Think you have strep? Answer two questions and check the big data | Vector blog →

Researchers at Boston Children’s Hospital are working on a system that incorporates local microbiology data with two easy questions patients can ask themselves to predict whether or not they should see a doctor.

We need more innovation like this, especially in terms of infectious diseases. Knowing the local burden of a given infection can dramatically improve diagnostic testing performance and inform whether or not such testing should be conducted [1]. Unfortunately, infection data is all too often siloed in hospital and clinic microbiology lab data.

  1. Remember from your basic epidemiology that positive predictive value is dependent on the prevalence of the disease. So, if we know there is a high prevalence of strep throat in the community based on local infection data, the predictive value of simple questions and even rapid strep tests increases.  ↩

Whose Data Is It Anyway? | The Health Care Blog →

Wow, electronic medical record vendors claim ownership of all of the data entered into their systems. It’s like if everything you wrote in Microsoft Word was owned by Microsoft [1]. I have heard of some of the big EMR companies creating ‘exchanges’ where they aggregate data from various hospitals for research. At the time, I thought that was strange and curious how they were able to do it with HIPAA. This is how.

  1. Google claimed similar ownership over data and files when it launched Google Drive. People were not happy at the time, but nobody talks about it anymore.  ↩

Hot Spotting - Innovative Approaches to Caring for the Very Ill | Wing of Zock →

Interview with Jeffrey Brenner MD, executive director of the Camden Coalition of Healthcare Providers and one of the persons behind hotspotting.

Dr Brenner:

Sit down at the foot of the bed, ask patients open-ended questions, and find out what’s going on in these peoples’ lives.

This is something that all physicians at all training levels should do. It’s an important step that we all too often skip in the pursuit of ‘efficiency’. We don’t really know a patient’s disease if we don’t know the patient.

Find out more about the AAMC’s Hot Spotting initiative and get involved.

[via Wing of Zock]

Why it’s the best time to be a healthcare entrepreneur | Rock Health →

Interesting interview with Zen Chu, the founder of HackingMedicine at MIT, about the digital health startup landscape. His reasons for why it’s the most exciting time to be a healthcare entrepreneur are at the bottom. I hope his third reason—“Large entrenched healthcare institutions are having a tough time adapting versus more agile startups”—is actually true, but I don’t know there is much evidence for that.

Health-Care Apps That Doctors Use | WSJ →

Kind of a disappointing list (see my last post) and several of the apps require institutional integration, so if you're hospital's IT department doesn't support it you can't use it (like Epic's iOS apps).

Medical apps needed, and not just for 'hipsters with chronic diseases' | Chicago Tribune →

John Carpenter:

[Dr. Scott Stern] said the growing wealth of medical knowledge doctors are expected to use and apply “is just mind-boggling and impossible to keep in your head. It’s clear that we have to do this better to deliver the kind of care that patients assume they are getting, and that they probably are often not getting.”

Reference apps for physicians are nice; they compose the largest number of physician-centric apps currently on the market. However, we need productivity apps for doctors. Why is there no great electronic prescribing app? Why don’t EMR vendors have simple apps for order entry?

I’m waiting for the day when I can walk into a patient’s hospital room, talk to them, examine them, discuss treatment options, then pull out my phone (PHONE, not tablet or going to a computer) and hit a few buttons to add new orders for the patient. I won’t have to enter login information and wait for the computer. I won’t have to enter the patient’s name; it will already know which patient’s room I’m in through RFID (and will have the consequent benefit of reducing errors). For the most common orders, it will only require a few taps. And it all of this has to be faster than a Google search.

That is what doctors need in terms of medical apps.

[via Wing of Zock]

Imagining the Post-Antibiotics Future | Medium →

Skip to about half way through the article where McKenna [1] discusses how many things we do in medicine depend on antibiotics (transplantation, cancer treatment, ICU care, surgery, safe childbirth, etc) and what the post-antibiotic era will mean for those therapies [2]. That is the truly scary and difficult to convey aspect our current antibiotic situation.

  1. Maryn McKenna is journalist who wrote ‘Superbug’ (an excellent read) and has become a tremendous voice for responsible antibiotic use.  ↩

  2. McKenna also recently wrote a shorter, more focused piece on Wired about the impact of ineffective antibiotics on the practice of medicine.  ↩

The Medical School Class of 2025 | Wing of Zock →

The med school class of 2025 started high school this fall. Interesting thought experiment to predict what will change over the next 8 years before they start their medical education.

In Search of More Primary-Care Doctors | WSJ →

This article points to the well-worn causes for our primary care shortage—too little pay relative to specialists and the hidden-curriculum against primary care. However, they also bring up an infrequently discussed factor—who we select to be doctors.

George Thibault…says that if the U.S. wants to produce more primary-care doctors, especially those who are willing to practice in disadvantaged and underserved areas, medical schools may need to change the way they select students. He says students who have strong ties to their community, want to form long-term relationships and have a commitment to public service are more likely to choose primary care than other students…

…Grades and test scores, [G. Richard Olds, the founding dean at UC-Riverside], can no longer be the exclusive criteria for entry into primary care. “I’d even argue that those with the highest grades and Medical College Admission Test scores may not make the best doctors.” Riverside seeks students with public-service work experience and those from disadvantaged backgrounds who are likely to return to their communities to practice.

Current premed curricula and medical school admissions heavily favor students interested in biology, chemistry, and physics. These disciplines emphasize basic science research and high technology. What medical disciplines tend to feature lab research and/or use of advanced technologies? Subspecialties, not primary care.

Texas’ Other Death Penalty | Texas Observer →

Well-written article from a medical student talking about working in her school's student-run free clinic and the safety net. She provides a nuanced policy discussion vividly detailed by some of her patients' stories.

2013 Medical Education Debt and Tuition Fact Card | AAMC →

Take a look at the second page. The amount of interest (only interest!) paid by graduates over the course of their loans (based on the median debt of $175,000) ranges from $151,000 to $317,000 [1]. Total costs are all in excess of $320,000. These are the figures that med students should think about.

  1. This is only looking at the first 4 sample repayments and ignoring the bottom two sample repayments that include loan forgiveness through public service programs (which often are not an option for most medical students).  ↩

Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics | Pediatrics →

Adam Hersh MD PhD, Mary Anne Jackson MD, and Lauri Hicks DO writing on behalf of the AAP Committee on Infectious Diseases:

A major objective of this clinical report is to provide a framework for clinical decision-making regarding antibiotic use for pediatric URIs. A point of emphasis is the importance of using stringent and validated clinical criteria when diagnosing acute otitis media (AOM), acute bacterial sinusitis, and pharyngitis caused by group A Streptococcus (GAS), as established through clinical guidelines…The careful application of [guidelines and other prescribing interventions] has the potential to mitigate overuse of antibiotics for pediatric URIs.

Why A Patient's Story Matters More Than A Computer Checklist | NPR Shots →

Why does this physician’s EMR contain so many checkboxes? Because checkboxes create discrete data that can then be easily parsed for billing purposes (the main use) and potentially research. We have not figured out how to parse natural language in medical records for these purposes…yet. Hopefully, systems will be designed to accomplish this and physicians can return to more narrative notes.

The other important part:

I could see twice as many patients if I could write their notes at the bedside while visiting with them. I would happily do this using paper or an EHR that took the same amount of time, but these are not options.

EMRs need to be as fast and easy to use as paper, but that doesn’t mean it has to (or should) work like paper. We may have to change the format of our notes (i.e.–blowup the SOAP note) and adjust our workflows.

Darwinian Health IT - Only well-designed EHRs will survive | tdwi →

This is an interesting piece that goes over many of the factors that are responsible for our current electronic medical record (EMR) system mess. However, it misses the most important one–the largest purchasers of EMR systems today are not physicians, but hospitals/large healthcare systems driven by their billing departments and IT departments. Their needs have consistently trumped those of physicians.

They also highlight a disturbing fact for individual physicians or smaller practices:

“The data suggests that it is likely we’ll see a sizable reduction in the number of EHR vendors listed for 2014 edition certification,” predicted Steven Posnack, director of federal policy, and Dustin Charles, a public health analyst, on the ONC’s September 13 blog post

The certification they are talking about here is Meaningful Use Stage 2. What happens to smaller practices who have invested significant amounts of money in recent years implementing an EMR system, only to find out that their system will no longer qualify for Meaningful Use (and the reimbursement that goes along with that qualification)?

✚ Hot spotting as educational tool

The AAMC has a new initiative to teach the next generation of physicians about ‘hot spotting’ and its role in providing high quality care while reducing costs. They have developed a toolkit to assist any medical student, resident, attending, or community physician in conducting their own hot spotting project with a patient from their practice.

I was immediately taken in by hot spotting when I read about in Atul Gawande’s 2011 New Yorker piece [1]. Around the same time, I heard about a research group that was taking a ‘80/20’ approach to prioritizing their initiatives. They were going to look at the 20% of diagnoses that accounted for 80% of their admissions. Electronic medical records enable both strategies and are good examples of using ‘big data’ to direct our efforts.

The initiative and toolkit put together by the AAMC is impressive. Their ‘10 Steps to Hot Spotting’ lays out a framework for comprehensively evaluating a patient who frequents the hospital.

A few thoughts:

  • Absolutely fantastic that their steps include going outside the hospital and clinic. Medical training should include more time for trainees in places providing supportive services (i.e.–nursing homes, physical rehab centers, shelters, mental health centers, etc).
  • Step 2 (essentially identifying the patient) seems like a high bar to pass. Their strategy requires (1) an excellent relationship with a specific care provider in an area likely to see candidate patients and (2) that person to recognize a suitable patient and contact the med student.
  • As written, their 10 steps don’t seem to incorporate identification of a mentor. I think–for med students especially–it would be very beneficial to have a mentor, especially if you can find someone with quality improvement experience/interests.
  • The final step should be presenting all of this at Grand Rounds!! If someone spent the time and effort to put together all of the materials described here, it would make for an amazing presentation. And don’t forget to include the patient (if possible).
  • This would make for a great project to include in quality improvement classes, which should be requisite for med school graduation. I wonder if such a project would count as quality improvement for board certifications now requiring a QI project [2].
Very to excited to see what comes out of this initiative. I think this is an excellent tool for introducing trainees to population-based health without the scary (and often boring) aspects of epidemiology and biostatistics.

  1. Of course, part of that was due to Dr Gawande’s great storytelling.  ↩

  2. For example, the American Board of Pediatrics now requires a pediatrician to complete a quality improvement project as one of four parts to their new Maintenance of Certification. I believe (but don’t know for sure) that other specialties are doing similar things.  ↩

Let’s do a ‘We Do’ | Stanford d.school →

Melissa Pelochino–a Stanford d.school fellow–describes how too often we go from ‘I Do’ (where a teacher models something) to ‘You Do’ (where the student does it independently), skipping the ‘We Do’ (an intermediate step where the teacher and student do something together). I think this is all too frequently true in medical school. In students’ third year, as they rotate from service to service, they may spend a day or two observing the residents and attendings seeing patients. However, within that first week, the med student is typically given a few patients and set loose. They go and see the patients independently and present the patient independently on rounds [1].

I think 3rd year med students, especially those in the first 6 months, would benefit tremendously from more ‘We Do’. Students and residents could see patients together, divvying up with encounter between the two. At times, I’ve had such educational experiences with exceptional residents and it was invaluable.

  1. A bit of an oversimplification. Med students will see and present patients independently, but the responsible resident is also seeing the patients as well. Residents backup the students on rounds and tactfully step in when a student misses something or there is a complicated question.  ↩