http://www.cfah.org/resources/gb/archives.cfm Good Behavior is a monthly series, written by the Center’s president, Jessie Gruman, PhD, and intended for health policy makers. The publication offers Dr. Gruman’s perspective on emerging health care issues, and provides insight based on evidence about how best to address them. Fri, 12 Mar 2010 03:49:00 EST Center for Advancing Health, Washington, DC, 2010 http://www.cfah.org/ en-us March 2010
He finds his own job threatened by a hotshot business school graduate who convinces the president of their company that it would be more efficient to do the long-distance layoffs via the Internet.

Sitting in a hotel bar, our hero makes a passionate speech to his young colleague about how important it is to fire people face-to-face: that a look in the eye, a few words that personalize the institutional rejection and a handshake allow them to maintain some small shred of dignity at the very moment they lose their identity as a valued employee.

This speech resonates with me as I contemplate the waves of e-mail notices in my inbox announcing new electronic tools and personalized Web-based services and sites that can help me take care of myself. I can take a picture of my rash with my iPhone and send it to my dermatologist. I can check online to see when I had my last tetanus shot or schedule my next mammogram. I like interacting with my doctors by e-mail about minor matters. And if I lived in the empty plains of Eastern Montana, I would probably often prefer a telemedicine visit with a doctor or nurse over a 10-hour round-trip drive for a 20-minute in-person appointment.

What takes place during an in-person visit -- the physical examination, the conversation, the look in the eye and the handshake -- that can’t be accomplished any other way?

I have a hunch that the value of the in-person firing -- as opposed to online -- so passionately defended by George Clooney's character is dwarfed by the value of the face-to-face, hands-on meeting between me and my doctor or nurse practitioner. . .that sometimes the interaction between us is a critically important part of my doctor’s diagnosis and treatment recommendations as well as my willingness to participate in care.

The active ingredients in that interaction are not widely specified or quantified. And while most people and most health professionals probably share my hunch that in- person interactions are sometimes critical, all of us appear to be willing to forego such contact at different times for reasons of convenience and expense.

High cost and poor efficiency are cruel taskmasters, though, and the drive -- by health plans, the government and providers -- to reduce the former and improve the latter is well served by out-sourcing interactions between us and our doctors to automated and Web-based programs and services. How will they -- and we -- know when the balance tips -- when the lack of the physical encounter, the look in the eye; the hand on the shoulder begin to erode the quality of care we receive and the outcomes we hope for?

Jessie Gruman, President
Center for Advancing Health]]> http://www.cfah.org/pdfs/Good%20Behavior/2010/CFAH_GBMAR10_web.pdf February 2010
This morning I read about a networked wireless pillbox that prompts people with chronic kidney disease to take their medication. This box not only reminds the person to take her drugs; it also lets her caregivers and her doctors know when she doesn't. Sounds a little like Big Brother in a bottle. But no matter: if people are to benefit from the treatment, they have to choreograph the ingestion of many pills at prescribed intervals throughout the day. The programmed nudges apparently can help them do this. Then I read that MedlinePlus is now available on my cell phone so I can look up the generic equivalents of my prescription drugs while I'm standing in the drug store. Cool, huh?

Every day I hear about six or seven new ways that I can use the Internet through my computer or my phone - to learn about the drugs I now take or might take; the doctors I now consult and those I might consult; the symptoms I now have and the diseases they might signify.

Plus much, much more.

The Web is so tempting and responsive that it's easy to spend hours online trying to figure out what that ringing is in my ear, whether there is something I can do about it, and if not, which of my many doctors to call.

I feel compelled to make use of health tools online. After all, there are sites that allow me to self-diagnose the symptom that troubles me right now - and a few minutes searching the Web is far more convenient and far less expensive than a trip to the doctor.

But the availability of online health tools raises new questions about changing expectations of our participation in our care.

If all this information and these tools are available online, to what extent am I responsible for using them? Our employers certainly expect us to do this when choosing providers and a health plan if we are so fortunate as to have a choice; the government expects us to use them: you can't responsibly choose a Part D Pharmacy Plan without going online. Some health plans expect it: the patient portion of their health records allows their members to schedule vaccinations and mammograms, refill prescriptions and make appointments. Arranging for us to do these chores online automatically eases the sponsors' administrative burden. And they work fine for me as long as I am relatively healthy.

But what are the limits of the expectations for my online participation? Will my employer, the government and my health plan also make arrangements so that I am not disadvantaged by my lack of participation - that is, that if I don't have the equipment, the time, the experience or the clear head to do these online chores, will I still receive decent, timely care?

Research on the digital divide tells a story about growing access to the Internet and increasing health- related searches. But that research doesn't do justice to describing what is at stake here: the growing requirement that we manage parts of our health care online and the risks that accrue to us when we are unable to do so.

Jessie Gruman, President
Center for Advancing Health]]> http://www.cfah.org/pdfs/Good%20Behavior/2010/CFAH_GBFEB10_web.pdf January 2010
Hey! No harm done. What's the big deal? I played my part in the error-control system of the hospital and everything went fine. As a frequent health care "flyer," the check-in processes are all too familiar to me and I was alert and feeling OK at the time.

But what happens to those who are not familiar, or who are disadvantaged by their pain, their illness, their inability to read and understand or their reluctance to challenge the authority of those upon whom they depend to save their lives? How do we expect them to protect themselves from errors like the ones I uncovered?

Most of us have heard about someone who has experienced a medical error that hurt or killed them. Last year marked the 10th anniversary of the Institute of Medicine's report on medical errors To Err is Human: Building a Safer Health System, turning the spotlight once again on the persistent riskiness of health care. Although the IOM findings spurred federal and state agencies and local hospitals to develop initiatives to reduce errors, journalists and researchers have found that not much has changed in the intervening 10 years. The original IOM report declared that each day, medical errors kill as many people as would the crash of a jumbo jet. Today, even the report's original authors agree that the threat of unsafe care to patients remains about the same as it was when the report was published.

I am alive today in part because of the medical technology that skilled clinicians have wielded repeatedly on my behalf. And I realize that advances in knowledge and technology contribute to increased complexity in health care delivery that in turn offers more opportunities for error. Because I am a frequent user of health care services, I have a keen ear for news about its safety: I also know that my care not only delivers relief from pain but also confers risks.

It is a tribute to the many patient advocacy and patient education groups that they recognize the extent to which we are on our own to protect ourselves from unsafe care: They have invested heavily in producing instructional materials - pamphlets, books and reminders in print and online - about how to prevent errors. But it is an uncomfortable situation in which we find ourselves, at once dependent on our doctors and nurses to use their expertise to ease our suffering while simultaneously being directed to question their competence and intentions.

Given the lack of progress in reducing medical errors over the past 10 years, it is fair to say that this situation will not likely change soon. Our role in protecting ourselves from medical errors is another example of how advances in health care place additional - often burdensome, sometimes unrealistic and occasionally futile - responsibilities on patients. The way health care is delivered in the United States today assumes that all of us will participate actively, knowledgeably and vigilantly in our care in order to benefit from it, regardless of our health, educational background or age.

How about it: Are you ready to do this?

Jessie Gruman, President
Center for Advancing Health]]> http://www.cfah.org/pdfs/Good%20Behavior/2010/CFAH_GBJAN10_web.pdf January 2010
Hey! No harm done. What's the big deal? I played my part in the error-control system of the hospital and everything went fine. As a frequent health care "flyer," the check-in processes are all too familiar to me and I was alert and feeling OK at the time.

But what happens to those who are not familiar, or who are disadvantaged by their pain, their illness, their inability to read and understand or their reluctance to challenge the authority of those upon whom they depend to save their lives? How do we expect them to protect themselves from errors like the ones I uncovered?

Most of us have heard about someone who has experienced a medical error that hurt or killed them. Last year marked the 10th anniversary of the Institute of Medicine's report on medical errors To Err is Human: Building a Safer Health System, turning the spotlight once again on the persistent riskiness of health care. Although the IOM findings spurred federal and state agencies and local hospitals to develop initiatives to reduce errors, journalists and researchers have found that not much has changed in the intervening 10 years. The original IOM report declared that each day, medical errors kill as many people as would the crash of a jumbo jet. Today, even the report's original authors agree that the threat of unsafe care to patients remains about the same as it was when the report was published.

I am alive today in part because of the medical technology that skilled clinicians have wielded repeatedly on my behalf. And I realize that advances in knowledge and technology contribute to increased complexity in health care delivery that in turn offers more opportunities for error. Because I am a frequent user of health care services, I have a keen ear for news about its safety: I also know that my care not only delivers relief from pain but also confers risks.

It is a tribute to the many patient advocacy and patient education groups that they recognize the extent to which we are on our own to protect ourselves from unsafe care: They have invested heavily in producing instructional materials - pamphlets, books and reminders in print and online - about how to prevent errors. But it is an uncomfortable situation in which we find ourselves, at once dependent on our doctors and nurses to use their expertise to ease our suffering while simultaneously being directed to question their competence and intentions.

Given the lack of progress in reducing medical errors over the past 10 years, it is fair to say that this situation will not likely change soon. Our role in protecting ourselves from medical errors is another example of how advances in health care place additional - often burdensome, sometimes unrealistic and occasionally futile - responsibilities on patients. The way health care is delivered in the United States today assumes that all of us will participate actively, knowledgeably and vigilantly in our care in order to benefit from it, regardless of our health, educational background or age.

How about it: Are you ready to do this?

Jessie Gruman, President
Center for Advancing Health]]> http://www.cfah.org/pdfs/Good%20Behavior/2010/CFAH_GBJAN10_web.pdf