Using Meetings At Hospitals

meetings in a hospitalSmall team meetings are a great way to both improve communication between staffers and set goals to deal with problems at the workplace, whether it’s in a hospital or a more traditional office.  For example, the Boston Medical Center internist teams meet every Friday morning to talk about issues specific to their groups, and once a month all of the teams come together for a larger meeting for big announcements and to celebrate successful efforts.  Such meetings help break down barriers and make improvement projects more effective by giving different team members a stronger voice in the decision-making process.  

In addition, meetings offer all team members a chance to show why certain changes are necessary; for example, the physician might not know why the front desk does things a certain way, and vice versa.  Team meetings are a great way to clear up any “mystery” with that.  Poor communication is a major problem in a hospital workplace, and practice managers sometimes offer directives that are unclear, unspecific or don’t properly convey the urgency.  On average, ineffective communication takes up 40 minutes of an employee’s day, costing about $5,200 a year for each staff member at a large hospital.  

The American Medical Association has a “STEPS Forward module”, which offers several ways for practice managers to effectively structure and schedule meetings.  These include scheduling meetings when patient care is least likely to conflict, limiting group size to make sure everybody has a voice, keeping meetings focused on the issues at hand and sticking to a consistent agenda.  For projects coming out of practice meetings, assign a point person who will coordinate the efforts and then report back to the group later.  But also make sure that you conduct regular follow-ups on goals and issues discussed during these meetings.  

If you’d like to learn more, you can click here!

New Pathology Center at Mount Sinai

Mount Sinai medical centerThe department of pathology at the Icahn School of Medicine at Mount Sinai has just established the Center for Computational and Systems Pathology, with the goal of using advanced computer science, mathematical techniques, cutting-edge microscope technology and AI to revolutionize pathology practice.  This new facility will explore efforts to more accurately classify diseases and guide treatment with computer vision and machine learning techniques.  It will also serve as a hub for the development of new tests, partnering with Mount Sinai-based “Precise Medical Diagnostics” (Precise MD).  

The new center will be overseen by Carlos Cordon-Cardo, MD PhD, and will be continuing his role as chair of the department of pathology at the Mount Sinai Health System and professor at the Icahn School of Medicine.  Associate professor Gerardo Fernandez, MD will be the medical director, working closely with pathology research professor Michael Donovan, MD PhD and Jack Zeineh, MD, director of technology for Precise MD.  Precise MD is developing new approaches to characterizing an individual’s cancer through combining multiple data sources and then using mathematical algorithms to analyze them, offering a more sophisticated alternative to standard approaches.  

In its initial phase this summer, Precise MD will complete a test used for patients who have had prostatectomies at Mount Sinai Health System to determine which of them are more likely to have a recurrence of cancer and may need additional therapy.  The approach will give researchers an in-depth knowledge about the biological behavior about prostate cancer, which will allow them to choose the appropriate patients for active surveillance.  A second test will follow next year, which will be used to characterize prostate cancer in newly-diagnosed patients, by which time all prostate cancer patients at Mount Sinai will have the chance to receive this test.  

If you’d like to learn more, you can click here!

Beware the IDES

Beware the IDESResearchers at the Stanford University School of Medicine have devised a way to significantly raise the sensitivity of a technique to identify and then sequence DNA from cancer cells that circulate in a person’s blood, with the hope that such “liquid biopsies” of easily-obtained blood samples could eventually replace the need to surgically obtain tumor tissue for study.

This new approach works by identifying errors that occur when tumor DNA is captured from the blood and prepared for sequencing.  Removing these errors from the sequencing results will allow researchers to more accurately find true cancer-associated mutations from even miniscule amounts of starting material.  Researchers say that this means they’ll be able to detect the presence of specific mutations in the cancer DNA that could help to drive treatment choices or detect the presence of residual cancer, getting us closer to reducing the need for invasive biopsies to identify tumor mutations or track response to therapies.

Even without treatment, cancer cells are constantly dividing and dying, releasing DNA into the bloodstream.  Learning to identify and read these and pick out the one in 1,000 or one million that come from a cancer could help clinicians quickly and noninvasively monitor the presence and volume of a tumor, a patient’s response to therapy and even how the tumor mutations evolve over time in the face of treatment or other selective pressures.  Researchers termed their new, two-pronged approach “integrated digital error suppression”, or IDES.  This builds upon a method called CAPP-Seq that was previously designed to capture very small amounts of tumor DNA from the blood.

IDES builds upon CAPP-Seq by addressing an inherent technical limitation: an inability to accurately sequence very small quantities of DNA.  Before any sequencing can be attempted, many copies need to be made of each double-stranded DNA fragment, in a process known as amplification, during which time the chance of introducing an error in the sequence becomes higher and higher.  Researchers, therefore, needed a way to determine whether mutations identified during the sequencing process came from the tumor or were introduced during the sequencing process.  They used “bar codes” that uniquely mark each original molecule to tag circulating double-stranded DNA molecules.  Since the strands of original DNA fit together, it’s possible to predict the sequence of one strand from the other.  Bar codes therefore allowed the researchers to match up the two strands and work from there.

Since it eliminates more false positives without sacrificing true positives, the researchers say that their technique is a significant advance.  Tagging top DNA molecules allows them to keep track of which molecules have been faithfully reproduced during the sequencing process.  The bar-coding approach was then combined with a computer algorithm meant to scan data and flag any possible trouble spots.  This combination allowed the researchers to filter out common sequencing mistakes far more efficiently than either technique used on its own.

If you’d like to learn more, you can click here!

The Rise of Telemedicine

The Rise of TelemedicineA recent survey has found that telemedicine has continued to evolve into a mainstream technology service, with a growing number of healthcare professionals viewing it as a top priority.  The 2016 Telemedicine Industry Benchmark Survey by the telemedicine software company Reach Health surveyed some 390 healthcare professionals, including executives, physicians, nurses and other professionals, gathering input on their priorities, objectives and challenges, telemedicine program models and management structures, service lines and settings.  Reach Health compared these findings to the results of last year’s survey in an effort to better understand the trends and changes in telemedicine.

Among the survey’s key findings was that nearly two-thirds of its participants viewed telemedicine as a top priority, representing a 10 percent increase from last year.  When surveyed about top objectives for telemedicine programs, patient-oriented objectives occupy the top three positions for most common objectives.  When asked to rate their success in achieving telemedicine program objectives, respondents indicated a high degree of success with those same top three objectives.  Respondents said that their highest degree of success came with providing remote or rural patients with access to specialists.

The survey report also took a look at telemedicine attributes that are most highly correlated with success.  The survey report authors said that some attributes exhibit a strong correlation with success, such as the priority of the telemedicine program as ranked among other hospital priorities.  For example, telemedicine programs ranked as a top priority are 62 percent more likely to be highly successful thank those who ranked it as a low priority.  If these telemedicine programs do have a dedicated program manager or coordinator, then they’re 43 percent more likely to be highly successful than those with a less focused program manager.

The survey also addressed telemedicine program challenges and survey participants identified, ranking their challenges in terms of those that remain unaddressed, partially addressed, fully addressed or not a challenge.  Issues tied in with reimbursement and electronic medical record systems were listed as the main challenges to telemedicine.  Determining ROI was also acknowledged as a challenge, although the survey authors noted that improving financial return was least frequently cited as a top objective.  Although compensation for physicians remains relatively high on the list of challenges, physician acceptance has improved compared to last year, and is fairly low on the list of challenges.

As the telemedicine industry comes of age, hospitals and healthcare systems have been exhibiting a rising trend toward an enterprise approach, with larger systems moving more quickly in this direction than smaller hospitals.  If you’d like to learn more, you can click here!

Brain Mysteries

Brain picture

In new research that’s been published in Proceedings of the National Academy of Sciences (PNAS), a team of scientists from the Hebrew University Hadassah Medical School unraveled a longstanding mystery of a fundamental property of the brain.  For a long time now, it’s been known that the brain uses topographic organization, or that parts of the brain that make similar types of computations are situated close to each other.  Yet in the case of pathology, these topographies may undergo reorganization.  Researchers have now shown that the continuity of these brain maps is being disturbed, and this continuity can be quantified, which allows them to be used as a biomarker for detecting neuropsychiatric disease.

To understand this relationship, the researchers investigated the role of topographic organizational continuity.  With functional MRI, they studied two types of unique populations: patients with injury to one side of the spinal cord that enabled comparison of disturbed and non-disturbed body sides, and patients going through surgical repair.  Such an approach enabled direct comparison in human patients with respect to their own self or before and after surgical intervention.  Instead of inducing lesions in animals, the team was able to repair the human patients and check them both before and after.  Unlike animals, patients were able to report their subjective experience, which is crucial for understanding high cognitive functions and neuropsychiatry.

The researchers have developed an algorithm that quantifies continuity of the patients’ brain maps.  Their results showed that in each individual patient, pathological processing was reflected by a discontinuity of topographic maps, as opposed to signal reduction.  Such findings have suggested that continuity is a primary principle in brain computation, although in pathological states, the brain could give up on this principle to retrieve as much information as possible, helping this serve as a biomarker for neurological pathologies.  The researchers are now trying to fine-tune their findings in neurosurgical patients in an effort to enable a better, patient-tailored diagnosis and follow-up.  They’ve also been extending their findings to other parts of brain processing, including vision, hearing, number processing and memory.  If you’d like to learn more about what they’ve been doing, feel free to click here!

A Lab in a Needle

While working alongside collaborators from two major institutions in Singapore, researchers at a lab in a needleHouston Methodist have developed a lab in a needle device that could provide instant results to routine lab tests to accelerate treatment and diagnosis by days.  One place where this device will be effective is in quickly detecting liver toxicity, a common side effect of chemotherapy.  It will test toxicity in 30 minutes; compare that to the several days it takes to currently perform the same test due to the multiple steps required before a physician interprets the test results and communicates them to the patient.

Developed by Houston Methodist, NTU Singapore, SIMTech and A*STAR, this invention was explained in the most recent issue of the Royal Society of Chemistry’s Lab on a Chip.  Investigators demonstrated that two important steps of the lab in a needle approach accurately detected liver toxicity in AST and ALT.  The proteins that these indicators represent are among the most sensitive and widely-used liver enyzmes in all liver function tests today.  The joint research group were looking to develop a new class of device to collect patient samples, prepare them for testing, evaluate toxicity and display results in one easy-to-use process that would allow doctors and patients to immediately discuss treatment options.

Sample preparation was accomplished on one chip that incorporated a miniature motor and microfluidics, while amplification was performed on a second connected chip.  Evaluations in the two examined gene markers of liver toxicity were then accurately detected and consistent with previously-known changes, indicating that lab in a needle is an appropriate diagnostic option.  According to the researchers, the next step is to integrate the sample preparation and analysis chips into a miniaturized device.  Both A*STAR and SIMTECH have manufacturing process capabilities to develop a cost effective lab in needle device that can be scaled for mass production.

This study outcome represents the first time that all processes involved in the lab in a needle were integrated together successfully, and represents an important step in bringing a new real-time, easy-to-use diagnostic to the clinic and field with an immediate potential to improve patient outcomes and quality of life.  If you’d like to learn more, you can click here!

Hackathons

Healthcare-focused “hackathon” events have become more and more popular over the hackathon iconyears, as digital apps developers have been able to apply their skills to solving some of the most intractable problems of healthcare.  In the DC metro area, there’s an upcoming 36-hour event to build apps for patients with PTSD.  In downtown Cleveland, a Medical Hackathon focused on big data is being held later this month.  I recently came across an article about the upcoming hackathon in Cleveland, and what this unique phenomenon in the field of medical informatics means.  The author spoke to several IT execs with the Cleveland Clinic, which serves as one of the lead partners in the event.

James Krouse of Nesco Resource, which is sponsoring the event in Cleveland, said that one goal of hackathons is to engender “unlikely conversations”; this means parties coming together that normally wouldn’t be in the same room.  While the city of Cleveland has been marked by poverty and struggle in earlier years, it now has a blossoming startup culture.  Krouse hopes that people coming together for the hackathon will help make connections that will help that startup culture grow even more.  William Morris, the associate chief information officer at Cleveland Clinic, agreed that hackathons are about establishing a “community”.  He added that health systems have been participating in these events because they have a direct need: to deliver higher-quality care at a lower cost, and technology has the potential to play a huge role in that.  He also said that it would give people the chance to turn data into knowledge through aggregating and managing data into knowledge by aggregating and managing data from wearables, sensors and activity monitors.

Beth Meese, the administrative director of technology and innovations at Cleveland Clinic, said that a hackathon allows people to see their clinical ideas developed and become part of an organization.  Clinical teams often don’t have an idea where to take ideas they want to be developed, so seeing something get developed paves the way for more innovation in the future.  Meese pointed out that there’s a startup mentality within the hospital systems, as people look to augment products and integrate them to address challenges within the healthcare system.

The Cleveland Medical Hackathon is being held on September 26 and 27 at the HIMSS Global Center for Health Innovation, and is free to attend and participate in, although you need to fill out an application first.  You can find the application at the Cleveland Medical Hackathon site.

Manipulating Pollen

Ragweed plant

Also known as Ambrosia, the ragweed plant is known for its aggressive pollen.

Recently, scientists at Helmholtz Zentrum in Munich have discovered that pollen of the common ragweed has higher concentrations of allergen when exposed to NO2 exhaust gases.  The study also indicates the presence of a possible new allergen in the plant.  Researchers of the Institute of Biochemical Plant Pathology (BIOP) studied how nitrogen oxides affect the pollen of the plant, specifically by fumigating the plants with various concentrations of NO2, which is generated during combustion processes of fuel.

The data from the study revealed that the stress on the plant caused by NO2 modulated the protein composition of the pollen, with different isoforms of the known allergen Amb a 1 being significantly elevated.  In addition, scientists observed that the pollen from NO2-treated plants have a significantly increased binding capacity to specific IgE antibodies of individuals who are allergic to ragweed, which frequently starts an allergic reaction in humans.  The plant researchers also identified a protein, not previously known to be an allergen in ragweed, that was present when NO2 levels were elevated.  It has a strong similarity with a protein form a rubber tree, in which context it was previously described as an allergen whose effect was also seen in fungi and other plants.

Due to air pollution, it is expected that the already aggressive ragweed pollen will become even more allergenic in the future.  Originating in the Americas, ragweed is believed to have come to Europe through imported birdseed, and due to climate change, it’s become widely dispersed across the continent.  Ragweed pollen is very aggressive, and since it doesn’t bloom until late summer, it lengthens the “season” for those who are allergic to it.  Studies have already shown that ragweed plants growing along highways are clearly more allergenic than those growing away from road traffic.  The researchers plan on doing further studies in the future, where they plan on showing that pollen only treated with NO2 can also elicit stronger in vivo reactions.

The Problem with UHC’s New Program

Out in Florida, the battle rages on between one of the country’s largest health insurance corporations and physicians, clinical laboratory managers and pathologists.  This fight started because of the restrictive, burdensome requirements imposed last fall by UnitedHealthcare (UHC) and administered by BeaconLBS on medical laboratory test ordering.  For one Florida rheumatologist, Olga Kromo, this new decision-support system that physicians currently have to use when ordering clinical laboratory tests is highly flawed.

Michael Weilert MD Ogla Kromo

Olga Kromo, the physician who has become an outspoken opponent of the new system imposed by UHC.

Other Florida physicians have begun to rally around Kromo, pointing out that the new system is time-consuming, onerous and difficult to use.  Kromo, however, has gone even further, claiming that the BeaconLBS system could have an adverse effect on patient care and increase negative outcomes across the board.  In a recent interview with “The Dark Report”, Kromo has explained that patients with connective tissue disease are at higher risk for other serious health conditions such as lymphoma.  This is true for patients with systemic lupus and Sjögren’s syndrome.  If ordering medical laboratory tests is overly complicated or time-consuming, she said, then patients may not get tested as much as needed for their physician to properly identify complications and spot the signs of ailments such as lymphoma early on.  Kromo is one of four doctors at the Arthritis and Rheumatic Care Center in Miami.

Among patients with lupus and Sjögren’s, Kromo says, there’s a high risk of developing lymphoma.  A clinical laboratory test is recommended for timely monitoring these patients, although UHC says that BeaconLBS needs to pre-authorize the test before doctors can run it.  If long-established clinical guidelines specify that a test is recommended for lupus patients with Sjögren’s, Kromo argues, why would physicians need to request authorization from a health insurer?  Kromo’s argument has raised a serious issue as to why UHS and its contractor, BeaconLBS, are interposing themselves between physicians and patients when physicians are ready to order medical lab tests that UHC requires to be pre-authorized.  Various state and national medical societies have written letters to UHC objecting to this interference with established medical standards of practice.

It takes a particularly long time to use the newly-required system and, since there’s a limited number of electronic interfaces between BeaconLBS and electronic health record systems, physicians need to enter orders for tests twice: once to obtain pre-notification ,and a second time to enter the order in the EHR.  As well as patient care concerns, Kromo has found the BeaconLBS system to be so difficult that those in her four-physician practice aren’t even using it, and instead are having a workaround with another lab.  If Kromo’s practice were to use the BeaconLBS system, she estimated that the phlebotomist on her team would need to stay an extra hour or two every day; just the paperwork for Beacon tests takes about 20 minutes per patient.  And since such a large percentage of Kromo’s patients (95%) need lab tests on almost every visit, this system significantly disrupts patient flow.

5 Steps To a “Learning Health System”

Michael weilert MD Amy Abernethy

Amy Abernethy

I recently came across an article by Dr. Amy Abernethy, who delivered the opening keynote address at the American Medical Informatics Association’s (AMIA) annual symposium.  Without good data to back it up, she says, patient-centeredness is nothing more than a buzzword.  And without a patient-centered focus and proper organization, data tends to be pretty useless.  Comparing the flood of data now available to the Amazon River, Abernethy declared the need for a vision for a way forward, called a learning health system.  This needs to be powered by a “river of data”, with a “North Star” to guide operations.  To Janet, this North Star is a 37 year-old patient with melanoma named Janet.

While speaking with Janet on the risks of interferon treatment, Abernethy pulled in records from various data streams that formed rivulets, which dumped into a large river of data.  Informaticians, as members of the AMIA call themselves, face two challenges: exploring all of this data now available to them and explaining it to practitioners, payers, administrators and patients.  According to Abernethy, the vernacular in informatics doesn’t align with that in other parts of healthcare, meaning that there needs to be a common language.  As healthcare professionals think about trying to bridge the communication gap, people find it safer to keep on their sides and not talk to each other, despite the fact that they could be learning so much.  Abernethy spoke of the need to get better at bringing data to standard clinical practice, and outlined five recommendations to do so:

1. Putting the patient at the center.  Patients are the anchors of Medical Informatics, and their stories help clinicians work better with data.

2. Having meaningful data by putting the information into the right context.  This information, says Abernethy, should be taken as more than just a snapshot in time, so that it can be repurposed for research.

3. Improve data quality by putting that data to use.  Informaticians need to use data to make sure that it’s accurate.  They care deeply about data’s quality, sanctity, security and validity.

4. Data needs to be trustworthy.  To get information from patients over time, there needs to be a system of trust, so that the data is valid.

5. Data must be interoperable.  Talking about Janet, Abernethy said that even if her disease does return, through her data, Informaticians can learn more about these diseases.  Abernethy noted that the Cancer Biomedical Informatics Grid (CaBIG) failed partially due to a breakdown in communications, since communicating the language and culture of informatics to clinical care at the time was nearly impossible.