Navigating Healthcare – Patient Safety and Personal Healthcare Management

How EMRs can detract from a clear narrative, and facilitate spoliation and obfuscation of evidence; UPMC and the Sweet death that wasn’t very sweet

Posted in Uncategorized by drnic on October 26, 2011

In a detailed and extensive post on the hcrenewal blog that covers the pending case from Pittsburgh and the challenges relative to complexity of EMR systems, understanding the data including all the meta data that is gathered within these systems but not always available for review by clinicians.

The post is illuminating on so many levels delving into the case providing links to the court papers and documents and offering analysis of the sequence of events both prior to the tragic loss of Mr Samuel Sweet’s life as well as the subsequent review and legal case.

Others can make their own minds up on the case – what is interesting is the detailed analysis and reference to actual data and documents for the EMR. It offers some window into the difficulties we face in practicing medicine in an increasingly complex arena and our increasing reliance and need to apply technology support the healthcare team deliver safe, appropriate and cost effective care to every patient, every time.


Apple Siri Advert – Speech Recognition in Action

Posted in Uncategorized by drnic on October 25, 2011

The Siri application in the latest Apple Advert showing off the power of your voice


Bad Science, Politics and the Need for Clinical Data

Posted in Uncategorized by drnic on October 24, 2011

Ben Goldacre, Saturday 31 October 2009, The Guardian.

Every now and then it’s fun to dip into the world of politics and find out what our lords and masters are saying about science. First we find Brooks Newmark, Conservative MP for Braintree, introducing a bill to reduce the age for cervical cancer screening to 20. The Sun has been running a campaign to lower the screening age, on the back of Jade Goody’s death at 28 from cervical cancer, and gathered 108,000 signatures on a petition. The Metro newspaper have commissioned a poll showing that 82% of 16 to 24-year olds in England agree with lowering the screening age.

“Cervical cancer may be rare in women under 25,” says Mr Newmark: “but it is inexcusable to dismiss the cases that occur as negligible statistics.” Oh, statistics. “We have a vaccination programme that ends at the age of 18 and a screening programme that begins at the age of 25. That leaves young women between the ages of 18 and 25 caught in a medical limbo, eligible for neither vaccination nor screening.”

Somebody should do something: an intuition which you will find at the bottom of many calls to extend screening programmes beyond the population in which they can provide useful information, and into low risk populations where they simply waste resources, or do more harm than good.

If screening worked, you would expect to see a reduced incidence of cervical cancer diagnoses in people who have been screened, compared with people who have not been screened, in the 5 years after screening: because precancerous lesions will have been detected and dealt with before they got to a more advanced stage.

In August 2009 the British Medical Journal published a large study examining this very question. It found that screening was associated with an 80% reduction at age 64, 60% at age 40, and so on. But cervical screening in women aged 20-24 has little or no impact on rates of invasive cervical cancer in the following 5 years. Only the Liberal Democrat MP Evan Harris introduced these findings to the debate (with the rather excellent line: “The honourable Member for Braintree cited evidence from The Sun, so I want to refer to a recent edition of the British Medical Journal”).

Meanwhile on the very same day David Tredinnick, Conservative MP for Bosworth, stood up to speak on medicine. Scientists and doctors who doubt the efficacy of alternative therapies are superstitious, ignorant, and racially prejudiced, he explained. “It is no good people saying that just because we cannot prove something, it does not work… I believe that the Department needs to be very open to the idea of energy transfers and the people who work in that sphere.”

He went on. “In 2001 I raised in the House the influence of the moon, on the basis of the evidence then that at certain phases of the moon there are more accidents. Surgeons will not operate because blood clotting is not effective and the police have to put more people on the street.”

Where does this moon stuff come from? “I am talking about a long-standing discipline—an art and a science—that has been with us since ancient Egyptian, Roman, Babylonian and Assyrian times. It is part of the Chinese, Muslim and Hindu cultures… Criticism is deeply offensive to those cultures,” says Tredinnnick: “and I have a Muslim college in my constituency.”

Any attempts to challenge Tredinnick’s ideas are based, he explains, on “superstition, ignorance and prejudice” by scientists who are “deeply prejudiced, and racially prejudiced too, which is troubling.” So I hardly dare to mention that Tredinnick tried and failed to claim £125 in parliamentary expenses for attending an intimate relationships course teaching how to “honour the female and also the male essence and the importance of celebrating each”, run by a homeopath.

Meanwhile the flag-bearers for conservatism at the Spectator are now promoting climate change denialism, as George Monbiot has pointed out, and Aids denialism, under the tedious flag of “only starting a debate”, even in their print edition. And finally, the NextLeft blog recently pointed out that of all the top ten conservative blogs, every single one is sceptical about man-made climate change. It could be an interesting five years ahead.

Ben Goldacre from the Guardian does a great job of exposing the world of politics and politicians as they step into the world of science.
As always Ben does a great job of exposing the lack of science and data as some politicians jump onto a personal hobby horse.

As he points out in the attempt to introduce Cervical Cancer Screening he suggests that despite “Cervical Cancer being rare in women under 25” and suggesting we “do something”.

The BMJ published a study in 2009 that did! And it demonstrated the value of screening in different age groups with “little or no impact” in the 20 – 24 age group.

Progress depends on data and introduction of new treatments, diagnosis and thinking should be based on scientific analysis of data and not on hunches.

The foundation of this is generating clinical data that can be analyzed and while our medical records are chocked full of data that remains locked in narrative blocks that are inaccessible to computer analysis without the extraction or abstraction of that information typically through manual steps

In a recent presentation at the Partners for Connected Health Symposium in Boston Last week Janet Dillione the Executive Vice President and General Manager, Healthcare Division, Nuance presented

The Voice of Healthcare, The Value of Understanding (Imperial)
– Janet Dillione, Executive Vice President and General Manager for Healthcare, Nuance Communications, Presented “The Voice of Healthcare, The Value of Understanding” that highlighted the potential for bridging this gap with technology that takes the narrative and turns it into clinically actionable data using advanced NLP technology; Clinical Language Understanding. This is the first step on what will be a critical pathway to the future of medicine based on data and science.

Impossible to Keep up with the news

Posted in Uncategorized by drnic on October 20, 2011
My news reader(Netnewswire) reports 27,773 unread feeds…



Complexity and frequency of clinical conditions #fuquahealth

Posted in Uncategorized by drnic on October 12, 2011

Hospitals make almost no headway in cutting readmissions

Posted in Uncategorized by drnic on October 11, 2011

Minimal progress in what is a challenging problem for healthcare facilities in preventing readmission of patients. Surgical patients fared the best with a 12.7% readmission rate which was unchanged but in the top 3 killer category Congestive Heart Failure remained a recalcitrant problem with 1 in 5 patients returning to hospital – up slightly from the previous years.
The good and bad news is the looming ICD10 coding requirements will increase the visibility of this failure in the care system.
Good news in the long term as to improve anything we have to be abel to measure it, the bad news that it will shine an uncomfortable spot light on failures in the coordination of care.
THe incentives are in place for facilities as the government steps up the pressure with penalties for facilities with readmissions for heart attacks, heart failure and pneumonia coming in 2012. But this is just the tip of the iceberg of incentives and penalties.
Fundamental to these changes is the need for clinical data and the ability to report on progress that can only be achieved with discreet data on all patients. Some of this will come from direct data entry but the vast majority is currently locked away in the narrative and bridging this gap without burdening the clinician with data entry tasks will be essential.

Recent advances in the ability to extract and tag discreet clinical data contained in the narrative has been shown and is emerging as key “must have” technology for providers. Increasingly this is being built on the foundation of speech recognition that has clearly reached the point of wide spread adoption and acceptance in the clinical community. Demonstration projects and solutions are already showing the ability to satisfy the data reporting requirements directly from dictated clinical reports using technology to extract the data instead of asking the clinicians to enter the data manually through forms and data entry tools.

These tools will be increasingly important as we are pushed along the path towards higher quality lower cost care which must be built on measurable clinical data for each and every patient seen and treated in the healthcare system.

Obama’s HHS shuts down public access to doctor malpractice data

Posted in Uncategorized by drnic on October 10, 2011

Patient advocacy groups are protesting the government’s shutdown of public access to data on malpractice and disciplinary actions involving thousands of doctors nationwide.

The National Practitioner Data Bank maintains confidential records that state medical boards, hospitals and insurance plans use in granting licenses or staff privileges to doctors.

Although records naming physicians aren’t available to the public, the data bank for many years provided access to its reports with the names of doctors and hospitals and other identifying information removed.

That changed Sept. 1 when the data bank removed these public-use files from its website. The action came shortly after it learned The Kansas City Star planned to use its reports.

The story, about doctors with long histories of alleged malpractice but who have not been disciplined by the Kansas or Missouri medical boards, was published on Sept. 4.

The Star linked anonymous data bank reports to a Johnson County neurosurgeon by matching its information to the contents of court records of malpractice cases. Journalists often use this technique to glean additional information about doctors from the data.

“We’ve seen (The Star’s) reporting and others that show your ability to triangulate on data bank data. We have a responsibility to make sure under federal law that it remains confidential,” said Martin Kramer, spokesman for the Health and Human Services Department’s Health Resources and Services Administration, the agency that oversees the data bank.

Kramer said his agency may make the public-use files available again after a “thorough analysis of the data field.” But that process probably will take at least six months and the files may not return in the same format as they had been.

Previously, the files could be downloaded from the data bank website as massive spreadsheets. Names of doctors were replaced by arbitrarily assigned practitioner numbers.

The ages of doctors and patients, as well as the dollar sums of malpractice payments, were presented as ranges, such as a doctor age 40 to 49, rather than as specific numbers.

The bank is not mandated to make public files immediately accessible on its website, but is required to respond to information requests.

“Whatever they do will probably make it more difficult to use the files in meaningful ways,” said Alan Levine, a health care researcher with Public Citizen’s Health Research Group, which advocates for patient safety

On Tuesday, Public Citizen sent a letter to the Health Resources and Services Administration objecting to the removal of the public-use files.

“The continued availability of this data is crucial to patient safety and research aimed at informed public policy decisions concerning malpractice, tort reform, peer review, and medical licensing. There simply is no substitute for the NPDB Public Use Data File if this vital research is to be continued,” the letter said.

The Association of Health Care Journalists also opposes removal of the files.

“We’re really disturbed by this,” said Charles Ornstein, president of the medical writer group. “We’ve seen our members do terrific work (with the files) that protects the public.”

Ornstein pointed to stories by the Hartford Courant in Connecticut and the Raleigh News & Observer in North Carolina citing the data bank’s public use files as a source on doctors whom they named.

“If it were not for this information used by reporters, their stories would not have been as strong,” he said.

“Why are they picking on this (Star) article?” asked Lisa McGiffert, director of Consumers Union’s Safe Patient Project. Consumers Union, which wants greater public disclosure by the data bank, will be asking the agency to put its files back online, she said.

“This administration (of President Barack Obama) has been touting their position for open government,” she said. “I see this action as totally counter to that.”

Kramer said the data bank was alerted to The Star’s reporting by Robert Tenny, a physician the newspaper was reporting upon. In order to provide Tenny with an opportunity to respond, The Star notified Tenny’s lawyer on Aug. 16 of specific information it intended to publish, including several matters contained in the data bank.

In a letter Aug. 26, the bank’s director Cynthia Grubbs advised The Star that violations of data bank confidentiality provisions are subject to a civil monetary penalties. (Read the letter here.) The Star, however, used only publicly available information from the Data Bank.

“A federal agency should not be intimidating reporters for using information that they put on their own website,” Ornstein said.

But Kramer said his agency must investigate any potential breaches of confidentiality.

“Once we became aware that this information may be made public, we had a responsibility to make sure that it remains confidential,” he said.

In an interesting development on open data access HHS removed public access to malpractice data that had previously been published online in anonymous form.
The Kansas City Star newspaper took the publicly available information and using well known and commonly used data matching techniques to link the data to individuals an in particular outing doctors with longstanding histories of alleged malpractice. This was followed by some strong arm tactics threatening the newspaper with legal action.

As the commentators note this is not welcome development and runs counter to the spirit of open government. It does not bode well for the proposed public rating system of healthcare facilities and clinical practice for patients.

Apple’s Siri voice recognition: sounds like Tomorrow’s World today

Posted in Uncategorized by drnic on October 10, 2011

If you grew up in England and were technically inclined you will remember “Tomorrow’s World” – it played live right before “Top of the Pops”
As the Guardian Article points out there was often mention of computers powered by voice…now with Apple’s Siri that distant future looks closer than ever.
In fact the “KNowledge Navigator” video is pretty much implemented in Siri (albeit it took from 1987 to 2011 to get into general availability)
Tight now that future is looking even more exciting and more accessible.

Hospital staff offered unpaid leave as trust announced ‘extraordinary financal measures’ (From This Is Local London)

Posted in Uncategorized by drnic on October 10, 2011

NHS hospital asking employees to work for free in “extraordinary measures”
This seems wrong on so many levels and will undoubtedly affect some more than others.

What Steve Jobs Means to Silicon Valley

Posted in Uncategorized by drnic on October 6, 2011

Awesome review of Steve Jobs with history and the his pathway through life. Interesting to note that he asked for some spare parts for a school project from William Hewlett (of HP fame) and received the parts and a summer job. Imagine how motivating that was. We need more of that today.