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Archive for the ‘eHealth (English)’ Category

“Teleworking is here to stay” has become a repeated catchphrase of those gurus dedicated to predicting the future. You can substitute “teleworking” for “telemedicine”. But there is more than one thing wrong with the simplification that the catchphrase implies.

To start with, both working systems have been with us for decades. The broader use of both systems during the Covid-19 pandemic has been prompted by need, not by choice. Doctors and workers have been forced to use it in order to avoid physical contact with patients or peers; it was not an alternative, it was a must.

Most of them had to get used to the new system in a matter of days, if not hours. They lacked proper training and, mostly for teleworkers, they had to provide their own equipment and internet connection. Again, it was not an alternative; it was a take it or take it.

For teleworking and telemedicine to be included permanently in our everyday life, it has to be by choice. And for that, many things have to change in the way work is organized and supervised.

Nowadays, timing is, in most cases, the yardstick of how work is supervised. Doctors and workers have their working hours contractually regulated. Their supervisors make every effort to make sure that those hours are fulfilled, rather than controlling objectives. These are very rarely set and only instituted in the very upper echelons of the working pyramid.

In both teleworking and telemedicine, productivity becomes the most important aspect. Productivity is measured against the accomplishment of objectives. And objectives are difficult to set in most cases. It was easy for manual work; so many meters of weaving, so many bolts. In telemedicine, would you set a number of patients assisted as an objective regardless of the complexity of the illness? Of course not. Would you set as an objective the number of reports, regardless of the quality of the report? Of course not.

This is the main change in the way work has to be organized in case we adopt teleworking and telemedicine as a real alternative to on-site working. Supervision has to drastically change from working-hours-based to working-objectives-based. A real challenge to the working system.

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When we talk about healthcare, even if nominally we are focusing on the patient, the reality is that we program the care process based on the capabilities and needs of the healthcare professional. If we didn’t do that, we still would have the family doctor coming home or, more realistically, Primary Care would be the prima donna of the healthcare process instead of the ugly duckling.

When we talk about social care, we rarely focus on the caregiver. We take for granted that the dear unmarried daughter will take care of her parents; is there anything better that she can do with her life? With that goes the assumption that the public purse does not need to divert its valuable resources to care for old people; there is always a family member willing to take care of the ageing person.

And this is the norm all over the world, and certainly all over the European Union.

In a previous post, “Beyond Covid-19”, in a back-of- the-envelope calculation, I estimated that Europe needs 23 million persons per year to work as caregivers. Let us assume that 10€ an hour is a reasonable medium wage in the EU, and we will get to a staggering 354,200 million € a year, roughly twice the annual budget of the EU.

I am not very optimistic about countries in the EU adding 2% of their GNP to their budgets. From now on, we will have to rely on imaginative approaches to care for our old people’s caregivers.

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I am taking the title from one of the chapters of the book New Ageing by Matthias Hollwich. The introduction to the chapter reads “At some point in our lives, things will get a bit harder and we will need help in one way or another. The best kind of help eases the way forward without replacing the capabilities we still have”.

It is this last sentence that has been haunting me for years. And not only in reference to informal care but also with formal care, including institutional care. Many years ago, I directed a study for nursing homes all over Spain. Of the many months I was involved in the project one comment from the director of one of the nursing homes has been engraved in my head. He told me, and I quote, “We are a factory of dependent persons; put an independent person in a nursing home and, in less than six months, that person will become dependent”.

Add to that, the above average incidence in the mortality rate that Covid-19 has caused in nursing homes all over Europe, from Sweden to Spain, and you will get a much less  rosy picture of nursing homes as a recourse for old people’s care.

A recent paper by the European Commission, Informal care in Europe: Exploring Formalisation, Availability and Quality, states that “Informal care forms a cornerstone of all long-term care (LTC) systems in Europe and is often seen as a cost-effective way of preventing institutionalisation and enabling users to remain at home”.

What I see as a problem is that, because of their lack of proper training, informal caregivers, and more if they are family members,  tend to overpower the old person: “Don’t do that”; “I’ll get it for you”; “Be careful, you’ll fall”, etc.. So, we go back to the beginning: the problem is to help the old person “without replacing the[ir] capabilities.”

We need to train informal caregivers. Basically, we need somehow to care for informal caregivers, to train and support them, even provide financial support for them, as the EC maintains. But training should be the first objective, since a properly trained caregiver will know how to take care of the old person and, equally important, of him or herself.

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I can understand that what happens today is more pressing than what will happen tomorrow, but that does not mean that today is more important. I think we should start looking at tomorrow and start planning what we will need for a world beyond Covid-19.

As of today, one of the few things we know for sure is that SARS-CoV-2, which produces the Covid-19, infects more old people and mainly those with previous chronicity. That means that it is old people who need more care.

Care that, we have also learned, would be better given at home than in nursing homes. Gathering vulnerable people in close quarters has proved not to be the best solution if we want to avoid the spread of a communicable disease.

Only if we are capable of building an army of caregivers will we be able to give home care in the EU to that 19% of the population aged 65 and older.

With a total population of almost 513 million people, we will need to take care of 97 million old people (all figures from Eurostat). Just for the sake of discussion, let us assume that we need one hour per day of care per old person. With an estimated 1.540 productive yearly hours per person, we will need almost 23 million caregivers. The fact that many of those 23 million will be informal caregivers does not make the hours and the people less essential.

Who will take care of that army of caregivers? Who will be providing training, moral and physical support for them? Very little is done today in that domain and almost nothing if we focus on informal caregivers. I think we must start getting ready to tackle caregivers’ needs, formal and informal, so that we will be able to provide our old people with the best possible care by the healthiest and most motivated caregivers.

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I have been wondering what the connection between people, especially old people, and a resilient society could be.

What is more resilient than an old person? They have demonstrated their resilience through the years. An 80 or 90 year old European has gone through at least one war, if not several if he or she is from one of those unfortunate countries (the Balkans, Ukraine, …) which have suffered also their own national wars.

And yet, when devising processes for a resilient society, we do not look to those generations that have proved to be resilient. What have they done to survive in such an unwelcome surrounding?

My answer is simple: adaptation.

I had a teacher in high school who provided an easy explanation for the difference between democracy and dictatorship. Dictatorship is like a concrete wall; it withstands high winds but if the wind grows strong enough it collapses and disappears. Democracy is like a wall made up of a sheet of paper; it bents with the wind and, when the wind does not blow anymore, it falls back in place. That is adaptation.

Going back to how to design for old age or for resilient societies, I think we should look at the same characteristic: adaptation. We will survive if we can adapt ourselves and our society to a changing world, be it new technologies or climate change.

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We all are moving fast. The baby-boomers (1946-1964) are coming of age … retirement age. If the silent generation (1920-1945) was the generation that absorbed the car and the telephone as routine communication tools, we would expect the baby-boomers to take information and communication technology (ICT) as their routine communication channel.

That is the case and, when dealing with today’s problems, the expectation becomes a truism. We all jump into using ICT to solve many of the aging problems that baby-boomers encounter. And, as it happens, this is the view that the European Commission holds: ICT is here to solve the ageing problem.

If we take the use of internet as a yardstick, the reality is that only 45% of the +65s use internet once a week or more in Europe. Descending to country level, the differences are striking: in Norway that figure is 82% and 12% in Bulgaria.

So, should we jump from analogic to digital in the blink of an eye or are we going to find the swimming pool empty? Wouldn’t it be more realistic to work on long-term structural change from analogic to digital transition, similar to the energy transition favored by the UN in the current COP25?

A transition of that kind will ensure that nobody will be left behind, a very important factor when we are talking about 55% of the +65s Europeans.

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Certainly we are living in interesting times. My first “serious” job was as Administrator of the Computing Centre at the Complutense University of Madrid. The centre was equipped with an IBM 360 which had a main memory smaller than my actual smart phone. So here we are, equipped with a powerful hand held instrument that, most of us, use for calling/texting friends and acquaintances, listening to music or watching TV shows. What a waste!

So, people around the world are trying to introduce us to the wonders of apps: smart little pieces of programming that are intended to make life easier for us. From advising us when the next bus is coming to how to navigate those streets we are not familiar with.

But there is another use that is being explored and promoted but still is not part of our lives. I am talking about those apps that are intended to change our lives. According to a recent report (mHealth App Economics 2017 http://www.research2guidance.com) there are some 350.000 health apps on the market. I have not found a similar study for other sectors, for example managing disasters, but a Google search for it gives 262 results, so it is not a fringe issue either.

Anyhow, the fact is that be it 350.000 or 262, the spread of those apps is meaningless. Do you know anybody in your circle using one app for a practical use in health or in security? I do not and I am closely involved with the socio-health sector, and have some connection with security issues.

The only possible conclusion is that the business model on which those apps rely are faulty. Most of them are built thinking of the future, a user that does not exist, either because the app is too complicated or because it is too simple. We are simply forgetting about user-centered co-design. We design things for the user but not with the user. Let´s try in 2018 to change our design mainframe and put the user in the centre of our efforts. That will make our times even more interesting.

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Ageing is a natural process. People age as soon as they are conceived. And society, so far, has been able to find a place for each phase of the ageing process: the nursery for the child, the school for the teenager, the working place for the mature person, and the bench in the sun for the older person. The division so far has been neat: child 0-12, teenager 13-19, mature 19-65, older person 66-infinite. And here is the problem: when +65 was more or less a homogeneous group, the last division worked reasonably well. But when the over 65 group keeps expanding its upper limit to higher and higher numbers, say 90 or even 100, who can even think that the 67 and the 95 year old have the same interests and needs?

Society has been able to smooth the transition from teenager to adulthood by providing a system for the teenager to start getting involved in adult activities, be it summer jobs or working grants.

But so far society has been unable to provide such a transition from adulthood to over 65. You reach retirement age and you are finished. No more getting up at 7am, no more chatting with colleagues, no more feeling productive. And all that in 24 hours.

Would it be so difficult to develop a system that allows phasing out retirement according to a person’s needs and expectations?

There are two main drawbacks, in society’s opinion, against keeping older people at work. From the employer’s point of view, older people have accumulated so many perks that they are more expensive than younger ones. There is also a pre-conceived idea about older people and their lower productivity. Productivity is the sum of speed and the lack of errors. By that definition, there is no evidence that an older person is less productive than a younger one. This pre-conceived idea about the lower productivity of older people is being revised (see The Economist: Special Report, “The Economics of longevity“).

The solution to these problems lies with the Regulator. Sensible and flexible labor regulation could easily overcome those drawbacks. What is needed is more political will to design solutions and less dramatization of the supposedly insurmountable problem that ageing is bringing to our society. Let´s get trade unions, business organizations and government to do their job and work together towards making the transition from adulthood to retirement smooth.

Enough is enough! I am not going to feel guilty for being over 65 and planning to live as long as possible and enjoying every minute of it!

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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.

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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.

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