Family Medicine Notes

My cousin Juliet posted a message on our family website that I think merits more global exposure.  Topic:  how expensive sheets are for the baby's bed.

"Baby sheets: I took a nice soft adult flat sheet bought on sale at Macy's or something (if you don't care about the color you can get something really luxurious and soft), cut it into more than four baby-sized pieces and finished the edges. Because you need tiny sheets when they're newborns (and not in the cot yet) and then slightly larger sheets when they're in the cot, and then larger sheets when they are a bit older, one large king-sized sheet will do the whole business. Just cut in half (don't rip!! this was my mistake), then in half again, and cut one of the halves in half, and you've got two tinies, and one or two medium, and one or two large (depending on how many cuts). Move aside Martha Stewart! "

Posted by Jacob Reider, MD at 05:47 PM | Permalink

Carl Gandola's bedside.org is active again .. so I guess he's been on service this month.  Too bad we can't get his colleagues (or his residents) to keep the fire burning when he's not on service!

"By osmosis and by repetition over this month we have all learned to communicate better about patients, to listen to their concerns (and think about sitting down in a chair at their bedside). We have developed management plans to improve individuals' health and relieve their pain. We have all worked hard, grown tired at times, learned, and been part of a team giving good care."

It's the beginning of the year for our 4th year medical students, and I am reminded again about the defferences between how we train physicians in residency  They struggle with career choices, and I struggle with how best to guide them.  Innately, Carl guides his learners to listen to their patients -- and to literally get down on their level by taking a seat at the bedside rather than maintain the physical dominance of standing above them.  If you were a patient in a hospital bed, would you prefer ...

 standing:

  or sitting?    

Which patient feels more empowered and involved in their care?

... and it's interesting to me that an educator in family medicine involves this in both his education, and in his discussions of education as an important part of healthcare ... while educators in other specialties just don't address these issues so routienly.   While our residents often refer to Behavioral Science sessions as "BS" ... this remains a required component in the training of family physicians (and no other specialty aside from psychiatry, of course), and an important differentiator in how physicians are trained.    There is also evidence  to support the hypothesis that this difference in training also may have impact on the healthcare that these physicians provide.

Posted by Jacob Reider, MD at 11:39 AM | Permalink | Comments (2)

Gross Anatomy is another weblog added to medlogs.com today .. and Mr Hassle's RSS feed is working, so she's there too now.

I enjoy the new medbloggers ... especially the medical students and residents.  It's great to see/hear their development as physicians. 

We've got an internal weblogging experiment going on here at Albany Medical College.  We've got beginning 2nd year medical students placed around the country in culturally diverse clinical settings, and they are all using a weblog to communicate their experiences with each other.  For the privacy of the patients, the physicians (even if no PHI is revealed) and the authors, it's all in a password - protected directory.  So you can't see it.    But it's top-notch stuff -- and I think that it's been a great demonstration that this sort of technology can be quite useful.     Are other educational institutions using weblogs in this way? 

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The AMA has released The Physician's Guide to Assessing and Counseling Older Drivers.  I'll admit that I have not read the whole 200 page document.  But it looks like a useful resource, with some screening tools and educational worksheets for both physicians and patients.

The AMA's web designers have a thing or two to learn about web user -interface though ... when you click on the link above .. you get to the page that promotes the resource.  It's a press release.  The user is then told to "Click here to view"  .. which leads to another page describing the resource ... along with links to 18 separate PDF files .. which one must click (18 times) to view the document.    What were they thinking?  If we wanted to read it on the web -- we sure didn't want to see it in PDF .. (recall that PDF is for printing - not for online reading) .. but if we want to print it ... uh .. we sure don't want to download 18 separate PDFs to print! ... well .. as a service to docnotes readers .. here's a link to the whole thing -- in printable form -- a bit smaller than PDF -- using Macromedia FlashPaper as a delivery mechanism.  Still not fit for web viewing, but at least you don't have to download 18 documents if you want it printed. 

Posted by Jacob Reider, MD at 03:03 AM | Permalink | Comments (1)

E-mail from our medical director today:

There is a new VIS (as of 7/28/2003) for the Meningococcal (Menomune) vaccine. The new form should be downloaded as a PDF and printed from immunize.org until you get printed copies.

Federal Law requires that we use the LATEST version of the VIS. (The outdated VIS is dated 3/21/2000.)

On a related note, there is a good article in Pediatrics on Immunization of Preterm and Low Birth Weight Infants (pdf) (HTML).

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Not to be confused with RSS 2.0 (!) ... Maybe tomorrow we'll build an Echo/Not Echo/Kuvop feed.

I've updated the URL to the link below so that it gets schedule data from the demo group.  If you want to see the native Oncalls view (or even modify the schedule) You can log in to the demo account at www.oncalls.com  with username "demo" and password "demo." 

To modify the schedule that you will see in the RSS feed, you have to put someone on call today - as the feed reports today's schedule.  (I suppose we could add a URL parameter with the date requested .. but that's tomorrow's project.)

You'll have to know some of the names of the providers in the Demo group, since the program won't let you put someone on call who doesn't exist in the system.  That would be bad.  So you can click on the EDIT menu and then MEMBERS to see (or add) members.  Then go to EDIT ==> Schedule to change the schedule.   Two notes: a) NO .. there's no "save" button.  It saves every entry when you move from field to field.  Cool, eh?  b) IE 5+ required for editing the schedule.  Sorry.  Log in with Username "Dork" and password "Demo" for a typical user's view that doesn't require IE

To see the data in a newsreader, use this url.  Here's what it looks like:

http://www.oncalls.com/rss/oncalls.cfm?dID=805&lg=%243X%2A9IP%20%20%0A&pg=%243XB%26HP%20%20%0A

What is all of that?

• http://www.oncalls.com/RSS/oncalls.cfm is the URL for the page that creates the RSS.
• dID=805 is the ID of the user for whom this feed is created.  Every user gets their own feed.
• lg=%243X%2A9IP%20%20%0A&pg=%243XB%26HP%20%20%0A   is the encrypted password for this user.  Don't bother trying to crack the code.  Every user has a unique encryption key in the database.  Dave came up with this (cool) method of making a reasonably safe method of providing RSS access to password protected data. 

And here's another idea:  Use AmphetaMailer to mail the results to whoever "needs" them. 

While we've built many methods for users to get at their data within our software, RSS enables the user to control this data by themselves.  Nice.  I'd love to hear from any current (or future) OnCalls users to hear how they are using this feature.  We can do weekly or monthly feeds as well ... if anyone asks for them.

Posted by Jacob Reider, MD at 01:05 AM | Permalink | Comments (1)

I've added several new Medical Weblogs to the medlogs.com aggregator:

• Diabetes:A primer of basic diabetes facts and information for those new to the disease and diagnosis.
• Hermes: Documenting the life of an internal medicine resident at the University of Washington.
• Women's Health:Another about.com site about ... women's health
• Mr Hassle's Long Underpants: Mr. Hassle's Long Underpants and Other Stories, by Doc Shazam. A young resident's perspectives about learning medicine, taking care of patients and being overworked. (actually - no RSS for this one yet -- so it's NOT on medlogs yet) ..

Posted by Jacob Reider, MD at 02:53 AM | Permalink | Comments (1)

It's been a (very) long time since I mentioned OnCalls.   The physician scheduling software that is the best-thing-since-sliced bread.  ;-)  ....  

Last week, Dave mentioned this post about RSS and calendars.  Hmm ... it got me thinkin ... In addition to the web interface, we've had a .Net client for Oncalls for about 6 months - but it's a heavyweight - since it requires .Net framework to install. 

Tonight while I watched the Red Sox win (will they make it this year?), I set up an RSS feed for OnCalls.  It was pretty easy.  Now any group that uses OnCalls can also use one of the many RSS readers or aggregators to see their call schedule. 

I've got to work out a few little issues .. but it seems to work quite well with rather little effort.  Here's a link to some demo data in RSS .. and here's a view of how it looks in FeedDemon:

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The PEW INTERNET & AMERICAN LIFE PROJECT reports that 80% of Americans search for health information online.

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Reuters Health Information (2003-07-25): Brazil bans ads for anti-impotence drugs.

Viagra ads, like those that featured soccer legend Pele, got the boot on Thursday when Brazil banned advertising of anti-impotence drugs

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What is the most efficient testing algorithm for diagnosing hepatitis C virus?

This is an interesting disucssion.  Bottom line: get the PCR first .. not the RIBA.  Makes sense to me.

Recommended Algorithm for Diagnosing HCV

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MIAC Card  - a good idea I've heard from at least 3 physician-nerds .. ("hey I've got this great idea") ... and the MIAC card is only one of several companies already providing the service.  A good idea?  Yes.  Original?  No.

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From the New York Times:  Apple Co-Founder Creates Electronic ID Tags.  What does this have to do with medicine, you ask?  Finding the ... patient, nurse, chart, physician ... is often a challenging task in a hospital.  these inexpensive tags could enhance care and improve the efficiency of many hospitals.

Posted by Jacob Reider, MD at 02:11 PM | Permalink

Thanks to Bruce for this link from the University of Wisconsin: Benign Breast Disease and Breast Cancer.

It's a very good overview of breast anatomy and how one can differeniate benign disease from cancer.

Posted by Jacob Reider, MD at 11:20 PM | Permalink

From The Register-Guard - Eugene, Oregon, USA a Guest Viewpoint written by Congressman Peter Defazio.

This guy is right no target.  Even Hillary's "radical" attempt to provide more coverage to people in this country was proposed with insurance company pass-through.  Man ... this is c-r-a-z-y.    Think about it.  The insurance companies have a responsibility to their stockholders to earn more money.  I'ts just like Coke and Chevy and Microsoft.  Thier product happens to be healthcare.  In order to earn more money -- their primary goal must be to provide fewer benefits to their "customers."  Competition can't possibly drive costs low enough - or care high enough.

More reliable info on this topic can be found here

Posted by Jacob Reider, MD at 12:37 AM | Permalink

Health Data Management: Why the SNOMED Deal is Important (July 02, 2003)

I know I'm beating a dead horse here .. but .. I promise ... this thing really IS important

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My article and commentary in The Journal of Family Practice on Sinusitis were published this month ...

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FAQs: Inclusion of SNOMED CT in the UMLS

From NLM ... a good overview of the Somed inclusion.

Have I mentioned that this is a big deal?  It's a big deal.

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Steve ... over at Tales of Hoffman says:

Do You Know Where You're Going To? Got a nice note from Alwin this morning. He's also wondering why Dave W. seems to be ignoring the Medical blogs (at least in terms of Bloggercon). Oh well. Maybe we can get something going ourselves...Here's a "crazy" idea. If you are a "medblogger", send me a list of the upcoming conferences you think you'll be attending over the next conference season. If I see any type of critical mass at one place or another, (or if I even see two of you going to the same spot at the same time) I'll set up a medical blogger meet. Let's see if this can work...

Nice idea, Steve. 

AMIA?
AAFP?
STFM?

Here's one .. let's do a Medlog worksop at a conference ... at the ... Medscape booth.  Set up a kinda theater-style demo (like the silly EMR vendors do) and give out dorky "Medical Blogger" baseball hats ... and we set up a sponsored medical weblog site using TypePad.  ... Hmm ..  ----------

ooh .. I'd better finish that next article for Medscape, or Kelly will come take my firstborn.

Posted by Jacob Reider, MD at 11:01 AM | Permalink | Comments (1)

Re-using water in PET bottles may be a health risk:

Obels.net Medical Weblog: Re-using water in PET bottles may be a health risk.

I missed this one last month.  An important concept to keep in mind.

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Last week's Snomed announcement has been a topic of some discussion on several listservs ... on Fam-Med, Dr Mullins cuts right to the chase in this little dialogue:

"For anyone interested there is an EMR, CliniFlow, that is fully functional and uses SnoMed for all diagnosis codes.

Kate Galambos, RN, MSN"

.. and he responds:

"Thanks ...  If I read your email correctly, CliniFlow utilizes  SNOMED for "diagnostic codes" not as a clinical vocabulary which would  be used to codify clinical information contained in the EMR.

If that is what you were saying, there are a number of EMRs which do that. My focus is on "terming" something to code non diagnosis information such as history physical, etc. The clinical narrative.

   Once again, thanks very much.
   Moon Mullins"

Sometimes Moon's ability to "get it" rubs people the wrong way.  He's a visionary .. and he doesn't mince his words.  Most vendors (and most users) don't get the difference that he's pointing out -- yet his point drives home the essential component of a well structured note.  The meaning of the words in the note are lost in the quicksand of free text if the note isn't created from an alphabet of terms that are attached to clear definitions.  Products that use templated to create a note often just use those templates (derived from hierarchies of clinical findings) to create ... free text! .. which is then causes all of the meaning of the composition to erode.

Huh?  you say?  (am I losing you in TechSpeak?  Are you wondering .. So What?) ...

Here's why it's important.   MIllie comes in and I build her note in my EMR.  If it helps me build the note with clinical terms and retains these links, then I might read a part of the note as:

"Here today for Type 2 Diabetes, Shortness of breath and bilateral LE swelling"  .. but rather than free text, the database behind the note reads:

"Here today for 44533, 12345 and 57686"

where the database holds:

TermID     TermText
44533       Type 2 Diabtes - no complications
12345       Shortness of breath
57686       bilateral LE swelling

So now my system can help me.  Apply rules to help me make decisions?  Sure .. since the system really knows what is going on .. not just free text.  I can also do reports on the data .. with real clinical terms, not billing codes.

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New in informatics: MRI: 5th Annual Survey of EHR Trends & Usage

This is an interesting overview of the goals, expectations and implementation of Electronic Health Records - a snapshot of where we are in 2003.

Posted by Jacob Reider, MD at 09:08 AM | Permalink

This story -- which barely made headlines in the lay press - is a big deal. There are some sources that picked it up and appropriately recognized the significance.

"Starting in January 2004, free-of-charge access to SNOMED CT core content and all version updates will be available through the NLM’s Unified Medical Language System (UMLS) Metathesaurus, a knowledge source containing biomedical concepts and terms from many controlled vocabularies and classifications.

 

Under the agreement, SNOMED CT will continue to be available directly from SNOMED International (SNOMED), a division of the CAP, in the SNOMED CT Structure."

Posted by Jacob Reider, MD at 01:01 AM | Permalink

Today's suggested reading:

BENIGN PAROXYSMAL POSITIONAL VERTIGO

It's a patient-oriented page - devoted to this annoying and complicated problem.  There are good illustrations of how to do the Eply maneuver, which is often quite effective.

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