Will 2015 be the year your watch teaches you about your health?

There is no known medical condition that enables an individual to predict the future. While such an ability would be extremely useful for myriad reasons, we have, instead, learned to hone and leverage our analytic skills to deduce what might occur, relying on the data we cull and parse to help forecast the future. So, when it comes to predicting the year ahead, we should consider the one we just had.

Regardless of which side of the exam table you sit, we’re all healthcare consumers

Consumer technology is often a good indicator of what type of capabilities and functionalities might be in store for health IT. This past year, we saw major players in the tech space announce their forays into healthcare. While this will not be without its challenges, it does not diminish the underlying fact that there is a need and want for better technology in healthcare— regardless of whether you are a patient looking to effectively manage your weight or a physician struggling to juggle patient care and administrative duties.

In the last year, we saw a wave of next-generation wearable devices flood the market, and as a result, we, as patient consumers, now have streamlined access to information such as our daily step count and average heart-rate on our watches. We know that ease-of-use, understandability, and some level of gameification:

“Congratulations! You’ve reached your target heart rate today!”

are vital to maintaining engagement.

I believe this is the beginning of something much larger, a groundswell movement that will result in patients wanting more information about their health data, and, more importantly, craving a better understanding of what all these numbers actually mean and how to positively impact them. Achieving this level of engagement demands a simpler intelligent interface that doesn’t require a learning curve, but is one that consumers can just use. Clever user interface designs can only go so far, particularly given the small visual real estate available on wearable devices, and the addition of capabilities such as intelligent voice assistants will be an integral part of this explosion of personal health management.

Having a heart-to-heart about your heart

Technology holds the potential to create clinical synergy, bringing patient consumers (who have become professional health IT consumers, or health prosumers) better intelligence about their personal health data and outlining the proactive measures they can take to become better partners in their own health. The average patient consumer may not have a reaction to the phrase

“Your Protime this week is 3.3,” but for someone with a heart condition, this number is very important and indicates how fast her blood is clotting. The data, while extremely useful to a clinician, is only helpful to the patient if she understands what it means and how she can take the right actions as a result.

The future is about patients managing their own care and working alongside clinicians to drive better outcomes. To the woman who has a Protime of 3.3, access to these results supplemented with clinical guidelines would mean that she wouldn’t need to wait for her physician to call with diet recommendations, she would know her blood is clotting too slowly and that she might have an inadequate protein consumption or might need to increase her vitamin K intake. If the number required that her Coumadin dosage be adjusted, this would be the point where her physician would reach out to her to discuss.

Although a basic example, it is one that has endless permutations when it comes to building a more engaged patient population. There is no one more invested in your health than you, and the person who cares the next most about keeping you well, is your physician. I believe that clinical synergy will be driven by both patients, who want to actively manage their chronic conditions and take meaningful preventative care measures, and physicians who want to empower their patients to better understand how the choices they make have significant health implications. Technology is the connective fiber that can enable the transmission of this important data, and help translate it into wisdom. And that truly is the crux—the data flowing between patient and physician must be relevant and meaningful. That ability for technology to determine the relevancy of health data information is just around the corner and soon our wearables will be able to notify our health information data that deviates from our personal “normal” results.

Approximately 75 percent of U.S. healthcare expenditure is related to chronic care management, imagine the impact this level of clinical synergy will have on driving a healthier population while reducing cost. I’m ready, are you?

This post originally appeared on WhatsNext

The #EMR, #Ebola and #Bigdata - what Can We Learn

After all the hype and knee jerk politics and media I was delighted to read this piece Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records by Upadhyay,  Sittig and Singh (PDF file here)

A thoughtful piece that drilled in to the detail of events surrounding the arrival and subsequent consultations, admission and treatment of Thomas Eric Duncan

who sadly died on October 8 succumbing to the ravages of the Ebola virus

As the authors state

The mishandling of US Patient Zero is receiving widespread media attention highlighting failures in disaster management, infectious disease control, national security, and emergency department (ED) care.....also brought decision-making vulnerabilities in the era of the Electronic Health Record (EHR) into the public eye

Much of the commentary generated "fear, uncertainty, and doubt about the competence of our health care delivery system" and while there were problems I agree with the authors that this is a “teachable moment”  and a chance to identify the missed opportunities and key issues that we can learn from

The authors used the publicly available documents and testimony in their quest and it is important to note that they did not have access to the full record, the EMR used or indeed all the pieces of the puzzle and made up for this in some areas with educated guesses.

It is interesting to note that in the first visit to the ED the patient's temperature spiked to 103 degrees accompanied by pain described by the patient as 8/10 in severity.

This from a Malaria Study but typical of the Spike in Temperature found with this disease

He was diagnosed on initial discharge included sinusitis but "but that CT scans of “head and abdomen” ordered during the ED visit showed no evidence of sinusitis" and perhaps with more attention and importantly time made available to the clinical staff would offer them the opportunity to focus on the history and examination and less on high tech investigation. In many cases clinicians are forced into their use not by clinical practice but rather to meet the production pressures - as the authors put it

A host of system-related factors detract from optimal conditions for critical thinking in the ED, leading clinicians to lose situational awareness. These include production pressures, distractions, and inefficient processes

The upshot was a discharge and subsequent return days later at and even then:

even after the second ED visit which led to hospitalization, strict Ebola isolation precautions were not followed for 2 days, until the diagnosis was confirmed by the CDC

Offering a window into the events that is made so much easier with the benefit of 20/20 hindsight

The authors offer some learning opportunities that are worth highlighting

Top of the list in would be working with software developers to improve EHR usability

As this case illustrates, EHR-based clinical workflows often fail to optimize information sharing amongst various team members, leading to lapses in recognizing specific clinical findings that could aid in rapid and accurate diagnosis

As an interesting addition none of the systems (or incentives) have any form of feedback loop built in to allow clinicians to learn from their actions.

As for the process of information capture - we have lost site of the information that is relevant in the fog of billing and regulatory driven template driven charting.

Condition-specific charting templates, drop-down selection lists, and checkboxes developed in response to billing or quality reporting requirements potentially distort history-taking, examination, and their accurate and comprehensive recording.. Clinicians also tend to ignore template-generated notes in their review process; often the signal-to-noise ratio in these notes is low. EHRs can lead to less verbal exchange, which is all the more needed and more effective when dealing with complex tasks and communicating critical information 

Right on except to say this does not "potentially distort history-taking" - it does distort history-taking and
not "EHRs can lead to less verbal exchange" - EHRs do lead to less verbal exchanges

The data entry requirements place an enormous burden on our clinical professionals

who are tasked and measured not on clinical practice and the delivery of great care but on specific content of documentation that is mandated to capture clinical information in specific ways determined by the reimbursement, coding and regulatory system.

Other factors, such as heavy data entry requirements and frequent copy-and-paste from previous notes, detract from critical thinking during the diagnostic decision-making process... For EHRs to be most effective, they need to be able to automatically sort through patient data, identify the pertinent findings, and present them in an easy to understand manner. Computer algorithms could combine patient-specific information with the latest evidence-based clinical knowledge to help clinicians reach the correct diagnosis

This is the next frontier of Healthcare technology and in particular clinical documentation - we know we can sort through patient data, identify the pertinent findings - focused in these examples on quality of care and evidence based guidelines and we know computer algorithms can use patient specific information combined with evidence based knowledge to help

Technology can help but there are some fundamental flaws in the design and management of healthcare that are fed by the current incentives. Many initiatives attempting to improve patient safety and value-based purchasing but don't focus on accuracy and timeliness of diagnosis and in particular Outpatient reimbursement policies do not reward diagnostic decision-making, teamwork, or quality time spent with the patient in making a diagnosis.

What you incent is what you get and this needs to be changed as well.

Connected Health and Accelerating the Adoption of #mHealth

I attended the Connected Healthcare Conference in San Diego yesterday
Accelerate mHealth Adoption: Deliver Results through Data Driven Business Models for End-User Engagement

Never has there been so much to play for in the mobile health landscape, a revolution is just round the corner with key players from the health care and consumer markets coming together to develop the mHealth industry. This Connected Health Summit will create a bridge bringing together hospitals, clinicians, providers, payers, software and hardware innovators, consumer groups and the wireless industry.

You can find the agenda here and the organizers will be publishing the presentations - there were many interesting insights

Andrew Litt, MD (@DrAndyLitt) (Principal at Cornice Health Ventures, LLC) opened the conference with a great overview of the industry and a slew of challenges and opportunities.

He sees our industry in Phase 1 - the Capture and Digitization of records
and we have yet to really move and explore Phase 2:

Move and Exchnage Data AND Analyze and Manage Data that is linked to Information Driven decision Making

And Phase 3:

Managing Patient Health

In our need to move from data to analysis and information he cited a statistic from a white paper: Analytics: The Nervous System of IT-Enabled Healthcare that sadly puts 80% of data in the EMR unstructured.
This is a fixable problem today with Clinical Language Understanding and we are seeing some results and a change in the industry to stop looking to doctors to be data entry clerks
He also cited Hospitals:

Hospitals are "remarkably inefficient organizations" - Andrew Litt #ConenctedHealth - #bigdata could help fix this
— Nick van Terheyden (@drnic1) October 14, 2014

Technology offers tremendous scope to not only fix these problems but get ahead of the problem (as is done in other industries like the Airline industry that has rebooked your flights before you even land and miss your connection). As he suggested could we use data to understand who is likely to develop a heart attack in the next 2 hours and try and change this outcome

But integrating mHealth into our workflow requires an mHealth Ecosystem:

mHealth needs an ecosystem that improves workflow and integrates data to reduce clinicians workload. This is why doctors and clinicians are resisting mHealth - they don’t like the change to the workflow that has little if any positive effect (for the doctor - they may have a positive effect for the individuals health) of reducing clinicians workload

Interesting comment on wearables and the perspective of doctors on these devices:

What bothers the doctor - mostly the people who are buying and using wearable fitness/activity trackers are the people that are young healthy fit and want to prove to (themselves/others) that they are young fit and healthy?

His graphic on Security and privacy was on the money:

Essential to balance Privacy of Health with interoperability but trust is the imperative
The stats he presented were troubling (at best)

• 96% - Percentage of all healthcare providers that had at least one data breach in the past two years
• 18 Million - Number of patients whose protected health information was breached between 2009 and 2011
• 60% - Proportion of healthcare providers that have had 2 or more breaches in the past 2 years
• 65% - Proportion of breaches reported involving mobile devices
• $50 - Black market value of a health record

The healthcare industry is under attack and is the most attacked industry today:

You might find these figures of the value of Healthcare data as it is valued on the black-market

Another interesting data point:

HIMSS records a total of 11,000 Healthcare Technology companies - less than 100 are large size and the balance of 10,900 are small business that are essentially capturing and scattering your data across many systems and data repositories...

Multiple other presentations and panelists that were all insightful. As always Jack Young (@youngjhmb) from Qualcomm Life Venture fund had some great insights - impossible to capture all of them but here are some:

Healthcare is moving out of the hospital into the home for many reasons but cost is a big driver:

and he suggested there was at least $1.5 Trillion in economic value as the industry shifts (shifting vs replacement?)

Many were surprised by his stat that users check their smart phone at least 150 times per day (just looking around my world this seems low) - in fact a quick check online suggests this is no longer valid and it is probably 221 times per day. Given this device is the one thing we will not leave home without and it now contains a range of sensors including:

• Accelerometer
• Gyroscope
• Magnetometers
• GPS
• Cameras
• Infrared
• Touchscreen
• Finger print
• Force
• NFC
• WiFi/Bluetooth/Cellular

We have the potential for more passive compliance with our patients (and as many stated in their presentations likely more accurate as self reported data is notoriously inaccurate)
He predicted a a 10x growth in wearables from 2014 - 2018 with 26% of this growth attributable to smart watches (I know hard to believe at this point but I think if you looked back 4 years ago the iPad had nothing like the level of penetration it does today)
iPad Growth Rate

I liked his assessment of the werable market place by researching the eBay Discount against the price of the new device:

and even worse for Smart Watches

I also presented “mHealth Reimbursement - Who Will Pay:
You can see it here at Slideshare or below:

mHealth Reimbursement : Who Will Pay? from Nick van Terheyden

What can we learn from Robin Williams in life and in Healthcare

Like many people the death of Robin Williams

was sad on so many levels and while my connection with him was limited to the exposure I had through his canvas of work, I like others felt I knew him.

He was not only prolific in his work with a list of films, interviews and shows (and if you have NetFlix - here's all the movies available there), but could often be found adding color and charisma in the most unusual places - in this story related by Christopher Reeve talking about his friendship as they walked past a lobster tank in a restaurant

One evening we went out to a local seafood restaurant, and as we passed by the lobster tank I casually wondered what they were all thinking in there. Whereupon Robin launched into a fifteen-minute routine: one lobster had escaped and was seen on the highway with his claw out holding a sign that said, ‘Maine.’ Another lobster from Brooklyn was saying, ‘C’mon, just take da rubber bands off,’ gearing up for a fight. A gay lobster wanted to redecorate the tank. People at nearby tables soon gave up any pretense of trying not to listen, and I had to massage my cheeks because my face hurt so much from laughing.”

Bet you wish you had been there to listen in!

The outpouring of grief, sadness and accolades was no surprise and while he may not be everyone’s favorite actor or character it is hard to imagine people feeling dislike for him.

He was a serious actor who’s work included playing characters with flaws
Good Will Hunting

Insomnia


And a personal Favorite (for the teacher we all wanted to have - Captain, My Captain)
The Dead Poet’s Society

But is best known for his comedic genius and unstoppable energy that could light up any room or interaction and turn even the most somber of moods into smiles and laughter

And his comedic view of what Lobsters were thinking in a tank as he demonstrated when he visited his longtime friend Christopher Reeve and making him smile for the first time after his accident

“As the day of the operation drew closer, it became more and more painful and frightening to contemplate,” wrote Reeve. “In spite of efforts to protect me from the truth, I already knew that I had only a fifty-fifty chance of surviving the surgery. I lay on my back, frozen, unable to avoid thinking the darkest thoughts. Then, at an especially bleak moment, the door flew open and in hurried a squat fellow with a blue scrub hat and a yellow surgical gown and glasses, speaking in a Russian accent. He announced that he was my proctologist, and that he had to examine me immediately. My first reaction was that either I was on way too many drugs or I was in fact brain damaged. But it was Robin Williams. He and his wife, Marsha, had materialized from who knows where. And for the first time since the accident, I laughed. My old friend had helped me know that somehow I was going to be okay.”

The friend we all want to have...?

With that in mind it can be hard to reconcile that character with someone who would take his own life:

• How is it possible that someone with what appeared to be so much joy and happiness who was surrounded by friends and family find themselves in such a state of despair to take an irreversible path and commit suicide?
• How is it possible that someone who outwardly seemed to have such a sharp insight into people and laughter who could make us all laugh at the most unlikely of issues or discussions could take his own life?
• How is it possible that someone with such a storied and successful career could drop into a state of depression with so much to live for and so many people who loved him and end his own life?
• How is it possible that a smart, intelligent and gifted individual with so many positive aspects to his life could see no alternative to ending his life and commit suicide?

We can be surrounded by people but be all alone

In what seems eerily insightful he talked about this in his “report to Orson” in the show Mork and Mindy in 1981 where Mork meets a famous celebrity (in this case it the famous celebrity is Robin Williams): “Mork Meets Robin Williams”. You can watch part of it here
Mork learns about the nature of fame on Earth and the toll it takes on those who get swept up in it, or try this link

There has been some mention of Parkinson’s Disease and this may have had a contributing role. But the underlying challenge was his battle with depression. On many occasions he had shared his struggle with depression and substance abuse and the ongoing challenge he personally faced dealing with his disease.

The word depression is used frequently by people to describe their feelings and emotions but it has a very specific meaning in medicine and is used to describe a mood disorder:

Clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for a longer period of time.

Not to be confused with sadness which is a temporary feeling that is normally associated with some negative aspect of our lives or surroundings and passes

Our understanding of depression is still limited – our treatment of this disease is still in its infancy and mostly limited to broad-brush therapies that impact neurotransmitters that are implicated but not exclusively associated with depression. We have (mostly) moved past separating and isolating people from the general population (although some would argue that our prison system is the new version of the sanatorium). But our ability to treat or cure depression remains stubbornly missing.

Our understanding of the brain is limited and despite laudable attempts to jumpstart the process
The NIH BRAIN Initiative.  progress however remains frustratingly slow and leaves our society with a subset of the population suffering from varying degrees of debilitating diseases of our brain including depression, mania and schizophrenia and many others.

So what did Robin Williams teach us in Life

Laughter is the best medicine

It is hard to pick a single moment from his incredible repertoire, so I picked 3:
Mrs Doubtfire
Explaining Golf
 Or this medley tour of cultures and accents all done in less than 2 minutes
Laugh and laugh loudly

Being different is not just OK its what makes life worth living

Endless compassion

and the real Patch Adams

What did Robin Williams Teach us in Death

We need empathy, compassion and tolerance in our society
Empathy: The Human Connection to Patient Care

Social Media can help link people but even with these digital connections humans may still feel disconnected and alone despite outward appearances to the contrary and connecting, engaging and reaching out is even more important today in our “connected” world

Suicide is painful – not only for the unnecessary loss of life but for the trail of despair it leaves behind for all the people wondering
what if....
should have....
could have done….

I’ve experienced it with friends and still think about them. In fact I was reminded when I read about two more suicides in New York: Suicides At NYU And New York Presbyterian–2 Physician Interns Jumped To Their Deaths of two promising lives brought to a final and sad end.

Don’t let that be your legacy and reach out to someone today and remind them and yourself why life is great for both of you

Health Insurance Reform - It's Not a Bumper to Bumper Warranty

We have some Healthcare reform in the US but we are still challenged with a system that is failing to deliver results. This piece recently: America Ranks No. 1 for Over-Priced, Inefficient Health Care featured the chart from the Commonwealth fund

That ranks the US last in a group of 11 industrialized countries.

As he puts it:

There is one way America is clearly exceptional:  we have a healthcare system that is dramatically more expensive than the rest of the industrialized world, but it doesn’t manage to make us any healthier.While  the Affordable Care Act attempts to address access it does little to address the cost of the system and the inefficiencies. This does not require a reduction in premiums it needs to address the costs built in to the system that we are all paying for in on form or another

Dr Hans Duvefelt wrote this piece on the healthcare blog: A Swedish Country Doctor’s Proposal for Health Insurance Reform that draws on his personal experience in "socialized medicine, student health, cash-only practices and government-sponsored rural health clinic working for an underserved, underinsured rural population."

His focus is as a primary care physician but most would agree this is one of the most challenging areas for reform with the shortage in clinicians and low reimbursement rates that is driving doctors out and certainly no encouraging our new generating of clinicians to dive into this essential area.

His main proposals center on basic services that are covered by a flat rate for populations

• Have the insurance company provide a flat rate in the $500/year range to patients’ freely chosen Primary Care Provider, similar to membership fees in Direct Care Medical Practices.
• Provide a prepaid card for basic healthcare, free from billing expenses and administration.

but importantly changing the responsibility and feedback on the cost from a central purchasing authority (the government for example) to the user themselves.

• Unused balances can be rolled over to the following years, letting patients “save” money to cover copays for future elective procedures.

And offers a pathway to specialty care with some appropriate oversight and appriroate levels of reimbursement.

• Keep prior authorizations for big-ticket items, both testing and procedures, if necessary for the health of the system.
• Keep specialty care fee-for-service.

 These are clever suggestions and would do much to encourage the patient engagement that will be, as Leonard Kish stated

Patient Engagement is the  Blockbuster drug of the century

He rightly points out that the current health “insurance” products are often poorly named - given that insurance that pays and copiers to identify diseases with screening but then stops short of paying to treat conditions and diseases when they are found through that screening. But most of all Insurance should be user driven and priorities and decision left in the hands of the individual and their clinician and not relegated to others who sit in offices emoted from clinical practice and focused on fiscal drivers not on care and quality fo life

Health insurance is not like anything else we call insurance; all other insurance products cover the unexpected and not the expected. Most people never collect on their homeowners’ insurance, and most people never total their car. Health insurance, on the other hand, is expected by many to be like a bumper-to-bumper warranty that insulates us from every misfortune or inconvenience by covering everything from the smallest and most mundane to the most catastrophic or esoteric.

His point about setting of priorities is important - no matter how you cut it there is no unlimited pot of money o resources to treat everything and everybody. These are difficult conversation and ripe for abuse by those with their own agenda’s through fear mongering and use of emotive terms like “Death Panels”.

None of this aspect of reform is simple but it needs to be addressed and included.

The United Kingdom’s National Health Service (NHS) may not be perfect but they have started this process of addressing the challenge of allocating resources in an open manner. They developed the the quality-adjusted life years measurement (QALY) out of the National Institute for Health and Care Excellence (NICE). There has been criticism and push back as there will always be but the concept and methodology use is not limited to the UK. While imperfect as Laozi (c 604 bc - c 531 bc) stated:
A journey of a thousand miles begins with a single step

There is lots of detail in this piece and I would encourage you to go over and read it

We Must All be Engaged in the Design, Delivery, and Re-imagination of Healthcare

Previously posted on HITConsultant

On a recent flight, I had my headphones on and the Rolling Stones’ “Satisfaction”

began to play.

It’s a song I have heard hundreds of times over the years, but I was struck by the difference listening to it with headphones made. With no distractions, I noticed the bass line, in time with the percussion, provides the perfect offset to Mick Jagger’s distinctively strained voice. It was a completely different experience than hearing the track play in the background of a movie or while at a restaurant. Being fully-immersed and listening only to that song allowed me to pick out and appreciate subtle details I had never noticed previously. It’s no surprise that things sound differently when you’re able to concentrate your full attention on what is being said, but as I was sitting there, I became acutely aware of the function headphones serve—they enable the wearer to listen, blocking out distractions.

That is exactly what we are seeking in healthcare and it has proven to be difficult to achieve – in part because of pace, complexity of care, and technology. For centuries, physicians have listened to their patients and relied on their senses— their powers of observation— and matched these insights with clinical experience to heal. Clinicians need to be able to listen and concentrate on what their patient is telling them and noticing those distinctive symptoms he or she may be exhibiting. As Sir William Osler

famously advised:

“Listen to your patient, he is telling you the diagnosis.”

Being able to dedicate your undivided attention to anything these days is a rarity, but in healthcare, it is a crucial but frequently missing element. The last thing you want to feel when you are at your most vulnerable is that your physician is multi-tasking. Patient satisfaction scores will suffer, but more concerning are the clinical risks and missed opportunities of distracted physicians.

Distracted clinicians are the result of what Dr. Steven Stack of the American Medical Association refers to as an “over-designed” health IT system.” In a recent discussion with industry leaders, he explained that we seem to have become victims of our own ambition. We have devised structures that don’t work for everyone and policies that create very real, very expensive consequences for those who don’t abide. And this has left physicians stretched too thin, trying to do more in less time without any direct impact on improving their ability to care for their patients.

So, maybe it’s time we scale back. Dr. John Halamka, CIO of Beth Israel Deaconess Medical Center and co-chair of the nation HIT Standards Committee, noted that while we are in this period of transition and growth, we need to focus on parsimony, or determining the smallest number of moving parts that need to be adjusted in order to create seamlessness in HIT. Quite simply put, while the cart has been upset, there is no reason to trample all over the apples.

The MIT Technology Review recently interviewed Sarah Lewis, a doctoral candidate at Yale, about her recent book that explores how different unlikely circumstances or paths, like failure, have often spurred innovation. Citing creative geniuses such as Cezanne and Beethoven to Nobel laureates, she defines failure as the gap between where one is and where one would like to be. Confronting this gap, she asserts, is important because it “lets people go deep with their failure while letting it be an entrepreneurial endeavor if they like, or an innovative discovery.” We, in health IT, are currently at that gap where there is a disparity between where we are and where we would like to be.

The recent ICD-10 delay has provided the perfect opportunity for us to find Halamka’s parsimony, leveraging solutions that work for physicians and creating consistency and impact wherever possible. Like medicine itself, there will be no one perfect solution for every physician or organization, but we need to begin finding things that work – from re-skinning EHRs with easy to use tools like single sign-on or mobility to systems that respond to voice, touch or swipe to improve the experience for clinicians and patients. We need to start thinking of health IT more like headphones, coming in different styles to suit preferences, but providing the same function of reducing distraction and enabling the clinician to focus on the inflections in their patients’ voices, and truly hearing what is being said.

As Mick Jagger poignantly remarked, “The past is a great place and I don’t want to erase it … but I don’t want to be its prisoner, either.” We have accomplished a lot, but it is time to learn from the past and break free from what isn’t working. I think we can get health IT satisfaction (despite what the song says), but to do so we must all be engaged in the design, delivery, and re-imagination of healthcare and its intersection with technology. This truly is the art of medicine and we are all virtuosos contributing to the next masterpiece of healthcare.

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're already overwhelmed with data, what we need is knowledge & wisdom" @jhalamka@NuanceHealth#artofmedicine

— Stephanie Rufo (@StephRufo27) March 27, 2014

"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

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.”

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.

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 NBCNews.com 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)

Thanksgiving, Decency and End of Life - Be Thankful you had the conversation now #health

Patients deserve the same standard and car that doctors receive when they need treatment. But as I have said before (Doctors Die Differently and more recently Treatment Creep in Medicine - sucking Decency out of Patients) we remain challenged especially when it comes to dying.

This piece by Dan Gorenstein, How Doctors Die: Showing Others the Way touched on these issues in a moving a thoughtful way.

Dr. Elizabeth D. McKinley’s battled breast cancer for 17 years but this past spring discovered the cancer had spread to her liver, lungs and brain. Her choice was to undergo more treatment that would have potentially debilitating and mind altering effects on her or change course, accept death and work on getting the best out of what was left of her life...as she put it

..time with her husband, a radiologist, and their two college-age children, and another summer to soak her feet in the Atlantic Ocean...“a little more time being me and not being somebody else.” 

And some of her fight was with her own family - the non-medical members

clinging to the promise of medicine as limitless

And the medical members of her family (her husband is a radiologist)

looking at her disease as doctors, who know the limits of medicine

Its not a difference in the effects of disease and death but rather an advantage of knowledge and information that lead to truly informed decisions "doctors have control over their quality of life before they die and this sadly is control that eludes most other members of society" and it would appear especially try here in the USA. More than half of deaths take place in hospital and not at home surrounded by people we love which is the way most say they want to "go".

So if you do nothing else this Thanksgiving - take the time to talk about the subject with the people you love and create and advance directive or living will. In many respects no better way to be thankful than to set out what is important and let everyone know, now when you are fit and healthy.

Wishing you all a very happy family and friend fill Thanksgiving

The Future of Healthcare as Seen Through the Eyes of @kpTotalHealth with @Tedeytan #HealthIT

I posted a piece that was published on FastCompany site at the end of last month:

Could The Future Of Health Care Mean No Waits In Hospitals?

It included a link to an original concept from the innovative Kaiser founder Dr Sidney R. Garfield


I shared this with my wife who is an accomplished midwife (she stopped counting her deliveries after she hit 1,000) and we both shared a laugh but as she pointed out - at the time it was a brilliant compromise between two competing interest:

On the one hand you have healthcare wanting to help mothers rest after giving birth

On the other hand you have mothers who's genes are screaming at them - be with your baby

In this particular instance the National Health Service (NHS) in England was ahead of its time, guided by an experienced and well respected cadre of midwives who promoted and encouraged rooming in of babies when they were born. We experienced this with our children but our youngest was born here in the United States and at the time it was a fight to stop the nurses from removing our daughter from the room

I had the privilege of visiting the Kaiser Total Health facility and spent an invigorating few hours with Dr Ted Eytan, Physician Director in the Kaiser Permanente Federation (@TedEytan and his blog)

He was kind enough to reply to my article in a tweet:

And the details even appeared in the wall of knowledge with the background that I captured here:

Ted shared a link to the original history
KP’s ‘Baby in the Drawer’ Helped Turn the Tide Back to Breastfeeding Babies after World War II Which tells the story of the driver on this innovation centered around better outcomes from keeping mothers and babies together:

Sidney R. Garfield he had read an interesting article about the now famous Yale University School of Medicine research experiments with rooming-in for mothers and babies

Kaiser Permanente has continued their continued innovation - Small Hospital, Big Idea which continues and contributes to their impressive growth:

An Impressive and consistent increase in Patients

All this is embodied in the Kaiser Total Health Center that brings together existing and new technology in innovative ways. Everything from the large screen introduction:

 Through to the handheld ultrasound device:

It includes patient education with the explosion of the obesity epidemics - captured in this video graphic

The mock up health room 

Mock up Patient Examination Room

and placed working technology in the reach of innovators, patients and clinicians

3-D Visualization for Patient Engagment on Medication

 and simple technology - but so important - two hand sets for one phone so patient and health care worker can both listen in to the same conversation with immediate availability for language translation (I'm willing to be we won't need a telephone for this simultaneous translation in the near future)

and the room and facility continues to be updated:

No doubt Ted who is is currently exploring the GoogleGlass Innovation (you can read about his exploration here in his blog "The USA #ThroughGlass") will be including some of his google glass experiences as they learn more about this innovation

I believe

Paper and manilla folders will become a thing of the past relegated to museums

this will be true and perhaps when I am lying in my hospital bed will look back at this age and think

Mostly, I know that someday, someone in my same CMIO and MD shoes will think how silly it was that doctors actually hand-typed patient notes

Interview from #Health2Con with @DocWeighsIn on #speechrecognition #HealthIT #NLP and beyond

Loved spending time with Dr Pat Salber (@DocWeighsIn) from the Health 2.0 conference that took place a couple of weeks ago

I had the privilege of watching her in action as she blended social media with the sessions at Health 2.0 and tweeted a picture of her in action

Here's how @Docweighsin is a leading trend setter for #health2con pic.twitter.com/T3Swrx7kmP
— Nick van Terheyden (@drnic1) October 1, 2013

We spent some time afterwards talking about innovation in HealthIT and documentation on subjects as wide and varied as Florence and INtelligent assistants through Speech Recognition and Natural Language Processing (NLP) or Clinical Language Understanding (CLU):

Consumer Reports on Healthcare - Can #HealthIT Fix the Problems

Consumer reports published a Medical Gripes report What bugs you most about your doctor?
We asked 1,000 people about their biggest medical gripes recently

It included the chart "Grip-o-Meter"

What struck me was the number of elements that could be addressed using Healthcare Technology (HealthIT). While technology may not be a panacea it is a tool to help resolve problems, improve efficiency and ease communication and flow of information

For example - "Test Results not communicated fast". In the current day and age of instant communications, mobile phones and messaging why is it patients are left waiting hours, days sometimes weeks to receive a test result. There has been some push back by the medical profession on releasing results without allowing the doctor an opportunity to explain or contact the patient. IN one site they offer this compromise - test results are held for 24 hours maximum to offer the doctor a chance o reach out to the patient but if they have not the results are automatically released anyway.

Given the pressure of time and the challenges we face with resources and the too frequent occurrences of missed communication of results sometimes resulting in poor outcomes it would seem offering an automated results communication tool to all patients would be a simple step in improving satisfaction? If I can get an automated alert when my favorite team is playing, when the score is close capturing a cell phone number when we carry out a test and using this for outbound messaging seems like an obvious step and one that #HealthIT could play a role.

I bet others could see ideas based on the other "Gripes" - send me a note or leave a comment and I'll pull this together into a more detail post

21 Bow Tie Salute to Farzad Mostashari

Like many in the healthcare IT industry, I was saddened by the announcement that Dr Farzad Mostashari (@Farzad_ONC) would be retiring. I would suggest as famed football legend Vince Lombardi said

"The strength of the group is the strength of the leaders"

And, for healthcare technology, Dr. Mostashari has been a great leader. I’ve outlined below some of the many contributions he has made to healthcare.

Dr. Mostashari joined the Office of the National Coordinator (ONC) in 2009, and has had a huge and positive impact on the implementation, development and overall perception of healthcare IT.  Personally impacted by the state of healthcare when his mother was admitted for arrhythmias, after having asked for the paper chart, he admitted;

I couldn’t even read the cardiology consult’s name

Perhaps this is one of the reasons he like me is a proud member of Regina Holliday (@ReginaHolliday) "Walking Gallery". This difficult, and highly personal, situation likely galvanized his vision as he took on the daunting tasks demanded by the role of the ONC. He inherited a department that had, in effect, been pushed over the edge of the luge and, whilst speeding wildly along this track, was expected steer a course that would deliver on a range of programs in record time:

• Meaningful Use of Electronic Health Records (EHR)
• Certification program for EHRs
• National Standards
• Grant programs
• Regional Extension Centers

And that was just what he knew about coming in. The team endured the challenges, weathered the storm in the "Office of No Christmas"

He rapidly earned a reputation as a leader who listened and was engaged.  He made many appearances and, although he may not have been the first, he was certainly an early adopter of social media and online engagement – clear indicators of his heartfelt passion to be part of the solution. As a customer service representative I recently encountered very astutely pointed out:

I can't do anything about the past, but I can help improve the future

Successes

It is hard to pick individual highlights from such an impressive record, but here's my list of Dr. Mostashari’s top 13 achievements and quotable/notable moments from his time in office:

1. Successfully delivering on the Stage 1 Meaningful Use, despite frustrations and the challenges of a fickle and change-resistant healthcare profession.  He gracefully offered a personal hand to help steer his colleagues:
   "Meaningful use is the best-we-could-make-it roadmap to prepare for delivery of higher quality care and mitigating some of the costs toward getting there, if it's a distraction we need to change it, and I want to hear from you personally."
2. Creating a viable technical assistance program that has touched many providers and hospitals through regional extension centers (REC).
3. Driving the successful adoption of electronic health records (EHRs) and electronic medical records (EMRs).
4. Interoperability (see note below on focus for the future)
5. Pushing for patient empowerment (He, like me, is a proud owner and runway model for the Regina Holliday Healthcare Collection).
6. As he said: "We’re on the right track to make meaningful use of meaningful use" 
7. ePrescribing
8. And as if to prove the point about his use of social media, this from his twitter feed: “We've made more progress with EHRs in the past 2 years then we have in 20"   
9. Championing the patient engagement he stated: "We cannot have it be profitable to hoard patient information"
10. Nailing the coffin shut on paper he said: "Once you close a paper file it's dead. You’re not able to move it or learn from it"
11. While this may not be his own personal quote but he applied cyberpunk science fiction, William F. Gibson famous quote to healthcare: “The future is already here – it’s just not evenly distributed.” by pointing out that we do have the technology - its just not being applied
12. Piloting Meaningful Use stage 2 criteria, which built on the success of stage 1, and pushed towards interoperability including standards for data sharing data, quality improvement, and quality measures that foster  patent engagement. As he put it: "We are using every lever at our disposal to increase the sharing of information" and "Patients need to care for themselves and become partners in their care"
13. Successfully weathering the storm of the controversial (or as he put it "headline grabbing") Health Affairs article based on data from 2008 that suggested that EHR technology was increasing the costs of healthcare.

The Future:

To the lucky individual taking the reins, I offer five suggested  areas of focus:

2. A friend once said to me: "You've put us on the horse, you might as well give us the ride." The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari's play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.

1. Continue the engaged and inclusive discussion with all the constituents and make social media a central part of that strategy both for ONC but also for the healthcare industry.
2. A friend once said to me: "You've put us on the horse, you might as well give us the ride" The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari's play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.
3. I must include a shout out for patient engagement. Nowhere else in the industry will you find such a large and untapped resource that is ready, willing – but perhaps not yet able to participate in the change. As I have stated many times:  when a doctor and patient are in a room, there is nobody, I repeat nobody, more interested in successful outcomes than the patient. Give them the tools and make them part of the solution.
4. Occasionally, the issue of Tort and Medical Negligence is raised, but it appears to have the "third rail" syndrome. Unless this is addressed, we will continue to see "defensive medicine" practiced. As I recently blogged in Science, Evidence and Clinical Practice, despite clear data that shows intensive monitoring causes more harm in normal care deliveries, we continue to see almost universal rates of this high-level monitoring.  While some may be attributable to the payment system, I believe a large part of this volume stems from the general inertia of and fear of litigation.
5. Above all - have fun. I made this point at every soccer practice when I was a coach. If you aren't having fun, there is little incentive to do well or, for that matter, to do at all. I know I am constantly amazed at the great fortune that finds me at this intersection of medicine and technology. I constantly have that feeling as if I paddled for the wave just at the right time:

"Surf's Up dude - ten foot waves of the Pier"

The Making of the 21 Bow Tie Salute

Dr Farzad Mostashari has been an incredible role model, a source of inspiration and a true visionary who has helped others see what the future of healthcare can look like. And so, in extreme appreciation of all that he has accomplished, I offer this 21 Bow Tie Salute.  

I was fortunate enough to have another wonderful role model, my father, take the time to teach me how to tie a bow tie, but for those of you wanting to learn the fine craft of tying a bow tie, instructions are included below (The 21 Bow Tie Salute was made with Real Bow Ties). 

Thanks Dad!

Here are some basic instructions:

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