Do we need Healthcare Without Borders?

Healthcare Without Borders

​Maneesh Juneja, a “Digital Health Futurist”, in this “Healthcare without borders?” article highlights some common misconceptions about the value of Mobile video ​consults with Doctors so I thought it might be helpful to share my views.

Some of us have used tools like Skype or Facetime on our phones, tablets and computers to conduct video calls with family and friends, or we may use tools in the office such as Lync to have video-conferences on our laptops with colleagues around the world. In my own experience, even when conducting video calls over 4G on my phone or super fast broadband at home, I regularly have issues with either the quality of the video or the call unexpectedly dropping. When it works, it’s great, but the point is that it doesn’t always work as well as it should

Perhaps Maneesh just needs to get some good tech help – check out a pic of Sir Stirling Moss making a 3G video call to 3G Doctor in 2010. I find it funny to see how commonplace it’s become today eg. in Dublin look up at any bus and you’ll see a tourist on the bus FaceTime calling their friends/family back home while they see the sights (no doubt this has been aided by Dublin bus making a smart move to provide customers with free WiFi).

​”​Virtual doctor visits​. ​When I hear about the growing trend of ‘virtual doctor visits’, it makes me curious, as I’ve never personally only ever seen a doctor in person​n

It’s really important that everyone starts understanding that there’s nothing virtual about consulting with a Doctor over a video or a voice call. ​

​”I note that in Scotland, patients in rural areas are being urged to Skype their doctor over Christmas

Isn’t that great news! Odd that they’ve chosen to specifically mention Skype though – perhaps NHS Scotland should hire Roy Lilley’s mother to lead their future planning team as this 93 year old ​was calling for this more than 2 years ago!​

​”​However, not everyone thinks replicating the 10 minute face-to-face doctor visit over video is what people actually want​

I think it’s important we all realise that the 2000 year old office visit model is simply no longer viable.

It amazes me that anyone would think it would make sense to be conducting undocumented consults in exactly the same style that we’ve been doing for 2000 years now that we all have mobile phones in our pockets that are more powerful than supercomputers from a few years ago.

Surely we all can see Mobile has transformed banking into something that looks nothing like it did when we grew up, so why does anyone in 2015 think that mobile will not transform how we consult with Healthcare Professionals?

Now that we can collapse time and space why would we always want to share information with Doctors within rushed in-office moments and do we really think Patients are going to tolerate being told by their Doctors that they’re wasting their time while their dog gets more joined up care than their child simply because of their lack of industry interest in adopting the tools of our time?

I went into this topic in more detail in the talk I gave at Doctors20 ​in Paris last year.

Sherpaa, has a different angle on the future of healthcare interactions. A telemedicine article speaks about Sherpaa in terms of, “It explodes the notion of the appointment altogether, encouraging patients to engage with a small staff of doctors at any time, for any reason, via text message through a website and app.

Since reading about how Glen Tullman’s son Sam FaceTime called their Doctor in 2012 I presumed Patients who are paying expensive subsciptions to access primary care services in the US were already being offered FaceTime access?

It’s a complete mystery to me as to why anyone would think that the SMS protocol that hasn’t changed a whole lot since being designed for telco engineers 20+ years ago is some ideal platform for Patients to use to interact with a team of Doctors.

It’s really fascinating to read on Sherpaa’s website about why they don’t use video, “First, and most importantly, not a single patient out of thousands and thousands of interactions over the last 3 years has ever asked for a video chat. That’s because people don’t, and won’t, actually choose video over email or phone to communicate with strangers or acquaintances.” That’s quite an interesting perspective,

It should be obvious that unless there’s an emotional connection and context (eg. a reason/need, etc) there’s little need for video calling. That’s why you see people just demoing the tech they just feel the need to wave at each other (eg. remember when Steve Jobs FaceTime called Jonny Ives at the launch) whereas in other uses of the same technology it’s hard to explain in words the value of the video connection.

Perhaps this service in the USA isn’t accessible to Carers (it’s not clear if the employees who have subscriptions are allowed to use the service to get help for their grandparents etc?) or the Patients subscribing to this service are mostly using the services to help them with technical aspects of accessing insurer provided care (this is a big issue due to the complexity of insurance coverage and lack of Primary Care in the USA).

Since I visited the NHS GP Clinic of Dr Tony Stern more than 5 years ago it’s been incredibly obvious to me: if you’re able bodied and aren’t too sick to get out of bed and already have a relationship with a Doctor the need for video calling that Doctor isn’t going to be that great because you already have all the trust etc.

But the problem most Patients face is that they don’t have convenient enough access to their Doctor because of demands on Doctor time and the lack of resources being provided to GPs to do their job eg. this is why AskMyGP is proving such a success as it lets Patients asynchronously communicate with their Doctor in a way that doesn’t completely disrupt the GPs workflow.

But it’s a very different story if you are someone who doesn’t already have a Doctor/Patient relationship or have a relationship that you don’t want to run the risk of ruining by confronting them based on some conflicting advice that you have read online etc.

If you want citizens to share their most sensitive private information and you’re going to make it possible based on that shared information to select the most appropriate Doctor for that Patients specific needs (which of course means they will have never met or have even heard of the Doctor they’ll be consulting with) you’re going to immediately see the value that Patients will take from every opportunity you provide with them to judge the Doctor because after all the whole point of the exercise is for the Patient to be able to accept an opinion and some advice that they’ll then feel confident enough to act on.

Related post: So why would one need to video call a Doctor versus just talking to them? 2010

and I note that Dr Punam Bhende in India has tried a number of platforms (including Skype) but found that Whatsapp worked the best for follow up visits

It’s terrible that India doesn’t have legislation in place to prevent Doctors from exposing Patient data and to close Doctors like this down but it stuns me that a HIMSS publication is sharing such bad practice without making that clear to the reader.

Perhaps we shouldn’t be surprised that 1 in 8 US citizens has had their private medical data shared with hackers and in the first 4 months of 2015 1 in 3 of all US data breaches were in Healthcare

“​The impact on continuity of care?​ ​Most services offering virtual doctor visits are focused on minor problems. Lower costs and greater convenience are often cited but some argue that making it easier to access primary care this way will actually increase demand, and that these services will end up increasing healthcare costs. What are the implications for continuity of care if you see a different doctor every time using these new services? Will the online doctor always have the ability to view your medical records?​

This is the same age old problem encountered widely eg. with the NHS’s NHS reDirect and 111 services that Patients would spend 30 mins describing their concerns to before getting some advice over the telephone which all amounted to nothing when they were referred to A&E or a Doctor appointment as they’d have to rinse and repeat the whole history taking process once again.

The vast majority of these problems disappear when you provide Patients with default access to all information and consultations are efficiently documented. ​

​”​Should the first visit always be in person, but subsequent visits be offered in person or online? A small study in the US has found that 75% of patients undergoing routine elective surgery would accept an online visit as their only follow-up with their surgeons. I wonder how much of today’s face-to-face interactions in healthcare can be shifted to the virtual realm? It’s not just the interactions with doctors, but nurses, pharmacists and a whole range of healthcare professionals

This whole idea of having the first visit always in person is something the Doctor associations and regulators seem to be very keen on but I think it’s a really outdated concept that will only really serve to prevent society from benefiting from mHealth. I can’t even imagine how such legislation might serve Doctors well eg. surely Patients would just bridge the gap by jumping on WhatsApp etc to insecurely consult with Doctors in India?

They might as well legislate that Patients need to see a Doctor before doing a search for health information.

​”​We might feel that seeing a doctor online will negatively impact the relationship between doctors and patients. What if the ‘distance’ in the online interaction encourages patients to express problems that they might not discuss in person? Reading the reviews from patients who have used these online providers is fascinating

I used to explain this point to Doctors but in 2015 it’s getting obvious that most Doctors would learn more about Patients by looking at their Facebook ads than the billing record that they refer to as an EHR.

​”​One review by Kristin Lackey of the Amwell app, demonstrates how modern technology is reshaping healthcare, “So cool In less than 10 minutes, I was able to speak with a doctor, get a diagnosis, prescription sent to the pharmacy and stay in my pj’s..If I hadn’t come across this app, I would have had to wait another 2 weeks to see my primary or find another. Thanks!”​”

I think this supposedly positive review is great until you actually want to know IF the prescription was needed. With the over/inappropriate prescription of medicines like antibiotics and pain killers being a real problem the world over we need to be responsible and ensure that medications are being prescribed responsibly. I think medicine will go in some very bad directions if provider organisations are benefiting from public ratings that praise them for readily prescribing medications.

​”However, another review by Tim Lovell demonstrates that it’s not always smooth sailing, “Had video trouble at first, but then visit went great. The provider cancelled the charge on the visit that didn’t work. Make sure you’re in a well lit area if you need anything examined

I think the refund of charge is a good fix here but this app rating mechanism also shows the value of having a feedback process and it’s worth noting that the vast majority of in-office consultations don’t come with that (one notable exception is in the UK where NHS England have made the Friends and Family Test a contractual requirement for all practices since 1st December last year).

Note: at 3G Doctor these video troubles aren’t issues as we provide Patients with asynchronous communication before the consult starts eg. all consults are followed up with a private means of providing feedback and if the consulting Doctor felt there would be any need to review images they would be able to request them from the Patient BEFORE the consultation ever started.

​”​And when technical problems occur, some creative thinking is required, as James Langerud mentions, “Great visit. A little technical glitch where the doctor could hear me but I could not hear him. Worked through by him writing on a notepad and I answered the questions.

​This just again highlights the need to use clinically validated interactive Questionnaires before online consulting makes any sense.

Related post: Want to know how to conduct effective online Doctor consultations (2010)


​”What’s exciting is that for those underserved communities, whether they are in rural America or rural China, the advances in technology when combined with changes to policy, processes and practice may make ‘seeing’ a doctor an everyday reality. How soon before we can all have healthcare without borders? Being able to virtually access the best doctors in the world is a dream that is now starting to take shape​”

At 3G Doctor we’re always having to refuse to consult Patients from around the world because UK/Irish Doctors have such a great reputation (unfortunately licensing/insurance regulations don’t permit this) and it’s obvious the Chinese mobile operators have been eyeing this opportunity for years but I think the challenge is not in a future where healthcare is provided without borders but in one were we modernise the regulations.

It’s hard to overestimate the value of local knowledge and practice and there are far too many charlatans abusing Patients for us to even think about making it easier for more dodgy quacks to do business. Regulat​ions might feel outdated at times but they’ve got us to where we are and it would be a colossal mistake to throw away all the benefits they provide Patients and Carers with.

​”​We have a generation of people growing up in a world where ‘on demand’ services are the default. As some of them become the patients of tomorrow, will they shift to the providers that can offer on demand, virtual doctor appointments? Do we expect a future where one day, seeing a primary care doctor in person will be a rare occurrence? Will the rise of virtual visits reduce the humanity in healthcare, given the absence of physical touch?​

This is happening but it’s not going at the speed it should. In his latest blog post AskMyGP CEO Harry Longman explains some of the reasons why it’s not happened in the NHS and it makes it really clear it’s not because Patients don’t want it:

GPs are business people, and they’re not stupid. They have worked out that it’s deeply against their interests to offer all their appointments online, despite the savings in administration. They know that if it takes 11 seconds to grab £27 worth of their time, they’ll see a lot of people who don’t need them and a lot of others who do will be left complaining to reception, never mind the clinical safety issues… …The airlines made the change all on their own. NHS England has the resources of the state, enforcement through the GP contract, publicity in every practice, even pays for all the online technology. And has reached 2.7%. Turning such an abject failure into success needs new thinking which makes this work for GPs

What do you think: Do we need Healthcare Without Borders?

About David Doherty
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