Technology as an Enabler
Tuesday, March 29, 2011
| Fariba Rahbary, Pharm.D.
About the Author: Fariba Rahbary, Pharm.D., Owner, Consultant, Pharmacist - Medication and Health Management Insights (Toronto, Ontario, Canada)
I enjoyed reading previous blogs about the advances in sensor technology and some of the challenges facing technology-enabled health communities. Dr. Kvedar in one of his previous blogs talked about “the psychology of adoption” as a major hurdle for connected health communities to overcome - this may be partly due to what a “community” represents to different people and a misconception over what the technology may try to replace in a community. To some people, a community can go beyond a region and accommodate its members based on feelings of trust, compassion and a sense of connectedness arising from working towards a common goal. To others, community is about personal and face-to-face contact and relationship building within a confined region; in this case it is felt that adopting technology may decrease personal contacts among members of a community and may slow down local businesses and centres thriving on local traffic for funding or revenue.
The word “technology” itself may have negative implications such as increased exposure to harmful radiation, psychological addiction, complexity of use, expensive equipments, automation and depersonalization. The psychology of adoption can be further influenced by compounding factors such as the degree of poverty and related co-morbidities that influence living conditions and the burden of disease particularly in low-income neighbourhoods and countries. Cost-effectiveness of technology adoption in this cost-sensitive era is always a concern especially if “attitudes” remain unchanged. As well, the fear that commercially motivated interests may influence and drive the market, create disease and a need for adoption of technology to treat or prevent the disease is so strong that it may prevent policy makers from considering new strategies such as adoption of technology-enabled care programs as a long-term sustainable solution to contain cost.
Changing “attitudes” is the single most difficult hurdle to overcome. Creating a culture of abuse, shame, and blame; promoting adversarial and fear mongering behaviour; demonstrating ruthless conducts in the interest of profit and political gains; demonizing and excluding certain groups based on their perceived conflict of interest or because of their ideological differences; measuring success and competence solely in terms of quantitative outcomes; failing to acknowledge medical mistakes or refusing to learn from them; hierarchical leadership, resistance to change and refusal to consider new models of practice, inability to engage in system thinking to address root-causes of errors and inefficiencies, failure to consider social and environmental determinants of health, turf wars, indifference and negligence, and stigmatization are just a few examples of attitudes that cost the health care system a lot more money than any dollar saved just by bringing innovation and technology into the health care system. Any meaningful transformation in health care needs genuine and committed leaders and mentors who are able to keep an open mind, examine different types of solutions or a combination of solutions with focus on the right measures and outcomes that can make health care (or some part of the system) more accountable, accessible, efficient, of high quality, and affordable realizing that no one solution may address all problem areas but may decrease the burden of care in such a way that could have a positive ripple or domino effect on other parts of the system. Adopting innovative prevention programs that improve the quality of life and reduce stress and burden of care on caregivers or patients should be a priority - refusing to embrace such initiatives based on political differences and ideological biases or in the interest of profit is the greatest disservice to people and the country.
Can a technology enabled connected health community be part of the solution? My answer is yes, for the following reasons:
We live in a society where many people maintain a very busy and active social and/or professional life well into their 80s and 90s. Living a busy life style, travelling, and spending time away from home has become a necessity for people who may have multiple medical conditions and may be on numerous medications, some of which may require close monitoring and follow-up by their trusted health care providers even when patients are away or on the go. Proliferation of allied health professions, explosion of medical and medication information, and increase in medical and health specialization have drastically changed the landscape of health care delivery. Navigating the system is becoming increasingly challenging and time-consuming. As people are becoming more and more technology savvy, self-care and self-management of minor ailments and some medical conditions are on the rise. People may need access to top tier specialists, professional services, crisis management specialists, reliable medical and health related information websites, and health support programs and services that may not be readily available in their surrounding region. At times, limited mobility may provide a challenge for face-to-face and in person interactions. Some people can (and actually prefer) to age at home yet would like access to monitoring devices and home care services and programs if and when they need it. Families or care givers of patients often have busy lives but may need to be available to provide care and support at home or during office visits; provide translational services, help patients understand and remember instructions given to them by their health care providers, and help patients to navigate different parts of the system as needed. These factors are just a few examples of why we need to take a new approach to health care delivery. How can a technology-enabled health community help?
Connected health technology makes some aspects of health care delivery easier and makes it more accessible. It facilitates interactive patient/consumer-provider navigation through the health care system and related health, wellness and preventive programs by using a variety of platforms and devices as “enablers” to overcome some fundamental barriers that can make the delivery of care inefficient, fragmented and at times impossible – mainly time, location, and portability/mobility. This would assist implementation of treatment plans and facilitates case coordination of patients, making development of multidisciplinary teams easier and less dependent on geographic proximity. It would promote introduction of innovative health, wellness, and prevention programs that are closely aligned with focusing on the whole person and how people actually live their lives at home or in the community. As a result, health care can become more integrated, collaborative and inclusive, in line with what can be done “with” a person in the absence of illness as opposed to “for” a patient in a sickness care system. For example, by connecting patients/primary care givers with providers in between or prior to office visits for monitoring and follow-up, connected health technology would allow patients or their primary care givers to perform a handful of tasks that can make office visits more meaningful and efficient. Connected health technology could facilitate the on-going conversation and dialogue between patients/care givers and the members of multidisciplinary team, allowing patients to get educated about their health and medical conditions or medications by qualified health care professionals at home or in the community so that office visits can be focused on treatment or addressing unanswered questions in the context of proposed course of treatment. As well, deployment of electronic health records, innovative and interactive use of technology to ease access to evidence-based guidelines, clinical pathways, and comparative effectiveness data could lead to increase in efficiency of the health care system.
It is important to note that a technology-enabled community is not necessarily about replacing face-to-face interactions and personal contacts or substituting for mainstream health care for the following reasons: First, in my opinion, access to quality care should be based on a person’s need rather than on their ability to pay. I just can’t fathom the idea of someone dying of a disease (e.g. cancer, HIV, etc.) just because they do not have money to see a physician or pay for their life-saving medical treatment or medications, in Canada, or in any part of the world... and in reality this happens quite often in different parts of the world. Second, we should keep an open mind and embrace all models of care that work and that show proven benefits. The presence of different care models should not be mutually exclusive even within the context of a universal health care system. Third, patients and/or providers have different preferred style of communication that need to be respected; some patients feel they prefer face-to-face and in person interactions to discuss certain medical conditions or treatment options and some providers feel they need to pick up non-verbal cues that may help them with their diagnosis or treatment. They are concerned that they may not be able to communicate effectively or that some non-verbal cues may get lost in translation if the interaction is not face-to-face. For example, as pharmacists, we are trained to read non-verbal cues by looking at the patients’ body language, their gait and posture, the smell of alcohol, cigarette, or illicit drugs on their body, their demeanor, and many other non-verbal cues all of which may impact how we identify, prevent, and resolve actual or potential medication related problems. Some pharmacists feel they need this face-to-face and in person interaction in order to provide their clinical services - this should be respected and acknowledged.
Can a technology enabled community partly address the supply and demand problem in health care delivery? I think so, because it would allow some services be offered to a wider group of patients and health care providers by minimizing barriers such as distance and time. For example, features such as video/virtual conferencing would allow provision of real-time in-services and continuing education programs to a larger group of healthcare providers and facilitate simultaneous and interactive discussions and information sharing among various facilities and providers. In addition, portability of health care and diagnostic devices would allow care to be provided in more locations, at home, in the community, in disaster zones, by a bed-side nurse, in remote areas, or remotely by a multidisciplinary team of qualified health care professionals, thereby decreasing the wait time for receiving care and reducing the burden of care on acute care departments and services. In addition, technology enabled devices allow access to health care providers remotely minimizing the cost associated with patient transfer, care coordination, and travelling time.
Connected health technology can also make triaging of care easier by enabling remote central monitoring services in various health care settings, at home or in the community. Connecting patients with the right providers and the right care settings based on acute manifested symptoms is the key. For example, a patient walking in a pharmacy looking for an over-the-counter product for self-management of his acute symptoms may in fact be in need of more urgent care by a primary care physician. A community pharmacist, through technology-enabled devices and real-time consultation services is in a perfect position to help patients select the most appropriate medications with a follow-up plan, or if needed promptly contact other primary care providers and refer the patient to another member of the multidisciplinary team or a community care clinic with the needed background information, or in some cases even provide contextualized medication case-management and health care navigation services as patients move across the continuum of care.
From a prevention perspective, technology can help people achieve a new level of health behaviour by making the tools we need to get healthy more accessible. Innovative use of technology can facilitate development and delivery of engaging and interactive health related information and programs that can encourage healthy behaviours and reinforce preventive measures at home, in the community, in the workplace, in health clinics, in schools or universities. This is particularly useful for those who would like to adopt healthy behaviours, but due to various life circumstances require continuous support, engagement, reinforcement, and coaching outside the realm of what can be provided by mainstream health care. As well, technology-enabled connected health could help health care providers and consumers to filter and translate billions of medical articles and related health and wellness information efficiently into a meaningful and contextualized format for people – making informed medical care, self-care, and healthy choices available “right at their fingertip”. This may proactively address the rising tide of commercialized care and consumerism in our society.
An interesting area of research in technology-enabled monitoring services is the development of sensors and devices that can analyze the environmental, physiological and psychological status of individuals, which can then be relayed back to various health care providers for further analysis and real-time consultation for diagnosis, treatment, or monitoring between patients’ health care providers. Sensor technology also plays a role in bio-feedback for stress-related disorders. In addition, sensor technology at various stages of research and development is evolving to perform a variety of functions such as measuring the levels of various substances (including medications) in the body, scanning health information on packaged food products, tracking the daily caloric and nutritional consumption and expenditure, analyzing body fat, muscle, hair, nail, and skin composition, detecting pollution in the air or in water, analyzing the composition of wastes in landfills, maximizing the soil condition in gardens or farming lands, increasing home safety and health monitoring, and assisting with the provision of emergency relief and wound care in disaster and remote areas. These sensors/devices are light, small, accurate and easy to use and can be embedded in a variety of portable (wired or wireless) tools for everyday use by front-line health care professionals and emergency relief service providers or in some cases for use by patients or consumers.
Sensors also play a great role in facilitating care of the elderly - from occupancy sensors for lighting to reduce the risk of falls, to devices and sensors that connect those with limited mobility to the outside community, or tracking devices that monitor movements (e.g. bed rail motion detectors), sensor technology has a great potential to allow seniors to continue living safely and independently at home or in the community. Sensors are also used to create tamper-proof pre-set conditions (e.g. electrical appliances, heating and cooling systems, air and water temperature control) to improve home safety. An important distinction between these devices is their requirement for the level of participation by the end users. Active sensors (i.e. those requiring manipulation or activation for recording or data collection) may not be appropriate for those with cognitive impairment or mental disorder, those with limited manual dexterity, or people at high risk for experiencing acute conditions that may render them unconscious. Passive monitors or remote sensors may be more appropriate in these cases and are starting to replace devices requiring client activation.
For Sign Language users, mobile sign language devices equipped with ultra sensitive motion detectors, enhanced videoconferencing technology, and superior image quality are at various stages of research and development. Another area of research has focused on using sensor technology in prosthetic devices to minimize discomfort and exposure to radiation during screening procedures (e.g. airport screening) in people who wear prosthetic devices. Researchers are also working on technology-enabled devices to help people with visual impairment “see” and orient themselves within the world. Vision “therapy” using sensor technology has tremendous potential to address some of the challenges people with visual impairment face on a daily basis.
Another area of research has focused on the development of wireless sensors that measure brain activity remotely and send the information to a satellite for further research. The data obtained through this method, combined with those obtained by physiological and environmental sensors and the information obtained about an individual’s DNA, saliva, etc., can help researchers, scientists, and providers gain a better insight about the person as a whole. As well, there are remote sensors at various stages of development that can identify individuals based on voice analysis; they can also analyze a person’s manual dexterity, visual acuity, reaction time and response to various stimuli (e.g. noise, music, radio and television programming, speeches, presentations, etc.) in real-time and relay the information back instantaneously for further research and analysis. Of course, in all these cases, the assumption is that the information sent to these sensors, the samples provided for testing, or the sensors themselves cannot be manipulated by the research subject or the patient. In a near future, these sensors could easily be downloaded to mobile devices for use. It is extremely important to realize that the information and data obtained by these sensors may not be useful or may be a source of misinformation if they are not interpreted properly or if they are not put in real patient context to explain a behaviour - for example a sensor may indicate non-compliance with taking a medication but may not provide enough background information about the underlying cause(s) of non-adherence.
While investing in more sophisticated technology and medical devices may not be an immediate solution to the challenges we currently face in the health care system, I tend to look at the tremendous potential that the responsible use of technology in health care can offer and make the connected health technology part of the vision for increasing efficiency and quality of care and interaction between patients and their trusted providers.
Funding and reimbursement remain a critical issue; the establishment of a reasonable payment plan and a strategy to align the reimbursement rates with the provider’s cost, health outcomes, and quality of service provided must be worked out and taken into consideration. As mentioned before, the only thing that a technology-enabled connected health community can’t do is to overcome the bureaucracy that impacts the balance between clinical needs and quality of care versus politically or commercially motivated targets – for that to happen we need to change “attitudes” and that would be a great topic for future discussions.
We need to acknowledge that improving the way health care services are delivered and investing in solutions that keep people healthy is in the interest of all stakeholders. So who should care enough to pay for the services or deliver these services? Should we separate medically necessary hospital and acute care services from primary or secondary prevention services? What about wellness programs? What should be the role of the federal government in enacting legislations that promote and protect the health of all its citizens? What should be role of private health care industries, insurance companies and benefit providers in “pre-authorization” of care? These are all valid questions that need to be discussed openly, democratically, with civility and transparency for a sustainable health care transformation to occur.
As always, it is up to health care providers to closely safeguard patients against the unethical and unnecessary use of new and evolving technology in health care and to advocate for its proper and responsible use in our society. “Commercializing health” and using these devices to medicate or treat the normal vagaries of the human condition should be strongly discouraged. But the fear of commercialization should not prevent us from supporting research and development of these products in service of the public. Obtaining a prior consent, respecting patient privacy, and maintaining the confidentially of patient information and health records are of paramount importance in any health care setting, but they become particularly important when we adopt technology in a connected health community to interact with patients. The tremendous potential for technology to improve this world, to treat, to heal, and to protect reminds me of this quote: “Although the world is full of suffering, it is also full of the overcoming of it.” - Helen Keller.
As usual, I enjoy reading thought provoking blogs and postings by the members of the Connected Health Community.