Category Archives: English

The Grand Challenges

The Grand Challenge Equations

If only the Grand Challenges were that simple!

The State of the Union message by President Obama focused around key challenges facing the United States to embrace the changing world. His list included:

  • education
  • innovation
  • infrastructure
  • government reform

This is not a bad list for starters. In my own work with clients, these are key recurring issues, which today take on new urgency, and are as relevant to the US as the EU and emerging countries. The one issue that does wake ministers of finance up in the middle of the night is the rising cost of healthcare, and that is its own challenge.

Let’s briefly reflect on each of these four, though, for now:

Education

A 10-year old girl in a public school will enter the world of higher education or employment in perhaps the year 2020: how is her experience of education preparing her for that world? Are her teachers the very best for developing her for the future, encouraging curiosity and helping her be adaptable and courageous? Is the higher education system ready for the challenges of the future? I somewhat despair about our universities, and do think they need to revisit their social mandate, as they are at present our key and only institutions for the inter-generational transmission of knowledge, yet academics seem pre-occupied with other matters (such as the length of the CV and research), while teaching seems to suffer. We need to re-energise the learning part of higher education, and not just through a technological fix of e-learning, but through the invention of new institutions of learning. Increasingly scarce public funding should not be wasted on unreformed higher education, but should reward innovative and potentially disruptive learning opportunities.

Innovation

Yes, more and better and faster. The historical forces that got us to the present have been silenced as we have become trapped in regulation and rules that discourage risk-taking, and reward the compliant at the expense of the disruptor. Companies and government, both, have trouble with trouble makers who don’t adopt the institutional rhetoric. Access to early-stage funding for innovations is weak and research suggests likely to be harder to get but governments may find themselves unable to provide all the necessary funding under current circumstances. Innovative ways to innovate and commercialise are necessary and which bridge the ‘valley of death’ with effective strategies that de-risk the innovation development process. Regretfully, to some extent, our universities frequently have a small view of their role here (technology transfer), but leaving this to others to take the risks is no longer an option. Entrepreneurialism is needed within the research communities, linked to real-world challenges (I am not ignoring the need for pure research to create new knowledge). And perhaps some better priority setting: while it may be nice to have the latest smartphone, we do need to solve the problem of malaria, unclean water, poor quality nutrition. These challenges do not go away just because we can text our friends more easily — yet within the smartphone technology may lie ways to solve these threats to humanity if we are creative enough to think those thoughts.

Infrastructure

This is the never-ending struggle for government and industry. Capital investments in public infrastructure offers opportunities for innovation to build faster, cheaper, better. Innovations in building technology can give us better roads, improved rail-links, better public housing. While we are focused on the digital technological infrastructure (of wireless and web), we cannot ignore the need to drive forward new infrastructure thinking around energy and transportation to name two big ones. Many (Western) governments may be trapped with legacy infrastructures, making it hard to leapfrog to new approaches. But perhaps we are at the point where we need to literally junk industrial-era infrastructure logic and make that leap of faith — in ourselves and our future. Timidity is no longer an option.

Government reform

“Smart government”. Is that an oxymoron? How has the digital revolution altered the size and structure of governments? Having looked at this issue, I find that governments are frequently wedded to ponderous and very hierarchical internal processes, characterised to a great extent by caution (legislate in haste, repent at leisure?).  We also find protective practices, which can make it hard to reform government working practices even when there is the will to act. Governments are expensive; indeed, governments are monopoly suppliers of government, and if they do their job badly, we all suffer. The next ‘bubble’ will likely be from the public sector, and in particular from central governments, where the need for reform is greatest. Open and transparent government has all of us as stakeholders and the more we take an interest as taxpayers in the functioning of government the greater the likelihood we will get the reforms for the government we need.

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Career guidance for autocrats

Charlie Chaplin from the film The Great Dictator

Charlie Chaplin from the film The Great Dictator

The health of nations and their peoples can be closely linked to the state of their leadership. David Owen, in his book “In Sickness and In Power” (review here), presents a variety of examples from recent history of leaders with illnesses and in what ways their illness affected their abilities as leaders.

One particularly important ‘illness’ he mentions is called hubris.  Hubris in leaders means they are unable to acknowledge defeat, read the handwriting on the wall, admit mistakes, and importantly, resign from office.

Some of our fellow travellers on planet Earth are inflicted with leaders subject to this illness, and who don’t know when to resign. The countries where this is apparent are many, not all are autocratic states, but it is in autocratic states that the power of the leaders can silence opposition and perpetuate their unhealthy tenure in office.

So here is some career guidance for autocrats:

  1. Nothing is forever.  You won’t understand this. As a probable psychopath you’ll cling to power until your hands are chopped off. But more importantly, you don’t understand history. Every single autocratic regime in history has either collapsed from within or been overthrown from abroad. Your time is limited, and you may think you’re different, that you’ll create some time-defying legacy, but you’re wrong. The problem is knowing when forever ends, as you are like the boiled frog — the incremental slow building up of social, political, economic forces inside your little world are relentlessly cooking you and you are not noticing this. You’ll learn too late that it is too late.  Better to go at at the top of your game (that way you don’t have to spend the rest of your life hiding in some desert with your money frozen in a Swiss bank account). But you don’t understand this either, as the good times are rolling for you and you don’t think about the future as you live in the here and now. Tick tock.
  2. Love your children. Your efforts to create a dynasty will only serve to delay the inevitable. If you are really concerned about your children, you will not want them to follow you. Succession within families, even monarchies, is a difficult process, and the accumulation of public dissent over the years and across generations means that you are often signing the death warrant for your children. As a caring father, (most autocrats are male; it has to do with testosterone), you should listen to your wife (assuming you’ve restrained yourself to one) who understands better than you that a dynastic approach will lead to the sudden termination of your children at the end of a rope or a bullet.  So better to decide that you are the first and last of your kind, and ensure your children get a good education and do not follow in your own footsteps.
  3. Trust others. Of course, this is hard to do as you are unlikely to trust many people, but think you can at least trust your family. If the only people you can trust are in your family, be warned: families can become breeding grounds of real jealousy, particularly between siblings — that’s why you shouldn’t buy off your brother’s affections by making him head of the secret police.  This advice only applies if you display normal human emotion such as love; otherwise, you treat your family simply as pawns in your self-serving game.
  4. Embrace dissent. Since you have probably run your country with an iron fist for sometime, people around you have become sycophants; better that than be put in one of your dirty jails. That means that you are not going to get good career advice from your advisors as they will be self-serving, too — you can probably still dish out the treats for those around you and there are always people who suck up to people like you (you like this, but fail to notice that it lacks sincerity). They will not tell you that you have passed your sell-by date. This means that you should be mindful of those who disagree with you, as they may be right. Exiling them only buys you time, as they have a tendency to show up a few years later to replace you.
  5. You can’t be a benevolent autocrat. This is an oxymoron. People don’t love you, despite what you may think. What you see as benevolence is really just evidence that you don’t think your fellow citizens are smart enough to lead their own lives; you act as though you are the only one who knows what they need. But this is of course silly, despite the fact that you may hold court in some palace where the ‘ordinary citizen’ comes for guidance, even justice. Such a forum is simply medieval and perpetuates your belief in your own importance, but carries little by way of real substance.  Furthermore, the evidence that you aren’t loved is all around you if you took the time to look: you travel everywhere in armoured vehicles, surround yourself with a private army, sleep fitfully, perhaps suffer from constipation and that can make anyone bad tempered. You kid yourself into thinking that you are acting in everyone’s best interests, but if you’ve read the other 4 points, you know you are living in a gilded hell.

It is worth adding that this advice can apply to all of us, whether democratically elected politicians, appointed chief executives, very rich, parents or simply ourselves.

The health consequences of the financial bailout of nations

food line

Debt Crisis: Waiting for healthcare

Along with austerity measures to bring debt-laden countries into improved financial health will come some actions with an impact on healthcare and the health of people.

Some examples have a specific impact and might include increasing the patient co-payment, introducing new co-payments, or  reducing public capital expenditure on healthcare infrastructure.

In other cases things are already happening: increasing premiums (Ireland), or increasing control of drug pricing (Spain).

Other actions will have a knock-on effect, such as increasing tuition fees which may impact student numbers and thus the supply of health professions (UK). Tighter access to debt will have some impact on new build in healthcare, as the ability of the state to finance new hospitals will be reduced along with willingness to fund the running costs (big hospitals cost hundreds of millions a year to run). Perhaps we may see some flight of research capacity as whole clinical research teams up-sticks and relocate to countries where investment in medical research is increasing (such as China and India).

And, as people find they are unable to afford to pay their health insurance, their costs are then picked up by the taxpayer. Countries with high rates of unemployment (many) will understand the carrying capacity needed to pay for the healthcare of the uninsured.

We know, broadly speaking, that people are happy with the quality of the healthcare that they receive.  The real issue is always about gaining access to that care. To date, most EU countries appear able to manage this (despite these costs contributing to their debt burden).

But for countries facing austerity measures, under what circumstances might reduced access to care begin to manifest itself. The issue then will be increased burden of ill-health, with all its consequences.

Will we not have converted a debt crisis into a health crisis?

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The world’s top 25 Innovation Cities

This is a list of the top 25 from the top 100 innovation cities prepared by Innovation Cities, based a combination of factors which together suggest a measure of innovation. More information at: http://www.innovation-cities.com/innovation-cities-top-100-index-top-cities/

  1. Boston
  2. Paris
  3. Amsterdam
  4. Vienna
  5. New York
  6. Frankfurt
  7. San Francisco
  8. Copenhagen
  9. Lyon
  10. Hamburg
  11. Berlin
  12. Toronto
  13. Stuttgart
  14. London
  15. Munich
  16. Milan
  17. Stockholm
  18. Hong Kong
  19. Melbourne
  20. Tokyo
  21. Rome
  22. Kyoto
  23. Washington DC
  24. Shanghai
  25. Dusseldorf

What’s a Health Policy Forum for, anyway?

pictogram for silence areas

Silence, please, presentation in progress.

In these days when the use of taxpayers’ money to bail out failing economies, and politicians are grappling with rising public debt, it is always timely to reflect on how the Commission spends our money. Without obvious evidence that it understands the notion of ‘belt-tightening’, meetings where the minutes are taken and the hours are lost will continue to proliferate without some mechanism to constrain this upward spiral of expenditure. Can Council members constrain this growth with the funding of the European institutions, when they themselves are beneficiaries of the very same profligacy with taxpayers’ money in their own countries?

As health is my area of expertise, I am always interested in how the Commission determines its direction in the health space, how it uses the various agencies operating at the EU level to counterbalance the influence of the member states. And of course how criticism is absorbed or neutralised within this great steampunk machine.

I wondered about this when I was reading the latest (draft) minutes of the renewed (!) Health Policy Forum. I was struck by the possibility that this group is not designed to be a critical participant in the developing of ideas and therefore, I wondered what purpose it served.

There is a clue on the Forum website: “The Health Policy Forum brings together pan-European stakeholder organisations in the health sector at EU level to ensure that the EU’s health strategy is open, transparent and responds to public concerns.”

But the efforts at renewal were designed specifically, as far as I can see, to align this group with the Commission’s workplan and to ensure that it acts favourably toward Commission initiatives. We read (of the opening of the meeting): “In her introduction to the meeting Ms Testori Coggi presented herself and underlined the importance, role and mandate of the EU Health Policy forum. She stressed in particular the importance of activities in the field of disease prevention and health promotion including lifestyle related activities and health literacy.” In other words, this is what is important, regardless of whether you think otherwise.  I have no difficulty with these as general goals but they are largely opaque generic terms. The devil is always in the detail, and that is what we didn’t read about.

The meeting must have been most enjoyable, as it seemed to consist of a parade of presentations (no doubt more ‘death by powerpoint’) by people telling the Forum attendees what they were doing. Why bring your brain to a meeting like this?

I was also taken by this interesting line in the minutes: “Member organisations of the EUHPF are in particular invited to talk to their constituencies in the Member States in view to engage as well the national, regional and local level with the aims and objectives of the EU 2020 strategy in order to strengthen the health and social impact in the implementation of the strategy.” In other words, your job it to get the word out, not to engage with ‘us’ critically about what the strategy should be. Do your job, we bought you lunch.

The minutes indicate that questions were asked, such as CPME’s on e-health and cross-border healthcare, to which the presidency ‘agreed’, but whether anything will actually happen isn’t clear. The questions were absorbed into the rhetoric of the meeting, with soft noises of agreement and acknowledgement. But nothing really challenging was asked (assuming the minutes reflect the dynamism of the meeting) and, no doubt, no one was offended.

I wonder if those attending knew they were quiety being co-opted to act as agents of policy rather than engage in a meaningful policy-oriented discussion within a market-place of ideas.

I guess that’s what a Health Policy Forum is for.

Is there a directory of entities like these, do we know what are they for, do we know what they cost, and do we know if they make a difference?

Am I bad tempered about this? No. I want these processes to work, I just worry that in the rush to be accepted as a stakeholder, these groups may neglect their critical perspective. One must always be mindful of rent-seeking behaviour by the Commission, especially when it comes to forms of consultation.

NOTE: The forum lasted one day, involved 10 Commission employees, a secretariat of 4 people, 2 people from the Council (Belgium, Spain) and some 67 people from the ‘renewed’ stakeholder membership.

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On Retirement and being healthy

Particulate matter collapsing and/or passing t...

Cognition declines with inactivity: keep busy!

The unrest in France over plans to raise the retirement age in 2018 to 62 contrast sharply with higher retirement ages in other countries and corresponding moves to increase retirement ages in the future.

What the protests ignore is the real importance of continuing to be active as we age.  There are specific problems people face when they leave the workforce, which can include lessened physical activity and decreased cognitive functioning. While we are still learning about mental decline, the brain does like to keep busy. With retirement can come dislocation from work-based social networks, a feeling of being tossed out of meaningful work, and general uselessness. Of course some jobs just get harder to do as we age (and that requires thinking about the nature of work, rather than the age of the worker).  That means we need to think of transition to other forms of activity such as part-time employment (France has such restrictive regulations that even the employment agencies won’t register a person over 61), further education and even self-employment.

Work is not just about labour (and its exploitation or not depending on your political perspective). We know more that working, the activity of being productive, is good for our mental health. One could interpret the protests in France as efforts to ensure that people enjoy declining health as they age, denial of opportunities to continue to be economically active and productive.

France is one a clutch of countries that has a weak entrepreneurial and innovation culture which denies the broader society the fruits and benefits of creativity later in life.  These countries will be better off ensuring that people continue to lead productive lives, and with some luck enjoy healthy ageing.

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Health Literacy and E-Health

Health literacy is moving up the political agenda at the European level, and the hope as always is that the direction of travel is truly empowering for citizens.  Having been involved in launching the world’s first digital interactive health channel for public access, in the UK in 2000, one thing I learned is not to assume that everyone is alike, that people make choices and that services need to respond to these choices. I also advised the Council of Europe on work on patient access to information over the Internet.

Much energy will no doubt go into health literacy, but there is little understanding of patient empowerment apart from the use of the words themselves. Health literacy, too, sounds like we ought to know what it means but when dealing with organised provider interests and risk aversion by public funding bodies, caution is required.  Much energy has already gone into e-health, with little services for the public to show for years of research and pilots. So we have a weak starting point.

Healthcare systems are poor doing what retailers take for granted, namely the segmentation of their users so they can create a range of service offerings that meet a broad range of people. Compare your hospital to Carrefour. When we launched the digital interactive TV channel, we worked with a simple framework drawing on work by the California HealthCare Foundation, “Health E-People” report. This helped us understand that there were different types of users with different needs, and that in developing content and services we needed to be mindful of this; we also conducted the first and most comprehensive ‘audience user study’ of the British health consumer ever undertaken, using media models to understand how people sought information, what they wanted to use it for and what the barriers were to its use for them. Recent work by the Pew Internet Project has identified the “9 Tribes of the Internet”, which has usefully taken our understanding into population segments based around how people use mobile and Internet-based technologies.

Many of the assumptions of literacy will focus on how people use health information in various forms.  But the wider use of technology, including wireless devices, is seen as a critical element of the future of healthcare.  So I have combined these two taxonomies to identify what I think are the key health literacy challenges for the 21st century for e-health.  I have only sketched out some relationships in the table below (it is not complete as this is a blog entry not a full blown report) but it gives an overview of the sort of considerations that are important.

There are also lessons for policy makers and people concerned with health literacy:

1. Eventually, the individual will have to own their own health record, and decide what to do with the information in it, with whom it get shared, and those who use that information will be accountable to the patient for the use of that information. Health literacy also requires control otherwise there is no reason for me to be engaged — others will help me if I get into trouble. The table below shows that some people will have trouble with this when technologies are a key element.

2. Not everyone will be digitally enabled. This is NOT a digital divide and is NOT evidence of social exclusion, but is a personal choice of people to lead their lives as they wish in a pluralistic society; this is hard for some policy makers to understand and the term ‘social exclusion’ is frequently used without an appreciation of personal choices. The key implication is that services will need to move very slowly to adopt technologies with some types of people. In time, perhaps people may adopt low level access and interactivity, but for many people technological interactivity will remain at best an option not a preference. Perhaps in some future world things may be different, but even today many people do not adopt common technologies, and with rising concerns about energy use and changes to personal lifestyles, we cannot assume the emergence of a uniform technologically based society in the next 5 years.

3.The benefits of technologies in the traditional health technology assessment model will need to pay much greater attention to the segment of the population likely to be involved as their distinct patterns of use and preferences suggest that a one-size-fits-all approach would never work. This means that designing and implementing e-health services, and other health technologies will need to be far more flexible when it comes to the structure of service delivery. This is hard for health systems to understand as they work on the basis of uniform service delivery, paying little attention to unique local or individual requirements. It is a provider dominated environment, not a consumer-centric one.

4. The tribes model suggests that even within health service organisations not everyone will necessarily buy into the technology revolution. Many people work in healthcare precisely because they want to have personal contact with people, and not through intermediating technologies. Since many patients also would have that preference, organisations may need to structure services and staffing to ensure the right mix of people service the public.

5. The great challenge of patient compliance, concordance, adherence (whatever the current term in vogue) may become more dependent on the features of the technologies, their design and ease of use, than on the willingness of the patient to follow a particular care regime. Helping people understand their limitations in using and working with technologies as matter of personal preferences will become very important, which increases the focus on personalisation of healthcare. Similarly, device designers and makers report they see their customer as the doctor (yes, just the doctor) as they specify what technology the patient uses; they do not see patients as customers, and therefore, may need to be encouraged to design technologies that patients and informal carers may use. There is a design revolution waiting here! (where are you Philippe Stark?)

The current approach to health systems in general, especially where the state is the main source of funding, leads to omnibus systems of service delivery, which largely ignore individual preferences — it is a system truly structured to favour provider interests. It would be a mistake to assume a similar approach with e-health and similarly with health literacy. Instead, we should be encouraging approaches which are sensitive to the preferences and usage patterns of individuals and which accommodate to their different literacy styles. In this way, too, we may actually see ehealth services being offered that people will value and use. And that will be a reason for people to become more health literate.

The 9 Tribes of the Internet
(% of US population data)

What each tribe wants from technology

Type of Health Person and their specific health expectations using technology

The Well

The Newly Diagnosed

Those with Long-Term Health Conditions

Digital Collaborators (perhaps 8% of population): always connected through broadband or wireless

a place to jack into the grid

tools for collaboration

want to be involved in experiments to enhance grid services

expect access to health information

symptom-checking and self-diagnosis

smart devices (e/m-health)

access to other people like themselves through social media

mobile and telehomecare in the smart home

expect electronic prescribing, test results, electronic appointment booking and access to their health record

expect email/text based links with care providers as a normal feature

Ambivalent Networkers (7%): use mobile technology selectively, but feel obliged to be connected

need help navigating information overload

may be non-compliant with services that are only digitally provided

offer choices between traditional and technologically enabled services

Media Movers (7%): engaged in sharing content online; but it is not about creativity or personal productivity

offer help to share their ideas, creations and content

offer social networking and opportunities to make connections

access to health information resources, directories and ability to personalise

access to social networking like-minded patients

opportunity to connect quickly and drive content

grid-based communities, and opportunities to drive content

Roving Nodes (9%): actively use mobile devices to organise their social and work lives

help them be efficient, especially as a parent as the majority are female

offer technologies that help them check up on things, particularly using cloud technologies

expect electronic prescribing, test results, electronic appointment booking and access to their health record

symptom-checking and self-diagnostic services that are very user-friendly

use push alerts and reminders for medicines, appointment, treatment plans

provide service options that do not require users to be adopters of the technologies but only of its functionality

Mobile Newbies (8%): really like their mobile phones, but don’t use internet much

offer how-to and coaching material

offer technology support

provide pathways to make finding information and services easy

mobile (on-demand) health information services

offer choices between traditional and technologically enabled services

make sure technologies come with a support service

focus technological support through the mobile device, not the desk-based computer

Desktop Veterans (13%): early internet adopters are happy to work from a desk to search for and access services and information; mobile phones are used to make phone calls

offer good technology and connections

highly self-sufficient searching for services, so offer self-service options

would value tutorials to help them engage in social media

expect electronic prescribing, test results, electronic appointment booking and access to their health record

symptom-checking and self-diagnostic services

may require accessibility technologies to meet their at-home preferences, rather than mobile health

may become an adopter though as long as it meets their self-sufficiency expectations

Drifting Surfers (14%): infrequent online users and users of mobile services; use technology for basic information gathering and would be unlikely to miss loss of internet or phone

don’t force technologically based applications at this group

most likely to drop technology that is hard to use

offer traditionally structured services

make sure any technologies are easy to use, as compliance may be more a function of the technology than the patient’s willingness to comply with a care regime

Information Encumbered (10%): see no great benefit from technology in their lives and are firmly rooted in old media

don’t force technologically based services or solutions at them

help them find information, navigate to services

make sure information is organised for easy use and access and not from multiple sources (will value a single authoritative provider)

offer choices between traditional and technologically enabled services but may be non-compliant with services that are only digitally provided

Tech Indifferent (10%): not heavy internet users, and don’t use mobile phones much and generally don’t see their value

technology is seen as not having any benefit to their lives

value public access facilities if they need access to digitally based services as they unlikely to have the necessary technology

depend on traditionally organised health services in physical locations

are more likely to think of high tech healthcare as low touch, as they associate care with people, not devices

May be prepared to learn to use technology, but it must work easily, and not require special expertise, and not detract from interaction with people

Off the Net (14%): do not use the internet or mobile phone and do not possess the technology, but may have in the past, but found it didn’t offer them anything of value

traditional services are most useful

community-based activities and social venues

may be influenced by baby steps internet courses

depend on traditionally organised health services in physical locations

are likely to be reluctant users of specialist health technology devices, but if required to may have difficulty even with relatively simple procedures

are more likely to think of high tech healthcare as low touch, as they associate care with people, not devices

Want to know more?

There is more heat than light in the e-health technology area, but I have found some material useful. E-health services don’t really exist as a general feature of healthcare systems, as most are still anchored around the telephone, or simple appointment booking and some electronic prescribing.

To get you started, it helps to think not so much about technologies but what they can do and why that is important. These two European reports may be a way in, though the reports may overcomplicate. There is a tendency for e-health to be seen from a service provider’s perspective and less so from the end-user/patient perspective.

Braun A, Barlow J, Borch K et al. (2003). Healthcare Technologies Roadmapping: the Effective Delivery of Healthcare in the Context of an Ageing Society; this document has a useful taxonomy of health technologies.

Cabrera M, Burgelman J-C, Boden M, da Costa O, Rodriguez C (2004) e-health in 2010: realising a knowledge-based approach to healthcare in the EU; this document outlines some of the skills needed for different groups of people who might use e-health technologies.

NOTE: Use a search engine to fine more or email me for a short bibliography.

Forecasting the present to improve healthcare

Internet Splat Map

Real-time data with hidden patterns

I once wrote about “on-demand, real-time, location-independent” healthcare. Today, we often think of this in the context of e-health or telehealth. The essential capability behind this string of terms was to capture the way that the ‘information value chain’ (digital information technology) could influence how healthcare is delivered. An interview I gave in Euractiv added that such technologies could be productively disruptive of cozy working practices in healthcare, by shifting the focus of healthcare decisively to the end-user, and away from provider interests.

For years we have seen investment in e-health technologies, but few services, and bold statements from the European Commission on the potential of e-health to bend the cost curve down. Now everyone wants to bend the curve down; most approaches, regretfully, rest on reducing activity within existing ways of working rather than adopting new ways. One difficulty here is obviously that with disruptive innovation in healthcare, healthcare work will change and that will have an impact on professional practice — when was the last time a health profession was made obsolete by technology. For some types of surgery, radiologists may become obsolete through interventional radiology which integrates real-time radiological technology into surgery. Something to think about, perhaps.

These thoughts bring up one important aspect of the use of information technology in healthcare, the ability to understand the present better in order to use resources better. Hospitals are notoriously bad at forecasting real-time demand for healthcare. They make various predictions that demand for emergency services may follow the cycle of the full-moon (true), and may correlate with large public events, but run-of-the-mill day to day capacity and resource management treats on-demand healthcare as an emergency

There is a technique used in some areas called ‘now casting’, an effort to correlate real-time information with short-term modelling of resource use, and to anticipate short-term demand.  The European Centre for Disease Prevention and Control, in a June 2009 report on surveillance during a pandemic, includes amongst it various methods the use of now-casting. Weather forecasts are a weather model which is continuously updated with real-time data. We may also be familiar with public health surveillance and digital technology has improved the quality of our models.  But real-time techniques (such as mapping) takes us into a new realm where demand can be better understood, to avoid inappropriate queueing and service rationing. For Europe, such capabilities to track information would be important, as information, like viruses, doesn’t respect borders; and real-time information healthcare capabilities for one member state would be capabilities for all.

The problem we have is that we are generally good at looking for things we know about, but not for things we don’t know about, and therefore are unable to anticipate. So our public health pandemic systems are surveillance systems, which focus on things we already know about; they cannot identify short term changes with emergent problems — unless we are looking, we won’t see.

A robust real-time healthcare information system would be agnostic to specific issues, as it would work to identify emergent patterns, and provide a picture of the situation to enable shorter-term or immediate responses.  We aren’t yet that smart to know what to look for — people have predicted the end of infectious diseases, the end of history, the end of poverty. The advantage of digital information technology is its ability to search for emergent patterns, to correlate perturbations as potential precursors of something to come (like monitoring a heart patient at home to detect early tell-tales, so the ambulance can be sent the day before the heart attack).

The advantages would be immediate, from better hospital resource management, to tracking emerging infections, to improving the ability of front-line services to be in the right place when they are needed.

Do you have suggestions?

Comment on this post with your suggestions on areas where improved data management in real-time could both drive down costs and improve healthcare. Also comment if you are already doing this.

Want to know more?

Mapping of influenza using real-time data feeds has featured on Google; a Canadian firm also does health mapping: Infonauts.

Use of now-casting in weather is used by meteorologists; the UK’s Met Office explains how it works here.

Nowcasting consumption using Google data is here.

Here’s one from 2004! using nowcasting of air quality to issue health alerts; linking this data with hospital admissions data for, say people with COPD, might offer improved real-time responses, perhaps even an anticipatory capacity to tell people to stay indoors. A UK project does this (this link is a Wikipedia entry on the project).

On the difference between truth and fantasy

Negative prediction value in binary classification

As we search for the solutions out of the recession, toward a better future and more competitive post-Lisbon (jargon!) economy, it is worth recalling some of the dumb things people have said that has often acted as a brake on progress and change. In healthcare in particular, prediction has a big role as models of the future are driven by the relentless march of demography and various assumptions about the progress of science and technology.

Equally relevant is the meaning of policies designed to drive forward change into the future based on the advice we take from people.

Bringing substantial change to healthcare (or education or whatever interests you) can be frustrated by people, who often from positions of authority, spout nonsense.  And while the items on the list below are famously wrong-headed, other commentators have said things that did make sense (and whose advice we did or did not take, like the few who worried about cheap housing in the US), but the problem is are we are just not very good at telling the difference.

Herewith a few gems (from a regretfully much longer list sourced from various documents); we can be glad their words were generally ignored. If nothing else, the list is testimony to hubris.

  • “…so many centuries after the Creation it is unlikely that anyone could find hitherto unknown lands of any value.” Committee advising King Ferdinand and Queen Isabella of Spain regarding a proposal by Christopher Columbus, 1486.
  • “What can be more palpably absurd than the prospect held out of locomotives traveling twice as fast as stagecoaches?” The Quarterly Review, March, 1825
  • “If a train speed is more than 180 km/h, passengers will suffocate” D. Lardner, Professor at the University of London, 1850
  • “Louis Pasteur’s theory of germs is ridiculous fiction”. Pierre Pachet, Professor of Physiology at Toulouse, 1872
  • “The abdomen, the chest, and the brain will forever be shut from the intrusion of the wise and humane surgeon”. Sir John Eric Ericksen, British surgeon, appointed Surgeon-Extraordinary to Queen Victoria 1873
  • “The Americans have need of the telephone, but we do not. We have plenty of messenger boys.” Sir William Preece, chief engineer of Britain’s General Post Office, The Economist, 1876
  • “Heavier-than-air flying machines are impossible.” Lord Kelvin, president, Royal Society, 1895
  • “Airplanes are interesting toys but of no military value.” Marechal Ferdinand Foch, Professor of Strategy, Ecole Superieure de Guerre.
  • “Everything that can be invented has been invented.” Charles H. Duell, Commissioner, U.S. Office of Patents, 1899
  • “There is a low probability that we will one day master the atomic energy” Robert Millikan, Nobel Prize in Physics, 1923
  • “I think there is a world market for maybe five computers.” Thomas Watson, chairman of IBM, 1943
  • “We have a computer here in Cambridge; there is one in Manchester and one at the National Physical Laboratory. I suppose there ought to be one in Scotland, but that’s about all.” Douglas Hartree, Physicist, 1951
  • “The world potential market for copying machines is 5000 at most.” IBM, to the eventual founders of Xerox, saying the photocopier had no market large enough to justify production, 1959
  • “If I had thought about it, I wouldn’t have done the experiment. The literature was full of examples that said you can’t do this.” Spencer Silver on the work that led to the 3-M “Post-It” Note
  • “We can close the books on infectious diseases.” William H. Steward, Surgeon General of the United States,  1969; speaking to the U.S. Congress – cited in The Killers Within: The Deadly Rise Of Drug-Resistant Bacteria by Mark J. Plotkin and Michael Shnayerson, 2003
  • “There is no reason anyone would want a computer in their home.” Ken Olson, president, chairman and founder of Digital Equipment Corp., 1977
  • “Satellite TV in Britain will be a flop.” Michael Tracey, head of the Broadcast Research Unit, Sunday Times (London) 1 December 1988

And to give us renewed vigor and energy, keep in mind what these sensible Europeans said the next time you are confronted by policies that don’t make much sense:

  • “The probable is what usually happens”. Aristotle  [Policy people often have trouble understanding that some things happen despite their best efforts to exert control; healthcare systems are complex and adaptive, but does policy consider that? The world is wicked.]
  • “It is a truth very certain that when it is not in our power to determine what is true we ought to follow what is most probable.Descartes, Discourse on Method [But policies are pursued frequently with little regard for the real world and a greater eye to political compromise; I doubt Descartes would have been employed as a policy advisor today.]
  • “It is remarkable that a science which began with the consideration of games of chance should have become the most important object of human knowledge. … The most important questions of life are, for the most part, really only problems of probability”. Laplace, Théorie Analytique des Probabilités, 1812 [It is perhaps worthy of further reflection as slavish pursuit of evidence-based policies ignore the fine print that says the evidence is only as good as the research behind it and much of that has varying degrees of statistical reliability.]

On noticing and not noticing — the challenge of wicked problems

Violinist Joshua Bell att...

In Washington, DC, at a Metro Station, on a cold January morning in 2007, a man with a violin played six Bach pieces for about 45 minutes. During that time, approximately 2,000 people went through the station, most of them on their way to work. Few paid the violinist much attention, either pausing briefly to listen, or tossing money into his hat as they rushed past — he made $32.00 for that hour. When he finished no one applauded, no one noticed.  Two days earlier, the violinist, Joshua Bell, a world-class musician, had played to a sold-out audience in Boston, where patrons had paid $100 per seat to listen to him play the same music

This event raises important questions, such as whether we recognise talent in unexpected situations and perhaps more importantly, how do we notice things.  What lessons can be drawn from this for Europe?

When we think about the complex challenges we face in our society, what stops us from doing the important, rather than the merely urgent?  After all, the Washington commuters felt compelled to respond to the urgency of their travel, and failed in their urgency to notice something different.

Instead of commuters, do we have Euro-crats and functionnaires rushing past the real problems on their way to solving small, but more easily managed problems and challenges? Do we have policies and governments that grasp the urgent and unimportant but miss the urgent and important?

Addressing the complex wickedness of contemporary challenges will never be easy. They are embedded in the very fabric of our world, and indeed, much of what passes for policy frequently exacerbates these problems, by being simple-minded, linear in analytical focus, and failing to grasp interconnectedness.

This is surprising given that the one key cause of the recent (and still rumbling away) financial crisis was the tightly coupled nature of financial institutions, a closeness that meant that it was virtually impossible to insulate one area from contagion from another area.  Not noticing this tightly-wound system is bad enough. Failing to ensure that future financial systems are more loosely coupled would be almost criminal. Instead, we are probably seeing even tighter winding of systems.

But the people who failed to notice problems are frequently the people asked to solve them, but they are trapped by their lack of noticing — they would walk past the violinist on the metro on their way to the concert. Of course, they would argue that the chances of another world-class violinist on the metro is close to zero, so they don’t need to be vigilant, but of course the next thing they won’t notice is something … they won’t notice.

And we will pay the penalty for that lack of foresight, thoughtfulness and insight.

We need people who can approach the world with an open and uncluttered perspective. Such people may not behave like the people we are used to as they notice things others don’t, link things others don’t. I’m also suggesting that recruitment practices themselves may be a source of systemic policy error.

The most important job for governments, the Commission, the Parliament, everyone, is to ensure openness (what I call porosity) to the wicked interconnectedness of the world, so they can avoid reducing real-world complexity to a series of simple-minded, linear, and probably in the long term, wrong-headed policy fixes.

And one thing is certain, we need to know if we are walking past something important on our way to somewhere else.