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Imaging Appropriateness: One Tool For All

Improving quality in radiology starts by ordering the right test at the time. But should one tool rule?


The use of evidence-based guidelines to help referring physicians and other providers make appropriate imaging and/or treatment decisions for specific clinical conditions goes back quite a few years.

The American College of Radiology (ACR) started developing guidelines—known as the ACR Appropriateness Criteria—for the correct use of imaging technologies back in 1993. The guidelines are developed by panels in diagnostic imaging, interventional radiology, and radiation oncology; and as of November 2013, they included 197 topics with over 900 variants.

According to Michael Bettmann, MD, professor of radiology at Wake Forest University Medical School and, until recently, the chairman of the ACR Appropriateness Criteria Oversight Committee, over those 20 years—and particularly over the last decade—there has been significant progress in the use of appropriateness criteria for imaging. “But the problem is that they aren’t necessarily being used in the right way, and they haven’t been incorporated properly into the way in which patient care is administered,” Bettmann said.

With this in mind, several years ago the leadership of ACR began considering the question of how it could distribute its appropriateness criteria “in a practical way as part of a physician’s normal workflow,” Bettmann said.

A decision was made to partner with a company called the National Decision Support Company (NDSC) of Andover, Mass, to commercialize the appropriateness criteria under the brand name ACR Select, which in a digital format provides EHR vendors like Epic with a direct method for healthcare organizations to integrate the ACR appropriateness criteria into their computerized ordering and electronic health record systems.

According to NDSC, more than 30 healthcare providers and radiology practices have now implemented ACR Select.

Why Clinical Decision Support?

The rapid increase in the utilization of advanced imaging in the decade leading up to the implementation of the Deficit Reduction Act in 2007—and the costs associated with all of those tests—led to concerns about whether imaging was being overused and questions about what could be done to ensure that it was being done appropriately.

Several clinical decision support (CDS) initiatives demonstrated the efficacy of CDS in increasing the rate of imaging that met appropriateness criteria, yet reduced overall imaging utilization. For example, in Minnesota, in the 3 years prior to 2006, high-tech diagnostic imaging utilization increased by 8% annually. But the introduction of a clinical decision support initiative in 2006 resulted in just a 1% growth in these exams in the 5 years between 2007 and 2012.

“The evidence is good that when you institute clinical decision support for radiology, you bend the growth curve of utilization of these expensive diagnostic imaging modalities,” said James McDonald, MD, vice chair of the department of radiology at the University of Arkansas for Medical Sciences. “Physicians are highly motivated to do the right thing—but even in specialty areas, physicians many times don’t know what the right test is to order, so that means there are a number of tests that shouldn’t have been done or should have been done in another way.”

As an example, McDonald pointed to a past experience he had with emergency room physicians concerning pulmonary embolism (PE) protocol CT scans. “In ER practice, they basically supplanted ventilated perfusion lung scans a long time ago,” he said, but the problem is that they come with substantial radiation dose.


What he advocated to his ER physicians was that in certain cases—such as a woman of child bearing age who complains of chest pains—a lung scan was in order if the patient had a clear chest x-ray and wasn’t wheezing, since “if the test is negative, it’s the best test in medicine for ruling out PE.”

“I had one informal discussion with them and their behavior changed overnight,” McDonald said. “Doctors just want to do the right thing—you just have to help them understand what the right thing is.” And that’s what CDS is designed to do, he added.

Other than the simple fact that it’s the “right thing to do,” McDonald said, there are substantive reasons for implementing clinical decision support.

For example, one of the first rules of patient care is “to do no harm,” pointed out McDonald, particularly when it comes to exams that involve exposure to radiation. If physicians can eliminate or reduce patient exposure to medical radiation through decision support, so much the better, said McDonald.

There are financial implications, as well, said Bettmann.  If imaging is being overused, that means the healthcare system is being overburdened financially, he said, “so if you follow the criteria, that should decrease costs.”

There is also the argument that by using clinical decision support and following appropriateness guidelines, physicians can protect themselves from litigation, Bettmann said.

With all of this in mind, McDonald began thinking about the need to implement clinical decision support at the University of Arkansas, particularly with the decision by the state to implement a new payment initiative—the Health Care Payment Improvement Initiative—which is an attempt to improve the quality of care by providing risk-based incentives to providers to deliver efficient, high-quality care.

It was also about this time that the university made the decision to invest in an installation of an EPIC electronic health system, through which it would be possible to implement ACR Select.

McDonald pushed for ACR Select adoption and got support from his chancellor, even when he explained that clinical decision support could negatively effect reimbursement by reducing imaging utilization.

“But he said, ‘It’s the right thing to do,’” McDonald recalled. “And, in reality, if [a test] won’t pass ACR Select muster, then the likelihood we get paid for it is small. So utilization will go down, we hope, and we believe that the tests that are going to get eliminated will predominately be tests we weren’t going to get paid for anyway. It’s kind of a leap of faith.”

The other factor to keep in mind, said McDonald, is that the Arkansas payment improvement initiative incentivizes providers who can lower costs while providing quality care, as compared to their peers. “If you’re one of the better performers, then you get incentivized with better payments the next year,” he pointed out. “It’s a brilliant system because it gives doctors an incentive to make good choices and gives radiologists an opportunity to distinguish themselves as real consultants. And I think tools like ACR Select will be a good way to help them.”

A National Standard?

The move toward clinical decision support could get a boost if the SGR (Sustainable Growth Rate) Repeal and Medicare Provider Payment Modernization Act of 2014 is eventually signed into law.

The bill, which has the support of the ACR, would require ordering physicians to use evidence-based decision support tools—such as ACR Select—to ensure advanced medical imaging tests or procedures are appropriate.

According to Bob Cooke, vice president of Marketing and Strategy for NDSC, one of the goals behind the decision to commercialize ACR Select is to establish “a national set of criteria for educating users on how to utilize imaging services—and to establish ACR and their appropriateness criteria as their standard.”

To be a standard, Cooke said, ACR Select needs to be accessible, consumable in “a meaningful, clinically relevant way,” there’s no vendor bias, and it has to be inexpensive enough “so that people aren’t thinking about the cost when it comes to implementing it.”

Right now, ACR Select customers are “a mix of enlightened people, with a focus on certain geographic areas where there is this focus on these kinds of quality utilization management initiatives,” said Cooke. “There’s a lot of activity in the Midwest.”

With its ongoing clinical decision support strategy, Minnesota is a particularly hot market for ACR Select. By the end of February of this year, more than 10 organizations across the state had adopted the tool.

As for the potential of CDS tools like ACR Select to replace other utilization management tools like radiology benefits management (RBM) companies, McDonald pointed out that if there is one thing that all doctors can agree on—radiologists and referring physicians alike—it’s that RBMs “are a pain in the butt.”

“The analogy I use is that radiology benefits managers are exactly like travel agents,” he said. “Thirty years ago, if you wanted to buy a plane ticket, you had to go through a travel agent, and this was just someone who sat at a computer looking at someone’s proprietary software and buying you a ticket. Now you just go online and do it yourself.”

RBMs are just a “1970s solution to a payment problem,” he said, and the solution seems to be this computerized evidence-based support—like ACR Select—that physicians can access in just a few clicks.

Cooke also said that considering there are direct costs associated with the use of

RBMs, ACR Select is something that payors should be particularly interested in. But they’ve been slow to adopt it.

“It’s a shift for them,” he said. “Yes, RBMs cost them money, but there are perceived savings there and they are comfortable [with using RBMs]. But we are starting to get them on board.”

An Alternative Model

One benefits management company with a model that’s different from the typical RBM is HealthHelp. HealthHelp is a specialty benefits management company that uses a “non-denial” model, said Anthony DeFrance, MD, chief medical officer of HealthHelp. “We don’t hard-deny care, so what we are counting on is that we can educate physicians so they can make more appropriate choices.”

Last year HealthHelp launched its own clinical decision support system called MedTree QDS, which has been integrated with its Consult program for radiology, cardiology, oncology, spinal surgery, and pain benefits management.

According to DeFrance, the appropriateness criteria used with HealthHelp’s CDS are “in alignment” with the criteria available from the ACR and other organizations like the American College of Cardiology. “The ACR’s rules are great, but there are gaps there and we have to fill them in,” said DeFrance. “I always emphasize that our rules are in alignment with theirs, but that our rules should be more extensive in terms of covering all of the possible things clinicians will call in for.”

The HealthHelp CDS tool is being rolled out piece by piece, and is currently being tested in some pilot markets. And while the response from users has been good, there are challenges, said DeFrance. For example, physicians typically have had to rely on office staff to get preauthorization for imaging exams, which means it wasn’t part of their workflow.

“That’s one of the biggest challenges we face in having a good CDS,” said DeFrance. “Making it so physicians can easily integrate it into their workflow, because if you can’t do that—and it’s not easy to use—then you’re going to get low adoption.”

This means that education plays a critical role in getting physicians to use the CDS, and to make it pay off. First, said DeFrance, physicians need to be educated as to why using clinical decision support makes sense, which means demonstrating to them that the CDS interface is easy to use, won’t interfere with their workflow, and will even help them reduce the number of full-time employees needed in their practice by eliminating the time spent by staff getting preauthorization.

Second, physician education comes in the form of showing them how to get the right test, at the right time, for the right indication. “One of the big advantages of clinical decision support,” DeFrance said, “is that it gives us the opportunity to educate clinicians as they are ordering tests, which will help them change their behavior over the long term so they start ordering more appropriate tests.”

Clearly, the push for the use of clinical decision support tools to help solve the problem of unnecessary imaging is here to stay. Only time will tell if ACR Select becomes the tool of choice.


NHS data-sharing ‘a no-brainer’, says health chief

The programme intends to link data from GP records with information from hospitals.

The programme intends to link data from GP records with information from hospitals.

Head of Medical Research Council defends scheme, which was delayed after doctors and patients raised concerns.

Data-sharing in the NHS would be seen as a “no brainer” by patients if the government explains the scheme properly, according to the head of the Medical Research Council.

Professor Sir John Savill defended the scheme insisting only “consent fetishists” could object to the plans.

The controversial project was pushed back until the autumn after patients, doctors and other professional organisations raised concerns that they had not been given enough time to learn about the project.

The programme intends to link data from GP records with information from hospitals to give an idea of what happens to patients at all stages of the NHS.

Sir John told the Times: “It could turn the UK into the best clinical laboratory in the world and the benefit would be felt first in the UK. This could change the game in health research and healthcare. The act of studying de-identified data in a safe haven without specific consent does not to my mind threaten confidentiality.

“Most people, once guarantees of doing our best to protect confidentially are explained, would say this is a no-brainer.”

He added that linking medical research studies with the scheme would further help the NHS meet the challenges of an ageing and more demanding society.

NHS England has said it would work with patients and professional groups to promote awareness of the initiative.

The data that will be extracted from GP systems includes information on family history, vaccinations, referrals for treatment, diagnoses and information about prescriptions.

It will also include biological values such as a patient’s blood pressure, body mass index and cholesterol levels.

The health secretary, Jeremy Hunt, plans to provide “rock-solid” assurance to patients that confidential information will not be sold for commercial insurance purposes.

Gene Sleuths Use Social Media to Help Map a New Disease

By Duke Medicine News and Communications – DURHAM, N.C. – By combining the modern tools of gene-sequencing and social media, a team of researchers has confirmed the identification of a new genetic disorder that causes severe impairments in children.

The new disease, called NGLY1 deficiency, is reported online in the March 20, 2014, issue of Genetics in Medicine, the journal of the American College of Genetics and Genomics.The study describes the disease in eight patients, confirming the work of Duke Medicine scientists who originally identified the genetic mutation in a single young patient in 2012.

Children with the genetic mutation have a distinctive inability to produce tears when they cry, but also have movement disorders, developmental delays and liver problems. The genetic defect is so rare that without social media, the eight affected children would have remained unknown to each other and to scientists, but instead were connected within months.

“After we got the original diagnosis, we worked really hard to find additional cases to confirm that we got it right,” said senior author David Goldstein, Ph.D., director of the Center for Human Genome Variation at Duke. “While we were working hard but making slow progress, the original family was writing about their experience and connecting with others on social media. They were able to find several more potential patients to be tested. This experience really brought home to all of us just how important family engagement is to this work and how important it is to think hard and long about every patient’s genome.”

Duke researchers and scientists across two continents worked to sequence the entire genomes and exomes of the individual patients, revealing the newly identified genetic defect that was shared among them all.

The mutation causes a deficiency of the N-glycanase 1 enzyme, which is crucial in the process of recycling misshapen proteins so their components can be reused. In children with a defective NGLY1 gene, the proteins build up, resulting in impairments.

“Because of the unusual clinical presentations – notably the absence of tears along with liver abnormalities – parents of other affected children in distant places recognized these features when they read social media posts by the original family,” said co-lead author Vandana Shashi, M.D., a medical geneticist at Duke who evaluated the first patient. “This enabled other children to be quickly identified and diagnosed.”

After the first patient underwent sequencing at Duke, since NGLY1 had not yet been associated with human disease and since this was the only patient with mutations in the gene, Goldstein and Shashi consulted the Ad Hoc Genetics Committee at Duke. Charged with the task of advising Duke researchers on scientific and ethical issues related to genomic research, the committee reviewed the clinical and genomic data on the patient and approved the communication of the NGLY1 mutations to the family as likely causing the child’s clinical symptoms.

“The Ad Hoc committee recognized that this study was venturing into uncharted territory, and we wanted to make the right decision,” said Nancy C. Andrews, M.D., Ph.D., dean of the Duke University School of Medicine who chaired the ad hoc committee at the time of the decision. “The guiding principle was that we had to do what was in the best interests of the patient and his family. I am delighted that this was how it turned out, and that this important discovery also benefits other patients around the world.”

Goldstein said work is now focused on finding potential therapies to treat the condition, and on identifying additional disorders that might be related.

“We don’t know how NGLY1 deficiency is causing the neurological findings seen in the children we’re treating,” said Gregory Enns, MB, ChB, associate professor of genetics in pediatrics at the Stanford University School of Medicine and co-lead author of the paper. “Once the gene defect is found, that’s when the work really begins.”

In addition to Goldstein and Shashi, study authors at Duke included Rebecca Crimian and Kelly Schoch. The research collaboration also included scientists from Emory University; the University of British Columbia in Canada; Klinik für Kinder und Jugendliche Epilepsiezentrum Kork in Germany; Nemours/Alfred I. duPont Hospital for Children in Orlando; Imperial College in London; Dalhousie University in Canada; Texas Children’s Hospital; Sanford-Burnham Medical Research Institute in La Jolla, Calif.; and the Howard Hughes Medical Institute at Baylor.

The Bertrand Might Research Fund provided support for the research; a full list of funding sources is available in the published study.

Could bedside TVs be used to give patients access to medical records?


Bedside systems can save nurses time, reduce administrative work and reduce food wastage.

Bedside systems can save nurses time, reduce administrative work and reduce food wastageTelevisions could be used to give instant access to medical notes and guidance, x-rays or scans, and dietary advice

There is good reason to be awed by NHS ambitions to gather the nation’s medical data electronically into a digital Domesday Book, but also cause to pause.

Why isn’t more priority being given to making the same information available electronically to patients, who might be said to have a prior claim, for free?

Evidence from a study in the US suggests that those on the receiving end of healthcare welcome having the access, and that clinical outcomes improve.

The Open Notes study involving 105 US doctors and published in 2012 found that 87% of patients allowed to look at their doctor’s notes did so at least once. The vast majority, 78%, said it helped them stick to treatment.

Despite concerns from all sides, 99% of patients wanted the project to continue. Significantly, none of the doctors taking part have yet opted out.

Technology is available to give the same sort of access digitally in the UK, and, in the case of hospitals, it is usually right by the bed already.

Nearly everyone in a ward has a television. What they may not know is that the technology delivering Game of Thrones can often do a lot more, such as instant access to medical notes, x-rays or scans, dietary advice and guidance about their condition. If only clinicians could be persuaded to use it.

Their failure to do so is clashing with a public expectation, which is encouraged by health secretary Jeremy Hunt, to see patient notes, both as a matter of democratic decency and to help recovery.

But this is not just about patients. The bedside systems have the potential to save nurses up to 25% of their time, freeing them from administrative work for tasks that often get sidelined.

They help reduce food wastage, estimated to cost the NHS £27m a year, by more accurately matching supply to demand; and they ensure that when beds become free, everyone knows it. In Great Ormond Street children’s hospital the systems are even used for school work.

A suspicion is that the main reason why patients still rarely see their notes, offline or online, is cultural. Some hospital managers still think too much access raises too many awkward questions.

Doctors and nurses would start to sanitise their language, goes the argument, fearing repercussions which could jeopardise treatment.

This is a false concern. Bedside systems have filters that allow clinicians access to information for their eyes only. There is no need to fear making frank observations – for example, that a patient has a fabricated illness or is “difficult”.

Unfortunately, the public sector in the UK has had an unhappy relationship with software, as a litany of stories about overspending and under delivery testify. Perhaps it just seems safer to use the ones by the beds for entertainment?

As a result, it is almost unsettling when the NHS cheerfully announces a ground-breaking gathering of patient data, and yet can still be inconvenienced by the arguably simpler task of allowing electronic access to the patients themselves.

While not every patient will want data, plenty will. Many are familiar and comfortable with what technology can offer. Why should they be denied it by their own healthcare provider – especially when others are being allowed to buy it?

Jeremy Hunt wrote recently that better data means better care. Better access to data means the same, as the Open Notes study found.

The current under-use of bedside computer systems by most NHS trusts is like owning a smartphone, but only using it to make calls: fine, but rather a waste.

The Differences Between Successful People and Unsuccessful People

People Success

A few weeks ago I received a postcard in the mail from the CEO of Petra Coach, the creator of Align Software and a fellow member of Entrepreneurs Organization. I’ve never met him, but Andy Bailey and his postcard that I hung up on my wall have already had a profound effect on me, reinforcing values I believe in and reminding me on a daily basis of the attitudes and habits that I know I need to embrace in order to become successful.

Below are the 16 differences between successful people and unsuccessful people that Andy Bailey and the postcard claim, followed by a picture of the postcard itself:

1. Embrace change vs. Fear change

Embracing change is one of the hardest things a person can do. With the world moving so fast and constantly changing, and technology accelerating faster than ever, we need to embrace what’s coming and adapt, rather than fear it, deny it or hide from it.

2. Want others to succeed vs. Secretly hope others fail

When you’re in an organization with a group of people, in order to be successful, you all have to be successful. We need to want to see our co-workers succeed and grow. If you wish for their demise, why even work with them at all?

3. Exude joy vs. Exude anger

In business and in life, it’s always better to be happy and exude that joy to others. It becomes contagious and encourages other to exude their joy as well. When people are happier they tend to be more focused and successful. If a person exudes anger, it puts everyone around them in a horrible, unmotivated mood and little success comes from it.

4. Accept responsibly for your failures vs. Blame others for your failures

Where there are ups, there are most always downs. Being a leader and successful businessperson means always having to accept responsibility for your failures. Blaming others solves nothing; it just puts other people down and absolutely no good comes from it.

5. Talk about ideas vs. Talk about people

What did we all learn in high school? Gossip gets you nowhere. Much of the time it’s false and most of the time it’s negative. Instead of gossiping about people, successful people talk about ideas. Sharing ideas with others will only make them better.

6. Share data & info vs. Hoard data & info

As we all learned in kindergarten, sharing is caring. In social media, in business and in life, sharing is important to be successful. When you share you info and data with others, you can get others involved in what you are doing to achieve success. Hoarding data and info is selfish and short-sighted.

7. Give people all the credit for their victories vs. Take all the credit from others

Teamwork is a key to success. When working with others, don’t take credit from their ideas. Letting others have their own victories and moments to shine motivates them and in the long term, the better they perform, the better you’ll look anyway.

8. Set goals and life plans vs. Do not set goals

You can’t possibly be successful without knowing where you’re going in life. A life vision board, 10 year plan, 3 year forecast, annual strategic plan, and daily goal lists are are useful tools of the mega-successful people in your life. Get your vision and goals down on paper!

9. Keep a journal vs. Say you keep a journal but don’t

Keeping a journal is a great way to jot down quick ideas or thoughts that come to mind that are not worth forgetting. Writing them down can lead to something even greater. You can even use mobile apps or your Notes function in your phone. But don’t fool yourself by saying you keep a journal and not following through.

10. Read every day vs. Watch TV every day

Reading every day educates you on new subjects. Whether you are reading a blog, your favorite magazine or a good book, you can learn and become more knowledgeable as you read. Watching television, on the other hand, may be good entertainment or an escape, but you’ll rarely get anything out of TV to help you become more successful.

11. Operate from a transformational perspective vs. Operate from a transactional perspective

Transformational leaders go above and beyond to reach success on another level. They focus on team building, motivation and collaboration across organizations. They’re always looking ahead to see how they can transform themselves and others, instead of looking to just make a sale or generate more revenue or get something out of the way.

12. Continuously learn vs. Fly by the seat of your pants

Continuously learning and improving is the only way to grow. You can be a step above your competition and become more flexible because you know more. If you just fly by the seat of your pants, you could be passing up opportunities that prevent you from learning (and growing!)

13. Compliment others vs. Criticize others

Complimenting someone is always a great way to show someone you care. A compliment gives a natural boost of energy to someone, and is an act of kindness that makes you feel better as well. Criticizing produces negativity and leads to nothing good.

14. Forgive others vs. Hold a grudge

Everybody makes mistakes; it’s human. The only way to get past the mistake is to forgive and move on. Dwelling on anger only makes things worse – for you.

15. Keep a “To-Be” list vs. Don’t know what you want to be

A “To-Be” list is a great way to strategize for the future. I want to be an elected official one day. I want to be a TED speaker. I want to be the CEO of a public company. I want to be a great father and husband. Unsuccessful people have no idea what they want to be. If you don’t know what you want to be, how can you achieve success? What do you want to be?

16. Have Gratitude vs Don’t appreciate others and the world around you.

Moments of gratitude, each and every one, transform my life each day- and unquestionably have made me more successful and more happy. The people who you are grateful for are often the ones who have a huge part in your success. Be sure to thank everyone you come in contact with and walk with a spirit of gratitude and appreciation and even wonder, about the world around you. Gratitude is the ultimate key to being successful in business and in life.

Successful vs Un

Head in the cloud, feet on the ground

As an on-demand society, we rely on our smartphones, tablets, and other cloud-connected devices to provide immediate access to information, complementing and enhancing every aspect of our lives. And when physicians go to work, they don’t set these expectations aside.

Face it: if the odds were high that your paycheck would not be correctly deposited into your online bank account, you wouldn’t bank online. But that’s not the case. Our general experience is that digital banking is highly accurate, and although errors are possible, we know they’re not probable. So, when we log in to our accounts to make deposits, transfer money or pay bills, we expect and assume those requests will be properly executed, on time and without incident. The impact this automated service has made on our everyday lives is significant: no more waiting in lines, no more rushing to get to the bank before closing time, quite simply, less hassle.

There was a time, however (not so long ago), when customers shied away from the idea of online banking because it was new and uncertain. But, as this technology became more advanced and secure, people developed confidence and flocked to it because deposits appeared correctly, bills were paid – all by the touch of a button or the use of their voice. The nature of technological evolution is that acceptance develops into confidence which, in turn, becomes reliance.

Consider a field such as natural language understanding (NLU) where we are seeing continual and rapid advancements in accuracy, also known as “precision and recall.” This technology is quietly becoming deeply embedded in the devices that we use daily to get our jobs done, making everyday life a little more convenient and productive. NLU is being embedded in applications to understand context, identify relationships found within documents and commands, and when this technology is leveraged in a user interface, it makes the user feel like the application is “predicting” what he or she wants to do next. Over time, this capability will blend into the tapestry of the applications we touch every day and become second nature to us. And, as fact-extraction accuracy rises to the level of “human agreeance,” the application of NLU will push the limits of what we have come to expect as a great (and productive) user experience.

As an on-demand society, we rely on our smartphones, tablets, and other cloud-connected devices to provide immediate access to information, complementing and enhancing every aspect of our lives. And when physicians go to work, they don’t set these expectations aside. They need the convenience of anytime, anywhere access to critical information without being tethered to a computer, and they need to jump through hoops quickly to get patients what they need. Clinical Language Understanding (CLU), which is NLU specifically purposed for the medical domain, is helping physicians navigate electronic medical records (EMRs), perform basic computerized-provider order entry (CPOE) tasks (such as ordering lab tests and medications), or when combined with speech recognition, create a patient note in seconds. For all of these use-models, the CLU engine is becoming deeply embedded in the core of cloud-based applications. It quietly operates in the background, simultaneously extracting facts and processing evidence through a variety of domain-specific knowledge bases. For example, when a physician documents a patient note, the engine drives Computer-Aided Physician Documentation (CAPD) queries back to the clinical teams, creating real-time decision support.

On the cutting edge of CLU’s application are virtual assistants, which use the cloud to enable dialogue between physicians and their clinical applications that uses meaningful information to enhance workflows and inform clinical decisions. This technology wields the immense power to transform how physicians interact with EMRs and share data with colleagues and their patients, fostering real-time decision support and, some day, qualifying as a trusted advisor in the pocket of the physician. This type of immediate feedback acts as a second set of eyes, relying on vast clinical knowledge bases to review the patient’s case and assist the physician in outlining different treatment options.

Technology, like CLU, is already beginning to transform how care is provided. It is, however, only a short matter of time before it becomes common-place for a conversation between a patient and her physician to be comprehended by an intelligent system that transcribes the dialogue, pulls up relevant health information, documents procedures, records reactions to treatments, and codes the office visit. And all without so much as a break in eye contact between the patient and her doctor. The future is here, bringing with it new use cases for NLU and cloud capabilities, positioning healthcare for the next phase of its evolution.


The next generation of health IT

It is time to forge the next generation of technology that helps physicians get back to practicing the art of medicine, and not working as data entry specialists.

In the last decade, technology has made massive strides in transforming a paper-based healthcare industry into a digital one; however, the unintended consequences of these implementations on our physicians have been significant.  We now stand on the threshold of new phase of health IT innovation, armed with the knowledge of end-user challenges.  It is time to forge the next generation of technology that helps physicians get back to practicing the art of medicine, and not working as data entry specialists.

This next generation of health IT needs to bring patients and physicians closer together.  Andrew Watson, MD, CMIO and Medical Director of the University of Pittsburgh Medical Center (UPMC) rightly stated: “There are 8,736 hours in a year, yet we expect a 60-minute annual wellness visit to keep our patients healthy for the remaining 8,735 hours of the year.  That amount of white noise between visits doesn’t work.”  We need to create solutions that enable us to stay in touch with our physicians.  In every other aspect of our lives, we rely on technology to keep us connected to family members, co-workers in other offices, and friends in distant cities.  Why do accept less connectivity when it comes to our own health care.

Technology needs to become the invisible partner to physicians, acting as an invisible scribe and second-opinion in the room, quickly scanning the tomes of patient’s family medical history to determine if a certain gene was documented at some point.  In the coming months, we will be featuring technology trends that are having the most impact on the health IT industry and explore the ways we can help physicians practice the art of medicine in a digital world.


A lost luxury: taking patients every step of the way


While health IT can be unwieldy at times, it holds incredible potential for positively changing how we, as doctors, are able to provide care to our patients.

As far back as I can remember, there was never a time when I didn’t want to be a physician.  It’s a choice in which there is no equivocation: either you want to be a doctor or you don’t.  It encompasses your life—there is no punching the clock, no walking away.  Illness doesn’t take vacations, disease doesn’t go away for the holidays, and pain doesn’t sleep.  As physicians, we have accepted these truths as basic facts of our daily lives.

While I realize that technology can be unwieldy at times, especially for those of us who “grew up” before computers and the internet, I also see the incredible potential it holds for positively changing how we, as doctors, are able to provide care to our patients.  Clinical information used to be the exclusive province of the select few, and this knowledge was then trickled down to patients; but I believe the electronic revolution in healthcare has allowed a shared and more collaborative relationship to develop.  The more patients understand, the better their ability to participate in their own care, and the better their personal choices and decisions will be.  In this pursuit, I have been using EHRs as a tool to help explain and work through health issues with my patients.

Sitting side-by-side in the exam room with my patient, and perhaps his or her family, I pull up the health record on my laptop and we review our notes from the last visit.  We discuss how treatments are working, complete templated fields together and, using a section I have created called “Instructions to the patient,” I outline action items and next steps.  I enlist their active participation in the creation of this take-home document, and the content of these clinical notes exceeds the basic information required by Meaningful Use clinical care documents (CCDs), which means I know my patients will leave my office with a thorough understanding of their current health status.

This is a new era of patient-physician collaboration.  We can leverage technology to enhance our partnership with our patients to create clinical notes that they can share with family members or use as a reminder of what they need to monitor and work on until our next visit.  These take-away instructions are an important piece of extending the continuum of care beyond the doctor’s office.

I have been a physician for more than 35 years, and, to me, being able to escort my patients every step of the way – whether it is through an illness or simply to the front desk at my office – is a big part of what being a physician is about.


Eight rules for success at work

We desire success at work and a satiating career. But what does it take to get there? In this article, I have jotted down traits that I have always adhered to. These work for me. These generic guidelines transcend industries and will help you too. If widely followed, they will also make the work environment a positive place for everyone.

success of work

  1. Be open-minded: All workplaces are not the same. So, it is best not to bring in rigid notions about your job, your team or your company. Instead, being open-minded allows you to imbibe the company culture and to successfully navigate through its dynamics. Observe, understand and quickly calibrate yourself to your new work environment.
  2. Learn: Boredom at a job typically sets in when you stop learning. Consistently strive to learn new skills and to apply them more efficiently. As Tennyson says, work “to strive, to seek, to find and not to yield.” This will keep you enthused and help you deliver more value for your organization.
  3. Enjoy: Work with a happy spirit. When you relish your work, your passion for what you do will show. Your happy and amicable demeanor will also influence positivity in the larger organization. On the other hand, if you don’t appreciate your job, step back and re-evaluate your fit/needs and pursue your heart.
  4. Communicate: Listen well and respond well. It is important to know your audience so you can customize your verbal or written communication. Think ahead, anticipate follow-up questions and be ready. Ensure that your message avoids ambiguities and is not warped or lost in translation. Share information, provide timely updates and call out expectations. Don’t be afraid. Communicate.
  5. Set the right expectation: Right from day one, you have to draw the line on what you want to do, are willing to do, and can do. Of course, this needs to be balanced against situations that need you to step up. If you have been stretching yourself at work without indicating so to your managers, you will be setting yourself up for that level of productivity all the time. This will ultimately lead to a bad work experience.
  6. Be diligent: Good work ethics are a must for success. You cannot expect your workplace to reward you if your commitment to the organization is not evident. The relationship between the employee and the company is built on mutual commitment, and diligence is integral to this dynamic. These four lines sum it all- “The heights by great men reached and kept
    Were not attained by sudden flight,
    But they, while their companions slept,
    Were toiling upward in the night.”
  7. Be yourself: You shine best when you are your natural self. Attempting to be someone you are not will result in unhappiness and also stunt success. When you have an artificial persona at work, you will also be outshone by others who can naturally perform similar responsibilities as their flair and interest levels will be much higher than yours.
  8. Be a good human: This one is closest to my heart. Your work place, much like your life outside of it, is all about people & relationships. Be it your bosses, peers, other teams, reports or customers, please display empathy. Put yourself in their shoes and appreciate the alternate perspective. In some situations, empathy and kindness are branded as weaknesses. On the contrary, they generate trust and foster a great working environment.

The truth is that there is no universal framework for success at work. It depends on individual capabilities and company DNA among other things. It also rests on whether you love what you do. However, you ill maximize the chances of your success by following a set of rules. The tenets I have articulated here resonate with me. Hope they provide you a basis for realizing your career goals too.

I would love to hear from you on other metrics you use. Please also comment if you disagree with this framework. Perhaps that will help me finesse my approach further.

More NHS hospitals failing to meet targets on treatment waiting times

Figures show 2.9m patients waiting for treatment in January, and 45,000 more not treated within 18 weeks than in January 2013.

The outpatients department at Heartlands hospital, Birmingham. NHS figures show that in January more patients were waiting in England for treatment than in the same month in 2013. Photograph: David Sillitoe for the Guardian

The outpatients department at Heartlands hospital, Birmingham. NHS figures show that in January more patients were waiting in England for treatment than in the same month in 2013. Photograph: David Sillitoe for the Guardian

Patients are waiting too long for surgery, treatment in A&E and vital diagnostic tests at growing numbers of hospitalsNHS figures show.

In all 2.9m people were waiting for treatment in January, up by 362,000 from the 2.538m seen in the same month in 2013, and 326,000 more than the 2.574m who were on the list for treatment when the coalition took over in May 2010.

That is the highest total recorded in January since records began in 2007-08 and the first time January’s total has been more than December’s. Until now it has always fallen in the first month of the year.

It may now reach 3m for the first time under the coalition – a figure last seen in March 2008 – in coming months.

The number of patients in England in January who had not been treated within the 18-week target enshrined in the NHS constitution hit 189,179, some 45,438 higher than the same month in 2013, though fewer than in May 2010. In addition, both mean and median waiting times are now the highest since early 2008.

The referral to treatment scheme data, published by NHS England and supplied by almost all hospitals, cover January 2014 and underlines how the service has faced rising demand, despite this winter not having brought the crisis some doctors and experts predicted.

Separate statistics for the 102 non-foundation trust hospitals – which are often among the NHS’s poorer-performing organisations – bear that out.

They show that those hospitals as a whole breached the requirement to treat 95% of A&E patients within four hours during both December and January, though only missed that key NHS target by a fraction of one per cent in December and 0.64% in January. Barking, Havering and Redbridge University Hospitals NHS Trust was January’s worst performer, recording just 84.99% compliance.

These hospitals also failed to treat 90% of admitted patients within the required 18 weeks in October, November, December and January because 20 trusts missed the target. North West London Hospitals NHS Trust managed just 69.65% in January.

Ten trusts also did not treat 95% of non-admitted within 18 weeks. Plymouth hospitals were the worst on 89.41%.

Non-foundation trusts also failed to ensure that no more than 1% of patients waited no more than six weeks for a diagnostic test in December and January. Royal Liverpool and Broadgreen University Hospitals NHS Trust fared worst, with 17.12% of patients waiting longer than six weeks, and 13.45% in West Hertfordshire Hospitals NHS Trust.

Those hospitals are also struggling to ensure that 85% of cancer patients are treated within 62 days of their GP referring them urgently. Some “have seen their performance slipping in the last period”, according to a report issued on Thursday by the NHS Trust Development Authority (TDA), which regulates the sector.

In January it emerged that 18 of the 147 foundation trust hospitals had breached that target in the last three months of 2013, up from just four the year before.

The TDA said that the ongoing squeeze on NHS budgets meant that “the challenge of maintaining national standards is harder than at any point in recent history”, though the sector had performed well in difficult circumstances this winter.

Jamie Reed, the shadow health minister, highlighted the lengthening waiting list for operations as “a worrying sign of what lies ahead for patients as NHS lists reach their longest in years.”

But a Department of Health spokesman insisted that “despite the NHS treating far more people, average waiting times are low and stable and the number of people waiting 18, 26 and 52 weeks is lower than in May 2010.”

Of the million or so patients who start treatment with a consultant every month “the overwhelming majority are seen and treated within 18 weeks”, he added.

David Flory, the TDA’s chief executive, acknowledged that the finances of the 102 trusts he supervises are “a source of significant concern” after 26 of them ran up a combined deficit this year of £458m and the sector as a whole overspent by £247m, with some trusts busting their budgets by as much as £40m.

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