Unless you spent the last two years in a Himalayan monastery, you are certainly aware of the bitter healthcare battle that unfolded in Washington. Underlying the nonsense about death panels from the right and claims of impending doom from the left lies a far more legitimate conflict about how we view healthcare – as a basic human right or as a market service. Conservatives generally ascribe to the latter, viewing non-emergent healthcare as a service delivered to Americans via a free-market.
Among the problems with that view (don’t worry, this isn’t going to be a liberal rant) is that Americans are far from informed consumers of healthcare. There is an enormous asymmetry of knowledge between the producers of the service (insurance companies, physicians, hospitals, etc) and the consumers a.k.a. patients. There is no ability to comparison shop for example – not only is it difficult for patients to assess costs for something like a knee replacement, there is no way for them to know who the best surgeon, surgery center, or rehab facility is.
There is clearly an emerging movement that claims to be working to empower patients to act as informed consumers. Physician and hospital rating services are exploding, cost information is beginning to emerge on web platforms, and TripAdvisor-equivalents for patients and physicians are taking off.
iTriage is an app that brings an impressive wealth of these resources to the palm of the patients hand. Its goal, according to its website, is to “give healthcare consumers crucial information in acute care settings.” Frankly, I was quite surprised by the utility of this app. At the same time, I am very concerned about some of the implications it could have for the practice of medicine and the patient-physician relationship. And the potential conflicts of interest are important consideration as this sector grows.
Before reviewing the app itself (next post), there are a few topics I’d like to touch on. To do that, I need to highlight some of the key features of the app. First, it allows patients to locate healthcare providers by proximity, whether an internist, specialist, urgent care, or emergency department. In addition, it provides immediate access to a HealthGrades report on that provider or facility, portions of which are free. Another key feature of the app is that it embeds access to various physician and nurse advice lines, all of which provide phone consultations for a fee. Rounding out the app are symptom and disease based resources providing information on symptoms, management, and even cost of treatment (this last feature is to be added).
So, first up is the business model in play here. Healthagen generates revenue from this app a few ways. Presumably, it receives some commissions for Healthgrade reports and advice line calls. It also offers promotional opportunities to physicians, who can add color, pictures, and numerous other features to their profiles in order to recruit more patients. It is this latter point that concerns me – as an app that professes to empower patients to make informed choices regarding healthcare, this strikes me as manipulation of what is supposed to be objective information that helps patients make good choices. It does not appear that Healthagen allows physicians or other providers to pay in order to bump their profile to the top of search lists, and I hope Healthagen keeps it that way.
Second, there is the issue of self-diagnosis and delayed treatment. In difficult economic times especially, all people (including patients) will try to minimize unnecessary costs. The difference between dodging a physician visit and a shopping trip, though, can be the difference between life and death. The last thing anyone wants is a patient looking up “abdominal pain” on this app, deciding its gastritis instead of appendicitis, and becoming septic two days later. Does that mean we should ban apps that provide this kind of information? No, not even if we could. It means that as these resources proliferate, it will become incredibly important for patients and physicians to have strong, trusting relationships. Physicians need to talk to patients about appropriate use of these kinds of resources, risks/benefits, and emphasize regular follow-up care.
Finally, we have to consider whether the information being provided actually “informs” consumers. HealthGrades, as with any physician or hospital rating service, has a number of problems that need to be overcome in methodology. For example, when comparing outcomes for, say, heart attacks, few services take into account the patient population served. Its not hard to imagine then why a suburban hospital treating a healthy population would do better on MI outcomes than an inner-city hospital with high substance abuse rates. The same applies really to any metric that could be used to rate physicians in a way that is useful to patients, one that helps them delineate who is better at managing diabetes, fixing a knee, and so on. It also creates a clear incentive for physicians to manipulate their patient pools (e.g. not take on patients with multiple comorbidities). Unfortunately, the patients most in need of a supporting physician may not be able to get one.
Believe it or not, I am actually a fan of patient reviews. Opponents generally argue that one bad outcome, however unavoidable, can earn a physician a bad review. I’d counter that research has shown that physicians are more likely to be sued if they have poor relationships with their patients, even if the bad outcome was not their fault. Patients don’t like to blame physicians with whom a good relationship has been built. I suspect they would also not write a bad review. But while HealthGrades provides this service (free), in the survey I did of local physicians, the most reviews I saw for any single physician was one, clearly not enough to inform patients in any meaningful way.
All in all, I think apps like iTriage are bound to proliferate, whatever problems and ethical concerns they may bring. I think its important that as physicians, we work with the industry to find ways that we can all better inform our patients – even when it comes to our own ability. It also increases the incentive for physicians to build strong relationships with their patients. At the end of the day, a more informed patient making educating decisions about their care is to everyone’s benefit.