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  • Personalising Quality of Care in Healthcare Professional’s Practice

    “What doesn’t get measured doesn’t get done.”-William Thomson

    John is a 55 year old software engineer at a large firm in Manila. For four consecutive days now, he had episodes of vague “chest heaviness” coupled with some difficulty breathing. Privately insured, he asked for a day off to seek their company physician’s consult. He drove an hour to the clinic, waited for another two hours in the waiting room before being seen by the company physician lasting for 15 minutes. He was given a list of diagnostics and was referred to a cardiologist. The process of seeing a cardiologist is almost the same, only this time, much longer.

    “Travel time was two hours because of traffic, waiting time doubled to four hours, diagnostics to 2 days yet being seen by a doctor lasted only for 8 minutes” said John.  “I’m nervous. I’m not sure if its about my chest tightness or the whole rigodon of trying to determine what cause it. All I’m told it was a Non Specific T wave changes. I don’t even know what that means but it took me two weeks to finish the whole check up thing!”

    Manang Tina is a 35 year old vegetable vendor. She temporarily stopped selling vegetables because her 7 year old daughter had a throat pain, difficultly eating food and fever for 3 days already. She asked her daughter’s teacher if she can be excused for a day. “I had to bring my daughter to the rural health unit” she said. At the RHU they had to wait for almost 4 hours before being seen by the doctor. Her daughter was seen and examined for 10 minutes. “She needs a CBC, a chest x-ray and urinalysis Manang Tina” said the doctor. “Have this done and come back here once the results are out. In the meantime, your daughter may take paracetamol and gargle with this liquid 3x a day” followed the doctor. The diagnostics took a week to finish, the fever and pain now gone and my daughter able to eat painlessly now. In fact she is already back in school. What shall I do with this lab results?” ask Manang Tina.

    In this digital age, did Mr. John or Manang Tina’s daughter, received quality health care?

    Quality of health care, defined
    Agency for Healthcare Research and Quality of the US Health and Human Resources Department cite The Institute of Medicine’s definition of health care quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” I has six domains- effectiveness, efficiency, equity, patient centeredness, safety and timelines but has concomittant consumer perspectives of staying healthy, getting better, living with illness, and coping with end of life.

    Complex, Divisive Issue
    Quality of care is a complex, multi dimensional topic that most healthcare professionals avoid discussing. True enough, learning quality health systems and models could take some 4 or  5 years of formal study and a lifetime of iteration and improvements. Simplifying quality of care seems to be an impossible task for every health stakeholder. Everyone have the answer to quality issues yet our health system is going everywhere but forward.

    “I leave that to experts” said Dr. D a busy private heart specialist. Dr. D is referring to quality assurance professionals, compliance personnel and regulatory agencies “to do their thing while we, healthcare professionals do what we’re good at- taking care of our patients.” We’re too busy to debate on such topic.” Dr. D explained.

    But if a healthcare professional, a primary mover and health stakeholder doesn’t have a good grasp of what quality care is, how does one know he’s providing one?

    “Look, I have a full, standing only waiting room at my clinic. If that’s not a measure of how patients see the quality of my care, I don’t know what is.” Said Dr. S a family physician.

    Making quality care, personal
    But how do we know we are giving the best of care to our patients? If you are a patient, how do you know you’re receiving quality medical care? What are our personal “yardstick” for “quality of care”? In the digital age where technological innovation has disrupted some areas of medicine- form intuition to precision diagnostics, did quality of care improved? How does this affect the present “business model” of physician’s practice? Of nursing care practice?

    These are just some of the questions a healthcare professional, student or even patients must confront head on to improve health care. While healthcare professionals need help from external personnel for regulatory compliance and quality assurance, quality of care should be “personal” to every health stakeholder. In this technological age where innovations have the potential to improve some aspects of our health system, every health stakeholder has the responsibility of knowing what quality of health care is.

    This is the topic of our #HealthXPh chat this Saturday 9PM Manila time. I’m inviting every health stakeholder out there- patients, healthcare students, healthcare professionals etc, join in your personal views on quality care in this interesting chat. In your personal practice ( if an MD, Nurse, allied professional), plan (if you are a student), experience (if you are a patient),

    • T1. What is your personal idea of quality health care and how do you measure it?
      T2. Name one innovative step you implemented to improve quality of care in your practice.
      T3. Name one technological innovation that should improve quality of healthcare in 3-5 years. Explain

    References:

    William Thomson (June 26, 1824–December 17, 1907), 1st Baron Kelvin, often referred to simply as Lord Kelvin, was an Irish mathematical physicist. https://en.wikiquote.org/wiki/William_Thomson

    Understanding Quality Measurement. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html

    Christensen, Clayton M., Jerome H. Grossman M.D., and Jason Hwang M.D. The Innovator’s Prescription: A Disruptive Solution for Health Care. McGraw-Hill, 2009.

  • Digital Divide in the Healthcare Industry | The haves and have nots of a healthcare professional in the digital age

    Castells broadly defined digital divide as “the inequality of access to the internet”. Scholman defined digital divide as “the gulf between those who have ready access to current digital technology and those who do not”. This definition included the consequential “social or educational inequality” that comes with this gap.

    An approximate measure of determining the extent of “digital divide” in a country is the NRI ranking.

    “The NRI is part of the World Economic Forum’s Global Information Technology Report 2015: ICTs for Inclusive Growth. The NRI identifies the capacity of countries to leverage Information and Communication Technologies (ICTs), by assessing the overall political and business environment, the level of ICT readiness and usage among the population, businesses and government, as well as the overall impacts of ICTs on the economy and society at large.”

    The Philippines ranked 77th, in the most recent, 2016 Global Information Technology Report by World Economic Forum.   That’s a notch down from our previous 76th ranking. Detailed results and subcategory analysis of this NRI ranking can be found in this site. We scored worst in infrastructure but other indices are no better. This, despite the country being tagged as the sms and social media capital of the world. Around 87% of our adult population spends average of six hours on the internet per day. Our internet and mobile population penetration is increasing also. So while, infrastructure (physical access, internet speed and portals) seem to be the biggest obstacle up front, it cannot account for the digital divide occurring in sectors where physical access is not the biggest concern.

    Health implications:
    While the greater portion of our general population is consequently denied physical access to internet because of poor hardware and network infrastructure, this is may not be true for the healthcare industry’s professionals such as doctors or nurses. Many healthcare professionals already have material and physical access to the internet. The recent Digital Asia report also showed many patients are are going to the internet for information regarding their health issues. Health information is increasingly made available over the internet . Healthcare professionals need more and more sophisticated skills to use electronic resources in improving healthcare services. This, despite the rising cost of accessing copyrighted, medical journals. This complicates the issue and resolution of digital divide. It places tension on patient- doctor relationships or collegial collaborations when either of the party belong to the opposing fences in this digital divide.

    T1. Is there a digital divide within the healthcare sector? Please elaborate on your answer.

    Scholman further subdivided digital divide in to mini gaps namely technological, content, gender and commercial divide. These mini gaps form many of the basis for surveys of the occurrence of digital divide among population. While this gives us an idea of how we fare in terms of our digital literacy with that of other countries, it does not account many other factors that contribute to digital divide other than infrastructure or physical access, like in healthcare.

    Scholman’s mini digital divides are often good when identifying or characterising gaps. I find Jan van Djik’s relational views of digital divide relevant when looking for strategic solutions. Jan van Djik’s proposes a relational framework for understanding digital divide and coined a cumulative, recursive model and successive kinds of access to digital technologies. (See figure 1) .

    Source: van Dijk (2005, p. 22) Figure 1: A Cumulative and Recursive Model of Successive Kinds of Access to Digital Technologies

    When a sector of society went pass the motivational and material access problem, they are still faced with another level of obstacle to hurdle the “digital divide” -namely skills and then usage access.

    T2. What’s most salient reason or contributor to this digital divide in the healthcare industry?

    In my opinion, this is what the health sector (the academe to be specific) should deal with to narrow that gap or digital divide in healthcare.

    T3. What do you think is the best solution to this type of digital gap in the health sector?

    This is the main topic for our discussion this Saturday July 7, 2018 9:00PM Manila time. Here are our guide questions:

    In your experience as a healthcare professional:

    • T1. Is there a digital divide within the healthcare sector? Please elaborate on your answer.
    • T2. What’s most salient reason to this digital divide in the healthcare sector?
    • T3. What do you think is the best solution to this type of digital gap in the health sector?

    Closing Thoughts:
    Digital literacy and digital scholarship has been put forward by many strategist as a way to narrow this gap in medicine. As a healthcare professional, what do you think could be your biggest contribution to advocating or promoting digital literacy or scholarship in the field of medicine?

    References:

    Castells, Manuel 2001 The Internet Galaxy: Reflections on the Internet, Business, and Society. New York: Oxford Univesity Press.

    Schloman, B. (May 7, 2004). Information Resources Column: “The Digital Divide: How Wide and How Deep?” Online Journal of Issues in Nursing. Available: http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/InformationResources/TheDigitalDivideHowWideandHowDeep.html

    van Dijk, J. A. (2005). A framework for understanding the digital divide. In The deepening divide: Inequality in the information society (pp. 9-26). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781452229812.n2

    World Economic Forum (2016). Global Information Technology Report 2016. Retrieved from http://reports.weforum.org/global-information-technology-report-2015/economies/#economy=PHL

    Department of information and communications Technology (June 6, 2016).Department of ICT Law takes effect today. Retrieved from http://dict.gov.ph/department-of-ict-law-takes-effect-today/

  • Nudges in Health: Physicians as choice architects

    Health choices could apparently be influenced or “nudged”. Consider the following hypothetical scene:

    A patient is seeking surgeon’s advise on a much needed surgical procedure and its risks. He asked two equally competent surgeons the same question.  “What is my risk of dying in this procedure doctor?”

    Here’s what the two surgeons replied:

    Doctor A: “Approximately one in 100 patients die in this procedure”.

    Doctor B: “Approximately 99% of patients live well after this procedure” 

    If you are the patient,  would you undergo the procedure? If so, who would you most likely ask to do the procedure on you? If not, which surgeon dissuaded you the most?

    Hypothetical and simplistic, this happen in many patient- surgeon conversations. In many instances, our answers are quite predictable. I’d probably wouldn’t undergo this procedure if I was listening only to Doctor A. If I chose to undergo the procedure, I’d ask surgeon B to do the procedure on me. That is, even if my risk for the procedure is technically the same between the two surgeons!

    Surprised? Don’t be. There’s nothing wrong with you either. Behavioural studies have suggested that many of our choices and consequent actions, aren’t as rational as we believe it to be. We’re homo sapiens after all.

    Physicians are trained to provide patients and the public with the best possible or optimal health choices.  We’re supposed to be adept at providing patients with evidence based health choices and convey this in a language the public would understand. Doctors are supposed to be experts on health statistics and evidence based researches in their own field. Prompt, timely  and effective communication or feedback is also key for patients to make optimal health choices. But are we really providing patients these two essential choice adjunct for them to make optimal choices?  Even experts in some fields don’t agree with each other’s interpretations of the “best evidence”. Just take for example, immunisation.  More over, we’re not better with communicating or giving feedback to patients as well. Even minute differences in framing responses (such as the scenario above) weighs heavily on patient choice.

    The rapid technological change in internet and communications was thought to democratise and exponentially increase access to health information. More information means better  or more rational health choices. Apparently, that’s not always the case. More than half of current smokers wanted to quit but don’t. Many food and lifestyle related diseases such as obesity, hypertension, diabetes are still on the rise. More choices doesn’t necessarily end up with  a optimal choices either. There’s a plethora of toothpaste choices in the grocery store but these did not significantly decrease the incidence tooth decay in the general population.   A “no-harm-yeah-whatever- choice” isn’t also acceptable. Take the case of some vitamins and herbal medicines. Many of these are harmless to patients but are found out to be totally ineffective for diseases it is advertised for. Vitamins are still one of the most sought after over the counter substance in the Philippines.

    Indeed, many behavioural studies have suggested that humans (physicians and patients included), don’t make optimal, rational choices most of the time. This is particularly true in fields which they lack expertise or effective communication abilities. In the field of medicine and health, healthcare professionals happen to be the the “experts”. Whatever communication abilities we have, patients (and colleagues) often seek our expertise for them to make rational health choices. 

    So how do we help patients make optimal decisions for their health?  In this edition of #HealthXPh tweetchat, we’ll explore how healthcare professionals, policy makers, health professions students, patients and advocates help patients make optimal health choices.  Whether you are a patient or a physician, here are our guide questions.

    • T1. What for you, is the most important factor in making optimal choices health? Why?
    • T2. What  is  least likely to influence your health choices? Why
    • T3. When current evidence is vague or equivocal at best,  what do you advice or who’s advice do you seek? Why?

    Join us this Saturday May 12, 2018 9PM Manila time by tweeting your answers to our guide questions (and chiming in your response to others’ too) with the hashtag “#HealthXPh” between 9-10PM Manila time. Of course, for #HealthXPh your opinion matters. 

    References:

    Kahneman, D. (2013). Thinking, fast and slow. New York: Farrar, Straus and Giroux.

    Thaler, R. H. (2016). Misbehaving: The making of behavioral economics.

    Thaler, R. H., & Sunstein, C. R. (2008). Nudge. New Haven: Yale University Press.

    Nisbett, R. E. (2015). Mindware: Tool for smart thinking.

     

  • For using Facebook and other social media platforms, how much of your personal privacy are you willing to give away?

    It blew right in our face.

    The “Facebook Scandal” (FB data breach with The Cambridge Analytica) shook many industries using  this social media platform to “influence” a particular interest.

    “We exploited Facebook to harvest millions of people’s profiles. And built models to exploit what we knew about them and target their inner demons…” Christopher Wylie, the whistleblower who worked with a Cambridge University academic to obtain these data using third party app, told the Observer.

    Mark Zuckerberg & Co built Facebook to fill its users’ need for socialising, online. We all knew however, that Facebook was also created to harvest data in the first place. This is in the fine print of FB’s terms of use you’ve agreed to, when you started using Facebook.   Although the company publicly admitted using data for their own regulated and targeted advertising algorithm alone,  it may have “unknowingly” provided  “limited data” to third party companies thru the various apps. Zuckerberg apologised for the “break of trust” given to them by their users because of this. What those “third party entities” do ( or did) with these data remains a mystery to the public.

    Remember how Target “snooped” on its customers and figured out a teen girls is pregnant before her father found out? By harvesting its customers’ shopping habits and using  predictive analysis, it was able to predict the most likely “next buys” of its customers and “structured” their stores to capture that buying intention. This pregnancy prediction model predicted with 87% accuracy that a lady would soon be delivering a baby if it buys vitamins, supplements, diapers or a blue rug!  We can only hypothesise about the staggering scenarios of “what ifs” if these breached data reached a not so well intentioned party. Elections, politics or buying habits are but to name three.

    In healthcare, privacy breaches are not only considered scandalous. It is  “deadly” as well for it may cost lives.

    To be fair to Facebook, healthcare (willingly or unwillingly) benefitted from some of the platforms “allure”. The relatively inexpensive, easy, accessible and wider user base are very good reasons for educating the masses about health  issues. It is also a very good alternative to ( or in fact dismantling) more traditional, expensive media platforms for getting across messages to a wide range of users.  There are probably thousands if not millions of patient support groups in FB.  Advocacy campaigns aimed at improving healthcare abound in this platform. There are also healthcare professionals who use FB as a listening and or speaking platforms for many well intentioned campaigns. In short, the healthcare industry through its stakeholders, are also benefitting from FB’s social media clout while knowingly giving away part of its privacy. Here’s where the conundrum begin and why this breach opened a  pandora’s box in healthcare.

    Imagine, if user profiles and data went into the hands of not so well intentioned healthcare industry player. What if this data is used “shape”, influence or manipulate minds to buy a particular product? Or tinkered, to accept or debunk certain healthcare issue without the benefit of validated research and recommended protocols by the medical community? What if the data are “manipulated’ to “influence” the medical community itself? This may or may not happen and regulations are something we- the healthcare stakeholders,  have to really look at in so many different ways.

    While social media regulation is still being debated, most rely on “self regulation” on what, when or how they do things on Facebook, to prevent data from falling into the “wrong hands”. Self regulation on social media  is though balancing act itself and remains a huge challenge to many of its users. #HealthXPh believe that educating the masses about health uses of these social media platforms’ plays a key role in this balancing act. This is what #HealthXPh is discussing (on Tweetchat) this Saturday March 24, 2018 9:00PM Manila Time .

    As a patient, healthcare professional, student, policy maker, or advocate, how much of your personal privacy are you willing to “give away” for using Facebook?

    • T1. Why would you or would you not deactivate your Facebook account?
      T2. For using FB, what kind “data” are you willing to give away and why?
      T3. What are your parameters for absolutely stopping Facebook use?

    We are inviting you to a lively discussion thru a twitter chat , this coming Saturday March 24, 2018 9:00PM Manila time. Join discussion!