Hiding Our Heads in the Sand

By Kim Bellard, April 24, 2020

There are so many stories about the coronavirus pandemic — some inspiring, some tragic, and all-too-many frustrating. In the world’s supposedly most advanced economy, we’ve struggled to produce enough ventilators, tests, even swabs, for heaven’s sake. I can’t stop thinking about infrastructure, especially unemployment systems.

The U.S. is seeing unemployment levels not seen since the Great Depression, and occurring in a matter of a couple months, not several years. Many unemployment systems could not manage the flood of applications.

The word that has been repeatedly used to describe unemployment systems is “antiquated.” Many are still mainframe systems based on COBOL, dating as far back as the 1960’s. New Jersey Governor Phil Murphy lamented: “We have systems that are 40 years-plus old, and there’ll be lots of postmortems. And one of them on our list will be how did we get here where we literally needed COBOL programmers?”

And, let’s be fair: it’s not just state unemployment systems dependent on COBOL; many key federal systems are as well, including some used by the IRS, HHS, Treasury, and DoD, not to mention many banking systems.

There had been precious little money spent on upgrading the systems to more modern architectures, or even to retaining the programmers who could keep them running. When making budget decisions, it often seems like there will always be time to modernize…until there isn’t. Like in a pandemic.

We’re a nation that tends to underfund public pensions, at the local, state, and federal levels. We’re a nation whose infrastructure — e.g., roads, bridges, railroads, dams, water and sewer systems — is rated D+ by the American Society of Civil Engineers. And, as the COVID-19 pandemic is making so very evident, we’re a nation that has been extremely shortsighted in funding public health.

A new report from the Trust for America’s Health minces no words. President and CEO John Auerbach charges: COVID-19 has shined a harsh spotlight on the country’s lack of preparedness for dealing with threats to Americans’ well-being. Years of cutting funding for public health and emergency preparedness programs has left the nation with a smaller-than-necessary public health workforce, limited testing capacity, an insufficient national stockpile, and archaic disease tracking systems — in summary, twentieth-century tools for dealing with twenty-first-century challenges.

Tom Frieden, formerly of the CDC, warns: “We need an army of contact tracers in every community of the US to be ready to find every contact and warn them to care for themselves and stop spreading it to others.” Unfortunately, as Brian Castrucci of the de Beaumont Foundation told Time: “We waited until the house was on fire before we started interviewing firefighters.”

Oh, now we’re seeing why we need to invest in public health. Now we see why we need to invest in better UI systems. Now we see why things like the federal emergency stockpile and the Defense Production Act are important. It’s not like we didn’t know that pandemics could happen and how devastating they could be; we just chose to not be prepared.

We’ve been hiding our heads in the sand.

We’ll get through this pandemic. Not all of us, and not without too many of the rest us suffering in many ways. We’re told that we’re probably not going back to “normal,” at least not anytime soon, that we’ll have to adjust to a “new normal.” I just hope that the new normal includes a more clear-eyed perspective on being prepared for when pandemics and other catastrophes do strike.

We may never be fully prepared for when emergencies do hit, but we certainly can do better than we’ve done so far with this one.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

The New Scarlet Letter

By Kim Bellard, March 26, 2020

If you live in one of the jurisdictions that have imposed stay-at-home requirements, you’re probably making your essential excursions — grocery store, pharmacy, even walks — with a wary eye towards anyone you come across. Do they have COVID-19? Have they been in contact with anyone who has? Are they keeping at least the recommended six feet away from you? In short, who is putting you at risk?

Well, of course, this being the 21st century, we’re turning to our smartphones to help us try to answer these questions. What this may lead to remains to be seen.

Last week Israel granted its domestic security agency emergency powers to track the mobile phone data of people who have (or may have) coronavirus. The intent is for the health ministry to track whether such persons are adhering to quarantine rules, and possibly to alert others who had previously come in contact with them.

China is using the AliPay Health Code to assign color codes to individuals based on their known health status — green, yellow, red. The system is used in real time to determine, for example, who can board mass transit or use public housing. It is being rolled out nationwide, despite the lack of transparency about how the codes are determined, used, or updated.

Singapore has developed a tool — TraceTogether — that uses Bluetooth to track whose phones have been in close contact, and for how long. If someone then tests positive for COVID-19, the health ministry can easily determine who has been in contact with them.

South Korea is using smartphone data to create a publicly available map of movements of known coronavirus patients, and aggressively message those who might have come in contact with them.

Unfortunately, the information about their movements is having significant ripple effects, disclosing destinations users might have preferred not be public, or attaching a stigma to places they frequented.

In the U.S., volunteers from several big tech companies built covidnearyou, which allows people to self-report such facts as any symptoms, travel history, or exposure to people who have tested positive. Anyone can then use their map to determine if there are affected individuals near them.

MIT’s Media Lab has developed Private Kit: Safe Paths, “An app that tracks where you have been and who you have crossed paths with — and then shares this personal data with other users in a privacy-preserving way.” Unlike efforts in some other countries, the data is encrypted and does not go through a central authority. MIT Technology Review says:

Going one step further, two San Francisco hospitals have developed a smart ring that is “able to detect body temperature and pulse.” It is aimed at health care professionals and workers, such as ER doctors, as an early indicator of COVID-19 exposure. It’s probably only a matter of time before laypersons demand a version.

One can easily imagine such a smart ring being connected to a smartphone app, perhaps even generating a color code, and broadcasting the individual’s status and location to others worried about potential exposure. I bet Alibaba would be happy to help.

Tagging people and then broadcasting that tag, along with location and even identity, could put people at risk of discrimination (e.g., refused service or contact) and even attacks.

And we need to bear in mind that whatever technology we bring to bear on this public health problem could subsequently be used for other problems, public health or other. We increasingly live in a surveillance society, and that can be to our benefit — or to our detriment. We don’t always realize the slippery slope we’re on until the slide has become irreversible.

I’m all for using technology to address public health crises. I’m just not clear what the ultimate price we’re going to have to pay for that, and that makes me nervous.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Time Really Can Be Money

By Kim Bellard, February 26, 2020

If you are not an IKEA fan, or haven’t been spending any time in Dubai, you may have missed the chain’s marketing campaign to help promote its second store in the area. Titled “Buy With Your Time,” customers got store credits for how long they spent getting to the store.

Gosh, that’s something that should make any self-respecting critic of the U.S. healthcare system perk up. Count me as intrigued.

The campaign involved checking the customer’s Google Maps’ Trip tab to determine how long it took them to get to the store. IKEA benchmarked the average hourly wage in Dubai, and converted the travel time into how much credit they’d generated. It works out to about $29/hour, or $0.48 per minute. Spend long enough getting there and you could get a free coffee table or even a bookcase. Prices in the store include the equivalent time currency.

It is believed to be the first time a retailer is letting customers use their time as a means of payment. The program seems to have been a success.

I love this campaign for a couple reasons. One is the concept that it recognizes that, yes, our time is valuable, and not just in a lip service sort of way. The second is that “money” is a broader, more elusive, concept than the formal forms of currency that we usually use.

Healthcare should be thinking about both of those.

Travel is often not a prime consideration in healthcare, with medical tourism and centers of excellence still not achieving mainstream status. We like our healthcare local, failing to recognize that, for most of us, local is far from the best care we could get. But what if, taking a page from Ikea’s campaign, the time we spend traveling to — and taking off work for — sources of higher quality care translated into credits that we could use to pay for that care?

More important than travel time is the waiting. I have railed before about how the healthcare system often treats our time almost contemptuously. As I put it previously, we wait to get appointments, we wait at appointments, we wait during appointments, we wait for results after appointments, and, if we’re in a hospital or nursing home, we spend most of our time waiting.

Healthcare should be valuing the time we spend in the system waiting for something to happen. Some parts of the healthcare system seem to track and report waiting time — e.g., urgent care centers or emergency departments come to mind — but they don’t seem to do much with that information.

Imagine instead of paying health insurance premiums we accrue credits for our good health behaviors, which can be redeemed when we need some sort of intervention to maintain or improve our health. Ikea couldn’t have done its campaign without Google Maps, and we’re getting close to the kind of 24/7 tracking options that would allow for us to determine and manage such credits.

The problem will be that no existing entities in the healthcare system are really equipped (or incented) to administer such an approach, opening the door to new types of market entrants. Maybe we should ask the people at IKEA…

IKEA’s effort may just have been a clever gimmick to promote a new store in an isolated location, but there are lessons to be learned from it nonetheless. As Mr. Aten suggested, turning pain points for the customer into a win for the customer is, in fact, a win. If there is something that we can all agree on, it is that healthcare has too many pain points for its customers. The question is: how can we turn them into wins for those customers?

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Quantum Theory of Health

By Kim Bellard, January 30, 2020

We’re pretty proud of modern medicine.  However, there has been increasing awareness of the impact our microbiota has on our health, and I think modern medicine is reaching the point classical physics did when quantum physics came along.  

Classical physics pictured the atom as kind of a miniature solar system, with well-defined particles revolving in definite orbits around the solid nucleus.  In quantum physics, though, particles don’t have specific positions or exact orbits, combine/recombine, get entangled, and pop in and out of existence.  At the quantum level everything is kind of fuzzy, but quantum theory itself is astoundingly predictive.  We’re fooled into thinking our macro view of the universe is true, but our perceptions are wrong.   

So it may be with modern medicine.  Our microbiota (including both the microbiome and mycobiome) both provide the fuzziness and dictate a significant portion of our health.   

Two articles in Science illustrate how we’re still just scratching our understanding of their impact.  The first, from Rodrigo Pérez Ortega, reports on two new studies. 

The first study found that the genetic structure of gut microbiome was more predictive of health than one’s own genes.  It was especially better for “complex” diseases that are attributed to both environmental and genetic factors.  Gut microbes are impacted sooner by environmental factors and thus serve as better predictors for such diseases. 

The second study found that a person’s microbiome could be used to predict their death 15 years later.  Presence of a certain family of bacteria led to a 15% higher mortality rate in the next 15 years.  Whether the bacteria are the cause of the mortality or a side effect of other factors is not clear. 

The second article was a study from B.B. Finlay, et. alia, that speculated that so-called non-communicable diseases (NCD) might actually be communicable, via the microbiome.  Their paper concludes:  “These findings could serve as a solid framework for microbiome profiling in clinical risk prediction, paving the way towards clinical applications of human microbiome sequencing aimed at prediction, prevention, and treatment of disease.”

Dr. Finlay says: “If our hypothesis is proven correct, it will rewrite the entire book on public health.”

Still, it is too early to get overly excited.   Everyone agrees more research is necessary.  Timothy Caulfield, the Research Director of the Health Law Institute at the University of Alberta, warns: “Gut hype is everywhere.”  He acknowledges that this is an exciting field with great promise, but cautions “it is still early days for microbiome research.”  

Think of modern medicine, with its germ theory of disease and its understanding of our body’s biomechanics, as classical physics.  Our recent discoveries about our microbiota are upending our notions about what disease is, what causes it, and how we should best deal with it.  Our supposed precision in medicine is illusionary.  

Modern medicine loves its antibiotics, despite the devastating impact they wreak on our microbiome.  It is fascinated with our genome, despite the fact that our microbiota’s genes greatly outweigh our own, and have more diversity.  Our microbiota change in ways that we don’t understand and, as yet, can’t even really track, much less predict the effect of. 

We need the equivalent of a quantum theory of health.  

Modern medicine is in the stage physics was in the early part of the 20th century, when the concept of quanta was known but the consequences of it were yet to be discovered.  

Modern medicine has had its Newtons, maybe even its Einsteins, but now it needs a new generation of scientists to develop more accurate theories of our health, no matter how counter-intuitive they might be.  

Welcome to a quantum theory of health.

This post is an abridged version of the original posting in The Health Care Blog.

Our Dunning-Kruger Healthcare System

By Kim Bellard, July 11, 2019

Psychologist David Dunning, originator of the eponymous Dunning-Kruger effect, recently gave an interview to Vox’s Brian Resnick. For those of you not familiar with the Dunning-Kruger effect, it refers to the cognitive bias that leads people to overestimate their knowledge or expertise. More importantly, those with low knowledge/ability are mostlikely to overestimate it.

Dr. Dunning believes that we tend to think that this effect only applies to others, or only to “stupid people,” when, in fact, it is something that impacts each of us As Dr. Dunning told Mr. Resnick, “The first rule of the Dunning-Kruger club is you don’t know you’re a member of the Dunning-Kruger club. People miss that.”

So, how does this relate to our healthcare system?

We brag about our excellent care, our great hospitals and doctors, and all those healthcare jobs powering local economies. Yet we have by far the most expensive healthcare system in the world, which is expensive not because it delivers better care or to more of its population than health systems in other countries, but because it feels it is justified in charging much higher prices. Our actual outcomes, quality of care, and equity are all woefully mediocre on a number of measures.

How many of you live in an area that has at least one hospital system claiming to be one of the “best” hospitals in the country? Similarly, how many of us like to believe that our doctors are “the best”? Perhaps they even have “best doctors” plaques in their offices to support this claim.

Statistically speaking, most of us receive average care, and some of us receive sub-standard care. We don’t live in Lake Wobegon. We can’t all be getting the best care, or even above-average care. Just look at how few hospitals earn high ratings from The Leapfrog Group.

In The Atlantic, Olga Khazan reported on a new study that suggests that, despite all their supposed superior knowledge, doctors don’t really make better patients than the rest of us. They get C-sections about as often, and about as unnecessarily as we do, they get about the same amount of unnecessary/low value tests, they’re not better at taking needed prescriptions.

As Michael Frakes, one of the authors told Ms. Khazan, the doctors “went through internships, residencies, fellowships. They’re super informed. And even then, they’re not doing that much better.” Professor Frakes speculated that even physicians tended to be “super deferential” to their own physicians, despite their own training and experience.

It is widely accepted that as much as a third of our healthcare services are unnecessary or inappropriate — even physicians admit that — but, of course, it is other physicians doing all that. No one likes to believe it is their doctor, and few doctors will admit that they are the problem.

Dunning-Kruger, indeed.

Much as they’d like us to, it is not enough for us to always assume that our healthcare professionals and institutions are qualified, much less “the best.” It is not enough for us to trust that their opinions are enough to base our care recommendations on. It is not enough to believe that local practice patterns are right for our care, even when they are at variance with national norms or best practices.

“Trust” is seen as essential to the patient-physician relationship, the supposed cornerstone of our healthcare system, but trust needs to be earned. We need facts. We need data. We need empirically-validated care. We need accountability.

Otherwise, we just fall victim to healthcare’s Dunning-Kruger effect.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting.

The Health Tech Our Toddlers Should Never Know

by Kim Bellard, May 23, 2019

Joanna Stern wrote a fun article for The Wall Street Journal: "The Tech My Toddler Will Never Know: Six Gadgets Headed for the Graveyard."  My immediate thought was about health tech's equivalent list.  There certainly is a lot of health tech that should be headed to the graveyard, but, knowing healthcare's propensity to hang on to its technology way too long, I had to modify her more optimistic headline to say "should" instead of "will."

One can always hope.  Here's my healthcare tech list:

1.  Faxes:  You knew it had to be at the top of the list.  Anyone under thirty who knows how to work a fax machine probably works in healthcare.  The reason faxes persist is because they supposedly offer some security advantages, but one suspects inertia plays at least a big a role. There are other options that can be equally "secure," while making the information digital. 

2.  Phone Trees:  We've all had to call healthcare organizations -- doctors' offices, testing facility, health plans, etc.  Most times, you first have to navigate a series of prompts to help specify why you are calling, presumably to get you closer to the right person.  There are probably studies that show it saves money for the companies that use them, and perhaps some that even claim its saves customers time, but this is not a technology most people like. By 2030 I want my AI -- Alexa, Siri, etc. -- to deal directly with the companies' AI to spare me from phone trees. 

3.  Multiple health records: I have at least five distinct health records that I know of, only two of which communicate to the other at all.  For people with more doctors and/or more complex health issues, I'm sure the situation is even worse.  EHRs are old technology, the cable of healthcare.  By 2030, we should each have a single health record that reflects the broad range of our health.

4.  Stethoscopes:   You've seen them. Your doctor probably has one.  Find the oldest photographs of doctors that exist and you might find them with stethoscopes; they are that old.” It's not that they are useless, but as it is that there are better alternatives, such as handheld ultrasounds or even smartphone apps.  For Pete's sake, people are working on real-life tricorders.   By 2030, seriously, can we be using its 21st century alternatives?  

5.  Endoscopes: Perhaps you've had a colonoscopy or other endoscopic procedure; not much fun, right?  We do a lot of them, they cost a lot of money (at least, in the U.S.), and they involve some impressive technology, but they're outdated. By 2030, we should be using things like ingestible pill cameras, with ingestible robots to take any needed samples or even conduct any microsurgery. 

6.  Chemotherapy: Chemotherapy is literally a lifesaver for many cancer patients, and a life-extender for many others.  We're constantly getting new breakthroughs in it, allowing more remissions or more months of life.  But it can pose a terrible burden -- physically, emotionally, and financially -- on the people getting it.  Chemotherapy has been likened to carpet bombing, with significant collateral damage.  Increasingly, there are alternatives that are more like "smart bombing" -- precision strikes that target only cancer cells, either killing or inhibiting them.  By 2030, perhaps cancer patients won't fear the treatments almost as much as the cancer.

Healthcare certainly has no shortage of technology that we should hope today's toddlers will never have to use or experience.  The above are just six suggestions, and you may have your own examples.  We can make these happen, by 2030; the question is, will we?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting.

Robots Need DNA Too

by Kim Bellard, April 22, 2019 

DNA, it seems, never ceases to amaze. Now scientists are using it to create new kinds of "lifelike" mechanisms.   Pandora, we may have found your box. 

Researchers from Cornell recently reported on their advances.  They used something called DASH -- DNA-based Assembly and Synthesis of Hierarchical -- to create "a DNA material with capabilities of metabolism, in addition to self-assembly and organization – three key traits of life."

That sends chills up my spine, and not necessarily in a good way. 

Lead author Shogo Hamada elaborated:

The designs are still primitive, but they showed a new route to create dynamic machines from biomolecules. We are at a first step of building lifelike robots by artificial metabolism.  Even from a simple design, we were able to create sophisticated behaviors like racing. Artificial metabolism could open a new frontier in robotics.

The reference to racing in his quote refers to the fact their mechanisms were capable to motion -- likened to how slime mold moves -- and they literally had their "lifelike materials" racing each other.  If I'm reading the research paper correctly, the mechanisms were even capable of hindering their competitor."

Well, that's lifelike, all right.

It wasn't all days at the race track; oh-by-the-way, they also demonstrated its potential for pathogen detection, which sounds like it could prove pretty useful.

These mechanisms eat, grow, move, replicate, evolve,and die.  Dr. Luo says: "More excitingly, the use of DNA gives the whole system a self-evolutionary possibility.  That is huge."  Dr. Hamada adds: "Ultimately, the system may lead to lifelike self-reproducing machines."

Those chills are back.

There has been a lot of attention on engineering advances that will allow for nanobots, including uses with our bodies and so-called "soft robots," but we should be given equal attention to what is called synthetic biology.

Synthetic biology isn't necessarily or even predominately about creating new kinds of biology, as the researchers at Cornell are doing, but reprogramming existing forms of life. They're being programmed to eat CO2 (thus helping with global warming), help with recycling, get rid of toxic wastes, even make medicines. 

A Columbia researcher believes that new techniques for programming bacteria, for example, "will help us personalize medical treatments by creating a patient’s cancer in a dish, and rapidly identify the best therapy for the specific individual."

In the not-too-distant future, we're going to be programming lifeforms and "lifelike materials" to do our bidding at the molecular or cellular level.  We've been debating and worrying about when A.I. might become truly intelligent, even self-aware, but the Cornell research is giving us something equally profound to debate: how to draw the line between "life" and "things"?

Medicine, healthcare, and health are going to have to develop more 21st century versions.  What we've been doing will look like brute force, human-centric approaches.  Synthetic biology and molecular engineering open up new and exciting possibilities, and some of those possibilities will upend the status quo in healthcare in ways we can barely even imagine now.  

It's not going to be enough to think of new approaches.  We're going to have to find new ways to even think about those new approaches.  
  
In the meantime, let's go watch some DASH dashes!

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting. 

The End of Health Insurance

By Kim Bellard, February 20, 2019 

Paul Tullis has an interesting article in Bloomberg about how self-driving cars might kill auto insurance “as we know it.” After all, if human error is responsible for 90% of auto accidents, and those humans are taken out of the equation, what’s left to insure? 

Many people don’t think much about autonomous vehicles, but Mr. Tullis reports that Michelle Krause, an Accenture insurance expert, says that their impact on auto insurance “…comes up in every strategic conversation” within insurers. 

It made me wonder: what would it take to kill health insurance…as we know it? 

Let’s think about what health insurance is for: Averting losses, Budgeting and Subsidization. I’ll take these in reverse order: 

Subsidization

Health insurance is not the right mechanism to do wealth transfers. It’s not what it is designed for, and it is not what it is good at. 

Budgeting

We need to stop expecting health insurance help us budget for expenses that, in any other aspect of our lives, we’d be paying for ourselves. 

Averting losses

Even if we accomplished both of the above, health insurance would still probably not look too different than it does now. Our healthcare system would still have catastrophic expenses, and we’d be looking for protection against them. We’d still have networks, negotiated prices, and tensions between those who deliver health care and those who pay for it. 

We have to attack the root problem, which is not just the prices, but also the costs. Some examples of how this can happen: 

Virtual care will allow us to get advice and even treatment where/when we want it, and increasing reliance on A.I. rather than human expertise will both cut direct costs and, hopefully, unnecessary treatments. 

DIY health is a trend that has promise to greatly impact costs. Whether it is hearing aids, insulin pumps, or “biohacking,” we’re starting to move away from reliance on expensive solutions from traditional healthcare sources to cheaper, even home-grown solutions.

Robots, right now, fall within the “more technology, more expensive” ethos of our current healthcare system, but that cannot last. Robots will get smarter and more versatile, we’ll get better at building them, and they’ll allow us to take costs out of healthcare in the way they’ve taken costs out of manufacturing. 

Hospitals are, as I’ve stated previously, “19th century institutions operating under 20th century business models in the 21st century.”

Prescription drugs are one of the biggest pain points for consumer healthcare spending. Part of this looks a lot like greed, part of it is the U.S. not negotiating prices as other countries do, and part of it reflects the long pipeline for drug discovery and development. The former two are more price issues than cost ones, but the latter one is one 21st century technology can help address.

We shouldn’t accept the status quo; not in how care is delivered, not in how much care costs, and certainly not in how it is financed. If auto insurers are discussing merging with automakers, Apple is thinking about its post-iPhone era, Ikea wants to become the “Amazon of furniture,” and Amazon’s own future may be more about cloud computing than retail, then certainly health insurers should be looking to a very different future.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Do Unto Robots As You…

by Kim Bellard, January 23, 2019

It was very clever of The New York Times to feature two diametrically different perspectives on robots on the same day: Do You Take This Robot… and Why Do We Hurt Robots? They help illustrate that, as robots become more like humans in their abilities and even appearance, we’re capable of treating them just as well, and as badly, as we do each other. 

We’re going to have robots in our healthcare system (Global Market Insights forecasts assistive healthcare robots could be a $1.2b market by 2024), in our workplaces, and in our homes. How to treat them is something we’re going to have to figure out. 

Written by Alex Williams, Do You Take This Robot… focuses on people actually falling in love with (or at least prefering to be involved with) robots. The term for it is “digisexual.” 

As Professor Neil McArthur, who studies such things, explained toDiscover last year: We use the term ‘digisexuals’ to describe people who, mostly as a result of these more intense and immersive new technologies, come to prefer sexual experiences that use them, who don’t necessarily feel the need to involve a human partner, and who define their sexual identity in terms of their use of these technologies.

And it’s not just about sex. There are a number of companion robots available or in the pipeline, such as: 

• Ubtech’s Walker. The company describes it as: “Walker is your agile smart companion — an intelligent, bipedal humanoid robot that aims to one day be an indispensable part of your family.”
• Washington State University’s more prosaically named Robot Activity Support System (RAS), aimed at helping people age in place.
• Toyota’s T-HR3, part of Toyota’s drive to put a robot in every home, which sounds like Bill Gates’ 1980’s vision for PCs. 
• Intuition Robot’s “social robot” ElliQ. 
• A number of cute robot pets., such as Zoetic’s Kiki or Sony’s Aibo.

All that sounds very helpful, so why, as Jonah Engel Bromwich describes in Why Do We Hurt Robots?, do we have situations like: A hitchhiking robot was beheaded in Philadelphia. A security robot was punched to the ground in Silicon Valley. Another security bot, in San Francisco, was covered in a tarp and smeared with barbecue sauce…In a mall in Osaka, Japan, three boys beat a humanoid robot with all their strength. In Moscow, a man attacked a teaching robot named Alantim with a baseball bat, kicking it to the ground, while the robot pleaded for help.

Cognitive psychologist Agnieszka Wykowska told Mr. Bromwich that we hurt robots in much the same way we hurt each other. She noted: “So you probably very easily engage in this psychological mechanism of social ostracism because it’s an out-group member. That’s something to discuss: the dehumanization of robots even though they’re not humans.”

Robots have already gotten married, been granted citizenship, and may be granted civil rights sooner than we expect. If corporations can be “people,” we better expect that robots will be as well.

We seem to think of robots as necessarily obeying Asimov’s Three Laws of Robotics, designed to ensure that robots could cause no harm to humans, but we often forget that even in the Asimov universe in which the laws applied, humans weren’t always “safe” from robots. More importantly, that was a fictional universe.

In our universe, though, self-driving cars can kill people, factory robots can spray people with bear repellent, and robots can learn to defend themselves. So if we think we can treat robots however we like, we may find ourselves on the other end of that same treatment.

Increasingly, our health is going to depend on how well robots (and other AI) treat us. It would be nice (and, not to mention, in our best interests) if we could treat them at least considerately in return.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

What College Can Teach Healthcare

by Kim Bellard, December 19, 2018 

Mitch Daniels, the former Governor of Indiana and current President of Purdue University, gave an interesting interview to The Wall Street Journal about what Purdue has been up to during his watch. Mr. Daniels — who knows a thing or two about healthcare — drew an explicit parallel to healthcare in the interview: 

“You’re selling something, a college diploma, that’s deemed a necessity. And you have total pricing power.” Better than that, “when you raise your prices, you not only don’t lower customers, you may actually attract new ones.” For lack of objective measures, “people associate the sticker price with quality: ‘If school A costs more than B, I guess it’s a better school.’” A third-party payer, the government, funds it all, so that “the customer — that is, the student and the family — feels insulated against the cost. A perfect formula for complacency.” 

Higher education is one area where prices seem to be rising even faster than in healthcare, and both much faster than wages. Student debt just hit a record $1.465 trillion — yes, trillion — and now trails only mortgage debt in size. 

We spend a lot more — nearly twice as much per student annually — on higher education than almost any other developed country, according to OECD. Yep, sounds like U.S. healthcare all right. 

Mr. Daniels is trying to change that. For one thing, he’s focused on holding the line on costs, such as by bringing Amazon in to help lower textbook prices. Purdue had raised tuition 36 years in a row prior to his arrival, and now has not raised them since 2012. 

But here’s what really caught my eye. Purdue pioneered the use of Income Share Agreements (ISAs), an idea attributed to economist Milton Friedman. Students don’t owe tuition during college, but six months after graduation they begin to pay a percentage of their income for a fixed number of years (e.g., 10 years). Repayment is capped at 2.5 the initial funding. Several other universities are now rolling out their own versions. 

The application of ISAs to healthcare may not be obvious. In an earlier post, for example, I suggested treating our health as a capital asset. We would seek to spend — invest — money on things that increase it, and avoid things that decrease it. It would, admittedly, be hard to quantify any of this, but doing so would force us to measure and to track. 

Perhaps a Healthcare Share Agreement (HCSA) would have a healthcare organization make a quantifiable prediction about your health, and what you pay each year would depend on how they do against that prediction. We’d have to agree on how to measure it, over what period of time, but both the prediction and the measurement are feasible (e.g., QALY). 

The payment could be in lieu of health insurance premiums or health care organization’s charges. The healthier-than-expected you are, the more you pay; the worse-than-expected you are, the less you pay. It’s value-based payment at the next level. It could be done as agreements with individuals and organizations, or, say, between health plans and health organizations at a population level. 

The key thing is for healthcare organizations to do what Purdue is doing: bet on their ability to actually make a positive impact in the lives of the people they serve. 

I don’t know how it would work. I don’t know if it can work. But I’d sure like for someone to give it a try, because the existing business models sure don’t seem to be working.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Too Much Stupid Stuff

by Kim Bellard, November 16, 2018

Melinda Ashton, M.D., has a great article in NEJM: Getting Rid of Stupid Stuff. It describes a program her health system (Hawaii Pacific Health) undertook to do exactly that, with some promising results.

The impetus of their program was to address the issue of burnout, specifically around documentation burdens. Their EHR had been in place for 10 years, and they reasoned that some tasks might no longer be necessary or appropriate. So, starting October 2017, they asked all employees to nominate anything in their EHR that was “poorly designed, unnecessary, or just plain stupid.”

Dr. Ashton and her team reminded employees that: “Stupid is in the eye of the beholder. Everything that we might now call stupid was thought to be a good idea at some point.” Fair enough. They expected nominations to be in three categories:

• unintended documentation that could easily be eliminated;
• documentation that was needed but that could be collected more efficiently;
• documentation that needed better training to accomplish.

They ended up getting nominations in all three categories, and have already implemented a number of changes, as well as eliminating 10 of the most frequent 12 physicians alerts. The program has now been extended beyond just documentation and beyond just the EHR because, as Dr. Ashton writes: “It appears that there is stupid stuff all around us.”

It would be easy but short-sighted to take healthcare’s collective frustration out on EHRs. But let’s not kid ourselves: EHRs are not the stupidest thing we have in healthcare. EHRs may, in fact, be the smartest stupid thing healthcare has done, because at least there are significant upsides to having EHRs, even if we’re not achieving them yet. There are plenty of things we do in healthcare that are just plain stupid.

Admit it: if you work in healthcare, you see stupid stuff every day. Some are things imposed on you from external sources, and some are things required by your own organization. As Dr. Ashton cautioned, some may have been a good idea at some point. Some may never have been a good idea. Some are things that just keep getting done simply because of habit/ tradition/rules. Some are stupid things that someone, somewhere, still thinks is a good idea but, when push comes to shoving patient care, aren’t. They’re still stupid, and should be stopped.

The program at Hawaii Pacific Health as aimed primarily at reducing daily frustrations for its employees, but we need to go much further. These kinds of programs need to attack daily frustrations for all stakeholders, and especially for patients.

If you are a healthcare leader, start a program like this. If you work in a healthcare organization, advocate for one until your leadership puts one in. If you are a patient or family member of one, don’t wait for a formal program from the healthcare organizations you interact with; speak up about the stupid stuff you see and have to deal with, and make sure your thoughts get to those organizations’ leadership.

It’s stupid to accept stupid stuff, especially with something as valuable as our health at stake.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Imagining the Future Us

By Kim Bellard, October 17, 2018

One of the most thought-provoking articles I've read lately is Tom Vanderbilt's Why Futurism Has a Cultural Blindspot in Nautilus.   In it, he discusses how our technological visions of the future seem to do much better on predicting the technology of that future than they do the culture in which they will be used. 

As he says, “But when it comes to culture we tend to believe not that the future will be very different than the present day, but that it will be roughly the same. Try to imagine yourself at some future date.... Chances are, that person resembles you now.” We need to keep this in mind when thinking about the future of healthcare: not just the nifty new technologies we'll have, but who and how we expect to use them. 

All too often, especially in healthcare, we develop technology to solve incremental issues, not foundational ones.  All too often, especially in healthcare, we develop technology and then try to fit it into our existing culture, rather than imagining the culture we want and developing technologies to help achieve it.

It's not so hard to imagine how technology will change what health care is likely to look like in the not-so-distant future. But, like imagining that "office of the future" in the 1960's, what will the healthcare system in which they are used look like? 

Here are some open questions about the culture in which all these cool technologies will be used. Will we live in a culture:

• that accepts health problems becoming financial disasters for some people?
• in which poor people can expect to get less care, to be less healthy, and to live less long?
• in which where you live dictates how well and how long you live, and the quality and quantity of care you receive?
• that treats social determinants of health and public health as secondary considerations?
• that treats health as primarily a medical concern, with too many people delegating responsibility for their health to their healthcare professionals and expecting some kind of medical interventions to deal with any health problems?
• that expects "treatment at any cost for any chance," especially for terminal issues? 
• that treats services like dental, vision, or "custodial" care as step-children?
• with an ever-growing array of medical experts? 
• that treats medical expertise as primarily a local/state-level issue, rather than a   national/international  one?  

If the healthcare system of the future looks pretty much like the healthcare system of today, just with more and better tech, we will have failed.  And probably be broke. 

We need a different culture for health, and that culture needs new designs.  Marcus Engman, the former head of design for Ikea, told FastCompany:  “I want to show there’s an alternative to marketing, which is actually design.  And if you work with design and communications in the right way, that would be the best kind of marketing, without buying media.”

I read that and I think "healthcare."  Substitute "health care" for "marketing" in Mr. Engman's quote and we start to get to what Steve Downs calls Building Health into the OS -- that is, designing to make health an integral part of our daily lives.  That's design.  That's a culture change.

We have a culture of health care -- or, more accurately, of medical care -- rather than a culture of health.  Technology can exacerbate this, or help change it.  It's up to us to imagine the future in which we're most likely to be healthy.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

In China, It’s the 21st Century

by Kim Bellard, September 21, 2018

It is 2018 everywhere, but not every country is treating being in the 21st century equally. China is rushing into it, even in healthcare, while the United States is tip-toeing its way towards the future. Especially in healthcare: Let’s look at a few examples:

5G: You may just be getting used to 4G, but 5G is right around the corner, with U.S. carriers expected to start offering networks in a few cities by the end of this year. Meanwhile, China has committed to having national 5G coverage by 2020, and the government is working closely with its private sector to spur development. U.S. wireless trade association CTIA believes China is leading the 5G race. Deloitte agrees; in a recent report, they cite reasons why China is leading, and warn that countries that adopt 5G first “are expected to experience disproportionate and compounding gains in macroeconomic benefits caused by “network effect.”’

Artificial Intelligence: Yes, the U.S. has been the leader in A.I., with some of the leading universities and tech companies working on it. That may not be enough. A year ago China announced that it intended to be the world leader in A.I. by 2025. China is far outspending the U.S. on A.I. research and infrastructure, coordinating efforts between government, research institutes, universities, and private companies. Dr. Steven White, a professor at China’s Tsinghua University, “likens the country’s succeed at all costs AI program to Russia’s Sputnik moment.” We have yet to have that wake-up call.

Quantum computing: Don’t worry if you don’t understand quantum computing; no one does. What matters is that quantum computing is literally a quantum leap above what current computing, so the first to deploy it will have unimaginable advantages. Take a guess what country is leading. Paul Stimers, the founder of the U.S. Quantum Industry Coalition, told CNN: “They [China] have a quantum satellite no one else has done, a communications network no one else has done, and workforce development program to bring new Chinese quantum engineers online. You start to say, that’s worrisome.”

Genetic research: The U.S. has been the leader in genetic research, but — you guessed it — that lead has been rapidly diminishing. Earlier this year, Eric Green, the head of the National Human Genome Research Institute told Asia Times: I do know that if you look in the last 15 years, the investment in genomics, in particular, have been more substantial in countries like China, South Korea, Singapore, and even places like Brazil. For example, the U.S. is still doing research on techniques like CRISPR, but The Wall Street Journal found that China is “racing ahead” in gene editing trials, in large part due to a more relaxed attitude towards regulation and possible ethical considerations.

When it comes to healthcare, China recognizes shortcomings of its existing system, and is rapidly trying to deploy 21st century solutions to it. China adopted a universal healthcare system in 2011 (about the same time the U.S. adopted ACA.)

Last year Fortune reported on China’s healthcare “boom,” spurred in part due to direct government investments and favorable regulatory processes. Similarly, earlier this year The New York Times noted U.S. tech companies’ interest in healthcare, but pointed out that their Chinese counterparts had already jumped in.

I don’t want to live in China, nor would I want to get my health care there. Yet. But if we don’t soon have our own “Sputnik moment” (or moments), we’re going to see the 21st century of healthcare happen in China, not here.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

First, Let’s Blow Up All the Hospitals

By Kim Bellard, August 27, 2018 

A few recent stories are, I believe, reaffirming one of the big problems about healthcare: hospitals are 19th century institutions operating under 20th century business models in the 21st century. It’s time to rethink what we want a “hospital” to be.

The Boston Globe reported on Stanford’s new Lucile Packard Children’s Hospital, which cost a cool $1.3 billion and is touted as, of course, the “hospital of the future.” As they describe it, it doesn’t look like a hospital at all, but rather: “It is some hybrid of hotel, museum, and high-tech laboratory.” The Globe notes a similarly ambitious, $1.2 billion renovation at Boston Children’s, along with big hospital projects in numerous other cities.

The problem is that hospitals are big and getting bigger, going from building to buildings to campuses. They are expensive and getting more expensive. At some point, we have to ask: is this really how we want to spend our healthcare dollar?

Some hospitals are figuring other ways to spend their — I mean, “our” — money on our health. Take Nationwide Children’s Hospital. Located in a somewhat blighted neighborhood of Columbus (OH), its Healthy Neighborhoods Healthy Families (HNHF) program “treats the neighborhood as the patient,” as their summary in Pediatrics put it.

The hospital is leading a partnership that has built 58 affordable housing units, renovated 71 homes, given out 158 home improvement projects, and helped spur a 58 unit housing/office development. They’ve also hired 800 local residents and instituted a jobs training program. They’re already seeing lower murder rates, higher high school graduation rates, and are studying impacts on emergency room visits, inpatient days, and rates of specific conditions such as asthma.

“This is a national trend,” Jason Corburn, professor of city and regional planning at the University of California, Berkeley, told NPR. “It’s happening in cities across the country,” citing similar efforts in Atlanta, Boston, New York, and Seattle.

It is true that hospitals (excuse me, “health systems”) are diversifying — building/buying satellite locations, free-standing emergency rooms, urgent care centers, and physician practices — but those big buildings remain the locus, and their sunk costs weigh on hospitals’ finances.

There’s a great quote from Philip Betbeze of HealthLeaders: “the future of the hospital is not a hospital.” The future requires, as Richard Darch, CEO of Archus, more recently wrote, “radically and fundamentally rethinking the hospital, and even discarding the term ‘hospital’ to the history books.”

I’d go further: not a building, not even a campus, but as a dispersed array of services — some medical, many not — that are delivered as close to our homes as possible (and, preferably, in our homes).

It requires us blowing up our concept of a “hospital.”

Don’t donate money for hospital expansion/renovation plans. Don’t buy bonds for them either. Don’t sit passively on hospital boards that push for them or expensive new equipment.Instead, we should be questioning: how can a “hospital” most impact our communities’ health? What kinds of investments in our communities’ health can they be making? How we do push healthcare and health down as close to where and how people live as possible?

The argument will always be, well, payors won’t pay for those kinds of things. The business models don’t support them. To that I say: it’s time not just for new kinds of “hospitals,” but also new kinds of business models.

Let’s get to it.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

The Sounds of Silence

By Kim Bellard, July 25, 2018

Listen closely, healthcare organizations and professionals: those sounds you are not hearing are the voices of people not speaking up, including patients. And that’s a problem.

Let’s start with the elephant in the room: a new study found that even when physicians actually asked patients why they were there, on average they only listened to the patient’s explanation for eleven — that’s 11 — seconds before interrupting them.

Think about that, and then think back to a doctor’s visit you had about something that was worrying you: could you have explained it in eleven seconds?

Believe it or not, that’s not the worst of it. Only 36% of the time did patients even get a chance to explain why they were there. Even then, two-thirds of them were interrupted before they had finished.

Primary care doctors did better, allowing 49% of patients to explain their agenda for being there, versus only 20% for specialists. Hurray for the primary care physicians…

The researchers say there are many reasons why physicians aren’t listening better, including time constraints, burnout, and lack of communications training. But still…11 seconds? For the minority that even get the chance to talk?

As Bruce Y. Lee said in Forbes, “A doctor’s visit shouldn’t feel like a Shark Tank pitch.”

As bad as this is, it is not the only area where not feeling able to speak up is a problem in healthcare. For example, a study in BMJ Quality and Safety found that 50% to 70% of family members with a loved one in the ICU were hesitant to speak about common care situations with safety implications.

It’s not just patients who are silenced. One study found that 90% of nurses don’t speak up to a physician even when they know a patient’s safety is at risk. Another survey, of medical students in their final year of school, found that 42% had experienced harassment and 84% had experienced belittlement.

A couple of years ago ProPublicalooked at why physicians stay silent about other physicians they know commit medical errors, including ones who do so repeatedly. One physician, speaking about his hospital, told them:

There’s not a culture where people care about feedback. You figure that if you make them mad they’ll come after you in peer review and quality assurance. They’ll figure out a way to get back at you.

It’s about power: who has it, or at least who we think has it. We trust our doctors (although not as much as our nurses!). We assume that more experienced doctors have more knowledge than newer doctors, that doctors know more than nurses, and that healthcare professionals know more than we do. We’re at the bottom of the knowledge tree.

But that may not be true. Dave deBronkart — e-patient Dave — likes to cite Warner Slack’s great quote: “Patients are the most underused resource.”

But healthcare professionals must be willing to listen, and they must ensure that they ask. And we must take the initiative to speak up.

Our values are wrong if we allow reimbursement considerations to squeeze our time with physicians to the point we’re not talking and they’re not listening. Our values are wrong if we’re conditioned to think our opinions and concerns do not matter. Our values are wrong if everyone is not only empowered but also expected to speak up, especially when we see or experience something we think is a problem.

Anybody listening?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

My Care. Your Rights

by Kim Bellard, June 27, 2018

I have, it seems, been laboring under a misconception. All these years I liked to believe that the healthcare system was about the patient. That was naive. I knew that a few people in healthcare were too focused on the money part of things, but what I was not paying enough attention to was that, for some healthcare professionals, what they do is about their beliefs, not my care.

The case in point was the recent situation in Peoria, Arizona, where a young woman was denied service by her pharmacist. Nicole Arteaga was nine weeks pregnant when her doctor told her the baby’s development had ceased. The doctor gave her an option for a surgical procedure or for a prescription drug that was likely to cause her to miscarry, and she choose the latter.

The pharmacist understood what the drug did, questioned why she was taking it, and refused to refill it due to “ethical reasons” — which is permissible under Arizona law (and in several other states). As she detailed in a Facebook post:

Ms. Arteaga ultimately was able to fill her prescription at another pharmacy — across town . What if there hadn’t been another pharmacy in town, or another pharmacist who didn’t have a “moral objection” to filling her prescription? What if, for medical reasons, there hadn’t been time to investigate other options?

Example number two: the Supreme Court just overturned a California law that required “crisis pregnancy centers” to tell pregnant women about the availability of abortion services. These centers typically oppose abortion on religious grounds. Justice Kennedy concurred with the majority, claiming: “Governments must not be allowed to force persons to express a message contrary to their deepest convictions.”

Governments have, of course, for years had no qualms about requiring abortion providers provide a number of messages that are contrary to their deepest convictions — some states require that they require pregnant women to get medically unnecessary ultrasounds before obtaining an abortion! — but apparently it matters whether you agree with the message or not.

None of this should, in 21st century America, be a surprise. We now have a “Conscience and Religious Freedom Center” within HHS, aimed at protecting “health care providers who refuse to perform, accommodate, or assist with certain health care services on religious or moral grounds.”

But it is not just federal law and it is not just about abortions. In Texas, for example, pharmacists have “exclusive authority” about whether to dispense a drug. They can choose when they do not wish to, and they don’t have to explain why then they opt not to.

Where does the line get drawn? What about a healthcare professional refusing to treat gay patients? What about one refusing to treat minority patients? What about male healthcare professional refusing to treat a female patient?.

You see, it’s not supposed to be about their religious or moral beliefs. They have every right to have them, and to express them. But when someone becomes a healthcare professional, it’s not supposed to be about them or their beliefs. It is supposed to be about what is best for the patient. It is about using their medical knowledge and training to help the patient as best they can, to the utmost of their abilities.

Our healthcare professionals don’t have to be like us. They don’t even have to like us, and they certainly don’t have to agree with us. But when we can’t depend on them doing what is best for us, then we’ve got a real problem.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Too Many Poor Excuses

By Kim Bellard, May 23, 2018 I am so tired of reading yet another story about how we — Americans — cannot afford things. Not luxury item. Increasingly, it seems like too many of us can’t afford what most people would consider basics — food, housing, child care, transportation. And health care, of course. A new study by the United Way ALICE Project found that 51 million households can’t afford a basic monthly budget that includes food, housing, health care, child care, and a cell phone. That is 43% of all U.S. households. ALICE stands for Assets Limited, Income Constrained, Employed. Of the 51 million households, two-thirds are ALICE ones. These are working households that, in a prior era, might have been thought of as middle class. Now they are living paycheck to paycheck, and fearing sudden expenses — like an unexpected health care bills. Maybe they can’t afford their insulin, their inhalers, or their epipens anymore. And, of course, God forbid they end up in the emergency room or get out-of-network care. Indeed, a hospital stay may result in a permanent reduction in income, even if you have insurance, according to a study released earlier this year. We shouldn’t be surprised that the Commonwealth Fund recently found that the percentage of Americans who feel confident they can afford the health care they need continues to fall. Only 62% re very or somewhat confident, down from 69% just three years ago. Twenty-four percent reported health care has become harder to afford over the last year. Another new study found that 40% of us skipped a recommended test or treatment due to cost, and 44% skipped seeing a doctor when sick or injured due to concerns about costs. More feared the cost of a serious illness than they did the serious illness itself. That is seriously wrong. And there are no signs of anything improving. The number of uninsured is rising again. Actions by the Trump Administration to undermine the ACA exchange markets are estimated to have drastic increases on health insurance premiums — potentially jumping by 35% to 94% over the next three years. Plus, HHS has proposed rules for so-called short-term health insurance policies that the CMS Actuary says will simply increase costs for everyone else, not to mention that those “covered” under those policies will find that coverage to be skimpy if/when they need it. This all adds up. Kaiser Health News reports that, in addition to bankruptcies due to health care bills, nearly 40% of adults under 65 have had their credit scores lowered due to medical debts. A 2014 Consumer Financial Protection Bureau report found that almost 20% of credit reports had at least one medical collection account listed. The sad truth is that only 39% of Americans say they could handle an unexpected expense of even $1,000 — and 34% had had a major unexpected expense over the past year. Not surprisingly, we are doing a terrible job saving for retirement. Increasingly, we’re both saying we’ll have to rely on Social Security for our retirement income, while lamenting that we’re not very confident it will be there when we need it. These problems are not about our having enough money. We do. They are not just problems for “poor people.” They are problems for the majority of us. These are problems of priorities, and somewhere along the way our have gotten screwed up. We’re making too many poor excuses for not doing more and for not doing better. It’s time to stop.   This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

No Signatures Required!

By Kim Bellard, April 18, 2018 If you live in the U.S., you've probably had the experience of paying for a meal using a credit card.  The server takes your card, disappears to somewhere in the back, does something with it that you can't see, and returns with your card, along with two paper receipts, one of which you need to sign. As of last week, the major credit card companies are no longer requiring that signature.  As a Mastercard person told CNET, "It is the right time to eliminate an antiquated practice."   No kidding.  Healthcare should be eliminating its antiquated practices too. Ending the requirement was announced last year, went away last week, but its actual demise will happen more slowly, as individual merchants can still require it.  Of course, the signature is only part of the antiquated process.  They're probably not looking up your card number on a monthly list of stolen cards any longer, nor using a manual imprinter to charge your card, but both using the physical card and taking it from you are steps that there are 21st century alternatives to.  Still, I'd be willing to bet that the credit card companies and merchants bring their processes fully into the 21st century before healthcare does. Let's go through some of these: ·         Healthcare still relies heavily on faxes. Supposedly it is because of security, "HIPAA," etc., but this reliance is a lot like requiring signatures for credit cards.  ·         In an era of ubiquitous smartphones, healthcare is still making heavy use of pagers, especially within hospitals.  ·         I can use an AMT pretty much anywhere in the world, and can not only access my bank account to obtain balance or transfer funds, but even to get cash on the spot.  In healthcare, I can't even go to a new doctor or healthcare facility without having to start from ground zero in terms of information about me (unless they are part of a health system I've already used).   ·         Patient portals have proliferated, with more options to do tasks online, but how many times do you visit a health care professional without having to fill out or sign yet another form?  ·         We can make online reservations for, say, restaurants, airlines, or hotels.  When it comes to making healthcare appointments, though, we're almost always forced to go through a tedious phone tree and end up negotiating with a human scheduler.   In 2018? ·         Manufacturers have overwhelmingly turned to just-in-time processes.  Meanwhile, in healthcare, an appointment time is usually at best an approximation; we expect to be seen late.  If you are in a facility expecting a test or procedure, it's even worse.  These aren't even 1960's levels of precision. ·         Telemedicine is widely available, but usually it won't be with your doctor and the doctor you end up getting won't have your medical history.  Shouldn't virtual visits usually be the first step?   ·         With healthcare there, no institution has access to even most of our medical history, which remains highly scattered, siloed, and sometimes even still paper-based.  How 1980's!   ·         We continue to urge people to get annual preventive exams, even though the value of them for most adults is highly dubious.  We still make people get unpleasant procedures like digital rectal exams, or tests of questionable value like PSAs or even mammograms.   In many ways, we do have "space age" healthcare, but that space age is too often more like 1960's NASA than 21st century SpaceX.  We can do better.  Much of healthcare has one foot firmly planted in the 21st century, and its vision looking forward.  But too much of it still has the other foot dragging in the 20th century. It is past time to not only identify but also to act upon antiquated practices in healthcare.   This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

It's About Time

By Kim Bellard, February 16, 2018 Chances are, the sun isn't directly overhead for you when it is for me.  That's why for most of human existence time was a local matter. Nowadays, we have time zones that span the globe, and we have clocks so accurate that satellites have to take into account relativistic time-dilation effects. Technology made the change possible, and necessary.  Health care should learn from this. It used to be that local time was good enough.  The village clock served your purposes.  It was the railroads that made this impractical.  People wanted to know when trains would arrive, and when they'd leave.  More importantly, if they weren't coordinated, trains traveling in different directions might -- and did -- run into each other. We treat health care much like we used to treat time. That is, it is largely local.  How it is practiced in one community may not be how it is practiced in the next community, or even the next hospital or physician practice within a community. .  The care you get will depend on, of course, what is wrong with you, but also on which physician you see.  Very few dispute that there is significant variation in care, or that it is probably bigger than it should be.  But there's not much evidence that it is getting any less.  We accept these variations because, well, that's how it has always been.  We accept them because we think our personal situation is unique.  We accept them because we trust our local experts.    We accept them for all the same reasons we used to accept that time should be local. Technology has made it both necessary and possible that we move away from this attitude. It is necessary because the scope of the problem is clear.  As Propublica put it in a recent expose of unnecessary procedures: "Wasted spending isn’t hard to find once researchers — and reporters — look for it."  Almost twenty years ago the Institute of Medicine estimated as many as 98,000 hospital deaths annually due to medical errors.   More recently, medical errors have been estimated to be the third leading cause of death in the U.S.  Yes, moving away from "local" health care is necessary. The good news is that it is possible.  We have the technology to consult with physicians who don't happen to be local, such as through telemedicine.  It is possible to get the "best" doctor for our needs, not just the closest. We have artificial intelligence that can analyze all that data plus all those medical studies that no human can possibly keep up with.  It is possible to come up with the "right" recommendations for us.    We have to stop thinking of health care as local.  The information it is based on is not.  The people who are best able to apply that information to our situation may not be. If I get a driver's license, I don't have to get another one when I drive to another state.  If I get on a plane, the pilot doesn't have to have a pilot's license from each state he/she lands in, or flies over.  But if I want to use a doctor who is in a different state (or country), that doctor needs a license from my state.     We've always justified such licensing by states wanting to ensure the safety of their citizens, but drivers and pilots can put those citizens at risk too.  It's not really about risk; it's more about controlling competition.  There is irrefutable evidence that local health care is rarely what is going to be best.  It might not be bad care, but most likely it's only going to be average.  Maybe we're willing to settle for that.  I'm not. Time for a change. This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Everything in Healthcare Is Design

By Kim Bellard, January 27, 2018

I've been thinking a lot about health and communities lately. But I keep coming back to Dr. Bon Ku is doing at JeffDESIGN.

I am somewhat late to this game.  Dr. Ku co-founded JeffDESIGN three years ago, as a "college within a college".  Since then it has received local, regional, and national attention.  Dr. Ku has done a TEDx talk on their efforts.  So I'm not exactly breaking new ground here.

More importantly, though, they are.

Basically, the goal of JeffDESIGN is to teach medical students "to apply design thinking to solve healthcare challenges." As obvious as that might seem, they believe it is the first such program in a medical school.

Their Health Design Lab is located in a former bank vault.  It looks more like a start-up than a medical school classroom, full of configurable tables, computers, whiteboards, even 3D printers. 

Students get to take on actual problems in the healthcare system, develop solutions, prototype them, and perhaps see them put into use.  Dr. Pugliese told NextCity:  "These kids are all going to graduate as physicians, and they’re going to have a whole new language that nobody who’s ever graduated from a med school has had before."

That's pretty cool.

Dr. Ku is by training an ER physician, and his experiences there shaped his views of the broader forces impacting health.  And, remember, this program -- and, presumably, this point-of-view -- is unique among medical schools.  It shouldn't be.

We simply don't think enough about design in healthcare.  Not the right designs, for the right reasons.  In a a podcast for Knowledge@Wharton, Dr. Ku complained that:

We settle for design mediocrity, like I said. When we design hospitals, we should want to design the best and most beautiful building which happens to be a hospital, but instead, we design mediocre buildings.

He went so far as to say: "most of us don't realize that everything in health care is design."

Think about that:  Everything. In. Health.  Care. Is. Design.

The problem that JeffDESIGN has, through no fault of its own, is that even if all physicians were similarly trained, physicians can't change everything that needs to be redesigned (or, as some would say, actually designed) -- not in healthcare and certainly not in our society. The problems go much deeper.

Too many designers are designing only within their bubble, and no matter how well designed that bubble is, all-too-often they don't think enough about how their bubble overlaps with the others.  Our health is impacted by everything we touch and interact with, and many of those interactions are not designed with our health in mind.  

Design thinking in healthcare isn't about making the process of getting medical care easier, although it should do that too.  Design thinking in healthcare should be about making the process of being healthy easier.  That's a much taller order of magnitude, and that's what Steve Downs meant by wanting to build health into the "operating system" of our daily lives.  

Dr. Ku would agree: you don't have to be trained as a designer to use design thinking.  Dr. Ku boils it down: "I think at the core of human-centered design or design thinking is deep empathy for the end user.”

Certainly anyone working in or around healthcare should have that.

Patients aren't the end users.  People are.  Care is not the end result.  Health is.  Let's design for them and for that.  If you don't have that kind of empathy, maybe you should be doing something else.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting