Patient Safety - Maybe we're looking at the wrong audience

I attempted to post the following comment on a post by Barbara Duck's entertaining and insightful blog (The Medical Quack) about in which she provides evidence that most applications that might have medical usage are not being used by people who download them.  However, I received an error message when validating the post so I'll just post it here.
  Today I spent a couple of hours with a physician colleague now working for a restart company designing an app for iPod/iPhone fitted with a medical grade bar code reader shell.  The design is to replace the tethered bar-code readers used in medication administration in the hospital to improve patient safety.  It was well designed and compared very favorably to other similar applications. But ...
... the bottom line is the whole time I was thinking that if this company's goal is patient safety they are targeting the wrong population. 
  Sure, medication errors occur in the hospital but when comparison to the medical errors that occur in total outside the walls of a medical facility,  hospital based errors maybe insignificant.  At least in the hospital there's a medically trained nurse selecting and delivering medications that are packaged and delivered by a pharmacist in the building with relatively clear instructions and tools on when and how to deliver them.  Not only that the patient is observed taking the medications.
  There are roughly 9000 hospitals in the United States and estimating the average beds per hospital at 100 we're looking at 900,000 beds.  At any given time there might be 900,000 medications being administered.
  In contrast there are roughly that many allopathic physicians probably averaging 20 patients a day and writing prescriptions on at least half of those patients so if my arithmetic is correct somewhere around 9,000,000 patients get prescriptions daily (some illegible). These patients go to the pharmacies receive their prescriptions, take them home and begin taking them without any medical supervision.  
Now, I'm a physician and even I have difficulty taking my one medication daily as I'm supposed to. In casual conversations with my golfing buddies I know many of them rarely follow directions closely, even for pain medications where they may take many more than prescribed or skip doses. Others experiment intentionally or unintentionally in delivery methods, others have difficulty remembering, can't differentiate between pills or have work schedules that prevent them from taking medications as directed.  Many also add over-the-counter medications without giving any thought to potential interactions.
  I would venture to say that on any day there are as many patient safety medication errors in the home than there are in all of the hospitals in a given year.
Instead of an iPhone app for the hospital nurses what this company needs to do is write one for all of the millions of patients who take medications at home. We need a very simple app that makes it easy for the physician, pharamacist, nurse or patient to either download or enter their prescriptions, number dispensed and have it do the following:
    1) alarm when a medication is due to be taken
    2) show a picture of the pill(s)
    3) either have two buttons beside each pill labeled "Taken"  "Not Taken" or just press the pill if taken and have a second button (X) if not taken.
  That's it. In the background the application would store the medication, time of administration and advance the counter.  When completed the device would automatically notify the physician or pharmacist the medication prescribed was completed or if a continuous medication that a refill or renewal was needed.
  This app would also provide the patient with drug to drug interactions so if they stopped by the counter to pick up Claritin, ibuprofen, whatever, they could photograph the UPC code and it would automatically be added to their medication list, alert the patient if the new medication would interfere with what they were already taking.
  It would also link to important drug information leaflets so they could review as often as they wanted by clicking on the picture of the pill how to take it, etc.
Finally, as mentioned above when the prescription expired the medication would drop from their list so they would always have a current, up-to-date list of medications to show their physicians (or better yet upload it) at the next visit along with a history of the administration over time (important for medications like warfarin).
  By targeting medication administration applications at patients rather than nurses or physicians and designing the applications for home use we might actually affect patient safety effectively AND lower physician office visits, admissions to hospitals and GASP begin to lower the cost of medical care.
  Continuing to focus on health care providers might be seen for the waste of time it probably is.

Uh, dibs on the patent!

From The Other Side - and the importance of Health Information Technology

Three and half days ago my wife and I decided to mount two carved bears in our front yard before I headed off to work. As I hoisted one of the 45 lb bears up a few rungs on the ladder one of the ladder's legs sunk into the soft mulch. In slow motion the bear, myself and the ladder toppled over and in the process shoved my supervising wife into a pile of stacked rocks sending them flying.

Neither one of us seemed injured although my wife had the breath knocked out of her and the bear lost a toe.  At the time she thought she might have cracked a rib but both of us being in medical field knew there wasn't much you could do about it. So we slowly dusted ourselves off and finished the job as you can see in the picture.

We debated having her come with me to my clinic to have X-rays to confirm whether or not she had fractured a rib or at worst case scenario didn't have a pneumo or hemothorax developing (even though she didn't have any signs of either). In the end decided against it as that would disrupt our normal activities.

Upon arriving home that evening she said her back and ribs were bothering her enough that I had to hold the leashes of both of our dogs as we took them for our customary evening walk around the block.  We retired and upon arising in the morning she continued to complain about rib and back pain and the sensation that she couldn't seem to catch her breath when she inhaled deeply.  Sure enough, the breath sounds on her right side were significantly diminished compared to the left and we headed off to the nearby emergency room.

Within 30 minutes the physician confirmed that her right lung was nearly complete collapsed and showed us the chest films.  There was absolutely no question about the diagnosis and over the next hour she was admitted, taken directly to interventional radiology where a chest-tube was placed under flouroscopy and wheeled up to her bed.

What does this have to do with technology?  Nothing so far but here's where information technology has made the last few days easier to handle than without technology.

First, the entire registration and admission process was electronic and took up less than 3 minutes of time.  The registration clerk came into the ER exam room with her tablet, set it on the Mayo stand and flashed through the registration screens, then flipped and twisted the screen around handing my wife the Wacomm pen for her to sign the consent to treat and initial the HIPAA documents.  Then she turned to me, pulled open another screen and "allowed" me to pay for the co-pay with a credit card then left the room.  No paper, no fuss and no paper-work delays in getting us admitted.  Technology allowed us to be seen and administrative "paperwork" collected quickly and in a way that did not interfere at all with patient care. Even I as a physician was impressed with how smooth it went.

Second, the physicians were keying in the orders leaving only a few hand-written floor orders to be carried up the the floor and as a result everyone knew what to do and when to do it minimizing angst and confusion.

Third, while this was going on I was able to slip to the side and log into my own clinic through the hospital's guest wi-fi system using my iPad that I had been using to read the morning's papers and keeping up with overnight e-mail while my wife was being examined. I did have a busy day scheduled with patient starting at 10am and going through 7pm that sandwiched an important meeting and as soon as I saw the chest film began the process of notifying the patients via our patient portal (or the nurses and schedulers for those who were not signed up with the portal) that they would be receiving a voice call as soon as the office opened up. Then I broadcast an regular e-mail to all of our clinic's staff as well as those who were scheduled for that meeting.  All of this took place before office hours and, like the registration and admission process, was accomplished without having to leave my wife's side or be tied to the phone.  No interruptions and misscommunications.

Fourth, and this might be the most important, one of my wife's first requests when she finally resigned herself to being admitted was for me to bring her laptop along with a good cup of her favorite Kuerig coffee and knitting bag.  Within a few minutes of getting settled into her room she was connected through the hospital's guest wi-fi network and happily watching the US Open in HD on her computer as well as researching her condition so she could explain to all of her friends what had happened.

Over the next 3 days my wife has been confined to her room and the only thing that has made this hospitalization tolerable for not only my wife but me is access to information technology.

• Note to hospitals: make sure you are providing this service to your patients or if not for them their family and loved ones.  It allows so many things to take place that otherwise would be disruptive.

My wife's only complaints so far has been the food and not being able to access her own records, particularly the X-ray images. 

• Note to hospitals: a web portal for hospitals should be in the planning stage as it is for just about every ambulatory office.  
• Patients have a lot of time on their hands and a lot of questions that just never seem to get answered by either the nurses or the physicians that make rounds.

This hospital is probably halfway to being fully digital but even so we've been able to see how several measures can speed up the process of admission.  I'm confident the same will be said about the discharge process.

We've already been electronically appraised of our co-pay estimate and have been able to address this virtually.  I'm sure that the total cost will be a shock to us (even though we're both in the medical field) and it remains to be seen whether the remainder of the stay and discharge will be as smooth as most of her stay.

Now if we could do something about the food!