The AI Will See You Now - What Happens Next? podcast on digital health

The AI will see you now

Susan Carland: Hi, I'm Dr Susan Carland and welcome to What Happens Next. In this episode, we'll look at what health care delivery could be like in the future and how technological change, innovation and advancement has been accelerated by Covid19.

Cathie Reid is the co-founder of Australia's epic group, including Epic Pharmacy and Epic Good Foundation and the co-founder of Icon Group. And she's passionate about new health solutions. She's also a Monash alumni from the Faculty of Pharmacy and Pharmaceutical Sciences. Cathie talks to us about the acceleration of change driven by the Covid pandemic.

Chris Bain is a Professor of Practice in Digital Health in the Monash Faculty of Information Technology, the first to ever hold this role. He leads the university's efforts in digital health, working with faculties and institutes across the university, as well as with a range of health industry partners. With more than 30 years experience in the health industry, including 12 in clinical medicine. Chris sees incredible potential for innovation and change for the better in health care delivery.

Chris Bain (CB): Hi, My name is Chris Bain and I’m the Professor of Practice in Digital Health, Monash University - it’s the first job of its kind in the university. So I lead efforts around digital health research and to some extent work with others around education around digital health and my background is heavily having actually been out in  health care for about 27 years in Victoria and then in the university for the last three years.

SC: We're in the middle of a global pandemic, just in case you hadn’t noticed, and what we have seen is there's been a real acceleration in using tech to deliver healthcare. You've been working in this area for a long time, though to most of us it's quite new. What do you think is now causing the pick up. Is it just the requirement of Covid? Do you think people are more open-minded to these sort of things now?

Cathie Reid (CB): Yes, Susan, I think, unfortunately, it's very practical, realistic reasons that people have started doing this more, and there's a bit of an illusion about what they're actually doing, which we might talk about as well. But, definitely the wariness of attending a practitioner face to face in the setting of a pandemic and a deliberate mechanism to avoid that where we can and also the fact that the government has sort of opened the gates on funding this kind of care, which has been a big stumbling block for many years to it's greater advancement. So the government has said we will actually fund healthcare practitioners to deliver care this way - that has always been a bit of a sticking point. So it's a combination of factors.

SC: So you think it was sort of the necessity of the moment and then that caused the government to say, Okay, we'll fund it.

CB: So those of us who have been working in the area, and I don't particularly specialise in telehealth, but it falls under a whole range of technologies I've been working with for a long time. But one of the biggest barriers noted in research here in Australia has been appropriate remuneration, and that's an important consideration. So if you're going to ask busy practitioners -  think of a GP, for instance, who’s historically set their whole business up about working in a particular way and getting funded by seeing patients face to face - it needs to be, you know, similarly equitable for them to make the switch, doing more consultations, virtually, assuming they have the right technology. It's just an inevitable thing of embedding any technology  - how is it fitting into somebody’s workflow? Can their business survive the transition? So it's not just a case of all those doctors want the money. It's a bit more complicated that,

SC: As I said before you've been working in this area for quite some time. Is there anything possible now that might not have been possible before?

CB: Yeah, look, there's certainly technological things that are possible, particularly driven by the pandemic. I think the thing that's most interestingly possible now is people have seen the ability to deliver more care at scale although there is a concern underpinning that we might come back to. So one of the sort of mental barriers, if you like, as well as a bit of an access barrier - so as part of this whole pandemic response there’s been greater access provided to some of the key reliable tools in this telehealth space much more broadly across the country, as well as paying people to use it. So we're hoping that what's really possible afterwards, if we get to an after, [inaudible] is that we could say, Well, okay, we could actually do that a lot more than we thought we could before. Now let's not slip all the way back. I sort of use the analogy as if we were - if maximum speed of telehealth is100K's, and we sort of went from 10 or 15 K's an hour right up to 90 very quickly, and there's been some problems with that, and things we need to watch for. We’re hoping we slip back to 40/50/60ks in a way that makes sense and not back to 10. That would be a concern if we don't learn from this opportunity.

SC: Obviously there's a lot of benefits we've seen during the pandemic to things like telehealth and lots of other healthcare innovations. Are there any potential problems or risks that we need to be aware of?

CB: Yeah, And look, we really need to take it - again, we just,  if we can get some clear headspace, which a lot of the rest of the country seem to have, Victoria doesn't have it at the moment - we can start to ask a couple of questions. So one is what happened to healthcare through that period. What actually happened? What does the data say?  People's care, was it sustained at a suitable level? And there's evidence already emerging that for some kinds of conditions that hasn't been the case.

SC:  What kind of conditions are the ones that seemed to not do as  well?

CB: Look, I think there's gonna be a whole range of them. But even in the last few days, for instance, and some of this is local data, and some of it is international data. Last few days, there was an article in the paper about people relatively dropping the use of post exposure prophylaxis for people who have man to man sex. Now, even the people who described that dip during the earlier stages of the pandemic say well, is that because people were behaving less riskily because they couldn't see other people, or was it because they didn't feel they could access a service? The other thing that came into the paper last week again was from the Australian Stroke Registry about access to stroke services. So people avoiding calling a doctor or calling an ambulance when they had stroke symptoms. So a dip in people actually wanting to seek care. I know that's also from speaking to people in different parts of the health system, anecdotally, are describing, you know, less heart attacks or perceptions or less trauma that makes sense - less road trauma, less alcohol induced violence. There are reasons for that. But there’s this really concerning picture evolving, and if you add to that, you know there's been examples in Australia of true virtual care through telehealth. So something like RPA virtual in Sydney has popped up treating Covid patients remotely. But when you look at the dominance of what's called the MBS items for telehealth since the pandemic, there’s figures saying that about 90% of that is actually just phone calls, it's not even using the video. So if you ask any health care professional, especially any doctor that has been around for a while, they know that you can't deliver the same quality of care across the board for all conditions over the phone as you can by seeing your patient. So a few things to worry about technologically. But more than anything, what's gonna have been the impact on health care delivery as we get through the other side of this?

SC: And I wondered when I heard about those examples. I've also heard about how oncologist are saying there's a worrying drop in the number of people that are presenting for cancer diagnosis, and I wondered, is that technology or is that just the pandemic people thinking well unless I’ve got Covid I really shouldn't clog up the hospitals, or I don't want to go to the hospital doctor in case I catch Covid here. Is it, how do we separate the two?

CB: Well, again, only really, by looking at it, I think, after the fact, when we've got head space to do so. You know every second researcher I'm aware of at Monash at the minute - it makes sense and also because that's where funding is coming is looking at Covid  things, you know, all about Covid - we'll have a bit of sense of our answers, those questions when we can ease off a bit and look at more normality. I think the answer is combination of both. I've got no doubt that some people are avoiding care. I mean, we've had significant health issues in our own family, you know, during the pandemic, and you see your own decision making process and how the system operates. But I'm sure some of it is because you know the option of telehealth just doesn't cut the mustard. In the way it apparently works, which is mainly the video and voice channels, it's not the same as having all the information you would face to face

SC: Right and just, yeah, getting a proper physical examination, I imagine. Do you think there might be some forms of health that might actually do really well under a telehealth model, for example, mental health services that people might be, you know, if they're in remote locations, or maybe they're feeling perhaps so depressed, they don't want to leave the house, but they can turn on the video on their phone and talk to someone, and that actually might be improved through this sort of technology?

CB: Yeah, so we certainly know, even from before the pandemic that some kinds of you know, health services and some kinds of benefits from telehealth seemed quite promising. So, obviously, people who live in remote locations, even relatively remote locations on the end of city, edge of cities with less specialist access than let alone rule and remote is evidence around that they benefit in terms of better access, reduced travel costs. Services like tele-psychiatry or tele-psychology, tele-dermatology, even some evidence around tele stroke services, all of different kinds  - suggests that people do okay with those things and could do better and their access gets better. As for the rest of the conditions, again, just going to have to wait and see. I mean, I think if you look on the technology side of the equation, you know, some of our own work. We're looking at extending what you can do over the wire if you like, beyond just speaking to someone and speaking with someone and looking at them, can we collect other kinds of information from them over the wire during the consultation? You can certainly do it in a remote, ongoing monitoring setting like RPA Virtual. But when you do that, that's almost like the old hospital in the home model, Virtual Hospital model. And people are effectively under the governance of a hospital service during that care episode. It’s a different thing to what's usually just a consultation and so I think there's interesting opportunities in what's more like a consultation model, so people can have much more in depth consultations that get closer to physical reality that they used to than they currently have with video and voice.

SC: All right, Chris, dream scenario - design for us your utopian vision of a health care system and healthcare service delivery. What does it look like? How can we make it better and really work the way we all want a health service to work?

CB: Yeeah, so just some simple things, I suppose, high level features of it. One thing, and we actually did some work about this recently, this idea of seamlessness. So it seems very clear that the system hasn't, certainly in Australia, and there’s some evidence from overseas, where I would say it has not transitioned seamlessly from face to face delivery to a telehealth delivery model. There's evidence coming up in those scenarios around particular clinical things we mentioned. There's the fact that people are reverting to phone calls. They're not actually using even the current technology to its full extent. So that idea of, you know,  the next pandemic comes, you flick a switch and really many things don't change because you're already doing a lot of enhanced telehealth consultations. And really, the people who needed to come to hospital still do. But the people who didn't -  you know, you’re already doing vast chunks of that via remote care, virtual care, telehealth. And so it's not such a breaking of the care routine, if you like.  So that's one way that that vision would be. We know we had that vision.

I think, too, going with that is that it's embedded in what people dio. It's no longer seen as a sort of break glass in case of emergency thing. We just do it because it made sense. And we have little examples of that now, but just not right across the system. I know cardiologists in hospitals whee I work, have been basically in the clinic setting already for a long time, you know, they might have 20 patients to see in the clinic, and the first ones a patient physically in the waiting room, they call them in. They see them. They do all their work, patient leaves, the next one's a virtual patient. They're waiting in a virtual waiting room, and so they just click through into the waiting room. The patient's there. They have the consultation. They do what they need to do,  documents and so forth. The next one is the physical patient. So that kind of seamlessness would be a marker that we've got this sort of utopian state. We’d hope that  - it’s critical, in fact, to have that utopian vision come to life - that the care standard doesn't drop. You know, we need to show that we're still doing the right things by patients in that state.

SC: As I said at the start, I don't know if you've heard, but we are in the middle of a pandemic, and it has had a bit of a change on how we do health care. What are the changes do you think we'll see going forward, or which ones do you think we'll stick to now that there has been significant disruption due to coronavirus in, you know, in our healthcare system?

CB: So I definitely think the one we want to stick to, to the extent we can show it's been safe and worthwhile, is more remote care, more telehealth. I think it would be a very bad thing and a huge lost opportunity to go back to that sort of 10 kms per hour trundling pace we had before. Especially if we can show it remains safe and it's cost effective. We can't -  we know even before the pandemic, we can't keep doing health care the same way. So Western countries en masse have acknowledged this. We can't just keep adding more and more people into the equation and more technology at the edges. We have to rethink how we do it or else we cannot keep up with the load. It's just a simple fact and even in trying, we will chew more and more and more money in doing it. I’m not saying, obviously, we shouldn't spend money on health care But we shouldn't throw it away, either, because it's also a scarce resource. So that's what I'm hoping stays. I'd be worried if it doesn't once we've got the evidence to hand. I'd like to think, too, though, that that's a springboard for all sorts of other things. So some of the sort of concepts I introduced before about, well what else can we now do over the wire? Now that we're basically using a VC connection to do more care, I think having got people used to that and also because in parallel separate from the pandemic in Australia, in our hospitals in particular we're finally putting in more and more electronic medical records systems. Now, they're not without their problems. But what they do mean is you increasingly get more and more of the data about patient care in a true electronic form. That opens the door to much more intelligent computational analysis to support care. And so hopefully you know, if you like we’ll have risen the tide and floated all the boats at the same time. And we can start having a different conversation about, a better conversation about technology supporting healthcare. But all the while making sure we're keeping it safe.

SC: I wonder how much of the work of things like digital health has been in trying to convince doctors and patients that it's an okay way to go. You know, I imagine myself as a patient or as a doctor, and it does feel like so much of -  beyond just the physical needing to be examined - so much of the interaction between doctor and patient is the doctor picking up on those very subtle, nonverbal cues, the way a person might move, or if they look uncomfortable or anything like that. Was it hard to convince people to get on board with this approach when it is so radically different to what we are used to doing, which is two people being in a room together?

CB: Yeah, look, I think in the case of telehealth in the pandemic, it wasn't hard. And the usual rationale and forces at play in that conversation sort of went out the window because of what was forced upon us in the pandemic. But that challenge is always there. It's there in every industry. When you talk about more technology in an industry, it remains. It will be there afterwards. And, you know, as long as health care, science and IT science and so forth keep pushing the boundaries we’ll still be having that conversation. And we should. But I think some people, you know, leap to places where the computer takes over and you don't see the doctor anymore and all of this kind of thing, which I don't think is a helpful conversation i think if we focus on what's best for the patient and we do the same by the patient in terms of the standard and quality, with more computational support because it helps in some other way, it might save money or whatever it may be. But I think those of us who work in the intersection and have also been doctors ourselves would like to think, for all kinds of health practitioners, some of the point of this is actually making their lives easier. It's doing things that the computer is good at while freeing them up. They spend more time having that human conversation and showing empathy because they're not running around looking for a test result that should be smack bang in front of them as soon as they want it, because that's still our reality a lot of times in Australia. So I think as long as we, you know, involve the right people who are the health care professionals, people like myself, who can sort of see both sides of that coin and, very critically, the community and patients, we can find the best of the situation and not leap to these dystopian outcomes in our minds and let that block us moving forward because I think that's not a good outcome either.

SC: Absolutely. And look, I think if there's one area we would all like to see telehealth, it's in the Covid test. None of us wanna have that swab stuck up our brains ever again. So if we could do that via the computer, perhaps that could be your next task. Chris. You’d get a Nobel Prize. Chris, this has been so fascinating. And you are absolutely right about us needing to look to the future with an open mindedness and not fear, and I think that will benefit all of us. Thank you so much for your time

CB: No worries Susan, it's my pleasure. 

SC: Let's hear from Cathie Reid.

CR: Hi, My name's Cathie Reid. I'm the co-founder of Australia's Epic Pharmacy group and also the co-founder of Icon Group, which includes Icon cancer centres and Slade health chemotherapy compound. inc. I've had a long interest and passion, I guess, for the role that digital health and digital technology can play in the delivery of health services.

SC: Cathie Reid, thank you so much for joining us.

CR: Absolute pleasure. I'm always interesting to chat, and particularly at these times,

SC:Well, you know, we're in a time where going to health care delivery via technology has really accelerated because of Covid. This is an area that you've been working in for quite some time. What do you think is possible now that might not have been before.

CR: I think the single biggest change that we've seen has been the education and up skilling of both consumers and health care professionals in interacting digitally. When you think about the average age of people, of consumers in the health care system, and particularly, I guess the frequent fliers, the ones who use the majority of the health care services, it tends to be that population that's over 65. Typically they haven't actually been the ones who have been using video calls and using a lot of the apps and the connected devices that a lot of younger people tend to use now almost a second nature. And I think the really big impact that the pandemic has had is on that kind of upskilling, because it's been the only way that those people have been able to have interaction with their children, with their grandchildren with their friends while we've all been in this sort of social restriction and isolation, it's meant that they actually all of a sudden have got very good and very familiar with using tools that they previously would never have used. And the same goes for doctors as well, because a lot of doctors aren't great with digital technology. But they've had, it's forced everybody to acquire those skills quite quickly. I think that's been really significant, it's removed one of the major blocks in the uptake of digital health and technology.

SC: Do you think these changes would have happened as fast if we hadn't had the pandemic to sort of push us in that direction.

CR: No, because well, particularly in the healthcare space, the things that we've been using, they're not new things. It's not like all of a sudden we've invented thes new mechanisms for enabling health care professionals to be able to do calls with patients or to receive access to results or to have the patients use connected devices that allows the transmission and the results through to their health care professionals. Nothing new has actually been invented during the course of the pandemic. It's just been uptake of tools that have existed for years that, you know, those of us who have been working in this space have really, really battled for years and years and years to actually get enabled and to be able to happen. So I think it's, yeah, the pandemic has driven the shift, but it hasn't actually created the products or the platforms that we're using. Its just enable their utilisation

SC: Apart from, you know, the obvious things like telehealth, is there any other digital or new approach to delivering health care that's become more popular during the pandemic that you're particularly excited about?

CR: Look, I think it's really been able to illustrate how effective monitoring people in their homes can actually be, and that some of those, even those readily available kind of off-the-shelf products can actually do a really nice job of being able to alert when an intervention is required and it's possibly given the ability for earlier detection in some instances. If you've actually got someone and even just using the example of diabetes management, if you've got someone who's actually having their diabetes managed and historically it's always been they've had a standard fortnightly appointment, essentially with their doctor, where they go in and they have a chat about how things are going and what's their blood sugar looked like for the last couple of weeks and on they take out their log book or they may be show them if they're recording it on an app what that actually looks like, that’s all very reactive to what’s happened in the past. Whereas being able to actually, because there's been a reduced ability to hospitalise people or to have people come in and access that care face to face, it's really illustrated just how easy it is. And in some cases it’s much more effective to be able to have that link set up where you've got the alert level set, and once that alert is reached, you know an intervention happens, which might be, you know, a zoom call or facetime call or whatever else to the patient to say, Hey, we've just seen you know, your sugar levels are trending up, what's going on? How are you feeling, what's actually going on? Let's get that into place. So I think it allows much more proactive management. So I think there's been a lot of really nice illustrations around on those sort of applications, as well as just the actual use of video calls.

SC: If you were suddenly made the boss of health, what kind of utopian vision of health care or health service delivery would you like to create for everyone? What would it look like?

CR: I think a blend.It's neither fully digital or neither fully physical, it's a blend of those physical and digital interactions where you use tech in a smart way like like we were just talking about to monitor and to alert when interventions are required and then trigger that intervention really quickly and needed using the technology. But again maintaining, though, that regular face to face interactions, to assess, I guess, those signs that that tech does tend to dull out. I mean, now we're all experts in video calls not just for health care, but for everything. And I think certainly one of the things that's become really apparent initially, everyone's like, Oh, how good is this, there's no difference in meeting face to face to meeting over Zoom, but then, after doing it for a couple of months, you go, you know what? It actually isn't the same. It's a very good alternative, but it's not the same. You don't get the same nuances that you can pick up in a face to face meeting on a video call, so I think it's where it is. The ideal is that blend of the physical and digital and marrying the two together.

SC: What changes do you think we'll see going forward now that we've had such a big change due to coronavirus. How do you think we will see health delivery alter in the future?

CR: Well, I think it's hard to be fully positive about it because I think we're already seeing this sort of rapid retreat in some instances to return to the ways of the past and, you know, human nature, we’re hardwired to resist change whenever we possibly can, and we’re actually already seeing this in health care that now, now that we have got the restrictions easing in many parts of the country and indeed in many parts of the world that haven't been, that haven't blocked people from having to go back to that traditional physically go to a doctor's physically go to a hospital, to get their service, we're actually seeing, you know, some of the those measures that were put in place to facilitate change actually being wound back quite quickly and telehealth is is a classic example of that, you know, we're already back to a scenario where you can only have a telehealth consults with a practice, a medical practice that you're already registered to, that you've had a face to face consult with the doctor in the last 12 months. So I think, unfortunately, the changes that we're seeing going forward are not always going to be positive because they're going to, they are in some instances, a bit of a clamber back to return to the way things were rather than what would possibly be more ideal and what have been the positives out of this and how it can create this new blended model moving forward.

SC: Is there a way you think we can better encourage patients and health practitioners to embrace some of the changes. You know, they've had a bit of a try of it  but, you know, in some parts of Australia, they are in lock down for the second time. So patients and health practitioners are having to at least test these out for a few weeks. What could we do to try to encourage them to keep it on board as just part of the suite of health delivery services that they use?

CR: Look, I think for many patients they will demand it, and and you know, it’s like anything -  much more change is consumer driven than industry-driven, it tends to be that once consumers have a particular experience, that's the experience that they expect going forward if it's better for them. If they see positives and they see benefits in it, then they will demand that going forward and I think that's where we are going to see the shift come from because, you know, for everybody doing their job often times it's easy to do your job in the way that you've always done it and without having to make significant changes. And I I think one of the things that's being illustrated in health care as well, that just some of the very basic infrastructure that existing healthcare has has led to real challenges for health care practitioners in being able to deliver services remotely. For example, you know, the very fact that so much medical software is still on premise, not in the cloud. It's actually meant that for a lot of doctors, in particular, you know, they've had to do telehealth, but they've still had to go into their surgery and work from there because that's where all of their records are and they don't have their patient files. Whereas if those systems had moved -  for people, many people working in other areas where we're all using everything's on Onedrive, for example, in an office based environment or Google drive, you can work from anywhere because you can access all of your files and all of your information regardless where you are. So there's an actual, quite significant infrastructure barriers and even the functionality of some of the different commonly used platforms in healthcare that are going to need some significant reworking before real long term change can be achieved.

SC: Cathie Reid, thank you so much you've given us really useful things to think about.

CR: You’re welcome. Thanks, Susan.

SC: In our next episode, we'll round up all the best practical tips from our experts about how you can embrace this healthcare revolution. As always, more information on what we talked about today can be found in the show notes, and I'll see you next time on What Happens Next.