Online GP services: The way forward or caveat emptor?

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Dr Ray Walley in the Medical Independent, 5th April 2018.

mHealth Insights

“We live in a world of rapid advancements in technology but with all the benefits, there are some dangers, as we have seen in relation to the current controversy on the harvesting of personal data.”

The thing I find incredible about hearing this from Doctors is that most Irish Doctors and HSE are already facilitating this. Despite probably the ‘biggest success’ of their €800M eHealth Ireland project (that I’ve been critical of since it’s inception as it was clearly building on obsolete tech) being the HealthMail.ie service they’re still not using email properly (regularly sending emails with all recipients listed) and routinely sending out highly sensitive and confidential Patient information to medics who use email services like Google, Yahoo and Hotmail (which collect and sell on information contained within these “strictly confidential” emails).

“The delivery and provision of healthcare has changed apace with technology, bringing many benefits to patients, and doctors have embraced such advances. Advances in technology can assist with GP learning and enable patients, but we must be careful in ensuring that all the technology does not undermine or damage patient care or health outcomes. In an unregulated environment, there can be real dangers.  The recent proliferation of online GP services is not just a matter of concern to doctors but also, as the evidence is gathered, to health regulators. We must learn from the mistakes that are happening in other jurisdictions and not rush to adopt models that may, in the longer term, be damaging to patients and undermine population health”

I don’t think online GP services do operate in an unregulated environment. Perhaps regulations aren’t being enforced but that’s not the same thing.

“The UK Care Quality Commission recently reviewed online prescribing by such companies and medical practitioners working for them. Such concern has it caused that leading news outlets in the UK reported on their findings.  Some of their comments included: “Safety is where we found the greatest concerns… In February 2018, we found that 43 per cent of the providers were not providing safe care according to the relevant regulations. Their specific concerns included:   Inappropriate prescribing of antibiotics and prescribing high volumes of opioid-based medicines without talking to the patient’s registered GP.   Unsatisfactory approaches to safeguarding children and those who may not have the mental capacity to understand or consent to a consultation.   Not collecting patient information or sharing information.   Inappropriate prescribing of medicines for long-term conditions”

As many critical articles about “Online GP services” do this one also didn’t take long to start mixing them up with “Online Prescription services”.  These are very different things and this would be a great place for regulators to act. In the meantime GPs shouldn’t be using confusion to cast stones at colleagues who have had the courage to move beyond the 2000 year old office visit only model of care.

I think the simple short answer is to only let people who are actual online GPs call themselves online GPs.

One really odd thing I notice about the CQC is that GPs are forever quoting it’s reviews to make their arguments despite the fact the organisations abilities to conduct reviewS have been widely deemed useless (and dangerous) by GPs in the UK.

“Another UK study found that online-based systems were contributing to inappropriate referrals to emergency departments. A recent study in regard to electronic alternatives to face-to-face consultations with GPs published in the British Journal of General Practice showed that such access did not help to alleviate workload pressures of GPs, nor did it improve access for patients. The Royal College of General Practitioners followed up this study with cautionary advice for its members, indicating that if practices chose to provide online and telephone consultations, then it should be only as part of the practice service and that GPs should continue to provide face-to-face consultations, patient safety being paramount in any clinical consultation”

I’ve covered the reasons for this finding extensively on this blog over the years. The NHS has worked hard to undermine GPs with the +£100M pa they keep pumping into their success failed triage services (branded NHS ReDirect, NHS 111, etc). The simple fact is online based communications should avail of clinically validated tools so that Patients Primary Care needs can be handled by their GPs because triaging isn’t the easy bit where you can cut corners it should be done by the most experienced Clinicians and their time used efficiently by letting Patients help and supporting them with the provision of Patient History Taking tools.

“These findings should not be ignored in Ireland and health regulators need to take notice. The bedrock of patient care in general practice is continuity and that is something that must be protected at all costs. All the medical evidence points to the positive link between continuity of care with a GP and better health outcomes for patients. There is a proven link between the provision of a personal GP and reduced hospital admissions, better mortality rates and more equitable delivery of healthcare across socio-economic groups”

I agree with this but it’s 2018 and a general practice clinic like Dr Ray Walley’s that has no website and is closed most of the time isn’t providing what most citizens of Ireland would consider to be continuity of care. What are people supposed to do to get continuity of care? Send a tweet to their GP?

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“The GP is at the centre of healthcare provision: Of the 25 million patient consultations in general practice, 90 per cent are dealt with by the GP without the need to refer to another service. This deeply personal relationship is reflected in a high level of patient satisfaction. The value that patients put on their GP, accompanied by a low rate of referral, is only possible where the GP has a long-standing relationship with the patient, access to a patient’s previous records, including attendance at the practice and out-of-hours service, referrals to secondary care, medication, a complete history of that patient and all the factors driving healthcare needs”

The GP was at the centre of healthcare provision but convenience is now a quality measure and Patients and Carers in Ireland are nearly all now carrying around supercomputers through which they’re able to Google their symptoms, Google their medications, Google their Doctors, read about their treatments, watch free videos about their conditions, etc.

Oh and because the world’s biggest corporation is betting the farm on it very soon they’ll be able to download their electronic medical records to their mobile…

“Sláintecare and the Health Service Capacity Review both cite the importance of general practice and the need to deliver more services through general practice. However, in the absence of any support or resources by the State, the potential for better patient outcomes is in danger. As Ireland grapples with the appropriate funding and provision of general practice, there is a race to the bottom to replace the existing GP model with alternative models that, although dressed-up as general practice to distract from their lack of long-term detailed analysis, are not general practice”

I think the simple short answer is to only let people who are actual online GPs call themselves online GPs.

“What we are now seeing is a commercially-driven shift from patients having a relationship with their GP, being partners with their GP in managing their health and wellbeing, to accessing healthcare on a pay-as-you-go basis. While there is of course a benefit in GPs using video consultations with their own patients in certain circumstances, this is not what the models being promoted are offering. In fact, it is the exact opposite. Healthcare in Ireland is fast becoming a commodity that is being driven by market forces, not by medical evidence or in the pursuit of quality patient care”

I think this has already pretty much happened in the USA where 100s of millions of VC debt have driven the growth of phone call services that have undermined the last few GPs.

I’m sure there is no political will in Ireland to stop major tech companies like Google undermining GPs by offering their Patients free video chats 24×7 so it’s really key that Irish GPs take the initiative and start providing online services to their Patients and we’re working with a few GP practices in Ireland now to bring in a successful service that’s already been deployed at scale in the NHS:

It’s interesting that Dr Ray Walley now states “While there is of course a benefit in GPs using video consultations with their own patients in certain circumstances” because in his own practice it seems he doesn’t even have a website and no means for Patients to discover whether they have the ‘certain circumstances’ for which a video consultation would be helpful.

“The ‘Uber-like’ apps that offer a so-called GP service emphasise access and speed, but there is no continuity of care and it is not a GP service. It is a service of convenience and from evidence to date, we can now see it has the potential to lead to inappropriate prescribing and safety issues. The doctors providing the system may be trained GPs, will likely make more money and have a less stressful career, but what they will provide will not be general practice”

Sounds like a simple trade description issue. If you’re not an actual online GP you’re not allowed to call yourself one. Call on the ICGP and NAGP to suspend any GPs contravening this for dishonest conduct. Nothing stops Dr Walley reporting them himself.

“Government must take action and ensure that a meaningful and evidence-based general practice service is provided to patients, with the required support and investment from the State. General practitioners are not Luddites by any measure and technology has a place, as long as it enhances patient care, not undermines it. The advice has to be caveat emptor”

Sadly the government has little no interest in properly supporting GPs, there’s an abundance of evidence that the office visit only consult model can be very dangerous (and we know that self-harm is the largest killer among 15 to 24-year-olds in Ireland), so buyer beware doesn’t apply because if you provide a service in 2018 and have no website and offer no means for a Patient to engage with you electronically they’re going to go somewhere else for advice.

*** UPDATE 15 April 2018 ***

Classic example of how an organisation like the RCGP is unaware that it is helping peddle misuse of the term ‘online GP’ by sharing news articles that use the term inappropriately:

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Going beyond killer apps: building a better mHealth evidence base

mHealth Insights

 

“mHealth relates to the provision of health-related services via a mobile device. It comprises multidimensional elements including provider, patient and administrative applications. Applications include consumer education and behaviour change, wearable sensors and point-of-care diagnostics, disease and population registries, electronic health records, decision support, provider tools (communication, workflow management, professional education) and healthcare management (human resources, financial monitoring, supply chain logistics)”

I see a lot of shortcomings in this definition and think the authors would’ve done better if they’d gone with the definition I proposed when I coined the term eg. in 2010.

“Although mHealth has potential to strengthen health systems worldwide, the evidence base is immature, and consequently, the opportunities to advance knowledge remain limited. Mobile devices and apps have become essential tools for disruptive change in many industries, but thus far, this has not happened in healthcare. Here, we discuss five interrelated reasons as to why mHealth has under delivered and highlight challenges and opportunities for mHealth researchers”

I think this is a popular myth held by researchers. In the real world (as I wrote here in 2009) successful mHealth applications are already commonplace across the world.

“The myth of the ‘killer app’. Disruptors often rely on a ‘killer app’—a highly popular application that users will consider indispensable for their needs. At last count, there were nearly 260 000 health apps on the market, but most downloads are never opened and consistent use is extremely rare. Further, these apps are often disease siloed, focus mainly on behaviour change, gloss over privacy issues and are not integrated into any overarching healthcare structure. Such apps struggle to achieve large-scale adoption because of their failure to address the needs of diverse stakeholders”

We’ve noted this happening time and again before (eg. “Majority of mHealth apps fail to engage patients”, NIH funded researchers spend $270 on misleadingly labelled iPhone apps & conclude that apps offered for ‘EDUCATIONAL USE ONLY’ can’t be relied on for ‘PROPER MEDICAL ADVICE’The Impact of mHealth Interventions: Systematic Review of Systematic Reviews, etc) and it’s a classic case of the researchers being failed by their imaginations. The reality should be obvious: it’s now cheaper to distribute high quality life saving medical information than it is to distribute water to most of the citizens living on this planet. The killer app is probably the baked in life saving potential that mobile connectivity offers.

“Most apps are consumer facing, whereas healthcare systems tend to be provider facing. This important distinction may explain why the ‘killer app’ approach is not the correct mindset. The diversity of users and the inability to address their varied problems results in user fickleness and ready abandonment of new technologies”

It’s odd to think that a group of researchers in 2018 feel their audiences need to be made aware that ‘most apps are consumer facing’. I know lots of researchers still get confused by all this but I’d of thought anyone reading the BMJ in 2018 is aware that the app stores have created an unprecedentedly low barrier to entry and that this means there are millions of cookie cutter apps some made by students having fun trying something out and posting it for it to be downloaded a few times (and probably never for real world use by an actual Patient/Carer).

The neat distinction between ‘consumer’ and ‘healthcare provider’ facing is also fast disappearing eg. see Apple Health Record.

“When tools are not connected to systems and human support, they are unlikely to be effective. Consequently, moving beyond a single solution focus towards a ‘health ecosystem’ approach is needed”

This hope of joining everything up before joining anything up is why in 2018 your dog has more joined up care than that provided by £multibillion teaching Hospitals to your sick child.

“Neglecting user perspectives and preferences. Related to the killer app mythology is the tendency to over engineer solutions before having an opportunity to fully understand user needs, contextual factors and the size and specifics of the problem that needs addressing. The Greentree consensus outlines nine principles for digital development, emphasising frequent and in-depth user engagement in all phases of the development process. It stresses the importance of understanding the ecosystem, designing for scale and sustainability, addressing privacy, using open standards and taking a data-driven approach”

This is such a dated concept and is only held by people who haven’t yet learnt how to use an app store. Who is making smartphone apps and neglects user perspectives and preferences??? Don’t the authors realise that apps all have public ratings posted by actual users and that developers are prioritising this feedback or getting fired in quick order?

“It also emphasises the need for multidisciplinary collaborations. Although researchers are often the subject matter experts, non-health specialists such as human factors engineers, human computer interaction specialists, anthropologists and ethicists can provide strong methodological frameworks for understanding user perspectives at all stages of the development, implementation, evaluation cycle”

This is  a classic misconception. In my opinion researchers are far from the subject matter experts and the basic flaws in this paper stand testament to that. The real subject matter experts are carers who just intrinsically know that ‘here’s my number’ is one of the most caring things you can say to a Patient.

“By not taking a user-centred approach, we risk over engineering solutions. The most promising use of mHealth to date has not been smartphone apps, but basic functions such as short messaging service or voice calls to address specific issues such as medication adherence and promoting smoking cessation”

This could only ever be written by someone who has never been involved in producing a mHealth app/service.

How are sms and voice calls to ‘address specific issues such as medication adherence and promoting smoking cessation’ still considered ‘promising’? Aren’t these already common and widespread eg. in 2012 Walgreens were generating more than $300M a month in revenue from their medication adherence/reordering app.

I think it’s important to realise native functions of mobiles now all start first as features/apps and the mobile brands get to enormous data sets that show their popularity/use/value in order to make the decision to make them native ‘basic functions’. A good example of how futuristic smartphone apps can quickly become ‘basic functions’ can be seen by studying Apple Health Record. Only weeks ago that wasn’t even imaginable to most and many very senior Doctors still can’t believe it!

“Apps are not pills. Researchers tend to lack a good understanding of how developers operate. Two commonly used industry standards include Waterfall and Agile development. Waterfall is a stepwise process whereby developers iteratively revise their software at each stage of the product development cycle based on target audience feedback. It may be particularly appropriate for large-scale system development. Agile design takes an incremental rather than sequential approach. Initial prototypes are usually simple and each development effort is completed in short sprint cycles with increasing maturity at each cycle. It is particularly useful when there is not a clear idea what might work. Whichever approach is used, initial deployments are unlikely to work perfectly. The interim goal should be a ‘good enough’ prototype, known in industry as the minimum viable product. These approaches highlight differing developer and researcher perspectives. The developer’s outlook is plastic, continually updating and refining a product to create novel solutions and stay ahead of the competition. By contrast, a researcher’s outlook is more static where interventions are viewed as pills—specific agents that are developed and tested in isolation of other factors. These differences in perspective are often disregarded. Understanding the developer’s approach can help research teams to get apps in front of users quickly, fail early and build from the lessons learnt. This approach can also avoid expensive ‘scope creep’ later in the development cycle when the app is more mature and user testing reveals a major redesign is needed”

I find this quite a bizarre piece of editorial. Why would anyone think developers must choose between 2 completely different approaches? Isn’t everyone aware that all the major pharma brands now have beyond the pill strategies?

“Rigid approaches to evaluate evolving technologies. While we strongly support the need for evaluations with randomised controlled trials (RCTs), there are several considerations in applying this design in mHealth. First, traditional RCT designs reflect ‘the static view’ described above—assuming an intervention is ‘fixed’ and external factors are standardised or adjusted for to avoid introducing a bias. This is anathema to software development where iteration, bug fixes and new releases as user experience grows are the norm—‘the perpetual beta’. The key consideration here is that we test principles rather than fixed apps”

I agree with this but sadly a lot of key decision makers in the Healthcare industry don’t even understand it eg. until recently the EU and major pharma brands were actually sponsoring a printed directory of mHealth apps!

MyHealthApps Directory

“A third and unexplored area is postmarketing surveillance mechanisms to safeguard against unintended consequences derived from mHealth-related activities”

I don’t think this is unexplored at all. What’s unexplored greatly is the potential for mHealth apps to support post marketing surveillance of medicines (something I’m currently working on with a leading vaccine brand).

“What are the priorities of those who pay for mHealth technologies? Public and commercial payers of health services play a central role in determining whether mHealth can be adopted at scale. Innovation in the business model is just as important as the apps themselves in promoting disruption. Greater attention to business model specifics may stimulate different research questions. From a researcher’s perspective, the priority is to demonstrate clinical effectiveness. This contrasts with the payer’s perspective which is broader and includes factors such as reduced administrative burden, improved workflows, greater patient and provider engagement and improved quality of care and outcomes at lower costs. The macroeconomic environment is also key to driving particular business models. While profits may be greater in high-income countries, the largest mHealth market in terms of user numbers will be in emerging economies. Just as the pharmaceutical industry tends to be segmented into low volume, high margin products for rich countries and high volume, cheaper products for poorer countries, mHealth markets are likely to evolve differently depending on the payer, provider and consumer environment. It is therefore important that the research community generate evidence on effective business models as much as effective apps”

This is why I think Apple is taking such a positive direction in it’s unique approach as a tech company to not be focused on what helps the Patient rather than what gets you reimbursement. I really hope Apple can make a product that’s great for Patients and can earn their trust because if they achieve that ambition they will once again change the world and I have every confidence that the business model will take care of itself (and will indeed dwarf their current annual revenues of ++$200B).

“Conclusion. Although some may be disillusioned by the lack of ‘blockbuster’ mHealth trials, we are optimistic that the evidence base for mHealth will grow substantially in coming years. Particular challenges remain, especially in low-income and middle-income country settings where literacy, health literacy, unavailability of smartphones and limited access to reliable data connectivity all pose adoption challenges. However, these factors are improving rapidly, and the opportunities for future growth are substantial. With increasing knowledge of what works and what the challenges are, we will arrive at a more nuanced understanding of the role of mHealth in improving health and healthcare”

Last week I presented to the medical students at UCD Medical School in Dublin. At this world leading medical school the future Doctors were being trained for a career that no longer exists using tools that are relics of a by gone era.

No doubt we could research every avenue (‘Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials’?) but we really don’t need to wish for ‘blockbuster’ mHealth trials we need to move beyond the 2,000 year old office visit only model of care and stop expecting medics to do the impossible because the Born Mobile generation wouldn’t actually believe that a Doctor would be allowed to work without at least a connected smartphone loaded with quality medical content.

“Competing interests: None declared”

I understand this is a challenging area but even a cursory appreciation of the George Institute’s work and it’s clear the organisation has several heavily vested commercial interests in this area eg. the George Institute has a ‘China Centre of mHealth Innovation’ that was set up with corporate sponsorship from Qualcomm to “improve community health care in China through the study of affordable, sustainable mHealth interventions, which target the nation’s leading causes of premature death and disability, while supporting the central government’s deepened commitment to health care reform” and it clearly benefits from a paper that in summary calls for more need for the work of researchers.

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mHealth for Paediatricians Course

mHealth for Paediatricians

We’ve had a request to produce a new module of the mHealth for Healthcare Professionals course (that we originally developed for the Healthcare Informatics Society) for Paediatricians and would like you to contribute, attend the meeting and suggest topics we should include.

It is a great honour for us to have Professor Sam Lingam MD (Hons) FRCPCH FRCP (Glas) DCH DRCOG, Consultant in Paediatrics and Adolescent Medicine & Medical Director of the Harley Street Paediatric Chambers, as Chair of the meeting.  An incredibly caring and experienced Paediatrician who has for 30+ years been sharing medical notes with Patients he will also be launching his new mHealth tool that enables Parents/Carers to share a high quality Paediatric Long Term Condition and Allergy History using their mobile at the meeting.

Below is a draft overview/schedule that will be updated as the event develops. The course will be live streamed and video recorded and the date for the meeting is provisionally set for Wednesday the 25th April 2018.

Overview of the opportunities and issues

Why mHealth has created a need to update clinical practice.

Challenges being encountered.

Deep dive into mHealth best practice

Giving your child a Mobile: when? why? how?

Sharing medical records and communicating with Parents/Carers

Vaccine Safety

Medication Safety

Mobiles give us superpowers: what are the opportunities to empower Patients with disabilities

Future Opportunities

Apple Health Record: Patients sharing their Medical Records with Doctors

ResearchKit: imagine the potential if every Patient could contribute to medical research

Note 1: The 1 hour CPD accredited course will be followed by a 1 hour CPD accredited course that trains Paediatricians to work with Patients/Carers who have used Prof Lingam’s Paediatric LTC & Allergy Questionnaire App and to use the Template for Paediatricians app with their Patients.

Note 2: The venue for the meeting is provisionally confirmed and has a capacity of just 100 delegates so we’ll be oversubscribed (Prof Lingam runs a monthly CPD meeting that is live streamed from the British Medical Association House that has a capacity of 200 and that’s regularly oversubscribed) so if you’d like to register to attend the meeting or livestream please get in touch via the comments below or by emailing David Doherty (david_doherty@3gdoctor.com) with your details.

 

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Harvard Business Review: Apple’s Pact with 13 Health Care Systems Might Actually Disrupt the Industry

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An interesting Harvard Business Review article by David Blumenthal and Aneesh Chopra propels some common misconceptions about Apple’s focus.

mHealth Insights

“An announcement on January 24 didn’t get the large amount of attention it deserved: Apple and 13 prominent health systems, including prestigious centers like Johns Hopkins and the University of Pennsylvania, disclosed an agreement that would allow Apple to download onto its various devices the electronic health data of those systems’ patients — with patients’ permission, of course”

I was think the reason it “didn’t get the large amount of attention it deserved” is because the David and Aneesh are talking about the mainstream media. Anyone with any real interest in seeing Patients and Carers get documented care was talking about Apple’s news but why would be media brands be overly interested in something that’s going to disrupt the situation from which their major advertising partners are generating their profits? Hasn’t the media always been like this with radically innovative new approaches? eg. it’s not like there were photography magazines writing about Philippe Kahn and the soldering work he did while his wife was in the labour ward.

“It could herald truly disruptive change in the U.S. health care system. The reason: It could liberate health care data for game-changing new uses, including empowering patients as never before”

All signs show it is eg. Dr Ricky BloomField’s demo at HIMSS18 stole the show and he wasn’t even on a proper stage.

“Since electronic health records (EHRs) became widespread over the last decade, there has been growing frustration over the inability to make electronic data liquid — to have it follow the patient throughout the health system and to be available for more sophisticated analysis in support of improved patient care and research. Most efforts to liberate and exchange health data have focused on getting doctors and hospitals to share it with one another. Those efforts continue, but progress has been slow. Frustration has increased interest in a very different approach to data sharing: Give patients their data, and let them control its destiny. Let them share it with whomever they wish in the course of their own health care journey”

I think it’s clear that this problem existed even before records went electronic and Patients and caring Clinicians have been frustrated for decades eg. Prof Sam Lingam was at Great Ormond Street Hospital in London 30 years ago sharing medical records with the Parents of some of the sickest children in the world.

“Several technology companies — including Google and Microsoft — tried this in the early 2000s, but their efforts failed. There just wasn’t that much electronic health data available at the time, since only a tiny fraction of doctors and hospitals had electronic records. Health systems were reluctant to share what data existed, seeing it as a valuable proprietary asset. The technology for giving outside entities access to electronic records kept by hospitals and doctors was underdeveloped. And EHR vendors were uninterested in promoting such access because the demand was weak and data sharing could spur competition from other vendors”

I think this overlooks the fact that we hadn’t had the Nokia Decade and most people didn’t have a personal means of being reached 24×7 or connecting to the internet. Apple is the world’s largest and most profitable corporation because it seized the opportunity to leverage the newest mass media. It’s now time for Clinicians and Patients to seize the opportunities to advance how healthcare is accessed.

“Those obstacles have now mostly melted away. Electronic health records and digitized health data are now ubiquitous. Various federal incentives and regulations now require providers to share data with other providers and with patients or face significant financial penalties. The Argonaut Project, a voluntary private sector collaborative, has provided guidelines for an open source, standardized application programming interface (API) that provides ready access to data stored in providers’ electronic records. Think of APIs as gateways into electronic data warehouses that now populate the health care landscape. Of note, the federal government now requires all vendors of electronic records to include these open APIs in their products to be federally certified.”

I don’t think the obstacles have mostly melted away. EHRs’and digitalised health data is far from ubiquitous. There’s also a massive issue that arises because Electronic Health Records are all too often just billing records rather than clinical records and in most cases have never even be reviewed by the Patients they relate to.

“A world in which patients have ready access to their own electronic data with the help of facilitators like Apple creates almost unfathomable opportunities to improve health care and health. First, participating patients would no longer be dependent on the bureaucracies of big health systems or on understaffed physician offices to make their own data available for further care. This could improve the quality of services and reduce cost through avoiding duplicative and unnecessary testing”

I think it’s becoming obvious: healthcare is going to become a Mobile Experience, just another thing we do with our mobiles (2012).

“Second, the liberation of patients’ data makes it possible for consumer-oriented third parties to use that data (with patients’ permission) to provide new and useful services that help patients manage their own health and make better health care choices. Such consumer-facing applications — if they are designed to be intuitive, useable, and accurate — have the potential to revolutionize patient-provider interactions and empower consumers in ways never before imagined in the history of medicine. Imagine Alexa- or Siri-style digital health advisors that can respond to consumer questions based on users’ unique health care data and informed by artificial intelligence. Health care could start to function much more like traditional economic markets”

It always amazes me how healthcare  industry professionals always seem to want to add the caveat that applications have to be “designed to be intuitive, useable, and accurate” in order to improve things. Maybe they don’t realise that unlike all the software that healthcare organisations waste $billions on every single bit of software that someone downloads to an iPhone comes with a universal rating system.

Related posts: “Majority of mHealth apps fail to engage patients”How Mobile First Clinical Trials & Ratings will transform the $100B Clinical Research Industry.

“Nevertheless, this vision of the future faces obstacles and uncertainties. First, large numbers of hospitals and doctors have to follow the lead of the 13 systems that have already jumped on board. There are encouraging signs that many more will join, but ultimately, there needs to be a clear business case for both providers and their IT allies to invest in this new partnership. Perhaps the most compelling would be widespread consumer demand for the service. For that demand to materialize, consumers have to receive something they value in return for giving third parties like Apple access to their data. This means that Apple and its future competitors will have to develop nifty consumer-facing apps that solve consumer health-related problems easily and cheaply. Those apps simply don’t exist at the moment”

This paragraph reminds of me of the age old definition of an expert: someone that can tell you exactly why you can’t do something. It’s interesting to note that the number of partner systems following the lead has already exceeded the authors expectations eg. the number of partners has already doubled.

“Second, the opportunities for fraud and abuse in this new world of data access are daunting. Most consumers will want to delegate to third parties the job of accessing, storing, managing, and analyzing their data. Making sure those third parties are trustworthy is critical, and unscrupulous actors will inevitably take advantage of unsophisticated patients. Health data is extremely valuable on illicit markets. And even honest but unsophisticated data stewards can create huge problems if they don’t adequately protect patient information. Federal and private sector organizations are trying to develop a voluntary but enforceable code of conduct to govern the behavior of private data stewards. This would be an important first step toward assuring that consumers are not victimized on the way to a brighter health care future”

I cannot see how we can be in a worse situation than that we have today where the Patient the data relates to isn’t even getting to access it.

“Third, once new companies start to develop consumer-facing health applications based on patients’ own health care data, the quality of those applications could become an important issue. If they offer advice, it needs to be reliable. If they promise a service, they need to deliver. Some applications may fall within the existing regulatory authorities of U.S. federal agencies like the Food and Drug Administration or the Federal Trade Commission. If not, the question of whether and how to assure that the advice furnished consumers is valid and reliable will certainly arise as a matter of public policy”

I cannot see how we can be in a worse situation than that we have today where the Patient information is being misused and Patients aren’t even getting to access it.

“These problems notwithstanding, the announcement of this collaboration between leading American providers of health and information technology services likely signals a new era in health and medicine. The partnership and its results will not solve all our health care problems. But they could really shake things up. And that is what the U.S. health system needs”

I remember the news said the Apple’s original iPhone “Could really shake things up” whereas Mobile industry gurus who understood the complexities of the industry (like Tomi Ahonen) straight out called it a new era and the ‘Jesus Phone’.

We’ve got the same happening with Apple’s push into healthcare except now they’re the  world’s most valuable corporation, have a $300Billion cash reserves, own the world’s most valuable brand and have had their senior management already tell the world that they are going all in on Healthcare and expect the revenues they generate by helping Patients to dwarf their existing business.

*** UPDATE 19 July 2018 ***

I shared an update to this on Linkedin and a couple of very highly respected medics made interesting comments:

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“If you define disruption as redistribution of HC resource$ to Apple, maybe.  If you define disruption as delivering improved value=outcomes/costs for patients and their physicians, absolutely not.  https://www.linkedin.com/pulse/connectivity-interoperability-our-lifetime-howard-green-md/

Howard Green, MD (Dermatology & Dermatology Apps)

Reply by David Doherty: Interesting that you don’t see enabling Patients to view and share health information as helpful. Does being able to look at your own financial transactions on your banks app or online statement harm your financial health Howard?

Reply by Howard Green, MD: As a physician working where the rubber meets the road in the translational zone between tech and real life medicine I’m really into demonstrated large value for patients and physicians. Every physician knows that patients viewing and sharing health information on their devices beyond portals is a variable which hasn’t been fully examined regarding it’s effects on prevention, medical, surgical or palliative outcomes and costs unless standardized and interoperable. Carrying medical records is not bad, but simply holding your medical records on your device isn’t going to create massive innovative value in Healthcare which we need to deliver safe quality affordable innovative HC to all Americans. https://www.linkedin.com/pulse/empowered-patient-isnt-howard-green-md/

Interoperable standardized EHR’s would negate the need for Apples siloed product.  But as long as patient data remains proprietary and contributes to the EBITDA of the big 5 controlling industries of HC we’ll never see interoperability or value in our time. https://www.linkedin.com/pulse/connectivity-interoperability-our-lifetime-howard-green-md/

“Now to see if it actually improved pattient outcomes”

George Margelis (Medical Practitioner with a passion for improving healhcare)

Reply by David Doherty: I have a colleague who has been sharing Medical Records with Patients & Carers for decades (you can read a paper published on his work 32 years ago here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1778713/?page=1 ) and without a doubt it transforms the opportunity to improve Patient Outcomes. I have no doubt that it’s going to radically transform the capacity and opportunity for Patients and their Carers to understand and improve their own health. Until now the Medical Records were being used to help the financial health of hospitals/insurers/pharma/etc/etc so why aren’t you optimistic about the potential for Patients to see info about their healthcare? Step into a Carers shoes for a minute by watching Regina Holliday (one of those annoying “Mrs A-Type” personalities!) explain what it feels like to be excluded from being able to look at even the most basic documentation of a loved ones care: https://mhealthinsight.com/2013/01/09/of-all-the-horrible-things-that-happened-the-worse-was-the-lack-of-access-to-information/

Reply by Howard Green, MD (Dermatology & Dermatology Mobile Apps): Correct George, outcomes are the only products manufactured and produced in HC with patients. value=outcomes/costs. Let’s see the value! https://www.linkedin.com/pulse/health-care-marketing-emperor-has-clothes-howard-green-md/

understand and improve their own health? Took me 4 years of medical school, 8 years of post medical school graduate training and continuing education to just keep up with medicine and carrying a medical record on a device is going to innovate and disrupt healthcare? Why not free up physicians from the 100’s of thousands of hours every day they pay to input data into EHR’s just to be sold to ancillary industries for the profit of the EHR company to allow physicians to care for patients and innovate again. ???

Reply by David Doherty: Hi George & Howard,

Clearly this is a complex area. Why not join a debate on this specific topic (the impact of Apple Health) moderated by my good friend John Bennett MD at InternetMedicine.com.

Get a feel for the debate by watching a discussion we had recently when CNBC ran an article calling Telemedicine a bust because a few VC’s are losing their money on bets they’re laying on insurers paying for video consulting services:

https://mhealthinsight.com/2018/07/01/why-telemedicine-is-a-bust/

or this group discussion of Mobile Health:

https://mhealthinsight.com/2017/04/22/join-the-hangout-mobile-health-what-it-is-today/

If you want to go ahead I’ll send an email to John and he’ll get it arranged for a time that suits all. I think it’ll be a very informative debate.

Reply by George Margelis (Medical Practitioner with a passion for improving healhcare):

Thanks David. I think it is important that we discuss this openly. In Australia we have a national shared health record which has great potential to transform care. We are working through how to get it to deliver benefit, and one of our challenges is clinician and consumer engagement. Just setting up the infrastructure is not enough. Developing clinically useful use cases and making them the standard modus operandi is the key. I applaud your work in demonstrating the possibilities, we now need to enable them at scale to get the benefit. Keep up the good work.

I know Regina well, as well as my old friend Daniel Z. Sands, MD, MPH who has been espousing this for decades. Personally I think Open Notes is the best solution, but clinicians need to be trained in writing better notes suitable for broad consumption. Each step in an incremental improvement, but we still have a long way to go.

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Help us produce 2 new mHealth lectures for Medical Students next week

George B Shaw Apples and Ideas

Next week (Thursday 29th March 2018) I’m giving a couple of lectures at University College Dublin Medical School on the topics of “How would the BornMobile generation redesign Medicine?”  and “The Future role of the Doctor“.

The lectures will build on the mHealth course for Healthcare Professionals that we built for the Healthcare Informatics Society but I thought it would be a good idea to crowdsource ideas here by outlining a draft skeleton of the presentations and inviting your thoughts and suggestions (easiest way is via email or the comments box below – and messages will remain private unless you request otherwise).

In appreciation of your help I’ll give you a credit at the end of the lectures (both lectures will be video recorded and shared on YouTube).

How would the BornMobile generation redesign Medicine?

  • Introduction

Background.

Why the most powerful lesson I got at Medical School came from a Patient as we looked at the internet together.

  • Keeping current with the tools of our time.

Moores Law: Your iPhone has a faster CPU than that used by a £10Million Surgical Robot

Half of US Medical Students believe that using a Mobile in front of Colleagues & Patients would make them appear less competent

If you attend a Medical School that still doesn’t give you mHealth tools the data now shows that they are failing you

If Patients see you uncomfortable using a mobile they may doubt how current your medical knowledge is.

It’s critical we also appreciate that the mobile phone in your pocket provides the quickest way to end your career…

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…or even worse.

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PLEASE TAKE THESE POWERFUL DEVICES SERIOUSLY AND TAKE TIME TO LEARN HOW TO USE THEM because ‘here’s my mobile number’ is now one of the most caring things you can say to a Patient or Carer.

  • Description of the Born Mobile Generation & the disconnect with modern medicine.

Joined up medical records: Dog Vs Child

Treat me like a statistic and save my life.

There’s probably not a Doctor in Ireland who wouldn’t get a sizeable GDPR fine if they were inspected today yet Cancer Research charities are paying private investigators to research the family and friends of children who have cancer, the NHS is giving away the detailed healthcare records of millions of Patients to the world’s biggest advertising company (Google) without even notifying Patients who never even had access to the same info and referral agents are paying google millions while masquerading as free helplines for drug addicts (while generating millions in finder fees for rehab services).

      • Describe how the Healthcare Industry is failing to keep up with the changing needs of Patients and Carers

“Go and Get Help” no longer makes sense.

International Diabetes Federation: Let’s embed mHealth and make it a compulsory embedded part of care for Patients who have diabetes.

The ability to use “Voice to Text” should be an entry requirement for Medical School in 2018.

  • Imagine how we could use the internet together?

Mobile is transforming the Internet and creating the Internet of Things: how will that transform medicine.

  • Beyond the office visit model

Nutrition, Chronic Disease and Behaviour Change Focus.

  • We need to bring the tools we use socially to work

You’re probably going to start working in a Hospital that expects you to use as many as 20 different software programmes and a heap of obsolete tech like fax machines and pagers. It’s time Medical Schools required students to always carry the latest smartphone & use it in their exams because we need to prepare them for a career in which they will always have a connected smartphone (at least as powerful as an iPhone X) and your Patients will have one too. How do you plan to leverage that?

Imagine a world where Medical Notes are shared with Patients and Carers…

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Imagine a world where Patients create the Healthcare Record?

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Imagine a world where Patients bring the Healthcare Record to the Consultation?

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  • News & Published Research Literacy training

A Doctors career is being transformed by Patients/Carers looking up information. The phrase “Can we talk about this information” is coming at the profession like a freight train.

      • Online sharing of lectures

Instills Transparency, Confidence in the profession. Useful Patient information: imagine how it might help the Parent of a child on dialysis if they watched the UCD nephrology course.

UCD should pride itself on the number of Medical Schools around the world that copy their lectures. When information is cheaper to distribute than water the value you offer is determined by the quality of the information you share.

      • What would the world’s best Medical School look like?

Paperless, socially connected tuition designed to teach and build team working skills.

MD FastTrack for Experienced Nurses.

International students graduating at UCD after resitting their Final year in the world’s most modern medical school.

“The Future Role of the Doctor?

The future Doctor is one that is capable of asking “What Does John Need?” and confident to not just intensify treatment.

The Future Patient brings their own data – why do we need this to happen (Primary care physicians in the US spend nearly 2 hours on EHR tasks per hour of direct patient care) and what changes do we need to make to accommodate this?

Imagine if every Patient you treat is in a Clinical Trial

Long term commitment to proving your Trustworthiness and Professionalism so that you can be an Independent impartial advisor capable of reducing over treatment and overdiagnosis and making preventative connections with Patients that will help them change their behaviours.

How do you develop trust with Patients in a world that’s upside down and while Doctors get threatened with GDPR fines the leading teaching Hospitals are being rebranded by corporations that sell Patients down the road to scammers, the world’s biggest corporation was practically seed funded by illegal drug adverts and is now selling personal data on insured Patients to rehab referral agents who masquerade as a ‘free helpline’ for addicts:

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Where will the Smartphone Medical take us?

From: “Please give me 36 seconds to tell my story” to “The Doctor Can See you now & thanks to data Doctors are able to select Patients that they know, understand and feel a connection with”.

How do you prepare for a career in which you won’t be allowed to practice without a smartphone loaded with up to date content, mHealth accessories and exhaustive clinical decision support tools?

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The implications of Artificial Intelligence and Machine Learning.

The need to get good at discerning between potential, hype and opportunities:

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What if you never got to diagnose a Patient? What type of a Doctor will we need when every Patient you ever meet already has a diagnosis?

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What if the Ageing process is slowed or abolished?

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Does this pass your “Mother Test”?

Don’t strive for perfection, instead pledge to never to repeat a mistake.

UPDATE: Draft slides for first lecture:

 

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What Do Tomorrow’s Doctors REALLY Think of mHealth Technology?

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Nathan Ratner, a third-year medical student at the University of Minnesota and third-place finisher in last year’s Elsevier Hackathon in Finland, talks to Eric Wicklund at mHealth Intelligence, about the promise of mobile health technology.

mHealth Insight

The ability to look up information in an efficient and targeted way is critical to getting the right information, right when I need it.  For instance, UpToDate, which is an online resource designed by clinicians for clinicians, is a type of Wikipedia for healthcare professionals, and it has an incredibly wide database of peer-reviewed articles, written by MDs and PhDs. In addition, Johns Hopkins University produces an antibiotic guide. I use it through an app on my phone. Those are just a couple of examples of digital resources that I have utilized extensively throughout my medical education so far, and I plan to continue utilizing them throughout my career. It shows the potential for how much impact these kinds of services can have to really improve both the efficiency and efficacy of education”

I think despite survey results suggesting that ‘Half of US Medical Students believe that using a Mobile in front of Colleagues & Patients would make them appear less competent’ I think it’s clear that even medical students who are studying in medical schools that are failing them because they haven’t gone paperless with made for iPad course materials they still don’t think twice about using their mobile as a tool. How long before we update the dinosaurs and start examining medics on their ability to use a content loaded smartphone and requiring them to have/use it when with Patients?

 

The mobile phone or tablet is like the modern-day doctor’s bag. Suddenly we as physicians have vast resources at our fingertips that enable us to better educate patients about their disease process, our recommendations for a treatment plan and possible side effects or complications. This is a huge benefit to the therapeutic relationship”

 

The amazing thing is I think the Smartphone Medical from 2013 URL showed that it’s already so much more than that eg. your smartphone has a faster processor than a surgical robot from just a few years ago (and no one ever had a surgical robot or an ECG machine in their Doctors bag did they?).

“I would like to use mHealth to facilitate greater interaction with patients. This is not mentioned that often, but I think it is one of the greatest benefits of mHealth. When you have a situation where you have an expert who has all of this knowledge in their head, and they’re just dispensing edicts, such as, “This is what I think you have (and) this is what I think the appropriate treatment is,” whether intentionally or not, it can create an asymmetric power dynamic. However, if you are able to look up information with the patient, that facilitates a more collaborative relationship. Building that therapeutic alliance is more important than ever, because there are so many conditions that require a tremendous amount of active patient management and self-care in order to ensure successful outcomes”

I really hope when Doctors get to properly experience looking up information with Patients (this was the most transformational thing that I experienced 20 years ago at Medical School back in he early days of the internet) because when they do that its only a very small step before they realise Patients have more often than not got more time, interest and ability to look things up so we need to start teaching medics to work with Patients who have already looked things up.

“An easy criticism to make is we’re devaluing the doctor. People may say, “Well, anyone can just look this information up.”  But I don’t think it’s the access to the information that’s actually going to change medicine, because doctors still need to know all of this.  Medical school is not going to get easier. What’s going to change is how we share information, how we communicate, and my hope is that, as the system of global health becomes more robust for physicians, the same thing will happen for patients. I want to see the health literacy patients possess increase”

I see this as a common misconception amongst Doctors who don’t share online content with their Patients. It’s surprising that young medical students still think it’s possible (or desirable) for us to try and produce Doctors who know everything.

“I think the greatest risk is how information is shared with the general public. If it’s done right, then the good information gets through, and it’s accessible. When it goes wrong, patients can end up doing themselves a disservice. Patients do their own research and develop ideas about what may be wrong with them and what it will take to cure them based on that information. When physicians inform patients the interpretation of the patient’s research is not correct or does not fit the situation, physicians risk losing physician/patient trust. That’s happening now. Information that’s made accessible to patients needs to be done in such a way that there’s a clear bright line between the information that’s valid and information that is not. The mHealth ecosystem is being formed right now; if there isn’t a lot of care taken to really educate patients and form these systems so that there’s a clear delineation between what’s information you can trust and what’s information that may have an agenda behind it, you could see issues at a much bigger scale than we have now. But this is also one of the issues that mHealth can have a tremendous role in solving”

With government healthcare systems giving the health records of millions of their citizens to foreign advertising companies without even thinking about consent, the pharmaceutical giant Roche now owning FlatIron – the leading US provider of EHR’s for Oncologists and Teladoc and IBM Watson partnering to give 2nd opinions to Patients who are already under the care of an oncologist I think this is without doubt a major challenge but it’s not going to be solved by mHealth per se but by smart clinicians who are prepared to make themselves accessible and work transparently in order to help Patients and Carers trust them.

I’m most looking forward to services that can interact with patients in a way that help to give them critical information when they need it. I imagine a SIRI-like device that could access your medical record, know your history and, with the algorithm, be able to synthesize that information and give you a quick and reliable answer to the question, “Do I need to go to the emergency room for this?” “No, you called a bunch of times before about this, and you don’t need to worry,” or “Yeah, you should go to the emergency room.””

I think we’ll arrive at that situation by recording millions of fully documented Consultations with Doctors and incorporating the feedback from the Patient journey. A great reason in and of itself to evolve on from the 2000+ year old office visit only model of care.

“Medicine, especially at the primary care level, and even at the specialist level, will become more automated. It’s inevitable. One thing I hope to pursue through my career is to maintain the human element, to really emphasize communication and relationship-building within these technologies, like the economist Richard Thaler, who was awarded the 2017 Nobel Prize for Economics. All of his work was building humans back into these very analytical economic models, and I think there’s a lot of benefit and cost savings that comes with automation, but I do think that we run the risk of losing the human relationship, that research shows, is in fact critical to positive therapeutic outcomes”

I think it’s abundantly clear that in the drive for efficiency and profiteering the sick care system has disrupted the very thing that Patients want: a human relationship with someone who cares about them. It’s optimistic to hear a medical student expressing such an observation but hopefully it’s not another one of those common sense things that US medics are being taught to ‘grow out of’.

“Honestly, the thing I’ve been most interested in recently is the success of telehealth in sharing medical knowledge, especially for places where there are physician shortages. The two most prominent examples right now are stroke codes in rural hospitals, where there’s no on-staff neurologist. There’s a service that allows emergency physicians to immediately have access to a neurologist. For example, I’m in Minnesota, and in northern Minnesota there are some rural areas where there’s just no on-staff neurologist at these critical access hospitals, but with the push of a button they can have a neurologist – literally, a world-class neurologist at an academic health center here in the Twin Cities, on the video screen, and they can look up a patient’s records and talk through the entire management of the stroke with the emergency doctors. What that does is saves critical minutes and seconds from having to transport that patient to a different hospital, to being able to manage it right there and try to save as much brain tissue as possible”

Such a simple innovation that’s been obivous for years. It stuns me that we still have major Professional bodies representing tens of thousands of Doctors whining about the Physician shortage while just paying lip service to the opportunity to use the tools of our time.

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Apple gives a beta product demo and has a booth offering jobs at #HIMSS18

 

There’s no livestream from #HIMSS18 but in a classic example of what happens when you let pesky Patients come along to medical conferences: they point their mobile at the presenter, video what they see and share it.

Thank you “e-Patient Dave deBronkart” for so generously sharing this talk by Dr Ricky Bloomfield, Apple’s Clinical & Health Informatics Lead.

mHealth Insight

Apple Health is being presented at a Healthcare conference. 

I know it’s becoming a thing for Apple to talk at external conferences but it’s still very rare for their executives to present at a conference that isn’t organised by Apple Inc. particularly on such a low key stage (why didn’t HIMSS schedule this as a keynote talk in the main ballroom or as a fireside with Hal Wolf??).

“we’re very excited about this but it’s a first step and we think it’s very important to engage the ecosystem and we’re very excited about the response that we’ve got to see other EHR vendors and other healthcare systems come onboard and work with a standards based approach supporting the architectural implementation guide, and we’re also interested in doing a lot more and becoming and so shameless plug at the recruiting fair tomorrow we have a booth if you’re interested in learning more about what we do and possibly exploring job opportunities there feel free to stop by…”.

It would’ve been great to see this talk live streamed on Apple’s website (as they do with normal Apple product launches/presentations) particularly given that Apple are wanting transparency in all they do in healthcare and welcoming feedback (they are after all dealing here with people’s most private information).

“We announced this in January with 12 health systems and we now have over twice that listed and this list is growing quickly and the feedback that we have gotten since we announced this has been phenomenal.  People are really excited to be a part of this because they want to empower consumers with their health information”

Although I’m surprised to hear Apple referring to ‘Patients’ as ‘Consumers’ (as this could become very problematic down the road) it should be obvious that EHR Provider valuations are going to fall off a cliff when their investors see that this hasn’t just happened but it’s getting substantial traction.

“Consumers might not always know the branded name of a health system that they went to, they might just remember the location so (we made it possible to search via location)”

This must be quite awkward for the marketing teams at the big healthcare provider brands that are already involved. It’s obviously true but I’m surprised Apple isn’t feigning a little to them to let them think their brands have some value in the eyes of Patients (until they’re at least a little further down the road with this).

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That screenshot says 1000 words. I better get working on an update to the mHealth course that I produce for the Computer Society. How long before Patients are expected to share their record with their Doctor (instead of the other way around)?

I think my new module will be titled something catchy like: “Can you airdrop me a copy of that please?”.

Dr Ricky Bloomfield

It’s great that there’s a 37 year old Doctor giving this demo but it’s surprising that they haven’t got a more experienced clinician (perhaps a Family Doctor – and yes I know they’re like hens teeth in the USA) but Ricky has all the right credentials to help Apple disrupt the EHR market with a MobileFirst approach eg. prior to working for Apple on the HealthKit ResearchKit and Health Record products he was Director of Mobile Strategy at Duke University Health System and he used to blog as “The Mobile Doc” and he’s active on Twitter too @RickyBloomfield:

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NOTE: Katie McMillan at Duke Mobile App Gateway has authored a useful guide to getting started with Apple Health Record:

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Related Posts:

Apple’s Health Records App: a ripple or a roar

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