Tuesday, December 21, 2010

Nuance eScription Receives 7th Consecutive Best IN KLAS award

Nuance’s eScription Platform Honored with Seventh Consecutive Best-in-KLAS Award

Seven Consecutive Best in KLAS Awards, Market Growth and Continued Delivery of Innovation Reinforces eScription as Leading Solution for Hosted, Background Speech Recognition

BURLINGTON, Mass., – December 20, 2010Nuance Communications, Inc. (NASDAQ: NUAN) today announced that its eScription platform has received a Best in KLAS award for the seventh consecutive year. With a score of 89.8, the eScription platform ranked the highest in the speech recognition category, surpassing its score from 2009 even as the platform’s usage has dramatically grown with both new and existing customers. Today, the number of active dictating clinicians who use eScription is up by 24 percent since one year ago.

The Best in KLAS Award is driven solely from customer feedback, a testament to the demonstrated benefits of the eScription platform and the service and support provided to eScription customers. According to Nuance’s review of past Top 20 Best in KLAS Awards reports, Nuance is one of only four other healthcare IT vendors that have achieved a Best in KLAS product award for the past seven consecutive years. As noted in the KLAS report, 98 percent of customers surveyed indicated they would buy eScription again; this high level of customer satisfaction and confidence comes in 12 percentage points higher than the next highest ranked background speech solution.

“Throughout our partnership with Nuance, the eScription platform has never disappointed and in fact, has met or exceeded all expectations,” said Jonathan Bowers, Vice President Information Services, Carolinas HealthCare System.  “eScription’s ranking as the best speech recognition solution does not come as a surprise.  In 2006, we leveraged KLAS’ ratings as part of our speech recognition vendor selection; our diligence and intuition to partner with Nuance was validated. Today, we’ve reduced report turnaround time by an average of 75 percent, realized significant cost savings and as we approach an annual run rate of 100 million lines through the platform, we are confident with eScription as our standard speech recognition solution across all Carolinas HealthCare System sites.”  

Nuance’s focus on customer satisfaction was echoed at the recent annual Conversations Healthcare 2010 user meeting, where 39 healthcare organizations were recognized for saving one million dollars or more on medical transcription costs as a result of implementing eScription. Cumulatively, eScription Million Dollar Award recipients have reported savings of more than $140 million.

“2010 marks the eScription platform’s seventh consecutive Best in KLAS award, a year of growth for the platform and a year of innovation across our portfolio,” said Janet Dillione, executive vice president, Nuance Healthcare. “Nuance is honored to be recognized by KLAS and by our customers. This distinction comes at an exciting time, one in which we are focused on delivering more value to our customer base and the healthcare industry at large.”

Emphasizing Nuance’s commitment to innovation, earlier this month Nuance launched Dragon Medical Mobile Recorder, an iPhone app that offers clinicians a new level of clinical documentation flexibility by enabling mobile point-of-care dictation that is connected to Nuance’s speech-enabled transcription platforms, including eScription.

2010 Top 20 Best in KLAS Awards were determined based on 25 performance criteria in five categories: Sales and Contracting; Implementation and Training; Functionality and Upgrades; Service and Support; and General. KLAS, a market research firm, published its latest findings in the 2010 Top 20 Best in KLAS Awards: Software & Professional Services report (December 2010). The product rankings are derived from product evaluations and confidential interviews with healthcare information technology (HIT) customers, incorporating performance data collected over the past 12 months (November 15, 2009 – November 15, 2010).

eScription is Nuance Healthcare’s leading on-demand, enterprise-wide transcription platform.  Whether a healthcare organization has an in-house staff of medical transcriptionists (MTs) or uses a fully outsourced approach, eScription is proven to help healthcare organizations reduce document turnaround time, improve consistency and quality, and save costs, without impacting clinician workflow.

About KLAS

KLAS is a research firm specializing in monitoring and reporting the performance of healthcare vendors. KLAS’ mission is to improve delivery, by independently measuring vendor performance for the benefit of our healthcare provider partners, consultants, investors, and vendors. Working together with executives from over 4500 hospitals and over 2500 clinics, KLAS delivers timely reports, trends, and statistics, which provide a solid overview of vendor performance in the industry. KLAS measures performance of software, professional services, and medical equipment vendors. For more information, go to www.KLASresearch.com, email marketing@KLASresearch.com, or call 1-800-920-4109 to speak with a KLAS representative. © 2008 KLAS Enterprises, LLC. All rights reserved.

Nuance’s Healthcare Business

Nuance’s healthcare portfolio of proven, speech-enabled clinical documentation and communication solutions enable healthcare provider organizations to improve financial performance, enhance patient care, and increase patient safety. With more than 10,000 healthcare provider organization customers and 450,000 clinician customers worldwide, Nuance has the experience and solutions that meet the individual needs of any size healthcare provider organization.

Nuance Communications, Inc.

Nuance is a leading provider of speech and imaging solutions for businesses and consumers around the world. Its technologies, applications and services make the user experience more compelling by transforming the way people interact with information and how they create, share and use documents. Every day, millions of users and thousands of businesses experience Nuance’s proven applications and professional services. For more information, please visit www.nuance.com.

Nuance and the Nuance logo are trademarks or registered trademarks of Nuance Communications, Inc. or its affiliates in the United States and/or other countries. All other company names or product names may be the trademarks of their respective owners.

The statements in this press release, relating to future plans or future events or services, are forward-looking statements which are subject to specific risks and uncertainties.  There are a number of factors which could cause actual events or results to differ materially from those indicated in such forward looking statements, including fluctuations in demand for the Nuance products, the relationship with the customer or partner and the continued development of Nuance products.  The reader is warned not to rely on these forward-looking statements without reservation, since these are simply reflections of the current situation.  Nuance disclaims any obligation to update any forward-looking statements as a result of developments occurring after the date of this document.

eScription racks up a 7th consecutive "Best in KLAS" concurrent with a big expansion in the user base up by 24% since last year.
This is a huge testament to the Nuance team who have worked tirelessly to maintain quality and customer service and contributed over $140 Million dollars in savings to multiple healthcare organizations
Thanks to the customers for their vote of confidence and congratulations to the Nuance team who continue to excel at delivering increasing value to the healthcare industry

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Friday, December 17, 2010

Technology helping Physicans Improve their Practice Management

The ability to access clinical information while make clinical rounds proved to be especially helpful to Jon Wahrenberger, M.D., a cardiologist at Dartmouth- Hitchcock Medical Center in Lebanon, NH where he was able to access information real time while at the patient's side and used as a collaborative tool with patients reviewing the information with the doctor

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Wednesday, December 15, 2010

NLP in Healthcare Part 2

Following up from my post back in June (NLP in Health care) the Jeopardy challenge is on - coming to your TV February 14 - 16. There was lots of coverage of the announcement
This from the Washington Post - "'Jeopardy!' to pit humans against IBM machine" and the IBM release
Ken Jennings and Brad Rutter two of the leading Jeopardy winners will go up against Watson. Jennings had the game show's longest winning streak at 74 games in a row and Rutter has won the most money standing at $3.3 million.

What is Watson

But what's important is the possible future applications:
IBM is hoping the technology it exhibits will have some practical uses eventually, for instance helping doctors diagnose illnesses or solving customer problems at technical support centers.
Applying this in healthcare is part of the partnership announced back in October and featured in the posting  "Clinical Documentation Challenges". It will be exciting to see the performance of Watson in Jeopardy on live TV but its the application of this in healthcare that will present some revolutionary opportunities...watch this space

iPad in practice: Applying the apps

iPad takes healthcare by storm - there are still some difficulties but form factor, battery life and ease of use win users over

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Monday, December 13, 2010

President's Council of Advisors on Science and Technology (PCAST) to Release Health Information Technology Report

President's Council of Advisors on Science and Technology (PCAST) to Release Health Information Technology Report


- Kathleen Sebelius, Secretary, HHS
- Lawrence Summers, Assistant to the President for Economic Policy and Director, National Economic Council
- David Blumenthal, National Coordinator for Health IT
- Eric Lander and Christine Cassel, President's Council of Advisors on Science and Technology
- Private-Sector Discussants

This video is also available at

We accept comments in the spirit of our comment policy:

U.S. Department of Health & Human Services (HHS) 

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Wednesday, December 8, 2010

Evidence Based Medicine, Medical Malpractice and Incentives

A recent Dustin Comic like all good comics hit the proverbial nail on the head

Unfortunately the healthcare reform fails to address key aspects to the incentive problem in healthcare. The system remains centered on measuring what we do for patients rather than the end result.

There are moves by employers and the insurance industry to incentives patients towards healthier behavior. This approach is not without problems as highlighted in this piece in the New England Journal of Medicine "Carrots, Sticks, and Health Care Reform — Problems with Wellness Incentives" where the authors highlight the challenges for employers, employees and insurance in creating incentive and how this can introduce inequities that do more harm than good. As they point out
If people could lose weight, stop smoking, or reduce cholesterol simply by deciding to do so, the analogy might be appropriate. But in that case, few would have had weight, smoking, or cholesterol problems in the first place
There is no doubt that patient incentives must be part of the solution but require thoughtful design and implementation to avoid the pitfalls
Incentives for healthy behavior may be part of an effective national response to risk factors for chronic disease. Wrongly implemented, however, they can introduce substantial inequity into the health insurance system. It is a problem if the people who are less likely to benefit from the programs are those who may need them more.
But incentives aligned to the practice of evidence based medicine and in particular the financial challenges facing the ever increasing ordering of tests is where there seems to be significant progress. The announcement of a statewide adoption of Radport by the Institute of Clinical Systems Improvement (ICSI), a nonprofit comprising 60 medical groups, 9,000 physicians, and six payers and health plans was covered extensively at RSNA 2010 in Chicago this year and featured in this piece in Information Week "System Helps Doctors Pick The Right Tests" demonstrating a saving of $27 Million over the preceding year
During the yearlong pilot involving more than 2,300 ICSI-member physicians, ICSI saw no growth in the number of high-tech diagnostic imaging tests ordered. In previous years, the number of tests ordered grew about 8% annually...The lack of growth translates to a savings about $28 million for the year
But any discussion on incentives needs to include the issue of malpractice - liability drives behavior in the same way as incentives do (in some respects its incentive in another from). Peter Orszag opinion in the NY Times Malpractice Methodology makes the point that
The health care legislation that Congress enacted earlier this year, contrary to much of today’s overheated rhetoric, does many things right. But it does almost nothing to reform medical malpractice laws. Lawmakers missed an important opportunity to shield from malpractice liability any doctors who followed evidence-based guidelines in treating their patients.
President Obama weighed in on this issue in June 2009 when he spoke to the American Medical Association when he highlighted the "unnecessary tests and treatments (ordered by doctors) only because they believe it will protect them from a lawsuit" and as he put it
We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines
Medicine remains "more evidence-free" than should be the case:
One estimate suggests that it takes 17 years on average to incorporate new research findings into widespread practice
Addressing the issue of liability can take the traditional approach of limiting punitive damages but as Peter Orszag said "provide safe harbor for doctors who follow evidence-based guidelines" is a much better idea and one that would sit well with patients and doctors alike (I'd be interested to hear from lawyers who agree or disagree on the merits of such an approach).

There are some initial moves in this direction and a need to implement technology to help guide the treatment (as we see with ICSI) and all this would also lead to higher quality of care for everyone and possibly a new system that reimbursed based on the quality of care delivered versus the quantity of care.

Monday, December 6, 2010

8 years on HRT still prescribed in risky high dose format

Despite a Randomized clinical trials (RCT) some eight years ago physicians continue to prescribe hormone replacement therapy (HRT) with regular dosage despite the risks associated with this therapy

High-Dose HRT Still Prevalent (CME/CE)

More evidence for the requirement for clinical support tools and integration of evidence based medicine (EBM) into regular clinical practice. Capturing clinical data at the point of care to enable these tools to provide relevant clinical input and guidance is critical to increasing quality and safety in medicine. The journey begins with capturing clinically actionable data as part of the documentation process without burdening the physician with hunt and click data entry tasks.

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Thursday, November 11, 2010

Radiology Examinations - How Much is Too Much

As is often the cases conflicting information in the media on the benefits of screen, x-rays and healthcare.
This piece in the NY Times: CT Scans Cut Lung Cancer Deaths, Study Finds suggests that annual CT Scans of current and former smokers reduces the risk of death form lung cancer:
Annual CT scans of current and former heavy smokers reduced their risk of death from lung cancer by 20 percent, a huge government-financed study has found. Even more surprising, the scans seem to reduce the risks of death from other causes as well, suggesting that the scans could be catching other illnesses.
And while there does seem to be some benefit as Dr Patz (professor of radiology at Duke who helped devise the study) put it:
he was far from convinced that a thorough analysis would show that widespread CT screening would prove beneficial in preventing most lung cancer deaths. Dr. Patz said that the biology of lung cancer has long suggested that the size of cancerous lung tumors tells little about the stage of the disease. “If we look at this study carefully, we may suggest that there is some benefit in high-risk individuals, but I’m not there yet,” Dr. Patz said.
And before you run out the door to get your CT scan its worth taking note of Dr Ben Goldacre's insightful blog Bad Science that takes a hard look at the science behind claims and does a great job debunking the myths and taking a hard look at statistics. But as we have seen over the last few months there is an increasing focus on excessive use of imaging technologies. Earlier this year the Imaging e-Ordering Coalition (Co Chaired by our very own Scott Cowsill) Successfully made a case to congress to include computer-based physician order entry (CPOE) solutions as a potential method for imaging utilization management in recently passed health care legislation:
the Coalition is making several recommendations to policy makers in Congress and CMS...One of the recommendations is that imaging CPOE tools should be based on consensus medical guidelines and literature, such as the ACR's appropriateness criteria. Another recommendation is that CPOE and decision support tools should be compatible with any CMS-approved electronic medical record (EMR) systems and be able to track results.
In recent news the Healthcare alliance aims to improve the imaging process, Changing the Game the coalition continues to push for
E-Ordering, also referred to as clinical decision support (CDS) (to) provide(s) physicians with real-time, electronic access to pre-exam, case-by-case decisions linked to evidence-based clinical guidelines and tailored to a patient’s specific circumstances
and cites a 7-year study at MGH (pub 2009) that showed a dramatic decrease in the growth rates of several imaging exams
  • CT exams down from 12% growth to 1%
  • MR exams down from 12% dropped to 7%
  • Ultrasound down from 9% to 4%
So with that in mind the concurrent news that Minnesota’s Institute for Clinical Systems Improvement (ICSI) is spearheading the First Statewide Effort to Help Ensure Patients Receive Appropriate High-Tech Diagnostic Imaging Tests that is targeted to save Minnesota healthcare community more than $28 million annually (this was the savings estimated from the year long pilot with 2,300 physicians from five Minnesota medical groups, five health plans taking part. You can read more about it here, and here in the Star Tribune in Minneapolis St Paul and here on ZDNet

The process and challenges are outlined in this video:

Showing how you can help the busy clinician by providing them with a simple, intelligent and above all standardized appropriateness criteria to guide the clinician in ordering the most appropriate study for the patient at the time of consultation. This improved patient satisfaction, clinic efficiencies and reduced administrative costs. While there will be those who distrust technology over seeing clinical decision making the solution does not force or prevent clinicians from ordering the test they deem the most appropriate. What it does do is provide evidence based guidance on the suitability or clinical appropriateness of the test.

How do you feel as a patient or as a clinician on technology guiding care choices? Like it or not expect to see more as we continue to cope with a veritable Tsunami of clinical data, studies and discoveries that by some estimates require a doctor to read for 70 hours per week just to keep up in their one speciality.

Friday, November 5, 2010

The Problem with Problem Lists

A colleague and friend wrote this great piece for Health Management Technology : The Problem with Problem Lists in which he reviews the history of the problem list (now over 40 years old!) and while

While their value in patient care has been demonstrated in countless studies, physicians have historically adopted them with much less enthusiasm than one would expect.

They are not as prevalent or pervasive as you might expect. IN fact this was subject to an extensive discussion on a list serv and I made the point here that managing these expanding list of problems can be a significant challenge for any system. It tends to be easy to add problems but as Davide points out 

While patients’ diseases, symptoms and risk factors evolve and change, the corresponding items on the electronic problem list tend to age rapidly and may soon become irrelevant or even inaccurate. For example, a certain symptom may have disappeared, or an initial diagnosis may have been further defined, making the initial description too generic to guide actual care. Additionally, as multiple specialists engage with a patient, they focus on problems that are both different and overlapping. While each provider contributes to the problem lists (from different perspectives), patient data rapidly becomes repetitive or redundant, rendering the electronic problem list less useful

As one of the commentators pointed out clearly defining what should be captured and documented int he problem list is a god place to start and supplementing that by cleaning up old information (archiving old details, problems and information that perhaps was relevant but has now either been over taken by events (OBE) or was relevant for a specific episode of care but is now not.

But capturing the latest information from the range of inputs remains a challenge and facilitating narrative based documentation 

to preserve detailed and expressive descriptions of patients and their stories and are commonly accepted as the best way to capture and arrange the informational background on which effective diagnostic reasoning is based.

Is preferred by many but unfortunately 

The final output of such systems is a textual clinical note.

Technology is now starting to address this problem by providing tools that analyze the content of the narrative, understanding the underlying clinical description and intent of the physician.

Consider this sentence: “The otitis media for which the patient was seen last month appears to be fully resolved.” CLU automatically and reliably assesses that the “otitis media” is “resolved” and thus should be removed from the list of current problems. Today, this action would require manual editing of the data. However, with CLU this happens automatically, with the physician confirming the deletion.

Thereby bridging the clinical divide between the physicians desire and need to document the full clinical condition in narrative form capturing all nuanced detail of the patient's history and the need to automatically extract clinical data and facilitate the integration of structured semantically interoperable data directly into the EMR.

Timely innovation given the major push towards electronic medical records as part of the governments incentives in ARRA and HITECH and relevant in any clinical setting where narrative remains the key data captured.

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Monday, October 18, 2010

Meaningful Use and Clinical Documentation

We are facing significant changes to the world of clinical documentation with the big push encompassed in the Meaningful Use requirements that push provides and healthcare facilities inexorably towards an electronic medical record (EMR) but there remain significant concerns over the potential impact these solutions can and will have on our clinical documentation.

In this piece in the Archives of Internal Medicine (Subscription required):Time Spent on Clinical Documentation: Is Technology a Help or a Hindrance? (abstract) the review of the excessive burden of clerical work was cited as a detractor to the learning process for residents buried in a quagmire of administrative burdens. While the authors acknowledge the value that EHRs bring including more efficient and safer order entry, easily accessible clinical information, and the ability to facilitate documentation through decision support or documentation templates. While these positive effects can streamline and potentially diminish the low value tasks their experience at the University of Chicago demonstrated that
residents often research a new patient extensively on the EHR prior to the history taking and physical examination, preferring to obtain information via clerical work rather than direct patient assessment. In addition, the well-described habits of "cutting and pasting" notes or copying forward previous notes with minor daily updates are work-arounds that may save time but provide little opportunity for education and reflection about a patient's course

This was further emphasized a recent interview in Healthcare Informatics Medical Documentation and Meaningful Use focusing on the challenges of meaningful use and the loss of the narrative:
Policymakers have been too caught up in discrete data fields, putting the narrative element of the medical transcription process in jeopardy (and) meaningful use rules do not go far enough in guaranteeing that information is robust enough to provide a basis for complex clinical decisions and coordinate patient care. “Granularity and specificity have been overlooked,”

As he point out
It would be unfortunate to sacrifice the nuanced reporting by an overemphasis on discrete data. Structured reporting does not necessarily mean sacrificing the whole, nuanced record

But if you remain unconvinced this excellent paper "Communication of Clinically Relevant Information in Electronic Health Records: A Comparison between Structured Data and Unrestricted Physician Language" in the AHIMA Journal Perspectives carried a study to determine what information is lost when free dictation of data is replaced with structured entry of information?:
If physicians restrict themselves primarily to structured data entry, what happens to the “nuances of patient variability”

According to the authors nobody has yet attempted to answer this particular question which leaves a major gap in our understanding of the long term impact of the EMR on our clinical knowledge in the context of data, information, knowledge, wisdom (DIKW). And while there are some advantages to the capture of structured data and integration of information from different sources and disparate systems (an important goal in the meaningful use framework) the disadvantages of this limited selection of choices include the increased time to document (= less time with patients or for patients) but more importantly "discrete data may not catch the nuances of patient variability".

The study while limited in size attacks the problem systematically and in sufficient details to arrive at what can only be described as very troubling conclusions. Naturally dictated cardiology notes were manually highlighted with information that would be captured in a a structured data entry system. These annotated notes were then reviewed by two independent physician experts who were asked to review the highlighting of the notes and imagine himself as a physician assuming responsibility for the patient, and to imagine that the highlighting had been added by the previous physician, indicating what he or she believed to be clinically relevant and necessary to include in the communication. In an inspirational piece of design there was no mention of the EMR/EHR and structured note taking so the content was reviewed in pure clinical terms - brilliant! The experts scored missing content that was marked up rating the missing content (if any) in terms of the severity of the omission:
1 - Minimal Severity through to
5 - failing to mark up the language was extremely severe, in terms of having serious consequences for the care of the patient if that clinically relevant information had not been communicated to you

The results, even in the most conservative analysis:
(they) find that 50 percent of the notes include at least one omission rated 3 or higher on a 5-point scale, and 25 percent contain omissions rated 4 or higher

So fully 25% of notes contain omissions that rated 4 or 5 on the severity of the clinical impact of that omission! With less conservative analysis at least one expert showed 100% of notes as containing at least one omission rated with severity of 3 or higher, with 5.25 such omissions on average and omissions with “serious consequences for the care of the patient” (severity rating equal to 5) in fully 55 percent of the notes!
That's worth restating:
All notes contained clinically significant omissions (Grade 3 or higher) and on average contained 5.25 such omissions and over half contained severe omissions!

The content that was missed in some cases could be added to flexible systems but there were distinct pieces of nuanced or detailed elaborations of information and temporal/logical content and the clinician thought process for example:
- after identifying reporting severe pain in one patient’s neck and back, the dictating physician adds that she was “almost brought to tears just in getting her up on the examination table.” Both experts found it relevant that a patient was “able to walk on flat levels and walk at a moderate pace for one hour without abnormal shortness of breath or chest pain.”
- a patient’s nonsustained ventricular tachycardia (fast heart rate) occurred “during post myocardial infarction care…far removed from the time of his infarction.” The cardiologist found it highly relevant, for another patient, that the dictating physician was “hesitant to recommend his FAA certification renewal” without a repeat of a previous catheterization.
- the physician recommends continuing Toprol because it “seems to be controlling [the patient’s] palpitations well.” In another, the dictating physician considers discomfort to be “suggestive of angina.” In a third, the dictating physician expresses a belief that results of stress testing “would rule out significant major coronary artery disease, despite it being a somewhat incomplete study.”

While the study size is small and there are some potential acknowledge bias the design and conservative analysis suggests the problems is very significant and adds further weight when considering the methods for capturing and recoding clinical data. And while it is possible that adding this missing content is possible with the free text fields replete in EMR systems I have heard clinicians say they have modified their patient diagnostic review process to avoid the "other" field specifically to limit the time necessary to type this content into the "other" box. Adding speech recognition technology can decrease the time to populate these boxes but providing a more elegant and integrated solution that allows for capture of the full patient story and clinical history. As the authors conclude:
Even under quite conservative assumptions, we have found that important clinical information, detail, and nuance would fail to be captured by an EHR standard’s discrete fields, with potentially serious consequences for the patient. Such omissions could potentially influence not only clinical care, but the progression from data to information to knowledge discovery in clinical research. Clearly the question merits further attention and study.

In the inimitable words from Master Po in the iconic 70s TV Series Kung Fu:

Tread lightly grasshopper

The narrative must be integrated and preserved and will remain a fundamental foundation of clinical knowledge now and into the future of healthcare information systems. How are you preserving the information in your EMR or have you seen the record dumbed down?

Sunday, October 17, 2010

Vaccination suits

While the idea of law suits against vaccine manufactures is appealing. Opening these doors to a multitude of frivolous cases will have a chilling effect on vaccine development and vaccine use

Supreme Court Considers Vaccine Injury Case

On the list of snake oil challenges is the vaccine causes autism bunkum. Unsupported in any scientific study but perpetuated by a wide range of people who may have good intentions but are using their influence to damage years of hard work building vaccination programs and relegating serious and life threatening diseases to the  history books

Let's hope the Supreme court can take account of these effects as they consider this case. If not we could be in for a rash of diseases.

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Adults need Tetanus Diptheria Boosters too

Don't think immunization is just for kids its not. Adults need those boosters too

Adults Not Getting Tdap Boosters (CME/CE)

Have you had yours?

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Thursday, October 14, 2010

Physical examination a dying art that needs to be resurrected

In a timely piece from the NY Times featuring Dr Verghese who continues to demo strategy and teach medical students that the physical examination is an essential part of the clinician patient interaction. 

At Stanford, Dr. Abraham Verghese on a mission to bring back something he considers a lost art: the physical exam.

In what seems much like the House brilliance of observation combined with a ready wit and and extensive knowledge of medicine Dr. Abraham Verghese vividly demonstrates the value and contribution of the physical examination and worries that the skill is being lost in American medicine and is not being taught to medical students in the US. 

The physical exam should not be relegated to history books and while time pressures make spending time on this intimate interaction difficult the rewards are not just found in more clinical information but also closer links to patients. 

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Wednesday, October 6, 2010

Clinical Documentation Challenges

We are on a path to roll out a large swathe of Electronic Health Records (EHR) but a recent report published on the AISHealth.com Audits of Electronic Health Records Cloning Reveal Documentation Problems That Put Compliance at Risk will give many folks reasons to pause and consider their strategy in rolling out electronic medical records and reconsider how they capture information in these systems.

Interestingly the article suggests that EHR's "can reduce the time it takes physicians to document patient encounters" but there is a fair amount of research suggesting that EHR can increase the burden and time taken to document. A study in the Healthcare Ledger in March 2009 showed an increase of ~ 4x when documenting using the EHR and there is increasing concern that the current burden of clerical work being required of medical residents is limiting the educational opportunities and failing to teach our future doctors the process of reflection and distillation of a patient history that is an essential part of the diagnostic process (Doll and Arora 2010). Add to that that many EHR systems limit the potential for capturing the complete clinical story of the patient as outlined in a recent study “Communication of Clinically Relevant Information in Electronic Health Records: A Comparison between Structured Data and Unrestricted Physician Language” (Resnik, Niv et al 2010) in a systematic comparison between free natural language dictations and information codified by structured categories in an EHR demonstrated a failure to capture clinically significant information. Even in the most conservative estimate the study demonstrated 25% clinical omissions that rated 4-5 on a 1–5 scale of seriousness (1 being minimal severity and 5 meaning severe).

However the access to real time information and improved legibility deliver significant benefits and advances into our healthcare system. But as Nina Youngstrom points out:
CMS and Medicare contractors are wary of classic EHR physician documentation shortcuts — cloning (cut and paste), macros and templates — and audits are bearing out their concerns
As the audit demonstrated "Each note should contain individualized data that supports the medical necessity of the visit or procedure.” and problems stem from EHR documentation shortcuts:
  • Cloning (cutting and pasting): Physicians copy information from previous patient encounters (e.g., demographic, history of present illness, exam, medical decision making) and paste it in the current encounter.
  • Templates: Physicians fill out templates for patient encounters that cover a lot of ground with a few key strokes. The review of systems is pre-filled with the term “negative” for each organ system. For positive answers, physicians must change “negative” to reflect the positive response given by the patient.
  • Macros: Macros are a type of EHR shortcut that allows the entry of generous customized data quickly. Though initially CMS resisted the use of macros, the agency gave its approval for their use by teaching physicians (see Medicare Transmittal 811). With macros, teaching physicians, for instance, type in “.liv” to convey “liver exam,” which triggers a drop-down menu of choices for the next step.

So avoiding these pitfalls and capturing the essence of the clinical consultation in the "Medical decision making" which is the cognitive process and is hard to document with templates and macros is key to both good quality documentation as well as avoiding potential CMS audits and challenges in the future.

There is no one size fits all to these challenges and in different clinical circumstances different solutions will be beneficial but providing tools to document the complete narrative and extract key data elements will help drive clinically actionable data into the EHR while maintaining the decision making process that includes taking and documenting a full history without burdening the physician with mundane data entry tasks. Clinical Language Understanding offers to bridge this divide capturing the voice with proven voice recognition Technology (Dragon Medical) and the exciting addition of Clinical Language Understanding: The video demonstrates the CLU in action offering an alternative path for clinicians weary from screen based data entry:

Or you can see the video here, and can see Paul Ricci on CNBC "Street Signs” hosted by Erin Burnett "Nuance Partners with IBM":

and read about the collaboration with IBM here. What would you rather be doing? Manual data entry or dictating. This announcement and the work underway offers a solution that bridges the divide between the need for clinically actionable data and physicians desire to capture the complete clinical story for the patient.

Thursday, September 23, 2010

Voice is Ready for Prime Time

Mike Elgan said so......: Say it with me: Voice is ready for prime time, It's time for the victory of voice to shout down the tyranny of text in this enlightening piece that had many comments all in the positive relative the to advance of technology
Talking is the best user interface...Language is natural to people and universal to all cultures. Language is a spoken medium. Written language is merely the symbolic representation of spoken language. It's an abstraction, but a necessary one.

And he asked But is the technology there yet?. You bet!
In the future, we'll talk to our computers and they'll talk back. We know this is true because talking is the most natural way for human beings to communicate. The evolution of the human-machine interface always moves the workload of interaction from the person to the computer. The perfect UI would be a natural conversation, just like you have with other people.

Could not have said it better myself! This is especially true in the healthcare setting where clinicians are overwhelmed with paper work and documentation requirements. As Mike points out there are hurdles, no insurmountable
  • Technology: creation of software (supported by powerful hardware) that can understand spoken language
  • Technology: content must be searchable. Text can be indexed, and we've grown addicted to the ability to search for and find the things we've written, and
  • Cultural: the barrier to voice-based computer interaction is one of habit. We've grown used to typing on keyboards. Although speaking is natural, speaking to a computer feels a little weird at first. And people generally don't like learning a new way to do things.

In the piece he features three products that address these issues and go much farther VoiceBase for indexing and searching, DialtoDo to convert spoken utterances into action, and as he puts it the Mother of All Voice Applications, Dragon NaturallySpeaking 11 from Nuance.
Dragon NaturallySpeaking takes dictation so accurately that it begins to approach Steve Jobs' favorite word: "Magical." For the first week of use, I was actually shocked when it correctly recognized obscure names, extremely technical terms, brand names with correct capitalization (for example, iPhone) and performed other unlikely feats. Since I started using it, I've written the first drafts of all of my columns and blog posts, including this column, using Dragon NaturallySpeaking.

But as Mike points out the downside to this innovations, speed and accuracy that is especially relevant to healthcare is the lack of time to think. Many of us use typing time as thinking time....if you lose the typing time you lose the thinking time and generating content becomes a little more challenging at first:
The accuracy has an unexpected and very welcome side effect: It makes it easier to write. I assumed that typing was automatic, requiring little brain power. But using Dragon has demonstrated that mental energy was diverted from the task of typing to the task of thinking, which is what makes writing so much easier. I can also write faster using Dragon.

This requires a change in behavior and an adaptation to the lost thinking time that can make clinicians feel less productive as they have to pause during dictations. But for those that already adapted to dictation and that process is easy (think existing dictating clinicians who use a telephone or hand held recorder device to dictate and generate clinical notes using traditional dictation and transcription) then a move to dictating directly to your PC is one step closer.

But be warned as he identified "It's not feasible yet for most people to completely abandon keyboards, mice and text and interact entirely via the spoken word." - so don't try to make that happen or expect it to happen. Again think of the telephone and texting - in some respects Texting could be considered a retrograde step but for many (read millions) texting is preferable to actually using the phone to speak to someone.

Embrace the tools that make sense in your work and home life and importantly as I said in this piece at HealthCareIt Guy Blog: Top 10 tips for successfully using speech recognition in EHRs and healthcare apps spend the money on a good microphone

I'll leave you with Mike's closing comments:
And what can I say about Dragon NaturallySpeaking 11? It's the biggest user interface advance since the iPhone. The bottom line is that voice is finally ready for prime time. I've decided to continue my experiment indefinitely and to keep pushing the voice envelope as far as it will go. Voice makes using a computer faster, easier and a lot more fun.

How about you - have you made the jump? Can it work for you in your environment and if not what is is the barrier to using voice in your world?

Wednesday, September 22, 2010

Fish oil studies

No doubt the recently presented abstract on fish oil will drive even more alternative medicine claims. The study currently preliminary:

HFSA: Fish Oil Benefits Early Heart Failure (CME/CE)

As always the data requires careful analysis and while superficially linking taking fish oil to reducing cardiac diseases but there are problems with this approach

- the study was arrows out on patients with Cardiomyopathy
- study is preliminary and yet to be reviewed and published in a peer review journal

While taking fish oil may not cause harm (apart from your wallet) linking this abstract for the purpose of selling more fish oil is a major part of the misleading activities that take place to confuse the general public and persuade them to buy unnecessary alternative therapies. 

Posted via email from drnic's posterous

Dementia to increase by 85% over next 20 Years

In yet another noteAble challenge faced in the healthcare system over the coming years is the massive increase in Dementia over the next 20 years. Expect to see an additional 85% more in the next 20 years

Report Predicts Massive Dementia Burden

This is another symptom of the baby boomers getting older tied to the inevitable health decline we all suffer with age. 

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MedIcare moves to Fingerprinting

In a move away from "pay and chase" to fraud prevention Medicare will start to ask for fingerprint and background checks on some beneficiaries in an attempt to decrease fraud

Medicare Proposes New Anti-Fraud Measures

Challenging problem with big money at stake but seems this strategy may fall foul of individual rights based on innocent until proven guilty?

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Length of Compression stocking Matters in DVT Prevention

For Compression Hose, Length Matters (CME/CE)

Using above knee bs cAlf length compression TED stockings improves prevention of DVTs in at risk patients

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Thursday, September 16, 2010

Junior Doctors Hours

The topic of hours and fatigue in medicine continues to rumble on with no real resolution in site. A couple of recent articles and news items highlighted the continuing challenges.

The Daily Mail reported the Coroners' comments and verdict in this piece (Coroner hits out at doctors' hours after patient dies) and Doctors.Net also featured the report: Junior Hours Blamed at Inquest (membership required)
An elderly man died in hospital after waiting five hours to see a doctor. After being told how Roland Holbrow died without seeing a doctor, a coroner yesterday criticized European rules that restricting junior medics' working hours.
Michael Rose described the European Working Time Directive....'Hospitals are running into problems,' he said. 'I can see the clear warning signs, although I am not going to refer this to Mr Lansley as I think he will already be aware of it.
There's no shortage of views from both sides of this discussion:

Those in favor of restricting hours
..I don't agree that anyone should work that amount of hours, its not safe, and it courses problems in the future.
..criticise the PCT for not employing enough Doctors.
..Hospitals at fault here for NOT recruiting sufficient staff to provide proper shift cover... instead, they've been reducing manning levels instead so as not to exceed the WTD hours limit
..At the end of the day though do we really want to be treated by a doctor who has been on duty for over 12 hours. Pilots and the like are restricted on hours worked for safety reasons so should we really be seeing a doctor who is dead on his/her feet and then expect them to make the correct diagnosis first time every time. I doubt if many hospital administrators have a clue what happens overnite in their hospital and how bad things are they will have left by 5 30 in any case

And those that think we need to return to longer hours so junior doctors get "more experience"
..Good to see such a courageous coroner and Clinical Director, both willing to speak unpopular truths. We must unshackle Juniors from the restrictions of the "New Deal", and EWTD, whilst maintaining a sensible work / not work life balance. Also we need a 24/7 365 days a year fully active acute sector i.e. more flexible working all round, and likely more doctors
..can some one explain to me why FY1's were taken off doing night shifts and regular weekends? It seems ridiculous that we have a national shortage of doctors yet a massively under used resource of Dr's needing exposure so as to mature into decision making
..A few facts about EWTD. 1. It was never intended for the professions. I know of no professional (or other successful person in other walks of life) who has worked ONLY 48hrs pw when 'on the way up' (or indeed having 'arrived'!)

Even some senior surgeons weighed in in a letter to the Telegraph suggesting limiting hours will have a significant adverse impact on patient care. In fact they have been arguing that junior doctors need to work more hours
The College and others have consistently argued that junior doctors need to work more than the 48 hours per week permitted by the European Working Time Directive in order to amass enough experience and learning to become safe and competent surgeons.

Interesting a study just out in the Journal of Amarican Medical Association: "Presenteeism Among Resident Physicians" and was featured in the NPR Shots Blog Doctors-In-Training May Give More Than Medical Care:
nearly 60 percent of respondents said they had worked while sick at least once and nearly a third reported having worked while sick more than once. At one "outlier" hospital not named in the study, 100 percent of the respondents reported having reported to work while sick.
A related problem, the survey found, is that busy medical residents (who are already known to not get enough sleep in the early years of post-medical school training, despite rules attempting to ensure they do) also reported not having enough time to see a doctor for their own medical care.

One thing is for sure - tired people are not giving their best. As one junior doctor put it
In the last 2 weeks I have worked 105 hours without a day off. This is my rota and includes no overtime. I would say my patient care was compromised at the end as was my love for the job. ....I have maximum 2 hours of teaching every other week as the wards are too busy to leave the rest of the time

Managing the hours and providing a good working environment is going to be essential. Technology will play a role in helping reduce work burdens and creating efficiencies but updating our training system must be included in the update to our health systems

Tuesday, September 14, 2010

Shout Out to Dr Frances Oldham Kelsey - Iconic Image for the FDA

Dr Frances Oldham Kelsey was ahead of her time and is to be honored tomorrow for her contribution in preventing a a much larger Kevadon (better known as Thalidomide) disaster that occurred in Europe:

50 years on much of her insistence on scientific rigor and data remain the main stay of drug review and our process for managing new drugs and procedures. INteresting for someone who got the job because her name sounded like a man's

She was hired sight unseen by Dr. Eugene Geiling, a renowned pharmacology professor at theUniversity of Chicago, because he read her name as Francis. When she got the acceptance letter, in 1936, she realized his mistake and asked a professor at McGill University whether she could accept the job.

Not sure things have changed as much as we might like given the intense focus currently on Women's Equality Day on inequality on women's opportunities and pay

Dr. Kelsey demanded better tests for thalidomide. She also distrusted Merrell, a company that had a history of confrontations with the F.D.A. She soon discovered that Kevadon had been linked in Europe with reports of nerve damage — reports the company had failed to provide her.
“I had the feeling throughout the day,” she wrote after a meeting with company executives, “that they were at no time being wholly frank with me and that this attitude has obtained in all our conferences, etc., regarding this drug.”

Again - not sure things have changed much and we must continue to demand science and data to support treatments

Posted via email from drnic's posterous

3-D Printing WIll Impact Joint Replacements Soon

New developments in technology to allow for the creation of components in real time in three dimensions

imagine the possibilities for grafts, artificial organs and joints built customized to the individual. We are starting to see customized drugs - it won't be long before we see customized implants and even artificial organs.

Posted via email from drnic's posterous

Tuesday, September 7, 2010

Health Care Wastefulness Is Detailed in Studies

I'm what is probably no big surprise we find detailed studies showing billions wasted with unnecessary vista to the doctor and the ED:
Health Care Wastefulness Is Detailed in Studies

A heavy reliance on emergency rooms care is seen as a sign of weaknesses in the primary health care system.

If there's a lesson here it's the fixing of the healthcare system involves everyone of us. Making good choices, intelligent use of resources and an acceptance that things are going to change in the way we decide on care, who receives what and when
Are you playing your part

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Friday, September 3, 2010

Dragon Helps Matchmaking

The latest in a an annual competition looking for unusual and innovative users of Dragon the winner of the 2010 I speak Dragon contest EvanUp posted a story Dragon NaturallySpeaking: a matchmaker - a truly heart warming story of adversity that was overcome by chance introduction linked to Dragon and culminated in marriage......EvanUp the author was diagnosed with MS

After a few strange experiences with blurred vision and numbness, I was diagnosed with multiple sclerosis and was absolutely terrified by what it might do to me.

His local administrator suggested he try Dragon and pointed him to another user who told him without any hesitation or reservation matter-of-factly:

“I have MS. It started affecting my hands so I got Dragon. It saved my career. Why do you ask?"

Sharing a common bond and enemy the two formed a friendship that culminated in marriage and as EvanUp puts it:

Dragon NaturallySpeaking and multiple sclerosis served as our extremely unlikely matchmakers, and the luckiest break I've ever had

In what is important in life this ranks up at the top on my list and aside from congratulating EvanUp for winning the competition I want to thank him for sharing his quite personal but truly positive outlook on life in the shadow of adversity.

Wednesday, September 1, 2010

What is Clinical Informatics

In a recent online discussion the question was posed "what makes up the skills and requirements of a CMIO". There was much discussion on the nature of the job, the skills needed and where new recruits needed to go to get those skills. But one reply stood out linking the skill set to everything we learn and do as clincinas. So with the permission of of a W Joseph Ketcherside MD, CEO of the Ketcherside Group and a Clinical informaticist who also practices of clinical medicine I post his response in it's entirety

Our patient (a health care system) comes to us with a Chief Complaint (I want to install an EMR).
We gather a little more specific information by taking a History of Present Illness (Why do you want to install an EMR? Improved safety? Decrease cost? Improve quality? Integrate inpatient and outpatient care? And so on.)
We take some Past Medical History (What systems have you worked with before? Any successful implementations? Failed ones?)
We do the ROS (How do you sit in the market? Market share? Referral areas and types? What are the financials? What is the culture overall?
What academic relationships do you have? What is your system's relationship to the community? And so on.)
Then, we do the Physical Exam (Current state analysis and documentation. Palpate the database. Auscultate the medical staff.)
We develop a Differential Diagnosis (Major processes that could be impacted and possible solutions.)
We work with the patient (health system) to determine what a good health outcome would be for them (Future state model).
We come to agreement on a treatment plan (Implementation roadmap and project plans) that will reach that future state.
Then we operate (implement) and, hopefully, are lucky enough to provide ongoing care (continued improvements).
So, I still practice medicine. When I was a neurosurgeon I cared for multi-system organisms (people).
As a clinical informaticist, my patients are multi-organism systems. But, they are still my patients.
And, sitting in the ED on a Saturday night of a CPOE go-live, I would observe that CPOE implementation is exactly like clipping an aneurysm - hours and hours of boredom randomly interspersed with moments of stark terror.
So that's my two cents on the practice of Applied Clinical Informatics.

This resonates with me and is close to the points I made in a guest posting over at Healthcare
IT Today "A Day in the Life of a CMIO. WHat's your experience - what makes a good healthcare informaticist?

Tuesday, August 24, 2010

Top 10 Reasons to go Digital in Healthcare

In the Spirit of helping those that face the digital tidal wave of technology in healthcare with trepidation I offer the following top ten reasons why this will be a good thing and include some thoughts on easing the transition from current methods to a digitized clinical office

1) Ready Access for Everyone
Paper medical records cause harm and in multiple studies have been shown to fail to deliver the necessary information to all the clinicians involved in care. In a study I quoted some years ago done by then Arthur Anderson they found that in less than half of patients cases the relevant clinical notes were neither available or could be found at the time the patient was seen. Digital records are available to everyone involved in the care of the team who has access. Instant availability provides referring physicians and specialists as well as the patients with a copy of medical record quickly and conveniently.

2) Digital Record are More Easily Kept Up To Date
New innovations and digitization allows for the capture of information by the patient prior to a visit. Almost every clinical facility asks patients to fill in forms as they sit in a waiting room – the information contained in these forms is marginal at best and locked away on a piece of paper. From a patient perspective the information has likely been provided to multiple other offices and clinical providers. Digital records are on the pathway to effective and meaningful sharing of clinical data that will remove the need to render or re capture the same information. Focusing on capturing it once and allowing the patient to review it for correctness and completeness at the time of the visit is likely to lead to a much higher quality more accurate medical record. It may seem foreign to many clinicians but the patient probably has the biggest vested interest in an accurate and complete medical record more so than anyone else involved in the clinical care process. In some cases the digital record can be shared with the patient ahead of time online in a secure environment and they can check, update and complete this before arriving for their appointment.

3) Filtering and presentation
Clinical information captured as data throughout the continuum of care can be presented in innovative and more useful ways ("Can Electronic Clinical Documentation Help Prevent Diagnostic Errors"; N Engl J Med 362;12 March 25, 2010 pdf).
Seeing a single blood pressure reading adds little to the clinical decision-making process. Seeing the blood pressure plotted over time with a clear upward trend is far more useful in identifying hypertension that requires treatment.

4) No Need to Loose the Narrative
Capturing the whole story remains an essential component of any clinical record with the history contributing anywhere up to 80% of the final diagnosis. As part of any move to the digital medical record the inclusion of this narrative and the ability to record it without interfering with the normal workflow is a must. EHR’s have a wide range of tools and techniques for capturing and recording the patient record and there is wide variation in their use. Different specialties have different needs – in ophthalmology there are many data points routinely collected and form filling on a computer or digital tablet is likely to be efficient. General medicine on the other hand is dependant on the narrative and the detail behind the symptom. In this case it is important to provide tools to capture the data efficiently without adding to the time required for documentation. Historically these notes were hand written which probably induced an element of brevity. Hand written notes were replaced by dictation and transcription which while efficient for the clinicians introduced delays in the availability of information to the referring physician and other clinicians and proved costly. Recent moves introduced templates and forms along with tools to create these notes and while they work in some cases there are disadvantages of losing the patient story, and the inability to convey the meaning (“The transition from paper to electronic inpatient physician notes”; J Am Med Infom Assoc 2010; 17:108-111 abstract). Speech remains the most common means of communication and providing tools to capture the clinical story and convert that into a digital record have been successful in many settings (Fallon clinic Study). The key to success is offering a progressive blend of tools and methods to accommodate individual preferences and situational constraints. No one method suits all circumstances and all individuals and providing choice is the key to success. Present a choice and allow regular dictation and transcription while offering a pathway to more structured data entry, either through computer based forms entry or using speech recognition dictating directly into the EMR. (Save the clinical narrative)

5) Creating Structure and Data
If the narrative forms is an essential part of any clinical record so is structured data but generating both elements remains a challenging prospect for the busy clinician. New technologies on the horizon will automatically process the narrative and extract data elements to be placed directly into fields within an EMR. Using clinical language understanding (CLU) in conjunction with speech recognition technologies allows the clinician to document a succinct evaluation and description while automatically producing a discrete and codified problem list among other key clinical values. Codification renders this data useful to the EMR making it semantically interoperable. This forms the basis of the decision support, evidence based medicine and the error catching for ePrescribing solutions that have built in databases of contra indications based on specific clinical conditions (an allergy for instance) or careful monitoring and adjustment of doses based on renal function test (Gentamicin for example needs careful monitoring of renal function to prevent hearing damage)

6) Practical Clinical Support Tools
Human memory alone cannot guarantee the right questions and clinical information is gathered and applied to arrive at the most likely differential diagnosis. The landscape of clinical knowledge is rapidly changing and becoming more complex. Doctors need approximately 2 million pieces of information to practice medicine and subscribe to an average of 7 journals representing approximately 2,500 articles per year that they must read, process and then apply in order to stay current – an all but impossible task that is only getting harder (Sackett DL: Surveys of self-reported reading times of consultants in Oxford, Birmingham, Milton-Keynes, Bristol, Leicester, and Glasgow, 1995. In Rosenberg WMC, Richardson WS, Haynes RB, Sackett DL. Evidence-Based Medicine. London: Churchill -Livingstone). Digital records are the basis for applying knowledge and providing decision support to busy clinicians. While these alerts and tools are still in their nascent form, many are far to intrusive and can be triggered too easily. Refinement of these tools will bring about better quality of care helping prevent errors and facilitating informed decision making for patients and clinicians.

7) ePrescribing – The Key to Safer More Efficient Prescribing
Electronic prescribing appears to reduce the rate of medication errors and should be an integral part of any clinical system. While the process of entering a prescription can seem arduous initially efficiency is rapidly achieved through frequent use and user customized and system stored favorites and pre populated prescriptions can ease this pain. Add to that the value of legible prescriptions that are almost instantly available to pharmacies and help the patient and the pharmacist and clinicians deliver the right drug with the right dose to the right patient at the right time. And built in to the prescribing system are contra indications, allergies and drug-drug interactions that can be caught as part of the prescribing activity, reducing medication errors and improving the quality of care.

8) Timely and Failsafe Communications
Computers are good at repetitive tasks and once programmed never forget. Tracking results, tests and clinical findings and ensuring that urgent communications reach the intended recipient every time is easier using a digital record. Much of our personal lives are now organized using mobile hand held devices that include calendars, automatic alerts and alarms, so could be our digital medical record. I receive notification from my bank when an unusual transaction exceeding a specific amount is authorized from my credit card. A digital record can identify unusual or abnormal results and highlight the information to the clinical team including communicating the information to the patient. Even with the best intentions paper based communication can and do break down. There are many examples a condition being identified correctly but a breakdown in communication to the patient or the correct caregiver may have led to an unfortunate, but potentially avoidable consequences.

9) Security
While much has been made of security issues associated with digital medical records the reality is that medical records than the old paper records. Furthermore access is easily tracked and audited. Ensuring the right level of security is essential. There has been many stories of paper records that frequently “walked” out of hospitals, clinics and into the back of cars, offices and even dumpsters.

10) Mobility and Portability
We live in a rapidly changing world and recent natural disasters have demonstrated the need for mobility and portability. Hurricane Katrina demonstrated the need to create medical records that are available in more than one location and are effectively backed up. There were few patients affected by Hurricane Katrina that were able to leave the area and attend another facilities and receive care without significant interruption. For example Veterans who fled the area almost instantly had their medical records available in other VA hospitals. While this might be an extreme example of crisis mobility and extraordinary circumstances our population and society is far more mobile than ever before. People no longer live their entire life in the same location. In addition to facilitating mobility, digital records deliver built in redundancies and create backups and copies to ensure survivability of information. But mobility is not just about the record but the ability of the clinician to access the record from any location and at any time. Seeing patients out of hours has always been difficult with the lack of available information – digital records that are accessible from any location and even on portable devices can provide instant access to key data to help clinicians manage patients efficiently. Reviewing a medical record on a mobile phone may not be ideal but having access to information even on a small screen is preferable to having no information as the basis of clinical decisions on patient care.

Digitizing medical records is not so much a destination but a journey and one that we must all take. There are challenges but the benefits are clear. The question you must ask yourself as a physician is can you afford not to go digital and more importantly can your patients.

Average wait time in ED 4 hours

Average wait time for "emergency" treatment is in excess of 4 hours. As the article puts it: Fast Treatment Rare in Emergency Departments
>>enough time to watch 4 episodes of the TV series ER!
Actually more like 6 if you removed the adverts
A sorry state of affairs that reflects the strain on the service and a high degree of inappropriate use driven by financial pressures, uncertainty and ignorance
There must be big savings to be had in focusing on this problem, creating better low cost (or free) alternatives, and including some push to stop unnecessary usage. 

Posted via email from drnic's posterous

Sledding injuries can be severe

It is probably no great surprise that sledding injuries occur in children but the severity especially in children under 4 years of age tends to be more severe and more likely to be a head injury. The commonest injury across all groups was fractures followed by contusions and abrasions 

Sledding Injuries Common in Kids, Can Be Severe (CME/CE)

It may seem a long way off as we sit in the heat of the summer but it will be sledding season soon

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Oil spill clean up workers likely to experience more healt problems

Previous spill clean ups show increased health problems in the workers including respiratory problems and even some chromosomal changes
Oil Spill Clean-Up Tied to Adverse Health Effects (CME/CE)

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Tuesday, August 17, 2010

Brain Trauma Can Mimic Lou Gehrig’s Disease

Fascinating study released suggesting that ALS (commonly known as Lou Gehrig's disease) is mis diagnosed in many athletes suffering head trauma and concussion as well as military veterans: >>Study Says Brain Trauma Can Mimic Lou Gehrig’s Disease:
A new study suggests that concussions and head trauma can cause degenerative diseases similar to A.L.S. and that Lou Gehrig may not have had Lou Gehrig’s disease.
Aside from the important emphasis on the significance of brain trauma that is occurring in our athletes in particular our younger athletes there is some interesting analysis of the etiology and process that seems linked to proteins produced as a result of the trauma that persist and travel in the nervous system to cause further permanent damage. Unfortunately despite significant advances even this progress begs even more questions regarding the brains function and more importantly how to protect it and limit damage. This will be interesting research to watch and especially important for our youth sports Programs.

Monday, August 16, 2010

Would you like a statin with that Burger

Perhaps a better strategy might be not eating the burger and shake rather than offering packets of Statins to go with excess fat and food intake:
A Burger, Shake, and Some Statins
But practical challenges seem to prevent our ever increasingly over weight society from moderating input so this could prove to be a practical approach that works. You might even find food manufacturers and restaurant offering to add it to food for you. In some respects this is similar to the addition of the anti dote to overdose of acetaminophen (Tylenol) that is available and would prevent liver damage in the case of over dosage. But like this concept statins may suffer the same challenge - economics. While most recognize the value of extra safety of adding the antidote to Acetaminophen this version has limited sales as it costs more and cannot compete with cheaper version that don't contain the antidote. Adding statins will likely be an economic issue not to mention the side effects that accompany statin therapy
Would you take food with statins for prevention?

FDA Warning on Fake Tourniquets

In what is likely to be a troubling problem that will likely occur with increasing frequency the FDA has warned that there are a number of counterfeit copies of military-grade tourniquets which may either break or fail to function as well as the original. FDA Warns Consumers of Fake Tourniquets

These are devices to designed to restrict the blood flow on limbs in urgent and elective situations.
Fakes of the emergency medical device have a weak plastic tension rod that may bend or break before adequate therapy is applied, FDA tests of the counterfeit found. The lack of pressure may not sufficiently stop blood flow and may cause excessive blood loss in patients.
Hard to identify fakes although sourcing from approved suppliers and looking for "National Supply Number on the product's C-A-T logo its side, NSN6515-01-521-7676" might help. I suspect this will be a recurring problem with many other devices and products. The challenge with these fakes is that unlike fake rolex these fakes coudl cause significant harm, even death.