The future of Joel

As Google Buzz rolled out and I made the switch to an Android phone (Motorola Droid), I struggled with where to invest my time and social media. I went through a previous effort to determine where to update virtually. Here is what it has come down to for me personally.

1. LinkedIn: This is purely my professional space. I do not plan on updating status or other personal information on the site. This is publicly searchable and I engage here with other professionals in the health care and consulting industries.

2. Twitter: While I still am not enamored with Twitter I see that it has become a viable social networking solution. My only plan here is to update specific Buzz posts as well as any posts on this blog here. It will hopefully drive traffic to this site versus the other way around.

3. Facebook: This is my purely personal space. While I have connected with a select few business professionals here, I may scale back. Here I update with family pictures, notes on events, connect with formal classmates. Folks..pretty sure Facebook is here to stay.

4. Buzz: This will be a mix between personal and professional. The beauty of Google is its ease of sorting between showing personal information to friends and professional information to the public. I plan to update some buzz posts on to twitter but this is still a wait-and-see product for me.

5. Ning: I have a variety of Ning Networks (Church, Blazeman Warrior, I Am Tri) that I engage for social networking with specific groups. Its group functions are currently superior to what is offered on Facebook but maybe that will be taken over some day?

5. Abandoned Services: Here are the list I have almost completely abandoned for one reason or another:
– MySpace
– Orkut
– Message Boards
– Chat Rooms

6. Services I have no desire to use:
– Foursquare
– Windows Live Spaces
– MyLife

Thoughts from the readers here? Which services to you use and which ones do you find most useful (both personally and professionally).

The iPad goes live at BIDMC

The following is a guest post from Dr. Larry Nathanson MD, who leads BIDMC’s Emergency Medicine Informatics efforts. (Note that the photo contains only fictitious patient names):
I had been anxiously awaiting the arrival of my iPad –This is the form factor I have been asking (begging) of all the vendors for years. I’m very happy to say that it appears to be living up to my high expectations.
The screen is gorgeous. It’s very clear and bright, I had no trouble seeing the screen in bright outdoor light. The machine seems extremely responsive — it reacts immediately to user input and the browser renders pages as fast as my laptop. In landscape mode, its surprisingly easy to type on the on screen keyboard. I wouldn’t call it “touch typing” but the autocorrection fixes almost all of the typos that are introduced when I just let my fingers fly. It turns out to be much easier to enter data than I expected, and in fact this entire review was typed completely on my iPad.
I tested it today during my shift in the ER. Initial tests with our clinical applications went amazingly well. The ED dashboard, WebOMR and Provider Order Entry all appear to function well without modification. The popup blocker does try to get in the way of new windows, but it’s a only a minor annoyance. The EKGs look better onscreen than on paper. It was great having all of the clinical information right at the bedside to discuss with the patient. The only problem was that the increase in efficiency was offset by the patients and family who wanted to gawk at it.
The battery life is one of the most astounding features. I don’t know how they did it but the claimed 10 hour run time might actually be more accurate than the usual inflated claims that I’m used to for mobile devices. The device arrived at full charge and after testing all day and leaving it playing several full length movies the battery still had 40% left. This could easily make it through an entire ER shift on one charge, eliminating the need for hot swappable batteries.
I am a little concerned about how well it will hold up in a clinical environment, particularly the abuse it will get in the ER. The case is very smooth and the rounded bottom makes it easy for it to slide out of a hand or off a table. I don’t get the feeling it will be as forgiving of drops as some better padded (albeit heavier) devices. I’m hoping someone will create a case that has a hand strap on the back (like the Panasonic MCA has).
One problem that plagues all tablets that I’ve used clinically is the difficulty entering strong passwords. The onscreen keyboards of mobile devices makes it much harder to quickly enter numbers, symbols and mixed case and is, in my opinion, one of the biggest barriers to medical tablet adoption. A biometric, or other creative way of addressing this will likely be needed.
From a consumer electronics point of view I’m also impressed. When just web surfing or watching video I do like that I can just lean back and hold the iPad as I would a book or magazine. My wife found that she preferred the iPad Kindle program to the actual Kindle device. (That bodes poorly for my plans to develop software on it!)
In summary, I’m very excited — the form factor is close to perfect and it’s robust enough to keep up with a busy ER. I think this is one of the most promising developments in medical mobile computing in a long time.
There is one major drawback however: Now my iPhone seems slow and inadequate!
Sent from my iPad

Rethinking Clinical Documentation

Over the past 5 years, I worked with HITSP and the HIT Standards Committee to select standards for exchanging clinical summaries. But what exactly is a clinical summary?
There is common agreement about the need to exchange codified, structured data for problem lists, medications, allergies, and labs.
However, what is the role of unstructured clinical documentation text?
Some have suggested that unstructured text is hard to navigate, at times repetitious, and challenging for computers to interpret.
I believe the exchange of free text notes such as operative reports, history&physicals, ED charts, consult notes, and discharge summaries is very important.
Consider this example.
A 40 year male with no family history of heart disease presents to the ED at 3am with a chief complaint of chest pain and left arm numbness. The EKG is normal, a stress test is normal, labs are normal, and a cardiology consult is completed. The patient is discharged on H2 blockers with a diagnosis of gastritis.
A summary which only includes a problem and med list may state a Problem List of Gastritis and a Medication List of Prilosec OTC.
When the patient next visits an Emergency Department, no one will know about the cardiology consult, the differential diagnosis considered, and the thought process that led to the diagnosis of gastritis to explain the chest pain.
An entire workup will be started from scratch.
There is a great article in the March 25, 2010 of the New England Journal of Medicine “Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?” by Gordon D. Schiff, M.D., and David W. Bates, M.D. in which the authors note:
“Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties.”
I agree.
Notes should be included as part of clinical summaries.
However, we should do all we can to improve the quality of notes.
Over the next year, we hope to try a radically different approach to clinical documentation at BIDMC which we think will leverage all the strengths of the full text note as described by Drs. Schiff and Bates without the repetition and navigation issues.
Today’s inpatient charges are a collection of SOAP notes written by the medical student, intern, resident, fellow, attending, and consultants largely for billing and medico-legal purposes.
What if the chart was recast as a communication vehicle for the entire team that summarized the day’s events and collective wisdom on next steps?
Our answer – a daily Wiki entry for each patient authored by the entire team and signed/locked by the attending at the end of each day.
How will this work?
Think of it as a private wikipedia build inside our clinical systems and hosted in our data center.
Each member of the care team will use our Team Census application to view the list of patients for whom the team is responsible.
Clicking on any patient name will bring up the daily Wiki. Each member can add documentation, revise existing text, and leverage the work of others on the team until the attending makes the final edits and signs/locks the day’s documentation. Just like a wiki, a complete journal shows all all edits/changes/deletes, so no information is lost. Importantly the day’s wiki entry has one physical exam, one assessment, and one plan – not 17 repetitive entries saying the same thing that often appears in today’s paper charts.
The idea of a daily wiki entry for each patient creates highly readable succinct documentation authored by the entire team with a medical legal record of the process that was used to generate it. It’s a perfect single document to share with the referring clinician and the patient/patient’s family.
After our initial pilot work, I’m guessing we’ll also engage the patient and families to add to the Wiki, reflecting the shared decision making between the team, the patient, and the patient’s family.
We’re in the design stage now, but I’ll report back on how it goes.
A daily patient Wiki as unified clinical documentation, exchanged with the team, other providers, and the patient. I bet even the free-text naysayers will agree that this should be part of the clinical summary!

Customer Disservice: Health Care #FAILs again and again

Disservice (dĭs-sûr’vĭs)

  1. A harmful action; an injury
  2. An act that is not just

Our health care system is completely devoid of customer service. It is pathetic.

I took my son to have a simple tympanostomy (ear tubes) procedure this morning. I show up, sign in and take my seat amidsts the throngs of people in the surgical center waiting room. I brought my laptop and some reading materials to bunker down for the long wait ahead.

20 minutes later I get called up front to sign some additional paperwork. Instead of being greeted, 15 documents each complete with a full page of legalese is shoved my way regarding various aspects of responsibility, payment, agreement, arbitration, and host of other information. The grumpy lady has clearly done this a thousand times and she has absolutely no tolerance for any of my questions. She paries my first few skillfully, but I don’t let her blunt my questions regarding the finances.

She shows me that the facility is charging me $5,600 but that fee has been reduced by the insurance to $1,799. This is an all in fee for the facility only (includes staff, equipment, monitoring, etc) and does not include fees charged by the physician and the anesthesiologist. I ask what those charges will be (I already knew ahead of time), but she says she is not responsible for their charges and that I would have to speak with those providers about that. I start asking her why they don’t bundle everything into one price so I can compare across various combinations of facilities and providers. She has no idea what I am talking about and ends the conversation by giving me their phone numbers. Take your seat Mister, how dare you ask a question about pricing comes across clearly as she stares me down to my seat.

I immediately pick up the phone and talk to the physician office. After about 10 minutes, I finally get the billing person who is able to provide me the CPT code (69436) and Zip Code (92691) as well as what they charge for procedure ($345). I tell here I am not interested in her price because it is irrelevant and that Blue Cross has already dictated the price that you are going to get. A little defensive, she then relays to me the the administratively set Blue Cross reimbursement that has been dictated to this particular physician ($208.08).  I then ask her about bundling of services and created an Ear Tube product that would include all the components so that I can compare across facilities and providers. She has no idea what I am talking about. I give her the hamburger example (I don’t get separate receipts for tomoatoes, buns, and burger – I get a single price for the thing I want – the complete hamburger). I refer her to as an example and she thinks this sounds like a good idea.  When I ask why they don’t do it now that she understands, she says that she doesn’t think the physicians would ever agree to work in that way. She tells me she will pass this along to the physicians, and with a laugh that indicates that will never happen, we end the call.

Next, I call the anesthesiologist group. First the lady attempts to tell me she can’t give the pricing because it is a HIPAA violation. I quickly disabuse her of her ignorance and get her manager on the phone. Anesthesia is unique in all of medicine because anesthesiologist charge for their time in increments called units (typically 15 minutes). So they get a “set up” fee and a “time-based” fee for their services, both in terms of units. So I ask them what their per unit charge is and the manager tells me that it is proprietary information. I call him out on it and say that pricing information is not proprietary, perhaps his costs structure is, but he has a duty to tell me the cost of the service I am about to engage him in. I am pretty frothy at this point and really lay into this guy. He still refuses to tell me his proprietary, negotiated per unit rate with Blue Cross but relents on giving me the overall price. He then passes me along to someone else who looks up in their database and tells me the cost will be either $300 or $360 for the procedure for either a 15 minute or 30 minute anesthesia time. So, knowing they go in 15 minute unit increments, I can tell that there is either 5 or 6 units involved, and therefore a $60 / unit price. So, full pricing is 4 units “setup” and either 1 or 2 units for their time. So much for your proprietary formula and negotiated pricing. $60 bucks every 15 minutes or $240/hour for anesthesiologist time. Thats mid-tier lawyer rates for South Orange County but interesting in how at least this type of physician’s time might be valued by insurance companies.

So finally, after about 45 minutes of phone time, by someone who knows the ins and outs, all the secret handshakes and covert codes, and most aspects of healthcare financing, I am able to arrive at an all in price for a very simple surgical procedures:

CPT Code: 69436
Zip Code: 92691
Facility Fee: $1,699.00
Surgeon Fee:  $208.08
Anesethsiologist Fee: $360.00
TOTAL:  $2,267.08

This is great to know the price information for my selected combination of facility and physicians. However, I have no information on outcomes achieved, safety rates, customer satisfaction, or other metrics to determine if I would not be better off with a different combination of facilities and physicians. What do you think the response was when I attempted to ask about health outcomes for my physician?

Pin drop, anyone?

This is not just another rant, but meant to highlight that the very basic, fundamental courtesies expected during a consumer transaction are all but non-existent in health care. Simple things like getting pricing information, like getting helpful customer service, like understanding what you are buying, and the quality features that attract you to purchase something in the first place. Health care should be one area where customer service is impeccable. I believe you begin to see “brands” emerge that get this, invest in it, and deliver it consistently over time. Looking forward to the ongoing retailization of health care – it truly needs it.