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What if the president worked like doctors today?

What if the president worked like doctors today? | Healthcare and Technology news | Scoop.it

Perhaps doctors should be more like the president.

After all, we also carry the ultimate responsibility for our constituents, even though we, too, have team members who do part of that work.

The way I understand things to work at the White House, those other team members collect, review and prioritize the information the president needs in order to manage his, and all our, business.


That is how things used to work in medicine, too, before computerization revolutionized our workflows. Nurses, medical assistants or secretaries would open the mail, gather the faxes, look over the lab and x-ray reports and put them on physicians’ desks in a certain order. Highly abnormal or time-sensitive information would be prioritized over routine “signature needed” forms, and in my case, essentially normal reports on patients already scheduled to be seen within a few days wouldn’t even reach my eyes until the patient appointment.

Computers changed all that.

Now, most of the information goes straight to the doctors’ inboxes, unseen by other human eyes in the office. This is said to be faster. It is, to a degree, in the sense that the information leaves the laboratory or the x-ray department faster via their Internet-connected computers. But in the typical medical office, we have now turned decision-making doctors into frontline mail sorters and de facto bottlenecks of routine information.

The average doctor sees a different patient every fifteen minutes and the medical assistant rooms patients, takes vital signs, inputs visit information into the EMR and listens to voicemails, which are turned into physician emails. At the same time, the doctor’s electronic inbox is continually filling up with lab reports, x-ray results, consultation reports, electronic prescription refill requests, emails from case managers, and messages from counsellors and other care team members to please read and respond to their issues.

So when does the doctor check his or her inbox?

Between patients is the way many people imagined this system to work. But, how much time do we have between all those back to back fifteen-minute patient encounters? And how do we prioritize in those precious moments between the various types of new information waiting for our review?

Most EMRs color code urgent or abnormal reports, but when it comes to standard laboratory panels, normal patients statistically have 5 percent of their results outside the normal range without being sick, so the majority of complete blood counts and comprehensive metabolic profiles show up red, whether they contain panic values or just statistical noise.

Where does a doctor even begin a two-minute dash through their overflowing virtual inbox?

By lunchtime, or after the last patient visit is over, we dive into the information that has been waiting all day, speedily delivered but bottle-necked for hours while we have been seeing patients.

Imagine if the White House IT department instituted a similar workflow for the president: After a day of speeches, audiences with foreign dignitaries, ribbon cuttings and baby kissing, he has a few minutes before the state dinner, and hastily types in his multiple passwords on the executive computer.

A hundred messages await. One of them contains information about hostile troop movements on our border, another a ransom demand from extremists threatening to blow up our embassy in a faraway land, but most of them are routine missives, reports and requests marked “urgent” in hopes of grabbing the president’s attention.

Is that any way to run a country? No, and any such proposal would surely be vetoed by the commander in chief. But that is exactly how information is managed in today’s medical office, on the front lines of primary care.

Tick-tock, doc! Three patients are waiting, no more time for refills, emails or test results, urgent or not.

And stop reminiscing about having a secretary. Who do you think you are? The president?


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Gilbert C FAURE's curator insight, January 14, 2015 8:52 AM

Most EMRs color code urgent or abnormal reports, but when it comes to standard laboratory panels, normal patients statistically have 5 percent of their results outside the normal range without being sick, so the majority of complete blood counts and comprehensive metabolic profiles show up red, whether they contain panic values or just statistical noise.

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Your keys to safer, even more secure healthcare cloud services

Your keys to safer, even more secure healthcare cloud services | Healthcare and Technology news | Scoop.it

In my last HealthBlog post, I made the case that we need to focus more on simplicity in healthcare and health IT. Simplicity should be the watchword for solutions in 2015. Thus far, many technology, business and delivery system solutions in the healthcare sector seem to be making life harder instead of better. Isn’t technology supposed to help set us free?

I think cloud computing and storage falls into the category of something that should make health IT solutions better, more scalable, easier to manage, easier to use, and less costly. Now, I’ll admit that when the world first started talking about cloud computing for healthcare, I was a bit of a skeptic. However, I also know that both IT leaders and clinicians have long been seeking solutions that don’t take a basement full of servers and a large staff of IT professionals to manage. “Plug and Play” is a much better strategy for healthcare if you can find it. For that reason alone, health customers around the world have been migrating more and more of their IT to the cloud. The cloud delivers greater simplicity and helps lower costs.

Of course in healthcare, especially where personally identifiable health information is at play, you can’t just focus on simplicity without paying a whole lot of attention to privacy and security. If anything keeps healthcare organizations at distance from considering public cloud solutions for their IT needs, it is concerns about that. Many of those concerns can be addressed by working with IT providers that are fully HIPAA aware and willing to sign Business Associate Agreements (BAA) with their clients. But I think health organization IT leaders are seeking even more assurance than that when they turn over their precious data for safe keeping with a public cloud services provider. They are also seeking world-class tools to help manage the services and data they are trusting to the cloud. That’s why today’s announcement from Microsoft is good news for hospitals and health organizations. Forgive me if this is a bit techie, but I know IT professionals will fully appreciate the news about something we are calling Azure Key Vault.

Azure Key Vault helps customers safeguard and control keys and secrets using a Hardware Security Module (HSM) appliance in the cloud, with ease and at cloud-scale. Key Vault can be configured in minutes, without the need to deploy, wait for, or manage an HSM and has a single programming model across HSM-protected and software-protected keys.

This makes it easier and more economical for customers to encrypt sensitive data, sign certificates, and safeguard secrets in the cloud. For example, with Key Vault, customers can easily encrypt a SQL Server Virtual Machine with TDE (Transparent Data Encryption) using the SQL Server Connector available for Key Vault. Furthermore, customers can deploy an encrypted Virtual Machine with CloudLink SecureVM with the master keys in Key Vault.

So, there you have it. One more reason for hospitals and healthcare systems to turn to the cloud to simplify what they do and help IT departments focus more on their organization’s core business (patient care) and less on projects to maintain complex IT infrastructure and storage.

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Competition helped innovate computers: Can it do the same for...

Competition helped innovate computers: Can it do the same for... | Healthcare and Technology news | Scoop.it

My lifetime has spanned many of the important developments in the Age of Computers. Back in 1969 when I entered college, I was a frequent visitor to the Kiewit Computing Center, the lair of a GE-635 computer that filled several rooms. Students had access to the computer via noisy teletypes and a multiuser operating system known as Dartmouth Time Sharing. We wrote simple programs in BASIC, a language created by two of the Dartmouth professors, John Kemeny and Tom Kurtz.  In 1969 even the hoary old operating system Unix was still a year or two in the future. There have been huge changes in computers since then. The smart phone I carry in my pocket today is light-years more powerful than that huge old-time computer.  It has been an interesting journey from those distant days to the present.


With the 1980s came the personal computer. Microcomputers they were called then, to distinguish them from the previous generation of minicomputers (which were about the size of a refrigerator). The Apple II was a breakthrough system, followed by the more business oriented IBM PC. There were other systems from various companies, some of which don’t exist anymore. Many of the systems were incompatible with each other, so special versions of software were required for each system. Microsoft’s MS-DOS, a variant of another disk operating system called CP/M, won the operating system battle, and eventually all PCs were pretty much interchangeable, running MS-DOS. Apple was the outlier, hanging on to a small market share after abandoning the Apple II and Steve Jobs. The Macintosh, incorporating a graphical user interface (GUI) that was ahead of its time, was the inspiration for Microsoft Windows 95, and through the 90s the GUI became dominant. This was also the era of the rise of the Internet and the Dotcoms. Microsoft put Internet Explore in Windows, making it difficult to install other browsers, leading to Internet browser pioneer Netscape going out of business and anti-trust suits against Microsoft. Desktop PCs were dominant. Laptops were fairly primitive and clunky. Microsoft was at the height of its hegemony.

Then along came the millennium, and with the iPod, Apple, now back under the direction of Jobs, made a complete turnaround. Since then we have seen a revolution in computing with the introduction of mobile computing: smartphones and tablets. This is disruptive technology at its finest. The playing field and the rules of the game have changed since the 1990s, when Microsoft was dominant. Apple is a major player as is Google. Apple has succeeded because of tight integration and control of both hardware and software. Google went the route of web-based applications and computing in the cloud. Microsoft, the least nimble of the three, has struggled. Giving Windows a facelift every few years and expecting everyone to upgrade to the new version doesn’t cut it anymore. More and more people are using their phones and tablets as their primary computing devices, platforms that for the most part are not running Microsoft software. Microsoft is putting all their eggs in the basket that predicts that laptops and tablets are going to converge into a single device. I’m not sure they are wrong. Laptop sales have fallen.

But I personally still see tablets as devices to consume content (like read eBooks and email, and browse the web), whereas for creation of content (writing blogs like this one, or programming) a laptop is far easier to use. So I end up using both. Apple seems to realize that at least for now both devices play a role, and so they have two operating systems tailored for the two classes of device. Yet their upcoming versions of Mac OS and iOS also show signs of convergence. Clearly having one device to do both jobs would be nice; I just can’t envision what this device would look like.

So competition is back in the computing business, which is good. There are all sorts of directions computing can go at this point. There are a lot of choices. There have been a lot of changes. App stores with small, free or inexpensive apps compete with the old paradigm of expensive bloated, monolithic software programs. It seemed for a while that web-based apps would dominate. These are apps that run in a browser and so are platform-independent. Good idea, especially for developers who only need to write the code once. But despite being a good idea, this is not what consumers want on their smart phones and tablets. They want native apps on each platform. So the developer (I include myself here) is forced to write two versions of each app: one in Objective C (and soon in Apple’s new Swift language) for iOS, and one in Java for Android. Oh well, such is life.

Obviously all these changes have affected health care as well. The Internet of Things — the linking together of smart devices — shows great potential for application to health care. Not only can we monitor our individual activities with devices such as FitBit, but we also have the potential to link together all those “machines that go ping” in the hospital. The hemodynamics monitors, the ventilators, the ECG machines, and so on could be all accessible by smart phone or tablet. Integration of health care technology and patient data is certainly feasible, but, like everything else in health care, innovation is bogged down by over-regulation and the vested interests of powerful players who certainly don’t welcome competition. I hope this situation eventually improves so that health care too can take advantage of the cutting edge of the technological revolution we are experiencing today.



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Epic-IBM DoD EHR Modernization Award Bid Making Progress | EHRintelligence.com

Epic-IBM DoD EHR Modernization Award Bid Making Progress | EHRintelligence.com | Healthcare and Technology news | Scoop.it

Epic Systems and IBM continue to strengthen their pitch to land the $11-billion Department of Defense (DoD) EHR modernization award  with the formation of an advisory group and continued testing of its proposed EHR technology at a pilot site in West Virginia, according to multiple reports.

During a press event in Washington, DC, representatives from both companies revealed the progress of the Epic-IBM proposal for the Defense Healthcare Management Systems Modernization (DHMSM) contract.

Adam Mazmanian of FCW reports that the Epic-IBM partnership has already expended significant resources into testing the Epic EHR technology at Allegany Ballistics Laboratory in West Virginia in order to meet the demands of the DHMSM program to have initial capability beginning in 2016.

“What we wanted to do was have Epic running and have the opportunity to integrate and test, add new functionality, integrate other pieces of the big package so that there were no surprises,” IBM’s Managing Partner of Federal Services Andy Maner told reporters. “We just wanted to make sure we were getting ahead. Obviously Epic is live all over the country, but we wanted to be a step ahead in a DOD-hardened environment.”

Testing at laboratory began in November 2014, which allows both IBM and Epic to assess the performance of the latter’s EHR technology within technological environment on par with the DoD’s guidelines for security.

“For IBM this is a grand challenge that comes once in a decade, or once in a century,” Maner maintained. “One of the things that we wanted to do was to establish a path of work, really over the last year, so that if and when … we are awarded it, we are ready to go on day one.”

Accompanying these revelations about EHR testing activities was news that IBM and Epic had named 17 healthcare executives to an advisory group in their pursuit of the DHMSM contract. As Darius Tahir of Modern Healthcare reports, group members represent several nationally-recognized health systems as well as one industry group and a retired member of the Armed Forces:

  • Kaiser Permanente
  • Geisinger Health System
  • Mercy Health
  • Partners HealthCare
  • Sentara Health
  • American Medical Informatics Association
  • Maj. Will Lyles, Retired

Earlier this year, IBM and Epic revealed their intentions to compete for the DHMSM contract. The awardees of the contract will be responsible for replacing and modernizing aspects of the DoD’s current Military Health System (MHS) clinical systems.

“We would be honored to be part of the solution to modernize the MHS,” Epic Systems President Carl Dvorak said in June. “In collaboration with IBM, we can provide a successful implementation that will support innovation and interoperability within military healthcare.”

IBM and Epic will have to contend with pitches from other groups including Allscripts, PricewaterhouseCooper, and others.

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Computers Replacing Doctors, Innovation and the Quantified Self: An Interview with Atul Gawande | The Health Care Blog

Computers Replacing Doctors, Innovation and the Quantified Self: An Interview with Atul Gawande | The Health Care Blog | Healthcare and Technology news | Scoop.it

Atul Gawande is the preeminent physician-writer of this generation. His new book, Being Mortal, is a runaway bestseller, as have been his three prior books, Complications, Better, and The Checklist Manifesto.

One of the joys of my recent sabbatical in Boston was the opportunity to spend some time with Atul, getting to see what an inspirational leader and superb mentor he is, along with being a warm and menschy human being. In my continued series of interviews I conducted for The Digital Doctor, my forthcoming book on health IT, here are excerpts from my conversation with Atul Gawande on July 28, 2014 in Boston.

I began by asking him about his innovation incubator, Ariadne Labs, and how he decides which issues to focus on.

Gawande: Yeah, I’m in the innovation space, but in a funny way. Our goal is to create the most basic systems required for people to get marked improvements in the results of care. We’re working in surgery, childbirth, and end-of-life care.

The very first place we’ve gone is to non-technology innovations. Such as, what are the 19 critical things that have to happen when the patient comes in an operating room and goes under anesthesia? When the incision is made? Before the incision is made? Before the patient leaves the room? It’s like that early phase of the aviation world, when it was just a basic set of checklists.

In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology. They have to do with asking some very simple, very basic questions that we never ask. Asking people who are near the end of life what their goals are. Or making sure that clinicians wash their hands.

Once we’ve recognized the recipe for really great performance, the second thing we’ve discovered is that our most important resource for improving the ability of teams to follow through on those really critical things is data. Information is our most valuable resource, yet we treat it like a byproduct. The systems we have – Epic and our other systems – are not particularly useful right now in helping us execute on these objectives. We’re having to build systems around those systems.

The third insight is that, for the most part, the issues have less to do with systems than with governance. The people who are buying these systems, installing these systems, and determining how they’re to be used… What are they responsible for? What are their objectives? We’re having to figure out how to get quality and outcomes higher on the list of priorities of everybody running health systems.

Our dumb checklist, or our incredibly sophisticated predictive analytics algorithm, or that incredibly expensive EHR system… none of those change that fundamental failure – the failure of governance. And none of them can, no matter how you design them.

Gawande raised the example of hospitalists. He asked me about my group at UCSF, which has – by focusing on performance improvement as our core mission – become a key innovation engine at our institution.

AG: I think your hospitalist example is really important. Over and over again, it’s the pattern I see: a powerful idea creates a momentum of its own. When you’ve shown that there’s an obvious better way to take care of people. It’s controversial, and hospitalists can be used in ways that destroy the original intent. I’m sure you think about this all the time.

But when it works, it forces the leadership change. Leadership didn’t create hospitalists. Hospitalists created leadership. I think that’s the way it happens.

The same kind of thing happened with anesthesia. People didn’t say, “Oh, we have to find a better way to manage the pain of patients, because surgery is causing horrible suffering.” Somebody came up with an idea, and demonstrated that you could relieve this problem. But it required incredible system change. You had to double the number of people working in operating rooms at a time when the United States had a lower GDP than China does today. “We’ve got a better way of doing surgery. Oh, and it will involve doubling the number of physicians you have providing the care?” Is that a great model? It was dismissed as totally non-viable, can’t work. But it didn’t matter. It was too important, and it became the driver of leadership change, rather than the other way around.

A similar thing happened with Paul Farmer. There were debates for a decade about whether you could treat HIV in poor patients. Oh they don’t have watches, they can’t take the drugs, they can’t do this, they can’t do that. Farmer is like, “Fuck it!” I am going to Haiti, and I’m going to do it in a little old clinic in the middle of nowhere. And no, they didn’t change a whole country … but they changed a paradigm.

I think that’s the cool thing, that it’s not the technology. It was the values and the core idea that demonstrated you could accomplish this, that got you there.

I asked Gawande a question I asked most of my interviewees: Will computers replace physicians?

AG: The variousness of the healthcare world is pretty extreme. When we look at the way that disease presents itself, we’re moving increasingly away from science. When it turned out that lung cancer is not one disease, but rather that it’s four or five different histologic subtypes, that made it more complicated. Now we know there are 47 – and the number is growing – genes that, in different combinations, govern the behavior of those cancers. Forty-seven genes, and then you look at the multiples of different ways that people have these genes. Now we learn that the epigenetics and the expression of those genes are incredibly dependent on the environment. Did they smoke, how did that affect the genes? Did they have any kind of industrial exposure? How old are they at the time that the cancer appears?

Our cells on our little Excel spreadsheets are getting smaller and smaller and smaller. We’re getting back to the world of the 18th century “art of medicine,” where everything is becoming an “eyeball test.” The danger is that it becomes actually increasingly data-free – that every single person becomes a case of one. That becomes impossible to learn from. Period.

Where we’re moving, I think, is towards saying, “I have a class of people. I’m going to try Process A on this class of people who have some combination of these different genes,” and stuff like that. And then, does that process lead to better outcomes? The processes will be things like, “I’m going to watch them for three months. Then if X happens, I’m going to do an operation. If Y happens, I’m going to give them chemotherapy.” That increasingly becomes the way we learn.

RW: In your work as a physician, do you think care is getting better or getting worse?

AG: I think it’s massively better.

RW: Why?

AG: It’s fundamentally because of values, more than technology. I think we’ve changed our values over time. That patient suffering matters. I remember as a surgical trainee, I was expected to inflict levels of pain that today are just not acceptable. In my first month as a resident, I went into an operation to do a rib removal on a young girl. I’d never done one before; I had a month of operating experience. A fellow was standing at the door in his scrubs, saying, “Yeah, yeah, yeah, cut there.” The attending is in another room. I didn’t know what the hell I was doing.

The culture was, even to suggest that was a problem, meant you were weak.

Gawande asked me how I perceived the training environment today – particularly the tension between the patient and the technology.

RW: The residents’ instinct about teamwork is much better than mine was. I mean, the idea of my caring about what the nurses thought just wasn’t on my radar screen. And the residents’ instinct to get back to the bedside – when they’re spending all their time on the computers, they feel this loss and I think they’re trying to reconnect with their patients. We’re trying to create structures to allow that to happen.

But it’s hard – the residents feel they’re caught up in this world where everything they need to know is on the computer screen. That’s creating angst in their day-to-day life. You go up to the floor of the medical service in my hospital, and there are no doctors there. They come, they see the patients, and then they escape to this tribal room where all 15 residents hang out together, each doing his or her computer work. That means that many of the informal interactions that used to occur between the docs and the nurses, or the docs and the patients and their families, have withered away.

AG: Everything that they’re measured on and that defines their success happens outside the patient’s room.

RW: Correct.

AG: There’s a difference in surgery training. Everything that you’re measured on and that matters happens in the operating room. Although the patient’s asleep, the residents are having to work on their people-to-people interactions. How do you handle yourself with the nurses? How do you handle yourself with the doctors? What are your skills? They’re trying to figure it out and navigate it. It’s often a complete mystery to the students, and for a long time to the residents, too.

But except in the most egregious cases where you really piss off a patient, their success – being labeled an A versus a B – relates to “how much do I really know this patient?” It’s not getting my to-do list done for the day. Yet getting through the to-do list is the dominant task.

And we’ve both contributed to discoveries that indicate that all these little steps on the to-do list matter. It’s become an endless list of details that really, really, really matter. Do you have the right combination of antibiotics? Is the head of the bed at 30 degrees? When I think about the to-do list that I had when I was an intern, and the to-do list that the residents have today – today’s is just massively longer.

I closed by asking Gawande about the concept of the Quantified Self – patients wearing sensors and accumulating all kinds of personal data. While he is generally supportive of the concept, he has a concern, one that echoes the central theme of Being Mortal.

AG: I worry that we could become tyrannized by a combination of experts and sensors that have no close relationship to our priorities. That’s why I just keep coming back to the values. We’re here to alleviating suffering. I think it’s about this deeper connection we all have to something important.


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