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On fortune telling for health informatics
International Journal of Medical Informatics 66 (2002) 95 /106 www.elsevier.com/locate/ijmedinf
On fortune telling for health informatics J.R. Mo¨hr School of Health Information Science, University of Victoria, PO Box 3050, Victoria, BC, Canada V8W 3P5
Abstract This paper examines the paper of Haux et al. in this issue of this journal. It gives some background on specifics of the German health care system, which underlie the theses and prognoses proposed by Haux et al. In analogy to a forecast of the future of health informatics, which is now 10 years old, I then suggest that these attempts meet two types of challenges: / that of overestimating the positive effects of recent advances, which later are found not to scale up; and / that of blind spots with respect to unforeseen significant advances. The attempt to find indications of such in the projections of Haux et al. leads, among other, to the conclusion that the projections of direct linkages between patients and care providers may be overoptimistic. As to wheather the deviating opinions matter in the end, it is concluded that the technology advances may require less attention that the restructuring of the health care system required to take advantage of the advances of technology. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: German health care system; Health care; Health informatics
1. Introduction Once more, R. Haux and his group in Heidelberg have provided us with a stimulating and thought provoking paper; one that begs for examination, analysis and comment. And I am grateful for the invitation of the editors to provide such. The paper by Haux, Ammenwerth, Herzog and Knaup addresses a very important question: what will the future of health care and health informatics look like and what should we, therefore, concentrate our efforts on? What should the funders of
our research prioritize, in order to take advantage of what our field has to offer to the pressing issues in health care of today and in the near future? The authors approach this task by summarizing some issues that currently characterize* or have characterized in the recent past* the German health care system. They then propose a number of theses and associated prognoses of what similar characteristics might look like 10 years from now* e.g. in 2013. The prognoses are formulated as measurable features, which should allow* in the year 2013* to test whether the theses were right or wrong* a daring and stimulating exercise indeed! /
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E-mail address: [email protected] (J.R. Mo¨hr).
1386-5056/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 3 8 6 - 5 0 5 6 ( 0 2 ) 0 0 0 4 1 - 2
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Rather than dealing with the theses one by one, I will approach my comment from a somewhat different angle. I will try to ferret out what of the features is specifically German* which might, therefore, affect the generalizability of recommendations and conclusions. I will then compare this effort at predicting the future with another one for which we now have the benefit of hindsight. We can see from this exercise where we tend to be over optimistic and where we have blind spots. And finally, I will try to explore somewhat the question of the extent to which the scenario provided by Haux et al. might scale up. I will address these issues from the perspective of my work in health informatics in the 1970s and early 1980s in Germany, and since then in Canada, including involvement in telemedicine/telehealth. /
2. German specifics It is a merit of the authors to have provided a snapshot of the German health care environment, because all too often we here in North America assume too easily that the rest of the world functions* or if it does not that it should function* just like us, minor differences between the Canadian and the US American health care system notwithstanding. So this in itself is worthwhile information. Beyond that, the paper must be appreciated for its provocative value. However, some of the specifically German features are not really spelled out but rather transcend the assumptions regarding the future developments tacitly. And so it may be worth pointing them out so that readers not familiar with the German environment can appreciate them and assess the proposed consequences and recommendations. References to the paper by Haux et al. will be provided by giving the number of theses or /
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prognoses from the Haux paper in brackets, e.g. (T.1), as a reference to thesis one in the Haux paper. While I feel reasonably au courrant with respect to health informatics and telehealth, my German experience is certainly dated. I am, therefore, not able to validly assess certain developments in Germany. For instance, the authors suggest several trends, which seem modeled after developments in the USA. Examples are the increase of ‘alliances’ between practitioners and hospitals (P3.1, P3.2). These seem reminiscent of the managed care networks that evolved in the USA over the last decade, and I am unable to judge to what extent this development is likely to be echoed in Germany. Similar caveats apply to my assessment of the prognosis that DRG type categorizations will affect the German reimbursement scheme (P6.1). But now to the German specifics: . In Germany, university hospitals are large teaching and research institutions receiving public funds for research as well as patient care, with typically between 1000 and 2000 inpatient beds serving tens of thousands of inpatients and hundreds of thousands of outpatients annually. They are part of the university and are staffed with employed medical personnel. These hospitals typically provide the opportunity for chiefs of staff to treat ‘private patients’ on a fee for service basis, which results in a significant top up of the salary of those enjoying these privileges. . This remuneration scheme applies to essentially all hospitals and makes for a salaried physician population in excess of 50% of all physicians professionally engaged in patient care, as well as a pervasive fee for service system. . The private practitioners are reimbursed on a fee for services basis as in Canada and the
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USA. Therefore, managing fee for service claims is a pervasive preoccupation in health informatics in Germany, one spiced by the availability of in excess of a thousand insurance companies to which a number of group schedules apply, which are changed asynchronously and at irregular intervals. The population of practicing physicians is distinct from the population of hospital physicians in Germany. General practitioners and specialists in private practice treat most of the patients seeking medical care. They do this in their (typically single physician) practices and generally do not take care of their patients while these are in hospital. The 5% or so of patients who are admitted to a hospital during a 3 months accounting period (a quarter) is in fact handed over into the care of a different medical team. This system constitutes not only a built in second opinion but also ensures that specialists in hospitals carry out difficult procedures in comparatively high volumes, and are, therefore, able to maintain specialized skills. The system does, on the other hand, generate a need for communication about the care of the patient. Hence support for documentation and communication through health informatics is of high priority* as evident in the paper by Haux et al. The vast majority of the German population (up to a fairly high threshold of income) is compulsorily insured for health care* a social achievement introduced by Bismarck in 1871. The employer and the employee typically make contributions to the insurance in proportion to the wages of the employee. However, everybody is free to top up this compulsory insurance by ‘private insurance’ if he or she can afford it. This will /
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buy additional services to those that compulsory insurance covers* such as the care by a specific chief of service in a famous university hospital. This is behind the prediction that ‘the private participation of patients in their healthcare cost will increase’ (P6.2). . One consequence of the demands that this reimbursement system puts on data management is the introduction of a ‘health insurance license’ (Versicherten Ausweis) based on a chip card and associated technology infrastructure in doctors’ offices and hospitals. This was introduced in the mid-nineties. The available infrastructure is the basis for the temptation to introduce a chip card that actually contains medical data. Haux and coworkers judge this as not immediately imminent (see P12.3), and I agree. . In Germany, professional accreditation for physicians is bestowed by ‘chambers of ¨ rztekammern), somewhat siphysicians’ (A milar to the Colleges of Physicians and Surgeons in Canada, or the Boards of medical specialties in the USA. These accreditations are for such fields as general practice, internal medicine, etc. But they also recognize sub-specialization such as cardiology, balneology, and yes, medical informatics. In regard to this subspecialization, Haux et al. foresee further differentiation (P7.1). /
3. The challenge of predicting the future of health informatics It is certainly a fascinating mental exercise to attempt to predict the future, and the future of health informatics in particular. It is important too, particularly for those of us in the business of doing and directing research,
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the development of informatics tools, and for those of us engaged in teaching health informatics. Having been engaged in all of these pursuits for over 30 years affords me a basis for savoring the challenges that predicting the future in health informatics poses, and the consequences of misjudgment. One example is the evolution of our curricula. If I remember correctly, the first curriculum in health informatics provided by the University of Heidelberg in the early 1970s was* among others* heavy on measurement theory and instrumentation, biosignal processing, statistics, and data bases, but did not include imaging, pattern recognition, speech analysis or information retrieval. The curriculum was, of course, updated many times since, but the process made us aware of our blind spots and misjudgments. An illustrative example of what predictions come true, what predictions do not materialize, and most importantly perhaps, what major breakthroughs happen even if unforeseen, is provided by something that is a staple of my courses to this day: the video ‘Imagine’ produced by Hewlett Packard in the early nineties. I was introduced to it at Medinfo’92 in Geneva. The very professionally done video interleaves three scenarios and illustrates the potential role of advanced ICT: /
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I) The MI scenario: a man, probably an executive in his late fifties, suffers a myocardial infraction and is rushed to the local tertiary care facility on a stretcher while an emergency physician runs alongside, dictating his findings into an attached computer, which promptly transcribes the dictation and simultaneously displays a 3D video of the cardiac motion. Computers further support communication with the patient’s family physician, monitor the diagnosis and therapy,
identify a cardiac arrest, and contribute heavily to the eventual saving of the patient’s life. II) The amanita scenario: a little girl who may be 8-year old, is rushed to the emergency because she is feeling acutely sick. It turns out that while ‘berry picking’ she tried some mushrooms (?!). An image produced by the computer allows her to identify (!!!!) the culprit as belonging to the amanita family. But the impending implosion of her liver is halted by a quickly established contact to a specialist in a Swiss University hospital who conveniently just invented the saving cure. III) The CEO scenario: the CEO of the hospital starts his work by logging into his computer addressing the very personable machine with casually chosen words and reviews his video messages. Among them is one from an (attractive female) department head who urges for an expansion of the cathlab facilities. Continuing his casual intercourse with the computer, the CEO suggests the machine provide him with statistics on the cathlab usage. Some hours later he is provided with a shiny graph that allows him to convince the board of directors of his favored solution to the problem. Thanks to the computer, all problems of the key figures are solved. I like this video and so do my students. Like most commercial videos, it insults your intelligence slightly. But it also gets you thinking and expands the realm of the imaginable. It is of interest here because, 10 years later, we can assess what of the developments, which are asserted to be within technology’s reach, have in fact been achieved in the meantime, which have not, and what important advances that have in fact happened in the meantime were not predicted.
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3.1. What has been achieved
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medical terminology* and hence health informatics* does, of course, not appear in the video either. To point this out is not to discredit the value of this particular video, nor of the attempt to read the crystal ball and tell the fortune of health informatics. The merit of both is hard to overestimate. The purpose is to draw attention to the types of pitfalls that are in the path to success in such endeavors. The pitfalls include that we sometimes succumb to over-estimating technological promises. We are unable to assess the complexity of certain tasks, or the consequences of scaling certain approaches up to general usage. On top of that, the events with the greatest impact often occur outside the laboriously charted territory of considerately planned advances. They happen in an intellectual space for which most of us are blind. The consequences are serious surprises* often good, but sometimes also very bad. So the question is perhaps: does the vision presented by Haux et al. have similar elements of over judging the potential of developments which may not happen, and does this vision perhaps not include components that are likely to happen? And, even more importantly, does this have any bearing on the validity of the recommendations and conclusions proposed by these authors? /
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The ability to watch video images of organ function* as in the MI case* independent of the location of the machine that produced them is almost there. A little more bandwidth with wireless connections and a little more processing capacity of the peripher al viewing devices and we have it. Same with continuous speech recognition, although noisy environments like a team racing a cart with a moaning patient along a busy hospital floor will probably continue to pose a challenge for some time to come. /
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3.2. What has not been achieved Computers are still a long way away from producing not only esthetically pleasing but sensible problem specific output to casually formulated complex questions* continuous speech recognition not withstanding, as in the CEO scenario. And the ability to find the right expert just in time within the myriad of potentially relevant advances, as in the Amanita case, will also probably remain on the wish list for a good while. /
3.3. What has happened that was unforeseen Consumer informatics mediated by the Internet is to me the most obvious unforeseen development. In particular, the active role that health care consumers in the form of problem specific interest groups* for prostate cancer, autism, in vitro fertilization, etc.* play in the provision of high quality web sites [1]. These web sites address not only the interests and information needs of health care consumers in an unprecedented manner, but in addition the emotional needs. This is not apparent in the video that is at least 10year old. And the genomics and proteonics revolution and its impact on patient care and
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4. Assessment of theses, prognoses and scenario The theses, prognoses and scenario provided by Haux et al. are sober, measured and reasoned. Many of the theses will probably prove correct, as measured by the associated prognoses, and I look forward to being around to test them in 2013.
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Let us concentrate then on potential overconfidence or oversights. And if we find any, let us try to address the questions of whether they matter regarding the recommendations and conclusions. In trying to answer these questions, we reach into a realm of beliefs, ideology, convictions and are in danger of leaving the realm of reason* but then, why not? The daring of the authors who provided the stimulus, and that of the editors who provided the invitation to stick out one’s neck deserve some daring in return. One of the premises clearly spelled out in the paper by Haux et al. is that the evolution of the western industrialized world continues without major disruptions, such as energy crises, an uprising against globalization, or the take-over of a fundamental ideology of one type or another. Let’s leave it at that, even if our trust in this straightforward progression of advances is shattered by the events that occurred after the original German version of the paper was drafted. Since this is not really about science fiction, I will not try to predict the unpredictable. Another explicit provision underlying the theses provided by Haux et al. is that the use of ‘terminologically uniform documentation’ is beneficial (Section 4.1, The three main goals. . .). I am pleased to take issue with this (what else would an editorial comment be good for?). While it is highly desirable to use standard terminology for communication among machines, and while great progress has been made in this regard with respect to the communication of data for well-defined purposes, I am very pessimistic that uniform terminology across disciplines provides added value. While it is meritorious to standardize the format and content of lab reports and imaging data, and while it is very beneficial to standardize the terminology of cardiologists, /
oncologists, etc., it is in my view a futile hope, and, therefore, an undesirable goal, to come up with a uniform terminology, a catchall across diverse disciplines, one that is, e.g. of equal value to a general practitioner, a pathologist or a radiologist. The reasons are several: . The experience basis of these* and all other* disciplines is fundamentally dissimilar. A general practitioner does not usually carry a microscope around with her, and a pathologist is rarely exposed to the expression of human suffering and distress, and to the ways of coping with it that are the base of the experience of the general practitioner. There is similarly little overlap among the experience of either with that of the radiologist. And while all three specialists will use such terms as ‘gastritis’ routinely, the GP will not ever see inflammation of the gastric mucosa of her patients to whom she applies this term, and the experience of the radiologist will be confined to light and shadow quite removed from the pain of the executive in distress. . The analogous principle applies to all other disciplines and subspecialties. Enforcing a standard terminology across them will only force the inappropriate use of terms for dissimilar real world entities and dissimilar concepts. A deterioration of the extensional validity of the terms would be the result, and with it, that of the statistics produced on this basis. Statistics would reflect language characteristics and documentation habits rather than objective facts. They would do this to an even greater extent than they do already. That, however, is no help, even if objects and concepts were static. . However, they are not. Medical concepts evolve continuously. And this dynamism can be expected to accelerate rather than to /
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settle down, given the volume of new insights generated, e.g. by the advances in genomics and proteonics. The more detailed insights, and the ability for further differentiation is usually available to a few sub-specialists first. Forcing standardization across disciplines would at the very least impose an unnecessarily coarse grid on the communication between specialties. It would indirectly affect the perception of practitioners. At worst, it would arrest progress in medicine. Does this have implications for the recommendations re: ICT development? Emphatically yes! Rather than putting efforts into defining and enforcing standard terminologies, it would be necessary to devise approaches that allow to flexibly and adaptively characterize medical concepts and to translate them among disparate disciplines, and among the information systems in their support. And this effort is worth making, even if it is more difficult than ‘standardization’, and even if generally applicable solutions may elude us beyond the 10 year window in question. An area eclipsed in the Imagine video of 10 years ago, and still in the scenario provided by Haux et al., is the powerful contribution to the area of health informatics that health care consumers make nowadays. Haux et al. see consumer health informatics as a contribution from professionals, from university hospitals certainly, but maybe also government agencies or industry. In contrast, I am profoundly impressed by the quality of a number of websites that consumers themselves have created [1]. If one only had to cater to an information need, the quality of the contents of these web sites could be measured in terms of correctness of their contents. And even in this respect they often surpass the professional offerings, when they provide information
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desired by their intended audience that is not available from other sources, e.g. ratings of providers. But they cater to important different needs of the intended audience. For instance, they cater to emotional needs. And in this latter regard they far surpass the products of academic or commercial suppliers. These web sites fill a need for communication and the sharing of experiences not previously met by health care providers in the industrialized world. They address a blind spot of the professional community. These offerings are there* often without external funding or with minimal contributions of the traditional R&D sources. All the provider community has to do is to embrace them, to integrate them into their practice, and to learn from them. And we certainly have examples that this change in attitude is happening. A pioneering example is BabyCareLink [2], which allows the families of premature infants to monitor the progress of their children and siblings while these are treated in neonatal intensive care units. The communication is provided by simple web cams and computers* a tremendous achievement in the care for the patients and the support of their families: the use of the Internet as communication device for people separated by illness, disease and the peculiarities of institutional care. Similarly, a prominent feature of the Telehealth Programs currently under way in Canada is the support of ‘family visits’, e.g. for children undergoing chemotherapy in isolation in distant institutions, or for children with terminal conditions in a palliative care facility [3]. Through video conferencing they are connected to their families or friends, who may reside many hundreds of kilometers away. Again, comparatively minor technical advances but major changes in attitude, in the orientation of health care, and the services covered are a prerequisite for the provision of /
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these important services. And while the scattering of sparse populations over huge remote areas may not be an issue in densely populated Europe, the attempt to bridge isolation may be just as desirable over short physical distances. Now to the scenario: Haux et al. take an approach similar to the Imagine video in that they depict a single imaginary case: a patient with a decade of coronary artery problems, first manifesting themselves more or less right about now, gets into serious trouble 10 years from now and uses a network of telemedicine to communicate directly and through his wife with his family physician* depicted politically correct as a woman* and with the nearby German-style university hospital. As in the Imagine video, the outcome is positive. Let us address the question of whether this scenario scales up. What if this kind of practice was available to the portion of the population that needs it? Calculations based data from the early 1970s show that about one case per day afflicted by any of 20 groups of health problems might feel enticed to use a telemedical emergency consultation per day in any single physician practice (see Appendix A for justification of numbers). This assumes that a patient would go the route depicted in the scenario in an emergency: communicate his/ her vital signs to the family physician, and ask for advice and directions. What about the other 50% of the less common diagnoses/problem consultations? If we assume that they lead to the same number of emergency contacts, we are at two telemedical emergency contacts per day. If we add one contact initiated by a care taker/relative/ significant other who has a rational reason to call, as in the scenario, we are at 4 telemedical emergency contacts per day. That is now one contact every other hour of a busy 8-h business day! Imagine the disruption to an /
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orderly practice day that this would mean! Recent investigations in Canada show that physicians in rural practices do already work 60 h a week! In the rough estimates, we have not accounted for calls related to relief from social obligations (‘I am sick, I have to stay in bed today’), calls related to prevention, calls by career hypochondriacs, etc. We also have not accounted for the fact that the telemedical emergency calls will likely take much more than the proverbial 5 min of the doctor’s time allocated per contact in many fee for service environments (In the early 1970s, we actually measured a median of less than 3 min per contact of direct physician time, not including the 10% of contacts where the patient did not contact the physician at all but was dealt with by other staff! [4]). So, does the scenario scale up? I believe not. What are the consequences for the development of technology? A change in the architecture of health institutions may make sense. It may be necessary to provide special callin centers that can take care of the calls that arise from health care consumers if one feels it is necessary to provide this kind of service. For instance, in British Columbia, Canada, every household has been provided with a hard copy book* backed up by a web site* on common health problems [5]. It contains information on how to cope with the problems* and a toll free number that patients can call any time of day to get advice, including the advice to seek professional help from a physician or other health professional. This call-in service is staffed by registered nurses and is supposed to decrease the pressure on the medical system while improving well-being of the population. Provided these kind of services prove beneficial and without serious side effects, I can see them being more widely adopted over the next 10 years, even in /
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evenly and densely populated areas like Germany. Here in British Columbia, we are also working on the establishment of a telemedical network which will link specialists in tertiary care centers* such as university hospitals* with health care providers, not patients, in remote regions, often hundreds and thousands of kilometers away. Our very preliminary experiences with this type of network, which does NOT provide ‘health care consumers’ with direct access to their providers, are impressive. They show that it is enough of a challenge to the educated, motivated health care professional to decide when to and when NOT to use the service, to think twice about extending this consultation service directly to the health care consumer. If the consultation access via telemedicine is provided to the consumer, the typical fallacy that pervades much of the ICT optimism of the last half-century may occur. This is that technologies will allow us to spend more time for health care. We are simply not geared to spend all the time we ‘have’ on patient care. There are many competing demands, serious and frivolous. But beyond that, I am old enough to remember the times when it was possible as a health care provider to peruse a privy without being called into action by a beeping pager. This is a reminder that through multiple interferences, indiscriminate use of ICT fragments the time available for any one task and produces the opposite effect of what we intend. As a consequence we are unable to do anything well, and have no time left at all, unless defensive measures are taken. And this is a worry. I would hate to see a scenario evolve, where patients with a problem have to limp forever through a maze of recorded messages without ever getting to talk to the person the advice of who is desired, if not needed. This is a distressingly common occurrence in banks, airlines and government /
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institutions nowadays. But just such a situation might result from linking patients with monitoring equipment to providers who are not specifically equipped to handle the new demands. The development of new, specialized care teams as suggested above could provide a vent that avoids protective measures that amount to a denial of access, and which could result from indiscriminate linkage. If the scenario provided by Haux et al. may not scale up well, it also seems to have some over-optimistic features. The Information and Communication Assistant (InCoA) of the physician in the scenario is reminiscent of the savant computer that the CEO uses in the Imagine video: even before the patient, or his wife, take the initiative, the InCoA alerts the doctor of a problem with the patient. This alert is based on the data that are periodically and automatically uploaded from the implanted monitoring device that the patient wears. Given the problems with even simple alarms that have not been resolved over the past 30 years, this feature may continue to elude us in 10 years ahead. And again, the issue of upscalability: presumably all risk patients of the doctor would wear such devices* unless the devices are only covered by ‘private insurance’. The estimations in the appendix show that one can assume that this may be hundreds of patients, within the population of 5000 10 000 that a typical practice cares for in Germany. Haux et al. predict that ‘more than 5% of chronically ill patients’ will make use of such monitoring devices (P29.1). According to the numbers presented in the appendix, this could easily be in the range of 250 500 patients of the population of any given practice. Further, if every one of the patients was connected to several institutions (e.g. to the practice of a GP and to a cardiologist at the university hospital* as /
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proposed in the scenario) it would even be more patients at each institution. Let us assume 200 patients, or 2 4% of the clientele uses monitoring devices of one type or other. Then a 1% false positive alarm rate per day will amount to 20 unnecessary alerts per day* and I have yet to see a device that is this accurate (I carry with me a vivid memory of a sojourn in Rome, where I seem to never have been out of earshot of a hooting or honking car alarm). In summary, I am extremely pessimistic with respect to the achievability of this kind of telemedical safety network. But again, there are alternatives. The specialized call-in centers have been mentioned above. A complement to the Canadian version of care is a quickly expanding US American model, where home care services are provided by specialized companies who employ armies of professional home care personnel. Naturally, these companies engage in tele-homecare, which is monitored by organized teams. But there are other alternatives. Some of our colleagues in Italy are experimenting with a patient specific web site that is accessible wherever Internet access is provided. It contains a summary of a risk patient’s relevant data, judiciously selected by a professional [6]. This is an interesting, very original alternative to the techno solution in question. The wellselected, patient specific data are under the control of the patient, but accessible to providers when needed. The system uses the old fashioned ‘iatrotropic stimulus’ as trigger for the initiation of interaction with the health care system. A patient who is not distressed or worried may not access a physician or other professional. But the system shares this feature with the rest of most of our health care systems. And I believe, it is important to avoid the mechanical false alarms. Regarding the consequences: the technology innovation that an extension of the /
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Pinciroli approach requires is comparatively modest. But it requires a different type of human effort, perhaps a different type of professional: the experience of our Italian colleagues shows that the abstracting of the medical record in such a way that the result is complete and useful to the professional, but also understandable to the patient, is a serious challenge. But it may be a useful and* given appropriate mechanisms for remuneration* lucrative occupation for physicians, including those with a need for part time occupation or with handicaps. /
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5. The implications Does all this matter in the end? Given the uncertainty of the fundamental premises* no oil crises, etc.* probably not. If we assume that we can and have to continue our efforts towards improvement of health care with the available or emerging technology, and that we can do this in our accustomed sheltered affluent societies, then it might matter a great deal. I can largely agree with most of the recommendations and goals proposed by Haux et al. ‘Patient centered recording and use of medical data for cooperative care’ is certainly a worthwhile goal. But I would put efforts into having humans intelligently abstract the information needed by providers as well as patients, rather than decree uniform terminologies for all. This, of course, has implications for the research we do and for what we attempt to educate our professionals for. And in this respect the most important outcome of the exercise we went through is for me that the architecture of the social and health care systems may need even more attention than the technology. And this may, of course, mean that the solutions in Germany /
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Table 1 Estimation of number of emergency contacts based on [4] Estimation of number of emergency contacts
Percent of diagnoses
Number of diagnoses
Number of cases
Emergency factor
Myocardial infarction Hypertension Lower back pain Respiratory infection Diabetes mellitus Atherosclerotic disease Ischemic heart disease Asthma Arthritis/arthrosis Kidney infections Liver disease Varicosis Emphysema Myocardial insufficiency Total # of diagnoses Emergency contacts per quarter Emergency contacts per day
9 7 7 4 3 3 3 2 2 2 2 2 2 2
202 157 157 90 67 67 67 45 45 45 45 45 45 45 2240
48 37 37 21 16 16 16 11 11 11 11 11 11 11
0.1 0.2 0.1 0.3 0.1 0.1 0.2 0.3 0.1 0.3 0.3 0.1 0.2 0.2
4.8 7.4 3.7 6.3 1.6 1.6 3.2 3.3 1.1 3.3 3.3 1.1 2.2 2.2 45.1 0.5
will be different than in other parts of the world. The distillation of current, valid comprehensive knowledge advocated by Haux et al. is certainly also a valid goal. The diligent work done in many places, in abstracting the essence of medical progress from literature, to create and update clinical practice guidelines (CPGs) has to be continued [7]. The same applies to efforts to translate these CPGs into machine executable routines [8]. However, we may not achieve the goal of interoperative CPGs within the next decade, as the progress in this latter respect over the last decade shows* the period since invention of the medical logic modules and the Arden Syntax [9], for instance. And while pursuing these goals, we should not overlook the fact that patients* ‘health care consumers’* have qualitatively different needs. A much simpler approach than the attempt to make hard core medical knowledge digestible* if not palatable* to patients, might be to simply embrace and nurture the /
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Emergency contacts
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many valid and exceedingly complementary initiatives that our customers have already come up with on their own. As far as the use of patient data for research and reporting is concerned, I fully agree with the need for thorough planning and design emphasized by Haux et al. Precisely this would be fostered if one would not create a soup of all data acquired anywhere using a uniform terminology, but if one would judiciously abstract the essence of data useful for clinical care, patient information, or administration, as advocated above. And finally, I agree totally that it would be nice if our political movers and shakers and the institutions we work in would adopt such a comprehensive program. But the cost pressures might continue to provide an excuse not to do so. Finally a disclaimer: of course, a discipline as comprehensive and pervasive as health informatics has many facets not mentioned in the above. But I will leave it to others to comment, e.g. on the impact of telemanipula-
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tion on tele-robotic surgery, of population health monitoring on the detection of biohazards or bioterrorism, and on the use of telehealth in response to catastrophes, natural or otherwise. There are others eminently more qualified than I to do this.
Acknowledgements As all my papers, this one has also benefited from expert type scripting by Nicole Grimm, and rigorous editorial review by Chris Anglin.
tacts and the number of diagnoses per contact is not independent of the diagnostic categories in question. The estimate is, therefore, just that. We then do a further rough assumption, which is the probability, with which a case of a defined diagnostic category will initiate an emergency contact during the 3-month period in question. Here we differentiate between the different diagnostic categories, assigning an ‘emergency factor’ between 1 and 3. Given that the numbers are based on the number of persons who actually went through the trouble to visit a physician an average of three times per quarter, the assumption that there is a 10 30% probability of them using an emergency contact during a 3-month period is probably not exaggerated. The emergency contacts so derived add up to 45 per 3-month period, or to five per day. /
Appendix A: Justification of frequency estimates Our source is a report published in the 1970s, investigating time and frequency characteristics in 13 physicians’ practices in Germany [4]. Since there is anecdotal evidence that the characteristics are not fundamentally different, 25 years later, in other fee for service family practices, we assume that the basic characteristics did not change much, even though we have not researched this issue thoroughly. In our investigation, general practitioners treated an average of 1400 patients per quarter, with an average of three contacts per patient during that time period, and 1.5 diagnoses recorded per contact. This amounts to 1400 3 1.6 2240 diagnoses per quarter. The relative distribution of the 20 most frequently diagnosed conditions is given in Table 1. These account for 50% of all diagnoses. On this basis we can calculate the average number of diagnoses in each category. By dividing the figures by 3 for each of three contacts per 3-month period, and by 1.4 for the average number of cases corresponding to the diagnostic categories. This calculation disregards the fact that the number of con/
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References [1] J.R. Moehr, Guidelines, the Internet, and personal health: insights from the Canadian HEALNet experience, Meth. Inform. Med. (2002), 41, in press. [2] M. Kolbasuk McGee, C. Murphy, 25 Innovators In Collaboration /collaboration is about more than squeezing out supply-chain costs, Information Week, 2001. [3] BC Telehealth Program: http://www.ha.bc.ca/page.cfm/telehlthlnk. [4] J.R. Moehr, K.D. Haehn (Eds.), Verdenstudie-Strukturanalyse Allgemeinmedizinischer Praxen. Schriftenreihe des Zentralinstituts fuer die kassenaerztliche Versorgung in der Bundesrepublik Deutschland, Deutscher Aerzteverlag, Koeln, 1977. [5] BC Health Guide: http://bchealthguide.org/. [6] F. Pinciroli, D. Nahaissi, M.J. Boschini, R. Ferrari, G. Meloni, M. Camnasio, et al., Security concept in ‘MyAngelWeb’ a website for the individual patient at risk of emergency, Int. J. Med. Inform. 60 (2) (2000) 203 /210. [7] B. Haynes, P. Glasziou, S. Straus, Advances in evidencebased information resources for clinical practice, ACP J. Club. 132 (1) (2000) A11 /A14. [8] P.D. Johnson, S.W. Tu, M.A. Musen, I.P., A virtual medical record for guideline-based decision support, Proc. AMIA Symp. (2001) 294 /298. [9] G. Hripcsak, Arden syntax for medical logic modules, MD Comput. 8 (2) (1991) 76 /78.
On fortune telling for health informatics J.R. Mo¨hr School of Health Information Science, University of Victoria, PO Box 3050, Victoria, BC, Canada V8W 3P5
Abstract This paper examines the paper of Haux et al. in this issue of this journal. It gives some background on specifics of the German health care system, which underlie the theses and prognoses proposed by Haux et al. In analogy to a forecast of the future of health informatics, which is now 10 years old, I then suggest that these attempts meet two types of challenges: / that of overestimating the positive effects of recent advances, which later are found not to scale up; and / that of blind spots with respect to unforeseen significant advances. The attempt to find indications of such in the projections of Haux et al. leads, among other, to the conclusion that the projections of direct linkages between patients and care providers may be overoptimistic. As to wheather the deviating opinions matter in the end, it is concluded that the technology advances may require less attention that the restructuring of the health care system required to take advantage of the advances of technology. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: German health care system; Health care; Health informatics
1. Introduction Once more, R. Haux and his group in Heidelberg have provided us with a stimulating and thought provoking paper; one that begs for examination, analysis and comment. And I am grateful for the invitation of the editors to provide such. The paper by Haux, Ammenwerth, Herzog and Knaup addresses a very important question: what will the future of health care and health informatics look like and what should we, therefore, concentrate our efforts on? What should the funders of
our research prioritize, in order to take advantage of what our field has to offer to the pressing issues in health care of today and in the near future? The authors approach this task by summarizing some issues that currently characterize* or have characterized in the recent past* the German health care system. They then propose a number of theses and associated prognoses of what similar characteristics might look like 10 years from now* e.g. in 2013. The prognoses are formulated as measurable features, which should allow* in the year 2013* to test whether the theses were right or wrong* a daring and stimulating exercise indeed! /
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E-mail address: [email protected] (J.R. Mo¨hr).
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Rather than dealing with the theses one by one, I will approach my comment from a somewhat different angle. I will try to ferret out what of the features is specifically German* which might, therefore, affect the generalizability of recommendations and conclusions. I will then compare this effort at predicting the future with another one for which we now have the benefit of hindsight. We can see from this exercise where we tend to be over optimistic and where we have blind spots. And finally, I will try to explore somewhat the question of the extent to which the scenario provided by Haux et al. might scale up. I will address these issues from the perspective of my work in health informatics in the 1970s and early 1980s in Germany, and since then in Canada, including involvement in telemedicine/telehealth. /
2. German specifics It is a merit of the authors to have provided a snapshot of the German health care environment, because all too often we here in North America assume too easily that the rest of the world functions* or if it does not that it should function* just like us, minor differences between the Canadian and the US American health care system notwithstanding. So this in itself is worthwhile information. Beyond that, the paper must be appreciated for its provocative value. However, some of the specifically German features are not really spelled out but rather transcend the assumptions regarding the future developments tacitly. And so it may be worth pointing them out so that readers not familiar with the German environment can appreciate them and assess the proposed consequences and recommendations. References to the paper by Haux et al. will be provided by giving the number of theses or /
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prognoses from the Haux paper in brackets, e.g. (T.1), as a reference to thesis one in the Haux paper. While I feel reasonably au courrant with respect to health informatics and telehealth, my German experience is certainly dated. I am, therefore, not able to validly assess certain developments in Germany. For instance, the authors suggest several trends, which seem modeled after developments in the USA. Examples are the increase of ‘alliances’ between practitioners and hospitals (P3.1, P3.2). These seem reminiscent of the managed care networks that evolved in the USA over the last decade, and I am unable to judge to what extent this development is likely to be echoed in Germany. Similar caveats apply to my assessment of the prognosis that DRG type categorizations will affect the German reimbursement scheme (P6.1). But now to the German specifics: . In Germany, university hospitals are large teaching and research institutions receiving public funds for research as well as patient care, with typically between 1000 and 2000 inpatient beds serving tens of thousands of inpatients and hundreds of thousands of outpatients annually. They are part of the university and are staffed with employed medical personnel. These hospitals typically provide the opportunity for chiefs of staff to treat ‘private patients’ on a fee for service basis, which results in a significant top up of the salary of those enjoying these privileges. . This remuneration scheme applies to essentially all hospitals and makes for a salaried physician population in excess of 50% of all physicians professionally engaged in patient care, as well as a pervasive fee for service system. . The private practitioners are reimbursed on a fee for services basis as in Canada and the
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USA. Therefore, managing fee for service claims is a pervasive preoccupation in health informatics in Germany, one spiced by the availability of in excess of a thousand insurance companies to which a number of group schedules apply, which are changed asynchronously and at irregular intervals. The population of practicing physicians is distinct from the population of hospital physicians in Germany. General practitioners and specialists in private practice treat most of the patients seeking medical care. They do this in their (typically single physician) practices and generally do not take care of their patients while these are in hospital. The 5% or so of patients who are admitted to a hospital during a 3 months accounting period (a quarter) is in fact handed over into the care of a different medical team. This system constitutes not only a built in second opinion but also ensures that specialists in hospitals carry out difficult procedures in comparatively high volumes, and are, therefore, able to maintain specialized skills. The system does, on the other hand, generate a need for communication about the care of the patient. Hence support for documentation and communication through health informatics is of high priority* as evident in the paper by Haux et al. The vast majority of the German population (up to a fairly high threshold of income) is compulsorily insured for health care* a social achievement introduced by Bismarck in 1871. The employer and the employee typically make contributions to the insurance in proportion to the wages of the employee. However, everybody is free to top up this compulsory insurance by ‘private insurance’ if he or she can afford it. This will /
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buy additional services to those that compulsory insurance covers* such as the care by a specific chief of service in a famous university hospital. This is behind the prediction that ‘the private participation of patients in their healthcare cost will increase’ (P6.2). . One consequence of the demands that this reimbursement system puts on data management is the introduction of a ‘health insurance license’ (Versicherten Ausweis) based on a chip card and associated technology infrastructure in doctors’ offices and hospitals. This was introduced in the mid-nineties. The available infrastructure is the basis for the temptation to introduce a chip card that actually contains medical data. Haux and coworkers judge this as not immediately imminent (see P12.3), and I agree. . In Germany, professional accreditation for physicians is bestowed by ‘chambers of ¨ rztekammern), somewhat siphysicians’ (A milar to the Colleges of Physicians and Surgeons in Canada, or the Boards of medical specialties in the USA. These accreditations are for such fields as general practice, internal medicine, etc. But they also recognize sub-specialization such as cardiology, balneology, and yes, medical informatics. In regard to this subspecialization, Haux et al. foresee further differentiation (P7.1). /
3. The challenge of predicting the future of health informatics It is certainly a fascinating mental exercise to attempt to predict the future, and the future of health informatics in particular. It is important too, particularly for those of us in the business of doing and directing research,
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the development of informatics tools, and for those of us engaged in teaching health informatics. Having been engaged in all of these pursuits for over 30 years affords me a basis for savoring the challenges that predicting the future in health informatics poses, and the consequences of misjudgment. One example is the evolution of our curricula. If I remember correctly, the first curriculum in health informatics provided by the University of Heidelberg in the early 1970s was* among others* heavy on measurement theory and instrumentation, biosignal processing, statistics, and data bases, but did not include imaging, pattern recognition, speech analysis or information retrieval. The curriculum was, of course, updated many times since, but the process made us aware of our blind spots and misjudgments. An illustrative example of what predictions come true, what predictions do not materialize, and most importantly perhaps, what major breakthroughs happen even if unforeseen, is provided by something that is a staple of my courses to this day: the video ‘Imagine’ produced by Hewlett Packard in the early nineties. I was introduced to it at Medinfo’92 in Geneva. The very professionally done video interleaves three scenarios and illustrates the potential role of advanced ICT: /
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I) The MI scenario: a man, probably an executive in his late fifties, suffers a myocardial infraction and is rushed to the local tertiary care facility on a stretcher while an emergency physician runs alongside, dictating his findings into an attached computer, which promptly transcribes the dictation and simultaneously displays a 3D video of the cardiac motion. Computers further support communication with the patient’s family physician, monitor the diagnosis and therapy,
identify a cardiac arrest, and contribute heavily to the eventual saving of the patient’s life. II) The amanita scenario: a little girl who may be 8-year old, is rushed to the emergency because she is feeling acutely sick. It turns out that while ‘berry picking’ she tried some mushrooms (?!). An image produced by the computer allows her to identify (!!!!) the culprit as belonging to the amanita family. But the impending implosion of her liver is halted by a quickly established contact to a specialist in a Swiss University hospital who conveniently just invented the saving cure. III) The CEO scenario: the CEO of the hospital starts his work by logging into his computer addressing the very personable machine with casually chosen words and reviews his video messages. Among them is one from an (attractive female) department head who urges for an expansion of the cathlab facilities. Continuing his casual intercourse with the computer, the CEO suggests the machine provide him with statistics on the cathlab usage. Some hours later he is provided with a shiny graph that allows him to convince the board of directors of his favored solution to the problem. Thanks to the computer, all problems of the key figures are solved. I like this video and so do my students. Like most commercial videos, it insults your intelligence slightly. But it also gets you thinking and expands the realm of the imaginable. It is of interest here because, 10 years later, we can assess what of the developments, which are asserted to be within technology’s reach, have in fact been achieved in the meantime, which have not, and what important advances that have in fact happened in the meantime were not predicted.
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medical terminology* and hence health informatics* does, of course, not appear in the video either. To point this out is not to discredit the value of this particular video, nor of the attempt to read the crystal ball and tell the fortune of health informatics. The merit of both is hard to overestimate. The purpose is to draw attention to the types of pitfalls that are in the path to success in such endeavors. The pitfalls include that we sometimes succumb to over-estimating technological promises. We are unable to assess the complexity of certain tasks, or the consequences of scaling certain approaches up to general usage. On top of that, the events with the greatest impact often occur outside the laboriously charted territory of considerately planned advances. They happen in an intellectual space for which most of us are blind. The consequences are serious surprises* often good, but sometimes also very bad. So the question is perhaps: does the vision presented by Haux et al. have similar elements of over judging the potential of developments which may not happen, and does this vision perhaps not include components that are likely to happen? And, even more importantly, does this have any bearing on the validity of the recommendations and conclusions proposed by these authors? /
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The ability to watch video images of organ function* as in the MI case* independent of the location of the machine that produced them is almost there. A little more bandwidth with wireless connections and a little more processing capacity of the peripher al viewing devices and we have it. Same with continuous speech recognition, although noisy environments like a team racing a cart with a moaning patient along a busy hospital floor will probably continue to pose a challenge for some time to come. /
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3.2. What has not been achieved Computers are still a long way away from producing not only esthetically pleasing but sensible problem specific output to casually formulated complex questions* continuous speech recognition not withstanding, as in the CEO scenario. And the ability to find the right expert just in time within the myriad of potentially relevant advances, as in the Amanita case, will also probably remain on the wish list for a good while. /
3.3. What has happened that was unforeseen Consumer informatics mediated by the Internet is to me the most obvious unforeseen development. In particular, the active role that health care consumers in the form of problem specific interest groups* for prostate cancer, autism, in vitro fertilization, etc.* play in the provision of high quality web sites [1]. These web sites address not only the interests and information needs of health care consumers in an unprecedented manner, but in addition the emotional needs. This is not apparent in the video that is at least 10year old. And the genomics and proteonics revolution and its impact on patient care and
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4. Assessment of theses, prognoses and scenario The theses, prognoses and scenario provided by Haux et al. are sober, measured and reasoned. Many of the theses will probably prove correct, as measured by the associated prognoses, and I look forward to being around to test them in 2013.
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Let us concentrate then on potential overconfidence or oversights. And if we find any, let us try to address the questions of whether they matter regarding the recommendations and conclusions. In trying to answer these questions, we reach into a realm of beliefs, ideology, convictions and are in danger of leaving the realm of reason* but then, why not? The daring of the authors who provided the stimulus, and that of the editors who provided the invitation to stick out one’s neck deserve some daring in return. One of the premises clearly spelled out in the paper by Haux et al. is that the evolution of the western industrialized world continues without major disruptions, such as energy crises, an uprising against globalization, or the take-over of a fundamental ideology of one type or another. Let’s leave it at that, even if our trust in this straightforward progression of advances is shattered by the events that occurred after the original German version of the paper was drafted. Since this is not really about science fiction, I will not try to predict the unpredictable. Another explicit provision underlying the theses provided by Haux et al. is that the use of ‘terminologically uniform documentation’ is beneficial (Section 4.1, The three main goals. . .). I am pleased to take issue with this (what else would an editorial comment be good for?). While it is highly desirable to use standard terminology for communication among machines, and while great progress has been made in this regard with respect to the communication of data for well-defined purposes, I am very pessimistic that uniform terminology across disciplines provides added value. While it is meritorious to standardize the format and content of lab reports and imaging data, and while it is very beneficial to standardize the terminology of cardiologists, /
oncologists, etc., it is in my view a futile hope, and, therefore, an undesirable goal, to come up with a uniform terminology, a catchall across diverse disciplines, one that is, e.g. of equal value to a general practitioner, a pathologist or a radiologist. The reasons are several: . The experience basis of these* and all other* disciplines is fundamentally dissimilar. A general practitioner does not usually carry a microscope around with her, and a pathologist is rarely exposed to the expression of human suffering and distress, and to the ways of coping with it that are the base of the experience of the general practitioner. There is similarly little overlap among the experience of either with that of the radiologist. And while all three specialists will use such terms as ‘gastritis’ routinely, the GP will not ever see inflammation of the gastric mucosa of her patients to whom she applies this term, and the experience of the radiologist will be confined to light and shadow quite removed from the pain of the executive in distress. . The analogous principle applies to all other disciplines and subspecialties. Enforcing a standard terminology across them will only force the inappropriate use of terms for dissimilar real world entities and dissimilar concepts. A deterioration of the extensional validity of the terms would be the result, and with it, that of the statistics produced on this basis. Statistics would reflect language characteristics and documentation habits rather than objective facts. They would do this to an even greater extent than they do already. That, however, is no help, even if objects and concepts were static. . However, they are not. Medical concepts evolve continuously. And this dynamism can be expected to accelerate rather than to /
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settle down, given the volume of new insights generated, e.g. by the advances in genomics and proteonics. The more detailed insights, and the ability for further differentiation is usually available to a few sub-specialists first. Forcing standardization across disciplines would at the very least impose an unnecessarily coarse grid on the communication between specialties. It would indirectly affect the perception of practitioners. At worst, it would arrest progress in medicine. Does this have implications for the recommendations re: ICT development? Emphatically yes! Rather than putting efforts into defining and enforcing standard terminologies, it would be necessary to devise approaches that allow to flexibly and adaptively characterize medical concepts and to translate them among disparate disciplines, and among the information systems in their support. And this effort is worth making, even if it is more difficult than ‘standardization’, and even if generally applicable solutions may elude us beyond the 10 year window in question. An area eclipsed in the Imagine video of 10 years ago, and still in the scenario provided by Haux et al., is the powerful contribution to the area of health informatics that health care consumers make nowadays. Haux et al. see consumer health informatics as a contribution from professionals, from university hospitals certainly, but maybe also government agencies or industry. In contrast, I am profoundly impressed by the quality of a number of websites that consumers themselves have created [1]. If one only had to cater to an information need, the quality of the contents of these web sites could be measured in terms of correctness of their contents. And even in this respect they often surpass the professional offerings, when they provide information
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desired by their intended audience that is not available from other sources, e.g. ratings of providers. But they cater to important different needs of the intended audience. For instance, they cater to emotional needs. And in this latter regard they far surpass the products of academic or commercial suppliers. These web sites fill a need for communication and the sharing of experiences not previously met by health care providers in the industrialized world. They address a blind spot of the professional community. These offerings are there* often without external funding or with minimal contributions of the traditional R&D sources. All the provider community has to do is to embrace them, to integrate them into their practice, and to learn from them. And we certainly have examples that this change in attitude is happening. A pioneering example is BabyCareLink [2], which allows the families of premature infants to monitor the progress of their children and siblings while these are treated in neonatal intensive care units. The communication is provided by simple web cams and computers* a tremendous achievement in the care for the patients and the support of their families: the use of the Internet as communication device for people separated by illness, disease and the peculiarities of institutional care. Similarly, a prominent feature of the Telehealth Programs currently under way in Canada is the support of ‘family visits’, e.g. for children undergoing chemotherapy in isolation in distant institutions, or for children with terminal conditions in a palliative care facility [3]. Through video conferencing they are connected to their families or friends, who may reside many hundreds of kilometers away. Again, comparatively minor technical advances but major changes in attitude, in the orientation of health care, and the services covered are a prerequisite for the provision of /
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these important services. And while the scattering of sparse populations over huge remote areas may not be an issue in densely populated Europe, the attempt to bridge isolation may be just as desirable over short physical distances. Now to the scenario: Haux et al. take an approach similar to the Imagine video in that they depict a single imaginary case: a patient with a decade of coronary artery problems, first manifesting themselves more or less right about now, gets into serious trouble 10 years from now and uses a network of telemedicine to communicate directly and through his wife with his family physician* depicted politically correct as a woman* and with the nearby German-style university hospital. As in the Imagine video, the outcome is positive. Let us address the question of whether this scenario scales up. What if this kind of practice was available to the portion of the population that needs it? Calculations based data from the early 1970s show that about one case per day afflicted by any of 20 groups of health problems might feel enticed to use a telemedical emergency consultation per day in any single physician practice (see Appendix A for justification of numbers). This assumes that a patient would go the route depicted in the scenario in an emergency: communicate his/ her vital signs to the family physician, and ask for advice and directions. What about the other 50% of the less common diagnoses/problem consultations? If we assume that they lead to the same number of emergency contacts, we are at two telemedical emergency contacts per day. If we add one contact initiated by a care taker/relative/ significant other who has a rational reason to call, as in the scenario, we are at 4 telemedical emergency contacts per day. That is now one contact every other hour of a busy 8-h business day! Imagine the disruption to an /
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orderly practice day that this would mean! Recent investigations in Canada show that physicians in rural practices do already work 60 h a week! In the rough estimates, we have not accounted for calls related to relief from social obligations (‘I am sick, I have to stay in bed today’), calls related to prevention, calls by career hypochondriacs, etc. We also have not accounted for the fact that the telemedical emergency calls will likely take much more than the proverbial 5 min of the doctor’s time allocated per contact in many fee for service environments (In the early 1970s, we actually measured a median of less than 3 min per contact of direct physician time, not including the 10% of contacts where the patient did not contact the physician at all but was dealt with by other staff! [4]). So, does the scenario scale up? I believe not. What are the consequences for the development of technology? A change in the architecture of health institutions may make sense. It may be necessary to provide special callin centers that can take care of the calls that arise from health care consumers if one feels it is necessary to provide this kind of service. For instance, in British Columbia, Canada, every household has been provided with a hard copy book* backed up by a web site* on common health problems [5]. It contains information on how to cope with the problems* and a toll free number that patients can call any time of day to get advice, including the advice to seek professional help from a physician or other health professional. This call-in service is staffed by registered nurses and is supposed to decrease the pressure on the medical system while improving well-being of the population. Provided these kind of services prove beneficial and without serious side effects, I can see them being more widely adopted over the next 10 years, even in /
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evenly and densely populated areas like Germany. Here in British Columbia, we are also working on the establishment of a telemedical network which will link specialists in tertiary care centers* such as university hospitals* with health care providers, not patients, in remote regions, often hundreds and thousands of kilometers away. Our very preliminary experiences with this type of network, which does NOT provide ‘health care consumers’ with direct access to their providers, are impressive. They show that it is enough of a challenge to the educated, motivated health care professional to decide when to and when NOT to use the service, to think twice about extending this consultation service directly to the health care consumer. If the consultation access via telemedicine is provided to the consumer, the typical fallacy that pervades much of the ICT optimism of the last half-century may occur. This is that technologies will allow us to spend more time for health care. We are simply not geared to spend all the time we ‘have’ on patient care. There are many competing demands, serious and frivolous. But beyond that, I am old enough to remember the times when it was possible as a health care provider to peruse a privy without being called into action by a beeping pager. This is a reminder that through multiple interferences, indiscriminate use of ICT fragments the time available for any one task and produces the opposite effect of what we intend. As a consequence we are unable to do anything well, and have no time left at all, unless defensive measures are taken. And this is a worry. I would hate to see a scenario evolve, where patients with a problem have to limp forever through a maze of recorded messages without ever getting to talk to the person the advice of who is desired, if not needed. This is a distressingly common occurrence in banks, airlines and government /
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institutions nowadays. But just such a situation might result from linking patients with monitoring equipment to providers who are not specifically equipped to handle the new demands. The development of new, specialized care teams as suggested above could provide a vent that avoids protective measures that amount to a denial of access, and which could result from indiscriminate linkage. If the scenario provided by Haux et al. may not scale up well, it also seems to have some over-optimistic features. The Information and Communication Assistant (InCoA) of the physician in the scenario is reminiscent of the savant computer that the CEO uses in the Imagine video: even before the patient, or his wife, take the initiative, the InCoA alerts the doctor of a problem with the patient. This alert is based on the data that are periodically and automatically uploaded from the implanted monitoring device that the patient wears. Given the problems with even simple alarms that have not been resolved over the past 30 years, this feature may continue to elude us in 10 years ahead. And again, the issue of upscalability: presumably all risk patients of the doctor would wear such devices* unless the devices are only covered by ‘private insurance’. The estimations in the appendix show that one can assume that this may be hundreds of patients, within the population of 5000 10 000 that a typical practice cares for in Germany. Haux et al. predict that ‘more than 5% of chronically ill patients’ will make use of such monitoring devices (P29.1). According to the numbers presented in the appendix, this could easily be in the range of 250 500 patients of the population of any given practice. Further, if every one of the patients was connected to several institutions (e.g. to the practice of a GP and to a cardiologist at the university hospital* as /
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proposed in the scenario) it would even be more patients at each institution. Let us assume 200 patients, or 2 4% of the clientele uses monitoring devices of one type or other. Then a 1% false positive alarm rate per day will amount to 20 unnecessary alerts per day* and I have yet to see a device that is this accurate (I carry with me a vivid memory of a sojourn in Rome, where I seem to never have been out of earshot of a hooting or honking car alarm). In summary, I am extremely pessimistic with respect to the achievability of this kind of telemedical safety network. But again, there are alternatives. The specialized call-in centers have been mentioned above. A complement to the Canadian version of care is a quickly expanding US American model, where home care services are provided by specialized companies who employ armies of professional home care personnel. Naturally, these companies engage in tele-homecare, which is monitored by organized teams. But there are other alternatives. Some of our colleagues in Italy are experimenting with a patient specific web site that is accessible wherever Internet access is provided. It contains a summary of a risk patient’s relevant data, judiciously selected by a professional [6]. This is an interesting, very original alternative to the techno solution in question. The wellselected, patient specific data are under the control of the patient, but accessible to providers when needed. The system uses the old fashioned ‘iatrotropic stimulus’ as trigger for the initiation of interaction with the health care system. A patient who is not distressed or worried may not access a physician or other professional. But the system shares this feature with the rest of most of our health care systems. And I believe, it is important to avoid the mechanical false alarms. Regarding the consequences: the technology innovation that an extension of the /
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Pinciroli approach requires is comparatively modest. But it requires a different type of human effort, perhaps a different type of professional: the experience of our Italian colleagues shows that the abstracting of the medical record in such a way that the result is complete and useful to the professional, but also understandable to the patient, is a serious challenge. But it may be a useful and* given appropriate mechanisms for remuneration* lucrative occupation for physicians, including those with a need for part time occupation or with handicaps. /
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5. The implications Does all this matter in the end? Given the uncertainty of the fundamental premises* no oil crises, etc.* probably not. If we assume that we can and have to continue our efforts towards improvement of health care with the available or emerging technology, and that we can do this in our accustomed sheltered affluent societies, then it might matter a great deal. I can largely agree with most of the recommendations and goals proposed by Haux et al. ‘Patient centered recording and use of medical data for cooperative care’ is certainly a worthwhile goal. But I would put efforts into having humans intelligently abstract the information needed by providers as well as patients, rather than decree uniform terminologies for all. This, of course, has implications for the research we do and for what we attempt to educate our professionals for. And in this respect the most important outcome of the exercise we went through is for me that the architecture of the social and health care systems may need even more attention than the technology. And this may, of course, mean that the solutions in Germany /
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Table 1 Estimation of number of emergency contacts based on [4] Estimation of number of emergency contacts
Percent of diagnoses
Number of diagnoses
Number of cases
Emergency factor
Myocardial infarction Hypertension Lower back pain Respiratory infection Diabetes mellitus Atherosclerotic disease Ischemic heart disease Asthma Arthritis/arthrosis Kidney infections Liver disease Varicosis Emphysema Myocardial insufficiency Total # of diagnoses Emergency contacts per quarter Emergency contacts per day
9 7 7 4 3 3 3 2 2 2 2 2 2 2
202 157 157 90 67 67 67 45 45 45 45 45 45 45 2240
48 37 37 21 16 16 16 11 11 11 11 11 11 11
0.1 0.2 0.1 0.3 0.1 0.1 0.2 0.3 0.1 0.3 0.3 0.1 0.2 0.2
4.8 7.4 3.7 6.3 1.6 1.6 3.2 3.3 1.1 3.3 3.3 1.1 2.2 2.2 45.1 0.5
will be different than in other parts of the world. The distillation of current, valid comprehensive knowledge advocated by Haux et al. is certainly also a valid goal. The diligent work done in many places, in abstracting the essence of medical progress from literature, to create and update clinical practice guidelines (CPGs) has to be continued [7]. The same applies to efforts to translate these CPGs into machine executable routines [8]. However, we may not achieve the goal of interoperative CPGs within the next decade, as the progress in this latter respect over the last decade shows* the period since invention of the medical logic modules and the Arden Syntax [9], for instance. And while pursuing these goals, we should not overlook the fact that patients* ‘health care consumers’* have qualitatively different needs. A much simpler approach than the attempt to make hard core medical knowledge digestible* if not palatable* to patients, might be to simply embrace and nurture the /
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Emergency contacts
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many valid and exceedingly complementary initiatives that our customers have already come up with on their own. As far as the use of patient data for research and reporting is concerned, I fully agree with the need for thorough planning and design emphasized by Haux et al. Precisely this would be fostered if one would not create a soup of all data acquired anywhere using a uniform terminology, but if one would judiciously abstract the essence of data useful for clinical care, patient information, or administration, as advocated above. And finally, I agree totally that it would be nice if our political movers and shakers and the institutions we work in would adopt such a comprehensive program. But the cost pressures might continue to provide an excuse not to do so. Finally a disclaimer: of course, a discipline as comprehensive and pervasive as health informatics has many facets not mentioned in the above. But I will leave it to others to comment, e.g. on the impact of telemanipula-
J.R. Mo¨hr / International Journal of Medical Informatics 66 (2002) 95 /106
106
tion on tele-robotic surgery, of population health monitoring on the detection of biohazards or bioterrorism, and on the use of telehealth in response to catastrophes, natural or otherwise. There are others eminently more qualified than I to do this.
Acknowledgements As all my papers, this one has also benefited from expert type scripting by Nicole Grimm, and rigorous editorial review by Chris Anglin.
tacts and the number of diagnoses per contact is not independent of the diagnostic categories in question. The estimate is, therefore, just that. We then do a further rough assumption, which is the probability, with which a case of a defined diagnostic category will initiate an emergency contact during the 3-month period in question. Here we differentiate between the different diagnostic categories, assigning an ‘emergency factor’ between 1 and 3. Given that the numbers are based on the number of persons who actually went through the trouble to visit a physician an average of three times per quarter, the assumption that there is a 10 30% probability of them using an emergency contact during a 3-month period is probably not exaggerated. The emergency contacts so derived add up to 45 per 3-month period, or to five per day. /
Appendix A: Justification of frequency estimates Our source is a report published in the 1970s, investigating time and frequency characteristics in 13 physicians’ practices in Germany [4]. Since there is anecdotal evidence that the characteristics are not fundamentally different, 25 years later, in other fee for service family practices, we assume that the basic characteristics did not change much, even though we have not researched this issue thoroughly. In our investigation, general practitioners treated an average of 1400 patients per quarter, with an average of three contacts per patient during that time period, and 1.5 diagnoses recorded per contact. This amounts to 1400 3 1.6 2240 diagnoses per quarter. The relative distribution of the 20 most frequently diagnosed conditions is given in Table 1. These account for 50% of all diagnoses. On this basis we can calculate the average number of diagnoses in each category. By dividing the figures by 3 for each of three contacts per 3-month period, and by 1.4 for the average number of cases corresponding to the diagnostic categories. This calculation disregards the fact that the number of con/
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References [1] J.R. Moehr, Guidelines, the Internet, and personal health: insights from the Canadian HEALNet experience, Meth. Inform. Med. (2002), 41, in press. [2] M. Kolbasuk McGee, C. Murphy, 25 Innovators In Collaboration /collaboration is about more than squeezing out supply-chain costs, Information Week, 2001. [3] BC Telehealth Program: http://www.ha.bc.ca/page.cfm/telehlthlnk. [4] J.R. Moehr, K.D. Haehn (Eds.), Verdenstudie-Strukturanalyse Allgemeinmedizinischer Praxen. Schriftenreihe des Zentralinstituts fuer die kassenaerztliche Versorgung in der Bundesrepublik Deutschland, Deutscher Aerzteverlag, Koeln, 1977. [5] BC Health Guide: http://bchealthguide.org/. [6] F. Pinciroli, D. Nahaissi, M.J. Boschini, R. Ferrari, G. Meloni, M. Camnasio, et al., Security concept in ‘MyAngelWeb’ a website for the individual patient at risk of emergency, Int. J. Med. Inform. 60 (2) (2000) 203 /210. [7] B. Haynes, P. Glasziou, S. Straus, Advances in evidencebased information resources for clinical practice, ACP J. Club. 132 (1) (2000) A11 /A14. [8] P.D. Johnson, S.W. Tu, M.A. Musen, I.P., A virtual medical record for guideline-based decision support, Proc. AMIA Symp. (2001) 294 /298. [9] G. Hripcsak, Arden syntax for medical logic modules, MD Comput. 8 (2) (1991) 76 /78.