Upping the Technological Imperative

Ambulances May Get Virtual Doctors | AP | 12.26.04

PITTSBURGH - Researchers are developing technology for ambulances to improve communications and perhaps more importantly, place virtual doctors inside in transit.

Mountains, valleys, bad weather and long distances between hospitals make communication with emergency room physicians spotty at best and nonexistent at worst.

“It always seems to happen when we’ve got a critical patient and you’ve really got to talk to a doctor,” said Jim Effinger, a paramedic with 23 years experience in rural Pennsylvania.

The U.S. Office of Naval Research is funding research for the First Responder Emergency Communications-Mobile with hopes to one day apply it to the battlefield.

The FREC-M uses an international maritime satellite and varying frequencies to bridge communication gaps. It has multiple cameras inside and outside a standard ambulance, which looks like any other, save for several satellite and GPS domes on top.

Researchers working on “virtual doctors” | 12.27.04 |

Researchers with the U.S. Navy are developing an experimental ambulance that will include “virtual doctors.” Dubbed the First Responder Emergency Communications-Mobile (FREC-M), the ambulance will rely on GPS, satellite communications and a range of cameras to relay info on patients to doctors, who can instruct onboard paramedics on treatment options. …

No confirmation on rumors that the National Association of Trial Lawyers is working on a $500,000 “virtual lawyer” that will be able to chase the FREC-M and serve malpractice suits.

The old technological imperative crossing incentives with healthcare’s economic imperatives again. How much should be spent for advance technologies for the very few when we have very many without basic healthcare access.

Upping the Rural Ante

Rural Emergency Crews Fear Proposed Rules | AP | 12.28.04

CENTER, N.D. - The emergency medical technicians in this town are familiar faces from the high school, the county clerk’s office and the coal mine. And like many of their counterparts around the country, members of the Center squad are worried that proposed national standards could more than double the amount of training they must have and thin their ranks.

“A lot of people can’t comprehend what it’s like to drive 345 miles and not see a house, not see anything, and to have to cover that,” said Mickie Eide, the squad’s leader. “If you keep requiring us to do more, there’s going to be less of us to do it.”

The revamped certification rules are being developed for federal regulators by doctors, EMTs and state emergency medical directors.

Supporters say more training requirements would ensure a better qualified national corps of emergency medical providers. But in rural areas where volunteer crews are the rule, many fear the change will limit the pool of new recruits and force experienced EMTs to drop out.

“This is one of the most difficult decisions that I have been involved in in EMS (emergency medical service) in the last 20 years at the national level,” said Bob Brown, director of the National Registry of Emergency Medical Technicians.

The goal is a national standard that would guarantee highly trained workers in ambulances across the nation, Brown said. …

Compassionate Connectivity

Patient’s status is now just click away | Sacramento Bee | 12.28.04

Sutter lets families create Web pages with information.

Family and friends of patients in Sutter hospitals can now keep in touch without repetitious phone calls to a hospital room or nurse’s station via updates on the Internet.

A new service called Care-Pages allows the patient’s family to create a private and personalized Web page that will post whatever information the family wants to release to those given a secure password. …

Nicely done!

eICUs

Enhanced intensive care system allows remote access to patients | USA Today | 12.28.04

… The hospital’s parent, Kaleida Health System, is among an expanding number of hospital systems adopting “enhanced intensive care” technology — known as eICU — that allows critical care doctors and nurses to monitor dozens of patients at different hospitals simultaneously, much like an air traffic controller keeps track of multiple planes. …

Leapfrog Group, a nonprofit coalition of business and other groups working to improve hospital operations, has cited a severe shortage of intensivists practicing in the United States — less than 6,000 at a time when nearly 5 million patients are admitted to ICUs each year. …

Intensivist, hospitalist, and their real-time digital surrogates (eICUs) are where medicine is going—along with nurse staffing ratios, these are going to be big ticket marketing tools for quality establishments.

Healthy Sunshine

California Hospitals Open Books, Showing Huge Price Differences | WSJ | 12.27.04

At some California hospitals, a tablet of Tylenol, or its generic version, acetaminophen, is billed at $5 or $5.50. Others charge $7, or even $9, for a single pill. One Los Angeles hospital charges just 12 cents a tablet, while at a few facilities it’s free. The retail price of brand-name Tylenol is about eight or nine cents each. The generic goes for a nickel or less.

A new law in California mandates that hospitals there do what few hospitals in America will: open up their “chargemasters,” books that show thousands of list prices for medical goods and services. An examination of chargemasters at several hospitals shows that pricing strategies fluctuate wildly — on everything from brain scans to painkillers to leeches. Depending on a hospital’s pricing method, the charge for the same commodity or service, such as a blood test, can vary by as much as 17-fold from one institution to another. …

Dozens of lawsuits have been filed in recent months by lawyers alleging that nonprofit hospitals are price-gouging the poor and uninsured. Hospitals long seen as charitable organizations are being forced to defend themselves against allegations they have preyed on patients for debts that were inflated. …

Hospitals began marking up the prices of various goods and services. But they didn’t always know what their rivals charged because of antitrust restrictions. Each hospital came up with its own formula. In some cases, retail prices for certain procedures, such as a routine chest X-ray, rose even as the costs of those services declined. …

At UC Davis, Mr. McGowan’s pricing decision on acetaminophen was influenced by an Ann Landers column he read years ago. In it, someone complained about a hospital bill for aspirin. Anticipating the day someone would complain about the same thing at his hospital, he tinkered with his usual pricing formulas and set the price at $1.

Mr. McGowan says there’s a good reason his hospital charges much more for the tablets than a consumer would pay at a drugstore. “I suggest that you call the drugstore,” he says, “and ask them to bring you one Tylenol delivered to your bedside by a registered nurse after you have a prescription from a doctor, along with a glass of water, and see what they charge.”

Healthcare desparately needs, and at least in California, finally gets a sunshine law. One has to admire Mr. McGowan’s (supra) chutzpah, his analogy only has validity if the customer is standing at the pharmacy counter and asks for the Tylenol—to be fair you must compare marginal cost with marginal cost, not the fixed cost—the pharmacy does not have to burden the cost of Tylenol with the discounting provided other medications. The real interesting follow-on piece should be what the costs are, not only amongst hospitals but, amongst payer catagories at the same hospital…

See also EMedConcepts

Semantic Searching

At I.B.M., That Google Thing Is So Yesterday | NYT | 12.26.04

SUDDENLY, the computer world is interesting again. The last three months of 2004 brought more innovation, faster, than users have seen in years. The recent flow of products and services differs from those of previous hotly competitive eras in two ways. The most attractive offerings are free, and they are concentrated in the newly sexy field of “search.”

Google, current heavyweight among systems for searching the Internet, has not let up from its pattern of introducing features and products every few weeks. Apart from its celebrated plan to index the contents of several university libraries, Google has recently released “beta” (trial) versions of Google Scholar, which returns abstracts of academic papers and shows how often they are cited by other scholars, and Google Suggest, a weirdly intriguing feature that tries to guess the object of your search after you have typed only a letter or two. …

Two weeks before our meeting, I.B.M. released OmniFind, the first program to take advantage of its new strategy for solving search problems. This approach, which it calls unstructured information management architecture, or UIMA, will, according to I.B.M., lead to a third generation in the ability to retrieve computerized data. The first generation, according to this scheme, is simple keyword match - finding all documents that contain a certain name or address. This is all most desktop search systems can do - or need to do, because you’re mainly looking for an e-mail message or memorandum you already know is there. The next generation is the Web-based search now best performed by Google, which uses keywords and many other indicators to match a query to a list of sites. …

I.B.M. says that its tools will make possible a further search approach, that of “discovery systems” that will extract the underlying meaning from stored material no matter how it is structured (databases, e-mail files, audio recordings, pictures or video files) or even what language it is in. …

Semantics and the semantic web is where this is all headed—can Google Semantics be too far off?

Rubbing Their Noses

Program Coaxes Hospitals to See Treatments Under Their Noses | NYT | 12.25.04

The federal government is now telling patients whether their local hospitals are doing what they should.

For now, the effort involves three common and deadly afflictions of the elderly - heart attacks, heart failure and pneumonia - and asks about lifesaving treatments that everyone agrees should be given but that hospitals and doctors often forget to give.

The expectation, though, is that this is just the beginning; other diseases, other treatments and surgery are next. Within a few years, individual doctors will be rated as well.

Using incentives like bonus pay and deterrents like public humiliation, it is a bold new effort by the federal government, along with organizations of hospitals, doctors, nurses, and health researchers, to push providers to use proven remedies for common ailments.

And it is a response to a sobering reality: lifesaving treatments often are forgotten while doctors and hospitals lavish patients with an abundance of care, which can involve expensive procedures of questionable value. The results are high costs, unnecessary medicine and wasted opportunities to save lives and improve health. …

The hospital ratings are being done by Medicare and posted on the Internet. …

See also NQF (PDF) and JCAHO.

This is very important! If we are going to cover the 45 million that are disenfranchised from healthcare and offer Medicare drug benefits we must have programs that management both the overuse and underuse of existing healthcare services.

Two EDS ads come to mind: cat herding and building airplanes in the sky.

Merry Christmas

Looking for Disruption

Let me weave several themes together…but first some background fabrics:

Disruptive Technology

Definition

The term disruptive technology was coined by Clayton M. Christensen to describe a new, lower performance, but less expensive product. The disruptive technology starts by gaining a foothold in the low-end (and less demanding part) of the market, successively moving up-market through performance improvements, and finally displacing the incumbent’s product.

By contrast, a sustaining technology provides improved performance and according to Christensen will almost always be incorporated into the incumbent’s product.

Theory

In certain markets, the rate at which products improve exceeds the rate at which customers can learn and adopt the new performance. Therefore, at some point the performance of the product overshoots the needs of certain customer segments.

At this point, a disruptive technology may enter the market and provide a product which has lower performance than the incumbent, but exceeds the requirements of certain segments thereby gaining a foothold in the market. Christensen distinguishes between low-end disruption which targets customers that have been overshot and new-market disruption which targets customers that could previously not be served profitably by the incumbent.

RSS

RSS or Really Simple Syndication is a family of XML-based communication standards with the following members:

• Rich Site Summary (RSS 0.9x and RSS 2.0)
• RDF Site Summary (RSS 0.9 and 1.0) (RDF: Resource Description Framework)

Functionally, RSS (pronounced “arr-ess-ess”) is a web syndication protocol primarily used by news websites and weblogs. A program known as an RSS aggregator or feed reader can check RSS-enabled webpages on behalf of a user and display any updated articles that it finds. RSS saves users from having to repeatedly visit favorite websites to check for new content or be notified of updates via email. …

BitTorrent

BitTorrent is a peer-to-peer (P2P) file distribution tool written by programmer Bram Cohen which was debuted at CodeCon 2002. It is written in Python and is released under the MIT License.

Most notably, BitTorrent allows many people to download the same file without slowing down everyone else’s download. It does this by having downloaders swap portions of a file with one another, instead of all downloading from a single server. This way, each new downloader not only uses up bandwidth but also contributes bandwidth back to the swarm. Such contributions are encouraged because every client trying to upload to other clients gets the fastest downloads. …

Broadcatching

Broadcatching refers to the use of RSS feeds and BitTorrent peer to peer file sharing as an alternative to distributing multimedia content on the Internet. It is a play on words, in contrast to broadcasting. …

Podcasting

The term podcasting plays upon the terms broadcasting and webcasting and is derived from the name of the iPod portable music player, the playback device of choice of many early podcast listeners. podcasting is not directly associated with Apple’s iPod device or iTunes jukebox software. Podcasting is similar to time-shifted video software and devices like TiVo, which let you watch what you want when you want by recording and storing video, except that podcasting is used for audio and is currently free of charge. Note, however, that this technology can be used to pull any kind of file, including software updates, pictures, and videos.

iPod

The iPod is a portable MP3 player designed and marketed by Apple Computer. It stores audio on a built-in hard drive, which gives it a much larger capacity than portable audio players that rely on flash memory. It can also serve as an external hard disk while connected to a computer; a user can store any kind of file on it.

iTunes

iTunes is a computer program made by Apple Computer intended to play, organize and buy music files.

Users are able to organize their music into playlists, edit file information, record compact discs, copy files to a digital music player, purchase music on the Internet through its built-in music store, run a visualizer to display graphical effects in time to the music as well as encode music into a number of different audio formats.

iTunes stores metadata about the audio files in two files. The first is a binary file called iTunes 4 Music Library that uses its own music library format, independent of the audio format’s tag capabilities (for example the ID3 tag). The second file, called iTunes Music Library.xml, uses XML format, allowing developers to easily write applications that can access the information (e.g. Apple’s own iDVD, iMovie, and iPhoto or Freshly Squeezed Software’s Rock Star).

iMix

iMix is a feature in the music jukebok/online store, iTunes that allows users to publish playlists through the music store and share them with the public.

Personal Digital Assistant

Personal digital assistants (PDAs) are handheld devices that were originally designed as personal organizers, but became much more versatile over the years. A basic PDA usually includes a clock, date book, address book, task list, memo pad and a simple calculator. One major advantage of using PDAs is their ability to synchronize data with desktop, notebook and desknote computers.

Here starts the weave:

I’ve been using computers since college in the ’70s—dabbled with Basic, APL, Fortran and others. Moved to the Mac in 1987 and then to several iterations of the Newton PDAs starting in 1993. And then onto Windows in 1998, followed by WinCE and PocketPC PDAs. In 2000, came the move to PalmOS PDAs—presently on the 4^th iteration.

In April, I discovered the most powerful and potentially most versatile device I’ve every seen—the iPod. With the exception to the Macintosh and PalmOS PDAs most of computer-based technology is difficult at best to learn and be proficient at. If the auto industry produced products like software and hardware companies do—we would all still be riding horses and pulling buggies. The complexities and lack of reliability is staggering in the sense that we, as a society, have accepted as normative such mediocrity.

Originally, I had purchased the iPod to hold my law school lectures and (of course) music so I could do my lectures while driving to and fro from work. Now the 4^th generation iPod has arrived—iPod Photo, and the true disruptive nature of this Apple product began to glimmer. Finally, a product from Apple that will not only be emulated (e.g., Mac) but dominate.

For quite sometime now I’ve been using the premier online textbook eMedicine—I don’t think I’ll ever purchase another major text in Emergency Medicine. Why? I have it available at home and in the ER—and never out-of-date. Addtionally, I use two wonderful products on my PDAs: PEPID and Epocrates. Both products are the type you learn to love and hate. The content and the ease of the PDA interface are excellent; however, the installations of both product is what is leading me to the belief that there must be a fundamentally disruptive technology coming for content delivery. Both are hostile to security software on the PC, coupled with the slow and frequently disrupted “auto-update” feature have caused me to disable the auto-updates. Contrast this with the complete ease of loading the iPod and accessing the iTunes store.

Almost all my medical journals are available in either HTML or PDF formats—so the physical journals have very short half-lives. My legal journals, well lets just say—they’re still crossing the digital divide.

The disruption I’m looking for is professional content (medical and legal for my context) that is able to be streamed in BitTorrent enclosures and podcasted to a professional quality iPod. There is no reason that the technology base installed for audio, image, and soon video podcasting cannot be adapted to free the content of PEPID, Epocrates, Emedicine, etc. from the PC and PDA-paradigms. We need to have medical information broadcatching. The harbingers are here and here. We should be able to create and distribute best practices, procedural sedation protocols, antibiotic sensitivities, CPTs, insurance formularies, etc. by the professional equivalent of an iMix created with an analogous iTunes via RSS…this is where the computer industry (and its lesser sibling, the PDA industry) needs to get disrupted by the “lower performance” content-rich information appliance industry—STAT. And make it wireless!

I’m looking for a disruption for Christmas…

Revised Circuits

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