Smart pills with sensors as well as miniature implants placed, e.g., under the skin are predicted to grasp minds and souls of the consumers cramping fitness devices like wrist bands or watches. Thus, the “Smart Pills Technologies Market (2012-2017),”  report forecasts the global smart pills market to reach $965 million by the year 2017, while Gartner expects shipments in the smart garment category to jump from 0.1 million units in 2014 to 26 million units in 2016.

The grid of miniature interconnected devices, mostly sensors that can be wearable or implantable (known as a body area network (BAN), can radically transform the mainstream of Healthcare. Registering multiple parameters such as body temperature, perspiration, electrical conductivity of the skin or electric field distribution around the body, the Internet of Health (IoH) can provide data which, if properly interpreted, would track multiple disorders of the organism’s subsystems casting a deeper insight into the origin of diseases such as diabetes or cancer.

What disruptive changes can IoH bring to our Health system, in particular, to consumers and patients?

  • Transition to Holistic health.

For centuries, medicine has been collecting physiological facts to describe various human organs with limited understanding of their interplay, the approach often leading to misdiagnosis and medical errors. The IoH technologies are expected to overcome such pitfalls. This topic discussed by respectable scientists at the 2015 BIO International Convention in Philadelphia. Thus Donald Jones, the chief executive officer of Trial Fusion, argued that gadgets should be viewed as “nodes on the net” or transmission hubs emitting important information from different sources to help researchers form a more comprehensive picture of a person’s illness.

BrainSixthSence

It is curious that some successful endeavors are already springing not from medical, but e.g. automotive industries. All of us are used to a quick car sanity check before we start the trip. Multiple sensors are “calling” different parts of the machine to inspect its health. Why not to check the driver? The Sixth Sense by Jaguar/Land Rover attempts to monitor a driver’s fatigue or lack of concentration by combining multiple measurements such as heart rate, respiration and brain activity collected through sensors embedded in the steering wheel. Other automotive manufactures like Ford, Toyota or General Motors are taking the same direction.

The indigestible sensors will revolutionize diagnostics by monitoring health status noninvasively under natural conditions.  A tiny pill travelling through the human body interacting with saliva, blood, urine and/or gastric juices will be collecting data to provide a multidimensional view of the human organism. The information is wirelessly transmitted to physicians to identify early deviations from the individual’s health stability.

Scientists from the Weizmann Institute Israel are having an ambitious goal to develop   “lab-on-the molecular”, a combination of fluorescent molecular sensors  that integrate the properties of molecular luminescent sensors and cross-reactive sensor arrays (the so-called chemical ‘noses/tongues’). On the one hand, molecular sensors can differentiate between a wide range of analyte combinations and concentrations; on the other hand, they can operate in the microscopic world, which macroscopic analytical devices cannot access. Responding to the slightest chemical modifications of the molecular complexes in the organism such sensors are able to operate as “smart diagnostic devices”, kind of molecular spies. Suitable platforms for luminescent sensors are nanoobjects, in particular, semiconductor or noble metal quantum dots that can interface with molecular complexes in the living organism.

 

  • Noninvasive diagnostics

The mainstream of medical diagnostics methods tends to interfere with the human body, often stretching organism to the extremes thus pushing it out of its stability margins. For example, the ubiquitous exercise-electrocardiogram (stress ECG or cardiac stress treadmills) so favored by the doctors can be detrimental for the patients, in some cases leading to aortic stenosis and heart attacks as well as contingently causing nausea, high blood pressure or chest pain/angina pectoris. (Myocardial infarction in approximately 1:5000 tests and death in about 1:10 000 tests, Freedman B. Cardiac Society of Australia and New Zealand. Safety and performance guidelines for clinical exercise stress testing. 2010, http://www.csanz.edu.au.) .

Erik Topol, chief academic officer Scripps Health (San Diego) and one of the strongest proponents of the consumer oriented nanotechnology is working with Axel Scherer, PhD, of Caltech on tiny blood stream nano sensor chips that might spot predecessors of a heart attack. The sensors are picking up a specific genomic signal coming from endothelial cells that are sloughed off an artery wall in a precursory period before a heart attack. By transmitting the alert via smartphone to the cardiologist the myocardial infarction potentially can be prevented.

SmartGarmet

Personal wearable sensor garments can soon become a fashion.

This HealthWatch , 15-lead ECG-sensing T-shirt can read heart rate, blood pressure, detect cardiac irregularities and other vital signs that can be the key to preventing heart attacks. Data is generated in real time and reaches doctors immediately. The design is quite practical: one can throw this T-shirt in the laundry with the rest of your clothes. Cardiologists can observe their patients remotely, without hooking them up to a heart-measuring device in doctor’s office.

Endoscopy or colonoscopy can be a nightmare for patients suffering from gastroenterological illnesses such as, e.g., Crohn’s disease or ulcerative colitis.  The inflammation can be located in the small intestine that doctors can barely see. A tiny camera size of a vitamin pill such as used in the Beth Israel Hospital in New York City is travelling through the guts taking pictures every few seconds and transmitting them to a device on a patient’s belt.

Recently the Technion-Israel Institute of Technology together with Alpha Szenszor, the Boston-based manufacturer of carbon nanotube sensing equipment, announced the commercial version of Na nose, the device that has been proven in numerous international clinical trials to differentiate between various types and classifications of cancer with up to 95 percent accuracy. Patients breathe into a tube; the Na-Nose analyzes more than 1,000 different gases that are contained in the breath to identify those that may indicate potential disorders.  Normally patients with suspected lung cancer have to go through a CT scan when they feel the first symptoms. That maybe too late.  Cumbersome and invasive biopsies of tumors can disturb malignant cells and provoke their further spreading. The introduction of nanosensor technology to medical practices allows spotting the location of suspected cancer at a very early stage. The whole procedure is much cheaper and hence more affordable.

  • Personalization of Healthcare.

The traditional European healthcare was regarding a patient is a statistical unit. The conclusion that followed was “what is good for the majority will work for a given individual”. This principle is the foundation of the contemporary pharmaceutical industry. Millions of people are prescribed the same medications with the strong requirements to comply with “what the doctor tells them”. The attempt to understand how medication impacts a given individual was largely neglected. The result is that 50% of patients are not taking their medications as prescribed. Almost all medications aimed at treating people with long term chronic conditions have severe side effects that are revealed gradually with the substance accumulation in the body. The human metabolic systems vary from person to person and hence differently absorb medications into the bloodstream. In some cases a drug dosing may be too sudden and too much active ingredients enter the narrow absorption window; in other cases, an insufficient amount of drug is absorbed and the active ingredients get quickly flushed outside the body. Considering that people over 65 are taking five or more prescriptions, the threat of drug interactions, negative side effects or overdose is quite acute. Moreover, most medications can be poisonous unless taken in proper doses.

Accordion Pill

The Israeli company Intec  has designed an oral drug delivery system, the Accordion Pill  that looks like an ordinary-sized capsule but once inside the stomach it unfolds like an accordion to monitor the absorption of the swallowed drugs. The pill can be programmed to retain the acting pharmaceutical ingredients in the stomach for as long as 24 hours, so instead of taking 5 pills a day one can administer the medication only once.

Another good example of a digestible microchip was designed by a company called Proteus.  When swallowed, the chip with embedded sensors generates the “slight voltage in response to digestive juices,” which sends a signal to the surface of the patient’s skin. An attached patch catches the signal and transmits information to a doctor’s mobile phone. A device can also monitor patient’s heart rate, respiration and temperature informing the physician on how this particular patient is responding to medications. The point is that the doctor can adjust the treatment to the particular patient vs. forcing him to comply blindly with what “is normally believed to work”.

 

Conclusion:

The Internet of Health, the network of wearable or implanted sensors is disrupting the fundamental principles of traditional medical methodology such as treating disease vs. sustaining health, addressing anonymous patients vs. individuals, relying on intuition vs. measurable facts.

For the first time a patient has a chance to be treated as a human being vs. a collection of organs and receive care without going through torturous procedures that in some cases can be devastating for health.

The IoH might generate the new flow of applications and portable devices capable of addressing vital health issue helping people to understand and measure their everyday health conditions. The market of current Health and Fitness devices designed merely for strong and healthy has to give way to the one of new technologies dedicated for those who need it most.

 

Despite the long history of medical scholarship and research, the answer is still not straightforward. Science is based on measurable facts verified in multiple experiments. Moreover, scientific facts hold universally. For example, gravitation, conservation laws or Newton’s law of inertia work everywhere in the Universe. Therefore scientific results could be regarded as objective.

Massachusetts, USA --- Doctor Peering into Crystal Ball While Patient Waits --- Image by © Cary Wolinsky/Aurora Photos/Corbis

Art, on the contrary, relies on intuition and inspiration and is intimately connected to its creator. Therefore it has a local value and is subjective by nature.  Between those two extremes oscillates medicine.

Contrary to positive sciences such as physics, chemistry or biology, the ambivalent status of medicine is dwelling on three major misconceptions, often preventing objective diagnostics and effective therapy.

 

 

Total is a sum of its parts.

For centuries, medicine was collecting individual physiological facts trying to describe various human organs, with limited attempts to understand their interplay.

Contrary to its oriental sisters such as Chinese or Indian medical techniques (e.g., TCM and Ayurveda) that assumed the universal interconnectedness within a person, among people, their health, and the Universe, the Western medicine believed that after “fixing” the injured subsystem with a prescribed treatment or medications the whole organism would return to its equilibrium. The entire homeostatic system of human body was dissected by the mainstream of European medicine into various diseases. This approach  is now reflected by a set of diverse medical specialties such as gastroenterology, cardiology, psychiatry, etc. The knowledge in each of the specialties was mostly evolving within itself – deep, but narrow.

This approach has a fundamental deficiency well known in other natural sciences, e.g., in physics of complex systems (and human body is a complex system): the sum of parts does not constitute the whole.

Body as its parts

Health is a holistic notion. There is no such thing as a partial health. The human organism can be regarded as a complex open system in a state of delicate equilibrium exchanging chemical substances, energy and entropy (information) with the outer world. Since the whole organism consists of a number of strongly coupled and cohesively working subsystems, the failure of any one of them tends to provoke an avalanche of other failures. Therefore, separate treatment of a single organ, disregarding impact of a disease on other subsystems or recklessly administering strong locally acting medications, may result in complications involving other organs.

This “focused” approach in medicine also leads to ignoring side effects. Take for example the wide-spread medication known as Bisoprolol, a readily prescribed beta-blocker to treat hypertension. It reduces the activity of the heart by blocking tiny areas (called beta-adrenergic receptors) where the messages are received by the heart muscle. But for patients, suffering from cardio problems, often associated with hypertension, this medication can provoke a shortage of breath and a cardiac rhythm disturbance, most frequently dangerous arrhythmia or bradycardia (especially when prescribed together with calcium channel blockers).

Many experienced physicians innately acknowledge the deficiencies of such fragmented knowledge, attempting to compensate them with intuition, rather than relying on prescribed guidance that can be based on the same erroneous assumption of compartmentalization. Quoting Dr. Jeffrey Braithwaite, Foundation Director, Australian Institute of Health Innovation: “slavish adherence to increasingly voluminous and often piecemeal guidelines is an obstacle to flexible, intuitive, effective care” [1].

The European medicine, unlike science, has drifted toward a technique of intuitive feature extractions and subjective judgements called “Art” when successful, and when not, then paving the way towards false diagnostics and medical errors.

  • Individual equals statistical unit.

Clinical protocols and medical guidance adopted by European medicine mostly rely on averaged statistical data i.e. individual characteristics are largely neglected (being habitually labeled as “unspecific“). This method is fundamentally wrong since it is based on an implicit assumption of the Gauss distribution underlying medical statistics. Yet the statistics of emergent diseases, similarly to heavy accident statistics, seem to obey power law distributions rather than exponential ones. Note that statistical results, e.g. produced in clinical trials, in fact do not answer the crucial question: what is the best strategy for a specific individual.

Therefore the whole concept of “evidence-based medicine” which is actually based not on evidence, but on statistical simplifications does not suggest what is good for a given patient. The fact acknowledged by a number of physicians.

Medical science is applying statistical approach to models assuming their complete symmetry (i.e. that the models are basically the same), but in reality medicine is using statistics in regard to humans that are different by default. Therefore relying on statistical methods in individual medical cases is not always correct. The consequence is that many medical techniques can be more harmful than beneficial for patients.

Take for example the “sugar curve”, which is a colloquial name for a glucose tolerance curve (whose linear part is usually known as a dynamic range). Such a test nominally requiring the glucose intake not exceeding 125 g (who really controls it?) but can be indiscriminately administered, e.g., to the patients already having diabetic ketoacidosis. The beginning of adverse effects such as vertigo, blurred vision or even fainting occurs not rarely and marks the diabetic health boundary, in extreme cases leading to coma.

Another example is the ubiquitous exercise-electrocardiogram (stress ECG or cardiac stress treadmills) which is favored by the doctors but can be contingently detrimental for patients, e.g., suffering from hypertension. One patient complained that his blood pressure during ECG stress test raised up to 285 systolic and 190 diastolic. Nevertheless, his cardiologist proceeded with the test, since a patient did not complain of the chest pain, a symptom obviously more important for a cardiological test than a  blood  pressure (AD).

  • Focus on disease vs. health

Although the notions “health” and “medicine” are commonly used interchangeably in various contexts, there is a crucial difference between them. Medicine deals with deviations from healthy conditions and treats diseases mostly by medications, surgery and, since comparatively recent times, by laser and ionizing radiation. The very term “medicine” stems from the ancient “art of healing” i.e. returning to health. It is not accidentally that the object of treatment in medicine is known as “patient” whereas health can (and should) be maintained in any person.

'Don't worry. We still have a few more treatment options available.'

People feel themselves healthy as long as their organisms are capable to maintain stability under an influx of external real-life influences such as stress, psychic overload, microorganisms, fungi, allergens, etc. Contrary to the dominant – and unverifiable – presumption that diseases mainly arise from erroneous behavior or unreliable functioning of individual body organs, partly genetically determined, the idea of a holistic health leads to the concept that diseases are rooted in the very foundation of the complexity of a human organism that involves numerous interconnected components and subsystems. The possibility of a disease may not spring from the failure of a distinct body part (organ), although it can be manifested as such, but can be the property of the whole organism. Hence radical treatment of a single organ can have a overall negative effect, driving health of its stability margins.

The deficiencies of a fragmented approach to treating health is most vividly demonstrated in case of complex disabilities such as, e.g., chronic fatigue syndrome, or CFS when a person feels so tired that he/she is unable to complete normal daily activities. The CHF Health Center recognizes that “the fatigue syndrome has no known cause and is difficult to diagnose”. So the therapy decides to focus on “the major symptoms” that allegedly “can be treated”.

But how can one treat symptoms leaving aside the cause and even unable to properly diagnose the disease? Instead of bringing a patient back to healthy conditions, the therapy relies on a variety of medications such as antidepressants that are purposefully changing the balance of brain chemicals (neurotransmitters). Although it is generally stated that antidepressants have no severe side effects, such frequently prescribed medications as adapin or doxepin can provoke pathological conditions such as orthostatic hypotension, tachycardia, ventricular arrhythmias and even lead to breast cancer.

The European medicine is gradually adopting the approach of “maintaining health of the healthy” and supporting natural resources of the organism to help it to return it to its stable conditions. For example the oncological immunotherapy with medications such as, e.g., Keytrouda (Pembrolizumab (formerly MK-3475 and Lambrolizumab) is focused on strengthening the body’s natural immune system impelling it to attack and destroy the cancerous cells, rather than trying to destroy the malignant tumor by means of dangerous chemical drugs that come with serious side effects.

 

 Conclusion:

With no intention to diminish the achievements of the contemporary medicine, one has to accept that it is lagging behind positivistic sciences in understanding human organism as a cohesive complex system with tight interplay of its related parts.

 The mainstream of physicians are still treating a disease vs. treating a patient to maintain her/his health. This approach often leads to wrong diagnostics, medical errors and serious side effects that endanger patients.

True there are a lot of achievements performed with the help of modern medical (in fact physical) technologies such as X-rays, CT, MRI, PET screening, pulsed lasers, proton therapy or other advanced procedures. But the majority of such technologies should be applied carefully and by thoroughly trained staff since they are still based on invasive methods that disturb health and can be harmful for a patient.

“Great expectations” are connected with the development of sophisticated body sensors designed to convert the body physiological characteristics such as pulse rate, blood pressure, ECG (electrocardiogram), EEG (electroencephalogram),) PPG (photoplethysmogram), ENG (electronystagmogram) and EMG (electromyogram) signals, local thermal (infrared) emission, skin wetness, etc. into sequences of electric pulses and further into digital signals that can be processed by some central unit, at present by a computer or a smartphone. By collecting biological feedbacks from an individual organism in a noninvasive way, body sensors may help physicians to transit from the illusive intuitive descriptions of arbitrary selected symptoms, to objective and measurable manifestations of a health status.

The physicians of the future will require a new type of education which will help to overcome traditional pitfalls of medicine. The new type of medical knowledge will encompass multiple areas of natural sciences such as physics, chemistry, and biology to address the fundamental laws of the human organism viewed as a complex biological system (a metabolic reactor) rather than adhering to fragmented clinical methods. We see the emergence of such a converged knowledge already with the development of new branches of science such as, e.g., bioengineering, bioinformatics, computational biology, etc. that are already opening new opportunities for medicine and healthcare. Until this knowledge fusion fully happens medicine, according to William Olser, one of the founding professors of Johns Hopkins Hospital, will remain “the science of uncertainty and the art of probability”.

  1. https://healthmanagement.org/c/healthmanagement/issuearticle/guest-editorial-3?utm_source=Newsletter&utm_medium=Email&utm_campaign=Content
  2. http://www.cdc.gov/ncbddd/autism/index.html
  3. http://www.bcpa.co.uk/factsheets/Angina.htm

Continuity of medical services and accessibility of care are hallmarks of a successful healthcare system. Unfortunately this vision is not always attainable for a professional rehabilitation considering its habitually high costs. Specifically, if we talk about multiple intuitively demarcated deficiencies such as, e.g., Mild Cognitive Impairment (MCI), which is loosely defined by Mayo Clinic  as an “intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia”.

Is MCI really a disease or is it a signature of a normal aging process, perhaps aggravated by some bad  life habits, e.g., smoking, alcohol or lack of physical exercise? Considering some of the alleged MCI symptoms [1] such as “forgetting things more often” or “losing your train of thought or the thread of conversations, books or movies” (which may very well happen to a young person when one stares at the TV screen with a glass of wine after a long and stressful day) many of us could be on the way to MCI if not already there. Can we better understand the real causes and possibly prevent cognitive deteriorations such as MCI, dementia or Alzheimer’s disease (AD)?

Recalling the rapid population aging, especially in the developed countries which, according to WHO, will reach by 2050 approximately 2 billion people aged over 60 thus accounting for 22% of world’s population, the preventive measures against MCI will be crucial for the world social and economic stability. We should start exercising our brain, just as we are getting used to keep our bodies fit.

How can we train something so intangible as Mind and Soul in a way that every person can easily afford it?

To address this challenge the Spanish group of medical researchers and IT experts designed NeuroAtHome, a virtual rehabilitation platform for people diagnosed with Mild Cognitive Impairment. The system includes more than 100 rehabilitation tasks destined to treat specific motor or cognitive functions.NeuroatHOMEMCI2An individual is offered a set of cognitive and physical 3D videogame exercises tailored to his/her capacities and needs. A natural user interface allows one to work on the task distantly with hands’ gestures (or even eye movements), so that a physician can check both cognitive status and the precision of the motoric.  The complexities of the task corresponds to the Global Deterioration Scale (GDS), developed by Dr. Barry Reisberg that provides an overview of the stages of cognitive function for those suffering from a primary degenerative dementia.

Each rehabilitation task performed by a patient is quantified: Neuro@Home Pro measures the number of successfully completed tasks, response time and total number of completed tasks. The rehabilitation team can evaluate the progress not only by observations, but by “measurable” facts. New rehabilitation tasks may be added, existing ones modified or the program can be entirely stopped if not considered useful anymore. In a word: the therapy can be personalized and adjusted to the individual needs of a patient.

NeurAtHomePNG.PNGExamplesOne part of NeuroAtHome is installed in an individual’s home, another one in a clinic. A physician can monitor his patient remotely from any location (e.g., from the hospital or physician’s house), while patients can definitely cut on long distance travelling.The system is utilizing Microsoft Kinect sensors such as IR Emitter and IR depth sensor for capturing body motions, including facial contractions, and to create digital skeleton. Tilt sensors are calculating the correct angle and position of the body while color sensors detect the slightest fluctuations in the skin color such as emerging paleness or redness.   As blood passes the vessels, Kinect camera recognizes the variations of the facial color intensity to establish how fast the blood is pumping. This helps the physician to objectively detect the level of the stress a patient experiences from exercises and to adjust the program.NeuroAtHomeMCI

The results of the performance are stowed in Microsoft Cloud Azure platform for further analysis. Physical data are collected and stored into patient’s profile by Kinect, so the next time one reaches the system it recognizes its user.With NeuroAtHome monthly subscription one can have an  access to multiple virtual training programs.

The overall rehabilitation is now considerably cheaper than the traditional treatments provided by  clinics where normally a patient is discharged not when she or he is fit, but when the insurance expects her/him to leave.

More and more clinics are looking for new ways to make the rehabilitation therapy more affordable to provide the high quality treatment  as long as individual requires.  One of such clinics is Hospital La Pedrera that has already treated 175 patients using the NeuroAtHome rehabilitation platform. When asked if they would like to continue the training, 99.4% of patients found the virtual therapy highly motivating. NeuroAtHome allowed patients to receive, on average, 30% more physical therapy sessions and 15% more cognitive therapy sessions using the same available resources. The increased efficiency resulted in improved patient outcomes: patients that used NeuroAtHome were discharged, on average, 3 days earlier.

During the first quarter of 2015, NeuroAtHome reached 4,000 patients delivering over 300,000 sessions, in both medical and home environment.

The spectrum of personalized training programs address multiple aspects of impairments: from muscular–skeleton, to brain and spinal cord injuries, from chronic and neurodegenerative conditions to active aging.

If the technology can capture and analyze practically unlimited number of individual cognitive sings for providing personalized therapy, could it now offer a more measurable insight into the nature of cognitive impairments? I believe it is the time one tries it.

Resources:

  1. http://www.alz.org/dementia/downloads/topicsheet_mci.pdf

Countries across the world are striving to improve their national Healthcare systems. Can we learn some best practices from such endeavors to make the Healthcare a universal success? In my previous blog I was arguing that the success of the national healthcare system does not directly depend on financing models: public, private or the mix of both. The important factor is that citizens are included in the process of decisions in regard to the scope and quality of services they receive.

Healthcare system does not exist in a social vacuum, but is functioning in coherence with other national socio-political institutions. The more value the individual life means for the nation, the more efforts the government undertakes to protect this life. Therefore one can notice without any high-brow scholar studies the correlation between the level of democratic maturity and the quality of life and medicine in the country.

Thus France, Belgium, Germany, UK, Netherlands, Sweden, Switzerland and other developed European countries have a life expectancies within the range of 80-87. Countries like Eritrea, Ethiopia, Tadzhikistan and Russia have life expectancy within the range of 60-69.

CountryHealthRanking

But the mature healthcare systems of the developed world are also not on the same level. Thus United States, one of the biggest spender on healthcare in the World (17% of GDP), is underperforming compared to the European countries such as France, Germany, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom. More than 27% of Americans think that they need to fundamentally change their Healthcare system compared to 4% population of UK or 5% of the Dutch people. The mortality ratio amenable to healthcare is also higher in the US (96 deaths per 100.000 population) compared to EU countries such as France (55 deaths per 100.000 population, Sweden 61, Norway 64 or Netherlands 66 deaths per 100.000 citizens [1].

The UK is leading the Commonwealth fund 2014 survey scoring high for the quality of care, efficiency and low cost at the point of service, with Switzerland coming an overall second and Sweden as the third. Patients, from their side, are having a slightly different view, according to the 2014 Euro Health Consumer Index  survey, giving preferences to Netherlands, Switzerland and Norway.

The UK and Norway have public system predominantly funded through general taxation and earmarked taxes. The Netherlands and Switzerland have a strong emphasis on individual contributions and direct citizens’ payments.

What those countries with seemingly different approaches to the healthcare management have nevertheless in common? The underlying aspect that unites them all is the strong public impact on the quality and distribution of Healthcare services. Despite the fact that the direct patient’s experience is still not yet regularly captured by the professional medical community (only 1% of GPs in France, 7% in Norway and 15% in Switzerland are routinely receiving and reviewing patient satisfaction and experience data), there are other channels citizen can use to express their opinion on the services they receive. Such channels are:

  1. Local decision makers.

Decisions regarding citizens’ healthcare could be taken centrally, e.g., as in the US or locally, e.g., as in Switzerland. The closer the gap between citizens and healthcare decision makers, the more adjustable is the system to the needs of its constituents.

26 Swiss cantons are largely responsible for the provision of health care operated by private insurance companies primarily on a regional basis. Similar to states, cantons are sovereign in all matters, including health care.

In Sweden county councils’ expenditures on healthcare amount to nearly 72 percent, 8 percent to municipalities, leaving only to about 2 percent to the central governments (Statistics Sweden, 2014).

Local governmental organizations are often much more receptive to citizens aspirations and complaints. After all, patients are part of their electorate. They may very well be their neighbors or people they meet in the local pub.  The important factor: one can directly look into the eyes of those authorities and ask tough questions.

Countries with the centralized governmental health management nevertheless tend to delegate responsibilities to local authorities to avoid monopoly and to balance their own power. Thus UK has established Healthwatch, a national body to promote patient interests in each locality. The local Healthwatches support people’s complaints, reporting their concerns to Healthwatch England, which can then recommend actions to the Care Quality Commission. In addition, local NHS bodies, including general practices, hospital trusts and commissioning groups, are expected to support their own patient engagement groups and initiatives. Norway, where the government has an overall responsibility of providing care, municipalities are playing a strong role in care delivery, especially in the area of primary care.

On the contrary, when the gap between the consumers (e.g., patients) and the service delivery providers such as centralized government organizations or large Health Insurance funds is huge and the relationships are depersonalized, the chasm is often filled by bureaucracy and the voices of citizens are doused.  In this case, the authorities are lured to protect their own interests vs. the interests of their constituents.

Could it be the reason why the US Healthcare reforms driven by the government in combination with huge conglomerates such as Medicare and Medicaid have more challenges and less success than their European counterparts? The latter have a stronger orientation to pushing the decisions towards local authorities that are more receptive to public control.

  1. Direct financial involvement of citizens

The US spend twice as much money per capita on healthcare as the average developed country. Nevertheless the life expectancies in the country (79 years) is lower than in the majority of the developed countries in the world. The key to the successful care therefore is not the the amount of spending, but in its intelligent distribution.

The Dutch and the Swiss healthcare systems can be viewed as an interesting example of the citizen’s “quality control” over healthcare services through the direct involvement in financial mechanisms. After both countries decided to erase the barriers between private and public insurances, citizens were obliged to buy the “basic package” of the minimum health insurance deal that covers all ‘essential healthcare’ set by the government. The logic was the following: if you pay directly, you know what you should get. Dutch and Swiss consumers are keenly aware of the costs of their health insurance as well as of services they are guaranteed to receive. Contrary to that, health services covered by large health insurance funds or through payroll taxes are much less transparent and utterly depersonalized. One is contributing to the pool, not always being sure what one can fish out of it.

If you pay you can choose a supplier or a vendor. Competition is always a strong mechanism to leverage quality and accessibility of care. Dutch patients can switch between 40 private small health insurance houses all over the country. Switzerland has a similar approach with a 100 small private insurance companies to manage care. All of them are competing on price and quality, struggling to keep premiums low and quality high for fear of losing customers and profits.

We like places where everybody knows us and welcomes with a smile, therefore we normally prefer our small local bakery to the large supermarket. If we do not like the price and quality of muffins in our bakery we are going to another one around the corner. Why can’t we transfer this model to the healthcare?

3. Patient-oriented information technology.

There is a clear correlation between the advancement of healthcare and acceptance of ICT. The UK was one of the first countries to embark on the large-scale national eHealth Project. By 2013, nearly half the population of England had a Summary Care Record. Electronic transfers (from general practices to pharmacies) are widely used for prescriptions and for the storage and distribution of digital images (e.g., scans, X-rays). The Choose and Book system provides patients with the online choice of hospital where they prefer to be treated. Through MyNHS Portal patients can monitor the performance of hospitals and GPs in their area, providing direct comments and recommendations.

Sweden is another country that uses ICT extensively to enhance care of its citizens.  The 1177 services in Sweden are providing a 24 hours access to medical staff to advise patients on recommended treatments. Additionally, there is a collaborative initiative between all county councils and regions to provide online information about pharmaceuticals, medical conditions, and pathways for seeking care, known as 1177.se.

The spread of wearable devices empowered by consumer mobile applications generated “mHealth” – a collection of electronic options of providing care. Not only mHealth gave way to  new citizens services like online booking, remote diagnostics, patient monitoring and online rehabilitation, it also generated independent channels for citizens to express their opinion on the level of services they were receiving as well as on the their governments’ efforts to improve such services.

HV2

Yet the majority of medical systems were not interconnected, thus preventing data sharing between physicians and patients. Interoperability seemed to be an insurmountable barrier for the eHealth success.

The evolution of the Cloud technologies was a big step forward.  They allowed patients and physicians to communicate with each other remotely, sharing data from Electronic Medical Records (EMR) and Personal Health Records (PHR). Systems such as Microsoft HealthVault® originally launched in 2007 in the USA is available now world-wide. Such systems help individuals to collect, manage and share their medical and wellness information. Some of the examples include common clinical types (medication prescriptions, allergies, etc.), demographics, health state measurements (blood glucose, blood pressure, etc.), fitness level (e.g., measured by heart rate and blood pressure) and the commensurate arrangements (exercise sessions) as well as unstructured information (such as scanned images and other documents). HealthVault is available on the Web as well as from mobile and tablet appstore by Microsoft and other providers. Other IT vendors such as Apple with Health Kit or Samsung with SAMI  are catching up.

Are the above three pillars sufficient to make the healthcare system more patient-oriented and successful? Apparently not, but they are indispensable to start with.

References:

  1. International Profiles of Health Care Systems 2014

With all current and future healthcare reforms, there is one fundamental question that underlies them all: is our healthcare just a business or is it a guaranteed service to protect citizens’ lives and well-being? Which way leads to Dr. Jekyll and which one to Mr. Hide?

J&Hide

Citizens’ right to life is one of the basic principles of the European Welfare states. Governments are protecting their citizens with armies, social services and, last but not least, their healthcare systems. This protection costs money. With 17% of US GDP and 7-11% of the GDP in developed EU countries spent on Healthcare [1], more and more voices are questioning whether healthcare should be a commercial endeavor rather than a guaranteed service the citizens are to receive. After all, pharmaceutical industries as well as many others (e.g. medical equipment production) have been making their profits on Healthcare for a longtime with the unanimous social acceptance.

It is this “last mile” – this point of care such as primary or hospital care that we are still struggling with. On the one hand, all healthcare services including salaries of health providers, nurses, laboratory tests, etc. cost money. On the other hand, our humanistic consciousness cannot tolerate the vision of people dying just because they cannot afford adequate medical services.  So how relevant to healthcare are fundamental principles underlying any commercial business models?

    • Drive for revenue is a core priority for business: Is the ultimate goal of the national healthcare system to derive more revenue? Or is it still to make their citizens healthier and to improve their mortality and morbidity rate? On top of that, not all private healthcare enterprises are straightforward revenue-driven. For example, more than 90% of Dutch hospitals are owned and managed on a private, but not-for-profit basis.
    • Market share: The more products you sell the higher is your revenue, the more stable is your business. While for some private hospitals it may be crucial to increase the number of their patients, one can hardly consider the rise of patient cohorts as the ultimate goal of the national healthcare systems.
    • Customer satisfaction: Here we hope to find some similarities with Healthcare. For commercial enterprises, customer satisfaction is, in ideal case, taken for granted since they do not want to lose business to competition. But is patient satisfaction is always the key performance indicator (KPI) for every hospital overshadowing financial indicators, length of stay, bed occupancy and so on? Can patients always easily change a hospital or a health insurance company?
  • Return on Investments (RoI): Business investors are usually risking their own money. In the case of healthcare, let us not forget amidst all the commercial vs. “health for free” discussions that it is the citizens that are paying for the healthcare services. Either they have already paid with their taxes to refill the budgets of their governments or regularly transfer money to their health insurances. Are they entitled to get a part of the revenue like a normal investor?

Healthcare as a system cannot meet the classical requirements of a commercial enterprise just because of its strong social significance. Talking about public, private, “cost free” or commercial healthcare we are rather referring to the ratio of private vs. public contributions within the national healthcare systems. But those contributions ultimately have one source of funding, namely the taxpayer. In this sense the difference between public and private is fairly obscure.

 Is private healthcare better than public?

Private insurance companies will assure you that of course it is. You can set up an appointment faster, get a professor that will presumably operate you better; you will be put in a separate room and get a special three-course menu with meals at your bed side. Of course you should pay for these benefits, hence the price for private insurances vs. public ones is usually significantly higher. But does it really worth the money?

PublicvsPrivate

The big issue with some of the private health insurances, at least in Germany, is restricted flexibility. One is always welcome to step in, provided one has a sufficient income level (currently earning more than 54.900 € annually), but has no way to step out i.e. to switch back to public insurance. On top of that, in private insurance plans you cannot accumulate your contributions to compensate for the services you would most probably need in your later years, at least if you change the insurer. You have to pay over and over again. The deficiency of such a system can be shocking for some patients, e.g., for a 42 year old privately insured German patient who suddenly got cancer. Prior to that he lost his job. His private health insurance to which he had been diligently paying premiums all his life refused to cover treatments. The man was sent to suffer – quietly or painfully – at home.

An increasing number of people in Germany are seeking to switch to public health insurance plans, but the German law imposes stringent constraints on private patients desiring to migrate to public insurance companies. Moreover, the German insurers are vehemently lobbying the ban or at least significant limitations on the operations of the foreign insurers – so far quite successfully despite the EU unified market requirements.

Is public better than private?

One of the advantages of public care is its social accessibility. Yes, you can wait for months, but at least you will receive some level of services guaranteed by the Government. There are of course some problems: general rules such as the Governmental health regulations appear arbitrary and can hardly be influenced by the patients. Furthermore, it is often hard to decide what exactly patients are paying for. If the citizens are stripped of the ability to decide which doctor or hospital, or service they can choose, some bureaucrats will decide for them, and the competition between health organizations will be distorted.

Sometimes it can lead to the decisions our minds find hard to accept. Such as the decision  of the National Health Services (NHS) UK to pay general practitioners in England £50 bonuses for placing patients on controversial ‘death lists’ in order to reduce the number of occupied hospital beds and thus healthcare costs. The doctors received payment for every care home patient they successfully signed up to an end of life plan.

BedOccupancy

Only 6 doctors raised their voices in UK against Liverpool Care Pathway Liverpool Care pathway , which allows medical staff to withhold fluid and drugs in a patient’s final days, claiming that it is the kindest way of letting them slip away.  But this “kindest way” could turn simply into murdering patients.

90-year-old Kathleen Vine was staying for months in the South-East of England with dislocated shoulder after doctors at a hospital told her relatives that she had only 48 hours to live. Fortunately relatives did not believe the prognoses, since from their perspective the lady looked not bad. “Nanny was sitting up in bed and she was saying, ‘I’m really hungry, I’m really thirsty.’” Kathleen was immediately taken home where she lives happily now with her relatives. “I was being left to die. If it hadn’t have been for my family I would be dead now. I would just have been another statistic on the books,” she told later.

The Hippocratic Oath “I will not give poison to anyone though asked to do so, nor will I suggest such a plan” has become hopelessly obsolete, as this event testifies.

  In a letter to The Daily Telegraph doctors claimed that tens of thousands of patients with terminal illnesses were placed annually on a “death pathway” to help end their lives. Informed consent was not always being sought either from the relatives or from those patients who were still in control of their faculties. The prevailing assumption apparently was that patients do not understand all the complexities of healthcare business.

Conclusion.

What controls business is the market and the market are consumers. If the healthcare system wants to be successful for a long time, be it privately or publicly funded, it has to follow the same rules: be accountable to the consumers, in other words to citizens. The crucial point seems not the ratio of public or private spending in healthcare, but who actually controls the distribution and the quality of care: consumers or the bureaucracy, be it government or the private corporate bureaucrats.

Looking at the successful European Healthcare systems at the top of 2014 Euro Health Consumer Index  one can notice a  distinct commonality: the ability of citizens to impact costs and efficiency of care services they receive either through direct financial contributions of individuals or due to control and easy intervention of local authorities. HealthSat

If people are putting their skin in the game, they should be able to measure the level and quality of the services they receive either with their money, their voices or with their feet. After all, we are all actual or potential patients no matter what our profession is, and we want to see our healthcare system as a “point of care” and not the point of no return.

 

 

References.

  1. http://www.pbs.org/newshour/rundown/health-costs-how-the-us-compares-with-other-countries/
  2. http://www.civitas.org.uk/nhs/download/netherlands.pdf
  3. http://www.civitas.org.uk/nhs/download/switzerland.pdf

What does it take for a medical professional to express at least the same level of empathy to patients we are accustomed to receive in a civilized environment? And consequently what do patients perceive as a good quality care?

Looking at many comments on the subject published by medical professionals, one can identify at least three modes of thinking:

 

PatienSat
1.Patient satisfaction depends on physician’s workload.

2.Give patients what they want to make them happy

3.The doctor knows better.

 

With respect to all the opinions, how do patients and family caregivers fit to this triad?

 

Patient satisfaction depends on physicians’ workload.

One of the widely spread complains often heard in medical environment is that about the lack of personnel which causes fatigue leading to lower quality care. Looking at such arguments from a patient perspective, one starts wondering: if this is so, why almost every day a new doctor is visiting a patient asking the same set of questions? It is not a rarity that a patient is visited by three or four doctors a day each of them repeating the same standard questions: age, weight and the reason for hospitalization. Then all of them are promptly leaving. No wonder that up to 90 percent of patients are unable to correctly name their treating physician. If for a physician a patient is an anonymous bunch of organs and problems, a physician for a patients turns into the bunch of functions.

But there can be exceptions. The name of the doctor the patients from Endocrinology Department of Krankenhaus (hospital) Schwabing will remember is Dr. M. Walter. Not because he had a habit of gently patting patients’ shoulders and charming them with a dazzling smile. This doctor was sitting next to the patient questioning him about her or his symptoms and life habits as long as it was needed to make a clear picture in regard to a patient’s health conditions. This was specifically important for Dr. Walter’s patients since the medical discipline he specialized in was diabetology, and diabetes is an intricate metabolic disorder requiring a lot of knowledge as well as understanding of minute details related to patient’s daily habits – the factor largely overlooked by many busy physicians. Sometimes Dr. Walter looked exhausted and nervous, but even the most skeptical patients were convinced that he had a professional interest – if not in their personalities, but at least in their health problems. It is this conviction that created a sustainable patient’s satisfaction and trust.

Genuine interest in a specific health situation is the hallmark of professionalism which patients immediately spot. It is manifested through the ability to listen and looking at the patient vs. impartially applying the prescribed clinical pathways. True, it is often safer for a physician to follow a recommended pathway avoiding the risk of your own decision. But a blind trust in the approved “cookbook” could pose a danger for patients.

In their book “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests,”the authors Drs. Leana Wen and Joshua Kosowsky describe a college kid who had a hangover after a night of partying. After saying she had “worst headache of her life” the “Rule-Out Subarachnoid Hemorrhage” pathway was immediately triggered. The girl went through the CT scan, which was predictably negative. Nevertheless, she would have gone through the enforced lumbar puncture, should she hadn’t escaped throughout a side door.

Patients and relatives do not expect enforced love and abundance of services from the medical staff. But they expect a professional attention and interest to cure their disease vs. its formal treatment.

Patient satisfaction can be bought.

One of the prejudices widely spread in the medical environment states: to achieve a high score on patient satisfaction simply give patients what they want. In an often quoted Dr. William Sonnenberg’s article Patient Satisfaction is Overrated the author suggests: “The mandate is simple, never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.”

educated patient

It is true that patients in pain may demand opioids to reduce sufferings. But after they are calmly and clearly explained that the overdose could be harmful, they normally stop insisting. What patient cannot tolerate is being inadequately treated due to deliberately misguided actions.

A patient I was observing was staying for a week at Intensive Care Unit (ICU) where he was recovering from a cardio surgery. The doctor confirmed that all tests were satisfactory to move this person back to his room. Looking at the patient one could clearly spot a fever. Nevertheless, a nurse was insisting that a temperature was quite normal. I went back to ICU and asked the assistant to give me a thermometer, explaining my concerns. He kindly gave it to me despite the risk of being punished for breaking up the rules: only the nurse responsible for a given patient was allowed to use a thermometer.

Apparently the assistant has valued the patient safety more than the rules in the hospital and, perhaps, more than his own career. The temperature of this patient was 39.5°C. He was urgently given antibiotics. The first question the doctor asked when he was informed about the complications was: “Who gave him a thermometer?” Of course I did not betray the ICU assistant for the sake of an immediate trust established between him, the patient and myself. I still do not quite get why the nurse decided to lie so outrageously. To be untroubled by additional care?

Doctor knows better.

The assumption that patient satisfaction depends on “giving them whatever they are asking for” implies that patients are ignorant and illiterate, another widely spread myth in the medical community (occasionally mixed with wishful thinking). A senior physician from Kaiser Permanente once honestly confessed that patients nowadays are often more educated about their illnesses than doctors themselves. “They have only one disease and it is their own, so they study it damn well, while we do not have time to read all the new literature coming out”.

One of the studies conducted by the Health Service Research among patients with type 1 diabetes showed that those of them who became familiar with their disease through trainings and the Internet were more knowledgeable than many of the healthcare professionals they have encountered.

The ability and willingness of patients to educate themselves, especially in cases of rare diseases, was confirmed by Professor Peter Mortimer of St. George’s Hospital in London. A world-renowned medical expert on lymphoedema told his Irish patients at an open day in Cork that they are “likely to know more” about the condition than the doctors who see them.

For medical professionals who believe that they receive their unquestionable authority and knowledge together with the white robe, the educated patient is a pain. Often such doctors perceive the patients’ questions as an attempt to challenge their professionalism. Some of them openly complain of losing the untouchable status of the pillars of their community the pillars of their community and becoming “like everybody else: insecure, discontented and anxious about the future.” On top of that such attitude makes the doctors “impatient, occasionally indifferent, at times dismissive or paternalistic”.

Contrariwise, for the physicians who have a still unsaturated curiosity and a professional desire to solve a problem, an educated patient can be a stimulating partner. When such a patient sees a genuine interest in her/his case, the level of cooperation between physician and patient is high.

Active patient engagement based on trust and shared knowledge can bring a distinct economic value to a hospital. According to one of the studies, patients who received enhanced decision-making support ultimately had 5.3 percent lower overall medical costs than those receiving only the usual support. The enhanced-support group is also characterized by 12.5 percent fewer hospital readmissions and 20.9 percent fewer preference-sensitive heart surgeries. Shared decisions making through these relatively low-cost models can extend the benefits of patient satisfaction and engagement [1].

Doctors who are concerned about their intact authorities more than about assisting their patients are rarely good doctors. Behind the paternalistic aura or play-acting behavior hides the inability or unwillingness to learn new discoveries in their professional area to meet the growing demands of their patients.

The last word on “empathy”

“Empathy” and “kindness” is on the radar of professional discussions. There are even suggestions to include ethical courses as part of medical education curricula. But can one really teach compassion or “study” empathy? Sympathy is not something you learn at school unless you protected your weaker friend from the bunch of thugs or brought home a bleeding cat that had been hit by a car. One can try to mimic kindness, but people always spot when it is fake.

Those who are venturing to go to the medical profession are accepting the burden of responsibilities to serve their patients at the risk of their own well-being. We see such doctors in the Red Cross and the “Doctors without Borders” organizations. They deserve our unanimous respect.

But let us be honest: not everyone is born to do this job. Physicians who are indifferent to their patients are not full professionals and should not be considered as ones, although being indifferent to patients is occasionally considered a right attitude within the medical community. You cannot be a professional in the subject you dislike, especially if it is a human being. People are visiting physicians not to spend their time on enduring tortures and risky procedures. They expect results. Citizens are paying for their conditions to be clearly improved with their time, money and health. Healthcare professionals should never forget about it.

References:

  1. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=86

 

I remember sitting in the Intensive Care Unit (ISU) attending a patient after cardio surgery. The usually quiet atmosphere of ISU was interrupted by electrifying fuss: the physician on duty was peeping into the corridor, the assistant was nervously sorting patients’ charts. It was clear that the Doctors’ Round was about to start. Indeed, in about 10 minutes the doors of ISU opened wide and He appeared: the Chief Medical Doctor, the head of Cardiology Department surrounded by his suite, with medical students bringing up the procession rear. He looked at the monitors placed above patients’ beds. The ISU doctor rashly stepped forward attempting to provide the Chief with some comments on patients’ charts, but apparently it was not part of the ritual. He was immediately dismissed by a haughty remark: “Ich bin hier” (“I am here”). In a few minutes the show was over and the King departed silently, followed by all his men.

Chief Doctor

I came up to the ISU caregiver (German: Krankenpfleger) who was sitting during the whole ceremony impartially studying patients’ charts over his computer. Apparently he did not have a role in the “Doctor’s Rounds” scenario: he got his own line of reporting through the Chief Nurse. “Why did not anybody tell the Chief Doctor that the patient is still having chest pains?” The caregiver (who obviously was intelligent and educated) smiled ironically: “Because the Chief Doctor did not ask about it.” I looked at the electronic medical record (EMR) at the computer screen. The information there pertained only to the patients’ conditions at ISU. Knowing that before getting to ISU the patient I observed was treated in the Cardiology Department, while initially arriving from the Neurology Department, I asked the caregiver if the doctor could see what had happened with the patient there. “No, he cannot. The physician from the Cardiology Department cannot see what happened to the same patient in the Neurology Department”. The reason was not technical: the SAP EMR system was running throughout the entire hospital, being able to collect and share data from all its departments and labs. It was a pure human factor: doctors did not want to share patients’ data (occasionally referring to some vague Data Protection Acts). “It is very simple, explained to me the ISU caregiver, if they control information they control the patient treatment and all accompanying processes. If they share it, somebody may disclose their mistakes”.

The fear of making a mistake and the ensuing punishment, be it administrative, financial or moral, seems to permeate the whole hospital culture. True, the stakes are high and although it is a common knowledge that “to err is human”, sometimes it is hard to accept this tenet for a sympathizing doctor when looking at the frustrated relative who has just lost his dear one or while talking to a supervisor who will be only too glad to give you a full blame. Yet the inability to handle mistakes, hiding them instead of analyzing their roots to avoid similar ones in the future is very close to a deliberate patient harm.

Silence and the breach in communication provoke medical errors that can lead to upwards of 1,000 deaths per day and cost trillions of dollars in health care costs each year as discussed recently at KQED’s Forum. A study from UC San Francisco discovered that improving communication between health providers can reduce patient injuries from medical errors by 30 percent.

So why despite all the evidence and discussions on the patient safety doctors are persistently ignoring the basic common sense principle that “one head is good, but two are better?” Why are they ready to sacrifice the well-being and, sometimes, the lives of their patients for the sake of control and unquestionable authority? One of the reasons is the authoritarian culture pervading most of the hospitals. Questioning your superior’s decision even on a minor issue and, in particular, in behalf of a patient may frustrate your boss and eventually impede one’s career promotion. Moreover, a mistake may undermine the authority, so it is better to handle it later in a closed inner circle. This “hidden curricula” that former medical students learn in the hospitals teaches them that patients’ satisfaction is finally not the prime objective of their professional activities.

Thus, the atmosphere of mistrust emerges that does not make people happy in any professional environment. One of the physicians that was working for a large, for-profit, hospital group published in the online discussion that the goal for patient satisfaction in his hospital was always set at 100%. The goal for employee satisfaction… 27%, and it never got close to even that. The doctors’ satisfaction always hovered around 15%. Can an unhappy doctor make a patient happy?

A stiff hierarchical structure is the underlying problem in the majority of European Health organizations. It is going deep into the history of medical education when a medical student has for many years to be a silent apprentice, almost a servant, for his supervisor. In former times, this approach to educating the would-be doctors was partially justified: a physician should be able to do everything – from healing wounds to taking child delivery, and his decisions were solely based on his own experience and intuition. However, with the diversification of the modern European medicine and expertise going deep but narrow, unquestionable authorities coming from top to bottom could be dangerous.

The inability of openly sharing one’s concerns in regard to medical procedures, negligence of one’s colleagues observations together with the fear to speak up may lead to serious, sometimes fatal consequences. The results of the survey conducted late 1980s through the early 1990s by Australian researchers showed that the vast majority of medical errors, some 70‑80 per cent, are related to interactions within the health care team (Australian Commission on Safety and Quality in Health Care). Since that the Australian research team is prompting a range of initiatives. One of the most important is the “open disclosure” framework, under which patients and their families are told immediately when something has gone wrong. Slowly and painfully, it started bringing the results: overall, serious adverse events decreased by 10% in the five years to 2012. Of the 53 million patient interactions nationwide each year the chance of a serious medical error occurring has become significantly lower, at 0.000201% [1].

Nevertheless, the authoritarian, hierarchical structure still prevails in the medical environment and the majority of medical schools. A UCLA study UCLA study found that 85 percent of all third-year medical students had been subjected to bullying based on medical hierarchy. Another study published in 2012 and conducted over the course of 13 years at the University of California, Los Angeles David Geffen School of Medicine, showed that more than 50 per cent of medical students across the US said they experienced some form of mistreatment. The implications could be wide ranged. People bullied in their youth, later derive fear to speak up. To compensate for the loss of self-esteem they may tend to oppress others who are junior and socially weaker than they are. They may also choose to ignore their professional duty to protect the patients’ interests and safety for the sake of maintaining good relationships with their supervisors.

Medical Student

Thus, the researchers from the Maimonides Medical Center in New York have run the experiment among 55 students who had to go through a laparoscopic surgery simulator. Half of the students were encouraged to speak up their minds on the procedure whereas others were instructed to do what the supervisor was telling them. Subsequently, a surgical mistake was deliberately made by the senior surgeon when he instructed students to cut without burning. The students in the encouraged group were significantly more likely to speak up (23 of 28 [82%]) vs. 8 of 27 [30%] from the group that was told just to follow the supervisor’s instructions.

To interrupt the domino effect of silence and submissiveness, it is important to encourage medical students to flag errors on their patients behalf when the students are still full of humanistic aspirations and Hippocratic Oath to ”preserve the purity of my life and my arts” is not yet poisoned by a professional cynicism.

If the authoritarian culture of obedience and blame will prevail in medical environment, we shall see more and more Chief Medical Doctors ignoring the opinions of their assistants, more physicians neglecting nurses and disregarding their patients. The result will be an increased miscommunication between medical teams leading to the enhancement of medical errors ratio and eventually putting patients under a high risk.

References:

  1. Reducing-medical-errors-one-patient-at-a-time.

 

Patient engagement is said to be the prerequisite to improve the European health system. With the rapid growth of aging population and cumulative costs for hospitalization, patients are expected to take over part of the burden by actively controlling their own health.

But practices in many European hospitals still contradict those brilliant intentions. As soon as you cross hospital’s threshold you are stripped not only of your personal belongings, but of your identity as such. You are no more an engineer, teacher or a musician. You are just a patient and a patient, according to etymology of the word “is the one who suffers”. It seems that the following basic rule of human behavior cease to work in hospitals: people are engaged with those whom they like and who sympathize with them. The majority of physicians, for sure, are accepting those norms outside of their professional milieu. So why is this culture not common in hospitals?

Indifference as a self-protection.

One can often hear from medical professionals: “If I sympathize with all my patients I will not be able to treat them”, “I am also a human and cannot break my heart over every individual”, “I am alone, and you (patients) are many”.

We can understand physicians: with a burden of responsibilities, often long exhausting hours of work, one develops a psychological barrier to protect her/himself from emotional distress and sorrows. With years one gets used to it. The self-protection turns into disengagement and finally indifference. Just another job.

Waitng

When you arrive at a hotel, most often a receptionist will smile to you and a butler offers to carry your luggage. When you arrive at a hospital you may sit for hours absolutely neglected by the medical staff.

Listening and hearing others is the vital part of communication. Not in the hospital, not when you are already there. Often doctors’ rounds resemble a brief excursion through the Zoo, but with less excitement. The excursion is reduced to a mere five-minute (at maximum) demonstration of a patient to the chief physician surrounded by tacit assistants. The medical guru is sorting out notes with lab tests, hardly looking at the patient himself. The verdict will be delivered to the patient later in written. A simple handshake calling a patient by name or a question: “How are you doing today?” are obviously not yet the part of a standard procedure.

Hospitals are not the luxury resorts. But one will still expect care and not brute enforcement such as, e.g., exerted on a patient in a Munich hospital who was fiercely tied to the bed on the first night after a serious open heart operation. According to the Intensive Care Unit (ICU) nursing apprentices on duty that night, the patient attempted to take off the oxygen mask and thus could harm himself. Apparently they were not listening to what a patient was trying to tell them: there was no oxygen supply in the mask and he was simply suffocating. The two strong young trainees, assisted by a belligerent staff nurse who obviously knew nothing of the case but was a priori hostile to the patient, jumped on the half-paralyzed man knotting him to the bedside to interrupt his protests and to prevent him from pressing the emergency button. The subdermal injuries caused by fastening the patient were so hard and the bruises so deep that one of his hands was damaged forever.

Attracted by the noise in the middle of the night and attempting to help his roommate, another patient jumped out of his bed to call the police. He was running along the corridor with a rubber tube hanging from his side until he was caught be the alarmed nurses who ran after him with wild cries. One could imagine such scenes in the Woody Allen movies, should it not actually happen in one of the most prominent hospitals in Germany. Apparently the Chief of the Department was not shocked by the case: though impressed by extensive purpish bruises on the patient’s skin, he merely shrugged his shoulders explaining that he did not have enough money to keep professional nurses in ICU. The worst thing was that everybody wanted to hush up the case as soon instead of exploring the grounds for such outrageous behavior of the nurses.

Not listening to patients could be killing. In a different case a man was so depressed after an operation that he confessed to the nurse his intention to commit a suicide. The nurse consulted a physician, but the complaint was brushed off as a “just another post-operative syndrome”. Three days later the patient jumped out of the window. Should somebody at that time stopped to talk at least for a couple of minutes to a poor chap or just put a hand on his shoulder, maybe he would still be alive.

Healthcare as a business

Inasmuch as we like to think about healthcare as of a social responsibility and humanism, it is in fact a big business. Concerns about costs in Healthcare communities almost prevail over the discussions about patient’s safety. Complex logistics, transportation, suppliers, engineering issues, etc. are of course the essential part of the whole healthcare system. Not the least are the insurance companies, those brokers between patients and medical professionals that control huge chunks of healthcare funds. It is Health Insurances and not the medical professionals that too often decide what services should be delivered to patients and what shouldn’t. In Germany, according to AOK Health Insurance 2014 report which has provoked indignation among the physicians and hospitals alike, there were annually 19.000 preventable hospital deaths in the country [1]. For a comparison: car accidents took away the same year 3.290 lives.

InsurancesOne of the reasons for such appalling results (in particular, discussed in the German ZDF news program) was the amount of unnecessary surgeries performed in hospitals that expose patients to the risk of infection, collateral organ damages and finally death. According to the ‘Medical Experts Online’, a company that provides patients a platform for a second medical opinion, in 66% of cases the first recommendation in favor of surgical intervention was found inappropriate [2]. The situation in the US seems to be no better. In fact, unnecessary surgeries might account for 10% to 20% of all operations in some specialties, including a wide range of cardiac procedures [3].

So why insurances are spending money on procedures that are not only unnecessary, but harmful? The more money insurances spent, the more likely they receive additional funds or increase member contributions (the “premiums”) the next year. On the other hand, hospitals are rewarded with a bonus for each operation. Considering that each surgery costs in average about 40K euro, this is quite a lucrative business. The only unhappy creature is a patient who ultimately has to cover everything with his own health and money.

Under such a model, patient satisfaction is one of the last KPIs a hospital is concerned about. Patient has no choice: her or his clinical pathway was predetermined by Insurances.

Can patient satisfaction make healthcare prosperous?

One of such examples was a hospital in Torrevieja, Spain, a private and public partnership between Torrevieja Salud (the health system of Torrevieja) and the Government of Valencia. Dr. Barcia, at that time the Chief Executive Office of the hospital, had a difficult challenge: according to his agreement with the Government of Valencia, he received 571 euro per patient from the Government compared to 898 euro spent in average by a Public hospital in Spain. Should he nevertheless get a surplus through effective management, it could be reinvested into the hospital and his staff. Dr. Barcia staked on reducing excessive administrative costs and attracting more patients, e.g., out of 600.000 tourists that are coming annually to Valencia. The deal was strict: if a patient was not satisfied with care in Torrevieja and moves to another hospital, Dr. Barcia had to finance her/his full treatment in a new institution.

The challenge was not only to design an economic formula with effective care, but to make it repeatable as an accountable standard procedure. The first task was to cut on routine administration costs such as due to registration and numerous files filling. By 2007, this hospital was already fully automated.

Torrevijea.1png

Every morning Dr. Barcia was checking the “barometer” of his clinic. In 10 minutes he could get an overview of the hospital’s “Rhythm of Business” through Florence, the hospital management system designed by Miguel Ortiz, CIO of the hospital, together with his 8 team members.

Among 400 Key Performance Indicators (KPI) the patients’ satisfaction was among the highest priorities. Each patient‘s complain was registered and analyzed by the system. Doctors, not squeezed with the limits of standard protocols, were focusing on the outcomes: the effective cure and the ultimate patient satisfaction. The system captured the best clinical practices focused on individuals vs. a commonly adopted standard “average” patient.

The reception area was no longer a place for endless frustrating waiting. Patients were able to book their appointments via the patient portal. The system could automatically recalculate the waiting time letting them know when exactly they have to arrive. Such services have been available at airports for a long time. Why not in the hospital?

Doctors were no longer spending hours reading patient charts prior to visits: they could access the system from the comfort of their homes. As a result, the waiting time in Torrevieja was 50% lower than in other Spanish hospitals.

Effective management supported by IT saved 327 euro per patient. The difference Dr. Barcia reinvested in cutting-edge equipment as well as in trainings and incentives for his personal. Thus, the average income of the medical staff in Torrevieja was 40% higher than across the region. That attracted skilled physicians from all over the world. Patients from private hospitals nearby were often considering moving to Public Hospital of Torrevieja.

The efficiency of Torrevieja management was reflected not only by numbers. One could actually spot it the moment you were in. Suddenly you noticed a doctor talking to a nurse about a patient case – an unusual picture indeed. Observations made by the nurses were an integral and indispensable part of the care process under Dr. Barcia’s management. In the pediatric department I saw a farther sitting next to his child. A nurse came in asking the father if he may need something to eat or drink. In many hospitals I was visiting, relatives were most probably considered as camels: nobody cared if they eat or drink at all. A doctor dropped by to say hello to his patient. No formal round: just to cheer him up a bit. In many European hospitals medical professionals are working in teams: every day a new physician will see the same patient, so at the end both patient and his relatives are confused: who is really responsible? Whom can I talk to?

After one year Torrevieja Hospital under Dr. Barcia management was recognized as the best middle-size hospital in Spain. The hospital management formula based on patient satisfaction proved to be economically and professionally effective.

Florence, the IT management system, was later transformed into Green Cube, fully automated patient-centric IT system offered now to other hospitals together with the management consultancy.

Somebody would say that the heart of Dr. Barcia’s success were talented people, others would attribute the Torrevieja Hospital performance to an excellent IT system. Both are right. But nothing would have worked without the initial question: what can I do better for my patients? To make our Healthcare system better medical professionals should at least care and sympathize with their patients, regarding them as individuals and not as a mere collection of organs, although the latter view is presumed professional.

References:

  1. http://www.finanzen.de/news/14942/aok-krankenhaus-report-2014-rund-19000-tode-wegen-behandlungsfehler
  2. http://www.atelier.net/en/trends/articles/doctors-20-online-second-opinion-verifies-need-surgical-operation_430159
  3. http://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/

Can medical and consumer MHealth applications finally converge?.

For wearable devices and consumer applications to be successful, they should address more serious health issues than just Wellness and Fitness. This was the conclusion of the recent Juniper Research report which echoed many other respectable sources. As discussed in my previous blog the approaching wave of consumer wearable devices, people are getting increasingly bored with compulsively calculating their calories, steps and BMIs and expect mobile applications to shift to more serious health indicators, in particular, related to such areas as chronic disease management, active aging or disease prevention. Physicians, for their part, do not trust data coming from consumer applications that were not clinically tested.

There is an apparent gap between consumer devices, applications they are linked to and users’ aspirations. Nevertheless, developers continue to enthusiastically yield applications nourished with data with no meaningful use. If such trend sustains, the commercial mHealth applications will rapidly face public disillusionment followed by a collapse of startups that invested their money and intelligence in developing such applications.

But there is a light at the end of a tunnel. It seems that medical professionals together with engineering companies are entering the field by designing new types of medical devices that can collect data capable of providing physicians a much deeper insight into complex health issues. These portable wirelessly connected and miniature devices can assemble vital health parameter measurements such as ECG, blood pressure or blood glucose concentration, sending data to applications accessible to physicians anytime anywhere. If these endeavors are extended to the consumer market, we may see a new wave of commercial health devices and applications with wide acceptance from both consumer and professional medical environment.

I remember visiting the Amosov National Institute of Cardiovascular Surgery, one of the largest and most recognized cardiology centers in Kiev, the capital of Ukraine. A cardio surgeon, apparently coming directly from the Operation Theater, showed me a long line of people scuffling in the corridor. They came from all over Ukraine clutching CDs with their cardio images only to be diagnosed by the Amosov Institute experts. “We really do not know if these people are fit to travel”, explained the cardiologist. “Some of them may be at risk of a heart arrest on their way to the clinic. At the same time, we often have to respond to emergency calls travelling with full ammunition only to discover that the alarm was false. Imagine if somebody might really be in need at this very moment”.

Other European countries, with a much better Healthcare system than Ukraine, encounter similar problems. Pressed by costs, workload stress and time associated with visiting patients in remote areas, physicians are considering options that will allow them more flexibility in treating their patients. Patients, from their side, are ready to embrace services enabling them to be connected to their physician from home or anywhere. Instead of being “tied” to the bulky equipment installed in the hospitals every time an individual needs an ECG or an ultrasonic test, a patient can be linked to the physician or nurse directly going through the same checkup from a comfort of their home.

There are already some good examples of wearable equipment designed by medical engineering companies.

The Austrian company MedCubes’ product RemoteCase has recently received “the State Award for Consulting and IT”, the national prestigious acknowledgement for innovation.

MedCube

The solution is intended to link physicians to patients who have limited access to healthcare services. Compact and light wirelessly connected medical device “in–a-box” provides the wide range of high-quality measurements including 12-channel ECG, FastECG, stethoscope, oximetry, thermometer, blood pressure and blood sugar units, dermascope, otoscope, weight scale or selected rapid tests. The collected patient data are stored to a centrally located MedCubes private cloud system. Medical data are transmitted to PCs, tablets or smart phones accessible to physicians, depending on their role in the clinical process.

Physicians can run a remote triage based on more than 70 symptoms for each patient registered in the system. The measurements results are going directly to an application designed by MedCube. The elegant graphical interface allows doctors to easily navigate through multiple data.  screenshot_mainscreen_small

When a nurse is visiting a patient, she can take the assessments from a Fast ECG, oximeter or blood pressure device and save it to the central system for doctors to examine the results. The external specialists can get a limited access to the anonymized patients’ data if the “second opinion is required”. Physician can make an audio/video-chat with their colleagues, start chatting with a nurse or directly with a patient. The emergency visits are no more an unexpected surprise: physicians know exactly what to expect when they receive a call, while patients have a feeling that their situation is under a professional control no matter if they are in or out of the hospital.

The ultimate dream of medical engineering is to design devices that would help to monitor patients 24×7 with the minimum involvement on behalf of a physician.

The U.S. Food and Drug Administration has recently approved CardioMEMS Hearth Failure Management System, the first-ever wireless monitoring tool aimed to reduce heart failure hospitalizations and improve quality of life for cardio patients.

CardioMEMA

A tiny, wireless monitoring sensor, not bigger than a dime, is implanted in the pulmonary artery to measure pulmonary artery pressure, a procedure normally conducted in the hospital when patient’s heart failure conditions become critical. The new wireless option allows doctors to monitors patients remotely from home. After implanting a sensor via a catheterization procedure a patient is able to read data of his cardio pulmonary pressure from a small device installed in his/her house. The data are immediately sent to the secure Web site monitored by a physician who, if necessary, will be able to adjust medications and treatment process to patient’s health conditions.

According to the results of CHAMPION Trial American Heart Association 2014 the the devices can help clinicians to reduced HF admissions by 37% [1]

Conclusion

Contrary to the flood of allegedly consumer health applications designed for “healthy and wealthy” that fail to address the needs of chronically ill, aging or poor, the new wave of applications linked to miniature medical devices are embracing those who can really benefit from mHealth promises. Extended to the commercial environment, such device applications could finally bridge the gap between consumer and professional medical environment. A prudent developer should consider building connections to medical engineering companies, such as MedCube or the likes, to design applications with relevant health data sets to be successful on the market.

 

  1. Adamson et al., Impact of Wireless Pulmonary Artery Pressure Monitoring on Heart Failure Hospitalizations and 30-Day Readmissions in Medicare-Eligible Patients with NYHA Class III Heart Failure: Results from the CHAMPION Trial AHA 2014, Chicago. Abstract 16744