Navigating Healthcare – Patient Safety and Personal Healthcare Management

Treating Mental Health

Posted in Uncategorized by drnic on July 6, 2017

Don’t judge my path if you haven’t walked my journey

Mental Labels

Just the term “Mental” induces reactions and responses from every corner of our society, and mostly they are not positive. Perhaps part of the problem can be attributed to the broad and different definitions applied to the term that includes its use as an adjective relating to the mind or disorders of the mind but it also has an informal us as “insane” or “crazy”

It’s no wonder that when we refer to someone as having “Mental problems” or a “Mental Condition” – so perhaps we need to change the terminology to start addressing “Mental” health as part of our overall health. The precision of language and terminology is important but we have a tendency that appears to be increasingly misused, or perhaps it just appears that was because it is magnified by social media and the 24/7/365 news cycle. For example, the term “Depression” is a clinical diagnosis that has some very specific symptoms and durations but the term is used excessively in place of sadness, misery, or sorrow. SO for this article, I will refer to “Diseases of the Brain” rather than “Mental Disorders”


Part of Physical Health

A recent article by John Campo, MD, Professor, and chair of the Department of Psychiatry at Ohio State University pointed out the mismatch between the prevalence and impact of diseases of the brain and the lack of legitimacy as a “real disease

The treatment of mental illness has long been held back by the sense that disorders of emotion, thinking, and behavior somehow lack legitimacy and instead reflect individual weakness or poor life choices

Some of this likely stems from our lack fo understanding relative to brain disorders evidenced in history by the way we viewed and “treated” anyone deemed to be unusual or different. These attitudes date back to at leat the 13th Century and “St. Mary of Bethlehem” in London built in 1247 and used as an institution for the insane. It was colloquially referred to as “Bedlam” hospital (yes that is where the term “Bedlam” came from) that featured horrific treatments from “rotational Therapy”

Imagine being stuck on the Mad Hatters Tea Cup ride at high speed for hours


And extended to beatings, bloodletting, and starvation! This sordid history is covered by the Museum of Healthcare Blog. This attitude extended into my medical school training where we were dispatched to Friern Hospital (formerly Colney Hatch Lunatic Asylum) that at its peak was home to some 2,500 patients with disorders of the brain. My clinical experience there included a harrowing personal experience that still shapes my behavior to this day.


Long corridors with Wards radiating out


Moving to Whole Care


The disconnect between the specialty of Psychiatry and the rest of medicine is rooted in our inability to observe and explain the workings of the brain. Even some of our treatments work but we struggle to understand why or how. This manifests in the challenge of honest acceptance of having a disease of the brain and being able to find help to treat that condition. For most people, our exposure to this world is limited to the Hollywood lens, like “Awakenings” starring Robin Williams and Robert de Niro



It is sad to note that Robin Williams suffered a sometimes public struggle with a brain disorder and ultimately committed suicide secondary to his suffering of Lewy Body Dementia

Based on the true story and book “Awakenings” written by Oliver Sachs – the British Neurologist, naturalist, and author who died back in 2015. He was a prolific writer who wrote with such eloquence and mastery of language you can lose yourself in his books.

Papa would tell me,
‘is not a science,
but the intuitive art
of wooing Nature.’

The Art of Healing – W.H. Auden


Science is Helping

The good news is that technology and science are helping as we unlock some of the mysteries of the brain’s function and the diseases that impact function. In fact, in many instances, we are discovering that the brain plays a much larger role in many diseases and we ignore this at our peril. We continue to unlock the chemical and physiological functions in the brain and as the science advances so too does the integration of the specialty psychiatry under the same roof as the rest of medicine.

There are now a number of initiatives working to expand our understanding, coordinate research, results, and findings that included the 2013 announcement by President Obama for the “BRAIN Initiative” (Brain Research through Advancing Innovative Neurotechnologies) that is homed at the National Institute of Health (NIH) and complemented by the The Human Brain Project from the European Union. The initiatives are not without problems and uncertainty of funding continues to challenge progress but understanding, science, and data remain a central requirement to progress.

There are some areas of progress from industry and Arshya Vahabzadeh, MD, the Chief Medical Officer at Brainpower has been championing Virtual Reality and Augmented Reality as a tool to help the growing population of Autism patients handle the complex world of emotions and human interactions. As he highlighted Virtual and Augmented Reality was a hot topic at the recent American Psychiatric Association Meeting


And was featured in this Medscape article: Virtual Reality a Game Changer for Psychiatry (Medscape)


Incremental Improvements in Brain Disorders

As Dr. Campo pointed out

Better understanding of the human brain and the biological nature of the mind will help, but it won’t be enough. How we think about mental health matters. When mental health is ultimately recognized as essential to physical health, not an extraneous element of it, then we will have access to true, complete, modern medicine

Changing the narrative and words may seem trivial but for any change to take place we need education and awareness that removes the stigma and fear associated with disorders of the brain and deliver the same compassion and care that patients with cancer or heart disease receive.

So my thoughts for some incremental improvements you can make addressing disorders of the brain

  • Words Matter – it’s not “Mental Health/Disorder” – it is Disease or Disorder of the Brain
  • Ask, listen and most importantly digest and be there as we interact with others – read Maneesh Juneja  blog – Being Human
  • From a clinical perspective – the clinical history and the detail of the Presenting Complaint and History of Present Illness remain the mainstay of diagnosis and understanding
  • Read or listen to Oliver Sach’s – you can find his books – or watch his TED Talk, or hear him on Science Friday or NPR or read one of his articles


What small change have you seen that makes a difference in the support of people with disorders of the brain. What one thing could we do that would have a big impact in this area?

You can also follow me here on medium, on twitter, or on facebook




MasterChef in Healthcare: Integrating Social Media

Posted in #hcsm, #mHealth, Healthcare Technology, HealthIT, HIT, HITsm by drnic on April 15, 2015

Social Media is rapidly becoming an integral part of our lives. Despite the pervasive nature of the communication channel healthcare remains a technology laggard. This presentation from HIMSS15 Wednesday Apr 15) will offer insights to help understand why healthcare professionals should join the community, participate in the discussion and how can do so successfully.


I presented this topic at HIMSS15 on Wednesday Apr 15 – you can find the listing here. As promised I am posting a summary of the points as well as a link to the Slideshare for that presentation

You can find the presentation on my slideshare (nvt) here

Master chef in healthcare- integrating social media – @DrNic1 from Nick van Terheyden




Technology is all pervasive in our lives and Social media is everywhere – in fact in a recent survey of 3,000 people conducted in the US, UK and Germany to help counter the limited time with their physicians, patients are seeking information and embracing technology outside of the doctor’s office to come to appointments prepared. Approximately 80 percent of patients feel engaged in their own health:

  • 68 percent of patients bring a list of questions to each doctor’s consult;
  • 39 percent have checked WebMD or another online source in advance; and
  • 20 percent bring personal health data from outside monitors.



You can see some 87%o f US adults are online in this Pew internet research so if you are not on board you are missing a huge opportunity but more importantly your patients are forming an opinion about you before they meet you




 What is Social Media

  • It’s a conversation, not a lecture
  • It’s an extension of everyday interactionCollaboration
  • It’s group driven, not top-down
  • It’s messy, disorganized & hard to control
  • It’s a tool, not an end-point
  • But most of all…



If you have not already – go to twitter and sign up for an account

What to Tweet

  • What you have read that you want to share with others
  • When and where you are speaking
  • Something you post on your blog
  • A link to a Web site that you find interesting
  • Listen to conversations happening online using keywords (hashtags, lists and searches) – learn from your colleagues, friends and patients
  • Befriend people – and then earn their trust by solve problems, answering queries, helping and providing useful information
  • Share information, valuable content with them
  • Questions and Requests for information and help – crowdsourcing answers
  • At a minimum – Lurk, Listen and Learn

There are many HashTags to follow and starting by assign friends and colleagues what they follow is a a good start but then get involved – join an online chat and community and take a look at the listing of healthcare hash tags from symplur. Listed below are a few of the healthcare hash tags I follow:

#hcsm (h/c social media)
#HCLDR (healthcare leaders)
#HITsm (health IT social media)#MedEd (medical education)
#eolchat (end of life/elder chat)
#BCSM (breast-cancer social media)
#LCSM (lung-cancer social media)
#BTSM (brain tumor social media)
#S4PM (Society for participatory medicine)

But I received a aggregated list when I polled my followed that included all these:


#POWHIT – People & Organizations improving Workflow w/HIT


#JACR 4th Thurs 12pm EST
#LCSM Every other Thurs 8pm EST
#BCSM Mon 9pm ET
#HCLDR Tues 8:30pm EST
#MedEd Thurs 9pm EST


@twubs @hashtracking or @tweetreachapp


My thanks to all my twitter friends who contributed

@HealthcareWen @HIMSS @lsaldanamd @sjdmd @HealthcareWen @DrJosephKim @dirkstanley @dlschermd @Docweighsin @RossMartin @CraigJoseph @RobertWahMD @ishakir @SteltsMD @JenniferJoeMD @StevenChanMD @CIBR_News @Jim_Rawson_MD @aussiclydesdale @ACRselect @AdamFuhriman @Gregmogel @ruthcarlosmd @techguy @MandiBPro @HITshrink @ahier @RandaPerkinsMD @motorcycle_guy @wareflo @susannahfox @Lygeia @ePatientDave @CMichaelGibson @Colin_Hung @annelizhannan @MelSmithJones @Paul_Sonnier @JennDennard @HIStalk @JohnNosta @2healthguru @lsaldanamd @lisagualtieri @EricTopol @ShahidNShah @DanMunro @Daniel_Kraft


Put yourself somewhere on the Social Media Adoption Curve



Add LinkedIn and Facebook – they offer a different channel and voice – Facebook tends to be more social and LinkedIn tends to be more professional/business orientated

There are some good examples already out there

The Mayo Clinic has several properties and their own published guide book to social media and the University of Maryland Medical Center that has blended many channels

What Not to Do

The JAMA 2012 report Online posting of unprofessional content by medical students highlighted a high proportion of violations and problems and there are plenty of examples of people who failed use basic common sense – I personally like the 12 word Simple Social Media Policy from the Mayo

Don’t Lie
Don’t Pry
Don’t Cheat
Can’t Delete
Don’t Steal
Don’t Reveal



  • Social Media for Physicians is a Game Changer
  • Social media, when effective, will establish a physician’s brand and connect him/her with those in need of their services
  • With increased deductibles, more consumers will “shop” using social media sites.
  • Social Media will Expand the Physician’s Role with Patients
  • Social media is shaping patient encounters with physicians and that impact is expected to increase significantly
  • Extending the patient experience will foster existing patient relationships and improve patient outcomes, especially for long-term chronic conditions.


Where are you on the social media ladder and are you going to climb higher?




MasterChef in Healthcare: Integrating Social Media was originally published on Dr Nick – The Incrementalist

Improving Security by Default

Security by Default

The opening Keynote by Parisa Tabriz | Director of Engineering, Google: Optimistic Dissatisfaction with the Status Quo: Steps We Must Take to Improve Security in Complex Landscapes covered the journey taken by Google to bring the status of browsing into the Security age. It was sobering to see that a company like Google with the resources available started this journey in 2014 and only now starting to see significant progress – 4 years so far. Their path, like so many others, was a series of incremental steps to improvement and change


Security, as described by Parisa, is much like the Wacka-Mole game

The biggest round of applause came when she stated:



But the biggest round of applause came when Parisa stated:

Blockchain is not going to solve all your security problems

Clearly not a lot of support for Blockchain in the BlackHat audience….. yet?

From the journey taken to securing the Chrome browser the key learning boiled down to three elements

  1. Tackle the Root Cause
  2. Project Zero (disrupt the industry)
  3. More Transparency and Collaboration – shared security goals


Ultimately it is hacking the status quo and bureaucracy is achieved through Incremental steps that challenge the status quo. For those that don’t remember the concept of bug bounties was controversial initially now it is the gold standard
Also, Auto updates of security patches were controversial now not so much

Interesting slide of the different presentation of “secured” site in chrome

Chrome Connection Indicators circa 2014

In their survey, most users perceived the second choice as normal and secure. Over time they have moved the security indicators bringing along a large consortium of people along the way

Rethinking the Security Indicators

And in bringing together experts Parisa highlighted something I have long advocated in Engineering healthcare technology – the people creating and experts in the technology are rarely the right people to optimize usability – as she put it

Security people are rarely the right people to ask about usability in security interactions/interfaces


“Be a team player, don’t be a jerk”

Also noted that Google Page Rank used as an influencer


Incremental Steps to Security

At the press conference afterward what one incremental step should you take in securing your enterprise:

Getting everyone pulling in the same direction is a key requirement

Focus on finding the incentive and/or ROI for the people who are responsible for security

Everyone has too much on their plate – what is required is allowing people to focus on the security as a priority over all the other tasks on their to-do lists. This was true with project zero and with the https push (remember this took from 2104 to 2018)

I will leave you with this as a closing thought

A Product that has no security flaws/bugs probably just doesn’t know about them


Improving Security by Default was originally published on Dr Nick – The Incrementalist

Telehealth is Here – Getting There Quicker with Incremental Steps

Telehealth is Here – Getting There Quicker with Incremental Steps

The Incrementalist Graphic Til Jolly

This week I am talking to Dr. Til Jolly, CMO for Specialists on Call (SOC) Telemed who are delivering enterprise-wide telemedicine to over 450 hospitals

Dr Jolly is an Emergency Room physician with a fascinating background that includes working for the NFL Super Bowl “Emergency Preparedness Team” planning super bowls around the country over multiple locations. He shares some of his experiences in that role and some of the things he learned along the way – learning from previous events, clear role assignment and division and above all practice (he’s talking about the medical teams but I’m sure that’s true for the NFL teams :-))

We talk about the small incremental improvements that have been adding up in Telehealth delivery – as he puts it the barriers are not technology anymore and there has been some good progress around reimbursement. In an interesting twist and different perspective he looks back with fondness at the introduction of the Fax machine and the positive impact it had on care with the ability to fax EKG’s direct to clinicians.

The resistance is no longer coming from patients and in some instances is clinicians and health systems who want to find “traditional” methods of care delivery but the writing on the wall is clear: Telehealth is here to stay and will be a major part of helping support our aging population even mitigating some of the loneliness these individuals have

Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

Telehealth is Here – Getting There Quicker with Incremental Steps was originally published on Dr Nick – The Incrementalist

Defending Science

The Fake Science Factory

Inside the Fake Science Factory

In hindsight, the Waset publishing organization (I’m not linking to it so as not to help their SEO – waset DOT org) should have refunded Chris (Suggy) Sumner’s money when he asked for it, but the rest of Science thanks them for not doing that. So launched a year-long deep dive into the underbelly of predatory publishing partnered with Svea Eckert (@sveckert) (who blew away any sense of privacy with the outstanding “Dark Data” presentation last year at DefCon25 – take a look at the presentation here) alongside Till Krause (@TillKrause)

Suggy’s trip to present his paper in October 2017 in Copenhagen proved to be a big disappointment with a room filled with a small cadre of presenters and no conference attendees to speak of. He teamed up with Svea and Till who set about a project to investigate this organization and others in the space of predatory publishing (something Jeffrey Beal has long campaigning against who was besieged by legal threats he could not fight as an individual – his list lives on here).

The Science Paper Sting

They Used the SCIgen auto paper generator to create a paper and submitted it for one of the conferences on the Waset site. The paper was accepted and they arrived ready to present the nonsense paper, word for word to a similar audience seen by Suggy. Their biggest challenge holding a straight face and not bursting out laughing as they read the paper. They received an award and certificate for “Best Presentation”

Best Paper Award

They had another junk paper accepted promoting Bees as a cure to Cancer – one they tried to withdraw explaining it was junk and not wanting to add to the morass of fake claims but were told this would cost an additional fee to remove!

The Data

In a combined effort the team reviewed and downloaded the publicly available data from the websites of the offending publications and organizations they had identified a whopping list of 44,476 conferences!

Data Aggregated from Target Organizations

They created a database to analyze the results with total numbers of abstracts for each of the organizations (Omics and Waset – leading the way in papers both more than double the next nearest at 60,000+ abstracts). The grand total:

179,239 Abstracts and 400,000 authors

(As they pointed out this is 5% of the total of published papers but the trend in the last 10 years is troubling seeing a huge increase) and impacting our academic institutions as seen in their data

Elite Universities Publishing Stats
Top US Institutions Publishing Stats


The Impact

The harm from these publications extends far beyond the individual papers and authors financial loss for the cost of publishing and attendance. As they highlighted the “validation” these papers give to false claims have allowed snake oil predators to justify their claims as seen with GcMAF “treatment” for Cancer. These claims are amplified by media personalities – with a well-known media personality from Germany Miriam Pielhau (Dr Hope) who was featured in their short film you can watch with English subtitles here

She like many others reached for any last hope as she battled cancer leaving a legacy behind that promoted this remedy – which is set to go to trial in the UK this November which alleges it is being sold using fake studies. And manufacturers have been using these resources to justify marketing for their products (Philip Morris and their smokeless tobacco, Bayer promoting Aspirin and Vitamin C for example) and well beyond healthcare into other science domains and used by lobbying groups as justification for their positions. But this just scapes the surface and the group highlighted several other targets:

  • Autism
  • Chronic Fatigue
  • Cancers
  • Depression
  • Anxiety
  • And there are many who combat the pseudo-science on a daily basis – some facing extreme assaults on their lives, families, and reputations – these people are my heroes.

What do we Do

We need to be part of the solution – identifying these organizations and calling out predatory publishers and conferences. The presenters have joined forces with other media organizations around the world who are also researching these groups and publishing – this recent piece in the Guardian – Predatory Publishers who Churn Out Fake Science

More than 175,000 scientific articles have been produced by five of the largest “predatory open-access publishers”, including India-based Omics publishing group and the Turkish World Academy of Science, Engineering and Technology, or Waset

And continue to seek partners and participants to help remove these groups and paper. This attacks the very foundation of our decisions and actions – especially true in medicine. Take a look at their work, reach out and follow up with them as you identify other potential organizations, conferences, and publishers and participate everywhere you can in addressing claims that are not substantiated by peer review articles backed up by real science

The full presentation – Updated (13Aug2018) Presentation – Inside the Fake Science Factory

My thanks to Suggy, Svea, and Till for an outstanding piece of work and presentation – all credit to them for everything above

Defending Science was originally published on Dr Nick – The Incrementalist

How Does Technology Reach Escape Velocity

Posted in Disruptive, Future, Incremental, Innovation, Technology by drnic on July 31, 2018

How Does Technology Reach Escape Velocity

Alfred Poor – Editor and Publisher of Health Tech Insider

This week I am talking to Alfred Poor, Editor and Publisher of Health Tech Insider (@AlfredPoor) and a long-standing member of the technology community dating back to the early and exciting days of the first personal computers when he worked as a reporter at PC Magazine

Fair use of copyrighted material in the context of PC Magazine

NewImageListen in to hear about his front-row seat to this revolution and hear about the days of Comdex and PC Expo which “were not that big of a show”. These early experiences have shaped razor sharp insights into what creates success in innovation.

Do you remember the famous “Printer Issue” of the PC World Magazine – by all accounts the most read and shared (and to be clear shared in those days was a physical activity not digitally) issue every year – offering early insights into user-based design that proved highly successful for one company






We talk about Brownian motion and how to identify the technology that will reach escape velocity.

“How do you increase the success rate”

Listen in to hear what Alfred has seen beyond the constant drive to efficiency and surprisingly:

“Don’t make what people need”

As he describes the key assets center on teams and some simple rules and concepts that can mean the difference of being a footnote to history or a brand that explodes onto the stage.

Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

How Does Technology Reach Escape Velocity was originally published on Dr Nick – The Incrementalist

Who Own’s Your Medical Record

Posted in Uncategorized by drnic on August 15, 2017

You do!
To be honest this was almost as much as I was willing to write – I don’t see this as a debatable item – it’s your health, your data (about you) and therefore you own it
I know I differ from many in the healthcare field who perceive this data to be very much the domain of the health care provider.

This piece by Karoli “Who Owns the Medical Record?” reviews recent experiences trying to combat a denial for drug coverage that required full information on treatments and justification which engendered a big struggle with those folks who had the data and record

The concepts presented of the patient as the platform makes sense and creating an environment that does not require a “big system” or “Big government” owning and managing this data makes sense.

We are a long way from this position but today I would suggest each and every patient should insist on receiving a full copy of their record in a digital exchangeable form where possible but failing that in paper form.

I have mine – do you have yours?


Social Media Insights from MayoInOz

Posted in Healthcare Technology by drnic on July 29, 2017

I attended the MayoinOz conference some time back and captured some of the key elements of the presentations and discussions

The core principle – Teamwork


If the #Mayo Bros had Twitter: “The best interest of the #patient is the only interest to be considered” #MayoInOz

— ANZCA (@ANZCA) November 14, 2016

We are being disrupted  – captured perfectly in this one slide from Andrew Grills highlighting volumes of activity of WhatsApp vs the SMS text volume

Just in case you thought we had not moved to Digital: WhatsApp volume far higher than SMS text messaging #mayoinoz

— Nick van Terheyden (@drnic1) November 14, 2016


Social is not a channel – although as several commentators pointed out many companies have jumped on the Social Media Band wagon and use it as another channel to pump content to potential customers

Top skills in demands as surveyed by LinkedIn feature data analysis and statistical

Moving to the cognitive era – Humans + Machines. It is not Artificial Intelligence but rather augmented intelligence

Test out your profile ith a Watson Analysis

If the #Mayo Bros had Twitter: “The best interest of the #patient is the only interest to be considered” #MayoInOz

— ANZCA (@ANZCA) November 14, 2016


The last best experience has anyone has anywhere becomes the minimum expectation for the experience they want everywhere

This captures everything about competition

Your competitors are everyone – FedEx, Airlines, Hotels etc

So true. Think airlines/hotel rooms #MayoInOz

— Michelle Carnovale (@M_Carnovale) November 14, 2016


Social Media Insights from MayoInOz was originally published on DrNic1

The Appliance of Science

Posted in Uncategorized by drnic on July 27, 2017

Hurry up and Implement

Innovation has had a tendency to move at glacial pace and history is littered with scientific discoveries that took a long time to reach our world and have an impact on our lives.

Philosophiæ Naturalis Principia Mathematica – Wikipedia (Photo Wikipedia)

So many areas in our lives – math and complex numbers discovered in the 16th Century that were originally described as “imaginary” numbers as if to emphasize their impracticality and it was hundreds of years before they were used in earnest in calculations with alternating current and impedance. In physics, we have seen incredible insights from the basic observational details of Newton in the Philosophiæ Naturalis Principia Mathematica to Einstein’s astounding revelations in the Theory of Special Relativity and the Theory of General  Relativity. The insights from these continue to provide breakthroughs in our understanding of the world

In Biology, Darwin’s theories contained in his book On the Origin of Species were deemed heretical at the time and yet now are considered to be the foundation of evolutionary biology.

Medicine proves to be no different and we have seen repeated instances of rejection and challenge to new technologies and insights. When René Laennec came up with the original stethoscope it was famously referred to in the Times of London:


“it will never come into general use notwithstanding its value. It is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble to both the patient and the practitioner; and because its hue and character are foreign and opposed to all our habits and associations. It is just not going to get used.”

New Treatments Applied Slowly

It takes on average 17 years for an innovation to reach general application in healthcare – in this paper in the Journal of the Royal Society of Medicine 17 Years is the time for Translational Research. The authors reviewed multiple papers to ascertain the time delay in the application of medical insights into clinical practice. This table from “2000 Year Book of Medical Informatics Balas Boren Managing Clinical Knowledge for HC Improvement”


Clinical Procedure Landmark Trial Current Rate Use (2000)
Flu Vaccination 1968 55%
Thrombolytic therapy 1971 20%
Pneumococcal vaccination 1977 35.6%
Diabetic eye exam 1981 38.4%
Beta blockers after MI 1982 61.9%
Mammography 1982 70.4%
Cholesterol screening 1984 65%
Fecal occult blood test 1986 17%
Diabetic foot care 1983 20%


To be clear I am not advocating the application of unproven ideas and theories but rather taking advances that have been proven with studies and expanding access to everyone.

Patient Engagement

We have seen multiple instances of patients who have refused to accept the current state of affairs in their conditions and treatment – Dave deBronkart (aka ePatient Dave) was an early advocate and trailblazer. In January 2007 he received a diagnosis of Stage 4, Grade 4 Renal Carcinoma and his prognosis was not good (that’s an understatement). Had he accepted the prognosis and the standard treatment he would not be here today. He did not and together with his care team he pushed the boundaries of the disease and our understanding and joined a clinical trial for a new therapy that was successful. 10 years on he is thankfully here and continues to advocate and push the boundaries of patient engagement and participation.

Not all therapies apply and not all patients are good candidates for new therapies but it’s a fair assessment that most of us would want a similar life-saving therapy for a catastrophic disease. Teasing out what works and what does not remains an ongoing challenge in science. Science and Discovery are littered with many blind alleys, failures and course corrections but it is these failures that contribute to our continued progress.



The new age of “all the data” is going to change the way we innovate and discover as Chris Anderson from Wired asked, “What can Science Learn from Google as he suggested, The end of Theory: The Data Deluge makes the Scientific Method Obsolete“.

At the petabyte scale, information is not a matter of simple three- and four-dimensional taxonomy and order but of dimensionally agnostic statistics. It calls for an entirely different approach, one that requires us to lose the tether of data as something that can be visualized in its totality. It forces us to view data mathematically first and establish a context for it later

Learning to use a “computer” of this scale may be challenging. But the opportunity is great: The new availability of huge amounts of data, along with the statistical tools to crunch these numbers, offers a whole new way of understanding the world. Correlation supersedes causation, and science can advance even without coherent models, unified theories, or really any mechanistic explanation at all.

Applying Knowledge Today

So now we are facing a future where information and discoveries are arriving at an increasing rate – look no further than the Exponential Medicine site (Part of Singularity University) and attend the great Exponential Medicine Conference that takes place each year in San Diego to get an idea of the Tsunami of innovation coming our way. So how do we capitalize on this increase knowledge acquisition so that the best information is applied each and every time we look for insights and treatments in medicine.

Incremental Improvements to Adoption of Innovation

For the incremental approach, it’s turning these insights into small actionable pieces that can be applied at each of the intersection points

  • It’s making the information available in its entirety to everyone involved in the care – this includes not just the clinicians but also the patients and their family and friends (with the approval of the owner of the data – the patient)
  • Abolish Selective reporting – Make the research data widely available and importantly publish all the data, not just the data that matches the desired outcome or result
  • Be open to change and alternatives – recognize the resistance to change is inherent in all of, acceptance can be the first step in change
  • Find common ground and practice guidelines where possible to reach agreement and limit the variation in care that occurs in treatment that comes with your location and treating entity

Do you have any better suggestions? What small change have you seen that makes a difference to speed up the appliance of science in healthcare? What one thing could we do that would have a big impact in this area?

You can also follow me here on medium, on twitter, or on facebook

Why The Patient Story Should Always Take Center Stage

Posted in Uncategorized by drnic on July 21, 2017

I recently discovered that one of the great storytellers of our day – Malcolm Gladwell has a new podcast – Revisionist History. Each episode (he is now into Season 2) takes a look at some piece of history and through some delightful storytelling revisits the history and our perceptions of events. It reminded me of this piece I wrote some time back focused on the importance of storytelling in and the history we capture from our patients.

The Patient Story

Stories are the backbone of who we are. They provide context, insight, subtle and not-so-subtle hints about ourselves and those around us. They teach us lessons and help us determine similarities and differences so that we can avoid mistakes and replicate success.

Much like Malcolm Gladwell’s new podcast, the popular Serial podcast is dedicated to deeply exploring different narratives, stories, and evidence, in order to find insight into a mystery. I found it fascinating for myriad reasons, but mostly for the way it was told. And, at the beginning of each episode is the reminder: “This is Serial: one story told week by week.”

It’s engaging and thought-provoking, but what I like most is that it forces the listener to consider the same principle case from different perspectives. I was struck by how similar this journalistic process of poring over reports and talking with people to hear their perspectives is to the art of medicine. When a patient comes to see you with a set of symptoms, you have your checklist: you examine him, you ask questions, maybe order lab tests.

If your patient’s condition persists, you might talk to his son, who brought him into the follow-up appointment, and he might mention something his father had forgotten or dismissed as irrelevant. You carefully listen to what is said, and what is not said, noting anything that is out of the ordinary. You use that patient’s chart as your journalist’s notepad.

The Luxury of Time

The difference is that physicians don’t always have the luxury of time. Whether it’s because treatment decisions need to be made or there is a line of patients waiting to be seen, they need to have quick access to the most relevant data and best practices so they can make informed decisions and recommendations to their patients. They need to be able to collaborate with a specialist to look at a medical image and report together, discussing whether that secondary finding is something more than it appears.

Compounding matters are that as the healthcare industry awkwardly shifts to value-based care, physicians have been forced to precariously straddle the line between two oppositional models, and amidst it all, they try desperately to not let the tumult affect their patients. They’re beholden to the regulatory bodies that govern how they practice and they have sworn an oath to protect and care for those who have entrusted them with one of their most valuable gifts: their health.

As Drs. Patrick Ober and William Applegate so eloquently as succinctly articulated in their recent article “The electronic health record: Are we the tools of our tools?”:


“Attentiveness to the nuances of communication is an essential attribute of a skilled physician; in its quest for medical standardization, the EHR discourages nuances and promotes functional medical illiteracy.”

Time Pressure is Killing the Story

Physicians are being forced to make hard choices, and one of these sacrifices often comes at the expense of the patient story. And when you lose that story, the patient becomes a collection of somewhat unconnected data points. This has a profound downstream impact as the next attending physician will have to go through the same rigorous exercise of asking questions and sleuthing around, which not only frustrates the patient, it can lead to unnecessary wasted time.

The overall health IT endgame is the right one: creating a continuous and integrated care cycle that helps drive the best care outcomes. While technology is a key component in the healthcare ecosystem, it should only play a supporting role. It helps sifts through the massive amounts of data and appeases the regulatory requirements so that the physician can listen attentively to his patient as she walks him through the series of changes and symptoms she has experienced.

In healthcare, the story is everything. Nothing happens in a vacuum. As physicians, it is our responsibility to listen to our patients and their family members, noting the details, and helping them understand and treat their symptoms. We can’t do this if we’re not paying attention.


Capturing the Story

It’s not a lack of willingness on the part of the healthcare professionals but rather the time pressures of other tasks that have precluded the capture of the story. What small improvements could we make in the system to increase the time for patients to share their story?

  • Maximizing the time with the clinician requires we ease the burden of administrative tasks from the clinical team
  • Identify any tasks that can be carried out by others – simple administrative functions that could be assigned to other members of the team
  • Patient engagement can occur long before the face to face visit with their clinicians and allow patients access to their records and the ability to validate and update their information
  • Move the healthcare payment model to value-based care and drop the requirement of documentation for the purposes of billing would change the focus of the consultation to be clinical, not financial

This is an important area for clinicians – we recognize the value of the history and to this day the history still contributes some 80% to the diagnosis of a patient’s condition. This alone should provide the impetus to change the system to allow the patient story to be front and center.

Do you have any better suggestions? What small change have you seen that makes a difference in the use of Telehealth services. What one thing could we do that would have a big impact in this area?



This piece originally appeared on HITConusltant

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Employee Empowerment to Help Patients

Posted in Uncategorized by drnic on July 18, 2017

Delivering Outstanding Service

I had a frustrating experience with a bank this week that had so many opportunities for correction and improvement. The short version was a requirement to follow a policy that no one could explain requiring additional steps necessary because the bank had taken so long to follow their process. At various points, the employees were forced to follow a senseless protocol and policy and given no flexibility. In some cases, it may not be possible to bend policy – perhaps because of regulatory requirements but when we reached of an extraordinarily frustrating experience I tried to tease out an apology or even an acceptance that perhaps this was not the best outcome and there might have been a better way. The lack of employee empowerment prevented them from accepting any responsibility, offering an apology and they were firmly stuck to a script filled with hollow “I understand your frustration” statements.


Healthcare and Satisfaction

There is an interesting connection between the soft aspects of the patient experience and customer satisfaction. The actual clinical experience and quality is important – and some would suggest the most important component. But in talking to patients, simple aspects of the experience that included reducing waiting times, personal interactions and communications. But if the staff are not enabled to deliver a good experience and find themselves pressured by production metrics that preclude the important human connection and support that patient crave. It is easy to lose sight of the human elements as we strive for efficiency and the system pushes us to squeeze more and more cost out of any activity.


Customer is Always Right

This is an age-old adage that no matter what “The Customer is always Right”. In healthcare, this can be a difficult strategy especially when given the poor information available for making decisions and the inherent bias built into our system to provide unnecessary care. Take the prescribing of antibiotics that has reached epic proportions that recent data suggests has reached levels as high as 30% that are unnecessary.


Incremental Improvements in Employee Empowerment

Recognizing the challenge of changing policy which can be a long journey my suggestions for incremental improvements start with empowerment

For any staff that deal with patients/customers

  • Empower your employees to make localized instant decisions
  • Provide them with a set fo guidelines on what they can do and offer
  • Set the boundary conditions but empower them to respond in cases of unhappy/upset patients
  • It could be as simple as offering a Gift Card for a Coffee or Snack accompanied by a genuine heartfelt apology
  • Provide a pathway for problems to be reported, reviewed by the team with input from everyone and accept suggestions and ideas on how things could have been improved or even fixed


You won’t just get happier patients – you will get happier employees


Do you have any better suggestions? What small change have you seen that makes a difference empowering your employees? What one thing could we do that would have a big impact in this area?


You can also follow me here on medium, on twitter, or on facebook

The Internet of Things Changes Everything in Healthcare

Posted in Healthcare Technology by drnic on July 16, 2017
Remote Consultation for Pre-operative Assessment

The Internet of Things is Changing Everything in Healthcare

While there remains some resistance to the idea of tracking everything there is increasing use and now results from the IoT. It ranges from the simple – weighing scales that record and report weight loss and gain, not just for health and fitness but as an early indicator of problems in Congestive Heart Failure to the complex ideas of tracking pills and compliance with RFI tagged medication

Expect this sector to explode

The Internet of Things Changes Everything in Healthcare was originally published on Dr Nick – The Incrementalist