Sunday, April 27, 2008

"Clinical Plagiarism": Calling EMR copy/paste what it is

Although I'm headed into traditional medical librarianship, being in the thick of healthcare IT for years has left an indelible impression on me. Granted, most of that time I had no earthly clue exactly how the different components I was ordering in my purchasing role to the tune of millions of dollars to avert zomg Y2K!1!!!1!! were or how all the billing systems worked with one another, but during my health informatics classes I had way too many moments of Oh! THAT'S what that was about! I still remember an Ask Me About HL7 button someone had in his office a decade ago, then last year in an agonizing class... there was HL7. Aie! Flashbacks!

As a result of all that, I'm acutely sensitive to the issues surrounding electronic health or medical records (EHRs or EMRs). I'm still not seeing a clear trend in definitions to distinguish one from the other so my own preference is EMR. Whenever I see anyone writing about EMRs, I am usually there. I love seeing the issues from as many viewpoints as possible because there is so much concern and so little agreement over just about every component of them.

One concern I have seen mentioned repeatedly as both a praise (saving time, improving accuracy, insurance coding) and a caution (reducing accuracy due to copying wrong info) is the ability to copy descriptive text that is frequently used in patient records. I have seen some modified versions of this happening as part of my own healthcare, although without grilling the medical staff it appeared to be the use of pre-formatted template wording from one section of my EMR to another that didn't have a template.

Today I read a post in Health Care Renewal, a group blog concerned with "Addressing threats to health care's core values, especially those stemming from concentration and abuse of power" that highlighted a term for this phenomenon from a New England Journal of Medicine editorial that put an entirely different light on it for me: Clinical plagiarism.

It could be that I'm so recently from grad school where we had the Fear of Plagiarism drilled into us more than anything else, but the more I think about it the more I agree with calling a spade a spade. We expect students to research the literature and case studies, but come up with their own terms and thoughts while properly citing their resources. Why should we expect any less from our doctors? Do we want to be the patient who is either copied or pasted, with whatever makes our medical history unique and 'off the charts' (i.e. no standard template wording exists for what we have going on) either carried forward or someone else's information accidentally given to us without our knowledge? Consumer views of EMRs are not full compendiums of medical data and terminology and generally offer summaries of lab tests, after-visit summaries and related material in regular language.

These are the things that keep me up at night if I'm not careful.

Week 7 assignment: Podcasting & Online Hosted Video

Write a blog entry discussing how you felt about the experience of using YouTube and what you think about this service. Do you see any potential uses for Podcasting in the library? If so what and why?

YouTube has long been the I have a commercial/some Muppets show/random bit of pop culture stuck in my brain and I must see it NOW if it's ever going to leave resource, although it's heartening to see some more serious fare on it over the last few years. I certainly don't have official stats but usage counts I'm seeing still seem to support the casual surfing use with some questionable copyrighted material issues along the way.

I still believe that most medical libraries will choose to publish any audio/video content they create with Camtasia or other screen-capture recordings on internal servers to publish on their own websites. This clearly indicates a "for educational use only" context that (usually with permission) avoids possible copyright ruckus with vendors regarding screenshots of their products. I see the same situation for podcasts for cataloging/class webpage-linking purposes and control in case of revisions or corrections.

For my video post, I want to bring to your recollection Randy Pausch, the Carnegie Mellon professor with pancreatic cancer who gave an amazing last lecture in September 2007 when he was told he had a maximum of 6 months of good health left.

He's passed that mark and still alive and testifying before Congress. He also filmed a public service announcement (PSA) for the Pancreatic Cancer Action Network. He closed with The human spirit is much more powerful than any biological disease. Indeed.

Friday, April 18, 2008

Week 6 assignment: Online photo sharing

Blog about the process [uploading online photos] on your personal blog for this course and share how this concept might be used in your library.

Are you sure you can handle this? The instructions were to upload a picture to our Facebook account and our blog, and I did... although only you, dear readers, get the full scope of what I was up to this afternoon:

All is not as it seems

The beauty of the Flickr preview is that all may not necessarily be as it seems. This is a triptych created with an external Mosaic Maker and if someone were to see a preview it only shows the middle picture where I look perfectly normal. That middle picture is also the one I put on Facebook.

The other two are rather reflective of my state of mind as I'm realizing that the past 10 years of my completely-non-library career aren't relevant to my medical library job that I'm starting on May 1st. It's a good change, absolutely, but a strange one to process on a cognitive level. How can a decade of work not matter and the slate be wiped clean to begin again when I already feel so old?

Oh wait, my personal reflections are not part of the assignment. My bad.

As for how Flickr could be used in our particular library, I'm not all that convinced it would. What medical images we do have in an academic medical library are tucked in both proprietary and open access databases with a variety of search methods available, cataloging structures, and vast quantities of storage space. If we have any unorganized and unpublished images in our collection that aren't under copyright, we'd probably create our own database to manage them (like these) instead of using Flickr. I didn't realize the American Social Hygiene posters existed before now and am off to have some fun surfing those!

Tuesday, April 15, 2008

I fear change, I will keep my bushes: EBM, email & human nature

My husband just made fun of me for trying to find a Quizno's commercial from the turn of the century without success.

(May 12, 2009 edit: Bless you Xyc0, you have FOUND THE VIDEO!!)

Perhaps you remember it. The opening dialog is between two three primitively dressed British actors (and another standing around) at a ranch on the outskirts of Los Angeles (no, really), one wearing pants with the others holding on to what looks like a tumbleweed for apparel, and they meet and greet one another...

Primitive Brit 1: Aah! You are cursed with the legs of a goat!

Primitive Brit 2: Nay, these are pants! No more thorns and bugs!

Primitive Brit 1: I'd like to wear pants!

Primitive Brit 3: I fear change, and I will keep my bushes.

The part about hanging on to the tumbleweed because of fearing change has been on my mind today. I have read, re-read and am still pondering a blog entry from yesterday that caught my attention via Kevin MD about evidence-based medicine (EBM) and the difficulty in persuading physicians to change their practice. I cannot summarize the historical background quickly so please give it a read if you're curious about how long it took between the first randomized control trial (RCT) & setting best practice standards (hint: 1 century is about halfway there) and while we may promote EBM to resistant audiences, we're unlikely to die in a 19th century insane asylum in part due to physician resistance to installing plumbing for handwashing (RIP Dr.
Semmelweis, we're still fighting ventilator-associated pneumonia (VAP) and Methicillin-resistant Staphylococcus aureus (MRSA) over the same thing).

What really got my attention was this section, based in part on Asch SM, Kerr EA, Keesy J et al., Who is at greatest risk for receiving poor quality health care? New England Journal of Medicine, 2006 Mar 16;354(11):1147-56.

"The gap between what we know works and what is actually done is substantial enough to warrant attention," the NEJM study concluded.

"What can we do to break through this impasse?" the researchers asked. "Given the complexity and diversity of the health care system, there will be no simple solution. A key component of any solution, however, make information available...with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality." In other words, we desperately need electronic medical records, and the data from those records needs to be consolidated in order to establish benchmarks for performance and best practice guidelines.

But even the best healthcare information technology will not help if physicians resist the fact that medical knowledge is constantly changing, Lalvani points out. Too often, physicians stick to the treatments they have always used, declaring that if tens of thousands of physicians do it this way, it must work.
I'm not certain I would agree with the author's inclusion of "we desperately need electronic medical records" (EMRs) because without careful user needs assessment, research, integration & training EMRs can backfire just as easily as whatever the latest 'ooh!' technology toy du jour does. There is not currently and I doubt there can be a one-size-fits-all EMR (we won't even touch the hot potato clinical decision support systems (CDSS) part of the equation!) as long as we have so many different key players in the health care industry.

Resistance to change, however, is an undeniable part of human nature that is most successfully overcome through extreme patience, persistence and education in conjunction with assessing user information needs (before, during & after) to determine the proposed changes will/are actually work(ing). In our MLA class we had an episode last week where, despite being instructed to post blog entries or contact our online instructors via chat with gentle reminders along the way, there was an outbreak of using an email listserv to communicate participant thoughts regarding the class. The listserv manager finally limited postings to instructors because the emails were becoming way too numerous.

I find this fascinating: we, as medical librarians and agents of change (I need a badge), in a class specifically for learning about new online communication technologies... went straight back to the familiar standard email listserv without hesitation even when we were told not to do so from the beginning.

Wow. Talk about fearing those goat legs and hanging onto the tumbleweeds in the face of change! I hope the class remembers this listserv stint when we experience difficulty in reaching/teaching our users regarding EBM (and other changes) though. We have great curriculum sources such as the EBM Librarian Wiki, but it takes time and knowledge of your users to teach new ways of practice. I think this is especially true when it comes to students who are learning from clinicians who have 'always done it this way.' If there's too much, too fast or any semblance 'you're doing it wrong' as part of the instruction to a group of people who are given a high level of societal power... well, it's not exactly surprising that hospital libraries are closing because they aren't perceived as valuable, is it? At least they haven't carted the librarians off to the insane asylum (yet)!

Sunday, April 13, 2008

Week 5 assignment: Web office tools

Is this the future of all software products? What do you think?

Oh I certainly hope not. Please, no.

The use of Google Docs or related online document services is one of the two areas in the course I haven't had prior experience with. I was poking around minding my own business on it this evening (I doubt Sunday evening/early Monday morning is a high usage time, nothing is posted about systems being down for maintenance) and suddenly it froze.

I assumed the problem was my system connection, refreshed, and found a spreadsheet uploaded twice. No big deal, I deleted the extra copy, but then received


That is exactly what I wouldn't want to see if I was working on something urgent without a backup copy of our collective workgroup edits, which I don't believe we can create at Google Docs because otherwise that sort of defeats the sole source purpose. I'm a much bigger proponent of LOCKSS than 'You can trust us to keep this safe, ya sure ya betcha!' Have you ever seen a professional photographer with external dual hard drive failure? It's not a pretty picture, no pun intended, and I value my own professional work just as highly.

For casual writing and presentation projects I can see web office tools working well, but my geek husband balked at the idea of putting any sort of spreadsheet with data that is remotely confidential on Google Docs for security reasons. I'm probably too entrenched in academia assumption that all relevant parties have access to the same shared drive that is well-taken care of with backups to give web office tools a realistic shot, and was am still too OCD to let go of 'my' presentation final edit if I'm a lead for class or other situations. I could see myself becoming completely unhinged at an unexpected 'Your the best!' title that was added 5 minutes before I gave a presentation.

Tuesday, April 8, 2008

Freak or geek by osmosis? Reflections on librarians' distance education

While I am enjoying the MLA Web 2.0 101 class, I have a confession to make: my sociocultural anthropology side is learning far more by observing my colleagues in the course than my librarian side is with the curriculum. Sorry. Apparently I'm such a Lackluster Veteran (although I don't quite fit the demographics, what are you?) that it's a serious challenge for me to be 'ooh, ahh!' about Web 2.0.

When we arrived at the midpoint of our 8 week class, more than a few colleagues expressed dismay at falling behind due to a variety of reasons that mostly involve time and/or technology & requesting/proposing alternate arrangements. I am certainly sympathetic to the demands of the life/work/education balance yet somewhat puzzled. There appear to be common expectations that our coursework would tidily fit in with our regular routine at our jobs without any extra effort (i.e. homework) required.

I'm fascinated by this and want to understand why as a future online teacher. Were these expectations because the class is free? Online? Massive at over 600? Something in the way it was marketed to MLA members? Having the curriculum administered via a blog? How is this class any different than a college course where professors surely must hear the same things from students at midterms? Do we truly value CEs or see them as something we sit through, grab our certificates for our points then head out without much further reflection on the material?

As I've shared in my profile, I was a full time distance education library school student for 16 months while working at a non-library job 24 hours a week and being some semblance of a wife & mom to a preschooler. If there was a Most Non-Existant Friend award for 2006-2007 I probably would have won it, but I think most of my friends understood & have forgiven me :)

I say this not to boast or suggest taking that life/work/education balance to anyone (I'd discourage it unless you want to question your sanity on a regular basis), but to note that I'm still not certain if I am a freak or a geek by osmosis by being online since the early 1990s and comfortable with learning information in whatever form as rapidly as possible. I have to be careful as I teach in the future to realize that many (most?) of my colleagues are not set on automatic information-seeking overdrive, although I believe that many (most?) of our users are. Of course this depends on our particular library and services, but perhaps this is part of the current disconnect where users are not perceiving libraries as being of value.

Saturday, April 5, 2008

Week 4 assignment: Social bookmarking

Can you see the potential of this tool for research assistance? Or just as an easy way to create bookmarks that can be accessed from anywhere?

I certainly see the value of creating a personal go-anywhere set of bookmarks that is accessible via any computer. I do want to highlight that just because we use doesn't mean we have to expose our possibly bizarre mix of bookmarks (my colleagues and future users might wonder about my range of Victoriana, goth music & genealogy interests!) for the entire Internet to see: check out how you can set privacy filters. Rebecca Brown from the National Network of Libraries of Medicine, MidContinental Region (NN/LM MCR) offered a Social Bookmarking class that is archived and I highly recommend this for some additional insights regarding the cognitive process behind tagging (freedom vs. control) that I hadn't thought about before in addition to a guided tour of importing existing bookmarks and other features.

As for research assistance, I can see value in social bookmarking with the important caveat of first determining if the user or specialized user group perceives this as a valuable service after a brief explanation. We can annotate in notes to help users determine the importance of or otherwise rank resources within a category, but I'm a bit concerned that there's not an efficient way to list them as #1,2,3 etc without renaming the link as such and that can be distracting plus high maintenance for the future. At this point I believe RSS feeds for PubMed searches rank a bit higher for research/currency in our field, but I also haven't checked out Connotea yet which seems more on target for health sciences.

Friday, April 4, 2008

Your call is being forwarded: POPLINE search engine reconnected

Finally, an official response from Johns Hopkins regarding POPLINE via ResourceShelf.

I was informed this morning that the word “abortion” was blocked as a search term in the POPLINE family planning database administered by the Bloomberg School’s Center for Communication Programs. POPLINE provides evidence-based information on reproductive health and family planning and is the world’s largest database on these issues.

USAID, which funds POPLINE, found two items in the database related to abortion that did not fit POPLINE criteria. The agency then made an inquiry to POPLINE administrators. Following this inquiry, the POPLINE administrators at the Center for Communication Programs made the decision to restrict abortion as a search term.

I could not disagree more strongly with this decision, and I have ordered that the POPLINE administrators restore “abortion” as a search term immediately. I will also launch an inquiry to determine why this change occurred.

The Johns Hopkins Bloomberg School of Public Health is dedicated to the advancement and dissemination of knowledge and not its restriction.


Michael J. Klag, MD, MPH
Dean, Johns Hopkins Bloomberg School of Public Health

I will be quite interested in the results of this inquiry.

As of noon Pacific Daylight Time, 1320 records are now available via basic search.

Please hold: Reconnection at POPLINE?

After yesterday's discussion of POPLINE apparently listing 'abortion' as a stopword for their search engine, I have just now rerun a POPLINE basic search on abortion 3 times in the span of several minutes.

14, 48, then 67 records were available via this search. Interesting.

There is still no mention that I can find on POPLINE regarding this alleged action, nor has there been an update at ResourceShelf which was told they would receive an update today.

Now at 11 am Pacific time, the results are up to 105.

The question still remains: What, if any other relevant search terms, may have also been coded as stop words... and why?

Thursday, April 3, 2008

The number you have dialed is no longer in service: Intentional disconnection at POPLINE?

I'll admit I joined a major listserv in my field solely because of the fallout from last week's ruckus regarding the PhD student from Harvard, and was dismayed by some of the comments made there by my colleagues regarding the situation. I initially wanted to write further about the matter, but David Rothman & The Krafty Librarian have covered additional perspectives well. I'm still mulling over how to identify relevant national, regional and community medical blogs and the roles medical librarians can serve in both participation and outreach on them.

However, I've watched the listserv traffic with alarm today at what appears to be search term censorship at POPLINE, a federally-funded search engine operated at Johns Hopkins that bills itself as "the world's largest database on reproductive health."

There's just one (known, what else might there be?) small problem: a librarian conducting a query earlier this week found fewer records than previous searches. For a comprehensive database, that means something about the way the database is organized/indexed has changed when nothing else with the query has or there's some type of problem.

You can see the problematic indexing in action yourself: enter abortion in the subject box, click search and voila... nothing. Now try entering abortion in the subject box, then clicking browse index, which brings a popup box (Inmagic, blech! I'm having library school dbase programming flashbacks!) Enter abortion again there, then click the Go to button, and you'll pull up the term with almost 25,000 records. Next, click paste and you'll notice the formatting in the main search box changes to ="Abortion" Click the search button again, and all of the records display.

The reason from Johns Hopkins for this convoluted search nonsense at the world's largest database on reproductive health appears so incredulous that I'm still suspicious that there is a horrible April Fool's Day joke being played here:

Yes we did make a change in POPLINE. We recently made all abortion
terms stop words. As a federally funded project, we decided this was
best for now.
, according to an email forward supposedly originating from Debbie Dickson on April 1st.

Stepping outside our library jargon, stop words are terms like a, and, the: most search engines don't look for these terms unless a search is specifically constructed to include them because they aren't relevant to the information being sought.

No one can find a way to explain to me how the term abortion, which includes not just the major subject but areas like spontaneous abortion = miscarriage, is not relevant to a search of a reproductive health database, and I will not stand for it as a newly minted librarian and former Project Censored student reviewer. If it starts and succeeds with POPLINE, who is to say MedlinePlus isn't next as a federally funded agency?

This is currently on the front page of Wired with a link to their listing in the Privacy, Security, Politics & Crime section.

I am expressing my dismay to Johns Hopkins regarding this decision and hope that you will as well.

Tuesday, April 1, 2008

AH ha ha ha stayin' aLIIIIIIIVE!

From the Wall Street Journal health blog, very smart move to go straight to YouTube with this but unfortunate that I'll probably have John Travolta's hips come to mind if I ever need to do CPR now:

The contrast between this and how long it took to get public service announcements (PSAs) and decide on their airtime rotation at my old college radio station in the mid-90s is mind boggling.