Last night my wife and I had occasion to be consumers in the healthcare system: a visit to the E.R. (nowadays called the E.D.) for a flare-up of her foot problem. We used digital resources in two ways: digital x-rays, and hospital quality data provided by the government – your tax dollars at work, to enable informed choice, if you use it! We did.
History:
- 11 years ago Ginny broke her left foot just before we went on a long trip. The break wasn’t obvious at the time – she’s had foot and leg pain for decades – but during the trip it got really bad. A nurse in Belgium wrapped it tightly, and by the time we got home, it was back to normal, pain-wise – as okay as it ever is.
- In 2008 a flare-up led us to get a consult at Beth Israel Deaconess in Boston. The ortho diagnosed a non-union fracture, untreated prognosis – a break that was not recognized at the time and “healed” wrong. The x-rays also showed extensive bone cysts – fluid-filled holes where there should be solid bone. This would make it hard to fix the bones because there’s not enough bone to screw anything into. So, at the time, the patient (Ginny) and doctor agreed on watchful waiting. The cysts also weaken the bone, contributing to pain.
- Life has gone on, with the ups and downs that are familiar to anyone with chronic pain.
Current episode and decision to act:
Ginny works as a veterinarian, part time. That can involve being on your feet a lot; she uses a rolling stool or chair as much as possible. Usually her work is limited to a day now and then, but this week she had a lot of work, ending with three days in a row. By last night she was beyond limping; we got out old crutches, and she (who usually says “I don’t need to see a doctor, I know what they’ll say”) agreed to go to the ER.
A key factor for “act now” is that on Friday we leave for Spain, to participate in an e-patient summer course, “Patients and Professionals in Web 2.0,” co-organized by Luis Luque Fernandez (LinkedIn, Twitter) and the Basque government, in the beautiful city of Bilbao, followed by a dinner meeting in Barcelona. If anything needs to be done to the foot, Ginny wanted to get started now. (The memory of the severe pain in 2000, when far from home, is persuasive.)
Choosing a provider:
Our usual hospital is Beth Israel Deaconess, an hour away. But she (a medically knowledgeable non-MD) judged that all we needed was an x-ray to answer the basic question, what’s going on? Is it broken, or what? So we considered the two hospitals in our town, Nashua NH.
I decided to practice what I preach, and look at the information about hospital quality that our government has been publishing on the Hospital Compare site. I wanted to compare those with our downtown hospital, and with the excellent Lahey Clinic, halfway as far.
I went to HospitalCompare.hhs.gov, entered my location, and picked the two locals. They both have good patient satisfaction ratings, in the 70-80% range. (I hope this link will show you what we saw: http://bit.ly/m767E7)
Available data: The site has no data specific to E.R.s, but patients/consumers must use what we have… it offers overall patient satisfaction ratings, which is worth something. Like, do they know how to listen to what’s important to patients, and do something about it?? Sample item: “Patients who reported that the area around their room was ‘Always’ quiet at night.” Y’think that would be obvious? Many hospitals seem to not care much about that. (Believe me, I’ve been there.)
Usability: You can compare up to 3 hospitals at a time. I couldn’t expand the search radius beyond 25 miles – that would be a great addition – so to get at the other hospitals I changed location to Boston and selected the other two I wanted to know about. http://bit.ly/mf5sIN
Conclusion: I was happily surprised to see that the local hospitals were rated at least as high as downtown, and higher in most cases. So we went to Southern New Hampshire Medical Center, which is affiliated with the Dartmouth Hitchcock group. (Note: savvy statistics users know there can be many reasons for different numbers: for instance the downtown hospitals’ “customer mix” may be substantially different, including that they may be plain old “tough customers,” harder to please, compared to New Hampshire. I know that; I take the numbers at face value, not as gospel.)
For comparison we brought the CD of Ginny’s 2008 x-ray at Beth Israel Deaconess.
The visit:
Having heard horror stories of 2 hour, 3 hour, even 6 hour waits in overcrowded ERs, you can imagine our pleasure that there was only one family ahead of us. We were talking with the triage nurse within 5 minutes of checking in.
The staff were a little surprised about our having our previous x-ray – they didn’t seem to have a way to read it. But each image CD I’ve seen from different places comes with its own viewing software, and I brought my own PC. :)
Ginny was into x-ray within 15 minutes of arrival, and I was sent to wait in the room where we’d meet a doc.
After Ginny got to me we waited about a half hour. During the wait I fired up my PC and got the previous x-ray image zoomed in to the relevant part. (Not trivial – the DICOM image viewer my hospital provides on the disk is pretty stinky to figure out.)
The doc examined her, compared x-rays, talked; he was good at listening without interrupting (a common problem with busy doctors). He said there’s no new fracture, and suggested a few things. Ginny asked to take home a copy of the new x-ray. Then we waited 15-20 minutes for the nurse to come with crutch advice, a copy of the new x-ray on CD, podiatrist referrals.
Meanwhile, I was live-tweeting the whole thing. :-) (For people who wonder, the hashtag was #EPDWER – e-Patient Dave’s wife in the ER. The tweets aren’t particularly inspiring.)
All told, we were there 90 minutes. It was a fine experience – couldn’t have asked for much more. No need to pay for parking, either, in a non-city hospital.
Outcome:
- Given the news that there’s no new pathology (e.g. a break), doctor and patient again agreed to just keep an eye on it.
- He gave a prescription for pain-killer if needed, but she’ll probably manage it as she has before, with ibuprofen and occasional IcyHot products.
- She’ll stay off her feet as much as possible for a while. (She has no work scheduled this week.)
- For our upcoming trip, we’ll arrange for wheelchairs at the airports, to deal with those looooooong corridors and customs lines. And I’ll include this story in my speech.
- If she wants further follow-up, she’ll consider podiatrists.
p.s. As we prepared to go home Ginny said, “I spoke up and asked for a copy of my x-ray – aren’t you proud of me?” Yes, darling, I’m proud that you said “Gimme my data,” and said it more nicely than your husband sometimes does.:-)
p.p.s. The new CD has much better viewing software on it – still not trivial to figure out but not nearly as clunky. Here’s hoping that as more and more ordinary people ask for their data, vendors will see that better and better software will be a competitive advantage. A real live market for patient-friendly software might even arise!
HiDave,
Hope Ginny recovers quickly!
Would like to comment on your p.p.s.: In Greece we are far advanced on e-health in this specific field!!
My radiologist (private practice, in the public sector hospitals there are no such gimmicks) here delivers a fully executable CD that means that you can see the vertebral column en face and profil, turn it, enlarge it, measure each vertebra, measure the inclination of the column, and much more and this not now in 2011 but since 2007. This is a specialised private orthopedic practice in Athens that requests this kind of X-ray for taking detailed and accurate info for building custom corrective “corsets” for conditions such as cyphosis, lordosis and the like http://www.spondylos.gr. The radiologist’ practice unfortunately is not yet online.
Thanks for the reminder about getting your data before leaving. With a scattered set of healthcare providers (including a wonderful endo at St. Joseph’s in Nashua), it’s hard to remember this especially with X-rays. I wonder if it’s possible to separate the images from the software so you can use a viewer of your choice?
There must be, somehow – but I don’t know. I’ll ask Twitter and Facebook!
Dave, most of the software allows the images to be exported/saved as jpg files. I’ve done that before to have some read by a doctor who didn’t have the same program and couldn’t open my CD. I simply extracted them and put them all in a PDF for him to read. He loved it! You lose some of the features of the software that way (like changing the contrast).
Thanks, Robin – on these x-rays the ability to adjust contrast is vital – when the tarsals are clear the “ice cube” bones in the arch are pure white. I agree that saving as JPEG is one thing, better than nothing, but I want the raw data to display in MY choice of tools.
In the same way I can take my Quicken data to any advisor I want, I wanna take my RAW DATA (for which I paid, perhaps through some intermediary) to another analyst.
In this case we have a 2008 disk with a fairly crappy viewer, and a 2011 disk with a better-UI McKesson viewer. Neither comes close to what Picasa can do to enhance an image! I don’t know enough about the image data formats but I bet if consumer software companies could create MyKidsXRays.com, things would advance a lot faster.
That’s disruption, baby… putting power in the hands of people who benefit or suffer depending on how well CARE happens.
P.S. I hope Ginny’s foot is feeling better. (I always get CD’s of any imaging while there. I like a personal copy. And I’ve had imaging done all over the U.S. from coast to coast.)
A comment from Facebook:
“You can recreate the 3D images through the 3d function of Osirix (it’s opensource) if you have CT slices. You just import the folder. Let me know if more help is needed.”
I haven’t looked recently but a couple of years ago the open source tools I looked at were pretty clunky – is Osirix user friendly?
Yes, Osirix has evolved since it’s previous versions, still a Radiology software (means too much buttons clustered) however, you can simply click on the create 3d model from a set of CT slices…it does it automatically. I recommend this pdf intro from Osirix website: http://bit.ly/jPdJFl
It can be useful both for Radio and Non-Radio users.
Let me know if you want me to post a quick tutorial online.
A year later I got a Mac and switched to using Osirix. I’d completely forgotten this mention of it – and WOW is it incredible! I think for any e-patient dealing with radiology images, Osirix alone is sufficient reason to get a Mac. I’m not kidding – it’s THAT much better.
I should make a screencast movie of what Ginny’s foot looks like in 3D, at varying levels of depth. It’s unbelievable, like a science fiction movie or something I’d see on Nova. And that’s just the free version, not the professional version.
dave, thanks for taking the time to write about a GOOD experience with the healthcare system. with so many opportunities for improvement, it can be easy to just focus on those and ignore stories like this.
p.s. hope you and ginny have a great time in spain!
I feel much better today after my sweet husband wheeled me around Provincetown in a wheelchair yesterday…..thanks Dave. IcyHot patch worked very well today.
Awwwwww! Huge grin and <3 <3 <3 here.
Re wheelchair: turnabout is fair play. Seems to me 4 years ago you did a fair amount of that for me.
(So, lady, don't push it! Keep resting & recovering for the trip!)
FYI, I posted this blog post and we talked about it for 20 minutes in my interoperability/standards class.Main comments were ER not set up for receiving documents the wayradiology would be and resolution on laptop not good enough for diagnosis. But even with interoperability issues, larger issue might be IT dept lockdown of network computers so that wouldn’t be able to enter foreign CD or launch software because of security policy.
I’ve never worn these “toning shoes” and this NYT article doesn’t mention foot pain, but a LOT of the comments following this article do mention foot pain so I pass it along in case it’s worth a try (or leads to any ideas):
http://tv.nytimes.com/2010/11/22/arts/television/22lebowitz.html
CORRECTION!!! to my last post!
THIS is the correct toning shoes/foot pain link:
http://well.blogs.nytimes.com/2011/07/13/can-shoes-really-tone-the-body/
Sorry for the confusion. (But the Lebowitz documentary is really good, too…)
If you want to look more deeply at the HospitalCompare data, you will also find that there clinical quality results (to the left of the patient satisfaction results box, click on the tab labeled “Process of Care Measures.”) While there are not currently any measures reported strictly on emergency department treatment, some of the standards for the other disease states can indicate what a hospital’s ED is like: AMI-Aspirin at Arrival, AMI-PCI within 90 minutes of arrival, and Pneumonia-Blood culture in the ED.
There is a measure set in development for ED, but the data is not being published yet (see http://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228760129036
but prepare yourself, this may be a lot more than you wanted to know.)
Happy comparing!
Hi, I am also from Greece, running my own Physiotherapy clinic (our website is https://www.skoliosi.com/ )
and I can confirm that Osirix in Mac is very good to view x-rays,MRI’s etc