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Interactions with the health care system – a visit to the doctor’s office March 17, 2010

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

I was doing some exercises Monday night and I tweaked my wrist during a moment when I lost my focus (and balance). After a night of discomfort and pain, I decided to try and see my doctor to rule out anything serious. I did some searching on the internet and found a good article titled “ulnar-sided wrist pain” which provided some very detailed information about the different types of pain in the wrist.

Scheduling the Appointment
I tried to schedule an appointment with my family doctor who is part of a group practice at the local medical centre. Unfortunately, when I tried calling in the morning, all of the lines were busy. It seems that every time I try to call the medical centre, the lines are always busy and that it’s practically impossible to schedule an appointment. Fortunately, the medical centre is only a few blocks away so I made the trek to make an appointment with the faint hope that they might be able to see me soon. No luck, but they could see me at 5pm later that day (Tuesday). Question – why does the receptionist have to ask what the problem is? Isn’t that something of a personal and private issue that should be discussed only with the patient and his health professional(s)?

Arriving and Waiting
Against my better judgement, I arrived at the medical centre 15 minutes early and checked in. There was the asking of for the health card and then I was asked to sit and wait. I ended-up waiting about 45 minutes before my name was called. I really didn’t notice the time passing as I brought some reading material (the December 2009 issue of Harvard Business Review spotlighting Innovation). I only thought about the time when I finished an article or when someone sitting next to me was called by the nurse.

Watching
Sitting in the waiting area, I tried to observe what was happening. Most of the patients looked bored as they sat and waited. The receptionists were busy chirping on their headsets and taking appointments or receiving newly arrived patients. I noted a clerk filing documents in the health records – she had a good sized stack of nearly 15 cm in height. Given how many pieces of documentation a medical centre receives, I can understand some of the frustration of trying to convert to an electronic system. There are just so many business processes that need to be synchronized in order to transition from paper given all of the potential inputs a patient’s record can have.

Seeing the Doctor
After walking into one of the exam rooms, the nurse asked me my name and then asked if I was seeing the doctor because of my wrist. She nodded and then asked me to take a seat: “the doctor will see you shortly” and then left the room, partially closing the door. After a few minutes, my family doctor walked in and asked me how I was doing. I told him that I hurt my wrist and wanted to make sure I didn’t do any serious harm. He asked me how I did it, examined my (right) wrist and compared it to the other, noting that there was some swelling and heat in the area. He poked and prodded different areas of my wrist and had me do some movements to test my range of motion. His diagnosis was that it was probably a sprain and indicated that wrist injuries are notoriously difficult to diagnose because of the complexity of the joint. He said there’s a small possibility of a fracture and ordered an x-ray. His final words were that if the pain persists after three weeks then I probably did something serious. Otherwise, I need to wait and see because the pain my “go away in a few days” or take weeks to months to heal.

Off to the Xray!
I walked over to the in-location x-ray service and presented the order to the clerk who was reading a book and looked very bored. After showing my health card, I was asked to wait for the technician. I heard a typewriter in the background as I waited. Once the technician called me, I was taken to the back and asked to deposit my things in a small cubicle before being led to the x-ray room. I had four shots taken of my wrist of different angles. Two of them had to be taken again as the film didn’t develop. As I waited for the x-rays to be processed, the developing machine looked like it was made in the 1970s. I also noticed a large plastic container with two different liquids. I forget the names of the two fluids, but they apparently need to be mixed. I got a chuckle from the hand-drawn line near the bottom with the word “refill”.

The technician gave me the processed x-rays and then I walked them back to my physician. He was with a patient so I waited just outside of the nurse’s station. The doctor walked out a minute later and we looked at the x-rays at the station. I know I couldn’t see any fractures, but I don’t really know how to spot a fracture. My doctor agreed that there was nothing wrong and sent me on my way as he moved to another exam room to see another patient.

Some Thoughts About My Visit
All in all, I was at the doctor’s office around 70 minutes and I interacted with my physician, a nurse, the receptionist, and the x-ray technicians for maybe 10 minutes total. As I examined how the very busy medical centre operated, I was trying to see if electronic solutions could make a significant impact on the practice. At first glance, I would have to say “no” as everything seems optimized to the physician’s needs – the nurse or office staff provide everything for the physician and patients are made to wait until the doctor is ready to see him/her.

From a cost perspective, would a computerized system (including electronic lab results and x-ray/diagnostic imaging) make much sense? I don’t know. The patient information is still stored via paper and much of it seems to be arriving from external sources. Notes are taken on paper and stored in the filing area which has very little physical cost compared with an electronic system which would have licensing fees, hardware, and electricity costs. Perhaps some of the clerks who do the filing could be let go or assigned different tasks. I can’t see much productivity gain in terms of having electronic imaging as the physician seems to be operating at near 100% utilization in terms of time.

What would make a big difference to a patient, however, would be an electronic scheduling system which could be accessed either by phone or on the Internet. But, I see this as being unlikely in the near future as the physician and the medical centre would lose power over its scheduling. Right now the receptionists act as the gate-keepers, restricting access to physicians.

I think the ‘last mile’ of physician offices is something that needs to be addressed as a great number of health care interactions take place there. Yet, I can understand why there is some reluctance to move toward electronic/computerized tools. The business case does not seem readily apparent. Some form of time-motion study using ethnographic methods and a formal business case should be conducted to take a look at this issue. Physicians are not the ones who are inconvenienced by paper based systems (as far as I can tell), especially if there is little information sharing outside of the physician’s office. I’m not blaming physicians at all – in fact, I think they get a bum rap sometimes because they are easy to pick on. Most of them are trying their best to navigate a system that is broken and doesn’t really support them to try and do more than operate their offices like a business. Physicians are people who have bills to pay and probably get frustrated too.

One final thought before I end this post (my wrist is starting to bother me now), with so many patients waiting to see the doctor, there has to be a way to make that time useful, either to the patient or some health care service. I was wondering if the medical centre could have a sign that indicated the approximate waiting time to be seen so that I could take a step outside or do something if the wait is 30 minutes or longer. Restaurants have the pager system that calls waiting patrons when their table becomes available. Couldn’t something similar be developed for physician offices? But why would the physicians care? They have people waiting regardless. Again, the challenge remains that patients are not at the centre of the system – the physicians are. Until we address this issue, then I can’t see meaningful changes occurring.

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Lessons from my father… January 10, 2009

Posted by Hans in : analysis, nature of ehealth , add a comment

My father’s most recent health experience and his visit to the ER has highlighted a few things about health and managing one’s care. Here are some things to take from my dad’s experience:

  1. eHealth Can Improve Coordination of Care: In this case, having a single care record could have prevented this mis-hap. Our family doc saw my dad somewhat regularly and was more aware of my dad’s progress. He made a recommendation, but this information wasn’t passed along to the specialist. Only after visiting the ER and a call from the ER doc did all of the docs get together to coordinate things.
  2. Being a Good Patient is More Than Following "Doctor’s Orders": My dad is great a following directions. Because of his diabetes, our family physician told him to start exercising and change his diet. The next day, he started walking and now he runs 5-10km each day and is very active. He also has changed how he eats and has essentially cut out refined sugars. Normally, most patients don’t follow instructions well (and thus the issue of patient compliance), but my dad did and improved markedly to the point where he doesn’t need medications because he can control his condition through lifestyle changes. But, simply following orders didn’t really help my dad. Which brings me to the next lesson…
  3. Patients Need to Take Ownership: My dad is great a following orders, but he is very passive. He doesn’t ask questions and doesn’t look to take initiative. Part of this may be that he doesn’t feel comfortable in this role. But as our health care system continues to evolve, a significant understanding is that patients will be more active in managing their care. As such, patients MUST take ownership over their care: ask questions, read and learn about your condition, collect and keep copies of your care record, know what your lab results are, etc.
  4. Not Everything Is Preventable: In my dad’s case, this point doesn’t really apply, but all of my health education and training remind me that when we deal with people (and their health), not everything is preventable. Medical science only knows so much and can only go so far. There are so many things going on that predicting how all of the interactions may turn out is nearly impossible: your genetic predisposition, environmental exposure,your personality, the food you eat/diet, the air, drugs/medications, daily cleaning and grooming products, EMFs from electronic devices – these all interact with one another and no-one really knows how. Even if you do everything *right*, you can’t prevent some things.

My dad is fine now, but his experience highlights some things that we all should be doing. Hopefully some of these lessons will help someone get better care and health.

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ehealth’s elusive return on investment September 2, 2008

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

Government Health IT published an interesting article titled, "The quest for value". The author, Nancy Ferris, reports on some of the challenges, difficulties, and frustrations with trying to demonstrate a return on investment (ROI) or tangible cost savings when using information technologies within health care settings.

My own research and experience in this area has me believe that the main assertion of the article is more or less true – that the link to tangible, measurable results (i.e., ROI) is difficult. I would add that the main reason for this difficulty is because there is no direct causal link between use of IT in health care and outcomes, or at the very least, the link is so weak, that other factors drown out the benefits. A report released by the EU (www.financing-ehealth.eu) titled "Conceptual framework, healthcare and eHealth investment context and challenges" presents some similar findings that the benefits are only realized in the future (see the latter parts of the report).

Personally, I think this concept of trying to identify a cost-savings or return on investment in health care is a bit absurd. Even in industry, trying to calculate return on investment regarding the use of IT is a challenge. I can’t remember the exact quotation, but a CEO of Fedex (or UPS) once indicated that even though they can’t completely identify the ROI of using IT, they said that they can’t NOT use IT and said that it’s just the cost of doing business.

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A new architecture for EHRs? February 5, 2008

Posted by Hans in : analysis , 4comments

Amidst the efforts to develop the elusive electronic health record (EHR) and to modernise our health care systems are many technical challenges that need to be addressed.  One significant challenge is integrating information from a variety of difference sources (i.e., lab systems, pharmacy systems, scheduling systems, directories, nursing and physician notes, etc) and to present this information in a coherent, user friendly fashion.  In the past, I’ve participated in some of the technical discussions regarding potential solutions and let me tell you that there are no easy solutions.  We’re talking about massive amounts of data needing to be transferred between different points.  Then we also need to talk about how to take this data and make the information accessible to the health care provider (and ultimately the patient) at the time and place needed.

From my understanding, much of this integration work has gone along the path of developing systems that function as "dashboards" by collecting and aggregating information from various sources.  I discussed this concept with Khaled El-Emam in the past and he indicated that database technology isn’t yet sophisticated enough to do massive real-time push updates.  It can be done on a small scale, but the model doesn’t scale.  I noted this point when the University Health Network (UHN) started moving towards an enterprise clinical data ware-house.  The original thought was to update all of the hospitals clinical systems in real time as new patient data was created.  Unfortunately, practical limitations forced the real-time aspect to be abandoned.  I wasn’t privy to the final solution, but I’m told that the solution that was agreed upon was batch updates nightly for things that were time dependent and weekly (or even monthly) updates for other types of data.  We’re talking about a single hospital corporation having difficulty updating its own systems – granted, UHN is one of Canada’s largest hospital corporations and has three main hospital sites with over 10,000 staff, so we’re not talking about a small organization.

I was notified of a proposed alternative method of integrating information within an electronic health record by Vitaly Latush.  He outlines:

"an alternative approach to implementation of a nation-wide easily accessible electronic health record solution based upon the "publish-discover" paradigm successfully used on the global scale to manage immense volumes of non-integrated information available through the Internet"

His main argument against the current architecture/model is that integrating data from all of the different data sources is far too complex because it is based on exchanging data based upon standardized rules.  Latush suggests that a model based on how the Internet currently operates is far more efficient and ultimately more effective.

In this alternative model, he suggests that data sources, be it physicians in an office, labs, or hospitals should only be responsible for "announcing" that new data is available and then providing access to this information.  I would assume that some sort of RSS technology (or a derivative) would be used.  Instead of waiting for some program or system to take this data and integrate it into a dashboard, users would search for information, like they do on Google or any other type of search engine.  Health information would be aggregated by some sort of unique patient identifiers or other keywords.

Latush suggests the following advantages of this model over the existing architecture:

  1. Minimum integration effort – searching for information is now the main function
  2. Based on *proven* Internet principles
  3. Does not require new technologies or skills
  4. Can be built on top of existing health information systems very easily
  5. Facilitates incremental incremental improvements of the functional EHR
  6. Suited for unstructured data manipulation
  7. Cost-efficient in terms of up front cost and maintenance
  8. Self-organizing

 After reading the white paper, I have to admit that the idea is interesting and deserves some investigation.  Here are some thoughts I have about this idea:

Again, this idea sounds very interesting.  From my understanding of things here in Ontario, I believe that some of these concepts may be adopted already or at the very least being discussed.  As the health system moves toward regionalized and integrated models, the need to share information becomes greater.  Regardless of your thoughts on this specific proposal, I think the value is in the discussion and generation of new ideas.  As well all know, health care is important but sometimes takes a back-seat to more "sexy" things like new technologies or recent events.

I highly recommend you read Vitaly Latush’s blog post on this topic or read his white paper, titled "EHR 2.0 – new Electronic Record concept".

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A voice against irrational exuberance in ehealth January 23, 2008

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

For those interested in a somewhat contrarian viewpoint about ehealth, I suggest you check out Scot Silverstein.  I just recently came across his site documenting some "common examples of health care IT difficulties".  You can also listen to his interview available via the Government Health IT site – an excellent site.

In his interview, Dr. Silverstein raises some very important points:

My interest in Dr. Silverstein’s work is in our common view on technology:  that there’s great potential to make positive changes, but that success isn’t a certainty – what is commonly referred to as "technological determinism".  I’ve written as far back as 2004 about technological determinism and ehealth, namely to be skeptical about the absolute certainty that the IT professionals have about ehealth (e.g., my post about IBM building computer models to solve health care’s woes).  I think it’s important to have a balanced view on being hopeful of the possibilities, but also being realistic about the challenges (some final thoughts from a 2005 ehealth conference).

I hope to do some more reading on his website to see what other nuggets I can glean from his work.

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One step at a time: Pharmacists and physicians exchange patient data electronically January 22, 2008

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

Canada Health Infoway announced a first in Canada:  Pharmacists and physicians exchanging medical data stored in patients’ electronic medical records.

Pharmacists can now “access lab test results, allergies and other vital data from consenting patients’ electronic medical records”, allowing them to “collaborate with physicians and the rest of the provider team and resolve drug-related issues more effectively and efficiently for their patients”.  The physicians seem also seem to be ecstatic about this new development as they are now able to “make better use of the expertise provided by pharmacists, make more efficient use of my time and hopefully, provides a more convenient and effective patient experience”.  This announcement is another sign of increased collaboration between the various health professionals in the system.

On a personal note, I can attest to how difficult this project must have been.  On a few occasions, I’ve been involved with developing “data dictionaries” from within an institution and across multiple institutions.  All I can say is that the task is tedious.  I spent six months reconciling definitions of indicators across a multi-site hospital because each department measured things differently.

Now that pharmacists and physicians have access to the same information about a patient, what’s next?  I’ve been participating in a home care knowledge translation course and a trend I’ve been noticing is exploring increased roles for pharmacists – notably in the area of education and medication checks.  The research that we’ve reviewed suggests that pharmacists haven’t made much of an impact (yet).

Regardless, I think this announcement by Canada Health Infoway is a great first step.  I would have liked to have known how the pharmacists are using this information.  What’s next?

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The “Google generation” and some implications for ehealth January 18, 2008

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

The findings of a recent report on how the "Google generation" uses technology and searched for information has some potential implications for ehealth (view the full report [35 slides] or read a summary article via ars technica).  In this case, the Google generation was defined as those kids born since 1993.

Kids seem to be familiar and comfortable using technology (i.e., what people would call ‘technologically savvy’).  However, this competence in using technology doesn’t translate into their ability to find information.  Assumptions about youngsters improving their search skills by experimentation and use alone would seem to be false.  What else was interesting was that kids prefer interactive activities (duh!), but they weren’t so picky about visual over text.  Visual was preferred to text, but it wasn’t a huge difference.

For those of us interested in ehealth, I think there are some important things we need to consider.  For example, my supervisor, Alex Jadad, often likes to challenge people by saying that we need to build a system that our kids will use because they are technologically savvy.  They may be more comfortable with information and communication technologies, but we can’t assume they’ll be "experts".  Some things to consider:

What seems clear is that we need to be careful about the assumptions we make about people using technology.  Young people may have a head start in terms of comfort and familiarity, but they aren’t "automagically" experts of finding information.  In fact, according to this study, their comfort and familiarity may lead to a shallow understanding of technology.  Something to think about.

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What can ehealth learn from Steve Jobs, Apple Inc., and Macworld? January 18, 2008

Posted by Hans in : analysis, conferences & conventions, news, opinion , 2comments

As in the past, I watched the 2008 Macworld keynote address by Steve Jobs.  This time, I was a bit surprised by some of the responses of the media and crowd.  Apple’s stock getting hammered didn’t help.  In any case, I think there are some good lessons for ehealth, and health care in general, that can be learned from Steve Jobs, Apple Inc., and Macworld.  Here are five lessons that we can learn:

1.  Focus on the user experience
This one should be a "no-brainer", as Steve Jobs always emphasizes building products that provide an excellent user experience.  You can see this in the design of Apple products.  For whatever reason, health care, and by extension ehealth, hasn’t really focused on the patient experience.  It is, however, getting better.  But, we’re still far away from anything remotely resembling a "patient-centered" system.  The system needs to change its orientation from being health care practitioner centered (i.e., physician) to putting patients first – and I don’t just mean lip-service, but real change.

An analogy of this would be the largely stereotyped caricatures of Microsoft and Apple.  Microsoft is seen as catering to the needs of business, whereas Apple promotes itself as a "consumer" oriented company.  This would translate into ehealth catering either to the existing institutional and professional powers versus patients and consumers.  FOCUS ON THE PATIENT EXPERIENCE!

2.  Demand excellence
Steve Jobs is portrayed as some tyrannical CEO who can be difficult.  However, he is known as a person who does not compromise and demands excellence from all staff and employees.  We can all learn to not compromise and give-in, but push for something better by demanding excellence.  Patients probably know this intuitively, but haven’t really had an organized voice to channel their expectations.  I know that individuals in the health care system all push to be the best they can be, but sometimes the rules, the bureaucracy, and the system just grind people down.  All of us need to demand ehealth to be excellent and not just convenient.

3.  "Think different"
This was a campaign slogan for Apple a few years ago.  I think it’s apt for ehealth of today.  Instead of succumbing to the often cited difficulties and generally accepted ways of doing things, we in the ehealth field have an amazing opportunity to push the boundaries and imagine all of the possibilities of what can be done to make things better.  Normally I hate the phrase of "thinking outside the box", but I think it fits here.  Apple Inc. is known to do things differently.  With so much more at stake, shouldn’t we also "think different"?

4.  Celebrate achievements & build excitement
I think Macworld is a great example of an event that gathers people together to celebrate the past achievements of the past year and also build excitement for the upcoming year.  eHealth needs to do more of this.  I know that there are annual conferences in the US, in Canada, and in other parts of the world, but they sure don’t get much press coverage.  If the Canadian conferences are any example, these are generally attended by industry folks with very little publicity.  A while back, I pondered the idea of having an ehealth or a health Olympics.  Maybe it’s time that we band together to create something bigger that can garner more attention and more excitement.  I don’t know about you, but whenever I talk about ehealth and the possibilities, I get excited.  We have a good chance to be important contributors in helping to make health care better for everyone.  We need to capture this excitement and inspire others.  Macworld does a great job of this for the "Apple faithful", but also generates quite a bit of buzz from non-Apple customers.

5.  Build partnerships
Apple is starting to learn how to build partnerships that are meaningful (e.g., Intel and Google).  Sure, they’re not great at it, but they’re trying.  The ehealth field can learn from this.  Instead of trying to do things on their own, we need to get together and build partnerships.  The problems and challenges are far too big for any one company or group to do it alone.  Governments and private sector groups working together is a good start.  Instead of competing with one another, we should encourage co-opetition so that more can be achieved.  But, don’t forget the patient!  The patient needs to be included in this partnership too.

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Peering into the (ehealth) fog of war … January 16, 2008

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

At one point in time, a long time ago (around 2000), I wondered if centralized, government maintained electronic health records was the way to go.  In defense of this position, my arguments revolved around the notions of efficiency and control, in that it was easier for systems to be monitored, maintained, and updated if they were all in one place.  But, as anyone with a technical background could point out, there are significant technical issues behind such a strategy.  It would seem that some people agree: "German doctors say no to centrally stored patient records".

What I find interesting is the proposed "counter" solution:

As an alternative, the German private doctors’ body is suggesting the use of encrypted USB-sticks. These could be handed over to patients and would carry all relevant patient data, including digital images such as radiographs or CT-scans

Wow.  I haven’t heard a call for the use of physical based media in quite some time.  Personally, I thought that this line of thinking was disappearing as the feasibility of cloud computing increases and slowly becomes a realistic option.  In all fairness, there are a few other very interesting points raised by the group representing the German physicians.

After reading this article, I get the distinct feeling that as of 2008, we’re staring into the "fog of war" as no-one is certain as to what strategies or solutions will ultimately prove successful.  Might be interesting to start documenting what ideas people think will work or not work.

From my involvement in this industry in North America, I got the distinct impression that a strategy that mixes personal and public records was emerging.  Basically, health care organizations and governments (depending on their level of involvement in the delivery of care) would maintain an electronic record that is stored and available to authorized parties of the "system" (be it regional or otherwise).  Patients would then maintain some sort of "personal health record" that they can control.  The organizational records are often deemed to be the "electronic health record".  Maybe it’s me, but the title, "electronic health record" seems to have a more legitimate or official connotation than "personal health record".

It will be interesting to see what strategy(s) emerges.

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ehealth election madness September 26, 2007

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

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.

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