Virtual care use ignited by #COVID19 pandemic

Massey2

The COVID-19 pandemic has provided the opportunity for Canada to go from “worst to first” in using virtual care and assessing its impact.

That’s according to Dr. Sacha Bhatia (@sacha_bhatia), FM Hill Chair in Health Systems Solutions and the Chief Medical Innovation Officer at Women’s College Hospital in Toronto and currently one of the country’s more eloquent advocates for virtual care.

Dr. Bhatia made the comment during his participation in a virtual discussion hosted by Massey College. The Massey Dialogues session was hosted by Principal Nathalie Des Rosiers and also featured former University of Toronto medical school dean Dr. Catherine Whiteside and Massey fellow and medical student Krish Bilimoria (@KHBilimoria).

In addition to virtual care, the wide-ranging discussion also touched on changing attitudes towards sharing patient data and the need to adjust medical education to prepare new physicians to practise in a virtual environment.

Dr. Bhatia noted the approach and attitude of physicians towards virtual care has changed significantly in the last couple of months because COVID-19 introduced new risks to physical contact for both physicians and patients. “In some ways the COVID pandemic was the match that lit the fire around this revolution in virtual care,” he said.

When it was announced that half of all patients visits in China would be conducted virtually when the pandemic was at its peak in that country, many viewed this as being unattainable. But now, he said, 70% of patient consults in some areas of Canada are occurring virtually and in some instances the use of virtual visits has grown by 780%.

The paradox that Canada has been a pioneer and is admired globally for developing telemedicine to service remote and isolated communities but lags other countries in integrating virtual care into routine practice was touched on.

Dr. Bhatia said “tremendous inertia” against using virtual care in most physician practices in Canada was coupled with concerns about patient privacy, quality of care issues and “the elephant in the room” – adequate remuneration for virtual consults.

With the significant growth in virtual care, Dr. Bhatia said an important issue now is determining the impact of this on the quality of care and outcomes. “This has happened very fast and we don’t know what the impact of that is going to be,” he said.

“There was a rush for us to do this to protect our patients and providers … but now if we’re going to make it sustainable we need to do the research to begin to understand what the impact of that has been. Canada has an opportunity here to be a real leader internationally in understanding the impact of virtual care and changing the care model.”

Many standards of practice for virtual care have not yet been fully developed, Dr. Bhatia acknowledged.

“There are a lot of conditions for which we are making up as we go to be perfectly honest”

As a medical student, Bilimoria said questions now have to be asked about how clinical skills and evaluation will have to change to adapt to virtual care models. “How do you evaluate and assess patients virtually?”

(The importance of adapting medical education to deal with virtual care is a key but underappreciated part of the Virtual Care Task Force report released earlier this year by the Canadian Medical Association, Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada)

“I think medical student involvement at all levels from education to research is going to be absolutely critical,” said Dr. Bhatia.

Dr. Whiteside said another component of the current reshaping of care delivery is digital care and the challenge of allowing patients to have access their own medical records while at the same time allowing those involved in their circle of care to also share the information. She noted that privacy legislation in various jurisdictions across the country is being opened up so access to data can be more patient-centric.

With the COVID-19 pandemic, Dr. Bhatia noted “research and practise are effectively occurring in real time” and this makes it even more important that new models for collecting and sharing data are put in place.  “Using research will actively help develop new treatments and new approaches that will potentially help save lives not in six or seven years from now but literally next month.”

He said there needs to be a much more pragmatic approach to how we think of data and privacy and that the public must be engaged in that conversation.

All participants in the discussion raised the issue of equity and concerns that virtual care is not necessarily being provided in an equitable fashion. Dr. Bhatia said this is of special concern given data that marginalized groups are already being impacted to a greater degree by COVID-19.

However, Dr. Whiteside said “COVID is enabling us to actually get closer to that kind of productive and positive relationship that we need to really move the agenda forward for access to data (and) engagement of patients and their caregivers in decision making”

The full Massey Dialogues session can be accessed here.

The (healthcare) social CEO: Now more than ever

SocialCEO

The social CEO: Now More Than Ever

Social media can make you a stronger healthcare leader – especially in times of crisis such as the current #COVID-19 pandemic.

One need only look to individuals such as @DrJoshuaTepper, the current president and CEO of North York General Hospital and former CEO of Health Quality Ontario. Over the past few years, Tepper has shown seemingly effortlessly how he uses Twitter to engage with different audiences, espouse views that matter to him, and amplify messages from the organizations which he is represents.

But Tepper and others like him continue to be the minority in the Canadian healthcare system.

Which is why Damian Corbet’s book The Social Ceo: How Social Media Can Make You A Stronger Leader (@TheSocialCsuite) released last year is particularly relevant. In the book, Corbet provides strategies and techniques leaders can use to develop and maintain strong social media platforms.

Corbet also provides a number of first person case studies of CEOs in various industries who have harnessed social media to advance their agendas. For the healthcare sector, Corbet could not have chosen a better voice than that of Julia Hanigsberg (@Hanigsberg), the President and CEO of Holland Bloorview (@hbkidshospital) in Toronto.

As with Tepper, Hanigsberg, has proven adept at using social media and especially Twitter to develop a respected presence and expand her role as CEO to incorporate new communications channels.

As she writes in the book, “my approach has been to use social media as an extension of transparency in my leadership … If you imagine the quintessential open-door leadership approach, how much more effective is it if that door is open to all of Twitter?”

Hanigsberg

CEOs such as Hanigsberg and Tepper have been able to use their strong presence on Twitter and other social media platforms to become trusted and credible voices when it comes to COVID-19.  It is easy to find many other good examples in Canada such as @AlexMunter, the president and CEO of the Children’s Hospital of Eastern Ontario and relative neophyte social media presence @BrucePSquires, the President of McMaster Children’s Hospital.

In national or provincial healthcare organizations examples again are easy to find, such as @DorisGrinspun, CEO of the Registered Nurses Association of Ontario and @EGruenwoldt, President and CEO of Children’s Healthcare Canada.

They all bring an an authentic presence, transparency, and credibility to the discussions taking place.

But social media is not for all healthcare CEOs.

If it does not fit your personal style and if you do not have the support of a strong communications team, social media can be at best an onerous additional burden and at worst a public relations nightmare. Communications staff can help with providing strategic guidance and monitoring of social media accounts but those CEOs who abdicate their personal accounts totally to the control over others are missing the point, big time.

It needs particular skills and presence to be willing to put yourself forward on social media and to be the target of every member of the public (and/or staff) who are unhappy about your particular organization. Also, in many Canadian organizations and associations, the CEO is not the official spokesperson for the group and that often precludes them having a strong professional role on social.

Some healthcare organizations such as Michael Garron Hospital in Toronto took an organized approach some years ago and trained the C-Suite as a unit on how to use social media effectively. This paid off with individuals such as hospital VP @IreneAndress continuing to use Twitter to great advantage.

However, many healthcare organizations continue to struggle to develop comprehensive social media strategies and find a fit for the CEO in those strategies.

After reading Corbet’s book I quickly roughed up a list of pros and cons for healthcare CEO involvement on social media:

Why the CEO should be on social.

  • Raise profile of CEO as chief spokesperson for the organization
  • Amplify work of the organization
  • Provide a more personalized approach
  • Permits more engagement with others than corporate account
  • Potential to increase credibility of the organization
  • Provide ability to network/connect with other senior-level health care administrators
  • Allows use of other social strategies such as tweet chats
  • “Go where you stakeholders/constituents are”

Challenges/drawbacks

  • Needs personal attention to be effective (e.g. posts not done by corporate staff)
  • Can be time consuming to monitor and manage
  • Can open CEO to attacks and unpleasant interactions
  • Can raise unreasonable expectations from those expecting direct action from CEO
  • May not match personal style/approach of CEO

As noted above, social media is not for all CEOs.

But for those or are interested and looking for a handy primer, The Social CEO is a good, current primer.

Help for the helpers: #Covidwellness tips

Emily

Last Thursday evening, a small but dedicated group participated in a #COVIDWellness tweetchat and shared tips and advice for supporting healthcare providers during the current COVID19 pandemic.

Organized by @ChildHealthCan, the chat was co-hosted by @BrucePSquires, president of McMaster Children’s Hospital, @DrGigiOsler, past-president of @CMA_DOCS, and @KathyReid5, nursing leader at Stollery Children’s Hospital.

The hosts and others shared not only useful information on dealing with today’s situation but also for one hour created a positive community

Much of the information provided reinforced what other credible individuals have been saying about maintaining good mental and physical health during this time while striving to stay safe but connected.

A small sampling from the chat follows:

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Twitter in the Age of #COVID19

Coronavirus-CDC

In this the year of Our Lord 2020 we truly are seeing the power of Twitter and social media.

As individuals around the world struggle to cope with physical distancing and social isolation, Twitter and other mainstream social media channels have become major conduits for information and networking and are arguably strengthening many people’s mental health by helping ward off isolation.

Just as the spread of COVID-19 has been enabled by our global culture and ability to span the world in hours, so the global reach of social media has enabled people to stay in contact and informed even as they are confined to their homes. And COVID-19 is very definitely where it is at right now. Ninety-five percent if not more of the tweets now appearing in my feed from the 4,000 plus people I follow (admittedly mainly health-care related), deal with COVID-19 issues.

However, it is well worth remembering that Twitter and the like are just media platforms and are neither inherently good nor bad. And so, along with enabling better communications and interactions, social media platforms are once again showing with the COVID-19 pandemic how easy it is to transmit and amplify erroneous and downright dangerous information.

Another challenge is the asynchronous, ominpresent, yet selective nature of social media. Tweets are appearing in my feed that first appeared 3-4, if not more days ago – not a good thing given the fast-moving nature of what we understand about this pandemic. Information about outbreaks, number of cases, and availability of badly needed health care supplies needs to be timely to be useful and that is often not the case with what is appearing on social media.

Also, tweets are appearing from around the world – another challenge for those of us in countries such as Canada where public health measures and other badly needed information is determined at the provincial level. Much of what we are seeing is not relevant to our own situation and can be misleading.

Social media such as Twitter allow us to choose who we follow. This selection bias means we are not getting the whole picture and can be misled about what is going on in the world around us – another critical failing if we are isolated at home. The good news is that in a stream such as mine which is so heavily health-care focused, many good people are retweeting solid scientific evidence or opinion from others I am not following directly. Unfortunately, I am sure people in other echo chambers are having poor or inaccurate information amplified. And for those of us who spend their time predominately on social media and dealing with health care in Canada we need to remember the vast majority of physicians and other health care professionals have neither the time nor interest in social media, thereby limiting our ability to view what they are contributing.

Yet, I believe my Twitter worldview to be fairly balanced. For every picture of people ignoring social distancing and filling the beaches of Sydney, Australia or Clearwater, Florida there are pictures of dedicated health care workers going about their work.

Unfortunately the unprecedented situation we find ourselves facing this pandemic have caused some to forget the basic principles of being on social media – being transparent, accurate and respectful: And in the case of health care, respecting patient privacy and confidentiality especially if that person is a physician or healthcare worker infected as a result of their work.

With social media potentially being the window on the world for many of us for some time to come those principles of human conduct which have served us so well in other avenues of life should remain top of mind.

(Image from the CDC)

 

 

 

 

 

 

TikTok – Time for physicians to pay attention?

Naheed

Meet Dr. Naheed Dosani (@NaheedD), a palliative care physician at the William Osler Health System north of Toronto and arguably Canada’s first TikTok physician superstar.

Since the beginning of the year, Dr. Dosani has been using the new social media platform to educate the public about palliative care and end-of-life issues. With more than 6,000 followers since January, his posts have more than 400,00 views and some of his videos have received more than 800 comments.

Describing itself as “a destination for short-form mobile videos”, TikTok is a Chinese-owned app that was launched in 2017 and has become hugely successful, especially among young people, as a place to post short-form lip-synch videos and act-out memes. Not surprisingly, in the short-time of its existence, some physicians and health care organizations have been quick to take advantage of TikTok to spread their messages.

Some of the medical profession’s initial forays into TikTok have proven controversial while other physicians in the US are garnering thousands of followers and millions of views for their humorous but informative posts.

As a recent New York Times article noted:

Although medical professionals have long taken to social media to share healthy messages or promote their work, TikTok poses a new set of challenges, even for the internet adept. Popular posts on the app tend to be short, musical and humorous, complicating the task of physicians hoping to share nuanced lessons on health issues like vaping, coronavirus, nutrition and things you shouldn’t dip in soy sauce. And some physicians who are using the platform to spread credible information have found themselves the targets of harassment.

One of the most high-profile of these cases was Dr. Nicole Baldwin, a pediatrician in Cincinnati, who had a TikTok post about vaccine-preventable diseases and countering the notion that vaccines cause autism. She received a number of threats through her social media accounts including one that said “Dead doctors don’t lie.”

The activity prompted one of medicine’s most astute students of social media, Dr. Bryan Vartabedian (@Doctor_V) to write several blogs (@33charts) about the platform and comment “When you look at what Dr. Baldwin went through after this simple video it might make you wonder why any doctor would participate in this kind of thing.”

He added:

So is this kind of education and personal exposure still a physician’s obligation? I have to wonder. Dr. Baldwin’s experience is not what health professionals deserve when they decide to join the public conversation. While bullying isn’t new, I always believed that the crowd would correct the rogue outliers – regulation wasn’t necessary. But the anti-vaccine misinformation warfare unit increasingly defies all normal social forces. 

In a follow-up post, he noted “nobody cares about TikTok. Just like no one cares about electricity,” noting it was the connection social media brings that people care about,and not the platform.

I recently asked Dr. Dosani (via Twitter of course) about his experiences with TikTok:

What prompted you to try Tik Tok in this way? 

I’ve always been active on social media, especially Twitter. Over the years, I’ve found it to be an important way to connect with likeminded people who are interested in issues related to palliative care and social justice in healthcare.

When I learned about TikTok, I was intrigued by the opportunity to build this community with general audiences in a creative and engaging way. Particularly with an audience so ready to learn more about the topics I am focused on as a physician.

What has the feedback been from your peers and others- good or bad?

 I have been encouraged by the response from my peers who also value the importance of public education on palliative care and social justice issues. Those of us working in palliative care routinely explain what we do with our patients, families and sometimes even health professionals.

This platform has provided a powerful opportunity to broaden the conversation through brief, bite-sized bits of credible information.

Do you think this platform works for a topic such as palliative care?

Absolutely. While dying and death is something that affects us all, palliative care is still a relatively unknown or misunderstood area of care. I’ve been overwhelmed by the response to my posts so far. I have heard from thousands of people who have shared their support and their experiences. This encourages me to keep the conversation going and hopefully reach people who will benefit from a greater understanding of palliative care and social justice.

While Dr. Dosani is one of the first Canadian physicians I know of to take advantage of TikTok others have been quick to find time for the new platform.

Most recently the World Health Organization has partnered with TikTok to circulate information about COVID-19TikTokWHO

With every new popular social media platform there are some within medicine and health care who will be quick to sense its value. While some like Twitter prove of lasting value, others like Snapchat have proven much more limited in adding value.

As always, for TikTok, time will only tell. But physicians like Dr. Dosani are certainly help show the way.

Doing virtual care right: Organized medicine in Canada speaks up

Virtualcare

A major new report on virtual care in Canada is significant not only for its (extensive) content and recommendations but perhaps more importantly for who compiled and released the report.

The report comes from a task force representing Canada’s three main national medical organizations – the Canadian Medical Association, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada – working in an almost unprecedented collaboration. Given that the report also had the involvement of patients, families and caregivers, it merits receiving serious attention.

Rather than attempt to tackle digital health as a whole – which would arguably include AI, genomics, 3D printing and any number of other technological advances – the task force focused just on virtual care which it defines as “any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies, with the aim of facilitating or maximizing the quality and effectiveness of patient care.”

The mandate of the task force was to “to develop strategies and recommendations for promoting the delivery of publicly insured medical services — by the Canadian medical community — through virtual means.”

The report contains a very comprehensive overview of the history and current status of virtual both in Canada and elsewhere but what is most striking is the outlook taken by task force members and the recommendations that arose from that outlook.

The task force makes it clear a national framework is required to advance what the report sees as a clear requirement to incorporate virtual care into the publicly funded health care system.

Without such a framework, the task force cautions “there is a risk that a series of fragmented virtual care services will be established that detract from continuity  and potentially lead to quality of care issues.” However, the report does acknowledge work already being done at the federal as well as the provincial/territorial levels to advance virtual care and urges that the task force recommendations should build on these initiatives.

“While the majority of Canadian physicians’ offices and health care facilities now use some form of digital record keeping, and a majority of households have Internet access, there is a long way to go in terms of the use of digital technology to provide publicly insured, virtual care,” the report states. It also state that “consumer demand and the ability to improve access mean virtual care will become more and more prevalent in the Canadian health care system” but notes this “will remain fragmented and be delivered inequitably unless appropriate steps are taken.”

Task force members are also firmly committed to the concept that virtual care should be incorporated into the continuity of care provided by existing health care teams – rather than being offered as separate services. However, the task force acknowledges the nuances of what virtual care can do, stating “although virtual care has the potential to increase access to medical and health care, it also has the potential to exacerbate inequalities in access to care, both in terms of geography and socioeconomic status.”

The patient focus on the report should not be understated. “Notions of patient ownership of health information and actual access to information are often at odds,” the report notes, adding “Canada lacks national standards to support patients having electronic access to their health information wherever they are in the country.” This led the task force to adopt the principle that “in a virtual care ecosystem, patients and family should have digital access to their entire suite of health information (health and social services) according to managed protocols that uphold ownership, custodianship, autonomy, security, privacy, data integrity and quality care.”

The report also acknowledges the additional pressures that working in an electronic environment and can place on the medical profession. “These concerns are real, but can be mitigated by a considered approach to health information technology design and deployment that supports user-friendly workflow and by ensuring requirements to deliver virtual care do not place additional burdens on the medical profession. The report also contains has a major recommendation for addressing remuneration to encourage physicians to use virtual care platforms.

Overall, the report contains far more than the summary above and the summaries of the deliberations of each of the task force working groups; interoperability and governance, licensure and quality of care, payment models, and medical education, each merit a closer read.

 

AI and the Canadian doctor

Naylor

In the deluge of recent presentations on artificial intelligence (AI) and medicine,  one of the more relevant for Canadian doctors came at last month’s annual meeting of the Canadian Medical Protective Association (@CMPAMembers).

The video of that presentation has just become available and gives people an opportunity to hear from CMPA Executive Director and CEO Dr. Hartley Stern and Dr. David Naylor (@CDavidNaylor), professor of medicine and president emeritus of the University of Toronto and one of the most respected voices in Canadian health care.

Given that the CMPA provides legal advice to physicians, Dr. Stern’s comments were particularly relevant, and Dr. Naylor had the opportunity to expand on remarks he published last year in the Journal of the American Medical Association on the topic.

“Every area with images at its core for practice will become a realm where AI will have transformative effects ,” Dr. Nayor said, because of ability of a computer algorithm to quickly analyze individual pixels rather than just patterns and to characterize in much greater detail.

“Used intelligently (and) used to augment human intelligence, AI can streamline workflow and relieve us of drudgery and give us time to better physicians caring for people.” In addition, he said, AI can help solve complex analytic problems and capitalize of the widening availability and richness of data.

“Many of these algorithms will be at their best supporting us and not making decisions on their own,” he said.

On the negative side, Dr. Naylor said, AI has the potential to devalue judgement and dehumanize care, is dependent on the quality of information on which algorithms are based and makes decisions where causal pathways are hard to determine.

When it comes to the potential uses for AI in medicine, Dr. Naylor said, “these are early days,” noting Dr. Eric Topol’s assessment that few of the algorithms currently in use have been rigorously tested and evaluated. And, he said, nobody has yet established how to critically evaluate publications dealing with AI because they vary so much.

Dr. Naylor said physicians should take the middle ground and not be stampeded into either unquestionably rejecting or accepting the value of AI in medicine. The integration of AI into medicine will either be smooth or disruptive, Dr. Naylor concluded, and which way it goes will depend to a large degree on physicians.

Speaking after Dr. Naylor, Dr. Stern reiterated the potential benefits and challenges for using AI and deep learning in medicine. “There is great promise that we can improve diagnostic accuracy,” he said, and  the ability of physicians to improve treatment plans can be improved, while reducing costs and the overuse of medical tests.

The promise, if properly implemented, is that AI will be able to transform the healthcare system and in so doing improve well-being and quality of life for physicians, Dr. Stern said.

However, he added, the regulatory framework and legal environment for using AI lags significantly behind the development of the technology.

For AI to be properly integrated into health care, Dr. Stern, said individual physicians need to be able to trust that the technology will do what it says it is going to do. One of the roles of CMPA, he said, will be to provide a bridge between the interest in these technologies from physicians and patients and their trust in them.

With poor communication being a main reason for complaints about physicians to regulatory authorities and the CMPA, the ability of physicians to properly explain the algorithms used by AI to their patients will be of critical importance. “You are going to have to learn how to tell that patient what this AI is going to do for you.”

Dr. Stern went on to then elaborate a number of key challenges to integrating AI including considerations of patient privacy while gathering the immense amounts of data required to develop reliable algorithms.

“In our environment, health care professionals are accountable clinical diagnosis and treatment plans. It’s you, not the machine.” He noted the Canadian regulatory and legal framework is not yet established for determining accountability when a wrong diagnosis is made based on an incorrect algorithm.

Dr. Stern urged the audience to get involved with medical associations and regulatory authorities in developing frameworks to provide adequate protections for physicians. “Without a clear policy, you are at risk.”

The session was accompanied by the release of a CMPA background document: “Can I get an (artificial) second opinion?” That document notes: “While AI can provide information for you to consider, it is important to ensure that actual medical care provided to the patient reflects your own recommendations based on objective evidence and sound medical judgment.”

(Image: Dr. David Naylor from CMPA video)