E-health: 2175
The story begins:
[begin]
Recent archaeological diggings in the UK have unearthed a treasure trove of early 21st century computer storage devices. After extensive restoration (these were stored in a magnetic physical media, far different from our cognitively-conjugated quantum dots we use today), we now have more insight into the experiences of people living in this era of rapid technological and social change, the very hinge point between today and the industrial revolution of so many centuries ago.
Professor Jean Bartolemeny, of EuroU Berlin GmbH, a leading researcher on the early years of this century, had this to say:
“It is quite extraordinary to find such an intact diary of the first of the post-modern patients. As you know, the post-modern patient emerged in the late 20th century, and follows the development of medicine as practised then until we entered the post-doctor era in 2025 with physical models of disease and the emergence of practical machine intelligences, so familiar today.
Certainly, in the early years, clinical change was characterised by extensive new methods of treatment led by the biotechnology industries, which brought to market significant new treatments for genetic diseases starting with cystic fibrosis in 2010, until genetic treatments became generally available by 2050. The emergence, though, of physics in medicine redefined our understanding of the human body, allowing us to probe clinical processes at a physical level, completing the imaging innovations started with early CT, MRI and PET technologies, leading to quantum effect diagnostics and theranostic interventions.
But in the early years, patients experienced a tension between their own desires to be in control of their own health care needs and the control exercised by dominant power blocks within the society. This was a push/pull between consumer and patient choice and rapidly deteriorating ability of healthcare systems to manage their major cost drivers: chiefly infrastructure costs and labour. The initially slow introduction of health telematic technology, or as we now call it, “B-Well”, shifted control to citizen initiated care systems but did cause considerable anxieties amongst health professionals. Indeed, the first health television channel created the insights to develop what we now consider normal in health provision, as long ago as 2000.
The so-called “doc-wars” of the early 21st century ended professional control away from acute and invasive medicine to community-based health provided by a wider mix of health specialists and alternative therapists. This reenergised patients to seek control of their own health needs. And it is instructive to recall the terrible horrors of the early biotechnology “mistakes” that by 2020 had created the “technology with a social face” movement, of course, as if it were other than that, but in those early days, technology was expensive, and poorly integrated into healthcare and was mainly in use by professionals, the rapid expansion of artificial intelligence into patient-use device technologies still a few years away.
It is important to appreciate the tremendous power exerted by what was known as a “hospital”; these often quite large and complex organisations operated like the primitive factories of the industrial revolution which created them, with health specialists acting like members of traditional crafts or guilds, controlling what went on inside. The effect on people was to perpetuate a socially defined sick role. As advanced multimedia applications moved into health, these large institutions gradually shrank, became fewer in number until they transformed into the small community centres we take for granted today. The legions of managers who ran these institutions shrank accordingly as more democratic systems of management emerged, supported by the very same clinical technology, to manage the patient’s health record, document the integrated care pathways, and of course pay the bills.
Even with greater longevity, the burden of ill-health has become much more manageable. We are reminded of the obesity decades of 2030 to 2050, when life expectancy actually fell as large numbers of people with obesity related ill-health succumbed. The ‘great thinning’ this produced, led to significant rethinking about diet and nutrition, and of course on what went into food in the first place.
I must confess that much of what these records have revealed is important social history of period over 150 years ago, and about which much has become folklore. Despite extensive record keeping, much has been lost, decayed away, and almost nothing of important social history has been retained. This is why this material, which appears to have been a personal diary is so important and sheds new light into this era.”
extracted Diary notes of Vivian Rowley, dating is difficult but appears to be around 2020
…picked up some sort of virus visiting Caracas last week. had my knowbot [a primitive machine intelligence] scan recent similar reported illnesses on HealthMaps on the web [an early network], it found a trend and e’d my local healther to arrange for medicine to be delivered. i went out later to visit friends before completing my study of emissions from electric cars for the Independent Tempes ….
…welcomed the new family to the neighbourhood and helped them arrange the transfer of their web connections to the local health services affinity node. we also reviewed the online healthnet resources. i suggested that Eds Polyclinic, next to WaitBury’s, provided good response times and had 24/7 services with online and teleconsulting to speciality services. The clinic offers extensive at-home services and is progressive compared to the more traditional local GP practice. i mentioned that i was particularly excited about the new home-visiting surgery service as well as the drive-in care clinic which the nurse practitioner head of the clinic is introducing. the clinic keeps asking us to e our local MPs to complain that OfHealth takes too long to issue the local service licences. i suppose that makes sense, but the PharmaCare services are just as good even though some of the local health commissioners are still on about whether the private services are properly regulated; they’re so out of touch….
…maybe i’ll send Sandy, this year’s manager of the clinic, a note saying i’ll vote for her next year as manager; she is clearly community spirited….
…visited my parents at home yesterday just as mum was having a hip adjustment done. it acted up while she was on hols in rome, but she couldnt get the parts and the econsult from rome was disrupted by server problems, but having her healthpassport handy is a plus, and the fact they’ve finally got rid of having to remember pins is such a plus. anyway, i think shes going to have words with the engineer who installed it. at least she doesnt have the older less reliable “non-organic” hips. dad was out having a low-stress jog according the emetry monitor in the kitchen which was also automatically updating his health record. The predictive algorithm [a precursor to what developed into physical disease models] was recording all this for future reference.
[end]
So what might all this mean?
What is often not fully appreciated is the impact technology can have on the patient’s perception of care. Increasingly, as technology intervenes between the patient and the care provider, we will be faced with important social questions about how these technological possibilities should be embraced, and what their impact is likely to be, on the patient, and how we organise care, itself.
One of the emerging trends is that patients will receive care closer to their homes; this is partly being driven by clinical innovations that seem to require less and less the traditional notion of a hospital and by the merging of voice, data, and image (telephone, computer and television) into a multimedia stew which permits various new ways of connecting an individual person with an individual health practitioner. The emergence of “location-independent real-time care” is a serious reality if we can resolve how to ensure that clinically important information (such as the individual’s health record) can be equally available.
Certainly, rapid progress is being made in health telematics involving the use of electronic digital imaging and data transfer to facilitate remote diagnostics, and remote messaging.
There are interesting possibilities which bring together thinking about the decentralisation of care, with advances in technology. We should want the individual patient to be much more within the clinical decision-making process — in fact, we should see the clinical decision processes within the patient’s needs and care priorities and not the other way round. With patient control of the their health record, we should see movement in the conceptual reorganisation of care. Along with patients having more information about possible care options, as well as generally being more informed about health matters.
The impact on management in healthcare as we now know it will be to marginalise traditional control notions of management, and move to more overtly democratic forms of decision-making and resource management — is this what some people today call consumer-directed healthcare? Perhaps not, but conceptually this is in the right frame.
In some ways greater use involvement could help the government achieve sustained reductions in the cost of management by shifting the management tasks to those who directly engage in health care transactions, namely the patient and the doctor, pharmacist or nurse, etc. This shifting of the management “value chain” towards the patient is no different from what the private sector is doing when they seek to enhance the value of their product to potential purchasers with value-added services. And indeed, in many cases we, as purchasers, are increasingly making management decisions when we buy food, book a holiday or eat lunch. Healthcare delivery, though, has tended not to learn that much from other sectors of the economy, very much an intellectual closed shop. A type of myopia, funded at great public expense.
The clinical workplace, viewed today as the hospital or clinic, has really changed little over the century and retains features of the industrial revolution.E-health and information-based technology will not just alter the structure of care, but will alter the structure of the industry itself, in the same way that information technology has not just made it easier to check our bank balance, but has altered the structure of the banking industry itself. This disruptive potential exists.
But if you think of people being given local anaesthetics for day surgery, can we continue to use the current practically-designed operating theatres — won’t we want them to look more pleasant and inviting. Hospitals are complex places to manage, not near the customer, and contain a dizzying array of systems, processes and activities which are rarely optimised on their own, let alone with respect to each other. This leads to systems problems, failures on the order of the space programme, but with insights better associated with running a local grocery store.
So if the clinical workplace changes, then how it is managed and resourced will change, too. It is here that informed consumers create their expectations, and health specialists respond. Managers are often the most removed from the care environment and often contend that they have specialist skills to manage the complex aspects of care. There is a gulf here which is not in the public interest.
We await the e-health revolution.
NOTE:
This is a revised/updated version of a paper first presented at the Royal College of Medicine Telemedicine Roundtable, 1995, and the Telemedicine in Wales Conference, 1996. Still waiting….