Archive for June 2008
- a conceptual foundation for how the design industry can participate in social impact work
- a network of key players in this space
The New York Times reports that Most Doctors Aren’t Using Electronic Health Records. However, the New England Journal of Medicine study released June 18th notes paradoxically “doctors who use electronic health records say overwhelmingly that such records have helped improve the quality and timeliness of care.” The benefits are overwhelmingly positive: “82% [of doctors using electronic medical records] said they improved the quality of clinical decisions, 86% said they helped in avoiding medication errors, and 85% said they improved the delivery of preventative care.” Clearly, electronic medical records could be a tremendous aid in improving health outcomes, shifting the balance of care from costly medical intervention to relatively inexpensive prevention measures, and reducing medical errors.
“Yet fewer than one in five of the nation’s doctors has started using such records.” Only 4% of doctors surveyed were using “fully functional” electronic records that can record clinical and demographic data, results of lab tests, issue orders and inform clinical decisions (such as warning about drug interactions). 13% of respondents reported using a “basic” clinical system, which lacks clinical decision support and some order-entry capability.
The barriers cited are largely economic, with doctors in small practices citing prohibitive capital costs for adopting a new system, lost income from not seeing patients, and no existing electronic medical record software that meets the needs of small to medium practices. In an attempt to speed adoption, the government has announced a Medicare program that will offer incentives to practices to transition to electronic medical records.
“What we see is a deficit in innovation, and that is something innovators and the capital markets can address,” said Dr. David J. Brailer, who leads a firm that invests in medical ventures, Health Evolution Partners.
After conducting several retrospective folder reviews, I believe the conventional patient folder is actually an obstacle to good patient care. Folders are often lost or duplicated, and they take time to retrieve. Basic patient information is duplicated in every physician’s notes, handwriting is often illegible, there is no alert system for medication errors, guidelines for patient management, or flags for unusual findings or reminders on lab results. Despite a fully integrated health system in South Africa, the reliance on paper records causes fragmentation of patient information, and disrupts continuity of care.
Why go with paper when you could have electronic medical records?
IDEO’s CEO, Tim Brown, wrote an article for June’s Harvard Business Review. This is a great introduction to design thinking.
Although many others became involved in the [Shimano “Coasting”] project when it reached the implementation phase, the application of design thinking in the earliest stages of innovation is what led to this complete solution. Indeed, the single thing one would have expected the design team to be responsible for—the look of the bikes—was intentionally deferred to later in the development process, when the team created a reference design to inspire the bike companies’ own design teams.
A couple extensions to Brown’s statements about the Aravind Eye Care System:
Much of its innovative energy has focused on bringing both preventive care and diagnostic screening to the countryside. Since 1990 Aravind has held “eye camps” in India’s rural areas, in an effort to register patients, administer eye exams, teach eye care, and identify people who may require surgery or advanced diagnostic services or who have conditions that warrant monitoring.
In developing its system of care, Aravind has consistently exhibited many characteristics of design thinking. It has used as a creative springboard two constraints: the poverty and remoteness of its clientele and its own lack of access to expensive solutions. For example, a pair of intraocular lenses made in the West costs $200, which severely limited the number of patients Aravind could help. Rather than try to persuade suppliers to change the way they did things, Aravind built its own solution: a manufacturing plant in the basement of one of its hospitals. It eventually discovered that it could use relatively inexpensive technology to produce lenses for $4 a pair.
First, Aravind did try to persuade suppliers to change the way they did things. The promise of a huge latent market was not convincing enough for existing suppliers to drop the price of their intraocular lenses (IOL). It was then that Aravind built its own capacity to produce lenses, in what came to be known as Aurolab. I would argue that both their attempts at negotiation with IOL manufacturers and their decision to produce their own lenses were reflective of design thinking.
- International crowd. I was pleasantly surprised by the significant international attendance at this conference. Based on an accumulation of experiences, I think I had set my expectations low.
- Sharing the conference. Through kaisernetwork.org, globalhealthtv.org, and sharing presentations, the Global Health Council is pulling its weight in terms of dissemination and sharing. But it doesn’t need to stop there. The reason I blogged so actively from the conference is to share the experience, the discussions, and the debates with those in the global health community who were not there. It’s great that the GHC is doing its part, but it’s up to the participants to take it one step further – not simply to report on it, but to provide commentary, to tie together disparate threads, to engage a wider community in timely discussions. The last conference I attended before this was CHI 2008 (Human Factors in Computing) in Florence. CHI and GHC each had about 2000 attendees and both are well-respected conferences. But the former has significantly more content in the blogosphere (5-10x). The tools are free and accessible, so I don’t buy the excuse of CHI being more tech-savvy. It is about the importance we place on sharing information.
- Listen to the people. This was a theme that kept coming up throughout the conference (see each of my previous posts from the conference). Probably related to both the community health theme and a realization that we have historically done a poor job of understanding people and communities in global health. Not just listening to people, but re-emphasizing primary healthcare, localized systems, and the merits of patience.
- There’s more to it than health systems. The discussions focused largely on health systems and not enough on other aspects of public health. (I am complicit in this – the work I was presenting was well within the framework of health systems.)
- Where’s the rest of the West? All of Seattle was there, but very few people besides. From California, there were only 4 from Berkeley, 2 from UCSF, and a handful from the rest of the state. Also, other than North America, the Western Hemisphere seemed to be MIA (besides my Bolivian roommate).
- Technology is not neutral. The way people at the conference were talking about technology – e.g. PDAs and LifeStraws – assured me that technology has maintained its magical allure. We need to deal with technology the same way that we deal with branding in microfranchising, social marketing of condoms, and HIV/AIDS IEC campaigns. That is, we need to determine what will be most effective by understanding how people value and perceive technology. And we need to realize that, like any innovation, there will be different solutions for different places.
You know what happened in the 1960s? Here are several things:
- The first debate for a presidential election was televised.
- The Soviets sent the first man into space and the Americans need a man in space, too.
- The Berlin Wall was built.
- The Peace Corps was launched.
- Rachel Carson warned that our earth would die of pollution and chemicals.
- Martin Luther King Jr. made the speech, “I have a Dream”.
- The first Civil Rights bill was passed to stop racial discrimination.
- President Johnson ordered bombing raids on North Vietnam.
- Woodstock happened.
- Malcolm X, JFK and MLK were assassinated.
The other thing that happened – the passage fo the Foreign Assistance Act. See the below short video and campaign for why this is important:
For more on this very cool video by CGD see their website devoted to this here and think about signing their petition. They also have a great set of blogs, the health one (Global Health Policy) is here.
Friday ended with an impressive lineup of global health leaders discussing the disconnect between horizontal and vertical funding in the plenary session titled Meeting Along the Diagonal: Where the First and Last Mile Connect. A webcast of this session, and 2-3 others from the Global Health Council Conference, will be available on kaisernetwork.org starting Tues-3-Jun-2008. It’s nearly 2 hours long, but brings together ideas from the Gates Foundation, WHO, the Global Health Council, and USAID. As much as it was about these organizations and the types of organizations (foundation, multilateral, advocacy, bilateral), it was about the individuals who spoke their minds:
- Jaime Sepulveda, Director, Integrated Health Solutions Development, Bill & Melinda Gates Foundation
- Margaret Chan, Director-General, World Health Organization
- Nils Daulaire, President and CEO, Global Health Council
- Henrietta H. Fore, Administrator, U.S. Agency for International Development, Director, U.S. United States Foreign Assistance
- Fore: “horizontal aspects to vertical programs”
- Sepulveda: “integration”
- Chan: “connect”
- Nils: “fractal”
- Delivery (personal and non-personal services)
- Resource Generation (people, information, vaccines, technology)
- Walsh J A & Warren K S. Selective primary health care: an interim strategy for disease control in developing countries. N. Engl. J. Med. 301.967-74, 1979.
- An “forgotten” article that Sepulveda wrote in the 1980s in the Bulletin of the WHO on the topic of “diagonalism”, but perhaps not in those words. (I wasn’t able to find it, but if you know of the article, please post a link as a comment.)
- Dentzer told her she was “the James Brown of global health”, a reference to her work ethic
- “What works for Hong Kong doesn’t work for Zambia.” This sounds obvious, but there was quite a lot of talk at this conference about exporting successful models from one country to another. I’m not saying you can’t learn from successes, but there is at least some better work we need to do in adapting those models to different situations.
- “Primary healthcare faded from the vocabulary of global health.” She cited Periago’s “crushed” comment from earlier in the day. In fact, she brought in a lot of examples of what other people were saying throughout the day, so it’s clear that she was listening.
- One of the other examples she brought up was a Johns Hopkins professor who in a morning comment advocated for “health impact assessments” like “environmental impact assessments” prior to doing something new. (Sorry, don’t know the name of the JHU professor.)
- “Famous soft drink”. She didn’t name it because she didn’t want to advertise for it, but asked “why can’t we get to the same areas of the world?” (a reference to technologies like vaccines and medicines). If we can’t do that, “we fail our people”.
- “It’s easy to blame people when you fail.”
- In referring to her 30+ years of experience: “I look young, but I’m not”.
- “Primary healthcare was alive” in places like Brazil, India, and Argentina, even though it wasn’t in the “official vocabulary”.
- “I’m not going to repeat the WHO definition of health. To me health is a social objective.”
- In indicating that we need to train more mid-level professionals: “For the clinicians in the audience, don’t worry, there’s plenty of work.”
- “We have not listened enough.” “We underestimate the ingenuity of the community.” “If you say ‘talk is one thing, walk is another’, I rest my case.”
- “We are insular. We only look at the health sector.” We need to look at safe water and sanitation, education, etc.
- “Ministry of Health [alone] cannot handle the complexity of the situation.”
- “Let’s be realistic. Even NGOs are making profits.”
- “Why is it that working with industry is seen as dirty?” “Industry is part of the solution.” We need to work with food and pharmaceutical industries.
- Peer review is “another elephant in the room”- Chan identified most of the elephants. It is a process by which “your friends condone your work”.
And my favorite, because it directly addresses the work I do and that we need to advocate for in the development of new technologies and services:
- “I didn’t realize that the color of bednets makes a difference.”
- “It wasn’t until we brought in the anthropologists that we found out that the color red represented death.”
- They changed the color to yellow and people started to use them.