Dr. Daniel Sands, Founder of the Society For Participatory Medicine

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Mark Masselli: This is Conversations on Health Care, I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well Margaret awareness month is ending with something of a
controversy. There has been a lot of reaction to the recent changes announced by The
American Cancer Society regarding new mammogram guidelines.

Margaret Flinter: Well the previous guidelines suggested that w omen receive an annual
mammogram beginning at age 40. The new guideline suggest that routine screenings
should begin at age 45 and only earlier if there is a family history or other risk factors
and only every other year for women 55 and over. This new r ecommendation is not
being fully accepted by some clinicians at very top cancer hospitals.

Mark Masselli: The American Cancer Society based the new guidelines and data that
showed the average risk for women didn’t seem to increase until women were closer to
menopause. Meanwhile these recommendations are actually more conservative than
those suggested a few years ago, by The United States Preventative Service task force,
which said that women should wait till age 50 to begin annual mammograms.

Margaret Fli nter: Cancer hospitals like Memorial Sloan Kettering and MD Anderson
Cancer Centers say they are going to continue their policy of recommending annual
mammograms starting at age 40 at least for the time being.

Mark Masselli: Yeah, but as per the new guid elines, also comes from the growing
movement to reduce harm and unnecessary medical intervention for average risk
women who has suspicious mammograms and then undergo invasive procedures only
to discover that it was a false positive.

Margaret Flinter: The new guidelines though give discretion to patients and clinicians to
choose to opt for earlier screenings saying that insurance should cover all
mammograms that are ordered for whatever reason they are ordered.

Mark Masselli: This story is probably going t o spark a lot of more frank conversations
between women and their providers on this personal and important health screening
and the more dialogue patients have with their providers, the better opportunity
everyone has to achieve better health and better ou tcomes.

Margaret Flinter: Well that’s something that our guest today is quite passionate about.
Dr. Daniel Sands is cofounder of The Society for Participatory Medicine, who seeks to
develop a clinical model where patients are really empowered and engaged . He has

been at the forefront of this movement, which is taking hold. So we really look forward
to that conversation.

Mark Masselli: Lori Robertson stops by, The Managing Editor of Factcheck.org looks at
false claims made by The Health Policy in the Pu blic Domain, but no matter what the
topic, you can hear all of our guests by going to chcradio.com

Margaret Flinter: And as always if you have comments, remember to email us at
[email protected] or find us on Facebook or Twitter because we love to hear from
you. Now we’ll get to our interview with Dr. Daniel Sands in just a moment.

Mark Ma sselli: But first here is our producer Marianne O'Hare with this week's headline
news.

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Marianne O'Hare: I'm Marianne O'Hare with these Health Care Headlines. The Head
of The American Cancer Society says the new mammography guidelines are with th e
most honest things to come out of the organization in years. Dr. Otis Brawley saying
the new guidelines recommending women don’t begin annual mammograms till age 45
instead of age 40 is based on rigorous analysis of decades of data on the matter and
tha t while increased use of mammograms saves lives, it’s also caused much harm as
well. The ACS recommendations are causing a cavalcadive responses including many
from cancer treatment specialists you cautioned against a quick switch to the later
mammography start date. Pay for performance is coming to health care a bit slowly in
August, Medicare Official’s released 2014 financial details showing, so far, the ACOs
have not saved the Government money. The 20 ACOs in , The Pioneer , reported total
savings of 41 1 million dollars, but after paying bonuses the ACOs recorded a net loss of
2.6 million to the Medicare Trust Fund. Ano ther reason to get more shuteye – not
enough sleep can lead to early disease and an earlier death. A recent study at South
Korea shows chronic sleep deprivation of less than 6 hours per night can lead of onset
of metabolic syndrome. Participants were followed during two 3 - year periods. About
560 people in this study or about 22% developed metabolic syndrome. Short sleep
duration was li nked to about 30% increased risk of high blood sugar and access belly
fat as well as 56% higher odds of hypertension compared to those who slept longer. All
the times, they are changing in somewhat attitudes about marijuana use. A study done
from 2001 to 2002 showed about 4% of American adults admitted to Pot use during that
year from 2012 to 2013 about 10% of Americans had admitted to using Pot. Study
showed especially large increases among women, Blacks, Hispanics, Southerners and
Middle aged and older people. The researchers write, if the amount of US adults using
marijuana increases soon will, the number of those with marijuana use disorders. I'm
Marianne O'Hare with these Health Care Headlines.

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Mark Masselli: We're speaking today with Dr. Daniel Sands, Founder and Co Chair of
The Society for Participatory Medicine, A Faculty Member at Howard Medical School;
Dr. Sands is an Internist focusing on Primary Care Transformation. He was Chief
Medical Officer at Sysco and prior to that Chief M edical Director at Zix Corporation,
developing early technologies for E - Prescribing. Dr. Sands also developed some of the
Nation’s first patient portals, and electronic health records. Dr. Sands is a member of
The American College of Physicians and The A merican College of Medical Informatics.
He is named one of the 20 people who make healthcare better by Health Leader’s
Magazine. He earned his degree from Bryan University, Ohio State College of Medicine
and Howard School of Public Health. Dr. Sands wel come to Conversations on Health
Care.

Dr. Sands : Thank you very much Mark.

Mark Masselli: Yeah it’s great and you are one of the pioneers in the discipline of
participatory medicine , which is now gaining some traction across the healthcare
landscape and I’m wondering if you could tell our listeners, describe what you mean by
Participatory Medicine Model?

Dr. Sands : Sure. We often think about healthcare as a service industry. To me, that
feels like a carwash. So it’s just that, you know, healthcare is kind of like a carwash.
The car is dirty and needs to be washed, goes to carwash and somehow they come out
and they are healthy, they fixed, but we are not succeeding in many ways in the
healthcare system, we don’t get the outcomes that we need. We meani ng, doctors and
patients, we need to both be engaged in the process of healthcare that is different from
a service industry. I would argue that healthcare really is collaboration and
collaboration depends on a number of things: open communication, sharing of
information, and one of those is engagement. So this collaboration, I would say, is
participatory medicine, that’s how I would define it.

Margaret Flinter: Well Dr. Sands, patients run the full spectrum. I know you are Co
chair of The Society for Pa rticipatory Medicine e - Patient Dave deBronkart has been a
guest on the show, but there is an exemplar perhaps of a highly motivated patient who
really engaged in his own recovery doing battle was staged for kidney cancer, but I
would really like to hear yo u prospective on what we might call the everyday patients
with more typical or be sometimes quite complex healthcare management issues, and
which strategies are you deploying or thinking about to engage the primary care patient
population to be more engage d?

Dr. Sands: Certainly, patients who have life threatening illnesses, like they, really, you
know, have an urgent need to get more engaged in their health, but I would argue that

at it benefits any patient with any condition, so patients who need to exer cise more need
to improve their diet more. You know, how do we engage patients, who just don’t want
to be engaged. There are some patients who are challenged with this idea of
participatory medicine, for reasons that are not related to us. There may be cultural
reasons. But I think it’s coming upon us to lower barriers to patient engagement
whenever possible. Part of that is making sure that patients have easy access to the
tool they need to take care of themselves and we should encourage them to seek out
information as well as their own persona health information, that is their medical
records, we should make easy for them to access that. The third kind of information
they need to be able to access is access information from other patients like them, and
in addition they need to be able to access care conveniently. So we make it very
difficult, for example, for patients to get an appointment with us. It takes for ever and
finally they just give up. So lowering barriers I think is one of the ways tha t you can
engage patients. Patients get turned off when they are just sort of stone walled by the
healthcare system. They can’t stand how difficult it is to interact with the practice and
yet the patients don’t want to pack half a day out of their lives and come to see us if it’s
something that doesn’t need to be done in a face - to - face visit, and God know they can’t
reach us by phone! So I view patient engagement as any other behavior change. In
primary care we are dealing with patients who need to make behavior change, whether
it’s a start taking a medication they need to be taking or whether it’s quitting smoking.
So a model that I use in my practice for patients in behavior change situation is The
Prochaska Model . It’s a matter of assessing where in dividuals are on a rediness to
change continuum. What you want to do with any behavior changes to start to assess
where they are and then move them up to the next box and then prevent them from
slipping back. So I do that as I look at patients in my prac tice and you know how willing
they are to get engaged in their health? And then there are other patients who are, you
know, really thinking that, yeah, they want to get more engaged to their health and so by
doing that, we can, sort of move patients along through this continuum, through the
Prochaska Stages and, I think we really can get patients get engaged in their health.

Mark Masselli: You know, I want to give applaud to both you and e - Patient Dave, who
is not only your patient but you also co wrot e a book called Let Patients help, you know,
one of the things that we hear from patients all the time is about the frustration of getting
access to their own health data and I am wondering sort of that cultural change, I am
wondering if you could use The 5 steps to move the medical practices forward and

Margaret Flinter: That’s bit of a pre calculation.

Mark Masselli: Yes, we are doing that and so wondering what you thought is about
what’s holding back and how is Society for Participatory Medicine cu ltivating
conversations within the community?

Dr. Sands: Yeah, this is a really sticky problem in the society about interoperability of
health records, you know if you are getting your care in New York and you happen to be
in Boston seeing me, I should me , I should be able to have access to your records, your
health records.

Mark Masselli: Send a care to your patient.

Dr. Sands: Right, send a care to my patient might work but, a nd frankly, we have a
huge issue throughout The United States with that, you know, ever if they are rally
close, I can’t get that information, so physicians have had to rely still on fax machines,
or just be content with not really knowing and just repeati ng whatever tests need to be
done, because we could probably have a whole hour long discussion about all of the
issues related to that. Patients expect that, that should happen. They believe that, that
interoperability should take place. You know, I thi nk they are frustrated by that. We, at
The Society for Participatory Medicine did a national survey and we found out that vast
majority of patient you know, the people out there, expected that kind of information
should be available to their doctors, but there is a whole other issue, which is that what
about having you have access to your records from me. That is fortunately a little bit
easier than it has been in the past. So as you mentioned earlier I co developed one of
the first portals that gave pat ients access to their records and today patients not only
have access to their records, but they have access to their notes as well. You know, so
if you have a patient portal up, that patient portal gives the patient the ability to have
access to their re cords. And fortunately, it is a requirement that doctors have patient
portals through which, patients can access their records and even view, download and
transmit their records. But I think still, many doctors are uncomfortable with that notion.

Margare t Flinter: Well so much is transforming, in primary care, but one area that has
not moved fast as forward is we might have contemplated is the way people get paid
and fee for service pretty much still dominates the landscape and yet these elements of
tran sformation, you’ve been so interested in care management that happens without
patients coming in the office. Secure e - mail and telemedicine protocols been and yet
not one of those things is associated with payment. Do you see this payment
transformation accelerating?

Dr. Sands: You know, upfront, I would say that telemedicine actually is increasingly
reimbursed, so that is one thing that certainly is. I’ve been using e - mail in my practice
since 1991, perhaps a very long time ago. In 1998 I collected th e very first guidelines of
how to use e - mail with patients because we already knew from surveys that patient
wanted to e - mail with their doctors, the doctors weren’t letting them. And still today,
doctors are concerned about it. So one of the objections the doctors have had from
very early on has been an issue well, I don’t get paid for it. You know, and you don’t get
paid for talking on the phone with patients either. The only thing we get paid for really is

seeing patient in the office. We have to co mmunicate with our patients somehow. We
just have to and so right now your only option is the telephone. And so, would you
rather talk to the patient on the phone, recognizing that it takes longer, or would you
rather just exchange a quick e - mail. Years ago when I was really doing a lot of
investigations in this area, there was a study showing that an average telephone
communication with the patient took 5 minutes, and average e - communication with the
patient took 2 minutes. So why wouldn’t I want to do the e - mail with them, and the other
thing doctors complain about is, “well why should I take care of patients for free?” Well
in the pay for service world we bill at different levels. Wouldn’t you rather use your
office time for taking care of patients, who really need to be seen because they are
sicker? But if I can bill at a higher lever for that time that’s a better thing and maybe it’s
through video conferencing or maybe it’s through the phone or maybe it’s through
secure messaging. You know, certa inly, well over 50% of doctors have some element
of quality reimbursements in their contract and that’s going to increase in the coming
years. I don’t think there is anyone who really thinks that this is ending. You know, our
changes in attitude when we are with the patient is not something that takes more time,
admitting we don’t know when a patient asks a question rather than sort of making
something up or ignoring then or whatever, that doesn’t take more time. Encouraging
patients to read about their illness through things they find on the internet or through
patient support communities online, that’s the stuff that doesn’t take more time either.
So I think there is a lot we can do to practice participator medicine without requiring
more time of us.

M ark Masselli: We are speaking today with Dr. Daniel Sands, Internist, Medical
Informatics Expert, and Founder of The Society for Participatory Medicine, which seeks
to promote a model of actively engaged, patients, caregivers and providers across a
contin uum of care. You know, when you are talking earlier about the, sort of, patient’s
expectation on health, interoperability and that they have all the information available
and you now have over the last, half a dozen years, tens of millions of Americans no w
utilizing some kind of health tracking or monitoring device that data really hasn’t found a
home. Apple’s launched it’s healthcare product, other players like Google and
Samsung, but you just spoke at The Health 2.0 Conference where many of these health
tech entrepreneurs conversed, so what’s the buzz of the conference regarding these
new emerging health IT platforms especially platforms that have the power to transform
care as well as research?

Dr. Sands: I think there is certainly a lot of excitement about the fact that oh, you know,
patients can track their own information and they can get feedback from a computer
about how they are doing and this and that, I think that the, if we want that information
to be actually a part of our medical record and p art of our medical care that’s a whole
different ball of wax, but you know, if I really want this, you know, my doctor to be part of

this conversation, that’s a whole different thing. One of the things about the health Apps
and there are you know, dependi ng on what you read, there maybe 60 thousand
different health Apps out there. Not that many of them you know, would acquire, really
clinically useful information, and then there are the tracking devices, many of which
people are buying using for a short w hile and putting them in the drawer and so the
average user is using them from 1 to 6 months. Then there is an issue of accuracy. So
let’s suppose that I am tracking my footsteps and it’s just not accurate. I mean, there
was a New York Times review, may be year or so ago, and they used, I don’t know, 5
different tracking devices and they put them all on themselves and they all got wildly
different numbers about how much activity that way. So, on the other hand, we have
opportunities like blood pressure c uffs and scales, and things, there are FDA certified,
so I think it’s really important to think about that issue about their interface and in fact,
there is a whole group of people out there that they are part of something they call the
quantified self mov ement and they are interested in tracking everything they can about
themselves and if they just have enough information and then they will be able to keep
themselves healthy then, and of course if you practice medicine and you know, that
that’s just not tr ue. So if we are going to incorporate any of this information into the
healthcare system, you know, as we are paid, as we are moving from pay for services
to pay for value, and we need to improve the outcomes of patients who have chronic
conditions you kn ow, one of the things we need to do is we need to understand what’s
going on with them all the time, not just in this 15 minutes that they are in the doctor’s
office. And so one of the ways you might do that is through frequent light touches in
between vi sits instead of visits. But then this data, needs to come back through the
doctor’s office in a way that is, that we are filtering the signal from the noise. So we are
identifying important trends and showing them to the practice. What we want to know i s
what is the significant trend so that we know who we need to reach out to.

Margaret Flinter: We have been speaking today with Dr. Daniel Sands, Internist,
Medical Informatics Expert, and The Founder of The Society for Participatory Medicine.
You can le arn more about his work by going to his website doctordanysands.com or
follow him twitter at doctordanysands or through The Society for Participatory Medicine
at s4pm. Dr. Sands, thank you so much for joining us on conversations on healthcare
today.

Dr. S ands: Thank you very much.

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Mark Masselli: At Conversations on Healthcare we want our audience to be truly in the
know when it comes to the facts about healthcare reform and policy. Lori Robertson is
an award winning journalist and managing editor of FactCheck.org a nonpartisan, non -

profit consumer advocate for voters that aim to reduce the level of deception in US
politics. Lori what have you got for us this week?

Lori Robertson: Well Jim Bush claimed that while President Obama had promis ed to
lower health insurance premiums by 2500 dollars per famil y, The President’s own team,
it says premiums will increase by 2900 dollars over the next 10 years. That’s
misleading. While Obama didn’t always make it clear, he wasn’t promising to cut
prem iums but rather promising to cut the rate of growth in premiums. As for the future,
the centers for Medicare and Medicaid services project private insurance premiums per
enrollee will rise by nearly 2900 dollars over 9 years, but that is moderate growth b y
historical standards. Bush’s comparison leaves the impression that a 2900 dollar
increase would be a market departure from Obama’s promise, but it’s actually an apple
to orange’s comparison. We have no problem with Bush faulting The President for his
b roking promise, in fact we’ve fact checked Obama’s misleading claim several time over
the years. But Obama was talking about a 2500 dollar reduction compared with what
would have happened without The Affordable Care Act or other changes to the
healthcare system. Bush’s 2900 dollar increase figure meanwhile is a stray increase.
He gets that figure from the latest National Health Expenditures Report, from the
centers for Medicare and Medicaid Services. The 2900 dollar increase which is from
2015 to 2024 w ould be an average 5.82% increase per private health insurance
enrollee per year. How does that compared to the past the rate of increase was 5% per
year from 2007 to 2008 and before Obama took office from 2000 to 2008 it was 9.4%.
The national health ex penditure’s reports said that the growth rate would “remain
modest” from 2015 through 2018 and then pick up in a delayed response to stronger
economic growth, and that’s my fact check for this week , I'm Lori Robertson Managing
Editor of FactCheck.org.

Marg aret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players. And is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you'd like checked email us at
chc radio.com we'll have FactCheck.org's Lori Robertson check it out for you here on
Conversations on Healthcare.

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Margaret Flinter: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and to everyday l ives. Each year more than 1
million babies die at birth and another 3 million die within the first few weeks of life, often
from preventable causes. And when babies are born prematurely the risks escalate.
Newborns, in particular primes have a considera ble amount of difficulty regulating their
own body temperature and without access to incubators babies in the third world often

still come to hypothermia. That had our former Stanford MBA student Jane Chan
thinking, how do we develop a low cost solution t o the problem?

Jane Chan: My team and I realized, what was needed was a local solution. Something
that could work without electricity, that was simple enough for a mother or a midwife to
use. Give that the majority of births still take place in the home . We needed something
that was portable, something that could be sterilized and reused across multiple babies,
and something ultra low cost compared to the 20,000 dollars that an incubator in the US
costs.

Margaret Flinter: Speaking at a recent Ted Talk, Chan said that they developed a
cocoon like device called simply embrace. A thermal body wraps that encases the
baby , and helps regulate body temperature for up to 6 hours.

Jane Chan: What you see here looks nothing like an incubator. It looks like a s mall
sleeping bag for baby. It’s waterproof. There is no seems inside, so you can sterilize it
very easily, but the magic is in this pouch of wax. This is a phase change material. It’s
a wax - like substance, with a melting point of human body temperatur e at 37 degrees
Celsius. You can melt this simply using hot water and then when it melts it’s able to
maintain on constant temperature for 4 to 6 hours at a time, after which you simply
reheat the pouch, and it creates a warm micro environment for the bab y.

Margaret Flinter: And Chan and her developers have managed to keep the cost of the
embrace baby warmer at around 25 dollars per unit. So fortunately the product in 2010,
they estimate that over 150,000 babies’ lives may have been saved with the device ,
which is easy to sterilize and design for multiple uses. The Embrace and Feel Warmer
has earned numerous international awards for design and efficacy, a low cost, high
tech, portable temperature regulator, designed to regulate primes body temperatures t o
ensure that they not only survive premature birth but ultimately thrive as well. Now
that’s a bright idea.

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Margaret Flinter: This is Conversations on Healthcare, I'm Margaret Flinter.

Mark Masselli: And I'm Mark Masselli, peace and health.

Fem ale: Conversations on Healthcare broadcast from the campus of WESU at
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