This appeared last week:
Digital health success hinges on four principles
Bianca Phillips
Bernard Robertson-Dunn
Bernard Robertson-Dunn
This is the third article in a series on the making of the digital health revolution.
IN 2012, Dr Eric Topol published The creative destruction of medicine: how the digital revolution will create better health care.
Dr Topol’s book is excellent in describing the problems with the current health care industry. At the end of the book he observes:
“Not a single aspect of health and medicine today will ultimately be spared or unaffected in some way. Doctors, hospitals, the life science industry, government, and its regulatory bodies: all are subject to radical transformation.”
Dr Topol’s book was written over a decade after a report from the Committee on Quality Health Care in America, which was part of the Institute of Medicine – Crossing the quality chasm: a new health system for the 21st century.
Why are we still far from seeing mainstream uptake of digital health?
The major reasons are that it is unclear whether the benefits of digital health technologies outweigh the risks and costs. There is also the fact that digital health involves a shift in mindset about how medicine should be practised. And we don’t have a consensus among clinicians, technologists and lawmakers of what the future should be, other than it must be different from what we have today.
The current approach
In applying IT to health care a common assumption is that the application of technology that was designed to solve other problems through standardisation, industrialisation and production lines will work with health care. What is happening in some cases, electronic health records being an obvious example, is that technology-driven solutions cause more problems than they solve. There are an increasing number of reports that doctors are spending considerable time on data entry resulting in dissatisfaction and sometimes burnout.
Many digital health initiatives today focus on symptom-driven, statistical, pattern-matching, correlation and risk reduction approaches. The transformation of health care requires a radical change to this approach to make medicine more personalised to the individual patient.
The future paradigm
The advancement of personalised medicine is a priority of governments and research institutions around the world, and rightly so given the impact that it could have on individual health and wellbeing.
Personalised medicine is concerned with understanding the uniqueness of individuals, not just from assessing their DNA but their lifetime experiences, their behaviour, and their interactions with their environment, and diagnosing and treating patients by identifying causes and effects and treating the cause.
In order to shift towards personalised medicine four things are needed:
- the acquisition of more and better data from the patient at the time and point of care;
- diagnostic tools and models that understand and interpret these data;
- treatment that addresses the cause of the problem; and
- a health care system that efficiently utilises this radically different approach to clinical medicine.
Real advances will not come from automating what is done today, but from a deeper understanding of how to identify the key characteristics of a person, their condition as presented at the point of care, and individually tailored treatment plans that are constantly monitored and adapted as the patient adapts.
An illustration of the complexity of understanding and treating the unique systems of the individual is the example of neurogastroenterology.
Medical science is discovering that the human digestive tract has a nervous system second only to that of the brain. There are also biological sensors and actuators that control the complex behaviour of digestion, absorption and waste disposal. Fully understanding this subsystem of human biology will require engagement with those more familiar with industrial automation and control systems. Achieving a good understanding is made more complex because there is no definitive design; it is often self-healing and is constantly interacting with external influences. Neurogastroenterology is only one area where the study of dynamic systems and control theory are essential to the transformation of health care.
The personalised medicine movement explores individualised health from various perspectives. One such perspective is that of pharmacogenomics, which looks at how our genes affect our reaction to particular medications. The United States Food and Drug Administration recently approved a direct-to-consumer pharmacogenomic test, offered by company 23andMe.
The limitation at present is that tests such as these are still far from being relied upon in clinical practice:
“Eric Topol, a geneticist at the Scripps Research Institute, points out that the genome variants they are analyzing are very limited. It’s simply too early. A review published by the American Psychiatric Association task force concludes that while initial data on the association of genetics and drugs has been promising, there’s not enough evidence to justify the widespread use of pharmacogenetic tests”.
Other advances in the field of personalised medicine include epigenomics, which seeks to understand the “on” and “off” switches of our genes, how these switches are altered by our environments, and the ways in which genetic instructions are used by cells when these changes arise.
“Until recently, scientists thought that human diseases were caused mainly by changes in DNA sequence, infectious agents such as bacteria and viruses, or environmental agents. Now, however, researchers have demonstrated that changes in the epigenome also can cause, or result from, disease. Epigenomics, thus, has become a vital part of efforts to better understand the human body and to improve human health. Epigenomic maps may someday enable doctors to determine an individual’s health status and tailor a patient’s response to therapies.”
National Human Genome Research Institute
Epigenomics
Epigenomics
A direct-to-consumer epigenomic test is currently offered through the company Chronomics. However, the test is limited to assessing biological age, smoke exposure and metabolic state.
The exposome is another field of enquiry looking at how our environment influences our health. The exposome focuses on how the totality of our environment from conception onwards affects our internal environment. Digital health technologies can serve an important role in this field:
“New tools and technologies that can be applied to address these challenges include exposure biomarker technologies, geographical mapping and remote sensing technologies, smartphone applications and personal exposure sensors, and high-throughput molecular ‘omics’ techniques”
Other areas that will have implications for personalised medicine include transcriptomics, proteomics, phenomics, microbiomics and metabolomics.
More here:
To me what is being raised here is the suitability of our present technological paradigms to address what really makes the delivery of safe, quality and consistent care so difficult. We need tools that empower and support clinicians, in all aspects of care delivery, and to date we have not been able to properly imagine, design and implement those tools.
The level of frustration and annoyance with what presently exists tells us that.
This recent article highlights the problem:
Study Links Stress from Using EHRs to Physician Burnout
by Heather Landi, Associate Editor
More than a third of primary care physicians reported all three measures of EHR-related stress
Physician burnout continues to be a significant issue in the healthcare and healthcare IT industries, and at the same time, electronic health records (EHRs) are consistently cited as a top burnout factor for physicians.
A commonly referenced study published in the Annals of Internal Medicine in 2016 found that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day.
Findings from a new study published this week in the Journal of the American Medical Informatics Association indicates that stress from using EHRs is associated with burnout, particularly for primary care doctors, such as pediatricians, family medicine physicians and general internists.
Common causes of EHR-related stress include too little time for documentation, time spent at home managing records and EHR user interfaces that are not intuitive to the physicians who use them, according to the study, based on responses from 4,200 practicing physicians.
“You don't want your doctor to be burned out or frustrated by the technology that stands between you and them,” Rebekah Gardner, M.D., an associate professor of medicine at Brown University's Warren Alpert Medical School, and lead author of the study, said in a statement. “In this paper, we show that EHR stress is associated with burnout, even after controlling for a lot of different demographic and practice characteristics. Quantitatively, physicians who have identified these stressors are more likely to be burned out than physicians who haven't."
https://www.healthcare-informatics.com/news-item/ehr/study-links-stress-using-ehrs-physician-burnout
Here is what the US Government is thinking about the issue:
Bottom line – a fundamental rethink and so on is required. You can be sure the myHR is not part of the answer!
What do you think is?
David.
3 comments:
"What do you think is?"
That's a silly question. It's also a rhetorical question. Have you not provided the answer by saying "a fundamental rethink and so on (whatever so on means) is required."
Calls for a fundamental rethink have been made loud and clear for many years to no avail. Therefore it is futile to keep suggesting the way forward lies in a fu mb fundamental rethink. A ccompletely different strategy and approach to the problem is required by others who have not been tainted and poisoned by current approach to public sector thinking.
I think you will find while government and ADHA have been co-designing the colour scheme for the user interface life has passed them by. That has left a gap, that gap presented market place needs and options for new commercial models. What ADHA is discovering is this is transparent to them (if they care to look) but not open to them. So transparency is a view, open is invitation access.
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