the writing on the wall when my EMR vendor insisted I pay for 4 days of onsite training before I could use their system.  I don't want to learn a new language, and my patients want it even less.  Just as a medication a patient cannot afford is useless, a technology a patient won't use is also useless.  Tech can go either way on this: either making difficult tasks easy or making simple things complicated.  This is where Steve Jobs was right: design simplicity.

I don't want my patients to have a separate log-in for each part of their care.  I want a single sign-in and a uniform experience.  I want an app that they press which pops up options to "refill my meds," "contact my doctor," "update my record," and "look up a result."  I don't want them to need to own certain software or download files.  It's got to be easy and well-designed.

Putting it together

So in thinking about this wish list, it occurred to me that there is one company that could deliver all of the goods here: Google.  Apple and Microsoft have many of the same tools, but they are far more proprietary in their approach.  If I share a spreadsheet with a patient, I don't want to have to worry they own Excel.  If I want to do a video chat, I don't want to have to consider if they've got a device that can do FaceTime.  Google does email, spreadsheets, video chat, groups, web pages, organizes data, and has lots of cat videos to boot.  And all of these services are easy to use and free.  Most of them are free.

So should Google get back into health IT?  Didn't they already try health IT and fail?  Ah, but it's not just having the right tool that is important, it's knowing how to use it.

So, Google, if you really are interested in changing the world for the better, you know where to find me.  I suppose I'd be willing to talk.

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