Monday, 17 April 2017

#ClinicSpeak & #SocialMedicine: social medicine the next healthcare revolution

Are you engaging in social medicine? #ClinicSpeak #SocialMedicine #MSBlog

The current big topic in the study of evolution is 'cultural evolution' and how the human brain is wired to be social. We are social animals and like to be connected. This is why we are tribal and flock to cities in our billions. The real success of the internet, or the web, is the 'social web'. The most successful tech products are social products. Facebook, Whats-app, Instragram, Google+, Pinterest, Waze, etc. Why have we not picked-up on this in healthcare and run with it? I think it is because healthcare, similar to education, as a field is slow to adopt new technologies and ways of doing things. 


The perspective article below in a recent NEJM makes the case for shared clinics. or as I now prefer to call them 'social clinics'. The concept is not new; we have posted on the topic several times before under the term 'group clinics'. The current healthcare model in relation to MS diagnosis and management is based on a synchronous model of one-to-one consultations typically in specialised centres. This requires pwMS to travel long-distances, to get a cursory examination and very short amount of time with their HCP. Both the HCP and the user, you a pwMS, are more often than not dissatisfied with the consultation. There must be a better way of doing things.   

At Barts-MS we plan to change the options available to our patients and have been successful in getting a grant to test several new initiatives to make our service more responsive. We plan to expand our on-line offering; essentially a better curated and easier to navigate information portal. At present this is text-based, but we will need it to make it multimedia and include video and podcasts (see below). We now offer telephone and Skype clinics. We have tested a 'Falls and Bone Health' group clinic and are now in he process of testing a few more topics. Our annual MS Research Day needs to become a more frequent event, perhaps smaller and more focused. We envisage running these using a similar format to our MS Roadshows to the regional hospitals in our local network. If successful we hope to be able to make all these offerings a permanent feature at Barts Health. 

Most practice of medicine, including MS, is not rocket science and getting pwMS to self-manage and to help others self-manage is potentially a game-changer. Importantly, we are certain that if implemented well we can get better outcomes, whilst saving the NHS money. 

My family gave me a Google Home Assistant for my birthday last week. Although I am still learning and teaching the assistant it has already revolutionised my life. I simply speak to it to do tasks that used to take me minutes to complete. Already the device has killed our Sonos music system in the kitchen; over the weekend we have played all our music through Google Home. Can you imaging using the Google Home Assistant to deliver healthcare? For example, you simply say 'Hey Google, I have MS please tell me how to manage my MS fatigue'. The Google Assistant will then offer a selection of formats and you could, for example, choose a podcast to listen to on MS fatigue self-management. As the use of assistant is hands-free it will revolutionise how disabled pwMS communicate with their families, carers, HCPs and other pwMS. The potential applications for this technology are endless. 

If anybody from Google is reading this post, or if you have a contact within Google who can help, I would love to discuss implementing a MS self-management system using the Google Home Assistant. We live in exciting times; the potential that technology offers to change how we practice medicine is endless, but when we design these services/systems they need to be social.

If you are engaging in social medicine please let us know. Similarly, if you have any ideas around social medicine please share them. Thanks. 


Ramdas & Darzi. Adopting Innovations in Care Delivery — The Case of Shared Medical Appointments. N Engl J Med 2017; 376:1105-1107. 

Excerpts:

...... Transformative innovations in care delivery often fail to spread. Consider shared medical appointments, in which patients receive one-on-one physician consultations in the presence of others with similar conditions. Shared appointments are used for routine care of chronic conditions, patient education, and even physical exams. Providers find that they can improve outcomes and patient satisfaction while dramatically reducing waiting times and costs.....

........ Patients benefit from interacting with their peers and hearing answers to questions that may be relevant to them. Doctors avoid repeating common advice, which improves their productivity and enables higher-quality interactions with individual patients. Increased system capacity reduces waiting times even for patients who opt for traditional one-on-one appointments. Shared appointments have been used successfully for over 15 years at the Cleveland Clinic, in the Kaiser Permanente system, and elsewhere......

...... Shared service delivery isn’t a new concept. Group interventions are common for primary prevention (e.g., encouraging smokers to quit) and secondary prevention (e.g., helping patients with chronic obstructive pulmonary disease to avoid complications). Group-based programs such as Alcoholics Anonymous and Weight Watchers allow people to acknowledge that they have a problem and start working toward solutions......

....... Given the effectiveness of group interventions, why aren’t doctors routinely using them to treat physical and mental conditions? We believe four crucial components are missing: rigorous scientific evidence supporting the value of shared appointments, easy ways to pilot and refine shared-appointment models before applying them in particular care settings, regulatory changes or incentives that support the use of such models, and relevant patient and clinician education. Such enablers are necessary for any highly innovative service-delivery model to become standard......

..... Shared medical appointments change the boundaries of health care services because fellow patients, rather than only the doctor, can provide information and support......

..... With any new delivery model, regulation and participation incentives influence uptake.....

...... Finally, patient education could stimulate interest in shared appointments.....

....... When altering an interaction as unstructured and personal as a doctor visit, patient education is critical. Many patients may hesitate to participate in a shared appointment for their annual physical, imagining that they would meet fellow patients in their underwear. In fact, in a typical shared physical for female patients at the Cleveland Clinic, the doctor performs pelvic and breast exams and discusses test results with each patient in private. The remainder of the appointment is conducted as a shared appointment. By sitting in on shared appointments as unbilled observers, patients can experience for themselves the less tangible benefits of peer interaction.....

...... Doctors also need education. Large health care organizations could experiment with new care models and invite doctors within their system to observe and learn......

....... Indeed, these needs apply to all new delivery models: to accelerate their adoption, we will need to embrace new strategies for collecting evidence on their outcomes; find safe, quick, and cheap ways to experiment; offer incentives to providers; and educate stakeholders....

23 comments:

  1. Just a thought about group clinics. Be careful how you "group" people. Whilst I have previously has group physio which was brilliant, I find the group infusion rooms a daunting place. Not sure about a group clinic, we all differ so much in attitude and our current disease course.

    NHS guided internet resource would be good. I like the shift ms videos, and at my first ms appointment my consultant told me specific websites to look at which was helpful and stopped me going to far astray.

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    1. Group clinics are voluntary; you can engage or not. The difference is instead of a 15 minute consultation you get close to 3 hours contact time with HCPs and about 10 minutes one-on-one at the end.

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  2. Podcasts would be great; I could listen to them whilst taking my daily walk.

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  3. I'm not sure about group clinics. I value my confidential one to one time with my neurologist. I feel my MS is private.
    I don't mind giving up my MS nurse time. As long as they are contactable by email or phone to answer questions if needed.

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    1. Poor nurse. Are they less important that the neurologist?

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    2. I guess I self manage as much as possible and I've had MS a while now, so I'm now clued up on things MS related.

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  4. Group clinics? No way. I have too many questions specific to me and it's hard enough getting the complex information I need without others distracting. And I do not like talking to people about my MS. It is private, involving many extremely personal issues.

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  5. "Can you imaging using the Google Home Assistant to deliver healthcare? "

    Certainly not.

    For one thing, there are massive privacy questions with this. Google saves a lot of information.

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    1. I agree, there is too much of Google in the world already.

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  6. Skype clinics sound good in theory but I would be concerned aspects could be missed not being in person face to face. I guess it could be ok for routine appointments, the pwMS has had MS for some time and theres not much change in their condition.

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  7. For my current and last DMT I have used Facebook groups for support and information. Some have been better moderated than others, international groups include very different cultures, but they can be very helpful in answering questions as to whether things are likely to be side effects, MS or other, and therefore where you next go to seek help - otc meds, gp, MSologists.

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  8. Re. "This requires pwMS to travel long-distances, to get a cursory examination and very short amount of time with their HCP."

    I don't get an examination when I see my neuro for routine appointments. Is this something some neuros do and others don't do?

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    1. If you don't get examined you don't get an EDSS measured, which is why we are pushing the web-EDSS as a proxy. It is usually better to spend the appointment discussing things than being examined, but on some occasions the latter is essential.

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  9. Lucky Prof G! What an amazing thought to use Google home assistant to help with MS and may be other health issues. In a way we already use google, the hard way.
    The problem is people don't trust technology. so unless every body is happy to have an assistant the effort and cost will not be worthwhile. However podcast will be very welcome. I have been to MS research days and wish they were podcasted as many more people would have been able to benefit.

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    1. Nobody trusts new technology; but at some point in time it becomes indispensable otherwise you get left behind.

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  10. I think its a great idea. I think it helps to relate to others in similar situation, how they manage certain symptoms and makes it a really open frank discussion. I've nothing to hide and happy to discuss as it is what it is, and if others have found ways to manage things better, or if I can how I manage things which would help someone else then that's brilliant. And you still get your 121 at the end.

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  11. Ah, machine learning.

    Yes... technology WILL transform care just as it has been doing.

    The day will come where holograms deliver one's neurologist into the home.

    Towards google: https://plus.google.com/+SundarPichai

    Rick said he's actually pretty responsive.

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  12. Great idea on the Google Home concept. I can probably help out (my wife has MS & loves your blog - doing great, post-R2 lemtrada). I work in IT and currently playing around in this space.

    I'll put forward a conceptual idea (and I'll leave ethics out of it - ML/AI overtaking the world/ big brother stuff is real in the wrong hands, but let's assume we are all doing the right thing).

    Note: there are lots of other challenges, but I'll put forward the main ones:

    layer 1 - "expose the service". Once you create what we call a Conversational User Interface (UI), you can expose it anywhere - google home, amazon echo/alexa. apple siri, slack, skype, email, text..etc... This is relatively straight-forward, but complicated. A good engineer will expose the service on multiple channels for maximum coverage.
    Advice: start with google, but don't restrict yourself.

    layer 2 - "Design the conversation". This is really difficult - by far the biggest challenge. For a conversational UI, you have no visual prompt (like a menu or a button). You "speak" your command. A "narrow" service like weather still has multiple variations (or utterances):

    - what's the weather like
    - Will it rain today
    - Is it hot today
    - what's the temperature today
    - tell me about the weather in London

    So mapping these "utterances" into an "intent" is relatively easy. There are only so many ways you can ask about the weather.

    A medical service like an "MS advisor intent" would (I imagine) have many, many ways to "trigger" it. This is a whole new field of UX (User Experience) and everyone is just learning about this. It's also a conversation, so it'll go back and forward a few times.
    Advice: engage with a good designer who has worked with Conversation before.

    layer 3 - "create the correct advice". You have this well covered. Once you map the utterance to an intent, you effectively "orchestrate" it to the correct piece of advice. Think of it as an engine of rules - you already have all this in your blog. e.g. when someone needs X, point them at Y resource (i.e. podcast, blog..etc...).
    Advice: get help from an engineer, but you guys are by far the experts here.

    Hope that all makes sense, I'm happy to discuss further or do a little research for you. One small event that gives you a peek at this space is this http://convercon.ie/ happening in Dublin in May 2017 - I may have some involvement in it.

    As a note, the creators of these platforms (google, Amazon, Apple..etc...) would see this idea as an "App", so they will give loads of support, it's unlikely they'd build it for you (but will be extremely helpful).

    Let me know if you have further queries - I'm very grateful for the good work you do and it certainly has helped us in our journey.

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    1. Just a thought, Could we not start by saying"hey Google, take me to MS Speak"which would open up a database. I am not an IT person but expect there would have to be a database which has info on DMT etc. A little like the Wolfram Alpha that Siri uses.

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    2. We're coding for the 3D Prof G hologram as we speak.

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  13. Just had an idea that would work. What about a blogging platform for voice? It could be could called Podder?

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  14. Podder is, indeed, a good idea. Same problem though, people do not like technology! My son, an astronomer, has MS and can not use his hands or feet. Technology allows him to be in control, he teaches on line course in Astronomy and also teaches A level students (privately) in Maths, Physics, Chemistry and Biology. He manoeuvres his wheelchair by voice and head control which interface with the computer to move the cursor when he plays Bridge on line. He leads a very fulfilled and busy life, thanks to technology!
    More is gained by embracing technology than lost. I am all for Podder.

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    1. What about your privacy? And then, when you google something now, you'll get a range of answers - but when google is just providing you with one answer, who will decide which answer it is? Google will. And it will sell the spot to the highest bidder. So you won't get the best advice, or even good advice - you'll just get the product someone paid most to place.

      Technology is not in itself bad or good - but I do not trust companies to act in anyone's interest except their own.

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