Monthly Archives: May 2014

Medicine in the Age of Mobile Technology: How Tablets Are Transforming the Patient Encounter

Medicine is becoming mobile.  Physicians, nurses and other healthcare providers must be able to quickly assimilate and react to an overwhelming stream of data.  Tablet technologies, such as the Apple iPad, have been incorporated into the workflows of many clinics, emergency rooms and hospitals.  Medical Schools and Residency programs are quickly adapting the technology for teaching.  While tablets do present some security challenges, most clinicians who are currently using them tout them as revolutionary and efficient. Moreover, there appear to be many new medical uses for tablet technologies in the pipeline that may forever change the way medicine is practiced.

Tablet Utilization:  Pros and Cons

Many hospitals are now using tablet technology to help physicians and other treatment team members prepare and interact with patients while on the move.  With healthcare reform and cost containment strategies, many hospital systems are looking for ways to streamline care and cut costs.  Potential advantages of tablet use include the ability to improve workflow on rounds, reduce staffing requirements, and increase productivity and efficiency without compromising patient outcomes.  In many centers, physicians are able to “sync” their devices wirelessly or via sync stations located throughout the hospital.  Rather than moving to a computer terminal to sit down and review labs, consult notes, test results, etc, a team can move through the hallways and discuss these findings via an interaction on the iPad.  There is virtually no downtime and less staff is required to see patients in an efficient way.  When interacting with patients in their room, caregivers can actually show them images and results and discuss findings with them.  In fact, a recent study from the University of Sydney showed that secondary review of radiology study images on an iPad was just as good as a standard LCD computer screen.  For patients, it improves education and engagement in the care plan when they are able to see an image or test result as they discuss the finding with their providers.  When patients have a better understanding of their medical problem and are able to participate in their treatment plans, outcomes improve.  Tablet technology helps facilitate this type of engagement.

Some centers are incorporating their EMR (electronic medical record) into the tablet via a mobile application and this allows for quicker documentation and immediate record of the day’s plan for the patient–available for all team members to access “real time”.  The EMR mandates put in place by the federal government have become a burden to many facilities and providers–by interfacing with these technologies via tablet technology, adoption of EMR and efficiency of documentation may improve.

As with any computerized medical record or medical application, security and HIPPA regulatory compliance are always a concern.  In addition, the small size and mobility of the iPad device makes keeping the devices in the hospital a challenge.  Although several major academic medical centers, including Massachusetts General Hospital have begun to incorporate tablet technologies into their practice, many others have not due to the cost of stocking the institution with the relatively expensive devices.  Now, many EMR companies, including EPIC (a major EMR player in academic centers) have created secure applications for tablets and other mobile devices that protect privacy and are HIPPA compliant.

Tablet Technology:  Future Applications in Medicine?

At this point, we are only seeing the tip of the iceberg when it comes to mobile technology in medicine.  Tablets are very powerful, portable, and user friendly.  I believe that these devices will become standard issue in medical schools across the country.  Rather than spending 1000 dollars per student on printed materials for a year of medical education, schools such as the Yale University School of Medicine are now issuing iPads to all students and utilizing the iPad for nearly all curriculum related materials.  According to the AAMC, tablet technology is being adopted all over the country and is being used to replace reams of learning materials on paper.  In a recent survey of medical students published in the Journal of the American Medical Library Association, most students go utilize electronic based medical resources at least once a day and over 35% use a variety of mobile devices to access information.

Applications continue to be developed that have important educational roles in medicine–apps for learning EKGs, reviewing histology, learning pharmacology and others are becoming mainstream and will likely be an integral part of medical education going forward.  A recently published study in JAMA: Internal Medicine evaluated the changes in resident efficiency when using iPad devices for clinical work.  In the study, the authors found that the utilization of mobile devices improved workflow and both perceived and actual resident physician efficiency.  In fact, orders on post call patients were placed earlier–before 7am rounds–likely resulting in improved care and more timely delivery of medications, treatment plans and orders for diagnostic studies.

For patients, tablet technologies may improve their visit experience and may help reduce medical errors.  I can foresee a clinic where patients check in for their appointment and are given an iPad to fill out forms and answer a wellness screening questionnaire prior to their visit with their primary care doctor.  With more “meaningful use” requirements imposed by government bureaucrats, these electronic screening opportunities will allow clinicians to not only meet regulatory requirements but also continue to spend meaningful time with their patients during a visit.  In addition, patients can have the opportunity to review imaging with their clinician at their side and actually “see” what the doctor is able to see.

For physicians, the possible applications of tablet technologies are endless.  Ultimately, I believe that these mobile technologies will revolutionize medicine and allow for care to be provided to patients who have previously been underserved.  Tablet based electronic patient encounters are on the horizon.  As physicians we must ensure that we continue to embrace technology and we must not resist change–medicine remains both a science and an art.  We must continue to strive to incorporate BOTH technology and human touch into our patient encounters.  Change is coming–we must adapt and embrace these technologies in order to provide our patients with the healthcare and caring that they deserve.

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Healthcare Industry CEOs and the Cost of Care: Too Many Men (and Women) in Black (Suits)?

Healthcare reform is a reality.  The ACA and its associated mandates have forever changed the landscape of medicine in the US today.  The Obama administration touts the goals of reform as providing affordable, cost effective, high quality care for all Americans.  Certainly these are noble and lofty goals–but have we completely missed the mark?  Today, many remain uninsured and the majority that have signed up for the exchanges are simply those who have lost their healthcare coverage from other providers.  Healthcare costs in the US remain above those of all other industrialized countries while physician salaries in the US continue to fall.  Even though the US spends more dollars per capita on healthcare than any other country on earth, our outcomes, when compared to other nations,  remain mediocre at best.

What about cost?  Who is actually delivering care?

Over the last 30 years, hospital administrators and CEOs have grown by 2500% while physicians have grown by only a modest amount.  In fact, according to the American Academy of Family Practice, there must be a 25% increase in primary care doctors over the next 10 years in order to keep pace with demand.  Multiple independent surveys (published by the AAMC) indicate a significant shortfall of all types of physicians nationally by the year 2020.  As administrators and insurance company executives grow, hospital staff and services continue to be cut—nurses and doctors are asked to care for more patients with fewer resources.  Executives continue to tout savings within their organizations and boards award these administrators with enormous financial bonuses.

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Source :  BLS and Hammelstein/Wool handler

Where are the Doctors in all of this?

The short answer is that physicians are caring for patients and managing the piles of paperwork that the government and other healthcare organizations and executives have created for them.  Doctors are now consumed with checking boxes, implementing EMRs and transitioning to a new coding system for billing—all while seeing increasing patient loads and meeting increasingly steep clinical demands.

This week in the New York Times, Elisabeth Rosenthal penned an article that spells out what many physicians have known for a very long time—the administrators and hospitals are the high wage earners–not the doctors.  As the numbers of administrators continues to rise exponentially, many independent physicians and physician groups are being driven to integrate with or leave practice altogether in order to remain fiscally viable.  According the the Times, the salaries of many administrators and CEOs (in both the hospitals and the insurance industry) are outpacing salaries of both general practice physicians, surgeons and even most specialists.  Astronomical wages such as those earned by Aetna’s CEO (total package over 36 million dollars) and others are a big contributing factor to the trillions of dollars that we spend on healthcare each year.  According to the New York Times, healthcare administrative costs make up nearly 30% of the total US healthcare bill.  Obviously, large corporations and CEOs will argue that these wages are necessary to attract the best and brightest executives to the healthcare industry.  What is there to attract the best and brightest scientists to medicine?  Certainly altruism is a big part of what physicians are about but economic realities must still come into play when bright young students are choosing careers (while accumulating graduate and professional school debt at record paces).

Why then does it seem as though physicians are the only target for reform?

That answer is simple–hospital administrators and insurance company CEOs are well trained businessmen (and women) with MBAs from prestigious schools.  They understand politics and how to effectively lobby.  They have been actively involved in reform and have participated in discussions on Capitol Hill rather than watch the change happen around them.  When costs are cut from the healthcare expenditures, they have made erudite moves–they have worked effectively to isolate themselves and their institutions from the cuts that are affecting the rest of the industry.   While reimbursement for office visits and procedures falls to less than 50% through many of the exchanges and other government based programs such as Medicare and Medicaid, CEOs and hospital administrators continue to financially outpace their colleagues in other sectors of business.

As physicians, we must continue to focus on our patients and their well being.  Individually, we must continue to provide outstanding, efficient, quality care to those who depend on us every single day.  As a group, however, doctors must begin to work harder to influence those in Washington for change.  While healthcare reform is essential and must be accomplished in a fiscally responsible way, it is my hope that those in a position to effect change will recognize that we must begin to better regulate and limit those in CEO and administrative positions in both the insurance and hospital industries.  Just as we reduce the numbers of nurses on the floor to care for patients in order to save healthcare dollars, maybe we should eliminate a few VPs with fancy offices on the top floors of our hospitals.  Which one do you think will positively impact patients more–fewer nurses or fewer dark suits?

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Practicing Medicine in the Digital Age: Challenges & Opportunities of the Virtual Encounter

The digital age of medicine is upon us.  This past week at the opening Plenary session at the Annual Heart Rhythm Society Meetings, we heard Dr Eric Topol and others tell us that we must embrace social networking in order to engage patients and improve care.  The Affordable Care Act has now changed the landscape of medical practice in the US–we must do more to focus on preventative care and work harder to curtail costs.  More patients are insured and a primary care shortage is upon us (according to data from the AAFP).  In fact, it is estimated that we must create an additional 65 training spots in primary care every year for the next 10 years in order to keep up with the demand–this is assuming that the AAFP estimate of a 25% growth in workforce will be needed to meet the growing pool of insured Americans.  In addition, preventative services will require frequent follow up, patient engagement and support services.

Patients are more connected than ever–most patients now go to the internet to prepare for office visits and come armed with lots of information.  Office visits are already now dominated by keyboards and EMRs–it only seems logical that the next step will be virtual access for physicians and patients.  With growing primary care shortages and an increasing pool of patients needed access to care, telemedicine is likely to play a much larger role in the future.  The concept of telemedicine is not new–remote areas and hospitals have been utilizing telemedicine consults in order to provide specialist support for primary care physicians with limited access.

This week, the Wall Street Journal’s Belinda Beck reported on the growing telemedicine business–doctors seeing patients via computer portals from nearly anywhere in the world.  Several web based companies are now regularly hosting virtual doctor visits online where physicians and patients interact via phone and internet.  Patients describe symptoms and discuss issues with their virtual doctor and are then prescribed therapy–all for a cost of only 40-50 dollars.  Most visits are completed within 15 minutes and no travel is required for either doctor or patient.  Advocates argue that for simple straightforward problems telemedicine visits are much more cost effective and also provide high quality efficient patient care.  Critics have voiced concerns over the quality of care, lack of doctor-patient relationship and the over-prescription of antibiotics.  Some argue that when a virtual visit occurs, diagnosis is made more difficult due to a lack of physical exam.  In addition, data obtained by the Wall Street Journal from Rand, indicate that virtual visits are more likely to result in the prescription of an antibiotic.

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(Graphic from JAMA Internal Medicine and Published in the WSJ)

As you may expect, guidelines from regulatory agencies and medical boards are currently in the works.  Virtual physicians will be held to the same standards as in person office visits and continuity of care is being encouraged by allowing patients to choose their virtual doctor rather than have the provider randomly assigned.  In addition, the Federation of State Medical Boards is now recommending that all virtual doctors are licensed in the state in which the patient that is treated resides.  However, this particular requirement for licensing does not really make good sense if the objective of telemedicine is to provide care to those with limited access to physicians.  Virtual medicine has the potential to meet significant primary care needs in remote, rural and underserved communities and may be an alternative to in person treatment of simple, straightforward medical problems.

As we continue to reform the US healthcare system, many challenges must be met and overcome.  Providing affordable, high quality, efficient care to a growing number of insured Americans is a significant task.  With the advent of digital medicine and advancements in mobile technologies, it is now possible to provide care to patients who may otherwise remain unserved.  Wearable sensors, mobile devices that can obtain real time electrocardiograms and other technologies in development make it possible to receive diagnostic data from remote locations.   In order to be successful, we must embrace change and utilize the digital tools that are now available to provide care to those who so badly need it.
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(Image source: Screen grab via YouTube TED talk by Dr Eric Topol)