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Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 

 

 

 

 

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Sunday
Aug182013

Big Data Consequences

Health Informatics and Data Analytics are burgeoning fields following on the footsteps of ehealth efforts. Big Data is now touted as the solution to solving health care costs by mining for numbers and patterns. Some influential people believe that the "Watsonization" of health care is also at hand whereby computers will diagnose the disease or advise on next steps.

I can't help think of how the car industry has evolved from mechanics to computer identification as to why the dashboard is flashing various lights....problem is that patients aren't cars or widgets with replaceable mother boards. They are a complex combination of emotional, psychological, physiological matter held together with bones and flesh. And our brains...way more than grey and white matter with some synapsing neurons and a few sulci.

As always the devil is in the details and at a time when clear communication and positive relationships are acknowledged as key to patient well being and patient satisfaction, efforts are in full swing to mine for data from health records or any other data that various networks and health systems can get their hands on.

Whether it is analysis of care coordination, readmissions or even medication compliance we should acknowledge upfront that numbers don't tell the whole story. Human behaviour is as complex as our physiology and when we combine the complexity of providers with the complexity of patients and the complexity of our environments we have something that even Big Data  cannot fully elucidate.

For providers it means a system of payment more focused on generating data that can be tied to funding either positive or more likely negative as economies fail to grow.

As provider funding is tied to data and generating patient indices or outcomes deemed "positive", expect a greater attempt by providers to choose more optimum practice locations or select patient populations. The law of unintended consequences will be in full swing.

When governments tie financial incentives to patient selection for various kinds of care including the murky "end of life care", we can expect Liverpool Care Pathway type events to occur.

Providers incented to select patients for end of life pathways and hospitals provided with funding to deny patients care is not a recipe for trust.

Who will the patient trust to give them medical advice on their care when the physician or nurse or other is conflicted in their attempt to preserve the system or limit care?

How do we ration based on evidence or quality or value when there are so many unknowns?

When do we determine that a patient should have an "end of life discussion"?

Why does any decision-maker in health care believe that Big Data can take the place of the relationships that humans seem to need so deeply?

When will the public and patients come to the realization of the risks inherent in the sharing of their personal data for government rationing efforts?

What does Big Data do to caring and compassion?

None of this is to say that evidence isn't important in creating understanding of medical science. Neither is it to say that we don't need statistics and facts.

It's just to say that as we create more complexity and try to comfort ourselves in data, we are mixing a recipe for more costs and not better outcomes either in patient satisfaction or in eventual quality of life.

As always, I'm grateful for your insights!

 

 

Reader Comments (339)

R:

Big data will identify precisely the "big consumers" who then will targeted to use the system better. Problem is the the big consumers, will continue to be big consumers. The data is will know a very small percent of the population consumes the resources. The more precise we can make diagnoses on rarer conditions, the more cost will rise. that's why the push for end of life care. More committees to be struck to "ethically" cut off care, based on cost.

Everyone must participate in a closed system. Taxes are collected, committees are struck of funded providers on how best to ration the tax monies they control, by establishing the cutoffs that will be established to initiate end of life care. The ultimate acknowledgement, the state has won.
August 18, 2013 | Unregistered CommentermovingforwardOntario
"Problem is the the big consumers, will continue to be big consumers"-mfO
Well, that's the issue isn't it because as we spend more to co-ordinate care for these people they will still cost more.

As for the state having " won" , don't think so. The state will ultimately be stuck between the pitchfork carrying public and the harsh realities of a stagnant economy.
"Problem is the big consumers, will continue to be big consumers"-mfO
Well, that's the issue isn't it because as we spend more to co-ordinate care for these people they will still cost more. - R

Absolutely. The big consumers will continue to be big consumers, and there are more being created as we treat more and more previously untreated conditions, with high costs. Cataracts, hip replacements, etc were just the beginning.

Taxes will go up. More committees will be struck to find efficiency. Still waiting the Supreme Court decision - can providers cut off care to speed up end of life issues, to save money?

One hears the OMA committee on death got lots of activist applicants to help make the process more efficient.

The perfect monopoly. All must receive health care from the single system, all care provided by tax resources distributed by providers/managers paid by the system, as services get rationed no way to buy them, as rationing accelerates, end of life care must be reviewed to help you out the monopoly.

The state has won, comrades.
August 18, 2013 | Unregistered CommentermovingforwardOntario
mfO,
The strange thing is that futile care only be identified as "futile" after the patient dies.
I have no crystal ball do you?
But then again, with the push from some provinces for euthanasia perhaps there will be a predetermined death time- an expiry date of sorts. A rather horrific thought in my opinion. This is NOT the way forward.
So this is the latest in a long line of " solutions" that prove not to be solutions at all and paradoxically created further unintended problems that required even more so called "solutions" .

" Watsonization" of health care already occurs in science fiction where futurists anticipate patients stepping in some kind of contraption that would diagnose and cure in an instant....our central planners see too many science fiction movies ( I don't think that they can read).

To the paragraph starting with "Whether it is the analysis of care coordination, readmissions and even medication compliance...." should be added the medication itself...is it the actual medication, or is it a ba$tardization of the original product with unknowable contents and properties....as the Chinese state Zoos reveal a lion may look like a lion until it barks.
August 18, 2013 | Unregistered CommenterAndris
<<One hears the OMA committee on death got lots of activist applicants to help make the process more efficient.>> - mfO

We can almost predict how this is going to roll out:

■ OMA activist fueled panel leads government down an aggressive path
■ Early adoption and success leads to some small gains
■ Sensing an opportunity to expand early success, government links financial incentives to continued adoption
■ Cracks in process begin - cases of inappropriate patient selection and/or hyper-aggressive selection occur
■ Local media publicize these cases and make link to incentivization
■ Cases are brought forward to Question Period in the Legislature
■ For next events see "eHealth" or "ORNGE"

For goodness sake, it they decide to name the new care pathway after a community, make sure that it isn't the one in which you live!
August 18, 2013 | Unregistered CommenterExecutive Lead Blogger
"Good medicine does not mean grinding diagnoses and treatment plans out of large collections of facts. It means understanding the patient. And there are many facets of the patient that tend not to shine through if the electronic medical record is all we have to go on. A robot can collect and process data, but good medicine requires more than information management. It takes effective communication, deep insight, and genuine compassion."
ELB,
It's predictable.
Quebec physician association appears to be pushing hard for euthanasia. Does it have anything to do with their economic situation in Quebec.

People have been dying in the modern world for a very long time. Suddenly there is a push for euthanasia when a lagging economy coincides with aging pop'n and inability for public hc monopoly to fund it. No coincidence.
R:

But one of Ontario's solutions is to pump up immigration of healthy young who will pay taxes, but not draw on health care, thus allowing a slow , responsible, euthanasia policy to evolve. The big data solution = the under 40s put more in than they draw out, bring them in.
August 18, 2013 | Unregistered CommentermovingforwardOntario
Immigration would have to quickly more than double to even budge the dependency ratio. Immigration will not solve our demographic problem and neither will doubling the fertility rate as of today. It is too late.
The pharmaceutical companies think Big Data is the wave of the future.

Read this and laugh.
http://www.pharmalive.com/op-ed-entering-golden-age-big-data

I don't think we are just "plies of carbon, nitrogen and oxygen".....what a materialist worldview. Bah.
August 18, 2013 | Unregistered CommenterOutpatientPharmD
R:

"futile care" - Cost of therapy exceeds the economical payback the patient can provide. The beauty of the QALY system is that value of life to central has been determined. Only thing left is the politics.
August 18, 2013 | Unregistered CommentermovingforwardOntario
OpPD,
I think there is important information in the link you shared...the only issue I have with it is the conclusion. There will not be a "Golden Age" of Genomics, just new understanding and more complexity that will require policy changes and new approaches. Overall, the funding problem will remain in that we have too much demand for too few resources. No Golden Age.
Overall, the funding problem will remain in that we have too much demand for too few resources. No Golden Age. -R

The "futile care" on the end of life folks will be stopped. Quebec will lead the national process.

The plan is good, and agreed on.
August 18, 2013 | Unregistered CommentermovingforwardOntario
The "futile care" on the end of life folks will be stopped. Quebec will lead the national process.`-mfo

Identifying futile care is not easy. When the 80 yo with dementia falls and comes in to the ER and is found to have pneumonia, treating the pneumonia and injuries is not futile care if the patient survives. On the other had if the same patient succumbs to the pneumonia, the treatment could be labelled futile. It is difficult to know when a frail elderly person will rally with treatment or not. It just depends on a whole lot of things.

There are cases of frail elderly patients in hospital who are not doing well with pneumonia (Mandela for instance) and it is expected they will die. Heroic measures are not in consideration. The patient`s meds are all stopped. They recover and go home to have the whole process the next few months and on and on for years.

At what point do you not treat a patient who is functioning in the community with reasonable first steps in care for usual things....
Modern day Interns spend 12% of their time with patients...40% of their time with hospital information services...thank god that I trained when there were no "hospital information services" other than the worn hospital information bulletins , curling up at the edges, ignored on a board that everyone brushed past.

Who is looking after patients as the interns are preoccupied by the hospital information services and the nurses are too busy with their box ticking on computers to look after them?

Quebec will lead the way....the primary euthenasia prototype study will focus on non pure laines....Anglos would do nicely.
August 18, 2013 | Unregistered CommenterAndris
The trouble with initiating these processes is that noone knows where they will lead...one thing for certain they won't lead to where the initiators anticipated they would lead...likely nowhere close.

Primo non nocere should be tattooed on their foreheads...but they are not...the imitators are always so supremely confident...one wonders if they would be so eager if we had a system where they are put against a wall and shot if their predicted goals were not met.
August 18, 2013 | Unregistered CommenterAndris
Looks like the end of life debate is unfolding right on cue with the CMA issuing a statement on the matter today. Nothing wrong with the advanced directive discussion but as Realist points out it is no coincidence that the discussion has started in the two provinces which are the most indebted and have an aging population. Peterborough, Ontario is now the oldest city in the country.

I still remember when my mother was called urgently in the middle of the night as her mother (my grandmother) was admitted to hospital at the age of 70 with a small MI. The resident wanted an immediate verbal DNR order and suggested the family come right away. When we arrived the 65 year old attending cardiologist apologized for the early morning call from the young resident who saw the white hair and assumed it was time to die at the age of seventy. The patient went on to live another 24 years in her own home on two medications and then died at the age of 96 in the nursing home.

Beware of the white hair reflex if you are attending a hospital in Ontario especially as the tax base shrinks further. There may actually be good reason to dye one's hair in order to avoid a futile care pathway designation by some young activist physician who has been inculcated in medical school that the role of physician is to help the state decide who is entitled to what resources.

This is not going to end well.


"August 18, on the cusp of its three-day meeting, the Canadian Medical Association (CMA) called on all levels of government to cooperate in creating a seniors’ strategy, citing the looming pressure ageing baby boomers will place on the health-care system.

“The anxiety Canadians have about health care in their so-called golden years is both real and well-founded,” Dr. Anna Reid, CMA president, said in a news release. “Let there be no doubt that a national strategy for seniors’ health care should be a federal priority.”"

http://www.cmaj.ca/site/earlyreleases/18aug13_Canada_needs_seniors_health_care_strategy_CMA_report_card.xhtml
August 18, 2013 | Unregistered CommenterCanary in a Coal Mine
Andri: The current prevailing winds will soon cause the self-preservation instinct t0 kick in in the profession. The mantra will soon become "primum MIHI non nocere...sadly..
August 18, 2013 | Unregistered CommenterSybil
Beware of the white hair reflex-CICM
Good advice.

One question, even though I understand the CMA is the medical lobby group at the federal level...why is it that the only solution that is voiced is to call for the federal government to fix things...
R:

Those who do not "contribute" will be culled out, if they consume health care. Where possible, they will be discharge to home care, which is really just discharging to no care.
August 19, 2013 | Unregistered CommentermovingforwardOntario
There may actually be good reason to dye one's hair in order to avoid a futile care pathway designation by some young activist physician who has been inculcated in medical school that the role of physician is to help the state decide who is entitled to what resources. -CICM

It will not be a physician, it will be a nurse navigator.
August 19, 2013 | Unregistered CommentermovingforwardOntario
The issue will be will the young pay the tax burden. Some of the burden can be covered by increasing inheritance taxes, but the bulk will need to be on the youth. Will they provide it, or accelerate the euthanasia path. The costs are at the end of life.
August 19, 2013 | Unregistered CommentermovingforwardOntario
Much of the end of life issue will be driven by the pending Supreme Court case.
August 19, 2013 | Unregistered CommentermovingforwardOntario
Mfo,
You are assuming that the public will accept the changes that are anticipated. I am willing to bet that a large proportion will not and will demand access to non-industrial care and will be willing to pay for it. Free is only acceptable when the quality is maintained above a certain threshold.
August 19, 2013 | Unregistered CommenterCanary in a Coal Mine
"Anti-aging experiments like that at Einstein have scientists talking seriously about the average lifespan rising by decades, possibly to 120 years, and academics pondering the consequences. What would it mean for the solvency of the health-care system or public pensions?"

http://www.theglobeandmail.com/life/health-and-fitness/health/science-could-add-decades-to-the-average-human-lifespan/article13816506/
August 19, 2013 | Unregistered CommenterCanary in a Coal Mine
CICM

The public which can afford avoiding the end of life "rush" represents a very small group. Most can't afford to purchase health care of any sort, and will get shuffled out.

Most of the population that now consumed health care, can't afford its cost.
August 19, 2013 | Unregistered CommentermovingforwardOntario
Time for me to get a good undetectable toupee....long blond locks should do.

Time for Botox as well....one wonders if the botoxed will get a better rating when the end of life nurse practitioner walks through the ward carrying her i Pad, box ticking away.

Relatives should go to visit their loved ones with a make up artist, to rouge up the cheeks of those about to be assessed.

Best donate money , dated for a month ahead, uncashable if demised, to the hospital ( more than the end of life bonuses ) so that one can pass muster.
August 19, 2013 | Unregistered CommenterAndris
If waiting for care is good, no care must be even better.

“Don't you see that the whole aim of Newspeak is to narrow the range of thought? In the end we shall make thought-crime literally impossible, because there will be no words in which to express it. Every concept that can ever be needed will be expressed by eactly one word, with its meaning rigidly defined and all its subsidiary meanings rubbed out and forgotten. . . . The process will still be continuing long after you and I are dead. Every year fewer and fewer words, and the range of consciousness always a little smaller. Even now, of course, there's no reason or excuse for commiting thought-crime. It's merely a question of self-discipline, reality-control. But in the end there won't be any need even for that. . . . Has it ever occcured to you, Winston, that by the year 2050, at the very latest, not a single human being will be alive who could understand such a conversation as we are having now?”

― George Orwell, 1984
August 19, 2013 | Unregistered CommenterEklimek
DrK:

As we redefine care, new words and action appear. "Care" will shortly disappear in that it has buried in it "concern for well-being". Processing time will replace care, time in to time out. How fast one can be processed in.

As health care became "free", it has become a service available from central we are entitled too because it is prepaid. Because it is prepaid, it has no service standard, you get what we want to do. That is the service.
August 19, 2013 | Unregistered CommentermovingforwardOntario
<<Much of the end of life issue will be driven by the pending Supreme Court case. >> -mfO

Entirely possible. There is still a chance, however, that the Supremes may decide that this is a public policy issue and not a legal issue and punt it back to the Province - with a timeline and consultation requirements for action.

Then it becomes political and Ontarians are not Quebecers...Ontarians do not have the appetite for this discussion.
August 19, 2013 | Unregistered CommenterExecutive Lead Blogger
ELB


It should be a public policy decision and not a legal issue. It will be interesting.

Public policy. You are dying and will consume more resource than you can provide back, We agree for moral reasons, we support that regardless of cost. It is an acknowledged waste of resources but the moral value exceeds the economic value, and we support moral value,

or,

your economic value to society exceeds your economic value. We must terminate you because your carbon cost to the planet has too high a cost to others,
Tough issue, but it is here.
August 19, 2013 | Unregistered CommentermovingforwardOntario
Physicians advocate for prevention throughout the lifespan then, when the prevention has worked well and people reach old age with related frailty there is a policy push to hasten "end of life" patients on their way.

I'm having difficulty reconciling these two actions.

Prevent, Prevent, Prevent, then "time to die". Really?
"And of course, the health care component of our taxes would likewise be removed. "

When pigs fly, maybe...
August 20, 2013 | Unregistered CommenterSybil
One arm of government advocates the extension of life spans...the other to shorten them.

The shorters will win.

One benefit off increased longevity is that more will qualify for the " end of life " bonuses.
August 20, 2013 | Unregistered CommenterAndris
Unless we are prepared to increase the resources, someone is going to get care designed to reduce their draw of treatments that won't help them.
August 20, 2013 | Unregistered CommentermovingforwardOntario
At CMA General Council there is movement towards promoting "the right care, by the right providers" yet the patient-centredness seems to be replaced by what the medical profession deems appropriate.
This is not new...but as science changes to reveal more personalized differences, I have to ask exactly how the patient will ever be at the decision-making centre as costs control the gatekeeping which is determined by incomplete evidence.

Will the patient be given the option to choose the care that they are informed about with respect to evidence of benefit or not if they still want it?

Evidence-based care is great but we should acknowledge that it is incomplete and increasingly so as we identify more genetic differences that lead to disease.
The door is just being opened to genomics and the microbiome. We have a long way to go to understand fully. Until then, will the patient have a say in where they believe they are on the spectrum of evidence?
Think you can get tough on the API issue in China? Try again:
http://www.pharmalive.com/china-stymies-fda-inspection-plans-by-delaying-visas

Meanwhile in the UK:
http://www.pharmatimes.com/Article/13-08-20/UK_gives_prescribing_powers_to_physios_podiatrists.aspx
One reason ostensibly is because "At the moment every year thousands of people with diabetes have to endure unnecessary amputations as the specialist care that they need to ensure quick treatment is not in place", she noted.
Can this be true????
Good grief. Care in India or Chile would be better.
August 21, 2013 | Unregistered CommenterOutpatientPharmD
OpPD,
Thanks for keeping up to date with the desperation of other countries. It does make me wonder where we are headed....
The plan is good. Free unlimited care for all disease with no restriction on resources.
August 21, 2013 | Unregistered CommentermovingforwardOntario
Outpatient I would not be surprised if UK health care tourists go to either India or Chile to have these procedures carried out.

The USA was our bolt hole for medical procedures if not available in Canada...under Obamacare where could our team treated diabetics go with their Peripheral vascular disease and near gangrenous toes if in the same situation as those in the British NHS who are getting their legs amputated.

Our system as mentioned before seems to follow the policies of the UK's NHS tweaked so as to be described as having been made "in Canada".
August 21, 2013 | Unregistered CommenterAndris
Hard to capture the significance of this.

" ... amputations as the specialist care that they need to ensure quick treatment is not in place"

Diabetic disease, a chonic problem that is stated to require "specialists care", is acomodated by empowering physiotherapists (and others) to prescribe? Is this like passing out accordions to soldiers on the frontlines? Medical specialists trained for 9 years are replaced by this?
August 21, 2013 | Unregistered CommenterEklimek
"It is one of the essential features of such incompetence that the person so afflicted is incapable of knowing that he is incompetent. To have such knowledge would already be to remedy a good portion of the offense."

http://gagne.homedns.org/%7Etgagne/contrib/unskilled.html

as Charles Darwin (1871) sagely noted over a century ago, “ignorance more frequently begets confidence than does knowledge” (p. 3).
August 21, 2013 | Unregistered CommenterEklimek
"At its policy convention in Calgary this week, the Canadian Medical Association was poised to debate one of the most emotionally charged and ethically perilous issues in medicine: doctor-assisted death.

But physicians got bogged down in semantics, in lengthy discussions about the appropriate language to use to describe hastening death at the end of life, and deferred real debate to a later, unspecified date and another unspecified time.

In short, fear prevailed."

http://www.theglobeandmail.com/life/health-and-fitness/health/fears-prevailed-during-cma-policy-debate-on-euthanasia/article13910392/
August 22, 2013 | Unregistered CommenterCanary in a Coal Mine
Why not just call it "hastening death at the end of life for resource conservation of the pooled resources".

One can free it of potential ethical, moral, racial, etc bias by stating the purpose. Central has determined better use of the available resources than prolonging your life.
August 22, 2013 | Unregistered CommentermovingforwardOntario
"Why not just call it "hastening death at the end of life for resource conservation of the pooled resources"."

Well said mfO.
How soon do we get the names of central's 'hastening death" committee members?
August 22, 2013 | Unregistered CommentermovingforwardOntario
"Hastening death at end of life for resource conservation of the pooled resources" is as good a name for such a committee as any.

The tortured attempt at the CMA to come up with the right words was likely an attempt to say just that without saying that.

The "Calgary end of life care pathway " didn't fly...I can'y imagine why.
August 22, 2013 | Unregistered CommenterAndris

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