Tech Medicine

Tech Medicine Signing Off

2010-04-17T11:16:00.001-07:00

I'll be taking a break from Tech Medicine as Healthline redesigns its Health Experts Network. If you're interested in more musings on technology and medicine, here's how to find me:

Blog: Info-Snacks
Twitter: JoshuaSchwimmer
Nephrology and Internal Medicine: www.kidneydoctor.us

The First iPad Reviews and News Roundup

2010-03-31T19:51:00.000-07:00

Image via CrunchBase

The first iPad reviews are out, and they're very positive. Here's a selection of the reviews (compiled by MacRumors):

Here's a roundup of recent medical blogs commentary on the iPad:

iMedical Apps has a nice review of how 5 medical apps might appear on the iPad, including the Blausten Human Atlas, Visual Dx Mobile, Procedures Consult, OsiriX and eFilm, and Papers.

The Unofficial Apple Weblog features a review of Carter's Encyclopedia of Health and Medicine, an app designed specifically for the iPad. (This is not an eBook, but a full app with searchable interactive skeletons, etc.) Check out the video:

CareCloud, a new cloud-based EHR, plans to have an iPad version. Epic already has an iPhone app and presumably will have an iPad version available. Allscripts is rumored to have an upcoming EHR for the iPad. (No word on whether other EHRs plan on having an iPad app. If you have any information, please post a comment.)

According to Macworld, 1 in 5 doctors plan to buy an iPad. The Practice Fusion Blog has a discussion of other iPad-related surveys of doctors and healthcare professionals.

Healthcare Technology Online has a discussion of the pros of cons of the iPad in healthcare.

Finally, on Satish Misra attempts to temper the enthusiasms surrounding the iPad. On a post on KevinMD.com titled "Why healthcare may not embrace the iPad," Misra notes that the iPad lacks some features identified as "must-have" in a survey of physicians, including fingerprint access, an RFID reader, camera, and a barcode scanner. However, he noted that many physicians are enthusiastic about the iPad, and according to an Epocrates survey, 20% plan to buy one within 1 year and at least 40% are interested.

I'll have more information about the iPad next week (after I've had a chance to actually test it myself). Stay tuned.

Dr. Schwimmer practices Nephrology in New York City and also blogs at Info-Stream.

The Checklist Manifesto Reviewed

2010-03-27T10:10:00.000-07:00

Image by americanlibraries via Flickr

Spoiler alert. Atul's Gawandes new book, The Checklist Manifesto, begins and ends with an ocean of blood. Each of these gruesome bookends is a surgical catastrophe which illustrates the major point of the book: how a simple, "unsexy" checklist can improve medical care.

Many excellent reviews of The Checklist Manifesto have already been written. (See, for example, Bob Wachter's.) You may have read these reviews. You may have decided that the book's apparently simple premise — checklists improve medical care, okay, I got it — means you don't have to read it. You'd be wrong.

This is the third Gawande book I've read, and it's his best one. (That's saying something, because I was previously interviewed by Google and heaped praise on Gawande's book Complications. See my discussion of that book on Tech Medicine here.) The Checklist Manifesto is about medical care, but less than a third of it is directly related to medicine. During the book's spiral meandering, it discusses the applications of checklists in construction, aviation, finance, rock tours, and restaurants.

Far from diluting the point, these forays into other fields strengthen the idea that practicing medicine is so complex that simple tools are needed and other professions have already figured this out. (Besides, it's entertaining to hear the surgeon Gawande tell about his visits to the kitchens of restaurants where they won't let him touch their knives, his vertigo at the top of half-built buildings where he's lectured about checklists in construction, and his own failure at creating a surgical checklist which required a visit to Boeing's "checklist factory" where aviation checklists are made.)

Gawande's book has been occasionally criticized for not presenting a "balanced" view of checklists. The concern is that checklists add layers of bureaucracy and eliminate spontaneity and free thinking. While this is a valid point, the book's main focus — it's a manifesto, after all — is that well-designed checklists, which take care of the simple tasks, actually allow professionals more freedom and spontaneity by allowing them to concentrate on the complex parts of their jobs.

It's a great book. Go read.

Dr. Schwimmer practices Nephrology in New York City and also blogs at Info-Stream.

Disclosure: Links are Amazon Affiliates.

Google Suggest and Healthcare

2009-12-02T19:10:00.000-08:00

When you type a search query into Google's web search, a feature called Google Suggest will offer searches that other users have typed that are similar to the one you're typing. Sometimes, this can provide an eye-opening view of how the Internet — or at least, the people who search Google — feel about a particular topic.

For example, here are the Google suggested searches for "Doctors are..."

In case you were wondering — no, thousands are people aren't all searching for "doctors are sadists who like to play god and watch lesser people scream" because they necessarily feel that way — it's a quote from the movie Juno.

Here are some other similar searches from Google Suggest.

Nurses are:

nurses are great
nurses are angels
nurses are mean
nurses are heroes

Medicine is:

medicine is keystone of the arch of socialism
medicine is working but u.s. economy isn't healthy yet
medicine is an art
medicine is not candy

Hospitals are:

hosptials are generally categorized as nonprofit for-profit or governmental
hospitals are cold
hospitals are challenged by competition for paying patients
hospitals are dangerous

I am sick:

I am sick and tired of being sick and tired
I am sick in spanish
I am sick of being fat
I am sick of obama
I am sick and tired hillary clinton
I am sick all the time
I am sick and bored

Dr. Schwimmer practices Nephrology in New York City and also blogs at Info-Stream.

Connecting with Physicians Online, a Study by Google

2009-11-30T18:03:00.000-08:00

Image via Wikipedia

In November 2009 Hall & Partner published a study sponsored by Google titled "Connecting with Physicians Online." (Here's the webinar on YouTube and here's the PDF of the presentation.)

The study's aim was to better understand how physicians use the internet in their clinical practices. As you'd expect from a study sponsored by Google, it was particularly focused on how physicians use search.

The study surveyed 411 physicians from a range of specialties (PCPs, endocrinologist, cardiologists, psychiatrist) and with a range of experience (2 - 30 years in practice) on their use of the internet in clinical practice. Additionally, various clinical scenarios were presented designed to mimic actual situations the physicians might encounter.

Here are some of the findings. All these percentages seem low to me.

86% of physicians have used the internet to gather health, medical, or prescription drug information.
Only 21% of physicians who use the internet in their clinical setting access the internet for medical information in the patient exam room.
58% of physicians access the internet more than once daily.
Only 81% of physicians use search engines. Of these, 92% use Google (naturally), but only 13% use Google Scholar. (I'm not certain where Pubmed fits into this — I presume it falls under "search engine.")
Physicians most commonly searched online for general condition information and specific drug information.
As a result of online research, physicians made a change in medication or initiated a treatment about 30% of the the time.
78% (only 78%?!) believe the Internet has made practicing medicine easier.
8% of all physicians clicked sponsored links, but 21% of psychiatrists clicked on sponsored links. (Analyze that.)
92% of physicians clicked on the first search result.

To delve further into the summary PDF, click here.

Dr. Schwimmer practices Nephrology in New York City and also blogs at Info-Stream.

Laparoscopic Surgery Performed at 4X HD

2009-11-14T05:38:00.000-08:00

The holy grail of resolution is not high definition video, but telepresence — resolution so good it feels like you're looking through a window, not a TV set or a monitor. Resolution so detailed you feel like you are there.

The RED Digital Cinema Camera Company offers a new line of high definition video cameras which have gained an enthusiastic following among directors. (For example, Steven Soderbergh said that "Shooting with RED is like hearing the Beatles for the first time. RED sees the way I see.") Here's a sample of HD video of Paris shot with the RED.

Dr. Steven Palter, an obstetrician/gynecologist and fertility specialist, recently performed the world's first laparoscopic surgery with the RED camera at a resolution equivalent to 4X HD. The procedure was presented on October 20 at the 65th Annual Meeting of the American Society for Reproductive Medicine (ASRM) in Atlanta. According to Dr. Palter,

"The images are the sharpest, most detail-rich and color-correct endoscopic images ever created anywhere. There is not a more accurate view inside the human body... By increasing resolution to this level we allow the surgeon to be actually immersed in images that surpass the live surgical experience. The resolution approaches that of the human eye but it is combined with 10 fold magnification through the telescope which operates just inches away from the disease. The progress from regular surgical film technology is like comparing sitting in an HD home theater to watching a video on a cell phone..."

More information may be found at Doc in the Machine.

Finding Doctors and Health Care Professionals on Twitter

2009-11-13T16:50:00.000-08:00

Image by luc legay via Flickr

A little over a year ago, before Twitter was the tech/pop culture phenomenon it is today, doctors like myself had a problem: how do you identify other health professionals on Twitter? (At the time, there must have been at least dozens. Dozens.)

This was the first solution. In retrospect, it was hilariously cobbled-together:

This is a feed containing the conversations of all known doctors and medical students who use Twitter: http://feeds.feedburner.com/doctorsontwitter. (If that doesn't work, you can try the original feed from Yahoo Pipes instead.) Technical details, for those interested: I used this list of doctors/medical students on Kidney Notes, ran each person's Twitter feed through Yahoo Pipes, then burned a FeedBurner feed.

When FriendFeed debuted, I created "The Doctor's Room," which was populated by both Twitter feeds and RSS feeds of physicians. Unfortunately, the "room" feature was poorly designed by FriendFeed (which has since been acquired by Facebook). Like the Yahoo Pipes experiment, the FriendFeed room was an educational failure.

A month ago, Twitter finally debuted the "lists" feature, allowing each user to create subscribable lists of other users. Below is a sample. (For clarity, the second column is the number of users in the list, the third column is the number of users subscribed to the list. Got it?)

While not a perfect solution, lists are a simple way to discover health care practitioners on Twitter. (Finally.) Services like Listorious have also appeared which use the Twitter API to create searchable lists of lists.

For easy reference, here's a list of some of the more popular lists of doctors on Twitter:

(You can find me at twitter.com/JoshuaSchwimmer. The full lists of lists which include me is at twitter.com/JoshuaSchwimmer/lists/memberships. This post also appears on The Efficient MD.)

Hilarious Journal Articles and NCBI ROFL

2009-09-12T19:13:00.000-07:00

Levitating Frog, Image via Wikipedia

Two years ago, I began collecting "hilarious journal articles" and posting them on kidneynotes.com. Here's a sample:

At last count, I had collected 98 articles. If you're interested, you can peruse the entire collection at delicious.com.

(Please note that sometimes these articles are about conditions that are deadly serious, and my intention is not to make fun of anyone, but to show appreciation for humor in scientific writing, which is often dry.)

Hilarious journal articles even have their own awards: the Ig Nobel Prizes, which has been presented at Harvard since 1991. You'll find the complete collection of prize winners here.

And since January of 2009, two Molecular and Cell Biology graduate students at UC Berkeley have written a blog devoted entirely to squirt-milk-out-your-nose grade scientific research. Their website is NCBI ROFL, which stands for National Center for Biotechnology Information — creators of PubMed, where most of the abstracts are published — Rolling On The Floor Laughing.

It's outstanding. Go have a look.

Information Overload, the Index Medicus, and PubMed

2009-07-31T18:40:00.000-07:00

Image by Nuevo Anden via Flickr

The growth of medical knowledge is difficult to visualize. One classic representation is the Index Medicus — a comprehensive index of medical journal articles — whose bound copies filled the shelves of medical libraries for 125 years. In 2004, however, the National Library of Medicine decided to stop publishing the Index. The first reason was practical: the Index Medicus had grown from 82 pounds in 1985 to an estimated 152 pounds in 2004. The second and more important reason was the widespread availability of the search engine PubMed — an electronic database of medical literature available for free via the Internet — which made the printed index obsolete. Compared to the Index Medicus, PubMed was more convenient, could be searched more easily, could be updated more quickly, and certainly weighed less. Copies of the Index Medicus are now a historical curiosity; many physicians now search the medical literature exclusively through PubMed.

The story of the Index Medicus and its successor, PubMed, illustrates three ideas.

First, the quantity of new medical information is more than any single physician can absorb, and keeping up to date with this expanding body of knowledge is challenging. As of April 2009, for example, PubMed contained information on 18,782,970 citations in the medical literature and was adding over 670,000 new entries per year. Doctors must not only absorb this flood of new ideas about treating, diagnosing, preventing, and understanding disease — deciding which information is relevant and which is not — but also learn how to apply and explain this knowledge to the patient sitting with them in the exam room or laying ill in a hospital bed.

Second, in parallel with this unprecedented expansion in medical knowledge, new media and technologies have emerged — of which PubMed is one example — which has made the task of searching, organizing, and retrieving relevant information easier. Potential sources of information for physicians include not only printed journal articles like those indexed in PubMed, but lectures, case conferences, and newer Internet resources such as reference tools (e.g., UpToDate), discussion groups, online expert systems, clinical resource tools, and podcasts.

Third, the expansion of medical information and proliferation of new technologies has required physicians to develop new skills and strategies to keep their knowledge current. Often, the availability of new knowledge overwhelms physicians’ ability to process it, a condition known as information overload. In physician’s offices, one symptom of information overload is the common spectacle of unread piles of medical journals stacked up on every available horizontal space.

While many medical schools now require classes on searching the medical literature and evidence-based medicine, few resources have been available designed to teach physicians how to learn and practice medicine more efficiently. (That's why, over two years ago, I started writing The Efficient MD blog.)

Since then, I'm glad to report that online resources for physicians have proliferated. Ways of improving efficiency and reducing information overload are now common topics on medical blogs. For example, see recents posts in Life in the Fast Lane, Clinical Cases and Images, and Musings of a Distractible Mind.

Thanks for reading!

--

(Much appreciation to Jacque-Lynne Schulman, Stephen Greenberg, Margaret Vugrin, and Dean Giustini for helping me with an updated estimate of the weight of the Index Medicus. Any inaccuracies in this post are, of course, my own.)

The Efficient MD blog

Case Study of a Physician's Use of the iPhone 3GS (Part 1)

2009-07-05T19:06:00.000-07:00

I recently upgraded my original iPhone, which I purchased two years ago, to the iPhone 3GS. Truthfully, I wasn't expecting much of a change. Sure, I read the marketing hype — faster processor! 3G speed! GPS! voice control! better camera! — but I didn't expect the new model to make much of a difference in my daily clinical practice as a nephrologist.

Boy, was I wrong. I've been using the 3GS so much that by the end of the day, I've not only burned through the iPhone's battery, but I often burn through the external battery in my Mophie Juice Pack Air case as well. (I highly recommend the Mophie, by the way, which removes a subtle disincentive to using the device because you're worried you may run out of battery life.)

The following is a multi-part description of my own use of the iPhone 3GS. In my experience, the best way to learn to use a new gadget is to look over the shoulders of others, watch how they use it, ask lots of questions, and experiment constantly. (Most iPhone owners are familiar with the phenomenon of having someone grab their phone, scroll through the applications they have installed and ask, "What's that one do?")

So if you have an iPhone, and are a health care professional or patient, this will hopefully be helpful. Even if you don't have an iPhone, some of the applications I describe are available for other PDAs — or they soon will be, since the iPhone has significantly raised the bar for what a mobile device can accomplish.

(Original drafts of these posts were written on the iPhone app BlogPress.)

(This post also appears on The Efficient MD.)

Medical Apps for the iPhone: Diagnosaurus, ICD9 Consult, and WellAdult

2009-04-22T19:48:00.001-07:00

As of this writing, there are over 400 medical applications in the iTunes App Store. Whether you're a health care provider or patient, and whether you have an iPhone or iPod Touch or not, it's worth exploring the impressive range of applications available for this new mobile platform. (Later this year, when iPhone 3.0 is introduced, these applications will be able to interact directly with compatible medical devices, like glucometers and blood pressure monitors.) Here's a brief introduction to three medical apps in the iTunes App Store.

Diagnosaurus. Many medical specialties—and Internal Medicine in particular—require working through a "differential" of possible causes of a patient's clinical presentation. Diagnosaurus ($.99) provides a polished interface for searching differential diagnoses for over 1000 conditions, divided by organ systems, symptoms, and diseases. As a bonus, at the end of each list is provided a list of links to related differentials. For example, "acute hepatiis" and "cholestatis" are listed at the end of "AST/ALT increased." Much like Wikipedia, you can spent half an hour browsing and clicking through links. For $.99, it's a steal.

ICD9 Consult. Health care providers must frequently scramble to come up with ICD9 codes for unusual or complex diagnoses in order to bill appropriately. ICD9 Consult ($29.99) is an excellent solution for those moments when you don't have time to consult a thick book or spend time seaching online for the right code. It allows you to easily search through the different codes or browse by type of disorder (infections, circulatory, respiratory, etc.) or procedure. At $29.99, it's not cheap, but if it saves you enough time, it's worth it.

WellAdult. The guidelines for optional clinical preventive services for adults—when to perform cholesterol tests or colonoscopies, for example—are scattered among many different expert organizations and are sometimes contradictory. WellAdult ($2.99) provides an easily navigatable database of recommendations from all major organizations for adults of different ages. Click on "Women Ages 50 - 64," for example, and you can easily compare the reommendations of different organizations for testing lipids, blood pressure, vaccinations, and cancer screening. For $2.99, this app is well worth it.

Dealing with Information Overload

2009-04-02T18:34:00.001-07:00

Information overload is an occupational hazard of practicing medicine, especially if you spend time online. There's too much potentially useful stuff out there for one person to process effectively: journals, news sites, RSS feeds, wikis, blogs, webinars, Flickr, Facebook groups, CME courses, Google alerts... And don't get me started on Twitter.

Two of my favorite medical bloggers—Bertalan Meskó from ScienceRoll and Dr. Ves Dimov from Clinical Cases & Images—recently shared their methods for dealing with information overload.

Clinical Cases & Images uses Twitter innovatively, to share interesting items from his feed reader, which he then aggregates into blog posts: "Health News of the Day," for example, and "Selection of My Twitter Favorites." (What's Twitter? Twitter is an instant messaging service, a microblog, a social networking phenomenon, a chatroom, the best crowdsourcing utility ever invented, or a colossal waste of time — depending on who you ask.) Ves also discusses using Google Reader, Google Bookmarks, and shares his backup strategies.

Bertalan Meskó from ScienceRoll writes about using Tweetdeck to filter the 1000 (!) users he follows on Twitter. He also uses Friendfeed and the "best of the day" feature to identify interesting discussions. He mentions Microplaza, Twilerts, and Tweetbeep—three services I've never heard of—to filter out interesting discussions and posts. Bertalan also uses Google Alerts—of which I'm a great fan—to track any content published about him or other topics of interest. He ends with my Life Hacks for Doctors presentation, which has received more than 10,000 views to date. (w00t.)

What strategies and resources do you use to deal with information overload?

(Also posted on The Efficient MD.)

Monthly Introduction to Tech Medicine

2009-03-22T12:35:00.000-07:00

Image from WikipediaWhat's this blog all about?

My goal in Tech Medicine will be to explore the intersection of medicine, new technologies, and the Internet. This is a purposefully broad topic. Several times weekly I will post focused reviews of issues interesting to health professionals and nonprofessionals alike. Posts may include examinations of medical devices, pharmaceuticals, scientific advances, internet services, and other technologies involving health care and the practice of medicine. Mirroring as it does the nature of the Internet and the sometimes surprising nature of new technologies, the content may also include topics that are wonderful, unusual, hilarious, or strange.

What are some recent posts on Tech Medicine?

Topics of recent posts have included Twitter Dispatches from the New England Journal of Medicine, Robert Scoble Interviews Healthline's CEO, Health 2.0 Conference Updates, The Health 2.0 Conference, Futurology and Medicine, A Comparison of "Mediquations," "MediMath," and "Medical Calculator" for the iPhone, and The Problem with EMRs in the United States.
Who are you?

I'm trained as a nephrologist (a kidney and blood pressure specialist). For the last three years I've written Kidney Notes, a blog designed to filter and process medical news. Most recently, Kidney Notes has become a collection of links, commentary, and scraps of information — a reference database of interesting things with the help of a popular social bookmarking service called del.icio.us. While I will continue posting to Kidney Notes, several friends have asked me to write longer posts of original content — and this is what I will be writing on Tech Medicine. Recently, I have also written a blog on personal productivity called The Efficient MD (in association with the American College of Physicians) and hosted The Efficient MD Wiki. I'm also writing a book with the American College of Physicians on physician productivity and life hacks. My collected posts may be found on jschwimmer.net, a tumblelog.

There are many topics I plan to cover, but I'm also open to suggestions, tips, and even posts by guest bloggers. My email is techmedicine@gmail.com.

Thanks for reading!

Tech Medicine Links for 2.9.9

2009-02-09T17:15:00.000-08:00

Bertalan Meskó from Scienceroll.com attended the Medicine Meets Virtual Reality (MMVR) 17 conference. He's posted some pictures here and here.

The Seattle Times published an article titled, "With Smartphone, Doctors Reinvent House Calls."

Google is working on a peer review system, gpeerreview.

1. First, you read someone's paper.
2. Next, write a review. (The review is just a simple text file that contains a few scores and your opinions about the paper.)
3. Use GPeerReview to sign the review. (It will add a hash of the paper to your review, then it will use GPG to digitally sign the review.)
4. Send the signed review to the author. If the author likes the review, he/she will include it with his/her list of published works.
5. Prospective employers or other persons can easily verify that the reviews are valid.

A new report from Manhattan Research discusses the use of online social networks by physicians. iHealthBeat has a summary. Sermo and Medscape Connect are the two biggest online physician communities, each with about 100,000 users.

Physicians participating in such online communities are more likely to:

* Be primary care physicians;
* Be female;
* Own a PDA or smartphone;
* Go online during or between patient consultations; and
* Be slightly younger than the average physician.

Finally, In The New York Times, Alan Krueger writes about calculating the opportunity cost of the time patients spend waiting for physicians. His conclusions are surprising.

If you count health care-related activities writ large – including time traveling to a doctor, waiting to see a doctor, being examined and treated, taking medication, obtaining medical care for others, and paying bills – the average American spent 1.1 hours a week obtaining health care in 2007...

If we value all people’s time at the average hourly wage of production and nonsupervisory workers ($17.43 in 2007), Americans spent the equivalent of $240 billion on health care in 2007.

Notable New iPhone Medical Apps: ECG Guide and Safe OR

2009-02-08T14:44:00.001-08:00

Many users of the iPhone — and certainly developers — view it not so much as a phone, but as a handheld computing platform. The iTunes App Store currently lists more than 200 applications in the "medical" category. "Notable New Medical iPhone Apps" is an occasional series describing apps that I use and/or recommend.

The ECG Guide is an impressively detailed ECG reference for the iPhone and iPod touch. For $4.99, it features sections on ECG basics (such as the function of the ECG and positioning); ECG interpretation; waves and segements; chamber enlargement; ischemic and infarction; arrythmias; and a selection on miscellaneous clinical conditions such as hypothermia, dextrocardia, and brugada syndrome. The ECG Guide also features 100 high-resolution ECG examples and a quiz. (The text and sample ECGs rotate to landscape mode and are easily visible when you zoom in.) It's perfect for medical students, residents, and any health care practitioner who wants to have immediate access to a detailed ECG reference guide.

Safe OR: Safety Checklist is based on the 19-point WHO surgical safety checklist published in the New England Journal of Medicine Article, "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population." In the study, use of the checklist was associated with a reduction in mortality of over 40%. The checklist includes questions to be asked prior to induction of anesthesia (for example, "Have you confirmed patient identity?" and "Is the surgical site marked?"); questions prior to the skin incision (for example, "Confirm all team members have introduced themselves by name and role." and "Has antibiotic prophylaxis been given within the last 60 minutes?"); and questions prior to the patient leaving the OR (for example, "Has the nurse verbally confirmed with team that instrument, sponge, and needle counts are correct?"). Safe OR is available for only $1.99 in the App Store.

Best Tech Medicine Posts of 2008 (Part 2)

2009-01-03T16:35:00.000-08:00

Image by satosphere via Flickr

Happy New Year. The following is part 2 of a collection of the best posts from Tech Medicine in 2008.

The New 3G iPhone, Doctors, The App Store, and Medicine

What follows is the result of a brief brainstorming session about potential applications of the iPhone for doctors. Some have already been announced for the iPhone, are available on other platforms, or are currently in development. Let's see how many of these applications are eventually released and sold in the App store. My guess? All of them.

Your Next Stethoscope Should be Electronic. Here's Why. (Littmann Electronic Stethoscope Model 3000 Review)

To test the performance of the Model 3000, an internal medicine resident and I listened to the heart of a patient with hypertrophic obstructive cardiomyopathy. We each auscultated the patient's murmur with both a conventional acoustic stethoscope and the Model 3000 — but to level the playing field, we placed the electronic stethoscope on the patient's hospital gown and placed the acoustic stethoscope directly on the patient's skin. We heard the patient's murmur better with the electronic stethoscope on the patient's clothes than we did with the acoustic stethoscope on bare skin.

The Doctor's Room on FriendFeed

Enter FriendFeed, founded by a few ex-Google employees. The entire service is based on an obvious concept — that people you like can introduce you to information you’re likely to enjoy. (Strangely, although the concept is obvious, it’s difficult to wrap your brain around, and it took me months before I really understood it.) Briefly, FriendFeed allows you to create a stream (or feed) of your activities on the net — blog posts, pictures or videos you like, comments on Twitter, and data from over 40 other services that you may choose to share. Other people can then “subscribe” to you, see what you’re doing, and post comments on your feed.

How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere (Part 1 of 3)

In contrast, the digital world — and we can substitute "cyberspace" or
"the cloud" or your favorite phrase here — is inhabited by electronic
medical records, web-based email, and online databases. The
characteristic of this world is that information is searchable,
available-anywhere, and (hopefully) securely backed-up online in
multiple locations.

Bulletproof Backup Strategies

The ideal backup system should be invisible — that is, you should "set it
and forget it," but trust that it will work when you most need it.
Fortunately, the price of online storage and of external hard drives
has plummeted in recent years, and backup systems have become simpler,
more reliable, and less expensive.

Creating a Voicemail System for Patients using Free or Inexpensive Services Online (Google's Grand Central and CommuniKate)

One of the biggest flaws with the telephone system in many doctor's offices
is that human beings — with limited time and attention — are often
involved when they don’t need to be. They spend too much time triaging
calls and scribbling down messages. And when humans really do need to
be involved, they’re busy, much to the frustration of patients calling
the typical doctor’s office.

100+ Tips for Doctors on Call (Part 1)

Several weekends ago, while seeing nearly fifty patients in the hospital, I
asked readers of this blog and my followers on Twitter a question:
"What advice do you have for physicians on call?"

Twitter Dispatches from the New England Journal of Medicine's Horizons Conference

We can be thankful for a new trend that's emerged among medical bloggers: twittering useful dispatches from the conferences they attend.

Medical Applications in the iTunes App Store for the iPhone and iPod Touch

As of this writing, there are are over 100 medical applications for the
iPhone and the iPod Touch in the iTunes App Store. (The link is here.)
Less than six months ago, as the store was launched, I tried to guess
what applications might become available. Let's revisit that list to
see which apps have been released so far.

Best Tech Medicine Posts of 2008 (Part 1)

2009-01-02T16:28:00.001-08:00

Image by satosphere via Flickr

Happy New Year. The following is a collection of the best posts from Tech Medicine in 2008.

Take a Contract out on Yourself on StickK.com

And this is where it gets even more interesting. Let's say you support gun control. So you tell StickK that if you don’t accomplish your goal, you want all the money you’ve put down to go to the National Rifle Association. (Conversely, if you are against gun control, the money could go to the Fund to Stop Gun Violence.)

Is it better if your heart stops in a mall?

So what's the implication? You're better off arresting in a crowded mall with an automatic defibrillator nearby than you are in a hospital with trained personnel?

Post-Surgery Rounding by Robots as Good as Rounding by Actual Humans

Surprisingly, the study showed that between the two groups -- human-rounding vs. robot-rounding -- there was no difference in complication rates, length of hospital stay, and patient satisfaction.

Plans for Microsoft's HealthVault, a Personal Health Record

PHRs have the potential, at least in theory, to significantly improve communication between doctors, hospitals, and patients. The ideas is that patients and participating health providers can enter data into an online database. All the information in this database -- including allergies, medical conditions, medications, and laboratory results -- would be available to any provider who needed it. No more fumbling with handwritten lists of medications or calls to doctors offices to obtain a patients medical history. Ideally, all this information should be easily and securely available to any healthcare provider, anytime. (For an example of how this might work in the case of a patient presenting with a heart attack, see this article from the American Academy of Family Physicians.)

Medicare (and now other Insurers) will no longer pay for "Preventable Hospital Errors"

On the other hand, these complications are only potentially preventable. Even after following best practices, there are certain conditions -- like lower extremity blood clots, intravenous and urinary catheter infections , and C. Diff colitis -- that are likely to happen in the sickest hospital patients. Viewed another way, these rules are just another way of reducing payments to hospitals that are already on shaky grounds financially. Invariably, the list of uncovered medical conditions will grow to include many situations that may not "reasonably have been prevented," but for which insurance companies would simply prefer not to pay.

Google Book Search and Medical Education

Initially modest, the project has evolved into a screamingly useful, many-headed creature built on a massive body of books — and I mean massive, as in the complete searchable text of several university libraries. Google Book Search also includes lots of extras, including links to book reviews, references on websites, references from other books, and Google Maps of every place each book mentions.

The Physician Success Strategies Conference: What Can Doctors Learn From Consultants?

Many of my colleagues and I have experienced our desks disappearing under a pile of papers and charts, suddenly realizing that we’re an hour and a half behind schedule in the office, or finishing our workday to discover that we still have a stack of urgent messages that need answering. And physicians, almost universally, have been forced to see more patients, more quickly, yet are reimbursed less for their efforts.

Eavesdrop on Doctors and Medical Students on Twitter

Twitter is an instant messaging service, a microblog, a social networking phenomenon, a chatroom, the best crowdsourcing utility ever invented, or a colossal waste of time — depending on who you ask.

Slideshare and the Lifehacks for Doctors Presentation

Life hacks are productivity strategies that solve everyday problems — especially problems related to information overload. Slideshare featured Life Hacks for Doctors on their home page. In a week, it was viewed over 1300 times. The service also features tagging and searching for presentations, and it allows you to create your own groups, for example, Improving Medical Practice and Health 2.0. Slideshows occupy a singular category of knowledge. The results of a Slideshare search are qualitatively different from what you'd find from searching Google or YouTube. Here's the best way I can describe it: the presentations on Slideshare are concentrated, surfable bursts of thought.

My Experience Creating a Medical Wiki

I recently decided to start a new medical wiki — The Efficient MD Wiki, focused on productivity tips for doctors — and I took this opportunity to review some of the available wiki platforms and hosting services. It was a daunting task. I'll share my experiences here for those interested in starting their own wiki.

Electronic Stethoscope Oddities

2009-01-01T15:25:00.001-08:00

Happy New Year!

If acoustic stethoscopes — the kind physicians have used for over two hundred years — are the equivalent of typewriters, then electronic stethoscopes are like word processors. Okay, this analogy is non-intuitive, but hear me out. Electronic stethoscopes, like word processors, are newer, more expensive than the previous generation, and are — well — electronic, with all the advantages and disadvantages this implies.

The advantages to electronic stethoscopes are many. As I've written previously in my review of the Littman Electronic Stethoscope Model 3000, it's simply easier to hear heart and lung sounds with an electronic stethoscope than it is with an acoustic stethoscope. (For real-world examples of this, see the previous review.) Plus, some models, like the Littmann 4100 Electronic Stethoscope, allow you to record and playback — think copy and paste — heart and lung sounds for reference or teaching.

But anything electronic is prone to failure, and when electronic stethoscopes fail, they fail spectacularly. Don't misunderstand: I'm a fan of my Littman Model 3000, but it's worth pointing out the oddities you should expect if you decide to purchase one of these things. (Some of these observations are taken from my postings on Twitter.)

First — and this might sound obvious — the electronic stethoscope requires batteries. Eventually, these batteries will die. Unexpectedly. At exactly the wrong moment. Almost certainly, when you're examining a patient. At this time, your electronic stethoscope will make a sad little noise, then — silence. An eerie silence. And unless you're walking around with an extra AA battery in your pocket — which you will suddenly realize is probably a good idea — you will then say, apologetically, "I'm sorry. The battery in my electronic stethoscope just died."

Second, if you carry around an iPhone or a BlackBerry, you will experience intermittently the faint faraway static of your mobile device as you're listening to the heart of a patient. And while this doesn't interfere with your physical exam, it's unnerving.

Finally, if you were planning to place another type of diaphgram on your electronic stethoscope — such as the excellent SafeSeal stethoscope covers by DRG — don't. It will cause unbelievable amounts of feedback. As I learned recently, placing incompatible diaphragms on electronic stethoscopes makes your patients' hearts sound like they're being played by Jimi Hendrix.

Medical Applications in the iTunes App Store for the iPhone and iPod Touch

2008-12-06T19:12:00.001-08:00

As of this writing, there are are over 100 medical applications for the iPhone and the iPod Touch in the iTunes App Store. (The link is here.) Less than six months ago, as the store was launched, I tried to guess what applications might become available. Let's revisit that list to see which apps have been released so far. (This is not meant to be an exhaustive list of applications, and please feel free to leave comments if the holes in my knowledge are obvious.)

Drug database: Epocrates Rx is currently the most popular medical application for the iPhone. Several other drug databases are also available.
Anatomical atlas: Netter's Anatomy Flash Cards is based on Netter's Atlas of Human Anatomy.
Medical calculator: There are at least five. The most popular is Medical Calculator, which is free.
Interface for electronic health records: There are several. iChart EMR is the most popular, for $139.99.
Viewer of radiologic images: OsiriX, an open source program, is a DICOM image viewer. It's $19.99
Interface for laboratory results: To my knowledge, there is no interface yet for viewing labs from companies like Quest and Bioreference.
An expert system to help with differential diagnoses: A cursory review of the avvailable applications shows no expert system for differential diagnoses (which I'll definine as a program that produces differential diagnoses for a list of signs and symptoms).
Messaging system for laboratory alerts and hospital pages: While there are no programs, to my knowledge, specifically for this purpose, many hospitals offer communication by SMS.
Interface for medical devices (like ultrasounds and EKG machines): No programs are yet available.
Dictation recorder: A search of [iphone AND dictation] reveals several apps, such as Voxie, and others which have yet to be released. I don't have personal experience with any of these programs.
Device for electronic prescribing: No programs yet available, to my knowledge.
Device for directly receiving and reading medical journals and podcasts: While there are many PDF readers for the iPhone, I haven't seen a program that automatically downloads medical journals (as is available for the Palm platform). Medical podcasts can now be downloaded directly to the phone.
Medical book reader: Lexi-COMPLETE offers several medical books for the iPhone.
Reminder system for patient visits and meetings synced remotely with the office through Mobile Me: Again, not yet available.
Display for patient education videos: I've written previously about using YouTube as a source for patient education videos, but to my knowledge, applications specifically made for this purpose are not available.
Medical simulator (ACLS, for example): While I know of no simulators, an ACLS reference is available for $4.99.
Telemedicine device (pending the eventual release of iChat and a videoconferencing system): Not, to my knowledge, yet available.
Interface for medical literature searches (Pubmed, Google Scholar): PubSearch is an interface for PubMed, and it costs all of $0.99.
Word processing device for papers (I'm still waiting for a bluetooth keyboard): Several substitutes for Apple's built-in Notes application are available, but no bluetooth keyboard yet.
Communication device for hospital teams (Using Twitter or another system): I'm not aware of any hospital team that uses Twitter (or Yammer). If you do, please write in.
Secure system for messaging/emailing patients: Not yet available.
CME course viewer (with text and/or video): Several are available, including Epocrates Rx and ReachMD CME.

Comments are encouraged so I can give you credit for pointing out applications that I've missed.

Tech Medicine Links for 12.5.8

2008-12-05T20:14:00.001-08:00

Lexi-Comp now offers their line of medical applications for the iPhone and iPod touch. The databases offered include Lexi Drugs, a drug database; Harrison's Practice, a diagnosis and management tool; Lexi-infectious Disease, a guide to diagnosing and treating infections, and Lexi-Poisoning & Toxicology, which includes detailed information on drugs and toxins; as well as many other applications. (There are now over a hundred medical applications in the iTunes App Store.)

Here's a video showing how physicians at the University of Calgary are using the iPhone to view radiology images to improve patient care. The title is "This is your brain on an iPhone:"

Physicians at the Cleveland Clinic have picked the top 10 medical innovations for 2009. For more details, you can download a booklet from the 6th Annual Medical Innovation Summit here.

1. Use of Circulating Tumor Cell Technology:

Use of new technology to measure circulating tumor cells as a predictor of success of chemotherapy.
2. Warm Organ Perfusion Device:

Warm organ perfusion device to preserve organs for transplantation during transplant.
3. Diaphragm Pacing System:

Use of a diaphragm (phrenic nerve) stimulator to enable paralyzed
patients to breath without the assistance of a mechanical ventilator.
4. Multi-Spectral Imaging Systems:

Improvements in multi-spectral image analysis to assess multiple protein pathway configuration in a single sample/cell.
5. Percutaneous Mitral Valve Regurgitation Repair:

Use of a special clip to percutaneously repair mitral valve regurgitation (MVR).
6. New Strategies for Creating Vaccines for Avian Flu:

Use of new strategies for creating vaccines for avian flu, including
genetically-engineered virus-like particles (VLPs) as the basis for
vaccines.
7. LESS and NOTES Applications:

Laparoendoscopic single-site surgery (LESS) and Natural Orifice
Transluminal Endoscopy (NOTES) for nephrectomy, cystectomy,
prostatectomy, colon resection, and other applications.
8. Integration of Diffusion Tensor Imaging (Tractography):

Integration of diffusion tensor imaging (tractography) with surgical
navigation of the brain to minimize damage to fiber tracts during brain
surgery.
9. Doppler-Guided Uterine Artery Occlusion:

Doppler-guided non-invasive transvaginal uterine artery occlusion for treatment of symptomatic uterine fibroids.
10. Private Sector National Health Information Exchange:

Use of a common exchange standard among participants to enable access through the Internet regardless of provider source.

A study in the New England Journal of Medicine looked at the diagnostic performance of coronary angiography by 64-Row CT — that is, whether a CT scan can accurately predict whether a patient has a significant narrowing of the coronary arteries. The study showed that CT angiograms have a sensitivity of 85% and specificity of 90%, suggesting that the new test is not yet accurate enough to replace coronary angiography. The accompanying editorial is titled, "Pay Now, Benefits May Follow."

--

Tech Medicine Links is a collection of selected developments in the world of technology and health care. Have a suggestion? Please email techmedicine@gmail.com.

Tech Medicine Links for 11.23.8

2008-11-23T11:45:00.001-08:00

Think Anatomy is an impressive collection of the best anatomy study aids on the net.

This week, Clinical Cases and Images hosts the Medicine 2.0 Blog Carnival. See especially 10 Reasons Why I Use Twitter, Strengths and Challenges of Medical Education in Virtual Worlds, New Idea: Use Twitter for Daily Q&A for Board Preparation, and Screencasting and Podcasting: Experience of the Yale Medical Library.

A new study by the MacArthur Foundation suggests "America’s youth are developing important social and technical skills online – often in ways adults do not understand or value."

Real time digital dictation for doctors is coming to the iTunes App Store. Via the press release for Anymodal CDS Mobile (which, as of this writing, doesn't yet seem to be available):

While clinical dictation was possible before via telephone or PDA
devices, the resulting report was not available for hours. AnyModal
CDS Mobile delivers documents in real time to the physician's
iPhone, making it the first device to capture, understand and transcribe
dictation in real-time. Physicians can now immediately review and sign
off on a clinical document.

JustAnswer Health is a service which allows physicians and other health experts to provide answers to health-related questions in real-time for a fee.

In The Lancet, researchers report transplanting a "tissue-engineered airway," that is, a windpipe cultured from stem cells. (Coverage from Medpage Today is here.)

Stumped by Medical Abbreviations? Now there's a $0.99 iPhone App with 1600 commonly used terms. (Helpful for students and patients trying to understand their own medical records.)

Tech Medicine Links for 11.17.8

2008-11-17T19:31:00.001-08:00

Osirix, the open-source Mac image viewer which I wrote about in my last post, now has an iPhone app. (Via Not Totally Rad.)

Parentdish has a review of their favorite iPhone apps for parents, including a baby monitor, a nursing tracker, a cookbook app with over 160,000 recipes, a white noise app, a drawing app, a diaper tracking app, a grocery list app, a dictionary of food additives, and a game for preschoolers.

For $1.99, the Pocket First Aid and CPR Guide iPhone app has dozens of articles on topics including CPR, the Heimlich maneuver, bites, bruises, burns, seizures, diabetic emergencies, "fever, nausea, blisters, and tooth loss," and "bug, snake, and mammal bites."

Enough about the iPhone for now — Phillips research has introduced the "iPill," an intelligent pill about 1 x 2.5 cm which contains a chip, battery, pH and temperature sensors, fluid pump, drug reservoir, and wireless transceiver.

Certain digestive disorders, like inflammatory bowel disease, may best be treated by targeted drug delivery at the site of activity. Medications that are given systemically, like steroids, have many potential side effects, and targeted drug delivery systems like the iPill may potentially reduce this risk by allowing a smaller dose of medication to be given locally.

Via the Web site:

What Philips Research has developed is a pill that can be swallowed
with food or water in the normal way and is then carried along by
the normal movement of food through the gut. Knowing where the iPill
is in the gut relies on the fact that the gut’s pH value (a measure
of acidity) rises sharply upon exiting the stomach and becomes
progressively alkaline from the upper intestine onwards. In
addition, there is typically a noticeable drop in pH between the
small intestine and the colon. Armed with pH information, which is
measured by the iPill itself, and data about typical transit times
through the gut, the iPill’s location in the gut can be determined
with good accuracy. Where greater accuracy is required, external
medical imaging equipment could be introduced. Locations where the
drug needs to be released could also be determined by medical
imaging – for example, endoscopy, MRI or CT scans.

Using OsiriX to Guide Surgery

2008-11-15T17:06:00.001-08:00

Apple's Web site has a feature on the use of OsiriX, a mac-based open-source software system for viewing radiologic images. A surgical team at Teikyo University Chiba Medical Center in Japan uses Osirix to project "surgical roadmaps" on patients as they perform minimally invasive surgery.

For patients with early-stage gastric or colonic cancer, the surgical team typically opts for minimally invasive laparoscopic surgery. With the patient anesthetized, Sugimoto projects OsiriX-generated 3D images onto the body surface of the patient with an Epson EMP-1715 projector. Using a motion-sensing wireless remote, Sugimoto uses physiological markers (such as the navel) to register the image to the patient’s body. Then using a Color Look Up Table (CLUT) feature in OsiriX, he makes the skin of the image transparent. The display now shows the patient’s internal body parts and the area that he will need to operate on.

Osirix, which is easy to learn, allows the surgeons to use the 3D images as a reference and guide during surgery. The images may be rotated to provide the surgeons a real-time view of the operation. The remote may also be linked to the laparascope, allowing the image on the display and the image on the scope monitor to move simultaneously. Dr. Sugimoto provides more details on the use of Osirix during surgery:

“The 3D visualization shows us relationships between the cancer and the
arterial vessels and other surrounding organs,” says Sugimoto. “It also
allows us to see the extent of the spread of cancer. When a patient has
upper biliary (bile duct) cancer, we have to cut the liver. If the
patient has lower bile duct cancer we have to remove the pancreatic
head and duodenum. The HBP system is very complex; that’s why 3D
visualization in the OR is so crucial. When doing a midline open
surgery, the surgeon can only see the organs from the top. With OsiriX
on the Mac, surgeons can rotate and see the surrounding organs in 3D to
guide them during surgery.”

More information on OsiriX may be found here.

Tech Medicine Links for 11.14.8

2008-11-14T19:17:00.001-08:00

Image via Wikipedia

A new study by Manhattan Research looks at the number of physicians who use the Internet and other digital technologies in their practices. According to the survey, 36% of physicians communicate with their patients online and 54% of physicians own a smartphone. (Thanks to Sean Khozin.)

Google searches for search words related to the flu — "flu," "symptoms of the flu," and the like — are significantly associated with flu outbreaks. In fact, the data on flu-related searches closely mirror the actual incidence of flu activity but are available two weeks earlier than the Centers for Disease Controls own data. The paper, accepted in the journal Nature, is "Detecting Influenza Epidemics using Search Engine Query Data."

iPod headphones — even those that are disconnected — can interfere with pacemakers and implantable defibrillators. The abstract from the American Heart Association is here.

“For patients with pacemakers, exposure to the headphones can force the
device to deliver signals to the heart, causing it to beat without
regard to the patients’ underlying heart rhythm,” he said. “Exposure of
a defibrillator to the headphones can temporarily deactivate the
defibrillator.” In most cases, removal of the headphones restores
normal device function.

The MDRD equation is commonly used by physicians to estimate kidney function. New data suggests that the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation may be even more accurate. (If you know of an online calculator for the new equation, please leave a comment.)

Dr. Atul Gawande appeared on the Charlie Rose Show and discussed using checklists to improve patient safety. Dr. Val has a report.

Tech Medicine Links is a collection of selected developments in the worlds of technology and health care. Have a suggestion? Please email techmedicine@gmail.com.

Monthly Introduction to Tech Medicine

2008-10-30T19:14:00.000-07:00

Image from WikipediaWhat's this blog all about?

My goal in Tech Medicine will be to explore the intersection of medicine, new technologies, and the Internet. This is a purposefully broad topic. Several times weekly I will post focused reviews of issues interesting to health professionals and nonprofessionals alike. Posts may include examinations of medical devices, pharmaceuticals, scientific advances, internet services, and other technologies involving health care and the practice of medicine. Mirroring as it does the nature of the Internet and the sometimes surprising nature of new technologies, the content may also include topics that are wonderful, unusual, hilarious, or strange.

What are some recent posts on Tech Medicine?

Topics of recent posts have included Twitter Dispatches from the New England Journal of Medicine, Robert Scoble Interviews Healthline's CEO, Health 2.0 Conference Updates, The Health 2.0 Conference, Futurology and Medicine, A Comparison of "Mediquations," "MediMath," and "Medical Calculator" for the iPhone, and The Problem with EMRs in the United States.

Who are you?

I'm trained as a nephrologist (a kidney and blood pressure specialist). For the last three years I've written Kidney Notes, a blog designed to filter and process medical news. Most recently, Kidney Notes has become a collection of links, commentary, and scraps of information — a reference database of interesting things with the help of a popular social bookmarking service called del.icio.us. While I will continue posting to Kidney Notes, several friends have asked me to write longer posts of original content — and this is what I will be writing on Tech Medicine. Recently, I have also written a blog on personal productivity called The Efficient MD (in association with the American College of Physicians) and hosted The Efficient MD Wiki. I'm also writing a book with the American College of Physicians on physician productivity and life hacks. My collected posts may be found on jschwimmer.net, a tumblelog.

There are many topics I plan to cover, but I'm also open to suggestions, tips, and even posts by guest bloggers. My email is techmedicine@gmail.com.

Thanks for reading!