Navigating Healthcare – Patient Safety and Personal Healthcare Management

Top 10 Reasons to go Digital in Healthcare

Posted in EMR, Health Reform, Healthcare Standards by drnic on August 24, 2010

In the Spirit of helping those that face the digital tidal wave of technology in healthcare with trepidation I offer the following top ten reasons why this will be a good thing and include some thoughts on easing the transition from current methods to a digitized clinical office

1) Ready Access for Everyone
Paper medical records cause harm and in multiple studies have been shown to fail to deliver the necessary information to all the clinicians involved in care. In a study I quoted some years ago done by then Arthur Anderson they found that in less than half of patients cases the relevant clinical notes were neither available or could be found at the time the patient was seen. Digital records are available to everyone involved in the care of the team who has access. Instant availability provides referring physicians and specialists as well as the patients with a copy of medical record quickly and conveniently.

2) Digital Record are More Easily Kept Up To Date
New innovations and digitization allows for the capture of information by the patient prior to a visit. Almost every clinical facility asks patients to fill in forms as they sit in a waiting room – the information contained in these forms is marginal at best and locked away on a piece of paper. From a patient perspective the information has likely been provided to multiple other offices and clinical providers. Digital records are on the pathway to effective and meaningful sharing of clinical data that will remove the need to render or re capture the same information. Focusing on capturing it once and allowing the patient to review it for correctness and completeness at the time of the visit is likely to lead to a much higher quality more accurate medical record. It may seem foreign to many clinicians but the patient probably has the biggest vested interest in an accurate and complete medical record more so than anyone else involved in the clinical care process. In some cases the digital record can be shared with the patient ahead of time online in a secure environment and they can check, update and complete this before arriving for their appointment.

3) Filtering and presentation

Clinical information captured as data throughout the continuum of care can be presented in innovative and more useful ways (“Can Electronic Clinical Documentation Help Prevent Diagnostic Errors”; N Engl J Med 362;12 March 25, 2010 pdf).

Seeing a single blood pressure reading adds little to the clinical decision-making process. Seeing the blood pressure plotted over time with a clear upward trend is far more useful in identifying hypertension that requires treatment.

4) No Need to Loose the Narrative
Capturing the whole story remains an essential component of any clinical record with the history contributing anywhere up to 80% of the final diagnosis. As part of any move to the digital medical record the inclusion of this narrative and the ability to record it without interfering with the normal workflow is a must. EHR’s have a wide range of tools and techniques for capturing and recording the patient record and there is wide variation in their use. Different specialties have different needs – in ophthalmology there are many data points routinely collected and form filling on a computer or digital tablet is likely to be efficient. General medicine on the other hand is dependant on the narrative and the detail behind the symptom. In this case it is important to provide tools to capture the data efficiently without adding to the time required for documentation. Historically these notes were hand written which probably induced an element of brevity. Hand written notes were replaced by dictation and transcription which while efficient for the clinicians introduced delays in the availability of information to the referring physician and other clinicians and proved costly. Recent moves introduced templates and forms along with tools to create these notes and while they work in some cases there are disadvantages of losing the patient story, and the inability to convey the meaning (“The transition from paper to electronic inpatient physician notes”; J Am Med Infom Assoc 2010; 17:108-111 abstract). Speech remains the most common means of communication and providing tools to capture the clinical story and convert that into a digital record have been successful in many settings (Fallon clinic Study). The key to success is offering a progressive blend of tools and methods to accommodate individual preferences and situational constraints. No one method suits all circumstances and all individuals and providing choice is the key to success. Present a choice and allow regular dictation and transcription while offering a pathway to more structured data entry, either through computer based forms entry or using speech recognition dictating directly into the EMR. (Save the clinical narrative)

5) Creating Structure and Data
If the narrative forms is an essential part of any clinical record so is structured data but generating both elements remains a challenging prospect for the busy clinician. New technologies on the horizon will automatically process the narrative and extract data elements to be placed directly into fields within an EMR. Using clinical language understanding (CLU) in conjunction with speech recognition technologies allows the clinician to document a succinct evaluation and description while automatically producing a discrete and codified problem list among other key clinical values. Codification renders this data useful to the EMR making it semantically interoperable. This forms the basis of the decision support, evidence based medicine and the error catching for ePrescribing solutions that have built in databases of contra indications based on specific clinical conditions (an allergy for instance) or careful monitoring and adjustment of doses based on renal function test (Gentamicin for example needs careful monitoring of renal function to prevent hearing damage)

6) Practical Clinical Support Tools
Human memory alone cannot guarantee the right questions and clinical information is gathered and applied to arrive at the most likely differential diagnosis. The landscape of clinical knowledge is rapidly changing and becoming more complex. Doctors need approximately 2 million pieces of information to practice medicine and subscribe to an average of 7 journals representing approximately 2,500 articles per year that they must read, process and then apply in order to stay current – an all but impossible task that is only getting harder (Sackett DL: Surveys of self-reported reading times of consultants in Oxford, Birmingham, Milton-Keynes, Bristol, Leicester, and Glasgow, 1995. In Rosenberg WMC, Richardson WS, Haynes RB, Sackett DL. Evidence-Based Medicine. London: Churchill -Livingstone). Digital records are the basis for applying knowledge and providing decision support to busy clinicians. While these alerts and tools are still in their nascent form, many are far to intrusive and can be triggered too easily. Refinement of these tools will bring about better quality of care helping prevent errors and facilitating informed decision making for patients and clinicians.

7) ePrescribing – The Key to Safer More Efficient Prescribing
Electronic prescribing appears to reduce the rate of medication errors and should be an integral part of any clinical system. While the process of entering a prescription can seem arduous initially efficiency is rapidly achieved through frequent use and user customized and system stored favorites and pre populated prescriptions can ease this pain. Add to that the value of legible prescriptions that are almost instantly available to pharmacies and help the patient and the pharmacist and clinicians deliver the right drug with the right dose to the right patient at the right time. And built in to the prescribing system are contra indications, allergies and drug-drug interactions that can be caught as part of the prescribing activity, reducing medication errors and improving the quality of care.

8) Timely and Failsafe Communications
Computers are good at repetitive tasks and once programmed never forget. Tracking results, tests and clinical findings and ensuring that urgent communications reach the intended recipient every time is easier using a digital record. Much of our personal lives are now organized using mobile hand held devices that include calendars, automatic alerts and alarms, so could be our digital medical record. I receive notification from my bank when an unusual transaction exceeding a specific amount is authorized from my credit card. A digital record can identify unusual or abnormal results and highlight the information to the clinical team including communicating the information to the patient. Even with the best intentions paper based communication can and do break down. There are many examples a condition being identified correctly but a breakdown in communication to the patient or the correct caregiver may have led to an unfortunate, but potentially avoidable consequences.

9) Security
While much has been made of security issues associated with digital medical records the reality is that medical records than the old paper records. Furthermore access is easily tracked and audited. Ensuring the right level of security is essential. There has been many stories of paper records that frequently “walked” out of hospitals, clinics and into the back of cars, offices and even dumpsters.

10) Mobility and Portability
We live in a rapidly changing world and recent natural disasters have demonstrated the need for mobility and portability. Hurricane Katrina demonstrated the need to create medical records that are available in more than one location and are effectively backed up. There were few patients affected by Hurricane Katrina that were able to leave the area and attend another facilities and receive care without significant interruption. For example Veterans who fled the area almost instantly had their medical records available in other VA hospitals. While this might be an extreme example of crisis mobility and extraordinary circumstances our population and society is far more mobile than ever before. People no longer live their entire life in the same location. In addition to facilitating mobility, digital records deliver built in redundancies and create backups and copies to ensure survivability of information. But mobility is not just about the record but the ability of the clinician to access the record from any location and at any time. Seeing patients out of hours has always been difficult with the lack of available information – digital records that are accessible from any location and even on portable devices can provide instant access to key data to help clinicians manage patients efficiently. Reviewing a medical record on a mobile phone may not be ideal but having access to information even on a small screen is preferable to having no information as the basis of clinical decisions on patient care.

Digitizing medical records is not so much a destination but a journey and one that we must all take. There are challenges but the benefits are clear. The question you must ask yourself as a physician is can you afford not to go digital and more importantly can your patients.

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Average wait time in ED 4 hours

Posted in Uncategorized by drnic on August 24, 2010
Average wait time for “emergency” treatment is in excess of 4 hours. As the article puts it: Fast Treatment Rare in Emergency Departments
>>enough time to watch 4 episodes of the TV series ER!
Actually more like 6 if you removed the adverts
A sorry state of affairs that reflects the strain on the service and a high degree of inappropriate use driven by financial pressures, uncertainty and ignorance
There must be big savings to be had in focusing on this problem, creating better low cost (or free) alternatives, and including some push to stop unnecessary usage. 

Sledding injuries can be severe

Posted in Uncategorized by drnic on August 24, 2010
It is probably no great surprise that sledding injuries occur in children but the severity especially in children under 4 years of age tends to be more severe and more likely to be a head injury. The commonest injury across all groups was fractures followed by contusions and abrasions 

Sledding Injuries Common in Kids, Can Be Severe (CME/CE)

It may seem a long way off as we sit in the heat of the summer but it will be sledding season soon

Oil spill clean up workers likely to experience more healt problems

Posted in Uncategorized by drnic on August 24, 2010
Previous spill clean ups show increased health problems in the workers including respiratory problems and even some chromosomal changes
Oil Spill Clean-Up Tied to Adverse Health Effects (CME/CE)

Brain Trauma Can Mimic Lou Gehrig’s Disease

Posted in ALS, Lou Gehrig's Disease, Sports Injury by drnic on August 17, 2010
Fascinating study released suggesting that ALS (commonly known as Lou Gehrig’s disease) is mis diagnosed in many athletes suffering head trauma and concussion as well as military veterans: >>Study Says Brain Trauma Can Mimic Lou Gehrig’s Disease:
A new study suggests that concussions and head trauma can cause degenerative diseases similar to A.L.S. and that Lou Gehrig may not have had Lou Gehrig’s disease.
http://nyti.ms/c6Y9Xs
Aside from the important emphasis on the significance of brain trauma that is occurring in our athletes in particular our younger athletes there is some interesting analysis of the etiology and process that seems linked to proteins produced as a result of the trauma that persist and travel in the nervous system to cause further permanent damage. Unfortunately despite significant advances even this progress begs even more questions regarding the brains function and more importantly how to protect it and limit damage. This will be interesting research to watch and especially important for our youth sports Programs.

Would you like a statin with that Burger

Posted in DrVoice, Nutrition, Personal Health, Statin by drnic on August 16, 2010
Perhaps a better strategy might be not eating the burger and shake rather than offering packets of Statins to go with excess fat and food intake:
A Burger, Shake, and Some Statins
But practical challenges seem to prevent our ever increasingly over weight society from moderating input so this could prove to be a practical approach that works. You might even find food manufacturers and restaurant offering to add it to food for you. In some respects this is similar to the addition of the anti dote to overdose of acetaminophen (Tylenol) that is available and would prevent liver damage in the case of over dosage. But like this concept statins may suffer the same challenge – economics. While most recognize the value of extra safety of adding the antidote to Acetaminophen this version has limited sales as it costs more and cannot compete with cheaper version that don’t contain the antidote. Adding statins will likely be an economic issue not to mention the side effects that accompany statin therapy
Would you take food with statins for prevention?

FDA Warning on Fake Tourniquets

Posted in Medical Devices by drnic on August 16, 2010

In what is likely to be a troubling problem that will likely occur with increasing frequency the FDA has warned that there are a number of counterfeit copies of military-grade tourniquets which may either break or fail to function as well as the original. FDA Warns Consumers of Fake Tourniquets

These are devices to designed to restrict the blood flow on limbs in urgent and elective situations.

Fakes of the emergency medical device have a weak plastic tension rod that may bend or break before adequate therapy is applied, FDA tests of the counterfeit found. The lack of pressure may not sufficiently stop blood flow and may cause excessive blood loss in patients.

Hard to identify fakes although sourcing from approved suppliers and looking for “National Supply Number on the product’s C-A-T logo its side, NSN6515-01-521-7676” might help. I suspect this will be a recurring problem with many other devices and products. The challenge with these fakes is that unlike fake rolex these fakes coudl cause significant harm, even death.

Nuance Medical Search Application Now Available

Posted in DrVoice, iPhone, Mobile by drnic on August 12, 2010

Nuance released their latest offering for the iPhone today (as previewed at HIMSS 2010)- it was reviewed in several journals including

AppAdvice: Dragon Search Goes Medical with a favorable review

Once again, Nuance Communications has another excellent app on their hands, although this one is much more narrowly tailored. But if you’re working in the medicinal field and want something to aid you on-the-fly with great speech recognition, then this is definitely a great choice. It’s simply a great pocket companion for you while on the job in case you need to reference something or get a refresher on a condition

You can download the App in iTunes here its free and in the same genre as some other medical search applications that include:
PubSearchPlus from deathraypizza! that provides an iPhone search front end to PubMed
Medical Search from Intelligentmobiles – designed to help find medical practitioners nearby
and some medical code search apps

The principle and idea is simple – tap to dictate the search term and automatically submit this to several popular medical sources:

Each of these search tabs appears in a slider across the top and offers a quick look at the search results for each of the medical sources. So for example – searching for “Pheochromocytoma” and results are displayed for each of the tabs:
Nuance Medical Search 001.jpgIMONuance Medical Search 002.jpg

Medline: Nuance Medical Search 003.jpg
MedscapeNuance Medical Search 004.jpg

As with many iPhone apps the individual links can be viewed directly on the screen and opened in the iPhone Safari browser. You can read more on the Nuance web site here and watch a video demo here.

Go ahead – give it a try and download it from the iTunes store now and let me know what you think

A Day in the Life

Posted in DrVoice by drnic on August 10, 2010

Guest posting on Healthcare IT Central today that featured a Day in the Life of a CMIO (thanks to Gwen Darling for posting). As I state in the piece

What follows is modeled on the Hollywood principle to make a series interesting – compress activity that might span days, weeks and even months into a single day and one episode

It’s many different activities compressed into a single day – hopefully makes for more interesting reading and more useful to anyone thinking about a career as a CMIO, certainly on the vendor side.

Insight into Aspergers

Posted in Healthcare Information by drnic on August 9, 2010

Joshua has Asperger’s and in an interesting twist to the StoryCorp project he interviewed his mom in I this touching piece.

Joshua Littman, a 12-year-old boy with Asperger’s syndrome, interviews his mother, Sarah. Joshua’s unique questions and Sarah’s loving, unguarded answers reveal a beautiful relationship that reminds us of the best—and the most challenging—parts of being a parent. Read more here

Q&A from StoryCorps on Vimeo.

A reminder to all of us – some of the choice quotes/questions from straight talking Joshua:

  • I feel like everyone seems to like Amy more… she’s the perfect little child
  • I have better quality friends but less quantity
  • Did I turn out to be the son you wanted me to b when I was born – did I meet your expectations
  • I was the one who made you a parent
  • Ever thought you couldn’t cope with having a child

I am humbled by both mother and son.

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