Saturday, November 8, 2014

Developing a CA firm (CA as in clinical audit) to audit healthcare information toward better transparency and accountability

Our current UDHC passion is spent in trying to develop a unique CA firm (CA as in clinical audit) where Indian health care students activists/enthusiasts/entrepreneurs can interface with patient information requirements to audit the information (in the prescriptions provided by the direct agents of the patients aka clinicians) and you will find a lot of such information in the prescriptions available at the individual patient records here

In our work with 'patient centered learning' we have felt this need for training in EBM and we have designed an elective curriculum in 'blended learning' in our institute here which has been attended by students globally.

If you agree to collaborate in further developing a potential transparent health interface (which already exists here), we can train any health entrepreneur who wishes to make a difference here in our institute/practice area (completely hands on) and completely free of cost.These activists/entrepreneurs can then utilize the training to open their own UDHC clinics in their chosen locations on a fee for service model(preferably in collaboration with an medical practitioner)?
Patient centred online learning has a lot to give to our patients and health professional trainees that it is a pity we are currently not utilizing a fraction of it! Can we think of expanding our practice area beyond the confines of our academic institute (which mostly functions from 9 AM to 4 PM) and moving it to a private practice community clinic setting where these clinical entrepreneurs are anyway likely to practice in their own future?

The selected graduates need to be savvy in computer mediated communication and learning and we could also have a run in period of 1-4 weeks to decide their suitability for the program.
These trained activists/entrepreneurs can also work with govt bodies to perform large scale clinical audit surveys in hospitals and large group practices where clinicians (unwittingly?) engage in non-evidence based practices (unknowingly working in collusion with the drug industry?

Hoping we can collaborate with 'like minded individuals' for this 'Patient centered Clinical Audit and Research Entrepreneurship' development program to currently unemployed/employed Indian graduates looking for clinical-entrepreneurship-career options (and we can help to provide free training) and perhaps this can help pave the way forward to a 'transparent and evidence based healthcare ecosystem' in India?

Inputs in web-based conversations from like minded individual LMI on the above thoughts:

LMI: I have some basic questions which I am elaborating below:

1. When you say we can develop Clinical Auditors and you can train them, I would like to ask that what is the market need for such Clinical Auditors. Who will hire such guys? Hospitals? Regulatory agencies? I need this answer because I believe that any new concept which is being introduced, howsoever revolutionary it may be, it has to be introduced in an evolutionary way so that people responsible for propagating it continue to get commercial or some other benefit out of it. Without a perceived or proven benefit, such initiatives may die their own death. So, to repeat, where will this skill be used and what commercial benefit can the trainees hope to achieve?

2. About entrepreneurs using training to open own UDHC clinics: I am not clear on this model. Till now, UDHC supported clinic is an online network of physicians who are voluntarily giving advice on certain cases for no commercial benefit. How does this get converted into a biz model? I would need to understand this better.
Very good ideas need to be cloaked in commercially viable models for them to become big enough to become self-viable and widely adopted. I have lots of hopes in this model but i also feel that someone needs to build a business model around this so that this is not seen as a voluntary or self-improvement or charitable kind of work but as mainstream technology driven initiative having significant impact on patient outcomes. May be a mobile accompaniment app for providers would boost the network.

Reply to the above inputs by 'I':

1) I had initially thought there would be a market need to audit every clinical workflow as much as there is a market need for a chartered accountant CA to audit business workflow. Initially i had 'naively' assumed that the need for a Chartered accountant was a 'felt' need from all business houses who pay the CAs to audit their business so that it gets considerably improved and their business stands to gain from their audits. The current reality is probably different (from what i could gather after talking to a few chartered accountants who said they are asked to audit because of regulatory pressures from the Govt and if there was no 'law' making audit mandatory for business houses they would not thrive at all). :-)

So i guess current clinical auditors do not have any market till we have any such law but i am sure we can still utilize the skills of the UDHC trained workforce (trained not just in clinical audit but primarily in clinical information communication) to fit into our overall basic business model (that may in a manner drive the need for regulatory change to create a niche for Clinical Auditors). More about the business model below:

2) I have recently decided to begin private practice in addition to my hospital based clinical practice and primarily this decision as well as subsequent workflow for the private practice is dependent on the UDHC business model.

The business model (cash-flow and workflow) is something like this:

a) Clinical encounter fee from patient (Let us assume the number 100/- only for simplifying expression of the data): Health professional sees patient in his clinic for a fee and asks his 'trained clinical information communicator entrepreneur/trained clinical health educator/entrepreneur' TCHE to prepare an online record in UDHC (which is more like an evolving case report of the patient with various bits and pieces of available information around the patient strewn coherently for meaningful use) after obtaining informed consent from the patient from the form downloadable here

b)) Fee division: Physician 70/- and TCHE (20/-) for the first and subsequent visits (10/- could go to the online as well as offline managers/developers of this entire workflow).

Workflow: Physician primarily writes on the prescription slips (as per common-current workflow with minimal change pressures for the physician) and this is promptly uploaded on the site (after patient de-identification) by the TCHE who also types out a proper history of the patient in the narrative space on the web based record. See this illustrative example here The TCHE here is our medicine office clerk who is trained to take a clinical history (using her common sense and in Hindi...she is currently not very proficient in English) and input data (again in Hindi using English fonts) to the site. You can also see the uploaded prescriptions that i wrote for the patient and in the same narrative space we have pasted the subsequent conversations around this patient in our processing forum (tabula rasa). We could further train the TCHE (particularly if the candidate has a nursing or pharmacy background) to become a complete physician's assistant (also well trained in medical information processing aka clinical problem solving). You may ask what would distinguish a fully trained TCHE from a very good primary care physician then? Well the TCHE can nurture the information workflow but may not still be able to make the final decision and make the prescription orders. But yes if the same training was given to an MBBS s/he may become a very good primary care physician.

The other important workflow of the TCHE would be to take all the phone calls from the patients for the physician and if indicated enter those conversations into the patient's web based record to keep the physician asynchronously in the loop.In fact this model can be fast tracked with more and more patient users being generated through a telephonic introduction to the physician's and TCHE's practice following which (if the patient is satisfied after the first phone call and a phone call generated web record) the patient could decide to come and meet the physician and TCHE for the first face to face clinical encounter.

The success of the model (as in most health care delivery models) would be heavily dependent on the level of training and learning-sustenance achieved in both the actors (physician as well as TCHEs) and the UDHC website is perhaps in some ways functioning as a differently structured 'web based learning management tool' for these actors (as well as the patient) and the entire information that may rapidly accumulate in this open database can again be 'mined' to gain further insights in health-cognition. In future this can be developed into a sustainable 'home-care' model integrating pharma and nursing trained TCHEs into this model.

Inputs from above like minded individuals on email:

LMI: In this case it is important then to rephrase our clinical auditors to someone who is more "useful" to an organization. It may merely be cloaking the same wine in new bottle but it is necessary to appeal to people's basic understanding that any course or training has to be useful to them and also to an organisation. It may be a good idea to explore the possibility that can your CA training become a module for NABH training? Can we approach NABH and have their stamp or certification involved? This way, the training will attract more people. Now I know that you want only genuinely interested people to come to you but the initial step may be to first target and reach a critical mass of supply and create a demand, if it does not exist.

I: Sure. NABH is a very good idea.  I am already 'informally' training a B Sc undergraduate student who is supported by one of my patients (who is buying his lap-top). I find this initial investment of
a lap top and internet connection a big hindrance among the trainees that i am getting here locally but without that our course may not be able to deliver 90%. :-(

LMI: This is a good example. My question is that why would you think of fee sharing model when the kind of work is actually almost like that of a scribe or a medical transcriptionist or clerk. This appears like there just needs to be a data entry operator who is scanning and uploading most files or dictations. There seems to be little value-add from this scribe. On the other hand, training an MBBS to do this is creating an expensive clerk; and anyway we need to consider the industry preference that doctors don't really like to record computerised records. Can we just not continue to train disadvantaged section individuals to become doctor's scribes for a salary e.g. 5-6k/month or so? e.g a person with lower limb polio or a lower limb amputee can be a good candidate for this job. I am not convinced that MBBS doctors would be best suited for this. But I am open to discuss this. I am sure your idea has a basis which is eluding me.

I: Well i feel we are training people for the long haul and i would like to see each of these trainees go to a Phd level which in turn will raise the academic standing of our model? (See this:here)

LMI: There are some companies I know of, who are using this concept on commercial basis. We can talk about this when we talk, but once again, a TCHE is increasingly looking like a non-physician to me. May be a para-med or asha or anganwadi worker etc.

I: You are right but every TCHE is a potential TCSE (More here)

LMI: Now here is a disconnect. you are terming this project as a "learning management tool" while I am seeing this as a "Network for clinical expert opinion" tool. While the tool is same, I'd need to understand where is this headed. Learning systems, though highly desirable, have poor acceptance with medical colleges' principals who have just about had enough on MCI curriculum compliance. So I am trying to see if this can be sustained as a model which is its own carrot and brings tangible advantages.

I: You are right but this is actually a 'learning network for clinical problem solving tool.' All expert opinions are vetted by comparing with recent best evidence and then the moderator and the patient's primary physician decides what suggestions would best fit the patient's requirements. This is primarily a 'basic-doctor emancipation' tool that allows primary care physicians to be super-physicians utilizing the services of a 'learning-network. The MCI may someday appreciate the fact we can use this model to train a basic doctor much better than all previous models and record all our learning in individual (faculty-students) learning portfolios. :-)

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