Patient engagement with muscle

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When Dave deBronkart (@ePatientDave) wanted access to his own medical record several years ago in the US, he didn’t just fill out a form requesting this information or politely ask the hospital involved, he went public in a big way, loudly demanding “Give me my damn data!”

While his act was not unique it can arguably be seen as initiating a new era of the muscular type of patient engagement currently prevalent in the US. These are patients who are not prepared to sit meekly and wait for an invitation to participate in decisions about their own health care or the health of patients in general.

Engaged patients are demanding their place at the health care decision-making table and have little patience for policy makers or conference organizers who want to keep discussions of patient engagement at theoretical level.

Look at the growth of the #patientsincluded movement in which conferences globally are being told they should include patients at all levels of planning and presenting health care information in a way that accommodates patients.  Anyone who dares hold a conference on patient engagement without having patients on the planning committee and speaker list risks being loudly shamed on social media. Even one element of #ehealth2017 has not been spared such criticism.

Similarly, recent discussions on social media are asking very pointed questions about why patient are often the only ones at the table who are not being paid for their time to provide their input.

This new form of patient engagement is transforming how health care is being planned and delivered in Canada but frankly we still trail the US in truly integrating this approach. Canada has several engaged patient leaders but none with the profile of their American counterparts.

Which bring us to the June 2 pre-conference symposium on Consumer Digital Health at #ehealth2017.

The keynote speaker will be Lygeia Ricciardi (@Lygeia), a US based expert in consumer engagement and digital health. Lygeia established and directed the Office of Consumer eHealth at the Office of the National Coordinator for Health IT (ONC) in the US federal government and is a compelling speaker. The presentation promises to deliver an update on major emerging trends in patient engagement

COACH, Infoway and the Canadian Institute for Health Information (CIHI) will follow Ricciardi’s keynote address with breakout sessions on different aspects of empowering healthcare consumers. This symposium should provide an invaluable snapshot of where Canada will be heading in the next few years.

Health Quality Ontario (for which I work), is currently one of the national leaders in providing the tools and infrastructure to meaningfully involve patients in health care decision-making.

It’s not a straightforward or easy task.

As Health Quality Ontario CEO Dr. Joshua Tepper wrote in @HealthyDebate blog post two years ago, “simply ‘commanding’ or ‘expecting’ health system providers and leaders to engage with patients is unrealistic.

In addition, he noted, “the patients we need to hear from the most are often the hardest to reach. Those who face economic, social, language, cultural, physical and psychological challenges to engagement will need thoughtful and respectful partnership efforts.”

For all of this, he concluded “courage is going to be a pre-requisite.”

Even as more patient involvement in health care planning and delivery is mandated in legislation and becoming embedded in the culture of quality care in Canada, hearing from US experts like Ricciardi is important to help us map where things are heading.

In a digital world, health care delivery models may be determined by jurisdictions but trends such as patient engagement effortlessly cross borders and Canada’s engaged patient community are quick to learn from their peers elsewhere and apply the lessons here.

Broken windows in the house of medicine

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At a time when physicians are feeling besieged from all sides it hardly seems fair to write about the lack of civility demonstrated by some members of the profession on social media.

But it’s still an important issue that needs to be addressed – with the caveat that no profession or segment of society is blameless when it comes to such behavior and the focus is due to the focus of this particular blog.

The post is prompted by a recent workshop held at the annual Canadian Conference on Physician Leadership (#CCPL17) held in Vancouver titled “Professionalism and respect within the profession: demonstrating leadership and creating a safe space for debate”.

The good news from the discussion: social media is not to blame for outbreaks of incivility and bullying which can occur between physicians. The bad news? Incivility appears to be rampant throughout medicine and has yet to be satisfactorily addressed.

The impetus for the workshop was a fracas on social media last summer associated with a vote on a proposed fee deal for the Ontario Medical Association which saw a leader of the OMA student association subjected to threatening social media posts, and the subsequent public attention drawn to the dispute,

The decision was taken by conference organizers in Vancouver not just to focus on physician behavior on social media but rather to look at incivility and bad behavior in medicine in general and work being undertaken by the Canadian Medical Association (@CMA_docs) to address this in the spirit of professionalism.

During the discussion, Dr. Michael Kaufmann, the recently retired head of the physician health program in Ontario noted he dealt with problems caused by incivility between physicians on a weekly basis. It was also stated that hundreds of physicians across the country have been or will found guilty of unprofessional conduct by demonstrating disruptive behavior.

“The lack of civility in the medical profession is mindboggling,” is how one physician audience member described the scope of this behavior. Or, as Dr. Kaufmann put it more poetically, “we have some broken windows in the house of medicine.”

So, while social media is clearly not to blame for doctors behaving badly the point was also made that social media can breed incivility by prompting spur-of-the-moment outbursts, misinterpretations due to the sketchiness of the posts, and in some cases, the dimension of anonymity.

With the medical profession feeling under attack from all sides, views that break ranks with the majority are going to be challenged, often emotionally. Students and recent graduates are often the most common targets because they are said not to understand the realities of the situation.

The problem is that social media is not designed to promote measured, respectful debate.

“We will tell you when you can speak and what you can speak about,” is how panel member Dr. Dennis Kendel (@DennisKendel), a Saskatchewan physician and active tweeter described the response when he was seen as questioning that pro-physician unity.

Sadly, social media continues to be severely underused by physician as a professional tool for information gathering and networking (despite being used by peer leader in many areas).

It is also clear that the rules of engagement on social media platforms by their very nature can aggravate instances of poor communication and cause difficult situations to deteriorate.

Despite encouraging social media use at the Vancouver conference, organizers and speakers appeared very cognizant of this. Witness the fact that more than once, delegates were cautioned against tweeting certain remarks or asked to do so with a degree of exquisite sensitivity rarely taught professional journalists let alone well-intentioned civilian commentators.

Well, as the late Hunter S. Thompson might have remarked, this particular missive seems to be drawing to a close without pulling together all the narrative threads as required.

So:

  • It’s a tough time to be a physician
  • It’s a tougher time to be a young physician with unpopular views
  • It is to be hoped the CMA initiative will have an impact
  • Social media is impacting discourse across society in positive and negative ways we have yet to fully figure out.

(A) I, Radiologist

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Born of the discovery of the x-ray by Wilhelm Roentgen in 1895, the specialty of radiology is suddenly facing perhaps its greatest challenge with advent of artificial intelligence (AI) and machine learning.

Radiologists who have adapted to all manner of new diagnostic modalities over the generations now find themselves facing the prospect of machines which read and interpret imaging results quicker and more accurately than they can.

The Canadian Association of Radiologists (@CARadiologists) recently held its 80th annual meeting in Montreal and among the posters was one advertising that next year’s meeting would focus on AI. One wonders, given the speed with which AI and other technologies such as 3D printing are transforming radiology and medicine in general, whether next year is maybe too late to grapple with the issues raised.

The program committee of the CAR may have unconsciously acknowledged this as many sessions at this year’s meeting dealt with advanced technologies and at least two speakers dealt directly with the future role of the radiologist.

In addition, one of the highlights of the exhibit hall was IBM Watson Health (@IBMWatsonHealth). Last year, IBM created the Watson Health medical imaging collaborative, a global initiative with more than 26 leading health systems, academic centres, and imaging companies (they are currently looking Canadian participants) to bring cognitive imaging into daily practice. Earlier this year, IBM launched the Watson Imaging Review to reduce practice-pattern variation and reconcile differences between a patient’s administrative record and his or her clinical diagnosis.

One of the IBM staff was heard telling a CAR delegate, Watson “is not here to take your job away, it’s here to make your job easier.”

Presentations on AI and machine learning were matched by discussions of 3D printing, another technology currently transforming radiology and health care delivery.

Dr. Frank Rybicki, chief of radiology at the University of Ottawa and chief of medical imaging at The Ottawa Hospital, gave a comprehensive overview of how 3D printing is transforming many areas of medicine. The Ottawa Hospital recently opened the first 3D printing program based at a Canadian hospital.

Dr. Rybicki predicted that soon every hospital would have such a program as 3D printing moves from niche interventions to a leading role in reconstructive surgery, and cardiovascular and neurological interventions as well as supplying models to improve physician-patient communications and reducing peri- and post-operative complications.

“3D printing is the information delivery system of the current radiology generation,” he said, such as the young radiologists from Memorial University of Newfoundland who presented a paper showing the value of 3D printing of blood vessels to help educate the public and medical students.

It was a past-president of CAR, Dr. Ted Lyons from the University of Manitoba who bluntly outlined the future facing radiologists as a result of all these changes.

He noted that one of the fundamental roles of radiologists – reading and interpreting x-ray film – has almost already totally disappeared with the advent of PACS (picture archiving and communication systems).  By 2035, he predicted, all x-rays, CT scans and MRIs will be read and interpreted by machines.

The way forward for radiologists is twofold according to Dr. Lyons; firstly by becoming more than a “faceless name” who interprets images in a darkened room and being more directly involved and engaged with other clinicians and patients at the bedside. The second fundamental need, he said, is for radiologists to become data scientists and lead the integration of AI into radiology practice.

Dr. Lyons presentation was complemented later in the meeting by a presentation from a SickKids Hospital, Toronto radiologist Dr. Erika Mann who reiterated how radiologists need to become more patient-centred if they wish to remain relevant.

 

 

Is failing to use an EMR unprofessional conduct?

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It has come to this.

Some hospitals in Toronto are starting to use virtual reality in patient care (to help ease pre-operative anxiety). Yet, there are still family physicians in the province using paper charts to record and monitor the health of their patients: Not many for sure and far, far fewer than a decade ago an (an increase from 37% to 73% between 2009 and 2015).

But nonetheless, in an era where the health technology envelope is being pushed harder and faster than ever before, the most recent international comparison of use of electronic medical records (EMRs) by family doctors shows Canada continues to lag behind countries such as the U.K. and New Zealand where use is almost universal.

This finding comes from a study released earlier this year by the Canadian Institute for Health Information (CIHI) in partnership with the Canadian Institutes of Health Research, and with co-funding from Canada Health Infoway looking at data from the Commonwealth Fund 2015 survey of 10 countries.

Maybe the time has come to seriously ask whether the acceptable standard of care for family doctors practising in Canada involves using an EMR and that failure to do so could be seen as failing to maintain that professional standard.

It is a question that was first asked quietly more than a decade ago, back in the twilight era when only the most forward looking physicians and jurisdictions were using EMRs routinely. Now, when EMRs have hugely increased functionality and proved their value in efficiently managing the health of populations, the question can surely be asked with more authority.

Of course, nobody wants to force some physicians to use technology they don’t like, don’t understand, and which can sometimes lead to gross inefficiencies in the use of their time. In fact we can imagine there may be parts of the country where a physician still cannot even purchase a reliable EMR. And we in Canada still struggle with interconnectivity and many family doctors remain stranded on ‘electronic islands’ unable to use their EMR to communicate effectively with others in their community.

But the reality is that electronic storage of patient data is here to stay whether the medical profession likes it or not.  With almost three quarters of Canadian family physicians now using EMRs for patient care the time has to come to ask medical licensing authorities whether they need to apply more diligence to observing those doctors who choose not to rely on paper records.

The failure of family doctors to totally embrace electronic records is hindering both patient care management and population health management. Even of those who use EMRs, the CIH report notes fewer than half routinely use the system for at least 2 of the following: electronic alerts or prompts about a potential problem with drug dose or drug interaction; reminder notices for patients when it is time for regular preventive or follow-up care; alerts or prompts to provide patients with test results; and/or reminders for guideline-based interventions and/or screening tests.

Surely the time has come for this to change.

Teledermatology: Every picture tells a story (#AAD17)

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One can imagine the era of modern telemedicine beginning with dermatology.

“Hey, I have this rash. Mind if I e-mail you a picture so you can tell me how to deal with it”?

While teledermatology can actually be a far more complex and sophisticated interaction between patient and doctor, that core ability to send an image of the key diagnostic feature is what has led some dermatologists to be involved in telemedicine for almost two decades now.

And with telemedicine and virtual medicine now entering prime time, it is not a surprise that more dermatologists are focusing on teledermatology as a way to allow more people to access quality care.

What is somewhat more surprising is that fact that after two decades of practice, the dermatology specialty still lacks a good remuneration model and more importantly agreed upon standards for how quality care should be delivered.

The recent annual meeting of the American Academy of Dermatology (#AAD17) meeting in Orlando provided a snapshot, if you will, of all these issues. Not only was teledermatology the focus of at least two educational sessions, it was also the subject of one of the plenary named lectures.

In her plenary presentation, Dr. Carrie Kovarik (@carriekovarik), associate professor of dermatology at the University of Pennsylvania and a

teledermatology pioneer, gave a blunt assessment of telemedicine in her specialty.

“There are people in the middle who see teledermatology as a good thing when it is used to provide quality care and provide access,” she said in an interview published in the conference newsletter. “Unfortunately, there are also people on one end of the spectrum who think this is a way to make a lot of money and sell products. Then there are people at the opposite end who are afraid that telemedicine is eventually going to take away their patients.”

If that was the bleak overview of telemedicine within the speciality, Kovarik’s assessment of how unprofessional and unethical websites are exploiting patients by offering teledermatology services was worse. “We have businesses that have scaled-up teledermatology using non-dermatologists, anonymous apps and apps where the patients have to self-diagnose.”

Despite the potential value of teledermatology for improving access to underserviced areas and populations through the U.S., in her speech Kovarik noted only 12 States currently reimburse specialists for the “store forward” approach in which pictures of a patient are assessed after they are taken.

Another challenge is that in many instances the patient’s primary care provider receives no payment for helping facilitate the process by, for example, taking high-quality images of the patient for the dermatologist to assess.

However at the end of the day, despite all these challenges, Kovarik predicted it would be harder and harder for dermatologists to avoid telemedicine.

The key she said was to ensure the quality of care provided is the same as that seen in a face-to-face encounter.

 

A death on Twitter

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I was on a train moving through the darkness of Eastern Ontario between Toronto and Ottawa when I saw the notification on Twitter that the body of Dr. Elana Fric-Shamji, a family physician at Scarborough General Hospital in Toronto had been found.

It was news that hit the small but active community of Ontario doctors using social media very hard because Dr. Fric-Shamji had been one of them.

For a couple of hours before the announcement of the body’s discovery there had been uneasy communications between some on Twitter after a news report that she had been reported missing. Those worried comments were quickly followed by expressions of sadness and dismay.

Her Twitter account reflected the vibracy of an individual who was enjoying playing with the media as well as becoming more engaged in the local politics of medicine in Ontario.

“What can I say, I love Lord of the Rings,” was her final tweet.

Days earlier, Dr. Fric-Shamji had found Twitter fame (such as it is) with a tweet posted as part of the #trudeaueulogies hashtag mocking Canada’s Prime Minister for praising Fidel Castro at his death, without remarking on the negative qualities of his rule.

“Saddened about the passing of Sauron who, while heavy-handed, did advocate for open borders and usher in industrial era,” tweeted Dr. Fric-Shamji in a tweet that yielded 622 retweets and 945 likes. (For those needing an explanation, Sauron is the main villain in Lord of the Rings)

A week previously, Dr. Fric-Shamji had participated in the council meeting of the Ontario Medical Association – the body which represents the province’s physicians. It was a cathartic meeting for an organization badly torn recently by internal divisions on how to deal with a government unwilling to negotiate on equal terms.

It is also an organization whose members have made transformative changes through the use of social media, and especially Twitter, as internal advocacy and networking tools.

Many who were in attendance at that meeting remembered Dr. Fric-Shamji and her excitement with her new roles and opportunities – in both the professional and personal spheres.

“Proud to represent #Scarborough physicians at #OMACouncil16,” she had tweeted. “Unity, change and advocacy on the agenda.”

The day after the announcement of her death, the Ontario Medical Association issued a news release from President Dr. Virginia Walley, also posted to Twitter, noting how the “close knit community” of Ontario doctors was stunned by the “tragic news” of her untimely death.

That community is now looking for a way to honour Dr. Fric-Shamji’s legacy and help her three surviving young children.

It took a couple of days for the print media to catch up but local and national newspaper are now filled by the story of her death and news that her physician husband had been charged with her murder.

Dr. Fric-Shamjii is not the first of the Twitter physician community to die this year.

Dr. Kate Granger (#hellomynameis) passed away after arguably bringing more humanity to the provision of medical care in the U.K. by asking those providing care to identify themselves by name. Tens of thousands have been touched by her message and her last days of life.

And there were others.  Dr. David Lewis (@DrPlumEU) who died a few years ago, for instance, lives on through his Twitter account which continues to curate news content based on parameters set by Dr. Lewis himself.

I did not know Dr. Fric-Shamji personally and I am not a physician but I was one of 157 people she followed on Twitter … and I followed her.

I felt a few words should be said from here.

Walk and chew gum @Helenbevan? I fear not

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Is it possible to walk and chew gum at the same time?

Helen Bevan, the leading expert in transformative change for the U.K.’s National Health Service recently posed a similar question to an audience at a major health policy conference in Toronto, Canada and the answer, unfortunately, was ‘no’.

The actual issue raised by Bevan had nothing to do with ambulation and mastication but rather with the potential to listen and comprehend a speaker while simultaneously engaging with others in a discussion of the speaker’s comments on social media.

Results of the real time experiment seemed to suggest there is a limit to the amount of engagement even the most dedicated networkers can undertake with one of the best social media tools – Twitter – while also paying attention to an absorbing presenter.

At her suggestion, a few people tried gamely to discuss issues raised by Bevan on Twitter while she was still speaking, but these conversations quickly petered out as those in the audience returned their attention to Bevan, and directly tweeting her comments.

What Bevan definitely did not do was undermine her argument about the power of social media to expand the dissemination of the important ideas – even though this exercise may have provided fuel for those who argue that live tweeting distracts from taking full benefit from listening to speakers at conferences.

Watching a graphic representation of tweeting during Bevan’s plenary address at the Health Quality Transformation conference is like watching a fireworks display as Bevan’s point on the map explodes as hundreds of tweets referencing @HelenBevan and her presentation spread out over the map during the hour of her talk.

The growing power of the type of informal networks that social media platforms support to make real change in the health care system was one of the key themes in the multiple keynote and more informal presentations Bevan made while attending a number of meetings hosted by Health Quality Ontario.

She also talked about the importance of the new connectivity these social media platforms provide to link people within organizations as well as nationally and globally.

But Bevan’s impromptu attempt to get people to participate in multi-task engagement suggests there are some limits to what even social media can accomplish if you ask that it all happen at the same time.