professor jeremy wyatt- health futures: real or virtual?
TRANSCRIPT
What I am going to say
Healthcare problems now and in the future Examples of virtual healthcare Benefits of virtual healthcare So can we provide all healthcare
virtually… And should we ?
Current problems with UK healthcare
Designed-in features from 1948: Focus on acute disease not chronic problems
or prevention Patients typecast as passive / reluctant
partners Poor information sharing, re-use Reliant on imported doctors and nursesUnintended problems:• Expensive - £120Bn pa. (£40 / person
week)• Hard for many to access and navigate -
inequalities• Inconvenient for people with children,
jobs…• Patchy coverage (“postcode prescribing”)• A significant cause of morbidity
17 million UK people with long term conditions
Complex, co-morbities
Higher risk
Lower risk
1/4 needing most professional care
3/4 - 13 Million - suitable for supported self care –
“Virtual healthcare”
Health care professionals may only interact with people with a chronic disease for a few hours a year… the rest of the time patients care for themselves…
Access to health professionals
Source: NHS Policy Unit. United Kingdom figures.
Demand for care
Labour supply
Demographic challenges to NHS capacity
Other serious future challenges Obesity epidemic Social isolation and mental health
consequences New infectious diseases – bird flu,
SARS, others (mega cities; tourism) Greater inequalities - cost of energy,
global warming
Transforming health care
Old model of care New modelFocus on acute conditions Focus on long term conditions
Reactive management Prevention & continuing care
Hospital centred Embedded in homes & communities
Disjointed episodes Integrated with people’s lives
Doctor dependent Team based, shared record
Patient as passive recipient Patient as partner
Self care infrequent Self care encouraged & supported
Use of ICT rare Dependent on ICT & devices
For public: Trust-marked reference sources Cancer etc. support forums Online personal electronic health records Telehealth to support self care in long term
conditions Cyber doctor
For health services: eLearning Transcription of dictated reports Remote reporting of X rays, pathology
slides Remote control of surgical robots
What is digital healthcare“Redesigned services supported by appropriate digital technologies”
Devices to support virtual healthcare
Helping Hand medicine reminderwww.medicom.com
Ambient orb to monitor health statuswww.ambient.com
Diabetes monitor & insulin pump
Trial of teledermatology to prevent GP referrals
With Depts. of Medical Informatics and Primary Care, AMC Amsterdam
Trial results: nearly 1/3 of dermatology
clinic visits could have been prevented
A future virtual health scenarioMrs Smith has high blood pressure and wakes with a headache. She worries that her implanted drug reservoir may be empty. Her ambient health orb is a reassuring green, so she turns to her video wall and asks “Cyberdoc, how is my blood pressure recently?”
The voice responds “Your drug reservoir needs a refill in 3 weeks but blood pressure readings are under control recently and normal today. Your blood sugar sensor shows normal readings too. Do you have some symptoms you want to discuss?”
Meanwhile Mrs Smith’s wall graphs her recent blood pressure and lists the 20 most common symptoms in people of her age group locally.
She responds, “No, don’t worry. Remind me to book my refill in two weeks, please.”
Wyatt & Sullivan, BMJ 2005
All of th
is technology exists to
day
Benefits of virtual healthcare
Allows patients and carers to do more Responsive to user needs:
– Dis-intermediation – talk direct to specialist– Delivery anywhere (mHealth), anytime
(global)– Mass customisation – the long tail
Greater patient control over data (Mydex)
Better data improves CQI, research Access to a wider market – health
tourism Lower cost of delivery (?)
But what must we do in real world ?
History taking (tele-presence ?) Clinical examination, palpation (kiosk
with haptics ?) Psychotherapy (Computer based
behaviour therapy) Taking blood etc. specimens (blood /
saliva self testing kits, lab on chip) Invasive procedures, surgery (kiosk
with robot?)
MSN messenger chat with NHS Direct nurse
Coventry pilot study: too slow, high false
positive rate – project cancelled
Other considerationsHealth systems: Cost releasing, cost effective technologies ? Professional mistrust in data from
elsewhere Changes to health professional roles Quality assurance, eg. for point of care
testing “Volume effect” - excellence in training,
CQI, research
Public: Safety Equity of access – “cyber divide” Acceptability / trust – eg. vulnerable elderly Risks to personal privacy of large central
databases
Ethics of “Using
computers to
change what we
think and do” –
even when it’s for
our own good ?
Ethics of labelling people for medical convenience ?
Implanted Chips Provide Access to Medical History
Across the USA, more than 1,000 people have tiny ID chips implanted beneath their skin that give emergency room personnel instant access to that person's medical information.
Joanne Silberner, covered in National Public Radio’s Morning Edition, August 15, 2005
Risks of technology
Expensive Poor fit with the
real problem Unintended
consequences Dehumanising
Holistic health service ?
Risk of a “Great Revulsion” (Muir Gray), eg GM foods
In Cheltenham people already spend as much on complementary therapies as NHS spends on community services
Those who can, might opt for old fashioned, face-to-face, holistic care
Independent nanorobots with
smart softw
are to stop disease
before it develops
Implanted calorie counter/blood sugar
monitor with beeper for weight loss
Growing new Telomeres from stem cells to make us immortalNicotin
e or drug aversion im
plants
Future Health Technologies Institute, www.fhti.org
Pill based endoscopy
Augmented reality for surgeons
Virtual intelligent Healthcare Workers
Injected nano robots to clear arterial plaque,
fight cancer & infection
Artificial brain stimulator –
eg. “sex chip”
“We know it works”
“The OPALS Major Trauma Study showed that full advanced life-support programs did not decrease mortality or morbidity for major trauma patients... during advanced life-support, mortality was greater among patients with Glasgow Coma Scale scores < 9”
How to develop future health technologies ?
“Heart surgeons need a decision support system
to advise them which operation to carry out”
“Following Bristol enquiry, heart surgeons agreed to audit their
performance and use these data to inform their practice”
Technology-led pushCreative, unfettered by constraintsOccasional game changersAssumes we understand body / mindMay only apply to rare problemHigh cost may eliminate itSafety issues only emerge lateEmbedded in lab, company
Problem-led pullDominated by constraintsSteady progressWill never fully understand them“Rare” problems are together 20% of HC
Costs come down with volumeSafety part of problem definitionEmbedded in clinic, health system
What is the Institute of Digital Healthcare?
Emphasises technology development, assessment & eHealth innovation
A collaborative network with incubator, demonstrator and facilitator
8 academic and research staff and 7 PhD students
www.idh.warwick.ac.uk
• A 5-year partnership between NHS & Warwick to promote R&D in - and uptake of - digital healthcare
Conclusions
1. Many factors push us towards virtual healthcare2. Safety, effectiveness and cost effectiveness not yet
established3. Ethical, access and other public policy issues (Big Society
or Big Brother ?)4. Explore implications of virtual futures and choose a
direction of travel
Factors favouring successful innovations
Cost compared to size of benefit
Immediacy of benefit
Proximity of benefit Transparency Trialability
EM Rogers – Diffusion of innovations
Internet-basedcare pathway accessed via Healthspace
Patient trying to reduce cardiac risk
General practicePractice nurse:
smoking cessation
Community servicesDietician:
monitor diet
HospitalClinical chemist:
raised cholesterol
Sports centreInstructor:
exercise programme
Patient
Pressures for more teleHealth – health@home ?
Risk management Cost of devices
Economies of scale, staffingCyber divide
Professional training
Hospital Home
ConsumerismSmart devicesMore people with LTCsCost of travelMRSA, C. DifficileCommunity linkageBetter outcomes
The role of the “telecarer”1. Enhanced human communication skills:• Active listening skills + motivational interviewing• Empowerment, shared decision making
2. Fluency in use of “new media”:• phone, voicemail, SMS• email with encryption, reading notification• web-mediated discussion, eg. MSN messenger, chat rooms, forums
3. New ways of working:• Patients / carers taking the lead• Trade off risks & benefits of email, SMS, VC, face to face• “Intimate health care” - sharing data, protocols, communication channels
with wider team, patient, carer:
“Telecarer”: 1 article on Pubmed so far, cf. 224 on “telecare”
Zany future health ideas Cell phone eye exam – MIT media lab Brain control of devices - Univ of Wisconsin Adam
Wilson created Twitter messages using nothing but his brain waves
Bionic senses / limbs – eg. synthetic retina Artificial brain simulator - Henry Markram Blue
Brain Project reverse-engineering human brain within a supercomputer,
Artificial brain stimulator – eg. “sex chip” - Tipu Aziz of Oxford. Cf. the orgasmatron, in Woody Allen's 1973 movie "Sleeper."
[incredible journey]
Results & next steps
Time spent on site: No. of pages visited:Fogg’s methods used: Median 108 seconds Mean 3.7, SD 2.8Control web site: Median 47 seconds Mean 2.6, SD 1.9Ratios: 2.3 : 1 1.4 : 1, p = 0.006
Next steps - look at actual health-related behaviours:
• Funding obtained from NHS Chief Scientist for further randomised study on decisions to join NHS organ transplant register
• Leverhulme grant applied for to work with City Council to increase participation in sport & use of their facilities
Impact on web browsing behaviour:
Tele-healthcare innovation force field
SimpleSafeEasy to useSame / better outcomesSupportive opinion leadersMinimal learning / changeExcellent tech. supportCost releasing
ComplexRisks unknown
Public refusal (GM foods)Professional refusal (SCR)
Media slogan: “2nd class care”Poor implementation
Duplicates current service
Some potential harms from tele-healthcare
False positives distract busy clinical staff, require extra resources; false negatives wrongly reassure patient
Differential uptake by younger, educated public may worsen health inequalities (“Cyber divide”)
Some people find it intrusive / mechanistic - loss of regular human contact [4% in JIT study, 2008]
Exposing large scale problems that NHS cannot manage
When does tele-healthcare help ?
Heart failure (Inglis et al, CDSR 2010): • Reduced mortality by 44% (RR 0.66, CI 0.54-0.81, p < 0.001) • Reduced CHF-related admissions by 23% (RR 0.77)
Diabetes (Farmer et al SR, 2005): • Reduced HbA1C by 0.1% (95% CI -0.4% to 0.04%)• Use of services either no different or increased with telehealth
Bronchitis (Polisena et al SR, 2010): • Mortality may be greater in telephone-support group (RR = 1.2;
95% CI 0.84 to 1.75)• Reduced hospitalization and emergency department visits; but
impact on hospital bed days varied
What to measure in pilot studies ?
Safety – risks for intended & other users Feasibility – impact on NHS staff; potential clinical
benefitsAcceptability: to patients, carers & staff, across
full range of age, ethnic, socio economic groups (TMPQ instrument – Demiris 2002)
Eminovic et al. J Med Internet Res. 2004; 6 : E17
Serious questions about tele-healthcare
How often - & by how much - does it:• Increase the proportion of people who can
be safely cared for at home ?• Support self care, improve outcomes ?• Widen access to scarce professional skills ?• Reduce travel & carbon footprint ?• Decrease healthcare resource utilization,
saving scarce public money ?
Simple versus complex tele-healthcare
• Two trials compared simple phone monitoring of patients with heart failure by nurses (cost £1200 per patient year) with device-based telemonitoring (£6000)
• Same impact on admissions & outcomes
-> Phone monitoring 5X more cost effective
Chaudhry SI et al. Telemonitoring for patients with chronic heart failure: a systematic review. Journal of Cardiac Failure 2007; 13:56-62
Arden Digital Healthcare Demonstrator
Aim: to demonstrate full scale digital healthcare & learn from the experience
Covers 1M people across Coventry & Warwickshire PCTs
Links with:– NHS Local digital services– Coventry Total Place pilot– Local Health Innovation & Education Cluster– Etc.
Tele-healthcare suitability scaleMany reasons why tele-healthcare can fail: disease itself, personal preferences, disability, environment…
Need reliable, valid scale to estimate chance that TH will be accepted / effective for each person
IDH working with psychologists & others to develop and validate the scale
All collaborators welcome !
Sources
Andy Black - Future of acute hospital
Sue Francis – 2020 Vision report Chris Ham / Candace Imison
report JW article BMJ Big Society BMJ on kiosks etc. – Big brother Sci Fi insights – ubiquitous CCTV
etc. Foresight report with MP
Digital healthcare innovation opportunities
Health promotion
Screening Test choice &
interpretation
Prognosis; drug choice & dose, self
care
Supported self care
Relevant activities:
Candidate technologies
Websites,serious
games…
MSN triage, NHSDirect,
kiosks…
Telemedicine, decision
support…
Prescribing alerts, telehealth, prediction rules…
Virtual ward, hospice…
Healthy Symptoms DiagnosisLong term condition End of life
Lifeline
= 1 / 2000th of waking hours
Time spent with doctor by person with long term condition
Responsibilities of unpaid carers
• Technology can give carers time off – or extend their responsibilities (“Dad, can you keep an eye on my diabetes while I’m clubbing in Ibiza?”)
• How much should the NHS rely on unpaid carers to support patients ?
How to help ?
Avoid waste - everyone, everywhere only do what we know works (Cochrane)
Virtual / digital healthcare:– More self care & health promotion,
less hospital care– Anticipatory / targeted care