No contemporary discussion about healthcare and tech is complete without addressing the work currently sitting on top of Amazon's Health Care Delivery bestseller list.
I respect Topol's long track record in medicine, and his ability to crank out an entire, fact-filled book about the revolutionary changes technology is bringing to healthcare. But I'm leery of going as far as he does. As a book title from another bestselling author on disruptive innovation suggests, healthcare definitely needs to be disrupted. But I would stop short of creatively destroying it.
Why? Mostly because the many innovations Topol describes in this book are not quite ready for prime time. It's not that they won't set the theme for many years of medical innovations to come. They will. And this book, among others, will provide a blueprint for this innovation.
But science takes time, even in the Internet age. I learned this when I completed a certificate in clinical trial design and management at the University of California San Diego Extension last year.
The rush to develop new healthcare solutions is littered with stories of failure. Some of them made Topol's book. Vioxx, an anti-inflammatory drug that Topol challenged, is only one of the latest failures of the regulatory system to reign in innovation when its side effects turn deadly.
An essential paradox of The Creative Destruction of Medicine is that personalized medicine will avoid the Vioxxes of the future by tailoring drugs, therapeutics, and devices to the targeted populations that will be effectively treated, yet it does not adequately explain how the U.S. healthcare system, in its critically impacted current condition, will manage to pay for these new personalized solutions.
Topol supposes that the power of the Internet, the digitization of the human body including genomics, and the reduced need for large-scale populations for clinical trials, will eliminate sufficient waste and save sufficient money to make such personalized medicines affordable and cost-effective. I guess Topol thinks the free market, radiating from today's concierge medicine, will take care of the rest.
I am not so confident. My basis for saying so does not originate solely in my 220 hours of study of clinical trials, although my study of that badly broken system of innovation was illuminating.
Instead, I am leery because some of the assurances from academia and industry sound eerily reminiscent of assurances of the tech industry of the 1980s and 1990s that technology advancements would vastly increase worker productivity.
The fact that productivity gains remained largely flat through a period of vast investment in technology improvements meant that predicting such gains solely on the basis of Moore's Law, and the proliferation of sensors everywhere, is a risky business.
Moore's Law, as a reminder, states that the number of transistors that can be placed inexpensively on an integrated circuit doubles approximately every two years. Today's iPhones and iPads are a product of 50 years of Moore's Law.
Topol's book starts out by celebrating the many advances that Moore's Law-driven technologies have brought to so many industries—with the notable exception of healthcare, an industry he characterizes as having "hardening of the arteries."
But in the pages that follow, I find many examples of suggested innovations that I just have a hard time believing are really here yet.
For every genome sequence mentioned in the book, one could ask: How many genomes remain unsequenced? And although the cost of sequencing is dropping, what does the total tab look like for sequencing all the genomes that need to be sequenced?
Since disease management is moving to a personalized perspective, that number is bound to be astronomical. And I'm aware that in treating things like tumors, the genome of the tumor can mutate in its evolution, requiring repetitive sequencing of just a single tumor. That sounds like a lot more sequencing to me. Even if, as Topol suggests at one point, we start by looking at every base of particular regions of the genome, it's a daunting task.
It's always a struggle to know how much of a particular present-day technology to teach to students. Topol suggests that medical students no longer need to learn much biochemistry and physics, and would instead substitute learning on genomics and social networking technology, among other things. It makes good copy, but is it good science?
I'm mildly surprised that a book this recent doesn't pay more attention to the impending role that machine-driven algorithms will play in decoding the secrets of genomic medicine. I question the utility of having one's genome to browse on an iPad, even though as Topol points out, a browser for this exists.
To his credit, at one point Topol notes the risk that a new generation of digital hypochondriacs may be in the offing. I share his disgust that organizations such as the American Medical Association have opposed giving patients their full medical records, for fear of misinterpretation.
But it's also true that the vast amounts of personal medical information being liberated by electronic medical records, sensors, and remote monitoring, could unleash a new wave of medical quackery like nothing we've ever seen. A host of already-existing Web sites are leading that unfortunate vanguard.
The most problematic portion of the book may be where Topol triumphantly predicts the creatively destructive effect that social networking will have on medicine. First of all, he pays inadequate attention to the very real privacy risks that today's commercial social networks represent. A company such as Facebook is not getting rich by protecting the personal information of its members to the greatest extent possible.
Although Facebook's privacy controls are more sophisticated that any of its rivals, its arbitrary changes to its privacy policies and continued friction with governments and privacy groups is an indicator that storing one's health record in a social network is a courageous act, unless the patient is the equivalent of a digital exhibitionist.
To return to my key point, it is all well and good to say that "it will not be long until digitizing a person unlocks the root cause for what is wrong." But such short-term expectations are unrealistic.
Back when I wrote about technology strictly for an IT audience, we journalists dreaded the so-called airline magazine article effect, where a promising new technology was touted. CEOs rushed into immature technology based on those articles, and often got burned.
My heart goes out to doctors who are encountering patients who expect too much too soon based on reading Topol's book. It is the equivalent, albeit highly informed and documented, of one of those airline magazine articles.
To those who simply say it's the new taking over from the old, I'm 54 years old and still learning many new tricks. So are many of the 50-something healthcare executives and doctors I talk to weekly here at HealthLeaders. We don't need to be replaced by the digerati generation in order for healthcare to be fixed.
We are part of the solution, not part of the problem. There are bad doctors, bad executives, and bad technologies. But we the experienced ones don't need to be lined up in front of some metaphorical wrecking ball.
I was born with esophageal astresia, a condition where the esophagus ends in a blind-ended pouch rather than normally connecting to the stomach. When I was three days old, a surgeon whose name I do not know at the University of Michigan Medical School saved my life. So I guess I'm biased when I say that the U.S. healthcare system, with all its faults, doesn't need creative destruction. But it does need to be shook up, and that process is underway.
By my calculations, 2013 will be one of the trickiest years in tech since Y2K.
Why? Not because of EHRs, HIEs, or the other technology acronyms so familiar to healthcare executives. The biggest reason is the release of Windows 8, Microsoft's most radical rethink of Windows since Windows 95.
Windows remains the dominant OS in healthcare institutions, as at most organizations. The new interface-lift is expected as early as fall 2012, to be followed by a long period of upgrades and retraining. Gone will be the familiar overlapping windows and pull-down menus so familiar to Windows users since way, way back. (I used Windows 3.0 back in 1990, so I'm a longtime menu puller-downer.)
Replacing this will be the radically new Metro user interface, where applications are tiled but not overlapping, where menus and mouse movements give way largely to gestures and touch-driven commands to make applications maximize, minimize, and do cool stuff.
It's all very inspired by the success of the iPad, itself a radical rethink on the old Macintosh user interface. Apple doesn't officially support the iPad with a mouse, although at the recent American Telemedicine Conference, I saw a variety of iPads paired with third-party keyboards and even a few mice to recreate that PC experience.
Metro still retains the mouse when running on desktops, but it's the "Windows 8" name that will cause healthcare (and many users in general) the most grief. As of last Saturday, purchasers of systems with the current Windows 7 installed are eligible to upgrade to Windows 8 for less than $15.
Generally these upgrades are a headache for all of IT. It's usually better to start with a fresh system. I wish Microsoft would dispense with the whole idea of upgrading from one OS to another. There's a history of bad experiences.
However you get Windows 8, if you're used to the Windows you know and love/hate, you're in for a disruptive transition. Windows 8 removes the "start" button in the lower-left corner, replacing it with a Charm Bar that's invisible until you drag your pointer via mouse or touch to the top or bottom of the screen (or press Control-C if you're a real geek).
I understand why aesthetically Microsoft has to remove the Start button, but this is going to cause no end of grief when it comes to retraining users comfortable with Windows 7 or earlier versions. Now couple this with the trend permitting healthcare staff to bring their own devices to work, a trend accelerated by the iPad. More and more of those devices in 2013 will be running Windows 8, as Microsoft starts leaning on computer makers to ship Windows 8 as the default operating system. Based on a marketing blitz, those BYODers who don't get Windows 8 will start mailing in those $15 coupons for the upgrade.
It gets worse. There will be a version of Windows 8 for tablet computers running the ARM processor. But those tablets will only run new-style Metro applications. Older Win32 pull-down-menu applications won't even run on those tablets, but they will run on tablets powered by Intel processors. I'm not saying those applications will look good or run well on tablets, but some will and some won't. Did I mention that all these different operating systems are called "Windows"? Are you confused yet?
It's all good news for the iPad, in my opinion. At HealthLeaders Media, our coverage of the iPad in healthcare attracts huge readership numbers. But there are so many Windows users out there, and so many devices running Windows, that there is bound to be some grassroots adoption of Windows 8 in healthcare.
Of course healthcare EMR vendors will be developing Windows 8 front-ends to their systems throughout this year and especially next, and I don't envy their job. Certain ways of using EMRs will have to change, just as they have with iPad versions of those systems. This complicates training, as it won't be practical or even necessarily possible for a healthcare provider to suddenly swap out desktop and laptop deployments for touch-based ones. The new user interfaces look promising, but they are a radical rethink.
In a year when so many providers will be struggling to complete their first year of Meaningful Use implementation, those Windows 8 systems trickling in will seem like a very unwelcome annoyance. But some of those Windows 8 users are bound to be in executive suites. Good luck convincing your Windows-loving CEO that he can't have his Windows anymore or that his executive dashboard can't be made to work with Windows 8.
I should say here that Microsoft is to be commended for trying to modernize the Windows user interface. The company just picked the absolute worst time to do it as far as healthcare is concerned. But with the continuing revolutions in healthcare tech, maybe there would never be a best time.
One irony of the greatest success in private EHR implementation, at Kaiser Permanente, is that all those systems are running Windows XP, a long-obsolete version of Windows.
Extended support for Windows XP is due to conclude on April 8, 2014—less than two years away. I would bet that security patches for XP will continue to be provided for several years after that. Meanwhile, the automatic Windows Update service, whose familiar, unwanted reminders pop up everywhere from PowerPoint presentations to billboards, will be cajoling XP users (and Vista users, and Windows 7 users) to upgrade version components stat. As more and more healthcare providers turn their screens around so patients can follow along with their EMRs during consults, those pop-ups won't inspire confidence in healthcare's digital future.
Our healthcare systems are becoming so sensitive to technological considerations that Microsoft might be well advised to stage a formal clinical trial of Windows 8. The good news is, as with all clinical trials, years would be needed to complete to prove its safety and efficacy. By then, we'd almost be ready for it.
It is far too easy in this country to set up and run a pill mill. Recently I attended a session on healthcare fraud and abuse detection where a former regulator noted that in the state of Florida, all that was required to set up an online pharmacy was to prove one was 19 years or older.
Now here come federal lawmakers, trying to solve a problem that may in large part belong to the states. And one such effort, unless amended, uses such broad brush strokes that it threatens to choke off a very good technology-based healthcare program.
Mission Hospital in Asheville, North Carolina is the tertiary hospital serving the 18 counties of western North Carolina. Rural primary and secondary hospitals there are isolated and lack many specialists. Psychiatrists and neurologists are in particularly short supply.
In February 2011, new technology started offering a way for psychiatric patients in those outlying hospitals to get good specialist care without making the treacherous drive over two-lane mountain roads to Asheville.
The program uses a robot from InTouch Technologies, able to freely wander from consult to consult in the local emergency rooms. A psychiatrist sitting in Mission Hospital in Asheville is able to see and hear patients in the remote EDs, and those patients can see and hear the psychiatrist.
"It's all HIPAA-compliant and encrypted," says Carrie Castellon, director of telehealth for Mission Health.
The telepsych program was so successful that Mission Hospital added a second specialty in June 2011 to assess possible stroke victims in these EDs. Using the same robot technology to assess patients, neurologists at Mission can now assess whether clot-busting drugs should be administered to patients in those EDs. "With strokes, time is brains," Castellon says. "Otherwise, if patients were traveling to Asheville or to the closest primary stroke center, we're talking lots of minutes and lots of brains that could be lost."
Although psychiatrists can make decisions less urgently, it doesn't make sense from a time or efficiency standpoint to put them on the state's twisty western roads, and have them drive from remote hospital to remote hospital to make rounds. Patients may just end up sitting in the ED for hours waiting to be transferred to an inpatient psychiatric facility for evaluation.
In many cases, the remote consult from Asheville, using the robots, is sufficient for the psychiatrist to prescribe a new medication or change in medication, Castellon says.
But here's where those federal lawmakers enter the picture.
At least two bills pending in Congress would crack down on pill mills, those notorious health providers and pharmacies skirting the law to contribute to the epidemic of prescription drug overdoses in this country. The CDC's most recent data shows more dying in the U.S. from prescription drug overdoses than from overdoses of illegal drugs.
But the bills are written in such a way as to make illegal the telepsych consults in North Carolina if controlled substances are prescribed without the psychiatrist meeting face-to-face with the patient.
"While we support the effort to stop the inappropriate prescribing of prescriptions, this legislation could have negative and unintended consequences on important telehealth services that we deliver to our patients in western North Carolina," wrote Rowena Buffett Timms, senior vice president of government and community relations, in a letter to U.S. Senator Kay Hagen (D- NC).
As of press time, Sen. Hagen's office had not responded to my inquiry on this proposed legislation, but I hope that her effort to elicit feedback on the bill will result in an amendment that recognizes that face-to-face consultations in 2012 can also be achieved with a robot such as Mission Hospital's.
In her letter, Timms supports the effort to crack down on prescription drug abuse, unscrupulous clinics, and pill mills.
I wouldn't be surprised if technology such as robots can be used to facilitate abuse, so it may not be as simple as writing in an exception for the kind of technology discussed here. Legislation has to be thoughtfully written.
But some form of flexibility must be found to save valuable programs such as Mission Hospital's outreach to its isolated, rural population.
At the very least, the legislation must acknowledge the existence of teleconsults in the reimbursable fee schedules in use by Medicare and Medicaid.
When I suggested to Mission Hospital's Castellon that some decision makers would respond more to the money-saving elements of teleconsults than to its life-saving benefits, she echoed a sentiment I hear often: Patients need this technology regardless of how much money it saves.
One child psychiatrist Castellon I spoke with notes that delayed treatment affects her patients "personally, socially, at home, and at school, not only affecting how they see the world, but how their family and school functions."
Another branch of government, the U.S. Department of Agriculture, recently awarded Mission Hospital $419,000 to expand its telehealth program in largely rural western North Carolina.
"It's a win to the local clinic or hospital, because they won't be boarded up, because they're seeing patients, and it's a win for us because we're able to provide that care more efficiently throughout the region."
With four member hospitals already participating, and three hospitals to be added in the next year, Mission Hospital's robot-powered remote consults deserve continued support, not to get tangled up in the pill mill controversy.
Now, how about putting in some tougher licensing for online pharmacies in Florida?
If you've flown lately, you've seen them everywhere: e-books, running on Kindles, on iPads, on any number of tablet devices. Get ready to see them a lot in healthcare too.
Prompted by an announcement that yet another standard desk reference had been released in e-book form, I wonder if we've reached a tipping point yet where the standard nurse or doctor's desk reference on paper has gone the way of the telephone book. I normally recycle these phone company dinosaurs as soon as they land on my doorstep.
Think of the upside. E-books are fully indexed. Any occurrence of a word is searchable with a touch. Paper-based indexing systems just can't compete.
Publishers can update e-books as often as necessary. Paper-based desk reference books are still updated at least (and often, at most) once a year.
But e-books aren't free. In fact, according to one medical librarian I talked with recently, they can cost more per copy than the individual paper editions of the same book, particularly when purchased by an institution and not by an individual.
Healthcare costs are already skyrocketing, so the last thing medical libraries need is a huge increase in the cost of acquiring the books and journals they require to keep clinicians well-informed.
Some medical libraries rely heavily on their version of the interlibrary loan program one finds at many public libraries. When the book in question is an e-book, however, that medical library has to negotiate successfully with the e-book publisher to permit interlibrary loans, which often take the form of producing a PDF of a particular journal article or chapter and providing just that PDF to the requesting medical library.
Some e-book publishers are having none of that, however, prohibiting interlibrary loans of their e-book titles. So the great benefits of e-books end up begin matched by the aggravating complexities of license agreements and digital restriction management. (Don't call it digital rights management.)
It came as a mild surprise to the medical librarian in question, Michelle Kraft of the Cleveland Clinic, that the new e-book that I'd learned of was being offered at the same price as the paper equivalent.
Kraft is a thought leader in this area, having presented to the Medical Library Association in 2010 on e-books. Kraft evaluates and implements online resources for use within the Cleveland Clinic health care system.
"That tipping point I don't think is going to happen tomorrow," Kraft says. "I think we're in the process of tipping. It's a long process."
The past four years have seen another tipping point of sorts at the Cleveland Clinic medical library. Four years ago, it had 800 subscriptions to print journals. Today, that number is down to eight. I had to ask Kraft to repeat that number to be sure I had heard her correctly.
Of course those journals are still available at Cleveland Clinic, only now they're electronic edition. But typically, access is via a Web browser. And with journals in particular, the notion of an interlibrary loan can go away once it's in electronic form.
I've seen journals that are accessible only within the computer networks of a particular university, for example, but not from the larger Internet, due to licensing restrictions.
Then there's the lag that many journals have in reaching the platform of choice: the e-book. Many electronic copies of journals are still browser-based, not e-book based, Kraft says.
Cost is a big concern for medical libraries. Cleveland Clinic's library budget is basically held flat, with increases for inflation and for "explainable increases" in subscription rates, Kraft says. Moving from a book to an e-book can be one of those explainable increases.
When the publisher Lipincott approached me to tout its new e-book version of The Nursing Drug Handbook, I got a chance to speak to the publisher's chief nurse, Judith McCann MSN RN. I suggested to her that the current shortage of nurses and doctors suggests it's time for a revolution in the education of nurses and doctors in training. Could e-books be it?
"The amount of information [nurses and doctors] have to absorb today is phenomenal," McCann says. "The books themselves have probably quadrupled in size in the last 25 years."
So if nothing else, toting around the e-book version on a tablet is a lot less effort physically. Add to that the fact that the drug interactions in the new Lipincott book get updated weekly, based on new data from the FDA, and then add in the easy search and other e-book features, and it's hard to make a case for staying with paper.
Demand for even the paper drug references is such that nurses and doctors who don't get copies issued by their institutions often end up beyond them and paying for them out of pocket. That could be a considerable extra cost, so hospitals should defray or underwrite this cost as a component of keeping employee satisfaction high.
Some reading this might counter that electronic medical records come with their own drug interaction database. I asked McCann about this.
"A lot of those EMR drug interaction systems are pharmacy-based," she says. "We use nursing considerations. For example, one adverse reaction to a drug might be dry mouth. We say remember to encourage the patient to drink or do something to alleviate the dry mouth. That's nursing care as opposed to medical care. We turn it into the nursing actions that are related to that particular drug."
The e-book is only going to grow in importance in healthcare. Consider the ability on many e-book platforms for the reader to easily highlight material. Now add a social element. On the Kindle, e-books I've read can display highlighted passages as gleaned from other readers of the same book. It's another great way to learn and keep current.
Let's just hope in the rush to electronic medical records that e-books remain affordable and accessible. Let's hope some of what made traditional medical libraries great, such as interlibrary loans, remains a part of the solution.
The transition away from print journals from great institutions such as Cleveland Clinic is bound to impact smaller medical libraries that can't afford their own medical journal subscriptions and have relied on interlibrary loans.
McCann told me one other poignant story. It seems that back in her hospital days, some of the paper references had a habit of walking off. So nurses drilled a hole up in the corner of the book. "We took a chain and attached it to the drug cart," she says.
That's testimony to the power of information in healthcare, and the lengths to which staff will go to have access to it. In the brave new world of e-books, we have to preserve and expand that access.
If Marcus Welby, MD, were practicing on TV today, would he be letting data drive his decision-making? I'm on a journey to find the answer to this and related questions. Last week this journey took me to Atlanta for a HealthLeaders Media Roundtable on business intelligence and predictive analytics, and then onward to North Carolina for a conference dedicated to healthcare analytics.
While in North Carolina, I got to sit down with Don Berwick, MD, former administrator at the Centers for Medicare & Medicaid Services, and prior to that, founding CEO of the Institute for Healthcare Improvement. We talked about data analytics, but our discussion ranged far and wide around healthcare IT. Here is a portion of our conversation.
HealthLeaders Media:How far along is healthcare with its adoption of analytics? Berwick: I certainly see the potential. At CMS we did do some early trials with Oak Ridge National Laboratory, which has tremendous data capacity. [CMS] gave them access to privacy-protected Medicare information. They have tremendous analytic capacity, and it was stunning what they did. I remember visiting Oak Ridge, and they had modeled some uses of Medicare and Medicaid data, and they were coming up with insights right away, of geographic patterns of variation that I don't think Health Services researchers knew about.
HealthLeaders Media: Why was Oak Ridge doing this? I don't think of them usually in this space.
Berwick: Oak Ridge is not just a Department of Energy supplier. They work with other government agencies that want to contract with them to do essentially analytics and data mining. The one place I saw analytics working was in our early work on predictive analytics for fraud. The Affordable Care Act suite of efforts to reduce fraud involves the traditional what they call pay-and-chase, which is enforcement. You find something wrong and you prosecute. We were working with the Department of Justice and the FBI and local law enforcement to catch criminals. That's traditional and effective. You need to do it. But it's, after all, after the horse has left the barn.
So upstream from that, there's prevention. Make sure that the people that want to offer home healthcare or durable medical equipment, that they're qualified to do so, they don't have a history that makes you suspicious, and since there's a very high concentration of fraud in certain parts of Medicare payment, one's able to target prequalification as an area. But I thought the most promising was predictive analytics, which was take the data and turn loose the ability to go through it looking for weird patterns. The technology was ready.
Along about this time, I took a vacation with my wife in Turkey. I got online to buy a ticket for an internal flight in Turkey from Istanbul to an interior village, and I'd say a minute or two later, my cell phone rang, and it was American Express saying, "Just checking—a purchase was made in Turkey. Is this you?" Well it's the same thing, where we can get not just retrospective but almost real-time signals. I remember the first run of predictive analytics, the volume of insights and ideas and hot spots that were spotted, it was really something.
HealthLeaders Media:I was listening to a podcast with Dr. Lynn Vogel, CIO of MD Anderson Cancer Center, who told an interviewer that the number of facts going into physicians' decisions on treatment is growing exponentially. What's the healthcare system going to do about that?
Berwick: It is doing [things] about it. I don't know what Dr. Vogel meant by that comment particularly, but there are at least two meanings. One is that the science base is expanding vastly. A few years ago, I did a Google search to see how many randomized clinical trials in the world are underway right now, and the number that came up in the search was 40,000. At any one time there are 40,000 randomized trials underway. The concept that an individual human mind could possibly search through that and find out what's relevant to your needs when I see you in my office, that obviously is folly. There has to be some intermediation of the science so that someone, some technologically supported, trusted agent is digesting that and making it available. We're quite a way along there. We've had wonderful work, professionally led by the American College of Physicians and the American College of Surgeons and the cardiologists to do exactly that: intermediate between the scientific wealth and direct application. So I think that's going okay. I'm sure it could be better. There's been some ambivalence in public policy around this. This is the big debate about clinical effectiveness research, which is this kind of confusing question as to should we use science in decision-making? We actually are asking that question. Hopefully we'll get over that at some point.
On the [care] delivery side, the data stream is overwhelming now. Every beep on a monitor is a data point. There are some successes. For example, Intermountain Healthcare has for years had in the ICU real-time data collection, multiple facts about a patient that can help guide action in real time. You'll see more and more of that. I don't think that's conventional. I think most docs are still bathing in that kind of data without much help.
HealthLeaders Media:In all the debate about Meaningful Use, it seems to me that the incentives don't encourage knowledge transfer from the successful innovators, like Intermountain, to those who are following.
Berwick: We're just barely in Phase 1. The concept of meaningful use is going to grow. What doctor in the end would not want access, if it were technically available, to the answer to the question, Who does the best at this, or What does Mayo think, or Where's the best science? We're just in an adolescent moment in terms of evolution of that kind of knowledge transfer. Right now, my daughter is a second-year resident in medicine at the Brigham hospital in Boston. When I was in training, the message was, put it all in your head. Get it in your head. Read it, memorize it, and then spout it out at Rounds. They carry their iPhones on Rounds. So a question comes up, and they're using their iPhones and iPads right there to get the information. Why would they store it in their head if it's in the world? That's a basic human factors design idea. Knowledge in the world is more useful than knowledge in the head. Young doctors and nurses are coming from a totally different mindset about access to knowledge.
Not long before I joined HealthLeaders, I found myself engrossed in a subject that involved technology and medicine, but took place far from the operating room.
The subject was mountain climbing. And the parallels to health system leadership are many. I'll explain. Scaling one of the world's tallest peaks remains an expensive endeavor. Not all calamities can be foreseen. Risks are high. Public exposure is great. (These days, many mountaineers tweet their way to the top.)
In each endeavor, technology continues to make great strides, but often requires a leap of faith, and months, if not years, of preparation. And yet, the best expeditions are guided by seasoned veterans who've often learned the hard way, through failure.
In healthcare, as in mountain climbing, there is great pressure and prestige in being first. But what's playing out now in healthcare technology is, in part, the downside of being first. In mountaineering, trying to get to the top first, you can end up like George Mallory did in 1922: dying somewhere short of the summit.
In healthcare, those who rushed into a hodgepodge of electronic medical record technology a few years back are now, sometimes, paying a bitter price. They may have realized incremental savings on this or that subsystem, but these systems may not talk to each other, and have no easy way to be upgraded to do so.
Along comes the juggernaut that is Meaningful Use. Like an unwanted early summer monsoon in the Himalayas, Meaningful Use deadlines are staring healthcare providers in the face. In the Himalayas, competing mountain-climbing teams must learn to cooperate and coordinate their expeditions if all wish to reach the summit and descend before the bad weather moves in.
Healthcare isn't so lucky.
Nowhere does that scramble present itself right now like the comments flowing into the Centers for Medicare & Medicaid Services as the deadline approaches for feedback on Meaningful Use Stage 2 rules. Even with a year's delay, extending Stage 1 into 2013, it's inevitable that in the course of climbing the Meaningful Use mountain, the stronger teams will pull farther ahead, and the weaker teams will fall further behind.
How one reacts to this development probably speaks to one's political leanings. In mountaineering, there are those who feel that strong climbers should make allowances for weaker ones, and there are those who feel just as strongly that strong climbers deserve the prerogatives of their abilities.
On the slopes, though, there are inevitable conflicts. Weaker climbers start earlier and clog up fixed lines. Stronger climbers may have to start even earlier to avoid climber traffic jams, or if they start later, must carefully wind their way around the weaker climbers—a risky maneuver.
In the healthcare world, our equivalent of these bottlenecks is the handful of vendors implementing most of the Meaningful Use electronic medical records in software. Some are like the toughest mountain guides, demanding much preparation on the part of their customers before they can even get their number on the waiting list.
Other vendors may be bogged down, spending 80 percent of their effort on a small number of providers who bring a disorganized hodgepodge of existing systems to the table and expect the vendor to work miracles, while well-prepared providers languish, waiting for their numbers to be called.
In the tough and unforgiving mountains, miracles are few and far between. Teams can only do so much climbing each day. In tech, it's been demonstrable for nearly 50 years that adding people to a software development project doesn't even linearly improve productivity of that project. The reality is somewhere far shorter than that.
So, what to do? Should we really slow down the Meaningful Use movement to allow the weaker climbers to catch up?
It all depends on what you define as success.
In mountain climbing, only one climber in each expedition is going to be first to the top. That climber will often garner all the accolades while fellow climbers, maybe only a few minutes behind, often play second fiddle in the media and the history books.
In technology, healthcare leaders often pride themselves on being first. That isn't going to change, no matter what Meaningful Use rules CMS devises, or how they change after the end of this comment period.
My own opinion is we should let the smartest, most clever, and most well-provisioned Meaningful Users get to the top at their own pace. They should not let anything the rest of the climbers are doing slow them down. Compelling success stories, as you well read in these pages, will inspire those coming behind them.
If that means letting some of the better-prepared providers jump their place in line, so be it.
But we should also give a helping hand to those climbers who are struggling. They may not have the best equipment. They may have great challenges in other areas of their enterprises. It should be possible for the leading practitioners of Meaningful Use to pass along their expertise, just as veteran mountain climbers do.
So in general, let's sweeten the incentives to achieve Meaningful Use in all its stages, and lessen or postpone the disincentives. And let's also apply our knowledge as an industry as widely as possible. The worst mountain climbing disasters usually occur because of ignorance of conditions.
Let's find ever more ways to network to each other to see that all get to the goal and back safely. As mountain climber Ed Viesturs likes to say about climbing, getting to the top is optional. Getting down is mandatory.
Flying cars. Teleportation. A cure for the common cold. Voice recognition.
The future always seems to never arrive. But get ready to start checking that last one off your list.
I've been following efforts to get voice recognition going since, well, Captain Kirk spoke to the Starship Enterprise's computer back in the original Star Trek TV series in the 1960s.
Now, there's a hospital in Chicago that would recognize everyone on that bridge from Kirk to Mr. Sulu and even Ensign Chekov.
At Advocate Illinois Masonic Medical Center, a 410-bed hospital south of Wrigley Field, the future has arrived. Eighteen months into a full rollout of voice recognition–powered technology, physicians and other staff have replaced their paper notes with 25,000 voice- and keyboard-generated notes per month.
Equally powered-up is Adem Arslani, MS, RN, director of information systems and clinical informatics at Advocate Illinois Masonic. He had plenty to say (naturally) when we spoke last week.
Voice recognition turns out to need a few things that weren't around in the 1960s when IBM first started attempting it, using the entire power of a mainframe. Those things, in decreasing order of importance, are: lots of CPU processing power, really good microphones with noise cancellation technology for noisy hospital environments, and software that knows when to suggest something and when to get out of the way. The final, nontechnological, component is commitment from the CEO on down to make it work.
Today the technology is on such a roll at Advocate Illinois Masonic that the CEO makes time to gently remind those straggling physicians still dictating their notes for expensive transcription that there is a better way that costs less, and it's running at every desktop in the facility.
The transition started, as it often does, with a crisis, in the form of the Joint Commission, which a while back visited Advocate Illinois Masonic because of some issues about illegible paper documentation.
With an imperative to improve documentation quality and drive adoption of the hospital's electronic medical record, Arslani and his team selected a leading voice recognition technology and set about creating numerous templates and macros to implement Advocate Illinois Masonic's physician workflow at the service level.
The base technology and add-ons customize the experience for physicians and organize all their commands and templates in a way that can be accessed from the handheld microphone they use for voice input, Arslani says.
"The first thing the physician will do is push a button … so they can see all their templates," he says. "They just select a template or speak into it to generate that template right into the note."
Arslani's got it even worse than the bridge of the Enterprise, with 27 different languages spoken at Illinois Masonic. But the software is up to the task. "The great thing is it actually compensates for heavy accents and the accuracy is quite impressive," he says.
When the project began, Advocate Illinois Masonic spent between $40,000 to $45,000 a month in transcription costs, and employed 6 ½ full-time-equivalent internal in-house transcriptionists. Today, the costs have plummeted to $3,000 to $8,000 a month and the FTEs are gone.
Only 30 to 40 physicians still dictate for transcription, and these are physicians who don't practice frequently at the hospital. By July, to entice these stragglers to join the voice recognition revolution, Arslani's team will let them perform voice input even from their home computers, using ordinary PC microphones which are sufficient in the quieter home environment.
Other incentives will help get stragglers there as well. Templates in the software can prompt physicians to comply with various regulations, Arslani says. For instance, all procedure notes must include the following statement: "The integrity of all instruments and equipment used on the patient during the procedure remained intact after use." All the provider has to do is use a command to insert the sentence into the note.
Now, no system is perfect, and if speech has an Achilles' heel, it's probably the ambiguity built into the English language. "Sometimes it picks up a different word, and we even show that in our demonstrations," Arslani says. "Down in medical records, they pick these things up and get right to the physician. After a while, physicians are cognizant of that. But I've got to tell you, [overall] it makes the doctor much more efficient. From the quality of the documentation, it is far superior than the written note."
That difference is one of quantity as well as quality. Physicians do five times as much documentation as they did on paper systems, Arslani says. "Before, we were only seeing maybe one note per patient day," he says. "Now we're seeing 3 ½ to 4 ½ notes per patient day. That's incredible!"
The voice recognition tools make EMR adoption essentially a done deal. Advocate Illinois Masonic attested to Stage 1 of Meaningful Use last September, and is on track for Stage 2, Arslani says.
"We've worked awfully hard these past 3 ½ years to get where we are, and I have to tell you our demand for site visits has gone through the roof," he says. A CIO from Australia who recently visited pronounced it the highlight of his site visit, he adds.
If you want resource-intensive voice recognition software, get ready to roll out current PC hardware if what you have is aged. Arslani recommends PCs with 2 gigabytes of RAM minimum, even better with 4 gigabytes. A 100 megabit-per-second local area network is a must. Advocate Illinois Masonic opted for 1 gigabit-per-second for each desktop. These days, that level of throughput doesn't cost a lot more.
Part of what triggered my interest in voice recognition was the popular column I wrote last week on whether EMRs are killing the traditional narrative. We're at a dangerous point in EMR adoption where the prevalence of older point-and-click EMR interfaces provide digitized healthcare—but at the cost of a lost narration and even repetitive globs of text cut-and-pasted into EMRs by rushed physicians.
Talking to Arslani, I see hope that incorporating voice recognition into the solution can help with both problems. Physicians freed from the keyboard leave demonstrably richer and lengthier notes in EMRs. And the narrative flow, though different than what came before on paper, isn't lost, just evolved.
Still, even after 50 years, voice recognition is in its early days. Systems still have to be trained and are best used with the kind of templates described here. The current state of the art doesn't mean we can leave voice mails that some computer will understand. So more work remains. It will be interesting to see where voice recognition is in another few years, in healthcare and in society in general.
Lyle Berkowitz, MD, has graced the pages of HealthLeaders Media before, but with the new twist his story is taking, healthcare technology leaders everywhere should take notice.
Berkowitz had recently founded the Szollosi Healthcare Innovation Program while continuing his primary care practice at Northwestern Memorial Physicians Group, the largest primary care group in the city of Chicago.
Now, in addition to these ongoing duties, add entrepreneur to his CV. In the process, he's using more technology to disrupt current healthcare best practices.
"I'd argue that primary care physicians should never have to be directly responsible for preventive care measures," Berkowitz says. "When I say that, people gasp. But when you look at the most efficient clinics and some of the highest-quality clinics, they actually have shifted a lot of that work to nurses who are very focused on that particular issue."
Back in 2010, Berkowitz was speaking on this very topic at the Mayo Clinic's invitation on how EMRs could make doctors' lives easier. In the audience were two young aspiring consultants who got so excited about a mock-up Berkowitz was showing, they proposed a new company to put actions behind Berkowitz's philosophy and inspiration. Thus was born Healthfinch. Berkowitz is chairman and chief medical officer and leaves the day-to-day operation to his partners.
Today, Healthfinch ties into most popular EMRs and runs prescription refill requests through a Web service, making it simple for physicians to delegate those refill requests to nurses and other medical office support staff.
At Elmhurst Clinic, based in nearby Elmhurst, Ill., one physician using the Healthfinch service is seeing real productivity gains. He sees less than half the refill request messages he used to see, according to Elmhurst Clinic CEO Donald Lurye, MD, MMM, CPE.
"The management of refills is a major activity, particularly in primary care where you're dealing with a lot of people with multiple chronic illnesses, that can have complicated prescription regimens and necessarily so," Lurye tells HealthLeaders Media.
"Dealing with refill requests sounds simple but it isn't. Many times, there's a need for a physician taking a look at a chart to decide whether a refill is appropriate. It can involve checking to see whether various types of follow-up have occurred, or whether certain lab tests have been done in a timely manner, that either just need to be done for monitoring or should be there to guide the therapy."
Healthfinch's rules-based engine, configurable by the Healthfinch staff in collaboration with customers such as Elmurst, automates the decision-making and offloads it from doctors.
When I first heard of this concept, I figured there might always be some super-cautious, belt-and-suspenders type physicians who would still insist on checking every detail.
"First of all, the protocols that Lyle presented to us initially were very conservative, and correctly so," Lurye says. "In fact, in his own personal use, he was still looking at every refill request. He just wanted to see, 'Okay, these are the things I think can be done automated. Now let's see if I actually agree with myself.' And we did the same thing here. And we've kept it fairly conservative. So that's one answer.
"And again, if we ever needed to they're fairly easy to adjust."
As for the rest of the care team, "it really makes them feel much more like participants," Lurye says. Refill requests can be "opportunities for patient education and encouraging people to come back in for necessary care."
Deployed initially in primary care, the Healthfinch service will find its way into Elmhurst's specialty practices, Lurye says.
Healthfinch is extracting info from the NextGen EMR in use at Elmhurst. I was surprised that existing EMRs don't yet have the refill-request-delegation features built into them.
"The evolution of EMRs didn't really come from the clinical side so much," Lurye says. "The real return on investment on EMRs initially was that they helped to do charge capture better and meet coding criteria for various types of visits. They've become over time much, much more clinically oriented, and that's great."
Berkowitz sees EMRs as a platform on which a multitude of apps can be built, much as apps now get built on mobile platforms such as Apple's iOS or Google's Android.
"EMR vendors are pretty much focused on Meaningful Use right now," he says. "Nothing in Meaningful Use really says, 'Make a tool that makes the doctor more efficient.' Our tool doesn't help Meaningful Use. It simply helps the doctor be more efficient and provide higher-quality care."
EMR vendors are beginning to open up their platforms to allow third-party vendors to build these apps. "Allscripts and Greenway are leading the charge," Berkowitz says. Others will follow. For now, that means apps such as Healthfinch have to find more cumbersome ways to extract and use data.
But clearly this notion of EMR apps is going to be much, much bigger than just delegating refill requests. The healthcare ecosystem, ranging from payers to caregivers and encompassing financial analysts, quality mavens, and researchers, is starting to tap vast quantities of patient data that will accelerate the pace of innovation in healthcare technology by leaps and bounds.
To me it's very encouraging that there are physician-leaders such as Berkowitz who, while keeping their day jobs, have found ways in their spare time to advance this ball. The message is clear to healthcare technology vendors: If the Lyle Berkowitzes of the world can get this done, you should, too—and more.
I've attended hundreds of Silicon Valley technology conferences, but last Saturday was the first one led by a hospital executive determined to disrupt how tech improves patient health.
Paul Tang, MD, is vice president and chief innovation and technology officer at the Palo Alto Medical Foundation (PAMF), a Sutter Health affiliate with 1,200 physicians in Palo Alto, CA.
What Tang is doing challenges our conventional thinking about how technology gets developed in healthcare, by borrowing from techniques that are all around Silicon Valley.
Tang has issued a challenge to developers: Create a low-cost, hospital-backed social safety net for seniors.
"The hard part about doing these new things, these disruptive innovations, isn't really about coming up with the ideas," Tang told a packed room at the Computer History Museum in Mountain View, Calif. "It's really about getting the old ones out."
In a study released six months ago, Tang said, a review of 26 readmission prediction models, two found that perceived social isolation—rather than actual isolation—was a more important determinant of bad outcomes than any objective measure of social isolation. Individuals with adequate social relationships have a 50 percent greater survival rate than those with poor or insufficient social relationships. It's as big a factor to survivability as smoking cessation.
In studies PAMF conducted, one quote from a senior stood out: "Your world dies before you do." Anecdotal evidence abounds regarding the quick decline of surviving spouses. Tang's developer challenge aims to do something about it.
The project goes by the name linkAges and Tang kicked it off April 14 with a hackathon and a rousing speech by newly-appointed U.S. Chief Technology Officer and Assistant to the President (and former HHS CTO) Todd Park, among others. The "big, hairy audacious goal" is to create a hospital-sponsored social safety net for seniors who need rides or other support and in return can offer their own skills and talents, such as gardening, in a barter system that ends up costing the hospital system practically nothing.
The primary enabling technology is the mobile phone, now ubiquitous, with apps powered by vast amounts of free U.S. government data, published in machine-readable form, and ready to present to seniors everything from the locations of farmer's markets to directories of healthcare facilities.
In the process, seniors become engaged, energized, develop new bonds, and are motivated to seek out and ask for help.
It's the next step beyond meaningful use. Call it Meaningful Life. "What if we created activities of meaningful life and supported that instead?" Tang asks.
Undergirding and supporting all this will be a network of sensors, many connected to those mobile phones, which will detect any changes in daily living patterns of seniors. This technology, famously championed by Intel Fellow Eric Dishman for the past ten years, extends the telemetry of hospitals into the home, and aims to track changes in physical condition on a moment-by-moment basis, between doctor visits, which is when those changes occur anyway.
This level of healthcare system knowledge of our lives will creep out some people. I certainly wouldn't feel comfortable with my health insurance company knowing too much about my activities of daily living. But for seniors living in isolation, this trend has been coming for a long time. Japan is way ahead of the U.S. on this one, even investigating robots in the home to assist seniors.
The true disruption of linkAges is imagining the hospital or healthcare system as the hub of the social network despite these concerns. Certainly there are lots of social networks already, and in Silicon Valley, the thought of one more triggers groans from the digerati. But your garden-variety social network such as Facebook doesn't have at its core the notion of improving health, let alone something as specific as looking after seniors with an eye toward cutting readmission rates.
If this is played right, healthcare systems can become change agents for lots of ills that afflict communities and inform population health concerns. Park pointed out one health app in particular that won last year's HHS competition. Food Oasis. It allows seniors (or anyone) living in one of the infamous "food deserts," where fresh fruit and vegetables are seldom sold, to text their requests to a farmer's market which then would set up local deliveries—a system that can also lower the cost of fresh foods to all by creating a delivery mechanism more efficient than traditional grocery stores.
I will be very interested to see what apps the linkAges competition produces when the accelerator hits its July 30 deadline for the first round.
I'll be even more interested to see what DIY social services develop around PAMF when those apps hit the street, and how those apps affect readmission rates for PAMF. I also suspect this is the first of many hospital-led challenges to use communities, developers, and technology to disrupt the pace of change in healthcare.
Technology can be a wonderful thing. It can also be a cold and dehumanizing thing.
Unfortunately, in medicine, that often happens with one and the same device.
The very instruments that diagnose and treat us can often make us feel more like test subjects than patients receiving care. Anyone who's ever had an MRI knows the device that can find what's ailing us is also oppressively big and noisy. Woe to you if you're claustrophobic.
But technology is now being applied in the interests of healing the entire patient—mind, body, and soul.
It's happening in a big way, perhaps appropriately, next door to Hollywood, where the entertainment industry cranks out one technology-fueled blockbuster after another.
At the two-year-old Roy and Patricia Disney Family Cancer Center in Burbank, CA, patients receiving radiation at the oncology department don't just get an identifying wristband when they check in. They also get a radio-frequency identification (RFID) card.
Now, you'd expect the card to be able to let staff easily locate the patient, but what you might not be expecting is that every exam or treatment room the patient visits can sense them and adjust the room to their preferences.
Using a keypad, "they can actually preprogram their card for their music, their scenery, their temperature, and their color scheme," says administrator Jennifer Schaab. During any future visits, the card remembers these previously set preferences and more—even video—from the minute they walk in the door until the minute they leave.
For patients receiving radiation 10 to 30 times, "usually radiation is not something you want to remember," Schaab says. "This just helps to relax them and give them the control back again."
Perhaps the first center of its kind in the U.S. to employ this technology, the Disney Family Cancer Center was a project of the family of Roy Disney, nephew of Walt Disney and a longtime executive at The Walt Disney Company. The family worked with the Providence Saint Joseph Medical Center, where the Cancer Center is located, to raise the money through their foundations to build and operate the center.
I believe that what they've built is a harbinger of a kind of personalized ambience that eventually will inform a lot of patient care both inside and outside of hospital walls. The technology involved, like many that came before, is riding down the cost curve from rich person's plaything to another tool in the modern architect's toolbox.
Right now, the Disney Family Cancer Center is a showcase for several vendors whose technology went into building the environment, Schaab says. "Elekta provided all of our machines and our electronic medical record, JCI is the liaison that had to connect all of our different systems together, and Connexall is what we used for this RFID system," she says.
It all started with the vision of the center's medical director and previous service area director. "We wanted it to be very patient-centered, and really about healing the mind, body, and soul," Schaab says. "With that in mind, we really just started looking forward to all the futuristic opportunities that were out there, and when we learned about this, we just couldn't say no and kept moving forward."
The radiation department sees about 2,600 new patients a year. Providence Saint Joseph absorbs the cost of the RFID system so that it doesn't increase the patient's cost of care.
As yet, there's no data to show that the more pleasant experience has a material effect on the health of the patients. "Nothing has been published yet," Schaab says. "Patients always say how wonderful it is to be able to have this control back in their life on a day when they have no control. In the cancer world, everything's taken away from you. So now we're giving them back some of that control.
"We've had patients who may need to go into a meditative state to really relax themselves before getting radiation. They may be claustrophobic or have a lot of anxiety, so this really has helped to alleviate those symptoms," she says.
While all the evidence may not yet be in, all around healthcare, patients and their loved ones are taking control of their experience, and technology often plays a part. Patient advocate Regina Holliday, who lost her husband to kidney cancer, blogs and shares her paintings online as a form of healing and as a way of raising concerns about patients receiving appropriate care.
And much closer to home, my own wife, River Abeje, just won honorable mention at the 2012 International Black Women's Film Festival for a movie she made on her iPhone during her treatment for and recovery from breast cancer in 2008 and 2009.
So I know firsthand how powerful a force even the simplest technology can be in healing. As we continue to deploy one amazing technological advance after another, let's remember to heal the entire patient, and let them have as much control as they can along the way.
