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Digital twins of hearts could help diagnose and treat cardiac disease This piece from The Economist describes efforts by a group, based in Belgium and England, to create a digital version of an individual’s heart that can be used for simulations and problem solving, based on their unique organ. It’s a technique that has been …

Technology and Medicine Read More »

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In 1999 McGraw-Hill published a book, co-authored by Jeff Bauer, a prominent health futurist, and me, a frontline rural family doctor, entitled Telemedicine and the Reinvention of Healthcare. Telehealth was so promising, we said then, that we expected these technologies to lead the way to not just reforming, but to reinventing healthcare. We asked the …

Telemedicine and COVID-19: I Was into Telemedicine when Telemedicine Wasn’t Cool Read More »

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When I was an intern at Cook County Hospital in Chicago, for each of our patients who didn’t make it, we house staff received a good mark on our academic record if the family consented to an autopsy. Autopsy rates were also taken into account when the medical training institution itself was up for re-accreditation. …

Whose Record is it Anyway? Read More »

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The electronic medical record (EMR) has delivered on some on its promise to put patient information at the fingertips of the practicing clinician.  Before the EMR, I’d wistfully read about airplane mechanics who carried a tablet that served as a gateway to everything there was to know about the plane they were working on, as …

Godzilla vs. Megalon Read More »

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Here’s the gist of a conversation I just had with a longtime friend.  Patty’s practiced a couple of medical subspecialties, as well as completed a rigorous fellowship in medical ethics.  A ton of experience caring for patients, along with her intelligence and compassion, has made her pretty wise.  This is a doctor who gets both the intellectual and the emotional pieces of being a physician and a healer.

The conversation naturally turned to one of our favorite subjects, the poor medical care that results way too often when doctors don’t listen to patients.  She told me about a demented old woman she’d just been asked to see.  Four days prior, this unfortunate patient had landed in the intensive care unit after suffering a disastrous medical event.  By the time Patty saw her in the ICU, the woman had a tube in her mouth with one end in her trachea and the other attached to a respirator that breathed for her; an IV poking out of her neck that delivered fluids to the central veins in her chest, and another line that reached into her heart all the way from an artery in her wrist.  No doubt there was a catheter in her bladder too.

It was my friend’s job, as the ethicist attached to the intensive care unit, to talk to the family about how they wanted to proceed.  Even among professionals who encounter death and dying all the time, many are surprisingly uncomfortable with talking to patients and their loved ones about resuscitation status.  Death is a scary subject.  Years on the front lines as a hospice physician and ethicist have made Patty comfortable with, even eager to ask these difficult questions because, almost always, it’s a great relief for people near the end of life to be asked directly what they want and be given the opportunity to respond with clear, honest answers.

This old woman’s family, upon being posed the dreaded question of code status, answered, immediately and definitively, that their mother, wife, grandmother, did not wish to be resuscitated; that, in fact, she never even would have wanted to be intubated.  So the ethicist/physician informed the staff, who immediately turned off the respirator and removed the endotracheal tube.  She died peacefully a few minutes later.  In the meantime, Patty went to the computer, called up the patient’s electronic medical record (EMR), and checked the boxes for “Do Not Resuscitate” and “Do Not Intubate.”

It was that simple.  When I was in medical school, long before there were EMRs, we used to say, “When all else fails, talk to the patient.”  If the people taking care of that old woman had just bothered to ask her family what she wanted before they placed her on the slippery slope of intervention that comes with a bed in the ICU, huge amounts of suffering and expense could have been avoided.  This is an example of how a simple EMR checklist, by reminding providers to ask a question and document the answer, could have been a tremendous boon to the quality of care.  If only the professionals had used it.

Unfortunately, the electronic medical record, with its endless checklists and cut-and-pasted gobbledygook, too often gets in the way of asking the sorts of questions and documenting the answers that are crucial to caring for a patient.  Ethics consults are not a billable medical service.  Patty can afford to ask open-ended questions because nobody in the business office cares how many boxes she checks in the EMR when she records a patient encounter.  In general, the more items a provider can document they inquired about or examined, the more the billing office can charge.  If a doctor clicks to indicate they have asked about urinary burning and poked the belly of the patient, that counts as one system queried and one examined.  On the other hand, there is not an box to check that indicates a bone marrow transplant patient is so concerned about his 8-year-old daughter who has missed a week of school because of a cold, compounded by worry about her father and conflict with the grandmother who’s caring for her, that he’s threatening to leave the hospital and return home immediately, in spite of the increased risk of acquiring a fatal infection on the outside.

My friend can type such a story into the EMR or even dictate it and have an automated transcription system turn it into pretty good prose.  She tells me nurses and doctors often go to her notes, written in English, to learn so much more about how their patients are doing than vital signs, laboratory results, imaging reports and lists of checkmarks from the clinical encounter can tell them.  When she needs to know something about her patient beyond the homogenized data that appear in the EMR, Patty actually talks to the patient’s doctor or, even better, to their nurse.

Certainly, we cannot practice medicine without real data.  But if we don’t have the real stories too, we’re being mechanics, not doctors.  People are people, not machines.  What makes us tick cannot be reduced to blueprints.

How to do justice to both data and story is the crux issue for the EMR.  So far I have not seen a good solution on the horizon.  Before too long, I hope, artificial intelligence will get good enough at turning narrative prose into usable data that we can have our story cake and eat the data too.

Beyond the crucial pieces of information that are left out now when we care for people, what scares me most is the way that cramming the process of care into what fits into the schema implicit in an EMR (no matter how detailed the blueprint) transforms how we think about caring for people.  It’s always been hard to get medical students to ask open-ended questions.  I worry that today’s trainees are so comfortable with their eyes on a screen and their fingers on a keypad that it’s harder than ever for them to learn the value of looking a patient in the eye, taking their hand, and asking, “What scares you?” then sitting back and listening for the answer; not to mention documenting that information in a way that is of use to the person working the next shift in the ICU.

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In May 2017 the Boeing Corporation, legendary for the safety and performance of the aircraft it has produced since 1916, rolled out the latest update of its workhorse 737 passenger plane, the 737 MAX.   Seventeen months later, in October 2018, an Indonesian Air flight crashed, killing everyone onboard that 737 MAX.  Five months after that another 737 MAX, this one flown by Ethiopian Airlines, fell from the air, with the loss of all passengers and crew.  A total of 346 people died in these 2 tragic events.

The Boeing 737 MAX is constructed from 367,000 parts, strung together with 10 million lines of computer code.  It’s a wonder that any device this complicated can fly at all, let alone be entrusted with hundreds of lives, day after day, year after year.  Nevertheless, the 737 MAX is a bone-chilling exception to the amazing safety record of modern aviation.  The plane is still grounded, as investigators pour over everything from crash debris to corporate minutes.

Here’s an emerging picture of the 737 MAX disasters, as reported in the December 23 issue of Bloomberg Business Week.  (The story is in Business Week because, needless to say, the loss in money is huge, about $5billion so far; in reputation, it’s incalculable.)  “…the most fundamental breakdown at Boeing may have been a lack of appreciation of how humans respond under stress–both in the machine it was designing and in its own organization.” The pressure to make customer training a profit center and disputes with the pilots’ union over hiring outside contractors amped up the corporate chaos level as the new aircraft was being birthed.  Moving flight simulators from Seattle, where the planes were designed and built, to Miami may have been Boeing’s biggest misstep.  The company put a continent between the engineers who contrive the machine and the flight instructors who observe in their simulators (hopefully almost all) the things that can go wrong when human being meets silicon and aluminum, long before anybody is hurt.

… …better it should be your doctor!

No matter how spectacular the latest disasters, the airline industry does way, way better than the medical industry.  A study published in the medical journal, BMJ, in 2016 estimated that 250,000 Americans die every year from medical error, making it the third leading cause of death, after heart disease and cancer.  Some estimates place the number at over 400,000.  Going with the lower estimate, a quarter-million deaths per year comes to about three 737 MAXes, fully loaded with passengers and crew, crashing every day!

If you think Boeing experienced a certain degree of corporate chaos that contributed to fatal outcomes, you ain’t seen nothing until you’ve stepped into the world of healthcare.  Time after time the electronic systems that ought to foster communication and collaboration among the various people that literally hold people’s lives in their hands don’t even talk to each other.  Even within institutions, systems are too often clumsy and make-work.

Need I tell you that communicating electronically with patients, all of which falls under the rubric of telehealth, is woefully inadequate?  Just think about how many things you can accomplish easily and securely online with your bank or how it is finding and purchasing the airline tickets that best meet your travel needs, compared with how you communicate with your healthcare providers.

Every breakdown in communication increases the likelihood that sub-optimal, harmful or even fatal healthcare events will occur.  If the oncologist (cancer doctor) isn’t informed about what the nephrologist (kidney doctor) is doing, the patient could receive a bigger dose of chemotherapy than their kidneys can handle.  If an office-based nurse practitioner doesn’t know that a person was recently discharged from the hospital after hip surgery the clinician might not know to suspect a life-threatening blood clot in the lungs when the muddled patient calls because they’re anxious.

The technology ought to be the easy part.  Internet protocols are standardized.  Most of what needs to be done can be accomplished with inexpensive devices.  Nearly everybody has a computer and/or a smartphone that can transmit and receive data, including voice (that’s what a plain old telephone does), images and video.  It’s the people that are the hard part; that is, the people individually and as they gang up in institutions.

In order to maintain a market advantage, health system A doesn’t want health system B to get its hands on its proprietary patient data… and vice versa.  One set of doctors uses Mac IOS, another uses Windows.  Managers must decide either to support both operating systems, with added glitches and complications, or else risk disempowering and angering a large segment of their physician clients.  In the interest of “upcoding” (increasing charges) the billing department has insisted that nurses and doctors use checklist templates to record all encounters with patients, detracting from the richness (stories) in the medical record, while alienating the people on the front lines, as well as adding an hour or two to their daily workload.  The medical licensing board in one state insists that every out-of-state doctor who does a telemedicine consult on even a single one of its residents get a full medical license–a tedious, expensive and slow process–no matter that the out-of-state physician may be the best expert to care for that sort of patient or that there is a severe shortage of that specialty in the state.

In healthcare, training simulators are at least a half-century behind where they are in aviation.  To be fair, it’s way easier to simulate a standard machine made of metal and silicon and such than it is an infinitely varied, non-standardized human body.  Still, electronic technology could be a great boon for healthcare quality and safety.  The lowest hanging fruits dangle from strong limbs of well-tested communication protocols and simple devices.  The willingness and structures for collaboration are what’s missing.  It’s killing us.

The post It’s Always about the People appeared first on Marc Ringel | Author & Healthcare Professional.

“If doctors were in charge of airports, they would never have installed radar. They just would have put intensive care units all around them.” —Larry Weed

Doctors tend to be a pretty conservative lot. So are healthcare administrators. Physicians are prone to believe that the foremost priority is to maintain their authority to determine what is best for patients. For administrators, the crux issue is to provide services that generate the most profit (“margin” in the “not-for-profit” world), while doing what they can to match what their institutions offer to what people really need.

Doctors do what we think is optimum for patients. Patient preferences are not necessarily at the forefront of our decision-making.

These days it’s healthcare administrators, much more than doctors, who decide what is to be done in healthcare. Administrators may survey consumers in the course of deciding what to do. But patient desires generally take a back seat, at best.

 How Has Consumer-Driven Telemedicine Changed Healthcare?

Things are changing in the digital age. With few exceptions, every one of my patients has internet access, which means a large share of the medical information that is available to me is also available to them. As a physician, my value to patients resides less today in the information I can put my hands on and more, based on my education and experience, in throttling down the fire hose of medical knowledge to a manageable stream and choosing just the right fly to fish that stream for what a particular patient needs at a particular moment. Since information is power, patients are more my peers than they used to be in the healthcare transaction, in the same way as the Kelly Blue Book Online and Carfax have leveled the playing field between me and a car salesperson.

What Are The Effects of Biometrics and Telemedicine?

Electronic devices themselves are also helping people to take power over their own healthcare. Folks with diabetes have been checking their blood sugars for years, with ever more reliable, inexpensive and connected devices. Glucose levels obtained with these monitors are automatically graphed onto charts and interpreted by smart algorithms. Results may be sent automatically to healthcare providers and also may be shared with other people who have diabetes, in an exchange of experience and advice that can only come from someone with the same disease. A good deal of this activity is initiated and sustained outside of healthcare institutions. It is what marketers call “consumer-driven.”

What is Consumer-Driven Telehealth?

Much of telehealth these days is consumer-driven. Let me repeat the definition of telemedicine from my book, Digital Healing: People, Information and Healthcare, quoted in the last installment of this blog:

Telemedicine is the use of electronic information and communication technology to overcome barriers of distance and time when delivering healthcare.

Notice that this description does not say who the deliverer is. It could even be the patient themself, which is, in fact, the case with the array of gadgets that people now wear on their wrists, made by the likes of Apple, Garmin, Samsung, and Fitbit, plus a zillion others. A simple device can monitor heart rate, steps taken and distance traversed. A fancy one can continuously measure heart rate, blood pressure, breathing rate, steps taken, distance traveled on foot or bicycle, calories burned, sleep time, stages of sleep, and swimming time; as well as incorporating a GPS to gauge position on the earth and elevation gain and loss. You can upload the data to your smartphone or computer, share it with friends or competitors, and even send it to your provider’s office. Graphs will display trends for any and all of these functions. Keep in mind, though, that a significant chunk of data, even from the best devices, is not very accurate or reliable.

Will My Healthcare Provider Accept Data From Wearable Technology?

Some medical practices will accept these data. Your provider’s medical record may have a file in which to tuck unsolicited physiologic data, but it won’t have a way to make sense of them. With or without an EMR, nobody really knows what to do with these data. No convincing case has been made yet in the medical literature for a measurable effect on wellness, fitness, leanness or anything else a person who straps on one of these devices would hope to achieve. If activity and physiologic monitors do wind up helping individuals or groups, they will probably discover it for themselves, not because a doctor, nurse, exercise physiologist or dietitian has come up with a bright idea about how to do it.

Effects of Big Data and Telemedicine

According to International Data Corporation, last year the self-monitoring market grew 27.5% worldwide; that’s 172.2 million units sold. If you’re interested in joining the burgeoning ranks of the self-monitored, learn as much as you can about it, including educating yourself online about what device to buy. Then go for it. If you think your provider might collaborate, ask them to. But don’t expect, at this point, that a health professional will know much more than you about what to do with a ton of not-so-reliable physiologic data.

Image credit: raconteur.net

Is Self-Monitoring Your Health A Good Idea?

Let me repeat, there are not good studies that demonstrate the benefit of self-monitoring. Go about it slowly and deliberately. Talk to friends about what they’re doing. You and your consumer-driven pals will probably figure it out. Perhaps you’ll even be able to educate a health professional or two.

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What is “telemedicine” and “telehealth?”

Here’s what people imagine telehealth to be, an interactive real-time video consultation between a doctor and a remote patient.

Telehealth is that, of course.

It’s even better when the consultation is enhanced with instruments that let a doctor (or other provider like a nurse practitioner or physician assistant), examine a patient’s eardrum or listen to their heart from afar.

Access to a shared electronic medical record makes the encounter that much more powerful.

Phrase trends of "telehealth" vs. "telemedicine"

View Graph on Ngram Viewer

As a rural family doctor, I did telemedicine many times every day, a decade before I owned a computer, let alone a smartphone. In the days when there were only landlines, I gave medical advice to patients and sought advice on challenging cases from colleagues over the phone.

That was telemedicine.

I was practicing medicine from a distance. Likewise, when I called a prescription to the pharmacy or an order to the laboratory. After a few years, I was faxing some of those prescriptions and orders.

That was telemedicine too.

You may have noticed that I’ve used both words, “telemedicine” and “telehealth.” The word “telehealth” came along in the 1980s, about 15 years after “telemedicine” first appears in Ngram.

The word “health” is meant to convey a broader scope of practice than “medicine,” which implies just a physician-based medical practice. “Telehealth” includes for example: consultations with therapists or dietitians; support groups; and lately, self-monitoring and uploading of everything, from steps taken to blood sugar to mood.

Truth is, most everybody, including me, uses “telemedicine” and “telehealth” interchangeably.

How Modern Telehealth Has Influenced Healthcare

In 1999 McGraw-Hill released a book I co-wrote with healthcare futurist Jeff Bauer, Telemedicine and the Reinvention of Healthcare. Jeff and I came up with this definition for our book:

“Telemedicine is the combined use of telecommunications and computer technologies to improve the efficiency and effectiveness of healthcare services by liberating caregivers from the traditional constraints of place and time and by empowering consumers to make informed choices in a competitive marketplace.”

That’s a mouthful. But it holds up pretty well, I think, considering it’s 190 tech-years (19 people-years) old.

What Is Telemedicine and Digital Healing?

For my book, Digital Healing: People, Information and Healthcare, published last year by Taylor&Francis and released in audio version by Audible, I wrote this streamlined definition, “Telemedicine is the use of electronic information and communication technology to overcome barriers of distance and time when delivering healthcare.”

It’s about using technology to subdue distance and time. Period. Which means that the questions and pictures about a rash that you send to me electronically or that I forward on to a dermatologist are telemedicine.

The care doesn’t have to happen in real time—it can be based on information that is stored-and-forwarded.

Whether you called me with your initial query or contacted me with pictures and questions via my practice’s patient portal, it’s all telemedicine. It’s all care at a distance.

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What is Telehealth?

Once we grasp that telemedicine is based on a broad set of communication tools, we can begin to solve real problems and meet real needs, usually at reasonable cost. The technology itself gets cheaper, more reliable and easier to use every day.  

“Let’s get a cool interactive video system. Now, what’s the problem?” describes a process that is 180 degrees from what it ought to be.

It should go more like this, “We see patients with acute strokes at our rural emergency room. The sooner we get clot buster drugs into their system, the more stroke patients we could save from a lifetime of disability. But if we give this potent medication to the wrong patient, such as one whose brain event is the result of a bleed, not a clot, we could make things catastrophically worse. We need a neurologist to interpret the acute brain CT scan and advise us how to proceed; and we need them right away, because time is neurons. The longer the delay in administering anti-coagulation, the worse the outcome.”

Fortunately, I have in my rural ER a CT scanner and a stock of anticoagulant. I am present myself to interview and examine the patient. As a family doctor, what I need most of all is for a neurologist or a radiologist to interpret the radiology image. The hospital’s CT scanner must have a broadband connection so it can send the digital “films” STAT for expert interpretation.

Crucially, there has to be a protocol on the receiving end for a consultant to look at the images immediately and call me back with the results. We need a system. That’s the challenge. These days the technology is pretty standard.

Parenthetically, what we don’t need is for the consulting doctor and me to be able to see each other on a video monitor nor, for that matter, for the patient and distant doc to be in visual contact. That’s how one big hospital organization in my state sold their acute stroke management system, by featuring their fancy, new video system.

“Let us do a telemedicine consult,” they said. And people bought it.

Telehealth Isn’t a Magic Solution

The real-time video just made the whole interaction more cumbersome, especially in the old days of telemedicine when you had to wheel a cart bearing a big monitor and a heavy codec (the video equivalent of a modem) up to the patient bedside and hook it up to hard wiring that had been installed in the room.

Fortunately, this medical center does have excellent stroke doctors who give good advice and a well-oiled system for communicating with referrers. But it was the sizzle of *T*E*L*E*M*E*D*I*C*I*N*E* more than the steak of immediate expert consultation that made their program go, and also made it more expensive.

Telemedicine Should Enhance Healthcare, Not Replace It

Whether you’re a provider or a patient, located in the city or in the country, try to think of telemedicine as a set of tools, no different than what you have in your shop. Sometimes you need a table saw to make a cut. Sometimes all you need is a razor blade.

Choosing the right tool for the job is critical. But first you have to understand what that job is.

In healthcare that means that sometimes you may need a high-end video system for talking a distant surgeon through a hairy procedure and sometimes you’ll just need the telephone to reassure a worried parent.

It’s all communication. And it’s all telehealth.

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