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Addressing the diaspora: Return of Service Contract for healthcare workers
There is 1 physician per 1, 153 Filipinos according to WHO’s Global Health Observatory physician density data. In remote areas of the Philippines however, the ratio is lower at one physician per 33,000 Filipinos. WHO recommends a 1 is to 1,000 (or less) physician to population density. This is just one of the many healthcare concerns we should address if we are to achieve this country’s millenium development goals.

The Philippine health system devolved most (at least in paper) of its health care implementation to the local and regional government units. Except for a few retained and autonomous healthcare institutions, the Department of Health only oversees and “augments” health needs of this country. The rest of health planning, policies, and implementation are up to the various local government units.

The lack of medical practitioners in the rural areas is attributed to several factors:

The diaspora of physicians from the Philippines to practice abroad is one of these factors. Majority of those who stayed in the Philippines opt to practice in urbanized cities, where their medical education and training suits the work environment. Practice of profession is also more profitable in urban centers. A lot of Filipino physicians also choose to work as a private practitioner for a more sustainable income rather than work in a government healthcare institution.

The lack of infrastructure and suitable working environment also discourages many doctors to practice in rural areas.. Most LGUs are unable to hire the necessary healthcare professionals in their locality. This, despite the law mandating LGUs to spend 30-35 percent of their internal revenue allotment to health needs of their locality. For decades, Department of Health’s response to doctors shortage is the Doctors to the Barrios program, started by then DOH secretary and Senator Juan Flavier. The program which has been lauded and popular at that time, had its successes limited to areas they are implemented.

One of proposed solution is the return of service contracting for graduates of government subsidized medical schools. Graduates of government subsidized medical schools are required to render service in the country for a specified number of years.

Join us this Saturday at #HealthXPh as we nitpick return service contracting as a solution to the lack of physicians in the country
- T1. Do you agree that healthcare workers in government subsidized schools render return of service after graduation? Why or why not?
  T2. How can we keep our doctors from leaving the country after return of service?
  T3. How do we keep our medical education attune with the health goals of the country?
Don’t forget 9:00PM Manila Time October 1, 2016, #HealthXPh tweetchat live. Join the discussion!
October 1, 2016
Are patient “proxy measures” helpful in assessing the quality of care rendered by a healthcare professional?
A patient consulted me years ago for a draining sinus in his right leg. He previously underwent several surgeries in the leg for multiple open fractures in the lower extremities sustained from a motorcycle crash. The fractures got infected despite repeated surgeries. After almost 6 months of treatment, clinical and laboratory findings suggest the infection is “controlled’ and the draining sinus is healing. The surgeon applied a closed circular leg cast on his right lower extremity.

“I asked the doctor if he can place a cast window over the wound” said the patient. The doctor replied “there’s no need for that”. “Your wounds are healed and I’m placing cast so your leg bones will unite”.

Two weeks after, the cast emitted a foul smelling odor. His right leg is still on circular’ long leg cast when he came to our clinic. The foot part of that cast is nowhere to be found and the patient is “walking” with crutches on his affected leg. After opening the cast, a draining sinus is again right where the wound is supposed to be “healed”. The worst part of this experience according to the patient is not that he had another draining sinus heralding an infection, but this.

“We asked the surgeon to place a cast window over the wound, but he didn’t listen. The odor is unbearable, I couldn’t clean it. Everybody avoided me because I smell very bad.

The phrase “he didn’t listen” stuck even now that I am in my private orthopedic practice. It served as a constant reminder for me of how I will ultimately gauge the quality of care I deliver as a physician. This may arguably be, a very controversial mantra of service for a healthcare professional. Personally though, I’m reminding myself why I am in the business of medicine and who I’m supposed to be “servicing” first . Patients. They are exactly why I wanted to be a doctor in the first place.

A very interesting offshoot of this patient encounter was the fact that he wasn’t really concerned of another infection. It is the fact that the doctor “didn’t listen to him”.

Scientific evidence and Peer reviews

Quality of care for physicians is measured by how well we render service using available scientific evidence and peer reviews by colleagues. No matter how we try to convey these scientific evidence into understandable bits of information, patients seem to have a “different” criteria of measuring the quality of care we render to them.

In the example I mentioned above, the patient measured the “quality” of care rendered not by how “scientific” his chronic leg infection was managed, but by how the doctor “listened” to his suggestion.

No matter how physicians strive to be objective, patients will always take their “health experience” as personal. The context of this health experience is a manifestation of their personality, values and expectations. Thus patient measures health care effectiveness by making comparisons of what physicians do against what they understand, of what they “experience”. In short, patients uses proxy measures- a reasonable default because often, the complexity of medical science baffles even the best of its practitioners.

What is a Proxy Measure? A proxy is an indirect measure of the desired outcome which is itself strongly correlated to that outcome. It is commonly used when direct measures of the outcome are unobservable and/or unavailable. An organization should use a proxy measure when there is little or no data available about the program being implemented, but the outcome the program is designed to influence has an existing and commonly accepted proxy.

A lady patient once whispered to me asking my team to leave the room for a moment and come back after 5 minutes. “I just had my bedside bath and I’m still in my underwear when your service entered my hospital room”. She said he would appreciate it next time if the station nurses warned us before going inside the room. Respect for the patient’s privacy as an individual or a person rather than just as a disease or medical condition is another proxy measure most patients used to gauge us physicians.

A third proxy measure that is of interest to me too is how well coordinated is my whole medical service team. A patient once asked a nurse who was dressing her wounds why she and not the surgeon is cleaning her wound bedside, the nurse replied “I’m did because I was ordered to”. When patients sees the healthcare team in disarray or is uninformed about his or her treatment plan, it reflects bad on the whole healthcare team.

These are just some of the proxy measures that patients use that I personally had experience. Some physicians would argue for or against the validity of these proxy measures. Personally though, many patients do not really care what “99.99% of patients with this medical condition get well” meant for their own illnesses. Their health experience matters most. If this is true and valid, why are proxy measures not included in the physicians criteria for assessing the quality of care we deliver?

Join us this Saturday, August 13, 2016 9PM Manila time as we discuss the importance patient proxy measures in assessing the delivery of care by health professionals
- T1. Are patient “proxy measures” valid measures for quality of health care? Why or why not?
- T2. What are your top three patient proxy measures of care and how do you validate (investigate) these measures as a physician?
- T3. Is it helpful if we incorporate “patient proxy measures” into our system of assessing quality of service? Why or Why not?
Again, see you this Saturday 9PM for another lively, interesting tweet chat by using the #healthxph.

Resources:
1. Gitbooks https://centerforgov.gitbooks.io/benchmarking/content/Proxy.html
2. Patient Safety Quality Improvement, Department of Family and Community Medicine, Duke University School of Medicine http://patientsafetyed.duhs.duke.edu/module_a/measurement/proxy_measures.html
August 13, 2016
How should healthcare professionals respond to a medically related social media posting?
If you were the medical professionals in these two examples, how would you respond to social media postings related to your actions?
- Case # 1: A medical intern was captured on a cellphone video, was ate bedside of a patient, holding a phone on his left hand and a paper ( a referral letter? ) on the other hand. This video was posted on Facebook with a caption (in Filipino language) “Are all doctors like this?…My patient is near death and he still does this?”
- Case # 2: A physician regularly conducting medical missions in one hinterland wrote several letters to local government authorities regarding the unusual prevalence of Hepatitis B in one tribe of local indigenous people. He asked for help to the same authorities for years. He related help never came from the government sector. As a last resort, he posted his difficulties on Facebook. This Facebook postings did receive a ton of encouragement and support. What’s more scathing though is the few “negative comments”. The physician is clearly devastated.
What’s common in these two examples?

Trial by publicity spinoff

First, the healthcare professional’s medical actions went public via a social media site. Second, while both healthcare professionals received encouragements and support, the negative comments hurt more in both cases.

Negative publicity

“Negative publicity” is one reason why healthcare professionals shy away from social media. Negative publicity take toll on personal and professional life. The reality is someone- somewhere and somehow, will post something about our medical actions online. It’s simply a question of “when”.

Key components of a social media response

A previous tweetchat about protecting online reputation summarises two key components of a social media response- a prompt but well thought out reply. A prompt, well thought out social media response could only come from a personal or institutional social network strategy.

Social Media Response Strategy

The recent spate of healthcare related negative comments online urges us to examine deeper these response strategies. Vanderbuilt University Medical Center developed a Social Network Response Guide for healthcare professionals on how to respond to social media postings related to their profession. You can find that algorithm here.

Dr. Iris Isip Tan adapted this Social Network Response Guide for UPCM/ PGH in developing their own social media policy.

Vanderbuilt University Medical Center Social Network Response Guide as quoted and modified by Dr. Iris Isip-Tan for use of UPCM-PGH in developing their own social media policy ( Photo courtesy of Dr. Iris Isip- Tan)

The end goal of this guide is for the healthcare professional to have a calibrated response using the strategy of transparency, timelines for thinking and responding, a more personal tone and credible sources. How we implement this algorithm to our own specific case is one of the main goals of this tweetchat.

Join us this Saturday July 9, 2016 9 PM Manila time as we discuss how should healthcare professionals respond to social media posting related to the profession
Our aim for this upcoming chat is to provide template guides for healthcare professionals in responding to social media postings related to our profession.
- T1: How should healthcare professionals respond if the social media post about him or her is “positive”
  T2: How should healthcare professionals respond if the social media post about him or her is “negative”
  T3: How should healthcare professionals act if you are not directly related to the social media post or posting is not within your area of expertise.
Join the discussion via twitter, using the #HealthXPh in all your tweets, answering the above topic questions, from 9-10PM Manila time July 9, 2016.
July 9, 2016
Patient centric healthcare technology, anyone?
Carlos is not my patient. Well not yet and probably never will be. Here’s why.

Carlos is a 35/M who complained of knee pain after playing badminton one weekend. He sought consult from their company physician who requested x-rays of his knee and was referred to an orthopedist for evaluation. Carlo is single, lives alone in his house and works as an information technologist in one company . He took a week off work because he could hardly walk and his knee in pain. He scheduled that appointment with orthopedist, hired a pedicab to fetch him in his house, bring him to the diagnostic center to have his xray taken then ferry him back to his house. He has to wait for 3 days to get the results of his xrays, then hire that pedicab again to ferry him to and back from the diagnostic center just to get the results. Never mind the long queue for just getting the plates.

On the appointment day he hired a pedicab again to fetch him in his house, bring him to the orthopedist clinic and back. He have to queue in line, get his priority number, sit and wait for his time to be called and examined by the orthopedists. Never mind if the call is an hour late, for some unknown reasons. After being seen and examined, he showed his xray and lab results to the orthopedist, “Not enough for a diagnosis” was his physicians words. So the orthopedist ordered another diagnostic, an MRI, prescribed him some pain meds and was advised follow up with MRI results.

His knee pain unbearable, Carlos asked pedicab driver to bring him to the nearest pharmacy to buy his pain meds. He soon found out it is not available there, so he went on looking for it in other pharmacies. Only then he can get home and rest his knee.

The whole rigodon took Carlos the whole day, while bearing the pain on his knee. Thinking about an MRI made Carlos sigh in frustration. Not only that the MRI cost so much but the idea of repeating the whole rigodon doing this diagnostic and bringing it to the orthopedists just so his knees wouldn’t be painful anymore, is just too painful than his “painful” knee. Why is it that with all this healthcare technology- EMRs, Digitalized lab results, imaging, eased the work of healthcare providers but not of the patients?

Of course Carlos is a fictional character. But what he went through is a chimera of the “regular” charades most patients go through when they seek physician consult. Technology is supposedly going to ease these for him, but It hadn’t trickled down to patients yet. While most healthcare providers (institutions, physicians) benefited from the use of technology in healthcare, many patients like Carlos do not share this sentiment.

Join us this Saturday June 4, 2016 9:00 PM Manila time to crowdsource a patient centric approach in easing patient burden in health processes

Many healthcare technology innovations and movers want to solve this problem-easing out the patients burden for health processes, by efficientisizing technology on the provider side. Which in some systems worked out, eventually. I’m not a health information tech guy but like Carlos, I’m very much interested in easing out this health processes burden for patients.
- T1. Are there any health technology innovation models that will actually lessen the “patient burden” in the healthcare processes?
As we all know, the shift to patient centric model of healthcare system, from a provider centric system isn’t exactly a fantastic honeymoon between providers and patients. Health is definitely not easy on change. Most of us knew that patient driven health is the future of medicine and we aren’t ready to accept it yet. Thats why there’s quite a few who are developing technologies that eases out the patient’s burden.
- T2. What are the opportunities and challenges in a patient centric/ driven healthcare technologies?
While Carlos story is well know to healthcare professionals (and will cringe at the thought) not a few will dismiss this as “part” of being a patient. The irony of it all that sometimes, the pain we’re giving patients going through this health process is even worse that what he or she already have from his/her medical condition. “I’m sharing this doctor because you know what’s best for me” resonates both the frustration and godly adulation patients have for their physicians.
- T3. As a patient or patient advocate any patient centric health technology you think (or experienced) that have eased out the patient’s burden? How?
Carlos’ story is a story told so many times. As a physician I have my armamentarium of healthcare tech to help ease out the burden of practice, but have none to unburden my patient’s charade. This often bear much on my decision to order (or not) a diagnostic procedure, a referral, a prescription or even follow up. Patient’s rarely comply because, as a matter fact it takes more than just the patient to go though this burden. Not even us physicians. We can cry foul, or technology sucks. But patients, they rarely have..

So patient centric healthcare technology anyone?

Join us this Saturday June 4, 2016 9:00 PM Manila time to crowdsource a patient centric approach in easing patient burden in health processes!
June 4, 2016
Disruptions in Health: Healthcare information technology in a limited resource community
How could information technology improve healthcare in a limited resource community?

This is one of the questions asked in one of the health information technology appreciation talk I gave recently.

When care is complex, expensive, and inconvenient, many afflictions simply go untreated.

Health information technology is a broad concept that encompasses an array of technologies to store, share, and analyze health information. In primary care, examples of health IT include the following:
- Clinical decision support.
- Computerized disease registries. (e.g. Trauma registries)
- Computerized provider order entry.(CPOE)
- Consumer health IT applications. (e.g. wearables)
- Electronic medical record systems (EMRs, EHRs, and PHRs).
- Electronic prescribing.
- Telehealth
HIT ultimately aims to help healthcare providers provide excellent care to their patient. HIT does this by improving point of care areas along the patient – provider flow, from the time patient goes in the hospital to the time he/she went out and up to their home. (see figure below)

Conventional flow of patient /point of care in a hospital setting

Some of these HITs (EMR, CPOE) have been shown to reduce medical errors by up to 80%, prescription errors by up to 55%. While HIT has the potential to reduce utilization of healthcare, investing in HIT is not cheap so far. The main challenges are investing cost and resources.

The real hope is in disruptive innovations in health that uses these information technologies to bring down healthcare cost but improve quality of care.

Disruptive innovation, a term of art coined by Clayton Christensen, describes a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors. – See more at: http://www.claytonchristensen.com/key-concepts/#sthash.iNDhe9BG.dpuf

Areas like telemedicine and consumer health products are just beginning to pick up trend. But cost and quality of care metrics has yet to be validated to yield a significant disruption.

Information technology that has potential in improving quality of care

So going back to the question earlier, I’m a believer that somehow a disruptive innovation would breakthrough with these sets of HIT and improve delivery of healthcare in low resource communities.

I’m inviting all health stakeholders- MDs, Nurses, allied med professions, policy makers, health institutions, research groups, pharma and medical devices to a tweetchat this Saturday May 14, 2016 9PM Manila time.

Lets crowdsource ideas from HIT thought leaders and healthcare community what would these potential disruptions and innovations that will impact low resource communities.
- T1. What health information technology you use now to provide quality care and why?
- T2. What specific disruptive information technology do you think would improve delivery of care at a lower cost in limited resource community (like PH)? How?
- T3. What is the main challenge to this disruptive technology? Research? Policy?Education?
Don’t forget to use #HealthXPh. Se you all!

Readings:

https://www.healthit.gov/patients-families/basics-health-it

https://hbr.org/2000/09/will-disruptive-innovations-cure-health-care

Disruptive Innovations That Will Change Your Life in Health Care

http://www.forbes.com/sites/ashoka/2013/04/23/disruptive-innovation-a-prescription-for-better-health-care/#f7dfd447c442

http://mobihealthnews.com/31470/revisiting-how-christensens-disruption-innovation-in-healthcare-means-decentralization
May 14, 2016