• Personalised care
  • Dr Conuslta’s eHealth and technology business model’s transforming Brazil’s healthcare

    Extending healthcare access is one of eHealth’s objectives. Using it to improve healthcare efficiency can help, but modestly. Dr Conuslta, a Brazilian start up in 2011, shows that an imaginative and innovative business model that uses eHealth and medical technology to relocate blocks of healthcare and slashes its costs for low-income families may have more impact. It’s a model that can fit Africa’s UHC goals.

    An article in Forbes describes the initiative. Dr. Consulta charged patients a flat $30 fee for a consultation with a physician of their choosing from 50 specialties. Some patients pay nothing, depending on their health condition and ability to pay. Prices for on-site exams, such as MRIs, blood tests and mammograms range from $3 to $30.

    Typical premiums for Brazil’s health insurance plans for access to one GP can be about $120 a month Off-site exam fees for lab work or specialist visits can be about $200 each, more than six times Dr Consulta’s higher rates. Only about 25% of Brazil’s population can afford this.

    These low prices are achieved by a business model that invests in diagnostic technology and services in clinics and using AI to develop its own EMRs. It also engages some healthcare professionals as co-workers who use Dr Consulta’s clinics as a resource, not as employees. These combine to achieve high patient volumes, long-term relationships with patients and low-price out-of-pocket payments that sustain financial viability. The large, stored clinical data volume helps to achieve precise medical outcomes, which in turn, reinforces this long-term  relationships with patients

    Dr Consulta’s eHealth includes AI to analyse scientific and medical statistics to identify the probability of people contracting chronic health conditions. It can then treat them promptly to minimise or eliminate the risks. It engages patients with updated information and recommendations about their illnesses or conditions.

    These bespoke communications are constructed from information in the core health management data warehouse using the Oracle marketing tool Responsys. For each patient, using age, health history and treatment plan, the Responsys automatically recommends:

    The new health services provide links for patients to schedule services. After each visit, Dr Consulta sends follow-up surveys to solicit feedback on patients’ experiences with their doctors and their results. Cloud applications support its marketing, finance and supply chains complete the eHealth profile. While it’s extensive and modern, its benefits depend on the transformative impact of its business model. Large, established hospitals with eHealth legacies are often less agile in reaching under-served, low-income patients. Dr Consulta’s a healthcare model that Africa’s health system could consider as part of their UHC pursuits.

  • GPS tracking finds a role for dementia patients

    Location, location, location’s not just a property agents’ mantra for house hunting and valuations. It’s essential for dementia patients and their health workers and family carers too. Knowing the whereabouts of the patients and loved ones can be supported by GPS. A NHS organisation in Dorset, UK’s testing a tracking device in shoe insoles to know patients’ locations and help to keep them safe.

    It was reported in a BBC Radio 4 programme that alerts are sent to carers’ mobiles when users stray from designated areas. The can be a nursing home yard or garden. The GPS can pinpoint patients precisely to map. When they stray, they can be found, minimising the risk of harm and needing hospital care. 

    Alz Products makes trackers prices at £75 and a £26 monthly fee. They can be transferred to other footwear, so it’s a price per user. 

    A report from the South Central Region of the Dementia Action Alliance South Central Region says there are 670,000 people with dementia in England and 550,000 friends and family acting as their primary carers. Socio-economic costs across healthcare, social care and wider society are estimated at £19b in 2011. It’s more than cancer, heart disease or stroke costs.   

    These kinds of impacts from imaginative innovation offer Africa’s eHealth programmes direct patient and healthcare benefits. They need a significant place in their strategies and plans.

  • How can online health information avoid negative results?

    Type “health information” into your favourite search tool.  Then, prepare to scroll through over 2.6 million results. The negative effect of these sources on users hasn’t been examined.  A study led by Reem El Sherif at the Department of Family Medicine at McGill University in Montreal, and published in the Journal of Medical Internet Research (JMIR), aims to deal with it.

    Two goals are:

    Describe negative outcomes in primary careIdentify potential preventive strategies from users, health practitioners and health librarians.

    It found three types of interdependent negative outcomes:

    Internal, such as increased worryingInterpersonal, such as a tension in patient-clinician relationshipsService-related, such as postponing clinical encounters.

    The study links them as:

    Three types of strategies were identified that aim to reduce these negative outcomes. They were:

    Providing users with reliable informationEducating users on how to assess websites that provide health informationHelping users to present and discuss their online information with health professionals, their social networks or librarians.

    These are integrated too:

    Librarians have a core role in minimising negative outcomes. Responsible for providing reliable health information and advocating the advantages of using health websites, they’re well positioned to implement the preventive strategies. Their work with users and health practitioners can integrate them with users’ health information–seeking and ensure the reliability of the information they find and use. Improving health literacy can lead to fewer internal tensions. Librarians can also develop discussions with health practitioners, leading to fewer interpersonal tensions. Their third contribution’s helping users to find relevant information so they can make better health and health care decisions, leading to fewer service-related tensions.

    While this might seem a bit obvious, the researchers identified two barriers that needed overcoming. One’s a lack of awareness of available health librarian services. The other’s a lack of access to health librarians by the public. A possible solution is to train community librarians working in public facilities, such as libraries, on how to provide health information services.

    Africa’s health systems should consider these additional costs of online health information. Without these resources, their investments in online health information may not realise the benefits requires of them, so an inadequate return.

  • 3D printing makes a breakthrough in personalised healthcare

    3D printing may open up a whole new chapter of opportunities in the pharmaceutical industry.  There are a number of ways it could be used; drug dosage forms, supporting delivery, or helping to research cures.

    3D printing, also called stereolithography, creates objects by fusing different materials, layer by layer, to form a physical version of a digital 3D image. In the last 15 years, 3D printing has expanded into the healthcare industry, where it’s used to create custom prosthetics and dental implants. 

    Now, there may be an opportunity to use it for personalised healthcare as well.  This was achieved by Aprecia Pharmaceuticals who became the first pharmaceutical company to produce an FDA approved 3D printed pill for epilepsy in 2015.   The drug is made using their proprietary ZipDose Technology platform to produce a high-dose of leviteracetam in a rapidly disintegrating, easy-to-swallow form. 

    Personalised 3D-printed medications, deploying customised dosages, may serve particularly well for patients who respond to the same drugs in different ways.  It may also allow pills to be printed in a complex construct of layers, using a combination of drugs to treat multiple conditions at once.  This could help reduce adverse drug reactions and poor adherence to medications for patients on multiple medications. For Africa, this could be a solution for adherence to ARV and TB medication, especially amongst children and the elderly.

  • eVisits create more visits

    Long before eHealth, the 18th century Scottish poet and farmer, Robert Burns, alerted us to the risks of projects having a mind of their own. His poem to a Mouse, a field mouse to be precise, gave us a permanent truth that "The best laid schemes o' mice an' men / Gang aft agley.” Since then, management and academic gurus have encapsulated it in more prosaic theories.

    Another human condition inspired by his field mouse was “I backward cast my e'e, On prospects drear!” A big advantage of retrospective evaluations is identifying unintended consequences. These can be extra benefits or extra costs. At an extreme, they can make a problem worse, such as Black Swan events, Nassim Nicholas Taleb’s concept, or unmitigated large-scale risks. Robert King Merton, a US sociologist awarded the National Medal of Science, promoted the concept. It’s important for eHealth strategists, planners and developers know if and when they’ve created any. Then, they need to fix any that are adverse, not rationalise them.

    A study published by Social Science Research Network (SSRN) found two unintended consequences arising from eVisits, a secure messaging service  between patients and providers. Generic goals are to improve healthcare quality and increase providers’ capacity. The team from Wisconsin University and Wharton School at Pennsylvania University found that eVisits create about 6% extra office visits by patients to their doctors. It also found mixed results on phone visits and patients’ health.

    The increased demand reduced capacity. It redeployed time allocated to phone visits, and 15% fewer new patients were accepted by doctors each month following their eVisits implementation. These results are from almost 100,000 patients over five years from 2008 to 2013, a period that includes eVisits’ rollout and diffusion.

    Taken together, the two findings may be good value for the 6% who may be accessing healthcare they need, but they might have delayed or foregone. It’s not good for the 15% who may have given up on healthcare they need.

    The adverse effect was more pronounced for healthcare organisations already at or near capacity. These seem like high priorities for eVisits’ potential. The study also reveals the difference between eHealth’s potential and its probable net benefits. Rarely, if ever, does eHealth operate at its full potential. A probable performance below this can create viable net benefits. Falling well short creates negative results.

    Africa’s health systems can test these unintended scenarios using effective business case methodologies. Risk adjustments that convert an ostensibly attractive project into a negative can reveal the scope for unintended consequences to come into play. It provides decision-takers an opportunity to deal with them prior to the event.  While another of Burns’ lines was sceptical about estimating. He thought “Foresight may be vain.”

    Maybe, but it’s better to model and test an unwelcome future than stumble into it.

  • IHE’s point of care ID management

    Accurate unique patients’ IDs are more than essential. Deviations from them can cause harm when using electronic sensors to observe patients’ physiological states are a common part of clinical treatment of patients, especially those critically ill. Recognising the importance of correct patient IDs in this context, the IHE Patient Care Device Technical Committee has published Point-of-Care Identity Management, a white paper for consultation. It considered comments submitted by 26 February 2017 and will now be moving on to finalise the proposals.

    With devices providing routine and regular mission-critical data, clinicians must be able to rely on the accuracy, currency, completeness and routing of eMessages between these devices and systems. Where this fails, treatment may be harmful rather than helpful. The IHE concept of Device-Patient Association (DPA) is consistent with the five rights of medication administration, the right patient, drug, dose, route and time.

    For devices, it translates into the right patient, devices and time. Every measurement must go to the right chart, every chart must have every measurement, and every device command affecting a patient must be sent to the correct device acting on that patient.

    The white paper:

    Reviews use cases and system architectures in which electronic information exchanges about device-patient associations may and may not be beneficialDiscusses risk analysis approaches that may be appropriate for institutions reviewing their risks of data misdirection due to incomplete, incorrect or untimely DPA assumptionsSuggests basic eMessaging formats for reporting, collecting, disseminating and querying DPAs.

    As Africa’s health systems expands in EHRs, mHealth and medical device investments, adopting and applying the IHE’s standards are crucial. The white paper’s a lot more than just essential reading.

  • Check your sexual health at home with Everlywell

    Most Sexually Transmitted Diseases (STDs), sometimes referred to as Sexually Transmitted Infections (STIs), do not reveal their symptoms initially. This covert nature creates a risk of passing the disease on to other people.

    The WHO says there’s a daily global prevalence of more than a million acquired STD. Trichomoniasis, chlamydia, gonorrhea and syphilis are the most common STDs. Globally, they’re responsible for 143 million, 131 million, 78 million, and 5.6 million infections respectively. 

    In 2015, the Centre for Disease Control and Prevention (CDC) reported a record increase of STDs in the age group between 15 and 24 years old. Over 1.5 million chlamydia cases and 400,000 new cases of gonorrhea were reported. These alarming rates propelled Everlywell to add STDs testing to their repertoire to equip young people with a simple, hassle-free way to access tests.

    Everlywell, based in Austin Texas, launched its diagnostic testing kit last September. It offers a digital platform which provides a convenient at-home testing for clients says an article in MobiHealthNews. By avoiding numerous doctors’ appointments and lab results, Everlywell provides online test orders with required samples sent to the nearest certified laboratory for analysis. Here, expert physicians review the results and report them back online after a few days. It’s like Computerised Physician Order Entry (CPOE) with patients replacing physicians.

    The STD diagnostic test kit costs $249. It deals with diseases such as HIV, syphilis, herpes type 2, gonorrhea and chlamydia. In cases of abnormal results, like testing positive for a curable or incurable condition, trained physicians follow-up, provide prescriptions for required medications and, for life changing results, will provide counselling services and guide you through the next steps.

    Young people globally face many barriers when they access or receive reproductive health services and quality STD prevention and management services. This is especially true for many African countries that don’t have the resources to allocate to STD prevention and treatment.  These barriers include, lack of transportation, long waiting times, conflicts between clinic hours and work or school schedules, embarrassment and stigma attached to seeking STD services, and concerns about privacy and confidentiality. Consequently, many would rather suffer in silence than try to seek help. By enabling people to perform STD tests in the comfort of their own homes, Everlywell, bridges these gaps. It encourages and increases STD testing, and provides a frequent, easier, less embarrassing and more convenient way to test, treat and manage STDs. For this initiative to succeed in African countries, the cost and healthcare capacity to care for more patients need addressing.

  • Capacity for more genome data's needed

    A team for universities and institutes in Seattle and Cambridge Massachusetts has tracked the family trees of individual cells in zebrafish. As more genome data becomes available for personalised care, eHealth will have to expand its capacity to hold and use the data. The findings are in Science. 

    It was already known that multicellular systems develop from single cells through specific lineages, but tracing methods scale poorly to entire, complex organisms. To improve on this, the team used genome editing for progressive and cumulative diverse mutations in a DNA barcode. They repeated it over numerous rounds of cell division.

    The barcode’s an array of Clustered Regularly Interspaced Short Palindromic Repeat (CRISPR)/Cas9 target sites. It marks cells and enables elucidation of lineage relationships using mutation patterns mutations shared between cells. In cell culture and zebrafish, the team showed rates and patterns of editing as tunable, and that thousands of lineage-informative barcode alleles, gene variants, can be generated.

    Samples of hundreds of thousands of cells from individual zebrafish identified most cells in adult organs deriving from relatively few embryonic progenitors. Future genome editing of synthetic target arrays for lineage tracing using GESTALT can generate large-scale maps of cell lineage in multicellular systems for normal development and diseases.

    This type of genome data and knowledge seems set to keep expanding. Using it routinely for mainstream healthcare will need expanded eHealth capacity. It’s another investment stream for Africa’s health systems to consider for their eHealth strategies. They’re becoming more challenging.

  • Eight technologies are changing healthcare

    There’s no denying that healthcare has undergone dramatic changes in the last ten years. New technology and innovations available to patients enables them monitor and take responsibility for their own health, and improved devices and tools available to doctors and other health professionals can make more informed decisions. Healthcare technology keeps moving along. An article in The Guardian looked at the top eight technologies that’ll keep transforming healthcare. For Africa, the balance and pace of investment in the eight technologies will be different to developed countries.

    The smartphone

    Although not new, it’s clear that the smartphone’s healthcare potential’s yet to be realised. Smartphones can serve as the hub for new diagnostic and treatment technologies. We’ve seen apps developed to support a wide range of healthcare activities, such as healthier life-styles, diabetic patients, treatment adherence and depression. Patients can also use tools like the AliveCOR ECG, embedded in a smartphone case, which helps interpret heart test results via an app and facilitates sharing with clinicians. They’re also ideal for gathering large amounts of data to improve understanding of diseases in populations.

    At-home or portable diagnostics

    Clinicians can now bring hospital-level diagnostics devices to patients’ homes, such as portable x-ray machines, blood-testing kits and other technologies.

    Implantable drug-delivery

    Drug adherence is a big problem, especially for patients with long term conditions. It’s estimated that between a third and a half of all medication prescribed to people with long-term conditions isn’t taken as recommended. Several technologies are already under development to address the problem. There’s sensor technology so small it can be swallowed and combined with drugs in smart pill form. When the pill dissolves in the stomach, the sensor’s activated and transmits data through a wearable patch to a smartphone app. Patients and clinicians can see how well they are adhering to their prescription, though it raises important questions about patients’ privacy and autonomy.

    Digital therapy

    Digital therapeutics are health or social care interventions delivered using a smartphone or a laptop. They embed clinical practice and therapy into a digital form to provide computerised cognitive behavioural therapy (CBT)

    Genome sequencing

    Advances in genome sequencing and the associated field of genomics will give doctors a better understanding of how diseases affect different individuals and populations. These genetic profiles of people’s diseases and knowledge of their response to treatment, it should be possible to predict their response to treatment and prognosis more reliably.

    Artificial intelligence

    Machine learning is a type of artificial intelligence that enables computers to learn without being explicitly programmed, meaning they can teach themselves to change when exposed to new data. Enlitic, IBM’s Watson division and Google’s Deep Mind have started to explore potential applications in healthcare.

    Blockchains

    Blockchains are decentralised databases that keep records of how data’s created and changed over time. They’re trusted as authoritative records without a single, central authority guaranteeing accuracy and security. Electronic health records are widely used, but they are usually centralised, provided by a small number of suppliers. Some commentators have described how records using blockchain technology would bring benefits like resilience and encourage interoperability, with patients and clinicians given encryption keys to control who sees the data.

    Online communities

    Social networks bring together people with interests in healthcare to support each other, share learning and provide platforms for tracking health data, helping people manage their condition and contributing to research. 

    New technologies bring new opportunities for Africa’s health systems. They can help to improve the accuracy, reliability, availability and add value of information gathered, change how and where care’s delivered and offer new ways to prevent, predict, detect and treat illness. The numerous choices makes rigorous strategies, plans and investment decisions challenging, but essential.

  • Better patient identification = better patient care

    Complete and accurate patient identification’s a long-standing challenge for Africa’s health systems. Health Data Management has a report by Imprivata on Improving patient care with positive patient identification. It starts with the premise that efficient, quality care starts with positive patient identification (ID), then errors jeopardise patient safety, impede patient engagement and cause serious financial and cost inefficiencies.

    In the USA, the scale of the problem’s a duplicate medical record rate 8 to 12%, with about 40% of records with blank or default values in one of the key data fields of first name, last name, date of birth, gender or social security number. The American Health Information Management Association (AHIMA) identified these in “Building an Enterprise Master Person Index and at its Convention presentation on Technology Influence on Data Integrity & Impact on Patient Safety in 2008. An estimated 92% of duplicate errors arise from inpatient registration ID mistakes. It’s reasonable to assume that Africa’s health systems aren’t better than this. 

    Imprivata says that effective patient ID systems should: 

    Minimise the opportunity for human error by providing a robust biometric alternative to paper and oral patient ID processes Minimis the chances of algorithmic error by using a strong, unique patient ID method Optimising interoperability by integrating directly with existing information systems by creating a 1:1 match between each patient and their unique medical records Maximise patient adoption and ease of use by providing intuitive, non-intrusive design, easy ICT management, and a pleasant patient experience.

    Africa’s health systems and eHealth seem a long way from a biometric solution. Imprivata’s four goals still offer a set of objectives that Africa’s eHealth can move towards. It needs an extra step adding with a reliable link to better registration of births and deaths.