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Last year, I posted about Alexa being able used to access complex health information. Microsoft, on the other hand, has taken a different approach to the use of a chatbot/AI for healthcare. Instead of the chatbot being able to access your health record, why not have it answer routine questions patients have prior to an appointment?

With this goal in mind, Microsoft has created the Microsoft Healthcare Bot, which is a service that allows healthcare organizations to streamline their processes, and take some of the workload off of their staff. What I like about this service is that it allows for “basic” questions to be answered – issues like clinic hours, when results can be expected, or whether to fast before a blood test, can all be answered. It also has a built-in escalation system, where if a patient needs more information, or if they can’t get the answer they need, the AI will pass them on to a person who can answer their questions with the current transcript, ensuring a smooth patient experience. So the idea is that these will address easier questions where a quick response is possible, thus freeing up staff time to deal with more complex or technical concerns.

Microsofts webchat application is used to interface with the health bot

Now, there are definitely concerns with such an approach. Perhaps most importantly, the “personal” touch of someone reassuring patients prior to their test, and putting their mind at ease, is something that a chatbot is not equipped to handle. On top of that, there are security concerns, which is why these programs are being developed to be in compliant with regulations like the Health Insurance Portability and Accountability Act (HIPAA), and the General Data Protection Regulation (GDPR).

Quest Diagnostics is a company that has started using the Microsoft chatbot already, and the following was reported from Venturebeat:

Multibillion-dollar diagnostic services provider Quest Diagnostics piloted a bot that helped people who visited the website during call center hours find testing locations, schedule appointments, and get answers to non-medical questions, such as whether to fast before a blood draw and when to expect results. (It autonomously handed exchanges off to human reps in the event it became confused or wasn’t able to help with something.) In a survey Quest Diagnostics conducted post-deployment, 50 percent of respondents said they vastly preferred to engage with such a chatbot than a website search box or FAQ section. (emphasis mine)

So from the above, there’s definitely a need for this service in the healthcare space.  I’ve used similar services for non-healthcare related applications and I’ve appreciated the speed with which I can have my issue resolved – often well before I would have been able to talk to a person. It also allows me to do this, but if something else needs my attention, I can minimize it and come back to it later, which is obviously not an option when you are chatting with someone else.

Now one thing to note is that this is all part of a more holistic play for the healthcare space by Microsoft. Specifically, their cloud-based platform (Azure) allows for users to modify their chatbot to suit their company, as well as plug into their other offerings. To that end, Healthcare NExT (New Experiences and Technology) will be Microsofts in-house division focused on bringing together different data sources, AI, research and technology to “transform patient and clinician empowerment.” It’s an ambitious goal, but as we move from data warehouses to data lakes (and then to data <insert newest metaphor here>), we need to have a common set of tools and programs that can make the most of this information; otherwise we’re no further ahead than where we were 10 years ago – just instead of filing cabinets we have file servers. One of the ones I’m most interested in is Project InnerEye, which promises to allow for quicker radiotherapy planning for physicians through 3D generation of scans in minutes rather than hours.

For those who want to give the Healthcare Bot a try, it’s available here on Thoughtstuff.

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Last week, the Eat-Lancet Commission released their first report, titled “Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems.” We’re reaching a breaking point as a species, with our population growth rapidly outstripping what the Earth is capable of supporting. UN population estimates state that, in the last fifty years, our population has gone from 3.7 billion to 7.8 billion; and in the next fifty, it will increase to a whopping 10.6 billion people. However, concomitantly with this population change, has been a change in our diets. Globally, we have shifted to unhealthy foods that are high in calories, heavily processed, and heavily dependent on meats, which are more difficult to sustain as the global population increases, and it is this challenge that the Eat-Lancet Commission is trying to tackle. From their website:

Meeting the Sustainable Development Goals and the Paris Agreement targets to reduce carbon emissions means urgently and fundamentally changing the way we eat and produce food. But key questions remain unanswered and a lack of scientific consensus is slowing down governments, businesses and civil society actors who want to take action:

  • We don’t have a scientific consensus to define what is a healthy diet for all humans.

  • We don’t have a comprehensive review of how food production must change to be sustainable.

  • We don’t have clear, science-based guidelines telling all actors how we can provide humans with healthy diets from a sustainable food system.

They justify why the food system is one to focus on, based on the disproportionate burden it places on the planet. While agriculture occupies ~40% of global land, it is responsible for up to 30% of greenhouse gas emissions, and 70% of freshwater usage. This has effects on other species, with land use threatening some with extinction, and overfishing (another aspect of the food system) increasing the environmental burden on marine systems. They argue that since the food system is predicated on what people consume, changing diets is the first step to changing the priorities of our food system.

Which leads to the obvious question – what do we need to do to save the planet, and ensure future generations can live here? One aspect of the report that I really liked was the range of “briefs” they produced, aimed at everyone from cities, farmers, food service professionals, healthcare professionals, and the general public. Given the range of readers here, I’ve highlighted some steps that everyone can follow to help achieve the goals of a sustainable health system (check here for the full list):

  1. A plant-based diet has more options than we realize. Generally, we only sample a fraction of available food. Across price ranges, cultures, age groups, and individual preferences, there are many different meal options available to us.
  2. Plants can be a source of protein. Many plants are both healthy and sustainable sources of dietary protein.
  3. Go easy on meat consumption. Meat is an important source of nutrients, but eating excessive amounts of meat is harmful for both our health and the planet. The report recommends we aim to consume “less than 98 grams of red meat (pork, beef or lamb), 203 grams of poultry and 196 grams of fish per week.”
  4. Vote with your plate. Markets will follow demand, and so the more people purchase sustainable foods, the more the food industry will produce in that area.
  5. Plan the week ahead. Healthy and sustainable eating is easier if you can plan meals for the week. This will ensure you enjoy what you eat, as well as ensure diversity in your meals.

There are many other points raised in the brief, and, to the authors credit, are generally tangible actions you can take if you are so inclined.

The EAT-Lancet Commission on Food, Planet, Health (source)

Now, there’s a lot to unpack here, and it will be challenging to implement. In fact, when researching for this piece, I came across as much hate for the report as support, with a lot of skepticism coming from the audience. The idea of changing your diet to include red meat to only include one burger a week, or one large steak a month, is a large change that many are not either ready, willing, or able to do. However, minor changes can still set us on the path for success, and encouraging others while expanding our own cooking can still help benefit us all.

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Last week, I discussed the five biggest health trends to keep an eye on in 2019. To recap, the first three items were:

  1. Putting patients at the centre of our healthcare system
  2. Using data effectively to improve outcomes
  3. Disrupting existing care paradigms

Today, I’ll be continuing on that theme, with items 4 and 5 on that list.

4. Ensuring that data are kept secure

A fully integrated, fully connected data warehouse is a wonderful idea that has a lot of benefits for all. However, placing all of our proverbial healtcare data eggs in one basket also makes it a very appealing target for hackers. One of the key healthcare stories that came out of last year was the WannaCry attacks on the National Health Service in the UK. Approximately 16 health services organizations were hit by these ransomware attacks, which demanded organizations pay $300 to $600 to restore access. This led to ~6,900 appointments being cancelled, although NHS England did say that no patient data was compromised or stolen as a result. Given the richness of the data available, the sheer number of devices that could be accessed (desktops, laptops, phones, medical devices), this has led to cybersecurity experts saying that it’s not “if” a healthcare organization is attacked, it’s a matter of “when.” Therefore, we need security measures in place to ensure data are protected from this happening again.

The only foolproof way to secure data is to not allow access to it – defeating the whole purpose of an integrated data warehouse. Several data governance frameworks have therefore cropped up to answer questions like the below:

  • Where does the data come from?
  • Is the data of high quality?
  • Who manages the inflow of data (including new and existing data)?
  • How are data elements defined?
  • How is data transferred between stakeholders?
  • Who is allowed to access the data, and under what constraints?
  • What are the relevant laws/legislation that need to be adhered to?

From the above, you can see that the team must consist of a range of stakeholders. It’s not enough to have data reside in the IT department if it’s being used by physicians to measure adverse events, or by the business intelligence team to understand where money is being spent in a hospital. The teams need to exist side by side, and a governance team needs to have representation from all stakeholders, including patients, to ensure that the right data is available, at the right time, to the right people.

5. Making sure we care for healthcare providers

An issue that received quite a bit of coverage in 2018 was physician burnout. The combination of time pressures, lack of control, new systems (e.g., EMRs), as well as the emotional nature of the work, puts physicians at high risk of burnout and exhaustion (West, 2018; Southwick, 2018; Downing, 2018). In addition to the effect this has on physicians, this can also result in suboptimal patient care, and increased costs to the healthcare system. Contributors to burnout vary, and include issues such as work factors (e.g., inefficient work processes), as well as individual factors (age and sex both appear to predict future burnout). As a result, tailored solutions to different problems are required. For example, if work inefficiency is identified as a driver of burnout, then optimizing medical records and workflows may be a solution that can be adopted.

While much of the research has focused on physician burnout, there is also growing evidence that nurses and other health professionals are also susceptible to the same forces. A study described in HBR analyzed data from >80,000 health care professionals, including nurses, physicians and other health professionals. They studied two characteristics associated with burnout:

  • Activation, or “the extent to which a person is motivated by his or her work and feels it is meaningful”
  • Decompression, or “is the degree to which one can withdraw, recharge and enjoy life outside of work”

What was really interesting was that while all three groups had similar levels of activation, i.e., they all felt as motivated about their work, the physician group had the lowest decompression scores, i.e., while the nurses and other health professionals groups could withdraw and recharge, physicians were less able to do this.

As technology becomes more intertwined in patient care, and as more sophisticated systems are introduced and implemented, the perspective of the provider has to be kept in mind. While a shiny new system may sound great in theory, if in practice if it’s not tailored around efficient workflows, it may be a barrier to success.

===

And there you go! The five trends that I think 2019 will bring to healthcare. What do you think? Do you agree or do you have suggestions for additional trends to keep an eye out for?

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Last week, I started discussed the five biggest health trends to keep an eye on in 2019. To recap, the first three items were:

  1. Putting patients at the centre of our healthcare system
  2. Using data effectively to improve outcomes
  3. Disrupting existing care paradigms

Today, I’ll be continuing on that theme, with items 4 and 5 on that list.

4. Ensuring that data are kept secure

A fully integrated, fully connected data warehouse is a wonderful idea that has a lot of benefits for all. However, placing all of our proverbial healtcare data eggs in one basket also makes it a very appealing target for hackers. One of the key healthcare stories that came out of last year was the WannaCry attacks on the National Health Service in the UK. Approximately 16 health services organizations were hit by these ransomware attacks, which demanded organizations pay $300 to $600 to restore access. This led to ~6,900 appointments being cancelled, although NHS England did say that no patient data was compromised or stolen as a result. Given the richness of the data available, the sheer number of devices that could be accessed (desktops, laptops, phones, medical devices), this has led to cybersecurity experts saying that it’s not “if” a healthcare organization is attacked, it’s a matter of “when.” Therefore, we need security measures in place to ensure data are protected from this happening again.

The only foolproof way to secure data is to not allow access to it – defeating the whole purpose of an integrated data warehouse. Several data governance frameworks have therefore cropped up to answer questions like the below:

  • Where does the data come from?
  • Is the data of high quality?
  • Who manages the inflow of data (including new and existing data)?
  • How are data elements defined?
  • How is data transferred between stakeholders?
  • Who is allowed to access the data, and under what constraints?
  • What are the relevant laws/legislation that need to be adhered to?

From the above, you can see that the team must consist of a range of stakeholders. It’s not enough to have data reside in the IT department if it’s being used by physicians to measure adverse events, or by the business intelligence team to understand where money is being spent in a hospital. The teams need to exist side by side, and a governance team needs to have representation from all stakeholders, including patients, to ensure that the right data is available, at the right time, to the right people.

5. Making sure we care for healthcare providers

An issue that received quite a bit of coverage in 2018 was physician burnout. The combination of time pressures, lack of control, new systems (e.g., EMRs), as well as the emotional nature of the work, puts physicians at high risk of burnout and exhaustion (West, 2018; Southwick, 2018; Downing, 2018). In addition to the effect this has on physicians, this can also result in suboptimal patient care, and increased costs to the healthcare system. Contributors to burnout vary, and include issues such as work factors (e.g., inefficient work processes), as well as individual factors (age and sex both appear to predict future burnout). As a result, tailored solutions to different problems are required. For example, if work inefficiency is identified as a driver of burnout, then optimizing medical records and workflows may be a solution that can be adopted.

While much of the research has focused on physician burnout, there is also growing evidence that nurses and other health professionals are also susceptible to the same forces. A study described in HBR analyzed data from >80,000 health care professionals, including nurses, physicians and other health professionals. They studied two characteristics associated with burnout:

  • Activation, or “the extent to which a person is motivated by his or her work and feels it is meaningful”
  • Decompression, or “is the degree to which one can withdraw, recharge and enjoy life outside of work”

What was really interesting was that while all three groups had similar levels of activation, i.e., they all felt as motivated about their work, the physician group had the lowest decompression scores, i.e., while the nurses and other health professionals groups could withdraw and recharge, physicians were less able to do this.

As technology becomes more intertwined in patient care, and as more sophisticated systems are introduced and implemented, the perspective of the provider has to be kept in mind. While a shiny new system may sound great in theory, if in practice if it’s not tailored around efficient workflows, it may be a barrier to success.

===

And there you go! The five trends that I think 2019 will bring to healthcare. What do you think? Do you agree or do you have suggestions for additional trends to keep an eye out for?

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As we start a new year, every company and healthcare professional starts to think about what innovations the new year could bring. While some have very positive and innovative results, there are also risks we have to consider. Below, I’ve listed what I think are the five trends to watch in 2019.

1. Putting patients at the centre of our healthcare system

The patient perspective has been one that has been discussed for a long time, and is slowly becoming a normal part of any health-related project, whether that’s a clinical trial, designing a new hospital, or when designing healthcare policy. The mantra of “nothing about us, without us,” has taken hold, and is being used in very different parts of the healthcare system, with the same objective of ensuring that the patient/end-users voice is heard. At a systems-level, the Ministry of Health and Long-Term Care in my home province of Ontario, Canada set up the Patient and Family Advisory Council to help advise the province on healthcare priorities and ensure the patient voice was heard. At a hospital/provider level, Kaiser Permanente has 400 patient advisers serving on more than 50 patient advisory councils, ensuring that the patient voice is included at all parts of the care journey. From their website:

Advisers are brought together as local and regional councils that offer input and guidance in areas such as facilities design, leadership structure and physician hires. They often shadow a patient (with the patient’s permission) to better understand the care experience. Some councils have committees that focus on specific topics, such as maternity and child care, transgender issues, breast cancer experience and visiting hours.

Designing and implementing a patient engagement program does require work from all stakeholders involved. This excellent journal article in Clinical Trials by Bray Patrick-Lake delves into this in more detail, and provides recommendations for all stakeholders, research sponsors, and patient groups to provide practical advice when implementing this sort of initiative.

2. Using data effectively to improve outcomes

In almost every health-care setting, data is underpinning every conversation. Questions such as “where are the test results,” “have you had this test before,” and “how can we predict if this person will be back in the emergency room,” are ones with clear implications for healthcare providers, and with the power of data, can help improve outcomes for patients while simultaneously lowering costs for providers. One estimate from March 2018 suggested that around 30% of the world’s daily data production is healthcare data – lab test results, medical images, biopsies, medical claims, academic research, etc.

However, healthcare is still at the nascent stages of the Big Data Revolution. In industries such as banking, algorithms and models are already used to understand behaviours, and to predict what you will need next. Did you buy a new gym bag this January as part of your new years resolutions? In about a week (or less) you can expect emails from the same seller for new gym t-shirts, shorts, and other apparel to go with your new bag. However, we don’t have that same level of sophistication in healthcare (yet). Data exist in separate silos, with primary care records not liaising with hospital visits, and while your doctor might write a prescription for a medication, they have no way to see if you actually took the drug they gave you.

Once all these systems are integrated and able to talk to each other, the power is incredible. Healthcare providers will be able to map out the patient journey to understand how patients experience the healthcare system in the real-world, rather than just through their understanding of their role in the patient journey. With this, we will be able to answer questions like “how many patients visit their primary care doctor prior to going to the emergency department,” and “after discharge from the hospital, how many patients go back to the emergency without seeing another healthcare professional?” Some of these questions we might be able to answer now, but with limitations. With a truly integrated system, we will not only be able to map out the patient journey, we will also be able to then overlay these on existing patients to predict their likelihood of developing certain outcomes. If we know that 75% of the time, patients with conditions A, B, and C develop diabetes within 5 years, we can launch interventions to help them before they develop these outcomes.

3. Disrupting existing care paradigms

One of the biggest companies in the world made a huge splash last year by moving into the healthcare space. Amazon’s move to acquire PillPack, as well their filing of a patent to allow Alexa to pick up a cold or cough, shows they have a very ambitious targets for their role in the healthcare industry. To quote this article from CNBC:

So imagine you have a sore throat. You let Alexa know, and it responds by asking if you want to book an appointment at the doctor’s office or get a virtual consult. You pick the virtual option, and the doctor through Alexa asks you about your symptoms. It decides to send a courier to your home with a tiny portable device to do some basic tests for things like strep throat. The strep test is positive, so the virtual doc sends over a prescription for an antibiotic. (We’re assuming that all the Amazon services are fully compliant with privacy and other laws.)

The idea that Amazon already owns a lot of these services, or that they could likely acquire the missing pieces, shows where they think the healthcare system is going. And to be fair to other innovators in the space, they aren’t the only company pursuing this objective. Maple is a Canadian company that allows you to connect with a doctor using your phone, tablet or computer, all from the comfort of your own home. In 2019, we can expect more providers to start offering this as an option to an in-person visit, especially for follow-up visits for low-risk patients.

Come back next Monday for Part 2!

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The Consumer Electronics Show (CES) is an annual event that attracts over 180,000 attendees each year, showcasing the most cutting edge, revolutionary technology imaginable. Of interest to readers of PHP however, will be the Digital Health Summit, which focuses on how technology can revolutionize healthcare and wellness. In fact, healthcare has become so ingrained in CES, that attendees can now earn CME (continuing medical education) credits for some of the sessions. I’ve highlighted a few of these innovations below; it remains to be seen how well they work in the real world, and if patients are interested in this sort of technology.

Improvements to existing fitness trackers

While current fitness trackers can measure activity, improvements to them, as well as improvements to their ecosystem, will allow for patients to track activity, as well as blood glucose, blood pressure, weight, and other biologic measurements. Being able to track your overall health, and see how it is trending over time, will allow those with multiple conditions to track their health and identify risk factors before they escalate.

Pria by Black and Decker: Medication management made easy The PRIA by Black+Decker is an automated medication management and home health assistant (Photo from their Facebook Page)

Medication management is an ongoing struggle for patients, especially when dosing is irregular, or when different medications require different dosing scheduled. The PRIA by BLACK+DECKER Home Care Companion is an automated medication management and home health assistant that allows a caregiver to monitor an individuals medication and healthcare schedule. It is able to schedule different medication doses and schedules, provide reminder alerts, and track visits (source).

Addison: Your healthcare virtual assistant

Similar to the above, but take even further is Addison Care. This is a virtual assistant created by Electronic Caregiver. Not only is it capable of reminding users to take medications (and then being able to track adherence), it can also measure health performance. It’s a very ambitious project that was several years in development, but as you can see below, the system is very interactive, using voice activation, cameras, and other feedback mechanisms to get a more in-depth understanding of someones health state. The video below provides more detail on how it can assess a patients risk of falling:

Thought leadership in healthcare

In addition to the device above, CES also has a series of interesting talks scheduled, including:

  • Boldly Going Where No Tech’s Gone Before: A session focused on incorporating the patient perspective into healthcare, ranging from clinical trials to hospital care
  • Patient Decade Commences: Tear Down These Walls!: Continuing the patient theme, this session will be focused on patient generated health data, and includes a patient advocate as part of the panel
  • The Solution to the Opioid Crisis No One Is Talking About: A panel that sounds like something out of Star Trek will be discussing “… a bright light we refer to as Neuromodulation—a discreet, FDA-approved, implantable neural device holding powerful capabilities to intervene in the adoption of opioids by confronting the root of the cause—PAIN.”
  • Gamechanger Seqster Unites Health Data & Genomics: The idea of a single health care record owned by the patient is something of a pipedream for patient privacy advocates. However, in this session, the CEO of Seqster proposes their solution for this incredibly difficult problem.

It’ll be interesting to see what else is announced at CES; this is what I could find before the conference starts, but it remains to be seen what other innovations come about afterwards. In addition, I’m curious to see how well these innovations work in the real world, and how companies respond to concerns around patient privacy, and what feedback systems they put in place to ensure patient safety is paramount.

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Previously, I talked about smart speakers , how they can be used as a way to find health information, and some of the implications this has for the delivery of healthcare. I want to switch gears a little bit now, and discuss how we, as patients, search for information prior to going to the doctor. To talk about that, I’m going to focus on a recently published report by KRC Research, titled “The Great American Search for Healthcare Information,” which was a survey of 1700 American adults who searched for health-related information at least once a year. The study found that 81% of Americans fit this category, which means that approximately 261 million Americans are searching online for health information, of which 34% are searching for this information monthly, and 18%, or almost 1 in 5 people, are searching for health-related information weekly. This is a large proportion of people searching for information on a very regular basis. With the wealth of information out there, some of which is accurate, but a non-zero percentage of which is inaccurate at best, and fraudulent at worst, understanding how patients manage their care outside of the healthcare system, and what their concerns are, can help providers improve their delivery mechanisms and approach to patients.

Perhaps one of the best aspects of being able to find health information online is that there are a diverse range of sources available. Indeed, this was listed by 54% of the respondents as one of the main benefits of healthcare information today. However, the contrast to this is that there is a lot of false or misleading information out there, and almost the same percentage of respondents identified this as a problem (52%). This is further exacerbated by patients being concerned about studies that contradict each other, which makes it harder to know which is “right.”

Concerns patients have about health information online can inform how apps and programs should be developed and delivered (Photo by rawpixel.com from Pexels)

One of the interesting aspects of this report was their findings on differences between generations, particularly baby boomers (1946-1964) vs millennials (1981-1996). Personal preference for the specific cut points aside (I know some 1981 folks who would be very angry at being called millenials), there were some interesting differences in the perception of information. For example, while ~60% of boomers and greatest generation respondents were likely to report being concerned about health related information being used to sell you products and services, this was only a concern for a third of millenials (36%). There were also interesting differences in how they use digital health products – while 37% of millenials used health-related smartphone or tablet apps, only 19% of boomer did. While this may not be surprising, it does have implications for how providers may need to use different approaches to reach these different patient groups.

One thing that should be noted though, that despite the increased availability of chatbots, telemedicine, apps, smart speakers, and other ways one can get health information, the top sources are still the traditional ones: friends, family and your family doctor. In fact, while 53% of respondents cited medical websites as their most recent source for health-related information, the next two most common sources were medical doctors (48%) and family members (26%). Knowing someone, or having personal contact with a provider, may still carry more impact than a website that a patient may read, especially if this means they can make sense of conflicting articles they have read. Another item that differed wildly by generation was that while 83% of boomers said they “always listen to their doctor”, this was only 69% among millenials. On the other hand, 38% of millenials said they trust their peers more than medical professionals, while this was only 14% among boomers. There may be skepticism of medical professionals in this age group, and this may be an issue providers should focus on as millenials age in the age groups where health issues start to emerge. The implications for this could be important as well, especially if it results in non-adherence to medication, lifestyle changes, or people not following physician advice and guidance.

I highly recommend checking out the report in more detail and drawing your own conclusions, as there is a wealth of information contained within. I was drawn to the similarities and differences between generations, as this may point to a need to develop targeted and focused services for individuals at each age group to ensure they are engaged and empowered with accurate information to manage their health.

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By Junaid Nabi, MD, MPH, is a Research Associate in Surgery at Harvard Medical School, Boston (Twitter: @JunaidNabiMD). Thilmeeza Hussain is a former deputy ambassador of the Maldives to the United Nations (@Thilmeeza). Abhilasha Karkey, MD, DPhil, is a medical microbiologist at the Oxford University Clinical Research Unit in Kathmandu, Nepal (@abhilashakarkey). They are 2018 New Voices Fellows at the Aspen Institute, Washington, D.C.

Each one of us grew up in a region that is surrounded by such beauty that tourists from across the globe flock to see the marvels of nature. Whether it is the bright and snowy glaciers of Kashmir (JN), turquoise blue waters of Maldives (TH), or the imposing and majestic mountains of Nepal (AK) – each place signifies millions of years of natural processes that led to such unique landscapes.

Slowly, but surely, we are losing the places we grew up in; the places we call home. Unless global health practitioners work towards reducing global greenhouse gas emissions by 2030, the health of the global population is threatened as well.

The recent report by the fourth National Climate Assessment by the U.S. government and United Nations Intergovernmental Panel on Climate Change (IPCC) is a devastating reminder of what is at stake. The 700-page report declared that, as a planet, we have only 12 years to institute comprehensive international policies that protect the environment, before the damage to our environment is irreversible.

Every year, inch-by-inch, the shimmering glaciers in Kashmir are receding, the white sandy beaches of Maldives are eroding, and it is getting increasingly difficult—if not impossible—for people in Nepal to live alongside unstable weather changes that have engulfed the Himalayan range. Thousands of people are losing their homes, while countless others are losing their ability to make a decent living.

The response requires individual action and political will—both of which are lacking.

Our actions can affect everyone around us, including those in other countries (Photo by slon_dot_pics from Pexels)

To start with, as IPCC has suggested, reliance on fossil fuels and coal for industrial and infrastructure purposes needs to be reduced by 66 percent. That can happen only with international cooperation. Action on the part of ordinary citizens is no longer going to be enough to bring meaningful change, individual apathy is not the greatest threat to climate change. While we must continue to consume less meat, carpool when possible, and take shorter showers we should concentrate our efforts on bringing policy changes and electing officials into office who are willing to bring the necessary changes.

We are already witnessing the health effects of international political apathy. Antibiotic resistance, especially in chronic infections, is undoing the massive success global health has achieved in the last few decades. A recent study from the University of Toronto and Boston Children’s Hospital on the relationship between rising temperatures and antibiotic resistance reported that with rising temperatures, the probability of a person acquiring a drug-resistant infection is higher.

Dengue, a mosquito-borne infection that leads to significant disability and loss of income in low- and middle-income countries, has been effectively controlled through large-scale global health endeavors. Now, with rising temperatures, these projects may be jeopardized. Research on trends in global dengue incidence has revealed that infection rates have increased significantly over the last half century, and large part of this trend has been driven by rising global temperatures.

These changes put a particular stress on low- and middle-income countries as they often need to balance current healthcare needs with an impending healthcare crisis. Surprisingly, this rise in the dengue incidence is not limited to countries in the global south; these worrying trends threaten European countries as well, environments where lack of historical infections put their populations at significant risk. We don’t have the luxury of waiting to fix this.

In the remote hills of western Nepal, climate change is impeding healthcare delivery and threatening lives right now. We witnessed one such example recently: A 17-year-old girl in obstructed labor needed emergency care that local caregivers couldn’t provide. Landslides from the heavy monsoon rains had blocked roadways to the nearest hospital. The only option was to fly. The monsoon season was supposed to be over, but rain has become erratic these days—unpredictable and scary. The plane arrived safely—this time—whisking the girl and her mother away to the hospital. Ironically, the same airplane that saved her life is contributing to climate change. And what about the next time a patient needs emergency care? Will unpredictable rains prevent an air rescue?

Climate change is advancing more rapidly in the high Himalayas than in many other parts of the world, affecting both people and natural systems. Increasing temperatures mean shrinking snow caps and rapidly rising glacial lakes. More than 50 glacial lake outburst events have been recorded in the Himalayan region leading to flooding of pastures, damaging people’s lives and property in the mountains and also in downstream areas.

Around the tropical Maldives, beach erosion, coral bleaching, and contaminated freshwater aquifers show today’s toll of climate change—these changes will alter the natural history and symptomology of clinical conditions in this small island state. Clean freshwater is no longer available in many islands across the country, so people are relying on desalinated water or harvesting rainwater during monsoons—directly altering their way of life. South Asia as a region is especially vulnerable to climate change because of factors such as high poverty and low adaptive capacity.

Climate change, together with health inequality and infectious diseases, is a major challenge in public health in this region and around the globe. It is likely to influence mortality and morbidity due to mosquito- and animal-borne diseases, water-borne diseases, flooding and malnutrition.

It is essential to recognize that while the challenge of global warming may seem insurmountable, and the available time to act running out, we still have an opportunity to preserve the beauty and sustainability of our planet. This is our only home.

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About a year ago, my wife and I got a Sonos Beam for our house. With built-in Amazon Alexa, I thought this would be a pretty awesome way to interact with the TV, and would allow me to live out my dream of being on the USS Enterprise, asking Alexa to make me coffee, order groceries, and at the very least, start playing A State of Trance on Spotify.

After a year, I’ve realized a few things. One, Alexa can do a lot of things. Timers while you cook? Check. Turn the volume up and down? Check. Link to your thermostat? You got it. However, there are other tasks it can’t do so well. Do you want it to play music by Ricky Martin? It might read out the Wikipedia entry for the name “Martin” instead (true story).

Which made me very interested in this recent article in HBR, discussing the use of smart speakers in healthcare. See, smart speakers are very good at “discrete” tasks, where they can look up an answer in a database. Questions like “what is the weather tomorrow” works really well, because it can 1) check your current location, 2) pull up the weather for tomorrow, 3) read the weather for tomorrow. Very straightforward, and very simple steps. However, how does a voice assistant deal with complex data from health records?

Smart speakers can help you in your personal life – but how can they help improve the healthcare experience? (Photo by Caio Resende from Pexels)

That’s where the Innovation and Digital Health Accelerator (IDHA) at Boston Children’s Hospital comes into play. As a healthcare incubator, IDHA is well positioned to bring together key stakeholders to identify important questions, and then develop and test answers to those practical and applied healthcare questions. The article provides an example of 3 pilots that IDHA has rolled out – the ICU, organ transplant, and home health decisions. Each of these uses voice assistants to their strengths, helping enhance patient care. The example for the ICU is below:

The intensive care unit. In the health care setting, where sterile operating fields and infection control are priorities, hands-free, immediate access to information has big advantages in terms of safety and efficiency. IDHA’s voice deployment in the Boston Children’s ICU allows nurses to ask for key administrative information: “Who is the charge nurse on 7 South?” “How many beds are available on 8 East?” Clinicians are finding voice most useful for getting information that would otherwise involve picking up the phone, searching through documents, or walking down the hall. (Source)

What is perhaps the most striking is that physicians seem to be quite receptive to the idea of voice assistants in their practice. Of the paediatricians surveyed, 48% were willing to use voice assistants in their clinics, while only 16% were against it. However, there were concerns raised about how to roll this out – it would need to be done in a way that, if physicians were using the software, they could do it privately, without patients being able to hear them. The reasoning for this is twofold – the first is that they will use the responses to inform their clinical decision making, but ultimately they will make the decision themselves. The second is around patient privacy. Not only do they not want others to be able to overhear their conversation, they also want to know where the information is being uploaded, how it is being stored and secured, and how it can be accessed and by whom. While EMR’s and similar systems are being built with those in mind, voice assistants would need to follow the same privacy legislation laid out to ensure patients are adequately protected.

Windows 10 How-To: Hey, Cortana - YouTube

While I enjoy having a smart speaker in the house for personal use, the technology is still quite young and needs refinement before it can be used in professional settings, especially medical settings. However, with the speed of advancement that these products are making, this is the time to be thinking and planning how these devices can further enhance patient care and empower the patient experience.

Note: I’ve used “smart speaker” and “voice assistant” synonymously here, but there are nuances. A smart speaker is the hardware – which can be improved through better microphones, noise cancelling, beam forming, and other hardware upgrades. On the other hand, a voice assistant is like Amazon’s Alexa, Google’s Ok Google, or Apple’s Siri. This is a software agent that parses language and processes instructions, which is why sometimes Alexa can do something while Siri struggles, or vice versa.

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As we start a new year, every company and healthcare professional starts to think about what innovations the new year could bring. While some have very positive and innovative results, there are also risks we have to consider. Below, I’ve listed what I think are the five trends to watch in 2019.

1. Putting patients at the centre of our healthcare system

The patient perspective has been one that has been discussed for a long time, and is slowly becoming a normal part of any health-related project, whether that’s a clinical trial, designing a new hospital, or when designing healthcare policy. The mantra of “nothing about us, without us,” has taken hold, and is being used in very different parts of the healthcare system, with the same objective of ensuring that the patient/end-users voice is heard. At a systems-level, the Ministry of Health and Long-Term Care in my home province of Ontario, Canada set up the Patient and Family Advisory Council to help advise the province on healthcare priorities and ensure the patient voice was heard. At a hospital/provider level, Kaiser Permanente has 400 patient advisers serving on more than 50 patient advisory councils, ensuring that the patient voice is included at all parts of the care journey. From their website:

Advisers are brought together as local and regional councils that offer input and guidance in areas such as facilities design, leadership structure and physician hires. They often shadow a patient (with the patient’s permission) to better understand the care experience. Some councils have committees that focus on specific topics, such as maternity and child care, transgender issues, breast cancer experience and visiting hours.

Designing and implementing a patient engagement program does require work from all stakeholders involved. This excellent journal article in Clinical Trials by Bray Patrick-Lake delves into this in more detail, and provides recommendations for all stakeholders, research sponsors, and patient groups to provide practical advice when implementing this sort of initiative.

2. Using data effectively to improve outcomes

In almost every health-care setting, data is underpinning every conversation. Questions such as “where are the test results,” “have you had this test before,” and “how can we predict if this person will be back in the emergency room,” are ones with clear implications for healthcare providers, and with the power of data, can help improve outcomes for patients while simultaneously lowering costs for providers. One estimate from March 2018 suggested that around 30% of the world’s daily data production is healthcare data – lab test results, medical images, biopsies, medical claims, academic research, etc.

However, healthcare is still at the nascent stages of the Big Data Revolution. In industries such as banking, algorithms and models are already used to understand behaviours, and to predict what you will need next. Did you buy a new gym bag this January as part of your new years resolutions? In about a week (or less) you can expect emails from the same seller for new gym t-shirts, shorts, and other apparel to go with your new bag. However, we don’t have that same level of sophistication in healthcare (yet). Data exist in separate silos, with primary care records not liaising with hospital visits, and while your doctor might write a prescription for a medication, they have no way to see if you actually took the drug they gave you.

Once all these systems are integrated and able to talk to each other, the power is incredible. Healthcare providers will be able to map out the patient journey to understand how patients experience the healthcare system in the real-world, rather than just through their understanding of their role in the patient journey. With this, we will be able to answer questions like “how many patients visit their primary care doctor prior to going to the emergency department,” and “after discharge from the hospital, how many patients go back to the emergency without seeing another healthcare professional?” Some of these questions we might be able to answer now, but with limitations. With a truly integrated system, we will not only be able to map out the patient journey, we will also be able to then overlay these on existing patients to predict their likelihood of developing certain outcomes. If we know that 75% of the time, patients with conditions A, B, and C develop diabetes within 5 years, we can launch interventions to help them before they develop these outcomes.

3. Disrupting existing care paradigms

One of the biggest companies in the world made a huge splash last year by moving into the healthcare space. Amazon’s move to acquire PillPack, as well their filing of a patent to allow Alexa to pick up a cold or cough, shows they have a very ambitious targets for their role in the healthcare industry. To quote this article from CNBC:

So imagine you have a sore throat. You let Alexa know, and it responds by asking if you want to book an appointment at the doctor’s office or get a virtual consult. You pick the virtual option, and the doctor through Alexa asks you about your symptoms. It decides to send a courier to your home with a tiny portable device to do some basic tests for things like strep throat. The strep test is positive, so the virtual doc sends over a prescription for an antibiotic. (We’re assuming that all the Amazon services are fully compliant with privacy and other laws.)

The idea that Amazon already owns a lot of these services, or that they could likely acquire the missing pieces, shows where they think the healthcare system is going. And to be fair to other innovators in the space, they aren’t the only company pursuing this objective. Maple is a Canadian company that allows you to connect with a doctor using your phone, tablet or computer, all from the comfort of your own home. In 2019, we can expect more providers to start offering this as an option to an in-person visit, especially for follow-up visits for low-risk patients.

Come back next Monday for Part 2!

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