Firefox for Android

Since my recent Xoom upgrade to Android 4 Ice Cream Sandwich, I can now run Allscripts Eprescribe on Firefox. It previously only worked with the Opera browser. Firefox runs faster than Opera and doesn't have the annoying zooming feature. Maybe I can make more use of my Android tablet in the exam room.

Medication Reconcilation

Figuring out what medications a patient is actually taking can be very challenging. Patients often don't know what medications they take and often what you write in the chart often doesn't reflect reality. Patients may run out of a drug and neglect to refill or they may decide to stop the drug on their own.

One solution is to have patients maintain their own medication lists which they update at their office visits or if they are seen in the emergency department or in the hospital. One of my patients uses MyMedSchedule. He had a renal transplant which requires him to take antirejection medications which interact with other commonly prescribed medications. This program http://www.mymedschedule.com was recommended by the transplant clinic. It produces nice lists with pictures of the pills. He brings a printout to every office visit for me to review.

I tried the iphone app. It has medication reminders which are a bit annoying. The pill pictures work well for branded drugs like Myfortic, a drug taken by the transplant patient, but generic drugs, which most patients take, have no pictures. Still having the list on your phone saves having to print out a list for an office visit. Also in an emergency a patient could take out his phone and show the list to the hospital staff.

Organizing a Paper Avalanche. Camscanner and Evernote

Mountains of paper accumulate around me every week. Part of my work as an Internist requires me to attend meetings or CME classes. I make hand written notes on the handouts and agendas. Writing the notes helps me remember important ideas. The problem is what to do with the notes and handouts. I recently got an iPhone 4S which is equipped with a very nice camera. The camera is good enough to not only record clinical images as I noted in an earlier post but also to produce easy to read images of notes and handouts from meetings.

Now that I had digital copies of notes, I needed to organize them. I settled on Evernote which is a free form data base. It can hold images, text and even sound. I have organized my meetings and classes into note books. I can access them on a PC at work, a Mac at home, my Xoom tablet, and my iPhone.

The best part is the process. I attend the meeting and take notes. When the meeting is over I take out the iPhone and CamScan my notes. The even light in the typical conference room is perfect for image capture. Evernote can capture images directly but I prefer the image processing tools in CamScanner. I import them into Evernote and then I'm done. I can toss the paper and refer to the digital images whenever I want wherever I am.

Zooming the Xoom

In April I became the first doctor I know of to get an Android tablet computer. I wanted to try out Android and perhaps have a machine to write software for as my earlier attemps to become an iphone developer weren't very fruitful. I already have an iphone and am very familiar with the iOS operating system so this would give me a chance to try something new. Also Android appeals to my early adopter hacker personality as it has more options and is a bit messy compared to the Apple iOS.

I chose the Xoom because it was the best and first Android tablet to run the Honeycomb operating system or Android 3.0. I got the WiFi only version because I was mostly looking for a machine to use at the office and the nursing home and both locations have WiFi. I have tethered the device to my iPhone via bluetooth but it is kind of slow. My first experiences were a bit rocky but now two upgrades later things are much better. I now have Android 3.2, support for USB devices and SD storage, and a boatload of software which wasn't available in April.

I use several browsers to access Allscripts eprescribe. Opera supports all the feaures but is slow. Chrome and Boat and Dolphin work well but sometimes I have trouble adding a prescription to the scriptpad with those. Another piece of software I can use is the Splashtop desktop.This streams the desktop of my desktop PC to the Xoom. This is a bit slow but all the functionality of the original software running in Internet Explorer is retained. I might use this later on to access the electronic medical record when it arrives at my office in the near future.

It is fun to use the tablet in the exam room. I look up contacts and surf the web with my patients. I can use the Android version of Epocrates to check medication doses or look up drug interactions. The tablet form factor is more patient friendly than the laptop and lighter then the Windows tablet I had before. It also has a much better battery life.

I got a tablet version of Blogger and I am using it to write this post. Hopefully that will mean more frequent posting in the near future :) .

A Nursing Home Gets Wired

The next few weeks are going to be filled with WIRED fun. I started off the month of March with Sigma Care, the new electronic medical record, (EMR), for one of my nursing homes. Digitizing the nursing home has been a long-term project. I have used spreadsheets and relational data base programs to organize my nursing home lists and to print forms to use for charting. Finally, I have a non-hospital EMR to play with.

For the first time at this nursing home, I can print a list of my patients sorted by nursing unit. I can also see my patient's medication list without looking through the medication administration record, (MAR). Writing orders and labs on the computer is a bit hard to do this first week, because I'm not used to it, but being able to see all my orders on a screen without having to read bad handwriting in the MAR has been worth it.

This evening I had to verify orders for one of my partner's patients who was readmitted. I brought up the list on my Mac and was able to find two medications that were missing from the hospital discharge medication list. The nurse was having trouble pronouncing the names of some of the drugs, (a common occurrence). This was not a problem as I could figure out what she was saying because I had the list in front of me.

I also was able to see the list on my iPhone by using the Opera browser. I heard that you can see the lists on Android devices as well. I will be trying out this EMR on several devices including the iPad and the Xoom during the next few weeks and will have more to say on hand-held devices soon.

This week I will be trained on Dragon speech recognition software by my hospital so I should have some interesting news to report next time.

Ingenious Medical Imaging 2-Patient generated images

Sometimes patients will send you pictures of themselves for diagnosis.

A patient called me early this Sunday complaining of redness and swelling at the site of a tetanus shot from several days earlier. I thought it might be a common immunologic reaction to the vaccine. I told him to come to the office on Monday so I could take a look at the arm. He told me he was skiing near Lake Tahoe. He was worried and so he offered to email me a picture in hopes I might make a diagnosis.

The initial results were quite disappointing.

The later that day I called him back and asked him to send another image. The second image was much clearer and it was obvious this was a bruise related to bleeding under the skin at the injection site. The bruise was starting to spread out under the skin which made it appear larger which alarmed the patient. Actually the bruise was fading and flattening out and once reassured my patient returned to the slopes.

What did I tell my patient to get the image to clear up?

First you need to know what kind of camera your patient is using. In this case it was an iPhone3GS. I have an iPhone 3G and so I know that it has a low resolution camera without flash. Also the first image is out of focus and underexposed. It could be out of focus because the camera was too close and couldn't focus or the shutter speed was too slow because the image was taken indoors with out a flash.

I asked the patient to hold the camera further away from his body to allow the camera to focus properly and also to give the image some scale. I also asked him to stand next to a window to allow natural light to be used which rendered the colors more accurately and allowed the camera to use a higher shutter speed to avoid blur.

A camera phone can be used as a diagnostic tool. Remember it is just like any other camera and distance to the subject and lighting are very important. Newer phones are outfitted with more sophisticated imaging so likely image quality will improve. Doctors need to expect more patient generated images in the future.

Ingenious Medical Imaging

While sitting in the doctors lounge at Advocate Illinois Masonic Medical Center, I noticed that an ENT physician Dr. T. K. Venkatesan had a new Apple iPhone 4. I have an older model the 3g and was curious what new app he was using. He was emailing a photo of a patient's surgery to his practice partner Dr. Michael Friedman to get his input on the case. The photo was of extremely high resolution and the display on the iPhone 4 was very sharp and bright. T. K. was able to show me extreme detail in the surgical site by zooming in on the image. Dr. Friedman did not need to be in the room and could view the same image on his own iPhone and give immediate feedback or take a look at the image later on his home or office computer. This technology can help physicians collaborate on difficult cases. The physicians need not be in the same room or the same hospital or even in the same country. I use my iPhone for tracking patients and looking up drug interactions and clinical data. It also is a great tool for communication. I had limited the communication use mostly of text and emails with my nurses and patients. I felt the camera was not a very useful addition to a cell phone. I now can see that I was mistaken. The high resolution cameras and displays on the newer cell phones open a new way of exchanging clinical information now in living color.

Click Here to view an image of a patient who had a nasal tumor resection and was undergoing a reconstructive flap procedure. Use the back button on your browser to return to the blog. WARNING this is a graphic medical image.

I came across another example of high resolution imaging also in the same doctors lounge.

Dr. Frank DiMaria a wound care specialist uses an inexpensive

point and shoot digital camera to document his work in healing complex wounds. We were able to discuss a mutual patient by looking at images stored on his thumb drive on one of the PCs in the doctors lounge. While not as sexy as the iPhone it is quite an effective use of imaging technology which is of low cost and high quality.

Click Here to view an image of an pressure ulcer in various stages of healing. Use your browser's back button to return to the blog. WARNING this is a graphic medical image.

In wound care and otolaryngology, a picture is worth a thousand words. I could see this technology being useful in other specialties like dermatology to view skin lesions or even cardiology to look at ECGs. Let me know if you have come across any other other examples of Ingenious Medical Imaging.