Lifedrivedoc.com began as a place to talk about the Lifedrive. It soon became apparent that it was much more than that. Since moving on from my Lifedrive, I am engaged in more avenues of technology. That technology has intersected with my professional life - Medicine as well as my social life.

As noted above, the blog is about a lot of things in relation to technology. If you are looking for Lifedrive related material, I am currently dividing the blog so that those searches will be easy for you to find. Most of them will be pre 2007, that should help. Additionally, if you are looking for the links that used to be on the left border. They will be back up in a different format soon. I do enjoy reading about new things to do with the Lifedrive, so you can feel free to let me know about those. I will also post those on the site.

If you are having trouble getting an RSS Feed, click on the feed link below or type this into your reader: http://feeds.feedburner.com/lifedrivedoccom


Friday, April 18, 2008

Lifedrive Essentials: BILITOOL (For Medical Professionals)

Have you ever been enamored by a piece of software that you just had to take a pause, inhale slowly and say "wow!?" Well I did just that this last weekend. One of our beloved nurses on the floor, decided that she had had enough of the waffling that most physicians do when they get a bilirubin level on a newborn. She had been made aware, by the Residents-in-Training of a new online tool called BILITOOL.ORG. This online program allows you to put in the date and time of birth of a baby and the hour at which the blood was drawn (if you know the age of the baby already, it has the ability to accept that as well). It will then take all of the data from the now relished and quoted BHUTANI GRAPH and display not only the risk category that your baby is in, but offer suggestions about when to place the baby on phototherapy.

I keep a copy of the BHUTANI GRAPH in my pocket at all times. I made a copy of it when the paper first came out and decreased its size, laminating it and saving it in my wallet. I do the same thing for the immunization schedules. My decision making is always done on a patient by patient basis mainly taken from BHUTANI's paper (Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics . 1999;103:6-14).

So, if I have a baby who is term and has a lot of bruising or a cephalohematoma, I know very well that within the first 24 hours, that baby is going to have a high bilirubin level. Whether it is high enough to start phototherapy has always been the issue. Many of us will not do this unless the numbers approach 18; then there are some who will wait for 20; or 14 (all numbers at 48 hours). However, for myself, if the index of suspicion is high ie. ABO incompatibility, uncertain dates, prolific jaundice after 12 hours, a mother with beta strep, I am inclined to start phototherpy a lot earlier than the allotted 24 hours. In fact, I am inclined to order a bili at 12 hours based on my index of suspicion and the aforementioned issues (obvious jaundice and decreased responsiveness) and on the AAP guidelines. But not everyone will do this. As clinicians, we still have that index of suspicion and clinical awareness and independence.

So where is the line drawn? For our seasoned nurse, it became a never ending battle among physicians. One would start phototherapy, one would not. Same scenario, different treatment plans. And none of the plans were wrong, usually leading to the same outcome --> Healthy baby.

Naturally, I was skeptical about BILITOOL at first, until I found that it conformed to the BHUTANI graph completely. I was particularly fascinated by the fact that the program took into account the various factors that accompanied the baby. All of the ones listed above are incorporated into the decision making model. A link to the Pediatrics listing for risk factors is a plus. The decision to start phototherapy is outlined in a nice table. See the diagram below:

Palm Software

What is an added plus for this program is the fact that the program, in addition to being online, is also available as a standalone download for all Palm devices. And does it work brilliantly? It is probably even better on the Palm than online. You are again greeted with two different ways to enter data, either by length of time or by date and time of birth:

Once the data is entered, you press (Calculate Risk Zone) and voila, you are greeted with the essential information taken from the BHUTANI GRAPH:

The beauty of this is that not only is there risk stratification, there is also a guideline as to whether to start Phototherapy or not:

Risk stratification is further defined by pressing one of the icons, where you are led to definitions of high, medium and low risk:

In the event that you have a baby "who is on the fence," you are also given the neurotoxicity risk factors to consider. As the adage goes, "Cure the problem and you'll cure the disease." So correcting the acidosis or the sepsis will enhance the correction of the bilirubinemia. This is priceless, particularly if you are not thinking about G6PD deficiency or hypoalbuminemia:

And finally, threshold guidelines are given for the baby, with age and other considerations given. This is really priceless:

Again, these numbers correspond not only to the BHUTANI GRAPH and paper, but also to the American Academy of Pediatrics (AAP) guidelines on the treatment of hyperbilirubinemia, with risk factors. This is really an impressive piece of work.

The authors are also impressive. Drs. Tony Burgos and Chris Longhurst are both Assistant Professors at Stanford University School of Medicine. Dr. Burgos is the Medical Director at Stanford's Lucille Packard Children's Hospital, while Dr. Longhurst is Physician lead and director of Informatics. Dr. Stuart Turner is at the Health Informatics Graduate Program at U.C. Davis.

This is an impressive lead of physicians heading this program. The software is free and appears to be a part of the Creative Commons license. Unbelievable, for the amount of work that must have gone into this piece of software, both on the online side and on the Palm side. I commend Drs. Burgos, Longhurst and Turner for creating this incredible tool. It is one of the best that I have seen in a long time.

If you deal with newborn babies, this piece of software is a must-have in your collection. I am still looking for flaws after a week of dealing with 3 hyperbili babies and I have yet to find one. The papers used for reference are of the finest caliber that can be found on the subject. They are peer reviewed and in the authoratitive journal on Pediatrics in America. Again, I highly recommend that you go to www.bilitool.org, you will not be disappointed.


More on Epocrates......

Today, I have learned that Epocrates will be filing an IPO, with the expected symbol: EPOC, presumably on the NASDAQ. I only hope that my concerns about privacy will be heeded and that EPOC will not hold all of the names/members in its database as pawns to be sold to the nearest advertiser. That is my new fear. I have concerns about companies trying to make earnings reports each quarter and what they will do to make it happen.

Hopefully, growth will come from organic growth of membership and subscriptions and not from nefarious selling of names and prescribing practices.


Wednesday, April 09, 2008

Caveat Emptor: Apple SDK - will it change the Medical PDA?

From the very first day that the iPhone was mentioned, I pictured the writing on the wall. Palm would be knocked from its seat atop the medical apps world. Windows CE/Mobile would be a 3rd class citizen. I saw images of xrays, speech recognition software, e-readers with superior screens and that virtual keyboard, which seemed to beat graffiti, hands down overtaking anything that had ever preceded it.

However, from my perch, overlooking the sea of change, I perceived something else. It came to me last month when Steve Jobs debuted the iPhone SDK. One of the programs shown, running natively on the iPhone was EPOCRATES - My favorite medical app. Although I was happy to see EPOCRATES joining the sea of change, I began to have a slightly negative chill run through my veins this week.

One of the nice things about EPOCRATES is its seemless nature, jumping back and forth between applications and searches and updating itself almost automatically. However, herein lies the problem. PRIVACY !!!

For those of us who use EPOCRATES daily, we know that the company saves a list of the drug searches that are placed in the search box. If we use the online version, these searches are recorded. What becomes of these searches? Who views them? Are they open to scrutiny from drug companies etc ?

And who can forget the day when you bought your first PDA and it appeared robust, clean and snappy. Then you installed a few apps and suddenly you found your then large 64 mb memory turning to scraps and your brand new spiffy device beginning to crawl, falling victim to MEMORY HOGGING!

EPOCRATES is huge! It literally takes over your Palm device when you install it. It begs to be updated if you are 30 days out. It allows you to earn CME on your device by browsing over documents. Data, unknown to you, is sent back to Epocrates. What becomes of it? What else is being sent to EPOCRATES?

Don't get me wrong. I think EPOCRATES is fantastic. I have just signed up for another year to use them, but I use them as an example. There are a lot of companies competing to be a part of the Apple halo effect. There is pent up demand, akin to the early Palm days. But could we find ourselves in the same software bind that beckons us to leave Palm or Windows CE/Mobile? Will the new medical software take up 1/2 to 3/4 of the disk space, leaving what little space on the device useless, thus slowing the machine down to a dull roar? Will we be the subject of constant data mining, going on behind the scenes, with programs calling back to home (How would you like to be on vacation in another state, using your iPhone, not knowing that you are being tracked by one of the pieces of software that you have installed, because it calls home every time you turn on your device)?

We are all looking at the fantastic potential the iPhone and possibly other new devices have in store for us. But we must be careful not to let this fascination with advancement cloud our judgment, giving away our souls in the process. Medicine is an art and a science, but if we let others dictate what we should do, even surreptitiously, just to make life a little easier, we stand the chance of not living up to our maxim: Primum non nocere. As we embark upon this great future, we must DEMAND this of the software makers also.