Centering Equity in the Implementation of Emerging Digital Health Technologies: AI, genomic medicine, digital media

Despite unprecedented spending on health in the United States and the rapid expansion in types and innovations of digital health technologies, many populations still get sick and die at higher rates than others. 

To address these persistent health inequities in the US, it will be crucial to center health equity in the implementation of digital health technologies, such as artificial intelligence or personalized genomic medicine. As the two nascent fields of health equity and digital equity find their footing after rapid implementation and scale-up in the post–coronavirus disease 2019 pandemic world, a focus on equitable implementation is particularly important to ensure that digital health technologies do not perpetuate or create new health inequities. However, to date, these fields have had a limited or siloed focus on equitable implementation.

This paper is the inaugural report in the RAND Center to Advance Racial Equity Policy Methods Volume series. This paper will be the first to center health equity in the implementation of digital health technologies by adapting a methodological framework for its implementation to support the planning and evaluation of digital health technologies. Without an explicit focus on equitable implementation, digital health technologies run the risk of further exacerbating existing health inequities or creating new ones. This paper offers approaches to policymakers, implementation scientists, clinical scientists, government regulatory bodies, and those working in the health and digital technology fields to take the lead in centering equity.

The paper, first describe the persistent health inequities in the United States and how the rapid adoption of digital health technologies can perpetuate those inequities. Then they discuss challenges and limitations of Implementation Science (IS) in centering equity in the rapid adoption of digital health technologies and translating these technologies into equitable improvements in public health. Next, they provide examples of how IS process and evaluation frameworks can be adapted to focus on digital and health equity to leverage emerging health technologies to course correct and address inequitable health outcomes.

Finally, they discuss how these adapted IS process and evaluation frameworks can be applied to address the pitfalls—and realize the promise—of three emerging fields at the intersection of racial and digital health equity: (1) genomic medicine, (2) artificial intelligence (AI) (specifically large language models [LLMs]), and (3) participatory digital media (e.g., blogs, digital stories).

Photo Jordi Soldevila. Gaza. Geometries de la injustícia

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Health Care 2030: the transition from hospital-based systems to primary care, community, and social care–based systems.

Health Care 2030: The Coming Transformation (2021) by Eyal Zimlichman, Wendy Nicklin, Rajesh Aggarwal, and David W. Bates

The problems in our health care systems include subpar quality and patient safety, a misplaced focus on acute care rather than on prevention and population health, inadequate person centeredness, and unsustainable cost.

The next decade will see considerable transformation in how health systems are designed, propelled by opportunities such as digital health, growing consumerism, and mounting financial constraints.

The Covid-19 pandemic has also necessitated and accelerated significant transformations.

The authors discuss gaps and barriers in the current design of health and health systems, and the needed escalation of transformation including transition from hospital-based systems to primary care, community, and social care–based systems.

They also assess the future evolution of payment systems leading toward sustainable health, changes in provider roles, and the entrance of new nontraditional players

Photo Jordi Soldevila. Homenatge a Toni Catany Austeritat

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The addiction to technology adoption in health

A major driver of cost growth in health care is the rapid increase in the utilisation of existing technology and not simply the adoption of new technology.

Health economists and health technology assessment analysts have become obsessed by technology adoption questions and have largely ignored ‘technology management’ questions.

Technology management would include the life-cycle assessment of technologies in use, to assess their real-world performance; and monitoring of technology indication creep. A rebalancing of focus might serve to encourage a more self-critical and learning culture amongst those involved in technology evaluation analysis.

Further, health economists and health technology assessment analysts could make a more significant contribution to system efficiency through rebalancing their efforts away from technology adoption questions towards technology management issues.

Article (pdf) 
Url: Health Economics:  

Authors: Cam Donaldson , Stirling Bryan , Craig Mitton

photo: Rose generated by Artificial Intelligence Sant Jordi 2022 (UPC)

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Health care technology and COVID-19: what will happen in the long term?

Research published by the Health Foundation in march 2021 explores the challenges of implementing health care technologies and investigates patient and staff experiences of technology during the first phase of the coronavirus (COVID-19) pandemic. It draws on learning from the Health Foundation’s programmes and YouGov surveys of over 4,000 UK adults and over 1,000 NHS staff conducted in October 2020.

During the pandemic, there has been increased NHS use of both established and newer technologies to reduce face-to-face contact and manage demand. Phone consultations dominate, followed by some well-established uses of technology, such as booking appointments by phone or using the NHS website. But some emerging or less established uses of technology, including several explicitly promoted by national bodies, are also apparent. For example, accessing care records electronically, devices for home monitoring, video consultations, and the NHS app.

The research finds that while most of those who used technology more during the early phase of the pandemic found the experience positive, half of these users aged 55 and older (50%) and nearly half of those with a carer (46%) – groups that may have higher need for health care – thought these technology-enabled approaches made for worse quality of care.

Furthermore, the report finds that while 49% of the public and 61% of NHS staff surveyed thought the NHS should be looking to use technology-enabled approaches more in future, a significant minority of both public (36%) and NHS staff surveyed (31%) were unconvinced about the long-term use of these approaches.

While technologies were rolled out with impressive speed, some aspects of implementation – such as evaluation, co-design and customisation – will necessarily have been shortcut, and will need revisiting after the emergency phase of the pandemic is over. Furthermore, many technologies were rolled out specifically to serve pandemic response objectives such as social distancing, so will need to be ‘reoriented’ and developed to serve wider quality and productivity objectives in future.

Through a refresh of the NHS long term plan and other national strategies, policymakers will need to support front-line teams to revisit aspects of implementation and 'reorient' technology-based interventions to serve longer term quality and productivity objectives. Central to this will be evaluating their impact on care quality and developing a vision of ‘what good looks like’.

Access to pdf article (2021)

photo: Strawberry Thief, furnishing fabric, designed by William Morris, made by Morris & Co., 1883, © Victoria and Albert Museum, London 
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Public engagement for technological innovations: new evidence

 

 

With the promise to improve lives, and the offer of abundant opportunities, technological innovation is regarded as a crucial enabler for the advancement of societies and economies at large.

Technologies and their applications, however, also present an array of social, economic and regulatory challenges. How to harness the benefits of technological innovation while addressing the risks associated with these developments is the subject of much discussion by governments, regulators, industry, academia and the general public.

A key aspect associated with these discussions and debates is public engagement, which is increasingly being recognised by stakeholders as a critical instrument to encourage transparency and openness, increase representativeness, and build trust in decision making and the technologies themselves. Public engagement is a broad term that is used in a variety of sectors (e.g. in research, healthcare and policymaking). In the context of technological innovation, public engagement is used to describe the involvement of a diverse group of people (the general public, but also other key groups such as lobbyists, civil society organisations and social influencers) in discussions and debates about potential applications of new and emerging technologies, their governance, regulation and the wider issues that could arise from the way that they are developed and adopted.

Better Regulation Executive (BRE), a unit from the Department for Business, Energy and Industrial Strategy in Uk commisioned a report to find recent evidence, in the form of a literature review and case studies, on the use of public engagement for technological innovation.

BRE Report (2021) PDF and data

The report describes the evidence including:

• Existing examples of public engagement techniques and ten case studies to illustrate how public engagement has been applied around technological innovation
• The impact of the public engagement techniques on, for example, the design of regulatory frameworks, business models, technology adoption and public trust
• Formal evaluation of the effectiveness of the public engagement techniques around technological innovation

The report offer some cross-cutting lessons:

• The use of multiple techniques over the course of the public engagement process can help to engage different ‘publics’ appropriately.
• Spreading public engagement over time allows for reflection and embedding of concepts.
• Having an impact on trust in technologies and technological innovation requires time and considered debate to increase accountability and more systematic public engagement.
• A multi-stakeholder, collaborative approach to public engagement helps to develop informed and considered judgements.
• Using online and digital-enabled public engagement techniques can potentially increase the speed, scale, inclusivity,and geographical coverage of engagement.
• Using some atypical techniques can potentially render public engagement more tangible and user-friendly and could also increase the diversity of participation.
• Having an impact on outcomes such as regulation, policy and market adoption of technological innovation typically requires buy-in and engagement with the right stakeholders.
• It is important to build evaluation into public engagement processes to track impacts and outcomes over time.

photo:NASA (Jan 29, 2021, the day after its full Moon phase. International Space Station orbited 264 miles above China near the Mongolian border.

The Spanish National Health Service: chinese porcelain

 

The principles and goals of the Spanish National Health System focus on universality, free access, equity and fairness of financing. The evolution of performance measures over the last decade shows the resilience of the health system to the recent economic crisis. In terms of mortality and self perceived health it does not seem to have affected heavily at least in the sort term, although some structural reforms may be required in the medium and long term, specially to avoid the increasing income inequality, poverty, and risk of social exclusions that worsen the health indicators.

Here we have some ligth about some policy iniciatives and reforms that experts said should be adressed in the Spanish National Health System

• Cuadernos Económicos de ICE  scientific journal edited by the Secretariat of State for Trade (Government of Spain) since 1977. The current issue published in january 2019. Eight articles written by well known researchers from health economics and public health reviewing these hot topics: 

1. The arrival of new technologies with innovative mechanisms and health financing decisions.
2. Areas of public-private collaboration in health systems. focusing on continuing medical education, health research and health care management.
3. The healthcare management, its quality and the consideration of the impact of this quality on health outcomes.
4. The hospital expenditure and hospitalization evolution in the Spanish National Health System (SNS), during the period 2004-2009 and 2010-2015, analyzing their trends and medical practice variability between health areas.
5. Coordination between the health care system and the long-term care system.
6. Public health go beyond the performance of health care services. Health problems are global and require actions at a global level.
7. Good governance is a prerequisite for changing the health policy and the design of the National Health System in the right direction. Good governance in terms of: prioritization, comprehensive health policy, leadership, national health agency, and cultural and intellectual environment.
8. Economic crisis and health: lessons learned and recommendations for the future,

  Acces Full issue (pdf)  CICE Issue (2018)

• The European Observatory on Health Systems and Policies released a new health system review (HiT) on Spain.

Acces (pdf) Spain HiT (2018)

photo: "Homeless", 2005. google search words: name of the 25th richest people in the world in 2004 by Forbes (Joan Fontcuberta)  
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Ideas are becoming more expensive to find.

In Are Ideas Getting Harder to Find? (NBER Working Paper No. 23782), Nicholas Bloom, Charles I. Jones, John Van Reenen, and Michael Webb argue that, to maintain a given rate of economic growth, resources devoted to research must increase over time.

In many growth models, economic growth arises from people creating ideas, and the long-run growth rate is the product of two terms: the effective number of researchers and their research productivity.

The authors present a wide range of evidence from various industries, products, and firms showing that research effort is rising substantially while research productivity is declining sharply. They cite both aggregate evidence and measures of R&D productivity in specific industries, in particular computers, agriculture, and medicine.

A good example is Moore’s Law. The number of researchers required today to achieve the famous doubling every two years of the density of computer chips is more than 18 times larger than the number required in the early 1970s. Across a broad range of case studies at various levels of (dis)aggregation, they find that ideas — and in particular the exponential growth they imply — are getting harder and harder to find. Exponential growth results from the large increases in research effort that offset its declining productivity.

They argue that a single-minded focus on the quantity of undiscovered ideas is unhelpful. It is not just how many ideas for productivity growth are left, but what it would cost to get them out of the ground – and, crucially, how much we’re prepared to spend to do it. For a long time, geologists have been forecasting ‘peak oil’, only to be surprised by new deep-sea discoveries and shale oil. We, likewise, see a continuing stream of innovations. But, just as newer oil sources are increasingly costly to extract, coming up with new ideas is getting more expensive. There have been technological improvements, but these require the devotion of ever-growing amounts of resources to the research process to maintain steady rates of improvement

These days, pushing the frontier of knowledge out requires mastering an ever-larger body of knowledge, meaning that students have to stay longer in university, and researchers increasingly work in larger teams whose members are more specialised. This all pushes up costs. Returning to the oil metaphor, we are digging deeper into a trickier part of the rock.

Access to the article (pdf): Are Ideas Getting Harder to Find?
Commentary from the authors: Ideas aren’t running out, but they are getting more expensive to find


photo: Until our two activists and our members of the Catalonia Cabinet could come back to Catalonia and will be released from jail I'll publish a dark photo.
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health technology/expenditure relationship

The effect of insurance expansion on the diffusion of new technologies is not a well-understood phenomenon.

Burton A. Weisbrod published in 1991 in the Journal of Economic Literature: The Health Care Quadrilemma: An Essay on Technological Change, Insurance, Quality of Care, and Cost Containment. The Weisbrod proposition in his article is that the expansion in health care insurance produces a cost increasing in new technologies and how new technologies induces demand for insurance. There is an inexorable link between the broadening and deepening of health insurance coverage and the development of new health-care technologies.

Joan Costa-Font and Alistair McGuire  and Victoria Serra-Sastre published in 2012 The “Weisbrod Quadrilemma” Revisited: Insurance Incentives on New Health Technologies

In their study, they attempted to produce empirical tests of Weisbrod thesis and find supportive evidence. The paper presents evidence of a link between insurance and technology diffusion using OECD panel data and taking advantage of a dynamic specification structure. The empirical estimates indicate that higher degrees of private expenditure on health care correlate with higher levels of R&D in health care, consistent with the hypothesis forwarded by Weisbrod that increasing insurance coverage boosts technology adoption. However, their findings also suggest that increasing public funding of health care appears to lower technological adoption, which is consistent with the exercising of monopsony power and an objective of cost containment.

photo: (*) Photosolde
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open data in health care organizations

Open data definition: Data that is easily accessible, machine-readable, accessible for free or at negligible cost, and with minimal limitations on its use, transformation, and distribution.
See the video: #opendatafilm 12m

Why Open Data in health care organization?

Transparency. 
In a well-functioning, democratic society citizens need to know what their health organizations are doing. To do that, they must be able freely to access data and information and to share that information with other citizens.

• Transparency isn't just about looking for what the managers or the personnel are earning (an old fashioned idea). It is also about people empowering themselves to be better able to make decisions about their lifes: choosing the hospital with better treatment outcomes after analyse and compare different data procedures.
• Transparency isn’t just about access, it is also about sharing and reuse — often, to understand material it needs to be analyzed and visualized and this requires that the material be open so that it can be freely used and reused. Open data helps organizations to create data more efficient.

Participation.
Citizens are not able to engage with their health organizations.
By opening up data, citizens are enabled to be much more directly informed. This is more than transparency: it’s about making a full “read/write” society, not just about knowing what is happening in the process of governing or managing a health care organization but being able to contribute to it. Patients, their families and citizens in general push the organization to be more responsive.

[Want to know how a Catalan Health Care organization are tackling open data?: SAGESSA Open Data]

Other useful information: 
Health Open Data Catalan Health Service
The Open Data Era in Health and Social Care NHS England (2014)

photo: galaxy IDCS 1426 (NASA)
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Why projects fail?

 

The postmortem examination of failed projects reveals that long before the failure there were significant symptons or as Leon Kappelman says "EARLY WARNING SIGNS (EWSs)". Kappelmann et. al., wrote an article where they explained that the EWS were related to "people" and "process".

The six people-related EWSs are:

1. Lack of top management support
2. Weak project manager
3. No stakeholder involvement and/or participation
4. Weak commitment of project team
5. Team members requisite knowledge and/or skills
6. Subject matter experts are overscheduled

 The six processes-related EWSs are:

1. Lack of documented requirements and/or success criteria
2. No change control process
3. Ineffective schedule planning and/or management
4. Communication breakdown among stakeholders
5. Resources assigned to a higher priority project
6. No bussiness case for the project  

Acces to the article: Leon A. Kappelman, et al (2006)

For those interested in project management I would reccomend this blog:
Informatica++ /Gestión de Proyectos,  The blog came from the Universitat Oberta de Catalunya. One of the authors José Ramon Rodríguez recomended it.


Bob Landry—The LIFE Picture Collection/Getty Images. 1946. The chase: the dog is carrying a message, is trailed by British foreign office man, a Nazi, a midget, a red-haired Mata Hari and Groucho.
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Evaluation of industrial policy: methodological issues and policy lessons

Industrial policy, covers a multitude of policy instruments and approaches. While there has been a recent revival of interest in industrial policy around the world, systematic evidence of efficacy is relatively scarce.

This new OECD report (Evaluation of industrial policy (2014)) brings together the work of an OECD expert group that has considered recent evidence from the evaluation of industrial policy.

The report focuses on three specific policy areas, namely:

• support for R&D;
• capital market interventions (with a focus on risk capital);
• public procurement for innovation.

It also examines three areas where packages of industrial policy measures are generally applied:

• sector approaches including public-private partnerships PPP);
• policies towards clusters and business networks;
• national industrial strategies.

In many areas of industrial policy, evaluation faces particular methodological challenges. These challenges are outlined in the report, which concludes by drawing together the main policy lessons from the available evaluation evidence.

In particular the recomendations to the policy makers are:

• Make an explicit commitment to the evaluation of industrial policy
• Insist on the development of data and evaluation strategies before programmes can begin.
• Choose evaluation techniques appropriate to the programmes concerned.
• Evaluate industrial strategy using mixed methods.
• Insist on full disclosure in evaluation reports.
• Create robust governance mechanisms to ensure evaluation is objective and free of political influence.
• Develop effective mechanisms for policy learning

RELATED POST

photo: (*) Photosolde
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International Day Surgery activity: how many doctors are interested in looking that?

OECD Health Statistics 2014 (the new name of the online database OECD Health Data) offers the most comprehensive source of comparable statistics on health and health systems across OECD countries. It is an essential tool to carry out comparative analyses and draw lessons from international comparisons of diverse health systems.

One interesting area to compare is the surgical procedures, specially the variations between countries using day surgery. OECD compares data from 1990 until now of a short list of surgical procedures like cataract, tonsillectomy, repair of inguinal hernia or cholescystectomy... showing the total number of procedures performed as inpatient cases, day cases or in certain instances, as outpatient cases. Also as a percentage and per 100.000 population

Some questions a doctor observing data should ask himself:

• Why our country is different from countries like us?
• Why are we doing less/more day surgery than others?
• Are these variations reflecting innapropiate use of inpatien rates?
• Are we under-use some recommended practice?
• Are the incentives payment affect our surgical decisions?
• Is the property of hospital affecting? public vs private hospital
• Is an organizational matter? how the hospital is organized
• Is a problem of my department?

Related Publications: OECD 2012. How many surgical procedures performed as inpatient and day cases

Definition: Day surgery.

• Day-care discharge: Is the release of a patient who was formally admitted in a hospital for receiving planned medical and paramedical services, and who was discharged on the same day.
• Outpatient: Procedures on patients who are not formally admitted in hospital or in any other health care facility: 1) Procedures performed in outpatient departments in hospitals;: 2) Procedures performed in emergency departments; 3) Procedures performed outside hospitals (ambulatory sector).

Photo: W. Eugene Smith—Time & Life Pictures/Getty Images
Dr. Ernest Ceriani makes a house call on foot, Kremmling, Colo., 1948. __________________________________________________________________________