Text Messaging's Healthcare Applications

One of the topics I enjoy talking about in regards to Health 2.0 is the effect text messaging will have on healthcare. Intelecare already uses (and has used for 3 years) text messaging as one of the delivery methods for our patient /caregiver created medical adherence reminders. BJ Fogg at Stanford held a Texting4Health conference in February, where a number of uses for texting in healthcare were presented, such as texting for AIDS testing clinics, and a smoking cessation program. Other companies, such as WellSphere, are also using texts as way to transmit health related information - such as where you can find a health food store or gym in your immediate area.

I have been looking at trends in mobile advertising and text usage, but I didn't really think that it had reached this point.

According to eMarketer: "The average mobile subscriber in the US sent and received more SMS text messages than mobile telephone calls during Q2 2008, according to Nielsen. This was the second consecutive quarter in which the average number of text messages was significantly higher than the average number of phone calls."

This is simply outstanding. As you can see from the chart, it is not just the tweens and Millenials using texts. My X Generation still sends more texts, and the 56 + crowd even does it. The US is also still way behind the rest of the world.

Quick Story: In 1999 or 2000 I was on a ski trip with my half-brother, Ricardo, who grew up and lives in London. He was looking at his phone and punching buttons (he was 18 or so at the time). I asked what he was doing, and he said "texting my friends". I asked what that was, he explained, and I said "why don't you call them"? His answer was that it was simpler, cheaper, and he can do it on "the sly".

It took me up until last year to really embrace sending text messages. I started with simple texts like "running late" or "what are you up to", which led to more complicated answers to queries, directions, twitter updates, etc... Now instead of "call me" it is "text me".

The uses in healthcare, for me, are most readily available for tracking information like glucose readings (I think SugarStats uses this), blood pressure monitoring, etc... I don't think texting your physician will catch on so rapidly, but it can happen.

AJ Fortin has a great post from this spring: 101 Things to Do With A Mobile Phone in Healthcare.

What are other uses you can think of for texting in healthcare? Please add your comments!

Found Around the Web Today

It has been awhile since I have posted a "What I am Reading" or "What I have Found" post, so here you go. Some interesting stuff out there that sparked my interest.

From Reuter's Health, a report on Sex Bias in Control of Cancer Pain:

"How well pain is managed in people with cancer apparently differs between men and women, new research hints. Dr. Kristine A. Donovan, of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, and colleagues examined pain severity and the adequacy of pain management in 131 cancer patients newly referred to a multidisciplinary cancer pain clinic." Full Story

From LifeScript, a study that shows 1 in 5 Diabetics do not take their medication as prescribed. "Too many diabetics are neglecting to take life-saving prescription medicines regularly, one study warned. Published in the Archives of Internal Medicine, the study estimated that 21% of diabetics fail to adhere to their prescription schedule." Full Story

Allan Showalter, MD from AlignMap discusses the Implications Of The Redundant Patient Compliance Review. I like to post abstracts and some compliance reviews, but his blog posts are always more insightful, biting and from an MD's perspective. Full Story

And lastly, from the International Journal of STD and AIDS: Factors associated with lack of antiretroviral adherence among adolescents in a reference centre in Rio de Janeiro, Brazil. Full Story.

Wal Mart and Caterpillar Team Up for No-Copays

I have said it in meetings, in emails and on Twitter: Wal Mart can revolutionize healthcare in this country. They have the power to change the way patients get and pay for their medications. Already, Wal Mart has changed the pharmacy industry by introducing their $4 generic drug program in the fall of 2006. This program made every pharmacy, from Target and CVS to Farmer Joe and Hannafords, also offer $4 generics to compete.

This program has saved Wal Mart customers $1 BILLION already. THAT is impressive.

One of the programs for aiding the US healthcare system and helping patients become healthier is employer /health plan sponsored lower co-pays and free medication for chronic diseases. This is not my original idea, as several companies have offered these services to their employees, but one that I fully support and believe will make a difference in medication non-adherence. As we know, forgetfulness is the #1 reason, with drug prices, side effects and drug education being the other factors that contribute to this pandemic.

Wal Mart and Caterpillar are taking this idea a step further by offering no co-pays for employees taking Tier-1 generics.

"Caterpillar Inc. and Wal-Mart Stores Inc. have embarked on a pilot drug program that could revolutionize the prescription drug industry, officials from both companies said Monday.

Select salaried and management employees of Caterpillar as well as its retirees and surviving spouses can get Tier-1 generic drugs filled for no co-payment at all Wal-Mart, Sam's Clubs and Neighborhood Market stores now through Dec. 31, 2009, as part of the program that began earlier this month.

The co-payment for the generic drugs is $5 at other pharmacies.

While about 70,000 Caterpillar employees are affected now, that could expand to include union-represented employees who opt into the company's HMO plan beginning Jan. 1, 2009, said spokeswoman Rachel Potts. Open enrollment begins in November."

I think this is another fantastic program and shows the real power Wal Mart has to influence the US Healthcare industry.

"The goal of the pilot program, on which Caterpillar and Wal-Mart negotiated for several months, was to remove unnecessary costs from the health care equation, said Todd Bisping, Caterpillar's pharmacy benefits manager.

It does that by eliminating the middle man, so to speak, in the pharmaceutical management process. Most companies contract with an outside pharmacy benefits manager to set rates on prescription drugs, rates co-payments are designed to cover to defray the company's costs.

Caterpillar negotiated directly with Wal-Mart on the rates, saving it money and enabling Caterpillar to then waive the co-payment for its employees and retirees, Bisping said."

You can read the full story from the Peoria Journal Star.

Personal Voice and other Medication Adherence "Scams"

I subscribe to a number of Google Alerts regarding medication non/ adherence /compliance. For the most part they are pretty spot on regarding articles with my chosen keywords, new research, blog posts etc... At least once a day is a link to a faux blog that simply lists keywords with advertising and links to other spam sites.

Once such site came up today, but also revealed some useful information - ie. NCPIE is promoting October as Talk About Prescriptions Month (more on this in another post) but they have a broken link to the site.

The text isn't well written, but they do promote the importance of medication adherence and the role of the caregiver. It mentions a service called Personal Voice with a link to the website Family Focus Working Caregivers that has broken links and some healthcare information. Overall a horribly designed site, but offers the Personal Voice service which will call your loved ones for you in case you do not have the time to make sure they are taking their medications.

I called the number provided to get an information package. The voicemail thanked me for calling and asked me to dial the extension I wanted. I dialed "0" and got a voicemail that simply stated "Personal Voice". I did a Google Search for "Personal Voice Inc." and here is what I got:

At first I thought it was just a problem with them managing their online reputation - since the first four results are negative. I then read the posts and they all describe the service as a scam. They deduct money from one's checking account monthly, yet do not provide a service. They are tied to another company which is a debit-for-credit-card scam as well.

This just makes me mad. A company using medication non-adherence rates to scare caregivers into signing up for a service that is simply a scam to make money. Luckily they are now being investigated by the FBI. I have encountered a number of email phishing scams this year, and other online attempts to get information, but this is the first I have seen involving medication non-adherence.

Caregivers out there, be careful with the services you sign up for. Make sure they are legitimate and will provide a beneficial service for your loved ones. Check with the better business bureau and do a Google Search to check the company's reputation.

I have not included any links from this post on purpose.

Adheris Study Finds First 30 Days on Antidepressants Critical for Medication Adherence

I had a call a few months back where I was pitching Intelecare's Services. The prospect asked "who are your competitors". I gave the answer, "well, no one". I know it is not the proper VC answer, however, at the time (March) there wasn't anyone in our space doing what we do.

No one has a robust, web-based proprietary medical messaging platform that sends patient and caregiver created reminders via email, text and voice messaging. No one offers our hosted and enterprise solutions to industry. No one has 3.2M users and sends out 4M reminders daily. No one has a pro bono program that gives away their technology. No one is developing the next generation in Adherence 2.0 applications like we are.

Since that call, a handful of competitors have emerged offering similar products. In fact, one such competitor even used the same phrasing we have used on our website for two years to describe the services they offer and the industries they serve.

Competitors aside, Intelecare is still the gold standard - no matter how many other companies come into the space.

Even though our competitors charge for their reminders, we still offer a free service to patients and caregivers to ensure that they are helped with the #1 cause of medical non-adherence, forgetfulness. We still integrate our reminder platform into any existing web portal - both as an out of the box hosted solution and as a fully customized enterprise solution. We still offer our hosted email reminder platform pro-bono to non-profits that specialize in chronic disease states.

That being said, I found a press release from Adheris today announcing a study which results "showed that patients new to antidepressant treatment and those who had restarted therapy after a lapse of 6 or more months were twice as likely to discontinue therapy in the first 30 days of treatment versus patients previously dispensed an antidepressant."

This is significant because the first 30 days of therapy are integral to a patient continuing their therapy. "The practical implications of this study are that while all patients lapsed at an alarming rate over time, increased patient follow-up and education within the first 30 days of therapy in newly treated and lapsed patients restarting therapy are critical to help improve adherence and patient outcomes."

Adheris is a fantastic company that has been in the space for over 9 years. They are focused on increasing patient adherence and education at the pharmacy level. Several times I have been asked to compare our services to theirs - however it is apples and oranges. We are both trying to get to the same goal - increasing patient medication adherence - we just have two distinct ways of doing it.

Medication non-adherence costs the US $300 BILLION annually in unnecessary health care costs and lost revenue. 1 in 2 patients does not take their medications as directed with 84% of them citing forgetfulness as the reason.

I think this market is big enough for a few players with different ideas of how to end this pandemic. It not only takes reminders, but education and lower drug costs to help eradicate the problem which affects us all in one way or another.

Frequency of and Risk Factors for Preventable Medication-Related Hospital Admissions in the Netherlands

Today's medication adherence themed abstract is brought to you by the Archives of Internal Medicine. Adverse medication reactions are not simply restricted to the US. As this study shows, even The Netherlands, with their advanced healthcare system, still could prevent almost half (46%) of their medication related hospital admissions.

Medication-related problems that lead to hospitalization have been the subject of many studies, many of which were limited to 1 hospital or lacked patient follow-up. Furthermore, little information exists on potential risk factors associated with preventable medication-related hospitalizations.

A prospective multicenter study was conducted to determine the frequency and patient outcomes of medication-related hospital admissions. A case-control design was used to determine risk factors for potentially preventable admissions. All unplanned admissions in 21 hospitals were assessed during 40 days.

Controls were patients admitted for elective surgery. Cases and controls were followed up until hospital discharge. The frequency of medication-related hospital admissions, potential preventability, and outcomes were assessed. For potentially preventable medication-related admissions, risk factors were identified in the case-control study.

Almost 13 000 unplanned admissions were screened, of which 714 (5.6%) were medication related. Almost half (46.5%) of these admissions were potentially preventable, resulting in 332 case patients matched with 332 controls. Outcomes were favorable in most patients.

The main determinants of preventable medication-related hospital admissions were impaired cognition (odds ratio, 11.9; 95% confidence interval, 3.9-36.3), 4 or more comorbidities (8.1; 3.1-21.7), dependent living situation (3.0; 1.4-6.5), impaired renal function (2.6; 1.6-4.2), nonadherence to medication regimen (2.3; 1.4-3.8), and polypharmacy (2.7; 1.6-4.4).

Adverse drug events are an important cause of hospitalizations, and almost half are potentially preventable. The identified risk factors provide a starting point for preventing medication-related hospital admissions.

Interview With The Chief Scientist of Express Scripts from STLToday

Here is a quickie from the St. Louis Post Dispatch. It seems to be an interview with the Chief Scientist from Express Scripts, however it is just a series of questions and answers without any reference text. I do think these are interesting questions though, and really makes me think about mail order pharmacies.

Why aren't you doing it? The costs are reduced for 90 day supplies. It makes perfect sense to me, since I am on two maintenance medications, yet I still have not done it - why? I do not really know. I printed out the form, and then it sat on my desk for a week. I think I took it home, then it was put in a drawer and lost it. We have since changed health plans, so maybe I will look into it again.

Enjoy the Q and A:

Can you give a brief explanation of Express Scripts' Center for Cost-Effective Consumerism?

The center brings together leading experts in behavioral economics to gain an advanced understanding of human behavior applied to health care. The center uses this information to help bring about positive health behavior change one consumer at a time. Right now, we're focused on procrastination as one major obstacle to better behavior.

One of the center's recent studies found patients were more likely to take medications as directed when they received those medications through the mail. Can you discuss these findings?

The study found that medication compliance was about 8 percentage points higher at home delivery than retail in key therapy classes: diabetes, high cholesterol and high blood pressure. The study involved more than 70,000 patients followed for nine months, and the design was such that we are confident that the difference in therapy adherence was due directly to home delivery.

Do you know any reasons why patients receiving drugs through mail order are more compliant?

There are at least two issues. First, it's clear that some of the noncompliance is due to procrastination when it comes to getting refills. This leads to gaps in compliance because patients wind up not having their medications. Because home delivery offers 90-day supplies, there are fewer refills needed and thus fewer gaps.

Second, our data show that patients in home delivery are far more engaged; they call us more often, log in to our website more often and increasingly view us as a trusted partner. This helps us communicate more effectively with them about their care.

Why don't more patients choose mail order?

Based on our work with the center's advisory board, we think it's more about procrastination than an active decision not to use home delivery.

In the past, moving to home delivery meant filling out forms, calling the doctor for a new prescription written for 90-day fills, etc. Express Scripts has new programs that take almost all of that work off patients' shoulders, so we expect a lot more of them to take advantage of home delivery going forward.

What should employers and other health insurer purchasers do if they want to encourage their employees or members to use mail order?

Clearly, financial incentives are not enough to drive members to home delivery. In addition to making sure patients save money on their co-payments at mail, employers and insurers should work with a PBM partner that can address the issue of procrastination and communicate effectively with patients.

Abstracts from Medline

Today I found several abstracts related to medication non-adherence, specifically these four that deal with measurement. All are from the HighWire Press out of Stanford.


ONE: Testing the psychometric properties of the Medication Adherence Scale in patients with heart failure

Many factors may contribute to medication nonadherence in heart failure (HF), but no standard measure exists to evaluate factors associated with nonadherence. To fill this gap, we developed the Medication Adherence Scale (MAS) and tested its reliability and validity in patients with HF.

Questionnaire data were collected from 100 patients with HF at baseline using the MAS, and objective adherence data were collected for 3 consecutive months using the Medication Event Monitoring System.

Principal component analysis yielded three factors that explained 63% of the variance in medication adherence: knowledge, attitudes, and barriers to medication adherence. Cronbach's alphas for these subscales ranged from .75 to .94, which supported their internal consistency. The Spearman rho correlation coefficients between the Medication Event Monitoring System and Knowledge, Attitudes, and Barriers scores were .25 to .31 (P < .05), demonstrating support for construct validity.

These results support the reliability and validity of the MAS as a measure of knowledge, attitudes, and barriers of medication adherence.

TWO: Revision and validation of the medication adherence self-efficacy scale (MASES) in hypertensive African Americans

Study purpose was to revise and examine the validity of the Medication Adherence Self-Efficacy Scale (MASES) in an independent sample of 168 hypertensive African Americans: mean age 54 years (SD = 12.36); 86% female; 76% high school education or greater. Participants provided demographic information; completed the MASES, self-report and electronic measures of medication adherence at baseline and three months.

Confirmatory (CFA), exploratory (EFA) factor analyses, and classical test theory (CTT) analyses suggested that MASES is unidimensional and internally reliable. Item response theory (IRT) analyses led to a revised 13-item version of the scale: MASES-R. EFA, CTT, and IRT results provide a foundation of support for MASES-R reliability and validity for African Americans with hypertension. Research examining MASES-R psychometric properties in other ethnic groups will improve generalizability of findings and utility of the scale across groups. The MASES-R is brief, quick to administer, and can capture useful data on adherence self-efficacy.

THREE: Methods of assessing adherence to inhaled corticosteroid therapy in children and adolescents: adherence rates and their implications for clinical practice

Nonadherence to inhaled corticosteroid therapy is common and has a negative effect on clinical control, as well as increasing morbidity rates, mortality rates and health care costs. This review was conducted using direct searches, together with the following sources: Medline; HighWire; and the Latin American and Caribbean Health Sciences Literature database. Searches included articles published between 1992 and 2008. The following methods of assessing adherence, listed in ascending order by degree of objectivity, were identified: patient or family reports; clinical judgment; weighing/dispensing of medication, electronic medication monitoring; and (rarely) biochemical analysis.

Adherence rates ranged from 30 to 70%. It is recognized that the degree of adherence determined by patient/family reports or by clinical judgment is exaggerated in comparison with that obtained using electronic medication monitors. Physicians should bear in mind that true adherence rates are lower than those reported by patients, and this should be considered in cases of poor clinical control. Weighing the spray quantifies the medication and infers adherence. However, there can be deliberate emptying of inhalers and medication sharing. Pharmacies provide the dates on which the medication was dispensed and refilled. This strategy is valid and should be used in Brazil.

The use of electronic medication monitors, which provide the date and time of each triggering of the medication device, although costly, is the most accurate method of assessing adherence. The results obtained with such monitors demonstrate that adherence was lower than expected. Physicians should improve their knowledge on patient adherence and use accurate methods of assessing such adherence.

FOUR: Evidence-based Assessment of Adherence to Medical Treatments in Pediatric Psychology

Adherence to medical regimens for children and adolescents with chronic conditions is generally below 50% and is considered the single, greatest cause of treatment failure. As the prevalence of chronic illnesses in pediatric populations increases and awareness of the negative consequences of poor adherence become clearer, the need for reliable and valid measures of adherence has grown.

This review evaluated empirical evidence for 18 measures utilizing three assessment methods: (a) self-report or structured interviews, (b) daily diary methods, and (c) electronic monitors.

Ten measures met the "well-established" evidence-based (EBA) criteria.

Several recommendations for improving adherence assessment were made. In particular, consideration should be given to the use of innovative technologies that provide a window into the "real time" behaviors of patients and families. Providing written treatment plans, identifying barriers to good adherence, and examining racial and ethnic differences in attitudes, beliefs and behaviors affecting adherence were strongly recommended.

Express Scripts Studies Show Home Delivery Improves Medication Adherence and Generic Sales

Two studies released from by Express Scripts show that home delivery 1) improves patient medication adherence, and 2) increases generic sales. Good for pharmacos for Express Scripts to increase adherence, however bad for pharmacos when Express Scripts wants to increase generic traffic. Good for patients, providers, and payors all around.

It is kind of a duh! revelation when you think that improving access to medication, as well as medication possession will also increase medication adherence. I mean if I have a 90 day supply sent to me at home, I will more likely take my meds on day 32 than I will if I have a 30 day script and need to refill it at my local pharmacy.

The method of introducing the generic was by a letter, another duh! revelation that by increasing patient knowledge of the generic, you increase patient acceptance and uptake. Six months ago my formulary changed and one of my scripts went up to a $75 co-pay. I asked if there was a generic and had my doc prescribe that instead. No one told me of the generic, but if I had been informed, I would have chosen it and lowered my costs earlier. It wasn’t until I was presented with a bill 3x of what I normally paid, that I asked – actually it took two refills to understand the increase, as my wife picked up the first refill and no one told her of the increase.

From MarketWatch

“In one study, compliance, or taking a medication as prescribed by your doctor, was nearly eight percentage points higher for home delivery pharmacy patients taking medications to treat high blood pressure. These patients were 78.6 percent compliant, but those using a retail pharmacy were 70.8 percent compliant.”

“….Cox explained that in addition to cost savings, home delivery promotes better medication compliance through patient communications such as refill reminders by phone or email, renewal assistance, a convenient reorder process, and less frequent re-ordering.”

“In the second study, a letter alerting patients to the availability of a generic alternative, the likelihood of choosing generics in home delivery was 34% greater compared to the impact in retail. The letters were sent following the introduction of generic Ambien(R) (zolpidem) in 2007.”

“Express Scripts estimates that use of generic sleeping aids will increase to 70 percent of all sleeping aid prescriptions in 2008. However, even that increase will not capture the $1.5 billion in additional savings available nationwide for commercial and government-paid plans from realizing the category's full generic potential of 95 percent.”

“The Center was inspired by research showing that a targeted communications program implemented around the 2006 introduction of generic Zocor (simvastatin) was nearly two to three times more effective than financial incentives alone. The greatest impact came among consumers using the company's home delivery pharmacy. The campaign generated over a billion dollars in savings for Express Scripts' pharmacy benefit plan sponsors and consumers.”


8% is a fair amount in the adherence game. Congrats Express Scripts. Also in saving BILLIONS of dollars for their clients, Express Scripts should be commended. And an increase of 34% in generics from home delivery v. retail is outstanding.

At HealthCampDC, we had a short discussion about generics v. brands. The public does not actually know generic names, just the brand. “Oh, give me the generic of Zocor” not “I want simvastatin”. It is up to doctors, PBMs, and pharmacies to alert the patients as to what exists in the generic market to lower health care costs.

I wish two of my meds had generic equivalents, as they are $40 a month – not that this is so much, but it adds up, plus my wife’s scripts, plus our son’s script, and doctors’ bills and specialists. It was so much easier and inexpensive when I was single and did not go to the doctor. I can only imagine what the downturn in the economy is going to do to the average family and their healthcare costs.

Follow-up On Retail Clinics

As a follow-up to my post on retail clinics last Tuesday, here are two links to blog posts which explore the topic more extensively than I.

Jane Sarasohn-Kahn of Health Populi talks about the lower costs and better access of retail clinics but at the price of raising overall costs.

Thoughts from Lab Soft News on the subject.

iGuard Medication Alerts

Do you know about iGuard? I never want to sound like a salesperson, but it is a great service "launched in 2007 as a startup venture funded by Quintiles Transnational...to promote better communication and research about drug safety." Huh? A little bit of hype, and you wonder, how are they going to do that?

On the surface, iGuard is a DDI checker, "a healthcare service that helps monitor the safety of your medications (including prescription drugs, over-the-counter drugs, nutritional supplements and herbal extracts)" like ePocrates, DoubleCheckMD and PharmaSurveyor, but has a lot of other benefits as well. FD I know and have spoken with representatives from all of these companies - and they all do more than just check for drug interactions. I am just placing them in this category for now.

I signed up for iGuard a few months back, seeing if there was any synergy with Intelecare and kind of forgot about it, as I know the drugs I take do not have any interactions with each other. A few days ago I was twittering about another Health 2.0 company, and a VP of Quintiles pinged me to ask if I had heard of iGuard. I replied I had an account and went back to look at it again.

Users add the medications they are taking, and their health problems to see if there are any side effects, and then can get information about said meds and conditions. The interface for the medications is very user friendly with Wikipedia content, prescribing info, indications, fact & figures, side effects, as well as charts based on other users on the same drug and feedback from other patients.

For Niaspan ER, the health information is very straight forward: "This product is used in the treatment of patients with high lipid levels (including cholesterol). It's exact mechanism of action is not well understood." I did not know that researchers and MDs did not know how Niaspan works! Learning already. My risk rating is 2, meaning no harmful long-term side effects or interactions. 2,630 patients using iGuard take Niaspan, 53% have side effects (flushing being the most common), 7.0 satisfaction score (mine is a 9), etc... Point being, lots of great information, and a anonymous comment board to post.

This is what got me thinking about them today however, an email from them that stated the FDA is stopping the import of medicines from Ranbaxy Laboratories due to the concerns they are not following US standard for good manufacturing practices. Here is part of the email:

"Although Tricor is one of the medications manufactured by Ranbaxy, drug shortages are not expected because, in most instances, there are enough other suppliers that can help meet demand for Tricor.

For more information, please visit:

* * * *

This alert will have very little impact on most patients. However, you should be aware that your pharmacy may dispense Tricor manufactured by a different generic company the next time you get your prescription filled.  The effectiveness and safety of generic medication is equal, but some tablets or capsules look different depending on the manufacturer. If your prescription ever looks different, it is always a good idea to ask your pharmacist why the tablets or capsules look different.

This alert is not related to any safety concerns with Ranbaxy products currently distributed in the United States. If you are using medicine covered by this alert you should continue to take it as directed - the risk of suddenly stopping this medication is likely to be greater than any risk associated with their manufacturing. If you have any additional questions about how this FDA alert affects your medications, please talk with your pharmacist."

I got this email at 7:45 pm last night, after I had "shut down" for the day - and stopped inputing information via the web. I read this around 11 pm and thought wow, this is great. Of course I could get this news with the information I read throughout the day, however it was presented to me before the news broke, and provided me with a calm, knowing that I would be OK with my Tricor.

HealthCampDC Part Two - Something I forgot

Looking over tweets from Friday #HealthCampDC08, I completely forgot about a conversation one of the campers started regarding a blood test he wanted his MD to run for him. It was part of a two year check-up that he had self-prescribed. It was a young MD, who stated that she needed to put a note in his chart that said he was very sexually active to get approval from his insurance. That is not such a great note to have in your permanent file.

The MD was trying to be helpful, and get the test passed, however it was the wrong way to do it. One of the MDs at HealthCampDC stated that “... physicians aren't trained to know where those codes go (DRGs)… we get paid for diagnoses”.

This brought up the question: What is in your file, and will this prevent you from getting insurance down the line?

Do you know what is in your file? Has some doctor made a note that was an incorrect or "fake" diagnosis, yet needed to address an issue for a test?

I have been thinking about writing a post about a recent trip to the emergency room - not the point - but when I was there, I got a chest X-ray to make sure everything was hunky-dory. The technician called a few days later and said the hospital sent me a letter suggesting I get a follow-up X-ray three month later because they found an abnormal "shadow". It probably wasn't anything, but they had to protect themselves in case it was lung cancer.

Of course my wife freaked out, and made me go to our PCP. My MD found nothing to support me getting a chest X-ray and said that my insurance would probably not pay for it. It has been three weeks and I haven't heard anything yet regarding approval.

Point being, what if she put something in my chart that hinted at lung cancer. I did smoke on and off for 12 years (only a few cigs a day) but would this effect me getting health insurance in the future?

Again: Do you know what is in your file? You can request it once a year to check on it and make sure there isn't any false or incorrect information.

RAND Study: Patients Without PCP Go To Retail Clinics

I found this article in in Drug Store News yesterday, but I am a little late to post. On a personal note, when I quit my job and became a independent consultant in the late 90s, I did not have health insurance for a year, then paid for it for two years, never used it and stopped paying for it. I was 26 to 29. When I became engaged, my father-in-law wanted to make sure I had insurance, so his daughter would be covered in case she quit her job. We then set-up insurance through the restaurant I own.

However, my wife and I did not have PCPs for two years, and used the Westport Walk-in clinic as our go to MD. We never had a problem - just walked in and waited maybe 20 minutes at most. I think you could even schedule follow-up appointments The last time I saw my new PCP, I waited almost 45 mins!

The MDs did a great job with all of our medical problems, from Lyme Disease, hypothyroid, nasal infection, to a sprained wrist. Granted a walk-in clinic is more of a medical home that a retail-based clinic, but I wanted to personalize the story a bit.

NEW YORK (Sep. 10) A recently released study by nonprofit research organization RAND Corp. found that many retail-based clinic patients do not have a regular health care provider, which is further evidence as to the important role that retail-based clinics play in today’s healthcare system.

“These clinics appear to attract patients who are not routine users of the current health care system,” stated lead author Dr. Ateev Mehrotra, a professor at the University of Pittsburgh School of Medicine and a research at RAND. “For these patients, the convenience offered by retail clinics may be more important than the continuity provided by a personal physician.”

The study, published in the September/October issue of the journal Health Affairs, analyzed the details of more than 1.3 million visits to retail clinics between 2000 and 2007. The data was obtained from eight retail clinic operators that accounted for three-quarters of the clinics in operation as of July 2007. FULL ARTICLE.

The HealthCampDC Experience

I went down to Washington DC to attend HealthCampDC on Friday (09.12.08), an "unconference" organized by Mark Scrimshire, a Strategic Consultant and Change Agent. I wasn't sure what to expect. From the group that signed up, I follow four on Twitter, and have spoken with two in the past - so I thought it would be a great opportunity to meet them in person.

As for the agenda? There was no agenda until the group decided what we were going to talk about. Such is the style of BarCamp. Of the 25 people who signed up, only 9 of us made it to the CareFirst offices.

It was a great group and made the day more intimate - representing payor HIT, NIH HIT, consultants for State and Government, MD consultants, Health Ranger, Pollster/e-patient and me.

We had a quick networking session over coffee and muffins, then we all made a dash to the board to post the topics we wanted to discuss.

We all commented how this methodology was much better than a regular conference where people show up with a slide presentation and bore everyone to death. We ended up choosing about 5 different session topics, then sat around a table to discuss. And discuss we did.

Mark did a wonderful job of hosting and organizing, as well as live blogging through the event. Here is his post on the morning sessions, and his recap post of the event.

Our first topics revolved around two projects that two campers were working on. Susannah Fox from the Pew Internet & American Life Project is putting together a new study on Social Media and Health and Lygeia Ricciardi is working on a project to raise patient awareness and adoption of physician sharing of EHRs.

Both topics sparked lots of back and forth about polls, their importance, Health 2.0 tools, EMRs /PHRs access and ownership. Some of the quotes that I have in my notes:

"Don't believe polls that do not include cell phones".
"Everyone is a media company".
"Don't offer consumers a service, offer them a solution".
"CIOs career is based on how many people work under them".
“The only people without access to electronic health records are the patient themselves”.

Ted Eytan, MD mentioned two real world scenarios he has experienced where a EMR would come in handy. 1) A non-English speaking man collapsed on the street in front of him - no one knew what medications he was on or if he had any medical conditions. 2) A cashier at Whole Foods had a medication reaction, yet no one knew what she was on or her conditions, and no one could find her purse. What do you do as a spectator, EMT, MD when the patient is unconcious and you have no idea if what you are doing is going to help or hurt them?

This led into a discussion about primary v. secondary access to healthcare information and services – patient v. family caregiver. How do you engage Helen Keller or her caregiver? 20% are satisfied not being engaged in their healthcare decisions.

“The HealthCare challenge is bigger than any one person or company can tackle alone”.
“We all have to own a part of the solution".
"We are all agents of change”.

Jen McCabe Gorman gave a quick recap of her Medicine 2.0 presentation for the NextHealth model that she and her Dutch group have been working on. Susannah Fox has a great write up over at e-patients.net. I sort of understand their model - here is the Slideshare , the NextHealth research paper and Jen's post about the presentation, but I think I need to walk through it once it is online to fully understand.

“Not all patients are consumers, but all consumers will at some point become patients”.
“The hyper-connected patient (2%) will drive activity and innovation”.
"Everyone can be overwhelmed by the system whether you are the patient, payer, provider or consumer".
"I feel kinda stoopid". This was a major thread through the day.

In the afternoon, we started with a discussion of the tools we, as healthcare professionals, use to keep abreast of new technologies and our peers. The longest discussion was about Twitter (which I have written about before).

Other tools mentioned were lots of Google apps: search, alerts, reader - as well as Delicious, RSS Feeds, Jing, Summize, Friend Feed, Stickam, Feedinformer, blogs and YouTube. There was a Stickam live feed of the event which I did not know about until someone twittered me about it. I learned that Google Reader has a search function so you can add RSS feeds based on the topics you follow.

David Hale gave a presentation on a Drug Identification tool that is being developed by the NIH's National Library of Medicine. It uses FDA pictures and codes to identify pills. We talked about the value of the service as so many patients have unidentified medications. Used the example of medications from Katrina – patients had pill bottles without labels – how to identify them? Would like this tool to be the definitive database for patients, providers, poison control, etc…

The final topics: How can we get DC to become the center for Health 2.0? And where do we go from here? We were but a small group, but everyone has a voice, and has contacts. Who do you get involved? I asked who are the decision makers that can effect change - who has the loudest voice? Patients, providers, payors (probably not), entrepreneurs? Does the squeaky wheel get the grease?

This HealthCamp was a great place to start the East Coast discussion about Health 2.0 and how to enact that change. To quote Mark again: "Despite the scale of the challenge being so great one realization was reached. The Washington DC area is at the epicenter of the transformation of HealthCare. All the major providers compete in this market. Major Provider networks operate, researchers are here, Venture Capitalists are here, Technologists are here, charities representing critical diseases have representation here and the politicians and Federal operations that will pass legislation that will drive change are here. Everyone is in this market. The Washington DC are has all the elements to be the epicenter of Health 2.0."

Next events are HealthCampNy, an uncoference at the Health 2.0 Conference, and another HealthCampDC in late January or February '09.

Thank you again to Mark and all the campers who participated and made HealthCampDC08 such a gerat event! It was a pleasure to meet you all and I look forward to continuing the conversation.

Medication Noncompliance and Substance Abuse Among Patients with Schizophrenia

Today's medication adherence related abstract comes from Psychiatry Online. It is from a Veterans Affairs Field Program for Mental Health and was originally published over 10 years ago, however it is still often cited. The results are not that surprising, however it brought to mind alcoholism and how it is related to medication non-adherence and to mental health.

With both schizophrenia and bipolar disorder, the rates of alcoholism are much higher than the average. I have always viewed this alcoholism as self-medicating behavior - thus the patients are adherent to their self prescribed drinking regime. I wonder how side effects came into play as most of the psychiatric medications heighten the effects to alcohol?

The study examined the effect of medication noncompliance and substance abuse on symptoms of schizophrenia.

Short-term inpatients with a diagnosis of schizophrenia were enrolled in a longitudinal outcomes study and continued to receive standard care after discharge. At baseline and six-month follow-up, Brief Psychiatric Rating Scale (BPRS) scores and data on subjects' reported medication compliance, drug and alcohol abuse, usual living arrangements, and observed side effects were obtained. The number of outpatient contacts during the follow-up period was obtained from medical records. Relationships between the dependent variables-medication noncompliance and follow-up BPRS scores-and the independent variables were analyzed using logistic and linear regression models.

Medication noncompliance was significantly associated with substance abuse. Subjects who abused substances, had no outpatient contact, and were noncompliant with medication had significantly greater symptom severity than other groups.

Substance abuse is strongly associated with medication noncompliance among patients with schizophrenia. The combination of substance abuse, medication noncompliance, and lack of outpatient contact appears to define a particularly high-risk group.

Make Naruto Shoes For Less Than $3

Mangafairy has made these Naruto shoes for £2 (less than US$3), they last for about an Expo, and are great for a couple of wears, easy an cheap.
Here is the tutorial as posted in YouTube...

Choose Suitable Character to Cosplay

It’s so obvious that every fellow have their favorite anime & manga characters which they aspire to cosplay. However, does the one suit your style? Choosing right and fitted character is one of the significant parts in cosplay. If you’ve chosen the right character , it’s effortless to elaborate your acting potential and present your indulge in this character. If not, to display the perfect performance seems not so easy though there are other ways to fix some flaw. I think, before you seriously take steps on the stage, it’s indispensable to possess this unpleasant preparation that perhaps few laymen would place an adverse critic on your defective play.

So let’s talk about how to choose the suitable character to cosplay , In part one, I will talk about the boys cosplay.:)

For Boys

The first is to pay attention to your figure. If you are almost the same figure: referred to your height, weight, body proportion to the role you tend to act, it’s easy to present acceptable show with average costume. And regardless of your fullness or slimness, tallness or shortness, there are always countless characters to choose, which is superior to girls’ cosplay. The second part is to be cautious to some specific details such as the charm, the face cheek, or the behavioral styles of the character. A babyface to play a rough guy is strange and sort of missing the spirit. Grounded this two parts be accomplished well, the performance is to some extent a perfect show.

And below, you will see some good and bad cosplay from the cosplay boys , so how do you think of their cosplay?

Comparison of cosplay matching style

For Girls

Unlike boys, the most important thing is about the actress’ body figure. As girls’ costumes have more pattern and stylish design than boys’, and even several body exposures, thus it’s better to find the advantage and disadvantage of the player, so as to choose the fit garment. For instance, if your legs look not so perfect, you can select long dress or trousers; the figure is round in normal clothes, you may pick up something that won’t reveal your curves. These concepts are the same clothes matching principles as in everyday life. Except this, nearly every other disconformity could be fixed up by other artificial methods, such as cosmetic, fake hair, small accessories.

Moreover, in capturing the spirit and charm of the role, girls could use cosmetic to demonstrate different effect, which brings numerous advantages to the performance. For example, rich make-up makes the actress sophisticated and gaudy, while pale make-up tends to display a sense of purity and innocence.

Specifically, about the crossplay. Normal situation is girls crossplay as boys, because female’s cheek curve is tender and reserved, which brings unexpected effect in transvestite. So if you’ve picked up the right character, you can take the chance to have a try. On the contrary, boys - character as girls sometimes is totally for fun, and some is seriously to display the grace and elegance of female. It is not a denial for your hard work, but a various degrees of acceptation. For the audience, I think it is better to cheer up for the crossplay for their courage.
(Written by Alice Hana)

Naruto Cosplay Tutorial

This is an online video tutorial on making Naruto Uzumaki (thanks to Shimmi) as appear in YouTube. For note, you should sew the scarf on the hood not glue but it was good.

One-month adherence in children with new-onset epilepsy: white-coat compliance does not occur.

Today's Medication Adherence related abstract comes from Medscape.

Adherence to antiepileptic drug therapy plays an important role in the effectiveness of pharmacologic treatment of epilepsy. The purpose of this study was to use an objective measure of adherence to (1) document patterns of adherence for the first month of therapy for children with new-onset epilepsy, (2) examine differences in adherence by demographic and epilepsy variables, and (3) determine whether treatment adherence improves for a short time before a clinic visit (eg, "white-coat compliance").

Participants included 35 children with new-onset epilepsy (mean age: 7.2 years; 34% female; 66% white) and their caregivers. Children had a diagnosis of partial (60%), generalized (29%), or unclassified (11%) epilepsy. Adherence to treatment was electronically monitored with Medication Event Monitoring System TrackCap, starting with the first antiepileptic drug dose. Adherence was calculated across a 1-month period and for the 1, 3, and 5 days before and 3 days after the clinic appointment.

Adherence for the first month of treatment in children with new-onset epilepsy was 79.4%. One-month adherence was higher in children of married parents and those with higher socioeconomic status but did not correlate with child's gender, age, epilepsy type, prescribed medication, seizure frequency, or length of time since seizure onset. Adherence across the entire 1-month period was not different from adherence for the 1, 3, or 5 days before or 3 days after the clinic visit.

Poor adherence seen for children with new-onset epilepsy during the first month of antiepileptic drug therapy is a cause for concern. Several demographic variables influence adherence to treatment, whereas the proximity to a clinic visit does not. Additional studies are needed to document whether this trend continues longitudinally and determine the clinical impact of poor adherence.

I wonder if the adherence rates dropping has something to do with the caregivers? 79% is not that bad - better than average - but it is only for 1 month, and with a severe affliction such as epilepsy, being able to see the effects of non-adherence has a serious impact.

Highlight HEALTH Cancer Research Blog Carnival - Stand Up To Cancer

This post will attempt to cover a host of topics, so I apologize if it rambles a bit.

First off I was very flattered today to be included in a Cancer Research Blog Carnival on Highlight HEALTH. I checked my email at 3 am while feeding Gray this morning and there was an email from Walter Jessen (author of Highlight HEALTH, neuro-oncology research scientist and bioinformatician) stating he included me in the Carnival.

This is significant for a few reasons:

1st: The Carnival is in support of Stand Up To Cancer a fundraiser tonight at 8 PM on ABC, NBC and CBS benefiting Cancer Research. “In 2008, over half a million Americans are expected to die of cancer, more than 1,500 people a day. Cancer is the second most common cause of death in the U.S., accounting for 1 in every 4 deaths. Nevertheless, since 2003 the U.S. government’s cancer research budget has been cut every single year”.

Matthew Zachary and Dr. Leonard Sender from I’m Too Young For This! will be in the front row, making sure their voice is heard, as there is barely any funding for young adult cancer research.

2nd: I never thought I would be included in a blog carnival, however my post was added because it is an abstract about a video game improving medical adherence in cancer patients. It made me wonder the reach and importance of my blog posts, and also made me think of what I am doing with this blog. My intentions have changed a few times since creating the blog last year, and they keep evolving each month.

3rd: I “met” Walter Jessen on Twitter. I don’t remember how exactly, but I was following someone who was following him, so I started following him and he reciprocated with a follow. We have communicated a few times over tweeets about various topics. I count this as one of the reasons I was included in the Carnival.

I have been working on a blog post about Twitter for health, and how I use it. This is a prime example. I never would have have crossed paths with Walter outside of Twitter – he is in Ohio and although in a somewhat related field, I probably would not have sought him out. I could have discovered his Highlight HEALTH blog, posted some comments and emailed him – but this still relates to social media and its importance in connecting people of like minds.

To further exalt Twitter, I have had a few “conversations” with MDs all over the country about medication adherence, hospital readmit rates, and other front line problems they face with patients. These communications would not have taken place without Twitter.

Another Twitter praise is for conference coverage. I cannot go to Medicine 2.0 in Toronto (started Wednesday), and there is a presentation by the NextHealth team I really want to see. Luckily I am following a few people who are there, and twittering the event. Of course I will read blog posts, see the Slideshare, and probably speak with the presenters next week, but Twitter brings an immediacy that I cannot find elsewhere.

Of course you can also mention the disaster coverage, and the DNC, RNC coverage – Twitter breaks all the news before others. But that is further off the topic.

In conclusion, I am very honored to be included in the Blog Carnival and hope to have something more substantial to add next time; watch and donate to Stand Up To Cancer and support I'm To Young For This!; and join the conversation on Twitter - you can follow me.

Here are Walter's final thoughts from his post on Highlight HEALTH:

The Cancer Research Blog Carnival is looking for future hosts. You can find both the hosting schedule and past editions at the Cancer Research Blog Carnival website .

For more information on the U.S. investment in cancer research, you can read the NCI’s plan and budget proposal for fiscal year 2009.

Randomized Controlled Trial of a Pictogram-Based Intervention to Reduce Dosing Errors and Improve Adherence Among Caregivers of Young Children

Today's medication adherence related abstract comes from the Annals of Pediatrics & Adolescent Medicine.

See my COMMENTS at the end.

Objective: To evaluate the efficacy of a pictogram-based health literacy intervention to decrease liquid medication administration errors by caregivers of young children.

Design: Randomized controlled trial.

Setting: Urban public hospital pediatric emergency department.

Participants: Parents and caregivers (N = 245) of children aged 30 days to 8 years who were prescribed liquid medications (daily dose or "as needed").

Intervention: Medication counseling using plain language, pictogram-based medication instruction sheets. Control subjects received standard medication counseling.

Outcome Measures: Medication knowledge and practice, dosing accuracy, and adherence.

Results: Of 245 randomized caregivers, 227 underwent follow-up assessments (intervention group, 113; control group, 114). Of these, 99 were prescribed a daily dose medication, and 158 were prescribed medication taken as needed.

Intervention caregivers had fewer errors in observed dosing accuracy (>20% deviation from prescribed dose) compared with caregivers who received routine counseling (daily dose: 5.4% vs 47.8%; absolute risk reduction [ARR], 42.4% [95% confidence interval, 24.0%-57.0%]; number needed to treat [NNT], 2 [2-4]; as needed: 15.6% vs 40.0%; ARR, 24.4% (8.7%-38.8%); NNT, 4 [3-12]). Of intervention caregivers, 9.3% were nonadherent (ie, did not give within 20% of the total prescribed doses) compared with 38.0% of controls (ARR, 28.7% [11.4%-43.7%]; NNT, 3 [2-9]).

Improvements were also seen for knowledge of appropriate preparation for both medication types, as well as knowledge of frequency for those prescribed daily dose medications.

Conclusion: A plain language, pictogram-based intervention used as part of medication counseling resulted in decreased medication dosing errors and improved adherence among multiethnic, low socioeconomic status caregivers whose children were treated at an urban pediatric emergency department.

I recently attended a webinar hosted by a medical education company. They write their brochures and outreach materials for a 5th grade reading level. The average for healthcare related educational materials is geared towards an 8th grade reading level, but they are now going lower. To me that is quite scary for patients whose caregivers might not understand their medical regime and the medications they administer. Glad to see there is a study that has proven the efficacy of "dumbing down" medication instructions.

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