Sermo is an online network for physicians — currently, over 60,000 of them. (I've written about the Sermo community previously, and I've written about meeting Sermo's CEO, Dr. Daniel Palestrant.) One of the advantage of social networks like Sermo is that it allows groups to quickly formulate and vote on ideas. The physicians of Sermo — over a thousand of them — have used the network to craft "An Open Letter from America's Physicians." I recently had the pleasure of meeting Dr. Sean Khozin, who originally proposed the idea of a group letter from Sermo physicians. He and the writers did a great job. The text of the letter is below. To sign the letter, visit Sermo.
Dear Fellow Americans,
For decades the United States has led the world in healthcare. We have enjoyed the finest hospitals, medical schools, research, technology, and resources. Unfortunately, our healthcare system has lost focus to the point where patient wellbeing is placed after politics, profits, and special interests. Healthcare costs are on the rise and patients have lost their freedom of choice. These trends are hurting our economy and compromising the doctor-patient relationship. As a result, it has become difficult for physicians to deliver the best possible care.
Our heavily fragmented healthcare system has made it very difficult for you, the American public, to get the care you need. As your physicians, we want to partner with you to address the critical defects of the system as outlined below:
* You are paying a lot for healthcare and not receiving enough in return. Your insurance premiums continue to increase while your healthcare options are dwindling. Gatekeepers, insurance networks, and restrictive regulations limit your choice of doctors and your access to care.
* You have been made dependent on complicated and expensive health insurance plans. Employers are forced to take money out of your paycheck to purchase health coverage. If you lose your job, you are left with no safety net and the money you have paid for health coverage vanishes.
* The time you spend with your physician has become remarkably brief due to regulatory hurdles requiring doctors to spend more time on documentation than with you.
We believe the following factors have made our current healthcare system unsustainable:
* The insurance industry's undue authority and oppressive control over healthcare processes
* Excessive and misguided government regulation
* The practice of defensive medicine in response to a harmful and costly legal environment
We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients' health have absolute control. This letter is merely a summary of the most important problems in our current system. We believe that by partnering with the public we can start to demand real change and formulate practical solutions.
We invite you, our patients, friends, neighbors, and employers to unite with us at this important time in the history of healthcare in the United States. Together, we can guarantee our nation a healthier tomorrow.
Please talk to your doctor about this letter and visit Doctors Unite for more information.
Sermo's CEO, Dr. Daniel Palestrant, invited users in New York City out to dinner near Times Square last week. (Sermo is the largest online community for physicians, allowing doctors to ask each other questions, vote on answers, and post comments. Some questions are also asked by clients, primarily Wall Street firms, which pay physicians for their answers through Sermo.)
Palestrant, the CEO and founder of one of the most successful and interesting "Health 2.0" companies, is not what you'd expect. Tieless, youthful, open, engaged, informed, and passionate, he spent four hours nonstop in conversation. If I wasn't already a fan of the community and a believer in Sermo's mission, I was when I stepped out the door at midnight.
The following are brief notes from the dinner.
* The name "Sermo" ("conversation" in Latin) originated when Palestrant was being treated with prednisone for a herniated disk -- "in a steroid psychosis," he joked.
* Sermo had three phases. "Kvetch club," commentary on Paris Hilton, and (now) "useful clinical tool."
* The responses that physicians provide are anonymized. No one -- including Pfizer or other clients of Sermo -- can tell who has voted in a particular way. He was very clear on this. (Comments on posts are a different story. These can be traced back to individuals and their self-provided profiles.)
* Palestrant apologized and took full responsibility for the previously circulated screenshots which appeared to show that clients could view the results of individual physicians. That was apparently a mistake, as the information was actually anonymized. "We were a rookie company," he said.
* We talked about how physicians have lost their market power and have been unwilling, unable, or unaccustomed to sharing information.
* "The United States health care system is larger than the economy of China and it's a cottage industry."
* As has been reported everywhere, Pfizer is now partnering with Sermo, which some users have found controversial. Palestrant explained the move by saying that both physicians and companies like Pfizer have been looking for new (and less expensive) alternatives to drug reps visiting physicians in their offices. And since Pfizer and other companies already employ doctors who visit Sermo, this would at least allow industry doctors to be clearly labeled.
* Pfizer and other companies would also be at risk of having their products criticized by the Sermo community. These criticisms could not be removed by the companies.
* I sensed that, partially in response to concerns over its arrangement with Pfizer, Sermo is about to become even more radically transparent. Palestrant said that they plan to divide the message boards into two groups: one with posts by physicians only, the other with posts by clients.
* Sponsored posts make up only 2% of Sermo.
* Sermo posts will soon be linked to clinical guidelines (through "hotspots"), which users can then comment and vote on.
* Palestrant provided a few examples of problems that were noticed by the Sermo community before the mainstream media -- problems with certain models of pacemakers, for example, and generic Wellbutrin.
* 50% of physicians on Sermo are over 45. This is stunning, considering the demographic of the typical web user.
* For a lot of physicians, especially for those not in academic communities, Sermo functions as a virtual doctor's lounge or grand rounds.
* They've timed it so physicians can post to Sermo in 50 seconds or less.
* We spoke about ways of visually presenting complicated threads of comments from users with different rankings. I mentioned Slashdot. He said that Paul Resnick, who has analyzed Slashdot, is analyzing Sermo.
* Sermo takes pains not to censor the posts of individual users. However, in certain cases, they've consulted with ethicists at the University of Pennsylvania.
* And lastly, Sermo is run entirely on Macs.
As someone who's been involved with online communities for over two decades, I appreciate the difficulty in creating one that works. (In a tangent, Palestrant and I spoke about Cory Doctorow's comparison of online communities to nuclear reactors that are always in danger of melting down.) Having spent time with Daniel Palestrant, I'm convinced he actually knows what he's talking about. And that's important, because the community is walking a fine line. On one side are physicians who are fiercely independent and suspicious of outside influence; on the other are pharmaceutical companies and investment firms which are essential to the business model.
Having met Palestrant, I think that if anyone can make this work, it's probably him. I admire his vision for the community, and I'm interested in where Sermo will go next.
Sermo was founded on the idea of information arbitrage, that there's valuable information locked in the heads of physicians, if you could only figure out a way to get to it.
The way Sermo works is this: physicians ask and answer anonymous questions, but some of the questions are also asked by firms. When physicians answer some of these questions, they get paid, but they don't know which questions will pay them. So the incentive is to answer as many questions as possible. Sermo is basically an experiment in classical conditioning, it mines physicians for information by turning them into compulsive gamblers and taking advantage of their desire to collaborate. And it works very well.
It's only about a year old but Sermo is the largest online network of physicians that's ever existed. Sermo is also partnering with the AMA and the FDA, who are interested in information from Sermo about the safety of medical products. Sermo may actually be a better way to encourage physicians to report problems with drugs and devices than the FDA's own website.
Naturally, prior to the conference, I was curious about the Sermo community's response to the question, "What do you consider to be the most disruptive change in healthcare?" (The full posting on Sermo, which you can access if you are a physician and have a free account, is here.)
Here are the top five responses:
The growing trend toward having non-MD's (i.e., insurance companies) making decisions about treatment options. (35%)
Too many to pick just one. (15%)
Quality improvement and quality measures driven by computers and administered by non-medical bureaucrats. (10%)
"Google Health" [The survey was administered before Adam Bosworth left Google]. (8%)
Widespread use of electronic medical records. (7%)
Proliferation of physician extenders, PA's NP's, etc (7%)
I'm going to talk briefly about the disruptive potential of online communities of physicians and patients.
These online communities are an big part of what people have called "Health 2.0." Of course, this is just a buzzword, like "Web 2.0," but it's a buzzword that means something.
Early this month the Economist had an article about Health 2.0, which they defined as "user generated healthcare." In Health 2.0 communities, the content and value is not generated by outside experts, but by the users themselves, by healthcare providers and patients, who interact to share information and insights.
These online communities may be very different from one another -- and I'll give you some examples of them in a minute -- but they all have a couple of things in common: they're all public, collaborative, and simple to use. And this combination can be very powerful and disruptive.
For example, there's a website called Wikipedia which is perhaps the best example of a community that's a major source of health information for a lot of people. If you haven't seen it, Wikipedia is a free online version of an encyclopedia that anyone in the world with an internet connection can read and edit. I'll say that again -- anyone in the world can read it and edit it.
This idea seemed crazy at first and still seems kind of crazy, but it actually seems to work. Wikipedia is now 15 times as large as the entire Encyclopedia Britannica. And partly because of Wikipedia, very few people read the Encyclopedia Britannica anymore.
And what's written on Wikipedia definitely matters. Wikipedia is one of the top ten websites worldwide. Wikipedia is often one of the first places people go if they're diagnosed with a new disease, or if they want to research a person or a corporation. The definitions on Wikipedia are often near the top of any Google search.
But again, it's amazing that Wikipedia works at all, because anyone with an internet connection can change any of the definitions. And that's potentially very scary.
But the system works because it's self policing -- errors are picked up and changed by the users. But of course that still leaves some potential for significant inaccuracies and abuse.
[The author Charles Stross points out that if you extrapolate from current trends in computing, sooner or later everyone in this room will have an entry on Wikipedia. Try to imagine what they might be like.]
I'm going to talk about some other Health 2.0 communities that have the potential to be as disruptive as Wikipedia.
For example, there's an online community for physicians called Sermo. Sermo was founded on the idea of information arbitrage, that there's valuable information locked in the heads of physicians, if you could only figure out a way to get to it.
The way Sermo works is this: physicians ask and answer anonymous questions, but some of the questions are also asked by firms. When physicians answer some of these questions, they get paid, but they don't know which questions will pay them. So the incentive is to answer as many questions as possible. Sermo is basically an experiment in classical conditioning, it mines physicians for information by turning them into compulsive gamblers and taking advantage of their desire to collaborate. And it works very well.
It's only about a year old but Sermo is the largest online network of physicians that's ever existed. Sermo is also partnering with the AMA and the FDA, who are interested in information from Sermo about the safety of medical products. Sermo may actually be a better way to encourage physicians to report problems with drugs and devices than the FDA's own website.
There are also many online communities for patients, including sites with names like Organized Wisdom, Revolution Health, and Patients Like Me. These sites offer a number of services. They function as support groups for people whose physicians may not know enough about their disease or who don't have the time to explain it. They also allow patients to share their collective insights with one another. And they allow them to rate different sources of health information on the web. Some people like to use the phrase that "people are the new algorithm."
And some of these sites also allow patients to rate their doctors, health systems, and health products. And this is potentially disruptive, but not necessarily in a bad way. If people can search on Google for a review of your organization as easily as they can search for a review of a toaster, that can be a powerful incentive to change for the better. But as with Wikipedia, there's obviously a potential for inaccuracy and abuse.
And finally, there's also thriving community of medical blogs, which are online interactive journals written by patients, physicians, and other health care professionals. Many healthcare blogs contain hidden gems of information. And there's a sustained level of discussion on blogs that's hard to find anywhere else.
For example, there's a blog called "Kevin, MD" which collects all the most interesting stories in the media in one place. There's a blog called "Running a Hospital" by the CEO of Beth Israel Deaconess in Boston. And the Wall Street Journal even now has it's own excellent Health Care Blog, which I recommend to anyone interested in the business of healthcare. And the interactive nature of blogs is essential, because sometimes the comments can be more interesting than the original posts themselves.
To summarize: technologies like Wikipedia, blogs, and online communities have the potential to dramatically change and improve communication in the healthcare industry.
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