Answer to Medical Quiz

The answer is # 5:Black hairy tongue (lingua villosa nigra) may be associated with the presence of chromogenic organisms (e.g., C. albicans) and the use of certain medications (e.g., doxycycline and bismuth). The pathophysiology is thought to be due to proliferation of the filiform papillae of the tongue, which stain black with porphyrin-producing chromogenic bacteria or yeast.I take exception to

Cool Technology of the Week

Have you ever wanted to record MP3's of voice or a musical instrument? Since the iPod does not do this, the easy way to record sound is to buy a portable MP3 recorder such as the Edirol R-09, M-Audio MicroTrack or Zoom H2.

However, then you're stuck with yet another gadget that does only one thing. Why not use your existing laptop for this purpose?

I tried it and the sound quality was so bad, that I was ready to give up. My audiophile friends explained that typical microphones really need a pre-amp before plugging them into a laptop. However, I did not want to spend the money on a high quality microphone plus pre-amp.

I discovered an entirely different technology that worked perfectly - USB Microphones. These devices include a high quality analog microphone, a pre-amp and an analog to digital converter. They plug directly into a USB port and do not use the audio components of your computer at all! Here's an overview of the technology and the leading products

I purchased a Blue Snowball Microphone for $100 and was amazed by its quality. I used the Snowball with my Mac using Garage Band, my Ubuntu Linux laptop using Audacity and a Windows XP laptop using Sound Recorder. Here's a sample of my Shakuhachi Japanese Flute recorded with the Snowball.

The Blue Snowball USB Microphone - truly a Cool Technology

In my Cool Technology of the Week entry two weeks ago, I discussed the Orb. This week, our Orbs went live. Per this picture, we've placed an Orb on the CEO's desk and linked it to our Emergency Department waiting room volume metrics.

The Orb supports 35 different colors and glows Blue if no patients are waiting, Greens for 1 to 5, Yellows for 6 to 10, Reds for 11 to 20 and Flashing Red for over 20. We were able to create this fully automated "glance-able" interface in one day by simply repurposing existing Service Orientated Architecture (SOA) tools already deployed in our clinical systems. If it is successful in the CEOs office, we'll add additional Orbs and a menu of performance metrics to track.

Medical Quiz - How Smart Are you?

Which condition could cause this type of finding in the mouth? (Click on illustration to get a close up view ). Answer will be posted tomorrow.

Grand Rounds

This weeks "Grand Rounds" of medical blogs is being hosted by Prudence, MD. I'm happy to report she found EverythingHealth worth a mention in her review of the weeks best blogs. Check her out for great blogging links

The Cost of Information Technology

I'm often asked how about my budgets for hospital information systems. In the interest of transparency here it is, in narrative and spreadsheet form.

Typically, Academic Health Centers spend about 2.5% of their operating budget on Information Technology. Our budget is between 1.8-3.1% depending on what you include. Overall, we receive $37.1 million out of BIDMC's $1,195 milllion dollar budget (3.1%) but we provide services for many non-BIDMC entities which are charged back. We also provide Media Services/Telemedicine, Library Services, Telecommunications and Health Information management services (medical records). If you remove these items to create an apples to apples comparison with other academic health centers, the percentage drops to 1.8%. These percentages are mixed blessing. Although it's laudable we can do so much with under 2% of the operating budget, there are clearly opportunities to enhance operations via additional IT expenditures.

The narrative is a breakdown of direct and indirect IS costs. Important to note - it includes fringe benefits, leased space costs and utilities, and capital depreciation on IS related items. It also includes the cost of services provided to non-BIDMC sites who we charge for our service. The grand total is $59m; much higher than our net operating budget. To properly represent the cost of an application such as Peoplesoft or Email, you really need to include these expenses. At the bottom of the table, I show the revenue recovered from other entities and address some of the typical questions often asked about operating and capital comparisons.

The spreadsheet shows the IS expense for FY08 for each of our cost centers. This includes a breakdown of fringe, space/utilities, and depreciation. We depreciate everything on a 5 year basis for purposes of the allocation.

This year's $169.4m BIDMC capital includes $57.8m for our new Center for Life Sciences Research building and $23m for backfilling vacated space as researchers move into the new building. The $15.4m IS capital budget also includes $3.4m for the Center for Life Sciences build out of telecom and network services. If you remove these for both BIDMC and IS, we are 13.5% of the total. The remainder is $8.5m for infrastructure, $.5m for Peoplesoft, and $3m for Disaster Recovery.

The most difficult variable to express when comparing institutions is the quality of information systems. Quality for IS comes through reliability, fast transaction speeds, application breadth and depth, and customer satisfaction. At present, I believe that the capital and operating budgets I've provided here will result in more than 99.9% reliability, under 2 second transactions speeds in all applications, reasonable progress on our effort to be 85% electronic in all our care areas, and high customer satisfaction. As I often say, providing Information Systems is a continuous journey, so we will continue to seek additional budgets to support ever evolving user requirements.

Germs- A Traveler's Companion

I read an article about the top places to find "germs" and travel is a big exposure.I am not afraid of germs because I know they are ubiquitous and there is no way to eradicate bacteria, but having just returned from an overnight in a Hotel...I realize I have been in the midst of a virtual hothouse of germs. Think about these bacteria and virus infested environments:Hotel room remote control:

Devices for Bedside Computing

We're currently evaluating several devices for mobile bedside computing including subnotebooks (Dell D420, Lenovo X61), tablets (Motion Computing LE1600), and small form factor devices (the Apple iPhone/iPod Touch, Emano-Tec MedTab ). I will write another blog entry on stationary bedside computing devices such as wall mounted thin client devices.

Our early results are that nothing on the market yet meets our ideal requirements:
8 hour battery life
Can be easily disinfected to prevent the transmission of disease
Can be dropped 5 feet without significant damage
Under 2 pounds

Here's a list of those machines which attempt to fill the niche for mobile bedside computers

DellD420
Battery Life - 3 hours
Ability to disinfect - poor
Drop resistance - fair
Size/Weight - 8.3 x 11.6 x 1/ 3.0 pounds

Lenovo X61
Battery Life - 6 hours
Ability to disinfect - poor
Drop resistance - fair
Size/Weight - 8.3 x 10.5 x 1.4 / 3.6 pounds

Motion Computing C5 (Also known as the Intel Mobile Clinical Assistant)
Battery Life - 3 hours
Ability to disinfect - excellent
Drop resistance - good
Size/Weight - 10.0" x 10.0" x .95” / 3.3 pounds

Motion Computing LS800
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 8.94” x 6.69” x 0.87”/ 2.2 pounds

Motion Computing LE1700
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 11.65" x 9.64" x 0.74” / 3.3 pounds

Apple iPhone/iPod Touch
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - fair
Size/Weight - 2.4 x 4.5 x .46/ 4.8 ounces

Emano-Tec MedTab(a startup which is just entering the market)
Battery Life - 24 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 5.5" X 7.5" X 0.5"/12 ounces

I'm personally carrying around the Dell D420 and Lenovo X61 to assess their reliability and durability.

We're piloting 5 LE1700's in our Emergency Department. The LE1700 has a 12.1" screen size compared to a 10.4" in the C5 and 8.4" i the LS800. We're testing it with a medication reconciliation application and will soon know more about its support of clinician workflow. In general, all the Motion Computing devices seem rugged, relatively easy to disinfect, and well engineered. However, battery life is limited to 3 hours, so we'll need to keep charging stations handy throughout the department.

The Emano-tec MedTab form factor and battery life are ideal. It uses an eInk display just like the recently announced Amazon Kindle. The lack of color may be a major limitation for some applications. At present, the device is not available in large quantities, so we're testing a prototype, also in our Emergency Department.

The iPod Touch is promising. A slightly larger form factor and better power management (longer life and/or hot swappable batteries) could make this an ideal medical device. Apple's attention to human interface features really shows here, but it's clearly intended to be a device for personal, not business use. We're testing it with our Emergency Department dashboard application.

Size and battery life for laptops is not as relevant if used as a Computer on Wheels on carts. We use two kinds of carts - The unpowered Ergoton StyleView and the powered Infologix SL Ultra Cart

The hardware and software development efforts of the past few years are getting us closer to the ideal mobile clinical device. At BIDMC one challenge is the difficulty involved in secure authentication. We use secure passwords (requiring capital letters, numbers, symbols, etc) which are difficult to rapidly enter via a tablet. Solutions include biometrics (we are testing Omnipass) and novel login mechanisms such as graphical authentication.

More to come as we complete our evaluation by the end of the year. I welcome any comments on other's experiences with mobile bedside computing devices.