A Real Mobile Clinical Assistant

When are we going to cut out the clinician and just have the computer make the diagnosis based on the input, and then print out the script?

A modern day tricorder. Or a precursor to. Nice!

Looks familiar....

Doc should change his avatar back to Bones.

As great as this is, it won't see widespread use for a long time. On top of the cost-per-unit, trying to train every nurse/provider (many of whom are not very tech-savvy)  how to operate one of those is not the easiest thing to do.

I have a post cooking on just that...

Why do you think that, annatar? The cost savings and time benefit along with the connectivity would (to me) seem self evident.

Gimme (minus the pointy ears)!

I work in a health system with about ~80 combined hospitals and clinics, and we actually support another mobile device for ordering/tracking medications on patients. The device is little more than a glorified PDA/armband scanner with some custom software to order/track meds, and runs about $1600 per unit. Something like this would easily cost a lot more. The main problem, though, is maintaining support, not the up-front costs of buying it. Not all hospitals/clinics are using EMRs (electronic medical record), ours that do generally have complex interfaces to link all their various solutions (Lab, radiology, inpatient, clinics, etc) together into something that actually works, and this would be another link in the chain. And, as I mentioned, a lot of the providers and nurses who would be using these are not as comfortable with the quickly-expanding technology as we are and these kinds of things are very intimidating and takes a very long time to transition to using a new device or system.

For newer/smaller hospitals/clinics that don't have anything currently and are just looking into expanding into the various EMR solutions now, this may be a good thing. But we've been at it for about 5 years now and we still don't have all of our hospitals and clinics converted, and we're not even going to consider restarting the cycle again

Basically, it's all about the logistics of incorporating this device into the existing systems. It will be a very slow process, hence my comment that it won't become widespread for quite a while.

This unit costs $1,899 MSRP. It's well worth it, and would pay for itself over a relatively short period of time. The EMR interface could be patched/tailored.

I truly believe this could be a wonderful addition to Visiting Nurses, peripheral clinics and Physicians as well.

And this is where the vast majority of the work is. Like I said, the device is great. But it's not like you can just pick it up and have it function the way you need it. Physicians and nurses are already used to doing something one way, they will want any new device/system to allow them to do things the same way. There are complicated internal politics (if you will) that go on behind the scenes, too.

The device itself is definitely great. But picking it up to use it in practice is complicated.

     In the beginning it will be slow, that's a given. But in the long run the benefits IMO far outweigh the cost. Besides, as it becomes more widely used it will be like anything else. Another will create a similar machine under a different name. Competition will drive the price down and before you know it we got tricorders. Cell phones went the same way. The were the communicators. A Feinberg device already exists. Has for some time now albeit somewhat larger and not as sensitive. Not to mention that a working tractor beam exists, also on a very small scale that can push/pull atoms. Cloaking devices, transporters ..... next.

You want thought, facts and an opinion, i'll give you some.

There have been an awful lot of Medical threads in the last 1 or 2 months. The people that have the ability to truly comment are very limited to say the least. Therefore what you get is just a lot of opinion comments like I’m going to do here. I’m no expert by any means but can talk about the med cart that was mentioned and a couple other things that I consider myself as knowing to be fact. Many times actual hand on and seeing is better than stuff that is written that you read someone expects us to believe all the time. I spent 6 straight weeks in the hospital, seven days a week and many hours each day. Also had several other extended visits in the past 6 years up to 2009.

Save money, I don’t know about that. The nurses got to know me pretty well and would answer a lot of questions so I had some about the med carts after watching what was going on for about 3 weeks. Sure the nurses were using them because they had to but most actually didn’t like it except for one reason. When they had to get drugs for a patient they use to go to the med room. Pull them out and get them to the patient. With the carts the patient actually waits longer and the only comment made to me by more than one nurse was “at least this thing keeps us out of the rooms longer” They now explained how they had to extra careful to push the right buttons and bring up the correct information which takes longer than the old way. I guess they didn’t know telling me this stuff is something they really shouldn’t do but some aren’t too smart with common sense I guess.

Now there is no question that records can be better maintained and that everyone will be able to see the same information. But save money, not what I saw and actually believe is no way.

It was said “This unit costs $1,899 MSRP” What wasn’t said is how many millions of the units it would take to actually communicate the way it’s so easily thought about. Another thing not mentioned and this is fact. Who actually pays for this stuff? You know the patient in many ways. First the insurance companies increase prices. Then not just the patient but everyone with insurance pays higher premiums. Now to try and keep those down the insurance make new plans with higher co-pays. So we all pay for record keeping actually. So nothing is what you can call cheap or only cost $$$. The bottom line is the hospitals and insurance companies will just raise fees and we will pay for it.

I’m not against advances that can save a life or make an operation easier or even new computer systems. However some tech. company comes up with something and we are just supposed to get it. Some people get a new cell phone as soon as it comes out. Do they need it no, not at all, but if they want it, enjoy it and can afford it then go get it. Doesn’t mean every new gadget that comes out has to be purchased for every business at the cost of the people.

In ending you may say what the hell did Dave just say. Well I can tell you this and anyone can comment on what I said but you won’t change my mind. I’m not a Doctor but after the amount of time I spent in hospitals during a 5 year period ( and it wasn’t me with the problem) I can tell you there is a lot of waist and many people that are supposed to know what they are doing but sure don’t do it. There are some caring doctors and nurses but they are limited. I knew sooner or later I would blow up so to speak on one of these Medical threads so I guess it was my time.

You go Dave... 

It's easy to see the potential benefits of such immediacy and simplicity at the point of care (we're currently using an iPad as a dumb terminal in the exam room).  'Nother thing altogether to integrate it into a system.  We are 15 months into a transition to EMR and are about half-way there.  The minutiae are killer and all EMR systems have interfaces which require brute force memorization of everything.  Nothing is intuitive.  Nothing.  And it will benefit no one else until they have interoperable systems with easy access to what we document.  Not to mention the fact that in the course of the normal chaos, not everything can be documented in a linear, real-time fashion; in fact, much of it can't.

The hospital where I've practiced for 30 years (now a two-hospital system with about 400-450 active beds combined) has been through at least 3 multimillion dollar computer system conversions over the past 15 years and is now looking at spending $88 million bucks to implement a unified EMR.  That's nearly $200k per bed.  Before we 'do' anything to the patient in it.  Gonna take a lot of 'bad things avoided' to get a reasonable ROI.  The 'savings' assumed to adhere to adoption of such systems will be very difficult to identify and substantial hidden (and domino) costs will be ignored.  At times, I'm inclined to see a parallel to the 'spend our way out of debt' approach to the economy.

And I'm a fan.

Typically, systems evolve. They change, and become more complex. That costs. It's like the ripples of a stone cast in a pond. We advance at different times in different areas and at different rates. These cause other changes.

I think your objections might better be directed at the organization of health care finance, because that as well as Medicare/caid, Defense and Entitlement spending as well as Social Security need serious fixing and the clowns of all the parties in Washington lack the brains and courage to do it.

Dave, I have no doubts you've had negative experiences you're angry about. You know what? Everyone has. You and I also share something I don't need to explain.

I naturally write about Medicine and tech because of my Profession but also because of requests. I'd be happy if you'd pm me with any requests you might have.

I've had both positive and negative experiences.  I love access to diagnostic imaging right on my computer in the office; almost all the radiology practices here provide direct access to images now.  I love ePocrates.  I've become a big fan of electronic prescribing.  I'm the (semi-qualified, self-educated) network administrator for our 4-physician practice.  I'm a technophile by nature, so almost any tech enhancements to medical practice interest me.  And I enjoy the challenge of making them work to the benefit of my patients (and me, every once in awhile anyway).

But I have a very healthy cynicism about who will benefit from widespread adoption of EMR systems.  Right now, if I had paid my own hard-earned income for the privilege of adopting an EMR, I'd be really pissed.  It's a huge upfront cost which will never be recouped at the practice level, in either reimbursement or 'efficiency'.  Entities higher up the food chain will eventually reap benefits through more & more highly granular control over what happens to who when, or through controlled access to aggregate data, but us frontliners are hosed.  EMR's are simply not designed to improve efficiency at the point of care, quite reasonably because that is not their purpose, which is data collection and centralized 'command and control'.  Furthermore, barriers to exercising clinical judgement and practicing the 'art' of medicine will grow higher and higher until both are abandoned as not worth the trouble.  The path of least resistance will become progressively constrained at the bedside.

Data-element-driven documentation is cumbersome, time-consuming, of little direct benefit to patients or physicians, and creates blizzards of meaningless words, in which, occasionally, are buried tidbits of clinically relevant information.  It does not lend itself to narrative, nuance, intuition or academic contemplation.  95% of what passes for an encounter record these days is generic mouseclick boilerplate whose intended audience is not other physicians or patients, but reviewers and bean-counters.  We not only practice defensive medicine because of our tort system, we practice defensive documentation because of the audit hordes with small-sample generalization rules which could wipe us out financially.  It will only get worse when ICD-10 is adopted, magnifying the complexity of documentation-justification tenfold.  We as a society are investing obscene amounts of money to generate lots of garbage, in the GIGO sense.

A physician friend of mine who worked for several years part-time at the local VA hospital liked to say that they had an absolutely marvelous electronic medical record system... completely devoid of meaningful content.  That's my fear - that we'll end up with '57 channels and nothin's on'.

Other than that, I think EMR's are great.

I've been holding my tongue on this, suffering in silence, so I'm just going to put it out here.  As a 52-year-old medical transcriptionist, EMR is the most frightening 3 letters in the alphabet.  It means my job is even MORE obsolete than what speech recognition has done to it.  I've already had my liveable wage cut in half, with EMR I have no income. 

It's too late for me to go back to college to learn something new -- there's no way I'd live long enough to be able to pay back the student loans. 

Seth, I hope you know the kind of anxiety these sorts of posts cause me.

E/M Coding is at fault.

If MD's had the cajones to strike and treat ICU/CCU and very sick patients only... and tell the insurance co's to eff off, thinks would be much better. funny. I predicted this 28 years ago. Everyone laughed. I periodically remind them when they spout 'predictions'.

I dictate to my iPad. AirPrint. Short office notes. Patients sign forms designed for level 3-5 as to how long they were there and what was done.

EMR's in the VA system were purchased based on political considerationjs. It was originally an accounting/inventory program. Wright-Pat has Dragonspeak to try and decrease the dictation, but it's nonsense to see MD's sitting and typing. To the job offer said, "Thanks but no thanks". They program each patient for 1/2 hr. because the MD types for 15. They wonder why they're losing money.

If everyone just said, "No!" and stood their ground, things would change. zNo one will because they lack the "T". So what you said above? It'll continue. Until we stop treating the politicians.

So I'll ask again: If you have suggestions for topics, or a favorite you'd like to see something on, please pm me. Bear in mind that Island Dog does Stardock software, skinning and site news, and RnD does skinner spotlights.

No intent to cause anxiety, Karen. Transcription is a "gourmet" item.... no money really dedicated to it...

Hospital Administrators keep telling us that costs are rising but reimbursement isn't. The try to ditch Medical patients because they aren't reimbursed as well as the Surgical ones. Odd how the Administrator's salary doesn't drop, but sems to rise... much like the corporate ceo's they emulate, while sanctimoniously mouthing platitudes about "Patient Rights", "Centers of Excellence" at the same time their insidious, hostile and destructive management techniques turn the workplace into hell.

I feel for you, k10w3.

Not so long ago there were 30-40 full-time medical transcriptionists employed by the local branch of a large high-profile multi-specialty medical clinic whose name shall not be spoken.  The annual allocated cost per physician for medical transcription, including salaries, benefits, space, equipment and supplies was approximately $30,000.

Per doctor.  Per year.

My primary hospital had about a dozen full-time transcriptionists in 1980.  Today it employs none.

With reimbursements essentially frozen at 1980 levels in equivalent dollar terms, something(s) just had to give.

Yes, DrJBHL, we owe a huge debt of gratitude to our 'friends' at the AMA, don't we?

Interesting you mention typing.  I've been personally typing my own notes since I got my first Apple IIc.  I can prepare an accurate, concise visit note, one that is actually useful to me and other physicians, in far less time than it takes to dictate a note (whether using voice recognition or transcriptionist) and review it for accuracy.  There is the bare minimum E/M fluff in there (I'm not completely stupid), but you'd be able to glean a pretty comprehensive clinical picture of any of my patients from a 3 minute review of their most recent note, which never exceeds one side of a single page.  They are Word documents printed in TIF (faxable) format and imported into the EMR, often before the patient is off premises (sorry, k10w3).

I know I've taken this a little OT, so I'll get off my horse now.

Not OT, Daiwa. I appreciate it. I do mine on iPad/AirPrint and DragonDictate app. I'm sorry too, Karen but with reimbursement rates at 1980 levels (yes, frozen since then), I can't afford transcription. Interesting how we got to essentially identical solutions, Daiwa.

Looking forward to AirPrint being capable of printing to networked printers in a Windows environment (which it was touted to do before it was released).  Not sure it will happen, cryptic as Apple tends to be (Jobs just said, 'Don't believe everything you hear' when he was asked about rumors that AirPrint support for networked Windows printers was 'dead').

http://jaxov.com/2010/11/download-airprint-installer-for-windows-7-xp-vista/

http://mobile.eurosmartz.com/products/printcentral.html 

Print n Share looks interesting, but I need to print from within a virtualized (Citrix Receiver) Windows environment to network printers (via TCP ports) which I doubt it supports.  Might grab it for other iPad printing needs, though, since I don't have any WiFi printers.