While my friend insists that he doesn’t have a moral issue with embracing the world of two-tiered medicine, he compared it to buying a high-priced BMW M6.

“What is more important to me, access to a doctor or a fancy car?” he asked.

I wondered if he felt like he had to justify it to me, or to himself.

Would the same justification be needed if he were telling me about paying more to send his child to a private school, taking a long-awaited European vacation with his wife or even going to a hair stylist versus a barber?

In a capitalistic society, what could be more reasonable than deciding to pay more to receive a higher level of service and access from the person you rely on most for your healthcare?

Like education, I believe that everyone in our country has a right to receive good healthcare regardless of ability to pay. But, if I have the means and decide that it is important to me to have a comprehensive two-hour physical, 24/7 access and other perks from my doctor, then I should be able to buy it.

P&G, the consumer goods and services conglomerate that bought MDVIP last year, is banking that many people will feel the same way. It considers healthcare a key segment in its portfolio of businesses and MDVIP is the hottest company they have in that sector. It currently has 450 physicians serving 160,000 patients.

Piedmont Healthcare employs five primary care physicians who are part of MDVIP. While this is a small fraction of the 140 primary care doctors that Piedmont employs, it provides an important option for consumers wanting to pay more to have a doctor who limits his practice to 600 patients, compared to the average of 2,000 in a typical physician practice.

Because of this math, a concern about concierge medicine is that it will worsen the primary care physician shortage in the United States. But I wonder if more of our best and brightest might pursue a career in primary care if there are more market-based compensation options. After all, while they are worthy options, not every lawyer wants to spend his career as a public defender and not every engineer wants to work for the Army Corps of Engineers.

“Are physicians public servants or independent entrepreneurs?” my friend the cardiologist asked.

Won’t we all be better off if we leave that choice up to them?

For all the amazing potential held by personalized electronic health records (EHRs) the biggest obstacle to their wide spread use is getting physicians to consider corresponding with patients by e-mail as part of their jobs. In order to enable patients to communicate with their physicians and keep their EHR updated, most electronic medical records vendors provide a “patient portal.”

There are some good reasons why doctors aren’t crazy about the idea of providing thousands of patients with an electronic link to their office. Most physicians, who still practice under a fee-for-service reimbursement, do not get paid for answering patients e-mail, and their work days are already insanely busy.

Epic, the healthcare information technology company which now has more than 10 million people using its EHR called myChart, has compiled a list of reasons that doctors give to avoid using the tool to link with their patients. While many of these are eventually proven to be false concerns, they include: their in-boxes will be immediately flooded with patients’ questions; they will be giving away free care; and patients are already impressed with their care, so it isn’t necessary.

Despite all these concerns and the very real demands on their income, work days, and professional autonomy, there is a rather selfish reason why physicians should consider using a personalized EHR with their patients.

“It’s just so handy,” says Dr. Patrick Coleman, an internist with Piedmont Physicians Group. His practice uses NextMD, a patient portal that is part of the NextGen electronic medical record.

Piedmont Healthcare will transition to using Epic myChart beginning in August 2012.

Dr. Coleman admits to having a lot of the same concerns of other physicians until he was forced to start using NextMD more than two years ago and discovered “this isn’t so bad.”

He estimates that he responds to five to 10 e-mails a day from patients and it takes him less than 15 minutes. His staff handles the e-mails requesting prescription refills, scheduling appointments, and other items that don’t require a physician’s time. Corresponding with his patients by e-mail eliminates phone tag that occurs when patients call his office with questions.

“E-mail is so much easier on my staff,” says Dr. Coleman, who estimates that about half his patients use it.

He says e-mail has changed the way he practices medicine. He uses voice recognition software to e-mail lab results to his patients, complete with his explanation of the findings, within 36 hours.

Dr. Coleman expects that we are only beginning to see changes that will involve the patient. He envisions a day when the practice can actually start the physician visit at home. For example, a patient with a sore throat may complete a questionnaire that will then be integrated in the patient record and make the visit that much more efficient.

With a shortage of 45,000 primary care physicians projected by 2020, we are going to need more efficient ways of providing care, according to Andy Miller, editor of Georgia Health News.

In the meantime, for the many physicians being pressured to offer e-mail correspondence to their patients, remember the brave discovery of those who have gone before you: “this isn’t so bad.”

And that’s just the beginning. Having a robust, integrated on-line health record will cause more change in healthcare than any other single development in the past 50 years. It will open the door for widespread use of mobile health apps, telemedicine, and developments that we can’t even imagine yet.

Making this sea of change happen is a counterculture software company, called Epic, that most people outside of healthcare have never heard of. The change that Apple’s products started in the recording and publishing industries, Epic’s myChart will start in healthcare.

Sure, there are other personalized electronic health records (EHRs) now. But, what currently stands for a personalized EHR has made very little impact in how care is delivered.

For there to be real change, an EHR needs to connect the information from everywhere you get care. Also, doctors need to embrace using this on-line tool as a way to interact with patients.

The reason that personalized EHRs haven’t caught on yet is that users have to input most of the data (think of Quicken in its early days) and most doctors are understandably worried that too many of their patients will want to become on-line pen pals.

An industry that has caused so much political turmoil (“Obamacare”), been accused of wrecking the bottom lines of Fortune 500 companies (GM says it spends more on employee healthcare than steel) and represents one-sixth of our economy now stands to be changed by a somewhat eccentric, privately-held Verona, Wisconsin company. How can that be?

Epic, through the vision of its creator and CEO Judy Faulkner, has focused relentlessly for more than 30 years on having its customers successfully install and use its products. The company has been passionate about continually making its software better and pushing towards a vision of improving healthcare. Along the way, it has made a lot of money, but that seems to be more of an enabler than the goal.

Epic has no debt, no stockholders (other than employees), no overseas outsourcing (highly unusual for a technology company), and seemingly nobody to answer to, other than its customers.

All of its products – software for running the business and clinical side of physician offices, emergency departments, hospital inpatient departments, hospital outpatient departments and a growing list of other stops along the healthcare continuum – were developed by Epic. The products are built on a common technology platform and are seamlessly integrated. The patient record that the primary care physician uses in his office is the same one used by the ICU nurse in the hospital.

By contrast, most other major healthcare IT companies are publicly-held, seem distracted by the pressure of quarterly financial returns to keep investors happy, and are often cobbled together through mergers and acquisition. Their products have limited ability to share information because they aren’t developed on the same platform and, until recent federal mandates, many of these organizations did not place an emphasis on the development of technologies that would enable system-to-system integration.

At Epic’s annual user group meeting last month, Epic COO Carl Dvorak explained to more than 6,000 attendees that the company had opted not to sign a well-publicized pledge recently made by 25 healthcare providers and IT companies to improve customer engagement. The idea of asking Epic leadership to sign a pledge to advance the cause of patient engagement seems like asking New England Patriot coach Bill Belichick to take a pledge to try to win football games.

In reference to the pledge, Carl said something to the effect of, “When other companies write press releases, we write code.”

Try using a press release to check the results of blood work, taken earlier in the day at your physician’s office, on your smartphone.

My 72-year-old wife, Pat, had her knee replaced five days ago. Everything about the operation has been just about perfect. As we recalled my completely opposite experience with prostate surgery seven years ago, we wondered why there was such a difference.

We both approached our operations healthy and optimistic, had excellent surgeons and large modern hospitals. The difference was in preparation, communication, and total focus on the patient. And, on her 75-year-old “coach,” me.

Pat’s surgeon, whom we met only a few months ago, has the uncanny ability of almost instantaneously becoming a good friend while simultaneously inspiring absolute confidence. A month before surgery, he gave us a large notebook containing everything we needed to know.

Two weeks later we attended Joint Camp with a dozen other patients and their coaches. A well informed, clear-speaking nurse and her PowerPoint presentation explained everything ahead of us: the mechanics of the operation, how and when to put on support stockings, exercises, schedules, medications, timetables—nothing was left out.

We learned we had reserved Joint Camp parking spaces one minute from the hospital’s front door. (With thousands of cars filling several huge parking lots, the normal walk is 15 minutes.)

Our small Virginia city is blessed with an outstanding hospital system whose administrator has been on the job here for over 30 years. He and his board of business and medical leaders—plus amazing community financial support—have transformed our primary, 50-year-old, 330-bed hospital into a modern, beautiful facility. I’m convinced that its wide curving halls, gardens, and overall beauty is one reason why every employee seems to greet every visitor with a smile and friendly hello—and why patients seem happier and healthier.

Last Tuesday morning, we quickly checked in at 7:30 for the 9:30 operation. In the waiting room I watched Pat’s progress on large, wall-mounted monitors: pre-op, op, post-op, recovery. About 10 a.m. the waiting room “mother” told me the operating room had called to report all was going perfectly.

Our magnificent surgeon appeared, beckoned me into a small room, and told me Pat had done a great job and her new knee was a complete success. Later on, up in her private room, every nurse, therapist, and orderly reiterated his assessment that Pat’s triumph was primarily her doing.

We ordered her room-service lunch from a surprisingly comprehensive menu. Then I returned to the car to carry in a suitcase, two plastic bags, and her walker. As I tried to gather it all up, a young female orderly walked up, told me she was just returning from lunch, and insisted on helping me carry it all up to the room.

The next afternoon and again Thursday morning brought more Joint Camp sessions of training, exercise, and therapy. This time there were only two other knee patients and one with a new hip along with their coaches. Thanks to the skill and gregariousness of our two therapists, we were all friends in minutes.

Surgery may be successful for many reasons. Of course it takes good people and facilities, but I think it’s vital that they all work to minimize the causes of stress via preparation and communication that instill confidence in the patient. And her coach.

Mom continues to recover nicely. Piedmont Healthcare also offers a version of joint camp – called A Joint Effort – for joint replacement patients.

Its on-line heart health assessment tool, called Life’s Simple 7, can determine if you have something called ideal cardiovascular health. Less than 1% of the population meets the criteria, and I couldn’t wait to find out if I was part of the genetically elite.

I never earned a Presidential Physical Fitness award as a kid. It took me until my senior year in high school to get my varsity letter, and I never made it beyond the B league in ALTA. But, earning the ideal cardiovascular health label could make up for all that. After all, I eat fruit and flax seed for breakfast, and I put in thousands of meters a week on my stationary rower. I want my 48-year-old body to be known for something special before it is too late.

Whether or not others are drawn to take the test for the same reason as me isn’t clear, but something is making them do it. The tool has been launched more than 181,000 times since first made available in 2010. The AHA is using the web-based tool as part of an effort to improve cardiovascular health of all Americans by 20% by 2020. The idea is that people who take the assessment will follow up with the AHA for more information on how to improve.

On-line health assessments provide consumers with a convenient and private way to learn if they have a risk that requires professional medical help. Google shows more than 57 million results for “free on-line health assessments.”

Are they worthwhile?

“I think that they have clinical value,” says Dr. Mark L. Cohen, Chief of Quality, Informatics and Research for the Piedmont Heart Institute. “With just some basic information, all known to the patient, it is possible to give a fairly accurate probability of having a ‘coronary event’ in the next 10 years.”

Piedmont Heart Institute has on-line assessment tools to detect risk of heart disease (HeartAware) and sleep disorders (SleepAware). People who learn they are at risk can follow up with medical professionals to determine next steps for diagnosis and treatment. It has been Piedmont’s experience that about two-thirds of those determined to be at-risk follow up for additional information.

As Dr. Cohen points out, one of the positive aspects of on-line health assessments is that people actually choose to use them, so it is a first step in taking a more active role with their own healthcare.

Perhaps many of us are taking these assessments to learn if we are in the same cardiovascular subset as Navy Seals, Michael Phelps, and tireless spinning instructors.

It turns out that I am not. While my scores on the lifestyle questions are strong, I was dinged by my borderline high blood pressure and a total cholesterol reading that stubbornly stays just above 200. My overall score is 7.9 out of 10, hardly ideal cardiovascular health.

While I am disappointed not to have ideal cardiovascular health, the results of the test are a good reminder to eat better and continue to measure by blood pressure daily. Perhaps others who take the test in hopes of claiming ideal cardiovascular health will also come away with a few tips on how to be healthier.

But, we said no. We know our son and know there are challenges and dangers to touring through a foreign land that he can’t appreciate yet. We really want him to have this kind of experience some time, but believe this trip is not in his best interest. Like any reasonable person about to turn 18 who doesn’t get what he wants, he told us he just might do it anyway. As a parent, that thought is a little scary.

Maybe doctors feel the same about their patients ignoring their decisions about what would be best for their health.

There was a recent article in New York Times about the growing interest in a treatment called P.R.P. (plasma rich platelets) to treat injured tendons and muscles. It has become the treatment du jour for professional athletes like Tiger Woods and Hines Ward. The claim is that it gets people healthy and back in the action quicker. Weekend warriors want it and are willing to pay $1,000 per shot. There is a growing commercial effort to exploit this attraction – vendors offering P.R.P. kits to doctors’ offices and articles on P.R.P. (with limited research) appearing in medical journals.

Only one problem. “It is unproven,” says Dr. Steve McCollum, an orthopaedic surgeon with Peachtree Orthopaedic Clinic. Not necessarily bad, says Dr. McCollum, but like so many other treatments that make sense and sound like they should work (i.e., soy to reduce menopause symptoms) there just isn’t a proven clinical benefit yet.

P.R.P. involves injecting the patient’s own plasma enriched blood into the site of the injury. While some people tend to get better after P.R.P., the same outcome might be possible by injecting saline or even just poking the injured site with a needle, says Dr. McCollum.

The New York Times article describes one doctor who doesn’t perform P.R.P. because it is not proven and his patients simply tell him they will go to another doctor who will.

And here is where the growing age of healthcare consumerism runs into problems. On-line information sources dramatically expand our knowledge of emerging treatments. An entire medical products industry, which is appropriately driven by making a profit, wants to further embolden consumers to push for what they want. In the middle stands the physician.

A recent blog in the New York Times describes the concern of some geriatricians if the cholesterol-lowering drug Lipitor is allowed to be sold over-the-counter, as the federal Food and Drug Administration is considering. Lipitor’s patent expires soon and the best way for Pfizer to maintain profitability is to make it available over-the-counter. However, people who use Lipitor, typically older adults, simply don’t know enough yet to be able to use it without physician supervision. Safe and effective use requires actively monitoring patients’ blood cholesterol levels. Otherwise mild-mannered doctors are begging the FDA to say no.

While there may be some exceptions, I believe that appropriate caution in a physician is a good thing, although probably underappreciated by patients.

“I am a second-wave kind of guy,” says Dr. McCollum. He spends his Sundays reading medical journals to stay current with what works. He says that he doesn’t jump on the bandwagon with new treatments, but “as soon as it is safe and effective, I’ll be on it.”

I wonder if Jack will finally thank us when we tell him that we are second-wave kind of parents.

This seems to be another paradox to the notion that we are moving towards healthcare consumerism, a world in which people want to take a more active role in their care.

If there is ever a good time to have a say in your care, it is at the end of life when families tend to be the most dysfunctional, providers are looking for guidance and the costs are highest.

Why do so few people take the opportunity to exercise control?

“We don’t do death very well in the United States,” says Sherry Henry, an advanced practice nurse who provides palliative care, or end-of-life care, at Piedmont Hospital. People tend to be uncomfortable talking about dying and reluctant to think about the realities of something that will happen to all of us, she says.

Hospitals and other healthcare institutions are required by federal law to promote and support the use of living wills, commonly called healthcare advance directives. Patients at Piedmont are asked on admission if they have a living will and, if they don’t, if they would like free help in preparing one.

Nate Brown, a lead patient representative at Piedmont, estimates that he is called to complete about 25 advance directives a month for patients and their families. Depending on how much the patient has thought through the answers in advance, it can take from 10 minutes to an hour. Occasionally he is contacted by people in the community, who aren’t hospital patients at the time, and he will complete the advance directive for them and keep it on file.

The advance directive, a legal document, lets the patient voice their wishes, even when they can no longer speak. “It is so wonderful when you can ask a patient what they want,” says Sherry Henry, referring to having the advance in hand for a patient who can no longer communicate, when family and providers are struggling with what to do next.

Doctors are trained to keep people alive, says Dr. Leigh Hamby, a board certified general surgeon and the Chief Medical Officer for Piedmont Healthcare. The healthcare system is generally programmed to keep our heart beating by any means necessary, unless we say that it is okay to stop.

My grandmother decided it was time to stop in her mid-80s after seven years on kidney dialysis. With her quality of life diminishing and her body rapidly failing, one day she told her doctors that she wouldn’t be continuing her three-times-a-week dialysis treatment. The decision meant that within days she would go into a coma and die.

After an initial attempt to change her mind, the doctors agreed and the staff at the nursing home did all they could to make her comfortable. Family flew in from all over and enjoyed several days of visiting and sharing a lifetime of memories before my grandmother gently went to sleep.

Sometimes being a good consumer is about knowing when to say “enough.” Unfortunately, many of us wait until it is too late.

An article in the New York Times recently suggested that many of us suffer from decision fatigue. In a world where we have more and more choices, we are physiologically capable of making only so many decisions. When too much information is thrown at us, sometimes we just shut down.

Now in its sixth year, CMS’ HospitalCompare.gov has evolved into a treasure chest of healthcare provider-specific statistics for consumers. Want to compare three metro Atlanta hospitals on mortality rates for heart disease? Easy. Want to compare the same hospital on overall patient satisfaction? No problem.

The amount of hospital quality data and the ease with which you can compare how hospitals match up is comparable to Consumer Reports (except there is no price data). As a long-time interested observer of publicly reported hospital quality data, I think the site is extraordinary.

But, I wonder…do people use it?

“I wonder that, too,” says Michaeleen Crowell, a legislative assistant who specializes in healthcare issues for U.S. Rep. John Lewis. She offered to contact the U.S. House Ways and Means committee staff, which oversees Medicare spending, saying that it would be good information to know.

“Have you ever had a patient ask you about something they found on HospitalCompare.gov?” I asked my internist Dr. William McClatchey.

He is a very tech savvy physician who has practiced for more than 30 years and has about 9,000 patients. “Never, not once,” he said.

It is hard to imagine that the use of such a data source wouldn’t spark questions that patients would want to ask their physician, the person they trust most for input on these issues.

What is a “best” hospital? How to choose the right hospital for you.

I called others—GMCF, the state-based organization charged with helping people use Medicare and the Center for Medical Consumers—and got essentially same response. Nobody could tell me if HospitalCompare.gov is really used by consumers.

I even called CMS. Could they tell me about activity on the site? How much is it used? They politely said they would have someone call me back, but never did.

Healthcare consultant Nate Kaufman said that HospitalCompare.gov is relevant because the media uses it. And they do, but they tend to use it in a sensationalistic way, and they sometimes get it wrong.

USA Today and NBC Atlanta Channel 11 ran a two-part story earlier this month that credited six local hospitals (including Piedmont Hospital) for having mortality rates below the national average. But a separate story identified two hospitals – Northside Hospital and Atlanta Medical Center – with mortality rates above the national average.

Later, after Northside apparently explained the findings, Channel 11 clarified that the hospital’s mortality rate was actually not statistically worse than national average. This fact was available and clearly stated on HospitalCompare.gov all the time. Not that anybody was looking.

Paige Jones, III, a certified fitness trainer at Piedmont Health & Fitness Club, says he gets that sometimes. While giving a tour of the facility to a middle-aged prospective member who was short and heavy, she pointed to a tall, thin young woman on the treadmill and seriously asked if Paige could make her look like that.

“Most people expect a trainer to be like a magician,” says Paige, who has been certified for nine years.

I went to Paige to learn more about how individuals are taking control of their health. These people, I reasoned, who through physician prodding or their own initiative, seek out an expert like Paige to help them control their bodies and health, must be on the leading edge of the self-empowerment movement.

Turns out, many show up expecting to tap into Paige’s empowerment rather than their own. He says some look at him “like a deer in the headlights,” when he explains that to get what they want – which is almost always to lose weight – the best results come from a routine that involves exercising five times a week for an hour a day and changing how they eat.

“They expect it to happen very quickly,” he says. About 50 percent of Paige’s clients drop out within a few months, which matches typical exercise routine adherence rates. The unfortunate reality of genetics also tends to get in the way of Paige’s ability to deliver a designer body.

Paige’s magic comes in working with each client to match their fitness regimen with their medical condition and their personal interests. For some, it is boot camp, for others its Zumba, but the common denominator for successful clients is that they find a way to put on their big boy or big girl workout pants and keep coming back. “It’s all about adherence,” says Paige.

“It’s a myth that we love exercising,” says Paige, a former Division I college football player and track athlete who looks like he walked off the cover of a Men’s Health magazine.

But it’s worth it. Orthopedic surgeon Dr. Russell Flint explains that even an extra pound of body weight can exert five times that amount of stress on your joints. Also, a recent study shows that even less rigorous, but still regular exercise, can substantially benefit your heart health.

And these outcomes, I continually tell myself as I mindlessly churn on the elliptical machine, are far more important than having awesome sculpted biceps that look like Paige’s.

The sad part is that I probably have a better chance of following through if my employer (Piedmont Healthcare) were to pay me a nickel for every stair I climbed.

“You’d think being healthy is enough, but it’s not,” says Ronald E. Bachman, one of the nation’s foremost experts on healthcare consumerism. (A benefit of writing this blog is having an excuse to invite brilliant thinkers like Ron to breakfast to talk about the future of healthcare.)

Being healthy isn’t enough?

New evidence continually shows that we are becoming less healthy as a nation. A study released last month showed obesity rates are rising in every state. Obesity is linked to a host of dangerous and expensive health conditions, including heart disease, stroke, and diabetes.

Ron sees employers as the best way out of this unhealthy mess.

“It’s about engaging people with financial incentives and rewards to make better health behavioral choices,” he says. Employers have the best opportunity to experiment with different incentives in their employee health insurance plans to learn what makes people change, says Ron.

I am depressed with the idea that healthy behavioral change, at least on a broad scale, can only be achieved through some form of paying people off.

In addition to finding the right financial incentive, says Ron, employers should provide the information needed to educate consumers. He describes the information gap as “the weakest” point in current system.

This was one of the reasons we created HealthWatchMD.com – to provide health information, specifically easy to understand explanations about new developments in medicine and healthcare. Dr. Martin’s segment on July 29 about the dangers of workplace sitting caused me to change my behavior as I described above.

But, there is other evidence that even when the information to guide a healthier lifestyle is available, it doesn’t inspire most people to actually change. Studies on the outcomes of requiring restaurants in some cities to post the calorie count for the items on their menu have recently been released. The expectation that providing calories counts will lead to healthier choices by consumers has met with mostly a thud, or more appropriately, a belch. One study from 2009 showed that people actually manage to increase their calorie intakes when the numbers were available.

Maybe we are just very early in the process of providing people with information to guide healthy lifestyles and it will take some time to change actions and habits.

At least the stairs at work won’t be crowded for while.