Five Technologies that will Change the Practice of Medicine

Speech Technology

Speech recognition offers efficiencies today but recent innovations and new technologies will expand the horizon of opportunity with speech technologies that will change the human computer interface, simplifying the interaction and offering new and innovative tools that increase efficiency and safety of healthcare delivery and reduce the administrative burden and decrease costs.

Medical Intelligence in the Cloud

We’re facing a tsunami of patient data. The ability to process and leverage this data at the point of care is gone. Cloud based intelligence, analyzing data content and delivering contextually relevant information in real-time will become essential.


Continuous Mobile Monitoring

Our current perspective of a patient’s healthcare record is comprised of snippets of our total healthcare record (imagine a piece of string as the record – all we get is a very short piece when we visit a doctor/facility). Continuous monitoring (wireless, cloud based and automatically monitored and tracked) changes this and offers more complete view of our health record and more important data that is not just single data points but trends and changes.

Personal Health Management

This is becoming essential as we move from a system that disconnects the purchaser from the payer. It’s as if we were buying a car but someone else was paying with no personal financial consequence – we would all buy Ferrari’s, Porsche etc. As we move away from this model, personal responsibility, personal health management tools and PHR's will become essential, not just for capturing and holding the data, but for helping people interpret and manage their own care. We will all become our own care coordinators for ourselves and our extended family, but will need the tools and solutions to help – these will come in form of PHP and health management tools.

Social Media in Healthcare

If World of Warcraft can engage a generation of young adults and teens to stay online, engaged and spending enormous sums of money, the gaming industry is doing something "right". Applying this to health and getting folks engaged is the next frontier. We have already seen that just giving a patient access to their medical record and putting a definitive Diagnosis of obesity has a positive impact on their behavior and general health. Imagine what else you could do with social media and gaming engagement.


But as always - don't forget the patient. As I have noted before Doctor Please Look at Me not Your EMR

This was amplified in a recent article in JAMA: A Piece Of My Mind (JAMA. 2012;307(23):2497-2498. doi:10.1001/jama.2012.4946) that included this drawing from a 7year old girl:

Save Money and Reduce Medical Errors

and improve the quality of healthcare!
HealthImaging featured a report Medical errors cost U.S. $17 billion in 2008 which estimated that

This figure amounted to 0.72 percent of the $2.39 trillion spent on healthcare that year in the U.S.

The study identified the sources based on medical claims estimating:

564,000 inpatient injuries (1.5 percent of all inpatient admissions in the U.S.) and 1.8 million outpatient injuries (0.15 percent of the estimated outpatient encounters nationwide)

Given the landmark publication "To Err is Human" from the IOM from November 1999 that estimated at that time:

...total costs (in­cluding the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide.

the progress remains frustratingly poor more than 10 years on. There is a top 10 list featured in the latest research that accounted for 69% of the costs

• Postoperative infections were the most costly error, ($3.3 billion)
• Pressure ulcers ($3.2 billion)
• Mechanical complications of noncardiac device implant or graft ($1 billion)
• Postlaminectomy syndrome ($995 million)
• Hemorrhage complicating a procedure ($678 million)
• Infection due to central venous catheter ($589 million)
• Pneumothorax (collapsed lung) ($569 million)
• Infection following infusion, injection, transfusion or vaccination ($566 million)
• Other complications of internal prosthetic device, implant and graft ($398 million
• Ventral (abdominal) hernia without mention of obstruction or gangrene ($342 million)

The list serves as a focal point for healthcare professionals and patients that offer significant opportunity for improvement in both costs and quality of care. With the announcement of Accountable Care Act (ACO) on March 31 by HHS will further focus the healthcare system on removing errors and delivering a more complete and holistic approach to care. There has been much written about the ACO concept with many commentators suggesting that organizations and healthcare facilities are not ready for these changes. I would suggest that we can neither afford as providers nor accept as patients any delay in a move towards fully accountable care that focuses on on putting the doctors and patients in better control of their care and linking reimbursement to outcomes

Meaningful Yoose - A Doctors Voice

Ross Martin MD (founder of the American College of Medical Informatimusicology as part of his self-proclamation as the world's leading singer/songwriter of health information technology standards development organization songs) has written a new song - a Rap this time on Meaningful Use. Driven by a desire to bring the "Pants on the Ground" by General Larry Platt tune to Meaningful Use:


The Meaningful Yoose Rap from Ross Martin on Vimeo.

"Now you're probably thinking man something ain't right, this dude ain't got the moves and his rappin ain't tight"

"Got that one straight - I may not be too cool but this message is important so I'm willing to play the fool, tips your hats to the cats from the ONC"

'nuff said!

Watson and Healthcare - What's All the Buzz

Fresh from an exciting and busy week at HIMSS in Orlando that was topped off with a personal highlight - witnessing the space shuttle launch from a Passenger Jet



















and the video:


There continues to be tremendous interest and excitement surrounding the potential for IBM's Jeopardy champion (Watson) to enhance medicine and ignite discussion on artificial intelligence in healthcare. This piece in the Boston Globe: The plan behind Watson: winning hearts captures the excitement and buzz we all felt at HIMSS last week that not only made Waston a household name it also garnered a huge audience with a big ratings swell. As Richard Mack put it:

“Watson has sparked the imaginations of those not just in the technology industry, but for an array of industries around the globe"

Indeed this thought provoking piece from Diagnostic Imaging: Will Watson Replace Radiologists? The question being what will the impact be in healthcare and specifically in radiology where radiologists review numerous images and base our findings on our experience and expertise, which are in turn based on reading articles and textbooks (our knowledge base) and as the author asks:

If we program all of these knowledge bases into a computer, then wouldn’t the computer be as good or likely even better than we are?

Interesting idea but I think this concept is more likely to follow form some of the automated image processing tools that are emerging, for example from Median Technologies and their LMS-Lung application:

that automates the detection, evaluation and follow-up of lesions identified in CT images. (this technology interestingly came out of missile tracking systems). Perhaps given identification of lesions and findings in images this could then be coordinated with existing reports using some component of Watson to link image findings with clinical conditions and provide some level of machine intelligence to support radiologists

But I think Dr Krishnaraj is right:

the personal relationship between a doctor and his patient can never be replaced. It is important, for example, to diagnose cancer, but how is that information communicated? I do not believe a computer will ever be able to demonstrate compassion or rest a hand of comforting support on the shoulder of a patient that is hurting

Watson is exciting technology but it does not replace the clinicians or the clinician patient interaction. Techcrunch reported on some of the back lash and lack of understanding in this piece: The Next Stop for IBM's Watson: Healthcare?. Watson does not replace human intelligence. In fact the opposite is true it supplements human intelligence providing ready access to the large amount of information available today much as we access this information in our daily lives. For example, imagine you are shopping for fruit and come across Papaya in the supermarket, you have heard its good but have no idea how to select a good papaya so you turn to your smartphone and speak or enter "How to tell a ripe papaya" (which returns 17,400 results including pictures, videos and how tos). You apply that knowledge and select a good papaya based on new information and understanding. Watson extends this capability by helping understand the underlying meaning of the terms and linking the right information together to present a closer match to possible answers. In healthcare we are overwhelmed with new information presented in the form of randomized controlled trials, publications and research papers. A quick look at one resource (The Cochrane Collaboration)

that is working to provide the best evidence for healthcare and the ~4,000 published Cochrane Reviews,  the Cochrane Library and the updated list of treatment guidance and review of protocols and you get a sense of the mass of data that clinicians need to read, digest, process and then apply in clinical practice. Dr Watson brings processing power to the clinical coal face to improve diagnostic accuracy, efficiency and patient safety but not to replace clinicians. Or as Dr Krishnaraj put it the

"personal relationship between a doctor and his patient can never be replaced"

Computer Assisted Physician Documentation

It was an exciting news day today with the announcement of a Strategic partnership between Nuance and 3M. Lots of coverage and keen interest from the press and healthcare industry as evidenced by the 290,000 search results in Google by 15:30 ET. While many of the news links were picking up 3M's Press Release and Nuance's Press Release it was the interview on HISTalk that provided a detailed look into the tremendous synergies between the two companies and excitement surrounding the concept of Computer-Assisted Physician Documentation. As John Lindekugel said

In a nutshell, we’re taking 3M’s industry-leading Clinical Documentation Improvement approach, which a lot of hospitals rely on today in their HIM and documentation improvement departments, and applying all the technology that Nuance brings and its industry-leading technology to deliver that content to the point of care, to the physician.

Replacing the manual time consuming and painful follow up process today with an automated tool that provides immediate feedback to the clinician at the point of care.....as one CMO put it "that's huge!".

For clinicians CAPD's immediate feedback adds up to

• More accurate and specific documentation that is more effective in assessing and communicating the patient's condition
• Reducing the burden of disruptive follow up questions and queries for Clinical Documentation Improvement (CDI) staff
• Improving the overall quality and detail of the Clinical document without excessive change in behavior or effort
• Achieving appropriate reimbursement with more accurate quality and detailed clinical reporting
• Ease the burden of the ICD10 transition

For any healthcare facility in the US CAPD means there are now automated tools to reduce the administrative burden on clinicians which will have a positive effect on clinician satisfaction and retention. More accurate information flowing through the clinical systems translates to accurate clinical risk and severity, reducing compliance risk and reducing administrative costs

All this will be on show at HIMSS next week in Orlando at 3M's Booth 3547 and Nuance's Booth 2744. If you will be at the show stop by and take a look. It will be a busy few days but there should be plenty of opportunities to talk to the folks involved in developing the solution and we are keen to get feedback from as wide arrange of stakeholders as possible.

Radiology Examinations - How Much is Too Much

As is often the cases conflicting information in the media on the benefits of screen, x-rays and healthcare.
This piece in the NY Times: CT Scans Cut Lung Cancer Deaths, Study Finds suggests that annual CT Scans of current and former smokers reduces the risk of death form lung cancer:

Annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent, a huge government-financed study has found. Even more surprising, the scans seem to reduce the risks of death from other causes as well, suggesting that the scans could be catching other illnesses.

And while there does seem to be some benefit as Dr Patz (professor of radiology at Duke who helped devise the study) put it:

he was far from convinced that a thorough analysis would show that widespread CT screening would prove beneficial in preventing most lung cancer deaths. Dr. Patz said that the biology of lung cancer has long suggested that the size of cancerous lung tumors tells little about the stage of the disease. “If we look at this study carefully, we may suggest that there is some benefit in high-risk individuals, but I’m not there yet,” Dr. Patz said.

And before you run out the door to get your CT scan its worth taking note of Dr Ben Goldacre's insightful blog Bad Science that takes a hard look at the science behind claims and does a great job debunking the myths and taking a hard look at statistics. But as we have seen over the last few months there is an increasing focus on excessive use of imaging technologies. Earlier this year the Imaging e-Ordering Coalition (Co Chaired by our very own Scott Cowsill) Successfully made a case to congress to include computer-based physician order entry (CPOE) solutions as a potential method for imaging utilization management in recently passed health care legislation:

the Coalition is making several recommendations to policy makers in Congress and CMS...One of the recommendations is that imaging CPOE tools should be based on consensus medical guidelines and literature, such as the ACR's appropriateness criteria. Another recommendation is that CPOE and decision support tools should be compatible with any CMS-approved electronic medical record (EMR) systems and be able to track results.

In recent news the Healthcare alliance aims to improve the imaging process, Changing the Game the coalition continues to push for

E-Ordering, also referred to as clinical decision support (CDS) (to) provide(s) physicians with real-time, electronic access to pre-exam, case-by-case decisions linked to evidence-based clinical guidelines and tailored to a patient’s specific circumstances

and cites a 7-year study at MGH (pub 2009) that showed a dramatic decrease in the growth rates of several imaging exams

• CT exams down from 12% growth to 1%
• MR exams down from 12% dropped to 7%
• Ultrasound down from 9% to 4%

So with that in mind the concurrent news that Minnesota’s Institute for Clinical Systems Improvement (ICSI) is spearheading the First Statewide Effort to Help Ensure Patients Receive Appropriate High-Tech Diagnostic Imaging Tests that is targeted to save Minnesota healthcare community more than $28 million annually (this was the savings estimated from the year long pilot with 2,300 physicians from five Minnesota medical groups, five health plans taking part. You can read more about it here, and here in the Star Tribune in Minneapolis St Paul and here on ZDNet

The process and challenges are outlined in this video:



Showing how you can help the busy clinician by providing them with a simple, intelligent and above all standardized appropriateness criteria to guide the clinician in ordering the most appropriate study for the patient at the time of consultation. This improved patient satisfaction, clinic efficiencies and reduced administrative costs. While there will be those who distrust technology over seeing clinical decision making the solution does not force or prevent clinicians from ordering the test they deem the most appropriate. What it does do is provide evidence based guidance on the suitability or clinical appropriateness of the test.

How do you feel as a patient or as a clinician on technology guiding care choices? Like it or not expect to see more as we continue to cope with a veritable Tsunami of clinical data, studies and discoveries that by some estimates require a doctor to read for 70 hours per week just to keep up in their one speciality.

Meaningful Use and Clinical Documentation

We are facing significant changes to the world of clinical documentation with the big push encompassed in the Meaningful Use requirements that push provides and healthcare facilities inexorably towards an electronic medical record (EMR) but there remain significant concerns over the potential impact these solutions can and will have on our clinical documentation.

In this piece in the Archives of Internal Medicine (Subscription required):Time Spent on Clinical Documentation: Is Technology a Help or a Hindrance? (abstract) the review of the excessive burden of clerical work was cited as a detractor to the learning process for residents buried in a quagmire of administrative burdens. While the authors acknowledge the value that EHRs bring including more efficient and safer order entry, easily accessible clinical information, and the ability to facilitate documentation through decision support or documentation templates. While these positive effects can streamline and potentially diminish the low value tasks their experience at the University of Chicago demonstrated that

residents often research a new patient extensively on the EHR prior to the history taking and physical examination, preferring to obtain information via clerical work rather than direct patient assessment. In addition, the well-described habits of "cutting and pasting" notes or copying forward previous notes with minor daily updates are work-arounds that may save time but provide little opportunity for education and reflection about a patient's course

This was further emphasized a recent interview in Healthcare Informatics Medical Documentation and Meaningful Use focusing on the challenges of meaningful use and the loss of the narrative:

Policymakers have been too caught up in discrete data fields, putting the narrative element of the medical transcription process in jeopardy (and) meaningful use rules do not go far enough in guaranteeing that information is robust enough to provide a basis for complex clinical decisions and coordinate patient care. “Granularity and specificity have been overlooked,”

As he point out

It would be unfortunate to sacrifice the nuanced reporting by an overemphasis on discrete data. Structured reporting does not necessarily mean sacrificing the whole, nuanced record

But if you remain unconvinced this excellent paper "Communication of Clinically Relevant Information in Electronic Health Records: A Comparison between Structured Data and Unrestricted Physician Language" in the AHIMA Journal Perspectives carried a study to determine what information is lost when free dictation of data is replaced with structured entry of information?:

If physicians restrict themselves primarily to structured data entry, what happens to the “nuances of patient variability”

According to the authors nobody has yet attempted to answer this particular question which leaves a major gap in our understanding of the long term impact of the EMR on our clinical knowledge in the context of data, information, knowledge, wisdom (DIKW). And while there are some advantages to the capture of structured data and integration of information from different sources and disparate systems (an important goal in the meaningful use framework) the disadvantages of this limited selection of choices include the increased time to document (= less time with patients or for patients) but more importantly "discrete data may not catch the nuances of patient variability".

The study while limited in size attacks the problem systematically and in sufficient details to arrive at what can only be described as very troubling conclusions. Naturally dictated cardiology notes were manually highlighted with information that would be captured in a a structured data entry system. These annotated notes were then reviewed by two independent physician experts who were asked to review the highlighting of the notes and imagine himself as a physician assuming responsibility for the patient, and to imagine that the highlighting had been added by the previous physician, indicating what he or she believed to be clinically relevant and necessary to include in the communication. In an inspirational piece of design there was no mention of the EMR/EHR and structured note taking so the content was reviewed in pure clinical terms - brilliant! The experts scored missing content that was marked up rating the missing content (if any) in terms of the severity of the omission:
1 - Minimal Severity through to
5 - failing to mark up the language was extremely severe, in terms of having serious consequences for the care of the patient if that clinically relevant information had not been communicated to you

The results, even in the most conservative analysis:

(they) find that 50 percent of the notes include at least one omission rated 3 or higher on a 5-point scale, and 25 percent contain omissions rated 4 or higher

So fully 25% of notes contain omissions that rated 4 or 5 on the severity of the clinical impact of that omission! With less conservative analysis at least one expert showed 100% of notes as containing at least one omission rated with severity of 3 or higher, with 5.25 such omissions on average and omissions with “serious consequences for the care of the patient” (severity rating equal to 5) in fully 55 percent of the notes!
That's worth restating:

All notes contained clinically significant omissions (Grade 3 or higher) and on average contained 5.25 such omissions and over half contained severe omissions!

The content that was missed in some cases could be added to flexible systems but there were distinct pieces of nuanced or detailed elaborations of information and temporal/logical content and the clinician thought process for example:

- after identifying reporting severe pain in one patient’s neck and back, the dictating physician adds that she was “almost brought to tears just in getting her up on the examination table.” Both experts found it relevant that a patient was “able to walk on flat levels and walk at a moderate pace for one hour without abnormal shortness of breath or chest pain.”
- a patient’s nonsustained ventricular tachycardia (fast heart rate) occurred “during post myocardial infarction care…far removed from the time of his infarction.” The cardiologist found it highly relevant, for another patient, that the dictating physician was “hesitant to recommend his FAA certification renewal” without a repeat of a previous catheterization.
- the physician recommends continuing Toprol because it “seems to be controlling [the patient’s] palpitations well.” In another, the dictating physician considers discomfort to be “suggestive of angina.” In a third, the dictating physician expresses a belief that results of stress testing “would rule out significant major coronary artery disease, despite it being a somewhat incomplete study.”

While the study size is small and there are some potential acknowledge bias the design and conservative analysis suggests the problems is very significant and adds further weight when considering the methods for capturing and recoding clinical data. And while it is possible that adding this missing content is possible with the free text fields replete in EMR systems I have heard clinicians say they have modified their patient diagnostic review process to avoid the "other" field specifically to limit the time necessary to type this content into the "other" box. Adding speech recognition technology can decrease the time to populate these boxes but providing a more elegant and integrated solution that allows for capture of the full patient story and clinical history. As the authors conclude:

Even under quite conservative assumptions, we have found that important clinical information, detail, and nuance would fail to be captured by an EHR standard’s discrete fields, with potentially serious consequences for the patient. Such omissions could potentially influence not only clinical care, but the progression from data to information to knowledge discovery in clinical research. Clearly the question merits further attention and study.

In the inimitable words from Master Po in the iconic 70s TV Series Kung Fu:

Tread lightly grasshopper

The narrative must be integrated and preserved and will remain a fundamental foundation of clinical knowledge now and into the future of healthcare information systems. How are you preserving the information in your EMR or have you seen the record dumbed down?

Voice is Ready for Prime Time

Mike Elgan said so......: Say it with me: Voice is ready for prime time, It's time for the victory of voice to shout down the tyranny of text in this enlightening piece that had many comments all in the positive relative the to advance of technology

Talking is the best user interface...Language is natural to people and universal to all cultures. Language is a spoken medium. Written language is merely the symbolic representation of spoken language. It's an abstraction, but a necessary one.

And he asked But is the technology there yet?. You bet!

In the future, we'll talk to our computers and they'll talk back. We know this is true because talking is the most natural way for human beings to communicate. The evolution of the human-machine interface always moves the workload of interaction from the person to the computer. The perfect UI would be a natural conversation, just like you have with other people.

Could not have said it better myself! This is especially true in the healthcare setting where clinicians are overwhelmed with paper work and documentation requirements. As Mike points out there are hurdles, no insurmountable

• Technology: creation of software (supported by powerful hardware) that can understand spoken language
• Technology: content must be searchable. Text can be indexed, and we've grown addicted to the ability to search for and find the things we've written, and
• Cultural: the barrier to voice-based computer interaction is one of habit. We've grown used to typing on keyboards. Although speaking is natural, speaking to a computer feels a little weird at first. And people generally don't like learning a new way to do things.

In the piece he features three products that address these issues and go much farther VoiceBase for indexing and searching, DialtoDo to convert spoken utterances into action, and as he puts it the Mother of All Voice Applications, Dragon NaturallySpeaking 11 from Nuance.

Dragon NaturallySpeaking takes dictation so accurately that it begins to approach Steve Jobs' favorite word: "Magical." For the first week of use, I was actually shocked when it correctly recognized obscure names, extremely technical terms, brand names with correct capitalization (for example, iPhone) and performed other unlikely feats. Since I started using it, I've written the first drafts of all of my columns and blog posts, including this column, using Dragon NaturallySpeaking.

But as Mike points out the downside to this innovations, speed and accuracy that is especially relevant to healthcare is the lack of time to think. Many of us use typing time as thinking time....if you lose the typing time you lose the thinking time and generating content becomes a little more challenging at first:

The accuracy has an unexpected and very welcome side effect: It makes it easier to write. I assumed that typing was automatic, requiring little brain power. But using Dragon has demonstrated that mental energy was diverted from the task of typing to the task of thinking, which is what makes writing so much easier. I can also write faster using Dragon.

This requires a change in behavior and an adaptation to the lost thinking time that can make clinicians feel less productive as they have to pause during dictations. But for those that already adapted to dictation and that process is easy (think existing dictating clinicians who use a telephone or hand held recorder device to dictate and generate clinical notes using traditional dictation and transcription) then a move to dictating directly to your PC is one step closer.

But be warned as he identified "It's not feasible yet for most people to completely abandon keyboards, mice and text and interact entirely via the spoken word." - so don't try to make that happen or expect it to happen. Again think of the telephone and texting - in some respects Texting could be considered a retrograde step but for many (read millions) texting is preferable to actually using the phone to speak to someone.

Embrace the tools that make sense in your work and home life and importantly as I said in this piece at HealthCareIt Guy Blog: Top 10 tips for successfully using speech recognition in EHRs and healthcare apps spend the money on a good microphone

I'll leave you with Mike's closing comments:

And what can I say about Dragon NaturallySpeaking 11? It's the biggest user interface advance since the iPhone. The bottom line is that voice is finally ready for prime time. I've decided to continue my experiment indefinitely and to keep pushing the voice envelope as far as it will go. Voice makes using a computer faster, easier and a lot more fun.

How about you - have you made the jump? Can it work for you in your environment and if not what is is the barrier to using voice in your world?

Junior Doctors Hours

The topic of hours and fatigue in medicine continues to rumble on with no real resolution in site. A couple of recent articles and news items highlighted the continuing challenges.

The Daily Mail reported the Coroners' comments and verdict in this piece (Coroner hits out at doctors' hours after patient dies) and Doctors.Net also featured the report: Junior Hours Blamed at Inquest (membership required)

An elderly man died in hospital after waiting five hours to see a doctor. After being told how Roland Holbrow died without seeing a doctor, a coroner yesterday criticized European rules that restricting junior medics' working hours.
Michael Rose described the European Working Time Directive....'Hospitals are running into problems,' he said. 'I can see the clear warning signs, although I am not going to refer this to Mr Lansley as I think he will already be aware of it.

There's no shortage of views from both sides of this discussion:

Those in favor of restricting hours

..I don't agree that anyone should work that amount of hours, its not safe, and it courses problems in the future.
..criticise the PCT for not employing enough Doctors.
..Hospitals at fault here for NOT recruiting sufficient staff to provide proper shift cover... instead, they've been reducing manning levels instead so as not to exceed the WTD hours limit
..At the end of the day though do we really want to be treated by a doctor who has been on duty for over 12 hours. Pilots and the like are restricted on hours worked for safety reasons so should we really be seeing a doctor who is dead on his/her feet and then expect them to make the correct diagnosis first time every time. I doubt if many hospital administrators have a clue what happens overnite in their hospital and how bad things are they will have left by 5 30 in any case

And those that think we need to return to longer hours so junior doctors get "more experience"

..Good to see such a courageous coroner and Clinical Director, both willing to speak unpopular truths. We must unshackle Juniors from the restrictions of the "New Deal", and EWTD, whilst maintaining a sensible work / not work life balance. Also we need a 24/7 365 days a year fully active acute sector i.e. more flexible working all round, and likely more doctors
..can some one explain to me why FY1's were taken off doing night shifts and regular weekends? It seems ridiculous that we have a national shortage of doctors yet a massively under used resource of Dr's needing exposure so as to mature into decision making
..A few facts about EWTD. 1. It was never intended for the professions. I know of no professional (or other successful person in other walks of life) who has worked ONLY 48hrs pw when 'on the way up' (or indeed having 'arrived'!)

Even some senior surgeons weighed in in a letter to the Telegraph suggesting limiting hours will have a significant adverse impact on patient care. In fact they have been arguing that junior doctors need to work more hours

The College and others have consistently argued that junior doctors need to work more than the 48 hours per week permitted by the European Working Time Directive in order to amass enough experience and learning to become safe and competent surgeons.

Interesting a study just out in the Journal of Amarican Medical Association: "Presenteeism Among Resident Physicians" and was featured in the NPR Shots Blog Doctors-In-Training May Give More Than Medical Care:

nearly 60 percent of respondents said they had worked while sick at least once and nearly a third reported having worked while sick more than once. At one "outlier" hospital not named in the study, 100 percent of the respondents reported having reported to work while sick.
A related problem, the survey found, is that busy medical residents (who are already known to not get enough sleep in the early years of post-medical school training, despite rules attempting to ensure they do) also reported not having enough time to see a doctor for their own medical care.

One thing is for sure - tired people are not giving their best. As one junior doctor put it

In the last 2 weeks I have worked 105 hours without a day off. This is my rota and includes no overtime. I would say my patient care was compromised at the end as was my love for the job. ....I have maximum 2 hours of teaching every other week as the wards are too busy to leave the rest of the time

Managing the hours and providing a good working environment is going to be essential. Technology will play a role in helping reduce work burdens and creating efficiencies but updating our training system must be included in the update to our health systems

Dragon Helps Matchmaking

The latest in a an annual competition looking for unusual and innovative users of Dragon the winner of the 2010 I speak Dragon contest EvanUp posted a story Dragon NaturallySpeaking: a matchmaker - a truly heart warming story of adversity that was overcome by chance introduction linked to Dragon and culminated in marriage......EvanUp the author was diagnosed with MS

After a few strange experiences with blurred vision and numbness, I was diagnosed with multiple sclerosis and was absolutely terrified by what it might do to me.

His local administrator suggested he try Dragon and pointed him to another user who told him without any hesitation or reservation matter-of-factly:

“I have MS. It started affecting my hands so I got Dragon. It saved my career. Why do you ask?"

Sharing a common bond and enemy the two formed a friendship that culminated in marriage and as EvanUp puts it:

Dragon NaturallySpeaking and multiple sclerosis served as our extremely unlikely matchmakers, and the luckiest break I've ever had

In what is important in life this ranks up at the top on my list and aside from congratulating EvanUp for winning the competition I want to thank him for sharing his quite personal but truly positive outlook on life in the shadow of adversity.

Would you like a statin with that Burger

Perhaps a better strategy might be not eating the burger and shake rather than offering packets of Statins to go with excess fat and food intake:
A Burger, Shake, and Some Statins
But practical challenges seem to prevent our ever increasingly over weight society from moderating input so this could prove to be a practical approach that works. You might even find food manufacturers and restaurant offering to add it to food for you. In some respects this is similar to the addition of the anti dote to overdose of acetaminophen (Tylenol) that is available and would prevent liver damage in the case of over dosage. But like this concept statins may suffer the same challenge - economics. While most recognize the value of extra safety of adding the antidote to Acetaminophen this version has limited sales as it costs more and cannot compete with cheaper version that don't contain the antidote. Adding statins will likely be an economic issue not to mention the side effects that accompany statin therapy

Would you take food with statins for prevention?

Nuance Medical Search Application Now Available

Nuance released their latest offering for the iPhone today (as previewed at HIMSS 2010)- it was reviewed in several journals including

AppAdvice: Dragon Search Goes Medical with a favorable review

Once again, Nuance Communications has another excellent app on their hands, although this one is much more narrowly tailored. But if you’re working in the medicinal field and want something to aid you on-the-fly with great speech recognition, then this is definitely a great choice. It’s simply a great pocket companion for you while on the job in case you need to reference something or get a refresher on a condition

You can download the App in iTunes here its free and in the same genre as some other medical search applications that include:
PubSearchPlus from deathraypizza! that provides an iPhone search front end to PubMed
Medical Search from Intelligentmobiles - designed to help find medical practitioners nearby
and some medical code search apps

The principle and idea is simple - tap to dictate the search term and automatically submit this to several popular medical sources:

• Google
• Medscape
• Intelligent Medical Objects (IMO)
• Drugs.mobi
• Medline

Each of these search tabs appears in a slider across the top and offers a quick look at the search results for each of the medical sources. So for example - searching for "Pheochromocytoma" and results are displayed for each of the tabs:
IMO

Medline:
Medscape


As with many iPhone apps the individual links can be viewed directly on the screen and opened in the iPhone Safari browser. You can read more on the Nuance web site here and watch a video demo here.

Go ahead - give it a try and download it from the iTunes store now and let me know what you think

A Day in the Life

Guest posting on Healthcare IT Central today that featured a Day in the Life of a CMIO (thanks to Gwen Darling for posting). As I state in the piece

What follows is modeled on the Hollywood principle to make a series interesting – compress activity that might span days, weeks and even months into a single day and one episode

It's many different activities compressed into a single day - hopefully makes for more interesting reading and more useful to anyone thinking about a career as a CMIO, certainly on the vendor side.

Reducing unecessary Tests

NPR featured a segment recently on the reducing unnecessary scans "Requiring Doctors To Justify Scans Reduces Waste" with a simple 9 point scale to demonstrate the value of a test in the diagnostic process. Low score means the test has limited or no value and high score means the test has a high chance of providing additional information to the diagnostic support process

For instance, ordering an MRI for uncomplicated, acute low-back pain could get a "2," or not such a hot idea, according to similar criteria developed by the American College of Radiology. But if the patient in pain had previously undergone back surgery, then the scan might get an "8," a score strongly in favor of an MRI.

Not only did the introduction of this assessment help in reducing the number of tests - a decrease from 5.4 to 1.9% of scans of the total number of scans but there was an overall improvement in the number of scans being ordered by physicians vs booked by support staff.

From a patient safety and quality of care long term studies have not been carried out but given the increasing focus seen on excessive radiation exposure linked to increased use of imaging - in particular CT scanning that include over dosage: "Two more hospitals report CT scan radiation overdoses" as well as [excess usage especially in children "Parents Can Help Limit Kids' Exposure to Medical Imaging")

All round - good progress in applying technology to help improve quality, reduce iatrogenic effects. Perhaps we might see this technology offered to patients to help them assess with their doctors the value of a test 

Posted via email from drnic's posterous

iPhone the Preferred Choice for Doctors

IN a study that holds little surprise to me (declaration I own no Apple stock and am not linked to them in any way aside from being a user): Doctors Choose iPhone over BlackBerry. While there may be much wrong with Apple product they get one very important aspect right - usability. I've said it before and again referring to my mother and the ease with which she adopted an Apple MacBook and an iPhone.

"Physician smartphone adoption is occurring more rapidly than with members of the general public," said Gregg Malkary, managing director at Spyglass. Moreover, Malkary added, "Physicians are showing a clear preference [almost double] for using the Apple iPhone (44 percent) over the RIM BlackBerry (25 percent)."

It's because Apple focused on ease of use. You can pick up the iPhone (and iPad) and use it - the instruction manual (to my mothers frustration) is only a few pages long and contains only the most basic of instruction and is easily absorbed in a few minutes

There is much to dislike (or perhaps be envious of) in the Apple world. THey control too much and limit people in ways that can irritate even frustrate. Bu really......ease of use is an essential prerequisite for technology adoption and this is true for Meaningful Use, EHR's, EMR's, diagnostic systems, evidence based medicine. If it is too complicated or intrusive it will struggle to gain acceptance and adoption.

iPad Cure All

The Atlantic featured a post by David Rothman that presented an iPad Stimulus plan: A national information stimulus plan: How iPad-style tablets could help educate millions and trim bureaucracy--not just be techno toys for the D.C. elite. Hold on - don't give up quite yet, it's not quite as crazy as it sounds and he makes some interesting and important points. And there was an update here

I know I am fighting a tide of folks who like to hold on to paper and feel reading a book cannot be done unless you are holding paper printed with ink but they said similar things about letters which have been replaced (love it or hate it) by e-mail. As it is, our library system is struggling and children's school text books remain an exercise in frustration of obsolete texts that contain markings, answers and missing pages and cost parents money each year. But it's healthcare where we can "slay the paper dragon"

Healthcare is the real paper dragon to slay, and the Americans might even live longer if we acted. The National Institutes of Health and other leading institutions could more effectively distribute medical information to doctors and patients alike, and the sick could use the same machines to monitor treatments and juggle around pills, not just track the financial details.

My own parents struggled with drug therapy creating a spreadsheet (well actually this was created by my brother and loaded up ready for updating by my mother) to track the multitude of pills, times and dosages necessary to comply with physician directions. Simplifying these instructions and sending them digitally in a form that can be consumed in an iPad like machine (to be clear this could even be a PC but the advantage of the iPad is the instant on, instant connection to the internet and reasonable compromise between screen size, use usability, mobility and portability) would be very attractive to many seniors struggling with their own treatment.

The cost of the Healthcare paper work mountain exceeds $1,000 per person in America so anything that attacks this problems is going to be desirable. But what David Rothman is referring to is not just about the technology of presentation but the underlying transportability (semantic interoperability) and he refers to the "magic of web links and facts consolidated via XML Based Technologies". Unfortunately the challenge for the current system is reaching that point of interoperability (Standards and Interoperability) given the history of paper and the wide variation in representation of diseases, drugs and therapies (they told me when I first went to medical school that learning medicine was equivalent to learning a new language in terms of the added vocabulary required to communicate with my peers; in fact Latin used to be required for any student wishing to study medicine - you can see some of the Latin terms in medicine here). Normalizing these terms and extracting the data is the challenge facing healthcare . There is a clear need for narrative in communication - this is how clinicians best communicate clinical information amongst the team and indeed to the patient (as can be seen here) but clinical systems and the EHR need data, but data input is difficult. Bringing these two worlds together is the thrust of clinical language understanding combining Natural Language Processing technology (NLP In Healthcare) with the emerging world of digitized medicine. David wants to

let patients themselves play more of a role in policing our health system, thereby lowering costs while actually taking up less of their time, thanks to the right automation

and they will (and must) but we have some significant steps to take to achieve his vision of dashboards and the easy and rapid sharing of information. At this point any small steps is good news (every journey begins with but a small step) and the simple process of e-mailing patients actionable health tips based on the doctors finds may seem mundane but its a start.

For now we have to deal with the existing system, navigating the insurance nightmare of cost and denials all the while trying to keep up on treatment plans, drugs and therapies and if you are like me not just for yourself but for multiple family members. For now in lieu of an iPad

1. Get a full copy of your medical record
2. Get everything in digital form if at all possible but if not in printed form - you can always scan and convert to a PDF document with text using optical character recognition (OCR)
3. Get a copy of your problem list including an explanation for things you don't understand
4. Full listing of drugs as well as ones you have taken in the past and stopped
5. Get your X-Rays again in digital form on CD is good but failing that get the actual films
6. Educate your self on your condition(s) - be an expert

We all face the same challenges but starting with a full set of information helps everyone. Over time doctors will be able to produce clinical records that contain the full story for the patient that includes the narrative and the data to help automate some of this activity. In the meantime you need to be part of the solution that coordinates your care.

Had good experiences or bad - let me know. Seen your records - what did you think? Was it useful to have your medical record?

Medical Technology - The Next Generation

Harvard business review blogger Jeff Goldsmith wrote a pretty damming write up on the healthcare technology sector: "Has the US Health Technology Sector Run out of Gas". He covers the lack of recent innovation and development across the board including pharmaceuticals, medical devices and even the once promising bio technology and personalized medicine/gene therapy concepts. But his summary of the healthcare IT sector was withering

Enterprise clinical information technology seems to have hit a similar flat spot. The major commercial IT platforms for hospitals and health systems are more than a decade old. Some of the older platforms are written in antique computer languages like COBOL and MUMPS, which predate the Internet by 20 years. Despite a societal investment of more than $100 billion, these tools have yet to demonstrate that they can reduce the cost or improve the efficiency of patient care. They remain cumbersome, expensive to install, maintain and operate. The user interfaces feel a lot like Windows 95 in an iPhone era.

Yikes! Is it really that bad.......there are probably plenty of clinicians, patients and even some IT vendors who might accept that in some cases it is bad - I bet many of you can still find a text based system using some form of terminal emulation still in use somewhere in your clinical facility. In fact asking anyone to use systems with these kind of interfaces would seem wrong and such systems should either be pushed out into the digital graveyard where they belong or at a pinch shield the user from these idiosyncratic requirements and counter intuitive user interfaces.

But there are innovations and new use of technology - :in the piece "E-health and Web 2.0: The doctor will tweet you now; Patients can now meet their doctors in 'the cloud'" we can see the adoption of this technology to providing a rapid response more suited to the new age of instant communication and busy lives we lead today. It might be hard for a physician in the 1950's to understand the need for this speed of communication but bear in mind the treatment choices in those days were limited. In fact the father of a friend of mine at school was a physician and he described to me his experience of a "crash call" or "code blue"

If a patient had a problem the nurses would summon the porter who would be dispatched to my room to wake me up. I would be woken by a knock on the door and informed there was a patient "going off" on Ward xxx. I would get up, get dressed, more often than not the porter would leave a cup of tea outside my door and I would take that and then leave for the ward. By the time I arrived one of two things had happened. The patient had either died or had improved of their own accord. Their syncope, myocardial infarction or whatever event that had taken place was either resolved or resolving or they had succumbed to that critical event. There was little we could do or offer in the early days and rushing to the ward made no sense

Today we live in a technology and information rich society where instant communication is expected and can and does make the difference. In fact:

Jeff Livingston, an obstetrician and gynecologist in Irving, Texas, said his 10-doctor practice has about 600 Facebook fans and more than 1,500 Twitter followers

That's no small following and I am betting many social networking gurus and experts can only look at those numbers with envy. We don't fully understand how this technology and communications systems will impact healthcare and the delivery system but one thing is for sure rapid innovation and change will be the status quo.

Redesigning Medicine

Through provoking piece in the Washington Post today - Health Reform's Next Test by Jim Yong Kim and James N Weinstein at Dartmouth Hitchkcock. As they state

It is well known that U.S. health-care costs, as a share of our economy, are the highest in the world but that compared to other industrialized countries, our results are the worst. The Dartmouth Atlas has documented the enormous waste in our system and shown that spending more money and performing more medical procedures do not equal better outcomes for patients.

So true and so troubling as health reform marches forward under the new law. We do deserve good care and the blame storming that continues to affect all the efforts is counter productive and as they point out

We cannot blame government or insurers or physicians for the complex and multilayered problem. No single group or entity created the puzzle that is our health-care system; it is not reasonable to expect one group to solve it

Their use case shines a spot light on the challenges we face

Consider the moving pieces of a patient-health system encounter. A patient comes into the emergency room. Immediately, judgments are made about how sick she is and what treatments she needs. There is no universal medical record for that patient, so the provider has no idea about her medical history, medication use or preexisting conditions. Incomplete information is relayed through layers of nurses, physicians, specialists and the shifts of personnel who replace them. In the absence of real-time information, tests are ordered and treatment decisions made. Perhaps after an overnight stay, barring complications from drug interactions or perhaps an unrecognized underlying condition, she is discharged, with no further transfer of information to a provider and, more important, no follow-up to see whether the treatment was effective

But it is this summary point that amplifies the point:

The symptoms were treated; the patient was not.

This is exactly the point and their attempt to set up the "Center for Health Care Delivery Science" is one step int he process of many that needs to start with a realistic look at the challenges we face and the need for everyone to be part of the solution and not part of the problem.

Reassessing Primary Care

In an article in the April 29 issue of the New England Journal of Medicine titled What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice (pdf) Richard Baron analyzes his practices activities. What is surprising is the extent to which non-reimbursed activities are part of the general work.
The breakdown of services averaged per visit and physician and by patient is shown below

Telephone calls averaged 23.7 per physician per day with close to 80% being handled directly by physician. Even running at peak efficiency with no time requirement to get to the phone, waiting on hold you can expect this to conservatively consume 2-3 minutes of time per day which equates to over an hour on phone calls per day. There were slightly fewer e-mails but the time taken to respond is likely to be a little longer to read and then respond. Add in prescription refills, laboratory reports and imaging and consultation reports and the time consumed for this ancillary activity has to be approaching 2-3 hours. The overhead of the system places an undue burden on primary care physicians and it is no surprise that medical school graduates are avoiding the field given the low reimbursement and declining compensation. As the author states in the summary:

The core of primary care remains the longitudinal, trusted relationship with the patient, in which diagnostic skill, therapeutic understanding, and compassion come together for the benefit of the patient who seeks our help. Achieving that mission for patients with varying communication and computer skills is a daily challenge, even as our office faces a fragmented payment system and rapidly evolving technology. The work we describe arises from the needs of patients in a society that assigns many roles to physicians — from making diagnoses and providing treatment to ordering tests and filling out forms — and the practice must be organized to respond reliably. How and by whom the work is done is a continuing project of primary care redesign, dependent on both the skills of available non physician staff and the extent of information-technology support.

Recent reviews of compensation compared the broad categories imply that while this compensation is not as good as specialist it is still better than many others. Healthaffairs reviewed compensation and asked: Can We Close The Income And Wealth Gap Between Specialists And Primary Care Physicians (full text requires subscription) but the chart showing compensation comparisons over time is helpful:


Primary care practitioners (PCP) are better compensated than next closest - an MBA graduate but significantly less than specialists (and Cardiology is not the highest compensated specialty - AMGA Medical Group Compensation and Financial Survey pdf here). All this does not bode well for what is a the lynch pin in patient management and longitudinal relationships with patients. As noted in a recent posting in the Health care blog Why We Need Private Primary Care Doctors - aside from the basic need there is a clear economic justification that supports empowering and paying PCP's and attracting more physicians into this specialist area. And as Rob Lamberts points out points out

The solution from an overall cost standpoint is to give primary care physicians incentive to do what they should be doing in the first place: keep people healthy and away from hospitals. Any system that places too much value on procedures is going to fail at this, as the institutions and individuals who profit off of the procedures are going to fight for control of PCP’s. Independent PCP’s who profit from keeping people well are the best thing for a system.

Which reminds me of a point made some time back on Universal Healthcare - Pay While you are Healthy which cited age old system in China

Hark back to days gone by in Chinese villages where the villagers paid the medicine man when they were healthy. When they fell ill they stopped paying until they were better and able to work again

And as KevinMD originally said

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour

The way to do that is using technology that supports not hinders clinical work flow and clinical thinking. Incorporate new tools and communication methods into the process and acknowledge their value by including them in compensation structure.

Do you agree - do you have better ideas on how to make things better and what technology or processes can be applied or improved - let em know and leave your comments

Mixed Results from Healthcare IT Technology

In an interesting article in HealthAffairs this month "Mixed Results In The Safety Performance Of Computerized Physician Order Entry" (abstract only - subscription required for full article) the authors carried out a simulation of Computerized Physician Order Entry (CPOE) effectiveness.

It is a unique study with a relatively small sample size (62 facilities) that was self selecting that does represent some bias through small sample size, self selection and simulation vs reality. All that said there is still a surprising conclusion that

Many hospitals only detected 44% of adverse drug events and the best performing only detected 70-80%.

Not only is this wide variation and poor results for a very costly highly disruptive technology that is mandated in meaningful use. There is a clear need to validate the value of technology that is being suggested and especially if it is being mandated in the complex world of healthcare

These are, as many folks have commented to me  "very interesting times" but lets not loose sight of the science that formed the basis of some of the most significant advances in medicine encompassed in Randomly Controlled Trials.

Does your experience vary. Have you seen the value of CPOE or has it been a challenge in your facility?
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