How to Quickly create "teaching" material - The Silhouette Sign

Loss of the radiology (X-ray ) rounds!
With the advent of the PACS (Picture Archiving and Communications System) X-ray films are becoming history. For some years now digital versions of x-ray images of patients are being viewed on monitors. These can be viewed by the clinicians ordering the imaging tests - on the hospital floors (wards) or in the clinics. This has eliminated the need to transport films and also the time honored X-ray rounds where the whole clinical team would trek down to the bowels of the hospital and look at the x-rays (and other images) of all their patients, often discussing these with the radiologist. This is still done for individual cases when there are questions but an educational session has become somewhat extinct.

Need for Radiology Education Material.
This has led to the need to provide education regarding reading of x-rays to clinical trainees at the point of care. Trainees can also look up videos on reading x-rays on YouTube and at other sites. Radiology educators interested in creating such teaching material can easily create this using a new iPad App called Showmeapp. The only thing you need is an iPad and an Internet connection to upload the video. If you have some images in your teaching file, you can import them to your iPad and then use these during the lesson.

An Example!
Here is an example of a short video on the famous Silhouette sign.

This took me about 5 minutes to make including time to upload. Not being a radiologist, there are probably some inaccuracies in this, but it makes the point I think. A radiologist could easily spend a few hours and create a library of such teaching videos and these would be an invaluable resource for all medical students, residents and practitioners.
Any takers?

Easy tool to create narrated picture stories and patient education material

Yesterday @amcunnigham posted a link to the showmeapp on Twitter.  It linked to a video of someone doodling.  Soon there were several people commenting about potential uses of this including @nlafferty suggesting how it could be used to capture the "Back of prescription pad" learning moments and @mikey3982 suggesting how it could be useful to talk and diagram out something in the middle of a tweet conversation.

The app is very simple and requires just a web connected iPad.  You doodle on the screen, or import a picture and annotate it or just do a math equation.  You can narrate while doing this.  It captures both the audio and the on screen events and with one click uploads them to the showmeapp web site.  From there, you can post to FaceBook or Twitter or get an embed code to include in your blog.

At present showmeapp is free and there are no restrictions to the length of the video.  Try it out!  I am sure you will like it and think of a dozen different ways to use it.  Here is my attempt at creating a patient education video re Barrett's esophagus.

The Filter Bubble in Medicine - Patients beware!

Eli Pariser coined the term "Filter Bubble" to suggest how web services customize the information we see online and thus can prevent us from getting exposed to information that could challenge or broaden our vision.  You can see his Ted Talk video here:

So how does this apply to medicine?
When a patient gets admitted to the hospital via the Emergency Department or gets transferred from another hospital, the information about the original reason for presentation is progressively filtered till an attending physician or a consultant on the hospital ward is at serious risk of being in a filter bubble.
So what does that mean?

  • The first person to see the patient and the family has the best chance to get a true history about the symptoms and the course of illness that led to the presentation.  That person has no other source of information but to talk to the patient and the family.
  • That person then, usually, documents this history in the paper or electronic medical record.  
  • Everyone who subsequently sees the patient tends to look at this record before interviewing the patient.  This does spare the patient repeated questioning but removes the physician one step away from the original source of information.  
  • In addition, the family members often leave the patient after they have given their version of the story to the first health care worker.
  • The patient often is also tired, unwell, and every physician has had the experience of the patient telling them, "I already answered all these questions.  Why don't you look it up and leave me alone!"  
  • What most patients are unaware of is that the history alone when properly elicited can diagnose more than 50% of the cases correctly!  History taking is an art and science and improves with experience.  Often the first person to interview the patient is either the least experienced or the least qualified.  
  • Also as the patient makes his/her way through the various tiers of the health system, a number of tests get ordered and results become available.  The information from these tests gets tagged into the history and often even replaces it.  Thus the patient with severe abdominal pain and nausea and vomiting becomes the patient with ileus and then the patient with pancreatitis and high triglycerides.  Somewhere along the line the fact that a new medication was recently started is filtered out of the information that the consultant or attending physician gets.  
  • The electronic health records have exacerbated this problem as the documentation is available long before the patient actually reaches the hospital ward and thus the filter bubble is created before any chance of getting the history from the original source!  
So what is the moral of the story?  
If you are a patient, or a relative, as far as possible try and provide history whenever a doctor asks about it.  History taking is critical and some information you provide might prevent a catastrophe'.  To all doctors in training, remember to go to the original source and get the story from the "horse's mouth" as far as possible.  Patients don't present with community acquired pneumonia, they present with fever, chills, shortness of breath and a cough!

Making EHRs more Meaningful for Physicians - Part III

Context Sensitive Right-Click (Control Click) Menu

Click on the full screen option (lower right corner) to experience this slide show in interactive manner:

Suppose you see a patient with an elevated creatinine level.  You have access to the electronic health records with all the medication administration records and imaging tests.
You try to see if this is a baseline value or a new elevation.  You pull up a range of creatinine values and see that the level has been fluctuating but is overall higher than what is was 1 year back.
You look for any insults to the kidney like contrast media.  You go to the imaging tab and look for all tests that had IV contrast media.  So you sort all the radiology test by date range to find a test that might have occurred prior to the rise in creatinine.  You then go through all the historical medications that could have been started prior the the rise in creatinine.
Even though all the information is there in the EHR which is a big improvement over the days of paper charts, it takes you 10-15 minutes to find all this information.

What if there was a context sensitive right click menu for things like lab values and medications that did this work for you?  Actually make the physicians job easier and improve care?  Instead of physicians just entering more data into the EHR, they actually benefit by getting organized data back from EHRs?

Some examples of such right click menu items might be:

–Start date
–Dose change date
–Stop date
–Stop reason
–Started/stopped by
–Indication/associated diagnosis
–Timeline of medication/class
–Timeline of associated labs (if appropriate) e.g. TFTs for levothyroxin, or amiodarone etc.

Lab results
–Previous n readings
–Graph of values on timeline
–Links to notes with related diagnosis (e.g. hypothyroidism codes for TSH) arranged on the timeline
–Links to meds/procedures that might impact the value on timeline (e.g. for TSH – show when amiodarone was started, for Creatinine – show when CT with contrast done, when aminoglycoside started etc).

So what would this look like:
Note: The slide show auto-advances.  Once you are on slide 2, Pause the show by clicking the Space bar,  follow the instructions at the bottom of the slide.  There are just 3 slides total.
This is just a simplified example.
Obviously some background work would need to be done before this can happen.  Thus we would need to identify the appropriate menu for lab tests and medications.  In addition, we would need to identify common events that are connected to each lab or medication.  I would suggest that there are probably a handful of lab tests - each with a handful of events that we can start with.  This would prove helpful in the vast majority of clinical settings.  As time passes we can make this more detailed and cover more tests and medications.

As a physician I and often faced by a patient who says, "But doctor, all the data is in there, in that computer!" The patient is often right (except the data is on a server somewhere) but what most non-clinicians don't understand is how many clicks and screen views it takes to make sense of all this data!

Making EHRs More Meaningful for Physicians - Part II

Peer rating of EHR notes!

One of the biggest problems with the profusion of meaningless data in EHRs is separating the wheat from the chaff, finding the proverbial needle in a haystack.
Something that the Web 2.0 has taught us is that the users who create data can also help to make it more meaningful.  Thus we have tags in Flickr and "likes" in Facebook.  How can we apply that to EHRs?
Every physician who has seen a patient for follow up after a long hospital admission knows what a relief it is to see a meaningful note that succinctly summarizes the hospital course.  For every useful note providing meaningful information there are tens of notes with meaningless words and phrases that don't add to patient care in any substantial way.
What if we have a thumbs up and thumbs down option next to every note?  What if anyone reading the note could give it an anonymous rating?  What if we let physicians see statistics of how many people had opened their note and how many of those rated it up or down?
Then users could filter the notes in the EHR by their ratings.  Also we could recognize the excellent work done by our infectious disease docs who document the best notes among all clinicians.  Maybe we could link this with a bonus just like we do for the meaningful use of EHRs!  

Making EHRs More Meaningful for Physicians - Part I

Using Social Media/Networking and Web 2.0 Ideas for EHRs.

While EHRs have a lot of potential, their design could be much better. There is a feeling that the needs of the physicians have been ignored during the design process. It is high time, physicians spoke up loud and clear on their needs.

As more information is collected within the EHR, it becomes progressively more difficult to review it in an efficient manner. This is due to several factors but I am going to focus on just 2 right now:

  • The office visit notes tend to be very long with the meaningful portions buried amongst all the requirements for medico-legal and billing and coding needs.
  • The information is not appropriately tagged or categorized.  For example, when I am managing a patient's reflux disease, I like to look at all the related notes, medications, tests etc. in one place. This would prevent overlooking something and provide better care while saving the physician time.
Web 2.0 means that users create content and help create meaning from the content by appropriately tagging and curating it.  In EHRs while care givers create content, it is not at present easy to make sense from it.  We rely on various system solutions like ICDs and CPTs which are often like fitting square pegs in round holes.  They serve the purpose for everyone but the physicians taking care of the patient.  It is high time, physicians did something to make sense of the EHR data for themselves.  So here is a proposal.
  1. With every note, the care giver will create a short Twitter-like post to summarize the thoughts and plans.
  2. This summary will be tagged with the appropriate organ-system or category (one or more)
  3. The patient's EHR will have an overview page with the (reverse) chronologically arranged Twitter-like summaries from every encounter.  These could be sorted/filtered/searched.
  4. The tags from these summaries would be used to create a wiki where each tag would be a topic and all summaries created by various physicians tagged by that topic would be automatically collated under that header.
Here is a mock-up of what this could look like.  To explore how this works, pause the presentation and click on the various tabs, hyperlinks and tags to see the proposed functionality.
Click here to see the slide set as a flipbook.
Or just take a quick look at the non-interactive images below:
A twitter feed of summaries from encounters.  Each summary is linked to the full note.

Office visit note with Summary at top.  Appropriate tags added.
A Wiki for the GI topic with all encounter summaries tagged with [gi].  Additionally has timeline for GI related decisions.
Medication tab showing timeline of medication changes with links to encounters notes when changes were made.
These are "back of the envelope" designs and clearly need to be thought through in detail.  The concept though should be quite obvious from these.  Any EHR company out there listening?  Someone want to build an open-source EHR based on these principles that will truly help the physician and the patients?  

The astute reader must have noticed the "Part-I" next to the title of this post.  Yes there is more to come.  

Leverage your Global Twitter network to find answers to Clinical Questions!

Just last night I got to experience first-hand how the Global Twitter Network can help one find answers to questions almost instantly.  When you use Twitter for a while, you get to know and trust people whom you communicate with frequently.  These people might have similar interests but also have expertise in various other areas and can help direct one to answers that might not be easy to find.  Just like any thing else on the web, one still has to appraise the evidence and apply it appropriately.  A great advantage of twitter is that around the globe, it is highly likely that someone is awake and has some time to look for the answer.  You can also "mention" a person you know might have the answer in your tweet and if thus draw their attention to the question.

So here is a brief example of how the Global Twitter Network works.