Patient engagement with muscle

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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.

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(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?

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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)

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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.

 

Texting medical trainees: “You don’t hear pagers going off any more.”

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Texting is the most common means used to communicate with residents and trainees, a small study of surgeons at a major Canadian teaching institution has shown.

While almost all of these surgeons reported using texting for patient related communications, the majority were not using encrypted devices and many were not aware if their hospital has a policy on texting.

The study from the University of Toronto, Women’s College Hospital and the University Health Network (UHN) is one of the first to shed some light on how a dominant means of communications in the modern world is being used in a medical setting.

The results were described by first author Mohammed Firdouse, a medical student, in a poster presentation at the recent Canadian Conference on Medical Education held in Montreal.

In the study, 98 general surgeons at UHN were asked to complete a 39-question online survey about their use of texting for patient-related communications and their awareness of regulations concerning the practice.

Approximately one third of those polled (33) responded to the survey.

More than 90% said they used texting for patient related communications and 60.7% said it was the most common way used to communicate with residents and trainees. However, only 14.3% of these staff surgeons said the used texting to communicate patient-related information with other staff.

The respondents identified speed and convenience as their main reasons for using texting.

Responses with respect to privacy and confidentiality with texting were more problematic.

Almost two-thirds of respondents (62.1%) said they did not have encrypted phones or did not know if their phones were secure while texting and 48.3% said they did not know if their hospital had a policy on texting. Even more respondents (72.4%) said they did not know if texting patient information is addressed in the Personal Health Information and Privacy Act.

These findings do not come as a surprise to Dr. Chris Simpson, past-president of the Canadian Medical Association and chief of cardiology at Queen’s University and Kingston General Hospital.

“You don’t hear pagers going off anymore,” he noted in an online interview.

“My sense – anecdotally, is that electronic communications (especially text) are commonplace between attending doctors and residents; between residents themselves, and less so between doctors and other health professionals.”

“Texting is fast, easy and accurate,” he said.

“Privacy is important but the horse is already out of the barn on this issue.”

“It will always be the responsibility of health care providers to safeguard the privacy of patient information that they have in their possession – this is true. But I am not convinced that texting info poses any greater risk to privacy that currently endorsed communication practices like faxing.”

“The challenge is for us all to find ways to enhance our ability to use electronic technologies in as low risk a way as possible – to establish a best practices culture that minimizes risk of privacy breaches. The answer can’t be and shouldn’t be an outright ban on texting,” said Dr. Simpson

Dr. Matthew Bromwich is an Ottawa pediatric otolaryngology surgeon and founder of Clearwater Clinical Limited and he has a keen interest in the development of mobile apps and the implications for patient privacy.

In an interview, he said, texting now has “100% penetration” in the health care sector and is an invaluable tool due to its convenience.

However, he expressed concerns that hospitals are still paying for pagers for staff that they do not use rather than tackling the issue of making their networks secure for mobile phone use and texting.

Bromwich said while clinicians and trainees can protect patient confidentiality by taking some care in how they frame texts, it would be far better for hospitals to address the issue especially as texting is particularly prone to illegal access.

 

To the EMR … and beyond

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For a conference that was about health information technology, it was all about health IT.

Allow me to explain.

The annual meeting of the Canadian Agency for Drugs and Technology in Health (@CADTH_ACMTS) is a showcase for health technology assessment (HTA) and the mission of the organization is to provide credible, impartial advice and evidence-based information about the effectiveness and cost-effectiveness of drugs and other health technologies.

What was noteworthy about this year’s meeting in Ottawa –  the largest yet for the organization with about 750 attendees – was the number of times electronic records (either EMRs or EHRs) were referenced as an essential feature for both gathering and for disseminating credible information to support evidence-based medicine.

Physician speakers repeatedly noted the need to have easy, point-of-care access at the time of the patient encounter, and to all of them this meant embedding that information in the electronic record.

More than one family doctor talked about being overwhelmed with guidelines and best practices and the need to integrate this information into the physician workflow to be useful – and EMRs as the natural place to do this.

The Canadian Association of Radiologists creates world-class clinical practice guidelines, but as Dr. Martin Reed, a pediatric radiologist from Edmonton told the meeting, one of the problems with these guidelines is that it is very hard to get people to use them.

He said there is now a feeling in the medical imaging community that the best way to do this is to integrate the guidelines into CPOE (computerized physician order entry) systems.

Given that some Canadian physicians still do not use EMRs and some (many?) hospitals are not using CPOE this could raise concerns about the quality of care being delivered.

On this information gathering front, the new focus on real-world data has placed an increased emphasis on the value of EMRs or EHRs to gather useful information to evaluate the effectiveness of drugs and technologies, the meeting was told.

“The starting point is having an EHR covering all of the caregivers. At that point the world is your oyster,” said Dr. Murray Ross (@murrayrossphd), leader of the Kaiser Institute for Health Policy in Oakland, CA.

Dr. C. Bernie Good (@CBGood23) who holds numerous roles with the US Department of Veterans Affairs gave numerous examples of how the extensive database gathered on VA patients through EHRs has helped support evidence-based drug prescribing.

And it does not end there.

As Anil Arora, assistant deputy minister in the Health Products and Food Branch, of Health Canada told the meeting it is not just the information being gathered in patient records that will need to be taken into consideration in the future – but also the wealth of patient data now being collected through wearables and other devices as well as through social media.

Given that we have by no means maximized the value of EMRs to gather this information in Canada, the challenges of extending the information sources to other digital repositories of patient information is currently problematic to say the least.

(Picture – Anil Arora. Courtesy CADTH)