Dr. Michael Tremblay is an eHealth expert and principal at Tremblay Consulting.
He was speaking to Gary Finnegan.
There has been considerable momentum in political and industry circles about the promise offered by eHealth in making health care more efficient. Is this optimism justified?
Yes. Efficiency in health care though can drive up costs - for instance, if you reduce the amount of time a patient stays in a hospital bed, you can of course increase the number of patients who can use that bed and hence increase your costs. The eHealth question is whether you want the patient in the hospital bed in the first place, and whether care can be provided through an eHealth service. eHealth creates the option of keeping patients out of higher cost hospitals, managing care from home, or enabling easier monitoring of patients from a distance. The eHealth promise for me is location-independent, real-time health care – anywhere, anytime care.
We have to be mindful, though, what parts of health care we are referring to when we speak of making health care more efficient. It is evident that much is done daily to improve the way health care, as it is currently organised, is delivered, but perhaps not as much as the public thinks. eHealth, though, changes the paradigm in many respects, by enabling remote sensing, embedded intelligent diagnostic equipment, integrating clinical/patient information, and so on. It can remove steps in clinical pathways, as well as make some clinical work itself obsolete. This is not something that sits easily within professionally demarcated clinical work.
We can learn a lot from looking at other industries that have introduced information technology to alter service structures, such as banking, airlines, online shopping, etc. Health care, though, is still very much a hands-on activity, and so eHealth, which purports to alter this, is seen by many as only part of the solution, while for others it is seen as the next generation of care itself. We hope eHealth will be as good as we think it can be.
Can eHealth help cut healthcare costs at a time of steep medical inflation?
Yes. Medical inflation is partly a function of the costs of research and the difficulty innovations have in being adopted in health systems; it is also a function of continuing efforts to reform existing systems of health-service delivery. The slow uptake of innovations in healthcare is partly driven by risk: aversion to putting public money at risk, which is understandable. However, eHealth challenges the key underlying logic of existing models of service delivery because it impacts two drivers of inflation in health care: the costs of labour, and the costs of buildings/infrastructure.
Do hospital managers and health professionals share the enthusiasm of politicians and technology buffs? Are they prepared for the disruptiveness such a radical change could bring?
I think hospital managers have a commitment to their organisation, and to keep it growing and expanding; they also have to deal with their staff, employment, clinical quality, etc. Health professionals will use technologies if they see clinical benefits. My view is that clinicians might actually adopt innovations faster if the technologies were easier to use. I don't think either is fully prepared to have a discussion on the potential disruptive impact of eHealth unless it improves clinical care, and maintains their professional role.
Unfortunately, roles will change and shift with disruption in health care and few want to have this discussion. Health professionals, though, are divided on how much control over care they would want their patients to have through eHealth, as it raises many professional issues about quality of care and the ability of patients to manage their own care. I think patients with chronic health problems can be trusted, as can parents with ill children, those sorts of areas.
Might doctors view telemedicine and home diagnostic kits as a threat to their status?
In fact they do. There have been reports on this subject. Such kits and services do challenge professional roles and their perceived responsibilities, and at a practical level they do replace a GP's diagnosis with that of the kit. But these kits and Internet-based systems can and do embed clinical knowledge and so replicate a clinician's use of that knowledge. We are also building physical models of disease, which involve causal models, to understand disease processes and this can enable greater use of diagnostic algorithms accessible to individuals.
Anyway, good self-testing kits in the end will differ little from what is done in a lab anyway, and patients can learn how to make sense of test results – pregnancy self-testing is a good example. We have certainly not seen the full potential of home diagnostic kits, so in the end clinicians will need to learn how to work with patients who use such kits and manage their own healthcare through eHealth technologies.
What about public perceptions of eHealth? Is public opinion keeping pace with technological progress?
In my view, the public has a weak understanding of eHealth. How should the public become involved? Why bother? The focus of attention is largely focused on eHealth developers, and what I call internal users of eHealth, i.e. doctors, nurses, etc.
The benefits of eHealth, though, accrue to the patients, and if we were to ensure wider salience of the issues surrounding eHealth, my view is that an informed public would seek eHealth services. People value their local hospital because they don't know what other options might be available. While it is perhaps not really in the interests of incumbent providers to discuss eHealth, insurers and payers, though, should be very interested in seeing these sorts of services expand. But these groups tend not to have a dialogue with the public about eHealth services, or any services for that matter.
In my own past, I helped found a digital interactive television channel for health, and we had over 60,000 homes use the service during the trial period. Public acceptance was high, interest was high, hard-to-reach groups such as men used the health information services, and so on. Unfortunately, I believe most technology companies still see doctors as the end-user of eHealth technologies rather than the consumer/patient.
Technological progress is putting applications on smart phones to help people manage their weight, and provide alerts when to take medicines; some are testing access to health records, transmitting sensor data. You can get these today. If I can do online banking, why can't I access my health records? If I can confirm my airline flight over my phone, why can't I renew a prescription? Our understanding of the possibilities of eHealth is bound up with wider social and technological progress, not apart from it.
I think we forget that as people focus on eHealth within a medically defined model of service delivery. Change the model, change the thinking. In the end, consumer-empowered eHealth could lead to the average person determining the structure and shape of healthcare services. There may be reasons why some people would fear that.
Are there any other practical barriers that might lead to resistance to eHealth?
Apart from the usual technological ones (interoperability, standards, security, privacy, etc.), I think the lack of a model to decide how to reimburse for eHealth services is a problem as this means that is hard for eHealth service providers to develop a business model which can give them some sustainability to offer a service in the first place. This in turn limits the ability of service providers to tell people that such services are available. Payers have to be willing to see eHealth as an investable area of activity worthy of their attention. This involves taking some risks, of course. We don't have much infrastructure in place for eHealth, apart from broadband and some functionality over mobile telephones; I would add I don't see availability of devices, sensors, etc. as a problem, as we can probably invent or build whatever we might need.
The barrier analogy I'd draw is to the adoption of electric cars. Everyone seems to agree they are a good idea, and save on this and that. The stumbling block is 'do we recharge cars from home or at 'juicing stations', or swap batteries at service stations? - in other words, the adoption of the technology and the realisation of the benefits actually depends on something rather more mundane – how do you keep the car charged up? There is no incentive to build a service station network for electric cars until there are enough electric cars to make it worthwhile, and around we go. eHealth is a bit like this.
The other more substantive barrier is that eHealth does have the potential to be seriously disruptive of care systems, certainly according to Clayton Christensen, who has looked at this in some detail. My experience with digital television health shows me that eHealth can really alter the public's expectations and response to their health, in a positive way. The stakes, though, are high for the people who work in healthcare, as eHealth could substantially alter the very structure of the healthcare system. This is where fear replaces optimism.
Read Dr Tremblay's blog on Blogactiv