The theme of the 12th edition was: the Future of Multi-Disciplinary Team Care.

The main topics covered this year were mostly recurring with respect to previous years:
1. Critical Indicators (CI) or Quality Indicators (QI)
2. Analysis of Variance, and Outcome Master
3. Pathway of Regional Cooperation
4. Multi-disciplinary Team
5. DPC (diagnosis procedure combination) and Clinical Pathway

Moreover, this year, 2 special guests were invited:
Prof. Shigeaki Hinohara, who turned 100 years old this year, and delivered a powerful message on stage, about the concept of Team Based Learning.  Truely amazing.
Prof. Junichiro Kawaguchi, professor of aerospacial research at Kyoko University, who talked about a completely unrelated topic (apparently, at least): the amazing story of Hayabusa, the spacecraft which made a 7 year trip into space before landing back on Earth, after multiple technical troubles.

And last but not least, this year’s conference also covered the terrible earthquake of Tohoku (Northern Japan) and its consequences in the medical world.

The attendence was more than 2,400 people, less than average, but not too bad considering the difficult year it was for Japan.

Here are a few notes I took.

Critical Indicators (CI) or Quality Indicators (QI)

• There are 3 types of CI: regarding structure, process and outcome.
• CI can be used to improve the quality of healthcare by repeating the PDCA cycle (Plan – Do – Check – Act).
• Variance analysis allows to find which factors negatively/positively influence CI/QI.
• Quantitative improvement is easy to grasp (e.g. reduce the length of stay in hospital), but qualitative improvement is more complex (e.g. influence of adding or removing a process step).
• St. Luke Intl. Hosp. publishes every year a book summarizing dozens of CI’s, mostly process-related.

Analysis of Variance, and Outcome Master

• “Variance” is, broadly speaking, a “deviation from the plan”. It can be an outcome not reached, but reaching an outcome earlier or later than planned is also a variance (although it can be “positive variance”). Adding/changing/removing an step in the process is also an occurrence of variance.
• There are many ways to record variance, the most exhaustive way being referred as “all variance”; every deviation is recorded (Prof. Katsuo is a proponent of “all variance” recording). Other ways are “gateway” and “sentinel”, which only record some occurrences.
• Proper recording of variance should describe the content (WHAT happened) and the reason (WHY it happened).
• Although recording variance as “free text” is possible, it makes its analysis impractical. It is more efficient to create a “master” for variance content and reasons and assign a code to each one. This relates to the work of Prof. Soejima who compiled a BOM (basic outcome master) which tries to unify vocabulary for describing outcomes.

Pathway of Regional Cooperation

• Several diseases, which must be taken care of in both acute and chronic stages, are well-suited for regional cooperation clinical pathway.
• The current situation is that, although big hospitals (and even clinics) may be equipped with high-end information systems, they are not well interconnected, and there is a whole (the biggest) part of the actors (including small medical centers, home nurses, home helpers, …) which is not connected together. It is therefore very common to exchange information through paper (fax) or more recently by sending Excel sheets back and forth via e-mail.
• Examples of systems enabling electronic data exchange for regional collaboration pathways are “Zaitaku Dr. Net”, “Net 4 U” (VPN network), as well as custom solutions (such as K-MIX, Kagawa Medical Information eXchange)
• The success of regional collaboration pathways relies on involving all actors including the attending physician, primary care doctor, nurses, home helpers, nutritionist, and last but not least, the patient and family. It is critical that all actors have a common view, and understand what are the goals (outcomes) of each step of the pathway.

Multi-disciplinary Team

• This was the main theme of this year’s conference.
• In his special talk, Prof. Hinohara suggested that for a team to work well together, they first should learn together (Team Based Learning).
• Team dynamics: forming, storming, norming, performing. It is important to understand which stage the team is in.
• The multi-disciplinary team includes all actors. In the “old” model, the doctor was at the center, playing the main role; today, not only doctors and nurses, but pharmacists, radiology technicians, examination technicians, nutritionists, physiotherapists,…
• Concrete examples where multi-disciplinary team care was studied: breast cancer care, nutrition screening test before leaving hospital, education of diabetic patients,…

DPC and Clinical Pathway

• DPC (diagnosis procedure combination) is a standard of the Japanese Ministry of Health Labor and Welfare (MHLW), which defines codification of all medical acts using 14-digit codes.
• DPC codes contain various information including disease, medical act or prescription, and complication.
• DPC is primarily used for accounting, but it appears to be very useful to obtain various information through data mining.
• DPC is not specifically related to Clinical Pathway, but it can be used in relation with CP, e.g. to infer current medical processes, to find out variability in processes, to detect variance, etc
• Several ways were proposed to visually show CP information extracted from DPC data and ways to improve CP (through PDCA cycle) by looking at these data.

Clinical pathway and effective recording

Interesting side track about use of IT to improve hospital workflow.

• POTV (Problem Oriented Timeline View) is a “timeline” plot of various EHR data with capability to “zoom out” in the time scale and view the whole patient’s life
• WATATUMI, an Android app on the nice and lightweight Samsung Galaxys tablet replacing an old and expensive PDA (Pocket@iEX) as a bed side terminal allowing among other patient identification (bracelet reading) and recording of vitals
• Discussion about how electronic CP software reduced error and double encoding, and made nurse record easier.

Lessons from clinical pathway introduction

Some nice alternative ways to mainstream CP software:

• Use of Yaghee document management system to compensate for shortcomings of the “NEC Megaoak HR” CP software, and efficiently record variance.
• Presentation of a custom CP software called “Flexi Path” (Nagano Hospital) which allows to not set a fixed duration for each step, but have a unit transition logic based on events or patient condition. This reminded me the PCAPS (patient condition adaptive pathway system).

The conference was concluded by a free discussion with doctors involved in the big Tohoku earthquake of March 11. Many witnessed what they did just after the earthquake, and how they adapted to the very serious situation that followed. Some difficult questions that arise:

• As a doctor/nurse, should you go and find your family before taking care of your patients?
• Should the non-patient refugees be welcomed in the hospital?

This was again a very interesting conference, with highly motivated participants. It is extremely interesting to meet with doctors who are not only experts in their field, but are also constantly preoccupied by making healthcare better, not concerned by their own interest.

Hier, j’ai fabrique ce sapin de Noel tout en bois.
Qu’en dites-vous?  Pas mal, non?
Il y a encore du travail pour le poncer, mais je pense ne pas le peindre et garder le bois brut.
Et en plus, il est demontable, ce qui est un avantage pour un sapin de Noel…

Keywords: safety, quality, healthcare IT, EMR, EHR, clinical pathway, balanced scorecards.

For those who are interested, abstracts are available here. Only in Japanese, unfortunately, but Google translate should allow you to get a feel of what they are about.

I found the 7 rules proposed in this video interesting, because I think they are slightly different from what I heard elsewhere (e.g. by Loic Le Meur or Guy Kawasaki). Although the message is probably the same, the way it’s presented here is nice.

Here are the 7 rules:
1. Outrageously curious, be sensitive to the trends.
2. If it’s something you like, study it.
3. Pay attention to changes in politics and economy.
4. Listen to others’ opinion but don’t let your direction be blurred.
5. Imagine yourself having succeeded.
6. Accomplish measurable goals.
7. Appropriately use people, things, money and information to deliver results.

It’s all very Japanese, because very pragmatic.

Several weeks passed already since we signed the deed. In fact, it is after we missed what we thought was the house of our dreams, that we found this wonderful house:

Our new house

And now, I would say we are happy to have “missed” the previous one, because this one is much better. It is a large house (140m2) on a beautiful parcel (240m2), with a little garden South. The house is already twenty years old, but it is in concrete with light steal structure, and it was built by a famous company (Sekisui House, 積水ハウス). Built during the economic “bubble” in Japan, its owner did not hesitate to pay the price and carefully chose every material. Great, really.

The neighborhood is also perfect: in an old “bunjôchi” (分譲地, that is, a residential area divided in similar parcels, quite spacious, at some point in time). It is very quiet, with woods nearby. What else could we ask for?

And when I think about it, I think it is by taking the time to visit many houses, and to compare them, that little by little, we discovered what we wanted. A house is something very personal: what I like, you may not necessarily like it. In our case, we realized what was important for us: a large house, a residential area (the neighborhood is almost as important as the house itself) and quiet, a strong construction, a house having its own caracter, something unusual. And we also found what was not so important for us: the distance from the station (we have a 15min bus ride to the station), newness (we actually didn’t want of a new house), services (eg: concierge) which you get in big buildings, nor even the distance from the center of Tokyo (although, all in all, it takes no more than 45 min by express train).

Once we found what we wanted, we had to hurry up: place an offer, and kick off loan requests to the banks. It is relatively difficult for a foreigner to get a morgage in Japan without having the permanent residence permit (eijuuken, 永住権) but it is not impossible. Large banks will generally request to fulfill the following conditions: have a rolling contract in a medium-size company, have cash corresponding to at least 20% of the total amount of the transaction, and having initiated the process to obtain the permanent resident permit in Japan (funny detail: it is enough to have submitted the file, but it is not necessary that the request be accepted, which is good because the processing usually takes a long time).

Then, less than two months later, we were in our new house. Everything went well because with the birth of our second daughter, we really started feeling a bit cramped in the appartment we occupied at that time.

To conclude, I’d say what I learned is to be patient and persevere to get what I really want.

Her name is Camille, and the Japanese transcription is 迦実 (kamii). Since I am often asked about the meaning of the name, here is a word of explanation: the first kanji, 迦 (ka) has actually no particular meaning in Japanese and is mainly used for transliteration of names. This character appears among others in the word shaka 釈迦 (which means Buddha), but the meaning I assign it personally is rather based on the ideogram structure: the central part 加 means “to add”, and the external part is “the path”, which I (very freely) translate as “the path of Life”. The second character 実, has a more obvious meaning: “fruit” or (in a different context) “certainty”. My own translation of Camille’s name is therefore “the fruits of a pathway of Life”. You can find it back in the little haiku (Japanese poem of 17 syllabes), which I composed for her:

Douce pluie d’automne.
Camille, tu portes les fruits
d’un chemin de Vie.

I have actually included this little haiku in the birth announcement card in Flash, which can be found here (don’t forget to turn the pages with the mouse!).

And here is a picture of Camille, and one of her elder daughter Manon, taken 2 and a half years ago. Did you say they look like each other?

 

I am not going to try summarizing Steiner education here (see the book, which I think gives a fairly good overview), but I just want to share with you an excerpt of the book which I felt particularly interesting:

[...] Waldorf education is based on man as a threefold being. That he thinks, feels and wills, that he is head, heart and limb, is taken to be obvious. Event that he consists of body, mind [...] and spirit [...] is widely accepted. Yet it can hardly be said that these distinctions have entered deeply into educational practice. There the intellectual approach has grown more dominant at all levels. [...]

The headwise approach, as we have called it, has serious consequences. Is the child brainy, will he be able to pass exams, are questions that weight greatly on parents. The non-exam child, the child in whom heart and limb do not keep pace with the head, comes to be looked on as inferior. Art and the crafts play second fiddle. Thus all the three phases, infant, child and adolescent, are pressed forward intellectually and this has consequence for the whole life. The clever ones are extolled, but where are the artists and the craftsmen who embellish life and give it greater quality? They are rare to find.

But the effects of overemphasis on head and brain learning go further than this. We see how children in the kindergarten lose their spontaneous genius for play. They grow restless, are bored or get uncontrolled, and then they need adults with their thought-out games and learning devices to engage and entertain them. What belongs properly to the first years of schooling is pushed down prematurely into the pre-school years. That means drawing the children into their nervous system, making them ‘heady’ too soon; but that in turn also means robbing them of their early powers of imagination, the source, if allowed to play itself out naturally, of greater creativity in later life. Then, as is seen so clearly in public life, we arrive at adults who fall short of demand, who cannot enter with imagination into the problems, mainly human problems, that confront them, and therefore cannot arrive at the needed solutions.

I personally completely agree with this analysis, although I reckon it may be seen as extreme and likely controversial. But I would be really interested to know what you think about this. Are our schools indeed too “intellectualizing”, or do you think it is just a normal evolution of the 21st century in which we live?

You may want to ask why this is interesting. Well, because it gave me the chance to observe my daughter in the exact same situation as one year before, and see her evolution in one year. Amazing! Last year, Manon was 19 months old (this year 2 years and 7 months) and you really can see the difference: she was a “passive” baby last year, and this year, she became an active child, who really takes part to the activities.

You can get a feeling through the pictures below (left are from 2007, right from 2008).

 
 
 

I have to admit I was quite busy, among other things by the acquisition of a new house (!) and by preparing the birth of our second child (!!) And while I hope coming back on these later, it is not about this I wanted to write today.

A question which occupies me these times is: How to keep myself up to date?

You will tell me to read the paper, or to browse RSS feeds. I (almost) don’t read the paper, but I do use Google reader at best, but although the tools is there, I realize it’s all about how you use it.

Google Reader

Which feeds to choose? Pierre told us about the importance to keep your feedreader “alive”, by adding new feeds and getting rid of those you don’t read, and I agree. But it requires you to be proactive. I sometimes see myself scrolling from one post to the other in a feed, without remembering a lot from my “reading” (apart being a good exercise for my mouse scrolling wheel, it’s not very useful). You need to throw away what’s not useful. Example: during the “D conference”, I thought it’d be nice to register to the “All Things Digital” feed, but now, I sometimes feel all these topics are not so interesting. –> Get rid of it!

But more importantly: how to find new feeds? This requires to surf more widely, which I don’t do often enough.

My favorite sources in Software Engineering are InfoQ and SE-Radio. I like to download the new episodes of SE-Radio and listen to them while I bike to work. It’s an excellent way to learn (more than being “up to date” because not all topics are really new).

This links me to what Pierre wrote in his post “What do they learn at school?” (waow, second reference to Pierre, he’ll become my guru!) It is even more important to continue learning, especially when you realize you didn’t learn anything at school…

Besides this, I enjoy entrepreneurs blogs, and blogs in the medical computing field, like this one or that one.

What about you? What are your sources of information?