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Human beings are more or less worried about the use other people could make of their data. From Mr. Trump to the little guy on the corner, everybody is aware that their data, their activity, is being recorded and exploited by somebody somewhere: people with good intentions and people with not so good intentions.

To be honest, the fact that Amazon records my purchases so that it can send me what their algorithm decides I like is not a concern for me. Little does the algorithm know that I buy mostly for my wife, so I get inundated with the things my wife probably wants.

But what about health related issues? The EU has issued, and most countries have adopted, a very sensitive legislation about how to treat health data. The problem arises when, thanks to IoT, a myriad of data is recorded that is not strictly health data. Data that is not sensitive in  isolation; for instance how much I walk, how much time I spend in front of the  TV, if I go or  to the bathroom or not, or if I wet my bed. All of those examples are indicators of my health status. All those indicators are gathered and recorded by unobtrusive sensors imbedded in my wrist-band, in my sofa, in the door to the bathroom, or in my mattress. All of them form part of the IoT. Are those sensors hacker-proof? Stand-alone information from any of those sensors is meaningless, but the combined information of all of them makes sense.

Now I can start worrying about what Amazon and others are gathering from my activity. If somebody puts that information together and adds the information from the many possible sensors I may end up having at home, that organization is going to know more about me than I care for them to know.

Summing up, we should be aware that there is no such thing as an innocent sensor. Before adopting the newest gadget, we should be aware that we may be broadcasting our information to the world. The choice to do so is ours (as a matter of fact the smartphone, adopted gladly by almost everybody, is the biggest – so far – recorder/transmitter of our information) but we should be aware of it and make an informed decision so as not to be sorry later.

And it looks like we are losing the battle. According to “Healthcare expenditure statistics” from Eurostat, “[The] highest share [of total healthcare expenditure] of current healthcare expenditure [related to preventive care] in 2014 was recorded in Italy and the United Kingdom (both 4.1 %), while at the other end of the range, shares of less than 1.0 % were recorded in Romania (0.8 %) and Cyprus (0.6 %).” At the other end “curative care and rehabilitative care services incurred more than 50.0 % of current healthcare expenditure in the vast majority of EU Member States”

It may be that this is the right balance, but allow me to doubt it. And my doubts grow as I focus on the demographic change taking place in Europe. The baby-boomers are getting older and we are not doing anything about it, despite the fact that it is probably a generation ready to embrace a healthier and more active life than previous older generations.

I have been wondering, since I started working for the healthcare and social sectors, why it is that prevention does not get the attention of our policy makers.

Many explanations come to mind. Of course, simply saying “they are stupid” is the easy one but I refuse to fall for it. I strongly feel that anybody who has attained a position of responsibility may have many faults, but being stupid cannot be one of them; they would never have reached that position of responsibility.

The urgency of solving the immediate problem may be one of the reasons; after all, if somebody has an acute illness something urgent has to be done. It is a plausible explanation but, if that were the case, policy makers would never plan for the future building new roads or housing developments since they would be too busy repairing the existing road network or the old houses in inner cities.

I am afraid that highways are built because they make the news. I am afraid that most of the things that our policy makers do are geared towards a 30 second appearance in prime time national TV news. If that assumption is right, then it is clear that the opening of a new hospital (curative and rehabilitative care) is a better news item than the establishment of a prevention scheme that does not require any new buildings, or any new expensive and photogenic equipment. It requires only brains and hands, probably the least photogenic tools of the healthcare process and, probably too, the most ignored by policy makers.

AGEING SOCIETIES

I was invited by The Economist to attend their conference on Ageing Societies, held in London (UK) during the 29th and 30th of November. I will not pretend to summarize one and a half days in this short post. I will try, nevertheless, to bring out those three interventions and a message that, to me, were more relevant.

Let´s start with the message. I have been involved with ageing for a long time. My first public intervention was at the London School of Economics in March 2011 although, previously, I attended the AAL Forum at Odense in 2010. Since then I have focused the problem on “older people”. No wonder, since I have worked with several hospitals dedicated to the rehabilitation of older people since 2006. Ten years make a mark on a person. So, the first realization was that at the conference we were not talking about “older people”; we were talking about “Ageing Societies”, which is completely different. The world population is ageing; from Asia to Europe and America and even in Africa. Societies are ageing. The socio-economic infrastructure was designed to care for a nice population pyramid, not for a population cylinder or, even worst, an inverted pyramid. Accordingly, we have to redesign the socio-economic infrastructure in general and the care infrastructure in particular so as to be able to handle an Ageing Society.

John Beard´s presentation (from the WHO) was a masterpiece introducing the importance of health care for the future of our societies. His presentation, based on the “Report on Ageing and Health”, highlighted two important aspects that we tend to forget. One is that older people are diverse. Probably because we are used to giving certain benefits linked to age, for example free entrance to museums or cheaper public transportation for over 65s, we put everybody over 65 into the same category. Of course this is not real and older people have very different functional capabilities. This was the second aspect. The category used to guide our efforts in dealing with an ageing society should be functional capability. The above mentioned report states that “burdens of disability and death arise from age related losses in hearing, seeing and moving, and non-communicable diseases”. So, it is my interpretation that we should move from focusing on age to focusing on those disabilities that hinder our functional capabilities. And it should be noticed that those kinds of disabilities do not come only with old age. They pop up at any time; how many young people need glasses?

It was mentioned by someone during the Focus on Asia interview that “the problem in an ageing society lies with the young people in their 30s”. Natalia Kanem (from the UN Population Fund) expanded on the same idea, and more. She introduced us, through the “The State of World Population 2016”, to the fact that “investing in 10-year-old girls could yield huge demographic dividends”. It all boils down to the same idea: prevention is the key to a successful design of our ageing societies. It is my belief that, unless we invest in our youth now, our societies are not going to be able to cope with the on-going demographic change.

And finally, the last intervention that I would like to bring to you was about breaking silos. When talking about ageing and its related problems, there is a part of society which focusses almost exclusively on social and health factors. There are also other professionals that focus exclusively on economic and financial factors. To my knowledge, very little has been done to bring those two worlds together. And a token sample of that lack is the composition of the speakers in the panel: both of them were from the financial sector with no representative of the other silo: the care sector. Nevertheless, the point was made: silos have to come down and the financial aspects of an ageing society have to be intertwined with the care aspects. So far their courses have run parallel. Now they should start running together.

I could summarize that tackling the problems of our ageing societies needs an intervention in our youth of today, fostering the development of their own functional capabilities in a holistic way, combining the socio-health-financial aspects of every human being.

And this is my summary of one and half days of a very intensive and interesting event.

In 1969, the supersonic aircraft Concorde was the first commercial airliner to replace the traditional and burdensome mechanical and hydro-mechanical flight control systems with the more sophisticated and secure fly-by-wire system. In essence, in a fly-by-wire aircraft the pilot moves the joystick sending messages to a central computer that, once the order has been processed and checked against the rest of the information received from sensors installed along the aircraft, sends an order to the appropriate part of the aircraft, e.g. the engine or the wings.

When fly-by-wire was first introduced, pilots complained that they were not “sensing” the aircraft; they were losing the feeling of how the aircraft was responding. Nowadays more sophisticated algorithms have introduced a feed-back to the pilots, enabling them to “feel the aircraft” like in the old days.

Socio-health care is in the process of going through the same kind of revolution with the same kind of professionals’ complaints. e-Care is introducing a new paradigm into the care process. Many practitioners feel that through long-distance technology, telemedicine for instance, they are losing touch with their patients. Is that true?

Obviously I don’t think so. Haven’t we been using telephone calls as a substitute for face to face meetings since early in the last century? Is not a telephone call effective for solving a myriad of problems that, in the nineteenth century could have resulted even in a war due to the slowness of the response? Think about it: the tools that e-Care puts in our hands are here to solve in minutes what in the old care process would have taken, and still takes, days. Those days are precious when at the other end of the line there is a suffering human being.

e-Care, health or social, is here to help the patient. This is something we should never forget. It is also a tool to help the practitioner to work in a more efficient way. It means the practitioner has to adapt to a new care process, forgetting the old ways in which the patient waited patiently in the waiting room to be seen by the all mighty care professional. That same professional who would explain, in the best of cases in an incomprehensible manner, what was going on.

Today, the patient will demand a clear explanation. A demand full of questions fed by the knowledge, good or bad, acquired on the web. Today the patient will not be patiently waiting, but will be impatiently expecting your to-the-point answers at the other end of the ICT system.

But also today, as a professional you have at your fingertips, or better at your “mouse tips”, more information than you ever dreamed of having. And the combination of general information, together with the much better and accurate information about your patient, puts you on a professional level that your predecessors in the field were never able to achieve.

Do not miss the opportunity, go e-Care! The sooner the better for your patients, and also for you.

Why is it so difficult to convince older people to adopt gadgets and new behavioural patterns that are meant to make their lives healthier and richer? A person who has not ever read will find it difficult to enjoy reading when turning 65. Behaviour is one of the most difficult things to change; ask any smoker or drinker. And it gets more difficult as we age. Habits form our core identity. As we age we tend to rely more and more on our way of doing things and tend to confront any change with the utmost suspicion.

This behavioural inertia is also ingrained in society. Almost every socio-health care system is based on a pattern of attending social and health problems. Care systems are traditionally designed to repair our ailments. If you have a problem we will take care of you. Don´t bother us if you just feel that probably you will have a problem in the near future; we don’t have time for it!

The combination of both behavioural patterns, personal and social, results in a rejection to adopting anything that means to change our old ways. Change then comes forcefully, meaning we have to change because there is no other way. Any change is, then, a public proclamation of some kind of unavoidable evolution in our system. If I am using a walking stick, it means that I am now frail. I am telling everybody that now I am frail, everybody assumes I am going downhill. Outcome: I will not use that dammed walking stick even if I fall!

If walking sticks became fashionable, as they were in the last century, my ailments would be stealthy; I would be using the walking stick just like everybody else, only I really need it.

If care systems insist on putting all their efforts into solving problems – tackling mainly acute problems-, there is no chance that we can incorporate new habits into the population. I know that for years there has been talk about the need to introduce prevention into our care systems. I know also that very little has been done. If you are in doubt, compare the amount that any system is investing in obesity induced illnesses and the amount spent on preventing obesity. I recognize also that the opening of a new acute hospital makes headlines with a nice picture of the Minister of Health, while a program for changing eating habits in children in an out of the way school does not make even a tiny article on page 45 of the local newspaper. Nevertheless, we all know that prevention is the only way to face a brighter future.

Prevention means that, as soon as possible in the person’s life, the system will help to change habits in order to avoid future complications. With that in mind, we will be able to introduce say, healthy eating apps that will be assimilated into our everyday life. The person will rely on the app when feeling at loss for ideas for tomorrow’s lunch. The odd search will become a habit, and the app will start recording what food is chosen, and letting the person know when he/she is eating more meat than necessary.

Compare this process with today’s. Today, I would go to the doctor when I felt sick, he will spot that I am eating a very unhealthy diet and recommend a complete overhaul of my eating habits. He may recommend an app to help me keep track of what I eat. I will struggle to follow the diet and will not use the app. My mind is telling me that I have been eating a lot of meat ever since I was young and I have enjoyed every minute of it. I will keep it that way till the grave, even if it means the grave closes nearer.

I think that the only way to success is to be able to induce a behavioural change in our target population. We know that behavioural changes are easier the younger the person is. We should then aim at incorporating as soon as possible into daily life those elements that will contribute in the future to a longer and healthier life. Get your walking stick today; do not wait for when you really need it. Or in a more up-to-date fashion, start getting acquainted with apps and other ICT gadgets today, before you really need them and feel old and battered.

From the developer/entrepreneur point of view, your customers are the social-health care systems; convince them that only by prevention will they have spare resources to attend the ageing society; change their behavioural pattern from solving acute problems to preventing problems. I know it is a long and burdensome process but it is the only way that your products will make it to the market, to those who need them.

If you come across anybody who has not heard of Internet of Things (IoT) be careful, the person surely comes from another planet. IoT is at the centre of any ICT research. Everybody is developing devices, claiming that these will interconnect to anything you already have or will have.

And yet, at home we still have several remote controls for our smart TV, for recording devices, and for the all present black box that allows us to enjoy hours of the most degrading TV shows. Of course, the sound system runs under another completely different set of remote controls: for the CD player, the tuner, not to mention the necessary turntable that we have brought to life again after having been convinced that the sound is a lot more natural on an analogic record than in a digitalized CD.

IoT’s promise is that all our gadgets will be interconnected inside our homes and even with the exterior. A different problem is whether I really want my fridge to send messages to my grocery store to replace that uneatable marmalade that my daughter in law gave me and that I have been struggling to finish for the past two months.

Although the promise is great, reality strikes back. As of today, only 6% of American households have a smart-home device, and 72% of Britons have no plans to adopt smart-home technology in the near future (The Economist 11.06.2016). Of course it does not help that some of the smart gadgets like the Samsung´s smart fridge goes for almost $ 6,000.

IoT marketing is probably missing the point, as has been the case in many new ICT developments. Putting the focus on the ICT novelty will not attract people. Unless the smart-home gadget solves a real problem, it is difficult to convince people to adapt it. Technology is available today for doing almost anything that anybody can think of. The problem is the generational divide. Young people full of energy devise new things that are meant for older people maybe two or even three generations apart. Have they asked those people what they really need? Have they participated in every phase of the development?

Just as a marker, go to the pictures of any of the ICT gatherings in the world and try to spot anybody older than 65. Even those gatherings especially dedicated to ageing, like the yearly AAL Forum which I have attended many years, are packed with young people full of ideas that will be tested on older people just because the rules say so, not really because they feel like it.

And then we come to the pure ICT problem of interconnectivity. It is essential to develop a common standard to allow seamless connectivity among gadgets from different makers. From what I know, that is being done more or less for industrial IoT, but something similar for the domestic domain is lacking.

In all, my bet is that IoT as something integrated in everyday life is a long way off. Only a concerted effort to develop an overall global standardisation, coupled with real intergeneration symbiosis, will bring forward the realization of the home IoT.

If the number of projects focusing on eHealth is any indication, the market must be huge. The recently published brochure “Research and Innovation in the field of ICT for Health and Wellbeing: an overview” lists 97 on-going or recently finished projects funded by the European Commission. By this measure eHealth apps should now be treated as an uncountable.

It has been said too many times that the ageing of the population will put an unmanageable strain on the social and healthcare sectors. It is (almost) public knowledge that only home-care delivery can somehow tackle the coming situation. If you still have any doubts, a recent article in The Economist can, in a nutshell, reassure you about the existence of a growing demand.

In order to respond to the challenge posed by the growing demand, we need to change the way care is delivered. Regarding social care, maybe only some small adjustments will be needed but, for healthcare, a drastic reengineering of the process is necessary.

Assessing the market by simply counting the number of prospective clients is not a valuable marketing approach. We already know that the number of older people living alone at home will increase. The problem is not the number of prospective clients. The problem is twofold: a) how can we reach that population? and b) what business model will bring eHealth into public domain?

The business model has to be ingrained within the care process. Unless distance care can deliver standards similar to face to face care, eHealth will remain the poor relative to traditional healthcare. To attain those standards the redesigning of the care process has to accommodate: a) the idiosyncrasies of the care professionals; b) the legal implications of distance care; and last but not least c) the trust of the care recipient.

Once the care process has been reengineered, then we could focus on designing the business model. For that, the main issue is who pays for what. Because today, most systems link care acts and payment, while home delivery is meant to reduce care acts, switching the burden from the care giver to the care receiver. Again, the alternative funding mode, per-capita payment, is directed to a single organization, while eHealth will switch the burden from healthcare to social-care. So the eHealth business model has to take into account that the healthcare giver is more successful when a) the care receiver does more towards his or her wellbeing, and b) social-care organizations are more active. Summing up, designing a business model that rewards the success of the organization by measuring how it activates other entities (care-recipient and/or social-care) is not easy.

If we successfully solve the business model conundrum, reaching out to our primary customers (care recipients) should be a piece of cake. Anybody will be willing to use a system that reduces the burdensome features of face to face care, e.g. time consumed in transportation and waiting to be seen. Anybody, – and the number of bodies is only increasing -, will grasp the advantages of permanent monitoring, easy access to advice and other advantages that eHealth can deliver. The point is, is eHealth ready to deliver?

Going through a check list of the situation today against the bare needs listed above, the answer is an unqualified NO.