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.
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 (in association with the American College of Physicians).
There are many topics I plan to cover, but I'm also open to suggestions and tips. Please email them to techmedicine@gmail.com.
Interventional Cardiologists Tested on Virtual Patient Simulators
Monday, March 31, 2008
Joshua Schwimmer, MD, FACP, FASN
Image from WikipediaCardiologists and other medical specialists are required to complete training and education "modules" by the American Board of Internal Medicine (ABIM) for renewal of their board certification. For the first time, the ABIM is allowing cardiologists to take one of these modules by performing cases on a life-sized mannequin, a virtual patient named "Simantha."
This virtual patient simulation is offered at one of six Medical Simulation Corporation’s six SimSuite education centers, located at major medical schools across the United States. The patient simulation is also offered at major cardiology conferences.
During the SimSuite session, which lasts between two and three hours, diplomates will perform cases on “Simantha,” a life-size mannequin, and answer two questionnaires. The simulator also includes six monitors that show displays found in an angiographic suite, and multimedia characters representing the patient, assistants and mentors.
Information on the simulated patient includes a pre-brief patient history and procedure simulation. The pre-brief patient history displays information about the patient and lists drugs given and examinations performed prior to the procedure. Diplomates completing the cases apply their practice knowledge and judgment in a real-time fashion. The system records comprehensive performance data which can be used separately or combined to create metrics for each scenario. Feedback will be provided to the diplomate once the data is analyzed by ABIM. Proctors will provide training in the use of the simulation technology and will allow you to practice on a training case before you begin the five simulations. Once finished, you will be asked to complete two surveys, one about your experience on the simulator and one about your interventional cardiology experience.
“The Interventional Cardiology Simulations represent the first time that ABIM has applied a simulation technology tool as a means of understanding cognitive and procedural proficiency as part of the self-evaluation component of Maintenance of Certification,” said Rebecca S. Lipner, PhD, Vice President of Psychometrics and Research Analysis at ABIM. “We believe that simulation reflects many of the experiences interventional cardiologists may face in practice, and we are planning to expand the number of available cases. In addition, we continue to explore applying simulation technology to the self-assessment process in various subspecialties.”
The Physician Success Strategies Conference: What Can Doctors Learn From Consultants?
Saturday, March 29, 2008
Joshua Schwimmer, MD, FACP, FASN
Many doctors, in their daily practice, have the nagging suspicion that there must be a better way to do things.
The blog focuses on strategies and ideas that doctors can use to stay organized, increase productivity, and take better care of patients. Many of my colleagues and I have experienced our desks disappearing under a pile of papers and charts, suddenly realizing that we’re an hour and a half behind schedule in the office, or finishing our workday to discover that we still have a stack of urgent messages that need answering. And physicians, almost universally, have been forced to see more patients, more quickly, yet are reimbursed less for their efforts.
Plenty of patients have the same feeling — that there must be a better way of doing things. They feel this when they're been trapped in a waiting room for over an hour. Or when they’re unable to reach their physician on the phone. Or when they’re rushed through a 10 minute visit without expressing the real reason they came to the doctor in the first place.
Just as doctors devote their careers to caring for patients, other professionals devote their careers to improving the productivity of individuals and organizations. I’ve highlighted some of them previously — like David Allen, author of Getting Things Done, and Marshall Zaslove, author of The Successful Physician. For doctors, there’s an entire landscape of consulting organizations that offer to improve the practice of medicine. In my initial review of consulting groups for this blog, one organization that stood out is the International Council for Quality Care (ICQC). Headed by Greg Korneluk, a healthcare consultant with 30 years experience, ICQC offers an impressively thorough approach to analyzing and improving medical practices. ICQC provides detailed physician benchmarking, clinical practice redesign, staff education, and conferences on improving performance. These services are aimed at both small practices and large organizations, at practices that accept insurance as well as “concierge” or “boutique” practices.
I was curious about what consulting services like ICQC might have to offer physicians. So last week, I accepted an invitation to write about a two-day conference hosted by ICQC called “Physician Success Strategies.” And let me be frank: I usually dislike conferences. As I listen to lectures, these are the questions in my mind: “Why am I here? Is this a good use of my time? Why couldn’t I get this information from a podcast, journal, or book?” As this was the first conference of its kind that I’d attended, I was admittedly skeptical: we’re in the trenches with patients every day, shouldn’t we be able to solve our own practice problems? What can physicians actually learn from consultants?
Quite a lot, it turns out. I left the conference with a notebook filled with ideas and the sense that this was definitely time well spent.
The Physicians Success Strategies conference is held monthly at the Boca Raton Resort and Club, a vast tourist destination and meeting-place in southern Florida. The 20 person group who attended included doctors, nurse practitioners, office managers, pharmacists, and the CFO and CEOs of medical systems. They came from all over the United States. Some had attended multiple times. In the words of one physician I spoke with, “I learn new things every time I’m here.”
And these professionals have real problems with their practices. Some of the multi-provider groups were receiving more than 100 phone messages from patients per hour. And some doctors who attended saw more than 50 - 60 patients a day.
Brita Hess, the president of ICQC, highlighted the problem of information overload in an initial presentation. One of the most striking diagrams of the day — and there were many — was an animation of the flow of people, objects, and information in a typical doctor’s office. Streaks of lines representing the movement of charts, messages, and doctors obscured the screen in a tangle of intersections. Most physician’s offices, it made you realize, were organizational disasters.
Greg Korneluk, ICQC’s founder and the main speaker, asked the audience a simple question: “What’s preventing you from having a perfect day?”
As they brainstormed, Greg sketched a mindmap of the answers. “Patients think my office is a factory.” “I’m not getting my phone calls.” “Patients wait for too long.” “I have to see too many patients in too little time.” “I’m not reimbursed enough.” “I don’t have time to actually listen to patients.”
Faced with the pressure of declining reimbursement on the bottom line, many practices would sacrifice quality of care to reduce costs. ICQC advises a different and perhaps controversial approach: increase the quality of care, and the bottom line will follow. Throughout the conference, videos were played of doctors who’ve successfully followed this model of putting quality first.
ICQC advocates a 360-degree approach to analyzing and improving the quality of care, encapsulated in the mnemonic “CARES+”:
Core Service: Quality Improvement, Clinical Documentation, Patient Education, Outcomes Management, Interpersonal Impact Access: Facilities & Technology, Records Management, Patient Flow, Time Management, Scheduling Systems Representation: Practice Positioning, Marketing & Public Relations, Ambiance & Decor, Patient Relations, Collegial Relations Economics: Optimal Utilization, Third Party Payments, Collections Management, Overhead Management, Financial Controls Staff & Support: Organizational Structure, Personal Policies, Performance Reviews, Hiring & maintenance, Productive Morale Attitude+: Pride in Profession, Taking Responsibility, Positive Expectations, Clear Vision, Action Orientation
Each of the obstacles to a “perfect day” were positioned in the CARES+ theoretical framework, and using this model, Greg Korneluk provided advice to solving problems commonly encountered in clinical practice. Some of the many strategies discussed in the two-day conference included organizing office staff into care teams, identifying and opening up bottlenecks in practice, strategies for complete documentation, optimal strategies for scheduling patients, and how to choreograph the ideal patient visit. The level of granularity was impressive. The discussion on patient interactions, for example, even included advice on how to knock, how to shake hands, and the importance of the right facial expressions.
ICQC’s ideas are widely applicable to different types of practices. Parts of the presentation were geared specifically towards “concierge” practices — where patients pay out of pocket for services and typically insurance is not accepted. But more broadly, ICQC focuses on the idea of adding value to medical practices, whether or not they fit the “concierge” model. If there are certain services that patients want — improved access to their physicians, specific procedures, or amenities — patient are willing to pay more. The final presentation outlined strategies for marketing and providing these “value-added” services to patients.
I surveyed the doctors at the concluding lunch. Their consensus was that the conference left them with a wealth of new strategies and ideas to improve their medical practices. And I agreed with them. While conferences like Physician Success Strategies are not for everyone, I believe that a majority of physicians would benefit from this kind of intensive focus on new ways of improving efficiency, productivity, and the quality of patient care.
Bioartificial Kidney Reduces Risk of Death from Acute Kidney Failure
Tuesday, March 25, 2008
Joshua Schwimmer, MD, FACP, FASN
Most patients with acute kidney failure receive hemodialysis -- a cleansing of the blood using a dialysis machine, a "man-made" kidney. However, acute kidney failure is associated with a high mortality rate, and researchers have been interested in whether the outcomes from kidney failure could be improved through the use of a "bioartificial kidney," which have the potential to more closely replicate the many functions of the human kidney.
The "renal assist device" (RAD) is a bioartificial kidney with tubules lined with actual donated human kidney cells. In an upcoming issue of the Journal of the American Society of Nephrology, Dr. H. David Humes demonstrates that the use of the RAD in patients with acute kidney failure is associated with improved mortality and recovery of renal function. While this device is still experimental, it raises the hope that outcomes from acute kidney failure can be improved with bioengineered devices like the RAD. From the press release:
"The cells are made available to carry out subtle metabolic and endocrine functions that the patient's failing kidneys can no longer perform, thereby staunching a cascading decline in the patient's health and allowing time for the patient's own organs to recover," Dr. Humes explains.
Outcomes were significantly better for AKI patients treated with the RAD. After one month, 33 percent of patients in the RAD group had died, compared to 61 percent of those treated with renal replacement therapy only. Patients who received the RAD were also more likely to be alive after six months. With adjustment for other factors, the risk of death was about 50 percent lower in the RAD group.
Patients in the RAD group also had a shorter time to return of kidney function. Overall, kidney function recovered in 53 percent of patients with RAD, compared to 28 percent without RAD. In both groups, about 20 percent of patients survived but never recovered kidney function, requiring chronic dialysis.
Although the initial results are encouraging, the benefits of RAD treatment need to be confirmed in larger studies. In addition, the researchers need to study the effects of changes in the design of the RAD, which are needed to accommodate mass production.
In the hospital, when I use my iPhone, I hear this all the time. What are the two biggest reasons doctors give for not switching to the iPhone? 1) They don't want to change their carrier to AT&T and 2) The iPhone can't run Epocrates or other third party software.
Most physicians have used Epocrates, which is a popular drug reference database accessible through PDAs and the internet. Back when I owned a Treo 650, I used Epocrates all the time. When I switched to the iPhone, I missed having immediate access to the Epocrates database -- though the inconvenience of having to access Epocrates through the internet was minor.
This month, the biggest complaint about the iPhone -- that it can't run third party software -- has been answered with the release of the iPhone SDK (software development kit). And to the surprise of many physicians, Epocrates was one of the first products to be showcased.
Health care professionals who are iPhone users -- or plan to purchase one -- are waiting until June, when the application store for third party iPhone software will go live. Realistically, however, our enthusiasm should be tempered by the understanding that third party software like Epocrates has already been available for the Treo and for Windows Mobile. Seen this way, iPhone users are only getting now what they should have received all along.
On the other hand, the iPhone is a unique platform. The part of the Epocrates video (shown above) that received the most enthusiastic response was the demonstration of the pill finder, which takes advantage of the iPhone's interface to identify and display medications based on their shape and color. In a handheld device, this feature is truly novel. The potential for a flood of new medical applications which take full advantage of the iPhone's strengths are what's really exciting for physicians. Will that be enough to make the iPhone the doctor's PDA of choice? We'll see.
I previously wrote about Dr. Jay Parkinson on Tech Medicine. He runs an innovative practice, primarily for the uninsured, involving housecalls and the integral use of email and instant messaging to facilitate communication with patients.
In association with Myca, Dr. Parkinson is launching a project called hello health:
Yesterday, we at Myca, announced hello health at the Health 2.0 conference in San Diego. hello health is the consumer brand of healthcare delivery powered by the Myca platform. It’s Geek Squad with doctors and a Netflix-priced monthly membership subscription fee — it is a branded healthcare “experience” that mixes “concierge service for all,” with house/office calls and web visits via email, IM, video chat, and text messaging. It’s Fed Ex, Apple, Whole Foods, Amazon, Toyota, Fresh Direct, and Geek Squad all applied to healthcare delivery.
* Video, voice and data communications across multiple platforms and channels, including mobile phones and PCs * Practice automation through documenting and archiving of communication * Intelligent system offers rules to validate diagnoses delivered through a compelling, easy-to-use interface * On-line personal health records * Secure access to each interaction for patients and doctors * Integrated scheduling and billing * Integration with remote monitoring devices and services * Online prescriptions with dosage guardrails and medication interactions alerts * Automatic medical coding for diagnostics and therapy * Ability to add nutrition and wellness features to support preventive medicine
For those of you following Google's entrance into the business of Electronic Health Records (EHRs), here's a roundup of recent developments and insights.
Google Health aims to solve an urgent need that dovetails with our overall mission of organizing patient information and making it accessible and useful. Through our health offering, our users will be empowered to collect, store, and manage their own medical records online.
Eric Schmidt, CEO of Google, gave the keynote at the Healthcare Information and Management Systems Society Annual Conference.
Matthew Holt of The Health Care Blog analyzed the concern that EHRs like Google Health aren't covered by the HIPAA privacy law, and decided that the benefits of EHRs outweigh the privacy risks.
The New York Times Bits Blog claimed that "the company’s new medical records system is largely about advertising, especially ads by drug companies."
A Google spokesman said, however, that the company may well put ads on future versions of the service. But it doesn’t even need to. Presumably parts of Google Health, like most everything Google does, will have a box that can be used to begin a Web search. The search results pages, of course, will have Google’s standard ads.
What won’t be standard, most likely, is the revenue that comes from those ads. Health is among the most lucrative categories of advertising, in part because there is no better way for drug companies to reach prospects than when they are searching for or reading about certain conditions.
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Image from WikipediaWhat's this blog all about?
