Acute appendicitis – There’s an app for that | Healthcare IT News

Radiologists can accurately diagnose acute appendicitis from a remote location with a mobile phone equipped with special software, according to a study presented Monday at the annual meeting of the Radiological Society of North America.

It’s really amazing that mobility is not seen as something that is imperative to the user experience in health care, completely underestimated as a basic need for health care applications. We’ll see a lot of these coming


Book Review – ‘What the Dog Saw – And Other Adventures,’ by Malcolm Gladwell – Review –

The themes of the collection are a good way to characterize Gladwell himself: a minor genius who unwittingly demonstrates the hazards of statistical reasoning and who occasionally blunders into spectacular failures.

Best quote I’ve ever seen on Gladwell. I’m glad he is who he is and that he brings attention to such important topics of our time. But he is frustrating to those who know better. I love the topics, love the style, but I’m way to often frustrated by the reasoning. He’ll often confuse correlation and causation and then discuss correlation and causation in the next chapter.

Does Twitter makes us smarter? Is Twitter a Complex Adaptive System? « emergent by design

Here’s where things get interesting. From a learning standpoint, there is proof emerging that using Twitter builds intelligence. A study revealed these benefits:

All of the study participants were new to Twitter and had not previously used it or any similar microblogging service…..In a relatively short period of time, the participants formed quite sophisticated peer networks…..Peer support became a key feature of this student network, with activity rising just prior to assessment deadlines or during revision for exams. Content analysis of the messages indicated clear evidence of the emergence of personal learning networks…..Twitter is also very attractive as a data collection tool for assessing and recording the student experience, with a wide range of free and increasingly sophisticated online analysis tools available.

I blogged about my own experience yesterday, and here’s more evidence from a brilliant post on the emerging system twitter and the social sphere is creating.

Is Twitter making us smarter?

Is an effective twitter network going to be a key determinant of success over the next several years?

Are we building a new layer on top of our societal cortex? A new associative ability as a society?

Will the social web save health care and the larger economy?

I’ve been using Twitter for almost a year now, and I’d say that my knowledge of my industry and related industries has acceleratand dramatically, probably 3-5x. There isn’t much big news or industry chatter that slips by with the people I follow and the information they so graciously provide. In the coming decade, sharing info online will be a strong professional advantage not just because of the economy of information you will receive in return, but because of how we connect with the participants in the knowledge economy. Your audience matters. They always have but now they’re more available.

So, too, has my social intelligence improved. I’m now connected to about half of the people that present at the major conferences, close to all of those that are using twitter. I get feedback from them daily that helps me refine and extend my knowledge base. It took a great deal of effort to get here, but it is priceless.

Which brings us to the question at hand. Reading the astonishingly cogent principles of the HIT standards committee this morning, I couldn’t help but wonder how much social media has provided the platform and the feedback to lead to principles that make this much sense? I’ve seen a lot of discussion online about what the role of the HIT standards committee should be, and I have the distinct sense that they listened. Call me an optimist by nature, but I also wonder if we are becoming smarter as as a society, in terms of people, context and information? And further, what will this will mean for health care and the economy at large?

As far as health care is concerned, the social sphere must, and will, get pulled into health care and the work that providers do. Just as sharing info professionally has and will define a large chunk of professional success going forward, sharing medical information with the right audience will lead to improved outcomes. The simple fact is that collaboration saves lives both through better communication, better coordination and better knowledge transfer across the many boundaries between various health care providers and their patients, as I’ve written before.

Today, seeing that SalesForce just launched an enterprise social app, Chatter, that will bring in a social element to the over 13,000 Sales Force apps, I can’t help but wonder what might happen if we had the same for health care. What if all applications, caregivers and patients were connected online. How fast would our understanding of medicine and the delivery of care improve? We can only hope that we’ll soon find out.

Still, I’m left wondering, will these various ecosystems connect or will we also be stuck with various silos of software, just web-based silos?

Part of the reason we haven’t seen social medicine take off yet (and part of the reason HIT hasn’t taken off) is that we can’t expect physicians  to do more work, manage more complexity or spend more money. These are significant barriers to adoption. Solutions must be simpler, more convenient and less expensive to be considered disruptive.

Sure, there are physician social networks (Sermo, et al), but relatively few are about getting actual work done. Those that are focused on getting work done ad extra steps.The ideal social/collaborative platform in medicine will be an extension of an EHR.

In order to to have collaboration and the social sphere as an extension of the EHR, we need to spend considerable time and energy working out the permissions and rights of medical information. Several articles and studies have recently documented that without sharing information beyond the traditional silos of health care, the benefits of EHRs are minimal if any. We need rights that act as a default for the society at large, and can be changed by patients.

We need a sort of creative commons for medical information. Patients must have the final say in how their information is shared, but there also needs to be a reasonable default to information sharing.

I have a hunch most people will not take the reigns on their health info unless they have clear benefits to doing so. For most people the benefits of managing health info are unclear, but the risks are readily apparent. The benefits of managing health info, possibly through tax incentives, must be clear, and the risks of sharing info must be minimized. Having a plan where people cannot be declined insurance for preexisting conditions will be a godsend to information sharing in medicine.

We need this so that doctors can collaborate more effectively. HIPAA has not helped collaboration. Collaboration is part of the fiber of the practice of medicine. Think Grand Rounds and Tumor Boards. Yet it has lacked a real patient focus using the power of the web in specific clinical cases. When physicians can collaborate about specific cases at the point of care (on some portable device) we will see incredible results.

Eventually, physicians will have EHRs at the point of care with subsets of the EHR shared withing a large community of physicians eager to share their knowledge. Why will be the incentives to sharing? As this brilliant set of presentations points out: People love to share when they have the right audience. Right now, EHRs have very little to do with sharing, they are more about process and correcting errors within a very local setting. When physicians know they have the right audience, they will be eager to share, and improve, their knowledge. Once it gets started, it’s a self-propogating cycle.

As far as the economy at large goes, nobody says it better than Juan Enriquez in this brilliant presentation. We are saddled with a mountain of debt, but we live in an open society capable of innovating quickly and rapidly increasing our collective intelligence. The collaborative web may be our saving grace in profound ways that we are only now beginning to realize from healthcare to government to everywhere. And this can only happen in a free society where there is little fear of sharing information, health-related or not.

(Thanks to all those on twitter who made this post possible by sharing information that I would likely have never seen otherwise.)


Interview with Practice Fusion’s CEO, Ryan Howard, about mobile EHRs.

I’m a believer that EHRs are going to move ever more onto mobile platforms and I’m curious what that might mean for the larger EHR market. In order to help answer that question, I spoke with Practice Fusion’s CEO, Ryan Howard.

Practice Fusion is launching mobile EHRs in Q1 of 2010, and although, Howard wasn’t as convinced as I am that mobile EHRs were the killer app for health care, he does believe that web/SaaS-based EHRs were really the only sensible option to support mobile EHRs.

Here’s the short version of the interview:
Q. How might SaaS EHR providers benefit from the shift to mobile?
“If you’re going to build a mobile (EHR) application, you essentially have three options:
1. You can build a native application that allows you to interact with the on-site system, but these are problematic because they still follow the same silo-based instance, you can’t share information among coworkers, if you’re a doctor you can’t hand off information to a nurse and you can’t pull in the power of the internet. 
2. You can have a hosted model with online access to a system, but these still need to point to a server or farm of servers somewhere. They are not a true SaaS play. Allscripts is one example. They still have the fundamental problem of not being able to share information across institutional boundaries. 
3. Or, you can have a fully hosted model on the internet that’s ideal for browser-enabled devices, that already runs web services and has the APIs developed and allows sharing of critical information in care. Building mobile applications for these systems is a natural fit.
What this comes down to is that a shift toward mobile will be a disaster for old-school proprietary client-server vendors that have their businesses built on ongoing fees because it will only bring more attention to their failures. Moving mobile means moving to web services and that just doesn’t fit with their business model or the way their companies are structured. How can they go from selling big, expensive proprietary systems to free or low-priced options? How will they convince their sales forces to promote these options?”
Q. Do you see a shift toward mobile EHRs?
“We get a lot of requests for it. It is one of our most requested features and we’ll be coming out with cross-platform (iPhone, Android, Blackberry) mobile solutions in the Spring of 2010, but I’m not 100% convinced this is the way physicians are going to want to interact with the EHR. I don’t see the same ability to interact with the same depth of information on these screens. The iTablet might be interesting, but I’m that’s not really mobile to me. It seems that will be browser-based access on a slightly larger screen, similar to netbooks.”
Q. What about your competitors?
“iChart, eClinicalworks and Allscripts I know are providing some mobile apps, but the functionality is so far limited, they have many of the problems just described and it’s unclear that people are buying.”
Q. Have you heard about Epic’s new trial with Stanford to deliver an iPhone app?
“I haven’t followed that, but I’m not overly concerned about what Epic’s doing. You look at Kaiser and what have they spent, $4 billion on Epic?
All industries have adopted SaaS in one form or another at this point. The economic imperatives are just too great to go in a different direction. Many of these legacy systems will not survive.  Unified authentication on a single platform of networks of networks with all data in real time and aggregated gives us the ability to do the things we did for our recent H1N1 reporting. There’s a huge value in being able to provide updates to the entire system automatically and do reporting across the network. This is also going to be critical for ARRA/HITECH. Practice Fusion can roll out required functionality much faster than traditional vendors.”
With these kinds of things in mind, there has been a lot of talk about secondary use of EHR data. Kaiser just received a grant to do some studies. Are you looking at secondary use of data?
“This is an area of huge interest that we are tracking, but don’t have any specific plans at this point.”

Next post will discuss the various options for implementing mobile medical applications.

EHRs and the Science of Care: This Generation’s Moon Shot?

This post was originally posted by me on the EHR Guy’s blog on Oct. 7th, and I’m reposting here for the record.

Remember 1999? Folks were promoting the Human Genome Project as the generational equivalent of the lunar landing and Columbus discovering America. Over the long term, they will likely be right, but the event itself was largely symbolic. Now we’re undergoing another major event, with little to no symbolism (certainly not enough), even though the very short-term benefits are potentially earth-shattering. I’m speaking to the potential for ARRA/HITECH in the improvement of medical care, which should be heralded as this generation’s moon shot.

Sure, I know what you’re thinking: there is perhaps no safer bet than shorting the success of HIT initiatives. Once again, it would be easy to predict failure at trying to fix a such a complex, non-adaptive  system. However, the simple difference here is that never before has anyone been able to answer the fundamental economic question of “who will pay for EHRs?” , and few have decided to pay, because it’s never been exactly clear who would stand the most to gain.

Here is what I think has been the crux of the problem as far as who could gain: For the most part, when we talk about medical records, we’re speaking to the continuity of care they can enable, which may work as a rather fuzzy, feel-good mantra, but what is too often overlooked is the science of care a national system of EHRs will enable. 

And so far, the results we are seeing indicate that even a partial success will produce stunning results. I imagine payers will be kicking themselves in years to comes asking, “Why didn’t we do this sooner?”

Exhibit A: Kaiser Colorado.  Kaiser’s Collaborative Cardiac Care Service (CCCS) “uses an electronic medical record and patient-tracking software to document all interactions with patients, track patient appointments, and collect data for evaluation of both short and long-term outcomes.” Studying over 10,000 patients has demonstrated that their integrated CCCS system has reduced mortalities associated with Coronary Arterry Disease (CAD) by a whopping 76%! Newer data suggests EHRs systems that regularly communicate with patients are highly effective at maintaining target lipid levels. Studies such as these strongly suggests that, as part of a coordinated care program, a nationwide system of EHRs may will be as historic as the lunar landing (and certainly no less difficult), but with direct and immediate benefits of millions of lives and hundreds of billions of dollars saved. As noted by David Blumenthal, the national coordinator of HIT, said earlier this month, “One thing we haven’t done is apply the scientific method in the practice of healthcare and medicine.” We as a nation have gone too long researching the mechanism of disease with far too little time spent researching the best practices in the delivery of care.

Other collaboration technology studies are beginning to show equally impressive results. A third party survey of Syndicom’s (a client) case-based physician collaboration communities have found that 90% of spine surgeons using these case collaboration tools feel they improve their ability to practice surgery and make recommendations. Within Syndicom’s community alone (over 1,000 spine surgeons), we’re talking about thousands, perhaps tens of thousands of patients with improved outcomes, reduced pain, and reduced costs on our health care system. Collaboration has been a cornerstone of medicine for centuries (think grand rounds and tumor boards), yet we are just beginning to see the benefits of web-based collaboration.

If HITECH succeeds only partially in increasing medical collaboration and communities, the $20 billion spent will be a bargain. In a nation where total medical and social costs attributed to CAD alone tops $475 Billion and affects 80 million Americans, the cost savings and life improvement potential is nothing short of spectacular for implementing a nationwide Kaiser-like CCCS system. When ten percent of patients account for 80% of all health care costs and 75% of those costs are related to chronic diseases such as CAD, the effective management of these diseases through effective health information is more beneficial than even the greatest blockbuster drug at reducing time in the hospital for high cost treatments and mortality. Savings of $50 Billion per year in CAD patients alone for a nationwide, connected EMRS is not unrealistic.

Studies such as those above suggest that we’ve been thinking about HIT the wrong way. If these technologies can improve patient outcomes so dramatically, shouldn’t they be considered part of the standard of care? Networked communication tools can improve treatments and protocols across the disease spectrum. If your cardiologist found a treatment that increased survival by 76% in all CAD patients over a 2 year period, could he be found negligent for denying the use of it? Would Medicare reimburse it? Absolutely! When you think of HIT as a method for improving treatment outcomes, it really makes perfect sense that the majority of ARRA/HITECH is funded as a CMS remibursement. The HIT portion of ARRA is a one time (hopefully) Medicare reimbursement for a systemic treatment that’s long overdue.

The Coming Shift to Mobile EHRs

The iPhone is the fastest growing consumer electronic platform in history and not just your average consumers are adopting it. 65% of physicians now have smart phones and half of these are iPhones.

What might these trends mean for EHRs? Morgan Stanley sees the mobile internet as the next big wave in the tech sector, driven by the smart phone. Something similar could be said about the HIS market: I see the mobile EHR market as the next big wave in HIS, driven largely by the wide adoption of mobile platforms by physicians.

Why are physicians choosing the iPhone? Evidence suggests that available medical applications are what is driving the use of the iPhone specifically by physicians.

There are now more than 750 iPhone applications available that are appropriate in a professional health care setting. They perform essentially 5 functions.

1. Research and reference, including patient education tools
2. Remote access to patient information when the physician is remote, eg AirstripOB.
3. Testing (eye charts and hearing tests)
4. Decision support and
5. EHRs, including iChart and AllScripts.

By far the mostly widely adopted apps are research and reference, but continued adoption is driving docs to ask for more apps on the iPhone from software vendors, including EHR and EMR vendors. PracticeFusion says this is one of their most requested updates. While historically EMR and EHR vendors have not been known for their willingness to provide requested features, with 30% of physicians planning on EHR purchases in the near term, they will no doubt exert some usability pressure on the market.

In fact, it’s already happening.

Some examples: Epic and iPhone are teaming up at Stanford medical center. iChart and Allscripts EHRs are now available at the Apple iTunes Store. In addition, Apple is rumored to be planning a focus on the health care market. Possibly to enable more EHRs on the iPhone, or possibly, a new device. As the rumors of the itablet also include rumors that the tablet will run the same OS as the iPhone, this will mean that all of the myriad of medical applications now available on the iPhone will be immediately available for the tablet, possibly in May or June of 2010. This could really drive rapid adoption of the potential for the tablet as a better form factor for health care. Although it’s still very early, 3M sees opportunity and has invested in mobile applications company Artificial Life. They will reportedly partner on mobile health and diabetes applications.

While Google’s Android phone OS may be a better platform, it simply won’t catch on without the apps to drive physician adoption. For many physicians, a smartphone without Epocrates is simply a non-starter. The one thing that might give the Android a boost is the iPhones marriage to AT&T. Unless iPhone can move onto a new carrier, apps might not be enough of an incentive for users to suffer through dropped calls.

As was noted by at the recent connected health conference, mobile medicine is less about the technology than the user experience. For physicians and EHRs, user experience means mobility above all else. EHRs are as much about collaboration (think “clinical groupware“) as continuity, and whether collaborative knowledge is in another department, another physician’s head or in a knowledge repository such as a research paper, medical dictionary or clinical decision support system, physicians need that knowledge at the point of care. Having the necessary knowledge literally “on hand” is critical.

If, as Clayton Cristensen says, disruptive change happens when new technologies are “simpler, more convenient and less expensive” (which often creates the user experience), EHRs on the iPhone or other mobile platforms will likely be very disruptive.

What’s your mobile strategy?

Next up: How SaaS EHR providers will stand to benefit from the coming wave of mobile EHRs.