United Kingdom Ends $17 Billion Electronic Medical Records Initiative

The Wall Street Journal on Sept 23, 2011 reported that the United Kingdom will scrap the entire electronic medical records (EMR) initiative that has been 9 years in the making with nearly 6.4 billion pounds already spent.

That action was hinted at back in August 2011 after a scathing parliamentary report stating the initiative to be wasteful and incapable of delivery.

I'm not surprised...

It's hard enough to get a group of doctors in one hospital to agree with a treatment plan let alone agree to a medical records system. The problem is exponentially more difficult when applying it to an entire country.

Physicians practice medicine differently... just like teachers have their own unique way of teaching kids. A method that may work for one doctor or teacher will not work for another. Even the method may change depending on how "busy" things are (teacher with a class of 5 kids versus 30 kids) so a doctor in a busy inner-city emergency room will have different flows and needs from an electronic medical records than a rural family practice with a sedate pace. Furthermore, the needs of a dermatologist is very different from a pediatrician. One can't expect a single EMR system to meet the needs of both perfectly just like one cannot expect a math teacher to use the same teaching methods as a singing teacher.

Forcing physicians to use a single standard electronic medical records without adapting to these realities is bound to fail no matter how much time, training, software, and hardware you throw at it.

A better alternative (my opinion), is to treat electronic medical records like the computers they reside on. There should be many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components... USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the "internet" that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems... but no... they don't communicate at all... which is why paper reports still exist... which are than scanned into the EMR.

Rather than the government (whether the United Kingdom or the United States) dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

The other more insidious side of EMR is the over-reaching health goal mandates which means well, but runs into the same problem of applying standards to all physicians. Take "meaningful use" set by the Centers of Medicare and Medicaid Services (CMS). One of the core measures of meaningful use is adult weight-screening and follow-up.

Now as an ENT specialist, I see patients specifically for earwax. Why in the world would I want to perform a weight-screening when all I want to do (and what the patient only wants me to do) is get earwax out???

Makes no sense.

Does it to you???

Reference:
U.K. Scrapping National Health IT Network. InformationWeek Healthcare. Aug 4, 2011
U.K. Ends Health-Service IT Upgrade. Wall Street Journal. Sept 23, 2011

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New Webpage on Facial Paralysis

Our office has produced a new webpage on the evaluation and management of facial paralysis without any other symptoms.

Click here to read more about this condition.

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Sermo iPhone App Review

Sermo is an online physician-only forum where doctors ask other doctors for advice. It's where we post particularly thorny/difficult medical issues we encounter in our patients (no patient identifiers of course) and pick the brains of thousands of other doctors across many different specialties throughout the Unites States for assistance.

For example, as an ENT, I can post a particularly unusual patient presentation that has me stumped... for example a weird rash on the face... and post it on Sermo. Hopefully, I would than get responses from not only other ENTs across the United States but also input from dermatologists, pathologists, internal medicine, pediatrics, etc.

This kind of multi-brain access has been invaluable, especially since being a solo ENT, I do not have the benefit of having a colleague to easily bounce questions off of.

Until recently, no iPhone app was available to access this forum... until now. Mind you, only physicians are allowed access.

I am fortunate to be one of the first to test out this new iPhone app when Sermo contacted me last month regarding my interest (which I was) and here are my initial impressions when the app was released July 5, 2011.

Overall, it is a functional app that is usable in all the ways I would use it on the desktop.

The homepage is where theoretically, all the most popular destinations on Sermo is shown.

Among the homepage buttons is "Followed" which are postings that I either am following or actively participating in.  It would also be nice if there's a button to direct me to my specialty postings rather than clicking on "Posts" (which lists all postings in chronological order) or "Popular" (which lists the most popular postings in terms of activity) and than selecting "Specialty" which is the 2nd most common destination for me. "History" lists all postings or messages that I recently visited.

Adding a new posting appears to be fairly straightforward with two options... One which is triggered by taking a picture (iConsult) of an abnormality (like a CT scan or a rash) as well as one without the need for a picture (Create Post). The iConsult button is a leap forward better than what the desktop can offer. With iConsult, I can use the iPhone to take a picture, add a brief background history, and post whereas with the desktop, you would have to take a picture, transfer to the computer, logon to Sermo, and add the photo manually when creating a new post. The iConsult has resulted in the addition of a new section on Sermo... when I last checked, there's already been 5 postings to this section.

With any postings, I can add a comment easily or view a brief bio by selecting on the commenter's user handle.

All in all, a great free app currently available for the iPhone only.

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ENT Practices and Physicians Who Twitter...

Did you know Fauquier ENT maintains one of the most comprehensive list of ENT physicians who twitter and are otherwise involved with social media not only in the United States, but in the world?

Check out the full list here. There are 76 and growing!

If you are an ENT practice or ENT physician not on the list, please let me know by DM @FauquierENT and I'll add you!

If you are a resident in otolaryngology, feel free to let me know as well.

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Doctors Don't Always Take Their Advice (ENT Perspective)

Reuters published an interesting story about research that showed doctors don't always recommend treatments to patients that they themselves would pursue if they were sick. In essence, if the doctor was the sick person, they would tend to pursue treatments that carry a higher risk of death but fewer severe side effects whereas patients pursue the exact opposite.

Though the clinical scenarios illustrated in the article/research is not reflective of an ENT practice (colon cancer and bird flu), I do see it quite often in other scenarios... the biggest one being when to perform a tracheostomy... hole placed in the throat for breathing purposes often performed in very sick patients in the ICU.

Trachs are often refused by the patient's family for as long as possible... even weeks until all other avenues have been exhausted before considering a trach.

Although this procedure may sound "scary" and many patients and their families automatically refuse to consider such a procedure, the following (unofficial) survey done on Sermo (online physician community) on February 19, 2008 on physicians nationwide may be illuminating on how worthwhile having this procedure is to recovery.

When US physicians were polled at what point they would consider a tracheostomy on themself or their loved one if prolonged intubation was expected, 50% stated trach should be done within the first 8 days of intubation of which 28% wanted it to be performed within 3-5 days. Only 15% would desire a trach after 12 days or longer intubation.

Read the Reuters story here.


Reference:
Better off not knowing: improving clinical care by limiting physician access to unsolicited diagnostic information. Arch Intern Med. 2011 Mar 28;171(6):487-8.

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Video of Monkey Behaving Like a ENT Doctor

All I can say is look at time 0:41 - 1:25 in the video clip below. If you can't see the video below, click here.

Coming soon to an otolaryngology office near you...

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Dr. Chang a Northern Virginia Top Doctor for 2011

Northern Virginia Magazine published their annual list of Top Doctors for 2011 in their February 2011 edition. Dr. Chang was listed as one of Northern Virginia's Top Doctor in the field of Otolaryngology (page 68).

Of note, Dr. Chang was nominated by his doctor peers opposed to nomination by a small panel.

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What is the Perfect Tablet Computer for Healthcare?

Many would argue (as I have) that the Apple iPad is THE perfect tablet computer for healthcare professionals. And for many of the mundane tasks of looking up or inputting information into an electronic medical records, that may be true. (Watch a video using the iPad to access MediTech as well as PACS here.)

However, there is a vast area of healthcare that the iPad just does not work at all.

That area is connecting to surgical equipment. Especially in the ENT world, there is a lot of microscopic and endoscopic work that is done. The software that records imagery from such devices are ALL based on the windows platform. Yes... we can record on to a CD, DVD, USB Memory Drive, etc and transfer the file to the iPad for viewing, but there's a lot of steps involved with that:

1) Record the video/image
2) Transfer to media of choice (CD, DVD, USB memory stick, etc)
3) Transfer file to PC/Mac
4) Move it iTunes/iPhoto
5) Synch with iPad

Geez louise!!!

I am currently aching for a highly portable tablet computer to connect to my JedMed Digicam in order to video-record fiberoptic endoscopy, ear work under the microscope, etc. The software the Digicam works with is only Windows compatible (and from my conversations with JedMed, there's no plans to make it work on any other platform in the foreseeable future).

As such, at this time, the Windows (and not iPad) world is the current way to go to address this deficiency. Not Google Android, iPad, Blackberry, etc.

In my mind, the best tablet for video work in the healthcare setting must have the following properties:

1) Windows 7 operating system for compatibility with surgical hardware
2) USB port
3) 10" Tablet for portability
4) Cheap (comparable to iPad)
5) Fast boot (SSD drive)

And WOW... I was amazed at the plethora of tablets introduced at the 2011 CES Convention Jan 6-9, 2011 in Las Vegas.

There were over 80 tablets that were introduced from big name companies to nobodies. Surely, there will a be a few which fits the bill?

Sadly, there were only a few that may fit my needs.

These include:

1) Samsung Note PC Series 7
2) Motion CL900 Windows Tablet

The Dell Inspiron Duo may possibly work, but the swinging screen just looks way too fragile.

What do others think? I'm pinning my hope on the Samsung model as the Motion tablet price is a bit much. The Samsung tablet is suppose to go on sale in March 2011 with a price tag around $699.

Watch a video the demonstrates the Samsung Note PC:

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Dr. Chris Chang Mentioned in a Medical Blog

Dr. Chris Chang and his blog was mentioned in an article in another medical blog "Dr. John M" on December 14, 2010.

"---One of the best ways to know something well is to teach it. Dr Chris Chang from the blog of the Fauquir ENT Consultants of Virginia writes about why he keeps a blog. His first reason is that it keeps him highly informed. No doubt about that. Could we bloggers get some CME credit, please?"

 Click here to read the whole story!

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Dr. House Video Clip Illustrating Doctor-Patient Communication Problems

In this classic video clip, Dr. House interviews a patient with asthma. Their interaction illustrates the problem of communication between doctor and patient that unfortunately too often occurs.

Errors in doctor-patient communication as shown by this video clip:

• Doctors assume that patients know how to use medications (or understand treatments) when they don't.
• Patients assume that they know how to use medications (or understand treatments) even if they don't.
• Doctors can be intimidated by patients who appear to know/understand their medical treatments when they truly don't.
• Patients can feel insulted when a doctor assumes they don't know how to use medications (or understand treatments) when they shouldn't because they really don't.

I feel Dr. House perfectly handled this particular situation... though it is unclear what he said AFTER the patient demonstrated how she uses inhalers.

Watch the video on YouTube here.

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Extremely Discounted Blood Tests for Cash-Paying or Uninsured Patients

Through the cooperation of Summit County Medical Society, LabCorp, and PrePaidLab, patients are now able to get lab tests done for a small fraction of the normal cost via the medial society website. Anyone near a LabCorp location nationwide is able to use this website to obtain the same low-cost blood tests.

For example, a lipid panel (cholesterol test) can cost as much as $148 for an uninsured person. The same test is available for less than $18 through the site.

Here are the steps to take:
1) Click here and choose the tests your doctor says you need.
2) Give the doctor's fax number, pay with a credit card, and print out the order.
3) Take the order to any LabCorp location in 47 states and have the work done.
4) Results are sent securely to the patient and the doctor, often within 24 hours.

Sound too good to be true? It really is true.

Read about this amazing offer on a news report from CNN here.

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Physician Marketing Using Groupon

For those not in the know, Groupon is a website that offers coupons and other savings on local merchandise and services. Groupon also has recently rejected a takeover bid by Google.

I recently encountered this amazing deal on Groupon offered by an ENT colleague, Dr. Ghaheri:

"$149 for Four Laser Hair-Removal Treatments at The Center for Aesthetic Medicine at The Oregon Clinic (Up to $1,000 Value)"

I wonder if such marketing and medical discount offerings like this will become the future. Clearly, procedures and other types of medical treatments that are not covered by insurance will be applicable.

For example... here are some medical treatments/services I am considering to discount on Groupon:

1) Injection snoreplasty for snoring
2) Botox injections for facial wrinkles
3) Hearing services and products including hearing aids
etc

Click here to check out Groupon and create an account!

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What Makes A Great Surgeon or Doctor?

Or for that matter, a great violinist? As many psychologists suggest (regardless of whether one is talking about sports, music, painting, astronomy, physics, etc), it entails:

1. Focused practice (at least 10,000 hours according to many)
2. Good coaching
3. Great role model to provide motivation

Does this apply to surgeons or doctors? I believe it absolutely does. 

Any person who puts in enough good training hours under the tutelage of a great teacher with a great role model to aspire to can become a more than competent physician. And as any highly trained professional can attest to, it requires continued training and practice to stay on top of one's game. As Vladimir Horowitz, a premiere concert pianist, once said, "If I skip practice for one day, I notice. If I skip practice for two days, my wife notices. If I skip practice for three days, the world notices."

How does this compare to a surgeon's training and professional career? To use myself as an example, while at Duke where I received 5 years of training to become a head and neck surgeon, I averaged about 110 hours of work training per week during my first 2 out of 5 years. In the last 3 years, I probably averaged around 90 hours a week for a grand total of 25,480 hours of training before I graduated and came to Northern Virginia to be in private practice. During that 5 years of training, I performed nearly 3,000 surgical cases under a master surgeon before graduating. Furthermore, I had plenty of role models at Duke for me to try to aspire towards. A "goal" so to speak, of the kind of surgeon I wanted to become.

A similar experience can be found for all physicians and doctors who go through the American medical training system.

Even after training, physician education is not completed... In fact, it never ends. Indeed, physicians are required to continue to receive education from master instructors, journals, or other text every year (Continuing Medical Education or CME) as well as undergo regular testing to ensure their knowledge is current and comprehensive.

(NOTE: Enforced around year 2005, physicians in training are now required to work no more than 80 hours per week. The number of years of training has remained the same. At this time, it is unclear whether this decrease in training hours has significantly impacted physician training in the United States or not.)

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Making Twitter Work for a Specialty Medical Practice (Like ENT)

I've been asked by a few ENT colleagues how I got Twitter to work for my practice and how in the world I managed to get more than a few dozen followers.

I've been at it for about 1 year now (up to 355 followers @FauquierENT) and here are a few tips to making it work for a medical practice... Just an opinion... And it may not apply to everyone...

• When you tweet something, always back it up with a useful link to a webpage using a link shortner like bit.ly or goo.gl.
• Tweet about topics that the LAY-PERSON would find interesting. Twittering about "Outcomes of Vascularized Bone Graft Reconstruction of the Mandible in Bisphosphonate-Related Osteonecrosis of the Jaws" is NOT going to garner you fans even if you personally as an ENT find it riveting reading. An example of a good tweet I recently posted is "Do Cell Phone Makers Secretly Know Cell Phones May Cause Health Problems? http://ht.ly/3bBUZ"
• Follow people you find interesting. They will follow you back typically and their followers will slowly start to follow you. Given I twitter about ENT topics, I make it a point to follow ALL otolaryngologists, respected medical journalists, and health related newspapers.
• Write a blog and use twitter to "advertise" your blog article.
• ADVERTISE on your website that you have a twitter account.
• Be active with tweets. Potential followers will not be that excited to follow you if you have something interesting to say only once every few weeks.
• IF you come across something interesting in a medical journal, tweet it, and support it with a link.

So there you have it... Now go sign up with twitter and don't forget to follow my tweets!

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Pediatric ENT Care of Warrenton, Virginia (Fauquier County)

Recently, there has been some confusion regarding whether our office deals with adults only or do we see kids as well... Strangely enough, we also get asked by parents whether our office sees adults when seeing a pediatric patient.

To clear up any confusion, our office does see kids AND adults... starting from birth to the elderly.

Dr. Chang who joined the office in October 2005, was named one of America's Top Physicians by the Consumer's Research Council of America in 2008 as well as a Northern Virginia Top Doctor for 2011 (to be published in February 2011).

Some common problems and procedures for which Dr. Chang sees kids specifically include:

- Tongue Tie Release (starting from ONE DAY OLD!)
- Tonsillectomy
- Adenoidectomy
- Sinus Surgery starting with adolescents
- Ear Tube placement
- Hearing Loss
- Nasal Obstruction
- Nasal Congestion
- Snotty Nose
- Speech Delay
AND many other issues...

Our office has even created videos on a few common pediatric procedures including tonsillectomy, adenoidectomy, earwax removal, ear tubes placement. Watch the video below on tonsillectomy.

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Nurses Followed by Doctors "Need" Coffee the Most According to Survey

CareerBuilder and Dunkin' Donuts performed a survey that was released to public on Sept 27, 2010 that listed those professions who needed coffee the most in rank order. The survey was performed on 3600 workers throughout the United States.

According to the survey, the professions with the highest proportions of workers stating they are less productive without coffee vary widely. Those who need coffee the most are:

1) Nurses
2) Physicians
3) Hotel workers
4) Designers/Architects
5) Financial/Insurance sales representatives
6) Food preparers
7) Engineers
8) Teachers
9) Marketing/Public Relations professionals
10) Scientists
11) Machine operators
12) Government workers

Hmmmmmm...

I personally have NEVER drank coffee... even during my residency when I worked 120+ hour shifts. I was too busy to wait in line to order coffee and never really picked the habit up of needing a caffeine buzz to function.

It probably helps that I am a morning person...

Read the survey report here.

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Difference Between In-Network vs Out-of-Network Health Insurance Coverage

To read more about general ideas (copays, deductibles, etc) of how health insurance coverage works, click here.

There are large health insurance companies that offer health insurance plans throughout the United States like Aetna, Anthem, Cigna, etc.

HOWEVER, just because you have one of these companies, does NOT mean that the health insurance benefits that apply in the state you live in apply to the other 49 states in the United States. Sometimes, even within the state, coverage may vary depending on whether the physician you see is IN-NETWORK or OUT-OF-NETWORK with your health insurance plan.

IN-NETWORK coverage means the doctor you see participates fully with your health insurance plan and the copays, deductibles, coinsurances, etc specified on your health insurance card applies.

OUT-OF-NETWORK coverage means that the doctor you see participates with your health insurance plan, but you will have to pay a MUCH larger portion of the bill as your health insurance plan will only cover a much smaller fraction of the charges.

In order to determine whether the doctor you will like to see is in-network or out-of-network, you will have to call your health insurance plan and ask.

Please be aware that your health insurance plan may not even offer out-of-network benefits in which case you are responsible to pay for everything if you see a provider who is not in-network.

A final last point is that some physicians may not even be in-network OR out-of-network with your health insurance plan. In this case, EVEN if you have out-of-network benefits, you will be responsible for all charges out-of-pocket.

To see what insurances we participate with in our office, click here. Just remember that we may be out-of-network, ESPECIALLY if you live in a different state from Virginia.

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The Perfect Computer for Healthcare and Electronic Medical Records

So I've been using computers in the healthcare setting for over a decade now. First at Yale than Duke. I've been thru the Veteran's Affairs Medical Center using Vista (New Haven, CT; Durham, NC; Asheville, NC; and Portland, OR). I've been at 5 different community hospitals on both the West and East Coasts. I've used all the different flavors of electronic medical records (EMR) in all these different locations/settings. I'm now using (not by choice) NextGen, Meditech, Rcopia, and PACS currently in the office, hospital operating suites, and inpatient settings.

Throughout this time period, I've used desktop computers, handhelds, laptops, netbooks, and tablet computers. I've even tried to cobble together a semi-functional iPad able to access all the different EMRs I need on a daily basis (read blog about this here).

What I discovered is that the perfect system (in my mind) is ALMOST there... just not quite yet. Maybe in the next few years, it will exist because all the pieces now exist! The bad news is that it does not exist RIGHT now.

So, here's my dream machine and the reasons. I hope some computer company is paying attention!

To understand how this all fits together, one needs to envision how my office works right now. There's a desktop computer in each exam room. Patients are taken back by a nurse and information inputted into the desktop computer. Than the computer is locked and the nurse leaves. The physician than soon follows, unlocks the computer, and then proceeds with further history, exam, and plans treatment which all gets documented in the computer. If tests are ordered (ie, hearing test, blood draw), the doctor leaves and sees another patient while the tests gets done before coming back. As such, the computer stays in the room with the patient. One can envision that there is a lot of back and forth into and out of an exam room movement of nurse, doctor, and patient. The computer gets locked every single time. Furthermore, I need EMR access when seeing patients in the hospital as well as during surgery.

First the Hardware:
• A tablet touchscreen (with no physical keyboard) 12 inches diagonal. That size hits the sweet spot. Any larger and the size itself becomes unwieldy to constantly move around as well as heavy by the end of a day. Any smaller and the screen real estate becomes so small to become inefficient. 12 inches diagonal also allows the possibility of an actual full-size virtual keyboard on the screen with adequate screen left-over to see what's going on.

My experiences with the iPad virtual keyboard was mixed (given it is somewhat smaller than full-size). I CAN do it and I did do it... I just didn't like it to the point I relied on a wireless bluetooth keyboard.

• Bluetooth technology and WiFi are a MUST because...

• With this tablet computer, one can dock it without wires or connector pins (similar in concept to Motion Computing JR3400 with its FlexDock). The docking station allows for use of regular USB keyboards and mouse along with direct ethernet wired connectivity. My dream machine docking station and tablet would communicate with each other using bluetooth or some other alternative short-range wireless technology which makes direct physical connection unnecessary. This is important, because I would have the docking station in each exam room. When I leave the exam room, I would have the option of taking the tablet (and therefore the screen) with me. The constant connecting and disconnecting of current docks is quite the pain given it requires an actual physical connecting port as well as precise placement. With the constant connecting and disconnecting, it opens the possibility for breaking as well.

What would be even cooler would be if the tablet charges when in its docking station using inductive charging similar to how a Philips Sonicare Toothbrush recharges.

Why do I even want a docking station? Several-fold. Ergonomics... I like the screen at my eye level. Also, I can still see the patient while typing away. If I depended on the virtual keyboard like on the iPad, I'm looking down which is not patient-friendly as well as a pain in the neck (from looking down). Also, though I guess I can learn to type fast on a virtual keyboard, I think I would still prefer the physical full-sized keyboard if given a choice. Furthermore, though wireless WiFi for all internet connectivity is nice in principal, it does introduce potential security problems as well as speed issues (wired ethernet in my experience is still the most reliable and fastest way of communication along with being secure).

However, WiFi connectivity is still important as pretty much every medical setting has WiFi and so one does have continuous high speed wireless access. Also, it would allow me to read a little bit of what's going on with a patient before walking into an exam room (I would load up the patient's chart using the touchscreen before walking into the exam room and docking the tablet). I just do not want to always DEPEND on WiFi.

A WiFi tablet touchscreen like the iPad is also great as one can BRING your office with you where-ever you go like the hospital and operating room without bringing a keyboard, mouse, etc. It's all self-contained. It's intuitive. It's all neatly packed into a simple, elegant tablet touchscreen that's highly portable and usable.

• Proximity security whereby the computer tablet "knows" you are right there. When you are no longer around the computer, it automatically locks. When you come back, it recognizes you and it automatically unlocks, all occurring invisibly to me without requiring me to actually do anything. I HATE the fact that I have 4 different userids with 4 different passwords to access the various EMR programs. Though I try to, I do not always remember to lock the computer 100% of the time. It should be all automatic. Does the technology exist? It sure does... It's called Single Sign-On for one userid and password that unlocks it all. And Xyloc by Ensure Technologies to allow for proximity recognition using RF technology. All I ask is that this technology be built-in to the hardware!

In a clinic where I'm constantly moving around where the tablet may not always be with me, due to HIPAA and HITECH, the computer needs to be secured. Though I try, I can not always remember 100% of the time to lock the computer. And same goes for my medical assistants. The security should be automatic, invisible, and secure.

The problem with biometric verification like fingerprint scanning or even ID card swipes is that I have to REMEMBER to do it. And the mere fact of doing it is aggravating because I would have to do it SO many times in a given day.

• Sturdy construction. The tablet is going to move around... a lot... It needs to stay working after being dropped from at least a height of 3 feet.

Which Brings Me to the Software:
What can I say? I LOVE the intuitive and simple interface of the iPad. Now, there's a few things I would tweak about it to make it MORE relevant in the healthcare setting.

• Multi-Tasking is a must. As I literally use Meditech (hospital EMR), NextGen (clinic EMR), Rcopia (electronic prescribing software), and PACS (radiology viewing software) all day long swapping back and forth even with a single patient encounter, I need to be able to easily jump between all these programs without shutting down the others. From what I understand, this functionality on the iPad will soon be reality with the release of the iOS4 operating system later June 2010.

• I constantly move back and forth among Meditech, NextGen, Rcopia, and PACS all day long. As such, having a few physical programmable buttons on one side of the screen on the edge would be wonderful which I could just press and it would take me immediately to my program of choice. Keyboard shortcut works, but imagine what touch-strokes would be required when I'm using it in pure tablet touchscreen mode...

• Apps already exist to connect via Citrix, Remote Desktop Connection, or screen mirroring... so I would just use those programs. If I was prone to unrealistic wishful thinking, I would ask for a single EMR program that incorporates Meditech, Nextgen, Rcopia, and PACS, but I do not forsee anything like that happening for decades (if ever). So, I'm going to stick with what is possible.

• A "tablet pen" is 100% optional and not necessary for use... Tablet touchscreen would be used predominantly using a finger(s) just like on the iPad. Personally, I do not foresee myself ever using a tablet pen. It's just one more thing that can get lost.

That's pretty much it! Is that so much to ask for???

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

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iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor

To read what I consider the perfect computer for healthcare, click here.


UPDATE 10/25/10: Watch video of using MediTech on the iPad

To give a little background, I am a ENT (otolaryngology-head and neck surgeon). I see patients in all sorts of environments including the hospital, operating room, and outpatient clinic. In the hospital, I use MediTech and PACS while in the clinic I use NextGen. Admittedly, I was not entirely convinced the iPad would ever be useful in this varied medical setting which utilized different EMR platforms when it first came out earlier this year.

However, several developments have occurred that has since changed my mind due to the ingenuity of app developers and other progressive technology that allows the iPad to connect with hospital and outpatient clinic electronic medical records (EMR) regardless of operating system and security settings.

The information provided here is based on using an Apple iPad 16GB model with WiFi only ($499).

Software

Foremost of these evolutions is the iPad/iPhone apps now available that allows for EMR access. To give some background, I use MediTech and PACS in the hospital and NextGen in the outpatient clinic. In order for me to access all electronic health records, two iPad apps are necessary:

1) LogMeIn: Wonderful app that allows the iPad to remotely control a Windows (or Mac) desktop computer anywhere in the world. The iPad app itself is $29.99. The LogMeIn desktop software (free) also needs to be downloaded to any desktop you want to access/control with the iPad. In essence, the iPad takes control of the desktop which you can see on the iPad screen. As such, any software including EMR programs like MediTech, NextGen, or indeed any other application (via Citrix) on the desktop, can be opened and visualized on the iPad. Click here to download this program.

The pictures below show MediTech as well as PACS being opened on the iPad using LogMeIn. The keyboard you see is a bluetooth keyboard wirelessly connected to the iPad (more on this below).

Of course, this method produces a slow response time as one is jumping through different networks to obtain medical records access (iPad --> LogMeIn --> Desktop --> Citrix --> Medical Records).

A more elegant solution would be direct Citrix/VPN access to the medical records (iPad --> Citrix/VPN --> Medical Records). Unfortunately, the hospital/clinic would need to upgrade their software in order to make this happen (which has not yet happened at my hospital). For those curious, the iPad software is called Citrix Receiver and is a FREE app download! Click here.

2) WinAdmin or Jump: Of course, if one is able to access medical records using terminal services (rather than citrix, VPN, etc), there's a perfect app for that called WinAdmin or Jump. Just punch in the same info you do to open terminal services on Windows and viola... the remote desktop appears on your iPad! Both  apps are iPad optimized and costs $8.99 for WinAdmin or $19.99 for Jump. Click here to download WinAdmin or here to download Jump. You can see a screenshot (to the right) where NextGen Master IM was opened up on the iPad using WinAdmin app.

The difference between Jump and WinAdmin are several-fold. Jump has better mouse usage controls (there's a mouse!), better virtual keyboard (including Tab, Esc, Function keys), and allows for external keyboard text entry. WinAdmin does not (so far). But I guess you get what you pay for! Having used both, I personally prefer Jump (originally purchased WinAdmin because it was cheaper).

SO, I basically use Jump to access NextGen which is accessible via terminal services and I use LogMeIn to access MediTech (as well as PACS viewer). As soon as direct Citrix access is available (should the hospital upgrade their Citrix software), I would change to Citrix Receiver instead of LogMeIn in a heartbeat.

Hardware

The keyboard is essential as I do a great deal of free-typing which is not easy (to type very fast) when using the iPad's virtual keyboard. As such, a bluetooth wireless keyboard is important for me to allow fast touch-typing. There are plenty of wireless keyboards out there... the one I use is the Apple Wireless Keyboard. However, this keyboard isn't perfect as the keyboard is bigger than the iPad and as such, needs to be carried around separately. I never even bothered getting the iPad Keyboard Dock as one MUST orient the keyboard vertically (in order to dock the iPad) which is not preferable when I used the iPad for accessing electronic medical records. For just that reason, I always keep the iPad screen locked in horizontal orientation.

As such, for me, the next piece of the iPad implementation for medical use is hardware. Here, I am most eagerly awaiting for the ClamCase which is supposed to be available for sale in Fall 2010. The "ClamCase" offers the perfect package in my mind:

• A nice case for the iPad for transportation

• A wireless bluetooth keyboard for freetyping

• Full use of the iPad as a standalone device in case I don't want to use the keyboard

• Keyboard fits within the case where you want it (so it can be opened up like a laptop)

What the ClamCase does that no other device offers is a wireless bluetooth keyboard BUILT-IN to the iPad case in a single beautiful package!

Here's a YouTube video showing the full features of the ClamCase:



Hopefully, it will live up to its hype and I will be basking in heaven using the iPad to do pretty much everything whether in the hospital, operating room, or clinic. Once multi-tasking becomes available with the next OS Upgrade (iOS4) later this month, that will be most awesome as than I can have NextGen, MediTech, and Safari up with Rcopia (the electronic prescribing program I use) all up and running simultaneously and I will be able to just switch among the programs without losing anything.

For now, I'm trying it out on a limited basis before ditching the old system (desktop computer in each exam room) and using iPad exclusively.

Will keep those interested updated on my experiences over time...

In meantime, read what I consider the perfect computer for healthcare here.

Related iPad and MediTech Blog Articles:
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

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We Now Offer Sterile Ear Piercing Using Lab-Tested, Hypoallergenic, Packaged & Sealed Earring Studs

Our office offers ear piercing by a doctor to patients in a manner superior to that obtained in most commerical locations. The ear piercings we provide are:

• Performed in a sterile manner (numbing offered as well)
• Ear studs placed are hypoallergenic
• Ear piercing system used has been laboratory tested, packaged, and sealed
• Hypoallergenic studs and clasps are individually sealed with disposable earpiercer - avoiding any concern of cross contamination

Better yet, we can perform this procedure at the same time as ear tube placement as well as any other surgical procedures including tonsillectomy and adenoidectomy! If your child is going to be under anesthesia, what better time to place earrings as well!

If awake, we do offer EMLA numbing cream prior to piercing (which reduces the pain by about 50%) or freezing with an ice cube.

Read more here as well as to see what earring studs are available.

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