More Social Media Guidlines for Physicians. Should We Care?

July 17, 2011

Late last year, the American Medical Association published guidelines to guide how physicians use social media.  Once the recommendations were made public, I posted that I did not think the guidelines were very helpful.  My overall sense was that the guidelines were designed more to discourage or limit physicians’ participation in social media…or at least highlight the risks of using social media.

Now, two other sets of guidelines have been released.  The Massachusetts Medical Society (MMS) released their guidelines about two months ago, and the British Medical Association recently made their guidelines public.

I’ve been meaning to review the guidelines in detail, but have not had the time to do so.  So I thought I would try and give an overview of where the guidelines are similar and where they differ.

Highlights of the MMS guidelines include:

  • Patient privacy is of the utmost importance.
  • Physicians should maximize privacy settings, but should not assume these settings are absolute.
  • Physicians must maintain professional boundaries if interacting with patients online.
  • Physicians should separate personal/private and professional information online, and should not connect with patients in public social media settings.
  • Physicians should be responsible for monitoring others’ use of social media: “when physicians see content posted by colleagues that appears unprofessional, they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.”
  • Physicians should disclose any relationships they have with any services or products that they review or discuss online.
  • Physicians must realize that any information posted online may affect how the public views physicians and the medical profession, might impact individual physicians’ reputations, and may have career consequences (especially for trainees).

I do not believe that these guidelines differ very much from the AMA guidelines I mentioned earlier.

Meanwhile, the BMA guidelines largely tread the same paths: protect patient privacy, disclose conflicts of interest when they exist, be aware of how your online posts and comments might reflect upon yourself and the medical profession, etc.  The BMA also specifically notes that “It would be inappropriate to post informal, personal or derogatory comments about patients or colleagues on public internet forums.” Of note, the BMA does not suggest that physicians should be responsible for policing each others’ online posts.

As was the case with the AMA guidelines, the BMA guidelines also emphasize the potential harms and risks of physician involvement in social media.

Maybe this is the nature of guidelines: to highlight how potential risks without focusing on the potential benefits.  But none of the guidlines–AMA, MMS, or BMA–discuss how to use social media effectively and successfully.  If physicians are only provided with cautions and warnings about social media, and are not given guidance on how social media can be used to enhance the health of individuals and communities, then physicians are hearing an unbalanced perspective.

In fact, some physicians have argued that health care professionals have an obligation to engage in social media: read Brian Vartbedian (@Doctor_V)’s perspective here, and watch a video of Dr. Wendy Sue Swanson (@SeattleMamaDoc)’s thoughts here.

So: on the one hand, physicians are called to engage with patients via social media.  On the other hand, professional organizations continue to urge physicians to exercise caution and care without discussing possible benefits and values of engaging with patients via social media.  So what do we do?

My thoughts: I put very little weight on these guidelines.  The AMA, MMS and BMA guidelines all tend lack specifics, and many of the cautions seem to be self-evident.  Responsible, professional physicians should not disclose patients’ private information while using social media, and responsible, professional physicians should be aware of the limitations of online privacy.  So long as a physician is using their common sense, then these guidelines offer little guidance.

So: I will continue using social media and I will continue encouraging fellow physicians to use social media.  I believe the value outweighs the potential risks, and that reasonable caution provides sufficient protection.  I will continue to look for guidelines that offer guidance an insight in the positive sense (how to get the best results and value from using social media) as opposed to only offering warnings and cautions.  Until those guidelines are released, I will continue to put very little weight on social media guidelines for physicians.


Can Social Media Reduce Medicare Readmissions?

July 10, 2011

Ben Miller (@Miller7) and I were recently invited to give a presentation at the Third National Medicare Readmissions Summit, to discuss whether we thought social media could reduce or prevent unnecessary hospital readmissions.  This is an issue that is becoming increasingly important, as Medicare will soon stop paying hospitals for any readmission within 30 days of hospital discharge.

As I’m short on time (I have been absent from here for a very long time), I am posting our slide set here:

I think the latter part of the presentation (after we highlight some of the social media tools we felt would be most useful) is the most interesting: we tried to come up with ideas and ways to use social media within currently-accepted guidelines/best practices/HIPAA requirements.

I’ll try and give this some additional thought later…I hope the slides suffice for now.


The Lay of the Land: How Ready are We for Health Care Communications and Social Media?

April 19, 2011

(A slightly different version of this post was originally written for Mayo Clinic’s Social Media Health Network, and was posted there April 19, 2011)

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As evidenced by the participation on this site, and on Twitter conversations such as the #hcsm chat on Sunday evenings, there is great interest and excitement around using social media (SocMed) tools to enhance health care communications. As a physician, I am very interested in determining the most effective and efficient ways to use SocMed to enhance patient care. However, in our excitement it is necessary to assess what patients think about health care communications and social media (hcsm). Two recent studies help assess the lay the of the land.

The first is an article from the Pew Internet & American Life Project. Pew Internet (headed by @SusannahFox) is a rich source of information regarding how the Internet is affecting Americans’ lives. In February 2011, Pew Internet published a report titled “Peer-to-peer Healthcare” that assessed how Americans are increasingly turning to the Internet for peer-to-peer support in times of illness. The report shows that 18% of poll respondents have been online to connect with others dealing with similar health problems. Nearly 1/4 of respondents with chronic illnesses such as diabetes, heart or lung disease, or cancer have been online to connect with peers. This aligns with the concept of the “e-patient” (pdf link) in which patients are described as equipped, enabled, empowered, engaged, equals, emancipated and experts. Through Internet connections, patients can help each other learn about their illnesses and treatment options and can empower each other to become partners in health care as opposed to just recipients of health care. Patient-to-patient communication appears to be even more valuable in the case of rare illnesses, in which patients are few and may live far away from each other.

However, patient-to-patient communication is not yet the standard form of communication regarding health issues. When asked where they sought help when ill, 20% of patients reported using peer-to-peer communication, 54% sought help from family and friends, and 70% received advice from a health care professional. Furthermore, the vast majority of such communication happened offline: only 5% of respondents had communicated online with a health care professional or fellow patient, and 15% had communicated online with family and friends. As noted above, online communication was much more common among those dealing with rare illnesses: over 50% of people dealing with a rare disease had used online communication to connect with family and friends and with others affected by the same illness. Different needs and different situations led to patients using different resources: there were some situations where health care professionals were favored, some where peers and family were favored, and some where each group was equally useful (summarized here).

This Pew Internet report demonstrates that patients use multiple sources of information, depending on their medical illnesses and the particular information they are seeking. Clearly, patient-to-patient communication is an important source of information–especially in cases of rare illnesses. However, most of this communication among patients, physicians, and family and friends is happening off-line.

At the same time, a March 2011 Capstrat-Public Policy Polling survey reported that most patients surveyed are not actively seeking to communicate with their health care providers online. 84% of respondents to this poll indicated that they would NOT use social media or instant messaging for medical communication even if offered by their physician. Among millennials (age 18-29 years old), 79% reported they would not take part in online communications with their health care provider. Online communication was more favored for administrative tasks, appointment scheduling, medical record access and nurse consultation as opposed to direct communication with a health care provider.

This poll is a bit limited in its implications–the survey was a general survey, and did not assess patients with chronic medical illnesses who might be more inclined to use online communication or patients who live in medically-underserved areas who might find online communication more efficient. However, it suggests that online channels are not yet ready to play a major role in health care communications between patients and health care providers. At the same time, there appear to be certain areas where online communication can be helpful and moving these tasks (nurse helplines, administrative tasks and scheduling, etc) to online channels can free up additional time for providers to communicate with patients through patients’ preferred methods.

Taken together, these reports provide a sense of where we stand as we assess using SocMed tools for health care communications. There are evidently some areas where SocMed and online communication tools can make a difference right now: dealing with general questions and administrative tasks, linking patients with chronic medical illnesses and especially those with rare illnesses, and communicating with family and friends in times of illness. We are not yet at a point where patients are ready to move to SocMed and online communications in large numbers.

Maybe this isn’t all bad, though. Patients may not be 100% ready to engage online or through SocMed channels, but it appears that physicians are not ready yet either. Ted Eytan (@TedEytan) discussed physicians readiness to engage in social media in a paper published in The Permanente Journal and a related blog post discussing the results of a poll of members of the physician-only online community Sermo.com. In the Sermo poll, only 15% of responding physicians indicated they definitely or certainly saw a role for SocMed as an integral part of their practice, patients, and community. The article in The Permanente Journal discusses the potential of SocMed, but notes that SocMed use is in its infancy for health care communications.

So: at this point neither patients nor physicians are rushing to engage with each other through SocMed channels, and each side probably has their reasons (including privacy, reimbursement, time commitments, etc). But there is clearly a minority on each side that is increasingly interested in using online and SocMed tools to promote communication. So let us start where we are: physicians should start to engage with patients in the areas where patients are comfortable doing so. Health care professionals can use SocMed “to build trust, promote management of health and wellness, and disseminate knowledge.” (from T. Eytan’s The Permanente Journal article already mentioned). Patients should continue to use these communication channels in the ways they feel most comfortable: communicating with friends and families, other patients, and (increasingly) health care providers.

As trust develops and as online relationships strengthen, we can transition to true health care-focused communication through online channels–something that will be facilitated by the development of patient-friendly secure portals that allow provider-patient communication through secure channels. We should continue working–on each side of the stethoscope–to develop and strengthen the networks that will allow us to provide the benefits of online health care communications to everyone once the tools and technology are further refined and patients and providers become increasingly comfortable and familiar with them.


Case Studies: Using #HCSM Tools to Enhance Patient Care

March 6, 2011

In medicine, much of how students are taught is through case studies.  Typically, the teacher “presents” a patient to the students (including history of current illness, past medical/family/social history, current medications, and relevant physical exam findings.  The students/learners are then expected to ask any clarifying questions that might be necessary, can ask for labs and imaging studies, and then puts together the list of possible diagnoses and possible treatment plans.  The goal is for the learners to actively participate in the process: rather than passively listening to a lecture, the back and forth discussion promotes learning.

In the next few months, I am fortunate enough to be presenting lectures about healthcare communications and social media (hcsm) at various state and national conferences.  In each case, part of the task will be to encourage physicians–who are often skeptical about hcsm–to consider exploring hcsm tools as a way to enhance patient care.  As part of preparing for these presentations, I thought I would brainstorm some ideas as to how hcsm tools can enhance patient care.  The basic question I am looking to address: How can hcsm tools and communication improve patient care, and what added value does hcsm provide to justify including it in an already busy day?

In the spirit of active learning, I present these ideas here as case studies: I have thought of ways that hcsm can be used, but I invite readers to comment, correct, or enhance these ideas.  Ask questions, seek clarification, or dispute the ideas–it is through this active learning that we can develop ideas that will encourage physicians to participate in hcsm.  Case studies and social media (SocMed) participation have similar goals: learning and reflection through social interactions and dialogue.  Adult learning occurs over time and is inherently social–social media and case studies both encourage this process.

I have chosen to present cases demonstrating the value of hcsm from the perspective of an individual physician, a medical practice, a large medical system, and a public health organization respectively.  A few ground rules:

  1. My focus will involve YouTube, Facebook and Twitter.
  2. Also included is a discussion of SMS and secure patient portals because of the need for private communication as part of providing healthcare services.
  3. Some ideas are somewhat simplistic, but I have included them for comprehensive understanding.
  4. There is some crossover: ideas listed under one category probably apply to others.  Unless there is incredible value in doing so, I have chosen not to repeat the same ideas to avoid redundancy.
  5. It is assumed you have at least some familiarity with SocMed.  I will use jargon like “followers”, “tweet”, etc without further clarification.  Please let me know if you require clarification.

Individual physician: example: my accounts, @RichmondDoc and RichmondDoc.blogspot.com.

  • Search for relevant health-related information that can you can forward to patients via who follow you.  This includes local health fairs, free or low-cost clinic information, health care screenings, etc.  This also includes forwarding links from national organizations such as American Diabetes Association, American Heart Association, American Medical Association, American Academy of Family Physicians, and other organizations.
  • Advocate for change/reform that you feel benefits patients by posting thoughts and links to important policy information.
  • Answer patients’ general health-related questions, and provide links to valid/trusted on-line resources that will help patients make decisions (such as linking to www.FamilyDoctor.org).
  • Use SocMed to keep on top of developments in medical care, health policy, and related health topics.
  • Participate in online Twitter discussions such as #hcsm, #MDChat, #hcsmLA to discover better uses for these tools, and to better understand what patients and other stakeholders expect from providers regarding hcsm.
  • Develop a YouTube channel where you can post discussions about relevant topics–either health-specific ideas, policy/politics discussions, etc.
  • Ask for help by surveying your account followers on questions they would like answered, and provide answers to others’ crowd-sourced questions.
  • Keep a blog that allows you to dig more deeply into complicated issues.  This can become a resource for patients seeking more information on certain issues.
  • Reach out to other SocMed users and develop productive and meaningful collaborations.  This very blog exists because of SocMed: the three authors “met” through Twitter and have communicated by e-mail and a few telephone calls, but have not actually met in person.  Similarly, three of the four presentations I am scheduled to give in the next four months will be shared presentations with people I met via Twitter: I have met @NickDawson in person but originally first met him through Twitter; I have only met @Miller7 via Twitter, e-mail and one phone call.  Even so, my involvement in hcsm has enhanced my professional skills and (I hope!) my position in the promotion/tenure process.
  • Each of these SocMed tools can be used for advocacy on behalf of patients, health reform, and health care delivery and payment reform.

Medical practice: example, MacArthur Ob/Gyn and its Facebook and Twitter accounts.

  • Broadcast information to patients who follow your accounts–this could include office hours, new services, vaccine availability, etc.
  • Send generic reminders to patients to take action for their health, such as checking blood sugars, taking medications, etc.  Patients can choose to follow your account and receive notification via SMS, meaning that your reminder could promote real-time action.  For added security, these messages could include encrypted SMS technology.  Small studies have already suggested that text message reminders can promote adherence to treatment plans.
  • Send “broadcast” messages to account followers tagged with certain hashtags, such as #bloodpressure or #diabetes.  Patients who choose to follow your account and who understand the hashtag (who have opted in) can then choose to contact the office for further action.  For example: Tweet “How have your blood sugars been running? #VCUHSDiabetes”  and patients who understand the hashtag may have already agreed to review their blood sugars and contact the office with the necessary information.  This could be a way to enhance disease self-management and to encourage better control of chronic illnesses.
  • Send direct messages via Twitter or Facebook to individual followers asking them to follow-up with the office via private portals or through traditional communication.  These messages do not align to HIPAA standards and would require discretion (and probably an in-house legal counsel review), but simply remind a particular person to contact the office through secure means.  For example, a message sent privately on Facebook or Twitter that simply asks a patient to contact the office could encourage follow-up without revealing any personal health information.
  • Engage in dialogue with patients about office practices and procedures, whether good or bad.  If patients have compliments, then one can respond positively.  If a patient has a concern or negative comment, this could be addressed and the conversation could be taken off-line for resolution.
  • Invite patients to contact the practice with general questions or comments, and use that information to respond either publicly or privately (as indicated) in order to enhance patient-centeredness and patient-connectedness.

Healthcare system: example, Bon Secours Richmond’s Facebook and Twitter accounts, or Mayo Clinic’s YouTube channel and  Facebook and Twitter accounts. 

  • Broadcast information about seminars, services, physicians, etc.
  • Connect with patients re: good and bad experiences with the system and/or its providers.
  • Develop a YouTube channel to highlight important information regarding the organization.  This would be easier for large systems than for individual providers, and can provide a great deal of information for patients in a very user-friendly way.  YouTube and other video services also provide patients with an opportunity to see the information being presented, which is an asset for patients who are more visual learners.
  • Reach out to consulting practices and referring providers to enhance the connections between those practices and your healthcare system.  This could improve referral patterns into one’s system (or a system’s hospital), and improve care for patients.
  • Reach out to public advocacy or local government agencies in order to provide the system’s expertise in addressing issues of health policy or health care.
  • Reach out to patient communities to offer information or speakers to promote the communities’ discussions about certain medical conditions.

Public health authorities: example, the Centers for Disease Control (CDC)’s YouTube channel, and its Facebook and Twitter accounts.

  • Provide information regarding healthy lifestyles and disease awareness and prevention messages.
  • Send out urgent information regarding developing health emergencies, epidemics, etc.  The CDC has a separate account dealing with healthcare emergencies, and this account could be used to push out information to the public in a very timely way.
  • Receive incoming information from the public (or from healthcare workers or lay health promoters) about patterns of illness that are present in a certain community.  The public health authorities can track these messages and look for any patterns that could indicate unusual events.
  • Actively develop a network of lay health workers and healthcare workers to act as surveillance  in the community.  This network could be linked by traditional SocMed tools, but can also use SMS notifications–especially in rural areas or developing nations.  Communication could flow both ways to note unusual patterns of illness or other signs of concern.
  • Linking lay health promoters with central agencies can also promote health outreach and health maintenance activities.  For example, a public health ministry in a developing nation could tweet its affiliated lay health promoters “Today is the day to provide anti-parasitic medications to your community.”  With one message, lay health promoters could receive the Tweet directly from Twitter or via SMS notification, and could then distribute the necessary medications throughout their target communities.
  • Similarly, public health organizations could use SocMed communication to address environmental emergencies such as floods, earthquakes, or tropical storms.  SocMed can be used for lay health workers to notify central authorities about events, and by central authorities to make communities of rescue and recovery plans.

Finally: any of these hcsm connections have to emphasize authenticity, relevance, trust, and bilateral communication and dialogue.  There is some role for broadcasting information, but at its heart hcsm/SocMed involves community.  Any user that is only sending information out without listening to any replies will be less successful than a user who is willing to talk with the target audience.  At the end of they day, all health care services exist to improve patients’ health.  In order to do that, we must listen to the patients’ voices.

Even if you choose to start working on only one or two of these ideas, you should start to see changes in your practice and your interactions with patients.  If you note and monitor these changes, you will be able to quantify them and adapt your hcsm use accordingly.

Please, feel free to comment/correct/debate/expand these ideas in the comments below.


Social Media ROI

December 3, 2010

Sharing a link to Howard Luks’s blog post where he discusses the return on investment (ROI) on physician involvement in social media (SM).  The post includes a brief video of Dr. Luks discussing his ROI from his active social media participation (he is @hjluks on Twitter, and runs his blog). 

Physicians and medical practices may be reluctant to engage in SM if they do not believe there is going to be a tangible result from their efforts.  Previous articles have suggested that the ROI from Twitter is likely to be very positive because of there is not much investment needed and hence any return would make the ROI look good.  But Dr. Luks’s experience–which admittedly might not be typical–would make the ROI incredibly positive. 

Dr. Luks notes that he had 14 patients in the last month who reported finding him via online resources.  If we conservatively expect that the patients only come once and had a standard evaluation (which I’ll conservatively estimate at around $150 for a new patient consultation), the charges from these visits would be $2,100.  If these patients end up requiring further care and additional visits (or if they require surgery or another procedure), then the return increases dramatically.

Maybe information of this sort will encourage health care providers and (maybe more importantly) medical practices and health care systems to consider engaging in SM.  I already believe it will benefit their public relations and their communities; Dr. Luks shows it might also benefit their bottom lines.


Using Mobile Technology to Improve Health Outcomes

December 1, 2010

It takes extending the definition of social media a little further than might seem obvious, but this study shows how mobile technology can be used to enhance health care.  The study used text messages to provide educational information about a medical problem and to help improve treatment adherence.  The results of the study were positive: better adherence, strong patient satisfaction scores, and a high proportion of patients willing to continue receiving the texts.

 

Admittedly this is a small study and lacked a control group, it presents interesting ideas for future study.  Participants in the study found the text messages to be useful and (presumably) non-intrusive, given how many would be willing to continue receiving messages in the future.  One could imagine a medical practice where a nurse or provider could send out such messages or reminders to patients who had difficult-to-control illnesses in order to educate and promote better outcomes.

 

The relevance to social media is this: as of right now, privacy concerns limit the ability to use social media for patient care.  The public nature of much of this communication means that personal health information cannot be shared in this setting.  However, posting educational information via Twitter or Facebook (which patients could chose to receive via SMS or text services) would be acceptable considering they are not targeted at any one person.  Similarly, medication reminders could be generally distributed through similar means.  Meanwhile, direct text or SMS messages sent to an individual could be used to actively target care more directly.  In this model, social media allows health care professionals to educate and promote health in a  general (but still interactive) way while not impinging on private matters.

 

Social media has great impact in sharing information with a community and engaging in general conversations.  Adding SMS or text messages to social media communication allows health care providers to target individual patients more effectively.  If this early report bears out, then the impact of social medial and mobile technology can be substantial.


How Social Media Can Enhance Medical Practice

September 5, 2010

For the last 8 months or so I have regularly participated in the Sunday evening #HCSM Twitter conversations.  These chats are a tremendous gathering of individuals from around the US and, increasingly, from around the globe.  I have noticed, though, that the trend is that few of the active participants are medical providers or medical professionals.  It seems to me that the diversity of opinion that is the strength of the sessions (in that they include physicians, patients, marketing professionals, educators, social media experts, etc) also makes it difficult to discuss how Twitter, Facebook and other social media tools can enhance medical practice and what challenges will present themselves.  I began engaging in the HCSM conversations because I truly believe that social media will enhance how health care providers and patients interact and engage with each other, but I also see many pitfalls and hurdles that need to be honestly evaluated and addressed in order to make that happen.

If you follow health care policy you know that there are major issues facing our current health care system.  Now that health care reform has been passed, more Americans will have access to health insurance than ever before.  At the same time we already face a shortage of primary care providers, meaning that many newly insured people will be unable to find a doctor.  This comes at a time when primary care physicians are feeling increasingly burned out by their practices.  Our health care delivery and payment systems undervalue face-to-face doctor/patient interactions, and insurance company restrictions and other administrative obligations throw up roadblocks that interfere with the core of medicine: the doctor/patient relationship.  Increasingly, doctors are seeking to provide patient-centered care, and patients are becoming more aware of the value they are getting for their health care expenses.  As these trends converge, patients will more actively seek better care and more efficient ways of obtaining access to that care. Likewise, physicians will find new ways to reach these patients.

One of the answers to these challenges is a rethinking of medical care under the “patient-centered medical home” (PCMH) model.  This model ideally allows physicians to change the nature of health care encounters by allowing “on-demand care” to develop: providing care through e-visits, communicating through texts and e-mail, and enhancing communication through social media techniques.  There are limits to doing this (eg HIPAA privacy requirements mean that physicians will not be able to provide diagnosis and treatment online) and there are plenty of gray areas (eg are texts private?), meaning that on-demand care will require expanding what we think of as social media to include secure e-mails and secure patient portals.

This expanded paradigm of patient-centered care will require blending payment models to include traditional fee-for-service, patient management fees (where physicians are paid for coordinating care) and on-demand care reimbursement.  This affords physicians the freedom to stop running on the “see-more-patients-to-make-more-money” treadmill.  If the PCMH model is put in place as envisioned, more and more care will be provided to patients who are outside of the office, and office visits will be used for new patients, patients with new problems, and patients who are have medical problems complicated enough that they cannot be cared for without face-to-face encounters.  This model would allow doctors to spend more time seeing, speaking with, and communicating with patients.  And this is where I think social medial will have an influence.

To effectively enhance access to patients’ health care providers, the PCMH principles must include some form of social media communication.  This will become more and more important the older the “millenial” generation gets– they include today’s college and medical students and tomorrow’s health care consumers.  Physicians and medial providers will need to adapt communication to accommodate those for whom even e-mail is too slow a method of communication.

I can foresee a time when physician offices communicate with patients through a combination of techniques: face to face visits when needed; secure e-mail when more detailed on-demand care is needed; texts to communicate blood sugar or blood pressure readings and medication adjustments or reminders; Twitter to allow physicians to provide information to the community; Facebook to provide practice information and some patient interaction online.  Consequently, physicians need to start thinking about redefining social media and enhancing the “health care” in HCSM now in order to be adequately prepared for the future.  The focus should remain on how to make doctor/patient communications improve outcomes and quality of care for patients.

Being that the use of social media is still in its infancy, many physicians and other health care providers have hesitated in fully diving in.  Issues of privacy, professional boundaries, reimbursement, and how to achieve work/life balance without perpetually being “on the clock” are as yet unresolved.  However, by moving physicians off the current high-volume treadmill, and by integrating social media as part of the PCMH model, the practice of medicine can be reinvigorated and the promise of health care reform made a reality.  I believe that patient-centered medical communication (PCMC) is a core element of making patient-centered care a reality.  I think that PCMC tools will support enhanced doctor/patient communication. Finally, I believe now is the time for serious thought and action to spur their implementation in delivering better care for all patients.


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