"Please Choose One"

A short story by Phillip Allen Green. Read this and be afraid. It describes my worst IT nightmares..

Please choose one:

The three words blink in front of me on the computer screen.

Please choose one:
Patient is-
☐Male     ☐Female 

I click FEMALE.

I watch as the auto-template feature fills in the paragraph for me based on my choices.

Patient #879302045

Patient is: 38-year-old female status post motor vehicle accident. Please acknowledge you have reviewed her allergies, medications, and past medical history.

I click YES.

Have you counseled her about smoking cessation?

I click NO.

A little animated icon of a doctor pops up on the screen. His mouth begins to move as if speaking. A speech bubble from a comic strip appears next to it.

“Tip of the day: smoking cessation is important for both the patient’s health and part of a complete billing record.” 

The animated doctor smiles and swings his stethoscope like a lasso.

I click ACKNOWLEDGE.

A new screen appears.

Please choose one:
The patient’s current emotional state is best described as-
☐ Distraught     ☐Calm     ☐ Agitated

I turn away from the computer to look at the patient. She lies curled in a ball on her side. Her bare feet stick out below the sheets halfway off the gurney. I notice she has a turquoise blue toe ring. She stares straight ahead. She plays with her patient ID band, twisting it round and round with her other hand. Makeup is smeared around small brown eyes. She stares blankly at the wall behind me. I clear my throat. She doesn’t blink. I clear it louder. Still nothing.

I look back to the computer. The same screen is still there.

Please choose one:
The patient’s current emotional state is best described as- 
☐ Distraught     ☐Calm     ☐ Agitated

I turn back around.

Blonde hair is matted to the right side of her face where tears have dried it to her skin. A thick strand of it hangs across her eyes and I wonder if it annoys her. I watch as tears reform in her eyes and run sideways across her face. A teardrop starts to grow on the side of her cheek. More tears are added until finally it falls from her face onto her tear soaked pillow.

Her chest rises and falls at a rapid pace. She is breathing fast, almost panting. It is a raspy sound. I bet if she spoke right now her voice would sound raw, the kind of scratchy raw that comes after too much screaming. But she doesn’t speak. She just lies there breathing with a thousand yard stare fixed to her face.

The computer dings.

Please choose one.

I click DISTRAUGHT.

The computer takes me to a new screen.

Please choose one:
Patient’s primary reason for being distraught-
☐Emotional     ☐Physical     ☐Other

The patient starts moaning. I look over. A guttural sound that is part wail, part cry spills out of her just loud enough for me to hear.

I click EMOTIONAL.

That selection triggers a new screen for me with new choices:

Please choose one:
What is the reason for patient’s emotional problem?
☐Intoxication   ☐Psychiatric   ☐Neurologic

Hmm, I look at her trying to decide which to choose. She is in a hospital gown. Her clothes were cut off with the trauma shears when she came in. She still smells like gasoline and blood and burnt plastic smoke. It burns my nose sitting this close to her and makes my eyes water.

There’s dried blood mixed with car oil and dirt on her chest. There is a lot of it. It covers her shoulders and the top of her breasts like a red patchy shawl, yet she is not injured. She has been examined and x-rayed and CAT scanned from head to toe. Her body is fine.

The computer dings again impatiently, prompting me to choose one.

Please choose one:
What is the reason for patient’s emotional problem?
☐Intoxication   ☐Psychiatric   ☐Neurologic

I click the Next arrow at the bottom of the screen to try and advance the page without choosing one.

PAGE INCOMPLETE- YOU MUST CHOOSE ONE pops up.

My mouse circles the screen hesitantly. I guess I will click… PSYCHIATRIC. In a way emotions are psychiatric, I tell myself.

Choosing psychiatric has opened a new screen.

The patient shifts on the bed. A glimmer on her head, reflecting the fluorescent lights above, attracts my attention. I lean in closer. There are shards of broken up windshield glass scattered throughout her hair. Some are brown from dirt from where she lay on the ground, some are stuck to her head from blood, and some are scattered on the sheet below her. The shards twinkle on the bed like little stars.

I frown, the nurse was supposed to clean her up. I wheel backwards on my doctor stool across the trauma room to the door. I lean my head out through the curtain.

I look around. I spot the patient’s nurse. She is sitting on the other side of the ER, working at a computer. I know she is trying to enter data from the patient’s visit to get her charting done. Well, I think, maybe someone else can help us.

I scan the ER. There are doctors and nurses everywhere down here, yet every single one that I see sits at a computer with their eyes chained to the screens and a scowl on their faces while they click and type, click and type. I bet the hospital could burn down around them and they wouldn’t notice.

“Hey!” I yell.

No one even looks up. The clicking and typing continue.

An old man standing in the doorway of another patient room makes eye contact with me. He scowls as he surveys our ER. He shakes his head in disgust. I blush and duck back into the room behind the curtain.

The computer dings twice now, prompting me to hurry up. I remember my patient throughput time is monitored and reported and compared to the national average. A timer has appeared on the bottom of the screen, letting me know that I am four minutes twenty-eight seconds past the average ER doctor throughput time.

The numbers keep climbing. If I spend too much time on one patient, I will get a letter from administration for not meeting my throughput quota. I wheel back up to the computer.

Please choose one:
Because you chose Psychiatric, patient was offered-
☐Counseling     ☐Medications     ☐Inpatient Care

A sob wracks my patient’s body interrupting me again. She shifts in the bed, leaving clumps of brown dirt crumbling on white sheets. She is absolutely filthy. I wonder how long she lay in that field before someone found her. She still stares at the wall, unresponsive.

I look back at the computer. I didn’t offer her any of these things. Maybe I should lie and click counseling so that I can finish her chart.

I click Next.

YOU MUST CHOOSE ONE pops up again.

Please choose one:
Because you chose Psychiatric, patient was offered-
☐Counseling    ☐Medications   ☐Inpatient Services

I try alt tab. No luck.

YOU MUST CHOOSE ONE.

I give up and click COUNSELING.

Another screen.

Please choose one:
Patient responded to counseling with:
☐Excellent Improvement ☐Some Improvement ☐No Improvement 

I click NO IMPROVEMENT.

The little doctor figure reappears on the screen. He’s holding up his index finger and a light bulb appears over his head as if he’s just had a fantastic idea he can’t wait to share with me.

“Dr. Tom Tip reminds you: Did you try offering a drink of water or a tissue? Surveys show that sometimes it’s the little things that make patients feel better.”

I look over at her. I can’t bring myself to offer her water. Her knuckles are blanched white from the death grip she has on the side rail. She’s mouthing the word NO over and over to herself and shaking her head back and forth. Her eyes are wide with terror and do not see me. The skin of her face is pulled taut with fear.

I know that look. She is seeing the moment. I know she is going to see it again and again for the rest of her life. It will come in nightmares, it will come in dreams, it will come at the worst possible moment of what should be happy occasions, more likely than not it will even come at the moment just before her own death no matter how long she lives. She will never escape it. Sixty-eight minutes ago her brain burned an image into the inside of her skull that she will never be able to unsee.

I click SKIP.

The doctor icon disappears, replaced by text.

Please choose one:
Did you offer the patient water?
☐Yes     ☐No

I click NO.

The little figure pops up again this time with a stern look on his face and his arms crossed.

“Surveys show patients like it when their doctors offer them water or a tissue. Patient satisfaction scores go up. Try it, you might be surprised.” He uncrosses his arms and holds out a little of glass of water.

For a brief second I imagine punching my fist through the computer screen. It would feel so good to climb the stairs to the top floor of the hospital with the computer stuck on my arm. I imagine spinning in a circle and launching it as hard as I can off the roof of the hospital towards the pavement below. I would give anything to see it smashed and destroyed and ruined, just as it has done to this profession I once loved.

But I know they would just replace it with another computer and just as quickly with another doctor.

I sigh and look around the room.

There is a cup on the counter.

I frown, it is awfully dirty.

I pick it up and turn it over.

A child’s tiny, bloody shoe falls out onto the counter.

The woman cries out, Oh God Oh God Oh God and grabs the child’s shoe before I can pick it up.

She holds it next to her face. She’s sobbing now and starting to scream. Oh God Oh God Oh God Oh God Oh God. She clenches the shoe to her chest. The blood on the shoe matches the blood on her chest.

The computer dings.

“Did you give the patient a cup of water?”

I lie and click YES.

“Good job!” The computer trumpets out a happy horn sound. It’s hard to hear over the patient’s screaming. The little doctor gives me a thumbs up and high fives a hand that appears on the screen next to him.

“Sometimes it’s the little things that make people feel better.” The doctor says.

I click NEXT.

The Patient Disposition Screen loads.

Please choose one:
Where is the patient going after the ER?
☐Home     ☐Admitted     ☐Transferred

I hover the mouse on the screen for a second, trying to decide.

I click HOME.

Please choose one:
How is the patient doing after your care for her?
☐Improved      ☐Not Improved     ☐Other

I look at her again.

I click NOT IMPROVED.

*WARNING*

This time the whole screen flashes. The little doctor is back, hands on his hips. His face is stern as the speech bubble appears next to his head. The letters are in red this time.

“Patients who are NOT improved should NOT be sent home. You clicked Psychiatric as her primary issue. Perhaps some medications would help the Healthcare Consumer. Would you like me to recommend some choices available on the hospital formulary?”

I ponder the question. Is there a drug for this? Something that will make her feel better? Something that doesn’t wear off like, ever?

I click NO.

Are you sure? The computer asks again.

I click YES.

A big red flag now pops up on screen and the computer buzzes like a half time buzzer in a sports game that I have just lost.

A note of this patient encounter has been sent to your Hospital Administrator for chart review of this patient. It is the goal of our healthcare facility to make patients feel better before they are discharged. You have acknowledged that you failed to do so. You will likely receive a lower patient satisfaction score for this.

Please acknowledge.

I click NO.

It flashes again.

Please acknowledge.

I click NO.

Please acknowledge.

I click NO.

A box pops up.

I am sorry, Valued Healthcare Provider, do you not understand the question? Would you like to fill out a service ticket?

☐Yes   ☐No

Please choose one.

The words blink at me on the screen.

I look over at the patient. She is on her side again, sobbing as she cradles the tiny shoe to her chest. Her eyes are squeezed shut and she’s rocking back and forth so hard the whole gurney is shaking.

I look back at the computer.

Please choose one.

I look back at my patient.

Please choose one.

Suddenly I get it. I choose.

I reach down and unplug the computer. The screen goes black.

Without the noise of the computer fan whirring, the room is suddenly silent- save for her quiet sobs.

A strange feeling comes over me, one I almost forgot existed after so many years.

I remember who I am and why I am here.

I stand up and take a deep breath. I step towards the patient and begin the long and tedious process of gently picking out the shards of bloody glass stuck throughout her hair. As I start to work she opens her eyes and blinks.

She sees me.

The terror filling them fades just a tiny bit.

For once the computer stays quiet.

I pick through the strands of her hair. The three words blink in my mind over and over.

Please choose one…

Please choose one…

Please choose one…

  

©Philip Allen Green

philipallengreen@hotmail.com

IT Laments From An ER Doc The 10th Anniversary Post on DoctorDalai.com

Fellow blogger and ER physician Edwin Leap, M.D. has apparently discovered the joys of poorly written software I've been bemoaning for so long.

In a December entry, Dr. Leap opens with an apology for the behavior of some less-than-tech-savvy physicians:

I know that, on many levels, physicians must be the absolute banes of your existence. We are grumpy and resistant to change. And some of us are still confused by graphing calculators, much less complex modern computer systems. We call you because we forgot our passwords, then because we forgot the new passwords. We call because the system crashes and we call because the voice recognition doesn’t work and we curse the screen and shake our collective fists at things that slow us every day. I get it.

He's a bit more conciliatory in this than I've been, but he's right. There are some docs for whom the acronym P.B.K.A.C. (Problem Between Keyboard and Chair) is 100% applicable. These unfortunate folks are the inspiration for Dalai's XIIth Law: 

XII. The PACS needs to be operable by the least technically-savvy radiologist on staff.

That being established, Dr. Leap takes the gloves off, and picks up my battle-flag, starting with his disgust with his EMR.

However, there are some things that you and those who develop your systems need to understand. Allow me to elucidate.

We didn’t ask for EMR in its current incarnation. It is now a gargantuan billing and data collection industry, with precious little utility in our day to day practices. As such, your bosses love it because it squeezes the last gasping penny out of every chart. They write your checks, we don’t. Nevertheless, we have difficulty being excited about ever more fields to fill out, ever more time-stamps, ever more screening exams, and the caucophanous symphony of key-strokes and mouse clicks that echo through the modern hospital and threaten to muffle the sound of suffering and human interaction.

The vast majority of EMR's, CPOE's, etc., are unwieldy, unusable pieces of convoluted trash, which add to the hours of the already full day of a busy physician. More on this in a moment.

Next, passwords and security make a lot of sense to you. You dwell in a world of hackers and identity theft and you worship at the silicon altar of HIPAA. We, however, are busily seeing patients and trying to do it as quickly as possible in hospitals, clinics and especially ER’s that have no ‘off’ switch but which do track our ‘quality’ in part by tracking our speed and efficiency. Thus, we have little time to spend logging on. And when we step away to, say, intubate a dying patient, the last thing we want to do is log back on to 1) the computer 2) the hospital EMR system and 3) the particular department system and 4) the radiology viewing system. But here’s the really, really important part: nobody is busily stalking behind us trying to look at medical records or interpret xrays on strangers so that they can violate their privacy. We’re watching; trust me.

It was a nice idea but now it’s a poison. It is the law of unintended consequences on steroids. It’s all redundant, irrelevant, obnoxious busy work that stands between us and efficiency. If you really insist on it, then make it all biometric with thumb prints. Because tracking usernames and passwords is starting to take up more of our fragile brains than drug doses and diagnoses. And that, my friends, is not good.

Yes, security. We all understand the importance of keeping hackers and other slime out of patient data. I wonder how many passwords Anthem had that didn't prevent 80 MILLION records from being compromised. Screw passwords. Let's try biometrics, wrist-worn RFID's, implanted chips, retina scans, anything that will get the job done painlessly (well, after the chip implant, anyway). We simply don't have the time to re-log in 35 times per day.

You might recall my tale of IT tyranny from the same Laws of PACS lecture wherein I used AutoHotKey to create a little macro script that pushed the button that kept my RIS active. IT at first banned the macro because "someone might use the program to bypass a password screen." Yeah, right. They knew quite well that I was the only radiologist in my group capable of even understanding how that might be done, and they knew me well enough to know that I wasn't going to do it. I did win out in the end, but as usual, it was a battle that really didn't need to be fought.

Dr. Leap continues his velvet-gloved attack, documenting another pet peeve of mine, the inability of IT to grasp the mission-criticality of what we physicians do, day in and day out.

Now, about tech support and system back-ups. We have to use these systems. There is no option. And we have to use them 24/7/365. Because that’s when people get sick and die. Therefore, every system needs to have a parallel back up system that kicks in whenever a data transfer or update or repair or anything else is happening. ‘We’ll be shutting down for four hours’ isn’t an option anymore. Since ‘we won’t see heart attacks for four hours’ isn’t an option either. Furthermore, when things are going badly, when we need a reset password or when the computers are locked up in some loop that looks like an alien language, we need help immediately. We don’t need ‘a ticket’ submitted. A round-the-clock job that requires EMR necessitates round-the-clock IT. No questions asked.

And finally, my new friend the ER doc rediscovers the travesties I've been bellowing about for just over 10 years on this very blog:

Finally, to those who design these monstrosities and those who buy them to the protests of clinicians, what are you thinking? Medicine is about caring for patients. And anything you create that makes it more difficult is an insult. Shame on you. You should do better, for your staff and for the patients who ultimately pay your salaries and fees.

Dr. Leap ends with a leap of niceness toward IT that I wish I could manifest as well...

And for you IT folks, I’m sorry. I’ll keep trying to do better. I generally know where to find ‘start’ when I’m talking to you and I can actually navigate the directions you give in a fairly efficient manner. I know that the disc drive isn’t a cup-holder and that I have PC, not a Mac. I’ve even been storing my passwords on my smart phone! I realize you have a tough job; made tougher for dealing with physicians and nurses.

All I’m saying is this: I understand your frustrations. Try to understand ours!

Yes, IT departments, and particularly software vendors...TRY to understand our frustrations. I have been blogging for TEN YEARS, saying basically the same thing. A significant plurality, if not the vast majority, of medical software is utter, complete, unmitigated GARBAGE. It is designed by engineers with no experience in healthcare and tuned to the specs of bean-counters, with no experience in healthcare. It is pitifully clear that absolutely NO thought has been given to the usability in the hands of those who need to make these abominations work in the process of treating patients and hopefully saving lives. It is nothing short of criminal, but it is no surprise. These Rube-Goldberg contraptions are NOT selected and purchased by the people that use them, but rather by those beholden to the bean-counters or other administrative influences, and those who wish to have the easiest time servicing the product.

Sadly, even after 10 years, I don't know the solution to this situation. CIO's and IT departments are not about to give up their influence over these huge expenditures, and I'm not sure how to take it away from them. Perhaps the only thing I can do is to slap the vendors in the face repeatedly with the fact that their software sucks, and hope that the subsequent embarrassment will prompt them to clean up their acts. I'm not holding my breath, and I have grave doubts that I've influenced anything much at all. Perhaps once I'm fully retired, I can turn my attention more fully toward this effort.

In the meantime, the frustration continues, with potentially deadly consequences.

Je Suis Juif, Je Suis Charlie

50 world leaders, and tens, maybe hundreds of thousands, marched in solidarity with the French cartoonists and Jewish civilians, slaughtered by radical Islamists. You will notice that Israeli Prime Minister Benjamin Netanyahu, as well as Palestinian leader Abbas, marched to either side of French President Holland. Not present? Our own President, the so-called leader of the Free World. His lame-duck, racist Attorney General was supposed to be our representative, but he was nowhere to be seen in the very extensive coverage.

What message did we just deliver to the rest of the world? That we don't care, that we are above it all, that we don't perceive a threat? Or maybe that some in our leadership might even sympathize with the goals of the terrorists? Outrageous? Sure, but there aren't too many other interpretations to be applied to this appalling lack of solidarity displayed by our leadership.

Despite this dangerous embarrassment, the rally gives me more hope for the future than I've had in a long time. Presently, Europe is well on the path to become Eurabia, due to lax immigration and policing (not to mention individual firearm) policies. There is every chance of a recapitulation of the Holocaust under the brand of Radical Islam. But today, this very day, maybe, just maybe, Europe has awakened to its deadly trajectory, and along with the rest of the world, might just take steps to reverse the trend. Maybe, just maybe, those who died did not do so in vain, but gave their lives to awaken the world to the reality of these monsters:  they murder Jews because they are Jews, they murder cartoonists because they are "offensive," they wish to silence any dissent, they hope eventually to conquer and "fundamentally transform" the entire planet.

Maybe, just maybe, we will see a reversal of the "no-go" neighborhoods. Maybe we will see a denial of institution of Sharia law within these ghettos. Maybe we will see the realization that Israel is being demonized based on lies from those who would destroy her and her people. Maybe there will be an understanding that anti-Semitism is a harbinger of the anti-West, anti-Colonial, anti-freedom agenda of these vermin, which has been adopted by the aging Marxist revolutionary wannabes that make up much of the Left in this and other Western nations.

Maybe.

This is a war, not simply for territory or for treasure, but for our very souls.

There is only one response:

"Je Suis Juif, Je Suis Charlie"

Apple Watch Clone?

I will probably be one of the first in line for the Apple Watch, at least if it can be ordered online. Supposedly, the grand release will come in March, with pricing ranging from $350 for the aluminum sport flavor to $5,000 or more for the gold "Edition" version. I'll probably go for the $500 steel on steel version:

Even though the darn thing hasn't even been released yet, there are manufacturers in China who have already cloned the look and feel, if not the mini iOS experience, and you can be the first on the block to have an Apple Watch, or at least something that looks like one:

A few reporters have had a chance to play with what may or may not be the same clone, and were not terribly impressed. Apparently the fake, I mean the AW08 Bluetooth Smart Watch, runs some form of Android, and was a little unstable. Oh, well.

If you are so inclined, this little fellow is available from AliExpress.com for only $48.36 with free shipping from Guangdong via Singapore Post. Actually, there are almost 200 of these listed with AliExpress. Get yours before Apple does something about it.

Spam, Spam, Spam, Spam...Lovely Spam, Wonderful E-mail and Telemarketing Spam...

We've all likely had about a hundred calls from "Rachel" at "Cardholder Services". This telemarketing-robocalling scam has been around for years. Several of the vermin perpetrating this garbage were shut down, but others have taken up the call, so to speak, and "Rachel" lives on. Apparently there are quite a few idiots out there who will give out their credit card number to the piece of excrement cold-calling their phone. There is indeed a sucker born every minute.

I've reported every instance to the FTC

https://complaints.donotcall.gov/complaint/complaintcheck.aspx

and of course all of my phones are listed with the Do Not Call Registry. Sadly, there is one little problem: Criminals don't seem to care about breaking the law by robocalling, nor do they seem inclined to take the time to see if my number is on the DNC or not. The cads.

Robocalls are a subset of the wider universe of criminal behavior taking place on our communication wires and airwaves. In this cesspool, I include robocalls, junk faxes, spam emails, hacking of banks, stores, and other financial operations even including the treasury of my own state. The miscreants range from lone, bored teenagers creating crude phishing emails from "Bank of Amerika" to boiler room operations here and abroad, to massive hack attacks on our financial infrastructure. The scariest endpoint is having one of these rogue operations take control of a power plant, which is at least theoretically possible via the 'net; I don't want to think about the consequences of that one.

The question we are all asking is this: Why isn't someone doing something about it!!??

Someone is, but the effort isn't even close to adequate. Both in government and industry, experts are trying to keep ahead of the criminals. The technology of our networks themselves makes it possible to cover one's tracks to the point of being invisible to law enforcement. Thus, hackers, telemarketers, and other thieves can ply their trade without fear of discovery. There is even a "dark internet" hidden from those who don't know how to access it, where what happens on the internet stays out of sight. Supposedly one can buy weapons, drugs, and other stuff you don't find at Amazon.com. Perhaps most importantly, the politics of the situation perpetuates it. Many, if not most, of the major internet hacks come from China, and are most likely government-sponsored. Ditto for Russia. There are telemarketing sweatshops in India that call via leased VOIP lines here in the US, and show up as spoofed (faked) numbers on your caller ID.

I'm particularly upset today over a message from the "IRS", informing us that we owe $4,785 dollars and are in violation of some statue or other. Calling the number in the message (generally a bad thing to do) connected us to a boiler-room operation staffed by people with a very clear Indian accent. No racist connotations here, children, but that's the accent they had. They keyed their scam by telephone number, and were quite confused when I gave them the direct line to the real IRS. More on them in a moment.

It is a sad state of affairs that criminals have access to more and better technology than their victims and our protectors.

There are a few common threads here. First and foremost, this garbage is all perpetrated by criminals, hoping to separate the suckers from their money. And because their marks are either stupid, greedy, or both, many of them actually respond, thinking they are getting something they are not entitled to have, such as Viagra without a prescription, their share of a Nigerian prince's ill-gotten oil money, a no-interest credit card, and so on. Fear of the IRS is a corollary which can get the weasels in your electronic door as well. Caveat emptor, as always.

I'm not a Big-Government supporter by any means, but this is an issue where our leaders have failed us. Yes, some of the criminals have been caught, but many more jump in to take their place, and most of these newer and nastier vermin are located overseas, immune from prosecution. Add to that, the carriers themselves, phone and broadband alike, are either too overwhelmed to do anything about this inundation, or are simply satisfied to receive the fees from the bottom-feeders or those who resell the service to them.

The Internet is supposedly an international operation, and "solutions" such as isolating Russia or China, or Nigeria from US traffic would hurt more people than it would help. (Well, OK, maybe cutting off Nigeria wouldn't be a tragedy, but I digress.) Still, I DO think there should be sanctions based on the criminal traffic coming from a particular nation.

So, we come back around to what we peons can do about all this. We can try to recruit our Congressmen to get to work on this issue. Ultimately, that is how we will have to fix the problem. In this case, it takes a government to stop the juggernaut. In the meantime, the only thing left for us victims to do is to report, report, and report. Sign up for the Do Not Call Registry, and tattle on anyone who violates it. Forward spam emails (with headers) to a service like SpamCop, which will find and notify the ISP involved. Get the telemarketer's phone number from Caller ID, and trace it down, using Google to start. In other words, Fight Back!

I did track the phone number from the IRS (Indian Robbing Scoundrels) to its VOIP provider, and that particular number was shut down. I'm sure, however, that the Banglore Bad Guys were able to crank up another US number within a few moments maximum. Just like smashing a cockroach; a dozen skitter out to take its place.

Perhaps the saddest commentary is from the IRS (the real one) itself. Its website has a link for reporting scams such as the one attempted on us. The first question:  "How much did you give the scammer?" There's a sucker born every minute, I guess, and criminals are very adept at finding them.

Yosemite Slam

Yosemite Sam, character copyright Warner Brothers Studios, image courtesy of  dailyinspires.com

I've been a lover of Apple products from almost the beginning. My very second computer was a Mac Plus with a whopping one MEG (yes MEGABYTE) of RAM. (My first computer was a TI 99 that didn't do much but hey, it was a computer!) I've since owned or been responsible for the purchase of well over one hundred Apple Macs, not to mention an equal number of iPhones and iPads, half a dozen or so iPods, and even a Newton. I keep hoping for Apple to get into the PACS/EMR game, as their approach to an interface would hopefully provide us with the usability and friendliness so sadly and sorely lacking in the current offerings.

While some might accuse me of being an Apple fanboy, and willing to swallow anything and everything they deliver, I must go public with a huge complaint.

My brand-new Macbook Pro Retina came with MacOSX 10.10, code named Yosemite, after the park and not Sam. It has not quite been trouble-free. In particular, it is affected by some WiFi bug that causes a random disconnect on the average of every five minutes or so. When this happens, one has to turn WiFi off and then on again, and this usually resets the problem.  I will anticipate doing this about 5 or 6 times while writing this piece.

This issue has now been reported thousands of times on multiple threads on the Apple Support Community bulletin board. Apple has released a few updates and we are now on 10.10.2, but still no WiFi joy. If you google the issue, you will find thousands of additional reports.

There have been other Apple issues of this magnitude over the years, such as the infamous iPhone 4 antenna glitch, wherein touching the metal band surrounding the phone which WAS the antenna shorted it out and limited the range of the internal radios. It didn't take Apple too long to fix this, mainly by giving away bumper cases (large rubber bands) that insulated the antenna from the user's grubby, moist paws.

The WiFi debacle, however, has not merited a response from Apple, nor will you see much mentioned about it in the mainstream Mac Media (MacLife, etc.) which depend on Apple's goodwill for their livelihood. For some reason Apple has chosen to neither acknowledge or fix this issue, and some others associated with Yosemite. The consensus is that Apple shoved 10.10 out the door too quickly, perhaps trying to keep things current with the last hardware release. All I know is that the WiFi reception, which is rather critical in a laptop, sucks, and it isn't getting fixed. The crowd posting on the Community board has offered numerous solutions, erase this, redo that, go into the guts of the OS and tweak thus-and-so...and none of them work for any period of time.

Frankly, I've had some intermittent WiFi problems with various Macs and iPads over the years that I haven't been able to document, but task me none the less. I'm convinced, for example, that my wife's original Macbook Air disrupted other user's WiFi, but I could never get that to happen consistently. Given the fact that the WiFi protocols are out there to be matched by the folks that make the routers and receivers, there really shouldn't be a problem, right?

But there is. It has been said that President Obama chose Joe Biden to be his Vice President as an insurance policy: no one would even consider impeaching Mr. Obama because we would then be left with Biden as Commander in Chief. (Excuse me while I wait for the nausea to pass.)  Similarly, Apple knows quite well that Microsoft is its insurance policy. Having Windoze 8.1 installed via Bootcamp on my same Macbook Retina, I can tell you it is absolutely horrid to use, having been written more for their Surface tablet (which I'm told is also a dog) and not for a run-of-the-mill keyboard/mouse setup. It is splashy and colorful, and full of features that do nothing but get in the way of actually using it. For me, and most Mac aficionados, switching completely to WinBlows is a complete last-ditch resort, which won't happen unless MacOSX reaches the point of total shut-down.

Still, Apple, and CEO Tim Cook, need to realize that they are testing the patience of their users, especially those of us who use these (formerly) wonderful machines for mission-critical and even life-saving applications. Sooner or later, someone will step into the void you are creating with your indifference toward a really serious problem.

Fix this. Now. Please. Next time, I won't say "Please".

An Hour and Thirty-Five Seconds With George W. Bush

It's a hard life, but someone has to do it.

I'm writing from frigid Chicago, where the air temperature is something around 20 degrees, and the wind chill is 50 below numbness. I'm here for the 100th Anniversary Edition of RSNA, and one must brave adverse conditions to attend so momentous an occasion.

If you are reading my illustrious blog, you must have some connection to radiology, and thus you've probably attended RSNA at least once. If so, you know that the most important part of the whole meeting is the parties that come after hours. In years past, the big vendors have put on some really incredible soirees, with open bars and buffets overflowing with prime rib and other expensive delicacies. 

Then came the economic bust, and the parties became fewer and further between.  But this year, there seem to be a few more than I've seen recently. In fact, I received about four invitations for tonight alone. Fortunately, the decision as to which to attend was quite easy. Zotec, our billing company, delivered the most incredible RSNA experience I've ever, well, experienced: An evening with former President George W. Bush in the Grand Ballroom of the Trump Hotel. 

Zotec is apparently doing quite well; the teaser on the video screens behind the homey staging with two armchairs touted the processing of $1 Billion in charges. I'm not sure what the average percentage of their fees might be, but if we assume even a low 7%, the Law Brothers who run the company are raking in $70M. Not too shabby in this day and age. 

Anyway, as a very good Zotec customer, Mrs. Dalai and I, as well as one of my former partners/new bosses were invited not only to the event, but to a photo-op with Mr. Bush as well. We arrived early, donned our wrist-bands, and queued up for our few seconds with the Man. We were most amused by the Secret Service agents with somewhat ill-fitting suits and earphones scoping out the crowd of mostly older docs and their wives. 

When our turn for the photo came, the President turned and greeted us, and put his arm around Mrs. Dalai and I, and we all smiled for the camera. (I'll post it when it arrives in the mail.) In the process, I said, "Mr. President, we miss you dearly," to which he chuckled, and Mrs. Dalai followed up with "Can we get you back?" W chuckled again and shook his head. "I'd be going back alone!" To which we responded, "You would still have a lot of support." We said our goodbyes, and proceeded on to the Trump Grand Ballroom (which wasn't all that large...someone needs to be fired) where the armchair talk shortly commenced.  

The format was informal, with Scott Law, Zotec CEO, sitting adjacent to the President on the stage. Mr. Law would ask a question, and Mr. Bush would answer, to enthusiastic applause. I won't try to reproduce the conversation, but several observations are in order. First and foremost, W is a witty, humble, and eloquent (yes, I said eloquent!) speaker. Over the course of the hour, we laughed and (almost) cried with him. We were taken to the heart of the Oval Office, Ground Zero, and the classroom in Florida where Mr. Bush was informed of the 9/11 attacks. In all of these scenarios, Mr. Bush conveyed a sense of duty to his country, humility in face of unimaginable responsibility, and fierce devotion to the defense of the nation he led for eight years. His goal after hearing of the airliners hitting the World Trade Center buildings and the Pentagon, was personified as the protection of the little girl who was reading a story to him that fateful morning. 

Having heard President Clinton speak at RSNA a few years back, I was struck by the huge discrepancy in the perception versus the reality of both men. Mr. Clinton, whom some think the greatest President ever, spoke in a disjointed manner, and spent much of the talk tooting his own horn about how much he had been doing for the poor in Third-World nations, and chastising us rich doctors to help. Mr. Bush, on the other hand, was witty, humble when the moment called for it, and proud when appropriate. And he spoke very clearly, very articulately, and again, eloquently. Those who have developed a visceral hatred of the man won't want to hear it, but W may well have been the most honest, loyal, and capable man to occupy the office in a very, very long time. He was labeled a "cowboy" and "stupid" by a media and a Leftist bunch that couldn't stand the fact that he didn't act like their vision of a Harvard-trained leader (he did receive an MBA from the Harvard Business School). For your information, President Bush used the word "strategy" about a dozen times, and he pronounced it properly. 

I thank Zotec for giving us the opportunity to see how someone with character behaves when given the greatest and hardest task known, in contrast to what we have seen on the news daily for the past several years. I am humbled and honored to have been in the presence of a truly great man. 

And I should also thank Zotec for doing a damn good job with our billing!

Meeting With The PACS Giants And Other RSNA Tales

There is a touch of melancholy for me here at RSNA 2014 to go with the 20 degree nip in the air. I'm not one to dwell much on the deep meanings of beginings and endings, but while strolling the exhibits today, I realized that I've been attending this monster of a convention on and off since I was a Nuclear Medicine Fellow in 1990. And it occurs to me that since I'm now semi-retired, it is possible that I won't return next year. But we'll see how that goes.

One of the joys of RSNA, and my fame, or at least notariety in the field, is the chance to meet up with those far more promienent in the field than I. Hence the title of this piece. I had the wonderful opportunity to share a cappuchino with two giants of PACS, Mike Cannavo and Dr. David Clunie. Mike I've known for years, but I had only communicated via email and AuntMinnie forums with David. I was very fortunate to get both of them together on the same couch for a few moments today. These two gentlemen have been involved in the business since before anyone could even spell PACS. They both have an amazing level of knowledge, not to mention various documentation, of those early days, and I'm urging them to collaborate on a book.  Maybe I would qualify for a footnote...

I am occasionally accosted, I mean greeted, by some of my loyal readers. In fact, when I stopped at one booth to say hello, a friend who was mentioned in an earlier post and was apparently embarassed by the fact that it proves he's one of my readers spotted me and exclaimed, "It's the Dalai! Shall I kiss your ring? Shall I kiss your ass?" To which I replied, "Not unless someone gets it on camera!"

Today was my informatics day, and I heard some talks about portable platforms, and SOA's, and image sharing. SOA's, aka Service Oriented Architecture, as presented by Dr. Paul Chang  are fascinating constructs with huge potential. Dr. Chang showed an example from U of C wherein the SOA determines if the patient has appropriate labs ordered, and if not, it initiates the order to acquire them. So much for us humans.

I also stopped by a booth or two.  (This is starting to sound like a third-grader's rendition of his trip to Disney World, but for me, that's quite appropriate.)

In my feeble-minded semi-retired state, I've decided not to continue my practice of posting every last little detail about demos and things. You really have to get your own hands on the software (well, the keyboard and mouse, but you know what I mean) to determine if something will work for you or not.  I do pride myself on attempting to wear multiple hats when I evaluate a program, which I think is the key to my success as my group's CTO as well as the premier radiologist PACS blogger (still the only one, but I'll take it).  I'd like to think I can make any commercial PACS client work; that's my ex-engineer hat in action. But I think I'm reasonably good as well at figuring out if something will work for my least-technically-savvy former partner, the one who calls from airplanes wanting to know how to adjust the volume on his laptop. So, in my new, lazier, partially-retired personna, I'm just going to sketch out the very basics and leave the picayune details for another time.

Here we go. I stopped at TeraRecon, and had a look at their latest offering, deconstructed PACS, which basically utilizes TR as a PACS overlay, uniting data from multiple data silos (coming from the Midwest I'm not used to anything other than corn and grain being stored in silos) and adding in the magic of advanced processing for a sort of super enterprise PACS.  From what I could see, there are still a few details to be worked out before the ssytem will work as I would want it to, but the TR folks are on their way. Ultimately, the overlay will require the ability to check for priors in all the silos (which they seem to have almost mastered) and be able to talk back and forth to the underlying PACS to manage workflow, which seems to be on its way. I was most amused and honored to be treated with equal deference to the chairman of a very well-known radiology department who was there at the time. The chairman had actually heard my Laws of PACS talk a while back, and urged me to keep up the good fight. And so I shall.

To be scrupulously fair, Visage has a similar approach to overlying PACS with an advanced imaging platform, but I ran out of time before I could see their latest. Apologies to Sam and Brad. I'll look at it ASAP. ***

I should break off into a separate post, but the following entry will be fairly short.

About three weeks ago, Agfa placed a test version of IMPAX 7 Agility PACS in our reading room, and I was able to have a few hours of playtime with it. I had promised not to report anything until talking with the important people at Agfa, and I usually honor my promises.  As a followup to the home test, I met with some Very important people in a spartan back room of the lavish Agfa booth. You would think that Agfa would not be happy with me, given the rather brutal treatment I've given them over the years. You would be wrong. Agfa has always been gracious in accepting my acerbic criticism and improving where possible. Agility is no exception, save the fact that I didn't really have to criticize as much as usual. Gone (FINALLY) is the tool-toggling I've whined about for years.  Available (FINALLY) is workable user-level hanging protocol creation. And so on. I had some complaints/observations about the way the latter worked, and some of my ideas had already been incorporated between my two recent exposures, and others hopefully will appear soon. There is very tight integration with the "top three" vendors of things like advanced processing and nuclear medicine. For example, my Segami Oasis will come up within the PACS viewport as if it were part of the PACS itself. For better or worse, the port basically reverts to the incoming programing, mouse-controls and all. Could there be a more unified approach to this? I'll have to play some more. Agfa has utilized hot-spots on the image for common controls like window-level, an approach I'm not fond of, for what that's worth.

Agility is considerably different than IMPAX 6 (once code-named Odyssey). It is a worthy successor, and frankly is somewhat more mainstream in operation and appearance than 6. When asked how I would grade it, I said that with the current improvements, I would give it a B+/A-. It has a way to go, but it does represent a significant step in the right direction.

As always, more to come!

*** ADDENDUM!!

I wandered by the Visage booth on my way back to the educational sessions from my $20 mediocre lunch, and I stopped to see my good friend Brad. Given the 10 minutes I could spare, he and the apps folks managed to give me a quick but thorough view of the latest version. It is impressive, all the more so to realize that the system operates with server-side rendering. This allows platform neutrality (it will run on my Mac, iPad, etc.) and really rapid loading of huge datasets since they don't actually go anywhere. Visage has outfitted a Very large healthcare operation with its version of a Deconstructed PACS, operated from a single main server (of course with failover backup) and six rendering servers. Brad tells me this configuration can handle tens of millions of images and hundreds of simultaneous users and still be at only 20% of its capacity. 

Visage has some very nice features such as a lesion marking function that gives volumetric information as well as orthoganal dimensions, nice for RECIST reporting. In its PACS implementation, Visage can dive into silos and match exams, and has a better hanging protocol than a new PACS version I've examined recently. It can handle all modalities, and even can produce MIPS from breast tomosynthesis, something I haven't seen before, altough it won't make me want to start back reading mammograms.  There is of course very powerful advanced imaging as well. 

I do have to point out two deficiencies, which Brad tells me nicely are only problematic for old, senile vacuum-tube loving knuckle draggers like myself (OK, he didn't say it that way, but I don't want you to think I have any sort of elevated opinion of myself). First, the level of automation of things like coronary vessel segmentation is limited. Visage's philosophy is that automated detection is not perfect, and the human eye may better detect a more aberrant vessel path. That's probably true, but I do like the joy of one button operation. (Anyone remember the line from the Lost in Space Movie where Major West launches the Jupiter 2 by saying "...And the monkey flips the switch...")

Secondly, this deconstructed PACS is designed to be driven by an EMR/EHR, speech recognition, RIS, etc. What Visage has declined to provide, and Brad says I don't need, is a worklist! Here we disagree. I come from a PACS driven workflow shop, and I like it that way. Apparently there are third parties who can provide a worklist, but I still think Visage should write their own. I'll be glad to help. 

And to my friends at Merge, please don't worry about the omission of your booth. I walked by a few times and you have all been very busy, hopefully with paying customers. I promise to review the updated PACS and other offerings online with you at a later date. Two days at RSNA is just not enough!!

EMR: Round Peg, Square Hole From The Sunrise Rounds Blog

Dalai's note:  My rather vocal presentation of my views on medical IT have earned me an international speaking career. It is sad to see that nothing much has changed over all the time I've been blogging and speaking on this issue. In fact, even though it is more ubiquitous, medical software remains as useless and confounding as ever. It is gratifying, however, to see others take up the cause of improving this potentially deadly deficit. As cross-published on KevinMD.com, this piece from Dr.  James Salwitz, an oncologist who blogs on SunriseRounds.com, takes a similar approach to lambast those who dump their (soft)wares on an unsuspecting medical community.

A 57-year-old doctor I know is retiring to teach at a local junior college. He is respected, enjoys practicing medicine and is beloved by his patients; therefore, I was surprised. While he is frustrated by the complexity of health insurance, tired by the long hours and angered by defensive medicine, the final straw is that he can not stand the world of the EMR.

As an Electronic Medical Record junkie, I would quit if I had to practice without a computerized information system. These programs are a dramatic improvement over the paper and pen way of keeping records. Still, I understand the onerous problems. Data entry is clumsy, painful and takes hours. Information is stored in a nearly random manner, not much better than papers tossed into a cardboard box. Every EMR program is different and none share vital patient data. Training is lousy, access is non-intuitive, support is spotty, costs are high and any gains seem to be countered by poorly timed system crashes.

Unhappy to lose a physician from our medical community, I find myself musing about what has gone wrong with a critical technology that has such shining potential. Computer systems fly giant aircraft around the world without incident, handle trillions of dollars of financial trade without a penny lost and allow hundreds of millions to tweet, Facebook or blog. Why is medical IT so bad?

The major problem with EMRs, as they are conceived and as they presently exist, is that they are round pegs in square holes. They are designed to gather and store information; shiny electronic file cabinets, and they are built around the primary function of billing; grinding out ICD-9 and CPT codes. That would be fine if that was what doctors actually do with their time and if making money was the primary goal of practicing medicine. However, surprise, surprise, what doctors really do is treat patients. EMRs often hinder, not assist, the giving of medical care.

A physician’s normal function is to interface between objective biology and the complexity of each human life. Often called “the art” of medicine, it is the act of bridging science to individual reality. Ask questions; test; collect information. Attempt to organize by creating of a list of possibilities, a differential diagnosis. Assimilate, screen and sift that data until you reach a final diagnosis. Then, implement therapy using science and the results of research, with compassion, patience and the skill of a teacher.

A functional electronic health delivery system would assist in this systematic decision process, actively participating in the query and analysis, adding scientific knowledge and observations based on state-of-the art recommendations. Help the doctor build the differential. Recommend testing or therapeutic alternatives. The EMR should be aligned with the doctor’s goals, which are the patient’s health.

The GPS in my car is first rate. Data input is verbal and flawless. It tells speed, direction, and continuously adjusts recommendations based on my progress and traffic impediments. It even throws in alerts about the weather. In other words, the GPS not only stores data, it tells me what to do with it, and is constantly updated by events far beyond my windshield, which I have not yet considered. Someday soon, that GPS will actually drive my car.

A health computational system should have, at a minimum, the functionality of that GPS. Easy data entry and access. Flawless expanding storage. Clear output. Actionable recommendations and observations, based not only on the patient, but on the science of medicine. An EMR should be updated continuously by clinical information such as labs, vital signs and tests, as well as the most recent scientific discoveries, even if they are made halfway around the world, delivering at the bedside the vast resources of Big Data. Help me care for the patient by complementing my work.

As the practice of medicine becomes logarithmically more complex with the expanding potential of genomic or “Personalized Medicine,” advanced information technology will be vital. No doctor will be able to assimilate an individual patient’s genome and thousands of actionable variables into a differential diagnosis or comprehensive treatment. The key will be real-time EMR support.

To date no one has taken the potential or complexity of EMRs seriously. The assumption is that these systems can be built by cottage industries, with the result that there are hundreds of rudimentary programs, all grossly inadequate. The average GPS is far more functional.

This slowly expanding area of IT research is called translational bioinformatics, but there have been relatively few dollars invested by the NIH in the basic science. Data input remains primitive. We have no backbone on which to create a national network to maintain and track individual records. There is no integration with decision making software or connection to research troves. Medicine relies on the doctor to connect the myriad dots, even as he or she is up at midnight, typing elementary progress notes into elementary office systems.

Doctors need and desire help in taking care of their patients, but instead they have a tool designed for secretaries and insurance auditors. We must re-address the goals of clinical IT to improve, empower and give medical care. The future of our patients and the future of health, depend on it. No amount of frustration and burned out physicians will force patient lives into slots built for dollars.

Epic Fails And Deadly IT Cultures (An OPINION Piece)

The Ebola Virus...Image courtesy of scienceblogs.com

It's bad enough that a fellow from Liberia by the name of Thomas Eric Duncan through hubris, stupidity, or simply bad luck brought Ebola to our shores. He did ultimately seek medical attention in the Emergency Room of Texas Health Presbyterian Hospital in Dallas when he became symptomatic with the characteristic fever and pain of an Ebola infection. In fact, he presented twice to the Dallas ER. In between his two visits, Mr. Duncan was set loose on a city of well over a million souls while his disease was at its most infectious level. (He has since died of the disease, and sadly, one of the nurses who cared for him now has it. Let us pray for her speedy recovery.) How could this breach of public health have happened? It seems to have something to do with IT, specifically, the configuration of the hospital's EHR.

CNBC quotes Jonathan Bush (as it turns out, Jonathan is the nephew and cousin of the former Presidents...hat tip to Ranjan), head of Athenahealth:

The failure of a Dallas hospital's electronic medical record system to flag a man who turned out to be infected with the Ebola virus underscores how clunky, outdated and inefficient health information systems typically are in the U.S., a medical IT CEO charged Friday.

"The worst supply chain in our society is the health information supply chain," said Bush. . . "It's just a wonderfully poignant example, reminder of how disconnected our health-care system is."

"It's just a very Stone-Age sector, because it's very conservative," Bush said. "Hospital health care is still in the era of pre-Internet software."

"The hyperbole should not be directed at Epic or those guys at Health Texas," Bush said. "The hyperbole has to be directed at the fact that health care is islands of information trying to separately manage a massively complex network . . . People trying to recreate their own micro-Internet inside their own little biosphere . . . that'll never, never, never be excellent," Bush said. "There's no 'network effect' in health care today."

How does this apply to Mr. Duncan unleashing Ebola in the heart of Texas?

The hospital Thursday night said when Duncan was first examined Sept. 25 by a nurse, he was asked a series of questions, including whether he had traveled outside of the U.S. in the prior month.

"He said that he had been in Africa," the hospital said in a statement. "The nurse entered that information in the nursing portion of the electronic medical record."

But it turns out that answer—which could have alerted doctors of the possibility Duncan had Ebola—was not relayed electronically to them because of "a flaw" in the way doctors' workflow portions of the electronic health records interacts with the nursing portions of the EHR.

"In our electronic health records, there are separate physician and nursing workflows," the hospital said. "The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order. As designed, the travel history would not automatically appear in the physician's standard workflow."

Of course, that particular problem at that particular hospital is now fixed. But . . .

"We have made this change to increase the visibility and documentation of the travel question in order to alert all providers," Texas Health said. " We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola."

Bush noted that typically when problems like the flaw in Texas Health's EHR system are fixed, "they're fixed only at the place where they appeared."

"Those mistakes are happening constantly," Bush said.

But, "philosophically I think hospitals should get out of the business of trying to program computer systems, and expand in the business of treating patients. But that's a standard thing that goes wrong with millions of configurations" of EHRs, he said.

Mr. Bush was quite tactful, but the implication of his statement is truly astounding. He is saying, perhaps not quite in so many words, that the IT department of the Texas Health hospital in Dallas, by poorly implementing (my opinion, not necessarily his) poorly designed (again, my opinion, not necessarily his) software, could be responsible for a disaster. This glitch has potentially allowed Ebola to spread further than it would have had Mr. Duncan been put immediately into confinement upon his first presentation. To be fair, the patient had been in contact with others before his first ER trip; still, we can assume he had more interaction with more people than he might have otherwise. We can only wait and see how many of his family members and acquaintences come down with the often-fatal disease. I should also mention that the ER physician should probably have thought to ask about foreign travel when presented with a feverish African national presumably speaking with an accent.

There is much online about Epic, Presby's EHR provider. Google will supply link after link after link if you so desire. There are several take-away messages: Epic has severe interconnectivity / interoperability problems, and it is a HUGE political player, with its founder Judith Faulkner being quite the Obama supporter. Faulkner, and Epic employees, have given millions to Mr. Obama and other Democratic causes. Epic has received significant federal subsidy money, and it is up for an $11 Billion government contract. Michelle Malkin also reports that:

Faulkner, an influential Obama campaign finance bundler, served as an adviser to David Blumenthal. He’s the White House health information technology guru in charge of dispensing the federal electronic medical records subsidies that Faulkner pushed President Obama to adopt. Faulkner also served on the same committee Blumenthal chaired.

Cozy arrangement, that.

I'm straying a little off-topic here, but I think it is unlikely in the extreme that Epic will shoulder even the slightest blame for Mr. Duncan's Dallas destruction. After all, as we say in the trade, PBKAC, Problem (was) Between Keyboard and Chair. In other words, it wasn't Epic's fault that whatever IT employee or committee failed to connect the dots and the map the critical foreign travel field from the  nurses' intake screen to the doctors' review screen. Oops. So sorry.

Personally, for what little it's worth, I do NOT let Epic, or any other software company, off the hook quite so easily, nor do I bow to the IT departments which often control such software but don't grasp the criticality of the workflow they are now governing, let alone the workflow itself.

I've ranted for pages and pages about image sharing, and how it is malpractice for patient images to be essentially held hostage by the IT and other administrative types who are adamant that the competing hospital across town (or across the street) will NEVER EVER be allowed to touch their precious data. And I've yowled and whined about PACS software that was clearly NOT written for use by any practicing radiologist I've ever met.

Please indulge me while I add to these rants.

I had the occasion to accompany Mrs. Dalai to her annual (8 years postponed) internist visit. Her doc showed me how much fun it is NOT to order something as simple as a PA and Lateral CXR in our illustrious EMR's bilious CPOE (Computerized Physician Order Entry) system. It is a complete miracle that any order at all is entered correctly in this absolute abortion of an interface, and I'm not at all surprised when the wrong order comes through for the wrong indication. The electronic chart function isn't any better. Finding a particular lab value can be an exercise in agony (akin to using some PACS I can name) and it just goes downhill from there. When I asked around to find out who OK'd this particular piece of garbage, I was met with shrugs and silence.

Do you sense a familiar refrain? (Lawyers please note...THIS IS ALL MY VERY OWN HUMBLE OPINION, as is every other word that I have ever written or ever will write, unless quoted from someone else, and worth every cent my dear readers paid for it.) Once again, here in the Health Care Field of Dreams, we have badly written, badly designed software, created with minimal input from those who have to use it, selected and then implemented by IT types who also don't have to use it and don't understand enough about those who do to get it done right. This has to stop. Right. Bloody. Now. Hit CNTL-ALT-Delete and start over.

With Epic and the government having their hands deep inside each others' panties, we may well be stuck with these unusable systems for the foreseeable future. (And as an aside, if you deconstruct the Meaningful Use rewards and penalties, doctors are being bribed to buy EHR's that have the certified and confirmed ability to transmit data to Washington, D.C., so again, we won't expect the government to do anything about anything.) But, the demise of Mr. Duncan, and no doubt dozens if not hundreds more that he inadvertently infected between his two ER visits may level the playing field.

It is clear that Epic's epic Dallas fail (which might not really be totally attributable to Epic per se, but rather to the way the product was set up in the field, not passing that one lil' bitty critical entry to where it should go), contributed to Mr. Duncan's being released when he should have been locked up in the local version of Wildfire. It is possible, just barely possible, that this tragic episode will awaken the public to the dangers inherent in the IT-controlled medical software industry and its acronymbysmal spawn, EHR's, CPOE's, and the occasional unruly PACS. Get enough people upset about this, and they will call their congressmen, and more importantly their lawyers. (I would submit that more gets done by class-action suit in this country than by Congress.)

I realize that replacing these huge legacy systems which were outdated before they were even conceived would cost somewhere in the trillions of dollars, and so I'm not holding my breath that this will ever happen. But maybe a few million and billion dollar suits and fines would get the attention of the Epics, the Cerners, McKessons, and all the others who create these nightmares. Or maybe, just maybe, the execs will read this, and the other rebellious propaganda we are starting to see online, and realize that they are causing damage rather than progress, and be inspired to turn it all around. I'm a staunch believer in the electronic record, PACS, computers, iPhones, Apple Watches, and anything else technical. This is the future, without question. But it has to be done right, and so far that hasn't happened.

We can hope that the late Mr. Duncan can accomplish in death what no one has yet been able to manage while alive.  We can hope, anyway...

Saving Candy Crush

What may seem obvious to some can be mysterious to others. Case in point: the introduction of Western-style toilets to parts of China. It was necessary to provide pictographic instructions to be sure the new equipment was utilized properly:

Assuming you have flown on a commercial airliner ever in your life, you've had to sit through what some would consider an equally-foolish instruction set: the safety briefing. This is how you buckle your seat belt, if the plane goes down somewhere it shouldn't, find the closest exit unless said exit is under water, in which case you should go elsewhere. And of course, if the oxygen masks should drop, grab them all for yourself and don't let anyone else have one unless they pay you a lot of money before they pass out.

In years past, we passengers have had no other entertainment during the safety spiel except for the airline magazine, and SkyMall catalog, and those get old fast. But about a year ago, the FAA allowed us to have our small personal electronic devices on during take-off and landing. And so, many of us have our phones or tablets running at all times, in Airplane Mode of course, playing Candy Crush while the frustrated flight attendants drone on about the unlikely possibility of a water landing on a trans-oceanic flight.

The flight attendants are not pleased about this. From the Wall Street Journal:

Lawyers for the nation’s largest flight-attendant union argued in federal court Friday to effectively reinstate a government ban on the use of electronic devices during takeoffs and landings.

The Association of Flight Attendants-CWA is suing the Federal Aviation Administration, saying the agency notice last year that paved the way for fliers to use their devices throughout flights violated federal regulations that require passengers to stow all items during takeoffs and landings.

Justice Department lawyers representing the FAA say the agency’s guidance, which permitted fliers to keep smaller devices in their hands during all phases of flight, doesn’t violate the stowage rule because small devices aren’t governed by it. The two sides argued the case Friday to a three-judge panel with the U.S. Court of Appeals for the D.C. Circuit. . .

Attorney Amanda Duré, who is representing the attendants union, said that since the policy change, many fliers have stopped listening to attendants’ emergency announcements and, in at least one incident, a tablet became a projectile during turbulence. The union also is concerned the devices could impede passengers’ exit from an aircraft during an emergency.

ONE tablet flew, and we have to take everyone's away. How do we know it wasn't thrown?

I have great respect for flight attendants. They don't have an easy job, and they have to deal with throngs of humanity, some of whom are more accustomed to the joys of Greyhound than The Friendly Skies. I remember the days when stewardesses (can I still use that term?) were all female, 22 years old and coiffed to the nines. This is no longer the case, for better or worse. But with the demise of "coffee, tea, or me," an element of customer service has gone by the wayside. There is at least a faint edge to the attitude of many attendants today, and downward spirals ala Alec Baldwin are not unheard of. I personally think the suit against the FAA is mostly a temper-tantrum, lashing out at the passengers who are now even more contemptuously ignoring the boring lecture that in a panic situation they would all forget anyway.

This adversarial situation does not have to continue. A little thinking outside the box, or at least inside a different box, could provide a very easy fix. It's time for the airlines to take a page from Disney's book. The Disney people know crowd control and safety better than most any other operation out there. I'm sure most of you have been to Disney World, or Disneyland, and thus you've been a passenger on Star Tours and the old Body Wars. While waiting the better part of a day for your 5 minutes on the ride, Disney entertains with various props and videos. In fact, just before boarding your StarFarter 2000, you will be shown this video:

As with comedy, it's all in the timing. . . We are all captive in the gate area while waiting to board the plane, and also while standing in line on the jetway while waiting on Ma and Pa Kettle to jam their entire life's possessions into the overhead bin. THIS is the time to show the safety video on strategically placed monitors! Make them funny, as Delta has started to do lately, and the message will get across far better than it does under the present system. Trust me and Disney, this will work!!!!

Here's one of the new Delta safety videos for your viewing pleasure:

If you think this might work, let the FAA and the airlines know your opinion. But please don't mention my name. I have some traveling to do, and I don't want to be the target of angry flight attendants. It seems they have some secret approaches to revenge:

1. Coded hand gestures
Flight attendants "employ all sorts of unofficial methods and codes" to deal with difficult fliers, reports Emma Messenger at the Daily Mail. A "subtle wag of a finger" behind someone's head means that he's lecherous and may get handsy (or worse) with the staff. To alert colleagues that a passenger is drunk, attendants cross their fingers over the hospitality cart.

2. High winds
At the end of a demanding flight, writes David Sedaris in The New Yorker, some attendants indulge in the peevish practice of "cropdusting" — silently passing wind as they walk down the aisle making their final checks. "Reclined in their seats, heads lolling to the side ... airplane passengers are prime fart targets," comments Maureen O'Connor at Gawker.

3. Dirty drinks
Ellen Simonette — author of Diary of a Dysfunctional Flight Attendant: The Queen of Sky Blog — reminisces in The New York Times about the time a colleague took revenge on a loudmouthed passenger by making him "a very special drink" in the privacy of the galley, rubbing the rim of his glass on the plane's "filthy floor" before serving it up with a "devious smile."

4. Abusing their powers
We've all seen the seat-belt sign light up in midflight, though there isn't a hint of turbulence. Blame your attendants, says the Daily Mail's Messenger, who often switch it on so they can "have a nice cup of tea and gossip in peace."

5. Starting a blog
Countless flight attendants vent about passengers by blogging anonymously. Dubai-based blogger Tampax Towers recently railed against fliers who hold up security lines by wearing metal-studded jeans, while, over at These Wings Talk, a catty account of an experience with a "One-Eyed Cyclops Passenger" makes for surprising reading.

Coffee, Tea, or Dalai?