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Technology in the ED: Boom or Bust
- 3. Using EHRs Meaningfully Improve quality, reduce disparities Engage patients Improve coordination, public health Privacy and security of information
- 12. Just as factory jobs were eliminated in the 20thcentury by new assembly- line robots, we were the first knowledge-industry workers put out of work by the new generation of "thinking" machines
- 15. Thanks! Nikhil Goyal, MD Residency Director, EM/IM Program Director of EM Informatics ngoyal1@hfhs.org @EMWhizz
Editor's Notes
- Welcome tech trends that have the potential to significantly impact the future of healthcare and specifically the ED Not about the latest gadget that helps us diagnose or treat a specific condition, Overall I’m a big fan of tech & computing, and I strongly believe that physicians using appropriate, well-designed technology can greatly improve healthcare in the US – resulting in better health for the population and improved career satisfaction for us. I’ll bring up a number of current and emerging technologies that exist right now. For each tech, I’ll talk about it’s current state, pros and cons, and then try to predict it’s future – will it have a significant impact on us 10, 20 years from now, or is it a bust. One piece of tech I don’t have is a time machine – but I’ve researched what has happened in the past, what is happening in our world outside of healthcare, based on this I will try to predict future At the end of the talk, I look forward to your thoughts and comments on what you think will be a big influence on our practice.
- Most significant transition in recent years. Thanks to a $27 BILLION incentive program from the federal government, promoting “meaningful use” of EMRs. MU is a bad word, but the idea is that you can’t just buy a shiny new product and get your check. You have to show that the EMR is actually doing something useful.
- The govt wants us to do 4 things with our EMRs Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, and population and public health Maintain privacy and security of patient health information But I think we can all wholeheartedly endorse the goals of MU All these goals a definitely achievable with EHRs. They offer multiple benefits to patients, doctors, hospital and public health. Huge step forward from paper charts in getting to this future. The problem is that EHR vendors have decided to go with a check the box mentality. Meet the minimum requirements required to get the money, in the easiest way possible. That’s why when MU asks for “clinical decision support” rules, we end up with a judgement on the “appropriateness” of our Head CT order on a person with HA, BP 200/150 and INR 20. Imagine an EHR that actually provides helpful clinical support. When you start working on a patient with Chest pain, it automatically enters and highlights the patient’s cardiac risk factors, flags any EKG changes, pulls the last stress test (from any hospital). Think Amazon – when you order a Head CT for stroke, the EHR tells you “people who wanted head CTs for stroke, also ordered coags and made the patient NPO. Click here to order these.” EHR acting in a support – helping us do what we want to do, rather than try to change what we do. So while our current implementation of EHRs are destined to die, my overall verdict on the success of the concept of EHRs is…
- …BOOM! EHRs are the way of the future, they offer a promise of fixing some of the most vexing problems with healthcare, problems that us as ED physicians and our patients struggle with on a daily basis. But all is not quite blue skies and sunshine for the future of EHRs.
- …because EMR Interfaces are terrible! This is the UI for most popular, industry leading EHR today. Henry Ford paid $350 million dollars for this.
- This is user interface for the most popular, industry leading search engine in 1998. It was the “starting page of the internet”. Google launched the same year. About 10 years later, Yahoo had dropped to about 20% of the market, in #2 place. Last year, Yahoo had 1/8 of the desktop search market, third place in three major competitors. Are doctors different than the general public/lay people? How many of us used Ovid in the past to find and access articles? What do we use now? Pubmed.gov If you have to spend tremendous time and resources in order to train people on how to use a product, to train people to not do what naturally comes to them, you are not looking at a success story.
- Boom or Bust? Bust. While I’m bullish on the concept of EHRs, these interfaces are going away The fundamental reason yahoo lost to google was that information was growing at a tremendous rate. Yahoo was a web catalog; they wanted to classify every page into a category and ask people to navigate their hierarchical tree. If you wanted info on Pneumonia, you went to health, then diseases, then infections… Google decided to take the approach of what people want as an end product – answers. Get them there as fast as possible. Reinvention of the EHR UI requires a fundamental rethinking of the medical record and the billing of healthcare in the US. Ask ourselves – what do we want to do? Provide outstanding healthcare to our patients and get paid for what we do. Scribes are a workaround; the future is better EHR interfaces. Using a car analogy, imagine a world where driving a car was so complex that everyone hired a chauffer. Is that a future we want? Is that sustainable? Cars are designed around intuitiveness. And the future is self-driving cars.
- It’s a shift in the way we approach computing. It’s a seamless integration of computing into our lives. “things” – devices, vehicles, buildings, objects embedded with sensors, software and network connectivity. Sensors allow them to interact directly with our physical environment. They can acquire data such as location, position, heart rate. Software allows them to turn this data into information, paint a picture that tells us something; the patient is bradycardic, you are walking into a starbucks and it’s 7am, so you probably want to order coffee Network connectivity allows these things to communicate with other things, and acquire information from the cloud. This turns information into actionable knowledge. So your mobile phone can talk to the starbucks cash register and automatically order your favorite kind of coffee. Or it can tell you that there are 10 other people in line at this starbucks, if you went to the other store around the corner you’d be better off. Finally these things are integrated into our workflow, into our lives. So getting this actionable intel, or making something happen the way you want it to, does not require that you do something different. They work according to how we do things, rather than make us work according to how they want it done. That’s how we have apps that can provide real-time translation services to almost any other language, including sign language. Apps that test your patient’s vision, apps that tell you if the rain will pause for just enough time for you to make it to your car.
- One example from Henry Ford EM is our WIRE app. The ACGME requires that every 6 months, we report to them how each residents is performing on 227 “milestones” or observable behaviors. A very complex task that requires observation, data collation, reporting that we were able to make intuitive and easy for our faculty. Our faculty can focus on teaching or residents rather than filling out forms, and the app helps them quickly report their observations. IoT is only getting bigger. Imagine a situation where your defibrillator talks to your car, and automatically pulls you over if you are about to get a shock. Or your standard patient monitor communicates with a medication delivery system for your patient in septic shock; it automatically gives fluids until the CVP is 8, then starts pressors, or inotropes depending on the MAP or SvO2. There’s a downside. The more connected you are, the more there is the threat of hacking and stealing your medical data. Credit card numbers, social security numbers, etc. sell for a few dollars or less on the black market. Health care data goes into the hundreds of dollars. We are big target An infusion pump made by Hospira was recalled because it could be remotely controlled to modify the infusion rates, etc. We’ve all heard of the Chrysler exploit affecting 1.4 million cars that could be remotely controlled, taking over steering, transmission and brakes. Thankfully companies are now paying a lot more attention to security when designing these products
- Overall, I’m calling this a boom. Technology will continue to make inroads into our lives, using “wearables” with novel sensors that monitor the human body, complex algorithms to turn data into information. The key to success is integration into how humans work Are nurses going to become obsolete with the IoT? When sensors can talk to medication delivery systems? Not at all! The role of nurses will evolve, as it has over the years. Sitting down with a patient, talking to them, understanding their goals and aspirations, that human touch cannot be substituted. How many nurses are complaining about the fact that they don’t get to measure a patient’s pulse or blood pressure? They are happy delegating this task to the machines and instead working on a higher level with more important tasks.
- Most people have heard of podcasts, essentially new version of books on tape. how many listen to them? How many use them as a means of becoming a better ER doc? Very hot right now, just about everyone wants to create their own podcast Good: human connection. A good narrator can really engage the audience more than a book ever could Bad: same issue as books; as good as the author and editor. Goal of learning is transfer of knowledge into the learner’s brain. The major inputs for our brain are the 5 senses, and arguable the most important sense, the one with the most bandwidth, is vision. Which is the one input completely ignored by podcasts.
- Verdict: bust. What’s the future? Augmented reality. But that’s a different talk
- Tons of excitement about Google Glass, which clearly was a bust. However, AR can enhance our brain’s major source of input – our vision. Enhance intubations
- Which brings us to the next step in where this is all headed – AI. AI is here. The most stark example is Watson, a computing system created by IBM that handily defeated two all-time Jeopardy champions.
- This is a quote from one of the Jeopardy champs. This is not a new concern; the artwork at the DIA from Diego Rivera and Frida Kahlo in the 1930s reflects concerns on how technology of the time was threatening our livelihood. Watson makes decisions in the following sequence – observe, interpret, evaluate and decide. Watson strengths: NLP – understand what the question is – most important pieces of info Information retrieval – search through data to form information that starts to paint a picture Knowledge representation - examine available gold-std data, form and test hypotheses Output? confidence-scored recommendations Sounds familiar? First partnership? Clinical decision making. First commercial application? Utilization management decisions Coming back to this quote, we live in a time where tech is transitioning from task to thought. In pop culture, AI is almost uniformly bad: Terminator, 2001, Her, Matrix, Ex Machina
- But I think the future is good. Here’s a cartoon on what could happen when computers start to control weapons I think AI has the potential to be huge help to humankind and to physicians in particular. Something that used to be done manually can happen in a more safe, timely, efficient, effective, equitable and (hopefully) patient-centered manner. Think of how CT scanning improved management of abdominal pain, head injury. Did that put neurosurgeons or EM physicians out of jobs? Just like any other technology, it has a lot of promise, and will bring with it a new set of problems. Key to it’s success is also how well it integrates with our lives, which can lead to a symbiotic relationship. Especially as we move into precision medicine, the combination of humans and computers will become increasingly necessary to deliver high-value care.
- Verdict: Boom Look forward to your thoughts and comments on what you think will be a big influence on our practice
- I’d love any questions