At the American Academy of Political and Social Science [AAPSS] annual meeting held in Philadelphia in 1973, the subject for the year’s review was “The Future Society: Aspects of America in the years 2000”. One of its speakers, George E. Ehrlich, Professor of Medicine at the Temple University School of Medicine, gave a presentation entitled “Health Challenges of the Future.” (The Annals of the American Academy of Political and Social Sciences, Vol. 408, July 1973, pp. 70-82). In his presentation, he stated the following:
“The computer will play an increasingly important role. Problem oriented records are already being developed to assist computer analysis. The clinical and historical features of patients’ illnesses will be analyzed by computers and correlated with the stored memory of the patient’s medical past. Appropriate laboratory and other ancillary data will then be automatically ordered, obtained and interpreted; diagnostic probabilities and therapeutic approached will be developed. The role of the physician will be one of clarification, sorting out and application of those measures still requiring human contributions.” [p. 72]
The role of the computer in medicine has very much defined the direction we are taking in 2013 in the Electronic Medical Records industry and the related fields of population health and epidemiology study. Dr. George Ehrlich didn’t elude to place and disease in his statement, although elsewhere in his speech he discusses briefly the problem that exists with the need for physicians in the most rural settings. When Ehrlich made this speech 40 years ago, he recognized that medicine was not going to meet the needs of the US population, pointing to the growing needs of people within rural settings which contrasted greatly with the growing numbers of specialty doctors and services being made more available at teaching and research facilities, health care providers normally absent from rural community settings.
The specialization of medicine makes it hard for this profession to produce enough doctors for every specialty, for every square mile of this country. Some physicians who are experts in their fields, need to be distributed evenly so that their unique skills are more evenly distributed. At least this is what Ehrlich believed. We don’t always see this happening in the 21st century.
Ehrlich’s insights from forty years ago into the need for highly specialized treatment facilities today, helps to define the Big Data industry and what it is turning into right now.
Ehrlich accurately predicted the transformation of hospitals in primary and tertiary care settings, inferring of course the presence of local hospitals serving as secondary care units. The same hospitals today have yet to fully employ the potentials of the IT world. Quite often we only understand disease patterns in the most basic ways. We failed to get a grasp of the nuances in disease patterns that exist in people, be these difference due to very small difference in age, genetic make up, or where they live.
In the next part of his presentation in 1973, Ehrlich states:
“Physicians will probably be required only at the centralized facilities; specially trained assistants will provide the data from the patient.”
According to Ehrlich, “the best team of doctors” will be placed at facilities where patients can be brought in a timely fashion to the best forms of health care out available. This is where the most costly, risky and most time consuming matters of treatment surgery would take place, not “in every village and in every corner.” This is a correct prediction of the development of the current facilities we now have in place, consisting of primary and secondary care facilities, with tertiary care teaching hospital settings and even high grade quarternary care level places that stand out as their own entities.
But along with specialization come dehumanization. Even more compelling is how correct he was about the people’s perception of the role of a computer in the medical world. Ehrlich writes
“Such a system may be depersonalized, of course. But it will still seem no more depersonalized than our present system appears to be to those who remember the kindly doctors whose long hours of sympathetic attendance compensated for his lack of cures. . . . While the new systems of health care may militate against the development of human bonds–the doctor-patient relationship–they will offer more medical care to more people”
This latter sentence of course was not so great a discovery. As time passed, so too did the quality of patient interactions with physicians, a result of times passed more than a result necessarily of personalities. As we strived to accomplish more in less time during the 1970s, we allowed the computer to become the means by which to achieve this goal. As a result we set the stage for dehumanizing health care and turning patients into products more than people.
The computer has greatly depersonalized the doctor-patient relationship that once existed between people and their caregiver. So what does adding GIS to the public health field do for health care? Are we depersonalizing health care more, or providing an opportunity to assign more value to the individual patient?
With this new technology, the least involved of people can now make the computer more a personal object that patients can look up, aspire to with their own health care. The computer makes it up to the patient to interpret how much he/she is willing to take on her own health matters and concerns. The computer also makes it possible for third parties to provide better care to patients, better access to medical records and history for the doctors, and better, more accurate predictions of the way in which population health will be moving during the next decade or two.
In a recent survey I administered to with more than 150 agencies, businesses, and organizations with some reason to be engaged in the use GIS for population health and economic research purposes, none of them were fully committed to the use of GIS for population health surveillance or epidemiological research. Those which did utilize GIS in some way for their annual business reports, tended to contract this work out or produced only a very rough description of their services, usually provided by someone without GIS training and without knowledge in spatial analysis systems.
As a follow up to my poorly supported survey, I engaged in “exploratory interviews” with businesses to see how involved they were with the GIS world. The result of these discussions to data have also demonstrated the non-committal attitude businesses have about the use of a GIS tool. These businesses include the largest businesses in this country devoted to EMR utilization, storage, retrieval, analysis, and selling, as well as the renting of storage space for companies that would like to engaged in data analysis, or the develop of software tools targeting towards industries that would like to make better spatial use of their medical data. To date, even the “biggest and best” medical data industries cannot engage in rapid spatial analysis routines.
The location of Big Businesses involved with Health Care, Health Care Data, HIT, and Big Data, evaluated for their implementation of a regularly operating GIS with the goal of health monitoring and disease surveillance — for each of these, no GIS was regularly used; one company was in a trial and error exploratory stage producing low grade maps. (ESRI, which defines the standards of course, is also displayed but is not included in this review.)
If you were a large business devote to health, and you were to approach any of these HIT companies with the hope of regularly monitoring your region’s population through the weekly or even monthly reporting of mapped data, using this to determine where your money would be better spent, or where a new clinic is needed due to a new high risk population, you are currently out of luck. Such a goal is not possible with the current systems that are out there, at least at the repetitive, multifaceted level. One issue can be addressed at a time in the current systems (many of the above mapped companies can achieve this), but sophisticated or multiple surveillance projects are out of reach for the time being. Neither the hardware, software, knowledge base, intellect, personal skills, imagination, nor desire exist out there in the business world to be able to engage in such a detailed review of people and their health. The biasness against the GIS method of analyzing health goes back decades if not a century or more, when the focus switched from environment and disease to the microbial cause for disease and people, and when the only interventions then possible and needed was the development of adequate quarantine practices.
GIS has been kept on the back burner in epidemiology because knowing how to manage GIS with regard to health requires a new set of unique skills, something which management hasn’t the knowledge base for, nor can it understand all of the values related to such a system. The common attitude seems to be that with advances in our knowledge of medicine, the last thing we need in the health profession according to leader is take on yet another complex specialty, a new skillset that has to be mastered, and a way of applying new math to everything we have been doing quite effectively using the old math techniques.
When it comes to the issue of GIS versus SAS for example, most people who perform population statistics in SAS believe that the current non-spatial, single value for the entire population method is a valid way to do geographical analyses. They provide for us various tables to read and list the towns the researched in descending order, and and then treat this presentation as if it was some sort of geographical review. What’s lacking from this technique of presentation is the topology or spatial relationships of the information being presented. Our eyes and minds have to stroll about the sheets and tables to correlate anything that about nearest neighboring communities, or comparable regions in our districts. GIS automatically incorporates that logic into its analyses–as I have said elsewhere, a single map can tell you what it took your company 50 to 100 pages to print out and never present in a clear concise, immediately educational fashion.
So the overall corporate attitude these past 10 to 15 years has been to dismiss the need to learn and know GIS and spatial statistics. Other at the receiving end are provided reports that are misleading, of limited use as a result of this non-spatial methodology. Whatever money we spend for whatever programs we develop with GIS in mind, we are spending unknown amounts on money for. The lack of a spatial analysis of information up front, prevents the researcher from finding out what he/she spent too much money for later by performing a spatial analysis, even if it is only as an after thought. We need to pre- and post- to know where we went wrong, just one of the two is useless.
So far, the medical community has engaged in everything that Ehrlich predicted 40 years ago in his presentation to AAPSS. The one exception is the last part of this paragraph excluded from the above quote, in which Ehrlich tells us that medicine will also result in the centralization of MD-care, with the placement of assistants to the MDs in rural, less centralized settings, sending whatever data is needed by the MDs to make their final decisions about patient care.
GIS allows for the understanding of people as individuals distributed spatially over time. Medical GIS allows for health care people to learn understand and know where specific problems exist, and where it is likely for others to emerge. The fact that spatial epidemiology has been used in a somewhat limited fashion in the current American health care system tells us that much of the health care field, the health information field and the health information technology field have a lot of catching up to do with what potential is out there for improving the medical system.
This site and most of its projects are aligned with my work as a PhD candidate focused on the idea of linking GIS to standard population health metrics in the managed care business world. This proposition for making new and better use of GIS as part of the current Big Data health care industry does so in such a way that it this new 3D mapping method constitutes disruptive form of innovation. One learns much more about population and areal health than can ever be learned using the standard processes being promoted as part of the new software tools out there.
The dilemma people faced by people who are working in the health care industry is this disconnect that exists between the need for adequate population health programs and social change, versus the needs businesses appeared to be focused more upon regarding earnings, income and their next investors. Grant it, health care is an expensive industry, but it is also a service to the people. Businesses tend to forget this part of their responsibility to the system at large, whenever they start to look at people as costomers, not patients.
Everyone knows the common sense proclamation that states ‘if everyone was perfectly healthy and never in need of care, that the health care world, its businesses, its employees, would no longer exist.’
In some ways, culture makes it necessary for health care facilities and employees to provide the care at these facilities that are needed for these programs to exist. Culture also gives us other avenues to take with regard to care related services. We can be very sick and in need of hospitals, surgeons, expensive drugs, equipment, surgical wards and tissue or organ donations, or we can be very healthy, in need of a smart preventive care provider instead to ensure that we don’t become the next hospital patient. Culture is what defines us as sick or healthy. Culture is what makes us victims of the ward or victims of ourselves and our good and bad habits.