1. Examining the Practice
of Medicine
Please
speak more
clearly

2. Basic Workflow of Medical
Practice
• Patients have a complaint or illness
• Doctor gathers the information
• Doctor determines a diagnosis or
approach
• Doctor communicates with the patient
• The doctor prescribes treatment

3. Let’s Take A Look

4. Welcome to UK :
Seminar Given Last Night in this Room

5. Richard Smith Intro

6. How is Medicine different from days
of Charles Dickens?
Patient’s have a complaint or illness
1. Ring up their GP
Might queue up to be seen
Doctor gathers the information
2. Information is entered into a
computer
Doctor determines a diagnosis or
approach
The doctor prescribes treatment

7. Medicine Today
Patient has a complaint or illness
Ring up their GP
Wait in Queue
Doctor gathers information and
puts it in computer
Patient enters information into the computer
Doctor reviews and interview
Doctor determines a diagnosis or approach
Doctor communicates with patient
The doctor prescribes treatment

8. Professor Ray Jones

9. Patient Computer
Dialogue

10. Doctor Patient Dialogue
“Dialogue between doctor and patient is a time-honored
process revered by the medical profession. During
conversation with his patient the doctor can establish
rapport, evaluate his patient’s ability to engage in
productive discussion, observe his patient’s nonverbal
behavior and collect historical information of clinical
relevance.…doctors as interviewers are busy, expensive
and sometimes hard to find. It seems reasonable,
therefore, to look for substitutes that will serve at least
some of the purposes of medical interviewing in
widespread and inexpensive ways.” Warner Slack

11. Physicians often use medical terminology that is
misunderstood by patients.

12. Studies show that 50% of psychosocial and psychiatric
problems are missed

13. 54% of patient problems and 45% of patient concerns are
neither elicited by the physician nor disclosed by the
patient.
Patient and physician do not agree on the presenting
complaint 50% of the time.

14. Physicians control the time of the interview.
Time is limited, and it is impossible to obtain complete
medical histories regularly from all interviewees during a
traditional interview.

15. Physicians ignore patients.

16. Alternative
Involving our patients

17. Individual Adoption
1. Knowledge
2. Persuasion
3. Decision
4. Implementation
5. Confirmation

22. Patient Computer Dialogue
• Mayo Proceedings in
January 2003
• Solves input problem
into computers
• Powerful Tool for
Quality
• Pilot: You want
passengers to use
electronic tickets

23. You are at the office
• A partner’s patient who has hypertension
comes to see you because in the last ten
days she has noted that her blood
pressure is elevated from its baseline.
• Meds Lisinopril 20 mg daily
• BP 152/93

27. What did we learn?
• We can not judge quality of care by
reviewing a chart!
• Inputs are important
• Computerized history provided more
information that was critical to this case,
and was valuable to the clinician

28. How does it work?

29. Patient Doing History

33. OUTPUT IS GIVEN TO YOU
• Given to you on paper
• Given to you in
electronic form like
into Word
• Directly into an EMR

34. ADVANTAGES
Collects more data
then a clinician
and organizes it
into a readable
form

37. Patient is better organized
Patients can do this

38. Patient collects information
that the clinician misses
• 40% of time
provided useful
information not
typically elicited
• Essential Questions
missed
• Pilot’s Checklist

39. How dangerous is health care?
Note: both dimensions are logarithmic scales
DANGEROUS REGULATED ULTRA-SAFE
(>1/1000) (<1/100K)
Health
Care Driving
10,000
Deaths per year
1,000
Scheduled
100 Chartered Airlines
Flights
Mountain European
Climbing Railroads
10
Bungee Manufacturing Nuclear
Jumping Power
10 10,000 100,000 1,000,000 10,000,000
Number of encounters per death

41. Socially Sensitive

42. Highly Adaptable
SARS

45. Others
• Patient controls interview-length of time
• Doctor only deals with positives
• Research
• Multimedia
• High patient acceptance
• Scales

46. Scales
• Zung Depression
• Rahe Stress Scale
• Urology Scales
• Wast
• Conners
• Anxiety
• Pain impairment
• Patient Education Needs

49. Tough Diagnosis

50. Jane Doe
Chief Complaint Sore throat
VS stable
Sore throat 3 days duration

53. We have basic history

54. Time of a Routine Office Visit
8 S
O
7 A
6 8
Minutes
P
E
5
4
3 Plan
2
1 Subj.
2
Obj. 2 Pat Ed
0
0.1
Traditional

55. Future Time of a Routine Office Visit
S
8
O
7 A
6 P
Minutes
E
5
4
3 Subj. Plan
2 Obj.
Pt. Ed
3
1 3 2 0.1 2
0
Software

56. Complete Physical
35 S
35
O
30 A
P
25 E
20 Subj 17
Minutes 15
15
10 7 8 7 Extra Time
5 Plan
5 Obj Subj
0.1 Plan 0.1
Obj
0
OLD NEW

57. Lets look at history
80/20 Rule
20% of your questions get you
80% of the content
Negatives are time intensive
Analogy Mining for Diamonds!

58. Mining-Topsoil sand it is easy
Open ended questions
Listening 2 minutes

59. What are the results of
All this labor

60. It is like Mining
Yes/No questioning-tailings

61. You can use a machine to
Do the hard time consuming
Work

62. You are in control
You will trust the work done
Check out a few things

65. Several Studies
• Acceptance has been documented in ethnic18
diverse groups, rural practices19, in prenatal
visits20, patients seeking a urologist help21,
adolescents22, sports examinations23, and
well child visits24. Reliability has been
assessed between personal interviews for
gynecologic patients25, preoperative
patients26, and general practice27-29.

66. UK Has Done Leading Work in
Documenting that it Works

67. Using the Internet to Practice
Medicine RSM September 21 2010
Dr Richard Sills
Thalidomide Trust and IMHUK

68. Healthlink
Facilitative telephone support line to help
Beneficiaries to access the Health Care that
they need.
Not a clinical service.
Anne Horton and Lizzie Hurst.

69. Healthlink
• About:
• Listening and synthesising histories and
helping to sort out priorities and what can
be done next to try and solve problems.
• Journeying with beneficiaries as they try to
get the help that they deserve.
• Collecting information that may be
generically useful and making it available.

70. Some numbers
l Beneficiaries that have used Healthlink:
211
l Medical/Health issues: 978 (4.6 per
individual)
l Problems accessing or communicating with
NHS 153
l Disability related accidents / falls: 27
l Abuse issues: 14
l Pain or Unpleasant sensation in extremity:
182

71. Healthlink needs
l Personal Health Record: to store
individual's own information so that they
can present it to Health Care Professionals
l Electronic Communications between
beneficiaries and Healthlink. Also with
Healthcare Professionals involved with
their care.
l Electronic communications between
experts to discuss Thalidomide related
cases.

72. Mandy De La Mere
file:///F:/UNP_Yours_22260_Mand%2314F47F.JPG

73. Mandy
l Disabled, blind and no useful arms
l Getting to and from doctors appointments
is more difficult.
l Can use Instant Medical History using
speech recognition and Screen reader
l Should be able to have electronic dialogue
with the Healthcare professionals involved
with her care.

74. Thank you
Richard Sills
rosills@medicalhistory.com

75. Individual Adoption
1. Knowledge
2. Persuasion
3. Decision
4. Implementation
5. Confirmation

76. It collects for appraisal a large
and comprehensive body of information
about the patient’s medical history
at no expenditure of the physician’s time;
it facilitates interview by making available
to the physician a preliminary survey
of the patient’s total medical problems;
its data being systematically arranged,
are easier to review than those
of conventional medical histories,
and, by calling attention
to the patient’s symptoms
and significant items of past history,
it assures that their investigation
will not be overlooked because
the physician lacked time to elicit them

77. DECIDING TO CHANGE

78. Aim #1: Health Care Must Be Safe
Aim #2: Health Care Must Be Effective
Aim #3: Health Care Must Be Patient- Centered
Aim #4: Health Care Must Be Timely
Aim #5: Health Care Must Be Efficient
Aim #6: Health Care Must Be Equitable

79. Case Study: Mayo Clinic’s 2700
online Visits
The Nuts and Bolts of Doing
Online Consultations
John Bachman
Saunders Professor of Primary Care
Mayo Foundation
Bachman.john@mayo,edu

80. 4 FACTORS
DECREASED COSTS
ACCESS FOR
PATIENTS
INCLUDES
SATISFACTION AND HAPPIER PROVIDERS
SENSE OF BEING
CARED FOR
IMPROVED QUALITY OF CARE

81. Paradigm Shift
• Patients appreciate a doctor-patient relation-
ship that involves electronic communication
• Telephone as a communication device is
expensive (labor) and inefficient (time)
• Online Consultation requires a paradigm shift.

82. Tools are here…
but not put together well
• What you do not want…. Is what you
imagine e-mail…..

83. E mail consultation
I had surgery on June 11th, things went pretty well as far as the surgery went. I did feel pretty awfull for the first 2 weeks and the day I left the hospital my incision
broke open---I had to pack it for 3 weeks then it was restitched and healed well.
I have to admit, the first couple of weeks I was really beginning to wonder if I had done the right thing but my mind is slowly changing. It is interesting to feel myself
slowly turn my priorities away from eating. It is consistently amazing to realize how much focus there is on food, in society and in my life specifically. Jim and I
always have a ton of company, from friends to family and you know, company centers around food!!
It is an amazing feeling to be full so quickly---I am still not used to that feeling. I do have my fears about not getting enough protein in, I seem to be having a problem
eating meats but I am not to regular foods yet and I am still trying to tell myself to slow down, that is such a hard habit to break! I can't really eat sweets, so far
anything too sweet just makes me sick. The adjustment of not drinking while eating is difficult too, but getting easier. The milk drinking is getting easier too.
I am so grateful for the year prior to the surgery---I know it was a long time and it was making me spitting mad at the time but................the group sessions were such
and asset to me ---I learned so much, I developed actual habits and restrictions in that year. I had pretty much given up sweets and over eating and I think that
has been a springboard for me with my diet now. I went to group every week with few exceptions. I learned so much about myself, others, and eating disorders.
I gained an insight that so diet could have ever brought to light. I learned to quit beating myself up, to recognize weaknesses and avoid them. I learned and
practiced the importance of activity. The importance of "self-talk" was emphasized and I used it as a tool every day---especially on the bad days. I learned that
it was never too late and that being over weight was not a sentence, that it was overcomable but that the road to overcoming was a difficult one and that I
needed help in changing from the well trodden path to a new one. I am now acutely aware of emotional eating, but I have no choice in the matter, I simply can
not indulge---it is so wonderful. I ended up losing 50 pounds in year that I went to group and I am very glad for that little boost. I had a fantastic group leader, I
really lucked out! Not for sure how much more I have lost but I know the total is well over 100 pounds. and yes..............I feel so much better. I can walk up the
back of St. Marys Hill without even getting out of breath. I am still riding bike and of course riding horse. In fact, Jim and I are going to Wyoming in September
for our 20th anniversary---we are taking our horses out to the Big Horns riding for a week---I am so excited--this has been a lifelong dream for me and now my
horse has 100+ less pounds to lug. Let me tell you, riding is so much more of a joy for me, it is like starting all over.
Karie is doing well, still in PA with Jason, they were home for 2 weeks this month and we really like him, he is very sweet and seems totally devoted to Karie---while I
don't care for his tatoos,(its a mom thing)he really is great. He had a great time in Minnesota---so maybe the might move back here.
Justin graduated and Jim and I are really empty nesting it---Justin is working in the cities and staying with my niece--he plans to attend RCTC winter quarter.
I am still going to school, I completed my Associates Degree last spring and I only have 22 credits left for my Bachelors.
I do so hope all is well with you, I think of you and your family often.
I want to thank you again Michelle for all of your years of care and concern, but most of all for directing me to this surgery and the journey that brought me to it.
please......................if you have any patients or aquaintences that would like to "chat" with me about my experience, feel free to use my name and give them my number or e-mail
address, I am more than happy to share.

84. Omissions
• What do you want from me?
• What medications are you taking?
• Are you allergic to anything?
• What chemist?
• Organized Approach
• Data is structured

85. Tools only part of it
Processes
Infrastructure
Culture

86. Infrastructure starts with an
Electronic Patient Portal
• Place to store data and communicate
online
• Secure
• Schedule appointments, Prescription
Refills, Look up lab studies, Do forms,
Patient Education, and
• ONLINE CONSULTATIONS

88. Primary Care Online

89. Restrictions
1. Short Leash- Committee supervised our
activities monthly
2. Learn as much about e-visits as possible
3. 3 year pilot or until our own Mayo portal
4. Patients had to come in to sign up
5. Residents of Minnesota only

90. Demonstrate, then the Online
Visit

91. Patient View

113. Doctor’s View

114. Others can see
On call

126. Exchange Data
You do not need to be seen
In Reality Why it Could Work
EVIDENCE BASED
PROTOCOLS

127. Results of
symptom
assessment
algorithms

128. Results of
patient
symptom
assessment

129. c

130. Which would you want?
• Call on telephone • Go Online
• Nursing time for • Clinician uses set protocol
protocol • Clinician checks prevention
• Clinician time to say ok • Instructions that are written
• Appointment desk • Prescription faxed
• Nurse faxes automatically
prescription • Time in minutes
• Verbal instructions
• Time in hours
• Clinic loses money

131. Save Time - Go
Online
PCOL

132. Our First Online Consultation

135. Patient was also scheduled for a mammogram

136. Registrations 1381
Registrations
PCOL Monthly Registration
350
TRAINING TESTING EXPANSION
300
250
Patients
200
150
100
50
0
Sept October November December January February March April
Months

137. End of 7 Months –
Processes and Vendor Figured Out!
1400 registrations
500 visits
110 billings

138. WE HAD A PAUSE
Institution issues

139. PAUSE
• Way too successful
• Moving outside of the scope of the pilot
• Meeting

140. SLOW DOWN
RECOVERY
COMPETENCY

141. We now can look at results

142. Totals 2 years
Largest Study Reported
• Total Registrations- 4282
– 7% primary family member
– Linked to 12%
• Online Consultations- 2531
• Total Consults Billed- 1159

143. What was the most common
online complaint ???

144. 293 different conditions were found

145. Who did the consultation???

146. What else did we learn?
71% were women
Youngest 4 days, oldest 86

148. 8-12

149. Prevent Visits to Office
• 40% of the time saved a visit
• 12.8% Come in
• 16% Protocols
• 11% of the time handled by “on call”

150. Insurances or Paid 457
35% billed

151. Ping Pong
• 29% of the time received a reply
• 31% of that was thank you
• 20% about was request
– What pharmacy?

152. Activities
New diagnosis and new prescription
(1,148 visits - 45%)
Refilling a prescription for prior diagnosis
(250 visits - 10%)
Ordering x-rays and procedures
(264 patients - 10%)
Ordering laboratory studies
(126 patients - 5%)

153. Three corollary studies
• The farther you lived from clinic more
likely to use on-line care
• No additional visits required as
compared to express clinic or office visit
• Patients generally reflected the
population of our practice

154. Pictures
• 49 pictures were sent in
• 2% of our practice
– Diaper rash
– Bites
– Contact dermatitis
• Prescription refills

155. Ideas for future

156. Messaging

157. Messaging
• Birth date
• Selected diseases (Pit stop)

158. Most VOVs have GDMS sent to
the Clinician
So what?

159. So in October we saved a life
• Dr. Furst ordered a colonoscopy based on
GDMS from a prescription refill
• Detected a localized adenocarcinoma

160. Messaging with Pit Spot

161. Where We Are
• Mayo is using its own portal
• All employee health doctors, 350 doctors
• Roll out to our specialists
• Bumpy

162. Cultural Change
• Staff knows to push people online
• Clinicians see as way of saving time
• Revenue source

165. In Conclusion
Successful pilot
Infrastructure
Processes
Cultural Changes
Deep Dive into Patient Computer Dialogue

166. Where are we?

167. How is Medicine different from days
of Charles Dickens?
Patient’s have a complaint or illness
1. Ring up their GP
Might queue up to be seen
Doctor gathers the information
2. Information is entered into a
computer
Doctor determines a diagnosis or
approach
The doctor prescribes treatment

168. Medicine Today
Patient has a complaint or illness
Ring up their GP
Wait in Queue
Doctor gathers information and
puts it in computer
Patient enters information into the computer
Doctor reviews and interview
Doctor determines a diagnosis or approach
Doctor communicates with patient
The doctor prescribes treatment

169. Advantages Disadvantages
Phone systems?

171. Sarah Bruml’s Office

172. ACTUAL MEASUREMENTS
Time Activity # Pats Time per Opportunity
pat
8:30-9:55 Phone Triage 5-15 7 pats/80 3 min/pat =10 pats/30
mins = 10 mins = 50% savings
min/pat
9:55-1PM Surgery 10 10 pts/180 3 min/pat=10 pats/30
mins = 18 mins = 17% savings
min/pt

173. Time During Day
Phone
Phone
90 minutes saved in an !! hour day (plus lunch)!
8

174. Link to Nursing
Link to Nurse by self

175. National Health Service Call ReportCall1d: 166697Patient Name: ADRIAN
Davies
Call Priority,HP01225810300, 16106/19593Call Reason: COUGH
TypeDescription
Date
TimePMHARTHRITIS14/12/200100:03 MEDICATIONDISTALGESIC14/12/200
100:03ALLERGYFISH14/12/200 100:03
User: Thomas, Sarah DatelTime: 13/12/2001 23:59 caller rang back -
breathing worse - reprioritised to a 3.
User: Phillips-winter, Beverley DatelTime: 13/12/2001 23:22
Had a cold earlier in the week. Breathing very heavy Burning feeling in
chest and when bad has pain in left shoulder. Family history of heart
disease but doesn’t think this is what he has. Is a heavy smoker. Taking
Wilkinson Bronchial Balsam which eased his breathing over the time on
the
Title: Cough User: Wilkes, Ann Date
Time: 14/12/2001 00:07 Cough Has the individual developed significant
breathing difficulty with high pitched or crowing sound when breathing
out?-NO Notes:COUGH AND COLD FOR A WEEK

176. Call Handler Okay. Right and how can we help you today?
Caller Right un well had a cold a little while ago ... well probably sort
of got rid of it um what's today... Thursday... so I probably got rid of it
Wednesday... sorry Monday or Tuesday
Call Handler Uh huh
Caller Um I've got to admit I'm a smoker but since I've had the cold
I've had this horrible burning feeling in my chest
Call Handler Uh huh
Caller Going down my windpipe and when it's really bad a chronic
pain in my left shoulder
Call HandlerRight
Caller Um, it feels as though my chest is becoming restricted and
everything else. I think I've got some form of bronchial infection
Call HandlerRight yes you are struggling to breathe at the moment
aren't you?
Caller

177. Call Handler Yes right
Caller Yes um which has certainly cut down my smoking which is a good
thing
Call Handler Uh huh
CallerBut it is getting to the point now where it is really getting sore and it
doesn't appear to be getting better
Call Handler Right
Caller And if I take the bronchial medicine... uh cough medicine that we
bought it just only gives about 2 minutes relief
Call Handler Right okay. So have you actually consulted your doctor at all?
CallerNot yet, it's just got very bad today
Call Handler It has
CallerYes
Call Handler Okay right. So I'm sorry .. you've got a burning feeling in your
chest and when it gets really bad you said it hurts in your shoulder?
Caller Yes. It feels as though um you know when you get a really bad chesty
cough you get that burning sensation in the windpipe

178. Call Handler
Right
CallerI've got that sort of feeling and I've got... when it gets
really bad like it isat the moment I get a pain in my left
shoulder
Call Handler Okay
Caller Un I don't think it's my heart cos we have... I have got a
family history of heart disease but I don't think it's that
because normally that's pins and needles in the left arm and
I've been warned on everything to lookout for so I mean its
just some form of infection but I just can't seem to knock it
away
Call Handler Okay. Right so and this has all been brought on
by the cold that you had earlier?
Caller I believe so yes
Call Handler Right. Okay, can I take your GP's details please?

179. Caller Yes. If I could... it's eased off completed now, I took
some medicine um sort of 10 minutes ago
Call Handler Yes
Caller I get about 2 minutes instant relief and then it really sort
of cripples me for a little while and then it starts easing off
and then it will ease off for a while and then I ... I'm doubled
up again you know sort of in absolute agony finding it difficult
to breathe again
Call Handler Right okay
Caller Um which makes me think it is something to do with
you know I .. is.. something to do with the thing because if it
was.. like I was a bit worried the first time it happened and felt
ooh hang on this could be my first heart attack coming up
here
Call Handler Uh huh
CallerUrn but I took some of this bronchial cough medicine
stuff and that cleared it away
Call Handler Right do you know what the actual name is of it?

180. Caller Yes ... I'll just get it
Call Handler Thank you
Caller Yes it's urn I must admit it was a bit frightening .... They
must like him
Call Handler Yes
Caller Well believe it or not its Wilkinson's you know the Wilco
brand
Call Handler Oh yes
Caller Yes mentholated bronchial balsam for the relief of ... for
the symptomatic relief of sore throats, coughs, colds and
catarrh. It's going down my neck as if it's going out of fashion at
the moment
Call Handler Right
Caller And obviously that ain't going do me any good either
Call Handler Right
CallerI don't normally like bothering the doctor but
Call Handler No
Caller You know... this has got so bad probably since 3 o'clock
this afternoon

181. Call Handler Right
Caller It's really started playing up
Call Handler Yes okay. Right that's no problem. If you hadn't
actually called us today what would you have done? Would you
have called your GP or?
Caller Um I would've probably suffered it to be honest
Call Handler Oh goodness, rightokay
Caller Laughing
Call Handler Oh dear okay, that's fine. What I shall do is actually
ask one of the nurses to call you back then if that's alright?

182. Output

183. Downside of having people
between doctor and patient
• Link to patient

184. Questionnaires

187. General
• Mayo Clinic-PPI 13 page form 216
questions, 25 spaces
• ACOG on line 90 questions
• How many are enough?

188. Domestic Violence
• J of Family Practice
using the
WAST(Woman abuse
Screening Tool)
• 8 questions
• UCC requirement. It
should be done on all
women
• 8% pick up rate
• Other things

192. Review of AFP in just one year
• 44 questionnaires (2 an issue)
• 4-37 questions
• CAGE-alcoholism
• Check list to Assessment areas for Maintaining
Healthy Geriatric Patients
• Depression scales
• Smoking Scales
• Lead

193. Using the questionnaires leads to
better outcomes than normal
patient interviewing!

194. Patients

195. Dr. Patrick Cadigan, a cardiologist and spokesman for Britain's Royal
College of Physicians, described Internet-based medicine as "second-
best," and said it was particularly difficult to make a diagnosis without
seeing a patient in person. "To lose personal contact with your
patients means you lose clues about what may be wrong with them,"
he said.
Cadigan worried some patients may not understand the difficulties of
being treated online.

196. A machine can come between
me and my patient!
• All of this is
true
• It need not
happen

197. He said some people might need some more in-
person prodding, as opposed to the standard
questionnaires employed by most websites, to
correctly answer questions about other health
conditions or medical treatment they were
already on.

198. •
"If you don't get a thorough medical history from the
patient, you could prescribe something that might have
adverse effects," he said. "I am concerned these
websites could be steering patients to treatments for a
financial incentive rather than for their own good."

199. Dr. Lori Heim, president of the American Academy
of Family Physicians, said examining pictures to
make some diagnoses may be OK, but warned
of potential problems such as doctors missing
symptoms elsewhere on the body the patient
hasn't photographed.

200. She said if patients had multiple symptoms or a condition
that naturally required a physical exam, like listening to
the heart, lungs or conducting joint exams, seeing a
doctor virtually wouldn't work. She said doctors should
be particularly careful about prescribing drugs like Viagra
and worried about the web sites becoming prescription
mills.

201. US talking about UK
Bershow believes e-visits can help primary care physicians
practice more efficiently. “They did a study in England
which demonstrated that a provider could complete an e-
visit in three minutes, so if you were really working
efficiently, you could do 20 e-visits per hour, which
obviously you cannot do in the clinical setting,” he says.
“Plus there’s no office overhead in terms of table paper,
gowns, tongue blades, etc.” Bershow adds that e-visits
can cut down on some unnecessary tests such as in the
case of a patient who has a history of yeast infections
and describes classic symptoms in the electronic inquiry.

208. • Procrastination

209. A winter storm was coming and
the wood supply was not
adequate
and you have a dull saw

210. The Problem of Delay and
Denial

214. They had to stop what they
were doing!

217. How long can we deny and
delay?

219. A generation!
• Go down in the boiler room where it is
dark, noisy, dirty, and greasy
• Go up into the sails and feel the wind in
your face and the see the beauty of the
sea
• Remember You are called a sailor
• What is a sailor without sails?

220. World changes
• Are we like sailors in
the ship?
• When confronted with
change we say
“doctors don’t do this”
• World has changed
• Still trying to act like it
has not
• Try to do things the
same way

221. Paradigm shift
• Problem is in the mind

222. The First Teaching of a JEDI...
The Problem is in our Minds
• Going Digital is a whole new way of doing
things
“No! No Different. Only Different in your mind”

223. Different in Your Mind
Behavior as Doctors
• To extinguish old behavior-uncomfortable
• To establish a new behavior-unsettling
• We like to be competent-This is a very
different environment

224. Describe this Wheelbarrow

225. Look at your brain when seeing
something new
• DENIAL
• DELAY
• DISPATCH

226. Not real – only in your mind

227. Point is
1. We start
2. We go negative
3. We stay negative
and keep going on
4. Why?

228. THE DOWNWARD SPIRAL

229. Brain has Two Parts
Reptilian Brain with
Human Cortex on top

230. Cave Man Finding Something New:
LIMBIC
1. I must
attack it
2. I must run
from it
Emotion

231. Later Developed system?
NEOCORTEX!
Think Ahead
Positive about the new
Open- minded
Suppress emotion

232. It is really important for the
forebrain to know the Power of
Negative Thought
...Limbic
• Neutral Environment
• Four positives to equal one negative
• Be positive, positive, positive, positive
and positive

233. Five Pennies

235. FEARS GENERATED
• Loss of money
• I can not do this and I will look stupid
• I may not survive
• It is too hard
• Let me wait, Let me run away, It will never
work
• Delay Dispatch Deny
• It is just too big

236. Good Potential Concern
• What is Good about this idea today?
Positive aspects first
• What Potential does this idea have for
tomorrow?
• How can we address Concerns in ways
that promote success?
• Talking Stick
• Candy

237. We Must Start With Our Minds
• Every decision has emotion
• Neutral environment
• Good potential concern

238. Paradigm shift
• Requires Creativity
– Blocked by judgments and work

241. Creativity means Destruction
• Clay Christensen

243. Beat competitors with asymmetry of
motivation
% of tons
Steel Quality
55%
Sheet steel
22%
l
Structural Stee
l
stee 8%
ed ds
uc rs & ro
rod Angle iron; ba
ill -p 4%
inim Rebar
ofm
ality
Qu
1975 1980 1985 1990

244. Characteristics
• Low quality
• Serve market that does
not need added features
or is not served
• Not a threat to traditional
market
• Companies leaving
market are praised until
the big drop

246. Another Example
Major Established
Electronics Markets:
Tabletop radios, floor-standing
televisions, computers,
Performance
telecomm.equipment, etc.
Portable TVs
Pocket radios
Path taken by
Hearing Aids established
vacuum tube
manufacturers
Time
Disruptive technology: transistors vs. vacuum tubes

250. Examples in Medicine
• Cardiac Surgery
• Angioplasty
• Stenting

251. Disruptions Amongst Healthcare
Professionals
re s
n nai
io
Complex u est
Q
ph one ks
T ele e ban
n
Ph o Performance
that the
marketplace
Complexity
needs or
of diagnosis
utilizes
and
treatment
re
Se lf-ca
Simple
Time
Patient Computer Dialogue

252. Patient Computer Dialogue is
Disruptive
Role of Thalidomide Trust
• New evolving products on faster track
– Beneficiaries of Thalidomide Trust will accept
early development
• Serve market that is not served
• Not a threat to traditional market

253. Other Models

254. Online Banking
• 40% of the banks in the U.S. offer internet banking
facilities worth mentioning
• The UK's first home online banking services[2] was set
up by Bank of Scotland for customers of the Nottingham
Building Society (NBS) in 1983

255. Online Banking
• Be that as it may, it is estimated that a total of 55
million families in America will be active users of
online banking by the year 2010.
•
• The number of online banking customers has
been increasing at an exponential rate.
http://ezinearticles.com/?History-of-Online-Banking&id=270075

256. Drivers
1. Reduce Cost
2. Competitive Advantage
3. Protect Strategic Position

257. Banking
• For example, while the cost of transaction
for money transfer was 40p for checking
and 10p for ATM, while it was only 1p for
Internet
• First ATM 40 years ago

258. Online banking
It is generally recognized that perceived risk
plays a negative role in decision to adopt a
new technology including Internet service
Regarding Internet banking, perceived risk
involves two concepts: security and trust.
Complexity is “the degree to which an
innovation is perceived as difficult to understand
and use” Ease of use”

261. Where is Patient Computer interaction in other industries and where in
Medicine
Where would you place yourself?

262. Characteristics
• earlier adopters have
– greater empathy
– less dogmatism
– less fatalism
– greater rationality
– great intelligence
– more favorable attitude toward change.

263. Speed of innovation
• the degree to which an
innovation is perceived as being consistent with
the existing values, past experiences and
the needs of potential of potential adopters
• negative attitudes cause resistance to
change and lack of management
commitment

264. Reminders

265. Speed of Innovations
Larger organizations do better than small
generally (implementation of online banking)

266. So What is Next?