Electronic Medical Records: Who's On the Menu?

with caption 'EMR's are saving time, money and making people safer how???' by El Mnopo

I recently finished The Last Lecture, the book written after Randy Pausch's inspiring lecture that delved into more of his stories. One of them brought to mind both the error message from an electronic medical record (EMR) above and some frustrating databases I've encountered. Dr. Pausch used to bring in videocassette recorders (VCRs, remember those?) to his classes on one day, then a sledgehammer on the next day to destroy them in front of his startled students. Why?

When we make something hard to use, people get upset. They become so angry that they want to destroy it. We don't want to create things that people will want to destroy.

His hope for his students creating new technologies now is that

Once in a while I come into their minds, swinging that sledgehammer, reminding them of the frustrated masses, yearning for simplicity.

While I can't advocate taking a sledgehammer to EMRs (they cost a heck of a lot more than a VCR) I can certainly understand the temptation to do so from system demonstrations/screenshots I've seen in addition to watching when the nurses, my doctor & lab staff enter data into my own. Simplicity seems to be an impossible dream for current systems, even if they are considered really good ones.

Nonetheless, the push is on to mandate EMRs in the United States and Scotland's National Health System is on track to be the first paperless health service in the world.

If you aren't at the table, then you are on the menu.

This response from Dr. Val Jones to Dr. Rob's discussion about a healthcare reform article isn't new but it is relevant to the healthcare information technology (health IT or HIT) stakeholder discussion for EMRs and the amounts of future funding coming down the federal pipeline for them.

Who is at the table? According to Dr. Rob, "Politicians, hospital corporations, pharmaceutical and insurance companies, and lobbyists". There is no mention of physicians or patients, the core of health care, although in theory they are there.

A look at 'Making Health Information Technology Work' at HealthIT.hhs.gov, bold emphasis mine, includes

Health IT will help consumers gather all of their health information in one place so they can consider it in as a whole.

It's important to note this is not about having a patient's health information in one place for a clinician to 'consider it'. How does a complete collection of health information transfer into patients' knowledge and understanding in order for them to 'consider it'? There is no Google Translate button for clinical data in EMRs to convert to consumer health language, and even if there was I wouldn't want to make decisions about my health based on that output.

How do you get the public to care about and support EMRs/health IT? A good first step is the video below that is available here:




How do you get medical librarians to care about and step up to their roles in EMRs and health IT? Yes, there are roles to be had here. Check out Librarians and the EHR: Envisioning the Future, which is where I learned about Woods Hole & why I applied to go there in order to develop a health informatics class geared towards medical librarians' involvement in health IT and particularly EMRs.

It was during a presentation at Woods Hole I learned about medical librarians' front-and-center involvement in a patient information portal not from the presenter himself while he was demonstrating the system, but on Twitter from Rachel Walden with a link to this 2007 JMLA article that covers their experience.

If that doesn't emphasize the fact that nobody will invite medical librarians to the table unless we step right up and take our own seats there, I'm not sure what does.

Perhaps a stronger version of 'you're on the menu' line may help. We are in the 21st century, where medical libraries are being abruptly closed or the librarian retires and institutions decide not to fill the position. Like the video above, the Vital Pathways resources are a step in the right direction for medical library advocacy although rather vague on direct librarian EHR/EMR/HIT involvement and I'm hopeful for much more meat in the white paper.

Perhaps the majority of medical librarians don't care about involvement in health IT. I hope I'm wrong, as there was stiff competition to attend Woods Hole and I know of other bright stars kicking butt out there. One of them wants my tomatillo salsa recipe. Maybe 'Cannot quit' should be our motto!

Friday Foolery #41: 150 years ago tomorrow

Oregon Trail mural Conestoga by mharrsch

In the words of her son, written sometime in the 1930s, a not-so-foolish but true story about my pioneer great-great-great grandmother. I don't have an ounce of her stamina.

I am now to record an event that was of common occurrence, but would no longer be considered possible among normal persons. William D. McIlroy and his wife Elizabeth had started the long journey into the wilderness with full knowledge of the fact that far out in that land of peril a child would be born to them. No physician was in the wagon train and no supplies such as we consider indispensable at the present time. There would be no place to go to for help or to purchase needed material or medicine. Among the pioneer people it was the custom to call in any woman of middle age who had been a mother to help the mother to be in the delivery of the baby. In older established settlements a regular midwife was generally available.

At Grass Springs, west of the summit of the Rocky Mountains, on July the 4th 1859, Sierra Ella McIlroy was born. She was their first child. The wagon train was delayed only one day because of the event, and still all went well with mother and child.

Can you imagine?

The family 1870 Bible page records Grass Springs as 8 miles west of Big Sandy River at Grass Springs then in what was known as Oregon Territory some 20 or 30 miles East of the East Fork of Green River on what was called Lander Cutoff on the road between the Mississippi River and Pacific Coast.

Sadly, the same Bible also records Sierra's death September 21, 1864 at about 4:00 PM at Hope Farm Prairie, Skookum Chuck, Lewis County, Washington Territory. Cause of death was diphtheria, she lasted about 5 hours and her throat closed. Age 5 years, 2 months and 17 days.


Happy 150th 4th of July birthday, great-great-great aunt Sierra. You were clearly way ahead of your current popularity and I wish DTap was around back then for you.

Live near DC and have an hour to help NLM?

From the MEDLIB-L listserv

Volunteers Needed for Web Site Evaluation

The Lister Hill National Center for Biomedical Communications at the
National Library of Medicine is seeking people interested in
evaluating a web site developed by NLM. The feedback received from
evaluators will help NLM develop effective and easy-to-use web
interfaces. Participants will be asked to spend one hour using a web
site on the Bethesda campus. Federal employees, contractors and
members of the public who can travel to NIH are encouraged to respond.
Although no monetary compensation can be offered, evaluators will
receive a small gift for their time. Forward this message to anyone
who might be interested in participating. Contact Sarah Ward at
saward@mail.nih.gov or (301) 496-9301 for more information.

Friday Foolery #40: PubMed citation blahs got you down?

With thanks to Berci, I am still cracking up over NCBI ROFL... a veritable treasure trove of hilarious PubMed citations that will liven up any class. Check them out and send in your own!

Veterinarians? Optimizing the sensory characteristics and acceptance of canned cat food: use of a human taste panel.
Podiatrists and/or radiologists? Feet rolled over by cars: radiological and histological considerations for experiments.
Urologists, jewelers and/or locksmiths? You have to see it to believe it.

Edit: Yes indeed, I covered this almost a full week before Boing Boing.

Medlibs Round: PubMed and Discoveries

PubMed class at StanfordEdTech

It is a pleasure and honor to host Medlibs Round here at Eagle Dawg Blog after a few delays I apologize for. The theme this month is PubMed, one of several databases in the the National Library of Medicine's (NLM) Entrez life sciences search engine developed by the National Center for Biotechnology Information (NCBI), and third party functionalities.

There is much more to the NLM than this single database though, and understanding the Entrez connectivity helps to explain some of the changes that are happening in PubMed today to lead to more research and better medicine for tomorrow. I hope you enjoy the ride!

What is this "Discovery" stuff NLM keeps mentioning?

NCBI's "Discovery Space" Facilitating SNP Research

The above chart refers to information in genetics but it was the 'discovery space' label that caught my attention. This illustrates NCBI's main purpose as not solely being the PubMed administrator but developing resources "for the better understanding of molecular processes affecting human health and disease" (source) which involves information in the other Entrez resources.

In December 2008, I did some research on the Discovery Initiative, "one of the most important projects NLM is working on." If you're not already familiar with the Discovery Initiative please take a look and here's the gist of it:

The bottom line for us is discovery. We want people to make discoveries, and if we’re using up real estate on the Web page for things people don’t click on, and if we can put things on there that would have been associated information, then we should do that.

The Discovery Initiative is behind some of what we are seeing with PubMed changes now after several years of work behind the scenes to encourage cross-referencing within Entrez. We are also starting to see communication from NLM including reference to the Discovery Initiative and suggested resources that appear in PubMed being called Ads. There still is not a clear description/explanation of the Discovery Initiative from a PubMed perspective in either the NLM Technical Bulletin or PubMed New/Noteworthy RSS feed, the resources we're encouraged to subscribe to for current PubMed news. The Discovery Initiative has received coverage in NCBI News in June, March, and February 2009.

Discovery is in the eye of the beholder

Marine Biological Laboratory (MBL) seal on the Lillie Laboratory

With that background about the Discovery Initiative covered, Shamsha Damani at MD Anderson created a very clear guide and commentary for her clinicians about the recent and upcoming changes in PubMed: What's New and What's Ahead, These include a great description and screenshots of the Discovery Initiative ads with the suggestion that "they are handy and are a great discovery tool when you are grasping at straws or have too many results to wade through." PubMed: My NCBI changes by Miner Library mentions the new ability to create custom filters as "a terrific new development."

Custom filters in PubMed. Fail. by Mark Rabnett of Gossypiboma begged to differ with this assessment of the custom filter changes due to encountering a failure with the saved searches tab.

In the second incident of NLM staff replying to blog complaints that I know of (the Harvard student being the first), an anonymous comment (supposedly a developer at NLM) was left on Mark's post saying the problem would be fixed. Shortly thereafter Mark posted PubMed custom filters: where the bee sucks which includes

I must apologize for the flippant remarks I made in my previous post. It must have been the nicotine. I hope that the snag with the NLM health literacy filter can be fixed. I intend to use Custom Filters frequently and uncomplainingly when all the kinks are worked out.

In a second comment, the supposed NLM developer replied

Enjoy your filters, and thank twitter’s re-tweets for getting your message across.

Why not have an official PubMed Twitter presence to directly offer feedback in the first place? Clearly someone there wants to engage. Often we hear complaints about PubMed and related services but with the email-only "official" feedback channel frequently is no acknowledgment from either NLM or users that a problem is taken care of, nor a way for others to see if an issue is Down for everyone or just me.

What's your Discovery?

Blue lobster at the Woods Hole Science Aquarium

PubMed Impact Factor from Alisha764's Blog explores the role of offering impact factors of journals and author information as a quality indicator in the wake of fake articles, journals and changed/fabricated data. This is not without controversy but indicates that many are seeking additional ways to check the quality of information. Merely saying something is indexed in MEDLINE is not enough to say it is authoritative health information since Time Magazine is there in the consumer health subset.

Five ways to improve PubMed from Gossypiboma includes his top results from the brainstorming suggestions during the recent Canadian Health Libraries Association conference about improving PubMed. A trick for #5 (Simplify the creation of permanent links to PubMed records) is to begin with http://pubmed.gov, take a look at an article for the PubMed identification number (PMID), then tack that on to the end for http://pubmed.gov/16719081

Shamsha Damani's guide includes

My one hope is to see NLM participate more in social media (especially Twitter!) so more voices are heard. The NLM reps at MLA’09 were extremely nice and open to suggestions; it would be nice if they could extend their presence in social networking venues as well.

I share this sentiment about social media as an official feedback channel for PubMed. This should not be via anonymous comments to blog entries but a sustained, active effort by both NLM and PubMed users utilizing some of the best practices learned from online participation formats such as the Open Government Dialogue.

There is hope for change on this front with the emergence of official Department of Health and Humans Services (HHS) Twitter accounts. @NLM_SIS is a legitimate account from Specialized Information Services (as is their SlideShare account... check out Semantic Processing of Twitter Traffic for Epidemic Surveillance) although considered experimental at this time. For the time being many, but not all, government agency presences on Twitter are essentially push-out news information sources similar to RSS feeds that don't usually interact with followers.

What have third party vendors Discovered?

Fiddler crabs in the Marine Resources Center at MBL

Got PubMed? Pubget Searches and Delivers Scientific PDFs from Bio-IT World news shares the news that this full-text PDF retrieval service has expanded quite a bit from when David Rothman covered it in April 2008, and has just announced it has partnered with 500 institutions including NIH itself (NLM is one of the 27 institutes of the National Institutes of Health).

Hope Leman posted GoPubMed: Interview with Michael Alvers at Next Generation Science where she asked some great questions of GoPubMed's CEO about why medical librarians and others should use this search engine instead of regular PubMed in addition to theoretical (the blended future role of search engine and social networking) to the practical (What's the difference between "find all" and "get all"?). This is a comprehensive interview well worth reading and reflecting upon over a coffee break.

Some non-PubMed but related tangents that were submitted along the discovery lines include Dr Shock MD PhD's posting about Online Medical Book Search and Clinical Cases and Images Blog's coverage of how to Create an automatic differential diagnosis list with Google Squared.


Panel at the MBL Associates Gift shop, home of cool socks

I recently attended the MBL/NLM BioMedical Informatics course and am still reflecting upon what Dr. Don Lindberg, Director of NLM, said regarding the emerging role of interactive publications. Wouldn't embedding an actual rhythm strip in a journal article involving electrocardiograms be a better use of online publications than a snapshot of one still image? I'll conclude with this image from his presentation:


You have seen what everyone else has seen. What do you think?

Friday Foolery #39: Save your bacon - use a bookmark

Bibliobuffet - The Legend of the Bacon Bookmark

Apparently plenty of library books have been returned with real live dead bacon strips as bookmarks in them! I had forgotten about the 2003 Unshelved strip (ha!) dealing with the matter and may just need to have Gene & Bill autograph a printout for me at the PNC/MLA 2009 meeting where they will be our speakers. No really, it's true! See "Banquet with the "Unshelved" guys" on October 19th?

The writer found many mentions of bacon bookmarks (including "book jerky" in Cinncinnati) although I do have to quibble that Multnomah County is is Oregon. If your location has a whole lot of Ks & Ts (Klickitat, Kittitas) or Ss and Qs with unclear pronounciation (Sequim, Snoqualmie), you're in Washington.

Friday Foolery #38: The Beacon of Evaluation turns into...

This is me on a 2 hour bus ride to Boston on Sunday, about to face 8.25 hours of plane rides on two flights after a week at Woods Hole:


At the time I claimed the top of my head really hadn't gone missing but I was wrong.

At work on Wednesday, I scanned through the table of contents for the recent journal of the American Evaluation Association and promptly misread the word 'beacon' as bacon and 'evaluation' as elevator.

Lo and behold,


The Bacon Elevator, brought to you by the World Famous Sporks of the Disney University.

It goes to show you that no matter what the subject is, bacon already has it covered.