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Episode Info: n to expect the providers to be on top of everything because there's so much stuff in a chart, it really is much better to let patients help. Janet:                                08:18                   So are you saying that, and I agree with you totally, I love your analogy too. Hey, nobody's going to get to be a better driver unless they get to drive. No one is going to appreciate their health records unless they see their health records. But are you saying that this is literally just having access to the EHR, whether you choose to engage with the electronic health record or not, is the point or is there a deeper level of information you think that patients need? Dave:                                 08:42                   That's an excellent question. I have a lot of conversations on this subject and that's a razor-sharp question. My goal is not to make people do anything a particular way. It's to help healthcare achieve its potential. I am deeply grateful to the highly skilled, trained, educated doctors, nurses, assistants, everyone who took good care of me when I was dying and in my business troubleshooting mindset. When I hear all the stories about medical errors or somebody didn't know about a side effect or just there are so many ways that the flood of information out there might not get to the point of need at the moment of need and what I want. First, we troubleshoot. We say, wow, there is too much information for anybody to know everything, so now what can we do? Some people say, well, it's the doctor's job to know everything. Dave:                                 09:50                   Well, well, I know you and I were immersed in this, but the general public has not had this OMG moment of realization yet. It's funny if the ePatient expects the doctor to know everything, it's a recipe for mischief. The same is true if the doctor expects to be treated like they know everything, you know? And that's so this is why this is a culture change, you know, in the women's movement. Well, what it taught to change mindsets and we thought we had it solved, but oh boy seems that it's an ongoing project. What it took to change mindsets was not just changing men's minds, but women's minds. Also long ago, early in my career, I had a woman who worked for me, literally said she couldn't do something. She said I'm just a girl. Like you see, you are a level three employee, which is a high level in a technical profession. Yeah. So it is a culture change. Janet:                                10:53                   All right, so what are the things you talk about as, as a goal or a priority on a professional side is that you really want social change and I think that's really the point that you were just making. But how do you envision social change helping healthcare and making healthcare easier for patients? Dave:                                 11:14                   Well, you know, just this morning, a patient blogger named Aaron Gilmer, Gilmer health law is her Twitter handle, posted something magnificent. One of the best achievements, I think in patient engagement with empowerment that I've ever seen. She has, an extreme mix of psychological and trauma and medical conditions and so on. She created two documents that are now in her chart that express what heart concerns are about being taken care of, how past traumas affect various things, what they should know, what she does in order to deal with it. And here's how I express my worry if I've been triggered. And so on. The first hospitals she gave it to, they looked at it and canceled her surgery. They basically said, get outta here. And she didn't bring it up again. She has a great blog post about it. We can link to it in the show notes. Dave:                                 12:18                   She didn't bring it up again. And then several years later, just recently she got additional care that happened to be in part of the same system. They ran across this and they said, thank you so much. And they have been using what she had expressed. They've been using those methods of talking with her and are you okay with this? And so on. See that's social change. In the old view, the doctor knows everything and those what you're supposed to get economically. This can be a major issue because in US healthcare, so much of what care providers are allowed to do is tied to reimbursement issues and there can be financial pressures. It really takes commitment as a caring profession to overcome that and in the new view, it really is important what matters to the individual patient and people are committed to care as a separate issue from the science that's being administered to the sick person. Janet:                                13:27                   Alright Dave, I'm having an epiphany here and I don't know why this never occurred to me. Although I will say I have the benefit of being a generally healthy person. I've never really had any serious health issues and a visit to the doctor will solve my problem. So I'm very, very fortunate in that regard. However, it never occurred to me that as a patient do I even have the right to add things to my own file and why we should allow patients to submit a patient statement. That kind of sets it up, especially if you're going from physician to physician, you'd have a complicated thing. Wouldn't you rather be able to say, here's my - just what Aaron Gilmer did - here's my story, here's my whatever. So that as you get from a specialist, to specialist, to specialist, they actually read just a paragraph about who you are as a person, not who you are as a series of medical diagnoses. Dave:                                 14:16                   Absolutely. And I imagine that in your work, I mean will you manage client relationships and your business? You need to understand what's important for them, right? You walk in, if you get on a first phone call with everyone and you just feel out the same thing you said to the last 12 people and here you go. Like it or not, I'm going to give you my off the shelf solution. Well, you don't like that. What's wrong with you? Right? You would think that the doctor knows what to do in every visit. But in today's world, you've got to ask yourself what, so what's the difference between what you do in service to your clients and what a physicians, MD, nurse practitioner - by the way, it was a nurse practitioner who first told Erin that he found that in her chart and he was so grateful for it. Dave:                                 15:10                   That's a whole separate discussion of how nurse practitioners generally have more of a cultural license, so to speak. Figuratively speaking, to just plain be caring professionals. What are the cultural reasons why we - in healthcare - we wouldn't start with finding out what's important. I mean, my doctor, the famous doctor Danny Sands, he was the one who in 2007 when it turns out I was dying. He, was the one who you have a good patient community and he didn't say stay off the Internet. He showed me where to go on the Internet. Janet:                                15:52                   Oh wow. He's unusual. Dave:                                 15:52                   Well that's, that's modern. That's modern today. He wears, I just saw on my last clinical visit with him, he has a button on his wife coat that says what matters to you with a question mark, what matters to you? Because you know, you prescribed somebody, okay, you got to eat better. Dave:                                 16:17                   You gotta do this, you've got to do that. That's all external shut up and do what I tell you. Unless it is grounded in me one thing, some form of a better life, to know that somebody really would love to live to see their grandchildren get married versus my bucket list has one big item. It's a month in Hawaii. You know? Then any recommendation for exercise or behavior change or anything. And that's, that's the point these days. We have so many options, treatment options and so on. All proper respect and appreciation to physicians who in today's economic environment, we'll take that extra time because they don't get paid any more for being that kind of a good physician. Janet:                                17:10                   Hmm. Okay. Dave, I want to ask your perspective on something. The world I'm in where, again, as a fortunately healthy person and in my podcast, the work I do tends to be with startups, with new companies, with digital health folks, with young people who are inventing apps and it's a very exciting world. However, I know you've spoken to physicians and healthcare practitioners in the hospital environment and one of the things that I feel is happening and I'm looking to you for clarification or validation is what's up with the medical schools? Are they focusing on integrating some of these new ideas and changes or are still training physicians the same way they always did? Therefore, we're just going to have one more generation of folks who want to say do as I say, Dave:                                 17:57                   Well, surprise, surprise. There's a spectrum. Whoever would have thought that there would be, we know social change takes generations, right? The conventional wisdom that I've heard physicians express to each other is, you don't want to be the first to do something new and you don't want to be the last, just stay in the middle of the pack. Now, surprise, surprise. That turns out to also be exactly how the curve in high tech innovation; there's to this curve where you have the early adopters, the innovators, then you have the early majority and so on, and then the laggards are the last ones to get into it. Some medical schools are primarily interested in preserving their reputation and their position. They want to do a good job of doing what's well accepted. I don't necessarily fault that. I do think it's a good way to guarantee that you will never be in leadership. Dave:                                 19:01                   You know, you may be leadership and reputation, but you'll never be leadership and turning out of the next generation of innovative, smartest, best future doctors. Others though new medical schools that come along and the best example that I know of is the Dell medical school at the University of Texas. That has just opened recently. An example of how they're willing to conspicuously differ because there is this thing that some of us learned in high school, high school biology, the Krebs cycle, how energy gets generated. And I don't remember a thing about it. And the important thing is it's always been something that doctors have to master in order to become an MB and then they never ever use it. So why is it taught and why is it so important? Some people think it's just to be obnoxious and make it difficult to get over that hump. Dave:                                 20:01                   Anyway, Dell medical school's conspicuously said, we're not teaching the Krebs Cycle. We've got better things to do with our time. And similarly there is a great social penalty within the medical community or going after something that is not well established with a larger body of published literature about it. So to get deeply into patient engagement today is risky in that context. People will say, where's the evidence for that? And that's good because once upon a time, you know, just within the last 50 years, it was discovered that doctors were doing a lot of things despite the that it doesn't work. Dave:                                 20:50                   And that's a whole separate subject. My point is it takes genuine vision and leadership to see that something is the new path forward, even if the literature doesn't exist for it. And some schools are beginning to do that, but not enough. I have begun lecturing to some medical schools. Just as one final hint of that. I opened an email late 2014 and it was an invitation from the Mayo Clinic, from their chief residents to be there visiting professor in internal medicine in 2015 despite the absence of any curriculum or anything of the sort. So I went to, we talked a lot about the future of the role of the patient. Janet:                                21:41                   Well, I love working with the team at Mayo Clinic. Now I haven't been on the clinical side, obviously I've been on the social media side, but the embracing new ideas and at least let's look at everything and what is it's potential impact is just a phenomenal philosophy that you don't turn your back on it till it's, you know, so proved, it's carved in stone. Dave, you've teamed up with probably one of the most well known medical futurists and medical device testers in the world. Dr Bertalan Mesko. What did you do with him and what is the digital health manifesto? Dave:                                 22:16                   Well, it's an ongoing thing. You know, and it's funny because this just freaks me out. One of the things that changed, I said if you live long enough, things change. Well, one thing that's happened is I am 12 years older than I was 12 years ago. And that means for instance that my daughter who was just getting out of college when I was sick is now a mid-career science teacher. And I can't believe this, but Bersi is younger than my daughter. And so there we are having these conversations and he's showing me all his digital gadgets and we actually both spoke at a conference. A company had a, an important user group meeting in Chicago a few months ago. We both spoke one after the other and he and I both are thinking in terms of what could we be achieving and what's holding it back. And we see, especially on LinkedIn, LinkedIn is a wonderful place for making connections and so on. But you'll also see in the same way that Twitter became a sort of a festering swamp of rumors and illusions. On LinkedIn, you can see investor type people, Silicon Valley type people getting frothed up about a wrong concept and just the fact that other people are getting excited about it makes it seem like this must be the right thing. So we decided together to publish this manifesto saying, Whoa, step back you guys. Just because something is an amazing new technology. I like to think of it in terms of the Pharma concept, pharmacological concept of what's the mechanism of action by which this new gadget is going to improve anything. You know, so many silicon valley inventions, as well, meaning as they were, turn out to not make any difference or they make a difference, but they don't get commercial uptake and they die. Dave:                                 24:26                   So we wanted to point out, here are the principles that you need to think about if you want to understand what's happening with digital health, because believe us, something real is happening. I used gadgets, for instance, to overcome prediabetes a few years ago, and everybody, I'm over 60 I'm well over 60 and a bunch of people said, look, people over 60 aren't going to ever change their behavior. It's a lost cause. Those people are ignorant. All right? So we said principals, it's a cultural transformation, not a technological revolution. All right? It's about behavior change. It's not about - see when I, when I got this prediabetes diagnosis, I went out and bought a Garmin wristband and I collected lots of data about my activity and my weight went up. Well. So here's the thing. Information enables behavior change, but it doesn't cause it. What produced weight loss for me and a victory was that I got into the YMCA's diabetes prevention program, which is a behavior change program. Okay? So it's not about having the technology. What's important about that from a business sense for a couple of years, cynics - so you have the enthusiasts on LinkedIn who are blabbing about how exciting this innovation is and then you always have the wave of cynics who come along and say, yeah, you know, where you go ahead and search, buy a Fitbit. You know what you find? You find ads for used ones that have been discarded on eBay. Those are stupid people who say that because somebody buys the Fitbit and they expect it to reverse their prediabetes stupid. And when I say stupid, I mean uninformed, right? It's okay for me. If somebody is uninformed and they admit it, which I do a lot. But if they are uninformed and they go around with their chest puffed out acting like they're smart, that's ignorant. Janet:                                26:36                   Well I know there's been conversations about around ADHD; that ADHD with med and no behavior modification, you're better off not taking the meds at all. So you have to understand how the medication or how the issue is impacting your body and be able to take action as well as work with the med. Dave:                                 26:57                   Well. And so now, to switch back to Erin Gilmer's perspective, because all this stuff is interrelated as everything cultural is. One of the first things I did online before the Internet was back on Compuserve. I started out being a discussion leader in desktop publishing and then I became one of the forum managers on the ADD forum back when it was called ADD. And one of the things you found there was that when the people who have the problem, and I still pitch this in speeches today for certain audiences, when the people who have the problem get the ability to express themselves and choose among options, one of the things you find is they may pursue different objectives than the therapists or being told to follow what's in the published literature, so as just one of many examples. We had one guy - and this was 1994 was when ADD was brand new - we had one guy who was a travel agent back in the days of travel agents. Did I mention that things change? And he was getting occupational therapy so he could tolerate sitting at his desk and the other patients in the community said, dude, get a job you enjoy, and he ended up becoming a UPS driver, which was a great job for our hyperactive person. Drive, drive, drive and run to the door, drive, drive, drive, run to the door at Christmas time you get bonuses for productivity. That's rethinking the issue. Anyway, my point is this really is like a seismic shift because if you shift to where you're giving the person who has the problem, permission and information and tools, what they come up with may be different than what was on offer at the hospital. That can be bad news for the hospital, but since the hospital only exists to improve health in the community, it's good for society. Janet:                                29:13                   No, that's an excellent point, Dave, and I definitely think it's one that hospitals need to hear just because you have a perspective that this, you're going to do this program, you're going to initiate this special effort or this patient initiative. It doesn't mean that the results are expected and you have to be willing to be flexible and learn from what you're doing as well as the patient learning from it. Dave:                                 29:39                   Well, and what I really hope, I don't want to sound like I'm rejecting doctors. That's the last thing. When I was sick, I did not reject doctors and go read up on herbal remedies. That might work. I went to the doctor, I still go to the doctor, but my doctor welcomes all of my doctors. Welcome me wanting to learn more and ask questions. That's the point. And now you want to know what's really ironic. So I have all these different apps. I have a wifi bathroom scale, I have my diet tracker or I'm counting fat grams, steps, and all of that stuff. My doctor can't see that data because there's big fancy hospital computer doesn't have an interface. So now we're in a world where all of a sudden I have access to a ton of data that he doesn't have. That is an inversion. Janet:                                30:40                   And so we have to figure out how to get those two things married up. Dave:                                 30:43                   Perhaps. It may be that he can do his job as well as he needs to without seeing all my data. But we were just approaching, there's a new it technology called FHIR - F H I R - which is just really maturing now after six or seven years of software development that will, for the first time, let people develop products that blend the hospital information, hospitals, plural. And my information from my devices. So there is a world coming where we can truly be partners in the same way that my tax accountant and I can both look at my Quickbooks data. Why as medicine not figured out that that's the best way. Now my tax accountant can coach me to stop doing this. See this over here? That number's too big. Why can't my doctor do that? My whole thing is helping healthcare achieve the available potential. Janet:                                31:47                   Oh, that's excellent. Announcer:                      31:49                   You've been listening to the Get Social Health podcast. The show notes are located to join our healthcare social media journey, follow @getsocialhealth on Twitter and start a conversation. Janet:                                32:04                   I hope you enjoyed today's podcast with Dave deBronkart. We're going to be talking about some of the projects he's working on and some exciting new things happening in his life in the next episode. So make sure you tune in for part two of our conversation with e-Patient Dave. Find Dave online: LinkedIn profile: Twitter: @ePatientDave.........
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