How is “Big Data” going to change healthcare?

I’m sure you’ve all heard the term. Whether it’s being used with technology, finance, marketing, healthcare, and even with gaming. But what is it exactly? You’ll find many different interpretations and definitions, but the one that most resonates with me, and what I believe the actual definition is is this:

Big Data is the collection and availability of multiple forms of data from multiple sources.

So what does that mean specifically to you or me? Well, we are at the cusp of transitioning into a brand new age. Up until now we’ve still been living in the Industrial Age. Business has been focused on creating products and centered on industry. The future is changing however, and up ahead is the Information Age. This new age is seeing integration of technology and data into all facets of business. From healthcare to video games, it’s revolutionizing how we look at our products and services and how we can better market and improve them.

Let’s start with the potential benefits that big data can bring. Multi-dimensional data can be used to collect data from patients to help with everything from clinical trials down to medication adherence. Big Pharma can use these tools to filter out potential “guinea piggers” from trials to help ensure higher quality data. They can also use that information to create more effective marketing platforms for their drugs by improving user interaction and engagement with the company and its products.

Hospitals and doctors can use big data to improve and streamline diagnostics. Social media data can be useful to tell where a patient has recently been or what they ate to aid in diagnosing any potential infections from food or outbreaks of a specific contagion. We may even be able to use this data to minimize the outbreak of a potential new contagion such as the Ebola outbreak into the western world in late 2014 into early 2015. Medicine is entirely based on data. From evidence based medicine to outcomes based medicine, it’s all about the data. So having more data may potentially make medicine both more efficient and more accurate. Think of how much faster we can catch an outbreak of E. Coli or Salmonella when we can see that the first two patients to have contracted the pathogen both posted on Instagram or Facebook about going to the same restaurant earlier in the week, or we see that two patients checking in to two hospitals around the US having both contracted the avian flu were both on the same flight coming out of the same country? While that data may likely raise more questions than answers, it may very well point us in the right direction and help us find the answer faster. It may very well be the next big breakthrough in medicine.

Hospitals and industries are not the only ones to benefit. Pharmacies will also be able to use that data to enhance services. Data from avenues such as social media and wearable tech may help the chains better patient behaviors and narrow down barriers to issues such as medication adherence. There is also the potential to integrate with existing technology to improve patient medication adherence by creating apps that can generate alarms to remind patients when to take certain medications they’ve been prescribed, or how best they can modify their diets or physical activity with reminders or built in phone or web apps that offer coaching or guidance.

On the flip-side of the coin, we have those that would use that data for purposes other than improving healthcare. That purpose would be to build business. Companies such as pharmacy benefit managers (PBMs) such as Express Scripts, Medco, and third party payers, such as the Centers for Medicare and Medicaid Services (CMS). These are in essence insurance companies. Let’s face it, they are a business, and as a business, their model works very well. They may be a proponent for using big data to improve healthcare, but the way in which they will use it is different. They will seek to use big data to enhance data or currently available generics, and drugs that are cheaper for them for buy and reimburse. Their entire logic structure is based on the following:

Why pay much more for a newer drug when the old one works well enough already? 

From a business standpoint, it does make sense. If we already know that the medicine that has been around for decades is already good enough, why should we pay for something that might work better, but is a lot more expensive? And that’s where we have the issue. Insurance companies are the middle of the road people. To them, “good enough” is all they need and want. As the British call it, “cheap and cheerful.” But let’s analyze that term. Cheap AND cheerful? Isn’t that an oxymoron? How can someone be cheerful about getting something cheap? The insurances can, but they’re a giant corporation, not the individual being treated. That, is exactly the problem, they are not thinking of the individuals. To the insurance companies, you are not a person, you are a claim number. Their entire purpose is to take your money, and try to minimize what they pay out. And while I’m not saying that’s right or wrong, because that IS how the business model operates, that needs changing. However, insurance companies using your data against you isn’t the biggest problem, the data itself is.

Not sure what I mean? Well, what is and has always been the biggest problem with technology, and everything that “smart” technology has brought? Not sure? The answer is security, as in privacy. In healthcare, we are talking about patient privacy, YOUR privacy. Whether it’s you have chronic headaches, or you have a debilitating disease, that knowledge is and should be only known to your healthcare providers, and yourself. The problem with using big data, is since nobody really knows how to use it yet, there are ways to get all sorts of information. The risk with that is you may see people or companies use it for more nefarious reasons. Imagine being blackmailed by someone to pay a ransom just for them not to tell your private patient information to your family members, or even worse, put it up on the internet. What would that privacy be worth to you? Would you pay? Worst off, what if your employer could use it to actually monitor your sick leaves or medical leaves? Not a big deal you might think, “because I only take sick days when I’m actually sick.” Well now what if they start polling that data and say that an average person with the flu is only out for 4 days, and if you take more than those allotted 4 days, it is no longer classified as sick? Changes things around does it not? The point, is that when they start using big data against you, there is no end to the limitations that can be imposed upon you.

There are THREE sides to every coin.

Now before you start writing on posters and printing up pickets, remember this, there are three sides to every coin. Don’t think so? Then let’s review. You have heads, tails, and the edge or rim of the coin. Yes, technically that counts as a side because a coin is a 3-dimensional object right? Right. Why did I bring that up randomly? Well, the sides of a coin present a great metaphor what approach you should use to view something. You have the good, the bad, and the line in between. Real life is often never as simple as a yes or no, a true or false. There are usually multiple approaches to the same situation.

Big Data is inescapable. It will change everything. What we need to do though, is try to sift through all the possibilities of big data, and try to separate out what’s useful, from what is not. We also need to take a closer look at what is beneficial, and what steps we can take to prevent data from being used against us. These are all issues we must deal with in the coming years. The first step in my opinion, is that we must try to make preventative steps now, rather than reactive steps later, when it’s too late.

How is “Big Data” going to change healthcare?

Why haven’t robots replaced pharmacists? Or doctors for that matter?

We’ve all seen the movies. Robots replacing humans at everyday tasks like vacuuming the floors, shuttling you around the city, and flying into war zones instead of pilots. Except, it’s no longer just a cool idea or concept, it’s happening for real. So, why isn’t it happening in healthcare? Well, in fact, it is, but with exceptions.

With technology becoming more advanced and accessible, it is becoming easier for businesses to find ways to streamline their standardized tasks and make their workflow more efficient. With healthcare, using technology can improve accuracy as well as increase efficiency in many tasks. So why don’t you see a robotic pharmacist or doctor? Let’s take a look at some of the reasons.

The personal touch

Perhaps one of the biggest things that people take for granted is the personal touch, or bedside manner as you will have it. It’s not easy for a medical professional to tell people the bad news that they don’t have long to live. Machines cannot express emotion, because they do not possess emotion. While you may think that you don’t need a pharmacist to express emotion, many patients find solace and comfort in asking medical questions they feel that the doctors will not give them an answer, or they just value a second opinion. If you’ve read my other posts, you’ll know that pharmacists are drug specialists. We know more about the medication than the doctors, because that’s our job. So when it comes to a question about medicine, the pharmacist is the one you ask. Yes, you can google or ask some software your medical question, and yes the responses are most likely what the pharmacist or doctor is going to tell you, but it’s the human touch makes all the difference in comforting or reinforcing the patient’s decision to continue or discontinue the medication.

Can a machine make the right judgement call?

The principle trouble with machines and technology is that they cannot inherently make a judgement call. And until we develop true artificial intelligence, even machine learning can only make a decision based on statistics. Trouble with that is that human life cannot boil down to statistical decisions. The best a machine can do is to run a statistical assessment of whether or not this will work, and even with machine learning, we have yet to be able to find that software can take all other variables into play when making a decision. I’m talking about decisions such as eating habits, medication adherence, and the little things in daily life that may affect how a person may or may not take their medicine. While we are finally able to start collecting such data, not everyone will welcome the intrusion in privacy, and that will pose a challenge to machine automation.

Another issue with the lack of judgement is, at what point will the machine outweigh the risk vs benefit? Because a machine does not understand pain, have compassion, or express emotion, it cannot judge discomfort for each individual. So how can we expect a machine to make the decision to dispense a medication to a patient or consult the doctor to discuss a potential alternative therapy? What will be the data driving those factors? And who will control the decisions based off that data?

Who is truly in control of your healthcare? And why does that matter with replacing pharmacists and doctors with robots?

The answer is… third-party payers, or your insurance. In truth, doctors and pharmacists have very minimal control over what medications you get. We constantly are being shown new drugs on the market that are promised to be more effective than older ones they are replacing. But that’s doesn’t mean you’ll get those drugs. Why? Because your insurance is ultimately making the decision in what they will or will not pay for. With the advancement of technology, we are able to collect more data from patients. While we as scientists and healthcare professionals may use technology try to improve our ability to treat our patients, not everyone in the industry will use that data accordingly. Why does this pose such a problem? One of the biggest fears of using multiple sources of data, or “big data” in healthcare, is that the insurance companies may use that data against you. They may use your disease conditions to lock you out of specific plans that you may otherwise have qualified for in order to get coverage to treat your condition.

System flaws in technology

Everything in science is data driven. And the improving technology is a welcome addition in collecting more data. However, technology and data by itself is not enough of a factor to replace a human with a machine. In healthcare, we should be using technology to work with us, not replace us. We also have to be extremely careful with data in healthcare, because patient sensitive information is at risk. Technology always has security risks, and having more data also increases risk. There is also the risk of manipulation of data. Human beings are able to interpret data, but do not make decisions only based on data. As brilliant a machine or computer can be even with machine learning, it is simply collecting more data in order to make a better statistical decision. If someone were able to manipulate that data to provide false data, then we may potentially create more problems than we are trying to solve.

Looking forward into the horizon

In the end, technology is a double-edged sword. There is limitless potential, yet also the potential for limitless destruction. it is up to humanity to step in and help modulate and decide how we apply technology, and to what limits we do so. Automation with robotics and machines may work great for many industries, but in healthcare, it can never truly replace people like doctors, pharmacists, and nurses. That’s because there is always going to be risk for system malfunctions and failures. Would you go to a hospital or clinic that only had robots and machines instead of doctors and nurses? Or a pharmacy that had a robot behind the counter and machines whirring around counting your medicine? Do you really think that machines and software are that trustworthy and without system flaws? I’ll leave you to think about it until next time.

Why haven’t robots replaced pharmacists? Or doctors for that matter?

Why does it take so long to fill a prescription?

Ah, the million dollar question. I can’t even count how many times I hear a patient ask me that question. Let’s stop for a second and go over that question. Why does it take you however long it takes in your line of work? If you say you can do it instantly, then stop and ask yourself what happens when you have to work with a team and technology. If you still say you can get it done in seconds, then I would love for you to share your story as to how you can be so efficient working with variables outside of your control.

Human beings are not robots, we cannot possibly be more efficient or faster than something mechanical that’s created specifically to accomplish a task it is designed to be efficient and fast at.

But I digress, so let’s get back to the issue at hand. People do not see all the other things that are going on while we are filling their prescription. And that can be answered really with just one statement. Because that person is only focused on themselves and their prescription. I don’t blame them, that’s just how human nature is.

“I just want my prescription, why does it matter to me what the other people are waiting for or dropping off. My time is valuable and my prescription should be done immediately.” 

That’s the general mentality of patients dropping off prescriptions. So much so sometimes they are surprised when I tell them that there are X many patients ahead of them.

The retail pharmacy business model works like this. When a patient comes to drop off a prescription, we ask them their information so we can pull up their medication profile. If they have no profile with us, we generate a new one, which takes extra time. Then we take their prescription and ask them if they are waiting or coming back. Here I believe is a potential point of improvement. When we ask if they are waiting for it, we are asking if they plan to physically wait for the presctiption at the store. What the patients are hearing however, is more to the tune of yea they will wait for it while they go accomplish other tasks such as shopping or going home to cook a meal. We as pharmacy staff cannot put in any other option than waiting or coming back so we give the patient the benefit of the doubt and assume they are actually waiting. When enough patients do this, wait times start piling up.

But wait, we’ve only gotten to step two of filling a prescription. There are four more to go. The next step is to type up the prescription and submit it to the insurance companies. Too often patients assume that we are the insurance or we directly control the copays for their medicines. The reality is that we have to type up the prescription and verify all the information is correct before we can submit the claim to be billed. Sometimes the insurance adjudicates the claim in seconds, and sometimes it doesn’t adjudicate at all. When the insurance doesn’t want to pay for it, we enter the dreaded prior authorization or drug not covered realm. This means the insurance believes the patient does not need to be on this therapy, and they prefer an alternative therapy that’s usually cheaper. It also requires extra time since in that situation, we must call the insurance and/or doctor to try to remedy the situation. We rely on internet connectivity and technology to aid us with this. It’s not the same as the doctors office calling the insurance to find out the copay for a procedure. We have to ensure all the information is correct because we are not directly administering the medicine to the patient unlike the doctor performing the procedure so there is a lot more that must be monitored and regulated.

Once adjudication is complete, and we get a paid claim, we can finally start filling the prescription. Now your prescription joins the stack of prescriptions that we are already working on. Most of the time we can actually fill your prescription within 30 seconds at this step. However, we’ve already spent a few minutes working just on your prescription to get thus far. Combine that with all the other patients also expecting to get prescriptions and you’ve got a recipe for frustration.

Almost done now, we get to the step where the pharmacist has to verify your prescription. I know most people here are thinking, we’ll wait a minute… Why didn’t this happen while they were typing up my prescription. Well technically, it did. However, we have to double check ourselves all the time. We do this because we are the last line of defense before you get the medication and we want to ensure you don’t get something that might hurt you. Here is where we take a closer look at the medication and dosage and try to ensure that not only the prescription was typed in and filed correctly, but also therapeutically appropriate. We also look at your med profile to make sure there are no drug interactions. If there are, we will intervene and follow up with the prescriber.

Oh you thought our job was to only lick, stick, count, and pour? Well, so does everyone else. 

Everyone agrees that times change right? The practice of pharmacy is no exception. Just like doctors, pharmacists are trained in medicine. The key difference is this: doctors are trained to diagnose the problem, while pharmacists are trained in which drug therapy is the most appropriate. Most people are not aware that pharmacists have now been upgraded with the additional specialty knowledge to join doctors as part of the medical team. Clinical pharmacists are now paving the way to more effective healthcare by being able to cut out some of the guesswork that prescribers used to have to deal with in terms of drug treatment. In working together with doctors, nurses, as well as the rest of those associated with providing healthcare, we have helped streamline the treatment process.

So finally, after we have done our final checks to make sure your prescription is both correct, as well as appropriate, we can finally dispense it to you. Did it take longer than your “can’t you just pull it off the shelf and give it to me?” Yes it did, but at least now you know why. Because we care about your health.

Why does it take so long to fill a prescription?

What’s the difference between brand and generic? Really?

source: fda.gov

As a practicing pharmacist, I get this question a lot. And here’s the honest truth; it depends. But before we go into that, you first have to understand what a brand medication is. I can already hear you saying to yourself, “Well, that’s the original and everything else is a copy.” Well, yes that’s true, but that’s not the full picture.

Here’s really how it works.

From the moment a pharmaceutical company finds a potential chemical that they think may have success as a drug, they will patent it. The patent protects them for 20 years, and within that time frame, the pharmaceutical companies must conduct all research and development on that chemical to provide to the FDA for approval, as well as figure out logistics and marketing data. Realistically, by the time the drug is actually FDA approved to be sold, the life on the patent is down to only about 7-10 years. That’s the first time the company can actually start making money off the drug.

Once the patent runs out, other companies can legally create the same drug, which is called a generic. There are actually two different kinds of generics, branded, and unbranded. For now, let’s focus on the generic class as a whole. So what’s a generic drug? How is it different from the brand?  A generic is chemically identical to the brand, meaning the active ingredient has to be the same as the brand. What can be different however, are the rest of the components, ie. the fillers.

Does that mean that all generics are as good as the brand? Not necessarily. While the vast majority of generics are just as good as the brand, there are exceptions to the rule. People with very sensitive digestions, or drugs with a very narrow therapeutic index (NTI) should stay with brand medications. There are also studies that have shown certain medications like Synthroid, have a difference in absorption between brand and generic. For those people that have been on brand, they should stay on brand. Or if they are thinking of making a switch to generic, they should start with a trial of generic for a month first.

I’m not advocating that patients only stay with brand. Generics offer for many a cheaper alternative to getting a more effective therapy to treat their conditions. Newer medicines are created to be more effective than older medicines or designed to have less side effects. Once these newer therapies go generic, it creates an opportunity for patients to transition to a possibly more effective medication for little to no additional cost.

To wrap up, I am not advocating sticking with brands when generics are available. I believe both brands, as well as generics, have their place in treatments for patients. It’s up to each patient and the healthcare team they work with to find the right therapy for them. At the end of the day, no amount of data is going to be able to tell you how one medicine or another is going to work better for you. It’s up to you to find that out yourself. That is why medicine is a practice, not an art. Each individual is unique, and must be treated on an individual basis.

What’s the difference between brand and generic? Really?