Docnotes

Momdocs

The Momdocs project is moving along a bit.  We originally built it because we use an Emr with not-so-good prenatal module. A few years ago, this company lost out to GE in a bidding war for Logician.  The plan, of course, was to throw their old EMR in the trash and use Logician.    Now there are rumors again about this company in the market for another EMR ... I wonder if these rumors have any basis ...

Anyway ...  Momdocs was an effort to make a perinatal record that didn't take forever to manage.  The Misys EMR simply can't build a record that the hospitals would accept.  So we were filling out the ACOG sheets by hand -- transcribing them from the EMR when our patients were approaching delivery.   It's too bad that we had to create another home-grown solution, but momdocs - like everything else we've built - is user-focused.  

The residency program is using it more and more, and I've not had much feedback ... so I guess that means they like it.

You can try it too ... log in with username:demo and password demo.  Looks like Barney Rubble is overdue.  We'll need to induce him soon.

Office Work

If we think about what physicians do, the physician-patient interaction is what springs to mind first.  

But ... we do other things too ...  how much else?

We've had our home-grown messaging system in place for about 18 months now, and I just did a little analysis of some of the data in the system.   We use the system for phone messages and patient - initiated e-mails.   When a patient calls with a question, a message is generated to the nurse or physician.  It's much better than paper messages - which we outlawed in the summer of 2002.   An average of 71 messages were generated in the system per day.  We have 2.5 physicians (2.0 until 11/03) and 2 nurses.  The 2.5  physicians received an average of 42 messages a day  -- so about 15 messages per physician.

Some messages are just FYI:  patient calls and nurse gives advice, sends FYI to physician.

Other messages represent work to be done -- either calling a patient or calling a physicians or (ugh) calling an insurance company.  This varies, but I find that when I call home with my ETA for dinner, if I have more than 10 items in my "in" box, It'll be more than 40 minutes to get home (I live about 90 seconds from the office).

The other work we do is review labs and make calls or send messages based on the lab results.  Our labs are scanned in to our "in" box as well.  In the same timeframe, we have scanned 42,562 pages -- about 170 per day (about 70 per physician per day).  Reviewing these takes time too.

When we did this work in the paper world, it was all represented by a pile of paper on the desk.  Now we can quantify how much work this represents, and perhaps we can figure out how much time to expect this to take -- which would ultimately determine how we budget our time and human resources.

.. no wonder I'm up so late ...

epocrates

Access ePocrates Rx Online for free during the month of February, 2004..

Click here: http://openhouse.epocrates.com

epocrates is a staple of physician practice in 2004.  Like most physicians - I use it many times every day.  Our nurses have started to use the desktop version (web-based) and it's one of the three or four applications always open on their desktop. 

"normal humans" can take a look at it too ... as the free trial is open to everyone.

CME and Medlogs

A month or so ago, I discussed (via e-mail of course) an idea with Enoch.  Here goes:  Develop a mechanism for providing Continuing Medical Education credit to physician readers of medical weblogs.  I suppose that nurses and NPs/PAs could do the same .. and I'm happy to help with that .. but our inital idea was to focus on the physicians.  Dr Bob already offers CME on his weblog, but it's a challenge to follow the path toward that credit .. and since he's an Internist - he can't offer AAFP credit - which is important to me (and my family physician colleagues).

Here's my proposal ... now that we're nearly ready to begin working on it.   We'll change medlogs.com a bit to highlight Medical weblogs that provide CME. 

Huh? ... ok .. here's goes ...

We identify 12 medical weblogs that qualify as high quality sources of medical information that would qualify as CME.  Sure .. if we have more than 12 .. that's ok, I suppose.  We'll need to form a core group of us to determine some criteria for inclusion  Pennie?  Bob? Enoch? Steve? ...

• We make sure that these weblogs meet the ACCME's ciriteria for web-based CME. 
• We define the GNOME for the learning experience
• Goals:  what we hope the learner will accomplish
• Needs: What do they need to reach these goals
• Methods:  How will we do this
• Objectives: What are the measurable events that we can track on the way toward the goals?
• Evaluation:  How will we evaluate what the learner has learned .. and whether our process was implemented properly.
• We identify 12 medical weblog authors who will volunteer to be responsible for a given month of the year.   Each volunteer would review all 12 weblogs every (week? 2 weeks? month?) and would develop a quiz that would test the participant's learning - and survey the particiant on the quality of the CME activity.
• We've got quiz-making software here at AMC, so it won't be too hard to get the feedback and quiz done every month.
• Splitting this up among 12 people will minimize the work we have to do individually.
• We'll need to do some work on this end to file the appropriate paperwork to be able to grant CME credit. 

Please post feedback to this post and/or send me a message if you would like to volunteer to be an author/collaborator. 

 

Early common infections may play a protective role in the aetiology of childhood leukaemia

This British Journal of Cancer paper suggests that childhood infections may prevent leukemia. 

The study was deigned to determine risks .. so we can't really draw any conculsions about prevention.  But it's an interesting idea.  We'll keep our ears open ...

... and it seems intuitively related to the literature on allergies .. and the observation that the cleaner we live ... the more likely we are to develop allergies. 

 

Popular Entries

A few notes today ...

• Aside from the entries in which I mention not-to-be-mentioned body parts, this post from nearly two years ago is one of the most linked-to posts I've written.  I like it too.  Kinda poetic, eh?  .. and if you ask "googlism.com" what Jacob Reider is ... the answer comes from this post.  I now know what I am .. or at least what I'm doing! 
• I have a heckler now that my wife  has found the weblog.  Sorry ... Cerumen = "ear wax"
• Jacob's famous chicken surprise .. goog and good for you.
• Handful of frozen chicken breast strips.  Get a 5 pound bag at BJ's or Costco for $10 
• Plop into hot cast-iron skillet .. fire on at med-hi
• Splash of Olive Oil
• ok ... another splash of Olive oil
• Blob of mild salsa ...
• Splash of V8 juice
• 2 oinions - sliced well.
• Get the onions UNDER the chicken now ... cover and cook for about 15 minutes.  As Maura always said ... "Chicken is not like a burger ... you don't need to flip it"

 

Coldfusion Weblog

CFBlog v.005 is Dave's next big hit.  It's built on Mach II.

Here's a spec-on-a-napkin (the best kind)

• Imports Radio and MovableType
• Generates RSS 2.0
• Won't Generate Atom (just to spite them!)
• Tackback
• Searching
• Multiple Blogs
• Multiple Authors
• "easy" mode with layout templates, etc (like Radio or TypePad)
• "hard" mode with customizable tags .. this will require basic coldfusion skills.
• Support for static or dynamic page generation
• RSS subscription (supporting the creation of mini-aggregators)
• Make breakfast
• WYSIWYG editing for posts and comments
• Spam-proof comments
• Support for categories

Handout for cerumen

This is a great handout for patients who have questions about cerumen removal.

Ears / Harvard / Boston

Dave responded to my post below.

I didn't have my facts right.  Dave called his primary care physician first.

I posted a response to the Boston Common weblog   post  (and his response) ... here's what I said:

Dave is sharing some tidbits of his personal life with us, and I shouldn't chastise him for doing so .. I should applaud him. This sort of transparency is educational. Dave is teaching ... and I suppose my goal was/is to teach as well.

Dave - I didn't mean to infer that you were casual about your care. My inference (albeit incorrect!) was that you -- like many -- have been taught -- by a system and culture that values specialty care above primary care -- to seek specialty care before the problem was evaualted by a family physician or general internist.   As point out, I was wrong about how this panned out.  Given your "celebrity" status, and your willingness to share these details of your personal life with us, I used this event as an example of a component of our healthcare system that I believe is dysfunctional.

It turns out that the example was a rotten one, but my sentiment about the dysfunctional system/culture remains the same.

Most patients who reach out to me are seen promptly and are referred to specialists only when necessary. Yes - we see patients on Saturday and Sunday and even at night.  Had you called me, I would have offered to see you in the office.  This is the core of what we do - we are the primary care physicians and we specialize in primary CARE -- not primary referral. We take care of very sick people and very well people. Young, old, pregnant, depressed, sexually active and impotent.

As one who teaches family medicine to medical students, I struggle with the biases against primary care every day. Specialists tell our students that family physicians are "stupid" or that the only role we should have is to "pop the pimples on farmers' butts and refer the rest of the patients to appropriate specialists." No kidding .. this came right out of one of my specialists colleagues' mouths.

My comment speaks to a culture of medicine -- and the role of primary care in how we treat our patients.

Yes .. I have a bit of a chip on my shoulder. (see above re: farmers butts). Primary care physicians are the Rodney Dangerfields of medicine.

We earn respect in an 8 x 10 room with our patients one-by-one-by-one. My post starts with a comment about Dave's encoiunter, but if one reads the whole post, you can see that I discuss much more than that.

Some places - and Harvard is one of them - have developed a culture that remains specialty -focused. I grew up in Boston - where I didn't know what a family physician was until I was 18.   Boston was one of the last of the major cities to host a residency in Family Medicine (There are several in the Boston Metro area now), and there remains NO family medicine education at Harvard. See this note in Harvard Medical School's weekly paper about the dearth of family medicine education at Harvard, and how unhappy the students are about this.  

 

Finally - since we're all in this to educate ... here's a link explaining why you shouldn't use q-tips in your ears .. and a reminder (I've posted on this one before) that colace (Docusate Sodium) is very good at softening earwax.  I sometimes suggest that people use this once a week to avoid impaction problems alltogether.

LED Headlamp

My sister gave me one of these headlamps a month or so ago.  They're made for hiking, and while they are not so cool looking as the headlamps made for medical use - they'are also about 1/10 the cost. I've been using it neary every day.  It's great for doing throat swabs (it always seems you need three hands for that) .. and anoscopy too.