Monday, May 31, 2010

Primum Succurrere: Telemedicine and fast access

Should telemedicine be prohibited because the doctor doesn't physically touch the patient?  That's the argument being made by the Texas Board of Health, according to a recent article in the New York Times at  The issue raised is that there might be subtle cues that are more likely to be noticed if the patient is there than over a video connection.

Like everything, this position has to be taken in moderation.  Good decisions aren't made by looking only at the possible risks, but at the possible benefits as well.  There will always be more information that could be gathered, but the real point is whether sufficient information is available to justify an action, and whether inaction would be worse.

We all make medical decisions, and we make them frequently.  My shoulder hurts: do I have bone cancer?  Should I drop everything and race to the emergency room?   I evaluate my  options using the information available to me, including the fact that I spent much of yesterday digging in the back yard, and conclude that it's more likely a soreness from fixing the plumbing under my wife's lawn fountain than something more ominous down in the marrow.  I feel reasonably confident that my arm will not snap off if I give it a couple of days and see what happens.  I'm not a medical doctor and I have no scans or X-rays to support my decision, but I'm making a decision of proportional scope and, in all likelihood, consequence.

Doctors do the same.  The real questions are how good the information is and what actions are appropriate based on that information.  And - at least as important - what level of inaction is acceptable?  Is it better to take some action, even if some things remain uncertain, or to wait until fuller information is available?  It’s the kind of question that faces doctors and paramedics every day.

Along with the familiar medical dictum, primum non nocere or "First, do no harm," there’s also a second one, equally important: primum succurrere,  "First, hasten to help."  Both philosophies, whether the considered evaluation prior to treatment, or the more urgent application of palliation or assistance, need fast, accurate information, and that’s home turf for telemedicine and medical telepresence. 

One morning as a young engineer, I had a realization so vital that I made it into a sign and hung it in my office:  "Every Decision Must Be Made on the Basis of Insufficient Information" (this was before computers, fonts and laser printers, so I actually had to exercise my drafting skills making that sign).  I realized that the search for full and complete information was inherently impossible because there was always another piece of data, somewhere, that might - just might - be relevant to a decision.  I realized that part of the value I brought to the job was my ability to evaluate the information available, to decide when I had enough to take action on.  

The same is true in medicine.  There’s always a process of deciding what information is necessary, and where enough has been accumulated to support a decision for a course of action.  This is where telemedicine has become such a valuable addition to the medical arsenal:  Telemedicine can cut the time for information delivery to a doctor by an order of magnitude or more.  This facilitates the processes of triage, diagnosis and treatment.  Siince time is often critical in medicine, this also means that telemedicine can save lives.  It's the doctor's responsibility to determine whether the available information is sufficient and reliable, and to decide what actions to take on the basis of that information.  This decision is never the same, however.   It’s different for every circumstance, and the doctor is in the best position to decide.  

Many of the major metrics of modern medicine are already available remotely, such as blood pressure, blood sugar, and pulse rate; even ultrasound scans are now available, delivered via iPhone.  Yes, there's always a chance that a physical visit might add a piece of information, but the incremental advantage of the physical visit, relative to the high cost of delay in many cases, has decreased in modern medicine; as Dr. Boultinghouse says in the NYT article, "in today’s world, the physical exam plays less and less of a role. We live in the age of imaging.”  Add in the growing availability of remote imaging devices such as microscopes and ear-nose-throat cameras, and the remote imaging arsenal is becoming extraordinarily powerful.

This is where modern telemedicine has become such a game-changer: by bringing secure,  live high-definition video, both one-way and two-way, between doctor and patient, it enables not only the directed examination necessary to understand a problem, but also a significant degree of the relationship-building and random observation that can play an important role in medicine as well.  In effect, HD telemedicine has brought much of the physical exam back into the game, even when doctor and patient are thousands of miles apart. 

Saturday, May 15, 2010

Redundant, Robust, and UC

Through the events of the past couple of years, we’re again seeing that the two essential elements of a communication strategy are redundancy and robustness.

The conventional meaning of redundancy is having a second phone as well as the deskphone, or a battery backup in case the AC fails.  But what I’m talking about goes beyond that: it’s not just separate duplicate abilities, it’s having communication paths that use different media entirely, maybe following different physical tracks or even different laws of physics. And similarly, while “robust” may mean a phone that you can drop, it doesn’t help much if the phone wire itself has been torn loose in a hurricane; the strategy, not just the device, needs to be robust.

This kind of redundant backup is something that we have in the wild, but often lose when we’re connected by technology. If we’re standing together and I talk to you, we’ve got some options when a thunderstorm strikes.  If you can’t hear me, you can see me and I can signal to you.  And if it’s dark, and you can’t see me either, I can tap you on the shoulder. So what has happened?  The audio failed, so I resorted to video; that didn’t work, so I went to touch.  Three entirely different media, and I was able to connect. Redundancy.

Closed standards destroy "robust" because they also close off options.  Texting, e-mail, videoconferencing, presence, shared workspaces, multiple unsynchronized clients, cloud and local implementations, there’s a mess of them and they keep coming, yet they often don't work together.  And that’s before we add Yammer and Twitter and Tumblr and Flickr and Facebook and LinkedIn and Myspace, Posterous, Qaiku, Ning, Digg, Mixx, Reddit…you see the problem? The proliferation of tools and media that’s supposed to be empowering us?  It’s disabling us.  What should strengthen us instead makes us more frail.

This is why this shaking-out in human communications called Unified Communications or UC, is so essentially linked to open standards.  It’s often presented as the next, uber-cooler, the even higher technology, but I see it as a naturalizing, a humanization, of this flock of new and augmented communication tools.  “Unified” is the important part here.  In the same way that my arm-waving is a natural extension of my shout, UC is all about making this rag-tag zoo tie together so one way of connecting is an effortless, obvious extension of another: I don’t need to look up another phone number, URL, or Skype name.  If one tool or one vendor chooses to use their own proprietary standard and can't talk to others, it's not really Unified at all.  Perhaps we should call those implementations "Fragmented Communications."  FC?

Finding ways of ensuring confident cross-platform connection via open-standards based UC will be one of the big enablers of human communication in our future.