March 16th, 2020 by Christian Seebode

The intention of this post is to describe problems that we are facing with our current information situation given the COVID-19 pandemic in healthcare and opportunities we have to improve this right now, in the near future and long term. This post aims to indicate some directions to solutions or mentions aspects of solutions. I strongly believe technology is advanced enough to leverage solutions but the focus on information technology or Patient Centered Information Technology is not strong enough. I also strongly believe that Information Cures if managed the right way in this and many other situations

This post is triggered by the current challenge that health systems face globally due to the COVID-19 pandemic caused by the SARS-CoV-2 Coronavirus, but it will revisit some of the known arguments coming from the considerations on Patient Centered Information Technology.

The patient centered perspective on COVID-19

In the middle of this crisis it becomes evident that it is essential to view and understand everything from a patient centered perspective since

  • Everybody is a patient regarding this pandemic whether ill or not
  • Patients are important actors to not only receive information but also to facilitate the right actions and to provide additional, essential information

Even if skills and possibilities are different in the patient population, since some people are working in healthcare and governmental functions and others not, still the basic information need is the same. This pandemic essentially democratizes lots of the information need, possibilities and fears that we are facing regardless of the fact that we are dealing with it or not. This post only mentions some of the important aspects and also reflects only my very personal view and experience …

These are some of the important patient centered questions that I want to mention in the context of the COVID-19 pandemic

  • How do I know if I am infected?, ill?, cured?, protected?, at risk? or not?

Answering these questions calls for an official, clear and transparent and understandable explanation of the current disease that is comprehensive to everybody in the patient population. It should be based on the most current evidence. Since the disease spreads quickly all information should be updated in real-time from an authorized source. Additionally, it needs to be known how the assessment for each question is actually done and where and how this information can be accessed. In fact, the real challenge here is not to update the information in real time (many advanced technological options are available to simulate disease spread and to calculates options). The real challenge is to communicate this in a comprehensive way that everybody understands what to do according to each individual level of health literacy (what everybody is able to understand from healthcare). Some information comes from reliable sources, but there is no way to determine if the information is understood by patients to make the right decision. The digital information society needs structure, transparency and control of information which works in both directions in times of a crisis.  (see also the questions about trust below)

  • How do I know if others are infected?, ill?, cured?, protected? at risk or not?

Official statistics are available to everybody. Knowing where to find reliable information is also important to know the situation of my neighborhood. Statistics don’t help to make the right individual decisions. The virus spreads locally and hence the local risk needs to be assessed. To identify infected and ill people quickly to secure others is vital for the safety of a whole population. Common analogue mechanisms to identify all persons that are at risk of the disease in the radius of an infected person are way too slow to allow precise and quick decisions. This leads to the necessary centrally imposed restrictions which are still no guarantee to protect the individual. The only thing that really helps is a precise tracking of personal contacts. This immediately triggers lots of data privacy concerns which are reasonable and correct. In times of a crisis of these dimensions individual rights will be reduced anyway in one way or the other. They should be administered in the most effective way possible. This calls for a clear and transparent risk model which doesn’t exist yet. The risk model has to weigh the right of the individual to be protected against the information need of the population/neighborhood to also protect themselves. Lots of options are available to make this work. In order to support local data sharing everybody would need the possibility e.g. to give consent to this. Even if not acceptable for some persons, examples from the ePatient context clearly show: privacy kills and openness saves life in some situations. If people are open to give feedback about their contacts and risk profiles this also helps to refine risk assessments and prognostic values on a global scale. Additionally, local information sharing leverages the possibility to organize support locally. The reorganization of healthcare services in favor of the most critical patients and the quarantine requirements in crisis blocks healthcare services away from the patient needs that would be available to them under normal conditions. Local information sharing bears the possibility to build local alternatives.

  • How do I know which information I can trust?

There is no official single source of information and trust. Even if official sources are well known and trusted the modern information economy is vulnerable. Sources and information should be certified and approved in a transparent way that makes it easy to identify trustworthy sources and information. As information changes also the information need changes. Together with the information also process of reassessing the information need of patients should be documented. Examples range from updating FAQs to supporting digital adaptive dialogs with patients. Alternative, untrusted sources would have less possibility to target any additional information need.  

  • How can I access healthcare services?

To know where my next healthcare facility is, is usually not a problem in a modern society with a functioning healthcare system. But still there are many unmet needs. In the COVID-19 situation one of the essential problems is that healthcare services become exhausted and personal contact carries a risk. Hence patients should have the possibility to access healthcare services differently. The separation of physical healthcare services from healthcare information services is a necessary distinction. Understandable information carries a huge value for each individual patient. It is essential to make sure information is understood by patients (see above). Information also flows easily both ways using remote connections. No physical contact necessary. Technically many different ways of accessing information are possible, reading documents, messages, becoming reminders or using direct calls with video support or not.  

  • How do I know what I must, must not, can or can’t do to help myself or to help others?

Every local government makes sure to enforce local restrictions and give guidance at this time. Since there are official protocols and regulations in place to assure this, all this happens according to official procedures. However, all these measures are rather coarsely grained since they address the need of a system and assures right and order and safety on a system, population level. This centralized architecture is absolutely necessary and out of question. But still there is a need to optimize and manage local actions in a decentralized manner. Transparency and local management of resources for health, food supply and information prevents panics and leverages local support. Open and transparent communication and information that flows back and forth between patients and health and governmental functions must be ensured. I trust this also happens already within the communication of the responsible persons. Adding value to support local actions for prevention or management and support for the workforce, childcare, public transport needs a local information management beyond purely health related questions to manage risks. There are many recent examples available how information systems support local resource management for housing, transport and care that are even successful businesses. To copy the same mechanisms in times of a crisis can achieve great value for patients and populations if there is a governance and transparency of these possibilities.

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Posted in Communication, Education, General, Information, Privacy, Security and Trust | Comments Off on The Patient Centered perspective on COVID-19
December 14th, 2019 by Christian Seebode

In the preceding posts of this series we learned about the Patient Centered Infrastructure and all its constituents that ensure a seamless patient journey which always supports a precise picture of the individual health situation, collects all information about possible outcomes and helps to perform the necessary tasks in order to reach the personal health goal whether it is a cure, a remission or just an improvement in daily life.

We learned that profile information should be collected with the knowledge that it represents attached to it and that it should be versioned as knowledge is constantly changing in order to keep track of the consequences of change.

The next piece of conceptual model of the Patient Centered Process is information retrieval. Information retrieval uses the information backed up in the Patient Centered Infrastructure whether it is collected in profiles or provided with medical service or by educational means. 

What is information in this context and what is retrieval? 

Informational retrieval is a discipline that combines methods and results of computer science, information theory and other sciences to provide the theoretical background for searching and finding content. You can read more of it here: https://en.wikipedia.org/wiki/Information_retrieval

Information retrieval for the Patient Centered Infrastructure means to give patients access to information and to provide the ability to assess the quality of this information according to the personal health situation, the individual level of health literacy and how this information can be used in other steps of the Patient Centered Process. This is not trivial at all.

In order to retrieve information, you first need an interface that supports retrieval actions. A very common understanding of retrievel supports search options on a repository like for example a database. First important thing is to understand how to issue the search and the search criteria. Is it a keyword or a combination of some? Is it some other information structure like an image or la results? Or is it a complete document or phrases written or spoken in natural languages? Or is it something completely different? Well, I would say it’s all of them. Impossible, you’d say. Well, is it?

At this point it is not necessary to make any real world concessions to what is possible or not. We are just collecting requirements. We didn’t make concessions to describe the profile step in the previous post, we won’t do it here and we certainly won’t do it in upcoming posts. We are just collecting problems and requirements. Solutions comes next, if ever …

When I started thinking about Patient Centered Concepts and blogging about it on http://patient-centered-it.com/ healthcare was moving along well established paths. It is still the case but today you feel that lots of money flows into a change towards patient centeredness, in fact the whole industry tries to understand what it means and the value it creates.  What I am trying to say is that given the current technological possibilities or even concrete products we don’t need to limit our view because future healthcare will need a couple of inventions that remain to be seen.

Roughly speaking information retrieval in the Patient Centered Infrastructure does everything in order to give patients access to information in a meaningful way.

This doesn’t exclusively mean that the result of this retrieval is something patients must read. It could be retrieval as part of a workflow step, information that is required to do a dialogue or just some information that configures a personalized device. In fact information becomes a first order artifact in medical procedures and becomes as important as other components in the process including therapeutic agents. 

But how does this work? What is needed conceptually and where does this lead us? 

Let’s just start simple, such that possibly everyone may follow. Using search engines like Google is an everyday task. Whatever you are looking for you will get some useful hints within seconds. The user interface is so simple and smart at the same time that virtually everyone who can input information will get some relevant results. In case of a search engine you type in something like keywords, phrases or an entire sentence which the search engine than maps somehow to the relevant results. This example is only simple because everyone is used to it. The technology behind it is far from simple. But let’s not bother about how this is implemented but rather how it is modeled. The only important fact here is that Input and output is related to the knowledge of the user. The input is usually much more related to the user’s knowledge than the output because the input usually is coming from the user. Lets ignore the cases when it doesn’t for a while. In case of the search engine the input usually uses a textual representation, mostly human language, and the output also is a collection of texts or links to texts that are related to the input. Without digging too deep into information science here the most relevant concepts of this retrieval process are the input or the query and the result in its most abstract sense. Contributing components are also the knowledge or literacy of the user and the model, in its most abstract sense, of the search engine. However the most important relationship remains, like the input is related to the knowledge or literacy of the user, the relevance of the output is it too. A relevant output should always have some meaning for the requester, if it has not it is just useless, even if it is correct. 

Now let’s move away from this simple, known example and bypass all other retrieval technologies and models like databases of all kinds and step directly into the Patient Centered Infrastructure as defined by this series of posts. 

What does it mean to query information from a Patient Centered Infrastructure? How is information represented, processed and how results are represented? Well, there’s not a single and simple answer to that. Stepping back to the posts about Profiles in a Patient Centered Infrastructure this means at least that we can use Profile as an important source of information. Additionally of course all data sources that are linked with the Profile may be queried too.

But we need to look at the use cases for information retrieval first before we can understand what is needed and more important how it is needed. Information retrieval from a Patient Centered Infrastructure will always be embedded in a higher level use case like engaging with a medical service, communicating with other stakeholders or making decisions about possible process steps. The use case defines not only the domain and the vocabulary but also the process and interactions. To put it in a simple way without the need for formal definitions, which are of course necessary for a sound scientific model, information retrieval from a Patient Centered Infrastructure means to access just the right amount of information as required by the current use case or interaction with the infrastructure. This could be pretty simple like just asking for a definition of a word or it or it could be amazingly difficult like calculating the recommendation of the next best step like adjusting a medication dosage or selecting the best choice for an interventional procedure in the given situation, or just the next best available person to talk to.

The Patient Centered Infrastructure itself has no predefined knowledge about how to retrieve information and less even what it means (see upcoming post about knowledge management), it only provides the infrastructure to connect use case provider and consumer together in a pretty dynamic fashion. 

Before we take a look on what is needed to realize this pretty big picture let’s have a look on the requirements. 

Patients should be viewed as active stakeholders in consumer health information technology development (http://www.jmir.org/2018/4/e128/) and this is true for all stakeholders of the Patient Centered Infrastructure. This requires a very dynamic, declarative or data-driven approach about how to define requirements, interactions or processes. Trust in health information and belief in the effectiveness of information security safeguards increases perceptions of patient care quality (http://www.jmir.org/2018/4/e107/). Safety and trust is a first order requirement for the Patient Centered Infrastructure in order to make it work. It has to be very transparent and concise about safety levels and even the comparison with perceived safety. WhatsApp, SMS, and email are effective and widely used ICTs that can promote communication between cancer patients and physicians (http://www.jmir.org/2018/2/e50/). The adoption and integration of everyday ICTs is a big factor for popularity and ease of use of the Patient Centered Infrastructure. Health care professionals should assist patients’ medical decision making by initiating as much dialogue with patients as possible, providing credible and convincing health information to patients, and guiding patients where to look for accurate, comprehensive, and understandable online health information (http://www.jmir.org/2018/2/e47/). Privacy, security and trust in the Patient Centered Infrastructure are still high priority first order requirements but become relative to the goals of the patient. As long as patients execute their rights on data privacy they are in charge to govern all data related processes. Part of the Patient Centered Infrastructure would be a possibility for patients to become more than only data subjects. GDPR and other regulation assume that data controllers are distinct entities that support patients rights. For a Patient Centered Infrastructure it makes sense to define data owners that also own part of the Patient Centered Infrastructure regarding the use of their own data. Even if that sounds a little constructed it makes sense if you think about the consequences of data policies supporting the wrong goals. There is enough evidence even if anecdotal that privacy kills and openness saves life (in some situations) (https://www.jmir.org/2019/11/e17045/). Information retrieval and access become even political dimensions in that sense. My personal guiding principle deduced from that is: Information cures (see upcoming post). This is why you won’t want patients not having this cure. Patients as information provider are then curing actors, health providers but only in a context that supports the right level of access and literacy: the Patient Centered Infrastructure

Education (see upcoming post) and communication reflecting the individual level of health literacy also requires a very flexible mechanism to query information and calculate results according to the current use case. Internet health information seeking can improve the patient-physician relationship depending on whether the patient discusses the information with the physician and on their prior relationship (http://www.jmir.org/2017/1/e9/). 

Lets collect some requirements as user stories regarding information retrieval from the Patient Centered Infrastructure (not exhaustive at all):

  • As a patient I want to be an active stakeholder in consumer health information technology development (again all stakeholders are required in that role) for the Patient Centered Infrastructure
  • As a patient I want constant participation in definition of requirements, interactions or processes for information retrieval and quality from the Patient Centered Infrastructure
  • As a patient I want to have and control trust in health information and belief in the effectiveness of information security for information management and retrieval in the Patient Centered Infrastructure
  • As a patient I want control all security levels of the data and information that I own
  • As a patient I want to understand the tools and methods I use for information retrieval from the Patient Centered Infrastructure
  • As a patient I want to select the tools and methods I use for information retrieval from the Patient Centered Infrastructure
  • As a patient I want to retrieve information that fits perfectly into my personal health pathway/process without the need for me to specify the informational need explicitly. (I just own my information and the process; the information need is determined implicitly but I can adjust it)
  • As a patient I want to issue queries and retrieve information according to my individual level of health literacy and my learning curve
  • As a patient I want to be an information provider in the Patient Centered Infrastructure with a transparent contribution for other stakeholders to use it for the health and wealth of others

How to do all that? 

According to the conception of this post I could have asked question and specified requirement only in relation to things that I personally understand. Which kind of means or gives at least hope that technology exists that could support all requirements and use cases. I personally do believe that we are not solving a technological problem here. Everything that is required could be leveraged by human interaction alone. Technology just makes it faster and at some points more reliable. Retrieval from a Patient Centered Infrastructure requires a cultural change to make accessible what already exists. 

And change is underway, accompanied by technology or driven by it. If it is a way to help patients to receive the right educational material about diabetes (https://www.jmir.org/2017/10/e342/) or a method to support information retrieval from web scale sources to evidence based practices (https://www.jmir.org/2019/8/e12621/) (even if targeted mainly at health care practitioners).

All this shows that technology only helps to ask the right questions but is not the principal reason for change. 

Stay tuned for upcoming posts about knowledge management and education…

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Posted in Education, General, Information, Privacy, Security and Trust, Web | Comments Off on A Patient Centered Infrastructure – Part 4 – Information Retrieval
December 27th, 2017 by Christian Seebode

In part one we learned about the requirements and the need to build a Patient Centered Infrastructure. In part two we learned about the Patient Centered Process. This article explains the need for profile information in the Patient Centered Process.

Profile Information as explained in the previous article references all the necessary actions to collect health data and access them again at any stage of a healthcare process or any step inside the Patient Centered Process. This already says a lot. And it contains a clear statement why a Patient Centered Profile is something very different from a traditional EHR Profile. EPR or EHR implementations are traditionally trying to collect healthcare data in a way that they act as data sinks for healthcare processes. Standardization efforts have tried to assure interoperability of these data oriented tools.(EHR Profiles)

The success was very limited. One fundamental reason for this is that healthcare itself is not a data based culture. Healthcare traditionally was and hopefully always will be a value oriented culture with its undisputable objectives providing and maintaining health of people and populations

Data collection to support these goals was done ever since to document experience. With a modern and more scientific medicine data became more important and the primary tool of proof for effects and success. However there is always this always this fundamental bias involved in any attempt to collects data from one patient, in one situation according to the question that needs to be answered. The dimensions of who, why, what, when, where and how are responsible for the establishment of any data silo, that is so difficult to break down again.

For data to represent valuable information it must reference all the knowledge of all these dimensions together with their concrete values along these dimensions. It is very often not understood how a data value is biased by the method of generating it or the time or the question behind it. Data quality almost always does not transcend one or more dimensions. This is a fundamental problem for any value based healthcare system that relies on data collection.

I don’t want to describe the problem any deeper than that. In fact is makes more sense to thinks about possible solutions. Well, the designated solution of this series is called the Patient Centered Infrastructure. Together with the Patient Centered Process it takes care of (re)assigning value to profile information. How this can be done will be topic of upcoming article. Here we just focus on the necessary aspects of profile information.

The Patient Centered Profile makes sure that all values are conserved together with the knowledge behind its acquisition. In fact that is not very simple. The expanded (and probably exaggerated and unnecessary) version of this claim is that the necessary knowledge to document a lab value contains also the science that led to the discovery of the method of acquisition itself and the concrete instance and method of the measurement. But more importantly the knowledge that leads to the understanding of the lab value needs to be referenced. That includes also the patient’s knowledge according to the individual level of health literacy. This is a powerful statement. In fact the central claim is in order to break down siloes it is necessary to (re)assign knowledge to profile information in a very agile and dynamic way. How this is done will be documented in upcoming articles. We will now have a look at how profile information itself should be managed.

The Patient Centered Profile contains data collections accumulated in the Patient Centered Process and supports all the necessary dimensions to interpret the data in a meaningful way rendering information to understand the pathway of the patient. Dimensions are supported as views or filters on the data. Semantic filtering can be used to document particular diagnostics or questions. The most necessary dimensions are who, why, what, when, where and how data was acquired and of course the knowledge necessary for understanding, but of course now restricted to these. Dimensions can be added dynamically. It is very important to attach the necessary knowledge explicitly. There is no such thing as implicit knowledge which usually is the main reasons to build unbreakable data siloes. Doctors and patients should be able to look at the Patient Centered Profile using different levels of knowledge but still referencing the same data in a way that a Patient Centered Dialogue is supported. An example for using different relevant knowledge or at least emphasizing different views would be a red blood cell count which for the doctor is related to the condition of anemia and for the patient it is related more to the clinical symptoms like fatigue and of course the treatment depending on the type of anemia. Even if both use different working knowledge concepts attached to the same data, they are enabled to cooperate on that condition.

This means that a semantic patient profile or patient record always has the working knowledge attached to it that helps to interpret the data according to the health situation or condition. This is very important for rare conditions where you have to collect common conditions which usually lead to common interpretations in a different way usually hidden form the view. An example for this would be Fabry’s disease where many symptoms are caused by a rare genetic defect and not by very common diseases. In fact a semantic profile supporting different views on the data is the key to effective translational medicine.

This article only motivates the fundamental data structure for supporting semantic profiles within the Patient Centered Process. Upcoming posts will document the necessary processes and intelligence that manipulates semantic profiles in a meaningful way. A Patient Centered Profile supports different views on the data as already mentioned. A Patient Centered Profile is constantly updated as new data or knowledge flows in. These different versions along the time dimension can be compared and manipulated in a transactional way to support differential analysis.

Conclusion

The patient Centered Profile collects medical data from unlimited sources and stores them together with the knowledge concepts attached that are needed for interpretation according to a certain question or condition. It supports various views and different outcomes along multiple dimensions and can be updated and manipulated to support different views on the same situations. The knowledge management and mining processes will be documented in upcoming posts

September 24th, 2017 by Christian Seebode

In part one we learned about the requirements and the need to build a Patient Centered Infrastructure. The central purpose of this infrastructure is to empower patients to participate in healthcare processes. This participation is based on the individual level of health literacy of each patient. Increasing health literacy and offering participation are the main building blocks of the Patient Centered Infrastructure. Information becomes a central resource for the outcome of patient healthcare pathways.

In this part we will have a look on the necessary actions that need to be taken in order to participate and to understand and reflect participation. Traditionally healthcare supports a very common picture of health and illness and what is necessary to be cured and stay healthy (https://en.wikipedia.org/wiki/Traditional_medicine).

Within this commonality resides good and evil side by side. Medical science ever since tried to understand the common things. There’s a very catchy statement that describes the nature of medical wisdom that supports medial practice: ‘common things are common’. Meaning that what you know about many patients helps you to understand the situation of an individual patient. Symptoms, therapies and outcomes are the result of statistical observations and analysis in their majority and that’s OK. However, often enough it is not OK. With the same relentless statistical precision, we find situations that need uncommon, rare and need individual reasoning (https://en.wikipedia.org/wiki/Rare_disease).

As a consequence medical science is on a way to uncover a deeper understanding of the individuality and variability of health, illness and the consideration of any personal situation and this changes the face of medical science (https://www.statnews.com/2017/08/02/randomized-controlled-trials-medical-research/).

But even if we focus on common things and subscribe to the general notion that all patients can be treated and healed according to the prevailing medical knowledge that is based on the observation of populations, groups and communities with a count greater than one, every process with patients is based on individual interactions or at least the individual knowledge of each patient or his health literacy. This is why healthcare delivery was an individual process ever since. And even more than that since medical science builds much more knowledge and wisdom on the parts of a patient than the patient as a whole, there’s enough probability that any scientific understanding of health and illness is still wrong enough given any individual situation.

In this blog post we try to imagine patients as active participants of a process and individual caretakers of themselves. This is an important step. We try to model the patient behavior from the patient perspective and not from the scientific basis. We try to understand patients like consumers of their health demanding information, communication, education, safety and trust and of course treatment. The patient acts as an individual according to or her individual knowledge and beliefs. Apart from what we know about biology and medicine this is a crucial ingredient to care of people and keep them healthy. You can’t treat patients only according to their biology or what is known from that. That would be like flying an airplane just relying on physics. It works but it doesn’t guarantee a happy landing. Customer demand and satisfaction are among the most important influences on commercial aviation and the education and behavior of the airline personnel. Imagine yourself as a passenger always in a state of emergency. This wouldn’t be a desirable perspective. So what is needed for healthcare is what is taken for granted in other sectors, even if this is just a very rough comparison.

But the commercial perspective of healthcare is just one aspect to support a Patient Centered Process. It is an important one but there’s much more to it than meets the eye yet. We begin here to imagine the Patient Centered Process as an important basis to healthcare delivery and also as a tool to redefine the understanding of health and illness. There is a probability that it may host the missing perspectives on individual patients which are necessary to understand the individual nature of disease more completely than before. It connects all participants of healthcare processes into one uniform process model. The steps of the process may be performed by actions, services or other processes. This we will learn walking the process step by step. This blog post gives a summary of all steps; the follow ups explain each step in detail.

The Patient Centered Process

Since the Patient Centered Process is circular there is no start or end. For each patient, the process starts with a different step. The process runs forever in the lifetime of an individual patient and it is important to consider that is already running for each and every one of us just that this has been happening virtually without any technological support for the process itself. And even if there is technological support for some process steps already happening like for example access to an electronic medical record or a patient forum these technological steps are not supporting the process as a whole as long as they are not integrated. But with integration it should converge into a single process where each step represents also everything that happened before. Once the Patient Centered Infrastructure is completely integrated for a patient there is only single process running for each patient and the reason it is running is not a disease or illness condition but the patient himself and his or her experience. We have to be aware that every day, every moment we make choices or learn things that directly or indirectly influences health outcomes. If it is the way we compose our diet or the travel destination we choose or even simpler the amount of sleep we get. Everything counts; everything influences the path we take in relation to a healthy lifestyle.

Recent developments in precision medicine highlight the genetic diversity of humans in relation to the biological foundations of individual disease and health. This opens new possibilities to describe the genetic situation of a patient and to analyze this in contrast to the phenotypical presentation and the clinical findings (https://en.wikipedia.org/wiki/Precision_medicine).

The Patient Centered Process supports a way not only to manage this information between experts and patients but also to add new ways to do research in a collaborative way.

The Patient Centered Infrastructure together with the Patient Centered Process empowers patients because it provides access to information, people and services in a structured way as it channels all actions taken back into the process. The infrastructure provides the technological basis to support education that empowers patients to improve health literacy. This aims at breaking down the silos that medicine and healthcare is suffering from while still ensuring the necessary amount of privacy and trust. The necessary level of protection is also a highly individual aspect. Every patient has an individual understanding of what is to be protected and what not. The Patient Centered Infrastructure provides the necessary tools and fine grained control of individual security. But what does individual behavior mean? And how can it be supported? Even if this gets very complicated in the end

a very simple example may document this. Many conventional therapies only fail because patients don’t understand the rules or just forget about to take the pills (https://news.aetna.com/2016/08/causes-half-chronic-disease-treatment-failures/).

Traditional medicine is not very eager in explaining this or trying to do something about it. Drug delivery is models break it down to its biological or mechanical characteristics. But patients need to take it first before any biological effects can happen. In general behavior contributes a great deal to what health is or means for a single patient or person. In fact it represents the state of health. In fact health related behavior is so difficult to assess and measure for what it means for health outcomes but intuitively there seems to be a huge impact. Medicine and medical science has achieved great results in order to save or improve the life of everyone but there is still no standard way to control health related behavior. How could that be? It can only be the patient itself that effectively controls it. This is why any attempt to deal with the connection between health related behavior and outcome, has to be patient centered. So if we build a Patient Centered Infrastructure that guarantees compliance and adherence in a way that drug effects are within the calculated ranges, for example we need to put the patient in control and we already do something big. But we want more. The traditional way drugs are designed and tested and applied is not patient centered at all. Imagine a situation where the whole Patient Centered Infrastructure is able to deliver the same outcome drug therapy does or even better, the information contained in the Patient Centered Infrastructure is able to simulate the individual path of patients. This is what we want. But this is a huge endeavor. However I believe this is possible. With the Patient Centered Infrastructure as a tool the picture of health and healthcare becomes more and more complete because it takes all the information into account that was left aside so far but its importance can’t be underestimated. But let’s keep it simple for now. We actually are learning, we don’ know yet exactly how everything works out together. But we can propose the ingredients.

And this is how it works. The steps of the Patient Centered Process that contribute to the outcome are the following:

  • Profile. Profile references all the necessary actions to collect health data and access them again at any stage of a healthcare process or any step inside the Patient Centered Process.
  • Information retrieval. This step is fundamentally different from the Profile step because it contains the possibility to identify more information than just directly the data that is managed by the profile step. The intelligence that is needed to do this could be contributed by algorithms or human beings or anything else with the ability to do this. Information retrieval is a very individual process and not only a technical one. It connects the profile information, any other relevant sources and the individual knowledge or health literacy of the patient accessing the information
  • Knowledge Management. Collects, formalizes and manages the knowledge needed to associate data, information, behavior and literacy. Knowledge is a first order artifact inside the Patient Centered Infrastructure and not only something that is encapsulated inside science or human brains. It is generated on the fly but persists after the fly. It is important that every patient knows what he or she knows. Knowledge management helps to organize this important resource.
  • Education. All the actions necessary to produce reliable and intelligent behavior, knowledge, literacy and empowerment. This means not only for one patient but for the whole system. Educational support should be able to improve outcomes directly. It can thus be considered as a kind of therapy in the broader sense. But in many cases this is not enough. Since knowledge is a primary resource in the Patient Centered Process the need for education can be assessed and the educational action can be planned on an individual level
  • Medical Services. All actions that are related to health interventions that are not covered by the other steps. Usually performed by health professionals but not necessarily. Even more important the medical services are subscribed and ordered by the patient directly and not by any party acting on his or her behalf. Within the process the need for every medical service becomes very transparent and its effect completely understood. Examples are second opinion, lab orders, consultancy, imaging services or even genetic sequencing.

This is a very coarse process model. It is possible that it will be extended according to process innovation. But for now that’s it. Behind the steps there is a quality framework that ensures the quality and outcome of the whole process. This and details of each step we be describes in the follow up posts.

August 12th, 2015 by Christian Seebode

Healthcare delivery is in permanent crisis. Worldwide. At least the leading economies of the world are facing a problem that healthcare delivery based on state of the art medicine is not possible in a cost efficient way. At the same time the cost structure is not transparent to the patients or anyone and the main value of healthcare delivery: health is not seen as a common goal which needs permanent attention.

Healthcare without Patients

Traditionally healthcare delivery tries to hide the complexity of medicine away from patients. Even if the patient as a person is involved in diagnostic or therapeutic procedures, he or she inhabits a rather passive role. A patient doesn’t need to know exactly what is going in order to cure him. At least this is a very common practice among healthcare professionals. Not only that this view ignores the significance of a patient in healthcare delivery, this is completely wrong and dangerous too. The participation of a patient in healthcare delivery is restricted often enough only to patient interviews, and medical procedures to some extent as far as the contribution is really needed, as in encounters with a psychological background or just physical presence to get blood samples etc.

Sometimes a patient appears to physicians just as a collection of data. There is a funny saying used among radiologists which tells the whole story:

‘Do the impossible: go and see the patient’

The consequence of such a situation is that healthcare delivery in most situations renders to be less than optimal. The patient is most underrated resource in healthcare delivery. This is tragic because the motivation and participation has a great influence on the outcome of any disease or health related situation.

Defining the patient centered infrastructure

Putting the patient in the center sounds like a good plan. But where exactly is the center? Is it where the patient already is or is it somewhere else? This whole blog is about finding answers to this question. At least about what information technology should contribute to find an answer. To understand the issue of centeredness it seems straightforward to claim a couple of services which may contribute to the well being of a patient, to provide patients with information, communication, education and trust. This is what I call a patient centered infrastructure. Within a couple of posts I will outline the notion of an infrastructure which does exactly this.

This infrastructure is about technology, mostly software, but technology itself is just the road, maybe the car, the driver is the patient. And then there is people needed to teach driving. We start with a simple question. How do you know that you are sick? It is mainly because you don’t feel well. In fact this is your condition and usually you decide that you are not OK. At this point it doesn’t matter if you are sick or not according to medical teaching or diagnostics. The decision itself is enough to justify the following. For the sake of simplicity I am ignoring the cases where someone else tells you that you are sick and you don’t feel sick. That is too complicated right now.

So what you are doing about this? Well the answer depends on your level of health literacy; this is how much you know about the health condition you are in. If you are a doctor you may understand a lot if not you need someone to tell you. But exactly what? Do you want to know everything or just what to do to be well again? This is the next decision you make and it influences your path to become well again fundamentally, much more than the first one. If it is a conscious decision or no is also influenced by your level of health literacy. In fact health literacy is such a central concept to the discussion of the Patient Centered Infrastructure that we need to define it

the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions

The level of health literacy is diverse and there is no widely accepted process or solution to improve this situation. It is an implicit ingredient of the healthcare delivery process. Where patient education is performed it is not a central component of healthcare delivery but mainly an optional procedure.

Healthcare progress is related to the availability of new diagnostic and therapeutic procedures, but also to the development of new delivery methods. Evidence Based Medicine is such a progress that collects the availability of tools and methods of clinical practice into a framework of decision support. The availability of information technology, the internet and tools, services and practices that uses them gives us another possibility to achieve progress. This cannot be reduced to technology alone because the combination of the above has an impact on society and the way we live. But all these advance can’t just be restricted to the provider perspective.

Health literacy is an individual condition and every patient may have different information needs. This is another perspective of the mismatch between current healthcare models and patients needs. Medicine traditionally tries to define common answers to common problem which works for the majority of patients but nor for all. The tendency to integrate more individual traits into healthcare is a way to achieve better outcomes for individuals. Defining and understanding the individual better, not only in terms of informational needs but also physiologically, psychologically and genetically is a very powerful tendency in current medical research (Personal medicine, precision medicine). All this sums up to the tendency of a more value oriented medicine where each patient is able to define the outcome on an individual basis.

So how can patients interact and what exactly is needed? Many patients try to improve their health literacy and skills on their own using Google and the information available on the internet. This has some benefits but causes sometimes the opposite result. Health literacy is reduced because the information available does not fit into the individual situation. Doctors treating these wrongly informed patients spend time and resources to get them back on track. Or patients just make the wrong decision based on this information. For the Patient Centered Infrastructure this is the most important and undisputable claim:

  • As patient I want to find information that is related to my health situation

Suppose that this works and the Patient Centered Infrastructure is able to deliver this information. What am I going to do with it? First thing (but not restricted to) is that you want to share this with somebody:

  • As patient I want to share information that is related to my health situation

Could be my doctor, other patients or family members. Could be everything or just a part of it. Whatever makes sense for me I will define it.

All this implies that the Patient Centered Infrastructure knows enough about me that it is able to determine all necessary relationships for my health situation. It knows my data, my level of health literacy, my goals. It knows me. Sounds like science fiction? Well, it is definitely science but not fiction. We will continue with more aspects in upcoming posts.

The Patient Centered Infrastructure is a model that supports the Patient Centered Process and a service infrastructure that serves the informational needs of patients. But more than that it helps making information a valuable resource for the outcome of patients. We will continue to document the features and aspects of that model in upcoming posts.

A paper of the Patient Centered Infrastructure has been published for IMECS2013

http://www.iaeng.org/publication/IMECS2013/IMECS2013_pp200-202.pdf

[Certificate of Merit for The 2013 IAENG International Conference on Computer Science]

March 22nd, 2014 by Christian Seebode

Very motivating article about the changes to future healthcare systems and how these are related to contributing sciences connected to ICT. My personal analysis would be that ICT powered methods like Patient Centered IT leverages new dreamstime_xs_31010215ways healthcare is defined. Intervention becomes Outcome. However the methods to deliver this new quality are only slowly evolving. There should be no fear about local emerging ecosystems organized as ‘networks which may challenge conventional delivery models’ as cited in the article because the conditions that dominate healthcare delivery may have a very locally and individually  restricted scope.  Upcoming investigations will have to identify the variables that describes each scoped ecosystem spatially, logically, timely and organizationally. Very interesting

http://www.medicine20.com/2014/1/e2/

November 20th, 2013 by Christian Seebode

This a very interesting post about some facts of the drivers of changing healthcare. The impact of information and communication is measurable. However the measurements are often related to coarse grained concepts like healthcare costs. Information in the role of a therapeutical intervention or in the role of a framework for a changing society needs other measures. Value oriented measurements are notdreamstime_xs_28963746 available short term. The development of apropriate methods to measure outcome in a long termin is just not availabale. However it it seems intuitive to see the relationship between the documented difficulty of understanding health related information and the difficulty to follow medical advice. We tend to build causal relationships between documented facts.This may not be the best option. But there is a lot more research needed to identify relationships between the facts that may support a positive influence on health literacy and outcome. Enjoy the graphics.

http://www.healthcarecommunication.com/Main/Articles/b289910b-db75-4704-82c6-badf32f73c0d.aspx

May 5th, 2013 by Christian Seebode

A systematic review of social media for healthcare documents some very important influences and aspects of these platforms when used for health interactions. However social media is only one necessary development that contributes to let patients particpate in healthcare delivery. The whole development is quite new and people are adapting and adopting so that real experience is still small, but taken just the benefits brings to the front what always has been happening dreamstime_xs_21373938and was always part of healthcare: the social character and interaction between people.

Please read

http://www.jmir.org/2013/4/e85/

to get a good overview.

The limitations of social media

Social media tools remain informal, unregulated mechanisms for information collection, sharing, and promotion, so the information is of varying quality and consistency. Similar issues exist with traditional Internet sites, but these issues are being heightened by the interactive nature of social media, which allows lay-users to upload information regardless of quality. Reliability may be monitored by responsible bodies using automated processes, employed to signal when content has been significantly edited, and progress is being made in automated quality detection.

are mainly attributable to the immature nature of the platforms in general. Social Media is just too general pupose to be used for healthcare purposes. There is a need for reliablity, meaning and accuracy. Personalization of content can be achieved but what is missing is the ability to handle the intense nature of medical knowledge. My approach is the complete Patient Centered Infrastructure which i will document in this blog

May 5th, 2013 by Christian Seebode

This blog is about Patient Centered Information Technology. It assumes that there is a true and realistic benefit for people using information technology for their healthcare compared to those that doesn’t. This may be hard to prove but with more and more people engaging in this and havin the possibility the culture of healthcare is changing making this a reality. However it needs basic access and technological support for everyone. This study depicts the situation for people not having enough resources to participatedreamstime_xs_21179918

http://www.jmir.org/2013/5/e93/

Given vulnerable low-income homebound older adults’ substantial health and mental needs, examining their ability to search for high-quality health information/resources and make informed decisions about applying the information to improve their quality of life may be particularly useful.

Internet access and education must become a first order resource for healthcare and should be paid by health insurance plans and considered by welfare organizations. Just like any other measures that improves outcomes.

April 14th, 2013 by Christian Seebode

The following study contains some promising results

http://www.jmir.org/2013/3/e65/

Patients with full EHR seem to be encouraged to particpate more in healthcare delivery. The EHR access triggers some behaviour to improve health literacy and active participation to cope with and handle zhe information contained in EHR. This is all in line with the concepts of the Patients Centered Process which i will document in a follow-up post

Especially this is important:

Concern about workload is likely more complex. Patients’ accounts suggest that sharing all records reduce workload in some areas, for example, fewer visits or decreasing requests for copies of records. At the same time, participants’ experiences also challenge traditional roles for patients and physicians.

This references a change in culture and is related to the effort done in healthcare delivery. Patients claim a different role in an active position.