Nick van Terheyden, M.D.

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Hello, I’m Dr. Nick the Incrementalist here today to talk about Blunders and Wonders

This Week’s Blunder: Excess Testing and Overexposure to Radiation

The healthcare system is working as designed — we have a system that incentivizes activity commonly known as fee for service. Compounding this is lack of interoperability that prevents information from being shared between systems and sometimes it’s not shared at all.

So, when a patient visits their doctor, he might not have access to the most recent results or tests that have been ordered, and needing this information, he orders tests to be repeated. For simple noninvasive tests, that’s an economic problem, but for anything that includes radiology imaging, especially CT scans, this creates an excess exposure to radiation that’s known to cause disease — the more exposure, more disease.

The healthcare system is working to reduce this exposure, but the excess still occurs, putting patients at unnecessary risk. Sometimes this can be ordering tests that are not clinically warranted, and this can be reduced by providing easy access to the clinical guidelines agreed through consensus by experts of the recommended testing for presenting conditions and importantly offering the ordering clinician the easy option of the safest recommended choice and the underlying reasons as to why. It extends to tracking the exposure for patients from their medical records that should be immediately available and universally shareable and should contain not just the clinical results, but a running total of radiation exposure available to everyone concerned for the care of the patient to facilitate making the right choices when ordering additional tests.

Making the data available is the first step in delivering safer, more economic care, and should be a basic requirement of any system being used, and a requirement on the part of patients.

>> WATCH: Blunders and Wonders: Home Medical Care & Digital Stethoscopes

This Week’s Wonder: Treating Diseases by Changing Your Microbiome

Since science managed to sequence the human DNA, the techniques have allowed for both faster and cheaper sequencing to take place, and we have been on this fast path to new insights into our bodies. In the case of our gut, and the microbiome our human cells are outnumbered 10 to 1 by bacteria. Early results have revealed some signatures in individuals with disease in the make-up of their gut bacteria, and there are a slew of companies jumping into that space who see the potential for using that information to not only diagnose disease, but beyond. As Mr. Spock might say, ‘If a disease impacts the make-up of our microbiome, then logically, changing the microbiome might impact, or even cure the disease.’ There have been tantalizing instances of this concept in some studies published, with the most recent study by the Gothenburg scientists, who initially looked at five patients with type-2 diabetes and 10 diabetes-free control subjects, but then they went on to confirm their findings in a larger study involving 649 people. They investigated the effect of imidazole propionate on sugar metabolism and found that the molecule affected a signaling pathway previously linked to metabolic-related diseases by directly activating a specific protein, p38gamma.

These findings provide answers to the question about the nature of the underlying mechanisms of how the gut microbiome is linked to obesity, diabetes and cardiovascular disease. As the researchers highlighted, these new insights pave the way for identification of bacteria-induced mechanisms and will allow the stratification of patient populations and identifying new, more personalized forms of treatment, that will likely include some manipulation of the microbiome as part of disease treatment.

Until next time, I’m Dr. Nick, the Incrementalist — don’t let perfection stand in the way of progress

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More Blunders and Wonders of the Digital Transformation:

High-Risk Healthcare Data & Vaccine Reluctance

Videos

Insights to how overexposure to radiation can be reduced and how changing our microbiomes can lead to a healthier life.

Blunders and Wonders: Overexposure to Radiation & Changing Your Microbiome

Hello I’m Dr. Nick the Incrementalist and here today to talk about Blunders and Wonders.

This Week’s Blunder: Home Medical Care Device User Design

Care is moving out of the hospital and into the home and that’s a good thing. Just ask anyone where they would like to spend their life and especially their twilight years. I know I’d like to end my days at home. You’ll never hear a response “the hospital.”

To achieve this safely we have been on a steady march to equipping the medical home with technology that can help monitor our health using technology that keeps tabs on key body systems.

But some devices used in the home are designed for use in hospitals, and more importantly, by trained professionals. And handing these over to elderly patients and their family care givers can be a recipe for disaster. Even when they do come with manuals and labels, oftentimes in print so small as to be illegible to anyone with eye sight affected by presbyopia — you know that frustrating experience that occurs with age that means you now need reading glasses.

This is as much about user design as it is care giver knowledge, and it is made worse by the unpredictable nature of the varied environments that we find in our homes.

The push to the medical home demands a new found focus on user design and designing systems that cater to all levels of knowledge and experience, and remove the potential for failure or mistakes by designing systems that fail safely and elegantly. User focused design is spotty at best in healthcare, and the failures have been balanced by training of users, but that’s not scalable nor is it appropriate in the home setting. So, for the new digital home age, let’s focus on delivering a great, perfect experience for those home-based users.

This Week’s Wonder: A New Digital Stethoscope

I know, a little bit of a surprise to some given that some in the digital health space have declared the stethoscope dead. But this is a new take on the stethoscope.

My father was an engineer. His ear was tuned to listen to machines and engines, and he could tell something was wrong by the change of the sounds he heard. Same was true in the stethoscope and the experienced clinicians who I would watch in awe as they’d listen to a patient’s heart and correctly determine the disease just by observing the patient and listening to the sounds.

But stethoscope design has changed little since its invention in 1816 by Rene Laennec. So, it was about time it received a makeover, and the team from the Rochester Institute of Technology used innovative digital signal processing techniques. They included digital signal filtering, advanced beat-based rejection, algorithms and ensemble averaging. They combined precision sensors, electrocardiogram technology and machine learning applications into one piece of equipment to better detect heart ailments and beyond. The new systems improve the acoustic diagnostics with spectral analysis and taps into machine learning techniques using automated neural networks to learn and recognize defects. This was the same pattern recognition that the consultants of yesteryear were famous for. They developed and used them to treat their patients with characteristic flair. Now we are starting to develop technology to provide access to those insights to the junior clinicians who lacked the personal experience to develop that in the early part of their career.

Until next time, I’m Dr. Nick, the Incrementalist — don’t let perfection stand in the way of progress.

As care moves out of the hospital, healthcare must grapple with a number of issues.

Blunders and Wonders: Home Medical Care & Digital Stethoscopes

Hello, I’m Dr. Nick the Incrementalist and am here today to talk about Blunders and Wonders.

This week’s Blunder: Leaving Behind Equipment.

If you’re like me, you may have lost one of your favorite garden tools or a screwdriver, leaving it carefully positioned next to a job you were carrying out, but forgot when you finished, and cleared everything away. In the surgical setting, that’s a much bigger problem and one that still occurs with surprising frequency. 

Surgical sponges that are unintentionally left inside the patient after the surgical site is closed, can lead to infection and other serious complications, including the need for secondary operations, and surgical teams and operating room staff work hard to prevent these events with manual counts of the items before, during and after any procedure. But that task is done in different ways and faces some varied challenges depending on the procedure and the general flow for that team. It might seem strange that this is even possible. A white sponge can quickly assume the color of the cavity it is inserted into, leaving it near invisible to a visual inspection.

So, while the counts and check list remain a main stay of prevention, there are new technologies that offer some improvements. Everything from using special dyes that can be visualized prior to closure, to using tags attached to everything much like the tags on items in shops that set off alarms if they are removed from the store. 

In this case, technology can help, and it needs to become part of the systems built into every operating room that would help prevent these errors.

This week’s Wonder: New Treatment for Sleep Disorders.

Sleep is the foundation of health, yet it remains a major challenge for many people.

Insomnia is one of the major sleep problems, with an estimated prevalence of 10% to 15% in the general population, and 30% to 60% in the older population. Sleep apnea affects 20 million people in the U.S. alone, and it is impacting the general health of the population, and according to some studies, it has a bigger impact than poor diet.

Moreover, insomnia frequently occurs with a wide-range of psychiatric disorders, including depression and anorexia. 

Treating sleep disorders should start with good sleep hygiene, that includes setting yourself up for success. But when that fails for some recalcitrant or unresponsive patients, the medical profession has turned to treating insomnia with drugs that induce the wrong kind of restorative sleep that we are in desperate need of , and are plagued by a wide-range of adverse effects, including muscle relaxation, rebound insomnia, changes in appetite, next-day sedation, cognitive impairment, amnesic effects, and development of drug tolerance and dependence.

So, it is good news to hear that a recent paper published in the 

by researchers at the International Institute for Integrative Sleep Medicine at the University of Tsukuba has identified a new receptor target. Their new molecule signals inducing sleep that is indistinguishable from the major component of natural sleep, known as slow-wave sleep, which may offer a new therapy option and good sleep without all the unwelcome side effects.

This was a mice model, so until we see this tested in human systems, it is something of a long shot, so in the meantime, focus on good sleep hygiene.

Actionable insights to reduce the likelihood of medical errors and improvements in our understanding of sleep hygiene.

Blunders and Wonders: Forgotten Equipment & Sleep Disorder Treatments

Hello! I’m Dr. Nick the Incrementalist, and I’m here today to talk about Blunders and Wonders.

This week’s Blunder: Misconnecting equipment. We are not big users of diesel fuel for cars in the US, but on the European continent it’s very popular. For anyone visiting who’s not familiar, they might make the mistake of taking the commonly found diesel nozzle and putting that into the gas tank of a gasoline or petrol driven car. In fact, that’s mostly not possible since the nozzle is designed to be bigger, so it won’t fit into the gas tank opening. It’s a simple but effective safety measure.

The same principle has been applied to anesthesia — removing as many opportunities for errors by standardizing on connectors for specific gases and cylinders that prevent connection of the wrong line to the machine.

Sadly, this is not a pervasive safety measure throughout healthcare and you only have to watch one of the latest Hollywood medical dramas or set foot into a hospital to see the array of tubes and connectors that are ever-present at the bedside. We use these connectors for a wide range of medical support to the patient that includes nutrients and drains. Misconnecting these tubes to the wrong source can result in serious medical issues like delivering the wrong product to the wrong part of the body.

Creating a standard for each of these connectors that prevents the connection of a nutrient line to a venous or arterial line on a patient is a simple safety feature that would go a long way toward reducing errors. The FDA has urged making the connectors uniform to prevent misconnects, but these are voluntary guidelines and misconnects continue.

In the interim, for your incremental step, don't modify or adapt intravenous or feeding devices. Use color coding if at all possible and trace lines from end to end every time there’s a change or as part of a hand off.

This week’s wonder: Treatments that keep on giving. We have a range of treatments that require continuous medication to maintain an appropriate dose to treat disease. No matter what we give to a patient, the extraordinary body systems are designed to get rid of substances from our body, and that’s true of drugs we use to treat disease. You’ll be familiar with that if you take any medication, as the majority come in the form of a pill that you take once every day, sometimes multiple times per day. For tablets it’s relatively easy to maintain the appropriate dose, but for drugs that must be injected, that creates some challenges — especially if access is limited.

Such is the case for a treatment of age-related macular degeneration that causes blindness. Unfortunately, despite finding a highly effective drug that can prevent the disease, we still see a lot of people going blind because it has to be administered by injection every 6-8 weeks, which is a challenge for elderly patients who lack good access to transportation.

The research presented at annual meeting of the American Academy of Ophthalmology (AAO) recently offered a new hope, showing off an implantable drug delivery system that meant patients could go up to 15 months between injections. But the news, in my mind, is even better since this methodology can be applied to other drugs and potentially in other countries where access to healthcare can be even harder and less frequent and consistent, like Africa. Now it might be possible to develop low cost delivery mechanisms for other lifesaving drugs as well as this one.

Until next time I’m Dr Nick, the Incrementalist — don’t let perfection stand in the way of progress.

How foolproofing anesthesia-delivery tube connections and putting R&D dollars into longer-acting injectables can improve efficiency and reduce risk. 

Blunders and Wonders: Misconnecting Equipment & Drug Delivery 

Hello! I’m Dr. Nick, the Incrementalist, and here today to talk about Blunders and Wonders

This week’s Blunder: Failure to secure healthcare systems. Healthcare data is very lucrative for attackers, representing a rich tapestry of information that offers multiple potential value points for resale to the hacking community. That’s alongside the fact that hackers know healthcare data is not typically very secure, not to mention their affinity for out-of-data operating systems, which all add up to a veritable feeding frenzy of attacks on healthcare data and systems

Healthcare data and systems have a huge target on their back, so ignoring this from the hospital perspective or the vendor perspective is misguided. Making sure hardware, software and all the devices are upgraded to the latest releases is not a “nice to have,” but an essential part of offering a safe and trustworthy service to your patients.

As part of any new installation or upgrade, include a planned obsolescence of the systems you are replacing. Too often, old systems and devices persist in facilities because no one was charged with the responsibility of removing them. Probably much like your own home, where you likely have a tray of old devices that you no longer use, but you just haven’t got around to getting rid of. The difference in healthcare is that those devices represent potential risks to patient safety and data security.

Ultimately, your employees are your first and best line of defense. Empower them to both understand these risks, call them out and mitigate them directly, where possible, and if not, implement clear lines of escalation to the help desks, who can take action on the keen insights provided by the employees on the front line of delivering care. This will help provide protection to your system and data.

Your incremental step for dealing with these threats is to stop seeing cybersecurity as a cost and to see it as an investment in the safe, trustworthy delivery of healthcare.

Wonder: Vaccines for the Immunocompromised

This week’s wonder: Vaccines for the immunocompromised. Let’s be clear: Vaccines save lives. There is no question that they have contributed to some of the biggest advances in improved healthy living and have even almost wiped out diseases. In fact, it would have been impossible for me to imagine when I was training to be a doctor over 30 years ago that I would see a resurgence of pertussis or whooping cough and measles, but that’s where we are.

The underlying reasons are complex, but relate to an unfounded lack of trust in vaccines thanks to fraudulent claims and amplification of these messages in social media. The consequence of this is a reduction in herd immunity that exposes at-risk groups, who are unable to be vaccinated to diseases long thought to have been eradicated.

So while we struggle to educate the population, let’s look at a recently published study in the Journal of Immunology that identified a new target protein that is important in regulating the immune response called CBLB in mouse models. This can be targeted in combination with an inactivated vaccine to elicit immunity through a unique T cell pathway and this offers hope to an approach that may lead to protective vaccines for immune-impaired patients, such as those undergoing chemotherapy, immunosuppressive therapy, or immune deficiency.

That’s great news for the wide collection of people who sadly now live in the shadow of fear of diseases that should have been left as a historical footnote but have reemerged as a threat.

Until next time I’m Dr. Nick, the Incrementalist — don’t let perfection stand in the way of progress.

EMR Interfaces and Continuous Blood Pressure Monitors

Healthcare data security and patient vaccine adherence should be viewed as investments, not costs. 
 

Blunders and Wonders: High-Risk Healthcare Data & Vaccine Reluctance

Hello! I’m Dr. Nick, the Incrementalist, and I’m here today to talk about Blunders and Wonders.

This week’s Blunder: Cancer’s double blow. There’s something deeply wrong with a healthcare system that takes a patient recently diagnosed with cancer and kicks them while they’re down. That’s the finding of a recently published study in the American Journal of Medicine. A longitudinal study that looked at data from the Health and Retirement Study from 1998 to 2014, that collects data on people aged 50 and over. They looked at patients’ financial status prior to receiving a cancer diagnosis, and then again at year two and year four for post diagnosis.

With the increasing shift of costs in healthcare to the patient, the impact of cancer diagnosis was debilitating, revealing over 40 percent of people had depleted their life assets, and by year four almost 40 percent had become financially insolvent. In other words, they had gone bankrupt. Over half of all people with cancer experienced house repossession, bankruptcy, loss of independence, and relationship breakdowns. That’s a bleak picture for anyone with a disease that is the second leading cause of death in the United States. The direct medical disease costs in the US run to $80 billion per year.

In this instance, the open sharing of data through open notes and transparency is the path to mitigating this opening up clinical records, costs and research to everyone so they make informed decisions, even if those decisions put everyone in an uncomfortable position.

Cancer is an equal opportunity offender. With some exceptions, it strikes for no reason and with no specific underlying cause or warning. In other words, it’s the random drawing over which we can do little to mitigate and have little control. So current circumstances mean that not only do patients face the devastating news of a diagnosis of a severe disease, but they also must face the financial burden this will place on them and their family.

Wonder: Visual Tools to Help Assess Sugar Consumption

This week’s Wonder: Visual tools to help assess sugar consumption. I know I’m a visual person, and I suspect many of you are too. So the discovery of the Sneaky Sugar website that offers you a visual representation of the amount of sugar in common foodstuffs was a simple but powerful idea.

We have reached an inevitable conclusion on food consumption and sugar: too much sugar is bad for you. What’s the right amount of sugar depends as much on you as it does on what else is in your diet, but the World Health Organization (WHO) recommends a maximum of 25 grams of sugar per person per day. That’s about 11 sugar cubes per day.

The challenge many of us have is consuming less sugar in our diet. When that sugar comes in the form of sugar cubes or granules it’s easy to assess how much we are eating. But when it’s hidden inside everyday products, it can be challenging to understand how much we are putting into our bodies every day. As the site points out, they identify 60 different ways that the nutrition labels on foodstuffs can say sugar.

The site offers you a handy way to educate yourself and identify the hidden sources of sugar that add up to push your total consumption each day past the recommended daily allowance. By way of an example, a handful of your favorite candy probably contains more than your daily allowance, as does your favorite large coffee drink.

. Don’t let perfection stand in the way of progress.

Over half of all people with cancer experienced house repossession, bankruptcy, loss of independence, and relationship breakdowns. That’s a bleak picture.

Blunders and Wonders: Cancer's Price Tag & Sneaky Sugar

This week’s Blunder: open access to your medical record. A recent study published in the Journal of the American Medical Association looked at US hospitals’ compliance with the regulations in the US for patients’ requests for access to their own medical records, and it made for some pretty sobering reading.

Dating back to 1996, patients have had the right to their medical record in the format they request, assuming the records are reproducible in the requested format at a reasonable cost. In fact, this one requirement is at the foundation of the Walking Gallery movement created by Regina Holliday and her “73 cents” mural. That was the price Regina was charged per page for copies of her late husband’s medical records.

That was 2009 — almost 10 years ago – and yet in this study, we find that hospitals are not meeting the mandated release timeframes, formats, charges, and availability of medical records. Costs for release of a 200-page record ranged from zero to $540. In an interesting twist, for those hospitals still stuck on limiting access to patients’ laboratory results, some patients proceed directly to medical records released directly from the phlebotomy lab to request the release of the results frustrated with hospital policy that either prevents or delays release directly to patients.

As Leonard Kisch famously said back in 2012, “Patient engagement is the blockbuster drug of the century.” If you could bottle it up and sell it, results would be so good that people would be falling over themselves to buy it. But engagement does not come in a data-opaque or data-missing scenario. So get with the federally mandated program and make the release of records and results an economic- and experience-easy process.

This week’s wonder: The gene editing of mosquito genes to eliminate malaria. Malaria is a killer — a big one that’s killing almost half a million people a year. And it’s not just malaria. Mosquitos carry Yellow fever, Dengue fever, and West Nile virus, alongside Zika, which caused major concern across several countries in the last year or so.

The latest test of the CRISPR gene editing tool published in Nature Biotechnology featured a novel gene drive that spread specific genes through a population of several generations. Tests were conducted in a closed experimental laboratory setup, so no release into the wild, and targeted gender determination, basically stopping females form being produced after eight generations. This essentially crashed the mosquito population, and unlike previous attempts, no resistance was developed to the gene therapy.

Next stop is a larger, more lifelike test, mimicking tropical conditions and looking at the impact on the food webs and predators. Assuming continued success, this could be a major breakthrough on the road to suppressing malaria and other mosquito borne illnuesses, but that might not be for another five to 10 years.

Why so long? Well, although many of you might not be big fans of mosquitos, they are an integral part of our ecosystem, providing an essential food source for fish, other insects, birds, and they even pollinate plants. The unintended consequence of eradication might have a severe or catastrophic impact on our world, like we have seen with other with other well-intentioned human manipulation of ecosystems, like introduction of the toad, kudzu and wolf snail. So there’s hope on eliminating a major killer, but more work to be done.

Until next time, I’m Dr. Nick, the Incrementalist. Don’t let perfection stand in the way of progress.

The Opioid Epidemic’s Tech Problem & Digitization of Health Records

Get with the federally mandated program and make the release of medical records easier for patients.
 

Blunders and Wonders: Patient Access & CRISPR

. And I'm here today to talk about Blunders & Wonders.

Blunder: The EMR User Interface and Standardization

This week's Blunder: The EMR user interface and standardization. As I mentioned last week, the JAMIA-published study on the usability of electronic medical records showed there's 61 clicks required to prescribe Tylenol.

This week, I wanted to focus on the standardization and the incredible variation seen implemented in the same EMR systems in different facilities. For the same measurement of clicks and time for Tylenol prescribing, the authors found variability for a low of 14 clicks and 45 seconds, to a high of 61 clicks and 70 seconds for the same task.

>> WATCH: Last week's episode on Unusable EMRs

The study included measurements from two of the leading EMR products in the marketplace from Epic and Cerner. And yet, they found wide variation in the time and clicks to complete similar tasks.

Can you imagine stepping into your car and not knowing where the key to start the engine goes? Or how to turn on the lights at night? Or operate the windscreen wipers? The answer, of course, is no.

The industry has long since standardized on critical control location and operation to allow anyone with knowledge acquired on any car to operate all cars safely.

But our EMR systems have developed over an extended period of time. Innovations and concepts arriving at different times through different vendors creating this smorgasbord of interfaces and interactions that challenges even the most technology adept users.

Some of this is perhaps mistakenly seen as differentiation and the marketing of a better product. Yet we know from cars that differentiation is clear between brands despite the standardization of the user interface.

We need to rethink the whole design of these interfaces and bring in experts in user-centered design. The people who start from the principle of "nothing is off limits to change," and importantly, your first ideas are more likely to be tossed out. In fact, all ideas are sacrificial lambs in a good design process that will ultimately end up so that things should be as simple as possible but no simpler.

Wonder: Continuous Blood Pressure Monitoring

This week's wonder: continuous blood pressure monitoring. Hypertension is a silent killer. One in three adults in the United States have hypertension. Thats approximately 70 million people. And by our best estimates some 13 million people aren't even aware that they have hypertension.

In what's a nice piece of lateral thinking, researchers at the University of California San Diego are working on a patch that continuously measures someone's central blood pressure using a silicon elastomer ultrasound patch that generates sound that penetrates the skin, reflects off the wearer's tissues and blood. The reflections are sent back to the sensor and the researchers were able to continuously and accurately monitor central blood pressure, which they compared to a tonometer - a pressure sensor on the skin - and the results between those two devices were in sync with a very small variance between the two methods.

 In an interesting and potentially useful twist, the device can be placed in different locations. In the case of the study, at the neck, offering insights into blood pressure and flow in different parts of the body.

It's still early days, and since the device needs power it has to be connected to a laptop, and there remains the challenge of understanding the difference between the central blood pressure and its relationship to the peripheral arterial blood pressure that we measure in the arm, and what the predictive nature of these two measures are.

I know personally, I'm excited for any technology that can get to accurate measures of my blood pressure with a continuous, non-invasive technique to help understand the variability of this measurement, and to help manage and mitigate the associated cardiovascular disease that's killing so many people today.

Until next time, I'm Dr. Nick, the Incrementalist. Don't let perfection stand in the way of progress.

More Blunders & Wonders of Healthcare's Digital Transformation:

The auto industry standardized critical control location in cars to allow anyone with knowledge on any car to operate all cars safely. But our EMR systems have been developed piecemeal, to the detriment of its users.

Blunders and Wonders: EMR Interfaces and Continuous Blood Pressure Monitors

Hello! I'm Dr. Nick, the Incrementalist, and I'm here today to talk about Blunders & Wonders.

This week's Blunder: Usability and the electronic medical record (EMR). The Journal of Medical Informatics and Health and Biomedicine, or JMIR, published a study recently on the usability of electronic medical records.

There was so much to unpack in the details of the study, but one data point stood out to me: 61 clicks required to prescribe Tylenol for a patient every four to six hours. This worked out to over a minute of time.

As one commentator online noted in an exchange with me, they struggle to reconcile this with the ubiquitous nature of barcode scanning capabilities that we're finding extremely efficient, and are making our everyday lives easier. Most frequently for most of you, this occurs in the supermarket, where the purchase of scanning items has devolved down to the individual shopper in the self-service aisle.

But even with barcode scanning you can still find major inefficiencies in the design of workflow and it fails to take account of the circumstances on the ground. Imagine if the supermarket required you to scan the shelf sign, scan the shopping list, then scan the item itself on the shelf, open the box, take out one of the items, scan that, scan your cart...

Well, you get the picture. Now mistaking penne pasta for linguini is not a total disaster, unless of course you've got a three year-old who refuses to eat anything but penne pasta. But in medicine, getting the wrong drug to the wrong patient is a huge safety issue.

It comes back to designed thinking - that we should start with no preconceived notions or mandates, otherwise it risks just automating an existing process with technology that offers so many alternatives to the way that we can rethink the design.

We saw the move from steam-powered machinery that had pulleys that failed to immediately apply the thinking around electric motors, and just replicated the system of pulleys that were necessary for the steam-driven engine. It was some time later that rethinking the design placed those motors conveniently at the point of the production line.

So it is with EMRs. An automated system optimized for paper introduced inefficiencies that take away the clinician's focus from their patient and onto the technology.

This week's wonder: the ultrasound transducer that could turn a smartphone into an ultrasound machine for $100.

There's no question that ultrasound technology has had a major positive effect on medicine. It's added amazing new insights into the workings of our bodies and to the process of diagnosing and understanding disease. In fact, the original insights came from the animal kingdom and the echolocation capabilities of bats that were given a boost following the sinking of the Titanic.

We've seen advances of this technology with the addition of different modes, adding Doppler sensing, and offering progressively more information and more detail to the output.

All these systems are based on piezoelectric crystals that vibrate to produce the ultrasound waves, but researchers at the University of Columbia have broken that mold with a new transducer, replacing the piezoelectric crystals with a tiny vibrating drum made up of a polymer resin called polyCMUTs, or polymer capacitive micro-machined ultrasound transducers, which have lower power requirements, fewer manufacturing steps, and are hence cheaper to manufacture.

The images seen were as good, and in some cases sharper than those produced with traditional piezoelectric transducers. Based on their research, it looks like we could be seeing transducers miniaturized to the size of a small band-aid that could be stuck on the patient's chest for continuous monitoring, opening up a whole new domain for all this data and collection and insights into individual bodies and organs and functions.

Until next time, I'm Dr. Nick, The Incrementalist. Don't let perfection stand in the way of progress.

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Digital Health Blunders and Wonders: The Opioid Epidemic’s Tech Problem & Digitization of Health Records

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Digital Health Blunders and Wonders: Medical Intake Forms & CRISPR for Duchenne’s

Why we’re thinking about EMRs all wrong, and how mhealth gives us new windows into the human body.
 

Blunders and Wonders: Unusable EMRs & Smartphone Ultrasounds

Hello! I'm Dr. Nick, the Incrementalist, and I'm here today to talk about Blunders & Wonders. 

Digital Health Blunder: Opioid Crisis & Treatment 

This week's blunder involves the opioid crisis and its treatment. 

The statistics are staggering. This crisis has been killing us steadily over the last several years. Here in the US, over 100 people a day die of an opioid-related overdose, and 2.1 million have some form of opioid misuse disorder. 

Currently we're struggling to find ways of easing this addiction. One of the tools available is with a medication assistance program, using a combination of naloxone and buprenorphine, whose history of development dates back to the 1960s, when the researchers tried to synthesize a drug that was as effective as morphine, but shared some of the undesirable effects of dependence and addiction. 

They were ultimately successful and the new drug was released and has been in use since the late 1970s. 

>>> READ: Rise of the Anti-Opioid Algorithm

The patent has long since expired and generics are available, which is great news given the desperate need for ways and means to treat and manage the burgeoning demand of opioid-dependent people. 

But it was the news that Richard Sackler, a member of the family that founded the Purdue Pharmaceuticals company, the one accused of fueling the opioid crisis, has filed, and was issued a patent for a new formulation of this drug. With this in place, they get to benefit from a formulation of a drug designed to treat addiction, that they're accused by more than 1,000 jurisdictions of fueling. 

There are other potential methods for treating opioid addiction, such as those being developed and tested by Pear Therapeutics as an adjunct therapy, and clearly interesting enough for the FDA to launch an innovation challenge seeking developers of medical devices and digital health technologies that can provide a novel solution to detecting, treating and preventing opioid abuse. 

Digitial Health Wonder: The Digitization of Science & Healthcare

This week's wonder: The digitization of science and healthcare.

You may have missed the news of the tragic fire that burnt Brazil's natural history museum at the beginning of the month, but it was hard to miss the commentary from so many people expressing the sadness and the loss of so many irreplaceable holotypes. 

The totals aren't in, but the risk is to some 20 million specimens, and as one commentator aptly put it, this was a lobotomy of the Brazilian memory. 

>>>READ: Interoperability During disasters: Lessons from Tragedy

Which brings me to the digitization in healthcare. Through the tragedy of hurricane Katrina and the displacement of so many and the destruction of medical records, a new age of digitization and health exchanges was accelerated. With the 

, many patients are finding their access to their latest records and treatments is improved thanks to the resilience of this process and the backups. 

There are some limitations to this digitization that's dependent on what exactly you digitize. DNA of the lost fossils cannot be recreated from the scans, but the bones and the mechanical features can. What's interesting about this effort and its potential, is the crowdsourcing aspect. The internet is already trying to help, putting out a call for any images to put into a database and use a 3D modeling platform - Sketchfab - to compile the images and recreate what they can. 

You have to love the community effort and the spirit, which reminds me a lot of the patient-engagement community, and the projects that share knowledge and insights, and collectively hack health for the better of everyone. Case in point: the Four Thieves Vinegar group, who hacked the EpiPen and created an affordable EpiPencil version using all the tools available in our technology-packed world. 

As for DNA, given the ongoing decline of the genome sequencing cost, that, at its current rate, will allow for not just the sequencing of the individual, but the sequencing of all our biomes, and may be done on a regular basis, we might be well on our way to full digitization. 

As is often the case, want to get a sense of where this might go? You can turn to Hollywood. For some historical perspective on sequencing, check out the dystopian "Gattaca," and for the future storage of humans, "Transendence" gives you a peek into the digitization of the brain. 

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Following Hurricane Florence, many patients are finding access to their latest records and treatments is improved thanks to the resilience of digitized records and their cloud backups.