#hcsmLA: Barriers to Adoption (part 1)

March 27, 2011

The #hcsm chat on Twitter has been an incredibly valuable forum for interested participants to discuss the potential uses, challenges, benefits, and risks involved in using social media to enhance healthcare communications.  Through these chats, I have learned a great deal from very smart and very insightful people, and I believe that social media (SocMed) will play an important role in health care and physician/patient communications in the future.

As a result of the interest and participation in the #hcsm chats, other #hcsm chats have started around the globe: Europe, Canada, Silicon Valley, and Latin America.  The hcsm Latin America chat (#hcsmLA) holds a particular interest for me: I lived in Latin America for 10 years as a child (Venezuela, Argentina, and Panama).  These days, I participate in medical service and community development trips in the Dominican Republic twice a year.  Here in Richmond, I work with a patient population that includes many patients from Central America.  These experiences make me feel connected to that part of the world, and I am very interested in using SocMed tools to enhance health care for vulnerable communities both in the United States and in Latin America.

During a recent #hcsmLA chat, I asked the group what obstacles they saw in the adoption of SocMed tools in Latin America.  Those involved in the discussion presumed that access to technology resources would be limited, including high speed internet, computers, etc.  I was interested in discussing other barriers to SocMed adoption, and a few of the #hcsmLA participants were willing to discuss in more detail.  In this post, I will outline some of the discussion and provide a few additional thoughts.  There will also be at least one additional post on this topic, so stay tuned.

During the discussion on March 1st (link in Spanish), @xaviervel noted that those already interested in SocMed communications will need to take an active role in promoting use of the technology and driving its use, but noted that the promise of the technology could enhance teaching and medical education.  @rgenneroriganti pointed out that developing nations in Latin America SMS technology would precede the development of health 2.0, but that SocMed innovation could allow for the development of an entirely new level of healthcare systems and provide a new way for patients to access care.

@cicarca mentioned that one of the major limits was the concern about moving healthcare communication from a monologue to a dialogue (but did not note if this would be fear on the part of patients or of providers), and @AmatoDan agreed that Latin American culture characterized by traditionalism and conservatism would be unlikely to adopt new SocMed-based practices very easily.  @Camilonacho felt that the major barrier would be in sharing and distributing information out of fear of empowering patients.  @mariohitschfeld stated that resistance to accepting SocMed would be shared among older people, but not by younger generations.  @vj_CR (Valentina Jaramillo, #hcsmLA’s moderator) pointed out that Latin Americans are more accustomed to hierarchical (“vertical”) relationships, and would have a hard time envisioning an alternative.

To overcome these barriers and challenges to adopting SocMed in Latin America, @AmatoDan suggested that advocates demonstrate SocMed’s ease, convenience, and ready access to information.  @cicarca stated that other ways to overcome barriers to SocMed involvement include increased comfort in internet-based communication in general, and by the creation of exclusive physician communities (where physicians can create and share information freely) .  @xaviervel stated that he thought it would be easier for medical professionals to encourage SocMed adoption instead of patients in light of present hierarchical structures.

Based on these #hcsmLA interactions (with participants in Chile, El Salvador, and Venezuela), I suspect that Latin America faces many of the same challenges to adopting SocMed that are present in the United States, only more so.  SocMed adoption for healthcare communications in the U.S. involve helping patients become engaged and activated, ensuring that information is made freely available, and encouraging conservative medical organizations to honestly consider how SocMed can benefit health care for both patients and providers.  Latin American has two additional obstacles: technical challenges (lack of high speed internet and easily-accessible computer resources) and a stronger tradition of vertical and hierarchical medical communities that may not be as receptive to patient-based (and patient-centered) initiatives.  This would make it even more important to ensure that interested physicians (who may have better access to technology and who can demonstrate the value of SocMed to their peers) need to link with active and engaged patients to move SocMed adoption forward.

Carmen Gonzalez (one of this blog’s co-authors and @crgonzalez on Twitter) has noted some Latin American countries are already making use of SocMed communications, so the obstacles listed above are not universal.  Hopefully, those nations that have been more proactive in exploring #hcsm can be models for those that are just starting to explore their options.

That means that use of SocMed to connect physicians and patients will allow the necessary relationships to develop that will advance SocMed adoption.  By successfully using SocMed, patients and physicians in Latin America can prove the concept and encourage their peers at each level to join them.

(The #hcsmLA Twitter chat is held at 20:00 hrs GMT -3.  This means on the East Coast the chat is at 7 pm EDT/6 pm EST.  The majority of the chat is in Spanish.)

HCSM and the Patient-Centered Medical Home

March 16, 2011

Yesterday, Ben Miller (@miller7) and I presented a the Third National Patient Centered Medical Home Summit in Philadelphia.  The talk was well-received, and many in the audience indicated that many of these ideas were new to them.

If you would like to get a sense of the presentation, here is the slide show:

Needs Assessment and Social Media: A Match Made in Heaven

March 14, 2011

Previously, I posted an article on outcomes in SMHC. The post stated the following: “An outcome is the result of an experiment or other situation involving uncertainty”. http://www.stats.gla.ac.uk/steps/glossary/probability.html.

We are uncertain about what works in HCSM, the degree to which outcomes are a function of other variables, and why. I presented the views of two experienced market researchers who are involved in measuring and evaluating outcomes. Outcomes in SMHC will aid us in identifying what works, what doesn’t, why, why not, and help identify ways to improve those outcomes. Applying outcomes measurement, needs assessment, goals, etc. to SM in healthcare or any other communication or learning strategy will improve patient care.

Needs assessment is the other bookend of a learning/education plan. Between a needs assessment and the outcome are the objectives, strategies, and tactics to achieve the goals.

I do not view SM in and of itself as a major driver of change in healthcare (HC). It is a tactic, a tool, and one element of any number of strategies (e.g. marketing, sales, awareness, listening, learning, etc.)

In order to effectively apply a tactic to strategy that achieves an objective we need to understand what is happening, why, and what are the needs. A well constructed simple needs assessment can identify gaps in your patient’s knowledge and establish objectives. Once this is done you’ll be able to create a strategy and apply the right tactic. (social media, direct mail, chats, texting,etc.)

What is a needs assessment? Wikipedia provides and excellent place to start: Needs assessment is a process for determining and addressing needs, or “gaps” between current conditions and desired conditions, often used for improvement in individuals, education/training, organizations, or communities. The need can be a desire to improve current performance or to correct a deficiency. The idea of needs assessment, as part of the planning process, has been used under different names for a long time. In the past 50 years, it has been an essential element of educational planning.

The following is from Dr. Bob Kizlik at http://www.adprima.com : “Just remember, any needs assessment is really nothing more than an organized, systematic way to gather information relative to some goal. It is the quality and attainability of the goal that sets the stage for everything.”

Let’s say you are a PCP with an average patient population. Approximately 8.3% of your 1,200 patients have active diabetes. You’ve reviewed your charts and find that there are about 25 patients whose HbA1c is averaging >9%. This is troubling because you are consistent in managing your diabetic population. Why are the majority of your patients’ in better control and this subset is not? To what can you attribute to this finding? What changes you can make that would lower the 9%?
Performing a simple needs assessment would offer valuable knowledge regarding this observation and can identify why this gap may exist and potential ways to close it.

By identifying the 9% you’ve begun a needs assessment–namely you’ve completed a chart audit. At this point your goal should be to determine if what you’re observing in your practice is similar or different from other practices. Are other practices seeing similar numbers to your? Are their numbers a function of staffing?

This can be done by:

Seeking expert opinion from a colleague with a practice similar to yours. Do they have similar numbers to yours? If not what are they doing differently? Is their outcomes a function of staff training, patient education, patient population, etc? Was this a goal they set out to achieve?

Once you’ve spoken with colleagues the next area that you may want to look at are national guidelines. A review of current guidelines may point to areas and actions that can aid in improving these patients HbA1c. It will also provide data regarding reasons patients are not adhering to treatment.

Finally, speaking with patients and staff will give you additional data. There are two ways to approach this. One approach are patients interviews or a survey. But before you begin you’ll need to identify what you are looking for.

These patients are not achieving the goals that the majority of your patients are achieving in regards to HbA1c. You have determined that you are doing the proper education and training and working within established guidelines. The majority of your patients are within the norms. What needs to be understood are standards this group has in regard to their knowledge, their skill in managing the disease day to day, their attitude toward the disease, their own healthcare, and their ability to accomplish tasks (diet, exercise, monitoring, etc.). Remember most people don’t know what they don’t know so direct questions may not help in understanding why that gap exists.

You may want to mail or email the questionnaire to all patients with diabetes in your practice for a comparative data set. Or you can just send it to those within the population you want to improve outcomes for. Another option is to offer to the survey to patients when they are in the office for a visit.

What I would recommend is that you state that the questionnaire is not directly related to them but for you to understand your patients with diabetes. It is a fact-finding exercise. This includes them as part of a resource not a target. They need to feel part of your practice, not an object of it. I won’t detail a questionnaire here. Rather I will present a way to capture the data and knowledge.

Capture some demographic data including resources patients use or trust in learning about diabetes. (All within HIPPA guidelines) But the key is to understand the knowledge and/or behavior these patients have in regard to diabetes. One tool are vignettes. Vignettes move the discussion from first person to third.

A vignette can be written similar to a case:

A 50-year-old neighbor comes to you and says he was just diagnosed with diabetes. He knows you have diabetes and respects your opinion. He is not sure he understands what he is suppose to about food and asks you what kinds of carbohydrates he should be eating?
Kidney beans
What would you tell him?

In this way the patient is speaking to someone else and sharing their knowledge etc. in a non-judgmental environment. They become a resource and their answers are not about themselves. It is someone else. The fact is they will answer based on their knowledge and behavior. You’ve identified their knowledge without asking them what they know or don’t.

Without knowing where your patients reside in their understanding, knowledge, and behavior it is difficult to identify ways to close a healthcare gap in your practice that brings about beneficial health. It is far easier and more effective to create messages and tactics when you know why problems exist. If your needs assessment identified that a majority of this population was unsure of proper diet and they were active in some SM, holding monthly chats moderated by a nutritionist may change behavior. Needs assessment can make SM more efficient and productive.

I realize the time and effort to perform a needs assessment may be beyond the abilities of a busy practice. What I hope I’ve presented here is an opportunity to consider ways to improve outcomes at the practice level. Perhaps a number of practices or systems can join together to perform a larger needs assessment in order to share data that will change patient care.

In the end what I believe we need to do in HCSM is bring tools that are proven in learning to patients and practices. Until we examine educational needs of patients and measure outcomes throwing tactics like social media at patients in a random fashion will not yield the results we are seeking. We need to be as deliberate as P&G in our efforts to understand patient knowledge, learning needs, and behavior in healthcare at the individual practice level. Healthcare is local and personal.

“Better health is not a science problem, it’s an information problem.”

I welcome your thoughts and ideas regarding needs assessments and outcomes for patients at a practice level.

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.

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