Friday, December 30, 2011

Creating beautiful memories with dual monitors

  • A lot of us have dual monitors for our computers
  • Windows does not have a very good built-in multiple monitor management tool
  • When we travel, we take lots of snapshots with our digital cameras but these don't do justice to some of the majestic sights
  • Panoramic shots would be great but we don't all have appropriate lenses
  • Mobile phones have built-in apps to help take panoramic shots but they cannot match a good camera for results on individual photos
How can we take great high resolution panoramic snapshots and then make them a desktop image spanning 2 monitors?

Step 1.
Take panoramic shots with your camera overlapping successive frames while keeping the camera level and without changing the settings as you swivel left to right to capture the vista.  A suggestion I have is to try and set up the camera to enable the tallest structure in the panorama to be captured.  You don't want to change the field of view in the middle of the panorama.  In addition, wait till there are no moving people in the field of view.  Otherwise you will capture the same person in two or more frames if s/he moved while you were taking the shots or get "chopped off" as in the photo below.
Another panorama
At Chichen Itza
at chichen itza
Cropped image
You will also need to do some centering, straightening and cropping of the stitched image. With some efforts you can convert the above image to look like this:

Step 2.
Download the pics to your computer and use Hugin [] to stitch these together.  I posted about this earlier.  Lifehacker has a great post on this. Hugin is a free utility with great features.  It has a bit of a learning curve but well worth the efforts.

Step 3.
Use Display Fusion [] to load the panorama you created in step 2 and span it across 2 monitors. Display Fusion is a free download (though there is a premium version with more features).  (Macs apparently have this functionality built-in and don't need this tool).

So there you go, 2 free apps to make your vacation memories stay alive on your dual monitors.  All you have to do is remember to take overlapping photos with your camera while keeping the camera settings constant.  The rest you can do when you get home!

Here are some other panoramic shots:
Backyard Panorama Fall Foliage

Soccer fields

Saturday, December 17, 2011

Providing health care In The Wild! Technology on a shoestring budget.

Students in our medical school have since 2009 "adopted" a village in rural Peru.  They go there for a month at a time accompanied by faculty members to provide various health services.

While there are many challenges, technology is a big help.

One key challenge was to learn about the population and document this and pass it on to the next group of students using an Electronic Medical Records system.  This would help them plan on bringing appropriate supplies e.g. eye glasses, education material etc.

OpenMRS:  This is an excellent, robust open source electronic medical records system that was developed out of a partnership (Regenstrief Institute @ Indiana University and Partners in Health).  This is available here.
It lets you create custom fields, forms and reports.  We wanted to capture the data at the point of care at the clinic where we would work.  This would save the time of entering data from paper forms to the database and hopefully decrease errors.
  One problem we have in rural Peru is a reliable power supply.  So we decided to create an ad-hoc wireless network using a laptop as a Server or host and tablet computers as the data entry devices.  The plan is to take some extra extended batteries for the laptop so it can run constantly for about 8-10 hours and the tablets should last for at least 6-8 hours if we don't use them for anything else.  We would charge everything overnight at the hotel be set for the next day at the clinic.

iPad (on right) connected to Laptop (Hosting ad-hoc network)

Another challenge is language - the folks there speak Spanish.

The students and faculty are getting a crash course in Spanish from some of the students who are quite fluent in this.  Luckily there is a free medical Spanish app

Another challenge is checking the visual acuity so we can give the correct eye glasses.  We have an ophthalmologist in the group who is training all the students.  But getting them to learn refraction using retinoscopy may not be feasible.

Just saw this amazing video of a $2 device that can be attached to a smartphone that lets you measure the refractive error in a few seconds.  Am hoping to get in touch with the genius inventor to see if we can get one or two of these devices to help the cause.

It is quite amazing how we are getting to a point where the portable devices are going to be able to change the world - a model where the health care provider goes to the patient rather than the other way around!  This may seem like something we need in rural and underserved areas in third world countries but why can't we use this right here in the US?  Is it because of our financial models or the legal system?

Sunday, December 11, 2011

Media, Social Media and Medical Research - Do we need to police the hype cycle?

By now everyone knows the story of "Sitting for prolonged periods makes your bum bigger".  The news was flashed all over the WWW and Social Media. A Google search reveals over 2 million results for this search phrase since October 17the when this study came out.  The news media was splashed with images like this.  In addition, it was spread by Twitter and Facebook.

From The Telegraph (
You can get an abstract of the study here but the full article is behind a pay wall.  The key point is that this study was done in a lab by artificially putting a stretching force on cells.  The research is important to understand how mechanical forces can affect differentiation of fat cells and the pathways that can impact this.

The problem is how this basic science experiment has been extrapolated to a clinical outcome without sufficient evidence and distributed so widely.  Sure sitting for long periods is probably not good for you as some studies have shown. So probably no harm done.  Unfortunately this is happening all the time for all kinds of studies.  In the age of 24 hour news cycles, live blogs and various measures of your social influence, the media tend to sensationalize news to get a wider distribution rather than analyze and report it responsibly.  We know about many such stories that were incorrectly reported and then had to be retracted but not before they had spread all over the Web.  This is not going to change in the foreseeable future.

The social media do not have a good rating systems for who provides authentic balanced information.  People tend to be rated based on # of followers, # of shares/retweets/mentions thus again perpetuating the need for sensationalizing the news.

As personalized news filters (Zite, Currents, Flipboard) and Social Media becomes the predominant manner in which we get our news, we need to develop a rating system for sources that are authentic, balanced and diligent about going to and analyzing the primary sources. This is even more important as patients search for information on their conditions and become more involved in their own health.  There are a number of respected web sites for health related information but they may not be able to updated quickly enough.  Also the user would have to go to that site to get the information.

We can leverage the features of various search tools that tag a search result with names of our contacts who have +1ed it.  The late  sidewiki was another such feature that could help.  Maybe this will all get sorted out in time, maybe we just need to be patient or maybe the move to have real names in Google Profiles is a move to make this happen?  Twitter in the meantime has stopped the Verified account for the public.  Still all it does is identify who you are, we need to know if something you post or retweet is verified information.  Will at some point, folks start giving +1 to the person than the news item?

Friday, December 9, 2011

Google Currents! Become a Mobile Publisher

Google came out with one of its most awesome products (after Gmail, Google docs, Google+, Google Reader....), well its a great product, OK!!

Screen Shot from my Android Tablet Showing "Currents"

I just created a Magazine from my Blog and it is now published on Google Currents!

If you want to see it, here are the steps:
1.  Download Google Currents App to your iOS or Android device.
2.  Sign in with your Google Account
3.  Go to the Library
4.  Search (at top of left column)
5.  Search for "Technology in (medical) Education
6.  Subscribe to the one with my image on it.
Or just open this link on your device browser

OR Scan this code with your device qrcode
Well so why am I so excited?
I am thinking about all the applications of this tool

1.  Publishers (content creators) can now publish their content to various mobile formats for free using an RSS feed.
2.  You can create bundles of content e.g. Journal Publishers could create tabs for the magazine with links to Editorials, Perspectives, etc.
3.  The articles can share with Google+ or other services like Twitter and thus enable discussions and collaboration in the online space.

How is this different from Google Reader?
- The user interface is very nice
- More likely to attract a newbie physician to subscribe to this rather than to an RSS feed in Google Reader.
- The ability to create bundles of blog posts, photos (Flickr/Picasa Web) or Videos (YouTube Channels) can make for great stream of updated content that learners can view in one place.

How intrusive will the advertisements be?  Lets wait and see.

Wednesday, December 7, 2011

Meaningful Use Core Measure # 13 - The Patient Generated Clinical Visit Summary

One of the Meaningful Core Measures is to provide a clinical summary of the office visit [PDF] to each patient.  This a well-intended measure as we know that patients will often retain only a part of all the information that they received at the office visit.  The summary needs to contain very important information about the visit and decisions made during the visit including patient instructions.

Patients when they leave the office often go out with a sheaf of papers and find it difficult to know which ones they really need to read.

I have been actually giving the patient the "task" of creating their own summary of the office visit.  Once we have gone through the history and exam and labs, I will engage them in a discussion on next steps.  Then I ask them to summarize the plans and action steps and write them down on a piece of paper.   They write down what they agree to do instead of what I would tell them to do.  They take this paper with them as a summary of the visit in addition to the EHR  generated printed after visit summary.

This activity can take a couple minutes but is incredibly powerful.  There is something about a patient's own handwritten plan that cannot be replicated by a physician generated print out.

This is a summary created by a hypothetical patient who was diagnosed with high blood pressure.
Patient Generated After Visit Summary
How different is it when a patient-physician discussion results in the patient writing down himself that he will cut back on the alcohol vs a physician telling him to cut back and then handing him a printed patient instruction?

This process has another advantage - it gives the physician an idea about the patient's literacy level.  This has to be addressed in a sensitive manner but is incredibly useful information that each physician should know but often does not.  This may also not be appropriate for patients with writing disability (Parkinson's or Rheumatoid).  In these cases you can ask a patient to tell you what to write down.

If you want you can take scan the handrwitten document with an app on your iphone or android and upload into the EHR (make sure your HIPAA police are OK with this.  One option is not to have any patient identifiers on the image like the one above)

Tuesday, December 6, 2011

Frictionless sharing does not work in EHRs

Mark Zuckerberg when introducing the latest updates for Facebook popularized the term frictionless sharing.  What it means is the user does not have to do anything specific to share something with friends on Facebook.  Thus if you are listening to some music on Spotify, your friends could see what you are listening to without your having to do anything.  You could opt out of this, but by default you are opted-in!

This is actually not a new concept.  Primary care providers have been exposed to this in the EHR for a while.  

  • One fine day, out of the blue, you get some results for liver function tests in your EHR inbox.  The test results are normal.  This is a young adult patient for whom you are listed as the PCP but you have not seen in several years.  You try to find out who ordered the tests and why the results were sent to you. After multiple clicks and 10 minutes of searching you find out that the person had a positive TB test and a normal Chest X-ray and was going to get started on Isoniazid (INH) by an infectious disease specialist.  The specialist thought she was doing the patient and me a courtesy by sharing this result with me.  I want to know what's going on with my patients but I think this process was too well lubricated.  We need some friction.  I want the specialist to put a short message to tell me the what and the why and just summarize that the liver tests were normal.  
  • Another day you start getting a stream of lab results for one of your patients.  Some of them are quite abnormal.  You drop everything to attend to these.  You find out that the patient is admitted to the hospital and the results are being copied to you as a courtesy.  Great, I get to learn that my patient is hospitalized and what is going on.  Problem is it was not urgent, he was already being attended to and all I needed to know was a summary of reason of admission and who the attending physician was in the hospital so I could contact him/her to discuss.
Doctors realized quite quickly that frictionless sharing in EHR is not efficient and while useful, it could be done in a much better way.  Automatic sharing increase noise/signal ratio and in an EHR world where doctors are swamped with copied charts, patient messages, refill requests and test results, it just does not work. I am sure we will realize that this holds true for the social media world too!  Actually we are being warned already!

Sunday, November 27, 2011

EHRs - Creating or Combating Information Overload? Time for Siri and Watson to step up to the plate

I have been using Electronic Health Records now for over 10 years.  Like most physicians who have used EHRs, I would not ever go back to a paper-based medical record.  

Having said that, it is important to recognize some of the potential problems created by some EHR products.  One potential pitfall of some EHRs is the number of steps it takes to find information that is in the system.  Yes, it may be easier to find than in an old paper-based system but it is still far from ideal.  Also there is a lot more information that is accessible.

To illustrate my point, let take a hypothetical scenario that most physicians will recognize from real life.

You are working in a hospital and you note that one of your patients has anemia on the complete blood count test.  Reported along with the hemoglobin are some other important numbers like the average size of the red blood cells.  This helps to narrow down the list of causes of his anemia.  One would of course want to make sure from the patient if there is history of this condition or of bleeding.  In addition usually you would need more data from the EHR e.g.
  • Previous levels of hemoglobin
  • A trend of hemoglobin values over several years
  • Previous work-ups for anemia like reticulocyte counts, iron studies, vitamin b12 levels etc.
  • Previous investigations for bleeding sources e.g. endoscopy or colonoscopy where appropriate.
  • Notes from previous consultations with a hematologist
This information tends to be quite fragmented in the EHRs which are often organized under categories like lab results, radiology, cardiology, notes, etc.  Reports of a colonoscopy procedure may be found under the notes section and the results of the biopsy done during the colonoscopy may be under the lab results section with no hyperlink between the two.  Recommendations from the gastroenterologist who did the colonoscopy may be found under the letter to patient section.  Collecting this information from the EHR can take a lot of mouse clicks and several minutes depending on the user interface and various hardware, software, database and networking variables.  This is time well-spent as this information can give one a diagnosis or at least guide our approach to care.

Unfortunately, this is usually only one of several issues that this patient might have.  He could have an abnormal kidney function test, a low level of sodium, an abnormality on the chest x-ray (with radiologist recommending a CT scan), a question of a prior heart attack on the EKG etc.  Tracking down each of these thoroughly could take a significant amount of time.  

To complicate matters the EHRs may be fragmented between inpatient and outpatient areas requiring additional work to access the ambulatory records.  

As all this time starts adding up, it may be quite tempting for providers to simply reorder a set of tests for working up the anemia rather than look up the prior information.  This process is made simpler due to "Order sets" that are available in EHRs to make test ordering easier and standardized.  Thus with a couple of clicks you can reorder all the tests and await the results.  

One of the potential benefits of EHRs is to prevent duplicate test ordering.  Unfortunately unless we develop ways for providers to more easily review data in a meaningful manner, this dream may not be realized.  The worst part of this scenario is that as providers order more tests, we have more data to review thus perpetuating the information overload.  

So what are the possible solutions?
  • Contextually appropriate menus -e.g right click on an abnormal test result to get prior test results.
  • Data visualization tools that can generate graphs of trends and associated factors with one click.  While most EHRs have graphing tools, it takes several steps (selecting data range, tests etc) to generate these.  
  • Built-in review sets - If we can have order sets for ordering related sets of tests, we can easily develop review sets for looking up test results and make these built-in.  Some EHRs allow providers to create these filters or review sets but a lot of physicians are unaware of this functionality.  
  • Have a view that is based on issues rather than dates.  Thus just like your e-mail client's conversation view, would it not be easier to see a patients problem list and then click on a problem to see all tests, notes, letters etc related to that problem?  Yes it would take some time to tag each item with the problem but the returns would be well worth it.
  • Have a mechanism for capturing the time spent reviewing data and automatically documenting a summary of the data reviewed with hyperlinks to the data in the visit note.  Presently physicians have to document what they reviewed by typing/dictating/copy-pasting into their notes. This is an inefficient process which could be improved. This will help the physician by saving time and also allow for billing using the time code. 
  • Dr. Watson and Siri?  Allow the Watson system to analyze the patient's EHR and then allow querying of the database using a Siri-like voice recognition and natural language processing.  
The Hype Cycle from Gartner
EHRs may be going through a peak of inflated expectations or the trough of disillusionment depending on your point of view (See Hype Cycle in Wikipedia).  As we start applying innovative technology to EHRs we should soon (hopefully) be on the slope of enlightenment that will help realize their full potential.

Friday, November 4, 2011

Non-Managed Learning to Change Behavior and Outcomes?

Recently I read a post about a terrific education experiment by Jeff Utecht.  He created tests about Google Apps and students took these on their own.  As they passed these tests they were awarded belts and widgets.  The students were self motivated and they answered the questions by searching for and finding information (no rote memorization).  Apparently the experiment was a resounding success.

Our Center for Online Medical Education and Training (COMET) is doing a similar project on a large scale.  Working with our office of healthy environment, we have created an "EcoCaregiver" course.  The 40,000 employees of our health system can self-enroll themselves in the course.  This is not Managed Learning!

The course has several modules:

  1. Waste Minimization
  2. Energy
  3. Food
  4. Water
  5. Sustainability
  6. Buildings
  7. Climate
  8. Toxic materials
  9. Transportation
Employees can choose the module/s they want to take.  For each module they successfully complete, they get a badge that they can wear/display.  As part of responsibility for earning a badge they will try and educate and enforce eco-friendly activities in their work areas, e.g. encourage turning off of monitors and lights etc.

The entire course is hosted on our Moodle-based collaborative learning platform.    Participants will engage in collaborative online exercises including writing blogs about their experiences and sharing these with each other.

I am glad to see the success of Jeff Utecht's Google Apps education experiment.  This hopefully bodes well for our large intervention that might change behavior and even outcomes!  

We go live in 2 weeks and will post about our experience in a few months.

Saturday, October 29, 2011

Using GoAnimate to create Case Scenarios

Case scenarios are critical in medical education.  They make the content more real and applicable to work and thus add value.  This point was borne out during a recent course I co-directed on the use of technology in medical education.  As a part of the course, physicians worked in teams to create eLearning modules.

4 out of the 5 teams chose to use an animated video to introduce their module.  One of these team chose Xtranormal for their video but the 3 other teams chose GoAnimate.  Physicians found it relatively easy to use these tools.  

One of the most striking examples of these videos was one to help introduce the importance of describing a skin lesion.  

Besides priming the learner for clinical content, these videos can be used as lead ins for training on communication skills or focused history taking.  
Here is a link to an animated video to lead in to a discussion on communicating with an Angry Patient.

Education technology folks working with faculty in medical schools or with residency programs should consider introducing these educators to use of animated videos in their teaching.

Summary of advantages of animated videos for medical education:

  1. Relatively easy to create
  2. Can be embedded or linked from any eLearning content or Learning Management System
  3. Makes the course content more real and thus adds value
  4. Makes eLearning more fun
  5. Can you used as basis for a face to face discussion with learners
  6. No HIPAA issues
  7. Easy to share/disseminate

Wednesday, October 26, 2011

Can physician adopt technology in Medical Education?

I was invited to help organize a 5 day course on use of technology in medical education for about 40 physicians.  Part of the course consists of the physicians working in small groups over the 5 days to create eLearning module that they would present to the rest of the class on the last day.

Over the first few days of the course we covered principles of instructional design, various tools for creating interactivity, various web 2.0 tools, theories of learning and knowledge and the community of inquiry model.

Today is the evening of the third day of the course and here are some very gratifying signs.

One of the physicians created this amazing first blog post.

Participants created incredible flowcharts and storyboards

And they worked together in very active groups

To cap if off one physician made our day by using some of the tools we demonstrated to create this animated video
GoAnimate.comThank You Liz, Tom and Neil!

by Aaron Ang

Have 2 more days to go but it already has been an incredibly positive, humbling and gratifying experience. Can't wait to see the final product demonstrations!  But I can already say the answer to the question in the title of this post is an emphatic YES!

Thursday, October 6, 2011

Steve Jobs - What if he had taken on the HIT challenge?

Yesterday, I saw something that made me think of the difference between a "techy" and a "regular" doctor's approach to technology.
We were installing an upgrade to a popular medical dictation software.  The upgrade was over the network and was to occur seamlessly overnight.
Unfortunately, in the morning when providers logged in, they saw a big message in the middle of their screens saying the software would now be installed and during this process, they would not be able to use various software including MS Outlook.
To make matters worse, this was a long install process and the message would stay on top of all other windows.

When the IT person was told about the problem the response was,
"What's the big deal?  Just drag the message window down so it does not interfere with other windows, and use web Outlook.  What if you can't dictate you notes for a while?  Just use the keyboard!"
I am sure a number of docs had figured that out and went about their work.  But many were complaining...

The world is made up of 2 kinds of people (simplistic view with lots of assumptions):

  1. Those who love Linux because it is open and they can tinker with it and troubleshoot it and they get a thrill out of making a difficult thing work.  Some of these same people would prefer a PC over a Mac because of similar reasons.  They love messing with the hardware and drivers and they know how not to get viruses.  They would hate a device where they cannot modify the OS or hardware!
    I would venture to suggest that these same people may also get a kick out of fixing their furnace and replacing a faucet.
    These might also be the folks in the IT industry.
  2. Those who want to take a device out of the box and just have it work.  They want to use the device to do what it is bought for without worrying about trouble shooting the device.

Fixing things and finding workarounds is fun and gives the person satisfaction from having solved a tough problem.  But when time is short, when there is important work to be done, when the interface creates inefficiencies, it causes a lot of frustration.  Having worked on both sides of the fence (Clinical and IT) it is quite obvious that the 2 sides don't speak the same language, are clearly not on the same page.  Our current EHR systems are a classic example.

Physicians probably don't know what exactly they want but they know what they have is not ideal.  They want someone to figure out what their needs are and create something simple that works that actually helps them take better care of their patients in less time.

I really wonder if Steve Jobs ever got to see one of these EHR interfaces and work-flows, saw the chaos of a clinician's day, the frustrations, the inefficiencies, ....
An iPad is arguably the best media consumption device ever made.  EHRs have a ton of data, and docs need a device with the right form factor and data visualization to consume information about their patients as they walk from room to room.

Would he have taken on the challenge to fix it?  Would he have made a difference in people's lives by improving care via better HIT products?  Did we lose a huge opportunity in his untimely death?

Sunday, October 2, 2011

Blogger Dynamic Views

Recently Blogger announced the Dynamic View Templates which can make your blog look very stylish and also increase the speed with which it will load.  So now you can allow a large number of your posts to show up on one page and let the user choose which one to read instead of scrolling through "older and newer" or other navigation methods.
There are seven templates to choose from.  I like the magazine view (shown here) but you don't have to decide on one. All the templates offer a drop down to choose a preferred view to the reader.

I did not convert my template to one of the dynamic view templates.  Instead I added a HTML/javascript gadget to the top right side that lets readers choose to see the blog in a dynamic view.  There are still browsers out there that will not support a dynamic view template.  At some point I will probably convert to a dynamic template.  

Thursday, September 29, 2011

The Indisputable Benefit of Social Media and Web 2.0

Earlier today, we submitted a proposal to do a workshop for medical educators on learning how to use Social Media tools.  Who is "We" you ask?
Therein lies the story.

Anne Marie Cunningham (@ancunningham) in Cardiff, Wales, UK
Natalie Lafferty (@nlafferty) at Dundee, Scotland, UK and
I (@Neil_Mehta) at Cleveland, OH, USA

As you can imagine planning the content and flow of a highly interactive and hands on activity needs excellent collaboration, best done face to face.  But we were separated by time and distance.

We planned the entire workshop using Google tools.  There are some really useful features (some recently added) that make it easy and efficient to collaborate.  I am going to highlight a few.

  1. Google Docs: We all know how you can create and share a Google document with multiple people.  The comment feature is particularly useful.  Much like MS Word, you can highlight a sentence and insert a comment.  But in Google Docs, if someone else comments on your comment, you automatically get an email with the new comment and a link back to the document.
  2. Google+ allows you to have a rich discussion on a topic and keep it private - between the collaborators.  You get e-mails when someone adds to the discussion and also get notification on the Google bar.
  3. Google Hangout provides a free method for multi-user video conferencing.  The quality is excellent as long as all parties have good broadband connections.  If necessary, one can "mute" the video to improve audio quality.
  4. Google Hangout recently added extra features which allow you to share your screen or even share and edit a Google Document collaboratively.  
  5. You can also take notes during the Hangout.  The notes are automatically saved in Google Docs and are available after the Hangout session.  Participants who clicked on and viewed the notes during the Hangout can see these in their Google documents.
  6. Scheduling a Hangout can be a problem as right now Google+ is not directly linked to Google Calendar.  But you can create Available appointment slots on your Google calendar and ask people to reserve these.  After trying this once, we switched to Doodle.
Overall I think all 3 of us learned a lot about these features and I for one would recommend these without hesitation for anyone collaborating over a different time zones or even across the campus!

There is a lot of buzz about using Social Media in (medical) education.  There are a lot of people reluctant to jump into the fray, often for valid reasons.  This story is a very good example of one indisputable advantage of Social Media and Web 2.0.  I have never met Anne Marie Cunningham or Natalie Lafferty face to face.  Still we got to "know" each other via Social Media (mostly via Twitter and reading each other's blogs) and found that we share a lot of common interests around medical education and were able to collaborate on a workshop at an international meeting.  
Social media helps us connect with people who one would never otherwise meet, and helps overcome logistic barriers to collaborate with them.  It helps broaden our horizons and in a true social constructivist sense, it  helps us learn.

Saturday, September 10, 2011

Making the most of learning opportunities - "Informal learning outside the classroom"

A Weekend Morning Story with a Moral for Medical Education

We wonder about how technology impacts education and whether it makes educators forget pedagogy as they eagerly incorporate the latest shiny toy or software into the classroom.  But there are times when I am just glad that we have the resources we do.

This Saturday morning I woke up to the sound of rolling thunder and rain beating against the window.  This was a matter of great import as I had to take our daughter to her soccer game about 40 miles away.  We were already cutting it fine (as we usually do for weekend morning games) as we jumped into the car.  Still I had enough of my wits about me to stow my iPad and MiFi between the seats.

You see I had a plan.  I knew the first questions she was going to ask me as she put on her cleats and her shin guards.  The questions would be:
1.  Dad, how far is this place?  Will we get there in time?
2.  Will they cancel the game due to the weather?

And instead of just telling her what I had already looked up, I asked her to fire up the iPad and look it up herself.  She knew this was going to be one of those trips, "I suppose you got the MiFi and you are not just going to tell me the answer!"  So we switched the MiFi on, connected to it with the iPad and were all set.  We had plenty of time, and so I let her figure it out.

So what were the tasks:
1.  Go to e-mail and get the address of the soccer field
2.  Punch that into Google Maps
3.  Fire up and look at the radar and cloud maps
4.  Learn what the different colors on the map meant
5..  Play the video to see which way the storm was moving.
6.  Estimate what the weather would be at the field by the time we got there.

The good news was that the storm was going to move out by the time we got there.  She loves soccer and she was thrilled to know that the game would be played.  I was happy to see that she learned how to use these tools to find answers for herself.  The technology made it possible to use her motivation and the car trip for this great learning opportunity.

As we work with medical students and residents, we have to remember that most of the learning does not occur in the classroom.  As we work together to solve clinical problems we should guide them and help them use various tools to find the answers for themselves.  

Saturday, September 3, 2011

Incorporating Web 2.0 tools in a Workshop on Web 2.0 tools for lifelong learning

Recently I organized a workshop for 1st year medical students on using Web 2.0 tools for lifelong learning.

Some educators have assumed that medical students are digital natives or early digital immigrants and thus just because of the year of their birth have an innate understanding of the Web and Web 2.0 tools.  This is an assumption that people are now questioning.

People currently in their 30s to 60's straddle the Web era having spent a significant portion of their "cognitive" lives prior to 1990.  They experienced "traditional education" and are in the unique position of understanding Social Media by activating their prior knowledge.

As I set about planning this workshop I had several questions:

  • How could I gauge the students' prior experiences with these tools? (begin without assumptions of the students experience and understanding due to being early digital immigrants)
  • How could I get them engaged in this topic?
  • I did not want to use a traditional lecture format to help them understand Web 2.0 education tools.  How could I incorporate actual Web 2.0 use into the education experience?
This is how I set up the workshop:
  1. Asked the class to create Google and Twitter accounts (could create an account that they could delete later if they did not want to share their real accounts with class).
  2. Created a spreadsheet on our internal Sharepoint site for students to enter their names, Google account and Twitter handles
  3. Invited the class to Google+ and put them all in one Circle.
  4. Asked the students to include me in one of their Circles so they could see my post.
  5. Asked students to follow each other on Twitter.  They did not have to follow everyone but maybe the colleagues from their PBL small groups.
  6. Asked the students to go to Google Reader and subscribe to PLOS  One Alerts (
  7. Click on the drop down next to PLOS One Alerts and click on "More like this" and choose Science Current issue.
    I could also have asked them to do the following but did not think of this then:
  8. In the search box type Google and Memory and see the results show the article we were discussing on Google+
  9. Read any article they liked from the 2 feeds and send to Twitter.  
Pre-Workshop Activities:
  1. Posted the Science article on how use of Google has changed the way we remember on Google+.  I limited this to the circle of students.  No one outside the Circle could see their comments.  Also disabled re-sharing of the post to keep the conversation private.
  2. Put some guiding questions under the link to the article:
    1. When you read information on the Internet/Web do you
      Remember the information or
      Remember how to find it or
      Both or
    2. How does this apply to how you study and learn medicine?
  3. Asked the class to comment on the article and these questions.
  4. I checked back and added comments to students' responses
At the Workshop:
  1. This was a 2-hour session.  I planned to spend the time covering
    1. Concept of Information Overload
    2. Need to use Web 2.0 tools to create filters
    3. Transactive and external memory
    4. Use of Google Reader and Diigo as examples of creating a Web 2.0 external memory system
    5. Define Social Media and types of SoMe
    6. Community of Inquiry model (Randy Garrison et al)
    7. Social Constructivism (Vygotsky) and how it relates to Social Media
  2. What we actually did:
    1. Audience response to gauge use of FB, Twitter, Google+ (could have used but just went with our clickers)
    2. ARS to see how many had tried the Google Reader exercise
    3. Discussion on these 2 topics
    4. Discussion on formal and informal learning and need to become life long learners
    5. Demonstration of Google Reader and how I use it, including sharing articles and commenting on them with residents and students.
    6. Demonstration of Diigo - especially the ability to highlight bookmarked pages and to take notes.
    7. Ask them to log into Twitter and post what they thought about the use of Google Reader and Diigo using a specific hashtag
    8. Break - I started Twitter Fountain and projected the posts with the hashtags on the screen.  As students came back into the classroom, they were able to see what everyone else had posted about what they had learned.
    9. Reviewed the discussion on the post on Google+ on the Science article.
    10. Examples of Twitter case discussions, Twitter journal clubs, Google Hangout
    11. Discussion and close
  3. What did I learn?
    1. Awareness of Feed readers and social bookmarking tools was very low.
    2. These were very enthusiastically received by the students.  A number of twitter posts were about how they planned to start using these.
    3. Students felt use of Social Networks in education was more appropriate for later stages of their training when they were more scattered and in less formal settings e.g. during practice, during clinical rotations etc.

Thursday, August 25, 2011

Doc why are you asking me all these questions? All that information is in the computer!

Disclaimer: This is a hypothetical case - any resemblance to anyone is purely coincidental.
Addendum 8/28/2011 Link to G+ discussion on this post 

Students learn about patient centered interviewing and focusing on patient problems and complaints.  That is the point of HPI (History of present illness).  When they come to work with a primary care provider, who has know his/her patients for a long time, some of these question can be irritating to the patient who expects the physician to remember everything about their health history.

The HPI helps when approaching a patient with a new problem. Students are often not familiar with the patient who has 5 serious chronic problems but no complaints.  They start by asking something like, "So what brings you in today?" and they get something like "Oh, this is just a follow up.  I am fine!" and then they don't know what to do next.

Part of the problem is that many medical students get only an acute exposure to chronic diseases.  They do an 8 week rotation in Internal Medicine where they almost never see the same patient again.

Recently I had a patient who came in to establish care.  She was the first patient of the day and she was 15 minutes late.  I had come in earlier than usual as I knew I had a third year student with me in clinic.  Because of these reasons, I got time to review her EHR data in some detail.  She had received all her care at our institution and this meant all her data was in one system.

The student was very bright and very comfortable with history taking but new to EHRs.  The previous day, she had faced the typical patient scenario, "Why are you asking me all these questions?  Its all there in the computer!"

After that last encounter, we had discussed how a lot of information can be gleaned from the EHR.  So we had decided to spend some time going over the strategy of using the EHR prior to seeing the patient.

We started off by looking at a Patient summary screen (a snapshot of her problem list, medications and health maintenance alerts). We saw that she had the following issues noted in the EHR by her previous physician:

1.  Hyperlipidemia
2.  Goiter
3.  Smoker
4.  Hypertension
Her medications included
1.  HCTZ 25
2.  Pravastatin 40

So in this patient we went over her chronic issues (problem list) and dug into each one to see what we could glean from the EHR.  This is how the conversation went:

1.  Lets look at the hyperlipidemia.  What would you want to know?
  • Last lipid level
  • Target LDL (how do we calculate this?) 
  • What medication, dose, is she compliant, tolerating?
  • Liver test results
  • Diet and exercise
So we click on Chart review >>; Lab results>> Select the last 2 lipid panels >> view in table form >> find that her LDL was about 150 1 year back.
We discuss ATP III >> go to the ATP calculator online >> put in her risk factors >> calculate that her LDL should be less than 130 mg/dL
We assume that whoever ordered that last lipid panel must have done something when the LDL came back above the target.  Go to Medication tab >> medication history >> sort by therapeutic class >> look for lipid lower meds >> find that she used to be on pravastatin 20 and had been increased to 40 mg after the date of the lab.  Did that work?  Lab results >> see that lipids and ALT had been ordered for 3 months after the change in dosage but not done.
So we create one agenda item: Find out if she is taking the 40 mg dose, and check lipids on that dose.

I recall reading about the new JAMA study on the dietary portfolio (oatmeal, soy and nuts) being better than just following a low saturated fat diet at lowering cholesterol.  Find it in Google Reader easily and share with student.
Create second agenda item: Discuss diet with patient and d/w her re' this study

2.  Goiter:  What questions do we have?
  • Has this been worked up? 
  • What was found?
  • What was done?
  • What is her thyroid status?
  • She is not on any meds so is she euthyroid?
So we click on the problem "Goiter" in the EHR and find that it was first noted in 2007.
Chart review >> Imaging>> USG thyroid >> has one large nodule and rest diffusely enlarged.
D/w student what she would do>> FNA >> Who does this? Endocrinology>> chart review >> Encounter tab >> sort by department >>Endocrinology >> saw them in 2008 >> had an FNA done>> Lab results tab>> Sort by test >> Surgical pathology >> Thyroid bx>> Benign. Also check last TSH >> low normal 2 years back.

Create agenda: Update problem list with this information so next physician does not have to do this again! Another agenda item: Ask also about symptoms and recheck TSH.

3.  Smoker: What would you want to know?
  • Is she still smoking?
  • If so is she interested in quitting?
Create agenda to ask these questions.

4.  Hypertension:  What would you want to know?
  • What is the BP today?
  • Is she taking her medication?  and side effect?
  • How has her control been?
  • Any evidence of end organ involvement?
In EHR to go graphs>> BP >> see that she is usually <140/80 over last 4 years
Chart review >> Cardiology>> Echo >> none, EKG >> normal (no evidence of LVH)
Chart review >> Lab results >> BMP>> Creatinine normal, K normal; UA >> no Hb or protein.

Create agenda: Ask about home BP measurements, does she have a machine, do cardiovascular exam for murmur, gallop, heave, bruit, pulses and look at fundus.

The student looks at me amazed!  She did not know the EHR could hold the answers to so many questions. I tell her how she can create her own agenda before going into the exam room.  Once she has elicited the patient's agenda and addressed it, she needs to cover the items on her own agenda.  Hopefully both the agendas are the same.  Hopefully there is time to cover both the agendas.  

We have spent 30 minutes discussing and reviewing all these issues.  We are lucky we got an early start and the patient was late!

So what is the point of this story?
1.  EHRs can hold an amazing amount of important information
2.  Getting this information out of the EHR takes a lot of time, clicks and knowledge of where to find this information.
3.  These benefits are visible when all the data is in one system.  If the consultants and labs and imaging were all done at different places, this would not be possible.  Even when external reports are scanned in, this data is not easily accessible.  As we develop electronic data interfaces this should not be a problem.
4.  Some patients expect that just because all the information is in the computer, it is also in the physician's brain!  Wish they could realize how much effort it takes to dig all this information out.
5.  As physicians use EHRs and spend time reviewing and summarizing the information, they should take time to encode it in a way that makes it easy for the next provider or the subsequent visit.
6.  Students learn how to get the history from the primary source but will also need to get comfortable getting the data from the EHR in a meaningful manner.  While looking up the information in the EHR prior to talking to a patient can create a huge bias and a kind of filter bubble, it is a great way to look up chronic problems.
7.  The time that it takes to review all the information occurs outside the exam room and it can become non-reimbursed care.  Doing this review is very important for patient care.  Will this become a non-issue once we move to ACO's?

Sunday, August 14, 2011

Health care and the Social (Media) Anxiety Syndrome - Do we need Baby Steps?

Let me state first off that there is no defined entity called "Social (Media) Anxiety Syndrome"*.  I am using it just as a metaphor. Social Media holds a lot of potential for the health care professionals.  Is fear of the medium inappropriately leading to professionals avoiding this "social situation"? Have we created a Social Media Anxiety syndrome?

We are aware of the social anxiety disorder or social phobia.  Among its many features are (this is a convenient list for the purpose of this post and not a strict definition):

  • Avoidance of interaction with others
  • Fear of being in a group, or being the center of attention
  • Fear that is made worse by a lack of social skills or experience in social situations
  • Possibly false beliefs about social situations
  • These factors lead to avoidance to of social situations.
Let us take a health care worker who has not used social media.  
  • It is possible that s/he would equate the term "Social Media" with Facebook and Twitter
  • Will likely be exposed to reports of unprofessional conduct on FB and Twitter and is afraid of getting in trouble
  • May be unaware of how one can have a closed Facebook account (so no patient can send you a friend request), how one can have protected tweets so only authorized people can see them.
  • Is quite unaware of useful applications of social media (e.g. RSS and feed readers to stay current with literature, use of Twitter to create a personal learning network, use of blogs to practice reflection etc.)
  • As a result avoids the entire medium. 
While there are clearly legitimate concerns about the use of Social Media by health care professionals, some of the potential problems can be averted by taking appropriate safeguards and some of the beliefs may be false.  It is possible that the voice of some experts is missing from the social media universe due to unfounded fears about this "social situation". 

Have we created a social media anxiety syndrome that prevents the voice of key people from being heard?  Do we need to develop some "baby steps" to help them?  Something like these:

Baby steps for Twitter:
  • Create a private account (Called protecting your tweets) and practice tweeting  - try adding a link to an online journal article and a short comment.  No one else can see this tweet unless you authorize it.  
  • Under “Whom to Follow” find someone whose ideas and writings you want to follow e.g.Atul Gawande.  His Twitter handle is Atul_Gawande.  You will now see their comments and links to articles and speeches.  
  • After you have added a few tweets, ask a friend or colleague who uses twitter to follow you.  You will need to authorize this.  They can give you feedback and show you some tips and tricks.
  • Create a private group twitter account - you can use GroupTweet for this.  This can be used to share informal learning objectives between residents on hospital service or longitudinal clinic)
  • Once you feel comfortable, you can unprotect your account and move towards creating a global learning network for yourself.
Do you believe that Social Media has some value for a health professional? If so would it be more valuable if more professionals were to participate in this medium? If so what is stopping them? Can we help remove some barriers? Should we even bother?

* [Since writing this I found that the term "Social Media Anxiety Disorder" has been used in 2010 by Phil Baumann for describing Pharma's Social Media Anxiety Disorder. The term "Social Network Anxiety Disorder was used in 2008 by Nicole Ferraro]

Friday, August 12, 2011

Getting comfortable with Uncertainty

Medical students are usually taught a rather comprehensive approach to history and physical exam.  They appear to go through a mental check list of all the things that need to be asked and examined.  They start off by following this check list regardless of presentation.  They may also think that a test is needed to rule in or rule out each condition on the differential.  It takes them a while to realize that a good history and physical can diagnose almost 70-80% of unknown cases presenting in the out-patient clinic and that even when one is not sure of the diagnosis, one does not always have to order tests.

When they first show up in clinics students tend to be quite confused that the clinical world is very different from the one they were training for.  The experienced doctor seems to ask questions in a very different order than what they expected and seems to be quite comfortable with uncertainty, tending to order far fewer tests than they would have thought.

What can we do to ease the transition to the clinical years?
Some techniques I have tried are:
  1. I teach a mantra that "Time is a diagnostic tool".  This is particularly true in outpatient medicine.  Some conditions can best diagnosed by waiting and watching.  Either they will go away or they will show new features which will help diagnose them.  
  2. Empiric treatment is also a diagnostic tool.  Sometimes a short course of medication can help - if the condition gets better (or it does not) it can point to the diagnosis.
  3. I give them a framework and ask them to try and place the patients possible diagnoses (from the differential) into one of 3 buckets (categories):
    1. Potentially serious (e.g. life threatening) and urgent (needs to be diagnosed or ruled out quickly)
    2. Potentially serious but not (very) urgent  - this is on a scale 
    3. Likely not serious and not urgent
I then ask them to see if they can eliminate any condition on their differential that falls into category 1.  If that cannot be done, they need to absolutely do some thing right away including ordering a test.  If they can, then they have time and then they can try still order a test or try empiric treatment or wait and watch.

Forcing a student to try and place the likely possible conditions in these categories helps them ask the questions that matter rather than go down a checklist of HPI and ROS and PMH that are often irrelevant.

They students are often confused that they spend a long time with the patient asking questions and doing a head to toe exam and then when the preceptors talk to the patient, they ask one or two pointed questions or check a couple of physical exam findings that change the management completely (see table).  Discussing this with the student early in their clinical rotation can help smooth their transition and reduce their frustration.


Category 1

Category 2

Category 3

Low back pain

Epidural metastases (history of cancer), abscess (Systemic features of infection), (Spine tenderness), (Nocturnal pain)

Sciatica (Straight leg raise test)

Muscle strain (paraspinal tenderness, history of unusual exertion)

Chest pain

Acute coronary syndrome (previous stress test/cath,), aortic dissection  features of affected arteries or nerves e.g horner/recc laryngeal etc)

GERD, viral pericarditis (systemic features, rub, EKG findings)

Rib/muscle strain (reproducible tenderness)


Aneurysm (neuro findings check the pupils disc), Temporal arteritis (age, jaw claudication, eye symptoms, scalp tenderness)

Migraine (photophonophobia, triggers, caffeine)

Scalp hematoma from minor injury

The items in parentheses are just examples of types of questions or exam findings that may not be part of the standard check list that a student my use. These not meant to be inclusive of all such questions. Also there are several guidelines that students can be directed to e.g. the guidelines regarding which head injuries should get a CT scan.

[This is not to say that there is no role for the comprehensive H and P.  Often the students will discover something important about a patient that their primary care provider was unaware of.  This is especially important in someone who has an unresolved symptom/s even after being seen by multiple providers/consultants.  A fresh look at the case with a systematic approach can reveal clues to the answer.

Clinicians will sometimes miss a diagnosis but if the patient is appropriately instructed regarding any red flags and followed closely, the prognosis will usually not be any different.]

Saturday, July 16, 2011

Using Social Media in Medical Education

Recently I gave a medical informatics grand rounds on the topic of Social Media in Medical Education.  The overarching goal of the presentation was:

  • to expose the audience to various examples of use of SoMe in education and
  • to let them draw connections between some of the theories of learning (and knowledge) and these examples

The outline of the presentation:

  • Get beyond the issues of Professionalism.  While a very important issue it should not scare students and physicians away for a potentially very useful and powerful medium for learning
  • Brief overview of some theories of learning and knowledge.  To make the point, I somewhat oversimplified these - took some editorial liberties with the descriptions.  This was done keeping in mind the needs of the audience.  Also this was not the focus of the topic.  I was making the point that some of these create a good framework to help understand the role of social media in education. 
  • Differentiate Social Media and Web 2.0 from static one-way media like print media.
  • Types of Social Media - Publishing, Sharing, Discussing, Networking, Location, Commerce etc.
  • Reference to recent Talk of the Nation on NPR re' the education of Net Generation.
  • Examples of use of Social Media for education
    • Blogs - opportunities for conversations with thought leaders (George Siemens), place for personal reflection, and sharing those with society.
    • Watching a Khan Academy video and summarizing it in a blog post.
    • Google+ example of deep and rich conversations with experts whom you would not normally be able to communicate with.
    • Twitter example of #meded chats and #twitjc journals clubs (reference to one on surgical checklists that had Atul Gawande participating, case discussions (Nick Bennett's #micro140)
    • Hangout - examples of use - can we use this as a model of office hours for professors (Stephen Downes)
    • The web 2.0 learning cycle from Google Reader to Blogs and Social Learning Networks with examples of how interacting with people in these networks has generated rich discussions and new ideas. 
    Using social media in medical education (link to Slideshare - view with speaker notes) (These slides were edited from a presentation at medical informatics grand rounds.  The slide notes were added to substitute for the lack of an audio recording).

  • Our trainees grew up with online social media, this is how they collaborate, interact.
  • When they enter the medical profession, they can leverage these skills to enhance their learning. 
  • While they need to be aware of how to be professional in this space, let us not scare them away from this potentially useful tool. 
  • Our educators need to keep an open mind and personally experience this medium before passing judgment.

Thursday, July 14, 2011

Sharing from Google Reader to Google+

One of the tenets of social constructionism is that learning is most effective when a learner's experience includes constructing a meaningful object.  In the world of online social media, this can include a blog post or a comment on an article.

I tend to read all my journals as an RSS feed in Google Reader.  I have blogged about this model before.  I then use Google Reader's "Send to" feature to share certain articles on Facebook or Twitter with a few additional comments summarizing my take home points on the article.  This can generate some additional comments from followers and friends sometimes leading to rich discussions.

Googleplus is a terrific tool for such discussions.  
  • I have a chance to share with a wider audience (since I don't limit my circles like I did on facebook) 
  • There is no 140 character limits like on Twitter and the comments are organized like a conversation.
Big Problem:
Google Reader does not have a Send to Google+ feature!!  Google what were you thinking?  Sparks is no replacement for Google Reader.

Now there is a nice workaround
  • On Chrome:  
    • Set up Buzz to connect to your Google Reader shared items
    • Share from Google Reader to Buzz
    • In G+ profile page to to the Buzz tab
    • Click on Share in the Google bar at the top right of the page
    • Drag the hyperlinked title from item in Buzz to the share box, select your circle and share
  • In FireFox (courtsey 
    • You can drop links from Google Reader items directly to the Share box on the top right.  
  • In both cases, make sure you first click to open the share box.  Then drag and drop the link.
Have fun!

Monday, July 11, 2011

Educational Applications of Google+ Hangout

Google+ has taken off like a rocket growing to an estimated 4.5 million users in 1 week.  One of the "wow" features of G+ is Hangout.

Hangout allows you to create a multi-user video chat with up to 10 participants.  You see feeds from all 10 webcams at the bottom of the screen.  When person speaks, the software automatically presents the speakers webcam feed in the main window.  The quality is remarkably good depending mainly on the connection speed of individual users.

An additional neat feature is a G+ user can start a Hangout session that is visible only to a specified group of contacts.  There is also the ability to carry out a concurrent text chat session.

So how can we use this educationally?  Here are some examples:
  • Pose a question to a Twitter chat audience e.g. #meded and allow groups of participants to discuss the question in a Hangout Session and then report back to the Twitter stream.
  • Upload a YouTube video of a hypothetical case - use an animation tool to simulate a doctor patient encounter.  Launch this video during a Hangout session so all participants can watch it together, and follow this up with a moderated discussion.
  • Invite thought leaders to discuss a controversial topic on a Hangout session.  Record the session using something like CamStudio.  Then upload the entire recording to YouTube to share with viewers.  Can use this YouTube vodcast as focus of a future Hangout session.

So what do you think?  The technology bar has really been lowered.  You can with this free tools bridge geographic and logistic divides to have a real conversation!

Saturday, July 9, 2011

Lesson from Agatha Christie: Rediscovering Windows Tablet and OneNote for education

In the last 3 months I feel like I am living an Agatha Christie murder mystery.  Agatha Christie had several tricks for preventing us from guessing who the murderer was.  One trick she used multiple times was to have a person be the prime suspect early on in the book.  Then they would be exonerated and we would start thinking of someone else.  In the end, that would be the person who would be revealed to be the murderer.  So what is the point of this?

Instead of a murderer, suppose the question is "What is the right computer and software for (medical) students?"
Many years ago I had thought it would be a convertible Windows tablet computer with OneNote.  After trying it out for 2 years our study showed that students did not find it useful.   Since then having explored many other options, including netbooks, PDAs, regular laptops and iPads, I am gravitating back to the Windows convertible with OneNote.  Why do I say that?

Lets start by identifying some requirements:

  1. A device that is portable (relatively speaking) - size, weight, battery life
  2. Has both a keyboard and ability to write on the screen - ideally with both stylus and finger - drawing concept maps, take notes, 
  3. Options for installing from a wide menu of open source useful software.
  4. Capture digital information from multiple formats (documents, presentations, web pages) and store it for annotation, highlighting etc.
  5. Flexibility in organizing all the artifacts in various ways - at various levels - e.g. move things around easily on a page, organize pages under sections etc...
  6. Share working material with multiple collaborators and with multiple computers 
  7. Allow multiple collaborators to work on same document
  8. Be able to work online and offline - with automatic/seamless syncing of material.
  9. Mechanism for someone who does not have the software to be able to at least see the material.  (The assumption in this model is that all students have the same setup.
So the solution I am looking at is a smallish convertible HP elitebook 2740p with Windows 7 and Office 2007 or 2010 which includes OneNote.  

The HP 2740p has a screen that supports both stylus and multi-touch.  It has a very slim unobtrusive battery that extends its life to 10 hours.  
OneNote has terrific features - everything I mentioned above - with some outstanding features being:
  1. The file organization is built into the software itself - thus no need to look for the file explorer to find what you need 
  2. There is a superb search feature - that catalogs every artifiact
  3. You can grab any web page or part of it with a screen clipping tool
  4. Handwriting recognition tool
  5. Print to OneNote option from your list of printers
  6. Ability to move artifacts around on a page like post it notes
  7. Awesome and flexible heirarchy of organizing - Notebook>Section Groups>Sections>Pages>Subpages
  8. Internal hyperlinks to any page or artifact on a page
  9. Live sharing by IP address with anyone over the Internet
  10. Shared notebook feature for working with collaborators
  11. Audio narration, video captures
  12. Tag pages/artifacts with question mark, star, to-dos
  13. Am sure there is a lot more.
Here is an example of me working on my thoughts regarding Google+ and how it is similar to and different from Facebook and Twitter.

I created a new Social Media Notebook
Created sections for each of the 3
On page one of Facebook you see a list of topics I planned to write about. 
2 of them are checked off
There is a diagram of who sees whose posts on Facebook.

On the next page I am collecting artifacts that I can use to think about the Facebook privacy settings.
These are screen clippings with my annotations - was quickly able to scratch over the identifiers on the screen clipping.  

In the last few months I saw the HP elitebook 2740 with it stunning features and immediately recalled the thrill I had felt in the early 2000's when the first windows convertibles came out.  
I saw how one of our medical students used OneNote on a regular windows (non-tablet) laptop to collect all the information he had come across in year 1 of medical school
I saw how a local middle school has every student use a similar convertible laptop to collaborate with each other and with the teacher for 4 years, collaborating on group projects even from off campus, submitting assignments by sharing sections with the teacher who can annotate the assessment in a shared space and build their portfolio of learning.
I saw how we can keep a shared notebook on a shared folder on dropbox and use the online OneNote app.  

Sometimes the best solution is the one that is right in front of you.  Just like an Agatha Christie book, the solution was the first suspected one!
OneNote might be the best software that did not get marketed!  It may be time to rediscover this.