Guest posting by Allyson Knapper
This video explores the history and use of electronic health records (EHR) in U.S. hospitals
Category Archives: Design
Wearables: Not totally useless
Guest posting by Alisa Momin
The wearable technology market has been criticized repeatedly for failing to cater to patients who actually need to monitor their health on a regular basis in order to keep up good health and a decent quality of life. Instead, the industry is producing flashy technology for everyday people without chronic conditions or any real need use to track their sleep cycles or steps for about two minutes, before inevitably tossing them aside after the originality wears off. How many of us have tried tracking the amount of steps we take per day, or logging the amount of calories we digest and burn? How long did these practices last? Probably not long.
How do we fix this problem and make this kind of technology widespread and long lasting in the healthcare industry, where it has so much potential? By proving to people that wearables can actually help people detect chronic conditions, illnesses, or diseases before they have the chance to do much harm, we can overcome the lack of interest in wearables. We can also thereby move toward patients and consumers that actually have a need for this tech—especially aging patients with several chronic conditions. This is exactly what is happening now.
Recent news in healthcare is disproving the apparent uselessness of the current wearable technology market. The Scripps Translational Science Institute has received a grant from the USAID for its program that uses Sotera Wireless’ ViSi Mobile System to continuously monitor the blood pressure, pulse rate, ECG, breathing rate, temperature, etc. of Ebola patients through a wearable sensor. Ultimately, this would help in identifying warning signs of Ebola early on, before the virus has the opportunity to spread. Doctors’ chances to miss changes in health status will be significantly reduced, as they would receive the data collected regularly. This project, called STAMP2, could monitor up to 500 patients, with the potential to grow even further.
Why is this important? I believe this could be a new approach for this industry that opens up the usability of wearables on a global scale. If physicians become more aware of the widespread use of wearables, especially in preventing health concerns even as devastating as an Ebola outbreak, they will become more invested in applying this technology to their own aging patients in order to prevent or detect chronic conditions earlier. Patients tend to trust their doctors—44.2% have said their doctors’ recommendations would be an incentive to use a fitness tracking device. Hopefully, as wearables start to show that they are useful in healthcare, they will have the opportunity to impact more patients in the future.
http://www.wired.com/2014/11/where-fitness-trackers-fail/
http://technologyadvice.com/medical/blog/study-wearable-technology-preventative-healthcare/
Changing Physician Behavior: The Insurmountable Barrier?
Guest posting by Jesal Shah
Going forward, as identified by many in the first critique session, the most challenging task in our campaign to increase HIV screening by physicians will be the aspect of changing doctor behavior. Most health education efforts are usually patient-centered; moreover, a majority of recent attempts to change doctor and hospital practices have involved top-down, reimbursement and incentive-based mechanisms rooted in economics. This includes remuneration forms, such as salary, capitation, fee-for-service and diagnosis-related groups, as well as reinforcement schemes, like pay-for-performance or financial penalties. However, these strategies are beyond our limited institutional know-how and power.
Increasing physician testing of HIV will be particularly challenging, because screening benefits are not immediate. It’s as Dr. Atul Gawande, a prominent surgeon, health policy expert and author, puts it, “an invisible problem”. In his piece, “Slow Ideas”, Dr. Gawande contrasts the difference between the widespread adoptions of anesthesia, which provided visible benefits and eased doctor’s workflow, and the slow implementation of antiseptic protocols and technologies, which had less immediate returns and required greater doctor effort. Evidence for a certain practice in itself is not enough to build acceptance in the medical community.1,2 While there are very few high quality studies examining physician behavior change models/strategies, the status quo dissemination through publication, pamphlets or guidelines has been shown to be largely ineffective.2,3 These methods are extremely passive and distant; efforts, which are active and interactive, have been demonstrated to be more successful. These include in-person educational outreach or academic detailing. There has also been evidence supporting the utility of reminders or audit-then-feedback approaches. Overall, there are other innovative individual piloted techniques, such as Dr. Vivian Lee’s tactic to capitalize on the intrinsic competitive nature of physicians or Dr. Gawande’s mentorship network, which uses persistent human connection to promote behavior change. However, the most important message ingrained in literature is that multifaceted interventions tackling various barriers is better than a single campaign.2,3 This echoes the suggestions of many at the critique session, including our problem owner. Physician behavior change is an insurmountable barrier when approached narrowly, but in combination, many of the above techniques and others, can hopefully facilitate a change in HIV screening practices.
Sources:
- Gawande, Atul. “Slow Ideas.” The New Yorker. The New Yorker, 29 July 2013. Web. 14 Feb. 2015.
- Grimshaw, J. M., M. P. Eccles, A. E. Walker, and R. E. Thomas. “Changing Physicians’ Behavior: What Works and Thoughts on Getting More Things to Work.” Journal of Continued Education of Health Professionals 22.4 (2002): 237-43. PubMed. Web. 14 Feb. 2015.
- Smith, W. R. “Evidence for the Effectiveness of Techniques to Change Physician Behavior.” Chest 118 (2000): 8-17. PubMed. Web. 14 Feb. 2015.
An Example of Relaxing the “Every Patient is Unique” Assumption
Guest post by Andrew Dumit
“Lowering Health Care Costs Is Hard Because Every Patient Is Unique.” 1
This statement is not false – far from it, in fact. Yet, while it was a featured article in the Atlantic in 2013, framing this statement as the complete truth is paralyzing medical professionals from taking action.
One place where this belief has caused inaction is at local hospital, which is home to a world-class pediatric liver transplant team. My team has been tasked with lowering the cost per patient for the hospital by reducing the length of stay of pediatric liver transplant recipients, which the team at the local hospital has been unsuccessful at accomplishing. For each of the many lives saved there, a complex process must be completed, which includes three major steps: preparing the patient for surgery, performing the surgery, and preparing the patient for discharge. In the first two steps, the team has got their routine down, but the last step is where my team seeks to make an impact.
The question I asked myself was: how could relaxing the assumption that every patient is unique make an impact in the length of stay metric? To answer this question, I looked to a study done by a team that deals with adult liver transplants out of the University of North Carolina Health Care, Chapel Hill. Through their comprehensive study of their own length of stay, the team there concluded that “clear expectations, improved teamwork, and a multidisciplinary clinical pathway were key elements in achieving and maintaining these gains.”2 With this in mind, the aspect of the study that I’ll be investigating in the remainder of this post is how the clinical pathway created by the UNC team brought about tangible results by relaxing the uniqueness assumption
First, I looked at what was the thing keeping the local hospital from making similar changes to those performed in the UNC study. In the local hospital setting, the mantra that every patient is unique appears to reign supreme. Because of this, members of the local hospital’s team have been unable to take any meaningful steps towards truly changing the routine filled with miscommunication and inefficiency. By using the uniqueness of each patient as an excuse, the team refuses to treat some aspects of patients similarly. Conversely, the team in the UNC study went against the grain and tried to identify steps that were similar across patients to optimize those steps.
How did the UNC study take advantage of this relaxed assumption? Their checklist is a prime example. It sets forth the steps for each of the members of the team that must be completed before a patient can be discharged. In one way, this could be seen as homogenizing the patients and this seems to be the case at the local hospital. In fact, the current method for keeping track of a patient is a checklist unique to that patient. The local checklist is very much opposite to that of the UNC checklist, which is the same patient to patient. The reasoning behind the checklist at the local hospital seems to follow from idea that every patient is unique. However, their sparse list has not shown any improvement in length of stay, whereas the comprehensive and consistent pathway created by the team at UNC significantly reduced the length of stay.
Ultimately, in the case of the clinical pathway, if just a small number of tasks are similar patient to patient then making those tasks consistent and require the least additional effort possible can significantly speed up the process. And, if it’s true, which it appears to be, that more than just a small number of tasks are consistent patient to patient, we’ve found a truly tangible way to reduce length of stay by relaxing the assumption that every patient is completely unique.
The one thing I hope people take away from this blog post is that this is just one instance where the patient uniqueness idea has barred improvements in patient care. I don’t mean to say that we shouldn’t treat patients as unique, but I think it’s incredibly important to realize that we shouldn’t just look at patients for their differences. Instead, we should look for certain things about them that are the same and exploit those similarities to improve patient care and reduce hospital costs.
References:
- http://www.theatlantic.com/health/archive/2013/09/lowering-health-care-costs-is-hard-because-every-patient-is-unique/279950/
- Toledo, Alexander H., Tracy Carroll, Emily Arnold, Zeynep Tulu, Tom Caffey, Lauren E. Kearns, and David A. Gerber. “Reducing Liver Transplant Length of Stay: A Lean Six Sigma Approach.” Progress in Transplantation 23.4 (2013): 350-64. Web.
Physicians and Technology-Use Considerations
Guest post by Jesal Shah
Our class readings have touched on technology/social media utilization across various demographics: the elderly, the low-income population, American adults, individuals with and without chronic diseases, etc. We also examined how the online infrastructure and community can be utilized in patient-disease narratives/data sharing (e.g. ePatient Dave) as well as creative physician expression (e.g. zDogg M.D.). However, our design project aims to create a physician-oriented campaign to increase HIV testing. This population emphasis poses a unique question: how can we best utilize technology for a group of physicians who are highly educated, scientifically engaged, restricted by time, ethnically mixed and varied in age, amongst other criteria. After all, eHealth, in addition to those involved in the technology process, is targeted to not only patients, but also physicians. Here are four out of several considerations when thinking about doctors and technology use:
1. Physicians rarely engage in e-mail conversation with patients.1
This conclusion serves as an indicator for general informal outlets of patient-physician communication. There are significant barriers, such as general negative attitudes and inertia, reimbursement issues as well as patient confidentiality, which challenge much more organic forms of interaction through technology.
2. Time strengthens resistance to change.1
Those within one decade of medical practice were more likely to use technology (tracked by online journal access and utilization of real-time clinical decision making services) in their profession than those in their third decade of work. This also reflects general trends of society and age. For our project, it may be interesting to examine age demographics of the Harris Health primary care physicians.
3. Patients have surpassed physicians in incorporating IT for health purposes.1, 2
Patients tend to be much more willing to explore healthcare topics online than even physicians. Is this because of pedagogical methods in medical schools, information abundance online, poorly designed real-time clinical decision making services or something else?
4. Digital divide amongst Physicians: the adopters and the restrainers.
While there is considerable survey data that point to certain specific technologies/applications being adopted more widely by physicians, a study by Deloitte highlights the existing digital divide amongst physicians. They found that 78% of the 57% of physicians who don’t use smart phones for clinical purposes do not intend to change in the future. Those who adopted were more inclined to show greater enthusiasm for health technology in general.
Overall, this is only the beginning of the discussion surrounding physicians’ relationship with technology in the medical sphere. Hope to share more knowledge and firsthand experience in another blog post this semester!
1. Grant, Richard W., Eric G. Campbell, Russell L. Gruen, Timothy G. Ferris, and David Blumenthal. “Prevalence of Basic Information Technology Use by U.S. Physicians.” Journal of General Internal Medicine 21.11 (2006): 1150-155. Web. 8 Feb. 2015.
2. Baker, Laurence, Todd H. Wagner, Sara Singer, and M. K. Bundorf. “Use of the Internet and E-mail for Health Care Information: Results From a National Survey.” JAMA: The Journal of the American Medical Association 289.18 (2003): 2400-406. Web. 8 Feb. 2015.
3. Glenn, Brandon. “Nearly 60% of Physicians Don’t Use Mobile Technology for Clinical Purposes.” Medical Economics. N.p., 15 May 2013. Web. 08 Feb. 2015.