The Future of Health Management

Improving the current state of the health of Americans and health care in the United States has been made a top priority by President Obama. The proposed reform entails changes in how health care is paid for, and mandates the use of technology to help make the reforms effective, measurable and maintainable. In fact the administration is making good on some of the promised stimulus money by releasing over $27 Million as part of the American Recovery and Reinvestment Act of 2009 (ARRA), specifically for technology in health care. Dr. David Blumenthal, National Coordinator for Health Information Technology, has voiced the belief that adoption of technology in a meaningful way (yet to be specifically defined) will improve health care quality and reduce medical errors. (Health and Human Services, 2009)

In the sections to follow I'll describe how technology, the Internet and other communication media, do now and will continue to play a major role in the improvement of our health as individuals, and as a nation. Funding for such innovations will be briefly discussed because it is an important reality, and a current barrier in many situations, but does not have a major focus.

We’ll begin at a very high level view to get a picture of our current state as a nation, and then we’ll look at some examples of how specific health challenges can be effectively managed by physicians and other health care providers with the aid of current and very soon to come technologies.
We’ll also take an exciting look at how some technologies currently in development may be implemented to help an example patient reach measurable goals and maintain healthy lifestyle changes.

Health Status of Americans

In a 2008 study the United Health Foundation looked at twenty two measures to quantify America’s health rankings. (United Health Foundation, 2008) I am going to use this study to quantify the health status of Americans to frame our health problems that reform and technology can help individuals and providers to mitigate.

This ongoing study uses determinants and health outcomes to rank each of the fifty states, and broader measures to compare us to other countries. The determinants were weighted either positively or negatively, and being causal in nature they represent factors that impact health, such as personal behaviors (e.g. smoking and prevalence of obesity), community and environmental factors, public and health etc. Outcomes represent the effects, and were measured by either death or missed work days.

In the last nineteen years, many improvements in several measured decreases in infectious disease, prevalence of smoking and immunization coverage. Many measures which had improved since 1990 are once again listed as challenges including children in poverty and immunization coverage. The prevalence of obesity has increased 127% since 1990. (Table 7, “National Changes since 1990”).

According to the study by the United Health Foundation Japan has the highest Healthy Life Expectancy at seventy five years, we rank twenty-seventh along with Portugal and Slovenia. (Table 6, “International Comparisons”, section on “Comparison to Other Nations”). We can use our epidemic of obesity, and the associated increased risk of chronic diseases such as type-two diabetes, high blood pressure, cardiovascular disease; stroke; as well as colon, kidney and breast cancers to focus on how technology can help Americans improve their health. As a country we are finally beginning to see that preventative health care may save more money than our historical model of ‘sick care’. Health care reform will push individuals to select healthier behaviors to maintain wellness and manage chronic illness. Technology is and will continue to play a major role.

The Current Role of Technology and the Internet to Manage Health

The citizens of the world have already embraced the Internet as a major source of health information. It can be a very reliable and beneficial resource to patients. According to our text, Dr. Peter Yellowlees (2008), notes that over sixty percent of Internet users, more than 140 million people, had used the Internet for researching a health topic. There are 231.5 million web sites on the Internet (WolframAlpha Computational Knowledge Engine. 2009), but it is very difficult to find a reliable number of them that pertain to health. The World Health Organization (WHO) (2009) has 747 links to national health related websites in about 192 countries world-wide. Even the WHO makes notation as to the difficulty of keeping track of the actual number of sites and valid links. Dr Yellowlees estimated that there were 100 times more health words on the Internet in 2008 than in 2000 (2008). (The sum of the 2008 estimate is about 3,047 million, or over 3 billion health words!). While it may be difficult to quantify the number of Internet health resources, there are many, many sites.

Patients and providers alike are using the Internet for a vast number of reasons. Important to this paper is the use of the Internet to help patients and providers manage health. Patients can look up symptoms, medications, health & wellness topics, treatments and procedures from reliable sources. Patients can also find physicians for a traditional appointment or even get a consultation online. The National Institute of Health (NIH) provides information for consumers to help them find reliable sources: “MedlinePlus Guide to Healthy Web Surfing” (NIH , 2009). Printed resources such as Dr. Yellowlees’ book provide a safe guide as a bridge for newcomers from the world of printed media to the Internet and related technologies.

Physicians are already using the Internet as a connection to the patient’s Electronic Health Record (EHR), perform research or access clinical trials data, or even to remotely visit a patient or other provider on behalf of a patient for consultations and more advanced activities using Telemedicine. These are only a few of the many current uses of the Internet by physicians for health care.

The American Telemedicine Association (ATA) website lists many services such as referrals and consultations, remote patient monitoring, medical/health professional education and includes Internet use for consumer health education. (2009) Other health care venues such as home care use Telemedicine to provide services to patients in remote locations from larger metropolitan areas where specialty health care resources are more plentiful. Telemedicine saves money in both patient travel and provider travel.

Telemedicine can enhance available services to a remote location with sophisticated devices and technologies. For example a specialty surgeon hundreds of miles away can be present and even assist in procedures or surgeries using robotics or other advanced peripheral devices. This has been especially beneficial in war zones where general surgeons must perform highly specialized and intricate surgeries to save lives and minimize long term disabilities in wounded soldiers. (Poropatich, 2009).

Telemedicine also can network hospitals, clinics and other care sites using private networks, dedicated telemedicine networks or the Internet. Provider physicians or other care agencies such as home health can connect to patients in clinics or their own homes using a varied number of technologies from telephone to video. Providers can visit face to face with patients, or indirectly using automation to monitor patient status indicators such as blood pressure, blood sugar or a number of other metrics using devices. Perhaps the most known and used telemedicine service “Web-based e-health patient service sites” expand services described above (consumer outreach for example) by providing some direct care services over the Internet. (ATA, 2009). I have not discussed email, scheduling and other common Internet enabled communications methods, but they are widely used today.

Other Internet services currently available offer individuals the ability to keep their health records online, and some providers (Health Systems, hospitals or Physician practices for example) can link their EHRs to the patient’s online health record to provide continuity of information across time and the continuum of care. Microsoft Health Vault is an example of such a service. (2009).

Funding for Telemedicine services remains limited, and privacy concerns continue to hamper acceptance of some Internet technology usage for health care purposes.
The current administration’s Health Care Reform initiatives are impaired in part because of worry about the privacy of health information on the Internet. Despite 1996 HIPAA legislation, breaches in privacy continue to occur in hospitals, with insurance companies and government agencies (Pear, 2009) eroding the confidence of legislators and the general public when these breaches reach us in the news.

Other creative uses of technology entail use of virtual worlds such as Second Life. These are in use now. There are many locations in Second Life that provide either marketing information for new, futuristic health facilities, or provide a virtual health education experience for both the lay public and students in a health care profession. Some impressive uses of Second Life for such purposes can be previewed on YouTube:

1. Virtual Hallucinations – a Second Life virtual experience that demonstrates in a very experiential way the hallucinations of patients with Schizophrenia: http://www.youtube.com/watch?v=s33Y5nI5Wbc
2. Cisco Hospital of the Future – Palomar West a Second Life virtual walk through of a Cisco connected hospital campus under construction in Southern California: http://www.youtube.com/watch?v=KMtMWdlX9Z8
3. MD Kiosk, virtual health island on Second Life, provides a large number of interactive educational experiences to watch and explore: http://www.youtube.com/watch?v=U3Szet7MJEM
4. UC Davis Mass Prophylaxis Research & Virtual Hallucinations in Second Life, part of this video shows a little bit of a mass prophylaxis clinic training site in Second Life for a bioterrorist event: http://www.youtube.com/watch?v=8fggzZSFKcU

I am optimistic that Health Care Reform legislation will pass this year, and hopefully will significantly help both the funding and privacy problems; this will be a big step to move us forward to what is to come.

Exciting Internet and Related Technologies are Around the Corner

Already we are seeing glimpses of how physicians and individuals alike will use technology connected by the Internet to communicate and continue to improve the health of our nation, and more safely treat illness with better outcomes.

A simple patient scenario can demonstrate some exciting possibilities. Since obesity is a major health problem in the U.S. along with the associated health problems, such a patient with hypertension and pre-diabetes is a great candidate for technology based health management.

Perhaps our patient, knowing he’s overweight has been ignoring some shortness of breath and fatigue for some time, but recently has had more symptoms, such as excessive thirst. Our patient has already been on the Internet to review symptoms and has found a physician, an internal medicine / endocrinologist thinking perhaps he might have diabetes or some heart problems or both. He used “Health Grades” (an independent healthcare ratings organization) to find a highly recommended physician, but only has office visits periodically near him because he lives in a remote area and has transportation problems.

Our patient uses the Internet for a lot of research on the tests, medications and some health behavior changes such as diet and exercise prescribed after the follow-up visit to the physician. But our patient has difficulty getting out, and for him, compliance to a diet and exercise program is difficult.

Since the physician is used to caring for patients with limited access to services, he sets the patient up with some innovative services (such as the XBOX 360 game console with some extra equipment). And since the patient is already computer literate, the patient is an excellent candidate for a virtual rehabilitation program.

The program includes attending nutrition classes with a number of his other patients in a virtual world. So, if our patient is a little shy or self conscious, her virtual self can be created to be whatever she wants to look like. These nutrition classes are interactive, but use an avatar instead of a video camera image of her real self. Instead of using a keyboard or joystick, our patient is interacting with the computer system itself, no hands. (Hands Free PC, 2009). The game console provides a hands free, virtual experience with other participants linked through the Internet to the nutrition class.

The program also requires the patient to get at least 175 minutes per week of exercise, monitored to make sure that she doesn’t have any untoward symptoms that require intervention. Or that if she does, EMS can be summoned immediately. This system has EMS connectivity for just that purpose; it was set up much like ‘Life Line’ when the console was set up. Our patient gets on the treadmill with the electrodes placed appropriately and begins to walk at the pace prescribed. The virtual therapist is monitoring our patient, and the patient can chat with other patients, like in a gym if she likes. She can see the instructor on her wide screen TV, and interact with any of the participants. The console monitors her physiological parameters, but also her facial expressions and body language and the therapist inquires appropriately. The virtual therapist can even suggest the appropriate technique or posture, or to speed up or slow down.

If our patient would prefer to continue without other participants, and choose virtual participants instead, he can choose that option, perhaps because of his schedule.

Using the same technology the patient can visit with the physician’s nurse practitioner every week to monitor progress. (The patient is already docking his blood glucose meter after each test so that the physician office has the results almost immediately)

After only a few months of this rehab program our patient is now diet controlled for blood sugars, and has lost 25 pounds. Our patient will continue on the program until the goals are met and maintained for a prescribed period of time.

All of this will soon be a reality; such technology is already in development. The creators of Second Life are working on similar technology as the XBOX Company. (Kapor, 2009)

With funding, research and creativity; with EHRs and RHIOs sharing and storing discrete data for analysis, and patients actively involved in their health management, the future of health management can and will be greatly enhanced, and the United States will have population health status measures more in keeping with our health care expenditures.

References

American Telemedicine Association. (2009) Telemedicine Services and Delivery Mechanisms. Retrieved September 30, 2009 from http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3333

Hands Free PC. (2009). XBOX 360 Project Natal. Retrieved September 29, 2009 from: http://www.xbox.com/en-US/live/projectnatal/

Health Grades. (2009). Find a Doctor. Retrieved September 30, 2009 from: http://www.healthgrades.com/find-a-doctor

Kapor, M. (2009). Hands Free 3D: Second Life Navigation Demo. Retrieved September 24, 2009 from: http://www.youtube.com/watch?v=2t52gkAwJq8&feature=channel_page

Microsoft Health Vault. Welcome to Microsoft Health Vault, Be Well. Connected. Retrieved September 26, 2009, from: http://www.healthvault.com/Industry/index.html

National Institute of Health. (2009) MedlinePlus Guide to Healthy Web Surfing. Retrieved September 30, 2009 from http://www.nlm.nih.gov/medlineplus/healthywebsurfing.html

Pear, R. (2009). Privacy Issue Complicates Push to Link Medical Data. The New York Times. Retrieved September 30, 2009 from: http://www.nytimes.com/2009/01/18/us/politics/18health.html?_r=1

Poropatich, R. (2009). Innovations in Health Informatics for the Armed Forces. Retrieved September 15, 2009, from UC Davis Health Informatics Extension Web Site: http://hera-ucdavis.tegrity.com/tegrityUtils/InstructorViewer.aspx?directLink=1&startTime=0&currSessionGUID=25d75fe4-0caf-4dc9-a766-f89335fede84&httpSessionKey=82b45cf0-a473-4843-b44b-69a7041e5cb7

United Health Foundation. (2008). America’s Health Rankings. Retrieved September 26, 2009, from http://www.americashealthrankings.org/2008/index.html

US Department of Health and Human Services (HHS). (September 29, 2009). Secretary Sebelius Releases $27.8 Million in Recovery Act Funds to Expand the Use of Health Information Technology. Retrieved September 29, 2009, from http://www.hhs.gov/news/press/2009pres/09/20090929a.html

WolframAlpha Computational Knowledge Engine. (2009). Retrieved September 30, 2009, from http://www.wolframalpha.com/input/?i=number+of+web+sites

World Health Organization. (2009). Links to National Health-Related websites. Retrieved September 30, 2009 from http://apps.who.int/whosis/database/national_sites/index.cfm

Yellowlees, P. (2008). Your Health in the Information Age – How you and your doctor can use the Internet to work together. Bloomington: iUniverse.

Home Visits Coming Back? How about Tele-home visits!?

An exiting article aired on NPR Morning Edition today. I really do hope that home visits make a return to physician practice, but I'd like to see tele-home care become part of the model too....

On the program, one physician is making home visits, and accessing the patient's EMR using his laptop. Dr. Eric Beachy, making his home visit mentioned the challenges that remain in remote areas with lack of connectivity, but the advantages are many. There was some mention that newer, younger physicians thought this might be old fashioned. But he could be making the same visit using telemedicine.

I'd like to see this taken a step further... It's great that the physician is visiting face to face, but I think it's the right time for tele-home care to finally open up!

In the late 1990s I worked for a vendor on a home care product. I was lucky to be able to make a home visit to a patient with COPD and Diabetes via telephone and television (no PC was involved with this program). I was in Lawrence KS and the patient was hundreds of miles away in Western KS. The research project which ended around 2000 was able to show a very significant reduction in re-hospitalizations and ED visits when the nurse could visit more frequently via tele-home care. (The patients were remote and more frequent visits were expensive and time consuming)

I still believe that tele-home care, home monitoring and other telemedicine options are going to be important in managing / maintaining the health and wellness of our population in the future.

The Homecare Technology Association of America has been working on this for many years already - http://www.hctaa.org/accomplishments.html

Please check out the radio program:
Old-Fashioned Medicine Needs Assist From WiFi
http://www.npr.org/templates/story/story.php?storyId=113018106

Patient access to medical record

Even though there are now laws to allow patients access to their medical records, it is not an easy task. Physicians still have mixed feelings about allowing patients to see the notes they've written in the chart. Check out the article and link below to review the debate.

Personally I think it is a great idea:
-Patients can see exactly what the Dr said and check their own resources to clarify the information and learn more about their plan of care
-Patients who are checking their records online are apt to be more involved in their care
-As patients review their information, if they discuss with family or friends, the patient has more support for following the plan for longer term benefit
-Generally a more transparent process keeps everyone honest

The article is at NPR.org
Doctors Don't Agree On Letting Patients See Notes
http://www.npr.org/templates/story/story.php?storyId=112971637

“Internet Addiction” is a symptom (?)

I found many and read a few resources on the Internet for "Internet Addiction"; some are research based and some just articles on the topic. Based on this reading and my own experience in life and patient care, I would have to hypothesize (validating with further research) that indeed there are people who appear on the surface to be addicted to the Internet, but the real problem that must be addressed, after symptom control is accomplished is the underlying obsession and compulsive tendency.

While there is a valid tool (Widyanto L and McMurran M., 2004) to identify the problem, I don’t think it should have it’s own DSM-IV category, that is, it's own diagnostic category.

I worry that to give it a category of its own would just continue to bloat health care expenditures that just treat symptoms and not underlying causes. I have seen alcoholics quit alcohol and then become ‘addicted’ to another thing, like cigarettes, religion, work or sex to name a few because the underlying issue was never treated. There is a lot of money to be made by creating boutique facilities, retreat centers with tunnel-visioned counselors (who may not have any real credentials at all) that may be effective at relieving the currently-presenting compulsive online behavior, but in the end, unless the root of the problem is addressed, another compulsion may arise. In some people there may be a lifelong need to evaluate and monitor their compulsive tendencies.

Treating Internet Addiction by itself is like treating CHF with Lasix and then sending the patient home when the shortness of breath is relieved after the fluid overload is resolved. Eventually the fluid overload will return, and you’ll be treating the symptoms again. The improvements in the quality of life are short-lived.

The symptoms, (obsession with and compulsive use of the Internet) are only a manifestation of one of the many obsessive and or compulsive behaviors found in alcoholism, sex addiction, workaholism, drug addiction (really, any substance addiction or abuse)

Briefly, I think a better way to state the diagnosis of Internet Addiction would be as a sub category of an obsessive-compulsive disorder, with the specific symptoms and characteristics of each different thing a person can be ‘addicted’ to being part of the symptom and treatment portion. (e.g. “Obsessive compulsive disorder as manifested by compulsive pornography surfing, chat room voyeurism and online gaming”), Such a ‘label’ I hope would not only encourage treating the symptoms, but also encourage getting to the root of the problem, which may involve long-term or lifetime maintenance therapy and or meds. The Goal of my idea is to improve the overall feeling of well-being for the patient for life. Solving the symptoms of one addiction provides temporary relief, but does little to treat or resolve the underlying issue.

My proposal does not exclude, for example, the patient attending a 12 step program to relate with peers with similar symptoms instead of lumping them all together, but allows for a multi-faceted treatment program aimed at the underlying problem, with the goal of life long wellness.

References and Additional Reading:

Widyanto L and McMurran M. (07Aug2004). The psychometric properties of the internet addiction test. Retrieved 18Sep2009 from the World Wide Web: http://www.ncbi.nlm.nih.gov/pubmed/15331031

Internet Addiction Disorder. Retrieved 18Sep2009 from the World Wide Web:
http://en.wikipedia.org/wiki/Internet_addiction

GERANIOS, NICHOLAS K. (15Sep2009). Internet addiction center opens. Retrieved 18Sep2009 from the World Wide Web:
http://www.miamiherald.com/business/technology/story/1234240.html

TimesOnline(18Sep2009) Heavensfield centre opens its doors to America’s internet addicts.Retrieved 18Sep2009 from the World Wide Web: http://technology.timesonline.co.uk/tol/news/tech_and_web/gadgets_and_gaming/article6839222.ece

TimesOnline(26Aug2009) Internet addiction among China’s teenagers spawns brutal boot camps.Retrieved 18Sep2009 from the World Wide Web: http://technology.timesonline.co.uk/tol/news/tech_and_web/the_web/article6809831.ece

Center for Internet Addiction Recovery. Internet Addiction Test (IAT) Retrieved 18Sep2009 from the World Wide Web:
http://www.netaddiction.com/resources/internet_addiction_test.htm

King, S. A. (1996). Is the Internet Addictive, or Are Addicts Using the Internet? Retrieved 18Sep2009 from the World Wide Web:
http://webpages.charter.net/stormking/iad.html

Uses of 2nd Life in Dr-Patient Relationships

Use of Second Life (SL) for Doctor - Patient Relationships
In an article “A Survey of Health Sites in SL”, several Second Life uses related to Healthcare are discussed – Education and Awareness, Support, Training, Marketing and Promotion of health services and Research.
There are 34 places or activities in SL for dissemination of health information which include links to web sites, video, slides, search information and interactive experiences such as games and classrooms.
I can see that Second Life is especially useful for psychiatric patients. The demonstration on YouTube regarding virtual hallucinations was very interesting, if a bit disturbing. It expressed to me what it must sound like, and somewhat it feels like to have both auditory and visual hallucinations while walking through a benign environment. It was surreal to hear a voice expressing how worthless the patient is, and that they should kill themselves.
I can see that Second Life will be very useful in Patient-Provider relationships for expressing subjective symptoms such as hallucinations, but I can also see that it will be very useful for patient education. Interactive, graphical and audio presentations can be provided to those with limited reading skills.
The Healthinfo Island location was very interesting – I could spend days there looking at the information in the Consumer Health Library. What a fun way to get information!
I can also see that this would be a good way for me to check in to the Dr’s office for some specific follow-up to see how I was doing on particular learning objectives if I had a self care regimen to follow, or to meet up with other patients for support.
It may be too, that how a person creates their avatar may have some meaningful information for the physician, again, back to the psychological aspects – about body image, and why a person chose a particular avatar. (That is if the person understood how to create one – it isn’t that easy to edit once you’ve selected one). That is too, if the Dr knows who the avatar represents – anonymity is also an advantage in the virtual world.
Anonymity is especially helpful for the patient when asking questions initially about personal health information that might be difficult to talk about in person such as HIV, or perhaps a substance abuse problem.
One downside that I can see is that the patient must have access to a computer with the capabilities to download and run the Second Life software (or similar software), and the patient, or someone must help him/her be able to get it loaded and running. Or, the patient must have access to a computer that can run the software, with enough security (if it is a shared computer) to keep the patient’s login and other information secure.
As time goes on, more and more people will have that computer access, and computers and broadband access will enable use of applications such as Second Life to become more useful to more people.
Do you think that people will use Second Life for Health Care information, or to visit their physician? What are the barriers to use that you can see?

Hello and Welcome

Hello all,

This is my first Blog, and my first public post for an important topic - that is Health Care Informatics (HI), but mostly about the people aspect that HI must address.

My goal is simple - I want to start discussions about how we can get people, both health care professionals and the lay public, including patients to feel more comfortable and confident with using computer technology in managing personal health, the health care of patients and of our population.

First of all, I'm going to borrow a definition of Health Care Informatics (or Biomedical/Health Informatics) from Dr Don Detmer, MD 2004 President and CEO of AMIA (American Medical Informatics Association)
An integrative scientific field that draws upon the information sciences and related technology to enhance the knowledge base of the health sciences to improve health care, biomedical and clinical research, education, management and policy.

Health Care Informatics as noted above is about how technology will be able to help us to improve health care - however, I would like to invite conversation about your experience as to the 'people' issues; both potential and actual barriers that we have faced in HIT/HIS (Healthcare Information Systems) implementations and the future implementations. Hopefully these implementations will lead this country (and the world) to the widespread adoption of Electronic Health Records (EHRs), and also Personal Health Records (PHRs).

In my experience I have seen problems with adoption within the healthcare community as Nurses and Doctors struggle to move away from their paper record to an electronic world. It is not just a technology phobia - as that is melting away as we all become more familiar with computers, the Internet, etc, but more fundamentally; I see a lack of understanding regarding what an EHR actually is (in part, it brings real time access to infomration) and how to make the real time access a reality. This is but one fundamental misunderstanding that I have seen affecting successful implementation of an EHRs.

For example, some clinicians who are using HIT currently continue to believe that by writing progress notes or charting data on to a paper document and scanning in to the record (sometimes at the end of the day) are activities that produce an EHR. While this may be technically true, if we don't have real time entry of discrete data, or scanning at the point of care (not ideal as it is not discrete or trendable for example), we can't come close to reaching the goals we all seek for EHRs. If our goals are to enable research, interoperability and decision support - we must all understand what it takes.

When users are frustrated with a system that doesn't provide what they're looking for when they need it - yet they don't use the technology in front of them to it's capability for discrete entry for example (it does take a little longer to input the data into a form) it's no wonder we don't have the adoption we're looking for. They're not seeing the value.

• How can we educate our fellow healthcare providers to better understand the underlying principles so that they use the systems we implement to their potential? (and gain compliance to effective use of systems and processes)
• Can we expect HIT to reach a point where Voice to Text, or OCR can help clinicians quickly enter standardized data that is of use to research, quality management, trending and eventually best practice?
• What are your thoughts and experiences on this topic

I hope this is an interesting topic - I see it as a fundamental hurdle to be overcome for the adoption of EHRs and PHRs to succeed.

Thanks for listening!

Marie