Monday, November 26, 2012

Perspectives on the Changing Healthcare Landscape

Dr Azhar Alani, MBChB, MBA View Dr Azhar Alani, MBChB, MBA's profile on LinkedIn

Healthcare has finally had its eureka moment: put the patient at the centre of everything. Hence the need to look at the industry in a completely different way. If we adapt the patient’s perspective, it will be easier to recognize and manage one of the biggest issues healthcare industry is inflected with today: process waste. In the US healthcare system alone, $1.3 million is being lost every minute in non-value added activities (process waste)(1). Adapting this new perspective - the customer’s viewpoint, will help us understand why the healthcare system needs an overhaul: re-designed to be truly patient-centred. It’s not all about systems and processes, however. At the heart of this journey is changing mindsets.

Without changing mindsets, healthcare industry will remain crippled by its old ways trying desperately to adapt to new realities. One of the approaches to changing mindsets is through a consulting practice called change management: the effort to introduce new ways of doing old things focusing on the behaviour and culture to the effect of changing how people think about their work. However, we need to ask the question: how can we change the mindsets of healthcare managers; those trying to introduce change in the first place?


Changing Delivery Model

Healthcare delivery is structurally changing - archaic ways can no longer cope with the changing environment: cost constraints, patients' expectations and the plethora of new technologies. One analogy that comes to mind is the musical chairs game. This traditional group game illustrates the current situation of healthcare delivery model. By arranging a number of chairs (n), participating players (n+1) are asked to run round the chairs while music is playing. Each time the music stops, players try to sit down on one of the chairs. As there are more players than chairs, one person will be left out each round. Imagine the public healthcare delivery system as the chairs around which patients circling until all resources are exhausted and they would either go private or just endure pain. We are trying to turn this set up inside out: we want to make the healthcare delivery system circle around patients in a truly patient-centred fashion, so that patients themselves empowered with knowledge and ownership of their own medical information will be able to choose the best way to receive the care that would be suitable for their circumstances and life style. It’s the inverse of musical chairs game; if you like. 


Patient-Centred Care (PCC)

There are several interpretations for PCC. The Institute of Medicine’s (IoM) definition is a well-accepted one: ‘providing care that is respectable of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions’. Add to that the fact we in healthcare can no longer deliver what the patient needs single-handedly in a job-shop fashion as it used to be the case decades ago. Healthcare delivery is a function of organization design – team work plays a vital role in ensuring quality of care; where quality is defined by how closely outcomes meet patient’s expectations. The IoM goes on to offer a list of services and aspects that constitute PPC approach:

·         compassion, empathy and responsiveness to needs, values and expressed preferences
·         co-ordination and integration
·         information, communication and education
·         physical comfort
·         emotional support, relieving fear and anxiety - and
·         involvement of family and friends.


Patients Know Best

Disruptive innovation has been talked about and discussed inside and out of business schools around the world. Some large corporates took it to heart and established a creative milieu to foster innovation, and made sure such small satellite units are attached to the corporate head-quarters through a “dotted line” arrangement to give it as much freedom and space as needed for the new ideas to flow. A British company has tried to not only disrupt healthcare industry, but also to adapt the patient-centred care approach by changing the “musical chairs” model. Dr Mohammad Al-Ubaydli, CEO and founder of Patients Know Best(2), has devised a new subscription-based system that revolves around the patient. A medical doctor, software specialist and management consultant, Dr Al-Ubaydli represents the new generation of healthcare professionals daring to cross to the other side to change the industry inside out. “Medicine is basically an information industry. It’s all about knowing the right information of the right person at the right time,” Dr Al-Ubaydli was quoted saying as he was describing the idea behind business. In this new approach to making IT work for healthcare, Dr Al-Ubaydli wants to put patients and clinicians in the driving seat, rather than the technology being introduced. Traditionally and unfortunately now all too familiar, previous attempts to modernize healthcare using IT have failed spectacularly, if Connecting for Health (CfH) programme in the UK is anything to go by. 


From "Paternalistic" to "Participatory" Medicine

We need to move from the out-dated “paternalistic medicine” model of doctors-know-best model to the innovative and more logical for this day and age: what Dr Al-Ubaydli calls “participatory medicine” where patients are at the centre as well as taking part within the whole delivery team (clinicians, healthcare-givers, IT, others). One of the reasons Dr Al-Ubaydli attributes the failure of CfH programme to is the top-down approach that was followed in architecting the healthcare landscape in the UK. Through Patients Know Best model, individual patients have at their disposal their own information and can give permission to whoever needs access to their information as and when at the point of care. With the participatory medicine model, the focus is the other way round: it’s a bottom-up approach.
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(1) From A Global Village publication, "Enabling E—Health A Revolution for Informatics in Health Care" by Simon Kennedy & Benjamin Berk, The Boston Consulting Group http://aglobalvillage.org/journal/issue4/ihealth/kennedy/
(2) Visit www.patientsknowbest.com/

Thursday, November 22, 2012

Unlocking value trapped in BMJ-rejected papers


It's been said that the BMJ* is a big rejection machine(1). Out of approximately 8,000 manuscripts received each year only 7% are accepted. Comments and suggestions provided by editors and/or reviewers represent a wealth of knowledge only available for the original authors. Is there a way we can unlock value trapped in the remarks provided by BMJ editorship?

The short answer is yes. In a study published in Occupational and Environmental Medicine journal(2), it was estimated that more than 50% of rejected papers were published somewhere else, the majority of which were issued in the first two years after rejection. Even though only 10% of those rejected were published in journals with a higher impact factor(3), one can say that not all unaccepted papers go to a lower-ranking journal. The figure of 50% appears to be common among other major journals, like Cardiovascular Research(4). I think the situation with BMJ is similar to these major papers. How could authors then succeed in publishing more than half of their rejected papers? Well, in some cases the credit goes to what can labelled as constructive criticism: comments and suggestions from the editorship of the rejecting journal. Authors in these cases incorporate changes recommended by editors and/or reviewers and sometimes even do a total rewrite. This means there is a knowledge asset that will be useful if shared with other authors.

A proposal
To answer the question of how to unlock this valuable resource, I suggest we build a database for a selection from these unaccepted papers. Below is a summary of this proposal:
a. Initially submitted manuscripts are tagged with comment markers (in technical jargon: metadata tags). While BMJ editors/reviewers are scrutinising these manuscripts, they can enter their suggestions and remarks as “Comments” to be captured by the information-holding place (ie metadata tags)
b. If this particular paper is rejected (there is a 93% chance that is the case with initially submitted manuscripts to the BMJ(5)), then all personal references are removed to de-identify the original and make it anonymous (information like author names and other bits of content chosen by the authors (to avoid copyright infringements and to protect intellectual property of the authors).
c. A database is to be created to host all of the binned material (which is now anonymous). The database system will do the job of indexing and grouping all of these materials in meaningful groups.
d. This database will then be made available for those who are about to write or submit a paper. Access will be logged and managed by the database system making sure that security measures are in place.
e. With time, there will be a build up of knowledge from the bits and pieces of information which will be contributed by editors and/or reviewers. It can be thought of as a “wisdom database” as it will be a place where accumulated scientific or otherwise learning is kept. 


Avoiding pitfalls and obstacles

Authors can learn from other people’s mistakes by examining failed attempts and analysing the reasons of rejection to understand better BMJ editors’ logic. Knowing some of the frequent errors can help steer your writing journey away from editors’ recycle bin. Sometimes it’s common sense that separates an accepted paper from a failed one. According to Jeff Skousen, a West Virginia University professor(6), “Scientists who publish know some of the pitfalls and obstacles that hinder the publishing process, especially in the top-tier journals.” With “wisdom database” in place we can alleviate the pain that many of us have to endure when trying to pass through BMJ gatekeepers (also known as editors). 


Intellectual property

Publication in scientific literature serves as a means to secure knowledge ownership claims besides being an efficient vehicle for communicating this body of knowledge. It’s one of the unwritten rules in research community that a scientific experiment is not complete until results have been published. One of the issues this proposal would face if implemented is how to address the intellectual property (IP)(7)area. I have already mentioned that it will be left to authors to decide on what to be stored and what’s not for IP reasons. I suggest we leave it to authors the choice to opt in this scheme (ie all papers are opted out unless authors decide otherwise). The area of IP would have to be examined carefully and would represent an important part of the detailed plan of this proposal if put in practice.


The future

Admittedly, this can prove a slow process; hence patience and determination from all involved will drive it forward to make it happen. It is an organic tool in the sense that it will grow dynamically and be refined as it gets larger and learn more to be “wiser.” Initially there will rapid quantitative growth as the database will increase in volume with every new article entered. With time, the database will mature and grow qualitatively. When the benefits of this database are reaped, there will hopefully be a positive effect on BMJ’s prospective authors. With this database we will create a self-tuning system of continuous refinement. To take it forward, I suggest we experiment with a pilot scheme and I will be happy to start the groundwork straightaway. I see this change, if taken up, as something that would send ripples to all other major journals. I sincerely hope that the BMJ will take the lead in this initiative. Over to you BMJ..
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Azhar Alani, MBChB, MBA
Business Management Consultant
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* BMJ - British Medical Journal, is just a representative example and not the only publication addressed by this article. Visit www.bmj.com
1)  Trish Groves, Kamran Abbasi, “Screening research papers by reading abstracts”, BMJ  2004;329:470-471 (28 August).
2)  B Nemery, “What happens to the manuscripts that have not been accepted for publication in Occupational and Environmental Medicine?” Occup. Environ Med. 2001;58;604-607.
3)  Impact factor is an indicator that reflects the average number of citations received by the average article of a journal per year. For more on impact factor: Amin M, Mabe M. “Impact factors: use and abuse.” Perspectives in Publishing 2000;1-6.
4)  Opthof T, Furstner F, van Geer M, et al, “Regrets or no regrets? No regrets! The fate of rejected manuscripts. Cardiovasc Res 2000;45;255-8.
5)  Information on analysis of papers submitted to BMJ for publication can be found on BMJ website at http://bmj.bmjjournals.com/advice/ms_breakdown.shtml
6)  M Celeste Simon, “Writing a paper that will get published” The Scientist 15[7]: 30, April 2, 2001.
7)  For more on intellectual property go to http://www.intellectual-property.gov.uk/