Stanford Medicine X ePatient Application 2013

Applicant Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Photo

Why do we need this? If you win a scholarship, we would like to recognize your accomplishment on our Medicine X website. By uploading your photo, you agree to give us permission to use it on our website. We will also need your photo to create an ID badge for the conference.

Please Upload your Photo*

Please upload a digital photo of your face for use by Medicine X on our website and on your ID badge in the event that you are award an epatient scholarship. (JPEG, PNG, GIF are all acceptable formats).

Scholarship Track Preferences

Please indicate to which ePatient Scholarship Track(s) you wish to apply.*

Engagement & Producer
Presenter
Design
Leadership

Please refer to the ePatient scholarship program page for more information about the different tracks. You may apply in only one track.

Conference Attendance: We expect our epatient scholars to attend all three days of the conference (Sept 27-29, 2013). Is there any reason that you may not be able to attend all three days?*

No. I can attend all three days.
Yes, I have an issue that prevents me from attending all three days.

Since you answered "Yes" above, please explain why you cannot attend all three days of the conference.

General Applicant Questions

Why do you want to come to Medicine X at Stanford?*

What do you hope to learn by attending the conference?*

Please use the space below to tell us a little about what you have done in the past that might be an example of engaging the community as an ePatient.*

We would like to be clear in our belief that everyone will be or has been a patient at some point in his/her life.

However, the candidates that will be most successful in obtaining a scholarship will be the ePatients who are engaged in their community, for example, those that work with ePatient organizations or have shown in the past that they engage the public as ePatients through social media or blogging. Other considerations also include patients who have experience being empowered (usually by technology), equipped (by knowledge), engaged (in their care) and enabled (to care for himself or herself).

Why do you believe you should be selected for a scholarship to attend Medicine X at Stanford?*

Engagement & Producer Track Questions

Description: The purpose of the engagement track is to provide an opportunity for epatients to attend Stanford Medicine X and engage with the community, both at the conference, and with the larger world through social media. Besides providing a patient voice to the proceedings, scholars will help share and disseminate the knowledge they learn to further educate and inspire others.

Selection Criteria: Successful applicants will demonstrate a history of patient engagement and community outreach and advocacy, with preference for individuals using emerging technologies such as blogs, Twitter, and social media to pursue these goals.

Please tell us why you are interested in the engagement track and how you would use the scholarship opportunity to engage with the Medicine X audience and the world at large. If you are a PRODUCER, please explain what content you would create DURING the conference and how would you share it with the world?*

Presenter Track Questions

Description: The purpose of the presenter track is to provide an opportunity for epatients to attend and speak at the Stanford Medicine X conference. By providing a patient voice to the proceedings, scholars will help share and disseminate the knowledge to educate and inspire others.

Selection Criteria: Applicants will be asked to submit a speaking proposal that describes their story and what they would like to speak about. Patient talks in the presenter track will be five minutes in length and follow a pecha kucha/ignite format. Applications will be considered for talks in the following topic areas:

On the ePatient: How do you consider yourself an epatient?
On Participtory Medicine: How do you participate in your own care?
On Problems and Hurdles: As an epatient, what hurdles have you encountered and how did you overcome them?
How does technology enable you to care for your loved one?

Please select the topic for your 5 minute talk*

Please describe the five minute talk you would give as an ePatient presenter on the Medicine X main stage. Please provide an summary or outline of your talk.*

Design Track Questions

Description:The purpose of the design track is to provide an opportunity for epatients to serve as the inspiration and nexus of a patient-centered design project facilitated by the health and wellness team at IDEO. Besides providing a patient voice to the proceedings, scholars will help share and disseminate the knowledge to educate and inspire others.

Selection Criteria: We are interested in receiving applications from patients who are passionate about adding the patient voice to the process of solving health care problems. Patients should have experience in managing a chronic disease and use technology to help facilitate their own care. Successful applicants will be able to articulate why their chronic medical problem needs thoughtful problem solvers and design thinkers to help improve their care. The successful applicant will then work with an IDEO designer to draft a problem statement that will become the focus of the Stanford Medicine X Design challenge. The winning team will have the opportunity to present their work from the Medicine X main stage.

Agreement to participate in Medicine X | IDEO Design Challenge*

Participation in the design track requires sharing your personal story and working with an IDEO designer between March 15 and April 15, 2013 to develop a problem statement for the Stanford Medicine X | IDEO design challenge workshop. You must agree to participate in the Medicine X | IDEO Design Challenge workshop, work with an IDEO designer to develop a problem statement, and present your project to the challenge jury and (if selected) on the Medicine X main stage.

Please tell us about your chronic medical condition and how you have used technology to manage your help. Please discuss the problem statement you would have the IDEO designer and workshop team help you solve. How would various health care stakeholders (health care providers, researchers and technologists) help you solve this problem?*

Leadership Track Questions

Description: The purpose of the leadership track is to provide an opportunity for epatients to attend Stanford Medicine X and gain leadership skills and experience in order to develop a new generation of epatient leaders. Scholars will be paired with leadership mentors (epatients who have attended a previous Medicine X conference), lead epatient activities and help share and disseminate the knowledge they learn to further educate and inspire others.

Selection Criteria: Successful applicants will demonstrate a history of patient engagement and community outreach and advocacy, with preference for individuals using emerging technologies such as blogs, Twitter, and social media to pursue these goals. Successful applicants should demonstrate leadership potential and articulate how they would use a leadership position in the epatient community to advance their specific goals and objectives.

Agreement to participate in two-year leadership track*

The leadership track is a two-year opportunity designed to nurture a new generation of ePatient leaders engaged in the use of health information technologies to empower peer-to-peer healthcare, participatory medicine and patient-centered care. We ask for applicants to commit to attending two consecutive years of Medicine X (2013 and 2014).

Please tell us about your leadership experience and/or potential. What have you done that demonstrates a commitment to leadership in the ePatient arena? If selected for this unique program, how would you use this opportunity to advance the use of health information technologies to empower peer-to-peer healthcare, participatory medicine and patient-centered care?*

Consent to Contact

I agree to allow Medicine X to contact me by email about the conference. (We are a non-profit conference and may on rare occasion send information we think will be of interest to you on behalf of our partners)*

Yes
No

Stanford Medicine X ePatient Scholarship Application 2013