The Optimized Doctor

I’m happier doing patient messages these days. That’s because of a little feature that we turned on in EPIC, our electronic medical record. The change doesn’t make me any faster or smarter. It doesn’t make me any more money. It merely adds a sprinkle of meaning to the work I do, and that has made all the difference.

In contrast to the usually glamorous portrayal of physicians’ work, most of our days are mundane. On a typical clinic day I’ll get up to a dozen requests from patients asking for something. Usually it’s just a refill, but several are from patients asking for a earlier appointment, when there are none. Or asking for a stronger treatment, when there aren’t any. Most of these requests are from patients who do not have interesting diagnoses or require sophisticated treatments. They are the itchy, and they remain itchy despite my advice. After a long day of seeing patients, the long list of messages that requires action feels endless, burdensome. Optimizing extenders has made me more efficient, but the work that remains isn’t fulfilling. A subtle change in our EMR has helped, though.

What is different? Our EPIC now includes a photo of each patient. That’s it. Ostensibly, having a photo is a security feature: it allows us to positively identify a patient, thereby reducing the risk that we treat an imposter posing as that patient (a small but real problem with drug seekers).

Why might this matter for physician satisfaction? Because seeing a patient photo brings an actual person to the top of mind. This changes our emotional connection to the work: how we interpret work is all that matters when it comes to job satisfaction. This is why volunteer work is so rewarding, despite having no monetary incentive, and why highly compensated professions, like those of many Wall Street traders, can ultimately fail to be fulfilling.

Tonight, long after the sun has set, I’m still working through messages. The next one, however, is not from any patient with nummular eczema. I see it’s from Mrs. Morales (not her real name), a sweet older woman with a warm smile and rich accent. She teaches water aerobics and she spent 5 minutes describing a typical Puerto Rican dinner (lots of stews) during her last appointment with me. Seeing her smiling face in the top left corner of the chart reminds me that the work I’m doing is for someone I know, someone I care for.

Radiologists have actually studied this phenomenon. Like much of medicine, radiology can be tedious. Researchers devised a simple test to see if making radiology work more human could improve not only the experience for, but also the effectiveness of, doctors. With patients’ consent, they took photos of 300 participants before their films were sent for reading. Radiologists who saw a patient’s photo along with their radiographic studies reported feeling more empathy for their patients. They also reported reading cases with photos more meticulously than those cases without photos. But that’s not all. When the radiologists were later shown the same films but without the patient photos, the doctors were less likely to notice incidental findings in the radiographs. The authors concluded that seeing patient photos made radiologists both more effective and more empathic (ScienceDaily 2008 Dec 14).

So consider adding photos of your patients to your EMR. Then remember to take a second or two to look at them before engaging in the task to be done. You, and your patients, will be better off because of it.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter. He has no conflicts related to the topic of this column.

I’m happier doing patient messages these days. That’s because of a little feature that we turned on in EPIC, our electronic medical record. The change doesn’t make me any faster or smarter. It doesn’t make me any more money. It merely adds a sprinkle of meaning to the work I do, and that has made all the difference.

In contrast to the usually glamorous portrayal of physicians’ work, most of our days are mundane. On a typical clinic day I’ll get up to a dozen requests from patients asking for something. Usually it’s just a refill, but several are from patients asking for a earlier appointment, when there are none. Or asking for a stronger treatment, when there aren’t any. Most of these requests are from patients who do not have interesting diagnoses or require sophisticated treatments. They are the itchy, and they remain itchy despite my advice. After a long day of seeing patients, the long list of messages that requires action feels endless, burdensome. Optimizing extenders has made me more efficient, but the work that remains isn’t fulfilling. A subtle change in our EMR has helped, though.

What is different? Our EPIC now includes a photo of each patient. That’s it. Ostensibly, having a photo is a security feature: it allows us to positively identify a patient, thereby reducing the risk that we treat an imposter posing as that patient (a small but real problem with drug seekers).

Why might this matter for physician satisfaction? Because seeing a patient photo brings an actual person to the top of mind. This changes our emotional connection to the work: how we interpret work is all that matters when it comes to job satisfaction. This is why volunteer work is so rewarding, despite having no monetary incentive, and why highly compensated professions, like those of many Wall Street traders, can ultimately fail to be fulfilling.

Tonight, long after the sun has set, I’m still working through messages. The next one, however, is not from any patient with nummular eczema. I see it’s from Mrs. Morales (not her real name), a sweet older woman with a warm smile and rich accent. She teaches water aerobics and she spent 5 minutes describing a typical Puerto Rican dinner (lots of stews) during her last appointment with me. Seeing her smiling face in the top left corner of the chart reminds me that the work I’m doing is for someone I know, someone I care for.

Radiologists have actually studied this phenomenon. Like much of medicine, radiology can be tedious. Researchers devised a simple test to see if making radiology work more human could improve not only the experience for, but also the effectiveness of, doctors. With patients’ consent, they took photos of 300 participants before their films were sent for reading. Radiologists who saw a patient’s photo along with their radiographic studies reported feeling more empathy for their patients. They also reported reading cases with photos more meticulously than those cases without photos. But that’s not all. When the radiologists were later shown the same films but without the patient photos, the doctors were less likely to notice incidental findings in the radiographs. The authors concluded that seeing patient photos made radiologists both more effective and more empathic (ScienceDaily 2008 Dec 14).

So consider adding photos of your patients to your EMR. Then remember to take a second or two to look at them before engaging in the task to be done. You, and your patients, will be better off because of it.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter. He has no conflicts related to the topic of this column.

I’m happier doing patient messages these days. That’s because of a little feature that we turned on in EPIC, our electronic medical record. The change doesn’t make me any faster or smarter. It doesn’t make me any more money. It merely adds a sprinkle of meaning to the work I do, and that has made all the difference.

In contrast to the usually glamorous portrayal of physicians’ work, most of our days are mundane. On a typical clinic day I’ll get up to a dozen requests from patients asking for something. Usually it’s just a refill, but several are from patients asking for a earlier appointment, when there are none. Or asking for a stronger treatment, when there aren’t any. Most of these requests are from patients who do not have interesting diagnoses or require sophisticated treatments. They are the itchy, and they remain itchy despite my advice. After a long day of seeing patients, the long list of messages that requires action feels endless, burdensome. Optimizing extenders has made me more efficient, but the work that remains isn’t fulfilling. A subtle change in our EMR has helped, though.

What is different? Our EPIC now includes a photo of each patient. That’s it. Ostensibly, having a photo is a security feature: it allows us to positively identify a patient, thereby reducing the risk that we treat an imposter posing as that patient (a small but real problem with drug seekers).

Why might this matter for physician satisfaction? Because seeing a patient photo brings an actual person to the top of mind. This changes our emotional connection to the work: how we interpret work is all that matters when it comes to job satisfaction. This is why volunteer work is so rewarding, despite having no monetary incentive, and why highly compensated professions, like those of many Wall Street traders, can ultimately fail to be fulfilling.

Tonight, long after the sun has set, I’m still working through messages. The next one, however, is not from any patient with nummular eczema. I see it’s from Mrs. Morales (not her real name), a sweet older woman with a warm smile and rich accent. She teaches water aerobics and she spent 5 minutes describing a typical Puerto Rican dinner (lots of stews) during her last appointment with me. Seeing her smiling face in the top left corner of the chart reminds me that the work I’m doing is for someone I know, someone I care for.

Radiologists have actually studied this phenomenon. Like much of medicine, radiology can be tedious. Researchers devised a simple test to see if making radiology work more human could improve not only the experience for, but also the effectiveness of, doctors. With patients’ consent, they took photos of 300 participants before their films were sent for reading. Radiologists who saw a patient’s photo along with their radiographic studies reported feeling more empathy for their patients. They also reported reading cases with photos more meticulously than those cases without photos. But that’s not all. When the radiologists were later shown the same films but without the patient photos, the doctors were less likely to notice incidental findings in the radiographs. The authors concluded that seeing patient photos made radiologists both more effective and more empathic (ScienceDaily 2008 Dec 14).

So consider adding photos of your patients to your EMR. Then remember to take a second or two to look at them before engaging in the task to be done. You, and your patients, will be better off because of it.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter. He has no conflicts related to the topic of this column.

“Keep an eye on that one, and call me if it changes,” is as much a stock phrase for dermatologists as “Wear your sunscreen.” Yet, how do patients know if a mole changes? I’m quite sure many of my patients wouldn’t notice if I shaved my head and grew a beard, let alone notice if 1 of 30 moles on their back changed color.

Mole Mapper is an iPhone app developed by the department of dermatology at Oregon Health and Science University (OHSU) to solve this problem. The app provides a framework for patients to photo, measure, and track their moles. With clear instructions, an anatomical map, and sophisticated markers, it is a significant aid for motivated patients who want medical-grade photos suitable for tracking.

To standardize the photos, the app prompts you to include a nickel, dime, or quarter in photos with nevi of interest. The user then calibrates the app by pinching onscreen circles overlying the photo such that they correspond exactly to the circumference of the coin and to the mole. Using a coin as a standard, the app then calculates the precise size of the mole regardless of the size of the photo. For example, photos taken 2 feet and 4 feet away both give the same diameter because both photos are calibrated by the dime in each.

The app was developed by a cancer biologist, Dan Webster, Ph.D., to help his wife monitor her moles between dermatology appointments. Interestingly, it was largely developed by a single person, a sign that creating apps is nearly entering into a DIY era. This increases the possibility for useful health care tools to be developed while also increasing the already crushing crowd of apps, few of which are truly useful.

The app’s functionality would not have been possible without the inclusion of Apple’s ResearchKit and Sage Bionetworks’ Bridge Server. ResearchKit provided open-source tools to facilitate informed consent over the phone and the ability to conduct participant surveys, among other activities. Bridge Server enabled the app to encrypt and securely transfer participant data from the phone to firewalled storage. The combination of these two software frameworks is paving the way for an exciting future of integrated technology and biomedical research.

According to Dan Webster, “ResearchKit is a game-changer because it provides an open-source platform for elegant informed consent, measurement tools, and participant data protection. The ability for participants to have so few barriers to contribute to a research study is the truly transformative aspect of ResearchKit, and we have seen unprecedented numbers of research study enrollees as a result.”

But that’s not all. The app is more than just a consumer tool for tracking – ResearchKit allows OHSU researchers to gather data on nevi, track them over time, and learn characteristics associated with melanoma from user-generated outcomes. This could significantly increase our understanding of melanoma and perhaps spawn an artificially intelligent app that learns to diagnose melanoma without human assistance.

Because of the institutional review board’s requirements for their research, users must be 18 years old to participate in the study. The app gracefully walks users through the consent process and even has a knowledge check at the end to ensure that they understood the risks and benefits of participating. The consent process is so streamlined that it ought to be a model for us to consent any patient for any reason.

To be clear, the app does not make diagnoses. It only provides a framework for patients to photograph their moles and track them. It also politely prompts users to rephotograph moles every 30 days so changes can be recorded.

There are apps with similar names, so be sure you have Mole Mapper from Sage Bionetworks. I tried it out to offer my experience here. Taking photos was as simple as any photo on an iPhone. Like any selfie, however, there are azimuth limits to the human arm – you can’t get shots in remote bodily corners easily. Also, placing a coin on yourself is easier said than done, unless you want to use your bubble gum to hold it in place while you take the shot. (I asked for assistance from my wife instead.)

The photos I took were accurate when compared with the measured diameter in real life, but there are still user-dependent adjustments that could lead to large artifacts. Making the measurement circles even slightly smaller or larger around the coin or the mole can lead to more than a millimeter of margins of error. If detecting melanoma requires less than 1-mm error in mole changes, then this could limit its usefulness.

Whether or not it leads to an app that automatically diagnoses melanoma from patient mole selfies, Mole Mapper has value. Any tool that empowers patients to be actively involved in their care and to meticulously monitor their moles will surely help us in keeping them safe.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter. He has no conflicts relating to the topic of this column.

“Keep an eye on that one, and call me if it changes,” is as much a stock phrase for dermatologists as “Wear your sunscreen.” Yet, how do patients know if a mole changes? I’m quite sure many of my patients wouldn’t notice if I shaved my head and grew a beard, let alone notice if 1 of 30 moles on their back changed color.

Mole Mapper is an iPhone app developed by the department of dermatology at Oregon Health and Science University (OHSU) to solve this problem. The app provides a framework for patients to photo, measure, and track their moles. With clear instructions, an anatomical map, and sophisticated markers, it is a significant aid for motivated patients who want medical-grade photos suitable for tracking.

To standardize the photos, the app prompts you to include a nickel, dime, or quarter in photos with nevi of interest. The user then calibrates the app by pinching onscreen circles overlying the photo such that they correspond exactly to the circumference of the coin and to the mole. Using a coin as a standard, the app then calculates the precise size of the mole regardless of the size of the photo. For example, photos taken 2 feet and 4 feet away both give the same diameter because both photos are calibrated by the dime in each.

The app was developed by a cancer biologist, Dan Webster, Ph.D., to help his wife monitor her moles between dermatology appointments. Interestingly, it was largely developed by a single person, a sign that creating apps is nearly entering into a DIY era. This increases the possibility for useful health care tools to be developed while also increasing the already crushing crowd of apps, few of which are truly useful.

The app’s functionality would not have been possible without the inclusion of Apple’s ResearchKit and Sage Bionetworks’ Bridge Server. ResearchKit provided open-source tools to facilitate informed consent over the phone and the ability to conduct participant surveys, among other activities. Bridge Server enabled the app to encrypt and securely transfer participant data from the phone to firewalled storage. The combination of these two software frameworks is paving the way for an exciting future of integrated technology and biomedical research.

According to Dan Webster, “ResearchKit is a game-changer because it provides an open-source platform for elegant informed consent, measurement tools, and participant data protection. The ability for participants to have so few barriers to contribute to a research study is the truly transformative aspect of ResearchKit, and we have seen unprecedented numbers of research study enrollees as a result.”

But that’s not all. The app is more than just a consumer tool for tracking – ResearchKit allows OHSU researchers to gather data on nevi, track them over time, and learn characteristics associated with melanoma from user-generated outcomes. This could significantly increase our understanding of melanoma and perhaps spawn an artificially intelligent app that learns to diagnose melanoma without human assistance.

Because of the institutional review board’s requirements for their research, users must be 18 years old to participate in the study. The app gracefully walks users through the consent process and even has a knowledge check at the end to ensure that they understood the risks and benefits of participating. The consent process is so streamlined that it ought to be a model for us to consent any patient for any reason.

To be clear, the app does not make diagnoses. It only provides a framework for patients to photograph their moles and track them. It also politely prompts users to rephotograph moles every 30 days so changes can be recorded.

There are apps with similar names, so be sure you have Mole Mapper from Sage Bionetworks. I tried it out to offer my experience here. Taking photos was as simple as any photo on an iPhone. Like any selfie, however, there are azimuth limits to the human arm – you can’t get shots in remote bodily corners easily. Also, placing a coin on yourself is easier said than done, unless you want to use your bubble gum to hold it in place while you take the shot. (I asked for assistance from my wife instead.)

The photos I took were accurate when compared with the measured diameter in real life, but there are still user-dependent adjustments that could lead to large artifacts. Making the measurement circles even slightly smaller or larger around the coin or the mole can lead to more than a millimeter of margins of error. If detecting melanoma requires less than 1-mm error in mole changes, then this could limit its usefulness.

Whether or not it leads to an app that automatically diagnoses melanoma from patient mole selfies, Mole Mapper has value. Any tool that empowers patients to be actively involved in their care and to meticulously monitor their moles will surely help us in keeping them safe.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter. He has no conflicts relating to the topic of this column.

“Keep an eye on that one, and call me if it changes,” is as much a stock phrase for dermatologists as “Wear your sunscreen.” Yet, how do patients know if a mole changes? I’m quite sure many of my patients wouldn’t notice if I shaved my head and grew a beard, let alone notice if 1 of 30 moles on their back changed color.

Mole Mapper is an iPhone app developed by the department of dermatology at Oregon Health and Science University (OHSU) to solve this problem. The app provides a framework for patients to photo, measure, and track their moles. With clear instructions, an anatomical map, and sophisticated markers, it is a significant aid for motivated patients who want medical-grade photos suitable for tracking.

To standardize the photos, the app prompts you to include a nickel, dime, or quarter in photos with nevi of interest. The user then calibrates the app by pinching onscreen circles overlying the photo such that they correspond exactly to the circumference of the coin and to the mole. Using a coin as a standard, the app then calculates the precise size of the mole regardless of the size of the photo. For example, photos taken 2 feet and 4 feet away both give the same diameter because both photos are calibrated by the dime in each.

The app was developed by a cancer biologist, Dan Webster, Ph.D., to help his wife monitor her moles between dermatology appointments. Interestingly, it was largely developed by a single person, a sign that creating apps is nearly entering into a DIY era. This increases the possibility for useful health care tools to be developed while also increasing the already crushing crowd of apps, few of which are truly useful.

The app’s functionality would not have been possible without the inclusion of Apple’s ResearchKit and Sage Bionetworks’ Bridge Server. ResearchKit provided open-source tools to facilitate informed consent over the phone and the ability to conduct participant surveys, among other activities. Bridge Server enabled the app to encrypt and securely transfer participant data from the phone to firewalled storage. The combination of these two software frameworks is paving the way for an exciting future of integrated technology and biomedical research.

According to Dan Webster, “ResearchKit is a game-changer because it provides an open-source platform for elegant informed consent, measurement tools, and participant data protection. The ability for participants to have so few barriers to contribute to a research study is the truly transformative aspect of ResearchKit, and we have seen unprecedented numbers of research study enrollees as a result.”

But that’s not all. The app is more than just a consumer tool for tracking – ResearchKit allows OHSU researchers to gather data on nevi, track them over time, and learn characteristics associated with melanoma from user-generated outcomes. This could significantly increase our understanding of melanoma and perhaps spawn an artificially intelligent app that learns to diagnose melanoma without human assistance.

Because of the institutional review board’s requirements for their research, users must be 18 years old to participate in the study. The app gracefully walks users through the consent process and even has a knowledge check at the end to ensure that they understood the risks and benefits of participating. The consent process is so streamlined that it ought to be a model for us to consent any patient for any reason.

To be clear, the app does not make diagnoses. It only provides a framework for patients to photograph their moles and track them. It also politely prompts users to rephotograph moles every 30 days so changes can be recorded.

There are apps with similar names, so be sure you have Mole Mapper from Sage Bionetworks. I tried it out to offer my experience here. Taking photos was as simple as any photo on an iPhone. Like any selfie, however, there are azimuth limits to the human arm – you can’t get shots in remote bodily corners easily. Also, placing a coin on yourself is easier said than done, unless you want to use your bubble gum to hold it in place while you take the shot. (I asked for assistance from my wife instead.)

The photos I took were accurate when compared with the measured diameter in real life, but there are still user-dependent adjustments that could lead to large artifacts. Making the measurement circles even slightly smaller or larger around the coin or the mole can lead to more than a millimeter of margins of error. If detecting melanoma requires less than 1-mm error in mole changes, then this could limit its usefulness.

Whether or not it leads to an app that automatically diagnoses melanoma from patient mole selfies, Mole Mapper has value. Any tool that empowers patients to be actively involved in their care and to meticulously monitor their moles will surely help us in keeping them safe.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter. He has no conflicts relating to the topic of this column.

FaceTime with my mother would be better described as ForeheadTime. She loves to use video for our Sunday calls, yet when she does, she always talks into her iPhone as if it’s a speakerphone. As a result, all I see is the top of her head. “Mom. Lower the phone. Mom, I can’t see you,” I must repeat weekly.

Video provides a richer experience compared with telephone. It allows for a deeper, emotional connection. That’s why moms like mine prefer it to telephone conversations. In medicine, video visits are uncommon, but that’s changing as payers are now reimbursing and patients are demanding the service. For many, they offer a far more convenient and still effective method to receive medical care. Psychiatry is an obvious example. Less obvious, but still effective examples, include endocrinology, pediatrics, primary care, surgery (post operatively), and dermatology.

Like the example with my mom, quality of the experience matters, and issues often arise not from the technology, but from the technique. Making eye contact is more difficult on video, and not looking patients in the eye can harm doctor-patient bonding. Here are a few basic tips when using video with your patients:

• Be sure the light source is in front of you. Having windows behind you often puts you in shadow.

• The best place for the camera is at the top of your screen. It’s nearly impossible to look into the camera and see the patient if the camera is next to the screen instead of above.

• Remember, to look directly at the patient, you have to look into the camera. This is tricky and easy to forget.

• Be sure your entire head and upper torso are in the frame. Talking heads can be intimidating.

• When possible, use a headset with a microphone. Headsets help both you and your patient hear better and give the patient an increased sense of privacy.

• Generally speaking, video visits take as long or longer than in-person visits. Remember to be patient as some of your patients may experience technical difficulties. Our IT colleagues have a word for it: “picnic,” which stands for “Problem In Chair Not In Computer.” You should also train your staff to aid you and the patients. For instance, if a patient is struggling with the computer, you might have your assistant help him or her while you move on to the next patient.

• Although the patient can be home, it is best for you to be in your office. It’s possible to do video consults from home, but it is more difficult because you have to ensure that both your technology and your environment are secure and private. Otherwise, you risk violating HIPAA or other compliance requirements.

• Be sure to get the appropriate consent before conducting a virtual visit. In California, it requires only verbal consent, but your state’s requirements might be different.

• As for your appearance, there’s a reason why Kennedy won the Kennedy-Nixon debates. Video does reveal details that you might not want emphasized. A two-day beard might appear hip in person but unkempt and uncaring online. Bold stripes or checks on your shirt sometimes appear distorted, so opt for solids in soft shades. Scrubs are okay, but be sure to check your neckline, particularly as you move about. Whether it’s clothing or accessories, avoid anything overly distracting.

Video visits have had a long, slow ramp-up, but they seem to be gaining momentum. You may not use them in your practice now, but it’s likely we all will someday. Soon.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter.

FaceTime with my mother would be better described as ForeheadTime. She loves to use video for our Sunday calls, yet when she does, she always talks into her iPhone as if it’s a speakerphone. As a result, all I see is the top of her head. “Mom. Lower the phone. Mom, I can’t see you,” I must repeat weekly.

Video provides a richer experience compared with telephone. It allows for a deeper, emotional connection. That’s why moms like mine prefer it to telephone conversations. In medicine, video visits are uncommon, but that’s changing as payers are now reimbursing and patients are demanding the service. For many, they offer a far more convenient and still effective method to receive medical care. Psychiatry is an obvious example. Less obvious, but still effective examples, include endocrinology, pediatrics, primary care, surgery (post operatively), and dermatology.

Like the example with my mom, quality of the experience matters, and issues often arise not from the technology, but from the technique. Making eye contact is more difficult on video, and not looking patients in the eye can harm doctor-patient bonding. Here are a few basic tips when using video with your patients:

• Be sure the light source is in front of you. Having windows behind you often puts you in shadow.

• The best place for the camera is at the top of your screen. It’s nearly impossible to look into the camera and see the patient if the camera is next to the screen instead of above.

• Remember, to look directly at the patient, you have to look into the camera. This is tricky and easy to forget.

• Be sure your entire head and upper torso are in the frame. Talking heads can be intimidating.

• When possible, use a headset with a microphone. Headsets help both you and your patient hear better and give the patient an increased sense of privacy.

• Generally speaking, video visits take as long or longer than in-person visits. Remember to be patient as some of your patients may experience technical difficulties. Our IT colleagues have a word for it: “picnic,” which stands for “Problem In Chair Not In Computer.” You should also train your staff to aid you and the patients. For instance, if a patient is struggling with the computer, you might have your assistant help him or her while you move on to the next patient.

• Although the patient can be home, it is best for you to be in your office. It’s possible to do video consults from home, but it is more difficult because you have to ensure that both your technology and your environment are secure and private. Otherwise, you risk violating HIPAA or other compliance requirements.

• Be sure to get the appropriate consent before conducting a virtual visit. In California, it requires only verbal consent, but your state’s requirements might be different.

• As for your appearance, there’s a reason why Kennedy won the Kennedy-Nixon debates. Video does reveal details that you might not want emphasized. A two-day beard might appear hip in person but unkempt and uncaring online. Bold stripes or checks on your shirt sometimes appear distorted, so opt for solids in soft shades. Scrubs are okay, but be sure to check your neckline, particularly as you move about. Whether it’s clothing or accessories, avoid anything overly distracting.

Video visits have had a long, slow ramp-up, but they seem to be gaining momentum. You may not use them in your practice now, but it’s likely we all will someday. Soon.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter.

FaceTime with my mother would be better described as ForeheadTime. She loves to use video for our Sunday calls, yet when she does, she always talks into her iPhone as if it’s a speakerphone. As a result, all I see is the top of her head. “Mom. Lower the phone. Mom, I can’t see you,” I must repeat weekly.

Video provides a richer experience compared with telephone. It allows for a deeper, emotional connection. That’s why moms like mine prefer it to telephone conversations. In medicine, video visits are uncommon, but that’s changing as payers are now reimbursing and patients are demanding the service. For many, they offer a far more convenient and still effective method to receive medical care. Psychiatry is an obvious example. Less obvious, but still effective examples, include endocrinology, pediatrics, primary care, surgery (post operatively), and dermatology.

Like the example with my mom, quality of the experience matters, and issues often arise not from the technology, but from the technique. Making eye contact is more difficult on video, and not looking patients in the eye can harm doctor-patient bonding. Here are a few basic tips when using video with your patients:

• Be sure the light source is in front of you. Having windows behind you often puts you in shadow.

• The best place for the camera is at the top of your screen. It’s nearly impossible to look into the camera and see the patient if the camera is next to the screen instead of above.

• Remember, to look directly at the patient, you have to look into the camera. This is tricky and easy to forget.

• Be sure your entire head and upper torso are in the frame. Talking heads can be intimidating.

• When possible, use a headset with a microphone. Headsets help both you and your patient hear better and give the patient an increased sense of privacy.

• Generally speaking, video visits take as long or longer than in-person visits. Remember to be patient as some of your patients may experience technical difficulties. Our IT colleagues have a word for it: “picnic,” which stands for “Problem In Chair Not In Computer.” You should also train your staff to aid you and the patients. For instance, if a patient is struggling with the computer, you might have your assistant help him or her while you move on to the next patient.

• Although the patient can be home, it is best for you to be in your office. It’s possible to do video consults from home, but it is more difficult because you have to ensure that both your technology and your environment are secure and private. Otherwise, you risk violating HIPAA or other compliance requirements.

• Be sure to get the appropriate consent before conducting a virtual visit. In California, it requires only verbal consent, but your state’s requirements might be different.

• As for your appearance, there’s a reason why Kennedy won the Kennedy-Nixon debates. Video does reveal details that you might not want emphasized. A two-day beard might appear hip in person but unkempt and uncaring online. Bold stripes or checks on your shirt sometimes appear distorted, so opt for solids in soft shades. Scrubs are okay, but be sure to check your neckline, particularly as you move about. Whether it’s clothing or accessories, avoid anything overly distracting.

Video visits have had a long, slow ramp-up, but they seem to be gaining momentum. You may not use them in your practice now, but it’s likely we all will someday. Soon.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. He is @dermdoc on Twitter.

Design thinking isn’t only for products such as the Apple watch. It is a methodology used to improve customer experiences not only with products but also with services. Much in the same way that the SOAP note shaped our thinking about diagnosis and treatment, design thinking provides a scaffold to help us better understand the needs and wants of customers, or in our case, patients.

Design thinking uses specific tools and methodologies to understand experiences from others’ perspectives. From its roots in Silicon Valley, design thinking has grown steadily in its influence. Its first high priests were people such as Steve Jobs and David Kelly, who famously designed the computer mouse. The principles learned or applied to increasingly complicated products and services led to the growth of an entire industry in Palo Alto, Calif., with companies such as IDEO and gurus such as IDEO CEO and President Tim Brown of Stanford (Calif.) University has an entire graduate school program on design thinking called d.school while Coursera offers online courses on design thinking.

The principles are simple: The better you understand your customers and their needs, the better you can design your services. There are many toolkits that are available for you to try for free. Empathy Mapping is an easy one you could apply to your practice to enhance your patients’ experience.

The idea behind this technique is to immerse yourself in your patient’s world. Pick a time when your practice is closed. Then take a journey through your office as if you were a patient. It’s important that you keep the experience as close to reality as possible. Start before you even arrive at your office. What is the experience like driving to your office? Do patients have to fight traffic to get to you? Is parking easy to find? How far must they walk from their car to get to your office? What is your check-in process like? Are patients greeted by name? Are they first handed paperwork to complete? Or are they introduced and warmly welcomed to your practice first?

What’s the experience like in the waiting room? Take note of not only what your patients see but also what they hear, smell, touch, and say. What experience does your furniture give patients? What type of magazines are available to them? Do you have Wi-Fi? Is there a television? If so, is it showing simply an advertisement, or is it something that your patients would connect with? Is there music playing?

Using the same process, continue your journey through an entire patient visit. Make note of what the experience is like walking back to your exam rooms. What do your patients see and smell while sitting in an exam room waiting for you? Does it smell of isopropyl alcohol? Is it cold or hot? What’s it like to sit in your room wearing nothing but a patient gown? Are there instruments such as cryo guns that could be intimidating to patients? All of these factors can be modified and thus “designed” to optimize the experience for your patients. Continue this journey including a physical exam and discussion with the doctor and other providers and assistants.

This is a great exercise not only for you but more importantly for your staff. Ask your staff to take notes as they walk through the same empathy mapping journey. It will give them an entirely new and valuable perspective on what it’s like to be a patient in your office. Once you’ve completed your empathy mapping, sit with your team and brainstorm about opportunities to improve the experience for your patients. Ask yourselves what things surprised you. What things do you feel could have the largest impact on your patients’ experience in your office? In what ways can you modify the spaces in your office to optimize your patients’ experience?

Having done this exercise in my own clinic, I found it highly impactful. It gave me a deeper understanding of and appreciation for my patients and caused me to make several minor but important changes in my exam room and to my and my staff’s interactions with patients. I hope you have a similarly informative experience.

If you’re interested in learning more about design thinking, then check out the following books and articles:

• “Change by Design: How Design Thinking Transforms Organization and Inspires Innovation,” by Tim Brown (New York: Harper Business, 2009).

• “The Art of Innovation,” by Tom Kelley (New York: A Currency Book, Doubleday, Random House, 2001).

• Design Thinking Comes of Age, by Jon Kolko (Harv Bus Rev. Sep 2015;pp 66-71).

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Design thinking isn’t only for products such as the Apple watch. It is a methodology used to improve customer experiences not only with products but also with services. Much in the same way that the SOAP note shaped our thinking about diagnosis and treatment, design thinking provides a scaffold to help us better understand the needs and wants of customers, or in our case, patients.

Design thinking uses specific tools and methodologies to understand experiences from others’ perspectives. From its roots in Silicon Valley, design thinking has grown steadily in its influence. Its first high priests were people such as Steve Jobs and David Kelly, who famously designed the computer mouse. The principles learned or applied to increasingly complicated products and services led to the growth of an entire industry in Palo Alto, Calif., with companies such as IDEO and gurus such as IDEO CEO and President Tim Brown of Stanford (Calif.) University has an entire graduate school program on design thinking called d.school while Coursera offers online courses on design thinking.

The principles are simple: The better you understand your customers and their needs, the better you can design your services. There are many toolkits that are available for you to try for free. Empathy Mapping is an easy one you could apply to your practice to enhance your patients’ experience.

The idea behind this technique is to immerse yourself in your patient’s world. Pick a time when your practice is closed. Then take a journey through your office as if you were a patient. It’s important that you keep the experience as close to reality as possible. Start before you even arrive at your office. What is the experience like driving to your office? Do patients have to fight traffic to get to you? Is parking easy to find? How far must they walk from their car to get to your office? What is your check-in process like? Are patients greeted by name? Are they first handed paperwork to complete? Or are they introduced and warmly welcomed to your practice first?

What’s the experience like in the waiting room? Take note of not only what your patients see but also what they hear, smell, touch, and say. What experience does your furniture give patients? What type of magazines are available to them? Do you have Wi-Fi? Is there a television? If so, is it showing simply an advertisement, or is it something that your patients would connect with? Is there music playing?

Using the same process, continue your journey through an entire patient visit. Make note of what the experience is like walking back to your exam rooms. What do your patients see and smell while sitting in an exam room waiting for you? Does it smell of isopropyl alcohol? Is it cold or hot? What’s it like to sit in your room wearing nothing but a patient gown? Are there instruments such as cryo guns that could be intimidating to patients? All of these factors can be modified and thus “designed” to optimize the experience for your patients. Continue this journey including a physical exam and discussion with the doctor and other providers and assistants.

This is a great exercise not only for you but more importantly for your staff. Ask your staff to take notes as they walk through the same empathy mapping journey. It will give them an entirely new and valuable perspective on what it’s like to be a patient in your office. Once you’ve completed your empathy mapping, sit with your team and brainstorm about opportunities to improve the experience for your patients. Ask yourselves what things surprised you. What things do you feel could have the largest impact on your patients’ experience in your office? In what ways can you modify the spaces in your office to optimize your patients’ experience?

Having done this exercise in my own clinic, I found it highly impactful. It gave me a deeper understanding of and appreciation for my patients and caused me to make several minor but important changes in my exam room and to my and my staff’s interactions with patients. I hope you have a similarly informative experience.

If you’re interested in learning more about design thinking, then check out the following books and articles:

• “Change by Design: How Design Thinking Transforms Organization and Inspires Innovation,” by Tim Brown (New York: Harper Business, 2009).

• “The Art of Innovation,” by Tom Kelley (New York: A Currency Book, Doubleday, Random House, 2001).

• Design Thinking Comes of Age, by Jon Kolko (Harv Bus Rev. Sep 2015;pp 66-71).

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Design thinking isn’t only for products such as the Apple watch. It is a methodology used to improve customer experiences not only with products but also with services. Much in the same way that the SOAP note shaped our thinking about diagnosis and treatment, design thinking provides a scaffold to help us better understand the needs and wants of customers, or in our case, patients.

Design thinking uses specific tools and methodologies to understand experiences from others’ perspectives. From its roots in Silicon Valley, design thinking has grown steadily in its influence. Its first high priests were people such as Steve Jobs and David Kelly, who famously designed the computer mouse. The principles learned or applied to increasingly complicated products and services led to the growth of an entire industry in Palo Alto, Calif., with companies such as IDEO and gurus such as IDEO CEO and President Tim Brown of Stanford (Calif.) University has an entire graduate school program on design thinking called d.school while Coursera offers online courses on design thinking.

The principles are simple: The better you understand your customers and their needs, the better you can design your services. There are many toolkits that are available for you to try for free. Empathy Mapping is an easy one you could apply to your practice to enhance your patients’ experience.

The idea behind this technique is to immerse yourself in your patient’s world. Pick a time when your practice is closed. Then take a journey through your office as if you were a patient. It’s important that you keep the experience as close to reality as possible. Start before you even arrive at your office. What is the experience like driving to your office? Do patients have to fight traffic to get to you? Is parking easy to find? How far must they walk from their car to get to your office? What is your check-in process like? Are patients greeted by name? Are they first handed paperwork to complete? Or are they introduced and warmly welcomed to your practice first?

What’s the experience like in the waiting room? Take note of not only what your patients see but also what they hear, smell, touch, and say. What experience does your furniture give patients? What type of magazines are available to them? Do you have Wi-Fi? Is there a television? If so, is it showing simply an advertisement, or is it something that your patients would connect with? Is there music playing?

Using the same process, continue your journey through an entire patient visit. Make note of what the experience is like walking back to your exam rooms. What do your patients see and smell while sitting in an exam room waiting for you? Does it smell of isopropyl alcohol? Is it cold or hot? What’s it like to sit in your room wearing nothing but a patient gown? Are there instruments such as cryo guns that could be intimidating to patients? All of these factors can be modified and thus “designed” to optimize the experience for your patients. Continue this journey including a physical exam and discussion with the doctor and other providers and assistants.

This is a great exercise not only for you but more importantly for your staff. Ask your staff to take notes as they walk through the same empathy mapping journey. It will give them an entirely new and valuable perspective on what it’s like to be a patient in your office. Once you’ve completed your empathy mapping, sit with your team and brainstorm about opportunities to improve the experience for your patients. Ask yourselves what things surprised you. What things do you feel could have the largest impact on your patients’ experience in your office? In what ways can you modify the spaces in your office to optimize your patients’ experience?

Having done this exercise in my own clinic, I found it highly impactful. It gave me a deeper understanding of and appreciation for my patients and caused me to make several minor but important changes in my exam room and to my and my staff’s interactions with patients. I hope you have a similarly informative experience.

If you’re interested in learning more about design thinking, then check out the following books and articles:

• “Change by Design: How Design Thinking Transforms Organization and Inspires Innovation,” by Tim Brown (New York: Harper Business, 2009).

• “The Art of Innovation,” by Tom Kelley (New York: A Currency Book, Doubleday, Random House, 2001).

• Design Thinking Comes of Age, by Jon Kolko (Harv Bus Rev. Sep 2015;pp 66-71).

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.

“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.

I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.

The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.

As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.

We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.

I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.

Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.

We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.

Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.

“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.

I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.

The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.

As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.

We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.

I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.

Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.

We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.

Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.

“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.

I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.

The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.

As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.

We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.

I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.

Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.

We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.

Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency has now come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their charts, including all their doctors’ notes.

Patients have always had the right to see their records. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their charts. They’d have to supply a reason and usually pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

kokouu/iStockphoto.com

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas 1 in 3 patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions. One-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including MD notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges: First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Sounds like a case of medieval pimples, but actually it’s pretty harmless. Or consider, “Differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It must also include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law were viewable by her. That would clearly be a case of bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency has now come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their charts, including all their doctors’ notes.

Patients have always had the right to see their records. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their charts. They’d have to supply a reason and usually pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

kokouu/iStockphoto.com

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas 1 in 3 patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions. One-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including MD notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges: First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Sounds like a case of medieval pimples, but actually it’s pretty harmless. Or consider, “Differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It must also include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law were viewable by her. That would clearly be a case of bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency has now come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their charts, including all their doctors’ notes.

Patients have always had the right to see their records. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their charts. They’d have to supply a reason and usually pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

kokouu/iStockphoto.com

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas 1 in 3 patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions. One-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including MD notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges: First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Sounds like a case of medieval pimples, but actually it’s pretty harmless. Or consider, “Differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It must also include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law were viewable by her. That would clearly be a case of bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency now has come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their chart including all their providers’ notes.

Patients always have had the right to see their record. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their chart. They would have to supply a reason and often pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas one in three patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions, although one-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including physician notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges. First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Not as bad as it sounds. Or consider, “differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It also must include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law was viewable by her. Clearly, bad transparency, bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency now has come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their chart including all their providers’ notes.

Patients always have had the right to see their record. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their chart. They would have to supply a reason and often pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas one in three patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions, although one-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including physician notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges. First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Not as bad as it sounds. Or consider, “differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It also must include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law was viewable by her. Clearly, bad transparency, bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency now has come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their chart including all their providers’ notes.

Patients always have had the right to see their record. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their chart. They would have to supply a reason and often pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas one in three patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions, although one-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including physician notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges. First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Not as bad as it sounds. Or consider, “differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It also must include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law was viewable by her. Clearly, bad transparency, bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

The last time I spoke with my 70-year-old mother in Rhode Island, I asked her how she made out at her latest dermatology appointment. She burst forth: “Don’t get me started! The doctor spent the whole time with his face in the computer screen. He hardly examined me!” It went downhill from there.

I feel both her pain and his. As a Gen-X physician, I’m in a unique position. I trained in the pre-EHR age with the Dr. Marcus Welby–type physicians my parents knew and admired. I have also embraced the digitization of medicine and the advances this affords. At Kaiser Permanente, I help run one of the country’s most robust telemedicine programs, and I answer dozens of patient e-mails each week. Yet I too experience the frustration of having to split my attention between my screens and my patients.

At conferences and in articles, it seems the chasm between physicians who eagerly embrace the new digital world of medicine and those who long for the way things used to be is expanding rather than shrinking. Too often, there is insufficient dialogue between these two groups. Dr. Robert Wachter hopes to change that.

Professor and associate chair of the department of medicine at the University of California, San Francisco, Dr. Wachter has authored six books, has developed the concept of the “hospitalist,” and has been a leader in patient safety. His latest book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (McGraw-Hill, 2015) has been hailed as a “must read” for physicians and other health care practitioners. I agree.

Medicine is in the midst of profound change that is as frightening as it is exciting. Dr. Wachter captures this tension through memorable patient stories and interviews. He argues that technology has made medicine both better and worse. It has enabled clinicians to improve diagnostics and health care delivery. Consider the explosive growth of “big data” in health care and of patient empowerment (e-mailing, texting, Skyping, OpenNotes). Yet, an astute observer acknowledges technology’s shortfalls. For example, what happens when information is incorrectly entered in an EHR? What are physicians to do with the massive patient data we receive?

To illustrate his theme, Dr. Wachter examines EHRs in depth. He argues that the most brilliant engineers can create the most complex computer systems, but if they’re not implemented and funded systemically, how will they be successful? Why would private practice physicians want to relinquish their “tried-and-true paper prescription and record system for an expensive and complex EHR?” And what happens when EHRs don’t talk to one another?

Despite their obvious advantages, EHRs have several drawbacks, including poor usability, time-consuming data entry (that adversely affects the doctor-patient relationship), the high cost of implementation, and decreased satisfaction among physicians with their jobs, Dr. Wachter notes. Who has the solution to these problems? Is it Silicon Valley? Or did they create the problem? (Dr. Wachter spends a great deal of time interviewing key players from that region.) Ultimately, he determines that the EHR, despite its brilliant advantages, wasn’t designed to give both physicians and patients what they really want.

The most compelling patient story that Dr. Wachter shares concerns a teenage boy who nearly died from an overdose of an antibiotic. He shows with devastating clarity how one wrong click of the keypad can lead to tragedy. No one – physicians, nurses, nor pharmacists – caught the error (the patient was administered 38.5 tablets instead of 1 tablet). Why? Dr. Wachter blames our “blind trust” in computers, which causes us to not question when something seems wrong. Moreover, multiple warnings went unheeded by nurses, who probably suffered from “alert fatigue,” desensitization to warning alarms (think of the ubiquitous car alarms sounding and how no one reacts to them), he says.

This leads to Dr. Wachter’s dive into the “complex interface between technology and people.” At what point do computers stop assisting physicians and begin replacing them? While he clearly believes that the human component of the doctor-patient relationship is irreplaceable, he does acknowledge through interviews with people such as Vinod Khosla, cofounder of Sun Microsystems, that computers will continue to “displace” much of the physician’s diagnostic and prescription work.

As Dr. Wachter seesaws through both sides of this argument, he finds himself “stick[ing] up for my teams: humans and the subset of humans called doctors.” After all, isn’t diagnostic skill at the core of an astute clinician’s arsenal? How do we relinquish it to computers?

What about technologies like OpenNotes that empower patients? How will this affect the doctor-patient relationship? What are we to do about patients who make bad choices, opt for high copays to save money up front, or choose Minute Clinics for all their health care needs? Will patients be harmed by such openness? The jury is still out.

For those who like clear black-and-white answers, Dr. Wachter’s book will seem maddeningly gray. Yet as a practicing clinician, I found it enlightening and thought provoking, and hope you will, too. I also hope it prompts you to step away from the computer, walk next door to your colleague’s office, and start a real-life conversation.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

The last time I spoke with my 70-year-old mother in Rhode Island, I asked her how she made out at her latest dermatology appointment. She burst forth: “Don’t get me started! The doctor spent the whole time with his face in the computer screen. He hardly examined me!” It went downhill from there.

I feel both her pain and his. As a Gen-X physician, I’m in a unique position. I trained in the pre-EHR age with the Dr. Marcus Welby–type physicians my parents knew and admired. I have also embraced the digitization of medicine and the advances this affords. At Kaiser Permanente, I help run one of the country’s most robust telemedicine programs, and I answer dozens of patient e-mails each week. Yet I too experience the frustration of having to split my attention between my screens and my patients.

At conferences and in articles, it seems the chasm between physicians who eagerly embrace the new digital world of medicine and those who long for the way things used to be is expanding rather than shrinking. Too often, there is insufficient dialogue between these two groups. Dr. Robert Wachter hopes to change that.

Professor and associate chair of the department of medicine at the University of California, San Francisco, Dr. Wachter has authored six books, has developed the concept of the “hospitalist,” and has been a leader in patient safety. His latest book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (McGraw-Hill, 2015) has been hailed as a “must read” for physicians and other health care practitioners. I agree.

Medicine is in the midst of profound change that is as frightening as it is exciting. Dr. Wachter captures this tension through memorable patient stories and interviews. He argues that technology has made medicine both better and worse. It has enabled clinicians to improve diagnostics and health care delivery. Consider the explosive growth of “big data” in health care and of patient empowerment (e-mailing, texting, Skyping, OpenNotes). Yet, an astute observer acknowledges technology’s shortfalls. For example, what happens when information is incorrectly entered in an EHR? What are physicians to do with the massive patient data we receive?

To illustrate his theme, Dr. Wachter examines EHRs in depth. He argues that the most brilliant engineers can create the most complex computer systems, but if they’re not implemented and funded systemically, how will they be successful? Why would private practice physicians want to relinquish their “tried-and-true paper prescription and record system for an expensive and complex EHR?” And what happens when EHRs don’t talk to one another?

Despite their obvious advantages, EHRs have several drawbacks, including poor usability, time-consuming data entry (that adversely affects the doctor-patient relationship), the high cost of implementation, and decreased satisfaction among physicians with their jobs, Dr. Wachter notes. Who has the solution to these problems? Is it Silicon Valley? Or did they create the problem? (Dr. Wachter spends a great deal of time interviewing key players from that region.) Ultimately, he determines that the EHR, despite its brilliant advantages, wasn’t designed to give both physicians and patients what they really want.

The most compelling patient story that Dr. Wachter shares concerns a teenage boy who nearly died from an overdose of an antibiotic. He shows with devastating clarity how one wrong click of the keypad can lead to tragedy. No one – physicians, nurses, nor pharmacists – caught the error (the patient was administered 38.5 tablets instead of 1 tablet). Why? Dr. Wachter blames our “blind trust” in computers, which causes us to not question when something seems wrong. Moreover, multiple warnings went unheeded by nurses, who probably suffered from “alert fatigue,” desensitization to warning alarms (think of the ubiquitous car alarms sounding and how no one reacts to them), he says.

This leads to Dr. Wachter’s dive into the “complex interface between technology and people.” At what point do computers stop assisting physicians and begin replacing them? While he clearly believes that the human component of the doctor-patient relationship is irreplaceable, he does acknowledge through interviews with people such as Vinod Khosla, cofounder of Sun Microsystems, that computers will continue to “displace” much of the physician’s diagnostic and prescription work.

As Dr. Wachter seesaws through both sides of this argument, he finds himself “stick[ing] up for my teams: humans and the subset of humans called doctors.” After all, isn’t diagnostic skill at the core of an astute clinician’s arsenal? How do we relinquish it to computers?

What about technologies like OpenNotes that empower patients? How will this affect the doctor-patient relationship? What are we to do about patients who make bad choices, opt for high copays to save money up front, or choose Minute Clinics for all their health care needs? Will patients be harmed by such openness? The jury is still out.

For those who like clear black-and-white answers, Dr. Wachter’s book will seem maddeningly gray. Yet as a practicing clinician, I found it enlightening and thought provoking, and hope you will, too. I also hope it prompts you to step away from the computer, walk next door to your colleague’s office, and start a real-life conversation.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

The last time I spoke with my 70-year-old mother in Rhode Island, I asked her how she made out at her latest dermatology appointment. She burst forth: “Don’t get me started! The doctor spent the whole time with his face in the computer screen. He hardly examined me!” It went downhill from there.

I feel both her pain and his. As a Gen-X physician, I’m in a unique position. I trained in the pre-EHR age with the Dr. Marcus Welby–type physicians my parents knew and admired. I have also embraced the digitization of medicine and the advances this affords. At Kaiser Permanente, I help run one of the country’s most robust telemedicine programs, and I answer dozens of patient e-mails each week. Yet I too experience the frustration of having to split my attention between my screens and my patients.

At conferences and in articles, it seems the chasm between physicians who eagerly embrace the new digital world of medicine and those who long for the way things used to be is expanding rather than shrinking. Too often, there is insufficient dialogue between these two groups. Dr. Robert Wachter hopes to change that.

Professor and associate chair of the department of medicine at the University of California, San Francisco, Dr. Wachter has authored six books, has developed the concept of the “hospitalist,” and has been a leader in patient safety. His latest book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (McGraw-Hill, 2015) has been hailed as a “must read” for physicians and other health care practitioners. I agree.

Medicine is in the midst of profound change that is as frightening as it is exciting. Dr. Wachter captures this tension through memorable patient stories and interviews. He argues that technology has made medicine both better and worse. It has enabled clinicians to improve diagnostics and health care delivery. Consider the explosive growth of “big data” in health care and of patient empowerment (e-mailing, texting, Skyping, OpenNotes). Yet, an astute observer acknowledges technology’s shortfalls. For example, what happens when information is incorrectly entered in an EHR? What are physicians to do with the massive patient data we receive?

To illustrate his theme, Dr. Wachter examines EHRs in depth. He argues that the most brilliant engineers can create the most complex computer systems, but if they’re not implemented and funded systemically, how will they be successful? Why would private practice physicians want to relinquish their “tried-and-true paper prescription and record system for an expensive and complex EHR?” And what happens when EHRs don’t talk to one another?

Despite their obvious advantages, EHRs have several drawbacks, including poor usability, time-consuming data entry (that adversely affects the doctor-patient relationship), the high cost of implementation, and decreased satisfaction among physicians with their jobs, Dr. Wachter notes. Who has the solution to these problems? Is it Silicon Valley? Or did they create the problem? (Dr. Wachter spends a great deal of time interviewing key players from that region.) Ultimately, he determines that the EHR, despite its brilliant advantages, wasn’t designed to give both physicians and patients what they really want.

The most compelling patient story that Dr. Wachter shares concerns a teenage boy who nearly died from an overdose of an antibiotic. He shows with devastating clarity how one wrong click of the keypad can lead to tragedy. No one – physicians, nurses, nor pharmacists – caught the error (the patient was administered 38.5 tablets instead of 1 tablet). Why? Dr. Wachter blames our “blind trust” in computers, which causes us to not question when something seems wrong. Moreover, multiple warnings went unheeded by nurses, who probably suffered from “alert fatigue,” desensitization to warning alarms (think of the ubiquitous car alarms sounding and how no one reacts to them), he says.

This leads to Dr. Wachter’s dive into the “complex interface between technology and people.” At what point do computers stop assisting physicians and begin replacing them? While he clearly believes that the human component of the doctor-patient relationship is irreplaceable, he does acknowledge through interviews with people such as Vinod Khosla, cofounder of Sun Microsystems, that computers will continue to “displace” much of the physician’s diagnostic and prescription work.

As Dr. Wachter seesaws through both sides of this argument, he finds himself “stick[ing] up for my teams: humans and the subset of humans called doctors.” After all, isn’t diagnostic skill at the core of an astute clinician’s arsenal? How do we relinquish it to computers?

What about technologies like OpenNotes that empower patients? How will this affect the doctor-patient relationship? What are we to do about patients who make bad choices, opt for high copays to save money up front, or choose Minute Clinics for all their health care needs? Will patients be harmed by such openness? The jury is still out.

For those who like clear black-and-white answers, Dr. Wachter’s book will seem maddeningly gray. Yet as a practicing clinician, I found it enlightening and thought provoking, and hope you will, too. I also hope it prompts you to step away from the computer, walk next door to your colleague’s office, and start a real-life conversation.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Why has teledermatology never taken off? Technically, we’ve been able to do it for years, yet most providers have been unwilling. This year, however, I expect we will cross the tipping point. The convergence of digital health records, expanding reimbursement, and consumerization of health care have led to a surge in demand, and now a supply of teledermatology services.

Much of this growth is from direct-to-consumer teledermatology providers. These are telehealth services marketed to patients where they access a dermatologist directly, paying out of pocket or with insurance. One such company is the aptly named Direct Dermatology.

Founded in 2009, it is an online dermatology clinic that provides 24/7 access to board-certified dermatologists. It is experiencing rapid growth and is currently looking to expand its network of dermatologists. For this month’s column, I share an interview with Dr. David Wong, cofounder of Direct Dermatology and clinical associate professor at Stanford (Calif.) University. I have no financial or other conflicts of interest to disclose.

Initially, telehealth was designed to serve rural communities with limited access to health care. Today it is used more widely. Would you share some examples of its use?

Dr. Wong: Much of the initial telehealth efforts and success have been in rural communities because telehealth solves a major problem of access to medical care in underserved areas. But it can be extremely valuable in all geographic areas, not just rural communities. Access is a problem even in urban areas, where wait time for a dermatologist appointment averages over 1 month. Telehealth has the potential to not only improve access, but also to improve quality of care and deliver care more efficiently for the patient, provider, and overall health system.

Teledermatology is being used by several employers as a benefit to their employees to provide convenient and timely access to dermatologists and decrease employee time away from work. There are several direct-to-consumer online teledermatology services that are being used by patients in all communities, especially urban communities.

The fact is that the majority of dermatology cases are seen by primary care physicians. If teledermatology can provide rapid, efficient, and reliable access to experienced dermatologists, the quality of dermatology care in the country will improve.

Please share some of the tangible benefits of teledermatology, such as triage, reducing the disparity in access to dermatologists, employer benefits, etc.

Another factor is that dermatology problems don’t occur only during business hours – we are seeing a growing number of cases submitted from our own patients over the weekend or in the evening. The ability to evaluate acutely developing skin problems within a few hours, such as rashes in children, can alleviate a lot of anxiety and avoid unnecessary emergency room costs.

Teledermatology also is beneficial to dermatologists in allowing us to provide care from anywhere on a flexible schedule. We don’t have to go into the office to “see” our patients. Both patient and provider satisfaction in our office’s teledermatology practice is very high.

Reimbursement has been a major drawback with telehealth. For example, Medicare reimburses for telemedicine services in some states, but others have restrictions. There are also more restrictions on the “store-and-forward” format than for the live, interactive format. Would you shed some light on this?

Dr. Wong: Yes, reimbursement has been a barrier to telehealth. But that is changing. A total of 22 states and the District of Columbia have passed parity laws for private insurance coverage of telemedicine, and 10 states have pending legislation. But whether telemedicine is actually covered by each health plan varies even in those 22 states. And coverage can vary depending on whether it is store-and-forward or live interactive teledermatology. Medicare still only covers store-and-forward teledermatology under a federal demonstration program in the states of Hawaii and Alaska. We believe that the ultimate driving force – delivery of high-quality and cost-effective specialty care to more patients – will continue to support the current trend in expanded telemedicine coverage.
 

What type of liability do dermatologists face when using telehealth?

Dr. Wong: The good news is that there have not been any malpractice lawsuits related to teledermatology to date. But physicians performing telehealth services should ensure that their malpractice liability insurance policy covers the exact form of telehealth that will be provided (just as it covers any other medical services that physicians provide), prior to starting to provide those services. Most medical malpractice insurance does not automatically cover telehealth services. In addition, be sure to understand state regulations about licensing, informed consent, and online prescribing.

How do patients feel about teledermatology? Do you notice any differences regarding patients’ gender and age?

Dr. Wong: I’m going to specifically speak about “store-and-forward” teledermatology, which is the predominant mode of teledermatology being used today. Store-and-forward teledermatology is an asynchronous mode where pictures of the skin problem and medical history are sent to the dermatologist. In general, patients love teledermatology. It is convenient; they don’t have to take time off from their busy schedules. They don’t have to wait for the next available appointment in my clinic. They can get answers and are placed on treatment that same day. In our practice, there is an opportunity for rapid, secure communication exchange with the dermatologist during the consultation as well. Of course, there are skeptics who wonder whether dermatologists can really make an accurate diagnosis with a picture. But once patients experience the service, they are typically very satisfied with what our dermatologists can do and with the quality of care. Anecdotally, we’re seeing a nearly equal distribution of male and female consumers seeking care through teledermatology. Individuals in their 30s comprise the largest age segment, but we see patients from all age groups, even pediatric cases sent by parents.

What do you say to physicians who are concerned that teledermatology will eventually replace in-person visits and erode the doctor-patient relationship?

Dr. Wong: Teledermatology will never completely replace in-person visits. But it will become an important component of our practices. Teledermatology can actually improve the doctor-patient relationship because it allows for increased connectivity between doctor and patient. It is important for dermatologists to define how teledermatology enhances our existing practices by improving the quality of care and actually strengthening our relationship with our patients.

What advice do you have for dermatologists who are considering implementing teledermatology in their practice?

Dr. Wong: Speak with other dermatologists who have had experience with providing teledermatology services in their practices. Learn from their best practices. In addition to adopting a new technology, think through how it incorporates into your clinic operations. And pay attention to regulatory and legal compliance in an environment where there is constant change.

What are your predictions for the future of teledermatology?

Dr. Wong: The future of teledermatology is exciting. It is now an important tool to provide even better care to our patients. The technology for high-quality photography from mobile devices has rapidly advanced, and in most cases, when done properly, the resulting images are as good as – or better than – what you can see with the unaided human eye in an exam room. Because of the way our field has thoughtfully implemented teledermatology alongside traditional dermatology, teledermatology will very soon become a standard of care. The term “teledermatology” will no longer be used because it will simply be a standard part of dermatology practice.

For more information and contacts, please visit DirectDermatology.com.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Why has teledermatology never taken off? Technically, we’ve been able to do it for years, yet most providers have been unwilling. This year, however, I expect we will cross the tipping point. The convergence of digital health records, expanding reimbursement, and consumerization of health care have led to a surge in demand, and now a supply of teledermatology services.

Much of this growth is from direct-to-consumer teledermatology providers. These are telehealth services marketed to patients where they access a dermatologist directly, paying out of pocket or with insurance. One such company is the aptly named Direct Dermatology.

Founded in 2009, it is an online dermatology clinic that provides 24/7 access to board-certified dermatologists. It is experiencing rapid growth and is currently looking to expand its network of dermatologists. For this month’s column, I share an interview with Dr. David Wong, cofounder of Direct Dermatology and clinical associate professor at Stanford (Calif.) University. I have no financial or other conflicts of interest to disclose.

Initially, telehealth was designed to serve rural communities with limited access to health care. Today it is used more widely. Would you share some examples of its use?

Dr. Wong: Much of the initial telehealth efforts and success have been in rural communities because telehealth solves a major problem of access to medical care in underserved areas. But it can be extremely valuable in all geographic areas, not just rural communities. Access is a problem even in urban areas, where wait time for a dermatologist appointment averages over 1 month. Telehealth has the potential to not only improve access, but also to improve quality of care and deliver care more efficiently for the patient, provider, and overall health system.

Teledermatology is being used by several employers as a benefit to their employees to provide convenient and timely access to dermatologists and decrease employee time away from work. There are several direct-to-consumer online teledermatology services that are being used by patients in all communities, especially urban communities.

The fact is that the majority of dermatology cases are seen by primary care physicians. If teledermatology can provide rapid, efficient, and reliable access to experienced dermatologists, the quality of dermatology care in the country will improve.

Please share some of the tangible benefits of teledermatology, such as triage, reducing the disparity in access to dermatologists, employer benefits, etc.

Another factor is that dermatology problems don’t occur only during business hours – we are seeing a growing number of cases submitted from our own patients over the weekend or in the evening. The ability to evaluate acutely developing skin problems within a few hours, such as rashes in children, can alleviate a lot of anxiety and avoid unnecessary emergency room costs.

Teledermatology also is beneficial to dermatologists in allowing us to provide care from anywhere on a flexible schedule. We don’t have to go into the office to “see” our patients. Both patient and provider satisfaction in our office’s teledermatology practice is very high.

Reimbursement has been a major drawback with telehealth. For example, Medicare reimburses for telemedicine services in some states, but others have restrictions. There are also more restrictions on the “store-and-forward” format than for the live, interactive format. Would you shed some light on this?

Dr. Wong: Yes, reimbursement has been a barrier to telehealth. But that is changing. A total of 22 states and the District of Columbia have passed parity laws for private insurance coverage of telemedicine, and 10 states have pending legislation. But whether telemedicine is actually covered by each health plan varies even in those 22 states. And coverage can vary depending on whether it is store-and-forward or live interactive teledermatology. Medicare still only covers store-and-forward teledermatology under a federal demonstration program in the states of Hawaii and Alaska. We believe that the ultimate driving force – delivery of high-quality and cost-effective specialty care to more patients – will continue to support the current trend in expanded telemedicine coverage.
 

What type of liability do dermatologists face when using telehealth?

Dr. Wong: The good news is that there have not been any malpractice lawsuits related to teledermatology to date. But physicians performing telehealth services should ensure that their malpractice liability insurance policy covers the exact form of telehealth that will be provided (just as it covers any other medical services that physicians provide), prior to starting to provide those services. Most medical malpractice insurance does not automatically cover telehealth services. In addition, be sure to understand state regulations about licensing, informed consent, and online prescribing.

How do patients feel about teledermatology? Do you notice any differences regarding patients’ gender and age?

Dr. Wong: I’m going to specifically speak about “store-and-forward” teledermatology, which is the predominant mode of teledermatology being used today. Store-and-forward teledermatology is an asynchronous mode where pictures of the skin problem and medical history are sent to the dermatologist. In general, patients love teledermatology. It is convenient; they don’t have to take time off from their busy schedules. They don’t have to wait for the next available appointment in my clinic. They can get answers and are placed on treatment that same day. In our practice, there is an opportunity for rapid, secure communication exchange with the dermatologist during the consultation as well. Of course, there are skeptics who wonder whether dermatologists can really make an accurate diagnosis with a picture. But once patients experience the service, they are typically very satisfied with what our dermatologists can do and with the quality of care. Anecdotally, we’re seeing a nearly equal distribution of male and female consumers seeking care through teledermatology. Individuals in their 30s comprise the largest age segment, but we see patients from all age groups, even pediatric cases sent by parents.

What do you say to physicians who are concerned that teledermatology will eventually replace in-person visits and erode the doctor-patient relationship?

Dr. Wong: Teledermatology will never completely replace in-person visits. But it will become an important component of our practices. Teledermatology can actually improve the doctor-patient relationship because it allows for increased connectivity between doctor and patient. It is important for dermatologists to define how teledermatology enhances our existing practices by improving the quality of care and actually strengthening our relationship with our patients.

What advice do you have for dermatologists who are considering implementing teledermatology in their practice?

Dr. Wong: Speak with other dermatologists who have had experience with providing teledermatology services in their practices. Learn from their best practices. In addition to adopting a new technology, think through how it incorporates into your clinic operations. And pay attention to regulatory and legal compliance in an environment where there is constant change.

What are your predictions for the future of teledermatology?

Dr. Wong: The future of teledermatology is exciting. It is now an important tool to provide even better care to our patients. The technology for high-quality photography from mobile devices has rapidly advanced, and in most cases, when done properly, the resulting images are as good as – or better than – what you can see with the unaided human eye in an exam room. Because of the way our field has thoughtfully implemented teledermatology alongside traditional dermatology, teledermatology will very soon become a standard of care. The term “teledermatology” will no longer be used because it will simply be a standard part of dermatology practice.

For more information and contacts, please visit DirectDermatology.com.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Why has teledermatology never taken off? Technically, we’ve been able to do it for years, yet most providers have been unwilling. This year, however, I expect we will cross the tipping point. The convergence of digital health records, expanding reimbursement, and consumerization of health care have led to a surge in demand, and now a supply of teledermatology services.

Much of this growth is from direct-to-consumer teledermatology providers. These are telehealth services marketed to patients where they access a dermatologist directly, paying out of pocket or with insurance. One such company is the aptly named Direct Dermatology.

Founded in 2009, it is an online dermatology clinic that provides 24/7 access to board-certified dermatologists. It is experiencing rapid growth and is currently looking to expand its network of dermatologists. For this month’s column, I share an interview with Dr. David Wong, cofounder of Direct Dermatology and clinical associate professor at Stanford (Calif.) University. I have no financial or other conflicts of interest to disclose.

Initially, telehealth was designed to serve rural communities with limited access to health care. Today it is used more widely. Would you share some examples of its use?

Dr. Wong: Much of the initial telehealth efforts and success have been in rural communities because telehealth solves a major problem of access to medical care in underserved areas. But it can be extremely valuable in all geographic areas, not just rural communities. Access is a problem even in urban areas, where wait time for a dermatologist appointment averages over 1 month. Telehealth has the potential to not only improve access, but also to improve quality of care and deliver care more efficiently for the patient, provider, and overall health system.

Teledermatology is being used by several employers as a benefit to their employees to provide convenient and timely access to dermatologists and decrease employee time away from work. There are several direct-to-consumer online teledermatology services that are being used by patients in all communities, especially urban communities.

The fact is that the majority of dermatology cases are seen by primary care physicians. If teledermatology can provide rapid, efficient, and reliable access to experienced dermatologists, the quality of dermatology care in the country will improve.

Please share some of the tangible benefits of teledermatology, such as triage, reducing the disparity in access to dermatologists, employer benefits, etc.

Another factor is that dermatology problems don’t occur only during business hours – we are seeing a growing number of cases submitted from our own patients over the weekend or in the evening. The ability to evaluate acutely developing skin problems within a few hours, such as rashes in children, can alleviate a lot of anxiety and avoid unnecessary emergency room costs.

Teledermatology also is beneficial to dermatologists in allowing us to provide care from anywhere on a flexible schedule. We don’t have to go into the office to “see” our patients. Both patient and provider satisfaction in our office’s teledermatology practice is very high.

Reimbursement has been a major drawback with telehealth. For example, Medicare reimburses for telemedicine services in some states, but others have restrictions. There are also more restrictions on the “store-and-forward” format than for the live, interactive format. Would you shed some light on this?

Dr. Wong: Yes, reimbursement has been a barrier to telehealth. But that is changing. A total of 22 states and the District of Columbia have passed parity laws for private insurance coverage of telemedicine, and 10 states have pending legislation. But whether telemedicine is actually covered by each health plan varies even in those 22 states. And coverage can vary depending on whether it is store-and-forward or live interactive teledermatology. Medicare still only covers store-and-forward teledermatology under a federal demonstration program in the states of Hawaii and Alaska. We believe that the ultimate driving force – delivery of high-quality and cost-effective specialty care to more patients – will continue to support the current trend in expanded telemedicine coverage.
 

What type of liability do dermatologists face when using telehealth?

Dr. Wong: The good news is that there have not been any malpractice lawsuits related to teledermatology to date. But physicians performing telehealth services should ensure that their malpractice liability insurance policy covers the exact form of telehealth that will be provided (just as it covers any other medical services that physicians provide), prior to starting to provide those services. Most medical malpractice insurance does not automatically cover telehealth services. In addition, be sure to understand state regulations about licensing, informed consent, and online prescribing.

How do patients feel about teledermatology? Do you notice any differences regarding patients’ gender and age?

Dr. Wong: I’m going to specifically speak about “store-and-forward” teledermatology, which is the predominant mode of teledermatology being used today. Store-and-forward teledermatology is an asynchronous mode where pictures of the skin problem and medical history are sent to the dermatologist. In general, patients love teledermatology. It is convenient; they don’t have to take time off from their busy schedules. They don’t have to wait for the next available appointment in my clinic. They can get answers and are placed on treatment that same day. In our practice, there is an opportunity for rapid, secure communication exchange with the dermatologist during the consultation as well. Of course, there are skeptics who wonder whether dermatologists can really make an accurate diagnosis with a picture. But once patients experience the service, they are typically very satisfied with what our dermatologists can do and with the quality of care. Anecdotally, we’re seeing a nearly equal distribution of male and female consumers seeking care through teledermatology. Individuals in their 30s comprise the largest age segment, but we see patients from all age groups, even pediatric cases sent by parents.

What do you say to physicians who are concerned that teledermatology will eventually replace in-person visits and erode the doctor-patient relationship?

Dr. Wong: Teledermatology will never completely replace in-person visits. But it will become an important component of our practices. Teledermatology can actually improve the doctor-patient relationship because it allows for increased connectivity between doctor and patient. It is important for dermatologists to define how teledermatology enhances our existing practices by improving the quality of care and actually strengthening our relationship with our patients.

What advice do you have for dermatologists who are considering implementing teledermatology in their practice?

Dr. Wong: Speak with other dermatologists who have had experience with providing teledermatology services in their practices. Learn from their best practices. In addition to adopting a new technology, think through how it incorporates into your clinic operations. And pay attention to regulatory and legal compliance in an environment where there is constant change.

What are your predictions for the future of teledermatology?

Dr. Wong: The future of teledermatology is exciting. It is now an important tool to provide even better care to our patients. The technology for high-quality photography from mobile devices has rapidly advanced, and in most cases, when done properly, the resulting images are as good as – or better than – what you can see with the unaided human eye in an exam room. Because of the way our field has thoughtfully implemented teledermatology alongside traditional dermatology, teledermatology will very soon become a standard of care. The term “teledermatology” will no longer be used because it will simply be a standard part of dermatology practice.

For more information and contacts, please visit DirectDermatology.com.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.