what is the most likely reason the author refers to the bust of hippocrates in paragraph 3?
J Public Health Res. 2013 December i; 2(3): e28.
Applied science and the Hereafter of Healthcare
Received 2013 Nov one; Accepted 2013 Nov 1.
Abstract
Healthcare changes dramatically considering 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 back up for healthcare, etc) will drive innovation, human factors volition remain 1 of the stable limitations of breakthroughs. No predictions can satisfy everybody; instead, this commodity explores fragments of the future to meet how to think more clearly well-nigh how to go where nosotros want to get.
Key words: hereafter healthcare engineering science, human factors
Introduction
Pluck a nurse and surgeon out of the nineteenth century and transport them into a modern 21st century hospital and information technology would exist a thoroughly recognizable identify, with the same hierarchies and strict cultures. Patients treated as helpless, stripped of their clothes and possessions, lying in beds and almost completely ignorant of their illness. They might be disappointed in our treatment particularly of quondam people, but I don't recollect it would surprise them.
If our 2 time-travellers were able to nourish a post-mortem and listen in on a discussion of man error, very little would seem novel. Clinicians would nonetheless be in denial, lawyers would still exist hovering, and the delay and deny civilization would be no surprise. Yet, the changes that would surprise the nurse and surgeon are all changes to applied science. Infusion pumps, dialysis machines, antibiotics, centre valves, MRI scanners, even paw washing stations would be new ideas. All the hidden applied science used in the laboratories backside the scenes, from path labs to decontamination, would exist startlingly new if it was noticed.
Although the medical civilization is similar, there have been dramatic technological changes, and actually these changes would be hard to explain. Does anybody even know how an infusion pump works? They used to be clockwork (and earlier that, gravity fed) and now almost everything contains a computer and has a colourful screen and lots of buttons. Implanted defibrillators that use telephone networks and web sites to go on cardiologists upward to date with their patients are just magic; new pharmaceuticals that change moods, modify blood force per unit area, or impale leaner: all are mod magic. On reflection, given the centuries of stability, it is amazing how much healthcare has changed in the last 150 years – and one wonders how this accelerating footstep of change will proceed in the future.
Arthur C. Clarke, the prolific futurist and science fiction writer, famously said that any sufficiently advanced engineering science is indistinguishable from magic. Perhaps the main divergence for the couple lifted out of the nineteenth century is they are sure information technology's magic, whereas we take stopped thinking nearly it, and but accept information technology for granted!
Time-traveling fiction starts to dig into many interesting problems we might unremarkably avoid thinking about. What well-nigh organ harvesting? What about enhanced humans? What about the end of antibiotics? Will robots accept over? Then on.
Some of what seems to us today like science fiction is going to exist routine in the future, perhaps even in our lifetimes. Still much of today's human being story most relationships, hopes, error, grief and denial is going to remain entirely recognizable in the time to come. We will nonetheless accept authority gradients, we will yet take controversy over human being error, and patients will all the same be fabricated helpless so that they are easier to care for. The reason is that applied science is driven by the market: if somebody has an thought that they can turn into a concrete realization that they can sell, they can also patent it or license information technology, and thereby make a return on their investment. This, in turn, will encourage them to find ways of making it smaller and cheaper, and marketing it on a larger scale; thus it is technology-driven. In dissimilarity, human culture does not make profit for everyone. Improving civilization means admitting somebody or some process was not proficient plenty to beginning with, and who wants to do that, specially when lawyers are watching? There is lilliputian economical incentive to improve culture.
Atul Gawande makes a similar betoken about the Globe Health Organisation's Surgical Safety Checklist.1 The checklist is a simple slice of newspaper that helps change human behaviour – it helps check the patient has been correctly identified, helps introduce everybody by proper name (to reduce authority gradients), and and then on. It's simple and saves lives – more than effectively than many drugs. Gawande asks who will promote such an idea when nobody makes whatsoever turn a profit from it? It's just a bit of paper anybody can print. If it was a technology (such equally a patented drug) that promised the aforementioned improvements in outcomes, everybody would exist ownership it, and the pharmaceutical visitor making it would be promoting it heavily. Patients would inquire for information technology to be used. Merely a piece of paper anybody tin print is not exciting enough. Crucially, the only person who benefits from the checklist is the patient (the clinicians benefit indirectly, considering 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 fourth dimension-travelling fiction is a small example of the power of using science fiction to assist envisage and plan our future. In contrast to the usual tunnel vision prediction of future trends, which often highlight glowingly positive ideas, science fiction lets united states of america explore and communicate futures we want to live in past telling rounded stories we tin can engage with. More importantly, science fiction can also explore dystopian futures we want to avert; George Orwell's 1984 helped avoid his dystopia happening (and then far anyway).
In the present paper we take not space to create further stories, only nosotros commend the method to both manufacturers and consumers of applied science – the hospitals, clinicians and patient groups, and particularly to designers.two
When we tell good stories, we get into them, only there is not i story almost the hereafter. Anything is possible, and we need lots of stories, to explore good and bad and indifferent choices. Moreover, when we get to the future, information technology as well volition have another hereafter. At that place is non one hereafter, but many. Nosotros will never discover satisfactory solutions to anything, as there will always exist new things to attempt and explore. This week it might be the Cloud or improved tongue processing, but before we've got that working properly, somebody will have invented something that solves fifty-fifty more than bug and sounds equally seductive. Yet while technology drives changes in healthcare, the primal problems of wellbeing, health and happiness, will remain.
The piece of cake story is that the hereafter will be better. Technology will accelerate and there will ever be new and exciting solutions. Today we have robotic keyhole surgery, and things can only get better. We have intelligent decision aids to better diagnosis, and they will but go improve. Some people would point to the underlying drivers: technology is getting faster, better and smaller. Moore's Law says the speed of innovation is accelerating. The simple story is nosotros will just bask the ride. However, the more circuitous story exposes trade-offs. For example, new computers are indeed much faster, simply to have advantage of them we beginning accept had to throw away the slower computers so they tin can be replaced, and then we 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 proceed up – information technology costs us a lot, and a lot of solutions that excited us yesterday are already in landfill. The faster we go, then, the more nosotros tin expect incompatibilities, and indeed greater spread betwixt those at the sharp finish of developments and those without the resources to do good. When nosotros honestly think well-nigh the future, we take to broaden our spotlight from the few exciting ideas that concenter our attention to the wider problems, the broader context of alter and complexity, in which those innovations could be used finer. Every bit good science fiction does so well, turning an exciting idea into a fully-worked out story helps united states explore the bug more realistically.
Rather than develop a single story near the futurity, this paper now turns to presenting principles, themes and scenarios that a good writer might integrate to create a coherent flick.
Key points well-nigh futures for healthcare
Patients are the reason for healthcare and they should be at the centre of it. This commodity, still, is about possible technological trends and drivers in healthcare; it should therefore be read in conjunction with patient-cantered perspectives like the Royal College of Physician'due south Time to come Hospital: Caring For Medical Patients report.3
Technology does non have an calendar of helping healthcare, nevertheless much nosotros might like to focus on benefits. It develops because of miniaturization, lowering costs of product, and and then on, non considering it makes people well, but rather because it tin can find ways of making coin and reinvesting it. Koppel and Gordon'south edited volume Get-go Exercise Less Damage is recommended as an overview of problems.4
The footstep of change is accelerating: our time travellers from a hundred years ago were surprised at a few things, just had they travelled back in time, with a few minor bumps like William Harvey discovering blood circulation, very little changes all the way back to Hippocrates.
Human nature does non change, at to the lowest degree not on these technological timescales. The authority structures in healthcare, the division of labour, the pretence that clinicians know everything, and other human being factors are slow to change. Despite our noesis of germ theory and antisepsis, nosotros are still resistant to washing our hands.
In that location are many futures to plan for. Every bit soon equally we get to our future, at that place will be some other – and we will increasingly be seeing partially-completed solutions superseded past even ameliorate ideas. Today we might be thinking we just need to computerize all patient records, merely before we've finished doing that some fancy new applied science volition change what nosotros desire to do or how we should practise information technology. For the foreseeable future, nosotros will take to alive with fragmented and partially working technologies.
Nosotros need to take the time to come seriously equally, literally, it is all we take, and certainly all our children will accept – and we can be certain that equally we get older, nosotros are going to end upwardly with all the bug of one-time age. Surely, nosotros want healthcare to improve in the futurity? We should put effort into futurity planning, not one time, but continuously.
In the residual of this article, nosotros will make repeated comparisons between technological factors and human factors. Often these drivers are non aligned (one of the key messages of this article), and applied science is therefore unlikely to develop in ways that are optimal for healthcare on its own accordance. Our concepts of ourselves, from conception to death, equally individuals, families and every bit communities, are inextricably linked to technological possibilities. We ought to have a Future Healthcare Found, which will be kept continually decorated prioritizing and reprioritizing principles to guide and align healthcare and technological developments together. One imagines such an plant giving guidance legal and regulatory guidance, for example as has already happened in ad hoc ways in some countries addressing advances such as fertilization technologies.
Technical factors
Healthcare is just a marketplace for technology 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 exist done by people. Before infusion pumps, nurses had to requite injections every then frequently; the infusion pump technology automated that. Now the nurse'southward time is freed up for other activities, and if the manufacturer has used engineering science in the production of the infusion pump – as they surely will take – they can reduce the cost of production for exactly the same reasons. Some plastic moulding procedure will make millions of infusion pumps as hands as it makes i; once ane infusion pump has been programmed in software, it costs essentially nix to plan them all. This virtuous circle of using technology to make technology ensures prices drop, market share increases, and profit margins increase, which in plough allows the manufacturer to invest in more cunning product and distribution technologies.
However, what is important to notice is that these benefits do not accrue to custom or rare issues that cannot be mass-produced. This means that a applied science like an MRI scanner that tin can scan anyone as well is going to be much more pop than a technology that has to exist customized to a detail patient's conditions.
Personal healthcare
Already, the assumptions of mass product are changing. For case, today's 3D printers are capable of making objects of any shape; they are slightly less efficient than standard mass production, but the costs of custom objects of certain sorts has been lowered significantly. It is at present possible to custom make titanium implants the correct shape and size to fit. Going farther, it is widely envisaged that custom drugs will be manufactured, customized to the patient'south illness and genetic makeup. While this seems to exist enormously benign to patients, at that place are dangers. For instance, a customized drug may be very constructive, simply its side effects volition be unique to the patient too, and therefore harder to diagnose and manage.
Personal healthcare has an interesting technological imperative. If we tin personalize healthcare, we become population-sized markets: instead of selling to clinicians, manufacturers tin sell to individuals – a market place 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 than efficient. In the future the quantity of information volition increase dramatically considering of genomics (and the huge genomics of our symbiotic leaner) and personalized medicine, and every bit more patient data is collected, more than insights volition become bachelor.
If computers collect information on patient affliction, treatments and outcomes, one automatically obtains valuable data on the effectiveness of those treatments, or relations between side effects and patient characteristics across whole populations. Huge amounts of data volition exist collected, hence the name big information. Once the infrastructures have been fix up, the incremental toll of adding 1 new patient will exist essentially nothing, and this economy of scale will drive farther technical developments. Epidemiologists will do good enormously, but the benefits to individuals are less obvious, except in the long run from big data'due south contribution to the progress of medical science more more often than not.
Social media, patient power, mobile health and education
Stopping people going to hospital in the first place and empowering people to care for themselves and their families is something computers are already doing well. But as patients are empowered, is their new-found knowledge helpful or unrealistically raising their expectations? Today, the net is problematic, as there is no consistent mode anyone can distinguish snake oil from sense, how patients can distinguish reasonable treatment from misguided hope – in that location volition always exist a lot of solutions hunting for the patient's money. Technical solutions to this problem include providing accredited high-quality data; cultural solutions include improving teaching. When somebody has a knee injury at twoscore this should not exist the start time they meet the bewildering amount of variable information and social media on the cyberspace! Their direction of their condition – whatsoever it is – would be much improved if they had been exposed to sensible strategies since preschool.
Dramatic, transformational integration of technologies
There is not space here to fully explore the vast range of probable and meaning technological breakthroughs. Consider nanohealth, encephalon implants, artificial organs, networked sensors, genomics, exoskeletons ... just a few of the potentially transformative developments already under fashion. Some of these technologies are going to transform our whole arroyo to affliction and health – in the same way that the nineteenth century evolution of anaesthetics inverse gild'due south moral approach to pain. Pain and suffering used to be inevitable; now nosotros similar to think we take a right to painless procedures – and in turn this has influenced everything, from our handling of patients to our handling of animals (why should animals suffer? is a very mod question). New technologies, like nanohealth, are going to accept ethical implications that will exist hard to anticipate. Sometimes ethical issues volition exist hard to negotiate because they will be credible only later on somebody has got things working and already has a business-driven perspective.
Security, privacy and monitoring
In a earth beset with major security concerns (like terrorism) it is inevitable that all technologies, even in those healthcare, volition be aligned with national priorities. For case, taking patients' fingerprints and other biomedical identifiers will go easier (perhaps driven by consumer finance, such as credit card security); and, every bit it becomes easier, gathering data for state security will happen equally a side-effect of routine clinical practice. The state will be able to identify illegal immigrants and outlaws and others; the current notion of patient confidentiality volition be eroded in a fashion that will be impossible for clinicians to control.
Today we may think this would be objectionable, but it is salutary to recollect that nosotros happily divulge all sorts of personal data during our utilize of mobile phones, credit cards, as well every bit during our employ of the internet. Nosotros unthinkingly cede our privacy because of the huge convenience of ownership stuff on the internet. It seems to make losing our identities a lilliputian price to pay. When because future healthcare trends nosotros can expect similar trade-offs; it will be like shooting fish in a barrel to slide into levels of surveillance we practice non now like, falling for it because of the healthcare benefits we desire. 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 frequently signed off without sufficient thought.
It is increasingly petty to collect data well-nigh patients and the quality of patient care. This information can exist aggregated and help discover variation in treatment and outcomes, and hence help improve quality – which is good. On the other hand, data inevitably distances the managing director from the patient every bit an individual: possibly the fundamental notions of patient care volition lose out to organizational or land concerns, because price management and security, non care, becomes to be the point of the information.
Health 2.0
There are many areas where the calibration and unit profits of the healthcare market will bulldoze technical developments. Collectively, this technology-driven progress in healthcare is sometimes called Wellness 2.0, to distinguish information technology from what we are doing now – Health 1.0. While Health 2.0 is exciting, it is sobering to realize that perhaps it is just the start of an upgrade path: Health two.0 will have problems we solve with Wellness iii.1, and in turn that will develop into Wellness iv or whatever. While it seems obvious technology will continually advance, information technology is going to be harder to ensure that each iteration of engineering satisfactorily achieves what information technology claims to achieve, without having to be fixed upward and upgraded soon later on.
Unfortunately, few manufacturers stay in business selling us perfect solutions; they stay in business by selling us something to keep u.s.a. consuming: a service, something to rent, a disposable product, a product that wears out, or a production that goes obsolete. Certainly Health 2.0 will lead inexorably to more developments, any they will exist. The danger is that it will brand us eager to upgrade before we have even realized the promised benefits of Health 2.0. Somehow, we demand to work with manufacturers to align their interests of staying in business with our interests of having a predictable and stable life. Nosotros might do that by distinguishing infrastructure, which is provided about once, with consumables that are provided regularly. This is the economic model of infusion pumps: you lot buy an infusion pump once, only the giving sets are replaced after each infusion. Over time, the manufacturer makes more profit on the easily reproduced plastic tubing than the complex pump, and everyone is happy.
In some areas, the consumables will be information itself. This costs nothing to reproduce, merely people own information technology and want to make a return on their investment. Thus patient data will be endemic so that its owners – rarely the patients! – can make money from it. Data is stored in computers in data formats, and often these are proprietary: the format of a patient information system belongs to the manufacturer. This leads to the danger that the patient data is inaccessible except on the terms the manufacturer imposes. It may be plush to convert it into other formats, say to upgrade to a unlike manufacturer'south systems. Worse, if a manufacturer goes bust, some data may be lost. This is a very real problem, as our inability to use information on paper tape, cards, cassette tapes, magnetic tape, VHS tapes – none of them very old technologies – and so along, testifies. A desirable technological tendency, and so, in fact a tendency that bucks the trend to date, has to exist the assurance that information remains accessible and usable over long periods of time – at least a 100 years, which is way longer than any electronic technology!
Hacking and open up health
Healthcare sensors can be readily bought off the internet, and information technology is easy for technically-minded people today to build sophisticated equipment (to hack) to collect and analyse any personal or clinical data using their own computers. Credit-card sized computers like Arduinos and a few biomedical sensors toll about the same as a drug prescription!
Some individuals are already obsessed with collecting as much wellness-related data equally they possibly can about themselves – it is non just people will illnesses, but people who want to pb healthier lifestyles or be better athletes. If these people upload their data and contribute to aggregated data, they are contributing to citizen wellness – just like open scientific discipline,5 except tackling healthcare problems. At its simplest, they would be contributing to epidemiological studies; at its best, they would be helping build databases and web systems that other people can find their medical conditions in, and hence find back up communities. Many patients end up with more fourth dimension on their easily than they expected, and this is how some choose to use their fourth dimension: solving their own problems and helping others.
Hacking is not restricted to patients: a doctor using a laryngoscope has the option of paying commercial prices for a video recorder (e.g., to record images to send to an ENT specialist), or more conveniently recording the video on their iPhone – about a 1,000 times cheaper.
The bespeak is, engineering is empowering people to do what they want to practice, and in the futurity patients are going to take some of the initiative away from professional healthcare, especially for diagnosis, chronic illnesses, and lifestyle advice.
Technology is diverse and surprising
These are some of some powerful technological drivers, and it is hard to draw a line nether the discussion. Nosotros have not discussed many technologies that are both critical and heady such as nanohealth, personalized healthcare, mobile health, telehealth and and then on – the beginnings of all of these are already available and in use in first adopter places. What the brief discussion illustrates is the diversity, the rapid pervasiveness, and the complex merchandise-offs of future technologies.
Bridging future gaps
The science fiction author William Gibson says the time to come has already happened – we just don't know where. All the ideas we discuss in this article about the future have happened.
From considering technological drivers, we at present plough to human futures. We believe these will be more stable and less likely to alter, but volition heighten increasingly unexpected interactions with the new technologies. In areas like homo error this is alarming, for if we believe that technology improves – why else would we adopt it? – so, as man error volition still occur, the error must even more surely exist due to the humans involved, non the improved technologies which were intended to pattern out mistake. In other words, the irresistible drive to adopt improved engineering may exacerbate our management of human fault. The economical drivers that push button technologies have vested interests in promoting benefits and belittling problems. And healthcare has no end of problems: we all desire and expect better care, costs are rising and performance is declining; living longer, and living with chronic disease, are other issues. Healthcare staff are over-worked and under-resourced... it is hard to imagine technology changing that. On the opposite, many technologies (take MRI scanners, heart implants) are very expensive, and buying into them will exacerbate financial pressures.
Rubber, security and regulation
In the future at that place will remain an enduring stardom betwixt safety and security. In healthcare these hateful different things: safety is about patient and staff safety – basically, following Hippocrates outset do no impairment – and security is about controlling admission, in particular so that intruders, rogue patients and staff cannot get inappropriate patient access, whether that is informational admission or physical admission.
Security means stopping bad people doing bad things. If a banking concern loses money to fraud, this is non unexpected – we all know there are plenty of bad people around who want to go at our money. It follows that it is the bank'due south responsibility to provide security.
Safety means stopping practiced people doing bad things. If a nurse is involved in an untoward incident, this is neither normal nor expected. It is easy, then, to call back the good nurse has gone bad and therefore they are to blame – this is the conventional bad apple approach to rubber. Indeed, if a good nurse has gone bad, this is a serious betrayal of our high regard of the nurse, which makes things fifty-fifty worse. The bad apple theory is very appealing: getting rid of this bad nurse appears to solve the problem.
In brusk: security is seen as an organizational responsibility (e.1000., the banking concern'due south or the hospital'south), whereas safe is seen as the individual's responsibility (e.g., the nurse's). Technology improves things that generate return on investment (security, speed, efficiency, scale and achieve) and rubber will not do that while users are scapegoated.
Moreover, safety is hard to assess up-front end, unlike simple claims for low price, speed or efficiency. Unless regulation requires safety to be assured, we would await prophylactic to take second place. We therefore anticipate an increasing debate between rubber concerns on the one mitt and regulatory brunt on the other. Since currently the regulatory brunt for technology is negligible, certainly compared to the rigors of pharmaceutical development, much could exist gained past strengthening regulation. We propose careful attention needs to be paid to statutory regulation. To avoid hasty regulation that is ineffective or rapidly obsolete, we need to think very clearly. Today at that place is a lively debate most regulating computer engineering; some say (for example) mobile apps should be more tightly regulated; others say that rigorous protocols (such equally randomized controlled trials) have so long the technologies will be obsolete one time at that place is formal evidence 1 way or the other.
Solving the right bug
Conventional patient records are paper records in folders in cabinets. Many patients have extensive patient records, lab results and so on, and fifty-fifty more patients have patient records that are in many places – in hospitals they have visited, consultant'due south offices, general practices, and then on. They are rarely all together where the patient is, ofttimes they go lost or duplicated, and sometimes destroyed by fire or floods. Many healthcare providers take trucks shipping patient records around their areas.
The obvious thing to do is to computerize all the records, and then utilise 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 work, all we need to do is set upward a program to scan or blazon up all the existing newspaper records. Chore 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's medical history. If we have just computerized the patient records, all we have washed is made the big, scattered piles of paper into something that can be viewed on a estimator screen, but now the clinician can only view 1 window at a time, and they may easily lose the large pic. Information may be scrolled off the screen, or be curtained behind pop-ups. In fact, nosotros accept simply swapped the unusability of piles of paper for the unusability of a user interface.
While we are very familiar with the means that paper records can fail, unfortunately we are much less familiar with the ways that computerized records are hard to use and may mislead u.s..
Tom Landauer'south volume The Problem with Computers makes the insightful indicate that computers are enormously successful in areas where in that location is commonality that can be computerized — banking, communications, stock command, function documents, email are all good examples.6 Areas where they have been less successful are those where success depends on the human element. My bank account works just like your depository financial institution account, so computerizing either of our accounts is the aforementioned as computerizing anybody'southward. But my patient records are different to yours. The computerization of my records does not help computerize yours or anyone else's. Well, that is not quite true. Computerizing my records helps computerize yours, just when those records are used, nosotros and the healthcare professionals using them volition have different issues. Every bit the healthcare estimator systems scale upward to handle more patients, the usability problems get compounded – in contrast, as bank accounts are scaled upward, things go more compatible and easier to automate successfully. (Banks also have a very different arroyo to problems; a British bank does not take to handle my Russian currency or it can accuse me exorbitant rates, but a hospital that ignored my 10 rays would exist negligent.)
In healthcare, we accept to pay more attention to the wide context of how information is used.
This is the business of User Centered Design (UCD), which Landauer describes well. The ideas have been taken up in international standards. In detail, healthcare technologies must be developed using UCD processes, such as ISO Standard 62366 etc.7 One of the almost important features of the standards is that they make clear that new technologies are not going to be perfect and need to be tested and improved to amend friction match how people really use them.
UCD is essential in the battle against information overload and the police force of unintended consequences. Applied science is introduced to solve a problem or to improve performance, but this then changes people'due south behaviour and new problems may emerge.
Originally, electronic mail seemed like a wonderful idea – information technology is cheap, fast, saves newspaper, and so on. But we are victims of its very success: at present people accept and so many emails that they are overloaded (information technology is hard to prioritize), to say nada of spam and phishing, flames and people sending irrelevant or erroneous emails to thousands of recipients. It is at present possible for an ill-conceived email to waste thousands of hours when it is send to many staff. Emails are a recognized and growing trouble; merely the aforementioned trend is affecting test results, patient records, drug-drug interaction reports. For all of these reasonable tasks it seems obvious they should be computerized, but doing so frequently results in increasing amounts of low-level data that can distract people from doing their real job.
UCD helps because information technology emphasizes that no innovation is ever finished: we have to see how it is used, and continually improve it. E-mail, and the remainder, have a style to become, and UCD promotes that at each step we should be user-centred (driven by the needs of users and what they are trying to exercise) rather than technology-centred.
Unfortunately, engineering science creates new users. Computers need technicians and managers, and these users too contribute to the UCD improvement cycle. However if we are non very conscientious, the direction of the applied science gets a life of its own that takes a higher priority that delivering improved patient care. When investments are fabricated, the experts are consulted – only now the experts appear to exist the technologists rather than the healthcare professionals or fifty-fifty the patients. This can cause many problems.
Systems that are nether-performing and hence need improving oft induce workarounds past their users. For example, passwords may not work very well, and then nurses notice ways to get on with their jobs regardless. Unfortunately the people the other side of the computers just run across the systems apparently working; they do not see the workarounds or the unintended risks nurses may exist creating as they become things to work. When the system is improved, the workarounds are non considered sufficiently, and the new system may have unanticipated bug 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. Simply a few years later, one of Thomas Edison's administration, Clarence Dally, who had been enamoured with the potential of X-rays died, of cancer because he had been experimenting with them every day (Figure 1).
Clarence Dally X-raying his hand, from the New York World, Baronial 3, 1903, page 1 (American Newspaper Repository).
Information technology is now obvious that X-rays are not adventure-free. Every exposure to X-rays helps a patient yet at the same fourth dimension exposes them to take a chance; information technology is now routine to make a careful trade-off between the benefits and risks. Similarly, we now recognize that pharmaceuticals are not magic and risk-free. In fact, nosotros hardly understand how many pharmaceuticals piece of work, and it is routine – in fact, a requirement – to perform the gold standard randomized control trial (RCT) and other forms of careful experiment before allowing drugs to exist released to the market for wider use. Despite our all-time endeavours, we accept a growing awareness of worrying and circuitous side-furnishings, such every bit growing antibiotic resistance that has arisen from over-enthusiastic use of antibiotics (not least in fauna husbandry). Some of the original miracle antibiotics are no longer effective.
Ben Goldacre's provocative volume Bad Pharma documents how pharmaceutical development sometimes side steps best practice, and promotes drugs that accept untoward side effects and other problems.8 For example in a large RCT, some patients may die for unrelated reasons. The question then is what to do with their data; it is very tempting to treat them as if they had survived and had been cured. Another example success bias in the scientific literature: authors of scientific papers want to publish their successes rather than their failures. So the literature nether-represents drug trials that fail or uncover unwanted complications. In plow, this means that systematic studies of drug trials cannot get the right baseline for experiments, since many experiments are not published. Regulation is starting to address this problem.
Goldacre makes clear that pharmaceutical development fails scientific standards; all the same engineering science development, such as robotics or computer system development, does not even aspire to the scientific standards that pharmaceutical research is aware it fails to achieve. As Goldacre puts information technology, pharmaceutical R&D is close to immoral; yet engineering R&D is ignorant. This is worrying for the future, as technological developments may not be adequately tested, tested without satisfactory controls, and nether conditions of vested interests. (Most of the studies arguing Doc Order Entry systems are either skilful or bad are written by people using the single systems they are publishing nearly; they are non practiced scientific discipline.) New technologies may accept unfortunate side-furnishings or other problems (such as forcing risky workarounds) that nobody has seriously looked for, let lonely rigorously assessed.
The concluding paragraph makes a stiff merits, but it is justifiable. Modern infusion pumps volition have been certified for clinical use, and thus patently passing the applicable safety tests and standards. Yet modern infusion pumps are driven by computer software (east.g., in their firmware), which tin can be modified at volition by the manufacturers and parameterized by hospital technicians. Indeed, software is regularly updated to set bugs and to make modest tweaks. Modifying software tin can completely change the behaviour of devices. What makes the software control of devices so highly-seasoned is that manufacturers can create a diverseness of devices for different marketplace sectors all on top of the aforementioned architecture. Changing the software tin change a device from, say, a simple infusion pump to a dose error reduction intelligent pump. But such changes can be made afterwards it has been certified for use, without whatever farther regulatory control. Furthermore, one will struggle in vain to find any scientific literature on the assessment, let lonely RCTs, for such devices. It does non exist. On the contrary there is a growing literature on the rubber problems of infusion pumps.9
Ane can hope that the future trends include tightening the culture of technology development. The standards need improving, and the laisse faire culture of contemporary development needs addressing. In many means, today's medical technology is at a maturity level comparable to the unsafe at any speed automobile of the 1960s.10 If we do non address the lax scientific standards of technology development, information technology is unlikely that future engineering science interventions will improve safety or other desirable measures of healthcare performance.
Human factors
The nature of human expertise is that it makes errors likely,11 and clinicians are highly-skilled experts. To become skilful at some process means automating it, doing some or all of the task without continual reference to the wider state of affairs. For example, when y'all learn to drive a motorcar, you are consciously enlightened of many factors (such every bit clutch control), but as you gain expertise, driving becomes automated and you lot are able focus on higher-level goals. Equally an expert commuter, yous may find it seems easy to hold a chat on a mobile telephone, as y'all now have the spare cognitive resources to exercise so. Unfortunately if something unusual happens, say if a child runs into the road, y'all may not exist paying enough attention to the situation to take appropriate activity – ironically, when you were less of an expert driver, yous would have had to pay very close attention to road conditions, and you lot may not take been driving and so fast either! The signal is that as new technologies will ameliorate things, nosotros humans will notwithstanding make errors.
Human factors is already a problem today: complicated gadgets induce use errors. In that location is a balance between the time and endeavour a manufacturer is going to spend making some technology easy to utilise (and safe to use) when the economics of selling the product may non prioritize those qualities. Usually new technology is procured because it promises to improve efficiency or reduce costs; safety is an issue covered past insurance, and is rarely part of the procurement requirements. Regulation requires some basic rubber, only the features that sell devices ofttimes conspire to make the use of the devices more circuitous. As we discussed with modes, above, the more features the more complex a device is to use. Still typically features sell technology, and the difficulty of use is pushed onto bug for the users. If there is an untoward incident, it is much easier to arraign inadequate grooming (i.e., the user's incompetence) rather than the complexity of the system being used.
Human being factors – issues such as situational awareness, tunnel vision, and so on – is a large and important area. In that location are two questions for the future: how can applied science help, and how can engineering science be improved to be intrinsically safer?
How can technology assist?
In time-pressured environments, humans often suffer from tunnel vision – focusing on the original task and overlooking larger situational awareness. The classic example is intubating a patient. This is a demanding, time-critical procedure. The longer information technology takes, the more pressurized the clinician is to consummate the process. Sometimes the patient will go into problems, and a tracheotomy is needed – urgently. Sometimes the clinician is so focused on the intubation that the warning signs are missed, with disastrous consequences. Hither, technology can assist by using monitoring technologies. Remote monitoring of the patient's vital signs can enable a trained person out of the pressured environment to make helpful comments: Hi! I can see you have about x seconds before you need to stop... Such ideas lead to concepts like the electronic ICU (eICU) where a command room monitors perhaps 100 beds. Feel with such technologies has been positive, specially if careful steps are taken to avoid a them and us division between the clinicians doing the piece of work and the clinicians monitoring them. Usually a staff rotation is used, so everyone experiences both sides of the camera.
How can engineering science be designed ameliorate?
Manufacturers tin employ better design processes, such as those outlined in standards such equally ISO 62366.7 Doing this effectively is hard piece of work, and with rush to marketplace information technology is tempting to exercise the bare minimum, for all the reasons discussed elsewhere in this article. Here nosotros can mention three useful ideas:
Discovering use errors takes a long time, and this conflicts with rapid entry to marketplace. The solution may be to design systems 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 detail so that the manufacturer gets a practiced insight into how the device is being used or is declining to be used. Currently, this information rarely gets back to manufacturers in a useful form.
Many apply errors follow predictable patterns. So-called post-completion errors are common and hard to eliminate simply by improving human procedures. A nurse may use a claret glucometer to mensurate a patient'south claret saccharide levels. The nurse moves on to the next patient, and so puts the blood glucometer in a docking station to upload all readings. As described, at this signal the nurse has failed to make a written note of the levels on the patient'southward newspaper notes, nonetheless because the device has docked, it has discarded all recordings. This is a mail-completion error: the nurse made the error subsequently they had finished. The solution is to redesign the engineering, and there are many options here. Why delete uploaded data, for example? Why not take a reminder in the device to ostend the nurse has recorded data earlier taking another reading? Why record manually on newspaper 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), merely more thoughtful pattern can avoid them.
Physicality
The huge leverage computer engineering science brings, because it is virtual and tin exercise anything with data (and hence the same piece of engineering can be mass produced for a huge market place that has not be preconceived), has a downwards side. Humans are physical.
The trouble can be illustrated very simply. In the one-time days books where physical objects, and they looked and felt different. A well-read book would await worn, and an unread volume would look new. You would recognize bookmarks sticking out of books, y'all could write annotations in the margins, y'all would know how much yous have got left to read before you finish it. You could put a volume past the front door of your house to remind you to pick it up in the morning; you lot could leave a book by your bed so it was set up for next time yous wanted to read yourself to sleep. And so on. Now, with electronic readers, all books and documents look the aforementioned – like the general-purpose computer they are on. Of course, the estimator can create colourful covers and images, but the physical object is always the same: namely, the computer or tablet.
In the one-time days a patient would go to their doctor and get a newspaper prescription. They would so go round to the chemist and get their medicines. 1 problem with this process was that paper prescriptions were notoriously difficult to read, and there was a danger of incorrect dispensing. Today, this process has been computerized. The doctor sends the prescription electronically to the chemist's shop, and the chemist's shop can dispense the drugs almost immediately.
Unfortunately, the patient has lost the concrete prescription in this procedure. They exit the doc'southward engagement conveying nothing. In that location is nothing to remind them to become to the pharmacy to choice upwards the drugs. Indeed, pharmacies are now having to dispose of drugs that were efficiently dispensed equally shortly as they were prescribed but were never collected by the patient.
Just equally electronic books are a gift to book publishers – because the expensive paper book is replaced with a cheap electronic book, free to reproduce once but 1 re-create has been prepared – increasing use of computers in healthcare is irresistible. 10-ray photographs no longer need to be developed, put in folders, held upwards against viewing screens. They can be emailed. But what they take 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 mistake), only information technology is very easy to wait at the wrong patient'due south X-ray – considering they all wait the same without their physicality.
Unfortunately physicality is in direct conflict with the driving economic science. Pieces of newspaper are very familiar and nosotros understand exactly how they work, but computer screens are cost-effective precisely because they can brandish lots of information repeatedly without add-on costs. Still from a safety perspective, the screens all expect so similar they may be confused.
One solution to this is skeuomorphism: making new technologies imitate onetime (and hence more familiar) technologies, otherwise known equally using the right design metaphor. The example here would be to improve the display so that the newspaper data being displayed looks more than like bodily paper – perhaps with torn edges, discolouring if oft used, and and then on.
A 2nd solution is affordance: make things look like how they are intended to be used. For case, a cup with a handle has the affordance that encourages you to selection information technology upwardly past its handle. Particularly in emergencies, people demand to know what to exercise intuitively – and affordance is a key part of design.
Thirdly, we tin make computers disappear – what is left is a concrete object which happens to do something complicated, merely it has been made invisible to the user. RFID tags and smart chips can be embedded inside objects so that they tin can do things and interact with each other, only the object appears to exist normal. A nice case is the hotel key card; so far as a hotel guest is concerned they behave just like room keys, only inside some sophisticated cryptography creates a host of benefits – for example, unlike losing a physical central information technology is not a problem if you lose a key menu, and the locks do non need to be replaced. When patients routinely take ID tags embedded in them, many of the current problems of patient barcodes will disappear – no uncertainty to be replaced by different problems!
This article is not the place for a deep word on pattern,12 but it is of import to point out that looking up skeuomorphism or affordance on the internet reveals a huge diversity of conflicting opinions. In other words, these ideas are ways to fence almost design, non ways to blueprint. One however has to practice detailed work to make hereafter technologies successful, regardless of their supposed affordances. Despite having prissy words to talk well-nigh good design, no future volition exist an inevitable success.
Enhanced and bionic humans
Although we accept said that human factors will remain a abiding for the foreseeable future, there is nothing to stop technology enhancing people. Technology will not exist used but to monitor and help make people well, but will be used to brand them improve – ameliorate equally sportsmen, as healthcare professionals, or whatever. We already have augmented reality, where surgeons can see an enhanced view of the insides of patients. If patients can have encephalon implants to heighten their lives (to manage Parkinson, for example) surgeons volition have implants to meliorate their skills, using robotics to reduce tremor or computers to reduce error. Later on all, the core of the humble reckoner – which reduces drug dose calculation errors – has already shrunk in size from tabular array-peak clockwork of 50 years ago to something so small it could be swallowed.
Who are the protagonists?
Thinking about the hereafter is scientific discipline fiction. Key to the success of any story is to help the reader place with the key character; or in the nowadays context of thinking about healthcare futures, are nosotros writing from a patient's perspective or from a technologist'southward, or a healthcare professional's, or ... the story makes choices, and if the choices marshal with our ain interests the story seems more plausible and persuasive.
If the market place has adult profitable technologies, it follows that we (you and me) want those technologies. This truism needs emphasizing. Manufacture stays in business organization making what we want to buy. Industry is skillful at adapting to brand what we find irresistible: this is market place competition. The manufacturers who are amend at seducing united states survive and abound. As a consumer, I beloved iPads (at least I did in 2013), but that does not hateful that iPads can do much practiced in a professional healthcare surround. Should we fill hospitals with iPads? I office of me, the private consumer, says yeah, they are wonderful! It is interesting how Blackberries were driven by employers, but iPhones and iPads are being driven by consumers; increasingly the employee is dictating what technology the organization they work for uses. But the other part of me, the clinician, the scientist, the technician, asks for show that they will truly improve healthcare. Information technology doesn't make such a practiced story for me to say I am non certain! If I am in healthcare procurement, I have to remember very advisedly to distinguish what I covet equally a consumer from what will actually improve the organization I work for.
It is certain that getting bear witness, doing experiments (RCTs?) will delay the market, and there will be huge pressures on us to believe in the wonderful visions, rather than in the necessity of conscientious evolution. Healthcare is complex, and simply throwing technology at information technology volition not in itself change annihilation usefully, other than costing us a lot of coin (which is exactly what the market wants united states to do). As we approach the future, we need to learn how to plan our resources much more carefully and experimentally. The subtle cost-benefits of X-rays were not credible immediately, and they rather ruined the original magical story.
People trying to sell united states the hereafter will certainly latch into our acquisitive consumer natures – this is who we are as individuals. They are less likely to latch into usa every bit patients or clinicians, and thus – while being an engrossing story – they may miss the point and sell usa on technological ideas that do not really better the world so much every bit satisfy our consumerist urges. Ane of the important things scientific discipline fiction teaches u.s.a. is that the future will not be populated just by sensible solutions. While we promise for a happy ending, there will be problems and fifty-fifty wicked plans, evil empires and natural disasters to overcome along the way.
Who makes the future?
The future of healthcare is virtually the patient (or stopping people becoming patients), but patients are not the master stakeholders in healthcare. Insurance companies, big pharma, doctors, managers, suppliers, builders, governments and many other forces will influence the futurity. Will innovation help patients or will it be partly to help 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 have certainly increased the book and turnover of the business. Moreover, now patient records are computerized, with the obvious benefits, there are also bug. To get issues fixed, upgrades have to be purchased, and this can be very expensive. Patient records were in one case on paper; now they are in proprietary formats, and the manufacturer can lock in the user to their particular organisation, then buying upgrades – perpetuating the lock in – seems cheaper than moving over to an culling system.
Conclusions: what we need to do
If nosotros don't know where we are going, we won't know when we don't get there says the quotable Yogi Berra. The market place volition surely effigy out a way to make money, and applied science volition accelerate in miraculous means. Instead, nosotros demand to figure out a way to have healthier and happier patients (and non only treating them every bit individuals), and to exercise that we've got to focus on integrating engineering science with culture rather than focusing on technology alone.
In my view the key thing is to think clearly. Initiatives like the UK Royal College of Physicians Future Hospital Commission, where thought-leaders – patients and healthcare professionals – accept sat down and worked out what sort of future hospital they demand are to be commended;3 more chiefly, they take articulated principles, non merely specific solutions. Such principles are or should exist timeless; we should non programme the future by being technology-driven (e.g., implementing cloud, nanohealth, etc) but by improving along criteria behind principles (such as improving patient care or staff back up). Articulating the principles of the futures we desire should be a continual process, not a one-off activeness; every twenty-four hour period at that place is a new future to plan, and new discoveries that will change our minds well-nigh what is possible and likely. Hereafter planning should be every bit much a routine role of healthcare as responsive care is. If we don't know what we need, we will get what is piece of cake and profitable to make; as nosotros emphasized above, what we need and what we want are often confused.
Are we making the healthcare future we want? 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 place they had hoped for. What stories would they have back to help direct their technological trends and developments?
Acknowledgements
The author acknowledges the very stimulating and encouraging comments almost particularly from Annegret Hannawa, Ross Koppel, Don Norman, Ben Shneiderman and the anonymous referees.
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Articles from Journal of Public Wellness Research are provided here courtesy of PAGEPress
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4147743/
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