Would you swipe left on a healthier you?

2015 health IT innovation holds the promise of turning massive amounts of personal health data into usable information that can keep you healthier -- and it's conveniently accessible on your phone.

It’s always comical to watch movies from the 1980s, not only for the distinct style choices that typified that decade, but to see the type of technology most of us can still recall using. It’s nearly impossible to believe we used to happily lug around three pound mobile phones with antennas and back-up battery packs, but they offered a convenience the likes of which we had never seen before. While heading to the 2015 Mobile World Congress (MWC)

one of the most prominent tradeshows in the tech industry, I couldn’t help but think about the pace of change and get excited about the digital health innovations that will be showcased.

We tend to take for granted the conveniences and time-saving effects such innovation has on our lives. Prior to the pervasiveness of mobile technology, if you were walking down the street and you saw someone collapse, you would need to find the nearest store or phone booth to call for help. In fact, most of us probably knew which corners on our daily commute had pay phones. Now, even if you’ve left your phone in the car (an unthinkable these days) you can comfortably rely on the fact that someone nearby will have theirs in the case of an emergency.

Is your heart in it?

From a healthcare perspective, the interconnectivity of devices is fascinating and holds a lot of potential for engaging patients and improving health outcomes. Innovations such as smart watches, which are being outfitted with fitness trackers and heart rate monitoring sensors, can alert the wearer he has achieved 10,000 steps that day or that a runner has reached her target heart rate

While innovations such as these are always exciting, the bigger picture is about creating a healthier population. According to the World Health Organization, cardiovascular disease is the number one cause of death in the world today. Factors such as poor diet and lack of physical activity are some of the main contributors to the disease— and they are also elements most of us struggle to balance. In other words Lifestyle is the biggest contributor to your health as you can see in this video




Wearable devices designed with intuitive interfaces hold the possibility of helping us maintain that balance, remind us of our inactivity, track our daily caloric intake, remind us of how many hours, minutes, and days it has been since our last cigarette (even Spock spoke out against smoking)

When smart watches and fitness bands are tethered to mobile devices, we can layer on more practical applications for personal health management. What if you were walking down the street and your wearable could sense you were having a minor heart arrhythmia, send a signal to your phone, and have it call for help or advice? Or, perhaps, much like our phones can now alert us to poor traffic for our daily commute, what if your wearable, knowing you are diabetic, could sense low blood sugar, sync this data with your phone and tell you some appropriate restaurants and grocery stores nearby? They will be able to translate personal health data into steps and actions we, as patients, can take to better manage our care and keep ourselves healthier.

Engagement ROI

The benefits of an engaged patient population are numerous. Not only will people be healthier, but consider the above World Health Organization cardiovascular disease statistics and the associated costs of care, medication, and lost productivity, not to mention the personal impact on each of us. For coronary heart disease alone, the U.S. spends $108.9 billion. If people were more dialed in to their health— tracking, monitoring, and being rewarded by insurance companies for adherence to healthy lifestyle activities— imagine the savings both in lives and dollars. And with the pervasiveness of health IT innovation, we are seeing more consumer-facing health apps, such as Sharecare’s AskMD, becoming standard features on mobile devices. People can now use these apps to walk them through their symptoms, offer guidance on managing chronic conditions, and remind them to check in with their doctors.

We’ve come a long way from the shoe-box sized mobile phones of the ‘80s and it will be interesting to see a glimpse of our future technologies, widgets and devices on display at CES 2015. One thing is certain: whether you’re a physician or a patient, we’re all still consumers and our expectations for efficiency and conveniences on mobile devices will play a large role in the next phase our health evolution. In fact, I imagine the current wearable will be considered clunky and dated in as little as 10 years. We might find our lives equipped with even more svelte tools integrated with all of our healthcare data and real-time advisors, apps or avatars that coach, coerce or cheer us on through daily choices to keep our lives and health on the ideal track.


The original article appeared in WhatsNext

CES 2015 - Turning a techie into a modern-day Odysseus

As a physician and a CMIO, I’m forever seeking the latest technology offerings that might help us solve some of the very complex problems that exist in healthcare. With that goal in mind, I set out across the CES 2015 showroom floor, seeking the best in health innovation.

While it was interesting to see all the fitness and consumer health apps, I found myself spending extra time looking at non-healthcare related technologies, drawn in one direction or the other based on the “oohs” and “ahhs” of crowds marveling at incredible and unfettered innovation. I made countless stops along the way, and spoke to many different creators about the potential healthcare implications of their products, and I quickly realized that the future of health IT innovation will be a combination of various consumer technologies that are carefully sutured together.

Internet of Healthcare Things (IoHCT)

The interconnectivity of devices has been a growing trend in the consumer world, but it is one that has not really made its foray into healthcare. When it does, the potential will be astounding. I spoke with La Crosse Technology,


They collect data from weather systems, such as temperature, humidity, etc. They have developed the ability to leverage this data to adjust home heating and cooling systems according to the current weather conditions. Practical and money-saving for sure, but it is easy to extrapolate the benefits of such technology to patient consumers.

Imagine the impact this could have for someone suffering from chronic respiratory issues or severe asthma: they could receive guidance on what is going on outside and perhaps take extra medication to cope with poor air quality.






Additionally, such data could be used to send important reminders to help patients better cope with their medical issues, for instance, a virtual assistant that says “Heavy snow is on the way for the next three days, and I noticed your drug supply was down to two days, you should refill today so you don’t run out while the weather is bad and traveling is difficult.”

I also met with Butterfleye

a company that develops in-home monitoring systems.

Although there were many players in the home-monitoring space, I found this one compelling as it was easy to install and designed to learn, adapting to daily occurrences and routines as opposed to being programed. Imagine the value of setting this device up in the home of an elderly patient or loved one and using it not for security purposes, but for peace-of-mind, to make sure there is activity and movement and to learn of a fall or worsening condition more quickly.

Because the system is able to learn, it can discern the difference between a dog or cat roaming about the house and a person, so if there was an incident, a pet won’t “trick” the system into thinking the individual is actually walking about the room. While personal alerts are helpful if the individual is conscious and is wearing a medical alert device, a system such as this could help identify more severe life-threatening health conditions, and, with an intelligent virtual assistant, could ask residents if they are okay and call for help, if they get a negative or no response.

A Modern-day Techie Odysseus

Those familiar with the story of Odysseus know that he spent seven years sailing the seas trying to return to his homeland, Ithaca. What started out as a point A to point B trip, became a journey that forced him to see things differently. He was drawn in by all sorts of alluring (and not so alluring) options along the way, and when he finally returned home, he did so a wiser man. Meandering through the labyrinth-like CES showroom floor, I saw everything from robots that attach to windows
Solving that challenging problem of dirty windows on the outside

And clean the outside, to alluring bionic sensor


 Technology that allows users to control devices via subtle muscle movement from behind their ears.

A Nod to 3-D Printing

3D printing is taking off and I saw multiple exciting innovations of the technology on the show floor that included developments around materials and the ability to print metals and food. As you can see from this Geek Beat clip we are heading for a reality of the Star Trek Replicator



Healthcare is just scratching the surface and you can get a sense of some of the excitement in this piece by Dave deBronkart (ePatientdave): The Future Is Leaking In: "The Patient Will See You Now" Is 3D Printed Reality

Health and Fitness Apps Get a MakeOver

As my colleague Rebecca Paquette pointed out in her post on CES we are getting people to talk to things more naturally.

Chances are if you’re into staying fit, you’re into tracking all of the data that goes into keeping you happy and healthy. But tracking that data shouldn’t be a workout unto itself. The amount of time we spend logging meals, activity and sleep could be much better used burning more calories, or, if you’re like me, getting more shut eye (I forget to log it, then scramble to get it in before I fall asleep).

This consumer health prototype app on the Samsung Gear S from Nuance turns the process of interacting with these devices on its head as featured in this interview at CESLive

You lift your wrist, say “I had two eggs with multigrain toast, and coffee,” and voila – meal logged, calories tracked.

But the best thing about wandering the show is that it makes you see things differently, helps you think about things in a new way. It’s about pushing the limits, finding new use cases, new possible technology partnerships to create an even more robust, more powerful solution to address what people need.

Healthcare impacts many different types of people, from patients and clinicians, to administrators, coders and compliance officers— just to name a few. The common denominator, regardless of who you are, is that we all seek the best possible health outcomes. Having the opportunity to not only see, but experience, all different types of technology with untapped healthcare potential was incredible. It wasn’t about finding the health-specific applications and devices that would magically solve any one challenge, but about seeing the copious options available to consumers en masse, and talking with innovators about the potential cross-over and blending of technologies to advance healthcare today and in the future

This post originally appeared on WhatsNext

CES 2015 - The Year of Digital Health and Wearables

This year I have the privilege of attending CES2015 in Las Vegas - for those of you who have not been before its big..even by Las Vegas standards.

CES attracts 150,000 visitors (all looking for the same cabs so I’m willing to bet that Uber is not going to work as well), occupies 2,000,000 sq ft of space (35 football fields - American or the rest of the world soccer) and includes 3,500 companies

This year the DigitalHealthCES meeting runs concurrently and I believe is in its 4th year. Further evidence of the merger of health, consumer and the engaged patient equipped with mobile technology and wearables.

As my friend John Lynn said in his post Initial CES 2015 Observations. He sees the top trends as

• 3D Printers
• Drones, and
• Wearables

The first two not closely linked to healthcare (except perhaps this recent recent student suggestion of an Ambulance drone to deliver help to heart attack victims).

Wearables are front and center and John cites the Amstrip company with a band aid style monitoring concept. I expect clothing and in particular sports to lead this charge with the initial interest in optimizing training and athletic performance as we saw from the World Cup last year and the miCoach system from Adidas that was in use by the winners Germany.

Needless to say others are joining the fray with clothing brands such as Asics, Under Armour and Ralph Lauren now offering clothes to monitor all sorts of parameters

This year may see the emergence of more from the Internet of Things (IoT) - or the new term the Internet of Everything (IoE).

Everything connected and controlled through a consumer friendly hub which will include the wearable and monitoring concepts.

This is as simple as ceiling fans and cooling systems and thermostats but with healthcare making this even more interesting and the learning potential of these intelligent systems and their Artificial Intelligence offering insights into our lives to help turn unhealthy behaviors and activities into healthy choices.

So much of our healthcare expenditure is related to chronic care management, imagine the impact this level of synergy and motivation will have on driving a healthier population while reducing cost.

I’m ready, are you?

Bridging the Digital DIvide

This week I will be at the Medicine 2.0 Conference on a panel Bridging the Patient Digital Divide moderated by
Melody Smith Jones

and includes
Lauren Still

and
Nick Genes

The session was put together by Melody to take on the oft talked about but perhaps poorly understood “Digital Divide”. Patients spend less than 1% of their time with doctors - the balance of our time represents (lost) opportunity to interact with people helping them live fulfilling healthy lives and making the best possible choices.

On average, patients only spend 1% of their time in the clinical care setting.  Traditional medicine has focused upon patient engagement during that eight minute doctor visit.  Yet, it is the other 99% of the time, when patients are at home, at work, at school, and in their communities that matters most.  It is outreach to patients while they are living, working, and playing that determines how their overall wellness is managed.

We have seen a plethora of technologies that attempt to address this area with everything from diet and fitness apps to specific applications designed to address long term health issues.
But there is variability with access in the community to information technology preventing access and knowledge and skills necessary to derive the value from these tools. Melody has addressed this divide specifically focusing on apps doe Low-Income Mothers in her recent post: 3 High Health Apps for Low-Income Moms. Check out Melody’s top 3 picks for low income mothers - some great apps focusing on the Food stamps including clever use of Bar code scanning technology to check eligibility of food and the nutritional value and a novel use of simple text messaging to improve maternal and newborn health <----- approach="" font="" love="" of="" simplicity="" the="" this="">

As she points out many of us make assumptions about accessibility to technology in lower social economic groups- as she puts it

Many make an assumption that those with low income or low education levels would not have mobile technology to use in the first place

But despite the budgetary restrictions we see a very high level of adoption of mobile technology - this is true worldwide as demonstrated by the statistics of mobile phone in the world: More People Have Cell Phones Than Toilets, U.N. Study Shows.

Out of the world’s estimated 7 billion people, 6 billion have access to mobile phones. Only 4.5 billion have access to working toilets.

In one of my personal areas of passion - Africa that is replete with examples of successful use of technology to impact the health of the population at levels that we can only dream of here in “the West".  Here in this study: Text message reminders improve healthcare practice in rural Africa
and this piece in the Atlantic: Medicine by Text Message: Learning From the Developing World

It might seem counter intuitive to spend money on what some might consider a luxury or discretionary spend - but for some this is the only means of communication replacing the plain old telephone line (POTS) and these devices come with capabilities and a reach that was pervasively unavailable to many in our society. The statics suggest as many as 80% of low income consumers own a mobile device.

But despite this opportunity the technology and apps are often times targeted at the higher income who already have fitter healthier lifestyles. Some of this is because of the existing developer community (higher social economic group) who develop for the problems they perceive and the harsh economics - this is where the money is (or at least we think it is). Despite Malaria being such a big killer there is limited investment in prevention and treatment of the disease as it affects the poor nations with limited capacity to buy any solutions that are developed despite significant progress and the impact of World Malaria Day

This was covered eloquently by J.C. Herz at wired in this piece: Wearables Are Totally Failing the People Who Need Them Most. We are awash with wearables, new devices and new apps and buckling under a Tsunami of data but:

...developers continue flocking to a saturated market filled with hipster pet rocks, devices that gather reams of largely superficial information for young people whose health isn’t in question, or at risk. It’s a shame because the people who could most benefit from this technology—the old, the chronically ill, the poor—are being ignored. Indeed, companies seem more interested in helping the affluent and tech-savvy sculpt their abs and run 5Ks than navigating the labyrinthine world of the FDA, HIPAA, and the other alphabet soup bureaucracies.

There are some economic reasons for these current trends, some social aspects of the development community but these may be based on false belief of the economics when you consider the opportunity exists to shake up the $2 trillion annual cost of chronic disease….!
I’m with Kabir Kasagood, director of business development for Qualcomm Life who said

Go from the children’s table to the grown-up table...If you’re serious about this, embrace the FDA. Learn how HIPAA works... move away from fitness and go hardcore into health. That’s where the money is

Around 45% of US adults are dealing with at least on chronic condition and picking on one Diabetes and look at the market opportunity of $6.3 Billion spent on blood glucose strips gives you a sense of the economics of this market. These are motivated people for whom the quantified self can mean the difference between an (expensive) admission to hospital or managing and improving at home.

At some point, you’ve got to ask yourself whether it’s just the friction created by health-industry regulation—the HIPAA security rules and FDA approval (or waiver) process and the hassle of integration with legacy systems. Or is it too daunting for a twenty-something engineer to develop technology for people who aren’t like them at all? An obese diabetic on a motorized scooter? Or a frail old lady with memory loss? Or her caregiver? Someone who’s three bus transfers away from a doctor’s office? 

We plan to address these issues in our panel - if you can’t join us maybe you can join the conversation using the hash tag from the conference #Med2 here at Symplur

Dunkirk Spirit: How physicians support patients overcoming adversity

This article originally appeared on WhatsNext: Healthcare
One in eight U.S. women will develop invasive breast cancer over the course of her lifetime.  In 2014 alone, an estimated 295,000 new cases of invasive breast cancer are expected to be diagnosed.  That’s approximately 808 cases per day.

That’s ~640 cases per day or a little over 1 case per hour (26 per day)1

But these statistics don’t matter.  Whether it’s one-in-eight or one-in-3 million, the impact of the illness is what matters—not the numbers.  It immediately becomes a reality to you.  We can never forget that healthcare is personal, something my colleague, Melissa Dirth, articulated beautifully in her recent post “When 1 in 8” was no longer just a statistic to me.”

As a physician, sharing unfavorable findings and test results is always a sobering moment, no matter how many times you’ve done it before.  We all struggle to find the right words, and look for ways to be supportive as you allow your patient to handle the shock that accompanies such news.  We all have different viewpoints and our perspective on the disease is colored by our own life experiences and the individual circumstances.

What never ceases to amaze me, however, is the strength of the human spirit.  Despite the hard road stretching before them, so many of our patients face breast cancer with what the British would term “Dunkirk Spirit,” that inner strength that helps patients and their families overcome tremendous adversity.

Dunkirk Spirit

It is, in my opinion, one of the reasons that make cancer sufferers and survivors such an important and compelling tableau of courage.

Unfortunately, one of the essential elements that quickly becomes lost in the morass of technology is the Art of Medicine, and our ability as doctors to spend the time focused on our patient and their relatives.  As clinicians, we intuitively know the statistics associated with the disease and can interpret them to understand the impact the diagnosis we have just communicated with the patient is likely to have, but there is so much more to providing care.  We don’t just treat the condition, the physical body—we are caregivers and healers, and we seek to help the whole patient.

Technology can help in healthcare, but it is not the goal nor should it ever be the focus.  Yet, in some cases, it has detracted from our ability to provide care and compassion.  To deliver on the promise of great healthcare we have to return to the Art of Medicine and enable, not disable, our clinicians with the technology we develop.

To learn more about the role technology plays in the Art of Medicine, read: “There’s no room in technology in end-of-life care decisions"

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.

Physician Symposium #DrHIT #HIMSS14

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

The challenge of SGR “fix(es)” and the evolution of the systems we are implementing and the value proposition. As he put it

Quality of care is improved with better information — saving lives and money

But Health Technology is not easy to implement:

Health tech is hard, but harder part is changing #workflow & #workforce. @RobertWahMD#HIMSS14#DrHIT Org alignment: pic.twitter.com/AQsX1a3846

— Wen Dombrowski MD (@HealthcareWen) February 23, 2014

And layered on top is the increasing challenge of securing the data with hackers seeing healthcare data as 15x more valuable than financial hacked data!

MT @CraigJoseph: #DrHIT@RobertWahMD Arms race btwn those trying to protect patient data & those trying to get it. Who'll win? #HIMSS14

— HIMSS (@HIMSS) February 23, 2014

What we need is coordinated care and Dr Wah offered this visual of the way forward

Christine Bechtel focused on the Activate Evidence Based Patient Engagement and as she reported - Patients like doctors who have an EHR

Patients think EHRs help doctors deliver better care

• Timely access to information, sharing info across care team, med history, managing health conditions
• Overall, EHRs were rated between 23%-37% points higher than paper on these elements

Interesting since doctors have been reported as saying they dislike the EHR but patients like seeing their doctors with an EHR

MT @drnic1: 80% patients say online #EHR access improves #health and a reason to stay with a practice. #DrHIT#Himss14#HITworks

— HIMSS (@HIMSS) February 23, 2014

The sad thing was this session was concurrent with @ePatientDave in another room - The Connected Patient: Learning How Patients Can Help in Healthcare only social media united these sessions

@cmaer@ePatientDave Missed opportunity - would be so much better to have those two intersecting rather than in parallel #DrHit#HIMSS14

— Susan Shaw (@drsusanshaw) February 23, 2014

As for Jonathan Teich and his session Improving Outcomes with CDS - he used his personal experience where peer pressure (as he described it 3rd time he was pressured to take on an expert triple diamond ski slope) he finally agreed and ended up in a serious ski accident fracturing multiple vertebrae. Interesting analogy relative to the Clinical Decision Support System and the pressure this applies to clinical practice sometimes inappropriately...
Interesting look at alerts and the potential for providing more than just alerts but actually providing intelligent data that distill down to 10 types of CDS interactions

1. Immediate Alerts: warnings and critiques
2. Event-driven alerts and reminders
3. Order Sets, Care Plans and Protocols
4. Parameter Guidance
5. Smart Documentation Forms Improving Outcomes with Clinical Decision Support: An Implementer’s Guide (HIMSS, Second edition, 2011)
6. Relevant Data Summaries (Single-patient)
7. Multi-patient Monitors and Dashboards
8. Predictive and Retrospective Analytics
9. Filtered Reference Information and Knowledge Resources
10. Expert Workup Advisors

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

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

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

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

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

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

Cardiology Result

and the PSA result

I know where I'd like to be receiving my care (and lab results) from! Great finish to the session. So as he summarized where we should be with patient engagement an data

• Open your data to your patients
• Patients understand more than we think
• Teach patients how to use data effectively – This can save you time in the long run
• Put your patients to work on their own health!
• Vendor work on how patients will view big data
• It’s a new drug, research the risks and benefits

Great start to what will be a busy HIMSS

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:

News and sources include:

Healthcare IT News

ONC

Running out of Time

All truly great thoughts are conceived by walking
Friedrich Nietzsche

Don't walk behind me; I may not lead. Don't walk in front of me; I may not follow. Just walk beside me and be my friend
Albert Camus

I met Regina Holliday a while back at one of the many conferences that she attends:

At this conference she was there to present and was also creating a painting. Her reputation had preceded her and I was excited to meet her in person and hear her story first hand. I had seen some jackets at conferences and had discovered the story behind the Walking Gallery. An idea that came from a tragic story in a healthcare system that is broken











Back in 2011 a video was made featuring many from the gallery filmed at the Kaiser Permanente Total Health Center:


The Walking Gallery from Eidolon Films on Vimeo.

You can see her presentation on Slideshare here:

But there is nothing that could match the power of hearing this in person.

Regina offered to paint my story and it was months before I could pull together some photographs and sit down to articulate my personal journey in healthcare but that all came together a few weeks ago, almost in time for another walking gallery gathering. With so much going on Regina knew what she was going to paint but had not (as the picture shows)

 managed to download it quite yet

My journey to medical school and joining an honorable and privileged profession started when I was still at school and I remember the seminal moment that made me realize this was the pathway I wanted to take:

I was visiting my older brother in London we exited from Victoria rail station just as somebody had been run over by a bus. I watched as my brother pushed his way to the front of the crowd and he stooped own while very one watched - he was a doctor and knew what to do. As I stood on the sidelines watching I realized that I want to be doing rather than watching

I was a very young medical student and while I enjoyed medical school there was no doubting the fact that I was dealing with something that was really quite unique and challenging emotionally. Life and death was part of normal clinical activities and shortly after my 22 birthday I graduated

I have been heard to joke that the TV Series Doogie Howser was modeled on me as that was some years later - he was also the original blogger.

My Story

Running Out of Time

Practicing medicine in the United Kingdom in the national health service which while delivering great care placed an enormous burden on the people delivering that care. The environment was challenging, especially for a young junior doctor and I found myself questioning what I'd let myself in for. My first clinical job I worked 132 hours per week, I had Tuesday and Thursday evening off. At the time, that was the norm and all of my colleagues had the same work schedule as I did and I noticed that my senior colleagues not only had that working schedule but also took on more clinical responsibility. My weekends were hellacious, waking up on Friday morning and not finishing until Monday evening. I shared the work with a colleague and friend by the name of Niamh Anson. We would share the on-call work and split the activities, with one of us covering wards and the other covering the emergency department admissions.

The constant and chronic sleep deprivation took its toll and I repeatedly questioned the job I was doing and indeed whether I was even safe. The nurses proved to be our saving grace and several occasions when we made mistakes through simple tiredness they caught these mistakes and quietly corrected or prevented our errors. I don't remember a single time of being on call when I wasn't up most of the night and typically at leas every hour. Rarely did this not require a visit to either the ward or the emergency department. Many the time, I would walk from my living quarters to the emergency department angry at the system that would place such a burden on anyone and wondering if there was something wrong with me.

On one particular day my two team members were not at the hospital. Niamh was on holiday, one which had been booked many weeks ago but as is normally the case medical staffing had failed as usual to find replacement. By two in the afternoon, the emergency department had 17 patients waiting to be seen by me, there was a patient in intensive care on a ventilator that was having problems, and the cardiac care unit had a patient that was having a lignocaine reaction. I reached breaking point and called medical staffing, and told them I was quitting. Their reaction, humorous in hindsight but at the time not, was to tell me that my contract did not allow for me to quit. Fortunately the ward sister from the cardiac care unit intervened and quietly called my two attending's. The next thing I knew I received a call from one of them asking me to meet him in the emergency department. I thought my career was over and proceeded down to meet him expecting to be blasted and read the riot act. I was pleasantly surprised to find my two consultants there stuck into seeing patients and helping me out. One of them admitted all of the patients in the ED department while the other dealt with the patient on the intensive care unit in the coronary care unit.

Between us we were able to triage and treat all the patients by the end of the afternoon. Even now as I think back to that story I still find myself quite emotional about the experience and support from two outstanding individuals. They rounded it out by insisting that we went to the local pub for a drink (non-alcholic of course) and listened to me and provided counsel and support.

Sadly they were not typical of the senior staff in the health system and most took the view that they had suffered this level of overwork and therefore everybody else should experience the same. This was a recurring theme throughout my time as a clinician and I found most disturbing and many times very depressing.

If I am walking with two other men, each of them will serve as my teacher. I will pick out the good points of the one and imitate them, and the bad points of the other and correct them in myself.
Confucius

I remember vividly one instance where the attending surgeon I was working for heard that I was taking a sabbatical and thinking about leaving medicine. He started by saying that I was terrible shame, and I thought he was about to offer some guidance/support and thoughts about where the system is wrong and how I might cope with it. Sadly he proved to be similar to many of his colleagues and peers and felt that the system was wrong in allowing me into medical school. The system should of been better at weeding me out since there was clearly something wrong with me not with the system. He like many of his peers believed the baptism by fire, sleep deprivation and the general demeaning of junior doctors was an essential part of training and character building. As he put it, he had experienced this in his junior doctor days and he'd survived and done fine. What he failed to appreciate was that at the time he was practicing as a junior doctor, emergency call was typically a Porter coming to his door knocking on his door to tell him that somebody was "going off" and leaving a cup of tea for him. He would dress himself, drink his tea and proceed to the ward, where the patient had either died or survived, but there was very little that he could do to influence the outcome. My experience consisted of being surgically attached to an emergency page that would bark out at me at all hours, telling me to go to a ward or location in the hospital for an emergency resuscitation the could take anywhere from five – 60 minutes.

There is no easy walk to freedom anywhere, and many of us will have to pass through the valley of the shadow of death again and again before we reach the mountaintop of our desires
Nelson Mandela

My friend and colleague Niamh Anson

had many of the same experiences and like several of my colleagues elected to move away from the system leaving the NHS for Australia, perhaps hoping that this system would be more bearable. Sadly some years later she committed suicide as too many of my colleagues and friends do.

So my Walking Gallery Jacket:

As Regina described the picture:

The sky represents the never ending shifts as does the hour glass. The medical students and doctors are all standing beside me, also exhausted. My friend and colleague Niamh Anson jumping off the hour glass due to stress....

In what can only be described as a "stroke of luck" the painting of my jacket was caught on Fox 5 News doing a piece on the Walking Gallery (right around 00:24 -> 00:50 and around 01:28):

DC News Weather Sports FOX 5 DC WTTG
Or if the vide does not appear you can click this link



My jacket coming at number 227 - I hope we get all of these together one day.

If you don't like the road you're walking, start paving another one.
Dolly Parton

Like everyone else - I too have an oath to wear my jacket and use it as a tool to spread the word and effect change:

No one saves us but ourselves. No one can and no one may. We ourselves must walk the path
Buddha

Khan Academy Approach Poised to Solve a "Wicked Problem" in Healthcare

here

via thedoctorweighsin.com

Great article on the potential for social media in healthcare and highlighting the phenomenal job the Salaman Khan has done (of the Khan Academy,/a>) with education online.
There are some nice examples of use of video and social media to help in patient engagement and education and as David Chase points out addressing the exploding number of patients who will be accessing the healthcare system will need these kind fo tools and techniques if we are going to be abel to cope and keep up

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Topol on 5 Devices Physicians Need to Know About

Welcome to this new series, Topol on The Creative Destruction of Medicine, which is named for my new book, The Creative Destruction of Medicine. I'm Dr. Eric Topol, Director of the Scripps Translational Science Institute and Editor-in-Chief of Medscape Genomic Medicine and theheart.org. In this series I will detail the driving forces behind what I believe is the biggest shakeup in the history of medicine.

What I'll be doing in these segments is outlining the parts of my book that represent the digital revolution occurring in the practice of medicine and how this revolution can radically improve the healthcare of the future. In this segment, I'd like to play the role of Dr. Gizmodo and show you many of the devices that I think are transforming medicine today. These devices represent an exciting opportunity as we move forward in the practice of medicine.

Let me just run through some of these. This is 2012, obviously, and this is something that we're going to build upon. You're used to wireless devices that can be used for fitness and health, but these are now breaking the medical sphere. One device you may have already noticed turns your smartphone into an electrocardiogram (ECG). The ECG adaptor comes in the form of a case that fits on the back of a smartphone or in a credit card-size version. Both contain 2 sensors. With the first model, you put the smartphone into the case and then pull up the app -- in this case I'm using the AliveCor app -- and put 2 fingers on each of the sensors to set up a circuit for the heart rhythm. Soon you'll see an ECG. What's great about this is you don't just get a cardiogram, which would be like a lead II equivalent; using the "credit card" version, you get all the V-leads across the chest as well. I have found this to be really helpful. It even helped me diagnose an anterior wall myocardial infarction in a passenger on a flight. It was supposed to be a nonstop flight, but, because of my diagnosis, it wound up stopping along the way. As an aside, after the passenger was taken off the plane to get reperfusion catheter-based therapy at a hospital, the pilots and flight attendants all wanted to have their cardiograms checked.

The second device I will show you is another adaptation of the smartphone, but this one is for measuring blood glucose. Obviously we do that now with finger-sticks, but the whole idea is to get away from finger-sticks. I'm wearing a sensor right now that can be worn on the arm. It also can be worn on the abdomen. What's nice about this is that I can just turn on my phone, and every minute I get an update of my blood glucose right on the opening screen of the phone. It's a really nice tool, because then I can look at the trends over the course of 3, 6, 12, or even 24 hours. It plays a big behavioral modification type of a role, because when you're looking at your phone, as you would be for checking email or surfing the Web, you also are integrating what you eat and your activity with how your glucose responds. This is going to be very helpful for patients -- not only those with diabetes, but also those who are at risk for diabetes, have metabolic syndrome, or are considered to be in the prediabetic state.

The third device I'd like to talk about is another device from the cardiovascular arena that comes in the form of an adhesive patch. It's called the iRhythm, and I tried this out on myself. It's really a neat device, because the results are sent by mail to the patient. You put it on your chest for 2 weeks, and then you mail it back. It's the Netflix equivalent of a cardiovascular exam. The company then sends the patient 2 weeks' worth of heart rhythm detection. I think it's a far better, practical way, as compared to the Holter monitor wireless device. It's not as time-continuous as the ECG or glucose device, but it's in that spectrum.

I want to now explain a fourth device, which I use on my iPad. This device allows physicians the ability to monitor patients in the intensive care unit on their iPads. I use it to monitor patients at the Scripps ICU. You can use it for any ICU that allows for the electronic transmission of data. Right now, I'm monitoring 4 patients simultaneously. You can change the field to monitor up to 8 patients simultaneously. This is a great way to monitor patients in the ICU because you can do it remotely and from anywhere in the world where you have access to the Web. This is just to give you a sense of what this innovative software sensor can do to change the face of medicine.

Finally, I wanted to describe is something that I've become reliant upon, and that's this high-resolution ultrasound device known as the Vscan. I use this in every patient to listen to their heart. In fact, I haven't used a stethoscope for over 2 years to listen to a patient's heart. What's really striking about this is that it's a real stethoscope. "Scope" means look into. "Steth" is the chest. And so now I carry this in my pocket, and it's just great. I still need a stethoscope for the lungs, but for the heart this is terrific. You just pop it open, put a little gel on the tip of the probe, and get a quick, complete readout with the patient looking on as well. I'm sharing their image on the Vscan while I'm acquiring it and it only takes about a minute. We validated its usefulness in an Annals of Internal Medicine paper, in July 2011,^[1] describing how it compares favorably to the in-hospital ultrasound echo lab-type image. This could be another very useful device in emergency departments, where the wireless loops could be sent to a cardiologist. Another application it could be used for is detecting an abdominal aortic aneurysm. Paramedics who are out in the field, or at a trauma case, could use this to wirelessly send these video loops to get input from a radiologist or expertise from any physician for interpretation.

These are just a few of the gadgets that give you a feel for the innovative, transformative, and really radical changes that will be seen going forward in medicine. Thanks for watching this segment. We'll be back soon with more on The Creative Destruction of Medicine. Until next time, I'm Dr. Eric Topol.

via medscape.com

I am excited to be talking with Dr Eric Topol on Friday and hope you will be able to join me. To help prepare you for the conversation and the breadth of areas that Dr Topol covers I am posting his vide presentations from Medscape that provide quick intros to different areas. This one looks at 5 devices that will change the future of Medicine.

Smartphone as an ECG

Stickless Glucometers for Continuous Monitoring

The NetFlix Cardiovascular exam - worn for 2 weeks and mailed for Review

Mobile ICU Monitoring

The Mobile Ultrasound

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Visualizing an e-Patient’s Medical Life History

via e-patients.net

What a great post from Katie McCurdy on the new age of medicine and the fact that the medical record needs to be more than single points of data recorded when we stop by a healthcare facility or clinical office.

Katie comes at this as an interaction designer so is able to create a coherent and easy to digest record which might be harder for others. But as she rightly points out

a patient-generated timeline, if that artifact makes the storytelling process easier for the patient & more coherent for the doctor, it adds a lot of value even if the doctor doesn’t want to take time to carefully analyze it.

Agreed - and as many of the e-Patients have demonstrated capturing and understanding data is helpful in the successful management of their care. And importantly as Edward Tufte has demonstrated repeatedly clear presentation of data is the key to understanding.

Doctors may not have the time to assemble the record in these formats and while there is a challenge presentation of multiple formats the process of capturing and documenting alone is valuable and likely to lead better understanding for the patient and the clinical care team.

What a great resource to have an engaged e-Patient who has a background in interaction design working on a project like this.

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