The near term (Horizon 2) promises exciting and provocative proposals for the envisioned role of emerging technology in health services. Personalized medication. Concierge medical advising for the masses. And iPads (or whatever they become) for everyone.
In Dr. Eric Topol’s The Creative Destruction of Medicine there are fantastic ideas for the possibilities of technology and their envisioned disruptions to current quagmires. The future doesn’t happen all at once, of course. We must fit these ideas into a larger frame of human need, cultural fit, and institutional services design.
Personalized medication might be the easy part. Personalized medicine requires changing business models, which means changing practices, not just technology.
Technology is not an independent disruptor, and always has unplanned (but not necessarily unforeseeable) consequences. Sometimes the consequences are to make some current trends stronger. Technology integration is not a democratic process. Policy, power bases, and financing interact with any technology in a system as massive as the US healthcare system.
Mobile will not Save Healthcare
One point I keep seeing is that mobile technology will have a transformative effect on patient engagement.
“More than 40 percent of us are ‘hyper-connected’ as defined by using 7 different devices and 9 different applications in order to stay as screen connected as possible, from restaurants, from bed, and even in places of worship.”
Its pretty speculative to say that “x technology” will save 197B (over 25 years!) as in the perfectly titled: Mobile: The health-care fix we’ve been waiting for?
Its reasonable to assume that everyone will have a cellphone. Its not likely that the millions of less-well off and less-healthy will live the hyper-connected lifestyle, smartphone or not. The assumption of connectivity for health purposes is a technology-driven utopian ideal, and ignores the real world data and all of our experience with adherence to medication. If we’re confused by what medication to take (or prescribe), how are we to choose among the thousands of healthcare apps (16,000 according to some counts)? If our doctor has trouble seeing the whole person when in front of them, how are thousands of micro-apps going to integrate to generate an emergent, whole picture of personal health? That’s a huge design challenge.
These are technology assumptions (Because We Can) that impose a cultural consequence (We Ought To). Sure, many people – the most healthy of us and the better educated – will adhere to the new virtual prescription.
But many people, not only the populace, but physicians, will reject the virtual tethered engagement that is assumed to replace F2F encounters. That doesn’t mean we shouldn’t try designing this care path in the best ways possible. But mobile technology is being heralded as a solution a priori. Others will propose that social technology will be adopted at such a level that it will be “the answer.”
These are technology alternatives to which services will adapt, but are not universal and cannot be prescribed as such.
Just observe for yourself: At what point will clinicians adopt Internet-based communication technologies to manage multiple channels of verified patient contact? Wouldn’t primary care be using email services by now – after 20 years of commercial development – if easy, rapid virtual communication channels were helpful in managing a practice? Its not a simple problem. There are reasons healthcare is different. You can make your employees use email, or (like a consultancy I once worked for, Atos Origin) NOT use email at all. But you can’t make your patients use a certain media, channel, or delivery system. And you can’t even make doctors use email.
Social will not Save Healthcare
For healthcare, Facebook is not our infrastructure. And the Internet does not automatically engage individuals around their own personal care. There are many human factors and design reasons we are not even close to this assertion yet.
When we observe actual practice, it becomes clearer why. Healthcare practice is not tech-driven, even if it is science driven. Clinicians are slow and careful adopters, and by the time they change practice its been such a gradual change it doesn’t appear as a “transformation.” Many advances and miracles in medicine and technique turn out to be less than expected, or they are even outed as dangerous (as with many high profile pharma products). Should we appreciate that physicians are skeptical and slow adopters? Perhaps you don’t want to try the latest medication until the effects are observable in the population for some time.
Articles like this WSJ are tech boostering. And while Dr. Topol is chastising medicine for being slow adopters, he is also making medicine wrong for the way it is, for its cultural “resistance” to technology.
Resistance is not always bad – you don’t want to introduce too many experimental changes because some believe its the inevitable next big thing. And overwhelming doctors and nurses with posts and updates on a “Facebook for patients” is probably the last thing most working clinicians want to add to their schedule.
Technology will not Save Healthcare
Smart handhelds and new embedded sensors will have a huge impact on practice and patient self-management. But they are not universal. Humans are still messy and don’t follow instructions well. What will the proportion of exceptions be, and how will the increase in older and more complex patients affect healthcare service? Doctors are already time-maximized, and the last thing most of them want is “more alerts” the pings associated with discrete patient monitoring.
Finally, these popular articles, and most of what I see in healthcare technology, mix up the units of design and analysis and expect a miracle to happen that jumps the gap between levels. This is key to my recent presentation at Webvisions in Portland last week, although I’m not sure the message is clear. Designers new to healthcare need to understand the reasoning gap in sociotechnology design.
We take a technology – say a smartphone – which relates to behaviors centred on an individual unit of analysis (the human patient). Then we infer a change to “transforming practice” (social and activity unit), which is a level jump without a clear reasoning bridge. We then extrapolate to the future impact on the healthcare system (institutional unit), which is level jump 2.
In reality there is no chain reaction across these units of analysis and design. Each level has its own lifeworld and must be understood on its own terms.These are leaps of faith, not of service design.
Most proposals that promise disruptive innovation of healthcare exhibit such a conflation of levels. The more serious proposals for systemic disruption are those that go deeply into one level of analysis (e.g. Bohmer’s institutional level or Christensen and Porter’s policy level). The leap from information technology to institutional service change is bigger than it appears Electronic medical records are proving that point.
Yes, today’s reality doesn’t make a compelling story, its heavy with the weight of research and the persistence of our current institutions. This is where the challenges of healthcare system design truly live, in finding the pathways that connect between technological possibilities, rigorous innovation of clinical practices, and enlightened institutional decision making.
