Straight outta Ojai: CMIOs Part of Planet Alignment

In a great review by Mark Hagland: "CMIOs at the Hot Center: Planets Seen Aligning at AMDIS" he highlights the he annual Physician-Computer Connection Symposium, held in Ojai (Pronounced oh high) Valley Inn and Spa in Ojai, Calif. that I also had the pleasure of attending. A busy 2 1/2 days of learning, meeting, talking, eating and fantastic surroundings for running with the added benefit of running into old colleagues and friends).

Although Farzad Mostashari, M.D could nto be there in person he did manage to take the time to join the group by telephone and provide his insight on the latest developments included the much tweeted comment "

"ICD10 is a firm data don't expect a delay"

and for those of you watching this trend this comment will give pause for thought

ICD-10 is reported to be less of an IT issue and more of a physician documentation issue.

Which will make many clinicians shudder at the thoughts of increased regulatory and coding mandates to comply with in what is already a time challenged and complex environment...they will be looking for technical help and that will be driven in large part by the cohort of current and emerging CMIOs. 

As Mark puts it

CMIOs, as well as other physician and clinician informaticists, are in a more central position than ever before in terms of our need for them to help lead clinical transformation of healthcare. Indeed, it’s unimaginable how we as a society might achieve the “new healthcare”—one with improved patient safety, care quality, patient and family satisfaction, clinician effectiveness, cost-effectiveness, accountability, and transparency—without CMIOs and their fellow physician and clinician informaticists. In short, the levels of responsibility set to land in CMIOs' laps are potentially staggering.

There is increasing focus in the US and interestingly now on the other side of the pond where EHI has launched an CCIO (Chief Clinical Information Officer) Campaign that recently received executive support from Lord Howe from the British government. 

As Mark puts it CMIOs are at the center of an exciting time and will be an essential part of the equation to bringing the healthcare system, clicking and screaming, into the 21st Century. I'm proud to be part of this group and look forward to an exciting and fun ride

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5% of US Population responsible for 50% Healthcare Spend

In a report from the National Journal: Report: 5 Percent of People Account for Half of U.S. Health Care Spending a small minority of patients generate 50% of the costs of care in the US:

• ~50%  of the U.S. population accounted for only 3.1 percent of all expenditures
• 10 percent of the population hogged 63.6 percent of all health spending
• Top 5  percent of the population accounted for 47.5 percent of all spending, and
• Top 1 percent accounted for 20.2 percent.

While the average person incurred about $233 in costs in 2008 for health care services, those in the top half of spending cost insurers, the government, or themselves $7,317. The top 1 percent cost $76,476.

Much of the higher costs is linked to older patients with patients over 55 making up the largest proportion of the higher spending group but chronic conditions contribute significantly with people with at least one chronic health condition were two to four times more likely to have spending in the top 5 percent group.

The analysis revealed the high spend group had a much higher incidence of preventable chronic disease including

• >50% of the high spend group had high blood pressure
• > 1/3 had high cholesterol
• >1/4 had diabetes

Focusing on preventative healthcare and targeting preventable disease before it becomes high cost is critical to curbing cost and improving health.

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Doctors offer unapproved stem cell therapies

Troubling developments when the medical profession starts offering untested therapies

Doctors offer unapproved stem cell therapies
http://usat.ly/kCyYJC

Is this r rally the way forward in medicine?

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The Doctor is Alwasy In

80% of the planet have a cell phone - the latest challenge creating an artificial intelligence that can diagnose patients better than board certified doctors

Burt Rutan (chief of Scaled Composites) astronaut Brian Binnie managed to show the world that space travel was possible in October 2004 with SpaceShipOne's second flight

into suborbital space within five days of the first flight

thanks in no small part to eh Ansari X-Prize foundation challenge

The foundation is setting up many other prizes with the Tricoder Prize targeting healthcare accessibility through mobile platform diagnostics

mobile solution that can inexpensively diagnose patients by combining expert systems and medical point-of-care data—such as lab-on-a-chip or wireless sensors, provide a recommended course of treatment, and upload all relevant data to the cloud.

Coming to a phone near you......

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In Flight Emergencies

A recent article in the NY Times When Doctors Are Called to the Rescue in Mid-flight on inflight emergencies brought a flood of memories back for me. The landscape has changed dramatically from the first time I got involved in an "inflight" emergency.

In the the first incident that I can recall it was only just inflight. I was accompanied by two nurse friends (Sarah and Wendy) I had worked with at my hospital as we escorted a group of terminally sick children on a trip of a lifetime to Disney from the United Kingdom. We were on the final leg returning home and the plane (this was PanAm) had left the gate in Miami. I had spotted a gentleman across the aisle who was looking very distressed. My colleagues noticed the same thing and we had a brief exchange on how we might deal with a patient given the close quarters of the aisles and seats. As the plane taxied to take off position he because increasingly uncomfortable, short of breath and diaphoretic (sweaty). As the engines were spooling up I was at his side calling passengers to see if anyone had an sub-lingual Glyceryl Trinitrate (GTN aka Nitroglycerine). Since that incident I used to carry a spray with me on every aircraft ride until the liquid rules at which time it became impossible.

We administered borrowed GTN, aborted the take off roll and returned to the gate. By the time we got to the gate and the paramedics boarded the plane he had improved and his vitals had returned to normal. The US Paramedics were quite dismissive - to their view there was nothing wrong with him and we had wasted their time and the airline's. The gentleman asked our advice on what to do - should he proceed with the flight or get off and be checked out. Sadly in most of these cases we never find out what happens but I am pleased to say that he elected to leave and be checked out on the ground.

Since that incident I always carry my stethoscope and used to carry other items - mainly because the airlines had little in the way of medical equipment or drugs. Since the banning of liquids and the overly aggressive nature of security much of this equipment has been either confiscated as as security risk or just not worth the hassle of security delays.

Much has changed and in my most recent involvement I was pleasantly surprised to open a medical kit with both equipment (intubation, IV fluids and IV equipment, forceps) and also and a case full of useful drugs (useful in this instance include IV agents for heart, seizure and hypoglycemia) or sometime both:

But as Dr Abramson points out: “With some planes, it’s a hospital in a box, and they have everything you could ever want. But often they look like they’ve been picked over.”

There are probably better controls these days especially since many of these kist contained controlled drugs and the regulations now require equipment to be available but I'm betting ymmv

In many cases the in-flight kit includes and Automatic Emergency Cardiac Defibrillator (AECD) - often abbreviated to AED which attaches to patients and will assess rhythm and administer shocks semi automatically. I've had occasion to use one of these one time. This was the model on the aircraft I was on at the time:

Attaching it to a patient who had no discernible blood pressure was unconscious and once connected in apparent asystole that spontaneously reverted to sinus rhythm before the shock was administered (much to the relief of the patient who woke up to find himself attached to the device as it issued an audible warning of rhythm problems)

From my own personal recollection my experiences have included the following conditions

- kidney stone

- psychotic episode

- alcohol intoxication

- gastritis/food poisoning

- angina

- severe migraine

- hypotension of unknown etiology

The general incidence of in flight emergencies has risen

Since the earliest days of commercial aviation, airlines have coped with medical emergencies in flight by calling on physicians who happen to be passengers. And as more people travel by air, the number of emergencies has risen accordingly. “Passenger health is becoming more and more of an issue, because of increased life expectancy and more people flying with pre-existing conditions,” said Dr. Paulo Alves, a vice president at MedAire, a company that provides crew members with medical advice from physicians on the ground.

My personal experience has been cyclical with a spate of incidences followed by none for months. But the experience is challenging at best:

Airborne calls for medical assistance pose a singular challenge for physicians, who find themselves suddenly caring for a stranger whose history they don’t know, often with a problem well outside their specialty, in a setting with limited equipment but no shortage of onlookers scrutinizing their every move

What I found interesting was that despite being in a deep sleep (working as a junior doctor gives you all the skills necessary to sleep anywhere, anytime and any place) I have had several occasions where the announcement requesting medial assistance is like your own child's cry - it stands out and woke me up.

As for thanks - I've received everything from snide remarks (Miami EMT's) to thanks, bottles of wine and my personal favorite the opportunity to sit in the jump seat for landing (fantastic view and a rare opportunity to watch the landing process first hand). Like my colleagues your desire to help is vested in the original intent that is among the purest expressions of their Hippocratic oath. It would always be nice to know how the patient did following intervention but I'm willing to bet that privacy regulations make this a challenging request to fulfill even if the patients who would likely be willing to share the outcomes

There remain challenges in the system and with the improvement of medical equipment and drugs. But the identification of individuals available to help is still relatively poor. Like Dr Abramson:

He also books his flights with “Dr.” in front of his name. “That’s so that if I’m asleep, they might wake me,” he said. And he doesn’t take sleeping pills or drink alcohol in flight. “The last thing you want to do is be woken up and not be with it,” 

my flights are all booked with "Dr" in front of my name but since that moniker is used by a wide range of people (PhD's, dentists, vets, optometry, chiropractor, pharmacy, psychology, homeopathy, physical therapy, lawyers) and then there are the British Surgeons who go by Mr, Mrs or Miss.

I have also had instance of being asked to provide proof of my medical degree. To a set of flight attendants on one flight my inability to show my medical degree relegated me to observer as the dermatologist and medical student attempted to deal with a falling blood pressure of unknown etiology. Lufthansa do have a program that allows you to fax your medical degree to their offices and they mark your frequent flyer record with an annotation that shows up whenever you fly to alert the flight crew that you are a doctor and willing to be called upon when you fly - that seems smart but is not replicated by any other airline to my knowledge. 

If I had a wish list it would include some means to validate my ability to help by providing my medical degree to the airlines, the opportunity to review the equipment and support ahead of time (in all instances where I have opened medical kits I have, with permission, dug into the box extensively to find out what is available for future reference) and some formal reporting mechanism and follow up.

We all step up to the plate when asked - it would be nice if the airlines acknowledged that in some way as they lean on these resources on a daily basis and provided support and acknowledgement that was not as arbitrary as it is today.

What has your experiences been - have you had in flight problems and how did you deal with them. Are there any air lines better than others at managing this request and in the support they provide?

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Intuit in Healthcare - A Waking Giant?

Intuit is well known in finance and the commercial world and an interesting article by Austin Merritt on Software Advice "Intuit Health: A Sleeping Giant with Big Potential" highlights the potential this company has in the healthcare space applying the principles so successfully used in their industry leading personal finance solutions (Quicken, Quickbooks, TurboTax etc). The strategy has been to offer highly competitive easy to use products that new businesses can use when starting out:

Intuit has muscled their way to significant market share in the retail, manufacturing, distribution, nonprofit, property management, and construction industries primarily through its QuickBooks product line. Companies in these industries adopt QuickBooks when they’re just starting out. As they grow, they ease into industry-specific packages from Intuit that replace, or integrate with, QuickBooks. The transition works nicely for Intuit and QuickBooks users. It creates headaches for their vertically-focused competitors.

The strategy has proven effective in getting companies bought into the Intuit family and while not large revenue generators there were additional add on services (Intuit payment services, Bill Pay etc). The methodology is being repeated in healthcare with "Quicken Health Expense Tracker"

that allows insurance companies to provide patients with a clear breakdown of what they pay and what the patients owe. Patients naturally then pay through Bill Pay. Cha-ching for Intuit.

But for this to be effective Intuit needs to pull in clinicians with integrated solution that would include an easy to use EMR. Intuit acquired MedFusion a good first step in delivering a practical solution to clinicians in desperate need an easy to use solution to help manage their office and their patients clinical information not just appointments, laboratory results and prescription refills.

The short list presented:

• MediSoft / Lytec
• Office Ally
• HealthFusion / MediTouch
• Practice Fusion
• Kareo
• AdvancedMD

And while it is impossible to present all the possible options given the long list of EMR vendors for what is currently their sweet spot of small practices my list would include eClincalWorks, Greenway and Sage to mention a few. While not meeting the proposed list of small companies there are some interesting opportunities for a big splash and really placing Intuit definitively in the healthcare space

I've passed comment on Intuit before as an interesting company to watch in the healthcare space. Their success will largely be determined by their ability to translate their simple easy to use concepts so successful in personal and company finance into the complex and challenging world of healthcare.

Save Money and Reduce Medical Errors

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

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

The study identified the sources based on medical claims estimating:

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

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

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

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

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

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

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.