Monday, April 21, 2014

How Americans Die

How Americans Die
This is a fantastic visual presentation of data that you can look at in more detail on the Bloomberg Site
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If the embedded page does not work head over there directly here

The main points highlighted
  • The mortality rate fell by about 17 percent from 1968 through 2010, years for which we have detailed data...Almost all of this improvement can be attributed to improved survival prospects for males
  • The surge in for 25- to 44-year-olds was caused by AIDS, which at its peak, killed more than 40,000 Americans a year (more than 30,000 of whom were 25 to 44 years old)
  • AIDS was the single biggest killer of Americans who should otherwise have been in the prime of their lives (Sobering Statistic)
  • 45- to 54-year-olds are less likely to die from disease, they have become much more likely to commit suicide or die from drugs
  • How does suicide and drugs compare to other violent deaths across the population? Far greater than firearm related deaths, and on the rise. (Suicide and has recently become the number one violent cause of death) - (Sad Statistic)
  • The downside of living longer is that it dramatically increases the odds of getting dementia or Alzheimer's
  • The rise of Alzheimer's and other forms of dementia has had a big impact on health-care costs because these diseases kill their victims slowly. About 40 percent of the total increase in Medicare spending since 2011 can be attributed to greater spending on Alzheimer's treatment

They do a great job of slicing the data by cohorts of age groups showing how much we have improved mortality and how our 25 and under age group is benefiting from the health improvements with the lower mortality and higher life expectancy than any other cohrot

Friday, April 18, 2014

Giving Personal Health Advice to Family and Friends

In an interesting post on the medscape site (subscription/registration probably required): The Pitfalls of Giving Free Advice to Family and Friends Shelly Reese described some of the challenges of giving medical advice

to friends and family (even if you are a wannabe Dr Phil).

As she puts it the path can sometimes lead to challenging areas of ethics and professional boundaries.
How do you address or deflect such requests? Unfortunately, there are no easy answers. It depends a lot on you, your boundaries, and the situation.
And she links to the AMA Guidelines
The American Medical Association (AMA) Code of Medical Ethics is clear, however: "Physicians generally should not treat themselves or members of their immediate families."[1] The statement goes on to provide an extensive list of good reasons why, including personal feelings that may unduly influence medical judgment, difficulty discussing sensitive topics during a medical history, and concerns over patient autonomy (Ref: American Medical Association. Code of Medical Ethics Opinion 8.19: Self-treatment or treatment of immediate family members. Issued June 1993.)
Some of the challenges of simple advice include

  • Escalation to more complex or persistent advice 
  • Long distance diagnosis with missing data
  • Lack of Doctor/Patient relationship and documentation
  • Litigation
  • Impaired judgement 
  • Changing and coloring of relationships

In one section she describes the challenges of dealing with family members and says
"I try not to give too much medical advice, even to my parents. I see my role as an advocate: to help them synthesize information when they have questions. When my mother calls and says, 'I'm short of breath and I don't know what to do,' I walk her through all the things her doctor has talked to her about: Have you taken your blood pressure and pulse? Do you know how many times you're breathing per minute?"
Good advice on being the patient advocate and healthcare manager for your family members (which many already are)
In the end it boils down to personal judgement and your own boundaries.
Questions are appropriate and to be expected, Caplan says, but doctors have to wrestle with themselves in determining how to respond if they're to act responsibly and ethically. "When close friends and family ask for medical advice, that's always a matter for introspection, and at the end of the day, it's not resolved by codes of ethics but by considered individual judgments."
It used to be as the trusted source of knowledge where access to information was limited this was a significant responsibility but with the age of

and medical applications like
AskMD, iTriage and HealthTap to mention a few you might find there is fewer and fewer requests. So for those of you that like the opportunity to help others out...enjoy it while you can mHealth and Telemedicine may be changing the landscape and soon!

Monday, April 14, 2014

Social Media in Healthcare

Social Media is here to stay and its impact in Healthcare has been impressive and far reaching.

If you still need convincing - look no further than this piece 24 Outstanding Statistics & Figures on How Social Media has Impacted the Health Care Industry that features a host of examples. As they put it
In a generation that is more likely to go online to answer general health questions then ask a doctor
And that’s the point our population and customers are changing and they are using the internet and social media as a major source and guide to their care.
A few choice data points:
90% of respondents from 18 to 24 years of age said they would trust medical information shared by others on their social media networks
This may be the younger generation but in many instances they are becoming the healthcare support infrastructure for their parents and will use the same methodology to for their parents care as their own
31% of health care professionals use social media for professional networking
I am willing to be this is increasing and I only have to look at my own twitter feed and lists of doctors I am connected with, follow and use as major source and guides
41% of people said social media would affect their choice of a specific doctor, hospital, or medical facility
Ignore this at your peril - 2 in 5 of your patients are looking at social media to guide their healthcare selection.
And the opportunity and impact will increase as we see the penetration of mobile devices increasing
International Telecommunications Union estimates that global penetration of mobile devices has reached 87% as of 2011
So for those of you already online the impact and effect will increase. Those of you not….well that train has left the station. This graphic by Howard Luks (@hjluks) captures the extent of the opportunities

Friday, March 28, 2014

Getting Doctors Back to the Patient - Part 1

The Panel "The Art of Medicine" Panel (part of the Art of Medicine campaign) took place yesterday from 9 - 11am at the Boston's W Hotel, 100 Stuart St, Boston, MA

Our panelists from Left to Right
  • John D. Halamka, MD, MS, CIO of Beth Israel Deaconess Medical Center (and Life as  healthcare CIO blog and @jhalamka)
  • Keith Dreyer, DO, PhD, FACR, Vice Chairman of Department of Radiology, Massachusetts General Hospital 
  • Adam Landman, MD, MS, MIS, MHS, CMIO, Health Information and Integration at Brigham and Women's Hospital (@landmaad)
  • Steven J. Stack, MD, past chair of the American Medical Association (AMA); served on multiple federal advisory groups for ONC on HIT, practicing emergency physician  
and at the far right moderated by Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, Vice President of Physician Services, Nuance Communications

And it was very well attended:

Today, physicians are struggling to serve their patients’ needs in a healthcare system that seems to work against them at every turn. While technology has the potential to vastly improve healthcare overall, issues remain when it comes to usability, data-entry and complementing patient care vs. competing with it.

In part 1 I have attempted to capture the underlying sentiments and thoughts form our panelists together with some thoughts on potential ways to help resolve these areas and problems.

The panel opened with the original Art of Medicine video:

The session was divided into several separate discussions - the first of which the Issues of today:

There has been an increasing burden placed on physicians to document more and more detail but no additional time to do this and in fact probably less and they struggle with the increasing information over load and the challenge of processing - As John Halamka put it:
"We need wisdom and today's #EHR make that hard to get from patient info to give me what I need now" 
"3 petabytes of patient data...overwhelmed with data, we just need information, knowledge"

This is combined with the increasing regulations which the panel viewed as directly linked to the increasing need for HealthIT tools to help deal with these regulations. As Adam Landmaan put it the design of the EHR’s is based on the design focus and in the current fee for service health system is designed largely support the physicians to capture and document optimize for bill not for patient care

But I thought Keith Dreyer captured the sentiment well when he described technology as decreasing our ability to communicate

“I couldn't imagine dictating into a microphone in talking with my family "

And we are seeing declining capture off the patient’s story in the EHR

Some snapshots of ideas thoughts from our panelists included:

  • IT tools driving “note bloat” of information that is non-specific to the patient
  • Physicians need timely “wisdom” to positively effect patient care at the time of encounter
  • “Big bang” of government funding for EHR adoption has generated massive amounts of information that is, at present, unmanageable
  • At stage now of EHRs where they are “one size fits all,” so not customized to specific specialty/setting needs
  • Need to identify the smallest number of moving parts (IT tools) to facilitate patient care
  • Need for monolithic (“one size fits all”) IT solutions is driven by babel of nomenclature
  • Quality measures show that there is a problem, but not the causality

There was much more discussions and thoughts on solutions but one of the concepts that stood out for me was this one from Adam Landmaan straight out of the Television Reality show - copying the Shark Tank concept

That will be an interesting panel and team event and look forward to hearing the results

 We need to return to the Art of Medicine and as one panelist put it:

People sought out Doctors in the past even when they actively hurt you and bled you

They did this because the doctor provided compassion and care that had the best intentions - they cared about their patient and the Art of Medicine

Physicians don’t act on business motives. They act on patient care motives.

You can see the #ArtofMedicine HashTag Social Media Statistics here and analytics here

Monday, March 24, 2014

What Patients Want - The Art of Medicine

The Art of Medicine Panel (part of the Art of Medicine campaign) is hosted this week and I am looking forward to hearing from our panelists:

  • John D. Halamka, MD, MS, CIO of Beth Israel Deaconess Medical Center (and Life as  healthcare CIO blog and @jhalamka)
  • Steven J. Stack, MD, past chair of the American Medical Association (AMA); served on multiple federal advisory groups for ONC on HIT, practicing emergency physician  
  • Keith Dreyer, DO, PhD, FACR, Vice Chairman of Department of Radiology, Massachusetts General Hospital 
  • Adam Landman, MD, MS, MIS, MHS, CMIO, Health Information and Integration at Brigham and Women's Hospital (@landmaad)

and moderated by Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, Vice President of
      Physician Services, Nuance Communications

The panel is taking place this Thursday from 9 - 11am at the Boston's W Hotel, 100 Stuart St, Boston, MA. If you have not already you can register here: The event is free of charge,

Sadly many physician are feeling the strain as noted in this piece (Are Physicians the Cure to Healthcare’s Bugs?):

"waking up in the morning, and not looking forward to going to work"

As this piece (Doctors and Tech: Who Serves Whom?) in the Atlantic pointed out

Technology should serve doctors, rather than doctors serving technology

The sad reality of our technology environment is taking the focus away from people

We love our mobile technology

But is this the right interaction all the time?

And it is true in healthcare especially (The Cost of Technology)
“If we want doctors to do better work, we need to give them better work to do.”

and to do that doctors have to engage in the design of these solutions and the clinical community and the #HealthIT world must address these issues:
Just as we can’t expect a patient with heart disease to know intrinsically to maintain a low-sodium diet, we can’t expect the healthcare industry to know how to fix everything unless we speak up and advocate for change (especially with the other loud voices of insurers and politicians speaking on “our behalf”)
Some solutions are not technical as this Tweet by "Dr K" @MedschoolAdvice)
We have the rare opportunity to shape the future of healthcare infused with technology and I, for one, want to be part of developing a solution that helps the next generation of physicians offer that comforting touch as they deliver an even greater level of care to their patients

Download the Art of Medicine eGuide here and join me and the panelist on Thursday as they discuss they start to shape a better HealthIT future for everyone. I will be live tweeting from the panel (#ArtofMedicine) and will post a summary after the event.

Tuesday, March 18, 2014

Google Glass in Healthcare - Part 1 the Basic Facts

HIMSS was exciting and despite the HIS Talk HISies awarding Google Glass the most over rated technology:

I know I am biased as one of the lucky Google Glass Explorer as can be seen in this post from MedCity Watching for Wearables at #HIMSS14:

I think they are wrong and its not just Glass that will provide better more ready access to essential clinical data.

Not to say that the initial program like many launches have had their problems with early releases of technology not quite ready for prime time - remember the 1987 Apple Newton:

Even the omnipresent iPad struggled initially - most have probably forgotten the initial lukewarm reception of the iPad

had Apple talking about a price reduction.

Mat Honan (one on the same “Epic Hack”) wrote a piece about his early experiences “My Year with Google Glass” that highlighted some early acceptance challenges

  • Glass is socially awkward
  • People get angry at Glass
  • Wearing Glass separates you

and I would add Glass interrupts normal conversations and social behavior - but that is all now and like the mobile phone I believe it will be come a natural part of our technical fabric. Think back to 2007 and how pulling out a phone in a meeting was frowned upon - now it seems part of the fabric of many of the meetings I attend.
But it was Mat’s commentary on the impact it had on his perception fo phones that really stuck out for me
Glass kind of made me hate my phone — or any phone. It made me realize how much they have captured our attention. Phones separate us from our lives in all sorts of ways. Here we are together, looking at little screens, interacting (at best) with people who aren’t here. Looking at our hands instead of each other. Documenting instead of experiencing.
Which resonates with me an the Art of Medicine campaign and the struggle clinicians have with focusing on the patient (To learn more, download the eGuide Art of Medicine in a digital world). As Dr. Edward C. Grendys, Jr. said in his article: There’s no room for technology in end-of-life care decisions:
From initial diagnosis through to surgical therapies, chemotherapy treatments and even end-of-life care, my job is to listen, assess and provide educated decisions that ultimately impact the health and wellness of another human being…. it’s my belief that when talking face-to-face with a patient about a care plan aimed at eradicating their body of a disease that threatens to take them away from their family, there’s no room for paper, computers and/or mobile devices. In these most intimate of conversations, the focus has always and must remain on the communication between the caregiver and the patient on the receiving end. That, in its purest essence, is what practicing the art of medicine is truly all about.

That’s not to say that Google Glass can solve this problem and in its current state and acceptance it might cause more challenges - but the potential is there to blend information access and capture into a physician patient interaction that remains all about the patient

Glass will provide improved access to essential clinical data to clinicians but as my friend Chuck Webster has pointed out on several occasions this is not just for clinicians. Patients are already accessing the internet in droves for clinical information, researching their conditions and that of their relatives and communities abound with resources and support for conditions from common to rare.

Before talking about some of the potential medical applications it is worth detailing the technology. Google Glass is basically a computer with 12Gb of memory attached to your head in the form of glasses. It has a heads up display with voice activation and has some apps that can be installed:


  • Google Glass is basically a computer attached to a pair of glasses
  • Google Glass has a display that is projected in front of the Right Eye that is a high resolution display equivalent of a 25 inch high definition screen from eight feet away
  • Google Glass has a camera that points forward and can take pictures (5MP) or video (720p) that is closely aligned with the view you see from your own eyes
  • Google Glass is voice activated using speech recognition to interact with the glass computer
  • Google Glass works best when connected to the internet
  • Google Glass Integrates with an Andorid Phone with a limited set of functions available for the iPhone
  • Google Glass has no built in illumination so pictures or video taken in dark conditions do not work well
  • The screen can be hard to see in bright light
There are many myths circulating:


  • If someone is wearing Google Glass they are recording me
    • False - The device is not set up to record continuously and will only record a video or photo based on an action by the wearer (either a spoken request
      • OK Glass, take a picture
      • or by pressing a button on the google glass device
  • Once Someone Has recorded something on Google Glass it is Publicly Posted
    • False - it requires an action on the part of the Glass owner to post the material to the internet otherwise it resides on the Google Glass device. It will be synchronized with the users Google+ account for automatic backup (much like photos are backed up from the iPhone to iCloud but like iCloud remain private to the user unless they elect to share them)
  • Google Glass is constantly capturing data and transmitting it to the Internet
    • False. Without an internet connection Google Glass simply stores any recorded information in the glass memory. And unless you have set it to record there is no data being captured
  • Google Glass tracks users and unsuspecting bystanders
    • False - Google Glass is not tracking or recording anything unless instructed to do so by the user
So who is using this technology, where are they using it and how are they using it in Healthcare. This article covered some of the early concepts and featured a short list of potential applications
  • Video sharing and storage: Physicians could record medical visits and store them for future reference or share the footage with other doctors.
  • A diagnostic reference: If Glass is integrated with an electronic medical record (EMR), it could provide a real-time feed of the patient’s vital signs.
  • A textbook alternative: Rather than referring to a medical textbook, physicians can perform a search on the fly with their Google Glass.
  • Emergency room/war zone care: As storied venture capitalist Marc Andreessen proposed in a recent interview, consider ”dealing with wounded patients and right there in their field of vision, if they’re trying to do any kind of procedure, they’ll have step-by-step instructions walking them through it.” In a trauma situation, doctors need to keep their hands free.
  • Helping medical students learn: As suggested by one blogger, a surgeon might live stream a live — and potentially rare — surgery to residents and students.
  • Preventing medical errors: With an electronic medical record integration, a nurse can scan the medication to confirm whether it’s the correct drug dose and right patient

In its simplest form just transmitting images in real time can offer some advantages for diagnosis - in Rhode Island they are planning on implementing Google Glass for the ED doctors to obtain real time consults with dermatologists.

And this from Kareo showing a patient education application that records the physician patient interaction and then makes it available afterwards for additional review:

In this case featured in the ER doctors use Google Glass and QR codes to identify patients which featured Dr. John Halamka, CIO of Beth Israel Deaconess Medical Center which he talked about in his blog detailing their experience (oddly the article talking about this refers to text that appears to have been changed or taken down):
When a clinician walks into an emergency department room, he or she looks at [a] bar code (a QR or Quick Response code) placed on the wall. Google Glass immediately recognizes the room and then the ED Dashboard sends information about the patient in that room to the glasses, appearing in the clinician’s field of vision. The clinician can speak with the patient, examine the patient, and perform procedures while seeing problems, vital signs, lab results and other data.

And this concept by the way was top of everyone's wish list that I talked to in my unofficial survey of engaged and interested observers of my own pair. I'll paraphrase
If I could get it to recognize someone and provide me with their name when I meet them that would be fantastic!
But it is in urgent care where there is so much potential:

This recent piece on Healium featured in the Seattle King5 News Station: Seattle Doctor testing Google Glass for Surgery in the ER (click on the link if the video does not show below to see it in action)

"If I want to look at for example radiology I can double tap ‘radiology...There's his chest x-ray, it just popped up, oh he's got a middle lobe pneumonia"

Part 2 will cover medical applications and how Google Glass technology can be applied in a busy clinical setting

Tuesday, February 25, 2014

The Art of Medicine CIO Breakfast - What Needs to Change to Get Doctors Back to the Patient?

Medicine is part science.... Part art.

The relationship between physicians and patients is at the core of healing. This begins with hearing and understanding. We want to reimagine healthcare—where physicians can get back to the art of medicine and were delighted to be joined by panelists:

Dr. Mark Kelemen, Senior Vice President, CMIO, University of Maryland Medical System
Dr. Charles H. Bell, Vice President, Advanced Clinical Applications, Hospital Corporation of America (HCA)
Stuart James, CIO, Sutter Health
Dr. Andrew Watson, CMIO, University of Pittsburgh Medical Center (UPMC) (@arwmd)

The panel was moderated by our very own
Dr. Paul Weygandt, Vice President, Physician Services, Nuance
Keith Belton, Senior Director, Clinical Documentation Solutions Marketing, Nuance

and attended by some 50 attendees with varying backgrounds and perspectives

The underlying question:

How do return the focus to the patient. How can physicians navigate the changes and challenges of today’s complex healthcare environment while doing what matters most to them – listening and caring for patients?

The panel discussion addresses current physician frustrations with technology and what needs to change to keep them focused on patients and not data entry. It was clear that the physician’s voice and medical decision making is what matters most in practicing the art of medicine and how do physicians and patients both benefit?

 We know from surveys that
  • 36% of physicians say that EHRs interfere with face-to-face communication during patient care
  • 80% of physicians say “patient relationships” are the most satisfying part of practicing medicine
  • 28% of an average ER physician’s time is spent directly with patients
  • and from a recent HIMSS session interesting Patients prefer doctors to have an EHR
This is about the changing face of healthcare – it’s not just about technology. It’s about how we envision healthcare. How do we explain to providers that this isn’t about technology – this is about a new world order coming to healthcare
Posting every patients Magnesium level multiple times in a note is not good clinical care #artofmedicine #himss14
One of our panelists asked the audience:

How many Docs would go to facility with no #EMR and used paper - no hands went up
We do see value in Health Information Technology

One of the overriding concerns was the need for cultural change. The office or hospital based physician system is struggling to meet the patient needs today. They want to have the right nurse or physician there for them at the right time and indeed at the right place with telemedicine. It’s about cloud-based/consumer-based healthcare.

More consumer-friendly healthcare

We need to get back to that local physician practice – with technology in the middle as a supporting actor but not the main event

Technology cannot be an impediment to taking care of patients

Many physicians are in this field because we are trying to drive change but are struggling with the existing system that fail them. When I see a patient I have to review 10 systems, carry out at least 4 major systems examinations before I can submit a claim that properly reflects the care I delivered:
 I am not taking care of the patient I am taking care of a computer

Dr Andrew Watson told the story of a patient under his care with a terrible antibiotic resistant infection that a patient developed in hospital and he was now under constant supervision adn intensive therapy. But as he said - he never needed to come into hospital - he could have been treated at home. Poignant reminder that Telemedicine is not just about reducing cost - it can be better for the patient and offer better results.

Dr Bell is waiting for the MIDI (musical instrument digital interface) moment so that he can plug into the medical record and go.
As a musician he remembers the implementation of the MIDI interface in the early 1980’s that allowed music manufacturers to create one standard that was royalty free and widely adopted for the benefit of the user musicians and the vendors. He wants that in healthcare - so do I.
Until we change the mandate on clinicians to document 8 of 10 systems to be fairly compensated for the care given  
And importantly the concept of Bring Your Own Device (BYOD) is bringing functional tools into the healthcare setting and will/is revolutionize the care being delivered. As one panelist put it:

my iPad never complains, is always there, has the latest information and access to latest medical updates

To summarize:

  • We need strategies for bringing the focus back to the physician-patient interaction and removing impediments to that relationship
  • Healthcare organizations should be and are encouraging/valuing physician professionalism
  • This is about the changing face of healthcare – it’s not about technology. It’s about how we envision healthcare. How do we explain to providers that this isn’t about technology – this is about a new world order coming to healthcare

Come join the conversation at The Art of Medicine or come to the panel session Thursday, March 27, 2014, 9:00 - 11:00 am EST at the W Hotel,100 Stuart Street, Boston, 02116

Sunday, February 23, 2014

Physician Symposium #DrHIT #HIMSS14

The Physician (#DrHIT) Symposium at #HIMSS14
Opening session was eloquently covered by Robert Wah, MD (@RobertWahMD) detailing the spectrum of issues ranging from the new Healthcare System:

The challenge of SGR “fix(es)” and the evolution of the systems we are implementing and the value proposition. As he put it
Quality of care is improved with better information — saving lives and money
But Health Technology is not easy to implement:
And layered on top is the increasing challenge of securing the data with hackers seeing healthcare data as 15x more valuable than financial hacked data!
What we need is coordinated care and Dr Wah offered this visual of the way forward

Christine Bechtel focused on the Activate Evidence Based Patient Engagement and as she reported - Patients like doctors who have an EHR
Patients think EHRs help doctors deliver better care
  • Timely access to information, sharing info across care team, med history, managing health conditions
  • Overall, EHRs were rated between 23%-37% points higher than paper on these elements
Interesting since doctors have been reported as saying they dislike the EHR but patients like seeing their doctors with an EHR

The sad thing was this session was concurrent with @ePatientDave in another room - The Connected Patient: Learning How Patients Can Help in Healthcare only social media united these sessions
As for Jonathan Teich and his session Improving Outcomes with CDS - he used his personal experience where peer pressure (as he described it 3rd time he was pressured to take on an expert triple diamond ski slope) he finally agreed and ended up in a serious ski accident fracturing multiple vertebrae. Interesting analogy relative to the Clinical Decision Support System and the pressure this applies to clinical practice sometimes inappropriately...
Interesting look at alerts and the potential for providing more than just alerts but actually providing intelligent data that distill down to 10 types of CDS interactions
  1. Immediate Alerts: warnings and critiques
  2. Event-driven alerts and reminders
  3. Order Sets, Care Plans and Protocols
  4. Parameter Guidance
  5. Smart Documentation Forms Improving Outcomes with Clinical Decision Support: An Implementer’s Guide (HIMSS, Second edition, 2011)
  6. Relevant Data Summaries (Single-patient)
  7. Multi-patient Monitors and Dashboards
  8. Predictive and Retrospective Analytics
  9. Filtered Reference Information and Knowledge Resources
  10. Expert Workup Advisors

And the important summary slide was the CDS Five Rights (Right information, people, formats, channels and times)

And returned to one of the core opportunities - Patient Engagement with a a session by Henry Feldman, MD FACP: Informatics Enabling Patient Transparency. He asked the same questions as another presenter - how many fo the audience considered themselves a patient (Still only a shabby 80%) and then took this further asking

  • You feel that you know exactly what your provider was thinking in making his decisions
  • You think the clinical systems helped your provider understand comprehensively everything about you
  • You build clinical systems or are a provider
  • With the inevitable decline in hands up
  • You think your (or anyone else’s) software truly helps the patient or even the provider understand comprehensively or transparently what is going on

Sadly we are not near this and the reality is much further with physicians thinking patients are unsophisticated. Yes at he pointed out the airline industry gets it and even the DMV/MVA gets it offering customer engagement models:
Their experience and stats blow the unfounded resistance out of the water

  • Only 2% of patients found notes more confusing than helpful
  • Only 2% found the note content offensive
  • 92% said they take better care of themselves
  • 87% were better prepared for visits

Importantly we need to turn data into information for patients and he cited the Wired example of a Laboratory test (Blood Test Gets a Makeover Steve Leckart) and the makeover for
Basic Labs

Cardiology Result

and the PSA result

I know where I'd like to be receiving my care (and lab results) from! Great finish to the session. So as he summarized where we should be with patient engagement an data
  • Open your data to your patients
  • Patients understand more than we think
  • Teach patients how to use data effectively – This can save you time in the long run
  • Put your patients to work on their own health!
  • Vendor work on how patients will view big data
  • It’s a new drug, research the risks and benefits
Great start to what will be a busy HIMSS

Art of Medicine at #HIMSS14

The new Art of Medicine campaign is focused on getting physicians back to their original roots - the reason we all stepped over the threshold of medical education and into an honorable profession to serve our community. Its all about the patient but changes in the healthcare system and in particular changes with technology have taken the focus away from our patients and onto the technology in our office. Recent study conducted by Northwester University highlighted the distraction physicians feel away form their patients by the EMR

As Steve Schiff, MD a practicing cardiologists puts it
As far back as I can remember, there was never a time when I didn’t want to be a physician. It’s a choice in which there is no equivocation: either you want to be a doctor or you don’t.
The campaign includes an e-Guide: The Art of Medicine in A Digital World replete with thoughts, suggestions and concepts to manage the digital world while remaining focused on the most important person in the examination room - the patient. The release was covered in this piece by HIT Consultant and referenced the panel taking place next month in Boston.
Many of the thoughts and ideas were captured in the Top 38 lessons from Digital Health CEO’s from Rock Health. I picked a few choice quotes that capture the spirit and intent fo the Art of Medicine for me:
“Healthcare is yet to be transformed by technology.” - Joshua Kushner
“You need a degree of foolishness to cause disruptive change in healthcare. Dare to dream.” - Vinod Khosla
“If you’re going to re-invent healthcare you have to start from scratch.” - Vinod Khosla
“The key to good product is invisibility for the user.”
“Partnership is going to be absolutely key to taking healthcare to the next transition in evolution.” - Sue Siegel
  The campaign kicked off this week with this resource page - The Art of Medicine and a short video highlighting the challenges and opportunites

There will be much discussion at HIMSS14 around the topic and we are looking forward to hosting the panel on Thursday, March 27, 2014, 9:00-11:00 a.m. at Boston’s W Hotel. You can find out more and/or register here or come by our booth 3765 at HIMSS14.
“The science of medicine goes nowhere if you leave the human element out of the equation. Curing our patients starts with listening to them.”

Friday, February 14, 2014

Are Physicians the Cure to Healthcare’s Bugs?

This post originally appeared on HIT Consultant

During a recent and troubling discussion with a physician friend, he described to me a new ailment he’s been experiencing: waking up in the morning, and not looking forward to going to work.  The reality is that he is not alone.  It’s no secret that physicians across the country, regardless of their specialty or location, are reaching their limit for juggling new requirements, technology upgrades,  and policy changes, all while trying to deliver personalized, quality care to their patients.  As a result, busy physicians are, quite understandably feeling pressured and pulled away from direct patient care and critical clinical-decision making, and, at the end of the day, that is what matters most to patients and physicians alike.  
It is easy to imagine the impact overloaded and dissatisfied physicians could have on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and how these regulatory pressures and so many new healthcare technologies could be linked to the decline of the “art of medicine.”  But are we, in fact, misdiagnosing the problem?

A recent study from Johns Hopkins University found that internal medicine interns are lacking proper bedside etiquette, which is not only essential to providing quality care, it directly impacts medical outcomes and patient satisfaction scores.  Focusing on five key elements of proper patient-physician decorum, researchers tracked whether or not hospital interns:
  1. Introduced themselves, 
  2. Explained their role in the patient’s care,
  3. Touched the patient,
  4. Asked open-ended questions, or
  5. Sat down with the patient during the visit.  
Results revealed that interns touched their patients (either during a physical exam, handshake or gentle, supportive touch) 65 percent of the time and asked open-ended questions 75 percent of the time, but introduced themselves only 40 percent of the time, explained their role merely 37 percent of the time, and actually sat down during only nine percent of the visits.  Such results are disconcerting, at best, and reveal a more pressing truth: These basic and critical communication deficiencies that are essential to providing holistic patient care are not being taught.

The study exposes the reality that the shift away from patient focus and the “art of medicine” isn’t just stemming from increased physician workloads caused by new policies and changing technologies.  It is infiltrating our profession through a change in training, as well.  While we have reduced junior doctors’ work hours for safety reasons, we have not adjusted the overall length of training they receive.  Medical students, our future physicians, are not receiving the holistic education that helps them balance keen scientific skills with compassionate delivery.

But, as they say, “knowledge is power,” and now that we are starting to pinpoint conditions that are tearing at our profession, we can start to heal them.  We can’t expect our medical interns to know how to handle difficult and emotional situations unless we show them.  We need to teach them how to engage with patients, earn their trust, really listen and understand them.  They need to be able to view what their patients say through both a  lens of science and medicine, as well as  a  lens of compassion and caring, in order to help them get and stay well.

And what of the technology challenges that are driving wedges between patients and physicians?  While there is no denying that much of health information technology is putting pressure on physicians and forcing them to adapt to new methodologies, these challenges are a necessary to revolutionizing patient care.  They are, in essence, the basis of growth and the very nature of science.  If it weren’t for boldly trying new approaches, we might still be relying on leeches and blood-letting to cure melancholia.   Just as we can’t expect a patient with heart disease to know intrinsically to maintain a low-sodium diet, we can’t expect the healthcare industry to know how to fix everything unless we speak up and advocate for change (especially with the other loud voices of insurers and politicians speaking on “our behalf”).

We must be mindful that as physicians, it is our sworn duty to defend the practice of delivering the best care to our patients from anything that threatens to impinge on that quality.  We need to stay engaged and be responsive; and that also means we need to assist with diagnosing major technology pain points and identify when something isn’t working.  We have the rare opportunity to shape the future of healthcare infused with technology and I, for one, want to be part of developing a solution that helps the next generation of physicians offer that comforting touch as they deliver an even greater level of care to their patients.

Tuesday, February 11, 2014

Clinical Documentation in the Electronic Health Record

Many years ago I remember an excited friend who worked for one of the vendors of electronic medical records (really this was more of a billing and patient tracking and management system than and Electronic Health record) desperate to show me some of their new applications – in particular a module they had developed to capture clinical data. He pulled out his “laptop” (it was more of a luggable)

Fired up the application, selected a patient and proceeded to enter a blood pressure: click, click, click, click, click, click, click, click…..some 20 clicks later he had entered a blood pressure of 120/80. He was excited and I was not.
I am constantly reminded of this as I watch doctors interact with systems and especially with the ongoing focus on blood pressure (Did you know that May is the National High Blood Pressure Education Month) and the video challenge from ONC
“To create an under 2 minute compelling video sharing how they use health IT or consumer e-health tools to manage high blood pressure”
The winners can be seen here
Key to the challenge is having the data for monitoring as emphasized in the Six Sigma techniques of DMAIC
  • Define
  • Measure
  • Analyze
  • Improve
  • Control
Capturing that data without burdening our clinical staff who should be focused on the patient not on intrusive and distracting tasks of data entry. I made this point a number of years ago "Doctor Please Look at Me not Your EMR" that came from a personal experience in our local practice and as my then 10 year old succinctly put it at the time
“I wish the doctor had spent as much time with me as she did with her PC”
But data is essential and getting this into our medical record is essential to derive the value from these systems. So the study published in Journal of the American Medial Informatics Association (JAMIA): "Method of electronic health record documentation and quality of primary care" who’s conclusion implied that dictating clinical notes “appeared to have worse quality of care than physicians who used structured EHR documentation”.

Digging into the details suggested this was based on old data (2004 – 2008), measured the quality of documentation not the care and that choice in tools is the key to success in EHR implementations and clinicians satisfaction

There are good reasons that dictation as a means of capturing clinical documentation has been so successful for such a long time – it is easy to do, efficient and saves time. But the gap between the narrative text created and the clinical data we need to manage our patients widens with each report created. The JAMIA report highlighted the impact this can have on care, offering some insight into the potential decrease in the quality of care that results in disconnecting the clinician from the interaction and clinical decision support tools and data that is built into the EHR. But the process of entering this data must not intrude into the clinical interaction with patients. All is not lost – Natural Language Processing (NLP) tools are bridging this divide allowing clinicians to use their preferred method to capture the patient’s clinical information in narrative form and extracting out the discreet data that is essential for the EHR systems that need the data to drive the decision support tools and workflow processes.

So clinicians can have their cake and eat it too and best of all it allows them to return to the art of medicine and focus on the patient not the technology.

Tuesday, January 28, 2014

Vaccines Don't Cause Autism - Vaccinate your Kids

It can be frustrating to be a clinician in the era of the internet and instantaneous availability of data especially when the reliability and accuracy is variable. But this is the world we live in and there is plenty of data showing that patients are accessing information in ever increasing numbers. The challenge has been helping patients filter the data for both relevance and accuracy.
Vaccination has been at the epicenter of a these challenges for some years - in fact long before the wide spread use of the internet thanks to a piece published in The Lancet in 1998  and unusually retracted. In fact the BMJ published a paper in 2011 declaring the paper fraudulent - as they noted in the discussion the lead author (now stripped of his medical degree and academic credentials) was clearly actively perpetrating the fraud
Who perpetrated this fraud? There is no doubt that it was Wakefield. Is it possible that he was wrong, but not dishonest: that he was so incompetent that he was unable to fairly describe the project, or to report even one of the 12 children’s cases accurately? No. A great deal of thought and effort must have gone into drafting the paper to achieve the results he wanted: the discrepancies all led in one direction; misreporting was gross. Moreover, although the scale of the GMC’s 217 day hearing precluded additional charges focused directly on the fraud, the panel found him guilty of dishonesty concerning the study’s admissions criteria, its funding by the Legal Aid Board, and his statements about it afterwards
Sadly despite repeated studies and investigations. Despite the retraction of the original article by the Lancet. Despite the other authors personally retracting the paper we still hear about a “link”. Sadly some high profile individuals continue to perpetrate the fraud (notably the model Jenny McCarthy and most recently the “reporter” Katie Couric).
I saw the posting by Aaron Carroll MD, MS is a Professor of Pediatrics and Assistant Dean for Research Mentoring at Indiana University School of Medicine (the Incidental Economist) last week when he posted this map of the real effects of this in Vaccine Preventable Outbreaks (click on the map button on the left if necessary)
In fact Dan Munro posted his own take on this piece: Big Data Crushes Anti-Vaccination Movement. As he sadly notes
Add a well known celebrity (or two) and the effects can be powerful, long term and hard to refute.
 And ss Dr Carroll notes the impact can be seen in the chart above:
  • All of that red, which seems to dominate? It’s measles. It’s even peeking through in the United States, and it’s smothering the United Kingdom.
  • If you get rid of the measles, you can start to see mumps. Again, crushing the UK and popping up in the US.
  • Both measles and mumps are part of the MMR vaccine.
  • Almost all the whooping cough is in the United States.
But the best part of this post is his accompanying video - included below - well worth watching the full 8 minutes
Expertly and accurately put.
Vaccinate your kids….please.

Monday, January 27, 2014

Security, Security, #Security.....Encrypt your Drives by Default #HIT #hcsm #privacy

I was reminded of there Jerry Maguire movie clip when I read the latest in a long line of security breach stories - this one emanating from Canada where this group is in hot water over a massive 620,000 patient data breach…taking 4 months to notify authorities. Apparently Canada does not have a national Breach notification rule like the US and the public “Wall of Shame"
Canada does not have a federal health data breach notification requirement. But the Canadian provinces have their own rules, including some that mandate notification. Under Alberta's Health Information Act, which was enacted in 2001, the reporting of health data breaches is voluntary, privacy experts say.
 They might want to change that...

In this latest release Medicentres Family Health Care Clinics, a 27-clinic medical group in Western Canada had an unencrypted clinic laptop stolen from one of the clinic's IT consultants.
The laptop contained 620,000 patient names, dates of birth, health card numbers, medical diagnoses and billing codes, officials said.
Here in the US the chart of complaints is depressing

How many more data breaches will we see before everyone understands the need to pay close attention to security.
Encrypting your hard drives for all machines that contain patient information and demanding all staff and consultants and anyone that has access to patient data encrypts their drive and data would have prevented this.

Wednesday, January 22, 2014

Integrating Clinical Documentation Improvement into the Doctors Workflow

We know doctors are under an ever increasing load may eventually break their backs..if nothing else its increasing the overall pain

In a recent study of physician attitudes toward clinical documentation technology and processes clinicians the majority of clinicians said they would be more responsive to Clinical Documentation Improvement (CDI) clarifications if they were delivered in real-time within their normal documentation workflow in the electronic health record (EHR). They report being "disrupted" by queries for additional information
after they’ve documented in a patient chart or worse, after the patient is discharged.  All believe that ICD-10 will make matters much worse
With #HealthIT a growing portion of how doctors do their jobs they want to be involved in technology decisions yet most were not involved in clinical documentation technology decisions for their organization. And timing is everything - going back to answer questions after you have left the patient or worse after the patient has left "the building".

So what is the difference between success and failure of a CDI program

As the study points out physicians’ growing dissatisfaction in being
saddled with processes that distract them from clinical care, while being excluded from the decision-making process of choosing things that impact them every day
Technology should be simple and work for physicians and the key to changing the experience is to eliminate rework
Rework in clinical documentation is the enemy of efficiency
As Brian Yeaman, MD CMIO for Norman Regional Health System puts it
Using things like CLU and applying that to the ICD-10 code book to help me refine that diagnosis or ask me whether it’s the left or right or an upper or lower extremity are tremendous because it has a significant impact on our bottom line, and it’s also a physician satisfier … and on the back side we are not getting so many coding queries

And Reid Conant, MD President and CEO of Conant and Associates says
“Now we can provide our physicians with tools to get real-time feedback to not only change that document, but also change their behavior for the next document. That’s what organizations are looking for, and frankly, that’s what the doctors are looking for.”

We can achieve ICD10 compliance without breaking the back of clinicians

Tuesday, January 14, 2014

Are you "Under Observation"

This is not news for many in the healthcare profession as they face the challenges of billing rules and regulations and the sometimes obscure idiosyncrasy - but as you can see form this piece on NBC for many patients this is a surprise and a costly one at that

Visit for breaking news, world news, and news about the economy

Hospitals are told that they "have to" use this status (Under Observation) if the patient doesn't meet a host of criteria for "Admission" all being driven by a series of guidelines that are publicly available although not well known and much of it in response to the RAC audits
All this is set to get worse with the “Two Midnight” rule (you can see some guidance here and some of the issues on this here)

Friday, January 10, 2014

Just what the Doctor Offered #NLP #artofmedicine #hcr #HealthIT #hcsm

This piece in Wired Natural Language Tech and Medicine: Just What the Doctor Ordered by our very own Joe Petro (SVP of Engineering) as he puts it
Somethings gotta give!
Yes it does. Healthcare and in particular doctors are juggling far too many changes
And like the picture of Aaron Gregg who achieved the world record of the most catches of chainsaws in 2008 (88 btw) doctors are doing their best to keep up but they are reaching their limits. We continue to ask doctors to do more with less, their focus is forced further away from the physician-patient interaction.
Technology can help and Natural Language Processing is transforming how consumers interact with technology in a more conversational, natural way. And in Healthcare we have taken this approach and applied it calling it Clinical Language Understanding (CLU) and importantly will allow physicians to get back to the Art of Medicine
Amongst other things we can:
  • Simplify Interactions with the EHR
  • Balance the Need for Patient Narrative and Structured Data
  • Increase Documentation Specificity in Real-Time
Much like NLU has helped drive intelligent, natural interactions between consumers and technology, CLU will help re-humanize healthcare. By enabling physicians to focus on the patient, not the technology, providers can begin to embrace a next-generation approach to healthcare that will drive efficient, intelligent clinical decisions that impact each and every facet of patient care.
It’s an exciting time with CLU and NLP as a critical enabler in helping doctors be more productivity in the new digital era of healthcare and maintain focus on what matters most: patient care.

Friday, December 13, 2013

23 and Me and

The FDA issued a warning letter to 23andMe on Nov 22, 2013. There followed a slew of articles, posts, tweets and commentary - amongst the many
And this piece on Forbes on the class action suit and this older piece that talked about the service before this news hit and then followed up with this piece "23andMe Saga Doesn’t Bode Well for EMR Genetics Integration" and David Katz: Return to Sender, Genome Unknown: Seven Reasons I Will Return My Personal Genome Kit

Declaration: I am a 23andMe customer - I liked the concept and was excited by the price point that made the service accessible and cost maybe that explains my quick reaction (per the K├╝bler-Ross model of grief of Denial, Anger, Bargaining, Depression, Acceptance) to many of the posts and negative feedback pushing back.

I am still processing the news and not sure exactly where I sit - personally I am glad I got in before the health information was blocked. Maybe this is a purely personal position coming from the privilege of being a physician. In fact this piece on Forbes/Quora: What Do Doctors Think About 23andme?
probably captures the viewpoint I have different from others. In fact the images summarize how many people might approach this
Hmmm - you can see the logic and while the point made that not all information is relevant or important my view is firmly on the side of the patient being allowed to make that decision themselves.  It is always worrying to me that someone else is filtering information and making decisions as to what they consider to be important to me - how can they know?

The example cited is one of a fit healthy individual making a decision based on genetic testing that suggests they might be at increased risk of cardiac disease that needs to be put int he context of them being fit and healthy
In fact they state
This is why every ethical healthcare provider follows this mantra: do not order a test or perform a procedure if it will not change your management of the patient, because doing so may cause needless harm/risk to the patient and will cause needless damage to the patient’s finances.
A reasonable position and one perhaps we might expect the FDA to support.....yet the FDA allows for direct to consumer advertising in the US.....? That seems at odds with the stance taken on genetic testing. There is no doubting that extra testing can cause additional stress and concern - putting everyone into an MRI is a bad idea since we identify around 20% "findings" many (may even be most) of which are incidental. I personally am delighted with my 23andMe results that include genetic details and insights that help me make my own personal health decisions.

I gave up personal genetic information to 23andMe who like any other cooperation could misuse it, may not protect it sufficiently or may share it with insufficient privacy protections to shield me from being identified. But that was my choice and in this instance I felt the risks outweighed the benefits.

But the cynic in me can't help but think that this may all be money related especially given the recent spat over the BRCA gene testing that was recently struck down but remains the tip of the patent iceberg.

This piece on KevinMD: 23andMe and the FDA: Did the government overreach? probably captures my basic views on the subject. As Dr Marroquin states
One worry is that people might undergo unnecessary tests and procedures based on the information 23andMe provides.  For example, critics worry that a woman who is found to have a false-positive BRCA mutation might have a prophylactic mastectomy inappropriately.  This seems to me to be an impractical concern.  It is difficult imagine a surgeon operating in such a situation without first verifying the genetic testing through another lab and extensively discussing the benefits and risks of such an approach with the patient.
Quite - it might create a worthwhile discussion between a patient and their healthcare provider. In another example the risk of Alzheimer's which a customer might feel powerless to prevent but I would suggest that this may not be true in the future and as one friend and colleague told me when he shared his results that showed an increase risk of Alzheimer's:
It just means I am going to play more sudoku as I get older
That seemed like a good strategy and attitude. It is also important to note:
It turns out, however, that people seem to be less psychologically devastated by adverse genetic test results than many of the experts anticipated.  For instance, a study published in the New England Journal of Medicine found that “in sample of subjects who completed follow-up after undergoing consumer genomewide testing, such testing did not result in any measurable short-term changes in psychological health, diet or exercise behavior, or use of screening tests.
On balance I'd rather have the choice than have the government make decisions about what data I can access. I say this with all due respect to my clinical colleagues who may disagree and the many that had exchanges with me in other social media forums.

I would also explicitly state that this is a personal view and does not represent that of my employer nor does it represent clinical guidance.

Friday, December 6, 2013

Peace #Inspiration Love - Nelson #Mandela - I'm a Rainbow Too #tribute

Nelson (Rolihlahla) Mandela or Mandiba as he was know to many

was an inspiration for many with his incredible strength and especially his compassion and moral courage despite his 25 year incarceration. His strength contributed to the Rainbow Nation. In the words of another early lost talent Bob Marley:

I Want you to know I'm a rainbow too

You can take the boy out fo Africa, but you can't take Africa out of the boy. Today I am proud to call myself an African and stand tall with the people of Africa at this time of sorrow

He managed to bring light into any situation and there are so many tributes across the web - you can read his biography here - hard to pick on any but I liked Richard Branson's here
and included this great version of the classic song by "Biko" that was performed by
Peter Gabriel performed Biko a cappella at the unveiling of Steve Biko’s statue and the whole crowd sang every word. He said: "I have been living with the words (of the song) for a long time. It is a sense of completion to be here." You could see tears in Madiba’s eyes - it was one of the most emotive moments of all of our lives.

and Time's 10 songs to remember Manndiba by

The Nelson Mandela Foundation posted its own message. But it was his words that summed it up for me and I have quoted many times:

What counts in life is not the mere fact that we have lived. It is what difference we have made to the lives of others that will determine the significance of the life we lead.” — Nelson Mandela

My deepest sympathies and condolences to the Mandela Family, the Nation of South Africa, the Continent of Africa and his friends around the world

Hamba kahle Madiba
(Go well/stay well)