The NHS at 70

The crown jewels of British society

The NHS was the crown jewels of British society providing healthcare to every member of society no matter who they were, where they came from and what personal resources they had. It was the great leveler of society creating a single standard of care and service that was accessible to rich, poor and disenfranchised and it was well loved.
To me personally, it was my guide and educator – I was lucky to attend one of the great London medical schools – The Royal Free Hospital School of Medicine. The “Free” hospital created to treat all comers and the original medical school (The London School of Medicine for Women) for women created in an era when women were not admitted to British Medical schools

That hospital and the NHS provided me with a first-class medical school education, access to groundbreaking research that included the early work and discoveries around HIV/AIDS, Hemophilia, Liver disorders and beyond.
The staff in every department were friends, colleagues and members of a community that were family and all pulled in the same direction – that of the patient. I spent time working in different areas during my time, staffing the manual telephone switchboard, helping the porters and security staff, nurses, technologists, and maintenance and quickly realized the well-oiled NHS machine demanded a family of committed people to make it work and deliver outstanding care each and every day.

What Could We Do Better

As we know today, and probably knew 70 years ago and before, healthcare is as much about our environment and resources as it is about medical treatments, technology, and innovation. We know that 60-80% of health is attributable to lifestyle but fail to take account of this in the NHS and in the majority of health systems from around the world.

 

We need a WellCare system not Healthcare

 

The system spends large sums of money providing medications to the population but fails to take account of the most basic needs of the population and acknowledge that food is also a drug. What we put into our bodies contributes to our health and well-being. Failing to acknowledge and manage these elements of health with sleep as the foundation and exercise and nutrition built on top has created a system that treats the failing of these issues at great financial and personal patient cost. Investing in the prevention would create a WellCare system and not the Healthcare System that the NHS is.

Manage and Allocate the Limited Resources with Transparency

It’s an unpleasant fact that few want to address or even acknowledge but the reality of treating people is that in this day and age of innovation, scientific progress and developments we could spend every last penny on treating patients. There is an unlimited supply of possible treatments and a never-ending procession of people needing those treatments. But not all treatments are created equally – some don’t work, some are harmful and in the cases of those that do work there is the wide disparity in the effectiveness and cost. Any healthcare system needs a means of assessing the effectiveness of treatments that includes the financial and resource cost linked to the improvements. The problem with a “free” (the NHS is not free – it is simply free at the point of care, paid for through taxation of the individuals) is the inducement of un-economic behavior by individuals looking for every last treatment option no matter the cost or effectiveness. That path is unsustainable and breaks the system and ultimately harms patients.

Enable Informed Decision Making for Everyone

Doctors Die Differently and do so because they understand the economic and personal tradeoffs between treatments and quality of life. In the data presented by the Johns Hopkins Study of a Lifetime we see a big discrepancy in treatment choices between doctors and everyone else. We make our choices in the context of the knowledge of effectiveness weighed against the personal cost of treatments and quality of life impact. An open an honest assessment of treatment that is clinically effective would level the disparity in treatment choices selected by patients. As a society, we struggle to discuss end of life but it is a reality that everyone faces and we must find ways to educate and support people through all aspects of life and death.

Technology and innovation is essential to the future of the NHS

The future of a scalable meritocratic system accessible to all that does not bankrupt society will be dependent on technology and innovation. Humans remain the core constituents of any compassionate caring system and technology is a supporting player. But as Michael Dell put it:

Technology has always been about enabling human potential

Technology has always been about Enabling Human Potential

Technology does not replace the human beings or interaction but rather augments it in ways that extend our capabilities and improves the accessibility and economics.

It is an impossible task for humans to process the amount of data currently being generated about our patients, the knowledge derived from research and advances in science and put it into the context of treatments at the point of care when it is needed most.

We have expanded beyond the human brains capacity to absorb, process and apply the knowledge and must rely on technology to augment the brains abilities and place information into the context of the individual patient and the care choices available.

Selecting the innovations that deliver the most value

Innovation impacts each and every area of the NHS and will continue to do so but the challenge will be to select the innovations that deliver the most value to the largest number of people based on scientific peer reviews.

Innovation is not confined to the clinical treatment but extends to every element of the NHS system and the delivery of wellness care. It is changing the design of facilities to include features that improve care and outcomes – for example by adding natural light and open spaces.

Innovation is allowing patients the option to access their care team at any time and from any location – for example bringing the care team to the patient as we used to do with home visits but now using technology to extend the reach and scalability.

Innovation is building rooms and beds that can be efficiently and effectively cleaned between visits while maintaining comfort and welcoming surroundings. It is using available data to predict potential health issues before they occur and reaching out to patients helping to guide them to better healthier choices and wellness. Innovation is allowing parents to stay with their child in the hospital when they are sick and in need of care in comfortable and caring surroundings.

Innovation is offering dignity and compassion to those facing death and offering realistic options for no treatment and hospice care.

What can Britain and the NHS learn from the rest of the world?

Over 700 years ago, China had village doctors who were paid by the villagers when they were well but received no money when the patients were sick. This is the principle of wellness over sickness care. In Norway, they have a wide and uniform implementation of a digital health record that is accessible to everyone that needs it including the patient – tied together with a unique patient identifier designed for that purpose. One Citizen, one record.

The European Union allows citizens to cross borders and different health systems but to receive urgent care while traveling and administers the cross-country charges, managing fees and removing the patient from worrying about payments while they are sick and abroad.

Look also to Africa and the innovation that takes place on a continent with access to far fewer resources and technology to see what’s possible with the existing technology. Small incremental steps in using technology to boost healthcare services such as text messaging have been wildly successful and yet remain simple, easy to implement and understand and accessible through all social groups in society.

In Rwanda, they have integrated drone delivery for hard-to-reach locations, offering lifesaving support that was previously almost impossible. Expect to see more of this and bi-directional capabilities for resources, tests, and samples as well as lifesaving treatments.

Finally, in Korea, they have a culture of celebrating aging and the elderly that includes dignity in end of life and the inclusion of everyone in the family and their health. Korean culture sees the 60th and 70th birthday as a big family affair and the inclusion and the universal expectation that roles reverse once parents age, and that it is an adult child’s honorable duty to care for his or her parents’ health.”

A version of this appeared previously here

The NHS at 70 was originally published on Dr Nick – The Incrementalist

Value-based care Making proprietary PACS and basic VNAs extinct

The move toward value-based reimbursement is shaking up traditional healthcare in all kinds of ways, as connectivity and cost-effectiveness become critical attributes in care delivery. Proprietary PACS, used in image acquisition systems, are starting to feel the squeeze from this dual pressure, as vendor-neutral archives take over many of their functions.

A recent study by Markets and Markets predicts a PACS-less Radiology world by 2018. Donald Dennison, Society for Imaging Informatics in Medicine (SIIM) Board director-at-large and the chair of the American College of Radiology (ACR) Connect Committee told attendees at the opening session for SIIM 2015, there are three external market forces that are trickling down into the imaging informatics world and leading to the demise of PACS: Money, EMR adoption and consolidation.

While PACS have traditionally been the workhorses of diagnostic imaging, providing workflows, viewing and archiving, their use of proprietary formats severely limited the ability of an organization to freely share images and created unnecessary and expensive complications in managing storage. They are a prime example of the episodic-care model, in which care delivery processes were created without regard to the broader needs of a patient. With the move toward value-based care, this episodic approach is rapidly being replaced by a patient-centric model, and proprietary silos are rapidly and rightly going the way of the dinosaur. In this case, value-based payments are the meteor strike that will so radically change the environment that these beasts are no longer equipped for survival.

Vendor-neutral archives (VNA), which can gather all the images into a standardized, patient-centered storage model, makes image sharing much easier. And VNAs have added on workflow and viewing capabilities that make PACS mostly superfluous. While having a VNA to unify all your diagnostic imaging is a good idea, it also has limitations. A simple VNA is more evolved than a PACS, but without more evolution and growth, it too will be unable to survive in the changed environment created by value-based payments. Fortunately, the VNA model is more adaptable than most PACS and is rapidly evolving to be far more than a DICOM-image repository.

An important part of value-based care is the ability to unify all data associated with a patient and deliver the right parts of that data where and when they are needed. That requires not only DICOM images, but also associated clinical data and documents and non-DICOM documentary images (such photos to document wound care). And all of that data must be integrated with the patient’s electronic health record. Finally, a layer of analytics is needed to ensure that relevant data can be extracted as needed.

Beyond individual patients, we have an opportunity to learn more about the progression of diseases if we can use this unified data in our predictive and population health analytics. In an article in Clinical Innovation+Technology, radiologists Eliot Siegel, MD and Gary Wendt, MD noted that this larger, unified data may soon offer unique value for diagnostic purposes and new clinical insights.

 

The article quotes Dr. Wendt (Dr. Wendt is the vice chair of informatics, professor of radiology, and enterprise director of medical imaging at the University of Wisconsin-Madison) saying

“Today when people are talking about big data and data mining, they are still talking about text. They’re not talking about actually mining content out of images. I think that’s probably the next generation, actually processing image data, not just text data. Ultimately, the clinical impact of such next-generation image archiving would come from the creation of more relevant reports [..based on data mining…]. This would be especially beneficial in oncology, where treatments can be modified based on tumor progression, and comparisons to similar cohorts of patients at an oncologist’s fingertips would be useful,”

As the VNA grows beyond image archiving, maybe a new name will be needed. The pre-release statement for a new IDC report (due out in December 2015) suggests a new description: Application Independent Clinical Archive. But I still like Dell’s name for our version of this archive (I work for Dell): Unified Clinical Archive.

By whatever name you call it, we are moving toward a truly patient-centered archive that will offer far more value than PACS or the simpler versions of VNAs. That’s good for all of us.

This article originally appeared on Autnminnie

 

Value-based care Making proprietary PACS and basic VNAs extinct was originally published on Dr Nick van Terheyden, MD

21 Bow Tie Salute to Farzad Mostashari

Like many in the healthcare IT industry, I was saddened by the announcement that Dr Farzad Mostashari (@Farzad_ONC) would be retiring. I would suggest as famed football legend Vince Lombardi said

“The strength of the group is the strength of the leaders”

And, for healthcare technology, Dr. Mostashari has been a great leader. I’ve outlined below some of the many contributions he has made to healthcare.

Dr. Mostashari joined the Office of the National Coordinator (ONC) in 2009, and has had a huge and positive impact on the implementation, development and overall perception of healthcare IT.  Personally impacted by the state of healthcare when his mother was admitted for arrhythmias, after having asked for the paper chart, he admitted;

I couldn’t even read the cardiology consult’s name

Perhaps this is one of the reasons he like me is a proud member of Regina Holliday (@ReginaHolliday) “Walking Gallery“. This difficult, and highly personal, situation likely galvanized his vision as he took on the daunting tasks demanded by the role of the ONC. He inherited a department that had, in effect, been pushed over the edge of the luge and, whilst speeding wildly along this track, was expected steer a course that would deliver on a range of programs in record time:

• Meaningful Use of Electronic Health Records (EHR)
• Certification program for EHRs
• National Standards
• Grant programs
• Regional Extension Centers

And that was just what he knew about coming in. The team endured the challenges, weathered the storm in the “Office of No Christmas”

He rapidly earned a reputation as a leader who listened and was engaged.  He made many appearances and, although he may not have been the first, he was certainly an early adopter of social media and online engagement – clear indicators of his heartfelt passion to be part of the solution. As a customer service representative I recently encountered very astutely pointed out:

I can’t do anything about the past, but I can help improve the future

Successes

It is hard to pick individual highlights from such an impressive record, but here’s my list of Dr. Mostashari’s top 13 achievements and quotable/notable moments from his time in office:

1. Successfully delivering on the Stage 1 Meaningful Use, despite frustrations and the challenges of a fickle and change-resistant healthcare profession.  He gracefully offered a personal hand to help steer his colleagues:
   “Meaningful use is the best-we-could-make-it roadmap to prepare for delivery of higher quality care and mitigating some of the costs toward getting there, if it’s a distraction we need to change it, and I want to hear from you personally.”
2. Creating a viable technical assistance program that has touched many providers and hospitals through regional extension centers (REC).
3. Driving the successful adoption of electronic health records (EHRs) and electronic medical records (EMRs).
4. Interoperability (see note below on focus for the future)
5. Pushing for patient empowerment (He, like me, is a proud owner and runway model for the Regina Holliday Healthcare Collection).
6. As he said: “We’re on the right track to make meaningful use of meaningful use” 
7. ePrescribing
8. And as if to prove the point about his use of social media, this from his twitter feed: “We’ve made more progress with EHRs in the past 2 years then we have in 20”   
9. Championing the patient engagement he stated: “We cannot have it be profitable to hoard patient information“
10. Nailing the coffin shut on paper he said: “Once you close a paper file it’s dead. You’re not able to move it or learn from it“
11. While this may not be his own personal quote but he applied cyberpunk science fiction, William F. Gibson famous quote to healthcare: “The future is already here – it’s just not evenly distributed.” by pointing out that we do have the technology – its just not being applied
12. Piloting Meaningful Use stage 2 criteria, which built on the success of stage 1, and pushed towards interoperability including standards for data sharing data, quality improvement, and quality measures that foster  patent engagement. As he put it: “We are using every lever at our disposal to increase the sharing of information” and “Patients need to care for themselves and become partners in their care“
13. Successfully weathering the storm of the controversial (or as he put it “headline grabbing“) Health Affairs article based on data from 2008 that suggested that EHR technology was increasing the costs of healthcare.

The Future:

To the lucky individual taking the reins, I offer five suggested  areas of focus:

2. A friend once said to me: “You’ve put us on the horse, you might as well give us the ride.” The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari’s play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.

1. Continue the engaged and inclusive discussion with all the constituents and make social media a central part of that strategy both for ONC but also for the healthcare industry.
2. A friend once said to me: “You’ve put us on the horse, you might as well give us the ride” The same can be said of payment reform, which must shift from quantity-based to quality-based payment. And taking a sheet from Dr Mostashari’s play book, every journey starts with a single, small action, so even a small dent would be a welcome shift.
3. I must include a shout out for patient engagement. Nowhere else in the industry will you find such a large and untapped resource that is ready, willing – but perhaps not yet able to participate in the change. As I have stated many times:  when a doctor and patient are in a room, there is nobody, I repeat nobody, more interested in successful outcomes than the patient. Give them the tools and make them part of the solution.
4. Occasionally, the issue of Tort and Medical Negligence is raised, but it appears to have the “third rail” syndrome. Unless this is addressed, we will continue to see “defensive medicine” practiced. As I recently blogged in Science, Evidence and Clinical Practice, despite clear data that shows intensive monitoring causes more harm in normal care deliveries, we continue to see almost universal rates of this high-level monitoring.  While some may be attributable to the payment system, I believe a large part of this volume stems from the general inertia of and fear of litigation.
5. Above all – have fun. I made this point at every soccer practice when I was a coach. If you aren’t having fun, there is little incentive to do well or, for that matter, to do at all. I know I am constantly amazed at the great fortune that finds me at this intersection of medicine and technology. I constantly have that feeling as if I paddled for the wave just at the right time:

“Surf’s Up dude – ten foot waves of the Pier”

The Making of the 21 Bow Tie Salute

Dr Farzad Mostashari has been an incredible role model, a source of inspiration and a true visionary who has helped others see what the future of healthcare can look like. And so, in extreme appreciation of all that he has accomplished, I offer this 21 Bow Tie Salute.  

I was fortunate enough to have another wonderful role model, my father, take the time to teach me how to tie a bow tie, but for those of you wanting to learn the fine craft of tying a bow tie, instructions are included below (The 21 Bow Tie Salute was made with Real Bow Ties). 

Thanks Dad!

Here are some basic instructions:

News and sources include:

Healthcare IT News

ONC

Yoda’s 1st Law Of Health Quality And Performance Improvement

Post a Comment

via statisticalmedievalist.blogspot.com

Great post on the challenges around pay for performance that highlights an interesting fact – Bill Clinton’s heart surgeon Dr Craig Smith has some relatively poor outcome measures…not because he has bad outcomes but because his practice takes some of the most high risk patients.
It is hard to take account of these numbers in the performance metrics.

So the next time you see performance or quality criteria – take a step back and dig deeper into the number

Posted via email from drnic’s posterous