Kenneth Kamler Profile 18Tondo interactive table Focus 20Posterior atlanto-axial dislocation without dens fracture Case 26Soft wool for hard bones Technology 34 How to solve problems creatively At Work 42

ISSN 1662-3282

The International Journal for Spine Care Professionals Volume 6

InSpine 3-10

The growing business of medical tourism

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34

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26

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Imprint

Editor-in-ChiefMichael E Janssen, USA

Managing EditorChi N Lam, USA

Deputy EditorsMichael Dittmar, MexicoMichael Daubs, USA

Editorial CommitteeChi N LamMonroe LevineUrs RüetschiJane WiedlerMichael Fawcett

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ISSN 1662-3282

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2 InSpine | Volume 6 | Issue 3

Table of contents

“Global” seems to be the new buzzword of the day. Even healthcare—traditionally a local or regional enterprise— now competes on an international level. Patients who require specialized care like spine surgery are looking more and more outside their homeland for medical treatment—cost savings is just one of many reasons. That’s why in this issue of InSpine we examine some of the emerging trends in medical tourism and the motivating factors that have spawned this new, global industry (p 10).

Cultural boundaries have also become more blurred nowadays. In the earlier days of medical dramas, TV series such as “M*A*S*H” were created in a fictitious setting. Today’s medical dramas, however, are of a different caliber. Worldwide syndicated shows like “House” or “Grey’s Anatomy” portray the behavior of doctors, nurses, and their patients in such realistic settings, that many viewers may have trouble drawing the line between reality and fiction. Several studies investigate this phenomenon, we give a brief overview on page 32.

On a more practical note, we discovered a new and rather unknown method to organize powerful, productive meetings as they happen in every medical practice. How the Reflective Adaptive Process (RAP) works and can be put to best use is explained on page 38. And as surgeons have to tackle all kinds of problems every day—not just medical ones—we include a hands-on guide to “creative problem solving” in this issue (p 42).

Enjoy this issue!

A world without borders

Michael E Janssen, DO

5 OPINION Spine surgeons today: too many meetings, too little time

6 PINBOARD

10 COVER STORY Medical tourism: seeking treatment anywhere

18 PROFILE Kenneth Kamler

20 SCIENCE Tondo interactive table

24 CENTERPOINT Harbourview Hospital, Seattle

26 CASE REPORT Posterior atlanto-axial dislocation without dens fracture

29 WHAT NOT TO DO

30 RESEARCH Cervical nucleoplasty using coblation technology

32 FOCUS How true are medical dramas?

34 TECHNOLOGY Soft wool for strong bones

38 AT WORK Can your practice RAP?

42 EXCELLENCE Creative problem solving. Thinking your way ahead

45 RADIOLOGY QUIZ

46 GLOBAL ADVENTURES FOR INSPINE READERS

Comments to the editorial board: inspine@aospine.org

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20 Science InSpine | Volume 6 | Issue 3

Identifying the cause of medical errors, both human and systemic, requires collaboration and openness as well as the efficient sourcing, retrieval, and analysis of clinical data. In reality, defensiveness and inefficiency often block the path to clarity and understanding. To help remove these barriers, Italian graduate student Valeria Donati created Tondo®, an interactive table with a user-friendly interface that helps clinicians and administrators get to the root of medical mistakes so they don’t happen again.

Tondo® interactive table: enabling collaboration and efficiency in clinical audits

Every year in the United States alone an estimated 98,000 patient deaths can be at tributed to medical error thus

making clinical audits that accurately identify and help to rectif y the root cause of these mistakes more essential than ever. [1]

Yet the fears and insecuri t ies of clinicians and adminis trators who par t icipate in the audit ing process of ten make for results that are any thing but clear cut and conclusive.

Communication, not confrontationThis unfor tunate reali t y became evident to Valeria Donati, 30, a graduate student in Inter-ac tion Design at IUAV Universit y of Venice while she was conducting research at a local hospital in order to identif y a suitable topic for her thesis.

“I came to understand that medical mistakes are like an epidemic and that many people die from every year,” she recalls.

With the encouragement of hospital s taf f, she read up on the issue in medical journals, magazines, and PowerPoint presentat ions, and she recognized that negative interpersonal behavior during clinical audits of ten exacerbated

the investigation.

“I interviewed doctors, facili tators, and clinical auditors and they all said that defensiveness during

audits is a really big problem because par ticipants star t to f ight,” Valeria says.

Her solution to the problem—and the subjec t of her thesis project—is Tondo® [‘round’ in Italian], an interactive

table that helps to take confrontation out of communica-t ion during the audit ing process so that par t icipants can

concentrate on the task at hand. “Tondo® aims to analyze the whole medical history of a person and to plan concretely how to avoid errors in the future.”Valeria Donati, Interactive Designer “Tondo”

Science 21

Efficient retrieval of medical dataThe table’s round shape and the fact that Valeria has designed a user-friendly interface that enables tabletop visuals and typography to be legible from all sides encourages a sense of equality among participants.

Tondo’s® intuitive features are disarmingly playful and easy to use, contrib-uting to a collaborative approach of investigation, discovery, and analysis. Large, round, touch-sensitive icons function to retrieve, open, and copy documents that with simple hand gestures can be distributed, rotated, magnified or minimized for better viewing. A finger can be used like a pen to ‘draw’ on an image and the drawing is simultaneously transferred to everyone else’s display.

“The visuals are very moveable,” Valeria explains, “so while the facilitator still has the main control of the situation and chooses which documents to open and who can speak, everyone can see everything that’s on the screen.”

Tondo’s® illuminated surface features a rotating ‘timeline’ that allows for date-specific retrieval of patient case files, medical reports, x-rays, and blood and other tests so that the details of a patient’s diagnosis and day-to-day treatment can be clearly seen, reconstructed, and reviewed.

This visual approach together with the quick and easy access to all medical data makes for a far superior identification and analysis of what and who went wrong than is possible from studying excel spreadsheets, which was the conventional auditing method that Valeria observed being used.

“With this new approach you can see the error on screen, its not just on paper or verbal, so everything is more clear,” Valeria explains.

Tondo® also has an internal memory where case notes are stored in an ‘error archive’ so that case reconstructions, conclusions and recommendations can be retrieved for future reference.

ERROR ARCHIVE

Clinical audit results are filed in an error archive stored in Tondo’s® internal memory. These results can be quickly retrieved, viewed on the tabletop screen, and edited using a touch-sensitive key-board. In the above fictional case exam-ple, the misdiagnosis of two patients was attributed to illegible clinical analysis data.

DOCUMENTATION

Date-specific retrieval of patient case files, medical reports, x-rays, and blood and other tests.

ICONS

Large, easy-to-use icons on Tondo’s® interface provide for the immediate retrieval of a patient’s medical data for a detailed analysis of how, when, and why a diagnosis or treat-ment went wrong.

INTERACTION

Tondo’s® tabletop screen allows clini-cians and admin-istrators to closely analyze every detail of a patient’s hos-pital stay, including medical reports, x-rays, blood tests, and ECGs. If an error has occurred, it can be seen and studied onscreen whereas in conventional audits this data, as well as the means to view it, may not be readily available.

Analysis Electrical recordingsError form

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Tondo® interactive table

22 Science InSpine | Volume 6 | Issue 3

Valeria DonatiValeria Donati, 30, is a native of Rome, Italy. She studied product and graphic design at Uni-versidade Lusiada in Lisbon for one year, followed by three years at La Sapienza Universit y

of Rome where in 2007 she earned a Bachelor ’s degree in industrial design. In 2008, she and her team won first prize in the mobile category of the Adobe Design Achievement

Awards for their projec t “What ’s Cooking?” She has completed internships at Studio Ruggieri Poggi in Rome, and at Prospect Design in London, England. In 2010, Valeria

graduated cum laude with a Masters degree in Visual and Multimedia Design, spe-cializing in Interac tion Design, from IUAV Universit y of Venice. She is currently

working as interac tion design intern at Siemens Corporate Research in Princeton, New Jersey. Her strengths are idea generation, problem solving, and graphic

and video development, and she is now discovering her interest in strategic thinking. She can be reached at valeria@corricorri.net.

Test groups approveValeria developed Tondo® with scientific support from the Clinical Risk Center of Tuscany, which provided regular feedback to ensure the prototype corresponded to a medical setting and met the requirements of a clinical audit.

An emphasis on round shapes in the table’s design was evidently the right choice. Test groups have found that Tondo’s® shape contributes to a more open, relaxed, and collaborative ambience and that its features are so intuitive and easy to use that participants require almost no training.

On many fronts Tondo® holds great promise and makes a strong case for greater involvement by designers in the areas of medical and healthcare devices. “The knowledge that designers have (information design, interac-tion design, service design) is not often applied to the design of systems or equipment in hospitals, though there are notable exceptions,” says Professor Gillian Crampton Smith, co-director of the Interaction Design programme at IUAV University of Venice, who supervised Valeria’s thesis project.

She believes that designers can offer healthcare: “logical design that makes errors difficult or impossible and that eases the cognitive load for people using complex machinery (eg, surgeons).”

Valeria concurs with this assessment. “The medical field has to be really technical, but clinicians need more intuitive interfaces to work with because the existing interfaces are always designed by engineers. A designer without an engineer can’t do anything, but I think that the opposite is also true.”

Crampton Smith agrees that at the moment, Valeria’s interest in designing for the healthcare sector may be the exception to the rule among young interaction designers, but she thinks this could change. “This is a field where designers can contribute to saving lives, which is a great reward for any young person. And problems in medical design are complex, which is challenging and enjoyable.”

“Corri! corri!”Valeria attributes her interest in healthcare to the three years she spent working as a radiology assistant at a hospital in Rome, her hometown, before she began her studies in design some six years ago.

Having now graduated cum laude from her Masters program in Interaction Design, Valeria is in the early days of an internship with Siemens Corporate Research in Princeton, New Jersey. “It’s perfect, really challenging, and interesting,” she reports.

In among her professional obligations she needs to find time to complete the Tondo® prototype and to consider the various offers from commercial developers that are quickly coming her way. “I’m trying to understand what could be the next best step,” she says, sounding just a bit under pressure, which is probably not unusual for her.

“My personal ‘aka’ is “corri! corri!” meaning “run! run!” because since starting my studies I’ve had to run a lot,” she says with a laugh. She agrees this could be taken as an indication of having found her true vocation. “I think I’m on the right way,” she says. “I would like to go ahead with interac-tion design for medical and healthcare devices. I want to do something to improve the quality of people’s lives.”

References

[1] L Toni Lewis, MD, President, Committee of Interns and Residents, December 2, 2008

In healthcare, also designers can contribute to saving lives, a great reward for any young person.Professor Gillian Crampton Smith, IUAV University, Venice

Web resources To see Tondo® in operation go to: www.vimeo.com/11240753www.corricorri.net/index.php?/valeria/Tondowww.interaction-venice.com

Science 23