What Impact Does The Rate Of Technological Change Have On The Delivery Of Health Care Services
J Public Health Res. 2013 Dec 1; 2(3): e28.
Technology and the Future of Healthcare
Received 2013 November 1; Accepted 2013 Nov 1.
Abstract
Healthcare changes dramatically because of technological developments, from anesthetics and antibiotics to magnetic resonance imaging scanners and radiotherapy. Future technological innovation is going to keep transforming healthcare, yet while technologies (new drugs and treatments, new devices, new social media support for healthcare, etc) will drive innovation, human factors volition remain one of the stable limitations of breakthroughs. No predictions tin satisfy everybody; instead, this commodity explores fragments of the future to meet how to think more clearly about how to become where we want to become.
Key words: future healthcare technology, human factors
Introduction
Pluck a nurse and surgeon out of the nineteenth century and transport them into a mod 21st century hospital and it would be a thoroughly recognizable place, with the same hierarchies and strict cultures. Patients treated as helpless, stripped of their dress and possessions, lying in beds and virtually completely ignorant of their illness. They might exist disappointed in our treatment particularly of sometime people, merely I don't think it would surprise them.
If our 2 time-travellers were able to nourish a postal service-mortem and listen in on a discussion of human error, very little would seem novel. Clinicians would still be in deprival, lawyers would nevertheless exist hovering, and the delay and deny culture would be no surprise. Withal, the changes that would surprise the nurse and surgeon are all changes to engineering. Infusion pumps, dialysis machines, antibiotics, middle valves, MRI scanners, even hand washing stations would be new ideas. All the hidden engineering used in the laboratories behind the scenes, from path labs to decontamination, would exist startlingly new if it was noticed.
Although the medical culture is similar, there have been dramatic technological changes, and really these changes would exist hard to explain. Does anybody fifty-fifty know how an infusion pump works? They used to exist clockwork (and before that, gravity fed) and now almost everything contains a figurer and has a colourful screen and lots of buttons. Implanted defibrillators that use telephone networks and spider web sites to proceed cardiologists up to date with their patients are just magic; new pharmaceuticals that change moods, change blood pressure, or kill bacteria: all are modern magic. On reflection, given the centuries of stability, it is amazing how much healthcare has inverse in the last 150 years – and i wonders how this accelerating pace of change will proceed in the futurity.
Arthur C. Clarke, the prolific futurist and science fiction author, famously said that any sufficiently advanced technology is duplicate from magic. Perhaps the main difference for the couple lifted out of the nineteenth century is they are sure it's magic, whereas we have stopped thinking about it, and just accept it for granted!
Time-traveling fiction starts to dig into many interesting issues we might normally avoid thinking nearly. What about organ harvesting? What about enhanced humans? What virtually the finish of antibiotics? Volition robots take over? And then on.
Some of what seems to u.s. today like science fiction is going to be routine in the future, maybe fifty-fifty in our lifetimes. Yet much of today's homo story almost relationships, hopes, mistake, grief and denial is going to remain entirely recognizable in the future. We will still have authority gradients, nosotros will still take controversy over human mistake, and patients will still exist made helpless so that they are easier to treat. The reason is that technology is driven by the market: if somebody has an idea that they can plough into a concrete realization that they can sell, they can also patent it or license it, and thereby make a render on their investment. This, in plough, volition encourage them to observe ways of making it smaller and cheaper, and marketing it on a larger calibration; thus it is technology-driven. In dissimilarity, human culture does not make turn a profit for everyone. Improving culture means admitting somebody or some process was non good enough to start with, and who wants to do that, especially when lawyers are watching? There is little economic incentive to meliorate culture.
Atul Gawande makes a similar signal nigh the Earth Health Arrangement's Surgical Safety Checklist.one The checklist is a simple piece of paper that helps change human being behaviour – it helps check the patient has been correctly identified, helps introduce everybody by name (to reduce authority gradients), and so on. It's uncomplicated and saves lives – more finer than many drugs. Gawande asks who will promote such an thought when nobody makes any profit from it? It's just a bit of paper anybody can impress. If it was a technology (such as a patented drug) that promised the same improvements in outcomes, everybody would be buying it, and the pharmaceutical visitor making it would be promoting it heavily. Patients would ask for it to be used. But a piece of newspaper anybody can print is not exciting enough. Crucially, the merely person who benefits from the checklist is the patient (the clinicians do good indirectly, because more successful operations mean less litigation). The patient is probably unconscious at the very moment they ought to be asking for it!
Science fiction
Our time-travelling fiction is a small instance of the ability of using scientific discipline fiction to assist envisage and plan our future. In dissimilarity to the usual tunnel vision prediction of hereafter trends, which often highlight glowingly positive ideas, science fiction lets us explore and communicate futures nosotros desire to live in by telling rounded stories nosotros can engage with. More importantly, scientific discipline fiction tin besides explore dystopian futures nosotros desire to avoid; George Orwell's 1984 helped avoid his dystopia happening (so far anyhow).
In the present newspaper we have not infinite to create further stories, but we commend the method to both manufacturers and consumers of engineering science – the hospitals, clinicians and patient groups, and specially to designers.ii
When we tell good stories, nosotros become into them, only there is non i story most the futurity. Anything is possible, and nosotros need lots of stories, to explore good and bad and indifferent choices. Moreover, when we go to the time to come, it besides volition have another future. There is non one future, but many. We volition never find satisfactory solutions to anything, every bit there will ever be new things to attempt and explore. This calendar week it might be the Cloud or improved natural language processing, but earlier nosotros've got that working properly, somebody will accept invented something that solves even more issues and sounds equally seductive. Notwithstanding while technology drives changes in healthcare, the fundamental problems of wellbeing, health and happiness, will remain.
The easy story is that the future will be better. Applied science will advance and there will always exist new and exciting solutions. Today we have robotic keyhole surgery, and things can only get better. We have intelligent decision aids to improve diagnosis, and they volition only go improve. Some people would bespeak to the underlying drivers: technology is getting faster, better and smaller. Moore'due south Law says the speed of innovation is accelerating. The uncomplicated story is nosotros will just enjoy the ride. Even so, the more than complex story exposes trade-offs. For example, new computers are indeed much faster, but to take advantage of them nosotros commencement have had to throw abroad the slower computers then they can be replaced, and then nosotros may well discover the patient information on the old computers won't work on the new ones. In fact, we are in a continual struggle to keep upwards – information technology costs us a lot, and a lot of solutions that excited us yesterday are already in landfill. The faster nosotros go, then, the more we can expect incompatibilities, and indeed greater spread betwixt those at the sharp cease of developments and those without the resources to benefit. When we honestly remember about the hereafter, nosotros take to augment our spotlight from the few exciting ideas that attract our attention to the wider issues, the broader context of change and complexity, in which those innovations could be used effectively. As good science fiction does so well, turning an exciting thought into a fully-worked out story helps us explore the problems more realistically.
Rather than develop a single story about the future, this newspaper at present turns to presenting principles, themes and scenarios that a skilful author might integrate to create a coherent movie.
Primal points about futures for healthcare
Patients are the reason for healthcare and they should be at the middle of it. This article, however, is almost possible technological trends and drivers in healthcare; it should therefore exist read in conjunction with patient-cantered perspectives similar the Imperial College of Dr.'south Future Infirmary: Caring For Medical Patients report.3
Technology does not accept an agenda of helping healthcare, however much we might like to focus on benefits. It develops because of miniaturization, lowering costs of production, and then on, not considering it makes people well, but rather because it tin can notice means of making money and reinvesting it. Koppel and Gordon's edited book Offset Do Less Damage is recommended as an overview of issues.4
The pace of change is accelerating: our time travellers from a hundred years agone were surprised at a few things, but had they travelled back in time, with a few pocket-sized bumps like William Harvey discovering blood circulation, very little changes all the way back to Hippocrates.
Man nature does not change, at least non on these technological timescales. The authorization structures in healthcare, the sectionalisation of labour, the pretence that clinicians know everything, and other human factors are deadening to change. Despite our knowledge of germ theory and antisepsis, we are still resistant to washing our easily.
There are many futures to plan for. As soon as we get to our future, there will be some other – and we volition increasingly be seeing partially-completed solutions superseded by fifty-fifty better ideas. Today we might be thinking we just need to computerize all patient records, but before nosotros've finished doing that some fancy new technology will change what we want to practise or how we should do information technology. For the foreseeable future, we will have to alive with fragmented and partially working technologies.
Nosotros need to accept the future seriously as, literally, it is all nosotros have, and certainly all our children will take – and we tin can be certain that as nosotros go older, we are going to finish up with all the problems of old historic period. Surely, nosotros want healthcare to improve in the future? We should put effort into time to come planning, not once, only continuously.
In the rest of this article, nosotros volition brand repeated comparisons between technological factors and human factors. Often these drivers are non aligned (1 of the fundamental messages of this article), and technology is therefore unlikely to develop in ways that are optimal for healthcare on its own accord. Our concepts of ourselves, from formulation to death, as individuals, families and equally communities, are inextricably linked to technological possibilities. We ought to have a Future Healthcare Found, which volition be kept continually decorated prioritizing and reprioritizing principles to guide and align healthcare and technological developments together. One imagines such an institute giving guidance legal and regulatory guidance, for case as has already happened in ad hoc means in some countries addressing advances such every bit fertilization technologies.
Technical factors
Healthcare is just a marketplace for applied science where consumers such as hospitals are happy to pay enormous amounts of money, particularly for prestige equipment, such as PET and MRI scanners and linear accelerators.
Accelerated cost savings
Technology automates and extends things that previously had to be done by people. Before infusion pumps, nurses had to give injections every so oftentimes; the infusion pump technology automated that. At present the nurse's time is freed up for other activities, and if the manufacturer has used engineering in the production of the infusion pump – equally they surely will have – they can reduce the cost of product for exactly the same reasons. Some plastic moulding process will make millions of infusion pumps as easily as information technology makes i; once i infusion pump has been programmed in software, it costs essentially nothing to programme them all. This virtuous circle of using technology to brand technology ensures prices drop, market share increases, and profit margins increase, which in turn allows the manufacturer to invest in more than cunning product and distribution technologies.
However, what is important to notice is that these benefits do not accumulate to custom or rare problems that cannot exist mass-produced. This means that a technology similar an MRI scanner that tin can scan anyone equally well is going to be much more than popular than a applied science that has to exist customized to a particular patient's conditions.
Personal healthcare
Already, the assumptions of mass product are irresolute. For instance, today'due south 3D printers are capable of making objects of any shape; they are slightly less efficient than standard mass product, just the costs of custom objects of certain sorts has been lowered significantly. It is now possible to custom make titanium implants the right shape and size to fit. Going further, it is widely envisaged that custom drugs will be manufactured, customized to the patient'south disease and genetic makeup. While this seems to be enormously beneficial to patients, there are dangers. For instance, a customized drug may be very effective, but its side furnishings volition be unique to the patient likewise, and therefore harder to diagnose and manage.
Personal healthcare has an interesting technological imperative. If we can personalize healthcare, we get population-sized markets: instead of selling to clinicians, manufacturers tin sell to individuals – a market 1000s of times larger.
Large data
Patients generate huge amounts of information – patient records – from X-rays to blood test results. Replacing newspaper with computerized summaries makes patient care easier and more efficient. In the time to come the quantity of information will increase dramatically because of genomics (and the huge genomics of our symbiotic bacteria) and personalized medicine, and equally more patient information is nerveless, more insights will get bachelor.
If computers collect data on patient illness, treatments and outcomes, one automatically obtains valuable information on the effectiveness of those treatments, or relations between side effects and patient characteristics across whole populations. Huge amounts of data volition be collected, hence the proper name big information. Once the infrastructures have been set, the incremental cost of adding i new patient will be essentially nothing, and this economic system of scale will bulldoze further technical developments. Epidemiologists will do good enormously, but the benefits to individuals are less obvious, except in the long run from big data'southward contribution to the progress of medical scientific discipline more more often than not.
Social media, patient power, mobile health and pedagogy
Stopping people going to infirmary in the first place and empowering people to care for themselves and their families is something computers are already doing well. Simply as patients are empowered, is their new-found knowledge helpful or unrealistically raising their expectations? Today, the cyberspace is problematic, as at that place is no consistent mode anyone can distinguish snake oil from sense, how patients can distinguish reasonable treatment from misguided hope – there will ever be a lot of solutions hunting for the patient'south money. Technical solutions to this problem include providing accredited high-quality information; cultural solutions include improving education. When somebody has a genu injury at 40 this should not be the first time they encounter the bewildering amount of variable information and social media on the internet! Their management of their condition – whatever it is – would be much improved if they had been exposed to sensible strategies since preschool.
Dramatic, transformational integration of technologies
In that location is non space here to fully explore the vast range of likely and pregnant technological breakthroughs. Consider nanohealth, brain implants, artificial organs, networked sensors, genomics, exoskeletons ... just a few of the potentially transformative developments already under style. Some of these technologies are going to transform our whole approach to illness and health – in the same way that the nineteenth century development of anaesthetics changed guild'due south moral approach to pain. Pain and suffering used to be inevitable; now we like to think we have a correct to painless procedures – and in turn this has influenced everything, from our treatment of patients to our handling of animals (why should animals suffer? is a very mod question). New technologies, like nanohealth, are going to take ethical implications that will be difficult to anticipate. Sometimes ethical issues volition be hard to negotiate because they will be apparent only after somebody has got things working and already has a business organization-driven perspective.
Security, privacy and monitoring
In a earth aggress with major security concerns (like terrorism) it is inevitable that all technologies, even in those healthcare, will be aligned with national priorities. For example, taking patients' fingerprints and other biomedical identifiers volition become easier (perchance driven past consumer finance, such as credit card security); and, as it becomes easier, gathering data for country security volition happen as a side-outcome of routine clinical practice. The land will be able to identify illegal immigrants and outlaws and others; the current notion of patient confidentiality will be eroded in a fashion that volition be impossible for clinicians to control.
Today we may think this would be objectionable, but it is salutary to recall that we happily divulge all sorts of personal data during our apply of mobile phones, credit cards, as well as during our use of the internet. We unthinkingly sacrifice our privacy because of the huge convenience of buying stuff on the internet. Information technology seems to brand losing our identities a trivial price to pay. When considering future healthcare trends we can expect like trade-offs; it will be easy to slide into levels of surveillance we do not now similar, falling for information technology because of the healthcare benefits we want. Surveillance is not the only downside of course – paying data rights owners; paying software licenses; signing off responsibilities for insurance liabilities – all happen, and are often signed off without sufficient thought.
Information technology is increasingly footling to collect information about patients and the quality of patient care. This information can be aggregated and assist observe variation in treatment and outcomes, and hence assist better quality – which is good. On the other hand, information inevitably distances the managing director from the patient every bit an individual: peradventure the key notions of patient care will lose out to organizational or state concerns, because cost management and security, not care, becomes to be the point of the information.
Wellness 2.0
There are many areas where the scale and unit profits of the healthcare marketplace will drive technical developments. Collectively, this technology-driven progress in healthcare is sometimes chosen Health ii.0, to distinguish it from what we are doing now – Health ane.0. While Health 2.0 is exciting, information technology is sobering to realize that possibly it is only the start of an upgrade path: Health ii.0 will accept problems we solve with Health three.1, and in turn that will develop into Health four or whatever. While information technology seems obvious technology will continually advance, it is going to exist harder to ensure that each iteration of technology satisfactorily achieves what it claims to attain, without having to exist fixed up and upgraded soon after.
Unfortunately, few manufacturers stay in business selling us perfect solutions; they stay in business by selling u.s. something to keep united states consuming: a service, something to rent, a disposable product, a product that wears out, or a product that goes obsolete. Certainly Health 2.0 volition lead inexorably to more developments, whatsoever they will exist. The danger is that information technology will make us eager to upgrade before we have even realized the promised benefits of Health 2.0. Somehow, we demand to piece of work with manufacturers to align their interests of staying in business organization with our interests of having a predictable and stable life. We might practice that by distinguishing infrastructure, which is provided about once, with consumables that are provided regularly. This is the economic model of infusion pumps: you buy an infusion pump in one case, simply the giving sets are replaced after each infusion. Over time, the manufacturer makes more turn a profit on the easily reproduced plastic tubing than the complex pump, and anybody is happy.
In some areas, the consumables will be data itself. This costs nothing to reproduce, but people own it and want to make a render on their investment. Thus patient data will be owned so that its owners – rarely the patients! – tin brand money from it. Information is stored in computers in data formats, and often these are proprietary: the format of a patient data arrangement belongs to the manufacturer. This leads to the danger that the patient data is inaccessible except on the terms the manufacturer imposes. It may exist plush to convert it into other formats, say to upgrade to a different manufacturer's systems. Worse, if a manufacturer goes bust, some data may be lost. This is a very real problem, as our inability to utilise information on newspaper tape, cards, cassette tapes, magnetic tape, VHS tapes – none of them very sometime technologies – then forth, testifies. A desirable technological trend, then, in fact a tendency that bucks the trend to appointment, has to be the assurance that data remains accessible and usable over long periods of time – at least a 100 years, which is way longer than whatever electronic technology!
Hacking and open health
Healthcare sensors tin exist readily bought off the internet, and it is easy for technically-minded people today to build sophisticated equipment (to hack) to collect and analyse any personal or clinical information using their own computers. Credit-card sized computers like Arduinos and a few biomedical sensors price about the aforementioned as a drug prescription!
Some individuals are already obsessed with collecting as much health-related data every bit they possibly can about themselves – information technology is not but people will illnesses, but people who want to lead healthier lifestyles or exist improve athletes. If these people upload their information and contribute to aggregated data, they are contributing to citizen health – just like open science,5 except tackling healthcare bug. At its simplest, they would exist contributing to epidemiological studies; at its best, they would exist helping build databases and web systems that other people can find their medical conditions in, and hence find back up communities. Many patients end upwardly with more than time on their hands than they expected, and this is how some choose to use their time: solving their own problems and helping others.
Hacking is not restricted to patients: a doctor using a laryngoscope has the choice of paying commercial prices for a video recorder (due east.g., to record images to send to an ENT specialist), or more conveniently recording the video on their iPhone – virtually a one,000 times cheaper.
The point is, engineering is empowering people to practise what they want to do, and in the future patients are going to take some of the initiative away from professional healthcare, specially for diagnosis, chronic illnesses, and lifestyle communication.
Technology is diverse and surprising
These are some of some powerful technological drivers, and information technology is hard to describe a line under the discussion. Nosotros have non discussed many technologies that are both disquisitional and exciting such as nanohealth, personalized healthcare, mobile health, telehealth then on – the beginnings of all of these are already bachelor and in use in starting time adopter places. What the brief discussion illustrates is the diverseness, the rapid pervasiveness, and the complex trade-offs of future technologies.
Bridging future gaps
The science fiction writer William Gibson says the futurity has already happened – we just don't know where. All the ideas we discuss in this commodity about the future have happened.
From considering technological drivers, we now turn to human futures. We believe these will be more stable and less probable to change, but will raise increasingly unexpected interactions with the new technologies. In areas like human error this is alarming, for if we believe that applied science improves – why else would we adopt it? – then, as human being mistake will still occur, the error must even more surely exist due to the humans involved, not the improved technologies which were intended to blueprint out mistake. In other words, the irresistible drive to adopt improved technology may exacerbate our direction of homo fault. The economic drivers that push button technologies have vested interests in promoting benefits and analytical problems. And healthcare has no cease of issues: we all want and expect better care, costs are rising and performance is failing; living longer, and living with chronic illness, are other problems. Healthcare staff are over-worked and nether-resourced... it is hard to imagine technology changing that. On the opposite, many technologies (accept MRI scanners, heart implants) are very expensive, and buying into them will exacerbate financial pressures.
Prophylactic, security and regulation
In the future there will remain an indelible distinction between prophylactic and security. In healthcare these mean different things: safety is well-nigh patient and staff safety – basically, following Hippocrates first exercise no damage – and security is nigh controlling access, in particular so that intruders, rogue patients and staff cannot become inappropriate patient access, whether that is informational access or concrete admission.
Security means stopping bad people doing bad things. If a banking concern loses money to fraud, this is not unexpected – we all know there are enough of bad people effectually who want to get at our coin. It follows that it is the banking concern's responsibility to provide security.
Safety means stopping good people doing bad things. If a nurse is involved in an untoward incident, this is neither normal nor expected. It is easy, then, to think the good nurse has gone bad and therefore they are to blame – this is the conventional bad apple arroyo to safe. Indeed, if a good nurse has gone bad, this is a serious expose of our high regard of the nurse, which makes things even worse. The bad apple theory is very highly-seasoned: getting rid of this bad nurse appears to solve the problem.
In brusque: security is seen as an organizational responsibility (e.g., the bank'southward or the hospital's), whereas condom is seen as the individual'due south responsibleness (east.g., the nurse'south). Technology improves things that generate render on investment (security, speed, efficiency, calibration and reach) and safe will not do that while users are scapegoated.
Moreover, prophylactic is hard to assess up-front end, dissimilar simple claims for low price, speed or efficiency. Unless regulation requires safety to be assured, we would expect condom to have second place. Nosotros therefore anticipate an increasing fence between rubber concerns on the one mitt and regulatory burden on the other. Since currently the regulatory brunt for technology is negligible, certainly compared to the rigors of pharmaceutical development, much could be gained by strengthening regulation. We suggest conscientious attending needs to be paid to statutory regulation. To avoid hasty regulation that is ineffective or rapidly obsolete, nosotros need to recall very clearly. Today there is a lively contend about regulating computer technology; some say (for instance) mobile apps should be more than tightly regulated; others say that rigorous protocols (such as randomized controlled trials) accept then long the technologies volition be obsolete one time at that place is formal evidence one way or the other.
Solving the correct problems
Conventional patient records are newspaper records in folders in cabinets. Many patients have all-encompassing patient records, lab results and so on, and fifty-fifty more patients have patient records that are in many places – in hospitals they accept visited, consultant's offices, general practices, and and so on. They are rarely all together where the patient is, often they become lost or duplicated, and sometimes destroyed by fire or floods. Many healthcare providers have trucks shipping patient records around their areas.
The obvious thing to practice is to computerize all the records, so use networks to ensure they are always available wherever they are needed. Looking at records on a screen is simpler than wading through piles of paper. Since computers already piece of work, all we need to do is gear up a program to scan or type up all the existing paper records. Job done!
Unfortunately this obvious solution creates new problems.
When a clinician examines a patient, they want to refer to the relevant parts of the patient'southward medical history. If nosotros have but computerized the patient records, all we have done is made the big, scattered piles of newspaper into something that can be viewed on a figurer screen, only now the clinician tin only view i window at a fourth dimension, and they may easily lose the big motion-picture show. Information may be scrolled off the screen, or be concealed behind pop-ups. In fact, we have merely swapped the unusability of piles of paper for the unusability of a user interface.
While nosotros are very familiar with the ways that newspaper records can neglect, unfortunately nosotros are much less familiar with the ways that computerized records are hard to use and may mislead us.
Tom Landauer's volume The Problem with Computers makes the insightful point that computers are enormously successful in areas where there is commonality that can be computerized — banking, communications, stock command, function documents, electronic mail are all good examples.6 Areas where they accept been less successful are those where success depends on the human element. My bank account works just like your banking concern account, then computerizing either of our accounts is the same as computerizing everyone's. But my patient records are unlike to yours. The computerization of my records does not assistance computerize yours or anyone else'due south. Well, that is not quite true. Computerizing my records helps computerize yours, but when those records are used, nosotros and the healthcare professionals using them will have different problems. As the healthcare reckoner systems scale up to handle more patients, the usability problems get compounded – in dissimilarity, as bank accounts are scaled up, things get more compatible and easier to automate successfully. (Banks also have a very different approach to problems; a British bank does not accept to handle my Russian currency or it can accuse me exorbitant rates, but a hospital that ignored my Ten rays would be negligent.)
In healthcare, we take to pay more attention to the wide context of how data is used.
This is the business of User Centered Pattern (UCD), which Landauer describes well. The ideas have been taken upwards in international standards. In particular, healthcare technologies must be developed using UCD processes, such equally ISO Standard 62366 etc.7 One of the well-nigh important features of the standards is that they brand articulate that new technologies are not going to be perfect and need to be tested and improved to better match how people really use them.
UCD is essential in the battle against information overload and the law of unintended consequences. Technology is introduced to solve a trouble or to amend operation, simply this and so changes people's behaviour and new issues may emerge.
Originally, email seemed like a wonderful idea – it is cheap, fast, saves paper, and so on. But nosotros are victims of its very success: now people have and so many emails that they are overloaded (it is difficult to prioritize), to say nothing of spam and phishing, flames and people sending irrelevant or erroneous emails to thousands of recipients. It is now possible for an ill-conceived email to waste matter thousands of hours when it is send to many staff. Emails are a recognized and growing problem; merely the same tendency is affecting test results, patient records, drug-drug interaction reports. For all of these reasonable tasks it seems obvious they should exist computerized, simply doing then oft results in increasing amounts of depression-level information that can distract people from doing their existent task.
UCD helps because information technology emphasizes that no innovation is always finished: we have to see how information technology is used, and continually improve information technology. Email, and the residual, have a way to become, and UCD promotes that at each footstep we should be user-centred (driven past the needs of users and what they are trying to do) rather than technology-centred.
Unfortunately, technology creates new users. Computers need technicians and managers, and these users as well contribute to the UCD comeback bicycle. However if we are not very conscientious, the management of the technology gets a life of its own that takes a higher priority that delivering improved patient care. When investments are fabricated, the experts are consulted – just now the experts announced to be the technologists rather than the healthcare professionals or even the patients. This can cause many problems.
Systems that are under-performing and hence need improving often induce workarounds by their users. For example, passwords may not work very well, and so nurses find means to get on with their jobs regardless. Unfortunately the people the other side of the computers just see the systems patently working; they do not come across the workarounds or the unintended risks nurses may be creating as they get things to work. When the system is improved, the workarounds are not considered sufficiently, and the new system may accept unanticipated problems that even workarounds cannot overcome.
The scientific discipline (rigor) dream (unqualified success) gap
X-rays were discovered by Wilhelm Röntgen in 1895 and immediately recognized every bit having huge potential for healthcare. Only a few years later, one of Thomas Edison'due south assistants, Clarence Dally, who had been enamoured with the potential of X-rays died, of cancer considering he had been experimenting with them every day (Figure i).
Clarence Coquet X-raying his mitt, from the New York World, August three, 1903, page 1 (American Paper Repository).
It is now obvious that Ten-rays are not risk-complimentary. Every exposure to 10-rays helps a patient yet at the same time exposes them to run a risk; information technology is now routine to make a careful merchandise-off betwixt the benefits and risks. Similarly, we now recognize that pharmaceuticals are non magic and run a risk-free. In fact, we hardly sympathise how many pharmaceuticals work, and information technology is routine – in fact, a requirement – to perform the aureate standard randomized control trial (RCT) and other forms of conscientious experiment before assuasive drugs to be released to the market for wider utilize. Despite our all-time endeavours, we have a growing awareness of worrying and circuitous side-furnishings, such as growing antibody resistance that has arisen from over-enthusiastic use of antibiotics (not least in beast husbandry). Some of the original miracle antibiotics are no longer effective.
Ben Goldacre's provocative book Bad Pharma documents how pharmaceutical development sometimes side steps best exercise, and promotes drugs that have untoward side effects and other issues.8 For instance in a large RCT, some patients may die for unrelated reasons. The question so is what to do with their information; it is very tempting to treat them as if they had survived and had been cured. Some other example success bias in the scientific literature: authors of scientific papers desire to publish their successes rather than their failures. And so the literature under-represents drug trials that neglect or uncover unwanted complications. In turn, this ways that systematic studies of drug trials cannot get the right baseline for experiments, since many experiments are non published. Regulation is starting to address this problem.
Goldacre makes clear that pharmaceutical evolution fails scientific standards; yet engineering development, such as robotics or computer system development, does not fifty-fifty aspire to the scientific standards that pharmaceutical research is aware information technology fails to attain. Equally Goldacre puts it, pharmaceutical R&D is close to immoral; notwithstanding applied science R&D is ignorant. This is worrying for the future, equally technological developments may not be adequately tested, tested without satisfactory controls, and under weather condition of vested interests. (Near of the studies arguing Medico Guild Entry systems are either good or bad are written by people using the single systems they are publishing near; they are not good scientific discipline.) New technologies may take unfortunate side-effects or other problems (such every bit forcing risky workarounds) that nobody has seriously looked for, let lone rigorously assessed.
The last paragraph makes a strong claim, but information technology is justifiable. Modern infusion pumps will take been certified for clinical use, and thus evidently passing the applicable rubber tests and standards. Nevertheless modern infusion pumps are driven by computer software (e.g., in their firmware), which can exist modified at will by the manufacturers and parameterized by hospital technicians. Indeed, software is regularly updated to fix bugs and to make pocket-size tweaks. Modifying software tin completely alter the behaviour of devices. What makes the software control of devices so appealing is that manufacturers tin create a variety of devices for different market place sectors all on top of the same architecture. Changing the software tin can modify a device from, say, a unproblematic infusion pump to a dose fault reduction intelligent pump. Just such changes can be made after it has been certified for apply, without whatever further regulatory control. Furthermore, one volition struggle in vain to find any scientific literature on the assessment, let alone RCTs, for such devices. Information technology does non be. On the contrary there is a growing literature on the rubber problems of infusion pumps.ix
Ane can hope that the hereafter trends include tightening the civilization of technology development. The standards demand improving, and the laisse faire culture of gimmicky development needs addressing. In many ways, today's medical engineering science is at a maturity level comparable to the unsafe at whatsoever speed car of the 1960s.10 If we do not address the lax scientific standards of applied science development, it is unlikely that future engineering science interventions will improve prophylactic or other desirable measures of healthcare performance.
Homo factors
The nature of human expertise is that information technology makes errors likely,xi and clinicians are highly-skilled experts. To become skillful at some process means automating it, doing some or all of the task without continual reference to the wider situation. For example, when yous learn to drive a car, you are consciously aware of many factors (such as clutch command), but as you gain expertise, driving becomes automated and you are able focus on higher-level goals. As an expert driver, yous may detect information technology seems easy to hold a conversation on a mobile phone, every bit yous at present accept the spare cerebral resource to do so. Unfortunately if something unusual happens, say if a child runs into the road, yous may not exist paying enough attention to the situation to accept advisable activity – ironically, when y'all were less of an practiced driver, y'all would have had to pay very close attending to road conditions, and y'all may not have been driving so fast either! The point is that as new technologies volition amend things, nosotros humans volition all the same make errors.
Human factors is already a problem today: complicated gadgets induce use errors. There is a remainder between the time and try a manufacturer is going to spend making some technology easy to use (and safe to utilise) when the economics of selling the production may not prioritize those qualities. Usually new engineering is procured because it promises to better efficiency or reduce costs; prophylactic is an issue covered past insurance, and is rarely function of the procurement requirements. Regulation requires some bones prophylactic, just the features that sell devices oftentimes conspire to make the utilize of the devices more complex. As we discussed with modes, above, the more than features the more complex a device is to use. Still typically features sell technology, and the difficulty of apply is pushed onto issues for the users. If there is an untoward incident, information technology is much easier to arraign inadequate training (i.e., the user's incompetence) rather than the complexity of the arrangement being used.
Human factors – bug such as situational awareness, tunnel vision, and and then on – is a large and important area. At that place are two questions for the future: how can technology assistance, and how can technology exist improved to be intrinsically safer?
How can technology help?
In fourth dimension-pressured environments, humans ofttimes endure from tunnel vision – focusing on the original task and overlooking larger situational sensation. The classic instance is intubating a patient. This is a demanding, time-critical procedure. The longer it takes, the more pressurized the clinician is to complete the procedure. Sometimes the patient volition get into problems, and a tracheotomy is needed – urgently. Sometimes the clinician is so focused on the intubation that the alarm signs are missed, with disastrous consequences. Hither, applied science tin can assist by using monitoring technologies. Remote monitoring of the patient's vital signs tin can enable a trained person out of the pressured environment to make helpful comments: How-do-you-do! I tin see yous accept about 10 seconds before y'all need to finish... Such ideas lead to concepts similar the electronic ICU (eICU) where a command room monitors perchance 100 beds. Experience with such technologies has been positive, peculiarly if careful steps are taken to avert a them and the states segmentation between the clinicians doing the work and the clinicians monitoring them. Normally a staff rotation is used, and so everyone experiences both sides of the camera.
How can technology exist designed improve?
Manufacturers tin apply better blueprint processes, such every bit those outlined in standards such every bit ISO 62366.7 Doing this effectively is difficult work, and with rush to market it is tempting to do the bare minimum, for all the reasons discussed elsewhere in this article. Here we can mention 3 useful ideas:
Discovering use errors takes a long fourth dimension, and this conflicts with rapid entry to marketplace. The solution may be to design systems and then that they can be improved in the field. This is actually easy – firmware is routinely upgraded for problems fixes anyway. What needs doing is logging device use in sufficient item and so that the manufacturer gets a adept insight into how the device is beingness used or is failing to be used. Currently, this information rarely gets back to manufacturers in a useful form.
Many use errors follow predictable patterns. And so-called post-completion errors are common and hard to eliminate just by improving human procedures. A nurse may utilize a claret glucometer to mensurate a patient'southward blood saccharide levels. The nurse moves on to the next patient, and so puts the claret glucometer in a docking station to upload all readings. As described, at this indicate the nurse has failed to make a written note of the levels on the patient's paper notes, yet because the device has docked, information technology has discarded all recordings. This is a postal service-completion error: the nurse made the error after they had finished. The solution is to redesign the technology, and there are many options here. Why delete uploaded information, for instance? Why not have a reminder in the device to confirm the nurse has recorded data before taking some other reading? Why record manually on paper patient notes anyhow? This is an example of how the standard operating procedures combined with congenital-in technological assumptions induce errors (which in this instance are unprofessional, and perhaps disciplinary offences), just more thoughtful pattern can avert them.
Physicality
The huge leverage figurer technology brings, because information technology is virtual and tin do anything with information (and hence the same piece of technology tin can be mass produced for a huge market that has not exist preconceived), has a down side. Humans are physical.
The trouble can be illustrated very but. In the one-time days books where physical objects, and they looked and felt different. A well-read book would look worn, and an unread book would look new. You would recognize bookmarks sticking out of books, you lot could write annotations in the margins, y'all would know how much you have got left to read earlier you end it. You could put a book by the forepart door of your house to remind you to selection it up in the morn; you lot could get out a volume by your bed so it was set for next time you wanted to read yourself to sleep. And then on. Now, with electronic readers, all books and documents look the same – like the general-purpose estimator they are on. Of course, the reckoner can create colourful covers and images, but the concrete object is always the aforementioned: namely, the computer or tablet.
In the old days a patient would go to their doc and become a paper prescription. They would then go round to the pharmacist and get their medicines. One problem with this procedure was that paper prescriptions were notoriously difficult to read, and there was a danger of wrong dispensing. Today, this procedure has been computerized. The doctor sends the prescription electronically to the pharmacy, and the chemist's can dispense the drugs almost immediately.
Unfortunately, the patient has lost the physical prescription in this process. They leave the medico'south appointment conveying zippo. In that location is nix to remind them to go to the pharmacy to option up the drugs. Indeed, pharmacies are now having to dispose of drugs that were efficiently dispensed as shortly every bit they were prescribed but were never nerveless by the patient.
Only as electronic books are a gift to book publishers – because the expensive paper volume is replaced with a cheap electronic book, costless to reproduce once but ane copy has been prepared – increasing use of computers in healthcare is irresistible. X-ray photographs no longer need to be developed, put in folders, held up confronting viewing screens. They can be emailed. Simply what they have gained, they have lost in physicality. It may no longer be possible to put an X-ray on a viewer back-to-forepart (hence causing a left/right error), but it is very easy to look at the wrong patient's X-ray – because they all look the same without their physicality.
Unfortunately physicality is in direct conflict with the driving economics. Pieces of paper are very familiar and we sympathize exactly how they work, but estimator screens are cost-effective precisely because they can display lots of information repeatedly without addition costs. Withal from a safety perspective, the screens all look then similar they may be dislocated.
Ane solution to this is skeuomorphism: making new technologies imitate sometime (and hence more familiar) technologies, otherwise known equally using the correct blueprint metaphor. The example here would be to meliorate the brandish and then that the paper information being displayed looks more like bodily paper – perhaps with torn edges, discolouring if oft used, and so on.
A second solution is affordance: brand things look like how they are intended to be used. For example, a cup with a handle has the affordance that encourages you to pick information technology up by its handle. Particularly in emergencies, people need to know what to practice intuitively – and affordance is a key part of design.
Thirdly, we can make computers disappear – what is left is a physical object which happens to do something complicated, but information technology has been made invisible to the user. RFID tags and smart fries can be embedded inside objects so that they tin can do things and interact with each other, merely the object appears to be normal. A overnice example is the hotel key bill of fare; so far every bit a hotel guest is concerned they behave simply similar room keys, merely inside some sophisticated cryptography creates a host of benefits – for case, unlike losing a physical key information technology is not a trouble if you lose a key card, and the locks do non demand to be replaced. When patients routinely have ID tags embedded in them, many of the current issues of patient barcodes will disappear – no doubt to be replaced by unlike issues!
This article is not the place for a deep discussion on pattern,12 simply it is important to point out that looking upward skeuomorphism or affordance on the internet reveals a huge multifariousness of alien opinions. In other words, these ideas are ways to fence virtually design, not ways to design. 1 yet has to exercise detailed piece of work to make futurity technologies successful, regardless of their supposed affordances. Despite having nice words to talk virtually good design, no hereafter will be an inevitable success.
Enhanced and bionic humans
Although we take said that human being factors will remain a constant for the foreseeable future, there is goose egg to stop technology enhancing people. Engineering science will not be used just to monitor and help make people well, but will be used to make them ameliorate – better as sportsmen, every bit healthcare professionals, or whatever. We already accept augmented reality, where surgeons tin see an enhanced view of the insides of patients. If patients tin take brain implants to enhance their lives (to manage Parkinson, for instance) surgeons volition have implants to amend their skills, using robotics to reduce tremor or computers to reduce error. After all, the core of the humble calculator – which reduces drug dose calculation errors – has already shrunk in size from tabular array-tiptop clockwork of 50 years ago to something so small it could be swallowed.
Who are the protagonists?
Thinking about the future is scientific discipline fiction. Key to the success of any story is to help the reader identify with the key character; or in the present context of thinking about healthcare futures, are we writing from a patient's perspective or from a technologist's, or a healthcare professional's, or ... the story makes choices, and if the choices align with our own interests the story seems more plausible and persuasive.
If the marketplace has developed profitable technologies, it follows that we (you lot and me) want those technologies. This truism needs emphasizing. Industry stays in concern making what we want to buy. Industry is good at adapting to make what nosotros find irresistible: this is market place contest. The manufacturers who are better at seducing us survive and grow. Equally a consumer, I love iPads (at least I did in 2013), but that does not mean that iPads tin do much good in a professional healthcare environment. Should nosotros fill up hospitals with iPads? One office of me, the individual consumer, says yes, they are wonderful! It is interesting how Blackberries were driven past employers, but iPhones and iPads are being driven past consumers; increasingly the employee is dictating what applied science the organization they piece of work for uses. But the other role of me, the clinician, the scientist, the technician, asks for evidence that they will truly ameliorate healthcare. It doesn't make such a proficient story for me to say I am not certain! If I am in healthcare procurement, I have to recollect very carefully to distinguish what I covet every bit a consumer from what will actually improve the arrangement I piece of work for.
It is certain that getting bear witness, doing experiments (RCTs?) volition delay the market place, and in that location volition be huge pressures on us to believe in the wonderful visions, rather than in the necessity of careful development. Healthcare is complex, and only throwing engineering at it will non in itself modify anything usefully, other than costing us a lot of money (which is exactly what the market wants us to do). As we approach the future, we need to acquire how to program our resources much more carefully and experimentally. The subtle cost-benefits of X-rays were not apparent immediately, and they rather ruined the original magical story.
People trying to sell us the hereafter will certainly latch into our acquisitive consumer natures – this is who we are equally individuals. They are less likely to latch into us as patients or clinicians, and thus – while existence an engrossing story – they may miss the point and sell us on technological ideas that do non actually better the world so much as satisfy our consumerist urges. I of the important things science fiction teaches u.s. is that the future volition not exist populated only by sensible solutions. While we hope for a happy ending, there will be problems and even wicked plans, evil empires and natural disasters to overcome forth the style.
Who makes the time to come?
The future of healthcare is well-nigh the patient (or stopping people becoming patients), but patients are not the primary stakeholders in healthcare. Insurance companies, big pharma, doctors, managers, suppliers, builders, governments and many other forces volition influence the future. Will innovation help patients or will it be partly to assistance monitor clinicians delivering healthcare?
It is interesting that since hospitals started introducing computers that the ratio of managers to clinicians has steadily increased; it is not totally clear that computers have made delivering healthcare more efficient or safer, but they accept certainly increased the volume and turnover of the business. Moreover, now patient records are computerized, with the obvious benefits, there are also problems. To go problems fixed, upgrades have to exist purchased, and this can exist very expensive. Patient records were once on paper; now they are in proprietary formats, and the manufacturer can lock in the user to their particular arrangement, so ownership upgrades – perpetuating the lock in – seems cheaper than moving over to an alternative arrangement.
Conclusions: what we need to do
If nosotros don't know where we are going, nosotros won't know when we don't get at that place says the quotable Yogi Berra. The market will surely figure out a way to make money, and technology will advance in miraculous ways. Instead, we need to figure out a way to take healthier and happier patients (and not only treating them as individuals), and to practice that we've got to focus on integrating engineering science with civilisation rather than focusing on technology alone.
In my view the key matter is to think conspicuously. Initiatives like the UK Royal College of Physicians Time to come Infirmary Commission, where idea-leaders – patients and healthcare professionals – have sat down and worked out what sort of future hospital they demand are to be commended;iii more importantly, they have articulated principles, not just specific solutions. Such principles are or should be timeless; we should not plan the future past being technology-driven (e.g., implementing deject, nanohealth, etc) but by improving along criteria backside principles (such every bit improving patient care or staff support). Articulating the principles of the futures we want should be a continual process, non a one-off activity; every twenty-four hours there is a new future to plan, and new discoveries that will change our minds most what is possible and likely. Futurity planning should be every bit much a routine part of healthcare every bit responsive intendance is. If nosotros don't know what we demand, we will get what is easy and assisting to make; as we emphasized above, what we need and what we desire are ofttimes confused.
Are we making the healthcare futurity we desire? If people from the past of a sudden materialized in front end of us, we would want to be able to convince them the world is the ameliorate identify they had hoped for. What stories would they accept back to help direct their technological trends and developments?
Acknowledgements
The writer acknowledges the very stimulating and encouraging comments most especially from Annegret Hannawa, Ross Koppel, Don Norman, Ben Shneiderman and the anonymous referees.
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Manufactures from Journal of Public Health Research are provided here courtesy of PAGEPress
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4147743/
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