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This article is meant to write down ideas and thoughts which lead to value creation for the healthcare process, not yet to create turnkey solutions. It is more of a though experiment than a clear cut solution. It deals with the evolving dynamics of the healthcare process, meaning the flow of interactions between care providers and care takers. The focus is on how to avoid the loss of efficiency and value due to gaps in the flow of people and information in healthcare. Healthcare is seen as a landscape in which people and information flow in-between locations of value creation. At each action point value is created by the care provider for the care taker. Information should flow regardless of the physical barriers (distance, walls) at the right time and the right place to those people who need it to do their work (physicians, nurses,..) regardless of their location (intramural, extramural, trans-mural). The information reaches the people wherever they need it and where they need it (strong identity management needed for security).
Figure 1: Healthcare embedded in a matrix of interacting systems. Patient and care provider become embedded in a supporting process filled with communicating systems. |
Figure 2: Increasing participation of interconnecting systems. The capabilities of the interposed systems to create true added value increases with their capabiliteis to process the content of the transfer. |
Essentialy the care-relation is a request and answer process between an individual asking for the solution of a problem related to its health. In primitive societies this one-on-one relation remains more or less intact. In modern society however, due to the increasing cost of healthcare, this relation becomes embedded into large networks of interrelated stakeholders. Only low-tech care (family) stays largely out of this increasingly complex web of interacting individuals and organizations.
Due to the level of complexity this process has reached nowadays, the patient itself becomes hidden under layers of organizational complexity which also become increasingly unmanageable to sustain. The overhead of the system and the resources required to keep the system affordable are reaching their limits in developed countries while in the developing world access to healthcare suboptimal. As there is no way back to the primitive situation, the only way out is to improve the efficiency of the entire process surrounding the patient care-provider relation (e.g. physician, nurse, …).
Figure 3: Managing digital relations. |
Figure 4: Questions and answers in the digital world. |
Part of the solution of the healthcare quagmire is to reinvent the entire process flow, with the goal to make it both perform more efficient (reduce cost) and more effective (reaching the right goal). This will require us to re-engineer the process and make it into a sustainable, lean, efficient and flexible system which is capable to deliver performance at the right place, time and person. Anything including the relation between care taker and provider should be optimized dramatically to reduce the overhead of the entire process and to refocus on the essential relation between patient and care provider (physician, nurse, ..). But simply converting the paper-based or digitized but siloed process to a networked workflow creates more even overhead and inconsistencies.
It may be better to think about the new process as a digital universe which needs to be shaped according to its own laws and inhabitants. An EHR is such an inhabitant, which will over time evolve into a more complete representation of a person and become an ExR or ELR (Electronic Life Record) in itself capable of interacting with other systems or call it inhabitants of the digital universe. Creating the digital process then becomes equivalent to creating an interrelated ExR world. The semantic web is a step in this direction. Each participant of the process, represented by its Electronic x Record or virtual persona becomes connected to the other stakeholders as in the physical world. The way they interact of course will be different and the interaction process differs (no paper shuffling equivalent). Some of the stakeholders in this flow may have no real world equivalent, but only act as virtual intermediates. Due to the internet, they can interact with the speed of light, so distances are no longer an issue. There should be a dynamic balance between the physical and virtual world and a topological map between both representations of the healthcare continuum. The inhabitants of this digital world, will be linked to real-world counterparts in the real world. The interfaces between this digital world become windows through which we interact to create a mesh of flows which run both in our physical world and in the digital world (a PC with a keyboard is such a window, albeit primitive). The internet of things is one such step towards this digital parallel world which becomes an internet of relations. The boundaries between the digital and physical world will become transparent and process flow will run back and forth through the physical analog and the digital world. The way we interface with the digital world needs a big improvement in both usability and capacity as today we are still not capable to interact in a way natural enough to allow for the required ease of use.
A patient his or her ExR will be part of the “database record” representing apects of a person in the digital environment, with healthcare-related information (CT, NMR, lab, …) part of this digital persona (an advanced database system with sockets linking it to its surroundings). Each ExR acts like an entity which itself belongs to multiple types (situational types) and its relationships present themselves as roles. Ideally, the digital representation should accompany each individual throughout its life and provide a “memory” for all healthcare related events (live events would be a more general description). This way a physician or a care-system could ask question to the digital representation, e.g. in case of an emergency. The willingness of the ExR to share information will depend on the trust it has to its digital counterpart. Our digital ID becomes the key to our digital companion and the secure link through which interfaces can connect. A digital ID may in the end resemble a sort of xPod which we carry around and plug into the digital web when we want to identify ourselves and interact digitally. At that moment our digital persona is activated and ready to go (as a spirit out of a lamp). A patient going through a CT-scan gets the result attached to its digital representation, although the data can stay at a server in the hospital or any secure vault. Whenever a physician needs the data, the virtual companion remembers the location and acts as an intermediary to ask for the data and provides them to the physician through its digital companion. The patient-centered healthcare system becomes a virtual reality. The data are the equivalent systems representing ourselves in-silico and the infrastructure nourishes and connects the data.
What and how this digital presentation operates is part of ongoing development, from an EHR to a complete virtual companion or ExR. The flexibility with which the digital components are capable to interact will to a large extent determine the feasibility of such a system. In a patient-physician encounter for instance, the patient explains his symptoms which are digitized into his digital companion to be remembered as part of its ExR, and who transmits them also to the digital companion of the physician which “tells” it’s real world counterpart what the anamnesis could suggest. The physician performs its clinical and technical exams and its digital counterpart acts as its agent in the digital world to manage the interactions with the radiologist and the lab ( a stethoscope not only transmits the sound to the physicians ears, but also to his digital companion for assistance - the web of things interconnects to the web of persona). The more sophisticated the digital companions become the more they are capable to create added value for the overall system by moving away from the mostly passive digital systems of today towards true physical-digital partnerships.
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