Joseph E. Scherger, MD, MPH Charles W. Smith, MD Health Care Online: The Impact of Revolution Health & eDocAmerica on Family Medicine Joseph E. Scherger, MD, MPH Charles W. Smith, MD

The Time Problem Time Needed for Chronic Illness Care Time Needed for Preventive Care Time Needed for Acute Care Total face to face time for 2500 patients Ann Fam Med 2005;3:209 Am J Pub Health 2003;93:635 10.6 hours a day for 2500 patients 7.4 hours a day 4.6 hours a day 22.6 hours/day

Primary Care Not Working Only 27% of hypertension is adequately controlled Only 26% of people with diabetes have blood pressures well controlled Only 25% of people with depression receive treatment 50% of patients hospitalized with CHF are readmitted within 90 days Compiled by the Institute for Healthcare Improvement, 2005

The Mistakes Doctors Make Misdiagnosis occurs in 15 to 20 percent of all cases, according to some research. It turns out that the mistakes are rarely due to technical factors, nor is misdiagnosis usually due to a doctor's lack of knowledge about what later is found to be the underlying disease. Rather, most errors in diagnosis arise because of mistakes in thinking.   Boston Globe - March 19, 2007

The Ticking Clock in the Doctor’s Office: Patients on routine visits to their primary doctors often have lots of questions but not enough time to get good answers NY Times Feb. 6, 2007

Information Technology Changing Medicine Knowledge Management and Decision Support Tools Patient Information EHR , All Clinical Data Communication Digital Connection of Patients with Caregivers

Internet use More than 1 billion people have logged on worldwide1 ~170 million users in America2,3 Over 550 billion Web-connected documents4 More than 2% of websites are health related5 Miniwatts Marketing Group. Internet usage statistics - The big picture: World Internet users and population stats [webpage]. 2006 Sept 18. Cited 2006, Oct 26. Available from: http://www.webcitation.org/5Jvohqbcu. Madden M. Data Memo: Internet penetration and impact [Pew Internet & American Life Project website]. [Washington DC: Pew Internet & American Life Project]; April 2006. Cited 2006 Oct 26. Available from: http://www.webcitation.org/5Jvpqm9DA. Lenhart A, Madden M, Hitlin P. Teens and Technology: Youth are leading the transition to a fully wired and mobile nation. Washington DC: Pew Internet & American Life Project; 2005 Jul 27. Cited 2006, Oct 26. Available from: http://www.webcitation.org/5JvqeTRG4. Lyman P, Varian HR. How much information [website on Internet]. Berkeley, Calif: University of California at Berkeley, School of Information Management and Systems; 2000. Available from: http://www2.sims.berkeley.edu/research/projects/how-much-info/. Powell J, Clarke A. The WWW of the World Wide Web: Who, what, and why? J Med Internet Res [serial online]. 2002 Jan-Mar;4(1):e4. Available at: http://www.jmir.org/2002/1/e4/. 1 Miniwatts Marketing Group, Internet usage statistics, 2006: http://www.webcitation.org/5Jvohqbcu. 2 Madden, Internet penetration, 2006, http://www.webcitation.org/5Jvpqm9DA. 3 Lenhart, et al., Teens and Technology, 2006, http://www.webcitation.org/5JvqeTRG4. 4 Lyman, et al., How much information, 2000, http://www2.sims.berkeley.edu/research/projects/how-much-info/. 5 Powell, et al., J Med Internet Res 2002, http://www.jmir.org/2002/1/e4/.

Health and the Internet 80% of adult Internet users (~ 95 million Americans) have searched the Internet for 1 of the 16 major health topics online1 specific disease or medical problem 66% certain medical treatment or procedure 51% sexual health information 11% 136 million Internet users have visited an online support group or website for a specific medical condition2 Fox S. Health Information Online. Washington, DC: Pew Internet & American Life Project; 2005. Available from: http://www.pewinternet.org/pdfs/PIP_Healthtopics_May05.pdf. Harris Interactive. Number of “cyberchondriacs" – Adults who have ever gone online for health information– Increases to an estimated 136 million nationwide. The Harris Poll® #59, August 1, 2006. [Cited 2006 Oct 27]. Available from: http://www.webcitation.org/5JwxUAaSq. Fox, Health Information Online, 2005. Harris Interactive. "Cyberchondriacs," 2006, http://www.webcitation.org/5JwxUAaSq.

Reasons for going online Search for health information Research a diagnosis or prescription Prepare for surgery or find out how to recover from one Seek and provide support 1. Harris Interactive. Number of "cyberchondriacs" – Adults who have ever gone online for health information– Increases to an estimated 136 million nationwide. The Harris Poll® #59, August 1, 2006. [Cited 2006 Oct 27]. Available from: http://www.webcitation.org/5JwxUAaSq. 1. Harris Interactive. "Cyberchondriacs," 2006, http://www.webcitation.org/5JwxUAaSq.

American adults seeking health information on the Internet Fox S, Fallows D. Internet Health Resources: Health searches and email have become more commonplace, but there is room for improvement in searches and overall Internet access. Washington, DC: Pew Internet & American Life Project; 2003 July 16. Available from: http://www.pewinternet.org/pdfs/PIP_Health_Report_July_2003.pdf. Fox S. Health Information Online. Washington, DC: Pew Internet & American Life Project; 2005. Available from: http://www.pewinternet.org/pdfs/PIP_Healthtopics_May05.pdf. Harris Interactive. Number of "cyberchondriacs" – U.S. adults who go online for health information – Increases to estimated 117 million. The Harris Poll® #54, July 15, 2005. [Cited 2006 Oct 27]. Available from: http://www.webcitation.org/5JwyuhThU. Sources: Fox, et al., Internet Health Resources, 2003. Fox, Health Information Online, 2005. Harris Interactive. "Cyberchondriacs," 2005, http://www.webcitation.org/5JwyuhThU.

Young Can’t Imagine Life Without Online Access Martha Irvine Associate Press December 5, 2004

Revolution Health Started by Steve Case, founder of America Online Goal: Become a medical home for people on the internet Coordinate health care services Became risk adverse Has become another health information website – www.revolutionhealth.com

Financial Models for Non Visit Care Shift of telephone to E-mail (time saver, $neutral) Reduce unnecessary visits (more $ in high demand office, less $ in lower demand) Payment for virtual care (e.g. Relay Health) Prepaid service fee (monthly ($30) or annual ($360)) Capitation and prepaid insurance! Pay for Performance incentives Group Visits, how to bill

Kaiser Permanente HealthConnect 24 Hour Access to Accurate and Comprehensive Health Care Information and Services

Health Care Will Become Continuous Health Care Over the Internet Will be the Greatest Disruption of our Age Patients Will Drive the Innovation Patients Will Have Their Medical Records Patients Have Access to All Medical Information Patients Will Communicate Far and Wide for Care What Will They Get From You?

A New Vision of Family Medicine Responsibility for a Population of Patients Manage Needs and Demands (Relationships and Knowledge) Prioritize Conditions and use a Team Approach Take the Time to be Effective (Time to Heal) Change our Concept and Application of Productivity

A New Model of Office Practice 50% more caring interactions each day 10-12 unhurried office visits each day Advanced access – do today’s work today Patients get all the time they need Patients receive the latest treatments

How? An interactive practice website is a new platform of communication 40-60% of patient needs handled online Electronic health records with imbedded knowledge management tools Great service

Wise Words from Dee Hock Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving the substance of the past by clothing it in the forms of the future. Preserve substance; modify form; know the difference.

Relationship Centered Care What is the 21st Century Application?