The Science of Medicine

Medicine is complex and providing the best possible care is a challenge, and it is getting more complex on a daily basis. I'm willing to bet that at least a few readers will still hold onto the belief that playing music, in particular Mozart, can improve brain function. IN fact searching Google Scholar reveals about 8,400 articles related to Mozart and brain function. There are even pages promoting the this concept "How to improve Brain Function". But as this NPR podcast (The Mozart Myth and More) points out it all started with an one page article published in 1993 Francis Rauscher: Listening to Mozart enhances spatial-temporal reasoning. What followed took the researcher unawares with television interviews, lots of media attention and even some hate mail and calls (because she was misquoted that rock music was not good for brain function)! In fact this limited experiment (36 students total) were able to improve spatial temporal test - nothing else, not general intelligence.

It's easy to misinterpret results and data and human nature probably pushes us towards believing in miracles and cures but what is important is we review the data carefully and base our decisions on science. In the blog "Bad Science" Ben Goldacre spends a lot of time and effort debunking myths and researching the the data to uncover the facts and interpret them correctly. He has exposed the Nutrition and Pills Industry and Fish Oil and a related piece on science and health reporting errors and this expose of Obvious Quacks. The challenge is we are deluged with information and sorting myth from reality is difficult for everyone from patients to clinicians.

For clinicians this problem is even more acute as they deal with debilitating work loads, time pressures and information overload that oftentimes are overwhelming even for standard cases. I've watched several colleagues recently treating patients an dealing with the information available in the electronic medical record (EMR). In all but a few instances the volume of data is overwhelming and processing this in the limited time available is a challenge. Add to this the need to verify existing data and update with new information and then capture the latest data relating to the patient which will become too much to burden the existing system of clinical care. Meaningful Use and the final rule making is pushing us towards EMR but for these systems to begin to address this information overload rather than add to it we have to find ways to capture clinical data without adding further work to the clinicians who is time challenged

As part of that initiative the Healthstory Project has created a vision of a comprehensive electronic clinical record that captures the all important data while retaining the complete patient clinical story. Part of the projects has been to develop a range of data standards for sharing that information and to date 5 draft for use standards have been issued and they are developing an additional 4 more. Getting the information into these formats will be a challenge and there are several efforts underway to facilitate this process. One of the members of the Healthstory Project Nuance (full disclosure they are my employer) is looking for pilot sites to test a prototype of their Clinical Language Understanding technology that is aimed at easing this burden and providing a bridge between the narrative documents generated currently by physicians and the structured data that is essential to fill these EMR's that will help deal with the information Tsunami in medicine and help guide patients and clinicians in delivering the best possible care. There are other developments underway and I have no doubt over the coming months we will see a range of solutions aimed at plugging the doctor more directly into the clinical knowledge base to help them (to help the patient) make clinical decisions with all the information, processed and assessed each and every time we reach a clinical decision point. Some of this will be about user interfaces and we might even end up with a Neo like interface

Its not as far fetched as you might think). some of it is about work flow and processing of information but the building block for all these improvements is based on capturing and processing information from the clinical interaction.

What's your experience been - have you got systems in place and have you developed work-flows to facilitate the clinical patient interaction? Has your doctor been able to capture information and process while you visits?

Meaningful Use is Here

The Meaningful Use and Standards have finally been issued and I had the fortune of sitting down with Janet Dillione, EVP and GM of Nuance Healthcare to get feedback on the final rules and their impact on the healthcare industry

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These are interesting times with some tremendous emerging technologies that will bring more and more elegant support to clinicians at the time of clinical decision making. Providing clinicians with usable solutions that do not decrease in their efficiency and reduce the time they have available with their patients.

There have already been some useful commentary in the New England Journal of Medicine (NEJM): "The “Meaningful Use” Regulation for Electronic Health Records by David Blumenthal, M.D., M.P.P., and Marilyn Tavenner, R.N., M.H.A. (pdf)". The final regulations provide some level of relaxation of the demands and requirements and the introduction of more choice offering a better balance between the drive towards digitizing clinical medicine with a nod to the existing complex infrastructure that is in place today and would be impossible to achieve without major disruptions to the delivery of healthcare. Overall they appear to have shifted the more demanding elements of meaningful use to later which allows for a slower more acceptable adoption curve

Expanding the choices and reducing the burden makes the move towards meaningful use more achievable by a larger proportion of the already time pressured clinicians. Even though there has been some practical relaxation of the standards the overall drive remains in place and there is a clear push towards the inevitable digitization of clinical care and the improvement in quality of care based on meaningful implementation of electronic medical records. As the NEJM article makes the point

Although the intent of our January proposals has been retained and indeed affirmed through the rule-making process, the final regulation also incorporates significant changes — a response to the comments and experience that diverse stakeholders shared with us. In particular, concerns about the pace and scope of implementation of meaningful use led us to adopt a two-track approach regarding the objectives that allow practices and hospitals to qualify for incentive payments in the first 2 years of the program.

John Halamka posted a brief summary in his posting "Meaningful Use and the Standards are Finalized" which included some links to the original documents. He summarizes

Overall this final rule maintains a balance between the policy objectives sought and the technology changes possible that are achievable now. There will still be 3 stages of meaningful use and later stages will be more demanding. All the original stage 1 requirements will still be part of meaningful use by stage 2

Later he posted an analysis of Final Standards rule here. He details the technical elements and summarized

The major recommendations of the Federal Advisory Committees have all been incorporated, enabling the industry to move forward with enhanced interoperability in a way that is technologically achievable today.

Interesting times and no doubt much more detailed analysis will follow

Keeping Medicines Narrative

Thought critical free-text physician notes are under threat in the current slew of Electronic Medical Records and are at risk of being washed away in the rush towards the digitization of medical records. In Jeff Barry's article in Health Management Technology; "Value of Unstructured patient narrative" he cites examples of

Throwing the patient out with the paper

In fact there has been increasing coverage of the challenge associated with delivering high quality medicine when you drive out the clinical narrative. As one colleague complained to me;

"the narrative is a big part of the value I bring, removing it dumbs down the information"

The challenge is described well in the piece "Mining Clinical Data: Road to Discovery"

For administrators and researchers, who need to extract data to develop reports, they would prefer all clinicians to enter information to the exact same manner, which means time is saved for the administrator, but not for the clinician...it's a trade off of who spends more time and who saves more time

For the busy clinician who currently derives little from the capturing of structured codified data there is little benefit for the extra and often frustratingly challenge extra time required to capture data in this structured form. It's very difficult to get clinicians to enter coded data as opposed to entering patient conditions.

There is a big push demanding structured data that is sweeping over clinicians who are increasingly highlighting the issue and pushing back refusing to become data entry clerks. While some may see this as simple resistance to change it is not just the physician who is loosing information. Patients will find their records relegated to a series of check boxes and lists and while this may provide information it does not cover the full story. The Clinical Narrative must be integrated into the EHR.

In addition to the patient and the clinical team as Jeffrey Barry notes the public health researchers also stand to gain from richer electronic patient narrative. As I frequently cite - Henry VIII medical record remains a shining example of the value of the narrative providing far more detail than could ever have been captured using a rigid form based data entry tool. There are many details available and exposes including this brief review refuting the common view that he died of syphilis



And this posting reviewing possible causes of death comparing to his symptoms and this article in the Journal of History of Medicine: "Henry VIII and Medical Study".

The unstructured free text of the physicians progress notes provide color to the unstructured data's black and white

In a recent case I observed the clinical note captured in free form using speech recognition that allowed the physician to record the information directly into the patents digital record providing immediate access to critical information to everyone on the care team. There was no delay in generating the note and even if it was possible to put this information into a structured form it would have taken far more time than the 1-2 minutes this took to create using speech recognition and since it was generated immediately and included in the EMR it was available to the full clinical team.

But all is not lost and as both articles highlight there are emerging tools that will bridge the divide between the free from narrative and the need to generate structured codified data both for analysis but also driving improvements in quality of care. In the examples provided a post processing by Natural Language Processing (NLP) technology that in a study from 2008 at the Regenstrief Institute and Indiana University School of Medicine where

researchers were able to produce sensitivity, specificity and positive predictive values exceeding 99 percent (detecting Methicillin Resistant Staphylococcus aurerus - MRSA)

That's impressive and already showing value from automating the extracting of information from free form text. There are limitations and the accuracy as variable as the terminology used by clinicians for the same condition but as IBM is showing with Watson the application of NLP in healthcare is rapidly approaching significant exciting new frontiers

Human interaction also is required because of the complexity of language and providing tools and a blended approach to capturing this information will be key to making this work. In this example Rob Stewart demonstrates a variety of ways of capturing structured information in a radiology setting:



There are many ways of approaching the problem and offering multiple choices that make physicians more efficient as they interact with patients will be the key to success and adoption.

Do you have tools or techniques that work well in your setting. What balance have you achieved between the digital need for structured data and the human need for narrative. Let me know - share your experiences or views.

Clinical Narrative Integrated into the EHR

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Clinical Narrative Integrated into the EHR - Nick van Terheyden.pdf (1178 KB)

From Health Data Matrix August 2009: Clinical Narrative Integrated into the EHR - Harmony with Healthstory

It’s been 40 years since we placed a man on the moon. It was a big step forward for mankind. We even had a re-creation of the experience via Twitter with live Tweets replicating the original timeline. The contributions of that mission and others led to enormous advancements in technology. Most people are familiar with the origins of Velcro, Tang, and Teflon, but medical science has also benefited from the space program1, especially our understanding of

human physiological function, telemedicine, remote monitoring, and robotics.

Clinicians, patients, and healthcare knowledge workers must all be asking how they can get, use, and generate the full Health Story. If they don’t, they may find that their world disappears, much like the Encyclopedia Britannica did when they failed to move with the times and find a way to offer their content and their huge database to the digital world

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