Overcoming the Challenge of Checklists: Access

In The Checklist Manifesto, Dr. Atul Gawande outlines some of the challenges associated with implementing checklists in clinical environments.

Checklists cannot take longer than 90 - 120 seconds to complete
Checklists have to assume a basic level of competency; they cannot be too basic or menial
Checklists must contextual in light of a variety of clinical scenarios and workflows
Checklists must be either READ-DO or DO-CONFIRM. A given checklist cannot mix and match READ-DO and DO-CONFIRM items.

Every medical professional we've interacted with - both clinical and administrative - understands the value of checklists. We are yet to encounter anyone that doesn't understand or believe in the value that checklists create.

Checklists can be used in any context in which there's a repeatable set of steps in which the cost of forgetting a step can be substantial. There are hundreds of workflows in hospitals in which forgetting a step can be detrimental to patient outcomes.

Despite this, adoption of checklists has been remarkably slow. Checklists are still only used in a narrow set of clinical environments. Why? Why aren't checklists being adopted in pharmacies, labs, in drug administration, or the ER?

People don't like doing more stuff. Medical professionals (MPs) are already overburdened with clinical documentation, meaningful use, defensive practices, etc. Although checklists can materially improve outcomes in many settings, they also introduce friction into existing workflows. As such, providers have only been adopting checklists in settings in which the cost of being wrong is extraordinarily high. Surgery is the highest acuity and riskiest avenue of care, but it's not the only that can materially improve from checklists.

How can we reduce the friction that checklists introduce? Let's consider the steps involved in completing a checklist:

First, the MP must recognize that a checklist should be used; second, the MP must physically access the checklist, which may be on paper, a wall, or computer; third, the MP must complete each item of checklist and document that each step was completed.

Pristine isn't tackling the first point of friction, yet. But we are dramatically reducing the friction required to complete items #2 and #3. By reducing friction, we are driving improved compliance, and ultimately improved outcomes and reduced costs. How do we reduce friction?

While wearing Pristine Glass, MPs just have to gently rock their head back, and say

"Ok Glass, start central line checklist"
"Ok Glass, start IV checklist"
"Ok Glass, start intubation checklist"

With Pristine CheckLists, MPs can access checklists without thinking, without going anywhere, and without using their hands. Pristine CheckLists dramatically reduce the friction between MPs and checklists.

Once the checklist has been initiated, MPs can navigate checklists with contextual voice commands such as:

"Washed hands"
"Prepped site with aseptic technique"
"Wore sterile gloves"

With Pristine CheckLists, MPs can access and complete checklists without interrupting their workflow. MPs can interact with and complete checklists while providing care. Pristine CheckLists represent an enormous leap forward in access and ease of use that will drive adoption of checklists in many places where they simply weren't practical or possible before.

Google Glass is Fueling Telemedicine Innovation

Telemedicine is the most profound initiative happening in medicine today. Telemedicine will do more to curb costs, increase access, and improve quality of life for both patients and providers than any single other initiative. With Google Glass fueling telemedicine innovation, these benefits will occur even faster.

Google Glass based telemedicine will have profound implications across many avenues of care:

1) Home visits - it's difficult for providers in a patient's home to beam in a consult. This is simply an ergonomics problem and Glass solves it.

2) ER - in ERs, Glass handily defeats telemedicine carts. The carts are clunky, in the way, and provide poor viewing angles

3) EMTs - EMTs still don't have a good way to beam in a remote consult. Glass is clearly the solution.

4) ORs - intra-operative surgical consults are virtually non-existant today. Glass will power intra-operative consults. In the same light, Glass will also drive improvements in surgical education through first person video.

5) Anesthesia - anesthesiologists are in many environments one layer-removed through CRNAs. CRNAs will wear Glass in the future to beam in anesthesiologists on demand.

6) Floor nurses - floor nurses will beam in a doctor on demand through Glass. 

Even without Google glass, telemedicine will power more than 50% of all care in the next 10 years. In 20 years, probably over 75%. According to BCC Research, the global telemedicine market will grow from $9.8 billion in 2010 to $27.3 billion in 2016, a CAGR of 18.6%.

Growth in telemedicine will fragment across many avenues:

1) Skype-like consults - American Well, Teladoc, Doctor on Demand, Vheda Healthcare. A few major providers such as Mayo Clinic are also extending themselves across the country. HealthSpot is offering telemedicine kiosks that will be placed in pharmacies and retail locations.
2) At-home monitoring - e.g., Qualcomm Life, Verizon, AT&T. Validic and Human API are also trying to provide a lot of the technology connectivity to bring this future to life.
3) Telemedicine carts - e.g., Rubbermaid, Telemedicine Systems, Polycom, Cisco.
4) Remotely drivable robots - e.g., Beam, Vgo, iRobot.

Avenues #1 and #2 are the hottest today. Startups and established companies are tackling telemedicine along these fronts. Perhaps the most dominant trend at the mHealth Summit was avenue #2.

Telemedicine carts have been around for sometime, and they are growing quickly. However, there has been little innovation in this space. That shouldn't be surprising since this market is serviced almost exclusively by established companies with dozens of business divisions.

Remotely drivable robots are a recent phenomenon. Although these robots can vary in look, there is almost no variability in function. These robots serve exclusively as as an autonomous iPad on wheels. They present an interesting vision of the future: a future in which doctors come to the hospital as little as possible because it's too time consuming to do so. I'm not entirely sure what that means for the future of hospital-based medicine.

The future of telemedicine is incredibly exciting. With Google Glass fueling telemedicine innovation, and other exciting trends, new energy and possibilities are emerging every day.

Communication is a Means to an End

Healthcare delivery is perhaps the most fragmented service on Earth. Medicine continues to fragment and specialize further every year. In The Checklist Manifesto, Dr. Atul Gawande joked that surgeons are specializing in left ear and right ear surgery. Healthcare delivery is fragmented across medical disciplines, job classes, job functions, geographies, and even within and among buildings on a medical campus.

Pristine envisions a future in which medical professionals communicate seamlessly with one another without thinking. Eyeware computers such as Google Glass will be the enabling technology.

Let's examine a few use cases:

For a general consult: "OK Glass, start an EyeSight call with Dr. Smith."

For a derm consult: "OK Glass, start an EyeSight call with a dermatologist."

With a CRNA wearing Glass in the OR: "OK Glass, start an EyeSight call with an anesthesiologist."

For a concerned nurse: "OK Glass, text Sally 'the patient in room 3 is doing fine.'"

For a physician in clinic: "OK Glass, text Dr. Johnson 'we discharged the patient in room 5.'"

For an EMT in the field: "OK Glass, start an EyeSight call with a trauma specialist, stat."

For a wound care nurse: "OK Glass, start an EyeSight call with a wound care specialist."

For an intensivist resident: "OK Glass, start an EyeSight call with my attending."

Glass presents the foundation to support the ultimate Pristine communication platform. Communication platforms have traditionally imposed a significant cost on medical professionals: using hands. But in many circumstances, medical professionals can't and shouldn't use their hands even though they need to communicate with others. Pristine's handsfree communication platform will open new communication channels.

Communication is a means to an end, not an end in and of itself. The most important result of seamless communication in medicine is that patients will have more access to better, more cost effective care. Communication lies at the crux of the triple aim: cost, quality, and access.

The Pristine Story: The Fun Begins

In the last episode of the Pristine Story, I mentioned that we'd be travelling all over the country visiting with medical centers. I'm happy to report that the last six weeks have been fruitful. We're going into 2014 with a strong pipeline. We're targeting first revenue in January. We are going to begin rolling out Pristine EyeSight to hospitals and outpatient centers on a regular basis starting in just a few weeks.

We are finally graduating from an R&D lab to a real company. I would like to thank everyone who's helped us get this far so quickly - employees, their families, advisors, investors, and beta users.

In 2013, we devoted most of our hiring efforts towards engineering. In 2014, we're going to devote the majority of our hiring efforts towards client success. We are, and will be, hiring project managers, trainers, support staff, and salesmen on a regular basis for the foreseeable future. We are seeking individuals with experience deploying and selling health IT solutions in hospitals. We're also looking for a product marketing manager. If you or anyone you know might be interested, please apply.

We are gearing up for our Series A round of financing, though we have a bit of room left in our seed round. We have been fortunate to find a great investor base that's been supporting us. I can't thank them enough.

I'll be attending the annual JP Morgan Healthcare Investors Conference in San Fransisco in a few weeks. Buzz and I will be at the annual HIMSS Conference in Orlando February 23 - 27. We're going to have fun running gamified live demos in the exhibit hall.

I kicked off 2013 by committing to write three blog posts per week. I put my money where my mouth was: I bet $10 / week using stickk.com. I haven't missed a single week. Having accomplished my New Year's resolution and as Pristine grows, I'm probably going to slow down to one or two posts per week. I've established five new years' resolutions for 2014, two of which will be enforced through stickk.com at $100 / month each. I highly encourage everyone to set New Year's resolutions and enforce them through stickk.com. I can say that blogging was among the top five decisions I made in my life; Pristine probably would've already failed had I not blogged.

2013 has been the craziest year of my life, and it's been hectic for all of Pristine's stakeholders. So I decided to recap the year into a blog post. I hope you enjoy it. It's one of my favorite blog posts of the year.

What Makes us Tick: Curiosity

Pristine is an organization built on the yin and yang of freedom and responsibility. Many organizations struggle to manage that delicate balance. We haven't figured it out, but we work towards it.

We've identified eight values that detail what freedom and responsibility mean.

Curiosity
Passion
Simplicity
Excellence
Selflessness
Communication
Respect
Accountability

This is the first in a series of posts that will explore what each value means at Pristine.

The first and most important value is curiosity. It's also my favorite.

Pristine was founded out of a passion for the novel, the new, and the exciting. We live at the cutting edge. We are an engineering driven organization. Engineers are king.

We are at the cusp of the eyeware computing revolution. Eyeware computers will vary significantly more than PCs, smartphones, and tablets because 1" changes in hardware will completely change the use cases and user experience of the device. 3", 4", and 5" smartphones are used to accomplish the same things. 8" and 10" tablets are used to accomplish the same tasks. 13" and 17" laptops accomplish the same tasks. But increasing the screen size of an eyeware computer from 1" to 3" completely changes how the device should be used. Glass will not be used to accomplish the same tasks as the Meta SpaceGlasses or the Atheer One.

It's our job to make sense of the incoming flood of eyeware hardware, build incredible user experiences for each, and determine where and how each hardware device should be deployed throughout the medical enterprise. We have awesomely fun challenges ahead. Our curiosity will drive the future of eyeware computing in medicine.

Eyeware computers break fundamental assumptions that have predicated human computer interaction for the past 30 years. Healthcare delivery was designed with last year's communication technologies in mind. It will be our job to help our clients redefine the future of healthcare delivery with the latest and great tools at their disposal.

Curiosity is not limited to engineering and product teams. We foster curiosity throughout the client success, marketing, and sales teams as well (not accounting though).

In sales and marketing, we face an enormous education challenge. We must overcome copious volumes of public misinformation about Glass. We must convince people that Glass isn't a silly toy. We must convince them Glass presents incredible new opportunities. Traditional marketing channels simply will not work. We must pioneer new means to marketing success.

And in client success, we have to change behaviors. Medical professionals (MPs) aren't wearing eyeware computers today. Many are scared of eyeware devices. The vast majority of MPs don't know what eyeware computers can do or how they work. We must open their eyes to the incredible opportunities that eyeware computers present.

We face a host of challenges that have never been faced before. We smile. We explore. We have fun. And we figure it out.