Chris Cates has updated his excellent "NNT" digrams for the management of acute otitis media. He's got these cool charts that help explain the concept of an NNT. I use these in the office .. pulling up his site on the internet and walking parents through these concepts. WHile 1st year medical students seem to have a problem with "NNT" -- mom and dad seem to "get it" without too much trouble.
European Physicians Especially in Sweden, Netherlands and Denmark, Lead U.S. in Use of Electronic Medical Records
Intereresting and useful reports on the barriers to Electronic Medical Records implenetation.
Top Barriers:
- Lack of Resources to invest in IT
- Time and effort to prepare the organization for EMR
- Difficulty integrating systems
- Difficulty establishing a good ROI
- Lack of provider support
- Skills and preferances of existing support staff
Today, the IOM released another report on the state of medical care and medical errors.
"We strived to view the health system from the perspective of patients, especially those with chronic conditions, where a premium is placed on care that is coordinated over time, across settings, and across multiple payers. Such a coordinated focus requires government programs and health care providers to unify and standardize their quality-improvement efforts. Our report encourages the federal government to take full advantage of its influential position to set the quality standard for the entire health care sector"
It's compelling stuff, and deserves a careful read at the very least. Their take-home message is a valuable one: if we are going to have significant, coordinated progress in reducing medical errors, and improving efficiency, there needs to be clear, agressive federal leadership.
I think that this is another suggestion that the "free market" doesn't apply to healthcare. While it may very well work for widgets and alkaline batteries and perhaps even corn meal .. healthcare .. and the enormous economies that are woven together around healthcare ... is different. I agree that we need to develop strong leadership to coordinate such an effort .. but .. as my former boss used to say .. "it's like herding cats."
Minnesota Senator Paul Wellstone died today. He was a great guy .. and a true friend of healthcare. Very sad.
One of the joys of being a physician is treating family members over the phone. For the past two weeks, I've done my best to help a family member 3000 miles away with rectal itching. Amid phone calls about "my hiney hole" ... we've run through the list of disorders that could be causing the problem. The note home from the kids' school about pinworm turned out to be a red herring .. as the course of mebendazole didn't help much, and the stool was negative for parasites.
And so this went on-and-on. Her physician (an internist) diagnosed hemorrhoids .. but treatment didn't help at all. ?A fungal infection? The physician tried antifungals. No change ... it even seemed a bit worse.
Weeks pass .. and still no resolution. I start to try to learn about the physical signs. The husband gets involved.. he reports a bright red area around the anus.
She's got two kids - 6 and 4. Hmmm ... the only thing I can think of that hasn't been considered is GABHS. I haven't seen "strep butt." in an adult .. but kids do get it .. and I see a few cases of it every year. Could this 36 year old mother-of-two-likely-strep-vectors get it? I don't see why not. I suggest this .. and suggest that she get a strep culture (or even a rapid test) from her physician.
End of long story: after working (very) hard to convince her physician (who had never heard of perianal strep) that this was a reasonable diagnostic test .. my relative received a phone call today from her very surprised physician - "very heavy GABHS."
While reasonably common in children, now we all know GABHS can be seen in adults too.
Back home in Smallbany today. Ian Finkel, the famous xylophone player (no .. I hadn't heard of him either), sat behind me on the plane. He doesn't look like this anymore. I bet he took this picture about 30 years ago. No kidding. He was playing a set on the Holland America cruise down the Mexican west coast, and Mrs. Frank (changed her name from Frankenstein during the 1950's) had been a passenger on the cruise. She loved his show .. and loved the cruise. Lots of playing bridge and relaxing. I worked some on the computer and didn't listen at all to their very entertaining conversation. One thing I can say about elderly jews - they certainly have character. Me in 40 years.
Speaking of which .. I finally was motivated today to look up the compliment paid by Mrs E. .. one of my favorite "little-old-jewish-lady" patients ... she called me a "sheyne punim."
Free 802.11 here in San Diego (with a very good signal). A nice addition to both the conference hall and the hotel room. The connection in the hotel room may not be intentional .. but it's been a welcome addition to a nice trip.
Dinner last night in the hotel with the computer zoo staff: Nancy Clark, John Epling, Richard Neill MD, Meredith Oliver, Bruce Seaton, and Howard Rubenstein. Beth Milligan couldn't make it. We walked over to Kansas City Barbecue and brought back a great meal, and sampled some of the local beer. As the hotel had run out of rooms when I arrived, Bruce and I ended up sharing a suite on the 11th floor with a balcony, living room, two bedrooms, to bathrooms, etc .. so it was the right place to have a little gathering. A relaxing way to spend the end of a busy day.
Most of use have worked together in various capacities before. Almost exactly 4 years ago, Nancy, Beth and I were on a panel at the 1998 AMIA PCIWG meeting.
Andy Ury also gave a talk at that meeting. He and I spent some time together yesterday .. and he paraphrased something that I think holds true for medical informatics -- and possible all good businesses: "It's harder to decide what NOT to do than it is to decide what to do." We have many opportunities ... both in software development and in our daily lives. Making good choices about business alliances, software implementations, even treatment decisions for/with patients. The choices are vast. The right choices are few.
With apologies to Slawson & Shaughnessy for borrowing their usefulness equation .. I would suggest that P = V / W. What do I mean by this? The priority of a project is a function of the value over work. This will one day be referred to as "Reider's Rule" at Harvard Business school ;-). Value, of course, is a subjective measure. Making a judgment about how valuable a palm client is to our oncalls application was a subjective decision. On a scale of 1 to 100 ... I give it an 80. Why? Physicians use palmpilots. Pulling the call schedule into the palmpilot would add significant value to those physicians who use them (most). Adding "pre-loaded" US holidays to the schedules automatically has been another user request. Sure .. it has some value .. but not nearly as much as the Palm client. So the "holidays" feature gets a 30. But we can't stop there and go ahead to do the palm client. This is where most project teams seem to falter. the marketers assess value and the engineers assess work. Without doing the prioritization together ... accurate prioritization can't occur.
Work is assessed as a function of time and/or money. One should always use a common factor for work. When we started using this at Albany Medical Center, we agreed to use dollars as our W. If a project was to be implemented by a vendor, the vendor's fee was the denominator. If internal resources were to be used, we would multiply the number of hours that were estimated by $125. So long as we're consistent, it doesn't really matter what we use.
A problem with the model started to arise when high-budget items started being prioritized. The multimullion $$ replacement of the radiology information system would NEVER attain a "P" value over 1 because the W was simply too big. So we started using share-root of W to normalize very high budget projects.
Back to our examples. Palm client implementation was outsourced .. with some internal coordination. Let's say this cost $10,000. So P = V/W .. P = 80/10,000. P= .008. Hmm ... let's try the Reider's Root Rule for high budget items: 80/100 = .8. Now let's compare that to the "holidays" request we estimate that it will take 20 hours to implement this (at $125/hr): P = 30/50 = 0.6 (I get 50 as my dominator by taking 125 * 20 = 2500 .. then I take the square root of that = 50).
So we implement the larger palm client project before the "holidays" feature .. even though holidays could be done more easily.
From Richard Winters:
According to the Medscape folks ... their site accounts for a significant percentage of this traffic. The increase in physician use of the internet for CME surprises me. In general, we don't have very long attention spans. We've got many "balls in the air" and our time is limited. We use the internet as a tool -- primarily for information retreival (to answer a specific question) and communication. Most of us use it for communication via e-mail and many are beginning to use more secure methods such as Relayhealth for communication with patients. (ooh .. I'd better check my messages) But CME requires a commitment of time. I need to sit down at the computer and know that I will devote 30 or 60 minutes to this activity. I've been a skeptic about online CME for this reason. Most of us would rather spend our precious time off with the kids. CME activities like the AAPF convention provide us with a chance to dedicate a few days to CME without the distractions of phones, e-mails, instant messages etc.
But attendance this year isn't what it had been at the peak. After 9/11, last year's attendance was ~ 4,000. This year it's ~4,700. So more physicians are here .. but perhaps they are carving out that time at home to do online CME rather than traveling. Medscape's Online CME permits printing .. so one isn't tied to the computer. This is good.
- from cio.com
Reading a few books on the trip:
Reality Coldfusion MX is an interesting book in "real world" application development with Coldfusion MX and Flash MX. It's making a compelling case for using Flash as a rich client. I hadn't been convinced .. but I'm warming up to the idea. We'll probably try some experiments with Oncalls next week. The hospital operators don't use a mouse. Their hands are always on the keyboard. If they are going to use Oncalls to look up who is on call .. they can't use the website. So the website is good for the physicians .. and for the schedulers ..but not for the operators. We've got two choices for the telephone operators: A Flash MX client, or a Windows .net application. So far, the .net application is winning.
Flash MX Actionscripting. Not so easy to read as Forta's book (but with fewer editing errors!) This book provides the cake tot he "reality" book's icing. It's the meat on how to do actionscripting. I never really took the time to learn. ActionScript is like Javascript .. so it's not too hard, but the whole "movie" metaphor is hard for me to adapt to. Born as a programmer in the early 1980's (BASIC, Pascal) .. I still have a hard time with object-oriented programming. Taking it up another level to think of my program as a series of "frames" in a "movie" is tough. I understand that it makes sense when I'm making an animation .. but it's hard to think of a web form as a movie.
.net user interfaces with C# I'm not a C# programmer. Not sure I'll ever be one. Dave works for me. He's a C# programmer. I need to uderstand what he's doing. I can't manage his work if I haven't a clue what he's doing.
I have a friend who is a manager at General Electric. He manages a team that develops turbine engines. He's a fluid mechanics engineer. He manages fluid mechanics sngineers. He and I were discussing the "joys" of management recently, and I observed that there is a high turnover of IT management. He wasn't surprised. "F=MA" He says. I get it. The domain isn't a moving target in mechanical engineering. IT managers have to keep up on technology.
A big day today. (yesterday)I'm in San Diego at the AAFP conference. 4700 family physicians. I'm one of a handful of folks who are staffing the computer "zoo" at the conference. It's an area on the exhibit floor where folks can go to learn about software and hardware. Lots of traffic today in the "PDA Chat Room" where folks came to learn how to use their Palm OS devices. Not many folks using WinCE.
Heard in the chat room:
"what is the essential software that should I load on to my PDA?"
Common answers:
Epocrates, 5 Minute Clinical Consult , Shots"Is there software that I can use to help me write progress notes really easily?"
Um ... no
"How do I check my e-mail?"
The concept of the "zoo" is a good one. The exhibit hall is a good place for folks to see software and hardware that many vendors are promoting .. but it's not a good environment to USE the software or speak with knoledgable folks about the products. Exhibitors are salespeople. In the zoo .. we try to provide folks with unbiased guidance. There are 30 computers loaded with software from many of the vendors. People can sit down and try the software. No one breathing down their neck.
And they can check their e-mail too.
Sam and I are building a tree House in the back yard. We've been spending time at ... 
Turns out that you don't need a building permit to build a tree House.
But things can get out of hand sometimes ..
We're keeping ours simple. Yet elegant ;-)
I just finished the taxes. NEXT year I'll do them on time .. ;-)
Last week, I was asked why I write "docnotes."
Easy answer. I write it for myself. Doogie Howser wrote that little diary at the end of every day ...
Bookmarks to interesting medical stuff .. and .. yes .. diary entries. You're welcome to read it too. These days there are a few hundred people who stumble in here every day. I hope you find something useful.
This study confirms that duct tape really does work to fix nearly anything.
In a post on Dave Winer's Scripting News today, Dave brings up the issue of information storage. He seems to be discussing hierarchic thinking. Dave has written outlining software for years. He's added complesity to the outliners . beginning with More in the dinosaur ages .. and forward to Frontier and Radio. I don't think that we all function so well with outliners. Not everyone THINKS that way .. even if one can DESCIBE what we're doing in a hierarchy.
So what?
I teach at a medical school. So I teach medicine. I also teach Medical Informatics to physicians. And I study medicine. And I study Medical Informatics.
These topics are vast. Many (?most) searches on the internet are related to medical information. In the early days of the internet, many "directories" were created to help people find the informationthat they were looking for. Yahoo was one of the first, of course .. and it was successful because it was well implemented. Medical Matrix was a great early resource for medical information -- for both physicians and patients. Yet in the practice of medicine, the information resources are so vast .. and the temporal pressure to find the RIGHT information NOW is so great that a directory simply falls apart.
My pal Dave Kauff came up with a hypothesis a few years ago .. he recognized that physicians don't really use the internet to find medical information very often .. even if they know that what they are looking for is "out there" somewhere. If I learned about a certain condition from a certain book when I was in medical school and I know that the information I'm looking for is on the page on the left-hand side about 2/3 of the way tthrough the book in the chapter on such-and-such and the book is on the bookshelf on the 3rd shelf up on the right hand side of my desk. .... then .. that's where I'll find it 1st. So Dave K says .. "if the docs can put the books on the bookshelf .. then maybe they can organize links to the data that they want if we make it easy for them.
So we teach people to use "MYHQ" .. which is STILL the best URL/Bookmark utility on the internet, and still free free free.
It works well, but not everyone likes it. Not everyone thinks that way.
Where am I going with this?
Dave Winer can superimpose a hierarchy of thoughts on how many people organize their homes. So long as we learn good searching strategies . (yes .. hierarchies again .. I hear you coming, Dave!) .. and maintain good search engines . it doesn't matter at all. We physicians have strugges for years to develop nomenclatures that describe medicine. ICPC, SNOMED and ICD-9 are all examples of such attempts. ugh.
I guess today's post is a work-in-progress. We'll see if I can make more sense of all of this later.
From Medpundit:
"A patient is seen and treated in the office. The doctor submits the bill to the insurance company, which, according to the contract it has with the doctor, is supposed to pay the bill within a certain number of days, say 30. On the thirtieth day the doctor doesn't get a payment. Instead he gets a form from the insurance company claiming they need more information about the visit. Was it for a pre-existing a condition? To make it even more difficult, the letter doesn't specify which diagnosis for that visit it has concerns about, and sometimes it doesn't even state the day of service. So, if a patient saw the doctor for two things - say an ear infection and to have his blood pressure medicine renewed, or if he's been to the office twice for two separate problems, the doctor's staff has to call to clarify things, a process which can take minutes to days. Then, the form has to be mailed back to the insurance company. They wonâ019t accept the information by phone. This happens even if the condition is clearly not a pre-existing one. In fact, I see it most frequently for office visits that have been for an acute problem such as an ankle sprain or an ear infection. The only reason the insurance company has for doing this is to delay payment by another couple of months."
ugh. This is my life. Well put, "medpundit."
This paper in BMJ this week sheds more light on the prostate cancer screening issue. Once again .. we learn that PSA testing doesn't save lives.
According to Frtiz's Hit List, the radio controlled fart machine may be threatened by federal legisation:
When a remote control is pressed, this device emits one of five prerecorded fart noises. Because these noises are stored in digital form, the device qualifies for regulation as a "digital media device" under the Hollings CBDTPA. If the CBDTPA passes, any newly manufactured fart machines will have to incorporate government-approved copy restriction technology.
The hollings legislation is stupid on many counts ... This is another such example that it misses the mark.
"When a loved one is hospitalized, it is sometimes difficult to get updates about their prognosis and progress. Concerned friends and family may be reluctant to call for fear of disturbing someone at a difficult time. Likewise, those who are charged with keeping everyone informed may find it fatiguing to repeat the same information again and again. That's where PatientUpdates.org comes in. PatientUpdates.org is both a website and a nonprofit organization that was created to provide a convenient and reliable way to keep friends and family updated on the condition of a hospitalized loved one free of charge. "
I haven't logged in .. but this website looks like a great service.
Our 4th year medical students are now applying for residency programs .. which means my role as an advisor to medical students shifts up a notch for at least a few months ... where to go .. what's a "good" residency .. etc.
Today a student e-mailed me a link to this article on the AMA's website. Overall, it's a good article ... but ... (there's alwasy a but) ... here's my response to her:
... interesting and useful .. but I would read this with one big caveat .. this article makes the common mistake of assuming that a "university" program is "academic" and "community" programs are not.
I am always careful not to use the term "academic" in this way.
Academic is an adjective that describes the level of "Academic" interest in the program .. it imples research, thoughtful grand-rounds meetings, faculty who are interested in teaching and learning ... a true LEARNING ENVIRONMENT .. rather than a practical hands-on trade-school environment.
The best residencies combine both .. but there are certainly shades of grey ...
There are some programs in university settings that are not at all "academic" as I define it above .. and community programs that are VERY academic.
Of course, my bias is clear. Though I'm on the faculty in a program that's affiliated with a medical school, I was educated at a residency in a small community hospital. Those in the ivory towers don't think much of the community programs. Indeed, I was counseled not to go to the program I attended by people I respected. But their advice was based on their ignorance -- not a good knowledge of what was available. "You like what you know"
"The average patient visiting a doctor in the United States gets 22 seconds for his initial statement, then the doctor takes the lead."
A new twist on an old story. Even those of us who try to be good at this .. sometimes fall short. If I catch myself starting to interrupt ... I bite my tongue (literally) to remind myself to keep quiet.
On Moday nights .. I sometimes volunteer at a local homeless shelter. Last night I was there with a few medical students. It's a good experience .. and I enjoy teaching the students while providing a service to the clients in teh shelter. As one of the students was interviewing a patient .. I noticed how often the student interrupted the patient. Active listening is clearly a skill that we need to focus on more in medical school.
Last week I treated a woman with antibiotics for a UTI. UTI is an extremely common problem in primary care, and is one of the most common infections seen in primary care... accounting for 14% of antibiotics prescribed. Her symptoms were compelling, and indeed, she had mild CVA tenderness .. suggesting that there was more than just lower tract disease. Nonetheless, I didn't want to treat her with antibiotics for any longer than necessary. As we know (examples here , here and here) ... this is a complex issue, and one that has been carefully studied. Antibiotic resistance is a growing probelm .. and public education remains necessary
Suggestions for reducing resistance..."there are three main ways to control selection and spread of resistant strains: by (i) reducing the amount of antibacterials used; (ii) using optimal dosages (avoiding underdosing) and treatments of short duration; and (iii) reducing the risk of transmission among young children attending daycare centres or kindergartens.
Is there evidence that a short course is effective in UTI? sure is ..
Short course in kids And more kids
Short course in Adults: "most antimicrobial agents given for 3 days are as effective as those given for longer duration, and adverse events tend to be found more often with longer treatment. "
So .. I have to consider a number of variables in my decision on how long to treat .. and of course I will recall that I am not the only smart, thoguthful person involved in this situation. The patient is an active participant in the treatment process (how often it seems that we physicians forget this !) ...
Considering all of this .. some would write an rx for 7 days and be done with it. Others would even write for 14 without a blink. But maybe she doesn't need 7 or 10 or 14 days. Maybe she needs 3. 3 is better than 7 (is better than 14). We'll get less resistance this way. But how will I know if it's OK to stop before 7 days? I won't. But she will. She knew she needed to come see me in the 1st place .. why shouldn't I trust her to know if she feels better? So I tell her to take the medication for 24 hrs after she feels entirely better. We'll call this the "Sick + 24" duration treatment. I use this sort of prescription in cases where there is either good evidence that antibiotics may not be necessary at all (otitis, sinusitis) or where a short duration is often effective (UTI, cellulitis).
Is there science to this treatment strategy? Not yet. But the rationale is clear, and consistent with the evidence. I could have just as given her a 3 or 5 day course .. and insisted that she "take it all." This sort of paternalistic command has always seemed odd to me. It is now clear that the duration of treatment is often arbitrary. While a 5 day course of antibiotics is standard now for otitis media, many physicians still treat for 10 days based on tradition. If we're going the respect our patients .. shouldn't we be honest about the rationale we're using for our decisionmaking about the duration of treatment?
A must-read for medical students .. testing posts from Amazon.
Heirs of General Practice
Author: John McPhee; $8.80 (Usually ships within 24 hours)
First rate McPhee
A former student sent me this book after her first year in medical studies and said "finally someone who tells it like it is". Definitely NOT about urban Medibusiness or the world of HMOS and doctors too busy to doctor, instead McPhee focuses on the lives and work of young doctors in rural Maine, bringing us their story and that of their patients with compassion and without either the cloying sentimentality or the muck-raking zeal that sometimes clogs this topic. A quick read & well worth it.
[Amazon Books: family Medicine]
Hey .. I just found another medical weblog. "Medrants" is an interesting site .. very nicely designed .. and updated quite frequently. I'm very impressed. The author is an internist at UAB. This entry (link above) is on celiac disease. I've diagnosed several cases ... it's much more common than I originally learned in medical school (as common as 1 in 200!) ... in the past year or so.. I think I've tested for it a handful of times .. and have diagnosed three patients with it. Key symptoms: frequent stools, anemia .. in a thin woman who "never gains weight."
