Join the “Do healthcare systems need their own app stores or could they achieve more by committing to training” #mHealthTV Hangout at 1am (London) on Monday 1 May 2017

#mHealthTV

Following last weeks fun #mHealthTV Hangout (click here for the video and transcript) organised by John Bennett MD at InternetMedicines.com we’re going to be hosting this weeks event on the topics that are discussed in this blog post about NHS England’s plans to continue pursuing the concept of having their own App Store.

Already confirmed to join us for the Hangout will be John Bennett MD in Miami (Florida) and Yuki Byambasuren MD in Queensland (Australia).

Refresh this blog post at the scheduled time and you will be able to watch the livestream video, ask questions and view the transcript (useful if you want to follow along in another language.

Note: if you have ideas or suggestions for a mHealthTV hangout or would like to join us for the discussion or sponsor one please get in touch via the comments below.

Draft Transcript/Links:

Dr John Bennett: Good evening this is Dr. John Bennett televising from Miami for mHealthTV or the mHealthStudio with David Doherty leading he did last week he’s doing it this week he’s a mHealth expert from Europe, we are also lucky to have Yuki Byambasuren MD a Doctor from Queensland Australia’s Bond University. Let’s do the introductions. First Yuki can you just tell us a little bit about yourself before we turn over to David.

Yuki Byambasuren, MD: Hi everyone and welcome thank you thank you John I’m a Doctor from Mongolia I’m currently doing a PhD degree at Bond University in the Centre for research in evidence-based practice. My project subject is smartphone health apps and their effectiveness and their potential to be used in a primary care settings

Dr John Bennett: welcome you’re the first person I ever met from Mongolia. okay very good okay David welcome could you tell about yourself David and what you do and then take off with the discussion?
David Doherty: (1:15) yes I’m David Doherty I’m a co-founder of a company called 3G Doctor and the discussion this week is going to be around a slightly contentious issue that’s happened here with NHS England who are backing the creation of their own App Store. So literally they’ve had 4 years been trying to create an app store and so far they’ve managed to only produce one approved app on their store but officially they say the library now is really going to get some legs to start growing and this is happening while you know the political domain over here is being dominated by conversations about brexit, breaking up from Europe so there’s a whole lot of funny stuff going on that’s impacting the mobile health care market and I write a blog called mHealth Insight where I talk about things that are happening and obviously the NHS with its huge budgets often does quite exciting things that are worth reporting on but this thing I thought was one of those stories that just didn’t make sense to me so I wrote the blog and the title was I know a 10 year old with a better grasp of how app stores work than NHS England I invited the two people who were mentioned in the story one of whom happened to be a Twitter follower of mine to join in on this discussion but haven’t had a reply yet. But literally it didn’t make sense to me so I tweeted about it wrote my normal mHealth Insights blog as I thought there are some lessons to be learnt from this and my suggestions for what should be done and then on Twitter this was picked up by Yuki who commented that ‘app stores don’t aim to provide what’s best for patients they’re gatekeepers and the NHS is at least trying to provide some safe apps why are you blaming them. And so that’s where this discussion starts because I think there isn’t enough understanding of the technical elements that are at play here. It’s not good enough to go and make things that sound good when you’re dealing with patients and you’re diverting attentions and interests of people away from mobile healthcare you’ve got to really
understand what’s going on technically in the market and so there was a little bit od debate on that discussion between myself and Yuki I thought you know why don’t we bring this into this week’s mHealthTV hang out because this is the type of thing that you know probably doesn’t work very well with the 160 character limits of Twitter and it’s great that Yuki said ok let’s do that.
Dr John Bennett: Yuki you now have your chance, Dave is live on the screen right?
Yuki Byambasuren, MD: yes Oh Twitter and debating things on Twitter is so hard especially as English is not my first language it’s like the third so I type and delete and retype and try to find the shortest word, it’s a great exercise for my English. So yes look you know how app store works you know at the latest count they have something like 200,000 apps under the health and fitness and medical categories which are the two categories in the app stores that pertain to health. I’m in all the app stores including you know an iOS Android you know Google Play and even the
smaller ones it’s the data from research2guidance a germany-based company on health statistics and market analysis so but however you know very small percentage of those apps will be genuinely health related interventional type apps and you know majority of it is just you know educational apps providing information or you know medication reminders or appointment making you know that kind of apps I believe however small percentage the interventional apps there are I believe that they need to be tested by fair trials like randomized control trials to show their full effectiveness and the reason I believe that the NHS wasn’t able to approve more than one apps in four years is actually telling sign that there’s a lack of well tested and proven effective apps it’s not so much of an you know incompetence on NHS Digital side I believe it’s reflective of the evidence you know level that’s out there so and Dave you said you provide training to medical professionals I understand, and you said you give them you know apps that work and you also provide them how to evaluate to teach them how to evaluate apps and
things and I’m very interested to know about your you know training or workshopc  can you tell me more about it
David Doherty: yeah so what we have is really challenging. you know it looks like it’s just this big minefield of all these apps and we’re just going to get a deluged with  250,000 apps, I mean how is anyone going to be able to find value in that? but it’s not
really like that that’s a that’s a situation which is being propelled by researchers who want you to buy their research and think that by telling you it is immensely complex they’ll achieve that. Do you use that store at all? Do you use healthcare apps with your Patients?
Yuki Byambasuren, MD: well because since I’m doing research in this field I just you know I download every app that claims to do you know something and every app that gets a you know the best app Awards from you know anywhere and try to test it out myself and I also do a literature search on you know trials that they’re testing apps and in order to find you know really good effective ones that are tested and so my phone is like you know full of apps it’s got probably about 200 apps and you know the quality is varying and literature also reflects that and for example you know review of all let’s say depression apps you know they’ve looked through very enduring very much detail you know apps and 300 apps and they ended up concluding basically there was none that was evidence-based and proven safe and you know ticking all the boxes and that worries me and I believe that’s a you know practical problem that we really need to address before we go on talking about how to mass implement it and you know widely disseminate it and things like that that’s that’s kind of my opinion so
David Doherty: okay so as a primary care doctor have you ever prescribed an app to a patient?
Yuki Byambasuren, MD:  no I’m not practicing here in Australia so I haven’t done that no
David Doherty: have you ever prescribed or  referred a patient to a website
Yuki Byambasuren, MD: yes I believe so when I was practicing back in Mongolia I used to keep Patients who speaks and understands English some websites like the Cochrane Collaboration website for the patients so it’s a you know all the evidence is translated into a layperson language and it’s easy to understand for patients and yeah I did refer to patient I referred my patients who are you know interested in knowing more about their conditions and interventions plus you know with good health literacy I directed them there yep
David Doherty: okay from the Cochrane Library that sounds really good, but was anything that you recommended Patient generated? you know like a patient community have you ever referred to a website like that?
Yuki Byambasuren, MD: um no. um at that time that was there was actually uh quite a few years ago and um at that time I wasn’t aware of uh you know a good forums patient forum as such and you know now there are many more of them um but no I didn’t use those forums.
David Doherty: Ok I work with doctors who do that on an every patient basis.
Dr John Bennett: You mean like PatientsLikeUs.com?
David Doherty: no. Every Patient these Doctors meet they refer to online content. Every single patient they meet that’s one of the primary objectives when we video consult with people at 3G Doctor. so we
are trying all the time to find you
content, videos, youtube videos, patient forums, patient discussion groups, research papers. that’s the one of the reasons why we have video calls with patients, it’s the reason why patients consult with us is because often they have found information on the internet that is challenging and want to discuss it. and we give them websites and things like that.
Dr John Bennett: (10:30) so therefore so you prescribe you prescribe videos also as well as medication obviously but videos you prescribe
David Doherty: yeah it’s really easy. okay so with our service we use a questionnaire that takes from the patient their history and obviously there’s lots of information revealed in that, things like BMI, and because it’s very easy to provide information personalized to patients once they’ve given you lots of information and because we have resources we can look to we can give patients things to help with those issues that they have brought up and I think it’s in that that we’ve come to the understanding that this idea that the NHS have an app store and being an arbitrator of what’s good or not is just not feasible, one technically, but two because obviously they don’t have sufficient understanding to be able to be that in place. The NHS seems like it’s a single organization it’s made up of almost 10,000 different companies many of them private many different operators in different regions with different budgets and different focuses and targets and what they’re trying to achieve. NHS England saying it’s going to create an app store is actually bringing a sort of administrative hurdle so if you think that you’re going to fix the issues with there being 250,000 apps to sift through. When you’re recommending apps to Patients you realise that all apps actually have a rating, so as soon as you see an app there’s a rating on it. So first of all you could not install apps from a NHS Appstore unless you are going to jailbreak your iPhone because an iPhone only allows you install apps from the Apple App Store. I think this shows a fundamental lack of understanding of the technical element at play here, the NHS may recommend an app to a Patient but then they will have to go over to the actual official app store where the Patient will be able to see other apps that are similar along with the customer feedback and ratings. Although it may be an uncomfortable place for us to be because this isn’t like the Cochrane Library accrediting everything we have, but we have to work with this even if it’s challenging but it gives rise to the opportunity to  give weight to the opinions of people that we respect in our profession,  but if you look at the NHS for example in the four years where it’s trying to make this App Store concept work we’ve seen mobile apps go to absolutely mainstream use by clinicians so I could point you to the BNF, in that last four years the BNF has been made free of charge to NHS Staff, the BNF is the British National formulary it’s an app that’s basically replaces a printed book that Doctors carry around and use to look up formulas before they prescribe a drug because it gives you all the up-to-date information. Now you can have your prescribing Bible on your phone or your iPad and there’s lots of advantages particularly as it’s now made free of charge to all doctors in the UK. Yet that’s not yet an accredited act by this app store so they’ve been very slow to on board things which already in massive mainstream use. Equally innovations are coming so quick that they haven’t even been able to respond to things like the Alivecor, the ECG you’re familiar with. Alivecor has produced an app that is now in such mainstream use screening patients in GP clinics yet NHS App Store hasn’t given it any recognition. Now compare that to the actual Apple AppStore where I can read personal reviews many clinicians have posted personal reviews, I think I posted our first review of the Alivecor ECG on the mHealth Insight blog about seven years ago so if the NHS is that slow at approving things aren’t they only going to really harm innovation and aren’t there many more much bigger opportunities for them to do good? you know for example as a primary care Doctor you’d probably be aware of the Royal College of GPs?
Yuki Byambasuren, MD: yes we have our my own Australian College of GPs here in Australia
David Doherty: Yes they actually work with a mobile operator I know but it’s been a funny relationship and it didn’t work very well. In the UK the Royal College of GPs have a membership exam and in that membership exam you automatically fail if you bring a mobile phone in with you. Now I’ve been calling for years to try and have the RCGP realise that a Doctor will not work a day in their life without a mobile phone and their response is that they don’t
understand what’s happening here because too many people are telling them the NHS
needs an app store that this is the way we discern quality when what we need to
realize is that every patient in the waiting is using a  smartphone, every doctor has
a smartphone and the minimum performance of the smartphone a doctor’s going to be using in primary care is going to be something equivalent to the latest iPhone 7 or iPhone 8. so you have to realise that’s what you’re going to be using for the rest of
your career why would you possibly want to examine and test that doctor when they are not using that tool? What we should be saying is as part of your exam I would like to see you manage a Patient who’s presenting problem is information they read on the Internet and I would like to see you using your phone or an iPad to actually manage that Patient better and we should be examining and training and testing that scenario not the scenario where I’m working against the clock to work it all out in my head because
when I went to school that’s how we used to do math exams, you know all my writings and my workings would all be in the margin but now we let children use
calculators but it’s not that those children are doing easy maths they’re doing far more complex problems with bigger calculus and bigger algebraic equations. In the same way we’ve got to let GPs use the tools of our time and we’re not going to stop talking about completely unfeasible technical barriers which can get in the way of that as Doctors are in a prime position to actually evaluate apps. Many of them have got family friends and have got their own medical conditions and they manage them with apps and so they have personal lived experiences of apps and they should be sharing those with Patients but also they should be sharing them with their colleagues you know if I find I’m sitting in a GP CPD meeting and there’s a Consultant Hematologist giving a talk and he recommends I use this app and I’m not saying here to just completely blindly follow everything you’re told but you’ve done that for decades with text books you know people have recommended text books and we’ve taken them on board things recommended in
medical papers so why is it that apps are so different? I’ve never had a textbook that automatically came with the ability for me to write on its public website that every other reader would see before they bought it what I thought about it and that’s a very powerful thing that the app stores offer. We have  this centralized place where if this app does something I don’t like or don’t approve of I can write that there and that’s what we got to be championing. The NHS should be championing this too. They should be saying we’ve got hundreds of thousands of healthcare professionals who could actually be adding value to the App Stores and that is where the value comes from,  when we go and we say it’s not our property but we can add value to it.
Dr John Bennett: you know David one interesting thing from talking to Yuki briefly the other day is that she actually goes to Patients, correct Yuki?, and asks them what apps they used cool
Yuki Byambasuren, MD:  yes that’s going to be my next study I’m going to interview GPs and their patients right in their waiting rooms if they you know already use apps and how did they find them how did they know that you know that good app and um also I wanted to explore what are the practical barriers and facilitators of you know prescribing apps in the real practice and I would also very interested to hear from David about you know you must have approached hundreds of you know thousands of Doctors to you know to for your services 3G Doctor platform in what kind of those who did not want to join or what kind of
barriers they you know did they cite and
20:33
what was your experience in that field
20:36
well I’ll share a post a few does a post
20:39
like an article I wrote for mobile
20:41
health news in 2009 and it was talking
20:44
about people saying you know these apps
20:47
aren’t gonna work you know it’s never
20:48
going to work these non feasible
20:50
prospect that we’re gonna have apps of
20:52
work what people are wearing current on
20:55
was the fact that SMS is a mobile health
20:58
care app SMS is used very commonly as a
21:02
emergency notification in the UK
21:07
hundreds of thousands of people are
21:09
registered to use SMS because they have
21:11
disabilities so for example they may be
21:15
deaf so they can’t use a normal
21:17
telephone to call emergency services and
21:21
those patients can register just with
21:24
the emergency 909 where emergency help
21:29
like telephone service to use it with
21:32
SMS so we have to be really appreciated
21:35
that many other technologies and that
21:38
where I saw this first was when I was
21:40
doing an early working mobile healthcare
21:41
I went into a clinic and I saw that you
21:45
know they said patients don’t want to
21:46
use their mobile phones for healthcare
21:48
so I did a poll of patients who were on
21:52
the pill and whether they had alarm
21:55
function calendar functions set up on
21:58
their mobile phone as reminders and they
22:00
all had that but an onlooker would say
22:04
none of them used mobile health care
22:05
apps they were actually using the
22:07
calendar and the alarm functions of
22:10
their very basic very cheap Nokia
22:14
we wouldn’t even think that was a phone
22:15
anymore that’s so old and undone but
22:18
actually very early days people were
22:20
using these tools
22:21
a reminder to take their pill in the
22:23
morning and this is this is quite common
22:26
and now patients don’t see the
22:27
distinction so patients will be using
22:30
you know absolute on patients use the
22:32
photos they uploaded to Facebook as
22:35
visual reminders of how their weights
22:37
changing or well changed or how their
22:40
helps to Tyrion so we’ve got to realize
22:42
that a lot of the content is inter
22:44
mixing you know it doesn’t have to sort
22:47
of belong in this very controlled
22:49
healthcare environment you know if you
22:51
show me your facebook pictures I can
22:55
often get a really good impression of
22:56
your order and psychologists will be
22:59
doing that with their patients here in
23:00
the UK and you know we’ll have the
23:03
patient show them their profile their
23:05
Facebook profile of what they’re
23:06
updating the comments they make on a lot
23:08
of people’s posts this is medical
23:11
content when you have the skills and
23:13
talent to read it and that’s where I
23:16
think we have to start realizing the
23:18
opportunity is you know calling an
23:21
emergency services on a mobile phone is
23:24
technically very different from a
23:26
landline
23:26
I can do it with the patient in front of
23:29
me and we had the first problem with
23:32
this in the UK when in about 2002 they
23:37
started getting completely inundated on
23:40
emergency call lines because Nokia have
23:43
made a phone that if you sort of rubbed
23:45
everything in your pocket the phone
23:47
would actually automatically ring
23:48
emergency services so again sort 20:40
23:52
fires and calls a day that they had to
23:55
go just silent corners the salon is an
23:59
awful lot of Technology there’s actually
24:00
in the back end trying to thickness
24:03
things like very specific location
24:05
coming through their call records on
24:07
that phone stuff like that it’s now
24:09
being shared and it’s really good for
24:11
patients because we have to be able to
24:14
manage you know major incidents and
24:18
things like that
24:18
and where people will be calling in
24:21
reporting things like road accidents you
24:24
know if you’re going on the motorway so
24:26
we have to
24:27
sometimes go down from this very
24:29
high-level thing that they’re
24:30
downloading and out and then realize
24:32
that actually mobile health care apps
24:34
often native functionality of the phones
24:37
you already have so we don’t have to
24:39
download them the phone sort does them
24:42
and a reason it does them is that mobile
24:44
companies have seen two successful apps
24:46
and then they’ve made of native features
24:49
of their phone and so there for example
24:53
obviously Apple healthcare is a really
24:56
classic example of that we’ve seen a
24:58
range of apps that people might use and
25:00
now these are sort of native apps that
25:02
just you get the phone out of the box
25:04
and it’s all sort of working there but
25:07
if you think about it you know ten
25:10
thousand people are going around the m25
25:11
and there’s a major pileup what actually
25:14
happens is the cellular networks
25:16
actually talk to the people who ring up
25:19
so it will say things like a lorry is
25:21
jackknifed on the eastbound carriageway
25:23
of the m25 between Junction eight and
25:26
nine if you’re calling to report that we
25:30
have already been noted thank you for
25:31
your call if there is extended
25:35
circumstances you’d like to share with
25:36
us if you can share of us or your
25:38
calling about a different thing please
25:39
hold the line that immediately filters
25:43
all the people who would be driving by
25:45
press the button try and ring emergency
25:47
services and it actually helps them stop
25:50
them just getting completely on datum
25:52
helps them do the job so very critical
25:54
Public Safety things I can explain in
25:56
that way and so sometimes it’s not all
26:00
about an app you download and similarly
26:03
obviously every phones caught now an app
26:06
that is a browser and so they can access
26:09
websites so we also have to look at that
26:12
being an atom
26:13
similarly the YouTube app you know that
26:15
I can send now patients a link that
26:18
literally opens up a video on their
26:20
phone so if I’ve got a patient with me
26:22
this is something that doctors aren’t
26:24
being trained enough to do I feel if
26:27
you’ve got a patient with me and I want
26:29
to explain con something quite a
26:30
difficult it can be really challenging
26:32
to do that inside two five ten minutes
26:35
do you normally have with your patient
26:37
and so giving the patient
26:39
in on their phone and saying watch that
26:42
and make another appointment with me if
26:45
it doesn’t help that can be really
26:48
useful because although the patient
26:49
could have gone and found that content
26:51
on their own they don’t know where to
26:54
look
26:54
they don’t know what sort of resources
26:57
to trust and so for example if I was
27:00
talking to a patient I want to explain
27:02
something and I could say yes my you
27:04
know a doctor I know professor John
27:06
Bachman and the Mayo Clinic produced a
27:08
professor of primary care produced an
27:10
amazing talk on that he’ll watch this
27:13
video really that’s actually better for
27:16
that patient let me spending 20 minutes
27:18
talking to basemen because the basically
27:19
one watch it in their own time pausing
27:22
whenever they want rewind when they
27:24
don’t understand bits look up bits that
27:27
are mentioned in it which they don’t get
27:29
there do that when we’re having a
27:30
one-to-one so sometimes when we look at
27:33
their health apps there’s things like
27:34
sending a patient a text message the
27:37
links to a video that will open on their
27:39
phone they can play and watch it
27:41
we’re opening something very rich we
27:44
don’t need to start saying is that
27:46
approved binding NHS we need to let
27:49
people be you know much more free just
27:51
like you are with handing out things
27:53
like leaflets to patients in your clinic
27:56
we’ve got to realize it’s not completely
27:58
different from that if that makes sense
28:01
does it yeah yes absolutely I mean
28:03
there’s no argument how incredible our
28:07
smartphones are you know as tools and
28:09
how much it’s been changing our lives in
28:12
every aspect I mean that’s just it’s one
28:14
of the most incredible you know pieces
28:16
of technology ever and in in Australia
28:19
on the Royal Australian College of GPs
28:21
we have a tool for GPS called handy
28:25
handbook of non-drug interventions
28:27
you’re short for um and for that and it
28:30
provides GPS with non-drug intervention
28:34
tools such as you know um people your
28:37
therapy for depression or you know apps
28:39
for smoking cessation and things like
28:41
that and and we always are looking for
28:43
evidence-based you know tools to provide
28:45
GPS as an alternative for pharmaceutical
28:48
interventions and I want to also go back
28:51
to your previous answer
28:53
you mentioned you wrote about a live
28:54
course seven years ago and you know
28:56
still you know no uptake or you know
28:58
take is very low and actually the
29:01
average average ah your duration between
29:05
a discovery and the practical
29:07
application is you know evaluated to be
29:09
seven and a half years in medicine I
29:11
mean that is long time and our Center
29:14
central research and evidence-based
29:15
practice we worked we recognize it as an
29:19
utter waste of you know resources and
29:21
it’s just way too long and by the time
29:23
it’s seven years if new discovery is
29:25
implemented the next you discover is
29:26
already out you know and so we’re really
29:28
lagging behind in in many areas and so
29:32
one of the things we do is to close an
29:34
evidence practice gap meaning that to
29:37
get the evidence as quick as possible to
29:39
the GPS directly like a bottom of a
29:41
bottom-up approach and it’s it’s quite
29:44
possible in Australia actually we’re
29:46
lucky here because the Australian
29:48
primary care system is you know you’re
29:51
very much independent it’s it’s
29:53
manageable plastic practices are you
29:56
know very independent and if you
29:58
directly approach the GPS in a certain
30:01
practice and work with them conducting
30:03
journal clubs and or a no evidence
30:05
workshops they do you know adopt it very
30:09
very quickly and and start implementing
30:11
it directly and as one of the things we
30:13
do and so you mentioned also about that
30:16
BNF act like we call here means you know
30:19
to be a the you know encyclopedia of all
30:23
all drugs and things um there are of
30:26
course you know many great acts and
30:28
tools for aim the doctors medical
30:30
students that are really you know making
30:33
their lives easier
30:34
but I thought we were talking about more
30:37
patient facing apps and um so you
30:40
mentioned you know App Store ratings is
30:42
you know a great way to go by choosing
30:45
you know what’s best I’ll give you one
30:48
example of alpha and that you know
30:51
MyFitnessPal it’s just been one of the
30:53
you know the highest rating apps it’s
30:55
been the longest time around you know
30:57
it’s been around for 10 15 years however
31:00
when it was tested in in our city when
31:03
doctors prescribed you know suggested a
31:06
My Fitness Pal for people wanting to
31:07
lose weight and said okay you know go
31:10
and you know do this record your food to
31:13
exercise blah blah blah and they gave a
31:16
they told the control group just you
31:19
know use whatever methods you want to
31:21
use to lose weight and and then they
31:25
measured their weight loss in you know
31:28
it one month after the prescription in
31:30
its six months they also had any insight
31:34
into their views of the ABS because they
31:36
were working with the creators of the
31:37
app so the creators of the app were able
31:39
to get the actual login plugging numbers
31:43
of the patients you know how many times
31:45
they were logging in and um you know as
31:48
opposed to the patient reporting oh I
31:50
use it everyday you know what I mean so
31:52
they had a hard data and what’s
31:54
interesting is that after what basically
31:56
it one month after being prescribed that
32:00
app the log in was zero it went down
32:04
like like basically zero and and then it
32:07
picked up a little bit um
32:09
about 10% before the six months um um
32:14
check check in and so that shows that
32:16
when left alone on to their own devices
32:19
with with apps you know it’s patience
32:22
you know easily bought since there are
32:23
abundance of apps they’re just you know
32:25
use it for a while if they don’t like it
32:27
they delete it and download the next
32:29
thing and um that’s not the most um it
32:35
took the best way to go about things
32:37
sure there’s an abundance of it however
32:39
if there was a effectively tested act
32:43
that’s you know proven to work that
32:45
incorporates lots of behavior change
32:47
you know Theory elements then it you
32:50
know maybe the adherence to the app
32:53
usage therefore the weight loss roofing
32:56
you know could be much better so in six
32:58
months none of the intervention the app
33:01
taste ad group and the control group
33:03
lost any weight basically there was
33:06
hardly any weight loss and so so that
33:10
shows that I prescribed being cannot
33:12
just solve everything on its own you
33:14
know just an app itself it has to be
33:16
with a frequent follow-up and check in
33:19
with
33:19
either a nurse practitioner or our GP
33:22
back again plus perhaps some people
33:25
would prefer you know like a a peer
33:27
support group you know either a Facebook
33:29
group or Twitter or what-have-you and uh
33:33
you know I think that would increase the
33:36
adherence and benefit of using an app
33:39
actually so without having to establish
33:43
these things if we just tell the
33:46
patients to you know go you know or or
33:48
ill here’s here’s in at five five star
33:51
rated ad and you know that it’s not
33:52
tested by any studies then it’s you know
33:57
that is also you know creating waste of
34:00
resources you know and if if there’s a
34:03
an entity like you know NHS or or
34:05
anything you know I’m kind of providing
34:08
a doing it please the basic vetting of
34:12
the ads and eliminate the the ones that
34:15
are not worthy of of the time and you
34:18
know an adherence and investment in
34:20
either partner from the doctors and
34:22
patients aside then I think it’s a good
34:24
thing um FDA announced that they will
34:27
only basically check apps that are um
34:32
like a medical device you know you know
34:36
the glucose monitoring and and you know
34:39
an insulin dose calculating and that
34:41
kind of things that are have that could
34:44
have a huge implications if gone wrong
34:46
and I mean I certainly understand that
34:49
it you know two hundred thousand other
34:50
things to and to look at as well nobody
34:52
can do that and in Australia there
34:54
hasn’t been any organized and
34:58
orchestrated effort to evaluate you know
35:01
or or provide safe apps in in
35:03
large-scale at all only the national
35:06
organizations like Black Dog instituted
35:09
mental health initiatives I’m sorry and
35:14
beyondblue and reach out with youth
35:16
mental health organization as well and
35:19
they provide a few apps that are being
35:23
you know proving kind of safe
35:26
so in sorry will let me back up to a
35:29
level of you know evidence that’s
35:32
required for apps
35:33
I think you know for pill reminding apps
35:36
and you know things like that it’s you
35:39
don’t really need like a really high
35:40
level you know evidence to show that
35:42
they work we all know that bill
35:44
reminders working because you know we’ve
35:46
been using our calendar apps right and
35:49
however on things like you know that
35:52
apps that are promising to change your
35:54
weight your mood and your you know
35:57
affecting your glucose level in your
35:59
blood this should be scrutinized a
36:01
little bit better more than you know
36:03
just a reminder app and I think you’re
36:08
trying to do too much I think this
36:12
doesn’t make sense because you’re just
36:14
trying to rush too quick to do certain
36:16
things you’re trying to be a judge of
36:20
apps so one of the things I’ve said
36:21
about a live chord is a live court
36:24
hasn’t actually had a long time to get
36:26
market there’s never been an ECG machine
36:29
it’s the fastest selling is missing the
36:32
world’s ever seen
36:33
it’s the world’s easiest to use the
36:35
world’s lowest cost ECG machine but it’s
36:38
also the fastest ever adopted ECG
36:40
machine I’ve been using ECG machines
36:42
over 20 years okay so my experience of
36:46
ECG machines and all about them so
36:49
immediately when I heard about this
36:51
kinda internet with this device and I
36:54
video called him like we’re doing now
36:56
and he showed me how it worked I
36:58
immediately knew that this was
37:00
technology which was going to be very
37:02
very disruptive so I wrote about it what
37:05
I’m saying is the NHS app store that
37:08
approves apps has never mentioned it has
37:11
never approved it and it’s already in
37:13
use at last count one in five GPS an
37:17
island is using an alive quad today this
37:21
is incredible innovation like this as
37:23
the rate of adoption has never been seen
37:26
like it now will back out of that okay
37:29
the appreciation of that is not going to
37:31
be done by some civil servants working
37:33
for NHS England because if they could do
37:36
that if they could tell which apps are
37:39
going to be the big hits with and they
37:41
could proactively go and find them they
37:43
would have proved a lot more than just
37:44
one in four years but also
37:47
they might as well be working as a VC
37:49
because I can get them as much
37:50
investment as they want if they think
37:52
they can understand things like a live
37:54
cause before the mass market does so you
37:57
just don’t have that talent proficiency
38:00
what also seems to be happening where
38:02
you’re picking Fitness Pal now I know
38:04
Fitness Pal very well one of the things
38:08
you’re doing is you’re trying okay a
38:10
doctor level to be like a Silicon Valley
38:15
VC and say make the bet on whether this
38:18
is good or not okay that’s not how it
38:22
works if that’s a really complicated
38:24
thing to do is this app going to be good
38:27
for patients one it’s not designed for
38:29
patients it’s designed for consumers you
38:32
want a fitness product twice call
38:34
fitness pal if you want to then go and
38:36
apply your version of how to test
38:39
randomized control trial to add up to an
38:42
app that was built for a completely
38:44
different purpose guess what you are
38:46
going to fail
38:48
make no dance about it but that doesn’t
38:51
mean the app is a failure it’s just your
38:53
version of using the app what’s
38:55
incredible is I saw these fitness
38:57
devices coming out these wrist-worn
38:59
devices when in Japan that technology
39:02
was native nearly Ted ten years ago on
39:06
what was called the rack of Raccoon
39:08
phones in Japan rocki rocki phone meant
39:11
a simple phone and it was used their
39:13
seniors would happen and these were
39:16
smart phones but they had very
39:17
easy-to-use features and they had a
39:20
Fitness pedometer right it was a little
39:22
man running man you’d see a little
39:23
symbol of war that was used widely by
39:25
doctors 10 years ago they didn’t have to
39:30
go and put wristbands on senior citizens
39:32
in Japan because they already had the
39:35
phone doing that so when the Japanese
39:37
saw the American mark again Fitness ah
39:39
they’ll they’ll come back to realize
39:41
Nick just carry their mobile phone so
39:44
what happened is a lot of hike was done
39:46
there in sales now if I was running one
39:49
of these randomized control university
39:52
programs probably I would have tested
39:55
the Fitbit in all out one should have
39:57
realized is actually that technology is
39:59
already in the mobile phone
40:01
and we carry the mobile phone with us we
40:04
don’t have to charge an extra device and
40:06
actually if I was doing the fitness for
40:09
you and you came to me someone
40:11
understands a little bit more about how
40:13
mobile healthcare works I would say
40:15
don’t bother with fitness pal just go
40:17
and look at the native pedometer
40:18
Apple puts on health care because what
40:21
you’ll find is you know that drop-off
40:23
that doesn’t exist so with the one where
40:27
they show maybe you probably seen on the
40:29
Apple watch which shows the thing you
40:32
don’t have to do anything it just does
40:34
this in the back Samsung had put this on
40:36
some of their Galaxy devices under their
40:37
self brand you know that that doesn’t
40:41
have the fall off because it’s just
40:42
native worked in the background and what
40:45
you’ll find and this is the reason why
40:47
health care organizations
40:49
shouldn’t try and build app stores
40:52
because I actually what’s happening
40:54
within the app stores at Android with
40:56
Google Play and with Apple iOS is the
40:59
most expensive piece of real estate is
41:01
in your pocket the little AMOLED screen
41:03
in your pocket on your phone and what
41:06
Apple have is they have all that
41:08
feedback from what’s going on when you
41:12
use apps and from that feedback Apple
41:16
develop their phones so if for example
41:19
you get a phone out of a box and you
41:23
authorize Apple to take that data from
41:25
it which most people do what then
41:27
happens is Apple see what you actually
41:29
do at your phone an Apple phone that
41:32
when when you spend 10% of your time
41:34
using the camera function they spend 20%
41:37
of their R&D on camera technology’s
41:40
photo imaging technologies when you
41:42
spend 20 percent on the pedometer
41:44
they’ll spend that much on it but also
41:46
they will see who it Fitness Pal who at
41:49
RunKeeper
41:50
who were added as my coach has made the
41:53
best most compelling app for fitness and
41:57
they will make that an 80 feature so
42:01
sometimes you hit these squabbles where
42:02
because apple’s copied my idea and made
42:04
this native or google’s bought us and
42:07
made us native part of the android
42:09
network that’s what’s actually going on
42:13
here and
42:14
so they’re ahead of us because they’ve
42:18
got the data and because they know the
42:20
market much better so us trying to go oh
42:23
I’ll pick an app and I’ll draw the
42:25
randomized control trial and hope that I
42:27
find something Apple’s already got that
42:30
data Apple already knows that that app
42:33
gets downloaded and it never gets used
42:35
or Apple already knew knows that gets
42:38
downloaded and loads of patients start
42:41
actively using it and it knows that for
42:44
diabetes Pal world’s number one diabetes
42:47
at you know for diabetics it knows this
42:50
data so where we should be doing this
42:52
stuff and saying look how as the NHS can
42:56
we help Apple how can we work with Apple
42:59
to actually put an accreditation within
43:02
the Apple Store how can we teach doctors
43:05
who recommend apps to one have social
43:08
media profiles and two to actively rate
43:12
their views of out on the Apple Store
43:15
you know I don’t hate you today but you
43:20
know in reality in Australia or England
43:23
or Ireland don’t talk to generally
43:27
recommend apps not necessarily approved
43:29
by the NIH or the Health Organization in
43:33
England or Australia they recommend apps
43:37
that they personally have found that are
43:40
good isn’t that how in reality how it
43:42
works today acne will happen if early
43:44
life goal so people like Eric Topol dr.
43:48
Eric Topol in in San Diego went on the
43:51
Kolbert show and pulled out this device
43:53
and actually blew everyone’s mind and
43:56
every cardiologist knew by the next the
44:00
next morning that was an ECG phone that
44:03
could go on your iPhone because every
44:05
patient going to them said Ivor bought
44:08
it on Amazon or went to the doctor said
44:11
hey does that work doctor so this is the
44:15
speed of innovation which we can count
44:17
on and so yes this is how it should work
44:20
we shouldn’t be waiting for an NHS which
44:22
takes four years to approve one app
44:24
there are much more nimble ways we
44:27
you make this ball roll that’s what I’m
44:30
encouraging and if we train the
44:32
collisions at heart this how to
44:34
recognize apps how to have a social
44:37
media profile how to put ratings on app
44:39
stores how to write reviews themselves
44:43
of apps in their field of specialty
44:45
that’s where the value comes because you
44:48
know if you’re a GP and you specialize
44:50
in dermatology and you write you know
44:53
what you think of apps and doctors who
44:56
use apps and how you can use it we can
44:58
learn far more from that than hoping
45:00
that the NHS will just approve gold
45:04
standard n CT properly approved and and
45:08
reality is that can’t even work because
45:09
the apps all really changed by the time
45:11
the randomized controlled finished
45:14
because every day the app developer gets
45:16
a list of feedback from patients using
45:18
it so it’s a moot you’re trying to say
45:21
you know we’ve got a rolling ball where
45:23
is it and well it was there and we
45:26
approved it but it was there but it’s
45:28
now over there and that’s the big
45:31
challenge of apps what we’ve got to do
45:33
that is have clinicians get on board
45:37
these companies invest in these
45:39
companies work with these companies
45:40
become advisors to these companies all
45:43
that comes from training them on mobile
45:46
health care you find an app and it’s
45:48
brilliant exactly what you want the
45:50
patient go and get yourself on the board
45:52
of that company that’s the type of
45:55
innovation we should be looking in the
45:58
NHS within inclinations we shouldn’t be
46:00
looking for them to tell us from on high
46:05
yes-no on everything reserves we ever do
46:07
right I agree with you about on you know
46:10
teaching doctors and future doctors
46:12
about you know use of technology use of
46:14
social media for their purposes and you
46:16
know plus apps and I want to go back to
46:19
you know again you know I’m medical apps
46:21
little eye medical apps
46:23
it’s an American doctors to to doctors
46:27
we started but you know any any doctor
46:30
can add a curation of apps there and
46:32
they do provide you know the latest
46:34
released medical apps both for patients
46:37
and doctors and they do write a review
46:39
on it
46:40
and there are actually some apps to help
46:43
doctors to prescribe apps like for
46:46
example at rx you know like the RX of
46:49
prescription sign and rx universe
46:52
however they wrote a review on rx
46:56
universe and they said oh you know
46:58
202,000 apps have been prescribed on it
47:00
and everything and I got on it I
47:02
downloaded it and got inside it and it
47:05
included um only handful apps that I’ve
47:08
never even heard of and the app itself
47:11
the rx
47:12
universe that looked really I mean
47:14
really wasn’t up to a standard of you
47:17
know any apps that anybody would like to
47:19
use and so they did
47:22
sterling review on again which makes me
47:24
wonder you know if if they are really
47:26
unbiased and you know not just kind of
47:29
promoting an app that they thought I
47:31
don’t know somebody had a deleverage on
47:35
so such kind of things an expert opinion
47:37
the fail ability of expert opinion is
47:40
that it can vary and differ so widely
47:42
that we cannot you know reliably uh you
47:47
use and trust and use one single inner
47:50
experts opinion that’s why
47:52
evidence-based medicine basically came
47:54
to be so that nobody can argue on the
47:56
quality of things if we you know agree
47:58
on it if it’s shown without any bias
48:01
without any with it with a high quality
48:04
trial then it’s it’s nobody can deny it
48:07
and or in or change it or twist it so
48:11
that’s the whole point of you know
48:13
evidence-based medicine and I believe
48:14
that apps as a medical intervention if
48:17
they taught themselves as in a medical
48:21
or health-related
48:22
intervention they need to be tasted just
48:24
like any other intervention that promise
48:27
to change your you know health and and
48:30
disease improve your disease and in the
48:33
meantime whilst we read with you about
48:35
the importance of teaching doctors how
48:38
to evaluate apps because the apps
48:40
landscape is constantly changing you
48:43
know add longevity is a huge problem
48:45
even the good app sometimes they just
48:47
disappear you know due to variety of
48:49
reasons of funding or otherwise plus
48:52
two apps are being born you know every
48:54
every minute most of the apps have also
48:57
a problem of being designed by a young
49:00
hip you know it take he who has a
49:04
healthy privilege but I what I like to
49:07
call that he doesn’t even know that he
49:09
has because he’s never lived with
49:11
chronic conditions more than one which
49:13
our aging population has a problem of
49:16
and so we need involvement of both those
49:19
patients and the specialists involvement
49:23
in creation of the app itself rather
49:26
than just you know going to an app store
49:28
and trial and error fine try to find a
49:30
good at by trial and error you know
49:32
downloading using it not liking it or
49:33
what have you so you know so it right
49:37
now we both need a library of safe apps
49:41
in face of utter lack of you know
49:45
evidence in effectiveness trials I’m you
49:48
know we can I suppose go to the
49:50
secondary level evidence and so you know
49:56
patients both patients and doctors do
49:58
need now a list of save apps to start
50:01
with to be going on it and plus they
50:05
need the beneficent feeling for
50:07
everything and teach them how to fish
50:09
and I’ll never go hungry so you know
50:11
it’s kind of similar lines I like to use
50:13
this analogy so um so you told me and
50:17
you teach doctors how to evaluate apps
50:19
you know the fishing lesson knowing
50:22
about it and what kind of frameworks do
50:24
you use I know of only three or four um
50:28
you know frameworks that evaluate apps
50:30
one is a Mars mobile app rating scale
50:34
and the other is in light it’s for all
50:38
health interventions including M health
50:40
interventions however these two
50:42
frameworks each has 20 odd domains with
50:48
each you know four to five little small
50:51
questions underneath so altogether it’s
50:54
you know 50 60 questions and answers
50:56
with nobody has time for you to go
50:58
through on the only one single app and
51:01
American Psychiatric Association in
51:04
January was
51:05
you know pioneered to release an ad
51:07
valuation guideline to for psychiatrists
51:10
and doctors as well in general it has
51:12
five domains and it’s a little bit more
51:15
usable compared to the the other two I
51:18
mentioned however still its design and
51:21
and model is you know I I don’t agree
51:25
with it with it because it’s a it’s a
51:26
pyramid model which means the the next
51:28
next level is filled up on the previous
51:30
level and in their design evidence is
51:33
tracked third after you know data safety
51:37
and risk and security issues plus
51:40
basically generic information and you
51:44
know I think that it should be more of a
51:46
network model where all those important
51:49
components that make a good app should
51:53
be on an even playing field you know
51:55
with interacting with each other um you
51:57
know equal take an equally seriously and
51:59
so yeah can you tell me more about the
52:02
evaluation teachings that you give to
52:07
medical professionals yeah I think again
52:09
you’re running really far you’re going
52:12
too fast for the understanding you’ve
52:14
got so what we’ve got here is the NHS
52:16
England is not some impartial
52:19
organisation it’s not an impartial
52:22
arbitrator of what’s good or bad okay
52:25
most patients who get care from the NHS
52:29
England can’t access their own medical
52:32
records the NHS has given Google
52:38
millions of patients records those
52:41
patients themselves can’t access those
52:44
records they never gave consent for an
52:47
advertising company in Silicon Valley to
52:49
get their medical records so it is far
52:51
from being an independent impartial
52:54
arbitrator you’d be better asking your
52:58
GP in terms of is this good for me or
53:01
not secondly you’ll probably find
53:04
something really useful in August 2015 I
53:07
wrote about actually this is related to
53:10
a live go again I wrote about new mi
53:12
bees which are thing from the National
53:15
Institute of Clinical Excellence and
53:18
that’s the found
53:18
because it appraises the clinical
53:21
significance so it basically talks about
53:24
the potential that the naps have to add
53:27
value in a clinical setting and alivecor
53:31
actually got it MIB
53:33
from the National Institute clinical
53:36
excellence in back in August 2015
53:40
so even though a live core had got a you
53:45
know it been seen on us TV every channel
53:48
it opened the Consumer Electronics Show
53:50
we’ve been used on mainstage by the CEO
53:53
of cork on OK cubes even though the
53:56
whole tech industry had seen it you know
53:58
all the big tech titles diet major
54:00
magazines have done it it still wasn’t
54:03
recognized by NHS England AppStore
54:06
approval but it had already had a
54:09
National Institute of Clinical
54:11
Excellence it might be written all about
54:13
it giving independent impartial advice
54:16
to clinicians so they feel more
54:18
confident opting and prescribing mobile
54:21
health care apps so there are tools for
54:24
that that actually are coming from that
54:28
what’s the clinical significance how can
54:31
we do that so we shouldn’t go and you
54:34
know run to you know try and get very
54:39
invested interest organizations to be
54:42
our impartial independent arbitrator
54:44
what’s good that makes sense yeah I do
54:49
um you hit on one thing there and Dave
54:51
you said NHS is not impartial and the
54:54
only way to get impartial and unbiased
54:59
evidence is by testing the interventions
55:03
so NHS I’m sure that they were you know
55:07
would have been looking for apps that
55:08
have been you know unbiased impartial II
55:10
tasted and they couldn’t find any more
55:13
than one in four years and I don’t know
55:16
if they’ve been looking for all the for
55:17
years if it goes down in but we’re not
55:19
the old yeah that’s because they don’t
55:21
they’re not capable of looking because
55:25
clearly there are apps out there which
55:27
are having massive significance which
55:30
are finding patients who got atrial
55:31
fibrillation
55:33
you know undetectable symptomless people
55:38
aren’t even aware they’ve got them it’s
55:39
picking up this and it’s helping them
55:41
prevent strokes so we know for a fact
55:43
the top cardiologists the atrial
55:45
fibrillation Association screen patients
55:48
at their function days so it’s not
55:51
they’re not looking they aren’t capable
55:54
of doing this they’ve spent four years
55:56
now I’m going to do this I’m only
55:58
picking one example I can tell you
56:00
before of mobile health care apps in
56:02
fact go on to the M health group on
56:04
LinkedIn you’ll see a thousand
56:06
introductions from most eMobile
56:09
healthcare developers we facts that are
56:10
brilliant and are making a massive
56:12
difference so we’ve got to be careful
56:14
that we don’t give the stick to say
56:18
what’s good or bad to an organization
56:20
which doesn’t really understand isn’t
56:24
impartial and hasn’t you know isn’t
56:27
doing very basic steps itself like where
56:29
where is NHS is training the NHS England
56:33
training program for people to use their
56:35
mobile phones safely and securely where
56:38
is where can doctors log on see patient
56:41
records where can patients log on these
56:43
are very fundamental things this is this
56:45
thing of running up million mile an hour
56:46
you forget these very fundamental things
56:48
I believe every patient in the UK should
56:53
be able to log on and see on their
56:56
mobile phone screen their medical
56:58
records until that’s achieved don’t go
57:01
telling me how you judge everyone else
57:04
to get me does that make sense yeah
57:06
absolutely I agree with you in terms of
57:09
patients owning their medical data and
57:11
you know genetic material and everything
57:14
has to do with their body and and their
57:17
health it’s it’s the same thing as well
57:19
you know a big issue in America as well
57:21
as in the doctor area couple talks about
57:23
you know patients owning their own you
57:25
know data and medical information I
57:26
think I’m seeing as it’s not happening
57:29
anywhere again you know same in
57:30
Australia as well you know we had have a
57:33
electronic medical record you know for
57:35
everyone and it was an opt-in opt-in
57:38
system but it never took off sadly and
57:40
then now they’re trying to try an
57:43
opt-out approach I
57:46
so so you reckon the NHS digital you
57:51
know the agency or department that’s
57:53
called an edge is digital that’s
57:54
responsible for the NHS you know apps
57:56
library and whatever is incapable of
57:59
finding the people who are aware of the
58:01
field and you know with the right
58:04
knowledge and capability well it’s been
58:06
going is proven that yeah they do you
58:10
recommend like the cardiology
58:11
Association of the day recommend here
58:17
the top 10 cardiology apps spot on
58:20
follow that’s what the NHS should be
58:22
doing in exchange should be going how
58:24
can we help the you know the for example
58:30
the Rd the British cardiology society to
58:34
produce its app how can we help the
58:39
atrial fibrillation Association produce
58:41
an app that we can any doors you know
58:45
that’s a much better it’s a different
58:47
use of the same budget it gets much
58:50
better result you know American Health
58:52
says you I mean Heart Association
58:53
whatever this specialized physician
58:55
groups there are also in organization
58:58
like you know a large organization and
59:00
what makes you think that those kind of
59:03
specialty colleges or organizations have
59:06
people with capacity to you know look
59:08
for find and curate and evaluate you
59:11
know medical or health apps when NH
59:14
cases so if I’m a cardiologist you know
59:18
in the Irish cardiology society that’s
59:21
what they do so the Irish cardiology
59:23
Society had me speaker there and I’ll
59:25
symposium four years ago and I demoed an
59:29
alive go and gave everyone any audience
59:30
of their life core so thinking and you
59:35
make sure that there can be in they can
59:37
be impartial like a you know specialize
59:39
our invasion we know with it from
59:41
experience with big pharmaceutical
59:43
companies you know doctors and
59:45
specialists having to stay impartial
59:47
independent from all you know outside
59:49
influence industry employees is the
59:52
massive massive problem and what if for
59:54
example one cardiologist is affiliated
59:57
with the you know let’s say in
59:58
you some you know in intervention in the
60:00
counter gask Euler health and you know
60:03
he’s got a vested interest in it and
60:05
he’s got a conflict of interest right
60:06
there and you know what I mean like how
60:08
do you prevent such kind of influence
60:11
and bias and I mean it’s knee ‘king into
60:14
into their opinions as an artist so
60:18
actually so what you’re looking at is a
60:20
hierarchy of where influence and control
60:24
and stuff like that been going on so if
60:26
you go into a speciality okay so you go
60:29
to something like atrial fibrillation
60:30
Association there’ll be some dude like
60:32
me who’s got it in their family and they
60:36
will go out and they will write on blogs
60:37
and stuff about patients this is the
60:39
thing this is what we need to do and
60:41
then the cardiologists we work with as a
60:44
people with this condition will then
60:47
regardless of how much peer pressure
60:49
they have how much money finances the
60:51
drug companies given they’ll have to
60:52
start adopting this because patients
60:55
will be using it like what happened with
60:56
a live course so in that situation it’s
61:00
a much smaller challenge than going to
61:04
the NHS England and saying hey what
61:07
about is to get me NHS England’s got to
61:10
cover every single medical special every
61:12
single thing so the amount of people are
61:14
trying to pull in for their attention
61:16
it’s just colossal whereas if you’re in
61:18
your sub-speciality then you’ve got an
61:22
opportunity to actually influence that
61:24
and where the yel HS can work is it can
61:26
say yes we’ve got these charities and
61:29
these you know speciality interest
61:31
groups and Royal College of GPs and
61:34
we’re going to work with them
61:37
where’s the RC GP zaps and you know
61:40
concrete some of them got really Gramps
61:42
coming out and that’s that’s a great
61:44
thing that’s not been done on NHS
61:47
England you know the Royal College of
61:49
gynecology and obstetricians and
61:52
gynecologists they’ve done I think ten
61:54
apps they’re not approved by NHS England
61:57
it’s that bizarre so they obviously so
62:01
know how to do this thing and what I’m
62:03
saying is the specialities they have a
62:05
vested interest because you know people
62:08
are looking on App Store’s for apps
62:12
by their treatment so you recommend the
62:14
various specialties recommend certain
62:16
number of apps for their specialty yeah
62:19
yeah the NHS gets behind it
62:22
and if the NHS has to pay these people
62:24
they don’t collaborate co-invest to
62:27
create apps parties their speciality
62:30
organizations believe patients and
62:32
clinicians need then what a good use of
62:35
their resources much better than trying
62:38
to create app store because that’s what
62:40
Apple and Google do yeah it doesn’t look
62:42
like it’s worth you know Dave and Yuki
62:45
have you heard of a company called
62:46
haptic haptic yet yes
62:50
yeah and they prescribed at how are they
62:52
doing I haven’t heard too much from them
62:54
have you either you heard when they
62:57
closed down yeah well I remember that
63:00
they’re big Dremel tables was the
63:03
prescription of of apps remember that
63:06
Yuki yes so I guess I guess that concept
63:11
didn’t fly Dave it didn’t they actually
63:14
been our business yeah yeah it didn’t
63:17
fly prescribing and write big we had to
63:22
close down yeah so what they say to
63:26
accompany me to makes an app is they say
63:29
you pay us and we put you on the board
63:32
so it’s another thing we have to do so
63:36
you know if you’re looking at accelerate
63:40
the market don’t create Ministry of
63:42
hurdles all NHS England in creating an
63:45
app store that technically isn’t even
63:48
feasible
63:48
all they’re doing is making a technical
63:50
diversion everyone to waste their time
63:53
and resources on that’s what I picked up
63:55
on my blog that’s my belief that’s what
63:57
I think is going on I might be proven
63:59
wrong they might in the next four years
64:01
due to apps and a booth them but I don’t
64:04
think that’s gonna make it even solid as
64:05
much progress whereas very very
64:08
efficient but um you know NHS they do
64:13
provide a list of safe apps you know
64:16
mental health apps and um you know
64:18
exercising or what-have-you but they I
64:21
think that approval the Dave is talking
64:23
about it’s in utter and
64:24
absolute kind of endorsing basis and
64:26
peace ad to work it’s been tested and
64:28
proven but but they do provide list of
64:30
apps now you go into the website and you
64:32
know go on to find NHS Choices then you
64:35
know you will see apps and even before
64:36
they close down for a while they did
64:38
provide um you know a list of apps for
64:43
patients and I I would still kind of you
64:46
know go for that kind of a nationally
64:50
recognized organization sources then
64:52
blindly trusting the AppStore evaluation
64:55
now that aside um we’re not going to
64:58
solve any chest problems today however
65:00
um let me go back to head TIGI can be
65:03
the reason that have to close down was
65:05
that somebody found just found that the
65:09
server they were storing some of their
65:11
patient information were on faith and um
65:14
there are other other similar
65:17
initiatives and like at prescription at
65:20
our X and our X Universe and the eye
65:23
medical apps they’re there all of their
65:25
intentions is to provide doctors with
65:27
list of apps that they can suggest to
65:28
their patients however it’s been stunted
65:32
because of the lack of the evidence
65:35
those people um you know because you
65:38
know in especially in America the
65:39
doctors are highly aware of a medical
65:44
legal consequences right so for example
65:46
in um since AEDPA wasn’t taking the lead
65:49
in orbit I mean varying medical health
65:53
apps that are safe and you know deem it
65:55
safe or unsafe um other organizations
65:57
picked up the vitally like for example
65:59
Federal Trade Commission I’m fine so far
66:02
about handful of apps for
66:04
unsubstantiated claims for example in
66:07
Europe my baby beets promised to turn
66:12
your iPhone microphones you know you put
66:14
it on your pregnant belly and you can
66:16
hear your baby’s things I mean and also
66:18
um the was the other apps um in lots of
66:23
acne treatment that they promise your
66:25
your phone lights going to cure your
66:27
acne and plus measurement of heart rates
66:31
and things you know some apps have been
66:32
totally crazy you look you’ve won I’ve
66:35
actually said my cardio I believe a
66:37
cardio we
66:38
two eyes if you hold after your exercise
66:40
you hold your phone and the cam
66:43
front-facing camera is gonna detect the
66:45
heart rate I mean that I mean anybody we
66:49
can say it’s it’s it’s Villani but you
66:51
know patients believed in it they had
66:53
hundreds and millions of downloads and
66:54
uses so so federal help I am actually
66:58
not argument okay okay you’re confusing
67:01
so many things here okay we’re getting
67:03
down to the peanuts of a haptic failed
67:05
not for the reasons you believe haptic
67:08
failed yes that was exposed but what
67:10
they exposed was there was no technical
67:14
feasibility it didn’t make sense just
67:17
like this NHS digital apps library
67:20
doesn’t make sense
67:21
because if I go on the thing and I see
67:24
on the apps on the digital apps library
67:27
or I see on the haptic I press the
67:29
button I want to download it I have to
67:31
be sent over to the App Store so the NHS
67:35
might say it’s digital apps library says
67:37
this is a five star certified brilliant
67:39
app I go over the App Store and it says
67:41
is zero rated it’s got negative feedback
67:44
from five customers they also reasons
67:46
why it’s rubbish and it also says next
67:49
to it other apps I could download
67:51
because that’s how the App Store works
67:54
yeah well App Store works so that you
67:57
can never make a difference to
68:00
understand if someone sees a certified
68:01
app and they go on the App Store it says
68:03
it’s rubbish use this one but we also
68:08
know that the internet comments
68:09
especially negative comments your
68:10
commentators have you know
68:11
self-selection bias and very very
68:14
comment what if the common what if the
68:16
comment is by username Eric Topol
68:19
and I can Google Eric Topol
68:22
and that app and it says why he
68:25
recommends the other app and that is
68:27
exactly the flaw of going into the App
68:29
Store and trying to choose apps or
68:31
that’s not floor that’s the design
68:33
that’s what’s brilliant about it Eric
68:36
Topol
68:36
every NHS gep can have a social media
68:39
profile at no cost early they can have a
68:43
social media profile and they can rain
68:45
apps the patients will go to and trust
68:47
that nobody has time to curate even ten
68:51
apps no doctor
68:52
as Eric Topol is not going to do that
68:54
that is not a solution bullet Eric Topol
68:56
has approved more than 10 apps Eric
68:58
Topol has endorsed far more than 10
69:00
items and those work are usually dr.
69:03
facing apps for for new medical
69:05
professionals rather than forfeiting
69:07
their big couple couple for patients but
69:08
but again you know how are you going to
69:10
find that couple of apps from two
69:12
hundred thousand apps because you can
69:14
write the beginning I said you’re
69:16
looking at the wrong problem most of
69:18
these apps you say to two hundred
69:19
thousand they’re just cookie cutter ones
69:21
their kids play around there’s a low
69:23
barrier to entry it’s not even like
69:25
printing a leaflet it’s piece of cake
69:27
the bacon app and put it on an app store
69:29
but they’ll even get really nice and
69:31
card lock google that haven’t got
69:33
endorsements by doctors this is what the
69:35
NHS should be doing it should be getting
69:38
the good abs endorsed and recommended by
69:40
doctors then we have a result then we
69:43
have something that goes on when you
69:44
talk about and perhaps it failed until
69:46
you can do that bit the bit to do that
69:49
is to actually educate trained doctors
69:52
only I’m not in other initiatives like
69:55
hectic that has a you know proving safe
69:58
servers and and you know data safety and
70:00
everything if they can do that let them
70:04
and let them live on the thing don’t get
70:07
government money and wasted on something
70:10
that is completely unproven and you’ve
70:13
already spent four years proving you are
70:15
incapable of doing it okay um so we’ve
70:20
been talking a lot about in NHS problems
70:23
and um I’d rather talk about you know
70:26
how in general any we can improve this
70:30
situation that what can work in any
70:32
country regardless of the national
70:34
health care system so you know a
70:36
recommended tiny about your app
70:39
evaluation tools like for example give
70:41
me the base in the most you know the big
70:43
categories for example you go through I
70:46
let you as a clinician
70:49
learn how to build your own social media
70:52
presence upload videos to YouTube
70:55
telling people about you and why they
70:57
should shops
70:58
okay you start to get their own set of
71:00
apps that they recommend or based on
71:02
their own experience yep and share with
71:05
and every time you go and give a talk
71:07
recommend out to your colleague okay so
71:10
it’s obvious that yogi it’s not
71:12
evidence-based but it’s preference that
71:15
the physician learns is that right Dave
71:17
so yeah it’s based on their experience
71:20
based on the eyes
71:22
it’s just season practical to me yogi
71:25
that every app needs to be evident based
71:26
I mean these apps I don’t think they
71:29
have the money to put it through trials
71:31
etc how do you propose evidence base to
71:35
be how do you propose an app to pass
71:39
approval to be evidence-based how do you
71:41
propose to do that right I don’t have a
71:44
solution that you know I’m actually
71:47
offering here I have been seeing from
71:49
the searches in the literature that many
71:51
medical initiatives I was and so my
71:54
first project was to locate the you know
71:57
evidence on the effectiveness of apps
71:59
and I did not find many and it was a
72:01
kind of a shocking and a disappointing
72:03
result however in the process I found
72:05
that many medical institutions Brunner
72:08
reputable institutions and universities
72:09
and medical centers around the world
72:12
have been working to create absinthe and
72:15
they’re doing it the right way by first
72:17
pilot tasting it with patients involving
72:20
patients and getting their feedback
72:21
improving improving their prototype and
72:25
your testing in a larger cohort and
72:27
improving it effective before they can
72:29
you know endorse and advise and put it
72:31
on on an app store however in that
72:34
process we are also finding that at
72:36
creation and especially effective at
72:39
creation is not that easy
72:41
for example group of you know if there’s
72:43
an renewing health initiative in Europe
72:46
going on and they are working on bipolar
72:49
disorder apps for example and you know
72:52
it’s a huge team of both technology know
72:55
tic and techie people plus psychiatrists
72:58
and psychologists and you know every day
73:01
every element you know from all the the
73:06
multi-faceted intervention would need
73:08
they had it in the team how in they
73:10
created an app tasted it all on on
73:12
patients and they found it was actually
73:14
making bipolar disorder patient symptoms
73:16
worse and
73:18
I mean you know that’s that’s how we
73:20
learn we do not learn by just trying out
73:23
apps from the app store and then you
73:25
know and not liking it in and going for
73:27
the next one next one which you know
73:28
created by um some kid somewhere good
73:31
okay I think you could keep giving me
73:34
anecdotes all night we started from this
73:37
thing the NHS is claimed to have an
73:40
envision where they will host leading
73:42
health care apps so they are accessible
73:45
trusted by the public I have put the
73:48
case tonight that there is no way the
73:51
team who spent four years managing to
73:54
prove one app and approved 21 others as
73:57
safe to use although they haven’t been
73:59
certified whatever that means that that
74:02
team is incapable of achieving that
74:04
vision
74:05
I’m sure the test of time will prove I
74:08
am right but I wish you very best in
74:12
that your hopes that the NHS is going to
74:15
achieve that and it’s going to become
74:17
some independent impartial arbitrator
74:19
apps that we all look to but I’m
74:22
recommending my followers like I
74:25
recommend doctors who support and
74:27
endorse apps to patients be on the right
74:30
side make a judgment call be out there
74:33
with your judgment because we wait
74:35
another four years for another app and
74:37
another twenty one apps to get that sort
74:39
of safe to use although they haven’t
74:41
been certified kite mark whatever that
74:43
means no patient will get access these
74:46
tools no clinician will start using the
74:50
most advanced tool in the world that’s
74:54
in the palm of their hand we cannot wait
74:56
an organization that doesn’t know how to
74:59
do this to deliver us what I think we
75:02
all want David I I wasn’t I was actually
75:06
giving you some evidence not anecdote
75:08
let me give you another one for you know
75:11
this act called glucose buddy it’s cheap
75:14
and it’s relatively simple and it was
75:16
freely available to everyone it still is
75:18
and a team of Australian researchers
75:22
tested it just simple prescribed the app
75:25
to diabetic patients and the control
75:27
group was continued as usual what
75:29
they’ve been using follow up with their
75:31
doctors every
75:31
three months or six months but the other
75:33
people and they were using the paper
75:35
diary you know how this absolutely
75:37
replacing paper diary in in monitoring
75:39
the glucose and stuff and in after nine
75:42
months they um the ad group click elated
75:46
hemoglobin level was reduced by almost
75:51
1.2 percent which is which is even
75:54
better than a diabetic drug reduction if
75:58
you’re diabetic dragon next on average
76:00
is 0.05
76:01
I mean 0.5% so this is a great example
76:05
of a simple add freely available that
76:07
can you know impact people’s lives even
76:10
better than a pharmaceutical
76:12
intervention and this can be done easily
76:15
if not about um all these all those acts
76:19
that are created by you know
76:20
non-professional people non-medical
76:22
professional people can kind of like
76:25
basically survive it out in the App
76:26
Store I mean they will hopefully fall
76:28
out however in the process I just
76:31
worried that they can you know actually
76:32
harm some patients you know the patients
76:34
just you know trying it out and if the
76:36
advice and the insulin calculation or
76:38
that you know those bad response
76:40
calculations were not based on in a
76:42
sound evidence then it could actually
76:43
harm patients and that’s just um you
76:46
know one of the things that I hope that
76:48
we should all aim to prevent by you know
76:53
approving and evaluating apps properly
76:56
and so basically that’s my bottom line
76:58
message that apps that promise to
77:01
influence your health and you know
77:03
behaviors change your behaviors then it
77:05
should be tested and proven effective
77:07
otherwise we’ll all be wasting our money
77:08
and time and efforts on on things that
77:12
are unproven okay you know I think in a
77:14
perfect world it would be great if every
77:16
app could be evidence tested but I think
77:19
it’s kind of impractical to have an app
77:22
evidence base to have a study done it’s
77:24
a whole level of bureaucracy and delay
77:27
of time I think a doctor’s
77:29
recommendation from based on his
77:31
experience should be sufficient but
77:36
that’s my view anyway so I’d like to
77:39
like to thank you both both you guys
77:41
from coming out I know Yuki you’re
77:44
looking forward to a hallo
77:45
eh over there in Australia it’s Labor
77:48
Day right yes okay and Dave are you Dave
77:52
you just finished a concert you’re
77:54
probably probably wiped out yeah but
77:57
also I’m looking forward to them the NHS
78:00
England certifying internet medicine
78:02
calm okay there we and I yeah I’m uh I’m
78:07
waiting for the phone to ring right now
78:09
it could be today well thank you both
78:12
very much
78:14
okay thank you very much and I’ll send
78:17
you the link so you can use it thank you
78:19
very much you you keep early you both
78:21
have a good day a good night thank you
78:23
John thank you David bye good night

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