Will your doctor be prepared to override you and your smartphone?

It is your classic sci-fi scenario. Remember HAL? Remember the synthetics in Alien(s)? Well now there is a storm brewing that will dramatically change healthcare. This change is coming due to the convergence of a number of trends in healthcare and a few disruptive technologies, of which the most important is the smartphone.
The key changes are:
  • patient use of the internet to obtain health information and make healthcare decisions
  • the slow but inexorable rise of electronic health records (EHR) 
  • digital modes of communication between patients and healthcare providers
  • the development of knowledge repositories for electronic decision support
  • the use of behavioural economic techniques, social media engagement and analytics, gamification and other methods to modify health behaviour. This change is epitomised by the life-logging, quantified health movement
  • the development of sophisticated diagnostic devices for personal use
Patients have been empowered by the internet. They come to my office clutching folders of printouts from the internet or hold-up their iPad for me to see what they’ve found. Some of this information is good and much extremely bad. Some patients handle this information well and a lot don’t have the health literacy skills to filter the good from the bad. A lot of my time as an oncologist is spent interpreting this information for patients, often after they’ve already spent a lot of money on dodgy treatments.
Electronic health records are already widely used, especially in primary care. EHR are increasingly integrated into hospital care. But these are disjointed. The next 10 years will see EHR start to be able to talk to each other to provide seamless transitions between healthcare settings. In Australia this will be built around the PCEHR. Ultimately cradle-to-grave healthcare data will be held in a cloud-based repository accesible by patients and their healthcare providers.
Communication between patients and their healthcare providers has been changing. Face-to-face is being supplemented with email, video calls and text-messaging. Doctors are remotely visiting patients in hospital by video enabled robots. Patients book appointments with doctors via mobile apps.
EHR can be more than an interface for a data repository for patients. Electronic decision support can be built into EHR to aid in the delivery of evidence based health care. Electronic decision support provides a knowledge base and rule book for quality and safety, particularly in relationship to prescribing. Linking patient data with analytics and knowledge repositories will not only takeover large chunks of patient management, especially in he hospital setting, but will also be capable of learning and improving care. Big data will be analysed for emerging health trends.
The quantified-self movement is slowly becoming mainstream. Life-logging relatively easy to measure end-points such weight, exercise and caloric intake is a simple means for managing weight. Assisted by mHealth apps on smartphones and tablets individuals can take their own control. Support through gamification and social networks may increase adherence and success in achieving health goals. Numerous other applications such as smoking and alcohol control, sleep management and habit changing are possible and already being undertaken.
Finally new diagnostics devices are emerging for the collection of health care data. The Holy Grail is the medical tricorder concept from Star Trek. This device is used to scan the patient and produce a medical diagnosis and provide treatment recommendations. How far away is this? The folk at Scanadu http://www.scanadu.com have a 12-18 month time horizon pending FDA approval. These devices will draw on and consolidate many aspects of the preceding 5 ideas. 
So imagine you are at home. Your love one feels sick – or maybe your ginger.io app tells you you are becoming sick. You scan your child and a diagnosis of an infection is made through analysis of combination of scanner data and manually (voice) entered symptoms. The software may also have trawled social networks and hospital data to identify common infections in your community. A diagnosis is provided that says your family member needs antibiotics and you should see a doctor for confirmatory tests and a prescription.
Here is where it gets tricky…..What if the doctor disagrees. Who do you trust? The interweb or the experience of the doctor? What if the doctor runs his own scan and his software from a rival company comes up with a different recommendation? Will the doctor overrule the software? What if the doctor is wrong and the software is right – or visa versa? Who is responsible? We wan’t patients to take responsibility for their health but will they take responsibility for their healthcare decisions? And hey, if the software is right – do we cut out the doctor – does a doctor in the cloud get to prescribe the antibiotics?
This technology is an awesome step-forward for healthcare, especially as the price of the technology will allow scalability even in low income countries. 
But is the healthcare system ready…..not even close.
Are the patients ready…..less than they think.
Even if initial uptake of tricorder technology is slow the need for regulatory management will be urgent.
Where are the opportunities? Developing robust knowledge bases. Suppporting data and decision support standards. Teaching people how to use the tech to support their healthcare decisions and to Be Medicinewise. And developing new models of electronic and human-based healthcare delivery.

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