Mayo clinic online_consultations

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Mayo clinic online_consultations

  1. 1. Examining the Practice of Medicine Please speak more clearly
  2. 2. Basic Workflow of Medical Practice• Patients have a complaint or illness• Doctor gathers the information• Doctor determines a diagnosis or approach• Doctor communicates with the patient• The doctor prescribes treatment
  3. 3. Let’s Take A Look
  4. 4. Welcome to UK : Seminar Given Last Night in this Room
  5. 5. Richard Smith Intro
  6. 6. How is Medicine different from days of Charles Dickens? Patient’s have a complaint or illness 1. Ring up their GP Might queue up to be seen Doctor gathers the information2. Information is entered into a computer Doctor determines a diagnosis or approach The doctor prescribes treatment
  7. 7. Medicine TodayPatient has a complaint or illness Ring up their GP Wait in Queue Doctor gathers information and puts it in computerPatient enters information into the computerDoctor reviews and interviewDoctor determines a diagnosis or approachDoctor communicates with patientThe doctor prescribes treatment
  8. 8. Professor Ray Jones
  9. 9. Patient Computer Dialogue
  10. 10. Doctor Patient Dialogue“Dialogue between doctor and patient is a time-honoredprocess revered by the medical profession. Duringconversation with his patient the doctor can establishrapport, evaluate his patient’s ability to engage inproductive discussion, observe his patient’s nonverbalbehavior and collect historical information of clinicalrelevance.…doctors as interviewers are busy, expensiveand sometimes hard to find. It seems reasonable,therefore, to look for substitutes that will serve at leastsome of the purposes of medical interviewing inwidespread and inexpensive ways.” Warner Slack
  11. 11. Physicians often use medical terminology that is misunderstood by patients.
  12. 12. Studies show that 50% of psychosocial and psychiatric problems are missed
  13. 13. 54% of patient problems and 45% of patient concerns are neither elicited by the physician nor disclosed by the patient. Patient and physician do not agree on the presenting complaint 50% of the time.
  14. 14. Physicians control the time of the interview.Time is limited, and it is impossible to obtain complete medical histories regularly from all interviewees during a traditional interview.
  15. 15. Physicians ignore patients.
  16. 16. AlternativeInvolving our patients
  17. 17. Individual Adoption1. Knowledge2. Persuasion3. Decision4. Implementation5. Confirmation
  18. 18. Patient Computer Dialogue • Mayo Proceedings in January 2003 • Solves input problem into computers • Powerful Tool for Quality • Pilot: You want passengers to use electronic tickets
  19. 19. You are at the office• A partner’s patient who has hypertension comes to see you because in the last ten days she has noted that her blood pressure is elevated from its baseline.• Meds Lisinopril 20 mg daily• BP 152/93
  20. 20. What did we learn?• We can not judge quality of care by reviewing a chart!• Inputs are important• Computerized history provided more information that was critical to this case, and was valuable to the clinician
  21. 21. How does it work?
  22. 22. Patient Doing History
  23. 23. OUTPUT IS GIVEN TO YOU • Given to you on paper • Given to you in electronic form like into Word • Directly into an EMR
  24. 24. ADVANTAGES Collects more data then a clinician and organizes it into a readable form
  25. 25. Patient is better organized Patients can do this
  26. 26. Patient collects information that the clinician misses • 40% of time provided useful information not typically elicited • Essential Questions missed • Pilot’s Checklist
  27. 27. How dangerous is health care? Note: both dimensions are logarithmic scales DANGEROUS REGULATED ULTRA-SAFE (>1/1000) (<1/100K) Health Care Driving 10,000Deaths per year 1,000 Scheduled 100 Chartered Airlines Flights Mountain European Climbing Railroads 10 Bungee Manufacturing Nuclear Jumping Power 10 10,000 100,000 1,000,000 10,000,000 Number of encounters per death
  28. 28. Socially Sensitive
  29. 29. Highly Adaptable SARS
  30. 30. Others• Patient controls interview-length of time• Doctor only deals with positives• Research• Multimedia• High patient acceptance• Scales
  31. 31. Scales• Zung Depression• Rahe Stress Scale• Urology Scales• Wast• Conners• Anxiety• Pain impairment• Patient Education Needs
  32. 32. Tough Diagnosis
  33. 33. Jane DoeChief Complaint Sore throat VS stableSore throat 3 days duration
  34. 34. We have basic history
  35. 35. Time of a Routine Office Visit 8 S O 7 A 6 8Minutes P E 5 4 3 Plan 2 1 Subj. 2 Obj. 2 Pat Ed 0 0.1 Traditional
  36. 36. Future Time of a Routine Office Visit S 8 O 7 A 6 PMinutes E 5 4 3 Subj. Plan 2 Obj. Pt. Ed 3 1 3 2 0.1 2 0 Software
  37. 37. Complete Physical 35 S 35 O 30 A P 25 E 20 Subj 17Minutes 15 15 10 7 8 7 Extra Time 5 Plan 5 Obj Subj 0.1 Plan 0.1 Obj 0 OLD NEW
  38. 38. Lets look at history 80/20 Rule20% of your questions get you 80% of the content Negatives are time intensiveAnalogy Mining for Diamonds!
  39. 39. Mining-Topsoil sand it is easy Open ended questions Listening 2 minutes
  40. 40. What are the results ofAll this labor
  41. 41. It is like MiningYes/No questioning-tailings
  42. 42. You can use a machine toDo the hard time consumingWork
  43. 43. You are in controlYou will trust the work doneCheck out a few things
  44. 44. Several Studies• Acceptance has been documented in ethnic18 diverse groups, rural practices19, in prenatal visits20, patients seeking a urologist help21, adolescents22, sports examinations23, and well child visits24. Reliability has been assessed between personal interviews for gynecologic patients25, preoperative patients26, and general practice27-29.
  45. 45. UK Has Done Leading Work in Documenting that it Works
  46. 46. Using the Internet to PracticeMedicine RSM September 21 2010 Dr Richard Sills Thalidomide Trust and IMHUK
  47. 47. Healthlink Facilitative telephone support line to helpBeneficiaries to access the Health Care that they need. Not a clinical service. Anne Horton and Lizzie Hurst.
  48. 48. Healthlink• About:• Listening and synthesising histories and helping to sort out priorities and what can be done next to try and solve problems.• Journeying with beneficiaries as they try to get the help that they deserve.• Collecting information that may be generically useful and making it available.
  49. 49. Some numbersl Beneficiaries that have used Healthlink: 211l Medical/Health issues: 978 (4.6 per individual)l Problems accessing or communicating with NHS 153l Disability related accidents / falls: 27l Abuse issues: 14l Pain or Unpleasant sensation in extremity: 182
  50. 50. Healthlink needsl Personal Health Record: to store individuals own information so that they can present it to Health Care Professionalsl Electronic Communications between beneficiaries and Healthlink. Also with Healthcare Professionals involved with their care.l Electronic communications between experts to discuss Thalidomide related cases.
  51. 51. Mandy De La Merefile:///F:/UNP_Yours_22260_Mand%2314F47F.JPG
  52. 52. Mandyl Disabled, blind and no useful armsl Getting to and from doctors appointments is more difficult.l Can use Instant Medical History using speech recognition and Screen readerl Should be able to have electronic dialogue with the Healthcare professionals involved with her care.
  53. 53. Thank you Richard Sillsrosills@medicalhistory.com
  54. 54. Individual Adoption1. Knowledge2. Persuasion3. Decision4. Implementation5. Confirmation
  55. 55. It collects for appraisal a large and comprehensive body of information about the patient’s medical historyat no expenditure of the physician’s time;it facilitates interview by making available to the physician a preliminary survey of the patient’s total medical problems; its data being systematically arranged, are easier to review than those of conventional medical histories, and, by calling attention to the patient’s symptoms and significant items of past history, it assures that their investigation will not be overlooked because the physician lacked time to elicit them
  56. 56. DECIDING TO CHANGE
  57. 57. Aim #1: Health Care Must Be SafeAim #2: Health Care Must Be EffectiveAim #3: Health Care Must Be Patient- CenteredAim #4: Health Care Must Be TimelyAim #5: Health Care Must Be EfficientAim #6: Health Care Must Be Equitable
  58. 58. Case Study: Mayo Clinic’s 2700 online Visits The Nuts and Bolts of Doing Online Consultations John Bachman Saunders Professor of Primary Care Mayo Foundation Bachman.john@mayo,edu
  59. 59. 4 FACTORS DECREASED COSTSACCESS FORPATIENTSINCLUDESSATISFACTION AND HAPPIER PROVIDERSSENSE OF BEINGCARED FOR IMPROVED QUALITY OF CARE
  60. 60. Paradigm Shift• Patients appreciate a doctor-patient relation- ship that involves electronic communication• Telephone as a communication device is expensive (labor) and inefficient (time)• Online Consultation requires a paradigm shift.
  61. 61. Tools are here… but not put together well• What you do not want…. Is what you imagine e-mail…..
  62. 62. E mail consultationI had surgery on June 11th, things went pretty well as far as the surgery went. I did feel pretty awfull for the first 2 weeks and the day I left the hospital my incision broke open---I had to pack it for 3 weeks then it was restitched and healed well.I have to admit, the first couple of weeks I was really beginning to wonder if I had done the right thing but my mind is slowly changing. It is interesting to feel myself slowly turn my priorities away from eating. It is consistently amazing to realize how much focus there is on food, in society and in my life specifically. Jim and I always have a ton of company, from friends to family and you know, company centers around food!!It is an amazing feeling to be full so quickly---I am still not used to that feeling. I do have my fears about not getting enough protein in, I seem to be having a problem eating meats but I am not to regular foods yet and I am still trying to tell myself to slow down, that is such a hard habit to break! I cant really eat sweets, so far anything too sweet just makes me sick. The adjustment of not drinking while eating is difficult too, but getting easier. The milk drinking is getting easier too.I am so grateful for the year prior to the surgery---I know it was a long time and it was making me spitting mad at the time but................the group sessions were such and asset to me ---I learned so much, I developed actual habits and restrictions in that year. I had pretty much given up sweets and over eating and I think that has been a springboard for me with my diet now. I went to group every week with few exceptions. I learned so much about myself, others, and eating disorders. I gained an insight that so diet could have ever brought to light. I learned to quit beating myself up, to recognize weaknesses and avoid them. I learned and practiced the importance of activity. The importance of "self-talk" was emphasized and I used it as a tool every day---especially on the bad days. I learned that it was never too late and that being over weight was not a sentence, that it was overcomable but that the road to overcoming was a difficult one and that I needed help in changing from the well trodden path to a new one. I am now acutely aware of emotional eating, but I have no choice in the matter, I simply can not indulge---it is so wonderful. I ended up losing 50 pounds in year that I went to group and I am very glad for that little boost. I had a fantastic group leader, I really lucked out! Not for sure how much more I have lost but I know the total is well over 100 pounds. and yes..............I feel so much better. I can walk up the back of St. Marys Hill without even getting out of breath. I am still riding bike and of course riding horse. In fact, Jim and I are going to Wyoming in September for our 20th anniversary---we are taking our horses out to the Big Horns riding for a week---I am so excited--this has been a lifelong dream for me and now my horse has 100+ less pounds to lug. Let me tell you, riding is so much more of a joy for me, it is like starting all over.Karie is doing well, still in PA with Jason, they were home for 2 weeks this month and we really like him, he is very sweet and seems totally devoted to Karie---while I dont care for his tatoos,(its a mom thing)he really is great. He had a great time in Minnesota---so maybe the might move back here.Justin graduated and Jim and I are really empty nesting it---Justin is working in the cities and staying with my niece--he plans to attend RCTC winter quarter.I am still going to school, I completed my Associates Degree last spring and I only have 22 credits left for my Bachelors.I do so hope all is well with you, I think of you and your family often.I want to thank you again Michelle for all of your years of care and concern, but most of all for directing me to this surgery and the journey that brought me to it.please......................if you have any patients or aquaintences that would like to "chat" with me about my experience, feel free to use my name and give them my number or e-mail address, I am more than happy to share.
  63. 63. Omissions• What do you want from me?• What medications are you taking?• Are you allergic to anything?• What chemist?• Organized Approach• Data is structured
  64. 64. Tools only part of it ProcessesInfrastructure Culture
  65. 65. Infrastructure starts with an Electronic Patient Portal• Place to store data and communicate online• Secure• Schedule appointments, Prescription Refills, Look up lab studies, Do forms, Patient Education, and• ONLINE CONSULTATIONS
  66. 66. Primary Care Online
  67. 67. Restrictions1. Short Leash- Committee supervised our activities monthly2. Learn as much about e-visits as possible3. 3 year pilot or until our own Mayo portal4. Patients had to come in to sign up5. Residents of Minnesota only
  68. 68. Demonstrate, then the Online Visit
  69. 69. Patient View
  70. 70. Doctor’s View
  71. 71. Others can see On call
  72. 72. Exchange DataYou do not need to be seenIn Reality Why it Could Work EVIDENCE BASED PROTOCOLS
  73. 73. Results of symptomassessment algorithms
  74. 74. Results of patient symptomassessment
  75. 75. c
  76. 76. Which would you want?• Call on telephone • Go Online• Nursing time for • Clinician uses set protocol protocol • Clinician checks prevention• Clinician time to say ok • Instructions that are written• Appointment desk • Prescription faxed• Nurse faxes automatically prescription • Time in minutes• Verbal instructions• Time in hours• Clinic loses money
  77. 77. Save Time - Go Online PCOL
  78. 78. Our First Online Consultation
  79. 79. Patient was also scheduled for a mammogram
  80. 80. Registrations 1381 Registrations PCOL Monthly Registration 350 TRAINING TESTING EXPANSION 300 250Patients 200 150 100 50 0 Sept October November December January February March April Months
  81. 81. End of 7 Months –Processes and Vendor Figured Out! 1400 registrations 500 visits 110 billings
  82. 82. WE HAD A PAUSE Institution issues
  83. 83. PAUSE• Way too successful• Moving outside of the scope of the pilot• Meeting
  84. 84. SLOW DOWNRECOVERY COMPETENCY
  85. 85. We now can look at results
  86. 86. Totals 2 years Largest Study Reported• Total Registrations- 4282 – 7% primary family member – Linked to 12%• Online Consultations- 2531• Total Consults Billed- 1159
  87. 87. What was the most common online complaint ???
  88. 88. 293 different conditions were found
  89. 89. Who did the consultation???
  90. 90. What else did we learn? 71% were women Youngest 4 days, oldest 86
  91. 91. 8-12
  92. 92. Prevent Visits to Office• 40% of the time saved a visit• 12.8% Come in• 16% Protocols• 11% of the time handled by “on call”
  93. 93. Insurances or Paid 457 35% billed
  94. 94. Ping Pong• 29% of the time received a reply• 31% of that was thank you• 20% about was request – What pharmacy?
  95. 95. ActivitiesNew diagnosis and new prescription (1,148 visits - 45%)Refilling a prescription for prior diagnosis (250 visits - 10%)Ordering x-rays and procedures (264 patients - 10%)Ordering laboratory studies (126 patients - 5%)
  96. 96. Three corollary studies• The farther you lived from clinic more likely to use on-line care• No additional visits required as compared to express clinic or office visit• Patients generally reflected the population of our practice
  97. 97. Pictures• 49 pictures were sent in• 2% of our practice – Diaper rash – Bites – Contact dermatitis• Prescription refills
  98. 98. Ideas for future
  99. 99. Messaging
  100. 100. Messaging• Birth date• Selected diseases (Pit stop)
  101. 101. Most VOVs have GDMS sent to the Clinician So what?
  102. 102. So in October we saved a life• Dr. Furst ordered a colonoscopy based on GDMS from a prescription refill• Detected a localized adenocarcinoma
  103. 103. Messaging with Pit Spot
  104. 104. Where We Are• Mayo is using its own portal• All employee health doctors, 350 doctors• Roll out to our specialists• Bumpy
  105. 105. Cultural Change• Staff knows to push people online• Clinicians see as way of saving time• Revenue source
  106. 106. In Conclusion Successful pilotInfrastructureProcessesCultural ChangesDeep Dive into Patient Computer Dialogue
  107. 107. Where are we?
  108. 108. How is Medicine different from days of Charles Dickens? Patient’s have a complaint or illness 1. Ring up their GP Might queue up to be seen Doctor gathers the information2. Information is entered into a computer Doctor determines a diagnosis or approach The doctor prescribes treatment
  109. 109. Medicine TodayPatient has a complaint or illness Ring up their GP Wait in Queue Doctor gathers information and puts it in computerPatient enters information into the computerDoctor reviews and interviewDoctor determines a diagnosis or approachDoctor communicates with patientThe doctor prescribes treatment
  110. 110. Advantages Disadvantages Phone systems?
  111. 111. Sarah Bruml’s Office
  112. 112. ACTUAL MEASUREMENTSTime Activity # Pats Time per Opportunity pat8:30-9:55 Phone Triage 5-15 7 pats/80 3 min/pat =10 pats/30 mins = 10 mins = 50% savings min/pat9:55-1PM Surgery 10 10 pts/180 3 min/pat=10 pats/30 mins = 18 mins = 17% savings min/pt
  113. 113. Time During Day Phone Phone90 minutes saved in an !! hour day (plus lunch)! 8
  114. 114. Link to NursingLink to Nurse by self
  115. 115. National Health Service Call ReportCall1d: 166697Patient Name: ADRIANDaviesCall Priority,HP01225810300, 16106/19593Call Reason: COUGHTypeDescriptionDateTimePMHARTHRITIS14/12/200100:03 MEDICATIONDISTALGESIC14/12/200100:03ALLERGYFISH14/12/200 100:03User: Thomas, Sarah DatelTime: 13/12/2001 23:59 caller rang back -breathing worse - reprioritised to a 3.User: Phillips-winter, Beverley DatelTime: 13/12/2001 23:22Had a cold earlier in the week. Breathing very heavy Burning feeling inchest and when bad has pain in left shoulder. Family history of heartdisease but doesn’t think this is what he has. Is a heavy smoker. TakingWilkinson Bronchial Balsam which eased his breathing over the time ontheTitle: Cough User: Wilkes, Ann DateTime: 14/12/2001 00:07 Cough Has the individual developed significantbreathing difficulty with high pitched or crowing sound when breathingout?-NO Notes:COUGH AND COLD FOR A WEEK
  116. 116. Call Handler Okay. Right and how can we help you today?Caller Right un well had a cold a little while ago ... well probably sortof got rid of it um whats today... Thursday... so I probably got rid of itWednesday... sorry Monday or TuesdayCall Handler Uh huhCaller Um Ive got to admit Im a smoker but since Ive had the coldIve had this horrible burning feeling in my chestCall Handler Uh huhCaller Going down my windpipe and when its really bad a chronicpain in my left shoulderCall HandlerRightCaller Um, it feels as though my chest is becoming restricted andeverything else. I think Ive got some form of bronchial infectionCall HandlerRight yes you are struggling to breathe at the momentarent you?Caller
  117. 117. Call Handler Yes rightCaller Yes um which has certainly cut down my smoking which is a goodthingCall Handler Uh huhCallerBut it is getting to the point now where it is really getting sore and itdoesnt appear to be getting betterCall Handler RightCaller And if I take the bronchial medicine... uh cough medicine that webought it just only gives about 2 minutes reliefCall Handler Right okay. So have you actually consulted your doctor at all?CallerNot yet, its just got very bad todayCall Handler It hasCallerYesCall Handler Okay right. So Im sorry .. youve got a burning feeling in yourchest and when it gets really bad you said it hurts in your shoulder?Caller Yes. It feels as though um you know when you get a really bad chestycough you get that burning sensation in the windpipe
  118. 118. Call HandlerRightCallerIve got that sort of feeling and Ive got... when it getsreally bad like it isat the moment I get a pain in my leftshoulderCall Handler OkayCaller Un I dont think its my heart cos we have... I have got afamily history of heart disease but I dont think its thatbecause normally thats pins and needles in the left arm andIve been warned on everything to lookout for so I mean itsjust some form of infection but I just cant seem to knock itawayCall Handler Okay. Right so and this has all been brought onby the cold that you had earlier?Caller I believe so yesCall Handler Right. Okay, can I take your GPs details please?
  119. 119. Caller Yes. If I could... its eased off completed now, I tooksome medicine um sort of 10 minutes agoCall Handler YesCaller I get about 2 minutes instant relief and then it really sortof cripples me for a little while and then it starts easing offand then it will ease off for a while and then I ... Im doubledup again you know sort of in absolute agony finding it difficultto breathe againCall Handler Right okayCaller Um which makes me think it is something to do withyou know I .. is.. something to do with the thing because if itwas.. like I was a bit worried the first time it happened and feltooh hang on this could be my first heart attack coming uphereCall Handler Uh huhCallerUrn but I took some of this bronchial cough medicinestuff and that cleared it awayCall Handler Right do you know what the actual name is of it?
  120. 120. Caller Yes ... Ill just get itCall Handler Thank youCaller Yes its urn I must admit it was a bit frightening .... Theymust like himCall Handler YesCaller Well believe it or not its Wilkinsons you know the WilcobrandCall Handler Oh yesCaller Yes mentholated bronchial balsam for the relief of ... forthe symptomatic relief of sore throats, coughs, colds andcatarrh. Its going down my neck as if its going out of fashion atthe momentCall Handler RightCaller And obviously that aint going do me any good eitherCall Handler RightCallerI dont normally like bothering the doctor butCall Handler NoCaller You know... this has got so bad probably since 3 oclockthis afternoon
  121. 121. Call Handler RightCaller Its really started playing upCall Handler Yes okay. Right thats no problem. If you hadntactually called us today what would you have done? Would youhave called your GP or?Caller Um I wouldve probably suffered it to be honestCall Handler Oh goodness, rightokayCaller LaughingCall Handler Oh dear okay, thats fine. What I shall do is actuallyask one of the nurses to call you back then if thats alright?
  122. 122. Output
  123. 123. Downside of having people between doctor and patient• Link to patient
  124. 124. Questionnaires
  125. 125. General• Mayo Clinic-PPI 13 page form 216 questions, 25 spaces• ACOG on line 90 questions• How many are enough?
  126. 126. Domestic Violence • J of Family Practice using the WAST(Woman abuse Screening Tool) • 8 questions • UCC requirement. It should be done on all women • 8% pick up rate • Other things
  127. 127. Review of AFP in just one year• 44 questionnaires (2 an issue)• 4-37 questions• CAGE-alcoholism• Check list to Assessment areas for Maintaining Healthy Geriatric Patients• Depression scales• Smoking Scales• Lead
  128. 128. Using the questionnaires leads to better outcomes than normal patient interviewing!
  129. 129. Patients
  130. 130. Dr. Patrick Cadigan, a cardiologist and spokesman for Britains Royal College of Physicians, described Internet-based medicine as "second- best," and said it was particularly difficult to make a diagnosis without seeing a patient in person. "To lose personal contact with your patients means you lose clues about what may be wrong with them," he said. Cadigan worried some patients may not understand the difficulties of being treated online.
  131. 131. A machine can come between me and my patient! • All of this is true • It need not happen
  132. 132. He said some people might need some more in- person prodding, as opposed to the standard questionnaires employed by most websites, to correctly answer questions about other health conditions or medical treatment they were already on.
  133. 133. • "If you dont get a thorough medical history from thepatient, you could prescribe something that might have adverse effects," he said. "I am concerned thesewebsites could be steering patients to treatments for a financial incentive rather than for their own good."
  134. 134. Dr. Lori Heim, president of the American Academy of Family Physicians, said examining pictures to make some diagnoses may be OK, but warned of potential problems such as doctors missing symptoms elsewhere on the body the patient hasnt photographed.
  135. 135. She said if patients had multiple symptoms or a condition that naturally required a physical exam, like listening to the heart, lungs or conducting joint exams, seeing a doctor virtually wouldnt work. She said doctors should be particularly careful about prescribing drugs like Viagra and worried about the web sites becoming prescription mills.
  136. 136. US talking about UKBershow believes e-visits can help primary care physicians practice more efficiently. “They did a study in England which demonstrated that a provider could complete an e- visit in three minutes, so if you were really working efficiently, you could do 20 e-visits per hour, which obviously you cannot do in the clinical setting,” he says. “Plus there’s no office overhead in terms of table paper, gowns, tongue blades, etc.” Bershow adds that e-visits can cut down on some unnecessary tests such as in the case of a patient who has a history of yeast infections and describes classic symptoms in the electronic inquiry.
  137. 137. • Procrastination
  138. 138. A winter storm was coming and the wood supply was not adequate and you have a dull saw
  139. 139. The Problem of Delay and Denial
  140. 140. They had to stop what they were doing!
  141. 141. How long can we deny and delay?
  142. 142. A generation!• Go down in the boiler room where it is dark, noisy, dirty, and greasy• Go up into the sails and feel the wind in your face and the see the beauty of the sea• Remember You are called a sailor• What is a sailor without sails?
  143. 143. World changes • Are we like sailors in the ship? • When confronted with change we say “doctors don’t do this” • World has changed • Still trying to act like it has not • Try to do things the same way
  144. 144. Paradigm shift• Problem is in the mind
  145. 145. The First Teaching of a JEDI... The Problem is in our Minds• Going Digital is a whole new way of doing things “No! No Different. Only Different in your mind”
  146. 146. Different in Your Mind Behavior as Doctors• To extinguish old behavior-uncomfortable• To establish a new behavior-unsettling• We like to be competent-This is a very different environment
  147. 147. Describe this Wheelbarrow
  148. 148. Look at your brain when seeing something new • DENIAL • DELAY • DISPATCH
  149. 149. Not real – only in your mind
  150. 150. Point is1. We start2. We go negative3. We stay negative and keep going on4. Why?
  151. 151. THE DOWNWARD SPIRAL
  152. 152. Brain has Two PartsReptilian Brain with Human Cortex on top
  153. 153. Cave Man Finding Something New: LIMBIC1. I must attack it2. I must run from it Emotion
  154. 154. Later Developed system? NEOCORTEX! Think Ahead Positive about the new Open- minded Suppress emotion
  155. 155. It is really important for theforebrain to know the Power of Negative Thought ...Limbic• Neutral Environment• Four positives to equal one negative• Be positive, positive, positive, positive and positive
  156. 156. Five Pennies
  157. 157. FEARS GENERATED• Loss of money• I can not do this and I will look stupid• I may not survive• It is too hard• Let me wait, Let me run away, It will never work• Delay Dispatch Deny• It is just too big
  158. 158. Good Potential Concern• What is Good about this idea today? Positive aspects first• What Potential does this idea have for tomorrow?• How can we address Concerns in ways that promote success?• Talking Stick• Candy
  159. 159. We Must Start With Our Minds• Every decision has emotion• Neutral environment• Good potential concern
  160. 160. Paradigm shift• Requires Creativity – Blocked by judgments and work
  161. 161. Creativity means Destruction• Clay Christensen
  162. 162. Beat competitors with asymmetry of motivation % of tonsSteel Quality 55% Sheet steel 22% l Structural Stee l stee 8% ed ds uc rs & ro rod Angle iron; ba ill -p 4% inim Rebar ofm ality Qu 1975 1980 1985 1990
  163. 163. Characteristics • Low quality • Serve market that does not need added features or is not served • Not a threat to traditional market • Companies leaving market are praised until the big drop
  164. 164. Another Example Major Established Electronics Markets: Tabletop radios, floor-standing televisions, computers,Performance telecomm.equipment, etc. Portable TVs Pocket radios Path taken by Hearing Aids established vacuum tube manufacturers Time Disruptive technology: transistors vs. vacuum tubes
  165. 165. Examples in Medicine• Cardiac Surgery• Angioplasty• Stenting
  166. 166. Disruptions Amongst Healthcare Professionals re s n nai io Complex u est Q ph one ks T ele e ban n Ph o Performance that the marketplaceComplexity needs orof diagnosis utilizes and treatment re Se lf-ca Simple Time Patient Computer Dialogue
  167. 167. Patient Computer Dialogue is Disruptive Role of Thalidomide Trust• New evolving products on faster track – Beneficiaries of Thalidomide Trust will accept early development• Serve market that is not served• Not a threat to traditional market
  168. 168. Other Models
  169. 169. Online Banking• 40% of the banks in the U.S. offer internet banking facilities worth mentioning• The UKs first home online banking services[2] was set up by Bank of Scotland for customers of the Nottingham Building Society (NBS) in 1983
  170. 170. Online Banking• Be that as it may, it is estimated that a total of 55 million families in America will be active users of online banking by the year 2010.•• The number of online banking customers has been increasing at an exponential rate. http://ezinearticles.com/?History-of-Online-Banking&id=270075
  171. 171. Drivers1. Reduce Cost2. Competitive Advantage3. Protect Strategic Position
  172. 172. Banking• For example, while the cost of transaction for money transfer was 40p for checking and 10p for ATM, while it was only 1p for Internet• First ATM 40 years ago
  173. 173. Online bankingIt is generally recognized that perceived risk plays a negative role in decision to adopt a new technology including Internet serviceRegarding Internet banking, perceived risk involves two concepts: security and trust.Complexity is “the degree to which an innovation is perceived as difficult to understand and use” Ease of use”
  174. 174. Where is Patient Computer interaction in other industries and where in Medicine Where would you place yourself?
  175. 175. Characteristics• earlier adopters have – greater empathy – less dogmatism – less fatalism – greater rationality – great intelligence – more favorable attitude toward change.
  176. 176. Speed of innovation• the degree to which an innovation is perceived as being consistent with the existing values, past experiences and the needs of potential of potential adopters• negative attitudes cause resistance to change and lack of management commitment
  177. 177. Reminders
  178. 178. Speed of Innovations Larger organizations do better than smallgenerally (implementation of online banking)
  179. 179. So What is Next?

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