Robotic Surgery Coming to s Hospital Near You

Robotic surgery is on the increase and for good reason. Its not just the ability to control movement more precisely but with the ability to create small instruments that are able to achieve the same function as larger more invasive instruments. As this interview with Dr Fernando (a colleague and alum from the Royal Free Hospital) highlights a Thymectomy would typically require a large incision down the front of the chest (Sternotomy) but with the use of Robotic Surgery the same result was achieved with three small incisions the largest being 1cm (less than 1/2")

<p style="width:640px">Robot helps performs surgery in Boston: MyFoxBOSTON.com</p>

You can get a sense from this marketing video for DaVinci Robotic systems

As they point out - 7 degrees of freedom make procedures that would be impossible for a human to perform.

This vide from the University of Maryland demonstrating Cardiac Surgery using Robots

It is probably not lost on readers the similarity that these controls have with our current slew of game controllers and those skills are related. In fact with the advent of the X-Box Kinect system that requires no controllers you have to wonder if we will see concepts that have more in common with the concepts many will remember from Minority Report

Technology enhancing our abilities not replacing them.

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Meaningful Use Day Of Reckoning - Slide Presentation from CDIA

As promised my Slide presentation has been uploaded to Slideshare on LinkedIn: "Meaningful Use Day Of Reckoning Health Story".
Click on the link below to view the presentation.
http://slidesha.re/ejqTv7

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Cloud Computing - Stepping into the Future

Cloud computing is on a target to generate billions in revenue and is experiencing something of a revival.  It's a revival when you consider that historically our access to computers used to be in the cloud...albeit the cloud was some data center and we were wired to that cloud with a hard wired terminal. Just look at this picture and the terminal behind me (circa 1980's when I was worked as a COBOL programmer and used machine language and JCL to submit these to the mainframe that was hundreds of miles away from my desk)!

This recent article in the NY Times (The Business Market Plays Cloud Computing Catch-Up) highlights the catch up on the part of the business market and predicting significant growth:

I.B.M., a bellwether in the corporate technology market, forecasts that it will have $7 billion in cloud revenue by 2015. Of the total, $4 billion will be customers shifting to cloud delivery from the company’s traditional software and services, and $3 billion is expected to be entirely new business.

and Dell is invest $1 billion over 2 years "largely for cloud offerings". Healthcare, while often a laggard in technology is also marching towards cloud based services realizing that complex software solutions can be delivered more cost effectively in a Cloud Based strategy. This 2009 paper on Cloud Computing and Healthcare; Bad Weather or Sunny Forecast? (pdf)  makes the point that this is an almost irreversible trend and entrants such as Microsoft and Google (HealthVault and Google Health) suggest this will be an increasing trend. Offering more solutions, more processing power and more storage at lower prices will provide a slew of choices and accelerate technological innovation in healthcare IT and while there are challenges and concerns relative to security and reliability the overall trend will have a positive impact.

In line with these trends is the announcement of the Nuance Dragon Mobile SDK and the Nuance Healthcare Development Program (NHDP)bringing Speech to the Cloud is significant offering a simple way for Independent Software Vendors (ISVs) and healthcare providers to integrate Nuance value added functionality directly into healthcare applications in the cloud. This brings streaming speech to the cloud allowing mobile devices and think clients to offer fast and accurate real time medical speech recognition. Integration is a snap and possible on multiple platforms including

• Apple IOS,
• Windows browsers : IE7 / IE8 / Chrome / Firefox,
• MacOS browsers: Safari / Firefox,
• Windows .NET

Calgary Scientific have already shown this integration off in the ResolutionMD mobile product and interest since the announcement has been great. Like many others we are

“We’re moving to where the puck is going in this industry,” 

Cloud computing will impact so many different areas in healthcare and technology in general and voice enabling these interactions will be key for some of these interfaces and given the level of interest will likely be offered soon.

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Car Maintenance Offer Solution to EMR Challenges

In a fun piece by the Onion titled: Quick-Lube Shop Masters Electronic Record Keeping Six Years Before Medical Industry offers an alternative solution to the current challenges of implementing an EHR. Since car maintenance is well tracked and probably many of us have experienced the sophistication of he follow up by your local lubrication center sending you a reminder that your car is due the following check ups Karl's Lube & Go is "6 years ahead of the medical industry"

A comprehensive digital cataloging system that keeps track of its customers' car maintenance history, oil-change needs, and past fuel-filter replacements puts Karl's Lube & Go's computerized record- keeping an estimated six years ahead of the medical industry's, sources confirmed Friday. "We figured that a basic database would help us with everything from scheduling regular appointments to predicting future lubrication requirements," said the proprietor of the local oil-change shop, Karl Lemke, who has no special logistical or programming skills, and who described his organizational methods, which are far more advanced than those of any hospital emergency room, as "basic, common-sense stuff." "We can even contact your insurance provider for you to see if you're covered and for how much, which means we can get to work on what's wrong without bothering you about it. The system not only saves me hundreds of thousands of dollars per year, but it saves my customers a bundle, too." 

Whilst tongue in cheek it has bothered me for many years to understand why I would unfailingly get reminders and even incentives from car maintenance but nothing from my local healthcare provider. But then maybe that has more to do with not having a primary care physician which as the USA article revealed: Half of men don't go to the doctor that revealed

45% don't even have a primary-care doctor

Yikes... and the survey goes further

40% of men in their 40s have never had their cholesterol tested, and 70% have never had a prostate exam

I tis no wonder men have a shorter life expectancy than women. Time to do something about this - it is not too late for a New Years resolution. Go find a primary care physician and schedule a check up.....today!

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Simulated acupuncture can treat nausea effectively in cancer patients undergoing radiotherapy

In a recent study comparing acupuncture with simulated acupuncture: 
Simulated acupuncture can treat nausea effectively in cancer patients undergoing radiotherapy
http://www.news-medical.net/news/20110324/Simulated-acupuncture-can-treat-nausea-effectively-in-cancer-patients-undergoing-radiotherapy.aspx

More compelling evidence of the power of the placebo effect and the power of our own thought and mind

The study from Karoli ska Institutet and Linköping University  in Sweden showed that patients, who received only standard care including medications for nausea, felt significantly more nau­sea than patients in both the real and simulated acupuncture groups.

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Meaningful Yoose - A Doctors Voice

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


The Meaningful Yoose Rap from Ross Martin on Vimeo.

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

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

'nuff said!

Glass Displays - A view into the future of Displays

Gorilla Glass (foundation of the iPhone display) - Imagine the possibilities in healthcare

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Watson and Healthcare - What's All the Buzz

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



















and the video:


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

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

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

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

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

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

But I think Dr Krishnaraj is right:

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

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

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

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

Fun meeting with @DrJosephKim #FreeEHR #Himss11

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Another interesting discussion with @techguy (John Lynn) #FreeEHR for HD TV

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Dr Watson Takes on Healthcare

Watson Emerges Champion in Jeopardy

Watson emerged the Jeopardy Champion last night with a resounding $ 77,147, beating both competitors (Ken Jennings:$ 24,000 and Brad Rutter:$21,600) by over 300% ($53,147/$55,547).

Hats off to Ken Jennings and Brad Rutter for taking on the challenge and doing such a great job

This was followed today with the joint Nuance/IBM Press Release: "IBM to Collaborate with Nuance to Apply IBM’s Watson Analytics Technology to Healthcare" (here on IBM and Nuance's site) that recognizes the tremendous value that Watson can bring to healthcare. Watson showed last night the major advances that have been made by IBM's “Deep Question Answering” (QA) research team:

the ability of a computer to understand natural human speech inquiries that pertain to a limitless range of topics, and to make informed judgments about requests

There was plenty of coverage as evidenced by the 15 Million hits in Google for the search (Jeopardy/Watson) with the vast majority highlighting Watson's superiority (Time Magazine: Winner, Dr Watson I presume, ZDNet: Watson's Next Adventure - Healthcare with Nuance, Information Week: IBM Nuance Envision Watson Helping Doctors, NY Times: Computer Wins on Jeopardy, Trivial It's Not andIBM Moving Watson Supercomputer Beyond 'Jeopardy' To Health-Care. Stephen Wolfram of Wolfram Alpha weighed in with this thoughtful post (Jeopardy IBM and Wolfram Alpha) comparing Watson and Wolfram Alpha and this more light hearted post If Google Played Jeopardy: Smartest Search Engine, But It’s No Ken Jennings where he challenged search engines with the simplified task of entering the same Jeopardy Clues

Google showed well

Leading them to suggest that

Either he’s (Ken Jennings) an immediate acquisition candidate in Mountain View and Redmond, or he should just start his own search engine and answer queries as they come in

There were other dissenters including this post Could Google Play Jeopardy Like IBM's Watson. Google has certainly cornered search and access of data but even if the data can be found with a google search and there are certainly some shared concepts in the search technologies I'm not sure that finding the data in a search page is the same as answering the question and really understanding the question. But the summary and analysis of Natural Langauge:

Natural Language Reality Check: The reality is that the technology that Watson demonstrates, while amazing in a game show, is overkill for what most people need. Those behind “natural language” search technologies have long trotted out sentences like the “Who’s in the pajamas” example above to demonstrate how “smart” their search tools are. And yet, most searches people do on search engines are only two or three words long.

Missed the mark and the analogy is flawed on several counts.  I would suggest that our interactions are deliberately simplified when we interact with Google - we work around the lack of understanding of the Google search engine. And while Watson may be overkill for "most people" the potential application in multiple areas dealing with ever increasing volumes of unstructured data it is healthcare that has been struggling with the challenge of overwhelming clinical knowledge and our inability to access and apply this at the time of care delivery. In this discussion on the possible healthcare applications of Wtason/DeepQA


Dr Herbert Chase (Professor of Clinical of Medicine at Columbia University) says:

For at least 30 years it has been impossible for a physician to master all the material to practice medicine at the highest level. Biomedical literature has doubled in size every seven years but patients want those facts at the doctors finger tips when they see him (the doctor)

It is this challenge of data that clinicians face every day as they attempt to deliver the best possible care to each and every patient at the time of the consultation and something their patients expect. Definitely not overkill for patients or doctors and given the Tsunami of medical knowledge and the challenge of sharing clinical data. DeepQA will add a new level of medical intelligence to support to clinicians is with the application of Natural Language Processing taken to a new level of understanding.

Back in June I talked about this technology and the potential for application in healthcare (NLP in Healthcare). In October Nuance announced our strategic partnership with IBM and I covered the news in this post: Clinical Documentation Challenges and then again building towards the Jeopardy challenge NLP in Healthcare Part 2 and most recently this week as part of the potential solution to the challenge of shareable clinical data and clinical data models (The PCAST Opportunity, HL7 CDA, UEL and SAGE)

The announcement today builds on a deep research and technology partnership that already exists in multiple areas between the companies. As one person pointed out in a note to me yesterday

"I cannot understand that Watson cannot 'hear' an opponents wrong answer. They text in the question and then Watson parses the english, algorithms swirl, etc. However, when an opponent speaks it cannot hear. So when a bad answer is spoken it is bound to repeat it.. "

That is part of the innovation and solutions that Nuance will contribute to the partnership which will also include the Clinical Language Understanding (CLU) Technology that will be used create new solutions that provide hospitals, physicians and caregivers access to critical and timely information expanding from recognizing what was said and parsing data to now understanding the intent and providing guidance. This will push us one step closer to intelligent medical analysis real time with the clinician to assist hospitals to utilize facts and knowledge as they migrate toward evidence-based and accountable care models:

Recognizing the tremendous value that Watson can bring to healthcare, Nuance and IBM have teamed to co-develop solutions that will transform vast amounts of clinical data into actionable information across the continuum of care. This endeavor is intended to unlock important medical knowledge and facts buried within huge volumes of data repositories, providing healthcare provider organizations, payers and individual physicians a new level of medical intelligence

It has been yet another exciting day in the world of healthcare technology

If you want to see the Jeopardy games you can watch them below
Part 1:

Part 2:

and Part 3:



And it is not just healthcare:

Computer Assisted Physician Documentation

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

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

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

For clinicians CAPD's immediate feedback adds up to

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

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

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

Playing Games with ONC Certification - Guest Post

Certification remains one of the basic building blocks of the incentive program from the Government. CMS provides a tool for finding certified EHR technology for practices as part of the EHR incentive program. As Houston Neal Director of Marketing at Software Advice points out "Certified" is the $44,000 buzzword. In this guest posting he drills down into the details of certification and provides a list of 5 key questions to ask to help avoid the pitfalls and make sure you will be eligible to receive the incentive payments:

Playing Games with ONC Certification

“Certified” is the $44,000 buzzword prefixing electronic health records (EHR) software. To qualify for Health Information Technology for Economic and Clincal Health (HITECH) Act incentive payments, you must use an EHR that is certified by the government. Additionally, you must use a system - or systems - that offer 100% of the functional and security capabilities required to meet “Meaningful Use” criteria.

Many EHR vendors are promoting their products as “certified,” but the claim can be misleading. There are three ways they could lead you astray:

Alternative Certifications

Before the HITECH Act, two organizations certified medical software:

●      Certification Commission for Health Information Technology (CCHIT) - CCHIT began certifying EHR software in 2006. Since then they have released 10 certification programs for ambulatory and inpatient EHRs.

●      KLAS - KLAS is a private organization that has gathered ratings on EHRs since 1997. Every year they rank EHR vendors and bestow a “Best in KLAS” award on the top 20.

In an effort to stand out from the other 300+ EHR systems on the market, vendors widely promote their CCHIT or KLAS credentials. They may even tack the word “certified” onto their CCHIT or KLAS approved product. This muddies the water for providers. They have to distinguish between CCHIT, KLAS and certification from an ONC-Authorized Testing and Certification Body (ONC-ATCB). While CCHIT and KLAS are meaningful credentials, they’re not the certifications that qualify for incentive funds.

This is especially confusing because CCHIT is now one of six organizations approved to certify EHRs for the HITECH Act. So, if an EHR vendor claims they have CCHIT certification, you’ll need to clarify which one. Is it ONC-ATCB certification, or one of CCHIT’s independent credentials?

Complete EHR vs EHR Module

Software vendors can receive ONC-ATCB certification for a complete EHR or an EHR module. This means a product doesn’t need to meet all criteria for Meaningful Use - instead, it can be partially certified if one or more functions meet a subset of requirements. For example, a vendor could certify their e-prescribing application or their patient portal.

This under-publicized detail could cost you thousands of dollars; by itself, a certified EHR module won’t make you eligible for incentive payments. You must use two or more modular EHRs that, combined, meet 100% of the ONC criteria. So while vendors can officially promote a module as having ONC-ATCB certification, it may fall short of making you eligible.

Guaranteed Incentive Payments

Be mindful of guaranteed incentive payments. It is reasonable for a vendor to guarantee they’ll meet certification criteria. In fact, you might make it a requirement in your purchase decision.

However, guaranteeing incentive payments is altogether different. Technology alone won’t make you eligible. EHRs are just a means to an end. Ultimately, you are responsible for achieving Meaningful Use status. So be wary of this type of guarantee. Read the fine print and find out how you are reimbursed if you don’t qualify for incentive payments. Does the vendor reimburse you the full amount of lost incentive payments? Or do you just get reimbursed for the cost of the software? You shouldn’t purchase a system based on this guarantee alone.

Five Key Questions to Ask Vendors

To help you avoid thse pitfalls, we put together a list of 5 questions to ask vendors. Answering these will put you in a good position to become eligible for incentive payments.

1.     Which certification does the EHR have: CCHIT, KLAS or ONC-ATCB? You must use an EHR that is ONC-ATCB certified in order to be eligible for incentive payments.

2.     Which product version has been certified? Ask the vendor for complete details of their ONC-ATCB 2011/2012 certification, including: product name and version, date certified, unique product identification number, the criteria for which they are certified, and the clinical quality measures for which they were tested.

3.     Does the vendor have certification for a complete EHR or an EHR module? If module, you will need to use more than one to be eligible for incentive payments. The ONC has created a handy website that allows you to build a list of EHR modules that meet 100% of ONC criteria.

4.     Will the vendor resubmit their EHR for final certification in 2012? The current certification is temporary and only lasts through 2011. Make sure your vendor has plans to reapply in 2012, and find out if they will certify a complete EHR or just a module.

5.     Are you purchasing through a reseller or other business partner that renamed the product? If so, make sure the renamed product has been approved by the ONC-ATCB. Even if it is the same version with identical features and functionality, it won’t make their Certified HIT Products List unless the original vendor reports it to an ONC-ATCB.

This article was written by Houston Neal of Software Advice. To view the original article, visit Playing Games with ONC Certification.

The PCAST Opportunity, HL7 CDA, UEL and SAGE

The recent publication of the PCAST Health Information Technology Report: Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward,  published December 8, 2010 (press release and covered in this webcast) and became something of a Piñata for comments. Vince Kuratis did a great job of pulling these comments and responses together in his his blog PCAST HIT Report Becomes a Political Piñata.

But Wes Rishell's post: "PCAST Opportunity: Documents vs. “Atomic Data Elements” that reviews the PCAST recommendations and digs into the details of the development of standards and the basis for the exchange of information (documents vs snippets or Molecules/atoms), exchange formats and Universal ExchangeLanguage (UEL) vs HL7 CDA does an excellent job of dissecting out some of the controversies and homing in on exchange of data and the standards in question as well as highlighting the challenges associated with pre and post coordination of data (read less codes requirements and more code requirements). Interestingly Wes estimates

from 20,000 to 100,000 (data elements) but a number of physicians seem to agree that a very useful collection of molecules and radicals would contain many fewer than 20,000. Stan’s presentation describes several different parallel efforts to enumerate the molecules using siloed methodologies. The one he is working on as identified more than 4,000.

He points to several related posts - this from John Halamka: Detailed Clinical Models that points to multiple other standards in development in other countries (Open EHR in Australia, ISO13972, Tolven's Open Source Clinical Data Definitions  and the National Health Service Logical Record Architecture) which all adds up to a pressing need for a Universal Exchange Language...and in my mind translates to a significant challenge in developing and then keeping up to date.

Both blogs point to an excellent detailed (almost 2 hours) presentation by Stan Huff (CMIO at Intermountain Healthcare): Practical Modeling issues: Representing Coded and Structured Patient Data in EHR Systems

select

And a link to some of the original work "Detailed Clinical Models for Shareable, Excutable Guidelines (pdf from MEDINFO 2004) that detailed the NIST funded multi institutional SAGE research project

sharable, executable clinical guidelines. The project envisions a system that enables the authoring, localization and execution of significant clinical guidelines in a vendor independent manner

One thing is for sure - this is a complex issue requiring much attention and focus since the coordination and sharing of data is a fundamental building block of effective, efficient and safe healthcare. Effective sharing of data appears to require standards and exchange languages. But today is the first of three part episodes of Jeopardy featuring Watson . I talked about this back in June and again in December. Tonight is the first night of the Waston Jeopardy challenge.
In the countdown to Jeopardy


It is clear IBM has pushed the limits of computing technology and "understand" the complex human language which Nuance has partnered to bring this same technology to Healthcare: Clinical Documentation Challenges that will apply a whole new way of looking at clinical documentation that reduces our dependance on codes, structure and defined clinical data models.

If we consider the adeptness of the human mind and our ability to understand the fine nuance detailed of clinical reports without the data being tagged or encoded this suggests that the Watson applied to healthcare concept may hold a critical key to exchange and intelligent use of data. Based on the existing standard of "documents" we can innovate and use these documents that are currently a natural part of clinical care.

So as Wes Rishell stated in his summary:

Documents will continue to be at the heart of information flow for patient care and one primary way of bundling clinical information about people

In conjunction with some form of

• evolving universal exchange language (UEL),
• encoding of data, and 
• reliable and simple ("but only as simple as possible, but not simpler") data representation

In conjunction with machine based understanding that I think we will see tonight has been advanced to new and exciting levels we will have a foundation of sharing data efficiently and intelligently in our healthcare system

EHRs and their Impact on Quality of Care

Headlines this week have provided much confusion in the march towards digitization of healthcare that were based on a Stanford study published in the Archives of Internal Medicine: Electronic Health Records and Clinical Decision Support Systems with a conclusion:

Our findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.

Needless to say a strong negative claim from a leading institution attracted a lot fo coverage (Medscape, Reuters, Health Data Management, iHealthBeat,  DotMedNews, Bloomberg.....and the list goes on). The power of the internet and the instantaneous nature of the news allows these stories to rapidly disseminate.

In fact some of this will add fuel to the HR408 Act  Spending Reduction Act of 2011 (the text of this can be found here). It is a far reaching bill attempting to reign in spending to the tune of 2.5 Trillion and includes several elements focusing on repeal of Healthcare IT stimulus spending S:302 which focuses on repealing the HITECH funding and investment - there was a good analysis in Health Data Management GOP Bill Puts Meaningful Use, HITECH Act in Peril that highlights the murky nature of the impact of this legislation.

But the power of the internet works both ways and there are several great articles that apply a sound analytical view on the study and highlight the limitations of the study. In this piece Dr WIlliam Hersh; Electronic Health Records Do Not Impact the Quality of Healthcare takes a long hard look at the study adn as he points out

Like almost all science that gets reported in the general media, there is more to this study than what is described in the headlines and news reports. The study was published in a prestigious medical journal by two Stanford researchers. The implementation of the research methods they used appears to be sound.

But as he points out there are serious limitations to this type of study based on the type of study and the data resources, in particular the study "used a data source collected for other purposes and he highlighted the following limitations:

1. A frequent challenge - the study looks at correlation, which does not mean causality
2. The quality measures used did not provide enough insight into actual quality improvement (process measures vs outcome measures)
3. No detail of the EHR's being used and if they had any decision support in place relative the the quality measures
4. THe care assessed was individual episodes of care and improvements in actual quality occur over multiple episodes of care (the longitudinal medical record)
5. Data analyzed was old (2005 - 2007) and in any field of technology including Healthcare Informatics this is old
6. No indication of the training and skill set of the clinicians being assessed and success and failure fo EHR's goes far beyond the technology and is closely tied to implementation and training

And there was extensive discussion that pointed to other articles and studies highlighting the benefits and in particular emphasize how early we are in this process. I imagine that for several other key inventions there was a similar response:

• The Electric light bulb
• Telephone

This 'telephone' has too many shortcomings to be seriously considered as a means of communication. The device is inherently of no value to us.

Western Union Internal Memo: 1876

• Automobile
• Microprocessor
• And even the internet and the world wide web

THis follow up piece by Clem McDonald: Clinical Decision Support and Rich Clinical Repositories: A Symbiotic Relationship that highlighted a range of other positive studies and identifies significant breakdown in the meta analysis that was carried out. As he states succinctly:

• First, and most important, the current article tells us nothing about which CDS guidelines were implemented in the systems that they studied. Practices and EHRs vary considerably in the number and type of CDS rules that they implement, and we do not know whether the CDS rules implemented by the practicesthat participated in the surveys addressed any of the 20 quality indicators evaluated by Romano and Stafford.
• Second, the current study and Garg and coauthors' review considered very different categories of guidelines. Most of the guidelines (60%) in Romano and Stafford's study concern medication use; none of them deals with immunizations or screening tests, which were the dominant subjects in the studies reviewed by Garg et al.3 Furthermore, in our experience, care providers are less willing to accept and act on automated reminders about initiating long-term drug therapy than about ordering a single test or an immunization.
• The third difference is that the current study examined the outcome of a single visit, while most of the trials reviewed by Garg and colleagues observed the cumulative effect of the CDS system on a patient over many visits.
• Finally, the data available from NAMCS/NHAMCS may be limited compared with what is contained in most of the EHRs used for Garg and coauthors' trials. For example, the NAMCS/NHAMCS instruments have roomto record only 8 medications, even though at least 17% of individuals older than 65 years take 10 or more medications.

The road to digitization of healthcare is long and filled with many ups and downs. This study adds the overall knowledge but should be taken in the context of what was studied and its contribution to guiding us down the correct path and not, as some would believe> halting the journey and returning to the dark ages of pen and paper.

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Excellent Meaningful Use Qualification for Incentive Matrix

Great post from Dr Halamka laying out the details of what is required to qualify for meaningful use incentives

http://mycourses.med.harvard.edu/ec_res/nt/36980CA6-E154-4820-A0ED-8B235138B79F/measures.pdf

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Nuance Self Service Mobile Developer Platform Announced Today

Nuance announced the launch of the Dragon Mobile SDK for iOS and Android via a new self-service website as part of the Nuance Mobile Developer Program.

>>>>Now mobile developers are able to quickly and easily leverage the powerful dictation and voice search capabilities at the core of the successful Dragon Dictationand Dragon Search apps, as well as Nuance’s trusted Vocalizer text-to-speech (TTS). 

In line with the explosion of mobile applications and similar to the model for Apple's Developer Application (XCode) the SDK is available (for both Apple iPhone/iPad/iPod Touch iOS 4.0 and for Android v2.1 and higher. Supporting multiple languages the offering provides instant access to "easy-to-integrate prepackaged wrappers and widgets for rapid inclusion of voice recognition into their applications, all through a self-service website. Developers also have access to an on-line forum for additional support, a variety of code samples and full documentation."

And all for free! Leveling the developer playing field and fostering innovation of speech enabled apps so that as Michael Thompson, SVP and GM of Nuance Mobile Division put it:

"If you can imagine it you can speech enable it"

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Adoption of EHR Likely to be Very High

So a recent survey from the CDC: NCHS Health E-Stat "Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates" (pdf version here) and reported on the US Department of Health and Human Services website HHS.gov "Surveys show significant proportions of hospitals and doctors already plan to adopt electronic health records and qualify for federal incentive payments" suggests that

• 80% of hospitals , AND
• 41% of Office based physicians

are intending to take advantage of the federal incentive payments for adoption and meaningful use of certified EHR's
And Dr David Blumenthal posted a video comment on the registration for EHR Incentive programs

This is substantially higher than a recent set of stats that had the rates posted much lower. This is good news all round if the incentive program has stimulated that much interest and desire to move towards the digitization of the medical record which for Stage 7 has barely reached double digits according to the most recent HIMSS Analytics assessment of EHR implementations.

For those wanting more information
Information about the incentive payments program is available on the CMS website and the Regional Extension Centers (RECs) technical assistance is available at the HealthIT web site. So for those still pondering if this is worthwhile investment it seems that healthcare systems and your clinical peers see this as a valuable and positive move. Do you want to watch the train leave the station or be on it?

Docs struggling financially, but new tech makes job easier

Survey: Docs struggling financially, but new tech makes job easier
http://www.healthcareitnews.com/news/survey-docs-struggling-financially-new-tech-makes-job-easier
Technology can actually make your life better...certainly according to doctors

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A national license to practice medicine

This needs to be fixed if telemedicine is ever to take off

A national license to practice medicine
http://www.kevinmd.com/blog/2011/01/national-license-practice-medicine.html

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