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Readers Write 4/2/12

April 2, 2012 Readers Write 1 Comment

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Cloud-Based Medical Data Exchange: Promising Results So Far
By Michael Trambert, MD

4-2-2012 8-18-31 PM

At RSNA 2011 and since then, my colleague Mark D. Kovacs, MD and I have been communicating to our peers about the new cloud-based services for exchanging imaging and other medical files.

Based on our study of an early adopter, Virginia Commonwealth University Medical Center (VCU), we’ve concluded that cloud-based medical data exchange has, in its best form at least, neatly addressed all of the major issues associated with older methods such as exchanging files by CD or VPN.

The “new” approach – which is actually about two years old and used by over 400 facilities – works seamlessly. Files are exchanged in minutes – reliably, securely, and at low cost. That includes exchanges between proprietary IT systems that don’t normally “talk to each other.” The cloud mediates the exchanges as easily as if it was e-mail being sent.

To appreciate what an improvement the cloud services represent, it helps to understand previous methods. Before the advent of cloud services, medical institutions turned to workaround solutions to deal with the incompatibility of proprietary healthcare IT systems.

The most popular of these was burning files to CD and sending them by mail, courier, or with the patient. Facilities that had a steady need for such exchanges with each other sometimes used virtual private networks (VPNs). For reports and other non-imaging files, some institutions used faxes.

The inherent problems with each of these methods are well known. But let’s examine the additional downstream problems.

Take, for instance, CDs – by far the most widely used method. This approach fails a significant percentage of the time, for reasons such as lost or misplaced CDs and files that can’t be opened. The significant time delay and risk of loss and or damage due to physical transport also undermines the rapid diagnosis and treatment of critically ill patients. Physical media makes it impossible to access studies contemporaneously from far away and by multiple caregiver / consultant sites.

When imaging studies are not successfully transferred, frustrated physicians at the treating institution often order redundant imaging studies. Studies show this occurs as much as 10% to 20% of the time. This unnecessary imaging exposes patients to excess radiation, which can contribute to cumulative deleterious effects. It also adds billions of unnecessary dollars to national healthcare costs.

VCU has been using a cloud-based service since late 2010. The cloud-mediated file transfers (in VCU’s case using a service called eMix) has been disruptive due to ease of use, speed, and dependability. Transfers are trouble-free.

As with any new approach — even one this simple — minor workflow adjustments were made. VCU is a Level I Trauma and referral center, so data exchanges usually involve other institutions’ sending files to VCU rather than vice versa. Those facilities had to switch over from a workflow built around burning and sending CDs to one requiring uploads to a cloud server. This required a simple change in workflow, much more efficient than burning CDs or utilizing VPNs.

Based on what we observed at VCU, Dr. Kovacs and I feel that change is exactly the right choice in this case. Cloud-based medical data exchange represents a boon to patient care because a patient’s imaging files, reports, and other crucial medical data from multiple previous providers can be sent to the current care provider whenever they are needed – in minutes, not days and with no hiccups in usability. Multiple consultants in geographically different locations can access this data from anywhere they require to provide input for a patient’s care.

These services also represent the efficiency gains that advocates such as the Bush and Obama administrations have been promising for healthcare IT in general. Unlike other forms of IT such as EHRs, some of the cloud-based services require no new capital purchases. That is, an institution does not have to purchase hardware or software. They simply have to pay a metered fee, as they do for electricity and water.

Besides eMix, current cloud-based services include lifeIMAGE and SeeMyRadiology, among a number of others. I cannot speak to the relative merits of each. But I can say that it’s nice to begin seeing the era of CD-burning and VPNs in our rear-view mirror.

Michael Trambert, MD. is the lead radiologist for PACS reengineering for the Cottage Health System and Sansum Clinic in Santa Barbara, CA.



ACHE Impressions
By Darkened Room Observer

After attending my third straight American College of Healthcare Executives’ Congress on Administration in Chicago, I’ve come away with the realization that there is a large vacuum of leadership within our industry.

I have attended the majority of sessions in the healthcare information technology “mastery series.” Each year, executive after executive talks about their success in implementing healthcare IT projects. When the question is asked, “To what do you attribute your success?“ the response is usually, “Well, I’m not really altogether sure.”

The lack of leadership this year was clearly evident a session in which a CEO got up in front of a group of about 200 people and said they decided that they did not want to go down the road of modifying a solution so, “We contracted with a vendor that didn’t allow customization to their product.”

Another CEO boasted that they chose a vendor who required them to hire a certain amount of people with specific talents and skills. The vendor would give the customer a rebate if they met specific milestones.

In another session, the CEO and CIO expounded on how well they were doing, based on the vendor’s established criteria and reporting mechanism.

With both financial and political pressures being applied to the healthcare marketplace at unprecedented levels, leadership to ensure that we are not simply doing things right, but are doing the right things is imperative. Yet we seem to have leadership that is so focused on ensuring that everyone is “happy” that they relegate true leadership, vision, and goal setting to their vendor. Although none of the presenters were allowed to disclose their vendor, it was clear to me that these entities were going to have epic changes to their businesses.

It appears that it may not be the actual technology a vendor brings to the table since the company in question deploys relatively arcane language, hardware technology, and definitely not state-of-the-art functionality by today’s standards. It has much more to do with a their philosophy of leadership by contract that appeals to this crop of hospital executives who lack the intestinal fortitude to ensure that their clinical staff change how they practice medicine as a result of implementing this new tool.

Can you imagine if the people marketing laparoscopic technology were required to modify their products to allow physicians to continue doing business as usual? Yet most vendors, in an effort to sell more in the short run, allow their clients to dictate modifications, enhancements, or wholesale scope changes in their contracts to “keep” clients.

Eventually these vendors suffer from trying to support 300 clients with extremely customized applications, setting the vendors up for failure. Like parenting or growing a good business, strong leadership and discipline are essential for truly happy children. Appeasing clients (like a child) only creates spoiled children.

Every time I turned around, it seemed that the only people exposing the truth were either from outside healthcare or were retired and finally saying what they couldn’t say while still needing a job.


Why Mobile Device Strategies are Missing the Point of the iPad
By Jared Sinclair RN

4-2-2012 8-25-34 PM

A friend of mine who has been a bedside nurse for many years has to lock herself in her bathroom whenever she surfs the web so that her elderly mother won’t complain about her wasting time with her laptop. My friend’s mother lived most of her adult life on another continent and without access to a computer. To her, a laptop is just another household object. She observes her daughter using the laptop as if she was mindlessly staring at a hunk of plastic and metal, while in fact, my friend is doing all kinds of things: researching, reading the news, paying bills, etc. The intangible nature of software is missed by her mother, who sees only the physical qualities of the machine itself.

Some of us in the healthcare tech industry have been making a similar mistake by thinking of mobile devices like the iPad as defined by their physical form. The form factor of a mobile device — the lack of a keyboard or a mouse — is what makes a mobile device portable, but portability is not its defining characteristic. A touch interface is what make a mobile device unique. This may seem obvious, but it deserves thoughtful consideration.

For many years, the PC industry itself also misunderstood this fact. While the iPad is far and away the most successful tablet, it is not the first tablet. PC manufacturers have been making tablets for years. Their products were never widely successful. Their approach was, in essence, to remove the keyboard and trackpad from a laptop and call it a tablet.

Because PC manufacturers didn’t write their own operating systems, they had no choice but to ship these tablets with Microsoft Windows. This operating system was not optimized for touch screens, which meant that the hardware had to conform to the limitations of the software and not vice versa. In other words, they had to require the use of a stylus. Smart managers would never have released these products on the market. The mistake of the PC manufacturers was in thinking that the defining quality of a tablet is its form factor.

The defining quality of a tablet is touch.

The iPad does not ship with the same operating system that ships with Apple’s desktops and laptops. It never will. IOS, the operating system that Apple created to run the iPad and the iPhone, was designed from the ground up for a multitouch experience. Other mobile operating systems, like Android and Microsoft’s Metro, have followed suit.

Without a mouse and a mouse cursor, many of the conventions that we take for granted when using traditional desktop or laptop operating systems vanish. Touch-based operating systems have no concept for right clicking, or for hovering the cursor. Because the tip of the human finger is much less accurate than the tiny one-pixel tip of a mouse cursor, on-screen buttons need to be much larger. Because touchscreens tend to be much smaller than desktop or laptop screens, care must be taken to maximize efficient use of screen real estate.

One of the main reasons for the iPad’s success compared to previous tablets is that it uses its constraints as advantages to be enhanced, rather than limitations to be overcome with a stylus. Gestures allow users to swipe, pinch, rotate, and flick through apps. User-interface designers create novel ways for people to interact with their apps based upon these gestures. Angry Birds, an app that everyone by now has enjoyed (or at least endured the sound of it being played), is much more fun on a touchscreen than on a PC.

It’s frustrating to read about hospitals so anxious to use the iPad in a clinical setting that, rather than waiting for a native app to be developed, they deliver a desktop EMR interface via a virtual client like the Citrix app. The experience is always dismal. This is not the fault of the EMR vendors. Their software was designed for a mouse and keyboard. It’s not surprising to hear physicians report that on-screen buttons are too small, or that it becomes tedious to constantly pinch and zoom in and out of a virtual image of a desktop EMR interface.

Healthcare IT leaders need to understand that a mobile device like an iPad is not defined by its hardware alone. Sports fans don’t buy high-definition televisions because they are rectangular. They buy them so that they can enjoy watching games with a clarity that they could not experience with any other kind of TV. For the same reason, consumers buy the iPad because it allows them to use a computer in ways that they could not use a computer before.

"Going mobile" is not a strategy. Any HIT mobile device plan that does not include touch-optimized native apps as part of its mission is doomed to failure or mediocrity. Sheer portability alone is not enough. Rather than cramming software paradigms designed for desktop computers into these brand new devices, we should be using the mobile device revolution as an opportunity to re-think the way we interact with our EMRs.

By the way, this article was dictated on an iPad. In a few years, we will probably all be talking about voice interaction the way I’m talking about touch today.

Jared Sinclair is a registered nurse and an iPhone and iPad developer. He’s the founder of Splint, a startup focused on developing mobile apps for bedside nurses. He is also the creator of Pillboxie, a fun medication reminder for iPhone and iPad. He lives in Nashville, TN.

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Currently there is "1 comment" on this Article:

  1. Very well said Jared. It is hard to believe that billion dollar companies that have limitless sources to hire as many good designers as they want put these desktop based EMRs on the iPad and expected it to work. They used the same technological savvy (reckless abandon) they used when they “designed” their lumbering desktop UIs in the first place. “Just get it out there.” “We can say we are iPad ready!”

    Did anyone in these billion dollar companies use their product once before putting it out there? If they did, I would love to meet these “Usability Experts” that these companies are so busy hiring that saw this constant pinching and expanding and said, “It’s ready for prime time!”

    Hopefully, some of these healthcare design conferences/ organizations will bear some fruit and make some user interfaces that can be, well, used.







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