Noctilucent Clouds

 

The recent launch of STS-119 provided a great demonstration of noctilucent clouds.  Launch was at 7:43 PM shortly after sunset. I viewed the launch from southern Florida just North of Naples.  As the Shuttle rose into the sky, it’s exhaust trail was highlighted with the red glow of the setting sun. As the shuttle reached an altitude of 60+ miles, it rose above the setting sun and it’s exhaust was directly highlighted with the full spectrum of sunlight. The image above was captured at 8:00 PM.  Several minutes later the lower portion of the exhaust trail was no longer highlighted leaving only the bright luminesence of the man made cloud in the upper atmosphere.  Over the next hour, the exhaust plume slowly dissipated and finally disappeared as the upper atmosphered darkened with the setting sun.

Here is a  video of the launch taken near Titusville.  Near the end of the video you can see the developing man made noctilucent cloud.   

Very thin clouds in the upper atmosphere are often not visible unless they are highlighted in an otherwise dark sky. These clouds typically appear during summer when water vapor content in the upper atmosphere is at it’s highest. The exhaust from the space shuttle is predominately water vapor and can  be a direct source of noctilucent ice crystals.  

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Upriver

15,000 years ago, glaciers covered central Wisconsin from the northeast extending to just east of present day Wausau and Stevens Point. As the climate warmed, glaciers released torrents of melt water causing deep gorges in locations throughout Wisconsin.  One such area can be seen just north of Hatley, the Dells of the Eau Claire River. On this stretch, the Eau Claire River cascades over outcrops of Precambrian-age rhyolite schist.  Rhyolite schist (a very hard rock) was formed through metamorphosis and later tilted to a nearly vertical position allowing the rock to split readily along the cleavage planes. In the dells, the river tumbles and spills across the rock’s cleavage planes while it runs smoothly in other areas where the river flows parallel to the planes. This image is looking upstream from the Dells just east of the bridge.

This is an HDR image. Several different exposures of the same scene were taken by changing only the shutter speed. The images were then combined using Photoshop and Photomatix.

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Bear Creek, Portage County, Wisconsin

 

Bear Creek is in eastern Portage County.  The image was taken on a bitterly cold morning from a bridge on Lime Lake Road.    This portion of the Creek stays open year round and is often mist covered early in the morning.  I had stopped by this location a dozen or so times hoping to image a pair of mallards living under the bridge.  I missed them again but captured this image. The trees had become ice coated the night before.  As the sun rose over the tree line, the cattails were thrown into an intense silhouette while the ice on the trees shimmered.

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Conflicts of Interest

The Pharmaceutical Research and Manufacturers of America (a pharmacy trade group organization) has recently announced new guidelines addressing conflicts of interest with clinicians.  Member pharmaceutical companies will be barred from distributing office supplies, clothes and other gifts with company logos or product brand names to physicians and clinics. The new guidelines also prohibits the companies from paying for physicians’ meals, including those during medical education events, and requires that all grant money allocated for continuing medical education programs be handled by personnel who are not from sales and marketing departments.  The guideline does not address the common practice of paying clinicians to promote drugs on a speaking circuit or serve as paid consultants.

A number of years ago, Ministry Health Care updated it’s corporate integrity policies banning the receipt of gifts of material value from any vendor and specifically restricting pharmaceutical representative access to our clinicians.  We had a few clinicians who bristled at the policy stating a pharmaceutical representative could not influence their decision-making. Drug companies simply would not waste their money trying to influence clinicians if their tactics did not work. 

Clinicians also related drug samples provided by pharmaceutical reps are given to needy patients. In response, we started a very successful Patient Drug Assistance Program. This program helps our needy patients apply for drug assistance directly from the drug company.

I am proud of the stance Ministry Health Care has taken and fully support it. It is also time for our government to establish similar policies for all government employees including our legislators.  Special interest group sponsored educational junkets are said to provide valuable education for our senators and congressmen; education that undoubtedly leaves them more favorably inclined to vote for legislation supported by their benefactors.

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Plover Halo

Ministry Medical Group-Plover, my medical practice building when I was a practicing clinician.  The image was captured during a very cold early fall morning.  Ice Crystals in the air caused defraction of light resulting in a halo and corona around the moon.

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Testing, Testing and More Testing

An electronic health record is a very complicated beast.  Not only complicated in it’s own right, but doubly complicated due to interfaces with many other products.  Installation of new software involves multiple rounds of testing to make sure the software will function as desired. In the early phases, the testing is only as robust as the technicians and analysts doing the testing.  With experience, repetitive testing can follow a standard script. 

Once the software is installed, testing must occur every time there is a change in software settings or an upgrade to the software program. Though vendors perform a series of tests prior to a release, there is never software without bugs.  The vendor can not test how you have deployed their product. Your testing needs to find where the product is no longer functioning as it did previously.  You have a certain element of control over the timing of testing when vendors send you new releases to install on your servers. You have no control over timing if your software is hosted by the vendor and updated on their schedule not yours. 

Today’s electronic health record is typically a summation of data gathered through multiple interfaces to products provided by a multitude of vendors.  Whenever any of the associated programs is updated, additional testing is necessary to ensure the integrity of the entire system.

Testing requirements quickly mount since the complexity of the system increase by the square of the number of elements involved. For example, if the number of connections doubles, the complexity of the system increases by a factor of four. Complexity increases the chance a small change in how a program operates, will have significant downstream effects.

As your  EHR  becomes more complex, you reach a point where automated testing scripts makes sense.

Double Light Path

 McDill Pond, Stevens Point, Wisconsin

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Medication Reconciliation

The implementation of our electronic health record is Ministry Health Care’s largest and most important patient safety and quality of care initiative.  Perhaps the largest improvement in patient safety will occur with improvements to our medication list allowing easier and more complete medication reconciliation.

Over the years, I have become convinced a patient’s outpatient current medication list just cannot be accurate without a total commitment to electronic prescribing.  Without an accurate medication list, medication reconciliation at every clinical encounter becomes very difficult to achieve. 

Medication reconciliation has become the standard within the hospital setting but is just now gaining momentum in the outpatient world.  Though most clinicians are reluctant to admit it, most of the time we are not 100% sure what medications the patient is taking. Patients often take medications differently than prescribed or are taking medications prescribed by other clinicians.  Pharmacies convert prescriptions from trade name to generic medications further adding to the confusion.  I have frequently found patients taking both the generic and trade name version of the same drug thinking they were actually taking different medications, not a double dose of the same medication. You will not reliably know what medications a patient is taking without a specific process of medication reconciliation that includes a monitoring for accuracy.

The electronic health record will allow us to have a single enterprise wide medication list that will be used for medication reconciliation at every outpatient clinical encounter and admission/discharge from our hospitals.

Male Cardinal

Outside Innovation

Ministry Health Care is a large organization spread over northern and central Wisconsin.  Communication is always a challenge and collaboration on projects is problematic.  When a project is centered around a campus, our usual mode is to host large gatherings soliciting input and feedback. 

Our electronic health record is a huge project involving multiple medical campuses.  I was contemplating how one obtains a collaborative atmosphere when a project spans a large geographically area when I happened to read a book by Patty Seybold titled Outside Innovation. 

Patty Seybold offers the following description of Outside Innovation:

“It’s when customers lead the design of your business processes, products, services, and business models. It’s when customers roll up their sleeves to co-design their products and your business. It’s when customers attract other customers to build a vital customer-centric ecosystem around your products and services. The good news is that customer-led innovation is one of the most predictably successful innovation processes. The bad news is that many managers and executives don’t yet believe in it. Today, that’s their loss. Ultimately, it may be their downfall.”

Outside Innovation provides multiple examples of how companies have used their customers to produce truly customer focused products. I was particularly intrigued reading how software had been successfully developed in a collaborative atmosphere.  Viewing our clinicians and staff as one of the customers of our EHR, I began to see how we had another avenue to build a collaborative atmosphere for our project.

We used Quickbase, a web based system wide resource available to us through Intuit, to construct a wiki variant.  A wiki is a type of website allowing visitors to add, remove, and sometimes edit the available content (you may be familiar with Wikipedia).  We place proposed EHR content and policies on the website and then invited our clinicians and staff to review and comment.  Though the proposed content cannot be edited, an adjacent comment section is in a forum format allowing each author to be identified.  We have found comments from one author invites others to post their own thoughts.  The comments are then incorporated into updated content.

Communication and collaboration within an organization must be in many forms.  The concepts outlined in Outside Innovation is another tool we can use to improve our effectiveness.

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