Google’s mission statement is: Organizing the World’s Information.   In terms of delivering content that can accomplish this, they have done a great job.  I use Gmail, a Google homepage, Google Calendar, and sometimes even Google Documents.  Yet there are times when they seem to blur the line between organizing and delivering information and influencing behavior.

In a recent lawsuit, American Airlines charges that Google is unfairly selling ad-words to competitors, so that if you type in “American Airlines” in a Google Search, the accompanying ads are those of the competitors. 

Google Adwords dive-bombed by American Airlines

By Cade Metz in San Francisco

Published Friday 17th August 2007 20:09 GMT

Yet another trademark owner has gone to war over Google’s keyword advertising. But this time it’s a name everyone knows: American Airlines.

Yesterday, the world’s largest airline slapped a federal suit on the world’s largest search engine, claiming that Google’s cash-cow of an ad system infringes on American’s rather extensive trademark portfolio.

“Some individuals and entities attempt to take advantage of consumers by marketing their products or services using the brands of others,” reads a filing with the US District for the Northern District of Texas. “This lawsuit involves exactly such a situation - efforts by certain companies to free ride on American Airlines’ brands through use of Google technology.”

Google is to blame, the suit argues, because it allows third-party businesses to piggy-back their ads on search engine keywords that violate American Airlines trademarks - like “American Airlines,” “AA,” and “A A.”

Close to a dozen companies have filled similar suits against Google, including Geico and American Blinds, but none can match the profile of an American Airlines. “Geico is a pretty well known brand,” Santa Clara University law professor and tech law blogger (http://blog.ericgoldman.org/archives/2007/08/american_airlin.htm) Eric Goldman told The Reg, “but American Airlines is one of those highest-echelon brands, one of the brands that almost everyone is familiar with.” And American Airlines has lots of money to pay its lawyers.

American’s argument is, shall we say, multi-faceted. On one level, the airline claims that Google is “directly” infringing its trademarks, that the search engine is using intellectual property owned by American Airlines to rake in cold, hard cash.

“The law doesn’t really distinguish between me slapping a competitor’s brand on my knock-off good and Google offering the ability to make a keyword match on its database,” Goldman told us. “The fact that Google is taking money for having made an association on someone’s trademark could, in theory, meet the trademark statute standards” - i.e. break the law.

What’s more, the suit argues, Google is actually suggesting that advertisers purchase keywords that violate American Airlines trademarks. “Google has a sandbox where it suggests what keywords [advertisers] should buy and it will routinely suggests third-party trademarks,” Goldman explained. “If you go onto the site and say ‘Hey, I’m thinking about advertising in the travel business,’ it will say ‘Have you considered the following keywords’ - and American Airlines trademarks may be on that list.”

The airline makes a boatload of additional claims - with some holding more water than others. At one point, it gets huffy because Google doesn’t allow keyword matches on its own trademark, and it complains that when you click on links related to American Airlines trademarks, you’re taken to sites that sell both American Airlines tickets and tickets from competitors. You might as well complain that your local grocery store is selling both Coke and Pepsi even though it ran a Pepsi ad in the local paper.

(read More)

This came to mind when I got an e-mail from Amy of Diabetes Mine.  To the right on my Gmail was the following:

Clicking on the top link (DiabetesIsCurable.com), you see the following:

If what the site says is really true, then there must be an enormous conspiracy that I am not aware of.  I don’t know any of the seven secrets of diabetes and am not presently withholding secrets from my patients about diabetes.

So you see why I am afraid.  Google gets the bulk of its revenue from advertising.  If they are willing to sell adwords to the highest bidder, what is stopping sites like this from overwhelming the legitimate medical websites?  What about the pharmaceutical companies doing the same thing?  At the very least, this will cause a huge amount of confusion on the part of patients looking for reliable medical information.

Google will have to do a huge amount of work to establish credibility with the medical profession.  If they are to put themselves forward as a legitimate website for healthcare related needs, they will either have to exercise a large amount of editorial control, or they will have to come up with a totally new financial model for their foray into the healthcare arena.

I am not sure they know the nature of the hornet’s nest they are stepping into.

The headline read: Electronic Health Records Don’t Lift Care.

Balderdash!

That’s like saying that cars don’t improve transportation compared to walking. Now, certainly if people don’t know how to drive, cars are not much use to them, but there is no way I would ever go back to practicing without my EMR. I couldn’t do it in good conscience.

To show why this is the case, let me go through my day today for you (this is not made up).

8:00 AM - Arrive in office, Log on to EMR. Check Schedule. Look over unfinished work on desktop. Look over labs from patients in office yesterday that came through interface. Any abnormal results are flagged and put on the top of my list.

Gentleman with wt loss and abdominal pain whose labs were OK, although sugar is up. I’ll address that later. Send him a letter:

Dear X:

Below is a summary of your recent labs:

Sodium: 135 Normal 135-148
Potassium: 4.3 Normal 3.5-5.5
Chloride: 99 Normal: 96-109
CO2: 23 Normal 20-32
BUN: 9 Normal: 5-26
Creatinine: 0.9 Normal 0.5-1.5
Glucose: 247 Normal 65-115
Calcium: 9.4 Normal 8.5-10.6

Summary: Electrolytes and kidney function are normal.

White blood cells: 6.3 Normal 3.5-10
Hemoglobin: 14.1 Normal 13-17
Hematocrit: 41.5 Normal: 38.5-52
Platelets: 266 Normal: 150-450

Interpretation: Normal - No Anemia or sign of infection.

Other labs look OK

All lab results get a letter. As of September we should be doing this through secure e-mail. I can’t wait.

8:15 AM - Check on Billing and Collections for the month so far. On target to be an OK month.

8:30 AM - Pretty much caught up on notes now. 1st patient (finally) in exam room. Check Protocols on each patient for labs/tests due and order appropriately (A1c, Lipids). I have actually picked up hypothyroidism a number of times as this reminds me to check a TSH on all patients with hyperlipidemia or osteoporosis. I have also become obsessive about mammograms/colon CA screening and have picked up a number of patients with early breast CA and adenomatous polyps.

I get a Framingham CV risk on each patient with hypertension, hyperlipidemia, and diabetes. This is how I gauge my treatment of lipids and hypertension. I generally show patients their risk on the screen in the exam room.

8:45 AM - Between patients, look over lipids that came back from yesterday. I run a Framingham risk on these as well and check all against NCEP guidelines:

Then I check to see how this compares to previous:

Doing better. Send a letter saying he is doing well.

9:00 AM - Noon

• Adult patients: We are enrolled in a clinical trial of reminders for GERD patients and the elderly on NSAID’s. Reminder only pops up when appropriate. This has definitely improved my care, as many patients don’t tell you if they are having significant GERD symptoms because they think it is just normal. Also it has helped me remember to use gastro-protective drugs when using NSAID’s in the elderly. Plus, we get paid for this. Not bad.
• I had a few patients I changed medical regimens significantly and so I printed a handout detailing the changes, giving them their medication list. They always appreciate leaving with something in their hands
• A gentleman came in for a depression recheck. He fills out a Beck inventory for depression and we follow the score serially. We do that on all depression rechecks.
• I alternated between adults and well-child checks during the first part of the morning. I love the little babies (especially the 2-6 month visits). Our EMR calculates the growth percentiles and automatically populates the growth curves. We print them out along with a table of the growth numbers, giving to the parents at each well visit. We also have a standard set of handouts given at each visit (that can be downloaded in PDF format from the website) and they put them in a 3-ring binder we give them at their first visit.
• I had a few patients who needed an EKG today (I do them every 5 years for hypertensive patients). The nurse hooks the leads directly into the USB port on the computer in the room and the EKG is imported directly into the patient’s chart with an interpretation. This makes it really easy to compare from previous EKG’s.
• When I do a routine follow-up for diabetes or hypertension, I check preventive protocols. I ended up ordering one mammogram and flagging myself in the future for when a colonoscopy was due (from a past history of polyps).
• Scheduling tests/consultations takes 2-3 mouse-clicks. I associate a diagnosis with the referral type and send it to our referral coordinator. Pt is sent to facility appropriate for their insurance with authorizations gotten if needed. This is often finished before I finish with the patient in the exam room.
• When we write prescriptions now, we fax them directly to the pharmacy. This ensures that the prescription gets there and it is generally ready when the patient arrives at the pharmacy. They love this fact.
• We are doing the PQRI pay for performance with Medicare. We are actually using a paper version of this because we could not think of a more efficient way to do it with the EMR. Our goal is efficiency, not being paperless. Yet the EMR helps tremendously when we have to look for DEXA scan results or diabetes numbers from the past. We should have no problem qualifying for the bonus (meager as it is).

I got done around 12:15 PM (I saw 13 patients this morning). Over lunch I catch up on any flags the nurses have sent regarding phone calls from patients. No charts are ever pulled for phone calls, and most of the phone calls are handled through protocols on our phone template, negating need to talk to the physician. Even if there is need to ask us questions, the process is very efficient.

Called Mrs. Dr. Rob at home. We got a piano delivered today. It’s the one I learned to play on that was in my parent’s home. They moved, and so needed to get rid of it. Yahoo!!

Also made plans to go to Borders tonight to wait with the kids for the release of the new Harry Potter book. Who will get first dibs? I have seniority!

1 - 4:30 PM

• Mix of well/sick, adults/kids - I generally see about 50/50 adults/kids, which I like. The sick visits take me about 5 minutes in general, and all documentation is done at the time of the visit. The well visits/routine follow-up take 15-20 minutes. The complicated follow-up is the main thing that requires some documentation after leaving the exam room. The rest is done when I leave.
• We do our billing on the EMR, sending it over to our billing software. Most of our billing is done when we leave the room, including immunizations, office tests, etc. Generally sick visits are 99213 (I almost never do a 99212) and rechecks are 99214 if there is any level of complexity to them. With EMR it is simple to appease the E/M gods - we have a way to check, but I know it well enough that I don’t have to check anymore.
• Sent off some labs and x-rays this afternoon. The local labs and radiology facilities accept the printed order from our EMR and don’t require paperwork.
• ADHD visits this afternoon - follow-up using Conner’s scale - form calculates T-Scores based on the age, sex, and whether parent or teacher is filling out form. We follow these scores serially as well.
• Old consults and radiology reports are scanned as PDF and in the patient’s chart within a day of receipt. Had to check cardiologist’s note to check patient’s story with what cardiologist said. Looked at old chest x-ray where patient had “Pneumonia” in the spring - just atelectasis.
• Last patient of the day had chest pain. It always happens on a Friday. EKG OK and had recent stress test. Start on Toprol and have him see Cardiology Monday. Send urgent flag that will appear on the desktop of our referral coordinator on Monday. She will fax my note and the EKG and get patient in on Monday or Tuesday.

It is now 5:45 and I am done. I have some labs to follow-up on, but I think I am going home and will just log on from there. I saw 13 patients this afternoon (total of 26 today - a fairly average day). Nurse questions are all answered. There are just 4 charts that need finishing (including that last patient). I’ll do them over the weekend when I get a chance.

I’d have been done much sooner if I had not been doing this.

You see how central our EMR is to basically everything I do. It improves my quality (without a doubt) and makes me more efficient. I’d probably do better without my stethoscope than without my EMR. Seriously.

Time to go home and play the piano.

Start Rant

OK, now that I caught your attention, I need to explain (before some of the wacky folks who visit Flea start thinking I am in their camp). First off, aside from germ theory, sterile technique, and public sanitation, I think immunizations have saved more lives and improved the quality of more people’s lives than nearly any other scientific discovery. Second off, I do not think there is any merit to the whole thimerosal/MMR/autism “debate.” I think vaccines are safe and should be used whenever possible.

So why say I hate immunizations? It is the business side of being a doctor that hates them, not the medical side. Immunizations:

• Are the largest line-item on our budget apart from staff salaries.
• Have incredibly small margins of profit, so any rejection, failure to pay by either patient or insurance company can turn our small profit into a loss.
• Are constantly changing, so it is never sure which immunizations are covered by whom, making it hard to know if we should bill the patient up-front or bill insurance.

Let me give a few illustrations.

Influenza Vaccine

It used to be that the influenza vaccine was something that we could not get our patients to take. “It just gives me the flu” was the common response when we tried to get patients get them. No matter what the evidence showed, patients just did not want to get that vaccine.

Then something strange happened. There were a few large flu epidemics and subsequent fear of a pandemic made people suddenly want to get the flu vaccine. Patients wanted flu shots, and our office ordered a large quantity of them for the flu season of 2005-2006.

Unfortunately, that was also the season when there was a manufacturing problem with the influenza vaccine and we suddenly could not get them. Now patients, instead of angrily refusing to get the vaccine, were furious that they could not get the vaccine. We actually had patients (who were not at high risk for influenza complications) scream at us because we would not give them a flu shot due to the fact that we were saving it for those who were at high risk.

This past year we again ordered a large quantity of vaccine, being assured that there was no manufacturing problem. We got our first 100 doses in September, but then were told it wouldn’t be until the end of November that we would get our next installation (of the 600 we ordered). Again we had angry patients.

To make matters more frustrating was the fact that Wal-Mart, Walgreens, and other pharmacies had plenty of flu vaccine. Why would we have problems getting them delivered to us while these businesses have plenty? I never got a good answer for that, but I have my suspicions that it regards a word that begins with “dol” and ends in “lar.” In any case, we canceled the remainder of our shipment because we did not want to get stuck with 500 doses and no patients to give them to. We would lose serious money from doing this - besides, we could just tell patients to get them at Wal-Mart.

The other problem we face is the use of influenza vaccines in children. The current recommendations are that children from age 6 months to 5 years of age be vaccinated. Yet, as Flea summarizes in his blog:

Shinga over at Breath Spa for Kids tells us about an analysis and comment article in BMJ on the efficacy and effectiveness of influenza vaccines.

It turns out that the inactive vaccines we fleas give to kids under 6 aren’t all that effective. For patients 6-23 months old the vaccine is no better than placebo, according the Cochrane Database of Systematic Reviews.

Live vaccines perform better, but we can’t give them to kids under 6 years of age.

The author of the BMJ piece, Tom Jefferson (presumably no relation to the founding father, but one never knows) concludes with not a small amount of disappointment that inactivated vaccines have little or no effect on the outcomes studied in the literature. In many cases, Jefferson notes, the methods used in these studies are poor.

At the end of the day, according to Jefferson, we need better study designs. In the meantime, we ought to ask ourselves why we make policy based on such crappy evidence?

Okay, I’ll ask the question: Why do we make policy based on such crappy evidence?

So we have the live vaccine (the nasal spray) that works well but is not covered by many insurances (and runs around $50). You can only use that between ages 5 and 50 - those who are least vulnerable and hardest to access. Then you have the less effective killed vaccine (the flu shot) that is the only one you can give to the high-risk populations. The low-risk people don’t want to pay the high price of the nasal spray (especially if insurance does not pay), so they use up the supply of the high-risk population.

Sigh.

I am not looking forward to flu season next year.

Adolescent Vaccines

“Some insurances don’t pay for adolescent vaccines,” my partner informed me yesterday. I wanted to give a girl the HPV Vaccine and the TDaP (The new vaccine for tetanus, diphtheria, and pertussis for teens and adults). We have to make these patients pay before getting the vaccine because we are not sure they will be covered by certain insurance companies. There have been several new vaccines for adolescents/pre-adolescents recently, including:

• Gardasil - the HPV vaccine. This is recommended by the AAP and CDC to be given to all girls starting at age 11. While there is a big controversy surrounding the vaccine, that is not what I want to address. The real problem for us is that it costs around $120 per dose, requires three doses, and is not covered by all insurances.
• Menactra - this is the meningiococcal vaccine. Meningiococcus is a bacteria that causes a devastating form of meningitis in teens and young adults (occasionally in younger children). It is on every doctor’s “dread” list, as it very rapidly kills previously healthy young people. This new vaccine is quite effective to prevent this disease and is recommended at age 11. It is required for entrance to college, yet many insurance carriers do not pay for it.
• TDAP - This vaccine is the tetanus booster that also treats pertussis, the bacteria that causes whooping cough. Studies have shown that the rate of pertussis in adults has steadily increased over the past number of years and this new vaccine helps prevent that. Yet insurance still does not reliably cover this.

On cue, I got the following communication from the AMA as I was writing this:

The AMA and the American Academy of Pediatrics co-hosted a meeting of key

stakeholder organizations last week to address many challenges for patients who

need vaccinations and the doctors who provide care for them.
One of the outcomes of the Immunization Congress is to establish several task

forces to pursue solutions to a specific set of problems surrounding access to

vaccination, medical practice costs, public health system shortfalls and how

vaccines are financed. Participants included 140 government and public health

officials, manufacturers, distributors, private payers, advocacy organizations,

pharmacy groups, community immunization providers and medical societies.


In related news, physicians who are experiencing problems with inappropriate

insurance reimbursements for immunization administration and vaccinations are

encouraged to file a compliance dispute under the multi-district litigation

(MDL) settlements with six of the nation’s largest health insurers. This process

has proved effective in making vaccines more available to patients, particularly

in North Carolina, where several outbreaks of meningococcal illness on college

campuses created demand for a vaccine that had been prohibitively expensive for

students.

Finally, the insurance reimbursement for these vaccines is often at or below the cost it is for us to buy the vaccine. We can (and do) make it up with “administration costs,” but end up having to raise the price for an already expensive vaccine just to make a profit.

So to summarize:

1. Immunizations are wonderful things that save lives and should be used more, not less.
2. Doctors have to buy the vaccines at very expensive rates and may not be paid by the insurance company, forcing them to charge the patient up-front or risk losing any profit.
3. The large number of new vaccines has made this situation far more confusing for patients and physicians.
4. Insurance companies capriciously set rates that are often not reasonable. They often continue not to pay for vaccines that are either required (for college entrance, for example) or greatly advantageous for patients.
5. Flu season has become a yearly debacle for my and many other physicians’ offices.

Rant completed.

Warning! This is a side of me that most of you do not know. I will be standing on a big ol’ soap box to shout this post out.

In his latest post, Flea talks about the phenomenon of Retail-Based Clinics (RBC) that are reportedly sprouting up around the country. These clinics are located in retail stores, such as Wal-Mart and Walgreens(I don’t think it is limited to stores beginning with “Wal,” however), and are staffed by Nurse Practitioners. The promise is that for a fair price (in the $50 range), you can be seen quickly (within 20 minutes) and have your problem taken care of. This gives the added bonus for those stores that the patients will be walking around the store while they wait to be seen as well as being far more likely to use their pharmacy after the visit.

The response from the medical community has been predictable. Lead by efforts of the American Association of Family Physicians, the idea of a “medical home” has arisen. A medical home is the “home base” for any given patient which will coordinate and/or deliver the bulk of the patient’s medical care. This is generally considered to be the realm of Family Physicians, Pediatricians, Internists, and to some extent OB/GYN’s. The clear message is that care should be physician driven and physician supervised. This drive has been joined by the American Medical Association, the American Academy of Pediatrics, and the American College of Physicians.

This sounds resonable to me. Why should patients fragment their care and get unsupervised care in a place with no access to their past medical history? Why should these companies be willfully trying to lower the overall quality of medical care?

Because the patients are sick of how doctors run their offices.

The view of the average physician is that patients have the opportunity to see them as long as there are spots on the schedule. Patients are there for the sake of the doctor - and they should be grateful for the good care they can get. It is worth it to wait to get good care, and those who don’t like it can go see another doctor.

Patients are often made to wait for many hours to be seen for even trivial problems. When urgent situations arise, such as a child with a fever or an acute back injury, often the first available appointment is not on the same day, and so the patient is given the choice to wait to be seen, or go to the ER or Prompt Care. Furthermore, even offices with “open access” scheduling which allows more patients to be seen on the same day force the patient through the maze of voice mail, phone menus, and non-medical operators. Oh yes, and you must call during the office hours and not during lunch.

What other industry operates this way? Why should it surprise us that patients are demanding better and entrepreneurs are responding to this need by side-stepping traditional physicians?

We have chosen to take a different approach to this threat. What we have learned is that we create very loyal patients when we respond to their needs. Here is how our practice has innovated to meet the changing needs of our patients:

1. We have a walk-in clinic from 7:30-9:00 AM and from 5:30-7:00 PM Every day. We are also open from 9:00 AM - Noon on Saturdays. These slots are for established patients (with some exceptions) and are triaged by the nurse to make sure it is truly a “quick sick” problem. We do not want to treat fatigue and depression as a walk-in. The rule of thumb is that these visits must be able to be handled in 5 minutes. When a patient tries to add on other chronic problems, we simply respond by saying, “that problem is too important for us to limit it to this 5-minute visit. We need to see you back for a scheduled appointment so it can get the time it deserves.” In 10 years, I have yet to have a patient object. In this situation the physicians rotate and so patients get whoever covers clinic that day.
2. We allow 1 work-in visit each hour to our schedule. These work-ins are also of the 5-minute variety. They can either by from patients walking into the office or calling ahead. In this situation, patients are preferentially scheduled with their regular physician.
3. We use an electronic medical record (and have been on it for the past 10 years) that lets us have quick access to the patients’ records and make assessments. Without our EMR, we would not really be able to do either of the first two items efficiently.
4. We are soon to launch a feature where patients will be able to request appointments and refills online. This will greatly reduce our phone traffic.
5. We are also soon to launch a “fast track,” where the patient can log on to our website and securely fill out their paperwork prior to coming to the office They can check their medications, allergies, update their social history,etc. prior to coming in. They can also fill out questionnaires pertaining to the type of visit they are having (well baby, diabetes recheck, sick visits, etc.) and all that information will go right into the patient’s chart on the EMR. When a patient has done this, the will be brought back to the exam room right away without having to fill out any paperwork. This will allow us to significantly shorten their waiting times while lessening our staff’s workload. Our goal will be to allow patients to be in and out of our office within 30 minutes for a quick visit.

I know that my patients understand it is better to get their care in one place. The problem is, the one place is often very difficult to get in to and so they seek alternatives. Our goal has been to give them the chance to see us without the hassle. This makes it far less likely for them to use the ER, Prompt Care, or Retail Clinic.

Instead of raising our fists in protest, we should take developments like Retail Clinics as a sign that we need to change. It is possible to do so and not compromise the quality of your care. Our office is going to be the first NCQA-Certified offices for the Diabetes Physician Recognition Program east of Atlanta in our state. Our quality numbers are far above the national norm, and patient satisfaction is quite high. I am convinced that we just need to learn to do better than we are doing rather than convince the consumer that we are already doing a good job. We have been able to do this and remain profitable. Our income has risen during a time when most physicians’ incomes are falling.

What’s the point? First, I get very tired of reading doctors whine about the state of things, thinking they are somehow powerless to change it. Yes, you cannot change the entire system, but you can make things better.

Second, I want folks to know what an “average” doctor can do. Yes, I am a geek, and quite intense…oh yes, and a little bit opinionated; but I am still just a private doctor in a small city in the south. This spring I am actually going to give a talk at the Spring ACP conference on the subject of practice innovation. Why? Because I am not scared to try.

Finally, I want to point out that we physicians are here for our patients and not the reverse. We need to not look at patients as the enemy. We need to not defend ourselves from their criticism, we need to listen to it.

Sounds crazy? You can come down and visit our practice and see us doing it.

Is this too serious for you? Well, then maybe you should just unleash your inner monkey…