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Understanding the Role of Technology in Patient-Provider Relationships

Posted: 26 Oct, 2015   Recommendations: 9   Replies: 52

In 2013, 78% of office-based physicians in the U.S. had adopted some type of Electronic Health Record (EHR) system, and 48% had the capability to implement a basic EHR system (Furukawa, et al). With the increasing trend towards the use of technology in patient interactions, almost one in six doctor visits will be virtual this year. eVisits not only save patients and doctors’ time, but are also estimated to save the healthcare industry up to $5 billion in 2015 alone (Deloitte, 2014).

While technology can ease the burden of paperwork, time constraints, and costs; these advances inevitably change the way patients interact with their providers. As the health care industry becomes more and more reliant on technology, some worry that the patient-provider relationship will be lost altogether. Others fear that not all technological innovations are created to solve the problems at hand.

In this virtual Expert Panel, panelists will share the role technology plays in the provider-patient relationship, as well as address how this technology is reshaping communication between patients and providers:

We are pleased to welcome the following group of Expert Panelists** to discuss how technology is reshaping communication between patients and providers.

• Jonathan Gordon, MBA - Director, Office of Strategy and Director, Health Policy Center, New York Presbyterian, Lecturer, Department of Health Policy and Research, Weill Cornell Medicine
• Anita Samarth - CEO, Clinovations Government + Health, Member of the Board of Directors at Costs of Care
• Alicia Staley - CEO/Chief Patient Officer of Akari Health
• Yuri Quintana, PhD – Director for Global Health Informatics, Division of Clinical Informatics, Beth Israel Deaconess Medical Center

** The opinions expressed by our Expert Panelists are their own, and do not necessarily represent those of their affiliated organizations.

Discussion Questions:

1) How has technology changed the way care is delivered? How are technology and the on-demand economy changing patients' expectations about how they access and receive care - and how do providers need to adapt in response?
2) What incentives drive the healthcare system to use technology, such as virtual nurses, to communicate with patients? How does the lack of access to technology in certain areas impact care?
3) How can providers and start-ups address the scale, scope and culture differences that can impede their collaboration? What are some of the challenges to preserving provider-patient relationships when implementing innovative technologies?
4) What would the ideal model of providers, patients, and technology look like? For example, how can organizations leverage communication between an informed, activated patient and a prepared, proactive care team?
5) Innovation is about changes to people, processes and technology. How do providers bridge the gap between identifying a promising innovation or technology and smoothly integrating it into the operations of their organization?

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve health care delivery in underserved populations in the US.

In an effort to understand the impact of our Expert Panels, we’ve created a short (4 question) survey. Your responses are greatly appreciated—please take the survey before the discussion begins:

We look forward to a rich discussion next week – please join the conversation and share your questions or comments!



Marie Teichman Replied at 3:00 PM, 26 Oct 2015

In preparation for next week's discussion, I wanted to share some resources that might be of interest. We encourage you to share additional resources on this important topic, as well as any questions you'd like to see our panel address next week. Looking forward to a great discussion!

Attached resources:

Sandeep Saluja Replied at 8:29 PM, 26 Oct 2015

Look forward to a rich discussion.

May I put forward a small personal need and seek a solution?

I have patients scattered over a wide geographical area and they interact with me through emails while I am able to physically meet them once in a while.I receive images,reports etc through emails.However,I do feel the need for a single online platform where all data of the patient was in one place and the patients could also directly upload their images or reports as they become available.

No fees is charged from the patients and the entire exercise is part of my voluntary service to the community.

Which online platform would best serve my needs?I would prefer a platform where I do not have to pay for the use since I also do not charge the patients.

Madhuri Gandikota Replied at 2:04 AM, 27 Oct 2015

Dear Rebecca,

Thank you very much for initiating this timely discussion.
Look forward to learn what are the trends in this emerging area.

Laura Krynski Replied at 6:37 AM, 27 Oct 2015

Hi everyone! I work in Buenos Aires (Argentina) where many profesionals are
increasingly using technology such una semana EMR, apps, platforms to
communicate with patients
We do not Have a written consensus yet, and we are trying to build one. We
are pediatricians working on TICS in the SAP (sociedad argentina de
If Anyone has access to this material It could be really useful as an
example to build our own document!! Having statments and written
regulations about this is a priority issue
Thank you!!
Btw I am looking forward to participate in the next week discussion

A/Prof. Terry HANNAN Replied at 8:45 AM, 27 Oct 2015

Laura please contact Dr Danny Sands in Boston he is considered one of the gurus in this area and he can also direct you to other sites.

Laura Krynski Replied at 11:29 AM, 27 Oct 2015

Dear Terry, thank you for your prompt answer
Can you help me contacting Dr Danny Sands?

A/Prof. Terry HANNAN Replied at 6:40 PM, 27 Oct 2015

Laura, here is Danny's email. Use my name - it should elicit a +ve response :)

Damon Ramsey Replied at 11:36 AM, 30 Oct 2015

Dear Sandeep, I am a software developer turned family doctor who runs a digital health company based out of Canada.
Our platform, InputHealth, is primarily built for the Canadian market but would just as easily serve in a setting like yours. Many of the principles that went into the design of the system are based off of facilitating "eVisits" and other asynchronous interactions with health care providers for better accessibility and flexibility. This includes secure messaging between patient and physician, but also structured questionnaire based approach to tracking outcomes and other patient data.

Please reach out to me at , we could discuss how this may fit into your practice of receiving communications from patients. While we are a for-profit company, in resource-poor or volunteer settings, it would be an honor to see our platform operating without costs to the provider and for the ultimate benefit of vulnerable populations.

Best wishes

Jon Gordon Panelist Replied at 9:53 PM, 1 Nov 2015

Good evening everyone. I'm looking forward to an active discussion.

By way of introduction, I am Director of Strategy and Director of the Health Policy Center at NewYork Presbyterian (though please note that all of my participation on this panel solely represents my own opinions). Over my time at NYP, I have been fortunate to work on a range of projects, from building our Medicare Shared Savings Program ACO, to designing a genomic medicine program, to creating a strategic vision for our IT department.

I have worked at NewYork-Presbyterian (NYP) since 2010, joining just two weeks before the ACA passed. Over that time, I have watched as the provider side of healthcare shifted from thinking that reform was just a replay of the 90s to truly grappling with what it means to deliver value in healthcare.

During my time at NYP, I have also been a mentor at Blueprint Health, a healthcare technology incubator in New York City. As a result, I've seen how a changing healthcare environment has benefitted from and been challenged by a range of new entrants spurred on by a second "dot com" boom.

Healthcare has always had a love-hate relationship with technology. Technology is an essential part of the care being delivered every day - but on the other hand, ask any clinician if they like using their EHR. And now, with lots of start-up companies looking to bring in technology, there is a huge amount of entrepreneurial energy attacking some very difficult problems in healthcare, and changing how we think about delivering care (I have heard that one hospital system cut their ambulatory building size by 100,000 square feet because they projected that 10% of care would be delivered via telehealth in the years ahead). But we have to figure out how to find the right balance - of putting technology in the service of clinicians, rather than simply throwing coders at the problem. Facebook's mantra used to be "move fast and break things" - but I think you'd be hard pressed to find anyone who thinks that's how the healthcare system should behave.

What's the right balance to strike? I look forward to hearing your thoughts.


Mia Angelica Alcantara-Santiago Replied at 4:33 AM, 2 Nov 2015

Good day! Looking forward for this discussion. Such a timely one I say.

Yuri Quintana Panelist Replied at 5:06 PM, 2 Nov 2015

(opinions below are my own, and not of employer or organizations mentioned)

Dear Colleagues,

I am an academic researcher working in the area of global health informatics. Having been in this field for over 20 years, I think we are finally at a point where e-health is reaching a global emergence that will benefit millions. The technology is becoming cheaper, more widely available, and more hospitals, patients, and government are making investments. There have been some catastrophic failures in e-health, but I think we see more successes than failures in future. I recently published a review article on e-care at a distance (telemedicine and e-health networks) and outlined some of the success stories and challenges. It is freely accessible here

Here are some thoughts I have on the initial questions posed.

1) How has technology changed the way care is delivered? How are technology and the on-demand economy changing patients' expectations about how they access and receive care - and how do providers need to adapt in response?

Web and mobile technologies have created many new ways to develop telemedicine and e-health consultations. Most studies show patients and providers are comfortable with e-visits. Kaiser in California and others have reported some good results with their programs. Hospitals are slow to adopt I think mainly due to limitations of reimbursement. Regulatory restrictions for HIPAA and other compliance needs adds to the cost of implementation in the USA, and modifying systems to adapt to privacy of other countries can add to export of technology. Perhaps we need to have government coordinate the privacy laws and make them clearer and simpler for industry, providers and patients. Is there any group working on reconciling and coordinating privacy and regulatory challenges to e-health services?

2) What incentives drive the healthcare system to use technology, such as virtual nurses, to communicate with patients? How does the lack of access to technology in certain areas impact care?

Reimbursement drives the decision of many providers. I think we need governments and insurance companies to be more proactive in reimbursing e-visits and e-follow up care. Some companies are implementing e-care visits on premise at work, and I think this is another positive way to move the industry forward. I think when patients leave health care providers to other health care providers that provide more e-health services, we will probably see more adoption. Innovation thrives when there are markets with open competition and choice.

Technology is becoming more accessible to all, particularly mobile phones. We need to make sure we are designing systems that mobile first ready since people who are on limited salary are more likely to have a phone than computers. Pew Internet study recently showed some interesting stats on this. There are millions without phone or computers and we need companies to make lower costs phones that are web enabled. This will benefit many sectors of society. What company is leading on this? Google, Huawei, Xiaomi (what is your prediction of who lead in low cost smartphone)

3) How can providers and start-ups address the scale, scope and culture differences that can impede their collaboration? What are some of the challenges to preserving provider-patient relationships when implementing innovative technologies?

Culture is an interesting question. There are geographic and ethnic cultures, and then there are corporate cultures. I think the later impedes growth more, although I don't have data on this (if you do please post). Many companies have a culture of risk and fear; they overcompensate on worrying about possible breaches and compliance problems and put many roadblocks to innovations. We need more leaders willing to manage risk at reasonable levels and take on innovations. I would be interesting in hearing from the community who they think is a progressive CEO or head of government agency that promotes change versus hinders it. Who is your favorite CEO? (One of my favorites is Richard Branson)

4) What would the ideal model of providers, patients, and technology look like? For example, how can organizations leverage communication between an informed, activated patient and a prepared, proactive care team?

I think patients know what they would like to see in systems and services, but often their voices are not heard by hospitals, industry or government. There are patient advocacy organizations that do great work in promoting values and preferences of patients. How can we help those organizations be more influential? Here are some of these groups (very short list, apologies for those omissions, but I would like to see what other organizations people follow)
In Canada, the Association for People-Centered Health and Canadian Connected Health and Wellness Project
In the United States, The Society for Participatory Medicine http::// and
The United Kingdom’, the Person-centered care online resource center
In Scotland, the Person-Centered Health and Care Collaborative promotes person centered-health care.
The International Alliance of Patients’ Organizations
What other groups belong here?

5) Innovation is about changes to people, processes, and technology. How do providers bridge the gap between identifying a promising innovation or technology and smoothly integrating it into the operations of their organization?

We have seen some hospitals deploy patient portals, but most of these implementations are one-way. Patients have access to their record (or part of their record) but can not engage with their healthcare provider to ask follow-up questions or schedule e-visits. Part of the problem is reimbursement (or lack of), resistance to make investments in implementing solutions due to financial or regulatory concerns. Another major problem is that patient-reported data can overwhelm providers who already have limited by time. Who pays the physician or nurse to review more data between visits. How we validate data from external devices? How do we provide quality assurance for these new services and processes?

Despite all these challenges, I am on optimist. I think we will find solutions that reduce costs and improve patient access and quality of care. We need to do the design of systems in collaboration with patients and providers and other stakeholders. We need to evaluate the benefits and costs, and share those results more widely. I think we are moving in that direction, but transparent and proper evaluations are key.

Yuri Quintana, Ph.D.
Director, Global Health Informatics, Beth Israel Deaconess Medical Center
Assistant Professor of Medicine, Harvard Medical School

Anita Samarth Panelist Replied at 7:42 AM, 3 Nov 2015

Hi, this is Anita Samarth - I’m excited to serve on the Expert Panel this week! During the day, I’m co-founder and CEO of Clinovations Government + Health, focused on the intersection of health, technology, and policy/government. I’m also on the Board of Directors for Costs of Care. For the last 20+ years, I’ve been working with provider orgs and public sector initiatives specifically in the area of health IT and electronic health records and the impact on the patient-provider relationship in terms of measuring and improving quality, engagement, and costs. I’ll be responding to postings daily throughout the week. When preparing for this topic and reading initial posts, I thought of a number of resources that I’ll keep a log of and post as the week’s discussion concludes.

For the Monday/first topic, I’ll focus more on the change of patients’ expectations as it’s important to keep the patient at the center of our discussions, so why not start with that?! Patients are used to having information at their fingertips - and surprisingly, although patients are increasing awareness of EHRs and electronic health information, we’re just now seeing a shift in the Quantified Self movement with wearables, etc., but patients are still trying to understand what health information they can obtain from providers electronically. We’re seeing eVisits/Telehealth and the convenient care options provided by retail medicine, PCMH/increased care access models, and provider portals shifting patient expectations to what’s available in terms of online interactions with their providers.

The reality in the technology space is that we’re seeing lots of technology opportunities and barriers to patient-provider communication. We have a wide range of interactions today - where some providers are texting with their patients and reviewing health info/images online, while others do not access patient-generated health data. I’ve been seeing a shift in provider organizations and organizations implementing new care delivery models embrace and innovate in use of technology. We’re gaining progress in standardizing datasets that can be exchanged between EHRs and with patients. App developers are trying to develop solutions that consume this data to change the status quo of patient-provider interactions. It’s the most fun time to be in health technology!

Jon Gordon Panelist Replied at 8:06 AM, 3 Nov 2015


Thanks for those great thoughts. I agree with your points, and want to further highlight something that you brought up - namely, the issue of reimbursement. I've seen firsthand how reimbursement drives decision-making. Telehealth is a great example of this: Medicare telehealth reimbursement policies are incredibly restrictive (you have to be in a rural physician shortage area to qualify, and even then it is certain codes). Until reimbursement policies encourage the adoption of innovative technologies (Medicare's willingness to allow telehealth to be used to meet the requirements of the chronic care management code is a step in the right direction), technology adoption is always going to be hampered by the "but how does the reimbursement work?" question. Alternative payment models such as ACOs and bundled payments can help move in this direction, but for now, fee-for-service is dominant in most markets - even ones that talk about risk.


Hamish Fraser, MBChB, MRCP, MSc Replied at 8:54 AM, 3 Nov 2015

Thanks Yuri for the interesting and comprehensive review of these issues and the chapter on “eCare at a Distance” on ResearchGate. Is that published anywhere else?

I think you highlight well the interesting challenge with the field of “telehealth” that there are lots of increasingly effective and low cost technologies to for improving Patient Provider relationships, including patient living in low income settings. At the same time there remain big challenges in optimizing the systems to make the best use of provider/clinician time. An example is in the care of chronic diseases at home. A whole series of studies have looked at home care of heart failure patients and systematic reviews show overall benefits in outcomes and costs. The problem is that there are big variations in the measured benefits, with some of the largest randomized controlled trials being neutral. One problem that has been noted is that the interventions actually used range from email and electronic communications with patients about their weight and symptoms, all the way to implanted pressure monitors in patient’s hearts… I should note that the Whole System Demonstrator study that you mention in the UK became very controversial due to heavy political intervention to promote the results as positive before the studies were published. The consensus of the UK health informatics community is that it was a negative study showing no convincing benefits once all the data and analyses were released.

Looking at the core principles of caring for heart failure patients can be helpful – early detection of deterioration can allow small changes in treatment that prevent larger complications, hospital admissions and mortality. Each patient will have their own set of characteristics including disease type and severity, treatment regimen, home circumstances, family support, access to technology and communications and comfort with IT. It may be best to look at the sub-set of patients who have promising characteristics for using technology and accept that others are not ready for it and need more supportive care from nurses or community healthcare workers (CHWs) etc.

An example of this in low income settings might be support for patient’s drug adherence e.g. for HIV treatment. For the sake of discussion you could simplify the options into technology (text messages or mobile phone calls) and people (community healthcare workers in the home or nurses at a clinic). Initial studies in Kenya showed a benefit from text messaging (e.g. Lester et al) but later ones in Cameroon and India were negative, so it is still a work in progress. The research community is now looking very carefully at how text messages and voice calls are delivered and the precise wording and context and whether they are based in psychological theories of behavior change. Another issue with the initial studies were that they targeted populations with very low adherence rates to HIV treatment. Countries that relied on CHWs to do Directly Observed Therapy (e.g. Rwanda, Haiti) seem to have much better levels of adherence than the intervention groups that received the text messages in Kenya. There is also some evidence that having a person monitoring the text messages and following up with the patients directly can help – more of a telecare approach than just an automated reminder. It seems likely that in some situations text messaging can work well and in others you need a more human directed intervention to improve adherence and home care more generally.

Finally I am much more convinced of the role of technology in ensuring accurate testing of patients and ensuring the results get back to the clinician or patient directly (an area discussed recently on GHDonline). A series of studies have shown improvements in quality of care with lab information systems for HIV and MDR-TB (Blaya et al). A recent study by Siedner et al in Uganda showed that text messaging of HIV test results to patients along with payment towards travel costs can increase the percentage patients returning to start treatment and reduce delays: “median time to ART initiation was 47 days (IQR 11–75) versus 12 days (IQR 5–19), (P < 0.001) post intervention”.

So the tools are there to improve care with better communication but there are still challenges to getting the right mix whether in high, medium or low income settings!

Hamish Fraser

Lester, Richard T., Paul Ritvo, Edward J. Mills, Antony Kariri, Sarah Karanja, Michael H. Chung, William Jack et al. "Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial." The Lancet 376, no. 9755 (2010): 1838-1845.

Blaya JA, Shin SS, Yagui M, Contreras C, Cegielski P, Yale G, Suarez C, Asencios L, Bayona J, Kim J, Fraser HS. Reducing communication delays and improving quality of care with a tuberculosis laboratory information system in resource poor environments: a cluster randomized controlled trial.
PLOS ONE. 2014; 9(4): e90110

Siedner, Mark J., Alexander J. Lankowski, Michael Kanyesigye, Mwebesa B. Bwana, Jessica E. Haberer, and David R. Bangsberg. "A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study." BMC medicine 13, no. 1 (2015): 160.

Richard Lester Replied at 11:26 AM, 3 Nov 2015

Thanks Hamish, and all. Yes, we have great opportunity for both the power and simplicity of digital and mobile communications technology to change and improve the way health services are delivered and received, and ideally to improve health outcomes. It is important to note that the precise details of the communication strategy used in each intervention is critical - so SMS trials showing some interventions work to change health behaviours, and some haven't, is expected and useful- not contradictory (just like all medications of a class don't work the same). The most critical issues, in my mind, are that the intervention/innovation is:
1) based on solving and actual problem (or truly improving on an existing way of doing things);
2) maximally reaches the intended population;
3) provides the value that the intervention proposes directly to the users.
For example, in informative studies for mHealth, patients consistently say they'd like to use their mobile phones for access and communication with their health providers - not as medications reminders (noting that simple alarms and other memory devices have long pre-existed mobile phones and do not harness the full two way power of mobile phone communications). It is not surprising then that medication reminders consistently do not improve patient treatment adherence in clinical trials (despite many tech providers repeatedly 'hoping' or pitching that they will), and that two way communications via SMS more consistently do lead to positive adherence behavior change (see the excellent review and Forest plot diagram by Wald et al. in the link below that demonstrates almost all text messaging intervention effectiveness in the literature is from 2-way vs one-way communication). For our program, WelTel, the SMS outpatient support intervention that Hamish mentioned, this has moved forward from the WelTel Kenya1 HIV treatment support trial (Lancet 2010 referenced in the prior post) and has been additionally adopted in Canadian and US settings, but also for other disease outpatient management support in TB, and in Asthma as an example of a non-infectious chronic disease. While additional RCTs are underway, ongoing qualitative evaluation demonstrates the primary value for patients is 'feeling connected and cared for' and having communication access to their expert providers when needed. The primary value for front-line healthcare providers is a more effective and efficient way to proactively support outpatients (see paper by Murray et al link below). In attempting to scale up the evidence-based service widely, we've developed an easy-to-use and scalable software service that enable patient registration, automated SMS checkins, and a simple management interface for healthcare providers to improve their work flow. As part of a Grand Challenges Canada and Amref Kenya partnership in northern Kenya the technology service has also been developed to work in SMS mode alone (when internet bandwidth is slow or unreliable) meaning that the system can be deployed reliably in almost anywhere with even a basic cell phone network. This is critical for efforts such as reaching the UNAIDS 90 90 90 goals of supporting 20 million people with HIV for effective ART by 2020 - mostly in resource limited settings where internet connectivity would not adequately support fully online approaches.
In terms of accessing the WelTel SMS service, for either highly developed health systems or in LMIC you can go through or contact me at . I'm also interested to follow these experiences of others.

Attached resources:

Yuri Quintana Panelist Replied at 2:22 PM, 3 Nov 2015

Here is the citation to the paper I linked to earlier
Quintana Y, Safran C. eCare at a Distance: Opportunities and Challenges. Research on the use of Information and Communication Technologies in Brazilian health facilities - Health ICT 2014. Pgs 167-177. August 20, 2015.

It was part of a book published and released at MedInfo 2015 published by the Brazilian Internet Steering Committee ( It gives a good overview of current e-health in Brazil, and has a few international invited chapters.
The full book is free for download at link below


Anita Samarth Panelist Replied at 4:34 PM, 4 Nov 2015

Thanks Hamish and others for your comments. I thought I'd comment on the role of technology for access to lab results. As part of Meaningful Use, lab results are part of the dataset to release information to the patient portal from the EHR. This can be immediate upon resulting, but often, results are held for a few days to allow the provider to discuss results directly with the patient. In addition, the recently HIPAA Patient Access Rule enables patients to receive lab results (including physician ordered labs) directly from the lab upon request. This isn't necessarily electronic, but some of the larger labs have incorporated this functionality into their patient portals and apps. There can be different rules for tests where providing a result to the patient may cause harm to the patient, but it's not for all "sensitive" tests, so the patient access to results directly is improving and technology can facilitate this.

Anita Samarth Panelist Replied at 4:37 PM, 4 Nov 2015

@SandeepSaluja - there are USA-certified EHRs that include functionality for patient portals, patient-provider secure communications that could meet some of your needs. Some, such as Practice Fusion (not meant to be an endorsement) - are free - and although geared towards USA-based requirements and regulations, offer the patient-provider portal and secure messaging capabilities that may provide the functionality you're looking for. There are also a lot of apps popping up; I mention the EHRs as there are added security requirements to help assure that the information is transmitted/exchanged securely. Depending upon the country you're working in, there could be regulations and policies around storage of health information.

Sandeep Saluja Replied at 4:55 PM, 4 Nov 2015


A practical issue with Practice Fusion is their insistence on a US phone
number for registration.

Yuri Quintana Panelist Replied at 7:29 PM, 4 Nov 2015

In regards to >>How can providers and start-ups address the scale, scope and culture differences that can impede their collaboration?

I think have more accessible information via multiple channels (web, mobile) will ultimately prove to be beneficial to both patients and providers.

One way to improve provider-patient collaboration could be to provide patients access to their medical records. One of DCI Faculty Member Dr. Brad Crotty recently co-authored a paper that examined the impact of the OpenNotes project on patient safety in a paper titled "Connecting Patients and Clinicians: The Anticipated Effects of Open Notes on Patient Safety and Quality of Care". ( and and ) This project at three hospitals has provided patients the access to physician notes on their care. The preliminary results are showing positive outcomes on patient safety and quality of care as a result of having more open communication between doctors and patients.

Retrofitting a legacy web-system to mobile can be hard. Incorporating a mobile channel distribution from day one as part of any new patient communication system is key to implementing this in a timely and cost efficient way. For existing systems, deciding what to make mobile accessible should really involve discussions with patients.

We could have more patient representatives on advisory boards to healthcare providers to suggest priorities e-health strategy. But how many organizations do this?

How does your organization engage with patients to discuss priorities and strategies for e-health?


christophe millien Replied at 8:44 PM, 4 Nov 2015

technology could be a good instrument for improving health care.
using technology could decrease some visits in the clinic because patient could have access to have an appointment, to discuss with the physician about his treatment plan, about the secondary effect of the medication. that will increase the education level of the patient about the disease. creating a paper less system could be a good way to decrease paper that we use and by this way decrease use of trees to create paper and decrease the effect of deforestation. in term infrastructure you will not have to create a big archive. A virtual system could be use to save the medical record. one example of how technology is working in poor country is using a cell phone for sending an SMS to a patient to recall him about his schedule. now technology bust be central part of reflection about improving health care system around the wold because that could favor universal access quality care. creating cheaper material must be good way to favor social justice and economy in the same time in term of health care. now we can use a smarphone colposcop to screen the cancer of the cervix. A lot of stuffs are starting to be created for improving point of care services.

Madhuri Gandikota Replied at 5:30 AM, 5 Nov 2015

Great examples from Richard and Hamish, regarding the fine differenes between “One-way Vs. Two way communication” and all the thoughts and references of Yuri. As Anita has rightly pointed out this is a very exciting time. Though there is a tectonic shift in the culture of both the patient and provider, there are still concerns of social connection, security issues in many countries. Additional concerns many Apps, and how the technology is being adopted by Clinicians.
Positive examples are : Big giants such as Apple, Google are investing heavily in this area. An example is immediately after release of Parkinson’s disease research kit about 10,000 people signed up – a huge sample size !.
Wearables and Apps are changing the involvement of patient and their interactions with the care delivery team. For instance, MyFitnessPal is evaluated for $450 million with millions of followers. Most technological Apps are activity trackers and clinicians are slowly using the data from devices to understand patient behavior. Though these are taking some traction, in particular helpful in managing chronic health conditions such as Diabetes.

A/Prof. Terry HANNAN Replied at 7:12 AM, 5 Nov 2015

This discussion is an excellent example of how GHDOnline has become an effective educative tool. Hamish, Richard and Yuri verify the high quality input required for such a site and its discussion themes. This one has been very enlightening- thanks

Katie Foxall Replied at 8:09 AM, 5 Nov 2015

This may be something which people following this discussion would be interested in - the iManage Cancer initiative, a European Horizon2020 project, is planning to team serious games up with the latest in self-management technology to empower people living with cancer.

In this project (‘Empowering patients and strengthening self-management in cancer diseases’), 8 partners from 5 European countries are creating intelligent, fun new ways to let those with chronic illnesses manage their lives in a new way, all from their mobile phones. Significant improvements due to cancer research have led to more cancer patients being cured, and very many more enabled to live with their condition. The disease is now frequently managed as a chronic illness requiring long-term surveillance and, in some cases, maintenance treatment. As a chronic illness, however, there is an urgent need for patients and families to manage their own care.

The iManageCancer project will support this challenge and provide a cancer disease self-management platform designed according to the specific needs of patients and focusing on their wellbeing. The project is a recently launched European research activity to empower patients and strengthen their capability to manage their diseases through novel health apps and secure eHealth services.

Attached resource:

Judith Thermidor Replied at 9:22 AM, 6 Nov 2015

Hi everybody, thanks for sharing great opinion and your experience. It is a capital topic. my question for you is:
As technology can enable better relationship between patients? I so aggree with you, but I think relationship between clinicians and patients is decreasing by thecnology.
The patient–clinician relationship is central to the practice of medicine and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease, and recovery from it (General Medical Council 2006).
The role that technology can play in improving healthcare system represents potential benefits; even technology is slow and disparate in healthcare sector. The importance of technologies that interface with patients is at all stages of their health care experience: maintaining health, receiving care, and managing a condition. Innovation in better connection between clinicians and patients, keep contact, also electronical prescription. Nevertheless, an important patient need – and one that is often omitted in the context of technology – is that of the patient’s relationships with clinicians, patients and family.
I think technology is crucial to keep contact with patients, sharing data, better communication and sustainable evidence from information, facilitating better continuity of care but is so far to improve the relationship between clinicians and patients.

Joaquin Blaya, PhD Replied at 11:12 AM, 6 Nov 2015

That’s a really good question about how technology can improve patient-patient relationships, and you do see many online patient communities around specific diseases where patients can help and support each other.

Your comment hit on something that I’ve been mulling over the past couple of days which is IT in the relationship between patients and community health workers (CHW). There a lot of implementations of technology to help CHWs in developing countries, especially Africa, there’s even a large email group dedicated to this one topic (), but I just recently found that there are community health projects in the US as well, and a large one at New York Presbyterian, so my question is, are there experiences in the US of these tools for CHWs?

theresa cullen Replied at 11:49 AM, 6 Nov 2015

the community health aide program (CHAP) in Alaska is a wonderful and highly successful program that relies upon trained CHA to provide care in remote villages. Information is available at

in addition, the Community Health Aid Manual ( CHAM) was transitioned to an electronic format a few years ago through support from Indian Health Service as well as the Alaska tribes.

the CHAP program maintains and ensures that the manual ( including clinical pathways and guidelines) is maintained. The CHAP program has also used telemedicine for years ( as has much of the Indian Health Service) to provide care in remote parts of the US.

Timothy Simard Replied at 12:23 PM, 6 Nov 2015

Hi Everyone,
I am the founder and CEO of Anthurium Solutions, Inc. and the Anthurium Foundation based in Boston and have found this week's discussions and contributions to be informative and most inspiring.
Thank you.

Tim Simard
Anthurium Solutions, Inc.
POET: Enterprise Platform Solutions for Health Care
Clinician and Patient Consultation, Collaboration and Coordination
470 Atlantic Ave., 4th Floor
Boston, MA 02210
Mobile 781.249.0056

Anita Samarth Panelist Replied at 1:14 PM, 6 Nov 2015

I just saw this quote in in my email (credit goes to @POLITICO's Morning eHealth "Quote of the Day", and thought it was highly appropriate for this discussion: Anthem's Craig Samitt, comparing the way Medicare handles telemedicine - with its requirement that patients receive care in a health facility - to buying a book. "The old way was, we would get in a car to go to Barnes & Noble to buy a book. The new way is, we have to get in a car to go to an approved facility to go online, as opposed to going direct. This makes no sense." Thoughts and reactions in the context of this week's discussions?

Anita Samarth Panelist Replied at 1:18 PM, 6 Nov 2015

Responding to some of the comments on Community Health Workers (CHWs) - quite a bit of the CMS CMMI (Innovation) awardees involved use of CHWs. Round 1 Project Profiles:, Round 2 Project Profiles:

Jon Gordon Panelist Replied at 1:42 PM, 6 Nov 2015

There have been a number of interesting points made by participants that get to a bigger question about the relationship between people and technology - particularly in the context of healthcare. I think they point to an expectation gap for technology - between what patients and clinicians expect of the technology and what the companies producing it - especially start-ups - think it will do. So many companies speak about how what they are building will change the world. And perhaps someone like Apple, Amazon or Uber can claim to be driving that sort of a tectonic shift. In healthcare, however, care is fundamentally based on human relationships - so technology can be a tool to augment those relationships, but we're a long way away from it supplanting those relationships.

Consequently, I think everyone's expectations for technology need to be managed appropriately. This speaks to the need that I've heard in a lot of conversations around technology in my role at a provider - unless you adapt the technology to the provider's workflow, it won't be adopted successfully. Sure, it might not the most efficient workflow, but we need to recognize that perfect shouldn't be the enemy of good. And this, I think, speaks to the question that Marie posed for today:

Innovation is about changes to people, processes and technology. How do providers bridge the gap between identifying a promising innovation or technology and smoothly integrating it into the operations of their organization?

Change is often difficult in healthcare. So practically if you want to achieve change, you have to identify and anticipate the points of resistance - and then, rather than trying to beat them down, listening to and addressing their concerns. This argues for an incremental approach, rather than a disruptive one. It means working with stakeholders - work that can be slow and difficult - to get them on board.

The other option is to change the culture of the organization to one that is more open to innovation. That is no small feat - and is one that is fraught with risk of failure. For organizations that are more open to risk-taking (not typical in healthcare), this is a viable option. But you also need to align economic incentives to support the transformation you want to achieve.

Jon Gordon Panelist Replied at 1:46 PM, 6 Nov 2015

@Anita - the Medicare telehealth restrictions are quite draconian (originating site restrictions also manifest themselves in a lot of state parity laws - look at NY for example), but I think they are in large part driven by concerns over utilization. There's a fear that easier access to care will simply drive up usage, rather than actually improve patient care. And experience suggests that there is something to be said for that in a FFS environment. So how do we make sure beneficiaries get the right care at the right time? Alternative payment models will help.

Eric Aghan Replied at 2:03 PM, 6 Nov 2015

Dear Team,

Good question, I find educating my patient very easy when I have good literature that is friendly for both the patient and I to understand. I use up to date patient information regularly. I also try medscape but overall my patient feel more satisfied and appreciated that am not just using my gut feeling but what is known and right this has helped shape a culture of trust and confidence that to me is precious. Most often in low limited resource we tend to think our patients are not interested with what they are suffering from but on contrary.

In my view technology used appropriately can build good clinician-patient relationship.

Om G Replied at 2:15 PM, 6 Nov 2015

The only 'real' solution, again, is single payer.

When health is a right, preventative care can become a cultural norm,
reducing overall costs.

Richard Lester Replied at 2:37 PM, 6 Nov 2015

First - I agree with Terry the GHDOnline has been an invaluable resource for global discussion on this topic and others.
Regarding technology in the patient-provider relationship - there are two key ways I see patients use/value the digital technology for their health management:
1. Find and access information directly (e.g. go online on the web to search their illness, or perhaps receive targeted health information via email or text)
2. Interact with their health providers (communication)
3. (actually, Eric pointed this valuable 3rd above), which is patient knowledge that their providers are using up-to-date digital information can boost their own trust in their provider and thus strengthen the relationship via that trust).
Regarding the comment of whether digital technology facilitates (enhances) or interferes with (gets in the way of) the patient-provider relationship (point 2 above) - I think that depends very much on how the technology is used and the approach it comes from. For instance, a technology such as an App that attempts to replace/supplant the patient-provider communication may attempt to provide valuable information (as in point 1) but risks being perceived as detracting from their valued interaction with the healthcare provider. I think it is worth asking for each intervention:
Does this try to replace (provide an alternate to) or facilitate the provider-patient interaction? If it replaces it - how will patients perceive that value shift?
I don't think any patient would rather have a computer or machine make the final decision to diagnose or triage their problem at this day in age... so its a value question worth asking.

Yuri Quintana Panelist Replied at 5:34 PM, 6 Nov 2015

In regards to today's question >>Innovation is about changes to people, processes, and technology. How do providers bridge the gap between identifying a promising innovation or technology and smoothly integrating it into the operations of their organization?

Integration is key to having pilot programs become part of routine care and be sustained. I think this is a problem for start-ups since doing negotiations with healthcare systems to scale up takes months if not years, and most start-ups don't have the time and funds to sustain that period. I think healthcare organizations need to speed up the process for integrating innovations into routine care. I would like to hear from GHDonlne members that were part of a start-up that could share their experience on negotiating with health care systems the integration of their technologies into the enterprise of a health system.

Some hospitals have innovation centers to either create innovations and/or help integrate external innovations into the hospital.
Here is recent news article on this topic
It is not clear if such centers are succeeding. Sometimes these centers become viewed as external programs to main hospital, and other staff become less receptive to that group.
Has anyone been part of such a group? What was your experience?

Nolan Bushnell, a serial entrepreneur and the first person to hire Steve Jobs , wrote an interesting book on innovation
Finding the Next Steve Jobs: How to Find, Keep, and Nurture Talent
In one of the chapters he talks about innovation centers in organizations, and says they need to be far enough from the organization so they can innovate new ideas, but close enough to stay relevant and influential.
Doing this in health care space seems very difficult. What are your thoughts on this?


Yuri Quintana, Ph.D.
Director, Global Health Informatics, Division of Clinical Informatics, BIDMC
Assistant Professor of Medicine, Harvard Medical School

Anita Samarth Panelist Replied at 6:40 PM, 6 Nov 2015

The integration of startup solutions and tools is changing within health systems. Historically, IT depts and CIOs were "safest" when relying upon "tried and true" COTS solutions. Health systems are recognizing the need to be more innovative and have the ability to implement solutions (including mobile/technology solutions) outside of the pre-set IT budget and roadmaps. Thus the trend in "Innovation Centers" within health systems. These "Innovation Centers" provide the opportunity for in-house quick solutions/development and introduction of start ups with a proof-of-concept approach. It's a longer path for startup products to be incorporated into mainstream, but it's understandable that the health system wants to vet the solution (and its sustainability) prior to adopting it.

Anita Samarth Panelist Replied at 6:47 PM, 6 Nov 2015

One more question for the group as we bring this week's discussion to a close... It's been great to hear positive and engaged discussion on using technology to enhance the patient-provider relationship. In the real-world we see so much communication happening with providers who are texting patients and emailing patients - this is all outside the EHR/PHR/Secure Messaging workflow - such as sharing device (e.g., fitbit, glucometer, blood pressure, weights) information. How are you seeing the "information overload" for providers (EHR, phone messages/notes, voicemail, email, EHR secure message, text messages, faxed referrals) affecting the provider willingness and ability to interact with patients?

Paul Nelson Replied at 1:46 AM, 7 Nov 2015


Two years ago, I began to look at a data set from 2001 through 2006 that listed the maternal mortality ratio (MMR) of each state during this time interval. When arranged from best to worst and paired with each state's associated years of independent survival past age sixty-five, a Pearson Correlation was -0.95, i.e., the states with the highest MMR also had the shortest average survival past age 65. If we accept the hypothesis that responsively accessible healthcare for all citizens would be necessary to reduce our nations MMR, then we could promote both our nation's MMR and the years of survival after age 65 by healthcare reform focused on the development of equitably available and culturally accessible Primary Healthcare for each citizen, community by community. Presumably, there would be an improvement of all healthcare to become justly efficient and reliably effective. The two data sets of maternal mortality and survival after age 65 have also prompted my curiosity as to what may have occurred 30-40 years ago to out nation's healthcare industry. Another analysis of our nation's MMR is its steady worsening since the late 1960s. Since I began medical school in 1963, the most significant change in the fabric of a medical school has been the prominent disappearance of volunteer faculty, many of whom had been shaped by the collaborative work environment of a military hospital. These skills were thereafter shaped by the day to day connection with individual patient's, periodic crisis and their health care during a time span of many years, un-hindered by the survival demands of a large institution.

Coincident with the line of thought above, I periodically speak with my colleagues about the excess cost of our nation's healthcare, arguably more than $600 Billion annually. Its the equivalent of 6 Iraqi wars fought simultaneously for 365 days. I have also prepared an analysis proposing a means to promote efficient and effective healthcare, without a single payer system of cost control. I have sent copies of this analysis to Congressmen, OP-Ed columnists, three Healthcare reform Blogs and several Commentary authors appearing in major medical journals. Overall, I receive no feedback. In effect, I worry that the next recession will bring about the closing of several large hospital systems as a result of an inability to finance its hospital's cash-flow. By that time, the ability to achieve healthcare reform based on Altruism, Collaboration, Excellence, Transparency and Trust will be largely gone, forever. Innovation run amok.


Yuri Quintana Panelist Replied at 11:23 AM, 7 Nov 2015


Your comments are very interesting and insightful. It sparked the question of how do we measure the state of our health system, and how do make sure innovations reach everyone.
I think I found your webpage (if another site, let me know, I will take a look at it).

In regards to how we measure maternal health, I just attended the global maternal and newborn health conference in Mexico
They released the new global report on maternal and newborn health
The good news is that many countries in have made progress in improving newborn and maternal death rates. (see page 10 in link above)
Here is an interview with the report's lead author
He says, "I would say a combination of addressing social determinants ... [and] things within health - but not just evidence-based interventions ... also the way to deliver them"...

In May, there was there was the release Save the Children's 16th annual State of the World's Mothers 2015 report.
Disturbingly, USA rate for maternal mortality went up.
Below are various points of view on this. Some think it is how report deaths, others view it a problem social determinants of health and of how our health system is (dis)organized.
Has Maternal Mortality Really Doubled in the U.S.?
How the U.S. ranks in maternal and child health
The Poverty/Health Connection in US Children
Poor Treatment of Urban Mothers Earns US Poor Ranking from NGO

So despite all the research dollars, innovation centers, public and political debates, we still can get it together as a nation to improve the care for ALL newborns and mothers.

We need more people centers focused on translating innovations into solutions that can be scaled. This type of funding is difficult to get for larger implementation programs.
One group that is doing some very interesting work in Ariadne Labs, here in Boston. They are implementing and evaluating the Better Birth Checklist in India in a very large trial
I think the key to expanding innovations into sustainable programs, will be more implementation science work like this.
We need more people trained in informatics, design thinking, systems design, programs evaluation. We will need funding for training more people and evaluating our programs on a larger scale. We have a program at our division in this area for graduate medical informatics, and there are others similar around the USA, funded in part by our National Library of Medicine, and a growing number of these programs in other countries. I am hoping the future governments worldwide will prioritize these programs.


Yuri Quintana, Ph.D.
Director, Global Health Informatics, Division of Clinical Informatics, BIDMC
Assistant Professor of Medicine, Harvard Medical School

Jostas Mwebembezi Replied at 12:37 PM, 7 Nov 2015

Technology for development: Actually you will to some extent agree with me that most people die because of lack of information
Pregnant women and mothers of newborn will need information for better health.

Therefore with the existence of communication technologies, access to information should not be a problem.
Most deaths are preventable. Integrating technology in healthcare would have a positive impact on people health and awareness as well behaviour change.

We are looking for funding to reach out and bridge the patient/client information gap.

Jostas Mwebembezi
Executive Director | Rwenzori Center for Research and Advocacy (RCRA)
P.O.Box 898,Fort-Portal, Uganda, East Africa || | | Skype:Justus325
Twitter:@JostasM | Direct:+256774553595/+25670167070 | Office: +256483660417

''Fostering innovations saving lives of women and children''

Paul Nelson Replied at 4:51 PM, 7 Nov 2015


The Home page of the website is simply:

I am not much a fan of random acts of innovation having much of an collective impact, however well intended, on the paradigm paralysis gripping our nation's healthcare industry. Fundamentally, the rapidly evolving portion of our national economy on the economic mandate for the health care of Complex Healthcare Needs has systematically deprived our healthcare of the resources necessary to serve the social mandate for the health care of Basic Healthcare Needs. Fundamentally, the social and economic resources for Primary Healthcare have been critically under-capitalized since 1970. As a result, the total cost of our healthcare industry is currently no longer sustainable. It is probable that the excess 'total cost' contributes at least $200 billion to our national debt, ANNUALLY.

Herbert Simon, many years ago said that for any group of people, the PARTICIPATION HYPOTHESIS states that "...significant changes in human behavior can be brought about rapidly only if the persons who are expected to change, participate in deciding what the change shall be and how it shall be made." As a model, our nation's agricultural industry is the most efficient among the world's developed nations. IT is likely that the Congressional, Smith-Lever Act of 1914 is substantially a major contributing factor for this outcome characterizing our nation's food supply. There are substantial benefits that have been possible for the agriculture industry that could apply to the needs of our nation's healthcare industry, county by county. See:


Laura Buguñá Replied at 4:59 AM, 9 Nov 2015

In response to Yuri's message from Nov 6 on Innovation in healthcare organisations and the best balance as regards involvement and independence, I am Innovation Coordinator in a healthcare centre nearby Barcelona that includes a 450 bed hospital and 9 primary care centres, and my view is that the strict safety and quality regulations are both an obstacle and a chance for innovation units. As has been said in the forum, it requires more prototyping and adaptation to local needs and we have to be patient and not pretend to change the system too rapidly.

Marie Teichman Replied at 9:08 AM, 9 Nov 2015

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We will be working on a Discussion Brief to summarize the key points from this Expert Panel, and will share details as soon as that is available on the website.

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Madhuri Gandikota Replied at 6:19 PM, 9 Nov 2015

In regards to Yuri’s question, “I would like to hear from GHDonlne members that were part of a start-up that could share their experience on negotiating with health care systems the integration of their technologies into the enterprise of a health system”,

I share here, my experience as startup founder in Health IT.
My Value Proposition: Harness meaningful information from huge biomedical data per standards of evidence based medicine and observational research.

Our Approach: Partnered with Software giant, SAP, with few health solutions/products (though with established financial and retail products ) to develop a solution in their development accelerator.

Experience with My Marketing:
• My personal efforts compete and present at conferences- Great interest in meetings. The follow-up is mostly still waiting.
• 1:1 letters to CIO’s, and other representatives: Mostly unanswered, but some polite acknowledgements.
• Federal Project grants: Not successful. Great product has tremendous value in future. Not yet committed to proprietary software. But no clear information/commitment/interest with open source. As we are bootstrapping, even a product development with open source will require Manhours-development time. Open to do it if there is a clear customer requirement. Given our IP with SAP, we cannot completely leave DesignerData.
• SAP Marketing team: We have “Go-to-market” agreements with SAP. Clear reason for slow market movement not known. Though,
to my knowledge SAP is very keen on getting into healthsector. So it is Work in progress.

My question is how to tap into hospital innovation centers. Is “Chicken or Egg first”. Do we develop a prototype and reach hospitals, or hospitals reaches us. How can a boot strapped startup get into the hospital pilots at the first place? I found conferences had some openings, but no budget for another conference. So in summary, startup idea-development of minimum viable/buyable product-first customer is almost like a life's journey. Perhaps on online community like GHDI, can help match-make startups and hospitals. That would be a great value.

Attached resources:

Naomi Muinga Replied at 2:49 AM, 13 Nov 2015

weighing in a little late to add a resource to this discussion. Just read the article below and thought it adds to this conersation.

Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine by Lisa Rosenbaum

and a link to the comments

Attached resource:

Leonardo Leonidas Replied at 3:13 AM, 13 Nov 2015

Ten Commandments To Reduce Diagnostic Errors

1. Thou shalt First "Do No Harm."

2. Thou shalt think of serious and treatable conditions and act on them
without delay.

3. Thou shalt remember that Diagnosis is History, History, History. Then
confirm with clinical examination and more history.

4. Thou shalt request a test only if it will change your plan or help in
predicting the outcome.

5. Thou shalt question "authority" such as your senior residents,
consultants, experts, or even National guidelines.

6. Thou shalt continue the debate and questioning even though the data is

7. Thou shalt maintain a high index so suspicion for uncommon
presentations of the common.

8. Thou shalt recognize your own beliefs, biasaes, prejudices, and
thinking style.

9. Thou shalt be wary of your hunches and intuitions. It is better to use
Evidence Based Medicine.

10. Thou shalt have an iPad* or a Tablet in your palm.

Given to my son, Len, and his class of 2001 during their graduation on May,
20, 2001 at Tufts University School of Medicine in Boston.
*Palm Pilot in the original edition

Leonardo Leonidas, MD
Assistant Clinical Professor in Pediatrics (retired)
Distinguished Career Teaching Award, 2009
Tufts University School of Medicine, Boston

Outstanding Alumnus, 2010
Overseas Teacher of the Year, 2006
University of the Philippines Medical Alumni Society


JINCAI WEI Replied at 6:15 AM, 13 Nov 2015


Thank you for share


Judith Thermidor Replied at 9:55 AM, 13 Nov 2015

Naomi, thank you very much to share your link. It's so helpful

Amal Bholah Replied at 2:34 PM, 17 Dec 2015

Dear Colleagues,

Thank you for this great Expert panel on "Understanding the Role of Technology in Patient-Provider Relationships." I would invite you to read the discussion brief which highlights key points, key resources and references.

Best regards,

Attached resource:
  • Discussion Brief (external URL)

    Link leads to:

X C Replied at 12:53 PM, 26 Dec 2015

Thank you for posting the Discussion brief to the panel discussion Amal. It was quite a great an enriching time discussing the ways technology is re-defining patient provider relationships with all of you.

Isabelle Celentano Replied at 10:09 AM, 25 Jan 2016

Many thanks again to our panelists and members who participated in this Expert Panel discussion last November!

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