Put technology in it's proper place

What do I expect from my healthcare providers?  Simple, I want them to use their skills at diagnosing and treating to fix me when I am unwell.  Will technology enable them to do that job better?  That is a complicated question. 

Let’s take a look at diagnosing.  A diagnosis is a ultimately a decision about what is causing a person to be unwell and that decision informs the treatment.  A recent study by Paley, examined the accuracy of diagnoses in an emergency department.  Residents were correct in their diagnosis 80.1% of the time, and senior physicians were right 84.4%.  Inversely 2 people out of 10 were misdiagnosed.  The study went on to validate the contributing factors to a successful diagnosis and confirmed that classic diagnostic tools such as reviewing patient history, physical exams and lab tests are critical.  It was identified that older clinicians rely on the history and physical to a greater degree than younger clinicians.  As a result, many recent graduates can only make cardiac diagnoses by echocardiography, relying more on technology for their decision making. 

This study reminded me of the discussions that emerged following Captain Sullenberger’s successful landing of Flight 1549 into the Hudson River.  The experts identified the primary reason for the successful ditching was the decision making of the flight crew members during the accident.  Captain Sullenberger’s years of experience with multiple aviation systems, including low tech gliders, directly influenced his decision making ability. 

I found it interesting that Captain Sullenberger, a safety expert was a proponent of building a balanced environment of learning and accountability to enhance safety and he even had a copy of A Just Culture in the cockpit.  A Just Culture is an environment where learning and accountability are fairly and constructively balanced and is critical for the creation of a safety culture. Without reporting of failures and problems, without openness and information sharing, a safety culture cannot flourish. 

Technology can be an important enabler to a just culture but it is only one part of a learning environment.  Technology provides skilled practitioners with a tool to do their job more accurately and faster, it does not replace the interpersonal skills and human judgement required to effectively diagnose and treat patients. 

A recent New York Times article The Face of Future Health Care  speaks to the role of technology in helping healthcare providers track patient care.  When Dr. Jennifer Slovis recently saw a patient, she was able to spot that the patient had an abnormal blood test several years ago. By reading through the patient’s medical history, she determined he was now overdue for an M.R.I. to check the status of a growth in his brain. She was able to e-mail his endocrinologist and schedule the necessary tests without the patient having to make an appointment with the specialist or her having to make her own diagnosis. “It saved a lot of starting over,” she said.

In measuring the value of technology in healthcare we need to focus on the practical 

applications not the hype. 

Forbes Magazine reported on the President’s Council of Advisors on Science and Technology who have concluded that “the impact of IT on health care over the past decade has so far been modest.” But, don’t underestimate what’s coming. It is nothing short of an explosion in innovation and creativity, facilitated by open systems and connectivity.  Here is where the real value lies.  Technology allows for a connected system that will help patients take responsibility for their health. Strong teams of physicians, nurses and caregivers will use an intelligent network to make their results better and their jobs easier. 

Sorry Watson, while we anxiously await your contributions to healthcare, you can’t replace the decision making skills of our healthcare professionals that are honed in a continuous learning environment. After all, your decision-making algorithms are informed by those of learned professionals and that learning, is constantly evolving.  Let’s all take a moment and think about the role of technology and how it can be used to build a just culture that encourages learning and rewards accountability in healthcare. 

I want technology to support my healthcare provider’s decisions, not the other way around.  After all, if my health stopped functioning and I needed an emergency landing, I’d put my trust in a medical version of Captain Sully any day of the week to guide me to safety. 

It’s your health.  It’s your health information.  Manage it well.  

How to fix healthcare? Start with carrots for consumers!

This week the Harvard Business Review took a stab at redefining the healthcare business model in What is the Business of Healthcare?   It was suggested the focus should be on health rather than healthcare, an honourable ideal.  Far be it for a simple goat to butt heads with HBR but I’m going out on a limb (goats actually can climb trees – google it) and take issue with this seminal magazine and its lofty school of higher learning.  The challenge with HBRs concept is, there isn’t any profit to be made in ‘health’ and healthcare in the US makes up 17.6% of GDP at a cost of $8,233 per person per year (highest per capita cost in the world). 

The problem is, if people don’t get ill, the economy will and that is simply messed up. 

Too much of our economy is built on profits derived from an ill population and not enough is built on profiting from a healthy population.  And, since money is in the driver’s seat, we won’t see significant change until consumers change their spending habits. 

North America has created the gold standard for a business model that profits from illness.  We have a society with relatively high longevity rates for a population as unhealthy as it is which means people are living a long time with chronic illnesses.  The North American food and transportation industries create products that negatively impact health and market them as lifestyle necessities.  Consumers adopt these unhealthy consumption behaviours and inevitably develop risk factors that lead to chronic illnesses such as diabetes and cardiovascular disease.  The healthcare industry then steps in to manage illnesses at great cost while continually improving interventions that allow citizens to live longer with their illnesses.  It’s insane.  Incentives are continually thrown in the wrong direction.

Why do we as consumers put up with it?  We have the power to change this unhealthy cycle with our purchasing power and lifestyle decisions.  But we need help; we need a little carrot to incent us in the right direction. 

 

In a recent article Patients need pay for performance too, Matt Patterson, makes the sensible case for incenting the consumer to achieve positive health goals.  “We need to build models that show patients the impact of making good health decisions now.”  Governments have spent years and millions on incenting healthcare professionals and institutions to create efficiencies and what we have to show for it is staggering growth in healthcare costs and record rates of poor health outcomes.  The reality is consumers have to participate in creating the change needed … so why have we not provided incentives to them? 

This is not rocket science, its common sense.  First, start at the source, we know that there are a handful of risk factors that increase our chances of developing a chronic disease and they are ALL avoidable and they are all measurable.  If we all maintained the following behaviours we would save the healthcare system billions:

• Consume a healthy diet of whole foods
• Participate in daily physical activity
• Reduce or quit tobacco use
• Moderate alcohol consumption
• Maintain a healthy weight

How do we incent people to adopt these behaviours?  Start by encouraging individuals to measure their behaviours in order to track participation and allow a reward based system.  We have to start somewhere and the early adopters are providing an environment to test an incentive program. 

The timing couldn’t be better for consumer engagement and incentives.  The digital/mobile health industry is rapidly growing with an estimated 1.7 Billion to download health apps by 2017  (that’s a lot of people tracking health indicators and governments didn’t have to spend a dime).  Why can’t we encourage more of that, why can’t we offer individuals incentives to meet their healthy lifestyle goals and maintain them.  Let’s encourage people to consume health products, and avoid consuming healthcare and let’s reward those choices.    

Wouldn’t it be great if a portion of the GDP currently spent on healthcare was spent instead on healthy food and active transportation?  Or what about a realignment of personal consumption from those unhealthy options (tobacco, processed food, alcohol) into healthy options (fresh foods, active transportation, fitness activities and even mobile devices to monitor our health behaviours).  We can succeed if we shift even a small portion of our economy to benefit from a healthy population rather than an ill population?    Let’s start with carrots.

It’s your health.  It’s your health information.  Manage it well. 

They are Women, hear them Roar!

Wednesday March 8^th is International Women’s Day. 

In celebration of the enormous contributions that women around the world are making to science and technology I bring you my favourite female contributors to the empowered healthcare consumer dialogue.  These are just a few of the female voices that the Fainting Goat follows and there are  many more inspiring, teaching, living and learning how to improve health through technology that I have yet to encounter.    I salute you, learn from you, seek inspiration from you and follow you (in a twitter way).  You are journalists, physicians, policy wonks, politicians, industry leaders, patient voices, students of healthcare, advocates for social justice, technologists, bloggers, developers and entrepreneurs.  You are also mothers, daughters, sisters and friends.   Happy International Women’s Day, may your efforts and voices stay strong for years to come.

Esther Dyson – Self-proclaimed “Internet Court Jester” – I first heard her speak recently at a broadcast of an Economist interview with Dyson and Dr. Daniel Kraft about Healthcare in 2013 and I was drawn to her refreshing voice and have been following her ever since @edyson on Twitter.   Esther Dyson is an achiever; she is an active angel investor in a variety of start-ups, for-profit and otherwise, around the world.  And, she seems to be having fun with just about everything she does.  I love that she has already published her epitaph on her business website EDventure “I wasn't done yet! There is still more to learn and to fix.”  Oh, and she has written a book (on my to-read list) Release 2.0 A Design for Living in the Digital Age.   

Regina Holliday – artist, advocate and brilliant visionary. What an incredible person, such an inspiration. Here is a link to  Regina Holliday's Medical Advocacy Blog.  If you haven’t heard of Regina, please do yourself a favour and read her blog then follow her on twitter @ReginaHolliday.  Regina is the brainchild behind The Walking Gallery (I hesitate to summarize this project for fear of not doing her work justice).  She creates beautiful works of art that represent the patient experience in healthcare or an aspect of ‘The System’ that would benefit from discussion and she reproduces them on the backs of business jackets and gives them to notable attendees at medical conferences.  The jackets stimulate discussion and beautifully illustrate how difficult it is to turn your back on the patient when their voice is always present.  Her personal story is vividly described in her blog and depicted in her own jacket, I leave that with you to experience. 

Jessie Gruman - author, epatient (4 time cancer survivor) and founder of the Centre for Advancing Health.  The Institute provides pragmatic resources to encourage all consumers to be a Prepared Patient.  She has authored a few books, check out After Shock.  What to do When the Doctor Gives You a Devastating Diagnosis.  Jessie tweets @jessiegruman and is a knowledgeable voice bridging the personal experience with her extensive understanding of healthcare and policy. 

Michelle Petersen – journalist and champion of innovation of health in pharma.  Michelle is founder of Health Innovations – A Platform to Enable All Sectors Within the Health Industry.  She is a prolific tweeter and brings a wealth of information on clinical trials and news from the pharmaceutical side of the industry.  Her blog is Health Innovations.  Follow her on twitter @shelleypetersen.   

Dr. Leslie Saxon – Lelsie works in the coolest place, the USC Centre for Body Computing – The CBC (not the Canadian Broadcasting Corporation) believes that technology solutions are not the problem (or the drivers of our terrific and ever rising health care costs), they are the solutions, and they represent the very best achievements in modern society.  The CBC is an innovation incubation center that commercializes wireless health products that will transcend policy and politics in the future.  She gave a great Ted Talk in 2010 on the need for technology in healthcare and provides a plain-speak explanation of why we shouldn't put patients in ‘information purgatory’.  Leslie is working in this rapidly emerging environment and her tweets highlight how quickly technology is driving the future of healthcare.  Follow her @DrLeslieSaxon. 

Jane Sarasohn-Kahn  - Healthy thinker – Jane is a health economist who works at the intersection of health and technology (my favourite corner).  In her most recent blog The future of sensors in health care – passive, designed, integrated, she explores how sensors will help consumers monitor and manage their health conditions.  Love the infographic too.  You can follow Jane @healthythinker or check out her website Health Populi . 

As my final shout-out in honour of International Women’s Day, I would like recognize the recently launched project, Chime for Change.   Despite the glossy celebrity endorsements, I’m optimistic that some awareness and good work may emerge from the effort.  The six women that I've highlighted are all North American women (Esther is Swiss born but a native of NYC now) a fact that does not escape me and I believe highlights the global aspect of gender inequality in science and technology.  We are so fortunate to live in a time and space where the contributions of women in science and technology are celebrated and their voices are heard, but not all women and girls have the same opportunities.  View the video, and if you see value in the effort, give them a follow @chimeforchange.  

As Hillary Clinton said  “It is past time for women to take their rightful place, side by side with men, in the rooms where the fates of peoples, where their children's and grandchildren's fates, are decided.”

It’s your health.  It’s your health information.  Manage it well.

Healthcare Needs a Superhero!

If you had to pick a superpower to use in a fight with cancer (or heart disease or multiple sclerosis) what would it be?  Truth, Evidence, Reality or Proof? 

No one doubts that Evidence and Proof will win the long game, but  will we still be alive by the time they build their impenetrable pyramid of Evidence to the point of Proof?  These days there is a lot of noise around the reality of ‘Evidence-Based Medicine’  Is Evidence Based Medicine only an Illusion and I long for Wonder Woman’s Golden Lasso of Truth to tie around the researchers and funders that navigate these concepts of Evidence before us.

As for Proof, we would all like some firm Evidence that would confirm to us that our ideas or beliefs are 100% correct … but Proof is a slippery concept and indeed, scientists prefer not to talk about ‘Proof’ at all.  They insist it is more useful to talk about Evidence – and if the Evidence really stacks up to support a claim, then we can be (reasonably) confident the claim is true. They say you can never ever really ‘PROVE’ anything in science at all!

If I’m determining my role in a strategy to battle my disease, I’m not sure I want Evidence or Proof as my superpowers. So it's a good thing these are the powers given to our healthcare providers.  They take on a tremendous burden juggling, justifying and continually re-educating themselves about what the powers of Evidence and Proof can and can't do and I'm grateful for their efforts. 

Now, Truth and Reality are powers that go hand in hand.  Truth is based on that which is true or in accordance with fact or Reality.  Reality is the state of things as they actually exist, rather than as they may appear or might be imagined. Reality includes everything that is and has been, whether or not it is observable or comprehensible.  Who possesses the power of Reality?  The only person who can speak to the Reality of your physical being is YOU. 

If healthcare is in need of a superhero (and who can honestly claim that it isn’t), then let that superhero be YOU, the healthcare consumer, armed with the growing and strengthening ability to quantify, document and share your Reality.   This is your superpower and it informs Truth. When you combine your superpower with your healthcare providers power of Evidence, you have a dynamic team.

The Fainting Goat is voting for a new Superhero I call “Veracity”, (I like the colour purple for the cape, what do you think?) representing Truth in accordance with fact or Reality.  Don the cape, embrace the moral code, protect your identity and join the fight for your good health. 

It’s your health.  It’s your health information.  Manage it well.

"What the Buck?" Award goes to ...

What the Buck? Award goes to the term “Medicolegal” and to Dr. Wes for propagating the term and all the barriers to innovation and patient-centred care that it represents. 

What the Buck? Award is bestowed upon hierarchical symbols that dominate healthcare despite having lost their crucial relevance in this new paradigm.   These symbols require thoughtful re-consideration of their place in the future of healthcare. 

Medicolegal, yes it is a word according to Merriam-Webster  (circa 1835) that means ‘of or relating to medicine and law’.  There is even a Medico-legal Association in Toronto where doctors and lawyers gather to discuss … oh, I get a headache just thinking about it. 

This week, in his blog When Patients Can Obtain Their Own EKG, Dr. Wes pondered the impacts of the AliveCor EKG case now that the FDA has licensed it as a medical device.  His comments perfectly illustrate what happens when innovation reaches implementation in an inefficient system like healthcare (read more on this issue Which way should healthcare Lean?).

The AliveCor EKG device and app allows patients to record, display, store, and transfer single-channel electrocardiogram (ECG) rhythms from their iphone.  The device has been making news for over a year.  Dr. Daniel Kraft participated in a clinical trial of the AliveCor EKG case and tweeted his EKG back in September 2011. The AliveCor EKG case was touted as one of the Big Tech Health Ideas that will change medicine in 2012 and the device made waves at this year’s Consumer Electronic Show as one of many devices contributing to the emerging quantified self-movement,

Dr. Wes and the term “medicolegal” are bestowed this award because of the importance that a respected healthcare professional put on the medicolegal implications above any other aspects of the device.  Devices should first be considered for their ability to improve health outcomes and increase efficiencies in the system.  If they don’t do one or the other, then their relevance should be questioned but Dr. Wes wasn’t questioning either, he was concerned about how the device will impact him as a cardiologist, “we are entering into new, uncharted medicolegal territory”.  Yes, Dr. Wes, you are no longer in Kansas, it’s a brave new world.  Specifically, Dr. Wes is concerned about; what are his responsibilities to the patient once he prescribes the device; does the device obligate him to be available around the clock to his patient; how will the EKG record be stored in his file; and what are the legal risks?  These probing questions could keep the medicolegal experts busy for years.

I’m not discounting his concerns or his authority to ask these important questions, healthcare administrations, governments and governing bodies should be asking these questions.  However, the discussion should not be isolated from the benefits that these devices may bring to both healthcare consumers and healthcare systems.  Not once did Dr. Wes identify what benefits the device could provide his patients despite acknowledging in his blog that his office provided a demonstration of the device and that he facilitated the prescription for the device for a patient.  If I was his patient, I would assume that if he is demonstrating and prescribing a device, he sees some benefits. 

By the end of his blog, I was left with an unpleasant taste in my mouth.  I sensed that the issue for him wasn’t whether or not the device provided benefits to his patients, but what his compensation should be for prescribing the device and for any impact the device might have on ‘workflow’.   He notes, “There are only so many hours of the day and since I must value that time, cannot bill for this EKG-reading service, and have no quality control over the caliber of the recordings submitted, I consider my interpretations of tracings sent to me to be provided to the patient as a "good Samaritan" in every legal sense of the term.” 

This is a familiar, well-trodden path that the medicolegals have carved out.  In due course, doctors will have quantified the value of their time for both prescribing and monitoring the device and their governing bodies will have negotiated a fee schedule for workflow associated with it.  The lawyers will wrestle with a risk analysis and measure the odds of litigation associated with the device and develop iron-clad terms and conditions, waivers and disclaimers.  When all that red tape is complete, we will see a surge in utilization of the AliveCor EKG device because doctors will be paid to work with it and patients will be asked to assume all the risk.   

This is what happens when medicolegal processes take over innovation.  Thanks Dr. Wes for the heads up. 

If you know a worthy recipient of the What the Buck? Award, send an email to the Fainting Goat at yourfaintinggoat@gmail.com

Which way should healthcare Lean?

There are two camps in the ongoing struggle to improve healthcare; ‘outside the system’ consumer/entrepreneur driven camp, and ‘inside the system’ healthcare administrator/government camp.  Both seem to be focused on improving health outcomes, reducing costs and improving patient experience (the Triple Aim) but despite common goals I see little evidence of these camps working together. 

So why is there so little collaboration between the two camps?   One reason could be in how each camp approaches a problem.   Entrepreneurs tackle a problem from a Ready, fire, aim approach,  while healthcare systems are traditional ready, aim, fire implementers, often so focused on perfecting the aim, the target has long moved away by the time they are ready to fire. 

There is some common rhetoric emerging from both camps.  In the entrepreneurs world "Lean Startup" (2008) is a popular approach for launching businesses and products that relies on validated learning, scientific experimentation, and iterative product releases to shorten product development cycles, measure progress, and gain valuable customer feedback.  In the healthcare administrator’s world, the Lean approach to healthcare focused on driving out waste so that all work adds value and serves the customer’s needs is gaining momentum.  Both processes depend on measuring results and this is the healthy change that will drive success.

Solutions will emerge when all parties recogize the strength that comes from the ability to measure success together.  The empowered healthcare consumer taking control of and measuring the factors influencing her health.  The healthcare provider working in partnership with the consumer implementing an effective approach to diagnose and treat the consumer that includes the measuring of outcomes.  And the healthcare administratorsand governments use those outcomes to measure the efficiency in the system.  

But it starts with the empowered consumer and there is a logical reason why. The empowered consumer is the link to bridging the incredible advances in healthcare technology emerging from forums like Future Med with the efforts of administrators and governments to make our healthcare systems more effective and efficient.  

The healthcare system isn’t ready for the quickly evolving space that health entrepreneurs are creating.  Bill Gates figured that out long ago, “The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.” Apply this to a healthcare innovation like electronic health records and you understand why the implementation of EHRs is in such chaos right now.  Healthcare has never been a system based on efficiency (whether it should is a debate for another blog).

It’s OK that the system can’t handle the changes in technology right now, because healthcare consumers are ready.  The opportunity before both camps is to recognize the importance of the empowered consumer and to encourage their participation.  Entrepreneurs seem to recognize this which is why many new devices are marketed to healthcare consumers.  What we need is recognition from administrators, governments and healthcare providers.  The Fainting Goat has some practical advice for all the participants in this important work: 

• To all the entrepreneurs out there, please keep the products coming and educate consumers along the way.  Empowering healthcare consumers requires a significant cultural shift and you are doing the heavy lifting.
• To the healthcare providers, partner with consumers to use self-tracking tools as a way to better inform their treatment strategies and diagnosis. 
• To administrators and governments, these technologies will enable you to save money if you work with them and the consumers who control them.  Break down the barriers to using these technologies and create some consumer-enabling incentives such as tax breaks or reduced insurance fees.   
• To healthcare consumers (that is every single one of us) take responsibility for managing your health in whatever way is comfortable to you. 

As for me, The Fainting Goat is anxiously awaiting the Misfit Shine set to arrive next month and will gladly consider any technology that will help me to live a long and healthy life. 

It’s your health.  It’s your health information.  Manage it well. 

The smartphone will see you now

I have a very simple goal.  I want to live a long, healthy life.  In order to accomplish this, my body needs to be functioning at its highest capacity.  But, my body is made up of multiple complex systems that I don’t fully understand and I require a trained healthcare professional to monitor it in order to ensure it is functioning properly…or do I?   Now, I can take on that role with the help of my smartphone. 

The role of family physicians in providing preventive care has been declining.  (See  What if doctors worked like dentists?)  This means healthcare consumers are left to be more proactive in managing and monitoring their health.  The good news is there a whole lot of options out there to help us. 

Smartphones – There’s an app for that!  Your phone has the potential to monitor all kinds of health conditions.  According to Dr. Eric Topel, noted digital health guru and author of The Creative Destruction of Medicine (my current read) “You can take the phone and make it a lab on a chip. You can do blood tests, saliva tests, urine tests – all kinds of things – sweat tests, through your phone. This is a powerful device,”

Pharmacists –This healthcare professional is looking to provide you with services to help manage your health.  Kroger’s Health Centre kiosks, for example provide customers with an easy and secure solution to consistently measure, monitor and improve body composition and other clinical conditions. Assessments include blood pressure, weight, body composition, BMI, color vision and the ability to upload blood glucose numbers and other biometric results.  And it’s free!

Paper and pencil - The  PEW Tracking for Health Report released this week identified that 69% of U.S. adults track a health indicator like weight, diet, exercise routine, or symptom.  Of those half track “in their heads, one-third keep notes on paper, and one in five use technology to keep tabs on their health status.  Technology is not the enabling factor, almost 50% of those studied didn't use technology at all. 

Are we ready to take on this role?  U.S. consumers’ desire to take an active role in their health decisions is growing, according to the Altarum Institute Survey of Consumer Health Care Opinions.  61% of people want to make health decisions either on their own (26%) or with input from their doctor (38%). The proportion of people wanting to be “completely in charge of my decisions” rose 4 percentage points in one year, from 2011.

Some people are actively participating in the digital health uprising, they are the early adopters, leading the way, motivating a consciousness rising.  We need to realize that the internet and self-tracking devices are just tools. The real change will come when we each recognize the value of taking responsibility for monitoring our own health.  We as consumers are the only ones who can make this happen.  For me, there is no greater value than living a long healthy life. 

It’s your health.  It’s your health information.  Manage it well.