Health: Where to from here?

This is truly THE global question today. But just as the Nobel peace prize committee has established itself as a questionable zeitgeist, I fear many health reform commentators are doing little more than talk. This beckons a general comment about two important recent developments, and a personal statement about the future of this blog.

There have been two announcements that made me sit up and take notice of late. Actually, make that three.

The first was from Dr. Ezekiel Emanuel in a speech to the Medical Group Management Association annual conference in the USA. I quote, “The problem in the system (healthcare) is not that we don’t have the right technologies,” said Emanuel, chair of bioethics at the National Institutes of Health, in addition to being the older brother of White House Chief of Staff Rahm Emanuel. “It’s how we connect with patients.”

That statement – how we connect with patients – sums up what I believe is the unstated need central to healthcare reform. Too many people are approaching things from an economic or systems focus when ultimately, everything depends on patient needs. This truism deserves more explanation.

Emanuel went on to speak of increasing this connection by making healthcare accessible in non-office settings including online. He also advocated such things as non-physician care when practical, on-site health clinics at large worksites and even a return to house calls.

This leads onto the second and third developments of late. The second is that NEHTA announced a shift in strategy on Australian health records. Realizing that a national centralized behemoth was never going to happen this century, they’re turning to industry to tout their wares. This is a great and sorely needed shift.

The third was a lonely voice crying in the medical training wilderness of Australia.

It comes from Michael Moore, not the doco-joker, but former ACT health minister. He says Australia’s medical colleges should hand over responsibility for training specialists to universities.

Now chief executive of leading advocacy group the Public Health Association of Australia, Moore said the change would lead to more trainees, easing fatigue loads. He said overworked doctors could thank the closed-shop attitude of their supervising colleges for ensuring trainee numbers “aren’t too high”.

“The training and control of who gets into the specialist programs is in the hands of colleges and it’s a poor system because it clearly suits the colleges to have fairly restrictive entrance,” he said. “If they maintain a relatively poor supply and a high demand, obviously they’re going to make more money. The logical system would be to take the training completely away from the colleges and move it to universities.”

This surely suits the current governments reform agenda. They are clearly frustrated by the closed-shop attitude of several medical colleges. The question is how this can be done?

These last two changes both point back to the first: health reform should begin with, and target, areas where patient needs can be met. Other changes will then follow more easily. If we go after big and immovable targets we will fail. but if treat health as the dynamic marketplace it is, and meet patient needs, the resistant stakeholders will be forced to follow lead. The introduction of patient controlled records and the broadening of medical training are key steps in this direction.

I want to finish by apologizing for my lack of posts in recent weeks. While busy with other things, I’ve also had some time to think about where to spend my time in the near future and am considering wrapping up this blog. Or at least rolling it up into something more specific such as a tool for research/reports on advancements in primary health management. I see little value in generating more gas around this roaring healthcare fire and hope to capture and funnel this heat towards building something worthwhile.

Will Patients Appreciate Big-Brother Pharmacists?

The Australian Pharmacy Guild has adapted software from the USA that allows pharmacists to track patient compliance with their medications. It is an attempt to get expand the professional role of pharmacists. And one drug company, Pfizer, has already teamed up with the guild to get pharmacists to coach patients at the point-of-dispensing if they seem to be missing doses of Lipitor.

It is a reality that compliance is an issue with many medications and therefore the software, named Mirixa, could be useful. But I wonder whether the creators considered what patients will think when a pharmacist leans over the counter and says, to their surprise, ‘you haven’t been taking your medication’! I’m sure, of course, they won’t do that because they will have read the guilds ‘motivational interviewing’ document for Mirixa.

It’s a principle in medicine that you never presume such knowledge, even is you think you have a good idea of compliance to a treatment prescribed. Patients hate doctors being paternalistic. So I find it very hard to see how patients will take to this approach unless they somehow ask to be signed up to the program (according to the consumer info this seems to be the case).

In fact, I wonder how this software fits in with our current privacy legislation? Perhaps someone can help me out? Mirixa does have a statement about privacy here.

Australian eHealth Update

A recent presentation (Jul ’09) from the NEHTA CEO Peter Flemming courtesy of ACHSE.

Distinction between EHR and EMR

I didn’t know there was one, but according to the Health Information and Management Systems Society, there is! Read about that difference here.

M-Health forging Ahead

Here are some great articles from mobilehealthnews.com on the uptake of mobile health solutions, particularly using the iphone:

Roche decides it’s time to enter mHealth. Roche Diagnostics inked a deal with Glucose Buddy iPhone app developer Healthagen, because Roche believes that the time to get into the wireless health market is now. While the company’s Accu-Chek educational program for diabetics is a far cry from meter integration for mobiles, Roche plans to work toward integrating glucometers in the future.

Interview: Mayo Clinic forges its mobile strategy. Every major provider of health services and information is trying to figure out how best to go mobile. Scott Eising, director of product management for Mayo Clinic’s Internet Services offered a peek behind the curtain at Mayo to discuss how the not-for-profit, integrated medical practice is planning to do just that. It covers basic functions mhealth is likely to use such as symptom checkers, and find a doctor, as well as more complex things like health and wellness trackers. Great article for anyone going into the mHealth sector. Best quote, “It’s a ways out but the key is not to wait until it gets here“.

Aetna: Ultimate goal is health info on-the-go. Aetna’s Head of Digital Engagement Strategy and Innovation Robert Heyl understands that health decisions mostly occur while people are going about their daily lives, so that’s why his ultimate goal is to take the information in SmartSource, Aetna’s online patient portal, and bring it to the mobile platform.

Interview: Google Health on mobile is criticial. Google Health Product Manager Roni Zeiger makes it clear that mobile phones, connected devices and mHealth applications will become a crucial part of Google’s health plans moving forward.

Facebook better than Games

From 6minutes.com.au:

Youngsters should put down the gaming console and log onto Facebook to improve their wellbeing, an Australian study has found.

The study, which surveyed over 900 adolescents aged between 13 and 19, found that Victorian youngsters spend more than two hours watching television each day, followed by 35 minutes playing video games and nearly 20 minutes on the computer.

Those who played video games rather than using the computer showed poorer health and higher levels of psychological distress, and computer users showed slightly lower behaviour problems than non-users.

While games may stimulate aggressive behaviour and reduce social involvement, the study notes that surfing the net may, in fact, encourage social networks and improve mental health.

“E-mailing and instant messaging are an important means of communication and interaction… Boys who spent more time on the internet and doing homework reported a more active lifestyle and higher self-perceived social support to those who used the computer for playing games,” the report’s authors say in Academic Pediatrics.

It’s kind of like saying ‘doing something is better than doing nothing’!

Another Medical Search Tool: Quertle

Looking for a new way to search the literature?

From www.quertle.info:

More than simple keyword searching: Quertle goes beyond simple term matching to identify the most salient information in the literature. Using a combination of linguistic methods, Quertle finds facts defined within documents, creating its own database of nearly 150 million relationships, and is able to report the ones that are relevant to your query. Quertle’s approach is based on a thorough understanding of biology and chemistry and was built from the ground up to address the unique needs of this technical literature.

Power Terms™: Quertle is able to extend its extensive biological and chemical sciences underpinnings to the definition of “Power Terms™” that represent a class of entities. For example, the Power Term™ called $Proteins represents all protein names, thus enabling unique queries such as “what $Proteins regulate cell cycle?”. Try it!

Easy exploration: Quertle provides a set of useful filters directly on the results page to help you navigate and explore the results. The “Key Concepts” filter automatically lists key concepts found in the result set so you can quickly focus in on concepts of interest. When a Power Term™ has been included in the query, the “Key Concepts” filter presents members of the Power Term™ class to answer your question. For the above example, all proteins that are involved in the regulation of cell cycle will be presented.

What content does Quertle cover?
Quertle uses MEDLINE® as provided by the National Library of Medicine. Additional document sources are coming. Let us know what you think we should add next.

Who is behind Quertle?
Quertle has been created by biomedical scientists, chemists, and linguistic experts, who have many decades of experience with research and finding relevant information to support that research.

PubGet – a new search tool

Ever been frustrated by the myriad of links and publishers pages you have to wade through to access a PDF? PubGet now allows you to cut out the middle man and get the file directly. It automatically checks your access rights from your home institution and delivers you straight to the paper of interest.

Websites that Rate Doctors having an Impact

In a world where patients can sound off about their doctors at RateMDs.com, Yelp, DrScore, Angie’s List, Vitals.com and some 35 other sites, what’s a doctor to do? In some cases, they’re striking back by demanding that patients sign contracts prohibiting them from making online comments in any media outlet without prior written consent from their practice.For more details read this Washington Post piece.

This trend is only just beginning is Australia where RateMDs.com now has quite a few Aussie doctors on it’s books. But it will change the way doctors operate, just as feedback should.

Some doctors are particularly concerned about the issue. In 2007, the Australian Medical Association condemned the idea. A company in the USA called, Medical Justice, offers a sample privacy agreement starting a $495 and monitors online comments for its 2,000 members. The general feeling is that online comments may do serious damage to a doctor’s reputation while revealing little about their real skills.

There has been some discussion about medical performance indicators in Australia for some time. There was talk of uploading information about a doctor’s mortality, complication and infection rates. This idea was squashed, particularly by surgeons who feared the stats might be misinterpreted where some surgeons do more difficult cases etc.

My view is that there is no way doctors can stop this trend. Feedback will happen some way some how. Where once it was through the daily gossip mills, now it’s online. This is all part of the consumer revolution that will bring, to use another mans term, disruptive innovation to medicine.

Effectiveness of Pharma Sales and Marketing

This BNET article outlines the latest to-20 ranking drug companies by sales and marketing productivity. It shows that productivity is increasing, despite recent lay-offs in sales forces. But, according to many, there is a long way to go.

BNET produced the numbers by dividing a company’s revenues by its spending on SG&A, producing a revenue yield per $1 of SG&A. The majority of SG&A costs are sales force and advertising expenses. The yield is a rough guide to how well a drug company martials its marketing resources each quarter.

This news comes as the debate about the need for sales reps continues. Many have suggested that the knowledge economy and IT will dramatically reduce the human interface of sales. However others, such as futurist Alvin Toffler, argue that one cannot do without the human interface. Technology may reduce it, but the human touch cannot be replaced. Already in Australia, electronic detailing is fast growing in popularity.

But IMS Health says pharma sales need an even bigger overhaul.

The pharma-market analysis firm says the industry should re-deploy about $15 billion in promotional spending because–to put it bluntly–those dollars aren’t yielding enough sales. Instead of viewing doctors’ offices as ground zero for most marketing efforts, drugmakers should broaden their focus to include drug-benefit plans. 

This analysis is supported by some interesting stats in this  Business Week article ‘The Doctor won’t see you now‘:

Big Pharma companies are learning that storming doctors’ offices with multiple overlapping salespeople is woefully inefficient. Fewer than 25% of visits to physicians result in actual face time, says investment bank Leerink Swann & Co. in a Jan. 3 report. That’s a lot of wasted effort for folks who typically cost their employers $200,000 per year. Other companies that could benefit from sales-force cuts include GlaxoSmithKline PLC (GSK ) and Sanofi-Aventis (SNY ), say Leerink analysts. Lehman Brothers Inc. (LEH ) adds Schering-Plough Corp. (SGP ) to that list and predicts that a 20% reduction in sales expenses across the industry would lift large-cap pharma earnings by 3%. Spokespeople for those companies say they have no current plans for cuts.

Pharmaceutical companies that have already shrunk their sales forces are finding innovative ways to do more with less. Bristol-Myers Squibb Co. (BMY ), which has cut 1,300 salespeople since 2004, tracks physicians’ prescribing patterns and adjusts its promotional activity accordingly. A full 18 months before its cholesterol-lowering drug Pravachol lost patent protection last April, the company halved the sales calls dedicated to the drug and instructed reps only to call on doctors who were already prescribing it. “We figured those who hadn’t prescribed it yet weren’t going to start now,” says Tony Hooper, Bristol’s president of U.S. pharmaceuticals. Despite the changes, prescription rates didn’t falter. Between 2000 and 2006, overall productivity per rep jumped more than 40%, Bristol says.

Some companies, including Bristol and Merck, are supplementing often brief physician visits with “e-detailing.” They might, for example, point doctors to interactive Web sites that teach them about new drugs and that can be updated instantly with fresh clinical-trial data to support their sales pitches.

For some interesting analysis on total marketing spends by pharma, see this article.