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 three 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) and hosted The Efficient MD Wiki. I'm also writing a book with the American College of Physicians on physician productivity and life hacks. My collected posts may be found on jschwimmer.net, a tumblelog.
There are many topics I plan to cover, but I'm also open to suggestions, tips, and even posts by guest bloggers. My email is techmedicine@gmail.com.
How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere, Part 3: How to Use Evernote as an Electronic Health Record (EHR)
Sunday, August 31, 2008
Joshua Schwimmer, MD, FACP, FASN
Please see part 1 for an introduction to Evernote and part 2 for an introduction to using Evernote as an EHR.
Let me be clear: I'm not suggesting that Evernote is a substitute for any of the excellent commercial EHRs currently available. The following is presented as a proof of concept only for how a simple, inexpensive, customizable EHR built on Evernote might work. Please see the disclaimer.
As always, HIPAA is a major issue: Evernote provides encrypted communication and many security safeguards, but it's uncertain whether Evernote fulfills all HIPAA requirements. (Update: Evernote has confirmed by email that, "At this time we do not plan to pursue HIPAA certification for our (consumer) Evernote service.") Thanks to those who directed me to the "Federal Security Standards for the Protection of Electronic Protected Health Information." Of course, if you're concerned about transmitting information to the Evernote servers, you can always instruct Evernote to keep all data on your local computer. This bypasses the HIPAA issue and you'd still be able to use Evernote, but this means that you won't be able to access patient data from the web unless you use a program like GoToMyPc.com.
A "hybrid EHR" has a combination of paper and digital elements. The following is a step-by-step guide to creating a hybrid EHR using Evernote that will allow you to type your notes directly into Evernote, use note templates, use shortcuts for commonly used sentences and paragraphs, print your notes for the paper medical record, and theoretically securely access your notes from the computer, the web, or the iPhone.
1. First, set up an Evernote account. (Sign up for the $5 a month premium account if you'd like your communication encrypted to the Evernote servers.)
2. Create a notebook on Evernote titled "Patient Notes" to separate these notes from other information you store on Evernote. (If you're concerned about HIPAA, be sure to set the notebook so that it doesn't sync with the Evernote servers.)
3. At this point, while you can immediately begin typing patient notes directly into Evernote, the system is most powerful if you create your own customized note templates for new patient visits and follow up visits. (See this post on creating customized note templates.) Ideally, you'd like to create "macros" or "snippets" which allow you to type a word which is "expanded" into a body of text. For example, you might type "NEWPATIENT" which would fill in a new patient template. Or typing "STATIN" might fill in — for example — "Benefits, alternatives, and risks of statin therapy discussed and patient consents. Advised not to drink grapefruit juice." Textexpander for the Mac and Activewords for the PC are both excellent programs that allow you to create these text shortcuts.
4. In Evernote, searching for and displaying previous patient visits is simple. You can easily copy and paste information from your previous note into the new patient note, then update all changes in medications, physical exam, etc., for the new visit.
5. Evernote also allows you to keep tracking of pending "To Do's" for patients, which turns out to be extraordinarily useful. (In Getting Things Done parlance, this would be called a "waiting for.") For example, let's say you've sent a patient for a chest X-ray or other test, and you'd like to ensure that the test stays on your radar screen and that you follow up on it. When you type the patient's note, simply click the blank checkbox in Evernote and it will automatically place the note in the "To Do" category. To review all your previous "To Do's" to see what tests are still pending, click on the "To Do's (Not Completed)" section in the sidebar. When you've received the chest X-ray or other test results, click the checkbox in the previous note, and you're done. (This is one of the simplest methods for keeping track of pending tests that I've ever seen.)
6. After the visit is complete, the patient's note can be printed, signed, and placed in the permanent medical record. Here's a sample workflow: a portable computer running Evernote is placed on a rolling laptop table, and the computer has a secure wireless connection a printer. After each patient is seen, the table is rolled between exam rooms. Meanwhile, the notes are wirelessly printed at the nurse's station then placed in the paper chart.
7. After the visit, let's say you hypothetically receive some new laboratory tests and need to retrieve the patient's previous note to help interpret them. Instead of hunting for the paper chart, you can simply open Evernote, search for the patient's name, and pull up the record. (Theoretically, if HIPAA wasn't a concern, you could also access your patient's note through the Evernote web application or through the Evernote iPhone app.)
Though Evernote is not specifically designed for doctors, it’s a useful tool for allowing physicians to capture and retrieve essential information in order to improve patient care. These three posts have provided just a small sample of how this program can be used. I'm interested to hear how other health care providers are using Evernote. Please feel free to comment.
How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere, Part 2: Using Evernote as an Electronic Health Record (EHR)
Saturday, August 30, 2008
Joshua Schwimmer, MD, FACP, FASN
Evernote is a new searchable, friendly, available-anywhere, online personal database — and for many health care providers, it's rapidly becoming indispensable. Part 1 provided an introduction to Evernote and described how to use it to file away journal articles. In this part, I'll discuss how health care providers can use Evernote as a hybrid electronic health record (EHR).
Let me be clear: I'm not suggesting that Evernote is a substitute for any of the excellent commercial EHRs currently available. The following is presented as a proof of concept only for how a simple, inexpensive, customizable EHR built on Evernote might work. Please see the disclaimer. As always, HIPAA is a major issue: Evernote provides encrypted communication and many security safeguards, but it's uncertain whether Evernote fulfills all HIPAA requirements. (Update: Evernote has confirmed by email that, "At this time we do not plan to pursue HIPAA certification for our (consumer) Evernote service." So, there you are.) Thanks to those who directed me to the "Federal Security Standards for the Protection of Electronic Protected Health Information." Of course, if you're concerned about transmitting information to the Evernote servers, you can always instruct Evernote to keep all data on your local computer. This bypasses the HIPAA issue and you'd still be able to use Evernote, but this means that you won't be able to access patient data from the web unless you use a program like GoToMyPc.com.
First, some background. EHRs have many advantages over paper medical records. With an EHR, when a patient calls with a question — or if a lab calls with a dangerously abnormal result — it's simple to pull up the medical history, medications, and details of the patient's last visit. In contrast, if you've used a paper medical record, you've occasionally waited in frustration until someone found the chart you needed. Very likely, you've also experienced an important chart being misfiled or lost.
If spending time looking for paper medical records is so inefficient, why do over 80% of physicians in the U.S. still use them? The barriers to switching from paper records to EHRs are many: expense, hours of training required, uncertain benefits, interfaces that are user-hostile (many EHRs inexplicably seem to model themselves after Windows 98), inertia, lack of flexibility, and concerns about being locked into a relationship with a single vendor.
I'm convinced another reason why more physicians haven't switched to EHRs is that there's previously been no middle ground. That is to say, until now there's been no easy way to realize some of the major benefits of EHRs — searchability, accessibility, cut-and-pasteability, and templates — without investing in a full-blown system.
That's where Evernote comes in. In addition to its other uses, Evernote can provide a secure, searchable, available-anywhere database of all patient notes and data. And even if you already use an EHR, you might still find Evernote useful to record information — phone messages or snapshots of lab reports, for example — when your usual EHR is not available.
Regarding the issue of security: the premium version of Evernote ($5 a month) offers encrypted communication with the Evernote servers. Here's what the website says:
Security and privacy are extremely important topics for Evernote users, and for good reason. Evernote would like to provide a single service to manage your memories for many years. To achieve this, we must provide a very high level of system and data security while offering users a variety of choices to manage their own privacy requirements. Here is a high-level overview of some of the ways in which your data is protected by Evernote.
When you add a note to the service, it is secured like your email would be at a high-end email provider. This means that your notes are stored in a private, locked cage at a guarded data center that can only be accessed by a small number of Evernote operations personnel. Administrative maintenance on these servers can only be performed through secure, encrypted communications by the same set of people. All network access to these servers is similarly protected by a set of firewalls and hardened servers. Your login information is only transmitted to the servers in encrypted form over SSL, and your passwords are not directly stored on any of our systems.
Evernote also confirmed through email that communication with the iPhone app — if you have a premium account — is also encrypted.
In Part 3, I'll provide step-by-step instructions for using Evernote as an EHR.
We've all heard stories of friends and colleagues who've lost weeks of work, irreplaceable pictures of their families, or their entire music collection because they didn't backup their computer regularly. Recently, my external hard drive — containing my only backups — crashed without warning, so I took that opportunity to reassess my own backup strategies.
It's impossible to hear this too often: if you don't backup regularly, you will regret it.
The ideal backup system should be invisible — that is, you should "set it and forget it," but trust that it will work when you most need it. Fortunately, the price of online storage and of external hard drives has plummeted in recent years, and backup systems have become simpler, more reliable, and less expensive.
On the Clinical Cases and Images Blog, Dr. Dimov discussed the strategies he uses for backing up his PC. In this post, I'll discuss some newer strategies that I use for backing up my MacBook Pro. (When applicable, I'll also discuss equivalent alternatives for the PC.)
Time Machine is a perfect example of a "set it and forget it" backup strategy. This application, built into the Mac's Leopard operating system, performs automatic hourly, daily, and weekly backups of your data to an external hard drive. If you have a Mac running Leopard, and you don't yet have a backup system, here's my advice: immediately purchase an external hard drive that's twice the size of your main computer's hard drive, plug it in, and run Time Machine. It's really that simple. (For Windows XP users, an alternative that performs the same function is SyncBack.)
But what if both your backup and computer are stolen, damaged, or corrupted? One solution is to keep two backups, one at work and one at home. Another solution is to use an inexpensive system that backs up your data online: I use and recommend Mozy. For $5 a month, Mozy will back up the contents of your entire hard drive and the contents of any external hard drives. It even provides 2 GB of storage free so you can try it out. While it's unlikely that you'll need an off-site backup, for $5 a month, the extra security is worth it. (Mozy works on both PCs and Macs.)
Of course backing up is important, but what if your computer's hard drive crashes and won't start? You may have a backup, but that won't help if you're trying to meet a deadline and can't access your data. In this situation, having a "bootable backup" — that is, a backup that can substitute completely for your main computer's hard drive — is critical. The best application for the Mac capable of making bootable backups is SuperDuper. I use a SimpleTech 250 GB external drive to automatically backup my 160 GB Macbook Pro every night. (If you know of an equivalent application for the PC capable of making bootable backups, please leave a comment.)
But what if you have hundreds of gigabytes of data to backup, such as scientific data, pictures, and/or movies of your family? I shoot uncompressed images with a Canon Digital Rebel XTi, take lots of movies with a Flip camera, and download hundreds of hours of video with Miro. Without additional space, I would quickly fill up both my main and external hard drives.
My solution? The Drobo — a "data storage robot" — recently dropped in price , so I purchased one when my old drive died (older, less expensive Drobo here; newer version here). For the last several months, it's worked great, and I couldn't be happier with it.
Drobo is designed to provide simple, invisible, expandable storage, and it works on both Mac and PC. It's based on the concept that every individual hard drive, sooner or later, will die unexpectedly. Drobo is a black box — figuratively and literally — in which you plug in up to 4 SATA drives of any size, for up to 4 terabytes of total storage. All the data you write to Drobo is fully backed up among the 4 drives. If one dies, no problem, the Drobo is "self-healing" — the drive bay LED will turn red, and you can pull the dead drive out and replace it with a new one. Your data remains safe. Drobo is particularly useful for storing movie files, archives of photos, or other data that doesn't need to be on your main computer. Drobo will also work well with Time Machine, and Mozy can slowly backup the contents of your Drobo for additional security.
That's my backup strategy. Any additional tips or comments on backups are welcome.
Lots of new health care apps for the iPhone. Among them is "Quitter," an app designed to help smokers quit.
Should the medical profession regulate medical bloggers? Dr. R. W. Donnell weighs in here. American Medical News discusses the issue here. A paper in the Journal of General Internal Medicine sparked the controvery with these conclusions:
Blogs are a growing part of the public face of the health professions. They offer physicians and nurses the opportunity to share their narratives. They also risk revealing confidential information or, in their tone or content, risk reflecting poorly on the blog authors and their professions. The health professions should assume some responsibility for helping authors and readers negotiate these challenges.
MedicalPlexus is a new professional network for physicians founded by a group of Harvard residents and MIT graduate students. Medgadget has a review.
As expected, medicare has expanded the list of "no-pay" hospital conditions. The Wall Street Journal comments.
Ozmosis compares Medpedia and Google Knol, both new Wikipedia-like environments aimed at the creation of authorotative content.
And finally, from MAKE Magazine: The Heart Robot is an "emotive puppet" that is designed to "investigate the effects that a seemingly emotional machine can have on humans."
The First Medical Calculator for the iPhone: Mediquations
Monday, August 18, 2008
Joshua Schwimmer, MD, FACP, FASN
I've lost count of the number of times I've been asked if the iPhone has a good medical calculator — usually by Palm Treo users who are interested in switching. My answer has always been, "No... not yet."
Until now. This week, a third (!) year medical student from the University of Texas published Mediquations, the first medical calculator for the iPhone. For $4.99, it's well worth it. (I can't believe I've had to wait this long to calculate glomerular filtration rates on the iPhone...) Here's an email from Zack Mahdavi, the apps creator. He'd like to hear from you if there are any equations you'd like included in the next version.
I am a third year medical student from The University of Texas Medical Branch (UTMB), a Computer Science major from The University of Texas at Austin, and an avid iPhone user. Apple recently introduced the App Store for the iPhone and iPod Touch that allows developers to build applications for the iPhone. My coworkers have been clamoring for a medical calculator for the iPhone for months, and I knew once the App Store was announced that this is an application I must build.
As a result, I built Mediquations. It is a native iPhone application that does not require an internet connection.
Features include: - Access to over 40 formulas and scores. - View the full equation for each formula - For some equations, view quick reference info and citations. - Support for US and SI units. - Built in search to find an equation fast.
The equations available include: • A-a O2 Gradient • Absolute Neutrophil Count • Age • Anion Gap • APGAR • Basal Energy Expenditure (Harris-Benedict Equation) • Bayesian Sensitivity/Specificity • Body Mass Index (BMI) • Body Surface Area (BSA) • Cardiac Output (Fick) • Cockcroft Gault GFR • Corrected QT (QTc) • Corrected Serum Calcium • Corrected Serum Phenytoin • Corrected Serum Sodium • Fractional Excretion of Sodium • Framingham Cardiac Risk Score • Free Water Deficit for Hypernatremia • Glasgow Coma Scale • Henderson-Hasselbach Equation • Hepatitis Discriminant Function • Ideal Body Weight (IBW) • LDL Cholesterol Estimation (Friedewald Equation) • Maintenance Fluids • MDRD GFR • Mean Arterial Pressure • MELD Score • Osmolality (Serum) • Osmotic Gap (Stool) • Parkland Formula • Peak Flow (predicted) • PELD Score • Ranson Criteria • Reticulocyte Production Index • Schwartz Pedi GFR • Temperature Conversion • Transtubular K Gradient • Weight Unit Conversion • Well's Criteria • Winters' Formula
I am also open to suggestions for other equations, so please let me know if the app is missing anything you’d find useful.
The app costs $4.99 and is available on Apple’s App Store via iTunes or via the App Store application on the iPhone/iPod Touch.
For more information, visit mediquations.com. I hope your visitors find it useful!
How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere (Part 1 of 3)
Monday, August 11, 2008
Joshua Schwimmer, MD, FACP, FASN
Evernote — a new searchable, available-anywhere, online personal database — recently became indispensable to my medical practice.
Technologies like Evernote make it obvious that we deal with information that lives in two worlds. The first, the physical world of paper, is populated by written medical records, scribbled notes, and stacks of printed journals that arrive in the mail. Information in this world is maddeningly localized — ask any physician who's struggled to find a missing lab report among piles of paper on their desk.
In contrast, the digital world — and we can substitute "cyberspace" or "the cloud" or your favorite phrase here — is inhabited by electronic medical records, web-based email, and online databases. The characteristic of this world is that information is searchable, available-anywhere, and (hopefully) securely backed-up online in multiple locations.
The beauty of Evernote is that it acts as a portal between the paper and digital worlds. Here's an example: let's say you've just read a review article on hypertension in the New England Journal of Medicine. This paper article contains an important table on drugs to treat hypertension that you'd like to refer to at a later time. Traditionally, articles like this would be torn out, stapled, and placed in a bulging filing cabinet for later retrieval. But too often, finding the article is too difficult, and it just takes up space for years until the information is outdated. Sound familiar?
By using Evernote, physicians can easily convert that critical table into digital form. (The journal itself can be recycled — it's no longer needed.) You can enter the table into Evernote in at least three ways:
By taking a photo using the camera on your phone and emailing it to your personal Evernote email address
By scanning the article directly into the Evernote program on your computer — I'm personally a fan of the Fujitsu Scansnap for quickly transferring any paper items I'd like to later retrieve to Evernote
By accessing the article on the NEJM website and using Evernote's "webclipping" program to highlight the table
Once in Evernote, the table can be named ("Table of Drugs to Treat Hypertension") and tagged ("Hypertension," "NEJM"). Evernote even recognizes the text in the table — for example, the drug "metoprolol" — and makes it all searchable. The online Evernote database synchronizes automatically with the Evernote database on your computer. And here's the beautiful thing — anytime you want to refer to that table, you can either
Search for "hypertension," "metoprolol," or "NEJM" on the Evernote program on your computer
Search Evernote online using any web browser
Search Evernote with the web browser on your mobile phone or with the Evernote program for the iPhone
The information in that article is now available almost anywhere. Just think of all the space you'll save in your filing cabinets by never filing away a journal article again.
But this is only a small taste of the capability of Evernote. Without much fanfare, the Evernote Corporation has created the perfect tool for designing a customizable, hybrid electronic health record (EHR). I'll explain how to create an EHR in Evernote in Part 2.
Creating a Voicemail System for Patients using Free or Inexpensive Services Online (Google's Grand Central and CommuniKate)
Thursday, August 07, 2008
Joshua Schwimmer, MD, FACP, FASN
Image via WikipediaIn doctor's offices, the telephone is critical for communicating with patients. Yet too often, the phone system is used inefficiently. Symptoms of this problem include scrawled messages spread out on doctor's desks, important messages never received, messages received too late, and patients put on hold for what seems like forever. Any doctor who's repeatedly been interrupted throughout their workday by non-urgent phone messages knows this problem well.
One of the biggest flaws with the telephone system in many doctor's offices is that human beings — with limited time and attention — are often involved when they don’t need to be. They spend too much time triaging calls and scribbling down messages. And when humans really do need to be involved, they’re busy, much to the frustration of patients calling the typical doctor’s office.
Here’s one solution to the problem: create an automated voicemail system for non-urgent messages from patients. These messages might include simple questions, requests for laboratory results, requests for refills, non-urgent clarifications, or any communication that isn’t urgent and doesn’t obviously require an office visit. The principle of productivity being followed here is filtering: any information that doesn't need to be dealt with immediately should be filed until later when it can be given the attention it deserves. Filtering non-urgent messages with a voicemail system frees up the phone lines and the time of the secretarial staff for matters that truly require their immediate attention.
Many doctor's offices already have an automated phone message that greets callers. The script for a typical system often sounds like this:
If this is a doctor's office or hospital or an urgent medical matter, press "1"... If you need refill authorization from the pharmacy, press "2"... If you'd like to discuss test results, press "3"... If you need to speak with a receptionist, press "4" or stay on the line...
In this system, certain non-urgent messages (options "2" and 3") will be filtered to voicemail, but other non-urgent messages for the physician will still require the attention of the secretarial staff.
A quick fix might be to add an extra option those non-urgent messages. Here's an example:
If this is a non-urgent message for the doctor that does not not need an immediate response, please press "5" to access the voicemail system.
If you don't have the ability to customize your voicemail system, there are many other free or inexpensive options available online. Services like Google's Grand Central and CommuniKate offer a dedicated number for voicemail messages that can be provided to patients. ("For any non-urgent messages, please call this number.") Google's Grand Central is free but has temporarily stopped accepting new applications, and CommuniKate costs approximately $30 a month. (I've used both.) Using a separate voicemail number that you provide to patients also gives you the option of testing it out to see if it works before changing your current system.
For years, I've offered patients a separate voicemail number for non-urgent calls, and it's worked very well. Here's a sample voicemail message:
You’ve reached the voicemail of Dr Roberts. If this is a medical emergency, please hang up and dial 911. If you must reach me immediately, please speak with the office at 212-555-5555 and have me paged. I check this voicemail daily and usually return calls within 2 business days. Please leave a non-urgent message here. Thank you.
The key to this system is to listen to the voicemail messages every business day, and return as many messages as possible daily. Services like Grand Central and CommuniKate make this process easier by offering visual voicemail: you can see a complete list of your messages and even listen to them online. If you work with a physician extender or PA, you can also have them prescreen your messages and answer those that don't require your personal attention.
There are several arguments against this system. The first is that it requires that patients exercise their judgment about what messages are urgent. In my experience, the number of truly urgent messages that patients leave on voicemail systems is very small, especially if your voicemail greeting is clear about what messages are appropriate and what messages aren't.
Another argument is that, "When people call they expect to speak to a doctor, not a machine" — except in practice, many patients don't. If the system works reliably, and messages are returned in a timely manner, most patients are perfectly content to leave voicemail messages. In many cases, it's actually quicker for them, too.
Of course, as with all the writing in this blog, these are only useful experiments and suggestions that have the potential to make a measurable different in your practice. They are are provided for informational purposes only. Use your judgment when applying them to your own practice. If this system works for you, please feel free to email me or post a comment. Of course, if you think that there's a major problem with this approach, please also leave a comment or email me. And if you've tried other free or inexpensive online voicemail systems, let me know. I'd be happy to amend the post with additional information.
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