Online Access to Clinicians: Impact on Utilization

By Brian Kerrigan (Own work) [CC-BY-SA-3.0
(http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

This recent article in JAMA reports on the results of a retrospective study of how online access to clinicians affects use of services.

The results are unexpected and contrary to conventional wisdom: patients with online access used substantially more services across the board including office visits, after hours advice, ED and inpatient admissions.

The study conducted by Kaiser Permanente, while subject to some limitations, is reasonably well constructed and looked at 24 months of utilization by established patients. Presumably the platform was Epic Systems patient portal MyChart.

This study throws some cold water on the current hopes that virtualization of the healthcare system will lead to decreased utilization. The thinking goes that if it is easier for patients and caregivers to connect, then simple matters will be handled "online" while those with chronic diseases will be more closely monitored and more likely to get help early when it is often easier to intervene before things escalate.

This study calls this into question.

Of course there are several potential flaws in the study - these are well described in the article. Clearly more studies are needed to validate or refute these findings.

The other, and ultimately most important question, is the overall long-term impact on clinical and financial OUTCOMES. It may be that online access leads to increased utlization that is both appropriate and ultimately more clinically effective.

If not, then we may have to rethink the use and value of online access.

The Clash of Domains

Paul Graham has an interesting post on coming up with good ideas for startups (and quickly weeding out the bad ones).

This part was particularly intriguing:

The clash of domains is a particularly fruitful source of ideas. If you know a lot about programming and you start learning about some other field, you'll probably see problems that software could solve. In fact, you're doubly likely to find good problems in another domain: (a) the inhabitants of that domain are not as likely as software people to have already solved their problems with software, and (b) since you come into the new domain totally ignorant, you don't even know what the status quo is to take it for granted.

Having spent a good part of my professional life working at the boundaries of different domains I have often found this to be both true and generalizable beyond software.

Obviously there can be a great benefits to being an "expert" with deep knowledge, but this can also blind one to new insights or perspectives. In addition, when you can bring knowledge from one area to another, this can create new insights and approaches. It can also provide a personal competitive advantage.

I've learned a lot about management from working in my vegetable garden. There is a time to plant and a time to harvest.  Spending a lot of time preparing the soil improves yield ("plant a 5 cent seed in a $1 hole). Pruning back will lead to better, more lush growth later.

In an age of increasing specialization, contrarians who pursue a wide variety of interests will sometimes produce the greatest breakthroughs.

Camels, Elephants & Cows, Oh My.

Are everywhere in Jaipur. For show and for work. Camel carts are common.

Met this guy at a roadside cafe:




Manish and Charuta ride an Elephant up to the Amber Fort:




Cows really are sacred in India - and for good reason. They graze and produce milk that sustains many a child and family. They are everywhere and roam freely, mixing in the streets with people and vehicles. It was not at all unusual to see a cow strolling down the main street as cars and taxis weave around. On more than one occasion I saw a few sitting in the median of a busy 6 lane highway calmly chewing their cud.

This one is was standing in the street just outside the very holy Brahma temple in Puskar:

Tears of Sadness. Tears of Joy.

One afternoon we load up in our trusty van and our insane, enraged driver takes us on another gut wrenching, harrowing drive. This time we are making the journey south across Rajasthan from Jaipur to Puskar Lake. The decision to go to Puskar, like most of our decisions on this trip is last minute and semi-random. Like me, my travel companions prefer to keep plans loose and seek opportunities for serendipity.

This one will turn out to be something truly magical! But, I'll get to that part soon enough.

The ride to Puskar fits a pattern that I'm becoming used to. Crazy driver? Check. Insane traffic? Check. Roads randomly punctuated by all manner of rest stops and small, dusty, dirty villages? Check. Phish tunes playing in my earplugs? Check. Great conversations and laughter with my travel companions. Double check.

This kind of travel wears you down quickly and between that and the jet lag - my body still has no idea what time zone I'm in - I grow tired and and a bit cranky. I think, this sure is a long way to go just to see some lake and an old temple. Not for the first time, or the last, I will be proven wrong.

Manish and Charuta explain to me that Pushkar Lake and the Brahmin Temple located there is one of the most holy Hindu sites in the world. They make casual remarks, "Maybe we should get married there. You can be the witness, ha ha." I know they plan to go to Las Vegas for a quick legal marriage in a few weeks followed by a celebration in India so I brush this off as fun fantasy by two happy lovers.

As we enter the town, it becomes clear that this is not just another day in this holy place. We are arriving near sunset on Kartik Poornima, the most holy day of the year!  The place is alive in a way that can't be described. There is something deep and spiritual here.




I am not a religious man. I'm a rationalist first and foremost. But I freely admit that the universe greatly exceeds our puny capacity to understand. I consider myself "mildly agnostic" believing humility is the best position to adopt. And yet, something special is going on in this place.

We reach the temple site which sits near the lake just as the sun is setting. There is a gathering place outside the temple with stairs that descend to the water. The crowd is buzzing, chanting and performing religious rites led by a small army of Hindu priests. The mystery and mystic feeling swells.




Manish and Charuta prepare to participate and encourage me to do so as well. I've tried to make it a practice to join in religious ceremonies that involve friends and family with an open heart (if not an exactly open mind) . The Jewish holidays and bar mitzvahs. Catholic mass. I've even attended Friday prayers at a mosque in a small town in Turkey. I am happy to participate.

We start as a small group with two Hindu priests but almost immediately they separate me from my friends. One priest goes with them while the other leads me down the ancient marble steps to the lake. The priest is friendly and his English is good enough that I can follow most of what he is telling me. He explains each step in the ritual and then leads me through the prayers. He marks my forehead in red and applies grains of rice. He ties a string around my wrist, "to bring you good luck as long as you wear." We chant and manipulate the ritual objects - a flower, a coconut, some water from the lake. I'm interested but in my normal detached observer way.

He begins to lead me through a series of prayers based on my answers to questions about my parents, my wife and my children.

Then something extraordinary happens. He asks me if I have lost someone close to me. I immediately flash to my beloved brother-in-law Jeff who died of cancer at a young age leaving my sister Ann a widow to raise her two beautiful girls alone. Something deep inside me cracks open. I can barely get the words out. "Yes", I say, "my brother-in-law Jeff". He responds, "Then we will pray for him and his soul will ascend to heaven immediately".

He begins to chant and I struggle to respond. Tears begin to flow. I have cried about Jeff a number of times thru the years. He has been gone a long time but the wound is always fresh. I've told Beth that I don't think I will ever get over it. Here, in this place I grieve again, feeling the pain deeply but also a bit of release. I don't really believe in Heaven or Hell but somehow, here I want to believe. My brother says Jeff is in Heaven sailing his boat on a beautiful sea. Tonight I can picture that clearly.

The ritual ends by anointing myself with water from the lake and casting the flower petals into the water. I gather myself and my emotions, make a small donation to support the priest and the local charity that feeds the village, and then wander off to find my friends.

I see them performing a ritual together led by first priest we met. I start to descend the stairs but another priest stops me and says I must not approach them, "They are performing a special ceremony". It is then that I realize that they are, in fact being married at this very moment and I am a witness.

Again I am overwhelmed and tears begin to flow again. But this time they are tears of joy. I think of my own wife Beth and the deep, rich history we share after almost 30 years together. I am filled with happiness and love for my friends. Even from this distance I can see the love in their eyes as they gaze at each other and perform the rituals.

As they ascend the stairs there is joy around them.... and now, a mischievous look in their eyes.




"Guess what we just did?", they almost giggle.

"You just got married!"

"How did you know?"

"How could I NOT know!"

I tell them how honored I am to have been a witness to all of this.

And I tell them about my tears.

First tears of sadness, then tears of joy.

Shopping

My wife will never believe this but I went shopping with Manish and Charuta for 4 solid hours and had good time!

Basically you sit and drink tea or coffee and they bring all kinds of things for you to look at. You pick out what you like and then bargain hard.



When you get hungry, they bring you hot food.


These were so good, we went back the next day and got some more to take on the road with us!



Thank goodness Charuta was there to help me pick it lots of beautiful things for all the beautiful women in my life (and to negotiate - she's tough!!)

Blending In

I like to blend in with the locals when I can. In this part of the world I can pass pretty easily. More often than not, locals would first speak to me in Hindi. Manish and Charuta would crack up when ever a local would approach us and speak to me rather than them.

A little sun, the right clothes, a string on my wrist and as along as I keep my mouth shut I'm all set:

Mustache Contest

Met this guy on the road from Delhi to Jaipur.




I think we all know who won this contest.