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Exception Report

Posted by Dr No on 26 November 2012

telemedicine.jpgTwitter health news of the weekend was iDoc, a Department of Health initiative to slash surgery visits by replacing them with technology, and so save nearly £3 billion. The fire was started late on Saturday evening at 11:11pm - 11 minutes, Dr No notes, after the end of The Killing (BBC Four), the Danish villains in high places procedural - by the ever vigilant Dr G, who tweeted ‘High hopes for IT at the GP's surgery’ and linked to the next day’s Sunday Expresso front page: “END OF THE DOCTOR'S SURGERY”. By Sunday morning the story was crackling nicely round twitter. Doctors would be replaced with iDocs, noctors by iNocs, and patients by iPocs. Skypesults and tweetsults would replace consults, and hashtags like #squits and #spotteddick would trend, allowing the @CMO to gauge at any time the #healthofthenation. It was not, it is fair to say, a vision which was warmly welcomed by medical tweeters and bloggers. Dr No even wrote a post, but choose not to publish, unlike McMargo, who rounded the day off with a heartfelt post that warned over-adoption of medical IT risked throwing granny out with the tea leaves. Dr No couldn’t agree more.

Or could he? Still he didn’t post his post. This usually happens because, as the post is being written, an obscure amber light goes on. Something isn’t quite as it should be. More often than not such suspicions have to do with sources. Fires can crackle very nicely round twitter, fuelled by the oxygen of outrage – yet another reason Dr No distrusts twitter – but bear little connection to the source. So Dr No started crawling back along the smoking trail towards the starting gun, the source of the fire.

The early online editions (later ones have a model-doctorette) of the Expresso’s front page feature a large photo of that well-known useful idiot, JC, the health secretary, looking as gormless as ever. The story, from a paper that can be relied upon to nail any ministerial money-saving-service-shredding NHS story to its front page, laced the story with a bit of xenophobia. Health bosses, it warned, planned to import from India a hideous cocktail of virtual clinics, skype consultations and mobile phone apps that ‘could spell the end of the traditional doctor’s surgery’. The story, even before it had got off the ground, was heading for the end-of-the-world-as-we-know-it stratosphere. Dr No’s warning light promptly went from amber to red.

Further down the story – which notably has not been reported widely elsewhere: the Mail has covered it a couple of times, once previously and once yesterday, and the Indie, late as ever to the Party, picked it up this morning – a hint emerges of the story’s cost-cutting-service-slashing trigger. A Dr Dan (yes, he is a medical doctor), Hon. Mem. for somewhere and for the time being an undersecretary at the DoH, had said last week that IT reforms would save £2.9 billion “almost immediately” - and improve the lives of most patients. Dr No’s red light started flashing.

As ever, Hansard is our friend. Dr Dan, who manages to look like the model man from IT, did indeed say ‘£2.9 billion’ ‘almost immediately’ last week. Here is the paragraph in full, from a speech made last Wednesday in Westminster Hall:

“There are infinite ways in which technology can transform how people access health and social care services. “Digital First”, a report published in July by the Department of Health, estimates that the NHS could save up to £2.9 billion by implementing just 10 simple actions to transform how people access health care. Those savings could be made almost immediately and with minimal investment by making use of existing technologies to reduce inappropriate face-to-face contacts.”

Dr No’s warning light went out. ‘Digital First’ is a months old report, and even now its home page is struggling to keep the lights on. Last time Dr No looked it was peppered with invisible typography, HTTP 500 warnings and exception reports. It’s the same old IT as we know and love it, with about as much chance of reaching the stratosphere as a diver in a diving suit. The doctor isn’t going to skype you now, or any time soon. It is a non-story, and that is why Dr No’s amber light went on in the first place, and he didn’t publish yesterday’s post.

So why today’s post? Because, non-stories notwithstanding, Dr No believes telemedicine does in fact have a lot to offer. Many doctors and patients already use the telephone safely and effectively, and there is no inherent risk in extending the use of telecommunications by other means. But there are huge obstacles, and one essential caveat. The obstacles are the obvious ones: IT staff can always be relied upon to stick the wrong plug into the wrong socket – Dr No rests his case on Digital First’s home page – and digital take up. Overall, about three out of four of us use the internet, but in the over-65s – and so the vast majority of patients – only one in four use the internet. Couple that to only one in three (of all of us) use the internet for banking and online payments – arguably a sensitive activity and so comparable to health – and the number of real patients plugged in and ready to go today who most need to be becomes pitifully small. The number will of course grow over time as today’s younger connected generations get older, but the process is going to take not years but decades. It may even be long enough to allow the IT goons to work out which plug goes in which socket.

The caveat is equally obvious, and is the one that crackled so briskly on twitter: the dehumanising effect of cyberdistancing on the practice of medicine, which is above all else an intimately human activity. McMargo’s post covers this risk eloquently and succinctly, and real risk it is, not least because of the risk of a two-tier, connected/not-connected, system. But Dr No is not over-concerned that we about to throw granny out with the tea leaves, because telemedicine is still very much in its infancy. Just as great risk, perhaps, is that, because of concerns, we throw the telemedicine baby out with the bath water – and that would be a great mistake.

1 comment:

The Witch Doctor started using telemedicine shortly after the Internet was born - in simple but careful ways that were considered quite sophisticated way back then. It worked well possibly because it was not imposed from above but rather tailored to the needs of the specialty by those working in it. The idea, though, was to produce a better service – not to save money. WD is probably even more enthusiastic about the uses of telemedicine than Dr No, but is also probably even more disturbed about it’s potential abuses than Dr McCartney.

WD fears it will become a bandwagon that is used for some silly purposes - some of them expensive, some dangerous, some useless, and some simply wrong because of it’s ability to drive a wedge between the iPocs and the iDocs and iNocs.

There is much non-specific talk-talk about telemedicine but simple solutions that will help patients are sometimes witlessly overlooked. Here’s a recent example:

Patient recovering in ENT ward from laryngectomy. Miserable. Can’t talk. Uses his own iPad to communicate. Staff, all marvel at the iPad never having used one before. They’d heard about them, they said, but never actually USED one. Patient asks if iPads are not available for use by other patients in similar circumstances. No, they’re not but now that they have seen the iContraption it is agreed it would be a boon for post-laryngectomy patients. The iPoc concerned is astonished that the iDocs in this particular specialty have not even acquainted themselves with an iPad. Not even his consultant. What faith should he have in them for this omission in their duty of care? However, the iPoc takes everything into his own hands. On discharge from the ward, he clicks on the iStore and orders an iPad for the ENT ward for patient use.

When fit enough he personally delivers it to them.

They are truly grateful.

This will make a difference, they said…….

True story.

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