Nick van Terheyden, MD

This book presents a comprehensive state-of the-art approach to digital health technologies and practices within the broad confines of healthcare practices. It provides a canvas to discuss emerging digital health solutions, propelled by the ubiquitous availability of miniaturized, personalized devices and affordable, easy to use wearable sensors, and innovative technologies like 3D printing, virtual and augmented reality and driverless robots and vehicles including drones. One of the most… Show more

This book presents a comprehensive state-of the-art approach to digital health technologies and practices within the broad confines of healthcare practices. It provides a canvas to discuss emerging digital health solutions, propelled by the ubiquitous availability of miniaturized, personalized devices and affordable, easy to use wearable sensors, and innovative technologies like 3D printing, virtual and augmented reality and driverless robots and vehicles including drones. One of the most significant promises the digital health solutions hold is to keep us healthier for longer, even with limited resources, while truly scaling the delivery of healthcare.

Digital Health: Scaling Healthcare to the World addresses the emerging trends and enabling technologies contributing to technological advances in healthcare practice in the 21st Century. These areas include generic topics such as mobile health and telemedicine, as well as specific concepts such as social media for health, wearables and quantified-self trends. Also covered are the psychological models leveraged in design of solutions to persuade us to follow some recommended actions, then the design and educational facets of the proposed innovations, as well as ethics, privacy, security, and liability aspects influencing its acceptance. Furthermore, sections on economic aspects of the proposed innovations are included, analyzing the potential business models and entrepreneurship opportunities in the domain. Show less

In passing the 21st Century Cures Act, Congress took bold steps toward more effective and precise treatments for a wide range of conditions. The act authorizes billions of dollars for medical research and is intended to speed up innovation in treatment discovery and delivery.

Tacked on near the end of the process was an amendment that may prove to be every bit as valuable to medical research as the act’s nearly $8 billion in funding. It directs HHS and the Office of the National Director… Show more

In passing the 21st Century Cures Act, Congress took bold steps toward more effective and precise treatments for a wide range of conditions. The act authorizes billions of dollars for medical research and is intended to speed up innovation in treatment discovery and delivery.

Tacked on near the end of the process was an amendment that may prove to be every bit as valuable to medical research as the act’s nearly $8 billion in funding. It directs HHS and the Office of the National Director for health information technology to make EHRs interoperable and facilitate the flow of information.

Healthcare providers have been gathering and storing electronic health data for the past decade at an astounding rate. We have an enormous amount of potential knowledge just waiting to be tapped. But because of a variety of barriers, that data has largely gone unused. It’s sitting there in data centers, but we just can’t get to it. Much of the original promise of EHRs has been lost because of the barriers to a free flow of information. Show less

Anyone who is paid under a fee-for-service model or who is part of a multi-specialty group that gets most of its revenue from procedures, has a big disincentive to cut costs, meaning that the best strategy is to do nothing.

The reader makes a valid point. Under fee-for-service, improving outcomes and reducing the need for services means cutting your revenue. A case in point is the Seton Family of Hospital’s campaign to reduce birth injuries, a successful project that earned the group the… Show more

Anyone who is paid under a fee-for-service model or who is part of a multi-specialty group that gets most of its revenue from procedures, has a big disincentive to cut costs, meaning that the best strategy is to do nothing.

The reader makes a valid point. Under fee-for-service, improving outcomes and reducing the need for services means cutting your revenue. A case in point is the Seton Family of Hospital’s campaign to reduce birth injuries, a successful project that earned the group the Joint Commission’s prestigious Codman Award in 2007. This group of hospitals reduced birth trauma by 93 percent despite having one of the lowest rates of birth trauma when they began the program. Conventional wisdom at the time was that some birth injuries are just not avoidable. Since then, they’ve had years with zero birth traumas. One result of this effort has been an 80 percent reduction in the average length of stay in the neonatal ICU for babies with birth injuries, from 15.8 days to just 3.1 days.

Those are fabulous results. Though birth injuries are rare, they are traumatic for the infant and family and can be very expensive to treat. The Seton results are a real victory for families and for the health system in general. But not so much for Seton’s bottom line. The improved care and outcomes netted Seton, by one executive’s estimate, a $1 million reduction in revenue.

Think of that. A hospital system does what is right and good and is punished with a large financial loss. That pretty much sums up the basic problem with the fee-for-service reimbursement model. If all Seton cared about was the bottom line, this project would be considered a disaster. While they fortunately care more about families than revenue, it just seems wrong that doing a good job results in financial punishment.
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Much of medical practice is as much a mystery to doctors as it is to patients.

Human physiology is so complex, and the external variables so numerous, that we often have no sure knowledge of why one patient did well or another patient didn't. Every physician longs for some way to really know what will work for each patient.

While we have come a long way, even in just the past five years, there is still so much left to be learned. The one thing that can help us reach greater… Show more

Much of medical practice is as much a mystery to doctors as it is to patients.

Human physiology is so complex, and the external variables so numerous, that we often have no sure knowledge of why one patient did well or another patient didn't. Every physician longs for some way to really know what will work for each patient.

While we have come a long way, even in just the past five years, there is still so much left to be learned. The one thing that can help us reach greater knowledge faster is data and analytics.
That's really the underlying value of electronic medical records: they represent a treasure trove of data waiting to be mined. With the right algorithms, we can use that data to find patterns that tell us what factors make a tangible difference in outcomes. It's the wisdom of the ages waiting to be read.

Perhaps the most valuable medical team member of the future will be a data scientist. These are the experts who understand how to tag and mine data and how to construct algorithms that find patterns accurately and can help us be more effective in delivering the best possible care every time.

For example, there is a great study from the University of Iowa Medical Center, in which gastroenterology surgeons are using real-time patient data in the operating room, combined with past data from gastric surgery patients, to predict who is at risk for developing a surgical site infection. This helps guide decisions in the OR as well as post-surgical care. While doctors know that a variety of modalities can reduce infection risk and promote healing, resources are not endless. By identifying patients who need high-level care, they can ensure that resources are targeted where they are needed most. The project has reduced surgical site infections by more than 50 percent in the gastroenterology patients whose care was guided by the analytics.
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The focus of population health efforts to date have been risk identification and stratification. Those two capabilities are, indeed, critical to improving the health of your populations. But they are only one part of a much bigger puzzle, and it’s time for healthcare executives to focus on the big picture.

It’s not hard to imagine why we’ve spent so much time on the analytics. While data integration remains a challenge, it’s a lot easier to extract data from numerous sources for… Show more

The focus of population health efforts to date have been risk identification and stratification. Those two capabilities are, indeed, critical to improving the health of your populations. But they are only one part of a much bigger puzzle, and it’s time for healthcare executives to focus on the big picture.

It’s not hard to imagine why we’ve spent so much time on the analytics. While data integration remains a challenge, it’s a lot easier to extract data from numerous sources for analytics than it is to create true interoperability among clinical applications. And analytics are a fairly clean project, with little of the messy human and cultural changes that are at the heart of the rest of the puzzle. So analytics are a good place to start.

Inevitably, though, healthcare executives are going to have to face these messy human and cultural changes, as well as the barriers to the free flow of information. Because once you identify the gaps, you have to close the gaps. And that requires facing these challenges head-on

The first step is to understand why the gaps exist. The analytics for that are more problematic and require a lot of socioeconomic data that is harder to get and harder to integrate than clinical and claims data. But it will be necessary.

One example of an organization that is attempting to do this combines the clinical and claims data with socioeconomic data to identify the hidden risks in a population. A western Massachusetts integrated health system includes in their risk algorithms factors such as distance from a patient’s home to a primary care provider and availability of transportation and family support. Their thinking is that if you live too far from a clinic or don’t have transportation or family support, you are less likely to get regular care. If you are at risk for diabetes or another chronic condition, those facts are red flags, because you aren’t likely to get the help and support you need to avoid that condition. Show less

If you are looking for a consensus on the success or failure of Medicare’s Accountable Care Organization experiment, you are not likely to find it. That’s because while most ACOs have improved the quality of care, few have been able to cut costs enough to earn meaningful financial rewards under the program. They have achieved only half of the goal of creating greater value.

So why are so many ACOs failing to meet the cost component of value? After all, better outcomes should translate… Show more

If you are looking for a consensus on the success or failure of Medicare’s Accountable Care Organization experiment, you are not likely to find it. That’s because while most ACOs have improved the quality of care, few have been able to cut costs enough to earn meaningful financial rewards under the program. They have achieved only half of the goal of creating greater value.

So why are so many ACOs failing to meet the cost component of value? After all, better outcomes should translate into lower costs.

Those challenges included infrastructure (misallocated resources, leading to inefficiencies); slow adoption of technology; a provider culture habituated on fee-for-service payment and a patient culture accustomed to being passive consumers of healthcare; and inertia (the systems’ problems have been around for a long time and will be difficult to overcome). Perhaps the biggest hurdles are the cultural challenges; human beings are creatures of habit, and even with the best of intentions, we tend to fall back on what we are used to doing, especially when we are in a hurry. And how many physicians have you met lately who have extra time on their hands? Despite the pessimism, most ACOs have improved quality scores, but just some have cut costs enough to earn a reward. Various industry experts have postulated several reasons for the uneven results, though most have pinned at least part of the blame on the lack of a free flow of data across the system.

But hospitals and health systems knew upfront they had siloed data and that the exchange of data would not be easy. My guess would be some ACOs underestimated the importance of data flow while others — the ones seeing the financial reward — took it far more seriously and put more effort and resources into breaking down the barriers.

So there is no simple answer to the question, “Why are ACOs failing to cut costs?” But maybe we could understand the problem better by asking a different question: Why are some ACOs succeeding? Show less

“It was the best of times, it was the worst of times...” So begins A Tale of Two Cities, Charles Dickens’ classic story about the French Revolution.

The quote goes on: “…it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair.”

It’s an eloquent summing up that could apply to just about any time of great… Show more

“It was the best of times, it was the worst of times...” So begins A Tale of Two Cities, Charles Dickens’ classic story about the French Revolution.

The quote goes on: “…it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair.”

It’s an eloquent summing up that could apply to just about any time of great change, including the current upheaval in healthcare. As with most major shifts – political, economic, social or otherwise – there will always be both winners and losers. There will be success and there will be failure. There will be those who celebrate the new direction, and those who mourn the passing of an era they loved.

I can understand both of those feelings. As a physician, I can share the sense of loss that many feel as they mourn the passing of an era of independence. Twenty years ago, most physician practices were autonomous businesses. Now most physicians are employed. In another 10 years, you will be hard-pressed to find a physician who is self-employed.

On the other hand, I celebrate the new direction toward more value and better outcomes for patients. Most people in our profession care deeply for their patients and want to see progress on this front, but many are not sure that value-based reimbursement and all the other changes — EMR adoption particularly — will really benefit the patient. So our job is to make sure the changes we make really pay off for patients and for our society as a whole.

It won’t be a slam dunk. Big changes often come with unintended consequences – side effects, if you will – and we all know how problematic side effects can be. Sometimes they are worse than the disease you are treating. So we will all need to be vigilant to be sure that we are moving in a positive direction, not just moving. Show less

Humans are a tribal species. Throughout our history, we have formed groups to help ourselves compete for resources, defend against threats and provide a social milieu. In modern society, one of our tribes is inevitably the people we work with. Bonds form and norms develop that become important to the people in the workplace. A culture develops that differentiates one organization from another.

This is especially true for groups of people who work together in challenging environments… Show more

Humans are a tribal species. Throughout our history, we have formed groups to help ourselves compete for resources, defend against threats and provide a social milieu. In modern society, one of our tribes is inevitably the people we work with. Bonds form and norms develop that become important to the people in the workplace. A culture develops that differentiates one organization from another.

This is especially true for groups of people who work together in challenging environments where the stakes are high, including most hospitals. Because healthcare workers know people’s lives are in their hands, they take organizational culture seriously. They identify with it and guard it fiercely.

Once a culture is established, it doesn't easily change because people learn to behave in ways that allow them to fit into the culture. (If they don’t fit in, often they either leave or are let go). Changing workplace culture means changing the way that people think and behave, which is never easy.

Mergers and acquisitions pose a culture challenge that will take patience and thoughtfulness to overcome. The temptation, if you are part of a larger organization that is acquiring a smaller organization, is to be The Borg.

Fans of the Star Trek TV series will remember that The Borg was a culture comprised of cyborgs that subsumed other cultures into it whether they wanted to be or not. As The Borg told its hapless victims, “Resistance is futile.” And while The Borg was a powerful culture, it brought chaos to the galaxy and spawned active resistance everywhere. They were hated and feared. Show less

If you are the CEO or the CIO of a hospital, you are facing a huge transformation as the industry moves from a fee-for-service environment toward a value-based reimbursement system. It will take time and a new focus on patient outcomes, not just treatments given, to succeed. That’s why your strategy for success needs to include new resources for analytics. Use of analytics will be an existential capability in this environment because it will determine not just your success but your… Show more

If you are the CEO or the CIO of a hospital, you are facing a huge transformation as the industry moves from a fee-for-service environment toward a value-based reimbursement system. It will take time and a new focus on patient outcomes, not just treatments given, to succeed. That’s why your strategy for success needs to include new resources for analytics. Use of analytics will be an existential capability in this environment because it will determine not just your success but your survival.

As payers turn increasingly to narrow networks, being the high-value, low-cost provider will be paramount, especially in a competitive market with duplication of high-end services. Analytic competency will help you be that top-tier provider.

While population health and risk stratification are the sexy topics in analytics these days, there are smaller, more discrete projects that use analytics and will sort the winners from the losers in the competition for higher reimbursements even more quickly than those larger projects.
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The most difficult task — and by far the most important one — faced by a hospital executive team is building a satisfying work environment that keeps clinical staff engaged and loyal.

More than any other organization, a hospital depends on a large cadre of highly trained staff, many of whom are in professions facing serious shortages. That means your best doctors, nurses, therapists, technologists and technicians have choices. If they aren't happy working at your hospital, there are… Show more

The most difficult task — and by far the most important one — faced by a hospital executive team is building a satisfying work environment that keeps clinical staff engaged and loyal.

More than any other organization, a hospital depends on a large cadre of highly trained staff, many of whom are in professions facing serious shortages. That means your best doctors, nurses, therapists, technologists and technicians have choices. If they aren't happy working at your hospital, there are dozens of other hospitals happy to hire them, often with a competitive salary and, in some cases, a signing bonus. So poor morale among staff is a critical issue for any hospital.

Low morale and high turnover not only make life difficult for executives, they adversely affect patient safety and satisfaction. Several studies have documented this effect. A 2011 study by a group at the University of Pennsylvania School of Nursing found "patient satisfaction levels are lower in hospitals with more nurses who are dissatisfied or burned out — a finding that signals problems with quality of care." A 2009 meta-analysis on the relationship between worker engagement and organizational outcomes found the difference between healthcare units with employee satisfaction ratings in the top quartile and those in the bottom quartile resulted in a 41 percent difference in patient safety incidents. Numerous other studies have detailed how low staff morale results in poorer quality work for healthcare staff in a variety of disciplines, from laboratory to imaging and pharmacy, and how high turnover disrupts patient care and safety.

Keeping staff morale high and turnover low can save lives. It's a very, very big deal for hospitals. So in a competitive environment, how do you hang on to your best staff and ensure they are focused on high quality care? Show less

Few physicians are eager to have that data pouring into their EHR. What are we supposed to do with this stuff? How do we make it useful? We don't need to know every step recorded by a Fitbit, and we don't need all the data from healthy patients. That said, there is a place for some of this data within our efforts to create a healthier nation.

U.S. ranks low because we don't manage chronic disease well
Population health is critical to the future of healthcare in the U.S. Compared with… Show more

Few physicians are eager to have that data pouring into their EHR. What are we supposed to do with this stuff? How do we make it useful? We don't need to know every step recorded by a Fitbit, and we don't need all the data from healthy patients. That said, there is a place for some of this data within our efforts to create a healthier nation.

U.S. ranks low because we don't manage chronic disease well
Population health is critical to the future of healthcare in the U.S. Compared with other developed nations, the U.S. has ranked poorly on cost and outcomes. This is predominantly our inability to effectively manage chronic disease, which shortens people's lives, degrades their quality of life and costs the U.S. healthcare system enormous amounts of money. If we learn how to effectively manage chronic conditions, and avoid hospitalizations and serious complications, we can improve life for patients and greatly reduce the ballooning cost burden we all share.

Caring for patients with chronic conditions is one of the toughest jobs we face as physicians, because these patients need help every day, not just in the clinic. We need to coach them toward better health behaviors. To do that, we need two things: frequent contact with the patients and accurate data about their health and activities. Show less

Searching for patient data in an EHR is rather like rummaging in that catch-all drawer most people have in their kitchen. You know the one — it's where everything goes that doesn't have a designated place or somehow doesn't get put where it belongs. That drawer has many useful items in it. All those jumbled bits and pieces may be useful someday, but you don't need them right now.

An EHR is a lot like that drawer. It has plenty of useful data in it, and a lot of other bits and pieces… Show more

Searching for patient data in an EHR is rather like rummaging in that catch-all drawer most people have in their kitchen. You know the one — it's where everything goes that doesn't have a designated place or somehow doesn't get put where it belongs. That drawer has many useful items in it. All those jumbled bits and pieces may be useful someday, but you don't need them right now.

An EHR is a lot like that drawer. It has plenty of useful data in it, and a lot of other bits and pieces that, with the right integration tools and the right analytics, will be useful someday. The problem is that right now you need a specific piece of patient data, and to find it you end up rummaging through a lot stuff that isn't of any help at the moment.

Worse yet, the data you need can be a test result that is locked up in another system. It's like knowing that you have a small screwdriver that is perfect the task at hand, but you loaned it to your neighbor. You could go knock on the door and ask for it, but they might take forever to answer the door, and then they'd have to rummage through their catch-all drawer to find it, and you just don't have time to mess with it. So you buy a new one.

Like that screwdriver, the data you need is often locked up in another nearby system, and you could get it if you asked for it, but you don't have time to knock on the digital door and wait around for the other system to find it and send it to you. So you order a new test. Show less

The constant flux in healthcare regulations and policy has left physicians feeling frustrated and disconnected from the Art of Medicine. Pulled in disparate directions and forced to change how they allocate time, use technology and document patient notes, has made them feel that the most rewarding part of their responsibilities — patient care — has been subsumed to less important administrative duties.

There’s a saying, “To a worm in horseradish, the world is horseradish,” meaning we are predominantly aware of that which we are surrounded by on a daily basis. Health IT, in all its intricacies and expansiveness, has become hyper focused on making sense of its nebulous infrastructures, working hard to prepare healthcare organizations for next new wave of regulations. Our world, while not horseradish, is composed of goals and milestones that are 100 percent contingent upon these systems.

Stories are the backbone of who we are. They provide context, insight, subtle and not-so-subtle hints about ourselves and those around us. They teach us lessons and help us determine similarities and differences so that we can avoid mistakes and replicate success.

This book suggests a shared methodology to uniform as much as possible the way of writing a radiologic report - how to most effectively communicate the results of an examination. The important role played by language also from a legal-forensic point of view is also considered. In this book, theoretical knowledge is transferred to everyday clinical practice. With its easy to use didactic text, it is the perfect tool for radiologists in a very accessible format.

Although speech recognition technology has the potential to address one of the most significant obstacles to the implementation of fully computerized medical records—the direct capture of physician notes—several challenges remain to be overcome. Over the last few years, speech recognition systems have improved to the point where some can interpret the meaning of words and produce high-quality documents with minimal human intervention. However, technical problems still exist, and further… Show more

Although speech recognition technology has the potential to address one of the most significant obstacles to the implementation of fully computerized medical records—the direct capture of physician notes—several challenges remain to be overcome. Over the last few years, speech recognition systems have improved to the point where some can interpret the meaning of words and produce high-quality documents with minimal human intervention. However, technical problems still exist, and further improvements are required if this tool is to become an adjunct to successful electronic documentation. The areas that need improvement are discussed. Show less