The Efficient MD — Innovations for Health Care

Evernote for Doctors Revisited: Privacy Issues and Yet More Uses

2008-09-28T16:06:00.005-04:00

I'm an unapologetic fan of Evernote, a new searchable, friendly, available-anywhere, online personal database. As I've written previously (See "How Doctors Can Use Evernote As a Professional Memory Accessible Anywhere"), Evernote is a near-perfect tool for physicians who need to gather lots of information in multiple forms for patient care or research — papers, webpages, protocols, and potentially even patient notes and laboratory tests – and would like that information searchable, taggable, and available on their computers, the web, and even their cellphone. For ensuring that all your information is available and fluid, Evernote is the best service I've seen.

But why is Evernote only a near-perfect tool for doctors? While Evernote has many privacy safeguards in place, it is not compliant with HIPAA, the United States' medical privacy law. While understandable — receiving HIPAA certification is not simple — this is, unfortunately, a big deal. Although communication to the Evernote servers is encrypted and access is protected, transmitting protected health information to the Evernote servers is not allowed (in the United States, at least — see AppleQuack's Evernote tips below).

Until Evernote receives certification — the cryptic quote from customer support was, "At this time we do not plan to pursue HIPAA certification for our (consumer) Evernote service" — here's an alternative solution. (And by all means, please suggest others if you think of them.)

Install Evernote to an encrypted account with a strong password. (On the Mac, you would create a secure account which uses the FileVault service.)
Create a Notebook in Evernote which does not sync to the Evernote servers.
Use this account and this notebook for all protected health information.

If Evernote were HIPAA-compliant, what other uses could doctors find for it? AppleQuack, an excellent productivity site for doctors written by a Dr. Cris Cuthbertson, an Australian surgeon, has a list of "20 Ways Surgeons Should Use Evernote." (Being in Australia, she doesn't need to comply with HIPAA.) Here are a few:

Photograph your operation notes
Remember procedure and disease codes
Keep patient information handouts accessible
Keep patient demographics
Remember treatment protocols
Photograph or scan business cards

What other uses have you found for Evernote?

100+ Tips for Being On Call in the Hospital

2008-09-25T21:47:00.009-04:00

Several weekends ago, while seeing nearly fifty patients in the hospital, I asked readers of this blog and my followers on Twitter a question: "What advice do you have for physicians on call?"

The question hit a nerve, and the result was over a hundred tips from a dozen different physicians. Some are directed at residents, others at attending physicians. Some tips apply to the daytime, some apply to 3 o'clock in the morning. Some tips are unrealistic. Some are thought experiments. Some tips might make your day go quicker, and some will purposefully slow you down. Some tips might improve the care of your patients, some might make you more mindful, and some might help you reconnect with the reasons you became a doctor in the first place.

There’s bound to be something here you'll find useful.

Thanks to everyone who generously contributed their advice, including Doctor Anonymous, Theresa Chan (Rural Doctoring), Jen McCabe Gorman, A. Mangla, Mark Johnson, Nephron129, Huck, and several anonymous physicians.

Addendum: For the most recent version of this page to which you can add your own advice, visit The Efficient MD Wiki.

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Drink more water. Does staying well hydrated affect your performance? In the rush to see patients, it’s easy to forget the simple things, like drinking water. Try drinking at regular intervals — say, every three hours. Set a timer to go off every three hours, and drink at least eight ounces of water. You might discover that this improves your mental acuity and performance.

Get outside at least once a day. Vow to get out for at least five or ten minutes every day (weather permitting, of course). Staying in the hospital too long can make anyone claustrophobic. Look at the horizon. Breathe the outside air. Get a fresh perspective.

Make a game of remembering names. Attempt to memorize as many of your patients’ names as you can. You may be one of those people born with the skill of instantly remembering names. Most of us aren’t so lucky, and we have to work hard at it. It’s a skill worth improving. Try memorizing the names of all the patients you see. One method is to say the persons name aloud to them (“Hello, Mr. Jones.”), Repeat the name three times to yourself, then focus on an unusual feature of the patient and connect this feature to the person's name.

Walk more quickly. Try walking 25% faster than you otherwise would. Observe the effect on the rapidity of your thinking.

Take the stairs instead of the elevator. If you need to walk up or down two flights, ditch the elevator and use the stairs. Extra credit: buy a pedometer and aim for 10,000 steps during the day.

Nap. If you feel sluggish in the middle of the afternoon, experiment with taking a 15 minute nap. (This is long enough to refresh you without causing you to fall into a deep sleep.)

Time yourself. Set a specific time to spend with each patient: say, 5 - 15 minutes with a follow up patient, and 30 minutes with a new patient. (Use a watch with a vibrating alarm, like the Dakota Vibe.)

Use a tally counter. Keep this in your pocket and record the notes you’ve written, or the times you’ve done something correct, or the small tasks you’ve accomplished. Aim for 100.

Connect with other people who are on call with you. There’s a certain friendly familiarity that comes with being one of the few people working in the hospital. Also, you may need them for consults, and they may need you.

Pay attention to your breathing. While walking in the hospital, quiet your mind and focus on the breath. Try to maintain your focus and concentrate only on the breath.

Refine one part of your physical exam. For ten patients in a row, pay particular attention to how you perform one part of the physical exam. Do a complete cardiac exam, or pulmonary exam. Do it the same for each patient. Analyze your technique.

Track down the coffee. Better yet: Find out who makes the coffee. Make friends with them. Quickly. Same with charge nurses. (Jen McCabe Gorman)

Maintain eye contact. Make a conscious attempt to keep your eyes focused on the eyes of your patients. Don’t look away. Occasionally switch from eye to eye. Maintaining eye contact tells your patients that you are paying attention to them. It’s easy to forget this and look at our list, or at the part of the body we’re performing the physical exam on — anywhere but the eyes.

Ask questions. Find out patients' backgrounds. Dr. Faith Fitzgerald has a story that she tells about a group of residents who purposefully presented to her “the most boring person on their team,” an utterly unremarkable old woman. After some questioning, Dr. Fitzgerald discovered that this woman was actually one of the last survivors of the Titanic. Everyone has a story. It’s easy to lose site of patients’ humanity when you’re rushing through the hospital on call. For at least a few of the patients you see, ask a question. Try to find out something about them. What have they worked as? Where do they live? What is interesting about them? Ask one question of each patient, like “Where have you worked in your life? Where have you lived?”

Do everything when you can. Eat when you can, sleep when you can, pee when you can. (Rural Doctoring)

Eat a Cliff Bar. Doctors notoriously are too involved with taking care of others to take care of themselves. We ignore our own bodies. We may be hungry or thirsty, but are rushing too quickly to pay attention. Midway through the morning, when you may feel yourself losing steam and are maybe slightly hungry, try having a snack. Something small, like a Cliff Bar. See if that gives you an extra boost of energy.

Get to the hospital ridiculously early. Wake up at 4 or 5 AM. Getting in early has advantages — it’s easier to concentrate and accomplish tasks if there are fewer people around. However, typically morning labs are not available until late in the morning or early in the afternoon, so this strategy may require you to check labs again. (If you haven’t slept much, getting in early works best when combined with a nap.)

Reevaluate your gear. Your day will be much more pleasant if you have the right equipment. Ever use a pen that didn’t write smoothly and felt awkward in your hand? Ever use a stethoscope with poor acoustics? These little things may not seem like much, but if you’re examining a lot of patients and if you’re required to write a lot of notes (assuming you’re not using an EMR), little things matter. Having the right gear can make the difference between being frustrated and relaxed at the end of the day.

Lie down whenever you can — even if only for a minute because it might turn into an hour. (Rural Doctoring)

Count stairs. Sometimes you'll be too damn tired to pay attention; wakes you up. (Jen McCabe Gorman)

Consciously write less. Make ever word count. Be sure to include the pertinent parts of the history, the pertinent positives and negatives, but be aware of the subtext to your notes — you are trying to establish in the reader’s mind your argument for a specific diagnosis or plan. For more on this idea, see Developing Clinical Problem Skills by Harold Barrows.

Consciously write more. As an experiment, imagine the worst possible outcome or potential diagnoses for some of your patient. How have you excluded these diagnoses? Take some extra time to convince the reader that your discarded diagnoses are not the correct ones and that further tests are not needed.

Don’t get distracted. "Being on Call can be overwhelming especially if you have to see over twenty patients. I usually get my list of patients in the morning and then geographically I make a 'plan of attack,' and then I go full steam ahead. Try not to chat with people although it can be tempting. Staying focused on the patients and their issues rather than what you want to do when you leave the hospital really makes my speed remain fairly contstant. There is nothing so novel here that you haven't heard before — make yourt plan of attack, stick to it, focus on the work without getting distracted." (A. Mangla)

Change your pen. If you’re used to a ball point pen, switch to a roller ball. If you’re used to a roller ball, try an inexpensive fountain pen or gel pen. It’s amazing what the difference of a pen can make in your mood and your writing. (If you write most of your notes electronically, obviously this advice doesn’t apply.)

Learn to recognize when people are sick. For residents: “If you think a patient has a chance of ‘crumping,’ ‘lay eyes’ on the patient early in the night so when you’re called at 2 AM you have a reference to compare to.” (Mark Johnson)

Say one encouraging thing to everyone (if possible). “You’re doing better.” “Your kidney function is improving.” “Everything looks stable.” It’s often difficult for patient’s to tell whether they’re improving or not. Even simple words of encouragement can lift someone’s spirit.

Respect the nurses. “Respectful interactions with RNs is key to survival. Rudeness results in bodies found in ditches.” (Rural Doctoring)

Don’t wear a watch. Does not looking at the clock make you faster?

Take a deep breath. If you become short tempered with patients or their families because of stress, catch yourself. Relax. Sit down.

When encountering complex differential diagnoses, use a mnemonic. For example, VINDICATUM: Vascular, Inflammatory, Neoplastic, Drug, Iatrogenic, Congenital, Autoimmune, Trauma, Unknown/Idiopathic, & Metabolic. For new patients with uncertain diagnoses, use this mnemonic.

Choose your rounding time carefully. “Certain period of the day are more conducive to rounding. 8AM is notoriously hard because the nurses are signing out and there is no workspace available. Family visiting hours, usually from 10 am until the early afternoon, can be tough too if you have a lot of patients to see. If you only have a few patients to see, this is probably the best time as you can take the time to explain things to the family and patient together. Like another person has written, avoid socializing.” (Anonymous)

Make sure your pager is on. Don’t laugh. (Doctor Anonymous)

For each patient, ask: how am I getting them closer to discharge? What’s the plan? How am I getting them to their goal of being well and out of the hospital? (Or failing that, how am I making them more comfortable, etc.)

Review ACLS. For residents: “Scan the CPR/ACLS protocols for about 90 seconds each AM while walking into the hospital in AM to refresh.” (Mark Johnson)

Normalize your patients. At some point during their hospital stay, most patients should be normalized. In the rush to manage more complex problems, this is easily overlooked. Normalization means turning a "patient" into a "normal person." This is accomplished by removing intravenous lines and catheters, stopping unnecessary medications, not drawing labs daily, getting people out of bed, and planning for discharge. A patient who is otherwise doing well may stay in the hospital for weeks (or even die) because of a complication like line sepsis, urinary tract infection from a catheter, or deep venous thrombosis. Sometimes, these complications may be prevented by early and aggressive normalization.

Take a stairway or elevator you’ve never used before. Many hospitals that I’ve worked at have multiple elevators and stairways, many of which I’ve never used. Experiment with using them.

Consciously relax. Doctors are often at their most stressed when on call. Ever few minutes, relax your facial muscles. Let your shoulders drop. Before seeing each patient, relax yourself.

Wake up early post call. For residents: “Set your alarm in AM for plenty of time to wake up & get a fresh cup of coffee (even if it means less sleep) prior to AM rounds.” (Mark Johnson)

Always give patient and their families the benefit of the doubt in any interactions. Presume that if they’re acting upset, or hostile, they have a reason. It may always not seem like a good reason to you, but presume it’s there. Try to see the reason. It’s surprising how often hostility melts away with a small amount of human kindness and empathy.

Avoid socializing. Recognize that being on call is a time that you need to get work done and socializing is not your goal.

Consciously socialize. Recognize that being on call is a time when you can deepen your relationships with other doctors.

Group your tasks. Similar tasks should be performed together. Rather than examining patients, checking labs, and writing notes, try doing each of these tasks at once — for example, examine all patients on the floor, check all labs for all patients, then write as many notes as you can. If you use this technique, be sure to ensure accuracy by writing small notes to yourself on an index card or on a note template so you don’t neglect to write down significant physical findings.

Triage. While it may be tempting to start at the top of the hospital and work your way down, or go from one floor to the other, it’s a better idea to see patients who are sick or require decisions early. That way, you’re less likely to discover that someone is unexpectedly sick at the end of the day. Of course, it’s better to see a few patients at each nurses station — it’s inefficient to constantly criss-cross your way through the hospital floors, returning to places you’ve already been. There’s a balance between seeing patients efficiently and seeing the most critical patients first.

Experiment with breaks. Take a five minute break every one to two hours. Athletes understand that for sustained peak performance you must take breaks. If you keep going at top speed for the whole day, you’ll burn out.

On an index card or PDA, write down everything you don't know. One of the best ways to learn more and learn efficiently is to keep a list of things you don’t know. Whenever you encounter a clinical question that you don’t know the answer to, write it down on an index card or PDA. (Assuming you don’t need to know the answer right then — if you do, by all means, look it up.) At the end of the day, devote some time to looking up the answer to every clinical question you have using a resource like UpToDate.

Have a printout of every patient you are covering in your pocket. "Keep to do list with check boxes next to each items. Write down tasks to be done at a particular time. For example, check labs on Mr. X, Mrs. Y, and Z at 2200. Keep commonly used numbers on the sheet or handy in your pocket (other residents, cardiology fellow, common hospital floor numbers.)" (Mark Johnson)

When “cross-covering” a patient, write down everything you do. (Mark Johnson)

Reevaluate your templates. Being on call is a stress test of the system.

Bring your favorite foods from home. “I bring 2 bottles of water and 2 sodas each weekend call. I like to bring ~6 sandwich bags of sliced cheese, crackers, nuts, carrots, dry cereal to snack on throughout the night, also a few chocolates makes the night.” (Mark Johnson)

If you’re staying overnight, stuff a call bag. One resident’s call bag includes a medical book, non-medical book, travel-sized deoderant, toothbrush, toilet paper, fresh pair of scrubs, undershirt, and underwear for the AM. (Mark Johnson)

Carefully choose your pocket resources. For residents, consider Massachussets General Hospital’s “Blue book,” Tarascon’s Internal Medicine/Critical Care, and Tarascon’s Pharmacopia. (MarkJohnson) I also liked On Call: Principles and Protocols.

Treat your call day just just like a regular work day. “I go through my same routine. I don't come in later, but rather at my usual time. I avoid nurse signout time (7am at our hospital) and I start with the most critically ill.” (Nephron129)

Write as you talk on the phone. You may often be put on hold or on a phone call which doesn’t require your full attention. Make productive use of this time. Write notes, check labs, or do other activities. The general principle is that there should be no downtime unless you want it.

Knock on the door (or the wall) before entering patients’ rooms. Even when you’re at your most harried, be polite. Patients will appreciate it, and when you do have time, being polite will be second nature.

Write standing. If you find that your energy is flagging, or that you your notes are overly lengthy, experiment with writing standing up.

Always keep a stack of business cards handy. Good advice generally, but especially while on call. You never know when a new patient or physician will ask for your card.

Find that zone of maximum benefit. Avoid defensive medicine, too much writing, and too much testing. The curves for you and for your patient are different.

Be kind. Say kind words to people who can't understand or hear you because they are unconscious. (Sometimes, they can hear you.)

Watch your body language. Face patients. Smile. Don’t rush. Don’t hunch your shoulders.

Have your fellow pre-round on everyone. Then come in at 8. (Huck)

Change up your routine. Start at a difference place in the hospital. Write with a different pen. Consciously alter large or small parts of your usual routine.

Some institutions film you. Be aware of how you appear. (Anonymous)

nephron129 said...

The best piece of advice for weekends on call came from one of my mentors. The people who are the most bitter are those who think that just because it's a weekend that somehow they can still make plans to attend some event in the early afternoon.
I try to avoid socializing but I also try to recognize when I've hit the wall and I need a break. I try to take 10-15 minutes to recharge in the late morning and then again in the early afternoon. It sounds silly but getting nourishment is important too. If you remember back to your intern days, you usually had a snack in your pocket or at least knew where the food was on the nursing units.
Just some thoughts.

Anonymous said...

MAKE SURE YOU KNOW WHERE THE PATIENTS ARE IN THE HOSPITAL:
WE HAVE A RATHER LARGE HOSPITAL. IT'S IRRITATING, AND TIME-WASTING, TO GO TO THE ICU TO SEE MRS X, ONLY TO FIND THAT SHE'S JUST BEEN TRANSFERRED TO THE REGULAR NURSING UNIT -- USUALLY THE ONE YOU WERE JUST AT -- WHICH IS THE EQUIVALENT OF 2 BLOCKS AWAY. SOMETIMES, EVEN THE PHYSICIAN SIGNING OUT TO ME MAY NOT KNOW THAT HIS/HER PT HAS BEEN OR WILL BE TRANSFERRED.

WE ALSO HAVE A TERRIBLE HOSPITAL EMR WHICH ITSELF MAKES IT HARD TO FIND PATIENTS, SO WE HAVE TO BE SURE THAT SIGN-OUTS AND CONSULTS GIVE US PATIENT'S EXACT FULL NAME. EG IF I WERE TOLD (ON THE PHONE) TO SEE A HARRISON BROWN, BUT HE'S REALLY HARRISON BROWNE, THIS EMR SYSTEM WOULD SIMPLY TELL US NO HARRISON BROWN IN SYSTEM -- OR WOULD GIVE US INFO ON WRONG PT.

FINALLY, MAKE SURE THE PT STAYS IN THE ROOM WHEN YOU'RE ON YOUR WAY. TELL NURSES TO VERIFY HE'S IN HIS ROOM AND KEEP HIM THERE. I'VE SOMETIMES GONE TO SEE A CONSULT (IN THE A.M.) FOUND, UPON ARRIVAL, THAT PT WAS DOWN AT MRI AND WOULDN'T BE BACK FOR AN HOUR, AND HAVE THEN HAD TO COME BACK LATER IN DAY (OR EVENING) TO DO WHAT I INTENDED TO DO AT 8 A.M. KEEP PT IN ROOM; THEY CAN DO THE MRI OR WHATEVER AFTER YOUR EVAL, UNLESS IT'S REALLY URGENT.

Huck said...

"Check in with your significant other EVERY call-night, set aside a time to talk, or at least text saying when you will call. They are lonely, and you get so busy that you can easily forgot.

Things I would like to implement
- "Jott" notes to myself to keep todo list on iphone
- Carry the hospital's cell phone (I found it took bulky, and phones are about everywhere)
- however if you do a lot of "page & run" its great to be able to page to cell phone, the uber-busy neurosurgeon residents are great @ this"

Theresa Chan (Rural Doctoring) said...

Physical survival on call

* Before call, determine food strategy. Some hospitals have horrendous food, residents almost always know where to call for delivery, etc. but bring food if you want alternatives/healthier stuff to eat.
* Sleep when you can:
o Even if you only have 5 minutes, it might turn into 20 minutes or an hour
o Don't be picky about where you nap--call room might be far away from where the action is. Nothing wrong with napping on a loveseat, 2 rolling chairs, the floor...
o Don't sleep on top of your pager if it is on vibrate mode, you probably won't feel it.
* Caffeine is helpful up to a point but drinking plenty of water or Gatorade is better for the long haul. You won't feel as seedy/sick after you get off call.
* Choose good shoes. Your feet will ache after being up for 24+ hours. Running shoes are good for some, clogs for others. Make sure they have good support and shock absorption. Some people wear TED hose.
* Bring a toothbrush. You will feel more human after freshening up.
* Bring Artifical Tears. Eyes feel weary and dry in the hospital at 0300.
* Apply deodorant before call. Please.

Call Team Strategies

* Before calling the attending/cardiologist/nephrologist, etc., page the rest of your team to see if they have to speak to the same person. Saves redundant beeps and attendings will be less grumpy as a result.

Cross-cover

* Have signouts on you, whether electronically or on paper. Make sure signouts are complete when you receive them.
* If there are labs to check on signout, make sure you check them. Also make sure the resident signing out tells you what to do with abnormals.
* If you're cruising around the wards/units, you might as well check in with the charge nurse to see if there are any questions/PRNs needed so you don't get beeped as soon as you leave. Similarly, if you get called to one ward, ask "Does anybody else need to speak to me?" before you get off the phone.
* Expect the most floor calls as soon as a new admission gets to the ward.
* Have strategies for the most common calls: fever, low/high bp, agitation
* Be nice to RNs when they call, but be clear about the info you need for specific questions, so they will learn to have that info ready when they call in the future. For example: if they are calling about hypertension, ask: has it been this high before? what meds is the patient on? HR?

Admissions

* In ER, write down vitals, labs, meds, allergies and look at ECGs/XR before you see the patient if possible
* Get the old chart. (Hopefully you have EMR and this won't be a big deal.)
* Don't automatically accept the ER attending's diagnosis
* History-taking: Get the big picture, then zoom in on details
* At first you may feel you need to write your H&P before you write orders, but take time to develop a running idea of the orders you need as you interview the patient. It will actually save you time in the future.
* Don't forget PRNs. Think about the poor schmo you're going to sign out to after call is over.

When you don't know the answer/what to do

* Talk to your senior resident
* Look stuff up in your favorite resource. Find one broad resource and stick to it. (I use UpToDate).
* Go look at the patient again
* If the issue is whether to do the LP/paracentesis/thoracentesis in the middle of the night, you're better off doing the procedure and getting the data then trying to justify not doing it the next day. When it come to paracentesis/thoracentesis, you can do a small-volume diagnostic tap at least [I can write up some instructions one day, or maybe your program already teaches residents how to do these.]

Prioritizing

* When on call, you're going to have multiple nurses, attendings, patients pulling your attention in 1,000,000 different directions. Get used to it. It doesn't get better after residency.
* Process requests/questions by urgency:
o Patient status deteriorating?
o Order or study needs to be done now or else you'll lose the opportunity to get essential data?
o Cranky attending on the phone and you need to speak to him/her?
* If none of the above are true, and if the situation will not create an irreversible calamity, it is far better for you to finish what you're doing right now, assuming it can be finished in 15-30 minutes or less, than it is for you to be pulled away and leave a task unfinished. What you want to avoid is having a dozen loose ends all around the hospital.
* Group tasks: if you're checking labs on the computer, take a second to run your list and check all the outstanding labs at once. Ditto radiology. Ditto dictations--once you're on the phone, get 'em all done.
* I cannot emphasize this enough: Dictate the same day you see the patient. It is painful at first but your life will get much better if you can get in the habit early.

Want to contribute your own advice? Please leave a comment.

Image Credit: Fractal Hospital, Flickr

About The Efficient MD

2008-09-22T16:48:00.016-04:00

Being a good doctor depends not only on who you are and what you know, but on the systems you use.

What's this website all about?

The Efficient MD is a weblog designed to help medical professionals increase their productivity, maximize their time and attention, and improve patient care. Although a vast amount of information is taught in medical school, fewer than 20% of doctors have heard a lecture on becoming more efficient. The Efficient MD is a review of innovations, "life hacks," gadgets, techniques, and useful tools designed to improve the professional lives of physicians and the health of their patients.

Who are you?

A busy practicing nephrologist. I started writing this blog because I was interested in applying ideas like those found in David Allen's book, Getting Things Done, to medical practice. I'm not a productivity guru or a consultant. (I'm also not "The Efficient MD" — that's just an ideal, and I need as much help as anybody.)

What topics have you written about?

Here's a brief selection:

Other items of interest: Google's interview with me discussing Google Book Search, The Efficient MD Wiki, an interview on physician productivity in Medscape, a mindmap of the methodology of Getting Things Done, and a slideshow on Life Hacks for Doctors.

Where can I read more?

I've contributed to several other blogs, including Kidney Notes, Tech Medicine, and Medgadget. You can also follow me on Twitter or conveniently view new posts in one place at jschwimmer.net.

Thanks for reading.

The Life Hacks for Doctors Slideshow

2008-09-12T12:00:00.001-04:00

The Life Hacks for Doctor Slideshow has been viewed over 7500 times. Thanks to everyone who viewed it and shared it with others — I didn't anticipate such an overwhelming response. By request, I've now made the file downloadable on SlideShare under a Creative Commons License.

Life Hacks For Doctors

View SlideShare presentation or Upload your own. (tags: efficiency physicians)

"Swivel Clip Copy Holder Mounts On Monitor-Swings Out Of Way"

2008-09-07T15:26:00.005-04:00

Not everything useful has to be high tech. Or expensive. Or complex.

One recent purchase that I've come to enjoy is a simple clip holder on the side of the monitor, suitable for displaying documents that you'd like to refer to while typing. Or just simply good for holding anything-at-all that provides you inspiration.

Mine is made by Fellowes, and on Amazon it goes by the nondescript name, "Swivel Clip Copy Holder Mounts On Monitor-Swings Out Of Way."

At the moment, the monitor clip holds the essay Better, by Merlin Mann. (It's one of his best.)

What simple tools do others recommend?

How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere, Part 2: Using Evernote as an Electronic Health Record (EHR)

2008-08-29T23:00:00.014-04:00

Evernote is a new searchable, friendly, available-anywhere, online personal database — and for many health care providers, it's rapidly becoming indispensable. Part 1 provided an introduction to Evernote and described how to use it to file away journal articles. In this part, I'll discuss how health care providers can use Evernote as a hybrid electronic health record (EHR).

Let me be clear: I'm not suggesting that Evernote is a substitute for any of the excellent commercial EHRs currently available. The following is presented as a proof of concept only for how a simple, inexpensive, customizable EHR built on Evernote might work. Please see the disclaimer.

As always, HIPAA is a major issue: Evernote provides encrypted communication and many security safeguards~~, but it's uncertain whether Evernote fulfills all HIPAA requirements~~. (Update: Evernote has confirmed by email that, "At this time we do not plan to pursue HIPAA certification for our (consumer) Evernote service." So, there you are.) Thanks to those who directed me to the "Federal Security Standards for the Protection of Electronic Protected Health Information." Of course, if you're concerned about transmitting information to the Evernote servers, you can always instruct Evernote to keep all data on your local computer. This bypasses the HIPAA issue and you'd still be able to use Evernote, but this means that you won't be able to access patient data from the web unless you use a program like GoToMyPc.com.

First, some background. EHRs have many advantages over paper medical records. With an EHR, when a patient calls with a question — or if a lab calls with a dangerously abnormal result — it's simple to pull up the medical history, medications, and details of the patient's last visit. In contrast, if you've used a paper medical record, you've occasionally waited in frustration until someone found the chart you needed. Very likely, you've also experienced an important chart being misfiled or lost.

If spending time looking for paper medical records is so inefficient, why do over 80% of physicians in the U.S. still use them? The barriers to switching from paper records to EHRs are many: expense, hours of training required, uncertain benefits, interfaces that are user-hostile (many EHRs inexplicably seem to model themselves after Windows 98), inertia, lack of flexibility, and concerns about being locked into a relationship with a single vendor.

I'm convinced another reason why more physicians haven't switched to EHRs is that there's previously been no middle ground. That is to say, until now there's been no easy way to realize some of the major benefits of EHRs — searchability, accessibility, cut-and-pasteability, and templates — without investing in a full-blown system.

That's where Evernote comes in. In addition to its other uses, Evernote can provide a secure, searchable, available-anywhere database of all patient notes and data. And even if you already use an EHR, you might still find Evernote useful to record information — phone messages or snapshots of lab reports, for example — when your usual EHR is not available.

Regarding the issue of security: the premium version of Evernote ($5 a month) offers encrypted communication with the Evernote servers. Here's what the website says:

Security and privacy are extremely important topics for Evernote users, and for good reason. Evernote would like to provide a single service to manage your memories for many years. To achieve this, we must provide a very high level of system and data security while offering users a variety of choices to manage their own privacy requirements. Here is a high-level overview of some of the ways in which your data is protected by Evernote.

When you add a note to the service, it is secured like your email would be at a high-end email provider. This means that your notes are stored in a private, locked cage at a guarded data center that can only be accessed by a small number of Evernote operations personnel. Administrative maintenance on these servers can only be performed through secure, encrypted communications by the same set of people. All network access to these servers is similarly protected by a set of firewalls and hardened servers. Your login information is only transmitted to the servers in encrypted form over SSL, and your passwords are not directly stored on any of our systems.

Evernote also confirmed through email that communication with the iPhone app — if you have a premium account — is also encrypted.

In part 3, I'll provide step-by-step instructions for using Evernote as an EHR.

How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere (Part 1 of 3)

2008-08-07T14:42:00.009-04:00

Evernote — a new searchable, available-anywhere, online personal database — recently became indispensable to my medical practice.

Technologies like Evernote make it obvious that we deal with information that lives in two worlds. The first, the physical world of paper, is populated by written medical records, scribbled notes, and stacks of printed journals that arrive in the mail. Information in this world is maddeningly localized — ask any physician who's struggled to find a missing lab report among piles of paper on their desk.

In contrast, the digital world — and we can substitute "cyberspace" or "the cloud" or your favorite phrase here — is inhabited by electronic medical records, web-based email, and online databases. The characteristic of this world is that information is searchable, available-anywhere, and (hopefully) securely backed-up online in multiple locations.

The beauty of Evernote is that it acts as a portal between the paper and digital worlds. Here's an example: let's say you've just read a review article on hypertension in the New England Journal of Medicine. This paper article contains an important table on drugs to treat hypertension that you'd like to refer to at a later time. Traditionally, articles like this would be torn out, stapled, and placed in a bulging filing cabinet for later retrieval. But too often, finding the article is too difficult, and it just takes up space for years until the information is outdated. Sound familiar?

By using Evernote, physicians can easily convert that critical table into digital form. (The journal itself can be recycled — it's no longer needed.) You can enter the table into Evernote in at least three ways:

By taking a photo using the camera on your phone and emailing it to your personal Evernote email address
By scanning the article directly into the Evernote program on your computer — I'm personally a fan of the Fujitsu Scansnap for quickly transferring any paper items I'd like to later retrieve to Evernote
By accessing the article on the NEJM website and using Evernote's "webclipping" program to highlight the table

Once in Evernote, the table can be named ("Table of Drugs to Treat Hypertension") and tagged ("Hypertension," "NEJM"). Evernote even recognizes the text in the table — for example, the drug "metoprolol" — and makes it all searchable. The online Evernote database synchronizes automatically with the Evernote database on your computer. And here's the beautiful thing — anytime you want to refer to that table, you can either

Search for "hypertension," "metoprolol," or "NEJM" on the Evernote program on your computer
Search Evernote online using any web browser
Search Evernote with the web browser on your mobile phone or with the Evernote program for the iPhone

The information in that article is now available almost anywhere. Just think of all the space you'll save in your filing cabinets by never filing away a journal article again.

But this is only a small taste of the capability of Evernote. Without much fanfare, the Evernote Corporation has created the perfect tool for designing a customizable, hybrid electronic health record (EHR). I'll explain how to create an EHR in Evernote in Part 2.

Creating a Voice Mail System for Patients using Free or Inexpensive Services Online (Google's Grand Central and CommuniKate)

2008-08-06T11:44:00.009-04:00

Image via WikipediaIn doctor's offices, the telephone is critical for communicating with patients. Yet too often, the phone system is used inefficiently. Symptoms of this problem include scrawled messages spread out on doctor's desks, important messages never received, messages received too late, and patients put on hold for what seems like forever. Any doctor who's repeatedly been interrupted throughout their workday by non-urgent phone messages knows this problem well.

One of the biggest flaws with the telephone system in many doctor's offices is that human beings — with limited time and attention — are often involved when they don’t need to be. They spend too much time triaging calls and scribbling down messages. And when humans really do need to be involved, they’re busy, much to the frustration of patients calling the typical doctor’s office.

Here’s one solution to the problem: create an automated voicemail system for non-urgent messages from patients. These messages might include simple questions, requests for laboratory results, requests for refills, non-urgent clarifications, or any communication that isn’t urgent and doesn’t obviously require an office visit. The principle of productivity being followed here is filtering: any information that doesn't need to be dealt with immediately should be filed until later when it can be given the attention it deserves. Filtering non-urgent messages with a voicemail system frees up the phone lines and the time of the secretarial staff for matters that truly require their immediate attention.

Many doctor's offices already have an automated phone message that greets callers. The script for a typical system often sounds like this:

If this is a doctor's office or hospital or an urgent medical matter, press "1"...
If you need refill authorization from the pharmacy, press "2"...
If you'd like to discuss test results, press "3"...
If you need to speak with a receptionist, press "4" or stay on the line...

In this system, certain non-urgent messages (options "2" and 3") will be filtered to voicemail, but other non-urgent messages for the physician will still require the attention of the secretarial staff.

A quick fix might be to add an extra option those non-urgent messages. Here's an example:

If this is a non-urgent message for the doctor that does not not need an immediate response, please press "5" to access the voicemail system.

If you don't have the ability to customize your voicemail system, there are many other free or inexpensive options available online. Services like Google's Grand Central and CommuniKate [Addendum: Apparently you need a promo code for CommuniKate now, I found one here] offer a dedicated number for voicemail messages that can be provided to patients. ("For any non-urgent messages, please call this number.") Google's Grand Central is free but has temporarily stopped accepting new applications, and CommuniKate costs approximately $30 a month. (I've used both.) Using a separate voicemail number that you provide to patients also gives you the option of testing it out to see if it works before changing your current system.

For years, I've offered patients a separate voicemail number for non-urgent calls, and it's worked very well. Here's a sample voicemail message:

You’ve reached the voicemail of Dr Roberts. If this is a medical emergency, please hang up and dial 911. If you must reach me immediately, please speak with the office at 212-555-5555 and have me paged. I check this voicemail daily and usually return calls within 2 business days. Please leave a non-urgent message here. Thank you.

The key to this system is to listen to the voicemail messages every business day, and return as many messages as possible daily. Services like Grand Central and CommuniKate make this process easier by offering visual voicemail: you can see a complete list of your messages and even listen to them online. If you work with a physician extender or PA, you can also have them prescreen your messages and answer those that don't require your personal attention.

There are several arguments against this system. The first is that it requires that patients exercise their judgment about what messages are urgent. In my experience, the number of truly urgent messages that patients leave on voicemail systems is very small, especially if your voicemail greeting is clear about what messages are appropriate and what messages aren't.

Another argument is that, "When people call they expect to speak to a doctor, not a machine" — except in practice, many patients don't. If the system works reliably, and messages are returned in a timely manner, most patients are perfectly content to leave voicemail messages. In many cases, it's actually quicker for them, too.

Of course, as with all the writing in this blog, these are only useful experiments and suggestions that have the potential to make a measurable difference in your practice. They are are provided for informational purposes only. Use your judgment when applying them to your own practice. If this system works for you, please feel free to email me or post a comment. Of course, if you think that there's a major problem with this approach, please also leave a comment or email me. And if you've tried other free or inexpensive online voicemail systems, let me know. I'd be happy to amend the post with additional information.

The Problem of "Too Much Stuff," by David Allen

2008-07-08T12:05:00.000-04:00

David Allen in BusinessWeek:

“Too much stuff to deal with” is the typical presenting issue declared by most professionals who lament their stress and fatigue. That’s an inappropriate diagnosis, though, and one that leads to “organizing” as an incomplete if not ineffective solution. The problem is not volume of incoming detail – it’s too much “potential meaning.”

Life Hacks for Doctors is the Slideshow of the Day on Slideshare

2008-06-02T11:41:00.005-04:00

Just received this email:

Your slideshow Life Hacks For Doctors has been selected as the 'Slideshow of the Day' on the SlideShare homepage.

Our editorial team would like to thank you for this awesome creation.

- The SlideShare team

Nice start to the week. On the home page, Slideshare also highlights other slideshows on Doctors, Medicine, and Web 2.0.

Life Hacks for Doctors: An Introduction

2008-05-16T21:20:00.003-04:00

I'm Writing a Book with the American College of Physicians

2008-04-04T08:29:00.010-04:00

The ink on the contract is drying, so I'm finally able to make this announcement: I'm writing a book with the American College of Physicians. This means that I'm humbly joining the ranks of other medical bloggers with book deals based on their blogs. (I'm aware of several, but I'd love to see a complete list.)

Writing a book was never my intention. I started The Efficient MD because I was interested in ways physicians could increase productivity and improve patient care using simple principles from books like Getting Things Done and The Successful Physician. I realized there were no websites devoted solely to lifehacks for the medical profession, so I decided to create one.

And as it turned out, the publishers at ACP Press became fans of this website. They felt, as I did, that this was a worthwhile topic. After several meetings, we decided to turn the ideas on this site into a book.

Some thoughts on the project:

The medical blogosphere will be prominently featured. The book will describe ways the blogosphere benefits both health care professionals and patients.
I've already spoken with several physicians and consultants with innovative ideas who will be featured in the book. If you'd like to be interviewed -- or if you'd like to offer help, feedback, stories, or ideas -- please contact me.
To make it easy for healthcare professionals to share their advice on medical practice with others, Dr. Ves Dimov -- Hospitalist at the Cleveland Clinic, Clinical Assistant Professor at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and writer of Clinical Cases and Images -- and I are creating The Efficient MD Wiki. Like Wikipedia, this will be a public website to which anyone can contribute. It will be devoted to clinical pearls, helpful links, general advice, and strategies for improving the practice of medicine.

More information to follow. Thanks for reading. Of course, comments and feedback are welcome.

Joshua Schwimmer, MD, FACP, FASN

About the American College of Physicians
The American College of Physicians (ACP) is a national organization of internists — physicians who specialize in the prevention, detection and treatment of illnesses in adults. ACP is the largest medical-specialty organization and second-largest physician group in the United States. Its membership of 125,000 includes internists, internal medicine subspecialists, and medical students, residents, and fellows.

Grazing on Web Data, Productivity Links

2008-03-29T21:14:00.005-04:00

Image from WikipediaA placeholder, until I can get the original research to add to the collection of hilarious journal articles:

Why We're Powerless to Avoid Grazing on Web Data

Also, new posts on on productivity:

A Selection of Articles from Medical Economics

2008-03-14T23:00:00.000-04:00

Medical Economics is an excellent resource for tips on productivity. Here are some articles I've recently read (free registration required):

An Effective Way to Use Assistants. One doctor increased his productivity by hiring three part time nurses and a medical assistant.

Successful Practices Do It Now. Discusses the use of techniques from Getting Things Done in medical practice.

Implementing an EHR: Going Live is No Snap. Discusses problems with three different practices try to implement their EHRs.

Taking the Pulse of Your Practice. How to decipher your bookkeeper's monthly report.

A Roundup of Recent Posts on Getting Things Done (GTD)

2008-03-02T21:10:00.001-05:00

Web Worker Daily has a three part interview with David Allen:

Michael Dolan writes on "getting the gunk out" of your system.

Allen's most recent article on the Huffington Post is "The Process is Personal."

A group of cognitive psychologists wrote a paper on GTD. From the abstract:

Allen (2001) proposed the “Getting Things Done” (GTD) method for personal productivity enhancement, and reduction of the stress caused by information overload. This paper argues that recent insights in psychology and cognitive science support and extend GTD’s recommendations. We first summarize GTD with the help of a flowchart. We then review the theories of situated, embodied and distributed cognition that purport to explain how the brain processes information and plans actions in the real world. The conclusion is that the brain heavily relies on the environment, to function as an external memory, a trigger for actions, and a source of affordances, disturbances and feedback. We then show how these principles are practically implemented in GTD, with its focus on organizing tasks into “actionable” external memories, and on opportunistic, situation-dependent execution. Finally, we propose an extension of GTD to support collaborative work, inspired by the concept of stigmergy.

Getting Things Done (GTD) on NPR and Other Links

2008-02-19T21:52:00.003-05:00

Getting Things Done was featured on NPR's All Things Considered: "Tech Junkies Crazy about Getting Things Done."

Merlin Mann of 43 Folders, who was mentioned on the show, posted his Best of GTD links.

For reference, my absurdly detailed mindmap of the GTD system is here.

Talk at Google by David Allen on Getting Things Done (GTD)

2008-02-10T22:15:00.000-05:00

Productivity Tips for Being on Call

2008-02-09T14:20:00.000-05:00

This weekend, I'm on call in the hospital and covering the practices of several other physicians. I'll be caring for more than 40 patients today. I'm curious: are there tips people would like to share for staying productive, focused, and sane while on call? I'll post a compendium of the best advice (with attributions and links, if you'd like). Please either leave a comment or email me at efficientmd@gmail.com. Thanks.

Merlin Mann's Macworld Presentation, "Living with Data"

2008-02-02T01:49:00.001-05:00

Merlin runs 43 Folders, the best-written personal productivity site on the web. (Also: he's hilarious.) The video of his Macworld presentation, "Living with Data," is here.

| View | Upload your own

Merlin Mann's "Vision track" presentation at Macworld Conference 2008 in San Francisco.

Theme: The cost of our time and attention is set too low.

Link: SlideShare Link

Introduction to The Efficient MD

2008-02-01T22:56:00.000-05:00

This is the text from an interview in Medscape (free registration required):

Dr. Genes: Why have you started writing this blog? Why "The Efficient MD"?

Dr. Schwimmer: The Efficient MD is the third blog I've written, and each serves a slightly different purpose. The first is Kidney Notes, an informal collection of interesting links related to medicine and technology. The second is Tech Medicine, a more in-depth exploration of technological issues of interest to healthcare professionals and nonprofessionals alike. While writing Kidney Notes and Tech Medicine, I also became interested in innovative ways of learning and helping physicians improve their efficiency to better care for patients. Putting my notes on personal productivity in one place seemed like a good idea, and Efficient MD became the third blog. To be clear: I'm not "The Efficient MD." That's just an ideal, and I need as much help as anybody.

Dr. Genes: I think some people might view "efficient blogging" as an oxymoron, because blogging has a reputation (in some circles!) of being something of a time waster. Why blog?

Dr. Schwimmer: Good question. At some point, every blogger (who isn't making a living blogging) probably asks themselves, "Why the hell am I doing this? Is it really worth my time?" The way I see it, writing a blog is like having a dog. It takes energy and time and constant attention, but if it's your thing, the rewards can be enormous and intangible.

In my case, blogging has made me a more efficient writer. It's introduced me to a variety of opinions, ideas, and people that I might not have otherwise encountered. And it's provided me with some unusual opportunities, like being featured in the Google Annual Report; appearing on a conference panel about the future of healthcare with physician executives from Microsoft and IBM; and, of course, being interviewed here.

Blogs are also a remarkably efficient tool for recording your thoughts and sharing them. What doctor doesn't have advice and reference material they'd like to share with friends, colleagues, current or potential patients, or their future self at some later date? Blogs are one way of making this easier. And in a few years, why shouldn't inexpensive mobile phones or PDAs have evolved to the point where blogging -- that is, the mobile sharing of information and media with small or large groups -- is second nature to most people?

Dr. Genes: Regarding efficiency, don't most healthcare providers pick up efficiency tricks in the process of their training? In other words, couldn't you say that all MDs are pretty efficient?

Dr. Schwimmer: Sure. Given the vast amounts of information most healthcare providers need to absorb and process, no provider would be able to get through their day without using some clever tricks to improve efficiency. But in my experience, most doctors come up with these tricks only in order to survive. On rare occasions do people step back and look at systems of practice in order to improve them. Harold Barrows, in Developing Clinical Problem-Solving Skills, calls this "metacognition." Barrows' book in particular I recommend highly to medical students and to anyone interested in thinking more deeply about the way they think about patients and their problems.

Just as physicians devote their careers to taking care of patients, other professionals devote their careers to helping people work better. If you listen, they can provide lots of useful advice. For example, I know many physicians who are undeniably brilliant but whose desks are a mess of papers, lab reports, and charts. Things get lost. They can't find anything, and it definitely reduces their efficiency. There's a simple device that can solve this problem called an inbox. But using inboxes properly is not as intuitive as you might think. It seems so simple, and it doesn't seem like it's something you need to be taught to use. As a result, many people don't use inboxes, or don't use them well.

The one book that might provide physicians with the biggest benefit in the shortest time is The Successful Physician by Marshall Zaslove. It's a wealth of tips and advice for improving clinical practice. Another book I recommend is Getting Things Done (GTD) by David Allen. GTD is a method that I personally find useful. It involves collecting undefined items, processing them to figure out what needs to be done, then organizing the "next actions" to be taken into contextual lists. (I provided a "mindmap" of the GTD system on my blog.) Using the methods in books like The Successful Physician and Getting Things Done can potentially help healthcare providers be more productive in half the time. I'm not exaggerating.

Take a Contract Out on Yourself on StickK.com

2008-01-17T23:06:00.001-05:00

The best way to achieve your goals, according to a new website, is to “put a contract out on yourself.”

The website, StickK.com, isn’t suggesting that you have yourself killed if you don’t meet your goals. Instead, StickK is a system — designed by a group of Yale economists — that allows you to lose real money if you don’t achieve a certain target, like shedding 10 pounds, quitting smoking, or exercising daily. According to StickK.com, you’re two to three times as likely to accomplish a goal with a "commitment contract."

Here’s how it works. You register with StickK, provide them a credit card, then enter a goal — for example, exercising three times a week. For the next month, you tell StickK, you’ll stake $30 -- or some other amount -- for every week you don’t achieve your exercise goal. You tell StickK your spouse will be the “referee” — he or she will judge your success or failure. For an added incentive, you also decide to make your commitment public, so your friends can see whether you’ve accomplished your goal.

And this is where it gets even more interesting. Let's say you support gun control. So you tell StickK that if you don’t accomplish your goal, you want all the money you’ve put down to go to the National Rifle Association. (Conversely, if you are against gun control, the money could go to the Fund to Stop Gun Violence.)

StickK then deducts $120 (4* $30) from your account on Paypal or from your credit card. If you accomplish your goal every week, you get all the money back. If you don’t, then for every week that you didn't accomplish your goal, $30 goes to the NRA. (Of course, you can also have the money go to a friend, or a charity you support, as well as what StickK calls an “anti-charity.”) How’s that for an incentive to achieve your goal?

Feed Reading, Three Ways

2007-12-29T13:43:00.000-05:00

Here's a simple version of the story of feeds.

First, the Internet had too much information. Then, RSS feeds came along, which were designed to reduce the torrent of information from the Internet into something more manageable. RSS feeds (or just "feeds") are simplified streams of information from websites: just the headlines, or if you want, the full text. No longer would you have to individually visit each site to read new content. By subscribing to the site's feed with an "feed reader," the content would now come to you. Quoting Wikipedia:

RSS is a family of Web feed formats used to publish frequently updated content such as blog entries, news headlines or podcasts. An RSS document, which is called a "feed," "web feed," or "channel," contains either a summary of content from an associated web site or the full text. RSS makes it possible for people to keep up with their favorite web sites in an automated manner that's easier than checking them manually.

RSS content can be read using software called an "RSS reader," "feed reader" or an "aggregator." The user subscribes to a feed by entering the feed's link into the reader or by clicking an RSS icon in a browser that initiates the subscription process. The reader checks the user's subscribed feeds regularly for new content, downloading any updates that it finds.

All good. But then, websites with useful information proliferated -- news, medical information, blogs -- and they all published feeds. And the feeds proliferated. And different feed readers also proliferated, each with their own advantages and disadvantages, some online (like Google Reader), some integrated with web browsers (like Firefox), and some standalone applications (like NewsGator).

And then there were too many feeds. Even with feed readers, it seems impossible to keep up with all the potentially important information that's out there. Feeds, that were initially designed to solve the problem of information overload, have actually contributed to the problem because they're too easy to subscribe to and read.

Here's one solution. In the following sections, I'll propose three methods of reading feeds using three different systems: Google Reader, Email, and Netvibes. Each of these methods is appropriate in different situations. And together, they can make the torrent of information from feeds manageable again.

--

To start, here are some initial questions to ask about any feed to which you're thinking of subscribing: "How important is this? Is this something I want to read every day? Is this website of sufficiently high importance and/or quality that I don't want to miss a single post?"

If you answer "Yes" to these questions, then the best way to read the feed is probably by email. (This is the first way of reading feeds that I'll discuss.) This might be counterintuitive (or even controversial). After all, isn't the purpose of feeds to provide a stream of information apart from the website itself and apart from your regular correspondence?

All true, but email remains the best way of ensuring that everything gets to you and nothing is lost. (And if you use gmail, forwarding feeds to email also ensures that all your feed content is forever archived and searchable).

However, reading feeds by email is a mixed blessing. If you aren't careful, feeds will clog up your inbox and you could easily become frustrated and not read them at all. Choose the feeds you read by email carefully.

My personal favorite service for converting RSS feeds to email is Feedburner -- it's fast, reliable, and the formatting is usually perfect. Certain websites, like BoingBoing, offer the option to subscribe by email through Feedburner on the main page. Other websites, like Tech Medicine, Kidney Notes, and The Efficient MD, also offer links to subscriptions by email. Most services like Feedburner offer the option to subscribe to the feed as a digest (one large, daily email of all posts) or as individualized emails. (I usually prefer the digest format.)

But what if the website doesn't offer the option to subscribe by email? Feedburner, as far as I know, doesn't allow you to subscribe by email unless the website allows it, but other services are available. Two popular services as Rssfwd and Feedblitz. After copying and pasting the feed's address, each website will then deliver the feeds to you by email. Rssfwd even offers a bookmark that you can place in your browser that allows you to automatically subscribe to the websites you visit. (I personally prefer Rssfwd to Feedblitz because the formatting on the iPhone is better.)

For medical news, two feeds that I subscribe to by email are Kevin, MD and The Wall Street Journal Health Blog. Non-medical sites that I subscribe to include Boing Boing and The Secret Diary of Steve Jobs.

--

In the last section, I suggested that the best way to read your most important feeds is by email.

But what if you don't want to read every word of the feed? What if the feed is important, but not that important?

Consider using a customized home page. Put simply, these pages allow you to display the headlines from multiple feeds on one page, like a newspaper. You can then quickly scan the feed's headlines for items of interest and click to reveal the full view.

Two popular free home page services are iGoogle and Netvibes. Each service allows you to create multiple tabs for different subjects. One tab, for example, could contain general news, while another could contain news about medicine, and a third could contain the tables of contents of popular journals. Here's a page from Netvibes, as an example. On this page, the feeds are all about science and technology:

The advantages of using customized home pages are many. The feed's recent items are all there, so it's unlikely that you'll miss any. You don't need to see the full text of the items, and you can click on any items that interest you. And can flexibly create tabs which contain different topics -- medicine, science, or whatever else you choose.

In the next section, we'll look at the third and final way of reading feeds: feed aggregators like Google Reader.

--

Let's recap. It's difficult (if not impossible) to keep up with all the new information posted to countless websites without using RSS feeds. In the first section, I suggested that the proliferation of feeds and the ease of reading them may have actually contributed to the problem of information overload. There's simply too much good stuff to read.

One strategy to deal with this problem is to use different methods to read different feeds, depending on their importance. In the second section, I argued that the best way to read your most important feeds is by email. For example, if you rely on Kevin, MD as a major source of medical news and you don't want to miss a single post, then visit Rssfwd.com and enter Kevin 's feed ("http://feeds.feedburner.com/KevinMd-MedicalWeblog"). That's it. Kevin will email you all new posts -- in daily digest form, if you prefer -- from now on.

In the last section, I suggested that some feeds are best read by using a customized home page, like iGoogle or Netvibes. If Rssfwd turns feeds into letters that are emailed to you, then iGoogle and Netvibes turn feeds into newspapers, complete with topic sections and headlines.

The third way of feed reading is to use a feed aggregator like Google Reader. This type of aggregator turns feed reading into the equivalent of surfing channels -- in the case of Google Reader, the new feed content (usually just the headlines) scrolls endlessly up the screen. Clicking on any headline reveals the full text.

This type of feed reader is most appropriate for content that you'd like to keep up with, but you don't mind missing. (Of course, it's possible to have all your feeds in Google Reader and make generous use of folders to ensure you don't miss the most important feeds.) Google Reader is the most sophisticated way of reading feeds, and has recently added many new features, like discovering new feeds and sharing feeds with your friends.

If you're feeling overwhelmed by the number of feeds you read, and you haven't yet tried Rssfwd.com, iGoogle/Netvibes, and Google Reader -- try them. They might simplify your life and make reading feeds manageable again.

Review of Sandy (iwantsandy.com), an Online Personal Assistant, for Medicine and Getting Things Done (GTD)

2007-11-18T12:20:00.001-05:00

Okay, let's say you already have a calendar, a to-do list (or perhaps multiple to-do lists organized by context), and a watch with an alarm -- why might you want to use Sandy (www.iwantsandy.com), a new online personal assistant?

Sandy's goal is to replace all those other life-organizing technologies. And while there are plenty of imperfections, she/it does the job remarkably well. And for free.

Here are some illustrations to show you how it works. Let's say you need to take a medication twice daily, at 9 am and 5 pm. One option is to put it on your calender with an alarm, or set your watch alarm to 9 am to 5 pm, or put it on a daily to-do list.

Alternatively, you could email Sandy the following:

remind me to take medication at 9am @daily
remind me to take medication at 5pm @daily
[experienced users could shorten this to "r take medication 5pm @daily"]

Every day, at 9 am and 5 pm, Sandy would then text message your mobile phone and/or email you to remind you to take your medication. (Initially, Sandy sends you a confirmation email with an ical attachment so the reminder could also be imported into most calendar programs.)

Another example. Let's say you're a physician, and John Smith is having a chest xray that you'd like to follow up on tomorrow. No problem. Email Sandy, "remind me to check JS cxr tomorrow at noon", and you're done. (Of course, remember to be careful about HIPAA privacy issues.)

And what if Sandy contacts you tomorrow at noon but you're too busy to check the xray at that time? Simply reply to her email with "snooze two hours" and she'll contact you again two hours later.

Sandy can also understand your voice by integrating with Jott.com, a service which converts spoken words to email. Let's say you're on your mobile phone and a colleague tells you about a meeting you have to attend tomorrow at 3pm. You're walking quickly and don't want to slow down, so you call Jott's toll-free number and have this conversation:

"Who do you want to Jott?"
"Sandy"
"Sandy. Is that correct?"
"Yes."
BEEP.
"Remind me about meeting tomorrow at 3pm."

And that's it. Sandy/Jott will email you a confirmation to ensure that they've heard you correctly (which in my experience, is practically 100% of the time), and then tomorrow before 3pm, you'll receive a text message reminding you about the meeting.

Sandy is also aimed at fans of David Allen's "Getting Things Done" methodology, as reminders can be extensively tagged by context. For example, if you needed to shop for a book for your friend Lucy's birthday either on Amazon.com or in a bookstore, you could email Sandy, "remind me to buy book for Lucy @todo @amazon @errand @bookstore @computer".

If you happen to be on Amazon.com, you could email Sandy, "lookup amazon", and she'll remind you about everything that you might want to purchase on Amazon, including Lucy's book.

Many online systems for GTD already exist. What makes Sandy interesting is that it has the potential, more than the others, to integrate a web interface, email, voice, calendars, and to do lists with a sophisticated reminder and tagging system that understands conversational English.

Currently, my to-do lists are either notes on the iPhone's notepad (@outside, @hospital) or are online in Gmail. (I use customized labels and filters in Gmail -- @office, @priority1, @timehigh, @toreply, etc. -- to organize both my emails and to-do lists. For more information on using Gmail to organize to-do lists, see here.)

Sandy is great for sending yourself reminders on-the-fly, but I'm not yet ready to use the service to manage my to-do lists. Compared with Gmail -- or with lists you create in a notepad or in a word processor -- Sandy is much slower and clunkier. The web interface, in particular, makes tagging and searching for multiple tags cumbersome. As far as I can tell, for example, you can't easily search for "@office @timehigh @priority1". Even so, I'm amazed by how well Sandy works for reminders, and I fully expect the web interface will improve with time.

Try it for yourself. It's a great product, and Sandy has the potential to become the most popular organizational system on the web.

The To-Do List Blog

2007-11-11T12:54:00.000-05:00

David Allen on "What is Organized?"

2007-10-06T19:43:00.000-04:00

Via the Huffington Post:

* I don't need or want it = trash
* I still need to decide what this means to me = IN basket item
* I might need to know this information = reference
* I use it = equipment and supplies
* I like to see it = decoration
* When I could possibly move on it, I want to see the action as an option = next action reminder, reviewed when and where it could be done
* I need to be reminded of this short-term outcome I've committed to = project list item, reviewed weekly
* I need to have this when I focus on a project = support material
* I might want to commit to this at any time in the future = Someday/maybe list item
* I might want to commit to this on or after a specific time in the future = calendared or "tickled" item incubated for review on a specific future date
* I want to achieve this "bigger" outcome = goals, objectives, visions that you review on some longer interval
* It's something someone else is doing that I care about = item on Waiting-For list, reviewed at least weekly
* I need to consider it when I do certain recurring activities = item on a checklist