jueves, 27 de enero de 2011

Remote control: patient-practitioner relationship in a digital era

The patient-practitioner relationship in a digital era is a challenge for national health systems. In the UK, the NHS is working hard toward new paths among patients and health professionals. I share a video and a paper for professional use.

Multi-channel NHS: Joanne Shaw from Mohammad Al-Ubaydli on Vimeo.

“The patient-practitioner
relationship is especially
complex and emotionally loaded.
Introducing any technology
into a human system can have
far-reaching effects that are
difficult to predict.”

Starting points for future development:

1. Power is not zero sum. Enhancing the role of patients need not diminish that of clinicians, quite
the reverse. The goal of shared decision-making is a win-win: better quality care through richer
relationships. For the vast majority of clinicians this means more time doing ‘what I came into the
job for’. Where individuals seek to preserve clinical authority for its own sake this should not be
condoned. Power is healthy, dominion is not.
2. Some of the reticence of clinicians to use certain technologies rests on misconceptions about their
effects, which can be addressed. For example:
Untested assumptions about ‘what patients want’ – studies into various health technologies
have found that clinicians consistently underestimate how many of their patients want to and
would benefit from interacting electronically.
32, 38
Beliefs that allowing direct access to clinicians through digital channels, such as email, will
result in patient overuse and a bombardment of demands for advice – international studies
into physician email have in fact shown manageable rates of use by those who are given access,
mostly replacing rather than supplementing other interactions.
3. The pervasive uncertainty about how to undertake digital interactions in a safe and legal manner
is a major driver of inaction, but one that can be overcome. Few clinicians participating in this study
had an understanding of what relevant guidance exists, or how legislation governing the use of
digital channels affects them. Our research revealed some highly inconsistent practices. In one
case a clinician refused to use secure email with patients because they could not guarantee it
was really that person they were communicating with, but was happy that those same patients
could obtain test results over the phone by simply giving their name and date of birth. In another
example a health practitioner was using social media sites to publicly discuss personal health
issues with their patients. If an information revolution is to take place in the NHS, clinicians need
to be guided as to what the limitations of digital medicine are and what innovations are possible in
their specialty.
4. Financial incentives have the potential to encourage the use of digital healthcare, or at least to
lessen the obstacles. Currently there are significant disincentives to move away from traditional
care, such as lower tariffs for telephone compared to face-to-face follow-up. While using economic
levers to actively encourage clinicians to use remote health tools may be questionable, current
monetary incentives should at least be re-examined to ensure that digital medicine remunerates
at the same level as face-to-face

5. It is important to remember that patients and the public are not identical. The ‘customer base’ of
the NHS is unlikely to have exactly the same preferences as the population taken as a whole does.
While there are a great many lessons that can be learnt from the commercial sector in how to
implement multi-channel delivery, the goal for the NHS is likely to be different in some important
ways to that of other service industries.
6. The goal of health technology is determined just as much by how it is used as by what it is. In
the same way that a medicine causes different results depending on a patient’s condition, so
the same technology will have different effects depending on the context in which it is applied.
May et al, for example, have observed that some of the most effective telecare systems have been
developed in remote communities to enable closer relationships between patient and clinician,
but that these are often adapted uncritically into urban contexts, where the aim is to reduce direct
communication so as to manage demand.
7. Serving the diversity of patients’ preferences cannot result in simply ‘doing more of everything’. While
offering a greater choice of channels is one of the defining characteristics of a multi-channel strategy,
this does not necessarily entail increasing capacity or pressure on the health service. Developing
digital tools in parallel to traditional services would not only duplicate resources but would undermine
much of their benefit by allowing longstanding inefficiencies in the system to remain unchallenged.
The value of digital channels in other industries has been their ability to fundamentally alter their
ways of working, rather than increasing capacity, while leaving the ‘core business’ unchanged

8. Compatibility should be a guiding principle of future digital development. Strategies that have
the potential for modularity allow for innovations not envisioned by the project’s commissioners
and designers. NPfIT’s development of key infrastructure on which to base this is an important
foundation from which new programs can benefit from a degree of standardisation across the
country. Perhaps even more potential lies in the release of electronic patient records in a standard,
internationally recognised, machine-readable format that external developers can use to create
custom-built tools for patients to use in managing their health.
9. National accreditation schemes such as the proposed ‘information standard’  may help to
give health leaders a basic level of confidence, but a long-term, concerted effort towards skills
development, showcasing best practice and making some small, early-stage investment in
products, is more likely to achieve results.
10. While there is value to be sought in innovation from large, medium and small-scale developers,
the potential for the public to engage with continuous improvement of the NHS through technology
must not be forgotten. Digital voice and the release of public data can enable the NHS to make
better use of this untapped patient resource, as well as its expert staff, to drive improvement.

Full Document:  Remote control