Navigating Healthcare – Patient Safety and Personal Healthcare Management

What Healthcare Design Can Learn from the Oscars

Posted in DigitalHealth, EHR, Healthcare Technology, HealthIT, HIT, Patient Safety, Technology by drnic on March 1, 2017

The snafu at the Oscars with another movie being announced as a winner before being corrected has created quite a stir!

Picture from Wikipedia
https://en.wikipedia.org/wiki/Academy_Awards

You can watch the fateful sequence here and the audience reaction captured by the LA Time photographer Al Seib

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User Design Thinking

The design of the User Interface is so important – as this article rightly points out: This Simple Design Change Would Have Saved The Oscars

Credit Reddit
https://www.reddit.com/r/Design/comments/5wfs74/another_award_show_cringe_brought_upon_by_bad/

As they point out – the largest thing on the card is the Academy’s logo – not useful information in this context. Simple changes would have made all the difference for the hosts reading the card including large print for the key pieces of data

Electronic Medical Records Design

The same is true for Electronic Medical Records (EMR’s). This has been an ongoing topic of discussion and challenge with the interaction – for example:

2009 Usability of Electronic Medical Records (pdf) – as they describe is a difficult task as crafting a system for the highly tangled tasks in medicine that includes that involves skilled users, complex functionality, and critical tasks is difficult in any form – and even more so from a digital user interface

Obvious problems with EMRs, such as loss of productivity and long training times, have deeper causes. These stem from the complex interaction of highly skilled physicians trying to complete complex tasks in a challenging work environment with a complex and not always usable medical information system. Yet, by applying user-centered design in this complex environment, usability professionals can contribute significantly to improving EMR usability. Greater productivity and lower costs with better health care may yet be our destiny.

Bearing in mind this was written 8 years ago we are still struggling to navigate to the greater productivity and lower costs that were the pot of gold at the end of this particular rainbow.

More recently

2013: Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications

We see the same challenges associated with the EMR design that contribute to suboptimal care and continue to frustrate the clinical team who’s task lists have increased in both volume and elements reducing the available time

Usability errors occur as a result of system complexity, lack of user-friendly functionality (e.g., confusing user interfaces), workflow incompatibility, or limitations of the user. Faulty functionality could mislead clinicians where there is a confusing screen display or when incorrect values result from a programming error that incorrectly converts from one measurement system to another (e.g., pounds to kilograms or Celsius to Fahrenheit). A new kind of error occurring in EHRs that is not an issue with paper-based records is an “adjacency error,” in which a provider selects an item next to the intended one in a drop-down menu, such as the wrong patient or medication.

 

And as recently as 2016 in Journal of Biomedical Informatics: Navigation in the electronic health record: A review of the safety and usability literature (behind a paywall)

A methodical review of the literature focused on the inefficient navigation of EMR’s that increases user’s cognitive load

Courtesy Pixabay

which may increase potential for errors, reduce efficiency, and increase fatigue.

As they noted, “usability researchers are frequently capturing navigation-related issues even in articles that did not explicitly state navigation as a focus. Capturing and synthesizing the literature on navigation is challenging because of the lack of uniform vocabulary. Navigation is a potential target for normative recommendations for improved interaction design for safer systems.

For anyone involved in user interface design or dealing with Electronic Medical Records and complex densely populated screens this challenge is clear. The path for healthcare is not as clear as it is for the Oscars

Using a simple San Serif Font – large print for the award category and the name of the winner followed by the people involved with the Oscars logo at the bottom.

User Design Thinking in Healthcare

Healthcare is not that simple – but that should not and does not stop us from learning from other industries to apply user design thinking to everything we do:

  • Designing with simplicity and ease of use in mind
  • Reducing not increasing cognitive load for clinicians
  • Removing or at least suppressing non-essential information from the immediate clinical dashboard
  • Capitalizing on existing intuitive multi-input interfaces that are prevalent everywhere else

The user interface remains challenging and requires a new level of focus and attention as we continue to increase the data load and resulting cognitive load on our busy time challenged clinical staff. Let’s not have an Oscar moment in healthcare

If you have ideas on how we can improve and accelerate the user centric design thinking in healthcare – share your thoughts below or reach out to me on any of my channels

 

 

What Healthcare Design Can Learn from the Oscars was originally published on DrNic1

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Joining the MedicAlert Board

MedicAlert

I am excited to be elected to the MedicAlert Board joining Jessica Federer, head of digital development at Bayer. As Barton Tretheway, CAE, chair of the MedicAlert Foundation Board pointed out

Their collective experience aligns with our priorities and will be immeasurable to us as we look to leverage the power of new technology to expand the mission of MedicAlert Foundation, which is designed to help save lives

Which succinctly captures my feelings around this additional role. I personally experienced the value of the MedicAlert solution, brand and promise when I practiced as an Emergency Room physician in the United Kingdom. It was part of the standard procedure for any patient who arrived unconscious or confused to look for the signature bracelet

Traditional Medical Alert Bracelet

 

With its iconic Caduceus (similar but different to the Rod of Asclepius) which was the traditional sign of the God Hermes and became established as the symbol of medicine in the United States in the late  19th Century.

History of MedicAlert

The Original MedicalAlert User – Linda Collins

The history of MedicAlert dates back to the Early 1950’s developed by parents of Linda Collins who had an who had an anaphylactic reaction to tetanus anti toxin (which in her instance she only received a small scratch test as was the practice in 1953) and had a severe reaction. She survive but her parents Dr Marion Collins and his wife Chrissie realized that she was at risk and made a paper bracelet and note that was attached to her coat detailing her severe allergy.

 

 

 

 

 

In fact the original MedicAlert Bracelet is now in the permanent collection of the Smithsonian Institution in Washington, D.C. Today

The Original Bracelet stored in the Smithsonian in Washington DC
The Original Bracelet stored in the Smithsonian in Washington DC

From these modest beginnings things have developed with early recognition by “Peace Officers”. The California Peace Officers magazine even ran an article back in January 1957 highlighting the MedicAlert bracelet to their members. In the era before mobile phones and always on communication it was a reliable way of identifying individuals and providing immediate access to a 24- hour phone line linked to critical and life saving information for that individual. This function continues today with a live 24/7 Emergency Response Service

I worked on one of these switchboards as a Medical Student many years ago

 

 

with full health and personal information including your personal health record and emergency contacts information and available in other countries including Australia, the UK, Canada and South Africa to mention a few through affiliates and partnered with many groups including AAFP, Alzheimer’s Association, ACEP, Autism Association, Philips LifeLine, National Alliance of Mental Illness, Food Allergy Initiative – to mention but a few

The age of computing brought new innovations and the ability to more readily store and retrieve more information for members and track and follow membership and presidential recognition dating back as far as April 9-16, 1978 when then President Jimmy Carter commemorated the occasion of MedicAlert and their contribution to Medic Alert week in April. Even Hollywood got in on the act with appearances of the MedicAlert in everything from the Today Show and Good Morning America to CHiPs

and Columbo

Peter Falk in Columbo

 

Moving into the Digital Age

The organization is moving into the digital age with solutions around stored medical records, moving to digital mobile formats and storage solutions and even exploring the potential for RFID enabled solutions and in partnership with the American Medical Association has a joint venture on advanced directives.

Back in 1956 Dr Marion Collins commented that

“I think I can save more lives with MedicAlert that I’ll ever save with my scalpel”

Which is much like my own perception of medicine and the opportunity of Digital Health that I saw 30 years ago and continues to be the case. It’s this combination of a storied brand and concept from MedicAlert as a foundation and the opportunity to update for the new Digital world we live in that presents such an exciting opportunity. We are facing a Silver Tsunami of people who struggle to age in their homes and technology and solutions that help them do so, safely and with the support of their relatives and the health system will be in high demand.

I’m looking forward to working with my fellow board members and the MedicAlert team to continue the tradition and build on the brand with a Digital update and twist

 

 

 

 

 

 

Joining the MedicAlert Board was originally published on Dr Nick van Terheyden, MD

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A Paper Towel as a Medical Record – Really! #safety #HealthIT #EHR #hcsm

I ran across this posting on Mark Hindle’s Twitter account:

The picture is shocking:

This is not just a hand written note as a simple reminder…this paper towel addresses the Pharmacy and says

“Please dispense Colecalciferol 20,000 units”

And it appears the pharmacy or maybe the nurses have dispenses this as evidenced by the “tick” over the top.

The Institute of Medicine published several studies including:

1999: To Err is Human
2001: Crossing the Quality Chasm

And the Journal of the Royal Society of Medicine Published a study in 2006; Poor handwriting remains a significant problem in medicine that stated:

Leape and Berwick called handwritten medical notes a ‘dinosaur long overdue for extinction

Yet here we are in 2013 and not only do we still have hand written notes but they are written on a paper towel……I’m left

A Paper Towel as a Medical Record – Really! #safety #HealthIT #EHR #hcsm

I ran across this posting on Mark Hindle’s Twitter account:

My Nan is in well publicised poorly performing hospital, this was in her notes last night – paper towel prescribing! pic.twitter.com/BdlLYy1gxD
— Mark Hindle (@mhindle2) August 15, 2013

The picture is shocking:

This is not just a hand written note as a simple reminder…this paper towel addresses the Pharmacy and says

“Please dispense Colecalciferol 20,000 units”

And it appears the pharmacy or maybe the nurses have dispenses this as evidenced by the “tick” over the top.

The Institute of Medicine published several studies including:

1999: To Err is Human
2001: Crossing the Quality Chasm

And the Journal of the Royal Society of Medicine Published a study in 2006; Poor handwriting remains a significant problem in medicine that stated:

Leape and Berwick called handwritten medical notes a ‘dinosaur long overdue for extinction

Yet here we are in 2013 and not only do we still have hand written notes but they are written on a paper towel……I’m left

 

A Paper Towel as a Medical Record – Really! #safety #HealthIT #EHR #hcsm was originally published on Dr Nick van Terheyden, MD

Running out of Time

All truly great thoughts are conceived by walking
Friedrich Nietzsche
Don’t walk behind me; I may not lead. Don’t walk in front of me; I may not follow. Just walk beside me and be my friend
Albert Camus

I met Regina Holliday a while back at one of the many conferences that she attends:

At this conference she was there to present and was also creating a painting. Her reputation had preceded her and I was excited to meet her in person and hear her story first hand. I had seen some jackets at conferences and had discovered the story behind the Walking Gallery. An idea that came from a tragic story in a healthcare system that is broken

Back in 2011 a video was made featuring many from the gallery filmed at the Kaiser Permanente Total Health Center:


The Walking Gallery from Eidolon Films on Vimeo.

You can see her presentation on Slideshare here:

But there is nothing that could match the power of hearing this in person.

Regina offered to paint my story and it was months before I could pull together some photographs and sit down to articulate my personal journey in healthcare but that all came together a few weeks ago, almost in time for another walking gallery gathering. With so much going on Regina knew what she was going to paint but had not (as the picture shows)

 managed to download it quite yet

My journey to medical school and joining an honorable and privileged profession started when I was still at school and I remember the seminal moment that made me realize this was the pathway I wanted to take:


I was visiting my older brother in London we exited from Victoria rail station just as somebody had been run over by a bus. I watched as my brother pushed his way to the front of the crowd and he stooped own while very one watched – he was a doctor and knew what to do. As I stood on the sidelines watching I realized that I want to be doing rather than watching

I was a very young medical student and while I enjoyed medical school there was no doubting the fact that I was dealing with something that was really quite unique and challenging emotionally. Life and death was part of normal clinical activities and shortly after my 22 birthday I graduated

I have been heard to joke that the TV Series Doogie Howser was modeled on me as that was some years later – he was also the original blogger.

My Story

Running Out of Time

Practicing medicine in the United Kingdom in the national health service which while delivering great care placed an enormous burden on the people delivering that care. The environment was challenging, especially for a young junior doctor and I found myself questioning what I’d let myself in for. My first clinical job I worked 132 hours per week, I had Tuesday and Thursday evening off. At the time, that was the norm and all of my colleagues had the same work schedule as I did and I noticed that my senior colleagues not only had that working schedule but also took on more clinical responsibility. My weekends were hellacious, waking up on Friday morning and not finishing until Monday evening. I shared the work with a colleague and friend by the name of Niamh Anson. We would share the on-call work and split the activities, with one of us covering wards and the other covering the emergency department admissions.

The constant and chronic sleep deprivation took its toll and I repeatedly questioned the job I was doing and indeed whether I was even safe. The nurses proved to be our saving grace and several occasions when we made mistakes through simple tiredness they caught these mistakes and quietly corrected or prevented our errors. I don’t remember a single time of being on call when I wasn’t up most of the night and typically at leas every hour. Rarely did this not require a visit to either the ward or the emergency department. Many the time, I would walk from my living quarters to the emergency department angry at the system that would place such a burden on anyone and wondering if there was something wrong with me.

On one particular day my two team members were not at the hospital. Niamh was on holiday, one which had been booked many weeks ago but as is normally the case medical staffing had failed as usual to find replacement. By two in the afternoon, the emergency department had 17 patients waiting to be seen by me, there was a patient in intensive care on a ventilator that was having problems, and the cardiac care unit had a patient that was having a lignocaine reaction. I reached breaking point and called medical staffing, and told them I was quitting. Their reaction, humorous in hindsight but at the time not, was to tell me that my contract did not allow for me to quit. Fortunately the ward sister from the cardiac care unit intervened and quietly called my two attending’s. The next thing I knew I received a call from one of them asking me to meet him in the emergency department. I thought my career was over and proceeded down to meet him expecting to be blasted and read the riot act. I was pleasantly surprised to find my two consultants there stuck into seeing patients and helping me out. One of them admitted all of the patients in the ED department while the other dealt with the patient on the intensive care unit in the coronary care unit.

Between us we were able to triage and treat all the patients by the end of the afternoon. Even now as I think back to that story I still find myself quite emotional about the experience and support from two outstanding individuals. They rounded it out by insisting that we went to the local pub for a drink (non-alcholic of course) and listened to me and provided counsel and support.

Sadly they were not typical of the senior staff in the health system and most took the view that they had suffered this level of overwork and therefore everybody else should experience the same. This was a recurring theme throughout my time as a clinician and I found most disturbing and many times very depressing.

If I am walking with two other men, each of them will serve as my teacher. I will pick out the good points of the one and imitate them, and the bad points of the other and correct them in myself.
Confucius

I remember vividly one instance where the attending surgeon I was working for heard that I was taking a sabbatical and thinking about leaving medicine. He started by saying that I was terrible shame, and I thought he was about to offer some guidance/support and thoughts about where the system is wrong and how I might cope with it. Sadly he proved to be similar to many of his colleagues and peers and felt that the system was wrong in allowing me into medical school. The system should of been better at weeding me out since there was clearly something wrong with me not with the system. He like many of his peers believed the baptism by fire, sleep deprivation and the general demeaning of junior doctors was an essential part of training and character building. As he put it, he had experienced this in his junior doctor days and he’d survived and done fine. What he failed to appreciate was that at the time he was practicing as a junior doctor, emergency call was typically a Porter coming to his door knocking on his door to tell him that somebody was “going off” and leaving a cup of tea for him. He would dress himself, drink his tea and proceed to the ward, where the patient had either died or survived, but there was very little that he could do to influence the outcome. My experience consisted of being surgically attached to an emergency page that would bark out at me at all hours, telling me to go to a ward or location in the hospital for an emergency resuscitation the could take anywhere from five – 60 minutes.

There is no easy walk to freedom anywhere, and many of us will have to pass through the valley of the shadow of death again and again before we reach the mountaintop of our desires
Nelson Mandela

My friend and colleague Niamh Anson

had many of the same experiences and like several of my colleagues elected to move away from the system leaving the NHS for Australia, perhaps hoping that this system would be more bearable. Sadly some years later she committed suicide as too many of my colleagues and friends do.

So my Walking Gallery Jacket:

As Regina described the picture:

The sky represents the never ending shifts as does the hour glass. The medical students and doctors are all standing beside me, also exhausted. My friend and colleague Niamh Anson jumping off the hour glass due to stress….

In what can only be described as a “stroke of luck” the painting of my jacket was caught on Fox 5 News doing a piece on the Walking Gallery (right around 00:24 -> 00:50 and around 01:28):

DC News Weather Sports FOX 5 DC WTTG
Or if the vide does not appear you can click this link

My jacket coming at number 227 – I hope we get all of these together one day.

If you don’t like the road you’re walking, start paving another one.
Dolly Parton

Like everyone else – I too have an oath to wear my jacket and use it as a tool to spread the word and effect change:

No one saves us but ourselves. No one can and no one may. We ourselves must walk the path
Buddha

Social Network Sways Vaccine Compliance

Posted in bigdata, HealthIT, Patient Safety, science, vaccine by drnic on April 23, 2013
Media_httpclf1medpage_izogp

Excellent article that demonstrates the challenges facing scientists and data. Despite the data clearly showing the benefits far outweighing the risks parents opinion and decision is swayed by “social norms”

As a society, we respect the privacy of healthcare decisions; however, if we are to sustain adherence to the recommended immunization schedule as a social norm, we need to learn how to empower immunizing parents to become vocal and talk with other parents, including prospective parents, about why they chose to immunize their children

Quite!

Clinical Documentation Lifeblood of Healthcare

Awesome video put together showcasing the various aspects of clinical documentation and why it is so important to capture the complete patient story in narrative form

Putting all the details means capturing the diabetes and loss of consciousness

Everything from Assure and the ability to capture anywhere and the exploding area of mobile integration of voice and all the follow up in the back end for HIM

Discussing the Future of Medicine and Randomized Trials with @EricTopol on Friday #Voiceofthedr

I am excited to be joined by one of the <a href="http://www.himssconference.org/Education/SpeakerDetail.aspx?ItemNumber=1691&navItemNumber=681
“>keynote speakers from HIMSS13 conference Dr Eric Topol – Author of
The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care and has been named in the list of the Top 100 Most Influential Physician Executive in Healthcare, 2012 by Modern Healthcare

We will be discussing amongst other things the challenge of clinical research as the speed of innovation in medicine accelerates. There is a better way as Dr Topol describes here: Get Rid of the Randomized Trial; Here’s a Better Way

Historically we ran large scale trials that were blinded – in other words patients would either receive treatment or a placebo – neither they nor their treating clinicians would know which protocol they were on. At the end of the results the data would be analyzed and demonstrate either the positive benefit fo the treatment or not.

But what if giving the patient results in the death of patients – is it ethical to give a placebo when this results in the death of patents that could have benefitted from the treatment.

In the new style of trial we use surrogate markers for disease in a specific genetically similar group:

Researchers will be testing a drug that binds amyloid, a monoclonal antibody, in just [300][1] family members. They’re not following these patients out to the point of where they get dementia. Instead, they are using surrogate markers to see whether or not the process of developing Alzheimer’s can be blocked using this drug. This is an exciting way in which we can study treatments that can potentially prevent Alzheimer’s in a very well-demarcated, very restricted population with a genetic defect, and then branch out to a much broader population of people who are at risk for Alzheimer’s. These are the types of trials of the future and, in fact, it would be great if we could get rid of the randomization and the placebo-controlled era going forward.

But is it safe and how will we ascertain if drugs are truly effective – Join me on Friday at 2:30 ET on VoiceoftheDoctor when I will be talking about this with Dr Eric Topol

Join me on Friday at 2:30 ET on VoiceoftheDoctor
There are three ways to tune in:

• Stream the show live – click the Listen Live Now to launch our Internet radio player.

• You can also call in. A few minutes before our show starts, call in the following number:  Call: 1-559-546-1880; Enter participant code: 840521#

•  HealthcareNOWradio.com is now on iTunes Radio!  Stream the show live – you’ll find this station listed under News/Talk

The Terrifying State of "Unaccountable" Healthcare

Posted in #hcr, Clinical Decision Making, EHR, Health Care Costs, Patient Safety by drnic on October 17, 2012
Media_httpsiwsjnetpub_dkarw

The latest book exposing the healthcare system and how broken it is from Dr Makary a surgeon from Johns Hopkins. As he says

Meet ‘Shrek,’ a doctor who insists on surgery in every case—and has a surgical-incision infection rate of 20%.

and more troubling

He quotes a recent Hopkins survey of employees of 60 high-quality hospitals, where more than half of the respondents said they would not feel comfortable receiving care in the unit in which they work

He makes the case for flat rate payment that removes the incentive for steering care to individual specialties devoid of any decision making that is for the benefit of the patient.

Take pancreatic cancer, half of Dr. Makary’s practice at Hopkins. With only a 15% cure rate, surgery is the only hope. But if the cancer is inoperable, patients may be offered chemo and radiation, which confer minimal benefit and yet make money for doctors and hospitals

There are detractors to this and without incentive there is a corresponding decline in efficiency so finding a balance between these two competing ideals seems necessary

Looks like another book to add to the reading list

Reducing unecessary Tests

Posted in DrVoice, Patient Safety, Radiation Exposure by drnic on August 5, 2010
NPR featured a segment recently on the reducing unnecessary scans “Requiring Doctors To Justify Scans Reduces Waste” with a simple 9 point scale to demonstrate the value of a test in the diagnostic process. Low score means the test has limited or no value and high score means the test has a high chance of providing additional information to the diagnostic support process

For instance, ordering an MRI for uncomplicated, acute low-back pain could get a “2,” or not such a hot idea, according to similar criteria developed by the American College of Radiology. But if the patient in pain had previously undergone back surgery, then the scan might get an “8,” a score strongly in favor of an MRI.

Not only did the introduction of this assessment help in reducing the number of tests – a decrease from 5.4 to 1.9% of scans of the total number of scans but there was an overall improvement in the number of scans being ordered by physicians vs booked by support staff.
From a patient safety and quality of care long term studies have not been carried out but given the increasing focus seen on excessive radiation exposure linked to increased use of imaging – in particular CT scanning that include over dosage: “Two more hospitals report CT scan radiation overdoses” as well as [excess usage especially in childrenParents Can Help Limit Kids’ Exposure to Medical Imaging“)
All round – good progress in applying technology to help improve quality, reduce iatrogenic effects. Perhaps we might see this technology offered to patients to help them assess with their doctors the value of a test 
Posted via email from drnic’s posterous