Thoughts on tumblr

Remember how people said there was no real need for a device category between smartphones and laptops? And then Apple sold 40 million iPads?

That's kind of how I felt about Tumblr.

Blogs are obviously great for musings, essays, and a web presence, and Twitter's fine for thoughts and links and pics. Why have something else, in between?

I don't really have a good answer, just like I can't fully articulate why the iPad experience is so much better than a laptop or smartphone. But I'm starting to see the appeal of Tumblr.

Beyond the usual accolades from early adopters / influencers, something that stayed with me was a quote from Tumblr's founder: "No one is proud of their identity on Facebook."

Medscape EM year in review

Medscape's EM editor asked Amal Mattu, Robert Glatter and me to discuss 2011's important papers in emergency medicine. I felt compelled to include an all-around terrible (but still important) paper, and a tidy nice decision-support paper for discharge prescriptions, among others. See what you think about my picks, as well as the great selections from Drs. Mattu and Glatter.

Thoughts on a reading, sharing & archiving solution

Music's pretty much done, right? It's fairly easy to hear any song you've ever liked, anywhere you happen to be. As a bonus, those songs can be stored, shared, tagged, rated, and linked to lyrics and album art.

Movies and TV... their delivery is not quite perfected, but the general outline seems apparent. Already I can watch the WKRP Turkey Drop episode in the kitchen on my iPad's Hulu app, and mirror it to my TV (via Apple's set top box) when I'm ready to sit on the couch. Other shows or films require more effort, though the combination of Netflix, iTunes, and for the remainder, torrents plus the Air Video server app, make it easy enough.

But reading? The written word, for whatever reason, still lags behind. While strides have been made, a simple and universal, Apple-like solution to the problem of reading, sharing and archiving remains elusive.

Airborne toxic event

Longtime readers know my fondness of comparing the healthcare industry to the airline industry (based on similar goals of training, rituals of safety, and differing approaches to error, for starters).

Recently I've learned of a new intersection between medicine and aviation, when Delta chose to air ads to their captive cabin audience purchased by NVIC, the National Vaccine Information Center. The ads talk about staying healthy, maintaining good hygiene, and asking your doctor questions about the different flu shots available -- to stay informed and keep all the options open.

Sounds ... innocuous ... right?

The IOM Weighs In on Health IT Safety

Thanks to a tip from Brian Ahier, I've caught wind of excerpts from the IOM report on Health IT Safety a few days before its scheduled release.

iWatch has the scoop:

But the push [to adopt electronic health records] is occurring so far without any agency really ‘watch dogging’ the safety of health IT — the software, hardware and systems that record and manage patients’ health information. These expensive devices by and large have not gone through any regulatory checks for safety in the way that food, drugs and other medical technology must; most of that oversight is handled by the FDA. But at the moment, no one is required to report instances of harm caused by health information devices and no government agency currently monitors their safety. 

“With all of that money, marketing and public outreach, most simply affirm the value of health IT as an article of faith, rather than investigate it via careful evaluation,” said Ross Koppel, adjunct professor of sociology at the University of Pennsylvania and its School of Medicine, and investigator for RAND Corporation. He is listed as one of the reviewers of the report.

I've read Ross Koppel's work, and seen him speak, and firmly believe he's a brilliant guy. But I disagree that we're accepting health IT's value on faith, because of marketing. We've seen IT transform the way we do business in every other sphere of American life, and many of us have experienced the benefits of easily retrieved patient records and clear, electronic communication between providers. As I've said before -- aside from a few train-wreck implementations, who would go back to paper records, if given the chance? Who would build a new hospital based on anything but an electronic system?

The IOM isn't saying paper's better, but they do recommend caution with, and further study of, health IT:

EHR Cutting & Pasting, in Perspective

I've started to think the medical record is akin to DNA. Maybe 10% (or less) is useful information; the rest is junk. When folks want to find a sequence of significance, risk or reassurance, they've got to search for the good stuff and filter out all the garbage.

But junk DNA is believed to have a purpose. Some regions of junk DNA are highly conserved -- found in organism after organism -- suggesting an important function. In medical charts, conserved regions are also repeated. And they also serve an important function.

It's this repetition that Dr. Bryan Vartabedian called "Cut and Paste medicine" in his excellent recent post. He's concerned that all these computer-generated phrases of historical elements, exam findings and decision-making makes all patients look alike, and hurts continuity of care, as it becomes harder to discern what's actually going with the patient.

It's a reasonable concern. This problem, created by documentation regulations, compounded by declining reimbursements, and exacerbated by quick-fix features of some electronic records, can be solved through technology, too. Just as researchers and geneticists built tools to sift through DNA, to find the small section they're looking for, we need to easily search through records to show the details of patient care relevant to us.

Anywhere but here

While the output here has fallen from blogborygmi's heyday, this site's original purpose was to foster writing opportunities with, you know, real publishing platforms. By that standard, this past year has been a good one. If you're interested in reading more of my stuff, from health informatics to social networks, see below:

RIP Google Health. A look at the nearly-late, nearly-great Google Health, and the prospects for personal health records. 

Twitter, and emergency response. What if social media was available on 9/11?  

Redefining EMR Usability. When I got into electronic medical record usability, I thought it'd be about physician satisfaction, consistency, and counting clicks for key tasks. Recent developments suggest, however, it's going to be about estimating and reducing errors. 

Getting Social. How social media can change the public face of emergency medicine.  

When Charts Cry Wolf. The evidence surrounding the annoying, often irrelevant drug interaction warnings served up by electronic medical records. 

EPMonthly EMR Roundtable.  A freewheeling discussion on electronic medical records, conducted by Mark Plaster and featuring Rick Bukata, Bruce Janiak, and yours truly. 

Meaningful Use: A Really Good Kick in the Pants. My interview with Maimonides CMIO (and emergency physician) Steven Davidson 

MU and You. A primer on meaningful use of electronic health records, and what it will mean for emergency medicine. 

The ACEP Sessions

At ACEP last week, @drsamko tweeted a stat from the great Amal Mattu: the audience forgets 40% of new content from a presentation within 20 minutes, and 90% after a week.

I replied, "The Twitter audience never forgets!" 

If I had more room, I might have been a little more precise. Twitter makes forgetting less likely, as pearls from different lectures can be broadcasted, shared and debated. 

But Twitter is not Google or Pubmed. Once shared, Tweets, like good talking points from a lecture, have a way of disappearing into the ether. 

So I applaud GruntDoc for his reprinting 95 theses tweets from ACEP, on a more permanent form on his blog (look at what we've come to, when blog posts are considered durable). 

Here are a few of my own from ACEP #SA11 lectures and wanderings (largely stripped of hashtags, grouped by lecture, oldest first). If you make it all the way down, I have some (brief) thoughts on process of tweeting from conferences.

Going to California

I'll be speaking at BlogWorld Expo in LA on November 4 at 4pm, on how social networks can influence patient outcomes.

I'll be joined by two distinguished physicians and social media pioneers, Dr. Jen Dyer and Dr. Val Jones. We'll make a few brief presentations and then field questions. The session will be immediately followed by happy hour.

Also, be sure to check out all the other great topics in the social health track, spread throughout the conference. The speakers with Twitter accounts (approximately all of us) are listed here and tweets about the conference have the #BWELA hashtag.

If you're on the fence about attending the conference, consider: promo code BWEVIP20 to knock 20% off the registration fee.

Goin' Mobile

Long before my colleagues knew me as "that guy who sewed a pocket into his white coat so he could use his iPad in the ED" ... but sometime after they knew me as "the guy with the blog" ... I like to think they knew me as "that guy who helped edit many editions of EM Practice, the evidence-based, presentation-focused journal of emergency medicine."

With this post, I can be all three guys at once, and recommend the wonderful, iPad-optimized PDF of of many fine flowcharts featured in EMPractice in recent years, now available for free. 

Every issue of EMPractice has a flowchart to help guide emergency decision-making with the best available evidence. We've taken a bunch of recent flowcharts and bundled them into a useful, navigable document that will bring the best evidence to the point of care. 

Of course this PDF works well on paper, and the hyperlinks will work on other computers or devices, but it's sized and designed with the iPad in mind. It's really great for teaching or reviewing, on shift. 

NB: I'm on the editorial board for EMPractice and had a small role in developing this PDF. 

Falling farther from just what we are

I like asking patients about their jobs. Sometimes it may seem relevant to the complaint. Other times, it could potentially help the therapeutic bond. Mostly, it's just interesting.

Occasionally, I'll hear a patient is not working; that he or she is on disability.

This can surprise me, especially when the patient's interview responses and examination seem quite appropriate and unremarkable.

Now, I'm not in an ED where this happens too often (or maybe I don't ask enough). At any rate, I haven't been compelled to blog about this phenomenon, like, for example, Edwin Leap recently did. And I'm certainly not of the mind that disability payments are responsible for the debt crisis, or that the vast majority of folks on disability don't deserve it.

Comin' down on the nightshift

I was contacted by the folks at RN Central about running an infographic about the dangers and errors associated with hospital night shifts.

They thought I should publish it, "since you run a site about nursing."

Since that statement is an error, and since the email was sent at night, I assume the sender had to be overworked or undertrained. That off-the-cuff assumption, it turns out, may be more rigorous than anything in the infographic.

Since Canada came along

Over email, some far-flung EM colleagues and I were discussing a case, where an elderly but generally healthy man developed a fever, went to an emergency department, had blood cultures drawn (as well as other labs, films and urine). Ultimately the old man was discharged home.

A few days later, on a weekend, a positive blood culture report (gram negative rods) prompted another ED attending on duty to call the patient at home. Over the phone, the patient said he felt fine; back to normal, no worse for wear. The ED attending considered the matter closed.

On Monday, the primary care doc reviewed the case, and, with ID, admitted the patient (who still felt fine) to the hospital for monitoring and IV antibiotics. Apparently a nastygram was sent to the weekend ED attending, as well, citing some kind of policy that gram negative rods can't be ignored.

My friend, the Canadian Doctor, commented:

This is ridiculous.  Because of the "unique" medico-legal climate in the US, there will never be an incentive for any physician to endorse conservative, less aggressive management.  Without the support of colleagues from other specialties for anything but aggressive knee-jerk responses, patients suffer the consequences of a peer-pressured physician environment where we must all cave to the most conservative (brainless) approach.  While I am comfortably protected in Canada (and its different set of imperfections, of course), I hope that this American death spiral of false logic and spineless non-decision making is arrested soon by some tort reform and financial accountability.

In the past I've really tried to shy away from policy discussions on this blog. There are already great sites for that sort of thing, and I don't want my words taken out of context or brought back to haunt me.

But I did tell my Canadian friend that his emailed paragraph was delicious enough to deserve a wider audience. With a few minor alterations, he's ok'd its appearance, here.

Signal in the sky

Notable figures such as Atul Gawande and Captain Sullenburger have, when discussing safety in medicine, drawn comparisons from the world of airline operations. Lots of people, actually, have made comparisons to these disparate fields.

If healthcare were more like aviation, the thinking goes, there would be fewer errors, greater transparency, and more uniform ways of doing things (and thus, presumably, lower costs). Gawande and Sully both talk about the egos of doctors, who view checklists as beneath them, who view their patients and practice as worthy of exceptions to guideline-based practice, who view their gestalt as superior to cookbooks and calculators.

No doubt, that's part of the problem. But consider: New York magazine publishes a list of top doctors, but not top pilots. Lots of people brag about the acclaimed specialist they see, but no one brags about the pilot that they've booked for their trip to Paris. I think society's expectations of physicians have never been in line with their expectations of air travel. The relationship between passenger and pilot is nothing like the relationship between patient and doctor, except that we rely on pilots and doctors to get us from point A to point B safely and smoothly.

US healthcare has maddening inefficiencies and rituals. But so, too, do airlines. I'm not even talking about TSA security theater (at least, not this time). Just consider the flight attendant preamble about using your seat as a flotation device in the event of a water landing, or the rules about electronics below 10,000 feet. These always seemed to me to be put in place by cautious administrators, years or decades ago, with a "better safe than sorry" rationale that's hard to study or rescind, once put in place.

These speeches and restrictions always reminded me of the over-the-top, out-of-date rules about cell phones in hospitals. Sure, there's one confirmed case that I'm aware of, years ago, where a mobile phone caused an IV infusion pump to malfunction. But it never seemed reasonable to extrapolate from that event, to banning personal communications at a time when patients and families are most inclined to get in touch.

Recently, the IATA issued a report on passenger-generated electronic interference with flight systems. Via TechCrunch:

The reported incidents were based on 125 airlines’ responses submitted between 2003 and 2009, noting that flight controls, autopilot, auto-thrust equipment, landing gear, and the communications kit were all allegedly affected by electronics use. Of course, not one of the seventy-five incidents were verified to be caused by electronic devices. Instead, the IATA reports that crew-members and pilots believed that electronics were the culprits in those cases.

In one instance, with two laptops being used nearby, the plane’s clock spun backwards and GPS readings began going off. In another example, altitude details were jumbled until the pilot asked passengers to turn off their gizmos. A Boeing advisor, Dave Carson, believes that the signals radiating from portable electronics can mess with sensors hidden in the passenger areas of a plane, and that those signals are far stronger than what Boeing considers acceptable during a flight.

I didn't know some sensors were in the passenger area, where nearby device signals could interfere. Still, the article goes on to say a true cause/effect relationship between portable electronic devices and malfunctioning sensors has not been demonstrated by any of these IATA incidents.

What I found particularly interesting were the outraged comments, in response to the "scofflow" writer who admitted to keeping his phone on during landing. He was attacked for jeopardizing the lives of everyone on every plane he's flown on. With 4000 flights a day in the US alone, and a lot of forgetful or sleeping passengers on each flight, I have a hard time believing that electronic interference poses any measurable risk. Even if all 125 citations over 6 years were really due to electronic interference, there were still no "bad outcomes" (to borrow from medical QA parlance) and the event rate, as commenters point out, was approaches zero and is far less than the odds of being struck by lightning.

Would these same outraged commenters angrily force a patient's family member to hang up their mobile phone, if they saw them talking in the ED near a stretcher? Would they yell at a car driver who's not wearing a seatbelt? Or do these commenters feel people who keep their devices on during plane takeoffs and landings are not just jeopardizing themselves, but perhaps the commenters as well?

This seems like yet another example of our attitudes and behaviors toward risks being poorly aligned to the actual danger. It's more David Ropiek's territory -- though I'm sure Sullenbuger and Gawande would agree, getting the public's perceptions to match the true hazards in aviation would make air travel a good deal more smooth and productive.

As for healthcare, it seems almost impossible to calculate how much money, time, and stress would be saved if patients' risk perceptions were brought into better agreement with true health risks. Yet I'm more optimistic that the culture of aviation -- with its transparency, uniformity, and lack of ego -- is more likely to lead to progressive policy changes and successful public education, when compared to the culture of medicine.

Paranoia strikes deep

You know, I already thought that someone at Apple shared my taste in music, as they've highlighted Goldfrapp albums on their site, on several occasions.

But sometimes, while surfing the web, some examples hit a little too close to home. For instance, here's an article on iPhone tracking, that happens to show my neighborhood in the Maps app.

Sure, you say, lots of iOS screenshots feature Central Park. Lest you think this is just Manhattanite navel-gazing, here's a new Medgadget post with a screenshot of the iPhone app called FindER that just happens to show the town I grew up in, and the hospital where my scalp lac was stapled (twenty years ago).

Maybe I'm reading too much into this. Or maybe I'm reading too much about iOS apps.

Best practices

Grand Rounds needs you.

Val Jones and I have recognized that GR works better when we invest in a higher profile  --

• e-mail blasts about the next host's deadline and address. 
• daily tweets through the @grandrounds account, highlighting links from that week's edition
• identifying and guiding new bloggers through the hosting process
• coordinating with other online health networks

Trouble is, neither Val or I are in a position right now to do this ourselves.

If you've got the time and inclination to tackle at least a couple of these items, contact us.

Through their vocations

According to this reputable source, (and backed up a little by this source) the concept of the modern grocery store was once laughable. Customers used to walk up to clerks with their shopping lists, and the clerks would fetch the items for them.

No one thought people would want to do the work of picking their own fruits and vegetables.

I think the same is true for CPOE -- computerized physician order entry.

I try to remember this when I encounter opposition to CPOE and electronic medical records (EMR). Sure, I learned for the oral board exam how to rattle off a long list of lab tests to order, medications to give, based on a clinical scenario. But I trained, and practice, with order sets on EMRs. It's just more natural for me to pick among preselected agents and doses, and prompts me to consider alternatives I might not have. I like perusing the items listed in front of me, or a few clicks away, just as I like to feel a few avocados before picking one to purchase.

CPOE is a hot topic, right now. I spent months with my colleagues creating and refining order sets for our new ED information system. I'm watching ACEP's informatics section settle on a policy statement on scribes, who many ED physicians rely on to interface with computerized systems. Here's my own recent piece for EPMonthly about drug-drug interaction warnings and coming era (hopefully) of smarter, more context-aware clinical decision support.

I suppose the analogy to decision support would be expiration dates, or nutrition labels, to help consumers shop. I'd also allow the comparison that modern EMRs are like a confusingly organized grocery store that requires hours of training, and federal incentive plans, before people shopped there.

Maybe the news that NIST is convening an EMR usability workshop should be interpreted in this light -- we've acknowledged that we're heading away from clerks and toward picking out our own items, but the store aisles are going to have to be laid out more intuitively.