Nicholas Genes, MD, PhD
emergency medicine informatics
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Posts
- May 21, 12
Twitter use during emergency medicine conferences.
Am J Emerg Med. 2012 Mar 16;
Authors: Nomura JT, Genes N, Bollinger HR, Bollinger M, Reed JF
PMID: 22424992 [PubMed - as supplied by publisher]
- May 21, 12
Variations in crowding and ambulance diversion in nine emergency departments.
Acad Emerg Med. 2011 Sep;18(9):941-6
Authors: Handel DA, Pines J, Aronsky D, Genes N, Ginde AA, Hackman J, Hilton JA, Hwang U, Kamali M, Powell E, Sattarian M, Fu R
Abstract
OBJECTIVES: The primary study aim was to examine the variations in crowding when an emergency department (ED) initiates ambulance diversion.
METHODS: This retrospective, multicenter study included nine geographically disparate EDs. Daily ED operational variables were collected during a 12-month period (January 2009 to December 2009), including total number of ED visits, mean overall length of stay (LOS), number of ED beds, and hours on ambulance diversion. The primary outcome variable was the "ED workload rate," a surrogate marker for daily ED crowding. It was calculated as the total number of daily ED visits multiplied by the overall mean LOS (in hours) and divided by the number of ED beds available for acute treatment in a given day. The primary predictor variables were ambulance diversion, as a dichotomous variable of whether or not an ED went on diversion at least once during a 24-hour period, diversion hour quintiles, and sites.
RESULTS: The annual ED census ranged from 43,000 to 101,000 patients. The percentage of days that an ED went on diversion at least once varied from 4.9% to 86.6%. On days with ambulance diversion, the mean ED workload rate varied from 17.1 to 62.1 patient LOS hours per ED bed among sites. The magnitude of variation in ED workload rate was similar on days without ambulance diversion. Differences in ED workload rate varied among sites, ranging from 1.0 to 6.0 patient LOS hours per ED bed. ED workload rate was higher on average on diversion days compared to nondiversion days. The mean difference between diversion and nondiversion was statistically significant for the majority of sites.
CONCLUSIONS: There was marked variation in ED workload rates and whether or not ambulance diversion occurred during a 24-hour period. This variability in initiating ambulance diversion suggests different or inconsistently applied decision-making criteria for initiating diversion.PMID: 21906203 [PubMed - indexed for MEDLINE]
- May 21, 12
Electronic collaboration: using technology to solve old problems of quality care.
Acad Emerg Med. 2010 Dec;17(12):1312-21
Authors: Baumlin KM, Genes N, Landman A, Shapiro JS, Taylor T, Janiak B,
Abstract
The participants of the Electronic Collaboration working group of the 2010 Academic Emergency Medicine consensus conference developed recommendations and research questions for improving regional quality of care through the use of electronic collaboration. A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) patient health information should be available electronically across the entire health care delivery system from the 9-1-1 call to the emergency department (ED) visit through hospitalization and outpatient care, 2) relevant patient health information should be shared electronically across the entire health care delivery system, 3) Web-based collaborative technologies should be employed to facilitate patient transfer and timely access to specialists, 4) personal health record adoption should be considered as a way to improve patient health, and 5) any comprehensive reform of regionalization in emergency care must include telemedicine. The workgroup emphasized the need for funding increases so that research in this new and exciting area can expand.PMID: 21122013 [PubMed - indexed for MEDLINE]
- May 21, 12
An Unusual Presentation of Twiddler's Syndrome.
J Emerg Med. 2010 Sep 18;
Authors: Close MD, Genes N
PMID: 20851557 [PubMed - as supplied by publisher]
- May 21, 12
Knowledge translation of the American College of Emergency Physicians' clinical policy on syncope using computerized clinical decision support.
Int J Emerg Med. 2010;3(2):97-104
Authors: Melnick ER, Genes NG, Chawla NK, Akerman M, Baumlin KM, Jagoda A
Abstract
AIMS: To influence physician practice behavior after implementation of a computerized clinical decision support system (CDSS) based upon the recommendations from the 2007 ACEP Clinical Policy on Syncope.
METHODS: This was a pre-post intervention with a prospective cohort and retrospective controls. We conducted a medical chart review of consecutive adult patients with syncope. A computerized CDSS prompting physicians to explain their decision-making regarding imaging and admission in syncope patients based upon ACEP Clinical Policy recommendations was embedded into the emergency department information system (EDIS). The medical records of 410 consecutive adult patients presenting with syncope were reviewed prior to implementation, and 301 records were reviewed after implementation. Primary outcomes were physician practice behavior demonstrated by admission rate and rate of head computed tomography (CT) imaging before and after implementation.
RESULTS: There was a significant difference in admission rate pre- and post-intervention (68.1% vs. 60.5% respectively, p = 0.036). There was no significant difference in the head CT imaging rate pre- and post-intervention (39.8% vs. 43.2%, p = 0.358). There were seven physicians who saw ten or more patients during the pre- and post-intervention. Subset analysis of these seven physicians' practice behavior revealed a slight significant difference in the admission rate pre- and post-intervention (74.3% vs. 63.9%, p = 0.0495) and no significant difference in the head CT scan rate pre- and post-intervention (42.9% vs. 45.4%, p = 0.660).
CONCLUSIONS: The introduction of an evidence-based CDSS based upon ACEP Clinical Policy recommendations on syncope correlated with a change in physician practice behavior in an urban academic emergency department. This change suggests emergency medicine clinical practice guideline recommendations can be incorporated into the physician workflow of an EDIS to enhance the quality of practice.PMID: 20606818 [PubMed]
- May 21, 12
Emergency department information system implementation and process redesign result in rapid and sustained financial enhancement at a large academic center.
Acad Emerg Med. 2010 May;17(5):527-35
Authors: Shapiro JS, Baumlin KM, Chawla N, Genes N, Godbold J, Ye F, Richardson LD
Abstract
OBJECTIVES: The objectives were to measure the financial impact of implementing a fully integrated emergency department information system (EDIS) and determine the length of time to "break even" on the initial investment.
METHODS: A before-and-after study design was performed using a framework of analysis consisting of four 15-month phases: 1) preimplementation, 2) peri-implementation, 3) postimplementation, and 4) sustained effects. Registration and financial data were reviewed. Costs and rates of professional and facility charges and receipts were calculated for the phases in question and compared against monthly averages for covariates such as volume, collections rates, acuity, age, admission rate, and insurance status with an autoregressive time series analysis using a segmented model. The break-even point was calculated by measuring cumulative monthly receipts for the last three study phases in excess of the average monthly receipts from the preimplementation phase, corrected for change in volume, and then plotting this against cumulative overall cost.
RESULTS: Time to break even on the initial EDIS investment was less than 8 months. Total revenue enhancement at the end of the 5-year study period was $16,138,953 with an increase of 69.40% in charges and 70.06% in receipts. This corresponds to an increase in receipts per patient from $50 to $90 for professional services and $131 to $183 for facilities charges. Other than volume, there were no significant changes in trends for covariates between the preimplementation and sustained-effects periods.
CONCLUSIONS: A comprehensive EDIS implementation with process redesign resulted in sustained increases in professional and facility revenues and a rapid initial break-even point. .PMID: 20536809 [PubMed - indexed for MEDLINE]
- May 21, 12
Comparison of frequency of inducible myocardial ischemia in patients presenting to emergency department with typical versus atypical or nonanginal chest pain.
Am J Cardiol. 2010 Jun 1;105(11):1561-4
Authors: Hermann LK, Weingart SD, Yoon YM, Genes NG, Nelson BP, Shearer PL, Duvall WL, Henzlova MJ
Abstract
The present study was designed to assess the value of the presenting symptom of "typical" anginal pain, "atypical/nonanginal" pain, or the lack of chest pain in predicting the presence of inducible myocardial ischemia using cardiac stress testing in emergency department patients being evaluated for possible acute coronary syndrome. We performed a retrospective observational study of adult patients who were evaluated for acute coronary syndrome in an emergency department chest pain unit. The presenting symptoms were obtained from a structured questionnaire administered before stress testing. Patient chest pain was categorized according to the presence of substernal chest pain or discomfort that was provoked by exertion or emotional stress and was relieved by rest and/or nitroglycerin. Chest pain was classified as "typical" angina if all 3 descriptors were present and "atypical" or "nonanginal" if <3 descriptors were present. All patients underwent serial biomarker and cardiac stress testing before discharge. A total of 2,525 patients met the eligibility criteria. Inducible ischemia on stress testing was found in 33 (14%, 95% confidence interval 10% to 19%) of the 231 patients who had typical anginal pain, 238 (11%, 95% confidence interval 10% to 13%) of the 2,140 patients presenting with atypical/nonanginal chest pain, and 25 (16%, 95% confidence interval 11% to 22%) of the 153 patients who had no complaint of chest pain on presentation. Compared to patients with atypical or no chest pain, patients with typical chest pain were not significantly more likely to have inducible ischemia on stress testing (likelihood ratio +1.25, 95% confidence interval 0.89 to 1.78). In conclusion, in our study, the patients who presented with "typical" angina were no more likely to have inducible myocardial ischemia on stress testing than patients with other presenting symptoms.PMID: 20494662 [PubMed - indexed for MEDLINE]
- May 21, 12
Health information exchange, biosurveillance efforts, and emergency department crowding during the spring 2009 H1N1 outbreak in New York City.
Ann Emerg Med. 2010 Mar;55(3):274-9
Authors: Shapiro JS, Genes N, Kuperman G, Chason K, , Richardson LD
Abstract
Novel H1N1 influenza spread rapidly around the world in spring 2009. Few places were as widely affected as the New York metropolitan area. Emergency departments (EDs) in the region experienced daily visit increases in 2 distinct temporal peaks, with means of 36.8% and 60.7% over baseline in April and May, respectively, and became, in a sense, the "canary in the coal mine" for the rest of the country as we braced ourselves for resurgent spread in the fall. Biosurveillance efforts by public health agencies can lead to earlier detection, potentially forestalling spread of outbreaks and leading to better situational awareness by frontline medical staff and public health workers as they respond to a crisis, but biosurveillance has traditionally relied on manual reporting by hospital administrators when they are least able: in the midst of a public health crisis. This article explores the use of health information exchange networks, which enable the secure flow of clinical data among otherwise unaffiliated providers across entire regions for the purposes of clinical care, as a tool for automated biosurveillance reporting. Additionally, this article uses a health information exchange to assess H1N1's effect on ED visit rates and discusses preparedness recommendations and lessons learned from the spring 2009 H1N1 experience across 11 geographically distinct EDs in New York City that participate in the health information exchange.PMID: 20079955 [PubMed - indexed for MEDLINE]
- May 21, 12
Images in emergency medicine. Hair artifact.
Ann Emerg Med. 2009 Apr;53(4):545, 573
Authors: Genes N, Lupow J
PMID: 19303516 [PubMed - indexed for MEDLINE]
- May 21, 12
Bringing journal club to the bedside in the form of a critical appraisal blog.
J Emerg Med. 2010 Oct;39(4):504-5
Authors: Genes N, Parekh S
PMID: 19168316 [PubMed - indexed for MEDLINE]
- May 21, 12
High risk hypertensives: pre-hospital management of acute myocardial infarction--results from the French nationwide registry USIC 2000.
Ann Cardiol Angeiol (Paris). 2006 Jan;55(1):6-10
Authors: Mulazzi I, Amar J, Cambou J, Hanania G, Guéret P, Vaur L, Blanchard D, Lablanche JM, Boutalbi Y, Genès N, Danchin N,
Abstract
OBJECTIVE: To assess the use of mobile coronary care units (MCU) in hypertensive patients previously treated for cardiovascular diseases in comparison with those with no history of cardiovascular disease and to estimate the influence of the use of MCU on cardiovascular outcome in this population.
PATIENTS: We used a nationwide prospective registry of all patients admitted for AMI in French intensive care units in 2000. Patients without history of hypertension or patients admitted with pulmonary oedema or cardiogenic shock were excluded. Men (N = 514) and women (N = 291) were analysed separately.
RESULTS: The proportion of patients with history of myocardial infarction, peripheral artery disease and stroke was not significantly higher in subjects who used physician-staffed MCU as compared with patients with no history of myocardial infarction, peripheral artery disease or stroke. In each sex, revascularization (pre hospital fibrinolysis, in hospital fibrinolysis or coronary angioplasty) were more frequent in patients who used MCU. Also, one year cardiovascular mortality was lower in men who used MCU.
CONCLUSION: Known high risk hypertensive patients did not use physician-staffed MCU more than subjects free of such condition. Education of hypertensive patients at risk during routine visits is required to increase of the use of physician-staffed MCU in case of symptoms suggestive of AMI.PMID: 16457029 [PubMed - indexed for MEDLINE]
- May 21, 12
Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcome: results from the French Nationwide USIC 2000 Registry.
Circulation. 2004 Oct 5;110(14):1909-15
Authors: Danchin N, Blanchard D, Steg PG, Sauval P, Hanania G, Goldstein P, Cambou JP, Guéret P, Vaur L, Boutalbi Y, Genès N, Lablanche JM,
Abstract
BACKGROUND: Limited data are available on the impact of prehospital thrombolysis (PHT) in the "real-world" setting.
METHODS AND RESULTS: Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction (< or =48 hours of symptom onset) in November 2000; 1922 patients (median age, 67 years; 73% men) with ST-segment-elevation infarction were included, of whom 180 (9%) received intravenous thrombolysis before hospital admission (PHT). Patients with PHT were younger than those with in-hospital thrombolysis, primary percutaneous interventions, or no reperfusion therapy. Median time from symptom onset to hospital admission was 3.6 hours for PHT, 3.5 hours for in-hospital lysis, 3.2 hours for primary percutaneous interventions, and 12 hours for no reperfusion therapy. In-hospital death was 3.3% for PHT, 8.0% for in-hospital lysis, 6.7% for primary percutaneous interventions, and 12.2% for no reperfusion therapy. One-year survival was 94%, 89%, 89%, and 79%, respectively. In a multivariate analysis of predictors of 1-year survival, PHT was associated with a 0.49 relative risk of death (95% CI, 0.24 to 1.00; P=0.05). When the analysis was limited to patients receiving reperfusion therapy, the relative risk of death for PHT was 0.52 (95% CI, 0.25 to 1.08; P=0.08). In patients with PHT admitted in < or =3.5 hours, in-hospital mortality was 0% and 1-year survival was 99%.
CONCLUSIONS: The 1-year outcome of patients treated with PHT compares favorably with that of patients treated with other modes of reperfusion therapy; this favorable trend persists after multivariate adjustment. Patients with PHT admitted very early have a very high 1-year survival rate.PMID: 15451803 [PubMed - indexed for MEDLINE]
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Tweets
- That's quite a resource you've built, @nyjsm RT @nickgenes - featured your iPad recommendations on http://t.co/S0PzOcGu
- The sound of the Twittersphere: http://t.co/BH3t4HwK (based on 500 UK twitter accounts content & "mood" - http://t.co/rIZOGUdX )May 19, 12 from web Reply, Retweet, Favorite
- Amazing; huge fraction of attendees. Wasn't even available on BB. RT @SAEMonline The #SAEM12 conference app was downloaded 967 times!
- The CDC's 2011 compendium on US health, now live http://t.co/PUkc9TjC
- #dddemoday kicks off to showcase innovative diabetes startups @ Blueprint Health http://t.co/zJhV2gRA
- Heading to BluePrint Health for the Diabetes Design Challenge #DDDemoDayMay 16, 12 from web Reply, Retweet, Favorite
- Interesting funding opportunity: http://t.co/6dVgmzgi CSPO “To Think, To Write, To Publish" Workshop funded by NSF grant
- New issue of EMPractice on the topic of ED arthritis by yours truly & new #sinaiem chief Makini Chisolm-Straker http://t.co/QKX3Dddm
- ACEP reconsiders ABIM's "Choose Wisely," but wants campaign for fewer interventions to include liability reform http://t.co/YRvvTavn
- Like Google's PageRank, peer-reviewed journal impact factor can be manipulated http://t.co/UQuZZzFp Emergence of a Citation Cartel
- Likert smile scale finally made an appearance at #sinaiem - like greeting an old, labile friend http://t.co/vtYWoFU0
- I'm judging the #sinaiem senior resident research projects tonight. Impressed by quality (especially thinking back to my graduating class)
- Mobile phone calls are getting shorter, and data has eclipsed voice on mobile http://t.co/1WfqiQgk The Call of the Future by Tom Vanderbilt
- I knew MA had great colleges & med schools, happy to hear K-12 is among world's best http://t.co/Cof69eXA Don’t Mess with Massachusetts
- @ScottJoing yeah, I half-expected WEA mobile alert system would require users to login, sign a EULA or add charges to my AT&T bill
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Posts
- May 10, 12
Members of the social media committee spoke today at SAEM about, well, online social networking and the emergency physician. Our presentations are available via Prezi: mine as well as Jason Nomura's and Rob Cooney's. We also had a conference call a few weeks ago where we covered some of these topics, moderated by Jim Miner and recorded by Scott Joing.
Below, I've added links to stories, papers and sources I referenced, in my presentation:
Matthew Strausburg's letter about Facebook's risk to his career
The malpractice trial outing of the anonymous pediatrician, Flea
Rhode Island EM physician Alexandra Thran's Facebook case and RISMB filing (PDF)
The nursing student, Doyle Byrnes, who posted a placenta photo on Facebook.
The Hayley Barbour clinic Tweet controversy
AMEDNews.com report on QuantiaMD survey of physicians use of social networks
Tips on HIPAA compliance while on social networks (and some notes on HIPAA compliance in social media policymaking)
Greysen et al, JAMA 2012 research letter on physician violations of online professionalism and state medical board disciplinary cases
Chretien et al, JAMA 2011 letter to the editor on physician usage of Twitter in 2010, broken down by specialty
Ed Bennett's list of hospital policies on social media
SAEM's social media guidelines
For further reading, Dr. Bryan Vartadedian's blog, 33 Charts has a lot of terrific writing on online professionalism: 1,2,3,4 - Jan 10, 12I love being at an academic institution for many reasons. One of which is that the residents keep me on my toes -- they've read the latest stuff, they want justification for proposed workups and treatment plans, and...
....they've got the sharpest grammar?
Yep. I can only imagine the patients watching us in the ED -- when we're not hunched over our keyboards, charting, reviewing and ordering, we can be seen gesticulating wildly about things like the placement of apostrophes in eponymous diseases.
For instance, can you pick what's proper, below?Down Syndrome or Down's syndrome
Legionnaire disease or Legionnaires' disease
The rule I've always heard is: if the disease is named for a patient, it deserves an apostrophe. If the disease is named for its discoverer, the apostrophe is inappropriate. Lou Gehrig's disease was his, and the Legionnaires had theirs, but Down didn't own his syndrome. More here.
The most consistently misattributed apostrophe, I think, belongs to Crohn -- though that's slowly changing, too. We'll leave for another time the discussion of proper possessive apostrophe usage when a name ends in s (Legionnaires' or Legionnaires's), perhaps until agreement can be reached the Chicago Manual of Style and AP Style.
I just want to highlight the body of work of Tsung O. Cheng, who has been writing about eponymous diseases and the inappropriateness of apostrophes for fifteen years -- including how to handle the situation when the discoverer of the condition is also a patient.
While Dr. Cheng is Professor of Medicine and has been a prolific author, churning out 10 medline-indexed publications on this trivial topic means either medical grammar is an exciting and contentious field for potential scholarship -- or that our system of academic promotion and peer review is kind of messed up.
So, I humbly suggest: Deciding on whether to devote one's energies to adding lines on one's CV, or actually trying to contribute to the body of knowledge in medicine, shall henceforth be known as Genes' dilemma. - Jan 06, 12
I've noticed more patients complain of gout recently -- maybe it's a sign the economy is improving (gout has long been considered a disease of excess).
As I discovered while revising Rosen's new chapter on arthritis emergencies, the price of colchicine, an ancient gout treatment, has gone way up lately -- while suggested regimens for treating gout have recently changed. These are not unrelated, and the connection is actually quite interesting. You see, colchicine was grandfathered-in as an approved therapy by the FDA at its inception in 1938. Its safety and efficacy were never formally reviewed by the FDA...
...until 2009, when URL Pharma submitted the results of their new trial to the FDA, showing comparable efficacy and somewhat improved safety to high-dose colchicine regimens, using a simple 1.2 mg dose followed by a 0.6 mg chaser an hour later.
The FDA, bound by Hatch-Waxman exclusivity, considered this a new indication for colchicine, and responded by granting 3 years of market exclusivity to URL Pharma. The price of colchicine (now called Colcrys) subsequently shot up from 9 cents a pill to $4.85 -- though if you read the drug company's site, they make it sound like they're doing patients a favor, protecting them from unapproved forms of the drug that worked well enough, for decades.
I appreciate the way the authors of this NEJM opinion piece considered this state of affairs:It seems reasonable to expect that costly new drugs or increases in drug prices would be accompanied by a substantial benefit in disease management to be enjoyed by these patients. This standard is not met by Colcrys; in this instance, the public may bear considerable costs for a poorly executed administrative goal.
Yep. A few US Senators sent URL Pharma a strongly-worded letter this past spring, but I don't think anything came of it (you can't say the company's done anything illegal, and our society is well past the point where we can expect corporations to act in any interest but their own).
I'll just be interested to see what happens in August 2012, when the 3-year exclusivity period should end and colchicine prices return to, hopefully, to a less painful place. - Jan 03, 12
I've been using my iPad in the ED, with my white coat's sewn-in iPad-sized pocket, for some time now -- mostly for patient and resident education, and to look up dosages or rashes. Hitting up my Evernote database or Dropbox documents is also useful. Occasionally I'll use my iPhone, for its LED light (when the otoscope can't reach to where I need to see) or rarely, its camera (in compliance with my hospital and department photo policy, naturally).
Our ED's EHR isn't quite accessible enough via iPad for me to quickly check results or place orders at the bedside -- right now it's just too cumbersome. But there's been progress -- enough so that I start to wonder about the flip side: instead of reviewing iOS medical apps and pining for an optimized EHR experience on the iPad, what if there are features of the iPad that could limit the utility of medical apps?
Well, there are some product design issues, like impact resistance and bacterial colonization, that have been discussed. But the operating system, iOS 5, has some quirks, too. Some have received a lot of attention. Some are maddening in their capriciousness.
But if you're an administrator, or an app developer, working on healthcare apps for folks with iPads, there's got to at least a few special considerations on your plate that you've never had to worry about, before (beyond the whole portrait/landscape issue). I've listed a few that seem novel to me, below:
1. Photostream, and iCloud. The other day, a colleague asked me to take a picture of an area behind her ear, to see how a lesion was healing. The next day, when I was home, polishing charts and playing tunes, my Apple TV's screensaver activated, and I found myself staring at my friend's ear, blown up to alarming proportions. My iPhone had sent the pic to the cloud, where iTunes found it and shared it with my set top box.
This is a separate issue from security, which I think Apple's iOS handles well enough. iPads can be locked and remotely wiped of data, if stolen. Facetime is HIPAA-compliant. But photostreaming is something that happens quietly, behind the scenes, and without much fanfare, until that pic your patient consented to is suddenly shared on all your devices and the cloud. Oh well -- hopefully your consent form has this possibility baked-in. And fortunately, Apple's finally made it possible to delete individual images from one's photostream.
2. My iPad knows when I'm sleeping. When I first pick it up after it's been laying dormant for a while, all the alerts and notifications that have been building up come tumbling out. In other words, iOS 5 is smart enough to know not to fire alerts when it's been off for hours and hasn't moved, and to let them build up and fire when I'm good and ready for them.
This is especially noteworthy, given my erratic sleep schedule.
I'm sometimes tempted to just pick up my iPad abruptly and unpredictably, hoping to catch it in the act of updating a Newsstand subscription or wireless sync. But if I've ever interrupted it, the iPad's never complained with any sluggishness or warnings.
It's a smart feature, but in healthcare there are some warnings that need to break through. And as iOS gradually replaces pagers and other communications systems, there are a few sleeping doctors that will need to be woken up -- instead of letting all alerts wait until the iPad's on.
3. Where's Save? When you've written a note in most iOS apps, it's just done. Automatically, quietly saved. In fact, it wasn't until I used the new Gmail app for iPad that I realized how incongruous the classic "Save" disk button looks in iOS.
But when you've finished a long draft in, say, Papers, and want to move on, it's a little unsettling to assume everything "just works" and your efforts are saved and retrievable. I've been burned too many times, in the past few decades. And frankly I think most of my colleagues would be paralyzed with fear if they'd written a patient note and there's no clunky, inelegant way to mark it as saved.
Hopefully this is only a problem we dinosaurs from the 80s will have to deal with. Perhaps we could get used to Apple's elegant solution, and maybe younger users will never feel weird about relying on the OS to act responsibly. But so long as developers like Google keep offering Save buttons, the iOS paradigm won't fully catch on (and a part of me will be relieved to click Save).
I've highlighted a few (relatively minor) quirks that may drive administrators, or users, crazy. There are undoubtedly others. Apple's innovations with tablets and iOS have led to great consumer products. But compromising for business uses has never been their strong suit. Getting these devices into hospitals, where they can make a big difference, will unfortunately require either administrators to be flexible and creative, or Apple to compromise. Immovable object, meet immovable force. - Jan 03, 12For years I noticed a burst of productivity around the holidays. stuff that had been hanging over my head for months would suddenly get done. New ideas would suddenly pop into my head.
I attributed it to things like the psychology of the calendar, or just having fewer emails to answer, or more unstructured time... But the recipe is simple:
Eat well. Sleep well. Stay connected to loved ones. Get some exercise.
That's it. That's all it really takes to complete projects, tackle nebulous fears, and poke the box. - Dec 15, 11
Today's ACEP Member Communication email (entitled Emergency Medicine Today, in affiliation with BulletinHealthcare) had this as its top story: Injuries Linked to Holiday Decorating on the Rise, from a website called HealthDay News. The reported cites a US Consumer Product Safety Commission press release, crafted with help from Underwriter Laboratories (the wire engineers). They claim:
In November and December 2010, more than 13,000 people were treated in U.S. emergency departments for injuries involving holiday decorations, up from 10,000 in 2007, and 12,000 in 2008 and 2009, according to the U.S. Consumer Product Safety Commission (CPSC).
"A well-watered tree, carefully placed candles, and carefully checked holiday light sets will help prevent the joy of the holidays from turning into a trip to the emergency room or the loss of your home," said CPSC chairman Inez Tenenbaum in an agency news release.
Good advice. Though it's been said many times, many ways. So when it came time for CPSC and UL to raise the topic, did we need the very questionable statistics to justify it?
If you're having trouble wrapping your head around the number of decoration-related emergency department visits, consider this similarly bizarre statistic: 8000-10,000 kids are injured each year from falling televisions. So, for perspective: in the November to December period, Americans now endure more holiday-decoration-related trauma than an entire year's worth of falling TVs (though, now that I think about it, there may be some overlap, like if while putting up some Christmas lights, Dad knocks over the TV and it lands on Junior's foot -- that could be one ED visit logged in both categories.)
Another way to think about it -- 13,000 visits over two months spread over the approximately 1800 EDs in the US translates to about seven (7) holiday-decoration-related visits per ED. Not much, when the average department sees 5000+ patients a month (and Americans visit the ED 130 million times a year). I'm not even sure it's significantly more than it was a few years ago, when EDs could expect -- get ready for it -- six (6) visits related to holiday decorating.
Still, I've yet to see my first misletoe-hanging trauma. I have seen more than my share of frankincense and/or angel dust intoxication lately, but I don't think that counts as a decoration-related ED visit.
In fact, I handle a lot of statistics and analysis for our ED, and I could not tell you how many holiday decoration injuries we've seen this year, or last. To really do it right (ie, publication-quality data that could stand up to peer review or joint commission scrutiny) we'd have to build a query to retrospectively through the text of all patient notes, looking for mentions of menorah fires or tree-felling injuries, then do a chart review. Or we could code a checkbox and ask our triage nurses to prospectively screen for this, along with suicidality, domestic violence, and HIV.
Probably what CPSC is doing, instead, is drawing from a few statewide databases or surveys like NHAMCS and generalizing broadly (certainly, there are no scholarly papers on holiday decoration emergencies -- the literature on falling TVs is much more robust).
Survey data is fine for identifying new threats to the population, or changes in abuse patterns, but it's hardly precise and when I see dozens of headlines about the rise in ED visits from holiday injuries (Google news counts 291 stories at the time of this writing) it makes me cringe. If next year's holiday decoration visits fall back down to 10,000, does that mean we've turned a corner on educating the public about the menace of holiday decorations? And so we won't need to be so vigilant anymore? Or is it just a statistical blip, well within the margin of error, not at all worthy of a headline?
And on that note, I must break off to do some holiday-related shopping, confident (but somewhat disturbed) in the knowledge I've now spent more time mulling this over than anyone involved in writing or selecting that press release for inclusion in ACEP's daily email. - Dec 08, 11
Heard about an old friend, sharing the stage with Billy Squier at our high school's send-off event (as another alum of some distinction noted, the building is being demolished).
Their performances got me thinking of a lot of the songs we practiced, growing up. And while I did say recently that music is "done" from the perspective that we can hear pretty much any song we'd ever want to hear, on demand, anywhere, the truth is there are some songs that seem lost to time.
If Google can't find a tune, does it really exist? There was some truly strange songs, burned into my head from repetition in middle school orchestra. From time to time, the tune or lyrics pop into my head -- but when I try to pin down that song -- Google's got nothing.
For instance, there was a whole awkward teen coming-of-age musical we put on. I think it was actually called Coming of Age. Songs included, "If I Had A Friend," "On the Outside, Looking In" and "Broken Home on the Range."
I want to know, were other middle schools forced to perform this, as well? Who wrote these songs? I'm not saying I'd be a fan, but I'm driven by a little nostalgia, plus the same kind of curiosity, I think, that drives people to hear Wesley Willis works.
Another example is a musical about singing troubadours -- this is the only reference I can find online. We praticed these songs on professional-looking sheet music, learning them by heart, just a few decades ago. Yet no trace of these songs seems to have made it into the digital era.
I suppose as every bit of trivia and ephemera from our lives makes its way onto the web, and we come to accept that no new experience will go undocumented, these last few holdouts will rankle, out of proportion to their significance. - Dec 02, 11
Sometimes, the blogosphere just decides they're going to discuss something in great detail. And now, with holiday travel upon us, we're talking about the inane rules that airlines inflict upon passengers -- especially the "turn off all electronic items that have off switches" rule at the beginning and end of flights.
This past summer, when the IATA issued a largely anecdotal report on a few dozen incidents with no real bad outcome (spanning a period covering millions of flights), I thought the time for discussion was ripe, and compared some of the rituals of aviation to similar maddening rituals in healthcare.But now James Fallows is covering the topic, and has terrific input from a diverse and smart audience (it helps that he's a pilot, himself, and a terrific writer). Read it all -- just not during takeoff or landing. - Dec 01, 11
I had a couple of slow shifts in the emergency department recently, around Thanksgiving. And it made me think of Nomar Garciaparra, the old Red Sox shortstop.
Nomar always had to throw off-balance, while running and jumping. You can see his style on display when throwing the ceremonial first pitch at Fenway last year.
In an interview (can't find the reference, sorry) he said he always had to throw this frenzied manner, even for an easy grounder where he'd normally have time to collect himself. If he paused too long to think about it, the throw would come off badly, he said.
I always thought this was a psychological issue -- dubbed "Steve Sax Syndrome" by some.
But on those slow holiday ED shifts, I think it's just a good habit. When you're used to functioning well at a fast pace, slowing it down doesn't necessarily make you any better. Our ED's workflows, our data collection, and our decision-making, all all calibrated to work at a certain speed. Slowing it down sometimes lets us unearth a valuable piece of information -- but more often, it just pushes the signal-to-noise ratio toward more noise.
And hey, it's not like Nomar's quirk kept him from having a stellar career. - Nov 30, 11
We've been considering FDA oversight of medical apps for a while, over at Medgadget.com. Now, the public comment period has concluded on the FDA's draft of how this oversight might look. The story:
The FDA will scrutinize medical apps that act as an accessory to a medical device and those that transform the mobile device into a medical device. A draft guidance issued by the FDA includes an extensive list of applications that will have to undergo review. Examples of apps that fall under the regulatory oversight are:
* Applications that allow the user to view medical images, such as digital mammography or digital images of potentially cancerous lesions on a mobile platform, and those that perform a health analysis or provide a diagnosis by trained health care professionals.
* Applications that allow the user to view patient-specific lab results.
* Applications that connect to a home use diagnostic medical device to collect historical data, or to receive, transmit, store, analyze, and display measurements from connected devices.
Great, right? The apps that do heavy lifting of patient information and connect to real medical devices get regulated, but the fun and educational apps I am working on remain free and open. Still, Harvey Castro, my favorite EM-doc-and-app-developer, was worried:“Overall, I believe safety is the most important item when it comes to providing patient care,” said Harvey Castro, MD, an app developer (www.deeppocketseries.com) and emergency physician. “Unfortunately, I believe this will hurt small businesses and entrepreneurs by making it cost-prohibitive to enter the market.”
“Applications will be dominated by a few companies capable of paying the high fees to get FDA approval. I will be saddened to see these changes in the future.”
For their part, the FDA said it's nothing to worry about:...the FDA said the regulatory requirements will not impede the advancement of medical apps. “We are eager to support the continued development of mobile medical apps without the burdensome regulations that would stifle innovation,” the spokesperson said.
I've perused the FDA's draft and still have a lot of questions. What if I install an app from a non-American app store -- could I still use it on American patients? What are the penalties for apps that should have been submitted for FDA review, but weren't? Will there be a grandfathering status, like with pre-1930's drugs? Will educational app makers have to submit a form asking for FDA exemptions?
The biggest question: will the FDA heed the recent IOM recommendation that another (non-FDA) government agency take up the regulation of EHR vendors? What if Congress fails to create such a body (I have a hard time imagining, in this political environment, how funding for creating a new regulatory agency would transpire). What if the FDA is the only agency that can expand its mandate? Wouldn't it act? Why should FDA expand to medical apps but not EHR?
The FDA has a proud and progressive tradition; the laws underlying its authority were passed in response to public outcry regarding food and vaccine preparation, and misleading labeling. There were big problems, improved by the FDA. Even now, critics argue the FDA doesn't go far enough -- approving medical devices later found to be flawed, and recalled.
So I don't understand this push into an area where they have no clear mandate, and where there's no public pressure (yet?) to intervene. Don't get me wrong -- I'm not opposed to the idea of med app oversight, someday. There's no doubt that would be good for Americans. I do worry, though, that by moving in to the medical apps realm before most people have ever used them, and before a bad outcome has even been encountered -- or learned from -- is premature. Though the FDA says they don't want to stifle innovation, I can't imagine that, with their current budget, their fees and regulations can be anything other than a significant hurdle for developers. - Nov 29, 11Many thanks to AfternoonNapper for hosting this week's edition of Grand Rounds.Next week, I host Grand Rounds... but not here! It'll be over at my new Tumblr blog.Want to be a part of it? Please mail me at nick -at- blogborygmi.com with the subject Grand Rounds, along with a URL link of your submission and a brief excerpt. Photos are also welcome!Submissions are due by 11:59PM, Sunday December 4 (Eastern US time). Then, head over to blogborygmi.tumblr.com on the morning of December 6 for the first Tumbl’d Grand Rounds.
- Nov 28, 11
Remember how people said there was no real need for a device category between smartphones and laptops? And then Apple sold 40 million iPads?
That's kind of how I felt about Tumblr.
Blogs are obviously great for musings, essays, and a web presence, and Twitter's fine for thoughts and links and pics. Why have something else, in between?
I don't really have a good answer, just like I can't fully articulate why the iPad experience is so much better than a laptop or smartphone. But I'm starting to see the appeal of Tumblr.
Beyond the usual accolades from early adopters / influencers, something that stayed with me was a quote from Tumblr's founder: "No one is proud of their identity on Facebook."
Very true. And true of a Twitter page, as well. But Tumblr sites... can be something to be proud of. And they're effortlessly fast to set up. While I have strong sentimental attachment to this site, Blogger's recent attempts to make themselves slick feel like so much else Google does these days -- uninspired, clunkier copies.
I've been looking for a way to breathe new life into the 8+ years of writing here. Tumblr's "random" button and their vibrant archive views are a great start. When you consider how easy is is on Tumblr to tag old posts, and how elegantly you can display redirect pages for tagged posts (or photos, or music) and offsite material in the sidebar, well, I was sold.
Then, of course, I had some buyer's remorse. Tumblr is unapologetically different from other social networks. It took me a while to even realize that their "dashboard" is nothing like Blogger's, and in fact more like Facebook's news feed. And it's taking me some time to get comfortable with "reblogging" which almost seems like effortless plagiarism, if you're not conscientious about citations.
Tumblr's search function is completely broken. I have to believe they're working on a fix, but probably making a point of taking their time -- as if to say we're living in a post-Google age.
While I lamented Tumblr's decision to stop importing RSS feeds a few months back, I see the wisdom. I would have gone to town with importing thousands of tweets and countless photos, on top of all these blog posts. As it is, it's still possible to reintroduce old content -- it just takes a little more effort. Just enough to tip content generation in Tumblr's favor, rather than using it as a lifestream repository like Evernote or Friendfeed.
Still, it was fun to watch people throw some hearts at some old photos I uploaded, and I didn't mind the occasional reblog. And really, Tumblr's too good-looking to fill it with a bunch of text links to tweets (maybe someday we'll have something like Postano's yolink feature, to fetch images and content from those links, along with the tweet).
Twitter will always remain to go-to choice for conversations and conferences, and I think Blogger will still be my first option for sit-down-and-think kind of writing. But for now when I'm browsing and come across something interesting, I'm just going to try Tumbling first. And I'll be watching to see what new tools come online, as Tumblr grows to become the next great social network. - Nov 25, 11
Medscape's EM editor asked Amal Mattu, Robert Glatter and me to discuss 2011's important papers in emergency medicine. I felt compelled to include an all-around terrible (but still important) paper, and a tidy nice decision-support paper for discharge prescriptions, among others. See what you think about my picks, as well as the great selections from Drs. Mattu and Glatter.
- Nov 21, 11
Music's pretty much done, right? It's fairly easy to hear any song you've ever liked, anywhere you happen to be. As a bonus, those songs can be stored, shared, tagged, rated, and linked to lyrics and album art.
Movies and TV... their delivery is not quite perfected, but the general outline seems apparent. Already I can watch the WKRP Turkey Drop episode in the kitchen on my iPad's Hulu app, and mirror it to my TV (via Apple's set top box) when I'm ready to sit on the couch. Other shows or films require more effort, though the combination of Netflix, iTunes, and for the remainder, torrents plus the Air Video server app, make it easy enough.
But reading? The written word, for whatever reason, still lags behind. While strides have been made, a simple and universal, Apple-like solution to the problem of reading, sharing and archiving remains elusive.
It seemed for a while that RSS was going to solve reading, but despite this, for a while, I resisted the call of RSS aggregators. I wanted to experience sites as the bloggers wanted them laid out -- if it was just uniformly presented text, I feared I'd lose some of the author's personality and voice. I had a hierarchy of bookmarks that I perused.
But I found, even with Grand Rounds, that I was missing out on new voices. Using bookmarks to visit older blogs that were sputtering out was frustrating. Messing with my bookmarks was not as simple as adding or rearranging RSS feeds. And so, at some point in 2006, I made the leap to Google Reader.
And for a while, things were great... I could efficiently consume the blogosphere, as never before. Until I came to regard catching up with RSS feeds as a chore.
So I muddled along, using a combination of bookmarks, Google Reader, and increasingly, Twitter feeds, to keep up with old friends and new sources. Good stuff I came across was starred, or retweeted, or bookmarked, or cut and pasted intoGoogle NotebookEvernote for future reference. Or Instapaper'd. Or posted to Facebook. At one point set up FriendFeed to aggregate all my commenting activity, but it was no way to absorb new information.
Then the iPad came along, and with it, Flipboard, Pulse, and the Kindle app. Flipboard hooked into my Google Reader feed but never made catching up on blogs seem like work -- instead, it felt like I was browsing through a magazine that featured all my old blog friends and twitter buds. Flipboard also let me retweet, or post links to my Facebook page. Pulse is a little less slick than Flipboard, but they make it easier to plow through more content, add new feeds, and share or save material. Kindle's app is pretty great, and lets me take notes that can be shared publicly. It's a little work, though, to turn that public notes page into an RSS feed or Evernote folder. Currently, the Newsstand periodicals don't offer any sharing or notes archives, which has really limited my use of them (though they're still fun to read).
That the iPad should be a superior device for browsing and sharing RSS, books, Twitter and Facebook feeds is not surprising -- there's been surprisingly little demand to bring Flipboard and its like to the Desktop; Kindle has a desktop version that I've only used for novelty's sake.
I just wonder if Google knows what it's lost, by neglecting the Reader experience (which has only gotten worse lately)? I think so. Sources say they've got something in the works to compete, for tablet browsing. And many expect Google+ to come out with the APIs to make this kind of sharing and logging possible. Just not yet (and maybe too late).
In the meantime, I'm starting to make use of ifttt (if this then that), a simpler version of Yahoo Pipes that monitors feeds, tweets, and calendars and carries out pre-programmed actions for you -- so my starred Tweets are automatically sent to Evernote, for instance, or Facebook photos tagged with me are sent to Dropbox.
Ifttt makes Twitter and FB more useful, but it only makes clear how limited these social networks are for archiving, by themselves. It seems there ought to be a universal browsing / sharing / archiving app, for Tweets, Facebook wall posts, RSS, eBooks, and magazines, that looks as slick as Flipboard but has more capacity and flexibility. The fact that I can imagine this means it's too obvious for Apple to be working on (and probably not profitable enough, either). I worry that Google's solution may not adequately incorporate Twitter and FB (because if it did, why use Google+?) Maybe Amazon will surprise us again, or maybe Flipboard, Pulse, Evernote, Instapaper, or another startup will make it happen.
Until then? It's surprising but the simple, ancient act of reading has failed to adapt, technologically, to the extent that music and video have. - Nov 14, 11
Longtime readers know my fondness of comparing the healthcare industry to the airline industry (based on similar goals of training, rituals of safety, and differing approaches to error, for starters).
Recently I've learned of a new intersection between medicine and aviation, when Delta chose to air ads to their captive cabin audience purchased by NVIC, the National Vaccine Information Center. The ads talk about staying healthy, maintaining good hygiene, and asking your doctor questions about the different flu shots available -- to stay informed and keep all the options open.
Sounds ... innocuous ... right?
Sure, the CDC recommends the influenza vaccine as the single best defense against influenza deaths, though additional hygiene measures can help. But what's the harm in asking questions of your doctor? Being informed?
Well, during the three-minute informercial, the NVIC website URL is shown. Their site is the opposite of information -- a mixture of pseudoscience and innuendo, laced with bromides about patriotism and personal freedom.
I recently flew Delta and didn't see (or recall seeing) this ad, though I do remember a loud car commercial right after takeoff, that I couldn't stop, or quiet. Inflight advertising is said to be unusually effective at prompting recall among passengers, well after landing. Since a fair number of people report some upper respiratory issues after flying, I've got to admit the NVIC initiative is well-planned.
But dangerous. In the words of AAP president, Dr. Robert Block:The AAP and many other child health organizations have worked hard to protect children and their families from unfounded and unscientific misinformation regarding vaccine safety. The influenza vaccine is safe and effective.
By providing advertising space to an organization like the NVIC, which opposes the nation’s recommended childhood immunization schedule and promotes the unscientific practice of delaying or skipping vaccines altogether, you are putting the lives of children at risk, leaving them unprotected from vaccine-preventable diseases. Diseases like influenza can have serious consequences. From September 2010 to August 2011, 115 children died from influenza disease, most of whom were unvaccinated.
A petition is circulating to ask Delta to stop putting their passengers at risk. For their part, Delta has said that they'll change their ad purchasing policy, and the NVIC ads will only run until the end of the month. Wolfram Alpha suggests that, at about 200,000 passengers a day, that's another three million viewings of the informercial.
I rounded the daily passenger rates up slightly, for the Thanksgiving rush. Maybe, though, we could round it down -- #dontflydelta is trending on Twitter.
At the recent BWELA conference social health track, a bunch of us were talking about ways healthcare providers could affect positive change, in a media sphere where stories, novelty and fear usually trump statistics and uncontroversial, boring truth. This sounds like just the opportunity we were looking for -- pushing for a measurable outcome (Delta stopping the ads early), fighting pseudoscience with evidence-based recommendations, and using social networks for a decidedly anti-viral purpose. - Nov 08, 11
Thanks to a tip from Brian Ahier, I've caught wind of excerpts from the IOM report on Health IT Safety a few days before its scheduled release.
iWatch has the scoop:But the push [to adopt electronic health records] is occurring so far without any agency really ‘watch dogging’ the safety of health IT — the software, hardware and systems that record and manage patients’ health information. These expensive devices by and large have not gone through any regulatory checks for safety in the way that food, drugs and other medical technology must; most of that oversight is handled by the FDA. But at the moment, no one is required to report instances of harm caused by health information devices and no government agency currently monitors their safety.
I've read Ross Koppel's work, and seen him speak, and firmly believe he's a brilliant guy. But I disagree that we're accepting health IT's value on faith, because of marketing. We've seen IT transform the way we do business in every other sphere of American life, and many of us have experienced the benefits of easily retrieved patient records and clear, electronic communication between providers. As I've said before -- aside from a few train-wreck implementations, who would go back to paper records, if given the chance? Who would build a new hospital based on anything but an electronic system?“With all of that money, marketing and public outreach, most simply affirm the value of health IT as an article of faith, rather than investigate it via careful evaluation,” said Ross Koppel, adjunct professor of sociology at the University of Pennsylvania and its School of Medicine, and investigator for RAND Corporation. He is listed as one of the reviewers of the report.
The IOM isn't saying paper's better, but they do recommend caution with, and further study of, health IT:...In its report, the IOM committee says the FDA would likely restrict market innovation in health IT, which could also jeopardize patient safety. Stringent regulations “can negatively impact the development of new technology by limiting implementation choices and restricting manufacturers’ flexibility to address complex issues,” the report says. The FDA currently receives voluntary reports of health IT-related incidents, but has no resources or protocols through which to take action; the agency has long fought a losing battle with health IT vendors over trying to monitor the technology.
The report also notes the agency does not have the investigative capabilities, funding or manpower to regulate devices such as electronic health records, personal health records or health information exchanges.
...To adequately oversee health IT safety, the committee recommends that the secretary of health and human services create and fund a new independent watchdog agency, along the lines of the National Transportation Safety Board. Like NTSB, the new agency would conduct investigations and make recommendations for all stakeholders, including the secretary of the health and human services, vendors and health care organizations. Vendors of the technology would be required to report adverse events, while reporting would be voluntary for clinicians. Like NTSB, though, the new agency would also have no enforcement power.
I'm all for reporting safety issues, near-misses and other risks of health IT. I think the vendors have really done themselves a disservice here by insisting on gag rules among their hospital clients -- doctors would be in violation of their contracts if they posted a screenshot of their EHR software online, let alone spoke publicly about some clunky or possibly dangerous glitches.
And I kind of like the idea of an NTSB-like agency, swooping in after a prescription error or lost bed assignment. Certainly, that model seems preferable to an FDA oversight, which might require extensive pre-implementation testing (beyond the current certification process) and I think would tend to slow down the pace of innovation and lock-in the clunky, slow interfaces doctors have come to expect from EHR.
But I have to ask: what country, what era, has the IOM been living in? Because expecting the creation of a new regulatory agency in the US in 2011, with an obstructionist Congress that's breaking filibuster records just to spite the administration, is a pipe dream.
And if no new regulatory agency is forthcoming, where does that leave the federal incentives for adoption and meaningful use of electronic health records? Already, the effort is stalled and seems likely be dragged out over an additional period. Now critics of MU will point to this phantom Health IT safety board, which ought to exist but probably won't, as a further excuse to delay, delay, delay. The status quo is cheaper. It's familiar. And so we'll keep handwriting notes and shooting paper orders through pneumatic tubes, in the name of patient safety.
The iWatch kicker:In its report, the IOM panel also recommended that more studies be conducted to quantify health IT-related deaths, serious injuries or unsafe conditions so that the safety concerns can be properly addressed. “You can only improve what you measure,” says the report.
So true! And what we have in place now, across the majority of US hospitals, is patient care managed with clipboards and three-ring binders, full of handwritten notes and orders. Can those be measured in a systematic way (you know, for the sake of improvement)? Of course not.
It seems like health IT is a victim of its own capabilities. Because technology lets us measure and record how we practice, it is scrutinized to a far greater extent than the antiquated system it aims to replace. Because we can't begin to calculate how dangerous the status quo paper-and-clipboard system is, we'll end up keeping it, longer than any other US industry. - Nov 01, 11
I've started to think the medical record is akin to DNA. Maybe 10% (or less) is useful information; the rest is junk. When folks want to find a sequence of significance, risk or reassurance, they've got to search for the good stuff and filter out all the garbage.
But junk DNA is believed to have a purpose. Some regions of junk DNA are highly conserved -- found in organism after organism -- suggesting an important function. In medical charts, conserved regions are also repeated. And they also serve an important function.
It's this repetition that Dr. Bryan Vartabedian called "Cut and Paste medicine" in his excellent recent post. He's concerned that all these computer-generated phrases of historical elements, exam findings and decision-making makes all patients look alike, and hurts continuity of care, as it becomes harder to discern what's actually going with the patient.
It's a reasonable concern. This problem, created by documentation regulations, compounded by declining reimbursements, and exacerbated by quick-fix features of some electronic records, can be solved through technology, too. Just as researchers and geneticists built tools to sift through DNA, to find the small section they're looking for, we need to easily search through records to show the details of patient care relevant to us.
Maybe this solution will simply highlight free-text sentences and paragraphs, and gray-out all the checkbox-generated prose. Maybe these searches will involve natural-language processing, or complex filters based on provider or position. I'm hopeful this problem will be solved, because medical records aren't getting shorter.
And here's where my analogy with DNA breaks down: junk DNA is also called "noncoding regions" because those sequences don't code for proteins. But in the medical chart, those junk sections are actually designed for coders -- they have key phrases that medical billing companies look for, to show to the insurance companies, to pay us. You could be providing the most competent, compassionate, time-consuming care in the world, but if those phrases aren't in the chart, nobody gets reimbursed. Other instances of these oft-repeated, computer-generated phrases in medical charts are designed to protect against legal liability, which also serves the financial interest of providers and healthcare institutions.
The good stuff, the free-text prose that describes what the doctor is thinking, may only be a short paragraph in a sea of vital signs and lab results and macros and checkbox-generated text. While this section is the most important part of the chart to future caregivers, from a medical billing perspective, it's essentially a noncoding region.
There was a time when medical charts were short and designed soley to communicate patient care to future providers. Medpundit once wrote of a mentor who could boil down an encounter to two terms, like "ROM - Amox" (right otitis media, given amoxicillin). Years later, a similarly simple encounter would have to run for 10 or 20 lines of prose.
By 2008, Peter Viccellio wrote:When an ED visit for a cough, with diagnosis of pneumonia, consumes 17 pages of print, something has gone awry. (Or perhaps things went awry when pulmonary edema was no longer considered an emergency unless there was a documented family history, social history, and 10 reviews of systems.)
True. Things have gone awry. But I can't see any way back. So tell me: why should the medical chart ever printed, in a hospital? (Besides the increasingly rare scenario where a patient moves from an electronic part of the hospital to a paper-chart area). And if the chart's not printed, well, why should anyone on the care team have to scroll through 17 screens' worth of prose? Caregivers should see the parts of the chart really relevant to patient care.
Let's recognize the vast majority of the chart for what it is: coding regions that keep the hospital or the practice afloat, and comparatively safe from prosecution. These sections are not really important for patient care, and they're the last thing I want to see when I pull up a chart about a prior visit. Recognizing that, and building EHR search and display functions around that, and you'll solve a good deal of the frustration around electronic records and their cut-and-paste confusion.
The biggest reason we haven't done this already, I think, is pride. It's too painful to admit that most of what we're doing on the computer is not directly relevant to patient care. Let's get past that, recognize the checkboxes and macros serve a primarily financial function, and give those sections the low status they deserve when we run our searches and pull up our charts. - Oct 31, 11
While the output here has fallen from blogborygmi's heyday, this site's original purpose was to foster writing opportunities with, you know, real publishing platforms. By that standard, this past year has been a good one. If you're interested in reading more of my stuff, from health informatics to social networks, see below:
RIP Google Health. A look at the nearly-late, nearly-great Google Health, and the prospects for personal health records.
Twitter, and emergency response. What if social media was available on 9/11?
Redefining EMR Usability. When I got into electronic medical record usability, I thought it'd be about physician satisfaction, consistency, and counting clicks for key tasks. Recent developments suggest, however, it's going to be about estimating and reducing errors.
Getting Social. How social media can change the public face of emergency medicine.
When Charts Cry Wolf. The evidence surrounding the annoying, often irrelevant drug interaction warnings served up by electronic medical records.
EPMonthly EMR Roundtable. A freewheeling discussion on electronic medical records, conducted by Mark Plaster and featuring Rick Bukata, Bruce Janiak, and yours truly.
Meaningful Use: A Really Good Kick in the Pants. My interview with Maimonides CMIO (and emergency physician) Steven Davidson
MU and You. A primer on meaningful use of electronic health records, and what it will mean for emergency medicine.
- Oct 24, 11
At ACEP last week, @drsamko tweeted a stat from the great Amal Mattu: the audience forgets 40% of new content from a presentation within 20 minutes, and 90% after a week.
I replied, "The Twitter audience never forgets!"If I had more room, I might have been a little more precise. Twitter makes forgetting less likely, as pearls from different lectures can be broadcasted, shared and debated.But Twitter is not Google or Pubmed. Once shared, Tweets, like good talking points from a lecture, have a way of disappearing into the ether.So I applaud GruntDoc for his reprinting 95thesestweets from ACEP, on a more permanent form on his blog (look at what we've come to, when blog posts are considered durable).Here are a few of my own from ACEP #SA11 lectures and wanderings (largely stripped of hashtags, grouped by lecture, oldest first). If you make it all the way down, I have some (brief) thoughts on process of tweeting from conferences.At infectious disease trivia session at #SA11. Learned: mortgage foreclosures led to neglected swimming pools, big rise in west Nile virus
Listeria! 2 month incubation period means maybe we haven't heard the last of cantaloupe scare. Pregnant pts particularly vulnerable
West coast heroin is not as pure as what we have in NYC. More incidence of botulism. They keep the antitoxin at airports!
Fidaxomicin for c. diff is $300 a day -But good compliance and better at preventing recurrence than flagyl. Beats a fecal transplant
@gruntdoc I think most of my patients would rather pay big $ for antibiotics than get poop transplant. Maybe I'm not explaining it well
Cook keynote #SA11: diff between 2006,2010 landslides in house? Small movements in independents who aren't watching fox, msnbc
Cook's #SA11 talk is a primer on politics,polls,electoral math, nothing (yet) on healthcare or even policy. Maybe that's why he was chosen?
Finally Cook #sa11 talks medicine, saying economy so bad, Obama will likely lose - if republicans can nominate a "placebo."
Cook #sa11: "I know less about health care than anyone in this room..." But he knows the politics of healthcare repeal pretty cold.
Cook done speaking? his conclusion is "dunno future of healthcare repeal; lots of uncertainty." wish keynote wasn't just handicapping
Watching @MDaware field questions by his poster (110) on residents' perceptions on teaching time vs value pic
Schoenberger on new ED gadgets: early gadget lit often written by investors, fans. But devices that take off don't depend on EBM
Schoenberger: McGrath video laryngoscope is too portable; easy to misplace this $10,000 instrument. Newer stuff cheaper, mountable
Schoenberger: King LT supraglottic device is replacing combitube in EMS purchasing. Single-use fiberoptic also show promise
@MDaware hmm maybe this speaker needs a better vendor rep; the high price of McGrath was a major talking point
Schoenberger: ultraportable sono smartphone based devices are cool but wait for an iPad device: that may be sweet spot for EM docs
Schoenberger is showing videos of S-cut trauma shears in staged competitions. So much destroyed leather!
Bmeye Nexfin noninvasive monitoring can tell (to some degree) cardiac output, stroke volume and SVR from a pulse-ox like device
There's a device coming out that will transmit EKG data through a shirt to an iOS device. Looking forward to getting rid of wires
Schoenberger just gave a plug to @Medgadget, then @epmonthly to keep up with device news
Interesting times at the @epmonthly board meeting this morning. Now off to ACEP's informatics section meeting
@RogersMatthew AR goggles!? We're still adapting to informatics as an approved subspecialty & writing an EMR pt safety white paper
Now at anesthetic lecture #SA11 learning evidence for bupivicaine, which seems to decrease opioid consumption days after drug is cleared
Kip Benko on supraperiosteal injection: topical first, insert bevel to bone, inject to get at the root (2/3 of tooth is hidden)
Benko on infraorbital nerve block: "needle doesn't have to get into the foramen to work - this isn't golf."
Benko showed beautiful diagram: mental foramen, corner of mouth, infraorbital foramem, and pupil all line up. That pic worth 140 char
Benko tips: inject palms up (see your palms) for best control. Distracting lessens inject pain, so pull lip or press qtip near site
Benko: easy to miss inf alveolar nerve, hit buccal or lingual instead, numbing wrong part. Angle in from over contralateral canine
Next is one ive been looking foreward to: Badanowski & Rice, on medical liability in the age of electronic health records #EMR
known legal cases on #EMR: bad time stamp sync, delayed documentation, info entered on wrong charts, ignoring available info
So far this #EMR talk is short on specifics, no concrete actions to recommend. Are they still introducing the topic?
First real recommendation: have good backup plan when #EMR goes down; one makpractice case was lost by inadequate downtime system
@gruntdoc the poor readability of these slides is evocative of many poorly designed #EMR interfaces, may be intentional
Medical providers can be liable for use of faulty equipment; #EMR is no exception. You can't let known problems fester
Vendors make hospitals, EDs sign "hold harmless" clauses re: #EMR use or misuse #SA11 (they also gag users who try to speak out on dangers)
This #EMR talk degenerated into scaremongering. Just heard: "the lawyers are savvy, but the AMA is active." guess we're doomed
favorite #SA11 exhibit slogan? So far QuickClot leads with "the bleeding stops here" (from the makers of Combat Gauze) picMy goodness, the T-ring people have the best exhibitor poster (warning: not safe for lunch) pic
At Newman's #SA11 talk on the NNT for common EM therapies... Always eye-opening how limited our interventions really are
Newman stresses absolute risk reduction, over relative. And shows mortality scales from 0-100% to really put benefit in perspective
NNT for rhogam in threatened AB: infinite!? Not a single case report of isoimmunization in 1st trimester, some in 2nd.
Newman's covered some of this lit on his smartEM podcast, and http://theNNT.com
Newman on NNT for packing after abscess I&D: no recurrence benefit, hurts more, prevents good cosmesis.
Steroids for meningitis? NNT of 20 to prevent hearing loss... Better than mortality benefit of lytics/PCI for STEMI (NNT 40) Newman #SA11
Antibiotics in COPD exacerbation? NNT = 3 to prevent bounceback. As good as Mg++ for asthma to prevent admission. Great interventions
Newman got passionate, urging EM doctors treating arrest patients to think about etiology rather than blindly following ACLS cookbook
After Newman laid down evidence-based but counter-culture facts, he urged action plan: educate pts, prioritize interventions
At @M_lin's talk, she suggests fragile elderly lac repairs be improved by suturing through steri-strips, to prevent new skin tears
Wise suggestions from @M_Lin: tegaderm to limit spread of tissue adhesive, and tissue adhesive to affix avulsed fingernails
@M_Lin: Fast-absorbing gut suture plus tissue adhesive is perfect for wounds that need a little extra tension (like on chin)
Ooh clever: Sono tough-to-reach extremity lacerations to look for foreign bodies by placing hand/foot in water bath.
Off to hypertension lecture, mostly because I need a better way to reassure well patients that have no emergency
Bresler starts Rx for ED HTN if diastolic > 100 persistently. JNC recommends HCTZ (but what about K+?)
2010 AHA guideline: lowering systolic to 140mmHg in hemorrhagic stroke is probably safe. Big change
Show of hands at hypertension lecture: who's ever used fenoldopam? Mine was the only hand that went up #SA11 #practiceoutlier
Bresler treats his asymptomatic HTN ~220/110 pts with Clonidine x1, no Rx, which seems like treating numbers, not patient.
As I did this cutting and pasting, I had a few Twitter-like thoughts come to mind:- Someday, academic speakers may be evaluated on Tweeted comments, and on the quality of Twitter discussion they stimulate, as opposed to those Likert evaluation scales handed out at the end of talks.
- Tweeting (with geo-location enabled) lectured pearls may also be a way for students to demonstrate understanding / attendance to teachers / administrators.
- It's great that academic promotion boards are looking at social media influence alongside journal publications and other printed works. I wonder if the time-honored academic practice of double-dipping will find use, here. Just look at the mileage I'm getting from these tweets.
- Oct 19, 11
I'll be speaking at BlogWorld Expo in LA on November 4 at 4pm, on how social networks can influence patient outcomes.
I'll be joined by two distinguished physicians and social media pioneers, Dr. Jen Dyer and Dr. Val Jones. We'll make a few brief presentations and then field questions. The session will be immediately followed by happy hour.
Also, be sure to check out all the other great topics in the social health track, spread throughout the conference. The speakers with Twitter accounts (approximately all of us) are listed here and tweets about the conference have the #BWELA hashtag.
If you're on the fence about attending the conference, consider: promo code BWEVIP20 to knock 20% off the registration fee. - Oct 04, 11
Long before my colleagues knew me as "that guy who sewed a pocket into his white coat so he could use his iPad in the ED" ... but sometime after they knew me as "the guy with the blog" ... I like to think they knew me as "that guy who helped edit many editions of EM Practice, the evidence-based, presentation-focused journal of emergency medicine."
With this post, I can be all three guys at once, and recommend the wonderful, iPad-optimized PDF of of many fine flowcharts featured in EMPractice in recent years, now available for free.Every issue of EMPractice has a flowchart to help guide emergency decision-making with the best available evidence. We've taken a bunch of recent flowcharts and bundled them into a useful, navigable document that will bring the best evidence to the point of care.Of course this PDF works well on paper, and the hyperlinks will work on other computers or devices, but it's sized and designed with the iPad in mind. It's really great for teaching or reviewing, on shift.NB: I'm on the editorial board for EMPractice and had a small role in developing this PDF. - Oct 13, 11
I like asking patients about their jobs. Sometimes it may seem relevant to the complaint. Other times, it could potentially help the therapeutic bond. Mostly, it's just interesting.
Occasionally, I'll hear a patient is not working; that he or she is on disability.
This can surprise me, especially when the patient's interview responses and examination seem quite appropriate and unremarkable.
Now, I'm not in an ED where this happens too often (or maybe I don't ask enough). At any rate, I haven't been compelled to blog about this phenomenon, like, for example, Edwin Leap recently did. And I'm certainly not of the mind that disability payments are responsible for the debt crisis, or that the vast majority of folks on disability don't deserve it.
But I was recall my training in smoking cessation counseling; we were taught that every time a doctor elicits a smoking history but doesn't discourage the practice, a patient takes notice. Maybe the patient doesn't walk away thinking, "my smoking habit is healthy," but perhaps he or she ends up concluding it can't be such a big deal, if the doctor didn't dwell on it.
As a consequence of this training (and the research that backs it up) I do tend to dwell on smoking history. I have all kinds of statistical and anecdotal pearls to trot out, depending on the situation (wound healing, viral URI, heart disease, etc).
I wonder if the same thinking can be applied to those unexpectedly disabled that I see every now and then. Is there a phrase a physician can ask, that expresses some surprise at the incongruence of their presentation and disability status, without coming across as confrontational, or opening up a can of worms?
Perhaps it's just a variation of my formulation, a few paragraphs back: "You're on disability? That's surprising to me; you seem so capable."
And then, just listen. - Oct 04, 11
I was contacted by the folks at RN Central about running an infographic about the dangers and errors associated with hospital night shifts.
They thought I should publish it, "since you run a site about nursing."
Since that statement is an error, and since the email was sent at night, I assume the sender had to be overworked or undertrained. That off-the-cuff assumption, it turns out, may be more rigorous than anything in the infographic.
As I wrote in an exchange with the excellent Michelle Lin, this info graphic is horrible -- proclaiming lots of undocumented "facts" that you can't be sure about (are they pulled from the pre-work-hours reform era?) and "tips" no one can follow (such as "avoid going to the hospital during Spring Break" -- what?).
Other "pearls" just reflect reality: 50-70% of hospital admissions happen at night or on weekends! Well, hey, nights and weekends make up the majority of the week.
The chart is capped it by highlighting 5 bad outcomes across the US (world?) over the past 22 years. Does that enlighten anyone? My ED alone sees 100,000 patients a year.
The thing is, I've generally been a fan of this new wave of infographics. As Steven Davidson has pointed out, charts and graphs used to be designed with journals and powerpoint in mind; today's colorful and long infographics are built for the social media / Prezi age. And through web-surfing, I've definitely come across some nicely-distilled points in various economics and political infographics. Perhaps I like those kinds of infographics because I'm not versed enough in that field to catch the simplifications or misdirections, or to mind the lack of true citations.
Still, I think an infographic should make a succinct and compelling case, like "boost overnight staffing with more experienced providers" ... this one seems to be lashing out at all kinds of problems, from overnight staffing to residency training to preventable errors, and fails to make any compelling cause/effect relationship or implementable policy recommendation.
Worse -- if I wanted to learn more about that stat, "babies born at night are 16% likelier to die" (seriously, think about how ridiculous that number is without confidence intervals or ARR) where would I go? The Halifax Medical Malpractice Lawyer Blog? (that's one of the sources, next to WSJ and NEJM).
I just can't figure out who this infographic is trying to educate or warn. I think it's mostly a promotional tool for RN central. In the process, though, it's spreading fear and confusion. Be sure to only look at the chart during the day, when the muddled thinking and errors are less likely to harm you. - Oct 04, 11
Over email, some far-flung EM colleagues and I were discussing a case, where an elderly but generally healthy man developed a fever, went to an emergency department, had blood cultures drawn (as well as other labs, films and urine). Ultimately the old man was discharged home.
A few days later, on a weekend, a positive blood culture report (gram negative rods) prompted another ED attending on duty to call the patient at home. Over the phone, the patient said he felt fine; back to normal, no worse for wear. The ED attending considered the matter closed.
On Monday, the primary care doc reviewed the case, and, with ID, admitted the patient (who still felt fine) to the hospital for monitoring and IV antibiotics. Apparently a nastygram was sent to the weekend ED attending, as well, citing some kind of policy that gram negative rods can't be ignored.
My friend, the Canadian Doctor, commented:This is ridiculous. Because of the "unique" medico-legal climate in the US, there will never be an incentive for any physician to endorse conservative, less aggressive management. Without the support of colleagues from other specialties for anything but aggressive knee-jerk responses, patients suffer the consequences of a peer-pressured physician environment where we must all cave to the most conservative (brainless) approach. While I am comfortably protected in Canada (and its different set of imperfections, of course), I hope that this American death spiral of false logic and spineless non-decision making is arrested soon by some tort reform and financial accountability.
In the past I've really tried to shy away from policy discussions on this blog. There are already great sites for that sort of thing, and I don't want my words taken out of context or brought back to haunt me.
But I did tell my Canadian friend that his emailed paragraph was delicious enough to deserve a wider audience. With a few minor alterations, he's ok'd its appearance, here. - Sep 27, 11
Notable figures such as Atul Gawande and Captain Sullenburger have, when discussing safety in medicine, drawn comparisons from the world of airline operations. Lots of people, actually, have made comparisons to these disparate fields.
If healthcare were more like aviation, the thinking goes, there would be fewer errors, greater transparency, and more uniform ways of doing things (and thus, presumably, lower costs). Gawande and Sully both talk about the egos of doctors, who view checklists as beneath them, who view their patients and practice as worthy of exceptions to guideline-based practice, who view their gestalt as superior to cookbooks and calculators.
No doubt, that's part of the problem. But consider: New York magazine publishes a list of top doctors, but not top pilots. Lots of people brag about the acclaimed specialist they see, but no one brags about the pilot that they've booked for their trip to Paris. I think society's expectations of physicians have never been in line with their expectations of air travel. The relationship between passenger and pilot is nothing like the relationship between patient and doctor, except that we rely on pilots and doctors to get us from point A to point B safely and smoothly.
US healthcare has maddening inefficiencies and rituals. But so, too, do airlines. I'm not even talking about TSA security theater (at least, not this time). Just consider the flight attendant preamble about using your seat as a flotation device in the event of a water landing, or the rules about electronics below 10,000 feet. These always seemed to me to be put in place by cautious administrators, years or decades ago, with a "better safe than sorry" rationale that's hard to study or rescind, once put in place.
These speeches and restrictions always reminded me of the over-the-top, out-of-date rules about cell phones in hospitals. Sure, there's one confirmed case that I'm aware of, years ago, where a mobile phone caused an IV infusion pump to malfunction. But it never seemed reasonable to extrapolate from that event, to banning personal communications at a time when patients and families are most inclined to get in touch.
Recently, the IATA issued a report on passenger-generated electronic interference with flight systems. Via TechCrunch:The reported incidents were based on 125 airlines’ responses submitted between 2003 and 2009, noting that flight controls, autopilot, auto-thrust equipment, landing gear, and the communications kit were all allegedly affected by electronics use. Of course, not one of the seventy-five incidents were verified to be caused by electronic devices. Instead, the IATA reports that crew-members and pilots believed that electronics were the culprits in those cases.
In one instance, with two laptops being used nearby, the plane’s clock spun backwards and GPS readings began going off. In another example, altitude details were jumbled until the pilot asked passengers to turn off their gizmos. A Boeing advisor, Dave Carson, believes that the signals radiating from portable electronics can mess with sensors hidden in the passenger areas of a plane, and that those signals are far stronger than what Boeing considers acceptable during a flight.
I didn't know some sensors were in the passenger area, where nearby device signals could interfere. Still, the article goes on to say a true cause/effect relationship between portable electronic devices and malfunctioning sensors has not been demonstrated by any of these IATA incidents.
What I found particularly interesting were the outraged comments, in response to the "scofflow" writer who admitted to keeping his phone on during landing. He was attacked for jeopardizing the lives of everyone on every plane he's flown on. With 4000 flights a day in the US alone, and a lot of forgetful or sleeping passengers on each flight, I have a hard time believing that electronic interference poses any measurable risk. Even if all 125 citations over 6 years were really due to electronic interference, there were still no "bad outcomes" (to borrow from medical QA parlance) and the event rate, as commenters point out, was approaches zero and is far less than the odds of being struck by lightning.
Would these same outraged commenters angrily force a patient's family member to hang up their mobile phone, if they saw them talking in the ED near a stretcher? Would they yell at a car driver who's not wearing a seatbelt? Or do these commenters feel people who keep their devices on during plane takeoffs and landings are not just jeopardizing themselves, but perhaps the commenters as well?
This seems like yet another example of our attitudes and behaviors toward risks being poorly aligned to the actual danger. It's more David Ropiek's territory -- though I'm sure Sullenbuger and Gawande would agree, getting the public's perceptions to match the true hazards in aviation would make air travel a good deal more smooth and productive.
As for healthcare, it seems almost impossible to calculate how much money, time, and stress would be saved if patients' risk perceptions were brought into better agreement with true health risks. Yet I'm more optimistic that the culture of aviation -- with its transparency, uniformity, and lack of ego -- is more likely to lead to progressive policy changes and successful public education, when compared to the culture of medicine.
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Info
- Emergency Medicine Informatics ResearchMedical Practice | Greater New York City Area, USSummarySpecialties: Emergency Medicine, Informatics, Health Information Exchange, Clinical Decision Support, EDIS ImplementationExperience
- Jul 2009 - PresentAssistant Professor / Mount Sinai School of Medicine
- Jul 2009 - PresentEmergency Physician / Mount Sinai Medical Center
- Apr 2009 - PresentColumnist / EPMonthly
EducationAdditional Information-
Websites:
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Honors:Housestaff Excellence in Teaching Award, Mount Sinai School of Medicine, May 2009 Academic Chief Resident, Mount Sinai School of Medicine, Department of Emergency Medicine, May 2008
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Photos
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Recent Tracks
- From Above (with Nick Hornby) by Ben Folds
- From Above (with Nick Hornby) by Ben Folds
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- Landed by Ben Folds
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- Remind Me (Radio Edit) by Röyksopp
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- Puts Me to Work by Cate le Bon
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speaking
- Health IT, Social Networks and Emergency MedicineConsider Nicholas Genes as a speaker for your next conference.
Dr. Genes has spoken to national audiences on the topics of meaningful use of electronic health records, and the changing face of doctors-patient communication in the age of mobile apps and social networks. He also speaks on a variety of academic emergency medicine topics.
Dr. Genes is an award-winning presenter who offers evidence-based, engaging presentations for a variety of audiences, including physicians, students, health care executives and communication professionals.
