Archive for the ‘eHealth (English)’ Category

As the demographic pyramid evolves towards a demographic cylinder, we look to ICT as the solution. Even with the push that COVID-19 has meant for the use of ICT, I still doubt that ICT alone is the solution.

If we take ordering goods or services over internet for private use[i] as a proxy of the confidence of users in ICT, we can appreciate that even if between 2015 and 2020 there was an increase of ten points, from 62% to 72%, of internet users in EU27, there are still countries like Italy or Romania and Bulgaria with less than 50% of the population using internet for shopping.

Internet access follows a clear north-south divide[ii]: the population in northern countries who have never used internet is below 10%, while in southern countries, like Portugal or Romania, that percentage is above 20%, or even 30% in countries like Italy or Bulgaria.

Focusing on our target population: old people and informal carers, made up of mostly old carers and immigrants, only 32% of individuals over 64 have shopped online[iii]. Unfortunately, the same divide north-south happens with old people: while in places like Portugal, Greece and Romania less that 10% of old people have shopped online in the past 12 months, in countries like Belgium, Germany or Norway the percentage is above 40 or even 50%.

Going back to the question, is ICT the solution for caring for old people? The answer is a definitive no. Even in countries with a high percentage of old people with ICT literacy, we must assume that the normal evolution of ageing will make most of those people reliant on informal carers who not necessarily have the same ICT skills.

ICT is here to stay and with time will take a bigger and bigger role in the care sector but, as of today and in the near future, we will have to rely on informal carers. People mostly coming from eastern and southern countries in Europe with a lot of heart and passion for their job but little or no ICT skills. The challenge is to develop ICT solutions for these people. These solutions should be similar to WhatsApp, which is so successful because it is easy to use, and the rewards – communication with family and friends – are instant.

[i] Source Eurostat (online data code isoc_ec_ibuy)

[ii] Source Eurostat (online data code isoc_r_cux_i)

[iii] Source Eurostat (online data code isoc _ec_ib20)

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“Supportive policies such as respite care or training and counselling may […] be needed in order to sustain informal care as an important resource of our health care systems.” The quote comes from Ellen Verbakel et al in their paper on informal care in Europe[i]. But is it just “respite care or training and counselling” what is needed? The paper indicates that, on average, one in every three people in Europe are informal care givers. What is more, one in every six of those care givers is 65 or older. In a back of the envelope calculation, 22 million Europeans are informal care givers and over 65. I do not think that respite, training and counselling is enough.

In Europe, when reaching 65, most of the population looks forward to a nice peaceful retirement but instead, 22 million face a continuation of their dedication to somebody else with bad heath or ageing deterioration. This happens at a time when the carer is going through ageing himself. We need to manage the situation from a holistic point of view. The interrelation between carer and cared takes place in a particular environment: the home. Even if some aspects are outside of the participants’ control, such as the neighborhood, some others are within their reach. I am referring mostly to those aspects of the household that can make life easier and safer for both carer and cared. Aspects that are not only geared towards the comfort of the cared, but also to the comfort of the carer.

Ergonomics was born in the workplace. Its aim is to design the workplace taking into consideration the characteristics and limitations of the worker. The result is that, by reducing risk factors, the worker improves his performance. The workplace of the carer is the home. By introducing ergonomic design into the home, we can create a safer place for both carer and cared and a more efficient care process. And last, but by no means least, a more enjoyable life for the carer.

[i] Ellen Verbakel, Stian Tamlagsrønning, Lizzy Winstone, Erlend L. Fjær, Terje A. Eikemo, Informal care in Europe: findings from the European Social Survey (2014) special module on the social determinants of health, European Journal of Public Health, Volume 27, Issue suppl_1, February 2017, Pages 90–95, https://doi.org/10.1093/eurpub/ckw229

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The idea comes from a podcast by The Economist, “The New Old”, in which Andrew Scott from the London Business School discusses the importance of acting rather than reacting.

The point is that there are millions of ideas developed for old people. Few have moved from the drawing board into everyday life. This lack of adoption of new ideas seems to stem from the fact that it is too late for old people to adapt to new inventions and/or methods. And also, it is too late once morbidity has already developed.

As the title clearly expresses, what we should aim for is helping people to develop healthy habits that will make ageing a lot more bearable and enjoyable.

Prevention has traditionally been the black sheep of the socio-health sector. There is a lot of talk about it and very little action. Dare to type “self-help” in Google or in Amazon, and the number of entries is in the range of the thousands. But still, there is no action from the public socio-health system.

It is usually the case in organizations that they tend to put out fires, while forgetting the most vital step:  preventing the fire. Acknowledging that fact, it is no consolation to see that the socio-health sector acts in the same manner: attending those already sick and forgetting about preventing sickness.

So the trend continues, and what the formal public sector does not provide, falls into the hands of the private sector: filling the gap started years ago with the self-help books, and which today has moved from books to apps and ICT tools of all kinds.

Of course, I am not against the private sector coming to the rescue; on the contrary. What I would very much like is for the public socio-health sector to integrate into their system those apps and other prevention tools that would, in the long run, ameliorate pressure on the socio-health system. In short: to integrate the concept of helping people to age better.

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In a previous post, “Tele-rehabilitation to the rescue!”, I stressed the point that rehabilitation should be put at the front of the healthcare process. Rehabilitation is also an aspect that can be easily “translated” into ICT applications. Taking advantage of this aspect should be a prime consideration for managers in the healthcare sector.

Facilitating the access of rehabilitation apps to patients will reduce the burden on rehabilitation professionals and, equally important, will also reduce the expense in medication. Both items, health professionals and medication, are at the top of the healthcare budget. The point is that rehabilitation apps should be incorporated into the prescription alternatives open to the rehabilitation professional, and its cost should be assumed by the healthcare provider, just as medicines are.

In PhysUp, a company I founded a couple of years ago, we believe in rehabilitation. We design our products to fit the customer, centring on making them simple and user friendly. The aim is to integrate into the digital domain those people who, whether due to  age or  other factors, are not yet an integral part of the active digital population.

As an example of what we have done, I am presenting an app for stroke rehabilitation. We have developed it in English, “Gaming for stroke rehabilitation”, and in Spanish, “Rehabilitación para ictus ACV”. Both can be downloaded from Google Play.

I hope you find them useful as a tool for those patients recovering from a stroke, and that this will aid them in regaining their psychomotor abilities.https://play.google.com/store/apps/details?id=com.physup.stroke

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Rehabilitation is mostly understood as a side order of a full-blown treatment of an illness. Should it be so? The first casualty of that point of view is rehabilitation itself. Rehabilitation is “a set of interventions needed when a person is experiencing limitations in everyday physical, mental, and social functioning due to ageing or a health condition, including chronic diseases or disorders, injuries, or trauma”[i] The definition does not imply that rehabilitation should be linked to the treatment of an illness. My point is that rehabilitation should be linked to maintaining one’s physical or mental health: a prevention tool more than a cure.

If we take that approach, rehabilitation would become part of primary care as against being a by-product of specialist care. Primary care is the point to which a person will turn when feeling something is wrong with his/her health. That does not mean necessarily that the person is ill; that the person is a “patient”. I resent very much that word. The label “patient” is diminishing any way you look at it. Does it mean you must be tolerant with the health professional who is treating you? Or is it that you must endure your suffering? The use of the word “patient” limits also the scope that rehabilitation should have since it links rehabilitation to illness.

Rehabilitation should take a bigger role in humans’ wellbeing. A recent paper[ii] points out that almost one in three people on the planet needs some kind of rehabilitation. If we narrow the focus, 1.71 billion people have musculoskeletal conditions that could benefit from rehabilitation. Narrowing even more, around 30% of the population in the European Region has musculoskeletal problems.

With an ageing society, that percentage is only going to increase and the health system, or primary care for that matter, is not and will not be able to cope with the problem. A different approach must be taken to devise a system that relies more on prevention and less on after- the fact- cure. The situation represents a unique opportunity for developing easy to use ICT tools that help primary care professionals address the growing demand for preventive and curative rehabilitation therapies.

[i] Cieza A. Rehabilitation the health strategy of the 21st century, really? Arch Phys Med Rehabil 2019; 100: 2212–14. Cited by Cieza A. et al Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. thelancet.com on December 4, 2020

[ii] Cieza A. et al Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. thelancet.com on December 4, 2020. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2932340-0 Accessed 08.12.20

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During the pandemic we have taken for granted that all of us are digital natives. Nothing could be further from the truth. Only Millennials (1981-1993) and those younger can be considered digital natives; the rest of us need some kind of introduction or training to the digital world.

Now, bring this to the healthcare world. In the EU27, “One third of workers in health and social care are at least 50 years old,” according to Employment in Health and Long-Term Care Sector in European Countries (NEUJOBS Working Documents 2013).

And what about the population at large? “In 2019, more than one fifth (20.3 %) of the EU-27 population was aged 65 and over,” according to Population structure and ageing (Eurostat).

And yet, we assumed that it was easy to emigrate from an analogic care system to a digital one. No wonder most of us are still running around like chickens without a head trying to make sense of it all.

I have heard a lot of praising of the possibilities that the digital world could bring to our everyday lives. Massive investments in ICT; new apps that will change the way we manage our illnesses; gains in efficiency in the care system, etc. Unfortunately, I have not heard of how those 50-year olds and older healthcare practitioners, and those millions of 65s and older are going to be trained to understand and use those wonderful ICT gadgets.

I hope we are not sleepwalking towards a rude awakening in which those massive investments have been dumped in the garbage, because very few people understand their usefulness and even fewer people are prepared to use them.

Maybe there is still time to pause and think: think about the people who have to use the applications. Or maybe, is it simply to think about people?

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Due to the current situation, Primary Care has been brought to the limits of its endurance. This cannot come as a surprise. Most systems are tailored to the current needs that the system has to attend to, not to emergency situations. The job of Primary Care is to attend the day-to-day business of the population, acting as the front door to the health system, and to monitor the evolution of chronic patients.

Covid-19 has added a new dimension to this job description: doing the triage of the population in view of identifying those infected with the virus. It would not be a big problem if that were a normal procedure: anamnesis, decision, and derivation to the appropriate health resource or, as is the case of the flu, a recurrent winter event that can be pre-programmed. But this is not the case. To start with, SARs-CoV-2 is a very infectious virus that occurs throughout the entire year. The fact that it is highly infectious has changed the way the healthcare professional has to confront his/her prospective patient. The professional has to be equipped with Personal Protective Equipment (PPE), the premises have to be disinfected regularly, incoming people have to be pre-checked to avoid unnecessary contagion of personnel and contamination of the premises. All of these procedures necessarily slow the flow of patients precisely when the flow increases due to the pandemic. The result is a bottleneck in the system, and in an attempt to solve it, monitoring of chronic patients is sent to the back of the Primary Care priorities. The system assumes that a chronic patient will not evolve so quickly as to need urgent intervention: just take your medication and hope for the best.

But there is a solution. There are plenty of simple ICT applications to monitor vital signs and other signs like glucose. Unfortunately, we must admit that the biggest barrier to its introduction has come from healthcare professionals. While it is assumed that if the patient needs a medication, the healthcare professional will administer/prescribe it, it is still exceedingly rare that the same professional will prescribe an app. There is no explanation for this dichotomy. How can you explain that a professional will not recommend/prescribe something that is good for the patient and for himself/herself? It saves work for the professional and empowers the patient, allowing the latter more control of the management of his/her condition. There is for sure a long way to go, but the first step in the journey is to convince health professionals of the usefulness of ICT apps, probably using the same procedure that pharmaceutical companies use to introduce their products.

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The current Covid-19 pandemic has made possible the explosion of telemedicine. Those more reticent to its use, healthcare professionals, have discovered that it is an efficient working tool.

At the same time, individuals have discovered that they have to take their health in their own hands. There has been a lot of talk in recent years about empowering the patient/individual. But only when the pandemic has hit us have we discovered that there are a lot of health apps that can help us to keep fit or control our ailments. The Quarterly Digital Health Trends Report has some amazing figures. Comparing pre-covid and post-covid Google searches, terms like healthy-eating or healthy-living have increased by 385% or 850% respectively.

It is easy to see how those two trends are related. Professionals feel that they have to be more efficient in the way they provide their services; teleconferencing is a very efficient way to deal with some consultations that do not require an in-presence meeting of patient and medic. At the same time, we individuals have come to the conclusion that we should not take advantage of the medical services by drowning them  with requests that could be solved if only we were aware of the implications of our behavior: basically eating, drinking and exercising.

Eating, drinking, and exercising, probably together with complying with medication medical orders, are the realm of apps. There has been a 22% year on year increase of downloads in health and fitness apps (The State of Health & Fitness Apps, SensorTower, 2020). The more we use these kinds of apps, the less the pressure on medics. I know there is a long way to go till health and social services realize that prescribing apps saves money to the system. We will have to go through a long period in which we will have to pay for those apps that will help us to keep fit and healthy. But what is sure is that the money will be well spent.

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“… two-thirds of people aged 16 and over report to be in good health in 2016” (OECD/EU (2018), Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris.) Which means that one-third of Europeans think their health is less than optimal.

Taking care of roughly 170 million citizens is not easy. Our health systems are stressed to the limit even without the Covid-19 pandemic. But we have to deal with 170 million people with health problems, 340 million whom we don’t want to get sick, and all of the 510 million exposed to sar-cov-2.

To attend that demand there are approximately 1.7 million licensed physicians and 3.1 million practising nursing professionals. In relative terms, that means 333 physicians and 607 nurses per 100.000 persons (figures for 2018, Eurostat).

It has become quite clear that those numbers have not been able to cope with the pandemic; hence the second wave we are currently going through. I do not know, and what is more, nobody knows, who is to blame and where the fault lies. Only one thing is sure: healthcare professionals are overworked, non-urgent interventions are postponed, and the second wave is here.

We cannot “produce” healthcare professionals. “Importing” them should be ruled out. Depleting other countries of their professionals should be banned. Basically, this is saying: we take your professionals and you keep your pandemic. Furthermore, we will block your country so that no spill over will infect our sancta sanctorum.

Infrastructures are not easy to build and, in the best of scenarios, are just remedial actions for an already sick population.

If healthcare professionals cannot be produced and infrastructures come too late in the process to avoid illnesses, what is left? I can only identify ICT as the solution. Health and fitness Apps should be the solution to make a real difference. They are intended to prevent the user from becoming ill and help him to be fit. The time from inception to the market is relatively short.  And their price is in a range that most people can afford if, as is mostly the case, the healthcare system does not cover them.

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Remedial care, meaning actions taken after an ailment has been detected, has been the traditional focus of healthcare. Probably that is the reason why, when politicians decide to invest in healthcare, they put the emphasis on hospitals and fancy machinery. Let us not be cynical and think that it is because a picture taken in front of a multimillion-euro hospital looks better than one taken in front of a non-descript primary care building. Most probably, policy makers are the slaves of some defunct theory (to paraphrase Keynes).

They, or probably all of us, do not follow the advice – Keynes again- that “When my information changes, I alter my conclusions.” We see it on the current so-called second Covid-19 wave. There is a lot of talk about building more wards dedicated to Covid-19 – remedial – and little emphasis on reinforcing primary care – prevention – where the pressure for tests and tracing is mounting.

Contrary to reacting to a situation, preventing it is a lot more efficient and effective. Unfortunately, the Covid-19 pandemic has demonstrated how few preventive measures have been taken by all of us. We cannot say the problem lies solely with policy makers; it has been all of us who have decided not to take the most basic measures to fight the spread of the virus. We are all to blame.

Apart from the tracing app, there has been very little development of ICT based instruments to fight Covid-19. The fact is that we, as a society, tend to focus on the immediate, and not to look at the big picture: too many tactics and very little strategy. Confronting the problem as a Covid-19 problem will not solve the imbalance in favor of remedial care against prevention care.  We need to divert our investments, human and material, to primary care, where healthcare becomes much more than treating illnesses, where healthcare is preventing people from becoming ill. Thinking that way, I can see lots of ICT applications that could help primary care do its job: simple, user-friendly applications to be used by normal people, designed to help practitioners do their job and the population to remain fit and healthy.

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