First published in HIMSS UK in November 2016.
Answers to questions can change the world, of course they can! When I fly I so rarely check a suit-case in that I had forgotten the words that you are asked before every flight until this year’s summer holiday. Did you pack this case yourself, are any of these (dramatic wave over picture) items in the case, could this case have been tampered with?
Western, male, childish human behaviour always, always makes me want to answer different to how the desk operator expects at this point, but I don’t, I behave and move along the line. But this summer holiday season these questions did get me thinking about the parallels to healthcare. Are the questions the right questions, are they based on enough background information, are they asked at the right time and does anyone really consider what the answer could be?
In Ireland we have three projects known as Light House projects, specific disease areas of focus where we have applied investment that has delivered learning and solutions for the healthcare system. Interesting in the context of question asking in particular is the Bipolar Light House project; one of its early deliverables is a solution that allows the person suffering with the disorder to record their feelings daily. In time and with the patient’s awareness the questions will be prompted by other data, for example has the person been outside today, exercised, and interacted with others. The question and the context of the question is just as important as the answer in these circumstance! And yet current ‘best practice’ is to ask at each consultation, how have you felt over the last month?
And to match the current best practice we also have human nature, where the obvious answer in Ireland in particular is, ‘Grand, thanks’.
Cause no fuss, almost regardless of disease type is the patient ethos when it comes to the sharing of information, and perhaps even more so in complex mental health areas. If a patient wants to share information then it is our role, maybe even our main reason for being in the digital health industry in the future to enable this to happen.
Are the questions the right questions to ask, clinical practice knows because of the wealth of knowledge that clinicians have what the right questions are and how they need to be asked. This is fundamentally why we need clinicians involved in the design, build and test of every system deployed into our healthcare system. Seeking clinical support from the design phase onwards is not a simple task though, design comes with personal perspective and opinion and therefore getting to a point of consensus is always going to be difficult. Maybe then the arbitration vote on the design of an information system that is asking questions should be the patient, to truly deliver contextualised care where the right questions drive a type of care that is infinitely safer, more efficient and makes the care delivery feel like the fast lane for baggage check in and the first class lounge at the airport!
Questions in health need to be based on enough background information to make a difference to the care that the patient is going to receive in a short space of time in the initial consultation. Systems need to inspire the right question.
The airport questions have to be asked at the right time, in health we need to consider are our questions asked at the right time and by the right people. One of the most common perceived benefits to an EHR in an acute hospital is to remove the need to keep asking the patient the same questions over and over again, not just because, lets face it, it doesn’t instil confidence in the patient or the delivery of care but because it is simply inefficient and unsafe. But really an EHR in an acute hospital can do so much more than fix this issue when it comes to asking the right questions.
As Ireland prepares to go live with it’s first EHR in the maternity hospitals of the country we can see a huge enthusiasm amongst clinicians because the system is going to prompt them, based on data, to ask questions against early warning algorithms. The questions will be prompted because the patient is at the centre of a new type of ‘network’ where devices that measure are plugged into data and where the two spheres of influence, the measure and the data, can come together to inform the intelligence of the clinicians so much more than simple observational charts allow us to do today. That’s is why we, the health technologists, got into this business really, the connectivity of technology that allows us to create an Internet of Things that has the patient at the centre, maybe a new name for IoT in health, the Internet of the Patient, IotP!
If you did decide to answer the airport questions differently to the expected answer what would happen? I would hazard a guess a serious double take would be the first thing as the clerk behind the desk has probably never had anyone answer in any way other than to confirm the answers they expected to hear.
But when formulating the questions does anyone really consider what the answer could be? Imagine if a patient answered differently to expected, how much would it throw the care process. In 2006 I was seriously ill in hospital, no one knew why, no matter what questions were asked the team couldn’t get to bottom of it, so they put me in ICU and wired me up to every possible machine, turned down the lights and observed, when the questions fail observation and time are the only keys to unveiling the true nature of disease and illness. Questions answered can come from so many different quarters, in my case the fact I had travelled overseas was the key to unlocking what was wrong, but that took a more casual conversation than how are you feeling and could only be got to once I was stabilised. Somehow the ability to unlock that information needs to be a new focus for health if we are to deliver contextualised care. However the care that needs to be taken in unlocking the data and delivering it to the clinician needs to be significant, as Frank Buytendijk, a Gartner researcher has been describing for several years this could be considered to be ‘crossing the scary line’. The impact on care that data can have is phenomenal, but, two key actions need to be considered, firstly can the clinician handle the volume of data and second what privacy elements is the patient willing to give up to enable the clinician to have this information.
Imagine if we could give an answer that could cause a different question to be formulated! In so many other sectors digital information has already enabled business disruption to occur. If we can get to the point in health care where the question of the patient could actually move from how have you been for the last month to one where the clinician and patient already have the core data shared between them, the conversation can then move away from how to why and then to prevention. A clinician recently told me that the outpatient appoint for him, a psychiatrist, was as much a reminder to review the notes of key patients as it was an actual face to face appointment, with the right systems delivering the right information to all parties then that can become a shared responsibility and the mantra from the UK of no decision about me without me can be taken up even more strongly.
Next time I check a bag in at the airport I think I will have a little more time for the person asking the question, really they have an important job to do in simply asking the most simple of questions.