Digital transformation

Ever since the industrial revolution, there has been a fear of machines taking over our work and medicine is no different. There can be a feeling among digital health enthusiasts that doctors are anti-innovation and that they will have to reinvent them or be left behind. Nothing further from the truth in a profession where life-long learning is part of the course

Listen to this as a podcast courtesy of the IFMiL or Catalan Institute of Medical Education and Leadership.

Ever since the industrial revolution, there has been a fear of machines taking over our work and medicine is no different. There can be a feeling among digital health enthusiasts that doctors are anti-innovation and that they will have to reinvent themselves or be left behind. Nothing further from the truth in a profession where life-long learning is part of the course and having to think on your feet with every patient is the norm. What is true is that clinicians need to see a validated use for digital health solutions, and that may not be the use that the developers initially had in mind. Another aspect is that there is the mantra “first do no harm” is never far from any clinicians” mind and that reticence to adopt new technology is often coupled to a very real and not theoretical realisation that it is people’s life and health which are at risk if they don’t work. Every medication prescribed has been through a stringent, ongoing safety process and even then, as we sign digitally or with a pen, we do it knowing that is always a risk-benefit balance to our decision. It is not a dinosaur mentality which prevents clinicians unthinkingly adopting every new shiny digital health solution we are presented with. Instead, it is our primary function of being the patient’s advocate and therefore making sure the risk-benefit is in their favour.

Digital health technology, including lifestyle apps, don’t require clinical evidence to be released, and the need for them to be regulated, is discussed in episode 1 of this third series. Digital medicine software or hardware that intervenes and measures human health do need clinical evidence. Furthermore, when it comes to digital therapeutics, in which the technology delivers an intervention, that evidence needs to be not only clinical but also based on real-world outcomes.

Getting the clinicians onboard.

This leads to the question; how can we get valid digital medicine solutions into our daily practice? This is something at which Dr Cesar Morcillo at the Sanitas hospital in Barcelona has been looking. He argues that this is our opportunity to make the change to patient-centred care, and also to expand it to health workers who, as we are seeing in the current pandemic, can quickly become patients in themselves. The power of these digital solutions, whether on the ward in the hospital or at home after they have been discharged, is the ability to relay the information 24h not just the snapshot of time the doctor and nurse are at the bedside. Digital solutions have to be agile and responsive to patient needs. Aim for a good enough attitude to the first version, which is perfected in response to feedback from real patients and clinicians. This feedback needs to be complemented with data and evidence-based. The ability to harvest patient data and work with it in this way directly benefits the patients to whom the data belongs. Medicine is not a solitary practise and working in a transversal manner with other teams leads to better integration of digital health solutions. It also leads to improvement as they too will feedback on what works and what can be done better based on their expertise.

If the mindset is that of “improving a service rather than implementing a technology”, the introduction of new digital solutions is more likely to be successful.

Real-world examples.

Often successful innovation comes from HCP themselves. Being best placed to see the problem first-hand, they can then suggest solutions which work for their population within the framework of the services they already offer. One example of this is the fracture clinic at the Royal Sussex County Hospital in Brighton, England. A physiotherapist and an orthopaedic surgeon have saved the NHS over half a million pounds by enabling fracture and soft tissue injuries to be followed up virtually. As an EM doctor, I would see patients in the ED, x-ray if necessary, treat and discharge and then the patient would previously have had to come back to a fracture clinic at a hospital with terrible parking and access. Even more complicated for patients with injuries which decrease their mobility. Now, their details would be entered into the virtual fracture clinic referral with all contact details, physical examination and management plan from the ED. All of these patients get reviewed within 24h and receive a video message from the consultant or phone call. Further follow-up can also be virtual. Only patients really needing face to face contact have to come in. An example of innovation from within, this system has been extended to other hospitals. Although this is a model that existed in other parts of the world, the fact that it was introduced by colleagues and not externally, giving a real solution to a real problem meant that the uptake was smoother. All hospitals, whether in Spain or the NHS, have an innovation team. They are tasked with helping clinicians to transform their clinical solutions into reality. They have the experience and team to support clinicians who may otherwise be reticent to take on the non-clinical aspects of digital transformation. If you have an idea, it is worth contacting them even if you don’t want to take on the project yourself. As a practising clinician, you are best placed to see what problems and frustrations affect your day to day practise and offer suggestions for solutions from within.

Conclusion.

COVID-19 has accelerated the acceptance of digital health technologies, as has been mentioned in previous episodes. Telemonitoring and video consults are becoming the new norm, and there will be no turning back. As Eric Topol says, “Machines won’t replace physicians, but physicians using AI will soon replace those not using it.”

The digital doctor’s bag.

Listen to this as a podcast courtesy of the IFMiL or Catalan Institute of Medical Education and Leadership.

When you think of the traditional image of a doctor outside of the hospital or the consulting room, he or she always carries a bag. Much like Mary Poppin’s carpet bag, it is full of magical instruments. Apart from a stethoscope, this could also have included a sphingometer to measure the blood pressure and maybe a couple of syringes to administer an all curing medication. Times have changed, and today we have different instruments, but their objective remains the same: to be a diagnostic aid at the bedside. This is especially true in rural and remote areas where a transfer to a local hospital may be complicated and time-consuming. However, it is also true for patients with decreased mobility in an urban setting. These are the patients who already receive the home visits instead of coming in to see their GP at the surgery.

The concept of the digital doctor’s bag describes a combination of digital medicine devices linked to a smartphone or tablet. It also includes decision aid apps and even the EHR or electronic health record. The EHR means that the HCP has access to all the patient’s notes and results on the go, even those of other specialists.

Emergency visits, whether by a GP or a prehospital service, also benefit from having a digital doctor’s bag. This may mean the difference between transferring a patient to a hospital or keeping them at home. The obvious example is an ECG being recorded and being sent straight through to the cath lab and cardiologist on call. If the patient doesn’t fulfil cath lab criteria, they may well be transferred to their local hospital instead of being sent further afield. But some of the devices are used by the HCP in situ. The portability and decrease in the cost of hand-held ultrasound machines have made them very much more accessible. Ultrasound does remain operator dependant and rule in not rule out. Traditional stethoscopes are replaced by digital stethoscopes which record and analyse heart sounds to provide a visual representation. Listening then becomes optional. Portable spirometers as an add on to a smartphone which then adds the information to the patient’s own records can reduce clinic visits for chronic patients. They can also empower patients to identify and manage their exacerbations in combination with their HCP at a distance.

Digital dermatoscopes are another welcome addition to the doctor’s bag. Working with high quality augmented images, you can diagnose yourself, send to dermatologist colleague for a second opinion or even let the AI do it for you. In 2018 Haenssle et al. concluded that deep learning convolutional neural networks outperformed even dermatologists when it came to melanoma identification(1) and that all HCP no matter what their level could benefit from this technology.

Telemedicine – a brief introduction.

Listen to this post as a podcast instead.

What is it?

Telemedicine is, as its name explains, medicine at a distance. This can be synchronised in time with both doctor and patient being in contact at the same time or asynchronous with a time lag. Telemedicine has existed in one form or another as long as doctors have. Currently, telemedicine is usually understood to mean phone, email and video calls. A local example within the Catalan EHR is the e-consults where patients can email their doctor and receive a response within 48h working hours.

Advantages and disadvantages.

Like all technologies, there are pros and cons. In these times, especially, the lack of direct face to face contact is a basic infection control measure. A recent Cochrane review concluded that there were probably economic savings to be made, although there is generally a lack of evidence at this point(1). Savings can also be non-monetary. A Michigan geriatric service went from 0 to 91% of their visits virtually in the space of 5 weeks. They calculated that during this time that over 1135 travel miles had been saved with an average of 24 miles per virtual visit which probably reflects the geography they practise in(2).

However, telemedicine does have its detractors or at least those who point out that we should exercise a certain level of caution. The first point is the same as our first cited advantage, the fact that there is no contact.  Many physicians feel that the face to face and indeed hand to body part of their interaction is fundamental. They struggle with the thought of not having this part of the consult available. In another podcast, we will look at the digital health tools which are available to overcome at least in part this aspect.

Another negative which has been spoken about widely recently with people working from home is the fact that video calling is tiring. Video consultations are dependent on the availability and stability of the internet connection which, even at it’s best, will always have a slight lag. As Philippa Perry points out, video calling “is tiring because of the delay of the spoken word and gestures and expressions. So you have to listen to words and notice body language in two separate streams in your poor head”. She also points out that you get distracted by your own face. Video calling takes more concentration than our usual conversations.

There is also a perceived elitism that telemedicine is for young and smart technology-savvy patients, not for the older or patients with accessibility issues. However, the University of Chicago reports that 1 in 5 of people over 70 have had a telehealth visit since the pandemic started. 49% of these over 70s said that the experience was about the same as an in-person visit with only 4% saying it was much worse.

Resources.

Telemedicine is a new skill that has to be learnt for everyone. But there are resources out there to help both physicians and patients deal with the challenges. When it comes to breaking bad news remotely, the BMJ provides guidance which includes thinking about your tone of voice when you don’t have non-verbal communication to help you(3). The palliative care team at Chelsea and Westminster hospital have also produced a useful infographic, dealing with bad news. The NHS have produced infographics, videos and leaflets to help patients with video consultations. The NHS resources specifically recognise the varying demographics and possible challenges of all patients.

Another aspect is patient confidentiality. Clinicians have to bear in mind that they may not be able to see who else is listening in to the video consultation and that in situations of domestic abuse the patient’s freedom to give all the information may be limited. At the same time, a video consultation gives you a privileged view into someone’s life. There has been much discussion recently about what your zoom background says about you and when it comes to patients, it can help you decide if you feel they can cope at home or need extra help.

Regulatory aspects.

This leads us on to regulatory aspects of telemedicine. It goes without saying that the method of communication used needs to be compliant with data protection regulations. You can listen to previous podcasts dealing with health data and the GDPR.

However, regulation goes beyond the purely technical. Back as early as 2002, the Barcelona College of Physicians emitted a statement about the use of email and other types of electronic means for interacting with patients. Telemedicine was defined then as a complement to the interpersonal physician-patient relationship with a patient who had previously been seen in person. The current COVID-19 pandemic has accelerated the use of telemedicine, and the Madrid College of Physicians emitted new guidance in March 2020 saying that in the context of the current health emergency, a previous face to face visit may no longer be necessary.

COVID-19

COVID-19 has changed the world we live and practise in. Telemedicine, which was on the cusp of being mainstream, has now been implemented across the board. Concurrently, research has been undertaken looking at the validity of telemedicine in the COVID-19 pandemic context.

Phone triage.

Prof Greenhalgh produced an infographic for the primary care phone triage of COVID-19 and concluded that most patients with COVID-19 could be managed remotely, with advice on symptomatic management and self-isolation (4). Phone triage was found to be sufficient in many cases, but video would provide additional visual cues and a therapeutic presence. Breathlessness was highlighted as a concerning symptom with, for this team, there being no currently validated tool for assessing breathlessness remotely.

However, a recent New England Journal of Medicine article spoke of the Roth Score to evaluate shortness of breath and hypoxia(5) via telemedicine. The Roth Score is described as simply having the patient take a deep breath and count out loud to 20 as rapidly as possible while timing the time before the next breath. Being unable to count to 7 has a sensitivity of 100% for oxygenation less than 95%. Being unable to count for 5 seconds has a 91% sensitivity for an oxygenation saturation of less than 95%. I would argue that if the patient is that compromised normal conversation would already be alerting you to the fact that the patient has severe shortness of breath anyway. The team behind this article explain that COVID patients needing transfer to hospital were often not able to count to 7 in one breath.

Video consultations.

Oxford University professionals have also produced guidance on the use of videocalls for COVID-19 related consultations. Specifically, video consultations may be appropriate if the clinician or patient is self-isolating. This would also be the case for patients who have symptoms which could be due to COVID-19 or if the patient is well but needs additional reassurance. Patients in care homes may also benefit from video consultations if staff are on hand to give them the support they may need. Video consultations were deemed not to be appropriate for a series of patients, including assessing patients with potentially serious, high-risk conditions likely to need a physical examination. This included high-risk groups for poor outcomes from COVID-19 who are unwell. Situations where internal examinations, for example, gynaecological examinations, can not be deferred also mean that a video consultation would not be appropriate. It was also pointed out that some deaf and hard-of-hearing patients may find video difficult, but if they can lip-read and/or use the chat function, video may be better than telephone.

1.        Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2015.

2.        Dewar S, Lee PG, Suh TT, Min L. Uptake of Virtual Visits in A Geriatric Primary Care Clinic During the COVID-19 Pandemic. J Am Geriatr Soc [Internet]. n/a(n/a). Available from: https://doi.org/10.1111/jgs.16534

3.        Rimmer A. How can I break bad news remotely? BMJ [Internet]. 2020;369. Available from: https://www.bmj.com/content/369/bmj.m1876

4.        Greenhalgh Trisha, Koh Gerald Choon Huat CJC-19: a remote assessment in primary care B 2020; 368 :m1182. Covid-19: a remote assessment in primary care. BMJ. 2020;368:m1182.

5.        Hollander JE, Sites FD. The Transition from Reimagining to Recreating Health Care Is Now. NEJM Catal. 2020;

Why your #healthtech pizza can’t have too many toppings.

Have you ever been so exhausted with making decisions at work that you decide you just want pizza for dinner (any pizza, as long as someone else decides the toppings)? This decision fatigue (1) is a very real experience for all types of doctors and health professionals who spend their day taking important decisions with life or death consequences immediately or in the future. There has even been a scale developed to assess how health professionals are affected by this (2).

So when you present your amazing healthtech product with its many multiple options to clinicians, don’t feel offended that their eyes glaze over, or even droop. It’s not a case of reducing your offer of special functions available exclusive to your digital health product. Instead, tailor your product to the needs of the health professional in front of you.

What you really need to do is to know which functions will change their practise, decrease their levels of frustration with IT and set it up for them. Of course, they can do it themselves (this and a few more complicated procedures such as saving lives), but if you do it for them, you get a foot in the door. Leave it to them, and it will be pushed to the bottom of the non-urgent pile, and that is how digital health products end up not being implemented.

You can rail against health professionals pushing back against tech, but the reality is that if it doesn’t work for them, you are going to be the one left on the outside.

1. Linder JA, Doctor JN, Friedberg MW, et al. Time of Day and the Decision to Prescribe Antibiotics. JAMA Intern Med. 2014;174(12):2029–2031. doi:10.1001/jamainternmed.2014.5225 

2. Hickman RL, Pignatiello GA, Tahir S. Evaluation of the Decisional Fatigue Scale Among Surrogate Decision Makers of the Critically Ill. West J Nurs Res. 2018;