Tag Archives: technology

Intelligent medicines optimisation

A central feature of any high performing healthcare system or organisation includes best practice in medicines use and management. As all aspects of healthcare are under varying degrees of financial stress these days, cost controls and appropriate use of medicines must support the highest standards of clinical practice and safe patient care.

Medicines optimisation is one strategy as the use of medicines influences the quality of healthcare across the whole patient treatment pathway.

Failure to optimise the use of medicines across this pathway may arise from:

  • misuse of medicines (failure to prescribe when appropriate, prescribing when not appropriate, prescribing the wrong medicine, failure to reconcile medicines use across clinical hand-offs;
  • “clinical inertia” and failure to manage patients to goal (e.g. management of diabetes, and hypertension post aMI) [O’Connor PJ, SperlHillen JM, Johnson PE, Rush WA, Blitz WAR, Clinical inertia and outpatient medical errors, in Henriksen K, Battles JB, Marks ES et al, editors, Advances in Patient Safety: From Research to Implementation Vol 2: Concepts and Methodology), Agency for Healthcare Research and Quality, 2005];
  • failure to use or follow best-practice and rational prescribing guidance;
  • lack of synchronisation between the use of medicines (demand) and procurement (supply), with an impact on inventory management and
  • loss of cost control of the medicines budget.

The essential challenge is ensuring that the healthcare system and its constituent parts are fit for purpose to address and avoid these failures or at least minimise their negative impact.

Medicines costs are the fastest growing area of expenditure and comprise a major constituent of patient treatment and recovery.

The cost of drug mortality was described in 1995 [Johnson JA, Bootman JL. Drug-related morbidity and mortality; a cost of illness model. Arch Int Med. 1995;155:1949/56] showing the cost of drug mortality and morbidity in the USA and costed the impact at $76.6 billion per year (greater than the cost of diabetes).

The study was repeated five years later [Ernst FR, Grizzle A, Drug-related morbidity and mortality: updating the cost of illness model, J Am Pharm Assoc. 2001;41(2)] and the costs had doubled.

Evidence from a variety of jurisdictions suggests that drugs within the total cost of illness can be substantial, for instance:

  • Atrial fibrillation: drugs accounted for 20% of expenditure [Wolowacz SE, Samuel M, Brennan VK, Jasso-Mosqueda J-G, Van Gelder IC, The cost of illness of atrial fibrillation: a systematic review of the recent literature, EP Eurospace (2011)13 (10):1375-1385]
  • Pulmonary arterial hypertension: drugs accounted for 15% in a US study [Kirson NY, et al, Pulmonary arterial hypertension (PAH): direct costs of illness in the US privately insured population, Chest, 2010; 138.]

Upward pressure on the medicines budget include:

  • medicines with new indications (be careful, some of this is an artefact of drug regulation gamed by manufacturers)
  • changes in clinical practice which has an uplift effect on medicines use (especially if guidelines are poorly designed)
  • increasing the number of prescribers (keep in mind that prescribers are cost-drivers)
  • medicines for previously untreated conditions (this trades-off with reduced costs in misdiagnosis, mis-/delayed treatment)
  • therapeutic improvements over existing medicines, and
  • price increases (think of monopoly generic manufacturers, for instance).

Downward pressures include:

  • effective procurement methods (e.g. avoid giving winners of tenders ‘the whole market’ and ensure that rules enable generic competition)
  • use of drug and therapeutic committees and drug review processes (it is all about knowing where the money goes for improving value)
  • use of prescribing and substitution guidelines e.g. generic substitution (oh yes, enforcing it, too; it also helps to ensure OTC medicines are not reimbursed by insurance as this adds to competitive pricing pressure and improves patient choices)
  • positive and negative hospital formularies (yes, hard choices)
  • pro-active clinical pharmacy services engaged in both business and professional domains, (this means ensuring the expertise of pharmacists are central to decision-making) and
  • reduction of waste (you don’t want to know how much drug waste there is but estimates are up to 30% of expenditure is waste).

Additional sources of pressure in either direction come from:

  • population case-mix (that means paying attention of the health of the nation)
  • changing prevalence and incidence over time (also paying attention to the determinants of ill-health, particularly avoidable causes and effects by age cohorts)
  • performance and efficiency of clinical workflow across the patient pathway (this is where money gets wasted at light speed and where it can also be saved; clinicians are in control of workflow so engaging them in areas where they can make a difference matters a lot)
  • medicines payment and reimbursement practices including patient co-payments where they exist and the structure of hospital budgets or financing, (do we want to discuss the unintended and perverse consequences of the payment system?) and
  • healthcare system regulations (yes, where many problems are caused in the first place).

What Cognology says.

Many of the drivers of problems can be addressed through a combination of professional staff development, better use of information, particularly within decision-support systems to support guidelines and prescribing compliance, and organisational interventions.

 

Smarter and more Intelligent Healthcare in 2035

The King’s Fund, a UK health charity ran a scenario essay writing competition, and here is the link and of course congratulations to the winner: (winner, runner up and other scenarios, but not mine).

My scenario builds on the notion of service unbundling and draws on strong and weak signals of changes likely to impact health and social care perhaps to about 2035. The scenario is written as a retrospective view from the year 2047. My objective was to avoid a doctrinaire scenario.

Unbundling 2035

Between 2016 and 2035, the way that people worked had substantially changed by widespread digitisation of information. Smart machines and robots had moved from doing physical work to being central to much cognitive work and which led to fundamental restructuring of the economy. By 2035, taxation was changing from taxing people to taxing the work done by devices, cognologies, and robots.

The fault lines between reality and expectations were starkly evident during the 2020s, as public investment in health and social care struggled to cope with the rapidly changing world. People were becoming accustomed to flexible access to personalised services that came to them and expected the same from care provision. Rising displeasure at service decline led to middle-class flight to alternatives with rising use of private medical insurance, progressively fracturing the social contract that legitimated publicly-funded care. Indeed, by 2028, 38% of the population used private care, with over 55% amongst Millennials.

Fearful health and social executives and worried Ministers of Health had reacted to these stresses by pulling the system even more tightly together, to protect jobs and avoid the failure of publicly-funded institutions.

This fed further public displeasure by the dominant middle-aged Millennials who challenged the traditional approaches to health and social care. In the United Kingdom, for instance, this unrest led to the 2028 Referendum on their tax-funded healthcare system, leading to the replacement of this system with social insurers and personal Social and Health Care Savings Accounts.

The process of changes in health and social care around the world has become known as Unbundling. This brief historical retrospective outlines three of the key components of that unbundling.

The 1st Unbundling: of knowledge and clinical work

Professional knowledge was affected by digital technologies which had unbundled knowledge from the expert. This changed how expert knowledge was organised, used and accessed; research institutions and knowledge-based organisations were the first to feel the changes, with librarians being one of the first professions to face obsolescence. Rising under-employment, particularly in traditional male-dominated occupations was still being absorbed by the economy.

Routine cognitive work and access to information and services was increasingly provided by cognologies (intelligent technologies) or personal agents as they were called. Widely used across society, they were embedded in clinical workflow from diagnosis to autonomous minimally invasive surgery. By this time, jobs with “assistant” in the title had generally disappeared from the care system, despite having been seen as an innovative response to workforce shortages through the late 20-teens. These jobs had turned out to be uninteresting, and being highly fragmented, required time-consuming supervision.

The benefits of precision medicine were substantial by this time, enabling earlier diagnosis and simpler and less invasive treatments. Theranostics, the merging of diagnosis and therapy, unbundled the linear care pathway and the associated clinical and support work. This also led to the unbundling of specialist clinical services, laboratory testing and imaging from monopoly supply by hospitals. Indeed, the last hospital was planned in 2025, but by the time it opened in 2033, was deemed obsolete.

The 2nd Unbundling: of financing and payment

The unbearable and unsustainable rise in health and social care costs necessitated better ways to align individual behaviours and preferences with long term health and well-being. Behavioural science had shown that people did not always act in their own best interests; this meant the care system needed people to have ‘skin in the game’, best done by monetising highly salient personal risks.

Existing social insurance systems which used co-payments were more progressive in this direction, while countries with tax-funded systems were forced to reassess the use of co-payments, and financial incentives. The Millennials, having replaced the baby-boomers as the primary demographic group, were prepared to trade-off equity for more direct access to care. It also became politically difficult to advance equity as a goal against the evidence of poorer health outcomes as comparisons with peer countries drove performance improvements.

The use of medical/social savings accounts was one way that gave individuals control of their own money and building on consumerist behaviour, this directly led to improved service quality and incentivised provider performance as they could no longer hide behind the protecting veil of public funding. The social insurers were able to leverage significant reforms through novel payment systems, and influence individual health behaviours through value-based (or evidence-based) insurance not possible under a taxation system.

The 3rd Unbundling: of organisations

With people used to having their preferences met through personalised arrangements, care was organised around flexible patterns of provision able to respond easily to new models of care. This replaced the “tightly coupled” organisational approach known in the early part of the 21st century as “integration”, which we know led to constrained patient pathways, and limited patient choices unable to evolve with social, clinical and technological changes.

The big-data tipping point is reckoned to have occurred around 2025. Because the various technologies and cognologies had become ambient in care environments they were invisible to patients, informal carers, and care professionals alike; this enabled the genesis of smaller and more diverse working environments.

By 2032, medical consultants were no-longer hospital-based, having become clinical care social organisations, with their cheaper, smaller, portable, networked and intelligent clinical resources. Other care professionals had followed suit. These clinical groupings accessed additional clinical expertise on as-needed basis (known as the “Hollywood” work model); this way of organising clinical expertise helped downsize and reshape the provision of care and met patient expectations for a plurality of care experiences.

It takes time to shift from the reliance on monopoly supply of care from hospitals in those countries that continued to pursue a state monopoly role in care provision. However, most repurposed themselves quite quickly as focused factories, while the more research-oriented specialised in accelerating the translation of research into daily use, helped along by the new research discovery tools and the deepening impact of systems biology which was making clinical trials obsolete.

What Cognology Says

This Unbundling arose as a product of the evolution of social attitudes, informed by the emerging technological possibilities of the day. The period from 2016 to 2025 was a critical time for all countries, exacerbated by shortages in the workforce coupled with economic difficulties and political instability.

Today, in 2047, we are well removed from those stresses that caused such great anxiety. We must marvel, though, at the courage of those who were prepared to build what today is a leaner, simpler and more plural system, removed from politicised finance and management decisions.

It is hard to imagine our familiar home-based theranostic pods emerging had this trajectory of events not happened. As our Gen-Zeds enter middle age, they will, in their turn, reshape today’s system.

Plus ça change, plus c’est la même chose.

27 December 2047

Note on the Scenario

This scenario is informed by strong and weak signals, including:

Ayers A, Miller K, Park J, Schwartz L, Antcliff R. The Hollywood model: leveraging the capabilities of freelance talent to advance innovation and reduce risk. Research-Technology Management. 2016 Sep 2;59(5):27–37.

Babraham Institute. The zero person biotech company. Drug Baron. http://drugbaron.com/the-zero-person-biotech-company/

Cook D, Thompson JE, Habermann EB, Visscher SL, Dearani JA, Roger VL, et al. From ‘Solution Shop’ Model to ‘Focused Factory’ in hospital surgery: increasing care value and predictability. Health Affairs. 2014 May 1;33(5):746–55.

Cullis P. The personalized medicine revolution: how diagnosing and treating disease are about to change forever. Greystone Books, 2015.

Does machine learning spell the end of the data scientist? Innovation Enterprise. https://channels.theinnovationenterprise.com/articles/does-machine-learning-spell-the-end-of-the-data-scientist

Eberstadt, N. Men without work. Templeton, 2016.

Europe’s robots to become ‘electronic persons’ under draft plan. Reuters. www.reuters.com/article/us-europe-robotics-lawmaking-idUSKCN0Z72AY

First 3D-printed drug just unveiled: welcome to the future of medicine. https://futurism.com/first-3d-printed-drug-just-unveiled-welcome-future-medicine/

Ford M. The rise of the robots: technology and the threat of mass unemployment. Basic Books, 2015.

Frey BC, Osborne MA. The future of employment: how susceptible are jobs to computerisation? Oxford Martin School, Oxford University, 2013.

Generation uphill. The Economist. www.economist.com/news/special-report/21688591-millennials-are-brainiest-best-educated-generation-ever-yet-their-elders-often [accessed December 2016]

Lakdawalla DN, Bhattacharya J, Goldman DP. Are the young becoming more disabled? Health Affairs, 23(1-2004):168-176.

Susskind R, Susskind D. The future of the professions: how technology will transform the work of human experts. Oxford UP, 2015.

Topol E. The creative destruction of medicine: how the digital revolution will create better health care. Basic Books, 2012.

With Samsung’s ‘Bio-Processor,’ wearable health tech is about to get weird. Motherboard. http://motherboard.vice.com/read/with-samsungs-bio-processor-wearable-health-tech-is-about-to-get-weird

The digital future of 21st century arts organisations

A debate started on the Arts Journal on Leadership/Followership raises a number of challenges for arts groups.

In my view, the simple lead/follow dichotomy is not helpful as arts organisations are both repositories of a society’s culture (on behalf of people) and a way to placing before the public new ideas in way that engages and informs (on behalf of new ideas).

Bruno Frey has commented that people may not need to see the original piece of art itself but perhaps a print would do.

You are there!

Taking that notion further, why are exhibitions not online?  An opening could be a simple ‘app’ instead, and the show curated with additional content and searchable features, individual pieces could be zoomed and viewed in the round.

It would not cease to exist when the exhibition closed — a problem for exhibitions in the real world, and poorly captured in the exhibition catalogue. Few people can actually make it to many openings, and moving art around can damage the art itself. The modern world is increasingly location-independent with the use of smartphones and tablet computers making where we are less important when accessing information, people or events; this is likely to evolve further. Thinking past the current fad for social networking (and something will follow Facebook!) leads to a world where intelligent software ‘agents’ can help individuals find and view the art they are interested in, alert them to new shows.

Perhaps some people may be in a position to attend in person, but generally this is not true.

Digital technology allows time-shifting, so I can view the exhibition when I want and probably reduces my carbon footprint at the same time. The openings can be teleconferenced, so people can attend in real-time or listen to later. If I instead choose to attend, then the app becomes my personal guide, which I can annotate and keep.

Ah, but imagine a gallery of giant video screens, the real art protected. It does challenge us to reflect, as Frey does, on what it really is we want to see when we view art: is the experience of the art object itself (if so, why bother buy the catalogue or art books), an experience few really can have, or is it the art (in which case the sale of posters is explained).

It seems to me that arts organisation leadership might benefit from a dose of ‘disruptive’ thinking to embrace modern possibilities. We now have, for instance, galleries with searchable online catalogues, and we find some degree of interactive art itself, but this is a feature of the art not of the art experience. I wonder if today, the “2 second advantage” (to take from a book of that name) for arts organisations offers a clue on how to move beyond the collection idea to something rather different.

The notion of capturing artistic interests in ‘real time’ would enable a ‘video-enabled’ gallery to be able to anticipate art interests (though mindful that much needs to be made of the random ‘shock of the new’ that accompanies the joy of discovering a new artist), and assemble art for the individual in a way that helps them experience the art more personally. I miss not being able to visit some galleries which house art I like because I simply can’t afford the airfare to visit them — the ability to be telepresent in these galleries would be wonderful and at $£€4.99 worth a lot more than the book.

As I’ve said elsewhere, there’s an app for that.

Just a thought…….

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Hinge-point: the social media and technology revolution in the art world

“Hinge-point: the social media and technology revolution in the art world”

Originally published in Art of England, Issue 65, 2010. Reproduced with permission.

Recently, I went to an exhibit of a friend, who with colleagues, produced a piece called “Cases” using iPod videos as an installation probing the nature of health and the senses – son et lumière for the iPod generation. Their work resonated with thoughts I’d been having of the impact of new technology on art. Art and technology have always been linked, but it seemed to me as I looked at the iPod videos and listened to the eight different ‘cases’, that something potentially more disruptive might be on the horizon.

What interests me is that new and emerging technologies enable art to be made by a wider range of people, through a social-democratising, accessible and open process. “Who is the artist?” becomes a very interesting question.

Some food for thought…

Commuters crowd many corridors across the city during the morning rush-hour, all is hustle and bustle. Their sighs, words, movements, are captured by sensors, and translated into real-time images which animate the otherwise naked walls. The work is called “I’m thinking of you right now”.

My hand flicks, a gesture in space, and a coloured beam races across a wall embedded with nano-particle sized LEDs. I toss the Wii-Art wand into the air and another light curve spreads across the ceiling. The room will remember what I have done, but I can always change it later.

The 3D printer buzzes on the table beside me, chunks and bumps while a 3D sculpture takes shape made of polymers, resins and colouring. I have created a probably impossible object from samples of space that I bundled together with my smartphone camera and downloaded to my computer.

Slouching in my comfy chair, I put on the headset to have my thoughts read. I call up the latest issue of Art of England on my Plastic Logic e-reader. The computer records what I am thinking and produces a picture which I can play with later, or print out on canvas. Apparently, some people still use paint – how yesterday!

The artificial intelligence, called Alicia, shares my likes and dislikes. Alicia is my writing buddy and editor as I work on my next novel; she has a real instinct for narrative. My friend’s AI, he calls his Boris, is a painter and together they are an artist collaborative. Alicia apparently wrote Boris a poem. Should I be jealous?

One hundred people link their smartphones and flash-art a sunset, capturing what they see and collectively producing a single painting from 100 different perspectives at the same time. The image appears on YouTube and is viewed by 100 million people. 100,000 people buy the image for a pound.

I am less concerned with how artists today are using technology. Artists always adopt and test out new technologies, e.g. watercolour, acrylic paint, plastics, video, computer animation, digital printers, PhotoShop or GIMP, and so on.

What is significant is that new and emerging technologies lower the costs and time of art-making, and reducing these hurdles increases accessibility for people who in the past found the existing technologies (of paint, canvas, stone, clay) formidable. I think we’re at a hinge-point in art and art-making because of this and which could radically alter what we think of as the ‘art world’.

In the end, anyone can be an artist. Technologies will facilitate creativity to enable more people to have artistic expression. The Web and social media make collective art-making possible as we move beyond individual authorship. There will be implications for art schools – whom and what they teach; commissioning bodies — whom they support; galleries – what they are like; and artists – what they are for.

And the meaning of art will change. Art is often thought of as special, in public places, commissioned, housed in galleries where you can’t touch, exclusive, remote. Art can be obscure, requiring specialist interpretation; it is often inaccessible and mute to the majority of people. Through technologies, art will become embedded in the fabric of our lives; it will be ambient and ubiquitous. It will be social and shared as much as individual. By democratising art and art-making, new technologies and social media will make it more important and relevant.

Please touch the painting.

There’s an app for that

“There’s an app for that”

Originally published in Art of England, Issue 79, 2011. Reproduced with permission.

The last roll of Kodachrome film was shot by photographer Steve McCurry, and developed in the last place, apparently on Earth that has the equipment, a drug store in Kansas. Kodachrome represented a way of seeing, it was not just film. No more Kodachrome skies, no more trying to figure out what the 1973 song “Kodachrome” by Paul Simon means. But with my smartphone, there’s an app for that.

My rather large CD collection has been reduced to a digital gas in a player the size of my thumb, while the CDs are in the garage; the LPs are long gone but I still have my Rega™ turntable, but ‘just in case’ will never come. With my smartphone, there’s an app for playing my whole collection.

I traded in my square format 6×6 analogue film camera, not even a battery, for a pile of digital kit so I can ‘fix’ them on the computer. A bloodless way to interact with the world. Why bother even take the picture in the first place, as I could probably just download some images, and I’m just a cut-and-paste away from what is probably the nearest thing to digital heaven. But there’s an app for that, too.

I have a 1930s leaky camera with almost no adjustments that takes really moody pictures, and seems to capture the scene at the moment far better than digital manipulation ever will — is that possible? Using film meant the image-taking moment mattered and required what the photographer Freeman Patterson calls ‘the art of seeing’.

We look, but don’t see. Where is the in-the-moment feeling of exuberance when creative juices flow and time stops?

For under a thousand pounds you can now buy a 3D printer, a sort of Star Trek replicator that can literally ‘print’ 3D plastic objects, such as a vase, jewellery or something more abstract. Lose something? Print another. It sits on the corner of your desk.

The question is whether something from an app, or a 3D thingee, will ever be art worthy of note. I feel I want to distinguish between the brute force of the technology as a marvel (gee, look what I did, serendipity wins again!), and something that might have actually passed through a human mind in some mystically moment of creativity. McLuhan spoke of hot and cool media and of the message and medium. When do the tools of creativity become more important than the results?

But all this shall pass. The invention of photography was seen as the end of art, and so far that has proved at least premature. Are you a serious painter if you use acrylics rather than oil on the mandatory linen canvas? Good artists have always embraced new technologies and attained mastery over them to achieve sometimes stunning and sometimes pretty dire results. But today, are artists experimenting and pushing boundaries or just mucking around?

Could painting become a screen capture moment, or could sculpture be done by robots controlled by the artist, in the way that surgeons can use robots to perform precise surgery (yes, Virginia, there is a robot for brain surgery).

So, here I write this article on my computer with some wizzy writing software, and my analogue mind. Despite the software suggesting how to end a particular word, I hope it will never, ever be able to begin a sentence for me. And the same for art.

But perhaps there’s an app for that, too.