The Royal College of General Practitioners highlights Patient safety issues arising from GP fatigue

July 30, 2015

RCGP warn of risk of GP fatigue to Patient Safety

Fatigue among overworked GPs is becoming so prevalent that it could jeopardise patient safety on a widespread scale unless urgent action is taken to address this, the Royal College of General Practitioners warns today… …unrelenting and increasing workload pressures are pushing dedicated GPs to their limits as they try to cope with rocketing patient numbers with diminishing resources… …the College warns that there is considerable potential for patient harm – such as medication errors and mistaken patient identity – if GPs become persistently over-tired… …Patients are also routinely living with multiple and chronic conditions, which are far more complex to deal with, especially within the constraints of a standard 10-minute GP-patient consultation. In England, the number of patients with more than one long term condition was predicted to rise from 1.9 million in 2008 to 2.9 million in 2018… …RCGP Chair Dr Maureen Baker said: “GPs will always work in the best interests of their patients – even when they are putting their own health at risk – but ironically this can actually have an adverse effect on patient safety. Few of us would voluntarily board a plane flown by a visibly tired pilot or get on a train where we knew the driver had spent too much time at the controls – yet there are no methods or systems for addressing doctor and staff fatigue in general practice… …You might be able to do this for a short time, but when it becomes the norm, mistakes are going to be made

If there was a clinically validated means by which Patients could safely use the internet to reduce the need for office visits by 40% (or in NHS GP language 148 million consultations per year), was proven to work in the NHS and was getting great feedback from Patients would GPs be too fatigued to adopt it?

Related post: Are Patients wasting GPs time OR are undocumented Doctor office visit only models wasting everyone’s time?

Is our failure to document medicine and pay attention fuelling the exponential growth of bad medicine?

July 27, 2015

Isaac Kohane MD PhD talking at Exponential Medicine 2014

…a Malaysian Airline disappeared and the whole world was activated to figure out where it had gone and what had happened. At two of our top hospitals in Boston the following peak of heart attacks happened, so this was over the base line an 18% increase in heart attacks, and so what we were flying into this mountain of morbidity was not ‘a’ plane load but a thousand plane loads, then thousand plane loads of Patients with heart attacks. And guess what: no one ever noticed. It’s only when we did the analysis through the Electronic Health Record of the data that we became aware of it. So it’s like a thousand Malaysian 747’s just disappearing without a trace but in this case we caused it. We actually shot them down. We gave Vioxx (Rofecoxib) and we are the cause of that mortality and morbidity. We caused it. You’d give me a standing ovation maybe if we told you that we caused a 5% decrease in Heart Attacks, (well) we caused an 18% increase in Heart Attacks and we didn’t even know it and it was knowable, why? how do we know this?, because Kaiser Permanente took it off their formulary early on when they saw early papers suggesting that there was cardiotoxicity. That’s our healthcare system and guess what? I have many other papers that cite, some of which we’ve done, that tell you this is happening now. Today. We’re not paying attention. You know all these measures we’re hearing about: readmissions, this and that, there are huge signals that we’re missing if we could only be bother to be creative and look…

Isaac Kohane, MD, PhD, coDirector of the Centre for Biomedical Informatics at Harvard Medical School gave this fantastic talk about the Exponential Growth of Bad Medicine at last years’ stunning Exponential Medicine Conference. Click here to apply to join us for the 2015 event (9-12 November again in San Diego).

mHealth Insights

This is why I think new entrants from the mobile industry like Apple (who have got business models that benefit from being creative and looking for signals) are going to radically change how we practice medicine.

When you appreciate the imprecision of medicine and the loss of symptom information that takes place every time we try and get the busy/tired/expensive Doctor entering it via their computer (instead of letting Patients help) it’s hard to see how we’re going to continue to be allowed to refer to the undocumented practice of medicine as ‘caring’.

Related: This talk is also a very good reminder of why we need much greater transparency when we let managers/payers modify the decision support tools that Doctors rely on to prescribe medications to Patients.

“being a naive medical student I gave her my cell phone number”

July 26, 2015

JAMA Learning to Breath Elizabeth Levin MD

Reading this JAMA article by Elizabeth Levin MD reflecting on a medical school experience and it reminded me of the incredible efficiency with which some Medical Schools erode student empathy.

Let’s be clear: there are times where it isn’t appropriate to share your mobile number with a Patient but it’s not a sign of naiveity, giving your number to a Patient can be an incredibly caring thing to do and you get your authority from how much you care and Patients want to know how much you care before they want to know how much you know.

Join us at the NIH’s Mobile & Personal Technologies in Precision Medicine Workshop, 27-28 July 2015

July 26, 2015

NIH Precision Medicine Initiative

The Precision Medicine Initiative Working Group of the Advisory Committee to the NIH Director is hosting a public workshop at Intel’s HQ Campus in Santa Clara (it’s free to join the event on Livestream here) to discuss the scientific, methodological and practical considerations to inform the incorporation of mobile and personal technologies in the national research cohort of one million or more volunteers.

Key agenda discussions will include:

Potential benefits and barriers of employing mobile technologies in a large cohort study using the experiences of current smaller cohort studies that have incorporated these technologies. What is the desired functionality for a national research cohort mobile health app that would facilitate participant engagement and retention? What are some examples of the status of mobile technologies to measure a wide range of PMI cohort relevant variables (e.g. physiological, behavioral, and environmental)? What are the social and technical challenges that will be faced in using these technologies in a large cohort (including sampling bias/diversity, privacy/security, feasibility/validity, and data management/integration)? What are some practical uses of mobile technologies based on relevant national research cohort use cases? What are examples where the cohort might be used as a test bed for new and emerging technologies that will advance precision medicine?

Keynote speakers will include:

Greg Armstrong MD, Epidemiology and Cancer Control, St Jude Children’s Research Hospital
Rhoda Au PhD, Prof of Neurology at Boston University and Director of Neuropsychology, Framingham Heart Study
Gary Bennett PhD, Professor at Duke University and Co-Founder, Scale Down
Andrew Campbell PhD, Prof of Computer Science, Dartmouth College
Jorge Chavarro MD, Professor of Nutrition and Epidemiology, Harvard
Francis Collins MD PhD, Director, NIH
Josh Denny MD MS, Assoc Prof of Medicine & Biomedical Informatics, Vanderbilt University
Eric Dishman PhD, General Manager of Health & Life Sciences, Intel Corp
Ray Dorsey MD MBA, Director at the Centre for Human Experimental Therapeutics, University of Rochester
Emre Ertin PhD, Research Associate Professor, Ohio State University
Ram Fish MBA, VP mHealth, Samsung
Maribeth Gandy Coleman PhD, Director of Interactive Media Tech Centre, Georgia Tech
Esteban Gonzalez Burchard MD MPH, School of Pharmacy, UCSF
David Gustafson PhD, Centre for Health Enhancement, University of Wisconsin-Madison
Kathy Hudson PhD, Deputy Director, NIH
Anand Iyer PhD, Chief Data Science Officer, WellDoc
Michael Jerrett PhD, Fielding School of Public Health, UCLA
Andrew Kasarskis PhD, Vice Chairman Department of Genetics and Genomic Sciences, Mount Sinai
Jeff Kaye MD, Director of the Centre for Aging & Technology, OHSU
Sachin Kheterpal MD MBA, President of the Precision Medicine Initiative, University of Michigan
Deborah Kilpatrick PhD, CEO, Evidation Health
David Kotz PhD, Founder, True Health Coalition/GLiMMER Initiative
Anmol Madan PhD, CEO,
Spero Manson PhD, Assoc Dean of Research, University of Colorado Denver
Jessica Mega MD MPH, Assoc Prof of Medicine at Brigham and Women’s Hospital & Google Life Sciences
Kevin Patrick MD MS, Professor of Family & Preventive Medicine, UCSD
Bray Patrick-Lake MFS, Clinical Trials Transformation Initiative, Duke University
Sue Siegel, CEO at GE Ventures & Healthymagination at GE
Kathy Sigona, Health eHeart Study Participant & Alliance Steering Committee Member
Ida Sim MD PhD, Professor at UCSF & coFounder at Open mHealth
Bonnie Spring PhD, Institute for Public Health and Medicine, Northwestern University
Donna Spruijt-Metz PhD, Assoc Prof Preventive Medicine, USC
Mani Srivastava PhD MS, Professor, UCLA
Arthur Stone PhD, Prof of Psychology, University of Southern California

Event registration is now closed but you can join the livestream by simply clicking here and there’s also set to be some lively discussions on twitter #PMINetwork

Related: Comprehensive listing of mHealth events being held in 2015.

AME Publishing Company launch ‘The mHealth Journal’ – the official publication of the Society for Translational Medicine

July 24, 2015

The mHealth Journal

Don’t know how I missed the launch of this new publication (ISSN: 2306-9740) in March 2015 but better sharing it late than never.

I think the definition used for mHealth that attributes the first use of the term (incorrectly) to Brunel/Kingston Universities Robert Istepanian (“use of mobile technologies to improve public health, particularly in underserved populations; health research, training, and education applications; and delivery systems around the world“) will prove very limiting (feel welcome to consider our suggestion) but I’m sure that’s something that will get ironed out as the project expands which it no doubt will with the incredibly diverse group (and so many familiar faces and mHealth group members) that are already listed on the new Journal’s editorial board.

Editorial Board:

Steven Tucker, MD, FACP, FAMS, Tucker Medical, Novena Specialist Center, Singapore (Editor-In-Chief).
Stephen Agboola MD, Associate Director for Connected Health Data Science and Analytics, Partners HealthCare
Christian Assad-Kottner MD, Fogarty Institute of Innovation and Endovascular Fellow, El Camino Hospital
Richard Boxer MD FACS, Chief Medical Officer, Pager
Chee Jen Chang PhD, Professor, Chang Gung University (Taiwan)
Hammad Durrani MD MBBS MSC, Administrator Strategy Planning Communication, Aga Khan University Hospital (Afghanistan)
Julien de Salaberry, Founder/Chief Innovation Officer, The Propell Group (Singapore)
Rafael J. Grossmann MD FACS, Surgeon/TEDx+Keynote Speaker/Google Glass Explorer/Singularity U Alumnus
Yusong He MD PhD, Medical Affairs, Novartis (China)
Cees Hesp MA, mHealth Research Labs, PharmAccess Foundation (Netherlands)
Shariful Islam MD MPH MHR, Principal Investigator, ICDDR
Karin Källander MSc PhD, Senior Research Adviser, Malaria Consortium
Koen Kas PhD, CEO, InBioVeritas
Martin Kelly, Co-founder and CEO, HealthXL
Alain Labrique, Associate Professor, Johns Hopkins Bloomberg School of Public Health
Yong Li MD, General Surgeon, Guangdong General Hospital (China)
Donna Malvey, Associate Professor, University of Central Florida
Alisa Niksch MD, Director Pediatric Electrophysiology and the Pediatric Cardiopulmonary Exercise Lab, Tufts University Medical Centre
Paul Porter MD MBA, Assistant Professor of Emergency Medicine (Clinical) & Director Special Projects and Telemedicine, Brown University
Patricia Salber MD MBA, Founder and Host, The Doctor Weighs In
Donna J Slovensky PhD, School of Health Professions,University of Alabama at Birmingham
Honggang Tu M.M, CEO, MediCool Software, China
Olivia Velez, Senior mHealth Advisor at ICF International & eHealth Team Lead at USAID’s Maternal & Child Survival Program

Click here to Subscribe

Click here to submit a paper for the publication

Related: Also see the similarly titled “The Journal of mHealth” an online publication produced by Simedics:

The Journal of mHealth

Is Apple ResearchKit a “Powerful platform, dangerous playground”?

July 22, 2015

mHealthNews Apple ResearchKit

This mHealthNews “Analysis” of Apple’s ResearchKit by Gene Fry, the compliance officer and vice president of technology at Scrypt (a Document Management and Delivery Solutions company), is typical of the confusion that exists if you fail to appreciate that we live in a reputation economy where Communities Dominate Brands.

mHealth Insights

It’s hard to know where to start with this article as it’s peddling so many myths but a key thing to appreciate is that Apple’s ResearchKit endeavours are coming with ratings.

This past April, Apple launched ResearchKit – a framework used to develop apps that allow patients to participate anonymously in medical research studies. While these apps have the potential to advance medical research, there are concerns about privacy and security. In addition, the accuracy and integrity of the data being provided by participants is being questioned

I can’t understand why anyone thinks that a key feature of Researchkit is that medical research volunteers will want to be anonymous? I thought the opposite would be true eg. treat me like a statistic but if the efforts I go to help Kings College Hospital find the cure for cancer, or Oxford University understand depression so that thousands of lives aren’t lost to suicide every year I want my name in the history books thank you very much.

Perhaps there’s a confusion here with being able to participate privately eg. without having to tell everyone you’re doing it?

An organization or individual that wishes to create an app on the Apple ResearchKit or HealthKit framework does not need to meet HIPAA compliance, meaning that anyone can create an app providing it is IRB or ethics approved before it is available for download. The lack of compliance and regulation around these apps makes participants vulnerable. They are under the impression that they are providing medical information as part of a medical study to an authorized researcher, when in fact they could be sending data straight to a malicious developer who has created an app for the sole purpose of stealing personal medical information

I fail to see why particular lowering of barriers is thought to be such a big problem: Aren’t we all aware that there thousands of health tracking apps, millions of cookies & websites that already try to collect sensitive, private and personal information about Patients yet aren’t even traceable (never mind having IRB or Ethics approval)?

I’m intrigued to know why so many Health IT experts hold onto this idea that Patients want to give away all their personal information so easily when it’s clear most of the big failures in Health data theft have happened not through Patient failings but through the failure of healthcare organisations to protect this valuable data?

…With ePHI reportedly worth up to 10 times more than financial data on the black market, this method of harvesting data presents an easy opportunity for data thieves… …Apple states that the data collected from ResearchKit and HealthKit apps is not available to them – which, given the iCloud hacks they experienced recently, should reassure those providing healthcare data…

I sense from this that the author has an axe to grind with Apple or is just prepared to use any tenuous link to make a point. Follow the link and you find that it’s about ‘fake phishing emails‘ that ‘could‘ make customer passwords vulnerable and it’s clearly a non-story as it clearly states “Apple has yet to confirm the hack is authentic and no iCloud users appear to have been affected by the security bug“.

For those who have little idea about what a ‘phishing’ attack is: it’s typically a malicious email, SMS, pop-up message that asks you to enter your password. Look in your email spam folder and you’ll see at least 25,000 of them.

One look at the success of Apple Pay and it should be obvious this isn’t something Apple hasn’t started thinking about: they’ve got the best talent in the world working on it already. As healthcare platforms move to mobile we’ve actually got huge new opportunities to protect Patients from phishing eg. through multi-factor authentication via the device we all carry and leave turned on HealthKit is going to remove the need for all these vulnerable logins and passwords to even exist.

Another area in which ResearchKit has come under criticism is the data being collected from participants from a scientific and ethical standpoint. Firstly, to take part in the study the user has to be within a demographic likely to afford an iPhone. This would make the data collected from the studies too biased toward more homogenous populations, ruling out persons of a different ethnic or social background, which may include people who are potentially more susceptible to health problems

Winston Churchill famously said “A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty” and I think that’s really what’s going on here.

It should be obvious that the cost of an iPhone is insignificant when you appreciate the cost of a Clinical Trial. If it’s not think about the next 3 simple facts:

> Most clinical trials fail because they fail to recruit enough Patients to get started OR because Patients abandon the trial before it’s complete.

> 98% of data collection in clinical trials today happens within the four walls of research facilities.

> The average cost per Patient enrolled in a Oncology Trial in the US is somewhere in the region of $250,000.

When you realise how Researchkit has completely flipped the challenge of Patient recruitment and you realise the improvements in accuracy/reliability when data can be captured/shared anytime/anywhere it should be obvious that clinical trial designers can simply gift the latest Apple devices & connectivity to Participants.

We should not be surprised to learn that there are talented and passionate people working in the $100B/year Clinical Trial industry that are already doing this around the world and leaving behind their slow to adapt peers who are still using paper, faxes, etc.

Secondly, the participant only has to provide consent to take part in the study, meaning it is easier to lie on the initial screening questions to fake eligibility, as there is no way of vetting whether the participant has the condition being researched. This leaves it wide open to fraud, which in turn further undermines the integrity of the data

I find it hard to imagine how this is a challenge. Surely this is about as nonsensical as the Passport Office refusing to make application forms available in the post office as there would be no way of ensuring the people picking them up and filling them in are who they say they are.

What did you think on reading the article?

The #1 reason Doctors don’t want to provide Patients with documented video consults: it encourages internet research

July 20, 2015

Hospital to replace doctors with parents who have done their research

I used to think it was about money but I’ve met too many Doctors who have shown me this was a red herring (eg. brilliant NHS GPs like Dr Tony Stern, Dr Amir Hannan, etc). The reality is many Doctors still aren’t yet aware of the opportunity for the Internet to help Patients and they hold onto outdated ideas about Patients/Carers who present to them after doing some online research like those depicted in this satirical Spud Magazine (a fake health news website) article. It’s incredibly easy to find Doctors expressing these feelings in more subtle ways if you read around eg. the internet “has caused a lot of problems and increased our (GPs) workload”.

If you are a Healthcare Professional practicing in 2015 and you get a ‘heartbeat’ moment (British Journal of General Practice Feb 2010: ‘A heartbeat moment’: qualitative study of GP views of patients bringing health information from the internet to a consultation) when you learn that a Patient or Parent/Carer looks to the internet to improve their understanding of a diagnosis/treatment/health condition it’s time you were retrained.

We can’t continue to hide behind excuses or blame the Patients/Carers. We need to listen to Patients and evolve beyond the office visit model because the 2000 year evolution of medicine and the rise of chronic disease mean undocumented and unprepared in/out-in-5-minutes Doctor consults are increasingly a waste of everyones time

*** *** UPDATE 26 JULY 2015 *** ***

Seth Godin Can We Talk About This

I think Seth Godin is brilliantly on point with the suggestion of asking “Can we talk about this?” as a simple litmus test for a productive relationship:

If one professional says it to another, the answer is an emotion-free, “sure.” There’s no baggage. Talking is the point. Talking is what we do. We communicate to solve problems. On the other hand, if the question brings with it fear and agitation and, “uh oh, what’s wrong,” you can bet that important stuff goes undiscussed all the time

If you are a Patient or Carer who is getting interrupted before you’ve had 18 seconds to tell your story, has the information you researched on the internet printed and brought to the consultation immediately placed in the round file on the floor next to the door, etc, you can be sure that there’s fear, agitation and plenty of baggage that’s getting in the way of what could so easily be a productive relationship.



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