Nick van Terheyden, M.D.

home

authors

nick-van-terheyden-md

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

Get the best executive insights directly to your inbox. Sign up for our 

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. 

Nick van Terheyden, M.D.

Articles

Blunders and Wonders: Overexposure to Radiation & Changing Your Microbiome

Blunders and Wonders: Home Medical Care & Digital Stethoscopes

Blunders and Wonders: Forgotten Equipment & Sleep Disorder Treatments

Blunders and Wonders: Misconnecting Equipment & Drug Delivery