Should Doctors Wear White Coats?

The Doctor's white coat has been a symbol of the profession for decades.  In the 1800's and up through the early 20th Century, doctors wore street clothes while performing surgery...rolling up their sleeves and plunging dirty hands into patient's bodies.  They often were dressed in formal black, like the clergy to reflect the solemn nature of their role.  (And seeing a doctor was solemn indeed as

Heart Disease and Heart Attacks

This amazing site called Kahn Academy is just filled with information on every subject!  This video explains atherosclerosis, heart attack and heart failure.  Watch and learn.

Cool Technology of the Week

As BIDMC creates automated workflows, moving from a hybrid paper-electronic record to a completely electronic record, we are supporting multiple approaches to capture the data.   We use electronic forms, web-based structured documentation, voice recognition, PDF files with metadata that inserts them into the correct record, and scanning.

Today, Ricoh introduced the eWriter Solution, a combination digital clipboard and cloud based solution for capturing structured data such as consents, patient intake information, and home care data.   It uses an e-Ink display with WiFi/3G/GPS built in and a 20 hour battery life.

The idea is simple - when forms are created, they have an appearance just like paper using the same display as the Kindle.   A stylus is used to check boxes, add free text, sign forms etc.   Data is sent to cloud servers as PDFs, XML-encoded structured data, and pen pressure/velocity metadata to provide reliable assurance that a signature is real, should forensics ever be needed.

This approach works very well for those workflows that are highly distributed in sites without significant IT support, for workers who have an affinity for paper and find the use of iPads/iPods/iPhones a challenging learning curve, and for those tasks that easily automated through the use of pre-populated forms with largely structured responses.

Gathering signatures on pre-op consents is most often done in the community setting.  Capturing consents electronically in small provider offices via a cloud-based service makes great sense.

A wireless clipboard based on the e-ink display with cloud based services to gather structured data.

That's cool!

Why You Need a Colonoscopy

One of my pet peeves as a Physician is when people talk about screening tests "Preventing Cancer".  Mammograms, pap tests, prostate tests (PSA), X-rays, blood tests, ultrasounds do not prevent cancer.  The best they can do is detect an abnormality early and allow for treatment.  None of those tests prevent a malignancy.  There is one screening test, however, that CAN prevent cancer and that is a

Choosing a Great Single Malt

During my trip to Scotland I had the opportunity to learn more about single malts from my Scottish hosts.  If you really want to choose a great whisky, ask a Scotsman!

Andrew Morris, a Professor at the University of Dundee, and the person who invited me to Scotland, is a member of the Royal and Ancient Golf Club in St. Andrews.  For golfers, this is a sacred place, the home of golf.   Andrew is a member,  a remarkable honor since only 300 people in all of Scotland are members.   As we entered the club, I walked by the British Open trophy which sits next to the lockers of club members.   I looked at the name plate closest to me - "A. Palmer".

We retired to the "Great Room" under a painting of the Queen and asked about the single malts served by the club.   They serve two which are produced exclusively for the Royal and Ancient - an Islay (pronounced eye-lay) bottling from Western Scotland and a Speyside bottling from Eastern Scotland.    Western single malts are often more Peaty/Smokey/Earthy in character while Eastern single malts are more subtle with flavors of sherry and vanilla imparted from the casks they are aged in.   I ordered the Speyside and added just a drop of water to release the aroma.   Over 30 minutes I cradled the glass, sipping slowly to savor the amazing nose and palate.

As we left the Royal and Ancient at 10pm, people were still golfing on the 18th hole of the Old Course.

Here are the favorites suggested by the folks in Scotland I asked:

Lagavulin (Islay) - a smokey, peaty, complex  whisky  that is considered by many to be the finest single malt made in Scotland.   On most restaurant menus it commands a higher price because of its reputation and quality.

Highland Park (Orkney Islands) - a peaty whisky with a sweet/sour finish and subtle vanilla flavors.  The northernmost distillery in Scotland.

Talisker (Skye) - a peaty whisky, from the only distillery on Skye.  Robert Louis Stevenson regarded Talisker as 'the king of drinks' and who would argue with him?

There are many myths about Scotland - that kilt wearing, bag pipe playing,  freedom loving men (per Braveheart), are thrifty with their money and enjoy a wee dram in the pub on a daily basis.    I saw no kilts, heard no bag pipes, and although we did rehydrate at pubs after our hikes with fine Scottish ales, the only whisky I consumed was at the Royal and Ancient.   The Scottish are warm, gregarious, and selfless hosts.

Thank you Andrew for a remarkable experience and an amazing education about Scotland and its people.   I'll raise a toast with a freshly opened bottle of Lagavulin.

Facial Cellulitis

This 39 yer old woman had a small sore inside her nostril.  It worsened  and her nose started getting red so she was put on ciprofloxacin antibiotic.  The redness improved but 5 days into treatment two pustules developed and the erythema worsened.  A culture of one of the pustules grew out methicillin-resistant Staphylococcus aureus (MRSA).  She was treated with intravenous antibiotics and her

HIT Lessons Learned from Scotland

My trip to Scotland provided a remarkable opportunity to exchange ideas and experiences.

Scotland has nearly 100% adoption of electronic health records among general practioners and is making good progress in hospitals with innovative built/bought inpatient systems.   As in most countries, health information exchange is still evolving, but novel databases supporting disease management at the community level and an emergency care summary exchange are already live.

Here's what I learned while in Scotland

1.  Scotland has 5 million people - about the same size as Massachusetts.    There's a real "can do" attitude that makes significant change at the national and regional level possible.

2.  General Practictioners are passionate about IT.   There are 2 major electronic health records (Vision and EMIS) used in ambulatory settings in Scotland.  I was able to test them with demonstration patients and they seem to be a bit more focused on creating a journal of patient health events as compared to EHRs in the US which follow the Meaningful Use paradigm of structured problem lists,  e-prescribed medications, allergies, notes/reports, and coded diagnostic results.

3.  Healthcare information exchange between EHRs and hospitals is document centric.   My limited experience suggests that clinical encounter summaries in Scotland are shared via episode of care documents rather than structured data element exchange.

4.  There is a national healthcare identifier which enables records to be coordinated and aggregated in a national emergency care database, registries, and for continuity among caregivers.

5.  The National Health Service provides comprehensive care across all settings and therefore can drive innovation and adoption across the country.

Scotland has many of the same healthcare challenges as the US - increasing obesity, earlier onset and increased numbers of diabetics, and the worldwide issues of tobacco and alcohol use.  

Through the use of careplans/guidelines, registries, electronic health records, and care coordination across the community, Scotland is hard at work improving public health and population health.   I think of Scotland as an extraordinary testbed for healthcare IT implementation.  With its high adoption of EHRs among community clinicians, its bottom up approach to creating automation to meet the need of hospital stakeholders at a local level, and its population size that makes implementation doable, I highly recommend that vendors partner with Scottish healthcare provider organizations to test innovative solutions which can then be spread throughout the world after successful pilots.

Thanks for Andrew Morris and the University of Dundee for hosting me.  I look forward to our further work together.