Navigating Healthcare – Patient Safety and Personal Healthcare Management

Physicians Regret not learning Business Skills in Medical School

Posted in Uncategorized by drnic on August 18, 2011
Once exposed to the realities of practical and sustainable healthcare delivery physicians are quick to regret not learning more about the business side of medicine at medical school. In a posting on Kevin.MD “How can doctors understand the business side of medicine?” Michelle Mudge-Riley echos a frequent sentiment amongst her colleagues

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

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

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


 but was not responsible for the charges”.

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

I applaud the proposed additions to the medical curriculum that includes the addition of four domains:
  • health care systems and principles,
  • health care quality and safety,
  • value and equity, and
  • health politics and law
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The downside is the additional information that is loaded into an already packed and expanding course. The other unfortunate consequences of these changes and the increasing variability between healthcare systems is the diminishing nature of international equity. Medicine used to be one of several professions that offered graduates opportunities to travel the world and work in other countries. This ease of international movement has already diminished as these systems, processes and curriculum have diverged making international experience harder for the newer graduates


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

Posted in Uncategorized by drnic on August 15, 2011

August 15, 2011

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

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

Follow @ifw_cringely

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

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

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

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

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

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

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

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

Googola…! Blockbuster deal and blockbuster implications as Cringe puts it “Game on”!

Speech recognition technology making its way into EHR systems

Posted in Uncategorized by drnic on August 15, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Speech recognition technology on board within EHR systems

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

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

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

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

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

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

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

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

Data mining as next wave of speech recognition technology

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

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

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

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

“We’re not close to that yet, but that would be great,” he said.

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

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

Studies show we get things Wrong

Posted in Uncategorized by drnic on August 15, 2011
Hormone Replacement Therapy (HRT), Helicobacter Pylori are just a couple of the well known instances where apparent intransigence of the medical community prevented advancement in medical treatments. Turns out we get things wrong on both sides of the coin. Ben Goldacre highlighted some research in the New England Journal of Medicine in his piece Studies of studies show that we get things wrong and in the study 

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

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

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

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

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

Debunking magnetic field exposure and asthma

Posted in Uncategorized by drnic on August 8, 2011
Study from Kaiser in the US showed an increase in asthma in children with mothers exposed on one occasion to an increased magnetic field

Critics Slam Asthma Risk, Magnetic Fields Link

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

Carry on, situation normal

From Jeopardy! to Medical Diagnosis

Posted in Uncategorized by drnic on August 8, 2011

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