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Dr John Bennett: Good afternoon this is Dr John Bennett broadcasting from sunny Miami today at InternetMedicine.com in the mHealth studio we have the honour of having David Doherty of 3G Doctor. I’ve been following him for a couple years now on mhealthinsight.com and we’re going to have a kind of free form discussion. First we’ll introduce students before we turn things over to Dave. Hello Dianna! could you please describe what you do etc.
Dianna Medina: I’m currently in a master’s program at Larkin University here in Miami studying biomedical sciences and looking forward to taking my MCATs pretty soon and going into medical school.
Dr John Bennett: You’re welcome Dianna, welcome Mailenys Fuentes
Mailenys Fuentes: Well I’m also going to Larkin University studying a masters in biomedical sciences and studying for the mcat and I’m very glad to be here.
Dr John Bennett: okay Ehsan how are you from Ireland?
Ehsan Ghaffari: hi there i’m Ehsan from trinity College a third year med student and it’s a pleasure to meet you.
Dr John Bennett: yeah in the backyard of David almost and Marco
Marco Callo: good afternoon my name is Marko Antonio and I’m from Bolivia and dr. I’m glad to be here thanks for invitation yeah
Dr John Bennett: Marco is a frequent participant in our shows here and the main man Simon how are you doing Simon?
Simon R Downes PhD: I fine thank you it’s 3am here Tokyo it’s an honor to be here I’m a medical student in Japan and looking forward to the presentation thank you
Dr John Bennett: Good day David how are you doing?
David Doherty: good morning, good afternoon and good evening from us here in Dublin
Dr John Bennett: yeah with every way welcome David. I’ve been telling the panelists before we started I’ve been following you for years on your blog and that you’re a very honest reporter of what’s going on if you don’t like something you say. can you please describe your career how you got started in mhealth etc and your background?
David Doherty: yeah my first experience in life that I remember was actually using telephones in healthcare. I was in a sick children’s hospital with a brother of mine and I noticed that the Doctors made a noise that sounded as they came down the corridor and the reason they made a noise is that they had money in the bottom of the big deep white jacket pockets and I noticed when they told news to parents they would proffer those coins to the parent and it was when my mother was given these coins I was particularly interested because I thought it was money for the sweet shop but we went out of the ward, down the stairs and into the lobby of the hospital and she put them into this incredible machine that was sitting there and it was literally a payphone. but I thought obviously my mom was wasting the money and then I saw that emotional connection that she was having to our home and it was a dawning moment for me that the you know that this hospitals most powerful piece of technology was out there were all the smokers were in the lobby and you know it was letting you access billions of pounds of infrastructure the world over for just 10 pence. You could call the Mayo Clinic on that telephone line and then about 15 years later I enrolled at the Medical School next door to that hospital at UCL in London and I was the only student there with a mobile phone and people used to think why has this crazy kid got a mobile phone? what would you use that for, what a crazy device. And they actually fought i had taken the phone from home and took it with me for the day. They couldn’t believe that with this little digital cell phone I could actually make telephone calls but i actually had no reason to have that phone it was really expensive and I had somehow managed to get it by convincing my brother who was a Veterinary Surgeon, as I was living above a Vet Surgery at the time and helping him and so I got a Mobile to take to college by explaining to him the value of it as an alternative to the pagers and answer machines that were in use back then, You’ll remember those days yourself John, but literally there was me in my Medical School Library which I’ve since gone back and lectured in that had no internet connection and now when you go back there are no books there are just screens on desks. but the incredible step is that I’m still gobsmacked as to how slowly we are to adopt technology. In the UK the Royal College of General Practitioners has got a global reputation for training the best family Doctors in the world yet when you go to your MRCGP (membership) exam you are immediately failed if you actually bring a mobile phone into the exam, yet every single Patient in your waiting room has got a smartphone in their pocket and every Doctor is not going to work a day of their future career without the equivalent of something like an iPhone 7 in their pocket, yet we’re making these people not use this incredible cyborg technology – as Elon Musk calls it we’re already cyborgs whether we accept it or not so why aren’t we letting our Doctors use these superpowers? Part of my mission in starting a company that lets you video call a Doctor was also to help Doctors realize how we can actually use use these superpowers and I’ve developed the first CPD accredited course for doctors to teach them about mobile healthcare and I have provided that to esteemed colleagues at events across the world from the World Diabetes Congress in Vancouver to events in Istanbul Turkey. I’ve literally gone around the world learning from people about how they use mobile technologies in their markets and also sharing the insights that I get from that with other Clinicians because I think it’s time we moved on from stamping stuff on dead trees and started using these incredible technologies that are already the tools of our time. You know it’s nothing groundbreaking anymore so it’s really good timing because not only are we seeing all digital technologies converging to mobile phones but also we’ve seeing this incredible thing where mobile phones are going inside other technologies to power this thing that’s being called the Internet of Things because literally the internet is evolving from something that we manoeuvre around with a cursor or a mouse and click on things to something which is used by things interacting with machines so think of things like embedded glucometers or ECG machines with their own connectivity. Now there’s huge value that can come from these data insights but unless we all start using our mobile phones as Clinicians and letting Patients use their phones with us none of these things will be able to ever realise their potential. So that’s my biggest concern and biggest passion for making sure we all get on board and learn about this fascinating new mass media which is mobile the most misunderstood newest mass media most people just think it’s a device in their pocket providing a little internet and they don’t realize it’s as big a step change as we had with the TV or the printed press with Guttenberg. We’ve got this new mass media it’s very misunderstood at the moment and there’s a huge their wealth of potential that we can get when we understand it and utilize it.
Dr John Bennett: (7:30) you know Dave we’re in kind of a similar situation with hangouts we have a hard time convincing a lot of Doctors just to get on the internet to talk, to talk about whatever subject. some people seem to be afraid of the video screen almost. and I’m sure you start from the very beginning like the iPhone came around what 2007-2008 was that the first year?
David Doherty: no we were launched before that. Actually in Europe we had 3G video calls long before Facetime and back in 2006 as soon as mobile operators launched video calls we had the service live. We launched this at the royal society of medicine in November 2006.
Dr John Bennett: so you’ve been battling the whole way trying to get Physicians to use it?
David Doherty: (8:12) well it’s hard to call it a battle when you look at the adoption that we’ve seen since then. We came at this from the Physician side so my business partners are all GPs who have their own clinical practices built out of bricks and mortar so you know we didn’t have to challenge them. Patients want this, all we had to do was tell Patients we were there, make sure the service was safe and we did a bit of design to the service with 3GDoctor that’s worth filling you in on essentially what happens is the patient goes online completes an interactive medical history questionnaire that was actually developed initially in america by a company called Primetime Medical. The product is called Instant Medical History and it was clinically validated several years ago by Professor John Bachman who’s the Professor of Primary Care at the Mayo Clinic and it provides an incredible opportunity for patients to have their own time giving their history. Literally patients when given a blank email page or a page will write 10 pages or two lines. Patients aren’t always aware what things are relevant but this process also gives them time to consolidate their thoughts and feelings and share things. They can also complete things like depression scalings, you know the stuff that you’d be familiar with Consultant Psychiatrists using, Patients can actually fill this stuff in themselves. I see doctors complaining all the time that patients waste their time but the incredible thing we know is that US Doctors spend over half of their time doing clerical work that we know Patients are interested in doing, that they can do and that they’ve got the tools in their pockets to do it so it’s time we started letting patients give that history. This also provides opportunities for Doctors to not just be some sort of drone asking the same questions of their patients but go straight into really trying to help Patients with their information and so if we twin that with other stuff like a website you’ve seen – I mean seriously in 2017 we still have patients who go to their Doctor and try and share a webpage and the Doctor is like laughing at them thinking this is the most stupid thing that they’re ever going to do, what look up the YouTube video with their Patient. Whereas because our service is completely online and we don’t have the brick and mortar office we don’t have any problem with discussing online content with patients and just that alone is a huge opportunity. Since we started I’ve seen an awful lot of companies start up offering video consults and what they often try and do is the very difficult and dangerous prescribing part of the Doctor role rather than actually trying to help patients with information. With most Patients getting interrupted within 18 seconds of coming in the door and starting to talk to their Doctor, we here have an opportunity for the Patients to give all their history through the interactive questionnaire and then at the end they get free text box that they can use to share websites or any extra information they wish to share and the Doctor gets this in a concise familiar format before they actually do the video call. It means that Patients don’t pick the Doctor but the Doctor gets to pick the Patient. So we have a Doctor who looks at the output from the interactive history and decides which Doctor would be best suited to consulting with that Patient. Some of the things we find that actually aren’t going to be suited to a mobile video consult and what we can do in these instances is instead of charging the Patient for that consultation we can give them a null fee and just advise them to go to their Family Doctor with this printed report as it will make a help their Doctor make sense of their needs. And what the patient finds is that when they go to the Doctor with this letter from their Doctor will see this history printed out for them and realise we’ve done their job for them. It also means we support continuity of care. when we’ve seen a Patient they get access to a written report from us because immediately after the consult our Doctor writes notes and then Patients can just log in and download the PDF or share it. This report details all that was shared via the questions and answers and the info mentioned in the free text box together with the Doctors written report on the bottom of that. This supports continuity of care as when you go to see the next person you don’t have to repeat it all. This is a major problem facing telephone helplines or the insurance paid for video call services where the Patient has to go back to another Doctor and tell them all the things they said on the video or telephone call and that’s really ineffective because most doctors will just cut past a recount of events and just ask their Patient to tell them why they’re presenting and so you might’ve spent half an hour talking to a Doctor over video but because it lacked documentation you still have this complete disconnect and it just doesn’t support continuity of care because you can’t go back and easily review audio or video recordings. We also look to follow up with patients to for example check on how the advice worked out so that we can learn from our experiences and monitor how well we are doing and and that too just wouldn’t be possible if the content we were looking at was a 10 minute recording of a video call so the documentation part is very important. That’s a real key message with with the mobile phone everything’s documented you know every website you’ve been on big tech companies like Google and Facebook are tracking and they have all this data but you know when Patients go to the Doctor they walk in and it’s all new: “who are you? what do you do?” and it’s just quite bizarre that we just don’t have data sharing. One of the first things that’s needed to enable that is that we move care from the old way of doing it it was undocumented and you sort of tried to remember what the doctor said to this fully documented way which also helps the Doctors be concise and also helps them learn from the information that’s being shared but on top of that interactive history you can now add things like the Alivecor ECG readings, data that you can capture with your phone and so more and more increasingly going to see diagnostic stuff with bespoke questionnaires that go into that. so we are working with a paediatrician in London’s Harley Street and he’s probably the most experienced Consultant Paediatrician in Europe – his name is Professor Sam Lingam, and we’ve taken the questionnaires this guy starting creating in the 1970s. I think it was 1979 he was giving all of his Patients at Great Ormond Street Hospital in London access to their patient notes and another doctor looked at this and thought what is this bizarre doctor doing and so he wrote a paper reporting on what this experimental weird Doctor doing. and today he uses what he found is he had these long queues going out the door of Parents and he just didn’t have the time to sit with every one of them and take a history so he made a very basic questionnaire and it grew into a huge wad of paper that captured all the history info from the Parents and Grandparents. A lot of it was genetic history that today people are thinking they have to run to companies like 23andme for but actually you get most of this information by asking specific questions of parents you know things like how babies were delivered etc and he’s produced all this and we’re putting the questions into the Instant Medical History tool and also developing a service for him so it’s not just really basic stuff what we find we can help with. We can actually manage some of the most complex and difficult to diagnose patients that exist. Patients who in many cases have ding donged around doctors without documentation that when they actually take the time breathe deeply and complete their questionnaire they can give the best history they have ever given.
Dr John Bennett: (15:30) it seems probably no accident that Google’s seems to have access to a lot of NHS Patient records, is that correct?
David Doherty: I think we’re going to find that the NHS has given it all and we will probably find out in the future.
Dr John Bennett: yeah it’s funny Google seem to be making more headway in England with access to patient records than they are in America
David Doherty: yes but it’s quite contentious and there’s been a great paper published by a really smart lawyer who’s working at Cambridge University that reports on how Deepmind – they call it Deepmind but it’s owned by Google so it’s the AI part of Google -went into the Royal Free Hospital Trust to produce a very small app for Patients who are on dialysis but it turned out months down the line that someone found out through a freedom of information access request that actually they had been given access to Patient records going back 6 years and going forward ten years which is just literally half of all Patients in North London who have ever been in that trust despite the very small requirement for record access to produce the app. It appears that the rules don’t seem to apply to Google, you know the sort of things that they stop Clinicians like you John doing because of Patient Privacy issues, well these don’t seem to apply to Google. Possibly no one is big or brave enough to actually take on Google because like a lot of major tech companies their senior management appear to have a swinging door that let’s them move in and out of powerful PR jobs in government. So there are big issues but maybe there’s an upside because there’s certainly no value in squirrelling away all these records like the NHS has been doing for years. They’re still posting records through the postal system on CDs and stuff so that’s also not good you know. I think we should really welcome some of these tech companies but we should be careful to make sure that they’re very transparent and they should apologize when they make mistakes like this because clearly those millions of Patients who went into that Trust never gave consent for a company that sells advertising for a business to get their medical records and there’s privatization of the NHS really coming in that is going to confer huge value to companies like Google because as you know the insurers will pay for this information all day.
Dr John Bennett: yeah well going back to your the percentage of physician time spent on clerical tasks just today I saw a statistic that says exactly you said, in the uSA Doctors say that they spend 50% of their time doing clerical work. Would you say that percentage is a little better with your GP service?
David Doherty: I think what we’ve got to do is realize that the most underutilized resource in the whole healthcare industry is the Patient. They’ve got the capacity they’ve got the interest in getting this information correct. You know whenever they reveal Patient records to Patient’s the first thing is they find things are completely wrong, oh that wasn’t me, what are you talking about, this isn’t information about me, etc. I mean can you imagine if people’s bank accounts were being run in such a way that only the bank manager could ever look at your account statement and see what’s going on. We’d all be broke on the road you know so yeah we’ve just got to move beyond the status quo and there’s been some really good pioneers in the UK for example the fabulous Dr Amir Hannan, everyone should follow this GP and support him because he’s doing groundbreaking work since he took over the surgery that had been previously run by Dr Harold Shipman – the Doctor who was struck off and convicted of killing a lot of his Patients and he really got away of it because there wasn’t visibility of healthcare records. he was killing a lot of elderly patients and getting away with it as their children couldn’t really see what was going on with medications being prescribed. So when Dr Hannan went into that practice as their new GP obviously there was this huge lack of trust with the doctor so he came in and literally opened up the medical records to his Patients as these are yours. I think it’s sad that you needed a really harrowing situations like this that you have to just stop trying to keep going on the way you have been but actually the way he’s been practicing is interesting because he also used Instant Medical History with his Patients because you find that as soon as Patients can see their medical records immediately they want to talk about them and they have questions. As a smart Doctor letting Patients communicate with you enables you to provide more value because you can both see all the stuff that was done before and you can see why the patient’s got these concerns. Literally our job has got to evolve into being more about guiding Patients towards better information as it’s no longer good enough just to complain that Patients are looking up the wrong things on the internet. The opportunity here is to be more like the librarian and sign post Patients to good resources and knowing what resources will be useful comes from experience and having the medical records and letting Patients share with you their presenting concerns. We’ve actually had patients use our service that we just needed to point to a YouTube video and when I’ve shown this the doctors they were surprised that we didn’t call the patient but just asked them to check out a video and then decide if they still wanted a video consult. Doctors are just amazed at this and it’s clear this is a huge unmet training opportunity. Medical schools aren’t teaching future doctors how to share content with Patients and many of the older Doctors and Tutors are scratching their head and will say to me but you know these Patients could just look this up on YouTube themselves anyway but the difference between something given by you is similar to the value of buying drugs on the internet and being prescribed a medicine by a Doctor. This is the thing with digital content so we have to teach this, bake it right into how we teach medical students and the sad thing is I go to medical students they and they are sitting in their Anatomy room looking at dumb pieces of printed paper just like I did over 20 years ago and its a disgrace but one of the things i find is that there was a population of girls who all had iPads and iPad mini’s and they all had 3D4Medical all downloaded and I went up and I talked to them and I found they had all bought these themselves and there hadn’t been encouragement from the lecturers, I mean you cannot be a Professor of Anatomy and be thinking that somehow teaching people with printed pieces of paper is a 2017 thing to do. Children are growing up today thinking nothing of pressing a few buttons on this thing here and getting a car come and pick them up, or a food delivery or next day delivery of an ECG machine they can stick on the back of their phone. It’s a different world and we all have to live in that world because we’re supposed to care for Patients in that world.
Dr John Bennett: so generally medicines is kind of slow in acceptance of the digital world you feel?
David Doherty: a little bit slow but you know there’s there’s elements where it’s really flying, One of the other things I’m working on because I have some experience of Veterinary Medicine where they had electronic healthcare records 15 years ago. I noticed recetnly the CEO of the MacMillan Cancer Trust found her child who had a serious medical condition and was being seen by number of hospitals but had no access to medical records, and the two different NHS hospitals treating her themselves couldn’t access one anothers electronic healthcare records. And then she phoned up the out of hours Vet – and I know the person who installed this electronic healthcare record over ten years ago, and she was surprised how her little puppy dog had fully electronic records accessible from anywhere on an iPad. So we can learn from other medical practices and I gave a lecture recently at the Royal Veterinary College in London talking about how we should have One Medicine as you know half of this problem we have with antibiotics is an animal problem – anyway we can learn lots from looking at the bigger picture and I’m learning why Vets have been able to innovate in ways Physicians can’t. I normally find that the veterinary/human medicine difference provides a perfect sniff test of if something’s valuable or irrelevant and exists just because of a political reason, as you know there are a lot of EHR conferences you could actually spend literally about nine ten months a year touring around these big EHR events but they don’t have that in veterinary medicine at all. Vets would laugh at a lot of the things that the human medicine doctors are doing and so we can learn from that, there are differences clearly, but we have to realize that the reason why is often political and the big data companies are doing other things with the data relating to humans. we have to stop that you know and mHealth is how we’re going to make a lot of these very opaque company operations like within the pharmaceutical industry clear, this is the big opportunity Doctors have to help clean up their industry and really add value to what they are offering and start working more directly with Patients and taking out some of the powerful middlemen because the time Doctors waste on clerical duties is all too often serving some insurance corporation and not the Patient. Physicians need to stop serving other masters and get right back to their Patients. That’s really what we try to do at 3G Doctor as there’s no insurance company involved it’s just you the Patient with an independent impartial doctor and we really try to style it more like you’re accessing the advice of an uncle or auntie who’s a Doctor and how they would talk to you. So say you know you might meet your Uncle at a dinner party at Christmas or something you say hey uncle Chris I’ve got this issue with XYZ, uncle Chris doesn’t pull out drugs from his pocket, uncle Chris doesn’t sell you something, uncle Chris might give you a note and say go to your doctor and say this and this. And when you go to your Doctor you say your uncle Chris is a neurologist in Cambridge and he told you to bring this up. That’s the sort of thing we want to be doing, we don’t want to replace your family doctor as we know that that’s the best place for you to get care but so many young people particularly have lost that relationship and so many older people can’t connect to their busy GP. We’ve had a patient who had a parent who had a stroke and they’ve called their GP to talk about their Parents care and the GP has told them that because of privacy issues they can’t talk about this other Patients care and they’ve said what do you want me to do, bring my mum who you know has had a stroke in here with me? and they are told well that’s what has to happen. It should be obvious we just have a completely bizarre thing going on here whereas with us if they want to talk about something like their mom who has had a stroke it’s simple as just sharing this is her age this is what’s happening and they can do that over a video call with her present if need be. This is another big advantage of going on information that the Patient shares with us. Isn’t it a really weird thing that we’ve let this a big clerical job also disrupt our ability to actually care for people which is even more concerning than just being a waste of half of our time.
Dr John Bennett: okay david let’s see it the students have any questions or comments.
Simon R Downes PhD: I have a question… …thank you very much is very interesting to hear and i’m happy to hear about the company called interoperability and that one of the hangouts we’ve had is the difficulty particularly in the USA where the computer systems cannot talk with each other. I would like to see this change as it would be wonderful to be able to do this. another thing i was thinking about is that you are using video i was working for a company for a couple years where as a psychologist I was using text only to communicate with clients and the idea of bringing video came up but we never got to that point and I was wondering firstly do you have a text-based system if for example for people in remote areas that may not have video capability and well who is able to use video. thank you.
David Doherty: yes a great point. text is obviously the way people prefer to share information and with the service that actually comes through in the preconsult care that we provide through the questionnaire, so when you go on the questionnaire it asks about how you’re feeling, have you suffered from depression, how long you have felt depressed for and all those routine questions which would send any sane Doctor in need of care themselves if they had to spend the day asking them. Because the history is taken from the patient before the consult starts we’ve a new starting point. In terms of access to video calls almost 98% of the UK and Irish population have this and all of our Doctors are General Medical Council or Irish Medical Council registered and as part of the Insurance conditions we only provide care for Patients in the UK and Ireland. If for any reason a Patient can’t access video we of course can always fall back to a voice call because Patients register for our service using their mobile phone number so we text them before we call and then we call you on your number and if you can accept a video call then you’re fine if. If you’re in a rural area that doesn’t have 3G coverage you might have Wi-Fi in which case you can choose to have a FaceTime call even though mobile reception is poor.
Simon R Downes PhD: this wonderful I mean just throwing one more thing I mean I live in Tokyo and we have something come out last year called Pocket Doctor and that’s a video-based a similar system I think I’m if I’m catching you right but what we’re finding is that the younger people are there on to it but people who are maybe they’ve even into their both 40s 50s are a little bit behind in the technology. How can we train them to be ready to use this and to accept it in Japan where they’re very afraid of privacy and maybe how they look on the phone perhaps even. How do you prepare the patients for the experience
David Doherty: yeah like I say innovation happens very differently in different countries and we’ve had in Japan incredible things happen where for example you will know as this is five year old data but more than 80% of old age pensioners in Japan today have used mobile data services. so they are in ways more ready because as you know they’ll play CartRider with their grandkids like the South Koreans. But in some markets mHealth is completely illegal so when you sit there wondering how are Samsung and LG completely missing out on the opportunity to innovate and apply tech in the healthcare space it’s because it’s literally illegal in their home countries, so when their executives come over and they see people doing it here they go we could do that maybe as like a research project in a hospital but we couldn’t do that with ‘real’ Patients and so in these markets this still looks like a really experimental approach because of their mindset because like you say the legislation and privacy issues are restricting things. I once got to see details on LG’s big failed rollout of a telemedicine project and they had Patients who all had 50 inch TVs in their homes set up with webcams to let them video call their GP around the cornerand they showed me all the data on why this approach failed and yet they couldn’t identify the reasons. The first thing I asked was what healthcare content did they put on the TV and they’re like oh it wasn’t about content and I was like well what were you expecting them to discuss? And so it’s this type of disconnect that’s going on, if you don’t have content to discuss with the remote Medic and you don’t have access to your medical records none of these meetings will be very valuable and you might as well just go around the corner and walk into your GPs clinic – and in South Korea they have also got a very high GP per head of population ratio so it’s actually quite easy to go around and see the GP you know. In our case sometimes Patients don’t have an accessible GP, or they’re not registered with a GP, or they’re bed bound so they can’t get to the GP but it’s clear that every country seems to have its own unique little reasons why this hasn’t taken off. From Korea and Japan the powerhouses for mobile tech outdated legislation has just stopped innovation in its tracks. In Russia they’ve just recently passed a telemedicine bill and for the first time it has become legal and I’m over there next week trying to learn about what needs to be done. Japan’s really interesting because they have prioritized the responsibility society has to seniors but for some reason this disconnect still exists so clearly we have to learn from how others are innovating. One of the things we’re seeing in England is a much slower adoption of mobile by senior citizens so I’ve written a blog post about ‘how to teach your senior to use text messaging’ because we don’t have those things you have in Japan – in japan you have the Raku Raku phones and you can go in a phone shop and there’s a 70 year old there to help you, but when you tell this to a Doctor in the UK or Ireland their jaw would drop because they’ve only ever seen spotty young people working in phone shops. Things can be completely different in different markets but there are huge opportunities to learn from one another which is something I really try to do with the mHealthInsight.com blog and with the LinkedIn mHealth group that now has 8,000 members from all over the world. I get to see what companies like NTTDocomo are doing and it just baffles me because they’re trying to innovate in the face of outdated legislation. Samsung for example even have their own hospitals but they’re just completely missing the opportunity to lead this market.
Dr John Bennett: (33:55) we’ve had a really hard time getting doctors on to do hangouts Dave, we haven’t had one Korean Doctor and we’ve tried to get Japanese neurosurgeons but so far no success. it’ll take time I think in those countries but Simon you say it’s because the culturally the Oriental people don’t like to get in front of a camera?
Simon R Downes PhD: um it’s that and also yes privacy issues they’re very afraid. I can’t get doctors on Skype or even individuals they feel very worried about privacy issues in Japan it’s all very interesting but it is changing so I expect we’re going to be seeing acceptance and there’s this new laws passed for remote care of people in the country so they will be able to communicate with a company called Cure.Ly and we were trying to make some headway but it was all ready but it just didn’t get the take up.
Dr John Bennett: Any one else have any questions or comments?
Ehsan Ghaffari: I do first of all David thank you so much I love the talk i love you the great field that you’re interested in. i love it too. I’ve got three questions if you can answer quickly. The first question is so you mentioned really interesting point that the Patients don’t pick the doctors on your platform how do the doctors choose what Patients they can you know offer consultations to on your platform?
David Doherty: (35:36) so that is done on an individual basis, what we find today with triage is that healthcare organizations typically have the least experienced person trying to do it so for example when you ring up the NHS’s 111 telephone service they literally have a school leaver who’s reading a script off a screen and actually that’s where you should have your most experienced. so it might seem completely counterintuitive but if you gave a medical history to someone like John he could look at it in seconds and say that’s what we need to do with that Patient, that’s the type of Doctor that would be able to clear that up. In our case our first priority is which doctor we’ve got available for the Patient you know we have to be realistic about who’s available to make the call and the second thing is we get a very good feel for it you know. Some people will want to talk about something emotional so then it’s about which doctor is available who’s really emotive whereas if we’ve got someone who’s got done a lot of research who’s got the best internet research skills. That’s actually a big challenge and and is a skill we struggle to find in doctors when recruiting. We have to do more to develop these skills within doctors but also find ones who’ve got an actual interest in doing this, the reason I just fell at the feet of one Doctor colleague was because he had a sign in his waiting room which said that there was a weekly prize awarded for the patient who brought the most interesting research from the Internet to their appointment. Cool right? Well that is just the type of Doctor who needs to be providing this service. so if a patient for example wanted to discuss issues debated in a protracted argument on MumsNet, a website in which young mums discuss issues, this Doctor would be an ideal one to chuck in on that because there are all these opinions and some of them will be related to sales materials produced by commercial companies so a savvy doctors who has been around a while and heard all the sales pitches can and they are perfectly placed to get to the bottom of this stuff really quickly and help explain things to Patients. The direction of the consultation really depends on the out put of the Instant Medical History questionnaire that the Patient completes and that really is the best way of working with Patients but you know sometimes the Patient could be directed directly to their family doctor with the information but as you know some of us don’t have one so in that case the Doctor can really work with them to ensure that the next step they take is the right one.
Ehsan Ghaffari: (37:30) so the Doctors on your platform will pick the Patient’s they want to treat or do they get one at random to look at?
David Doherty: so we’ll have a doctor always on you call to screen the outputs of the Instant Medical History questionnaires as they are received and they in turn decide who is best placed to consult with that particular Patient. This decision is made based on who’s available so for example if tonight you were a Doctor working for us in Dublin and you’re available and let’s say a Patient shares information relating to something basic like for example blood in his urine, if we’re sure you can handle that you’re assigned that Patient and you can get on with it. Alternatively if we see a medical history that’s more challenging and this happens a lot because the questionnaires are interactive so Patients will often start with a keyword and then end up answering questions that might reveal a completely different issue for example something really really sensitive but non-urgent, in this case we might think one particular Doctor is a bit more emotive and so we’ll just ask the Patient if they mind if we call them in a hour when for example Dr. Kavanagh is going to be available and we think she’d be really suited to helping you as this Doctor specialises in this area. So we schedule you to see that particular Doctor because you know once you’ve done a few Patients with similar issues you can get really good because you’re learning all the time. Because Doctors typically get very little experience helping Patients who have done internet research which is mostly what we do, we find Doctors will quickly get more talented at covering certain topics. I think Doctors should really be encouraged to work on things they like doing, so often I see the morale in Doctors is so low and it’s quite obvious why if you think about it for example we’ve got Doctors who are new mothers are we’re dragging them back out to work in hectic 12 hour hospital shifts from which they’re spending 2 hours travelling time, it’s just ridiculous that we’re force fitting these talented professionals into this rigid job
structure because we can’t be imaginative. I mean do you know there are 4 million homeworkers in the UK and Ireland? So why are there no home working Doctor career opportunities offered to graduates there at Trinity?
Ehsan Ghaffari: silly isn’t?
David Doherty: (40:20) crazy, I mean look there’s all of us here talking away from different continents but there’s not a Doctor in the country who hasn’t got a smartphone in their pocket who could be working with Patients like this but no one’s ever talked to them about this opportunity so we have them leaving the career in droves instead of trying out the opportunity to be home working Doctors. I keep saying that we should have mHealth units in medical schools helping students appreciate that they can work from home as a career because medics can now have careers working from a veranda in Australia caring for Patients in the UK late at night. We need to have people talking up careers where Medics can put their feet up and be a big deal online you know ‘I’m gonna have the best reviews on trip advisor as I’m brilliant at this’, ‘i’m going to raise my family and i’m going to have this fantastic life and i’m going to really add value to patients who were struggling with stuff’ but instead what we have are Doctors writing in broadsheet newspapers about how they schedule a suicidal Patient for a consult at nine o’clock in the morning and then complain that the patient was minutes late. I mean why would anyone schedule a Patient who was suicidal and in this case the reason for the patient feeling suicidal was given as being eviction from her flat for non-payment of rent, is it any surprise that this Patient has money concerns after we’ve made them wait all weekend worrying about their life and expected them to take of work on Monday to come into the clinic. This must seem a bizarre world for those who think everything
must be managed with an office visit. Of course we’ve had 2000 years learning how to perfect the office visit only model but the mobile phone provides us with the opportunity to make a step change so that’s why I want to share everything we do widely. You know initially when I started this business my Doctor colleagues would say to me ‘oh David you’re going to give all your ideas away’ but now it’s becoming obvious giving ideas away creates value for example it’s how we market our company, it helps me to find and work with interesting people like John and the viewers of this hangout get value and so are inclined to want to trust and work with us too. If you’ve got valuable ideas my recommendation is to start give start giving them away. We’ve just heard from Simon there that a company in Japan has just started out doing what we launched 10 years ago people. We were told we were mad doing this and that no Patient would ever want to Video Consult with a Doctor and that we’d never have been able to recruit a single GP but sharing our journey and experience has been the root to building trust and recruiting talent and making money so that it remains a profitable venture that we can reinvest in. In the future most of the work Doctors do with Patients today will be done remotely so it’s important to realise we need to start becoming experienced at this.
Dr John Bennett: (43:00) a you have a training program correct? for healthcare professionals who want to learn about mHealth?
David Doherty: yes. I produced that for the health informatics society here in Dublin. They are also a part of the Irish Computer Society and it’s a really progressive organization that produces the European Computer Driver License which is a course for people to learn how to use IT proficiently and about 20 million European citizens have already done it. When they saw what we’re doing they realised that there was a need for a course to teach people how to start using mobile because there are loads of IT companies going into healthcare organisations selling expensive mHealth projects and promising to train staff on how to use it and what actually happens is that the IT firms presume that they are being paid to merely train the staff to use their app and not on how to use the technology and literally mobile phones have been invented and deployed so quickly it’s caught people out. Imagine if an ambulance or a helicopter was invented in the last five years and we were just giving staff keys to go off and pick up Patients? You know we don’t do any tests to see whether staff are competent in the use of this technology and we keep seeing medics getting in trouble because they were breaching policy by using apps like Whatsapp to share a medical information like a picture of an x-ray with colleagues. They did a survey in the UK on why so many Hospital Doctors were using whatsapp and it revealed it was because the corporate IT systems were so slow, buggy and expensive and just hard to use and unconnected they were using whatsapp for sharing private medical information. Hospitals think they need to punish staff and clamp down on this but actually they need to train staff better because there’s so much potential in what is clearly the most powerful tool we’ve all ever put in our hand. The upside of training is that you get much more value from mobiles and we’ve now developed modules of the course with bespoke focuses, for example on cardiology at the Irish Cardiac Society, for diabetes at the World Diabetes Congress.
Dr John Bennett: I think you’re doing such great work there
David Doherty: Thank and that’s why I’m so keen to help you with the mHealth Studio because I went to the World Diabetes Congress, a biannual event and the biggest event in the world diabetes industry and ran by the International Diabetes Federation in Vancouver and they sponsored Patients to fly in from all over the world on bursaries but when the Patient’s got there and started tweeting photos of presenters slides they were told off by the organizers publicly. Can you imagine what an insult that would be had you flown from Brisbane to Vancouver as you wanted to share info to help all the other diabetic patients and you’re like wow why are they’re angry at me for doing this? They’re getting a slap in the face for doing that because these scientific communities live in the past and don’t want to enable free sharing of information. To get a sense of how outdated this approach is consider that the only hour of content at that entire world diabetes congress was the hour I recorded and put on youtube. I just find that amazing, I mean has no one else working in Diabetes care got anything they want to share with people? Do we not see that we shouldn’t be doing the same conference every two years. Sharing let’s us say that’s been said that’s been done let’s move forward. You can’t keep saying the same thing every year if you make sharing the default because you could just watch last years lectures. We need to share to build the collective intelligence and move everyone on and I think that’s what you’re in a really unique place to do with these internet medicine hangouts.
Dr John Bennett: you know I’m glad you feel that way Dave. You know I couldn’t understand when I was talking to a group of physicians & phd’s on the internet saying you just take a smartphone to a conference and interview people and they looked at me
like I was crazy. This just takes a minute because you have an excellent camera and a means of communication from a conference – a place where other people would like to be. There’s nothing to stop you talking directly to the guy that just presented but what’s the huge change in mindset is needed before people do that?
David Doherty: (47:46) I find it’s been taken out of them during their training. You know if I sit you at a desk and I make you copy stuff out of books and learn it you. If I need you to memorize the content of books to do exams I’ve began taking out of you the ability you have to excel in an environment where all that information is stored on your phone. Today all that information in our medical school textbooks isn’t just on our phones it’s also in our Patients pocket on their phones too. I often ask Doctors if they have ever been googled by a Patient and some still think this isn’t happening. Go out in their waiting rooms and their Patients are on Goolge reading and writing reviews about them but the Doctors just don’t know how to find this so I show them on Facebook or wherever. A big opportunity lies in playing to a Doctors ego. We got involved in a really cool project called Harley Street TV about 8 years ago and found this really bizarre way to get really successful Doctors interested was to show them what happens when a Patient Googles their name. When you do this you often get an add for a rival clinician around the corner who are running Google adwords and the Clinician would normally say he’s going to sue them how dare they. Then you keep going down and you’re soon on page 5 and it’s all just rubbish out of date stuff about him and old hospitals he worked at before. Then we’d show how it can look for a colleague who was already working with us and the first thing you’d be greeted by was a lovely YouTube video on specific area of his expertise. Something else we learnt was that these medics weren’t primarily motivated by the impression it would make on Patients but rather that it had on their children or their childrens friends from school because googling what your friends parents do is now a common thing nowadays. Medics want to be proud of how they look on the internet so if I was you John I would just be saying look this is what comes up when I Google you but if you join us on InternetMedicine.com and record an interview that’s going to be the first thing anyone sees plus you can put a link to that on your Twitter account and you’re good to go, how could they say no to that? No one wants to look bad. and you know sometimes you’ve got to play to people’s ego to make them want to do it but the young ones we need to go and actually train them on the opportunities to share, it’s all about training.
Dr John Bennett: (50:10) well I think the students can probably answer this one, I mean I wish I was a student again because you must get taught from day one how to do things digitally is that correct? I mean first it’s a little different as all of you grew up with computers unlike me and you’re all very adept at Facebook etc etc but was it an easy transition for students to get into the digitalization of medicine?
Ehsan Ghaffari: for me like once you start getting into the internet young so like I just started through YouTube and Facebook and then automatically because those two platforms become a part of your daily life anything else would be so much so much easier to adapt to whereas I feel the older people when they come in they’re not bound
by Facebook or etc so they’re just like basically lost, they don’t have their own little home on the internet whereas like we’ve already have our own niche where we constantly have visited you know clicked the notification button every day and the internet sort of becomes home for you you know it becomes second nature and everything else is easier to learn. In terms of college we only had one project in three years so we’ve had one this year where they told us to do a study or an essay about health behavior changing apps and how useful they are etc which I did about some Chinese app which measures everything. It’s called iCare Health, by holding one finger behind the camera one finger in front it measures your blood pressure, your blood lipids, gives you your heart rate, your SATs your cell oxygen saturation and then you can like you can self monitor so it provides it puts it into a graph and you can monitor over time and then it gives you little ways on how to improve on each of them and it tells you if your results are normal or not but then when you come to use the coins which you get for measuring the shops in Chinese so you can’t really use the coins or anything but pretty awesome, just one essay.
Dr John Bennett: (53:20) Diane you’re being quiet today, you don’t have to say anything but do you have any comments or questions for David?
Dianna Medina: oh I just wanted to say a little bit about the topic that you just mentioned. It’s a little bit difficult kind of growing up in the internet world and having Google right there you always want to google search anything for a project or before you start actually finding resources or journals for references for any kind of paper and it’s difficult growing up in that and then trying to go to school and everything is like out of the book or out of this really old textbook or having to just search and get all your information from there as opposed to utilizing the new tech and the new apps that we have available in medicine. So I kind of feel like education is definitely a little bit behind in that sense where they’re trying to teach us the old way but we are learning in a totally different ways.
Dr John Bennett: wow so that just still occurs.
David Doherty: through the mHealth network that I’ve built up I get to learn some really interesting things for example students who are on the iPad project in some medical schools in the US that have completely thrown out not just the books but all printed content and the students there have written to me saying ‘hey David I really like your blog’ and when I’ve asked to look at their apps they’ve given me passwords to log inand check out what these students are doing and when I showed this to a student over here they think I’m like some man from the future because they don’t know how I’ve got all this stuff in the iPad and they want it because it’s obvious it makes studying so much easier. UCIrvine published a paper that showed if you were one of the students that was given the iPad that year you scored 26% higher. On my blog I wrote how if anyone now fails in a US medical school that hasn’t yet got on the iPad project you could probably take your school to court and win damages because it could be argued that they are failing you as long as you’re within 26% of the pass mark because rival medical schools have proven that the students perform better, and I think the reason they perform better is because you know when I’m going along with my histology book on the bus it’s hard to be getting it out in front of people and stuff like that but I can do the quizzes and all of that on the iPad app and so it’s much easier to fit this with your lifestyle and not break your back carrying every book around but also use five-minute opportunities to deep dive into a subject and do some research but also apps are better than books. Something I’ve noticed here in the UK and Ireland is that there’s such competition for medical school places that the students are really academic types. I often ask audiences to get their phones out and then ask for them to get their other phone out but medical students don’t typically have a second phone and they don’t seem to prioritise having the latest smartphones. These Medical Students are all playing grade 8 violin but they’re not into tech and I actually think we’ve got an endemic problem that we need to overcome as we know they’re never going to do surgery with just low tech scalpels so we’ve got to have to modernise. My anatomy lecturer told us to go and get a Nintendo Game Boy and that was back in the 1990’s in London and I really think Medical Students should be using smartphones in their exams. Remember calculators being banned from maths exams? Just as Math exams aren’t easier now that they have calculators because the questions are now more complex and of course these graduates use these tools to engineer better bridges etc because they trained with tech. We need to think like this in medicine which is why I picked up at the beginning that we have General Practitioners literally being failed if they bring a mobile phone into the membership exam. When or where in their career is a GP ever going to be without a mobile phone when working? If a Doctor ever practices medicine on the moon they’ll have a mobile so why are we telling them they can’t use this tool? Isn’t this part of the problem facing Patients who want to discuss youtube videos or something they heard John discussing at Larkin Community Hospital on an internet hangout. It just doesn’t make sense to be going to a doctor who’s sitting there with paper binders and an EHR that no one else can look at…
Dr John Bennett: (58:32) you know I thought it’d be a done deal David when they come out with that study you mentioned at UC Irvine were students were doing 26% better in their exams than compared with their associates who were traditionally trained I thought it’d be a slam dunk were all schools would go oh wow let’s all get iPads deployed. But as far as medical education it sounds like it hasn’t seemed to have occurred.
David Doherty: yeah ten years ago a good friend of mine Dr Henrik Andersonn from Sweden started a company and they produced this product called iDoc that was rolled out by the Welsh Deanery to every student with a mobile operator giving all the students free iPhones and before that they had bought these weird Microsoft PDA things so
that was really early on but they just kept picking the wrong platforms so every year you’d think this the future of Medical Education but they kept choosing to buy these unsupported Microsoft devices and burning themselves as the operating systems changed and the old ones would no longer be supported. Whereas these US Medical Schools have started with the iPad and the community of developers that Apple has inspired means that now the skills of the most talented developers in the world can now be reapplied to educational content. If you ever get the chance to check out the apps these students are using there are groundbreaking details that will blow you away. Are any of the students using any of 3D4Medical’s apps? Hands up? No one? Well you should, they do all these amazing Anatomy apps that allow you to learn through playing multiple choice quizzes. It even lets you share your scores with colleagues on Facebook groups and the Medical Schools are now able to mark students based on how their study group performs. It amazes me that medical schools are still training students to be individual performers because we know the job is about working as a part of a team. Because the iPad scores are all connected the administrative hurdle for lecturers to teach in this way has disappeared so students are now incentivised to pick up on when members of their team need a bit of extra help because individual scores impact on team performance, once students are rewarded for working as part of teams it just becomes natural to do things like Hangouts. The iPad enables medical students to be trained to work in teams and considering that’s what their career is going to be all about it should be a done deal you know but some of them say they’ve got reservations about buying iPads because they think they’re expensive or that the students will be playing games but seriously if you’re at Medical School your motivation isn’t to play computer games is it?
Dr John Bennett: I don’t think so no I don’t think so. Well David I won’t keep you too long
as you’ve spent a lot of time I really appreciate you coming out and also to all the students but could we get a view of the Kerry countryside?
David Doherty: okay okay did you get that?
Dr John Bennett: Wow that’s beautiful South Western Ireland there. Well I hope we can do a lot more of these David and thanks again for all the students. Now I’ll finish the televised part and then we can just chat so thank you very much.