Next-generation decision support technology is designed to match the way a physician thinks about signs, symptoms, and diagnoses, facilitating rapid diff erential diagnosis generation.

 and economic impact attributable to medical errors and high rates of misdiagnosis have eroded the public’s trust in the healthcare system. Some studies have found that up to 20% of medical diagnoses are incorrect. This can be attributed to several factors, including the nature of medical school training, fi nancially driven time pressures on doctors, a fragmented healthcare delivery system, and ever-increasing quantities of medical data. Th ere is simply too much to know and certainly too much for any primary care doctor to possibly memorize. Given this, why is diagnostic decision support technology so rarely used? Despite all the hand wringing about improving quality of care, this technology is often discussed but rarely implemented. Physicians cite complexity, cost, workfl ow diffi culties, and outright skepticism that clinical decision support works.  

What can change this? This may seem simplistic, but current clinical decision support technologies are missing one element that counters all of these claims: pictures. Visual diagnostic decision support technology addresses the non-analytical, instantaneous perceptual moment that occurs when the doctor examines the patient, which can help improve the diagnostic process tremendously, considering that many diseases have a skin or pattern clue, and a signifi cant percentage of a general practitioner’s diagnosis is visually based.

Medical errors due to physician orders and drug reactions grab headlines, but the more serious and underlying concern is misdiagnosis. The lack of attention accorded to diagnostic errors is due to the systemic and cultural complexities of reporting and collecting data on them. Yet, diagnostic error often initiates a cascade of subsequent errors—failure to use an indicated diagnostic test, misinterpretation of test results, failure to act on abnormal results, and incorrect treatment.  Physicians are taught a highly structured cognitive method in medical school, and they habituate this methodology throughout their training and subsequent practice. Medical education stresses memorization of basic science and clinical facts; this means that students must focus on prototypical “classic cases” rather than learn all the variants. As the medical student moves from the classroom to residency, training shifts to “practice-based” learning from unique clinic or hospital patient cases.

These residents soon realize that most patients do not neatly present as the textbook suggests. Th us, the life-long learning of the physician begins. Expertise evolves from interaction with thousands of patients, learning from the twists and turns of each individual case, synthesizing and remembering the vast array of symptom and examination patterns over a career. Our patients hope we have this expertise and assume if we are early in our careers that we have developed a methodology to think about, recognize, and diagnose their problem regardless of how much experience we actually have. Yet, a great number of patients will appear in our offices with patterns we have never seen in practice or read about in texts. Practitioners of family, internal, pediatric, or emergency medicine are expected to recognize patterns and make diagnoses that span all of the medical specialties. The frequent variants of common and rare diagnoses might be diffi cult for these non-specialty physicians

to recognize, even after 20 years of practice.

Many physicians readily admit they are insuffi ciently trained to recognize visual and skin or pattern-recognition-based clues that can assist in making a diagnosis. Th is challenge is compounded every day in fast-paced clinics, emergency rooms, and hospitals, where generalists are forced to make quick decisions, often with incomplete data and a dearth of experience in evaluating the subtleties of disease characteristics.

Building better efficacy: The value of visuals

Diagnostic decision support systems, though rarely used, allow physicians to enter a patient’s symptoms, lab results, and other data to build a textbased collection of diagnostic possibilities. However, current diagnostic systems limit the dynamic nature of medical diagnosis and do not allow for the incorporation of perceptual and visual data into clinical thinking.  Many physicians fi nd it diffi cult to describe the visual clues and patterns they observe, and extensive text on a page or screen makes it diffi cult to recognize patterns of disease.

There is a great need in medicine for a better visual approach to pattern recognition. The visual diagnostic decision support system (VDDSS) meets this need because it was designed to match the way a physician thinks about signs, symptoms, and diagnoses. It allows rapid visual and iconic search and entry of visual patient clues and presents multiple images and graphics of each disease alternative, demonstrating how each might look at different stages and in people of diff erent ages and ethnicities.

The difference between perception and cognition is a key differentiator between VDDSS and non-visual diagnostic decision support systems. In contrast to prior efforts in diagnostic decision support, the database interface and information management strategy used with VDDSS facilitate rapid comparisons and visual diff erential diagnosis generation. Many internal diseases present with visual clues that can be used as a leveraging tool when making a diagnosis. These objective clues and signs of internal disease often go unrecognized and uninterpreted by primary care clinicians, resulting in delayed diagnosis and reduced quality of care.  VDDSS uses search technology that requires data entry of patient symptoms, complaints, and other factors, providing a way to both narrow the scope of search results and simultaneously sort through a multitude of images to show not just the most common visual, but an image that is closest to the morphology entered by the user.

Combined with a purposefully designed visual display, image variants can be displayed to assist the user in recognition. While the human brain has remarkable innate abilities to pattern-match between like images, databases can more easily catalog variation. Until now, our human-computer interfaces in medicine have not been optimized to facilitate simultaneous pattern matching and differential diagnosis generation. By entering and selecting a patient’s findings as a combination of text and

images, clinicians can build a customized pictorial differential diagnosis in seconds, drawn from thousands of medical photographs and revealing the variation in presentation between—as well as within&mdash;diseases.

VDDSS solutions bring decision support to new levels of efficacy. The unusual variants of the common, as well as the rare, diagnoses are often difficult for the non-specialist to recognize because of broad training necessarily focused on prototypical “classic cases” across a wide area of medicine. Information tools that allow physicians to enter patient factors and perceptual and visual data provide powerful benefits for achieving more in-depth knowledge and diagnostic acuity. Visuals and data allow diagnosticians the best of both worlds: a superior technological synthesis of complex data along with the physician’s clinical

Art Papier, MD, is a practicing dermatologist, associate professor in Dermatology and Medical Informatics at the University of Rochester School of Medicine and Dentistry, and Chief Medical Officer and co-founder of Logical Images, a visual diagnostic decision support company in Rochester, NY. For more information, please visit 

Articles

Feature Articles

TechSectors: Diagnostics - A Picture Says a Thousand Words

Economic forces have caused the primary setting for disease management to shift from the inpatient to the ambulatory setting, where biomedical advances have allowed diagnostic procedures and therapeutics to take place in lower-cost clinic settings rather than inside hospitals. However, the bulk of clinical training still occurs in the hospital, where students are exposed to diseases that are not reflective of illnesses in the general population. Pressures to shorten hospital stays have resulted in lost opportunities to interact with and learn from patients. Another result of this shift is that medical students, novices in the healthcare team, become marginalized rather than engaged in the clinical decision-making process.

Computer-based technology, although not a panacea, can enhance medical education by broadening the spectrum of clinical experiences and content to which learners may be exposed. In addition, delivery via the Internet (characteristic of many of these programs) provides and organizes information at learners’ fingertips, when it is most needed. Computer-based instruction (CBI), in which education is central to the program, should be distinguished from general computer-based resources, such as

For medical students in their early years of training, websites focusing on the physical exam are most popular. Whether featuring lung sounds or displaying videos of the musculoskeletal exam performed by experts, these sites provide immediate and practical benefits to medical students as they learn to distinguish between normal and abnormal findings. Additionally, sophisticated graphical representation combined with animation creates a visualization paradigm that static diagrams in textbooks cannot match.

 is a notable example of this technology. It features a multi-layered presentation of the heart; moving the mouse over component labels causes the layers to appear and disappear dynamically, so that the user recognizes the complex relationship between the musculature, vascular, and bony structures of the chest. Another section traces the path of blood through various chambers of the heart, while synchronizing the heart sounds with valve closures, pressure waveforms in the diff erent heart chambers, and the EKG tracing. Medical students often learn these components separately without understanding how they interrelate. Incorporating dynamic new technologies into the instructional process will help learners to synthesize the concepts, likely leading to better retention and advanced application of information.

, created at the University of California Davis School of Medicine. This tool allows medical students to create muscular and cranial nerve palsies and observe their effects on eye movements. Although students may rarely encounter a real patient with abnormal eye movements, it is critical that they learn

the skill of correlating findings with their neurological basis.

Physical exam applications like the ones mentioned focus on the early years of medical school training; case-centered tools help instruct medical students during their clinical years. In particular, “virtual patients” were designed to fill gaps in clerkships by exposing students to diseases that they would not otherwise experience due to short clinical rotations and limited ambulatory experiences. 

 are defined as “computer programs that simulate real-life clinical scenarios in which the learner acts as a health care professional obtaining a history and physical exam and making diagnostic and therapeutic decisions.”

An example of a virtual patient from Harvard Medical School simulates the longitudinal care of a diabetic patient over the course of nine “virtual” years, condensing the case into several hours as it moves from diagnosis to the treatment of comorbidities, to the development of microvascular complications, and the initiation of insulin. Virtual patients can be used to expose learners to rare, “do-not-miss” events, such as ruptured aortic aneurysm, that might not occur during a three-month clerkship or even a three-year residency. They may permit a window into procedures such as a cardiac catheterization or initiate conversations in which trainees may not normally participate, such as a primary care physician giving bad news to a patient.

As the technology grows more sophisticated, so do the tools available for training our future health professionals. One of the most advanced applications of technology for medical education stems from work done at Stanford University School of Medicine in collaboration with 

., a software company. Developers have created a three-dimensional reproduction

of a physical treatment setting, in which participants may role play as nurses, physicians, emergency personnel, and patients by manipulating and communicating through avatar representations, much like the social networks formed on 

. A variety of scenarios and situations can be simulated; in one, participants must work as a team to triage and provide appropriate medical care for victims of a dirty bomb explosion. One advantage offered by the online format is that participants neither have to congregate in person to practice team training, nor are they limited by physical space to rehearse various medical scenarios.

The value of CBI arises from the rationale for simulation in general—the ability to practice skills of diagnosis and management without causing harm. Students experience the consequences of bad decision making in a memorable fashion but without exposing patients to injury. These programs also mitigate the negative effect of time and clinical opportunity on learning; students currently learn only what they happen to encounter and may never experience rare but important entities like anaphylactic shock. Virtual patients in particular offer the ability to manipulate time to enhance learning&mdash;for instance, speeding it up so you see the late complications of diabetes or slowing it down so the student can think about an abnormal EKG and go through the various steps of interpretation.

There are, of course, limitations to CBI. It is only meant to be a complement to the primary role of real patients for medical education. Communication skills, for instance, may not be as easily taught because the technology may not portray the interactions realistically, and in such cases, may need to rely on trained patient actors or on mannequin simulators. Additionally, computers cannot replace the role of the physician as mentor and role model.

The technology has advanced faster than researchers’ abilities to evaluate it. Studies in other domains, such as cognitive psychology and secondary education, show benefit from CBI compared to traditional methods of learning, but current studies in medical education are limited in subject size and generalizability. However, one of the most compelling anecdotal endorsements of CBI came from a French-Arab patient who viewed a video tutorial of the pelvic exam (go to 

 and click on “Pelvic Exam”) and relayed how much the videos had dispelled her fears before her first pelvic exam. It is a stark reminder that the focus of medical education must ultimately translate into benefi ts in patient care.

The future will bring further research and understanding about which applications of CBI are benefi cial and which are not. We will continue to see more hybrids between haptic touch devices (technology that uses vibrations, motion, and other forces to interface with the user via the sense of touch) and screen-based technologies, the spread of virtual reality applications, and enhanced artifi cial intelligence for communication and other interpersonal skills. Medical education will rely more on situated learning; that is, education will be at the point-of-care in response to immediate needs for information. Bounded only by human creativity and driven by the perpetual need for safe and eff ective medical training, the potential benefit of technology in training our future physicians seems limitless.

Grace Huang, MD, is the Director of Assessment at the Carl J. Shapiro Institute for Education and Research at Harvard Medical School (HMS) and Beth Israel Deaconess Medical Center (BIDMC). She is an assistant professor of Medicine at HMS and a hospitalist at BIDMC. She designs computer-based modules focusing on clinical skills, including physical diagnosis tutorials, interactive diagrams, and procedure-based instruction. She is also an expert on the use of virtual patients and computer-based simulations of clinical scenarios.

Innovative technology applications can be used to enhance the educational process and better prepare physicians to meet the challenges of daily practice.

Computer-based Instruction for Making Better Doctors

Health literacy requires more than just knowing how to read. It involves 

, including listening, analyzing, and decisionmaking. Patients are called on to demonstrate health literacy skills in a variety of situations when interacting with the healthcare system, including deciphering appointment slips; comprehending written and verbal instructions for prescription and OTC medications and supplements; understanding information in health brochures and other instructional and educational materials; comprehending and acting on instructions from healthcare professionals; filling out consent forms; and maneuvering through the often-complex modern healthcare system.

Literacy problems are not rare, nor are they trivial. The 

2003 National Assessment of Adult Literacy

 found that 43% of adults read at basic or below basic levels, which can translate into poor health outcomes. The 

Agency for Healthcare Research and Quality

 (AHRQ) found that for a number of health and healthcare topics, patients with low literacy had a worse prognosis than those with 

. Populations with sizeable percentages of people who have poor health literacy include the elderly, minorities, immigrants, low-income groups, and people with chronic mental and/ or physical health problems. 

 include lack of higher education, learning disability, cognitive decline among the elderly, and lack of regular reading resulting in diminishing ability over time.

It can be challenging to identify people with low health literacy, as these individuals will not necessarily volunteer their limitations.  Th ey often can be ashamed of their limitations and are very protective of them. Th ere is no particular “look” for someone with low health literacy; these individuals can be well-groomed, articulate, and appear quite intelligent (http:// caonline.amcancersoc.org/cgi/content/ abstract/52/3/134).

Formal tests of health literacy include the 

Rapid Estimate of Adult Literacy in Medicine

Test of Functional Health Literacy in Adults

 (TOFHLA). However, these are not one-size-fi ts-all tools—the lead author of the article on the REALM test only recommends using these formal instruments in clinical practice if the physician is willing to take the time to tailor the communication to the particular patient to be assessed with the formal test.

Physicians and other healthcare professionals must always be on the alert for patients with low health literacy. Beyond merely assuming that patients who are of older age or have limited formal education are at risk, there are several signs that may indicate a patient has low health literacy: claiming they forgot their glasses and therefore cannot read brochures or other print pieces received from your staff , always bringing family members with them to explain instructions and other information, and failing to properly or accurately complete patient intake forms or research surveys.

INTERNET-BASED COMMUNICATION With so many patients relying on the Internet as their main source of healthcare information, the diffi culty of the language used to present medical information can pose a major challenge. 

 found that 100% of the English-language websites evaluated off ered health information at the ninth-grade reading level or higher. Even the language used by physicians in written and oral communications with their patients may be confusing or unfamiliar. 

 offer a number of practical suggestions for clinicians to promote effective communication with patients.

When you are recommending websites to patients or printing pages from websites to distribute to patients, consider whether they are written for people with low health literacy. If you are not aware of specifi c websites that meet this criterion, then recommend those with lower grade reading levels. The typical website is often written at a 

National Work Group on Cancer and Literacy

 recommends that essential written communication for patients should be written at a fifth-grade reading level or lower.

How can you determine if a particular webpage is written at a lower grade reading level? One way is to copy and paste the text into Microsoft Word and calculate the 

. To do this, click “Tools” and select “Options” from the drop-down list (a), click the “Spelling and Grammar” tab (b), and then click the “Show Readability Statistics” checkbox ©.  Then click “Tools” again and select “Spelling and Grammar” from the drop-down menu (d). Word will highlight all spelling and grammar mistakes, off ering you the chance to correct or ignore them, and then display the readability statistics, including the Flesch-Kincaid grade level (e).

 recognizes every occurrence of a period as a sentence. Thus it will count abbreviations such as “Dr.,” numerical expressions with decimal points, and bulleted lists as very short sentences, which may lower the reading grade level. If necessary, edit those parts from the document to allow for a more accurate readability estimate.  When creating a page on a practice website, consider the grade level of the information and other content you plan to include.

 have been shown to be effective means of communicating with patients with low literacy levels. Research has also shown that 

 increases comprehension among patients with low health literacy.

Some physicians embrace e-mail as a way to communicate with their patients. It may be helpful to determine the two or three 

 of clinical importance you wish to convey and include only those in e-mails to patients; anything more than that may be too much content and potentially overwhelm patients with poor health literacy skills. It is also important to use 

, or “living room” language, when possible. Keep in mind that the patient may not be the one opening and reading the e-mail—a friend, family member, or caregiver may be opening and printing the content for the patient to read at a later time.

In addition to the e-mail recommendations, there are several 

 you can employ to promote understanding if you are communicating with your patient via instant message. Avoid asking, “Do you understand?” as many patients will respond “yes” regardless of whether they truly understand. Instead, use a “teach back” approach, in which you ask patients to state in their own words the information and instructions you have communicated to them.

Poor reading comprehension and defi ciencies in other health literacy skills are common and often diffi cult to detect in patients.  Failure to accommodate the needs of patients with low health literacy can result in poor communication, leading patients to misunderstand or ignore your instructions to the detriment of their health. By following the suggestions outlined above, you can help your patients understand and retain the information they need to make better decisions and experience better outcomes.

Dr. Fogel is an Oncology Net Guide editorial board member and an assistant professor in the department of economics at Brooklyn College of the City University of New York. He can be reached at 

Health literacy requires more than just knowing how to read. It involves a number of additional skills, including listening, analyzing, and decisionmaking. 

What Did You Just Say?: Health Literacy in the Information Age

Does the word “free” grab your attention? It sure gets mine. In the universe of computing, free software has always been fairly commonplace. There are many reasons for this, starting with the fact that software doesn’t cost much to produce, except for intellectual eff ort, which some people choose to give away for free. While some programmers and vendors are motivated by altruism, others simply want to show off their programming skills, and others ultimately want to sell you a product. Whatever the reason vendors have for giving it away, you can benefi t from downloading and using freeware and shareware.

reeware is software that is available for use at no cost.  Freeware is usually made available in a proprietary form that cannot be modifi ed, copied, or redistributed to somebody else. You can find freeware programs for virtually every computer platform, including Windows, Mac, UNIX, and DOS. Common examples of freeware include games, graphics (such as fonts and screensavers), offi ce productivity tools, and systems utilities.

Another form of “free” software is known as shareware. This “try-before-you-buy” software is a marketing method that allows the user to try out the software free of charge before purchasing it. Sometimes the trial version is the full version of the software; other times it off ers only a few of the product’s features.  Google the word “freeware,” and you will retrieve many sites that offer a wide variety of programs for download. These sites generally allow users to review and comment on the software, so you can see what’s popular and highly rated by peers. To protect your data, make sure to stick with legitimate sites that are secure and free of viruses and spyware. 

 is well organized and has a nice, clean interface.

 is an excellent example of a new form of freeware: the Web 2.0 application that exists only online. Intended to compete with the Microsoft Office suite, these free programs let you create and save documents, spreadsheets, and presentations online. I briefl y tested the word processing program and found it adequate for most basic writing tasks. It is missing a few high-end features, such as automatic spellchecking and an unlimited number of fonts, but it should cover most users’ needs. It even lets you insert tables and comments. The stripped-down presentation program is also basic but is a great alternative to purchasing Microsoft PowerPoint if you create just one or two presentations per year.

Th ere are many freeware programs specifi cally written for medical professionals. 

, for example, offers a free mobile drug and formulary reference. Two good sites for fi nding medically relevant freeware programs are 

. You can even find free versions of fairly sophisticated software, such as 

. It is a free, open source replacement for medical applications like Medical Manager, Health Pro, and Misys. One caveat: if knowing how to sync your PDA is basically the extent of your technical know-how, then this Linux program probably isn’t for you.  As I mentioned, shareware is more of a sales technique than a way for you to get free software; however, it does deliver real value because it lets you “test drive” an application before you buy it. Many well-known companies (including Microsoft, Adobe, and many others) let users try versions of their products for free. In my own EHR business, I have always allowed potential customers to try Amazing Charts in their own practice for three months before being asked to pay for it, and I am consistently told that this is a major factor in their decision to eventually purchase the system.

Personally, before I purchase any software, I search for free alternatives (usually on Google). If I don’t fi nd a free product that fi ts my needs, I try to fi nd a shareware version of the software and run it through its paces before paying a penny.

Dr. Bertman is Physician Editor-in-Chief of MDNG: Primary Care/ Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.  com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Does the word "free" grab your attention? It sure gets mine. 

Tech Talk: Get Your Software on the Cheap

Simon Cherry, professor and chair of biomedical engineering at UC Davis, discusses the combination of PET and MRI in a single scanner, which his lab built for laboratory mice studies, particularly in cancer research.

Until now, what has kept MRI and PET scans from being combined?

The two modalities have a big potential to interfere with each other. On the PET side, you worry about the very strong magnetic field environment from the MRI, and on the MRI side, you worry about the eff ect the materials in the PET scan will have on the uniformity of the magnetic fi eld and also the possibility that the PET anatomics will generate radiation that will perturb the MRI image.

PET and MRI studies in the same subjects have been done for many years, but the subjects have been moved from one scanner to the other. It’s very common to use both modalities, just not at the same time.

In traditional PET scanners, the detectors are based on photomultiplier tubes, which are extremely sensitive to magnetic fields. We moved to what’s called an avalanche photodiode (APD), a silicon sensor that’s very thin. Because the active region is so thin, it’s much more immune to magnetic fi elds. We’ve tested these devices in magnetic fi elds up to 9.4 tesla, and they work just fine.

On the MRI side, a number of things are important. First, arranging the components of the PET scanner symmetrically in the MRI scanner helps to prevent preservation of the magnetic fi eld. We also carefully shielded the electronics of the PET scanner to try to prevent radiofrequency interference. And we used materials wherever possible that have reasonable magnetic susceptibility, so that they are similar to human tissues. It’s all careful engineering to help protect artifacts on the MRI side.

What benefits will the combination provide to oncologists and their patients?

That’s the $1 million question for which we do not yet know the answer. We now have data that clearly show that this is feasible, and the question now is “are there applications out there that absolutely require PET and MRI data to be taken at the same time?” The things that spring immediately to mind are areas of the body in which MRI is a superior imaging technology to CT—the brain is an obvious case, as are the abdomen and pelvic areas. Particularly for oncology, you worry if you take the images a few hours apart in different scanners that things move around, and if you put the patient on two different beds, the organ positions are somewhat different.

It’s very hard to use computer software to register those two data sets. So, the ability to take the PET and MRI at the same time and know exactly where the PET’s localized with respect to the anatomy you get from the MRI, those applications are key. Just like PET/CT has had a huge role in oncology, I think PET/MRI will be the same. I think there is going to be a period of using this in the research arena to really understand what unique things can be done. For it to be a common, mainstream diagnostic tool, many other factors come into play, economics of course being one of them.

That’s harder to predict: will there be an application for which it makes a significant diagnostic difference and for which you can justify the cost (this is not going to be cheap)?

If you take this whole emerging field of molecular imaging, in which we’re really trying to image for example, specific sets of enzymes, they’re developing targeted agents to do this. As a tool that lets you really understand what you’re looking at and where the signal is coming from, the PET/MRI combo will be a really great device. For validating new biomarkers—many people are interested in using MRI as a biomarker for therapeutic effect&mdash;and to validate that specific radio tracing with PET in a pre-clinical situation and then clinical trials will be very helpful. I see a lot of applications in the research and drug development area. But my concern at a diagnostic level, as I mentioned, is where are the applications that justify the cost in a healthcare economy where, of course, costs are being tightly controlled for good reason. That’s going to be the challenge, but everyone said the same thing about PET/ CT 10 years ago; they weren’t quite sure what it was going to be used for. There were doubts about it being costeff ective. Now it is a mainstream modality, and nobody buys a PET scanner without a CT attached anymore. Maybe it will be the same with PET/MRI.

We’re trying now to develop a much-higher performance, second-generation system, and we’re also investing a lot of effort in trying to develop new imaging probes that are both MRI- and PET-visible at the same time.

TechSectors: Medical Devices: PET/MRI Combo

Cell phone applications, interactive video tutorials, online symptom navigators, and other high-tech tools are changing the way physicians approach patient education and are opening up new possibilities for patients seeking to learn more about their conditions and take control of their health.

In baseball, bats, balls, and gloves are commonly referred to as the “tools of the trade”—the equipment used by players to participate in and determine the outcome of the game. In medicine, tools of the trade have traditionally included a stethoscope and a sphygmomanometer by which physicians obtain information that can help them positively impact a patient’s health outcome. Those tools haven’t gone away, but healthcare providers have begun embracing new tools&mdash;technology tools, including cell phones, video, and the Internet&mdash;to help educate patients so they can make more informed decisions regarding their own health.

“When I was in training, the focus of medical care was in the hospital,” recalls Alan Greene, MD, chief medical officer at 

., a leading provider of high-quality, technology-driven health information solutions. “Th en it was in the outpatient setting. More and more, it’s moving to where people are in their daily lives; the places where they’re making their healthcare decisions.” Enabling that decision-making is the technology that is putting information in healthcare consumers’ hands whenever they need it, wherever they might be.

Peter Waegemann is chief executive officer of the 

Center for Cell Phone Applications in Healthcare

. An international leader in medical informatics, Waegemann believes that in the next 10 years, the cell phone will have the greatest impact on health information and technology. His vision is that in fi ve years time, “a large percentage of people, maybe even 100 million in this country, will have their basic health information on their cell phone.”

Waegemann says the cell phone can serve as the platform for consumer health-related

software, such as wellness-related programs and disease management programs. By off ering consumers health-related Internet access, cell phones can allow patients to quickly and easily look up information about medications or symptoms related to their health status.

Imagine a patient using her cell phone to look up a specifi c medication after it has been prescribed at a clinic visit, noting it interacts with another of her medications that she forgot to mention during the visit, and alerting her physician via the cell phone before the prescription is filled. “And it won’t only be for checking medications,” says Waegemann. “It will be for making decisions. When a consumer has a pain, they may not go to their doctor. Instead, they may look for advice on the Internet using their cell phone.”

Waegemann’s vision is already taking shape. The A.D.A.M. Symptom Navigator for the iPhone and new 

 is a free application introduced last month that is designed to help consumers match medical symptoms with relevant assessments and appropriate treatments. Adapted from A.D.A.M.’s standard edition of the Symptom Navigator, which is the backbone of many medical websites, including the National Library of Medicine, the tool addresses possible causes of symptoms and medical conditions, how to self-treat, when you should call a doctor, and how to prevent it in the future.

Symptom Navigator resides on the Web. A button on the iPhone’s screen quickly brings up an image of the human body. By touching the part of the body of interest, users are presented with a menu of related symptoms and walked through the possible causes, home care, and when to consult their doctor. “As a physician, it’s wonderful for me to know my patients have access to

this kind of quality data,” says Greene. “It makes patient discussions with physicians richer, deeper, and more efficient.”

Patricia Raymond, MD, FACP, FACG, a board-certified physician in gastroenterology and internal medicine in Chesapeake, VA, performs many colonoscopies as direct access, meaning that patients do not actually meet her prior to the procedure. As a result, she needed a way to educate her patients while also promoting some degree of bonding and familiarity. “If you’re going to come in and have me drop a sixfoot-long tube in your bottom, it better feel at least like you know me a little,” Raymond says.  She put up a 

, from which patients could view videos of her answering questions about colonoscopy.

Developing the script/answers to the questions was easy, says Raymond. She’d always been asked the same questions by patients over and over, so she wrote them down and divided them into pieces, or video clips, that were informative yet short enough that they wouldn’t lock up a patient’s computer during download. Total time for all the video components combined is

between 15 and 18 minutes, says Raymond, and patients “feel like they’ve gotten 15 minutes with me before I’ve even entered the room.”

Why video? Raymond says it’s important to use a level of technology that your patients are most comfortable with. Her patients are age 50 and older, so they’re not going to listen to podcasts. But, they’re savvy enough to use the Internet. And according to Raymond, studies have indicated that if patients are shown a video of the physician explaining something they’ll perceive a much longer contact time with the doctor than if they were limited to a standard office visit.

“[Th e video] is me saying the same thing over and over,” Raymond explains. “If I can have that same conversation with patients at their demand, at their convenience, then maybe they’ll feel more comfortable coming in for a colonoscopy, because they feel like they’ve already met me.”

, Inc. (IDI), based in Bethesda, MD, has taken the video-based exchange of information one step further. The company has developed a voiceactivated, interactive educational method it calls “virtual dialogue.” Individuals are able to conduct a virtual conversation with a real person, in this case a healthcare expert, whose images are pre-stored on the computer. Using a microphone, the user asks questions, and the expert responds. An intelligent scrolling prompt provides relevant questions for the user to ask, or the user may ask questions on their own.

IDI has conducted extensive scientifi c research to measure the eff ectiveness of the virtual conversation from two perspectives: transfer of knowledge from the expert to the user and the feeling of actually being in the presence of the expert. Testing was conducted both prior to and following users’ conversations. Knowledge gain, says president and CEO William Harless, PhD—who developed the virtual conversation method&mdash;has been exceptional.

“We engaged 70 women, 35 of whom were breast cancer patients and 35 of whom were women concerned about breast cancer,” Harless explains. “They each took a pre-test to determine how much they knew about breast cancer, had a virtual dialogue with the oncologists for about an hour, and then took a post-test. Th e average pre-test score was 65, and the average posttest score was 93. That has real implications for medical education.”

Anne Moessner, MSN, RN, CCRN, a clinical nurse specialist with Mayo Clinic in Rochester, MN, has been piloting IDI’s virtual dialogue for several years. She says that she and the families that she has run through the program’s traumatic brain injury series have been amazed by the life-like features of the technology. “[Th e families] feel like they’ve spoken to a person as opposed to passively watching a videotape,” says Moessner.  “I think it’s something about the technology that is very engaging.”

To facilitate the conversations, IDI researches and prepares a list of 75—125 questions that patients frequently ask about a particular topic, such as breast or prostate cancer. The questions are reviewed by the healthcare expert, who then answers the questions in front of a camera without a prepared script. Doing so, says Harless, makes the conversation spontaneous, as though the expert were answering the question live. Do individuals ever ask a question for which no answer has been prepared? Quite frequently, it turns out. But IDI executive vice president Marcia Zier says that’s good.

“Ninety-fi ve percent of everything they ask gets a reasonable answer,” she explains. “But if the basic information we provide is triggering new questions or more in-depth questions, we’re delighted, because now their real concerns are starting to surface. And when they talk with their physician, they’re going to have a more substantive conversation. It takes the patient to a diff erent level.”

From hospital and healthcare system hallways to physician offi ce waiting rooms, digital signage is becoming a popular method for personalizing medical information that not only gains patients’ attention, but educates them as well.  For example, at Lancaster General Hospital, in Lancaster, PA, sets of eight, 46-inch, NEC LCD panels form two separate one-by-four matrices that display everything from information on health awareness programs to photo collages showing various hospital departments at work.  Th e information is made available, but in a nonintrusive manner.

“With some other technologies, you have to go to a website and pull information; you have to ask for specific information,” explains Jeff Collard, president of Toronto-based 

, a developer of software for digital signage networks and electronic displays. “Digital signage is very much a visual communication medium where we push information. People don’t come in and ask for it; we make it available to them whether they ask for it or not. But it needs to be supportive of what the patient needs to know, and invite them to get involved.”

In that respect, digital signage is very much an interactive medium, not merely flashing static information. Consider the case of a hospitalized child. The parents inform the hospital that the child’s favorite toy is a stuffed dinosaur. That information is imbedded in the medical bracelet around the child’s wrist. When the child approaches a screen in a common area or the children’s play room, the screen will show a story about a dinosaur. “The bracelet triggers it, so the screen knows who’s in front of it,” says Collard. “Then it goes into this database and pulls out something that relates to that child.”

Collard says the thing to remember about digital signage is that it’s a visual communication medium, and people, he adds, pick up visual cues much better than actual words. And the messages that are communicated are unique and tailored to a specifi c audience. “If I have 20 screens in a hospital, I don’t send the same message to all of them,” he says. “Every location should be a unique message, because where you are in your head and what’s going on in your life in radiology is completely diff erent than in the maternity ward. We’re delivering specifi c messages to specifi c people at specifi c times and places to make them feel more comfortable and help them facilitate a decision.”

Digital signage can also gather information about patients and healthcare consumers when they make choices through a touch screen. That information, says Collard, goes back to the hospital or the doctor’s offi ce and enables the facility to learn how to provide even more effi cient information to the patient. “It’s all data driven,” says Collard, “and that’s where the value is.”

What do patients do in a physician office waiting room? They wait, of course. So, how about putting that waiting time to good use? Patricia Neafsey, RD, PhD, a nursing professor at the University of Connecticut School of Nursing, has developed software that helps counsel patients with their self-medication management through the use of computer touch-screens available to them in the waiting room. With the assistance of a $1 million grant from the National Institutes of Health, Neafsey’s Personal Education Program — Next Generation (often referred to as PEP-NG) is helping older adults with hypertension reduce dangerous self-medication practices.

While patients wait to see their doctor, they can work at a computer screen and respond to various prompts asking what medications they are on—what medication they take for their blood pressure, as well as medication they may take for common health problems, such as pain or stomach ailments. The computer program counsels them, showing them the possible drawbacks of taking multiple medications, and what medications may interact negatively with one another. Upon completion, patients receive a printout they can take with them when they meet with their doctor, allowing for further discussion and maximizing the time available for the appointment.

“Everything is written for a lower health literacy level,” explains Neafsey. “That’s extremely important. And every screen, every word, the size of the buttons, every color, and the speed of the animation has been tested in very structured usability studies, so we know that they are readable and engaging.”

They’re also effective. An initial test of the software showed that 82% of patients with high blood pressure were able to lower their blood pressure using the system over a four-month period. A second, larger study is currently underway with 264 patients at 11 primary care practices in Connecticut.

“These are teachable moments,” explains Neafsey of the time patients spend in physician waiting rooms. “We thought, let’s use the time people spend waiting to gather information, analyze it in real time, and deliver a personal education program that supports the whole regimen for treating hypertension.”

Using technology tools of the trade, A.D.A.M.’s Greene expects healthcare providers to capitalize on those teachable moments going forward. “Th is is really the beginning of a new era,” says Greene. “It’s a new era of tools for patients to be able to track their own health, monitor it, and make changes. It’s an exciting time in medicine. Th ere are some real positive changes happening.”

Ed Rabinowitz is a veteran healthcare journalist based in Bangor, PA.

Cell phone applications and other high-tech tools are changing the way physicians approach patient education.

Beyond Brochures: Using Tech to Teach Patients

The advantages of using wireless body sensors in healthcare are obvious: more autonomy for the patient, an improved quality of life, and better signal quality due to lack of bulky cables. The sensor nodes envisaged consist of a power source (eg, a battery), a sensor function, a processor for data processing, and a radio link to transfer the data wirelessly from the patient’s body to the doctor’s computer or patient’s personal health device. To achieve widespread use and acceptance by patients, the sensor nodes should be wearable (small and wireless) and maintenance-free.

The size of the sensor nodes is intrinsically related to power consumption, as the battery makes up most of the size of the sensor system. For this reason, researchers are developing ultra-low-power electronics that comprise the radio, the processor, and the sensor function. Such an ultra-low-power sensor chip was developed by the 

. An interesting feature of this chip is that it can be adjusted to enable it to read diff erent biopotential signals, including EEG (brain activity), ECG (heart activity), EMG (muscle activity), and EOG (eye movement) signals.

Patient acceptance will also depend on the maintenance load.  Researchers are looking for ways to use ‘green’ energy to power the sensor nodes. Photovoltaic cells (often referred to as solar cells) are a well-known alternative power source that can also be used for medical sensors. Although the sensors are often used in indoor conditions, the photovoltaic cells will generate enough energy to power the ultra-low-power electronics. Another, more obvious energy source for body-worn sensors is thermal energy. Th e heat dissipated from the body can be transformed into electrical energy using thermoelectric generator (TEG) components. Of course, the TEG components should be comfortable for their wearer. Small wrist devices that resemble a watch seem the most convenient for users. However, nighttime power generation by such devices can be interrupted, for example by putting the hand under a blanket while sleeping. Th e head is another interesting heat-generating body part with potential in this area.  Harnessing heat generated from the head can provide continuous performance—even during sleep because the brain temperature is wellmaintained.  It is expected that future systems will use a combination of energy harvesters (eg, photovoltaic cells and thermoelectric generators), as this will make the complete power scavenger system more robust to external and environmental perturbations.

Prototypes of wireless sensor nodes diff er by their form-factor, their autonomy, their building blocks, and their portability. Holst Centre and IMEC also developed prototypes based on the ultra-low-power EEG/ECG/ EMG/EOG chip and solar and thermal energy harvesting. A glimpse of the possibilities:

a. Wireless autonomous pulse-oxymeter, powered by heat from the inside of the wrist. Data are wirelessly transmitted to the doctor’s laptop.

b. EEG system in stretchable headband, including thermoelectric generators that are placed on the forehead, powering the EEG sensor node at the back of the head.

c. Diadem with integrated EEG electrodes, powered by solar energy and the heat dissipated from the person’s temples. Th is kind of EEG monitoring can be used to detect imbalance between the two halves of the brain, to detect certain kinds of brain trauma, and to monitor brain activity.

d. Wireless body area network for sleep staging, consisting of three wireless sensor nodes collecting data from 2-channel EEG, 2-channel EOG, and 1-channel EMG. Data are sent wirelessly to a computer in the patient’s room.

e. Wireless ECG patch, integrated on a fl exible substrate. It measures a bipolar ECG signal between two electrodes separated by 3cm to 4cm. Data are wirelessly transmitted to the patient’s smart health card or to the doctor’s computer.

The technology required to utilize wireless, self-powered body sensors is advancing steadily. These devices hold immense potential, with future applications limited only by the ingenuity and creativity of the researchers and engineers involved in their design. As the need for more accurate, continuous health monitoring becomes greater, wireless sensors are poised to play a key role in the evolution of healthcare.

, Europe’s leading independent research center in the field of micro- and nanoelectronics, nanotechnology, enabling design methods, and technologies for information and communications technology systems.

Julien Penders is the Program Manager at the 

, an independent centre for open innovation that develops generic technologies and technology platforms for wireless autonomous transducer solutions.

The advantages of using wireless body sensors in healthcare are obvious: more autonomy for the patient, an improved quality of life, and better signal quality due to lack of bulky cables.

Eye on Innovation: Wearable Sensors Use Body Heat

Dr. Jeff Shilt is a pediatric orthopedic surgeon and 

. Having raced in nine Ironman-distance triathlons and qualified for the World Championships in Hawaii in both the International Triathlon Union and Ironman distance, he brings unique insight into how endurance relates to medicine. He served as the US team physician for the ITU Triathlon World Championships in 2003 and 2005, working with elite, age-group, and physically challenged triathletes. Dr. Shilt has a particular interest in using his knowledge of endurance training to help patients with a variety of medical conditions or physical limitations.

Why did you decide to train for and compete in Ironman competitions?

A good friend of mine was graduating from medical school and suggested we compete in an Ironman during the break between school and residency. We chose the competition in Brazil, and my entire family traveled with us. My youngest brother also competed in the event. Since then, we’ve traveled around the world and used the races as annual family reunions.

Does competing help relieve the stress of practicing medicine?

Often people comment about the difficulty of long training hours and racing, but for me it is the time I refl ect on life, family, work, or whatever topic is rattling around in my brain. Endorphins make me feel good. Difficult or challenging workouts that leave me exhausted remove the need to worry about petty things and clear my mind. I really enjoy the exhausted-body-clear-mind state I achieve after difficult workouts and races.

How are you able to balance competing in Ironmans with practicing medicine?

I achieve balance by clearly defi ning and maintaining my priorities and efficiently using my time. My priorities remain: family, health, and clinical practice. I’m a better doctor when I’m healthy and stress-free. It certainly helps being disciplined to wake up at 5:00am to get a couple of hours training in the morning in order to preserve family time in the evening.

What is your ultimate goal in competing in the Ironman competitions?

To remain healthy and fit, provide inspiration, and apply the knowledge I’ve learned about improving one’s physiology and strength through endurance training to my patients.

Dr. Jeff Shilt is a pediatric orthopedic surgeon and multiple Ironman finisher. Having raced in nine Ironman-distance triathlons and qualified for the World Championships in Hawaii in both the International Triathlon Union and Ironman distance.

Split Personalities: Dr. Ironman

Better patient education may help alleviate the rising cost of healthcare and lead to better health outcomes, because it helps patients make more informed decisions about their healthcare. Although patients are taking a much more active role in maintaining their health than they were even five years ago, they still need guidance and education from their physicians; information therapy (Ix) can be an important part of this.

As the number of primary care physicians and nurses decreases, time becomes a precious commodity. In order to see as many patients a day as possible, physicians are often unable to spend enough time making sure their patients understand everything that was discussed during their visit and the instructions they were given. This is important because 

 have demonstrated that “people only really remember half of what they hear in the doctor’s office and what they do remember, they get wrong,” says Jan Oldenburg, Practice Leader, Health Portfolio, 

Kaiser Permanente Internet Services Group

One way to alleviate this problem is through information therapy (Ix). The Center for Information Therapy, an independent organization originally founded by Healthwise, defines Ix as “the timely prescription and availability of evidence-based health information to meet individuals’ specific needs and support sound decision making. 

 are specifically targeted to an individual’s needs at a particular moment in care and are delivered as part of the process of care.” They are an easy, safe, and cost-eff ective way for physicians to give patients health information—whether it is in print or posted online&mdash;that they can review after their visit. 

A physician may give his or her patient information during an appointment to review when he or she gets home, but how does the physician know if the patient actually looked at it? “If we provide information therapy where we tell patients to go to a website or give them brochures, it doesn’t mean it happened,” says Moe Ajam, PhD, president of Th e Patient Education Institute. “We have to simplify the information so it reaches all patients, and this is a very diffi cult job considering the diff erent learning styles and educational levels of patients.” Although brochures and lists of websites could qualify as Ix and may off er more detailed, clinical information, educational information presented in a fun, interactive way is more likely to keep a person’s attention; this is the advantage that comes with using technology like the Internet. “Technology itself can’t solve the problem, but technology can be an incredibly valuable tool,” says Seidman.

Many companies and organizations are developing Ix tools to present healthcare information to people using interactive technology through the Internet. Two groups leading the charge are Healthwise and The Patient Education Institute. 

 is a nonprofit organization that focuses on developing Ix tools to help people make better health decisions. “Our expertise at Healthwise is really taking the medical information and transferring it into a very accessible and useable form for the consumer,” says Healthwise Chief Medical Offi cer Steven Schneider, MD. “As we transfer information to a consumer we have to think, ‘What are they going to understand?’ and ‘What are they really going to want to know?’” The company offers a number of Ix tools, including Healthwise Knowledgebase and Ix HealthMastery Campaigns. 

The Knowledgebase includes information on nearly 8,000 healthcare topics and includes such tools as a Drug Interaction Checker; Decision Points, which help patients make decisions about tests and treatment options; Actionsets, which help them make informed choices about managing chronic illnesses and take control over their health; Illustrations; Custom Connections, which feature customized links and messages from outside organizations; and Topic Development Process, which helps patients maintain up-to-date information through the assistance of the Healthwise Medical Review Board. 

 are “ongoing, online self-management programs for people with complex, high-priority health issues” that “combine disease management interventions and live coaching practices in an online, interactive program so [physicians] can cost-eff ectively reach a larger population.” 

“Information therapy hooked with technology allows us to take advantage of the automation and [easily] move information back and forth between the doctor and the patient,” says Schneider. The 

 develops webcasts, illustrated handouts, and other Ix tools “to empower patients and healthcare providers through evidence-based patient education software that is engaging, eff ective, and ready to integrate with evolving clinical systems.” Its flagship product, 

 includes “interactive patient education programs that use illustrations and animations to simplify concepts, narration to read the text, and questions to verify understanding.”

include diagnosis and therapy, patient population groups classifi ed by age and gender, health and wellness, topics not usually discussed, surgery and invasive procedures, and disorders and conditions by body location or system. There are two types of tutorials: public tutorials, which allow anyone to access healthcare information; and clinical tutorials, which are implemented in the clinical setting and require patients to complete programs designated by their physician. “Technology has been instrumental in making [Ix] efficient, taking the redundancy out of it, and automatically documenting it,” says Ajam. Our healthcare system has many problems that need to be addressed. Some of the biggest problems include cost, quality of care, and staffing needs. Obviously, they will not be fi xed overnight, but physicians who use Ix might find that it can actually help alleviate some of the cost, quality of care, and staffi ng pressures by encouraging patients to take a more active role in their healthcare.

Physicians who use Ix will find that it can help with some of the most important aspects of practicing medicine: cost, quality of care, staffi ng, and patient education.

The rising cost of healthcare is putting the squeeze on patients and doctors. One way to help solve this problem is through more eff ective patient education (ie, Ix). “Many experts agree that [information therapy] is one of the best costeff ective ways of controlling major healthcare problems by providing information and ensuring that the patient understands it,” says Ajam.

Physicians are seeing more patients a day than ever before, which might make monitoring patients’ progress diffi cult; Ix can help improve quality of care. Patients now receive physicianapproved resources to learn not only about a specifi c medical condition or medical procedure, but also prevention methods and how to change lifestyle behavior. A well-informed patient is a better patient because they can make better personal health decisions. Information therapy is “part of the way that a doctor can help ensure that the [patient] actually understands the informational instructions that he or she has been given,” says Oldenburg.

The decreasing number of physicians will have an enormous impact on the quality of care and cost as the population ages. Ix helps with this, because physicians are able to provide further patient education outside of the offi ce, allowing for enhanced self-care. “As we give consumers these tools for managing their care and for connecting with other people, it really creates a lot of opportunities for more eff ective and effi cient care delivery,” says Seidman.

With the advent of the Internet, people have access to thousands of healthcare websites, many of which present unreliable information. This is a concern of physicians, because a lot of people use the Internet to look up healthcare information on their own. A 

 in October 2006 found “about 85 million Americans look for health information online without consistently examining the quality or appropriateness of the information they find.” The question is, “do they know how to determine if a website posts the most reliable and up-to-date information?” Ix is one way to make sure the right person receives the right information at the right time from his or her physician. “The transfer of information is the most important thing that happens in healthcare,” says Schneider. “I think that [Ix] is going to be the core piece of every medical interaction.”

Information therapy might not be the end-all solution to the problems within our healthcare system, but it is certainly a step in the right direction. “I think what’s guiding this trend is that patient education [leads to] better health outcomes, increases patient satisfaction, and reduces medical errors and perhaps liability,” says Ajam. Since its introduction to the healthcare system, Ix went from physicians giving out pamphlets and handouts to physicians prescribing interactive, online health programs; Ix has evolved as technology has evolved. “Technology enhances our ability to present people with the right information at the right time,” says Oldenburg. As technology advances, Ix will continue to evolve as a cost-eff ective tool that helps with staffi ng needs and helps improve quality of care.

Better patient education may help alleviate the rising cost of healthcare and lead to better health outcomes, because it helps patients make more informed decisions about their healthcare.

August 2008