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Posts Tagged ‘healthcare’

I have tried very hard not to write about the Covid-19 pandemic. Today I am giving up. I was going through some old documents about resilient societies and the Hyogo Framework for Action 2005-2015 came to the fore. Page 11 of the framework says, “Integrate disaster risk reduction planning into the health sector; promote the goal of ‘hospitals safe from disaster’ … and implement mitigation measures to reinforce existing health facilities, particularly those providing primary health care.” Faced with the actual international response to the pandemic, my only possible reaction is an unmitigated cry of desperation.

It is obvious that only those countries in Asia that suffered the previous avian flu pandemic were ready for the new SARS‑CoV‑2 pandemic. As for Europe, nothing was prepared and nothing was done. Not even the most basic Individual Protection Equipment was available. The recommendations of the Hyogo Framework were ignored and the Sendai Framework, which covers 2015-2030, has been no more than another document to be shelved in the library.

I am not too convinced that, once this pandemic passes, the healthcare sector is going to focus on preparing for the next one. That will require thinking about the future and not being caught in the day-to-day business of caring for the immediate. For many years, due perhaps to budget restrictions or to lack of political willingness, healthcare has been losing ground in most countries. According to Eurostat “… 16 of the EU Member States reported a lower ratio of healthcare expenditure to GDP in 2017 than in 2012 …. In the Member States where the ratio was higher in 2017 than it had been in 2012, the increase was 0.6 percentage points or less, …”

It was with those resources that Europe’s healthcare had to face the pandemic. No wonder, according to Eurostat,  there have been 700, 000 additional deaths in the EU and EFTA countries between March 2020 and the end of February 2021, against the average number of deaths in the previous three years, of which 25%  were in the period from mid-March to end of May 2020.

But now the point is: will Europe learn and adequately resource healthcare for the future or will it keep driving with dipped headlights?

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The Riyadh Declaration on Digital Health articulated seven priorities and nine recommendations to be adopted by the health community. Even though Covid-19 has been an accelerator of the adoption of ICT tools applied to the health sector, a deficit in the widespread adoption of digital tools to foster a better healthcare persists.

Of course, out of the 7+9 we could choose many culprits for the situation. But to me there are two recommendations that are the core of the problem:

Number 6: Cultivate a health and care workforce with the knowledge, skills, and training in data and digital technologies required to address current and future public health challenges

Number 8: Develop digital personal tools and services to support comprehensive health programmes (in disease prevention, testing, management, and vaccination) globally

Both recommendations focus on people; one on the healthcare professional, the other on the citizen. Both groups are eHealth users, and both groups are normally forgotten by the developer. The basic problem is the existence of a generation gap. Most ICT developers are millennials, the kind of person who, like somebody I was with yesterday, thinks that a 40-year-old person is “old”. They are not willing to pay attention to the reality of demographics. If they invested some minutes to the study of today’s demographics, they would discover that one third of healthcare workers are over 50, and that one fifth of the EU-27 population is over 65 (see Training for ICTs).

The point is that developers should have users in mind. I know that, at least in EU funded projects, it is a requirement to take end-users into the equation. And I know that efforts are made by the developing consortia to involve them. But the problem exists, and it exists because the process of getting an ICT application into the market starts with the ICT developer dreaming of a solution to a problem that the developer has identified, and then looking for an end user that fits the dream.

The correct process should have been, and very seldom is, for the end user to dream about solving his or her problem, and then identify the ICT developer that fulfils the dream. As you can see, the end user should be the driver of the process, not the back-seat passenger in the development vehicle. Acting this way will make it easier for ICT to reach its true potential.

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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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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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If we have to choose a single factor that came out of Covid-19, it would be teleworking and its corollary: the death of the city (The death of the city – Politico 17/08/2020) as we know it, since supposedly we can now move anywhere and continue working.

But is it true that we can move anywhere? Even if we disregard manufacturer workers, healthcare professionals, service providers, and other professionals that cannot possibly do their job by teleworking, there is a tendency by journalists to focus their assessment of the situation created by Covid-19 on a very narrow sector of the population: those 30-40 year olds that, like themselves, have no kids,  no health problems and who can telework without major problems.

Cities were invented, and they flourish, because they provide care from cradle to grave. They have the facilities to make sure you are born without problems. They provide the network for you to socialize with children of similar age and learn your first skills. They keep up their offer as you grow, so that you can meet your first love. And it goes on, so that when you become an adult, the city will provide you with a partner and a job where  you can interact with your peers and together come up with bright solutions for whatever your concerns may be.

The wheel continues: in the city, you have a hospital nearby for your children’s safe birth. Maybe the same hospital to which you will accompany your parents for a checkup.  And we have not mentioned anything about ample shopping experience, movies in different languages, and restaurants and bars to mingle.

To sum up; I can identify certain red lines that most people are not prepared to give up. Those are: close availability of healthcare services; ample supply of goods and services; and social activities. Do you know of any environment that can provide those three aspects other than a city?

Let us stop talking about the death of the city and start talking about making the city more humane. A place to enjoy even when going to work. With more room for pedestrians and less room for noisy cars. The place in which we have most of the conveniences within walking distance, forgetting about those horrible malls and huge office buildings. A habitable city.

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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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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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