Docnotes

Mark is still dead

Last week I wrote about Mark. 

Unfortunately - the bad dream that he had died wasn't a dream - and it's been a surreal week - re-connecting with old friends, and re-living formative memories.

Mark was a passionate, thoughtful person who worked so hard to make things RIGHT – while doing his best to have fun - with a unique serene yet sardonic demeanor.

In 1982, I was Mark’s apprentice for 12 months on the 144’ sailing ship – the Barkentine r/v Regina Maris – where he was Chief Engineer (El Jefe) – and I was the Assistant Engineer (El Lacayo) - earning $1 / day.

It’s Mark’s fault that I am a physician.

As we diagnosed, disassembled (and reassembled) diesel engines, bilge pumps, de-salinators and generators together – Mark taught me the fine art of diagnosis, decision making, and careful, patient action. 

In healthcare we call this SOAP (Subjective Objective Assessment and Plan) – On Six Forks Road (and Toyota) – it’s called PDCA (Plan-do-check-adjust).

Medical Educators call it GNOME.

Regardless of the name/ framework/ religion we use – it’s about thinking carefully, calmly and strategically about where you want to end up – then having the knowledge, skill and attitude to get you there.

We're on our way to Mark's memorial service now.  Marcie sent me this last night - which does a better job than I ever will in telling a short story about our friend:

 

Informatics Comeptency Evaluation

Let's say you want to evaluate the Medical INformatics Competency of a group of students, IT staff or physicians.

I'm working on an evaluation tool that should be EASY for anyone with these skills .. and a true challenge for those without.   

Take a look at it here. It's a Google spreadsheet so you will have to log in to Google Docs to edit it .. but feel free to do so.

Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis

When Bill Ventres and his colleagues published their paper last year on this topic - I was impressed, but for some reason I didn't write about it here or forward a link to all of my colleages as I should have done. Bill presented the paper at this year's STFM - and of course he uploaded his powerpoint to FMDRL. Required reading.

Customer Service - Heathcare, IT and Cell Phones

Sam's cellphone ws not working (again) so we spent 90 minutes at the Sprint store getitng it fixed (again) last night. As we walked away - he observed: "Dad - everyone in that store was angry."

He was right - we wondered together who had the stronger point - the angry lady who hadn't gotten her rebate check yet - or the clerk who kept insisting that the check "comes from corportate - I can't help you." Of course it was the angry lady. the clerk didn't take any ownership of this problem. All he did was insult her and do his best to push the problem away.

Bad bad bad.

Joel's got seven steps:

Seven steps to remarkable customer service - Joel on Software

In healthcare - we can't always fix a problem - but at the very least - we need to build an alliance with the patient/customer so that there is shared understanding of the problem - and shared investment in solving it.

Google Calendar for office schedules

A few days ago I made a comment about how the building blocks were there to pull together some "mashups" in medical practice.   I said it wasn't rocket science.   Here's a short description of how I solved a real-life problem in my practice. 

Problem:

• Dr Reider isn't as well organized as he could be.  Duh.  this is a common problem in healthcare.  Physicians work too much - we'd much rather spend time with our patients than at our desks reviewing paperwork, writing notes, etc.  Perhaps I'm worse than many others.  So be it.  Not going to change this old dog. 
  
• Sometimes I'm not scheduled to see patients in the office (yes - I have too many jobs - but let's keep on track here!) but I agree to see someone anyway.  Perhaps I am on the phone with someone who tells me that they can't get an appintment to see me for a few weeks .. and I say "well, Bob .. how about we see each other at 8:30 next Tuesday?"  So Bob gets scheduled .. and next Tuesday rolls around and Bob shows up .. but I'm not there because I forgot. 
  
• oops.  Office calls me.  I rush to the office .. see Bob.  All is well.   We hope.
  
• My attempt @  human solution was to have the office staff look @ tomorrow's schedule .. see if there are patients scheduled to see me on a day that I'm not usually "in" - and call to remind me.  Short version: this didn't work. 
  
• Enter technology:

Requirements:

• The system will be able to determine when the provider is scheduled to see a patient on a day that he is not otherwise scheduled to see patients.
• The system will be able to cause the provider to be reminded about the appointment(s) with enough warning to be able to be in the office on time - yet not so early (1 week) that he will forget.
• The system should - if possible - be able to add the appointment(s) to his calendar in google calendar, 30Boxes, or Outlook.

Implementation:

• I'm using the webservices that I created for our Misys Vision practice management system to get the information about the scheudle.  Easy.  Scheduled Task that runs on the server @ 6 PM
  
• GetSchedule("JMR",BeginDate,EndDate)  .. in this case - I get 1 day - tomorrow.
  
• I parse the data and decide if it's a "usual" day or a day I'm not supposed to be in
• If # rows returned > 4 .. End
  
• If $ rows returned < 4 .. then it's probably not an "in-office" day - so let's keep going
• Push the data to Google's API - to add an event for each visit
• Sending: BeginTime, EndTime, no patient identifier, description "patient scheduled"
• The scheduled visit is now on my google calendar.  I can now receive an alert from google via SMS .. or sync with my PDA, outlook, 30Boxes, etc.  Easy.  Google this - there are so many options these days .. from SyncML free solutions - to commercial products.   Perhaps that topic deserves another post ...
  

Homeland security reaches the anus

This note in the Lancet (sorry - free registration required) tells a compelling story about the state of our Homeland security.  I'll admit I've never seen a Seton .. so I would have been just as confused as the Homeland security physician (did you know we had homeland security physicians?)

MySpace for Healthcare?

Matt's Article in Health-IT World got a nice little article on social networking in healthcare.  It's a good little review of what's out there.  I'm not convinced that this stuff is going anywhere.  Physicians have too little time ...

What makes a good doctor = what makes a good plumber.

Medical Decisions are hard to make.  Even when they seem easy.  

I'd say that the TV show "House" is popular because Dr House seems to focus on giving patients what they need (honesty, transparency, certain treatments) and not necessarily what they want.   In his case - the difference between the two are entertaining.   Does that make him a good doctor? 

In real life - this is much harder.   There's ample evidence that physicians' decisions are based on many factors.  What's best for the patient is simply one of these factors. 

We've had a medical student working on our office recently - and it's been interesting to see my practice style mirrored in her eyes:

• I "actually listen" to my patients (who doesn't?   I wonder ...)
• I spend lots of time with my patients (no wonder I come home late every day!)
• I hear what they mean - not just what they say (the hardest part)

I re-told this story to her - in abbreviated form.  I posted it nearly 5 years ago - but the principles I tried to highlight then remain important yet under-represented on the Internet today.  Medical blogs are now far greater in quantity - yet I still think there are rather few of them  that express the transparency that the initial work a few of us were striving for back then.   There are so many competing interests - for our time, our money, and our attention.  Without good principles - I'd argue that there is no way for physicians to stay the course - and really make the best decisions for our patients.

The National Physicians Alliance is a relatively new organization that's building steam - based on good principles.  It's great to see an organization that is committed to "Advancing the core values of the medical profession: Service, Integrity, and Advocacy."   You can also read the NPA’s ISSUE BRIEF outlining reasons why physician prescribing data should not be made readily available to pharmaceutical companies.  The issue brief mentions describes how to opt out of pharmaceutical industry data gathering by enrolling in the AMA's Physician Data Restriction Program (PDRP).  Cool.  Check.  Done. 

Integrity is so important - yet so often suspect when there is opacity.  Exposing our patients to the uncertainties of our profession is a cornerstone of shared decision making - yet it takes so much more effort - and so much more time - I'm not surprised that so few physicians actually do it. 

The same goes for plumbers.  We had a "free" cleaning of our furnace performed by these folks last week.  The service rep called my wife at work and told her we needed a new humidifier element for $45.  He happened to have one.  Said OK.  We also needed a new solenoid for the humidifier for $89 "on order."   Turns out - I replaced the humidifier element about 6 months ago (should be done once/year) and the solenoid seems to work just fine to me.  You can listen to  his explanation - left on our voicemail.   Now -  look at the picture. Water running pretty well, if you ask me!   I filled an 18 ounce cup in under 30 seconds.  If that's a "very small amount of water" - I think Gary needs to go back to plumbing school.

Either Gary is stupid - or he's lying.  Either way - I can't trust him or his company ever again - as I suspect that he's got his interests above mine.  I could buy the solenoid (see link above) for $45 if I really needed one.  And I'm a little mad that he took my 6 month old humidifier element with him when he sold me the new one (it's the honeycomb thing in the picture).  Either way - he can't be trusted.

We need trustworthy plumbers, doctors, bankers, lawyers, software developers, etc.    The principles of the profession  must guide our decisions.  If not - we will always be distracted or seduced by the many other choices on our path.  Plumbers who invent problems, doctors who self-refer, and software developers focus more on the icing than the cake - all compromise their integrity in the same way - and will ultimately lose.   

Physician's First Watch Reviwed

Today Enoch reviews PFW. As usual, Enoch "gets it."

I've been involved with the project for a long time - and it has been a privilege to be involved in something so substantive.

In some ways - PFW serves one of the original goals that medical blogs were trying to reach: reviews of (and pointers to) important medical news on a regular basis. The "regular basis" is an important differentiator between weblogs and a professional he developed and provided resource such as PFW. There is no expectation that a blogger make a post every single day. On the other hand, a product such as PFW fields a reputation as a reliable new source by providing news and information on a daily basis.

Sometimes this is a true challenge, since there have been days in which there is clearly a dearth of truly important medical news.

It's interesting to see that medications gape has discovered and increased logs in the past 6 or 12 months. I remember when Steve Hoffman was there and Steve single-handedly motivated the company to provide RSS feeds well before most people knew what RSS feeds were. It even 18 months ago, it was hard to get Netscape to understand how powerful weblogs could be as a way to build and maintain readership.

And this is why PFW still differs quite a bit from weblogs: We provide important medical information in it claim, concise, well written summary that is deliver daily via e-mail or RSS. There is (by design) very little editorial opinion expressed about the content. In a conversation about the project with the neck a few months ago when I was in San Francisco, and when he pointed out that the discussion around the content may be just as informative or important for readers. He maybe right, but there is no reason that PFW can't serve as the nidus of such a discussion that takes place elsewhere.

For example, this story about salmeterol reminds us of the dangers of this long acting beta agonist when used incorrectly. I'm still not convinced that salmeterol is a dangerous drug inherently. salmeterol (like any medication) should be used carefully and appropriately. From my perspective, the article (and the previous warnings about salmeterol) or more about asthma than this medication. Asthma is a very serious illness and we need to understand that beta agonists (either short-acting or long acting) only treat the symptoms of this disease. Just as no one would expect albuterol two "cure" asthma, salmeterol plays no role in reducing inflammation as would corticosteroids or theophylline.

The staff editors and physician editorial board members of PFW discuss (by conference call) each article twice before publication. These conversations are often robust and educational for all involved, and sometimes I wish that the readership had access to some of the content of our discussions.

Yet if we remain focused on our goal of providing concise, well written summaries, perhaps the medical "blogosphere" will serve the function of creating and maintaining a forum for discussion of these important topics.

 

The EHR consolidation begins ..

CCHIT released the results of the first round of EHR certifications. Products that don't have certification will fall out of the marketplace. Yeh ... you can disagree .. and whine about CCHIT being a tax .. and how small vendors can't afford to do the certification .. but the certification is necessary and important. It does level the playing field a bit ...

Allscripts (HealthMatics Electronic Health Record 2006) Allscripts (TouchWorks Electronic Health Record 10.1.1) Cerner Corporation (PowerChart 2005.02) Companion Technologies (Companion EMR v8.5) eClinicalWorks (eClinicalWorks Version 7.0 Release 2) Emdeon Practice Services (Intergy® EHR v3.00) e-MDs (e-MDs Solution Series 6.1) Epic Systems (EpicCare Ambulatory EMR Spring 2006) GE Healthcare (Centricity® EMR 2005 Version 6.0)

JMJ Technologies (EncounterPRO® EHR 5.0) McKesson (Horizon Ambulatory Care Version 9.4) MCS-Medical Communication Systems (mMD.Net EHR 9.0.9) MedcomSoft (Record 2006 (V 3.0)) Medical Informatics Engineering(WebChart 4.23) Misys Healthcare Systems (Misys EMR 8.0) NextGen Healthcare Information Systems (NextGen EMR 5.3) Nightingale Informatix Corporation (myNightingale Physician Workstation 5.1) Practice Partner (Patient Records 9)