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. 

What if doctors worked like dentists? (Note to dentists, I realize that you are doctors too)

This week there was a hilarious video If Air Travel Worked Like Healthcare that parodied the inefficiencies and frustrations many of us experience with the healthcare system.   The video reminded me of a recent visit to my dentist, he was commenting on having to wait at our local emergency room for hours with his son who had potentially broken his arm.  He commented “if I ran my office like they run that emergency room, I’d be out of business in a month”.   

It made me wonder, what would it be like if my family doctor worked like my dentist.

Every six months my dentist calls me to book a preventative care appointment for cleaning and check-up.  My dentist offers evening and weekend appointments that make routine cleanings easy and convenient to book.  Every few years my dentist ensures I have x-rays updated; his office keeps track of that screening schedule and calls me to book the appointment.  During my appointment I spend most of my time with the hygienist who does all the cleaning and routine exam before calling in the dentist for a 5 minute consultation and chat.   If I require urgent care from my dentist his office will makes sure I am seen right away (usually the same day).  The continuity of my dental care is maintained by my dentist.

My family doctor (like most GPs) doesn’t believe in annual well visits so there are no preventative care appointments.    It is my responsibility to track my own periodic screening schedule (such as pap tests) based on government approved clinical guidelines and schedules that seem to change quite frequently. When I remember to call for my screening appointment it will take six months to book a ‘non-urgent’ appointment and I will have to mark it in all my calendars because no one from my doctor’s office will call to remind me.  My work/family schedule will have to accommodate the appointment when it comes due because rescheduling will mean 6 more months of waiting.  When I visit my doctor, she takes care of 100% of the visit.  If I require urgent care I usually find myself in a walk-in clinic or emergency room.  The continuity of my medical care is scattered among many providers.

In my ideal, imaginary healthcare system my doctor would run her office like my dentist.  All my preventative appointments would be monitored by her office, they would call me when I was due and it wouldn’t be my doctor who took care of these appointments, but an RN or even LPN.  My doctor’s office would also track and schedule my screening appointments and book me in within a reasonable timeframe that would include evening and weekend appointments.  Again, my doctor doesn’t need to perform these routine screenings, a nurse or nurse practitioner can with my doctor providing a brief consultation following the screening.  If I require urgent care that is not acute, I would be able to visit my family doctor within a day or two and the continuity of my medical care would be maintained in one office.

Last week I wrote about Prognostications and Health Policy citing the OMAs decision to not provide annual physicals.  This week the Washington Post ran an article Don't Open Wide, Annual Check-Ups Are Pretty Much Useless.  We could find all kinds of holes in both the OMAs decision and the research cited by the Post, but it is infinitely more enlightening to look the Mayo Clinic’s recently published a study Why Patients Visit Their Doctors: Assessing the Most Prevalent Conditions in a Defined American Population  

Here are the top 10 reasons people visit their family doctor

1. Skin disorders
2. Osteoarthritis/joint disorders
3. Back problems
4. Cholesterol problems
5. Upper respiratory conditions (not including asthma)
6. Anxiety, depression and bipolar disorder
7. Chronic neurologic disorders (such as Parkinson’s and Alzheimer’s diseases)
8. High blood pressure
9. Headaches/migraine
10. Diabetes

It seems strange to me that while family doctors don’t see a need for preventative care, they do spend the majority of their time responding to patients dealing with chronic conditions that could be prevented. 

I believe it's time to have a chat about the future of preventative care.  Who is responsible for monitoring it, what is the best way to manage it, how do we position government policies to incent it, how can healthcare consumers and practitioners work together and where does new technology fit in to keep everyone living to their optimal health.

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

Prognositcations and Health Policy

This week a number of interesting articles and announcements occurred.  The annual Consumer Electronics Show in Las Vegas provided lots of fodder for the quantified self-movement and prognosticators from around the world were exclaiming health innovation predictions for 2013.  Much of the exciting news centred on mobile health solutions, quantified-self tools and the emerging role of the consumer in the future of healthcare.

Mixed into all of this the Government of Ontario (Canada) and the Ontario Medical Association (OMA) announced that healthy people don't need physicals.   The agreement to eliminate the service will save millions of dollars in what the OMA claims are unnecessary tests and procedures as part of the annual physical or Periodic Health Examination (PHE).  In Canada, physicians and governments control the healthcare system and when they create a void by taking a service away such as annual physicals, one would think there would be an obligation to educate healthcare consumers on how to fill that void. 

Wow, I thought, what an incredible opportunity for the medical community to promote digital solutions for self-monitoring health status as a replacement for the annual physical.  What a great policy window for a government to offer tax rebates to consumers who purchase digital monitoring devices to self-manage their health.  But that didn’t happen.  Medical associations, while denying any value in annual physicals, continue to deny the effectiveness of digital self-monitoring. 

So, if the OMA claims that annual physicals are unnecessary, what is the role of physicians in preventative health care?  Who will benchmark an individual’s health status and who will assess and monitor an individual’s risk for chronic illness given that many factors are behavioural but many are also inherited? 

We know that chronic illnesses (diabetes, hypertension, arthritis, asthma, COPD and types of cancer) are creating a tremendous burden on healthcare systems around the world.  We know that managing chronic illnesses costs $190 Billion annually  in Canada and in the US, total direct and indirect costs from chronic disease were estimated to be $1.1 Trillion in 2003 (last time data was available).  We know that chronic illnesses are largely preventable. We know that certain behaviours increase our risk for chronic illness (smoking, being overweight, poor eating habits).

Preventing chronic illness and managing risk factors should be a collective priority for healthcare consumers, the medical community and governments. 

That said,  I don't oppose this shift away from physician-centric annual physicals but I want my primary care provider to acknowledge the role of self-monitoring and I want her to work with me to build our collective capacity in interpreting data from self-monitoring devices.  We need physicians and governments to agree on standards for self-monitoring devices that work from existing clinical practice guidelines and approved risk assessment tools.   We need them to partner with us.

Programming devices to alert individuals when their health is at risk is here now and it’s easy; however, having the medical community endorse the use of digital devices is a battle we will see played out for years to come.  The Fainting Goat optimistically predicts that annual physicals will be replaced by digital monitoring by 2015!!!  Well, maybe 2017 ... anyone for 2020? 

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

Connecting the Dots: Reflections on 2012

In 2012 a man with prosthetics ran in the Olympics, we landed a vehicle on Mars and someone jumped from the edge of space.  It was a year of truly amazing scientific advances.  

Steve Jobs once said, “You can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future.”  As I look back on some of the ‘dots’ I can see a pattern of evolution and discovery surrounding personal controlled health information percolating among health technology innovators.   I see momentum growing and I believe we are on the verge of meaningful access to our personal health information.  This movement will empower us to measurably improve our health and provide evidence of the benefits of collaboration between healthcare systems and healthcare consumers.

Here are my top 7 DOTS from 2012. 

1. Dave deBronkart (US) @ePatientDave is the original epatient passionately promoting the most underutilized resource in healthcare, the patient and he should know, he beat the odds and is alive today to tell his story.  Dave deBronkart: Meet e-Patient Dave Dave did it, you can do it too, just say Gimme my Dam Data.
2. Salvatore Iaconesi (Italy) @xdxd_vs_xdxd  - 39 year old Salvatore Iaconesi lives with with terminal brain cancer (an “unwanted passenger” in his body) and wants to transform the meaning of the word "cure” and the role of knowledge. He cracked the codes to his clinical records on September 10^th and posted them online inviting the world to respond to his CT scans, MRIs, lab notes and glioma diagnosis in whatever way they want.  Salvatore also spoke at TEDx in Rome The Cure where he explained how he took the hundreds of thousands of responses to build his personal strategy to combat his brain cancer. 
3. Richard Van As and Ivan Owen (South Africa & US)  – a year ago Richard lost 4 fingers from his right hand, around the same time, Ivan created a mechanical hand that could be worn and operated by a person’s actual hand.  Richard lives in South Africa and was searching the internet for a solution to his health issue and Ivan lives in the US and posted a video of his mechanical hand on YouTube.  The internet brought them together and for almost a year, the two have been engaged in an online collaboration to equip Richard with a prosthetic hand.  You can read about their story here Coming up Shorthanded.  
4. John Wilbanks (US)@23andme - John is a genome adventurer, his work on Pooling our Medical Data includes accessing his genome through 23 and Me and publishing it online to learn even more through international genome researchers and analysts.
5. Brian Goldman, MD (Canada) @cbcwhitecoat – ER doctor and host of CBC Radios White Coat Black Art.  His weekly show provides an important perspective of the healthcare system in Canada.
6. Berci Meski, MD (Hungary) @Berci – Medical doctor with PhD in genomics, his tweets are always informative and forward thinking with an eye on how technology can advance medicine.
7. Andrew Spong (UK) @andrewspong – with a focus on health communications Andrew circulates a wealth of information on patient-centred care.

There are many more inspirational people out there working to improve access to personal health information.  The movement is growing in strength, what will 2013 bring? 

All the best for a happy, healthy year. 

Fainting Goat