The recent history of electronic medical records in ambulatory care, or what we now call EHR (electronic health record) technology, can be divided roughly into three phases. Phase I, which lasted approximately 20 years, from about 1980 to the early 2000’s, was an era of exploration and early adaptation of computers to outpatient medicine. It coincided with the availability of PCs that were cheap enough to be owned by many doctors, and with the increased capacity of off-the-shelf software programs, mainly spreadsheet and database management systems such as Lotus, Excel, Access, and Microsoft’s SQL, to lend themselves to computerized capture of health data and information. Phase II coincided roughly with the American Academy of Family Physician’s (AAFP’s) commitment to health IT as a core competency of the organization, and with its support/promotion of the early commercial vendors in the Partners for Patients program, a national educational campaign inaugurated in 2002 which involved joint venturing with vendors that included Practice Partners, MedicaLogic, eClinicalWorks, and eMDs, among others. Several other physician membership organizations joined this effort to popularize EMRs, or crafted their own education programs for their members based on the AAFP’s model. The most popular Phase II products were, and still are for the most part, client-server software applications that run on local networks and PCs within the four walls of a practice, and tend to use very similar programming development tools, back-end databases, and support for peripherals such as printers. The industry grew, albeit sluggishly, from roughly 2002-present in an unregulated environment, with increasing support from quasi-official industry groups like HIMSS and CCHIT, and with the blessing of many professional organizations, including the AAFP, ACP, AOA, and the AAP. Best estimates are that the numbers of physicians using EHR technology from a commercial vendor roughly tripled during this period, from about 5% of physicians to about 15%. The Bush administration gave moral support to the industry, but did not provide funding or payment incentives, and mostly left the industry to itself to sort out the rules, including certification. The industry is now entering a new phase, one we predict will significantly depart from the previous two eras.Continue reading…
Obama Administration CTO Aneesh Chopra at Health 2.0
Op-Ed: Robot-assisted Surgery – The Leading Treatment for Prostate Cancer
Prostate cancer surgeons around the world are using surgical robots to assist in the most delicate operative procedures. Across the country, nearly 1,000 of these robots have entered hospital operating rooms, including our institution: Swedish Medical Center in Seattle, Wash.
These minimally invasive devices, called daVinci surgical robots, offer patients substantially less pain, short recovery time and quicker return to normal activities than traditional open surgery. And because of this, the da Vinci and I have done more than 900 procedures together.
The da Vinci robot assists me during surgery by taking my movements and making them better: more precision, greater freedom of movement and no surgical tremor. These robots offer unmatched surgical precision – meaning my hand cannot compare to the dexterity of the robotic arms. We simply cannot turn our hands 540 degrees. Da Vinci has 4 robotic arms, which I control at all times at the surgeon’s console. I look through a 3-D viewfinder at the console, which gives me visual depth, and a magnified view 10 to 15 times closer than human vision allows. This magnified view gives me more precision as well. Better visibility, better instrument movement means better surgery.
Through my years using da Vinci surgical technology, I know that it offers several advantages over conventional open surgery. These include less pain, faster recovery, and less blood loss which means reduced need for blood transfusions. Because the surgery is performed through small incisions there is less internal scarring and less risk of bowel adhesions.
Most importantly, with regard to prostate surgery, using the robot has demonstrated improved outcomes over open prostatectomy. In my experience this has resulted in less urinary incontinence, less erectile dysfunction, and excellent cancer control.
Coincidentally, I was diagnosed with prostate cancer in April 2006, and like all of my patients, the news was devastating. I looked at all the available treatment options and decided to pursue the robotic surgery over radiation therapy or open surgery. For me, radiation was a shotgun approach and the nerves that control sexual function are potentially at risk from the radiation. Having the prostate removed gave me information about the amount of cancer and whether it was contained inside the prostate. This is important in predicting the future behavior of the cancer and I would not get this critical information if I radiated the prostate.
Another important factor in my decision is that once radiation is performed, and if the cancer were to come back, surgery is not an option after radiation due to the high complication rate and difficulty created by the effects of radiation on the tissues. Tissue just does not heal well after it has been radiated. Conversely, if I had surgery first, and the cancer came back, then radiation was still an option. Essentially, I would be eliminating one treatment option if I had chosen radiation first.
Robot-assisted surgery allowed me to return to my normal activities quickly and this was important for my patients and practice. Through five small incisions about a half-inch in length, the robotic instruments and cameras are inserted into the patient (in this case, me). Compared to the open surgical incision, these incisions are significantly smaller and for many patients this alone is reason enough to consider the procedure over traditional open surgery. I was at home in just one day and at work within two weeks.
The typical prostate surgery patient after a more traditional operation is in the hospital two to three days and is recovering for four to six weeks. Almost all my patients have gone home the day following surgery, and most are back to normal activities by two weeks. 90 percent of my patients don’t take narcotic pain medication once they leave the hospital.
Today, prostate cancer affects 1 in 6 men in America. A non-smoking man, for example, is more likely to develop prostate cancer than he is to develop colon, bladder, melanoma, lymphoma and kidney cancers combined.
Every man is at risk for prostate cancer. While the causes for prostate cancer are largely unknown, one thing is certain – the chance of developing prostate cancer increases in men over 50. While age is clearly associated, I am seeing more and more men with prostate cancer under the age of 50 and even under 40. Close relatives of men with prostate cancer are also more likely to be affected.
This means that annually more than 192,000 men will be diagnosed with prostate cancer, and more than 27,000 men will die from the disease. This ranks prostate cancer as the second leading cause of cancer death in men just behind lung cancer.
However, the future is no longer as bleak as it once was. If caught early, prostate cancer is a treatable disease, which many men have survived. Today about 85 percent of prostate cancer surgery is performed using the da Vinci robot – it has become the norm for the surgical removal of the prostate.
As a surgeon, I’m acutely aware that the location of the prostate gland deep inside the pelvis makes these surgeries a complex and delicate procedure. Removing the prostate is just part of the procedure. Preserving the integrity of the tissues surrounding the prostate is essential to maintain urinary control and sexual function. That is why the benefits of robot-assisted surgery can be so critical.
Many men elect a robot-assisted prostatectomy because it often provides the fastest return to normal daily activities. My experience as both a surgeon and as a patient is proof. If you are diagnosed with prostate cancer, be sure to make an informed decision about your course of treatment by doing your homework and researching the best approaches available, including robot-assisted surgery.
Dr. James Porter is director of surgical robotics at Swedish Medical Center in Seattle, Wash. and a prostate cancer survivor. Under his leadership, Swedish is one of the first medical centers in the Pacific Northwest to perform robot-assisted surgery. Swedish’s robot-assisted surgical program was first established at Swedish in 2005. Since then, Swedish-affiliated surgeons have performed more than 2,000 procedures using the da Vinci Surgical System, more than any other robot-assisted surgical program in the Pacific Northwest. Dr. Porter is the first medical professional in the country to perform a retroperineral robot-assisted partial nephrectomy using the da Vinci robot (removal of a kidney tumor). Dr. Porter trains surgeons from around the globe how to use the da Vinci robot.
JSK (national treasure) on data liquidity, and how it fits into Health 2.0
Given that she taught me most of what I know about health IT I don’t know why I ever need reminding about how great Jane Sarasohn-Kahn is at keeping her finger on the pulse of health care, and how consistently good is her one daily post on Health Populi.
Yesterday was no different. She gave a great overview of a new PWC study on data liquidity. You’re going to hear lots from me and others in the coming days about data liquidity, substitutability, intermingling of applications, and unplatforms. But what’s happening on the edges of health care IT in the Health 2.0 movement is a combination of tools, content and transaction data beginning to flow between applications. More and more this is both enabling better management of the consumer (and clinicians) workflow experience and better ways to aggregate these new data sources for clinical decisions and research.
On day Two of the Health 2.0 Conference next week we’ll be showing this both in our panel on Data Drives Decisions, but also on the Tools panel which will feature a series of inter-operable applications sharing data. And we’ll also be showing the big players (Google, Microsoft & WebMD) as they move their offerings to a world where other service providers can use their platform.
Truly exciting times, but Jane points out that there are lots of barriers. She calls the PWC report
a sober analysis of what stands between transactions and raw data, and the ultimate goal of using that information: clinical transformation that benefits people.
And those barriers all center around the workflow, payment structure and institutional inertia of our current health care establishment.
the health industry en masse needs to shift the focus of data from transactions to quality and outcomes. This will require – surprise, surprise – incentives to, as PwC puts it, “induce all stakeholders to collect, report and use the data.”
Two big deals in Health 2.0
John Halamka writes about the small but important meeting this week at Harvard Medical School hosted by Zak Kohane and Ken Mandl. Because of the impending arrival of about 1,000 of my best friends next week at Health 2.0, I couldn’t go to that meeting. But it may be very important in putting the “cats and dogs” together to think about ways for new platforms with players like Halamka and David Kibbe (who have not been on the same side of these issues) both taking part.
Meanwhile, yesterday Microsoft released My Health Info. I got a quick preview and it’s essentially a layer over HealthVault that allows both Microsoft and others to build widgets that can be arranged on sites like MSN Health (and presumably many more to come) which directly connect with the individual’s data in HealthVault. It essentially is the cool user interface that HealthVault has been missing and it’s more evidence of Microsoft’s serious intentions in consumer health care.
If you’re at Health 2.0 next week you’ll see Microsoft’s My Health Info and hear much, much more about what David Kibbe is calling Clinical Groupware, and also many demonstrations about we’re starting to call “unplatforms”.
While health reform is arguing about multiple amendments in Baucus’ committee and making some of us despair, the tech world is showing some real promise.
What if I Had To Do HIT All Over Again?
By MARGALIT GUR-ARIE
This post is aimed at serving as an interlude to the “public option/death panels” discussions. No matter what healthcare reform bill, if any, is passed this fall, HIT will be part of the program. Four short years ago I was involved in the creation of a comprehensive, some would say monolithic, EMR/Practice Management/Billing system. This new product was built in reaction to the very large, very expensive and very clunky systems already on the market.
Remembrance of Things Past – The driving design considerations four years ago
- The problem – Paper charts are causing inefficient workflows in physician offices. It is hard to find pertinent information in a big chart and it is hard to analyze that information. Charts can only be accessed by one person at a time and cannot be accessed from outside the office. Charts are sometimes misplaced and may be lost during a fire or natural disaster. Every new chart costs money to create, store, pull and maintain.
- The solution – Application software that provides a computerized version of the paper chart – an Electronic Medical Record. Computers are great at storing and arranging data in all sorts of ways and formats. Computers can analyze, graph and report on enormous amounts of data. The software should be web based so it can be easily accessed from anywhere by multiple users simultaneously. No more misplaced charts and no more wasted office space and a SaaS solution would make sure the records are disaster proof.Continue reading…
Medical Students Want You to Know
How many of us can remember a world without cell phones? Today’s medical students would undoubtedly be among that group. So it is no wonder these future physicians rely heavily on technology as they embark on their career path. We surveyed more than 1,000 medical students who are Epocrates subscribers about technology (software, hardware and EMRs) and other pressing industry topics.
The survey found 45% of respondents currently use an iPhone or iPod-touch, followed by Palm and BlackBerry devices. Even prior to the launch of the iPhone, Apple has connected with this younger generation and continues to play to its strengths. Our survey did not address carrier preference, but it appears students may be more device focused; nearly 60% of non-smartphone users planning to purchase an iPhone within the next year. It is also worth noting that students may be looking at what device residents or attending physicians are using as well. In the first year of availability, over 100,000 physicians are actively using Epocrates software on an iPhone/iPod touch. We still see a significant number of physicians using BlackBerry and Palm devices, so we expect those respective populations to grow as well.
Why Standards Matter (1): The True Meaning of Interoperability
Americans are generally skeptical of words that otherwise intelligent and articulate people can’t pronounce. “Interoperability,” like nu-cu-lar, is one of these. After a while, these words can take on a mystique all their own.But interoperability is a hugely important word in the context of today’s ongoing debate about the use of EHR technology by physicians, hospitals, and patients too. The federal government is going to provide billions of dollars to encourage today’s fragmented health care providers to convert from mostly paper to mostly computerized information systems. It is critically important for these systems to talk with one another. We want health data to flow between and among these systems and to be, well, interoperable. And it isn’t now.
So how can this word be so difficult to put into action? Here’s a clue: a lot of people are confused about its meaning.Continue reading…
Is “Cloud Computing” Right for Health IT?
The announcement of Salesforce.com investing and coordinating development efforts with Practice Fusion has brought talk of “cloud computing” to the fore. Salesforce has been known as a leader in cloud computing, and moving healthcare IT to that “cloud” has raised questions by a number of observers. What, exactly, is “cloud computing?” Is it appropriate for health IT? What are the security issues and risks?
“Cloud computing” is a term described as a style of computing in which on-demand resources are provided as a service over the Internet. Software-as-a-service (SaaS) is a type of cloud computing, where users do not need to install or maintain any software themselves – simple Internet access and a browser are all that is needed. Users do not need to have knowledge of, expertise in, or control over the technology infrastructure in the “cloud” that supports them – the Internet site (e.g. Practice Fusion) provides a unified dashboard to the user, and works out the technical issues of presenting that data in the background.Continue reading…
The Doctor Is In and Logged On.
Wow. I’ve just taken care of three patients in 12 minutes, and I didn’t do it by “churning” them through my office as if it’s some sort of factory assembly line. Rather, those patients (their parents, more specifically — I’m a pediatrician), e-mailed me over a secure network with questions and descriptions of signs and symptoms.
One mother attached a digital photo of a rash on her 3-month-old daughter’s face; it turned out be nothing more serious than baby acne (it’ll go away in a month or so). Another mom had noticed that her son was missing one of his pre-kindergarten immunizations (she had pulled up his shot records online) and requested that I order it. And the father of a 5-month-old boy told me that his son has been constipated off and on for the last month. I e-mailed him a questionnaire so I could determine whether the family should try something at home or bring the child to the office.Continue reading…
