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Archive for the ‘Computers and Internet’ Category

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64 for 32

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

A Short List of Technologies Changing My Practice

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?

Hello new world!

Just migrated my Spaces blog to WordPress in order take advantages of increased capabilities.

This all was part of the process up updating Windows Live Essentials in which the familiar Messenger becomes integrated with Facebook (but Twitter for some strange reason was left behind) and other social media.  This process has opened my eyes to a new world of computing and information management that has the potential to be as disruptive as the migration of music to the web that occurred over the last half decade.

First, the recent tools essentially integrate local instances of the application with web-based social media. This just streamlines the social communicating by eliminating the need to jump apps to participate in virtual communication. The distinction between e-mail, instant messaging and social media begin to blur and probably will evaporate.

Second, and probably more important, these tools have the potential to eliminate the need for local computing.  It now really doesn’t matter what you by for yourself and essentially the need to carry around a computer wherever you go.

MS Office now is really functional on the web with a stripped down but eminently functional version of Office 10 that enables me to keep relatively simple spreadsheets in sync using any device (hope pivot tables come soon).

 

Ubiquitous access in the making

 

What’s actually happening is that each of us who have a Windows Live account have a virtual Sharepoint services that we can use to manage our documents using any device that can connect to the web.

 

Same look and feel as Office 10

 

This is causing me to rethink cloud based computing.  I attempted to use Google Apps but they behaved too much like web-based applications and also required me to learn and manage different front ends to manipulate the data.  Microsoft’s cloud-based Office, on the other hand, looks and acts identically to Office 10 applications on my PCs and, I’m assuming will mirror the Office 11 apps soon to be available on my Macs.

With regard to spreadsheets, the only feature really missing that I use frequently is pivot tables and once that’s there then it begins to raise the question whether I need to perpetually upgrade to the latest version of Office on all of the 4 machines I use regularly (2 Win7 devices, an iMac and MacPro).

To be sure locally installed programs do have many more features, can be used when not connected to the web, run faster and are not constrained by space or size that would require space upgrades on web sites.  But from a rigorous fiscal perspective it probably makes sense to migrate all of my data to the web and be done with worrying about or putting a lot of expense into locally owned applications.

So what will the world in the near future look like?  My guess is that we will all eventually subscribe to storage and applications in the cloud and be free from having to purchase, haul and struggle with local computers.  Virtually everything will be connected to everything and all we need to do is walk up to any device anywhere in the world, identify ourselves and have immediate access to our own computing resources with unlimited power and storage.

Cool.

The Power of M&M: Advice to Congress, Obama Administration and Healthcare Leaders

A remarkable article by Stephen Kim and Bill Powell appeared in last week’s Time Magazine titled Seoul: World’s Most Wired Megacity Gets More So.  In short, the article describes the results of South Korea’s massive investment in information technology infrastructure when their economy collapsed in the 1997 Asian financial crisis.  The outcome is a massively connected nation that has spurred economic growth, reduced corruption through transparency and many other gains. Hidden in this article is the validation of Metcalf and Moore’s laws … what I call the M&M Principle that I think should guide many healthcare decisions today.

 M&M

Metcalf’s Law: Robert Metcalf, inventor of the Ethernet and 3Com founder, suggested the power of a network is proportional to the square of the number of nodes on that network.  A healthcare analogy is that the power of an Electronic Medical Record in an individual physician office is marginally better than the paper it replaces.  Connect that EMR to one or more reference labs and it becomes much more powerful.  Connect it to local pharmacies and PBMs (Pharmacy Benefit Managers) and it becomes even more robust.  Connect it to other doctor’s office systems, especially those sharing the same patient watershed, and it becomes much more robust.  Connect it to local hospitals and the power surges again.  Connect it to Payers and it’s strength increases.  Connect it to Personal Health Records and it grows even larger.  It doesn’t take very many connections before the value of the connects dwarfs the value of the EMR.  Imagine the power of a single EMR if it was connected to all of the other EMRs in the nation

Moore’s Law:  Gordon Moore, Co-founder of Intel, published his law in 1965 which states the number of transistors that can be placed on a circuit board will double every 2 years.  There are many variations of this but the essential message is that digital computing and performance increases exponentially and the cost decreases exponentially.  This has led us to every smaller devices doing so much more than massive devices could do just a few years ago.  What used to take a building now can be done in a small hand-held device.  In short there’s a large amount of computational power available in just about anything imaginable.

The combination of Metcalf and Moore’s laws is exhibited clearly in Seoul where individuals can connect to governmental agencies through their cell phones while commuting and pick up official documents at finger-print enabled kiosks in a subway station as described in the article.

A similar healthcare analogy would be traveling patients could access their medications from their cell phones, order refills and pick them up at any local pharmacy or grocery store.

Next Steps Here

What does it take to make this happen?  We need to begin building roads not cars. Right now Congress and the Administration have many proposals but one that seems to be leading is to provide physicians with up to $40,000 incentive to purchase EMRs (which cost $25,000 – $50,000 per physician on average).  While this may prompt some physicians to do so many are finding out that a stand alone EMR is marginally better than the paper systems they replace. Many physicians that do invest in an EMR are shocked by the cost and difficulty of connecting that EMR to other sources of relevant patient information.  Most may be connected to one or more reference labs and can connect to PBMs but the majority are not. Consequently, each physician’s office must re-enter de novo every new patient’s clinical information, just like they do now in their paper worlds.  An analogy would be where the government would help every individual purchase a car to place in their driveway but would leave the individuals to build the roads.  What good is a car if there aren’t any roads?

That’s essentially the value proposition being given to physicians with the proposed $40K incentive.  It really doesn’t accomplish much.

If, on the other hand, the proposals would completely underwrite the cost of connecting any EMR to all of the necessary reference labs, pharmacies, other offices and hospitals then all of a sudden the paradigm changes.  The physician who stays in paper cannot leverage the connectivity.  For these physicians spending $25,000 – $50,000 on an EMR will be trivial as the cost of connecting to the world will be nothing.

All of a sudden they will gain the benefit of not having to reenter that new patient’s information but will know something about every new patient they see. This suddenly increases the value proposition of an EMR.

In short, the power of an EMR is exponentially proportional to the number of other EMRs and clinical information systems to which it connects.

Advice to Congress, Obama Administration and Healthcare Leaders

Build Roads not Cars!  The current proposals should be amended and the government should return to the business of building and supporting connectivity infrastructure and get out of the business of certifying and subsidizing the purchase of individual EMRs.  The government should completely underwrite the medical interfacing of all clinical systems whether they are physician office, pharmacy, payer or personal health systems and leave it up to the individuals who purchase these systems whether they want to plug in.

Will they?  Do you know of anyone who purchase a TV but doesn’t want the signal? A cell phone that doesn’t connect to the network?  A car that won’t be driven on the roads?

The value proposition of an EMR explodes when it can plug in to all of the other EMRs.  In short it really then becomes and Electronic Health Record rather than an Electronic Medical Record. 

Doing so will enable us to see many of the benefits the citizens of Korea now experience as described in the Time article referenced  earlier.

Of Linking and Sharing

Microsoft’s HealthVault has released their HealthVault Connection Center that begins to make Personal Health Records functional.  I’ve been experimenting with various Personal Health Records and have installed one, Healthe Connections (formerly IQHealth) as part of a patient portal.  One of the problems that we’ve uncovered is while these portals are great for looking at the Electronic Medical Record as a portal, they are really poor at enabling us to manage our own health information.
 
The primary difficulty with most PHRs is they are so labor intensive in that each of us as a patient must manually enter data into the record in order to maintain an accurate and up-to-date record.  Very few of us are willing to do so nor do we have the time and the expertise to do this.  Both Google Health and Microsoft’s HealthVault are working hard to make it easy for information to be automatically uploaded into the Personal Health Records and are creating database links to an ever increasing number of healthcare entities.  Microsoft has gone one step farther and also created a Windows Sidebar gadget that quickly enables a user to upload measurements into HealthVault effectively lowering the barrier to information maintenance.
The HealthVault connection center also contains an ever expanding set of links to electronic devices (glucometers, scales, blood pressure cuffs, etc.) that can be configured to upload their data directly into HealthVault via USB connections.  These are easily installed as using the Setup device.
 
Hopefully in the near future all EMRs will automatically be configured to link into one or all of these Personal Health Records which will eventually enable bidirectional data flow so that physicians using their own EMRs will automatically receive and update patient medical histories when patients register or schedule a visit.

A Social Media Model for Electronic Records

I’ve been thinking lately that the model towards where we’re heading is a combination of real-time social media linked to one or more EHRs and PHRs. For example, one of the problems we’re seeing in medicine is the cost (both in time and money) of real-time or near real-time contact with patients. Lack of this real-time contact usually means interventions occur too late, are too costly and sometimes ineffective. I’ve been really impressed with the ability of a group of people to address situations using a tool like Twitter with the primary access device being the smartphone (with 3.3 billion cell phones in the world and 90% of the world population living within reach of a cell phone signal, the smartphone is the natural platform for e-health services).

 In this model the physicians and their teams would follow patients in much the same way that we follow others using our Twitter accounts.  Patients, with access to their medical records would submit periodic short “tweets” with the tiny URLs pointing to specific parts of their charts. In this example a patient might walk into a drug store, take a blood pressure at one of those free electronic monitors and then tweet the results with a link to their vitals section in their charts. This tweet would be immediately seen by the provider team following this patient. If normal no intervention needed. On the other hand if the blood pressure was abnormal or trending one or more of the health team members would tweet the patient with instructions to increase or decrease their medications or take some intervention.  Takes very little time.

 So the two-way street would have a Twitter account  (as the Patient Centered Medical Home) with all of the patients who have identified that provider as their medical home following the health care team while the team follows all of the individual patients. This would allow a single team member to broadcast important information to all of their patients and patients to be assured they have instant access to all members of the team.  Both entities would share the access to the EMR, be able to contribute and link their conversations with the record.

 Of course we’d have to come up with technology so that all the followers don’t see all of the person-level tweets (but hey, that should be an easy technological problem to solve) and individual portions of the EMR should be able to be referenced in tweets (like tiny urls).  Again, that’s relatively easy solution. I would think we could do something where patients’ tweets would be treated like direct tweets but they could determine whether tweets in any directly are retweeted to the entire group of patients following their medical home or restricted.

We would want to make the record searchable by patients so they could link to other patients with similar problems and collectively manage their diseases in the way that www.dreveryone.com is trying to do.  This would allow providers and patients to gain from their collective wisdom.

I think we’re seeing the model for collaborative, cloud computing platforms being developed and will be able to use them daily with Office 10 later on this year. This application links a traditionally personal application to the web so that users can edit documents simultaneously, share portions via links.  In short, like Office 10, the EMR needs to move outside an individual physician’s office or hospital to the internet cloud, with each view or portion being directly linkable (with its own URL).  That would free up huge resources that are now spent on maintaining individual unique EMRs that only a few people can access.

There are some indications this is happening. Microsoft’s Healthvault and Google Health are finally making PHRs functional by focusing on the automated updates and linkages with providers’ EMRs, laboratories and 3rd party payers’ systems. Interestingly Google Health has been likened to Twitter while Microsoft’s Healthvault’s been likened to Facebook. I’ll be very interested in following www.dreveryone.com to see if researchers, clinicians and patients take the time to answer the surveys on each of their diseases and treatments.  Might radically change how we do outcomes studies and manage our patients based on global real-time survey responses.  Looks like I, and the patients, might be able to ask whether a specific medication really worked in the real world in real-time before prescribing it.

Hey, medicine is really getting exciting and the key is transparency and sharing of the medical record.  

 

It’s not EMRs it’s CONNECTIONS

Too much emphasis is being placed on individual physician office EMRs. When individual practices implement a stand alone EMR that’s not connected to others it’s marginally better than paper systems. The problem we have in medicine today is that most physician offices are mom-and-pop shops that don’t invest in the same systems or connections to the other physicians, hospitals, labs and 3rd party payers.
 
This isn’t surprising because most offices can barely afford the $15 – $30K per physician to implement a good EMR system and go paperless in their offices. Interfacing to all of the other offices, labs, hospitals and 3rd party paryers that are involved in the care of their patients would require an investment far greater than what was spent to digitalize their offices. Maintaining these interfaces is also very cost prohibitive.
 
The US government has failed in its responsibility to set interoperability standards and as a result most systems that are implemented at the office level cannot talk to other offices, often if the other office implemented the same system from the same vendor. One of the reasons the government has failed is that we don’t have a single payer system. A single payer system is distinct from a nation wide singer payer. Like Germany and other countries the government should be the single collector and distributor of premiums but we could have private adjudicators. In this scenario everyone would be adhering to the same rules and all computers would share the same underlying database build but would be free to choose from a large number of vendors.
 
Examples of this are the standards for rail systms where almost all railroads share the same track gauge so that a railroad car can travel coast to cost without having to unload and reload it’s contents. Another example is that all of us follow nearly identical rules of the road when driving so we can take our cars and travel anywhere without having to switch sides of the road or learn different traffic signs. Most cars also share similar controls.
 
Unfortunately those underlying rules are not present in the electronic medical record arena so there’s no easy way for the information collected in one doctor’s office or hospital to flow with the patient to other facilities. Until that happens we’re going to continue to flounder and not make much progress in the digitalization of health care. We may also continue to see marginal incremental gains instead of the large savings and efficiencies needed in medicine in order to meat future demands.