Digital health: A manifesto for the times


In 2008, Dr. Gunther Eysenbach, editor of the Journal of Medical Internet Research published a paper on the nature of what he termed Medicine 2.0 – and this paper formed the framework for the first World Congress on Social Media, Mobile Apps, Internet/Web 2.0 held in Toronto.

Eysenbach noted that “recent advances in web technologies and user interfaces have greatly changed the design, appearance, stickiness, and pervasiveness of Web applications, and in many cases transformed the way users interact with them. Perhaps equally importantly, it also has changed the expectations of users.” In addition, he said, these advances have coincided with the development of personal health records “with far-reaching consequences for patient involvement, as the gravity shifts away from health care providers as the sole custodian of medical data.”

Eysenbach talked about five major aspects (ideas, themes) emerging from Web 2.0 in health, health care, medicine, and science, which would outlive the specific tools and services offered: social networking, participation, apomediation, collaboration, and openness.

Among the attendees at the 2008 meeting was a Hungarian medical student Bertalan Meskó (@berci) who was to graduate the following year. A year later at the same conference, also held in Toronto, Dave deBronkart (@ePatientDave) gave his first major presentation in Canada around his rallying cry of “Give me my damn data”.

Fast forward a decade: Dave deBronkart, a stage IV cancer survivor, is probably the most high-profile patient advocate there is and Meskó is a medical futurist speaking to audiences worldwide. Together they have just published what they call a Digital Manifesto with six declarations they believe “are essential for correctly understanding what is and isn’t happening in digital health.”

You can read the manifesto yourself – it’s not long and speaks to much that will resonate with those working in digital health or with patient engagement. It talks about behavior change and educated and informed patients working with health care providers to take control of their own health using the manifest new technologies now available.

What I am struck by are the similarities between the Eysenbach piece and the manifesto – despite the gap of 10 years and the very different tone and purpose intended for the documents.

Both reference the significance of new digital tools and platforms and their importance as enablers of change, or in deBronkart and Meskó’s words: “A future where old hierarchies tumble down, the paternalistic patient-doctor relationship is no longer needed and disruptive technologies enable the democratization of care by democratizing knowledge. A future where all these are in place due to cultural transformation facilitated by disruptive technologies.”

The documents and these past 10 years also represent the dedication and common vision shared by many of those who work with digital health – be they patients, providers or researchers. In addition to Meskó and deBronkart, many of those who spoke or participated in the 2008 and 2009 conferences have remained active in digital health research.

“… we could say that medicine 2.0 is what ehealth was supposed to be all along”, Eysenbach wrote 10 years ago. deBronkart and Meskó say “A manifesto can …kindle new thinking among those who do see the light.”




#Ehealth2018: Beyond the keynotes


Ehealth 2018 to be held in Vancouver, May 27-30 continues to occupy an unchallenged position as Canada’s premier conference dealing with health information technology (IT) and digital health.

Now in its 18th year, the conference shines a light on where Canada stands when it comes to the introduction and implementation of new digital health technologies.

While the keynote speakers at the meeting provide the ‘wow factor’ for those in attendance it is the smaller focused concurrent sessions where one can get a truer sense of what is really going on in research and at the front-lines of care.

A brief review of the sessions and presentations on offer at e-Health 2018 offers some intriguing hints of how the health IT landscape is evolving. Bear in mind the caveat that session titles can often be misleading and relying on titles rather the entire abstracts can often lead – as many conference delegates have learned to their sorrow – to deep disappointment when the talk does not live up to expectations.

This year, even the session headings at e-Health 2018 are more helpful as they tend to be more explicit than most. For example, there is a session titled not just ‘Telehealth’ but “Geography and Telehealth: It’s Not Always Distance”. However, beware over-imaginative session copywriters who can come up with a title such as “Labs, Drugs and Rock and Roll”.

From the session headings it is clear that top-of-mind IT and digital topics such as block chain, telehealth and big data are high on the Canadian agenda this year just as they are south of the border.

Individual presentation headings – as always – range from the meaninglessly vague to the intriguing. It’s worth taking a look at the presenters as well, as this can point to some talks worth bookmarking.

For instance, Dr. Jeremy Theal from North York General Hospital, a leader in computerized physician order entry in Canada is scheduled to talk about “A Novel Provincial Approach to Implementing Advanced Hospital Information Systems”. Long-time digital health stalwart Glenn Lanteigne will be giving a talk titled “Blockchain in Healthcare – Separating the hype from reality,” and another noteworthy presenter will be eConsult pioneer Dr. Erin Keely talking about “Provider Experience – the Fourth Aim of Innovation in Healthcare Technology”.
With patient-centred care once again at the forefront there are also several presentations that seem to merit a look including these two:

  • The Secret is Out: Achieving High Patient Portal Adoption – Selina Brudnicki, University Health Network.
  • Engaged Patients Are Driving Healthcare Innovation and Efficiency – Shannon Malovec, TELUS Health.

As noted above, it is always buyer beware when it comes to picking presentations by title alone but for those of us interested in the use of social media in health care it might be difficult to resist Nishila Mehta’s scheduled presentation on “Data Mining Twitter to Detect Prescribing Cascades: A New Concept.”

However, as everyone has their own concerns and interests it is worth combing the program carefully to find those presentations that provide insights and new information for you personally.

Patient engagement with muscle


When Dave deBronkart (@ePatientDave) wanted access to his own medical record several years ago in the US, he didn’t just fill out a form requesting this information or politely ask the hospital involved, he went public in a big way, loudly demanding “Give me my damn data!”

While his act was not unique it can arguably be seen as initiating a new era of the muscular type of patient engagement currently prevalent in the US. These are patients who are not prepared to sit meekly and wait for an invitation to participate in decisions about their own health care or the health of patients in general.

Engaged patients are demanding their place at the health care decision-making table and have little patience for policy makers or conference organizers who want to keep discussions of patient engagement at theoretical level.

Look at the growth of the #patientsincluded movement in which conferences globally are being told they should include patients at all levels of planning and presenting health care information in a way that accommodates patients.  Anyone who dares hold a conference on patient engagement without having patients on the planning committee and speaker list risks being loudly shamed on social media. Even one element of #ehealth2017 has not been spared such criticism.

Similarly, recent discussions on social media are asking very pointed questions about why patient are often the only ones at the table who are not being paid for their time to provide their input.

This new form of patient engagement is transforming how health care is being planned and delivered in Canada but frankly we still trail the US in truly integrating this approach. Canada has several engaged patient leaders but none with the profile of their American counterparts.

Which bring us to the June 2 pre-conference symposium on Consumer Digital Health at #ehealth2017.

The keynote speaker will be Lygeia Ricciardi (@Lygeia), a US based expert in consumer engagement and digital health. Lygeia established and directed the Office of Consumer eHealth at the Office of the National Coordinator for Health IT (ONC) in the US federal government and is a compelling speaker. The presentation promises to deliver an update on major emerging trends in patient engagement

COACH, Infoway and the Canadian Institute for Health Information (CIHI) will follow Ricciardi’s keynote address with breakout sessions on different aspects of empowering healthcare consumers. This symposium should provide an invaluable snapshot of where Canada will be heading in the next few years.

Health Quality Ontario (for which I work), is currently one of the national leaders in providing the tools and infrastructure to meaningfully involve patients in health care decision-making.

It’s not a straightforward or easy task.

As Health Quality Ontario CEO Dr. Joshua Tepper wrote in @HealthyDebate blog post two years ago, “simply ‘commanding’ or ‘expecting’ health system providers and leaders to engage with patients is unrealistic.

In addition, he noted, “the patients we need to hear from the most are often the hardest to reach. Those who face economic, social, language, cultural, physical and psychological challenges to engagement will need thoughtful and respectful partnership efforts.”

For all of this, he concluded “courage is going to be a pre-requisite.”

Even as more patient involvement in health care planning and delivery is mandated in legislation and becoming embedded in the culture of quality care in Canada, hearing from US experts like Ricciardi is important to help us map where things are heading.

In a digital world, health care delivery models may be determined by jurisdictions but trends such as patient engagement effortlessly cross borders and Canada’s engaged patient community are quick to learn from their peers elsewhere and apply the lessons here.

(A) I, Radiologist

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Born of the discovery of the x-ray by Wilhelm Roentgen in 1895, the specialty of radiology is suddenly facing perhaps its greatest challenge with advent of artificial intelligence (AI) and machine learning.

Radiologists who have adapted to all manner of new diagnostic modalities over the generations now find themselves facing the prospect of machines which read and interpret imaging results quicker and more accurately than they can.

The Canadian Association of Radiologists (@CARadiologists) recently held its 80th annual meeting in Montreal and among the posters was one advertising that next year’s meeting would focus on AI. One wonders, given the speed with which AI and other technologies such as 3D printing are transforming radiology and medicine in general, whether next year is maybe too late to grapple with the issues raised.

The program committee of the CAR may have unconsciously acknowledged this as many sessions at this year’s meeting dealt with advanced technologies and at least two speakers dealt directly with the future role of the radiologist.

In addition, one of the highlights of the exhibit hall was IBM Watson Health (@IBMWatsonHealth). Last year, IBM created the Watson Health medical imaging collaborative, a global initiative with more than 26 leading health systems, academic centres, and imaging companies (they are currently looking Canadian participants) to bring cognitive imaging into daily practice. Earlier this year, IBM launched the Watson Imaging Review to reduce practice-pattern variation and reconcile differences between a patient’s administrative record and his or her clinical diagnosis.

One of the IBM staff was heard telling a CAR delegate, Watson “is not here to take your job away, it’s here to make your job easier.”

Presentations on AI and machine learning were matched by discussions of 3D printing, another technology currently transforming radiology and health care delivery.

Dr. Frank Rybicki, chief of radiology at the University of Ottawa and chief of medical imaging at The Ottawa Hospital, gave a comprehensive overview of how 3D printing is transforming many areas of medicine. The Ottawa Hospital recently opened the first 3D printing program based at a Canadian hospital.

Dr. Rybicki predicted that soon every hospital would have such a program as 3D printing moves from niche interventions to a leading role in reconstructive surgery, and cardiovascular and neurological interventions as well as supplying models to improve physician-patient communications and reducing peri- and post-operative complications.

“3D printing is the information delivery system of the current radiology generation,” he said, such as the young radiologists from Memorial University of Newfoundland who presented a paper showing the value of 3D printing of blood vessels to help educate the public and medical students.

It was a past-president of CAR, Dr. Ted Lyons from the University of Manitoba who bluntly outlined the future facing radiologists as a result of all these changes.

He noted that one of the fundamental roles of radiologists – reading and interpreting x-ray film – has almost already totally disappeared with the advent of PACS (picture archiving and communication systems).  By 2035, he predicted, all x-rays, CT scans and MRIs will be read and interpreted by machines.

The way forward for radiologists is twofold according to Dr. Lyons; firstly by becoming more than a “faceless name” who interprets images in a darkened room and being more directly involved and engaged with other clinicians and patients at the bedside. The second fundamental need, he said, is for radiologists to become data scientists and lead the integration of AI into radiology practice.

Dr. Lyons presentation was complemented later in the meeting by a presentation from a SickKids Hospital, Toronto radiologist Dr. Erika Mann who reiterated how radiologists need to become more patient-centred if they wish to remain relevant.



Is failing to use an EMR unprofessional conduct?


It has come to this.

Some hospitals in Toronto are starting to use virtual reality in patient care (to help ease pre-operative anxiety). Yet, there are still family physicians in the province using paper charts to record and monitor the health of their patients: Not many for sure and far, far fewer than a decade ago an (an increase from 37% to 73% between 2009 and 2015).

But nonetheless, in an era where the health technology envelope is being pushed harder and faster than ever before, the most recent international comparison of use of electronic medical records (EMRs) by family doctors shows Canada continues to lag behind countries such as the U.K. and New Zealand where use is almost universal.

This finding comes from a study released earlier this year by the Canadian Institute for Health Information (CIHI) in partnership with the Canadian Institutes of Health Research, and with co-funding from Canada Health Infoway looking at data from the Commonwealth Fund 2015 survey of 10 countries.

Maybe the time has come to seriously ask whether the acceptable standard of care for family doctors practising in Canada involves using an EMR and that failure to do so could be seen as failing to maintain that professional standard.

It is a question that was first asked quietly more than a decade ago, back in the twilight era when only the most forward looking physicians and jurisdictions were using EMRs routinely. Now, when EMRs have hugely increased functionality and proved their value in efficiently managing the health of populations, the question can surely be asked with more authority.

Of course, nobody wants to force some physicians to use technology they don’t like, don’t understand, and which can sometimes lead to gross inefficiencies in the use of their time. In fact we can imagine there may be parts of the country where a physician still cannot even purchase a reliable EMR. And we in Canada still struggle with interconnectivity and many family doctors remain stranded on ‘electronic islands’ unable to use their EMR to communicate effectively with others in their community.

But the reality is that electronic storage of patient data is here to stay whether the medical profession likes it or not.  With almost three quarters of Canadian family physicians now using EMRs for patient care the time has to come to ask medical licensing authorities whether they need to apply more diligence to observing those doctors who choose not to rely on paper records.

The failure of family doctors to totally embrace electronic records is hindering both patient care management and population health management. Even of those who use EMRs, the CIH report notes fewer than half routinely use the system for at least 2 of the following: electronic alerts or prompts about a potential problem with drug dose or drug interaction; reminder notices for patients when it is time for regular preventive or follow-up care; alerts or prompts to provide patients with test results; and/or reminders for guideline-based interventions and/or screening tests.

Surely the time has come for this to change.

Teledermatology: Every picture tells a story (#AAD17)


One can imagine the era of modern telemedicine beginning with dermatology.

“Hey, I have this rash. Mind if I e-mail you a picture so you can tell me how to deal with it”?

While teledermatology can actually be a far more complex and sophisticated interaction between patient and doctor, that core ability to send an image of the key diagnostic feature is what has led some dermatologists to be involved in telemedicine for almost two decades now.

And with telemedicine and virtual medicine now entering prime time, it is not a surprise that more dermatologists are focusing on teledermatology as a way to allow more people to access quality care.

What is somewhat more surprising is that fact that after two decades of practice, the dermatology specialty still lacks a good remuneration model and more importantly agreed upon standards for how quality care should be delivered.

The recent annual meeting of the American Academy of Dermatology (#AAD17) meeting in Orlando provided a snapshot, if you will, of all these issues. Not only was teledermatology the focus of at least two educational sessions, it was also the subject of one of the plenary named lectures.

In her plenary presentation, Dr. Carrie Kovarik (@carriekovarik), associate professor of dermatology at the University of Pennsylvania and a

teledermatology pioneer, gave a blunt assessment of telemedicine in her specialty.

“There are people in the middle who see teledermatology as a good thing when it is used to provide quality care and provide access,” she said in an interview published in the conference newsletter. “Unfortunately, there are also people on one end of the spectrum who think this is a way to make a lot of money and sell products. Then there are people at the opposite end who are afraid that telemedicine is eventually going to take away their patients.”

If that was the bleak overview of telemedicine within the speciality, Kovarik’s assessment of how unprofessional and unethical websites are exploiting patients by offering teledermatology services was worse. “We have businesses that have scaled-up teledermatology using non-dermatologists, anonymous apps and apps where the patients have to self-diagnose.”

Despite the potential value of teledermatology for improving access to underserviced areas and populations through the U.S., in her speech Kovarik noted only 12 States currently reimburse specialists for the “store forward” approach in which pictures of a patient are assessed after they are taken.

Another challenge is that in many instances the patient’s primary care provider receives no payment for helping facilitate the process by, for example, taking high-quality images of the patient for the dermatologist to assess.

However at the end of the day, despite all these challenges, Kovarik predicted it would be harder and harder for dermatologists to avoid telemedicine.

The key she said was to ensure the quality of care provided is the same as that seen in a face-to-face encounter.


#Ehealth2016 – inquiring minds want to know


ehealth_ambassadors_badge_300x300Canada’s premier conference on health information technology – #ehealth2016 – is now less than a month away.

That means it’s a good time to start to contemplate some of the big questions facing the health IT community in Canada and wondering whether this mega-meeting hosted in Vancouver.\, courtesy of COACH, Infoway and CIHI will provide any answers to these questions.

At its worst, this annual meeting can be an annoying combination of sometimes irrelevant keynote speakers and simultaneous sessions that do not live up to their titles/abstracts. But over the past decade e-health (however one chooses to write the name – hyphen, no hyphen, capital on ‘e’ or no capital on ‘e’ etc.) has become THE meeting for those interested in health IT to network, hear leaders in the field and gain insights into really interesting work going on at local/regional and provincial/territorial levels.

As an observer, I would suggest a few interesting questions this conference may help to provide answers for:

  • With the death or evolution of the big dinosaur programs for funding physician EMRs (POSP, PITO etc.) what is being done to continue to involve and engage physicians in improving how they use electronic records to improve care?
  • What is Infoway planning on doing with its new infusion of funding courtesy of the last federal budget?
  • Is patient engagement a thing in Canada in health IT and if so what does it mean?
  • Is the vendor space for EMRs and EHRs going to continue to consolidate ?
  • And that interoperability issue – is anything substantive happening to better connect physicians and hospitals.
  • Big data. (enough said).
  • Are hospitals and practitioners adapting to the mobile revolution in health?
  • Are these the correct questions to be asking? At HIMSS this year there was a big shift towards discussing digital connectivity beyond the electronic record and major discussions about data security in health. Should Canada be having those discussions too.

Inquiring minds want to know.