Docnotes

More on otitis media

For those of you who have been reading this weblog for a long time, you have probably noticed that one of my primary clinical interests is otitis media and it's closely related cousins: Sinusitis and bronchitis.  These conditions are the cause of the most frequent visits to physicians at children and adults in this country (aside from well-child care and prenatal visits).

These conditions may also represent the vast majority of antibiotic prescriptions that are written in this country and since all three of these conditions can usually be successfully treated without the use of antibiotics, appropriate diagnosis and deliberate management is important.

I say "deliberate management" because many patients care physicians medical students and residents think that when condition is not treated with an antibiotic, it isn't treated.  For example, in our electronic medical record, there is a template entry next to "upper respiratory infection" where the user has two choices: "Treat with antibiotic" and "no treatment."  

Of course, neither is appropriate care.  We need to give our patients to best tools that we can for the management of these perplexing problems. 

• Good information. 
• Good recommendations for symptomatic treatment including appropriate analgesics for otitis media and symptomatic relief for nasal congestion or persistent cough
• Access to care if symptoms worsen or don't improve after a given period of time

Today I found a few articles related to otitis media that seem interesting albeit somewhat concerning:

Augmentin causes autism this seems like a rather poorly done study which I hope no one at USA Today decides to write a feature article on.

In this review of acute mastoiditis, over 200 cases were reviewed during a 10 year period.  It's interesting to note that the average age was 16 and more of the patient's who presented with mastoiditis were being treated with antibiotics and those who were not.  Of course, we can't draw any conclusions about this because of the timeframe of the study (for most of this period, Antibiotics were the treatment of choice for otitis media) and because there certainly can't be any causality established with a retrospective study like this.

This study is an unfortunate and rather detailed review of the microbiology observed in a number of cases of patient's with sinusitis or otitis media.  The problem with this study is that it is clearly focused on disease oriented evidence rather than patient oriented evidence.   There is in fact no clinical correlation mentioned, and the conclusion of the study: The amoxicillin clavulanic acid should be used for the treatment of these conditions - is inherently suspect.

Respiratory syncytial virus is a common cause of otitis media and young children.

Pneumococcal vaccine will likely help in reducing the emergence of resistant pneumococcus.

This one deserves a bit of reformatting so that we can interpret the abstract a little more easily.

Pathogens:

• Streptococcus pneumoniae
• Haemophilus influenzae non-type b
• Moraxella catarrhalis
• Streptococcus pyogenes
• Staphylococcus aureus

So far, this isn't news ..

"Resistance to the eight antimicrobial agents used was found in 37 instances in the AOM group as compared to 99 instances in the ROM group (P < 0.005). "

OK .. we still haven't learned anything new ...

The difference between AOM and ROM was significant with Streptococcus pneumoniae resistance to amoxicillin (P < 0.005), to amoxicillin/clavulanate (P < 0.005), to trimethoprim/sulfamethoxazole (P < 0.01), to cefixime (P < 0.01) and to azithromycin (P < 0.01), and for H. influenzae resistance to amoxicillin (P < 0.025).

So the take-home message is clearly that treatment with antibiotics leads to the emergence of resistant organisms.  No kidding.

 

 

Fake Medical Weblogs - viral replication

Going over the "new addition request" entries from Medlogs just now .. I came across another one that I'm not sure how to handle.   The URL is medline-dot-blogspot-dot-com .. I don't want to make a link .. you you'll have to do the typing (or just remove the -dot-s). Making a link would build traffic for the site .. and I'm not sure that I want to do that. Looking at the "blog" and all recent posts .. there are a few things that make me think that this site is just a revenue ploy - to make money on Google advertising.

• The Name of the site includes the word "Medline" and "Library of Medicine."
• The site provides no information about the author.
• The site's content is cut/pasted verbatim from other websites. Yes .. there is "source" listed on every page .. but it's not really the true source. For example ... a recent entry on light therapy for SAD was copied from this URL at the Cleveland Clinic  .. but the source is only ClevelandClinic.org which doesn't really meet my understanding of appropriate attribution. Since the Cleveland Clinic's content says "©The Cleveland Clinic 2004" .. I think there is likely a copyright violation her as well. A paragraph or two may be ok .. but the whole article?
• Most obvious is that there are THREE separate "google ads" banners on the each page.
  So ... it looks like the site is here to attract people who are searching google for medical information .. perhaps looking for NLM or even Medline .. then build revenue from the advertising. baaad.

Am I over-reacting? Post a comment if you think I should add this to "medlogs" ... otherwise .. I'll delete it from the holding area .. and expect to see more like it.     This is why we need to have an editor for Medlogs ..

Influenza is here!

John wrote about this well done article from BBC on flu.  This year, we invested in a rapid flu test kit.  (CPT 87804)  It's excellent.  Works like a charm .. in about 5 minutes .. (yeh .. package says 10) .. and it's about as easy as a rapid strep test.  My partner diagnosed one person with flu last week .. and I saw two this week.  One was an 85 year old man who had been immunized.  So far this week .. I've used the test twice .. and both were positive.

I'm well known to be a flu-skeptic.  My kids even roll their eyes when friends or family report that they "have the flu." ... since it's almost always "a really bad cold."  .. Not the flu.

When telling patients they have a "really bad cold,"  I hope to be affirming how they feel.  they feel "really bad" and it's important that I convey that I am hearing them.  It's not "just a cold" (they hear:  get out of my office and don't waste my time) .. when I see patients with colds .. I am very careful to make sure that they know that I am taking them seriously .. that their body is working hard to get them better .. and that they don't have (fill in the blank ) .. Pneumonia or sinusitis or something that may cause me to think they would require antibiotics.

Both patients I saw this week were really really sick .. the "doc .. it hit me like a train . I had to have my neighbor drive me here" sick.  THIS is influenza. 

I'll call the health department and make sure I report these cases.

 

More Medical Weblogs

Not a week goes by without some additions to Medlogs.com. We're over 300 blogs now.  Yes, yes .. we'll provide an OPML sometime.  It's in the spec ;-)

I went through the submissions from the past week last night and added a handful .. along with many submissions of weblogs that just don't fit despite a medical slant.  Most are commercial websites that masquerade as blogs.  Perhaps this is a trend we need to watch for.  Ugh.

 My favorite new addition:

inteuri: to contemplate  - a poetic weblog written by an intern in psychiatry.

 

Usability again ;-)

Anticlue responded to my post from yesterday and missed my arguement entirely, while stepping back and lecturing me on what to do.

Here's my response.  For the readers who don't know ... Elyse and I are colleagues, and I have a great deal of respect for her ... which is why I'll let loose a bit here ... all in the interests of continuing a good debate between friends .. ;-)

Elyse, you make some good points .. but by working so hard to figure out what was wrong with what I was saying .. you miss the forest for the trees, and don't seem to acknowledge the importance of the concept that that I was discussing - that usability is important.  

1) Asking if usability was in the RFP is insulting .. and misses the point that I was talking about most point-of-care products .. not one in particular.   The argument that I have consistently made is that usability is the "bullet point" most often ignored on functional matrices ... and due to its subjectivity ... most vendors can wave their hands about how easy a product is to use .. but it's not.  Measuring how long it takes to do a lookup (patient, dx code, medication, procedure code, allergy) is one way to measure usability, since these lookups occur many times during a given provider/computer interaction.  How many keystrokes or mouse-clicks does it take to accomplish a given task?  Do you argue that it is better to accomplish something with more rather than fewer actions?  I don't see how this would make something safer - as you imply.

2) Replicating the functionality that google demonstrates (BTW - they are using XMLHttpRequest) can be done in many ways   .. and of course no one is going to load a full MPI for a large healthcare organization into the browser.  This would  be dumb, as you suggest .. and would likely be a security risk if any application were to be used through a browser remotely. (BTW - Dave points out that it's only one part of our app that loads it all .. the others re-poll the database with evey keystroke, like XMLHttpRequest).   But you CAN check in with the database and maintain a responsive user interface with every keystroke.  This is what Google demonstrates.  If they're doing it with a HUGE database (the Internet) .. and many more users than the typical healthcare organization would have at any given moment .. you can be certain that such functionality could be replicated on a smaller scale for a  healthcare application. 

Hundreds or even thousands of users is a tiny load compared to the load that Google's servers endure .. and recall that I was not only talking about patient lists.  When I use epocrates on my PDA to look up a medication, I can type the 1st few letters of a medication to find it.  This is good design.  Are you arguing that it would be better to have a 1980's style screen where I type in the medication name .. click "search" and then get back what I was searching for? (or not).  Your point about misspellings also misses the mark.  Indeed, it's the instant feedback that will REDUCE the likelihood of finding the wrong diagnosis, CPT code or patient name ... not enhance it.  Let's take the example of your last name.  Let's say I don't recall whether it's IE or EI or EE or I or EA.  So I type N (space) Ely.  Done.  I found you. Now with a "old method" search: Type Neelsen, Elyse .. hit return .. find nothing.  Back to the search screen.  Nealsen .. nope .. back to search .. etc etc.  Giving the user feedback about what's in the black hole of the database is better.. not  worse.  Vendors are beginning to take advantage of this .. with windows tools .. and XMLHttpRequest .. which is good.  I applaud the use of such techniques, and I hope to see more of it in healthcare applications, as I would predict we will - so that we can focus more of our time on patient care .. and less of our time on typing and clicking and (in the age of The Tablet PC) .. pen-tapping.  I don't think I need to put this in an RFP .. or even build consensus for this concept.  It's a given.

3) Your suggestions about my making a list of issues for my practice organization, and your comment about working WITH the vendor (do you imply that I would work AGAINST them?) are again puzzling  ... and I fear that you are making statements on your weblog about what you know (or think that you  know) about what I am doing for that organization ... which is well beyond the scope of my post.  While it is true that I have been vocal about my concerns about the usability of a product in the past ... I remain a passionate advocate for the user AND the vendor.   If we can't work together, there is no way for the product to meet the needs of the user.</rant>

On a lighter note ...

I'll finish with a quiz about usability - posed by one of my heroes (who has a three-letter name that rhymes with DOG) .. and challenge my readers to go find the answer.

Which takes less time?

a) Heating water in a microwave for one minute and ten seconds.

b) Heating water in a microwave for one minute and eleven seconds.

I'll post the answer tomorrow if no one figures this out.

Google = Usabilty, Medical Software != Usability

Google Suggest is a new implementation of google that takes the search screen to the next logical step. 

When Dave and I built the "mini-EMR"  for our practice three years ago - the search screen worked like this too.  Gmail works like this .. and it's silly that all search fields don't.  If google can do this with the whole Internet - there i sno reason that someone can't do it with their database.

That am I talkin about?  Autocomplete/autoselect.

Follow the link above and you'll see what I mean.  Type the 1st few letters of what you're looking for .. and you get feedback about what's available. This makes your data entry task easier.

Now contrast that with the traditional seach screen.  Programmers - stuck in the 1980's .. when there was 128k of RAM on the client ... create a search process like this: 

Type in what you are looking for
Click "submit" or "search"
Wait
Wait more
Now see a screen that lists theresults.  If you searched for "Smith" in the phone book - you have too much info so you have to do it all over again.  If you searched for "Smitj" because you can't type very well, you get nothing and you have to do it again. 


"Oh stop whining ... this doesn't add minutes to the process .. only seconds"  you say

But if I do this 50 times a day ... it may add minutes .. and if I do it 200 times a day ... it adds many many minutes.

What's better? 

To implement what Google's done, you can apply one of two strategies:
a) maintain a connection to the database/server.  On every keypress .. send the data back to the server .. and get back the results .. showing the top handful of results.  As the user keeps typing, the number of entries that meet the search critereia gets smaller .. and the item they are searching for is found.  No "back-and-forth" to the server for the user.  This is not very hard to do anymore - and there are methods for doing this with javascript, Flash, Coldfusion, PHP and I am sure many other web technologies.  It's also rather straightforward to do this in the Palm OS (epocrates does it) and in .Net.  Alas .. I don't know much about Mac proceamming anymore .. but I'd bet that this is supported there too.   Users should demand this sort of functionality in search screens. for all of their applications.

b) The other way to accomplish this is without a background connection to the database.  Instead of checking in with every keypress, load the database into the application or into the browser when the application (or browser window) opens.  Sure -- this won't work for big big databases, but it works better than you would expect for databases of fairly significant size.  In our Mini-EMR at the office, we have 5800 patients.  All 5800 firstnames, lastnames, ages and id numbers are loaded into the browser when the user logs in.  Searching for a patient takes only a few keypresses.  To Search for Bob Jones, I would type "Jo Bo" and I'd probably see him as one of my two or three results (along with Josie Boomerang, etc) .. and it all takes me less than a second.    If a pair of Geeks like me and Dave can figure this out .. so can the programmers at GE (Medicalogic), PMSI( Practice Partner), A4 (A4 EMR) and Misys (Misys EMR) .. and an array of others .. c'mon folks .. please help your users search for patients, medications, diagnoses, allergies and procedures much faster! .. You'll make our lives better .. and will imporve patient care.

Family Medicine Digital Resources Library

About 8 years ago, as a participant in the cool new thing called a "listserv" where family medicine educators would e-mail each other and talk about medical education ... someone suggested that we should create an online library where we could share digital resources. So I built one And it was hard to manage, moderate, etc.

 People shared viruses in addition to useful resources.

It got messy. So another version was born - which Dave helped to build .. after we built a similar online library for the Crozer-Keystone family medicine residency.

But it still didn't have a team of editors and librarians watching over it. So .. inspired and assisted by Helen Baker and Traci Nolte -- I wrote a grant for STFM to create an infrastructure for the library.

 The grant was funded and now we've started work. In addition to creating a spec for the software ... I've ordered up the servers.

We had a great talk last week with the guys from Heal and will likely staeal lots of their code to creat our version ... None of this is an excuse for the paucity of blog entries lately.

I still have to get my lecture notes and links from the PAFP meeting I spoke at a few weeks ago ... but that may have to wait one more day .. In the meantime ..

here are some interesting "must read" suggestions form the not-so-new thing called "Family-L" -- the listserv for family medicine educators, courtesy of Dan Sontheimer:


John Abrahamson's book, "Overdo$ed Amercia".

Another would be the Future of Family Medicine Project report "The Future of Family Medicine: A Collaborative Project of the Family Medicine Community" in Annals of Family Medicine, Vol. 2, Supplement 1, March/April 2004.

A book by the Harvard Negotiation Team Difficult Conversations: How to Discuss what Matters Most by Douglas Stone, Bruce Patton, Sheila Heen, Roger Fisher Good To Great, by Collins (book, in any chain bookstore, on surprising findings after studying persistently great companies)

The article is in the October 28th, 2004 NEJM by Chris Landrigan, MD et al about work hours in IM interns in the ICU. Prospectively they showed that sleep deprived interns made more mistakes than better rested interns.

Getting to Yes: Negotiating Agreement Without Giving In, by Roger Fisher, William Ury, and Bruce Patton. IOM's Health Professions Education: A Bridge To Quality (part of the Quality Chasm Series).

Chapter 3 "Primary Care :40 Stellar Community Health Centers" in the 2002 IOM Report: "Fostering Rapid Advaces in Health Care"

Health Affairs Web exclusive entitled: "Medicare Spending, The PhysicianWorkforce, And Beneficiaries' Quality Of Care"

The series of articles in NEJM about reforming the VA System via an emphasis on primary care and quality measurement

The Journal, "Health Affairs" Anil's Ghost by Michael Ondatje (author of The English Patient).

Closing the Chart: A Dying Physician Examines Family, Faith, and Medicine By Stephen Hsi

Atul Gawande in his New Yorker article has captured this difference in a much better literary effort. http://newyorker.com/printable/?fact/041206fa_fact

referrals again

This comment from Sparkler on my post a few months ago about referrals just appeared. 

...  A visit to the doctors office takes approximately 90 minutes - I see the doctor for maybe 2 minutes. That means that means nearly all of my care in that office is with staff who are great at common issues, but iffy on uncommon ones. I adore my doctor; he is excellent. This is not a criticism of him, but if I have anything uncommon I skip the gatekeeper visit and see the specialist. If you want to understand why patients demand referrals take a look at the entire experience of visiting a specialist versus a family doctor

It's interesting and disheartening that the physician is adored, yet the time with the physician is only 2 minutes. 

I would suggest that the patient needs a new physician who can spend more than 2 minutes with the patient -- since if 2 minutes really is the am't of time spent - the care is certainly substandard.  No physician can provide adequate care in 2 minutes. 

Scanning at home

At the office, we have great custon-built scanning software that Dave built.  It's worked flawlessly for 3 years now .. and aside from the fact that the TIFF files it makes are a bit bigger than they need to be (hin, hint Dave) ... it's grrreat.

I'm looking for something now to use at home that is just as easy to use.  This is not rocket science .. so I'm surprised that no company has yet produced software that does this elegantly.  If you know of one .. please leave a comment.

The crieteria for a quick and easy scanning solution:

 

• Easy to use
• Really, really easy - this means that there is one button "scan" and perhaps a menu to define options such as resolution or turn on duplex, etc. 
• Stores the files in folders in the OS (or FTP, I suppose) rather than a proprietary database
• Provised optional annotation or indexing of files .. with either a database (ODBC connection preferred) or a text/XML file that is stored locally or on a network drive
• Inexpensive.  This is not ricket science .. so we shouldn't pay for rocket science. 
• Stores files efficiently - in TIFF or .pdf
• Easy to use .. and really fast. 

What I've found so far:

edrawer - personal version is inexpensive .. but I can't download a demo .. and their website is so poorly designed it makes me wonder about their skills at making usable software.  I can't tell where the files are stored, but it looks like ley are ina database.  I don't want my files trapped in a database in 10 years.  I want them in the OS -- in hierarchies of folders.  They won't be trapped when the scanning software company goes out of business and my software won't work in Windows 2015 .. or Windux .. or Mac OS XV.

PaperMaster.  hmm .. looks enticing,, but again .. where are the files?

SinmpleIndex "the best value in scanning software" .. sores files in folders.  Inexpensive.  Downloaded the demo.  Scans a few images just fine .. then .. crash .. over and over ..

If you want to make sales .. then make sure your demo works.

Douxplorer is a "document managerment systerm."  It works.  But it stores the files in the database .. which has to live on your hard drive .. unless you pay for the professional version (n which case you can store the "library" (databse) on a server or shared folder.

InfoThek Docudex is the winner so far .. as it seems to do everything I want .. and it's developed elegantly.  I'm going to test it for a while to see if I can make it work well.