Nicholas Genes, MD, PhD
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Posts
- May 23, 13
Related Articles Predictors of patient length of stay in 9 emergency departments.
Am J Emerg Med. 2012 Nov;30(9):1860-4
Authors: Wiler JL, Handel DA, Ginde AA, Aronsky D, Genes NG, Hackman JL, Hilton JA, Hwang U, Kamali M, Pines JM, Powell E, Sattarian M, Fu R
Abstract
OBJECTIVES: Prolonged emergency department (ED) length of stay (LOS) is linked to adverse outcomes, decreased patient satisfaction, and ED crowding. This multicenter study identified factors associated with increased LOS.
METHODS: This retrospective study included 9 EDs from across the United States. Emergency department daily operational metrics were collected from calendar year 2009. A multivariable linear population average model was used with log-transformed LOS as the dependent variable to identify which ED operational variables are predictors of LOS for ED discharged, admitted, and overall ED patient categories.
RESULTS: Annual ED census ranged from 43,000 to 101,000 patients. The number of ED treatment beds ranged from 27 to 95. Median overall LOS for all sites was 5.4 hours. Daily percentage of admitted patients was found to be a significant predictor of discharged and admitted patient LOS. Higher daily percentage of discharged and eloped patients, more hours on ambulance diversion, and weekday (vs weekend) of patient presentation were significantly associated with prolonged LOS for discharged and admitted patients (P < .05). For each percentage of increase in discharged patients, there was a 1% associated decrease in overall LOS, whereas each percentage of increase in eloped patients was associated with a 1.2% increase in LOS.
CONCLUSIONS: Length of stay was increased on days with higher percentage daily admissions, higher elopements, higher periods of ambulance diversion, and during weekdays, whereas LOS was decreased on days with higher numbers of discharges and weekends. This is the first study to demonstrate this association across a broad group of hospitals.PMID: 22633732 [PubMed - indexed for MEDLINE]
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Tweets
- an #EHR company pivots - to generate diagnosis-based ads? http://t.co/zyJsMsC9F0 "Mitochon has some patents around CPT/ICD targeting of ads"
- Biz Stone: Rocking Natick http://t.co/OJo1Xf5xEu
- Experts already forego market loyalty cards, pay cash for junk food http://t.co/xjOIGzOqxM The scary future of the quantified self movement
- RT @Bob_Wachter: Health records stayed safe after OKCity #tornado @modrnhealthcr http://t.co/UpD7Jbf4eU Progress since Katrina, when thousn…
- been to a few "secret" bars in #NYC but this sounds amazing http://t.co/RENuX37KEM A New York City Water Tower Doubled As A Hidden Speakeasy
- I think DSM-5 + ICD-10 = bonanza for fans of drop-down lists and creative charting http://t.co/PDsS4xolZI
- SF as world capital? @mattyglesias muses (also recall: UN charter drawn up in SF) http://t.co/ptkusy8Xmd San Francisco upzone: Vulcan logic
- amazing Tumblr collects worst #NYC room listings - my fave so far is "Loft Bed Above Closet in Kitchen" http://t.co/dn80Q2NoVn
- My favorite headline for next month's @EPMonthly is "The Neglected Orifice" - I'll leave it to the reader to speculate...
- I'm totally impressed by the effort goes into each issue of @epmonthly - it's been great being clinical editor for June issue!
- "by 1986, a third of the hospital’s beds were filled by AIDS patients." http://t.co/afPK0nbykf Remembering St. Vincent's
- Thanks, guys! Planning to be at #ACEP13 - sure we'll have lots to discuss RT @EMDocBrett: @Takeokun definitely agree
- RT @tbtam: EPIC CEO "We are not close to perfect,we’re in the middle–somewhere between perfect and abysmal."As EPIC user I agree http://t.c…
- sunset in Arizona is always enhanced with misters #twp http://t.co/iXnBgk4uxE
- RT @bittelmethis: #TWP Phase 2 begins!! @LeeGutkind doing what does best, The Yellow Test http://t.co/aivrWLZPvz
- RT @ArtKellermannMD: We have child proof medicine bottles to prevent poisonings. Why not child proof guns? #kidsngunschat
- Even the blog post was wrong! see correction at the bottom http://t.co/xXc8bTITNR Nearly one-third of all death certificates are wrong
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Posts
- Apr 02, 13
While I've been focusing on peer-reviewed writing these days (though what could be more peer-reviewed than a blog?) you can see some of my thoughts on medicine & technology at ZocDoc's new site, The Doctor Blog.
Browse their site - you'll see some familiar faces from the Grand Rounds era.
Great content, too. - Jan 11, 13
We hear it all the time: one of the benefits of EHR will be to get a handle on physician practice variation. Between states, and even within departments, we diagnose and treat the same things very differently. By switching from paper to electronic charting, analysis of practice variation becomes a lot easier (it also becomes easier to steer physicians into following guidelines).
With all this focus on how doctors do things differently, I'd like to turn the focus, however briefly, on the practice variability of government.
Specifically, why is the physician's license fee so variable, from state to state? Little Rhode Island and big Texas both charge over $1000 to issue or renew a license, while Wisconsin is just $125. Are the medical boards in high-fee states doing so much more work than the low-fee states, to justify the expense? Can I expect faster licensure and more courteous phone staff in New York ($725 every 3 years) than Illinois ($300)?
Sadly, despite these systems moving to the web and facilitating electronic applications and payments, the pricing remains as impenetrable to me as ever. I hope we physicians can set a better example than our state licensing boards do. - Dec 31, 12
No one chooses emergency medicine for continuity of care. It's undoubtedly rewarding for most doctors to help manage patients through growth or disease, but the emergency physician doesn't get the chance to appreciate a patient's development over time.
Until now.
Electronic health records at my institution now give us over 9 years of continuity. Even when I'm just meeting a patient for the first time, I can look back and see their first visit to the pediatric ED for asthma, the appendectomy from a few years ago, the gastritis visit during college break that may or may not have been related to alcohol.
For older patients, I can see the visits that described the out-of-control hypertension, the subsequent CABG and later, stents... the descent into heart and renal failure.
I get a little nostalgic to see almost-forgotten names of residents and attendings who cared for these patients, before they graduated or took other positions. It's like we were all a part of this patient's life.
Recently I re-open a patient's old chart, to show a resident an unusual EKG from a while back. I felt a pang, when my EHR alerted me the patient had died.
It's tempting to compare electronic health records to other means of keeping up with people, electronically. Research suggests social networks are changing the nature of relationships - rather than a few close friends with whom we share important news and feelings, we're instead updating a wider, but shallower, group of acquaintances with more mundane aspects of life.
While that may be true, EHR's ability to show the timeline of a patient's past care is having a profound effect on emergency medicine - where before there were discrete events, EHR is giving the semblance of an ongoing relationship. Physicians may debate whether electronic records are worth the investment, but to my mind there's no question the investment is more than financial. - Dec 31, 12
Describe electronic clinical decision support to someone outside of healthcare.
They'll probably start conjuring images of Watson or Clippy - an automated guide who incorporates clinical data and provider habits, to offer suggestions to improve care.
And yet, despite advances in computing power and machine learning, and a massive push to adopt electronic records, clinical decision support remains stuck - so primitive that even 90's-era Clippy seems wise and helpful in comparison.
I think there are many culprits for this, but a big reason clinical decision support lags is that it's been hijacked by well-meaning hospital administrators. Instead of nudging doctors into learning new things, dosing meds appropriately for complex patients, ordering the proper tests, so far it's been mostly inane reminders written by bureaucrats. Instead of helping doctors make decisions, decision support has been used to boost compliance on various metrics of interest.
You see, when compliance with a federal measure at your institution is at 97%, steps need to be taken to get that up to 100%. And those steps often involve popups, and "hard stops" that disrupt your progress through a task, even if it doesn't quite apply to this particular patient or that particular situation.
Of course these metrics are important, and if you don't score well, CMS reimbursement could be withheld, and your institution will look bad on HospitalCompare.
But by hijacking an EHR's clinical decision support system to boost administrative goals, you've conditioned a generation of providers to ignore CDS popups and warnings. The alerts are often not really relevant to providing the best care. They're often not appropriate to the situation. And they get really annoying to busy physicians, when they delay appropriate care and add to their workload.
What's happened is that modern decision support has taken the most inquisitive, hardworking, and self-sacrificing group of people you're likely to meet, and turned them off to the idea that the EHR can be a teaching tool.
And I don't think there's a popup alert to reverse that clinical situation. - Dec 31, 12
I had an idea for an absurd indie comic strip about Corrective Action Plans - those in-depth multi-departmental administrative remedies that are developed in response to bad outcomes, dropped balls, missed communications. Over time we've taken to calling them CAPs.
The comic would follow the adventures of CAP'n America. He'd never arrive in time to save the day (in fact, he only worked business hours) but he would be sure to show up after a traffic accident or crime scene investigation and make sweeping pronouncements about how workflows will have to change.
Wouldn't that make for funny reading?
I still consider myself relatively new to medicine, but I think I've been around long enough to see the culture morph from closed-door, M&M-style reviews of cases... to CAPs. Maybe this is progress - certainly, it's change - but it's a far cry from the data-driven, common-sense laden discussions we don't seem to be having often enough.
CAPs seem like an outgrowth of Six Sigma mindset - getting to a defect rate of under 3 per million. Of course, when your ED sees half a million patients over five years, and a particular bad outcome happens once during that time, administrators don't like to be reminded that the failure rate is actually well in line with six sigma. They want a CAP, so that it never happens again.
Never is a powerful word in medicine. And "never" always comes with a cost, though sometimes it's not easy to measure that cost.
So what if the corrective action plan - to prevent that one really rare foulup - makes routine care a little bit worse? Length-of-stays and time-to-dispositions become a bit longer as doctors and nurses implement a new workflow. The delay is ok because it's all for a good cause, right?
But whenever we agree to a CAP - agree to revise our rules in response to a rare, awful event, rather than to address a routine awful events like extended boarding times or delays in prompt care, the process is stacked against us from the beginning. It's stacked against practitioners and against the vast majority of patients, too. And it becomes impossible to truly improve care.
How can we correct this process? - Jul 31, 12
I never thought I'd embrace dictation.
For emergency physicians, dictation varies department to department. Some require it, some make it an option, and for others it's an exotic luxury. For my part, I'd seen too many errors in transcription and watched too many colleagues struggle with a phrase over and over to get enthusiastic about it. I never considered investing in dictation software for my own workflow, since I'm not a bad typist and it wasn't something my department was offering to us.
Along came iOS 5 for the new iPad, and suddenly I found myself dictating emails and short messages. Dictation seems like a natural fit for the iPad, since I can't type particularly quickly on it, and I'm not writing or editing long pieces on it.
Plus, I enjoy Apple's style of dictation, where my phrase or sentence remains invisible as it's transported to their servers for transcription. This process has been derided as a step backward, by folks who are used to desktop dictation software showing your transcription word-by-word, on screen. But mentally checking each word can be its own distraction, and disrupts flow. Plus, Apple's way of doing dictation seems more like a fun gamble to see if they got the whole sentence correct.
So, when OS X Mountain Lion came out this week, with its Siri-like dictation feature, I finally gave computerized dictation a chance to help with my charting.
First, a couple of concessions:HIPAA -- Mountain Lion, like iOS 5 before it, sends your voice to Apple servers via the internet. Unlike other web-based dictation services that ensure and advertise HIPAA compliance, Apple offers no such guarantees. At least one iPad-based EHR vendor is recommending to exclude PHI (protected health information) in any dictated charts, and that seems like a wise course at this time.
Citrix -- I access my hospital's health records via a Citrix virtual desktop inside my browser. While Citrix can handle my trackpad movements and keyboard input, invoking dictation leaves it confused (nothing happens in Safari; in Chrome, the dictation icon appears on the edge of the window and fails to put text in the patient's chart). I'm forced to dictate onto a scratchpad and paste it into the chart.
So, no, it's not ideal. But after a dozen or so attempts, I have to say, it's not bad, either. My biggest concern going into this - that medical terms would go unrecognized or mis-transcribed - has not been borne out (or at least, I haven't minded the corrections).
Still, I'm finding some chart elements are more suited for typing than dictating:Easier to just type: "Complains of URI sx, sore throat and rhinorrhea, denies rash, no ear pain, no neck stiffness, no f/c no cough no SOB no CP no abd pain no dysuria no pedal edema."
Easier to dictate: "I discussed my differential and diagnostic plan with the patient, answered questions, and agreed to share her results with her primary care doctor when available." (Then again, some of the paragraphs or templates that I repeatedly use in charting are already encoded in my EHR's system for frequently regurgitating blocks of text.)
So, if the point of this is efficiency, I don't think OS X dictation can save me time - yet. Maybe with a bit of practice and some more judicious use, it can. But I think dictation's real value to me will be breaking up the monotony of typing up an inbox full of charts. And that's something worth talking about. - May 21, 12
I always liked the idea of the original Ambient Orb -- a device that just sits there, but changes color based on metrics of interest to you. Bad weather approaching? It turns red. Stock market up? Green.
CIO John Halamka famously placed one on Paul Levy's desk, to help the CEO effortlessly monitor the ED waiting room situation.
But colors can only express so much - I think the Ambient Orb could just communicate a few things like "Good" or "Bad" or "Really Bad" on whatever you programmed it to care about.
What really held me back, though, was the idea of spending $150 on a ball that passively monitors some situation, when more "active" monitoring was never more than a few clicks away.
Then came Twitter.
I've given Twitter and its users a lot of grief over the years, even as I've come to spend more time with them than any other social network. But Twitter seems built around the concept of passive monitoring.
Skimming a Twitter feed is a nice way to check in with friends and colleagues, and pick up some news or useful links. I'm getting comfortable with the idea that Tweets are a workable proxy for thoughts, and also starting to accept that software can accurately categorize Tweet content and deduce sentiment.
So maybe a Twitter feed isn't the best way to survey the hive mind.
The Listening Machine (hat tip: the Verge) is a project to follow 500 UK Twitter accounts and figures out the positivity or negativity (or neutrality) of Tweet content, as well as categorize the Tweets into one of eight subjects. The Tweets are then converted to music.
It seems to me that music might be better than color, to reflect the complexity of the Twitter stream. I've been listening on and off for the past few hours, and can pick up without much difficulty when the overall sentiment turns negative, and when the rate of tweets pick up. I wonder if it's possible to tell if the stream is featuring ponderous topics or light chitchat - or if the current discussion is weighted toward politics, or the arts.
The idea of catching a snippet of music and knowing the mood, engagement, and to some extent, the content of conversations in an area, is very appealing, though I think DJs already make something like this possible, when reading a crowd, picking up a vibe. Twitter analytics will just make the crowd's thoughts and feelings more quantifiable. - 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.
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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
Additional 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
- Anniversary Song by Cowboy Junkies
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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.
