Getting to a Better Patient Handoff

There's a need for training in how to communicate better

Mar 06, 2012 - Production Blog Author

Editor’s Note: Vineet Arora, MD, MPP, is an Associate Program
Director for the Internal Medicine Residency and Assistant Dean of
Scholarship & Discovery at University of Chicago’s Pritzker School of
. She blogs about medical education at FutureDocs.

My work studying handoffs began back in 2003, after I was chief resident at the
University of Chicago. Through our research, we found that even in optimal
situations (dedicated room, dedicated time, attending supervision, etc.), 60
percent of the time, the handoff receiver was not able to name the top issue
for the patient as determined by the sender–despite having access to the
written record. Part of the problem may be information overload; people simply
cannot decipher the importance of various items when faced with so much
information. Therefore, there’s a need for training in how to communicate

Imagine you’re writing a shopping list for somebody. If you’re putting it
together for a stranger, chances are you’ll be much more detailed in your
instructions than you would be with your spouse, who implicitly knows whether
“buy milk” means 2% or skim, thanks to your rich history of shared experiences.

What may be going on in hospital handoffs is that people are assuming that
they’re seeing the same things–so there’s that illusion of shared
experiences–but since those experiences are in reality happening successively,
there’s no opportunity to create a shared mental model of them. As a result,
directions may be vague and not precise enough for someone who does not
know a patient sufficiently to understand what to do.

In addition to verbal communication issues, there are also problems with the
written records. Eighty percent of handoff notes, for instance, contain a
medication omission of some kind. Electronic health records that integrate with
medications can certainly solve this problem. However, there are downsides to
integrating with EHRs. The ease of the copy-paste function means that handoff
notes are getting longer and longer. What you see is text that looks more like
a wiki than it does a synthesized problem list.

The best handoffs, both verbal and written, are concise and strike the right
balance between pertinent and thorough. They’re composed of a one-liner
diagnosis, followed by clear and specific anticipatory guidance that include
enough rationale so the recipient doesn’t have to guess at what the sender was

Along with in-hospital shift handoffs, effective handoff communication is also
the cornerstone for continuity between a hospital-based physician and a primary
care physician. Mobile HIPAA-secure messaging, such as what’s used on
Doximity, has the potential to promote real time physician communication
during these care transitions, such as keeping primary care physicians
up-to-date during a patient’s hospitalization, or to alert them that their
input is needed on a specific question. Some of our other work has shown that
hospital-based physicians spend a lot of time looking up contact information
for primary care physicians–so certainly there is also potential to tighten up
that side of the process and facilitate timely communication. So, whether
it’s in-hospital or out of the hospital, it’s important to remember to handle
the handoff with care.

5 Health Technology Trends to Watch in 2012

Dr. Felasfa Wodajo, an orthopedic oncologist in metro Washington, DC and mHealth editor at iMedicalApps, shares his predictions for the new year.

Jan 05, 2012 - Production Blog Author

One of the most personally rewarding sides of my role at iMedicalApps is consistent and early exposure to the many ways technology is influencing and in some cases changing the way we physicians think about healthcare.

In particular, the proliferation of medical apps has opened doors we just a few years ago wouldn’t have thought possible. Some represent huge opportunities, others are as yet more vague. I’d argue that much of that gray is due to the fact that doctors and medical societies are only just beginning to engage with the task of evaluating what’s feasible and what isn’t in this relatively new landscape.

Given our exposure to what’s needed in the field, I think the conversations we doctors initiate and participate in play a critical role in this process. To that end, I’m devoting this post to a cribsheet of the health tech trends that have proven robust in the past year.

1. Patient education programs

You interact with patients for a brief amount of time, but their questions keep going. We’re starting to see a few good apps, as exemplified by the Orca MD series, that are trying to offer the kind of credible answers that might be tough for patients to find on google or through their social networks.

2. Phones as medical devices

The image is especially appealing–physicians and patients walking around with these incredibly powerful computers right in their pockets. Radio-frequency identification and bluetooth will be a huge component of how this technology develops, enabling doctors to do things such as use a phone as a pressure sensor to find out if a cast is too tight. Another application: Instead of having an ICU where patients are monitored, scannable monitors could be used on their bodies.

3. Networking services for information sharing

HIPAA-compliant networks such as Doximity are benefiting from the two obvious features already on smartphones–cameras and location services. Both are making it easier to discuss cases and make referrals.

4. Apps as prescriptions for behavioral change

On iMedicalApps we’re getting ready to publish some interesting early research on centers that are harnessing existing technology to develop behavior change programs. These apps can track behavior patterns through location services, text prompts asking users to evaluate state-of-mind, and even offer facetime counseling. This is place for great opportunity as mobile phones, as truly personal devices, could help modify behavior at the time and place where it counts the most.

5. Data flow for health records

Health data is shifting toward becoming less and less human-centered. Imagine a patient having his or her weight taken, with that measurement flowing into the medical record passively and immediately from the scale. The implications for data aggregation are profound.

Online physician reviews: 6 essential actions

Word-of-mouth is the number one referral-driver among patients, and that’s no less true online, where testimonials really can reward you for a job well done

Dec 29, 2011 - Production Blog Author

Editor’s Note: Howard Luks, MD, is Chief of Sports Medicine and
Arthroscopy at University Orthopaedics, PC and Westchester Medical
, and blogs at

Digital content has profoundly changed the way we think of patient feedback and
referrals; what used to be private has now become very public, thanks to the
proliferation of review sites like Yelp and Angie’s list. This is
largely positive. Word-of-mouth is the number one referral-driver among
patients, and that’s no less true online, where testimonials really can reward
you for a job well done.

Nevertheless, like it or not, negative feedback is also part of this landscape.
No matter how hard you try, you’re never going to please absolutely everyone.
For example, you may have someone in your office with whom on a normal day
you’d get along extremely well, and you’re just running late. That person may
well go online and share that.

Patients have a right to freedom of speech, and you can’t practice as if each
case is a potential bad review. You can, however, take this newer, more public
feedback loop as an opportunity to assess how strong your communication lines
are–not just in the context of the broad social media universe, but also among
your existing patient base. Here, six factors to consider:

Make sure you’ve educated your staff on how to treat patients properly: A
well-managed practice is the easiest way to keep patients from being
disgruntled. Do a careful assessment of the experience in your office, thinking
about how well you and your staff handle common bottlenecks such as intake and
wait times.

Designate an on-site point-person to deal with patient dissatisfaction as it
In our office, we have a point person who has actually gone through
HR training for patient complaints. We’ve designated a comfortable room off of
the examining area, and if someone is unhappy, we bring him or her there to air

Give patients a way to reach someone directly after the fact: All of my
patients leave with an email address at which they can reach me. I make it
clear to them that I check it often, and if there’s a complaint, I’ll address
it directly.

Show who you are, online: Think about what your message is, how you’re
going to portray to yourself and select your site and topics carefully. I’m a
big believer in generating meaningful content, and giving other people a chance
to share it. One obvious benefit is that your online presence will drive down
any negative reviews, but more importantly, this kind of communication offers
patients additional ways to get to know you.

Remember that one bad comment won’t kill you: No matter how hard you try,
you’re inevitably going to annoy a patient or two. But you know what? It’s okay
to have a bad review. The world will hardly stop spinning. In fact, given that
75 to 85 percent of people never go past the second page of a search, it will
most likely not change course at all.

Let patients know you welcome positive reviews: The real message: Rather
than worrying about bad content, it’s much easier (and more rewarding) to focus
on generating the good. There’s absolutely no harm in being proactive about
engaging happy patients in supporting your public reputation, so be it through
your website or your office, be sure to invite them to post reviews on sites
like Yelp, or even a Testimonials page directly on your own site.

We've passed our 30,000 user milestone!

We’re excited about how far we’ve already come, and are looking forward to rolling out some new features in the next few months

Dec 03, 2011 - Production Blog Author

In April, when we first launched Doximity, we set a goal to reach 30,000
members before the end of the year. There are 600,000 physicians currently
practicing in the U.S., so 30,000 would represent 5% of our market. For
companies that rely on registered users, this is typically the point where
growth shifts well beyond early adopters.

This past week–just eight months later–we hit that mark. (You can read more
about it in the context of other healthcare companies in this TechCrunch blog
, and for even more nitty gritty, on our press page.) We’re also
wrapping up the year having become the largest medical professional network in
the U.S. To give you a sense of size, LinkedIn, which is the biggest
professional network overall and the only other such medical network requiring
real name users, currently has 15,000 physician members nationally.

We’re excited about how far we’ve already come, and are looking forward to
rolling out some new features in the next few months. Please continue to reach
out to us here, on the site, and through Facebook and Twitter.
We’re committed to addressing the unique needs of doctors and, as such, we take
your feedback very seriously.

The Doximity Team

Debate: Is Kaiser good for medicine? (Part 2)

When it comes to issues of choice, namely the freedom to pursue an untried or very tailored treatment plan, there are significant compromises

Nov 25, 2011 - Doximity Blog

Editor’s Note: Marc Lawrence, MD, is a member of Doximity’s Advisory

Last month, advisory board member Peter Alperin wrote an essay outlining
the strengths and advantages
of Kaiser and other integrated delivery
systems. Like Peter, I have worked for Kaiser, and I, too, have found it to
be a good place for doctors. While the pay isn’t overwhelmingly high, the
employee benefit program is excellent, and physicians certainly face a smaller
risk of litigation there than they would in independent practices. Patient
follow-up is exemplary, and standard procedures and courses of treatment are
carefully developed and researched. However, when it comes to issues of choice,
namely the freedom to pursue an untried or very tailored treatment plan, there
are significant compromises.

Kaiser has a certain way of delivering care, and the bottom line is that you
can’t just see any specialist you choose when you want to get a second opinion.
You first have to go through Kaiser’s own system. If you’re a patient with an
oddball disease–a rare cancer, for example–Kaiser is therefore a tough sell.
The bureaucracy can be frustrating, and the kind of deeply targeted care you
would get somewhere like MD Anderson or the Cleveland Clinic, while not
impossible, will be more challenging to pull off. It’s reasonable that
patients, empowered as they are with information resources, will resist having
to march through all the steps and go through all the Kaiser ropes when the end
result will be exactly what they already know–that they need to get care

Looking at this same issue from a physician’s perspective, one could argue that
Kaiser is getting considerable press for being the “right” system, but an
environment where there’s only one style of care is a limited one. Just as some
patients may not fit the Kaiser model, there are most certainly brilliant
doctors who don’t thrive in the kind of ultra-integrated environment.
Individuals whose personalities make them impatient to innovate, for instance,
will undoubtedly find the pace too slow. Because Kaiser is committed to proven
approaches, change does not come right away. In certain cases, there may be
other, more cutting-edge ways of delivering care that just haven’t yet made it
into the pipeline.

There are countless arguments for why Kaiser and other integrated care systems
are well-run and effective models, and I agree with the vast majority of them.
But as we continue to develop new approaches in healthcare, I want to make a
case for remembering to look outside of the box of what’s already working on a
broad scale, and continuing to make room for the small-scale and even the

Essential tips for easy digital content searches

With over 21 million citations, here are some shortcuts to navigate this abundance of information

Nov 18, 2011 - Doximity Blog

Editor’s Note: Jey Balachandran is a software engineer at Doximity.

For those of you tracking medicine’s digital shift, here’s some interesting
news: In January, 81 year-old William H. Welch Medical Library at Johns
Hopkins University will go completely online. The move was precipitated in
response to calculations showing that in a day only about 40 of the 400,000
books currently housed in the building were checked out compared to 35,000
downloaded online. By the end of the transfer, nearly 95% of the collection
will be available virtually.

The Hopkins case is, of course, a reflection of just how far the scales have
tipped in favor of online medical research. PubMed, for instance, now
comprises more than 21 million citations, and most journals make some if not
all of their content available on the Web. In the interest of maximizing
returns as you navigate this abundance information, it’s worth having a few

To get around needing to go back and login to your institution’s website, for
example, Doximity product developer Nate Gross wrote this basic
that allows readers easy journal login using their institution’s
proxy server. Additionally, whether you’re searching Google or an institution’s
online medical library, order counts. Most search engines will give strongest
weight to the first words you type in (if you know exactly what you want, add
quotation marks for extra heft). In addition, they’ll let you jump from your
search engine to a search within a specific website if you add a colon after
the last word of the search term, directly followed by the site name (no space
in between).

You probably already know to use “and,” “or” and “?” in searches just as you
would when you speak. Similarly, you can use the minus sign directly before a
word (again, no space in between) to exclude that word from your search. Also
helpful: When you’re vague on exact wording, you can simply type an asterix in
place of a word you think you might be missing–this essentially says “give me a
wildcard.” Another approach is to tell the engine to include synonyms in your
search by using the tilde symbol (looks like this: ~) directly before the word
in question. Lastly, once you get to your text, you’re actually able to
within it by holding down the “command” and “f” keys simultaneously.

For a more in-depth list of tips, we asked Welch library director Nancy K.
Roderer, and her colleagues Sue Woodson and Blair Anton to share some of their
best advice for navigating the digital stacks. Their top suggestions, below.

Books by an author/ISBN
To see the most popular books by an author we like
WorldCat Identities, an online catalog of over 72,000 library collections.
You’ll get your search results itemized according to popularity. (here’s a
sample search we did). The government also assigns each book what’s called
an ISBN number (you’ll see these listed on Amazon, for example). Most digital
stacks enable searches using just those digits.

Latest on my topic
A search in PubMed always returns its results by “most
recently added.” So, whenever you do your search, you’ll see the latest
information on your topic at the top of the results list.

Current issues of a journal I know
On a familiar subject, physicians often
know the relevant journals and the easiest thing to do is go to the website of
the journal and search there. Many journals now offer a pre-print or
articles-in-press service for very current articles on a topic. To stay up to
date afterwards, you can often also register your search for an alert service.
The journal runs your search on a fixed schedule and if the results include new
things you’ll receive those citations by email.

Introduction to a new subject
While Wikipedia is good for getting a general
overview of many topics, it doesn’t always work that well for clinical
questions. Google Scholar, on the other hand, covers the medical literature
and allows you to limit your results to the current year. But don’t forget
Google itself, either. It’s an excellent way to pull up media writing on
medical treatments or issues.

Cultivating a killer digital footprint: 6 tips for doctors

Go to Google right now, type your name and see what comes up.

Nov 08, 2011 - Doximity Blog

Editor’s note: Doximity Advisory Board member Bryan Vartabedian, MD,
is a pediatric gastroenterologist at Texas Children’s Hospital and blogs at
33 charts.

Go to Google right now, type your name and see what comes up. For better or
worse, that’s what people understand about you when they search for you.

As scary as that may sound, you have more control than you think. In fact, if
you don’t take charge of what’s created about you, someone else will be glad to
take care of it. Lee Aase, director of the Mayo Clinic Center for Social
tells marketing professionals that “the solution to pollution is
dilution.” In other words, you can’t control the negative, but you can sure
create lots of other stuff for people to see. Here, six powerful ways you can
influence your own online identity.

Create a LinkedIn profile. LinkedIn is basically a digital CV on
steroids. It’s where you park your current position and work history for
everyone from your future boss to your college roommate to peruse (if you don’t
want patients to link to you, be sure to shut off the “connections” feature).
The most effective profiles I’ve seen are those that have taken advantage of
the biographical “summary” feature. Check out Wendy Sue Swansons’s page to
see how she’s used it to promote herself as an advocate and media spokesperson.

Join Doximity. The profile that you create on Doximity is visible to
the public through the search engines, and I’d argue that it’s better suited
for physicians because it allows you to effectively highlight specific details
of medical training and practice settings. It’s also very tailored in terms
of connections: Doctors can colleague you, and patients can’t make that kind
of contact but will see relevant-to-them data such as your public phone

Write something. Perhaps the most powerful way for people to understand
what you’re about is to write about it. A move like launching your own blog
allows you to create an empire of tailored information. If you’re not inclined
to start your own site, see if your local hospital has a blog. More than
likely, they’ll be happy to add another good, original voice.

Tape something. Don’t like to write? Then grab a Flipcam and start your own
channel on YouTube. People love to watch videos, and YouTube searches
beautifully. Better yet, create your own videos and park them on a blog. Bottom
line, find the medium that’s comfortable for you and run with it.

Make use of SlideShare. In all likelihood, you have brilliant material
sitting on your computer right now. I’m talking about your old powerpoint
presentations. They can be a great way to tell about you and your expertise.
Use SlideShare to upload them for public viewing, making sure your name is
prominent on your account and in the description of the program.

Sign up for Some doctors may find too flashy, but
depending on your practice and what you’re looking to achieve, this service’s
one-page profile-generator can be a simple way to push out a little more

Bottom line: There’s no one “right” way to build your footprint, and a
lot of your choices will depend on where you want to go professionally. If
you’re looking to recruit patients as a cardiologist, for example, your
approach may be very different than that of a budding physician executive. My
strongest advice is to find a role model who’s doing what you want to do–don’t
be afraid to take a page from his or her playbook. Finally, always remember
that what you do and what you post is a reflection of you. Be smart.

Life is short, the art long. Why doctors love Apple.

In this sense, Jobs was the ultimate physician. He healed our technology pains.

Nov 02, 2011 - Production Blog Author

Editor’s Note: Jeff Tangney is Doximity’s CEO.

Epocrates, a company I co-founded, was one of four apps Steve Jobs chose to
present on stage during the AppStore launch back in 2008. He told us his own
doctor wouldn’t switch to an iPhone unless it had Epocrates. This lucky bit of
customer research gained us admission to a round-the-clock three-week
code-a-thon inside a guarded Apple conference room. After successive cuts, only
four of the 12 companies invited made it to the Apple stage. Through it all, no
one worked as hard as Steve. He sweat the details, the demo’s, the script;
left emails and voicemails at all hours; and somehow got us to work harder than
we ever had, for free. It was, to use a much-debated term of late, genius.

Last week, Steve Jobs’s biography was officially released, and with it, a
second round of well-considered articles about Jobs and his legacy. It has
launched a rich, detailed, almost “too soon” debate about Jobs as a man and how
we have come to define genius in this day and age. Here at Doximity (an Apple
fanboy shop if there ever were one), our head of design has already joked that
after reading Isaacson’s biography, he will now scream, swear and then cry to
get his way because “it’s what Steve would do.”

Isaacson’s biography concludes that history will place Jobs in the “pantheon
right next to Edison and Ford.” I don’t think that’s the right place. Edison
and Ford were brilliant engineers and shrewd businessmen who built incredibly
functional life-changing products. But they weren’t artists. And while Jobs was
an enormously effective engineering manager, he was not an engineer. He was a
businessman first and an artist at heart. His genius rose from creating
art–elegant design, playful flourishes, indeed happiness–out of other’s great

Physicians have always disproportionately favored Apple products. At Epocrates,
our physician users were four times more likely than average to have a Mac. At
Doximity today, iPhone users outnumber Android three to one while Android leads
iPhone in overall market share. Overall, seventy-five percent of US
physicians own not just a tablet or smartphone, but specifically some sort of
Apple device. Most chalk this up to the many years physicians spend in
academia, where Apple’s share is higher. But I have an alternate theory:
physicians appreciate art.

Hippocrates said it best: “life is short, the art long.” Medicine is an art. It
is rooted in science and utilizes the latest engineering, but healing is both
complex and subtle. It draws in those with an appreciative eye, an intuitive
aesthetic sense. From Hawkeye Pierce to House MD, our pop culture lionizes
gutsy individualists as physicians, and with good reason: doing the best for
your patient sometimes means breaking the rules. If Andreas Gruentzig, a German
cardiologist, had followed the rules, we wouldn’t know that catheters unclog

In this sense, Jobs was the ultimate physician. He healed our technology pains.
He broke the rules, creating new products that not only functioned
mechanically, but also displayed the subtle vigor and glow of a healthy
patient. And on a subconscious level, I think, physicians appreciate that
symmetry more than most.

As a person, Jobs put nearly all of his individual self into his professional
work. Like many physicians in practice today, his personal life was public and
his public life personal, not so much in the tabloid way we’re used to seeing
those words, but through his pride in and personal attachment to his work.

It is then doubly ironic that he was such a poor healer for himself. Our
sadness is mainly for ourselves, Steve. You had so much more to give us.

Could Siri be a game-changer for physicians?

Steve Jobs seems to have taken Arthur Clarke’s law to heart: “Any sufficiently advanced technology is indistinguishable from magic”

Oct 25, 2011 - Production Blog Author

Editor’s Note: Henry Wei, MD, is a board-certified internist and a
Clinical Instructor in Medicine at Weill-Cornell Medical College. He is
currently a Senior Medical Director at Aetna, where he leads Clinical
Research & Development for ActiveHealth Management. (The views and opinions
expressed here do not necessarily reflect those of Dr. Wei’s employers.)

By now you’ve probably heard plenty about Siri. Or perhaps Siri has heard
plenty about you. Siri, the speech recognition software Apple’s built into the
iPhone 4S, has been billed as an agile virtual assistant, able to perform
tasks ranging from taking dictation and sending the outcome as an email to
finding facts and scheduling appointments. But here’s something that hasn’t
gotten quite as much popular press: Siri is really good at medical terminology.
And swear words (more on that later).

I unboxed my own iPhone 4S after a recent clinic week. With a backlog of
patient notes, I became curious about dictating these cases–leaving out patient
names for reasons I’ll get into later. After watching some Will Ferrell
(who doesn’t?), I tested out the Siri feature using some very precise
medical terms–language I wouldn’t expect anyone but a physician to be using in
real life. But Siri got every word right off the bat, without any ambiguity–a
task that can be challenging for most humans, let alone a computerized

Impressed, I began testing Siri from the other perspective: the patient’s. What
if I say I have chest pain, or I’m depressed? Parsing through Siri’s replies,
which mostly had to do with finding the nearest hospital, I noticed that
these answers were coming from something more than just speech
recognition–actual meaning was being recognized. That was exciting to me; it
showed a layer of design and consideration beyond the literal. You see, my
day job involves developing clinical decision support and innovating
healthcare IT. When I see a system that’s strong enough with semantic meaning
to, say, take an order at the drive-up window of a fast food joint, I get

Siri’s technology isn’t unique to Apple, which apparently has partnered with
Nuance, the company with the near-monopoly on spech recognition. Elsewhere,
Google Voice and others have made great strides with similar services.

Regardless, this feels magical. That is, Steve Jobs seems to have taken Arthur
Clarke’s law
to heart: “Any sufficiently advanced technology is
indistinguishable from magic.” Siri is a consumer-level tool that starts
working right away–no instruction manual needed–and though most of us have no
idea how, it can match speech and meaning with appropriate tasks. When it works
well, it enables us to skip an entire step in the process of getting things
done. We can move from having an idea to being ready to put it in motion
without needing to search or transcribe.

Imagine, for example, if Siri or a similar service evolves to the point where a
doctor can just say out loud, “please order a CBC with differential, chemistry
panel and a lipid panel,” and the program were smart enough–and had enough data
on you and the patient–to interpret your meaning and remind you that you’d
recently ordered a CBC for this case, and you forgot to order a liver function
test. Having that kind of rapid work-check would be an incredibly valuable
safety and efficiency feature.

What if, even further down the line, Siri (or a device like it) were able to
sit as a fly on the wall, listening to the doctor-patient conversation to a
point where it could act as a second expert opinion for diagnoses. Today,
physicians practice primarily in a vacuum, with little oversight. It’s too
expensive and outright embarassing to have someone observe and coach you, as a
physician. Atul Gawande wrote recently on coaching and the experience of
being coached as a surgeon, noting that “we treat guidance for professionals as
a luxury.” But think if you had a technology that could be watching what
physicians did in real time with the goal of offering real coaching. For
instance, a continuous speech recognition system could notice specific syntax
and nuances of the patient’s wording that might indicate a higher risk of
medication non-adherence, and offering an appropriate strategy to overcome that
risk. This type of computerized guidance is–paradoxically–somewhat offensive to
me as a physician, but incredibly exciting to me as a patient.

Clearly, with further development, something like Siri can be game-changing for
medicine. But here, a caveat. Only if doctors really want it. Change always
seems to come with two elements. One is a profound need, but the other–and this
is the one we in healthcare frequently miss–is an actual desire to change. That
said, the more expert and more successful the workers in any given field
become, the less they’ll actually want any change.

More broadly, we should think of Daniel Pink, who speaks to the keys behind
motivation as Autonomy, Mastery, and Purpose. Doctors have for generations
performed medicine in a very autonomous manner; it’s one of the things we’re
good at. How good are we at relinquishing control, or even accepting external

Still, something like Siri has a leg up because it’s intuitive. Our own brains
spend a good deal of time decoding words and sounds, so speech-based
communication is more intuitive to us than a keyboard or even a touchscreen.
This type of user interface should bear a sense of satisfaction when we notice
the job is being done right. This intuitive component is something we just
don’t get from a lot of healthcare technology today, which suffers from the
“clicky-clicky problem,” a term that my wife (also a physician) coined when
describing the irritating way that most EMRs force doctors into drop-down
menus, radio buttons, and dozens of text entry boxes–death by clicks.

While I don’t foresee an immediate conversion to Siri-like decision support
services among the majority of physicians anytime soon — our desire for
autonomy is too strong–I do believe that its ability to slip into iPhone users’
everyday patterns will translate to longer-term adoption. I’d see its course
going something like this: We begin by using it in our personal lives.
Insidiously, it works its way into the administrative sphere of offices and
hospitals–not the doctors at first. From there, it makes its way into the
operating room, where, in an environment not dissimilar from driving a car,
we’d prefer not to have to type or touch anything to express our ideas,
queries, and commands. Finally it becomes truly pervasive not just among
early adopters
, but also those older doctors–particularly those used to
dictating already–who are so adept at what they’re doing that the effort of
change seems unnecessary.

One of our rate-limited steps may be the interoperability aspect. Nobody wants
a technology that functions in a vacuum; if you take a dictation, you’re going
to need it to be stored somewhere, and its semantic meaning interoperable with
other systems. We’ll need apps, and those take time to take from a concept in
someone’s head to actual living, breathing code and user interfaces. That said,
the SMART platform championed by Zak Kohane and Ken Mandl at Harvard, and
the iNexx platform from Medicity on the private side, are both very
promising at establishing an easier way to interoperable “apps” in the
healthcare environment.

Some people, like the good Dr. Alexander Blau at Doximity, have raised
important concerns about security and potential HIPAA violations with Siri.
It’s my sense that the patent for the technology suggests that the data are
either encrypted or have the option of being encrypted. Either way, I suspect
that Apple or Nuance will be asked to make this part a little more transparent
by healthcare IT companies interested in levering their technology–particularly
if they’re using any data as training data for the system. For the time being,
though, the possibility of HIPAA-insecurity well worth keeping in mind.
Longer-term, we’ll have to see if the FDA will start playing a larger
in regulating medical technologies that employ speech recognition.

Oh, the part about swear words? Well, believe it or not, back in medical
school, my roommates and I invented a game where we would call and swear at
toll-free automated voice response systems (e.g. MovieFone and airlines) to see
what the system would do. The smart systems would actually direct you to a live
human operator right away. Well, Siri actually recognizes a lot of obscenities,
and even has some pretty humorous responses. And at the end of the day, if
speech recognition technology in medicine starts to be able to pick up on the
emotional intent of users–not just the semantic meaning of, say, medical terms
or swear words–then my bet is that we’ll have entered a truly magical era of
Healthcare IT.

Debate: Is Kaiser good for medicine? (Part 1)

With over 8.7 million health plan members and 167,178 employees, Kaiser is the biggest managed care organization in the country.

Oct 19, 2011 - Doximity Blog

Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA Medical
. He previously led informatics at Brown and Toland Medical Group,
and has also worked at Epocrates.

In 2010, the New England Journal of Medicine published a study conducted
by the Kaiser Permanente Division of Research showing that since 2000, heart
attacks among a group of over 46,000 of its Northern California patients had
declined by 24%. To be sure, some of this could be attributed to possible broad
public health trends in that area, but the researchers also noted that the
decline coincided with improved control of cardiovascular risk factors at

This alone might not be quite so remarkable, but for the fact that
consistently, Kaiser scores at the top of almost every single quality care
measure it’s in. Just recently, it was one of nine health plans awarded
five stars by Medicare Advantage. Time and again I’ve seen the organization
take a rigorous approach toward analyzing what it’s doing well and what it’s
not doing well in the interest of improving processes of care. In other words,
the NEJM story reflects something of Kaiser’s DNA.

There are many factors at play here but one of the clear incentives is
financial—Kaiser realizes that it makes good financial sense to invest in
prevention and the systems needed to provide preventive care in a
cost-effective manner. Last year, Kaiser reported a combined net income of
$2 billion, and $44.2 billion in operating revenues. With over 8.7 million
health plan members and 167,178 employees, Kaiser is the biggest managed care
organization in the country. Large technological and programmatic investments
make more sense in an integrated system such as this, one that simultaneously
controls insurance, hospitals, and doctors–effectively, all three legs of the
healthcare stool.

Thirty years ago, Kaiser was cynically viewed as a place for doctors who
couldn’t make the cut of private practice. How misguided that view was. I’ve
found it interesting to see how far the pendulum has now swung: Not long ago, I
was asked to talk at a residency event at UCSF. Among the seven of us on
our panel, the vast majority of the questions went to the person from Kaiser.
To me, this spoke volumes of the changing face of medicine. The residents in
our audience (a large number of whom were women) were asking about quality of
life and flexibility of day care.

Much of this has, of course, been enabled by the fact that private practice
simply isn’t as lucrative as it once was. And I would argue that growing pains
notwithstanding, there are notable advantages to this new landscape. Physicians
tend to go to medical school because they like medicine, not because they want
to be business people. One big advantage of an integrated system like Kasier is
that doctors don’t have to think about making payroll, renting office space, or
finding a call service. Furthermore–and this is the secret sauce—working in a
group environment forces collaboration, something at which doctors have perhaps
not historically thrived, but from which ideas and progress can spring.

Is Kaiser perfect? Of course not. It isn’t the most nimble. By dividing itself
into regions, Kaiser works hard at mitigating the inevitable bureaucratic
slowdowns that come with size, but even so, each individual Permanente group
remains much larger than an average medical group. It can take a long time to
implement best practices across an organization of such size and complexity.

I do worry that Kasier is so dominant in some markets that without the promise
of growth or the threat of competition, there’s the risk that progress will
slow, and that the goal becomes more about making the cut than breaking new
ground, be it in patient care or keeping costs affordable. However, Kaiser has
to date consistently performed and it remains, in my opinion, the gold standard
for healthcare delivery in the US. In fact, if we broaden our view to
incorporate other health systems that are on the vanguard of change, like the
Mayo Clinic, Geisinger, or Intermountain Healthcare to name a
few, what is apparent is that a great deal of overall innovation action is
currently in integrated delivery systems, what’s apparent is that a great
deal of innovation action is currently in integrated delivery, suggesting a
real relevance for these systems as healthcare continues to change.

Come November, we’ll revisit this issue–from the opposing perspective.