A guest post from Dr. Cheryl Kerr, pediatrician and co-founder of ClickCare...

A few years ago, I was in the middle of an afternoon of patients when a 18-year-old girl came in with trouble walking.

L's Mom had dragged her into my office despite L's protests that she had probably injured herself at swim practice. When I asked L to walk down the hallway, I got chills. It sure didn't look like a twisted ankle: a classic part of the neurologic exam (walk on your heels) showed her right foot did not dorsiflex. My first impulse was deep concern because I really needed a consult. But from whom? An orthopedist? A neurologist? A neurosurgeon? The usual wait times to get in to see any of those specialists can top 8 weeks. Who should be first? Which specialty was most appropriate?

Luckily, I was able to use an early version of iClickCare to send simultaneous consult requests to the orthopedist, neurologist, and neurosurgeon. Within hours, when they had a chance to take a look at the consult, the orthopedist felt that since it was not an injury, another speciality might offer more. The neurologist, 2 hours away by car, offered to see the patient, but absolutely could not fit her into the schedule for a few months.  

The next day, the neurosurgeon operated on L, removing a spinal cord tumor.

When people ask me why we chose a "Hybrid Store and Forward" model for iClickCare's telemedicine platform, I always think of L. We chose this kind of collaboration (instead of teleconferencing, secure text messaging or any other platform) because it is the only option that allows: 

• Use of text, pictures, and video (crucial for sending a video of L's gait) 
• When-you-get-a-chance consults that let colleagues respond on their schedule
• No need to juggle time for video conference setup
• Simultaneous consults to let you ask questions of multiple folks -- in this case, an orthopedist, neurologist, and neurosurgeon
• Archiving of cases and media so that you can use them to teach and collaborate in the future

Curious how other providers use Hybrid Store and Forward telemedicine for medical collaboration and care coordination? We put together a free guide to pros and cons with a collection of case studies.

And for our overview of telemedicine options, advantages and disadvantages of different types, and a discussion of ROI: 

 

One advantage of hybrid store and forward telemedicine is that each and every medical collaboration becomes a teaching case. And store-and-forward, recorded video clips can be very exciting! This report of using Google Glass to allow students to see a surgeons view even from miles away is intriguing and wonderful. While only 1000 devices have been released for "Google Explorers", the concept fits one of our design philosophies: 'Use what is available.' This event was reported 16 September 2013, and not in the medical literature, but rather in the audio visual literature. 

A student was quoted:

“To have the opportunity to be a medical student and share in this technology is really exciting,” said Ryan Blackwell, a second-year medical student who watched the surgery remotely. “This could have huge implications, not only from the medical education perspective, but because a doctor can use this technology remotely, it could spread patient care all over the world in places that we don’t have it already.” 

We imagine that a student of Vesalius, Morgani or Fallopio, on 16 January 1594 would have been similarly excited. Consider he's standing in the Fabrici d'Aquapendente, standing, because it is to crowded to sit, with 200 people crowded over a dissecting table, he shares the fascination with future colleagues. We imagine William Harvey standing in the third and fourth row, first conceiving of the idea of circulation. We, ourselves, as newlyweds and medical students just finished with anatomy, had the privilege of visiting and stood in that same amphitheater and wondered...to this day.

The disseccting table was unique. It flipped the body at a moments notice, dropping it into a boat floating below in a secret canal. With the table turned an animal showed up on the other side. Dissection was implicitly, if not explicity, illegal. We wonder, also if, Dr. Christopher Kaeding, should have had something similar for HIPAA, HITECH and the Omnibus 2013 Reconciliaiton Law!

Try doing medical education (and collaboration!) for free on the iPad...

References:

Anatomic theater image: http://www.chimica.unipd.it/ispe12/Teatro%20Anatomico.jpg

http://www.c2meworld.com/consumption/ohio-state-doctor-shows-promise-of-google-glass-in-live-surgery/

http://www.unipd.it/esterni/visiteweb/english/pagine/teatro.htm

Which autobiographical account inspires you?

Lean In: Women, Work, and the Will to Lead, Facebook COO :Sheryl Sandberg (2013)
OR
Until I Say Good-Bye: My Year of Living with Joy :Susan Spencer-Wendel (2013)

To give you a tiny taste of Sheryl Sandberg's book, here are a few of the chapter titles:

     - Sit at the Table
     - Success and Likeability
     - Don't Leave Before You Leave
     - Make Your Partner a Real Partner
     - The Myth of Doing it All

Sheryl Sandberg is on Forbes' list of the most powerful people in the world. In her book, she encourages ambitious women to realize their own career goal, but also to make changes in their workplace so that other women can succeed, too. Sandberg tells women to have confidence in themselves and their knowledge, and to own their achievements.

I don't know if Susan Spencer-Wendell read or is trying to read Sheryl Sandberg's book. Susan is an award-winning journalist for the Palm Beach Post, who learned in June 2011 that she had amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease). At that time, she was 44 years old, with a devoted husband and 3 young children. She was so determined to complete a book describing this experience for her children and the rest of us, that with her minimal strength, she typed the manuscript with one thumb on her iPhone. No longer able to walk or even lift her arms, she tapped it out letter by letter. USA Today on March 11, 2013 speaks of some of the fabulous lessons expressed in this memoir:

"Her "year of joy" included everything from traveling in hopes of witnessing the Northern Lights — she did not — to tracking down family roots on Cyprus — she did — to visiting Kleinfeld Bridal in New York with her teenage daughter, Marina, only because she knows she won't be around when the real pilgrimage will take place."

Her children Marin, 15, Aubrey, 11. and Wesley, 9, have been adapting to the situation. Their Aunt Stephanie says: "They rub her nose. They brush her hair out of her eyes. They have very normal routines with their mother. Nothing is strange."

This goes to show that there are a lot of heroes here. Reportedly, Susan didn't want to switch to another piece of high-tech equipment because she didn't want to lose the time needed to learn another system. With her laser focus, her habit of meeting deadlines, AND HER RIGHT THUMB, she wrote the 362-page book Until I Say Good-Bye. It's now available on Amazon, and movie rights have been sold to Universal.

This is definitely a new twist on Store-and-Forward. After reading this book, like the effect of all good medicine, I felt lighter and stronger and more accepting. Susan says: "don't force the world to be the one you dream; the reality is better." If she can say that, most all of us can say it more and do more.

Sheryl Sandberg's Lean In is also inspirational. "Sit at the Table" is up front and center; otherwise how can one hear or be heard. She says that opportunities are rarely offered; they are seized. That's an understatement!

There are many criticisms (jealousies?) of Lean In, but it is an important follow-on to Betty Friedan's The Feminine Mystique and Gloria Steinem's Revolution from Within. Sheryl is a 43-year-old former Google executive with two Harvard degrees, who is calling on other women, as she puts it, to "lean in" and embrace success. Even though Sheryl knew the business world was listening, she had the intestinal fortitude to include personal examples, that readers are dying for, which are definitely supportive and inspiring. Moreover, the cited research is impressive, for instance the data showing positive correlations between success and likeability for men, and negative correlations between success and likeability for women. Sheryl's bibliography and footnotes are lengthy, and the statistics support the thesis that even in 2013 — women simply aren't making it to the top. She says: "Ten years of no progress is no progress" (spoken like a real COO). 

NPR relates: "Warren Buffet has very generously said that one of the reasons he was so successful is that he was only competing with half the population. Companies that use the full talents of everyone — those companies do better."

One of the HUFFPOST quotes from Sheryl's book is: "if we want a world with greater equality, we need to acknowledge that women are less likely to keep their hands up." Further a quote about working together: "As women must be more empowered at work, men must be more empowered at home."  Download "Caring for Baby" to help with that effort.

We need all of the people in this country and the world striving to be better, helping each other, and sticking their neck out to do that. She says: "This revolution will happen one family at a time."

Where have you heard that before?  Give your patients access, collaborate with their other providers, and leave a legacy of education. Let's get on with it...one step at a time; one thumb, one family, one patient, at a time.

Let us help assure funding continuation by making it easier for your project to access care for patients, empower providers to collaborate and educate future providers. A common thread found in the many, many of the awardees, is care coordination and that is the mission of ClickCare as recently described in the NYTimes and in a shout out by Steve Wozniak at the American Telemedicine Association.

CMS says that the following is involved for the continuation of funding:

            Replicable innovation:
The Affordable Care Act (a.k.a. Obamacare) may or may not change things, but iClickCare replicates coordinated care.

            Rapid implementation, 6 months or sooner:
ClickCare stands ready, with its agility, compliance and quick implementation. Six months can pass alarmingly quickly, especially when a program is being launched. December 6 is predated by summer, Thanksgiving, and the holiday season. That is not much time to work. We invite you to piggyback on 16 years of experience and software development.

            Workforce development and deployment:
Their frequent references to using midlevel providers to provide care. This is certainly a topic of our times, but is it innovative?  What about collaborating with those who are really at the bedside, home and workplace?  And doing it in a simple and user friendly manner!

            Efficient and sustainable use of funds:
Implementing iClickCare involves a software subscription on the internet, iPad or phone for a very low price that is further discounted for volume customers

            Reporting and monitoring:
iClickCare can provide both consultation and service to allow each member of your team to not only transfer data, communicate, coordinate, but also collaborate. Everything is archive and pdf reports show usage.

We at ClickCare stand ready to help you meet your goals of improving healthcare in our country!

We are awed, inspired, and appreciative of the contribution Steve Wozniak has made. As a pediatrician, I also know that stability, success and optimism must necessarily come from within, but need to be modeled by someone else.

At the American Telemedicine Annual Meeting 2012 keynote, Steve was asked about his family.  He mentioned some things about his father which may have made Steve, Steve. Listen to these few seconds of tape, captured, of course, with an iPhone, as he speaks of his childhood development and of his Dad.

Why are these comments included in this blog?  It's because we wish all Fathers the very best everyday, but especially on Father's Day, June 17th, 2012. And it is particularly impressive that in addition to everything else Dads do, like Steve's Dad, many also:

1. Are patient teachers

2. Bring out the best in their children, for a lifetime, and

2. Inspire laughter, which is very good medicine, along with medical collaboration and accountable care.

Steve Wozniak is also a published author with the release of his autobiography, iWoz: From Computer Geek to Cult Icon, available (as is our book iPhone Medical Photography) at these retailers:

Apple ITunes Store:

Amazon:

Barnes and Noble:

Google:

It all starts the beginning.  Share Caring for Baby.

Let me tell you a story about how these how these three resolutions for the New Year came to my mind.

My beeper went off for the emergency room on the day after Christmas. I was called to suture a chin laceration on a 14 year old middle linebacker who fell while ice skating with his sister.

After a couple of relaxing days off, I was shocked by the stress shown on the dedicated faces of the staff, from triage nurse to provider to aide. The sad part is that the stress was not from a sad death or a worrisome epidemic. It was due to our medical system-gone-bad where care for the patient has been distorted from care to “through-put.”  The pressure to perform, measured by quantity rather than quality, has become pervasive. Such quantity, of course, is supposed to be documented in our electronic health records which are often of dubious value to the problem at hand. We are victims of a broken system, but, we can control ourselves.

So here are the three resolutions that came to mind and hopefully will make the next year happier for us all.

1. Be kind 

2. Be collaborative

3. Be inventive

Of course, you are already trying to be kind to your colleagues. It is not their fault that they are grouchy, stressed, superficial, or non-communicative. Arrogant specialist or non-expert primary care provider... cut each a little slack.

You already want to collaborate with your colleagues. It makes you feel more relaxed, more confident, more efficient, more satisfied  You regain time for yourself from: telephone tag, cognitive clutter, or followups. You regain time from inefficiency and redundant work. You receive the satisfaction of having done the right thing.

Since you are the one in the trenches, you are often trying to be inventive. It is you who have the experience. Fix a little thing for yourself and you will fix it for others. The government wants your help. http://www.innovations.cms.gov/initiatives/innovation-challenge/  We can’t fix everything, but we can fix some things, and together maybe we can make a real difference. We welcome you to share your ideas with us via email or this blog.

This goes along with what JFK said: Ask not what your country can do for you, ask what you can do for your country.”  Just this new thinking may relieve stress for you and your colleagues in the new year. And further, we've attached Chapter 1 of Medical iPhone Photography for taking better iPhone collaborative clinical pictures to relieve your stress even more. After the holiday season, the full version is sold on Amazon (and the App Store and Barnes & Noble), in both electronic and Deluxe Paperback Edition.

• More than clinical photography? Can you photograph the xray viewer?
• Can you send ECG's or gastroscopy findings?
• What are some traps that need judgement?

We continue to be excited sharing decades of experience in use of photographs for better collaboration. In this chapter, you wil feel even more comfortable in documentation both descriptively and visually. Medical students, therapists, aides, all can send each other those unique pictures which will enhance care coordination and make healthcare immensely better.

For the past couple of months, our readers have seen how to enhance quality from that small camera "in your pocket." Together we are amazed at the results of imagination coupled with these simple techniques. We also marvel how simple and "good enough" combine with good judgement and good intent to greatly benefit the patient, but also give satisfaction and peacefulness to the provider.

This is the next to last chapter in Medical iPhone Photography until the book is complete...as both an iBook for the iPad or iPhone or a PDF for everything else. Then the book will become available in printed form for holiday giving to your favorite healthcare provider.

• Need for motion
• Limitations, are there any?
• Orientation, always land with the head up!
• Lighting helps

The previous chapters reminded us to: Take the picture. Hold the camera still. And archive the picture for easy retrieval! But what if the subject to moving?

Consider trying to analyze and describe a gait. A limp, unsteadiness, foot drop, hemiplegia, and tremor are all hard to describe...without a secure 15 second video! See the videos in our interactive PDF (on your desktop) or in the live EPUB (on your iPhone or iPad). Be in on the action.

Throughout the course of these 9 serial lessons we will show you how to maximize the remarkable capabilities of the iPhone, understand the principles of medical and clincal photography, and feel comfortable with documentation both descriptively and visually.

There is quite a history, but the value of good consistent clinical photographs is without change.

At this point in time, the quality from that small camera "in your pocket" is amazing because the picture is taken instead of missed. When coupled with the techniques in these chapters, the communication is only improved.

Medical iPhone Photography will be released one chapter a week until mid December...as both an iBook for the iPad or iPhone or a PDF for everything else. Then the book will become available in printed form for holiday giving to your favorite healthcare provider.

• How to get clear photographs,.

• How to zoom and use macro.

• Pardon me, but what about gloves?
  

Tricks for iPhone camera handling are discussed. It is also remembered that a blurry photograph is frustrating to see (unless it's a background) but it can be better than nothing. Whether you're a physician, a nurse practitioner, a therapist, an aide, or a specialist or anyone else who cares, this is just part of good communication.

While you are taking Thanksgiving pictures, REMEMBER TO HOLD THE CAMERA STILL. Clear photographs will even make Thanksgiving happier!

What a weekend!  We attended an exciting conference one day, and stumbled on a living legend the next.  Read how a confluence of disparate backgrounds gives all of us hope for the future and suggests that we can change the world.

"Pete, what is the greatest change that you've seen in your time?"

"The Information Revolution...if we use it right, it may save the human race."

Saturday, we found Pete in a local art shop in Beacon NY.  Peter "Pete" Seeger (born May 3, 1919) is an American folk singer and an iconic figure in the mid-twentieth century American folk music revival. Some of his favorites are: Where Have All the Flowers Gone, If I had a Hammer; and Turn, Turn, Turn. Pete has led people in improving, reclaiming, and detoxifying the Hudson River Valley.

The day before, we had the honor of hearing Todd Park, the CTO of Health and Human Service speak at the Tech Garden in Syracuse, N.Y. on Unleashing the Power of Data, IT, and Innovations to Improve Health

• decision support
• care management tools
• extended physician reach
• consumer engagement tools
• data mining

It was most inspiring that Todd said that we can innovate our way out of the healthcare crisis... care coordination, collaboration for improved health outcomes. Todd Park is a dynamic, charismatic speaker, and he was speaking to innovators of all ages saying that we have the greatest entrepreneurial opportunity since the birth of the internet. He talked about "a stitch in time," ACO's, meaningful use. CMS has $10 billion to use for reasearch and development to get value out of our recorded health data. He says that we shouldn't be paying for volume of service, but, instead, we should be paying for improved health and increased value.  This Land was Made for You and Me!  Certainly innovating our way out of the healthcare crisis would be a way of showing Pete that we are trying to use information in the right way.

To this end, Todd he moved his family and two very young children to Washington to liberate health data (Gov 2.0) and inspire the rest of us to improve the efficiencies of our country's healthcare. He said that he has never been so proud to be an American since he became the CTO of HHS. He wants to turn HHS into the NOAA of healthcare (NOAA is responsible for the data that spins The Weather Channel, weather.com, and nightly news weather, all in the interest of providing weather knowledge for our good). Think what this parallel could mean if applied consicentiously to healthcare delievery!

And feel free to check out the iClickCare innovation to make our medical days easier.

See a clip of the performance here.