Once again, it isn’t about the tech

From MobiHealthNews:

West Virginia hospital system sees readmission reductions from patient education initiative
A telehealth initiative at Charleston Area Medical Center led to reduced readmission rates for several chronic conditions, the health system reported today.

What led to the reductions wasn’t the advent of video consultations with specialists or sophisticated biometric sensor monitoring, but health information for patients and workflow integration for hospital staff via SmarTigr, TeleHealth Services’s interactive patient education and engagement platform that offers videos designed to educate patients about their care and medication

Technology is an enabler of improved patient self-management and improved clinician performance – not an end in itself.

More on the health education elements of this project:

As only 12 percent of US adults have the proficient health literacy required to self-manage their health, the four-hospital West Virginia system launched the initiative in 2015 to see what they could do to improve that statistic. With SmarTigr, they developed condition-specific curriculums – which are available in multiple languages – and then “prescribed” the videos, which are integrated into smart TVs, hospital software platforms and mobile applications. Patients then complete quizzes, and the hospital staff review reports of patient compliance and comprehension, and all measurements become part of the patient’s medical record.

“Self-management” can be a godterm, shutting down debate, but the sad reality that health literacy (and, I would argue, overall literacy) is such in the general population that it will remain a chimera.

Finally, this project involved frontline clinicians via a mechanism I hadn’t heard of before – the “nurse navigator”

Lilly developed a standard educational approach by working with registered nurse Beverly Thornton, CAMC’s Health Education and Research Institute education director, as well as two “nurse navigators,” who work directly with the front-line nurses. They developed disease-specific video prescriptions for CHF and COPD that give a detailed list of educational content videos patients are to watch before they are discharged, followed by quizzes.

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“actual clinic services with real doctors”

Again, from MobiHealthNews:

A new kind of doctor’s office opened in San Francisco this week: Forward, a membership-based healthcare startup founded by former Googler Adrian Aoun that infuses a brick-and-mortar office with data-driven technology and artificial intelligence.

For $149 per month, Forward members can come to the flagship office that features six examination rooms – equipped with interactive personalized displays – and doctors from some of the Bay Area’s top medical systems. Members are given wearable sensors that work with Forward’s proprietary AI for proactive monitoring that can alert members and their doctors of any abnormalities as well as capture, store and analyze data to develop personalized treatment plans. Members also have 24-7 mobile access to their data, rounding out what Aoun believes is a new type of preventative care.

What is interesting about this piece is that there are various other start-ups whose vision is not based on telemedicine or on “empowering consumers”, but on what is at its core the traditional surgery office except with much slicker tech. It is also interesting that Forward’s approach is based on a personal experience:

The impetus for Forward came from a personal experience of Aoun’s. When one of his close relatives had a heart attack, he found himself sitting in the ICU and realizing healthcare wasn’t quite what he thought it was. Seeing doctors having to obtain health records from multiple sources and wait days or weeks for test results and suffering from all-around communication breakdowns within their health system, he was inspired to create an alternative model – one focused on prevention, efficiency and connected tools to create a increasingly smart healthcare plans based on each individual’s needs and goals.

I took the title of this post from what I found a rather amusing aside in a later paragraph:

It also isn’t the first company to offer a hybrid of physical and digital services. In September 2016, startup Carbon Health opened its first clinic, also in San Francisco, that offers actual clinic services with real doctors

“actual clinic services with real doctors”! – sounds truly revolutionary – and quite a difference from the techno-utopian slant of the Financial Times piece I blogged about earlier in the week. At times readers may detect a certain weariness with the hype that surrounds digital health, the overuse of “revolutionary” and “transformative” and so on, the goes-without-saying presumption that healthcare is bloated and inefficient while tech is gleaming and slick and frictionless.  This is far from saying that healthcare doesn’t need change, and can’t learn from other fields – I look forward to hearing more about Forward.

“evolved strategy”: Online CBT provider Joyable lays off 20, shifts focus from direct-to-consumer to employers, providers

From MobiHealthNews:

“We let a number of talented people and friends go this week,” CEO Peter Shalek said in an emailed statement. “We did this in order to refocus our efforts on partnering with employers, insurers, and providers to increase access to evidence-based mental health care and to reduce costs. We are positioned financially to pursue this new strategy over the next several years. We’ve built a product known for having the best engagement and outcomes of any mental health-focused digital therapeutic, and we believe that our evolved strategy will allow us to reach and help the most people.”

In an interview, Shalek clarified that Joyable’s direct-to-consumer offering, an online cognitive behavioral therapy (CBT) and coaching program for social anxiety, isn’t going away completely: people currently using it will still be able to use it and new sign-ups will still be supported. But the company won’t put any more resources into developing or marketing the direct-to-consumer offering, and most of the staff involved in marketing and support for that product specifically were let go.

Shalek said that the company had always planned to go in this direction anyway and that, while they reached a lot of people, they recognized that the best way to move the needle meaningfully on social anxiety would be to help more people, which the company could accomplish by targeting populations that don’t need to pay for the service directly (the company charges individuals $23 per week for a 12-week course after a seven-day free trial).

With Joyable’s platform, first users are paired with a coach who has been trained in CBT techniques. Before starting the program, users are invited to speak to the coach for 30 minutes on a phone call about how social anxiety affects them and what they want to get out of the program. After that, the program helps consumers identify and understand their social anxiety triggers. Users must complete activities such as challenging anxious thoughts with evidence and developing alternative thoughts that are more helpful. Each activity takes around 10 minutes to complete.

From there, Joyable teaches users techniques to reduce their anxiety by putting themselves in anxious situations and working on applying the skills they learned. The coach supports the user throughout the program through text and email, and the user can also reach out for help whenever they want. The program is available online, and can also be accessed from smartphones and tablets.

One does wonder how much of Shalek’s statement on “evolved strategy” and the assurance “we always intended to go this direction anyway” masks a certain realisation that many online mental health providers are coming to: that, for all the hype and optimistic rhetoric about empowering “consumers”, ultimately engaging providers is a necessity for these technologies to actually reach the potential users who could benefit most.

Financial Times: How smartphones are transforming healthcare

This piece from last weekend’s FT magazine naturally caught my eye. It is rather techno-trumphalist narrative, with a few paragraphs of caveats on data privacy and lack of regulation in this area.However, the first and last quotations are from the CEO of Babylon an “artificially intelligent medical adviser” – the last words being:

But although we will continue to seek out physicians, it will not necessarily be because of their superior clinical skills. “If what you need is to solve a specific clinical problem, a diagnosis, then we can diagnose you better, faster, cheaper than a human doctor can,” Parsa says, with a wry smile. “Five years from now, technologically I do not believe you will have any need to see a human doctor for diagnosis… there is no scientific reason”

He would say that, wouldn’t he?

I’ve written before on the (much superior) Nature piece on “The Wild West of Health” care and have dashed off a few lines to the FT magazine on the lack of mention of the importance of clinical engagement. The piece is worth reading however, my allergy to mention of “transforming” and “revolutionising” healthcare

 

“Huge ($$), broken, and therefore easily fixed” : re-reading Neil Versel’s Feb 2013 column “Rewards for watching TV vs rewards for healthy behavior”

Ok, it may seem somewhat arbitrary to bring up a column on MobiHealthNews, a website which promises the latest in digital health news direct to your inbox. However this particular column, and also some of the responses which Versel provoked (collected here), struck a chord with me at the time and indeed largely inspired my presentation at this workshop at the 2013 eChallenges conference.

In 2012 I had beta tested a couple of apps in the general health field (I won’t go into any more specifics) – none of which seemed clinically useful. My interest in healthcare technology had flowed largely from my interest in technology in medical education. Versel’s column, and the comments attributed to “Cynical” in the follow up column by Brian Dolan, struck a chord. I also found they transcended the often labyrinthine structures of US Healthcare.

The key paragraph of Versel’s original column was this

What those projects all have in common is that they never figured out some of the basic realities of healthcare. Fitness and healthcare are distinct markets. The vast majority of healthcare spending comes not from workout freaks and the worried well, but from chronic diseases and acute care. Sure, you can prevent a lot of future ailments by promoting active lifestyles today, but you might not see a return on investment for decades.

..but an awful lot of it is worth quoting:

Pardon my skepticism, but hasn’t everyone peddling a DTC health tool focused on user engagement? Isn’t that the point of all the gamification apps, widgets and gizmos?

I never was able to find anything unique about Massive Health, other than its Massive Hype. It had a high-minded business name, a Silicon Valley rock star on board — namely former Mozilla Firefox creative lead Asa Raskin — and a lot of buzz. But no real breakthroughs or much in the way of actual products.

….

Another problem is that Massive Health, Google Health, Revolution Health and Keas never came to grips with the fact that healthcare is unlike any other industry.

In the case of Google and every other “untethered” personal health record out there, it didn’t fit physician workflow. That’s why I was disheartened to learn this week that one of the first twodevelopment partners for Walgreens’ new API for prescription refills is a PHR startup called Healthspek. I hate to say it, but that is bound to fail unless Walgreens finds a way to populate Healthspek records with pharmacy and Take Care Health System clinic data.

Predictably enough, there was a strong response to Versel’s column. Here is Dr Betsy Bennet:

As a health psychologist with a lot of years in pharma and healthcare, I am continually frustrated with the hype that accompanies most “health apps”. Not everyone enjoys computer games, not everyone wants to “share” the issues they’re ashamed of with their “social network”, not everyone is interested in being a “quantified self”. This is not to say that digital health is futile or a bad idea. But if we took the time to understand why so many doctors hate EHRs and patients are not interested in paying to “manage their health information” (What does that mean, anyway?) we would come a long way towards finding digital interventions that people actually want to use.

 

The most trenchant (particularly point 1) comment was from “Cynical”

Well written. This is one of the few columns (or rants) that actually understands the reality of healthcare and digital health (attending any health care conference will also highlight this divide). What I am finding is two fold:

1. The vast majority of these DTC products are created by people who have had success in other areas of “digital” – and therefore they build what they know – consumer facing apps / websites that just happen to be focused in health. They think that healthcare is huge ($$), broken, and therefore easily fixed using the same principals applied to music, banking, or finding a movie. But they have zero understanding of the “business of healthcare”, and as a result have no ability to actually sell their products into the health care industry – one of the slowest moving, convoluted, and cumbersome industries in the world.

2. Almost none of these products have any clinical knowledge closely integrated — many have a doctor (entrepreneur) on the “advisory board”, but in most cases there are no actual practicing physicians involved (physician founders are often still in med school, only practiced for a limited time, or never at all). This results in two problems – one of which the author notes – no understanding of workflow; the other being no real clinical efficacy for the product — meaning, they do not actually improve health, improve efficiency, or lower cost. Any physician will be able to lament the issues of self-reported data…

Instead of hanging out at gyms or restaurants building apps for diets or food I would recommend digital health entrepreneurs hang out in any casino in America around 1pm any day of the week – that is your audience. And until your product tests well with that group, you have no real shot.

This perspective from Jim Bloedau is also worth quoting., given how much of the rhetoric on healthcare and technology is focused on the dysfunctionality of the current system:

Who likes consuming healthcare? Nobody. How many providers have you heard say they wish they could spend more time in the office? Never. Because of this, the industry’s growth has been predicated on the idea that somebody else will do it all for me – employers will provide insurance and pay for it, doctors will provide care. This is also the driver of the traditional business model for healthcare that many pundits label as a “dysfunctional healthcare system.” Actually, the business of healthcare has been optimized as it has been designed – as a volume based business and is working very well.

Coming up to four years on, and from my own point of viewing having had further immersion in the health IT world, how does it stack up? Well, for one thing I seem not to hear the word “gamification” quite that much. There seems to be a realisation that having “clinical knowledge closely integrated” is not a nice to have have but an absolute sine qua non. Within the CCIO group and from my experience of the CCIO Summer school, there certain isn’t a sense that healthcare is going to be “easily fixed” by technology. Bob Wachter’s book and report also seem to have tempered much hype.

Yet an awful lot of Versel’s original critique and the responses he provoked still rings true about the wider culture and discussion of healthcare and technology, not in CCIO circles in my experience but elsewhere. There is still often a rather  inchoate assumption that the likes of the FitBit will in some sense transform things. As Cynical states above, in the majority of cases self-reported data is something there are issues with, (there are exceptions such as mood and sleep diaries, and Early Warning Signals systems in bipolar disorder, but there too a simplicity and judiciousness is key)

Re-reading his blog post I am also struck by his  lede, which was that mobile tech has enabled what could be described as the Axis of Sedentary to a far greater degree than it has enable the forces of exercise and healthy eating. Versel graciously spent some time on the phone with me prior to the EuroChallenges workshop linked to above and provided me with very many further insights. I would be interested to know what he makes of the scene outlined in his column now.

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.

#irishmed, Telemedicine and “Technodoctors”

This evening (all going well) I will participate in the Twitter #irishmed discussion, which is on telemedicine.

On one level, telemedicine does not apply all that much to me in the clinical area of psychiatry. It seems most appropriate for more data-driven specialties, or ones which have a much greater role for interpreting (and conveying the results of!) lab tests. Having said that, in the full sense of the term telemedicine does not just refer to video consultations but to any remote medical interaction. I spend a lot of time on the phone.

I do have a nagging worry about the loss of the richness of the clinical encounter in telemedicine. I am looking forward to having some interesting discussions on this this evening. I do worry that this is an area in which the technology can drive the process to a degree that may crowd out the clinical need.

The following quotes are ones I don’t necessarily agree with at all, but are worth pondering. The late GP/anthropologist Cecil Helman wrote quite scathingly of the “technodoctor.” In his posthumously published “An Amazing Murmur of the Heart”, he wrote:

 

Young Dr A, keen and intelligent, is an example of a new breed of doctor – the ones I call ‘techno-doctors’. He is an avid computer fan, as well as a physician. He likes nothing better than to sit in front of his computer screen, hour after hour, peering at it through his horn-rimmed spectacles, tap-tapping away at his keyboard. It’s a magic machine, for it contains within itself its own small, finite, rectangular world, a brightly coloured abstract landscape of signs and symbols. It seems to be a world that is much easier for Dr A to understand , and much easier for him to control, than the real world –  one largely without ambiguity and emotion.

Later in the same chapter he writes:

 

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.

Now, as I have previously written:

One suspects that Dr A is something of a straw man, and by putting listening to the patient in opposition to other aspects of practice, I fear that Dr Helman may have been stretching things to make a rhetorical point (surely one can make use of technology in practice, even be something of a “techno-doctor”, and nevertheless put the patient’s story at the heart of practice?) Furthermore, in its own way a recourse to anthropology or literature to “explain” a patient’s story can be as distancing, as intellectualizing, as invoking physiology, biochemistry or the genome. At times the anthropological explanations seem pat, all too convenient – even reductionist.

… and re-reading this passage from Helman today, involved as I am with the CCIO , Dr A seems even more of a straw man (“horned rimmed spectacles” indeed!) – I haven’t seen much evidence that the CCIO, which is fair to say includes a fair few “technodoctors” as well as technonurses, technophysios and technoAHPs in general, is devoted to reducing the human to pure information. Indeed, the aim is to put the person at the centre of care.

 

And yet… Helman’s critique is an important one. The essential point he makes is valid and reminds us of a besetting temptation when it comes to introducing technology into care. It is very easy for the technology to drive the process, rather than clinical need. Building robust ways of preventing this is one of the challenges of the eHealth agenda. And at the core, keeping the richness of human experience at the centre of the interaction is key. Telemedicine is a tool which has some fairly strong advantages, especially in bringing specialty expertise to remoter areas. However there would be a considerable loss if it became the dominant mode of clinical interaction.  Again from my review of An Amazing Murmur of the Heart:

 

In increasingly overloaded medical curricula, where an ever-expanding amount of physiological knowledge vies for attention with fields such as health economics and statistics, the fact that medicine is ultimately an enterprise about a single relationship with one other person – the patient – can get lost. Helman discusses the wounded healer archetype, relating it to the shamanic tradition. He is eloquent on the accumulated impact of so many experiences, even at a professional remove, of disease and death: “as a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.