"In the future we might not prescribe drugs all the time, we might prescribe apps." Singularity University's executive director of FutureMed Daniel Kraft M.D. sat down with me to discuss the biggest emerging trends in HealthTech.
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These are the slides from my talk at the 4th Annual Putting Patients First Conference in Mumbai.
If god were to manifest the world using technology, he would first create something like social media. Conceptually provide technology with the ability to understand the thoughts of a population
Further, anyone can setup an online site related to a treatment, a disease, a doctor, a drug , a concept or anything and see it grow into a popular site which in effect is simply the manifestation of a community which exists/ed but which no one ever knew of.
Obtaining informed consent is one of the most important things that a surgeon does.
I’d argue that obtaining informed consent is one of the most important things that a surgeon does — akin to the last stitch of an aortic anastomosis, the life-saving jolt of electricity to jumpstart a fibrillating heart, or the first pass of a scalpel during an emergent laparotomy.
Informed consent defines 21st-century medicine, contrasting sharply to the days of paternalistic care. Informed consent, when done properly, puts decision making into the hands of our patients. It can serve as a checkpoint to discuss goals of care and what constitutes a meaningful life for a particular patient.
It’s time we teach our trainees how to obtain informed consent the proper way. We need to slow down, pull up a chair, and look people in the eyes. We need to truly know our patients — how they understand their diagnoses, how they interface with medicine, their socioeconomic status, and education level. We must address goals of care with clear “if-then” statements.
When I teach younger residents how to obtain informed consent I often harp on a concept I learned in my undergraduate psychology class called theory of mind. Theory of mind is defined as “being able to infer the full range of mental states (beliefs, desires, intentions, imagination, emotions, etc.) that cause action.” In my opinion, theory of mind is an integral part of the consenting process that allows us to reverse roles, to see the world how our patients see it.
Halfway through obtaining informed consent from my patient, my attending steps in. He snags a stool from the corner of the room. He sits directly in front of the sick man. He talks about what life will be like for him as a new amputee.
He emphasizes the importance of diabetes control and smoking cessation. We may do everything we can and the man still may die. Would he want to live if it meant he could never go home again? He conveys the gravity of the current situation in a way that is pitch perfect. This, I think to myself, is how it’s done.
For surgeon trainees, just like making our first cut, informed consent is a skill learned by example and should be done under the watchful eye of our mentors. It’s time to pay it forward. Next time you are the chief resident, the senior attending, or anywhere in between, take a trainee with you and teach him or her how to obtain informed consent the right way. Do away with the notions of “efficiency” and speed. Your patients and your pupils will be eternally grateful.
If you are in India and are interested in using a cloud based solution for informed consent which is in accordance with the supreme court guidelines, please leave a message in the comments.
We launched http://doctor.myconsent.in/ about 6 weeks back and it is in Private Beta at the moment.
A new survey shows 96% of mobile health application users and medical professionals believe mobile health apps "improve their quality of life."
Meanwhile, 86% of providers surveyed said mobile health apps will improve their knowledge of patients' medical conditions.
For the survey, researchers polled 1,000 mobile health app users and 500 medical professionals.
Overall, the survey found that 96% of surveyed mobile health users and medical professionals said that mobile health apps "improve their quality of life."
Among mobile health app users, the survey found:
Among surveyed health care professionals, the survey showed:
In a study it was concluded that Web-based questionnaires can be used to validly collect data on many chronic disorders, allergies, and blood pressure readings among pregnant women
The aim of the said study was to assess the validity of a Web-based questionnaire on chronic medical conditions, allergies, and blood pressure readings against obstetric records and data from general practitioners.
The background of the said study is that Self-reported medical history information is included in many studies. However, data on the validity of Web-based questionnaires assessing medical history is scarce. If proven to be valid, Web-based questionnaires may provide researchers with an efficient means to collect data on this parameter in large populations
Self-reported questionnaire data were compared with obstetric records for 519 pregnant women participating in the Dutch PRegnancy and Infant DEvelopment (PRIDE) Study from July 2011 through November 2012.
These women completed Web-based questionnaires around their first prenatal care visit and in gestational weeks 17 and 34. We calculated kappa statistics (κ) and the observed proportions of positive and negative agreement between the baseline questionnaire and obstetric records for chronic conditions and allergies.
In case of inconsistencies between these 2 data sources, medical records from the woman’s general practitioner were consulted as the reference standard. For systolic and diastolic blood pressure, intraclass correlation coefficients (ICCs) were calculated for multiple data points.
more at http://www.jmir.org/2015/6/e149/
Thanks to technology, Gary Sullivan enjoys a new kind of relationship with his doctor. If he wakes up with a routine health question, the 73-year-old retired engineer simply taps out a secure message into his doctor’s electronic health records system. His Kaiser Permanente physician will answer later that day, sparing Sullivan a visit to the clinic near his Littleton, Colo., home and giving his doctor time to see those with more urgent needs.
Once you took medical questions directly to your doctor, who advised, tested and treated you. Today, not only are we turning to the Internet for everyday medical information, we’re also generating our own health data: using a smartphone, for example, to investigate a child’s ear pain or monitor blood pressure. We’re learning from our peers online how to cope and find new treatments. Our doctors can keep our records electronically, accessible to us through a patient portal. Some of us can make video visits with doctors, who can offer diagnoses and treatment plans via computer or smartphone.
With all these advances, a traditional paternalism in medicine is changing, too.
Online records, video consultations , text messaging based Q and A's and smartphone apps for medicine have now started gaining acceptance and are transforming the traditional clinic appointments and visits. This disruption in the patient provider workflow is to everyone's advantage.
The market of mobile health (mHealth) apps has rapidly evolved in the past decade. With more than 100,000 mHealth apps currently available, there is no centralized resource that collects information on these health-related apps for researchers in this field to effectively evaluate the strength and weakness of these apps.
The objective of this study was to create a centralized mHealth app repository. We expect the analysis of information in this repository to provide insights for future mHealth research developments.
We have developed a centralized resource that provides detailed information of more than 60,000 health-related apps from the Apple App Store and the Google Play Store. Using this information resource, we analyzed thousands of apps systematically and provide an overview of the trends for mHealth apps.
This unique database allows the meta-analysis of health-related apps and provides guidance for research designs of future apps in the mHealth field.
Doctors are using digital tools and willing to receive data feeds from their customers, but they are quite frustrated by poor usability of digital healthcare tools and difficulty getting measurable results
• EHRs are typically hard to use. Many doctors I know complain of spending several extra hours each day entering data to EHRs. In some practices medical scribes have been added to help with data entry.
• Doctors feel they have tons of data available to them, but few tools to use it to make intelligent and timely decisions.
New survey data from digital health agency Klick Health shows that diabetes patients who use digital tools to manage their health also feel healthier.
Klick Health employed Survey Sampling International (SSI) to poll 2,000 American adults with diabetes either online or via the telephone.
Based on responses about how they use technology to manage their health, they segmented the group into three categories: those who manage their health daily or weekly with integrated digital technologies (integrators), those who go online to seek health information on a monthly basis (seekers), and those who don’t use the internet to manage their health at all (traditionalists).
The integrators group, the true digital health users, made up just 18 percent of the sample, but 13 percent of integrators reported being in excellent health. Seekers made up 47 percent of the sample and 4 percent of seekers said they were in excellent health. Finally, the remaining 35 percent were traditionalists, and only 2 percent of that group reported being in excellent health.
Because it’s a survey based on self-reported health status, the data doesn’t prove that connected patients are actually healthier than non-connected patients. But it does provide evidence that either they’re healthier or they believe they’re healthier, which is significant in and of itself.
Nineteen percent of patients reported using mobile technology for a health-related activity. Of these, most wanted more data-driven interactions with their doctors. Two-thirds said they would like an app to remind them to take their medication, 75 percent wanted apps to connect them with their doctors, and 78 percent were open to sharing personally-collected health data with their doctors.
Overall, 80 percent of the mobile connected group were interested in having an app recommended to them by their doctor.
Whether newly insured, seeking care for the first time as an adult or disgruntled with a current provider, prospective patients represent golden opportunities for healthcare systems, hospitals, physicians and practices. Although organizations go to great lengths to attract local patients, many overlook the power of online physician profiles to boost their organizations’ local visibility and enhance the patient experience. These three step will show how physician profiles enhance the patient experience, how organizations can create successful physician profiles, and how timely real-world content can help.
Step 1 – Enhancing the patient experience
While two-thirds of consumers in a recent Strategy & survey of 2,339 U.S. residents indicated they were satisfied with their core healthcare benefits and 63% were satisfied with the cost and quality of their healthcare, less than half (40%) were satisfied with their overall experience shopping for healthcare and/or insurance.
Step 2 – How to create successful physician profiles
Search engine algorithms and their decision-making processes change often, but certain concepts and tactics remain consistent. Follow these steps to create successful physician profiles and ensure a strong digital presence, especially within local search results and on mobile devices.
It is important that all online hospital, practice and physician listings are accurate and up-to-date. All content contained in physician profiles should be current and fresh. Address and phone numbers should absolutely be correct and current, but this is just the beginning. Profiles should also contain current information regarding services offered, hours of operation, degrees, experience, accepted insurance plans, languages spoken and more. All of this information should be maintained and updated across all listings on owned and third-party sites.
Step 3 – Leverage timely real-world content to boost relevance and traffic
Being attentive to timely high profile health stories occupying the minds of current and prospective patients can pay big dividends for organizations seeking to stay top of mind and increase traffic to their websites and facilities by providing valuable information to the public. The simplest and most effective way to get started on this initiative is to align content and messaging with relevant high volume search terms.
Once physician profiles are in place and optimized for success, identifying and catering to timely concerns on the minds of current and prospective patients can take these patient acquisition tools to new heights. With few organizations effectively capitalizing on this local search marketing fundamental, healthcare organizations that embrace the opportunity often realize significant and prompt results.
At @plus91 we have been advocates of Online Profile Creation and Effective Management for All Physicians, Surgeons, Clinics and Hospitals as we believe its the foundation for providing the widespread benefits possible from Digital Health. Here is a post I did on the topic which was part of a book which came out a few years back.
Google Translate has only 57.7% accuracy when used for medical phrase translations and should not be trusted for important medical communications.
However, it still remains the most easily available and free initial mode of communication between a doctor and patient when language is a barrier.
Although caution is needed when life saving or legal communications are necessary, it can be a useful adjunct to human translation services when these are not available.
Read the research paper below which formed the above conclusion.
Communication is the cornerstone of medicine, without which we cannot interact with our patients. The General Medical Council’s Good Medical Practice states that “Doctors must listen to patients, take account of their views, and respond honestly to their questions. However, we still often interact with patients who do not speak the local language.
In the United Kingdom most hospitals have access to translation services, but they are expensive and often cumbersome. A complex and nuanced medical, ethical, and treatment discussion with patients whose knowledge of the local language is inadequate remains challenging. Indeed, even in a native language there is an element of translation from medical to lay terminology.
We recently treated a very sick child in our paediatric intensive care unit. The parents did not speak English, and there were no human translators available. Reluctantly we resorted to a web based translation tool. We were uncertain whether Google Translate was accurately translating our complex medical phrases. Fortunately our patient recovered, and a human translator later reassured us that we had conveyed information accurately.
We aimed to evaluate the accuracy and usefulness of Google Translate in translating common English medical statements.
Ten medical phrases were evaluated in 26 languages (8 Western European, 5 Eastern European, 11 Asian, and 2 African), giving 260 translated phrases. Of the total translations, 150 (57.7%) were correct while 110 (42.3%) were wrong. African languages scored lowest (45% correct), followed by Asian languages (46%), Eastern European next with 62%, and Western European languages were most accurate at 74%. The medical phrase that was best translated across all languages was “Your husband has the opportunity to donate his organs” (88.5%), while “Your child has been fitting” was translated accurately in only 7.7% (table⇓). Swahili scored lowest with only 10% correct, while Portuguese scored highest at 90%.
There were some serious errors. For instance, “Your child is fitting” translated in Swahili to “Your child is dead.” In Polish “Your husband has the opportunity to donate his organs” translated to “Your husband can donate his tools.” In Marathi “Your husband had a cardiac arrest” translated to “Your husband had an imprisonment of heart.” “Your wife needs to be ventilated” in Bengali translated to “Your wife wind movement needed.”
Google Translate is an easily available free online machine translation tool for 80 languages worldwide. However, we have found limited usefulness for medical phrases used in communications between patients and doctor.
We found many translations that were completely wrong. Google Translate uses statistical matching to translate rather than a dictionary/grammar rules approach, which leaves it open to nonsensical results.
Biogen Idec has partnered with Google X, Google’s business unit for long-term “moonshot” projects, to study outside factors that might contribute to the progression of multiple sclerosis (MS), according to a report from Bloomberg.
Using de-identified patientdata from its Down Syndrome Registry, theNational Institutes on Health has launched a subsite of its DS-Connect, creating a web portal for approved professionals that are planning clinical studies or recruiting patients to generate new research.
The NIH effort with Down Syndrome is intended to increase understanding of the disease and how to treat accompanying health problems, including the risk of autism, issues with hormones and glads, hearing loss, vision problems and heart abnormalities, officials said.
Researchers can view information on a participant’s health history, including symptoms, diagnoses and other medical information.
If approved for a higher level of access, researchers can perform customized searches of the data, proposed new survey questions or identify a pool of patients for clinical trials. The registry will coordinate requests for the latter with eligible participants who have indicated a willingness to enroll.
"Although computers and EHRs can facilitate and even improve clinical documentation, their use can also add complexities," according to a new paper from the American College of Physicians, which offers its take on usage strategies and better system design.
"In the past decade, medical records have become increasingly synonymous with electronic health records," write the authors of the new report, "Clinical Documentation in the 21st Century," published in the Annals of Internal Medicine.
In the not-too-distant future, EHRs – and the clinical notes contained therein – will evolve: "Existing technology, such as registries, portals, connected home monitoring devices and provider- and patient-controlled mobile devices, as well as technology not yet in use or even built, is likely to integrate with or possibly even replace the EHR (as currently conceptualized) as a primary vehicle for viewing and recording clinical documentation," they write.
Patient education used to be a cookie-cutter operation: Hire a spokesperson, plan an event and draft a static list of symptoms, then call it a day.
But in the wake of groundbreaking campaigns from AstraZeneca and Novartis, the industry may well have to raise its content-creation game—and cede considerable control to super-informed patients in the process.
Larry Dobrow reports on the two programs that have raised the
After an initial diagnosis, diabetes sufferers often experience a period of shock when they learn that everything has to change. Turkish mobile operator, Turkcell, and agency R/GA London have created an app to make adjusting to the necessary life changes much easier.
Instead of trying to persuade sufferers to adopt entirely new habits, tools and behaviors to monitor the condition, "healthmetre" deploys Instragram, a tool many people already use and taps into behaviors that people already have.
R/GA designed healthmetre to be a more human way to manage diabetes and help patients develop new, more healthy habits in a way that feels natural and thereby, helping them reach a level of consistency.
The idea is to make using the app as simple as possible, helping people stay motivated, complying with treatment and keeping the lines of communication with medical staff open.
Diabetes is an increasing problem across the world and Turkey has been particularly affected. The most recent statistics (2014) from the International Diabetes Federation show that Turkey has the highest rate of the illness in Europe, with an incidence of 14.7%, much higher than countries like, for example, the U.K. (5.4%) or mid-ranked Germany (7.9%).
The results of the 18-month trial are highly encouraging. Treatment compliance increased by 54%. Blood sugar levels decreased by 27% and complication forecasts decreased by 37%.
The worst part of a sniffle or a sore throat is wondering what it is you're coming down with
A new app, called HEALTHYDAY, comes from a division of Johnson & Johnson and uses sickness-searching algorithms to take the guesswork out of your hypochondria by warning you when the flu is overtaking your neighborhood or pollen is driving allergies sky-high. as a kind of subtle advertising for its products.
The basic health tips the app offers up don't outright tell you which medicines to buy — instead they are each "brought to you" by one of the company's over-the-counter brands, which include Zyrtec and Tylenol.
The app's algorithm syncs self-reported data from local doctor's offices, Google searches, social media mentions on Twitter and Facebook and user data from people who use the app, then funnels it down into easily digestible trends, blurbs and infographics, according to McNeil's VP of marketing Katie Devine.
In San Francisco, for example, the app warns of a particularly high risk of allergies and cold symptoms and a middling likelihood of the flu.
The team wants to expand the app's features with more ailments and information once it has a bigger user base.
The mobile health industry has been revolutionizing the way both doctors and patients approach medicine today. When it comes to addressing health issues, mobile health consumers are moving toward preventing disease and increasing fitness and wellness. Through fitness trackers and wearable devices, more patients are now focused on exercise and diet.
New technology developed by Howard Hughes Medical Institute (HHMI) researchers makes it possible to test for current and past infections with any known human virus by analyzing a single drop of a person's blood. The method, called VirScan, is an efficient alternative to existing diagnostics that test for specific viruses one at a time, according to the scientists.
With VirScan, researchers can run a single test to determine which viruses have infected an individual, rather than limiting their analysis to particular viruses.
That unbiased approach could uncover unexpected factors affecting individual patients' health, and also expands opportunities to analyze and compare viral infections in large populations. The analysis reportedly can be performed for about $25 per blood sample.
“We've developed a screening methodology to basically look back in time in people's sera and see what viruses they have experienced,” says Stephen J. Elledge, an HHMI investigator at Brigham and Women's Hospital who led an international team that developed VirScan. “Instead of testing for one individual virus at a time, which is labor intensive, we can assay all of these at once. It's one-stop shopping.”
VirScan works by screening the blood for antibodies against any of the 206 species of viruses known to infect humans. The immune system produces pathogen-specific antibodies when it encounters a virus for the first time, and it can continue to make those antibodies for years or decades after it clears an infection. That means VirScan not only identifies viral infections that the immune system is actively fighting, but also provides a history of an individual's past infections.
Mobile phones with operating systems and capable of running applications (smartphones) are increasingly being used in clinical settings. Medical calculating applications are popular mhealth apps for smartphones. These include, for example, apps that calculate the severity or likelihood of disease-based clinical scoring systems, such as determining the severity of liver disease, the likelihood of having a pulmonary embolism, and risk stratification in acute coronary syndrome. However, the accuracy of these apps has not been assessed.
The objective of this study was to evaluate the accuracy of smartphone-based medical calculation apps.
The results suggest that most medical calculating apps provide accurate and reliable results. The free apps that were 100% accurate and contained the most functions desired by internists were CliniCalc, Calculate by QxMD, and Medscape. When using medical calculating apps, the answers will likely be accurate; however, it is important to be careful when calculating MELD scores or Child-Pugh scores on some apps. Despite the few errors found, greater scrutiny is warranted to ensure full accuracy of smartphone medical calculator apps.
Read the entire publication abstract at : http://www.ncbi.nlm.nih.gov/pubmed/24491911
Although many people with serious diseases participate in online support communities, little research has investigated how participants elicit and provide social support on these sites.
This study by Yi-Chia Wang, Robert E Kraut, John M Levine Uses Computer-Aided Content Analysis to Examine the Dynamics of Online Social Support.
A high percentage of people with chronic or life-threatening diseases use online resources to obtain information about their condition and ways to cope with it. Although informational websites are the most popular, many people—especially cancer patients and survivors—participate in online health support communities.
A recent meta-analysis suggested that online support communities are effective in decreasing depression and increasing self-efficacy and quality of life. Although several clinical trials suggest that participation in Internet-based support communities improves emotional well-being, conclusions are ambiguous because most interventions have multiple components of which support group participation is only a part.
Moreover, research also shows that support interventions often do not provide the benefits they were designed to produce. Thus, much remains to be learned about when and why support is effective in online communities.
Conclusions of this study :
Self-disclosure is effective in eliciting emotional support, whereas question asking is effective in eliciting informational support. Moreover, perceptions that people desire particular kinds of support influence the support they receive. Finally, the type of support people receive affects the likelihood of their staying in or leaving the group. These results demonstrate the utility of machine learning methods for investigating the dynamics of social support exchange in online support communities.
more at : http://www.jmir.org/2015/4/e99/
Large computerised patient databases provide a useful source of real life observational data, and the General Practice Research Database (GPRD) has been successfully used to generate descriptive epidemiology data in chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD) and asthma from a large group of UK primary care practices.
Historically the limitations of the GPRD for clinical research were a time gap between GP data capture and availability for the researcher and limited links to other healthcare databases, although these are currently being addressed with the development of the Clinical Practice Research Datalink (CPRD) and in ongoing pilot work for Phase 4 pragmatic clinical trials . The use of electronic medical record (EMR) data in health research is a key objective in the Department of Health‟s national research strategy ]. EMR is increasingly adopted to support both efficiency and quality of patient care and to facilitate clinical research. Several studies have described the design and implementation of EMR, electronic data capture (EDC), data extraction and EMR retrieval systems to enable accurate and efficient data entry for clinical research to be performed on-site in real time .
In asthma and COPD, the application of EMR retrieval systems would enable the monitoring of large patient populations to support evaluation of comparative effectiveness, safety, and health care resource utilisation (HRU) of treatments in a real life setting.
Conclusion: Apollo and SIR data extracts into NWEH-LDB showed a high level of concordance for asthma and COPD patients. Longitudinal data analysis characterized the COPD and asthma populations in Salford including medications prescribed and health care utilisation outcomes suitable for clinical trial planning
Access the PDF at http://www.biomedcentral.com/content/pdf/s12911-015-0132-z.pdf
Although wearable devices have received significant attention for their ability to track an individual’s physical activity, most smartphone applications are just as accurate, according to a new research letter in JAMA.
The study tested 10 of the top-selling smartphone apps and devices in the United States by having 14 participants walk on a treadmill for 500 and 1,500 steps, each twice (for a total of 56 trials), and then recording their step counts.
Led by researchers at the Perelman School of Medicine and the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, this study is a follow-up to a recent JAMA viewpoint suggesting that there’s little evidence that wearable devices alone can change behavior and improve health for those that need it most.
Google is changing the way it displays search queries to pull medical facts directly into its results.
The medical information is being added to the company’s Knowledge Graph, which underpins Google’s instant search results and powers Google’s Now personal assistant and app. It will allow health questions to be answered directly, without a user having to click.
Google already does this with dictionary definitions, schedules for big sporting events and Wikipedia extracts for famous people. Knowledge Graph is essentially a built-in encyclopaedia, which pulls in facts, data and illustrations from various sources.
One in 20 searches on Google are health-related, according to the company. “We’ll show you typical symptoms and treatments, as well as details on how common the condition is – whether it’s critical, if it’s contagious, what ages it affects, and more,” said Prem Ramaswami, a product manager for Google’s search.
The future of health looks a lot like the fitness tracker you might already wear on your wrist or your waistband.
But instead of just keeping tabs on your activity level, high-tech sensors embedded throughout your home, your car and maybe even under your skin will keep tabs on your every waking moment.
And your sleeping moments too.
"A whole new day is coming," said Dr. Eric Topol, a cardiologist and director of the Scripps Translational Science Institute in La Jolla, considered a pioneer in the field of digital medicine.
This near-continuous data dump will revolutionize our healthcare system, Topol predicted, and will lead to micro-personalization of our diets, workouts, homes and even medical treatments.
The upshot, he said, is that this data onslaught puts control of your health back where it belongs: with you.
In many ways, the datafied future is already here, as much of that data are available but not yet used. The challenge will be to gather information from multiple sources and present it in a way that inspires more healthful activity and doesn't drive users to hypochondria.
Does your fitness tracker, for instance, motivate you to move 10,000 steps a day over the long run? But what if it alerted you that on days when you get 30 minutes less sleep than usual you tend to miss your goal? That might motivate you to get more sleep,.
Gradually, both will become integrated across the continuum of care. The reality is that, mHealth has succeeded and it has emerged as the winner and is changing the rules of healthcare.
A mhealth app (mobile based application) for managing diabetes is now US FDA approved, and has been allocated a ‘drug code’, which means that doctors can now prescribe an mHealth app in a similar manner as medicines ( drugs) and this will be reimbursed by the insurance companies. Now mHealth apps have the same status as drugs in the United States !
As patients become familiar with medical records and clinical notes, they consider new opportunities and risks. Some say they have become more careful about what information they share with clinicians, and some ask for more control over access to their information.
Providers are experimenting with strategies that help patients protect their privacy with regard to mental health, sexual function, suspected abuse, or other sensitive topics. And though family caregivers may find that reading notes improves their understanding of care plans and reduces stress, it's a complex task to establish separate proxy access based on patients' preferences about who gets to see what.
As transparent practice evolves, it's impossible to predict how much patients may stray from long-standing conventions. Portals afford patients secure access to their information, and doctor–patient confidentiality remains undisturbed.
But patients' attitudes toward privacy may change as online access allows them to share documents, including notes. A third of patients in the OpenNotes study expressed concern about privacy, but more than one in five shared a note with others who could clarify meanings, offer clinical insights or second opinions, or — for those participating in the patient's care — improve their own knowledge. Indeed, some patients may choose to post their providers' progress notes on Facebook, Twitter, medical forums, and other social media, potentially exposing clinicians to public scrutiny and crowd-fueled praise or criticism.