Navigating Healthcare – Patient Safety and Personal Healthcare Management

Healthcare in the Year 2030

The Year 2030

by Dr Nick van Terheyden (@DrNic1)

How will the world of medicine change in the next 15 years? Well 15 years ago AOL had just bought Time Warner, the human genome had just been deciphered and published and the first inhabitants of the International Space Station had arrived.

The Year 2030 – my bed has been tracking my vital signs throughout the night and notices I was restless and managed fewer REM cycles during sleep than usual. Prometheus (my personalized artificial automated agent) checks my calendar and traffic and elects to wake me an hour later. Appointments for the morning are rescheduled and my drone pick up is postponed. Prometheus sends an update to “Hestia” (my kitchen AI) with instructions to increase the energy component of my meals for the day to adapt for the lack of sleep and deliver a boost of energy with almond snacks through the day. Prometheus sends my updated sleep and vitals data to my personal health record. While I rest peacefully the rest of the household is awakened and sets about their day.

 

Time to Get Up

When it’s time to awaken, the bed starts warming to ease the process, the lights slowly turn on and the GPR (Galactic Public Radio) custom news cycle is playing gently in the background. My calendar has been reorganized, and there’s an additional appointment with Asclepius (My health AI) before I leave in the morning. My food is ready and waiting and contains a boost in energy, helping me wake up and acclimate after the poor night’s sleep. I hear the inbound calling for Asclepius and take the call. We review the reasons for my poor night’s sleep and agree I should track this more closely for the next few days to ward off any potential problems. In this instance Asclepius suggests no further investigation is warranted, but if I am worried a drone will be dispatched with some auto investigator tools to apply and track additional parameters if necessary.

Personal Drone
Personal Drone

As we finish my personal drone arrives and I step outside, catching my foot on a fallen replicator brick discarded by one of the children. As I fall my head strikes the corner of a table and carves into my cheek. Prometheus is immediately on top of the situation checking on my vitals, and while no major damage to my body, the cut will need review and probably some stitches. Checking with local urgent care facilities, the optimal treatment for me today is a quick trip to the urgent care clinic and my drone is reprogrammed to take me there immediately.

Urgent Care in the Future

As I arrive my MedicAlert Digital Bracelet transmits my allergy to lignocaine and identifies me based on the bracelet

and my retinal scan taken as I walk through the door, which authenticates my presence and consent initiates transfer of my medical data and records to the clinic.

Robot Nurse
Robot Nurse

 

 

I’m guided to a room where a robot nurse cleans my wound and positions me on the bed and brings in the Panacea (the medical repair robot). My medical record shows I have had a recent Tetanus shot, and a comparison of my previous vitals shows there are no serious changes that would warrant additional investigation. Repair completed, my records are updated with the new details and a drone appears to take me to work.

 

 

 

Medical Offices and Care in the Future

As I step into my office my team are all walking in (virtually) and the central console and screens around the room light up with data on our first patient. We process through the details provided by the various Artificial Intelligence agents and data gathering tools. “Jane” (name changed to preserve her privacy) has been having some frequent dizzy spells and falls – her mother had Meniere’s disease and a degenerative disease linked to the A2ML1-AS1 / ADAM20P1 / MTor Complex 2 / WDFY3-AS2 – we think there may be a link. Even though Jane does not have these gene expressions there may be a new epigenetic influencer she received that is affecting her stable sequence. We need to get to the bottom of this. Jane is here too (virtually) – with her mother and father – and they are looking at the same data, shown with basic annotations to help them understand the details.

South Korean Researchers unveil first CRISPR nanobot editor
South Korean Researchers unveil first CRISPR nanobot editor

We think we have an answer, but want to share the details and show Jane and her family the model of the CRISPR editor nanobot and its effects before we decide on the next course of action. Do we create a more realistic model of her body functions with the cell printer and test on that? Or is the confidence in our simulation high enough to warrant immediate therapy? Whatever we decide we will get real time approval from the GMAA (Galactic Medical Agent Agency that replaced the FDA in 2021). Jane and her family have seen a new therapy advertised and they want to understand how that might work for them. We pull up the details and all the data on patients and do an immediate comparison. The data’s questionable but, more importantly, it’s contraindicated in anyone with GRAMS domain, Heat Shock 70kDa protein expression and several others that disqualify Jane.

We elect a wait and see approach – so much easier these days with the real time monitoring and detailed data we have on patients that allows us the scope to wait and watch while reassuring patients. Directives are sent to their family “agents” and a drone dispatched to their location with some additional monitors for Jane to wear to give more detailed data on her for the next few days.

Amazon Prime Air Drone Delivery
Amazon Prime Air Drone Delivery

 

As we complete the consultation a drone arrives with my almond snacks and some water – perfect timing.

 

 

 

 

 

 

This post appeared in abbreviated form on SHIFT communication site – and is included in their downloadable ebook

 

Healthcare in the Year 2030 was originally published on DrNic1

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Population Health is a Team Sport

Designing an Effective Population Health Program

Population health is the topic du jour for the health care industry, and I’m glad to see us all focusing on this important issue. But there is a lot of confusion as to what, exactly, constitutes population health. Or more correctly, an effective population health system.

A good population health program consists of four major components:

  1. Identification and stratification of risk within a discrete population
  2. Dissemination of information to physicians, care coordinators or others designated to contact patients and arrange follow up.
  3. Appropriate follow up to further understand the risks for individual patients, identify gaps in care and design a care plan to help the patient improve his/her health status.
  4. Ongoing care individualized to each patient’s need. That might be coaching, medication reminders, telehealth visits, remote monitoring or other strategies customized to each person’s condition and socio-economic environment.

The key to making a population health program effective is ensuring that all four components are in place and working well. If there is a break anywhere in the chain, you lose the opportunity to improve patients’ health. The best analytics in the world are useless if the results do not quickly and easily pass into the hands of the people who can take action. And very good follow up and care planning can be ineffective if the ongoing support is lacking.

Friction

One of the biggest barriers to effective population health improvement is friction in the flow of information between health plans, hospitals/health systems and physicians. This has been a constant source of difficulty for the entire healthcare ecosystem for years, but with the new focus on population health and improving outcomes, it has reached a new level of urgency.

African heart disease is much lower
African heart disease is much lower

In traditional African societies coronary artery disease is virtually nonexistent, but in the migrant population to Western societies the rates are similar to those of the local population indicating that the primary determinants of these diseases are lifestyle and diet and not genetic. These indicators are a key asset in changing our healthcare system and addressing the current 75% of our healthcare spending that is focused on patients with chronic conditions which have their roots in lifestyle choices and behaviors. To address these challenges we need a way to better target our limited healthcare resources more cost effectively for maximum effect and identification and targeting with a robust population health system is no longer a nice to have – it’s a must.

To help patients improve their health, not just react to a situation that has already developed, requires information and insights. But in a survey of primary care physicians by The Commonwealth Fund, only 31% of U.S. physicians said they are notified when a patient is discharged from the hospital or seen in an emergency department. This is important information for primary care physicians, and is not that difficult to fix. All you need is standard protocol in place and a mechanism for notification. It could be a standard action that happens at every discharge. It could even be automated. If the retail industry can automatically send an email to confirm an order, hospitals and health systems should be able to send an automatic email to a physician with discharge information. But hospitals and health system executives haven’t made it a priority, so it doesn’t get fixed.

Get to know your team mates

This is just one example of the inward-looking approach that still permeates much of healthcare. Hospitals, nursing homes, skilled nursing facilities and other care providers pay attention to what happens within their organizations, but they neglect to look beyond. Organizations act as though the care they give is the only care patients receive. They forget that there are a multitude of other professionals who are also responsible for care and need to know what’s going on. We don’t just have data silos in healthcare, we have attitudinal silos that make data transfer and exchange an afterthought at best.

It’s like each care provider is a golfer alone on the course and the patient is the ball. As long as that lone golfer moves the ball forward, it’s all good.

The reality is that healthcare is a team sport, more like football (or soccer as it is called in the US) than golf. If you can’t make an accurate, effective pass to your team mates, you lose the ball.

Population Health a Team Sport
Team Sport

But patients aren’t balls, they’re human beings. When one member of the healthcare team fails to inform the rest of the team, a human being gets lost in the confusion with poor outcomes and frustrated patients.

In population health improvement, you have to play on a team, because it takes a wide variety of skills to make this all happen. And you have to be aware of all the other players on the team. The successful population programs include everyone who is part of the community – not just the healthcare system and resources but all aspects of the community. Dell Medical School held an inaugural event to crowd-source their population health strategy, coming up with areas of focus and metrics for success that included input from a wide range of stake holders. This is the kind of team based approach to population health that will help the whole community win – getting people healthy and staying healthy.

 

It starts with leadership

Most healthcare organizations are at least partly aware of the problem and are making efforts to solve it. But it is a complex problem, involving, as I noted above, attitudes as well as technology. To make data flow freely to those who need it, you have to have effective technology to integrate, manage and analyze the multitude of data streams in healthcare, and you also need leadership who prioritize data sharing over the competitive interests of conflicting health delivery systems. With free flowing information routed to all the interested parties including the oft forgotten but all important patient, in understandable and actionable form that includes the insights and management options we can successfully identify those at risk and develop appropriate interventions. By including the patient and personal care team that typically includes multiple family members we capitalize on underutilized resources that are both essential and highly effective at improving the trajectory for the patient’s outcome.

 

Custom Communication and Targeting

Traditional systems and methods have targeted the existing clinical systems and communications which, while suited to some, fail to adapt to the changing world of technology and the fact that people no longer go online – they live online. This doesn’t just apply to patients and their families; it’s increasingly true for clinicians. It can be as simple as a text based reminder for medication, timed to coincide with the patients personal schedule and preferences or as complex as an automated avatar with augmented intelligence that engages with the patient to assess their status and determine the need for additional intervention or personal follow up by the care team.

 

Each year HealthIT week raises awareness of technology in healthcare, bringing together innovators and key healthcare leaders who are diligently working together to make the best use of information technology to improve the healthcare systems and ultimately our each and everyone’s individual health. This past year we lost one of the titans whose personal journey of uncoordinated care she shared in her attempt to correct the system – Jess Jacobs (#UnicornJess). It might be too late for Jess but let this be the year we move past the individual approach in healthcare driven by underlying economics and focus on the team sport of population health and democratize access to the best possible care and outcomes to the widest swathe of people…worldwide.

 

This post originally appeared here

Population Health is a Team Sport was originally published on DrNic1

The Patient Electronic Show – CES

https://digitalhealthsummit.com
CES Digital Health Summit

Once again I am headed to CES this year. Last year the DigitalHealth pavilion was overflowing with people, innovation, and wearables designed to influence us to a healthier life.

The show still features the big sections of technology for cars, televisions and 3-D printers but much of the show is being turned over to healthcare and the Digital Health pavilion. Like my friend and colleague Jane Sarasohn-Kahn I see the big move towards high-deductible consumer driven health plans (HDHP) beinge a key part of the major uptake in digital health devices and wearables. We already got a sneak peek into this post the holiday period with FitBit rising to the top of the Apple App store charts and coming in in the top 3 of Amazon’s list of holiday gifts.

So this years hot trends

Wearables and the Internet of Medical Things

With personal financial responsibility comes a much bigger focus on the costs of healthcare services and how to avoid them. To avoid expensive costs later in life requires focus on behavior now on as captured in this excellent graphic from Bridgitte Piniewski, MD:

Lifestyle is the biggest factor in improving health
Lifestyle is the biggest factor in improving health

Expect CES 2016 to feature much more Digital Health and especially focused on the Internet of (Medical) Things – the key to engagement is making the workflow frictionless. Its no use creating yet another app or solution that requires consumers to download, install, learn or use yet another option. The success in this space will be around integrated solutions.

Wearables will expand and include even more data and the recent announcement of Samsung of the expanded capability in their new health-focused chip

that will add body fat, skeletal muscle mass, heart rate and rhythm, skin temperature, and stress level to the biometric tracking capabilities.

Expect many more additional features to the wearables mobile platform with add on modules, some already on show like the Philips Ultrasound, others work in progress

3-D Printing

Reaching new levels of innovation. Simple ideas like creating 3-D models base don actual patient anatomy prior to taking on complex surgery, printing prosthetics that are customized to the individual but now increasingly merged with wearables and printing biosensing strips that can be used for in home diagnostic testing. Researchers at Florida Atlantic University printed strip with bio material including antibodies and nanoparticles that can detect bacteria and viruses

 

Thin, lightweight and flexible materials developed by researchers at Florida Atlantic University, Stanford University and Harvard University, integrate cellulose paper and flexible polyester films as new diagnostic tools to detect bioagents in whole blood, serum and peritoneal fluid. Credit: Florida Atlantic University

Artificial Intelligence

Take a look at Lunit that helps physicians make accurate diagnosis with machine learning that offers object detection (application of existing technology to the healthcare domain)

http://lunit.io/static/img/illust_proj1.png

There are others including IBM’s Watson for Healthcare and in our Dell’s portfolio announced at RSNA ZebraMed

 

Repurposing Existing Technology

In my review from CES 2015 there were plenty of drones (with some medical applications) and technology to aid flying and use. Many were showing image stabilization as captured in my video here:

and I captured this on a custom video gimball
https://vine.co/v/ehj1nZH175x/embed/simplehttps://platform.vine.co/static/scripts/embed.js

We have so much opportunity to innovate in healthcare by repurposing existing technology for DigitalHealth. This image stabilization technology has been applied to the task of eating which for most of us is easy but for some eating is a challenge of hand stabilization due to tremors:

You can buy these from Giftware (which was acquired by Google).

Parkinson is one of the leading causes of these tremors (about 1 Million americans are living with Parkinson’s and an estimated 7-10 Million worldwide). Its a simple idea (not to diminish the brilliant application and innovation by the founders) and a testament to the bright minds that fill our world and will continue to find solutions to problems we face in healthcare.

Join me at CES16

We’ve come a long way from CES in 1967

So I invite you to follow along for #CES16 my twitter handle (@DrNic1), my Instagram (DrNic1) account for pictures and Vine (DrNick) for insights, posts, pictures and short video segments of innovation throughout the course of the show

 

If you are here come join me and my fellow panel participants:
Shai Gozani, M.D., Ph.D., CEO and President, NeuroMetrix, Inc.
Beth Bierman, Partner, Morgan Lewis & Bockius
Bakul Patel, Associate Director for Digital Health, FDA, Center for Devices

Roadmap to FDA Approval: What You Need to Know
3:30-4:30 PM Tuesday, January 5
Las Vegas Convention Center, North Hall, N259

The discussion will be moderated by Alfred Poor, Editor, Health Tech Insider

and on Thursday the DigitalHealth Summit that will be in the Venetian, Level 4, Lando 4304

 

The Patient Electronic Show – CES was originally published on DrNic1

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Calling Doctor Data

With a nod to Star Trek, Bones, Data and even the Holo Doctor

Much of medical practice is as much a mystery to doctors as it is to patients.

Human physiology is so complex, and the external variables so numerous, that we often have no sure knowledge of why one patient did well or another patient didn’t. Every physician longs for some way to really know what will work for each patient.

While we have come a long way, even in just the past five years, there is still so much left to be learned. The one thing that can help us reach greater knowledge faster is data and analytics.
That’s really the underlying value of electronic medical records: they represent a treasure trove of data waiting to be mined. With the right algorithms, we can use that data to find patterns that tell us what factors make a tangible difference in outcomes. It’s the wisdom of the ages waiting to be read.

Perhaps the most valuable medical team member of the future will be a data scientist. These are the experts who understand how to tag and mine data and how to construct algorithms that find patterns accurately and can help us be more effective in delivering the best possible care every time.

For example, there is a great study from the University of Iowa Medical Center, in which gastroenterology surgeons are using real-time patient data in the operating room, combined with past data from gastric surgery patients, to predict who is at risk for developing a surgical site infection. This helps guide decisions in the OR as well as post-surgical care. While doctors know that a variety of modalities can reduce infection risk and promote healing, resources are not endless. By identifying patients who need high-level care, they can ensure that resources are targeted where they are needed most. The project has reduced surgical site infections by more than 50 percent in the gastroenterology patients whose care was guided by the analytics.

So Dr. Data (as New York Times writer Steve Lohr calls one data scientist) is saving lives, even without a medical degree.

 

How do we know the predictions are accurate?

But here’s the catch: we’ve got to get the algorithms right. If we aren’t careful, we can draw conclusions that aren’t really there. To make giant leaps forward in understanding, we need a colleague on the case who really understands how to create algorithms that have practical value and accurate results.

Tom Hill, a colleague of mine at Dell, recently wrote a blog in which he noted the necessity of using a systematic, transparent approach to predictive analytics. “Harvesting big data carries with it the responsibility to do-the-right-thing with those data. Big or any data and predictive models in healthcare must be correct, access and tamper-proof (secure), must not discriminate, generally do-good, and not-do-any-harm.”

He goes on to talk about the need for transparency in analytics, so that those using the results understand what data is being used and how it is being analyzed. As changes or improvements are made, they must be documented, so that the transparency lives on.

I think this is a critical point for physicians who will be using the algorithms in the future. If our patients’ lives will depend on the quality of the analytics used to guide treatment decisions, we need to know that the algorithms are correct. We don’t want a black box that dispenses treatment prescriptions; instead, we want to know how the results are created, so that we can trust the advice offered and help guide future improvements.

Adopting analytics in ways that don’t risk lives

Dr. Hill’s point about “not doing harm” is well taken. As healthcare organizations add analytics to patient care, projects like the one at the University of Iowa is a good place to start. It takes a body of existing knowledge about a large population of gastroenterology surgical patients and analyzes what factors were associated with certain outcomes. It then takes that analysis and compares it to a specific patient, providing insight into how that patient may do in post-surgical care.


The likelihood of a result that harms a patient is small. At worst, a patient might receive more care than is really necessary, or might not be recommended for care that would help. But that happens all the time without any analytics intervention, so the risk to patients is not increased by using the insights from the analytics. And the care team can monitor to see that, if the patient needs more extensive post-surgical care, that care can be ordered.
Other initial analytics projects in healthcare are looking at ways to predict surges in demand for care, based on environmental factors, and those projects also aren’t likely to put patients in harm’s way.

These kinds of project allow an organization to use analytics for practical improvements, while also learning how to use these new insights. As the organization’s expertise grows, the complexity of the analytics projects will likely grow, too. But starting with a project of limited scope and low risk for patient harm is a smart idea.
It’s also a way to help build trust. Physicians may be somewhat leery of trusting an analytics program to help them make treatment decisions, especially if a recommendation flies in the face of what that doctor’s always done in the past. So institutions must be careful to build trust in analytics as they move forward. As physicians see the effectiveness of using these tools, they’ll be more willing to engage in analytics themselves. So how, when and why you use analytics really matters. And making sure that you’re working with a really good Dr. Data is important, because at least for the foreseeable future, medical practitioners will be working very closely with Dr. Data to make analytics a powerful force for good.

 

This piece originally appeared in Beckers Hospital Review: Calling Dr. Data: A new consultant is set to make medical care more effective

Calling Doctor Data was originally published on DrNic1

Speech and Medical Intelligence – Allowing Doctors to Focus on Patients Not Technology

I spent some time at Medicine 2.0 and participated on the panel Bridging the Digital Divide and will presented: Speech and Medical Intelligence – Allowing Doctors to Focus on Patients Not Technology

This is an exciting time for mobile devices and while we know there is a discrepancy in the accessibility of mobile technology (I’ll be participating on the panel Bridging the Patient Digital Divide) some of this divide in access can be linked to the complexity of this technology. With ubiquitous technology comes ubiquitous complexity – adn this is especially true for doctors who face challenging User Interfaces – captured here in this post: How Bad UX Killed Jenny. As doctors we feel we are loosing touch with the Art of Medicine

Which for many of us was the reason we started on the journey to being a healer. Physicians don’t go to medical school because they want to document and code clinical information. Doctors choose their path because of their compassion and desire to deliver care to patients in need. There are increasing physician frustrations with technology and their struggle to keep the focus on patients and not data entry.

Medicine is part science, part art. The relationship between physicians and patients is at the core of healing. This begins with hearing and understanding but is followed by focusing on the patient not the technology. I will be presenting our prototype “Florence” that combines artificial intelligence and speech recognition to offer innovative new speech technologies that help capture and understand not just what the clinician says but what they mean. With new tools that speech enabled systems we simplify access and empower clinicians to capture information and thoughts as they occur. Through the innovative use of natural language tools, context awareness and the generation of high-value clinically actionable medical information clinical systems become efficiently integrated into care delivery process offering the opportunity for doctors to return to the Art of Medicine and focus on the patient.

Here’s a video showing off Florence

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Virtual Assistants in your Future – Personal Healthcare Delivered

You can always rely on Hollywood to take concepts and extend them into the future – sometimes correctly (cloaking, holographic TV, forcefields and eco skeletons with mind control), sometimes incorrectly (aluminum dresses, atmosphere that is completely controlled, suspension bridge apartment housing). We have had speech recognition and Spock’s request:

So it was no surprise to find the latest Hollywood idea is the “Her” – a lonely writer develops a relationship with a newly developed operation system

Intriguing and challenging our current concepts with an exploration of artificial intelligence, voice and natural language technologies. These new styled avatars understand, listen and decipher what we say and something that Nuance has been developing and reinventing the relationship that people and technology can have. We can engage with our devices on our own terms and we have show these concepts in healthcare with our very own Florence – who is getting ready to launch in 2014

Ambitious you say – maybe but imagine the environment with intelligent personal assistants that hear you, understand you, know your likes and preferences – and in our world exist across your doctors office, the phone, surgery, hospital and elderly care and hospice. Cool? Liberating? Impossible?

If you’re Nuance, the idea is not only brilliant – it’s our focus and drive as we reinvent the relationship between people and technology. It is the chance to connect with your devices on human terms and presents infinite possibilities for intuitive interfaces that adapt to you.

Liberating our clinicians to focus on the patient and providing patients with someone they can talk to, interact with and who does have time for them. That future – coming to a doctors office near you:

Florence – the Intelligent Virtual Assistant for the #EHR [Video] #MHealth

Video of the presentation from the Health2.0 show in October 2013 of the Florence Demonstration
You can see Florence in action at the site
or in the video below

Artificial Intelligence – Good or Bad

Posted in AI, Artificial Intelligence, medical intelligence, virtual assistant by drnic on November 11, 2013

I received a link form a friend to this article Robots, Soldiers, & Cyborgs: The Future Of Warfare – I think in part because I post on the value and opportunity of the intelligent agent
In fact I just talked about this recently around the concept of smart shelves instead of selling shelves. It was this comment in the article that stood out

Are we at the beginning of an inevitable process leading to the rise of “killer robots” predicted by science fiction, or can robots actually make war less destructive?

We know technology can be used for good and bad but even with the concern of the possible super soldier ala Terminator and the Rise of the Machines in Judgement Day…as seen in the opening scene from Terminator 2

Remember folks – this is Hollywood. No battery or power issues amongst the many other challenging technical problems. There is a school of thought that we will reach singularity and artificial intelligence will have progressed to the point of a greater-than-human intelligence that will “radically change human civilization, and perhaps even human nature itself.

Critics are also concerned that advanced artificial intelligence (AI) could develop in directions not anticipated by scientists. Because of this unpredictability, the US military has indicated that it will never remove humans from the decision loop completely. While unmanned weapons systems will become gradually more autonomous so that they can carry out very specific missions with less human direction, they may never entirely replace human soldiers on the battlefield.

While there is some potential for the bad I remain optimistic that the inherent good prevails – we develop smarter, faster and better technology to deliver an improved world and a new era of Super Intelligence that will chaperone in a new and exciting era

Meanwhile adding medical intelligence to the systems we interact with to simplify the interaction freeing people up to focus on tasks and the individual – not the technology offers interesting and exciting potential and I found this latest piece Startup Gets Computers to Read Faces, Seeks Purpose Beyond Ads on reading faces another step toward intelligence which like the smart supermarket shelves can be used for good or bad….
Imagine the doctors office or even the hospital waiting area that is using technology to triage patents intelligently based on their needs not the time of their arrival.

Life is good – my glass is always full

Interview from #Health2Con with @DocWeighsIn on #speechrecognition #HealthIT #NLP and beyond

Loved spending time with Dr Pat Salber (@DocWeighsIn) from the Health 2.0 conference that took place a couple of weeks ago

I had the privilege of watching her in action as she blended social media with the sessions at Health 2.0 and tweeted a picture of her in action

We spent some time afterwards talking about innovation in HealthIT and documentation on subjects as wide and varied as Florence and INtelligent assistants through Speech Recognition and Natural Language Processing (NLP) or Clinical Language Understanding (CLU):

Technology and Focusing on the Patient

Posted in #hcr, Clinical Informatics, EHR, HealthIT, medical intelligence, Nuance, Speech Recognition by drnic on September 20, 2013

Always enjoying talking with John Lynn (Founder of the HealthcareScene.com (he goes by @techguy and @ehrandhit) and great discussion yesterday on “Technology and Focusing on the Patient” using a Google Hangout