Join us at “Transforming Community Pharmacies in to High Street Clinics”

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at The Arnold Hills, London Stadium, Queen Elizabeth Olympic Park, London E20 2ST

Transforming Community Pharmacies into High Street Clinics is a conference organised by NELLPC and will be held from 9-5pm on Thursday the 15th November 2018 at The Arnold Hills, London Stadium, Queen Elizabeth Olympic Park, London E20 2ST.

The conference will highlight the potential of delivering high quality and easily accessible, personalised healthcare in North East London, including clinical and public health services and the NHS 10-year plan. Matt Hancock, Health Secretary, said: “It is important to make the investment in primary care and community pharmacies, so people don’t need to go to hospital”.


Following the recently closed consultation, the NHS 10-year plan is set to include decisions on the future of personalised care and role of community pharmacy in delivery of clinical and prevention services;

Development of the integrated care providers (ICPs) contract, which is intended to allow health and care organisations to be funded to provide services for a local population in a coordinated way.

NHS England aiming to make ICP a mainstream model of care across England by 2020, following the rollout of ICP pilot programmes in 18 areas across England

The Government’s commitment to expand ICP and PHBs to between 50,000 and 100,000 people by March 2021.

Topics/Speakers will include:

Introduction & Background Prof David Taylor, Professor Emeritus of Pharmaceutical and Public Health Policy, UCL

Community Pharmacy in Primary Care Mr Steve Brine, Parliamentary under Secretary of State for Primary Care and Public Health at UK Dept of Health & MP for Winchester (invited)

NHS in 2030 (To Be Confirmed), Nesta

Integrated Care Ceri Jacobs, Managing Director, Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Pharmacists play vital role in improving patient health: Evidence to date Prof Margaret Watson, Professor of Health Services Research, Department of Pharmacy & Pharmacology, University of Bath

Delivering pharmacy based clinical services Bernadette Brown, Community Pharmacist, Cadham Pharmacy Health Centre, Glenrothes, Scotland

Social Prescribing: supporting patients to take more control of their own health and Population Health Dr Jagen John, General Practitioner & CCG Chair

Community Pharmacy as a High Street Clinic: Prevention and hospital discharge patients Hemant Patel, Pharmacist & four-time former president of the Royal Pharmaceutical Society

Workforce Development and pharmacy Professor Gail Flaming, Director of Education and Professional Development, Royal Pharmaceutical Society

Mobile Health: enabler of empowered patients David Doherty, Co-founder and Director, 3G Doctor

Digital enablement in integrated care systems Luke Readman, CIO, Tower Hamlets CCG

Integrated Care Provider Contract and community pharmacy Janaka Perera, Strategy & Programme Lead, North East London Local Pharmaceutical Committee

Proposed action points and Close Prof David Taylor, Professor Emeritus of Pharmaceutical and Public Health Policy, UCL

Attendance is free & places have been reserved for:

Commissioners of primary care, mental health and public health services and those
working to develop enablers for the delivery of high-quality services locally

Local councillors from the six boroughs including those on health and wellbeing boards

Local voluntary organisations

Hospital colleagues

Local pharmacists

HealthWatch Organisations

* * * Get in touch via the comments if you’d like me to arrange a VIP invite for you to attend * * *

Draft of my slides:


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Is Fraud the biggest driver of telemedicine revenues?

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Seven companies and four men have been charged with involvement in a $1 billion telemedicine fraud scheme involving allegedly filed false claims for payment and misleading doctors and patients in order to defraud private health benefit programs.

I think people are going to soon realise that type of insurance fraud is just this is the tip of an iceberg and the sooner regulators do their job and prevent this from being possible (or the success of Apple’s mHealth strategy kills off the Health Insurer vice grip on healthcare services) the better because in my opinion broad daylight scams like this are really what’s behind these huge speculative VC investments in zombie telemedicine companies and it’s having significant harm on the honest financial prospects of ethical companies who are trying to add value to Patients and Carers lives – like 3GDoctor 😉

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CNBC: AliveCor CEO on Kardia vs. Apple Watch

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A masterclass in leadership here by Alivecor CEO Vic Gundotra in conversation with CNBC.

On competition from the world’s most affluent and profitable corporation:

“we were kind of like a lone voice in the wilderness, like a restaurant in a remote part of town, and Apple have opened up the biggest restaurant right next to us and so we’ve got to congratulate Apple for bringing awareness to this space – that you can take a lifesaving EKG at home – and I don’t think most people realise that heart disease is the biggest killer in the world”

On why Alivecor is grateful for Apple entering into this space:

“we have a $99 product and it turns out the people who need this device the most are those that can afford it the least. So if you can’t afford a $400-$500 Apple Watch our $99 product is a pretty good way to go”

On if Alivecor will be able to compete with Apple’s marketing might:

“Apple just gave every Android user a life saving reason to move to their platform and of course they’ve got to be commended for that. But at Alivecor we’re not standing still. Today on CNBC we’re introducing our next generation device which is quite an extraordinary leap. today’s device is a single lead device like the new Apple Watch but the new device is 6 lead and it can give you 6 times the resolution for you and your cardiologist to see and really it goes after the holy grail, today you can detect AFib but you cannot pick up the earliest signs of a heart attack. Our goal, pending FDA clearance, is that we will be able to pick up the earliest signs of a heart attack even possibly before you are even feeling symptoms”  


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Study from the USA finds that Mental Health Patients trust Apple & Google more than their Doctors

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“Study: Majority of mental health patients would consider giving clinicians access to phone behaviors, locations” MobiHealthNews (Patient Willingness to Consent to Mobile Phone Data Collection for Mental Health Apps: Structured Questionnaire).

mHealth Insight

For more than a decade we’ve been vainly telling anyone who would listen about the urgent need and potential for mHealth and taking a mobile first approach to designing caring services but this report’s findings are very revealing.

“Researchers found that 41 percent of responders said they would be willing to install an app that would help doctors better diagnose mental health problems and provide treatment. An additional 43 percent said that they “may be willing to use such an app, provided they were given more information about how the app functioned.” Sixteen percent said they were not willing to use such an app”

I think the positive conclusions being made in this study are completely wrong. We live in a time when 99% of medics don’t realise that most of their Patients are already (perhaps unwillingly or unknowingly) sharing info with Apple and Google (and all their various affiliates and advertisers) that they would not even consider sharing with them…

Maybe this is why Apple’s CEO is making statements about how mHealth revenues at the world’s most profitable corporation are going to dwarf the revenues they make from their current business.

Related Post: The question should not be what are Mobiles doing to our Mental Health but what they could be doing for it.

Some interesting feedback from posting this on Linkedin:

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American Medical Association: 3 reasons why you need to completely redesign your EHR

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“3 reasons your Snapchat habit won’t help you master the EHR” by Brendan Murphy, Staff Writer at the AMA Wire.

“Whether you call them millennials or digital natives, there’s no denying that a generation of Americans, one that grew up along with their devices, is perceived to be more tech savvy than any that preceded it”

The born mobile generation is probably the most useful description as they were born in the Nokia Decade (even though most people still don’t yet realise a quirky Finish brand got to define the decade).

“Because of that technology and an unending roster of apps—from Snapchat to Stitcher and everything in between—today’s physicians in training seem to be more proficient in communicating and obtaining information. How does that translate to medical school or residency? When it comes to EHR training, one expert believes, it doesn’t”

I gave a lecture at the largest Medical School in Ireland on this topic recently. It’s fascinating because out of date educators and professional bodies with their out dated customs (banning mobile phones in exams as though there will ever be a day you work as a General Practitioner when you don’t have a mobile that’s at least as powerful as a iPhone X in your pocket, trying to train Doctors to work in an environment where they don’t use a mobile, etc) are being made to look really decrepit to the BornMobile who find it unbelieveable that a Doctor would even be allowed to work without a connected smartphone loaded with high quality content.

“AMA Wire® spoke with Blaine Y. Takesue, MD, a research scientist at the Regenstrief Institute and assistant professor of clinical medicine at Indiana University School of Medicine. Dr. Takesue offered three reasons digital natives may still be in foreign territory when it comes to learning the ins and outs of EHRs.

EHR data doesn’t effectively translate to devices

While smart devices have in many ways replaced clunky computers in a number of arenas, that is less the case in the EHR realm. The smaller screen is a hindrance when it comes to reading and entering data, Dr. Takesue said.“If you’re used to a mobile solution to problems, that’s a much different paradigm than sitting at a computer,” Dr. Takesue said. “It has a lot to do with real estate. EHRs haven’t translated well to a phone. You need to see a lot of data. There’s not enough real estate on a phone to do that without moving through multiple screens.””

I wonder what Dr Takesue thinks of popular smartphone apps like Skyscanner or AliBaba. Perhaps he doesn’t realise that there are people in the aviation/retail industry who were similarly challenged to see the opportunity to press a few buttons on a mobile phone to arrange their travel/shop. Perhaps he doesn’t know that it was unimaginable to millions of retails that their work could be done by customers interacting with the screen of their mobile phone? If you’re struggling to imagine the future a good exercise is trying to imagine the unthinkable things that mHealth makes possible…

Nick Mason 20 years ago it was unthinkable

It’s not a case of “EHRs haven’t translated well to a phone” it’s a case of we need to apply MobileFirst design to Health Records.

The people in the foreign country are not the Born Mobile generation it’s the medics and healthcare industry leadership who are wedded to thinking an Electronic Health Record is and must remain an unwieldy, dangerous bureaucratic billing engine that is inaccessible and incomprehensible to both Clinicians and Patients.

“Systems predate the smartphone

The EHR systems with which large health care organization’s work were created decades ago, and because of that, they don’t feature the same user functionality as newer devices.

“The problem is that many of the most widely used EHRs were not created from 2000 on—they were created last century,” Dr. Takesue said. “What we use in medicine and what we train our students on is legacy technology. There may be a solution that translates really well to mobile, which will allow questions to be answered quickly, but it’s not in wide use.””

It’s futile to hope that there is a bandaid that can offer a mere translation of EHR’s so that they work on mobile and all is well with the world. Starbucks and Walgreens didn’t find success by translating their online services they did it by rethinking what they.were doing and applying Mobile First design principles.

“EHRs aren’t intuitive

Your smartphone, search engine or voice-activated device seems at times to know what you’re going to say before you do. Products that function this way—when the server anticipates potential communications—use a form of artificial intelligence to push out answers and solutions. EHR systems work the opposite way.

“We call it a content pull,” Dr. Takesue said. “As a user, you have to go and pull content you want to see when you want to see it.

For device users, “it hurts expectations,” he added. EHRs “don’t provide the information to the user at the time that they need that information.”

It should be obvious that EHRs aren’t designed to serve the needs of Patients/Medics/Carers but to assist the objectives of profit generating businesses. This is not the reason to resist innovation but rather the design challenge. Trillions of dollars have been wasted on EHRs so don’t expect those benefiting from the status quo to be championing this or lobbying organisations like the AMA to aid their demise. Thankfully a Mobile brand (Apple – the world’s biggest and most profitable corporation) has a new product that they have set on disrupting the lucrative revenues that EHR companies are hoping to hold onto…

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What’s the ‘best’ example of ‘Digital Quackery’ you’ve seen?

Everyone’s getting worried these days about a new breed of quacks: app developers making health claims.

Interesting to note that some of those pointing the finger (eg. the American Medical Association) have already turned around once they arrived at the convenient conclusion that they’re ‘snake oil’ unless they pay us a few quid to certify they’re good.

It’s all given me an idea to compile a list of the best examples of “Digital Quackery”. I’ll kick off the list with a few I’ve seen and please feel encourage to add your favorites in the comments (with the reasons):

> The NHS Trust (University College London) that ordered a £400Million EHR from EPIC that was so incompetent at adopting tech that when they bought every member of staff an iPad the majority ended up in store cupboards.

> The Cove (music making app for young people experiencing bereavement) app that a NHS Hospital (St Mary’s in Paddington) wasted their money building.

> The ‘free’ app the NHS Royal Free got for their dialysis Patients to use (they paid for it by giving Google the comprehensive detailed medical records on 1.6Million unconsenting Patients).

> The video Doctor visit companies that masquerade as inexpensive quick ways to get a prescription but are really in the lucrative business of trading Patient data.

> The NHS’s £12+ Billion National Program for Information Technology (NPFit) that introduced an EHR concept that didn’t give Patients access to information even though we know how ridiculous this situation is.

> The Royal College of General Practitioners who ran a Video Consultation Skills Course  that wasn’t live-streamed or video recorded and was led by a GP who didn’t offer video consults and didn’t have a website.

Doctors in wealthy regions of the world ignoring Infection Control issues when experimenting with mHealth on the poor.

> Inefficient Digital Health ‘innovations’ that will lead to an explosion in costs while providing no benefit over the analogue alternatives.

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CNBC: Why TeleMedicine is a Bust

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A fascinating article on “Why telemedicine has been such a bust so far” by Christina Farr.

mHealth Insights

The first thing that should be obvious about why TeleMedicine is a bust can be seen at a glance. The newest mass media (Mobile) has made Telemedicine a bust in the same way that it’s made photography, hailing a cab, shopping in a record store, booking travel, booking a hotel, buying a toy or a house, etc, etc. Healthcare is becoming a Mobile Experience. We’re not dropping the ‘m’ in ‘mHealth’ we’re dropping the ‘Health’

CNBC have it captured well: A MAN IN WHITE COAT WITH A STETHOSCOPE TAPPING AT HIS MOBILE is a perfectly valid and useful depiction of telemedicine today. But watch a Patient using their own ECG machine and having their medical data read by a computer and referred if necessary to a Doctor (who may be casually dressed working from home while her children are at school) and you’ll realise just as video killed the radio star the incredible sensors in the super computers in our pockets have removed the tele (meaning is ‘distant’) and we now have to understand that healthcare is becoming a mobile experience (this is why it’s wiser to use the ‘mHealth’ term I coined 10+ years ago) because the potential for medicine/care is now always with us, continuously carried within arms reach and never turned off.

At the end of watching that video ask yourself do these Patients look like they are ‘distant’ from their medicine/care?

We have elderly Patients using these mHealth devices for years and when you ask them about their experience they’ve never felt closer to their medicine/care. There is no doubt that the convergence of healthcare to mobile (mHealth) has enabled us to evolve from TeleMedicine/Telecare.

“Telemedicine, or apps that let you consult with a doctor via video, was supposed to be the next big thing in health care But lack of awareness, questions about cost and reimbursement, and the human desire to talk to another person when sick have hampered the sector. Tech giants like Apple may ride to the rescue… Billions of investment dollars have been poured into apps and websites that offer this virtual consultations with physicians, ranging from Doctor on Demand to American Well. The theory behind them is that millennials would opt for a digital alternative to an in-person physician’s visit, if the option were available. And patients in remote, rural areas who are miles away from the nearest doctor would have few alternatives…   …But telemedicine is still far from mainstream. Even a study sponsored by a telemedicine provider from late 2017 still found that 82 percent of U.S. consumers do not use it”

I think this is an easy to have predicted outcome of telemedicine meeting with the needs of the USA’s Insurer led SickCare model. VC money has unsuprisingly been haemorrhaging from failing ventures because a subsidised video consult isn’t a substitute for a Doctor visit.

People may be gullible when it comes to sharing their data in exchange for online services (just look at the level of personal health info sharing that Patients provide to advertising networks like Facebook or Google) but most of the more experienced older people (who have healthcare needs or care for children or elderly Parents with them) realise there is value in sharing info with a Doctor who isn’t in the business of trading their personal health data.

Yes you can obviously bluff some naive people with the offer of cheap or free chats with a Doctor advice call but communities dominate brands and Patients/Carers are increasingly becoming aware that it’s not smart to subsidise/exchange your incredibly personal and revealing information with unnamed corporations for the advice of a Doctor.

“Why the lack of adoption? Several factors are to blame. The biggest, and most important, is that many U.S. consumers are still not aware they have the option to chat with their doctor over the phone or via video”

Surely this is just because while Clinicians like Prof John Bachman at the Mayo Clinic pioneered in the publishing the evidence for advancing relationships by moving beyond the office-visit-only relationship the USA’s Health Insurer led market has done everything to undermine the Family Doctor relationship/business so the idea of Family Doctors innovating to offer this effectively (like they now do in the NHS) is just unviable because there’s none of them.

“The awareness piece is a big problem,” admits Ian Tong, a physician and the chief medical officer at Doctor On Demand, an app that offers smartphone consultations for $75. Tong believes that part of the problem is the branding of the term “telemedicine,” which isn’t particularly descriptive, so he’s opting to use the term “video visits” instead when he talks to patients about it”

I think this is a mistake and is not realising the additional value that can be offered now that +100 million Americans can connect via video calls on devices that they always carry with them.

We all need to appreciate that mHealth makes expensive, inconvenient & impossible health care experiences inexpensive, ubiquitous & super convenient because when you are asking ‘what are the benefits of a documented consult with a Doctor over a Video Call?‘ the born mobile generation are struggling to think of reasons why you wouldn’t want to video consult with a Doctor…

mHealth isn’t about replacing office visits with video calls it’s about realising “Go and Get Help” no longer makes sense…

“Another setback: Patients heard of telemedicine apps often fear the expense, especially if it’s unclear whether they can use their health insurance. And in some cases, the apps are offering cash prices that are out of reach. $75 might be a stretch for some”

I think this reinforces the commitment to radical transformation of the USA’s healthcare system that Apple Inc senior management are all committing to eg. Apple’s CEO Tim Cook has made it clear that Apple has the unique privilege of not having to care about reimbursement and that they estimate that the upside of this is that they will create a company that will make their current business small (it’s currently the world’s largest and most profitable corporation!).

“Another common theme is that the doctors who are willing to work with app makers are inexperienced, or low-quality. Companies like Doctor on Demand will say they go out of their way to vet — and pay for — the best clinicians. But there is some merit to this concern, especially with the lower-quality services”

I think the opposite is becoming clear: Patients who see you uncomfortable using the mobile tech that everyone else is familiar with may lose confidence in how current you are with your medical knowledge.

“In 2016, researchers posing as patients turned to 16 different telemedicine apps to diagnose skin issues. The results? Some of the online doctors misdiagnosed conditions like syphilis, others prescribed unnecessary meds, and two of the sites used doctors who aren’t licensed to practice in the state the patient was located. The authors concluded that these apps repeatedly missed diagnoses by failing to ask simple, relevant questions”

This was some great work by Dr Jack Resneck and it made some great recommendations:

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but I think the websites tested were quite scammy eg. they published “a variety of disclaimers that they do “not provide health care services,” and do “not create a physician-patient relationship,” but we found that they did make diagnoses and offer specific treatment recommendations (without sending prescriptions to pharmacies)“.

I can’t see how Dr Resneck hasn’t been obliged to report the Doctors involved to their credentialing authorities before/at same time as publishing a public paper about how they are working dangerously and without licensure.

“Finally, even in the digital age, a lot of people simply want to see their doctor in person. They’re not Luddites. But sick, vulnerable people often need in-person reassurance from another human being in the room. A smartphone app simply won’t cut it”

I think this is classic view of someone who thinks video calls are about just trying to do what’s normally being done with an office visit. Just as Spotify didn’t try to recreate the record shop on our mobiles, Uber didn’t try and recreate the taxi rank, AirBnB didn’t try to recreate the work of the Hotel Reservations department, it’s invaluable that we all try to reimagine the opportunities we have to offer new supportive services to Patients who are always connected and are increasingly having a copy of their medical records and a means to easily and securely share them (this is the rocket fuel that drives demand for video consultations with independent impartial Doctors).

I think it’s important to realise the #1 reason Doctors don’t want to remotely video consult with their Patients is because it encourages Patients to do something most Doctors have little/no training helping Patients with.

“Will this ever change? Roy Schoenberg, the CEO of American Well, believes that doctors, insurers and employers will increasingly inform their patients about the option to use telemedicine, which will help consumers get over many of their fears. If they’ve already got a relationship with that doctor, a virtual consult might seem like an easier alternative to getting across town to a doctor’s office and sitting in a waiting room”

I think this is a very good measure of how wedded the USA healthcare system is to serving health insurers. Amercian Well has taken $210million in venture funding over 6 rounds yet still hasn’t realised the big opportunity is in offering services direct to Patients. Imagine the CEO’s at Uber/AirBnB/Spotify thought that the Taxis/Hotels/MusicLabels would inform their customers about the option to use their mobiles to get their product via their mobile phones!

“But getting doctors to jump on board is easier said than done, and takes time. Many are afraid of liability, as it’s possible to miss something during a remote visit. And for years, it wasn’t clear whether they would get paid as much as an in-person visit. Reimbursement questions are still getting resolved across different states, but most of the commercial and government plans are on board with the idea of telemedicine — at least in specific circumstances.Another marketing boost for telemedicine could come from the big tech companies. American Well got its a plug from Apple, which announced it would work with the company for its heart-health study, so that participants could get easy access to a doctor’s office if they needed it.”

This is a huge problem and the most effective thing we’ve seen to help with it is the provision of accredited mHealth training for Healthcare Professionals that we helped produce.

“Finally, many consumers who use high-quality telemedicine apps are spreading the word. “Consumers are realizing that it can all be done via an app, whether it’s getting a prescription, an exam or ordering labs,” said Doctor On Demand’s Tong. “There’s no need to sit in that waiting room anymore.””

I agree with this and think it’s even more positive. People using other (non-healthcare) apps are coming to expect healthcare services to work as seamlessly. We all know a rising tide raises all boats so has your organisation gone Mobile First yet?


*** UPDATE Monday 2 July 2018 ***

Tomorrow at 11am GMT I’ll be discussing this post in a FaceBookLive video discussion with Dr John Bennett MD (and guests) from

Follow InternetMedicine on Facebook/Twitter to get updates. Click back here after the discussion and  refresh the page and you’ll be able to replay the video recording of the discussion.

*** UPDATE Tuesday 3 July 2018 ***

Click here to watch the video over in the InternetMedicine ‘mHealth Studio’:

Links to videos suggested in the discussion:

At the Doctors2.0 Paris Conference David Doherty shares Mobile Video Consulting best practice.

Here is the link to the video of Apple Health Record being demoed by Dr Ricky Bloomfield at HIMSS.

*** UPDATE Wednesday 4 July 2018 ***

Some interesting feedback via Twitter chat with Irish GP Valerie Morris MD who has now for some unknown reason deleted her tweets which is a great shame as I was going to enjoy hearing Dr Morris explain how a ‘fully computerised’ GP doesn’t yet have a website nor offer Patients any access to Healthcare Records:

@mHealthInsight: I think the vast majority of Doctors outright dismiss the value of video consults yet so many prefer video consultations when they themselves need the advice of a Doctor

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@DrVBMK: David, don’t kid yourself. Telemedicine won’t replace the traditional Dr-Px consultation which includes EXAMINATION. Vocationally trained GPs know the risks involved if you don’t examine a patient. And guess what, Medical indemnity is higher for those engage in telemedicine.

@mHealthInsight: I think the issue is so many presume telemedicine must be about diagnosis & prescribing. You can also provide care, management, followup etc

@mHealthInsight: Would be great if you could join me and @InternetMeds for a discussion on this topic at noon today

@DrVBMK: Quick comment: Busy surgery all day – 2 emergencies this morning – child & adult – managed here then sent the ED. And I’m only halfway through my morning list. of patients. Lunchtime is for home visit to see palliative patient. How on earth do you provide care using telemedicine

@mHealthInsight: I think you’ve presumed that I think the benefits of telemedicine is an excuse for under resourcing GP services.

@mHealthInsight: I think you’ve presumed that I think the benefits of telemedicine is an excuse for under resourcing GP services.

@DrVBMK: It’s your words, not mine. You haven’t answered my question In earlier tweet.

@mHealthInsight: Video of the discussion with Dr John Bennett is now posted on @InternetMeds (skip the first 30 mins)

@mHealthInsight: in answer to “How on earth do you provide care using telemedicine”? you use your time efficiently, let Patients/Carers help you with documentation etc. It’s quite complicated (otherwise everyone would already be doing it) but you can learn from fellow GPs

@DrVBMK: Are you a GP? Your tweets don’t reflect that you are one nor does it reflect real life General Practice.

@mHealthInsight: would you like a job?

@DrVBMK: Medical indemnity for full time Irish GPs is no less than €20,000 per annum (more if you provide telemedicine, OOH, minor surgery etc). Will you pay that upfront???

@mHealthInsight: How big is your HSE list as if 500+ it’s well worth us meeting up as I’m sure I could save you a small fortune

@mHealthInsight: Probably best to email me as documented video consults with Patients that aren’t enticed with offers of prescription drugs is very low risk

@DrVBMK: 98% of GP practices are fully computerised. The only time I use a pen is to sign my name. I am from the old School of Medicine. A computer will never be the interface between me and my patient. I respectfully decline your offer. I love my job.

@mHealthInsight: Do you really think there is a single “fully computerised” GP practice in the whole of Ireland?

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