Lub-SHHRRR. Lub-SHHRRR. Lub-SHHRRR.
“Can you hear it?” she asked with a smile. The thin, pleasant lady seemed as struck by her murmur as I was. She was calm, perhaps amused by the clumsy second-year medical student listening to her heart.
“Yes, yes I can,” I replied, barely concealing my excitement. We had just learned about the heart sounds in class. This was my first time hearing anything abnormal on a patient, though it was impossible to miss—her heart was practically shouting at me.
Her mitral valve prolapse—a fairly common, benign condition—had progressed into acute mitral regurgitation. She came to the hospital short of breath because her faulty valve was letting blood back up into her lungs.
Though it was certainly frightening, surgery to fix the valve could wait a few weeks. But before doing anything, the surgical team wanted a picture of the blood vessels in her heart.
If the picture showed a blockage, the surgeons would have to perform two procedures: one to fix the blockage, and another to fix her valve. If her vessels were healthy, though, the surgeons could use a simpler approach focused just on her valve.
So she came to the interventional cardiologist who was teaching me for the day. Coronary angiograms are the interventionalists’ bread-and-butter procedure, done routinely to look for blockages and to guide stent placement. They involve snaking a catheter from the groin or arm through major blood vessels and up to the heart.
Under fluoroscopy (like a video X-ray), the cardiologists shoot contrast medium into the arteries, revealing the anatomy in exquisite detail.
The images are recorded electronically and accompanied by the cardiologist’s interpretation for anyone else who opens her medical record.
Though routine, these catheterizations aren’t trivial. Whenever you enter a blood vessel, you introduce the risk of bleeding and infection. Fluoroscopy is radiation, and contrast medium can damage the kidneys. And let’s not forget cost—reimbursing the interventional cardiologist, a radiology technician, and nursing staff costs Medicare almost $3,000 per case.
So I asked the cardiologist if such an invasive approach was really necessary.
Continue reading “Actually, High-Tech Imaging Can Be High-Value Medicine”
Filed Under: Tech, THCB
Tagged: angiograms, Costs, CTA, FutureMed, Imaging, Interventional cardiology, Karan Chhabra, MRI, Quality
Mar 6, 2014
There’s that line about art, “good artists copy, great artists steal.” There’s some debate about if Picasso said it first, but most of us geeks know it from Steve Jobs.
Often, I see things from companies and industries outside of healthcare —processes, products, best practices —which inspire me. I like these little inspirations because they often aren’t rocket science, but nonetheless fuel some creative thoughts about their applicability in healthcare.
The other night, around 9:00 PM on a holiday Monday, I ordered some obscure aviation stuff from Amazon. I needed a new headset, a leg-mounted chart holder, a paper calculating tool called an E6B computer and a portable canister of oxygen.
I have Amazon Prime, their subscription service which provides expedited 2 day shipping, so I expected to see my stuff on Wednesday afternoon. I was blown away when there was an Amazon box outside my door by 9:00 AM the next morning, Tuesday.
A box showed up early, big deal, right?
Here’s what I think happened and why I’m so impressed. I had been browsing for some aviation stuff for a few days. Amazon clearly knows and tracks my window shopping. It’s how they suggest items when you come back to the site.
I believe they preemptively moved some of those obscure aviation items to the closest distribution center in anticipation of my purchase. In fact, Amazon was awarded a patent for exactly that process last week.
By predicting my purchasing behavior, Amazon was able to beat my expectations for delivery – a known threat to their model is the instant gratification of local retail – and get my package to me in 12 hours.
We’ve got a lot of data in healthcare. That’s to the lagging but persistent implementation of electronic medical records, doctors and health systems are beginning to apply some big data science to their patient populations. For instance, any credible EMR can tell a physician how many of her patients have asthma.
More advanced systems, including bolt on solutions can look at disease panels and cross sample against last visit date. Mr. Smith, we see it’s been a year since your last visit, how’s your arthritis? Can we schedule you and appointment with Dr. Jones?
Continue reading “Amazon.com as a Delivery Model for Population Health”
Filed Under: Tech, THCB
Tagged: Amazon.com, Innovation, Nick Dawson, Population Health
Feb 27, 2014
Throughout the world, companies are embracing mobile devices to set customer expectations, enlist them in satisfying their own needs, and get workers to adhere to best practices. An effort under way at the Mayo Clinic shows how such technology can be used to improve outcomes and lower costs in health care.
Defining the care a patient can expect to receive and what the road to recovery will look like is crucial. When care expectations are not well defined or communicated, the process of care may drift, leading to unwarranted variation, reduced predictability, longer hospital stays, higher costs, poorer outcomes, and patient and provider dissatisfaction.
With all this in mind, a group at the Mayo Clinic led by the four of us developed and implemented a standardized practice model over a three-year period (2010-2012) that significantly reduced variation and improved predictability of care in adult cardiac surgery.
One of the developments that germinated in that effort was the interactive Mayo myCare program, which uses an iPad to provide patients with detailed descriptions of their treatment plans and clinical milestones, educational materials, and a daily “To Do” list, and to report their progress and identify problems to their providers.
Continue reading “How Mayo Clinic Is Using iPads to Empower Patients”
Filed Under: Tech, THCB
Tagged: cardiology, Costs, David Cook, iPad, Jeffrey Thompson, Joseph Dearani, Mayo Clinic, myCare, patient empowerment, Sharon Prinsen, Tech, Value
Feb 26, 2014
If you are a CEO or COO of a health care organization, and your IT people have been trying to get your attention, it’s time to have a serious sit-down with them.
If they haven’t been trying to get your attention, it’s time to have an more serious sit-down with them, complete with charts and graphs and arrows on fip charts.
Here’s why: Remember in November it was revealed that the Target retail chain’s computer systems were compromised? Some 70 million names, home addresses and phone numbers were stolen (pretty good raw material for identity theft) and 40 million credit card numbers.
It has turned out since then that some two dozen other companies, including Neiman-Marcus, the Michael’s arts-and-crafts chain and the White Lodging Services hotel management firm, have been hacked in similar ways, with the attackers software sitting in the companies’ servers, credit card machines and cash registers often for months before they were detected, sucking down every transaction, every bit of data moved about.
Hey wait, you say, I have every confidence in our computer security. Why we passed a security audit just recently.
Heh. So did Target — just before they discovered the break-in. They got a clean bill of health, and the auditors failed to find the malware installed on every server, every credit card terminal, every cash register.
Why? Because the attackers have gotten way more sophisticated, and they used new techniques and methods of entry. You can now buy ready-made hacking software designed to do this on the Internet for less than $1000.
Here’s the kicker: Target has security guards at the doors, it has those beeper tags on small high-value items so you can’t sneak them out without paying for them, it has burglar alarms — but the perps in the biggest heist in the company’s history entered through the thermostat.
Got that? The thermostat.
Continue reading “Why Healthcare Should Be Worried About the Target Cyber Attacks”
Filed Under: Tech, THCB
Tagged: cyber attacks, HIT, information security, Joe Flower, Target
Feb 11, 2014
Let’s get the disclaimer out of the way:
We love Uber.
As physicians with roots in the Bay Area, we use Uber all the time. The service is convenient, (usually) swift and consistently pleasant. With a few taps of a smartphone, we know where and when we’ll be picked up — and we can see the Uber driver coming to get us in real time.
When the vagaries of San Francisco public transit don’t accommodate our varying schedules, it’s Uber that’s the most reliable form of transportation. (It might be that we like having some immediate gratification.)
So when we caught wind of the news that Uber’s founding architect, Oscar Salazar, has taken on the challenge of applying the “Uber way” to health care delivery, there was quite a bit to immediately like. From our collective vantage point, Uber’s appeal is obvious. When you’re feeling sick, you want convenience and immediacy in your care — two things Uber has perfected.
And who wouldn’t be excited by the idea of keeping patients out of overcrowded emergency rooms and urgent care waiting rooms? The concept of returning those patients to their homes (where they can then be evaluated and receive basic care) seems so simple that it’s brilliant.
Continue reading “Uber for Health Care?? Not So Much.”
Filed Under: Tech, THCB
Tagged: Ali Ansary, Ali Khan, consumer driven health, Innovation, Iora Health, One Medical Group, primary care, Startups, Tasce Bongiovanni, Tech, Uber
Feb 6, 2014
I’ve been thinking about EMRs, electronic medical records, lately. It’s a subject, despite some professional experience, I don’t feel particularly close to. In fact, if anything, they are a source of consternation.
As an industry insider, I see them as an expensive albatross around our collective neck. As a human centered design advisor, I see them as an encumbrance for both providers and patients.
And, as a patient I see them largely as an opaque blob of data about me with a placating window in the form of a portal.
Which makes me wonder, am I obsessed with EMRs lately?
One of the reasons is certainly my personal interest in technology. And, while I don’t work in health IT, it’s natural to draw some connections. For instance,Wikipedia is consistently in among the top 10 most visited internet sites ( it is currently number 6 ).
And, say what you will about citing Wikipedia, but a 2010 study found it as accurate as Britanica.
Google trusts Wikipedia enough to use it as the primary source for its knowledge graph cards; and we’ve all settled a bar bet by finding some fact where a Wikipedia article is the canonical answer.
The secret sauce for Wikipedia is in it’s roots. Literally, the root of its name, wiki, describes the underlying structure. Wikis were the internet’s a solution to knowledge bases – large repositories of information about a process or thing. Companies had been using knowledge base software for years. Traditionally, a central maintainer, often a sort of corporate librarian, curated information, such as common answers to customer questions, so customer service reps could find it quickly.
Wikis democratize the knowledge base by allowing anyone to edit an entry. If you work for a company which sells widgets and you discover a new way to service the widget, you simply amend or append to the record in the corporate wiki. But what about the corporate librarian, they all cried. Except, no body cried.
It turns out, the network effect and the wisdom of crowds produce richer, more accurate databases of knowledge when the literal barrier to entity is removed. Make it easy for anyone to input knowledge, and the database and its accuracy grow.
And so it came to be, since anyone can edit almost any entry in the largest encyclopedia the world has ever known, Wikipedia is remarkably current and accurate.
So I wonder…what if medical records worked like Wikipedia?
What if, my record lived on some commonly accessible platform; not open to anyone, but accessible by my providers and I? Maybe we have to do some kind of online handshake to mutually access it.
What if we could both edit the record, at the same time? My doctors could put in their notes and I could add my own. Or I could edit theirs. And they could edit mine. Continue reading “What If EMRs Worked Like Wikipedia?”
Filed Under: Tech
Tagged: Design, EMRs, Nick Dawson, Privacy, Wikipedia, Wisdom of the Crowds
Feb 5, 2014
I recently had the privilege of becoming a Google Glass Explorer. Basically, this means I walk around with a funky pair of glass frames and look strange – even for an urban hospital setting.
The Glass has a built in camera, and a small display that you can see with numerous apps ranging from GPS navigation to searching the Web. As cool as this the technology is – is there any utility in the healthcare setting?
There is the capability of video chat, where a consulting physician can see what I would be seeing in the operating room, and tell me what I may be looking at and what to do next. Pristine Eyesight, based in Austin Texas, is trialing this use of Glass in University of California, Irvine. Applications for nursing are being developed as well. Yet will this truly impact quality? I am not sure.
Yet one thing that intrigues me about the Glass is the perspective given when using the video function. I recorded some small surgical procedures and reviewed the video afterwards. I watched where I placed my hands, how I held the needle driver, where I took my bites, and in general – what I looked at during the case.
I felt like an NFL Coach reviewing game tape. For the first time in my surgical career, I was able to really see what I did, a perspective that I had never before experienced. This lightweight device with built in eye protection was far more comfortable than any helmet-cam I had used, and the line of sight was right in tune with my visual field. So I began thinking – is there a way this tool can improve outcomes in healthcare?
According to the American College of Surgeons, almost 5,000,000 central venous catheters are placed annually in this country. Complications including placement failure, arterial puncture and pneumothorax range from 15-33% in numerous studies. So how is this common procedure taught?
The classic “watch one, do one, teach one” methodology has been modified over the years. Now, after watching a few lines placed, house staff must perform a certain number of central line placements (usually 5) under the supervision of a senior resident, fellow or attending. Once the appropriate number is reached, the trainee is “competent” to perform the procedure on his or her own. Yet are they truly competent? Perhaps the high complication rates result from a flaw in this classic teaching methodology?
Continue reading “Google Glass: A Paradigm Shift in Assessing Procedure Competency?”
Filed Under: Tech
Tagged: David Stein, Google Glass, Maintenance of Certification, Patient Safety, PBETs, Quality, Surgery, Tech
Feb 5, 2014
For the last five year or so, digital health has been the Rodney Dangerfield of investment sectors, getting more attention than respect, and garnering more page views than dollars.
However, two important events reported in the last several days suggest all this may be about to change.
First, Fortune’s Dan Primack broke the news on Saturday that Castlight Health — a startup co-founded by U.S. Chief Technology Officer Todd Park in 2008, with the intention of providing increased transparency to healthcare costs – has secretly filed an IPO; an astonishing valuation of around $2B is anticipated.
That’s both impressive growth and serious money, and suggests it’s possible to win – and win big – in digital health.
Second, two complimentary reports from last Friday collectively suggest that Apple is starting to take healthcare very seriously.
For starters, the New York Times reported that Apple executives met with the FDA in December 2013 to discuss mobile medical applications.
In addition, 9to5Mac, a website devoted to “Apple Intelligence,” claimed that the next version of the iPhone operating system, iOS8 – slated for release later this year – will introduce an application codenamed “Healthbook” that is “capable of monitoring and storing fitness statistics such as steps taken, calories burned, and miles walked,” according to 9to5Mac.
Continue reading “Apple Said to Weigh Digital Health Play”
Filed Under: Tech, THCB
Tagged: Apple, Castlight Health, David Shaywitz, digital health
Feb 3, 2014
As Meaningful Use 2014 EHRs come online this winter, clinicians across the country gain access the host of new features included in the MU 2014 Certification Requirements.
In this post, we’ll dig into one of these features: EHR-based secure e-mail capabilities that operate using the “Direct Project” specification. (If you’re new to this world: when you hear “Direct Project,” you should think “secure e-mail for healthcare.”)
It’s a party!
In theory, giving every clinician in the country a secure e-mail inbox ought to enable something amazing (and amazingly familiar, for anyone who has used e-mail outside of healthcare): the ability to converse electronically, back-and-forth, in one-on-one or one-to-many discussions with… well… whomever you choose.
… but not everybody’s invited
Unfortunately, the practice hasn’t caught up to the theory. EHRs provide restricted inboxes that allow messaging to some recipients but not others. Why? It comes down to “trust,” which is a broad topic that we’ll treat only glancingly, where it intersects with the technology.
One of the requirements for Direct Project messaging is security, which means (among other things) that messages must be encrypted as they travel. To properly handle encryption, the sender’s EHR software (or Health Information Service Provider) needs to reliably discover the recipient’s cryptographic certificate, extract a public key from that certificate, and use that public key to encrypt each message before sending it out over the wire.
So far so good.
Continue reading “Teach Your EMR to Do Email? Impossible!!?! Unthinkable??? Maybe Not”
Filed Under: Tech, THCB
Tagged: API, Boston Children's Hospital, Direct Project, EHR, HIT, Interoperability, Joshua Mandel, Meaningful Use Stage 2, SMART platform
Feb 1, 2014
The Cleveland Clinic is by far the best provider of cardiac care in the nation. If you have cancer there is no better place to be than Texas. Johns Hopkins is the greatest hospital in the America.
Why? Because US News and World Report suggests as much in its hospital rankings.
But which doctors at the Cleveland Clinic have the highest success rates in aortic valve repair surgeries? What are the standardized mortality rates due to cancer at University of Texas MD Anderson Cancer Center? Why exactly is Johns Hopkins the best?
We don’t have answers to these types of questions because in the United States, unlike in the United Kingdom, data is not readily available to healthcare consumers.
The truth is, the rankings with which most patients are familiar provide users with little. Instead, hospitals are evaluated largely by “reputation” while details that would actually be useful to patients seeking to maximize their healthcare experiences are omitted.
Of course, the lack of data available about US healthcare is not US News and World Report’s fault – it is indicative of a much larger issue. Lacking a centralized healthcare system, patients, news sources, and policy makers are left without the information necessary for proper decision-making.
While the United Kingdom’s National Health Service may have its own issues, one benefit of a system overseen by a single governmental entity is proper data gathering and reporting. If you’re a patient in the United Kingdom, you can look up everything from waiting times for both diagnostic procedures and referral-to-treatment all the way to mortality and outcome data by individual physician.
This is juxtaposed to the US healthcare system, where the best sources of data rely on voluntary reporting of information from one private entity to another.
Besides being riddled with issues, including a lack of standardization and oversight, the availability of data to patients becomes limited, manifesting itself in profit-driven endeavors like US News and World Report or initiatives like The Leap Frog Group that are far less well-known and contain too few indicators to be of real use.
The availability of data in the United Kingdom pays dividends. For example, greater understanding of performance has allowed policy makers to consolidate care centers that perform well and close those that hemorrhage money, cutting costs while improving outcomes. Even at the individual hospital level, the availability of patient data keeps groups on their toes.
Continue reading “Why Transparency Doesn’t Work.”
Filed Under: Tech, THCB
Tagged: Alexander Chaitoff, consumer driven health, Data, Hospital rankings, NHS, Patient Safety, Transparency, US News and World Report
Jan 30, 2014