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Wikis and eHealth May 30, 2005

Posted by Hans in : analysis, opinion , 2comments

I read this interesting article on Time.com describing the “wiki” phenomenon, titled “It’s a Wiki, Wiki World“. Could this wiki be a glimpse of the future eHealth/health care world?

My personal experiences with wikis have been via wikipedia.org and from an experimental (well, I call it experimental, but “development” may be a better term) wiki here at the Centre for Global eHealth Innovation. Honestly, when I first used the wiki at the Centre, I didn’t really know how it should be used, probably because most of my work was independent at the time. I can see how groups of people can quickly develop an advanced body of knowledge - as seen by wikipedia.org.

Could wikis be the future of health education? We already know that patients are becoming more proactive in their care and taking more ownership over decision making. I suspect that the existing newsgroups and on-line discussion forums form the basis of what we would call a “wiki”. These forums have information on treatment, symptom management, and information about living with conditions. If we were to distill this information, separating out the encouragement and other information, we’d probably have very specific information that could be used by other patients in a very accessible and patient-centered format.

I just think that wikis provide a means to concentrate and collect little bits of disparate information. In health care, we know that there is knowledge separated throughout the system, within people and with no systematic means of sharing it. Maybe wikis can provide a means of capturing and sharing information between patients, between providers, and between managers of the health system.

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Disruptive Technology #4: Ebay, auctions, and markets May 30, 2005

Posted by Hans in : analysis, opinion , 1 comment so far

I’ve noticed that “markets” have not been discussed as contributing to or (at the very least) affecting health care and eHealth. Perhaps this is because I am in a Canadian context where anything that remotely challenges the tenets of the Health Care Act are pooh-poohed and dismissed as being somehow “un-Canadian” or ideological. For today’s profile, I will focus on the disruptive technology that I call “markets, auctions, and eBay”.

Whether people like it or not, economic markets have a role to play. We accept them in almost every aspect of life except for health care. I’m not suggesting that we replace the centralized, publicly operated existing systems with privatized systems. But, I think that we need to begin to realize that markets and online auctions will play a role in the future of eHealth and health care. Initially, I suspect that physical goods will be bought and sold, but it will not take long for services to traded.

In Canada, we have a collection of provincial health systems that essentially pay for (but do not operate) health services. Recently, home care services were opened up to a competitive bidding process, under the guise of providing quality at a reasonable price. If we are out-sourcing and auctioning off services in home care, why can’t other aspects of care be auctioned through eBay?
In some sense, this type of behaviour already exists - we just don’t really seem to mind it. All you need to do is look at the selling of naming rights for new wings, clinical research chairs, and whatever else people are willing to get named.

From a patient’s perspective, why would they want to go on the Internet and bid for services? Well, quite simply, it comes down to a matter of choice and vulnerability. When faced with a desperate situation (i.e., a terminal disease or waiting for some certainty), people will generally do whatever they can to resolve the situation. In Canada, our system is grappling with the idea of rationalized care, which has resulted in (arguably) long wait times for services. If financially able, why wouldn’t a patient go on the Internet and acquire a diagnostic test, second opinion, or even treatment over the Internet or through some competitive bidding process. In this interconnected, global economy why can’t health professionals in other countries compete with local providers for services? Remember that in this emerging ehealth world, distance and place are not supposed to be barriers.

Again, I’m not suggesting we replace our systems with market-driven systems. I’m just hoping to open up the discussion and discourse on something that will have an impact on existing systems, whether we want it to happen or not. My sneaking suspicion will be that markets and for lack of a better term “eBay” services will first hit the area of scheduling in two ways.

First, I can imagine how health professionals may wish to differentiate themselves with other professionals by offering different time schedules, essentially creating a “market” for patients. Who wants to wait months for Doctor A if I can go next week to see Doctor B after hours?

Second, I suspect that patients may start bidding for more convenient and/or earlier time slots for access to diagnostic testing services (like the MRI), to see famous specialists, or even treatment options. This type of behaviour would probably happen unofficially where patients would contact patients with earlier and more “desirable” time slots and pay to either switch or give up their appointment.

Another likely scenario would be for governments to auction off patient care to private care providers, regional groups, or even hospitals. The government (or insurance company) would set a maximum rate and volume of services needed (e.g., dialysis or outpatient surgeries) and open it up to competition for the contract. I recall how in Alberta the government went to private care providers to treat patients so that wait times could be decreased (it was cataract surgery and hip replacements I think). The government paid the same rate as it was paying public hospitals.

Markets and eBay are likely to affect health care in the future. Who knows, we may end-up shopping for a doctor’s appointment online and bidding for services.

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Disruptive Technology #3: The digital home May 28, 2005

Posted by Hans in : analysis, opinion , 2comments

While we’re loathe to admit it, the digital home will likely alter the face of health care/ehealth in ways that we can only begin to imagine. The “digital home” is the technology that I will discuss in this post.

In Canada, health care interactions have traditionally been conducted in either a hospital or a physician’s office. While the “place” of health care is not likely to change too much in the near future, we must recognize that there is a growing push toward outpatient and community/home based services, mostly for economic reasons. Now, with information and communications technologies becoming more sophisticated, we are fast approaching a time when the home may be the dominant place of health care.

In previous posts, I have profiled video games and mobile devices as potentially being disruptive technologies. The home, with all of the convergence of technologies, is likely to be a disruptive technology - not as a singular technology, but as a package of technologies.

I think that many people (innocently) believe that health care the in future will similar to how it is today with the exception of a greater proportion of home and community based services. But, the thinking is that “home care” will be similar to how it is delivered today. I think that this line of thinking is completely wrong. At this year’s e-Health 2005 conference, we heard Dr. Louise Liang talk about how Kaiser-Permanente is moving towards a model of the “home as hub”, where the home is the primary place where health care takes place. This new thinking will likely have radical affects on how health care services are organized, delivered, and even accessed.

I’m not exactly sure how this will all turn out, but think about some of the technologies converging in the home that can have some affect:

We also have access to an advanced courier/delivery system that could be used to deliver services, diagnostic tests, and other things that are not required immediately. One of my committee members, Peter Coyte, argues that the only rational explanation for the existence of hospitals is an economic one - “economies of scale”. He argues that almost all of the things that happen in an institution like a hospital can take place in the home. Currently, it’s just more convenient to have most things concentrated in a hospital, but with advances in technology, this economic argument may soon break down.

Imagine being able to consult via the web with your physician for follow-ups and diagnoses, while a home care provider visits every so often to check-up on you. A courier service could delivery any needed supplies and pick-up any bio-matter for testing. High-definition media could be used in real time (or not) to communicate with specialists in different time zones around the world. If a surgery or procedure is required, a physician can schedule to drop by and perform minor procedures in the comfort of your own home.

I’m not saying that the digital home will mean the end of the hospital, but I think that the convergence of technologies in the home will affect health care/eHealth in significant ways. I may be totally off the mark - maybe health care professionals will turn their own homes into miniature clinics and perform procedures, linked-up with and supported by regional “hubs” that we currently call “hospitals”.

“Home as the hub” may have greater meaning in just a few years. The digital home will be more than just an entertainment nirvana. We just have to figure out what it will mean for health care.

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Disruptive Technology #2: iPods, handhelds, and mobile devices oh my! May 24, 2005

Posted by Hans in : analysis, opinion , 1 comment so far

In 2004, we saw the rise of the iPod digital music player (well, at least here in North America). The iPod was the must have device. I talk about the iPod because it is just the most recent iteration of another disruptive technology: handheld or mobile devices.

Handheld devices first caught on with the marketing of the “Palm Pilot”. This device was marketed as a “personal digital assistant” or “PDA” and was originally a great success. But, an electronic organizer can only do so much. Even as device manufacturers released more sophisticated versions, cynics predicted the demise of the handheld. I would argue that the PDA is dead, but that the “handheld” device will be the next thing that really shakes health care and eHealth.

The original handheld devices were unsophisticated. I think most people can accept the limitations of such a device. But, what people have really wanted is connectivity - to the Internet, to online resources, or the corporate information systems. So, with wireless connections and convergence with cellular technologies, handhelds are making a comeback as “smart-phones”. Research In Motion’s Blackberry is now the #1 selling handheld device. Blackberry and similar devices are starting to provide the type of functionality that health care professionals actually need.

I started this post by talking about the iPod because I think this device represents a different type of future. With devices starting to have memory to store large quantities of data, we will start to see a different health care environment. We’re going to see patients start recording data continuously from wherever they are. Mobile devices will likely become “interface” devices that allow health professionals to connect with health information systems, patients to record and retrieve data (or carry their personal health information), and biomedical devices to transmit data to handheld computers to be transmitted to another repository.

In two previous posts, I wrote about how sales of handheld computers are increasing (read it here), and also that health care professionals (i.e., physicians) are starting to use handhelds (read it here). I’m not suggesting that handhelds are for everyone or for everything. But, with the miniaturization of technology, there is going to be a great change in how we interact with one another and the health care system. With millions of these devices out there, and more and more people with mobile, wireless phones there is a great opportunity for something to happen (either good or bad - hopefully good).

We humans like to use our hands, and the handheld device seems to have the right form factor. Laptop computers are too clunky to carry around. Desktop computers are fixed to one location. Wearable computers may provide another future direction. For now, handheld computers seem to be the way to go.

Stay tuned for another post on my personal predictions on disruptive technologies in health care/eHealth. I have another four or five to go.

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Disruptive technology #1: Video games

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Disruptive technology #1: Video games May 19, 2005

Posted by Hans in : analysis, opinion , 4comments

In light of the recent announcements at this year’s Electronic Entertainment Expo (E3), I will start by profiling my first prediction for a disruptive technology: video games.

The video game industry has exploded from being entertainment for children to a $11 billion industry in the United States alone! What may surprise even more is that 50% of all Americans play video games, and the average age video-game players is 30 years (source: Entertainment Software Association). Believe me - they are in a living room near you! There are at least 120 million units out there already, and 2006 looks like it will be a blitz for new games and systems.
This past week, three new console systems were announced.

Microsoft announced its Xbox 360 slated for release during Christmas 2005.

Sony revealed the Playstation 3, scheduled for mid 2006.
Nintendo announced its latest system, called “Revolution”.

I haven’t even discussed portable/mobile game systems like Nintendo’s Gameboy family, Sony’s recent Playstation Portable (PSP), or Nokia’s game playing mobile phones.

What is quite remarkable is that video game systems are no longer units to play only games - they are slowly becoming media centres able to play and record music and videos.

I think that video games have the potential to change radically how people interact with the health care system. Honestly, I don’t really know how, but I think that video games will be very important in the future, moreso than we can imagine. I was surprised to learn that there is a professional video-game player circuit/league/tour. Top tier players earn in excess of $100,000 a year.

In terms of specific applications to health care, some early applications could include:

The above are only a few possible avenues that I think video games can take. By no means are these final. But, I’m pretty sure that video games have great potential to affect health care in the future. Who knows, maybe surgeries will look more like video games. The surgeon may use a controller to manipulate miniature robots complete the “mission” of healing the body.

Stay tuned for my next prediction on disruptive technologies.

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Long live the handheld! May 17, 2005

Posted by Hans in : analysis, news , 1 comment so far

It would seem that the “death of the handheld computer” is somewhat premature. An article in yesterday’s Globe & Mail reports how “smart phones” are being pushed by telecom companies and hardware manufacturers alike as the convergence device of the future.

I would agree that the original “personal digital assistant” (PDA) didn’t stand a chance - think “palm pilot” and how that company is in financial trouble. Basically, a small portable computer like that wasn’t really functional because it wasn’t powerful enough to do the things you want to do on your computer and had no “connectivity” to the Internet or other resources. But, I think the handheld form factor is here to stay.

I’m working on a series of postings outlining my personal predictions on disruptive technologies. I’ll write more about handhelds in a few days when I profile a new technology each day.

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Health care leads in wireless adoption May 16, 2005

Posted by Hans in : analysis, news , 1 comment so far

Now here’s an absolute surprise: health care is a leader in adopting wireless technology! Computerworld.com’s special report on “Mobile & Wireless” has an in-depth article on the use of wireless technology in health care.

The article presents findings of a survey by market research firm IDC conducted in 2004. IDC found that “more than 80% of 34 health care organizations polled said they have deployed wireless LANs or plan to deploy one in the next 12 months”. This result confirms the Healthcare Information and Management Systems Society (HIMSS) 2005 Leadership Survey result that 79% of 253 health care executives planned to use wireless information systems in the upcoming year.

The rest of the article discusses some of the applications that are utilizing the new wireless connectivity. Handheld computer use by physicians seem to top the list.

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"Open source" for the masses? A report on open source May 16, 2005

Posted by Hans in : analysis, research , 1 comment so far

Here’s an online resource that I forgot to write about. This report is titled “Wide Open: Open source methods and their future potential“. It’s freely available in electronic format.

I haven’t read the entire report in detail, but here’s the gist. The authors believe that “open source” methods, which have been successful in the software domain, can be applied to other disciplines, domains, and areas. Open source brings “principles and working methods which can help to produce better knowledge, goods or services, or make them available on more widely beneficial terms”. Sounds good, but I think the authors are coming from a biased perspective. By “biased”, I mean that they aren’t convinced of open source and don’t really understand it.

Basically, the authors suggest that the “peer review” process and collaborative model is somehow unique to open source (it isn’t). Eric Raymond refers to the “gift culture” in his book The Cathedral & the Bazaar (Paperback). Put it this way: the authors think that working together is some sort of novel approach only found in open source.

I don’t think the report presents any new information in and of itself. If you’re looking for a good read on open source, I’d suggest Raymond’s book (see above). But, if you’re looking for a reference to cite in a report or paper, this report may be something useful.

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eHealth and rural communities: Can eHealth keep hospitals from closing? May 12, 2005

Posted by Hans in : analysis, news, opinion , 1 comment so far

We keep talking about how eHealth will bring about benefits to the health care system by making it more efficient and effective, but I wonder if there isn’t a significant western, urban “group think”, or even myopic view at play here. In my (limited) dealings with health care issues concerning northern and rural parts of Canada, I have realized that the issues challenging rural areas are very different than those faced by large urban centres.

An article in today’s CBC reports of the impending closure of a small community hospital because it is losing six of its seven physicians. In an attempt to lure and keep physicians, the community offers physicians salaries of $300,000 (and more) to come and work in a small northern, rural community of about 10,000.

With the E-Health 2005 conference (arguably Canada’s pre-eminent forum for eHealth and health informatics) being completed last week, I wonder what types of solutions the delegates and presenters could suggest to this small community. I doubt that discussions and urges to adopt an electronic health record would be of much use to this community.

Question: how can eHealth benefit northern, rural, and remote communities? I met someone from the University of Guelph’s Rural Health Studies Program (Ms. Linda Mayhew) who was interested in this question. We had a very short discussion, but some of the challenges she mentioned seem more “real” than what the large urban centres seem to face. How can technology be used in real ways to help maintain health care organizations faced with crippling shortages of professional care providers (i.e., physicians and nurses)?

On the other hand, I wonder if we are approaching the problem the wrong way. No doubt, northern communities face real and challenging problems of recruiting and keeping health care professionals in their communities. I would also argue that other issues like addressing access issues because of distance, securing adequate funding, and acquiring expertise need to become a priority for decision makers at the governmental level. But, what if we are ultimately fighting a no-win situation? I mean, if we look at Christensen’s thesis that disruptive technologies are all around us, could we look to another solution (not necessarily an information and communications technology-based solution) that could help address some of the problems? What about looking at system-level reform? What about accredit nurses to do more in the health system? If we are looking at innovative and novel solutions to address real problems, why are we limiting the discussion to just looking at computer technologies rather than really examining alternative structures and models?

I suppose we are all stuck in this group think that all powerful technologies will somehow solve all of our problems. Neil Postman’s predictions of societies held in awe of technology may be closer to the truth than we think. The technology is only a tool that we use to address challenges that we, humans, face. I think that if we approach the question in this way, we would look at eHealth as something that can augment our abilities rather than as some panacea for a broken system.

So, what role is the role that eHealth can play in addressing Geraldton hospital’s plight? I think we all need to think long and hard to come-up with solutions to answer this question. If we can answer this question, I think many other rural communities could be much better off for it.

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Changing and challenging futures for eHealth companies May 11, 2005

Posted by Hans in : analysis, news, opinion , add a comment

Two recent articles suggest that the times are a changin’ for software companies (and eHealth companies too). The two articles are:

The first article, in my opinion, is more telling of the impending changes. Let’s face it - software companies (and technology companies in general) have not had good records of success at providing products that are reliable and available in timely fashion. In particular, large scale IT projects are notorious for cost over-runs and coming in years after they are promised. The Chief Technology Officer at Kaiser Permanente was reported as saying “The quality I get from you people is abysmal.” This comment echoes that of Richard Granger from the NHS complaining that the products he was offered were basically crap. It’s not just in health care that the track record has been horrible. Just think about everyone’s favourite whipping boy - Microsoft’s Windows with it’s security breaches and unreliability. Other executives are expressing similar thoughts - software companies need to provide better products or face the consequences.

Additionally, I think there will be another pressure on traditional software companies providing services to health care organizations - the customers themselves. In the second article, we see an emerging pattern of organizations licensing out their own internal systems to smaller groups like physicians and clinics. What we are seeing is health care trying to leverage their own infrastructure by becoming application service providers or ASPs as the industry calls this practice of “renting out” software and services. With organizations as large as Kaiser Permanente (KP), is it only a matter of time before KP decides to stop buying “off the shelf” products and buy an entire software company itself? If so, it seems like only a simple step before it enters the foray as a commercial entity, selling it’s own version of hospital record services, clinical decision support services, and whatever else health care organizations may need.

I’m not sure what types of deals the NHS has signed with its vendor community, but once the EHR roll-out in the United Kingdom is done, could the NHS also try to leverage its learning and infrastructure to other jurisdictions and start selling services? I mean, in the technology industry there is a history of licensing of intellectual property as the different parts get rolled up into something an end-user can use (e.g., IP cores).

Whether or not hospitals, HMOs, or other groups start to compete with existing health technology vendors is not the point. Software and technology providers will need to vastly improve the quality of their products as well as the type of support they provide, or else they may face a greater and more angry client base. I don’t mean just the hospitals themselves, but the population in general as a whole. Health care seems to be just on the verge of becoming the most important issue on people’s minds. With that will come scrutiny and pressure.

To all the software companies out there - you have been warned. Hopefully the message at Software 2005 Conference did not fall on deaf ears.

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