With an increasing amount of medical information on the Internet, patients are becoming more used to participating in their own healthcare. These authors examine how the evolution of Internet technology has changed the way patients interact with their healthcare providers and how podiatry practices can take advantage of the Web.
In 1995, the primary use of the Internet was e-mail for the masses. Later, doctors linked to hospitals and insurance companies for clinical information and insurance benefits coverage. Today, physicians are finding deeper avenues for the Internet that range from improved efficiencies (electronic medical records, digital transcription services) to continuing medical education and consultations with colleagues.
Ever since the introduction of the term “Web 2.0”″ in 2004, there has been much definitional obscurity about its true impact in medicine. Although no one has defined it clearly, we think the health-on-the-Internet evolution falls into three categories.
Health 1.0. This is today’s dying healthcare system in which doctors communicate information to their patients. It is a basic business-to-consumer business model in which the Internet is one big encyclopedia of aggregate knowledge. Some doctors maintain Web sites and others do not. Nevertheless, Health 1.0 has a command and control hierarchy where doctors are on top of the pyramid and patients are on the bottom.
Health 2.0. According to healthcare journalist Matthew Holt of http://www.thehealthcareblog.com , Healthcare 2.0 may be defined as: “information exchange plus technology.”
Holt says Health 2.0 “employs user-generated content, social networks and decision support tools to address the problems of inaccessible, fragmentary or unusable healthcare information. Healthcare 2.0 connects users to new kinds of information, fundamentally changing the consumer experience (e.g., buying insurance or deciding on/managing treatment), clinical decision-making (e.g., risk identification or use of best practices) and business processes (e.g., supply chain management or business analytics).”1
Therefore, if Health 1.0 is a static book, Health 2.0 is a dynamic discussion. For example, the power of the Internet is illustrated in the phenomenon of “crowd sourcing.” In this context, the term means to harvest the reach of social networking (wisdom of crowds) to solve a problem. For example, www.PodiatryPrep.com  is an example of how podiatrists connect for global board certification assistance.
Health 2.0-plus. The Dictionary of Health Insurance and Managed Care defines this emerging hybrid as a bridge uniting the philosophy of contemporary Health 2.0 with futuristic Health 3.0 technologies.2 Cisco System’s HealthPresence, developed in 2010, is one example. Using the network as a platform, HealthPresence combines video, audio and information to create an environment similar to what patients experience when they visit their own doctor.
Health 3.0. Soon patients will not only be seeking information but actionable intelligence. Patients will communicate almost as with another patient or doctor. The Internet offers some amazing opportunities. Imagine using your iPhone to send pictures and streaming videos of conditions for a second opinion.
John Luo, MD, of the Semel Institute for Neuroscience and Human Behavior at UCLA, lists three competitive trends that are challenging traditional Health 1.0 delivery and that are producing much fear and anxiety among medical practitioners.3
Health search and information for all stakeholders. Google, Yahoo, Bing, Buzz and Chrome are well known search engines while health-specific engines like Healia, Medstory, Healthline, ClinicalTrials.gov and PubMed are more detailed. Medical reference resources for patients include Medline’s Medical Subject Headings (MeSH), Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) and the National Cancer Institute (NCI) Thesarus.
Social networking for patients, employers and insurers. In the Health 2.0 world, social networking has a new meaning. For example, DailyStrength (http://www.dailystrength.org/ ) creates online journals while members give virtual “hugs” to support one another 24/7. PatientsLikeMe (http://www.patientslikeme.com/ ) focuses on neurologic, immunodeficiency, endocrine and mood disorders. Information is plotted graphically over time to help members see outcomes on specific symptoms. MedHelp (http://www.medhelp.org/ ) adds topic-based forums featuring physician experts while ReliefInsite.com focuses on chronic pain management.
Professional networking for medical providers. In the Health 2.0 space, Sermo.com is the largest online healthcare community with more than 115,000 community members. (Sermo does not allow member podiatrists at this time. A related site for DPMs is Podiatry.com.) At this site, physicians pose questions so that they can share clinical findings and unusual events to add to collective knowledge and advance patient care. Active physician licenses are verified upon entrance but doctors can maintain an anonymous profile thereafter.
Pharmaceutical companies pay to access the observations and clinical insights on Sermo, which may now be considered the de facto national medical membership organization, given that fewer than 18 percent of all MDs belong to the formerly august American Medical Association.4
Ozmosis (https://www.ozmosis.com/  home) is another site that pools and shares clinical pearls but its revenue comes from medical technology companies that sponsor forums seeking user experiences like iMedExchange (http://www.imedexchange.com/ ).
Other health networks are:
• Knol (http://knol.google.com/k )
• HealthLine (http://www.healthline.com/ )
• MedNotes (https://www.drugs.com/  mednotes.html)
• WebMD (http://www.webmd.com/ )
• BoardCertifiedDocs (http://www.boardcertifieddocs.com )
• MentalHealth (http://www.mentalhealth.net/ )
• ChainOnLine (http://www.chainonline.org )
• Medpedia (http://www.medpedia.com/ )
• Health Professionals Network (http://www.healthpronet.org/ )
• HCPLive (http://www.hcplive.com/ )
• The Doctor’s Channel (http://www.thedoctorschannel.com/ )
Health 2.0 platforms for all. Anyone can now create his or her own Web site, blog, vlog or e-forum. Popular build-your-own platforms are Ning (http://www.ning.com/ ), Blogger (http://www.blogger.com/ ), WordPress (http://wordpress.org/ ), TypePad (http://www.typepad.com/ ), Trifecta (http://www.trifectaky.com/index.php ), Tripod (http://www.tripod.lycos.com/ ) and Squarespace (http://www.squarespace.com/ ). These are virtually free and require minimal programming skills.
Of course, Health 2.0 has more than a few drawbacks.
Beware of physician, hospital and accreditation rating services. These sites offer anonymous ratings and credential information on medical providers. Patients are able to find financial, divorce, criminal, civil or malpractice information in some cases. Entire medical institutions may also be negatively implicated. Congress even temporarily revoked the Joint Commission’s statutory authority to accredit healthcare facilities in 2008 when faced with Health 2.0 competition from upstart DNV Healthcare Inc., a division of the Norwegian company Det Norske Veritas.
Therefore, some health entities have entire teams that monitor the social media spectrum for their mentions, using monitoring services like Meltwater, Radian6, Overtone, Vocus, Moreover and Google for 24/7 alerts.
However, because anyone can add good or bad feedback experiences, some entities are seeking to have their patients sign a contract designed to “respect privacy on the Internet” by agreeing not to post personal experiences or participate in online rating services. The ethical and legal ramifications of e-censorship are still emerging.
In retaliation, some doctors are starting blogs of their own, such as www.MedRants.com  and www.GruntDoc.com . Blogging also presents new risks of breaching patient privacy. As blogs proliferate, some practices and hospital privacy officers are considering policies that provide standards for doctors who are engaged in this activity.
In addition, there are Internet security concerns. The “Kneber botnet” virus of January 2010 gathered log-in credentials from infected computers and reported back to hackers. These hackers infiltrated Yahoo, Hotmail and Facebook accounts, as well as pharmaceutical giant Merck and Cardinal Health Inc.
Finally, beware of HIPAA privacy concerns. Office policy should require patients to give their consent for e-mail through a secure portal with a unique ID and password. Staff should not communicate via regular e-mail to patients. Portals may be integrated with electronic medical records (EMR). As noted on our blog and in our book Risk Management and Insurance Planning for Physicians and Advisors, always consider the potential impact of unintended EMR data breaches on professional liability.5
Eugene Schmuckler, PhD, of Medical Business Advisors, believes most Health 2.0 angst may be more generational than than anything else. Why?
Today, it is not uncommon to have three generations in a healthcare practice. We have the Baby Boomers, Generation X and now, Generation Y (also known as the Millennial Generation, Echo Boomers or the Trophy Generation). This newest generation of physicians has grown up with the Internet. They “get” the technology but do not always understand how to forge identities as physicians. Consultant Bruce Tulgan opines that Gen Y is going to be “the most high-performing civic-minded workforce in the history of the world, but they are also going to be the most high maintenance workforce in the history of the world.”6
Gen Y is completely comfortable with Health 2.0 initiatives. Rather than trying to get these people to conform to traditional healthcare business models, they should be empowered to lead the way into the future. On the other hand, some Baby Boomers are saying with sadness, “Medicine sure isn’t want it used to be.” Generation X is saying, “It’s about time things changed.” The latest generation to enter the medical workforce, Gen Y, is saying, “Ready or not, we are here. Get used to it.”
The era of Health 2.0 is not about controlling or dictating. It is about participation, empowerment and communication. Technology is not an end but the means to sharpen the questions a patient might ask when speaking to a medical professional.
We believe the biggest implication of Health 2.0 for DPMs is through artificial intelligence. For example, soon patients may use a sophisticated search engine to input the following query:
“I want to find a board certified female podiatric surgeon who’s done at least 100 Austin HAV repairs, who operates every Monday near my house, who takes my insurance at XYZ surgery center, and who has never been sued, speaks Farsi and enjoys playing the flute.”
Instantly, results would be back with an offer to set up an appointment.
What is the primary question going forward? Where on the Web do you want to go to interact with others about podiatry related topics? Is the digital podiatric workforce leading or lagging in adoption? Consider the following three potential scenarios.
1. Patient centered care (demand-driven) versus podiatrist centered care (supply-driven). Patient centered care is the antithesis of command control podiatry, in which patients are engaged collaborators rather than passive followers. This market responsive model has the following characteristics.
• 24/7/365 access versus 9 to 5 banker’s hours
• Early technology adopters versus late technology adopters
• Patient selected caregivers versus practice/MCO selected caregivers
• Patient time sensitive versus patient time insensitive
• Low office overhead versus high office overhead
• Fewer full-time employees (FTEs) versus more FTEs
• Same day open access medical services versus appointment scheduling
• Quality care versus quantity of care
• Preventative culture versus repeated interventions
• Physician-patient satisfaction versus enterprise-wide frustration
• Next generation healthcare versus last generation delivery chain
• Generalists versus surgeons
• Professionalism versus merchantism
2. The micro-podiatry practice business model. The emerging “micro-practice” model may be an ideal structure for podiatry given its limited body scope. A low overhead, technology driven, labor reduced, electronically connected and often mobile practice allows more doctor control and patient face time. It is ideal for those patients who pay cash, have a high deductible insurance plan or high co-pays. It is also ideal for an aging population and the renaissance of primary podiatric medicine on the horizon, despite some misguided surgical mavens and the Council on Podiatric Medical Education (CPME), which is too surgically oriented, or concierge practices.
3. Economically guaranteed podiatric care. Primary podiatric medicine is also ideal for the “satisfaction-guaranteed” model. Yet this economic business model may have begun with whole body medicine at the Detroit Medical Center. In 2007, this facility offered patients a credit of up to $100 if they were not satisfied with inpatient services or an overnight visit.7
In Time magazine, healthcare journalist Bonnie Rochman explored the ramifications of the “empowerment movement” she calls “Patient 2.0.” In her essay, she profiled the newly created Society for Participatory Medicine, which “encourages patients to learn as much as they can about their health and assists doctors to support patients on this data intensive quest.”8
As Holstein and Lundberg said, “All medical and health care is intensely personal: one patient, one professional, one moment, one decision. The patient is best served by fully participating. With American health care reform imminent, participation for self-preservation becomes even more important.”9
Finally, in the New England Journal of Medicine, Hartzband and Groopman claim that nothing in the history of medical innovation “has changed clinical practice more fundamentally than the Internet.”10 The increased access to medical information is “redefining the roles of physician and patient.”
Donald Berwick, MD, who leads the Center For Medicare and Medicaid Services (CMS), defined patient-centered care in a way that sounds much closer to nursing school models than any medical models. Berwick argues that it is all about asking the patient: “What do you want and need?” “What is your way?” “How am I doing at meeting your needs?” or “How can I help you?”11
Isn’t that what nurses — and doctors — once asked?
Although one may surmise that the next generation of Internet savvy doctors are most likely to turn up the volume in Health 2.0 participation, no patient of any age is inclined to go back to the Health 1.0 era, if Rochman, Lundberg, Hartzband, Groopman and Berwick are correct. Welcome to the future of lean and participatory podiatric medicine.
Dr. Marcinko is the co-founder of www.PodiatryPrep.com  and CEO of www.MedicalBusinessAdvisors.com , a practice management and advisory firm for physicians. He also publishes the blog www.MedicalExecutivePost.com . Dr. Marcinko is a member of the American Society of Health Economists and the Healthcare Information and Management Systems Society. A former visiting professor of business administration, he is also Editor-in-Chief of the institutional journal www.HealthcareFinancials.com  and the author of more than two dozen books in medicine, business, information technology and finance.
Professor Hetico is a former Certified Professional in Healthcare Quality. An Assistant Professor at several local graduate schools in Atlanta, she is also Managing Editor of www.HealthDictionarySeries.com  and the Executive Director for www.ePodiatryConsentForms.com.
For further reading, see “When Patients Ask About Online Information On Products And Procedures” in the January 2009 issue of Podiatry Today, “What Web Marketing Can Do For Your Practice” in the November 2004 issue, “Essential Insights On Electronic Medical Records” in the February 2010 issue or “How To Evaluate EMR Systems For Your Practice” in the April 2005 issue.
To access Podiatry Today’s blogs, visit www.podiatrytoday.com/blogs.
1. Matthew Holt, personal communication
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3. John Luo, MD, personal communication
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12. http://medicalexecutivepost.com/  2008/09/29/repeat-warning-on-physician-blogs/
13. Block BH. Open letter to the Council on Podiatric Medical Education. Podiatry Management, April/May 2010.
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18. Marcinko DE and Hetico HR. Advanced Business of Medical Practice, second edition, Springer Publishing, New York, 2005.
19. Schmuckler E. Medical Leadership and Self-Branding [Transforming the Next-Generation of Physician Executives]. Business of Medical Practice, third edition, Springer Publishing, New York, 2011.