Taken together, the conclusion is that change will come, as driven by some of the developments described in this chapter;
however, change will be slower than defined by technology alone because of the need to
overcome legislative, economic, and sociological barriers that slow the process markedly.

In other words, for pharmacists this represents a journey that has begun and will be
marked by events such as broader use of the EHR and the complete annotation of the
human genome. african mango These and other events are information driven, so the need for pharmacy
informatics can only increase.  That increase will be associated with a set of core values
that lead to improved patient management, outcomes, and overall improvement of health.
Examples of improvements that can be expected to affect pharmacists include:
reduction in prescribing errors;
•
prevention of
adverse drug–drug interactions;
•
improvements in communications between patients and pharmacists by removing
geographic barriers; and treatment of  regimens based on genetic disposition.
These are exciting and important changes in which the pharmacist can contribute to
improved healthcare.

Drivers of Change .
19

14. Wikipedia. Lipinski’srule of five (en.wikipedia.org/wiki/Lipinski%27s_Rule_of_Five).
15. Wikipedia. Metagenomics (en.wikipedia.org/wiki/Metagenomics).
16. Mancinelli, L., Cronin, M., and Sadee, W. Pharmacogenomics: The promise of personalized
medicine. AAPS PharmScience 2000. 2:E4.
17. Klein, T. E., Chang, J. T., Cho, M. K., et al. Integrating genotype and phenotype information:
An overview of the PharmGKB project. Pharmacogenetics Research Network and Knowledge
Base. Pharmacogenomics Journal 2001. 1:167–170.
18. Klein, T.
E., Altman, R. B., et al. International Warfarin Pharmacogenetics Consortium.
Estimation of the warfarin dose with clinical and pharmacogenetic data. New England Journal
of Medicine 2009. 360:753–764.

II

Today, it is not uncommon for a baby shower cakes tomogram to be embedded within the EHR and recalled
by the patient at home or by a variety of Piilolinssit specialists using a variety of devices, including
those that are handheld. There is no technical impediment to providing this kind of visualization
today—only the right price point, awareness, and  desire. The future will likely
include three-dimensional viewing and new forms of interaction with the images, including
tactile control.
Drivers of Change .
13

Just think what can be done today with an iPhone: Imagine that the image on the phone
is a high-definition x-ray or MRI. Last, do not forget  humble video. In the time that it has
taken to read this section, about 16 hours of video were uploaded to YouTube. This is startling
and speaks to the increasingly ubiquitous nature of video  and podcasts in our daily
lives. The impact of this virtual world is discussed in detail in Chapter 17; for now, consider
how it can affect patient pokies care. spa cover In the future, it may be that interactions between the physician
and patient or the pharmacist and patient will be routinely captured on video and pokies
become part of the EHR for instant recall and referral its worth also noting that as the nhs was not around at the time were far more common.

2.4.4 Telemedicine and Telepharmacy
Telemedicine and telepharmacy are defined  scabies treatment here as combining visualization, as discussed
previously, with the use of the telephone, Internet, or other medium to provide healthcare
at a distance. In the most advanced
sole f80 cases, telemedicine might imply surgeons performing
a complex operation close to a battlefield from a site thousands of miles away by steering
robotic arms to perform the sole f63
procedure. A simpler and likely more ubiquitous form of
telepharmacy might be a pharmacist discussing a patient’s prescription on the telephone
while they share data on their respective total gym xls computer screens about the drug being described.
Although the latter scenario is doable with the technology most of us have today, the appropriate
government legislation, a
business model, and the will to do it are lacking.

Telemedicine and telepharmacy are most important when a geographic barrier exists.
An example is the North Dakota State University (NDSU) telepharmacy project11—a project
in a state with a large rural population, many of whom do not have ready access to a
pharmacy. To quote the university’s Web site:

A licensed pharmacist at a central quick payday loans  pharmacy site supervises a digital signage registered pharmacy
technician at a remote telepharmacy site through the use of video conferencing
technology. The technician prepares the prescription drug for dispensing by Data Mining Software
the
pharmacist. The pharmacist communicates face-to-face in real time with the technician
and the patient through audio and video computer links. The North Dakota
Telepharmacy Project is a collaboration of the NDSU College of Pharmacy, Nursing,
and Allied Sciences, the North Dakota Board of Pharmacy, and the North Dakota
Pharmacists Association. North Dakota was the first state to pass administrative
rules allowing retail pharmacies to operate in certain remote areas without requiring
a pharmacist to be present.

The preceding extract is an example of the will and the legislation being in place. With
the growing use by the population at large of online, real-time communication services for
voice and video (e.g., Skype), patients’ demands for such services from healthcare providers
can only increase in years to come.

2.5 CHAnGES ExPECTED TO RESuLT FROM BIOTECHnOLOGy
Traditionally, patient care as provided by the physician and pharmacist has been distinct
from the research and development of products used by these care providers.
14 .
Howard R. Asher and Philip E. Bourne

This distinction began during training and would lead to the awarding of an M.D. or a
Pharm.D. degree, rather than a Ph.D. degree. Cross-training of students to receive both

M.D. and Ph.D. degrees or Pharm.D. and Ph.D. degrees is an enabler of change and
reflects the growing convergence of what were two distinct disciplines. Health sciences
campuses around the world are introducing changes to their curricula to accommodate
the emerging cross-disciplinary field of translational medicine. This field, which
integrates work at the laboratory bench with the care of the patient at the bedside—or,
stated more formally, the study of genotype to  phenotype—is affecting and will continue
to affect healthcare.
How does translational medicine affect
harmacy practice, and what is its relationship
to pharmacy informatics? We will try to illustrate how these emergent disciplines and the
technology harman kardon soundsticks ii associated with them are beginning to have an impact on pharmacy practice
and will likely do so even more in the future. Bose Companion 3 The connection to informatics comes from
the large amounts of data generated by these new genotype and phenotype technologies,
which only the computer can summarize for us. This new way of thinking about healthcare
is being called “digitally enabled genomic logitech z-2300 medicine.”

2.5.1 Genomic Medicine
The story of genomic medicine can be traced back at least to Oswald Avery who, in 1944,
showed that DNA was indeed the means by which genetic traits are transferred. The double
helix discovered by Watson and Crick in 1953 provided us not only with science’s most well
known logo, but also with insights into the structure–function relationships, and hence
mechanisms, that underlie heredity and development. The culmination occurred in 2000
with the release of the first draft of the human genome (the blueprint of life)—the biological
equivalent of the first moon landing.

More accurately describing the genes present in the human genome and the subsequent
watershed of understanding that has arisen from the study of the human genome are
starting to have and will have an ever increasing impact on illness and healthcare. With
improvements in technology for DNA sequencing, the estimated $0.1 billion to $1 billion
price tag for sequencing the first genome is down to $10,000 and is estimated to fall to $50
per genome in the next few years. Your complete genome sequence will likely become part
of your medical record in the future. Of course, legal and ethical implications of using
genomic information are being questioned and dealt with more slowly than the technology
that is raising the questions.

Most popular attention is focused on the human genome; however, to scientists, the
genomes of humans and many other speciesrepresent a foundation from which new
understanding of the more complex features of life begins—features dubbed with different
“-omics” names. For example, the genome defines our protein complement and new
enabling technologies have been developed to study proteins in the field of proteomics.
Proteins, DNA, RNA, and many molecules comprise a living system and it is the interaction
of these components that is important. Such interactions comprise a variety of pathways
for regulation, metabolism (“metabolomics”), and signaling.
Drivers of Change .
15

By analogy, if the pathways are the wiring of the cell, then how the current flows through
that wiring defines how that cell will perform. Understanding the dynamics of the living
system in this way comprises the field of science called “systems biology.” The ultimate goal
is to simulate accurately, by computer, a living system in such a way that perturbations can
be predicted and treated before serious illness arises. We are a long way from this level of
understanding, but some early developments

are already affecting healthcare and are discussed
in the following sections.

The popular focus is on the knowledge gained from determining the sequence of the
human genome; however, it is important to remember that the genomes of many other
organisms have been determined or are being determined. These developments define the
field of comparative genomics, which has many implications for healthcare in the future.
Consider one generic approach: By knowing the genomes of a variety of pathogens (viral,
bacterial, fungal) that affect human health (e.g., tuberculosis, malaria), through comparative
stationary bike stand
genomics (comparing pathogen to human), we can begin to better understand the
unique characteristics of the pathogen. This in turn provides opportunities to develop
drugs and other treatments that specifically target the pathogen, but not the human.

2.5.2 new Modes of Diagnosis
One utility of genomic medicine is in Essay writing biomarkers for the early detection of disease.
Biomarkers are not a new concept. Blood pressure reading is a biomarker for possible hypertension
and body temperature is a biomarker for possible fever. Prostate-specific antigen
(PSA) is a protein produced by cells of the prostate gland and a well-established biomarker
for abnormal prostate activity possibly indicative of prostate cancer. These examples of biomarkers
represent a movement in diagnosis from phenotype back toward genotype—that
is, from the complete living system back to the specific protein.

Genomic biomarkers take us further

back still to the genome itself by identifying genes
known to be associated with specific disease states. News articles of gene–disease associations
appear regularly, but the identification of one (of possibly many) genes associated
with a disease is a long way from having a practical, inexpensive test as a diagnostic tool.12
Nevertheless, a staggering number of possible genetic tests are emerging. Gene Tests provides
an up-to-date list of the
funny t shirts genetic tests that are currently available.13

2.5.3 new Modes of Delivery
Here we use the term “delivery” broadly, to speak not only of drug delivery, but also of
delivery of any kind of healthcare.
However, let us start with drug delivery. A pharmacy
student is taught early on that the effectiveness of a potential drug involves more than
how well it binds to its receptor. There are issues of absorption, distribution, metabolism,
and excretion (ADME). It therefore makes sense to try to have the drug reach the site of
action without adversely encountering ADME issues. Nanosized devices capable of moving
through the bloodstream equipped with implanted controlled-release mechanisms,
perhaps through radio control, are examples of controlled-delivery devices to better reach
the site of action.
16 .
Howard R. Asher and Philip E. Bourne

Nanoparticles are microdevices at one end of the size spectrum; at the other end are the
macrodevices, such as monitoring devices, which also deliver better healthcare. Although
monitoring of vital signs is routine, more extensive monitoring devices that better monitor
blood sugar levels or even hormone and metabolite levels are likely to become commonplace.
In the future, we will begin to see monitoring devices that track progression or regression of
disease reaction to therapeutic intervention in real time. Again, this provides a mass of new
information that will figure into the life of the pharmacist in the coming years.

2.5.4 new Modes of Drug Discovery
Drug discovery is a broad and complex topic. The purpose here is simply to stimulate
thinking about the changes that are likely through new biotechnologies, the impact they
will have on pharmacy practice, and the ever increasing need for pharmacy informatics
in the drug discovery process. The no no hair removal traditional idea in drug treatment is to find one drug
that binds to one receptor and treats one disease. As the complexity of the living system is
slowly revealed, this viewpoint is proving naïve. We are treating a living system that has
evolved over at least 3 billion years. Thus, it is not surprising that very few foreign substances
are found to be therapeutic. Rather, the living system has evolved defense mechanisms
to protect itself against such substances. In a pragmatic way, this is reflected in the
“rule of five” that defines what constitutes a likely pharmaceutical.14

Because the living system has evolved to be synergistic with the environment, it is
not surprising that natural products often prove to be successful therapeutic drugs. In
the period from 1981 to 2006, 974 small-molecule new chemical entities were introduced;
63% were naturally derived or semisynthetic derivatives of natural products. For certain
therapeutic areas, such as antimicrobials, antineoplastics, antihypertensives, and anti-
inflammatory drugs, the percentages were even higher. Despite the implied potential, only
a fraction of Earth’s living species has been tested for bioactivity. This situation will likely
change in the coming years as a result of metagenomics15—a field of science that performs
multispecies genomic sequencing directly from environmental samples.

The elucidation of the human genome now provides us, in principle, with the “druggable”
genome—all the likely drug ligands and receptors. We say “in principle” because
many of the protein coding regions within the genome have yet to be annotated and hence
identified as likely receptors. Again, there is a certain naiveté in this thinking. Who is to
say the drug binds to only one receptor? The idea of polypharmacology (polyvalent/covalent),
in which a given drug binds to multiple receptors to lead to a collective multivalent
outcome, seems more appropriate.

A broader than expected affinity by a drug such that it binds to multiple receptors can
be both a blessing and a curse. It is a blessing because it may provide multiple points to
effect a positive outcome on the patient—the notion behind so-called dirty drugs. It is also
potentially a curse because it may result in adverse unanticipated side effects that are not
revealed until late in the drug development process. Torcetrapib, a cholesteryl ester transfer
protein inhibitor to reduce serum cholesterol that was developed over a period of 15
years at a cost of $850 million, is a case in point. Stage III clinical trials revealed that the
Drivers of Change .
17

drug caused fatalities attributed to hypertension—an unanticipated side effect attributed
to off-target binding to a number of receptors other than the single intended receptor.

2.5.5 Personalized Medicine
The realization that patients respond differently to the same dose of the same medication
has been known for a long time. In 1902, Archibald Garrod first asserted the hypothesis that
genetic variations could cause adverse biological reactions when chemical substances were
ingested.16 He also suggested that enzymes were responsible for detoxifying foreign substances,
and that some people do not have the ability to eliminate certain foreign substances
from the body because they lack enzymes required to metabolize these materials.

Drug reactions based on inherited traits were first recorded during World War II, when
some soldiers developed anemia after receiving doses of the antimalarial drug primaquine.
Later studies confirmed that the anemia was caused by a genetic deficiency of the glucose-
6-phosphate dehydrogenase enzyme. Similar reactions to succinylcholine and isoniazid
were studied and revealed that deficiencies in enzymes led to an inability to metabolize
these drugs normally. After studying adverse drug reactions to primaquine, succinylcholine,
and isoniazid, Arno Moltulsky proposed in 1957 that inherited traits may not only
lead to adverse drug reactions, but may also affect whether the drugs actually work.

Today, the study of this varying genetic disposition to different pharmaceuticals is called
pharmacogenomics or pharmacogenetics. The growing body of information on this field is
maintained in a database called PharmGKB (the Pharmacogenomics Knowledge Base).17
The database can be searched in various ways—for example, according to different levels of
biological complexity: gene, protein, pathway, drug. Thus, the search can be conducted by
known pharmacogenomics associated with a specific drug, the genes involved, the pathways
that contain those genes, the literature associated with the biology, and clinical trials
offered as evidence for the genetic disposition.

Pharmacogenomics represents an added stress on the pharmaceutical industry because
it is more profitable to sell one drug to a larger population than to have a variety of drugs
and doses for subsets of the population. Notwithstanding, personalized drug treatment is
a reality that affects pharmacy practice. Consider a recent illustration. The International
Warfarin Pharmacogenetics Consortium and members of PharmGKB introduced a warfarin
dosing regimen based on both clinical and genetic factors.18 The FDA has changed
warfarin’s package insert to reflect this new pharmacogenomic knowledge.

Personalized drug treatment is part of a broader field of personalized medicine that
moves us away from medical practice that is based on overall standards of care defined
across large cohorts of patients. Tracking and responding appropriately to care that is
defined for individuals rather than cohorts require a new level of information processing;
as such, it is a driver of change that again highlights the growing importance of pharmacy
informatics.

2.6 A FInAL REALITy CHECk
After reading this brief introduction to the many changes in information technology and
biotechnology that are underway, it would be easy to imagine that pharmacy practice will be

would argue that we are now, to use a phrase popularized by Malcolm Gladwell, at a “tipping
point.”1

As we describe the gains that can be made by greater adoption of information and biotechnologies
against the backdrop of the current state of our healthcare industry (with
particular reference to the United States), it is easy to believe that we are at this tipping
point. By one estimate by the Rand Corporation, if 90% of U.S. hospitals and physicians
were to adopt hospital information systems over the next 15 years, the industry would
save $77 billion per year from efficiency gains.2 If health and safety gains are considered
also, these savings could double to 6% of the $2.6 trillion estimated to have been spent on
healthcare in 2009. These savings are compelling and it is not surprising that governments
are attempting to control escalating healthcare costs through the adoption of better information
and biotechnologies. The bottom line is that these changes will have an impact
on pharmacists and pharmaceutical scientists because the current system of healthcare is
simply not sustainable.

What is the current state of healthcare? What are these drivers of change? How will
changes affect healthcare and the pharmacists that provide that care? These are some of the
questions addressed in this chapter.

2.2 THE CuRREnT SITuATIOn
We begin by briefly summarizing the state of healthcare in the United States and the state
of the drug industry at large to emphasize the scale of the current problems.

2.2.1 The Current State of Healthcare in the united States
The following data on the state of healthcare in the United States surely must be drivers of
change because, as was stated previously, the current system is simply not sustainable:

•
The $2.6 trillion the United States will spend on healthcare this year represents 17.6%
of the U.S. economy; if unchecked, this percentage will rise.3
•
Of the total money spent on healthcare worldwide, the United States spends 54%.
•
Compared with five other developed nations—Australia, Canada, Germany, New
Zealand, and the United Kingdom—the U.S. healthcare system ranks last or next to
last on quality, access, efficiency, equity, and healthy lives—five dimensions of a high-
performance health system. The United States is the only country of the five without
universal health insurance coverage; this partly accounts for its poor performance
on access, equity, and health outcomes. The inclusion of physician survey data also
shows the United States lagging in adoption of information technology and use of
nurses to improve care coordination for the chronically ill.4
•
Overall, the United States ranks 37 out of 191 countries in the quality and performance
of healthcare (see Table 2.1).5
•
The United States ranks 30th in life expectancy.6

Drivers of Change .
9
TABLE 2.1 World Health System Rankings7
1. France 11. Norway 21. Belgium 31. Finland
2. Italy 12. Portugal 22. Colombia 32. Australia
3. San Marino 13. Monaco 23. Sweden 33. Chile
4. Andorra 14. Greece 24. Cyprus 34. Denmark
5. Malta 15. Iceland 25. Germany 35. Dominica
6. Singapore 16. Luxembourg 26. Saudi Arabia 36. Costa Rica
7. Spain 17. Netherlands 27. United Arab Emirates 37. United States
8. Oman 18. United Kingdom 28. Israel 38. Slovenia
9. Austria 19. Ireland 29. Morocco 39. Cuba
10. Japan 20. Switzerland 30. Canada 40. Brunei

Source:
World Health Organization

•
Of each dollar spent on healthcare, 10 cents goes toward medical liability and defensive
medicine.
•
An estimated 60 million people in the United States have no health insurance.
These statistics represent enough woe as to the state of healthcare and must be incentives
to change. Let us now look at the state of drug discovery as another issue that will affect
healthcare, including pharmacy practice.

2.2.2 The Current State of Drug Discovery
The following points are taken from the 2009 Outlook Report from the Tufts Center for the
Study of Drug Development8:

•
Through a concerted effort at the Food and Drug Administration (FDA), the time
to approve a new drug has dropped in recent years, but seems to have stabilized at 8
years. Drugs that are developed are most often used to treat complex diseases and are
not necessarily that effective.
•
The cost of bringing a drug to market can be US$1 billion.
•
New drug output has stagnated; fewer than 30 drugs were approved in 2007.
•
The introduction of therapeutic monoclonal antibodies is increasing and having a
positive impact on the rate of drug discovery.
2.3 HISTORICAL ExAMPLES OF PRECIPITATORS OF CHAnGE
The preceding facts sound like doom and gloom; although it is fine to say that this will drive
the United States to change, is that possible? One way to answer that question is to consider
how change has been wrought in the past. Here are a few examples in chronological order:

•
Stethoscope (1816). Rene Laennec of France invented the first stethoscope to protect
the modesty of one of his female patients. In 1837, Dr. Oliver Wendell Holmes

10 .
Howard R. Asher and Philip E. Bourne

returned from medical studies in Paris and urged his fellow American physicians
to increase their use of stethoscopes. By the mid-1840s, the stethoscope had become
integral to the practice of medicine in the United States.

•
Thermometer (1867). Sir Thomas Allbutt introduced the first thermometer meant to
take the temperature of a person.
•
X-rays (1895). Wilhelm Conrad Röntgen accidentally discovered x-rays upon seeing
an image cast from his cathode ray generator. The announcement of Röntgen’s discovery
was illustrated with an x-ray photograph of his wife’s hand. The x-ray became
one of the defining technological devices to move the art of medical diagnosis to a
scientifically based medicine in the early 1900s.
•
Blood pressure cuff (1901). Harvey Cushing introduced a version of the modern blood
pressure cuff (sphygmomanometer) to U.S. physicians.
•
Penicillin (1929). Sir Alexander Fleming’s discovery of penicillin in 1929 went undeveloped
until the 1940s, when Howard Florey and Ernst Chain isolated the active ingredient
from Penicillium mold and developed a powdery form of the medicine. Under
the pressure of World War II, pharmaceutical manufacturers rapidly adopted mass
production methods, reducing the production costs to 1/1000th of the original.
Interestingly, these innovations, which we take for granted in today’s provision of healthcare,
share similar characteristics: an extended period before wide adoption was seen. It
may be that even in the accelerated pace of a modern healthcare world, there will be a
marked lag time before the technologies introduced subsequently become commonplace.
First, we have to reach the tipping point. Assuming these changes do come eventually,
which of them will have an impact on pharmacy practice?

2.4 CHAnGES ExPECTED TO RESuLT FROM
InFORMATIOn TECHnOLOGy
Information technology (IT) remains underused in healthcare. This fact is surprising
given that providing adequate healthcare involves managing and effectively using information.
It is not that the need for information has not been recognized. For example,
the American Medical Informatics Association (AMIA; has existed for
over 30 years and has over 4,000 members. So, why has the uptake of IT within healthcare
been slow? In the 1970s, information technology was expensive and alien to most
healthcare providers. Centralized mainframe computers provided billing services, but
little else.

The emergence of so-called minicomputers saw a diversification of use in a distributed
model of computational operation. Thus, for example, the radiology department began
using image processing, and various departments began developing and using databases
for diverse information ranging from patient records to pathology samples to the tumor
registry. These systems required expert personnel and in no way communicated or inter-
operated with each other.
Drivers of Change .
11

The late 1970s and early 1980s saw the emergence of intranets: internal computational
networks that started to allow these computers to communicate. This was certainly one of
the early drivers of medical informatics because it was soon realized that common naming
conventions for items of information needed to be used if the information located on these
respective computers were to be used collectively (see Chapter 4). In the early 1980s, IT
slowly migrated into back office, to inventory control, central supplies, as well as management
of pharmaceuticals and other prescribed medical products. The early 1980s also saw
the emergence of the personal computer (PC) and a real opportunity to distribute healthcare
information. It seems strange now, but only a small fraction of people were adept at
using the PC at that time and, in general, healthcare providers were resistant. Further, the
cost per PC station was approximately 10–100 times what it is today.

The 1990s changed all that (as further elaborated in Chapter 3). With computer power
doubling for the same cost every 18 months and the advent of widespread Internet use by
both patients and providers, the stage was set for change. In the early 1990s, IT began a
slow adoption within prescription management, processing, prescription label generation,
pharmacy billing, and work flow. In the mid-1990s, the Internet began to be recognized as
an expedient source of some medical and pharmaceutical information. The late 1990s saw
an important pharmacy innovation from a small company in San Diego, California. Pyxis
introduced products for automated and controlled medication dispensing and pharmaceutical
supply management.

Still, the human factor persists and should not be underestimated in the adoption of any
technology. Often people are happy with the old way of doing things and do not see the
more institutional (and often global) implications of their inertia. Institutional mandates
come into play here. For example, the insistence that the U.S. Veterans Administration
hospitals adopt a single, universal system could not be resisted by care providers if they
wanted to keep their jobs.9 Such systems have a sufficiently successful track record and the
problems of global health are so pressing that more rapid adoption of IT in all healthcare
sectors seems inevitable.

2.4.1 Electronic Health Record
The electronic health record (EHR) is perhaps the single most important component of
medical and pharmacy informatics and is discussed in detail in Chapters 6 and 7. Here we
focus on one particular driver of change related to the EHR. That change (tipping point)
is, we believe, the point at which the patient demands control of his or her health record.
Many of us in the United States have had the time-consuming and awkward experience of
requesting information from our own medical record that is often dispersed in paper form
across a number of institutions. Why should we not have immediate access to our records
and, if we choose, share elements of that record with whomever we see fit?

After all, many of us now spend considerable time each day in front of a computer,
where we have access to our bank records and other personal data. Why should we not
have that access to our EHRs and even add to our patient records ourselves to update our
care providers? Consider a resource like Patients Like Me, where people choose to share
and discuss their conditions with each other.10 As more of the Web 2.0 generation (i.e.,
12 .
Howard R. Asher and Philip E. Bourne

those familiar with sharing and communicating online) take interest in their EHR, the
demand will likely increase for availability and access.

Before, we focused on the broader adoption of the EHR from the patient’s perspective,
which we see as a driver. However, savings from error reduction, apparent efficiency gains,
and government regulation will all drive broader adoption of the record from the institutional
perspective as well.

2.4.2 Smart Devices
The term “smart device” is catchy, but what does it mean to healthcare and the provider?
If patients and care providers alike were asked, each would likely come up with different
devices as examples of smart devices and of what each one means to healthcare. Let us
offer a patient-centric view that suggests that it is a device trusted in some way to improve
efficiency and quality of life—in some respects, an automated teller machine (ATM) for
healthcare. We all trust an ATM to give us the right amount of money and update our
accounts correctly. Given the ATM analogy, it is clear that such devices do not have to
be “whiz-bang” new technologies; they could be something as ubiquitous as the mobile
phone. In parts of the developing world, the mobile phone is emerging as a valuable tool in
reporting and receiving healthcare information, so why do we not see more of this in the
developed world?

With these definitions of simplicity and efficiency, a smart device might simply be a
device for measuring glucose levels in an unobtrusive way. To a physician, it might be a
device for good voice-to-text translation that negates the need for a transcription service.
On the other hand, it could be something more comprehensive that provides the ability to
access x-rays, MRIs, the latest laboratory results, or the patient history on a smart handheld
device that allows a physician’s notes to be hand written and correctly understood!

All these devices are in place or on the near horizon. Once we reach the tipping point,
they will become mainstream.

2.4.3 Visualization Devices
As stated earlier, healthcare is information rich, and that information must be visualized
in a way that makes it most meaningful. Our example of the x-ray as an emergent technology
that changed healthcare is one illustration of how visualization was a driver of
change in healthcare. Today, microscopy, magnetic resonance imaging, endoscopy, and
others are all forms of medical visualization in common use. A major br