Once a committee has decided on a plan of action, the next step is implementation — the rate-limiting factor that must occur after equipment or process has been approved! In my opinion, this step is the hardest to execute. And that's why systems look for champions (persons) to serve as catalysts to help "get things going."

Therefore, provider "buy in" must occur early. The only way for that to occur is to use physician-driven committees. The Physician Drivers should not be chosen based on seniority, but on an established record of excellence to get a particular job done. These people must have education in the field, be willing to learn new things, have up to date credentials, and must be great communicators to successfully get the word out.

I have learned that physicians with education in a field need to have a role in advancing new technologies or processes in the hospital system. That said, control of conflict of interest with appropriate checks and balances needs to occur so that stewardship takes place. The goal is high quality, low cost, and an exceptional patient experience. The sum of these 3 parts is VALUE!

Let me clarify. If there is an expensive product that I want to purchase because it is cool and will help give value to patients, there needs to be someone there to "check" my thinking and provide balance, so that my conflict of interest (wanting the product) doesn't get in the way of doing what is best for the system and the patient. Maybe, for example, cardiology does it better than nephrology, so I'll let them do it because its the right thing to do.

Remember, its now about the 3 P's (in addition to the 3 A's*): Person, Process, and Product.

1. Person: who is the best person or the most appropriate speciality for the job?
2. Process: what is the best process for the job? Should we use lean or Six Sigma?
3. Product: what is the best product defined as the one that is the most cost effective, the best manufactured, and the one that gets the job done. There should be high sensitivity, specificity, positive predictive value, and negative predictive value associated with any diagnostic product. Therapeutic machines should have outcomes data that prove efficacy to provide patient value.

Many hospitals have interest in creating a "virtual hospital." A virtual hospital is a system which has the ability to utilize "cutting edge" technology through top-notch manufacturing to detect disease onset earlier so that disease can be prevented. Moreover, a good virtual hospital should also have the ability to monitor hospital ward patients (the lowest level of care in the hospital) in real time, avoiding catastrophic events.

Please don't misunderstand. You CAN have it both ways. The only time a person, product, or process should replace what is currently in practice is when the math suggests that quality will improve while cost will ultimately decrease. Did you know that Toyota lost money on every Prius it sold initially? Now, they make the premier product for a profit and own the market. So the product may initially cost money, but if the system benefits in a positive way, then the money is well spent.

I'll clarify with an example:  I had the honor to work with the Alegent Hypothermia Group to develop a 5-hospital, system-wide protocol to cool out-of-hospital cardiac arrest patients -- therapeutic hypothermia after cardiac arrest. The evidence in favor of using hypothermia after cardiac arrest is phenomenal: for every 7 patients cooled, one life is saved (assuming an absolute risk reduction of 14%). Today's numbers, using Dr. Kern's protocol (the one in use at Alegent Health), are even more impressive. Please note: Dr Karl Kern from the University of Arizona will be one of the keynote speakers at the Annual Cardiology Update on September 24th at the Omaha Marriott Regency.

My understanding is that Alegent Health is the first and only hospital system in the region to offer the service at more than one hospital. During the discussions to bring the concept to fruition, we noted that infection during this process is a real concern. If a person is cold, how can we detect if there is an infection? In other words, how does fever present itself in a patient we are trying to cool? People have used "time to cooling" or "difficulty maintaining cooling" as a marker for infection. My opinion is we currently have no good options.

There is a product for continuous temperature monitoring (braintunnelgenix.com) not yet available in the United States. Their system uses continuous non-invasive temperature monitoring:

"The Brain Temperature Tunnel (BTT™) is a direct and undisturbed connection between the thermal storage area in the brain and the surface of the skin at the inner corner of the eye.

This "tunnel of light" enables humanity — for the first time in history — to have noninvasive, continuous temperature measurement."

Perhaps early knowledge of an increase in temperature will allow for earlier detection and management of infection in therapeutic hypothermia. The early warning may indicate the need for broader spectrum antibiotics in this setting.

So although the theory is good, the company needs to prove to the hospital system that the temperature sensor is better than what we have now in terms of length of stay, cost, and patient outcome -- survival.

Also, we have to watch out for lead-time bias. Wiki defines lead-time bias as the bias that occurs when two tests for a disease are compared, and one test (the new, experimental one) diagnoses the disease earlier, but there is no effect on the outcome of the disease—it may appear that the test prolongs survival, when in fact it only results in earlier diagnosis when compared to traditional methods. The time of death in lead time bias is the same. This concept is an important factor when evaluating the effectiveness of a specific test.

Here's the point: the product may be worth adopting in practice if there is a true benefit with earlier detection. However, once disease is detected by the product, there must be a system in place for the physician to act on the data. Because if a tree falls in the forest, it only makes a sound if someone is there to hear it.

In conclusion, I believe in using technology appropriately. In order to be adopted, the plan of action that is developed must be shown to be "better" than what is currently used. We need to consider using real measures of outcomes. The right people should perform the studies, using the right products and processes. In order to survive the current health care environment, our goal should be to improve quality while lowering costs thereby providing value to our patients.

*The 3 A's: Availability, Affability, Ability

Wiki defines jargon as a term that descrcibes the language used by people who work or live in a particular area (such as doctors or Nebraskans respectively). Jargon words are also used by people with a common interest (such as cribbage).

There are benefits to the use of jargon: a standard term may be given a more precise or unique usage among practitioners of a field. This allows for better communication among the members of group.

The major problem with using jargon is that in many cases this causes a barrier to communication with those not familiar with the language of the field (such as patients).

Let's use the term "snow" to develop this concept further. There is a relationship between the geographic area where people live and the need for knowing snow-jargon. For example, in order to survive the harsh Nebraska winter, people must have the ability to effectively communicate around the different terms for snow.

I have lived in the northern Midwest for a good portion of my adult life. I've had to learn these terms in order to be able to survive the winter, stay safe, and prepare for my workday -- nephrologists such as myself have to travel to many hospitals, kidney dialysis clinics, and outpatient clinics in order to provide service -- regardless of the weather. Also, I need to understand these terms in order to make sense of the weather report 6 months a year.

Compare Nebraska to Texas. I spent 2 months in Austin, Texas when I was in high school. I had the opportunity to take AP biology at the University. Its hot! Snow is rare and there is no need to know the 18 Nebraska snow words -- unless you plan to vacation up north!

Here is a short list of the words for snow used in Nebraska:

1. powder snow: frozen precipitation in the form of white or translucent hexagonal ice crystals that fall in soft, white flakes. People who ski prefer powder snow. I think of powder snow as "Rudolph the Red Nosed Reindeer" snow. Same thing as "snowfall" except used in the setting of skiing.
2. sleet: a mixture of rain and snow
3. slush: partially melted snow or ice
4. snowfall: frozen precipitation in the form of white or translucent hexagonal ice crystals that fall in soft, white flakes.
5. whiteout: the failure to maintain visibility in heavy snow. Very unsafe weather in which to drive.
6. hail: snow in the form of pellets of ice larger than 5 millimeters (0.2 inches) in diameter. I have seen softball sized hail. Imagine what a car looks like after being pounded by softball sized hail!
7. crust: this type of snow has a harder crust on top of softer powder snow. We see crust on the road after cars have been driving for a few hours after a snowfall.
8. blizzard: a very heavy snowstorm with high winds. Heavy winds are usually defined as at least 35 miles per hour.
9. ice: water frozen in the solid state.
10. icicle: ice resembling a pendent spear, formed by the freezing of dripping water.
11. dusting: a light sprinkling of snow.
12.  flurry: a light, brief snowfall. Not sure, but I think flurries have more snow than a dusting.
13. snowbank: a heap of snow. Snowbanks are created as a result of shoveling snow.
14. snowdrift: a heap of snow as a result of the wind.
15. snowstorm: a storm with heavy snowfall.
16. freezing rain: supercooled droplets that freeze on impact.
17. yellow snow: snow given a golden or yellow appearance by the presence in it of pine, cypress pollen, or anthropogenic material or animal-produced material (such as squirrel potty as my son would say).
18. black ice: a thin, nearly invisible coating of ice that forms on paved surfaces. People can lose control of their vehicles. Four wheel drive vehicles don't help you on ice. Black ice formation is a very difficult situation. Cruise control should not be used when driving on black ice.

People living in Texas have one word for snow:

1. snow: that white stuff we get every few years that our kids find cool, is impossible to drive in, and melts in a day.

So how does this discussion justify the need for medical jargon, and why does this important article fall under the heading of a medical blog? I speak a foreign language called "medicalese" -- the specialized terminology of the medical system. Latin is easier to learn than Medicalise! Medicalise is derived from Latin, Greek, English, and more. The standard medical dictionary has over 45,000 words. In order to communicate effectively, we need to use the jargon we spent 7-10 years initially learning, as well as all the new words that keep popping up.

Another language spoken all over the world that is similar to medicalese is Yiddish. Yiddish is spoken in the United States, Israel, Poland, Argentina, Brazil, United Kingdom, Russia, Canada, Ukraine, Belarus, Hungary, Mexico, Moldova, Lithuania, Belgium, Germany, Australia, France and elsewhere. Someone with knowledge of Yiddish and German in Germany can speak Yiddish to a person in Mexico who can speak Yiddish and Spanish. The German in this case can effectively communicate with the Mexican without having to learn another language.

Let's get back to medicalese. An example of using medicalese is heart failure. There are many terms associated with the condition, and the words we use can get quite complex. Consider the following example:

The patient has New York Heart Association Class IV heart failure with an estimated ejection fraction of 20 percent. He has SOB. He denies chest pain. Moreover, long term sleep apnea has led to pulmonary hypertension, cor pulmonale, and bilateral lower extremity edema. Aquapheresis is an option for this patient, but I think we need to make sure the patient has diuretic resistance first by checking a 24 hour urine collection for creatinine clearance and sodium. I will ask cardiology to calculate the caval index. A greater than 50% variation in inspiration, especially in this setting would suggest decreased effective circulating volume in the setting of total body hypervolemia -- a situation where aquapheresis can do wonders by safely removing water through ultrafiltration while decreasing the risk of acute kidney injury, especially if inline hematocrit monitoring is utilized. In addition, we should consider placement of an implantable defibrillator. Although the patient has chronic kidney disease IIIA, the benefits outweigh the risks because only 10 cc of contrast will be used. We can prophylax with mucomyst....

Still with me? The terms that are understandable may be taken as an insult to the patient without knowledge of how the language is spoken.  SOB is a term to describe "shortness of breath." Also, "denies" is a strong term. A patient reading this chart may misconstrue what doctors mean when this term is used. Using "denies" is a simple term we doctors use to rule out a diagnosis. There is nothing personal here!

Another, better way to say it: the patient's heart is not pumping correctly. A pacemaker might help prevent sudden death. The kidneys are working at 50% of normal so we need to be careful placing the pacemaker. Fluid removal using a machine may be helpful as well. If a person still has swelling in the legs on a high dose of water pills, we can go forward.

In my opinion, the best doctors are the ones who have the ability to communicate in a way that both their colleagues and their patients understand (such as the ability to speak both German and Yiddish). Did you know that "doctor" is from the Latin word "teacher"? That is what the best providers do -- they teach. Both descriptions above are necessary. The cardiologist needs to hear the first explanation; the patient needs to hear the second.

A patient with high blood pressure presented to my office with a severe headache. She has a history of seasonal allergies. The patient is adherent to her medication regimen. In the office, her blood pressure was 210/120. Normally, her blood pressure on therapy is 125/78. What is happening and what should we do?

It turns out the patient was outside with her family watching fireworks. Her allergies to pollen acted up, and she took pseudoephedrine to help control her symptoms. A side effect of this medication is hypertension.

I see a referral population which can be very different from the general population that sees a primary care practitioner. That said, I have seen many high blood pressure patients on allergy medications that have had bad outcomes: stroke, heart attack, kidney problems, and malignant (life-threatening) hypertension.

Both perennial and seasonal allergies can be annoying for a person. Its usually easy to tell an untreated patient with allergies because they give you the "allergic salute" (people with allergic rhinitis often rubs their noses using the index finger).

Many over the counter therapies for allergic rhinitis can worsen a patient's hypertension. For instance, phenylephrine, the active ingredient in Sudafed, can also increase a person's blood pressure. In fact, most decongestants (drugs that shrink the swollen membranes in the nose) may cause hypertension.

The best therapy for allergies in a patient with high blood pressure is an intra-nasal steroid. Avoidance of the allergens, if possible, also helps.

A cost-effective, generic nasal steroid that is not absorbed by the body is called fluticasone propionate which is currently $60 dollars a month at drugstore.com. Other steroid inhalers are available, but these can get very pricey.

There are other medication options for those on an extremely tight budget. The Walmart $4 list includes loratadine, which you can obtain via a prescription from your doctor. The medicine is generic and is the same thing as over the counter Claritin. This medicine is extremely effective and is a great second-line or add on therapy to the intranasal corticosteroid.

For those of you with hypertension and allergies who wish to try an over the counter nasal inhaler option, cromolyn sodium is available. Cromolyn stabilizes inflammatory cells which are involved in the allergy process. This medicine works. It is cost effective (around 12 dollars per inhaler), but the big downside here is that a person has to use it 4 times daily. I have found that many people are non-adherent to more than twice a day medication regimens. And if you don't take the medication it won't work. Therefore, Cromolyn is my third line therapy.

For those who do not like to take medication, nasal irrigation and saline sprays can be effective. Many of my patients find this form of therapy to be unappealing and give up on it quickly.

For the patient described here in the clinical vignette, I referred her back to her primary care physician for an allergy therapy assessment. I asked the patient to stop taking the pseudoephedrine and continue her current blood pressure medication therapy. Her blood pressure quickly returned to normal and with the help of her PCP (primary care physician), her allergies got better!