As the number of men and women with cardiac disease continues to grow, so too do the clinical indications for pacemakers and automatic implantable cardiac defibrillators. Taken together, there are going to be a lot more people in the near future who are dependent on implanted hardware to keep their hearts working normally. Until relatively recently, the sole form of monitoring of these patients was through regular clinic visits where these devices could be interrogated or unscheduled/emergency visits based on clinical events like shock delivery. While at HIMSS 2010 in Atlanta, I had the opportunity to speak with Tom Schultz at the Interoperability Booth, a space which demonstrates how different innovations could be pieced together to deliver care in new ways. He showed me how the Medtronic CareLink system, working with an electronic health record like Epic and Haiku, could not only notify a physician of a clinical event like AICD shock, but also allow the physician to intervene virtually immediately. And it looks like there is some data, courtesy of the CONNECT trial, showing real clinical benefits from this system. On top of that, there’s even a possibility that physicians will be able to adjust settings on implanted devices remotely.
Here’s how it works now.
It looks like the wishes of many iPhone and iPad users are soon to be answered. AppleInsider is reporting the approaching update of the iPhone OS, version 4.0, will include a “full on solution” for multi-tasking. While they acknowledge that there have been at least three previous such reports, this news is apparently from sources with a proven track record of providing reliable information. Unfortunately, there’s not much information on how Apple’s “solution” gets around the issues that had long been cited for the absence of this support – battery life, resource utilization, and security. However, those three factors are critical to the iPhone’s use in clinical practice. And with the growing adoption of mobile interfaces for electronic health records and e-prescribing, these three areas are critical to determining whether the iPhone and iPad will continue to develop as clinical tools. However, even assuming Apple has come up with a way to mitigate the negative effects multi-tasking would have on those critical areas, multi-tasking is a losing proposition for clinicians.
How many of your patients, inpatient or outpatient, have skin lesions? How do you approach these skin lesions? With befuddlement, with a frantic search of Up-to-Date articles, with an almost reflexive dermatology consult? Now there’s a point-of-care resource that promises to allow clinicians to generate a “visual differential diagnosis” for any skin condition we see. Here we review VisualDx Mobile from Logical Images, Inc, a “visual diagnostic decision support system”
First and foremost, with any point-of-care tool, reliability is key and in addition to all of these This app is from a reputed developer that employs over 100 practicing physicians on its editorial board to update its digital medical image collection, which numbers over 18,000 on this app. Logical Images, Inc (Rochester, NY) is a reputed medical technology company that has developed the world’s largest digital medical image library that includes over 60,000 images of visually presenting diseases (18,000 on this app). We previously featured a conversation with Dr. Art Papier, Co-Founder and Chief Scientific Officer of Logical Images (posted March 4, 2010). As mentioned in this conversation, the NIH has awarded Dr. Papier a $2 million grant to develop a standardized lexicon for dermatology. Moreover, VisualDx boasts of customers such as the Military Health System, Delaware Division of Public Health, Wyoming Department of Health, and many more. Long story short – we trust them.
As for the app itself, it is rather intuitive to use: the home screen (shown above) features two functions, aptly named “Build a Differential” and “Find a Diagnosis.”
The torrent of clinical information being made available on smartphones does not seem to be showing any signs of slowing. Merge Healthcare just announced March 1 an iPhone OS app, available for the iPad, that connects seamlessly with their eFilm workstation to make available patients’ studies as quickly as they are accessioned by the radiology technician. Many hospitals already use the eFilm Workstation for their radiologists to view studies stored on their hospital PACS (Picture Archiving and Communication System). What this announcement means is that a physician who works at that hospital can also now immediately view those high resolution images on their iPad.
While other imaging applications for the iPad and iPhone exist, such as Osirix which we reviewed previously, the advantage here is that the communication between the PACS server and the the mobile device is maintained transparently and securely by servers at Merge. I can attest that connecting Osirix to an imaging server is challenging, mostly due to the arcane requirements of the DICOM standard’s “Query & Retreive” method of communication. In exchange for this simplicity, however, the app owner is charged a $24.99 monthly subscription fee, in addition to the $9.99 purchase price. Merge also notes that this app is not intended for diagnostic use, and seemingly to reinforce this status, they have left out any measurement tools such as distance and radio-density, available on the Osirix app.
Medical practice is a big business. Conservative estimates put the total cost of medical malpractice at nearly $35 billion annually and, according to a Kaiser Family Foundation report, nearly $5 billion is paid in claims each year. With an average claims payment of about $300,000 and up to 50% of that going to the lawyers representing the patient, its not surprising that practically every show on cable television has at least one advertisement imploring patients who have suffered practically any bad outcome to contact a lawyer immediately for “the compensation they deserve.”
And its that aggressive pursuit of legal cases that suggests that malpractice lawyers would be receptive to new opportunities for revenue, such as in the area of emerging medical technologies. We’ve talked previously about issues of liability and electronic health record developers. And at least one recent report suggests that iPhone medical app developers, including electronic health record developers producing iPhone interfaces, should be wary that they could become potential targets.
Apple chose Oscars night to announce to the world the coming of their newest device, the iPad. Meanwhile, the folks interested in tech and health IT have been feverishly debating its significance in the medical sphere since its unveiling to the press in January. While its roots in the iPhone OS immediately gives it a huge library of ready applications and a highly-polished user experience, a few themes of disappointment have persisted.
The one complaint that is most commonly repeated is the absence of Flash support on the iPad (and iPhone). This means that any websites which use Flash for games, small applications or to show video clips will not work. iPhone users have long become accustomed to the small blue rectangles which are displayed wherever there is a Flash object on a website. The theme has been that, if the iPad is going to gain currency as a laptop/tablet device for general computing needs, not displaying Flash content is going to be a significant handicap. But that may not turn out to be an issue at all.
Interview with CareCloud CEO
One of the newer electronic health records (EHRs) on display at the recent HIMSS conference was by CareCloud. The name “CareCloud” reflects that the application lives in the “cloud” and not on your computer. There is no software to download, and patient records can be accessed from any computer using a web browser.
This web-based application delivery is similar to other EHRs on the market such as the popular & free Practice Fusion, MDLand, Hello Health, and Allscripts (which has both a hosted and client-server option). What differentiates CareCloud is that it is built with some of the same tools and features as consumer websites and that it places high value on graphic design. In particular, it is built with Ruby on Rails – a modern, highly-abstracted programming language well suited for rapid development of web applications – and uses open-source software for infrastructure components, where possible. These strategies allowed the company to build the entire application within 18 months and to continue to add features quickly. The user interface is written using Adobe Flex which outputs to Adobe Flash and allows for a very attractive, fluid interface and, as you can see in the accompanying video, leaves little to be desired in responsiveness when compared to a traditional desktop application.
Our goal here is simple – to help connect physicians, nurses, PA’s, NP’s, EMT’s, and students to the apps that will help make them better at caring for patients. Whether that’s by learning anatomy better, having tools to share with your patients, or an accessible refresher on how to do procedures, there’s a lot out there that could us and you take better care of physicians. So please let us know (in the comments section here) what apps you would like to see reviewed. We’d especially appreciate links to the app’s iTunes page. We want to be responsive to what our readers want, so give us a hand by pointing us to the apps you’d like to know more about. In the meantime, we’ll keep looking for apps that we want to make sure our peers to know about.
One of the pleasures of a large meeting like HIMSS is the chance to meet remarkable people who are creative and productive but with whom one would not otherwise cross paths. Dr. Yan Chow is a physician who’s career has spanned several spheres. He holds an advanced software engineering with three patents for network storage architecture and has launched a few Bay Area tech startups. Later, he decided to pursue an MBA and entered the Univ. California Berkeley School of Business as the “second oldest guy in the class” and, he says with a twinkle, graduated as valedictorian.
He continues to practice as a pediatrician at Northern California Kaiser but is also the director of the Kaiser Permanente Information Technology’s Innovation & Advanced Technology Group. This is a remarkable position that only a health care institution as large as Kaiser can create. In essence, his job is to survey the newest technologies and decide which ones could be implemented in the larger Kaiser health system. It is, undoubtedly, the dream job for any health care technology aficionado. But for the institution, it is a strategic asset that helps it to avoid costly purchasing mistakes. Kaiser also maintains the Sidney Garfield “Laboratory for Innovation,”a 35,000 Sq ft space with fully mocked up patient and operating rooms where real doctors and nurses trial new technologies. Dr. Chow told me a remarkable story of just how valuable these investments can be.
Smoking is an addiction – that’s something we all know. But the chemical addiction, i.e. the biochemical dependence that develops in a person’s brain, has been curable for quite some time. Drugs like Bupropion, Chantix, and the various forms of nicotine replacement are all pretty effective at tying a person over as their body withdraws from the nicotine they had been filling their lungs with for years or decades. What has been the bane of patients and healthcare providers alike is not really the “addiction,” its the associated behavior.
To be clear, I’m not saying that smokers are facing an easy task, but quite the opposite. Behaviors are patterns of learned behavior that become engrained in our brains, generally reinforced by stimuli such as the positive stimuli associated with smoking like taking a break from work, being at a bar with friends, or even getting the relaxed feeling nicotine generates. So the patient attempting to quit smoking is driven back to it by these stimuli – being at a bar, taking a “smoke break” with colleagues. All of this combines to reinforce smoking as a learned behavior and breaking that is the hardest part – that’s why so many smokers go clean frequently only to relapse months or even years later. So what does the iPhone have to do with this?
For anyone interested in global health, there are a cadre of organizations that typically spring to mind as leaders – the CDC, USAID, and the Gates Foundation for example. I had the opportunity while at HIMSS to chat with folks from another organization that put boots on the ground immediately after the Haiti earthquake, is running programs worldwide on a number of endemic diseases (HIV/AIDs, malaria, lymphatic filiarisis), and operates a high-tech lab in Atlanta to develop field tools for public health workers. This is all from what I knew as a major defense contractor. But you’d never guess the that if you talk to Amy King (VP, Health IT) and Tom Verbeck (CTO, Health IT) of Northrop Grunman. Northrop entered the public health sphere just over a decade ago, looking to parlay the expertise it had developed via defense work – such as IT capabilities from intelligence projects – into a new health IT division. Since then, it has grown to employ over 200 epidemiologists along with scores of engineers, developers, clinicians, and other professionals, all of whom apply their range of talents to world’s biggest global health problems.
You may be wondering where the “mobile health” part comes in. For that, lets talk about a specific project that Northrop worked on to track HIV/AIDs in the Dominican Republic – a great anecdote of how mobile technology, on easy to use mobile devices, plus a strong IT support infrastructure can make a big difference and even turn every iPhone owner in the world into a public health field worker.