e-Patient Dave IKF March 23 2013

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e-Patient Dave IKF March 23 2013

  1. 1. JAMIA, 1997 e-Patients Can Help Improve Healthcare “e-Patient Dave” deBronkart Twitter: @ePatientDave facebook.com / ePatientDave LinkedIn.com / in / ePatientDave© e-Patient Dave© e-Patient Dave dave@epatientdave.com Skype: ePatientDaveRe-use is permitted with this noticeRe-use is permitted with this notice
  2. 2. How I came to be here •  High tech marketing •  Data geek; tech trends; automation •  2007: Cancer discover & recovery •  2008: E-Patient blogger •  2009: Participatory Medicine, Public Speaker •  2010: full time© e-Patient Dave •  2011: internationalRe-use is permitted with this notice © e-Patient Dave Re-use is permitted with this notice
  3. 3. “I want to note especially the importance of the resource that is most often under- utilized in our information systems – our patients” Charles Safran MD, Beth Israel Deaconess quoting his colleague,Warner Slack MD Testimony to the House Ways & Means subcommittee on health, 2004© e-Patient DaveRe-use is permitted with this notice
  4. 4. Foundation Principles •  Patient is not a third person word –  Your time will come –  It’s a collective noun. •  Patients are the ultimate stakeholder –  Yet they’re often omitted from planning the future •  A pivotal force:The urge to care for our children and elders© e-Patient DaveRe-use is permitted with this notice
  5. 5. Doc Tom said, e-Patients.net founder “e-Patients are Equipped Tom Ferguson MD Engaged 1944-2006 Empowered© e-Patient DaveRe-use is permitted with this notice Enabled”
  6. 6. JAMIA, 1997© e-Patient DaveRe-use is permitted with this notice
  7. 7. Pt of future© e-Patient DaveRe-use is permitted with this notice
  8. 8. © e-Patient DaveRe-use is permitted with this notice
  9. 9. Me? An indicator •  Who’s getting online: –  1989: Me (CompuServe sysop) of the future?? –  2009: 83% of US adults (Pew) •  Who’s romancing online: –  1999: I met my wife (Match.com) –  2009: One in eight weddings in the U.S. met online –  2011: One in five couples met online© e-Patient DaveRe-use is permitted with this notice
  10. 10. The Engaged Patient 12 items in my pre-appointment “agenda” email© e-Patient DaveRe-use is permitted with this notice
  11. 11. The Incidental Finding Routine shoulder x-ray, Jan. 2, 2007 “Your  shoulder      will  be  fine  …      but  there’s        something        in  your  lung”  © e-Patient DaveRe-use is permitted with this notice
  12. 12. Multiple tumors in both lungs Where’s This From??© e-Patient DaveRe-use is permitted with this notice
  13. 13. Primary Tumor: Kidney© e-Patient DaveRe-use is permitted with this notice
  14. 14. E-Patient Activity 1: Researching my condition© e-Patient DaveRe-use is permitted with this notice
  15. 15. Classic Stage IV, Grade 4 Renal Cell Carcinoma Illustration on the drug company’s web site Median Survival:© e-Patient Dave 24 weeksRe-use is permitted with this notice
  16. 16. Facing the Reaper© e-Patient DaveRe-use is permitted with this notice
  17. 17. My mother© e-Patient DaveRe-use is permitted with this notice
  18. 18. My daughter© e-Patient DaveRe-use is permitted with this notice
  19. 19. After the shock you’re left with the question: What are my options? What can I do?© e-Patient DaveRe-use is permitted with this notice
  20. 20. Get engaged. Get it in gear. Do everything you can.© e-Patient DaveRe-use is permitted with this notice
  21. 21. E-Patient Activity 2: “My doctor prescribed ACOR” (Community of my patient peers)© e-Patient DaveRe-use is permitted with this notice
  22. 22. ACOR members told me: •  This is an uncommon disease – get to a hospital that does a lot of cases •  There’s no cure, but HDIL-2 sometimes works. –  When it does, about half the time it’s permanent –  The side effects are severe. •  Don’t let them give you anything else first •  Here are four doctors in your area who do it –  And one of them was at my hospital© e-Patient DaveRe-use is permitted with this notice
  23. 23. E-Patient Activity 3: Reading (and sharing) my hospital data online© e-Patient DaveRe-use is permitted with this notice
  24. 24. E-Patient Activity 4: My own social support network (CaringBridge.org - family and friends - journal & guestbook)© e-Patient DaveRe-use is permitted with this notice
  25. 25. E-Patient Activity 5: Tracking my data© e-Patient DaveRe-use is permitted with this notice
  26. 26. Surgery & Interleukin worked. Target Lesion 1 – Left Upper Lobe Baseline: 39x43 mm 50 weeks: 20x12 mm© e-Patient DaveRe-use is permitted with this notice
  27. 27. Nice curve!© e-Patient DaveRe-use is permitted with this notice
  28. 28. Question:© e-Patient DaveRe-use is permitted with this notice
  29. 29. How can it be that the most useful and relevant and up-to-the-minute information can exist outside of traditional channels?© e-Patient DaveRe-use is permitted with this notice
  30. 30. Dr. Lindberg: 400 years “If I read two journal articles every night, at the end of a year I’d be 400 years behind.” It’s not humanly possible to keep up.© e-Patient DaveRe-use is permitted with this notice
  31. 31. © e-Patient DaveRe-use is permitted with this notice
  32. 32. The lethal lag time: 2-5 years The time it takes after successful research is completed before publication is completed and the article’s been read. During this time, people who might have benefitted can die. Patients have all the time in the world to look for such things.© e-Patient DaveRe-use is permitted with this notice
  33. 33. Because of the Web, Patients Can Connect to Information and Each Other (and other Providers)© e-Patient DaveRe-use is permitted with this notice
  34. 34. Death by Googling: Not. (Dr. Gunther Eysenbach, Europe: 0 deaths found in a three year search) Compare with - “To Err is Human” (98,000 deaths/yr Nov 1999)© e-Patient DaveRe-use is permitted with this notice
  35. 35. “It may be more dangerous not to google “your condition.”© e-Patient DaveRe-use is permitted with this notice
  36. 36. © e-Patient DaveRe-use is permitted with this notice
  37. 37. What if his family had googled “splenectomy”?© e-Patient DaveRe-use is permitted with this notice
  38. 38. What if the care team had shared the care plan?© e-Patient DaveRe-use is permitted with this notice
  39. 39. Abington Memorial created one. (It’s just an EMR report)© e-Patient DaveRe-use is permitted with this notice
  40. 40. © e-Patient DaveRe-use is permitted with this notice
  41. 41. Seven Preliminary Conclusions (in Chapter 2) 1.  e-Patients have become valuable healthcare resources and providers should recognize them as such 2.  The art of empowering patients is trickier than we had thought 3.  We have underestimated patients’ ability to provide useful online resources 4.  We have overestimated the hazards of imperfect online health information 5.  Whenever possible, healthcare should take place on the patient’s turf. 6.  Clinicians can no longer go it alone 7.  The most effective way to improve healthcare is to make it more collaborative© e-Patient DaveRe-use is permitted with this notice
  42. 42. “These conclusions are no more anti-doctor or anti-medicine than Copernicus and Galileo ..were anti-astronomer.” Patients can simply contribute more today than in the past.© e-Patient DaveRe-use is permitted with this notice
  43. 43. E-Patient White Paper© e-Patient DaveRe-use is permitted with this notice
  44. 44. And finally: recognition from the establishment© e-Patient DaveRe-use is permitted with this notice
  45. 45. Institute of Medicine – Sept 2012 Major New Report: “Best Care at Lower Cost”© e-Patient DaveRe-use is permitted with this notice
  46. 46. Yes, the IOM itself says e-patients are an essential part of tomorrow’s healthcare. Patient-Clinician Partnerships Engaged, empowered patients— A learning health care system is anchored on patient needs and perspectives and promotes the inclusion of patients, families, and other caregivers as vital members of the continuously learning© e-Patient DaveRe-use is permitted with this notice care team.
  47. 47. JAMIA, 1997© e-Patient DaveRe-use is permitted with this notice
  48. 48. “How can patients participate if they can’t see what I see?” – Dr. Danny Sands© e-Patient DaveRe-use is permitted with this notice
  49. 49. Lesson learned: People perform better when they’re informed better.© e-Patient DaveRe-use is permitted with this notice
  50. 50. Corollary: It’s perverse to keep people in the dark and call them ignorant© e-Patient DaveRe-use is permitted with this notice
  51. 51. VA’s “Blue Button” 1 million 2012: (and DoD & Medicare) + Automatic!© e-Patient DaveRe-use is permitted with this notice
  52. 52. Informed Medical Decision Making© e-Patient DaveRe-use is permitted with this notice
  53. 53. The Dartmouth Atlas of Practice Variation Prostate treatment rates, by region Trans-urethral resection Radical prostatectomy© e-Patient DaveRe-use is permitted with this notice
  54. 54. Remedy: Shared Decision Making (SDM)© e-Patient DaveRe-use is permitted with this notice
  55. 55. Informed Consent© e-Patient DaveRe-use is permitted with this notice
  56. 56. Informed Choice© e-Patient DaveRe-use is permitted with this notice
  57. 57. Problem: Patients may not find value in all the technical details© e-Patient DaveRe-use is permitted with this notice
  58. 58. (In other words, to them, the discussion wasn’t patient centered)© e-Patient DaveRe-use is permitted with this notice
  59. 59. “Ultimately, it turned out to be the trade-off between peeing better and sex.”© e-Patient DaveRe-use is permitted with this notice
  60. 60. “And when it was stated in those terms, SDM flowed into the conversation.”© e-Patient DaveRe-use is permitted with this notice
  61. 61. BREAK© e-Patient DaveRe-use is permitted with this notice
  62. 62. 2.8 e-Patient Years in Pictures… December 2006 October 2007 May 2009© e-Patient DaveRe-use is permitted with this notice
  63. 63. © e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  64. 64. © e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  65. 65. You know it’s a revolution when…© e-Patient DaveRe-use is permitted with this notice
  66. 66. How a kidney cancer wife found the info she needed •  No insurance; no treatment. Then: •  Three bad hospitals; no help. Then: •  A friend said “I know a guy... on Twitter”© e-Patient DaveRe-use is permitted with this notice
  67. 67. © e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  68. 68. © e-Patient DaveRe-use is permitted with this notice
  69. 69. The Walking Gallery ReginaHolliday.blogspot.com Regina Holliday’s Medical Mural Advocacy Project© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  70. 70. Information makes a difference.© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  71. 71. © e-Patient DaveRe-use is permitted with this notice
  72. 72. © e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  73. 73. “Data Liberación” Todd Park Innovator Entrepreneur HHS Chief Tech Officer US Chief Tech Officer© e-Patient DaveRe-use is permitted with this notice
  74. 74. Case Study #3: Hugo Campos wants his ICD data© e-Patient DaveRe-use is permitted with this notice
  75. 75. © e-Patient DaveRe-use is permitted with this notice
  76. 76. Doctor Experience Full, unrestricted & convenient access.© e-Patient DaveRe-use is permitted with this notice
  77. 77. Patient Experience© e-Patient DaveRe-use is permitted with this notice
  78. 78. Activity $99 Fitbit© e-Patient DaveRe-use is permitted with this notice
  79. 79. Blood Pressure $129 Withings BP Monitor© e-Patient DaveRe-use is permitted with this notice
  80. 80. Weight $159 Withings WiFi Scale© e-Patient DaveRe-use is permitted with this notice
  81. 81. Sleep $149 Zeo Sleep Manager© e-Patient DaveRe-use is permitted with this notice
  82. 82. Implanted Cardiac Defibrillator $30,000 No data© e-Patient DaveRe-use is permitted with this notice
  83. 83. © e-Patient DaveRe-use is permitted with this notice
  84. 84. Raw data© e-Patient DaveRe-use is permitted with this notice
  85. 85. A patient to her doctor: (Rhode Island Quality Institute) “You make me sign a consent form to SHARE my data. You ought to ask my consent to HOARD it.”© e-Patient DaveRe-use is permitted with this notice
  86. 86. Objection: “My patients aren’t like that.” “They aren’t asking for this.”© e-Patient DaveRe-use is permitted with this notice
  87. 87. © e-Patient DaveRe-use is permitted with this notice
  88. 88. Web 2.0: “When the web began to harness the intelligence of its users.” – Tim O’Reilly© e-Patient DaveRe-use is permitted with this notice
  89. 89. Disempowered: Shrugs; “There’s nothin’ I can do…”© e-Patient DaveRe-use is permitted with this notice
  90. 90. Empowered: Self-aware – you know what you want Willing & able to© e-Patient Dave act on itRe-use is permitted with this notice
  91. 91. Engaged: Thinking; learning; acting; interacting© e-Patient DaveRe-use is permitted with this notice
  92. 92. Disengaged: Passive; receiving. A car in a car wash.© e-Patient DaveRe-use is permitted with this notice
  93. 93. How to start? Here’s the magic incantation© e-Patient DaveRe-use is permitted with this notice
  94. 94. “I’m the kind of patient who likes to understand as much as I can about my health.”© e-Patient DaveRe-use is permitted with this notice
  95. 95. “Could I ask some questions?”© e-Patient DaveRe-use is permitted with this notice
  96. 96. Obstacle to adoption: “Patients will flood us with time-wasting questions.”© e-Patient DaveRe-use is permitted with this notice
  97. 97. OpenNotes What happens when patients see their doctors’ notes?© e-Patient DaveRe-use is permitted with this notice
  98. 98. © e-Patient DaveRe-use is permitted with this notice
  99. 99. Announced this past Monday© e-Patient DaveRe-use is permitted with this notice
  100. 100. © e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  101. 101. © e-Patient DaveRe-use is permitted with this notice
  102. 102. •  99% of patients wanted to continue •  17-26% of docs preferred not to… – But when given the chance to stop, none did •  85-89% of patients said availability of open notes would influence their choice of providers and health plans © e-Patient DaveRe-use is permitted with this notice
  103. 103. Obstacle to adoption: “But patients don’t understand this stuff.”© e-Patient DaveRe-use is permitted with this notice
  104. 104. If the data’s unclear let’s MAKE it clear Like other industries do.© e-Patient DaveRe-use is permitted with this notice
  105. 105. Thomas Goetz, Wired© e-Patient DaveRe-use is permitted with this notice
  106. 106. Thomas Goetz, Wired “It’s time to redesign medical data”© e-Patient DaveRe-use is permitted with this notice
  107. 107. Same data – better software. Information: clearer. Consumer: informed, enabled.© e-Patient DaveRe-use is permitted with this notice
  108. 108. Psoas muscle (My kidney tumor was encroaching on it) my rendering on VisibleBody.com© e-Patient DaveRe-use is permitted with this notice
  109. 109. Why not “Google Earth for my body”?© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  110. 110. Really?© e-Patient DaveRe-use is permitted with this notice
  111. 111. OsiriX© e-Patient DaveRe-use is permitted with this notice
  112. 112. VeHU: Have you looked in your medical record? Do you know if it has mistakes?© e-Patient DaveRe-use is permitted with this notice
  113. 113. Dr. Eric Topol© e-Patient DaveRe-use is permitted with this notice
  114. 114. iPhone EKG?? 12/3/12: “FDA clears iPhone heart monitor, doctors can pre-order”© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  115. 115. Who owns the data? My view (on CafePress.com)© e-Patient DaveRe-use is permitted with this notice
  116. 116. A patient to Laura Adams: (Rhode Island Quality Institute) “You make me sign a consent form to SHARE my data. You oughta ask my consent to HOARD it.”© e-Patient DaveRe-use is permitted with this notice
  117. 117. Health on the Internet: Separating the Gold from the Garbage© e-Patient DaveRe-use is permitted with this notice
  118. 118. Nov. 2007: This googling patient was a nightmare (Title should have been “When the patient is a yahoo”!)© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  119. 119. o Feb. 2010: Sites like ACOR PatientsLikeMe: patients are creating value by connecting© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  120. 120. Jan. 2011: Googling patient helps doc find correct diagnosis more quickly© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  121. 121. http:// bit .ly / gold from garbage© e-Patient DaveRe-use is permitted with this notice
  122. 122. House addressing his residents: “OK, so you’re out of ideas! So??” “You think the stuff you learned four years ago is all there is??” “You think nothing new has come up since then??” “I know you’re busy. Have you asked the family if they can dig anything up?”© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  123. 123. “Shift Index” “We are shifting from a world where the key source of strategic advantage was in protecting and extracting value from a given set of knowledge stocks ...© e-Patient DaveRe-use is permitted with this notice
  124. 124. “Shift Index” “...into a world in which the focus of value creation is effective participation in knowledge flows.” –Thomas Friedman Pulitzer prize winner (3x) New York Times January 19, 2010© e-Patient DaveRe-use is permitted with this notice
  125. 125. “The Power of Pull” “Looking for things without a defined path and without knowing what they are”© e-Patient DaveRe-use is permitted with this notice
  126. 126. Britannica vs. Wikipedia© e-Patient DaveRe-use is permitted with this notice
  127. 127. Physician adoption of newpractices years after discovery Flu vaccine, year 32:The “17 years” thing 55% doing it, 45% still notFrom A. Balas, Institute of Medicine, in Yearbook of Medical Informatics 2000 Beta blockers, year 18: 62% doing it, 38% still not Cholesterol, year 16: 65% doing it, 35% still not Diabetic foot care, year 7: 20% doing it, 80% still not© e-Patient Dave Creative Commons Attribution / Share-AlikeRe-use is permitted with this notice May be distributed with this license included
  128. 128. © e-Patient DaveRe-use is permitted with this notice
  129. 129. Overheard: “You’re crazy if you don’t. check Wikipedia, and you’re a fool .if you stop there.”© e-Patient DaveRe-use is permitted with this notice
  130. 130. Watson remembers everything it’s read© e-Patient DaveRe-use is permitted with this notice
  131. 131. What if medical problem solving were suddenly an open book test where all the relevant facts were gathered and handed to you (including this week’s news) so you could spend your energy thinking?© e-Patient DaveRe-use is permitted with this notice
  132. 132. © e-Patient DaveRe-use is permitted with this notice
  133. 133. “May Require Refrigeration” cushings365.posterous.com, 9 / 17 / 10 •  “Panic!  For the first time, I got a note on my florinef that it might (MIGHT?) need to be refrigerated.  •  I didnt know that.  Should I have been doing that all along?  •  No one told me.” •  “I called the pharmacy.  •  They read what is on the printout which comes with the drug.  I had already read that. It wasnt helpful.”© e-Patient DaveRe-use is permitted with this notice
  134. 134. “May Require Refrigeration” cushings365.posterous.com, 9 / 17 / 10 •  “So, I asked the ones who know. My Cushie friends who take it. Those who have had BLA’s. •  “The verdict: –  No, thats a generic warning with fludrocortisone (generic). –  Only at extreme temps should it be refrigerated in the U.S. –  Some of the brands in the UK and other countries need refrigerated.”© e-Patient DaveRe-use is permitted with this notice
  135. 135. Dr. Eric Topol© e-Patient DaveRe-use is permitted with this notice
  136. 136. © e-Patient DaveRe-use is permitted with this notice
  137. 137. •  The practice of medicine is coming apart at the seams – “dis-integrating” – so the pieces can recombine in new ways© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  138. 138. •  Connectedness and disappearing boundaries mean we can know things we could not know in the past.© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  139. 139. •  In the past we had to guess at Rx based on demographics (similar populations). We’re starting to not need that.© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  140. 140. The Beery Twins© e-Patient DaveRe-use is permitted with this notice
  141. 141. The Beery Twins© e-Patient DaveRe-use is permitted with this notice
  142. 142. The Beery Twins today© e-Patient DaveRe-use is permitted with this notice
  143. 143. © e-Patient DaveRe-use is permitted with this notice
  144. 144. If the microscope’s happy but the patient’s not, has care been achieved? Has optimal care?? Was the money well spent for customer value?© e-Patient DaveRe-use is permitted with this notice
  145. 145. “Shift Index” “...into a world in which the focus of value creation is effective participation in knowledge flows.” –Thomas Friedman Pulitzer prize winner (3x) New York Times January 19, 2010© e-Patient DaveRe-use is permitted with this notice
  146. 146. Dutch IVF program had an insane idea •  Give patient couples a wiki, and six months to talk amongst them- selves. The promise: •  “We’ll give you anything you decide – your top ten choices. Unedited.”© e-Patient DaveRe-use is permitted with this notice
  147. 147. Top things IVF patients asked for •  I want insurers to reimburse six attempts.  •  I want insurance companies to only count it if a puncture or a replacement has taken place.  •  I want empathy from my doctor, not just technical or financial information.  •  I want separate waiting rooms for pregnant women and patients with a fertility treatment •  I want more time to make an appointment, even in the evening. © e-Patient DaveRe-use is permitted with this notice
  148. 148. Achieve ment! Compliance (Whose goal is it, anyway?)© e-Patient DaveRe-use is permitted with this notice
  149. 149. Peter Margolis, Cincinnati Children’s .5 x .5 = .25© e-Patient DaveRe-use is permitted with this notice
  150. 150. © e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  151. 151. © e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  152. 152. Are we barking up the wrong tree? Used with permission© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  153. 153. Used with permission© e-Patient Dave© e-Patient DaveRe-use is permitted with this noticeRe-use is permitted with this notice
  154. 154. Behavioral Economics •  Loss aversion is stronger than the desire to gain •  Cognitive framing; anchoring; ... •  But it’s tricky •  Even for really self-aware people, it’s not as easy as just giving them facts. •  That’s important for medicine.© e-Patient DaveRe-use is permitted with this notice
  155. 155. Physician as trusted authority “The oft-expressed fear that patients are using the internet to self-diagnose and self- medicate without reference to medical professionals does not emerge in national phone surveys or in this special rare- disease community© e-Patient Dave survey.”Re-use is permitted with this notice
  156. 156. “There’s crap on the internet. We need to get out there and balance it” Wendy Sue Swanson, MD Mother pediatrician @SeattleMamaDoc Facebook too© e-Patient DaveRe-use is permitted with this notice
  157. 157. An OB/Gyn on social media?? @MacObGyn •  “The more info we push out, the better decisions they make” •  “We’ve taken a demographic group and through connected technology they’re engaged in their health” •  “Our patients tell their friends – ‘and he’s on Facebook’”© e-Patient DaveRe-use is permitted with this notice
  158. 158. PatientsLikeMe lithium study© e-Patient DaveRe-use is permitted with this notice
  159. 159. © e-Patient DaveRe-use is permitted with this notice
  160. 160. Me: “Did being an engaged patient save me?” Dr. McDermott: “I have no doubt the interleukin killed the tumors.” “But I don’t know if you could have tolerated enough to do the job if you hadn’t gotten so involved”© e-Patient DaveRe-use is permitted with this notice
  161. 161. JAMIA, 1997 e-Patients Can Help Improve Healthcare “e-Patient Dave” deBronkart Twitter: @ePatientDave facebook.com / ePatientDave LinkedIn.com / in / ePatientDave© e-Patient Dave© e-Patient Dave dave@epatientdave.com Skype: ePatientDaveRe-use is permitted with this noticeRe-use is permitted with this notice

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