Malcolm Gladwell: In the cause of efficiency we’ve disrupted the very thing the Patient really wants

March 23, 2015

Bill Gurley and Malcolm Gladwell SXSW2015

I want to make one last point and that is I’m always curious when I talk to people like you about whether you make the error of assuming that more of the world is amenable to technological fixes than is actually the case. So let me give just this one example with digital health records: so when I talk to friends of mine who are Doctors who use these things (EHRs) they all hate them and it’s not clear that they hate them because they’re bad at design, they hate them conceptually and they hate them conceptually because they say here’s the problem: you’re the Patient, I’m the Doctor. Before the digital health record I’m talking to you, listening to you, emoting, holding your hands, whatever, then like it was 1970 I would talk into a dictaphone, my secretary would transcribe it and that would be it right? Now they say, what you’re doing is you’re on the keyboard and you’re not looking at the Patient and the Patient gets really upset. And what you have done is you have in the cause of efficiency disrupted the very thing that the Patient really wants in the encounter which is a personal connection with the provider. Now is it possible that this is simply an area of deeply important personal interaction that is not amenable to technological disruption

Malcolm Gladwell interviews Bill Gurley at #SXSW2015 (from 9.50).

I think Malcolm is spot on about the principle frustrations generated by the EHRs Doctors are forced to use but I’m a lot more optimistic because I use the technology that is helping Doctors leapfrog the keyboard and jump from the dictaphone to automated documentation of the physician narrative at the point of care to do my work (and write this blog).

I also think the Patient/Carer’s smartphone and clinically validated interactive Patient History Taking Tools are enabling the technological fix to be finally applied to the Patient side of the consultation. The disruptive opportunity for technology in healthcare that Patients and Doctors want lies in getting out of the way and letting Patient’s help.

HatTip: Dan Munro over in the Linkedin mHealth Group

Tim O’Reilly calls for the reinvention of the Healthcare Industry to serve people not institutions

March 17, 2015

In his talk ​(slides above) ​delivered yesterday at the South by Southwest event in Austin Texas, Tim O’Reilly ​used consumer technology​ ​examples such as the Apple Store, Uber/Lyft and Google Now​ ​to show where “the bar” is now​ ​set​ ​for user experience and​ ​the lessons there are for those of us looking to redesign healthcare.​ ​

​The talk shares ​​how the author thinks a Doctor’s visit ought to work:

• Phone detected on entry to office, hospital, or ER
• Insurance automatically checked
• Medical history automatically loaded into system
• Vitals and other quantified self info automatically loaded
• Data automatically used to sort queue and give wait times
• If ER, possible discharge to available nearby outpatient clinic or doctor’s office
• Portable medical record updated as patient exits
• (Aside: We also need payment reform!!!)
• Lets me rate my experience, and uses that rating to manage the quality of service

It continues to amaze me that so many really smart tech savvy people are still stuck on the idea that Doctor’s visits have to continue to start and take place within the four walls of a Doctors office.

It should be clear that with 70% of healthcare spending going to serving chronic illness the 2,000 year old healthcare model has expired, 93 year olds with iPads can’t understand why they can’t FaceTime their Doctors and the exciting opportunities for reinvention to serve Patients only really start to become possible when you stop holding tight to the idea that offices visits are the product of the healthcare industry.

If we’re going to compare things with consumer tech brands let’s be very clear: Apple doesn’t require you to visit the Apple Store to buy an iPhone, iPad or an App. 1.6 billion citizens have an Android smartphone but most have never seen a Google Office. Uber/Lyft have yet to build any taxi ranks…

Sir Stirling Moss 3G Video Calling 3G Doctor Dr Fiona Kavanagh

****** UPDATE 23:35 17 March 2015 ******

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A Doctor discovers an important question Patients should be asked. Imagine if was possible to ask & document it for every Patient before they even entered a consult room?

March 17, 2015

WashingtonPost A Doctor discovers an important question Patients should be asked

After 30 years of practice, I know that I can’t possibly solve this man’s medical conundrum. A cardiologist and a nephrologist haven’t been able to help him, I reflect, so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle… …Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try. Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?” I pause, then look this frail, dignified man in the eye. “What are your goals for your care?” I ask. “How can I help you?

Mitch Kaminski, a family physician for 30 years​ ​&​ ​Medical ​Director ​at​ AtlantiCare Physician Group​, writes in the Washington Post.

mHealth Insights

Reading his chart, I have an ominous feeling that this visit won’t be simple. A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath. He suffers from both congestive heart failure and renal failure. It’s a medical Catch-22: When one condition is treated and gets better, the other condition gets worse​

A great reminder that the 2,000 year old model of healthcare is no longer viable.

“​His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations. Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can’t blame him… …A cardiologist and a nephrologist haven’t been able to help him, I reflect, so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle…​ ..​.Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try​”

This is a classic case of ‘John’ where everyone is ​feeling limited to only being able to intensify the treatment.

​”​Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”​ ​I pause, then look this frail, dignified man in the eye.​ ​“What are your goals for your care?” I ask. “How can I help you?”​ ​The patient’s desire​. ​My intuition tells me that he, like many patients in their 80s, harbors a fund of hard-won wisdom.​ ​He won’t ask me to fix his kidneys or his heart, I think. He’ll say something noble and poignant: “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our 60th wedding anniversary.”​ ​His daughter, looking tense, also faces her father and waits.​ ​“I would like to be able to walk without falling,” he says. “Falling is horrible.”​ ​This catches me off guard.​ ​That’s all?​

It’s time Doctors stopped trying ​to gaze into a crystal ball to imagine what Patients want and start using the tools of our time to let Patients and Carers share their concerns, wishes and intentions at a time, place and pace that they’re comfortable with.

​”​I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?Two days later, and two months after we first met, I fill out his death certificate

I think this underlines the importance of letting Patients not only share their wishes with their Doctors but to also have it documented so that they can share this information with their family/carers. Perhaps a follow up questionnaire could be developed that could take away the guess work and ensure changing circumstances are also being considered eg. Why do the family want him to visit them all at home?, etc.

JackN​ in comments​: Production-line practice of medicine militates against the physician having time to ask and listen to what their patients want

This really is where I see the problems. The limited resources being committed to Primary Care mean we have Doctors in the UK (working in an NHS that spends a budget of nearly £100Billion per year) seeing 60 Patients a day and this doesn’t just make it hard for Doctors to ask all the questions they’d like but it also makes it difficult for Patients eg. Patients knowing they have only limited consult room time might want to spend it remedying the need they’ve booked the appointment for (in this case presumably the swollen legs and shortness of breath) rather than use it all up considering quite complex concepts (like life goals and end of life choices) with the clock ticking.

MaxxaM in comments​: Great story. Though it’s important to point out that not every patient is the same. An experienced doctor is someone who quickly recognizes which method of questioning or treatment works best for which patient and employs such method appropriately. The “best” pill, if there is such a thing, does not work on even most patients. That particular question “what are your goals of care? and how can I help you?” may work on some patients at CERTAIN situations and CERTAIN times may need to be asked not just to CERTAIN patients but CERTAIN relatives of those same patients at CERTAIN moments of the care. ​​My point is, doctors who read and like this articles should not start employing such a question indiscriminately. Same thing goes with readers who like this article; you should not expect a doctor to ask such a question to be competent​

I think this response is very interesting. ​Can you imagine how different this question might have been received if the Doctor didn’t have 30 years of Family Practice experience and was instead a fresh faced new graduate?

This is why I think we need to work really hard right now to immortalise the history taking skills of the world’s most experienced Doctors so that we don’t lose them to retirement and can add these life honed talents as tools to used to enable the younger and less experienced Doctors (who we urgently need to attract to work in Primary Care) to be more effective.

Adam Higerd in comments(in reply to MaxxaM​)​: No, the question itself is always valid. It is the responsibility of the physician to interpret the results. It would of course be foolishness for a physician to blindly accept the patient’s answer at all times. But UNDERSTANDING one’s patient is important, and making assumptions entails risk — asking the question carries no inherent risk; it’s a simple thing to do, and carries the potential of bringing up valuable insight​

I think this is technically correct but in practice the reality is for most it will be using up consultation time eg. there are risks if Doctor’s are using up this valuable limited time asking questions especially if they can be asked and documented prior to the consultation (Dr John Bachman, Professor of Primary Care at the Mayo Clinic, explains how this can be achieved in this excellent Mayo Clinic Proceedings Paper).

​”PLMichaelsArtist-at-Large in comments: Very nice work, Dr. Kaminski – without having seen this patient before, you not only came up with a question that he could give a good answer to, you created a caring relationship with him, short as it was… …I understand that everything is hectic and costly, and that most practitioners are doing all that they can, but those moments of true connection – coming from a good question – can do so much to alleviate some of the mental anguish that goes with being ill. It is clear that you did this for both the patient and his family

When medical history taking questionnaires are compassionately designed powerful moments of connection can happen even before they meet.

​”MEinVA1 in comments:​ ​It’s a little disturbing that so many people posting about this article view Dr. Kaminski’s discovery of collaboration with his patients through the narrow lens of end-of-life decision-making. His epiphany holds great potential across the spectrum of difficult situations in health care, from birth to death​

Another very important observation. The value of sympathetically designed medical history questionnaires extend from prenatal Consults, right through end of life and even into bereavement (for carers and family members of the deceased).

​”Nunyun in comments:​ ​Now this is what you call a “doctor.” Being a doctor should involve more than pushing pills, ordering tests, and hospital admittance. He did not take a paternalistic approach, but respected this gentleman’s autonomy, and for that he gained not only the patient’s respect, but the family’s … and mine, too. I’m going to “train” my doctor to ask me this … no, I take that back … I’m going to tell her “let me tell you what my goals are!”​

This is how I think documentation is totally transforming how medicine is practiced and one of the most important objectives that we’re trying to attain with the consultation report we provide Patients with following their 3GDoctor consultations.

How did you take away from Dr Mitch Kaminski’s article and the comments from readers?

Does Tim Cook have plans to define this decade by making “iPhone” synonymous with “mHealth”?

March 16, 2015

Will mHealth be the most profound change iPhone will make

In 2009 when Tomi Ahonen (the world’s most accurate mobile industry analyst) accurately predicted that the last decade would come to be known as the Nokia Decade I asked if the next decade would be defined by the convergence of health and mobile (the newest mass media).

It seems clear to me that Tim Cook, CEO of Apple (set to be the world’s first company to be valued at a $Trillion with a current cash pile in excess of $178Billion), might have some plans for the iPhone to define this decade by being the brand that becomes synonymous with mHealth.

HatTip: mHealthNews

If you think the product you make is Appointments the NHS makes no sense

March 16, 2015

How Patients can help we GPs make the NHS run better

This interesting ‘Views from the NHS frontline’ article by Dr David Turner, a GP working in London, in today’s Guardian shares some interesting insights into how GPs in the NHS think about the work they do before calling for “an open and honest debate, not just about what the NHS should be doing for patients, but what patients could do to make the NHS run better“.

mHealth Insights:

If the health service is going to thrive, patients must use the system more efficiently by keeping their scheduled appointments

I think it’s clear that we all need to move beyond the idea that the product we are making is scheduled visits.

The patient in front of me is five minutes late for her 10-minute appointment. As she sits down she tells me she is feeling suicidal, as her father has just been diagnosed with cancer and she is about to be evicted from her flat for non-payment of rent. It is 9.05am on a Monday and the waiting room is already standing room only. This is a slightly extreme scenario, but it does happen

The first question should not be why this Patient is 5 mins late but why anyone would want to see a Patient with needs like this at 9.05am on Monday morning (the busiest period in a GPs week)?

It’s highly unlikely that the appointment was scheduled over the weekend, or that her father was diagnosed over the weekend or that the non-payment of rent was an issue that manifested itself over the weekend so this is a Patient who’s probably been worrying and losing sleep all weekend and has probably had to take time off work (no doubt further escalating the problem of unpaid rent!).

Imagine how much better a Patient like this could work with Dr David Turner if he worked in a NHS GP practice that used the AskMyGP product (as used in NHS GP Dr Amir Hannan in Greater Manchester).

In London in 2015 you don’t need to wait for an available GP appointment to get financial advice. The Citizen’s Advice Bureau has a website, telephone number, local offices and a self-help website ( that provides practical, reliable information and suggestions like online budgeting tools that you won’t find within any medical school syllabus.

In London in 2015 you don’t need to wait for an available GP appointment to learn about the issues of caring for a father with Cancer. Cancer Research UK for example have forums dedicated to Caring for someone with cancer within their “Cancer Chat” Forums.

In London in 2015 you don’t need to ignore a packed waiting room for 5 minutes while you work out your Patient is late simply install a Patient Arrival System to manage your waiting room Patients so you can automatically begin seeing other Patients in this schedule gap.

When you appreciate that difficulty getting out of bed is often a symptom of depression I think it should be abundantly obvious that the best place to share your feelings about depression aren’t a rushed appointment in your GPs office at 9 am on Monday morning. I wonder if this Patient picked this time slot or if it was prescribed by the front desk receptionist when the Patient called in to make an appointment?

Whenever general practice is discussed in news reports, the main complaint seems to be that people cannot get appointments with their GP. There are many reasons for this. Chronic underfunding, combined with ever-increasing unfunded work being dumped on us are two major reasons why it is harder to see your family doctor. Another important reason, which the media seems to pay scant attention to, is the misuse of the system by patients themselves

I think this is just a design issue. GPs are trying to get away with a one size fits all model and the varying complexity of illness means we can no longer do this eg. Does ‘John’ need your time or attention?, the 2000 year old model of healthcare is broken forever, etc.

The practice I work in has four doctors and more than 7,500 registered patients. We have an average of about 50 appointments not attended every week (DNAs). Not cancelled appointments, just appointments that patients failed to attend. That’s 500 minutes of doctor time wasted every single week. We are not unusual; most practices will tell a similar story. We advertise the fact of this wasted doctor time in the waiting room and text patients to remind them of appointments, but it does not seem to make much difference

Yes mobile appointment reminders are a big help and ‘please confirm your attendance at tomorrows consult’ reminders can also help but they’re not a silver bullet solution to the failure of GPs to use the tools of our time.

When your GP surgery only offers in-office appointments why is anyone surprised that some Patients are making them and then not going? Is it really that hard for us to predict this behaviour? When appointments are limited and offered on a first come first served basis (without even attempting to consider the particular Patients needs) is it any surprise that Patients and Carers will want to confirm appointments when they know they don’t really need them because they are frightened that things might get worse later when the available appointments for that particular day are all gone?

We don’t have any spare consulting rooms and there’s no extra funding to hire consultants. In addition to this we have a dozen or so appointments cancelled at short notice. This is when patients phone to cancel but leave it so late that an appointment cannot be reused

Funding is a really big issue for innovation within NHS primary care. One solution I think is very promising is the Prime Minister Challenge Funding (the AskMyGP product qualifies for this so NHS GPs can have a secure online portal that can get a product added to their existing IT systems that can begin tackling capacity/demand challenges without the need to pay for all those expensive innovation consultants, IT experts, Pilots, Audits, etc).

Another area that needs highlighting is what a GP appointment is and what can be realistically achieved within it. When I started work as a GP 15 years ago many doctors were still operating on five-minute appointment slots. That gradually changed and now most surgeries will offer 10-minute appointments as routine. In those 10 minutes the patient has to walk to our room and explain their problems. We have to examine them, make a diagnosis and explain any necessary treatments or tests and then do the associated paperwork. Finally, we have to summarise all this to the patient then write our notes and do the required box-ticking for the government so we can get paid

A great reminder of how the modern NHS GP consult is increasingly being influenced by external political, financial and administrivia that sadly all too often have nothing to do with what’s best for the Patient or Doctor.

This, where I work, is often complicated by the patient speaking little or no English or the consultation taking place through an interpreter

Taking a history is hard enough but trying to do it through an interpreter is impossible with the demands and lack of resources being made available to GPs in the NHS today. It’s obvious that consultations that take place through an interpreter can be greatly aided by the use of interactive Medical History Taking software and with so many foreign trained NHS GPs it also enables better use of NHS talents eg. if there’s a life changing result that needs to be shared with a Patient it’s probably best to refer them to a Doctor colleague who speaks their language than to try and relay such sensitive information back and forwards through an interpreter.

How can we help prevent unethical and dangerous alternative uses of mHealth tech?

March 8, 2015

Dale Fox at Exponential Medicine 2013 THe worlds smallest XRay Machine

Watching this interesting Exponential Medicine 2013 talk by Dale Fox, CEO of Tribogenics, and I can’t help but think that the low cost pocketable X-Ray machine that his company has developed (that runs on nothing more than a 9 volt battery) is going to disrupt more than medical imaging as X-Ray technology finally arrives at it’s “transistor moment”.

Although I really don’t like to have to I’ve commented on several unethical applications of mHealth tech but I think the unintended ‘weapon’ applications of a pocketable inexpensive X-Ray machine will make these very obvious (take a look at the logistics, expense and collateral damage involved in the Russian state-sponsored operation to fatally poison Alexander Litvinenko).

Can you think of any ways that we can help ensure that mHealth technologies aren’t misused to cause harm instead of deliver health?

“Here’s my mobile phone number” is now one of the most caring things a Healthcare Professional can say.

March 6, 2015

Mary Haight Living with Hepatitis C is tough so I give my mobile number to Patients

I usually give my mobile number to patients and tell them to ring if they have a problem, much to the horror of my colleagues. I’m semi-retired now so don’t mind if people call. Some ring because of the side-effects of the medication, others because they need reassurance or a friendly voice… …My guilty pleasure is the American show Judge Judy, where a real-life judge sorts out people’s domestic disputes. She’s great. She sees things as they are, cuts to the chase and offers a practical solution. Maybe we should invite her to join the NHS

Mary Haight, Hepatitis Nurse Specialist, Hillingdon Hospitals Foundation Trust

Useful link: Here’s the form you need to nominate someone for a National Honour.


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