Can Social Media Replace Pre-Publication Peer-Review?

Richard Smith (former editor of BMJ) commented on the case control study of the XMRV (xenotropic murine leukemia virus related virus) as a cause of Chronic Fatigue Syndrome.  The study was published in Science and he comments that there were several problems and people called for a better peer-review process to avoid these problems in the future.

[Added 12/24/2010: There have been several comments for this post, highlighting some of the controversies regarding this topic.  "CFS" has had a lot of recent research and studies with very conflicting results.  The comment by Richard Smith mentioned above was made in March 2010, and a lot of research has been reported since then.  Hopefully we will soon find out the truth and hopefully get closer to providing a cure for our patients.  This post is NOT about appraising the evidence regarding the "CFS" literature and thus this is NOT a commentary on the Science study mentioned above.  It is about the problems with peer review process in general as identified by a former editor of a major journal,  and a tentative exploration for an alternative model, and barriers to such a model. The statements in the paragraph above referring to CFS and XMRV are there just to provide context.  For the purpose of this post, it could well have been another condition and a different study]

Richard Smith points out the problems with the current peer-review process:

• Faith based not evidence based
• Slow
• Expensive
• Largely a lottery
• Poor at detecting errors and fraud
• Stifles innovation
• Biased

He suggests that we move away from our bias for top journals and move away from the traditional peer-review process and use a "publish and then filter" process.  

This got me thinking about how this could work.

1. A central resource for online hosting of all research articles in each area of biomedical science.  We would not have multiple journals competing and catering to the same audience
2. There would be some kind of simple review process to filter out "junk" and "spam" publications
3. The articles would need to include all the necessary raw data so anyone could rerun the statistical tests and verify the results.
4. There would be a robust authentication scheme for authors.
5. Each article would have a place for commenting much like a blog, but you would need to have to be authenticated before submitting your comments.  There would be no anonymous comments.
6. Readers after logging in could rate each article on various criteria e.g. study design, practical value, etc...  
7. The comments could also be rated up or down
8. It would be possible to track how many times the article was cited, tweeted and posted on Facebook; how many times it was downloaded, favorited,  etc.
9. Other studies on the same topic would also be linked from the article making it easy to find all the studies in one place.
10. Part of the publication process would be to search for all the previously published related articles in this central repository and provide links to all of these.
11. Viewers could see a timeline of development of literature on a specific topic 
12. Over a period of time, some studies, authors, commentators would rise to the top.  
13. There would be a robust search and tagging system.
14. Some articles could be accompanied by "editorials".
15. Every time the IRB at an institution approved a protocol, it would create an entry in this central repository.  Investigators would have to provide their data and a short summary at end of the study even if they did not write it up fully.  This would remove the problem of publication bias for positive studies and make meta-analyses more complete.  If they did not provide this information, their ratings would go down.  

Most of this functionality already exists - just look at YouTube, Ebay, Amazon etc.  It would not take a lot to get this working.  The problem is breaking down the traditions and existing norms.  How can you replace the thrill and ego-boost that authors get from having their article accepted in a "top-tier" journal.  Would the really big multi-center randomized double blinded trials with positive results get submitted to this central resource instead of to a top tier journal?  Would universities change their criteria for promotion and tenure?

We need to break down some of the walled gardens of some of our "top" journals and level the playing field but it will be an uphill battle.

[Added 12/24/2010 - Looking at some of the comments for this post, there is clearly a lot of energy surrounding the research on "CFS".  Would it not be easier for folks looking to study this condition if all the studies reporting on "CFS" and possible connection to XMRV were published in the same repository, so they would not have to go to multiple journals and databases to find this information, all the raw data was available, the pros and cons of each study were transparently viewable and authenticated users could post comments in unmoderated fashion (like to this blog post) to add to the richness of the discussion?  Why do we need to have so many barriers to collaboratively finding solutions to such vexing problems?]

Barriers to use of Social Media in Medical Education

I just came across 2007 this study - an online survey- of UK medical students, house staff and physicians regarding their opinion regarding use of social media in medical education.  Invitations were sent by e-mail to 6000 people and 21% responded.  The barriers identified by the responders were:

1. Would like to use social media for my education but don't know how
2. Don't like to use technology for my education
3. Lack of awareness of quality resources - don't trust the content
4. Lack of access at workplace and lack of time.

These were 4 themes that emerged from 60 free text comments in the survey responses.  That's a pretty small percentage of people from those who responded who bothered to enter a free text comment.  Combine that with the 21% response rate and it suggests that we have to interpret the results with a degree of caution.  Unfortunately for studies like this (email invitations to large number of people) these types of numbers are not unusual. The authors need to be commended for the effort they made to get this data.  

The authors commented that respondents appeared to be generally interest in Web 2.0 tools including social media. 

Do these 4 themes cover all the reasons why doctors don't use social media?  In my experience, I think there are even now (in 2010) a lot of physicians who think that using social media in healthcare is a waste of time (different than not having time to use it) and that apps like FB and Twitter are used by a bunch of narcissistic mutual back slappers.  There are numerous ideas and examples of how social media are, or can be, used in medical education (examples).  The problem is that these discussions about uses of social media occur in the blogosphere or on Twitter or FB.  The Average Joe physician is unlikely to get exposed to these, unless it reaches the mainstream print journals.

Measuring true outcomes (Kirkpatrick Level 4) from educational interventions is difficult  but it will probably take a study that shows an impact on outcome measures that is published in a reputed journal to change some people's minds.   To make matters worse, the print journals are constantly publishing case studies and guidelines regarding professionalism (or the lack thereof) and social media and this scares away some of the physicians who might be interested in this medium.  Physicians have already been burned by adopting clinical practices without sufficient good evidence and then having to go back when these were proven wrong (e.g. hormone replacement therapy).  So one can understand why some will "look" before leaping!  Even with educational practices we have seen the rise and fall of Learning Management Systems.  How can medical educators and physicians be sure that social media is not just another fad?  

It reminds me of a talk I gave in 1995 titled "The Internet and Medicine: Why Physicians should Pay Attention" and later wrote up for a medical journal.  There is a great The New Yorker cover by Edward Sorel which shows Whistler's Mother looking skeptically at a telephone.  I had referred to this cover when I gave that talk in 1995.  Maybe it is time to bring out that old issue of The New Yorker!

A Practical Medical Informatics Curriculum for Medical Students

How can best prepare our medical students to practice medicine in world of technology?  A number of efforts have been made to create curricula for medical schools and also for special fellowships in medical informatics.  This is a very rapidly moving target and the products of these efforts need constant updating. 
The American Medical Informatics Association website states that "biomedical and health informatics applies principles of computer and information science to the advancement of life sciences research, health professions education, public health, and patient care"


If we had to develop a list of concepts that we need our graduating medical students to be familiar with; what would it include today?  Maybe, if our students were all self motivated, reflective, life long learners, all we would have to do it ensure that they know how to find answers to their problems and questions, share this list of concepts with them and we would be set; we would not even have to develop a course for this curriculum!

This list of Core topics for all medical students would look something like this: (clearly a work in progress):

1. Computers (desktops, laptops), mobile devices, smartphones, portable data storage devices
2. Networking and connectivity – Intranet, Internet, WWW, VPN, Wireless, Bluetooth, 4G etc
3. Software – Office (word processing, presentation, spreadsheet etc), Statistical software, Bibliography tools, Cloud computing, Browsers and add-ons, mind mapping etc.
4. EBM concepts – Information resources, information retrieval, Appraisal of literature, Application to clinical practice, guidelines etc, also related to this are the concepts of public health informatics
5. Communications – e-mail, list serv, text messaging, discussion groups, social media, professional and patient communication, presentations (live and online),  Web 2.0, blogs and Wikis, social networking
6. Data – data collection, organization, storage and representation, data standards (including HL7), data interchange,
7. Personal knowledge management, project management, organization tools
8. EHRs/EMRs, Personal (patient) health records, meaningful use, physician report cards, Quality metrics etc. ePrescribing, RxHub, etc.  (Some topics like PACS might be more relevant to those going to radiology)
9. Decision science (decision analysis, probability, test characteristics, likelihood ratios etc) , online and point of care decision support tools,  Clinical decision support (Alerts, reminders),
10. Ethics, professionalism, legal and regulatory issues, privacy, security, authenticity and encryption
11. Ontology, terminology (Thanks to comment from Anonymous)

There are areas that might be optional for some students and be offered as electives.

1. Education informatics – Learning management systems, virtual learning environments, personal and social learning environments 
2. Bioinformatics (genomics etc)
3. Research informatics 

What do you think?  What are some other concepts that every graduating medical student should have that are not included here or could be better defined/organized?  


For reference, here is a recent JAMIA article with a detailed curriculum for clinical informatics specialists.
J Am Med Inform Assoc. 2009;16:153–157. DOI 10.1197/jamia.M3045.
And
Here is the AAMC Medical School Objectives Project (MSOP) Phase II report that covers medical informatics and Public Health.  https://services.aamc.org/publications/showfile.cfm?file=version88.pdf&prd_id=199&prv_id=240&pdf_id=88

Google Reader to Facebook Journal Club Part II

The previous post on a model for using Google Reader and Facebook to create a Journal Club got a lot of responses.  I also added some refinements to the Model.  Here is a summary:

1. Concern about residents/students having to friend the faculty members of the group:  Group members do not have to be friends. So this should not be a concern. 
2. Using Groups vs Pages.  The biggest problem with FB Pages is that they cannot be closed or secret.  Students and residents would have concerns about their comments being visible to future employers and thus Pages are out.  
3. Secret vs. Closed Group.  If you make the group secret, them folks cannot even find it and so the group admin has to invite each member to the group.  This requires, I think, for the invitee to be a friend of the admin.With a closed group, the group name is still visible to non-members who can ask to be invited.  The advantage of a secret group is that comments made by members and not visible to their non-member friends. Group creators should not change their group from secret to closed without approval of the members.
4. Keeping the group active:  Members may not remember to visit the group even though they are logged into their Facebook account.  Posts on the Group wall will not show up on the members news feed.  Members will see posts by group members who are friends.  Thus members with friends who are active posters in the group will keep getting reminded to visit the group.  Admins can send e-mail notifications to group members to alert them about some critical posts.  Judicious use of this might help improve group activity.  Members can elect to get notified of posts.  None of these are ideal.  Wish FB would make for automatic posting of group messages on member walls an option.
5. Too many posts could be intimidating.  Would be a good idea to classify/organize the posts by specialty for example.  One way to do this is to have an RSS stream for each specialty's journals.  (or create tags for each specialty in Google reader and create a public RSS feed for each tag). Them import that feed into the Group using RSS Graffiti but under "Post as" select a different person.  Thus one could create a fictitious Pulmonary Doc FB account, make that person one of the admins for the group, and post all pulmonary journal articles under that person's name.  Use an image of the lungs for that Pulmonary Doc's profile pic.  Thus all posts of journal articles related to the lungs would be tagged by an image of the lungs.
   

Example of creating a cardiology feed with an image of the heart for quick identification

 So that's it for a quick update.

Model for a Journal Club using Google Reader and Facebook OR if the prophet does not go to the Mountain.... bring the journal club to FB!

Challenge:
Create a collaborative learning environment for discussing key journal articles for our residency program.

Proposed solution:
Create an automated method for posting key journal articles to an online discussion group.  Each article abstract should be a separate post in the forum with space for comments.

Assumptions:
With tighter duty hour restrictions, going online might be more acceptable.
Most residents use social networking (e.g. Facebook) and have Google accounts - so our solution should try and leverage these 2.
It would be more likely to succeed if we go to where the energy is (Facebook) rather than create a new site with a new log in.
A few faculty members or Chief Residents would take on the task of filtering and selecting the articles.

Model for using Google Reader and Facebook Groups for an Internal Medicine Journal Club

Steps:

1. Faculty member/Chief Residents set up Google Reader accounts
2. Subscribe to RSS feeds for some selected Journals in their specialty.
3. Periodically (at least weekly) review the feeds and share some of the most relevant articles in Google Reader
4. Find the RSS feed for their shared items list
5. Create a Group in Facebook (possibly a closed group so only members can view and comment)
6. Authorize the Facebook Application RSS Graffiti for this Group. (only group admins can do this)
7. Create a feed in RSS Graffiti with the RSS feed of the shared items list
8. Ensure that specific settings are modified and test for the posts to show up within about 30 minutes.
1. You have to authorize RSS Graffiti for your Facebook account before it will work on your Facebook Group.
2. You have to be the admin for that FB group
3. Edit the feed and under the Filter tab, make sure you change to date to when there are some items to show.  By default it is set to the time of creation of the feed in RSS Graffiti
4. Edit the feed and under the More tab, make sure you are posting as yourself and not as the Group.
9. Invite/add members to the Group.
10. Enjoy!

Screenshot of the Journal Club in a Closed Facebook Group

Resources:
Google Reader
Subscribe to important medicine journals with one click (you can also click on the button in the right column of this blog)
Facebook Groups
RSS Graffiti Blog and RSS Graffiti FB app

Example of an Interactive Online Mind Map

This is an example of a possible solution for a clinical education and technical problem.

So what was the problem?
Clinical Education: Students learn to do physical examination by organ systems.  But then they need to integrate the examination into a smooth, head to toe exam that is convenient for the patient.

Technical: What tools can you use to help the medical student capture their concepts in an organized manner.  Mind maps are the obvious solution.  But some mind maps while easy to create on the desktop do not collapse/expand easily when placed online.  Others are hosted solutions so you are not sure how long they will be around and who owns what.  Some use Java which is not compatible with iOS devices.  Is there a solution that lets you create and upload interactive online mind maps and host them yourself?  Will it allow for versions for mobile devices including iOS devices? Click here for a previous post about these issues.

I have written about the clinical education problem in the past.  A medical student I work with reflected on this issue and we came up with a mind map using Freemind to solve the technical problems.

So without much more ado, here is the mind map  (http://www.tinyurl.com/organizedpe).  It is organized in 3 tabs.
The organ system approach
The Head to Toe approach
The Tree view for mobile devices using JavaScript

Creating an online collaborative workspace for a conference

Our medical school is popularly called a "No grades, No tests, No lectures" program. One of the jewels of our program is a competency based assessment system that is based on an electronic portfolio that we built from the ground up. We have had many visitors come to see this system first hand and next year we are planning a conference of some of the most well- known names in portfolios use in medical education. This is an invitation only conference and we expect to produce a white paper on this topic.
To facilitate the various activities of this group leading up to the conference and after the conference, we decided to create an online collaborative workspace. There are several platforms like Basecamp, for example can serve this purpose but we decided to try and use Google sites for this purpose.

The required features were:

1. Restricted access
2. Members could upload links to useful websites
3. Members could create a bibliography on this topic
4. Discussion groups
5. Shared calendar
6. Collaborative authoring of documents
7. Data collection form

We found that it was relatively easy to accomplish everything we wanted with minimal effort.  The site was ready to be populated with content.

The Home Page of the Collaborative Workspace

We learned a lot along the way:

• Google sites can be set up to have access restricted to invitees only
• It has a very intuitive WYSIWYG site creation interface
• You can have left side bar and horizontal navigation and bread-crumbs are built-in
• You can use a number of existing themes or create your own custom theme
• You create a "file cabinet" page that allows members to upload files
• You can create list pages that allows members to add items to lists. The columns of the lists can be customized easily - we used this to create the Bibliography and list of useful web sites.
• The collaborative authoring requires the use of Google docs. You can start a Google doc by adding a title of the document. You can then share this document with all the members giving them editing rights. You then insert the goggle doc into a page on Google sites. This displays the entire document on the Google site with a link at the bottom to open the document for editing. Clicking this link opens the document in Google docs.  We used this to let members work together on the white paper.
• For the data collection you again use the spreadsheet function in Google docs. You create a form that connects to the spread sheet. Then you insert this form into a page on Google sites. If you want the embers to see the data collected by the form, you can publish the spreadsheet and insert it into a web page on the Google site.

Data Collection and Report using Embedded Google Spreadsheet

• For the discussions groups, we used Google groups. Again we gave all members access to the group. Then we used a gadget from the library to insert the Google group discussion into a page on Google site. iE8 does not allow this due to a cross-site filter. Even after I disabled the filter and restarted IE it did not work. It works fine on other browsers (I tried Chrome, Firefox and Safari). A workaround would be to provide a hyperlink to the Google groups discussion page on Google sites, or take the RSS feed from the discussion group and insert it using a gadget into the Google sites page. This last method will provide a read only view of the discussions, but members would have to go to the group itself to participate fin he discussion.

Discussion Groups using Embedded Google Groups

Once we did all this, we were ready to go. The whole effort took us <10 hours of work to be up and running. It was a great experience. Aimee who worked with me on this project was so enamored with Google sites that she is going to create something like this for one of her daughter's projects. Google has provided a very versatile set of tools that can be mixed and matched to create very functional collaborative web spaces.  With the recent Google decision not to allow uploading of files on Google Groups, this ability to integrate Google Sites with Google Groups becomes more important.

Creating Panoramic Photographs

Fall season is upon us bringing with it the beautiful color changes in the foliage.  Unfortunately the leaves will soon be gone, leaving behind depressingly barren trees and landscapes.  Individual snapshots are inadequate to capture the majestic vistas.  But how about capturing panaromic shots?  You can do this even if you don't have a very wide angle lens. 

Clevr is a quick and easy tool for creating panoramas from individual photographs but fails miserably when the images lack a distinct feature like building or similar structure.  I was able to get some success with shots of:
1.  Hawaiian Volcanoes
Lahania and
2.  Harbor with boat and slips
Lahania Harbor
Trees in general don't present such features and Clevr just does not work for creating panoramas of fall foliage.  But there is another program that is just awesome.  It is called Hugin and Lifehacker has a nice blog on it. 

Downloaded it yesterday and have 2 beautiful (even if I say so myself) creations from this.

1.  View of the backyard

2.  View of schools soccer fields

Using the Dragon Dictation Software with Electronic Health Records

The main campus of the health system where I work recently started rolling out the enterprise version of the Dragon dictation software (the medical version).  We are using the PowerMic II with the dictation software. We use Epic Systems Ambulatory and Inpatient EMR.  I have had the system installed for barely a day and I am totally hooked.
First impression is that the accuracy of the system for medical dictations is close to perfect.  It also does some pretty smart things like:

• When I say cat scan it changes it to CAT scan
• When I say milligrams it changes it to mg 
• When I say qd it changes it to once a day.

This was with about 15 min of training on the general (non-medical) text sample.  Even though I can type pretty fast, there is no way that I can type at the speed I can speak.  The only rate limiting step is thinking of what I want to say!

Immediate benefits:

• Notes read better, HPI (history of present illness) is more detailed and the A/P (Assessment and Plan) truly begins to reflect my thought process as I don't hesitate to elucidate due to time constraints.
• The software supports voice macros which overcome a lot of the GUI challenges of the EHR.  Thus instead of constantly going from the keyboard to the mouse to do mundane tasks like approving a refill and routing it to my secretary, I just say "approve and sign" and it take care of all of the approximately 15 mouse clicks and keystrokes.  I was able to incorporate my password into the macro and close the encounter using the same macro. 
• I find I am not hunching over the keyboard as much and I am sure my poor neck, shoulders and wrists will thank me for this.

What next:

• The PowerMic II comes with several programmable buttons, e.g. tab forward and tab back.  Will explore the best way to make use of these to improve efficiency
• Develop more efficient work flows for using this in combination with smart links, smart texts and smart phrases.  By programming "dot phrases" and saying "press F2" most of the functionality I use regularly can be met without touching the mouse or keyboard.
• Search for information on the web about people using this with Epic to see if they have posted tips, tricks etc.
• Use the system from within regular Microsoft Office applications like Outlook and Word.  My first foray into this, I found that the accuracy with regular English was not as good as that with medical terminology.
• We are moving to the Summer 09 version of Epic next month.  Wait to see how this will affect the work flow.  Quite possibly some of the voice macros will need to be reprogrammed - bummer!

I think this will be a great step forward towards getting more meaningful notes with people transcribing their own thoughts rather than copy-pasting existing notes.

Interactive Mind Maps on the Web

I have written about mind maps before.  These are great tools to summarize complex information and relationships between concepts.  In the past I have created a flowchart with bubbl.us and a few mind maps with Vue.

I really like Vue as it gives you the greatest flexibility in the look and content of your mind map.  It also is a tremendous tool for presentation with the use of pathways.  Combining hover zoom and pathways, one can create a very customized flow or a presentation and focus attention on specific nodes or groups of nodes.
The biggest draw back I have found with Vue is a non intuitive collapse and expand function for nodes.  The other drawback is the difficulty in publishing it to the web in an interactive format where a user can click on a node to collapse or expand it.  This functionality is helpful when a map gets really large or when a user is looking at it with a small screen device.

After a very brief search (meaning I probably missed some other good tools), I decided on Freemind for these 2 reasons:

1. Easy collapsing and expanding of nodes
2. Maintaining this functionality when publishing to the web.
3. It does have some formatting options that are quite sufficient for my purpose.

How do you go about this?

1. Download and install Freemind (Freemind.sourceforge.net)
2. Create your mind map
3. Save the mind map (*.mm) and upload to your web server.
4. Download the Freemind applet (zip file which includes an HTML template) (freemindbrowser.jar).  You need this hosted on your web server.
5. Create a HTML wrapper using a template included with the freemind applet zip file that points to the location of your freemindbrowser.jar file and your *.mm mind map file.
6. Upload this HTML file to the web server.
7. Make sure the MIME types on the web server for .mm are set to application/freemind.  You may need your server administration to do this for you.
8. Point your browser to this HTML file and you are all done.

Static Image exported from Freemind

Just to test out this functionality, I summarized this information HERE using Freemind as an interactive mind map.

Caveat - needs JRE to work.  User will be prompted to download this if they don't have it

Caveat - this means it will NOT work on iPad or other iOS devices as they don't support Java :-(

Story of my experiments with iPad (The first 24 hours!)

How I got around to actually getting an iPad is a long story - maybe to be told another time. Regardless, y'day at about 10.00 AM I ended up with one in my hands. Interestingly when I saw the FedEx tracking site, it showed it was shipped from China on July 15th and was delivered here in CLE on July 16th via Anchorage and Indiana. The world is indeed FLAT.

The packing was beautiful with one small card for instructions essentially stating, "Download iTunes to your computer and connect the iPad to your computer with provided cable". You cannot do anything with your 500 dollar device till you take these steps. After a >90 MB download and install, I was ready to go.

Some observations in random order:

1. The thing weighs more than it looks.  All the ads you see with people holding it in one hand and scrolling around with the other, had to be pretty short ads.  You cannot hold this in one hand for more than a few minutes without risking tendinitis.  I am sure we will start seeing some cases of this soon.  
2. The device is very sleek and smooth.  Looks beautiful and the screen is gorgeous.  This unfortunately makes it somewhat difficult to hold.  There is no area with some "rumble strips" that would make you feel comfortable holding it in one hand while taking it from one place to the next.  You would want to hold it between thumb and your fingers but you would worry about smudging up or putting too much pressure on the screen.  Once I get a case, it might be a non issue, I hope.
3. The device is quick to start and one gets to the home screen instantaneously partly because by default it does not ask one to set up a password.   I have not had time to research this but the feeling I get is that this is like a PC where by default we are getting the Guest User Account and the screen where we choose the user is bypassed unless you go into the device setting and then you can create a 4 digit PIN but the account still stays as a guest level one.  This clearly increases the security for the device from virus etc. but having only used PCs and Ubuntu previously, this makes me feel very hamstrung.  Also there is only a single user account, and thus if someone borrows my iPad, I would have to either disable my PW or share it.  Since data-entry is a bit of a pain on the device, one would like the device to remember all your log in information for sites and apps but then if you share the device, you would have problems.
4. The provided cable has the proprietary Apple docking plug on one end (connects to the iPad) and a USB plug on the other.  This end connects to the charger or computer.  Unfortunately it seems that connecting to a PC actually might drain the battery of the iPad instead of charging it!  It charges slowly only if connected to a Mac.  
5. Was glad to see the iPad was able to connect to a public WiFi and my home WEP enabled WiFi quite easily.
6. Was excited to see that there was Bluetooth built-in.  But when I tried to pair it with my Win 7 Laptop, it did not work.  Nor did it work when pairing with my Blackberry.  Seems the only purpose of the Bluetooth is to connect to headphones?  And possibly for multi-player games with other iOS device users. What a bummer!  
7. I wanted to get some photos from my laptop to the iPad so I could test the photo app.  No SD card slot, the Bluetooth does not allow file transfers. Me very sad :-(  
8. The only way it seems to transfer files is by connecting with the cable to your computer and use iTunes!   What if you have files on multiple computers that you want to get on the iPad?  Seems like you have to download and install iTunes on each machine, connect to each one with provided cable, and you get a prompt that says - you already have a syncing relationship with another computer, do you want to transfer all your "purchases" to this computer (or something to that effect)?  This even when I have no purchases.  There is something called home share that I have to investigate further. Of course you can buy a subscription to an Apple service call Mobile me that allows this simple functionality but charges for it.
9. Setting up iTunes required an interesting step - you have to provide your Credit card number even if you want to download just free apps.  Caused me some concern as one I don't like to give my CC # to anyone in general but more importantly, the iPad allows only a 4 digit PIN for a password.  I created a ShopSafe temporary CC# with 5 dollars credit and 2 month expiration.  I did find later that one can set up the iTunes log in to prompt for a password.  
10. iBooks: This is something I was interested in looking at, having recently played around with a friends Kindle 2.  iBooks is a free app in the Apple Store and was easy to install.  I tried to find books on the Apple store and kept coming up blank.  I searched for a title that I knew was available and it still did not find it.  Then realized that one has to look for books from the ibook app on the iPad.  If reading a book is one of your primary reasons for buying the iPad, forget about it.  Just get the Kindle instead.  The iPad is too heavy, the screen brightness is fatiguing.  One can adjust the brightness, or change the background to sepia, and flip the iPad to landscape mode to get a 2 page view.  But these are minor pluses, the only real plus might be the ability to read in the dark.
11. Some of the apps are just incredible - the Netflix app where I watched part of "24 hours" was superb, watching YouTube or Ted Talks was fun, the NPR app with 3 rows of horizontal scrolling thumbnails of stories was beautifully presented, the NY times editors picks is great.  
12. Up until now when I thought of user interface, I usually thought of the Graphical User Interface or GUI.  One also thought of the human computer interface as a separate issue. The form factor of the device was a third separate issue. The iPad more than any other device makes these 3 somewhat separate issues merge into one.  The iPad generally wins in the human computer interface area with the multi-touch screen, it has a distinct problem with the form factor - it is too heavy to hold in one hand for too long and does not have a built-in way to prop it up or easily carry it; and the GUI is very much dependent on the App builder but the ones I saw are beautiful.  The on screen keyboard was a bit of a wash for me - I stated to use one hand typing using multiple fingers as I was holding it with the other hand, or had to prop it up against something so I could type with both hands, still had to look at the keyboard as I was not confident of my "touch-typing".  When I placed it on my lap I had to elevate my knees by "tip-toeing" otherwise the screen would be sloping downwards and the display would flip over.  (one can lock this with a hardware button).
13. The other key issue is the balance between security and owner rights.  While someone might appreciate the security model, Apple in my humble opinion has gone to far to the extreme.  The other issue is forcing owners to use proprietary Apple tools - the docking port, the lack of SD card, forcing use of iTunes, inability to share with Bluetooth or tether with Bluetooth, all are very frustrating.  The lack of administrator rights and multi-user password options on login are disasters.  Apple could very easily have built a biometric device into the black frame around the screen so the login could have been quite seamless.  Users could enable the PW feature and also be able to log in as admin for "Apple Unapproved" uses/apps if they want.  The iPhone is a personal device and does not probably need multi-user accounts but the iPad is something that would be shared between users.
14. Since I am an Apple newbie, I am sure I will learn more soon but I can understand the folks whose first step when getting an iOS product is to Jailbreak it. 
15. My open e-mail to Mr. Jobs: 

"Can I suggest someways to make the iPad better?

• Add a sturdy metal rectangular wire that folds into the frame but can be pulled out to prop up the device and be unfolded completely to become a carrying handle.
• Allow transfer of files using Bluetooth and SD Cards
• Allow a log on password for admin rights or for use between multiple users - maybe embed a biometric device into the side to make this seamless
• Allow tethering with a data-enabled smartphone for Internet connectivity.
• Stop asking for CC numbers to set up iTunes account even to download free apps.
• Allow charging of the iPad when connected to a PC (not just a Mac)
• Start contributing the iPad users health plans to pay for their visits for treatment of tendinitis!

FIFA 2010 World Cup Schedule

So this post has absolutely nothing to do with medical education but with the World Cup less than 2 weeks away, I just had to post this! I got the ics file from the BBC website and imported it into Google Calendar. So you will notice that the details have TV coverage for UK :-( . If someone knows of a file with US TV coverage details, please let me know. The games at 2.30 PM on Sat and Sun are on ABC. When there are 2 concurrent games one of them will be on ESPN2. Otherwise most are on ESPN. The TV coverage begins 30 min prior to the game time on the calendar. The ESPN coverage schedule can be seen here.

So here is the FIFA 2010 World Cup public calendar.  The URL is http://www.google.com/calendar/embed?src=1kcr6i71o4s26l7sa4reshir44%40group.calendar.google.com&ctz=America/New_York

Remember what you read - Anthropology, Neuropsychology and Google Reader

I was struggling to identify a topic for a Grand Rounds I was giving to the Education Institute at the large health care institution where I work.  I had planned to discuss the use of a Personal Learning Network based on Google Reader (including sharing of items from journal feeds amongst members of the PLN).

Since this was an audience of health care professionals, I thought that using this tool to stay current with medical literature would resonate well with them.  Then driving to work one day I heard on NPR the story of how a study published in Science showed how we cannot focus on more than two tasks simultaneously.  I looked up the study and came across another one that discussed how the discovery of a 40,000 year old statue led to a theory of how the development of the prefrontal cortex and the working memory (previously called short term memory) gave the homo sapiens an extraordinary advantage over others and led to mankind becoming the dominant species.  Around the same time I found this fabulous animation by IBM about the "Internet of things" which talks about how we are being flooded by data and we need to create a mechanism for making sense of this data so we can use it.

This was really exciting reading and I ended up using the current accepted theory on how we learn and remember, how the prefrontal cortex and the hippocampus play a key role in working memory and long term memory respectively as an introduction to the talk on how we can stay updated with medical literature and avoid getting drowned.

Sounds like a complex talk right?  Well this is how my talk flowed:

• How does memory work?  
• Sensory Memory - stored for less than1 min, disappears unless your attention is drawn to it; e.g. the car on the freeway that is going faster than the others. 
• Working Memory - 
• Activated when we pay attention to sensory input
• We compare what we perceive to what we already know
• Process occurs in prefrontal cortex
• Story of the lion figurine and how the homo sapiens became dominant species
• Image of the skull as the frontal bones "bulged" forward as we evolved to accommodate the growing prefrontal brain. 
• Long term Memory
• Hippocampus plays a key role
• Each portion of the memory of an event is stored in the corresponding part of the brain and integrated by the Hippocampus
• Thus the memory of a concert could consist of:
• Sound of the music - stored in temporal cortex
• The visual of the conductor and the orchestra and the hall - stored in occipital cortex etc.
• When we remember the concert, the hippocampus pulls these together into what is called the episodic memory.
• If we go to many concerts, we make some "rules" about what a concert is e.g. the conductor waves his baton around, has his back to the audience, etc... these rules become what is called semantic memory.
• The process of creating long term memories is called learning
• Things that help in learning are attention, motivation, encoding...
• If we keep needing the same information multiple times, it can become so entrenched that it can be retrieved without the hippocampus.
• Retrieving memory is easier if you are in the same environment as when it was stored - e.g. using your own text book with its notes and highlighting.
• We are drowning in data:
• Keeping up with medical literature is very difficult
• too much new information
• presented in too many different places
• failure of filtering - user does not have sufficient control over what she/he wants to see
• Ideally there should be a user controlled stream of data 
• The user decides when to review this stream - remember that the brain can handle only 2 tasks well => we should set aside dedicated time for this review
• The user should have a method for encoding and classifying this data at time of review - these are factors that help in learning (creating long term semantic memory)
• The user should have tools for retrieving this data (searching) in same environment (this facilitates data retrieval)
• Segue to Google Reader
• Create Feeds from 
• journals
• customized pubmed searches
• literature reviews (ACP Journal Club +)
• Set aside time to review the articles
• Star, like etc to annotate them
• Tag with discipline/key words
• Share with personal learning network with comments
• Send by e-mail 
• Send to Facebook/Twitter
• These activities will help in learning 
• Has excellent search (Google) for retrieval of previously read articles
• Search by tag/star/keywords etc...
• Search using smartphone
• Same environment as when storing/encoding information facilitates retrieval
• Next steps
• Training of clinicians
• Making it easier by developing OPML bundles of feeds
• Training on Zotero as a tool to encode, annotate and store most useful subset of articles.

The Types of Evidence for the ePortfolio Generated at Various Stages

Educational institutions are embracing the concept of Portfolios for their students. The hope is that creating a portfolio will help the student become more reflective and introspective and help him/her become a life long learner. Thus for these institutions, the process of creating the Portfolio is probably more important that the actual content (evidence) in the portfolio.

But when this same student graduates and goes into a residency program or into practice, the hard evidence is what seems to be the most critical piece that is used in the selection/appointment process.

Thus medical schools need to develop a model for allowing the students to create their reflective portfolios but these models should also allow for export of hard evidence in a portable format that the students can take with them when they go for residency interviews. The same process then would get repeated during residency when the ACGME gets to the point of using portfolios in a more universal manner.

Thus as we think about ways for data from medical schools to be passed on to residency programs and then to other bodies like state licensing boards, we need to look at pieces of evidence from each stage of training and practice that would be relevant at the subsequent stage.

The schematic diagram above shows some of the evidence generated at each stage of education/practice.  The evidence below the horizontal line is likely the evidence that should be relevant to later stages.  We should keep this in mind as we develop models for data sharing for medical education and practice.

Musings on ePortfolios

The ePortfolio movement is maturing.  We are moving from a stage of a number of stand alone ePortfolios to developing more consensus regarding standards for interoperability e.g. the IMS and Leap2A.  Also there are 2 major open source ePortfolio tools - OSP and Mahara and these are to greater or lesser extent integrated with open source Virtual Learning Environments (VLEs) - Sakai and Moodle.  There are vendors who will help institutions with installation, training and support for these open source tools.  Of course there are several commercial systems too for ePortfolios.

Institutions thinking about going the ePortfolio route have to first think about portfolios without the "e".  They need to understand the purpose of the portfolio and need to get buy in from the faculty and the students.  While portfolios seem to make a great deal of education sense, left to themselves, most students will not create portfolios!  Ali Jafari has a nice article summarizing the issues in Educause 2004.

Once the decision regarding implementing portfolios is made, going electronic makes a lot of sense.  Institutions will need to make a decision re Build or Buy.  As they review their options, it would important to keep the functionalities in mind.  I have put together a mind map of issues to consider when building or buying an ePortfolio system.

I love Electronic Health Records but.....

The EHR freight train has left the station and is barrelling down the tracks. There is a lot of excitement and enthusiasm for EHRs and their potential role in saving money and improving quality. The government is giving out grants to encourage adoption of EHRs (when used meaningfully) and for training professionals to support needs of health information technology.

There are several studies showing how EHRs can improve quality of care and decrease cost of care. EHRs have a huge potential to increase efficiency in our health care system. Unfortunately there is not much data that shows an EHR created by a vendor and implemented in a large setting has changed outcomes for a large group of patients in a meaningful manner. Thus studies may show that there is an increase in compliance with guidelines for ordering a HbA1c (Average sugar test) but we don't know if that lead to actual improvement in diabetes outcomes like fewer patients going on to dialysis or blindness. Granted one reason we don't have such data is that such studies would take a long time to do and EHRs are relatively new.

But in the absence of such studies we have taken a leap of faith and are proceeding apace with implementing the EHRs as universally as possible. There has been a lot of focus on making electronic data interfaces, setting standards for sharing data, and certifying EHRs based on features like electronic prescribing, clinical decision support, etc. These are potentially huge factors in making EHRs actually deliver on their potential.

One factor that has been somewhat neglected is the impact of EHRs on a physician's day-to-day clinical experience. There are several potential problems with EHRs:

1. The User Interface, design of the functionality- the iPhone has been described as feeling like an extension of their body. A device that seamlessly integrates into one's daily life, that seems to know what you might want to do on each screen and presents those options. Think of how you want to grab a cup of coffee, your right hand goes to the handle and grasps it without any specific conscious instructions. Most EHRs are quite the opposite. They make simple tasks more difficult to do. Some examples-
• The screens are cluttered - one very popular EHR has 2 horizontal toolbars at the top, 2 vertical navigation bars at the left leaving about 1/3 of the screen workspace available at the bottom right.
• Simple tasks require you to constantly take your hand from the keyboard to the mouse and back.
• For tasks that you know that in most cases there is only one option, the program will lead you through multiple screens where you have to accept the defaults to proceed to the end. A good example is the request for a medication refill where the necessary information (name, strength, directions, refill# etc) are all presented on one screen. It is very possible you remember the patient and want to just approve this medication. One EHR software requires 5 clicks of the mouse on 3 separate screens to approve this medication. It has a button to "Approve" and then another to "Sign" instead of having a button "Approve and sign".
• You get a lab result showing abnormal kidney function. You would want to go back and see the last several results for this same test to see if this is a change. If it is worse than the last time it was checked 6 months back, you would want to select that 6 month time frame and look for any new medications prescribed during that time, any tests done with iodine contrast or any serious illness. While all this data is there in the EHR it would take 10-15 minutes to review this information with many clicks and screen loads.
2. The alerts for the clinical decision support system - The CDS have the potential to make EHRs the tool for improving quality and decrease cost. The problem is that they are very poorly implemented at most places. Some examples -
• Your patient has a reported allergy (a rash) with Sulfa in the EHR. You are about to refill a medication for this patient that has a remote chance of causing the same allergic reaction in patient with Sulfa allergy. The patient has been on this medication for several years and has not had any allergic reaction. The CDS unless it is well designed will pop up an alert when do submit the this refill request. The physicians come to expect that an alert will come up and they hit "Enter" without even reading the useless alert. This has led to even possibly useful alerts being ignored and we are losing a very valuable tool from our EHR.
  
• Alerts can help to prevent duplicate tests. But in one EHR product the alert is unable to distinguish between tests ordered for the future. Thus when I see a patient with diabetes and order a lab test for 4 months in the future, I get an alert telling me the patient had this same test done today, am I sure I want to order it again!
3. Potential barrier to patient physician communication in the exam room- The presence of a computer in the exam room can completely change the dynamics of the encounter. Theoretically the access to the huge amount of patient and reference information at the fingertips is a huge boon. Physicians can adapt to the presence of the computer and even leverage it to improve the dynamics and provide better quality care. But many patients and physicians struggle with this. The non-intuitive and poorly designed interfaces require physicians to focus more on the monitor. The need to use both keyboard and mouse to navigate the screen requires the physician to sit more squarely facing the monitor. This leads to poor eye contact, missing non verbal cues and even changes the driver of the interview from the patient to the computer prompts. The short visit times combined with more information to review and the pressure for timely completion of documentation adds a very tangible stressor in the equation. In the past, physicians would sit squarely facing the patient, taking notes in the paper chart in a very natural and unobtrusive manner. History taking can correctly diagnose over 50% of complaints in the ambulatory setting. Without a good history, physicians are more likely to take a shotgun approach and order more tests.
4. The quality of the documentation - EHRs allow several mechanisms for increasing more rapid documentation. There are smart phrases, templates, and ability to copy and paste. In the past when one had to hand write ones notes, we were parsimonious and focused. Every word and every phrase had a meaningful thought behind it. Now we have reports of voluminous notes where it is difficult to find the real information. Physician payment for an encounter is associated with the detail of the documentation (which is not necessarily the same as the thoroughness of the clinical encounter). The more thorough a clinical encounter, the less time a physician has to document all facets of the encounter. Templates can help to solve this problem. There is a financial incentive for more detailed documentation. The temptation to create and use templates that support a higher level of coding is huge. . The balance between appropriately detailed, cognitively rich, non-templated notes and a quick templated, copy pasted note may be difficult to achieve for many providers.
5. The quality of the information in the EHR - There is a risk of over reliance on the EHR for information that should be obtained from the patients. There are several examples of how the EHR information may be inaccurate:
• Entering information using drop downs and selections can cause problems. Thus instead of open-texting something like "Osteoarthritis of the left knee medial compartment" the physician might choose something like "Osteoarthritis generalized" Critical information is lost as data entry is difficult or time consuming
• Instead of asking a patient whether she smokes, a physician may just look this up in the EHR social history tab noting that this was updated at the visit with a colleague. He may not realize that the colleague made the same assumption and the information was not truly verified for a long time.
• A patient being admitted to a hospital from the Emergency room usually has the entire history and physical documented in the EHR by the ER physician. While waiting for the patient to reach the hospital floor, a physician may review this information and then not go through this process with the patient again. Often the patients will promote this, being tired and ill and just wanting to get some rest, they will say something like, "It is all in that computer, why are you asking me this again". The admitting physician writes a note based on the ER physician note and if there are any inaccuracies in there, they get cemented into the patients records.
• A patient when he first walks into the office, gets his Blood pressure checked by a nurse who enters it in a discrete field in the EHR. Often the physician may check this again and enter a different value into their notes. This information is not easily retrieved and the only information available as subsequent encounters is the one recorded by the nurse. This can lead to wrong decisions e.g. a medication being started if the BP appears to be poorly controlled.

These are some potentially major problems with the use of EHRs. Some of them fall into the no man's land and no one may take the responsibility of fixing them. Others have solutions that can be built into the program but will need to be implemented appropriately at each institution. These problems if left uncorrected have the potential of defeating the entire potential of EHRs.

3/26/2010
I am taking the liberty to embed a recent Dilbert strip here

Visual Understanding Environment (VUE)

Came across this very interestring and useful tool from the Tufts Academic Technology. I have written about Bubbl.us before as a mind-mapping utility. VUE appears to be much more than that. While I have not explored all the features yet, some things that stand out:

1. Lot of flexibility in placing and formating nodes - shapes, fills, outlines
2. Does not appear to have the ability to have a parent > child heirarchy but nodes and subnodes can be clustered to create something similar to a heirarchy. Does not allow collapsing and expanding subnodes attached to a node.
3. Links can be labelled, colored, and can even have curves or "S" shapes.
4. Extensive Keyboard shortcuts make it easy to zoom in, out, pan, focus, etc.
5. The beauty of the software is the ability to create presentations from the map
6. Each node can have text or images attached to it.
7. Pathways can be created linking nodes/subnodes in various orders and then a presentation can be created that displays the text/slides
8. When displaying the slides, moving the cursor to the extreme right will show all the nodes linked to the node being displayed allowing you to navigate your presentation in a non-linear manner
9. Multiple pathways can be created in the same concept map.
10. You can show nodes connected to a particular pathway by hiding the rest of the map.
11. The map can be exported in multiple formats
12. There is also a semantic search function that one can run on the concept map.
13. VUE also allow import from datasets including Zotero. I have not tried that yet but sounds fascinating that it will automatically create concept maps based on the imported references!
14. The part that I want to explore is how the map can be exported to OpenLabyrinth to quickly create virtual patient cases.

I am just scratching the surface as I have used this software for barely a week. I was running a course on "Technology in Teaching" at our institution and created the following VUE map.

During the course I took the participants on a journey from the fundamentals of learning theory (Yellow nodes) to understanding the learning environment (blue nodes) to the various technology solutions (green nodes). I created a couple of pathways that allowed them to see how each portion of the course related to the whole concept map.

Classroom Presenter

I was recently attending the Harvard Macy Institute Program for Euducators in the Health Professions. Robert Kegan was doing a masterful workshop and what got my attention was a his story of how he moved from using overheads to using a tablet PC.

Bob hates PowerPoint presentations because the content seems to be predefined and not responsive to audience needs or interests. He uses the Classroom Presenter on a tablet PC to help him keep his workshop interactive.

Once I got home I pulled out my old convertible PC (tablet/laptop) and loaded Classroom Presenter 3.1 which is a free software from the University of Washington. After playing around with it for a while, I was thrilled. I started pulling various unsuspecting colleagues into my room to show it off.

So what is so special about this software? Here are some features that stood out:

1. Instructor computer connected to student computer via network (wired or wireless LAN or via Internet)
2. Instructor can allow his/her slides to be displayed on student computer
3. Student can annotate these slides and save them on their compuers
4. Instructor can ask students to write answers to questions/label images etc and send back to Instructor
5. Instructor can do quick polls and display a histogram like report of responses.
6. Instructor can import PowerPoint slides or presentations into the software.
7. Instructor can keep toggle between several slide decks - the PowerPoint slides, whiteboard slides, student responses and quick polls.
8. While it would be best if the Instructor has a Tablet PC, the students can work with a regular desktop, laptop or tablet.
9. Can be used at a distance.

So how can this be used in a class? Here are 2 quick examples:

1. Think-pair-share: Instructor asks students to work on a question or problem in a small group and then each group writes/types its response into a slide and send back to instructor. The responses can be projected on a screen from the instructor's computer. This is the equivalent of using flip charts in small groups. The advantage is that as each group presents, their slide can be projected to the class, the slides created by all groups can be saved digitally and shared.

2. A histology instructor can share slides with the class and ask students to label specific cells or organelles and send back to the instuctor. This can be used to do needs analysis or assess cognition.

There must be many folks who have used this software in a creative manner. There are a ton of papers and presentations from the University of Washington. For example, there is a link to UCSD where they have developed the Ubiquitous Presenter, based on the Classroom Presenter. UP allows students to use any web enabled device like cell phones to link to the instructors presentation. It also appears to host the presentation and student annotations on a web server so students can review it later. Would love to hear of more examples.