Cisco recently released a very interesting report titled “The Health of Nations” which provided a perspective from health leaders from 16 countries
The paper has some very interesting insights into the healthcare systems of these countries. It points out that countries like the USA and Denmark, despite spending more than the international average on healthcare have lower than average life expectancies. It also looks at the consumer satisfaction of a country’s health system. Countries like Italy and France which have very high rankings in the WHO surveys have lower than average satisfaction rates by their citizens. The key message is that no healthcare system has actually delivered to its full potential, and there remains large untapped potential for healthcare systems to transform themselves into more efficient, effective, and accessible services going forward.
No surprise, being a technology company, the report talks about the role of technology in delivering this potential. However what it did point out to me was that there was a disconnect between what the key policy makers see as the major issues and what is being done on the ground to deliver on these reforms. Whilst the three key issues remained equitable access, efficiency and quality of care, practitioners on the ground keep talking about the blow out in costs of services. So they focus on cutting their costs of service, with the resultant decreases in access to service and challenges to their quality. As a result the system seems to get into a self defeating circle, manage costs at all costs and then do something heroic to enable equitable access; usually through short term expensive programs to shrink waiting lists or deliver on certain measurements of access to care that are not very relevant.
The other issue that was raised universally was the uneven distribution of healthcare professionals. Geographically they locate around urban and metropolitan areas, whilst unfortunately disease tends to spread itself out over less differentiated geographies. Human nature being what it is, once one has reached a certain point in their professional careers they tend to conglomerate with their peers. You can try and provide incentives for healthcare workers to live and work in regional and remote locations, but as healthcare professionals reach middle age, at the point where they are reaching the peak of their clinical careers, they also tend to make decisions about where they live and work based on more than just the needs of the community. It is hard to take your family away from the metropolitan community where you did your training, and move them out to the bush. I take my hat off to my healthcare professional colleagues that have had the courage to do that, but the statistics tell us they are in the minority.
However this is an area where technology really does become the enabler. To the data going down high speed fibre or wireless connections distance is not a problem. Video conferencing is part of the story, and in a fairly simplistic way can act as a surrogate for physical co location. However the advent of new technologies such as remote patient monitoring, mobile sensor technologies, data analytics and such like provide a new option as yet unexplored. What if we started to rethink how we deliver healthcare? Sure the model of Hippocrates still works in places where there are lots of physicians with time to spend with patients. But what if we asked our healthcare practitioners to think about how they would provide services if they did not have a lot of time. What information is relevant to them, or which will help them in their decision making. Do they really need to poke and prod a patient if they have access to relevant clinical information? Is Sir William Osler’s saying that listening to the patient will give you the diagnosis work better if we have a more structured, computer driven way of asking the patient the questions, rather than the relatively haphazard human systems we currently have today. Whilst all medical students are trained to do a systematic history of a patient, one of the first things they stop doing when they become time constrained is that full systematic history taking. However a computer doesn’t have that same restriction. It will do the full systematic evaluation all the time. It knows what questions it has asked, and which it hasn’t. So would a clinician’s time be more profitably used evaluating that information rather than obtaining it? In an ideal world we would gather and analyse the information, but alas few clinicians live in that ideal world.
So how do we move to a system where clinicians are rewarded for using their analytical skills rather than their collection skills? We have done that in the world of pathology. We don’t pay family doctors for taking blood, but we do pay them for looking at the results and discussing them with the patient. What if they could do the same thing from information gathered through monitoring systems that not only capture physiological information, but can also information on symptoms and other subjective responses. I believe we could make the health system much more efficient, because we will free up time currently spent gathering information for actually doing something with the information. I also believe that the systematic use of such technologies in the home will give us access to better information. How many patients walk out of their consultation with their doctor and on the way home say “I should have told the doctor about that other issue, but I forgot to bring it up during the visit”? I know I have done it myself, and I am a trained physician. What about those niggling pains or concerns you have which seem better when you finally get to see the doctor. With the right systems in place we can capture that information and provide it to the healthcare provider in a usable format so they can make their decisions.
There will remain times when you need a one to one personal consultation with your healthcare provider. That option should always remain. But there are also many times when you don’t, where by just sharing information in the right context better quality care can be delivered more efficiently. We need to provide our healthcare providers the opportunity to explore those opportunities. The only way to do that is to unshackle them from the current direct fee for service model and allow them to deliver care with different reimbursement models. The Medicare Local in Australia or the Accountable Care Organisation in the USA may be one way of doing it. What we need to do is make it easier for them to explore these types of opportunities.