This problem needs to be fixed - if the debt load for a student emerging from medical school training is that high their income needs will be very high just to make loan payments.
Average debt of $162,000 - $205,000: Imagine starting out your early life with that kind of debt load!
This week I will be joined by Clint McClellan (Twitter @clintmc1) who is Sr. Dir. of Strategic Marketing at Qualcomm Life and the President and Chairman of the Continua Health Alliance. HE and I will be talking about the Continua Health Alliance which is a non-profit, open industry organization of healthcare and technology companieswho are collaborating to improve personal healthcare.They are establishing a system of interoperable personal connected health solutions that will help empower everyone to enageg in their own personal health wellness amangement. Take a look at their vision video here
He and I will be discussing some fo the examples and soltuions in the personal health space and how these have eveolved from personal smartphones to dedicated gateways and what opportunities will open up for application developers?
There are three ways to tune in:
• Stream the show live – click the Listen Live Now to launch our Internet radio player.
• You can also call in. A few minutes before our show starts, call in the following number: Call: 1-559-546-1880; Enter participant code: 840521#
• HealthcareNOWradio.com is now on iTunes Radio! Stream the show live – you’ll find this station listed under News/Talk.
This week I will be joined by Clint McClellan (Twitter @clintmc1) who is Sr. Dir. of Strategic Marketing at Qualcomm Life and the President and Chairman of the Continua Health Alliance. HE and I will be talking about the Continua Health Alliance which is a non-profit, open industry organization of healthcare and technology companieswho are collaborating to improve personal healthcare.They are establishing a system of interoperable personal connected health solutions that will help empower everyone to enageg in their own personal health wellness amangement. Take a look at their vision video here
He and I will be discussing some fo the examples and soltuions in the personal health space and how these have eveolved from personal smartphones to dedicated gateways and what opportunities will open up for application developers?
There are three ways to tune in:
• Stream the show live – click the Listen Live Now to launch our Internet radio player.
• You can also call in. A few minutes before our show starts, call in the following number: Call: 1-559-546-1880; Enter participant code: 840521#
• HealthcareNOWradio.com is now on iTunes Radio! Stream the show live – you’ll find this station listed under News/Talk.
About 6 years ago Dow Chemical sponsored what became a series of iconic TV commercials – simply called The Human Element. They still crop up occasionally - and I still think they are CLIO worthy – but no wins to date. A summary of the soothing, violin accompanied voice-over went like this:
For each of us there is a moment of discovery. In the flash of a synapse we learn that life is elemental. This knowledge changes everything. We see all things connected. The element not listed on the chart – is the missing element – the human element. And when we add it to the equation – the chemistry changes. Every reaction is different. The human element is the element of change. Nothing is more fundamental. Nothing more elemental.
In the course of those same 6 years we’ve raced breathlessly – sometimes frantically – to bring the promise of new technology to healthcare. E-Health, M-Health, D-Health – all with varying degrees of success but all with the same triple aim – improved care, health and cost.
Xerox has new evidence to suggest that there are still some sizable gaps in at least one critical element of our healthcare transformation – and it’s that human element. A recent survey of 2,147 U.S. adults, conducted for Xerox by Harris Interactive found that only 26% want electronic health records (EHR’s). Even beyond that surprise, only 40% of respondents believe that EHR’s will deliver better, more efficient care – and that’s down 2% from last year’s survey. About 85% also said they have privacy concerns about EHR systems generally. Those concerns aren’t unfounded. Today’s headline over at ModernHealthcare reports that over the last 3 years there were over 470 healthcare data breaches that involved the medical records of over 20 million people.
Much of that human element relates to a variety of customer experiences around all the different dialog’s in healthcare (physician to hospital, hospital to payer, patient to doctor etc…). In this context, consumers are really all of us – regardless of any healthcare affiliation. Fundamentally changing these experiences isn’t as simple as slathering on a glitzy web design – or racing full throttle to the cloud and mobile. Recent headlines certainly aren’t conclusive – but they do suggest ample room for innovation and improvement – especially around that human element:
- A Physician Has Difficulty Selecting A Primary Care Doctor
- Badly Designed Electronic Medical Records Can Kill You
- Why EMR Is A Dirty Word To Many Doctors
Even with the big Enterprise IT decisions – headlines here often reflect areas of both significant risk and doubt:
- Cloud’s Thorniest Question – Does It Pay Off?
- Healthcare: Most Breached Industry In 2011
- Hospitals Struggle With BYOD, Want Clarity From Federal Regulators
In an effort to help providers to maximize the value of an EHR, Xerox turned to researchers at the venerable Palo Alto Research Center (PARC – a company that Xerox spun-off about 10 years ago) as a way to explore the landscape of innovation around EHR’s.
A big part of PARC’s healthcare work for Xerox is using ethnography and other social science methods to observe and analyze actual work practices – not just what people say they do – said Steve Hoover, CEO, PARC. If there’s one thing that this survey tells us, coupled with our own experiences, it’s that you should never develop or deploy technology outside of the human context.
PARC’s rich history in engineering innovation is legendary – spanning more than 40 years – and includes such key developments as laser printing, Ethernet, the modern personal computer, graphical user interface (GUI), object-oriented programming, ubiquitous computing, amorphous silicon (a-Si) applications, and advancing very-large-scale-integration (VLSI) for semiconductors.
Relative to healthcare, Xerox acquired ACS almost 3 years ago – which in turn acquired The Breakaway Group last fall (in part for their PromisePoint® technology – a kind of flight-simulator for large-scale EHR deployments). Last year, ACS signed a $500 million, 10-year agreement with Allscripts for hosted IT Services using Allscripts’ Sunrise Enterprise Suite to support EHR’s. These large scale connections (Xerox, ACS, Allscripts) combined with the innovation engines of companies like PARC and The Breakaway Group represent an exciting development. It’s where innovation – including the human element – meets scale – in healthcare. PARC’s influence is still relatively early – and most clearly represents the opportunity around that human element. Steve Hoover summarized it best:
PARC helped to usher in the era of ubiquitous computing – but in the evolution to truly personalized computing we recognized the critical importance of contextual computing. Bringing that deep understanding to large industries like healthcare is both a rich heritage – and an exciting opportunity. It’s also one we’re extremely passionate about.
Love this piece by @DanMunro on the missing "element" (love the graphic with an Atomic number of 8 - same as Oxygen and an Atomic weight of 7E-09)
As Dan points out this si the key ingredient that is missing in so much of the dicussion and includes everything from the dialog with the physician/hospital/payer) to the interaction with the EMR and the engagement with the Xerox Spin off PARC that has been exploring the EHR interaction for ten years.
Interesting concept to have a flight simulator version of EMR's which was exactly the process we went through about 20 years ago when we designed our paperless hospital in Glasgow. We built mock up rooms and tested them in earnest with real physicians, nurses and other ancillary staff to work out the workflow kinks in the room's ergonomics.
We need more of this and perhaps even an independent testing environment that takes the CCHIT testing and certification methodology a stage further.
I had the pleasure of talking with Chuck Webster, MD (@EHRWorkflow) over the last few days and weeks and he just posted this interview at his websitePosted via email from drnic's posterous
We found much in common (not justin healthcare but in books, space and science fiction) and he has kindly agreed to join me tomorrow for the #VoiceoftheDr radio show at 2:30 ET
We will be continuing the theme from this interview and discussing EMR usability, how interface design is so important and how it can be improved with the addition of intelligent speech interfaces and the importance of enabling clinicians to use narrative documentation as the source of truth in our march towards digitization of medicine and the medical record
>>>>>>>>
Natural language processing (NLP) applied to medical speech and text, also know as Clinical Language Understanding (CLU), is a hot topic. It promises to improve EHR user experience and extract valuable clinical knowledge from free text about patients. In keeping with this blog’s theme, NLP/CLU can improve EHR workflow and sometimes uses sophisticated workflow technology to span between users and systems.You can see the full interview at Video Interview and 10 Questions for Nuance’s Dr. Nick on Clinical Language Understanding via chuckwebster.com
10. Most of my previous questions are pretty “geeky.” So, to compensate, from the point of view of a current or potential EHR user, what’s the most important advice you can give them?
To me, the core issue is usability and interface design. The interface and technology has struggled to take off in part because the technology has been complex, hard to master and in many instances has required extensive and repeated training to use. The combination of SR [speech recognition] and CLU technology offers the opportunity to bridge the complexity chasm, removing the major barriers to adoption by making the technology intuitive and “friendly”. We can achieve this with intelligent design that capitalizes on the power of speech as a tool to remove the need to remember gateway commands and menu trees and doesn’t just convert what you say to text but actually understands the intent and applies the context of the EMR to the interaction. We have seen the early stages of this with the Siri tool that offers a new way of interacting with our mobile phone, using the context of your calendar, the day and date, location and other information to create a more human-like technology interface that is intuitive and less intimidating.
Anniversary of the Apollo 11 Landing on the moon set in motion with these words
First, I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the earth. No single space project in this period will be more impressive to mankind, or more important for the long-range exploration of space; and none will be so difficult or expensive to accomplish.
Sadly I do not think we have the same vision necessary to take the next giant leap
Apollo 11 Video Introduction
http://mfile.akamai.com/20356/mov/etouchsyst2.download.akamai.com/18355/qt.na...
Video Montage of Apollo 11 Moon Landing from 43 years ago today
http://mfile.akamai.com/20356/mov/etouchsyst2.download.akamai.com/18355/qt.na...
A research letter published online June 25 in Archives of Internal Medicine found that the rate of liability claims when EHRs were used was one-sixth the rate when EHRs were not used. Researchers say their findings suggest there was a reduction in errors associated with EHR use.
It’s entirely possible that there’s something still distinct and unusual about practices that adopted electronic health records earlier, and they just happen to practice in a way that reduces their risk of malpractice claims….But I think it’s equally plausible that there’s something about electronic health records that does reduce their risk.
That means patients need to knowing their numbers: what they mean, and how changing them can impact their future quality and length of life… where personal behavior change has the potential to do this
Not exactly medical but an area of great interest for me and one that is so fundamental to our world I thought worth talking about. If you want to get a sense of science and how little we still don't know or understand I recommend you read
Welcome. And congratulations. I am delighted that you could make it. Getting here wasn't easy, I know. In fact, I suspect it was a little tougher than you realize. To begin with, for you to be here now trillions of drifting atoms had somehow to assemble in an intricate and intriguingly obliging manner to create you. It's an arrangement so specialized and particular that it has never been tried before and will only exist this once. For the next many years (we hope) these tiny particles will uncomplainingly engage in all the billions of deft, cooperative efforts necessary to keep you intact and let you experience the supremely agreeable but generally underappreciated state known as existence.
The results are preliminary but the 5 sigma signal at around 125 GeV we’re seeing is dramatic. This is indeed a new particle. We know it must be a boson and it’s the heaviest boson ever found,” said CMS experiment spokesperson Joe Incandela. “The implications are very significant and it is precisely for this reason that we must be extremely diligent in all of our studies and cross-checks
‘What is the Higgs boson, and why do we want to find it?’
"We all agree, I think, that the current fee-for-service model has all the wrong incentives in it," said Swedish Medical Center CEO Kevin Brown. "The health-care system has been really fragmented, with independent entities all working for their own best interests."I liked the concept they talked about where:
Insurers and providers have worked together, rejiggering the typical payment model to shift incentives toward keeping people healthy instead of just running up bills when they're sick.Which reminded me of the ancient practice of paying the doctor in your village while you were healthy, only stopping paying him when you fell ill (I know simplistic but quite compelling). They did say that
The Affordable Care Act, which relies on private insurance, for the most part doesn't directly address costs.And while it represents a start (every journey begins with a step) there are still holes (tort and medical liability to mention a couple). Gregg responded and suggested that:
innovation will come via margins aka CMMI. Private market ACOs & direct practice models galloping aheadWe had a series of exchanges and I suggested that instead of the 140 character exchange he come on my radio show to discuss and he graciously agreed. Much as I did pre the release of the ruling, when I had the pleasure of talking with Sam Bierstock on March 30, we started with tentatively opposing views but in reality our opinions were not widely different. You can hear download that show here
decentralization through disruption leads to accessibility
"If you are wildly successful and innovative, you are doomed"
"Any Doctor who can be replaced by a computer should be"
So there was a lot of interest in the paper published in JAMIA
Method of electronic health record documentation and quality of primary care published on JAMI this month. A quick summary
They evaluated 18,569 primary care visits, 234 doctors in 2007-08
Their conclusion:
EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.
My Conclusions:
I don't follow that logic - what they appeared to measure was the quality of the documentation not the quality of care? The measures are measures of documentation not of quality of care or clinical outcome.
It was not clear to me if that data might have been in the documents but was not identified (extracted) to if they reviewed all the documents and abstracted that data to determine if the data was missing or not.
The study was carried out some time ago (2007 - 2008) - 4 years is an eternity in technology advancement. The iPhone was only launched in January 2007....look what that has done to the mobile world and telephones.
As I noted in my most recent VoiceoftheDoctor Radio Show with Dr Ruthann Litman, Dr Sidney Litman and Dr David Eibling it is the integration of solutions in a seamless way that will be successful and is measured by physician satisfaction. Turns out some doctors like dictating, some like using the keyboard and mouse, some like using speech recognition - and in the case study they are presented, some like to have a scribe/librarian/medical specialist do their keyboard interaction under their direction
The overall capture of quality elements was not great so we have not licked this problem yet (well not in 2008 anyway)
The ability to offer all methods but allow for the capture of these elements using technology is available today. This was nicely articulated in a piece just recently in HIT consultant in an interview with Carina Edwards - Understanding Clinical Language Understanding.
The Reliant Medical Group (formerly the Fallon Clinic) did a study presented at HIMSS in 2010 comparing quality of notes and showed an increase in the quality of notes with a hybrid approach of speech over pure EHR entry and dictation. In many respects I would suggest as similar study and results..just a different interpretation
I maintain that choice for clinicians is the key to success - offering them the right tool that fits their personal requirements and needs adn that includes all variations of documentation capture with NLP and Clinical Language Understanding to provide the bridge between narrative content and structured data essential for the intelligent management of patients and their care
June 15
Speaking with Ruthann Lipman, DO from the Department of Otolaryngology, Millcreek Community Hospital and David Eibling, MD, FACS from the Department of Otolaryngology, University of Pittsburgh and VA Pittsburgh who are presenting a paper at Human Factors and Ergonomics Society (HFES) this October titled:
"Re- engineering the Healthcare Team: Meeting the needs of Providers with Information Specialists"
June 22
Joel Selzer (@jbselz), the CEO Ozmosis will be joining me to discuss Social Media in Healthcare. Ozmosis has created a tool set that allows clincinas to engage in a secure environment allowing for easy collaboration and bringing Social media into the healthcare world
We have a list of doctors to follow on twitter and this list of docs and a listing of HIT folks who are influential in #hcsm in celebration of of Social Media Day. Certainly one of the leaders in this space - University of Maryland Medical Center has really shown what can be achieved. Even the US Army has gone created a guide for social media
June 29
Will round up the news from the past week including dicussion on these two papers that have created quite a stir
Escaping the EHR Trap from the NEJM (Jun 14), and
Method of EHR Documentation and Quality of Primary Care from JAMIA (May)
Join me on every Friday at 2:30 ET on VoiceoftheDoctor
Clinical documentation is an increasingly time consuming challenge for clinicians offering significant pressures that are vested in a range of requirements not always tightly aligned with clinical decision making.
Report of Dr. Charles A. LealeApril 15, 1865Having been the first of our profession who arrived to the assistance of our late President, and having been requested by Mrs. Lincoln to do what I could for him I assumed the charge until the Surgeon General and Dr. Stone his family physician arrived, which was about 20 minutes after we had placed him in bed in the house of Mr. Peterson opposite the theatre, and as I remained with him until his death, I humbly submit the following brief account.I arrived at Ford's Theatre about 8¼ P.M. April 14/65 and procured a seat in the dress circle about 40 feet from the President's Box. The play was then progressing and in a few minutes I saw the President, Mrs Lincoln, Major Rathbone and Miss Harris enter; while proceeding to the Box they were seen by the audience who cheered which was reciprocated by the President and Mrs Lincoln by a smile and bow.The party was preceded by an attendant who after opening the door of the box and closing it after they had all entered, took a seat nearby for himself.The theatre was well filled and the play of "Our American Cousin" progressed very pleasantly until about half past ten, when the report of a pistol was distinctly heard and about a minute after a man of low stature with black hair and eyes was seen leaping to the stage beneath, holding in his hand a drawn dagger.While descending his heel got entangled in the American flag, which was hung in front of the box, causing him to stumble when he struck the stage, but with a single bound he regained the use of his limbs and ran to the opposite side of the stage, flourishing in his hand a drawn dagger and disappearing behind the scene.I then heard cries that the "President had been murdered," which were followed by those of "Kill the murderer" "Shoot him" etc. which came from different parts of the audience.I immediately ran to the Presidents box and as soon as the door was opened was admitted and introduced to Mrs. Lincoln when she exclaimed several times, "O Doctor, do what you can for him, do what you can!" I told her we would do all that we possibly could.When I entered the box the ladies were very much excited. Mr. Lincoln was seated in a high backed arm-chair with his head leaning towards his right side supported by Mrs. Lincoln who was weeping bitterly. Miss Harris was near her left and behind the President.While approaching the President I sent a gentleman for brandy and another for water.When I reached the President he was in a state of general paralysis, his eyes were closed and he was in a profoundly comatose condition, while his breathing was intermittent and exceedingly stertorous. I placed my finger on his right radial pulse but could perceive no movement of the artery. As two gentlemen now arrived, I requested them to assist me to place him in a recumbent position, and as I held his head and shoulders, while doing this my hand came in contact with a clot of blood near his left shoulder.Supposing that he had been stabbed there I asked a gentleman to cut his coat and shirt off from that part, to enable me if possible to check the hemorrhage which I supposed took place from the subclavian artery or some of its branches.Before they had proceeded as far as the elbow I commenced to examine his head (as no wound near the shoulder was found) and soon passed my fingers over a large firm clot of blood situated about one inch below the superior curved line of the occipital bone.The coagula I easily removed and passed the little finger of my left hand through the perfectly smooth opening made by the ball, and found that it had entered the encephalon.As soon as I removed my finger a slight oozing of blood followed and his breathing became more regular and less stertorous. The brandy and water now arrived and a small quantity was placed in his mouth, which passed into his stomach where it was retained.Dr. C. F. Taft and Dr. A. F. A. King now arrived and after a moments consultation we agreed to have him removed to the nearest house, which we immediately did, the above named with others assisting.When we arrived at the door of the box, the passage was found to be densly crowded by those who were rushing towards that part of the theatre. I called out twice "Guards clear the passage," which was so soon done that we proceeded without a moments delay with the President and were not in the slightest interrupted until he was placed in bed in the house of Mr. Peterson, opposite the theatre, in less than 20 minutes from the time he was assassinated.The street in front of the theatre before we had left it was filled with the excited populace, a large number of whom followed us into the house.As soon as we arrived in the room offered to us, we placed the President in bed in a diagonal position; as the bed was too short, a part of the foot was removed to enable us to place him in a comfortable position.The windows were opened and at my request a Captain present made all leave the room except the medical gentlemen and friends.As soon as we placed him in bed we removed his clothes and covered him with blankets. While covering him I found his lower extremities very cold from his feet to a distance several inches above his knees.I then sent for bottles of hot water, and hot blankets, which were applied to his lower extremities and abdomen.Several other Physicians and Surgeons about this time arrived among whom was Dr. R. K. Stone who had been the President's Physician since the arrival of his family in the city.After having been introduced to Dr. Stone I asked him if he would assume charge (telling him at the time all that had been done and describing the wound) he said that he would and approved of the treatment.The Surgeon General and Surgeon Crane in a few minutes arrived and made an examination of the wound.When the President was first laid in bed a slight ecchymosis was noticed on his left eyelid and the pupil of that eye was slightly dilated, while the pupil of the right eye was contracted.About 11. P.M. the right eye began to protrude which was rapidly followed by an increase of the ecchymosis until it encircled the orbit extending above the supra orbital ridge and below the infra orbital foramen.The wound was kept open by the Surgeon General by means of a silver probe, and as the President was placed diagonally on the bed his head was supported in its position by Surgeon Crane and Dr. Taft relieving each other.About 2 A.M. the Hospital Steward who had been sent for a Nelatons probe, arrived and examination was made by the Surgeon General, who introduced it to a distance of about 2½ inches, when it came in contact with a foreign substance, which laid across the track of the ball.This being easily passed the probe was introduced several inches further, when it again touched a hard substance, which was at first supposed to be the ball, but as the bulb of the probe on its withdrawal did not indicate the mark of lead, it was generally thought to be another piece of loose bone.The probe was introduced a second time and the ball was supposed to be distinctly felt by the Surgeon General, Surgeon Crane and Dr Stone.After this second exploration nothing further was done with the wound except to keep the opening free from coagula, which if allowed to form and remain for a very short time, would produce signs of increased compression: the breathing becoming profoundly stertorous and intermittent and the pulse to be more feeble and irregular.His pulse which was several times counted by Dr. Ford and noted by Dr King, ranged until 12 P.M. from between 40 to 64 beats per minute, and his respiration about 24 per minute, were loud and stertorous.At 1 A.M. his pulse suddenly increasing in frequency to 100 per minute, but soon diminished gradually becoming less feeble until 2.54 A.M. when it was 48 and hardly perceptible.At 6.40 A.M. his pulse could not be counted, it being very intermittent, two or three pulsations being felt and followed by an intermission, when not the slightest movement of the artery could be felt.The inspirations now became very short, and the expirations very prolonged and labored accompanied by a gutteral sound.6.50 A.M. The respirations cease for some time and all eagerly look at their watches until the profound silence is disturbed by a prolonged inspiration, which was soon followed by a sonorous expiration.The Surgeon General now held his finger to the carotid artery. Col. Crane held his head, Dr Stone who was sitting on the bed, held his left pulse, and his right pulse was held by myself.At 7.20 A.M. he breathed his last and "the spirit fled to God who gave it."During the night the room was visited by many of his friends. Mrs Lincoln with Mrs. Senator Dixon came into the room three or four times during the night.The Presidents son Captn R. Lincoln, remained with his father during the greater part of the night.Immediately after death had taken place, we all bowed and the Rev. Dr. Gurley supplicated to God in behalf of the bereaved family and our afflicted country.True copy.(signed) Charles A. Leale M. D.
