Healthcare "On Demand": Reform 2.0

Over the past few years, I have often spoken of a vision of a healthcare system available to patients, on their terms (not just those of the doctors or insurance companies), when they (patients) are available (not just when the clinic is open or the doctor is available) wherever they may be physically located (not just at a particular building or part of the country). I believe strongly that technology innovations in Public Health and Healthcare could significantly help us address racial and ethnic healthcare disparities. While some undoubtedly believed this to be the stuff of science fiction, we may in fact be much closer to this possibility than most realize. The New York Times is reporting in a December 20 piece by Claire Cain Miller that Americans could soon be able to see a doctor, whenever they want to, without getting out of bed, in a modern-day version of the house call that takes place over the Web. OptumHealth, a division of UnitedHealth Group, the nation’s largest health insurer, is planning a nation wide roll out of what they call NowClinic, a service that connects patients and doctors using video chat, nationwide next year. Soon any patient, any where, with or without insurance, can have a virtual visit with a doctor for $45. OptumHealth believes NowClinic will improve health care by ameliorating some of the stresses on the system today, like wasted time dealing with appointments and insurance claims, a shortage of primary care physicians and limited access to care for many patients. The potential implications of this one innovation are in some ways staggering should this technology become widely used across the country. Other technology mediated practice innovations as well as technology mediated patient/caregiver/consumer support tools (Consumer Health Informatics) could similarly prove not only popular but beneficial to patients enabling improvements such as better medication adherence, thereby leading to improved treatment outcomes. At a population level, the results could be substantial. Videoconferencing with providers will in no way fix all that ails healthcare, but it is one huge step forward towards the goal of making healthcare more patient centered, while helping to fundamentally change the very nature of healthcare and how it is practiced. You might even call a vision of "On Demand" healthcare, Reform 2.0.

IT has begun

Congress appears to be on the verge of passing landmark Healthcare reform legislation which proponents argue will significantly improve healthcare for all Americans, in part by increasing the role of information technology in healthcare. Many understand that while passage of the bill may be eminent, achieving the results may yet be several years down the road. Still according to ABC News and MedPage Today, who surveyed more than 800 medical specialists and medical historians, four of the ten most important medical advances of the decade involved or were closely tied to Information Technology (IT). Coming in at #10, the development of functional MRI (fMRI) technology, allows scientists to “read minds” by tracking changes in the oxygen levels and blood flow to the brain. At #8, robotic surgery has enabled whole new worlds of minimally invasive surgery (surgery through tiny incisions) and remote surgery (where surgeon and patient may be separated by hundreds or thousands of miles). As such, patient recovery times are often shorter and less painful while in addition, many patients now can have access to surgeries that were not previously available. The second most important advance of the decade was the use of Health Information Technology by patients and providers. The impact of HIT in healthcare has already been significant, even without the new opportunities created by healthcare reform. These include enabling a physician to look up needed clinical information right at the bedside, to patients receiving bar codes when they are admitted to the Emergency Room, clinic or hospital. These bar codes follow the patient and appear on all patient related materials thereby significantly reducing misidentifications, mistakes with blood transfusions, IV infusions and a host of other potential medical errors. Finally, the most important medical advance of the decade was the completion of the Human Genome Project, which for the first time allowed scientists to read the complete set of human genetic information and begin to discover what our roughly 23,000 genes do. A feat made possible by the internet, advances in IT and computational biology. Soon, the final leg of the technology revolution stool will be completed. The development of mobile, wearable, web based, pervasive and ubiquitous computing tools that help patients and thier caregivers better manage their health or healthcare activities and decisions, will empower patients, not just their providers, to achieve thier health and healthcare goals while better managing the realities of daily life at home, school or on vacation. Admittedly, we still have a ways to go to reach this goal, but perhaps we can take solace in the fact that according to this group of medical experts, the IT revolution has already begun.

Avatar Health

In the October issue of the medical journal Pediatrics, researchers at Mount Sinai Hospital in New York published the results of a study showing that text messaging could significantly improve the rate of adherence among 41 young liver transplant patients. The text messages reminded the teens to take their medications and over the course of a year, the teens were more likely to take their medications than they had been before they started receiving the messages. Also the number of episodes of liver rejection dramatically decreased. The results suggest one way technology may help address some of the most challenging health and healthcare problems. But are these types of solutions just for Gen X and Gen Y? The answer may be a resounding No! Take for example the fact that there are literally thousands of applications available for the iPhone. Some people are increasingly trying to use the iPhone to adress health and healthcare needs. The Hollins Communications Research Institute (HCRI) has completed trials using Apple's iPhone as a stuttering therapy tool to enhance the transfer of new fluency skills from the clinical setting into real-life situations. Similarly the Trainerpack app for iPhone is a kind of personal physical trainer particularly for women-on-the-move. The application aims to provide a cost-effective exercising guide to the users. There are many other health apps avaialble for providers and consumers. Social networking (Web 2.0/Web 3.0) web sites like Second Life are also making thier mark in the consumer directed, patient centered health world. Here healthcare providers, educators, medical and public health researchers, patients and consumers all coexist as avatars in a virtual world that they control, complete with hospitals, clinics, patients seeking health and providers proving care and counseling services. Finally, according to a recent survey of 1,002 Americans, ages 18 and older by Kelton Research, 66% of Americans are interested in receiving health-related reminder e-mails and 52% would be open to receiving e-mails that provide them with feedback on their health progress. In addition, more than half (55%) reported that they thought the current healthcare system was fragmented in terms of helping people proactively manage their health. Almost half (49%) felt their health plans don’t help them stay well but rather only help them when they need to visit a doctor. Perhaps most interestingly though was the finding that most of the adults in this study (77%) were receptive to the idea of using technology to help them solve their healthcare needs. In this study 66% prefered e-mail while 57% viewed the telephone as the best technologies to use. Yet 10% were open to the use of text messaging,7% wanted instant messaging and 4% prefered videoconferencing. Studies like these suggest that among many Americans (teens, tweens and adults) the healthcare system may one day be able to proactively use technology such as electronic avatars who provide “health coaching” via the web, e-mail or phones to help individuals build healthier lifestyles, improve health habits, manage health concerns, better coordinate their care and reduce or eliminate disparities in health and healthcare.

HIT for Righter or Wronger

It too often seems, that promises and pitfalls notwithstanding, the way in which most people think about Health Information Technology (HIT) is as if they had a solution in need of a problem. HIT increasingly is promoted as the answer to what ails healthcare, but many have only general or vague notions of exactly what can be fixed by HIT or perhaps more importantly, how HIT would actually fix these problems. In my view, we have a people problem, not a technology problem. As noted by Harvard health economist David Cutler, one way to think about healthcare reform is to think about it in terms of 1) getting providers to do the right thing and 2) getting patients to do the right thing. Despite being a sweeping generalization and gross oversimplification, there is indeed some truth to this characterization of the health problem in the US. That said, solutions to a people (providers and/or patients) problem reside ultimately with people. Unless people (providers and patients) consistently do the rights things we will likely continue to have health and healthcare challenges. If, for example, in our rush to embrace technology, all we do is change the current paper based medical records to electronic medical records, we will still have the problem of missed clinical opportunities, misdiagnoses, inappropriate medication interactions because those providers who do not currently read the paper based medical records, will also not access the electronic medical records or they will access them to look for the same information they now look for and use that information in the same way they now use it. Thus this new technology, after much time, angst and money will likely result in exactly the same outcomes. If HIT is to achieve its promise and potential it must enable and or encourage people (providers AND patients) to do differently those things that need to be done differently, not just help people do things faster or help them to do the wrong things, well… wronger. This is why some are now beginning to use the term Health Improvement Technology (HiT). HiT refers to next generation HIT and technology innovations that improve  health and outcomes by delivering coordinated and seamless interactions across location and devices. The idea grows from a premise that we must first understand the fundamental problems then seek to understand if technology opportunities exist to address the identified problems wherever they exist, whether the problem is with providers or patients, in the hospital or in the home or community. If so, move forward. If not, stop. It builds on leadership that is unafraid to critically look at what we (providers, patients and policy makers) are doing in the context of what we should be doing to create health value (to providers AND to patients) without allowing distractions of reimbursement, infrastructure, organizational culture or protectionism to get in the way. What are the fundamental problems? What do we need to do to fix the problems for everyone involved? How do we make it happen? Period! Sounds like a strategy to eliminate healthcare disparities, reform healthcare and most importantly, improve the health of our nation.

Health IT: To Good to Be True?

The Obama administration has made Electronic Medical Records and Health Information Technology a centerpiece of its Health Reform proposals, suggesting that millions of dollars can be saved from fraud, abuse and waste.  Administration officials also contend that we may also be able to significantly improve the qualtiy of  healthcare through eHealth and other technology solutions. While the promise and potential are certainly real, the administration would do well not to oversell the prospects, at least in the short term, and avoid “reinventing the wheel” by learning from those who have gone before. The London Times is reporting that the National Program for IT (NPfIT), which aims to create a single electronic records system for 50 million patients in England, as well as providing electronic prescriptions and other services is not without significant challenges. For one, the global economic slowdown is forcing the British government to look for areas where spending can be cut or reduced. The program is reputed to be the largest non-military IT project in the world and has been criticized over delays to the proposed database of medical records and concerns that the system will not be secure. Fewer than 20 of the country’s large tertiary hospital systems (trusts) have installed electronic medical records under the project, despite an initial deadline for the whole country to have done so by 2010. At the program’s inception in 2000, British officials had defended the system, insisting that it could save the NHS approximately $2.5 billion by 2014. Another problem cited by The National Audit Office is that the Government underestimated the challenges involved in the project, pointing to the “serious delays” in applying new software to individual hospital systems. These concerns do not even take into consideration whether or not those 50 million British patients will even use the system or want their information to be available to others through the system. The truth is it always takes more than good intentions and a good idea to reap good rewards and outcomes. If health IT like health reform is ever to deliver on its potential, it will take a lot of planning, hard work, flexibility and a good dose of patience from all.