Monday, December 5, 2011

Social media to educate clinicians

In an interesting response to a problem of getting the word out 

>>>>Despite these compelling findings, an audit of UK hospitals in 2011 showed that, of 412 trauma patients who were ill enough to need a blood transfusion and therefore be eligible for tranexamic acid treatment, only 12 (3%) received the drug. The implementation rate in low-income and middle-income countries could well be lower still. The CRASH-2 trial results were published in this journal, widely reported in the international media, and presented at many trauma and intensive care conferences. How else could researchers reach out to practising clinicians and make them aware of this life-saving treatment?

Despite the compelling evidence implementation and uptake is low so the team came up with a "viral" video to get the word out. 
An enterprising idea that the CRASH-2 team rolls out today involves an adaptation of the concept of viral marketing—ie, a compelling video that internet users pass on to their online contacts. Drawing on the elements that tend to increase sharing (humour, surprise, emotion), the collaborators made a stop-motion animation in which a clay trauma victim, blood squirting heartily from a gaping hole in his abdomen, happily avoids imminent exsanguination by means of a timely injection. The video ends with an invitation to view the CRASH-2 trial results<<<<<

Expect more activities like this in the future

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Tuesday, November 22, 2011

What is HealthIT - Part 1

Soem interesting video presentation on HealthIT and Informatics from the Discovery Channel

Part 1:

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Wednesday, November 16, 2011

Wisdom from the Dalai Lama

Get on Board the Social Media Train or Get Left Behind Like the Bank of America

Bank Of America Just Had The Ultimate Social Media Fail

Julia La Roche | Nov. 15, 2011, 10:54 AM | 61,418 | 49

This makes you wonder if Bank of America, which is currently axing 30,000 of its staff globally, already cut their social media team.

Or if they don't already have a social media team, they should really consider getting one after this social media fail. 

It's been just a week since Google Plus started allowing for companies to have pages on the social networking site and it looks like someone already beat Bank of America to the punch, according to Carl Franzen at Talking Points Memo.

BofA's Google Plus profile bashes the already embattled Charlotte, North Carolina-based bank. The page, which is no longer available, features unflattering pictures of former CEO Ken Lewis and mocking wall posts.

One wall post said, "Living under a tarp? I am too. My TARP is much bigger, however, and billions of dollars more expensive."

It's possible that the page could have been created by the bank initially and then later hacked. 

However, according to Chester Wisniewski at the IT security blog NakedSecurity, the page was likely created by a group that tricked Google into thinking they were Bank of America. 

We've included a screen shot below. [via TalkingPointsMemo]

BofA Google Plus

Image: TalkingPointsMemo

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The power of social media - few hospitals or healthcare facilities have any focus on this area (building a web site and running and e-mail server does not count).
The University of Maryland Medical Center ( springs to mind as one of the leaders in this area with an impressive outreach and connection. I'm not sure what or how they staff it but am willing obey its built into every area and not confined to one or two social media job functions.

For those hospitals considering Social Media - this presentation on slideshare is a good foundation on why this is important and what it can do for your facility and originates from the University of Maryland:

This is not just some passing fad. It is messy and this troubles many facilities and executives as it is hard to control and manage but that is just part of our future engagement with our staff, patents and colleagues around the country and indeed world.

This train has left the station - get on board or get left behind

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Friday, November 11, 2011

Dragon Express - Available now in the App Store

Dragon express was released this week at an amazing introductory price of $49.99. Great news for people wanting to try out Dragon on their Mac and for anyone who wants to effectively speech enable their applications especially social media.

The App store has made the ease of purchase an installation a breeze and finding the app and installing is as simple as clicking the Dragon Express Logo 
or this link (which will take you to the web page and open up your App Store).

Watch the application in action with Peter Mahoney - the Dragon Dictator

There has been good coverage  from GigOMArs TechnicaMacWorld and Cult-of-theMac to mention a few and has done well in the App store rankings reaching #8 (behind 7 apple applications and one other "Growl"). Not bad for the first day

Let me know what you think and how you get on with the application

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Wednesday, November 9, 2011

Is Siri the New Personal Health Assistant and Coder?

Brian Dolan thinks so:

Based on our own in-house testing here at MobiHealthNews, Siri in its current form could be helpful to both patients and healthcare providers alike. After asking Siri a number of questions, we were surprised how she answered some and that she was able to answer others.

And even for coding in OCD-9

For health and diet

Release a product and people will find new and unimagined ways to use it. We are only just starting to scratch the surface of the potential

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Tuesday, November 8, 2011

The One Chart You Need To See To Understand Mobile


The "Blue Ocean" (non-smart phones ripe for putting smart phones in the hands of users) is "huge". There remains much opportunity in the mobile market place but the penetration is increasing for Apple and Android with Android on a tear with its open-source strategy.
Mobiel devices are the mainstay of communication tools for people and as these increase in penetration and function voice integration and in particular the addition of intelligent interaction will become increasingly important and necessary.
I imagine the speech recognition business opportunity chart would look very similar offering the potential for a ver exciting and dynamic upcoming year.
Once again - its so great to be in a cool business that's growing so dramatically.

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Improved systems for vehicle voice recognition coming


Cars that understand what you say....coming to a car near you.
Part of the ongoing push and the new age of speech recognition is the ability to understand what the driver asks for with interpretive system that include natural language processing (NLP) and some element of Artificial Intelligence (AI) to offer drivers a more conversational and useful interaction with their voice. A safer interaction that will be easier and faster.

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Monday, November 7, 2011

Butterfly Effect of Healthcare Quality Measures


In an interesting unanticipated effect the AHRQ has highlighted the potential for the government changes to encourage physicians
"... may "fire" noncompliant patients from their practices, push back against quality-improvement initiatives, and minimize patient empowerment efforts, CQ HealthBeat reports. Some physicians already are "firing" unvaccinated patients, noting that they pose a risk to others and reflect a lack of trust for physicians' medical advice.
Since there already appears to be some instances of this where patents are unvaccinated it may well extend to other groups and would certainly be classified as an unintended consequence.

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Tuesday, November 1, 2011

Mobile Voice Recognition is Going to Rock Your World | Apple's Siri on the iPhone 4S is leading the way | Business News Daily


Voice is cool! Voice recognition and its most recent persona - the now well known Siri on the Apple 4S is a star and has really captured the imagination of the public..... something we have been working at for a number of years in the healthcare sector.
The key to the success is the natural language understanding that is baked in to the solution. We have seen the value of this with the Dragon Go Product in the Apple App store and the healthcare sector is getting medical intelligence built into their solutions in the form of Clinical Langauge Understanding (CLU) and the latest medical intelligence in the new product of Computer Assisted Physician Documentation (CAPD)
Instant information and interaction comes to healthcare documentation helping create high quality specific detailed clinical documentation first time.

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Speaking in Context: Medical Language Models and Mobile Dictation

Speech recognition is an increasingly common interface - we interact with speech systems on the phone, using our phones and in our cars. But as Jonathan Dreyer points out in this piece - speech for general use is different to use in healthcare. In Healthcare it requires an appropriate context to attain the necessary levels of accuracy.
>>>What’s “humerus” to a clinician, and what’s “humorous” to a consumer are two very different things

Quite! So using the right versions tuned for the user and his domain - and int eh case of healthcare there are many different domains that can be applied for different specialties (Radiology, orthopedics, general surgery, general mention just a few). With the right context and model applied medical speech recognition has become an integral part of clinical solutions and is becoming increasingly important in mobile applications where the keyboard interface is not always ideal or as easily accessible.

So while general speech recognition solutions are delivering real value to derive the same results in healthcare it is important not to fall into the trap of offering generic solutions that will work but generate too many errors to make them useable and worse will turn clinicians off the tools before they have even had a chance to experience the results that are possible today with the right tools for medical speech recognition

So if you are looking to integrate speech into your healthcare applications - use the right version that includes the relevant context and vocabulary models to at the outset and help create a positive experience for users from the beginning.

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Wednesday, October 26, 2011

How EMRs can detract from a clear narrative, and facilitate spoliation and obfuscation of evidence; UPMC and the Sweet death that wasn't very sweet


In a detailed and extensive post on the hcrenewal blog that covers the pending case from Pittsburgh and the challenges relative to complexity of EMR systems, understanding the data including all the meta data that is gathered within these systems but not always available for review by clinicians.

The post is illuminating on so many levels delving into the case providing links to the court papers and documents and offering analysis of the sequence of events both prior to the tragic loss of Mr Samuel Sweet's life as well as the subsequent review and legal case.

Others can make their own minds up on the case - what is interesting is the detailed analysis and reference to actual data and documents for the EMR. It offers some window into the difficulties we face in practicing medicine in an increasingly complex arena and our increasing reliance and need to apply technology support the healthcare team deliver safe, appropriate and cost effective care to every patient, every time.

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Tuesday, October 25, 2011

Monday, October 24, 2011

Bad Science, Politics and the Need for Clinical Data

Ben Goldacre, Saturday 31 October 2009, The Guardian.

Every now and then it’s fun to dip into the world of politics and find out what our lords and masters are saying about science. First we find Brooks Newmark, Conservative MP for Braintree, introducing a bill to reduce the age for cervical cancer screening to 20. The Sun has been running a campaign to lower the screening age, on the back of Jade Goody’s death at 28 from cervical cancer, and gathered 108,000 signatures on a petition. The Metro newspaper have commissioned a poll showing that 82% of 16 to 24-year olds in England agree with lowering the screening age.

“Cervical cancer may be rare in women under 25,” says Mr Newmark: “but it is inexcusable to dismiss the cases that occur as negligible statistics.” Oh, statistics. “We have a vaccination programme that ends at the age of 18 and a screening programme that begins at the age of 25. That leaves young women between the ages of 18 and 25 caught in a medical limbo, eligible for neither vaccination nor screening.”

Somebody should do something: an intuition which you will find at the bottom of many calls to extend screening programmes beyond the population in which they can provide useful information, and into low risk populations where they simply waste resources, or do more harm than good.

If screening worked, you would expect to see a reduced incidence of cervical cancer diagnoses in people who have been screened, compared with people who have not been screened, in the 5 years after screening: because precancerous lesions will have been detected and dealt with before they got to a more advanced stage.

In August 2009 the British Medical Journal published a large study examining this very question. It found that screening was associated with an 80% reduction at age 64, 60% at age 40, and so on. But cervical screening in women aged 20-24 has little or no impact on rates of invasive cervical cancer in the following 5 years. Only the Liberal Democrat MP Evan Harris introduced these findings to the debate (with the rather excellent line: “The honourable Member for Braintree cited evidence from The Sun, so I want to refer to a recent edition of the British Medical Journal”).

Meanwhile on the very same day David Tredinnick, Conservative MP for Bosworth, stood up to speak on medicine. Scientists and doctors who doubt the efficacy of alternative therapies are superstitious, ignorant, and racially prejudiced, he explained. “It is no good people saying that just because we cannot prove something, it does not work… I believe that the Department needs to be very open to the idea of energy transfers and the people who work in that sphere.”

He went on. “In 2001 I raised in the House the influence of the moon, on the basis of the evidence then that at certain phases of the moon there are more accidents. Surgeons will not operate because blood clotting is not effective and the police have to put more people on the street.”

Where does this moon stuff come from? “I am talking about a long-standing discipline—an art and a science—that has been with us since ancient Egyptian, Roman, Babylonian and Assyrian times. It is part of the Chinese, Muslim and Hindu cultures… Criticism is deeply offensive to those cultures,” says Tredinnnick: “and I have a Muslim college in my constituency.”

Any attempts to challenge Tredinnick’s ideas are based, he explains, on “superstition, ignorance and prejudice” by scientists who are “deeply prejudiced, and racially prejudiced too, which is troubling.” So I hardly dare to mention that Tredinnick tried and failed to claim £125 in parliamentary expenses for attending an intimate relationships course teaching how to “honour the female and also the male essence and the importance of celebrating each”, run by a homeopath.

Meanwhile the flag-bearers for conservatism at the Spectator are now promoting climate change denialism, as George Monbiot has pointed out, and Aids denialism, under the tedious flag of “only starting a debate”, even in their print edition. And finally, the NextLeft blog recently pointed out that of all the top ten conservative blogs, every single one is sceptical about man-made climate change. It could be an interesting five years ahead.

Ben Goldacre from the Guardian does a great job of exposing the world of politics and politicians as they step into the world of science.
As always Ben does a great job of exposing the lack of science and data as some politicians jump onto a personal hobby horse.

As he points out in the attempt to introduce Cervical Cancer Screening he suggests that despite "Cervical Cancer being rare in women under 25" and suggesting we "do something".

The BMJ published a study in 2009 that did! And it demonstrated the value of screening in different age groups with "little or no impact" in the 20 - 24 age group.

Progress depends on data and introduction of new treatments, diagnosis and thinking should be based on scientific analysis of data and not on hunches.

The foundation of this is generating clinical data that can be analyzed and while our medical records are chocked full of data that remains locked in narrative blocks that are inaccessible to computer analysis without the extraction or abstraction of that information typically through manual steps

In a recent presentation at the Partners for Connected Health Symposium in Boston Last week Janet Dillione the Executive Vice President and General Manager, Healthcare Division, Nuance presented

The Voice of Healthcare, The Value of Understanding (Imperial)
- Janet Dillione, Executive Vice President and General Manager for Healthcare, Nuance Communications, Presented "The Voice of Healthcare, The Value of Understanding" that highlighted the potential for bridging this gap with technology that takes the narrative and turns it into clinically actionable data using advanced NLP technology; Clinical Language Understanding. This is the first step on what will be a critical pathway to the future of medicine based on data and science.

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Tuesday, October 11, 2011

Hospitals make almost no headway in cutting readmissions


Minimal progress in what is a challenging problem for healthcare facilities in preventing readmission of patients. Surgical patients fared the best with a 12.7% readmission rate which was unchanged but in the top 3 killer category Congestive Heart Failure remained a recalcitrant problem with 1 in 5 patients returning to hospital - up slightly from the previous years.
The good and bad news is the looming ICD10 coding requirements will increase the visibility of this failure in the care system.
Good news in the long term as to improve anything we have to be abel to measure it, the bad news that it will shine an uncomfortable spot light on failures in the coordination of care.
THe incentives are in place for facilities as the government steps up the pressure with penalties for facilities with readmissions for heart attacks, heart failure and pneumonia coming in 2012. But this is just the tip of the iceberg of incentives and penalties.
Fundamental to these changes is the need for clinical data and the ability to report on progress that can only be achieved with discreet data on all patients. Some of this will come from direct data entry but the vast majority is currently locked away in the narrative and bridging this gap without burdening the clinician with data entry tasks will be essential.

Recent advances in the ability to extract and tag discreet clinical data contained in the narrative has been shown and is emerging as key "must have" technology for providers. Increasingly this is being built on the foundation of speech recognition that has clearly reached the point of wide spread adoption and acceptance in the clinical community. Demonstration projects and solutions are already showing the ability to satisfy the data reporting requirements directly from dictated clinical reports using technology to extract the data instead of asking the clinicians to enter the data manually through forms and data entry tools.

These tools will be increasingly important as we are pushed along the path towards higher quality lower cost care which must be built on measurable clinical data for each and every patient seen and treated in the healthcare system.

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Monday, October 10, 2011

Obama’s HHS shuts down public access to doctor malpractice data

Patient advocacy groups are protesting the government’s shutdown of public access to data on malpractice and disciplinary actions involving thousands of doctors nationwide.

The National Practitioner Data Bank maintains confidential records that state medical boards, hospitals and insurance plans use in granting licenses or staff privileges to doctors.

Although records naming physicians aren’t available to the public, the data bank for many years provided access to its reports with the names of doctors and hospitals and other identifying information removed.

That changed Sept. 1 when the data bank removed these public-use files from its website. The action came shortly after it learned The Kansas City Star planned to use its reports.

The story, about doctors with long histories of alleged malpractice but who have not been disciplined by the Kansas or Missouri medical boards, was published on Sept. 4.

The Star linked anonymous data bank reports to a Johnson County neurosurgeon by matching its information to the contents of court records of malpractice cases. Journalists often use this technique to glean additional information about doctors from the data.

“We’ve seen (The Star’s) reporting and others that show your ability to triangulate on data bank data. We have a responsibility to make sure under federal law that it remains confidential,” said Martin Kramer, spokesman for the Health and Human Services Department’s Health Resources and Services Administration, the agency that oversees the data bank.

Kramer said his agency may make the public-use files available again after a “thorough analysis of the data field.” But that process probably will take at least six months and the files may not return in the same format as they had been.

Previously, the files could be downloaded from the data bank website as massive spreadsheets. Names of doctors were replaced by arbitrarily assigned practitioner numbers.

The ages of doctors and patients, as well as the dollar sums of malpractice payments, were presented as ranges, such as a doctor age 40 to 49, rather than as specific numbers.

The bank is not mandated to make public files immediately accessible on its website, but is required to respond to information requests.

“Whatever they do will probably make it more difficult to use the files in meaningful ways,” said Alan Levine, a health care researcher with Public Citizen’s Health Research Group, which advocates for patient safety

On Tuesday, Public Citizen sent a letter to the Health Resources and Services Administration objecting to the removal of the public-use files.

“The continued availability of this data is crucial to patient safety and research aimed at informed public policy decisions concerning malpractice, tort reform, peer review, and medical licensing. There simply is no substitute for the NPDB Public Use Data File if this vital research is to be continued,” the letter said.

The Association of Health Care Journalists also opposes removal of the files.

“We’re really disturbed by this,” said Charles Ornstein, president of the medical writer group. “We’ve seen our members do terrific work (with the files) that protects the public.”

Ornstein pointed to stories by the Hartford Courant in Connecticut and the Raleigh News & Observer in North Carolina citing the data bank’s public use files as a source on doctors whom they named.

“If it were not for this information used by reporters, their stories would not have been as strong,” he said.

“Why are they picking on this (Star) article?” asked Lisa McGiffert, director of Consumers Union’s Safe Patient Project. Consumers Union, which wants greater public disclosure by the data bank, will be asking the agency to put its files back online, she said.

“This administration (of President Barack Obama) has been touting their position for open government,” she said. “I see this action as totally counter to that.”

Kramer said the data bank was alerted to The Star’s reporting by Robert Tenny, a physician the newspaper was reporting upon. In order to provide Tenny with an opportunity to respond, The Star notified Tenny’s lawyer on Aug. 16 of specific information it intended to publish, including several matters contained in the data bank.

In a letter Aug. 26, the bank’s director Cynthia Grubbs advised The Star that violations of data bank confidentiality provisions are subject to a civil monetary penalties. (Read the letter here.) The Star, however, used only publicly available information from the Data Bank.

“A federal agency should not be intimidating reporters for using information that they put on their own website,” Ornstein said.

But Kramer said his agency must investigate any potential breaches of confidentiality.

“Once we became aware that this information may be made public, we had a responsibility to make sure that it remains confidential,” he said.

In an interesting development on open data access HHS removed public access to malpractice data that had previously been published online in anonymous form.
The Kansas City Star newspaper took the publicly available information and using well known and commonly used data matching techniques to link the data to individuals an in particular outing doctors with longstanding histories of alleged malpractice. This was followed by some strong arm tactics threatening the newspaper with legal action.

As the commentators note this is not welcome development and runs counter to the spirit of open government. It does not bode well for the proposed public rating system of healthcare facilities and clinical practice for patients.

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Apple's Siri voice recognition: sounds like Tomorrow's World today


If you grew up in England and were technically inclined you will remember "Tomorrow's World" - it played live right before "Top of the Pops"
As the Guardian Article points out there was often mention of computers powered by with Apple's Siri that distant future looks closer than ever.
In fact the "KNowledge Navigator" video is pretty much implemented in Siri (albeit it took from 1987 to 2011 to get into general availability)
Tight now that future is looking even more exciting and more accessible.

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Hospital staff offered unpaid leave as trust announced 'extraordinary financal measures' (From This Is Local London)


NHS hospital asking employees to work for free in "extraordinary measures"
This seems wrong on so many levels and will undoubtedly affect some more than others.

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Thursday, October 6, 2011

What Steve Jobs Means to Silicon Valley


Awesome review of Steve Jobs with history and the his pathway through life. Interesting to note that he asked for some spare parts for a school project from William Hewlett (of HP fame) and received the parts and a summer job. Imagine how motivating that was. We need more of that today.

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Wednesday, September 28, 2011

Former Apple CEO on Future of Medical Technology

Nice piece on FastCompany Former Apple CEO John Sculley On The Future Of Medical Technology And Health Care's Killer App 
As a trail blazer for original tablets in the 80's it must be gratifying to see the uptake of the iPad and it's competitors. In his mind not going to start with a single "killer app"

I think that the health care industry is so complex that it doesn't necessarily start with a single killer app. You go back to the early days of the personal computer--when I joined the industry, we really didn't know what the killer app was going to be. All we knew was that it was going to be possible to create very low-cost, shrink-wrapped applications. It wasn't for several years until we understood that electronic spreadsheets, word processors, and eventually desktop publishing would become killer apps.

But some combination of a solutions integrated and focused on ease of use. The technology has reached a point of penetration and ease of use that makes adoption that much easier in healthcare

So the intimidation of technology is no longer the issue now that it was just a few years ago.

I'd add one thing - the disruptive technology must include ease of interaction and data capture that does not inhibit adoption and as highlighted in this piece on MedScape EHR Voice Recognition: An End to the 'No Eye Contact' Problem which highlights the significant contribution of effectively speech enabling EHRs to

allows for maintenance of the doctor-patient relationship by minimizing the attention paid to the laptop computer inevitably and uncomfortably sitting between a physician and patient when using the point-and-click method

The same is true with other healthcare technology that can interfere with the clinician-patient interaction. As John Sculley said: "You combine those conditions and it creates an opportunity for entrepreneurs to come in and find disruptive solutions."

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Friday, September 23, 2011

Speed of light no Longer a Maximum

This piece of news is mind blowing - CERN scientists identified sub atomic particles traveling at a speed greater than the speed of light........
I need to repeat that:
CERN scientists identified sub atomic particles traveling at a speed greater than the speed of light.

Here's the paper and live conference today Friday Sep 23 at 16:00 Zurich time

This is "crazy" result could upend our understanding of our universe more than we have seen with previous revolutionary theories (Copernicus, Galileo, Einstein.....) 

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Speed of light no Longer a Maximum

This piece of news is mind blowing - CERN scientists identified sub atomic particles traveling at a speed greater than the speed of light........
I need to repeat that:
CERN scientists identified sub atomic particles traveling at a speed greater than the speed of light.

Here's the paper and live conference today Friday Sep 23 at 16:00 Zurich time

This is "crazy" result could upend our understanding of our universe more than we have seen with previous revolutionary theories (Copernicus, Galileo, Einstein.....) 

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Tuesday, September 20, 2011

mHealth Holy Grail

In a nice expose on the need for speech recognition on mobile devices: Accurate speech recognition: mHealth's Holy Grail for docs on Fierce Mobile Health   covers off the need for the inclusion of speech in the mHealth future. As they discovered

Doctors constantly tell me how much they love their iPhones and Android tablets, but they also complain about the difficulty of data input. Few find the touchscreen keyboard handy for inputting notes or updating their comments about patient progress. Most use the devices as data viewers.

Offering up MedMaster Mobile as a good example of integrating speech into a mobile healthcare application and speaks to the power and value that speech recognition brings to mobile devices in healthcare to ensure usability and quality data capture.

The article includes a good list of checkpoints when considering speech for the mobile platform including
  • Voice quality - The primary consideration in getting good results
  • Connectivity - if you rely on cloud based services you need a reliable good quality connection
  • Accuracy - with good voice quality will achieve the right results
  • Editing - one of the more challenging aspects is an easy way to edit any mistakes that do occur
So Speech Recognition is the secret ingredient to making mobile devices catch-on with clinicians and will transition these great mobile devices from cool but limited practical application to rock solid mobile tool set for mHealth

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Thursday, September 8, 2011

The 7 Deadly Sins of EMR implementation | Healthcare IT News

Congratulations! You've committed to an EMR, which is an accomplishment in itself. But the hardest part is still to come: getting it to work.

From failing to plan to skipping out on training, many mistakes can be made during the implementation process. And although they may not be as juicy as wrath, envy or lust, the Seven Deadly Sins of EMR implementation could wreak just as much havoc.

Steve Waldren, MD, director of the American Academy of Family Physicians' Center for Health IT, and Rosemarie Nelson, principal of the MGMA Consulting Group, gave us the worst sins providers can commit during EMR implementation.

[See also: Top 5 worst EMR myths.]

 1. Not doing your homework:  Avoiding supplier problems means background research and thorough evaluations of vendors and products. And beware: vendors tend to make promises they can't keep. According to Waldren, it's important to get the specifics down on paper. "Often, a doctor will ask if [an EMR] can do this or that, and a vendor will say yes. Then, they're surprised when in reality, it doesn't. Doctors need to make sure all expectations are met in writing."

2. Assuming the EMR is a magic bullet
: It's important to remember the EMR is a conversion, not an upgrade. Although the system will save you time and money in the long run, Waldren warns it isn't an instant fix to issues in the workplace. "Most people think an EMR solves problems," he said. "But an EMR will only amplify problems that already exist in the practice."

3. Not including nurses in the planning stages
: Nelson says doctors tend to think a new EMR is all about them. "They don't think about how much the nurse preps the chart, how often the nurse presents information to them, and how much the nurse handles patients over the phone," she said. Having nurses involved from the beginning avoids future conflicts, and considering their thoughts on product selection and implementation will only help with workflow. "[The implementation] needs to be done with the support of staff; everyone needs to be involved," added Waldren.


Nice highlight of some major faux pas on EHR implementation - I especially like Rosmarie Nelson's comment on forgetting nurses #3: "doctors tend to think an EMR is all about them"....quite

Other great points including training (and actually attending!), trying to replicate existing processes - business process reengineering was a catch phrase for a number of years and has dropped off from regular use but applies to all EMR implementations.

But perhaps most of all "Assuming the EHR is the magic bullet". I have said this before but worth re-itertaing...implementing an EHR is the first step in a journey that while it will have some interim destinations will continue to be a voyage of ongoing discovery. And that train has are either on the train or watching from the station as the train leaves.

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Thursday, August 18, 2011

Physicians Regret not learning Business Skills in Medical School

Once exposed to the realities of practical and sustainable healthcare delivery physicians are quick to regret not learning more about the business side of medicine at medical school. In a posting on Kevin.MD "How can doctors understand the business side of medicine?" Michelle Mudge-Riley echos a frequent sentiment amongst her colleagues

One thing I regret is not taking advantage of the Masters degree in Health Administration program at my medical school. At the time, I was focused solely on medicine and on being a doctor. I didn’t think the business side of medicine was all that important. In fact, I didn’t consider the business side of medicine at all.

While individuals may regret decisions on career pathway (the grass often appears greener on the on the other side of the fence) the article cited from the New England Journal of Medicine from February this year Advancing Medical Education by Teaching Health Policy makes the point that there has been a push for additional teaching as part of the medical student curriculum on health policy and health systems (from 1995) but more than 15 years later less than 50% of medical students "believed they'd been appropriately educated about topics such as medical economics and health care systems."

The science of Medicine is increasingly complex but so is the healthcare systems - new treatments need to be assessed not just from a clinical standpoint but an economic one. Comparing the effectiveness of treatments requires an understanding of economics and the practicalities of budgeting but the information and the skills have for too long been lacking in healthcare education and in day to day clinical practice. Patients and clinicians have been disconnected from the consequences of expenditure with third party payers responsible for managing costs. Much like the European Debt crisis where sudden access to inexpensive debt and limited immediate consequences of the use of debt created an unsustainable position or as one commentator put it  
"It was if Greece received an American Express Black (Centurion Card) 
 but was not responsible for the charges".

Clinicians remain handicapped with the the medical curriculum that still lacks inclusion of foundational knowledge and fails to develop the necessary analytical skills that would equip the key decision maker with all the tools to help navigate the complex adjunct economic decision making process that must be a part of sustainable clinical medicine.

I applaud the proposed additions to the medical curriculum that includes the addition of four domains:
  • health care systems and principles,
  • health care quality and safety,
  • value and equity, and
  • health politics and law
<img src="

The downside is the additional information that is loaded into an already packed and expanding course. The other unfortunate consequences of these changes and the increasing variability between healthcare systems is the diminishing nature of international equity. Medicine used to be one of several professions that offered graduates opportunities to travel the world and work in other countries. This ease of international movement has already diminished as these systems, processes and curriculum have diverged making international experience harder for the newer graduates

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Monday, August 15, 2011

MotoGoo, Motoogle, or Googola -- a big deal any way you slice it | Cringely - InfoWorld

August 15, 2011

MotoGoo, Motoogle, or Googola -- a big deal any way you slice it

Google just bought Motorola Mobility for $12.5 billion. Cringe isn't sure the Googlers will know what to do with it

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And I thought August was going to be a slow news month. That just changed, thanks to Google and its blockbuster $12.5 billion acquisition of Motorola Mobile.

All I can say is wow. Game on for real this time, Apple. See ya later, RIM. Helloooo, Microsoft? Can you hear me down there? Don't worry, we'll send some pods down to rescue you ... eventually.

[ Also on InfoWorld: Neil McAllister asks whether Google's best days are in the past. | For a humorous take on the tech industry's shenanigans, subscribe to Robert X. Cringely's Notes from the Underground newsletter and follow Cringely on Twitter. ]

As for HTC, Samsung, and LG: Hey, you had some good times with Android, but you knew it was never meant to last. Right?

This is an epic day for more than just business reasons. Motorola is one of a handful of companies responsible for creating the industry that pays my mortgage, and I don't mean blogging. And its history with cellphones is equally storied.

Until the iPhone came along, Motorola pretty much defined mobile phones, starting with the original DynaTAC in 1983, the first flip phone (the StarTac), and the first looks-so-cool-I-must-have-it fashion phone (the Razr). Then came the ill-fated Rokr and a long sojourn in the handset desert, followed by a recent comeback, thanks in large part to a a series of snazzy -- and some not so snazzy -- Android phones.

Sadly, I have one of the less snazzy ones: the Motorola Cliq, which is underpowered and overburdened with a godawful Blur "social interface" that does nothing but drain battery life and annoy me. I blame T-Mobile, not Motorola, for this monstrosity. Short of Google also buying a mobile carrier (like Sprint, which seems to be standing in the corner waiting for somebody to ask it to dance), I'm not sure GooMoto would be able to do anything to fix that.

More than mobile phones, though, this is really about tablets. Motorola Mobility makes the Xoom, the first tab to run Android 3.0 and still the worthiest contender to the iPad's throne. Google wants to get into the PC 3.0 business in a big way and figures it might as well own the whole schmear.

Googola...! Blockbuster deal and blockbuster implications as Cringe puts it "Game on"!

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Speech recognition technology making its way into EHR systems

Health care providers over the years have raised a number of objections to electronic health records -- they cost too much, disrupt practices already pressed for time and fail to mesh with the way medical offices work.

But there's an even more fundamental digital challenge -- some doctors don't want to busy their fingers on a keyboard. Indeed, manual data entry can be a barrier to EHR acceptance. Physicians may well prefer to document patient encounters in the traditional style, dictating notes and using a transcription service.

Against this backdrop, speech recognition technology offers doctors another way to fill out a patient’s electronic chart. Speech recognition systems, which may be installed on premise or accessed remotely, translate speech into text. The technology is already well established in health care, with radiology departments at the forefront.

The new twist is speech recognition technology's potential to become a widely used front end to an EHR system.

Reid Conant, M.D., an emergency medicine physician who practices at Tri-City Medical Center in Oceanside, Calif., believes speech recognition lies at the cusp of broader EHR implementation. Tri-City uses Nuance Communications Inc.'s Dragon Medial Enterprise Network Edition, which integrates with the hospital’s Cerner Corp. EHR system.

"We are still on the steep part of the curve," Conant said of the adoption rate.

Industry experts cite three reasons why speech recognition technology's role in EHR systems could be poised for growth.

  • Accuracy has improved significantly, which means doctors spend less time cleaning up notes.
  • EHR vendors are integrating voice recognition into their systems.
  • The federal government’s meaningful use initiative has expanded EHR adoption beyond early adopters. Potentially less tech savvy mass-market users may embrace voice as an alternative to the hunt-and-peck school of data entry.

That said, the technology faces a few obstacles. Voice dictation entered as unstructured text may present problems when it comes to extracting data for reporting and analysis. Vendors, however, aim to employ natural language processing to tag key clinical data for later retrieval.

Appeal of speech recognition technology: Talk, don't type

Steven Zuckerman, M.D., a neurologist with a solo practice in Baton Rouge, La., discovered keyboarding wasn't his forte when he adopted EHR. "I quickly figured out that I would not be the greatest typist in the world," he explained.

Zuckerman began exploring voice input several years ago, working with Nuance's Dragon 7. The initial experience proved somewhat frustrating.

"When I first started trying it out, the accuracy wasn't at the point where it was particularly efficient," he said, noting the many corrections that had to be made following the voice-to-text conversion.

Zuckerman retried speech recognition technology a few years later with Dragon 9. He has been using the software ever since.

Improvements in accuracy have swayed other physicians, Conant noted. He often encounters clinicians who previously tried voice input but balked at the amount of correction required. The latest generation of the technology changes minds.

"They see it and they are shocked," Conant said. "They realize they can dictate three or four detailed paragraphs of medical decision making and it is nearly perfect."

[Clinicians] realize they can dictate three or four detailed paragraphs of medical decision making and it is nearly perfect.

Reid Conant, M.D., emergency medicine physician, Tri-City Medical

Keith Belton, senior director of product marketing for Nuance's health care division, noted that Dragon 7, released in 2003, had 80% out-of-the-box accuracy -- that is, before a user trains the software to recognize his or her specific speech pattern. Version 10, the product included in Network Edition, features out-of-the-box accuracy in the mid to high nineties, he added.

Gregg Malkary, managing director of Spyglass Consulting Group, a mobile health IT consulting firm, acknowledged that the technology has improved significantly compared to where it stood several years back. But issues still remain with the level of accuracy, he said. Some providers may question the actual time savings of voice recognition if they still have to dive back into a document to check for accuracy.

As Malkary put it, "Is 90% good enough, or do I really need 99.9%?"

Speech recognition technology on board within EHR systems

Such concerns don't seem to have limited adoption at Tri-City. Use of voice in clinical documentation began in the emergency department in 2007 and has continued to spread. Wound care and workers' compensation doctors started using speech recognition technology about six months ago, Conant noted. Tri-City's hospitalists and subspecialty doctors will go live with voice in October.

The experience of earlier users encouraged more doctors to try voice. "They are seeing their colleagues using Dragon and are requesting the application," Conant said.

But doctors don't necessarily have to ask for speech recognition technology to have it at their disposal, as it is increasingly becoming a built-in feature of EHR systems. Greenway Medical Technologies Inc., for example, has agreed to integrate M*Modal’s cloud-based speech recognition technology into its EHR.

Similar deals may follow. Don Fallati, senior vice president of marketing at M*Modal maker Multimodal Technologies Inc., said other EHR vendors have contacted M*Modal to discuss integration. He sees a precedent for this type of link-up in radiology, where speech is already deeply embedded in picture archiving and communications systems (PACS) and radiology information systems (RIS).

Epocrates Inc., meanwhile, plans to integrate Nuance speech recognition technology into its forthcoming EHR system, currently in beta. Dr. Thomas Giannulli, chief medical information officer at Epocrates, said the product will feature speech alongside other data entry options such as point-and-click menus.

The arrival of voice as a standard EHR feature coincides with the government's push for wider EHR adoption. The federal meaningful use program, which runs through 2015, offers financial incentives to doctors and hospitals deploying EHR systems.

Raj Dharampuriya, M.D., chief medical officer and co-founder of EHR vendor eClinicalWorks LLC, said Washington's incentives have pushed the EHR market into more of a mass adoption phase.

"We're seeing more physicians come on board that are not as computer savvy," Dharampuriya said. "Voice provides a very nice phasing into EHRs."

Data mining as next wave of speech recognition technology

Doctors may find voice recognition useful as an EHR input tool, but vendors aim to push the technology farther. When physicians compile text narratives via voice, they end up with unstructured data that proves hard to tap for meaningful nuggets of information. Companies such as M*Modal and Nuance work to address this issue through natural language processing.

Pairing speech with EHR marks a stage one deployment of speech recognition technology, Fallati said. He said M*Modal’s "speech understanding" technology takes the voice-entered narrative and translates it into a searchable document. The document can then be mined for purposes such as quality reporting.

Nuance, for its part, pursues "clinical language understanding" -- an offshoot of natural language processing. The idea is to mine structured data from free-form text and tag the key clinical elements such as medications and health problems.

Zuckerman, the Baton Rouge neurologist, believes current developments in speech will eventually lead to the self-documenting office visit. He envisions exam rooms set up to selectively record the relevant details as doctor and patient verbally interact.

"We're not close to that yet, but that would be great," he said.

John Moore is a Syracuse, N.Y.-based freelance writer covering health IT, managed services and cloud computing. Let us know what you think about the story; email

Speech an integral part to an EHR implementation and the good news is increasing numbers of the EHR vendor community are integrating the technology - it's no longer an add on
And the good news is the narrative is no longer the barrier to actionable codified data as Clinical Language Understanding bring Medical Intelligence to the desktop using free form narrative dictation generating clinically actionable data

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Studies show we get things Wrong

Hormone Replacement Therapy (HRT), Helicobacter Pylori are just a couple of the well known instances where apparent intransigence of the medical community prevented advancement in medical treatments. Turns out we get things wrong on both sides of the coin. Ben Goldacre highlighted some research in the New England Journal of Medicine in his piece Studies of studies show that we get things wrong and in the study 

the remaining 51 were very interesting because they were, essentially, evenly split: 16 upheld a current practice as beneficial, 19 were inconclusive, and crucially, 16 found that a practice believed to be effective was, in fact, ineffective, or vice versa.

In fact in the case of HRT the limited data initially available was the best at the time and it was not until the large randomized trial showed the increased risk of heart attacks in patients taking HRT (a rise of 29%) that new information helped shape new treatments. As for Helicobacter Pylori - the cause of gastric ulcers - the ten years from

"the first murmur of a research finding to international guidelines recommending antibiotic treatment for all patients with ulcers"

May seem like a long time but assembling the trials, ensuring the safety and validating the data takes time. So while the time taken for general adoption of treatments things are not quite as bad as the conspiracy theories suggesting resistance to change and progress.

So the questions is will the increased access to large amounts of validated structured and encoded clinical data that can be compared and reconciled against patients and outcomes result in less time to get effective treatments to patients and even the potential to identify new treatments, links and causation. As far back as 1986 "Fish oil, Raynaud's syndrome, and undiscovered public knowledge" demonstrating the ability to link Fish Oil and the potential at reducing or treating Raynaud's disease. With the addition of clinically actionable data the potential to apply this as medical intelligence offers tremendous hope in accelerating the medical advancements and validating treatments faster and more effectively

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Monday, August 8, 2011

Debunking magnetic field exposure and asthma

Study from Kaiser in the US showed an increase in asthma in children with mothers exposed on one occasion to an increased magnetic field

Critics Slam Asthma Risk, Magnetic Fields Link

UK group debunks the study with lack of controls and accounting for other well known factors. Let's hoe the media picks up on this as quickly as they pick up on this study

Carry on, situation normal

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From Jeopardy! to Medical Diagnosis


Dr Watson coming to Healthcare hoping to help bring the latest information to the medical decision making of the clinician

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Friday, July 15, 2011

Straight outta Ojai: CMIOs Part of Planet Alignment

In a great review by Mark Hagland: "CMIOs at the Hot Center: Planets Seen Aligning at AMDIS" he highlights the he annual Physician-Computer Connection Symposium, held in Ojai (Pronounced oh high) Valley Inn and Spa in Ojai, Calif. that I also had the pleasure of attending. A busy 2 1/2 days of learning, meeting, talking, eating and fantastic surroundings for running with the added benefit of running into old colleagues and friends).

Although Farzad Mostashari, M.D could nto be there in person he did manage to take the time to join the group by telephone and provide his insight on the latest developments included the much tweeted comment "

"ICD10 is a firm data don't expect a delay"

and for those of you watching this trend this comment will give pause for thought

ICD-10 is reported to be less of an IT issue and more of a physician documentation issue.

Which will make many clinicians shudder at the thoughts of increased regulatory and coding mandates to comply with in what is already a time challenged and complex environment...they will be looking for technical help and that will be driven in large part by the cohort of current and emerging CMIOs. 
As Mark puts it

CMIOs, as well as other physician and clinician informaticists, are in a more central position than ever before in terms of our need for them to help lead clinical transformation of healthcare. Indeed, it’s unimaginable how we as a society might achieve the “new healthcare”—one with improved patient safety, care quality, patient and family satisfaction, clinician effectiveness, cost-effectiveness, accountability, and transparency—without CMIOs and their fellow physician and clinician informaticists. In short, the levels of responsibility set to land in CMIOs' laps are potentially staggering.

There is increasing focus in the US and interestingly now on the other side of the pond where EHI has launched an CCIO (Chief Clinical Information Officer) Campaign that recently received executive support from Lord Howe from the British government. 

As Mark puts it CMIOs are at the center of an exciting time and will be an essential part of the equation to bringing the healthcare system, clicking and screaming, into the 21st Century. I'm proud to be part of this group and look forward to an exciting and fun ride

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