An Alternate Reality for Healthcare

I’ve recently started watching “The Man in the High Castle,” a TV adaptation of a Philip K. Dick novel. It tells the story of what the world would have been like if Germany and Japan had won WWII. It really does make you consider how life would have been different, and how things that we take for granted now might have been totally different had the victors been the Axis instead of the Allied countries.

As a corollary, it made me think about what healthcare provision in the UK might have looked like if the NHS had not been created in 1948.

Prior to 1948, the provision of health services was largely private and mainly based on three sources:

  • Charity and the voluntary sector
  • Private health care: Hospitals were fee-paying or voluntary; primary care was mainly fee-paying or insurance-based
  • The Poor Law and local government: Poor Law hospitals were transferred to local government by the 1930 Poor Law Act

Bear in mind that average life expectancy in 1948 was far lower than it is today:

alternate reality blog image

There were a number of ways to assess whether someone was entitled to free healthcare provision, which mainly centred around means testing. Private healthcare could be bought directly from the hospitals or through private insurers (as is still done), and most payments were made upfront.

If the 1942 Beveridge Report proposing widespread reform to social welfare had not been written, and the NHS and welfare state had not been pushed into being, what might the state of healthcare be like today?

It could be very similar to the situation in a number of other European countries, such as France and Germany where there are a number of of statutory health insurers. People can join these through their employers, there is cost-sharing, some key exemptions, and around 10% of the population take private healthcare insurance (compared to 11% in the UK). Alternatively, could it have ended up more like the United States, where around 14% of people are uninsured for healthcare service provision?

Nations tend to be very protective of their approach to healthcare. So, as a Brit, I like to think that with the balance between left and right that the UK seems to strike in its governments (although the two have been more blurred over the last 20 years), we would not have reached the same situation that the United States has found itself in, spending over 17% of its GDP without achieving effective healthcare coverage for all those who need it. (As a comparator, the UK currently spends around 9% of its GDP on healthcare). Of course, my U.S. collegaues may be less enthusiastic than me about the provision of “socialized healthcare.”

It is possible that without the NHS, there could have been a more striking difference in the healthcare services available to the “haves” and the “have-nots.” Three-tiered healthcare services with only limited services available to those who are too poor or ill to pay, and a “squeezed middle” segment who are too rich to qualify for free treatment, and too poor to pay for everything they need.

For all of its faults, I’d argue that a healthcare system that is free at the point of care for all those who need to use it is a social ideal that many countries have strived for over the years. The NHS is not perfect, many people have to pay for their prescriptions, and the same doctor can be accessed far more rapidly for an elective treatment using private healthcare insurance than via the NHS. However, for the British people, it is the closest thing we have to a national religion, and woe betide the Man in the High Castle who tries to take it away from us.

Persuading the Unpersuadables

The other day I met with a new startup company that has as its core purpose the improvement of the health of people with chronic and pre-chronic conditions via a cognitive behavioural platform. This is not the first of this kind of solution I have seen, I’m sure it won’t be the last.

Invariably, they all seek to do the following:

1) Aggregate a wide variety of data sources from wearable apps

2) Utilise diaries, journals and other ways of recording situational context

3) Use prompts and notifications to ‘nudge’ behaviour

4) Give access to relevant educational materials

5) Link to care plan goals and involve referring clinicians in a “change” process

As I was taking to them, I tried to put myself in the shoes of a Clinical Services Director, someone who might be a buyer of this type of solution. What became very clear to me as the conversation progressed was this:

The sort of people who will check the app on a daily basis, log their activity and respond to prompts are the sort of people that probably would have followed a physician’s instructions anyway, at least for a while. They are the same people who would have followed the nutritional diet plan and exercise diary that the consultant might have given them.

If that’s the case, and I believe that it is, how does the platform add additional value for the purchasing client, other than capturing more information digitally?

It is my view that the majority of people, perhaps 75%, will not consistently respond positively to advice and directions from their clinicians. The challenge is to stop these people moving up the chronic care pyramid, necessitating more and more costly treatment as their conditions become more acute. That is exactly what these sorts of apps should do, and yet it seems to me that they really only target the 25% who are already amenable to specialist advice.

So how do we reach the others, how to persuade the unpersuadables?

Maybe everyone has been looking in the wrong place.

Currently, the holy grail of this type of solution is to join up as many health related apps as possible, taking the ‘quantified self’ to the broadest and deepest form of data collection possible. The belief being that, if we join up as much personal data as we can, we will achieve previously unknown insights into a patient’s behaviour and personal motivations, enabling us to start to change their approach to managing their health.

The problem is those people who not only won’t use the behaviour change app, but also won’t log the kind of information that the app needs to create the necessary behavioural ‘nudges’. However, many of these same people probably do use the multiple social apps, which record vast amounts of personal data.

  • Checking in somewhere on Facebook – we know where you are and what you are doing.
  • Capturing images on instagram – we know what you are seeing, doing, eating, etc.
  • Posting a tweet – we know what you are thinking about a particular issue and which ones interest you

So,  what if a health behaviour change (HBC) app could access the information gathered by the social apps you use, how might it use it?

You’ve just checked in to a Chinese restaurant on Facebook, the HBC app suggests what might be healthy options to choose from the menu. If you are diabetic, it could suggest how much eating a sweet and sour chicken and rice might affect your glucose levels, and the impact that might have on your body.

Perhaps you have recently been diagnosed with atrial fibrillation, and you Tweet about some nasty symptoms that you are now experiencing, the HBC app might suggest ways of managing this and direct you to some easily understandable literature.

Yes, it will be a fine line between being helpful, provocative and annoying, but in a sector that is constantly looking for the next ‘disruptor’, what is really needed is a way to disrupt unhealthy lifestyles and to educate patients to be more informed consumers of healthcare services. And after all, we’re prepared to accept intrusive advertising in our social apps, so why not intrusive health information?

How Much Should Your Doctor Know About You?

Should doctors “check out” their patients on social media before seeing them?

I went to the doctor. He x-rayed my head.
He stared for a moment and here’s what he said.
“With all of the junk that you have in your head
it’s kind of amazing you got out of bed.
The good news, at least, is you shouldn’t feel pain.
From what I can see here you don’t have a brain.”     By Kenn Nesbitt

When we go to the doctor, we may or may not have a pre-existing relationship with them. Maybe they are a family GP, who has known us since we were a kid and is almost a part of the family. Perhaps they are a doctor we have been referred to but never met before. Both hopefully know something about us, but there’s a difference between 20 years of visits and records and a short referral letter.

If the doctor doesn’t know much about us, should they do some “digging” on the Web and see what they can find out about us? By “Googling” they can find out information about the type of work we do, our address, and therefore our socio-economic group, our lifestyle and interests, even the sorts of topics that make us vocal (in 140 characters or less!).

Earlier this year, a research paper by professors at the Penn State College of Medicine highlighted the very real issue of doctors “Googling” their patients and questioned whether it was ethical. The paper suggested that guidelines should be put in place for doctors, as there is virtually no guidance available to them at the moment.

The code of conduct that the Penn State professors (including Maria Baker, Professor of Medicine) propose will have to include circumstances in which a doctor is justified in searching the Web for more information about their patients. These could include:

  1. Duty to re-contact/warn patient of possible harm
  2. Evidence of doctor shopping (visiting different doctors until a desired outcome is acquired)
  3. Evasive responses to logical clinical questions
  4. Claims in a patient’s personal or family history that seem improbable
  5. Discrepancies between a patient’s verbal history and clinical documentation
  6. Levels of urgency/aggressiveness are not justified by clinical assessment
  7. Receipt of discrediting information from other reliable health professionals that calls the patient’s story into question
  8. Inconsistent statements by the patient, or between a patient and their family members
  9. Suspicions regarding physical and/or substance abuse
  10. Concerns regarding suicide risk

Personally, I want my doctor to listen to what I have to say with an open mind. Any credible physician with experience has developed ways of ferreting out information quickly from their patients and can make an educated guess about whether they are being told the truth or not.

Medicine is very much a “people business” and the key characteristic of the transactions carried out is trust. If there is an erosion of that trust, then the relationship will fail, and the efficacy of the diagnoses and treatments delivered may well follow that same path.

Of course, I would want my doctor to have the most accurate information about me, so they can make the best decision about my care plan. If I was silly enough to lie to my doctor, then I would deserve the repercussions of that decision. Should the doctor try to counter that by doing their own research on me? I don’t think they should. While my doctor has a duty of care towards me, trawling the Web for my personal information is going well beyond what should reasonably be expected of them. Also, I’d be surprised if many doctors could actually find the time to do this.

I do recognize however, that doctors treat a wide variety of people, some of whom may be less rational or on a pathway to self-destruction. In those circumstances, should they go on a detective hunt, and if so, how far should they go? As the Penn State professors conclude, it’s an increasingly important question in the Internet age.

CSC Life Sciences Forum in Malaga (11th – 12th Feb 2015)

The weather in Malaga may not have been too hot, but the discussions within the Molina Lario hotel over two days last week were intense.

CSC hosted this forum, which attracted some of the top life science company execs from across central and southern Europe, as well as a roll call of leading technology providers.

Topics covered ranged from big data, cybersecurity and standards automation, to regulatory compliance outsourcing, digital transformation and agility. Gartner provided a well-researched overview of how the supply chain is evolving in life sciences, and there was a CIO round table which could easily have lasted twice as long as the time allocated to it.

The CIOs at the round table were: Albert Almajano of Grupo Indukern; Dietmar Bettio of Nobel Biocare; Matthias Moritz of Almirall; and Sergio Gistas of Esteve. They concluded that, as nowadays businesses can have ‘everything, everywhere’, the choices they make will be vital. Cost savings are important, but so of course is security. Big data is also seen as an essential tool for life sciences companies, but the CIOs agreed that there are still too few people who are sufficiently competent to interpret the resulting analysis.

Again, they all agreed that analytics from social media is coming to the fore. This is publicly available personal data, which people are providing openly and willingly through social media platforms. The panel felt that, within ethical guidelines, companies should look to leverage it wherever it makes sense to do so. Some are already using this externally-generated data to drive campaigns; for example, you can very quickly pick up trends on social media, such as a type of illness affecting a certain town or city. It will not be long at all before sales and marketing people will be able to ask these tools to tell them, “How are people feeling in Barcelona this week, and what might they need from us?”

The CIOs felt that services based in the cloud, especially from trusted providers such as CSC, were now safe to use. These are starting to be used to orchestrate and deploy resources, and new services such as ‘clinical trials in the cloud’ are starting to emerge. Several players may need to collaborate to generate content for these services, and the CIO panel was unanimous in saying that secure collaboration was becoming increasingly important to their enterprises.

The forum included a fabulous gala dinner at the Picasso Museum. I had been hoping for a private tour there, but it was not to be. Walking through the gleaming streets of Malaga with the orange trees heavy with fruit, we reminisced on what we had learned during the day. Life sciences is an industry sector perfectly positioned to exploit the new technologies that are already prevalent in markets such as financial services. While security and compliance are always a consideration, there are now trusted providers who can deliver a range of solutions and services to drive technology-enabled, and capital-efficient, innovation into pharmaceutical companies.

Genomic Googling – a new type of personalised search

Who should be able to access your most personal details?

Nearly a year ago, and with very little publicity given the significance of what it was doing, Google launched Google Genomics. Google Genomics is a cloud-based service, aimed at large hospitals and medical universities. It allows them to move DNA data into Google’s server farms, and provides  an interface or API to support detailed analysis of that data using the same algorithmic-based technology they apply to web searches.

The benefits are potentially vast, almost mind-boggling in fact.

Given that it takes a matter of minutes now to decode a human genome, and that the 100Gb of data produced costs around $20 per annum to store using a Google or Amazon cloud service, the scaling up of such a service is completely viable.

Imagine that you are a cancer sufferer, and your genome (and those of your tumour) have been decoded, uploaded to Google Genomics, and then matched against the others that are stored there. This process could predict which therapy or drug would offer you optimum results, based on the past experience of other patients with a similar genetic make up.

Now think of all the fuss that was made last year, when the NHS announced to patients that the initiative would allow their GP records to be shared with other care providers (and possibly the private sector). The Google Genetics initiative is in a whole different league to that.

Information about you that you might never have known, hidden traits, predispositions to illness and frailty – all could be interpreted by scientists from your genome and used in ways you could never have imagined. While this could benefit both you and humanity in general, we have to ask whether the benefits outweigh the potential risks.

We all know that data is never 100% secure. Government agencies and large companies (e.g. Sony) have their systems and repositories hacked far more frequently than the news headlines suggest. So, how do you feel about the risk that your most private data, the code that summarises you as a physical being, could become accessible to people who might misuse it?

It is a moral dilemma, and the issues of consent are significant.

Just because I give permission for my hospital to decode my genome to optimise my medication regime, that doesn’t mean that I consent to it being stored in a cloud that can then be accessed by other individuals and organisations, even if in an anonymised form.

On the other hand, if comparing my genome against 100 million others will extend the length and improve the quality of my life, is privacy a small price to pay?

Are we ready for personalised genetic testing

Here is the blog article I wrote for the global CSC website on this issue

link here

Make a ringtone out of music on your iPhone

Just got my new 3G iPhone and absolutely loving it!!

I found this very useful process for turning chunks of non DRM music on your iPhone into ringtones. I just tried it – it couldn’t be easier!! The only bit I’d change is right near the end when it says to drag and drop the new ringtone into your library. That didn’t work for me, but when  created a folder in my iTunes library called ringtones, moved the file there, then added that to my ringtones library, it worked fine.

Now all I need to work out is how to import all of the contacts off my orange SIM card into my iPhone. Anyone know how?

Visualisation periodic table

I know that I’ve posted a similar one to this before, but I really like the different visualisations shown on here. I just wish that you could click through to a template for each one!

Which chart to use?

Sometimes, you just can’t decide which chart is the right one to use. This handy flowchart helps you to decide.

Generic Work Process

Found this interesting list of work processes. Some of them (like the wizard of Oz one) I had never heard of before.