Hospital staff offered unpaid leave as trust announced 'extraordinary financal measures' (From This Is Local London)

via thisislocallondon.co.uk

NHS hospital asking employees to work for free in "extraordinary measures"
This seems wrong on so many levels and will undoubtedly affect some more than others.

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What Steve Jobs Means to Silicon Valley

via cultofmac.com

Awesome review of Steve Jobs with history and the his pathway through life. Interesting to note that he asked for some spare parts for a school project from William Hewlett (of HP fame) and received the parts and a summer job. Imagine how motivating that was. We need more of that today.

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Former Apple CEO on Future of Medical Technology

Nice piece on FastCompany Former Apple CEO John Sculley On The Future Of Medical Technology And Health Care's Killer App 

As a trail blazer for original tablets in the 80's it must be gratifying to see the uptake of the iPad and it's competitors. In his mind not going to start with a single "killer app"

I think that the health care industry is so complex that it doesn't necessarily start with a single killer app. You go back to the early days of the personal computer--when I joined the industry, we really didn't know what the killer app was going to be. All we knew was that it was going to be possible to create very low-cost, shrink-wrapped applications. It wasn't for several years until we understood that electronic spreadsheets, word processors, and eventually desktop publishing would become killer apps.

But some combination of a solutions integrated and focused on ease of use. The technology has reached a point of penetration and ease of use that makes adoption that much easier in healthcare

So the intimidation of technology is no longer the issue now that it was just a few years ago.

I'd add one thing - the disruptive technology must include ease of interaction and data capture that does not inhibit adoption and as highlighted in this piece on MedScape EHR Voice Recognition: An End to the 'No Eye Contact' Problem which highlights the significant contribution of effectively speech enabling EHRs to

allows for maintenance of the doctor-patient relationship by minimizing the attention paid to the laptop computer inevitably and uncomfortably sitting between a physician and patient when using the point-and-click method

The same is true with other healthcare technology that can interfere with the clinician-patient interaction. As John Sculley said: "You combine those conditions and it creates an opportunity for entrepreneurs to come in and find disruptive solutions."

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Speed of light no Longer a Maximum

This piece of news is mind blowing - CERN scientists identified sub atomic particles traveling at a speed greater than the speed of light........

I need to repeat that:

CERN scientists identified sub atomic particles traveling at a speed greater than the speed of light.

Here's the paper and live conference today Friday Sep 23 at 16:00 Zurich time

This is "crazy" result could upend our understanding of our universe more than we have seen with previous revolutionary theories (Copernicus, Galileo, Einstein.....) 

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Speed of light no Longer a Maximum

This piece of news is mind blowing - CERN scientists identified sub atomic particles traveling at a speed greater than the speed of light........

I need to repeat that:

CERN scientists identified sub atomic particles traveling at a speed greater than the speed of light.

Here's the paper and live conference today Friday Sep 23 at 16:00 Zurich time

This is "crazy" result could upend our understanding of our universe more than we have seen with previous revolutionary theories (Copernicus, Galileo, Einstein.....) 

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mHealth Holy Grail

In a nice expose on the need for speech recognition on mobile devices: Accurate speech recognition: mHealth's Holy Grail for docs on Fierce Mobile Health   covers off the need for the inclusion of speech in the mHealth future. As they discovered

Doctors constantly tell me how much they love their iPhones and Android tablets, but they also complain about the difficulty of data input. Few find the touchscreen keyboard handy for inputting notes or updating their comments about patient progress. Most use the devices as data viewers.

Offering up MedMaster Mobile as a good example of integrating speech into a mobile healthcare application and speaks to the power and value that speech recognition brings to mobile devices in healthcare to ensure usability and quality data capture.

The article includes a good list of checkpoints when considering speech for the mobile platform including

• Voice quality - The primary consideration in getting good results
• Connectivity - if you rely on cloud based services you need a reliable good quality connection
• Accuracy - with good voice quality will achieve the right results
• Editing - one of the more challenging aspects is an easy way to edit any mistakes that do occur

So Speech Recognition is the secret ingredient to making mobile devices catch-on with clinicians and will transition these great mobile devices from cool but limited practical application to rock solid mobile tool set for mHealth

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The 7 Deadly Sins of EMR implementation | Healthcare IT News

Congratulations! You've committed to an EMR, which is an accomplishment in itself. But the hardest part is still to come: getting it to work.

From failing to plan to skipping out on training, many mistakes can be made during the implementation process. And although they may not be as juicy as wrath, envy or lust, the Seven Deadly Sins of EMR implementation could wreak just as much havoc.

Steve Waldren, MD, director of the American Academy of Family Physicians' Center for Health IT, and Rosemarie Nelson, principal of the MGMA Consulting Group, gave us the worst sins providers can commit during EMR implementation.

[See also: Top 5 worst EMR myths.]

 1. Not doing your homework:  Avoiding supplier problems means background research and thorough evaluations of vendors and products. And beware: vendors tend to make promises they can't keep. According to Waldren, it's important to get the specifics down on paper. "Often, a doctor will ask if [an EMR] can do this or that, and a vendor will say yes. Then, they're surprised when in reality, it doesn't. Doctors need to make sure all expectations are met in writing."

2. Assuming the EMR is a magic bullet: It's important to remember the EMR is a conversion, not an upgrade. Although the system will save you time and money in the long run, Waldren warns it isn't an instant fix to issues in the workplace. "Most people think an EMR solves problems," he said. "But an EMR will only amplify problems that already exist in the practice."

3. Not including nurses in the planning stages: Nelson says doctors tend to think a new EMR is all about them. "They don't think about how much the nurse preps the chart, how often the nurse presents information to them, and how much the nurse handles patients over the phone," she said. Having nurses involved from the beginning avoids future conflicts, and considering their thoughts on product selection and implementation will only help with workflow. "[The implementation] needs to be done with the support of staff; everyone needs to be involved," added Waldren.

CONTINUED ON NEXT PAGE

via healthcareitnews.com

Nice highlight of some major faux pas on EHR implementation - I especially like Rosmarie Nelson's comment on forgetting nurses #3: "doctors tend to think an EMR is all about them"....quite

Other great points including training (and actually attending!), trying to replicate existing processes - business process reengineering was a catch phrase for a number of years and has dropped off from regular use but applies to all EMR implementations.

But perhaps most of all "Assuming the EHR is the magic bullet". I have said this before but worth re-itertaing...implementing an EHR is the first step in a journey that while it will have some interim destinations will continue to be a voyage of ongoing discovery. And that train has left..you are either on the train or watching from the station as the train leaves.

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Physicians Regret not learning Business Skills in Medical School

Once exposed to the realities of practical and sustainable healthcare delivery physicians are quick to regret not learning more about the business side of medicine at medical school. In a posting on Kevin.MD "How can doctors understand the business side of medicine?" Michelle Mudge-Riley echos a frequent sentiment amongst her colleagues

One thing I regret is not taking advantage of the Masters degree in Health Administration program at my medical school. At the time, I was focused solely on medicine and on being a doctor. I didn’t think the business side of medicine was all that important. In fact, I didn’t consider the business side of medicine at all.

While individuals may regret decisions on career pathway (the grass often appears greener on the on the other side of the fence) the article cited from the New England Journal of Medicine from February this year Advancing Medical Education by Teaching Health Policy makes the point that there has been a push for additional teaching as part of the medical student curriculum on health policy and health systems (from 1995) but more than 15 years later less than 50% of medical students "believed they'd been appropriately educated about topics such as medical economics and health care systems."

The science of Medicine is increasingly complex but so is the healthcare systems - new treatments need to be assessed not just from a clinical standpoint but an economic one. Comparing the effectiveness of treatments requires an understanding of economics and the practicalities of budgeting but the information and the skills have for too long been lacking in healthcare education and in day to day clinical practice. Patients and clinicians have been disconnected from the consequences of expenditure with third party payers responsible for managing costs. Much like the European Debt crisis where sudden access to inexpensive debt and limited immediate consequences of the use of debt created an unsustainable position or as one commentator put it  

"It was if Greece received an American Express Black (Centurion Card) 

 but was not responsible for the charges".

Clinicians remain handicapped with the the medical curriculum that still lacks inclusion of foundational knowledge and fails to develop the necessary analytical skills that would equip the key decision maker with all the tools to help navigate the complex adjunct economic decision making process that must be a part of sustainable clinical medicine.

I applaud the proposed additions to the medical curriculum that includes the addition of four domains:

• health care systems and principles,
• health care quality and safety,
• value and equity, and
• health politics and law

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The downside is the additional information that is loaded into an already packed and expanding course. The other unfortunate consequences of these changes and the increasing variability between healthcare systems is the diminishing nature of international equity. Medicine used to be one of several professions that offered graduates opportunities to travel the world and work in other countries. This ease of international movement has already diminished as these systems, processes and curriculum have diverged making international experience harder for the newer graduates

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MotoGoo, Motoogle, or Googola -- a big deal any way you slice it | Cringely - InfoWorld

August 15, 2011

MotoGoo, Motoogle, or Googola -- a big deal any way you slice it

Google just bought Motorola Mobility for $12.5 billion. Cringe isn't sure the Googlers will know what to do with it

By Robert X. Cringely | InfoWorld

Follow @ifw_cringely

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And I thought August was going to be a slow news month. That just changed, thanks to Google and its blockbuster $12.5 billion acquisition of Motorola Mobile.

All I can say is wow. Game on for real this time, Apple. See ya later, RIM. Helloooo, Microsoft? Can you hear me down there? Don't worry, we'll send some pods down to rescue you ... eventually.

[ Also on InfoWorld: Neil McAllister asks whether Google's best days are in the past. | For a humorous take on the tech industry's shenanigans, subscribe to Robert X. Cringely's Notes from the Underground newsletter and follow Cringely on Twitter. ]

As for HTC, Samsung, and LG: Hey, you had some good times with Android, but you knew it was never meant to last. Right?

This is an epic day for more than just business reasons. Motorola is one of a handful of companies responsible for creating the industry that pays my mortgage, and I don't mean blogging. And its history with cellphones is equally storied.

Until the iPhone came along, Motorola pretty much defined mobile phones, starting with the original DynaTAC in 1983, the first flip phone (the StarTac), and the first looks-so-cool-I-must-have-it fashion phone (the Razr). Then came the ill-fated Rokr and a long sojourn in the handset desert, followed by a recent comeback, thanks in large part to a a series of snazzy -- and some not so snazzy -- Android phones.

Sadly, I have one of the less snazzy ones: the Motorola Cliq, which is underpowered and overburdened with a godawful Blur "social interface" that does nothing but drain battery life and annoy me. I blame T-Mobile, not Motorola, for this monstrosity. Short of Google also buying a mobile carrier (like Sprint, which seems to be standing in the corner waiting for somebody to ask it to dance), I'm not sure GooMoto would be able to do anything to fix that.

More than mobile phones, though, this is really about tablets. Motorola Mobility makes the Xoom, the first tab to run Android 3.0 and still the worthiest contender to the iPad's throne. Google wants to get into the PC 3.0 business in a big way and figures it might as well own the whole schmear.

next page › 

12

Tags: cringely, android, intellectual property, m&a, smartphones, tablets, Great Googley Moogley, Motorola Mobility

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via infoworld.com

Googola...! Blockbuster deal and blockbuster implications as Cringe puts it "Game on"!

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Speech recognition technology making its way into EHR systems

Health care providers over the years have raised a number of objections to electronic health records -- they cost too much, disrupt practices already pressed for time and fail to mesh with the way medical offices work.

Learn more about using speech recognition technology

How to purchase, implement a medical speech recognition system

Meditab, speech recognition software help hospital cut paper trail

But there's an even more fundamental digital challenge -- some doctors don't want to busy their fingers on a keyboard. Indeed, manual data entry can be a barrier to EHR acceptance. Physicians may well prefer to document patient encounters in the traditional style, dictating notes and using a transcription service.

Against this backdrop, speech recognition technology offers doctors another way to fill out a patient’s electronic chart. Speech recognition systems, which may be installed on premise or accessed remotely, translate speech into text. The technology is already well established in health care, with radiology departments at the forefront.

The new twist is speech recognition technology's potential to become a widely used front end to an EHR system.

Reid Conant, M.D., an emergency medicine physician who practices at Tri-City Medical Center in Oceanside, Calif., believes speech recognition lies at the cusp of broader EHR implementation. Tri-City uses Nuance Communications Inc.'s Dragon Medial Enterprise Network Edition, which integrates with the hospital’s Cerner Corp. EHR system.

"We are still on the steep part of the curve," Conant said of the adoption rate.

Industry experts cite three reasons why speech recognition technology's role in EHR systems could be poised for growth.

• Accuracy has improved significantly, which means doctors spend less time cleaning up notes.
• EHR vendors are integrating voice recognition into their systems.
• The federal government’s meaningful use initiative has expanded EHR adoption beyond early adopters. Potentially less tech savvy mass-market users may embrace voice as an alternative to the hunt-and-peck school of data entry.

That said, the technology faces a few obstacles. Voice dictation entered as unstructured text may present problems when it comes to extracting data for reporting and analysis. Vendors, however, aim to employ natural language processing to tag key clinical data for later retrieval.

Appeal of speech recognition technology: Talk, don't type

Steven Zuckerman, M.D., a neurologist with a solo practice in Baton Rouge, La., discovered keyboarding wasn't his forte when he adopted EHR. "I quickly figured out that I would not be the greatest typist in the world," he explained.

Zuckerman began exploring voice input several years ago, working with Nuance's Dragon 7. The initial experience proved somewhat frustrating.

"When I first started trying it out, the accuracy wasn't at the point where it was particularly efficient," he said, noting the many corrections that had to be made following the voice-to-text conversion.

Zuckerman retried speech recognition technology a few years later with Dragon 9. He has been using the software ever since.

Improvements in accuracy have swayed other physicians, Conant noted. He often encounters clinicians who previously tried voice input but balked at the amount of correction required. The latest generation of the technology changes minds.

"They see it and they are shocked," Conant said. "They realize they can dictate three or four detailed paragraphs of medical decision making and it is nearly perfect."

[Clinicians] realize they can dictate three or four detailed paragraphs of medical decision making and it is nearly perfect.

Reid Conant, M.D., emergency medicine physician, Tri-City Medical

Keith Belton, senior director of product marketing for Nuance's health care division, noted that Dragon 7, released in 2003, had 80% out-of-the-box accuracy -- that is, before a user trains the software to recognize his or her specific speech pattern. Version 10, the product included in Network Edition, features out-of-the-box accuracy in the mid to high nineties, he added.

Gregg Malkary, managing director of Spyglass Consulting Group, a mobile health IT consulting firm, acknowledged that the technology has improved significantly compared to where it stood several years back. But issues still remain with the level of accuracy, he said. Some providers may question the actual time savings of voice recognition if they still have to dive back into a document to check for accuracy.

As Malkary put it, "Is 90% good enough, or do I really need 99.9%?"

Speech recognition technology on board within EHR systems

Such concerns don't seem to have limited adoption at Tri-City. Use of voice in clinical documentation began in the emergency department in 2007 and has continued to spread. Wound care and workers' compensation doctors started using speech recognition technology about six months ago, Conant noted. Tri-City's hospitalists and subspecialty doctors will go live with voice in October.

The experience of earlier users encouraged more doctors to try voice. "They are seeing their colleagues using Dragon and are requesting the application," Conant said.

But doctors don't necessarily have to ask for speech recognition technology to have it at their disposal, as it is increasingly becoming a built-in feature of EHR systems. Greenway Medical Technologies Inc., for example, has agreed to integrate M*Modal’s cloud-based speech recognition technology into its EHR.

Similar deals may follow. Don Fallati, senior vice president of marketing at M*Modal maker Multimodal Technologies Inc., said other EHR vendors have contacted M*Modal to discuss integration. He sees a precedent for this type of link-up in radiology, where speech is already deeply embedded in picture archiving and communications systems (PACS) and radiology information systems (RIS).

Epocrates Inc., meanwhile, plans to integrate Nuance speech recognition technology into its forthcoming EHR system, currently in beta. Dr. Thomas Giannulli, chief medical information officer at Epocrates, said the product will feature speech alongside other data entry options such as point-and-click menus.

The arrival of voice as a standard EHR feature coincides with the government's push for wider EHR adoption. The federal meaningful use program, which runs through 2015, offers financial incentives to doctors and hospitals deploying EHR systems.

Raj Dharampuriya, M.D., chief medical officer and co-founder of EHR vendor eClinicalWorks LLC, said Washington's incentives have pushed the EHR market into more of a mass adoption phase.

"We're seeing more physicians come on board that are not as computer savvy," Dharampuriya said. "Voice provides a very nice phasing into EHRs."

Data mining as next wave of speech recognition technology

Doctors may find voice recognition useful as an EHR input tool, but vendors aim to push the technology farther. When physicians compile text narratives via voice, they end up with unstructured data that proves hard to tap for meaningful nuggets of information. Companies such as M*Modal and Nuance work to address this issue through natural language processing.

Pairing speech with EHR marks a stage one deployment of speech recognition technology, Fallati said. He said M*Modal’s "speech understanding" technology takes the voice-entered narrative and translates it into a searchable document. The document can then be mined for purposes such as quality reporting.

Nuance, for its part, pursues "clinical language understanding" -- an offshoot of natural language processing. The idea is to mine structured data from free-form text and tag the key clinical elements such as medications and health problems.

Zuckerman, the Baton Rouge neurologist, believes current developments in speech will eventually lead to the self-documenting office visit. He envisions exam rooms set up to selectively record the relevant details as doctor and patient verbally interact.

"We're not close to that yet, but that would be great," he said.

John Moore is a Syracuse, N.Y.-based freelance writer covering health IT, managed services and cloud computing. Let us know what you think about the story; email editor@searchhealthit.com.

Related Topics: Organizing health care staff and networks, Clinical decision support systems, Electronic health record systems, VIEW ALL TAGS

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via searchhealthit.techtarget.com

Speech an integral part to an EHR implementation and the good news is increasing numbers of the EHR vendor community are integrating the technology - it's no longer an add on
And the good news is the narrative is no longer the barrier to actionable codified data as Clinical Language Understanding bring Medical Intelligence to the desktop using free form narrative dictation generating clinically actionable data

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Studies show we get things Wrong

Hormone Replacement Therapy (HRT), Helicobacter Pylori are just a couple of the well known instances where apparent intransigence of the medical community prevented advancement in medical treatments. Turns out we get things wrong on both sides of the coin. Ben Goldacre highlighted some research in the New England Journal of Medicine in his piece Studies of studies show that we get things wrong and in the study 

the remaining 51 were very interesting because they were, essentially, evenly split: 16 upheld a current practice as beneficial, 19 were inconclusive, and crucially, 16 found that a practice believed to be effective was, in fact, ineffective, or vice versa.

In fact in the case of HRT the limited data initially available was the best at the time and it was not until the large randomized trial showed the increased risk of heart attacks in patients taking HRT (a rise of 29%) that new information helped shape new treatments. As for Helicobacter Pylori - the cause of gastric ulcers - the ten years from

"the first murmur of a research finding to international guidelines recommending antibiotic treatment for all patients with ulcers"

May seem like a long time but assembling the trials, ensuring the safety and validating the data takes time. So while the time taken for general adoption of treatments things are not quite as bad as the conspiracy theories suggesting resistance to change and progress.

So the questions is will the increased access to large amounts of validated structured and encoded clinical data that can be compared and reconciled against patients and outcomes result in less time to get effective treatments to patients and even the potential to identify new treatments, links and causation. As far back as 1986 "Fish oil, Raynaud's syndrome, and undiscovered public knowledge" demonstrating the ability to link Fish Oil and the potential at reducing or treating Raynaud's disease. With the addition of clinically actionable data the potential to apply this as medical intelligence offers tremendous hope in accelerating the medical advancements and validating treatments faster and more effectively

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Debunking magnetic field exposure and asthma

Study from Kaiser in the US showed an increase in asthma in children with mothers exposed on one occasion to an increased magnetic field

Critics Slam Asthma Risk, Magnetic Fields Link

UK group debunks the study with lack of controls and accounting for other well known factors. Let's hoe the media picks up on this as quickly as they pick up on this study

Carry on, situation normal

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From Jeopardy! to Medical Diagnosis

via radiologytoday.net

Dr Watson coming to Healthcare hoping to help bring the latest information to the medical decision making of the clinician

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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?

Posted via email from drnic's posterous

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