Recently in clinical systems Category

The dilemma with healthcare reform partly stems from our unwillingness to throw our neighbors to the wolves. Source: Selling Among Wolves.

The good news this week is the trend in healthcare reform. It looks like the U.S. Legislature is once again finding itself incapable of passing meaningful healthcare-reform legislation. If this trend continues, what we'll be left with sometime next year is legislation that makes just enough change to allow the President and Congress to claim a victory, but not enough to make any real difference. This is not surprising, since it's been the same story for every major effort taken up by the current crop of Senators and Representatives.

It's good news because it means the Federal Government will at least do no harm. Or, at least no harm that can't easily be undone in the future.

We actually can't fault Congress for failing in fact, even if they find a way to succeed in headlines. There's a basic flaw in our health care system that can't be fixed. It's actually a flaw in the philosophical underpinnings of our society: we are incapable of applying the 95/5 rule from systems engineering to many of our social problems. We're seeing it in healthcare simply because that's the part of our social infrastructure that has most obviously run into a brick wall.

The 95/5 rule, like many systems engineering principles, sounds precise and quantitative, but isn't. It belongs in the realm of fuzzy logic, which only a few academics, and practically nobody else, understands. Unfortunately, nearly all decisions human beings are asked to make must be made using fuzzy logic. Fortunately, the ability to do fuzzy-logic analysis accurately and at blinding speed is one of the human brain's greatest strengths. Even better, the recognition of both fuzzy logic's importance and humans' aptitude for it is growing rapidly.

The 95/5 rule is just one expression of the fuzzy proposition that, as progress is made in any cumulative effort, gains become ever more difficult to achieve. (To the fuzzy-logic mavens out there: I know I've not couched this proposition in any rigorous way, but to do so would require a lot of verbiage that only you and I would want to read. Everyone else would go away, and thus miss out on today's exciting episode.)

The rule is an extreme version of the more familiar 80/20 rule, which says that 80% of the effort must be expended to achieve the last 20% of the gain. Conversely, the first 20% of the effort generally achieves 80% of the gain. Stated more generally, and more accurately, the effort needed to make further gains increases roughly exponentially with the gains already made. More fuzzily: you reach a point of diminishing returns.

Use the 95/5 rule when you've already blown past the 80% level. The next stop, of course, is the 99/1 rule that says you'll need 99% of the already-expended effort to get the next 1% gain. We try not to go there.

How this applies to healthcare is the simple statement that the easy gains have already been made. The reason healthcare costs are rising so rapidly is that we are now trying to push healthcare well past the point of diminishing returns. The Quixotic goal is highlighted by Pres. Obama's stated goal of providing health insurance for every dang American regardless of their ability to walk through the woods without bumping into trees.

Basically, we're trying to keep medical progress moving along a linear track. Ergo, the cost is rising exponentially.

In a misguided attempt to "fix the problem," most of us have, instead, tried to fix the blame on a boogeyman: the health insurance system. The theory seems to be that, if we can come up with a clever enough formula for health insurance, the cost of healthcare will take care of itself. This seems to be the tack Congress is taking, and, thank God, it isn't working. The cost of healthcare is taking care of itself, alright; it's expanding to take over the Universe!

In future blog entries, I hope to take a look at why medical progress is hitting a wall, and why we're fundamentally unable to deal with the situation. By way of a preview:

Medical progress is hitting a wall because most of the medical conditions that killed off our ancestors have already been eradicated. That was the easy stuff - requiring only a half dozen millennia to complete. Now, all we have to do is the hard stuff.

Human society can't deal with the problem because our basic moral and ethical assumptions don't allow us to throw our fellow human beings to the wolves.

To be sure, I do not have an answer. Like almost everyone else on the planet, I'm not ready to walk up to another human being, whether a loved one or stranger, look them in the eye, and say: "You're too old/sick/feeble/whatever to live. Go die!"

I know a lot of people willing to consider it as a philosophical exercise, but not-a-one who could bring themselves to do it in fact. Well, except maybe some inmates of institutions for the criminally insane.

Therein lies our dilemma.

Speakers to describe experiences of overseas healthcare systems.

"The primary purpose of comparative effectiveness research is to inform healthcare related decisions," according to Ted Buckley, Ph.D., Director of Economic Policy at the Biotechnology Industry Organization. While definitions of comparative effectiveness analysis methodology differ (Buckley lists four examples in his white paper The Complexities of Comparative Effectiveness), they commonly include three elements:

• Comparison of one treatment to one or more other treatments;
• Treatments compared are not limited to medications only;
• Both risks and benefits are included in the assessment .

Comparative effectiveness analysis potentially enters the debate over health-care reform as both content and method. Specifically, the role of comparative effectiveness as a method of choosing between clinical options may be institutionalized as part of the reforms mandated. Also, as a decision-making algorithm familiar in the medical profession, comparative effectiveness analysis could be applied to choosing between different reform proposals. Indeed, with suitably chosen effectiveness criteria, the methodology could be applied to essentially any decision in any field, from what to have for dinner to global economic policy.

On 1 October, the Center For Health Care Management & Policy at the Paul Merage School of Business at the University of California, Irvine plans to present a one-day conference entitled Comparative Effectiveness: Lessons From Abroad. Sponsored by Kaiser Permanente and the California HealthCare Foundation, the conference program includes talks by expert speakers from Britain, Canada, Germany, and the United States on key issues facing the nation on health care reform. Conference organizers hope to provide a unique venue for dialogue among private and public sector leaders that will help to determine what the U.S. can learn from other countries in using comparative effectiveness (CE) analysis to improve health care quality and efficiency.

The conference is aimed at:

• Physicians and nurses in administrative positions, physicians in private, group or clinical practice;
• Presidents, CEOs, trustees and senior management in provider and insurer organizations;
• Senior executives in pharmaceutical, medical device, biotech and other health care organizations who define strategy and policy;
• Employers who deal with the problem of ever-increasing health care costs while attempting to increase employee choice; and
• Government officials who define and implement health policy.

For more information contact Margaret M. Wong, Associate Director of the Center for Health Care Management & Policy at the Paul Merage School of Business, University of California Irvine by telephone at 949-824-8474, or by email at mwong@uci.edu.

Nearly every technophile on Earth has seen Star Wars medical droids subbing for human physicians, surgeons, and other medical professionals. Unlike most technological marvels portrayed by Hollywood as existing sometime in the far future, such robots aren't that far from reality. A case in point is GeckoSystems Intl. Corp.'s CareBot robotic elder-care system, which graduated to nurses' aid status with the addition of a miniaturized, solid state onboard blood pressure and pulse rate monitor.

Carebot interacting with house-bound individual.

"We believe that the incorporation of an onboard blood pressure/pulse rate monitoring system for our CareBots will further enhance their cost effective, utilitarian capabilities. Our CareBot's ability to automatically follow and verbally remind a designated care receiver at predetermined dates and times that their blood pressure/pulse rate needs to be checked by this onboard, integrated monitoring system will enable a higher level of safety, security and cost savings for those at home and in nursing homes, assisted care facilities, hospitals, etc.," observed Martin Spencer, President/CEO of GeckoSystems.

The company says CareBot is a multitasking personal robot incorporating advanced, proprietary AI engines. Given the CareBot's network connectivity and Internet accessibility, alerts of vital signs and other various healthcare events outside of normal range can be quickly sent by telephone, instant or text messaging, and/or email.

GeckoSystems uses sensor fusion extensively for actionable situation awareness in their complete multitasking personal robot, the CareBot. Their mobile robot's hardware and software architecture is designed to be expandable and upgradeable such that many years of cost effective usage can be readily achieved.

The primary market for this product is the family for use in eldercare, care for the chronically ill, and childcare. The primary distribution channel for this new home appliance is the thousands of independent personal computer retailers in the U.S.

Spencer suggests thinking of it as a new type of labor saving, time management automatic home appliance. The unit decreases the difficulty and stress for the caregiver who needs to watch over family members most, if not much, of the time day in and day out due to concerns about their well being, safety, and security. Not infrequently, the primary caregiver has a 24 hour, 7 days a week responsibility. There is concern that medication will be missed or the care receiver have an accident requiring immediate assistance. And the care receiver may be very resistant to a "stranger" coming in to her home and "running things" in the care giver's absence.

Spencer points out that the CareBot is a new kind of companion that always stays close to the care receiver, enabling family and friends to care for them from afar. It tells them jokes, retells family anecdotes, reminds them to take medication, reminds them that family is coming over soon (or not at all), recites Bible verses, plays favorite songs and/or other music. It alerts them when unexpected visitors, or intruders are present. It notifies designated caregivers when a potentially harmful event has occurred, such as a fall, fire in the home, or simply been not found by the CareBot for too long. It responds to calls for help and notifies those that the caregiver determined should be immediately notified when any predetermined adverse event occurs.

The family can customize the personality of the CareBot, modulating the voice's cadence to be fast or slow. The intonation can be breathy, or abrupt. The voice's volume can range from very loud to very soft. The response phrases from the CareBot for recognized words and phrases can be colloquial and/or unique to the family's own heritage. The personality can range from brassy to timid depending on how the caregiver, and others appropriate, chooses it to be.

Addition of medical-condition monitoring technology is a landmark for the robotic care system, upgrading its functionality from strictly social interaction as a companion (no mean feat itself!) to managed-care activity that may be beyond the capabilities of an untrained human caregiver.

Improving patient care and reducing overall healthcare costs through smart technology systems is a key priority of The American Recovery and Reinvestment Act of 2009. Allocated economic recovery funding includes $19 billion for grants and incentives that utilize health IT in order to save lives by reducing waste and decreasing medical errors.

One of the few trends in health care technology that promises to actually reduce costs while improving patient care is the move toward seamless networking of electronic patient records. The ultimate goal is to move all working records, from detailed test results to clinical history files for every individual, to electronic database form, and to make such records shareable between healthcare professionals on an as-needed basis. Likely, this will include wearable personal monitoring devices, such as for EKG and blood pressure, wirelessly linked into the database.

Development of this trend is proceeding as a number of parallel threads we expect to eventually converge. One of those threads is seamless sharing of medical records between institutions.

On Friday (3/20/09), a collaborative effort involving computer-system developer IBM, healthcare information technology developer MedVirginia, and the U.S. Social Security Administration (SSA) announced a first-of-a-kind electronic records exchange system to help speed the process of granting disability benefits for millions of Americans. Through the use of new software and services, the SSA claims to have shaved time needed to evaluate disability benefits from months to minutes.

The project, part of the U.S. Department of Health and Human Services' Nationwide Health Information Network (NHIN) Cooperative, represents the first health information exchange between a regional health information organization and a U.S. federal agency. The new system, which uses IBM's Health Information Provider (HSP) solution, is said to not only reduce processing times, but improve claims accuracy and reduce costs.

Spokespersons for the project explain that SSA uses individual medical records to determine almost 3 million disability claims each year. To make those decisions, the agency relies on doctors, hospitals, and other health professionals to provide medical information about patients. Through the migration from paper to electronic transmissions based on the patient's authorization, the agency is able to significantly reduce the time spent waiting for medical records and improve the service for those it serves. NHIN's goal is to enable secure access to such healthcare data and real time information sharing and exchange of healthcare data among physicians, patients, hospitals, laboratories and pharmacies, and other stakeholders, regardless of the location or application.

Providing such information-sharing infrastructure is, of course, key to achieving the ultimate goal of seamless integration of the healthcare IT system.

A couple or three generations ago, healthcare was personal. At least, it was perceived as personal. You had your personal healthcare professional -- called "your family doctor" -- who made house calls, knew your medical history by heart, and had treated you and your family for generations. He (back then, doctors were invariably males) made an effort to be easily accessible.

As time went on the "personal" disappeared from healthcare. Perhaps it was the rapid development and deployment of novel medical technologies during the 20th Century increasing the cost of running a doctor's office, so doctors had to expand their practices just to keep even. Perhaps we became hypochondriacs, consulting physicians so often that they couldn't get out of the office. I don't really know why. History of healthcare business trends is not my area of expertise.

What I do know is that a new generation of clinical technology is poised to change the way doctors run their offices, and, perhaps, put "personal" back in healthcare. For example, Tuesday (3/10) two emergency medicine physicians, Peter Hudson, M.D., and Wayne Guerra, M.D. introduced a new iPhone app called iTriage to provide consumers with actionable healthcare information. iTriage helps consumers evaluate their symptoms, lists potential diagnoses, and provides locations for treatment.

Consumers can access iTriage's expansive library of medical symptoms, diseases, and procedures to immediately see initial diagnostic options and get recommendations on the appropriate level of service required. iTriage integrates these results with geolocation technology to provide users with specific information on the most relevant nearby treatment facilities.

Users can tap into a national directory of emergency departments, urgent care facilities, retail clinics, and pharmacies through the app's proprietary healthcare-focused search engine. In addition to location-specific data for mapping purposes, consumers can get detailed information on these facilities including enhanced descriptions of capabilities and areas of specialization, links to appropriate web sites, hours of operation and contact information. Quality reports from HealthGrades on hospitals and physicians can be downloaded and emailed directly to users' iPhones. Marketed thorugh the developers' company, Healthagen, iTriage is currently available in the Apple App Store for $0.99.

In a similar development, on Wednesday (3/11) crisis information management technology vendor ESi released WebEOC for Hospitals, a crisis information management system designed to manage and communicate health information and hospital resources in real time.

"WebEOC for Hospitals gives hospital administrators and emergency managers real-time situational awareness of available resources," says ESi Director of Health Services William Glisson.

In a third development, also announced Tuesday, CAE, a provider of simulation and modeling technologies and integrated training solutions for civil aviation industry and national defense forces around the world announced signing contracts and alliances with Canadian organizations Michener Institute for Applied Health Sciences in Toronto, the Universite de Montreal, and the Winnipeg Regional Health Authority. Under the agreements, the entities will develop simulation-based healthcare training systems.

"The aviation simulation-based training model is becoming universally recognized as one of the effective ways to prepare healthcare professionals to care for patients and respond to critical situations while reducing the overall risk to patients," said Robert E. Brown, President and Chief Executive Officer of CAE. "CAE has already applied its technology and capabilities developed for the civil aviation and military markets to public safety and emergency response. Healthcare simulation is a natural extension of this know-how. By partnering with experts in the healthcare field, we will leverage our knowledge, experience and best practices in simulation-based aviation training to work with healthcare experts to deliver innovative education, technologies and service solutions in order to improve the safety and efficiency of the healthcare industry."

Whether these Healthcare de novo initiatives will help reduce healthcare costs while improving both service and clinical outcomes remains to be seen. Recent history is not encouraging. Healthcare costs over the past 50 years or so has increased more rapidly than just about any other measure of social activity. It certainly has increased faster than life expectancies!