1. Health futures: real or virtual ? Jeremy Wyatt Professor of eHealth Innovation j.c.wyatt@warwick.ac.uk

2. What I am going to say Healthcare problems now and in the future Examples of virtual healthcare Benefits of virtual healthcare So can we provide all healthcare virtually… And should we ?

4. Hard for many to access and navigate - inequalities

5. Inconvenient for people with children, jobs…

6. Patchy coverage (“postcode prescribing”)

8. Access to health professionals

9. Demographic challenges to NHS capacity Labour supply Demand for care Source: NHS Policy Unit. United Kingdom figures.

10. Other serious future challenges Obesity epidemic Social isolation and mental health consequences New infectious diseases – bird flu, SARS, others (mega cities; tourism) Greater inequalities - cost of energy, global warming

11. Transforming health care

12. What is digital healthcare “Redesigned services supported by appropriate digital technologies” For public: Trust-marked reference sources Cancer etc. support forums Online personal electronic health records Telehealth to support self care in long term conditions Cyber doctor For health services: eLearning Transcription of dictated reports Remote reporting of X rays, pathology slides Remote control of surgical robots

13. Devices to support virtual healthcare Diabetes monitor & insulin pump Helping Hand medicine reminder www.medicom.com Ambient orb to monitor health status www.ambient.com

14. Trial of teledermatology to prevent GP referrals Trial results: nearly 1/3 of dermatology clinic visits could have been prevented With Depts. of Medical Informatics and Primary Care, AMC Amsterdam

15. A future virtual health scenario Mrs Smith has high blood pressure and wakes with a headache. She worries that her implanted drug reservoir may be empty. Her ambient health orb is a reassuring green, so she turns to her video wall and asks “Cyberdoc, how is my blood pressure recently?” The voice responds “Your drug reservoir needs a refill in 3 weeks but blood pressure readings are under control recently and normal today. Your blood sugar sensor shows normal readings too. Do you have some symptoms you want to discuss?” Meanwhile Mrs Smith’s wall graphs her recent blood pressure and lists the 20 most common symptoms in people of her age group locally. She responds, “No, don’t worry. Remind me to book my refill in two weeks, please.” All of this technology exists today Wyatt & Sullivan, BMJ 2005

16. Benefits of virtual healthcare Allows patients and carers to do more Responsive to user needs: Dis-intermediation – talk direct to specialist Delivery anywhere (mHealth), anytime (global) Mass customisation – the long tail Greater patient control over data (Mydex) Better data improves CQI, research Access to a wider market – health tourism Lower cost of delivery (?)

17. But what must we do in real world ? History taking (tele-presence ?) Clinical examination, palpation (kiosk with haptics ?) Psychotherapy (Computer based behaviour therapy) Taking blood etc. specimens (blood / saliva self testing kits, lab on chip) Invasive procedures, surgery (kiosk with robot?)

18. MSN messenger chat with NHS Direct nurse Coventry pilot study: too slow, high false positive rate – project cancelled

19. Other considerations Health systems: Cost releasing, cost effective technologies ? Professional mistrust in data from elsewhere Changes to health professional roles Quality assurance, eg. for point of care testing “Volume effect” - excellence in training, CQI, research Public: Safety Equity of access – “cyber divide” Acceptability / trust – eg. vulnerable elderly Risks to personal privacy of large central databases

20. Ethics of “Using computers to change what we think and do” – even when it’s for our own good ?

21. Ethics of labelling people for medical convenience ? Implanted Chips Provide Access to Medical History Across the USA, more than 1,000 people have tiny ID chips implanted beneath their skin that give emergency room personnel instant access to that person's medical information. Joanne Silberner, covered in National Public Radio’s Morning Edition, August 15, 2005

22. Risks of technology Expensive Poor fit with the real problem Unintended consequences Dehumanising

23. Holistic health service ? Risk of a “Great Revulsion” (Muir Gray), eg GM foods In Cheltenham people already spend as much on complementary therapies as NHS spends on community services Those who can, might opt for old fashioned, face-to-face, holistic care

24. Virtual intelligent Healthcare Workers Implanted calorie counter/blood sugar monitor with beeper for weight loss Independent nanorobots with smart software to stop disease before it develops Injected nano robots to clear arterial plaque, fight cancer & infection Pill based endoscopy Augmented reality for surgeons Artificial brain stimulator – eg. “sex chip” Nicotine or drug aversion implants Growing new Telomeres from stem cells to make us immortal Future Health Technologies Institute, www.fhti.org

25. “We know it works” “The OPALS Major Trauma Study showed that full advanced life-support programs did not decrease mortality or morbidity for major trauma patients... during advanced life-support, mortality was greater among patients with Glasgow Coma Scale scores < 9”

26. How to develop future health technologies ? “Heart surgeons need a decision support system to advise them which operation to carry out” “Following Bristol enquiry, heart surgeons agreed to audit their performance and use these data to inform their practice”

28. Conclusions Many factors push us towards virtual healthcare Safety, effectiveness and cost effectiveness not yet established Ethical, access and other public policy issues (Big Society or Big Brother ?) Explore implications of virtual futures and choose a direction of travel

29. Factors favouring successful innovations Cost compared to size of benefit Immediacy of benefit Proximity of benefit Transparency Trialability EM Rogers – Diffusion of innovations

30. Internet-based care pathway accessed via Healthspace Patient trying to reduce cardiac risk General practice Practice nurse: smoking cessation Patient Community services Dietician: monitor diet Hospital Clinical chemist: raised cholesterol Sports centre Instructor: exercise programme

31. Pressures for more teleHealth – health@home ? Home Hospital Consumerism Smart devices More people with LTCs Cost of travel MRSA, C. Difficile Community linkage Better outcomes Risk management Cost of devices Economies of scale, staffing Cyber divide Professional training

32. The role of the “telecarer” 1. Enhanced human communication skills: Active listening skills + motivational interviewing Empowerment, shared decision making 2. Fluency in use of “new media”: phone, voicemail, SMS email with encryption, reading notification web-mediated discussion, eg. MSN messenger, chat rooms, forums 3. New ways of working: Patients / carers taking the lead Trade off risks & benefits of email, SMS, VC, face to face “Intimate health care” - sharing data, protocols, communication channels with wider team, patient, carer: “Telecarer”: 1 article on Pubmed so far, cf. 224 on “telecare”

33. Zany future health ideas Cell phone eye exam – MIT media lab Brain control of devices - Univ of Wisconsin Adam Wilson created Twitter messages using nothing but his brain waves Bionic senses / limbs – eg. synthetic retina Artificial brain simulator - Henry MarkramBlue Brain Project reverse-engineering human brain within a supercomputer, Artificial brain stimulator – eg. “sex chip” - Tipu Aziz of Oxford. Cf. the orgasmatron, in Woody Allen's 1973 movie "Sleeper." [incredible journey]

36. Some potential harms from tele-healthcare False positives distract busy clinical staff, require extra resources; false negatives wrongly reassure patient Differential uptake by younger, educated public may worsen health inequalities (“Cyber divide”) Some people find it intrusive / mechanistic - loss of regular human contact [4% in JIT study, 2008] Exposing large scale problems that NHS cannot manage

37. When does tele-healthcare help ? Heart failure (Inglis et al, CDSR 2010): Reduced mortality by 44% (RR 0.66, CI 0.54-0.81, p < 0.001) Reduced CHF-related admissions by 23% (RR 0.77) Diabetes (Farmer et al SR, 2005): Reduced HbA1C by 0.1% (95% CI -0.4% to 0.04%) Use of services either no different or increasedwith telehealth Bronchitis (Polisenaet al SR, 2010): Mortality may be greater in telephone-support group (RR = 1.2; 95% CI 0.84 to 1.75) Reduced hospitalization and emergency department visits; but impact on hospital bed days varied

38. What to measure in pilot studies ? Safety – risks for intended & other users Feasibility – impact on NHS staff; potential clinical benefits Acceptability: to patients, carers & staff, across full range of age, ethnic, socio economic groups (TMPQ instrument – Demiris 2002) Eminovic et al. J Med Internet Res.2004; 6 : E17

40. Support self care, improve outcomes ?

41. Widen access to scarce professional skills ?

42. Reduce travel & carbon footprint ?

44. Same impact on admissions & outcomes-> Phone monitoring 5X more cost effective Chaudhry SI et al. Telemonitoring for patients with chronic heart failure: a systematic review. Journal of Cardiac Failure 2007; 13:56-62

45. Arden Digital Healthcare Demonstrator Aim: to demonstrate full scale digital healthcare & learn from the experience Covers 1M people across Coventry & Warwickshire PCTs Links with: NHS Local digital services Coventry Total Place pilot Local Health Innovation & Education Cluster Etc.

46. Tele-healthcare suitability scale Many reasons why tele-healthcare can fail: disease itself, personal preferences, disability, environment… Need reliable, valid scale to estimate chance that TH will be accepted / effective for each person IDH working with psychologists &othersto develop and validate the scale All collaborators welcome !

47. Sources Andy Black - Future of acute hospital Sue Francis – 2020 Vision report Chris Ham / Candace Imisonreport JW article BMJ Big Society BMJ on kiosks etc. – Big brother Sci Fi insights – ubiquitous CCTV etc. Foresight report with MP

48. Digital healthcare innovation opportunities Lifeline Long term condition End of life Diagnosis Healthy Symptoms Relevant activities: Prognosis; drug choice & dose, self care Supported self care Test choice & interpretation Health promotion Screening Candidate technologies Virtual ward, hospice… Prescribing alerts, telehealth, prediction rules… MSN triage, NHSDirect, kiosks… Websites,serious games… Telemedicine, decision support…

49. = 1 / 2000th of waking hours Time spent with doctor by person with long term condition

50. Responsibilities of unpaid carers Technology can give carers time off – or extend their responsibilities (“Dad, can you keep an eye on my diabetes while I’m clubbing in Ibiza?”) How much should the NHS rely on unpaid carers to support patients ?

51. How to help ? Avoid waste - everyone, everywhere only do what we know works (Cochrane) Virtual / digital healthcare: More self care & health promotion, less hospital care Anticipatory / targeted care