The Science of Medicine

Medicine is complex and providing the best possible care is a challenge, and it is getting more complex on a daily basis. I'm willing to bet that at least a few readers will still hold onto the belief that playing music, in particular Mozart, can improve brain function. IN fact searching Google Scholar reveals about 8,400 articles related to Mozart and brain function. There are even pages promoting the this concept "How to improve Brain Function". But as this NPR podcast (The Mozart Myth and More) points out it all started with an one page article published in 1993 Francis Rauscher: Listening to Mozart enhances spatial-temporal reasoning. What followed took the researcher unawares with television interviews, lots of media attention and even some hate mail and calls (because she was misquoted that rock music was not good for brain function)! In fact this limited experiment (36 students total) were able to improve spatial temporal test - nothing else, not general intelligence.

It's easy to misinterpret results and data and human nature probably pushes us towards believing in miracles and cures but what is important is we review the data carefully and base our decisions on science. In the blog "Bad Science" Ben Goldacre spends a lot of time and effort debunking myths and researching the the data to uncover the facts and interpret them correctly. He has exposed the Nutrition and Pills Industry and Fish Oil and a related piece on science and health reporting errors and this expose of Obvious Quacks. The challenge is we are deluged with information and sorting myth from reality is difficult for everyone from patients to clinicians.

For clinicians this problem is even more acute as they deal with debilitating work loads, time pressures and information overload that oftentimes are overwhelming even for standard cases. I've watched several colleagues recently treating patients an dealing with the information available in the electronic medical record (EMR). In all but a few instances the volume of data is overwhelming and processing this in the limited time available is a challenge. Add to this the need to verify existing data and update with new information and then capture the latest data relating to the patient which will become too much to burden the existing system of clinical care. Meaningful Use and the final rule making is pushing us towards EMR but for these systems to begin to address this information overload rather than add to it we have to find ways to capture clinical data without adding further work to the clinicians who is time challenged

As part of that initiative the Healthstory Project has created a vision of a comprehensive electronic clinical record that captures the all important data while retaining the complete patient clinical story. Part of the projects has been to develop a range of data standards for sharing that information and to date 5 draft for use standards have been issued and they are developing an additional 4 more. Getting the information into these formats will be a challenge and there are several efforts underway to facilitate this process. One of the members of the Healthstory Project Nuance (full disclosure they are my employer) is looking for pilot sites to test a prototype of their Clinical Language Understanding technology that is aimed at easing this burden and providing a bridge between the narrative documents generated currently by physicians and the structured data that is essential to fill these EMR's that will help deal with the information Tsunami in medicine and help guide patients and clinicians in delivering the best possible care. There are other developments underway and I have no doubt over the coming months we will see a range of solutions aimed at plugging the doctor more directly into the clinical knowledge base to help them (to help the patient) make clinical decisions with all the information, processed and assessed each and every time we reach a clinical decision point. Some of this will be about user interfaces and we might even end up with a Neo like interface

Its not as far fetched as you might think). some of it is about work flow and processing of information but the building block for all these improvements is based on capturing and processing information from the clinical interaction.

What's your experience been - have you got systems in place and have you developed work-flows to facilitate the clinical patient interaction? Has your doctor been able to capture information and process while you visits?

Meaningful Use is Here

The Meaningful Use and Standards have finally been issued and I had the fortune of sitting down with Janet Dillione, EVP and GM of Nuance Healthcare to get feedback on the final rules and their impact on the healthcare industry

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These are interesting times with some tremendous emerging technologies that will bring more and more elegant support to clinicians at the time of clinical decision making. Providing clinicians with usable solutions that do not decrease in their efficiency and reduce the time they have available with their patients.

There have already been some useful commentary in the New England Journal of Medicine (NEJM): "The “Meaningful Use” Regulation for Electronic Health Records by David Blumenthal, M.D., M.P.P., and Marilyn Tavenner, R.N., M.H.A. (pdf)". The final regulations provide some level of relaxation of the demands and requirements and the introduction of more choice offering a better balance between the drive towards digitizing clinical medicine with a nod to the existing complex infrastructure that is in place today and would be impossible to achieve without major disruptions to the delivery of healthcare. Overall they appear to have shifted the more demanding elements of meaningful use to later which allows for a slower more acceptable adoption curve

Expanding the choices and reducing the burden makes the move towards meaningful use more achievable by a larger proportion of the already time pressured clinicians. Even though there has been some practical relaxation of the standards the overall drive remains in place and there is a clear push towards the inevitable digitization of clinical care and the improvement in quality of care based on meaningful implementation of electronic medical records. As the NEJM article makes the point

Although the intent of our January proposals has been retained and indeed affirmed through the rule-making process, the final regulation also incorporates significant changes — a response to the comments and experience that diverse stakeholders shared with us. In particular, concerns about the pace and scope of implementation of meaningful use led us to adopt a two-track approach regarding the objectives that allow practices and hospitals to qualify for incentive payments in the first 2 years of the program.

John Halamka posted a brief summary in his posting "Meaningful Use and the Standards are Finalized" which included some links to the original documents. He summarizes

Overall this final rule maintains a balance between the policy objectives sought and the technology changes possible that are achievable now. There will still be 3 stages of meaningful use and later stages will be more demanding. All the original stage 1 requirements will still be part of meaningful use by stage 2

Later he posted an analysis of Final Standards rule here. He details the technical elements and summarized

The major recommendations of the Federal Advisory Committees have all been incorporated, enabling the industry to move forward with enhanced interoperability in a way that is technologically achievable today.

Interesting times and no doubt much more detailed analysis will follow

Keeping Medicines Narrative

Thought critical free-text physician notes are under threat in the current slew of Electronic Medical Records and are at risk of being washed away in the rush towards the digitization of medical records. In Jeff Barry's article in Health Management Technology; "Value of Unstructured patient narrative" he cites examples of

Throwing the patient out with the paper

In fact there has been increasing coverage of the challenge associated with delivering high quality medicine when you drive out the clinical narrative. As one colleague complained to me;

"the narrative is a big part of the value I bring, removing it dumbs down the information"

The challenge is described well in the piece "Mining Clinical Data: Road to Discovery"

For administrators and researchers, who need to extract data to develop reports, they would prefer all clinicians to enter information to the exact same manner, which means time is saved for the administrator, but not for the clinician...it's a trade off of who spends more time and who saves more time

For the busy clinician who currently derives little from the capturing of structured codified data there is little benefit for the extra and often frustratingly challenge extra time required to capture data in this structured form. It's very difficult to get clinicians to enter coded data as opposed to entering patient conditions.

There is a big push demanding structured data that is sweeping over clinicians who are increasingly highlighting the issue and pushing back refusing to become data entry clerks. While some may see this as simple resistance to change it is not just the physician who is loosing information. Patients will find their records relegated to a series of check boxes and lists and while this may provide information it does not cover the full story. The Clinical Narrative must be integrated into the EHR.

In addition to the patient and the clinical team as Jeffrey Barry notes the public health researchers also stand to gain from richer electronic patient narrative. As I frequently cite - Henry VIII medical record remains a shining example of the value of the narrative providing far more detail than could ever have been captured using a rigid form based data entry tool. There are many details available and exposes including this brief review refuting the common view that he died of syphilis



And this posting reviewing possible causes of death comparing to his symptoms and this article in the Journal of History of Medicine: "Henry VIII and Medical Study".

The unstructured free text of the physicians progress notes provide color to the unstructured data's black and white

In a recent case I observed the clinical note captured in free form using speech recognition that allowed the physician to record the information directly into the patents digital record providing immediate access to critical information to everyone on the care team. There was no delay in generating the note and even if it was possible to put this information into a structured form it would have taken far more time than the 1-2 minutes this took to create using speech recognition and since it was generated immediately and included in the EMR it was available to the full clinical team.

But all is not lost and as both articles highlight there are emerging tools that will bridge the divide between the free from narrative and the need to generate structured codified data both for analysis but also driving improvements in quality of care. In the examples provided a post processing by Natural Language Processing (NLP) technology that in a study from 2008 at the Regenstrief Institute and Indiana University School of Medicine where

researchers were able to produce sensitivity, specificity and positive predictive values exceeding 99 percent (detecting Methicillin Resistant Staphylococcus aurerus - MRSA)

That's impressive and already showing value from automating the extracting of information from free form text. There are limitations and the accuracy as variable as the terminology used by clinicians for the same condition but as IBM is showing with Watson the application of NLP in healthcare is rapidly approaching significant exciting new frontiers

Human interaction also is required because of the complexity of language and providing tools and a blended approach to capturing this information will be key to making this work. In this example Rob Stewart demonstrates a variety of ways of capturing structured information in a radiology setting:



There are many ways of approaching the problem and offering multiple choices that make physicians more efficient as they interact with patients will be the key to success and adoption.

Do you have tools or techniques that work well in your setting. What balance have you achieved between the digital need for structured data and the human need for narrative. Let me know - share your experiences or views.

Clinical Narrative Integrated into the EHR

Download now or preview on posterous

Clinical Narrative Integrated into the EHR - Nick van Terheyden.pdf (1178 KB)

From Health Data Matrix August 2009: Clinical Narrative Integrated into the EHR - Harmony with Healthstory

It’s been 40 years since we placed a man on the moon. It was a big step forward for mankind. We even had a re-creation of the experience via Twitter with live Tweets replicating the original timeline. The contributions of that mission and others led to enormous advancements in technology. Most people are familiar with the origins of Velcro, Tang, and Teflon, but medical science has also benefited from the space program1, especially our understanding of

human physiological function, telemedicine, remote monitoring, and robotics.

Clinicians, patients, and healthcare knowledge workers must all be asking how they can get, use, and generate the full Health Story. If they don’t, they may find that their world disappears, much like the Encyclopedia Britannica did when they failed to move with the times and find a way to offer their content and their huge database to the digital world

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iPad Cure All

The Atlantic featured a post by David Rothman that presented an iPad Stimulus plan: A national information stimulus plan: How iPad-style tablets could help educate millions and trim bureaucracy--not just be techno toys for the D.C. elite. Hold on - don't give up quite yet, it's not quite as crazy as it sounds and he makes some interesting and important points. And there was an update here

I know I am fighting a tide of folks who like to hold on to paper and feel reading a book cannot be done unless you are holding paper printed with ink but they said similar things about letters which have been replaced (love it or hate it) by e-mail. As it is, our library system is struggling and children's school text books remain an exercise in frustration of obsolete texts that contain markings, answers and missing pages and cost parents money each year. But it's healthcare where we can "slay the paper dragon"

Healthcare is the real paper dragon to slay, and the Americans might even live longer if we acted. The National Institutes of Health and other leading institutions could more effectively distribute medical information to doctors and patients alike, and the sick could use the same machines to monitor treatments and juggle around pills, not just track the financial details.

My own parents struggled with drug therapy creating a spreadsheet (well actually this was created by my brother and loaded up ready for updating by my mother) to track the multitude of pills, times and dosages necessary to comply with physician directions. Simplifying these instructions and sending them digitally in a form that can be consumed in an iPad like machine (to be clear this could even be a PC but the advantage of the iPad is the instant on, instant connection to the internet and reasonable compromise between screen size, use usability, mobility and portability) would be very attractive to many seniors struggling with their own treatment.

The cost of the Healthcare paper work mountain exceeds $1,000 per person in America so anything that attacks this problems is going to be desirable. But what David Rothman is referring to is not just about the technology of presentation but the underlying transportability (semantic interoperability) and he refers to the "magic of web links and facts consolidated via XML Based Technologies". Unfortunately the challenge for the current system is reaching that point of interoperability (Standards and Interoperability) given the history of paper and the wide variation in representation of diseases, drugs and therapies (they told me when I first went to medical school that learning medicine was equivalent to learning a new language in terms of the added vocabulary required to communicate with my peers; in fact Latin used to be required for any student wishing to study medicine - you can see some of the Latin terms in medicine here). Normalizing these terms and extracting the data is the challenge facing healthcare . There is a clear need for narrative in communication - this is how clinicians best communicate clinical information amongst the team and indeed to the patient (as can be seen here) but clinical systems and the EHR need data, but data input is difficult. Bringing these two worlds together is the thrust of clinical language understanding combining Natural Language Processing technology (NLP In Healthcare) with the emerging world of digitized medicine. David wants to

let patients themselves play more of a role in policing our health system, thereby lowering costs while actually taking up less of their time, thanks to the right automation

and they will (and must) but we have some significant steps to take to achieve his vision of dashboards and the easy and rapid sharing of information. At this point any small steps is good news (every journey begins with but a small step) and the simple process of e-mailing patients actionable health tips based on the doctors finds may seem mundane but its a start.

For now we have to deal with the existing system, navigating the insurance nightmare of cost and denials all the while trying to keep up on treatment plans, drugs and therapies and if you are like me not just for yourself but for multiple family members. For now in lieu of an iPad

1. Get a full copy of your medical record
2. Get everything in digital form if at all possible but if not in printed form - you can always scan and convert to a PDF document with text using optical character recognition (OCR)
3. Get a copy of your problem list including an explanation for things you don't understand
4. Full listing of drugs as well as ones you have taken in the past and stopped
5. Get your X-Rays again in digital form on CD is good but failing that get the actual films
6. Educate your self on your condition(s) - be an expert

We all face the same challenges but starting with a full set of information helps everyone. Over time doctors will be able to produce clinical records that contain the full story for the patient that includes the narrative and the data to help automate some of this activity. In the meantime you need to be part of the solution that coordinates your care.

Had good experiences or bad - let me know. Seen your records - what did you think? Was it useful to have your medical record?

NLP in Healthcare

Along the lines of Deep Blue IBM is breaking new ground with its latest research innovation "Watson" focused no Natural Language Processing applied in this instance to the well known television game of Jeopardy. Take a look at the video that features the Super Computer Watson pitted against contestants in a real game of Jeopardy. The only accommodation for the "silicon based" life form was providing the questions as text rather than requiring the additional step of speech recognition

Certainly impressive and looking like a real leap forward even with errors occurring. This is of course a enormous task for any computer but even to achieve success in certain instances is extremely impressive and very exciting. Here we are 13 years on from Deep Blue's famous feat of beating Gary Kasparov at chess. The New York Times featured this in the magazine over the weekend: Insert Title. As they point out this is approaching the innovation we have seen on Star Trek

The computer on Star Trek is a question-answering machine, it understands what you’re asking and provides just the right chunk of response that you needed. When is the computer going to get to a point where the computer knows how to talk to you?

Well it seems we stepped a lot closer to the Hollywood vision that's been in place since 1963. In fact I have been making this point for a number of years. We have been fooled into believing Speech Recognition achieved much more than recognizing words. In fact Spock's original interaction with the computer in 1963

Computer, compute to the last digit the value of pi" -- Spock (Wolf in the Fold)

Was asking for much more than just speech recognition but included comprehension and then actions based on that comprehension
Over time we have seen many instances but the challenge of comprehension is brought home in Star Trek IV - The Voyage Home when Scotty discovers that speaking to a computer and expecting it to understand was beyond the capabilities:
As we see (even in Hollywood) computers continue to struggle with complexity in language (Direction Unclear):
But with Watson's success in what is a good analogy of the complexity of human language we are approaching the point of genuine interaction with technology and as some of the contestants intimated:

Several made references to Skynet, the computer system in the “Terminator” movies that achieves consciousness and decides humanity should be destroyed. “My husband and I talked about what my role in this was,” Samantha Boardman, a graduate student, told me jokingly. “Was I the thing that was going to help the A.I. become aware of itself?”

I think we are still a ways away from this but with the change in approach as opposed to trying to teach computers all the variations of data and linkage allowing the system to "learn" by feeding in data and creating algorithms that link data statistically for future inference.

Much like the challenge in medicine Watson applies extensive knowledge that has been previously analyzed and stored and importantly applies multiple algorithms to come up with a stack rank of answers. In fact in the of all the predictive systems available ones that take multiple predictions form different sources and then takes the most frequent tend to be the most accurate

Watson’s speed allows it to try thousands of ways of simultaneously tackling a “Jeopardy!” clue. Most question-answering systems rely on a handful of algorithms, but Ferrucci decided this was why those systems do not work very well: no single algorithm can simulate the human ability to parse language and facts. Instead, Watson uses more than a hundred algorithms at the same time to analyze a question in different ways, generating hundreds of possible solutions. Another set of algorithms ranks these answers according to plausibility; for example, if dozens of algorithms working in different directions all arrive at the same answer, it’s more likely to be the right one. In essence, Watson thinks in probabilities. It produces not one single “right” answer, but an enormous number of possibilities, then ranks them by assessing how likely each one is to answer the question.

Thinking about this system and its application to medicine we are stepping increasingly closer to analysis of multiple inputs of signs, symptoms and subsequently examination and laboratory testing and imaging. A number of years ago I saw a similar solution in very basic form that analyzed inputs as they arrived and started to produce a short list for differential diagnosis. The limitations at the time related to computing power and inputs but and to some degree the capture of knowledge in a form that could then be used. Watson turns this process on its head providing a means to input knowledge in large quantities that can then be analyzed, cataloged and then applied. There remains the question of what is valid information that can and should be accepted but even with this problem processing the rapidly expanding knowledge base automatically provides a means to help clinicians who today do not have the time to process all the moves/adds/changes to the clinical corpus of knowledge:

The problem right now is the procedures, the new procedures, the new medicines, the new capability is being generated faster than physicians can absorb on the front lines and it can be deployed

I don't see call centers being the route of interaction but much more likely as an adjunct tool providing guidance and short lists to the clinicians at the point of care of differential diagnosis and what steps (what additional history, examination or investigation) can help rule out or confirm the various choices. This may not be a patient level tool but as an adjunct to clinical knowledge is likely to offer significant support to clinical care and help improve the diagnosis and treatment of patients.

Combine this with a speech recognition tool that accurately renders the clinical data and you have some level of real time evidence based medicine that will revolutionize healthcare. DoctorNet will become self aware....very soon.

Medical Technology - The Next Generation

Harvard business review blogger Jeff Goldsmith wrote a pretty damming write up on the healthcare technology sector: "Has the US Health Technology Sector Run out of Gas". He covers the lack of recent innovation and development across the board including pharmaceuticals, medical devices and even the once promising bio technology and personalized medicine/gene therapy concepts. But his summary of the healthcare IT sector was withering

Enterprise clinical information technology seems to have hit a similar flat spot. The major commercial IT platforms for hospitals and health systems are more than a decade old. Some of the older platforms are written in antique computer languages like COBOL and MUMPS, which predate the Internet by 20 years. Despite a societal investment of more than $100 billion, these tools have yet to demonstrate that they can reduce the cost or improve the efficiency of patient care. They remain cumbersome, expensive to install, maintain and operate. The user interfaces feel a lot like Windows 95 in an iPhone era.

Yikes! Is it really that bad.......there are probably plenty of clinicians, patients and even some IT vendors who might accept that in some cases it is bad - I bet many of you can still find a text based system using some form of terminal emulation still in use somewhere in your clinical facility. In fact asking anyone to use systems with these kind of interfaces would seem wrong and such systems should either be pushed out into the digital graveyard where they belong or at a pinch shield the user from these idiosyncratic requirements and counter intuitive user interfaces.

But there are innovations and new use of technology - :in the piece "E-health and Web 2.0: The doctor will tweet you now; Patients can now meet their doctors in 'the cloud'" we can see the adoption of this technology to providing a rapid response more suited to the new age of instant communication and busy lives we lead today. It might be hard for a physician in the 1950's to understand the need for this speed of communication but bear in mind the treatment choices in those days were limited. In fact the father of a friend of mine at school was a physician and he described to me his experience of a "crash call" or "code blue"

If a patient had a problem the nurses would summon the porter who would be dispatched to my room to wake me up. I would be woken by a knock on the door and informed there was a patient "going off" on Ward xxx. I would get up, get dressed, more often than not the porter would leave a cup of tea outside my door and I would take that and then leave for the ward. By the time I arrived one of two things had happened. The patient had either died or had improved of their own accord. Their syncope, myocardial infarction or whatever event that had taken place was either resolved or resolving or they had succumbed to that critical event. There was little we could do or offer in the early days and rushing to the ward made no sense

Today we live in a technology and information rich society where instant communication is expected and can and does make the difference. In fact:

Jeff Livingston, an obstetrician and gynecologist in Irving, Texas, said his 10-doctor practice has about 600 Facebook fans and more than 1,500 Twitter followers

That's no small following and I am betting many social networking gurus and experts can only look at those numbers with envy. We don't fully understand how this technology and communications systems will impact healthcare and the delivery system but one thing is for sure rapid innovation and change will be the status quo.

Dartmouth Data under attack

In what will no doubt be a spirited debate the NY times (http://nyti.ms/a31hD3) has highlighted the Data Used to Justify Health Savings Can Be Shaky: http://nyti.ms/a31hD3

>>>>A report is used to show that Americans could save while maintaining quality, but that may not always hold<<

I am reminded of the quote from my math teacher: "there are lies, damn lies and statistics". His point at the tim was that figures can be manipulated to tell any story and careful analysis is always warranted. In healthcare this is very evident with the deluge of product sheets and "studies" designed to persude the medical profession that the latest drug is better than the current cheap generic.

Unfortunately in this case while there may be some refinement of the data necessary this should not cloud the essential point hammered home by the study and the investigators. Publishing the data makes institutions aware of variations in standards and cost of care that must be explained and will serve as the basis of of future reductions in cost of care and nationwide improvements in quality. 

Amongst other highlights in the study the link between higher utlilization and failure to improve outcomes is troubling: 

>>>>The evidence is that higher utilization does not extend life expectancy, and might be correlated with shorter life expectancy, compared with lower utilization. Therefore, sending people with chronic diseases to higher-efficiency, lower-utilization hospitals for their care could result in both lower spending and increased quality and length of life.”<<<<

It certainly provides caregivers as well as patient's data to base their care treatment decisions on.

We should debate the data but the nature and extent of the variations exposed cannot be explained away and point to the issue of incentive in US healthcare today. We incent the providers to do stuff. The more procedures, treatments and clinical tests you do the more you get paid. Coupled with the increasing squeeze on compensation levels and the drive to increased utilization can be easily understood. 

One of the six sigma core principles is that you cannot improve unless you have data and measure. The Dartmouth study and data while imperfect is a significant step in the right direction and should be embraced and used as a stepping stone in the long and winding pathway of healthcare reform. 

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Mobile Medicine

Mobility and medicine has long been a staple of clinicians lives. With the increasing penetration of wireless and connectivity we have seen increasing ability to access information on the move but data capture continued to be a challenge. Now technology is catching up and providing tools and technologies that will allow physicians to be effective anywhere, anytime and any place (almost)



As you can see from the video above and the original article posted iMedicalApps.com (Nuance Medical Transcription iPhone Medical App) that features both a dictation application for clinical notes example and the ability to voice in a medical search and return results from various clinical knowledge providers including Medscape, Epocrates, and Medline. Critical to this will be the SDK component allowing other vendors to include these tools in their applications speech enabling clinicians who need access to information and the ability to capture clinical data while on the move. As Felasfa Wodajo, MD stated in his post:

..seems to have generated a fair bit of interest, judging from other websites and the traffic at the booth. I suspect this is justified as physicians are only too happy to get rid of their dictaphones and not have to sit in front of a computer microphone

 This is just part of mobility and integrating the right tools into an increasingly mobile and distributed clinical care team will need some innovation especially when it comes to portability and power. Without belaboring the point Apple seems to have done it again with the iPad which has addressed the power issue with true all day usability. The only question now seems to be is it portable enough not to weigh too heavily on the clinician carrying the unit. The ergonomic challenges that occur as a result of having to hold the device and write on it at the same time remain. This was true when the tablet computers first hit the streets and a range of carrying cases appeared to help but never really solving the challenge of the constant weight applied to a wrist held in a horizontal orientation.


Meanwhile integrating alternative data capture methods to ease this burden will be important. How has your iPad experience been and is the weight and shape/size workable or not. Have you managed ot use the dictation method to capture data and was ti effective?

New Way Bacterium Spreads in Hospital

A new study from the UK has shown that the transmission of hospital aquired infections that used to be confined to contact and surfaceode has now been found air borne

>>>>A study finds that clostridium difficile, which causes deadly intestinal infections in patients, is not only spread by contact with contaminated surfaces but can also travel through the air.
This is troubling and will create even more challenges for patients admitted to hospitals

http://nyti.ms/adIGNi

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Redesigning Medicine

Through provoking piece in the Washington Post today - Health Reform's Next Test by Jim Yong Kim and James N Weinstein at Dartmouth Hitchkcock. As they state

It is well known that U.S. health-care costs, as a share of our economy, are the highest in the world but that compared to other industrialized countries, our results are the worst. The Dartmouth Atlas has documented the enormous waste in our system and shown that spending more money and performing more medical procedures do not equal better outcomes for patients.

So true and so troubling as health reform marches forward under the new law. We do deserve good care and the blame storming that continues to affect all the efforts is counter productive and as they point out

We cannot blame government or insurers or physicians for the complex and multilayered problem. No single group or entity created the puzzle that is our health-care system; it is not reasonable to expect one group to solve it

Their use case shines a spot light on the challenges we face

Consider the moving pieces of a patient-health system encounter. A patient comes into the emergency room. Immediately, judgments are made about how sick she is and what treatments she needs. There is no universal medical record for that patient, so the provider has no idea about her medical history, medication use or preexisting conditions. Incomplete information is relayed through layers of nurses, physicians, specialists and the shifts of personnel who replace them. In the absence of real-time information, tests are ordered and treatment decisions made. Perhaps after an overnight stay, barring complications from drug interactions or perhaps an unrecognized underlying condition, she is discharged, with no further transfer of information to a provider and, more important, no follow-up to see whether the treatment was effective

But it is this summary point that amplifies the point:

The symptoms were treated; the patient was not.

This is exactly the point and their attempt to set up the "Center for Health Care Delivery Science" is one step int he process of many that needs to start with a realistic look at the challenges we face and the need for everyone to be part of the solution and not part of the problem.

Busy physicians want to leverage power of dictation

The use of speech as an integral tool to clinical documentation and the capture of clinical knowledge continues to expand. In this piece from Healthcare IT News (Busy physicians want to leverage power of dictation) Dr Levine an OBGYN resident reports his experiences and states

speech recognition software allows me to "interpret out loud" and document at the same time. For example, when reviewing an electronic fetal heart monitor tracing or reading an EKG, it is much easier to say what I see, as I read it, than see, type, read, see, type, etc.

It really is easier, less distracting to the process and while some will find the experience difficult in front of the patient there are some benefits to this method that include engaging & educating patients and the additional check of the content by someone who probably has the biggest vested interest in the accuracy of the record and the contribution this has to a successful outcome

Don’t miss this boat – as Dr Levine states “I'm sure it's only a matter of time until we all have workstations that have microphones, because speech recognition truly is the way of the future”. It may not fit in all instances and there are good reasons texting is popular, voice remains the fastest and most efficient means of communicating. Speech technology is integrating this into our healthcare world to make life easier and more efficient.

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Narrative Key to Physicians Acceptance of EHR Systems

Hidden in an article that reviewed nursing opinions on computerized records: (AFT: Nurses Express Mixed Opinions on Computerized Records) was a striking data point

While 73 percent said implementation of the systems went smoothly, many problems were identified, including 52 percent who said physicians are refusing to use the new systems. Yikes - that alone is a pretty revealing statistic that suggests that hidden behind implementations are a lot of reluctant users
The overall results suggest mixed view on the value of computerization (49% said "new computerized systems have had a positive effect on patient care") there are negative effects

While they see computerized systems improving some aspects of care, pluralities of nurses also say that these systems have had a negative effect on stress levels (49 percent) and morale (37 percent).

and more importantly:

50 percent of the nurses said the computerized systems have had a negative effect on the amount of time needed to chart patient information, while 38 percent said they have had a positive effect, and 12 percent said they have had no real effect.

So half the clinical staff believe these systems are adding to the time necessary to chart patient care. While the recommendations include a list of additional resources, training and involvement the glaring omission in my mind is the lack of consideration of the impact which implies an acceptance that it is reasonable to accept that the system will add more time to the burden of documentation? Better to reject this demand (which in one facility I heard about equated to a reduction in patient throughput volumes of 30-40%!) and identify solution's that don't add burdensome and time consuming tasks but instead save time. Now there's a radical thought.

Interestingly there was a conference held last week in Boston (Governors Health Information Technology Annual Meeting) that included presentations from David Blumenthal the National Coordinator for Health Information Technology, HHS, Kathleen Sebelius Secretary of Dept HHS and the Massachusetts Governor Deval Patrick  On the second day a Panel Session - "Getting Clarity - Developing Effective Health IT Policies and Standards" included a question to the audience:

“How many doctors are in the audience?” – a sea of hands went up.
“How many are using an EMR?” – about 2/3 of the hands remained up.
“How many of you love it?”’- 2 hands remained: Dr. Larry Garber, who is a medical director for informatics at Fallon Clinic, and Dr. Michael Lee, a practicing pediatrician at Atrius Health.

As pointed out in this piece in FierceHealthIT Saving healthcare with the clinical narrative what is striking about these two individuals is that they are both avid users of speech recognition. The principle is clear. Clinicians prefer to use their voice to capture clinical information. Failing to provide this feature and effectively blending the narrative into the EHR while facilitating the easy capture of discreet data is a surefire recipe to poor adoption and less than stellar acceptance by physicians of clinical systems.

Narrative and the easy capture of the narrative is both good for adoption but more importantly it's essential for high quality clinical care.

Where are your systems with this technology and do you include the narrative and if so is it easy to do so?

Speech recognition systems evolve and Radiologists find Technology Increasingly Useful

Imaging Economics ran a piece on Speech Recognition in use at Greensboro and Mount Sinai

http://www.imagingeconomics.com/issues/articles/2010-05_02.asp

Speech and voice recognition systems have come a long way, and while no technology translates everything perfectly, expanding capabilities have increased both usefulness and effectiveness.

As for its use in the EMR

Yet, the integration of speech recognition for EMR users is likely inevitable, in part because without it, the value of the technology will wane

And it’s moving into other areas rapidly

Meanwhile, other disciplines, such as family practice and emergency care, are just beginning to explore the technology. “As far as the rest of health care, I think we’re seeing the early adopters starting to grab hold of the technology,” said Willis. These new users, however, will not—have—to—start—slow.

Posted via email from drnic's posterous

Reassessing Primary Care

In an article in the April 29 issue of the New England Journal of Medicine titled What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice (pdf) Richard Baron analyzes his practices activities. What is surprising is the extent to which non-reimbursed activities are part of the general work.
The breakdown of services averaged per visit and physician and by patient is shown below

Telephone calls averaged 23.7 per physician per day with close to 80% being handled directly by physician. Even running at peak efficiency with no time requirement to get to the phone, waiting on hold you can expect this to conservatively consume 2-3 minutes of time per day which equates to over an hour on phone calls per day. There were slightly fewer e-mails but the time taken to respond is likely to be a little longer to read and then respond. Add in prescription refills, laboratory reports and imaging and consultation reports and the time consumed for this ancillary activity has to be approaching 2-3 hours. The overhead of the system places an undue burden on primary care physicians and it is no surprise that medical school graduates are avoiding the field given the low reimbursement and declining compensation. As the author states in the summary:

The core of primary care remains the longitudinal, trusted relationship with the patient, in which diagnostic skill, therapeutic understanding, and compassion come together for the benefit of the patient who seeks our help. Achieving that mission for patients with varying communication and computer skills is a daily challenge, even as our office faces a fragmented payment system and rapidly evolving technology. The work we describe arises from the needs of patients in a society that assigns many roles to physicians — from making diagnoses and providing treatment to ordering tests and filling out forms — and the practice must be organized to respond reliably. How and by whom the work is done is a continuing project of primary care redesign, dependent on both the skills of available non physician staff and the extent of information-technology support.

Recent reviews of compensation compared the broad categories imply that while this compensation is not as good as specialist it is still better than many others. Healthaffairs reviewed compensation and asked: Can We Close The Income And Wealth Gap Between Specialists And Primary Care Physicians (full text requires subscription) but the chart showing compensation comparisons over time is helpful:


Primary care practitioners (PCP) are better compensated than next closest - an MBA graduate but significantly less than specialists (and Cardiology is not the highest compensated specialty - AMGA Medical Group Compensation and Financial Survey pdf here). All this does not bode well for what is a the lynch pin in patient management and longitudinal relationships with patients. As noted in a recent posting in the Health care blog Why We Need Private Primary Care Doctors - aside from the basic need there is a clear economic justification that supports empowering and paying PCP's and attracting more physicians into this specialist area. And as Rob Lamberts points out points out

The solution from an overall cost standpoint is to give primary care physicians incentive to do what they should be doing in the first place: keep people healthy and away from hospitals. Any system that places too much value on procedures is going to fail at this, as the institutions and individuals who profit off of the procedures are going to fight for control of PCP’s. Independent PCP’s who profit from keeping people well are the best thing for a system.

Which reminds me of a point made some time back on Universal Healthcare - Pay While you are Healthy which cited age old system in China

Hark back to days gone by in Chinese villages where the villagers paid the medicine man when they were healthy. When they fell ill they stopped paying until they were better and able to work again

And as KevinMD originally said

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour

The way to do that is using technology that supports not hinders clinical work flow and clinical thinking. Incorporate new tools and communication methods into the process and acknowledge their value by including them in compensation structure.

Do you agree - do you have better ideas on how to make things better and what technology or processes can be applied or improved - let em know and leave your comments

Password Security - Sanity

Finally some sanity in what has become a ridiculous storm of challenging and sometimes impossible hurdles. Microsoft Research has validated what I am betting the vast majority of users know already that

Many of these irritating security measures are a waste of time

This was featured in an article by Mark Pothier from the Boston Globe - "Please Do Not Change Your Password" and was featured in an NPR news piece on All Things Considered: Study: Computer Security Measures Not All Worth It. As usual with security it is a cost benefit trade off and what is deemed appropriate in one setting is maybe not the case in another. By the study calculation that one minute of collective user time fighting with a new password or alternative password requirements equals about $16 Billion per year!


In health care we manage and maintain confidential information and it does need to be secured but mandated password requirements that remain totally inconsistent across different applications and tools (and in some cases inconsistent within products) places barriers and in particular time loss on an already time challenged set of clinical workers. As the renown security expert Bruce Schneier commented on a failure of employees to adhere to strict computer polices

Schneier speculated that the employees knew following those policies would cut into their work time

And so it is in healthcare. Add complexity and mandated changes with specific rules for password construction (which btw often times are a mystery and unavailable to the user until *after* they have tried to create a password) and you have a recipe for insecure systems. Staff get into trouble for not completing work and while security breaches are a problem they do not represent the bigger risk

Failure to get work done is a bigger risk and outweighs any unspecified consequences of ignoring a security rule or three

Lets hope Healthcare IT folks take note and rather than ramming down security requirements they approach the concept with more flexibility and open mindedness

EMR Complications

Pauline Chen wrote a piece in the NY Times on April 22, 2010 titled: An Unforeseen Complication of Electronic Medical Records which in many respects is an understatement. There are many untended consequences big and small and while the appreciation of the benefits:

• fewer missing charts
• streamlined information and
• efficient work-flow patterns

It was with a smile I read the first specific problem identified at the outset

I realized I had no idea where to sit

With technology overtaking the office space and the design failing to take account of technology that was unimagined when the facility was originally on a drawing board it is not that surprising. The smile gave way to an element of sadness as I realized this was a problem I had faced when we built an innovative facility in Glasgow Scotland in 1993/4 that included a paperless medical record. We built mock up rooms, full size with all the components necessary for care to model the work flow, space an interaction. Including any PC was a challenge and the speed of change was best captured in the computer room. In the short 2 years it took to go from drawing board to build out the space allocated was halved as the technology got smaller, faster and cheaper and it was cheaper to cut the room in half rather than cooling the larger space.

Most doctors agree that the value of an EMR out weighs the costs (financial and personal) of implementing this disruptive technology;

Few, if any, of those interviewed would choose to revert to a paper-based records system. But all the physicians expressed concerns that EMR had less than salutary effects on the patient-doctor relationship, including difficulties replicating the narrative aspect of a patient’s illness and the constant interruptions from alerts and instant messaging

This remains one of the most persistent challenges and was true back in 1993/4 when we were implementing our paperless medical record. Doctors and patients are tuned into the same channel we all are WIIFM (what's in it for me) and to date the focus for most of these systems has been billing

most systems have been designed not with clinical needs in mind but to meet the demands of the fee-for-service payment system

In this rush to digitize the beleaguered clinicians has been forgotten and the rich characteristics of narrative than contains the fine nuanced detail necessary for rapid and complete transmission of information between clinical team participants is lost in digitizing and codification. As Dr Lin is quoted as saying:

How can you possibly point and click your way through a patient’s 10-year history

You can't and that's why the capture of the narrative and in particular facilitating that process without the requirement to, as Pauline Chen puts it:

spinning and wheeling back and forth between patient and computer than I did sitting still and listening

is an imperative in successfully rolling out EMR technology. Center to that is voice and facilitating the capture of this narrative without additional time burdens. To date Speech Recognition remains the only technology that has emerged to capture the narrative without burdening the physician. Historically the medical transcriptionist converted this audio into a structured, grammatically correct nicely formatted document. But today increasing volume of audio is processed using speech recognition technology that provides automation, efficiency and now in the clinical setting immediate conversion of this audio into digitized clinical content that is EMR ready.

Pauline is right clinicians need training to cope with this technology but I would suggest the less training that is required the better the adoption will be - just look at the iPhone, iTouch and most recently iPad. Apple took out complexity and created a device that an untrained 2 1/2 year old could pick it up and start using:

I'm not suggesting that clinicians cannot learn - but I do believe that design simplicity is lacking in clinical system and adding an intuitive and simple interface is essential. Part of that includes voice and intuitive voice control as can be seen here at the CES demo by Kristen Wylie

as well as voice capture as can be seen here in an interview of Dr David Stein here.

The status today - this technology is able to answer some of these challenges. Clinicians will be using EMR technologies in increasing numbers and Speech Recognition provides a bridge to the digital chasm between their need for patient interaction and the necessity to capture clinical data in EMR ready form.

Where are you in your implementation and what is helping and what is not. How does your doctor interact with you and what technology does he use?

Mixed Results from Healthcare IT Technology

In an interesting article in HealthAffairs this month "Mixed Results In The Safety Performance Of Computerized Physician Order Entry" (abstract only - subscription required for full article) the authors carried out a simulation of Computerized Physician Order Entry (CPOE) effectiveness.

It is a unique study with a relatively small sample size (62 facilities) that was self selecting that does represent some bias through small sample size, self selection and simulation vs reality. All that said there is still a surprising conclusion that

Many hospitals only detected 44% of adverse drug events and the best performing only detected 70-80%.

Not only is this wide variation and poor results for a very costly highly disruptive technology that is mandated in meaningful use. There is a clear need to validate the value of technology that is being suggested and especially if it is being mandated in the complex world of healthcare

These are, as many folks have commented to me  "very interesting times" but lets not loose sight of the science that formed the basis of some of the most significant advances in medicine encompassed in Randomly Controlled Trials.

Does your experience vary. Have you seen the value of CPOE or has it been a challenge in your facility?
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Clinical Documentation is at the Core of Healthcare Reform

Everyone agrees we need codified structured data for problem lists, medication, allergies and labs.......or do they?

John Halmka wrote a piece for HealthcareIT News earlier this month titled "Rethinking Clinical Documentation" in which he asks

what is the role of unstructured clinical documentation text

In many instances there has been an attempt to drive unstructured text out of the electronic medical record and while there is a challenge for computers and technology to understand unstructured text - we humans actually prefer the narrative for absorbing information. As John points out referring to the New England Journal of Medicine article in March this year "Can Electronic Clinical Documentation Help Prevent Diagnostic Errors" (full text here) the authors note:

Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient's history and making assessments, and notes should be designed to include discussion of uncertainties

I could not agree more and and have referred to the loss of knowledge and the nuanced information in the narrative resulting in the dumbing down of clinical notes and the Henry VIII's cause of death debate (we still debate this 463 years after he dies) and indeed in recent presentations on the ability to keep the narrative and structured data in harmony in my presentation at AHIMA: "Clinical Narrative and Structured Data in the EHR: Venus and Mars Live in Harmony with CDA4CDT". The Healthstory project allows for the two worlds to coexist happily providing the value John describes in his article for the clinicians while delivering the structured data essential for the clinical systems today. As John says in his blog

I agree. Notes should be included as part of clinical summaries. However, we should do all we can to improve the quality of notes

He is right the quality of these notes need to improve and while I look forward to hearing more about the Daily Patient Wiki (which has similarities to the "Facebook Medical Record") I suspect that we need to pay attention to the process of capture of information. While the keyboard, mouse and other tools are useful, they remain inefficient for many. Contrary to popular belief the QWERTY keyboard was not designed to slow typists down rather to prevent jams when typing at speed, but it is not the most efficient layout placing only one vowel on the home row. Solving this challenge remains the major barrier to adoption of clinical systems.

Clinicians will use whatever method is most efficient for them at the time they need it with different methods suiting at different times. We will see Minority Report concepts of visual interaction, traditional but improved screen, keyboard and mouse systems and even touch screen applications. I am willing to bet we will see an application for clinical data capture on the iPad before too long. But the predominant means of data capture today is using voice. Tools that facilitate the capture of voice and the conversion of this into useful clinical knowledge will remain a large component of any successful implementation and will bridge the adoption barriers that plague clinical system implementations.

Do you agree - where is your facility or practice on data capture and the inclusion of the narrative note?