Monday, 29 December 2014

Deconstruction of primary care

The renowned Harvard professor Michel Porter, with the collaboration of two GPs, one veteran, Thomas Lee, and the other on training, Erika Pabo, applied to primary care their well known proposals of adding value to clinical performances. Their article, published in Health Affairs, caused me to act cautiously because I didn’t believe any American proposal of reforming primary care could benefit us as we enjoy a much more evolved model. But when I noticed that the first author was Michael Porter, I couldn’t help taking a look.

Primary care (gatekeeper type), Porter and his colleagues say, is now served on a single dish, like a stew (they don’t actually say that). Continuous care prevails, always the same chef for every meal, an almost artistic development, case by case, plate by plate. According to them, this makes it difficult to measure the provided value. On the other hand, the most common model in the US, where the patient goes to a specialist in their own terms, is chaotic and promotes a disproportionate consumption of resources.

Monday, 22 December 2014

Recommendations against low value clinical practices. Are they useful?

Owen Dyer, a journalist and regular contributor to the British Medical Journal, following the Choosing Wisely campaign from the ABIM Foundation (a list of recommendations for clinical practice that both doctors and patients should question) in the US, makes an assessment of whether the lists of recommendations against low value clinical practices will manage to change the status quo or, on the contrary, the dynamics of the system will engulf them as it has done with many other initiatives.

Monday, 15 December 2014

The Hospital of the Future: New Report (UK)

Sir Michael Rawlins, Chairman of the National Institute for Health and Care Excellence (NICE) since its inception in 1999 until last year, is now Chairman of a committee called "Future Hospital Commission" which has been promoted by the Royal College of Physicians. In September 2013 this committee issued its first report and I think it’s worth discussing.

For starters, it seems appropriate to pick up the 5 challenges that hospitals are facing nowadays according to a previous Royal College of Physicians’ report:

1. Increased demand in an environment of reduced number of hospital beds
2. Case mixe’s gradual and persistent advance towards chronic diseases and geriatrics
3. Difficulties of coordination and continuity of services for admitted patients.
4. Services of uneven quality in the evenings and at weekends
5. Imminent crisis of professionals and training of new professionals

To face these challenges, according to the "Future Hospital Commission", the hospitals should consider reorganization based on the following principles:

Monday, 8 December 2014

Medicine focused on patient preference: visual aids

Some argue that the great innovation in this second decade of the twenty first century should be medicine based on patient preference. To understand it better, it’s about women being well informed of all probabilistic knowledge regarding the decision to have a mammogram screening or not. Therefore it is the woman who takes responsibility for her decision and not the government or insurance company of her choice. The same would be said for men and the PSA.

This approach would seem reasonable enough, if it were not for the fact that, according to a particular US survey (National Adult Literacy Survey), half of the population has difficulty in managing simple numerical operations. For this reason I have chosen this blog post by Kevin Pho, who has always been innovative in the field of clinical management, who presents an article by Peter Wei, a medical student, who gives us a visual aid developed by the Mayo Clinic. You can argue that those who struggle with mathematical operations will also have difficulties interpreting graphs, but if the graphics are designed to be understood its less of an issue and if that is not the case, consider the following:

Monday, 1 December 2014

High Value Healthcare: Porter and Lee proposals

Michael Porter, professor at Harvard Business School and Thomas Lee, Medical Director at Press Ganey, an organization aimed at improving the patient healthcare experience, published an article on the HBR Blog Network:  "Why health care is stuck and how to fix it". These two teachers, tired of analyzing the stubborn (and chaotic) reality of the American healthcare system, have decided to focus on making strategic proposals to change things.

How can it be that with so many good and well-intentioned people involved in reforming the American health system, they can’t find a solution? Almost the opposite happens: it seems that the opposing positions are increasingly reinforced.

The authors ask this rhetorical question, although they, far from disenchanted, still insist on the idea that solutions can only be systemic, as this is where the problems lie in the model.

Monday, 24 November 2014

Oncological Care: What does the IOM Report reveal?

Ten years after the first report, the Institute of Medicine has published a new study on the quality of cancer care in the United States, forced, according to experts, because the situation is far from improving. To better understand this work, we have to contextualize it in the United States, where they have serious problems of access to cancer care, coordination between professionals and exaggerated costs of clinical processes.

On the other hand, cancer care in our country is, obviously, more accessible and more coordinated than the United States, but nevertheless you will agree with me that we lack, by contrast, the evaluation and analytical capacity of Americans, and for this reason I believe that the findings presented in this report should teach us something with the intention of overcoming our own inefficiencies, because we do have them.

The IOM expert committee concluded that the model of cancer care in America is in crisis, mainly due to three factors: a) the clinical process too often does not focus on the patients’ preferences, b) many patients only receive palliative care at the end of life, and c) clinical decisions too often are not based on evidence.

Monday, 17 November 2014

"The Right Care Alliance" – The Statement of Principles

In 2012, The Lown Institute held a conference in Cambridge (Boston) with the motto "Avoiding Avoidable Care” which generated a statement aimed at creating a professional, academic and social movement in favour of a new health system that is sustainable, effective, rational, personalized and fair. You would think, of course, that the The Lown Institute refer only to the American system, which we all know is deeply unfair and expensive. And this would be so, if it wasn’t for the fact that, in a system like the Spanish, which is infinitely fairer than theirs, when we analyze it in detail we can also note the clinical practice’s undesirable variations of a scale comparable with the American’s.

For this reason, I think it's worth having a look at the statement promoted by The Lown Institute: "Declaration of Principles of the Right Care Alliance". Look at the following extract from the explanatory memorandum of the Declaration and judge whether they are timely or not:
  • Modern medicine offers significant benefits, but at the same time also has a great ability to cause damage.
  • The overuse of services is widespread and tacitly accepted by the modern healthcare system
  • Overuse exposes patients to iatrogenic disease.
  • Overuse distracts resources that could be used in real health needs or in investments in other non-health sectors that influence the health of people as social services, education, nutrition, etc.
  • The health sector industry can distort clinical decisions to the point of betraying patients’ trust. 

Monday, 10 November 2014

Resident’s values and the hidden training program

Dr. Rafael Manzanera, the author of this week’s selected tweet, is a doctor with a career related to the planning and management of public health. Now he is responsible for quality and "knowledge management" at MC Mutual.

Monday, 3 November 2014

Deprescribing: a Preventative Decalogue

Lluís Triquell is a hospital pharmacist, doctor and PDG IESE. As a managing partner of Antares Consulting, he has focused his field of expertise towards the bio-industry and pharmacy, areas where he is particularly active, both in his professional life and on Twitter.

Lluís Triquell’s tweet brings us to a Decalogue published in the online magazine NPS Medicinewise, an Australian organization specializing in searching for evidence in the field of medicine and in diagnostic tests. In this Decalogue, NPS offers a number of tips that should be taken into account when prescribing drugs to the elderly. It is, therefore, to prevent de- prescribing with 10 simple criteria.

Thank you, Lluís, for giving us this opportune link.

Jordi Varela

Monday, 27 October 2014

More material against low value clinical practices

Dr. Joan Escarrabill is the Chronic Care Program Director of the Clínic Hospital. As a pulmonologist, he trained and developed his career in Bellvitge Hospital, where he had the opportunity to exercise various responsibilities in the field of clinical management. And now he has given us the selected tweet that leads to "Mayo Clinic Proceedings".

If you click on the two links from Dr. Escarrabill’s tweets, you’ll reach a project (and the introductory editorial) which reviewed over two thousand articles published over 10 years in the New England Journal of Medicine with the rank of "Originals". This work has identified 146 studies that advise stopping certain medical practices that are failing to demonstrate expected clinical outcomes.

Therefore, Dr. Escarrabill with his tweet, offers us a new key to strengthen programs calling for clinical practice to focus only on the actions that are known to add value to the health of people (see posts from: "Too much medicine", "Less is more", "Choosing Wisely", "Do not do" and "Projecte Essencial"). This movement of clinical containment led by professionals is taking shape in the United States under the name "The Right Care Alliance".

Monday, 20 October 2014

New diseases: new?

Enrique Gavilán is a family physician who has a habit of providing good professional quality "material" on Twitter, especially with regards to evidence in overdiagnosis and overtreatment.

On this occasion, I have chosen a tweet from Dr Gavilán which refers to a work published in "PLOS Medicine" that analyzes 16 studies where there have been criteria changes in the diagnostic definitions of common diseases such as: hypertension, asthma, attention deficit hyperactivity disorder (ADHD), COPD and dementia, among others.

One finding of the study was that these changes in criteria were mainly in three directions: creation of pre-conditions, lowering superior analytical values ​​and introduction of methods of early diagnosis. Another discovery is that these changes in criteria, which only serve to increase the legion of people affected by supposedly pathological conditions, are not accompanied by evaluations of the negative or even harmful impact to the health of "new patients". And there's a final finding: many of these studies have been developed by researchers with an economic interest linked to pharmaceutical companies directly involved in the proposed criteria changes.

Jordi Varela

Monday, 13 October 2014

Rethinking the doctor’s appointment

Thomas Goetz, the author of the this tweet, has been executive director of "Wired" magazine (a reference in the world of technology and futurism), and he has joined the Robert Wood Johnson Foundation (RWJF). According to him, he now intends to implement innovative concepts that he has been promoting from "Wired" to see the intellectual production of RWJF, surely he will succeed.

The chosen tweet refers us to the RWJF Blog where he writes that the doctor's office is a place where the real value activity is being conducted and recognizes that the doctor's office is the most important resource of the health system. But then he adds from his particular vision, that in fact this resource has many details yet to be improved: the information between the parties is asymmetric, the communication is full of misunderstandings and as a result, often the patient leaves the office having heard, but not having understood some fact that then reduces a lot the effectiveness of the subsequent planned clinical procedure.

As he states in the blog, Thomas Goetz will devote his energy and knowledge to encourage improvements in this field. Therefore we’re looking forward to it.

Jordi Varela

Monday, 6 October 2014

Clinical safety: "The Leapfrog Group" and other benchmarkings

The Hospital Safety Score is a scaled assessment (A / B / C / D / E / F) of American hospitals that aims to provide that insurers and citizens have access to proven clinical safety information offered by each hospital in the system. The Hospital Safety Score is a summary of 26 parameters that feed on both a voluntary survey and official sources: AHRQ (Agency for Healthcare Research and Quality), CDC (Centre for Disease Control and Prevention), CMS (Centres for Medicare and Medicaid Services) and "American Hospital Association Annual Survey."

Monday, 29 September 2014

Hospital Benchmarking: Top 20 Iasist and "US News Best Hospitals"

Benchmarking is a healthy exercise but to do it in the healthcare field it’s necessary to have solid databases, to know how to select consistent indicators and how to adjust and refine the data to the maximum so that the results are really comparable. In this post I want to discuss the essence of two famous private competitions, one Spanish and one North American.

Iasist, a company specializing in health information management has announced the 15th edition of the Top 20, a competition amongst Spanish hospitals which is voluntary, free and anonymous where only the results of the nominees and the winners are published. The purpose of this competition is in the winners’ institutional prestige.

Monday, 22 September 2014

The heuristic effect on shared clinical decision

The Commonwealth Fund is a private, nearly century old organization that was created with the mission of promoting efficiency, quality and accessibility of the American health system.

Our tweet of the week, issued by the foundation, brings us to a very interesting article written by Lisa Rosenbaum, cardiologist, and published in "The New Yorker", where she uses several examples from her own practice to illustrate the difficulty of the exercise of "shared clinical decision." One of the cases discussed is that of her own mother, a cardiologist like her, who broke her arm in four places, and when faced with the severity of fractures, the orthopaedic surgeons advised her that she consider the possibility of surgery, which included a risk of between 20 and 50% of developing avascular necrosis of bone, while, if following a conservative treatment with immobilization and subsequent rehabilitation there was a risk, not estimated numerically, of  residual functional limitation and post-traumatic arthritis.

As Dr. Rosenbaum says in the article that the "shared clinical decision" is a very attractive proposition for politicians, investors and researchers, but, instead, in practice each day, the doctor who practices this technique faces two phenomena that are very difficult to handle: the first is called "heuristic effect", a concept that reflects the idea that us people, at decision time, allow ourselves to be influenced more by emotion than by the figures, such as: "a friend of mine died in the operating room and therefore no matter what they say, the doctor will not trick me", or the opposite: "the upstairs neighbour was operated on when it was too late to save her leg. I'll have to talk to the doctor to see if they should send me to the operating room". The second phenomenon is the unequal agency relationship established with the patient, and this is expressed when at the end, after sharing lots of information and lots of numbers, the patient looks at the doctor and asks, "Doctor, if it was your mother, what would you do?” Or as the author writes "You're my quarterback. Do you understand?".

Jordi Varela

Monday, 15 September 2014

Nurse demand management in primary care

Nurse demand management, aims to respond, within the scope of the nursing profession, to people who go to a primary care centre with a health problem that requires special attention. This clinical activity must be differentiated from the nurse triage in the emergency services, which offers: reception, attendance and classification of the problem, without any  further clinical activity.

In 2005, the Primary Care Center Can Bou in Castelldefels, near Barcelona, launched a pioneering experience in nurse demand management and subsequently prepared a "Guide to nursing interventions" with the following groups’ classification:
  1. The health problems where the formalization allows the nurses to be the ones who finalize the clinical process and therefore they themselves are responsible for the reception of patients and resolution of health problems.
  2. Problems of possible emergency intervention in which nurses are autonomous only in the first part of the algorithm. After, there’s a protocol point where the doctor intervenes.
  3. Health problems requiring an initial assessment of severity by the nurse prior to the doctor’s intervention.

Monday, 8 September 2014

Clinical Practice Guidelines of dubious ethical values feed malpractices

Shannon Brownlee is the author of "Overtreated. Why too much medicine is making us sicker and poorer." This book is the most significant piece of literature in the academic and social movement that empowers valuable clinical practice. The tweet chosen this week refers to "The Right Care Blog". It is an institutional blog of the "Lown Institute" where Mrs. Brownlee is vice president.

Upon entering the blog, you will see that the recommended post is "Conflicted guidelines breed conflicted practice", a text that comments on an article by Jeanne Lenzer in the BMJ, where it is argued that the connivance between the promoters of clinical practice guidelines and the industry are feeding inadequate practices. And to illustrate it, the author selects two examples that have experienced these problems with negative health outcomes of affected patients. One example is TPA, a clot solvent, and the other a recommendation of high dose of corticosteroids for the treatment of spinal cord injuries.

Now that there are many people and many institutions involved in making possible the practice of evidence should reach all corners of the system, it is relevant that there aren’t any ethical questions about the scientific basis of clinical practice.

Jordi Varela


Monday, 1 September 2014

Deprescribing in older people

Cristina Roure, Pharmacist and Vice President of Acadèmia de Ciències Mèdiques i de la Salut de Catalunya i de Baleares will explain a "deprescribing" project in her own hospital (Hospital de Terrassa). She also filled my desk with references that do no more than highlight the interest in combating, from the professional, clinical and pharmaceutical perspective, the polymedication of frail and elderly people. From all the references that I consulted, I have chosen a New Zealand-Australian source that I will summarize next. 

In New Zealand it has been estimated that 30% of people over 74 take five or more drugs, and about 10% take 10 or more. The drugs, says the reviewed publication, are often prescribed by different specialists, each of whom has followed a specific clinical practice guide for a condition or illness. Let's exemplify with a 70 year old woman suffering three chronic diseases and a couple of risk factors. This woman could easily be taking 19 daily doses of 12 different drugs at 5 different times of day, with a chance of generating 10 or more interactions.

Monday, 25 August 2014

Elderly: too much for too little

Richard Smith, former editor of the British Medical Journal, author of the selected tweet this week, asks: "Can we find ways to get more out of the costs of health and social services for older people?"

This tweet links back to his own blog where we can read about his mother’s case, a lovely woman who has lost her immediate memory and is drinking too much alcohol. The point is that his mother is no longer able to live alone, but is very stubborn and refuses to leave her home, so he and his mother are forced to make a pilgrimage to the health and social services in order to obtain the case assessment: diagnostic tests, questionnaires, specialist consultations, etc..

At the end, Richard Smith concludes that all the professional activities that have happened have contributed very little to the real needs of his mother. Finally a person from a voluntary agency who visits her each day was the one who actually provided solutions to their everyday life problems.

At the end of the post, the former editor asks: "Perhaps for these lonely older people, we need community revitalization rather than so many professionals."

Jordi Varela

Monday, 18 August 2014

Minimally Disruptive Medicine

"With regards to the chronic diseases, less can be more." The Wall Street Journal published that statement on the 8th of April last in an interview with Dr. Victor Montori, a diabetologist and Director of "Health Care Delivery Research Program" at a Mayo Clinic in Rochester. Dr. Montori told the journalist that one of the best strategies for the clinical management of patients with more than one chronic disease is to know how to slow down, namely how to give clinical practice some rest.

Reporter: What is minimally disruptive medicine?

Dr. Montori: Is the health care designed to achieve objectives of improved health for patients with various chronic conditions leaving the smallest possible footprint in their lives? To achieve this, patients and clinicians should jointly make decisions about which treatments are best suited to the patient’s lifestyle.

Monday, 11 August 2014

More access to family doctor, fewer emergency room visits

This tweet from Professor Robert Watcher UCSF (San Francisco) refers us to an article of which he is a co-author, framed in the English NHS. This is a wide-ranging population study, with the population corresponding to 7,856 family doctors and a full year of monitoring.

To assess the access to a family doctor a survey was used from which the following parameters have been chosen: seeing the family doctor within two days of the request, having the option of talking on the phone with the family doctor or the percentage of people who get to see the family doctor of their choice.

The study has shown that the quality of access to a family doctor reduces the number of spontaneous visits to hospital emergency departments.

Jordi Varela

Monday, 4 August 2014

The parsimonious medicine

I started the last Mondays’ post with the "Too much medicine" campaign from the British Medical Journal but in this one I want to talk about the "Less is more" article from "JAMA Internal Medicine" that began in April 2010 with the aim of bringing to our attention the side effects of diagnostic tests and treatments that from the outset are not expected to add any value.

Parsimonious medicine versus spending cuts

Dr. Jon Tilburt, an internist and researcher in biomedical ethics at the Mayo Clinic, and Dr. Christine Cassel, president of ABIM Foundation (see the Video that presents the "Choosing Wisely” campaign), in an article published in JAMA, attempt to differentiate between the ethics of "no budget and therefore I can’t request a test" and those of "this test does not suit you, it will not contribute anything new to what we already know, and additionally, the test itself carries risks that do not outweigh the expected benefits". According to the authors, as at the moment the two ethics are competing on the same stage, an effort must be made to explain them better from a professional point of view. 

Monday, 28 July 2014

Less is more: "Overtreated" by Shannon Brownlee

The campaign "Too much medicine" by the British Medical Journal wants to highlight the threat of over diagnosis to the health of individuals, and also expose the inherent waste of resources involved in inappropriate clinical practice. According to the BMJ, there is evidence that more and more people suffer from over diagnosis and overtreatment for a wide range of clinical circumstances such as cases of asthma, chronic renal failure or prostate and thyroid cancer. Through this campaign, the magazine plans to improve awareness among physicians of both the benefits and side effects of treatments and technologies, and thus find out how excesses can be reduced safely and properly.

The editor of the BMJ, Fiona Godlee, gives much attention to the campaign: “As medicine based on evidence, or clinical safety, were the movements of the previous decades, combating excess is a contemporary manifestation of an ancient desire: no harm when we want to heal".

To start talking about this campaign, I thought it would be appropriate to review the book “Overtreated" whose author, Shannon Brownlee is a science journalist who has published in Atlantic Monthly, New York Times, New Republic and Time.

Too much medicine

This is the title of the first chapter of the book, where she writes: “As most clinical practices have never been scientifically proven, when someone was faced with them, it turned out that many of them did not offer a good balance between damage and benefits, they only believed it and let’s review some clinical activities that, having had their base in the moment that have been evaluated, had to be rethought seriously such as tonsillectomies, hysterectomies, frontal lobotomies, radical mastectomies, arthroscopies knee arthritis, radiological screening for lung cancer, inhibitors of proton pump for stomach ulcers, menopause hormone therapy, high-dose chemotherapy for breast cancer, etc."

Monday, 21 July 2014

Impact of nurse staffing on clinical outcomes

In preparing this post, I invited Mireia Subirana, nurse and Director of Care Department at Hospital de  Vic (Catalonia), to present the contents of her doctoral thesis. It’s not a common occurrence for any nurse to get a doctor degree (University of Leeds). She now has a PhD degree and is a Fellow of the European Academy of Nursing Science.

But Subirana has not only been invited to praise her professional and academic career, but because I think it's worth explaining at exactly what point her research is at, having raised a hypothesis that affirms that if nurses from the hospital wards are well educated and the plans are well sized, this may have an impact on clinical outcomes of hospitalised patients. 

In the last ten years, research has established and endorsed the relationship between nurse staffing characteristics and clinical outcomes of hospitalised patients and thus objectifies the contribution of nurses in the care process. It remains to be found how this relationship is established, and the mechanisms that articulate it. This work, with a realistic methodological approach, identifies key factors in the process of care (monitoring, clinical trial, the level of training, experience and the tasks that they have not been able to do) along with the characteristics that define magnetic hospitals are articulated as possible mechanisms that could explain the impact of nurse staffing on patient outcomes.

Monday, 14 July 2014

Kaiser Permanente: the keys to success

Kaiser Permanente (KP) is an integrated managed care consortium, acting in California, and to a lesser extent on 8 other U.S. states. In the series of "Virtual Clinical Practice" I have already made ​​a brief presentation of the most relevant features of Kaiser Permanente to better understand the development of Health Connect, the electronic medical record of this insurer.

KP Results

What attracts us, European health managers, to KP are their excellent results, both in adjusted resource utilisation as well as in the quality of care which contrasts to the American environment where inequities in access, organisational and medical performance disorder prevails. To illustrate what I mean I have chosen this article:

Monday, 7 July 2014

Professional confederacy for clinical effectiveness

Clinical practice guidelines often struggle to implement a mandate in the world of real medicine. For this reason, the initiatives born in the professional world that rely on instruments within reach such as persuasion, training and clinical audit are genuinely remarkable.

To illustrate what I mean, I have chosen three projects from the sensitive field of hospital infections. The first is from a team of intensive care specialists in Michigan, the second of a group of Spanish intensivists lead by Mutua de Terrassa and the third of a multidisciplinary group from Sevilla.

Monday, 30 June 2014

Clinical practices that don't add value

The initiatives that warn of clinical practices that don’t add value or that contributes very little, are an advanced product of evidence-based medicine. This culture, which has the force of reason, often conflicts with several limitations to influence the actual practice of medicine. The first lies in the ‘original sin’, since most clinical trials leave out the very elderly and the multi-pathologies, the second has to do with the difficulties of adapting clinical practice guidelines to the actual circumstances surrounding each patient and the third is the influence of other factors, such as industry or popular culture, for example, when it comes to influencing clinical decisions.

This matter of little practical value is one of the most unclear of which I have addressed on the blog, and so I want to explain my opinion of the three main sources that today feed us information.

"Do not do” recommendations from NICE

This initiative stems from the futility that NICE experts have made of their own clinical practice guidelines. This is a list of quiet thousand recommendations including all specialties. Clearly they aren’t prohibited, but instead the prestigious agency experts warn that these practices don’t have sufficient scientific support.

To illustrate how these recommendations work, I have chosen five examples of the questions that NICE believes should not be posed:
  • Indicate hysterectomy as a first choice in cases of even strong bleeding
  • Prescribe antipyretics to prevent febrile seizures
  • Prescribe bevacizumab as first line in cases of metastatic colorectal cancer
  • Shaving the skin in surgical preparation
  • Hospitalising women with gestational hypertension

Monday, 23 June 2014

Mayo Clinic: lessons on management and governance

The Mayo Clinic is a network of non-profit health services based in Rochester (Minnesota). Mayo is essentially a group medical practice that has 3,800 doctors, researchers and over 50,000 employees. There are two features that identify this group: integrated clinical practice (especially in addressing complex cases), and research. The Mayo Clinic has been top of the U.S. News magazine for 20 years in a row and is among the one hundred best companies to work for, according to Fortune magazine.

In 1892 a group of doctors, led by brothers Will and Charlie Mayo, created a group of clinical practices, that from the start, had the vision to grow whilst retaining the essence of a cooperative and integrated medical practice, which, together with an early willingness to do research and teach, has earned them the prestige that they deserve today. If we consider the history of the Mayo Clinic in context, we can see the value of having defended the concept of a top-level project of professional services as it has survived the aggressive, speculative market of private medicine in the U.S.

The spirit of the Clinic

Take note of the values ​​that the Mayo brothers entrenched in the DNA of the organisation over one hundred years ago:
  • Continuing pursuit of the ideal of service and not profit
  • Continued primary and sincere concern for the care and welfare of each patient individually
  • Continuing interest by every member of the staff in the professional progress of every other member
  • Continuing effort towards excellence in everything that is done
  • Continuing conduct of all affairs with absolute integrity

Tino Martí generated model

This series concludes (for now) and to end we rely on the participation of Tino Martí, health economist and technologist who has focused his career in the field of health management, innovation and new technologies, particularly in primary care. Together with him we have worked on a conceptual model of innovation in clinical practice.

The model recognises that health care is currently provided in three stages: the health centre, the home and the cloud. The emergence of this third stage together with the possibility of remote assistance from the health centre is facilitating the emergence of new models of care that are challenging clinical practice by questioning the need for physical presence.

The main innovation is the digitisation of medical records and the ability to exchange information between systems. The electronic medical record acts as a platform for both the physical presence in clinical practice and the virtual by allowing the patient to access a subset of data represented by the personal health record and through the glue of services (patient portal). Alongside the systems of informed decisions, these services provide information to the patient and enable them to play a more active role.
The virtual consultation via email, telecare (videoconferencing) and monitoring using cloud connected computers (telehealth), form the communication layer of this model.
Finally, and with a promising yet unpredictable future, we have the patient’s social networks that contribute a relational layer to the model.

Infographic: Virtual Clinical Practice Model (T. Martí, J. Varela)

Not all components are present in all systems (a long way to go), nor is there a standard configuration for virtual clinical practice. Depending on your goals and the technology available, each practice must design and configure the elements that help to complete the personal assistance services or develop substitutes.

Reviewing experiences has provided us with various levels of evidence for effectiveness and efficiency represented below in the coloured bars in each chart element. It’s reasonable to use the existing evidence in evaluating the introduction of innovations in healthcare, especially in a time of scarce resources, but these circumstances should not obscure the fact that innovation is born from experimentation. The existing assessments of the models tend to focus on one element and not the system; therefore we evaluate tools in isolation instead of new models of care.

The introduction of new technology doesn’t usually prioritise on the cost effectiveness ratio, but rather the improvement to the quality and safety of care and the satisfaction of the participants.

As you have seen, we have only hinted at the innovation available from the current vogue of mobile technology and it deserves a separate chapter that we hope to cover in a near future post.

Monday, 16 June 2014

Personal Health Record

What is it?

A Personal Health Record (PHR) is an electronic resource containing clinical information necessary for people to be able to make decisions with regards to their health. A common feature of the PHR platforms that I have consulted is the accessibility that the patient has to a certain amount of relevant information from his/her medical records (hospital admission reports, emergency reports, lab results, etc.) Additionally there are other remarkable characteristics of PHR, not featured or adopted by all the platforms:
  • Scheduling doctor, nursing and test appointments.
  • Self-monitoring of relevant variables: blood glucose, blood pressure, physical activity, calorific intake, weight, etc. The patient is responsible for maintaining this element of the PHR. It is very useful for ‘at-risk’ and chronic patients.
  • Medication control and prescription management.
  • Access to radiology images. This is a technically sophisticated function often still under development.
  • Secure messaging Mailbox to connect with the healthcare team. See post "E–mail: it starts showing results"
  • Managing insurance policy (only American PHR).

Three American PHR