James Bond and the Proton Beam Device

James Bond slowly came to.  His head ached.  He could not move his arms.  Looking down, he saw his limbs were firmly attached to a large table. He was positioned beneath a huge, complex machine, from which a conical probe jutted straight at him.  Before he could make sense of his surroundings, his ears were filled with the booming voice of a familiar nemesis.

“Good morning Mr. Bond!  I trust you are well-rested?”

Bond:  “Professor Blocash!  I should have known.  What is this?”

Blocash:  “Why, you’re the first guest of my new Proton Beam Device.  There are only nine of them in America, and we control seven.  Your name is fitting.  You should have seen the size of the bond issue we had to float to finance this one.”

Bond:  “Do you expect me to talk?”

Blocash:  “Of course not.  But what I am going to do is demonstrate the device on your unsightly forearm mole.”

Bond:  “I thought this machine delivers precise energy to internal tumors without damaging surrounding tissue?”

Blocash:  “It does that, but we will eventually expand the indications.”

Bond:  “But this technology hasn’t been proven to be equivalent or superior to standard radiation!*”

Blocash:  “Mr. Bond, don’t you understand that doesn’t matter?  Medicare still pays for it.  It’s the same story with the DaVinci surgical robot and many other treatments.  Payments flow directly into my account.  And I don’t have to hire a single armed henchman!   This is far easier and more profitable than my other plans!”  [Rubs hands together menacingly]

Bond:  “But why would they pay you to provide expensive treatments that are of unproven value?”

Blocash:  [Pacing with hands clasped behind his back] “My organization donates generously to both American political parties, keeping them in a state of perpetual and profitable gridlock!  Even the simplest fixes could save their taxpayers a fortune.  Consider that for years Medicare continued to pay for outdated HIV infusion therapies.  Instead of writing a few lines of computer code, they didn’t react until a huge fraud ring in Miami stole millions billing those outdated codes!”

Bond:  “But if you build a Proton Beam Machine, other hospitals will have to do the same thing.  That leads to a hugely inefficient medical arms race.”

Blocash:  “We are not interested in an efficiently developed healthcare system.  Here the Byzantine regulations allow for far more creative options.  Also, patients don’t directly pay for the care they consume.  Skillful marketing can make them demand any technology we build!”

Bond:  “This can’t go on forever.  Patients do pay, just through increasing health costs borne by their employers.  They’ll stop you!”

Blocash:  “Perhaps, but not anytime soon.  Enough talk!  Engage the Proton Beam!”

Nurse:  “Professor we can’t do that.”

Blocash:  “Why not?”

Nurse:  “We haven’t completed the Time Out.”

 

 

 

* Author’s note:  The avoidance of damage to surrounding tissue may be one key indication for proton beam therapy, and this is not to suggest that the technology should never be used, only that it should be carefully studied before being implemented on a wide scale.

EMR Designers: Borrow From the Titans of Technology

Steve Jobs was referenced several times during the recent State of the Union address.  Healthcare was conspicuously absent from the speech, for a variety of reasons.  What might Steve thought of electronic medical records?  I would imagine he had some thoughts on the healthcare system, having unfortunately needed to access it during his illness.  Perhaps we will eventually learn what he thought of it.  However, his experience was almost certainly far smoother than an average person’s, given who he was.

Apple products are known for excellent function and design simplicity.  Would an Apple-EMR look anything like the presently available products?  Probably not.  Had he watched a surgeon (as I once did) fumble for 45 minutes trying to put in orders and notes for a procedure that took 30 minutes, his designers would likely receive a profanity-laden tirade.

The trouble with most EMRs is that they are written by techies, and are focused on capturing a large amount of extraneous data that has little to do with the overall care at hand.  Healthcare is a complex area that is made up of many fairly simple components.  The current generation of EMRs are overly complex and have not been implemented because practitioners or consumers (patients) demand or require them, but because government incentives (and soon, coercion) have been required to force their adoption by a sector that does not have a true need for the product.

Consider the quick-service restaurant sector.  Their version of the EMR is ubiquitous and necessary in order to serve customers and compete.  It enhances the operator-customer experience.  Here’s how it would look if a current EMR was adopted for restaurant use:

(From a recent exchange at McDonald’s.  Yes, even doctors occasionally eat there.)

Me:  “I’d like a Southern Chicken Sandwich.”

Staff:  “Your height and weight please?”

Me:  “Six feet four, 205 lbs.”

Staff: [narrows eyes in disbelief]

Staff:  “Any pets in the home?”

Me:  “What does this have to do with my order?”

Staff:  “What color is your couch?”

Me:  “Well, I’m still trying to clean a butter stain, and the cat  made a mess on it.  Let’s call it  beige-to-yellow.”

You get the point.  This sort of data collection erodes the user experience and impedes the purpose for which the system is supposed to serve.

Future EMRs will solve these problems.  It is not that the data is completely useless, but most is unnecessary and collecting it in the current fashion saps productivity and leads to all sorts of unintended consequences.  For example, specialists may scan, skip or ignore most of the pre-generated information from EMR referrals, focusing only on the issue for which they are being consulted.  Copy-and-paste can lead to absurd rounds of the children’s “Telephone Game”.  (Amputees with normal pulses in the limb, etc.)

Healthcare will eventually have full, well-designed EMR adoption.  But getting there will take a few more software generations.  Here are three easy ideas just by borrowing from what already works in tech.

1. Touchscreen navigation:  Akin to the old lightpen (precursor to the mouse), this makes it quick and easy to enter information.  Hand sanitizer at every workstation will help with germ fears.
2. Smart Software:  If Amazon knows what products you likely want, the EMR should know your order sets and what medications you typically prescribe.  An orthopod shouldn’t sift through a hundred obscure medications to select antibiotics and pain meds, and to put in his standard orders.
3. Simplify documentation:  When patients are seen for a specific problem, notes only need a small amount of information.  Extraneous details can be captured at the initial visit and any changes made later.  Put it on the sidebar of the page, so it is visible but does not crowd out the important information.

This is only a start, and larger organizations should lead the way as EMR costs are unfriendly for most offices.  Community physicians could use web-based EMRs hosted at the local hospital (free if on staff, perhaps subscription-based otherwise).

The U.K.’s scrapping of their EMR project should be considered carefully.  It’s high time for someone with a touch of Steve Jobs’ vision to create an EMR here so good that it won’t need carrots or sticks to be adopted.

Related articles

• Stimulus Funds Helped Some EMR Companies (emrelectronicmedicalrecords.com)

Making Sense of the French Silicone Breast Implant Scare

Europe’s debt and currency issues were briefly pushed aside when France recently announced that about 30,000 women should have removal of substandard silicone breast implants.   Manufactured by Poly Implant Prothese SA (PIP), these devices may have a higher than normal rupture rate, and the company has been accused of using inferior, non medical-grade silicone.

Silicone breast implants have had a convoluted history in the United States, and were taken off the market for cosmetic use from 1992-2006.  They were reintroduced with a new gel design and enhanced documentation and follow-up recommendations.  Since silicone breast implants tend to touch off fireworks whenever they are in the news, here are a few points for Americans to keep in mind.

1)       These silicone implants are not the ones used in the U.S.  Ours are different, and the FDA warned the French company of manufacturing problems back in 2000.

2)      The implants haven’t yet been proven to cause serious health effects.  It will take time until experts can determine what, if any problems will be attributed to the inferior materials.

3)      The potential safety issue is not the use of silicone in breast implants, but the use of non-medical grade material in the French devices.

Five years following the reintroduction of silicone breast implants in the U.S., an FDA review deemed them safe for use.  The association with a very rare form of lymphoma was noted.

The French case says more on the issue of proper government oversight of product safety than it does about the safety of properly-designed silicone breast implants.  The FDA deserves credit for their report regarding PIP’s manufacturing problems.  However, there are many questions that have yet to be answered as to why French authorities took so long to discover and act on the problem.

Related articles

• Despite Risks, Silicone Breast Implants Still Considered Safe (bellasugar.com)
• Breast implant scandal firm ‘used same faulty silicone in prosthetic testicles’ (mirror.co.uk)