Monthly Introduction to Tech Medicine

What's this blog all about?

My goal in Tech Medicine will be to explore the intersection of medicine, new technologies, and the Internet. This is a purposefully broad topic. Several times weekly I will post focused reviews of issues interesting to health professionals and nonprofessionals alike. Posts may include examinations of medical devices, pharmaceuticals, scientific advances, internet services, and other technologies involving health care and the practice of medicine. Mirroring as it does the nature of the Internet and the sometimes surprising nature of new technologies, the content may also include topics that are wonderful, unusual, hilarious, or strange.

What are some recent posts on Tech Medicine?

Recent posts have included digitizing paper medical records (and more medical uses of the iphone), my favorite ergonomic laptop bag, the social bookmarking site del.icio.us and a collection of hilarious journal articles, a review of the book "How Doctors Think,". a discussion of the drug Vaprisol, and further thoughts on patient-physician email.

Who are you?

I'm trained as a nephrologist (a kidney and blood pressure specialist). For the last two years I've written Kidney Notes, a blog designed to filter and process medical news. Most recently, Kidney Notes has become a collection of links, commentary, and scraps of information -- a reference database of interesting things with the help of a popular social bookmarking service called del.icio.us. While I will continue posting to Kidney Notes, several friends have asked me to write longer posts of original content -- and this is what I will be writing on Tech Medicine. (Recently, I have also written a blog on personal productivity called The Efficient MD.)

There are many topics I plan to cover, but I'm also open to suggestions and tips. Please email them to techmedicine@gmail.com.

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Interesting Links from the Last Week

The following are interesting links from the last week.

I haven't spent much time in Second Life, a 3D online virtual world with its own currency -- but Bertalan Meskó has. He's a medical student at the University of Debrecen, in Hungary, and he writes the ScienceRoll blog. Bertalan recently wrote about a medical conference complete with presentations inside Second Life.



In other news, scientists at the University of Rochester discovered one species' genome entirely inside another's.

Certain medical procedures, like cosmetic procedures and procedures on the eye, are frequently not covered by insurance. The New York Times reports that some doctors are arranging for interest-free financing to help people pay for these surgeries.

Also in the New York Times, science writer Jane Brody writes about ways of increasing the supply of organs for transplantation. One method involves harvesting organs from patients who have life support withdrawn -- "after cardiac death" -- which is ethically controversial. (See this recent article by Dr. Steinbrook in the New England Journal of Medicine for more information.)

The Washington Post looks at a recent study which suggests that doctors often disregard patients complaints of side effects from medication. In the study they talk about (which can be found here), patients complained of side effects from statins (a cholesterol lowering medication). These side effects included weakness or aching. Even though these are known potential side effects from statins, many doctors disregarded the connection between the side effect and the medication. The article also talks about Medwatch, the online FDA website which facilitates reporting of adverse effects from medications.

Labels: medical news

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Digitizing Paper Medical Records -- Medical Uses of the iPhone (Part 4)

I don't use electronic medical records (EMR). Let me qualify that: I don't use EMRs for when I write notes on patient visits; I do use online patient scheduling, I read laboratory studies online, and I do write orders for patients in the hospital online. But most of the notes I write on patients are on paper. (Although they're highly personalized templates, which increases efficiency and allows me to care for patients better.)

And I'm not alone. Only about 25% of doctors use EMRs. The reasons are varied, but many physicians do not want to invest in a proprietary system with uncertain benefits when paper has served them well for decades. (Google, in particular, is working on a free interoperable medical record system for patients and doctors which tackles these problems.)

EMRs definitely have advantages, one of which is instant access to patient records at crucial moments -- such as when a patient is admitted to the hospital or calls on the phone with an urgent problem. In these situations, it's helpful to have a recent medical history, labs, and a list of medications close at hand.

I've lately explored options of digitizing paper medical records. None of these are real solutions, of course, but they do suggest ways of forming a makeshift bridge between the paper and electronic world. (These solutions might be used by both providers and patients to make paper medical records more accessible electronically.)

I've previously written a three part series on medical uses of the iPhone (1, 2 & 3). Recently, there was a patient that I had seen in the office whose records I knew I would need to refer to in the hospital. I contemplated copying the records and bringing them along, but then I realized that I could just photograph them with the iPhone's camera and review them later. This worked surprisingly well -- when I pulled the photos up later, the resolution of the screen was more than adequate to read what I had written, and the multi-touch interface made zooming in on different sections of the note simple. I've began to photograph medical documents I might need to refer to later, like notes and lab tests.

A second option is the DocuPen RC800. (For a full description of this product, see the Planon website.) This is a mobile color scanner for documents that's the size of a large pen. While it doesn't allow you to carry around a viewable image of the document itself, it does allow you to upload the scanned document to a computer for viewing later. Conceivably, the documents could also be uploaded to a service like Box.net, an online storage system for documents and PDF files which, incidentally, has an interface for the iPhone.

To summarize: Many records are still paper based. I'd love to see a system which allows easy digitizing of these records. And these records should be easily accessible by a handheld computer. And this computer, ideally, should have a user interface as elegant and friendly as the iPhone's.

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My Favorite Ergonomic Laptop Bag

This post will be a departure from the regular topics of this blog. It will be about bags. Specifically laptop bags. And here is where I will rant. Most laptop bags are either backpacks, which are comfortable but unprofessional, or business bags, usually slung over one shoulder, which in my experience cause a tremendous amount of back strain and soreness. Those of you who have laptops will recognize this problem.

I've been searching for a compromise -- a business bag that is both professional looking, comfortable, versatile, and back-healthy. And I've found it.

BBP bags has a line of bags that I first encountered in the 5th Avenue Apple Store while searching for a bag to hold my Macbook Pro. (BBP stands for "BumBakPak.") These bags are "hybrids" -- that is, they easily convert from a slung-over-the-shoulder-type professional-looking messenger bag to the more back-friendly backpack bag, which is padded in all the right places.

I try to make a habit of walking as much as possible, and the BBP bag -- I have the hamptons hybrid bag in obsidian black -- definitely makes this more pleasant, particularly in backpack mode.

I'm convinced that people get used to uncomfortable bags and in subtle ways, this causes them to resist walking with them. I've walked a lot more with my laptop bag ever since I switched to the BBP bag. Even if you don't have a laptop but carry a heavy bag, I suggest you investigate the BBP line of bags. Your back will thank you.

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Del.icio.us and Hilarious Journal Articles

One of the most useful sites on the web is del.icio.us. (Yes, it's a pun; you type it in exactly like that.) In case you've not heard of it, del.icio.us is one of the best social bookmarking sites on the web. When you "bookmark" a web page in your browser, you're saving the link for future reference. Bookmarking a website on del.icio.us is similar, with a few major differences. First, other users can look at and subscribe to your bookmarks, and you can look at other users' bookmarks. You can also get a sense of the importance and popularity of a site by how many people have bookmarked it.

Second, you can apply "tags," which are labels, to each site. For example, you might bookmark the site healthline.com with the tags "health," "medicalinformation," "search," and "medicalblogs." You can then search or sort using tags. Bookmarks can be easily saved by using extensions for the firefox or internet explorer browsers.

Once you start using del.icio.us, it becomes your portable online filing system for the web. For health-related information in particular, del.icio.us can be used to tag and file away journal articles, health-related websites, news articles, and anything else you can think of that you might need for future reference.

Here's an example of how del.icio.us might be used. For the past two years, I've been collecting hilarious journal articles on del.icio.us, which I've then tagged with the label "hilariousjournalarticles." (Sometimes these articles are about conditions that are deadly serious, and my intention is not to make fun of anyone, but to show appreciation for humor in scientific writing, which is often dry.) Some recent articles have included:

• The untapped potential of virtual game worlds to shed light on real world epidemics
• Didgeridoo playing as a treatment for obstructive sleep apnea
• Differences between male physicians, surgeons, and film stars
• A randomized trial of placebo versus placebo

The full collection is here. Suggestions are welcome. Please email them to techmedicine@gmail.com.

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Grand Rounds is Up

Grand Rounds, this week's best posts of the medical blogosphere, is up at Med-Source. Thanks for including my post on Vaprisol, a new treatment for hyponatremia.

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Medicare Will No Longer Pay For "Preventable Hospital Errors"

Starting October 1, 2008, Medicare will no longer pay for certain hospital acquired conditions (errors, injuries, and infections) that could "reasonably have been prevented." (The New York Times article is here. The large pdf file of Medicare reimbursement rules is here; see page 290 for the new guidelines.)

The conditions that will no longer be covered include infections from urinary catheters, infections from central venous catheters, pressure ulcers, objects left in the body after surgery, air embolism, injuries from blood incompatibilities, mediastinitis as a complication of heart surgery, and falls.

Other conditions that could be added to the list in the future include surgical site infections, ventilator-associated pneumonia, Staph aureus bacteria, methicillin resistant Staph aureus infection, deep venous thrombosis, and Clostridium difficile colitis.

This is a complicated issue, and I have mixed feelings about the new rule. On the one hand, complications are the sometime unavoidable result of the use of medical devices like ventilators and intravenous catheters. On the other hand, as the Medicare rule outlines in the discussion, many of the conditions they list are potentially preventable. For example, the guidelines from the Centers for Disease Control for prevention of catheter-associated urinary tract infections are here and the guidelines for prevention of catheter-related bloodstream infections are here. One argument in favor of the Medicare rule is that it would encourage more hospitals and health care professionals to adhere to the guidelines, which could potentially save lives and reduce health care costs. Unfortunately, I fear that many of these complications may not be preventable, even when guidelines are followed, and the rule is merely an attempt to further reduce payments to hospital systems that are already on shaky ground financially.

Labels: medical errors, medicare

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Grand Rounds is Up

Grand Rounds, this week's best posts of the medical blogosphere, is up at Med Journal Watch. Thanks for including my post on Patient-Physician Email.

Labels: grand rounds, medicine

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"How Doctors Think" Reviewed

I'm almost finished reading Dr. Jerome Groopman's book on medical mistakes, "How Doctors Think."

Well, not reading, exactly. I'm listening to it as an audiobook from Audible.com on my iPhone. Audible provides audiobooks on a wide variety of topics, including many books on medicine and technology. I highly recommend them. If you're listening to audiobooks, I also recommend increasing the speed, which most iPods allow you to do, and the iPod also adjusts the pitch, so the voice isn't distorted. Finally, along with audiobooks, I also recommend medical podcasts, and I've written about podcasts before on Tech Medicine.

Back to "How Doctors Think." The book is a series of loosely related anecdotes about cases involving common errors in thinking. (A more accurate title would be "How Doctors Err.") Rather than adopting a dry academic tone on the subject of medical mistakes, Groopman chose to tell a series of stories of otherwise good clinicians who were led astray -- by choosing a convienent diagnosis, by failing to question a diagnosis, by letting emotion affect judgement, by not picking up on red flags in presentations of patients that should have prompted further reflection. While it only occasionally delves into academic research in how doctors think (and err), the book primarily focuses on narratives; this occasionally leaves the reader wishing for more detailed, technical, practical information on the nature of errors in medical thinking.

"How Doctors Think" is designed for both health care providers and patients. For providers, it provides a caution against making common mistakes. For patients, it urges them to be aware of the potential for mistakes in thinking and gives advice on how patients can help doctors arrive at the right diagnosis.

Labels: audiobooks, how doctors think, ipod, jerome groopman, medical errors

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Vaprisol (Conivaptan) -- a Treatment for Hyponatremia (Low Blood Sodium)

Vaprisol is a newly released drug treatment for low sodium in the blood (also called "hyponatremia").

First, some background. Hyponatremia is a medical condition that can have many possible causes. For various reasons, the body retains too much water and the blood sodium is diluted. Some causes of hyponatremia include losing body fluids (from vomiting, diarrhea, or from diuretics); an abnormally high level of antidiuretic hormone, also called vasopressin (related to medical problems like strokes or lung cancer); and other conditions like cirrhosis, congestive heart failure, and protein in the urine.

Hyponatremia can sometimes lead to swelling in the brain, which in some cases can cause confusion, seizures, and death. For an analysis of the case of Jennifer Strange, a radio show contestant who died from hyponatremia after drinking too much water, see here.

Vaprisol has been approved to treat hyponatremia related to conditions in which the body has not lost body fluid. It is not indicated for conditions like vomiting, in which the body's fluid is low.

Here's how it works. Usually, a gland in the brain called the pituitary released antidiurtic hormone (vasopressin) in response to a high concentration of sodium in the blood serum. More vasopressin causes the kidneys to retain more water, which causes the blood sodium to go down as the extra sodium is diluted by more water. In many cases of hyponatremia, the level of vasopressin is abnormally high and the body therefore retains too much water, driving the sodium level down.

Vaprisol is an intravenous medication which blocks the effect of vasopressin on the kidney. It's usually given as a bolus of 20 mg followed by a slow infusion. By blocking the effects of vasopressin, vaprisol causes the kidney to eliminate water (a "water diuresis"). This eventually causes the serum sodium to go up as the blood sodium becomes less diluted.

Cardiologists are also interested in the possible future use of Vaprisol to treat low sodium related to congestive heart failure, but it is not yet approved for this indication.

Labels: conivaptan, hyponatremia, nephrology, vaprisol

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Thoughts on Patient-Physician Email (Part 3)

In part 1, I talked about the reasons why physicians don't use email. In part 2, I discussed the benefits of patient-physician email. To summarize:

• Many patients would like to email their physicians.
• Many physicians are either unfamiliar with email or uncomfortable with giving patients the additional access that email provides.
• Email has the potential to strengthen the physician-patient relationship and improve both patient education and the quality of care.
• The HIPAA privacy law prohibits email between physicians and patients unless this communication is encrypted.
• Many commercial solutions for encrypted email between physicians and patients exist. Unfortunately, many of these solutions are either expensive, proprietary, and/or cumbersome to use. (If you would like to suggest a commercial email system that is inexpensive/free and easy to use, please comment.)
• Encrypted email systems that are cumbersome to use and/or require an elaborate login process will frustrate patients and discourage them from emailing providers.
• Many patients would prefer to use plain, unencrypted email to communicate with their physicians.

Ideally, an encrypted email system between patients and providers should be used. But what if one is not available and/or the patient would like to give permission to communicate protected health information over insecure, unencrypted email?

Different institutions have come up with their own solutions to this problem. This is an excerpt from Yale's Guidance on the Use of Email Containing Protected Health Information:

A provider may obtain informed consent from a patient via electronic messaging (e.g., email) by conducting the following consent exchange upon presentation of a patient query via electronic messaging (this example is for an email exchange):

I will be happy to respond to your query but to do so via email you must provide your consent, recognizing that email is not a secure form of communication. There is some risk that any protected health information that may be contained in such email may be disclosed to, or intercepted by, unauthorized third parties. I will use the minimum necessary amount of protected health information to respond to your query.

If you wish to conduct this discussion via email, please indicate your acceptance of this risk with your email reply. Alternatively, please call my office to arrange a phone conversation or office visit.

Columbia University also has a policy on email on their HIPAA information page:

If a patient requests email communications containing their PHI, the individual receiving the request must obtain a completed Request for Email Communications form from the patient AND must provide the patient with the Important Information about Provider/Patient Email form prior to processing the patient’s request.

(If you're interested, I've extracted the text from the forms on Kidney Notes.)

If you have other solutions to the problem of physician-patient email, please feel free to comment.

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Grand Rounds is Up

Thanks to David Williams of the Health Business Blog for including my post on Medical Uses of the iPhone.

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