Doximity Dialer

Sometimes simple is the best. I recently tried a new smartphone app – Doximity Dialer – that is just that. I have been so struck by it that I have started showing it off to people at any opportunity. It is incredibly simple to use (from download to using it in <5 minutes) and solves a straightforward, but common problem. It is 8pm and you’re at home working on messages in your EHR. You need to call your patient back about a lab test result. Enter this conundrum… You can either use *67 to block your caller ID in which case the patient will think it is a telemarketer calling and not answer. Or you can leave your caller ID on, in which case the patient now has your cel phone number. While some physicians have become comfortable with their patients having their cel phone numbers, many still have not.
Doximity Dialer allows you to “trick” Caller ID into showing a phone number of your choice, e.g. your office number, to the call recipient. This means that you can make calls to patients from your cel phone, but the patient sees your office number on Caller ID.  Now, they recognize the number as their doctor and will answer the phone, and doctors do not have to feel squeamish that a patient will have their personal cell phone number.
Win-win. Simple.

Could voice control of the EHR improve physician efficiency and satisfaction?

Farhad Manjoo, the NYTimes tech reviewer, wrote a story this week about the Amazon Echo, a device for the home using the Amazon Alexa voice recognition service to allow natural-feeling interactions with web searches and web-connected home devices. My immediate reaction was that this will be the human-computer interaction with the future EHR.

Where we now use the mouse and keyboard to search endlessly through complicated menus, in 5-10 years, we will instead be able to say aloud, “Order Mrs. Jones a metabolic panel, lipid panel, and A1C to be done today and again in 6 months. Send the order to the Quest lab. She also needs a bone density scan ordered to screen for osteoporosis. Make sure she has this scheduled and completed by the end of the year. Make a referral to Dr. Smithson in Cardiology for management of coronary artery disease. Send in a one-year refill of her metformin. At the end of our visit today, please send a letter with my full note from today’s visit to her primary care physician.”

As a physician speaks these orders, his shopping cart menu will build on-screen, allowing for verification that the system selected the right items. What now takes several minutes and immense cognitive effort could instead be completed with natural speech and minimal effort in far less time.

I hear from colleagues all the time that they are overwhelmed when using EHRs with too many buttons, menus, and too much clicking around. They feel disconnected from the patient sitting in their office, and that the computer screen has intruded in that relationship. Perhaps a natural language voice recognition system like Alexa is one step closer toward a more satisfying and connected experience for everyone.

The Case for a Patient-Centered EHR: My Dad (full post at Medscape.com)

In the 10 years since my father was diagnosed with multiple myeloma, he has accumulated thousands of lab results, hundreds of physician progress notes, and dozens of imaging studies. Because his myeloma has been hard to treat, and perhaps because he is a well-regarded physician in his field, he has accessed the best care available, including fantastic doctors and new therapies available at distant research centers.

Despite the fact that all of his physicians use electronic health records (EHRs), nobody actually has his medical record. It does not exist. Rather, his thousands upon thousands of data points are scattered across the country, with no one health system or physician having unified access to all of it, including my dad.

As a clinical informaticist, I spend a lot of time thinking about interoperability—the extent to which systems are able to exchange data and subsequently present those data such that they can be understood by a user—but nothing prepared me for seeing my dad play the role of his own health data aggregator.

Tracking data over time is a key component of multiple myeloma care. Imaging scans looking for bone lesions and the “light chain” blood tests that measure the myeloma cancer protein are done periodically to assess response to treatments. Each result, depending on its direction, either brings a sigh of relief or a rise in stress and fear along with a shift in treatment regimen. To optimize my dad’s care, his doctors would need to see the full picture: the imaging, labs, and each historical chemotherapy treatment over time.

You can imagine how this ideal interface would look, with a nice, clean graph showing his light chain results, imaging, medications tried (and failed), and the location of his treatment. But no such graph exists. Worse, it cannot exist in our current system because each health system where my father is treated is only responsible for their portion of his overall medical record.

Keep reading full post at Medscape.com (warning: requires Medscape account)

What’s the Health IT Buzzword of 2015? (Full post at Medscape.com)

Note: This is an excerpt from my first column at Medscape.com.

While walking my dog one recent evening, I listened to a podcast in which two Internet pioneers suggested that there are only two ways to make money: via “bundling” or “unbundling.”[1] They described everyday examples, such as the music industry, which started out by bundling individual songs into record albums. The music industry then turned to unbundling, when iTunes® sold individual songs for 99 cents, then bounced back to a bundling phase with such services as Spotify® or Rhapsody® that bundle entire music libraries to sell for a monthly fee.

A similar ebb and flow occurred with television. Cable TV channels have long bundled individual channels to be sold as a package. However, we are now seeing unbundling, with such services as HBO GO® selling individual channels to consumers.

Remember browsing the never-ending connections of the Internet on the World Wide Web using your desktop browser? The Web has also been unbundled. We all now have dozens of smartphone apps that offer unique, distinct, and generally siloed functionalities.

Bundling and Unbundling Digital Healthcare

Healthcare has experienced similar trends. Before the era of electronic health records (EHRs), the typical physician’s office had its own paper chart for each patient. Every chart was its own silo, unseen and inaccessible to other physicians’ offices. I can still remember working in my primary care clinic and having to ask my patients what their specialist had said in consultation, because I had no access to their consult note. Lab information systems, pathology systems, radiology systems, and billing systems were all separate.

Today, at medium-sized to large healthcare organizations, the enterprise EHR has facilitated the integration of these systems. Hundreds or thousands of physicians across an organization share a single chart for a patient, which includes the patient’s lab results, radiology results, pathology results, and billing functionality, providing a unified and accessible medical record for each patient at each healthcare institution.

At the same time, these institution-wide EHRs include potentially unwanted or unneeded functionalities, much like that bloated cable TV bundle at home. In some cases, EHRs contain some inferior modules that must be used simply because they came with the package, and they lack other capabilities that the organization really needs.

Entrepreneurs have seized this opportunity, filling these functionality gaps and creating thousands of digital health apps. Each app attempts to offer a slice of functionality to consumers or to the healthcare system that is either unique or of higher quality.

We are not yet able to allow healthcare organizations to create mix CDs

The trouble is that most apps create siloed data and siloed functionalities. Although the EHR is the centerpiece of clinical workflows, most apps do not easily interact with the EHR. Most apps do not exchange data with the EHR. Nor do most apps even interact with each other, allowing free flow of data between them.

This is “unbundled” digital health. It is the iTunes era. We are not yet able to allow healthcare organizations to create mix CDs, where there is an intentional order and flow from track to track. Instead, we remain in the era of “come and buy your favorite songs à la carte for 99 cents, stick them all on your iPod Shuffle, and hit ‘play.'”

Click here for the rest of the blog post.

Can 3D Sculpture Help Patients ‘Grasp’ Diabetes Data? (Full post at Medscape.com)

Note: This is an excerpt from my most recent column at Medscape.com (full post at Medscape).

Recently, I was given a first look at a fresh take on BG monitoring, created by artist and technologist Justus Harris. Justus is an artist and technologist based in Oakland, California, and Chicago who was diagnosed with type 1 diabetes at age 14 years. He is blazing a new trail by bringing together personalized health data and the tactile world, creating 3-dimensional (3D) data visualization sculptures.

Often the most exciting innovations happen at the intersection of disciplines, such as the intersection of art, technology, and medicine. Sitting at this crossroads, Justus created an object that can be viewed through many different lenses. As an art gallery piece, it is a form of self-expression for someone struggling with a chronic disease, using art to humanize the BG numbers that he lives with on a daily basis. As a medical education tool, it is a very creative method that connects a patient with his BG data in a 3D, tactile, and visual fashion. This approach could even become a way for someone with low health literacy to rapidly understand whether his diabetes is in good or poor control, beyond what glycated hemoglobin conveys.

To read the full post, please go to the article at Medscape.com (note: you will need to sign in to Medscape to access it)

The Four Key Features of EHR Integration: Move Beyond “Data Dumping”

A rapidly growing number of health innovations such as mobile apps, diagnostic tools, and sensors are being developed with a focus on enabling health and wellness outside of the traditional medical office visit. As Eric Topol points out in his new book, The Patient Will See You Now, many of these tools will help people independently understand and manage their health. A long history of medical paternalism will be overturned as health information is returned to the individual and autonomy restored. This is a great trend.

However, we do not have to create an “either-or” dynamic where some health information is held by the healthcare system and other information by the individual. These new technologies will be maximally useful when they enable and facilitate a deeper, richer dialogue within the context of existing doctor-patient relationships. To achieve this more coherent and comprehensive healthcare, we need to bring together the patient, her digital health information from new sources, the doctor, and the EHR.

These concepts of interoperability and EHR integration are being widely recognized as crucial over the next few years in healthcare, as evidenced by the JASON Task Force’s recommendations and the formation of the Argonaut Project.

What concerns me as a practicing physician and informaticist is when I hear people discuss EHR integration as if it means only this:

Data Dump

This represents the idea of taking every single data point collected by mobile apps, sensors, and other tools and passing it all straight through into the EHR. I am always reminded of one of my favorite scenes from I Love Lucy, but instead of desperately trying to stuff chocolates into my cheeks and clothing, the medical conveyer belt could make physicians unable to keep up with massive quantities of inbound data from patients.

I Love Lucy

I think it is this sentiment that has led to articles like this one posted in August 2014, saying that “doctors don’t care about your FitBit data.”

Doctors Dont Care About FitBit Data

I disagree. The truth is that I might care about your FitBit data, depending on the clinical situation, the context of that data, and the way in which it is presented to me. I just don’t know yet. I think it is very likely that there will be many of these situations where your activity tracker data matters a lot! We can do better. We can use new information sources when they are helpful and add value by weaving together a comprehensive view of a patient’s health information that facilitates better conversations between individuals and their doctors, and thus better care. This means that patient-generated data cannot be siloed off from the EHR. It instead must be incorporated into clinical workflows as part of the EHR. To achieve this vision of a more complete EHR integration, I think we need the following:

Four Key Features of EHR Integration

1: Discrete data points: I know, I know. Didn’t I just say we don’t want this? I actually believe we still do want access to discrete data. It just cannot be the beginning and then end of integration. Also, this refers not just to data coming in to an EHR from outside, but clinical data flowing out from an EHR to an app or analytic tool, such as your medication list, medical history, or recent hemoglobin A1c values.

2: Analytics and decision support: We need intelligent rules, filters, and analytics to help route information at the right time to the right person and right place. These rules will work best if they can use data from inside the EHR along with these new, patient-generated data sources.

3: App and workflow integration: Talented and innovative software developers and others are creating new ways of presenting information, such as disease-specific data visualizations. We need to make it easy for physicians to access these within the context of their daily work in the EHR. Physicians are not going to launch and log-on to their EHR and three different applications to compare data, no matter how snazzy and how much media buzz your new app has. Moreover, we should be able to do clinical documentation, make a therapy change, or order further diagnostic testing from within the confines of a new tool and have that documentation, prescription, or lab “order” feed back into our EHR for action. This will keep your medical chart and health record more comprehensive and easier to follow, with less information scattered around different places.

4: Communications integration: Finally, with all of this information passing back and forth, each system is going to be capable of sending and receiving messages between the doctor, patient, family members, and other care team members. Nobody will want to log-on to every individual account to check messages. So, we need to be able to intelligently integrate and route messages so that each person can send and receive messages from the “hub” application that makes most sense to them.

At the UCSF Center for Digital Health Innovation, we are excited to be working toward this vision of comprehensive, workflow-driven EHR integration.

(This post is based on a talk I gave at the Diabetes Technology Meeting in Bethesda, Maryland in November 2014.)

A Lesson In Clinical Decision Support: We Cannot Defeat Human Nature

      Our UCSF Clinical Informatics group met a few months ago with several representatives from a major Health IT vendor. The vendor, we’ll call them RxLabs, is a provider of pharmaceutical related knowledge in many domains, including decision support tools for the EHR. Our conversation centered around how to better customize medication alerts. We talked about the popular topic of “alert fatigue,” and how to improve EHR decision support tools to improve their impact, rather than just being white noise annoying clinicians.
      The vendor was walking us through a slide-deck about their hypotheses and data about EHR medication alerts and we were having a vibrant discussion about how to improve provider adherence with decision support. We saw slide after slide about how to make pop-ups smarter and about trying to get more buy-in from providers with paying attention to alerts. After all, why would a provider trying to take care of her patient ignore an alert that is trying to help provide an important message? It must be sloppiness or laziness on the part of providers!
      Ten minutes in to this conversation about drug alerts, up pops the following:
Windows 7 Display Alert
      I’ll give you a second to guess what happened next.
      Without a moment’s hesitation or thought, the presenter clicked the little X in the upper right corner. Our conversation went on. More slides. More data about medication alerts in the EHR. Ten minutes later, guess what happened?
      Up came the same pop-up Windows alert. The presenter again, hastily, without paying attention, and perhaps giving a small huff of displeasure, clicked the little X in the upper right corner. More slides, ten more minutes, same thing. You get the idea.
      This happened three times, with each passing pop-up, the presenter becoming slightly more annoyed. The fourth time the pop-up appeared, my colleague Russ Cucina, the Associate CMIO at UCSF, paused the presenter to have us all read the pop-up alert message. We took ten seconds together to learn that selecting any of the three choices rather than clicking the “x” would have satisfied the alert and kept it from coming back.
      The room broke out into laughter. We all understood our own hypocrisy. We cannot defeat human nature.
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