Miracle Workers at Shifa

Frankly I too am amazed at the success of Shifa Clinic. I think there is tremendous potential, especially with the excellent staff on board. I remember Saeed had started to offer medical advice through his homepage while still in medical school, well before the formation of Chowk. It`s nice to see two great ideas merge and become a success.

Bravo Shifa!

Very well Umair, well informative and mature piece. I am pleased to see such good, sincere and devoted people in our community.

Hats off to the Miracle Workers of Shifa.

You are absolutely right Umair, they are the gems of Chowk.

From the depths of my heart: Thank you all.

A question: How can one extend the influence of the resident medical expertise at Chowk to a wider segment of the population in Pakistan? The benefits are obvious.

A suggestion: We should seriously think of defining Shifa as a prototypical Cyber-Clinic. Apart from free consultations, it could also have a system for referrals and on-line appointments, again with obvious benefits to Chowk and to the practitioners. Obviously the method of conducting the business of medicine can be expanded to include the capabilities of a new medium.

a very well written, moving article. how nice it is to come across someone whose sense of wonder is still intact.

shandana

Re Wasiq:

Yes there is much that can and should be done to widen the scope of Shifa online and then to hook it up with channels/institutions off-line. The first order of the day (and one that will need to remain a priority) is staffing it further and increasing its network of doctors. Then we need to staff it with non-medical personnel - people who will help with technical development, staffing, marketing, financing, and building affiliations/partnerships with health providers (all over the world of course, not just Pakistan).


Re: Shandana and ``a sense of wonder``

Chowk will do that to you. Its the perfect antidote to... everything that one needs an antidote for :).

Re Anita.

Yes there is much energy in ``Internet telemedicine`` arena all of a sudden - Telemedicine itself has been around for some time of course.

Telemedicine on the Internet however is still in its infancy - there was no site worth the mention in 1996. Since the last year or two some very good initiatives have come up - the bulk of the sites out there though, are more ``medical repositories`` than true telemedicine. A few are by-charge only, others are doctor to doctor consultation only. There is for example, mediconsult.com which charges about $200 per consultation. There is partners.telemedicine.org (MGH initiative I think) which gives free consultation to doctors only. Its business model goes by generating inpatient and outpatient service usage - they generated over $500,000 in revenue in hospital services last year triggered by the free on-line consultations by their panel of experts.

So there are (at least ) two clear business models that telemedicine can follow. More (hybrids etc.) will develop naturally. Interestingly because of the nature of this medium, I dont see telemedicine being monpolized by the Big Names at all. Any successful telemedcine venture simply needs a partnership between technology and medicine. An ISP and a private clinic can launch a successful (i.e. profitable) telemedicine practice - and many will in the coming years. You dont need Mass General or Exxon.

And then there is the realm of medical services that are not strictly telemedicine in being a ``legally defined consultation`` but still invaluable. ``Guidance counselling/information dispensing`` is one - Shifa`s present turf. Even easier but very helpful is content such as Medical news & articles, excerpts from Medical journals (paraphrased for public consumption), Health encyclopedia/references, etc. The usual (and much maligned) Internet business models would apply to these services/content websites. As Andy Grove said in a speech at a recent convention, the Internet will revolutionize Healthcare and health management.

Many of these ideas and issues are exactly what I and the Shifa staff debate as we plan Shifa`s progress.

Umair, I totally agree with you - the potential benefits of information technology and computerization to Medicine are enormous, and are finally being realized. Just within the last year, there’s been so much change in our work environment for the better. The vast majority of communication among colleagues is now via e-mail instead of phone/pagers. I write all my clinical notes on-line - letters to referring physicians and patients are generated automatically from these (patients love having copies of all their notes), our order entries are computerized, billing is computerized, the pharmacy is on-line, laboratory results are on the Web, the medical record is electronic. The availability of MEDLINE on WWW for free (has abstracts of all medical articles published in indexed journals since 1966) puts more than 30 million scientific articles within reach of our fingertips. Many investigators now list their e-mail addresses in the abstract, so there is the ability to e-mail specific experts for their opinion on an unusual or rare condition. At Children’s there are templates for ER notes, discharge notes, clinic notes. Clicking on a few buttons generates the note in most ``standard`` illnesses. For example, if I see a three year old with ear pain, I can click on ``three years``, ``ear pain``, ``physical exam``, and I’ll get one of several algorithms to go down on depending on the history and findings. After choosing the most appropriate one, I have the choice of choosing one of several treatment options with headings like ``Otitis Media -Standard Plan`` and I have a note that has the history, the findings, the treatment (with the right dose of antibiotic calculated etc.), a printed prescription, and a hand-out for the patient with information about ear infections and the treatment given to that specific child, at the click of a few buttons. What I really enjoy is the look of astonishment on the patient’s face. They can’t figure out how I generated such a comprehensive note in the space of a couple of minutes.


Children’s Hospital, Boston has been a leader in Medical Informatics (The Sept 15’ ‘98 Annals of Internal Medicine article is from here). A friend of mine who has his own software firm, but is also a physician (trained as a pediatrician at Children’s) has been doing some amazing stuff to improve the efficiency and productivity of the hospital staff. Situations where there is a lot of room for improvement are enhanced communication with patients to supplement face to face physician-patient encounters. For example, ability of patients to make on-line appointments with physicians for non-urgent problems, the ability to make on-line referrals to other physicians within the system, informing patients of their laboratory results via e-mail, having Web sites that list all patient care services available, including physician credentials and areas of research (Children’s website does this - www.childrenshospital.org), answers to FAQs etc.

Coming to the question of the use of Internet for medical consultations, I can give you our experience and the problems with making it a revenue-generating operation. Presently, our system for offering consultation to patients and other physicians from outside the hospital is very inefficient. Community physicians either access the website, or call the main phone line. Patients call the main phone line, or send unsolicited e-mail via the web site. As a public service, each division dedicates a person who takes responsibility for getting back to the requester and provides consultation free of charge. For Infectious Diseases, I am that person (25% of my job description). The way the system works, is that whoever, and from wherever in the world (we routinely get out of state and international calls) or e-mails and asks for an Infectious Disease consult gets routed to my office. My secretary takes down a detailed history and e-mails me (or pages and e-mails me for urgents). I call them back according to the urgency of the problem, but within 24 hours, and also write an on-line note mailed back to my office (the recording is necessary for liability reasons).

Given the inefficiency of the system, and the volume of calls received, we have explored the possibility of having an Infectious Disease Website through which patients and other physicians seeking advice on a tough case can contact us, instead of the present calling on the phone system. However, there are several concerns. Firstly, since we offer this as a free service, we might be overwhelmed with requests, especially from people from whom we have no way of generating money. Children’s Hospital has been rated the number one hospital in the US (if not the world) for several years, so this concern is quite legitimate. Presently, only 5% of the calls that I handle result in the patient being seen at Children’s (barely enough to cover 25% of my salary - i.e. this service runs at a loss to the hospital). The remaining 95% are either calling from long-distance, or the patient is admitted at another hospital, or the problem can be taken care of by their own physician and a visit to Children’s is unnecessary, or its a patient already known to us, and its a follow-up call.

Secondly, for a patient calling directly who is from out of state, or from another country, it is illegal for me to be giving medical advice b/c I am not licensed in that state/country (its okay to be advising another physician, though), and its only a matter of time before states start cracking down on this (all we are waiting for is a couple of disasters to happen).

Thirdly, if we were to decide to charge for on-line consults, several problems arise: a) who would pay - physicians don’t want to, b/c in the managed care environment with intense competition for patients, they can easily find somebody who’ll do it for free as a matter of goodwill, or they’ll just develop a special relationship with a particular ID doc and bypass the call system (I get called by many community docs who’ve gotten to know me through the years, even when I am not on call - hey just today, a Saturday, a persistent doctor, now in Texas, who needed advice on a patient admitted at a local hospital, finding that he was unable to reach me at home, had me paged through the hospital operator. I was at the park with my daughter, and am not on call. So, I had to come home to find out who had paged me urgently to a number in Texas on Saturday - didn’t think to take my cell).

Insurers, obviously have conveniently refused to pay. So, it would have to be out of pocket expense for the patient. b) if we start charging patients on a credit card, tremendous ill will is created in the community which will backfire on our referral base. Additionally, if dishing out money from their own pocket is necessary, patients at least in the US and other industrialized countries are more likely to just seek medical care at a local expert’s office and have their insurance company foot the bill, or get their physician to call for them.

Fourthly, and most importantly, focusing on patients who contact us on-line, and trying to make money off them necessarily perpetuates, in fact, aggravates the disparity of health care offered to the haves and the have-nots. These represent the most educated elite who already have access to the best care. Most of us in academic medicine did not stay in academics to make more money. But that’s where the best expertise is available. Therefore, I do not see academic medical institutions starting to charge patients for consults given over the phone or via e-mail. These services should and most likely will remain free for anyone who seeks them.

On the other hand, I see a lot of potential for revenue generation in situations where small hospitals contract with academic medical institutions to tap into their expertise, since these are win-win situations for everyone involved. Let’s say a small peripheral hospital (P) contracts with the academic center (A) for neurological services. A patient with stroke presents to P. P has no neurologist of its own but contacts A’s neurologist and sets up a video-link through which the neurologist at A watches P’s doctor perform a history and physical exam, has opportunity to ask questions, and can look at the MRI and advise on further management. The patient wins b/c he/she doesn’t have to be transferred to a hospital far away from home, the peripheral hospital wins b/c they do not lose revenue on this patient, and also get away without having to have a neurologist on staff with his/her salary and benefits. The academic center wins b/c they can influence practice in a larger area, as well as make money on the consult. The insurance company wins b/c they are not saddled with the substantially increased costs of medical care at a tertiary care hospital.

This is I think the business model of Telemedicine that is the most viable, and will increasingly be seen. Of course international video-links are also possible and no licensure rules are violated since all care is directed through the local physician.

From the medical side anyway, there is an active effort underway from the Big Names to capitalize on Telemedicine technology. That is the model that the New England Medical Center is building with its international program. MGH is also actively building a program. Saad has been working on validating the accuracy of the neurological exam over a video-link so that the Neurological Service can expand its patient base to outside Massachusetts. Most academic medical centers that I am aware of now have an Informatics Department with full-time employees working on expanding their services. As you say, Medicine and Information Technology are finally getting married as we speak.

Anita

Not to deny the potential benefits of the Shifa Clinic and other such efforts. But these sites can also turn people into neem hakeems (semi-docs). And there is a well know urdu proverb: ``Neem hakeem vabal-e-jaan``.

Re: Goga
I `ve heard it as:

Neem Hakeem khatra-e-jaan,
Neem Mulla khatra-e- Iman.
There can of course be many colloquial variants of the saying, so yours can also be just another variant.

As for the premise of people becoming neem hakeems after reading Shifa,required reading clearly reminds people to see real docs. As opposed to the traditional model, where the patient was expected to know nothing about his illness, and was to have `faith` in the healer, modern medicine has (finally) learnt to respect people`s right to be knowledgeable about what ails them.

Some docs still find a knowledgeable patient or family quite threatening, but personally I believe that part of my duty to the patient is also to educate them and point them to other reliable sources of knowledge. An educated patient is much better equipped to handle his/ her illnesses, and able to make better informed decisions with their doctors.

Those who write to Shifa are not our patients, these are just folks looking for knowledge.

where can i see the previously asked questions at shifa
and how can i ask any question from shifa cyber clinic

do you know of any good psychiatrist in islamabad?
urgent reply needed. mqikram@yahoo.com