Indian Medicine

John's recent post on my "medical office mashup" comment is, as my colleague Paul would say, "spot-on." What I learned from his discussion: Long ago in a Minnesota far-far away .. where Gopher was born .. and professional wrestlers were still wrestling ... John used to look up at that cold sky and dream of medical mash-ups. In a weak moment - you can still see that little kid in John - but he's been hangin out with the suits lately - and they make him say things like this: "Building a 98% reliable solution from x integrating parts requires (1- x*y*z...) reliability from each component." Of course - he's right. That's the problem with the CIO types that he hangs out with -- they're usually right.  Too many points of failure, too many dependencies on "foreign" systems, etc.  Gotta do it the "enterprise" way.  But we've got to be able to dream these dreams - because they are the right ones to have. Sure - Google's calendar API will change and I'll zig with their zag - because for a user base of 1 person - this software is neither "mission critical" nor 100% reliable. If we did everything the enterprise way - there would be no Internet.  TBL's vision was that by connecting things - we can derive enormous value.  Consider this section of one of his most famous essays:  ... For all these visions, the real world in which the technologically rich field of High Energy Physics found itself in 1980 was one of incompatible networks, disk formats, data formats, and character encoding schemes, which made any attempt to transfer information between dislike systems a daunting and generally impractical task. This was particularly frustrating given that to a greater and greater extent computers were being used directly for most information handling, and so almost anything one might want to know was almost certainly recorded magnetically somewhere. Design Criteria The goal of the Web was to be a shared information space through which people (and machines) could communicate. The intent was that this space should span from a private information system to a public information, from high value carefully checked and designed material, to off-the-cuff ideas which make sense only to a few people and may never be read again. The design of the world-wide web was based on a few criteria. An information system must be able to record random associations between any arbitrary objects, unlike most database systems; If two sets of users started to use the system independently, to make a link from one system to another should be an incremental effort, not requiring unscalable operations such as the merging of link databases. Any attempt to constrain users as a whole to the use of particular languages or operating systems was always doomed to failure; Information must be available on all platforms, including future ones; Any attempt to constrain the mental model users have of data into a given pattern was always doomed to failure; If information within an organization is to be accurately represented in the system, entering or correcting it must be trivial for the person directly knowledgeable. Lots of what TBL said in 1996 (about physics in 1980) still applies to healthcare in 2007.  shame on us! So my tiny project (total time invested <2 hrs) is an example of how we might start thinking about the parts fitting together.   It's 2007 and there are companies out there that have already started to develop and deliver webservices that provide important parts of the EMR infrastructure.   They work today - and will do more tomorrow. Of course I've been wrong before ... a professional wrestler as Governor?  Never.  :-) technorati tags:EHR, EMR, Web, TBL, Faughnan

Medical Decisions are hard to make.  Even when they seem easy.   I'd say that the TV show "House" is popular because Dr House seems to focus on giving patients what they need (honesty, transparency, certain treatments) and not necessarily what they want.   In his case - the difference between the two are entertaining.   Does that make him a good doctor?  In real life - this is much harder.   There's ample evidence that physicians' decisions are based on many factors.  What's best for the patient is simply one of these factors.  We've had a medical student working on our office recently - and it's been interesting to see my practice style mirrored in her eyes: I "actually listen" to my patients (who doesn't?   I wonder ...) I spend lots of time with my patients (no wonder I come home late every day!) I hear what they mean - not just what they say (the hardest part) I re-told this story to her - in abbreviated form.  I posted it nearly 5 years ago - but the principles I tried to highlight then remain important yet under-represented on the Internet today.  Medical blogs are now far greater in quantity - yet I still think there are rather few of them  that express the transparency that the initial work a few of us were striving for back then.   There are so many competing interests - for our time, our money, and our attention.  Without good principles - I'd argue that there is no way for physicians to stay the course - and really make the best decisions for our patients. The National Physicians Alliance is a relatively new organization that's building steam - based on good principles.  It's great to see an organization that is committed to "Advancing the core values of the medical profession: Service, Integrity, and Advocacy."   You can also read the NPA’s ISSUE BRIEF outlining reasons why physician prescribing data should not be made readily available to pharmaceutical companies.  The issue brief mentions describes how to opt out of pharmaceutical industry data gathering by enrolling in the AMA's Physician Data Restriction Program (PDRP).  Cool.  Check.  Done.  Integrity is so important - yet so often suspect when there is opacity.  Exposing our patients to the uncertainties of our profession is a cornerstone of shared decision making - yet it takes so much more effort - and so much more time - I'm not surprised that so few physicians actually do it.  The same goes for plumbers.  We had a "free" cleaning of our furnace performed by these folks last week.  The service rep called my wife at work and told her we needed a new humidifier element for $45.  He happened to have one.  Said OK.  We also needed a new solenoid for the humidifier for $89 "on order."   Turns out - I replaced the humidifier element about 6 months ago (should be done once/year) and the solenoid seems to work just fine to me.  You can listen to  his explanation - left on our voicemail.   Now -  look at the picture. Water running pretty well, if you ask me!   I filled an 18 ounce cup in under 30 seconds.  If that's a "very small amount of water" - I think Gary needs to go back to plumbing school. Either Gary is stupid - or he's lying.  Either way - I can't trust him or his company ever again - as I suspect that he's got his interests above mine.  I could buy the solenoid (see link above) for $45 if I really needed one.  And I'm a little mad that he took my 6 month old humidifier element with him when he sold me the new one (it's the honeycomb thing in the picture).  Either way - he can't be trusted. We need trustworthy plumbers, doctors, bankers, lawyers, software developers, etc.    The principles of the profession  must guide our decisions.  If not - we will always be distracted or seduced by the many other choices on our path.  Plumbers who invent problems, doctors who self-refer, and software developers focus more on the icing than the cake - all compromise their integrity in the same way - and will ultimately lose.    ------------------------- When my patient called this morning - I overheard Amanda our nurse explain why I couldn't just call in an antibiotic for this problem (as was his request).   Taking my time in our visit  this morning to really learn his needs - while I taught him about the science behind our treatment options - took me 35 minutes more than it would have taken to prescribe azithromycin and shoosh him out the door.   Yet when he left the office - I was enthusiastically thanked  for helping him to understand this problem in a way that no other physician had ever done.   Not only will he get better this time (sans antibiotics, btw) - he'll also know how to manage the problem on his own next time - preventing his discomfort and his need for the visit to the office.  Had I given him what he asked for - I wouldn't have given him what he needed. 

Dave says we should all Choose RELAX insteat of xsd.  I'm convinced.  It'll take a lot more than this to move HL7 and ASTM (among others) as WC3 is seen as 'the authority.'

The Misys Clinical Insight Group Application is now online. This is a great opportunity for clinicians with interest and skills in informatics to work with a top-notch research and development team as the next generation of the Misys EHR and PM systems are designed and implemented. It's a part-time role (as much as 5 hrs/week) that involves detailed analysis of clinical workflows, review and analysis of use-cases, user interface designs, business requirements, and functional specifications, brainstorming with graphic and functional design analysts, and a few days of travel roughly every 6 months. Ideal candidates will have informatics education and/or significant implementation and/or development experience, and have a good understanding of usability principles and appreciation for the importance of human factors engineering in clinical applications. Questions? Fee free to contact me about the team and the work we're doing.