The future of healthcareLearn More

Are we are obstructing the doctor with gadgets?

Despite billions of dollars of investment in technology the results in healthcare are disappointing.

Information Technology (IT) surrounds us every day. IT products and services from smart phones and search engines to online banking and stock trading have been transformative. However, IT has made only modest and less than disruptive inroads into healthcare. Nicolas Terry (2013)

This was predicted in a prophetic article by Gregory Hackett (1990) when he concluded that:

The primary reason is that technology alone does not determine corporate performance and profitability. Employee skills and capabilities play a large role, as do the structures of day-to-day operations and the company’s policies and procedures. In addition the organisation must be flexible enough to respond to an increasingly dynamic environment. And products must meet customer requirements. Investment in Technology-The Service Sector Sinkhole? SMR Forum Service

However, there are still those who seem enamoured of machines:

Rapid growth of robotic industry is leading to novel applications in medical field. Evolution of new terminologies like tele-presence, tele-medicine, tele-consultation, tele-diagnosis, telerounding, tele-health centers, tele-doctors, tele-nurses are overwhelming and required to be readdressed.  Iftikhar

That way leads to a nightmarish world in which we push vulnerable people onto an assembly line and healthcare looks like this but also includes the dehumanising impact of machines:

….. hospitalists care for sick inpatients and are charged with rapid throughput by their administrative overlords; nocturnists do this job as well — but at night; intensivists take over when work in a critical care unit is required; transitionalists step in when the patient is ready to be moved on to rehabilitation (physiatrists) or into a skilled nursing facility (SNFists). Almost at the end of the line are the post-acutists in their long-term care facilities and the palliativists — tasked with keeping the patient home and comfortable — while ending the costly cycle of transfers back and forth to the hospital. Finally, as the physician-aid-in-dying movement continues to gain support, there will be suicidalists adept at handling the paperwork, negotiating the legal shoals and mixing the necessary ingredients when the time comes. Jerald Winakur- The Washington Post

Technology now impinges on every interaction- for better and for worse:

There were the many quiet voices who urged circumspection as long ago as 1990:

Diagnosis is a complex process more involved than producing a nosological label for a set of patient descriptors. Efficient and ethical diagnostic evaluation requires a broad knowledge of people and of disease states. The state of the art in computer-based medical diagnosis does not support the optimistic claim that people can now be replaced by more reliable diagnostic programs. Miller

One could not argue against technology as a tool but the art of medicine requires that technology helps the doctor. People are not disordered machines and the promise of better health is not forthcoming as we throw money at machines hoping for greater access, efficiency, and safety. However, there is now mounting evidence that the patient is not responding and it’s time to pause for thought, again.

It’s not that complicated. Healthcare works when the doctor and her patient are on the same page. So to what extent does a gadget or gizmo allow that? Does it help them to:

  1. Work out what’s wrong together?
  2. Make it easier for them to work together?
  3. Make it easier for them to achieve a goal together?

If it becomes a substitute for the doctor it will disappoint. People respond best to human doctors. No ifs or buts. Medical school 101. Doctors also have choices in how they deploy and interact with technology. Turning to face the computer, ordering a test and recommending an app aren’t always the way to the best outcome.

Picture by Guian Bolisay 

Much of what’s wrong with healthcare is in the consulting room

It’s not that complicated. Not really. So where do you look for pathology? Inspection, palpation, percussion and auscultation. How does it look, how does it feel, how does it sound and what do you hear when you know where to listen closely. I’m talking about healthcare. Take a helicopter ride through your business.

Access

What is the route to your service? Where is the delay? How long do people wait in the waiting room? How do you know? What do you know about the people who use your service even before they are seated in your waiting room?

Greeting

What happens when people call or arrive in person? What message is conveyed?

Welcome we’ll do our best to help you today OR you are lucky we are ‘fitting you in’.

Just stand there- I’m dealing with someone on the phone.

We have no time- go complain to the manager/politician/ bureaucrat-consider yourself drafted to the cause.

Hold the line. We are dealing with something far more important but your call is really important to us so just listen to how good we are as conveyed by our prerecorded message.

Associated with that is what is perceived about your attitude that is not verbalised?

Look at ALL these posters and the many ways you can be helping yourself instead of wasting our time.

People vomit and pee while they wait so the seats have to be cleaned with detergent. Plastic is the best option.

If you want a drink go buy one at a cafe.

We rely on donations for our toys and magazines- we don’t have to provide anything OK? Now if you don’t like the stuff just watch Dr. Phil.

What do you mean you have been waiting a couple of hours? This isn’t McDonalds now take a ticket, sit down, shut up and wait. And turn off your phone so you can hear the old lady at the desk who has an embarrassing problem.

Communication

How long is the meeting with the provider? How does that meeting unfold? What is conveyed during the meeting?

Welcome- I’m so sorry you are not well. Tell me what happened? OR I haven’t got long what do you want exactly, spit it out be quick about it I need to get on with the next guy. Didn’t you see the queue out there?

I’m the important one around here- you are lucky I’ve chosen to be here today. Let me tell you about my holiday, my kids, my new car. It’s fascinating really!

Room 5. Quickly. Never mind my name.

Test/ Referral and Prescription

What action is taken at the consult and are you confident that is the best possible action?

I don’t have time for talk- have this test and take another day off to see me next week.

I don’t have time for you to take off your umpteen layers- go have a scan.

The rep told me this works- I only have to write a script.

If you want to get better take my medicine/advice/ referral or get lost.

What medicine do you want? How do you spell that? Tell me slowly I’m writing it down on your script.

Outcome

What proportion of people takes your advice/medicine/test? How many people stopped smoking? How many were triggered to lose weight? How many are addicted to prescribed medicines? How many were prescribed treatment or tests that were not indicated? Where’s your data? What are your plans for dealing with this?

Team

To what extent can you say that when people transition to another healthcare professional either on site or elsewhere that the relevant information follows them? Is everyone on the same page with the same patient?

All of this matters. All of it. Some of you can fix tomorrow. No need to wait for another round of healthcare reform. No one said it was easy. And whatever their business the best don’t compromise.  A lot of what can be fixed in healthcare takes place behind the closed doors of the consulting room.

Picture by Daniele Oberti

The welcome rise of alternative providers

Two weeks ago an 80-year-old waited without food or drink for 14 hours in a Dublin city emergency department having fallen in her local supermarket. She was black and blue from head to toe a response to the call of gravity when she was launched off a faulty escalator. She was ‘triaged’ and seated next to drunken revelers who also managed to injure themselves on that fateful evening. She was seen for all of 10 minutes by a medical student and then briefly by a doctor who recorded that her visual acuity couldn’t be assessed because she didn’t have her glasses. With that, she was sent home with her granddaughter and asked to return a couple of days later when she again waited another 9 hours for a five-minute consultation presumably so that the doctor could make sure she hadn’t really injured herself and wasn’t going to sue the hospital as well as the supermarket.  I know this person and read the discharge summary even though her daughter and I live on the other side of the world. As far as we know the provider believes we should be thankful because they are very busy and at least ‘someone’ saw her.

What’s it like to be your patient?

  1. How long do your patients wait?
  2. How are they greeted on arrival and how do they feel about waiting?
  3. What do they do while they wait?
  4. How long do they see you on average?
  5. What do they expect from the visit?
  6. Why do you order tests? What difference do these tests make to the outcome?
  7. Why do you prescribe those drugs? How many people take them as prescribed?
  8. Why do you ask them to return for a review appointment?
  9. Why do your refer them to someone else?
  10. What do they tell their family about your service?

No business would survive without a handle on this information. Arguably some sectors of the business of healthcare only survive because of a monopoly.

A newer take on the organizational environment is the “Red Queen” theory, which highlights the relative nature of progress. The theory is borrowed from ecology’s Red Queen hypothesis that successful adaptation in one species is tantamount to a worsening environment for others, which must adapt in turn to cope with the new conditions. The theory’s name is inspired by the character in Lewis Carroll’s Through the Looking Glass who seems to be running but is staying on the same spot. In a 1996 paper, William Barnett describes Red Queen competition among organizations as a process of mutual learning. A company is forced by direct competition to improve its performance, in turn increasing the pressure on its rivals, thus creating a virtuous circle of learning and competition. Stanford Business

Certainly, the 80-year-old had no option but to go to a state hospital emergency department because there was a very real possibility that she had fractured something coming off that escalator. The hospital manager might say in her defense that they have no option but to offer the service as described, but where is the data to demonstrate that it is the lack of options rather than a lack of interest or talent in managing one of the most important services the state is charged by taxpayers to provide? The monopoly may be around a little longer when it comes to life-saving treatments but what about primary care? If this 80-year-old can wait 14 hours to be seen by a medical student there may be real scope for the service to be provided by someone who is qualified, will see her much sooner and offer her a cup of tea while she waits for the X-rays to be reported. What about the scope to provide better than what you offer?

Picture by Toms Baugis

No plan, no progress it’s a simple equation in healthcare

Every business manager can lay her hands on plans and policies and can probably recite the ‘vision statement’. I like the one for Lexmark printers because I think it works for healthcare clinics:

Customers for life. To earn our customers’ loyalty we must listen to them, anticipate their needs and act to create value in their eyes.

The manager’s shelves might house annual accounts, a policy for Human Resources,  a policy for health and safety, a policy for recruitment. The practice may have a chartered accountant, a registered financial advisor, a recruiter and an HR manager. Rarely if ever does a clinic have an appropriately qualified research consultant or a five year R&D plan or policy.

Therefore the manager relies on anecdotes and other people’s data to decide if the practice is delivering accessible and effective services. The practice relies on others to advocate for them and to defend the charges that are levied on their behalf. It’s all left to persons unknown in a far away bureaucracy.

The consumer relationship starts with the brand. Before you even meet the consumer, you must fully understand your brand. If you don’t know who you are as a brand, and what makes you different, better, and special, how do you expect a consumer to? You must clearly define a brand’s product benefits to set up more intimate, emotional bonds. It is these emotional bonds that will form the basis of a lasting consumer relationship. HBR

If you are a clinician in a practice what aspects of the practices’ vision are non-negotiable and how will you know if something is undermining that vision? How reliable and valid is your understanding of the following:

  1. What is the context in which the practice is located? What drives morbidity locally?
  2. How are people greeted at the practice? What do they notice about your premises?
  3. What is the commonest reason for attendance?
  4. How long is the average consultation?
  5. What is the outcome?
  6. How many people receive less than evidence based care? Why? What are the consequences?
  7. How many people take your advice? How many go elsewhere after coming to you?
  8. Which innovation is going to be introduced and tested in your practice in the next five years?
  9. What information will guide investment decisions in the practice?
  10. Are you participating in externally funded research? Why those projects and not others?

These questions are of great interest to the better companies. Companies that are ‘lovemarks’:

Lovemarks reach your heart as well as your mind, creating an intimate, emotional connection that you just can’t live without. Ever. Lovemarks

Never let innovation for a brand be something that happens randomly. It should fit strategically under the brand. At Beloved Brands, we believe the best brands build everything that touches the brand around a Big Idea, that guides the 5 magic moments to create a beloved brand, including the brand promise, brand story, innovation, purchase moment and the brand experience. beloved brands

If these issues are of interest to you I invite you to contact me to develop a plan for your practice.

Picture by UCL Mathematical and Physical Sciences

Why healthcare outcomes are resistant to policy change

13799802965_b07db37bf2_zAfter every match, the cricket coach gives feedback about how the match was won or lost. Whenever the team wins it’s usually because of high scoring batting, or a great performance by the bowlers. However, when they lose there’s almost always one reason—poor fielding, dropped catches, easily conceded single runs and inaccurate throws.

In medicine surgeons are the batsmen, in most games they are seldom in play for very long. When the surgeon gets involved the crowd holds its breath for something magical to happen and when it does they celebrate with ‘Mexican wave’. Physicians are akin to bowlers, trying different deliveries, aiming to make it difficult to concede runs, patiently waiting for an unforced error. Occasionally screaming at the umpire for a decision in their favour. In the limelight an over at a time.

General practitioners are the fielders, rarely flamboyant and hard to tell apart. Constantly moving across the field, often to simply return the ball back into play. Standing for hours in the hot sun, occasionally chasing a ball to the boundary. Always trying to limit the damage. No matter how good the batting or the bowling is, if those in the field are not fully engaged, or solving problems creatively, if they are not intuitive, or working for the common good, without waiting for instruction after every ball is delivered then the game is lost.

As a primary care practitioner I am aware that most of the patients I see won’t have life-threatening pathology, but occasionally I’ll get a chance to make a game-changing difference, and on other days, my patients feel safer knowing that I am there. I don’t need to make any fancy moves, most of the time what I do is simply ensure that I nip things in the bud.

In medicine, most people consult a general practitioner and not a surgeon. That’s where innovation has the scope to make a difference to most people. Without reference to the practitioners who work at the coalface no amount of policy change is likely to make a difference to outcomes. That’s because fielders can’t do their job with one hand tied behind their back or by ignoring the evidence of their own eyes, or by focusing other than on the ball. According to the experts good fielders:

  1. Don’t move. When the captain puts them somewhere they stay there until they are moved again.
  2.  Show confidence. Looking confident in the field can save many runs.
  3.  Will throw at the stumps whenever there is a chance.
  4. Back up.
  5. Want to get every ball.
  6. Are close enough. If they are on the boundary their job is to save fours so they stay as deep as possible without giving away two runs if they can.
  7. Know themselves. If they have a setback in the field, they are aware of how they will react to it.

These simple rules tell us that it is imperative to work with the fielders if the team is to win the match. Failing to do so, like failing to work with the doctors most likely to come into contact with patients leads to frustration. The emotion that most funders experience perhaps because they do not understand the business of doctoring. We need to reframe problems in healthcare as a failure to engage with front line staff.

Picture by Lawrence OP

Healthcare is not akin to internet shopping

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It’s encouraging when the patient asks you for your card after consulting about their warts. It suggests you have earned their trust and the next time they present you can expect to hear about something more worrying.

With regard to primary care there are those who believe there is money to be made by providing access to any doctor, anytime over the internet. However, the first commercial failure of this approach has just come to light. HealthSpot was featured in the New York Times, the BBC news and the HuffPost tech. According to posts on the internet:

HealthSpot Inc. told its largest pharmacy chain customer, Rite Aid Corp., that it would “cease operations” as of Dec. 31, and its telemedicine stations have shut down in Rite Aid pharmacies in northeast Ohio and the Dayton area.

And this after announcements in Mar 2015 that Internet provider Cox Communications was pouring money into HealthSpot, a telemedicine kiosk provider. At the time the Internet provider was reported to suggest that this could be:

As important to health care as ATMs have been to banking.

There was an expectation that doctors would virtually diagnose ailments such as allergies, bronchitis, the flu, earaches and ear infections, fevers, rashes, and sinus infections.

The model was nicely illustrated in this video.

But something appears to have gone drastically wrong and according to journalists attempts to reach the HealthSpot CEO have been unsuccessful. Commentators have been speculating that what may have contributed to the demise. An interesting comment was reported by Neil Versel

Jason Gorevic, CEO of telemedicine company Teladoc, expressed his belief that there are three critical elements to success in this industry segment: the technology platform, clinical capabilities and consumer engagement. “Consumer engagement is hard to do,”

And that may be the crucial point- the patient experience was not baked into the design of this innovation. The limitations of telemedicine in the context of primary care may be far greater than is being acknowledged by people who have very little insight into the business of doctoring.

Three years ago our research concluded:

Patients with minor self-limiting illnesses and those with medical emergencies are unlikely to be offered access to a GP by video. The process of establishing video consultations as routine practice will need to be endorsed by senior members of the profession and funding organizations. Video consultation techniques will also need to be taught in medical schools. Jiwa et al.

A minor illness provides an opportunity for the doctor to bank social capital, something that both will rely on when the symptoms presented at a future consultation suggest a life-threatening pathology.

Photo by C.C. Chapman

For best results next year leave the office now

A

Let’s agree what success looks like at work. It’s simply ‘better outcomes for those you serve’. It’s about improving on what was done yesterday. Machines can ‘do’ many things but they can’t imagine. People can be made to work like machines but unlike machines their ‘parts’ can’t be replaced easily when things start to fail. However people can be replaced. If you exist to ‘do’ things that could be done more efficiently or more profitably you will be replaced perhaps not today or tomorrow but soon enough. If your boss doesn’t sack you, one day in the foreseeable future you will walk out when it all gets too much to bear.

So your real value in whatever you do is the ability to add value and to do that reliably and sustainably.

Think of a time when you landed that job, made that discovery, found that break through, solved that problem. Could it all have been different? What if you had failed that exam? What if you had succumbed to that virus? What if you hadn’t met that key partner? What if they hadn’t supported you? What if the funds hadn’t been available? What if you hadn’t attended that course or crossed that road? What if Fleming hadn’t gone on holiday or noticed that Petri dish?

Often described as a careless lab technician, Fleming returned from a two-week vacation to find that a mold had developed on an accidentally contaminated staphylococcus culture plate. Upon examination of the mold, he noticed that the culture prevented the growth of staphylococci. Endocrine today.

What if the egg containing your genes hadn’t been fertilised? Your life by statistical computation is a miracle.

If you go back 10 generations (250 years) the chance of you being born at all is at most 1 divided by 6 x 10100 or
1 in 60000000000000000000000000000000000 00000000000000000000000000 000000000000000000000000000000000000.
In gambling, even a chance of 1 to 100 is not worth a gamble. Hooge

You don’t really ‘do’ anything other than join the dots, but first you need to see the dots. There is nothing you have including life that couldn’t be taken from you in an instant.

At this time of year, for many people, there is an opportunity to invigorate that part of the brain that is the crucible of creativity. For best results flood the senses with new experiences; listen to new songs, read, taste different food and let your brain prepare to solve problems by making room for new ideas. De-clutter, let go the oars and do that for the sake of those you serve if not yourself. So say to your boss this is the most important thing you are doing for him this year- sharpening the saw.

Do you believe this sound conducted by Morricone is the product of a mind focused on the banal? You too have done some extraordinary things this year- big things, little things, all of which point to your potential to improve this world. What you believe about where the ideas come from doesn’t matter because they will continue to flow into our experience notwithstanding your convictions. What will matter to your boss in January is that you have an active problem solving capacity. So take a holiday. Enjoy!

Picture by Claus Rebler

The way you practice medicine is about to change

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Healthcare reform is inevitable. We are not doing enough to meet the growing need for healthcare in our communities. A failure to act now could bankrupt our economies or reduce our capacity to maintain a productive, taxpaying workforce. Outcomes in healthcare have many drivers and are not limited to incentives to meet arbitrary targets. Attempts to reform healthcare have not been universally successful with many adverse consequences of misguided policies such as introducing ‘pay for performance’ especially in general practice. There is a limited supply of doctors in some parts of many countries with a relative oversupply elsewhere. There is much scope to improve access to doctors by deploying the Internet without forcing doctors to locate to those areas. There is much to do to reduce medical errors and to curb the cost of treatment. These ten very short videos are the case for the prosecution:

The population is getting older.

The prevalence of chronic disease is rising.

There are not enough doctors where they are needed.

There is scope to radically improve access to medical practitioners.

There is sometimes a failure to communicate with patients.

The cost of treatment is rising above the rate of inflation.

We conduct unnecessary investigations.

There are expensive medical errors.

There is limited flow of information across provider interfaces.

Plans to reform healthcare have not been universally successful.

Picture by Hendel Thistletop

Innovation is a product of leadership

339113868_1052c8c6a0_zInnovation is ‘a new idea, more effective device or process’. Innovation can be viewed as ‘the application of better solutions that meet new requirements, inarticulated needs, or existing market needs’. It is the fruit that appears on the branches of an organisation where every active component or member has at least what they need to thrive. Maslow identified the hierarchy of those needs. Not every ant in a colony is the queen. Not every ant has to gather food. However if the colony is to thrive every ant must play its part or work with others to solve a problem creatively.

The leader is only ever accepted in nature when the colony thrives. If the leader or potential leader has a limited capacity to facilitate the success of their colony, they are replaced or ejected. At the moment when the team faces a challenge that could impact on their capacity to be productive the individual team members must rise to the challenge. Any solution must not risk the colony. That means that foot soldiers need to live the mission of the colony, they must know the limitations of their mandate but not have to ask the ‘most senior manager’ if it’s OK to do something that brings success in their tasks.

Leaders embody the behaviours and attitudes that give the foot soldiers confidence. They communicate effectively. They ensure an adequate supply of that which underpins creativity. They ensure that the needs, as opposed to the wants of their team are satisfied.

The list of innovations produced by a company is a litmus test of the effectiveness of its leaders. The most prolific innovators foster a culture that will continue to contribute to human welfare. Their leaders have the capacity to ensure that each and every member of their team feels valued but also understand and accept the mission of the mothership. The employees learn to behave as part of the whole and yet feel empowered to boldly solve problems in their domain. A critical component in innovative human organisations is the enlightened and selfless exercise of power where relying on the natural response to chemical pheromones is not an option. If you believe you cannot be involved in any research or innovation where you work you may have a problem. An inventory of your new ideas may be a good place to start a review.

Picture by Kasi Metcalfe

A lens for new ideas

3168683736_304641aa66_zLast week our team  published a paper exploring the scope to improve the advice offered to patients (i.e. to change the behaviour of the practitioner). We focused on people with dementia who present with challenging behaviours because so much more is on offer to patients living with this condition than is promoted by doctors. The team explored the practitioners’ perspective on the issues with reference to simulations. Referring back to Lewin’s equation, B = ƒ(P, E) i.e. behavior is a function of the person in their environment.  Professional behaviour change is also subject to Fogg’s model  so behaviour is a function of motivation, ability and trigger (B=MAT).

In addition any consultation with a health care practitioner motivation is highest when the practitioner is:

  1. Rewarded for action (A) in those circumstances.
  2. Able to act within the time (T) available
  3. Has the scope to reduce risk (R) to the patient but also the risk of litigation or complaint

M = A+T+R

The ability (A) to do the needful is a function of:

  1. Cost (C) of the treatment or intervention
  2. Effort (E) required to access it

A = C+E

Finally the Trigger (T) to adopting the requisite behaviours are determined by:

  1. Recognising the patient (P) for whom the action is indicated
  2. Knowing (K) what is available in the circumstances

T=P+K

With this lens our data suggests that an intervention to increase referral to community support agencies (the desired behaviour) should consider the following:

Motivation

A: Some participants in the study expressed the view that care coordination would be unrewarding.

T: This was not specifically explored in relation to these scenarios however it is possible, that people presenting with such problems to a doctors office would require more time than is available in short primary care consultations.

R: Feedback to the practitioners on individual scenarios highlighted the risk of medicolegal consequences of a failure to act. There was a marked improvement in the proposed management plans when this was pointed out.

Ability

C: There was no cost to the practitioner or the patient in making a referral to a community support agency. However practitioners expressed the view that care coordination in this setting is ineffective.

E:In many cases it was considered difficult to coordinate the care of patients with behavioural problems in the context of  a dementia diagnosis, however the level of difficulty was not a factor in the decision to coordinate care for this group of patients. The data also suggests that older practitioners were more cynical about their ability to coordinate care.

Trigger

P:Some scenarios where the scope to assist was apparent were not recognised.

K: When practitioners were made aware of what was available to them, they were more likely to act.

Therefore an intervention that could promote referral to community support agencies for people exhibiting behaviour change in the context of dementia would have all of the following characteristics:

1. Emphasise the responsibility of primary care practitioners to act in these circumstances, including the medicolegal consequences of a failure to act.

2. Make it easier to find and refer to voluntary and statutory support agencies and

3. Where the motivation and ability has been optimised include reminders that specific patients would benefit from support – for example the driver whose cognitive function is a risk to other road users.

Picture by nhuisman