Medium high

So it's been three years since I sang the praises of Tumblr, and about two years since I last logged in. Much like the iPad was a "in between" device whose appeal plateaued as smartphones get bigger and laptops get more nimble, for me Tumblr was always stuck between short Tweets and real sit-down-and-think writing. And both Twitter and real writing are taking up more of my mindshare.

I've been writing and blogging a bunch (not here, of course) over at EPMonthly. Specifically I'm enjoying the weekly Crash Cart, commenting on new EM stories with Bill Sullivan and Mark Plaster. The fodder is chosen by the EPMonthly staff (lately Matt McGahen has been on fire), we try to keep the writing incisive but informative, and the whole thing is fun and rewarding.

Elsewhere on the web, my circle of Twitter contacts and sources has been great lately. And whenever I feel Twitter is grating, I just tweak my lists, add some fresh voices, and it all gets better again.

So for me Tumblr never took off, despite its strengths. The aggregator was spiffy, and I really liked how Tumblr allowed me to elegantly collect posts on certain topics, But I never was able to engage with the various Tumblr communities - posting and sharing things to Tumblr was like decorating a snazzy room that no one visited.

Still, I'm still drawn to the idea of reinvigorating my web presence. Which brings me to Medium, the popular writing platform that's trying hard to not be a blogging platform. Each article is beautiful; a pleasant experience to read and write. But they've deliberately made it hard to aggregate content or set up a 'presence' for yourself (in the mobile app, for instance, you can't view your own writing, or even search for it).

For a while I waited to make the leap to Medium; I just figured more features were on the way. Only now do I kind of understand what Ev & co have been up to: Medium can't be gamed - it will only show you quality writing. Yeah, it's recommendations are based on your interests and the kind of people you follow. But you can't leverage your page design or tags or posting frequency or social connections to increase the visibility of your writing. You just have to write well. It's as if they decided everything else - the blogrolls and hashtags and carnivals and follower counts - has all been a distraction.

So I'm going to give Medium a shot, sharing some pieces from EPMonthly and here that could use a little fresh air.

To be continued...

Order Sets & the Art of Medicine


When I was part of Jeff Neilson's illustrious Informatics Research panel at SAEM in Dallas this past spring (we were recently invited back for San Diego next year) I spoke on the topic of simple clinical decision support projects, particularly evidence-based order sets. I also talked about incorporating clinical calculators into orders, so trainees could enter discrete patient data into the EHR and see if the test they were considering was appropriate.

These are feasible research projects that can have measurable impacts in utilization or even care, don't require big budgets, and can be done in a resident-friendly timeframe. 

There was a question from the audience. Someone wanted to know if order sets and clinical calculators were antithetical to the idea of resident education - that organizing tests and meds by complaint, and building calculators into the EHR, made it too easy to be a doctor. Might we consider abandoning order sets and focusing on memorizing doses and appropriate indications for tests? By focusing on these things, were we failing to train doctors in the Art of Medicine? 

I was surprised by the question. Perhaps it's because I'm in a bubble - surrounded by colleagues who know as much (or more) than me about patient safety, bedside teaching, EHR usability, and evidence-based guidelines for care. 

I don't remember exactly how I responded. I said something about how order sets and clinical calculators are here to stay, unquestionably reduce errors, improve efficiency and encourage appropriate resource utilization (when implemented well) and the only challenge remaining is making them as current and easy-to-use as possible. 

That was a start, but I should have also pointed the audience member to the Checklist Manifesto, which covers the evidence, obstacles and psychology behind getting doctors to put their ego aside, be humble and make sure everything worth doing is getting done. After all, there was probably a time where pilots complained about losing the artistry of flying, but the public cared about their planes not crashing. Similarly, in an era where we are trying to get 100% compliance on core measures, when we're asked to do more, and see more, with less time and less support, it's imperative we make the EHR work for us as best it can. 

The Art of Medicine may have once involved regaling patients and staff with feats of memory; now it seems more appropriately about forming a fast rapport with patients, and explaining Bayesian algorithms for risk stratification. Let computers do what they're good at - lists and calculators - and let doctors have meaningful conversations with patients. This seems like the new state of the Art. 

Analyzing Twitter for Public Health Research - #med2 tutorial

Michael Chary and I presented our tutorial, Analyzing Twitter for Public Health Research, at the Medicine 2.0 World Congress in Maui just recently.

Our audience was a diverse group of clinicians and researchers. There was substantial pre-meeting prep, where we guided prospective attendees through registering on dev.twitter.com and GitHub, then logging into a new account on Codio and forking our repository full of setup scripts and sample code.

At the meeting we presented slides and references, passed around handouts and gave hands-on help and advice to the room.

We think we've given our audience a good foundation to apply new techniques for public health research, collect good data and draw reasonable conclusions from their results.

In the course of preparing this material, we also learned a lot, about how to effectively disseminate these techniques. Now we're looking for new venues to share what we've learned - perhaps there's a role for more traditional media...

More to come.

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.