Monday, December 29, 2014

Cataract Surgery and Cost

A wise ophthalmologist once said every person will eventually need cataract surgery if they live long enough.  The number of Americans over the age of 40 with cataracts is 20.5 million!  3 million plus Americans had cataract surgery in 2012.  As we live longer and longer cataracts and their removal has been more prevalent.

The good news cataract surgery has become a much more tolerable for patients over the years.  From a several day hospital stay to a 2 hour out patient procedure.  The complexity of the surgery and the additional benefits has also mushroomed.  Without getting into the medical detail of the surgery, it has moved from only requiring a single scalpel and a freeze probe. With the end result requiring glasses up to a 1/4 inch thick to see after the surgery. Today it's microsurgery involving an expensive microscope, micro tools, and over 1/2 million dollars of ultrasound and LASER machines.

Now the part everyone and no one wants to talk about: cost.  Technology is outpacing our capability to pay for it.  Medicare payment for cataract surgery has DECREASED by 61% while inflation during the same period has gone UP 73%.  So how is cataract surgery able to still be done and costs covered.  The system has become more efficient.  But you can only cut so much "fat" before there are critical changes in the process.

Having cataract surgery today with the "standard" methodology and equipment will restore vision. With the advent of multifocal implants and LASER cataract surgery, the vision is not only restored but patients may have better quality vision without glasses or contacts.  Is it essential to not where glasses, or is a mild glare at night time.

Monday, March 31, 2014

Social Media and Healthcare Marketing

Social Media is a type of publishing that can easily be used to market and disseminate information to a large group of people almost instantaneously.  It is easily created by an individual, or group of people, including government entities, and corporations. Healthcare marketing is a form of marketing of health-related products and services. Due to the sometimes private nature of healthcare products and services, social media has special considerations. Maintaining individual privacy is a very important concern in the use of social media in the healthcare field.  Also due to the self publishing nature of social media, vetting information is another factor which must be managed in using social media in the healthcare field. This document will show what social media is and its current state and future in the healthcare field.

Social media is a burgeoning field of media.  Healthcare too is changing rapidly. Marketing of healthcare, once literally prohibited by professional groups has now not only gained acceptance, but is expanding and growing. Just as healthcare marketing is evolving, social media is changing. Change in the computer age, or rather Internet age, is rapid. Concomitantly, changes in the lines between private life and what is public have become intentionally and unintentionally blurred. The role of social media in each individuals healthcare will change immensely over the next 5 years, just as social media itself will evolve.
Marketing once forbidden by professional associations, has gained slow acceptance in the healthcare field. Marketing, which had been perceived by the healthcare field as sales, has also grown.  Marketings' perception and purpose has developed. Marketing, in many fields and especially the healthcare field, is communicating content to potential clients. In the past radio, print, and roadside billboards were the mainstay of marketing. These modalities still persist and thrive but the Internet has opened many more avenues to communicate to potential clients.  Social Media and its various forms is one of these forms of communication. Social Media also provides a new aspect to marketing that older forms such as print don't offer. Social media allows two way communication, between the marketer and subject.

Social Media is an electronic form of communication that involves sharing of ideas, personal information, user-generated content and other content. It can be divided into one of 5 types:
Collaborative Projects / Crowdsourcing
Multiple users group together to produce content
Blogs or MicroBlogs
User generated content of opinion, information
Tumblr, Twitter
Areas where content is gathered and posted
Sites where users connect and share information within their groups
Facebook, Google+
Virtual Games or worlds
Games with interaction between the users
World of Warcraft, Steam

 Tracking the origin of ideas and concepts on the Internet are quite often hard to pin point due to the nature of much of the content being user generated and not centrally regulated.  Probably the earliest evidence of a social medial is Friends Reunited, still online today.  It was begun in 2000, to bring old school friends together in England.   The United States saw its first significant social media site in the form of Friendster.  Friendster now a gaming site, is no longer classified as a social networking site. It began 2003 and it had over one hundred million users in June of 2011.[i] As competition for Friendster, the site was developed.  Myspace originally set out to be a place where musicians and music could be shared.  It soon morphed into a place to  chat with friends.  Myspace has lost its number one social networking site position  to Facebook.  Facebook now boasts 1.11 billion registered users as of this writing.[ii]
Social media also includes other types of Internet sites other than the type of Facebook and Myspace.  Currently there are well over one hundred networks that involve sharing of information among its users.  Many of the sites specialize in subsets of information.  In other words, some sights promote sharing of crafts (eg. Pinterest), pictures (eg. Flickr), fitness/work outs, music, and dating just to name a few.
To describe each individual social media site is not the intent of this paper. The number of sites changes quite frequently and is rather large.  I will cover several of the other currently more popular sites today as they will be discussed later in this paper.
Twitter, the micro blogging site, was launched in 2006.  A blog is a website where an individual or group record essays of opinion or information. Twitter posts are limited to 140 characters, hence the term micro blogging.  The 140 limit is in place because Twitter was initially setup up to be used via SMS text messages on cell phones. This was the maximum amount of characters allowed in a text message sent by a cell phone at the time. The software today has the capability of longer messages, but the limit is now a self imposed limit by the creators of Twitter.  Twitter is typically used for announcement type messages sent to followers, although there is also a direct or private message option. is rapidly growing network similar to Twitter but allows a 256 character limit.
Facebook, is the most popular social network in the world, if judged by the number of registered users. These users create networks where photos, or messages are shared. Sharing can be limited to a group of selected users, or shared generally. How this information is being shared and to what degree has been debated. How much control over the information has also been debated and evolved. Google+ offered by, as the name implies, the search company Google, is a service similar to Facebook.
As I have mentioned previously, healthcare marketing to any degree is a relatively new process. And direct marketing to the patient with two way communication, is even newer.  Social media lends itself very well to direct marketing and contact with the patient. Just as in the past, people read about movie stars in magazines and newspapers, but now they also followthem on Twitter and can directly communicate with these celebrities. In the same way now patients can follow their hospital, doctor, or pharmaceutical company. This has opened a new avenue for patient and physician communication, from corporation or institution, to one on one, or any permutations thereof.
Social media by its very definition is public. Its sharing of information. The degree of sharing is important in the healthcare field. Healthcare information can be very general. But often, because of the aspect of the two way communication of Social Media offers, it can lead to medical information which can become very specific and private in nature.
Anyone that has gotten medical treatment within the last 15 years is familiar with HIPPA. HIPPA is an acronym for the Health Insurance Portability and Accountability Act.  It is a federal law passed by Congress in 1996. This act, and its subsequent revisions, attempts to do four main things: 1. Provide the ability to transfer and continue health insurance coverage; 2. Reduce health care fraud and abuse; 3. Mandate standards for healthcare information on electronic billing; and 4. Protect the confidential handling of health information.[iii] It can be debated, but wont be done in this paper, if the first three items were accomplished or not.  The last item, protecting the confidential handing of health information has become very important with the rate of information exchange and how it is exchanged. More specifically, HIPPA regulations state that healthcare providers and organizations, as well as anyone they do business with, follow procedures that protect the confidentiality and security of patients health information. Germane to this discussion it includes electronic information. It also stipulates that if information is shared, it should be done so that the minimum amount of information is disclosed to achieve the purpose or function.[iv] The information HIPPA protects is not only medical information (such as diseases, allergies, etc), but also billing information and actually any information your provider puts in your medical record. There are exceptions provided for law enforcement and social services. For example, if the healthcare provider suspects you may be a victim of a violent crime or may have committed a violent crime they are allowed to disclose this information.
Because of this requirement of privacy protection, Social Media must be approached judiciously. Disclosure of individual's medical condition or billing information should not be done on Social Media. While that may seem an obvious statement, abiding by it may not be as easy as it appears. Simple poor understanding of how the software or the medium operates can lead to overt unintentional disclosure. Although not medical information, there are many well know accounts of public figures posting material not intended for public use. Some of these have come from ignorance of the fact that posting this material on services like Twitter could lead to its disclosure to unintended recipients. Or they have been posted in error, similar to pressing the Reply allbutton instead replying individually to a coworker and criticizing your superior in the email.
Even if the best security is maintained, and no errors are committed, privacy can still be compromised. This concept is currently being debated but there is growing evidence that even if data is anonymized privacy cant be maintained. Latanya Sweeney demonstrated in 2000, using the 1990 census data, she was able to identify any individual with 87% certainty by using just three pieces of information: 1. Date of Birth, 2. Gender, and 3. Zip Code.[v] Many would assume if you had a database of patients only listing date of birth, gender, and zip code in the fields, individuals would not be able to identified. This is not the case. Ms. Sweeney has established a website where you can enter your date of birth, gender, zip code and determine how unique your set of data is: Most recently she published a paper taking anonymous participants in a DNA study. Of the 1,110 volunteers in the program who provided their date of birth, gender and zip code, she was able to identify by name, 97% of these participants.[vi] As previously stated, maintenance of privacy is very important in the healthcare field. Ms. Sweeneys work establishes we may not fully understand the tool of the Internet, and while we believe we have secured information, it may not be secured.
Ernest Rutherford, the father of nuclear physics, widely credited with splitting the first atom, and generally accepted as a brilliant thinker, said in a 1933 speech, The energy produced by the breaking down of the atom is a very poor kind of thing. Anyone who expects a source of power from the transformation of these atoms is talking moonshine.[vii] As history has proven, this genius  had clearly missed a major aspect of the atom. Future historical study will possibly show us undiscovered analytical points of the Big data, may currently be compromising our privacy right now.  In other words it may be more difficult to maintain privacy on the Internet, even more so than we understand now.
Currently 85% of all United States adults use the Internet. 91% of United States adults own a cell phone and 56% of those adults own a smartphone.  72% of Internet users say they looked online for health information within the past year.  About half of that search was on behalf of someone else or information access by proxy.[viii] The uses of Social Media and the Internet in regards to healthcare varies. Most of these interactions are currently though search engines, a smaller number of users begin their search at a health related site. Only 1% of the online health care seekers began their search at a social network such as Facebook.[ix]
Social media is still a new venue for healthcare related discussions. There is a large presence of healthcare organizations in Social Media. In a survey by Healthcare IT News, over 85% of hospitals surveyed had a Facebook page and two thirds had a twitter account. Because of this relative infancy of Social Media and healthcare, we are in an early adopter phase. Healthcare providers recognize Social Media as an area they must have a presence.  But the purpose of that presence is still forming and while presence is good, usage maybe slow. There are studies quantifying the number of healthcare providers with Social Media platforms, webpages, and consultants recommending healthcare providers establish a presence and how to do it, yet utilization studies are difficult to find. The Facebook page for, a well publicized program by the federal government, has 124,735 likes as of the writing of this paper. In contrast, General Electric has 964,151, Coca Cola has 70,604,356 likes, and the official Justin Beiber page has 56,032,637. This would indicate users have not found Social Media as major source of the their healthcare process.
Trust is still a large issue, mainly because a lack of history. Elizabeth Sillence, et. al., investigated how patients use the Internet in their healthcare. The paper concluded users wanted to learn from others with similar diseases and experiences. There was a reservation in accepting those experiences when there were too many experiences provided.[x] Expansion into the usage of Social Media needs to be refined. Sites such as WebMD may need to expand for more moderated user contribution. Tools like Twitter and Facebook are excellent platforms for this type of interaction. An obstacle for these platforms to provide a forum for medical exchange, maybe in the the stigmata of discussing, intimate medical conditions, in the same area you share vacation photos.
Physician and healthcare providers must be mindful the standards do not change because they are using social media vs a face to face encounter. In fact additional requirements should be considered because of possible privacy issues and inexperience with the medium. Additional professional boundaries must be maintained. Due to the venue, ie., a platform where personal photos are exchanged, recreational activities are shared, the dialogue between patient and healthcare provider shouldnt be intertwined with the other activities. While some restrictions must be maintained, a greater level of access to providers can also be accomplished. In non-urgent cases, answers can be shared at both the providers and consumers convenience. But again inexperience with the tools must be recognized. Doctors are trained to diagnosis and treat in a face to face setting. Diagnosis over the Internet is not taught in medical school. Going from a one-to-one model to a many-to-many model of interacting with patients should never fully occur. While many-to-many may work a majority of time, as is the case that most headaches are not symptoms of brain tumors, there is that rare case that needs to be considered. Until technologies can provide for these exceptions, general standard healthcare dogma and advice should be the mainstay of Social Media. Smoking cessation programs, educating diabetics of the importance of diet, how a hemoglobin a1C level will help diagnosis diabetes, or the benefits of exercise are all examples of good topics for Social Media at this point in time. As the technology progresses, new diagnosis, and screening devices will become more prevalent. The patient will be wearing a watch that posts their blood oxygen level, vital signs, blood sugar, EKG and yet other undiscovered medical factors.
Ambiguity of digital communication is a problem. A whole set of emoticons, or sideways smiley faces, have been created to overcome the lack of voice inflection, body language and mood of a online conversation. Safeguards should be in place to create policies providing guidelines for the types of issues appropriate for digital communication. Obviously, chest pain shouldnt be reported in an email.  More extensive well and published guidelines need to be created.  One example would be to only allow digital communication with regular and established patients. Diagnosis and treatment of a new patient should not be solely via online.
Education is an area which is well suited to Social Media. Wide distribution, often two way communication, are factors which make education the easiest to implement in the healthcare area of Social Media. The issue of vetting information becomes troublesome due to the size of the Internet. Essentially anyone with a computer or phone can post information, often without verification. This is contrasted by the FDA requirements for information provided on media such as television or radio. The FDA doesnt have the resources to police such information on the Internet. Expansion of sites such as WebMD or other vetted sites need to be established. Many Social Media sites on the Internet are vetted or policed by the same user that consume the content. The difficultly in applying this process to healthcare social media, is that there is an level of expertise required to properly analyze the online material.
The current usage of medical professionals using Social Media is rising. In a study performed in 2009, 80% of the doctors surveyed had accessed the Internet, 13% wrote a blog, 60% stated they used a social media site.[xi] This study also indicated the in the younger demographic of physician, these percentages were higher. The Annals of Internal Medical in April of 2013 has published a position paper on recommendations for physicians in this rapidly changing arena of Social Media, on how to enter it, and their conduct while in it.[xii] The idea that patient confidentiality is to be protected, is widely and easily agreed upon. More difficult questions become the patient-physician relationship and the perception of physician behaviors. Would a patients perception, or their relationship with their physician be changed if they saw a photo of physician holding a beer at a picnic on Facebook? Although the general societal norm accepts that adults of legal age can drink alcohol beverages, how will it effect the relationship between the patient and his or her physician? Similarly, although its a fact of life that your parents had sex or you wouldnt exist, just one would rather not be confronted with its conceptualization.
As previously discussed, many healthcare providers and healthcare institutions are presently using Social Media. The modality at present is usage in a general sense, rather than on a personal basis one to one, but one to many, is being adopted. General posts regarding the correct diet for a diabetic, reminders for general checkups, etc, are currently a mainstay of social media. Basically, these messages are akin to pubic service announcements. There have been and there are outliers. There have been live tweets of open heart surgery, including pictures.[xiii] A general search for just about any surgical procedure will turn up a resultant video of the procedure on Youtube. The appropriateness of these posts has been debated and no definitive conclusion has been reached.
As the general accepted norms of society change, so will the acceptance and expansion of Social Media in healthcare. Younger generations are growing up posting their lives on Facebook, or the current network du jour, their acceptance of a women, aka physician, who sutured their forehead last Monday, posting on Twitter rough day cant wait until Happy hourwill become more commonplace, for good or bad.
In the meantime, there are opinion papers or guidelines being produced to help healthcare providers navigate Social Media today. The AMA has set forth an opinion paper regarding Professionalism in the Use of Social Media. Their opinion states: 1. Physicians should be cognisant of standards of patient privacy in all environments; 2. Privacy settings should be used on Social Media but one must realize these settings are not absolute and content is unretractable; 3. Physicians must maintain appropriate boundaries in accordance with professional ethical guidelines, as they would in any other context; 4. Separate personal and professional content online; 5. Correct unprofessional behavior by colleagues; 6. Recognize online actions may effect your reputation.[xiv]
There will be new ways to use Social Media found in the future, but good examples of uses can be found today. Social Media reach is far and quick, urgent public health announcements can be quickly and widely disseminated. Facebook groups can be formed to promote good diet, exercise and similar type activities.
Social Media has rapidly involved over the past ten to fifteen years. While it took fifty plus years for every home to have a television, the penetration of the Internet and Social Media has far outpaced that. Due to societal changes and this evolution of personal interaction, Social Media has moved into healthcare. As the adoption and the usage of Social Media evolves its usage in the healthcare field needs to follow suit.  The healthcare field must keep higher vigilance of their usage, due to the sensitive nature of the information and duties healthcare providers purvey. Additionally, because of the possible great potential value in improving healthcare via the proper use of Social Media, and the rapid ascension of the medium itself, a large effort will be required to maintain both its positive usefulness and integrity.

[i] The Internet Archive,, Date of Access: July 31, 2013
[ii] Facebook First Quarter Report 2013,, Date of Access: July 31, 2013
[iii] Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, 104th United States Congress. (1996)
[iv] OCR HIPPA Privacy, MINIMUM NECESSARY, [45 CFR 164.502(b), 164.514(d)], December 3, 2002, Revised April 4, 2003
[v] Sweeney, L., Simple Demographics Often Identify People Uniquely. Carnegie Mellon University, Data Privacy Working Paper 3. Pittsburgh 2000
[vi] Sweeney, L., Abu A, and Winn J. Identifying Participants in the Personal Genome Project by Name. Harvard University. Data Privacy Lab. White Paper 1021-1. April 24, 2013.
[vii] The Times archives, 12 September 1933, "The British association breaking down the atom
[viii] Pew Internet: Health Project,, updated July 1, 2013, accessed July 31, 2013
[ix] Pew Internet: Health Project,, updated July 1, 2013, accessed July 31, 2013
[x] Sillence, E., Hardy, C., Briggs, P., WebSci13, May 24, 2013, Paris, France., ACM 978-1-4503-1889-1
[xi] Crystale Purvis Cooper, Cynthia A Gelb, Sun Hee Rim, Nikki A Hawkins, Juan L Rodriguez Lindsey Polonec, Physicians Who Use Social Media and Other Internet-based Communication Technologies, J Am Med Inform Assoc. 2012;19(6):960-964.
[xii] Jeanne M. Farnan, MD, MHPE, et. al, Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards, Ann Intern Med. 2013;158(8):620-627. doi:10.7326/0003-4819-158-8-201304160-00100
[xiv] John W. McMahon Sr., MD, Chair, Professionalism the Use of Social Media, CEJA Report 8-I-10, AMA Code of Medical Ethics Issued June 2011, adopted November 2010.