bridging the gap between new technology and clinical practice

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eHealth – bridging the gap between new technology and clinical practice

Séamus MacSuibhne

Consultant Psychiatrist, Health Services Executive, St Luke’s Hospital, Kilkenny

Ireland



Healthcare and technology

- Health systems are increasingly large parts of our economies, consuming increasingly large proportions of state budgets. The sustainability of health spending is often questioned, especially in the context of demographic change.

- Technology is often promoted as an answer to these resultant dilemmas, potentially improving the quality of care and the efficiency with which services are delivered. Given the vast sums spent on healthcare, it is also seen as an opportunity for the “next big thing” in technology to become highly profitable.



Barriers

• However, there are significant barriers between the introduction of new technologies and their adoption by patients and healthcare professionals.

• Neil Versel,, MobiHealthNews, Feb 7th 2013 “Rewards for Watching TV vs rewards for healthy behaviour” and follow up piece Brian Dolan Feb 12th 2013, “MobiHealthNews readers weight in on direct-to-consumer” – two articles focused on pitfalls of mobile direct-to-consumer health apps but which capture a lot of the deficiencies I would perceive in the approach of technologists to health issues



Quotes from Versel/Dolan article

• “What those projects all have in common is that they never worked out some of the basic realities of healthcare. Fitness and healthcare are distinct markers. The vast majority of healthcare spending comes not from workout freaks and the worried well, but from chronic diseases and acute care.”

• “The vast majority of these products are created by people who have had success in other areas of ‘digital’ – and therefore they build what they know – consumer facing apps/websites that just happen to be focused on health. They think that healthcare is huge ($$$), broken, and therefore easily fixed using the same principles applied to music, banking or finding a movie.”



Clinician’s Perspective

• Consultant Psychiatrist, St Luke’s Kilkenny• 4 main work locations• Department of Psychiatry (inpatient unit)• Outpatients Department• General Hospital Wards• Community Mental Health Services (off site)• Regular clinical sessions away from hospital and regular

home visits/nursing home assessments.• Service has an electronic (desktop based) patient

registration system but paper based patient records, with different sets of notes for inpatients/outpatients and different aspects of services.



The technological landscape at my work

• Carbon copy forms are used to refer service users to other disciplines within the mental health services. Bound registers are kept of patients seen by the service with separate volumes for on call, patients seen via general hospital etc.

• Work email is currently available to me at a single desktop, although there is the option of obtaining a specific work mobile device if I wished to explore it (at least a theoretical possibility!)

• There is a library on site with paper copies of journals. I personally have access to journals via other institutional links.



Slide Title

• Barriers to adoption of technology• -financial• -systematic• -institutional• -“practice”/professionalism• -labour-intensity• -concerns re data privacy• -concerns re equity of access



• Context of global economic crisis and specific issues in Ireland.

• Immediate financial cost of electronic patient record system which has led to it being “kicked down the road” despite benefits of reducing scope for errors and administrative costs

• Differences between healthcare and other markets – information asymmetry, lack of perfect information being available.



Systematic barriers

Any technology I might personally adopt would have to fit into wider systems.•Recently asked to beta test an app for taking patient histories on a mobile device.While impressive in ways, to integrate into existing notes I would have to make a hard copy•Not only within a particular hospital, but within a particular department of the hospital there are a range of systems, often operating in systemic silos. •Practice can be in multiple settings



Institutional barriers

• In my experience, healthcare institutions tend to be• Highly risk averse• Particularly conscious of potential legal liability• While these attributes are in ways justifiable and laudatory,

they may delay the adoption of technology• Inertia of the institutional – paper based notes (say) are

“working OK” and changing to an electronic system seems too involved.



Practitioner barriers

• Doctors and other healthcare professionals have their own ways of practice and of self-management. Some may have specific concerns or specific reluctance about technological approaches.

• My own example was alluded to above – although I have been told that it is possible that a dedicated mobile device for accessing email away from the desk would be a possibility.

• However, my role is as a clinician seeing patients rather than checking email and am happy to have access on certain days during the week.



Time/workflow

• Technologies may require a certain amount of training. Their use may also involve an investment of time. Unless this total use of time results in a net saving of time, or has some demonstrable and significant benefit over practice as usual, the technology is likely to be abandoned.

• Example – the App mentioned above for taking notes – overall it involved too much extra work to be clinically useful

• “physician workflow” – very often notes etc are written after a group of patients are seen



Data privacy/security

• From an institutional/legal perspective one of the major obstacles to adopting technologies in healthcare settings is concerns about access to personal data.

• Make it more likely to institutions to favour bespoke systems that are less likely to “speak to each other.”



Equity

• Health care workforces tend to be diverse in terms of age, level of formal education and other factors. Levels of computer literacy may vary.

• The above applies even more so to patients themselves. There is an ethical obligation to ensure that care is accessible to all. Even among the so called “digital generation” there is considerable variation in confidence and enthusiasm for technologies that are often assumed to be ubiquitous and popular (Vaidhyanathan)



Conclusion

• Already, there have been a plethora of ambitious digital attempts to “revolutionise” healthcare.

• “Massive Health, Google Health, Revolution Health and Keas never came to grips with the fact that healthcare is unlike any other industry. In the case of Google and every other “untethered” personal health record out there, it didn’t fit physician workflow.” – Neil Versel

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