Modern convenience

I'm glad some people choose to share their health data - be it RunKeeper routes and times, or WiThings weights or blood pressures, or the latest Quantified Self device. There's certainly evidence that social pressure can promote real change in people's lives.

It's just not for me. At least, not at this time.

But I'm finding the problem with these modern fitness apps is, they're each in a deadly competition for VC funding, for market share, for app store rankings. So they're under huge pressure to grow their user base - and that means, increasingly, pestering users to access one's contacts and one's social feeds.

So now, if I want to use RunKeeper, I've got to tap through all these social popups, to decline to share my info, after each run.

Is there a way I can just spend a few dollars to not be annoyed by my own software? I loved the Moves app, which was elegant and minimalist, and with its one-time up-front fee, didn't pester me with sharing popups. But then it was bought by Facebook - so it's likely my data's available for sharing, despite my efforts.

Folks used to argue that Apple could charge a premium for Macs because you were paying to eliminate cruft - so that you didn't have a desktop full of AOL, MSN, or other unwanted services. 

Now, with Google and Facebook matching Apple in terms of sleek design, the premium is simply going to be privacy, and lack of social prompts. 

Coming down on The Night Shift

I've been reviewing episodes of NBC's The Night Shift for EPMonthly. Specifically, I took the pilot, then episodes 5-8, while Dr. Aaron Bright handled episodes 2, 3 and 4.

It's not a good show. The plot twists are predictable. The characters are mostly caricatures. Worst of all, to me, is that the medicine is awful - it's absolutely impossible for an emergency physician to say, "We manage patients like that," or "That's what my job is like."

But I understand there are fans of the show. A lot of them. And they may want a collection of our medical impressions. So, here you go:

Episode 1 - Pilot
Episode 2 - "Second Chances"
Episode 3 - "Hog Wild"
Episode 4 - "Grace Under Fire"
Episode 5 - "Storm Watch"
Episode 6 - "Coming Home"
Episode 7 - "Blood Brothers"
Episode 8 - "Save Me"

Greg Henry also chimed in, with his opinion.

No doubt

I've been a proponent of social media for over a decade. Broadly distributing the tools for sharing one's thoughts just seemed like it would lead to better communication, more understanding - and would improve the culture.

When apps like Secret and Whisper appeared, I dismissed them as a aberrations; deliberately incomplete tools that provided some brief novelty but were fundamentally unserious. These apps seemed to be built around gossip, and provided no actionable information to users. No links to useful resources. No identity. It's as if someone took Twitter's biggest problems - difficulties with authenticity, a preponderance of trivia - and branded them as features.

But it doesn't take more than a few minutes reading user comments on any news (or recipe) site to see that authenticity, and discussing serious issues, is not working out as well as hoped. Years ago I wondered if tying online comments to one's identity would improve discourse - it's clear now that's not the case.

Instead of enabling broader understanding, social media tools have led to polarization and closed-mindedness. Social networks serve as an echo-chamber, reinforcing existing beliefs and promoting orthodoxy. No amount of evidence convinces people of anything, anymore, because someone in the network will always offer comforting, alternative interpretations of new facts, and no one wants to show weakness amongst their peer group.

But apps - 'networks' - like Secret can counter the self-assuredness and conformity that exists now in social networks. Because when I spend a few minutes on Secret, I come away questioning some assumptions, and reflecting on the writers' perspectives. It's regrettable that this questioning, this doubt, is something that has gradually disappeared from my other feeds. I only wish there was a way to re-integrate this humility back into non-anonyous social networks; Secret and its ilk exist entirely apart from the web, without standard tools for archiving or research.

I think we can all agree, though, that the Yo app is dumb.

Everything in its right place

I once chided my med school roommate for entering dozens of numbers into his landline phone's high-capacity speed-dialer. After programming a few frequently-dialed numbers, I argued, you'll end up wasting more time entering digits than you could ever save through speed-dailing - the effort outweighed the benefit.

He had a lengthy response, that appealed to a sense of order and touted the less-tangible benefits of reducing cognitive load. The phone is for calling people. By having people's numbers in the phone, instead of in a half-dozen notepads and desk drawers scattered about the apartment, he could make calls without much fuss. He didn't have to remember whose numbers resided where. He could unburden his mind to focus on other (presumably more involved) tasks.

I was still a little skeptical (why not keep a list of numbers by the phone?) but saw his point. And it's colored my organizational decisions ever since - especially since Allen's Getting Things Done places such high priority on reducing the mental stress associated with reminders - to improve clarity, creativity and fulfillment.

You can go FOAM again

Last month I got on stage at SAEM's Annual Meeting, and said (among other things) that excelling at medical education through social networks was a calling - one that I didn't hear. Despite being an early adopter of social media for EM education, it's clear when you look at the best exemplars of #FOAMed that there's a passion behind what they do. Just look at the prodigious output and quality at sites like ALiEM or Emcrit, for instance.

And while I've lodged some criticisms of #FOAMed (in the pages of EPMonthly and in a Skeptic's Guide to Emergency Medicine podcast), it's mostly because they've been so successful in teaching their areas of expertise that they risk crowding out EM core content. You can't blame the listeners, though - who wouldn't rather spend a few hours listening to experts discussing the finer points of critical care, instead of reading vanilla core content written in a scholarly, passive voice?

But I'm not trying to continue this debate - just point out that I think #FOAMed is evolving.

CMD 2014 talk on acute and chronic liver emergencies

Welcome, readers from Clinical Decision Making 2014 in sunny Ponte Vedra.

The most recent version of my slides (some tweaks from what's on your USB drives) is available.

You can also review my references and I've put up a cleaned up, slightly abridged version of my speaker's notes as well.

Questions and comments are always welcome! Leave a comment or find me on Twitter @nickgenes.

#SAEM14 panel discussions on social media scholarship & clinical decision support

I was very pleased this year to participate on two panels at SAEM in Dallas. 

On Thursday, I joined Michelle Lin and (remotely) Rob Cooney for the panel led by Jason Nomura, called "From Twitter to Tenure - Use of Social Media to Advance Your Academic Career" (search for DS067 in the program).

Jason has posted our session on his blog at his blog, and on YouTube. 

On Saturday I joined Adam Landman and Jason Shapiro in a didactic session led by Jeff Nielson, called "Emergency Informatics Research: Interesting, Approachable Projects for the Resident or Career Scientist" (search for DS095 in the program). I ended up citing a lot of enlightening papers on clinical decision support; these references are now available; may post a link to the talk or presentation, as well.

Counting clicks

This month, EPMonthly ran an article about the cost of poorly-designed EHR on ED operations. The EPMonthly authors - Augustine and Holstein - ask some good questions and made some good points. But the data they used to ground their piece came from a peer-reviewed article that unfortunately leaves a lot to be desired.

We ran an editor's note at the end of the EPMonthly piece, succinctly stating my objections to the original peer-reviewed research. But since this "4000 clicks" study has gotten traction elsewhere, I felt compelled to make my detailed criticisms of the article publicly available:

NYEMHPA Future of EHR / Future of EM presentation

I'm honored to be presenting this afternoon at the New York Emergency Medicine Health Policy Assembly, organized by the Emergency Department at North Shore - LIJ.

My prezi is available, as are my references. I'm told an audio file might become available as well.

Follow tweets from the conference with #NYEMHPA - and keep your fingers crossed that a Storify recap appears at +David Marcus' conference site.

Medical apps to facilitate EM clinical exam and decision-making

This Monday at ACEP's Scientific Assembly I'm presenting at the Learning Lounge on the topic of smartphone apps for physical exam and on-shift clinical decision-making. I'll be joined on Tuesday and Wednesday by Jason Wagner and Harvey Castro, respectively. 

You can download the ACEP13 app for more details; my abridged list of recommended apps for Emergency Medicine is also available via Dropbox. 

One's choice of medical smartphone apps is of course quite subjective, borne as much out of habit and circumstance as some standard of quality. I'd be really interested to hear other suggestions or comments about this list.  

CDM talk on updates in the diagnosis and management of ED arthritis

Welcome, readers from Clinical Decision Making. You've got a PowerPoint version of my talk on your USB drives; here's the link to today's Prezi.

I frequently mentioned Chris Carpenter's excellent 2011 systematic review of ED septic arthritis; Margaretten's Systematic Review for JAMA is also worth a look.

Other references from my talk:

  • Piper on the risks of local anesthetics on cartilage
  • Fitch 2008 on IA lidocaine for shoulder reduction in the ED

I encountered a bit of resistance to this when I presented it at Ponte Vedra: not too many do IA injections, but those who do said things like, "aw, come on, please, my patients love this"

I think I'll borrow a page from the Newman playbook and recommend shared decision-making with the patient - "while no studies have shown this dose or a one-time exposure in humans is dangerous, and the majority of patients who get pump infusions have no detectable adverse reaction years later, there is a risk and the benefit is just a few hours of relief, sooner"

Time on Task

There's a research paper making the rounds in the press and on social media, about Facebook usage in an emergency department.

It's called, "Online Social Network Use by Health Care Providers in a High Traffic Patient Care Environment" by Erik Black et al, and it's in JMIR, a popular informatics journal that I thought had a reputation for quality. I say this, because the methods were poorly described and the conclusions are grossly misleading.

Health policy wonks like Sarah Kliff made the following conclusion:
For every hour emergency department workers use a computer, they spend an average of 12 minutes on Facebook — and that time on the site actually goes up as the department becomes busier.
Researchers at the University of Florida monitored the workstations of 68 emergency department workstations for just over two weeks. They couldn’t see who was using each work station — it could have been a doctor, a nurse or another health-care worker — but they could see what they were looking at on the computer.
Over the 15-day period, the staff cumulatively visited 9,369 Facebook pages, spending an average of one of every five minutes of computer use on the site. Usage was much higher overnight. During the 7 p.m. to 7 a.m. shift, emergency department employees spent an average of 19.8 minutes per hour on Facebook. During the day, it came down to a much smaller 4.3 minutes.
It's just one academic ED, in Florida, over 15 days, more than three years ago - so, hardly representative of the specialty . And there's no way to tell if the usage is from doctors or nurses or techs or consultants from upstairs. And didn't we all look at FB more, back in 2009-2010, when this study was conducted?

But take a look at what the study results actually say:
In a 15-day period, health care workers spent an accumulated 4349 minutes (72.5 hours) browsing Facebook on workstations in one ED. ED staff cumulatively visited 9369 Facebook pages and spent, on average, 12.0 minutes per hour browsing Facebook.
This is not "using Facebook for 12 minutes per computer per hour" as Klift and others concluded. This is "using Facebook for 12 minutes per hour" total, across all of this large ED's staff and sixty-eight workstations.

If you broke usage down by computer, it's around 11 seconds per hour - which makes the author's opinion that FB usage is "unacceptably high" well, unacceptable.

Thanks to Jonathan Handler and the ACEP Informatics Section listserv for pointing out this article, and their analysis. UPDATE: Dr. Handler has a blog post on this topic up now, as well.

The politics of EHR implementation

I've pretty much kept my distance from the right-wing noise machine. They don't often talk about my professional interests, and when they do, it's not usually cited by a colleague or fellow academic.

But this morning, someone I respect shared this screed from Michelle Malkin on the great EDBA listserv - which I'd always equated with intelligent discussion of applied emergency medicine informatics.

So, let's dive into Malkin's piece on "Obama's crony," the CEO of Epic Systems:
The stimulus law provided a whopping $19 billion in “incentives” (read: subsidies) to force hospitals and medical professionals into converting from paper to electronic record-keeping systems.
I take issue with the past tense "provided" because these $19 billion will be allocated over many years, and only a small fraction has been given out already. And while $19 billion seems "whopping", healthcare spending was $2.7 trillion in 2011, and Medicare spending alone was $557 billion that year.
Obamacare bureaucrats claimed the government’s EMR mandate would save money and modernize health care.
This had nothing to do with "Obamacare" and in fact I don't think that term had been coined when the stimulus bill passed in February 2009. Lots of people thought, and still think, that EMR will save money in the long run (and moving from paper to electronic pretty much modernizes care, by definition). And of course, there's the reasonable expectation that patient care will be improved, too.
After hyping the alleged benefits for nearly a decade, the RAND Corporation finally admitted in January that its cost-savings predictions of $81 billion a year — used repeatedly to support the Obama EMR mandate — were, um, grossly overstated.
Among many factors, the researchers blamed “lack of interoperability” of records systems for the failure to bring down costs. And that is a funny thing, because it brings us right back to Faulkner and her well-connected company. You see, Epic Systems — the dominant EMR giant in America — is notorious for its lack of interoperability.
OK! Malkin has made a point that can't be dismissed out of hand: Epic systems do tend to be closed. There's lots to criticism about that system and the state of EHR in general. And yes, the 2005 Rand report (which, by the way, was funded by EHR vendors) estimated big savings and the "Obamacare bureaucrats" paid attention to it (though one has to wonder what Malkin would write if they had ignored the report.) Since that time, experts agree interoperability has limited the expected savings - but those many-billions a year are still anticipated soon .

And hey, allocating $19 billion over many years to generate annual savings greater than that - on a $550 billion dollar program - just doesn't seem so crazy to me. If additional savings are delayed a few years, well, it's still a reasonable investment, to say nothing of the other benefits from adopting EHR. Who knows? Medicare spending is already slowing, maybe EHR is involved? At least you can't argue: this part of the stimulus accomplished the goal of, well, stimulating economic activity (I've seen the construction activity at Epic HQ first hand).

But here's something to think about: If Epic runs the table and becomes a monopoly, as Malkin (and others) allege will happen, doesn't that render the issue of interoperability moot? Wouldn't that accelerate the cost savings? Seen in this light, Epic political influence doesn't just benefit their company, but the taxpayer as well. It seems like this is something Malkin would be rooting for, instead of decrying.

Of course, I don't think Malkin has thought through her argument - she's just stringing together half-truths to score points with her audience. Because on the topic of political influence, she notes:
Epic employees donated nearly $1 million to political parties and candidates between 1995 and 2012 — 82 percent of it to Democrats
Again, I think some perspective may help - averaged over 17 years, Epic employees gave less than $50,000 a year - in total - to the Democratic party. I wonder if this is the reason Republicans candidates lost so many presidential elections over this period. If $50k per year is all it takes to be an "Obama crony" then what does the $18 million Google spent in 2012 alone mean? What do you call the Koch brothers?
The shadow of tyranny and the stench of corruption are unmistakable.
Goodness. Well, we can agree something stinks. EHRs, and Epic in particular, are a subject worthy of debate, but Malkin's piece does nothing to advance understanding of policy or this industry.

(The last time I waded into a right-wing leaning discussion of electronic health records, over at the WSJ blog, commenters compared folks like me, who help implement and study EHR, to the Tuskegee researchers. Let's hope things have improved since then).

Another new day

While I've been focusing on peer-reviewed writing these days (though what could be more peer-reviewed than a blog?) you can see some of my thoughts on medicine & technology at ZocDoc's new site, The Doctor Blog.

Browse their site - you'll see some familiar faces from the Grand Rounds era.

Great content, too.

Enigma variations

We hear it all the time: one of the benefits of EHR will be to get a handle on physician practice variation. Between states, and even within departments, we diagnose and treat the same things very differently. By switching from paper to electronic charting, analysis of practice variation becomes a lot easier (it also becomes easier to steer physicians into following guidelines).

With all this focus on how doctors do things differently, I'd like to turn the focus, however briefly, on the practice variability of government.

Specifically, why is the physician's license fee so variable, from state to state? Little Rhode Island and big Texas both charge over $1000 to issue or renew a license, while Wisconsin is just $125. Are the medical boards in high-fee states doing so much more work than the low-fee states, to justify the expense? Can I expect faster licensure and more courteous phone staff in New York ($725 every 3 years) than Illinois ($300)?

Sadly, despite these systems moving to the web and facilitating electronic applications and payments, the pricing remains as impenetrable to me as ever. I hope we physicians can set a better example than our state licensing boards do.

Tincture of time

No one chooses emergency medicine for continuity of care. It's undoubtedly rewarding for most doctors to help manage patients through growth or disease, but the emergency physician doesn't get the chance to appreciate a patient's development over time.

Until now.

Electronic health records at my institution now give us over 9 years of continuity. Even when I'm just meeting a patient for the first time, I can look back and see their first visit to the pediatric ED for asthma, the appendectomy from a few years ago, the gastritis visit during college break that may or may not have been related to alcohol.

For older patients, I can see the visits that described the out-of-control hypertension, the subsequent CABG and later, stents... the descent into heart and renal failure.

I get a little nostalgic to see almost-forgotten names of residents and attendings who cared for these patients, before they graduated or took other positions. It's like we were all a part of this patient's life.

Recently I re-open a patient's old chart, to show a resident an unusual EKG from a while back. I felt a pang, when my EHR alerted me the patient had died.

It's tempting to compare electronic health records to other means of keeping up with people, electronically. Research suggests social networks are changing the nature of relationships - rather than a few close friends with whom we share important news and feelings, we're instead updating a wider, but shallower, group of acquaintances with more mundane aspects of life.

While that may be true, EHR's ability to show the timeline of a patient's past care is having a profound effect on emergency medicine -  where before there were discrete events, EHR is giving the semblance of an ongoing relationship. Physicians may debate whether electronic records are worth the investment, but to my mind there's no question the investment is more than financial.

Free to decide

Describe electronic clinical decision support to someone outside of healthcare.

They'll probably start conjuring images of Watson or Clippy - an automated guide who incorporates clinical data and provider habits, to offer suggestions to improve care.

And yet, despite advances in computing power and machine learning, and a massive push to adopt electronic records, clinical decision support remains stuck - so primitive that even 90's-era Clippy seems wise and helpful in comparison.

I think there are many culprits for this, but a big reason clinical decision support lags is that it's been hijacked by well-meaning hospital administrators. Instead of nudging doctors into learning new things, dosing meds appropriately for complex patients, ordering the proper tests, so far it's been mostly inane reminders written by bureaucrats. Instead of helping doctors make decisions, decision support has been used to boost compliance on various metrics of interest.

You see, when compliance with a federal measure at your institution is at 97%, steps need to be taken to get that up to 100%. And those steps often involve popups, and "hard stops" that disrupt your progress through a task, even if it doesn't quite apply to this particular patient or that particular situation.

Of course these metrics are important, and if you don't score well, CMS reimbursement could be withheld, and your institution will look bad on HospitalCompare.

But by hijacking an EHR's clinical decision support system to boost administrative goals, you've conditioned a generation of providers to ignore CDS popups and warnings. The alerts are often not really relevant to providing the best care. They're often not appropriate to the situation. And they get really annoying to busy physicians, when they delay appropriate care and add to their workload.

What's happened is that modern decision support has taken the most inquisitive, hardworking, and self-sacrificing group of people you're likely to meet, and turned them off to the idea that the EHR can be a teaching tool.

And I don't think there's a popup alert to reverse that clinical situation.