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Truman Medical Center’s Charitable Foundation has created a technology fund to provide incoming 1st year Family Medicine Resident physicians in the Department of Community and Family Med…

Source: iPad Pros for Primary Care Residents

Background

ipad-proTruman Medical Center’s Charitable Foundation has created a technology fund to provide incoming 1st year Family Medicine Resident physicians in the Department of Community and Family Medicine the resources necessary to practice medicine in the 21st Century.

  • This fund supports the cost of providing state-of-the art computers for each of the first year residents and to subsidize new technology tools that will help them learn and practice medicine.
  • This June, Truman Medical Center is implementing Cerner’s PowerChart Touch, a native Apple App version of the Electronic Medical Record used throughout Trum2016-05-31_19-44-49an’s system. The rollout will begin with the Department of Community and Family Medicine, with the new resident physicians leading the way.
  • These devices will be particularly helpful in giving resident’s the opportunity to install and use the flood of new mobile applications and app-linked medical
    diagnostic devices built for Apple iPhones and iPads. Effective use of these highly mobile devices will be able to improve the care they provide to Truman’s patients.  In the hands of primary care physicians this technology will help these physicians make speedy diagnoses and a lower cost wherever they are with patients.

Special Fundraising Event

Every year I have a tradition of walking and playing my age in holes of golf.  Later on this year I’ll be turning 66 so on June 23rd I’ll be walking and playing 66 holes of golf with Dr. Timothy Neufeld at the Nicklaus Club of LionsGate.  This year’s goal is $20,000 (roughly $300 per hole).

Stay tuned to my Facebook and Twitter feeds on 6/23 to follow me.  Once again Dr. Paul Terranova, Vice Chancellor for Research Emeritus at The University of Kansas, will be caddying for us.

Help us reach our goal by going on line and making your Tax-Free donation to Truman Medical Center Foundation’s Advanced Technology and Equipment Fund (see instructions below).

How To Make Your Contribution2016-05-31_19-46-38

From a computer or web site

  1. Point your browser to Truman Medical Center’s Charitable Foundation donation page https://app.mobilecause.com/f/v6x/n
  2. Select the amount of your donation (any amount will do but we’re shooting for $300 a hole)
  3. Complete the process conveniently and securely

From a mobile phone

  1. 1. Text “FPTECH” to 41444
  2. 2. Follow the donation link on the reply
  3. 3. Enter the amount and payment information
  4. 4. Encourage all of your friends to help

We will reach our goal if 300 people pledge $1 a hole but of course any amount will be appreciated.  Follow our progress at: https://app.mobilecause.com/public/campaigns_keywords/40425/graph?no_polling=false

Background


One of my convictions is:

  • The total cost of healthcare is proportional to the amount of technology available at the primary point of care.

A corollary is:

  • The closer a task is to the patient the more efficient care will be.

Until recently healthcare stood out as an outlier from other industries in that technological advances have not resulted in increased productivity with decreasing costs.  There are a myriad of reasons for this and one big reason is most high end medical technology is found in the most specialized and expensive venues; imaging centers, surgery suites, intensive cares, procedure rooms and sub specialist offices.

This is totally reasonable as over the last 20 years the reimbursement models (especially in the US) were heavily weighted in favor of high-cost procedures.  The return on technology investment in a surgical suite dwarfed that of any investment in a physician’s office.  Subspecialty and hospital based services are relatively large revenue sources.  Comparatively speaking almost no investment was made in the humble exam rooms where the overwhelming majority of care is being delivered.

This is beginning to change.  Newer value-based reimbursement models are now turning the revenue stream on it’s head.  In a shared savings, value-based reimbursement model the extremely expensive surgical suite and subspecialty care become cost centers rather than revenue sources.  The most profitable interventions migrate from the surgery suite and special procedure’s labs outwards to the clinic and even to the patient’s home.  The hospital becomes a “point of failure.”

Unfortunately we’re not ready for this.  Very few, if any, of our training programs are embracing heavy point-of-care technology investments at the periphery of healthcare system.  Physicians in training are not being shown how to exploit the thousands of very low cost yet high-tech devices to augment patient interactions.  The main reason is most primary care programs in Academic Medical Centers do not have the funds needed to purchase hand-held devices and apps to give to their residents-in-training and medical students. That needs to change if we’re going to be able to finally join other industries in leveraging technology to lower the cost of care for our patients.  To this end we’ve created a fund to invest capital in technology as close to the primary point of care as  possible.

Family Medicine Technology Fund


We have created a special technology fund to give Family Medicine Resident physicians at Truman Medical Center’ Department of Community and Family Medicine the resources necessary to practice medicine in the 21st Century.

  • A significant portion of this fund underwrites the cost of providing state-of-the art computers for each
    Smartphone Otoscope for Doctors and Patients

    Smartphone Otoscope for Doctors and Patients

    of the 14 first year residents and subsidizes the cost of upgrading 2nd and 3rd year resident’s devices.

  • Each year we see advanced portable diagnostic devices hitting the market that enable primary care physicians to make more accurate diagnoses immediately in the exam room while engaging their patients. These tools, like Cellscope’s Oto, a smart phone physicians use to capture pictures or movies of a patient’s ears to share immediately with the patient are going to be a fundamental part of the primary care physician’s toolkit.
    Other similar products include the MobiUS SP1 hand-held ultrasound units from companies like Mobisante,  smart phone driven Mobile ECG devices from AliveCor

    Mobile electrocardiogram for physicians and patients

    Mobile electrocardiogram for physicians and patients

    and even more robust solutions like Triomi’s 12-lead EKG device that is being developed by a new startup company here in Kansas City as part of the Sprint Accelerator’s program.
    Other diagnostic programs such as MIR’s Minispir Spirometer are capable of very quickly producing sophisticated flow-volume studies previously only available in specialist’s departments.
    These new instruments put into the hands of primary care physicians tools that speed up and lower the cost of obtaining diagnoses thereby enhancing the value of primary care medicine.
    Unfortunately they are not cost-free and often beyond the budget of our training program and certainly for our individual residents.  A major portion of this technology fund is used to purchase these for our resident physicans to learn to use while they are in our program and better prepared as they begin their careers.

  • This fund has also been used to provide extra large screens for residents to use as second screens for their laptops or stationary workstations. Expanding the screen real estate helps resident physicians in their day-to-day activities and learning by reducing the time needed to display the right information at the right time.

Special Fund Raising Event


Every year I have a tradition of either running my age in miles or, as I’ve gotten much older, switched to walking and playing my age in holes of golf.  This year I’ll be turning 65 so on June 18 or 19 (dependent on weather) I’ll be walking 65 holes of golf.  This year’s goal is $200 per hole or $13,000. Stay tuned to my Facebook and Twitter feeds to follow me.   Once again Dr. Paul Terranova will be caddying for me.  Please help me reach our goal by going on line and making your donation to the Family Medicine Technology fund.

How to Make A Contribution


  1. Point your browser to Truman Medical Center’s Charitable Foundation donation page https://foundation.trumed.org/donate,TMC Charitable Foundation
  2. Select the amount of your donation
  3. Make sure to select the Family Medicine Technology Fund2015-05-07_09-34-17
  4. Complete the process conveniently and securely

Computers for Resident Physicians

On June 25, 2014 I’m going to heft a set of golf clubs and hoof 64 holes of golf in one day in an attempt to raise $64,000 for 32 brilliant resident physicians in the University of Missouri Kansas City School of Medicine’s Community and Family Medicine Residency program.  Why?

The answer involves a 30 year journey from academic medicine away and back to academic medicine.  This journey involving stints in the C-Suite, departmental management, software development, consulting, primary care practice and retail medicine.  Many lessons were learned during that journey and I now have enough gray hairs to show for it and earned the responsibility of teaching again.

See One, Do One, Teach One

More than other disciplines medicine is driven by self learning in which after graduating from medical school the “see one, do one, teach one” approach becomes the most common method of learning.  The best learning is hands on after observing and then internalizing the experience by teaching a colleague but most importantly, the patient.

The exam room, like it or not, is a primary care physician’s surgical suite.  No surgical program would ever consider graduating surgeons who have never watched an attending do a procedure or use a critical surgical implement or device in an actual surgery.  Yet it appears that we’re very comfortable with graduating thousands of physicians without ever watching an attending physician do one key skill that will dominate their lives in the foreseeable future: Using a computer with a patient in the exam room.

Medical knowledge has exploded and we all recognize that it’s impossible for individual physicians, no matter how specialized they are, to keep up with the knowledge needed for good patient care.  Primary Care Physicians are responsible for more information than any specialists are since their services cover everything from the cradle to the grave.  The computer and access to the world is the primary care physician’s most important tool in delivering services and education to their patients.  Using that tool skillfully to meet the needs of the patient with the patient during the many visits is one of the core skill sets faculty need to be able to demonstrate and teach our new resident physicians and medical students.

Jail Cell Exam Rooms

Many academic medical centers are located in inner city environments and are obligated to see a large indigent population.  While this is laudable and serves a great purpose for clinical education it puts extreme pressure on academic institutions to adequately fund technology for their residents and faculty.  The tendency is to scarce capital into surgical, cardiac, cancer and other high-profile specialty and subspecialty areas that can be leveraged for more fund raising or used in highly reimbursed procedures.

Can't do 2 things at once

Can’t do 2 things at once

The result is the thousands of exam rooms in these centers are neglected.  For example, our exam room computers are over 5 years old, still use antiquated and officially unsupported Windows XP, have small 17″ screens and are plastered on the walls in places that force the physician to turn their back on the patient.  These systems are so full of security holes most of these them are locked down so they can only access the Electronic Medical Record.  They are incapable of being used to adequately answer the physician and patient’s questions and certainly can’t be used to access the vast amount of free web-based educational material.

As currently configured these devices are incapable of augmenting, participating and contributing effectively to the exam room visit.

Those few residents who have access to recent mobile hardware have an advantage in that they can use these devices to better access not only the Medical Record but sit next to the patient and use them to share with the patient the rich educational material to which they have access. Unfortunately the majority of residents do not have the financial resources for this.  Why don’t all resident physicians have the latest devices?  Most carry a very heavy undergraduate and graduate student loan burden (well into 6 digits) and are trying to exist on salaries that barely let them survive let alone make significant technology purchases.

They are heading into a world that is dependent on the latest technology yet have not “seen one,” let alone “do one.”  They have been learning in hopeless antiquated and dysfunctional jail cells.  When they graduate and enter clinics and partnerships that have more resources they have a hard time learning how to use this technology effectively while they are building their practices under the pressures of productivity.  Unfortunately most are going to head into clinics filled with exam rooms just like those they had in their training programs.

There are those who are using technology to transform the exam rooms into highly functioning facilities that manufacture magic moments for their patients.  The irony is these are rarely, if ever, found in academic medical centers.

The Computer in the Room

Technology can help transform exam rooms from jail cells to magic rooms.  We practice in a digital world and one of the computer’s functions in the exam room is to facilitate recording details of that visit for medical, legal and financial purposes.  But unlike many other transaction interactions, the exam room computer must augment the physician/patient interaction and become the 3rd person in the room.  Practices that are doing this effectively realize the patient-physician-computer triangle is key to effective communications.   Examples of these can be seen in the photos below where the computer is being used to not only gather information but educate the patient at the same time.

Accessing and sharing information with patient

Accessing and sharing information with patient

Doing Multiple Things Seamlessly

Doing Multiple Things Seamlessly

I’m fond of saying it’s one thing to learn to play a piano, another to play a recital but a whole different skill to play a piano in a piano bar.  Unlike a recital where the piano is the object the piano must accompany the conversation between the pianist and the patron in a piano bar.  This is a hard skill to learn and this whole project is designed to help our residents learn to use their computers to accompany the fundamental patient/physician conversation at the same time it’s doing the transactional functions.

While I’d like to completely replace all of the computers in all of the academic exam rooms I’m a realist to know very few institutions have the resources to do this.  However, we can accomplish much of the same thing by arming every one of our residents with state-of-the-art computers and then either using the existing monitors in the room or adding inexpensive monitors to which these devices can connect wirelessly to when needed.  These computers will not be locked down and the resident will be able to use them to access the needed resources such as Zygote Body, Up-To-Date, Visual Dx or any other resource needed at the point of care.

You Can Help

By logging into https://ecommerce.umkc.edu/giving and scrolling down to the bottom of the Donation web sitepage, select Other and then enter “Nicholas Fund – to be used for Family Practice resident technology”.   Then enter the amount you are donating to support the residents and my slogging out on June 25th.  You will enable us to provide these brilliant residents with the latest technology possible.  In the process you will be helping not only them, their patients but also sending a message that Primary Care is important. Please help me raise $64,000 for the 42 residents on June 25th, 2014.

Comments Welcomed

We implemented large 24″ HP 9100 and 9300 All-In-One touchscreen devices in our clinic’s exam rooms nearly a year ago for several reasons.

New interactive exam room monitors

  • The monitor is as much for the patient and whomever is with them as it is for the nurse or physician using it to document the encounter or provided education
  • Documenting at the point-of-care is easier and more intuitive when it can be shared with the patient
  • The device can be used for interactive diagnostic procedures as well as education
  • Improved productivity with large screens as multiple parts of the chart can be viewed simultaneously or part of the chart (we often have the patient summary open beside the note being created.  This allows the patient and the physician to make sure chronic disease management can be seamlessly worked into a visit for an unrelated acute problem.
  • Touch screen allow us to capture patient input in on-line surveys (pain, anxiety, depression, mental status exams, etc.) as well as display and capture procedure consents that may contain multimedia content and then also capture the patient’s signature  without having to resort to static paper forms that require manual effort to customize and then need to be scanned in.  This has the potential to increase productivity.

    Paperless point of care services

    Everything at the Point-Of-Care

  • Many imaging devices can be connected to these computers and then images captured be displayed on the screen in real-time for the patients to see, learn and be reassured that the diagnosis being made is correct. We are currently using
    • An inexpensive dermatoscope from Bodelin (Proscope) with two lenses; 10x and 30x.
    • Earscope from Dino-Lite
    • Spirometer from Winspir
    • All of our cameras have Eye-Fi cards in them so any photos taken wind up on the network server in a shared drive that we can then open and display on the screen (transfer usually takes less than a minute and begins automatically as soon as the shutter is snapped) and then imported into the EHR.

      Things to Connect into the EMR

  •  Have also experimented with the Littmann 3200 electronic stethoscope with BT connectivity to record WAV filesand capture images of murmurs.  However, BT connectivity issues, cost of Zargis software and length of time to capture a workable waveform interferes with normal visit and until those a resolved we find just playing back a murmur works well.Everyday new devices are being made available daily and we’re constantly being constrained by the limitations of most of the device-centric software and the inability to connect multiple devices at the same time.
  • But the biggest impact for my patients has been the use of the touch screen devices using Google’s BodyBrowser from Google Labs.  This tool is essentially Google Earth for the body and enables the provider and the patient to touch the screen and have that anatomic item identified, rotated, zoomed in and out.  When Google Labs was shut down this application was unavailable for a month or so and not only we physicians but the patients really missed that application. Fortunately this application is now available for free through Zygote Media at Zygotebody.com.

    Showing What Most Patients Never See

  • Secondly, the device is very useful during the examination where we can use our hands as well as the keyboard to illustrate and educate at the same time.  Most patients have no idea what a normal ear drum works like and now we have a lot of anecdotal stories of parents bringing in their children and wanting to see for themselves the child who’s complaining of earache does or doesn’t have a florid otitis media.  They are becoming accustomed to seeing the proof rather than just taking the physician’s word.
    Children also are very tolerant of the the probes if they are seeing on the screen and also can reach out and touch the screen to capture the image.

In addition to these type of uses we’re noticing and beginning to use these for knowledge search and patient education.  It’s not unusual for us to have various web pages, Youtube videos and also getting the patient to show us what they’ve been seeing.

Other use cases that are very handy is for those deaf patients or foreign language patients where we exchange the keyboard to interview them and can have our own words translated automatically in their language (sometime with interesting and comical results).

Going forward we are already noticing that 24″ is too small and are looking forward to upcoming devices and operating systems that would allow us to use MS Surface computing devices from Samsung as the standard exam room device.  The key is that the visit should be something special and be leveraged to engage the patient, increase transparency and generate magic moments where teaching and learning can take place.

Where it all began

A number of us in leadership positions at the University of Kansas Medical Center back in the mid 1990’s had a retreat at Deer Creek in Overland Park, KS.  One of the assignments given to each of us was to craft a personal mission statement.  

It just so happened that the year before one of my Japanese patients said that I needed to join a club and play golf if I was going to be the physician for the Japanese Counsulate still located in Kanas City, MO at the time.  I joined Deer Creek which was near to my house and found my soul in the process.  So many life lessons were learned that first year of seriously playing golf. In addition I observed and admired the physical and mental fitness of those 70 and 80 year old members who were playing most days.  Many of them were shooting their ages (something all golfers aspire to) and were living engaged and vibrant lives in their retirements.

Reflecting back on the task at hand; “your mission statement.”  The moderator emphasized this statement should be short, clear and be able to guide. I played around with a few inane, wonkish phrases that all seemed good but didn’t really reflect me. Then suddenly it came to me as my gaze drifted down on the 9th and 18th holes that flowed up to the clubhouse.  What about shooting my age?  At the time it was a long shot as my good scores were barely breaking 90.  Hmmmm.  Ninety.  That’s a good age to live to and even though it’s not a good score in your 40’s it’s a great score in your 90’s.  The doodling stopped an I scratched out “90 at 90” and then changed it to “90 @ 90” with conviction.

That became my mission statement.  For the last 16 years virtually every little decision has been aided by answering, “Will this help or hurt my chances of shooting 90 at 90?”  Now I’m at my high-school sophomore weight, fitter and enjoying life more than I ever thought possible thanks to a crazy little mission statement.

That’s what 90@90 is all about.

Was asked for a short list of what technologies have made a difference in my practice over the last year and I rapidly jotted down the following:

Large screen devices

  • Our clinic started with small notebook computers primarily designed for the physician and nurses to carry from room to room.  Severaly years ago it became apparent that we often needed to share what was on those screens with patients (primarily diagnostic imaging and lab results).  The hand-held devices didn’t cut it.
  • We moved to 19″ regular monitors and after some experimentation ditched the notebooks and took the minimal added time to log into inexpensive autologon desktops and increased the size of the monitors to 21″ swivel devices
  • Now have gone to 24″ HP All-In-One touchscreen devices for nurses and patient rooms because we discovered productivity is proportional to screen real estate and the added dimensions of the touch screen enabled us to include patient input into the documentation process in the exam room

Photos and videos

  • Having a current patient photo on every page view of the chart (usually in banner bar) reduces errors of performing actions on the wrong patient, reduces the need to dig for information (pictures jar our memories in ways names cannot)
  • Having pictures of rashes, wounds, deformities provides more information for downstream readers than any amount of words
  • Including videos of tremors, gaits, movements improves diagnoses
  • Provides excellent teaching tool
  • Has dramatically decreased the amount of descriptive text and time to completion of notes without sacrificing information
  • Enables visit-to-visit comparison that is just not possible with text

Electronic Messaging, especially with patients

  • Asynchronous messaging reduces interruptions for both the clinician and the patient and is more efficient than voice.  Patient’s complaints are in their own words eliminating the need for redundant recording of the interaction
  • Improves communication without adding cost and dramatically reduces time spent on the phone. Secure messaging enables electronic transfer of patient information to outside physicians in need of that information when normal record transfer mechanisms are not available

ePrescribe

  • Especially the External History has the potential to change the conversation (discovers those who have not filled prescriptions as well as those that are doctor shopping)
  • Also having access to the medications covered by specific plans and the co-pay for those medications is what I call REAL DECISION SUPPORT … now if only we could get the same push for covered services

Point of Care use

  • Improves timeliness and also accuracy of the interaction
  • Increases the perception of time spent with the patient
  • Increases confidence and satisfaction

Patient Access to chart, especially visit notes

  • Improves the accuracy, integrity and timeliness of the notes
  • Try to review and write the note (even though I’m using 100% template driven documentation in the clinic) with the patient as the next reader and editor of the note.  Takes a little more time but forces me to be judicious and accurate in my documentation which I’m convinced improves patient care

Interfaces and connections … Health Information Exchanges

  • The power of an EHR increases logarithmically with the number of systems to which it is connected
  • HIE connections have the potential to increase productivity (see new patients in the same time as established patients)  and why they are not catching on is beyond my comprehension as they enable a clinic to schedule and see new patients in the same time slots as established patients by dramatically reducing the amount of de novo data entry required to make medical decisions

There are many more technologies and infrastructure changes that are positively impacting health care but these are the ones that came to mind as fast as I could type them.

Comments?