Wednesday, November 3, 2010

Is online healthcare at a tipping point in 2010?

Online healthcare is becoming more accepted by both patients and doctors, and is, I believe, at a tipping point in 2010. By 2015 online communication between patients and doctors and the routine use of multimedia information will be the norm.

Patients will still be seen in person but our improved capacity to communicate electronically is, as Clayton Christensen has put it, a "disruptive innovation" that will revolutionize healthcare delivery. Providers will be routinely using these new technologies, such as email, telemedicine, electronic records, social networks and wireless mobile applications with patients. This will make healthcare more affordable, accessible and efficient.

These changes will be supplemented and strengthened by the availability of multimedia data. Electronic clinical information will be more freely available than today for both patients and doctors to review, comment on, pass to others for second opinions, and compare with clinical databases and disease registries. This data will be in multiple electronic formats - numeric, text-based, audio, digitized still pictures, video, radiologic, genomic and 3D streams. It will include data emanating from multiple medical monitoring and diagnostic devices as well as from ubiquitously available consumer devices such as cell phones. Patients and physicians will have to learn to navigate a "sea" of data, using new techniques to evaluate and analyze the relative importance of specific data points and elements of clinical information.

These two changes will mean that by 2015 the relationship that many patients have with their doctors will have expanded beyond the in-person interaction of today, and will increasingly occur literally anytime, anywhere in both online and in-person environments.

Peter Yellowlees is the author of "Your health in the information age - how you and your doctor can use the internet to work together."

Thursday, October 7, 2010

What is health informatics?

There is a lot of confusion about what exactly is health informatics - let me try and explain in a simplistic manner.

At the most basic level it is the discipline that creates a bridge between the clinical domains of knowledge and the domain of information technology.

It is sometimes hard to give a simple definition, but the American Medical Informatics Association has described it as follows:

"An emerging interdisciplinary and diverse field that:
  • combines health sciences (such as medicine, dentistry, nursing, pharmacy and allied health) with computer science, management and decision science, biostatistics, engineering and information technology.
  • solves problems in health care delivery, pharmaceutical, biomedical and health sciences research, health education and clinical decision making
  • is essential in all aspects of health care and biomedicine"

The cornerstones of health informatics are the ability to:

  • analyze data
  • manage knowledge
  • undertake data acquisition and representation
  • manage change
  • integrate information

Health informatics has a number of internal speciality areas, such as Medical/Clinical informatics, bioinformatics, nursing informatics, dental informatics, public health informatics and veterinary informatics.

Careers in health informatics exist in clinical care and research, personal health management for patients and consumers, public and population health, health policy and translational science. Informaticists help in the design, implementation, and use of systems that manage the increasingly complex and voluminous information in health care delivery and research.

There is an estimated need for 10,000 health informatics professionals in the next 5 years who will work in industry, academic institutinos, community based organizations, government agencies and the military, health care facilities, private practice, research organizations and private health practices.

This is an expanding and exciting field where high quality jobs are plentiful. It is not surprising that so many people are retraining and entering the profession of health informatics.

What is the truth about Health Reform?

Now that health reform is with us I thought it was worthwhile trying to summarize what I understand to be the truth about what it will mean. There are a number of pros and cons, and some areas that seem to be of equivocal benefit, depending on our personal views, so here is a brief summary...........

The positive aspects:
  • 95% of legal US citizens will have health insurance, compared to 83% now - an increase of 32 million people
  • Insurers cannot stop paying for people who are sick, even if they lose their jobs
  • People with previously known medical conditions cannot be refused health insurance
  • People who cannot afford health insurance will be able to obtain it relatively cheaply
  • Medicaid will expand significantly, and children will be able to stay on their parents insurance until they are 26

The negative aspects:
  • Most of the bill won't go into effect until 2014
  • The costs will be about $94 billion per year for the first 10 years - but these will be more than covered by cost savings and tax increases
  • Some states will have an increase in the cost of health insurance
  • The Individual Mandate means that you either have to buy health insurance of have a $2.5% tax increase
  • There is an extra tax on very expensive health insurance plans and for high income people

The equivocal issues:
  • The public option is not an option
  • More government involvement in healthcare, but remember that governments already pay for more than 65% of our healthcare, and hopefully this bill will reduce medical costs in the long run
  • There is no federal money for abortion
  • The extra regulation on insurance companies will probably increase costs, but will certainly increase quality, and will make sure that they spend at least 80% of their receipts on actual healthcare
  • Doctors will have increased access to information about which treatments are most cost-effective
  • Large employers have to offer insurance to all their employees or pay a fee

There are lots of other parts of health reform, but hopefully this very simple guide is helpful.

Thursday, September 30, 2010

What is Macrowikinomics?

I am currently reading the book "Macrowikinomics" by Don Tapscott and include a quote from it below for interest and to stimulate some discussion about the relevance of these ideas in healthcare.............

"In our previous book, Wikinomics (Portfolio 2006), we called this new force "mass collaboration" and argued that it was reaching a tipping point where social networking was becoming a new mode of social production that would forever change the way products and services are designed, manufactured, and marketed on a global basis. But, in the four years since penning the idea, it's clear that wikinomics has gone beyond a business or a technology trend to become a more encompassing societal shift. It's a bit like going from micro- to macroeconomics. In which case, wikinomics, defined as the art and science of mass collaboration in business, becomes macrowikinomics:the application of wikinomics and its core principles to society and all of it institutions. Just as millions have contributed to Wikipedia—and thousands still make ongoing contributions to large-scale collaborations like Linux and the human genome project—there is now a historic opportunity to marshal human skill, ingenuity, and intelligence on a mass scale to reevaluate and reposition many of our institutions for the coming decades and for future generations. After all, the potential for new models of collaboration does not end with the production of software, media, entertainment, and culture. Why not open-source government, education, science, the production of energy, and even health care?"

What do you think of this? I am fascinated by these thoughts and by their possible implications for the healthcare industry. Especially in the public health arena, where tracking of all sorts of disasters, epidemics, wars and the like can be undertaken by those actually affected with posting on sites containing geographic information systems - just as an example. Tapscott quotes one of the more popular participatory medicine sites - He says:

", is one of the Web's most vibrant health care communities, some 60,000 members believe that sharing their health care experiences and outcomes is good, and perhaps even integral, to speeding up the pace of research and fixing a broken health care system. Why? Because when patients share real-world data, collaboration on a global scale becomes possible. The health care system becomes more open and this in turn improves outcomes for patients, doctors and drug makers. New treatments can be evaluated and brought to market more quickly. Patients can learn about what's working for other patients like them and, in consultation with their doctors, make adjustments to their own treatment plans. All considered, communities such as PatientsLikeMe are leading the way toward a health care system that is cheaper, safer and better than what we have today."

I really like the idea of specialised social network sites, both open and closed, that are rapidly developing, where patients and doctors can mix and learn from each other - this seems especially helpful for those illnesses that are either common, like diabetes or heart disease, or rare, like Huntingdons Disease.

What does everyone else think? What sorts of health services are likely to be undertaken using the principles of "macrowikinomics"? It will be fascinating to see...............I look forward to comments and thoughts.

Thursday, August 5, 2010

Asynchronous Telepsychiatry is Feasible

The following press release was published by UC Davis on August 5th 2010

A new study by researchers at the UC Davis School of Medicine has found that psychiatrists can accurately assess a patient's mental health by viewing videotaped interviews that are sent to them for consultation and treatment recommendations.

The approach, called asynchronous telepsychiatry, uses store-and-forward technology, in which medical information is retrieved, stored and transmitted for later review using e-mail or Web applications. It has been used extensively for specialties like dermatology, with photos of skin conditions sent to dermatologists, or x-rays sent to radiologists for assessment.

However, the current study is the first to examine store-and-forward technology for psychiatry, said Peter Yellowlees, professor of psychiatry and behavioral sciences and the study’s lead author. “A Feasibility Study of the Use of Asynchronous Telepsychiatry for Psychiatric Consultations” is published in the August issue of the journal Psychiatric Services.

“We’ve demonstrated that this approach is feasible and very efficient,” said Yellowlees, who is an internationally recognized expert in telepsychiatry. “Using store-and-forward technology allows us to provide opinions to primary-care doctors much more quickly than would usually be the case.”

The researchers conducted the study to determine the effectiveness of asynchronous telepsychiatry for patients in Tulare County, a rural county in California's San Joaquin Valley. Sixty male and female patients between the ages of 27 and 64 who had mostly mild-to-moderate mental-health disorders were included in the study.

Researcher Alberto Odor, associate adjunct professor of anesthesiology and pain medicine, conducted 20- to 30-minute structured videotaped interviews at a community-based primary-care clinic. The videos were then uploaded to UC Davis’ specially designed Web-based telepsychiatry consultation record. Yellowlees and Donald Hilty, professor of psychiatry and behavioral sciences, reviewed the videotapes and provided psychiatric evaluations to the patients' community-based primary-care physicians.

Fifty-one percent of patients received diagnoses of mood disorders, 19 percent received diagnoses of substance use disorders, 32 percent received diagnoses of anxiety disorders and 5 percent received other diagnoses — including kleptomania, schizophrenia and parasomnia. Five patients also were diagnosed with disorders such as borderline personality disorder, obsessive-compulsive disorder or personality disorder. Some of the individuals had multiple diagnoses.

One patient was referred for a face-to-face consultation with a psychiatrist because of the possibility of a diagnosis of early psychosis. The psychiatrists recommended additional laboratory evaluations for more than 80 percent of patients and made recommendations for medication changes in 95 percent of patients. In instances where medication changes were recommended, physicians also received long-term treatment plans. A variety of psychotherapies, such as individual and cognitive-behavioral therapy, were recommended for many of the patients. Community-based primary-care physicians said they found the practice worked well, the study says.

The consulting psychiatrists provided feedback to referring physicians within two weeks, but asynchronous telepsychiatry could occur within 24 hours if it were to become a regular service, Yellowlees said.

Asynchronous telepsychiatry should not take the place of face-to-face psychiatric evaluations and is not suitable for patients with urgent psychiatric conditions, he said. But there are a number of circumstances in which it would be helpful in providing more primary-care physicians greater access to psychiatric consultations.

“There is a substantial shortage of psychiatrists,” Yellowlees said. “Asynchronous telepsychiatry would allow us to have better access to information about patients being referred by primary providers and to provide more comprehensive opinions. This approach could be used by the military and in many different rural and metropolitan settings. It signals the beginning of the true multimedia electronic medical record with clinical video recordings becoming part of the data set.”

In addition to Yellowlees, Hilty and Odor, other study authors include Ana-Maria Iosif and Michelle Burke Parish, both of UC Davis, and Karen Haught of the Tulare County Department of Public Health.

Yellowlees is the author of "Information Age Health - how you and your doctor can use the Internet to work together" available on Amazon and at

Thursday, February 25, 2010

What is Meaningful Use?

$19.2 billion in Recovery Act funding has been designated to modernize the health care system by promoting and expanding the adoption of health information technology, but what is going to happen? Like it or not, all health professionals will be significantly impacted by the Health Information Technology for Economic and Clinical Health Act, or HITECH, and we will all have to change the way we work.

A carrot and stick approach has been taken with HITECH, with incentive payments for implementing electronic medical records (EMR) starting in 2011 averaging $44,000 per physician who achieves “meaningful use” of EMR’s, and reductions in patient payments from 2017 for those who don’t. It is not sufficient for EMR’s to be installed or available – they have to be in demonstrable routine “meaningful” use.

The Centers for Medicare and Medicaid Services has released a 555 page document that outlines the requirements for “meaningful use”. The proposal contains 25 measures for physicians and 23 measures for hospitals.

Let’s examine some of these.

At least 80% of all unique patients seen per provider must have demographics, an up-to-date problem list of current and active diagnoses and an active medication and allergy list recorded electronically, while clinical summaries must be provided to patients for at least 80% of office visits. Computerized Physician Order Entry must be used for at least 80% of all orders, the functionality for drug-drug, drug-allergy and drug-formulary checks must be implemented and at least 75% of all prescriptions written per provider are to be transmitted electronically.
The other measures, many of which require interoperability with other data systems for public health purposes, are detailed on the HITECH website.

It is evident that achieving “meaningful use” will significantly change the way much of American medicine is practiced. Dr David Blumenthal, National Coordinator for Health IT, has agreed that the proposed rules aim to “stretch” the health care community, but not “break” it. This is an exciting opportunity to radically improve patient care, underpinned by informatics expertise, and is one that we should welcome and support.

A video version of this post is available on and at www.ucdmc.ucdavis/informatics

Monday, December 21, 2009

Can your doctor read your mind?

There is considerable research being undertaken on new ways of communicating. And I don't just mean communicating with each other as we talk, sing, shout or cry. I mean ways of communicating with other objects, such as cars, computers and other electronic devices. I also mean communicating with people who are in other parts of the world, and who we may or may not know. And I also mean communicating with animals, with people who are deaf and blind, or who are profoundly physically or mentally disabled.

We all know of many examples of our unconscious mind seemingly taking over and informing us of events occurring before they do actually happen - we call it "déjà vue." I will never forget my first memory of this. I was watching a soccer game on television, and I suddenly "knew" that a goal was about to be scored in a certain way, by a particular player, and within a couple of minutes exactly what I "knew" happened.

There are many other examples of the unconscious mind influencing us, our behavior, or our decisions over the ages, and books have been written, societies and religions formed and history influenced on multiple occasions by the strength of our unconscious and the many unconscious or inexplicable communications that occur in our world.

But how will the power of our unconscious mind be influential in healthcare? And will it be somehow linked with the research on communication that is occurring around the world at this time? Will it occur in tandem with research that is trying to define our moods, and which uses electrical currents through our bodies to predict, for instance, suicidal intent?

Let's move to a more mundane form of communication. This article was written with the aid of a voice recognition system. I spoke into a microphone and words appeared on the screen, mostly accurate, but needing some corrections. I also now write my patients notes using a similar system - straight into their electronic records, which I can also control with the voice system. So we are certainly starting to use voice control systems in everyday life, even if they are not yet perfect. But what is the natural extension of these sorts of activities, and how might they be used in the field of healthcare?

We all know that we can communicate just by looking at people. We also know that we can tell what another person is thinking, particularly if that person is very close or important to us. I know that I and my wife often realize that we are thinking the same thing at the same time - and much more frequently than should occur just by coincidence, or because we are in the same environment.

So will be able to eventually use these extra powers of communication with our doctors? Will it be possible for our doctors to literally "read" our minds - to download our thoughts straight into our electronic medical records? It is certainly possible for humans to use their minds to control other objects, without even needing to talk. A number of experiments have shown that our electrical brainwaves can be trained and used to control other objects, be they an artificial limb, or a computer joystick, and these experiments offer substantial hope to severely disabled people.

I think the answer is certainly "yes". But with a caveat. This will not occur soon. And we will have to have considerable ethical debates before any such programs are introduced into clinical practice. But it should be possible. After all, a doctors primary diagnostic skill is pattern recognition - we see simple, and often unusual patterns in massive amounts of data collected from patients, and equate these patterns with a diagnosis. So why should we not be able to extend this often unconscious skill in pattern recognition to include the power to "read" our patients more accurately. All doctors know certain colleagues who are frequently regarded as superior diagnosticians who already almost seem able to do this. So I suspect that in future, as we discover more about the interaction between the mind, the brain and the environment, that we will develop physical means of "mindreading". I wonder how that will affect the doctor-patient relationship?

Peter Yellowlees MD has recently published "Your health in the Information Age - how you and your doctor can use the Internet to work together" - available at most online bookstores.