eHealthcare Kawaraban

Do Not Challenge the Right to Command of the Physician

2011-09-02T21:48:00.005+12:00

Sun Tzu said, "If the opponent is occupying the strategic point (contentious ground) whose possession decides the dominant side in the battle, do not attack it."

This is especially true for a health IT project where a physician in a senior position is taking leadership role.

Of course, we should challenge any notions technically make no sense, but all of the stakeholders would be better off by simply letting the physician take the lead.

The physician is trained to be a leader in healthcare, so naturally feels most comfortable in a leading position.

Challenging the position would cause serious consequences as the physician fights for dear life to defend it. That would certainly be a losing battle for you except you are yourself a physician. What on earth is worth for it in health IT project management?

Let's concentrate on more productive things.

Ray Murakami

Do not halt at the fringe of healthcare world

2011-08-24T23:30:00.004+12:00

After departing from the comfort of the technical territory, the next challenge for an IT technician new to health IT would be testing the water of the field of medicine.

For anyone who are not from healthcare background, the hospital is a place you won't visit unless you are, or someone close to you is, in a deteriorated health condition, in other words, ill. Sometimes this makes interesting effect. Even if you are totally healthy you may feel ill just because you are in a hospital!

My advice is follow the maxim of Sun Tzu, "If you have entered enemy territory but not proceeded deep into it, that's facile ground. Do not halt there."

In fact, just visiting a hospital would not increase your knowledge about healthcare considerably. You need to more proactive to start learning something about medicine. Escorting your nanny to regular check-ups would not make you any closer to put "health" before your IT specialist title.

Ray Murakami

First, leave the comfort of the techy home territory

2011-08-23T19:31:00.006+12:00

As a health IT analyst having informatics as the primary expertise, there is one thing I have kept in my mind: never assume myself to be a technical expert, but commit to be a professional in healthcare.

Thus I have followed the maxim by Sun Tzu, "Never fight in your home territory. It's the dispersive ground where you can't keep the formation and morale."

If I resort to the position of a technical expert in general informatics, I would risk my focus to miss the ultimate costumer, the patient, by talking about the aspects only inside of computers and networks.

I have seen lots of health IT technicians who concentrate only on IT issues and are hesitant to leave their home territory. They made me feel left alone while we are talking with clinicians on technical issues. That's really the dispersive ground.

My tactics is refraining to use technical jargons as far as possible and introducing clinical examples as much as possible. That would move the battle ground a bit away from the technical ground and closer to the healthcare side where the clinicians and patients reside.

My personal observation is that most of the failed health IT projects have been fought on such dispersive grounds, intensively technical territories.

Ray Murakami

Revisiting Sun Tzu's Nine Grounds - This time Informatics meets Medicine.

2011-08-22T18:33:00.005+12:00

Sun Tzu said, "The history has seen clumsy victories by hurried hands, but never a perfect win by wary hands."

I am afraid that my blog is becoming another proof of his claim. So I will change my strategy to seek speed rather than perfection.

Since the last update, I have been studying at a postgraduate programme of health informatics and learned a lot. I would like to put them into the context of The Art of War by Sun Tzu.

To begin with, I am going to revisit the "Nine Grounds". This time from the proximity to informatics to the very heart of medicine.

This is also a challenge one of my lecturers put on me by pointing out that I am still playing safe in the realm of health informatics.

OK, let's start diving into the hostile territory :)

Ray Murakami

Interpreting Sun Tzu's "The Nine Situations" (1) Dispersive ground: Primary Care

2010-09-29T20:35:00.006+13:00

To illustrate the relevant strategies according to the occasions, Sun Tzu categorised the battle fields into nine categories. He dedicated a whole chapter to describe them, the eleventh chapter titled "The Nine Situations" in his "The Art of War".

Sun Tzu said, "The art of war recognizes nine varieties of ground: (1) Dispersive ground; (2) facile ground; (3) contentious ground; (4) open ground; (5) ground of intersecting highways; (6) serious ground; (7) difficult ground; (8) hemmed-in ground; (9) desperate ground."

Interestingly, they can be well interpreted within the healthcare context. In this issue, the first situation "Dispersive ground" is interpreted as Primary Care.

Firstly, look at the definition.

Sun Tzu said, "When a chieftain is fighting in his own territory, it is dispersive ground."

The chieftain who fights battle can be assimilated to a healthcare professional and a patient as they fight against diseases. In a primary care setting, a healthcare professional is a general practitioner or a primary care nurse who plays its role in its own territory. The patient is provided healthcare service in the proximity of its own community.

So far so good. Then secondly, what about strategy there?

Sun Tzu said, "On dispersive ground, therefore, fight not."

Because of proximity of the battlefield to home, soldiers rather run away than taking risk of fight. In healthcare context, a patient would not tolerate heavy stressful treatment or intervention. So in the primary care setting it would be wise to concentrate on prevention and health promotion rather than intensive battle against diseases.

The final words for this situation.

Sun Tzu said, "On dispersive ground, I would inspire my men with unity of purpose. "

In Primary Care setting, definitely this is very important point. The general practitioner and the primary care nurse should be informed of latest best practices and the awareness and participation of patient should be encouraged and supported by adequate information in the same purpose of lifting health.

So what should be dispersed here are the proper information and knowledge, not the people, or even worse, diseases.

The English texts of Sun Tzu's 'The Art of War' are from The Project Gutenberg eBook, The Art of War, by Sun Zu

Interpreting Sun Tzu's "The Nine Situations" within the healthcare context

2010-06-14T15:24:00.009+12:00

Interestingly, they can be well interpreted within the healthcare context. I will explain each variety of ground in each of following articles, but I would like to do a quick walk-though of "The Nine Situations" interpreted as nine clinical settings.

(1) Dispersive ground: Primary Care

Sun Tzu said, "When a chieftain is fighting in his own territory, it is dispersive ground." In a primary care setting, a general practitioner or a primary care nurse plays its role in its own territory and a patient is taken care in its own community.

(2) Facile ground: Day Surgery/Short Stay

Sun Tzu said, "When he has penetrated into hostile territory, but to no great distance, it is facile ground." In a day surgery/short stay setting, practitioners only perform non to minimally invasive care and a patient is admitted to the facility in a short period of time.

(3) Contentious ground: Open Clinics

Sun Tzu said, "Ground the possession of which imports great advantage to either side, is contentious ground." In an open clinic setting, the practitioners within a contract can utilise advanced equipment in the same open clinics and a patient can consult a number of services in the same location.

(4) Open Ground: Mobile Care

Sun Tzu said, "Ground on which each side has liberty of movement is open ground." In a mobile care setting, practitioners are equipped with an outfit which enables to provide health services anywhere practical and a patient have a choice where to receive services or sometimes portable devices do the job anywhere the patient carries them around.

(5) Ground of intersecting highways: Multidisciplinary Care

Sun Tzu said, "Ground which forms the key to three contiguous states, so that he who occupies it first has most of the Empire at his command, is a ground of intersecting highways." In a multidisciplinary care setting, the service includes multiple specialities and significant health outcomes can be achieved if an integrated management established there.

(6) Serious ground: Secondary Care

Sun Tzu said, "When an army has penetrated into the heart of a hostile country, leaving a number of fortified cities in its rear, it is serious ground." In a secondary care settings, practitioners perform invasive procedures which requires hospitalisation and a patient need to be admitted in a hospital with advanced facilities for both treatment and daily life. A large hospital is often described as a little city.

(7) Difficult ground: Tertiary Care

Sun Tzu said, "Mountain forests, rugged steeps, marshes and fens--all country that is hard to traverse: this is difficult ground." In a tertiary care setting, specialist cancer care, brain surgery and burns care - difficult cases which require personnel and facilities for special investigation and treatment are treated.

(8) Hemmed-in ground: Intensive Care

Sun Tzu said, "Ground which is reached through narrow gorges, and from which we can only retire by tortuous paths, so that a small number of the enemy would suffice to crush a large body of our men: this is hemmed in ground." In an intensive care setting, a patient can only be revived by tortuous paths, so that a small change of conditions would suffice to damage the whole body systems.

(9) Desperate ground: Emergency Medicine

Sun Tzu said, "Ground on which we can only be saved from destruction by fighting without delay, is desperate ground." In an emergency medicine setting, we can only be saved from treatments performed without delay.

How do you think of them? As Sun Tzu's categorisation is based on literally "invasiveness", "intensity" or "going how far" to fight the battle, it would be natural to be able to find equivalents in the healthcare context. You would see more of interesting correspondences as we study closer each variety of the battle grounds.

The English texts of Sun Tzu's 'The Art of War' are from The Project Gutenberg eBook, The Art of War, by Sun Zu

The Angel in While Was a Competent Mathematician

2010-05-25T00:37:00.013+12:00

One day I opened the web site of a local bank to check my account balance to find an advertisement that amused me. It read:

Banks should only treat you like a number if your mum named you "00-1247-6578-000."

Similarly I have heard a radio advertisement of personalised car licence number plates which goes like this:

If you don't call the dog you love "BCD345", why do that with your car?

Then what do you expect from nurse stereotype as "an angel in white" with regard to treating her client? It would be far from treating you like a number, wouldn't it?

Surely so was the original "the Angel in White", Florence Nightingale in the legendary service in the Crimean War but actually she was also a competent mathematician.

Sun Tzu said, "Many calculations lead to victory, and few calculations to defeat."

Her approach to patient care was based on statistical evidence and she was more a strategist than a tactician as an epidemiologist. So her victory was brought by many calculations as well as her dedication.

The English texts of Sun Tzu's 'The Art of War' are from The Project Gutenberg eBook, The Art of War, by Sun Zu

If Sun Tzu was around Today, He would be a Promoter of Immunisation Programmes

2010-03-01T21:53:00.009+13:00

Although the medical and scientific evidence suggests that the benefits of preventing suffering and death from infectious diseases outweigh rare adverse effects of immunization, governments around world are struggling to roll out immunisation programmes effectively.

Anti-vaccination movements in some countries have been so strong enough to jeopardise not only the specific immunisation programmes but also the whole research and development activities. Sadly my home country, Japan is one of the most significant in this regard, considering the potential contributions in this particular field which otherwise should be made by the country.

Many critics are from the fields of natural and/or holistic medicines mostly based on traditional wisdom. I think the very idea of inducing a cunning enemy itself, even after converted or neutralised, into our bodies to fight against its former friends contradicts our intuitive knowledge.

However, one of the best known traditional wisdom may be fully supportive to immunisation programmes.

Sun Tzu said, "The enemy's spies who have come to spy on us must be sought out, tempted with bribes, led away and comfortably housed. Thus they will become converted spies and available for our services."

When I hit upon the idea that healthcare as warfare against health problems is also based on deception, this phase came upon and I realised that immunisation was taking the same steps.

We identify the infectious agents, cultivate them as they are isolated and contained. Finally they are made into or used to create immunisation agents which are available for our immunisation services.

So if Sun Tzu was around today, I would not surprise seeing him to act as a profound promoter of immunisation programmes.

The English texts of Sun Tzu's 'The Art of War' are from The Project Gutenberg eBook, The Art of War, by Sun Zu

What you mean by Diagnosis

2010-01-20T16:04:00.007+13:00

Sun Tzu said, "If you know the enemy and know yourself, you need not fear the result of a hundred battles."

This is a very famous saying and probably you have already heard about in some forms.

The same applies to outcome of medical treatment. What matters is whether the diagnosis is right or not. The word diagnosis comes from Greeks, dia- (through, complete) and gnosis (knowledge).

Once the right diagnosis is made, it means complete knowledge of the enemy (disease and related condition) and yourself (various constraints on medical practices) is available. Then you need not fear the result.

Sun Tzu said, "If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle."

Let's hope next time we receive a diagnosis, that it actually means "complete knowledge."

The English texts of Sun Tzu's 'The Art of War' are from The Project Gutenberg eBook, The Art of War, by Sun Zu

Can you win all of your battles?

2010-01-17T09:42:00.014+13:00

Sun Tzu said, "To fight and conquer in all your battles is not supreme excellence; supreme excellence consists in breaking the enemy's resistance without fighting."

We boast of miracles that modern medicine made possible but these miracles require victims of predicaments to be cured in the first place. It would be better if these conditions do not happen at all.

As we discussed earlier, healthcare is warfare, and based on deception, it is the best if we do not need to mobilise its forces. Particularly any invasive interventions are to be avoided or minimised where possible.

Being healthy without any professional care is, no matter how unachievable it would be, the ideal. Then Sun Tzu also told us, the way to get closer to this ideal.

Sun Tzu said, "The good fighters of old first put themselves beyond the possibility of defeat, and then waited for an opportunity of defeating the enemy."

As though Sun Tzu foresaw recent emphasis on preventative medicine. The better you prepared to fight, the less you actually forced to. You would ultimately be able to defeat or subdue the enemy without any fighting.

Si Vis Pacem, Para Bellum - If you wish for peace, prepare for war. But it is not about piling up weapons but about elaborating strategies.

The English texts of Sun Tzu's 'The Art of War' are from The Project Gutenberg eBook, The Art of War, by Sun Zu

All warfare is based on deception, so is healthcare

2010-01-14T23:35:00.014+13:00

Sun Tzu said, "All warfare is based on deception." If it is followed by "So is healthcare." you would not believe it.

As you would not be buying medical paternalism which was so dominant in earlier times, you may argue against it by pointing recent emphasis on informed consent, patient/customer satisfaction, self-control and medical ethics.

But I think this notion is still quite relevant especially in terms of professional healthcare services. However the point is what should be actually deceived.

Of course, the health practitioner and the patient/customer should build mutual understanding to achieve the best results so this is not the case. Then how about their common enemies? Undesirable health conditions and the causes of them are what we should deal with deception.

Why with deception? Because when professional interventions are called for specific health conditions, they are already beyond human's natural coping mechanisms against physical, mental and social conditions. We have to deceive the agents causing implications to neutralise them and we also have to deceive our own defence responses against them to prevent overreaction or to revert irresponsiveness.

In fact, all medical interventions are outright criminal acts if administered by a person without credentials.

Like the enemy we fight against in war, the cause of our health problems are merciless to us. So we fight against them based on deception.

The English texts of Sun Tzu's 'The Art of War' are from The Project Gutenberg eBook, The Art of War, by Sun Zu

New Year's Resolution

2010-01-13T08:30:00.007+13:00

Just a few posts in last year, I would write much more often this year.

My Quest for the Holy Grail of Health Informatics has been not easy, but showing some progresses. However, there are some difficulties in writing these developing stories as blog posts, so I will take a bit different approach in this blog from now on.

Have you ever heard of Sun Tzu's 'The Art of War'? I recently read through it and watched a TV programme on History Channel featuring this ancient wisdom. I was really impressed by its comprehensiveness and relevance for over 2,400 years and even today, with regard to winning over merciless enemies.

Healthcare is literally 'a matter of life and death' as Sun Tzu perceived the art of war. In fact, it is a war we cannot afford to lose and 'a road either to safety or ruin' not only for a person but also for a nation.

As Sun Tzu dedicated a whole chapter to the intelligence, it is of crucial importance in healthcare, too. Health Informatics is what it is all about.

So I would like to discuss applications of the principles from 'The Art of War' into Health Informatics and/or Healthcare itself here. I am already brimming with ideas on the excerpts to put here. I hope you enjoy them, too.

The English texts of Sun Tzu's 'The Art of War' are from The Project Gutenberg eBook, The Art of War, by Sun Zu

It's Not a Pulp Fiction: Never Underestimate the Power of Paper

2009-09-09T19:25:00.009+12:00

This year I had a several chances to visit medical/dental clinics for check-ups.

My home doctor and dentist are using fully electronic medical/dental record systems (EMR/EDR), so my records are kept electronically and virtually nothing on paper. Even an X-ray image has been sent online. As a result, I don't have to carry a large brown envelope containing my records with a referral letter.

No wonder New Zealand ranks among top countries for primary care electronic health record adaptation. Then, are they paperless systems? No, I have whole lots of pieces of paper they printed out. Mainly bills and receipts and appointments. Maybe they could be substituted by email notifications. But I can bet I would be printing them out instead.

Once I really tried hard to get along without any paper at my work as health IT analyst. I felt obliged to do so as I was advocating "paperless" systems. But I had to throw away that practice eventually. It was just not practical. So I would never recommend it to health practitioners especially if they are to take care of me!

The power of paper should never be underestimated. It is said that we are using more paper than ever as IT adaptation become dominant. It quite matches my own observation. Actually the more IT advances the more useful and attractive its paper output becomes. So it gets just more and more irresistible.

Frankly speaking, in healthcare settings, physical cost of paper (and ink) is negligible compared with other significant resources. If a pack of paper can make difference in a life-and-death situation who cares its cost? What actually matter and should be reduced are the operational costs and potential errors in handling paper, not paper itself.

So I would like to propose a more accurate phrase to represent our practical goal: Paperwork-less EMR systems.

It All Began with a Request from Arthur

2009-08-24T20:22:00.006+12:00

His name was Arthur. He was my guru. He was the one who lead me to this path. I made my debut to the world of health IT standardisation as his potential successor.

His request to me was quite simple:

Look for the standard CONTENTS for comprehensive electronic medical record system (EMR), not for standard FUNCTIONALITY of EMR.

For over a decade, I have managed to survive and become a someone out of a novice at that time. The word for that kind of systems has changed over the time, EMR to EHR (Electronic Health Record) and then to PHR (Personal Health Record). It was lucky for me to be given the right initial direction. Because of it I have not gone off the course so much.

After all, functionality is about what the health provider as a user should do for the system to do his/her job. On the other hand, contents are about what the system has to offer to help to get his/her job done.

Without contents, the user with professional knowledge should administer every single command for the system in every detail. With common best practices as contents, the system can navigate the user through the complicated functionality according to his/her initiative.

Functionality attracts the user at the first look, but the beauty is found within contents. But how can we create such contents? We have to explore further to discover the answers.

Quest for the Holy Grail of Health Informatics

2009-08-20T18:08:00.010+12:00

I dedicate this particular post to my best mate, Lindsay.

If you are young enough, one morning after some decades, you may wake up to find a news headline like this:

The First Computer Scientist to Win the Novel Prize in Medicine:

--- for contributing to a grand breakthrough in medicine by designing the huge information anomaly detector dubbed as "Super-Kamiokande of Medical Science" which was essential for the discovery ---

Sounds like a cheap science fiction? Or a daydreamer's fantasy?

But there is one thing which some experts think might be able to make it happen.

Universal Semantic Interoperability - some call it Unified Field Theory of Health Informatics - which enables:

Whom - any humans from any backgrounds and any machines from any makes
What - to communicate and understand the healthcare information between each other
How - in full extent and depth, over ages and beyond generations to come.

Here begins the saga, the quest for this Holy Grail of Health Informatics.

Hopefully it is not a fiction, but a real-time documentary.