Hans Oh's eHealth Blog

Site Maintenance & Upgrades

2007-10-31T14:56:00.001-04:00

Sorry for not posting lately, but I’ve been busy working to secure some post-PhD opportunities and it’s been taking up most of my time. Nothing to share just yet, but it’s been hectic.

I will be changing hosting companies in the immediate future and plan to change blogging platform. For those interested, I’m currently using Blogger, but have decided to switch to Wordpress. The actual transfer should only take a day or two, but I’ll be spending the next little while verifying links and making sure everything gets transferred correctly. In my past experiences of changing software platforms, the process can be quite tiresome.

My apologies for any inconveniences, but I hope to be up and running soon. My timeline to have everything completed is mid-November.

Hans.

ehealth election madness

2007-09-26T22:37:00.001-04:00

Here in Ontario, we’re in the midst of a provincial election. Voting day is October 10, 2007 and I suspect that the level of attacks will increase as voting day approaches.

I’m not writing about political parties, but I am somewhat surprised with some of the debate regarding ehealth. The former government (Ontario Liberal Party led by Dalton McGuinty) has an election promise regarding the development of electronic health records and other health care related issues in their platform piece titled “Power to Patients”.

Create an electronic health record by 2015 and give Ontarians control over the information contained in it

What was interesting, however, was the response by one of the parties titled “Dalton McGuinty’s three ‘e’ approach to e-health”. They criticize McGuinty’s e-health strategy for being evasive, expensive, and election oriented for promising an electronic health record by 2015.

In all honesty, I’m not sure that I can disagree with any of the statements made in the press piece. On the other hand, having been on the “inside” during my brief stint on the Ontario Hospital eHealth Council, I know that things aren’t as easy as they appear. 2015 is far enough away that achieving a working electronic health record should be achievable. People compare Ontario’s progress with Alberta’s, but we have to understand that Alberta is unique (I briefly explained some of that in a previous post).

In any case, what was interesting is that when I searched the other major political parties’ websites, I couldn’t find any mention of a strategy or promise regarding e-health or electronic health records. Yup, the incumbent government hasn’t been perfect, but it would seem that they at least have a plan for e-health in Ontario, which seems more than what the other candidates seem to have. But then again, this could all be hype because of the election.

Upcoming: The World of Health IT conference & exhibition (Oct. 22-25, 2007)

2007-08-31T14:07:00.000-04:00

Scheduled for October 22–25, 2007 in Vienna, Austria, The World of Health IT Conference & Exhibition looks like it will be a big event.

The goal of the conference is to “bring the key stakeholders in healthcare delivery through technology together for the first time”. Many of the keynote speakers are either national or international directors of health systems. I suspect that there will be some very interesting sessions with plenty of networking. For anyone interested in the macro-level of health care delivery, this conference looks like a must-attend event.

Podcasting in healthcare - 2007 update

2007-08-30T12:45:00.001-04:00

As some of my readers might remember, I ran a series of posts on examining the potential role of podcasting in healthcare. At the time, I wasn’t too keen on podcasting in healthcare:

In my first post, Podcasting in Healthcare: Is there a future?, I discussed some of the challenges and potential uses of podcasting. My first thought was that podcasting would fill some need, but wouldn’t become overly popular because you have to listen to the episode, much like listening to the radio.
Shortly after, I did a quick scan of the available podcasts on Apple’s iTunes media software, titled “Podcasting in Health – A look at Apple iTunes v4.9 for health podcats”. At the time, there were very few podcats available.
A year later, I did a follow-up titled “Podcasting in Healthcare – Revisited 2006”. My thoughts hadn’t changed much, but there were some great comments that made me re-consider some of my positions.

Recently, I came across a post titled “Will Podcasting Survive?” on a blog that I follow (Read/WriteWeb). In this article, the author, Alex Iskold, examines podcasting as the evolution of radio. Even though the technologies available to create and distribute podcasts are more widely available than ever, this medium of podcasts seems to have stagnated. He presents some data/graphs to highlight and support the idea that podcasting is stagnating. He gives four main reasons for this trend:

Competition with video and blogs
Limited applicability
Monetization is a challenge
Competition from big media

He concludes with:

It appears that podcasts are not picking up steam, and rather, podcasting is actually slowing down. There is not enough incentive for people to jump exclusively into podcasting because of tight competition from video, blogs, big media and a lack of clear monetization methods. However, it does not mean that podcasts are not here to stay.

Iskold’s conclusions seem to support my thoughts about podcasting in health care, albeit his conclusions are a bit more general in nature. Specifically, podcasts are “something you need to specifically listen to. They typically consist of a discussion you need to be able to focus on to follow”, making podcasts much like listening to a lecture. For some, it will be great, but for others (the vast majority, in my opinion), podcasts will not have much value, other than to be another resource that can be accessed.

Well, a year has passed, and I ran an update using Apple’s iTunes media software (v7.3.2.6) and was surprised at some of the results.

Table 1: Podcasts by topic using Apple’s iTunes on Aug. 30, 2007 (1200 EST) from Canada

Topic/ Keyword	2006	2007	Notes
health	105	150	Mostly health and fitness offerings and a few educational offerings. E-health Insider has a podcast.
medicine	105	150	Seems like a hodge-podge of podcasts focusing on specific conditions. From the descriptions, I get a sense that these are styled like "talk-shows" or something like the CNN offering "Your Health with Dr. Sanjay Gupta" (he has a podcast available from the CNN's health page)
healthcare	84	141	A wide variety of topics covering improvement, education, self-help, and business. An interesting podcast by CDW talks about technology/IT management issues in healthcare.
doctor	105	150	Not really health focused, as the search returns anything using "doctor" in its name.
e-health/ehealth	1	6	Some very focused and interesting offerings including conference proceedings, e-health insider podcasts, an Australian industry publication podcast, and an individual podcast focusing on issues for Latin Americans.
telemedicine	1	3	Recordings from symposia.
telehealth	0	1	Weekly podcast from Canadian Society of Telehealth
informatics	5	139	Wow - what a surprise! I haven't had a chance to go through everything, but there seems to be quite a range of podcasts here ranging from comedy, education, careers, and topical listings
cancer	105	147	A good variety of podcasts, mostly related to education and self-help with a few personal accounts of living with cancer. I was a bit surprised by the small increase in numbers, as I expected this section to grow much more than the other topics.
patient	105	150	Again, a wide variety of topics focusing on self-help, education, and general health.
cardiovascular	20	39	Some very focused topics.

I was very much surprised by the significant jump in informatics and the few new ehealth podcasts. I didn’t expect those numbers at all. My expectation was to see more health topics (i.e., health, ancer or cardiovascular), when in fact there wasn’t quite as many - granted 40–50% increases are significant.

Given Iskold’s comments about the slowing trend of podcasting and increasing video content, I wonder if video will supplant podcasting in healthcare. Granted, there may be considerably more podcast offerings on the Internet that are not hooked-up with Apple’s iTunes software.

In my own personal experience, I stopped listening to podcasts on a regular basis. I can’t say exactly why I stopped. All I know is that I didn’t find listening to podcasts to neither particularly enjoyable (even for purely entertainment podcasts) nor efficient. I was always irritated at the slow pace of the discussion, or irritated at the difficulty in jumping to the topic of interest. In the end, I decided to stop altogether.

Now coming to a theatre near you: Capital Health is recruiting...

2007-08-26T19:03:00.000-04:00

I don’t know about you, but I generally don’t like to watch advertisements, especially the 10–20 minutes of paid advertisements just before the start of show at the movie theatre. Normally I pay little attention to the ads, but I almost fell out of my seat when I saw a recruiting ad for Capital Health, “one of the largest integrated health regions in Canada” (it’s located in Edmonton, Alberta). I don’t know about you, but I don’t expect to see recruiting ads for “health care careers” when watching the late showing of actions movies like “The Bourne Ultimatum”.

I was curious about the ad, and so I did a quick check of the Careers & Training section of the Capital Health site. For those interested, there are some interesting postings ranging from clinical, corporate, and even academic/research.

Upcoming: Consumer Health Informatics Conference (Oct. 30, 2007)

2007-08-24T08:11:00.000-04:00

For those interested in empowering consumers and patients, there’s an interesting upcoming conference: Consumer Health Inforamtics Conference. The goal of the conference is:

to focus on the technical, social, ethical and professional issues arising from consumer empowerment using information technology.

The conference is a one-day (Tuesday Oct. 30, 2007) event held at Ottawa’s National Arts Centre. The program seems very interesting and based on my knowledge of the speakers, should be a thought-provoking and challenge filled day.

A prescription for Google Health?

2007-08-21T14:39:00.001-04:00

About a year ago, Google indicated that “health care information matters”, with little to report since then. Google seemed to have formed a health board comprised of physicians and some patients to guide its efforts. Recently, I’ve read a few pieces speculating about Google’s efforts toward building a health care product/service (here and here).

In 2005, I had an idea for how Google could potentially disrupt health care. I even shared it with my supervisor, who thought it was an interesting idea and mentioned he would mention it during a meeting he had set-up with some senior execs at Google. Unfortunately, the meeting never took place, and I sort of forgot about it because of my studies.

My idea was that Google develop a personal health record using basic Web2.0 technologies already in its portfolio. Google has several services that could potentially be re-organized into a functional health information product:

Gmail & Google Talk - for communicating between health professionals and patients

Google Calendar – for scheduling

Blogger - to allow patients to record notes about daily activities, responses to medications, etc.

Google Video/YouTube & Picasa – for capturing images (e.g., wounds) and sharing video (e.g., teaching)

Search – the obvious one for searching for health information on the web or within the health product itself

Orkut – a social networking service that could be used to develop family trees, geneologies, and identify possible shared common environmental and/or hereditary factors

Google Office – could be modified to allow for recording and tracking of prescribed medications (using the spreadsheet application)

This idea of Google developing a consumer oriented electronic health record was based on the theory of disruptive innovations described by Clayton Christensen.

Currently, efforts are underway to develop electronic health records (EHRs) by governments, regional authorities, hospitals, health information companies, and pretty much everyone else in health care. EHRs have been somewhat of a “holy grail” in the health informatics community since the 1970s, promising an assortment of benefits. Currently, there is no standard EHR product available, and so vendors have been pitching integrated solutions for the last little while. In recent years, hospitals (at least in Canada) have been examining the possibility of assembling EHRs based on “best of breed” technologies - basically taking one component from company A and another component from company B etc. With more governments getting involved in setting an agenda for ehealth/eletronic health records, the vendors seem to be more open towards adopting standards for sharing information between systems and with other organizations (a push for a more regionalized model). Needless to say, these efforts are quite costly in terms of purchasing hardware, building-up an infrastructure, training, and licensing costs. Physicians and other smaller medical groups have been largely left alone to purchase products from vendors - which isn’t necessarily a bad thing.

So where does Google fit in? Well, Google could release a “free to use” personal electronic health record – here are some reported “screen shots” of the would-be Google product (looks like my suggestion might be pretty close). How would it work?

For patients
This product would be a central place that a patient could record and store health information. Information could be found on the web and then recorded for future reference (search). Patients could record some thoughts and questions about the information they found (blog or docs). Alternatively, patients could keep a “health diary” recording responses to medications, daily activities, food eaten, difficulties with activities, etc (blog). Some specialists have mentioned that patients don’t remember enough detail about past events to be helpful when first noticing symptoms, leading to delays in diagnosis/treatment and additional tests. Basically, all of the functions of a personal health record freely available to patients. The “home page” (or “about page”) could list pertinant information (age, existing conditions, allergies, etc). Basically, the patient version is an easy way for patients to view their own information, add additional information, and link to family members (social networking), and share with health professionals.

For providers
While patients can create large quantities of data (usually in text format), this isn’t so great for busy health professionals. Health professionals could be provided a “dashboard” that summarizes the information contained in electronic health record – things like charting medications taken with responses. Obviously some development of appropriate applications would need to take place. Ideally, lab data could be either imported or linked to provide a full picture of the patient. The best thing would be for Google to pitch this type of service to small physician offices who don’t have the expertise to set-up and maintain their own systems. All a physician would need is an internet connection and a few computer terminals. Scheduling could be handled either by the patient using the calendar service and monitored by some administrative staff. No more lost charts!

But wait…
Some will mention that this Google health product will not be “good enough” to meet everyone’s needs. You’re right. But it doesn’t need to be. Google can simply release this product and develop it by adding new features and functions along the way and go “up-market” (following the classic disruptive innovation curve). Of course, Google would need to insure security and privacy and be cognizant of any reglations and laws.

Others might point out that the existing vendors will not sit still. True, but most vendors are interested in making money, and thus they focus on selling to hospitals, HMOs, or other health care groups. Patients aren’t a lucrative market (yet). Vendors might release a product aimed at patients, but that’s more to ensure that hospitals will keep buying their products. Google has an inherent cost advantage here because its services are free to the users because it’s paid for (presumably) by advertisements. Google stays happy because it maintains its user base, and thus increasing its potential ad revenue. At first, the product might not have all the features, but new ones can be added quickly by opening up APIs so that developers can add new features, putting pressure on existing vendors to provide services at Google’s price points and pace (yikes – how do you compete against free?).

Another potential snag is that hospitals and lab companies will not want to share their data with Google. Yeah, that’s true. But, as more standards emerge and governments push for sharing of information, getting other players involved (like Google, Microsoft, or another firm) should be easier. It’s not a question of whether existing players want to, but more a question of when will they be forced to start sharing information.

As Christensen predicts, we’ll soon enter a stage of “commoditization and modularization” where standards allow for components to be swapped interchangeably (we may be closer than we think). If that’s the case, then vendors will need to switch their efforts at providing integrated products to focusing on specialized components like decision support modules, data visualization, or other applications that can “plug” into a larger framework.

I’m interested to see just what Google has up it’s sleeves. The idea that I’ve just described would also follow in Google’s current practice of releasing “beta” products, getting feedback and gaining market share, and then monetizing the product with new releases (see their history with their office products). In one scenario, Google could provide a suite of EHR products for physician offices for free, or with some basic support for an annual cost, slowly moving up the value chain. It’s unlikely that large hospital corporations will ditch the investments they’ve made in the near future. Besides, large corporations have much more demanding needs that Google probably can’t match initially. But, things may change. If enough patients start using Google’s services for Health, maybe there could be a radical shift in power from the health professionals to patients.

I don’t know about you, but I’m very curious to see what Google releases.

Nintendo Wii: A glimpse into the future of health promotion?

2007-07-11T20:05:00.000-04:00

I’ve been very impressed with the Nintendo Wii. The game system is simple to use and very fun. Even though I have a Sony Playstation 2, I hardly ever play it any more. When I do try to play it, I find the games to be far too complicated to play (especially trying to learn the complex controls for sports games). Personally, I think Nintendo has a great business plan that is taking advantage of the theory of disruptive innovations as described by Clayton Christensen.

Basically, Nintendo is expanding the market of game players and not competing for the same “hard-core” gamers that Sony and Microsoft target. Instead, Nintendo focuses on fun, easy to learn games that seem more family and group oriented. Okay, the graphics aren’t great, but after playing a Nintendo Wii, all I remember was how fun it was.

Nintendo just announced a new fitness product called the “Wii Fit”: it consists of “a flat, board-like object that rests on the floor and is touch-sensitive” (article via Arstechnica). The purpose is to use the game system to get into shape by engaging in fitness activities like yoga, aerobics, and other activities that get your heart pumping. With obesity a public health risk, maybe this product can get kids more physically active.

In the past, I wrote about how video games may be a disruptive force in health care. Maybe health promotion initiatives need to get more creative in trying to get the message out. I think the industry is doing its part, especially with groups like the Serious Games Initiative. I wonder if Nintendo’s new product(s) is just the beginning of a new type of gaming experience. After playing the Wii, I can understand how being active can make the gaming experience more enjoyable and interactive. Nintendo just seems to be more blatant about the health aspects.

JMIR a top health services and informatics journal

2007-06-23T19:52:00.001-04:00

For those interested in publishing their work, you should consider the Journal of Medical Internet Research (JMIR). JMIR is now the #2 medical informatics journal based on the ISI/SCI impact factor ratings, with a rating of 2.9. The “impact factor rating” is a statistical measure of how frequently articles from a specific journal are referenced by other articles. The thinking is that “better” articles will be referenced more frequently. You can read more about this announcement here.

The Imposter Phenomenon

2007-06-23T19:47:00.001-04:00

I attended a fascinating presentation earlier this week. The presentation was about the “imposter phenomenon” by Diane Zorn (PhD candidate at York University).

The Imposter Phenomenon is when high achievers (e.g., graduate students, professors, lawyers, physicians, etc) are “plagued by the fear that they are not as capable or intelligent as others think they are, that they cannot keep repeating their sucesses, and that they will reventually be found out as frauds”, despite outstanding accomplishments and frequent praise.

What I found most interesting was that this phenomenon isn’t so much an individual’s fault (according to Diane Zorn), but the result of environmental and cultural forces. In graduate school, the university culture fosters unhealthy lifestyles and often unwittingly promotes this imposter phenomenon. Diane Zorn presented data that showed how working to get a PhD is detrimental to your health: loss of hobbies, isolationism, decreased and dysfunctional communication skills, high incidence of depression, high stress, and so on.

One interesting finding was about Harvard. Apparently, Diane gets very positive feedback whenever she runs a seminar/workshop on this topic at universities and companies across North American and Europe. Audience members seem to share about their own insecurities and generally support Diane’s thinking about the imposter phenomenon. The one time she presented at Harvard, she got a completely different response - basically they disagreed with her. When she asked the Harvard audience about their response, they basically said “We’re at Harvard. Why would we feel that way”. As Diane said, Harvard looks like a perfect opportunity for a case study.

Could ehealth raise public awareness of clinical conditions?

2007-06-13T11:02:00.001-04:00

I came accross an interesting article published in BMC Medicine titled “Do citizens have minimum medical knowledge? A survey”. The authors found a “consistent and dramatic lack of knowledge in the general public about the typical signs and risk factors of relevant clinical conditions”. What surprised me was that this finding seemed to apply to those with and without medical backgrounds. Okay, granted the study was conducted in Switzerland and the authors only investigated a few conditions (COPD/heart disease and HIV/AIDS), but I think that this finding could probably be replicated. Here are two examples from my family’s recent history:

A few years back, our family didn’t realize that our grandmother had a stroke. She complained of a headache and that she “wasn’t feeling well” and had trouble seeing. We noticed that she slept a bit more than usual, but figured it was because she was a) older (almost 90 years), b) wasn’t feeling well on the account of a flu or cold (it was in the winter), and c) her cataracts was getting worse. One day, she got out of bed and walked into a wall and fell because her left side felt weak. She wasn’t feeling well and so we took her to see our family physician. After some tests were run, he said that she experienced a minor stroke but that there was nothing we could do now. He said that if we had brought her in sooner, we could have done something to help her.

Looking back, our entire family felt quite guilty. We could have helped her more, but didn’t. But, was there anything that we could have done? I mean, her symptoms were so generic and could describe a flue or cold. She seemed okay – just a bit tired. We didn’t notice anything until she actually fell, as she was quite independent until then. Our physician said that in the elderly a prolonged “headache” was a warning signal since our grandmother had high-blood pressure. How come no-one told us that?

The second example is with my father. He’s usually up quite early, but one day he woke up late and seemed somewhat disoriented. He was up late the night before. That morning, he seemed to have trouble articulating words. I only noticed because he was supposed to drive me to the commuter train. He didn’t seem in any shape to drive so my sister ended-up driving me. I mentioned this to my supervisor (Alex Jadad - a physician) and he said that I should take my dad to the hospital immediately. Apparently, his symptoms suggested something called TIA or “Transient Ischemic Attack” – it’s like a temporary stroke. Again, there’s no way I would have even considered his condition serious.

Anyway, I’m wondering if greater and more widespread use of the Internet for health purposes could increase awareness of symptoms of clinical conditions. I’m involved in the health care system and am well educated and yet had no clue what to look for. If educated medical folks like paramedics have difficulty, what chance to non-medical folk have?

There are probably two things that need to be done: better education of medical conditions and better use of technology.

What if mobile phone developers or even telecommunications companies provided some services that really could be helpful? For example, could some sort of software be developed where the primary user inputs some basic data (age, sex, existing conditions) and then ever so often, you get a text message asking you a few questions about your health or some health promotion note? I know this is somewhat “pie-in-the-sky” thinking, but we should see how we can use commonly available tools to really help people. Maybe it could be targetted – like having patients who have heart disease get these messages reminding them about warning signs or to monitor certain physiological measures. It’s a thought.

I would probably argue that the greatest challenge, with or without technology, will be to get the attention of regular people (like me) to know when something is potentially dangerous or not. We probably won’t get there until we start wearing bio-medical devices like a “shirt”. Even then we probably couldn’t monitor everything.

Patients want more performance information available online. Where do we go from here?

2007-06-12T11:42:00.001-04:00

Came across an interesting little blurb reporting on a survey. In the the survey conducted in the UK, nearly 80% of patients want “more information on how their NHS hospital performs available on the internet”. Nothing too shocking, right?

My first thought was to question whether or not this matters. From my personal experience working in the health care system, I’ve heard that some patients don’t really want to know. They may want to know if their providers are doing a great job (i.e., excellent or above average), but if access to physicians or services is very limited, patients (at least anecdotally) don’t want to know – care, however “below average” it may be, is still better than no care at all. As I continued to read the report, I thought this finding was particularly interesting:

Of those surveyed, 38% said they would use it to challenge or seek reassurance from their doctor, whilst only a minority (around 16%) would use it to choose or change their provider

Aha – just as I thought. People just want to know they aren’t receiving sub-standard care.

Just some other thoughts that I have about making comparative performance data available to the public:

There needs to be some better efforts in helping the public understand and make sense of the data that’s available. In Ontario, hospital performance is reported annually (OHA/Ministry of Health Hospital Report). I helped compile some data for a hospital a few years back for the initial report and I don’t think that the actual reporting and knowledge translation has gotten much better. Leafing through some of these reports is a challenge as you are just bombarded with numbers, tables, and figures.

A senior executive that I used to work for once told me that comparative performance data is mostly for marketing purposes (both internal and external). If you get excellent results, you promote the heck out of it and market yourself as a leader, hopefully being rewarded with either extra funding from the government or attracting more donations to your foundation. If your results aren’t so great (or “below average”), then you use it to kick-start some new internal “improvement” program while asking for more $$. “Well, we didn’t perform as well as we could because of financial constraints and challenges…”.

Now, what does “below average” or “above average” really mean? I suppose from research perspective, it’s like asking for the difference between statistical significance and clinical significance. When I take a look at some figures (Example: 2006 Acute Care report), I’d be hard-pressed to tell you what the difference on some of these tables. On page 50 looking at the table reporting adverse events for community hospitals, we see that Rouge Valley Hospital (Scarborough) was identified as “above average” while Sault Area Hospital (Sault Ste. Mary) was only “average” for the rate of Nurse Sensitive Medical Adverse Events. When we look at the actual numbers, Rouge Valley is 0.3 while the Sault Area hospital is 0.4 (note, I couldn’t even find what the denominator is (I think it’s a percentage, but I can’t be sure). In the case of a below average, Ross Memorial Hospital is 2.6 which seems quite a bit off from the other two I mentioned. But in reality, what does this mean to a patient?

Hey, I don’t want to give the wrong impression. I think it’s great that this type of information is becoming easier to access. I think it’s great that hospital executives are starting to examine performance (which I hope is a good proxy for the hard to define term “quality of care”). I think it’s great that patients and the public are starting to become more interested in the type and quality of care they are receiving. My question is “what is the next step”? Patients asked for performance data. The health system has responded. What is the response? Do we ask for more? Do we demand changes? Do we just say “thanks” and go on our way because my health provider is doing okay? Was this a make-work exercise if we don’t act on it? Where do we go from here?

I don’t have the answers but I’m hoping that as a group, we can figure something out.

In the news...Tuesday March 27, 2007

2007-03-27T09:53:00.001-04:00

I keep getting the feeling that we, here in Canada, are in a state of transition. There seems to be an undercurrent of dissatisfaction, unrest, and even some urgency. I don’t think I can point to any one particular event or thing as a definitive “sign”, but I get a sense that change is imminent.

Last night, Quebec held a provincial election and the results were noteworthy. We have a minority government in Quebec, the first in over 125 years. What was interesting was how an “upstart” political party (Action Democratique du Quebec or “ADQ” for short) created by a 36 yr. old managed to win 41 of 125 possible seats. While the Liberals will form the minority government, I think the traditional political parties should be worried. Is this a sign that people want change, or are they simply upset with the status quo? Needless to say, the political landscape in Quebec is changing.

Related to politics, the Ontario Medical Association is moving forward with their “Campaign for Healthier Care” and announced their six principles of healthier care (read document here). The six principles are: 1) Keep patients front and centre; 2) Focus on the future; 3) Be specific; 4) Think investment, not cost; 5) Apply what we know faster; and 6) Start now. Honestly, I’m not sure what I think about these six ideas. I’ll think about them and share my thoughts in a future post.

On a somewhat non-sequitur note, I’m somewhat astounded (and not necessarily in a positive way) that the general public is now expected to pay to hear senior government officials and other experts report on the progress of government initiatives. I received an email “invitation” to attend a healthcare roundtable titled “Wait Time Strategy: Is the strategy working?”. I checked out the web-site to learn more about the event and register, but was (perhaps naively) shocked to find out that I had to fork over $95 to attend this event. Okay, this specific event may be facilitated by a private organization (Direct Engagement Inc.) so in that regard, I can understand the profit motivation. But, since when (and why) are the governments abdicating its responsibilities to provide access to information and to report on its activities? Am I completely naive about this? In a few years, will we need to play $5 to speak to our Member of Parliament? Or, perhaps in a way to raise more funds for healthcare, we will need to pay $50 to view the contents of our health record and another $250 to get a copy of it. Perhaps in some crazy way, election campaigns will become television shows funded by advertisements available only on pay-per-view stations. If these speakers are being paid to attend, then shouldn’t there be at least some other forums and opportunities to facilitate public discourse? Neil Postman’s writings seem particularly prescient in light of these occurrences.

Telehealth Ontario: Is it doing more harm than good?

2007-01-17T17:07:00.001-05:00

A while back, I wrote about my experience using the Telehealth Ontario service. In my particular case, my experience was satisfactory.

As I understand things, Telehealth Ontario is meant to be a service that “can help you decide whether to care for yourself, make an appointment with your doctor, go to a clinic, contact a community service or go to a hospital emergency room”. Basically, the service is meant to advise people on whether they should wait to see their physician or go to the local emergency department (ED/ER). I think the rationale is to decrease the number of inappropriate visits to the ED/ER and (hopefully) decrease costs.

So far so good, right? Since I posted my experience, I’ve received several comments on the service both in support of and against the service (see the comments section at the bottom of the post). I’ve been mostly non-judgmental about the service so far, but a recent comment has made me wonder. “Dazed” shares his recent experience:

Disastrous.

We have a 6 week old daughter. Last night she was crying in a higher pitch than normal, and had not urinated in about 6 hours. My wife asked me to call telehealth for the first time. The "nurse" who answered started with questions about my daughter who essentially stopped crying about a minute into the call. She asked a question, I would give an answer and she would ask again. It became pretty apparent to myself my daughter was ok as she really didn't have any symptoms. However the nurse kept asking similar questions. She then asked how often my daughter was feeding and I replied every hour or two. The nurse then about 5 times said every few minutes is too much. She wouldn't listen to me. Eventually I grew frustrated and basically let her answer her own questions. Eventually she came to the conclusion my daughter was dehydrated. (Even after I had explained she had fed normally and had a dr. checkup 3 days previous and my daughter had been putting on weight very well). The nurse came back and said that I needed to get her to a hospital. I was a bit exhausted of her and frankly my daughter seemed ok just a bit cranky. To get off the call I finally said I would take her to an emergency centre.

This is where it gets bad. The phone rang about 3 minutes later, my wife answered and the nurse asked if we were taking my daughter to the hospital. We had spoken after I got off the phone, and we felt she was ok but would watch her. My wife said no to the nurse. The nurse immediately started asking about the welfare of the child, and why we were not going if I had said I was going to emergency. This went on for about 5 minutes when my wife, again to get off the call said we would visit a hospital.

My daughter calmed down, had a wet diaper and a stool movement and fell asleep.

2 hours later at 12:30 in the morning we get a call from CHILD SERVICES stating they had been contacted from Telehealth nurses and were fearful for my daughters safety. That we needed to report to an emergency room immediately and have a hospital official contact Child services that we had indeed arrived. We argued slightly but really just wanted this nightmare to go away. We asked for the nurses names and headed to the emergency room. Upon arrival we explained ourselves to the triage nurse who upon examing our daughter said this is a waste of time, that our daughter was fine, she said we seem like nice people and she called the Child services number. At first nobody answered. We had to wait 30 minutes (In the emergency room of a large Toronto hospital with a 6 week old infant-germs apparently had not entered the telehealth's nurses thoughts) for a child care rep to call back. The triage nurse said "what is telehealth doing, this child does not need to be here." The child services basically said the nurse at telehealth said the baby was in danger. The triage nurse said we were free to go, that if we wanted to we could see a doctor but it wasn't necessary. By this time feeling we were awful parents, we stayed for 2 hours waiting to see a doctor just to be sure. By this time we scared to take off my daughter diaper, just to "prove" she had now urinated, nothing seemed wrong. The doctor finally arrived, we explained our evening. He laughed and said telehealth and child services do this alot. He inspectect my daughter for 30 seconds, my daughter urinated on the examination table. The doctor appologized for us having to come in and said my daughter was fine.

So it ends. No today child services calls and say that they have to come with a nurse to inspect our home and give our daughter an examination. They said they can only come during working hours. Now I need to miss work. They have to have someone inspect my home. I am sure this is recorded by either health canada or the provincial government. I believe our family doctor needs to be contacted.

Obviously I have contacted an attorney, and have been advised to have someone in the house with us when the inspection takes place.

Could anyone help me in the sense that has anyone else gone through something like this. It is humiliating. If anything we are new parents, likely overly cautious, phoned telehealth for information and an opinion. Because of a 5 minute telephone call, poorly asked questions and not listening to answers, it has turned into a weeklong and now possibly litigious affair.

I will NEVER consider calling again. And by the way most nurses and doctors in emergency centres I have spoken with today, Telehealth is a massive burden on emergency rooms, doing the exact opposite of what it was attended for.

Do I have legal recourse?

All I can say is “wow”. I don’t know what exactly happened, but this recount sounds quite crazy. What exactly is Telehealth Ontario’s boundaries, responsibilities, and/or expectations? From the few accounts I’ve read, Telehealth Ontario seems to provide limited value as a service – it works for some, but may be a burden to others (like the ER docs or the family in the quotation above).

In all fairness to those who work at Telehealth Ontario, they probably don’t have the freedom to use their own judgment and determine which cases don’t need to be followed-up or not. I suspect that staff are required to follow some sort of script and aren’t allowed to deviate from the script for fear of litigation and other liabilities.

Regarding Dazed’s case, I don’t know if this incident is an exceptional case where the “system” seemingly has broken down somehow, or whether this example is Telehealth Ontario “in action”. I’m not blaming the Telehealth Ontario staff - they have guidelines to follow and are doing their job. The issue is that when we build a system with inflexible rules, there are no opportunities for common sense and good judgment to be applied.

As for specific advice for Dazed, I’m not really sure what to say. The hassles that you will most likely go through are really unfortunate. Your idea to have an attorney present is probably prudent just in case something really goes awry. If things don’t get resolved to your satisfaction, I’d probably recommend making some noise by trying to reach someone at the Telehealth Ontario offices, then contact either your local politician (both Provincial and Federal), and perhaps even contacting a reporter to see if they can help in some fashion – if not for yourself, then to prevent this type of incident from happening again. Other than that, I really don’t know what else to suggest.

To close this post, I’m not passing judgment on the telehealth service. I believe that the concept of a “free, confidential telephone service you can call to get health advice or general health information from a Registered Nurse” is an excellent one. My experience as an evaluator has taught me that much of the challenges lie in the implementation of the idea. Another item that is somewhat concerning would be the complains and comments from health care providers. Something needs to be done to address these concerns to make the service better. My question still remains: is Telehealth Ontario doing more harm than good? If we don’t know the answer, then maybe we need to find out.

Technical difficulties

2007-01-10T12:37:00.001-05:00

Happy 2007 everyone. I know I haven’t written in a while, but I’ve been busy with my dissertation.

I was doing some server maintenance (mostly back-ups and cleaning up some files) and I seem to be experiencing some technical difficulties with the blog. My apologies to anyone who is looking for older articles/posts and can’t get to them. Hopefully this issue will be resolved shortly.

Hans.

OHA Conference 2006

2006-11-06T19:47:00.000-05:00

I'm attending the OHA annual convention (www.ohahealthachieve.com) until Wednesday November 8th, 2006.

I can't speak for everyone else, but the OHA convention is an event that I look forward to attending each year, as there's much to learn from all of the different presentorss and vendor exhibits. I'll be writing up a summary of each day's events shortly.

EHR use in the United States

2006-10-17T09:14:00.000-04:00

Health Affairs has an interesting article titled "How common are electronic health records in the United States? A summary of the evidence". The authors reviewed the literature to try and determine the availability of and use of electronic health records (EHRs).

The short answer to the authors' question is: not very much. A reported 24% of physicians and 5% of hospitals have EHRs of some sort. Actually using the EHRs for clinical care (e.g., prescriptions or decision support) is another matter entirely. Personally, I was very surprised by the numbers, expecting hospitals to use electronic systems more than physicians. Maybe I've been exposed to the Canadian (well, mostly Ontario) environment too much, and in particular the hospital sector.

One thing I liked about this article was how the authors tried to break down the data into different areas: in-patient, out-patient, physician and safety-net providers (Who are these people? Are they paramedics and the sort?).

Looks like there's still plenty of work to be done still before EHRs become the norm.

Another tablet device for healthcare

2006-09-29T10:09:00.000-04:00

Intel recently announced a new "mobile computing platform for health care professionals", dubbed the mobile clinical assistant. I used to be a big fan of tablet-style computers for health care use, but recently, I'm not so sure that this form factor works (at least in hospital environments). I think the technology itself is great, but there's just something that doesn't seem to work. Read more about the mobile clinical assistant here.

At last year's OHA convention, I saw a few interesting products from Motion Computing. I wasn't able to test out the devices for any period of time, but I think they may be on to something. I'll try and post a profile and (preliminary) some thoughts of the products.

Learning from the past and living with legacy systems

2006-09-10T20:51:00.000-04:00

Over the past eight years that I’ve been in the “real world”, I’ve had opportunities to work at various parts of the health care system from promoting healthy behaviours to children of family violence, preparing a small community hospital implement a new electronic records system, developing a quality improvement program and conducting business process re-engineering projects at a large teaching hospital, to examining national, system-level issues at Health Canada.  Through-out my experiences, one thing that I’ve heard over and over is that using new electronic systems is not possible (or at least extremely difficult) because the health care system is saddled with limitations from existing (or legacy) systems.  The basic argument is that we need to leverage past investments that have been made (be it in information technology or otherwise), or else we are throwing away precious (and mostly tax-payer funded) resources.

In the past, I’ve never really subscribed to this reasoning, mostly because we see that companies and organizations in other industries (at times) move to another system by gutting their existing system.  Yes, these transfers and transitions can prove painful and often disastrous.  But, I suspect that if the need was significant, these companies would switch.  The health care system response has been that other industries have “more money and expertise” available to them.  Okay, on some level I agree.

But, at what point do we say that we need to make a “clean break” from supporting legacy systems and all of the limitations that we may inherit.  On some level, this issue is similar to what Microsoft faces when the company works on producing a newer version of its operating system (Vista).  The current project is late, millions of dollars over-budget, and much stripped down that originally intended (ouch!).  One of the criticisms of Microsoft’s current move is that the company continues to support and utilize many design features elements from past versions of windows (Windows95, Windows98, WindowsNT, and WindowsXP).  Previous versions of the operating system were designed, developed, and deployed in a much different “world” than exists today.  As such, Microsoft’s developers have had to make concessions to accommodate past decisions and design elements while trying to meet the demands of the present.  A hospital, for example, probably has to make a similar decision:  at what point does the existing information system hinder our current and future ability to move forward and make progress?  I’m sure the decision is not an easy one to make as the ramifications are likely to cost in the millions and affect the organization and partner groups for years to come.

Getting back to my original idea, I was reminded of this exact issue recently, albeit in a much smaller way.  For this blog, I’m currently using Google’s Blogger service.  I can’t really complain about Blogger as it provides a good package of services.  But, as I continue to blog, I realize that there are some additional features that I would like that aren’t available.  So, I’ve been checking out Wordpress’s services (both free [wordpress.com] and paid [wordpress.org]).  There are some features that I really like from Wordpress.  But, I have concerns about the challenges of migrating this blog to the new service, not to mention the potential broken links for people who have linked to my posts.  What I find particularly fascinating is how this particular issue relates to my research.  I am interested in evaluation theory and how evaluation may be (or may not be) conducted in health care in regards to ehealth innovations.  How do people conduct evaluations?  Are they structured?  Based on theory?  Based on some model?  What information is needed?  How do we get the information that we need?  How do we know that we have collected the right information?  Have we asked everyone who needs to be asked?  And so forth…

Perhaps I’ve been a bit rash in the past in not believing CIOs and other management types for being hesitant to switch to new systems.  As we move increasingly towards more ehealth solutions, what impact with changing systems have on patients and the individual users?  Will patients be saddled with deciding which system to maintain a copy of their own health information?  Will patients have any say as to what system(s) their health care provider organizations choose?  In my particular case, I’m finding that free services available on the Internet are great, but I need just a bit more than what is currently available.  But, having my own domain isn’t all that it’s cracked up to be.  Yes, I have complete freedom to set-up web services (as available by my hosting package), but I find that being saddled with the technical responsibilities of setting-up, maintaining, and testing new features isn’t all that fun for a non-technical person (as compared with a web developer or site administrator).  If I may be so bold, my strength is in creating and synthesizing new content, rather than focusing on the technical aspects of creating a web site.  Yes, I don’t mind the odd tinkering with web protocols to learn (that’s my curiosity), but I don’t have the time, patience, or training to set something up at the professional level.  Maybe that’s where the real issue is – finding a way of managing the intersection between the technical issues/requirements and the service/content providers.

For now, I’m still collecting information and trying to come to a conclusion about my blog.  I’m tempted to try using some of the evaluation theories/models that I’ve come across to see how they stack-up in helping decision makers come to a conclusion on whether to continue to use or to switch.  I would be more than happy to entertain any suggestions.  Basically, I like Wordpress’s capabilities in terms of categorizing and organizing posts and comments, providing (simple) file/picture hosting for posts, as well as providing options on providing permanent links to a post.  Blogger has some features that are not available in the free version of Wordpress (domain mapping/hosting, modification of your template.  More to come…

Should patients be worried about the security of their health information?

2006-08-30T17:26:00.000-04:00

Should people be worried about the security of their health information?  In the past, I used to believe that perhaps the issues of security and privacy (an issue that is related to but NOT identical to security) were overblown.  I would go so far as to suggest that those with vested interests used these two issues to maintain control and prevent sharing of information (that was the cynic in me).  Around the same time, I also held a similar idea that patients didn’t really concern themselves with privacy so much.  Most patients assume that health providers share information as needed and that explicit consent to share information between providers was the strangest (if not the dumbest) thing.  I also believed that health care organizations seemed relatively secure, based on the measures they take which include triple identity verification and limiting remote access.

Today, I’m not so sure if I feel as confident about the security of my health information.  Recently, a family member of mine was almost a victim of fraud (a stranger tried to withdraw a few thousand dollars from a personal account).  This incident is my personal connection with the issue of security.  The news has some more spectacular reports about security of health information:  a stolen laptop with data on 28,000 home care patients and a hospital firm is robbed of 10 computers.  To make matters worse, a survey finds that the majority of IT professionals don’t “feel confident they can prevent data breaches” (you can view the full report here).  Whoa – if IT professionals don’t feel that they have the necessary resources, are we waiting for a catastrophe?  Unfortunately, the survey doesn’t break down the results based on industry.  As a result, we don’t know if health care is any better (or worse) than the rest.

I’m not trying to sound like I’m paranoid or some cynic about ehealth and maintaining electronic records of our information.  I actually believe that we need to make more of our health information available in electronic format.  But, we need to be more vigilant about securing our health information.  For example, maybe IT professionals should draft some guidelines (if not rules) on how to dispose of technology, be it CDs/DVDs, hard-disks, or whatever else may contain health information.  As we slowly move away from paper, we will need to be more careful about how to dispose of old storage media.  For example, patients, in particular, should take care to learn how to dispose of their computers.

So, should you be worried about the security of your health information?  I would say “yes” only so that we don’t become lazy in protecting our information.  As individuals, some simple precautions could include:

Shred paper records – use a shredding device to dispose of paper based records (i.e., health information, bills, and any other information with your identity on it). I would recommend a shredder that cuts in “diamond” shaped patterns. I find that the “strip” method is easier to re-assemble paper records. A friend of mine goes so far as to throw out shredded documents over the course of several weeks (handfuls at a time in different bags containing “wet” materials from the kitchen).

Do not give out personal information over the phone: Unless you’re absolutely sure about the identity of the person on the other line, don’t give out personal information. In fact, if someone calls and asks for your information for “verification” purposes, ask them to tell you what they have. If it’s incorrect, call them back using the official number provided by the company. I’ve had to teach my parents not to give out their information over the phone (they’re a bit too trusting). Now, when they get a call from a credit card company or some other institution, they listen to what the person has to say and hang-up. They call the company back in five minutes and provide any information (if necessary). I’m sure if this method is not fool-proof, but it’s better than giving out your information willy-nilly.

Use pseudonyms on the Internet: I would suggest you create some fake online identity and use it for registering on websites. Try not to use websites that keep your credit care “on file” for your convenience.

Ask your health care provider about their security measures: I think we all need to keep our health care providers (be it your physician or your hospital) accountable about keeping our health information secure. Health care providers are busy and often over-worked and usually don’t have excess time to think about things other than taking care of people. As patients, we need to keep reminding them to remain vigilant. We, as patients, also need to help our health care providers too.

I’m pretty much out of ideas as to what else to do to help keep your health information safe. As individuals, we have to put a great deal of trust in the institutions that store and collect our health information. After the terrorist attack on September 11th, 2001, the American government told its citizens that everyone has to play a part in keeping one another safe. Sounds like good advice.

Disruptive Technologies in Health Care: A summary

2006-08-21T18:38:00.000-04:00

My apologies for not getting to this post sooner, but this past year has been ... eventful. Here is my list of disruptive technologies that could be used in to improve and change health care. I have included links to the entries highlighting each technology - no need to rehash what's already been written.

Disruptive technology #1:  Video games
http://www.blog.hansoh.com/2005/05/disruptive-technology-1-video-games.html

Disruptive technology #2:  Mobile devices
http://www.blog.hansoh.com/2005/05/disruptive-technology-2-ipods.html

Disruptive technology #3:  The digital home
http://www.blog.hansoh.com/2005/05/disruptive-technology-3-digital-home.html

Disruptive technology #4:  Ebay, auctions, and markets
http://www.blog.hansoh.com/2005/05/disruptive-technology-4-ebay-auctions.html

Disruptive technology #5:  Patient Reports
http://www.blog.hansoh.com/2005/06/disruptive-technology-5-patient.html

Disruptive technology #6:  Wearable technologies
http://www.blog.hansoh.com/2005/06/disruptive-technology-6-wearable.html

I thought about adding a few other technologies to this list, but decided otherwise.  I do, however, have a few “honourable” mentions that I want to highlight.

Peer-To-Peer (P2P) networking: Originally, I thought about distributed computing and possibly tapping into (then) popular file-sharing applications like Napster or Kazaa. But, as I continued to think about this technology, I couldn’t really think of any health care specific applications. In some way, applications like Skype could bring cheap voice over IP (VOIP) services by utilizing all the computers being deployed by health care institutions. But, is this “application” disruptive? Perhaps a very useful application of P2P networking may be the emergence of “grid computing” in health care. Maybe we can begin to harness computer power to address some of the very complex and processor intensive modeling of proteins or gene sequencing.

Quantum/Nano computing: If the quantum computer gets developed, I think there will be an overall change in society’s ability to do things with a computer, not just in health care. Unfortunately, this technology is still too far removed from any real world application, stuck in the development stage. But, imagine the possibilities with almost limitless computing power…some of those disruptive technologies I highlighted would sure be taken to another level.

Radio Frequency Identification (RFID): RFID is supposed to be the next big thing in business, particularly in asset management and inventory tracking. But, I’m not convinced that there will be such a large impact in health care. Already, we’re beginning to see simple RFID being extended to another level. HP announced the development of their “memory spot” technology. Just as well, I suppose that RFID and the subsequent developments will ultimately lead to the concept of ubiquitous computing.

This “runner-up” list and the highlighted disruptive technologies do have some very interesting possibilities for changing the health care system in many different ways. Ultimately, I believe that the most disruptive of all “technologies” will be the patient. Helping the patient is ultimately what this entire enterprise is about. And so, as long as the patient continues to challenge, to prod, to demand a better, more caring, and responsive system, the system will be forced to respond. These changes may take time and may not be right at first, but I’m confident that the changes will come. So, let’s keep empowering the patient!

I’d love to hear if anyone thinks that I have omitted any specific technologies or have included a technology that should not be included. I will try and revisit this topic in a year (or two) to see how my predictions have fared and whether and changes need to be made.

Upcoming Conference: Games for Health 2006 - Sept. 28-29, 2006

2006-08-15T13:30:00.000-04:00

Here's an announcement for an exciting upcoming conference: Games for Health 2006 Third Annual Conference Covering Intersection of Games, Health and Healthcare - September 28-29, 2006 - Baltimore.

Here's a description of the goal of the conference:

Summarizing the importance of the event, Ben Sawyer said, "Slowly but surely the last year has seen a growing appreciation for what modern day videogames can offer to healthcare. The combination of powerful technology, evolved interface design, and growing use among the next
wave of health care workers is creating a ripe environment for further growth in this field. What once seemed like an idea on the fringes is gaining impressive momentum and becoming a mainstream reality. Our goal each year with the Games for Health Conference is to move the space forward until the role games, game developers, and game technologies can play in something as critical as our own health is fully realized."

This conference does sound interesting and exciting. Almost a year ago, in a series on disruptive technologies in health care, I posted an entry (Disruptive Technology #1: Video Games) wondering what role video games could have in transforming and improving our health care system. Looks like some people in the US are already started.

In addition to content sessions, Games for Health 2006 features on-site demos of the latest efforts in the field, poster sessions, and important meet-up opportunities for researchers, assessment experts and various government and non-government health initiatives. Critical networking time is woven throughout the conference agenda, and the meeting features an evening reception sponsored by Virtual Heroes. "The Games for Health conference is designed to strengthen the intersection between health care and gaming. We’re excited to see more and more innovators from the health and gaming arenas working together to make a real impact on people's health everywhere,” said Ben Sawyer, co-founder of the Games for Health Project. The Games for Health Project is supported by the Robert Wood Johnson Foundation’s Pioneer Portfolio, which funds innovative projects that may stimulate breakthrough change in health and health care.

To PhD or not Phd?

2006-08-12T09:11:00.000-04:00

I’ve been asked on several occasions about studying ehealth/health informatics at the graduate level (i.e., masters or doctoral/PhD degrees). Some seem to be interested in advancing their own knowledge so that they can use their new found knowledge and skills to further their career in the workplace. For those interested in pursuing a doctoral degree (PhD), here’s a great resource that may help determine if the PhD/doctoral degree is right for you (http://www.cs.purdue.edu/homes/dec/essay.phd.html)

The information is provided by Purdue University and seems to be written with computer science students in mind, but the concepts seem applicable to other disciplines. Since I’m currently going through the PhD progress, I would have to say that this degree is not for everyone. You may have the skills and talent to complete the PhD, but all of the other aspects of the degree may not be a good “fit” for you. One thing that I’ve learned is that completing a PhD is like a marathon (not that I’ve ever run or completed one). The journey is quite lonely, as you only have yourself to get everything done. Basically, you have to love your topic so much that you are willing to forego other opportunities (a night out, vacations, relaxation, etc) so that you can work on your research. Usually, this means reading the latest journal articles, preparing a manuscript for publication, reviewing your data, or just thinking about your topic.

I’ve been thinking about a post about possible career options for those interested in ehealth/health informatics, so I’ll try and get something written up for the near future.

A look at the "dark side" of ehealth

2006-08-10T16:14:00.000-04:00

A look at the “dark side” of ehealth

In his book Amusing Ourselves to Death:  Public Discourse in the Age of Show Business,
Neil Postman writes about the unconscious effects of television in society.  He later generalizes that technologies inherently favour certain types of interaction, thinking, conceptualization, and communication.  For example, the written word (i.e., text) emphasizes rational, logical thought and expression, whereas multimedia (like television of the computer) utilizes and favours emotional responses visual stimulation.  These technologies (unconsciously) change how we interact with and conceptualize the world around us.  A good example is when movies switched from silent to spoken word pictures, or from black and white to colour.  For more on this topic, you can read the works of Marshall McLuhan.

So what does all of this have to do with ehealth?  As we move from the current versions of our health care system to one that is increasingly electronic, what types of changes can we expect to see?  Much has been written about all the potential positive effects of using ehealth, most notably making health care safer, more dynamic, and more cost-effective.  I do not doubt that some of these possibilities will be realized some time in the future.  But, what of the potential negative effects of ehealth?  Are we overlooking the “dark side” of ehealth?  (Note:  I’m going to focus on some of the systematic changes that we might see as Gunther Eysenbach has done some interesting work on the quality of health information and possible negative outcomes)

In the past, health care (or more aptly, medicine) has already seen a dramatic shift in the mid 1900’s.  Physicians were originally considered extended family members, making house calls and acting as healer, confidante, psychologist, and more.  With the advances in microbiology and emergence of science based medical programs like Johns Hopkins, community based practitioners were replaced by scientist-physicians who relied upon new scientific discoveries and now, the “best available evidence”.  Health care has seen a shift from individual to community based care.  In Canada, this shift has also been further institutionalized and cemented by the passing of legislative acts.  I’m not suggesting that these changes are bad.  I’m just recounting what has happened to try and see what might happen as we embark on the new ehealth world.

So, what’s in store for health care?  Here are some of thoughts on the potential dark side of “ehealth”:

Everything is electronic: Having your personal health information in an electronic format is very useful and beneficial. But, have you ever thought of the possible negative consequences? I’m not trying to sound alarmist, but let’s examine the possible scenarios. When everything is electronic, this information becomes available to anyone who can legally (or illegally) access it. The Veteran’s Affairs services had a laptop computer containing health information of 26.5 million patients stolen. Luckily the computer was recovered with no apparent information compromised. Does your local family practice have sufficient electronic security and privacy protection in place? Also, when everything is electronic, information (either correct or incorrect) can be spread across the “system” at an alarming rate. We learn from identity theft of credit fraud that having out-dated or incorrect information can be very problematic. Will health care be any different? I honestly don’t know.

Have you paid your electricity bill? As we move towards everything ehealth, are we setting ourselves up for a calamity? Electricity is something that we all need. If the power black-out of 2002 didn’t remind us, we should take note of what technology firms are doing because of the rising cost of electricity. Google and Yahoo are building server farms in rural areas to get access to electricity and purchasing lower powered equipment. What are our health care organizations and providers doing to ensure there will be electricity during times of crisis? I know that hospitals have gas generators to provide electricity, but petroleum is also becoming very expensive too. If our electrical systems were to go down, how will we get to the data when physical storage (i.e., paper) is no longer maintained? It’s just a thought.

Me, myself, and I: One of the assumptions with ehealth is that individuals will become “consumers” of health care, thus becoming more responsible over the management of their own health. I’m not opposed to this change as individuals should take care of themselves. But, aren’t we making a big assumption that people want this responsibility? This change means individuals will need to become more responsible over their own health information (e.g., who has access to it, where it is stored, etc.) and coordinating their care. If individuals are to maintain their own personal health records, what technical skills and resources do they need to be able to do this? In the past two weeks, I’ve had two computers die on me – recovering my information was a pain in the ass, but I was able to recover my data. If this happened to my parents when I wasn’t around, they’d be lost. Will individuals (or practitioners) be up to the task?

The disappearance of the family physician?: Okay, this one’s probably what I’m most interested in. As individuals become more involved and active in their own care, will we see the loss of general practitioners and family physicians? One of the advantages of ehealth is purportedly being able to access services irrespective of geography. In other areas of society, we have seen technology cut out the “middle-men”, allowing the individual to interact directly with the producers of the goods. Does this mean that we will see individual patients contacting specialists directly? Recently, my uncle had a need to see a specialist. Unfortunately, the specialist was only able to see him 6-8 months in the future. So, I asked around to see if some of my physician friends could help my uncle. They were. Unfortunately, my uncle’s family physician decided not to forward a referral and so my uncle couldn’t see the specialist a colleague suggested (even though he could be seen in a week or two). Will patients decide to skip seeing a family physician and go straight to the specialist?

Health care’s “last mile”: Because health care must be delivered by a person (at least until we develop electronic delivery systems), we still have to deal with what I will call “health care’s last mile”. In the telecommunications industry, the “last mile” is what they call the effort required to get the new technology to the consumer’s home (e.g., high-speed internet). Someone has to go and physically connect and configure connections (depending on the technology). In health care, people are needed to deliver care. Combined with the disappearance of the family physician, will we see our health care evolve into groups of specialists (who diagnose and consult) and nurses (who follow-up on the instructions at the local level)? We see this type of phenomenon occurring in business circles – the “bar-bell” effect. The “middle layers” of organizations are thinned out so that you are left with highly skilled executives overseeing a vast army of workers with very few middle-level managers. Maybe that’s why I don’t see overseas outsourcing as a viable option in healthcare. But, with more electronic resources being developed, what will the role of the family physician be? Nurses, of various qualifications, will likely be around to provide home care services, work in hospitals, and generally deliver care that individual patients cannot.

I’m not suggesting that we revert back to the “good ol’ days” of paper. But, I think we need to examine some of the potential changes that may occur. It’s this idea of informed consent (i.e., being aware of and understanding the potential risks and benefits). Do we really know what will happen as we move towards a completely ehealth system? Have we even thought about this issue? Or are we so enthralled by the new technologies, moving pictures, and sounds that we forget about what the consequences might be? After looking at some of these potential negative aspects/scenarios, I’m still a supporter of ehealth. I just think we need to start thinking more about what we want the technology to do for us, and to accept potential side-effects after some thought, rather than reacting to changes in a haphazard fashion.

One last thought to end this post. Noted futurist, Alvin Toffler, predicted that advanced technological societies will need to deal with something called massification and demassification – I’ll call it the paradox of the individualized groups. Are we going to see a fragmentation of the health care system because of our increased ability to access information and services irrespective of geography?

Author’s Notes:

I wrote this post using the new plug-in for Microsoft Word. Not sure that I like it, but I’ll give it a few more tries. On the plus, I can write a post without being connected to the Internet with all of the features of Word (I’m not sure if that’s a benefit, but it seems like an advantage over typing in a browser window on Blogger).

Sorry for not writing posts over this past summer, but I’ve been going through a series of minor health issues that have kept me from doing pretty much anything. As I get over one thing, another issue seems to pop up. Added to all of this fun was the fact that both my laptop and desktop died on me within a span of two weeks. Data recovery and trying to set-up a computer is not fun.

I have a few other posts planned, so be on the look-out. I’m hoping to write about open source in health care, a summary of my disruptive innovations in health care, and a few others.

Podcasting in Healthcare - Revisited 2006

2006-05-15T08:11:00.000-04:00

Almost a year ago, I posted an entry on the topic of podcasting in health care (Podcasting in Healthcare - Is there a future?) and then followed it up with a quick search of podcasts available on Apple's iTunes music store (Podcasting in Health - A look at Apple iTunes v4.9 for health podcasts). I have been surprised by the level of interest in this topic. Maybe it's time to revisit the topic now that a year has passed.

A recent survey suggested that "the iPod (and similar portable devices) has become a pop culture phenomenon, rapidly becoming a dynamic force in the way that music (and other content) is being purchased and consumed" (from iPodobserver article: Survey Finds: 'Podcasting is emerging as a viable content medium'). While not conclusive, these results could be interpreted as a shift in the way in which people access content. I'll concede that the availability of podcasts is making content more "portable" and convenient to access. But, I really question the notion that *everyone* is hip to this idea. I can't seem to find the article, but I recall reading about only a portion of society even being aware of the term "podcast". On the other hand, media types must be drooling at characteristics of podcast listeners: influential, educated, and mobile (article can be found here). These listeners probably have higher socio-economic status (i.e., have more money) and disposable income. In any case, I agree that podcasting is here to stay - maybe not in its current format, but in concept.

Okay, so let's take a look at what's available on the iTunes Music store (you need to access the store using Apple's freely available iTunes software) . Today is May 15, 2006 and I just ran a search of podcasts using a variety of different just like last year. Here are the results:

Keywords	Hits
Health	105
Medicine	105
Healthcare	84
Doctor	105
E-health/ehealth	1
Telemedicine	1
Telehealth	0
Informatics	5
Cancer	105
Patient	105
Cardiovascular	20

The number of podcasts (podcasts are usually a series of "episodes") is up since last year. For "health", "medicine", and "healthcare", there was considerable overlap between the three searches (sorry, but I didn't look any deeper into this). For the "doctor" search, a considerable number (almost half) were NOT health related - I suspect that the term "doctor" is now starting to be usurped by other fields (mostly as in someone who can fix something). The 105 entries for "cancer" and "patient" also showed some overlap. What is going on with the ehealth/health informatics people? Only two new podcasts in a year?

I was surprised that the vast majority of podcasts seem to be produced by and directed at health care professionals. The most common type of podcast seemed to be lectures or other similar educational vehicles. When I think about the topic some more, maybe these results shouldn't be too surprising. Organizations would have the infrastructure to support on-going podcasts - although Apple's work is making it easier for individuals to publish their own content.

Okay, so have my views and opinions on podcasting in healthcare changed since last year? Perhaps a little bit. I still believe that there is a role for podcasting, mostly in terms of education and knowledge translation activities. But, I still think the focus is still too health professional centric. Someone made a comment that patients would be interested in listening to health professionals explain and "educate" on a variety of health topics. I can see this happening, but from the podcasts that I was able to view quickly and/or listen, most of the podcasts seem to be direct recordings of lectures or rounds or something else. I wasn't able to identify any content that was specifically designed as a podcast that took advantage of the characteristics of the Internet. We still seem to be using podcasts as a substitute for a tape or CD.

I'll be honest. I'm somewhat biased against podcasts. Over the past year, I have tried to listen to a variety of podcasts (entertainment, golf, health, etc) totalling almost 10. My experience has been ... mixed. I'm very appreciative that the podcasts are available on the Internet (well - mostly via iTunes) so that I can catch-up on missed information (for example a lecture or other public speaking event). I also like that I can listen to the podcast at my convenience, mostly at a time of my choosing, but also in a location of my choosing because of MP3 players and portable computers. But, while listening to the podcasts, I found myself distracted and wishing that the pace would quicken (probably because I prefer reading to listening). Even when I tried to stay focused to listening to the podcast, I just felt weird sitting in front of the computer and just "listening" withough doing anything else. In many ways, I felt like I was listening to the radio. Who just sits and listens to the radio. Radio seems to have become background noise of the 21st century and helping to set a "mood". Some colleagues of mine rave about podcasts because they say listening passes the time during their commute to and from work. I can see how a podcast would be very convenient here. As you can see, my experience is mixed.

So, what does the future hold for podcasting in healthcare? I'm not sure. Some will probably think podcasting is wonderful because it frees them from having to read or allows them to make use of travelling time to learn something new. Others may find podcasting less efficient and convenient than reading because (at this point in time) searching and scanning audio is not as efficient as with text. Like I commented last year, podcasting in healthcare probably has a role, but will not be for everyone. I'm curious to see if things change in a year.