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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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Guide to program evaluation January 20, 2008

Posted by Hans in : research, resources , add a comment

Here’s a link to a free resource on program evaluation titled, Basic Guide to Program Evaluation.  The guide seems like a great resource for those who need help in getting started.  With some great summaries and tables comparing the pros/cons of different methods and designs, this guide seems like a great, free resource.

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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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Online Evaluation Resource Library January 12, 2008

Posted by Hans in : academics, research, resources , add a comment

Here’s an interesting resource for those interested in evaluation, titled the "Online Evaluation Resource Library" (OERL).  The goal of the OERL is to:

the continuous improvement of evaluations used to monitor and judge projects’ effectiveness. OERL provides a rich collection of evaluation best practices, guidelines for their applications to projects, and a forum for stimulating ongoing dialogue in the evaluation community. OERL is designed to support applications of sound evaluation methodologies to projects, not to replace a full course of study for those going into the evaluation field.

I did a quick search for resources regarding ehealth and related topics but didn’t find anything.  Maybe it’s an opportunity.  Nevertheless, for those interested in getting started on evaluations of health related IT projects, OERL might be a good resource for ideas.

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JMIR a top health services and informatics journal June 23, 2007

Posted by Hans in : academics, research , add a comment

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.

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Could ehealth raise public awareness of clinical conditions? June 13, 2007

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

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.

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Patients want more performance information available online. Where do we go from here? June 12, 2007

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

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.

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    EHR use in the United States October 17, 2006

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

    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.

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    Podcasting in Healthcare - Revisited 2006 May 15, 2006

    Posted by Hans in : analysis, research , 5comments

    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

    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) totaling 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” without 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 traveling 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.

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    Theme issue on "health information technology" from Health Affairs September 13, 2005

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

    Health Affairs, a “leading journal of health policy thought and research”, just released a theme issue on Health Information Technology. Sorry, but access to the full articles seems to be restricted to subscribers (try accessing it via an academic institution). The table of contents and abstracts are available for free.

    You can view the table of contents for this issue (Sept/Oct 2005 ; Vol 24; No. 5) and see that there are a number of interesting articles. I’m both surprised and not surprised that majority of the articles focus upon the electronic health record.

    Articles have been grouped by section:

    A quick perusal of the titles makes me believe that this issue will be very interesting and perhaps an important one given the rhetoric in the US at this time regarding costs and need for electronic health records. Not having yet read the issue, I would predict that this issue could prove to be a good measuring stick or reference point for the thinking and status of eHealth/health informatics in the US for years to come.

    After reading the issue, I’ll try my best and provide an annotated bibliography of the articles here on the blog. Disclaimer: I’m still working through some health issues, so the summaries/reviews may take a while for me to post. I still have a back-log of posts that I want to write, so please be patient with me.

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