Heard about an old friend, sharing the stage with Billy Squier at our high school's send-off event (as another alum of some distinction noted, the building is being demolished).

Their performances got me thinking of a lot of the songs we practiced, growing up. And while I did say recently that music is "done" from the perspective that we can hear pretty much any song we'd ever want to hear, on demand, anywhere, the truth is there are some songs that seem lost to time.

If Google can't find a tune, does it really exist? There was some truly strange songs, burned into my head from repetition in middle school orchestra. From time to time, the tune or lyrics pop into my head -- but when I try to pin down that song -- Google's got nothing.

For instance, there was a whole awkward teen coming-of-age musical we put on. I think it was actually called Coming of Age. Songs included, "If I Had A Friend," "On the Outside, Looking In" and "Broken Home on the Range."

I want to know, were other middle schools forced to perform this, as well? Who wrote these songs? I'm not saying I'd be a fan, but I'm driven by a little nostalgia, plus the same kind of curiosity, I think, that drives people to hear Wesley Willis works.

Another example is a musical about singing troubadours -- this is the only reference I can find online. We praticed these songs on professional-looking sheet music, learning them by heart, just a few decades ago. Yet no trace of these songs seems to have made it into the digital era.

I suppose as every bit of trivia and ephemera from our lives makes its way onto the web, and we come to accept that no new experience will go undocumented, these last few holdouts will rankle, out of proportion to their significance.

Heard about an old friend, sharing the stage with Billy Squier at our high school's send-off event (as another alum of some distinction noted, the building is being demolished).

Their performances got me thinking of a lot of the songs we practiced, growing up. And while I did say recently that music is "done" from the perspective that we can hear pretty much any song we'd ever want to hear, on demand, anywhere, the truth is there are some songs that seem lost to time.

If Google can't find a tune, does it really exist? There was some truly strange songs, burned into my head from repetition in middle school orchestra. From time to time, the tune or lyrics pop into my head -- but when I try to pin down that song -- Google's got nothing.

For instance, there was a whole awkward teen coming-of-age musical we put on. I think it was actually called Coming of Age. Songs included, "If I Had A Friend," "On the Outside, Looking In" and "Broken Home on the Range."

I want to know, were other middle schools forced to perform this, as well? Who wrote these songs? I'm not saying I'd be a fan, but I'm driven by a little nostalgia, plus the same kind of curiosity, I think, that drives people to hear Wesley Willis works.

Another example is a musical about singing troubadours -- this is the only reference I can find online. We praticed these songs on professional-looking sheet music, learning them by heart, just a few decades ago. Yet no trace of these songs seems to have made it into the digital era.

I suppose as every bit of trivia and ephemera from our lives makes its way onto the web, and we come to accept that no new experience will go undocumented, these last few holdouts will rankle, out of proportion to their significance.

Sometimes, the blogosphere just decides they're going to discuss something in great detail. And now, with holiday travel upon us, we're talking about the inane rules that airlines inflict upon passengers -- especially the "turn off all electronic items that have off switches" rule at the beginning and end of flights. 

Sometimes, the blogosphere just decides they're going to discuss something in great detail. And now, with holiday travel upon us, we're talking about the inane rules that airlines inflict upon passengers -- especially the "turn off all electronic items that have off switches" rule at the beginning and end of flights. 

Sometimes, the blogosphere just decides they're going to discuss something in great detail. And now, with holiday travel upon us, we're talking about the inane rules that airlines inflict upon passengers -- especially the "turn off all electronic items that have off switches" rule at the beginning and end of flights. 

I had a couple of slow shifts in the emergency department recently, around Thanksgiving. And it made me think of Nomar Garciaparra, the old Red Sox shortstop.

Nomar always had to throw off-balance, while running and jumping. You can see his style on display when throwing the ceremonial first pitch at Fenway last year.

In an interview (can't find the reference, sorry) he said he always had to throw this frenzied manner, even for an easy grounder where he'd normally have time to collect himself. If he paused too long to think about it, the throw would come off badly, he said.

I always thought this was a psychological issue -- dubbed "Steve Sax Syndrome" by some.

But on those slow holiday ED shifts, I think it's just a good habit. When you're used to functioning well at a fast pace, slowing it down doesn't necessarily make you any better. Our ED's workflows, our data collection, and our decision-making, all all calibrated to work at a certain speed. Slowing it down sometimes lets us unearth a valuable piece of information -- but more often, it just pushes the signal-to-noise ratio toward more noise.

And hey, it's not like Nomar's quirk kept him from having a stellar career.

I had a couple of slow shifts in the emergency department recently, around Thanksgiving. And it made me think of Nomar Garciaparra, the old Red Sox shortstop.

Nomar always had to throw off-balance, while running and jumping. You can see his style on display when throwing the ceremonial first pitch at Fenway last year.

In an interview (can't find the reference, sorry) he said he always had to throw this frenzied manner, even for an easy grounder where he'd normally have time to collect himself. If he paused too long to think about it, the throw would come off badly, he said.

I always thought this was a psychological issue -- dubbed "Steve Sax Syndrome" by some.

But on those slow holiday ED shifts, I think it's just a good habit. When you're used to functioning well at a fast pace, slowing it down doesn't necessarily make you any better. Our ED's workflows, our data collection, and our decision-making, all all calibrated to work at a certain speed. Slowing it down sometimes lets us unearth a valuable piece of information -- but more often, it just pushes the signal-to-noise ratio toward more noise.

And hey, it's not like Nomar's quirk kept him from having a stellar career.

I had a couple of slow shifts in the emergency department recently, around Thanksgiving. And it made me think of Nomar Garciaparra, the old Red Sox shortstop.

Nomar always had to throw off-balance, while running and jumping. You can see his style on display when throwing the ceremonial first pitch at Fenway last year.

In an interview (can't find the reference, sorry) he said he always had to throw this frenzied manner, even for an easy grounder where he'd normally have time to collect himself. If he paused too long to think about it, the throw would come off badly, he said.

I always thought this was a psychological issue -- dubbed "Steve Sax Syndrome" by some.

But on those slow holiday ED shifts, I think it's just a good habit. When you're used to functioning well at a fast pace, slowing it down doesn't necessarily make you any better. Our ED's workflows, our data collection, and our decision-making, all all calibrated to work at a certain speed. Slowing it down sometimes lets us unearth a valuable piece of information -- but more often, it just pushes the signal-to-noise ratio toward more noise.

And hey, it's not like Nomar's quirk kept him from having a stellar career.

We've been considering FDA oversight of medical apps for a while, over at Medgadget.com. Now, the public comment period has concluded on the FDA's draft of how this oversight might look. The story:

The FDA will scrutinize medical apps that act as an accessory to a medical device and those that transform the mobile device into a medical device. A draft guidance issued by the FDA includes an extensive list of applications that will have to undergo review. Examples of apps that fall under the regulatory oversight are:

* Applications that allow the user to view medical images, such as digital mammography or digital images of potentially cancerous lesions on a mobile platform, and those that perform a health analysis or provide a diagnosis by trained health care professionals.

* Applications that allow the user to view patient-specific lab results.

* Applications that connect to a home use diagnostic medical device to collect historical data, or to receive, transmit, store, analyze, and display measurements from connected devices.

Great, right? The apps that do heavy lifting of patient information and connect to real medical devices get regulated, but the fun and educational apps I am working on remain free and open. Still, Harvey Castro, my favorite EM-doc-and-app-developer, was worried:

"Overall, I believe safety is the most important item when it comes to providing patient care," said Harvey Castro, MD, an app developer (www.deeppocketseries.com) and emergency physician. "Unfortunately, I believe this will hurt small businesses and entrepreneurs by making it cost-prohibitive to enter the market."

"Applications will be dominated by a few companies capable of paying the high fees to get FDA approval. I will be saddened to see these changes in the future."

For their part, the FDA said it's nothing to worry about:

...the FDA said the regulatory requirements will not impede the advancement of medical apps. "We are eager to support the continued development of mobile medical apps without the burdensome regulations that would stifle innovation," the spokesperson said.

I've perused the FDA's draft and still have a lot of questions. What if I install an app from a non-American app store -- could I still use it on American patients? What are the penalties for apps that should have been submitted for FDA review, but weren't? Will there be a grandfathering status, like with pre-1930's drugs? Will educational app makers have to submit a form asking for FDA exemptions?

The biggest question: will the FDA heed the recent IOM recommendation that another (non-FDA) government agency take up the regulation of EHR vendors? What if Congress fails to create such a body (I have a hard time imagining, in this political environment, how funding for creating a new regulatory agency would transpire). What if the FDA is the only agency that can expand its mandate? Wouldn't it act? Why should FDA expand to medical apps but not EHR?

The FDA has a proud and progressive tradition; the laws underlying its authority were passed in response to public outcry regarding food and vaccine preparation, and misleading labeling. There were big problems, improved by the FDA. Even now, critics argue the FDA doesn't go far enough -- approving medical devices later found to be flawed, and recalled.

So I don't understand this push into an area where they have no clear mandate, and where there's no public pressure (yet?) to intervene. Don't get me wrong -- I'm not opposed to the idea of med app oversight, someday. There's no doubt that would be good for Americans. I do worry, though, that by moving in to the medical apps realm before most people have ever used them, and before a bad outcome has even been encountered -- or learned from -- is premature. Though the FDA says they don't want to stifle innovation, I can't imagine that, with their current budget, their fees and regulations can be anything other than a significant hurdle for developers.

We've been considering FDA oversight of medical apps for a while, over at Medgadget.com. Now, the public comment period has concluded on the FDA's draft of how this oversight might look. The story:

The FDA will scrutinize medical apps that act as an accessory to a medical device and those that transform the mobile device into a medical device. A draft guidance issued by the FDA includes an extensive list of applications that will have to undergo review. Examples of apps that fall under the regulatory oversight are:

* Applications that allow the user to view medical images, such as digital mammography or digital images of potentially cancerous lesions on a mobile platform, and those that perform a health analysis or provide a diagnosis by trained health care professionals.

* Applications that allow the user to view patient-specific lab results.

* Applications that connect to a home use diagnostic medical device to collect historical data, or to receive, transmit, store, analyze, and display measurements from connected devices.

Great, right? The apps that do heavy lifting of patient information and connect to real medical devices get regulated, but the fun and educational apps I am working on remain free and open. Still, Harvey Castro, my favorite EM-doc-and-app-developer, was worried:

"Overall, I believe safety is the most important item when it comes to providing patient care," said Harvey Castro, MD, an app developer (www.deeppocketseries.com) and emergency physician. "Unfortunately, I believe this will hurt small businesses and entrepreneurs by making it cost-prohibitive to enter the market."

"Applications will be dominated by a few companies capable of paying the high fees to get FDA approval. I will be saddened to see these changes in the future."

For their part, the FDA said it's nothing to worry about:

...the FDA said the regulatory requirements will not impede the advancement of medical apps. "We are eager to support the continued development of mobile medical apps without the burdensome regulations that would stifle innovation," the spokesperson said.

I've perused the FDA's draft and still have a lot of questions. What if I install an app from a non-American app store -- could I still use it on American patients? What are the penalties for apps that should have been submitted for FDA review, but weren't? Will there be a grandfathering status, like with pre-1930's drugs? Will educational app makers have to submit a form asking for FDA exemptions?

The biggest question: will the FDA heed the recent IOM recommendation that another (non-FDA) government agency take up the regulation of EHR vendors? What if Congress fails to create such a body (I have a hard time imagining, in this political environment, how funding for creating a new regulatory agency would transpire). What if the FDA is the only agency that can expand its mandate? Wouldn't it act? Why should FDA expand to medical apps but not EHR?

The FDA has a proud and progressive tradition; the laws underlying its authority were passed in response to public outcry regarding food and vaccine preparation, and misleading labeling. There were big problems, improved by the FDA. Even now, critics argue the FDA doesn't go far enough -- approving medical devices later found to be flawed, and recalled.

So I don't understand this push into an area where they have no clear mandate, and where there's no public pressure (yet?) to intervene. Don't get me wrong -- I'm not opposed to the idea of med app oversight, someday. There's no doubt that would be good for Americans. I do worry, though, that by moving in to the medical apps realm before most people have ever used them, and before a bad outcome has even been encountered -- or learned from -- is premature. Though the FDA says they don't want to stifle innovation, I can't imagine that, with their current budget, their fees and regulations can be anything other than a significant hurdle for developers.

We've been considering FDA oversight of medical apps for a while, over at Medgadget.com. Now, the public comment period has concluded on the FDA's draft of how this oversight might look. The story:

The FDA will scrutinize medical apps that act as an accessory to a medical device and those that transform the mobile device into a medical device. A draft guidance issued by the FDA includes an extensive list of applications that will have to undergo review. Examples of apps that fall under the regulatory oversight are:

* Applications that allow the user to view medical images, such as digital mammography or digital images of potentially cancerous lesions on a mobile platform, and those that perform a health analysis or provide a diagnosis by trained health care professionals.

* Applications that allow the user to view patient-specific lab results.

* Applications that connect to a home use diagnostic medical device to collect historical data, or to receive, transmit, store, analyze, and display measurements from connected devices.

Great, right? The apps that do heavy lifting of patient information and connect to real medical devices get regulated, but the fun and educational apps I am working on remain free and open. Still, Harvey Castro, my favorite EM-doc-and-app-developer, was worried:

"Overall, I believe safety is the most important item when it comes to providing patient care," said Harvey Castro, MD, an app developer (www.deeppocketseries.com) and emergency physician. "Unfortunately, I believe this will hurt small businesses and entrepreneurs by making it cost-prohibitive to enter the market."

"Applications will be dominated by a few companies capable of paying the high fees to get FDA approval. I will be saddened to see these changes in the future."

For their part, the FDA said it's nothing to worry about:

...the FDA said the regulatory requirements will not impede the advancement of medical apps. "We are eager to support the continued development of mobile medical apps without the burdensome regulations that would stifle innovation," the spokesperson said.

I've perused the FDA's draft and still have a lot of questions. What if I install an app from a non-American app store -- could I still use it on American patients? What are the penalties for apps that should have been submitted for FDA review, but weren't? Will there be a grandfathering status, like with pre-1930's drugs? Will educational app makers have to submit a form asking for FDA exemptions?

The biggest question: will the FDA heed the recent IOM recommendation that another (non-FDA) government agency take up the regulation of EHR vendors? What if Congress fails to create such a body (I have a hard time imagining, in this political environment, how funding for creating a new regulatory agency would transpire). What if the FDA is the only agency that can expand its mandate? Wouldn't it act? Why should FDA expand to medical apps but not EHR?

The FDA has a proud and progressive tradition; the laws underlying its authority were passed in response to public outcry regarding food and vaccine preparation, and misleading labeling. There were big problems, improved by the FDA. Even now, critics argue the FDA doesn't go far enough -- approving medical devices later found to be flawed, and recalled.

So I don't understand this push into an area where they have no clear mandate, and where there's no public pressure (yet?) to intervene. Don't get me wrong -- I'm not opposed to the idea of med app oversight, someday. There's no doubt that would be good for Americans. I do worry, though, that by moving in to the medical apps realm before most people have ever used them, and before a bad outcome has even been encountered -- or learned from -- is premature. Though the FDA says they don't want to stifle innovation, I can't imagine that, with their current budget, their fees and regulations can be anything other than a significant hurdle for developers.

Remember how people said there was no real need for a device category between smartphones and laptops? And then Apple sold 40 million iPads?

That's kind of how I felt about Tumblr.

Blogs are obviously great for musings, essays, and a web presence, and Twitter's fine for thoughts and links and pics. Why have something else, in between?

I don't really have a good answer, just like I can't fully articulate why the iPad experience is so much better than a laptop or smartphone. But I'm starting to see the appeal of Tumblr.

Beyond the usual accolades from early adopters / influencers, something that stayed with me was a quote from Tumblr's founder: "No one is proud of their identity on Facebook."

Very true. And true of a Twitter page, as well. But Tumblr sites... can be something to be proud of. And they're effortlessly fast to set up. While I have strong sentimental attachment to this site, Blogger's recent attempts to make themselves slick feel like so much else Google does these days -- uninspired, clunkier copies.

I've been looking for a way to breathe new life into the 8+ years of writing here. Tumblr's "random" button and their vibrant archive views are a great start. When you consider how easy is is on Tumblr to tag old posts, and how elegantly you can display redirect pages for tagged posts (or photos, or music) and offsite material in the sidebar, well, I was sold.

Then, of course, I had some buyer's remorse. Tumblr is unapologetically different from other social networks. It took me a while to even realize that their "dashboard" is nothing like Blogger's, and in fact more like Facebook's news feed. And it's taking me some time to get comfortable with "reblogging" which almost seems like effortless plagiarism, if you're not conscientious about citations.

Tumblr's search function is completely broken. I have to believe they're working on a fix, but probably making a point of taking their time -- as if to say we're living in a post-Google age.

While I lamented Tumblr's decision to stop importing RSS feeds a few months back, I see the wisdom. I would have gone to town with importing thousands of tweets and countless photos, on top of all these blog posts. As it is, it's still possible to reintroduce old content -- it just takes a little more effort. Just enough to tip content generation in Tumblr's favor, rather than using it as a lifestream repository like Evernote or Friendfeed.

Still, it was fun to watch people throw some hearts at some old photos I uploaded, and I didn't mind the occasional reblog. And really, Tumblr's too good-looking to fill it with a bunch of text links to tweets (maybe someday we'll have something like Postano's yolink feature, to fetch images and content from those links, along with the tweet).

Twitter will always remain to go-to choice for conversations and conferences, and I think Blogger will still be my first option for sit-down-and-think kind of writing. But for now when I'm browsing and come across something interesting, I'm just going to try Tumbling first. And I'll be watching to see what new tools come online, as Tumblr grows to become the next great social network.

Remember how people said there was no real need for a device category between smartphones and laptops? And then Apple sold 40 million iPads?

That's kind of how I felt about Tumblr.

Blogs are obviously great for musings, essays, and a web presence, and Twitter's fine for thoughts and links and pics. Why have something else, in between?

I don't really have a good answer, just like I can't fully articulate why the iPad experience is so much better than a laptop or smartphone. But I'm starting to see the appeal of Tumblr.

Beyond the usual accolades from early adopters / influencers, something that stayed with me was a quote from Tumblr's founder: "No one is proud of their identity on Facebook."

Very true. And true of a Twitter page, as well. But Tumblr sites... can be something to be proud of. And they're effortlessly fast to set up. While I have strong sentimental attachment to this site, Blogger's recent attempts to make themselves slick feel like so much else Google does these days -- uninspired, clunkier copies.

I've been looking for a way to breathe new life into the 8+ years of writing here. Tumblr's "random" button and their vibrant archive views are a great start. When you consider how easy is is on Tumblr to tag old posts, and how elegantly you can display redirect pages for tagged posts (or photos, or music) and offsite material in the sidebar, well, I was sold.

Then, of course, I had some buyer's remorse. Tumblr is unapologetically different from other social networks. It took me a while to even realize that their "dashboard" is nothing like Blogger's, and in fact more like Facebook's news feed. And it's taking me some time to get comfortable with "reblogging" which almost seems like effortless plagiarism, if you're not conscientious about citations.

Tumblr's search function is completely broken. I have to believe they're working on a fix, but probably making a point of taking their time -- as if to say we're living in a post-Google age.

While I lamented Tumblr's decision to stop importing RSS feeds a few months back, I see the wisdom. I would have gone to town with importing thousands of tweets and countless photos, on top of all these blog posts. As it is, it's still possible to reintroduce old content -- it just takes a little more effort. Just enough to tip content generation in Tumblr's favor, rather than using it as a lifestream repository like Evernote or Friendfeed.

Still, it was fun to watch people throw some hearts at some old photos I uploaded, and I didn't mind the occasional reblog. And really, Tumblr's too good-looking to fill it with a bunch of text links to tweets (maybe someday we'll have something like Postano's yolink feature, to fetch images and content from those links, along with the tweet).

Twitter will always remain to go-to choice for conversations and conferences, and I think Blogger will still be my first option for sit-down-and-think kind of writing. But for now when I'm browsing and come across something interesting, I'm just going to try Tumbling first. And I'll be watching to see what new tools come online, as Tumblr grows to become the next great social network.

Remember how people said there was no real need for a device category between smartphones and laptops? And then Apple sold 40 million iPads?

That's kind of how I felt about Tumblr.

Blogs are obviously great for musings, essays, and a web presence, and Twitter's fine for thoughts and links and pics. Why have something else, in between?

I don't really have a good answer, just like I can't fully articulate why the iPad experience is so much better than a laptop or smartphone. But I'm starting to see the appeal of Tumblr.

Beyond the usual accolades from early adopters / influencers, something that stayed with me was a quote from Tumblr's founder: "No one is proud of their identity on Facebook."

Very true. And true of a Twitter page, as well. But Tumblr sites... can be something to be proud of. And they're effortlessly fast to set up. While I have strong sentimental attachment to this site, Blogger's recent attempts to make themselves slick feel like so much else Google does these days -- uninspired, clunkier copies.

I've been looking for a way to breathe new life into the 8+ years of writing here. Tumblr's "random" button and their vibrant archive views are a great start. When you consider how easy is is on Tumblr to tag old posts, and how elegantly you can display redirect pages for tagged posts (or photos, or music) and offsite material in the sidebar, well, I was sold.

Then, of course, I had some buyer's remorse. Tumblr is unapologetically different from other social networks. It took me a while to even realize that their "dashboard" is nothing like Blogger's, and in fact more like Facebook's news feed. And it's taking me some time to get comfortable with "reblogging" which almost seems like effortless plagiarism, if you're not conscientious about citations.

Tumblr's search function is completely broken. I have to believe they're working on a fix, but probably making a point of taking their time -- as if to say we're living in a post-Google age.

While I lamented Tumblr's decision to stop importing RSS feeds a few months back, I see the wisdom. I would have gone to town with importing thousands of tweets and countless photos, on top of all these blog posts. As it is, it's still possible to reintroduce old content -- it just takes a little more effort. Just enough to tip content generation in Tumblr's favor, rather than using it as a lifestream repository like Evernote or Friendfeed.

Still, it was fun to watch people throw some hearts at some old photos I uploaded, and I didn't mind the occasional reblog. And really, Tumblr's too good-looking to fill it with a bunch of text links to tweets (maybe someday we'll have something like Postano's yolink feature, to fetch images and content from those links, along with the tweet).

Twitter will always remain to go-to choice for conversations and conferences, and I think Blogger will still be my first option for sit-down-and-think kind of writing. But for now when I'm browsing and come across something interesting, I'm just going to try Tumbling first. And I'll be watching to see what new tools come online, as Tumblr grows to become the next great social network.

Medscape's EM editor asked Amal Mattu, Robert Glatter and me to discuss 2011's important papers in emergency medicine. I felt compelled to include an all-around terrible (but still important) paper, and a tidy nice decision-support paper for discharge prescriptions, among others. See what you think about my picks, as well as the great selections from Drs. Mattu and Glatter.

Medscape's EM editor asked Amal Mattu, Robert Glatter and me to discuss 2011's important papers in emergency medicine. I felt compelled to include an all-around terrible (but still important) paper, and a tidy nice decision-support paper for discharge prescriptions, among others. See what you think about my picks, as well as the great selections from Drs. Mattu and Glatter.

Medscape's EM editor asked Amal Mattu, Robert Glatter and me to discuss 2011's important papers in emergency medicine. I felt compelled to include an all-around terrible (but still important) paper, and a tidy nice decision-support paper for discharge prescriptions, among others. See what you think about my picks, as well as the great selections from Drs. Mattu and Glatter.

Music's pretty much done, right? It's fairly easy to hear any song you've ever liked, anywhere you happen to be. As a bonus, those songs can be stored, shared, tagged, rated, and linked to lyrics and album art.

Movies and TV... their delivery is not quite perfected, but the general outline seems apparent. Already I can watch the WKRP Turkey Drop episode in the kitchen on my iPad's Hulu app, and mirror it to my TV (via Apple's set top box) when I'm ready to sit on the couch. Other shows or films require more effort, though the combination of Netflix, iTunes, and for the remainder, torrents plus the Air Video server app, make it easy enough.

But reading? The written word, for whatever reason, still lags behind. While strides have been made, a simple and universal, Apple-like solution to the problem of reading, sharing and archiving remains elusive.


It seemed for a while that RSS was going to solve reading, but despite this, for a while, I resisted the call of RSS aggregators. I wanted to experience sites as the bloggers wanted them laid out -- if it was just uniformly presented text, I feared I'd lose some of the author's personality and voice. I had a hierarchy of bookmarks that I perused.

But I found, even with Grand Rounds, that I was missing out on new voices. Using bookmarks to visit older blogs that were sputtering out was frustrating. Messing with my bookmarks was not as simple as adding or rearranging RSS feeds. And so, at some point in 2006, I made the leap to Google Reader.

And for a while, things were great... I could efficiently consume the blogosphere, as never before. Until I came to regard catching up with RSS feeds as a chore.

So I muddled along, using a combination of bookmarks, Google Reader, and increasingly, Twitter feeds, to keep up with old friends and new sources. Good stuff I came across was starred, or retweeted, or bookmarked, or cut and pasted into Google Notebook Evernote for future reference. Or Instapaper'd. Or posted to Facebook. At one point set up FriendFeed to aggregate all my commenting activity, but it was no way to absorb new information.

Then the iPad came along, and with it, Flipboard, Pulse, and the Kindle app. Flipboard hooked into my Google Reader feed but never made catching up on blogs seem like work -- instead, it felt like I was browsing through a magazine that featured all my old blog friends and twitter buds. Flipboard also let me retweet, or post links to my Facebook page. Pulse is a little less slick than Flipboard, but they make it easier to plow through more content, add new feeds, and share or save material. Kindle's app is pretty great, and lets me take notes that can be shared publicly. It's a little work, though, to turn that public notes page into an RSS feed or Evernote folder. Currently, the Newsstand periodicals don't offer any sharing or notes archives, which has really limited my use of them (though they're still fun to read).

That the iPad should be a superior device for browsing and sharing RSS, books, Twitter and Facebook feeds is not surprising -- there's been surprisingly little demand to bring Flipboard and its like to the Desktop; Kindle has a desktop version that I've only used for novelty's sake.

I just wonder if Google knows what it's lost, by neglecting the Reader experience (which has only gotten worse lately)? I think so. Sources say they've got something in the works to compete, for tablet browsing. And many expect Google+ to come out with the APIs to make this kind of sharing and logging possible. Just not yet (and maybe too late).

In the meantime, I'm starting to make use of ifttt (if this then that), a simpler version of Yahoo Pipes that monitors feeds, tweets, and calendars and carries out pre-programmed actions for you -- so my starred Tweets are automatically sent to Evernote, for instance, or Facebook photos tagged with me are sent to Dropbox.

Ifttt makes Twitter and FB more useful, but it only makes clear how limited these social networks are for archiving, by themselves. It seems there ought to be a universal browsing / sharing / archiving app, for Tweets, Facebook wall posts, RSS, eBooks, and magazines, that looks as slick as Flipboard but has more capacity and flexibility. The fact that I can imagine this means it's too obvious for Apple to be working on (and probably not profitable enough, either). I worry that Google's solution may not adequately incorporate Twitter and FB (because if it did, why use Google+?) Maybe Amazon will surprise us again, or maybe Flipboard, Pulse, Evernote, Instapaper, or another startup will make it happen.

Until then? It's surprising but the simple, ancient act of reading has failed to adapt, technologically, to the extent that music and video have.

Music's pretty much done, right? It's fairly easy to hear any song you've ever liked, anywhere you happen to be. As a bonus, those songs can be stored, shared, tagged, rated, and linked to lyrics and album art.

Movies and TV... their delivery is not quite perfected, but the general outline seems apparent. Already I can watch the WKRP Turkey Drop episode in the kitchen on my iPad's Hulu app, and mirror it to my TV (via Apple's set top box) when I'm ready to sit on the couch. Other shows or films require more effort, though the combination of Netflix, iTunes, and for the remainder, torrents plus the Air Video server app, make it easy enough.

But reading? The written word, for whatever reason, still lags behind. While strides have been made, a simple and universal, Apple-like solution to the problem of reading, sharing and archiving remains elusive.


It seemed for a while that RSS was going to solve reading, but despite this, for a while, I resisted the call of RSS aggregators. I wanted to experience sites as the bloggers wanted them laid out -- if it was just uniformly presented text, I feared I'd lose some of the author's personality and voice. I had a hierarchy of bookmarks that I perused.

But I found, even with Grand Rounds, that I was missing out on new voices. Using bookmarks to visit older blogs that were sputtering out was frustrating. Messing with my bookmarks was not as simple as adding or rearranging RSS feeds. And so, at some point in 2006, I made the leap to Google Reader.

And for a while, things were great... I could efficiently consume the blogosphere, as never before. Until I came to regard catching up with RSS feeds as a chore.

So I muddled along, using a combination of bookmarks, Google Reader, and increasingly, Twitter feeds, to keep up with old friends and new sources. Good stuff I came across was starred, or retweeted, or bookmarked, or cut and pasted into Google Notebook Evernote for future reference. Or Instapaper'd. Or posted to Facebook. At one point set up FriendFeed to aggregate all my commenting activity, but it was no way to absorb new information.

Then the iPad came along, and with it, Flipboard, Pulse, and the Kindle app. Flipboard hooked into my Google Reader feed but never made catching up on blogs seem like work -- instead, it felt like I was browsing through a magazine that featured all my old blog friends and twitter buds. Flipboard also let me retweet, or post links to my Facebook page. Pulse is a little less slick than Flipboard, but they make it easier to plow through more content, add new feeds, and share or save material. Kindle's app is pretty great, and lets me take notes that can be shared publicly. It's a little work, though, to turn that public notes page into an RSS feed or Evernote folder. Currently, the Newsstand periodicals don't offer any sharing or notes archives, which has really limited my use of them (though they're still fun to read).

That the iPad should be a superior device for browsing and sharing RSS, books, Twitter and Facebook feeds is not surprising -- there's been surprisingly little demand to bring Flipboard and its like to the Desktop; Kindle has a desktop version that I've only used for novelty's sake.

I just wonder if Google knows what it's lost, by neglecting the Reader experience (which has only gotten worse lately)? I think so. Sources say they've got something in the works to compete, for tablet browsing. And many expect Google+ to come out with the APIs to make this kind of sharing and logging possible. Just not yet (and maybe too late).

In the meantime, I'm starting to make use of ifttt (if this then that), a simpler version of Yahoo Pipes that monitors feeds, tweets, and calendars and carries out pre-programmed actions for you -- so my starred Tweets are automatically sent to Evernote, for instance, or Facebook photos tagged with me are sent to Dropbox.

Ifttt makes Twitter and FB more useful, but it only makes clear how limited these social networks are for archiving, by themselves. It seems there ought to be a universal browsing / sharing / archiving app, for Tweets, Facebook wall posts, RSS, eBooks, and magazines, that looks as slick as Flipboard but has more capacity and flexibility. The fact that I can imagine this means it's too obvious for Apple to be working on (and probably not profitable enough, either). I worry that Google's solution may not adequately incorporate Twitter and FB (because if it did, why use Google+?) Maybe Amazon will surprise us again, or maybe Flipboard, Pulse, Evernote, Instapaper, or another startup will make it happen.

Until then? It's surprising but the simple, ancient act of reading has failed to adapt, technologically, to the extent that music and video have.

Music's pretty much done, right? It's fairly easy to hear any song you've ever liked, anywhere you happen to be. As a bonus, those songs can be stored, shared, tagged, rated, and linked to lyrics and album art.

Movies and TV... their delivery is not quite perfected, but the general outline seems apparent. Already I can watch the WKRP Turkey Drop episode in the kitchen on my iPad's Hulu app, and mirror it to my TV (via Apple's set top box) when I'm ready to sit on the couch. Other shows or films require more effort, though the combination of Netflix, iTunes, and for the remainder, torrents plus the Air Video server app, make it easy enough.

But reading? The written word, for whatever reason, still lags behind. While strides have been made, a simple and universal, Apple-like solution to the problem of reading, sharing and archiving remains elusive.


It seemed for a while that RSS was going to solve reading, but despite this, for a while, I resisted the call of RSS aggregators. I wanted to experience sites as the bloggers wanted them laid out -- if it was just uniformly presented text, I feared I'd lose some of the author's personality and voice. I had a hierarchy of bookmarks that I perused.

But I found, even with Grand Rounds, that I was missing out on new voices. Using bookmarks to visit older blogs that were sputtering out was frustrating. Messing with my bookmarks was not as simple as adding or rearranging RSS feeds. And so, at some point in 2006, I made the leap to Google Reader.

And for a while, things were great... I could efficiently consume the blogosphere, as never before. Until I came to regard catching up with RSS feeds as a chore.

So I muddled along, using a combination of bookmarks, Google Reader, and increasingly, Twitter feeds, to keep up with old friends and new sources. Good stuff I came across was starred, or retweeted, or bookmarked, or cut and pasted into Google Notebook Evernote for future reference. Or Instapaper'd. Or posted to Facebook. At one point set up FriendFeed to aggregate all my commenting activity, but it was no way to absorb new information.

Then the iPad came along, and with it, Flipboard, Pulse, and the Kindle app. Flipboard hooked into my Google Reader feed but never made catching up on blogs seem like work -- instead, it felt like I was browsing through a magazine that featured all my old blog friends and twitter buds. Flipboard also let me retweet, or post links to my Facebook page. Pulse is a little less slick than Flipboard, but they make it easier to plow through more content, add new feeds, and share or save material. Kindle's app is pretty great, and lets me take notes that can be shared publicly. It's a little work, though, to turn that public notes page into an RSS feed or Evernote folder. Currently, the Newsstand periodicals don't offer any sharing or notes archives, which has really limited my use of them (though they're still fun to read).

That the iPad should be a superior device for browsing and sharing RSS, books, Twitter and Facebook feeds is not surprising -- there's been surprisingly little demand to bring Flipboard and its like to the Desktop; Kindle has a desktop version that I've only used for novelty's sake.

I just wonder if Google knows what it's lost, by neglecting the Reader experience (which has only gotten worse lately)? I think so. Sources say they've got something in the works to compete, for tablet browsing. And many expect Google+ to come out with the APIs to make this kind of sharing and logging possible. Just not yet (and maybe too late).

In the meantime, I'm starting to make use of ifttt (if this then that), a simpler version of Yahoo Pipes that monitors feeds, tweets, and calendars and carries out pre-programmed actions for you -- so my starred Tweets are automatically sent to Evernote, for instance, or Facebook photos tagged with me are sent to Dropbox.

Ifttt makes Twitter and FB more useful, but it only makes clear how limited these social networks are for archiving, by themselves. It seems there ought to be a universal browsing / sharing / archiving app, for Tweets, Facebook wall posts, RSS, eBooks, and magazines, that looks as slick as Flipboard but has more capacity and flexibility. The fact that I can imagine this means it's too obvious for Apple to be working on (and probably not profitable enough, either). I worry that Google's solution may not adequately incorporate Twitter and FB (because if it did, why use Google+?) Maybe Amazon will surprise us again, or maybe Flipboard, Pulse, Evernote, Instapaper, or another startup will make it happen.

Until then? It's surprising but the simple, ancient act of reading has failed to adapt, technologically, to the extent that music and video have.

Longtime readers know my fondness of comparing the healthcare industry to the airline industry (based on similar goals of training, rituals of safety, and differing approaches to error, for starters).

Recently I've learned of a new intersection between medicine and aviation, when Delta chose to air ads to their captive cabin audience purchased by NVIC, the National Vaccine Information Center. The ads talk about staying healthy, maintaining good hygiene, and asking your doctor questions about the different flu shots available -- to stay informed and keep all the options open.

Sounds ... innocuous ... right?



Sure, the CDC recommends the influenza vaccine as the single best defense against influenza deaths, though additional hygiene measures can help. But what's the harm in asking questions of your doctor? Being informed?

Well, during the three-minute informercial, the NVIC website URL is shown. Their site is the opposite of information -- a mixture of pseudoscience and innuendo, laced with bromides about patriotism and personal freedom.


I recently flew Delta and didn't see (or recall seeing) this ad, though I do remember a loud car commercial right after takeoff, that I couldn't stop, or quiet. Inflight advertising is said to be unusually effective at prompting recall among passengers, well after landing. Since a fair number of people report some upper respiratory issues after flying, I've got to admit the NVIC initiative is well-planned.

But dangerous. In the words of AAP president, Dr. Robert Block:

The AAP and many other child health organizations have worked hard to protect children and their families from unfounded and unscientific misinformation regarding vaccine safety. The influenza vaccine is safe and effective. 

By providing advertising space to an organization like the NVIC, which opposes the nation's recommended childhood immunization schedule and promotes the unscientific practice of delaying or skipping vaccines altogether, you are putting the lives of children at risk, leaving them unprotected from vaccine-preventable diseases. Diseases like influenza can have serious consequences. From September 2010 to August 2011, 115 children died from influenza disease, most of whom were unvaccinated.

A petition is circulating to ask Delta to stop putting their passengers at risk. For their part, Delta has said that they'll change their ad purchasing policy, and the NVIC ads will only run until the end of the month. Wolfram Alpha suggests that, at about 200,000 passengers a day, that's another three million viewings of the informercial.

I rounded the daily passenger rates up slightly, for the Thanksgiving rush. Maybe, though, we could round it down -- #dontflydelta is trending on Twitter.

At the recent BWELA conference social health track, a bunch of us were talking about ways healthcare providers could affect positive change, in a media sphere where stories, novelty and fear usually trump statistics and uncontroversial, boring truth. This sounds like just the opportunity we were looking for -- pushing for a measurable outcome (Delta stopping the ads early), fighting pseudoscience with evidence-based recommendations, and using social networks for a decidedly anti-viral purpose.

Longtime readers know my fondness of comparing the healthcare industry to the airline industry (based on similar goals of training, rituals of safety, and differing approaches to error, for starters).

Recently I've learned of a new intersection between medicine and aviation, when Delta chose to air ads to their captive cabin audience purchased by NVIC, the National Vaccine Information Center. The ads talk about staying healthy, maintaining good hygiene, and asking your doctor questions about the different flu shots available -- to stay informed and keep all the options open.

Sounds ... innocuous ... right?



Sure, the CDC recommends the influenza vaccine as the single best defense against influenza deaths, though additional hygiene measures can help. But what's the harm in asking questions of your doctor? Being informed?

Well, during the three-minute informercial, the NVIC website URL is shown. Their site is the opposite of information -- a mixture of pseudoscience and innuendo, laced with bromides about patriotism and personal freedom.


I recently flew Delta and didn't see (or recall seeing) this ad, though I do remember a loud car commercial right after takeoff, that I couldn't stop, or quiet. Inflight advertising is said to be unusually effective at prompting recall among passengers, well after landing. Since a fair number of people report some upper respiratory issues after flying, I've got to admit the NVIC initiative is well-planned.

But dangerous. In the words of AAP president, Dr. Robert Block:

The AAP and many other child health organizations have worked hard to protect children and their families from unfounded and unscientific misinformation regarding vaccine safety. The influenza vaccine is safe and effective. 

By providing advertising space to an organization like the NVIC, which opposes the nation's recommended childhood immunization schedule and promotes the unscientific practice of delaying or skipping vaccines altogether, you are putting the lives of children at risk, leaving them unprotected from vaccine-preventable diseases. Diseases like influenza can have serious consequences. From September 2010 to August 2011, 115 children died from influenza disease, most of whom were unvaccinated.

A petition is circulating to ask Delta to stop putting their passengers at risk. For their part, Delta has said that they'll change their ad purchasing policy, and the NVIC ads will only run until the end of the month. Wolfram Alpha suggests that, at about 200,000 passengers a day, that's another three million viewings of the informercial.

I rounded the daily passenger rates up slightly, for the Thanksgiving rush. Maybe, though, we could round it down -- #dontflydelta is trending on Twitter.

At the recent BWELA conference social health track, a bunch of us were talking about ways healthcare providers could affect positive change, in a media sphere where stories, novelty and fear usually trump statistics and uncontroversial, boring truth. This sounds like just the opportunity we were looking for -- pushing for a measurable outcome (Delta stopping the ads early), fighting pseudoscience with evidence-based recommendations, and using social networks for a decidedly anti-viral purpose.

Longtime readers know my fondness of comparing the healthcare industry to the airline industry (based on similar goals of training, rituals of safety, and differing approaches to error, for starters).

Recently I've learned of a new intersection between medicine and aviation, when Delta chose to air ads to their captive cabin audience purchased by NVIC, the National Vaccine Information Center. The ads talk about staying healthy, maintaining good hygiene, and asking your doctor questions about the different flu shots available -- to stay informed and keep all the options open.

Sounds ... innocuous ... right?



Sure, the CDC recommends the influenza vaccine as the single best defense against influenza deaths, though additional hygiene measures can help. But what's the harm in asking questions of your doctor? Being informed?

Well, during the three-minute informercial, the NVIC website URL is shown. Their site is the opposite of information -- a mixture of pseudoscience and innuendo, laced with bromides about patriotism and personal freedom.


I recently flew Delta and didn't see (or recall seeing) this ad, though I do remember a loud car commercial right after takeoff, that I couldn't stop, or quiet. Inflight advertising is said to be unusually effective at prompting recall among passengers, well after landing. Since a fair number of people report some upper respiratory issues after flying, I've got to admit the NVIC initiative is well-planned.

But dangerous. In the words of AAP president, Dr. Robert Block:

The AAP and many other child health organizations have worked hard to protect children and their families from unfounded and unscientific misinformation regarding vaccine safety. The influenza vaccine is safe and effective. 

By providing advertising space to an organization like the NVIC, which opposes the nation's recommended childhood immunization schedule and promotes the unscientific practice of delaying or skipping vaccines altogether, you are putting the lives of children at risk, leaving them unprotected from vaccine-preventable diseases. Diseases like influenza can have serious consequences. From September 2010 to August 2011, 115 children died from influenza disease, most of whom were unvaccinated.

A petition is circulating to ask Delta to stop putting their passengers at risk. For their part, Delta has said that they'll change their ad purchasing policy, and the NVIC ads will only run until the end of the month. Wolfram Alpha suggests that, at about 200,000 passengers a day, that's another three million viewings of the informercial.

I rounded the daily passenger rates up slightly, for the Thanksgiving rush. Maybe, though, we could round it down -- #dontflydelta is trending on Twitter.

At the recent BWELA conference social health track, a bunch of us were talking about ways healthcare providers could affect positive change, in a media sphere where stories, novelty and fear usually trump statistics and uncontroversial, boring truth. This sounds like just the opportunity we were looking for -- pushing for a measurable outcome (Delta stopping the ads early), fighting pseudoscience with evidence-based recommendations, and using social networks for a decidedly anti-viral purpose.

Thanks to a tip from Brian Ahier, I've caught wind of excerpts from the IOM report on Health IT Safety a few days before its scheduled release.

iWatch has the scoop:

But the push [to adopt electronic health records] is occurring so far without any agency really 'watch dogging' the safety of health IT -- the software, hardware and systems that record and manage patients' health information. These expensive devices by and large have not gone through any regulatory checks for safety in the way that food, drugs and other medical technology must; most of that oversight is handled by the FDA. But at the moment, no one is required to report instances of harm caused by health information devices and no government agency currently monitors their safety. 

"With all of that money, marketing and public outreach, most simply affirm the value of health IT as an article of faith, rather than investigate it via careful evaluation," said Ross Koppel, adjunct professor of sociology at the University of Pennsylvania and its School of Medicine, and investigator for RAND Corporation. He is listed as one of the reviewers of the report.

I've read Ross Koppel's work, and seen him speak, and firmly believe he's a brilliant guy. But I disagree that we're accepting health IT's value on faith, because of marketing. We've seen IT transform the way we do business in every other sphere of American life, and many of us have experienced the benefits of easily retrieved patient records and clear, electronic communication between providers. As I've said before -- aside from a few train-wreck implementations, who would go back to paper records, if given the chance? Who would build a new hospital based on anything but an electronic system?

The IOM isn't saying paper's better, but they do recommend caution with, and further study of, health IT:

...In its report, the IOM committee says the FDA would likely restrict market innovation in health IT, which could also jeopardize patient safety. Stringent regulations "can negatively impact the development of new technology by limiting implementation choices and restricting manufacturers' flexibility to address complex issues," the report says. The FDA currently receives voluntary reports of health IT-related incidents, but has no resources or protocols through which to take action; the agency has long fought a losing battle with health IT vendors over trying to monitor the technology. 

The report also notes the agency does not have the investigative capabilities, funding or manpower to regulate devices such as electronic health records, personal health records or health information exchanges. 

...To adequately oversee health IT safety, the committee recommends that the secretary of health and human services create and fund a new independent watchdog agency, along the lines of the National Transportation Safety Board. Like NTSB, the new agency would conduct investigations and make recommendations for all stakeholders, including the secretary of the health and human services, vendors and health care organizations. Vendors of the technology would be required to report adverse events, while reporting would be voluntary for clinicians.  Like NTSB, though, the new agency would also have no enforcement power.   

I'm all for reporting safety issues, near-misses and other risks of health IT. I think the vendors have really done themselves a disservice here by insisting on gag rules among their hospital clients -- doctors would be in violation of their contracts if they posted a screenshot of their EHR software online, let alone spoke publicly about some clunky or possibly dangerous glitches.

And I kind of like the idea of an NTSB-like agency, swooping in after a prescription error or lost bed assignment. Certainly, that model seems preferable to an FDA oversight, which might require extensive pre-implementation testing (beyond the current certification process) and I think would tend to slow down the pace of innovation and lock-in the clunky, slow interfaces doctors have come to expect from EHR.

But I have to ask: what country, what era, has the IOM been living in? Because expecting the creation of a new regulatory agency in the US in 2011, with an obstructionist Congress that's breaking filibuster records just to spite the administration, is a pipe dream.

And if no new regulatory agency is forthcoming, where does that leave the federal incentives for adoption and meaningful use of electronic health records? Already, the effort is stalled and seems likely be dragged out over an additional period. Now critics of MU will point to this phantom Health IT safety board, which ought to exist but probably won't, as a further excuse to delay, delay, delay. The status quo is cheaper. It's familiar. And so we'll keep handwriting notes and shooting paper orders through pneumatic tubes, in the name of patient safety.

The iWatch kicker:

In its report, the IOM panel also recommended that more studies be conducted to quantify health IT-related deaths, serious injuries or unsafe conditions so that the safety concerns can be properly addressed. "You can only improve what you measure," says the report.  

So true! And what we have in place now, across the majority of US hospitals, is patient care managed with clipboards and three-ring binders, full of handwritten notes and orders. Can those be measured in a systematic way (you know, for the sake of improvement)? Of course not.

It seems like health IT is a victim of its own capabilities. Because technology lets us measure and record how we practice, it is scrutinized to a far greater extent than the antiquated system it aims to replace. Because we can't begin to calculate how dangerous the status quo paper-and-clipboard system is, we'll end up keeping it, longer than any other US industry.

Thanks to a tip from Brian Ahier, I've caught wind of excerpts from the IOM report on Health IT Safety a few days before its scheduled release.

iWatch has the scoop:

But the push [to adopt electronic health records] is occurring so far without any agency really 'watch dogging' the safety of health IT -- the software, hardware and systems that record and manage patients' health information. These expensive devices by and large have not gone through any regulatory checks for safety in the way that food, drugs and other medical technology must; most of that oversight is handled by the FDA. But at the moment, no one is required to report instances of harm caused by health information devices and no government agency currently monitors their safety. 

"With all of that money, marketing and public outreach, most simply affirm the value of health IT as an article of faith, rather than investigate it via careful evaluation," said Ross Koppel, adjunct professor of sociology at the University of Pennsylvania and its School of Medicine, and investigator for RAND Corporation. He is listed as one of the reviewers of the report.

I've read Ross Koppel's work, and seen him speak, and firmly believe he's a brilliant guy. But I disagree that we're accepting health IT's value on faith, because of marketing. We've seen IT transform the way we do business in every other sphere of American life, and many of us have experienced the benefits of easily retrieved patient records and clear, electronic communication between providers. As I've said before -- aside from a few train-wreck implementations, who would go back to paper records, if given the chance? Who would build a new hospital based on anything but an electronic system?

The IOM isn't saying paper's better, but they do recommend caution with, and further study of, health IT:

...In its report, the IOM committee says the FDA would likely restrict market innovation in health IT, which could also jeopardize patient safety. Stringent regulations "can negatively impact the development of new technology by limiting implementation choices and restricting manufacturers' flexibility to address complex issues," the report says. The FDA currently receives voluntary reports of health IT-related incidents, but has no resources or protocols through which to take action; the agency has long fought a losing battle with health IT vendors over trying to monitor the technology. 

The report also notes the agency does not have the investigative capabilities, funding or manpower to regulate devices such as electronic health records, personal health records or health information exchanges. 

...To adequately oversee health IT safety, the committee recommends that the secretary of health and human services create and fund a new independent watchdog agency, along the lines of the National Transportation Safety Board. Like NTSB, the new agency would conduct investigations and make recommendations for all stakeholders, including the secretary of the health and human services, vendors and health care organizations. Vendors of the technology would be required to report adverse events, while reporting would be voluntary for clinicians.  Like NTSB, though, the new agency would also have no enforcement power.   

I'm all for reporting safety issues, near-misses and other risks of health IT. I think the vendors have really done themselves a disservice here by insisting on gag rules among their hospital clients -- doctors would be in violation of their contracts if they posted a screenshot of their EHR software online, let alone spoke publicly about some clunky or possibly dangerous glitches.

And I kind of like the idea of an NTSB-like agency, swooping in after a prescription error or lost bed assignment. Certainly, that model seems preferable to an FDA oversight, which might require extensive pre-implementation testing (beyond the current certification process) and I think would tend to slow down the pace of innovation and lock-in the clunky, slow interfaces doctors have come to expect from EHR.

But I have to ask: what country, what era, has the IOM been living in? Because expecting the creation of a new regulatory agency in the US in 2011, with an obstructionist Congress that's breaking filibuster records just to spite the administration, is a pipe dream.

And if no new regulatory agency is forthcoming, where does that leave the federal incentives for adoption and meaningful use of electronic health records? Already, the effort is stalled and seems likely be dragged out over an additional period. Now critics of MU will point to this phantom Health IT safety board, which ought to exist but probably won't, as a further excuse to delay, delay, delay. The status quo is cheaper. It's familiar. And so we'll keep handwriting notes and shooting paper orders through pneumatic tubes, in the name of patient safety.

The iWatch kicker:

In its report, the IOM panel also recommended that more studies be conducted to quantify health IT-related deaths, serious injuries or unsafe conditions so that the safety concerns can be properly addressed. "You can only improve what you measure," says the report.  

So true! And what we have in place now, across the majority of US hospitals, is patient care managed with clipboards and three-ring binders, full of handwritten notes and orders. Can those be measured in a systematic way (you know, for the sake of improvement)? Of course not.

It seems like health IT is a victim of its own capabilities. Because technology lets us measure and record how we practice, it is scrutinized to a far greater extent than the antiquated system it aims to replace. Because we can't begin to calculate how dangerous the status quo paper-and-clipboard system is, we'll end up keeping it, longer than any other US industry.

Thanks to a tip from Brian Ahier, I've caught wind of excerpts from the IOM report on Health IT Safety a few days before its scheduled release.

iWatch has the scoop:

But the push [to adopt electronic health records] is occurring so far without any agency really 'watch dogging' the safety of health IT -- the software, hardware and systems that record and manage patients' health information. These expensive devices by and large have not gone through any regulatory checks for safety in the way that food, drugs and other medical technology must; most of that oversight is handled by the FDA. But at the moment, no one is required to report instances of harm caused by health information devices and no government agency currently monitors their safety. 

"With all of that money, marketing and public outreach, most simply affirm the value of health IT as an article of faith, rather than investigate it via careful evaluation," said Ross Koppel, adjunct professor of sociology at the University of Pennsylvania and its School of Medicine, and investigator for RAND Corporation. He is listed as one of the reviewers of the report.

I've read Ross Koppel's work, and seen him speak, and firmly believe he's a brilliant guy. But I disagree that we're accepting health IT's value on faith, because of marketing. We've seen IT transform the way we do business in every other sphere of American life, and many of us have experienced the benefits of easily retrieved patient records and clear, electronic communication between providers. As I've said before -- aside from a few train-wreck implementations, who would go back to paper records, if given the chance? Who would build a new hospital based on anything but an electronic system?

The IOM isn't saying paper's better, but they do recommend caution with, and further study of, health IT:

...In its report, the IOM committee says the FDA would likely restrict market innovation in health IT, which could also jeopardize patient safety. Stringent regulations "can negatively impact the development of new technology by limiting implementation choices and restricting manufacturers' flexibility to address complex issues," the report says. The FDA currently receives voluntary reports of health IT-related incidents, but has no resources or protocols through which to take action; the agency has long fought a losing battle with health IT vendors over trying to monitor the technology. 

The report also notes the agency does not have the investigative capabilities, funding or manpower to regulate devices such as electronic health records, personal health records or health information exchanges. 

...To adequately oversee health IT safety, the committee recommends that the secretary of health and human services create and fund a new independent watchdog agency, along the lines of the National Transportation Safety Board. Like NTSB, the new agency would conduct investigations and make recommendations for all stakeholders, including the secretary of the health and human services, vendors and health care organizations. Vendors of the technology would be required to report adverse events, while reporting would be voluntary for clinicians.  Like NTSB, though, the new agency would also have no enforcement power.   

I'm all for reporting safety issues, near-misses and other risks of health IT. I think the vendors have really done themselves a disservice here by insisting on gag rules among their hospital clients -- doctors would be in violation of their contracts if they posted a screenshot of their EHR software online, let alone spoke publicly about some clunky or possibly dangerous glitches.

And I kind of like the idea of an NTSB-like agency, swooping in after a prescription error or lost bed assignment. Certainly, that model seems preferable to an FDA oversight, which might require extensive pre-implementation testing (beyond the current certification process) and I think would tend to slow down the pace of innovation and lock-in the clunky, slow interfaces doctors have come to expect from EHR.

But I have to ask: what country, what era, has the IOM been living in? Because expecting the creation of a new regulatory agency in the US in 2011, with an obstructionist Congress that's breaking filibuster records just to spite the administration, is a pipe dream.

And if no new regulatory agency is forthcoming, where does that leave the federal incentives for adoption and meaningful use of electronic health records? Already, the effort is stalled and seems likely be dragged out over an additional period. Now critics of MU will point to this phantom Health IT safety board, which ought to exist but probably won't, as a further excuse to delay, delay, delay. The status quo is cheaper. It's familiar. And so we'll keep handwriting notes and shooting paper orders through pneumatic tubes, in the name of patient safety.

The iWatch kicker:

In its report, the IOM panel also recommended that more studies be conducted to quantify health IT-related deaths, serious injuries or unsafe conditions so that the safety concerns can be properly addressed. "You can only improve what you measure," says the report.  

So true! And what we have in place now, across the majority of US hospitals, is patient care managed with clipboards and three-ring binders, full of handwritten notes and orders. Can those be measured in a systematic way (you know, for the sake of improvement)? Of course not.

It seems like health IT is a victim of its own capabilities. Because technology lets us measure and record how we practice, it is scrutinized to a far greater extent than the antiquated system it aims to replace. Because we can't begin to calculate how dangerous the status quo paper-and-clipboard system is, we'll end up keeping it, longer than any other US industry.

I've started to think the medical record is akin to DNA. Maybe 10% (or less) is useful information; the rest is junk. When folks want to find a sequence of significance, risk or reassurance, they've got to search for the good stuff and filter out all the garbage.

But junk DNA is believed to have a purpose. Some regions of junk DNA are highly conserved -- found in organism after organism -- suggesting an important function. In medical charts, conserved regions are also repeated. And they also serve an important function.

It's this repetition that Dr. Bryan Vartabedian called "Cut and Paste medicine" in his excellent recent post. He's concerned that all these computer-generated phrases of historical elements, exam findings and decision-making makes all patients look alike, and hurts continuity of care, as it becomes harder to discern what's actually going with the patient.

It's a reasonable concern. This problem, created by documentation regulations, compounded by declining reimbursements, and exacerbated by quick-fix features of some electronic records, can be solved through technology, too. Just as researchers and geneticists built tools to sift through DNA, to find the small section they're looking for, we need to easily search through records to show the details of patient care relevant to us.


Maybe this solution will simply highlight free-text sentences and paragraphs, and gray-out all the checkbox-generated prose. Maybe these searches will involve natural-language processing, or complex filters based on provider or position. I'm hopeful this problem will be solved, because medical records aren't getting shorter.

And here's where my analogy with DNA breaks down: junk DNA is also called "noncoding regions" because those sequences don't code for proteins. But in the medical chart, those junk sections are actually designed for coders -- they have key phrases that medical billing companies look for, to show to the insurance companies, to pay us. You could be providing the most competent, compassionate, time-consuming care in the world, but if those phrases aren't in the chart, nobody gets reimbursed. Other instances of these oft-repeated, computer-generated phrases in medical charts are designed to protect against legal liability, which also serves the financial interest of providers and healthcare institutions. 

The good stuff, the free-text prose that describes what the doctor is thinking, may only be a short paragraph in a sea of vital signs and lab results and macros and checkbox-generated text. While this section is the most important part of the chart to future caregivers, from a medical billing perspective, it's essentially a noncoding region.

There was a time when medical charts were short and designed soley to communicate patient care to  future providers. Medpundit once wrote of a mentor who could boil down an encounter to two terms, like "ROM - Amox" (right otitis media, given amoxicillin). Years later, a similarly simple encounter would have to run for 10 or 20 lines of prose.

By 2008, Peter Viccellio wrote:

When an ED visit for a cough, with diagnosis of pneumonia, consumes 17 pages of print, something has gone awry. (Or perhaps things went awry when pulmonary edema was no longer considered an emergency unless there was a documented family history, social history, and 10 reviews of systems.)

True. Things have gone awry. But I can't see any way back. So tell me: why should the medical chart ever printed, in a hospital? (Besides the increasingly rare scenario where a patient moves from an electronic part of the hospital to a paper-chart area). And if the chart's not printed, well, why should anyone on the care team have to scroll through 17 screens' worth of prose? Caregivers should see the parts of the chart really relevant to patient care.

Let's recognize the vast majority of the chart for what it is: coding regions that keep the hospital or the practice afloat, and comparatively safe from prosecution. These sections are not really important for patient care, and they're the last thing I want to see when I pull up a chart about a prior visit. Recognizing that, and building EHR search and display functions around that, and you'll solve a good deal of the frustration around electronic records and their cut-and-paste confusion.

The biggest reason we haven't done this already, I think, is pride. It's too painful to admit that most of what we're doing on the computer is not directly relevant to patient care. Let's get past that, recognize the checkboxes and macros serve a primarily financial function, and give those sections the low status they deserve when we run our searches and pull up our charts.