Author: Jenny Shao

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Future Doctors

Worldwide, almost everywhere, increased internet access and the growing use of digital devices have fundamentally altered the information available to patients. Patients are becoming more empowered by technology to make healthcare decisions; patients now commonly ask for more information and expect to be involved when making diagnostic and therapeutic choices.

At the same time, the healthcare system is becoming increasingly complex; every country is trying to figure out how to end the pandemic socially and medically.

As a result, many doctors feel unhappy, disempowered, and alienated from their work systems; they are seen as part of the problem rather than the solution.

The solution is undoubtedly directing us back to technology. The future of healthcare is data and work-smart people. Future doctors will probably need these characteristics enhanced:

  1. Healing ability: having knowledge and technical skills to heal people beyond treating disease. Healing and treating are related concepts, Healing, however, can come in many forms other than treating.
  2. Understanding of systems: doctors are no more the dominator but essential players in healthcare systems, from clinical teams to national and international systems. Doctors need to understand those complex systems and, more importantly, know how to improve them.
  3. Enthusiasm for learning and changing: medical students are taught that medical practice is a lifelong learning process. Nowadays, continuing learning is an essential survival skill; love to learn and change is a characteristic of future doctors.
  4. Comfort with technology: it is particularly true with information and digital technology; recognize that doctor plus technology will be much more effective than a doctor alone.
  5. Patient-centered: the concept of patient-centered care emerged in the early 50s; it exploded exponentially in the late 90s. As we strive to improve the quality of care, a patient-centered model can play a pivotal role in this process. More research is needed to explore the various attributes of patient-centered care, its acceptability, digital transformation, and comparative effectiveness in the healthcare arena.
  6. Understanding of evidence: doctors are educated about hierarchies of evidence. Future doctors must be capable of combining different types of shreds of evidence, analyzing and weighting them effectively. Learn to work with and apply algorithms.
  7. Profound ethical understanding: future doctors must recognize the moral issue and have the capacity to think and practice ethically.
  8. Communication skills: listening more than telling. Since Hippocrates’ time, medical school professors have taught their students to listen to their patients. Medical doctors all realize that the patient’s medical history and the patient’s account of his or her illness is the best source of information to make an accurate diagnosis and healing plan.
  9. Love of diversity: enjoying working with people from different backgrounds and of different views and skills.

Social, technological, and science is reforming the role of doctors rapidly. The change of the doctors is driven by patients, knowledge, the workforce, and technological change around us. The SARS-CoV-2 pandemic has thrust many changes upon the doctors in the new ways of thinking and working.

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Future Leadership for Women

Group Photo of all Students

Last year, I taught a leadership program for young students at the SIAS University in Henan Province in China. The World Academy for Future Women (WAFW) sponsors the program; 90% of students are young women aged 18-23. You can find here and here the detailed program and feedback from students

I noticed that less than 1% of my students were interested in or studying technological fields. The percentage is surprisingly low compared to other areas, such as education, healthcare, and business. 

According to a study published by European Union, only 17% of people working in technological fields are women, especially in the Information and Communications Technology (ICT) area.

There are still invisible barriers and glass ceilings that discourage women from studying science, technology, engineering and mathematics (STEM) at university. Despite the efforts made in elementary schools, high schools, and universities, little progress that been made if we look at the past few years.

We know that technology is growing rapidly and steadily. It is creating and will continue to develop numerous jobs for people with technological profiles in areas such as AI, data analytics, robotics, etc. The inadequate presence of women in technology does not just represent less opportunity but also society as a whole.

Historically, technology-related jobs have always been linked with machines, labour-intensive and consequently, making them potentially less attractive for women. However, today’s technology is associated with computers, data analytics, and intelligent systems. All these areas need more women who, on equal terms with men, are sensible and creative and assist in finding solutions to the biggest challenges of our times. 

Greater diversity at work would provide a global and more accurate view of our society’s significant challenges. It helps us better understand and effectively respond to the problems of the world in which we live; we need an equal social system in which men and women can be visible in all areas, especially in the technological sector.

If young women are not encouraged and left out, the gender gap continues to grow; it will be harder for us to address and overcome issues relating to economic and social problems.

We should expect and encourage more women to be interested in technology. Together, men and women develop unbiased recommendations for our society, machine-assisted senior care, intelligent healthcare systems, digital cities, and co-existing human and artificial intelligence. The proposals would address the significant challenges and solutions, that is, ethics and humanity. 

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Reflections on Global Covid QR code

I was reading CNN news this morning when having breakfast, Chinese President Xi at the recent G20 Summit is pushing for a global COVID-19 tracking system using QR codes to help fast-track international travel and business. 

China has mandated using Health QR Codes from February national wide; in the past nine months, the country has gained huge benefits and confidence in control the pandemic. 

I introduced the Healthcare QR codes in July 2020, in an event organized by AHIMA International.

Health QR Code is built on shared and interoperable digital technology platforms. It is applied in identifying individual, tracing individual’s locations, and subsequently empowered contact tracing. It is proven, efficient, convenient and useful. It is comprehensive, time accurate in comparison to the various types of apps. 

Privacy is considered necessary, public health is equally or maybe even more important as China has gone through SARS. People are more willing to be disciplined for their safety and society’s protection. 

Health QR Codes provide an option to international travellers to enter into China, presumably earlier down the road.

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How digital technology help contact tracing of COVID-19 pandemic

How could china quickly control the pandemic in such a practical way? What are the secrets? One secrete is using digital tools for contact tracing.

Contact tracing is a critical step in controlling COVID-19 pandemic. The coronavirus is highly contagious, spreading so fast, it is so overwhelming and impossible to do contact tracing in traditional ways. China has extensively applied digital technology in contact tracing that includes identifying and following-up with patients, identifying, notifying, and following up with the contact.

The digital tools were applied to help contact tracing for accuracy and efficiency. For example, apps were used for electronic surveillance, and people were informed if they took the same train or plane with suspected or confirmed cases, the doctor was informed if their patients had high risk.

The most crucial contact tracing digital tool is the Health Code.

  • Health Code is a unique personal code, generated and saved on a personal phone, shows the pandemic risk.
  • Health Code shows three different colours indicating health status and pandemic risk level: green colour means low risk; yellow colour means medium risk, and red colour means high risk.
  • Health Code colour is generated based on big data collected from different sources, mobile service vendors, social media, online payment platforms, all information about where the individuals have been to
  • It is straightforward to apply.
  • Health Code status is real-time and dynamic.
  • The 1st version of the Health Code was generated on Feb 5th, 2020, over one billion health codes are generated.
  • During the pandemic period, every person must show their health code when entering into a public place, such as residential complex (coming back home), shopping malls, train station, airports, office etc.
  • Health code was not the only measure; temperature check was used together to trace suspected cases.
  • There are limitations, for people who did not have a phone or did not bring their phone, who did not remember their ID number, whose phones did not support 4G or scanning barcode), the manual process was used for tracing.

We have noticed that the Health Code is beyond contact tracing; it is population tracing. It identifies an individual’s footprints, footprint crosses. It makes contact tracing accurate, compressive, more efficient and more effective.

How could China so quickly build and implement such big health code systems nationwide almost within 1 month, the reasons behind include:

  • Mobile phone and internet is popular (i.e. 900 million people have internet access, internet access is over 64.5%)
  • Big Data ecosystems are ready
  • Unique ID for every citizen every individual is available
  • The most important is that people’s acceptance of link ID to register for a phone number, social media access and payment platforms.

To summarize China’s experiences of fighting against the coronavirus:

  • Digital Technology has been applied in identifying individual, tracing individual’s locations, and subsequently empowered contact tracing. It is proved, efficient, and useful.
  • Privacy is considered necessary, but public health is equally or maybe even more important as China has gone through SARS. People are more willing to be disciplined for their safety and society’s protection.
  • Over one billion people have been traced during the pandemic period.
  • Tests are encouraged and available in the major cities.

China’s experiences are of help to the world,  the COVID-19 pandemic will be settled down soon worldwide, and we look forward to going back to everyday life.

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Let’s call it EHS!

Doctors are widely using EHRs in different clinical specialties and sub-specialties. In a 2018 survey of physicians by Deloitte, only 10% accepted their current EHR systems.  The rest wanted at least one area improved. Different studies have reported mixed findings, and a significant result is reasonably consistent: doctors are not satisfied with their EHR systems, EHR is a place to store data or a digital filing cabinet.

The biggest complaint is that the diagnosis and treatment flow in EHRs does not follow the thought process of a doctor, most times, it is the other way around where the doctor has to follow the flow of the EHR. 

Doctors have to spend time clicking and search around. What is EHR’s competitive advantage if it cannot easily search and display patient information for diagnosis process and treatment plan?

Modern EHR is wrongly defined by its legacy name, R (for the record) does not reflect its role in medical practice, and R also blocks innovative thinking as a solution. We should call EHS (Electronic Health Solution)

The thinking design of EHS must have the capability to support the diagnostic process. In particular, support the providers involved in the diagnostic process and reduce potential errors.

The researchers have described the critical attributes of safe EHS, including:

  • Easy retrieval of accurate, timely, and reliable native and imported data;
  • Simple and intuitive data displays;
  • Easy navigation;
  • Evidence at the point of care to aid decision making;
  • Enhancements to workflow, automating mundane tasks and streamlining work, never increasing physical or cognitive workload.

The thinking design of an EHS must provide a continuous treatment plan function. The treatment plan is a set of actions at a defined period for the clinical objectives of a patient.  Doctors want to track the progress and alter it as it goes along. Especially for personalized medicine, the doctor or case manager must have the ability to allocate a treatment plan and monitor each patient’s process.  Most EHR systems have a treatment plan function but not a patient-specific plan; there is no cohort management function for the case manager.

A thinking design of EHS thinks about the user interfaces to a deeper level, i.e., be intuitive and straightforward. A typical example of a design concept is to bold the data-fields rather than the label fields.  It is simple and makes sense.  Doctors are looking at the EHR screen all the time in daily practice, and they know where the label “Gender” or “Name” is.  There is no need to see the labels in bold all the time. Instead, they need to see the data in bold so that they can glance at it once.

EHR has come a long way but still has a long way to go. It is time to transform from ‘record’ to ‘solution’ thinking. EHS is a solution to traditional EHR, and it is to build a platform for clinical intelligence; it is a tool for formulating personalized care paths that everyone uses.

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Rapid Change and Fast Implementation of EHR/EMR

The world is changing very fast. Big will not beat small anymore. It will be the fast beating the slow. – Rupert Murdoch

During the pandemic, many hospitals have shared their experiences of rapidly improving the existing EHR/EMR systems. Some reported their success stories about fast virtual implementation and go-live. Covid-19 requires rethinking and refocusing on priorities. The decision-making process has been shortened, and the actions have moved faster.

1.    WHY need EHR/EMR?

 COVID-19 pandemic exposes both strengths and flaws of EHR/EMR systems. However, despite the frustration and disappointment from the front-line clinicians, we must first acknowledge that EHR/EMR architecture and platform have enormous value in controlling the pandemic and other widespread public health emergencies.

Paperless EHR/EMR system is essential and assured for early detection of the risks, report of abnormal conditions, rapid diagnosis, and the appropriate treatment and life support. 

Eliminating all the paper and minimizing direct contact is a must in the whole of the caring process.  The workflows need to be connected seamlessly and communicate effectively, such as identifying patients, booking appointments, admitting to ward, referring consultation, coordinating MDT review, electronic print, bed-side care, and post-discharge follow-up, etc. Also, the recommended Covid-19 protocols evolve very quickly, and EHR / EMR enables hospitals to implement changes far more uniformly.

2.    What EHR/EMR systems are the choice?

There is a varied range of EHR/EMR products locally and internationally. Robustness, interoperability, organizational feasibility is of choice. The advantages and power of such choice have been proven during the pandemic, ensuring patient care safety and quickly protecting clinical staff at the same time. The capability of information sharing allows hospitals to track and report abnormal conditions faster and accurately.

3.    How to rapidly improve and how to fast implement?

Most hospitals already have workable systems of daily huddles in place. A fast virtual implementation during the Covid-19  strengthens a lean approach, i.e., rational use of resources without waste, implementing the necessary changes.

Hospitals are more likely to make fast decisions, consider much less about those concerns that may delay the change progress. For example, before Covid-19, the staff often spend time in scoping requirements and developing and testing solutions before rolling out changes. This process has been modified to implement changes quickly. New EHR/EMR features are constructed to enable quick back-end editing as processes and guidance change frequently.

During the pandemic, social distancing pushed the implementation teamwork online, which makes communication, testing, and system configuration much harder, and almost impossible to maintain the same level of support and security as onsite. However, those success stories show that new needs invariably create and drive new methods. As Amelia Earhart said, the most difficult thing is the decision to act; the rest is merely tenacity.

The Covid-19 pandemic has forced numerous changes in daily clinical practice. Rapid responses in EHR/EMR help beat the virus and defend the patients. Stay lean to go fast.

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How can EHR/EMR Improve Medication Adherence?

Research shows that approximately 50% of patients do not take their medications as prescribed. The treatment of chronic illnesses commonly includes the long-term use of medication; however, the therapeutic benefits are often not achieved or maximized if patients don’t take them or are not adhering to the prescribed regimen.  

The factors contributing to poor medication adherence vary, but in general can be summarised into three categories:

  1. Those related to patients; for example, lack of understanding, inadequate involvement in the treatment decision–making process.
  2. Those related to care providers; such as prescribing complex regimens, insufficient explanation of usage, ineffective communication about adverse effects.
  3. Those related to health care systems; for example, limited access to care, visit time limitation, and lack of health information technology. 

It is recognized that poor medication adherence contributes to suboptimal clinical benefits; increasing adherence may have a more significant effect on health than any improvement in specific medical treatments (Sabate, WHO, 2003). 

How to make patients cooperate? What is a valuable tool to assist patients in forming adherence habits? The solutions need to be multifactorial and sustainable, they need to integrate coordinated efforts between care providers, patients, and health care systems. 

The medications are prescribed by doctors in an EHR/EMR system; therefore, EHR/EMR has a role and responsibility to launch such a medication adherence platform:

Recommended workflow and data scope include: 

  1. Prescription information generated in EHR/EMR. The EHR/EMR has appropriate interaction checks, allergy checks, cumulative dose checks, etc.
  2. Medication collection information in EHR/EMR or in linked pharmacy dispense system. In China, medication collection status is recorded into the EMR / EHR system since the vast majority of pharmacies are inside and operated by the hospital.
  3. Once the patient collects the medication, prescription information includes generic and brand names, usage instruction (before/after a meal, etc.), time of taking medication, side effects will be available to patients on their mobile phone, or online.
  4. The time of taking medication can be automatically added to the schedule.
  5. The patient will be alerted when the time is due.
  6. Patients can easily record the outcome, e.g., when medication is taken, what are the adverse reactions, etc.
  7. The patient’s administration record can be submitted to their care manager or primary care doctor for review, the treatment plan and regimens can be adjusted based on the report outcomes.

Depends on the local health systems, bring payers to such a platform could enforce adherence. Pay for adherence, pay for real treatment, pay for outcomes can be achieved based on seamless data. 

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A Digital Model of Doctor-Patient Relationship

The good physician treats the disease; the great physician treats the patient who has the disease (William Osler, 1849-1919).

The doctor-patient relationship impacts the success of treatment and caring much. Currently, the traditional patient-doctor encounter and relationship are challenged by care service demand, the emerging technologies, and the COVID-19 pandemic.

Patients expectations during an encounter with a doctor (Delbanco, 1992) are:

  • Patients want to understand the competence and efficacy of their doctors.
  • Patients want to understand how their illness or treatment will affect their lives,
  • Patients often worry that their doctors are not telling them everything they want to know.
  • Patients want doctors to focus on their pain, physical discomfort, and functional disabilities.
  • Patients want to discuss if their illness will affect their family, friends, and finances.
  • Patients worry about their future.
  • Patients worry and want to learn how to care for themselves away from the clinical setting.
  • Patients want to be able to check the health care system effectively and to be treated with dignity and respect.

When the doctor-patient relationship includes competence and caring communication, there will be better adherence to treatment; patients will be more likely to be satisfied with the care received and can achieve better outcomes and quality of life.

How can information technology help build a doctor’s competence? IoT has proved its capability of improving the accessibility of healthcare services. How can IoT help caring communication between doctors and patients?

There are 3 Patient-Doctor Relationship Models:

  1. Activity-Passivity Model:  it is most appropriate and often seen in emergencies. The patient seeks help and information, and the doctor provides care decisions, actively treats the patient, the patient passively accepts, and has little control.
  2. Guidance-Cooperation Model: this is based on the theory ‘doctor knows best’, it is the most common in current medical practice. In this model, the doctor recommends a treatment plan and the patient accepts in a cooperating way.
  3. Mutual Participation Model: the doctor and patient share information and responsibility for making decisions and planning treatment and recovery. Some have recommended that this is the most appropriate model for chronic disease management.

The implementation and adoption of The Mutual Participation Model heavily rely on clinical data interoperability, interpretation, and sharing in a meaningful and sensible way between the doctor and the patient and their families.

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COVID-19 outbreak test EHR/EMR

Electronic Medical record (EMR) and Electronic Health Record (EHR) in hospitals are tested by the Coronavirus Disease 2019 (COVID-19) outbreak. An integrated and mature EMR / EHR can be a powerful tool in early detection, fast reporting, rapid diagnosis, strict isolation, and the right treatment.

In China, COVID-19 is classified as Class B infectious diseases; however, it follows the preventive and control measures for Class A infectious diseases. Pre-examination and triage is the first step in preventing and controlling virus spreads in hospitals.

I observed a 3-level pre-examination and triage screening workflows implemented in a hospital EHR system in a private healthcare setting in Beijing for the pandemic control

The 1st level screening occurs at the entrance to the emergency room and the fever clinic. Every person entering the hospital building must wear a qualified mask and receive preliminary temperature checking. Screening information, including fever, cough, dyspnea, and epidemiological history, is recorded. Suspected patients are guided to the fever clinic for further examinations. Patients with negative screening results can enter into the hospital. The triage nurse put a round and colored sticker designed by the hospital on the patient’s coat. The marked patient then has access to other departments. The color of the round sticker is changed every day in a weekly cycle.

The 2nd level screening is to avoid patient gathering. It is conducted by the patient self with the assistance of the triage nurse when necessary. Patients complete and submit screening information in EMR on an iPad. If patients have negative results, the EMR flags a green icon, and then the patient can move in the hospital after a second temperature checking. If patients have positive results, the EMR flags a red icon indicating a risk of COVID-19. The nurse will verify and re-check the patient’s temperature. If Patients have an unexplained temperature ≥37.3℃ will be transferred to the fever clinic for further investigations. If patients have not completed the COVID-19 screening, a blue icon is displayed in the EHR, indicating that preliminary examinations are required.

The 3rd level screening is conducted by the doctor in the consultation room. The doctor checks epidemiological history, body temperature, clinical symptoms, body signs, blood test results, chest X-ray results, and CT results in the EHR, and make a medical risk assessment. The level of risk again links to the color of flags.

This 3-level screening is a real-time workflow and process, it guilds decision of patient allocation and isolation during outpatient service and inpatient hospitalization.

The hospital EHR / EMR system shows the advantages of fast mobile access, connecting care providers, real-time monitoring, review, and tracing of outpatients and inpatients. COVID-19 data are always analyzed and reported accurately.

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EMR, EHR and PHR

Many people do not realize the differences between an electronic medical record (EMR), electronic health record (EHR), and a personal health record (PHR), often use the terms EHR and EMR interchangeably. However, some differences define medical and health apart, distinguish ownership of patient information. 

An EMR is a digital version of clinical workflows that record the process of medical practice. 

  • The purpose of EMR is to document care provided, orders, order execution, results, reports, and other information related while caring for a patient. Documenting must be complete if care was not documented; it did not happen then.
  • The patient does not have direct access to their EMR during their hospitalization. They can, however, request copies of their records after discharge. 
  • Healthcare organizations must comply with the requirements of the local regulations in terms of EMR system governance and management.

An EHR is a digital version of integrated health information about individual patient or population. 

  • An EHR has the capability of sharing and exchanging information across different health care settings via network or cloud. EHR includes a varied range of data, including demographics, medical and social history, medication and allergies, immunization record, laboratory, and pathology test results, radiology images, vital signs, BMI, excises, health risks and outcomes, and insurance and billing information and so on.
  • The patient usually has some access given by their healthcare providers and organizations to view their records. 

A PHR collects, stores, centralizes, integrates an individual’s and family’s health information, share when the patient wants, where the patient wants, and with whom the patient chooses. 

  • PHR should securely manage lifelong personal health information, including subjective data like individual’s care preferences and wishes, data from own wearable devices. 
  • PHR is maintained by the patient, is operated by healthcare organizations. The intention is to provide a complete and accurate summary of an individual’s medical history, which is accessible online. 
  • The purpose of PHR is to maximize individual health benefits.

These three terms reflect the revolution of technology in the healthcare field, i.e., the progress of understanding, acceptance, and embracement of technology in daily practice, the role change of patient. These terms may be defined and used differently in countries and regions. Admittedly, technology has empowered care providers and patient than ever.