"Hello Health" (can this be serious?)

Imagine an electronic medical system that's physician-friendly and patient-friendly ... and it comes with neighborhood doctors who "care about the whole you."  

That's the promise offered by Hello Health, a new, concierge-model, primary care service in Brooklyn, with a new branch in the West Village.  It uses email communication between MDs and patients to break the artificial standard of a 15-25 minute office visit, a stricture commonly imposed by private insurers.  The goal, according to the site, is to renew the personal attention and old-fashioned relationship we patients once enjoyed with our family doctors.

Emails could reduce unneeded office visits in this new model.  By using graduated units of care (beginning with a simple patient query by email as the minimum unit), their approach can increase office visit length when required, and without long waits.  It would permit the docs to appropriately price and offer many levels of service, even house calls.  The cost to the patient rises with the time and the level of individual attention involved in a single consult.  The EMS software that allows for emails and access to patient records will also link MDs to colleagues and their own community of providers.   (Maybe a few yoga teachers too?)

Oh, by the way, other physicians can purchase the Hello Health system. That makes me wonder -- is the software the real news here or is it actually a workable clinical model?  And why do they have a name that reminds me of the ubiquitous Hello Kitty?  How serious are they?

 Hello Health also means goodbye to security because it's strictly pay as you go: there's no insurance billing.  But when you consider that almost 20% of Americans under age 65  lack insurance at the moment, that's not a bad market share.  Here's the article about it on Health Affairs.

What's missing?  Maybe some realism about how to maintain clear boundaries with patients.  What happens when the patient's credit card runs out?  Will the "personal attention" and the doctor-patient relationship they touted on the site terminate (like shutting off the tap when you haven't paid your water bill)?  That's the troubling scenario that insurance often helps us to avoid with our PCPs.  Imagine having the "relationship" ... and then when funds run out, your emails bounce back.  That's ugly.  

Hello Health is a new model worth exploring, but it may be another way to sell clinical software.  I'm not sure that they've solved the underlying problem: how to determine the amount and type of services offered to a patient according to need AND capacity to pay.  In an ethical system there has to be a good way to balance out this equation, and I'm not sure the heuristics are there yet! 

Still if emails can help doctors avoid unnecessary visits and patient backlogs .... it's not a bad start after all.

integrated vs. integrative health: which comes first?

A source at NIH told me that their share of the stimulus has been allocated within days of the President's announcement.  Basically every approved project in the pipeline will receive funding.  And as I type, staffers at NIH and on the Hill are completing final touches on the design of the much-ballyhooed, national, electronic medical records system.

So much for the yoga principle of reflection before action.

Evaluated  in the context of 2009 medical information technology, the "new" records system will be B.C.  Of course this stone-age system has some advantages.  It will reduce medication error and it will probably be coming soon to a medical center near you.  So let us rejoice in small blessings.

  If you want to get a glimpse of where we need to eventually take the system, that is,  if we are to have uniform, research-based standards of care in the U.S., visit the Harvard Catalyst site.  Catalyst is the portal to an extraordinary bioinformatics system being honed and refined around the ethical practice of computational information gathering [ie: bioinformatics, with a focus on genomic research and clinical records, and collaboration from the Divinity School on ethical guidelines].  Furthermore Catalyst assembles "information from every scientific core into an indexed, searchable data base."  When we realize that Harvard's "scientific core" includes the Medical School, the Dana Farber Cancer Institute,  and 16 leading facilities surrounding Cambridge, we have Harvard's permission to gasp in awe.  And they Twitter!

One question rages on, for me at least.  Can there be integrative (mind-body) care as part of a treatment plan unless we have integrated care (records sharing with patient privacy protection)?  And how can my services be incorporated into the primitive national system that's now in the works?

Patients don't like talking about their alternative care with their PCPs, and until they do, and until we all share and measure outcomes within the same electronic records system, there will be an unconscionable amount of waste in CAM (complementary alternative medicine).  I don't see why Medicare or private insurers should pay for yet another failed, disease-management approach.  CAM has not reduced costs in California where it is widely reimbursed.  Shared information and timely case management would have saved money.  

If you want to read about more CAM practitioners engaging in salutary self-criticism visit one of my favorite stops online The Health Care Blog, and Matthew Holt on the recent meeting on integrative health at the Institutes of Medicine.  Also check out the recent blog entry on employers masochistically funding market inefficiencies.  Because employers have no database to find an insurance program with the best fit, the "invisible hand" of the market fails to operate in medicine (once again!).

In the meantime, let's say a little prayer for all the possibilities that were wasted in this week's panicky rush to approve some -- any -- electronic medical system.  Perhaps it's another sign of lost trust in this society.  Advocates for quality healthcare feel they must sprint headlong to endorse an inadequate information system.  Otherwise the media howl their jeremiads and destroy public goodwill toward a more rational, comprehensive, and thoughtful approach that can't be summarized in a soundbite.

Breathe in, breathe out and say "whatever".

St Francis's hovel

I'm on a mini-retreat at Casa Chamisa a B&B in Los Ranchos de Albuquerque.  Every day I spend a few hours with my teacher and enjoy hours of personal practice every morning ... what a treat!  I was looking outside at dawn in a fairly rosy mood, and discovered something quite delightful on the verandah wall:  a lovely Mexican tile mural of St Francis feeding the birds. 

There seems to be a St Francis inspiration at this B&B.  Casa Chamisa has 5 chickens, two horses, 3 roosters, four cats and an "attack parrot" (that's the sign on her cage but Tildy is a sweetheart with a G-rated vocabulary). The furniture in my room floats on a cloud of cat hair.  Arnold Sargeant's hospitality and cooking are outstanding, but if you don't like critters, don't come here! 

 

On the plane to NM I read that fine, fine article in Harper's magazine (Luke Mitchell "Sick in the Head: Why America won't get the health care system it needs" February 2009).  

Mitchell shows why the health insurance lobby enthusiastically backs Obama's healthcare plan (universal coverage w/no single payer).  The new system will ride on the coattails of insurance company vendors who provide the multibillions' worth of computerized prescription and clinical records every year.   As they expand their industrial healthcare business model they'll achieve near-total mechanization of primary care treatment, a "streamlining" process that will eliminate most family physician-patient visits.

In the article, insurance industry leaders say they'll create economies in the new system by reducing the (already attenuated) amount of contact time between patient and physician.  

How will they begin?  Through a highly-regulated system of patient-doctor communication.  The article describes the prototype of an email system enabling patients to contact doctors ... the system integrates with an ATM-style, fully automated, pill-distribution system.  This plan may reduce medication error (that will be its selling point).  And it will be much easier for clinicians to over-prescribe unnecessary meds to patients without examining non-pharmaceutical treatments such as "talk" therapy, PT, yoga acupuncture (non-automated care).  

Only a very small part of the Obama stimulus law will try to measure the efficacy of meds vs. treatments that require lots more hands-on, personal, clinical care.  And insurers are trying to block this provision because even a small amount of research supporting non-pharmaceutical treatments could halt the gradual mechanization of care. 

Oh, and we can forget about doctor's visits as a standard part of insurance coverage: most symptoms that are anything less than acute or emergent will be emailed  by patients (that is, by those patients lucky enough to be part of the broadband system).  Maybe the really really lucky patients will be able to be "seen" on the doc's videoconference device.    

These changes are only a heartbeat away from implementation.  Patients complain all the time that the private-insurance model undermines their relationship with docs.  Things look to be getting worse.

We need to remember St Francis's home -- a "hovel" (in the words of one of his biographers).  There are apochryphal stories about how clerical examiners from Rome arrived in Assisi and were dismayed by St Francis's enthusiastic return to the vows of simplicity and poverty.  Shocked by the friars' tenement, and irregular housekeeping, the examiners nearly had the place condemned, ecclesiastically speaking.  The friars kept no customary "hours" because they were mendicants, begging for alms.  They trusted that prayer, and their relationships to their flocks (human and animal) would pull them through.  Francis's vow of poverty was a healing corrective to the entrenched materialism of the medieval church.

My point: there is a certain amount of  improvisation in healing relationships.  A student lets a small fact slip, an hour after my orderly, written intake, and as a result, I see the case in an entirely different, and clearer light.  Or I run into a doctor in the hallway, and remember to follow up about a student; important information is exchanged and the doctor finds good reason to call and check on the patient/student.

The unexpected connection, a serendipitous observation, the everyday accidents and slips that are part of an authentic communication experience will be LOST in the new automated system. 

Francis's example as a compassionate healer reminds us to be generous with ourselves not our material assets, to find surprising solutions together, and to aspire to be fully present in our connections to each other.  

If, as now seems inevitable, Americans allow medicine to be comprehensively automated, then alternative practitioners like me who preserve this authentic messiness in communication, need to be included despite issues of credentialling and expense. 

recovering our balance

OK, today's silly, hypothetical question (from too many hours spent teaching yoga perhaps?):

Given our inclination NOT to ... move in slow, deliberate ways ...to walk rather than drive ... to wean ourselves from drugs that interfere with our motor capacity ... or to do a daily personal yoga practice... I have to wonder whether we're collectively losing our chops as successful bipeds.  Instead of legs, we'll have long slender fins to push the car pedals.

Modern life is making us lose our balance.  According to author Scott McCredie, America is facing a near-epidemic in debilitating falls. I took a look at McCredie's newish book (new to me), Balance: recovering the lost sense. It's a collection of essays on the evolution evolution of balance, and contemporary masters of this sixth sense (see the Amazon page). 

Poor balance is common among students who come to the studio, so I treat it seriously.  Just one fall can lead to death within months for the very old.  But more often than not the falls begin in late youth and middle age.  The effects are cumulative, and they can make life very unpleasant through head injuries, torn ligaments, plates to hold together broken bones ... every serious injury increases the odds for future impairment (meaning less walking, balancing activity: the cycle that leads to the next fall is strengthened).

When students tell me they're having dizzy spells, or have fallen, I'm moved by their vulnerable, self-incriminating sadness. The guilt is strikingly common. And sometimes it results in the blame of others, "unsafe" surfaces, weather conditions etc.

Maybe a fall is one of the few times we can actually see a consequence from our inattantion, pretty much as the lapse occurs.  

Balanced movement is much harder when we're in a state of obsession, preoccupation, or anxiety, such as overreacting to an overreactive media.  

Yoga helps balance of course.  But it takes a kind of inner equilibrium to do an appropriate daily practice, which is what's required for any real progress.  When your balance is out of whack, that commitment comes hard, especially if you lack a close relationship with a teacher. So, balance deficits resist a "quick fix".   The sense remains an elusive combination of so many skills and faculties  (vision, attention, proprioception, and the vestibular functions of the inner ear, and can be affected by so many other factors, illness, hormonal changes etc).  So we need to practice, practice, practice.

Losing our balance may mean losing a lot more than firm feet on the ground.  From the mind-body perspective, it's associated with changes in thinking and judgment.  Biped alignment is one of the signal, evolutionary leaps that distinguish human consciousness. Placing the spine upright at a right angle to the ground, has had extraordinary consequences.  In this position, humans can more easily meditate and enjoy the "relaxed alertness" that leads to profound concentration, insight, and bliss.   

art therapy for cancer (post-surgery)

Today from Reuters, an illuminating article on a small, Swedish study that demonstrated significant clinical improvements in breast cancer patients from art therapy (link here). What caught my eye: the protocol offers time and space for expression and reflection.  Sounds like meditation to me.   Through an introspective and personal process guided by the teacher, patients gradually abandoned false ideas about the gender stereotype of a perfect, healthy female body.  And that gave them more hope.  Consequently their physical healing improved according to standard, quality-of-life measures.  Having worked with cancer-diagnosed students for some time now, I'd infer that  the art therapy was similar to meditation: a form of reflection and stable attention that can provide authentic insight and positive life changes.  

Personal anecdote: I recently attended a one-day art workshop with Lee Alter, one of Charlottesville's favorite watercolor painters.  Lee's work is light in touch, minimalist and abstract, and yet she reveres our sensuous world.  She favors subjects such as figures, flowers, her beloved musician friends, and nature.  

I learned so much from her teaching, especially from her demonstrations of using breath as a guide for each brushstroke.  This technique, and her gentle method of encouragement, seemed to generate a slow, intense hum of concentration through the sunny afternoon in a local studio ... several personal discoveries and breakthroughs followed.  One participant, a post-surgery cancer patient, is a devoted student and relies on these classes to further her healing.  

I felt I was actually seeing things differently (literally) the next day.  Hard to describe how: a bit more right brained, impressionistic, less conditioned vision.  It's so good, so lucky that an artist-teacher we know can help us discover parts of ourselves that are new and regenerate.