How Information Overload Sabotages Our Observation Skills | 99u

Bob Hambly:

It's our job to be better observers. We've become lazy about it.

In this talk, Hambly is addressing designers but I think his lessons are not only pertinent but prescient for physicians.

The basic job of a doctor is to take in information and make observations in order to generate creative ideas. Then, order those ideas in terms of their likelihood and again generate creative ideas for solutions. The medical colloquialisms are 'differential diagnosis' and 'treatment'. But, don't be fooled—these are creative enterprises.

In the world of electronic medical records, molecular testing, advanced imaging, and genomic data, we face the threat of information overload. Reams of information are at our fingertips. No longer do we have to be exhaustive historians, staunch observers of signs and symptoms, or careful practitioners of the physical exam. We've become lazy observers.

Yet, valuable information not contained in the records lies within the history and physical. The subtle symptom overshadowed by more salient problems; the travel history or environmental exposure not previously asked about; the close family member with a similar problem. How do we improve our observational skills?

For designers, Hambly suggests documenting observations in various media. For physicians, I think the key is long-form narratives of the History of Present Illness and careful documentation of the physical exam (our versions of documenting our observations). In our quest for efficiency (and more patients and more pay), we've reduced the HPI to a grocery list of signs and symptoms and copied templates of physical exams. While these may fulfill billing requirements, they are not useful later on when things don't turn out how we anticipated and we need to revisit the original patient presentation. Holding ourselves to a high standard also pushes us to gather enough information from the patient to form a thorough narrative. You'll see how much detail you've missed when you try to form a comprehensive, readable narrative.

The next best tool for avoiding information overload to improve our observational skills...don't look at the chart before seeing a patient. Gather all the information yourself. Don't rely on the admitting HPI or previous hospitalization notes for the basis of your narrative. Take the patient's own words; then use the other records and clinical data to enrich the narrative.

Such process takes time, a valuable commodity in medicine. But, practice breeds proficiency and speed. We (especially those of us still in training) need to ensure we are practicing the correct process. 

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Why the Creative Destruction of Healthcare May Not Be Such a Good Idea | The Health Care Blog

‘Disrupt’, ‘creatively destroy’, ‘flip’, ‘hack’, etc are tech buzzwords now commonplace in the healthcare public discourse. But, are they helpful or even accurate?

As Dr Bill Crounse points out in this piece and Brain Palmer noted in a Slate article about medical hackathons, lots of smart people within the medical world have been working on many of these tough problems for years. ‘Destructive’ language minimizes their work and the scope of the problems.

Nevermind these words are so widely used they have virtually lost all meaning.

Health care is far from perfect and change is needed, but what we need is actual improvement not overwrought rhetoric.

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Are Hackathons the Future of Medical Innovation? | Slate

Brian Palmer:

There’s an element of hubris to medical hackathons that can’t be ignored. Medical experts around the world have been trying to solve most of these kinds of problems for years.

Excellent examination of medical hackathons' power and limitations. It's very difficult to solve medicine's most vexing problems in a 24 hour binge, but you can chip away at the edges and generate many good, albeit nascent ideas.

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A Google Glass App That Would Be Hard for Even the Haters to Hate | recode

Or he could've just asked one of a dozen people in the room with him (i.e.—nurses, technicians, therapists, residents, med students, etc) to look at the record for him...

More importantly, anecdotal evidence, while compelling, is...anecdotal.

Also note, the Google Glass being used at BIDMC is not stock:

Wearable Intelligence strips and replaces the Google Glass software with a reformatted version of Android, so it can be locked down for specific uses and specific contexts. Doctors don’t have the option to tweet photos of patients, check their Facebook, or even take the device off the hospital Wi-Fi network. Google’s on-board speech recognition technology is replaced with a more specialized medical dictionary from Nuance.

More cost, more complexity to complete a rather inane task.

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Big data: are we making a big mistake? | FT Magazine

With the shortcomings of Google Flu Trends exposed last month, many have jumped at the chance to critique ‘big data’. A recent NY Times article on the subject has been widely circulated.

Rather than spouting off a grocery list of issues, this FT Magazine article provides some insight into the core problems with ‘big data’.

Most notably, they draw a distinction between ‘big data’ and ‘found data’:

But the “big data” that interests many companies is what we might call “found data”, the digital exhaust of web searches, credit card payments and mobiles pinging the nearest phone mast…Such data sets can be even bigger than the [Large Hadron Collider] data – Facebook’s is – but just as noteworthy is the fact that they are cheap to collect relative to their size, they are a messy collage of datapoints collected for disparate purposes and they can be updated in real time.

The ease and inexpensiveness of ‘found data’ leads to “theory-free analysis of mere correlations” which often breakdown due to the old statistical curmudgeons—sampling error and sampling bias.

The whole article is well-worth the time to gain some insight into ‘big data’.

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A new game plan for concussions | Apple

Beautiful page dedicated to how athletic trainers can use an iPad with the C3 Logix app from the Cleveland Clinic to capture data about concussions on the field.

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Is Maintenance of Certification Our Next Tuskegee? | Dr Wes

Dr Wes—a cardiac electrophysiologist and clinical teacher at the University of Chicago—takes the American Board of Internal Medicine to task over their newly mandated Maintenance of Certification (MOC) process. He argues that this new process violates the ethical standards promulgated in the 1979 Belmont Report.

This is a long, well-written critique of the ABIM’s MOC and well worth the time to read it. A few thoughts:

  • I find the comparison of the MOC to the Tuskegee Syphilis Study wholly inappropriate. Internal medicine physicians today are a far cry from poor African American sharecroppers from the rural South in the 1930s. Drawing corollaries between the two is disingenuous. Those in the Tuskegee Study were never told they had a disease, thus they had no recourse and many died due to a treatable disease. Physicians have been told about the MOC process and can formally address their complaints through the ABIM or, as Dr Wes is doing, seek redress through public discussion and pressure on the ABIM. I think it is suitable to frame the discussion within the principles outlined in the Belmont Report, but grossly inappropriate to make a comparison to the Tuskegee Syphilis Study.
  • The unproven nature of the MOC process could be translated to virtually all board exams. Little to no evidence exists demonstrating the value of USMLE Step Exams and speciality board exams. We need to critically evaluate how we demonstrate competency in medicine.
  • The costs for all of these unproven exams and certifications is staggering. The ABIM MOC program fee is $1,940 plus an additional $775 exam fee. For a subspecialist, the MOC fee is $2,560. Why do subspecialists have to pay $500 more?!? Seems like brazen profiteering off their colleagues.
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✚ More information about Apple's Healthbook

I first wrote about Healthbook back in early February when vague, disparate rumors began to coalesce.

Over the past week, more information has been leaked about the forthcoming product. 9to5Mac continues to provide the most information with detailed descriptions and screenshots of what Healthbook may eventually look like. In a a piece later in the week, 9to5Mac profiled Vital Connect’s HealthPatch—a temporary patch worn on the chest to track various biologic parameters. As noted in the article, several Vital Connect employees have recently been hired by Apple.

After 9to5Mac’s piece last Monday, Wired weighed in on the subject, speculating Apple’s move into this space could take the quantified self/mHealth movements mainstream with far reaching implications.

As I said back in February, I am excited to see what Apple can bring to health and fitness. But I also want to re-iterate:

The big elephant in the mHealth/quantified self room is that no one has quite figured out what to do with all the data. Some highly motivated quantified selfers are using it to change their habits, but what impact will it have on the rest of the world?

To this point I also want to add that as consumer apps and devices move more and more into the medical world—through measurement of biologic data such as blood sugar levels or pulse oximetry—the need for evidence in terms of safety and efficacy will grow stronger. Not only will doctors want to know they can rely on the data, the FDA will demand the evidence for safety. 23andMe ran afoul of the medical regulatory culture. We are comfortable with novel devices counting steps without much research, but not so much when it comes making therapeutic decisions based on data from untested devices. But, maybe Apple has learned from 23andMe’s missteps.

This summer should be interesting.

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Doctors and Tech: Who Serves Whom? | The Atlantic

Too many technological systems are built in ways that make sense to computer engineers but not to doctors…

This is the fundamental problem with current EMR systems. We can try to solve this problem by including more doctors in the design process, but ultimately we need more physicians with backgrounds in computer science and design. Medical schools should be actively recruiting computer science majors. And we need to find ways to incentivize developers who are currently working on weather and podcasting apps to develop the next great EMR.

“Every innovation should be tested not just to see if it increases revenue or cuts costs,” [Dr. Paul Weygandt] says, “but also to ensure that it enhances the doctor-patient relationship.”

Providing better electronic tools specifically tailored to facilitate the workflows of physicians will increase revenue and cut costs.

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Why is EHR usability overlooked for the sake of innovation? | EHR Intelligence

“My mission is to relieve physician suffering by improving usability of the software they use,” [Jeff Belden, MD] explains. “The problem right now is that doctors have to think really hard and what we know is that a lot of this stuff could be offloaded.”

Providing context-sensitive, timely information to physicians should be the ultimate goal for an EMR. Doctors should not spend much time at all gathering patient information to make a decision. Some companies are doing this by creating custom views for specific conditions like diabetes or patients requiring anti-coagulation.

What we really need is either (1) the ability to easily create our own custom views or (2) APIs that give developers access to the nuts and bolts of an EMR so they can create their own apps for viewing/entering data and writing orders.

The second solution is more difficult but far more appealing in that it has the potential to provide more robust solutions.

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Why Doctors Still Use Pen and Paper | The Atlantic

David Blumenthal, former National Coordinator for Health Information Technology:

The reason why the medical profession has been so slow to adopt technology at the point of contact with patients is that there is an asymmetry of benefits.

I disagree with Blumenthal's assessment that this is a marketplace problem. It's a usability problem.

Usability of current EMRs is so terrible that physicians do not see a benefit over pen and paper. Think about it in terms of email—would you use email if it required you to write out the message by hand, scan it into a computer, and then took 4 days to deliver it? Absolutely not. Email provides tremendous advantages in terms of convenience and speed over traditional mail. Doctors are not seeing advantages with EMRS in their day-to-day work over paper records.

With better usability, physicians would be able to do their jobs more easily and efficiently, with the hope of spending more time with patients and less time doing paperwork. Adoption will go through the roof with EMRs that are truly useful for doctors.

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Electronic Health Records—Expensive, Disruptive And Here To Stay | Forbes

According to Dr. Handler the answer is simple, “Computers need to do work for physicians rather than making physicians do work for the computer. Technologies should make it faster and easier for the treating physician to view relevant information, to document a useful patient story, and to make the best care decisions."

Exactly.

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Typing And Screening My Own Blood | RK.md

Rishi Kumar—an anesthesiology resident—talks about the experience of going to the lab and doing his own type and cross-match (the thing we do to make sure you get matched blood products).

I think we need more of this in medical education. I think there could be an entire class (during 4th year would be a good spot) dedicated to laboratory medicine. Students would actually get to perform the tests we often flippant order without a second thought to the labor required to produce the result. Not only would we imbue respect for the tests, but we would learn some of their shortcomings and nuances to their execution.

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