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Posts Tagged ‘ehealth’

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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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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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.

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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.

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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.

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The process from research to market for any drug includes, in a nut-shell, four phases: identify the need, research, test, and bring it to the market. The last two tasks could be translated into proving the efficacy of the drug (testing), and proving its efficiency (bringing it to the market) so that it is cost-effective. Are all those phases undertaken when dealing with eHealth systems? I think that a clear no is the answer. And if any of those phases are clearly missing, they are the last two a) is the eHealth system more efficient than the current system? b) is the eHealth system cost-effective? Therein lies probably one of the keys to the lack of adoption of eHealth systems across the EU in particular and the world in general.

We’ll assume that organizations are rational entities (I know it is a big assumption) and will not plunge into costs just for the sake of it. So, let us think that if an organization launches the research effort to develop a new eHealth system, it is because it has spotted a need for such a system.

Now for the testing phase. We all know that no drug will be approved if it has not been properly tested. We also understand that the specifications for testing an eHealth system, even if they could be inspired in the methodology for drug testing, have to be adapted to the particularities of ICT. We cannot expect an app to go through the same process as a drug. Developing an app is in the range of thousands of euros, while the development phase for a drug is in the order of millions of euros. But some kind of testing should be done and its results made public so as to prove the efficacy of the system. Please go to any of the online stores that sell apps and check how many include, or make reference to, their efficacy tests results.

eHealth has also a particular characteristic that a drug does not: eHealth interferes with the healthcare process in a way that a drug doesn’t. In this respect, testing the efficacy of a particular eHealth system poses some problems since the efficacy effect is spread throughout the whole healthcare system, while a drug focusses clearly on its effect on patients.

But if testing eHealth has been, in the best of cases, a patchy process, efficiency is completely forgotten. How can we convince a healthcare provider to adopt a particular eHealth system without demonstrating its cost-saving potential? How many eHealth systems do you know that have carried out any of the available techniques for measuring the probable added value to the patient and the healthcare provider? And again we should recognize the difficulty involved in evaluating the efficiency of eHealth. It is not only the previously mentioned spread effect across the healthcare system, but also its effect across other systems such as the social care system. In fact, sometimes an eHealth system has a more profound effect on the social care system than on the healthcare system itself.

But all those difficulties should not blind us to the need to perform, and make available to the public, the testing procedure and the added value calculation of our eHealth systems. I would recommend that the healthcare authorities who have started to approve certain apps, such as in Andalusia or England, make available the results of the efficacy and efficiency evaluations of those apps they approve.

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We are familiar with too many good ideas that never make it to the market and less frequently, brilliant marketing strategies selling a flop. A proper balance between the product and the business plan rarely occurs. That is probably why there are few companies like Zara or HM; only the chosen few can find the Holy Grail. But we all struggle to do our best and come up with the right balance that puts our product or services in the right spot in the market. The belief that that is achievable is what bring us together every time there is a gathering like this one. And the reason for this exposition is because we, the partners of AiB, believe that we are on the right track. First, let me go through briefly how the ideas that my colleagues have already explained can become a sellable thing. To start with, you may have gathered already that AiB has two heads, kind of like a Hydra.  The difference is that this one has only two heads, its breath is not poisonous but sweet, and its blood, instead of being deadly, heals. One of the heads of our friendly beast represents a service. AiB has been designed as a care service with the objective of detecting the risk of falls in the individual being cared for by a care service provider. Corresponding to that view, AiB as a service offers a complete software-hardware package that allows the care provider to screen the population under its care for a set of signs that will prompt the system to raise alarms. If this is the case, care professionals will perform a pre-evaluation of the person to double-check if the user should be included in the risk-prevention programme or if this is a false positive. Once the inclusion is decided upon, a multidisciplinary team will perform a complete check-up of the user and decide upon a personalized care plan for the user to follow. The care plan is a comprehensive set of neurological and physical exercises included in the system library, as well as any other action that the care professional decides, such as pharmacological therapy or dietetic recommendations. The system will request certain information by the user, mainly about environmental conditions, and prompt remedial actions to counter its risks. Once the personalized care plan is designed and introduced in the user terminal, the user will be asked to follow it by means of an agenda, reminders and so forth. Continuous follow-up of his or her performance will be recorded by the system, triggering alarms to the care professionals in case of deviation from the care plan or changes in the vital signs of the user. These events will allow the care professional to modify the personalized care plan accordingly. It will be obvious by now that AiB as a service is directed to socio-health organizations that can take advantage of the system to reduce the rate of falls in the population they cover, with a clear saving in the overall cost of care, which I am not going to go into since we all are aware of the cost of a hip replacement, for instance. The second nice head of our Hydra corresponds to the product that we envisage to earmark for the individual. In a nutshell, AiB as a product is a self-contained package for individual use by those concerned with their health, probably because they have already fallen or have seen their relatives fall. So it is for people who are aware of the personal cost of a fall in terms of days and/or health lost. The AiB product comprises a self-evaluation that will prompt a care plan, although obviously not at the level of the service care plan. The care plan includes a set of remedial actions that can be made in the environment, as well as physical and neurological exercises. A system of alarms will suggest the user refer to a care professional when deterioration in the performance of the user is detected. How does this translate into a business model? We have chosen the Business Model Canvas because it is as good or as bad as any other model but has the advantage of being simple and clear cut. I will concentrate on only two of the boxes of our model. First the customer segment, in the Canvas jargon. As you can see, we are targeting two completely different markets:  the professional care market and the individual, with basically the same body of knowledge.  Again our friendly Hydra comes to mind with two heads but only one body, and guarding against the perils of falls instead of the entrance to the Underworld. Second, the key activities. We have discussed a lot among the partners on how to proceed from here. We have been able to produce a thing, system and product for the prevention of falls, without killing each other.  A thing that is the sum of the efforts of very different organizations, from health care, to users, to ICT companies, to process designers, even an economist (myself). The result cannot be broken into parts so that each one takes its bit and markets it independently. So we arrived to a solution that has been in use for many years: the European Economic Interest Grouping. This legal figure is governed under European Community (EC) Council Regulation 2137/85. It allows us to continue collaborating while preserving the individuality of the members and separating the AiB undertaking from the other business of the partners. The use of the EEIG will allow the AiB partners to go on to the next step of industrializing our output. That will be our way forward. I am sorry I could not attend the event in person, but if you have any questions, feel free to ask either my colleagues present or contact me at the e-mail address shown on the screen. Thank you very much for your attention.

You can also whach the presentation at http://youtu.be/QZtK6AyvfN0

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