The first Christmas blizzard ever in Kansas City reminded me why my wife and I chose to live in Overland Park, a suburb of Kansas City on the Kansas Side of the state line Taxes. We chose it because property taxes were significantly higher than just across the border in Missouri. Huh? Doesn’t seem to make sense, you say. Apparently we’re not alone because we’re surrounded by neighbors who frequently get reminded of the benefits of living where taxes are higher and reaping the benefits of those shared expenses. The blizzard? Right. Three hours into the blizzard we saw city snow plows clearing our neighborhood streets. And they came back several times in a 24 hour period. None of us had problems getting out when we needed to. Today we went to Church, 2 days after the snow. The minute we crossed the state line we found ourselves maneuvering snow-packed streets littered with cars stuck in their driveways and communities locked in. Almost all of those who were at the early service lived on the Kansas Side while many on the Missouri side who lived only a few blocks from Church were homebound. Snow plows may never make it to their side streets before the snow melts. In our neighborhood most of us were out shoveling not only our driveways but our sidewalks. Those with snow blowers went from house to house without being asked wishing their neighbors a Merry Christmas. Even teen age school children put aside their Play Stations and cell phones to help. Why? I think a large part of it was that the streets were plowed and therefore the mobility barrier was only our driveways. That wouldn’t be the same if the streets were filled with 10 inches of snow. What good does it do to get out and shovel your driveway when you still can’t go anywhere? So what does this have to do with taxes? When people see their money going to local services like snow plows, good schools and civic government a stronger sense of community and pride exist. Ironically the more selfish people are in the short term the more isolated and costly it becomes for them to live as a community. Communities are made of those who are fortunate and those who are less fortunate. Those who reach out and help each other socially, fiscally, spiritually and neighborly are those who are healthier and live better. I was struck by an Randall Stross editorial by in the NY Times this morning titled, “Sorry, Shoppers, but Why Can’t Amazon Collect More Tax?” (http://www.nytimes.com/2009/12/27/business/27digi.html?_r=1&ref=technology). The article describes the elaborate efforts Mr. Bezos has gone to keep from paying taxes to the states in which they provide services. This gives Amazon a competitive advantage at the expense of teachers, civic services, public roads and a whole host of other tax-based services on which Amazon itself relies. Similar corporate measures are costing states up to $350 billion a year and we’re all suffering for it. Mr. Stross concludes “Amazon’s in-house counsel should help the company meet its civic obligations — and toss “entity isolation” in the trash can. Amazon’s employees are too scattered, its customer base and its sales too large and the states’ fiscal crisis too grave for it to continue to play tax-avoidance games.” Here, here. And the next time it snows, storms or a crisis hits. I’m glad I live in a community that takes it’s taxes seriously.
Sunday, December 27, 2009
Wednesday, December 16, 2009
The Uncertainty of Diagnoses
There was a sentinal event experienced when I matriculated into medical school at the age of 34. The dean of the medical school stood up and quoted a study that showed in 1983 up to 40% of the time the working diagnoses at Johns Hopkins were found to be in error on autopsy results. He then went on to say that by the time we finished residency most of the knowledge we'd memorized in medical school would be obsolete. That's when I went out and spent over $3,500 for a computer only to be crushed that there was very little software that would help me 1) get through medical school and 2) help with diagnosing and treating a patient.
A lot has happened since then but the promise of artificial intelligence, connected health information networks and computerization of health care hasn't really panned out the way I imagined over the last 25 years. But one thing that hasn't changed is the complexity of even simple diseases. Why?
Well, for one we don't practice medicine scientifically. Take a simple sore throat. We don't do viral and bacterial cultures on every one or even a random sample of patients to discover the exact pathogen with which we're dealing. There are probably over 200 viruses and 50 bacteria and a multitude of mechanical and environmental agents that will produce almost identical symptoms. We don't have instant tests with the exception of Rapid Strep, Rapid Influenza and Rapid Mono tests that can help us significantly. Thus for the vast majority of cases we are practicing blind. Fortunately most patient get well from this condition in 2 weeks no matter how we treat. The evidence suggests that with the exception of a very small minority of conditions NOT treating is better than treating but it is really hard to convince patients no treatment is better than treating.
I purchased QMR, Iliad and a subscription to AMANet to access Octo Barnett's DxPlain to help me come to correct diagnoses. What I and my colleagues discovered is that there were about 1,500 signs and symptoms that covered almost all of the known diseases (over 20,000 in the databases). That meant a large number of diseases presented with the same signs and symptoms. There were very few diseases that had pathognomonic signs or symptoms. Consequently we became pretty good at coming up the differential diagnosis (a list of the diseases that shared the same symptoms). Our goal was to rule in or rule out the diseases by ordering tests and procedures.
In primary care we see patients every 10-15 minutes. We go through the same process and usually have a relatively short differential list of diagnoses that we think we're treating. We order tests that are returned to us over the next few days. And yet we have to make a diagnosis for that visit at the time of the visit in order to get paid. We usually pick the most probably diagnosis at the visit and that goes on the claims that is processed electronically.
The labs will come back and either rule this diagnosis in or out. Guess what? There isn't a process for us to go back and amend the visit diagnosis with the correct one if a test ruled the original one out and replace it with another one. My guess is that over time up to 40% of the claims based diagnoses are totally bogus.
And then there are complicated diseases like Lupus Erythematosis or Fibromyalgia with no confirmatory tests. A patient may be seen up to 10 times before these "diagnoses of exclusion" are made. There is no systematic way to go back and amend the diagnoses of the previous 10 visits and change them to the final diagnosis made.
That's why most astute people will take claims based data in the ambulatory environment with a huge grain of salt. What may be more valuable is a big picture of all of the diagnoses over time to get an idea of what's going on with a patient. But that data is usually not available as it's hidden in many physician's charts, EMRs and insurance claims data.
We need a national system for experts to go through reams of claims based data, compare it with the symptoms documented and then systematically modify the diagnoses to improve their worth. That's probably not going to happen.
A lot has happened since then but the promise of artificial intelligence, connected health information networks and computerization of health care hasn't really panned out the way I imagined over the last 25 years. But one thing that hasn't changed is the complexity of even simple diseases. Why?
Well, for one we don't practice medicine scientifically. Take a simple sore throat. We don't do viral and bacterial cultures on every one or even a random sample of patients to discover the exact pathogen with which we're dealing. There are probably over 200 viruses and 50 bacteria and a multitude of mechanical and environmental agents that will produce almost identical symptoms. We don't have instant tests with the exception of Rapid Strep, Rapid Influenza and Rapid Mono tests that can help us significantly. Thus for the vast majority of cases we are practicing blind. Fortunately most patient get well from this condition in 2 weeks no matter how we treat. The evidence suggests that with the exception of a very small minority of conditions NOT treating is better than treating but it is really hard to convince patients no treatment is better than treating.
I purchased QMR, Iliad and a subscription to AMANet to access Octo Barnett's DxPlain to help me come to correct diagnoses. What I and my colleagues discovered is that there were about 1,500 signs and symptoms that covered almost all of the known diseases (over 20,000 in the databases). That meant a large number of diseases presented with the same signs and symptoms. There were very few diseases that had pathognomonic signs or symptoms. Consequently we became pretty good at coming up the differential diagnosis (a list of the diseases that shared the same symptoms). Our goal was to rule in or rule out the diseases by ordering tests and procedures.
In primary care we see patients every 10-15 minutes. We go through the same process and usually have a relatively short differential list of diagnoses that we think we're treating. We order tests that are returned to us over the next few days. And yet we have to make a diagnosis for that visit at the time of the visit in order to get paid. We usually pick the most probably diagnosis at the visit and that goes on the claims that is processed electronically.
The labs will come back and either rule this diagnosis in or out. Guess what? There isn't a process for us to go back and amend the visit diagnosis with the correct one if a test ruled the original one out and replace it with another one. My guess is that over time up to 40% of the claims based diagnoses are totally bogus.
And then there are complicated diseases like Lupus Erythematosis or Fibromyalgia with no confirmatory tests. A patient may be seen up to 10 times before these "diagnoses of exclusion" are made. There is no systematic way to go back and amend the diagnoses of the previous 10 visits and change them to the final diagnosis made.
That's why most astute people will take claims based data in the ambulatory environment with a huge grain of salt. What may be more valuable is a big picture of all of the diagnoses over time to get an idea of what's going on with a patient. But that data is usually not available as it's hidden in many physician's charts, EMRs and insurance claims data.
We need a national system for experts to go through reams of claims based data, compare it with the symptoms documented and then systematically modify the diagnoses to improve their worth. That's probably not going to happen.
Saturday, December 12, 2009
Digital sharing of data and compliance conundrum
The Situation
Saw one of my partner’s patients (new to me), a 71 year old woman with a history of hypertension, late in the afternoon with an 8 hour history of abdominal pain. She’d thrown up once but other than the epigastric pain was not that uncomfortable. Vitals were stable, EKG normal and acute abdominal films were unremarkable. Drew basic labs including pancreatic and liver enzymes and discussed with her the broad differential. She elected to go home and wait for the labs to be resulted. We batch our labs at the end of the day and since she was the next to last appointment of the day expediting the labs by ordering STAT would only add expense without improving the turn-around time.
Drove home, had a cocktail and enjoyed a meal with my family and then logged in to review that day’s labs (which by now were being resulted). To my dismay her liver and pancreatic enzymes were in the thousands. Called her cell phone to advise her to go to the emergency room right away. The patient’s choices were many including the hospital with whom I share an EMR. However, she was at her daughter’s home and there were two other hospitals very close by and she elected one of them rather than drive an hour to my own hospital.
Called the ER to discuss the case with the attending who said this was a “slam dunk” admission and transferred me to the Transfer Team so that the hospitalist could be notified. The hospitalist accepted the patient and asked if I could fax my visit note, recent labs, patient’s Face Sheet and summary to expedite care. No problem, I quickly gathered that information together, assembled them into a document while the physician was on the phone and was about to click the SEND on our e-mail and paused ...
The Problem
Was I doing HIPAA compliant? Probably not.
Even though I had the patient’s verbal consent to do “whatever was required” to get her into the hospital I doubted whether that would pass not only our own internal compliance officers but any state and federal regulator’s judgement.
Our system does have a HIPAA compliant Medical Record Printing (MRP) function that gathers all of the HIPAA variables (who, what, to whom and why) but only allows us to FAX to those devices that have been tested and validated. It doesn’t allow an end user to key in a new fax number. The MRP function has 2 options: Print and FAX. And then only to defined printers and fax numbers. There isn’t a way to generate a password protected PDF file that can be sent to where it’s needed. Nor can it generate HTML documents that could be sent to a secure web server into which anybody downstream who is given the correct password could log in to retrieve it.
Our system also comes with a patient portal allowing patients to access and then do whatever they want with their own information including a function that lets them share the record with another physician who can then log in as a new user and view that record. Over 80% of my patients are taking advantage of this but this was an elderly patient of my partner who is less aggressive in enrolling her patients. This patient didn’t have an account and therefore the other option of sharing her record with the next physician wasn’t available to her.
This information would significantly speed up the admission and workup process on this patient and it was needed in a matter of minutes, not hours or days. I had everything ready to go to the physician with one click of the SEND button. Should I? Which is more important? Compliance with old paper-based regulations or patient care?
Damn the torpedoes
I clicked the SEND button with only a little hesitation and felt good as the hospitalist thanked me profusely, complimented me on the thoroughness of the note which included the patient’s picture, all of the labs, radiologist’s preliminary interpretation and an image of the EKG. She wanted to know why more referring physicians weren’t more accommodating and suddenly realized how important leveraging technology was.
Solution?
There have been years of discussion in Healthcare Information Technology circles about standardizing communications between Health Information Systems, numerous detailed proposals and countless arguments on how Patient identifiable Health Information (PHI) should be transferred from one system to another. In the meantime these types of situations happen thousands of times each day. The overwhelming majority of them are accomplished by Medical Records department personnel locating a paper chart, scanning and faxing the appropriate material to another provider’s fax machine and then taken to the requesting physician. This process take time, often many hours transpire between the request and the fulfillment of that request and often involves many people and supplies. The process is at the mercy of the resolution of the scanner and fax machines so many times the data in the hands of the requesting physician is barely legible. All this time there are low cost solutions using everyday tools that enable the transfer of this information directly between the two physicians who are involved in the care of the patient.
Surely we can come up with better regulations to let us care for the patient without having to worry whether some compliance officer or regulatory will spank us after the fact.
Any ideas would be welcome and passed on to our vendor and our compliance officers. Uh, we’ll keep the regulators out of this one for the time being.
Saw one of my partner’s patients (new to me), a 71 year old woman with a history of hypertension, late in the afternoon with an 8 hour history of abdominal pain. She’d thrown up once but other than the epigastric pain was not that uncomfortable. Vitals were stable, EKG normal and acute abdominal films were unremarkable. Drew basic labs including pancreatic and liver enzymes and discussed with her the broad differential. She elected to go home and wait for the labs to be resulted. We batch our labs at the end of the day and since she was the next to last appointment of the day expediting the labs by ordering STAT would only add expense without improving the turn-around time.
Drove home, had a cocktail and enjoyed a meal with my family and then logged in to review that day’s labs (which by now were being resulted). To my dismay her liver and pancreatic enzymes were in the thousands. Called her cell phone to advise her to go to the emergency room right away. The patient’s choices were many including the hospital with whom I share an EMR. However, she was at her daughter’s home and there were two other hospitals very close by and she elected one of them rather than drive an hour to my own hospital.
Called the ER to discuss the case with the attending who said this was a “slam dunk” admission and transferred me to the Transfer Team so that the hospitalist could be notified. The hospitalist accepted the patient and asked if I could fax my visit note, recent labs, patient’s Face Sheet and summary to expedite care. No problem, I quickly gathered that information together, assembled them into a document while the physician was on the phone and was about to click the SEND on our e-mail and paused ...
The Problem
Was I doing HIPAA compliant? Probably not.
Even though I had the patient’s verbal consent to do “whatever was required” to get her into the hospital I doubted whether that would pass not only our own internal compliance officers but any state and federal regulator’s judgement.
Our system does have a HIPAA compliant Medical Record Printing (MRP) function that gathers all of the HIPAA variables (who, what, to whom and why) but only allows us to FAX to those devices that have been tested and validated. It doesn’t allow an end user to key in a new fax number. The MRP function has 2 options: Print and FAX. And then only to defined printers and fax numbers. There isn’t a way to generate a password protected PDF file that can be sent to where it’s needed. Nor can it generate HTML documents that could be sent to a secure web server into which anybody downstream who is given the correct password could log in to retrieve it.
Our system also comes with a patient portal allowing patients to access and then do whatever they want with their own information including a function that lets them share the record with another physician who can then log in as a new user and view that record. Over 80% of my patients are taking advantage of this but this was an elderly patient of my partner who is less aggressive in enrolling her patients. This patient didn’t have an account and therefore the other option of sharing her record with the next physician wasn’t available to her.
This information would significantly speed up the admission and workup process on this patient and it was needed in a matter of minutes, not hours or days. I had everything ready to go to the physician with one click of the SEND button. Should I? Which is more important? Compliance with old paper-based regulations or patient care?
Damn the torpedoes
I clicked the SEND button with only a little hesitation and felt good as the hospitalist thanked me profusely, complimented me on the thoroughness of the note which included the patient’s picture, all of the labs, radiologist’s preliminary interpretation and an image of the EKG. She wanted to know why more referring physicians weren’t more accommodating and suddenly realized how important leveraging technology was.
Solution?
There have been years of discussion in Healthcare Information Technology circles about standardizing communications between Health Information Systems, numerous detailed proposals and countless arguments on how Patient identifiable Health Information (PHI) should be transferred from one system to another. In the meantime these types of situations happen thousands of times each day. The overwhelming majority of them are accomplished by Medical Records department personnel locating a paper chart, scanning and faxing the appropriate material to another provider’s fax machine and then taken to the requesting physician. This process take time, often many hours transpire between the request and the fulfillment of that request and often involves many people and supplies. The process is at the mercy of the resolution of the scanner and fax machines so many times the data in the hands of the requesting physician is barely legible. All this time there are low cost solutions using everyday tools that enable the transfer of this information directly between the two physicians who are involved in the care of the patient.
Surely we can come up with better regulations to let us care for the patient without having to worry whether some compliance officer or regulatory will spank us after the fact.
Any ideas would be welcome and passed on to our vendor and our compliance officers. Uh, we’ll keep the regulators out of this one for the time being.
Wednesday, December 2, 2009
What I believe about EMRs and Medical Information
I matriculated into medical school relatively late in life (at the age of 34) back in '84. Purchased my first computer with all of our savings (more than $5,000 - can you believe they cost that much then?). My wife threatened to do nasty things to my gonads unless that investment paid off. Twenty five years later it has (thank goodness). Here's what I've learned in the interim:
Now there are equally several big lessons that I've learned in other areas of my life but I'm not sure I want to share those with the world now.
- First and foremost, unless information systems are aligned with human, bacterial and viral interactions they will never fulfill their promise of providing the "RIGHT information at the RIGHT time to the RIGHT people.
- Second, unless the patient is the primary user of the information system it will have trouble delivering a return on investiment. This is what is meant by patient centered approach to care.
- Third, the power of any electronic health or medical record is proportional to the number of other clinical information systems (hospitals, other doctor's offices, pharmacies, etc.) to which it is seamlessly linked.
- Fourth; until physicians begin to think like patients they will have trouble communicating and improving the health of their patients.
- Fifth; until we change the reimbursement formulas, we will never bend the cost-curve of medical care in the United States.
- Incidentally, this is a corollary of #4
Now there are equally several big lessons that I've learned in other areas of my life but I'm not sure I want to share those with the world now.
Friday, October 16, 2009
Healing Heat
Some of my most pleasant memories growing up in Japan were trundling across the street with my family to go to the neighborhood public bath or sento. That’s where many of learned to swim and the underwater trip from the 39° soaking tub to the 41° tub was an adventure. Later on our high school basketball coach would reward the team by walking to the nearby ofuroba where the team would soak away the soreness and then saunter back to the dorm wearing only yukatas with the steam rising into the frosty winter air. The spas and saunas in southern Germany rivaled the Japanese onsens for providing relaxing sweaty conversations with locals and vacationers. Rounds of golf in Korea are completed with a hot soaking bath or you can go to the local Jjimjilbang to bathe. Around the world there are many countries that have a rich public bathing tradition and whenever I’ve been fortunate to travel have felt they play a very large role in promoting physical and psychological health.
Looking back I think there are two very important health promoting forces in play. First, and foremost, is the power of heat (whether dry or moist) in washing away or killing harmful disease promoting viruses and bacteria as well as reducing allergy causing antigens. Time spent in these cleansing environments reduce the chance of subsequent infections and allergies. Second, is the social health that improves when you shed your clothes and interact with other people. The baths, steams, saunas and spas taken with others is much healthier for the psyche than those taken alone. I’m convinced these two factors, when combined, boost the immunity, relax the mind and stave off diseases.
I wonder if there would be less obesity if every day we knew we were going to be spending time naked with our friends and neighbors? Maybe it is entirely anecdotal but it seems that in countries with a public bathing tradition people spend less time watching TV and more time in conversation with each other. This carries over to how they eat as well. It seemed we spent more time around the table communing instead of the table being a place to wolf down the food and leave to watch TV or do something else. It was a place to spend time and enjoy the food and the companionship.
As a physician I’ve been advocating to my patients with a variety of ailments to invest time in going to the local Y where there is an excellent steam room and sauna. Alternatively they should invest in steam generators and convert one of their showers to a steam shower. Unfortunately very few of them follow that advice and I see them all too often in the clinic with one physical or psychological problem after another. For the cost of many prescriptions they could be experiencing the healing power of heat and begin to enjoy life.
Friday, October 9, 2009
Testing Livewriter
Am beginning to see a trend where applications, even those that are competing share the same information. This short blog is being written in the new Windows Live Writer and ostensibly will automatically post this to my Blogspot.com page and Windows Live Spaces.
I’m wondering how long it will be before this interaction translates into the healthcare electronic records? Right now there are a number of Personal Health Records enabling individuals to enter and have access to their health data from anywhere. The problem with most of these is that the data their doctor enters in their offices doesn’t automatically flow into their PHRs. There are some organizations, like Cleveland Clinic, who have formed relationships with Google Health and Microsoft’s HealthVault but most of us don’t go to Cleveland Clinic. We need to figure out how all EMRs being used in physician’s offices can be configured to automatically exchange data with each of the patients’ PHRs.
Recently gave a presentation about the importance of social media in health care. We’re a ways away from social media tools being integrated into EMRs but blogging, twitter, Facebook and other social media tools are laying the groundwork for the interoperability that we’re all wanting.
Playing around with what’s available and waiting for the plug-in that will allow me as an individual physician using a integrated EMR from Cerner along with other 100+ physicians and a hospital to concentrate on what I’m doing and seamlessly update my patients’ PHRs.
Friday, September 11, 2009
Littman 3200 BT Stethoscope & Zargis Cardioscan - Is the PC the problem?
Am midway through testing the Littman 3200 BT Stethoscope and accompanying Zargis Cardioscan and StethAssist software. First, the scope and software do work as advertised. User interface on the scope was relatively simple and didn't really require much training. Similarly the software (both the StethAssist which ships with the stethoscope) and the $395 Cardioscan software do work reasonably well. The problem is in the logistics.
Most of us physicians practice out of several exam rooms and usually are under significant time constraints. In my clinic we have wireless desktop PC's with large 21" swivel monitors that are primarily for the patient to view along with the physician our digital records, radiologic images and patient information. The EMR software (Cerner's PowerChart) is running on Citrix servers. Each of these devices is networked autologon device that is rigidly controlled for security purposes (limiting SD, BT local CD connections).
The Cardioscan software runs on a PC and after inputing the patient information and wirelessly connecting with the stethoscope guides the physician through the steps of collecting heart tones from the 4 standard chest locations (takes nearly 2 minutes to collect all of the information). When finished the softare analyzes the data and produces a graphical and sound output that highlights any murmurs that might be present.
So far so good. The problem is when I move from one exam room to another it's not easy to manage both the PC softare, the scope, the patient and the EMR that is collecting information at the point of care. Installing the software on each of the exam room machines is possible but in our clinic that would entail loading it on 32 devices. More limiting is that each of us with one of these stethoscopes would need to carry around the BT dongle and plugging it in to the networked devices would entail security changes that would compromise the network. Right now we have to carry our own tablets or notebooks into the room along with the scope in order to use it effectively. Even so, the logistics would quickly prevent the effective and timely use of this. The extra time would convert to lost appointments and revenue.
What's needed is for the software to reside on the scope itself allowing us to record a complete sequence. The scope is able to record data but only short segments that can't be paired with specific locations for the Cardioscan software. Unfortunately the small user interface prevents a challenge. What I'd really like to see is the Cardioscan software be published as an iPhone App. This would allow us the flexibility and freedom to move quickly in the exam rooms, on the floor and other locations and collect heart tones needed for downstream analysis and documentation.
There's another problem. The stethoscope costs around $400. It ships with a virtually useless SethAssist software that does not provide any analytical tools and has very limited functionality. Zargis then hits the user with another $400 for the more useful CardioScan software (and also nails you for $17 shipping and handling!). Spending $800 for an 80% solution sticks in my craw as a primary care physician and especially for medical students and residents who would find this most useful.
Recommendations to Littman and Zargis:
Most of us physicians practice out of several exam rooms and usually are under significant time constraints. In my clinic we have wireless desktop PC's with large 21" swivel monitors that are primarily for the patient to view along with the physician our digital records, radiologic images and patient information. The EMR software (Cerner's PowerChart) is running on Citrix servers. Each of these devices is networked autologon device that is rigidly controlled for security purposes (limiting SD, BT local CD connections).
So far so good. The problem is when I move from one exam room to another it's not easy to manage both the PC softare, the scope, the patient and the EMR that is collecting information at the point of care. Installing the software on each of the exam room machines is possible but in our clinic that would entail loading it on 32 devices. More limiting is that each of us with one of these stethoscopes would need to carry around the BT dongle and plugging it in to the networked devices would entail security changes that would compromise the network. Right now we have to carry our own tablets or notebooks into the room along with the scope in order to use it effectively. Even so, the logistics would quickly prevent the effective and timely use of this. The extra time would convert to lost appointments and revenue.
What's needed is for the software to reside on the scope itself allowing us to record a complete sequence. The scope is able to record data but only short segments that can't be paired with specific locations for the Cardioscan software. Unfortunately the small user interface prevents a challenge. What I'd really like to see is the Cardioscan software be published as an iPhone App. This would allow us the flexibility and freedom to move quickly in the exam rooms, on the floor and other locations and collect heart tones needed for downstream analysis and documentation.
There's another problem. The stethoscope costs around $400. It ships with a virtually useless SethAssist software that does not provide any analytical tools and has very limited functionality. Zargis then hits the user with another $400 for the more useful CardioScan software (and also nails you for $17 shipping and handling!). Spending $800 for an 80% solution sticks in my craw as a primary care physician and especially for medical students and residents who would find this most useful.
Recommendations to Littman and Zargis:
- Make sure the BT is BT2 allowing pairing with multiple devices.
- Enable the software to be easily installed on multiple devices.
- Lower the price of the software with residents and PCPs in mind
- Dump StethAssist and ship the system with CardioScan
- Create an iPhone, Pre and other BT enabled device App and enable pairing of the scope to all of these smart phones
Sunday, September 6, 2009
It takes an comedian to make sense of the healthcare debate
Twitterworld has bounced Al Franken's interaction with the Tea Party confontists. I watched in fascination how deference, respect and acknowledgement of other's points of view (no matter how idiotic) carried the day.
The more I watch this video the more humbled I am and vow to spend more time listening to others, making sure that I don't insult them (either on purpose or inadvertently).
We need more leaders like Mr. Franken.
The more I watch this video the more humbled I am and vow to spend more time listening to others, making sure that I don't insult them (either on purpose or inadvertently).
We need more leaders like Mr. Franken.
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