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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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Making sense of revenues and profits in health care March 12, 2010

Posted by Hans in : opinion , add a comment

I read this post on the Health Beat titled “Advice to hospitals in a downturn: Market the high-margin service” and I’m trying to come to grips with it.

Don’t get me wrong, the content itself was pretty much straight forward in that it provides advice on how to increase revenues. But, what I’m trying to get over is that the entire message just seems wrong to me. Perhaps being in Canada, I’m not used to speaking about increasing revenues within a health care context, at least not by hospitals. I recognize that there are business considerations that must be addressed, namely that health care is not free. Contrary to belief, health care in Canada isn’t free either. I understand the need to cover the costs of salaries, supplies, etc.

I’m going to think about this more and try to understand why the message just doesn’t sit well with me.

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Health care of the future? March 9, 2010

Posted by Hans in : opinion , add a comment

There was a very interesting series of posts at HBR Insight Center which focused on health care, specifically health care innovations. In the main post titled “Health Care of the Future“, the author presents a list of 10 innovations believed to have big impact.

  1. Checklists
  2. Behavioral Economics
  3. Patient Portals
  4. Payment Innovations
  5. Evidence-Based Decision Making
  6. Accountable Care Organizations
  7. Virtual Visits
  8. Regenerative Medicine
  9. Surgical Robots
  10. Genetic Medicine

I’ve thought about this list and I can’t really argue against any of the items listed here. I would, however, add point-of-care technologies (POCTs) and video games. In terms of video games, I’ve written about the potential to use gaming systems for health promotion (with Nintendo Wii as a great example) and also for other types of activities like teaching, interface development, simulation, and public engagement.

POCTs are poised to change the lab services market using a classic disruptive approach. Specialized knowledge is becoming more accessible as technologies advance. Individuals can now access diagnostic testing services in a matter of seconds at the point of care. I can see that treatments (based on an immediate diagnosis) can be developed to accompany the test. As an example, a blood sugar testing device could measure the sugar levels in your blood and then automatically inject the appropriate sugar/insulin based on pre-determined controls.

Do you see anything that is missed?

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The “y” in GE Healthymagination March 8, 2010

Posted by Hans in : opinion , add a comment

During the 2010 Vancouver Olympics, I noticed a series of advertisements being played repeatedly promoting GE Healthymagination. The ads themselves were fairly well done and seemed to do a good job of conveying the message that GE is serious about health care and about being an innovation leader.

Each time I watched the ad, I kept asking myself – why? Why is GE doing this type of advertisement? All of the products GE was promoting seemed geared toward hospitals or other types of health care organizations – definitely not something that a patient could buy. It’s not like a patient can go into a hospital, doctor’s office, or other health care facility and ask if they are using GE products.

I did, however, manage to check-out the website and was quite surprised by the projects they have listed (descriptions are from the website verbatim – March 2010).

As for the “why”, here’s the description from their website:

Almost everyone wants to make healthier choices, but they don’t always know how. The amount of information available on wellness, nutrition and exercise is overwhelming, to say the least. Even when we do know how to improve our health, we often try to make sweeping changes or set goals that seem too daunting to reach.

Healthymagination is about becoming healthier, through the sharing of imaginative ideas and proven solutions. It goes beyond innovations in the fields of technology and medicine, celebrating the people behind these advancements. Seeking to build stronger relationships between patients and doctors, GE created healthymagination to gather, share and discuss healthy ideas.

Because healthymagination is about becoming healthier together, it takes the form of multiple projects that you can participate in, whether you’re looking to change your lifestyle or fine-tune your approach to health. Making healthy decisions should be easy…and fun.

Guess the advertisement didn’t really match-up to the work that Healthymagination is doing (in my opinion). One project that would be great for GE to pursue is studying how to make health care more accessible (from a service perspective) and more cost-effective.

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Worlds colliding…industry vs. academia May 13, 2008

Posted by Hans in : academics, nature of ehealth, opinion , 1 comment so far

It’s interesting to see how differently ehealth is viewed by academics and industry.  To one, ehealth is the potential of using new mediums to explore ideas and possibilities, while to the other, ehealth is more of a means to an end.

For the past few years, I’ve been in the academic world exploring the limits of our existing evaluation theory as applied to ehealth innovations.  As a researcher (or perhaps more aptly, ‘would be’ researcher), I focused on the concepts of ehealth and how one could evaluate these constructs.  The pursuit was academic and intellectual, even though I tried my best to remain grounded in solving, what I perceived to be, real problems.  Perhaps that’s why much of my writing and thinking on this topic has been focused on the patient and how users of the technology (health care providers included) can be empowered by ehealth.

More recently, I’ve been exposed to the industry perspective of ehealth.  In this world, ehealth is all about programs and projects, about deployment schedules, funding options, and providing the framework to move a health care system along.  Here, there really isn’t any time for or value of the rigorous methodological approaches (and debates) surrounding randomized control trials, systematic reviews, or even articulating an epistemological viewpoint on how knowledge is constructed or derived.  Ehealth, in this context, is a business matter that requires analysis, forecast, and action.

For me, I feel somewhat stuck between two worlds, not having left the academic/research world, and yet being asked to help address some industry problems.  Discussions in the realm of industry hardly mention patients except in strategy/vision documents.  Ehealth is big business, dominated by government bodies and vendors.

I’m not saying that one is better than the other.  I merely point out something that wasn’t *real* to me until recently.  I always knew that industry is different and operated differently than the research world, but perhaps I was a bit naive about how much difference there really is.

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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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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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Podcasting in healthcare – 2007 update August 30, 2007

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

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:

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:

  1. Competition with video and blogs
  2. Limited applicability
  3. Monetization is a challenge
  4. 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.

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