Navigating Healthcare – Patient Safety and Personal Healthcare Management

Thanksgiving, Decency and End of Life – Be Thankful you had the conversation now #health

Patients deserve the same standard and car that doctors receive when they need treatment. But as I have said before (Doctors Die Differently and more recently Treatment Creep in Medicine – sucking Decency out of Patients) we remain challenged especially when it comes to dying.

This piece by Dan Gorenstein, How Doctors Die: Showing Others the Way touched on these issues in a moving a thoughtful way.

Dr. Elizabeth D. McKinley’s battled breast cancer for 17 years but this past spring discovered the cancer had spread to her liver, lungs and brain. Her choice was to undergo more treatment that would have potentially debilitating and mind altering effects on her or change course, accept death and work on getting the best out of what was left of her life…as she put it

..time with her husband, a radiologist, and their two college-age children, and another summer to soak her feet in the Atlantic Ocean…“a little more time being me and not being somebody else.” 

And some of her fight was with her own family – the non-medical members

clinging to the promise of medicine as limitless

And the medical members of her family (her husband is a radiologist)

looking at her disease as doctors, who know the limits of medicine

Its not a difference in the effects of disease and death but rather an advantage of knowledge and information that lead to truly informed decisions “doctors have control over their quality of life before they die and this sadly is control that eludes most other members of society” and it would appear especially try here in the USA. More than half of deaths take place in hospital and not at home surrounded by people we love which is the way most say they want to “go”.

So if you do nothing else this Thanksgiving – take the time to talk about the subject with the people you love and create and advance directive or living will. In many respects no better way to be thankful than to set out what is important and let everyone know, now when you are fit and healthy.

Wishing you all a very happy family and friend fill Thanksgiving

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Remembering those First Moments as a Junior #Doctor #hcsm

It’s a long time ago but in many respects that first shift is still fresh in my memory and it all came flooding back when I read this great piece by Deepak Chopra: My First Job: My Dark Night As A Real Doctor

He recounts his first night on call having arrived in to work in a 400 bed community hospital in New Jersey in the 1970’s and his first patient – “an expiration”
I cast my mind back to Friday 1st August 1986 and my first day – the Friday was significant as I discovered, marking the beginning of a weekend on call that commenced on Friday at 9am and finished at 5pm on Monday 4th August – yes that 80 hours! I don’t think I quite understood what that meant but I sure did by the end.
I was partnered with my medical school friend and colleague Niamh Anson part of my graduating class from the Royal Free Hospital School of Medicine. We were set to spend the next 6 months joined at the hip spending more time with each other than some married couples spend together. We would be each others support, backup, confidant and friend. I was lucky – she was the perfect balance to my brash youth and over confidence. She was a steady hand guiding through what were some very rough seas and although I did not know it at the time I was really lucky to be her partner offering me the chance to get to know her.
We worked for two consultants – Dr Woodgate and Dr Willoughby a cardiologist and a gastroenterologist and were joined by a dynamic registrar John Lee. Between us we took care of the cardiology patients, coronary care ward, coronary care monitoring unit and the gastroenterology patients day to day.  But come Friday afternoon took on medical responsibility for all medial patients, medical admissions through the Accident and Emergency Department (A&E aka as the ED) and the Intensive Care Unit. On top of that we (Niamh, John and I) were the code team – with the anesthetist (aka Gasman or Anesthesiologist) as the 4th member. I don’t remember how many patients this covered but it was a lot.
Our first day was filled with taking on responsibility for the day to day activities finding out how to get things done, where things were kept and most importantly getting to know the nurses who were the key to surviving the ordeal since they knew everything, had worked there for far longer than you (and many others) and had more relevant experience that you needed to learn from. I was reminded of the “Doctor in the House” film with Sir Lancelot Spratt from years back:

To be a successful surgeon you need the eye of a hawk, heart of a lion and the hands of a lady

And while I don’t remember all the nurses by name I remember all their kindness, support and actions that helped me survive the grueling assault course of medicine.

At 5pm we knew the patient load had changed as our “beepers” (aka pagers) started sounding like a cardiac monitor going off so frequently. There were missing orders for pain medication, tissued drips (a drip that was no longer working and needing to be re-done), admissions in the emergency department, patents with abnormal rhythms on the coronary care intensive unit, blood gases needing taken in ICU…..
Division of labor and unofficial coordination became the order of the day as Niamh and I split the work taking on admissions and ward coverage. I remember during that period working out my rate of pay based on the number of hours I did per week (typically 136 hours per week) and thinking that while I understood that I was inexperienced I felt worth a little more than the £1.36 per hour (roughly $2.20 per hour) given that I recall all the critical clinical decisions we made, the CPR we performed, the relatives we had to speak to give them the sad news that their spouse had died.
By Saturday afternoon we had been on call for 36 hours and there seemed no let up in activity. The nights were sometimes quieter but that was rarity. As a means of coping we split the night with either Niamh or I taking all the calls after midnight (except in the case of a code when it was all hands on deck necessary to cope with the high work load in these events). In one memorable night I remember 23 admissions coming through the emergency department – if I saw my bed it was never for more than a few minutes. The nurses were all familiar with the work load adn they knew when they paged us that even if we answered and said we were coming they would oftentimes have to page us a second and third time as we would answer but then fall immediately back to sleep. As for our performance and efficiency – I hesitate to imagine how poor we were at tasks and what our decision making would look like if it were assessed. The good news was that there were many experienced nurses involved who did not work the same hours so were not suffering the same chronic sleep deprivation and were checking up on our orders and activities, prompting and intervening as necessary to prevent errors
By Monday morning we were all frazzled – I’d lost count of the patients and problems we had dealt with, the patients who had died, the admissions and therapies started and the slew of clinical problems and disasters we had averted. We stopped taking call but our day did not finish then and for us Monday was a regular working day dealign with the normal work load of admissions, award rounds treatments and patient management. It was only at 5pm on Monday evening we finally stopped work and handed our patient cover over to the new on call team.
There was some solace in the genuine feeling that you were making the difference in people’s lives but much like Deepak Choopra I struggled with what I was actually delivering – was this really healthcare

In the end, after six years of studying, medicine was turning out to have too little to do with healing and making people happy. It had to do instead with my work in the hospital, into their lives, pronouncing a few of them, the most unlucky ones, as expirations. I thought about myself a lot before I forced myself to sleep, but, on reflection, I didn’t think about my patients much. We had all met and parted in a few moments. It would have been hard to look at them directly. 

What of the interaction as defined by Hippocrates

Even though a patient may be aware that his condition is perilous, he may yet recover because he has faith in the goodness of his physician…I will keep pure and holy both my life and my art.

I did not have a good feeling about the interactions – the fleeting exchanges with these people who were trusting me with their lives and the lives of their family. And as technology and innovation continued its march the reality of the practice of medicine changed

Practicing medicine as we do now makes a doctor’s life as nerve-racking as a soldier’s. It consists of an endless struggle to conquer disease, and to keep at this, a doctor must deny to himself that disease, and to keep at this, a doctor must deny to himself that disease ultimately wins. If you feel called to practice medicine, these are not the kinds of thoughts you permit yourself. But doctors do face up to them from time to time and wonder what the work is for

I had some great experiences – I had some awful ones and I continue to be part of what I consider an honorable profession and one I am privileged to be a contributing member . In fact on a recent flight there was a request for a doctor – a lady suffering an attack of pancreatitis but fortunately we were not far from our destination and my contribution was small and mostly not medical in nature helping to control and comfort for the short period of time till we arrived and then hand the patient on to the ground emergency medical staff. That transition proved to be sub-optimal and it was well over an hour before she was taken care of – I stayed of course, wanting to be sure that her care was transferred to the healthcare team on the ground. The following day I received a note from one of the flight attendants that made my day. She had searched for my name and found me and sent a note to the Nuance Web site thanking me for my assistance and complimenting me for my “display of genuine heart”. My contribution was not so much medical although that had played a part in the diagnosis, assessment and review of treatment options and the course of action. But what had made the difference was compassion – the focus on the person (and in this case there were two people and I ended up helping her companion navigate London Heathrow airport late at night to get her out to the accommodation they had booked). I had never doubted what I would do and was upset for this lady and her companion who’s holiday was not starting off well. This is why I did medicine – I wanted to be the contributor, the person caring for the patient. It is this fundamental aspect of medicine we seem to be loosing site of – I can certainly accept some blame – I have a keen eye towards technology and possibilities it offers – but at its hearts medicine is about people caring for people and providing the support that in many cases is the difference between a good or bad outcome (at least perceived by the patient anyway). In fact I tweeted something along these lines earlier this week:

People forget what you said and what you did but they remember how you made them feel

As Deepak Choopra quotes:

Rejoice at your inner powers, for they are the makers of wholeness and holiness in you,
Rejoice at seeing the light of day, for seeing makes truth and beauty possible. 
and he ends with

a physician must trust in Nature and be happy in himself

As a guding light that works for me – hope it works for you too

Discussing the Imapct of Social Networks on Healthcare with @EricTopol on Friday #VoieoftheDr

Posted in #voiceofthedoctor, #voiceofthedr, HealthIT, HIT, Personal Health by drnic on November 16, 2012

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 impact of Social Networking Impact on Medicine: Topol on Social Networking’s ‘Big Impact’ on Medicine.

Patients are moving in droves to online interactions and not just to access medical information online but also to interact with other people experiencing the same conditions or symptoms. But it is the opportunity for the positive social influence of people:

If you combine the capability of monitoring such things as blood pressure or glucose with social networking, then you can have managed competitions with your friends, your family, or your social networking cohort, and you can start to compete for such things as who has the best blood pressure or who has the best glucose level. This, of course, is beyond competitions as simple as who has the best weight or does the most activity in terms of number of steps

That is really exciting. I have had great positive experiences of this using a manual tracking system with colleagues for fitness and health monitoring and has now moved ingot he digital world in the form of FitBit tracking – you can see my <a href="http://www.fitbit.com/user/22SLLM
“>FitBit Profile here. Sadly I lost my FitBit device (it fell off while I was running) about a month ago so the profile and activity is a little light but it is central to my constant focus on personal health management

Will you be joining your friends and other patients online or are you still concerned about sharing your personal data or troubled by the security or impersonal nature of online interactions. 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

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

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Topol on 5 Devices Physicians Need to Know About

Posted in #voiceofthedoctor, EHR, HealthIT, Patient Engagement, Personal Health Management by drnic on November 14, 2012

Welcome to this new series, Topol on The Creative Destruction of Medicine, which is named for my new book, The Creative Destruction of Medicine. I’m Dr. Eric Topol, Director of the Scripps Translational Science Institute and Editor-in-Chief of Medscape Genomic Medicine and theheart.org. In this series I will detail the driving forces behind what I believe is the biggest shakeup in the history of medicine.

What I’ll be doing in these segments is outlining the parts of my book that represent the digital revolution occurring in the practice of medicine and how this revolution can radically improve the healthcare of the future. In this segment, I’d like to play the role of Dr. Gizmodo and show you many of the devices that I think are transforming medicine today. These devices represent an exciting opportunity as we move forward in the practice of medicine.

Let me just run through some of these. This is 2012, obviously, and this is something that we’re going to build upon. You’re used to wireless devices that can be used for fitness and health, but these are now breaking the medical sphere. One device you may have already noticed turns your smartphone into an electrocardiogram (ECG). The ECG adaptor comes in the form of a case that fits on the back of a smartphone or in a credit card-size version. Both contain 2 sensors. With the first model, you put the smartphone into the case and then pull up the app — in this case I’m using the AliveCor app — and put 2 fingers on each of the sensors to set up a circuit for the heart rhythm. Soon you’ll see an ECG. What’s great about this is you don’t just get a cardiogram, which would be like a lead II equivalent; using the “credit card” version, you get all the V-leads across the chest as well. I have found this to be really helpful. It even helped me diagnose an anterior wall myocardial infarction in a passenger on a flight. It was supposed to be a nonstop flight, but, because of my diagnosis, it wound up stopping along the way. As an aside, after the passenger was taken off the plane to get reperfusion catheter-based therapy at a hospital, the pilots and flight attendants all wanted to have their cardiograms checked.

The second device I will show you is another adaptation of the smartphone, but this one is for measuring blood glucose. Obviously we do that now with finger-sticks, but the whole idea is to get away from finger-sticks. I’m wearing a sensor right now that can be worn on the arm. It also can be worn on the abdomen. What’s nice about this is that I can just turn on my phone, and every minute I get an update of my blood glucose right on the opening screen of the phone. It’s a really nice tool, because then I can look at the trends over the course of 3, 6, 12, or even 24 hours. It plays a big behavioral modification type of a role, because when you’re looking at your phone, as you would be for checking email or surfing the Web, you also are integrating what you eat and your activity with how your glucose responds. This is going to be very helpful for patients — not only those with diabetes, but also those who are at risk for diabetes, have metabolic syndrome, or are considered to be in the prediabetic state.

The third device I’d like to talk about is another device from the cardiovascular arena that comes in the form of an adhesive patch. It’s called the iRhythm, and I tried this out on myself. It’s really a neat device, because the results are sent by mail to the patient. You put it on your chest for 2 weeks, and then you mail it back. It’s the Netflix equivalent of a cardiovascular exam. The company then sends the patient 2 weeks’ worth of heart rhythm detection. I think it’s a far better, practical way, as compared to the Holter monitor wireless device. It’s not as time-continuous as the ECG or glucose device, but it’s in that spectrum.

I want to now explain a fourth device, which I use on my iPad. This device allows physicians the ability to monitor patients in the intensive care unit on their iPads. I use it to monitor patients at the Scripps ICU. You can use it for any ICU that allows for the electronic transmission of data. Right now, I’m monitoring 4 patients simultaneously. You can change the field to monitor up to 8 patients simultaneously. This is a great way to monitor patients in the ICU because you can do it remotely and from anywhere in the world where you have access to the Web. This is just to give you a sense of what this innovative software sensor can do to change the face of medicine.

Finally, I wanted to describe is something that I’ve become reliant upon, and that’s this high-resolution ultrasound device known as the Vscan. I use this in every patient to listen to their heart. In fact, I haven’t used a stethoscope for over 2 years to listen to a patient’s heart. What’s really striking about this is that it’s a real stethoscope. “Scope” means look into. “Steth” is the chest. And so now I carry this in my pocket, and it’s just great. I still need a stethoscope for the lungs, but for the heart this is terrific. You just pop it open, put a little gel on the tip of the probe, and get a quick, complete readout with the patient looking on as well. I’m sharing their image on the Vscan while I’m acquiring it and it only takes about a minute. We validated its usefulness in an Annals of Internal Medicine paper, in July 2011,[1] describing how it compares favorably to the in-hospital ultrasound echo lab-type image. This could be another very useful device in emergency departments, where the wireless loops could be sent to a cardiologist. Another application it could be used for is detecting an abdominal aortic aneurysm. Paramedics who are out in the field, or at a trauma case, could use this to wirelessly send these video loops to get input from a radiologist or expertise from any physician for interpretation.

These are just a few of the gadgets that give you a feel for the innovative, transformative, and really radical changes that will be seen going forward in medicine. Thanks for watching this segment. We’ll be back soon with more on The Creative Destruction of Medicine. Until next time, I’m Dr. Eric Topol.

I am excited to be talking with Dr Eric Topol on Friday and hope you will be able to join me. To help prepare you for the conversation and the breadth of areas that Dr Topol covers I am posting his vide presentations from Medscape that provide quick intros to different areas. This one looks at 5 devices that will change the future of Medicine.

  • Smartphone as an ECG
  • Stickless Glucometers for Continuous Monitoring
  • The NetFlix Cardiovascular exam – worn for 2 weeks and mailed for Review
  • Mobile ICU Monitoring
  • The Mobile Ultrasound
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    Turning the smartphone from a telephone into a tricorder

    Posted in #voiceofthedoctor, EHR, HealthIT, Personal Health Management by drnic on November 6, 2012

    AliveCor

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    Earlier this year, well known cardiologist Eric Topol published his highly successful book, “The Creative Destruction of Medicine.” In it he describes several examples where smartphones, particularly the iPhone, have been morphed into first-rate medical devices with the potential to put clinical-level diagnostics in the hands of everyday users. Coincidentally, Topol was on a flight not long ago, returning from a lecture where he had spoken about a new device made by AliveCor. The pilot intoned an urgent, “is there a doctor on board?” In response, Topol took out the AliveCor prototype, recorded a highly accurate electrocardiogram (ECG) of an ailing passenger, and made a quick diagnosis from 35,000 feet.

    BGStar and iPhone

    As the leader in the smartphone revolution, the iPhone has been the platform of choice for early adopters in the health and quantified self arenas. Even so, there are a few shortcomings to development on the iPhone which, at least among DIYers, has led to Android becoming the path forward. Apple’s single-vendor solution and sequestering of many low-level input/output details behind the premise of ease of use have made interfacing the device to external sensors both a difficult and expensive proposition.

    While it can be nearly impossible to write an Android app that will work on every device out there, writing an app to work on one’s own smartphone or tablet is fairly straightforward. Another challenge to the smartphone as a medical device is that many important sensor variables are analog in nature. It is possible to use the analog-to-digital converter on the audio input for data acquisition, however in the absence of sophisticated multiplexing one is limited to a single channel (unless some kind of expansion device is used).

    Run tracking and calorie counting apps can certainly be regarded among the successes of the smartphone, but without dedicated sensor hardware, the philosophy of “there’s an app for that” only goes so far. A host of products now available for Android let users with a little bit of technical know-how create powerful devices previously found only in the domain of hospitals and law enforcement. One of the most successful expansion boards that allows Android devices to control external instruments and to orchestrate the collection of a variety of sensor data is the IOIO board. The system works well in wireless mode with most Bluetooth dongles, and its on-board FPGA gives 25 I/O channels, including plenty for analog input. It also handles analog output via pulse width modulation (PWM).

    Vendors like Sparkfun, a popular supplier for the Arduino developer market, have realized the power inherent in readily programmable smartphones. They provide inexpensive heart monitors, as well as CO2 gas, dissolved oxygen, and blood alcohol content (BAC) sensors. These sellers provide documentation and, most importantly, access to the source code. With this information, interfacing with a BAC sensor, for example, is relatively straightforward and, if appropriately calibrated by the user, very accurate.

    MK802

    MK802 Android PC

    USB stick computers running Android 4.0 (Ice Cream Sandwich) or newer, like the MK802, readily connect to boards like the IOIO, and can take the cost out of dedicating a phone or tablet to a sensor. They can log data to any of several storage mediums and cut a nice form factor when keyboards and displays are shed.

    Despite the advances, a few ugly details in the smartphone-based health field are no longer capable of being ignored. The FDA will be increasingly faced with the task of deciding when a phone or tablet becomes a medical device that needs to be regulated as such, and when it is simply the front end for another device. Manufacturers of products for the seemingly straightforward task of monitoring glucose or insulin will have to tread carefully. Others seeking to enhance the absorption of medications through the skin by opening transient microchannels with current or ultrasound, perhaps built into a smartwatch, even more so.

    In just a few years children wearing smart devices could become the norm. These gadgets could monitor variables like ambient peanut allergen using nanopore immunosensors with processing power to spare for forming dynamic early warning networks as conditions indicate. Without an efficient governance dispensing timely permission to use devices like the AlivecCor in humans, the initiation of life-saving care may too often begin with hardware designed and approved only for our pets. But if our regulatory structure organizes on the side of opening technological advancement, the future of these medical gadgets will be bright.

    Now read: X Prize offers $10 million for a real-life Star Trek medical tricorder

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    The X-Prize amanged ot jump start the commercial space program and has taken the same principles to medicine offering $10 million to create a real world Star Trek Tricorder
    We are closer than you think

  • Alive Cor has the ECG monitor
  • Calorie and Activity Trackers (multiple but my personal favorite FitBit)
  • Glucose Monitoring for Diabetics, and
  • recently continuous vital sign monitoring
  • There are standards out there – notably the Continua Alliance

    Exciting times as we add increasing functionality and capabilities to these devices and tremendous opportunities for engaging patients in the continuous management of their health.

    I will be discussing this and related topics with my guest @EricTopol on my >a href=”http://www.healthcarenowradio.com/programs/voice-of-the-doctor/”>Nov 16 Voice of the Doctor Show

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    Asking the Wrong Questions About the Electronic Health Record

    Posted in #voiceofthedoctor, #voiceofthedr, continua, EHR, HealthIT by drnic on September 21, 2012

    By Ashish Jha, MD

    The wrong question always produces an irrelevant answer, no matter how well-crafted that answer might be.  Unfortunately the debate on health information technology seems to be increasingly focused on the wrong question.  An Op-Ed in the Wall Street Journal argues that we have had a “Major Glitch” in the use of electronic health records (EHRs).  This follows on a series of recent studies that have asked the question “do EHRs save money?” Or “do EHRs improve quality?” with mixed results.  While the detractors point to the systematic review from McMaster, boosters point to the comprehensive review published in Health Affairs that found that 92% of Health IT studies showed some clinical or financial benefit. The debate, and the lack of a clear answer, have led some to argue that the federal investment of nearly $30 billion for health IT isn’t worth it.  The problem is that the WSJ piece, and the studies it points to, are asking the wrong question.  The right question is:  How do we ensure that EHRs help improve quality and reduce healthcare costs?

    The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate.  Paper-based records are part of the problem, creating a system where prescriptions are illegible, the system offers no guidance or feedback to clinicians, and there is little ability to avoid duplication of tests because the results from prior tests are never available.  Even more importantly, the paper-based world hampers improvement because it makes it hard to create a learning environment.  I have met lots of skeptics of today’s health information technology systems but I have not yet met many physicians who say they prefer practicing using paper-based records.

    The problem is that some Health IT boosters over-hyped EHRs.  They argued that simply installing EHRs will transform healthcare, improve quality, save money, solve the national debt crisis, and bring about world peace.  We are shocked to discover it hasn’t happened – and it won’t in the current healthcare system.

    Most EHR vendors today sell their products to doctors promising increased “revenue capture” (that is, improved billing resulting in greater payments to physicians and higher costs to the health care system).  In a fee-for-service world, the EHR, which is nothing but a tool, helps you get more “fee” for your “service”.  It’s not surprising that we aren’t seeing huge savings.

    To understand how to best leverage the potential of EHRs to help the US improve care and save money, we will have to answer a series of other related questions:  how do we create incentives in the marketplace that reward physicians who are high quality?  How do we allow physicians to capture efficiency gains?  Today, if a physician becomes more efficient, he/she will likely lose revenue to insurance companies or to government payers.  When Kaiser Permanente installed an EHR and gave patients the ability to use the electronic system to message their physicians, they saw their ambulatory care visit rate fall by 20%.  This is a disaster in a fee-for-service world.  Sure, Kaiser was able to see real financial gains from their EHR – but how do we help the thousands of other physicians and hospitals that are not Kaiser gain efficiencies from their EHR?  That’s the question I’d like to see answered.

    Now that we have made an important investment in EHRs, we need to figure out how to use this new technology to address the fact that the healthcare system is a mess.  We need to figure out how EHRs can promote coordination of care across sites, seamless flow of good clinical information, and smart analytics, to name a few things.  We simply can’t do that in a paper-based world.  I am sure that the healthcare industry single-handedly keeps the fax machine industry alive.  We need to stop. Period.  Every other part of our lives has become electronic and the benefits are clear.  Our lives are better because we bank online, communicate online, shop online.

    The debate over whether we should have EHRs is over.  Can we fix our broken healthcare system without a robust electronic health information infrastructure?  We can’t.  Instead of re-litigating that, we need to spend the next five years figuring out how to use EHRs to help us solve the big problems in healthcare.

    Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence.This post first appeared at the Health Affairs Blog.

    Filed Under: Tech, THCB

    Tagged: , , , Sep 19, 2012

    Interesting rebuttal to the WSJ article “Major Glitch” as Dr Jha says

    The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate

    Installing an EMR won’t change this since there is no silver bullet for our problems. EHRs like many of the technologies and initiatives are one part of the equation but they are definitely part o the soltuion
    What they look like and how we interact with them will probably be very different to the current interactions and will involve current technologies and probably some that have not even been imagined yet or applied in that way to healthcare. Can you imagine wearing Google Glasses in your practice – probably not but I am willing to bet some variant of this will become mainstream at some point in our healthcare delivery system
    Same is true of patient centered content and management. To that end I will be looking forward to talking to Clint McCellan (@clintmc1) this afternoon on this area and how we can push this aspect forward

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    VoiceoftheDoctor for the Month of September

    Posted in #voiceofthedoctor, #voiceofthedr, continua, Cybercrime, Healthstory, Personal Health Management, PHR by drnic on September 5, 2012
    This month we will be 
    Sep 7

    Brad Tritle (@BTritle)who is currenlty the chair of the HIMSS Social Media Task Force.  He is currently co-editing a forthcoming HIMSS book on consumer engagement and consulting under the Office of the National  Coordinator on consumer engagement for State HIEs and immunization registries. Amongst the areas of focus:

    • Health Information Exchange
    • Consumer e-health
    • Personal Health Records
    • privacy/security

    You can read his interview ith HIMSS here
    We will be discussing the dleivery of patinet care – where the patient and the change in system dleivery and technology innovation to achieve this including telehealth services for consumers, apps and how this relates to PHRs.  

    Sep 14
    ID Experts – Is the EHR a target for Cybercrime…..


    Sep 21

    Clint McClellan (Twitter @clintmc1) who is Sr. Dir. of Strategic Marketing at Qualcomm Life and the President and Chairman of the Continua Health Alliance. HE and I will be talking about the Continua Health Alliance which is a non-profit, open industry organization of healthcare and technology companieswho are collaborating to improve personal healthcare.They are establishing a system of interoperable personal connected health solutions that will help empower everyone to enageg in their own personal health wellness amangement. Take a look at their vision video here

    He and I will be discussing some of the examples and soltuions in the personal health space and how these have eveolved from personal smartphones to dedicated gateways and what opportunities will open up for application developers?

    Sep 28

    Healthstory – Liora Alschuler, CEO of the Lantana Group and co-founder of Healthstory initiative. She is Co-chair, HL7 Structured Documents Work Group responsible for HL7’s Clinical Document Architecture (CDA), the first standard for healthcare based on XML. 

    We will be discussing the Healthstory Intitaive and the recently finalized Meaningful Use Part 2 guidelines

    Join me this 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.

    Posted via email from drnic’s posterous

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    Five Technologies that will Change the Practice of Medicine

    Posted in #hcsm, #voiceofthedoctor, #voiceofthedr, DrVoice, EBM, EHR, EMR, Evidence Based Medicine, Healthcare Technology, HealthIT, NLP, Nuance, Personal Health, Speech Recognition by drnic on September 4, 2012

    Speech Technology

    Speech recognition offers efficiencies today but recent innovations and new technologies will expand the horizon of opportunity with speech technologies that will change the human computer interface, simplifying the interaction and offering new and innovative tools that increase efficiency and safety of healthcare delivery and reduce the administrative burden and decrease costs.

    Medical Intelligence in the Cloud

    We’re facing a tsunami of patient data. The ability to process and leverage this data at the point of care is gone. Cloud based intelligence, analyzing data content and delivering contextually relevant information in real-time will become essential.

    Continuous Mobile Monitoring

    Our current perspective of a patient’s healthcare record is comprised of snippets of our total healthcare record (imagine a piece of string as the record – all we get is a very short piece when we visit a doctor/facility). Continuous monitoring (wireless, cloud based and automatically monitored and tracked) changes this and offers more complete view of our health record and more important data that is not just single data points but trends and changes.

    Personal Health Management

    This is becoming essential as we move from a system that disconnects the purchaser from the payer. It’s as if we were buying a car but someone else was paying with no personal financial consequence – we would all buy Ferrari’s, Porsche etc. As we move away from this model, personal responsibility, personal health management tools and PHR’s will become essential, not just for capturing and holding the data, but for helping people interpret and manage their own care. We will all become our own care coordinators for ourselves and our extended family, but will need the tools and solutions to help – these will come in form of PHP and health management tools.

    Social Media in Healthcare

    If World of Warcraft can engage a generation of young adults and teens to stay online, engaged and spending enormous sums of money, the gaming industry is doing something “right”. Applying this to health and getting folks engaged is the next frontier. We have already seen that just giving a patient access to their medical record and putting a definitive Diagnosis of obesity has a positive impact on their behavior and general health. Imagine what else you could do with social media and gaming engagement.

    But as always – don’t forget the patient. As I have noted before Doctor Please Look at Me not Your EMR

    This was amplified in a recent article in JAMA: A Piece Of My Mind (JAMA. 2012;307(23):2497-2498. doi:10.1001/jama.2012.4946) that included this drawing from a 7year old girl:

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    Voice of the Doctor – August 10

    Posted in #voiceofthedoctor, #voiceofthedr, continua, Personal Health Management by drnic on August 7, 2012

    This week I will be joined by Clint McClellan (Twitter @clintmc1) who is Sr. Dir. of Strategic Marketing at Qualcomm Life and the President and Chairman of the Continua Health Alliance. HE and I will be talking about the Continua Health Alliance which is a non-profit, open industry organization of healthcare and technology companieswho are collaborating to improve personal healthcare.They are establishing a system of interoperable personal connected health solutions that will help empower everyone to enageg in their own personal health wellness amangement. Take a look at their vision video here

    He and I will be discussing some fo the examples and soltuions in the personal health space and how these have eveolved from personal smartphones to dedicated gateways and what opportunities will open up for application developers?

     

    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.

    leave a comment

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