Engaging clinicians and the evidence for informatics innovations

A few weeks ago Richard Gibson from Gartner spoke to members of the CCIO group. It was a fascinating, wide-ranging talk – managing the time effectively was a challenge. Dr Gibson talked about the implications for acute care and long term care of technological innovations – as might be obvious from my previous post here, I have a concern that much of the focus on empowerment via wearables and consumer technology misses the point that the vast bulk of healthcare is acute care and long term care. As Dr Gibson pointed out, at the rate things are going healthcare will be the only economic, social, indeed human activity in years to go

One long term concern I have about connected health approaches is engaging the wide group of clinicians. Groups like the CCIO do a good job (in my experience!) of engaging the already interested, more than likely unabashedly enthusiastic. At the other extreme, there always going to be some resistance to innovation almost on principle. In between, there is a larger group interested but perhaps sceptical.

One occasional response from peers to what I will call “informatics innovations” (to emphasise that this not about ICT but also about care planning and various other approaches that do not depend on “tech” for implementation) is to ask “where is the evidence?” And often this is not a call for empirical studies as such, but for an impossible standard – RCTs!

Now, I advocate for empirical studies of any innovation, and a willingness to admit when things are going wrong based on actual experience rather than theoretical evidence. In education, I strongly support the concept of Best Evidence Medical Education and indeed in following public debates and media coverage about education I personally find it frustrating that there is a sense that educational practice is purely opinion-based.

With innovation, the demand for the kind of RCT based evidence is something of a category error. There is also a wider issue of how “evidence-based” has migrated from healthcare to politics. In Helen Pearson’s Life Project we read how birth cohorts went from ignored, chronically underfunded studies ran by a few eccentrics to celebrated, slightly less underfunded, flagship projects of British epidemiology and sociology. Since the 1990s, they have enjoyed a policy vogue in tandem with a political emphasis on “evidence-based policy.” My own thought on this is that it is one thing to have an evidence base for a specific therapy in medical practice, quite another for a specific intervention in society itself.

I am also reminded of a passage in the closing chapters of Donald Berwick’s Escape Fire (I don’t have a copy of the book to hand so bear with me) which essentially consists of a dialogue between a younger, reforming doctor and an older, traditionally focused doctor. Somewhat in the manner of the Socratic dialogues in which (despite the meaning ascribed now to “Socratic”) Socrates turns out to be correct and his interlocutors wrong, the younger doctor has ready counters for the grumpy arguments of the older one. That is until towards the very end, when in a heartfelt speech the older doctor reveals his concerns not only about the changes of practice but what they mean for their own patients. It is easy to get into a false dichotomy between doctors open to change and those closed to change; often what can be perceived by eager reformers as resistance to change is based on legitimate concern about patient care. There are also concerns about an impersonal approach to medicine. Perhaps ensuring that colleagues know, to as robust a level as innovation allows, that patient care will be improved, is one way through this impasse.

 

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The individual, “characters” and social roles

Recently I read Alasdair MacIntyre’s “After Virtue.” On my other blog I have posted a range of quotes from that I found stimulating and provocative. One chapter, “Emotivism: Social Content and Social Context”, draws heavily on the work of Erving Goffman and also Philip Rieff’s work on therapeutic culture. In this chapter, which I found possibly the least convincing of the book (though perhaps for my own reason), MacIntyre discusses the notion of moral “characters” – the Therapist, the Rich Aesthete, the Manager. Most of his argument is around the Manager as character, in what is an assault on the idea of managerial culture and expertise.  Characters are not the same as social roles:

Characters specified thus must not be confused with social roles in general. For they are a very special type of social role which places a certain kind of moral constraint on the personality of those who inhabit them in a way in which many other social roles do not. I choose the word ‘character’ for them precisely because of the way it links dramatic and moral associations. Many modern occupational roles – that of a dentist or a garbage collector, for example – are not characters in the way that a modern bureaucratic manager is.

aftervirtue

For MacIntyre, the Therapist is one of those characters with dramatic and moral associations, although with a caveat you don’t always find in this kind of discourse:

It is of course important that in our culture the concept of the therapeutic has been given application far beyond the sphere of psychological medicine in which it obviously has its legitimate place… Philip Rieff has documented with devastating effect a number of the ways in which truth has been displaced as a value and replaced by psychological effectiveness.

This specific point is not one I am going to discuss at length now. The passage from MacIntyre I have found most helpful in this chapter – and one which perhaps offers a resolution of the somewhat uncomfortable air of “being a Character” is the following:

Contrast the quite different way in which a certain type of social role may embody beliefs so that the ideas, theories and doctrines expressed in and presupposed by the role may at least on some occasions be quite other than the ideas, theories and doctrines believed by the individual who inhabits the role. A Catholic priest in virtue of his role officiates at the mass, performs other rites and ceremonies and takes part in a variety of activities which embody or presuppose, implicitly or explictly, the beliefs of Catholic Christianity. Yet a particular ordained individual who does all these things may have lost his faith and his own beliefs may be quite other than and at variance with those expressed in the actions presented by his role. The same type of distinction between role and individual can be drawn in many other cases. [MacIntyre describes a trade union official who in his role acts in a way that “generally and characteristically presupposes that trade union goals … are legitimate goals” but who “may believe that trade unions are merely instruments for domesticating and corrupting the working class by diverting them from any interest in revolution.

As a psychiatrist, one is very often confronted with a certain response; in practice, in daily life, even in literature and the media. recently I read Patrick Leigh Fermor’s book on monasticism, A Time to Keep Silence.

timetokeepsilenceIn it he suddenly imagines a discourse between “a psychiatrist” and the monks, in which the psychiatrist seems keen to dismiss their lives as an expression of various neuroses etc. I can’t imagine, as a psychiatrist, ever doing such a thing; partly Leigh Fermor is reflecting the norms of his time (the 1950s). I have found it helpful, since reading MacIntyre’s passage, to reflect on the distinction between myself as the individual people encounter, and the social role and character they expect to encounter.

Unintended consequences and Health IT

Last week along with other members of the Irish CCIO group I attended the UK CCIO Network Summer School. Among many thought provoking presentations and a wonderful sense of collegiality (and the scale of the challenges ahead), one which stood out was actually a video presentation by Dr Robert Wachter, whose review into IT in the NHS (in England) is due in the coming weeks and who is also the author of “The Digital Doctor: Hype, Hope and Harm at the Dawn of Medicine’s Computer Age”

digitaldoctor

Amongst many other things, Dr Wachter discussed the unintended consequences of Health IT. He discussed how, pretty much overnight, radiology imaging systems destroyed “radiology rounds” and a certain kind of discussion of cases. He discussed how hospital doctors using eHealth systems sit in computer suites with other doctors, rather than being on the wards. Perhaps most strikingly, he showed a child’s picture of her visit to the doctor. in which the doctor is turned away from the patient and her mother, hunched over a keyboard:

childspic.png

This reminded me a little of Cecil Helman’s vision of the emergence of a “technodoctor”, which I suspected was something of a straw man:

Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

I still suspect this is overall a straw man, and Helman admits this “technodoctor” is “still only [part of] a minority” – but perhaps the picture above shows this is less of a straw man than we might be comfortable with.

Is there a way out of the trap of unintended consequences? On my other blog I have posted on Evgeny Morozov’s “To Solve Everything, Click Here.”  a book which, while I had many issue with Morozov’s style and approach (the post ended up being over 2000 words which is another unintended consequence), is extremely thought-provoking. Morozov positions himself against “epochalism” – the belief that because of technology (or other factors) we live in a unique era. He also decries “solutionism”, a more complex phenomenon, of which he writes:

I call the ideology that legitimizes and sanctions such aspirations “solutionism.” I borrow this unabashedly pejorative term from the world of architecture and urban planning – where it has come to refer to an unhealthy preoccupation with sexy, monumental and narrow-minded solutions – the kind of stuff that wows audiences at TED Conferences – to problems that are extremely complex, fluid and contentious. These are the kind of problems that, on careful examination, do not have to be defined in the singular and all-encompassing ways that “solutionists” have defined them; what’s contentious then, is not their proposed solution but their very definition of the problem itself. Design theorist Michael Dobbins has it right: solutionism presumes rather than investigates the problems that it is trying to solve, reaching “for the answer before the questions have been fully asked.” How problems are composed matters every bit as much as how problems are resolved.

As will be very clear from my other article, I don’t quite buy everything Morozov is selling (and definitely not the way he sells it!) , but in this passage I believe we are close to something that can help us avoid some of the traps that lead to unintended consequences. Of courses, these are by definition unintended, and so perhaps not that predictable, but by investigating rather than presuming the problems we are trying to solve, and not reaching for the answer before the questions have been fully asked, perhaps future children’s pictures of their trip to the hospital won’t feature a doctor turning their back on them to commune with the computer.

Great moments in personality research: Study of the personality of patients with spontaneous pneumothorax

If it wasn’t for EMBASE screening, I would never have come across this gem:

 

Study of the personality of patients with spontaneous pneumothorax

Martín Martín M1, Cuesta Serrahima L, Rami Porta R, Soler Insa P, Mateu Navarro M.

INTRODUCTION:
Medical psychology has contributed to a greater understanding of many diseases that are predominantly medical and has also helped to improve prognosis. This study explores a surgical entity, namely spontaneous pneumothorax.
OBJECTIVES:
The aim was to compare the personality, depression, anxiety and type-A behavior pattern in a group of 34 patients with spontaneous pneumothorax to a group of 33 control patients admitted for a variety of minor surgical procedures.
MATERIAL AND METHODS:
The following objective assessment instruments were used: Trait Anxiety Inventory, Beck Depression Inventory, Jenkins Activity Inventory, Eysenck Personality Questionnaire. The questionnaires were administered before the intervention of the surgeon and after an informative interview.
RESULTS:
The rate of type-A behavior was statistically different in the two groups. No differences were seen for personality, depression or anxiety.
CONCLUSION:
We conclude that type-A behavior patterns should be reduced in patients who suffer spontaneous pneumothorax in order to improve outcome.

I love that sweeping conclusion “type-A behaviour patterns should be reduced” – just like that! – but also admire the researchers choice of an apparently unpromising area to research. I will try, if I have time, to read the original paper.

Technology Symposium at the International Psychogeriatic Association, Berlin, October 14th 2015.

( I  began writing this post just after the meeting but for various reasons didn’t complete it. I have decided to leave the beginning unchanged despite the overlap with a more recent post)

 

Following on from my prior posts from a Hackathon , a CCIO meeting , and a symposium on trial methodology , I am going to continue using this blog as a sort of reflective journal on various meetings I go to. The technology/healthcare interface seems to be the main topic of these meetings.  There also seems to be a certain evolution here – from tech evangelisation at the Hackathon, to more sober tech governance/implementation at the CCIO, to the trial methodology symposium’s more tangential take on technology … and now to a big, grown-up (not that the other meetings weren’t grown up) international meetings.

I went to the International Psychogeriatric Association meeting in Berlin – the main focus of which is clinical factors relating to psychiatry of later life (or old age psychiatry, or psychogeriatrics, or older adult mental  health, or whatever combination of those words suits) – there was however a symposium session on technology in this field. This symposium doesn’t have any kind of microsite I can direct you to – just the general International Psychogeriatric Association page and you can scroll down to see the details of the speakers.

Assistive technology is one of those areas which is subject every so often to breathless pieces in the papers about the latest somewhat sinister developments in Japan. (that is as far as my first draft went! The rest is written some weeks later)

What was impressive about all three speakers was their seeming immunity to some of the more hype-ish aspects of this field. The first speaker was  Josien Shuurmans  of the Dutch-led eCare@home – which involves “Tablet-Based Ambient Assistance for Older Adults with Bipolar Disorder or Recurrent Depressive Episodes” Shuurmans gave a presentation which covered the pitfalls as well as the promise of such a project, particular the multinational ones which the European Union are so fond of funding. She described a very user-focused project – among the learnings she conveyed was the importance of ensuring clinicians bought into the project and were comfortable with the technology as well. Listening to her, eCare@home sounded like something that could be beneficial at any age, so I asked her how age-specific it is. It turns out certain features such as the visual design do take into account eyesight issues and motor skills issues, but these apply to any age group, especially given the general health issues that often accompany psychiatric issues.
Next was Maurice Mulvenna , Professor Computer Science in the University of Ulster. His speech was specifically on  “Monitoring and Analysis of Sleep Patterns of People with Dementia” but was a much more wide ranging and stimulating talk, which included this great image which says so so much about design vs the user experience. Mulvenna discussed the pitfalls (again!) of the apparently straightforward process of monitoring the sleep patterns of people with dementia, touching on a wide range of issues.
Finally Jeffrey Soar of the University of Queensland, with a vast range of experience in healthcare and in evaluation of technology in health care  – his talk was on “Technological Support for Dementia and Ageing” the meat of which was discussing the process of evaluating assisted living technologies, and what works and what doesn’t. This is an area in which the initial hype has been tempered by experience. What doesn’t work is perhaps easier to define than what works – solutions imposed by well meaning family  (or wider society) without consideration of the person’s own wishes or desires, and technology-focused approaches that can do cool things but perhaps aren’t really what the person wants. One of Prof Soar’s observations has already re-shaped my vision of what healthcare could be so I guess that’s a tribute.

 

Every sufficiently advanced little thing she does is indistinguishable from magic

This has been the longest hiatus on this blog so far, and  my last post on November 19th wasn’t exactly a deep meditation on anything.

I am hoping to re-invigorate things a little by successively blogging about three events I attended in the recent past – one last week, one the week before that, and one way back in October. Thinking about it I think this blog will increasingly become a platform for me to working out my thoughts on various matters relating to the intersection of technology and healthcare, medical education, and evidence-based practice/methodology questions. More general writing and “curation” of my old writing will appear on my other blog

On November 25th I attended another meeting of the CCIO, following on from the last one in September. The same caveat (“not only are these opinions not those of the CCIO, the HSE, or any other institution I may have links with, they are barely even those of myself.”) applies.

Unfortunately I couldn’t make the entire day so missed some of the morning session. I was fortunate enough to catch the talk by Robert Cooke , IT Delivery Director for Community Health, which encompasses my own professional area of mental health. As Robert said in his presentation infrastructure-wise particularly, mental health is starting from a low base for eHealth – and therefore infrastructure development is an important place to start.

As with pretty much all of the presentations I have seen at the CCIO Robert’s was particularly impressive in its blend of enthusiasm and a tough-minded realism about the size of the challenge. No one at these meetings is getting up and announcing that tech will magically sort out what ails healthcare. Indeed Robert strongly made the point that systems and processes need to be addressed before technology is applied, rather than waiting for it to be a magic bullet.

There were other very interesting presentations but the highlight was the breakaway group. In a relatively small group myself and three other CCIO members were facilitated in addressing  a) our vision for what eHealth could make the healthcare system look like in five years time, b) what barriers and enablers exist relating to this vision, and c) what would need to change. This exercise was part of the work UCD’s Applied Research in Connected Health team are doing on Ireland’s eHealth journey. As often happens, the discussion was so stimulating that we didn’t get to c) (and barely covered b) in time)

During the discussions about “the vision thing”, the famous Arthur C Clarke quote ““Any Sufficiently Advanced Technology Is Indistinguishable From Magic” kept coming into my mind, along with a memory of a point about Assisted Living Technologies made by Jeffrey Soar at the International Psychogeriatric Association congress in Berlin (which I drafted a blog post on and hope to actually complete very shortly) – those assisted living technologies that are successful are unobtrusive, in the background, invisible.

So much was the Arthur C Clarke quote going round my mind I was impelled to tweet it:

It turned out when I tweeted this that an extremely witty twist on the quote has already been minted:

So my vision for the future of healthcare is sitting in a room talking to someone, without a table or a barrier between us, with the appropriate information about that person in front of me (but not a bulky set of notes, or desktop computer, or distracting handheld device) in whatever form is more convivial to communication between us. We discuss whatever it is that has that person with me on that day, what they want from the interaction, what they want in the long term as well as the short term. In conversation we agree on a plan, if a “plan” is what emerges (perhaps, after all, the plan will be no plan) – perhaps referral onto others, perhaps certain investigations, perhaps changes to treatment. At the end, I am presented with a summary of this interaction and of the plan, prepared by a sufficiently advanced technology invisible during the interaction, which myself and the other person can agree on. And if so, the referrals happen, the investigations are ordered, and all the other things that now involve filling out carbon-copy forms and in one healthcare future will involve clicking through drop-down menus, just happen.

 

That’s it.