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Week 2: How Has the Practice of Medicine Changed in the Digital Age?

MOOC Summaries - Medicine in the Digital Age - Public Physician

Week 2: How Has the Practice of Medicine Changed in the Digital Age?

“Overview … Medical Information … How Doctors Access Information… Information in the Clinical Setting… Wearable Devices and Quantified Self.. The Public Physician… Opportunities and Challenges… New Obligation to Create.. “
(Source)

Summaries

  • Medical Information > Introduction To Week Two
  • Medical Information > How Doctors Access Information
  • Medical Information > Information In The Clinical Setting
  • Medical Information > The Wearable Device And The Quantified Self: The Devices
  • Medical Information > The Wearable Device And The Quantified Self: Data In The Clinical Setting
  • Expert Interview: Dr. Roni Zeiger
  • The Public Physician > The Rise of 'The Public Physician'
  • The Public Physician > The Public Physician: Opportunities and Challenges
  • The Public Physician > The New Obligation To Create
  • Expert Interview: Dr. Peter Killoran

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > Medical Information > Introduction To Week Two

  • Four social and technological forces that have an impact on the physician:
    • technology;
    • patient
    • democratized media;
    • access to information.
  • Every medical generation has been shaped by the technology then e.g. invention of the stethoscope 200 years ago in Paris made it possible to use sounds to diagnose and prognosticate.
  • We are now less dependent on the manual tools of physical diagnosis e.g. today, advanced imaging and genomics are fashioning us as interpreters of information.
  • Clay Christensen and Jason Wang, in their book, “The Innovator’s Prescription”, suggest a medical care spectrum ranging from intuitive to precise.
    • Intuitive medicine: care for conditions loosely diagnosed by symptoms and pattern recognition and treated with therapies of unclear efficacy; it is dependent on clinical judgement.
    • Precision medicine: care for diseases that can be precisely diagnosed and treated with predictable evidence-based treatments.
  • What has changed:
    • 19th century – treat symptoms;
    • 20th century – treat diseases;
    • 21st century – predict, prevent and preempt disease.
  • There are predictions that doctors may be replaced by technology but it is more likely what the doctors’ roles will be will be radically redefined; there is also insecurity amongst 21st century doctors: they want the precision while proving they can still do it all with their hands.
  • Democratized media now means patients are empowered – it will no longer be the “old” practice where  one came to the doctor and the doctor tells the patient what to do.
  • It also means every doctor now has his/her own communication channels and publication platforms (compared to the past when the doctor was dependent on a strict hierarchy).
  • In addition to the volume of information, there are also changes in the speed and immediacy and real time flow of information.
  • Doctors will now not only need to learn what they need to know, they will also have to learn how to access what they need to know.

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > Medical Information > How Doctors Access Information

  • A big question now is whether robots will replace doctors – a venture capitalist has even declared that technology can do 80% of what doctors do.
  • In the past, physicians memorized what they needed to know; a new generation of doctors now will access what they need to know.
  • New discoveries have thus outstripped any physician’s ability to keep up:
    • Digital technologies, such as supercomputers, have also exponentially expanded  scientific research activity, both at the population scale of big data and at the molecular scale of personal genome sequencing.
  • Computers will not replace a human doctor but augment him i.e. become part of a consultation process e.g.
    • AI systems (like IBM’s Watson) – in healthcare, the computer is a smart repository of the world’s research which the doctor consults to receive updated information that can eventually be tailored to patient.
  • This raises many questions about the doctor/patient relationship and what the larger role of the doctor.
  • Being able to contextualize information may be a new skill for human healthcare professionals – they are the intermediaries between data-driven personalized medicine and the nuanced, but powerful, social, economic, and cultural features of a patient’s life.
    • they will determine whether  a patient takes medications as prescribed, is suitable for surgery, or is ready to be moved from an ICU to a remote ICU at home.

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > Medical Information > Information In The Clinical Setting

  • Discuss electronic health records (EHR), which are also called electronic medical records (EMR).
  • It is very important to have very good health IT, whether one is a doctor, nurse, healthcare provider, or patient.
  • Health IT needs to:
    • be open;
    • be interconnected;
    • have an intuitive interface:
    • have great usability; and
    • easy adaptability.
  • Current system:
    • start with a patient;
    • patient has a problem;
    • doctor diagnoses;
    • doctor prescribes treatment;
    • patient gets better (or not) – and that is the outcome.
  • Ideally, the the healthcare system learns from every step above and closes the loop, where the outcomes are fed back into the system so that it can learn if the interventions were effective.
  • Digital medicine can make this happen, and  the significant investment in digital health is due to a push to reduce medical errors.
  • In 1999, the Institute of Medicine (IOM) published a now famous study called, “To Err is Human– Building a Safer Health System”, which concluded that there are 44,000 to 98,000 preventable deaths – at a cost of $17 to $29 billion – annually from medical errors in the United States (they attributed the errors to the arrogance of the “medical priesthood”).
  • In 2001, they followed up with a report called Crossing the Quality Chasm– A New Health System for the 21st Century, arguing for the importance of integrated EHRs, in a world where healthcare organizations, hospitals, and physician groups function as silos, without complete information about their patients.

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > Medical Information > The Wearable Device And The Quantified Self: The Devices

  • One of the complex new sources of information: self-tracking data captured by patients – consumer devices now allow patients to capture their own data continuously.
  • This can empower and increase patients’ ability to take charge of their health, but may also feel like Big Brother and it could be a lot of work, especially for those with complex health challenges.
  • Note: more data does not mean greater understanding or that if there is improved understanding, there will be actionable results.
  • A few useful reports
    • “Personal Data for the Public Good” (2014) by the California Institute for Telecommunications and Technology Institute in 2014;
    • “Here’s Looking at You: How Personal Health Information Is Being Tracked and Used” (2014) by Jane Sarasohn-Kahn for the California HealthCare Foundation;
    • “Tracking for Health” (2013) by Susannah Fox and Maeve Duggan for the Pew Research Center.
  • Self-tracking devices/technologies/apps  – whether as  widely available consumer electronics or fairly experimental research tools – are part of a larger movement sometimes called Quantified Self.
  • Data can be captured passively through the digital trails of our daily activities (e.g.  shop, read, or communicate online), or actively through wearing clothes or devices accessories designed to capture specific health metrics.
  • Devices can now capture many things, such as blood pressure, heart rhythm, respiratory rate, oxygen concentration in the blood, heart rate variability, cardiac output and stroke volume, galvanic skin response, body temperature, eye pressure, blood glucose, brain waves, intracranial pressure, muscle movements, components of lung function, mood, even diagnosis of Parkinson’s disease, schizophrenia, and more.
  • This data is generated outside of traditional clinical or research settings and may not always be valid or reliable for use in those settings, hence significant hurdles have to be cleared before doctors and researchers treat this data equal to the data they can collect.
  • Some of these hurdles can be cleared by device manufacturers, some by patients, and some by doctors themselves (e.g. their own attitudes towards data).
  • Self-tracking devices can improve on clinical data in several ways by being more accurate and honest:
    • they remove the variations due to white coat hypertension i.e. the tension a patient feels in a doctor’s office, thus producing  high and inaccurate blood pressure readings;
    • they capture many data points over extended periods of time, instead of only during a patient visit to the doctor;
    • they provide fairly objective data on behaviors, reducing the reliance of self-reporting, which can be subject to bias (e.g. recall, social acceptability etc).
  • So self-tracking devices can give us a more complete picture of our health.

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > Medical Information > The Wearable Device And The Quantified Self: Data In The Clinical Setting

  • Different studies have different estimates of what proportion of the population have used a wearable device.
  • A PWC report points out that early adopters of wearable devices tend to be young, affluent, more tech savvy and better educated, and probably not the ones who need health interventions.
  • The Pew study, “Tracking for Health,” found that 69% of American adults track at least one health indicator (e.g. weight, diet, exercise routine, or symptom) either for themselves or for someone else.
    • Many of them use low tech tracking e.g. pen, paper or memory.
    • Reasons they track:
      • manage a chronic disease (e.g. diabetes, high blood pressure,  asthma etc);
      • self-improvement (e.g. weight loss; improve performance);
      • pregnancy (track cycle and temperature);
      • baby development (e.g. babies’ sleep, weight gain, allergies etc).
    • Demographics: ~ same number of men and women self-track; older people track more than younger people
    • Education: college graduates track more than high school graduates, who track more those who are are not high school graduates.
    • 1/3 of those share their data with someone else, of which 52% share with a health or medical professional.
  • Patients may bring their own data and research to clinics and doctors so we need to think about how to incorporate such data into their health records (e.g. EHR).
  • This process should ideally be seamless, invisible, and automatic, but legacy EHR systems pose significant barriers e.g. little sharing between hospitals and specialists, and different organizations have to share these records inefficiently e.g. by faxing to each other.
  • There is a movement to open up EHR so that patients can access and use them:
    • Companies are trying to tackle this issue e.g. Apple HealthKit, HealthLoop, Mayo Clinic, Epic MyChart etc.
    • Federal government are also tackling this problem through projects like the Blue Button Initiative, where patients can download their EHR.
    • OpenNotes (supported by the Robert Wood Johnson Foundation) is pilot to explore what happens when patients can access clinicians’ notes in their EHRs.
  • The issue can also be considered as one of communication and digital health literacy, and there is a need for both doctors and patients to develop new literacies.

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > Expert Interview: Dr. Roni Zeiger > Interview With Dr. Roni Zeiger

  • Roni is former Chief Health Strategist for Google and now CEO of Smart Patients.
  • This interview will focus on patient engagement – Roni has said patients are the most underutilized resource in health care.
  • Patient engagement makes it sound the healthcare system is alright and it is the patients who need to come forward. This is not entirely correctly, just as it is not correct to think of it as “if only the patients would do what they are told”.
  • More useful to think of the idea of shared goals:
    • mutually agreed upon goals between healthcare professionals and i.e. patient, caregiver, doc, nurse practitioner etc;
    • how to best achieve them together.
  • We still practice medicine today pretending that we can solve everything in the once every three months, 15-minute visit to the doctor, and maybe the once every other year hospitalization.
  • The reality is much more complicated: a lot of health care happens between those visits including with their loved ones, other patients, friends, family, online etc.
  • We are still stuck thinking of patients as passive recipients of care and passive participants in clinical trials.
  • In fact, they can do things both for themselves and for their peers – they are underutilized collaborators.
  • Crowdsourcing is a useful strategy but it is largely a case of asking people questions and taking the average of the answers. But this sounds like a regression to the mean or a watering down; that is not what happens in really high quality networks of people.
  • An example of a good online patient community:
    • patients with lung cancer;
    • someone joins the community and asks a question e.g. about certain kinds of drugs;
    • a subset of the network such as 5% steps forward and leads the conversation because they have experience with those drugs – two of them have recently had a discussion with their clinician; one of them happens to be pretty good at reading the literature and has recently read up on the topic;
    • this subset of the network are those micro experts–  not experts in lung cancer, but they happen to have some relevant expertise in a given area.
    • An hour later someone else asks a very different question e.g. CT versus MRI scans and some aspect of lung cancer;
    • a different subset of the community might step forward and lead that conversation as the micro experts;
    • it is a different model than the traditional one we think of.
    • Instead it is a more distributed knowledge base which is more dynamic, where a question is posed and  collaboration happens.
  • In a really high functioning network, when a question is posed, the right kinds of micro expertise come together to help whoever is posing the question.
    • At the same time, with patients as micro experts, they also brings in expertise that are not traditionally found in medical settings at all.
  • The term patient-centered medicine has an interesting blind spot: it needs to be family-centered because the patient is going to need so much support.
    • The family caregiver is a key part of the equation but the current system is not really built around that.
    • Knowledge about caregiving might also be much richer in the patient community than in the typical clinician community.
  • Come to realize that despite how much attention has been been given to big data, the data doesn’t mean very much if it is not in the context of a story.
    • All of this matters most when it is put in the context of real people and real stories and you realize the data is just sort of things that should be sprinkled in little corners of the story.
  • A beautiful role of technology would be to give more people access to stories about others like them, thoughtfully elicit questions that would be most likely to make them comfortable telling a story, and tell them which story to look to next.
    • You could argue that’s what Amazon tries to do as it notices what you’ve read and what you might want to read next so there is a wonderful collision between stories and technology.
  • Role of technology:
    • It’s technology to give us better access to stories.
    • Overall, another complementary perspective is that technology is working really well when we forget that it’s there.
    • Definitely never heard the term graceful applied to an EMR, but it’s interesting to imagine what that might look like.
    • Technology also plays an important role for facilitating patient collaboration with health care providers or with each other e.g. getting patients more involved in the design of clinical trial, using simple and sophisticated technologies.
    • It is about  giving people an easier way to collaborate with each other –  which probably would work better if we could all get in a room together and a whiteboard with a great facilitator – but in healthcare, that is difficult as people are sick and in different places, different time zones etc, and an asynchronous collaboration can be very powerful and convenient just like asynchronous education.

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > The Public Physician > The Rise of ‘The Public Physician’

  • In the Digital Age, all doctors are public physicians.
  • In the past, perceptions of doctors were shaped by what patients saw in clinics, medical associations, institutions, journals, movies etc.
  • That perception of physician looking or behaving in a certain way has been replaced by the reality of wildly different opinions and voices and looks, and the public physician is present outside of the clinic and in the world.
  • The public physician also creates content, collaborates, writes, records, shares, connects, converses, blogs, create videos, publish e-books, share news, curate online content etc
  • The public physician is now involved in the dissemination of ideas beyond the conventional settings.
  • To have a significant impact online, physicians have to create content that everyone else is having conversations about; the public physician will have to function in a local and global network.

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > The Public Physician > The Public Physician: Opportunities and Challenges

  • Being a public physician brings with it a whole new set of challenges and opportunities, requiring a new set of skills and literacies.
  • Media analysts Henry Jenkins and Mizuko Ito have suggested the emergence of a participatory culture online, but doctors are trained to listen and follow, not create and participate.
  • ‘Personal versus professional’ is becoming a major issue online, personal and professional spaces are hard to separate, and there is a constant tension between online and offline lives.
  • Doctors can no longer choose to be public, but they can choose how they handle their public presence – if they don’t create their own story, someone else will.
  • Physicians will have to learn to managed their profiles and reputations and profiles, and human transparency, for example, is the currency of social media conversations.
  • Public physicians have to maintain some transparency and authenticity while maintaining the confidence of those they care for, while faced with time constraints.
  • Being able to think and work with others outside of medicine might be seen as a liability by some, but it is also an opportunity (e.g. to connect with patients and their families).

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > The Public Physician > The New Obligation To Create

  • Doctors have been trained to contain what they think and what they believe, but this is being challenged but he Digital Age.
  • 175 years ago, American poet Ralph Waldo Emerson suggested a critical social role for what he called the public intellectual: when a person trained in a discipline decides to write and speak to a larger audience than their professional colleagues.
  • The question of the moral obligation of the physician to participate as a public intellectual is illustrated by the discussions around vaccines and autism.
    • In 1998, a paper was published that wrongly connected the NMR vaccine with autism, causing the discussions on vaccines to be hijacked by an anti-vaccine minority.
    • It is arguable that this could have been avoided if paediatricians chose to participate in the conversation.
  • Imagine what if physicians shared everything they know and others could harness their knowledge and wisdom (e.g. packaging, tagging, and archiving, and that could be accessed by patients and students now and in the future).

Week 2: How Has the Practice of Medicine Changed in the Digital Age? > Expert Interview: Dr. Peter Killoran > Interview with Dr. Peter Killoran

  • Dr. Peter Killoran Lauren: faculty at UT Health in the School of Medicine in the Department of Anesthesiology and in the School of Biomedical Informatics.
  • EHR has many advantages e.g.
    • it is possible for multiple people in multiple locations to view that same information, even at the same time (is is particularly important as the doctor needs to make many decisions while physically away from the patient);
    • makes it possible to use computational techniques on it, and clinical decision support tools can be used;
    • automate the process of checking for drug-drug interactions;
    • could put laboratory results and medications together, and use algorithms to provide assistance on how to dose drugs depending on the patient’s condition;
    • put up-to-date electronic reference material in the same place as a patient’s information, to access the most up-to-date evidence based literature on treating a particular condition;
    • we can only use systems like Watson when the records are in digital form.
  • Different companies provide different types of EHRs, and they have different levels of functionality.
  • Paper can also be superior in some situations:
    • it is almost infinitely flexible (which computers find  difficult to replicate) e.g.  you can easily draw a picture, an anatomical diagram.
    • patients can  provide a handwriting sample which can be important in a doctor’s clinical thinking and diagnostics.
    • very simple to use compared to computer that require typing, or voice recognition etc.
    • patients’  stories are easier write down because most computer systems are designed to speed up routine documentation using pre-configured lists, and drop downs etc which structure the information in a way that can get in the way of telling a patient’s story.
    • it is easier to just stick a photograph on a piece of paper, whereas in a computer system, you need to have that specified as part of the design.
  • Electronic health records promised to change healthcare, but because they are complicated (because medicine is complex), many promises were not fulfilled.
  • In addition, EHR systems have been very proprietary and closed  in the past. It’s only now that systems are becoming more interoperable and more.
  • There is also potential for EHR to become more visual so clinicians, patients and other end users are can having a better visual and user experience, so that the information and data can be more easily understood, and thus support better decision making.

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photo: depositphotos/luislouro
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