Epatients: The hackers of the healthcare world

January 5, 2012

I help build open source software tools that patients can use to have greater control and influence over their own healthcare (like the Direct Project and Your Doctors Advice). As as result, I’ve become quite familiar with other tools that do the same sorts of things. There is a community of patients who are deeply interested in the ways in which they can become more engaged and how they can specifically use technology to achieve this. This community calls themselves epatients. The epatient community asked me to write a short collection of resources for “becoming an epatient.”The “e” in epatient is intentionally obscure. The initial assumption is that the “e” stands for “electronic,” as it does in “email.” But in fact, the “e” stands for “engaged” or “empowered.”

Nonetheless, reference to email is intentional: The epatient community recognizes that leveraging data is a critical part of empowering a person who happens to be sick. Patients must be “electronic” to become fully “engaged.” I think of epatients as the healthcare equivalent of makers and hackers. More importantly, they are the people I have in mind when I write software.Engaged patients get better healthcare. Not just a little bit better. Much better. This is not a thesis I am prepared to defend here, except to drop a link to the Journal of Participatory Medicine, which is a good resource for those seeking a full chronicle of this engaged effect (the benefits of engagement have been documented in the healthcare literature for years).Let’s go over some simple concepts that the rest of my epatient advice and resources are based on:

  • Your doctors are probably not managing your healthcare information. You should assume it is your responsibility. Otherwise, the people involved in your treatment process will often presume that this information simply does not exist.
  • Other patients, with similar conditions to yours, can have better information about your health problem than your doctors have.
  • Like the highway system, the healthcare system is generally beneficial, but there are dangers, and you need to learn to avoid them.

And here are two things you should keep in mind:

  • Whenever I say “patient,” I actually mean “the patient/caregiver team.” Often, the patient will not have the energy to do what is necessary to be fully engaged. It is critical that when the patient cannot be an epatient, that at least the patient’s team be an epatient proxy.
  • In regard to the “better information” I mentioned above, I don’t mean that your doctor is typically wrong and another patient is typically right about your diagnosis or treatment options. While that does happen on occasion, it is not the norm. Another patient’s information is “better” because your doctor typically does not have the visceral experience of being a patient. Your doctor doesn’t understand which lotion can make all of the difference or what position might let you get some sleep after a rough procedure. There is simply no substitute for experience. Sometimes that experience can make your life a little easier, and sometimes it can help you get the right treatments that literally will save your life. (This is the gist of epatient Dave deBronkart’s story.)

The first thing an epatient needs to do is find the right epatient community. For any common illness or group of symptoms, there is a community of people who are already connecting with each other over the Internet. For people with a recent cancer diagnosis ACOR is probably the right place to start. This is one of the oldest, largest and most active epatient communities. Sometimes, the tools that a particular community of epatients choose might be a little old school — things like traditional forums, or even list-serves. Do not judge a community by its adoption of technology, judge it by its activity level.There are efforts to create technology solutions that are specifically designed to enable patient communities. For a good example, check out PatientsLikeMe, which is representative of patient communities drifting more toward “patient social media.” I am happy to say that epatient tool makers like me are coming up with cool stuff constantly.

But the mature epatient is not impressed by new and shiny. Remember, it is the relationships and insights that matter here, not the technology. Whenever possible, you want the right information delivered over the wrong technology medium, rather than the other way around.For any serious common healthcare condition, there are probably several different communities of patients online that you can meet with. For common conditions, you might also be able to find a specific meetup in your area, or at least some kind of epatient meetup. If you have a rare disease, you might have trouble finding local resources, and you might only have one or two online communities to choose from. But for rare diseases, the online patient community as a whole is typically better informed than the average primary care physician on a particular condition.

Sometimes a physician might not understand or recommend treatment options that are offered outside their local healthcare community, an issue that can be compounded when they are unfamiliar with a particular type of diagnosis. It is even more critical for rare disease patients or caregivers to find a patient community and listen to them. For rare diseases and conditions, it is critical to understand what treatment options are offered in other areas and to be fully informed regarding sham clinics that often operate in under-regulated areas.How do you know you’ve found the right community? Here’s a good rule of thumb: If you can’t get a real response to a simple health question from the community within 24 hours, you should probably move on if there are other options.

Healthy epatient communities are vibrant and alive.You should also consider joining the Society for Participatory Medicine (SPM). The mailing list for the SPM is one of the most important cross-condition meeting places for epatients.If you are interested in the technology side, also pay attention to Health 2.0 (#health20), which has a Patients 2.0 (#patients20) community that is concerned with the “electronic” part of epatient. Generally, I find that Health 2.0 is the right place to find out-of-the-box thinking on healthcare information systems, especially those offered directly to consumers. I go there to get the down-low on my competitors and to find collaborators. Matthew Holt from Health 2.0 cross pollinates the healthcare blog, which is also worth adding to your RSS reader.The cross-disease epatient community uses Twitter more than Facebook or Google+ (for the time being), and the #epatient hashtag is your friend. I also recommend following@epatientdave, @reginaholliday, and @hhask as good starter accounts. If you care about the tech aspects of epatients, then check out @NateOsit or myself (@fredtrotter).

And if you’re interested in the activist portion of the epatient community, then look at the Occupy Healthcare roster.Once your healthcare information gets past a certain basic level of complexity, it becomes important that you have a personal health record (PHR). Your doctors should, eventually, be able to update your PHR. That means you need a PHR that supports the Direct Project. Right now, that is a short list, with Microsoft’s HealthVault at the top. As a FOSS advocate, that is not an endorsement I make lightly, but Microsoft’s health IT team has been surprisingly supportive of open source (i.e. patient empowering) technologies and they have relatively mature Direct support. Indivo is pretty much the only one to consider if you want to run your own PHR (it’s open source), but its Direct support is lagging. Something you should keep in mind: If you have only one doctor at a time, you do not need to obsess about the coordination of your own healthcare information; if you have more than one doctor, you do. You can manage this information with a PHR, or a notebook, or even an infographic.

What matters is that you need to do it, and do it carefully.Some of the people in the Quantified Self movement are patients who are trying to use data about themselves to improve their health. If that interests you (if you have a chronic condition, it should), then take a look at the Quantified Self website.There are two types of patients: those who are in crisis mode and those who are in maintenance mode. If you are in crisis mode, and you feel like your whole world has been turned upside down, then I recommend you read Dr. Carolyn Oliver’s book “Cautious Care: A Guide for patients.” The newest edition of this book is also available as a series of free PDF downloads from the Cautious Patient Foundation website. Here are direct links to thehospital part and the outpatient part. Dr. Oliver’s book is like a “defensive driving crash course” for the healthcare system.

If you are going to be staying up all night at the hospital (as a caregiver or a patient), and you have no idea what you should be paying attention to, this is the book that you should be reading. (Disclosure: I work for Dr. Oliver at the Cautious Patient Foundation.)If you are in maintenance mode, you should still start with Dr. Oliver’s books, but you can also extend your reading to the classics of the epatient movement. That process should always begin with the e-patient white paper, and I also recommend the book “Laugh, Sing, and Eat Like a Pig” for ethos purposes. Go to e-patients.net and click “categories” to find the content on that blog that seems relevant to you.If you are well, consider spending some time with these resources. When you become sick you do not want to be learning how this stuff works.

You will probably ignore this advice, and that’s fine. Just try to remember that this advice is here when you need it. Also, remember that these are not instructions for how to handle your illness; they’re instructions for findingthe instructions on how to handle your illness.If you are newly sick, then what I have written here will sound overwhelming. You are tired, scared and confused (and you don’t need some arrogant geek telling you that you need to use technology to look over your doctor’s shoulder). Recognize that you will not have the capacity to bring your intellect to bear on this the way you could when you were healthy.

It is very tempting to just check out and trust that the healthcare system is going to take good care of you. But please trust me on this: That’s a bad idea. The default settings on the healthcare system really suck. Your doctors will provide you with options, but they do not have the right perspective to help you make the right choices. Patients often ask their doctors, “What would you do if you were me?” The very, very best doctors reply, “But I am not you.” What you need to find are other people who share your values, who are living with the consequences of having made the choices that you are facing. I say this with both a deep sense of pride and a great deal of humility: My spiritual predecessors (health geeks) have made sure that the Internet can provide you with connections to these people.The Internet will make it easier to connect, which is awesome. If you cannot summon the strength to do this, fine — entrust someone you love with the task of connecting for you. I truly believe that it is impossible to be an epatient alone. Moreover, I believe that it is impossible not to be an epatient if you have shared your burden with even one other patient.

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