Using Social Media in Moderation

True love. Image by © Zero Creatives/cultura/Corbis
True love…
Image by © Zero Creatives/cultura/Corbis

I’ve been backing off from social media recently. For someone who writes a blog as well as publishing medical apps this may appear to be a risky tactic. In truth this retreat has not been completely voluntary. Something known as “real life” has been seeking my attention and gotten in the way of my online life interactions.

My fascination with social media has always fallen into the “love-hate” category. Maybe “addiction” is a more apropos word than fascination.  Social media addiction has supplanted the previous generation of technological addiction, television. Probably a similar fascination or addiction existed when radio was the dominant medium, but I don’t go back that far. The first reaction to television was amazement: “wow, there are moving pictures on the screen.” It didn’t matter that there were only 3 channels in black and white (later expanded slightly by adding fuzzy, low-budget local programs on UHF).  Nightly TV viewing became a dominant part of American life in the 50s and 60s. With cable, the number of channels rose, but the signal to noise ratio decreased. TV viewing, passive and mindless to begin with, only got more passive and more mindless. Yet the TV addiction, once begun, could not be shaken, at least not until a stronger drug/soporific became available. I’m afraid that stronger drug is social media on the Internet.

Just as voices decried the huge number of hours that the average American sat in front of the TV set in the past, so too some voices have expressed concern over the tightening grip of social media. There is a lot of good that social media does. It brings together geographically separated folks of similar interests. It is much more active than watching television: people text, message, tweet, post, and blog. But by the same token it is much more seductive — and more readily available, now that everyone carries a smart-phone. Despite social media’s mostly bland and not terribly informative content, withdrawal is difficult. There is anxiety about missing interesting tweets or Facebook posts. By nature of  the sheer volume of social media output, the occasional stuff that you might be interested in gets buried in the background noise of cat and baby pictures. So you end up either checking your Twitter or Facebook feed several times a day or living in fear.

Yet somehow the world went on before this torrent of social media posts, and we were none the poorer for its absence or at least living in blissful ignorance of what we were missing. It depresses me to see people walking down the street with their faces buried in their phones, or seemingly talking to the thin air, ignoring what is going on around them; or two people at lunch, staring down at their phones, not talking to each other. How social is social media if it actually decreases our sociability with each other in real life? I am not a Luddite and I don’t want social media to go away completely. Maybe just sometimes. Let’s not lose the delight of person to person conversations over dinner or lunch.  Taking a break from social media, whether due to life events, being out in the middle of the ocean somewhere away from WiFi, or just voluntarily chosen, can be a refreshing, mind-clearing act.  And the real world has a higher pixel density than your iPhone screen.  Take a look!

Is a Mobile Electronic Health Record Possible?

Looking for missing meaningful use button clicks.
Looking for missing meaningful use button clicks.

It’s been a while since my last rant about Electronic Health Records (EHRs), so let’s remedy that right now. EHRs in their current iteration are — how to put this delicately? — an unmitigated disaster. Nevertheless, much of the criticism of EHRs, including mine, has been in the destructive category. What about some constructive criticism? How could EHR software be made better?

I am not familiar with every EHR system out there. In fact my experience is pretty much limited to one system, which shall remain nameless, though I will give some clues as to which EHR I mean: its name contains four letters, two consonants and two vowels; the name has no pure rhyme in the English language, though it does have some near rhymes, such as the word septic; and the software is under the delusion that it is running in hyperspace, which may indicate that the programmers possess a sense of humor. There, I hope I have been obscure enough so I don’t get into trouble like I did before.

Current EHRs were developed before the mobile revolution, and it shows. Sure there are some mobile clients available, such as the puzzlingly Japanese named mobile app for the above-not-mentioned EHR system, but these mobile apps don’t match the functionality of the parent application, and, at least in my experience, have been virtually useless. It was possible though not practical to run the full EHR application in a virtual machine on a tablet.  Being a Windows based program, it was necessary to have various awkward, non-intuitive gestures in order use it, for example, in order to right-click. This was not a natural interface for an Android or iOS tablet though possibly a Windows-based tablet, such as the Microsoft Surface, might work better. I don’t have experience with the Surface, so I just don’t know how much it would help.

Having your EHR running at full functionality on a mobile device is very important for a number a reasons. First, every doctor already has a mobile device of some sort. Second, the alternatives to mobile devices are immobile devices, i.e. desktops, which take up a lot of space, are expensive, are constantly breaking down, and are apt to have security issues, such as the doctor forgetting to log off, thus exposing sensitive patient information to the next person who sits down at the computer. Remarkably, the desktop route seems to be the norm for hospital EHRs, with doctors queued up during busy rounding times waiting to get on a computer. Third, doctors are inherently mobile. In the hospital they go from room to room when they round. It is much more efficient to carry one’s EHR with him or her and just go from room to room than it is to go to a room, return to the nurses station to type into a desktop computer, then go to the next room and repeat the process. Having a truly mobile EHR would avoid the constant trips to the nurses station.  So why can’t an EHR fit into a mobile device?

One reason is that present EHRs try to be all things to everyone.  They are not just for record retrieval and note taking. No, they contain everything and the kitchen sink. The same EHR used by the doctors is used by the admissions office to check in a patient.  You may have no reason to enter anesthesia notes or insurance information but your EHR seems to want to do all that and more. Rather than breaking down EHR functions into different tools for different user roles, all functionality is combined together into one megalithic beast. Such a beast simply can’t fit into the mobile form factor. So we are left with the antiquated desktop computers, taking up precious space in the nurses stations, with quaint, 1990s style user interfaces that would rouse feelings of nostalgia if they weren’t so frustrating to use. And don’t get me started on the do-nothing “click-me” buttons that are required for “meaningful use.”

We used to have mobile record-keeping systems in medicine. They were called “charts.” Sure they were bulky and unwieldy, and often all the information that we wanted was not in them (most egregiously missing were X-rays). Nevertheless they were relatively portable, could be stacked on a mobile rack, and a doctor could go from patient room to room without having to return to the nurses station (other than to get a cup of coffee). Data input was via a pen, which is actually a very quick, if sometimes illegible, way to enter data. For all the deficiencies of such a primitive record keeping system, it was fast, productive, and allowed more face time with patients — qualities that current EHR systems don’t possess.

So, a well-designed EHR system — something that I don’t believe exists today — would take that old-fashioned model and make it work on a mobile device, such as a tablet. The doctor could go room to room, pull up the patient data, and then record, either by writing, dictating, or typing, a note. The key to making data input work on a tablet is brevity. Get rid of all the garbage that is automatically sucked into a progress note by today’s EHR systems: lab reports, X-ray reports, 12 point reviews of systems, accumulated cruft from old notes. If you look at the notes generated by these EHRs, the amount the doctor actually enters is typically very small. It is contained in the history section which often simply says something like this: “no change” and in the plan, which may be “s/p PTCA, discharge tomorrow.” All the other debris in the note is added merely to satisfy the coders and billing personnel, who will freak out if there the note isn’t long enough (low complexity of patient care, missing review of systems, etc.). They don’t really care if it is all just cut and pasted from the admission history and physical, as long as all the components are there for them to check off. As I have argued elsewhere, the close coupling of billing and documentation has to change in order to alleviate the current EHR disaster.

A useful EHR system is possible. For it to happen the current desktop-based model has to be thrown out.  We need to start over and develop a truly mobile EHR. One suggestion: get the input of doctors when designing an EHR. Now there’s a novel idea!

Mr. Toad’s Wild Ambulance Ride

Another Mr. Toad.  Picture in public domain.
Another Mr. Toad. Picture in public domain.

(Another American health care fable)

The ambulance siren wailed loudly and the madly rushing vehicle careered through the narrow streets. Time was of the essence, as is always the case when a life is in danger.

The occupant, the center of attention of the concerned paramedics, grasped the side-bars of the stretcher. The violent gyrations of the speeding ambulance weren’t helping the pain in his chest or the rapid pounding of his heart.

Just a few minutes before, he, Joseph Toad, a 60ish wealth manager, aiming for retirement in a couple of years, had been at a Starbucks near his office downtown, drinking coffee and waiting to meet a client. Little did he know that events out of his control were about to coalesce into a “perfect storm” of platelet adhesiveness, inflammation, and hypercoagulability. It was Monday. It was morning. He was male. He was 60ish. He had a Type A personality. His father had died when 60ish of a sudden heart attack. He had a big, stressful appointment with an important client coming up. All risk factors for coronary thrombosis. And so it happened.

The ambulance arrived soon after the Starbucks baristas made the 911 call. Electrodes were applied, IVs were started, nitroglycerin was given. The pain in his chest was still sitting there, like the proverbial elephant. It was imperative that he be brought to a hospital in short order.

Despite his chest discomfort, the seemingly reckless ambulance ride was taking even more of a toll on his nerves. “Slow down!” he suddenly shouted.

One of the uniformed paramedics turned to him. “Don’t worry,” he said, glancing up at the rapidly beeping cardiac monitor. The hint of fear in the tone of his voice did little to allay Mr. Toad’s concerns. “We should be at the hospital soon,” he added, trying to be reassuring.

“I’d like to get there in one piece,” Mr. Toad said in a mildly reproachful, joking manner. To take his mind off both the wild ride and his chest pain, he sought to continue the conversation with the paramedic. “Why is it taking so long to get there? We surely must have passed some hospitals by now.”

“Well…no,” replied the paramedic, whose name Mr. Toad could not make out on his name tag. “I think if you’ve lived in this town for any length of time you’d know that all four hospitals are located in the East End of town, within a quarter mile of each other.”

“I hadn’t given it much thought,” stated Mr. Toad. He himself lived in the East End. It was the wealthy part of town. Of the competing hospital systems in town, all had wanted to locate their hospitals closest to those clients who had the best insurance, and the greatest ability to co-pay. Being a wealth manager by profession, this strategy certainly made sense from the economic, if not humanitarian point of view. Mr. Toad briefly cursed the bad luck that had led him to have his heart attack while downtown and not at home, close to a hospital.

“Wait!” he exclaimed, struck by an idea. “What about the University Hospital? It’s downtown. It’s closer.”

Both the paramedics next to him snickered a little at this suggestion. The one who hadn’t spoken yet said, “I’m sure you wouldn’t want to go there. You are nicely dressed and trust me you wouldn’t fit in with the clientele at the University Hospital. Patients there are over 90% Medicaid, Medicare, or indigent. You wouldn’t fit in at all.”

“Besides,” the other paramedic chimed in, “our ambulance service has a contract with several of the Big Players in Healthcare in this town. We’re better off going to one of their hospitals.”

“Better for whom? Me or you? I’m the one with the heart attack!” shouted Mr. Toad. This wasn’t good for his blood pressure, which was rising.

“Whoa, sir. Calm down. My partner here is going to give you a little shot of morphine. That should help relax you and help you with that pain. Your condition looks pretty stable at this point. You will be better off taking a little longer ride, since the East End hospitals have state-of-the art heart cath labs, state-of-the-art equipment and state-of-the-art doctors. Door-to-balloon times are as short as anyplace in the country. At the University Hospital you would be treated by docs just out of medical school, or still in medical school. They probably wouldn’t take you to the cath lab at all. Maybe they’d just give you a thrombolytic, you know, a clot-buster. But that usually doesn’t work. And then you’d be in some ward with four other people, homeless types. And no TV.”  While he was talking the other paramedic prepared the injection and then gave the morphine through the IV.

Mr. Toad calmed down somewhat, though whether it was from the medication or the paramedic’s attempts at reassurance he couldn’t be sure. It still bothered him that by going to a more distant hospital there might be more of a risk of his dying during the ambulance ride. But he supposed they had all the equipment to revive him here in the ambulance if needed. Being a wealthy man he did admit to himself that he would prefer a private room to being in an open ward, and he knew that in the long run he would get better care if he got it in one of the fancy East End hospitals.

For a while he was silent, lost in his thoughts. The pain was not gone, but was down to a 3 out of 10, to use the pain scale the paramedics had taught him. The ambulance sped onward…

One of the paramedics was talking into a microphone. “What’s going on?” Mr. Toad asked.

“We’re radioing ahead to the EDs, you know, the emergency departments,” the other answered. “Sometimes one hospital cath lab is occupied, or there is a bed crunch and the hospital is on divert. Since we have a choice of four different hospitals, and they are all within a block of each other, we have a lot of options.”

“And I suppose you are letting them know my condition.”

“Well, they know you’re having a STEMI — that’s a serious heart attack — and, believe me, they know what they have to do.”

Again Mr. Toad felt reassured. They had to be close to the hospital now, and relief from his pain was probably not far away. Now that it was almost over, the long ambulance ride probably had been the right thing to do after all.

“Problem?” one of the paramedics asked the one at the radio.

“Yeah. Sts. Elizabeth and Bartholomew has closed off one of their cardiac units. They’re upgrading their TVs to 60 inch screens. They’re full and begging us not to stop there.”

“Too bad, probably shortest door-to-balloon time there, but check with Latter-Day-Saints, Haussmann Plaza, and HumanCare.”

Mr. Toad wasn’t really medically savvy, but realized the door-to-balloon time had something to do with how quickly his heart attack could be relieved. He knew that somehow the doctors used a catheter to put a balloon in the blocked artery and blew up the balloon to open the blockage. They then would place a metal stent to keep it open. He had watched something about this on the Discovery Channel, never realizing the information would apply to him.

There was no cause for alarm, but he found the morphine was wearing off, and his pain level was now a five.

“Damn!” the radio-operating paramedic exclaimed. “HumanCare is on divert too. Apparently they’ve been overloaded because of the shut down unit at Saints E and B.” The other paramedic also cursed under his breath, and quickly moved up to the little window at the front of the cab, where he communicated this information to the driver. In response, the vehicle braked suddenly and changed course.

“Heading around the block. Still have a couple more choices,” he informed his patient.

There wasn’t enough time to radio ahead, as they had already arrived at the Haussmann Plaza Hospital ED. The doors at the back of the cab flew open and the paramedics prepared to slide Mr. Toad’s stretcher outside. Looking out the open doors, Mr. Toad could not help but be impressed by the view — despite his mounting chest discomfort. Was it a 7? An 8? He began to wonder what difference it made. Still the view grabbed him and distracted him from his pain somewhat.

Haussmann’s was a glittering glass spire, the newest and most modern hospital in town. He remembered reading about it in the paper. It had the works. All private rooms of course. Amazing views out the huge windows. A huge ornate chandelier of Venetian glass adorned the spacious lobby. World famous chefs manned the wonderful kitchen where gourmet meals were the routine. Huge wall-mounted flat screen TV sets, with hundreds of channels, first run movies, and interactive video games. Free wifi Internet service. And, in addition to state-of-the-art traditional medicine, Haussmann’s also provided access to popular forms of alternative, or, as they termed it, complementary medicine. This included non-traditional remedies such as St. John’s Wort, Ginseng, ground up shark fins, and many herbs and spices, as well as treatments using acupuncture, chiropractic, homeopathy, naturopathy, and basically any -opathy the patients wanted. Holistic healing was the name of the game at Haussmann’s. Mr. Toad, thinking of the amenities, was happy he had ended up here.

“Whoa! Whoa, whoa, whoa, whoa!” someone shouted.

“What?” shouted back one of the paramedics.

“Didn’t you guys call ahead? Didn’t you hear?”

“Hear what?”

“Man, the Food Network’s here today. They’re filming an episode of Cupcake Wars right here in the hospital kitchen. They’re got the hospital Chief Chef on as one of the three judges!”

“Yeah, so?”

“So the place is shut down until tonight. In other words, we’re on divert big time right now. In fact, one of the show’s producers is taking some outside shots and wants your ambulance out of the picture, pronto.”

“Listen, we’re got an acute STEMI in here and he’s not thriving, if you know what I mean!” shouted the paramedic.

“Listen yourself. There’s a bunch of other hospitals within walking distance. Now shove off. Bobby Flay’s around here somewhere and he’s not going to be happy to see you.”

In a matter of seconds the paramedics had jumped back into the cab and the doors were shut. The ambulance took off with a screech of its tires.

“Hotchelds,” the two paramedics said, almost simulataneously.

“What?” muttered Joseph Toad. He was feeling a little dizzy, like maybe he was slipping into shock. He didn’t know what was going on, because he wasn’t a doctor, but he didn’t feel good.

“Hospital of the Church of the Latter Day Saints,” one them said. “It better not be on divert.”

“You going to call ahead?” one asked the other.

“Nah, what difference would it make. We don’t have any other options. And here we are already anyway.”

Once again the doors flew open and this time Mr. Toad was out of the ambulance before anyone could object. In moments he was inside the Emergency Department. The two paramedics were rapidly talking to a triage nurse. The nurse took down a few notes and then came over to Mr. Toad.

“Hello I’m Nurse Kelly, the triage nurse. I hope you’re having a good day. Tell me what hurts.”

“It’s my chest, nurse. It’s been hurting for more than an hour now. It’s taken a long time to get here because the other hospitals were on divert, and I’m worried my door-to-balloon time is going to be too long.”

The nurse smiled. “Oh, I wouldn’t worry about that. The door-to-balloon time only started when you went through our door, which just happened. It’s supposed to be under 90 minutes, so we still have plenty of time.” She brought up her clipboard and a pen. “There is some paperwork we need to complete, some documents and consents you need to read and sign, and we need to make you fully aware of this hospital’s compliance with the HIPAA law.”

“Please, nurse, get me a doctor right away,” Mr. Toad begged. “I think I am dying.”

The nurse looked serious. “Of course that is very serious. I always get worried when a patient says they think they are dying, because, nine times out of ten, they do. It’s like some kind of self-fulfilling prophecy. Look, we’ll skip the unimportant paperwork until later. I just need one crucial bit of information from you.”

Mr. Toad did not look good, even to a lay person. His skin was gray and clammy. His heart rate which had been fast was suddenly slowing down markedly. His pain felt like something trying to burst out of his chest, like the monster in the movie Alien. Weakly he responded to the nurse. “Anything, anything you want. But quickly please.”

“Of course, sir. Do you have your insurance card with you?”

Mr. Toad groaned, but somehow was not surprised by the question. He managed to pull his wallet out and get the card out. He handed it to the nurse.

“Oh,” she said. “Oh, oh, oh. This isn’t looking good.”

Mr. Toad thought she was referring to his condition, but she wasn’t.

“I’m sorry sir. You should have informed the ambulance personnel what insurance you have. We pulled our contract with National Happiness Insurance a month ago. They wouldn’t come to our terms in the contract negotiations. It’s a tragedy really. I had a lot of very nice patients with that insurance.”

Mr. Toad was speechless.

“But, good news. There are 3 other hospitals within a quarter mile of here that take National Happiness. According to federal law, in this situation our duty in the Emergency Department is to stabilize the patient so that he or she can be transferred to a facility that can provide longer term care.” The triage nurse took a quick gander at Mr. Toad, who at this point was beginning to lose consciousness.

“Good Lord, we don’t want an arrest on our hands.” She waved to the paramedics who were still there, having a cup of the awful ED coffee as was their usual practice after dropping off a patient.

“You there. We don’t take this man’s insurance. He can’t stay here.”

The two paramedics rushed over, grabbed the stretcher, and in a moment Mr. Toad was back in the ambulance. The third paramedic, who was the ambulance driver, started the engine and turned the flashing lights and siren back on. One of the other paramedics moved up to the little window that connected the cab of the ambulance with the driver’s compartment.

“University?” asked the driver.


Lanark — A Life in Four Books

Lanark by Alasdair Gray
Lanark by Alasdair Gray

Sometimes a statement that is ridiculed still bears a kernel of truth. The Internet really is a “series of tubes” — tubes that I tend to journey through frequently without a clear destination, much like the “mystery tours” my wife and I will sometimes take in our car. Sure, these wild expeditions may be considered by some to be a waste of time (or gas). Nevertheless, sometimes Brownian motion can lead you to unexpected discoveries.

One such Internet tube which is often the starting point for my random walks is the tube known as YouTube. Hidden among the various Trololo songs and Hitler Downfall parodies in YouTube are some real gems. Things like Christopher Hitchens in debate, Juya Wang concerts in high definition, Cab Calloway performing at his peak, episodes of The Thunderbirds (F.A.B!),  Gigliola Cinquetti singing Dio, Come Ti Amo, Marc-André Hamelin, Helene Fischer, Shirley Bassey, Renée Fleming, — the list of stuff to watch and listen to is virtually infinite. I have discovered a lot by surfing through YouTube.

And so it was that I looked up a favorite author of mine, Iain M. Banks. Unfortunately Banks died last year, of gall bladder cancer. He was a Scottish author, living on the shores of the Firth of Forth. He wrote both main stream fiction and science fiction. Most of his science fiction features a future galactic society known as “the Culture,” a near-utopia where there is no longer any want due to advances in technology. However humans, despite living the good life, are not their own masters, as artificial intelligence in the form of super-smart “Minds” has far outstripped human intelligence. The science fiction stories and novels of Banks are rife with clever plots and a wry sense of humor.

On YouTube there is the terminal interview with Banks, done at his home by a BBC reporter. The interview was done just a couple weeks before he died. Much like Christopher Hitchens, a fellow atheist, Banks shows little overt concern about his coming demise and indeed jokes about it. It is remarkable to see such sanguinity in the face of imminent death. But this post isn’t really about Banks (but go read his stuff anyway).

No, this is where the tangential nature of the Internet shows its face. In the midst of the interview with Banks, there is discussion of the novel Lanark, by Alasdair Gray. From the discussion it was clear that Banks admired Gray and this novel in particular. A little further reading on Wikipedia, and I found that Lanark is considered by many as the best novel written by a Scotsman in modern times. Being half a Scotsman myself, I was intrigued.

I am not a particularly fast reader, but I do read continuously and I am getting on in years, so I have read a lot. Much of what I have read may be considered by literary high-brows as trash: pulp fiction from the 1930s like Doc Savage or The Spider, however to counter this I have also read and enjoyed a lot of books that no one would consider trash: everything by Thomas Hardy from Desperate Remedies to Jude the Obscure, for example, or the works of all 3 of the Bronte sisters (yes, even Anne Bronte’s 2 novels) to William Makepeace Thackeray. I am somewhat of an omnivore when it comes to books, able to appreciate both Edgar Rice and William S. Burroughs. So, realizing that there was a great novel out there that I hadn’t read, by a Scotsman to boot, I went ahead and downloaded Lanark to my e-reader (which is just my phone at this point, my Nexus 7 tablet having kicked the bucket).

Lanark is a strange work. It contains the stories of two characters, seemingly unrelated, but possibly the same person. The character Lanark lives in a nightmare world, the city of Unthank, possibly in our future, but a future that is frankly psychotic. The characters are grotesque, à la Dickens or Mervyn Peake. Nevertheless the world of Lanark is certainly allegorical, with components paralleling our own governments, technology, and corporations. The satire is biting and scathing. Gray lists his own influences in the book (referring to these influences as “plagiarisms”), but the net result is certainly unique. There is a mixture of horror, humor, and pathos. Poor Lanark is unlucky in love and not appreciated, to say the least!

The other character is Duncan Thaw, who, as Gray himself admits, is largely autobiographical. Thaw’s story takes place in post-war Glasgow, and there are no fantastic elements to it. It is a story of an awkward adolescent, artistic to be sure, but also unlucky in love, unappreciated, and doomed by his own obsessions. It is touching, painful at times to read, and sad. But goodness, so well-written!

What is the connection between Lanark and Thaw? It’s not clear, though there are hints they are the same character (e.g. the sea-shells in Lanark’s pocket; Thaw’s last scene occurs on a beach). Gray plays with the structure of the novel which is in 4 sections. Books 3 and 4, the parts dealing with Lanark, wrap around Books 1 and 2, the parts centered on Thaw. Yes the order of the books is really 3, 1, 2, and 4. In addition there are similarly displaced Prologue and Epilogue, neither coming in the usual spot. At one point Lanark actually meets the book’s author, which is one of the funniest and strangest parts of the book. Following this there are footnotes referencing past and future chapters and characterizing the various “plagiarisms” supposedly present. Don’t skip those footnotes referencing future chapters because you are concerned about spoilers. Some of the oddest and funniest footnotes refer to chapters that don’t even exist in the book.

So what to make of this large (590 pages) book, first published in 1981? Like most great books, it is sui generis, a tour de force that is not repeatable. It was Gray’s first novel, taking 22 years to write, and none of his following works have been as popular. Inspired by Kafka, Goethe, Melville , H.G. Wells, William Blake, Dante, Vonnegut, as well as a slew of other authors that Gray lays out in a postscript, it nevertheless bears little resemblance to any other book I have read.  Despite the surrealism of the Unthank chapters, it is the very human and sad life of Thaw in the dreary city of Glasgow that is the most touching and memorable portion of the novel.

So I thank Iain Banks, not only for his wonderful novels, but also for leading me in his last days to Alasdair Gray and the marvelously bizarre Lanark.

Dark Clouds for the Sunshine Act

I finally decided to review my Sunshine Act data.  We are in the period of time when the data can be reviewed by physicians and disputed if necessary.  On September 30 the data will be released to the general public.  The data in question is a list of payments (whether food and drink, honoraria, travel expenses or whatever) submitted by drug and device companies for the previous year.  Theoretically the cost of every bagel or donut is counted and will be displayed on the web.  I don’t consider myself a major consumer of such resources, but it only seemed prudent to check out what was listed under my name before everyone else sees it.

Just getting to the data is not easy.  There is a 2 step registration process outlined here.  The instructions are contained on a 42 slide powerpoint presentation.  Undaunted, I plunged ahead.  During part of the process, I was asked questions like “where did my last bank loan come from” and other private information that I had no idea CMS would have in their files.  In another part of the process, there was a 15 minute time limit to answer the questions correctly.  Knowing your NPI number and your practice specialty code (this could easily have been a drop down list — I ended up googling the code) is necessary.  As we shall see below, all this caution to make sure that the person registering was actually me was a waste of time.

So, with the weary but satisfied feeling a hacker must get when finally breaking into a bank’s web site, I was finally in and the main screen confronted me.  Problem was it wasn’t clear what to do next.  After clicking around and getting cryptic error messages such as this one:

What the...?
What the…?

I finally got to where I needed to be.  But the spreadsheet I encountered was full of payments from drug companies I never dealt with.  After tediously viewing the details of each entry, I discovered that my data had been freely mixed with another doctor with my name who practices in Florida.  This despite having different addresses, different middle names, and, importantly, different NPI numbers!  Because of confidentiality concerns I won’t include the screenshots.  I ended up going through each and every entry and had to dispute at least half of the entries as being for the wrong physician.

A whole page of erroneous data
A whole page of erroneous data

Given my experience, I encourage everyone to check their own data.  I doubt I am the only one who has mistaken data.  All this could prove a huge embarrassment to physicians when the data is posted to the public on September 30th.  In reality it should be considered an embarrassment to CMS that they could make such a fundamental error.  It’s bad enough that we have to have this data posted (wouldn’t you like to see a similar database for congressmen?).  Since it’s now likely that it isn’t accurate only makes it worse.



When Downloads Take a Century


Back in the good old USA and the first thing that smacks me in the face is how bad my Internet service is. In Paris, France I clocked my Internet speed at 66 Mbit/s. Here in Parker, Colorado, just south of Denver, a major center for telecommunication companies, I clocked my speed at 0.93 Mbit/s. That’s not a whole lot better than a dial-up modem (remember those days?). That’s YouTube in low resolution mode, with lots of stuttering and buffering. That’s a no to Netflix and HBOGo. I would call this Third-World Internet service, except the service in the Third-World is probably better. The US is sorely lagging in providing good broadband service compared to Europe, for instance. In the face of this miserable service, huge internet service providers (ISPs) like Comcast and Time Warner Cable want to merge.  Sure, let’s see how much worse they can make their service!

My ISP is CenturyLink which provides Internet via DSL. There is no alternative provider where I live (Monopoly, anyone?). On their website they boast about their amazing connection speeds. But according to CenturyLink, the fastest service I can get in my home is a measly 1.5 Mbit/s, which they claim is what I am getting now. They blame my 0.93 Mbit/s measurement on other factors, like server speed. Right. I’m sure at 1.5 Mbit/s the rate limiting step is the server on the other end of the connection. Not that it matters. A full 1.5 Mbit/s is no cause for jubilation.

I have used this ISP and its predecessor QWest for the last 10 years. The connection speed has always been about 1 Mbit/s. When I have complained in the past about the slow speeds, they have said I would have to wait until they upgrade their lines. I have been waiting 10 years. So I wrote a nasty letter to them suggesting that their CEO, Glen F Post III, might consider parting with some of his $13.74 million per year salary  in order to “upgrade their lines.” I also filed a formal complaint with the FCC stating that CenturyLink misrepresented their connection speeds and weren’t doing anything to improve the speeds. Regarding this complaint, I just received a copy of the reply CenturyLink sent to the FCC. The letter states that Century Link advertises their “internet speeds as ‘up to’ the designated speed.” They then blamed the slower speed I was getting on “the latency of the internet as a whole” even though the speed test I was using was their very own speed test on their website. They then went on to say that “in reviewing this case with its DSL Escalations team, CENTURYLINK facility records have determined that the complainant’s premise is too far from the central office to qualify for a higher internet speed.”  Actually my “premise” is 1 mile outside the city limits sign of Parker, Colorado, a town of about 47,000 people, located 20 miles from Denver, Colorado, a city of about 650,000 people which sits in the middle of the Front Range area, which has a population of about 4.5 million people. So not really in the middle of nowhere, as one might assume from this letter. Yet surely there must be plans in the works to upgrade the infra-structure?  Not according to the letter: “Engineering records do not show the area on the list of upgrades for fiscal year 2014. CENTURYLINK will continue to monitor the area and apprise the consumers of any change in status.” Well, that’s reassuring.

The US government has invested heavily in the ISPs, who promised to bring broadband speeds to rural America (yes, living 20 miles from where the Denver Broncos play is rural America, at least in the eyes of my ISP). They have failed to deliver on this promise. This article  explains why. In brief, in exchange for propping up the virtual monopoly status of the ISPs, these same ISPs were supposed to invest in “the final mile” — improving the infra-structure to allow faster connection speeds. Other governments, such as in Europe, took to investing themselves in the Internet infra-structure, with results that far outstrip what is seen here. Of course you may live in a well-served area and might be getting great Internet service already. If so, consider yourself lucky. Not everyone is so fortunate.

So when you hear the ISPs whining about the need to overturn net neutrality, keep in mind that they are monopolies (or at best duopolies in some areas) who could care less about providing good service. Don’t trust them.

Maintaining Order in the Midst of Chaos

HP Lovecraft's Azathoth at the center of Ultimate Chaos.  "Azathoth". Licensed under CC BY-SA 3.0 via Wikimedia Commons.
HP Lovecraft’s Azathoth at the Center of Ultimate Chaos. “Azathoth“. Licensed under CC BY-SA 3.0 via Wikimedia Commons.

There are few jobs more chaotic than that of physician, at least based on my own experience. Yes there is a schedule of sorts: hospital rounds, procedures, office patients. Unfortunately things rarely go as planned. There is a particularly sick patient on rounds who needs a temporary pacing wire placed. There are more consults than expected. The procedure that was planned to take up to 2 hours takes 4 hours because of unexpected difficulties. Office patients are double booked. And then there are the phone calls. Referring doctors wanting advice or asking if a particularly tough patient can be seen quickly in the office. Nurses calling to clarify orders or to tell about a patient who isn’t doing well. Calls from Medicare or insurance company minions asking why a particular patient was still in the hospital and hadn’t been discharged yet. Other non-patient care related duties take up precious time. There are hospital staff requirements to take infantile online courses on Hazmat or Fire Safety. There are recurring CME (continuing medical education) and new MOC (maintenance of certification) requirements. Finally, believe it or not, doctors usually have a family life too. There have the same school concerts, hockey games, and sick kids that other working parents deal with.

As there are only 24 hours in a day, the net effect of all this running around was that I was perennially late for everything: late in the office, late for procedures, late, late, late.  I myself hate going to an appointment and waiting.  Most of my patients were understanding and good-natured about it, which only made me feel more guilty about being late.  But there didn’t seem to be much that I could do about it.

When things got really busy, interruptions would themselves have interruptions. For example, while writing my patient documentation in the office on my computer, my medical assistant would come in to talk to me about a different patient. While talking to her, a phone call would come in. I would take that call, then go back to the conversation with my MA, then finally back to the patient documentation — at least in theory, assuming I hadn’t forgotten where I was. This interruption process was so common that I began to analyze it — being the geek that I am — in computer terms. Computers also have “interrupts.”  A computer will be processing some task, say sorting a list, when you press a key on the keyboard. This generates an interrupt.  The current state of the task is stopped and pushed onto a certain area of memory called the “stack.” The keystroke is then processed, after which the original task is “popped” off the stack and resumed. Interrupts can also have interrupts with the result that multiple tasks are pushed onto the stack in backwards order (last in — first out).  It works for computers, but unfortunately human memory is fallible, so despite my analysis of the situation, I still often lost track of what I was doing when interrupted multiple times.  Utter Chaos!

Organization is the antithesis of Chaos. Like many people overwhelmed by disorder, I read a lot about the principles of organization. One book that I read in 2008 and that I highly recommend is David Allen’s Getting Things Done (GTD). Even if you don’t implement his entire system of organization, which is actually fairly complex, it would be hard not to come away from this book without some useful tips. A fundamental idea of GTD is to write things down. The whole GTD system is centered on having a “trusted system” to enter tasks so you don’t have to remember them yourself. This trusted system could be a notebook, index cards, scraps of paper, or, more high-tech, computer programs or apps designed to record notes. By writing everything down you can spend time actually doing tasks rather than worrying about what you are forgetting to do.

There is a lot more to the GTD system than just this and I encourage you to read the book. But even if you don’t implement the whole system, just getting things written down is a mind-lightening experience, almost zen-like. In the context of working as a doctor, I used a decidedly low-tech approach to implement a trusted system. I would have a piece of paper with me all day long — usually my hospital rounding list. I would use this to check off the patients I rounded on, adding diagnoses and billing level codes in tiny print. I would write down new patients on the list, including new consults and admissions, as well as patients I received calls about. I would write down little todo tasks, such as, check a troponin level or electrocardiogram, adding a little box that I could check when I completed the task. I could even handle nested interruptions with the list, jotting down a brief note about what I was doing at the time of each interruption so that I could resume where I left off. At the end of the day everything on the list should have been checked or crossed off, and I could discard it. Obviously my todo list often grew beyond one sheet of paper, in which case I would staple a blank one to the original. I realize that many physicians use such a system anyway, and this system is only in the most sketchy sense an implementation of the GTD system. Yet it upholds the spirit of the GTD system, which is to write your tasks down, with frequent reviews and updates.

Since I retired, I have had fewer tasks to organize and more time to develop more elaborate methods of organization. In the hectic world of medicine, nothing was faster or more effective than just writing things down with pen and paper. Nowadays, I gravitate more towards digital forms of organization. I don’t have just one program or app that I use for this. For ephemeral unimportant lists (like a shopping list) I like simple list making apps, such as Wunderlist. For entering notes or clipping webpages, I find Evernote is useful. As mentioned above, I am a longstanding computer geek and programmer. Ultimately the best organizational tool I have found is something called Org Mode which runs in the old-fashioned programmers text editor Emacs (I use that editor to write almost everything, including these posts). Unfortunately Emacs has a very steep learning curve, so I can’t recommend it (unless you too want to write computer programs). There are many other apps and tools to chose form nowadays to implement any organizational system imaginable.  So there are no excuses.  Life today is very complex and chaotic.  Everyone should work out their own organizational system and use it. With such a system, even in the field of medicine, order can come out of chaos!

Let the Sunshine In

sunshine_actYesterday I received an email from Medtronic. It was an early release version of the Sunshine Act data that they had sent to the government. The Sunshine Act, passed in 2010 but implemented in 2013, demands the collection and publication of data on payments to physicians in the form of food, travel, or other goods. This data will be made available online to the public in September of this year. Medtronic, a major manufacturer of pacemakers and implantable defibrillators, was nice enough to release to me the data on the money that they had spent on me. Below is a copy of the report.

Mann_III__David_E LN4CVKS

Perhaps a foreshadowing of what could go wrong with such a database, there is a $90.38 charge to Nancy’s Haute Affairs (I looked it up.  It is a restaurant, not an escort service) in Pensacola, Florida.  But I’ve never been to Pensacola in my life. So this charge is wrong. The rest of it appears to be lunch and breakfast stuff the Medtronic reps thoughtfully provided to our office, or to the break room at the various cath labs I worked at. In looking at these charges, it is important to remember that I did not ask Medtronic to go out and order some Panera. Medtronic brought it in, and once it’s there it is difficult to resist snatching a bagel, even though each bagel snatched results in another database entry under the Sunshine Act.  Given the natural tendency of hungry doctors (I almost never ate lunch at work) to partake of “free” food lying around, I think the more interesting question is not how much did each doctor consume, but rather, how much did a company such as Medtronic spend on doctors in an attempt to curry favor. I’m not sure if the Sunshine Act involves publication of that data, but it should.

There is no doubt that drug and device companies do try to target doctors in order to increase sales of their products, and money going from these companies to doctors is the major means of influence.  Doctors sign up to be on speaking panels for drug or device companies, even though they are not particularly expert on the specific drugs or devices they are talking about.  They receive a professional set of slides from the company and a nice stipend.  Other docs, particularly those in academic medicine, serve on advisory boards for companies, again resulting in a nice stipend as well as travel and lodging to exotic parts of the world.  Although there is a difference between the appearance of a conflict of interest and an actual conflict of interest, perhaps this distinction will appear a bit too fine when the actual dollar amounts these doctors receive are published.  The question becomes: how much money received is too much?  Any amount at all? More than $1000? More than $10,000? Arguments on what’s reasonable aside, there’s no doubt that some doctors are susceptible to this kind of influence, and others will just take the bagel and ignore where it came from.

When I was practicing as an electrophysiologist I felt I was in the latter category. The last thing I thought about when deciding what kind of device to put in was where my last bagel came from. My colleagues in electrophysiology I feel were similarly immune to this kind of influence. I can’t say the same about all my referring physicians.  Most didn’t care what brand device I put in, but there were some exceptions.  Some would call me with a referral of a patient who needed a pacemaker or implantable defibrillator and at the end of the presentation would close by saying: “and please put in a [insert specific brand name here] device.” Yes the device companies wine and dine the referring physicians who don’t actually put in the device, in order for them to pressure the implanting physician to use their specific devices. Admittedly some of these non-implanting referring physicians do device follow-up in their office, which usually involves a rep from the company actually coming to the office and doing the device interrogations (see my earlier post on this topic). These referring doctors will say they have a preference to follow a certain brand of device, which usually means they get along well with the particular rep from that company who comes to their office and does their work for them.  I always found this practice particularly annoying. I as the implanting physician should decide what device to put in, based on my judgment on what’s the best device for the patient. I’m sure the referring physician would not like it if I told him or her what brand stent to put in my patient.

So it would be naive to deny that there is any influence peddling going on between drug and device companies and physicians. Sure it probably pales in comparison to what goes on between lobbyists and politicians in Washington, but don’t hold your breath for Congress to shine the sunlight on their own activities. And based on the preliminary report I received, I’m sure there are going to be a lot of unhappy physicians when the final reports are released to the public in September.


A Stroll Down (Random Access) Memory Lane

Ye Olde Computer.  GE-635 at Kiewit Computing Center, Dartmouth College, circa 1969.
Ye Olde Computer. GE-635 at Kiewit Computing Center, Dartmouth College, circa 1969.

My lifetime has spanned many of the important developments in the Age of Computers. Back in 1969 when I entered college, I was a frequent visitor to the Kiewit Computing Center, the lair of a GE-635 computer that filled several rooms. Students had access to the computer via noisy teletypes and a multiuser operating system known as Dartmouth Time Sharing. We wrote simple programs in BASIC, a language created by two of the Dartmouth professors, John Kemeny and Tom Kurtz.  In 1969 even the hoary old operating system Unix was still a year or two in the future. There have been huge changes in computers since then. The smart phone I carry in my pocket today is light-years more powerful than that huge old-time computer.  It has been an interesting journey from those distant days to the present.

With the 1980s came the personal computer. Microcomputers they were called then, to distinguish them from the previous generation of minicomputers (which were about the size of a refrigerator). The Apple II was a breakthrough system, followed by the more business oriented IBM PC. There were other systems from various companies, some of which don’t exist anymore. Many of the systems were incompatible with each other, so special versions of software were required for each system. Microsoft’s MS-DOS, a variant of another disk operating system called CP/M, won the operating system battle, and eventually all PCs were pretty much interchangeable, running MS-DOS. Apple was the outlier, hanging on to a small market share after abandoning the Apple II and Steve Jobs. The Macintosh, incorporating a graphical user interface (GUI) that was ahead of its time, was the inspiration for Microsoft Windows 95, and through the 90s the GUI became dominant. This was also the era of the rise of the Internet and the Dotcoms. Microsoft put Internet Explorer in Windows, making it difficult to install other browsers, leading to Internet browser pioneer Netscape going out of business and anti-trust suits against Microsoft. Desktop PCs were dominant. Laptops were fairly primitive and clunky. Microsoft was at the height of its hegemony.

Then along came the millenium, and with the iPod, Apple, now back under the direction of Jobs, made a complete turnaround. Since then we have seen a revolution in computing with the introduction of mobile computing: smartphones and tablets. This is disruptive technology at its finest. The playing field and the rules of the game have changed since the 1990s, when Microsoft was dominant. Apple is a major player as is Google. Apple has succeeded because of tight integration and control of both hardware and software. Google went the route of web-based applications and computing in the cloud. Microsoft, the least nimble of the three, has struggled. Giving Windows a face-lift every few years and expecting everyone to upgrade to the new version doesn’t cut it anymore. More and more people are using their phones and tablets as their primary computing devices, platforms that for the most part are not running Microsoft software. Microsoft is putting all their eggs in the basket that predicts that laptops and tablets are going to converge into a single device. I’m not sure they are wrong. Laptop sales have fallen. But I personally still see tablets as devices to consume content (like read eBooks and email, and browse the web), whereas for creation of content (writing blogs like this one, or programming) a laptop is far easier to use. So I end up using both. Apple seems to realize that at least for now both devices play a role, and so they have two operating systems tailored for the two classes of device. Yet their upcoming versions of Mac OS and iOS also show signs of convergence. Clearly having one device to do both jobs would be nice; I just can’t envision what this device would look like.

So competition is back in the computing business, which is good. There are all sorts of directions computing can go at this point. There are a lot of choices. There have been a lot of changes. App stores with small, free or inexpensive apps compete with the old paradigm of expensive bloated, monolithic software programs. It seemed for a while that web-based apps would dominate. These are apps that run in a browser and so are platform-independent. Good idea, especially for developers who only need to write the code once. But despite being a good idea, this is not what consumers want on their smart phones and tablets. They want native apps on each platform. So the developer (I include myself here) is forced to write two versions of each app: one in Objective C (and soon in Apple’s new Swift language) for iOS, and one in Java for Android. Oh well, such is life.

Obviously all these changes have affected health care as well. The Internet of Things — the linking together of smart devices — shows great potential for application to health care. Not only can we monitor our individual activities with devices such as FitBit, but we also have the potential to link together all those “machines that go ping” in the hospital. The hemodynamics monitors, the ventilators, the ECG machines, and so on could be all accessible by smart phone or tablet. Integration of health care technology and patient data is certainly feasible, but, like everything else in health care, innovation is bogged down by over-regulation and the vested interests of powerful players who certainly don’t welcome competition. I hope this situation eventually improves so that health care too can take advantage of the cutting edge of the technological revolution we are experiencing today.


Futurama Revisited

GM Futurama exhibit 1964 New York World's Fair
GM Futurama exhibit 1964 New York World’s Fair

Fifty years ago my parents took me to the World’s Fair in New York. The year was 1964. I was twelve years old. It was a turbulent time in American history. The prior fall John F. Kennedy had been assassinated, initiating a long period of turmoil for the United States.  But it was still the era of America’s post-war technological greatness. The country was gearing up to fulfill Kennedy’s vision of a manned flight to the moon before the end of the decade. Products were still made in America, and we used the phrase “made in Japan” as a joke to mean something cheap and junky. People had savings accounts, and there were no credit cards. At the same time, racial discrimination and segregation were widespread. There was cringe-worthy sexism present, as anyone can tell by watching movies or TV shows from that era. There was no Medicare. US poverty levels were at an all time high. Lyndon Johnson and Congress went on to address some of these issues with the Civil Rights Act and the Social Security Act of 1965 which created Medicare and Medicaid. Johnson declared the War on Poverty in 1964 and poverty levels did fall. At the same time an undeclared war in southeast Asia was to cast a large shadow over his legacy and over the lives of boys turning 18 through the next decade.

Nevertheless it was a beautiful warm summer day when we visited the Fair. I remember the day well. Having devoured the Tom Swift, Jr. books and then science fiction of the 3 grandmasters, Asimov, Clarke, and Heinlein, I was filled with boundless optimism about the future of technology. The Fair was crowded with Americans that didn’t look much like Americans of today.  Neatly dressed.  Thin.  I was old enough to notice the pretty teenage girls who were just a few years older than I, working summer jobs at the fair. I remember riding up the elevator in one of the saucer-like observation towers (you know them, they play a prominent role in the movie “Men in Black”) and shyly eying the cute girl seated on a stool operating the elevator controls. Yes, for you younger readers, elevators used to be manually operated. The fair made a lot of predictions, but I don’t think automatic elevators was one of them.

The General Motors pavilion was aptly named Futurama. There is a YouTube video showing what it was like. I waited expectantly in the heat in a long line that stretched around the rectangular concrete windowless building. Inside we sat on cushioned chairs that automatically moved through the exhibit. There were vistas of a technologically rich future. Spacecraft exploring the moon. Scientists controlling the weather from a station in Antarctica. And in the environmentally naive outlook of that era, large machines cutting down rain forests to build roads to deliver “goods and prosperity.”

This exhibit was a highlight of the fair. Afterwards we went to the General Electric pavilion where we witnessed a demonstration of nuclear fusion (was it real? I honestly don’t know, and the Internet is vague about it). There was a loud bang and a bright light.  All very impressive, especially at my young age.

There have been a number of recent articles (e.g.  here, here, and here)  about the Fair and about which predictions it got right and which were wrong. Curiously there weren’t any predictions about medical science that I remember. Maybe I wasn’t paying attention. I think I wanted to be an astronaut back then. Pacemakers were brand new and digitalis and quinidine were staples for treatment of abnormal heart rhythms. The huge advances in medicine that were to come between now and then could not even be imagined.

I remember there was some stuff about computers, but at the time a single computer with less memory and processing power than that in my cell phone filled a large room. And yet it’s amazing that level of computing power was able to get us to the moon. The thought that everyone would carry their own personal computer/communicator in their pocket was pretty far-fetched. A few years later in Star Trek Captain Kirk would use something that looked like a flip-phone, but gosh, no capacitive touch screen! It did have a neat ring tone however.

The networking together of the world’s computers (aka the Internet) was certainly not predicted. Having the knowledge of the world a few mouse clicks away is probably the most significant advance of the last 20 years or so. It has altered our lives, I believe mostly for the good (except when I read YouTube comments), in a fashion unimaginable 50 years ago. I’m disappointed that the exploration of space didn’t turn out as predicted. Where are our moon colonies, or our base on Mars? But I’m happy with the way the Information Age has turned out, and I wouldn’t trade my ability to spend an evening browsing Gigliola Cinquetti videos on YouTube for anything.

The social changes that have occurred since then have been significant and generally for the good. Communism has been marginalized and the threat of nuclear war diminished. Religious fundamentalism remains a thorn in the side of humanity, as it has always been. Certainly there is still sexism and racism and we have further to go in correcting social injustice. But if I had told my dad back in the 60s that the United States would elect a black president, I’m sure he would have said something like “That’ll be the day!”