Primary Care
Unraveling the US Healthcare Puzzle
It has been a couple of weeks since the last time I updated the blog – lots of going on here, traveling around the US, and uncovering new problems/opportunities in the US healthcare system, meeting new people and attending a few other conferences besides Health 2.0 in San Francisco.
A few days ago I attended some sessions at the AdvaMed Convention in Washington DC. Really enjoyed a session at the NZ Embassy with AdvaMed participants as well as attending the International Delegates Forum where 30 odd companies got a chance to introduce themselves and facilitate networking and possibilities of new partnerships. Even though most attendees were from the medical device industry, AdvaMed was an excellent place to learn about new emerging technologies, problems those devices are trying to solve and find possible synergies for LHD with some of them. Was impressed by how NZTE (New Zealand Trade and Enterprise) are doing an excellent job of helping NZ innovative companies attain entry into the US market, get them up to speed with current legislation and obstacles, and expand their networks.
After that was the NCPA Convention (National Community Pharmacists Association) in Philadelphia. It was an excellent expo and invaluable day spent walking around, talking with people, learning more about Medicare Part D and MTM (Medication Therapy Management), discovering that it is such a new and therefore quite flexible market with so many opportunities and ways to go particularly in MTM services and retail chains. Everyone I was talking to are seeing retail chains being a new “one stop shop” for all kinds of healthcare services including receiving healthcare and medication review/optimization services. Lots of going on in this area, though it still seems to be quite vague in terms of best practices (probably a good thing in terms of opportunities). The main problem though is still reimbursement, i.e. who pays the pharmacist or any other qualified care provider for MTM services? And how much ? (especially taking into account all the complex cases where chronic or elderly patients are on multiple medications, and the review/reconciliation/risk management, optimization for complex cases can take over 2 hours while providers are reimbursed maximum for 1 hour, etc). I was able to meet with a few market leaders in the industry, and got very good insights.
Last stop before I head back to NZ is San Diego. Seems like my company is moving in the right direction and I have some interesting developments to announce soon in terms of our US operations and business. On November 3 I arrive in Wellington, NZ to attend the annual HINZ conference - the major NZ exhibition for Health IT. I am very much looking forward to that. As some of you may know NZ is a very innovative country yet with a small market NZ companies need pipelines to enter the vast US market. These past 4 weeks in the USA have gone a long way to creating our own pipeline for LHD into the US market.
Yours in health,
Hamish
Tools to assemble all the pieces of primary care data together – Part 2
Last Thursday (see my post from last week) I gave a talk to the General Practice Research Group at Otago University. one of the two main medical schools in New Zealand. It was a really interesting discussion, with much the interest being centered around providing General Practitioners with the ability to view medication regimes in a more easily and quickly comprehensible format.
There was also interest in using Lifetime Health Diary™ in extreme patient cases, where it can be difficult to draw up a complete patient background and keep track of it – particularly when a patient is seeing multiple practitioners and specialists. Some of the GPs present said they would like to try using it with some of their “problem patients”.
Perhaps unsurprisingly, there was also interest in Lifetime Health Diary™ assisting with smoother handoffs between different care settings and providers (including a better follow up and communication tool after discharge). One concrete example mentioned of interest was helping community pharmacies reconcile health and medication regimes of patients and providing a strong link between nursing homes, GPs and pharmacists. In other words, a genuine Health Reconciliation Tool.
This ties in strongly with another theme of interest – Distance Medicine and Rural Health. Rural pharmacies, as the only dispensary for many miles around, have the potential to serve as a pure source of community pharmacy usage – unlike in cities, where consumer choice in using any pharmacy creates data silos between patient and the various pharmacies and GPs they frequent.
I look forward to being able to release the view of our new medication optimisation tool in the next few days, I will post that on next week’s blog, and discuss why clinicians we have spoken to are looking forward to using it.
Yours in health,
Hamish
Tools to assemble all the pieces of primary care data together
This coming Thursday I give a talk to the General Practice Research Group at Otago University.
Otago University is one of the two main medical schools in New Zealand, and is highly regarded internationally for its innovative research and education of top class clinicians.
Some of the General Practitioners in the Department have expressed interest in Lifetime Health Diary™, especially as we are now beginning to be used on the ground by registered nurses in community health settings. Anything that can alleviate pressure points in healthcare delivery, particularly around early interventions and patient engagement, is something of interest to General Practice and I look forward to the opportunity to demonstrate what our product can do.
Topics I will be covering will include…
- How to improve communication between patient, community care provider & General Practitioner.
- Smoother handoffs between different care settings and providers (including better follow up and communication tool after discharge.
- Provide better and quicker understanding of poly-medication regimes.
- Medication Optimisation and measuring patient progress by regimes.
- Health Reconciliation Tool between rest homes, GPs and pharmacists.
- Distance medicine / Rural health.
- Green prescriptions (i.e. exercise and lifestyle recommendations), patient health management & patient safety.
- Preparing for the upcoming 40-year bulge of aging Baby Boomers
I look forward to writing up some notes about GP reaction, comments, and generally what happened at the talk next week.
Yours in health,
Hamish
Ray Avery’s Medicine Mondiale – affordable healthcare for all
Ray Avery in his garage lab
Aga and I went to see Ray Avery talk about his autobiography, Rebel with a Cause.
Ray has a mission for his life.
Use science to change the world
You can’t change the cards that you are dealt but you can change the way you play them. He sees success over a “diaspora” of difficulty. And so he set up Medicine Mondiale as an organisation to help him change the world.
We are trying to change world healthcare by getting global organisations who aren’t doing it well to improve their delivery and reduce the costs of doing so. For him, observation is the key to innovation and he learnt to observe closely because he is dyslexic and words are ‘shapes’ to his eye.
He continues
I started to look at the world to see what made things work. Few of our inventions come from linear academic research. We were investigating and watching in Kathmandu Hospitals. Incubators are ventilated and humidified with local water. This meant we were ‘cooking’ babies in a microbial broth coming from the water supply. So we patented an air filter which enabled local, unpurified water to be used.
Before this we worked on developing a cheaper inter-ocular lens for people with cataracts. This is an easy operation and truly life-changing. But each lens costs around US$300. The Fred Hollows Foundation recruited Avery to help build a factory making a new lens design in Eritrea both providing local skills, employment and around $2m profit per annum.
We collapsed the world price for inter ocular lenses from $300 to around $10.
I didn’t want to repeat the sins of other development agencies where a large percentage of programme funding never makes it to the people who need it. They get round this because ‘everything’ is categorised as programme funding including managers in the country of origin as well as visits around the globe so only around 15% of donations actually get to the project.
By an accident of birth around 90% of children have inadequate healthcare.
We think of ourselves as good global citizens. I see the world as a social anthropolgist and I think we can direct a proportion of our intelligensia to create a better world.
Think of a way you can make a difference.
What a great challenge – LifetimeHealthDiary will be thinking up ways to contribute to the disadvantaged.
Rebecca Caroe
Our First Community Group Meeting! (Part 2: Question & Feedback Session)
The participants from various organizations definitely saw the idea as an innovative way forward. Some great examples were brought up on why and how such a system could contribute to creating better health outcomes, provide economical advantages and prevent mistakes and oversights, and halt a growing inequality of health care access, stress and disengagement.
It was a great learning experience to see how lack of adequate health information for those disadvantaged such as the blind, deaf, sick children, people with chronic diseases, parents and caregivers ethnical groups leads to inability to manage, monitor or even access appropriate health care. For use by the blind the tool would need integration with ‘talking data’ but it was considered to be very positive for the hearing-impaired, as a very needed communication tool with health professionals. Also some noted this would be a great tool for recording children’s health – as children`s complete information is usually only known by the parents, but when the child reaches adulthood this information can be forgotten, or not passed on etc.
Almost 40 minutes discussion among 13 participants brought up lots of issues. The main ones examined were privacy and security. Some participants made the counter point that Lifetime Health Diary can be useful for privacy issues. Additionally some commented that privacy waivers are common place. The consensus seemed to be that perfect privacy and security are an ideal that must be strived for, but that it is even more important to simply start.
One example was given where deaf people health consultations often result in shouted conversations in front of other people, whereas this kind of Diary could act as a mediation tool.
Some barriers in uptake were identified as well. Computer literacy, access to the internet, cultural readiness and acceptance were those listed by participants.
Everybody`s involvement was definitely a sign of a great need to address current problems in a fast and cost efficient manner. The bottom-up approach was seen as the way to go, as community-based solutions are needed. Although many questions were fielded, there was a huge recognition and understanding that the Diary is a positive way forward and although there are no perfect solutions to some of the issues, a start needs to be made.
Funding
The participants suggested a couple of funding opportunities including the Tindall Foundation and Working Together More Fund, the Health Innovation Fund at the ACC, The Ministry of Health and some internal programmes run by participating organisations expressed their readiness to work together.
First steps forward
First step needs to be taken! The opportunity to do so will be in a study run by a team of Ignite Consultants. From Monday 23rd of August, five highly motivated, talented and hand-picked students will start to explore how Lifetime Health Diary™ can be helpful for different community groups. Study will be concentrated on the readiness of particular communities, including examining the motivation, perception, potential barriers, as well as looking into the usability of the technology which needs to be adjusted to the specific needs of people on the ground. The team of students will be working for 8 weeks under the guidance of Alec Holt, the Director of the Health Informatics programme at Otago University as well as mentors from the not-for-profit community
We believe that by working collaboratively on enabling the most disadvantaged in our communities and their caregivers to have better access to relevant and needed health information (which they can share with their doctors and other health professionals) can truly lead not only to better health outcomes, but significantly improve the quality of lives, engage and empower people to take charge of their health.
The Project is about to start…!
Our First Community Group Meeting! (Part 1: Introduction)
Yesterday, with help of Sue Russell from DCOSS, Ignite Consultants held a meeting under the theme: Healthy Community Enabled by Information: Social Innovation at Work. Representatives of nine different organisations attended. Despite very short notice they kindly came to share their ideas and feedback on what can be done to address some of the problems arising due to inefficient information management systems between patient, doctors, caregivers and other parties engaged in patient health management.
We started the meeting with everybody introducing themselves, I gave a short introduction followed by guest speaker Hamish MacDonald who presented his innovative technology, Lifetime Health Diary™
I met Hamish nearly one year ago, when running my Social Entrepreneurship Project. He approached me to tell me about the global mission of his company including the 5 billion plus of those who are the most health disadvantaged in the global community, including even in our communities such as the disabled, cultural minorities, people living with chronic conditions, the elderly, etc. who very often face significant challenges in obtaining adequate access and delivery of health services.
But it wasn’t till 2 months ago when he actually showed me what, together with his team, he managed to build and how the vision becomes reality. Intrigued, and seeing a huge potential in how this tool could help people with different disabilities, I took the idea to different organisations to see what they thought. The response was overwhelming.
Lifetime Health Diary™ is a secure, free, patient-owned, internet-based health diary for recording, monitoring and self-managing one’s health, as well practice health prevention. It captures and systemizes all data inputs into an easily understandable “Graphic Natural History” of your heath through lining up all your data by temporal correlation – which is a fancy way of saying your background lifestyle factors and life events are lined up by date alongside your clinical data. This allows your unique clinical story to be better understood by clinicians and caregivers that you personally invite by secure email link to view your health record.
During the meeting Hamish talked about his friend and business partner, Dr. Atsushi Matsunaga, the inventor of the software and a person very frustrated with the inability of the healthcare system to prevent illness in the first place. Hamish shared the history and idea behind the innovation outlining 7 Requirements for the system: i) Better health outcomes for you; ii) Quicker prognosis for your doctor; iii) Shared Patient Care among your Caregivers; iv) Interoperable amongst their different systems; v) All under your Control, vi) Transferable; Accessible, Portable & Private; vii) Free for both you and your doctor.
Hamish finished his short talk, and suddenly, “Access to information”, “Better health care delivery”, “Control and empowerment”, “Patient in the centre of the health system”…a lively discussion had suddenly started and Hamish was under a stream of questions. Details in the next blog post…!
What is the Secret to Better Health in Developing Societies?
Last week I went to a talk in Dunedin, New Zealand by one of the doers of the world, Dr Sujit Brahmochary, M.D. Dr Sujit started as a doctor with just a table 18 years ago in one of the poorest parts of India, Bengal. His Institute for Indian Mother & Child ( http://www.iimcmissioncal.org/ ) now touches the lives of 300,000 people and is growing quickly.
Dr Sujit’s description of what he had built over 18 years, for me turned out to be an interesting description of how he learned what made a difference to developing societies through a long journey of effort and learning. Learning from mistakes, and learning from continually getting deeper and deeper into his chosen mission in life.
He was born to a poor rural Indian family, but was fortunate enough to train to be a doctor in Belgium, so he could have earned a great living in Europe, or at least in a big Indian city. But instead he chose to make a difference in one India’s poorest states, Bengal. So he became a doctor in India. (80% of people in India live rurally, and 90% of these have no access to healthcare). Dr. Sujit made the point that Primary and Preventive Healthcare can solve 80% of health problems amongst the population. So he dedicated himself to helping the health of the poorest of the poor. “Being accessible is very important to build trust in the Developing World”. He started with just a single table.
He quickly realised that he could do little without a supply of medicines and equipment, so he worked to attain support and connections to assist in this need. “If you are right, then people will join with you.”"If you do good work, people will join with you.” Organisations such as the Japanese Consulate showed up and donated an X-ray machine.
But after a longer period of time, he realised that 40% of all healthcare problems could be solved by Nutrition, or “2 Meals a Day”. ”Nobody dies from starvation. You die from malnutrition, or a low immune system, or dehydration. The key is nutrition”. Nutrition for Dr Sujit is simply 2 meals a day, with protein, some fats, carbohydrates, vitamins, minerals and water. That is enough.
But more time passed, and Dr. Sujit realised something else. Education was the key. “Be a teacher first”. To be a better doctor, he had to be a better teacher, and teach people not just how to be healthy, how to prevent sickness, how to avoid germs, how to eat, but even more important how to live, how to grow, how to be strive and grow beyond your station in life you were born into (especially in India, with a very harsh caste system for those on the bottom rung of the ladder). In fact, now Dr. Sujit’s institute no longer builds medical centers (they have 6) but instead schools (they have 26 and growing). “If you take care of educating all the children of a village, a generation later, you won’t have to do anything more. They will take care of themselves and their village.” School students don’t get sick. Those who don’t go to school, are the ones who also tend to get sick.
More time passed, and Dr. Sujit realised that education could birth more easily out of Economic Development, in particular Professor Yunus’ Grameen Bank Model of Development (giving micro-loans to mothers so they could start a business and send their children to school instead of work in the fields).
Beyond Economics, lay stable Agriculture, because that is where good nutrition and the ability to provide for a family’s basic needs come from.
And finally, after everything else, came the final step; Social and Cultural Development. What really is Development? “It is giving everybody respect, and give them an opportunity.” So now, the Institute for Indian Mother & Child has 300,000 people within its care and growth. And Dr. Sujit after 18 years of hard work, has travelled full circle and knows deeply how to effect change in developing societies.
After the lecture, I commented to Dr. Sujit about how his journey seemed to go continually deeper, from wanting to be a doctor, to being a teacher, to an economist, farmer, and finally being a builder of communities. I asked him what role remote medicine/ education and the internet could play. He replied that it is coming. Already every classroom in his schools has a computer, and in 2-3 years from now, he believes the internet is the medium to concentrate on to achieve maximum penetration for education and development in the developing world. So it seems Lifetime Health Diary timing is very good for developing world as we move forward.
Yours in Health,
Hamish
Patient-centered healthcare – so where is the patient?
Sometimes you almost feel sorry for those in the medical industry trying hard to make healthcare more patient-centric. Pauline Chen M.D. writes in her latest blog post about the adoption of “Patient Medical Homes”. Designed to help patients see a full suite of caregivers under a single roof, they turn out to have often made patients feel dissatisfied and unsure.
Once again it turns out that patient perspectives were largely ignored and the Patient Medical Homes were designed by medical experts, with the ironic results of unhappy patients! What should be a great initiative misses the boat without patient involvement and feedback. Pauline writes “In working so hard to adopt changes on their patients’ behalf, clinicians had temporarily lost their focus on the patients themselves.”
Gosh, sounds a lot like the design of Electronic Health Records doesn’t it? One of the big surprises for me as I embarked on a study of healthcare delivery to help build Lifetime Health Diary™ was the apparent disinterest, even outright dismissive attitude that so many clinicians have in accepting “patient inputs” to Electronic Health Records. After all, in their view that would be “unreliable data”.
Perhaps it would be unreliable at a clinical level, but that doesn’t mean patient inputs should not be collected and taken note of. So many physicians have told me that “clinicians think in stories”. Even surgeons in the emergency-filled requirements of an ICU. It begs the question, “whose story?”. How can that story possibly be represented in a 15 minute consultation, or read off the chart of a patient in a hospital bed? It can’t and it never will be. Evidence Based Medicine may help define best practice clinical pathways, but it does nothing to make me the patient feel that my own story is being understood or even cared about.
In fact, what would happen if a significant amount of patient inputs were found to be reliable? Perhaps in some situations even more reliable than clinical data? Certainly at least for chronic illnesses it seems obvious that gains in patient engagement in terms of monitoring their lifestyle would likely outweigh any consideration of “non-clinical” patient inputs being collected and noticed in the first place.
So we shouldn’t really feel too sorry for most clinicians making the effort to be more patient-centric, because until that actually includes genuine patient inputs in the form of structured data (not just side notes) “patient-centric” is all too often just medical code for “clinician-centric opinion about the patient”.
In health,
Hamish MacDonald
