Category: DOCTOR

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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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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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Doctors Must Help Transforming EMR

Doctors and patients often complain about EMRs, often for the same reasons. Both say that doctors spend so much time on the computer, i.e., the number of clicks, taps, scroll up and down required to execute a routine task, or to find a result or report, doctors spend less time focusing on patient’s real needs of care.

Many doctors assume that an EMR system should simply mimic their simple paper processes; this concept has caused many of the problems associated with EMR today. The doctor needs to understand that EMR capabilities are far more beyond paper; it stands to reason there would be differences and complexity.

However, there are ways to integrate EMRs well into the clinical visit, to improve the doctor-patient relationship:

  • Preview the patient’s history and current presentation in EMR: getting familiar with the pertinent chief complaint and other clinical information before greeting the patient
  • Value the first minute by talking to the patient, not using or being busy with any technology
  • Explain what you’re doing: be open about everything you’re doing with the EMR in the patient’s presence.
  • Value the EMR: talk about the benefits of the EMR, use it as a useful tool for engaging patients; for example, let the patient look at the screening while you enter data, read and interpret lab results, and specialists’ reports. Always encourage the patient to ask questions and confirm the accuracy of information.
  • Be positive: if you display negative emotion, it influences the patient, leaves a wrong impression of the visit. The patient will never complain about a lousy EMR but will remember the unpleasant clinical experience and a frustrated doctor.
  • Keep eye contact: maintain it as much as possible throughout the visit. When a patient starts discussing a sensitive or emotional topic, always turn away from the screen and look only at the patient.

These practices can build trust with the patient, ensure the accuracy of the information entered into EMR, educate the patient, make the patient feels more participatory in their healthcare.

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Dr Henry Plummer, a Diversified Genius

Dr. Henry Plummer was a diversified genius. He was a physician, scientist, and engineer. One of his significant contributions to clinical practice is the implementation of a unified medical record system in Mayo Clinic. The medical records of the same patient were always kept in one location, in chronological order. That was in 1907, and the first patient record was created on July 1.

113 years later, we are building electronic medical record systems, trying hard to unify medical record numbers for the same patient across clinics, hospitals, cities, health systems, countries, and regions.

We are now trying to connect and integrate patients’ information from all perspectives, including clinical conditions, health status, social determinants, objective data given by laboratories, modalities, devices, and subjective feelings, personal preferences about how we want to be taken care of.

In the near future, everyone is possibly going to be accompanied by a ‘data buddy’ knowing more about ‘Who I Am’.