Interview, Primary Care News

What does technology enhanced primary care look like? By Dr Hussain Gandhi

Written by Dr Hussain Gandhi a GP in Nottingham and owner of eGPlearning – technology-enhanced primary care and learning. Contact @egplearning or @drgandalf52 or follow on YouTube :

Consumer use of technology is driving UK healthcare in the NHS to now innovate and adapt to meet the wants and needs of the public.

The NHS long term plan along with other recent documents by NHS Digital aims to prioritise digital healthcare both in terms of function and access. But what does this mean for the coalface clinician, how can we develop technology-enhanced primary care?

Technology is now an integral part of general practice. General practice was one of the first areas of medicine to truly embrace the use of IT creating electronic health records for patients in the 1970s leading to the UK becoming a world leader in computerized medical records keeping. However, fragmentation, issues with interoperability, failed and costly national projects and regional variations have led to complex systems of patient medical record keeping and stunted bureaucratic innovation.

Mobile access is likely to be the first area we see continued development. Accessing patients electronic medical records (EMR- a patient record created by providers for specific encounters in a care setting) by desktop is commonplace, however increasingly practices and federations are looking at mobile computing by laptops and tablets to allow mobile care both in and out the practice environment. Access and continuity of the EMR is a key factor for providing safe and integrated care, and as the providers of EMRs like SystmOne, EMIS, Vision INPS, and others move closer to mandated interoperable standards we may see an end to fragmented community care. Deeper integration with secondary care systems may bring about a true electronic health record (longitudinal collection of the electronic health information of individual patients)  when combined with personal health records (an electronic application for recording personal medical data that the individual patient controls and may make available to health providers) such as those held by patients from wearable data from Fitbits, Apple watches etc or systems like Patient Knows Best leading to a goal of true digital health care.

Particularly with tablet-based access, this can lead to rapid innovation and service with app and point of care MedTech or wearable integration. ORCHA which works with the NHS app library is providing valuable evaluation for clinically safe medical apps for use by both clinicians and patients.  For medtech, examples, of this already exist with the growing use of the Alivecor Kardia atrial fibrillation screening device. However further examples are the use of digital cameras or dermatoscopes for teledermatology integration, and even facilitating rapid referral via systems like Cupris for ear nose and throat pathways. Future options include cancer screening devices such as the Breath Biopsy® pilot in Cambridge.

Wearable which provides patient held data may prove valuable sources of information to deliver personalised healthcare. Simple examples are using sleep tracking to support changes to tackle insomnia, heart rate tracking to monitor cardiovascular changes and even geocaching to drive lifestyle change.

A further focus of personalised care will be with genomics. Possibilities include checking a patient’s genome for individual health condition risk factors and risk profiles for medications before initiation to reduce side effects and increase treatment outcomes.  

Maybe considering a tablet computer for each clinician may help to drive further innovation as more apps, Medtech and wearables develop for point of care patient use.

A further benefit of mobile computing in healthcare is the prospect of delivering remote care. With the current workforce crisis, we have seen an increase in digital consultations either by telephone and now with video consultation services. Being able to deliver care from any place by a telemedicine interface is likely to be a benefit to the federated model of care as anticipated by primary care networks (PCNs)  in the coming years. This can be beneficial for the clinical workforce and patients, but also needs careful implementation for the safety of care.

Last year, artificial intelligence (AI) arrived in primary care. With pre-triage systems being developed by companies to filter patients to services, we have heard of success and failure. AI will develop and the impact is unclear, however, many have their views. However, automated workflows like econsult and askmyGP are building traction and may become commonplace for practices and patient to manage for access to healthcare.  

How much blockchain will impact all of the above is unclear. Seen as a way to verify data, it is likely blockchain will innovate medical note access particularly with the increase of patient access to medical records. This is clearly a space to watch with interest as technology drives enhanced primary care.

However, the IT infrastructure is a key challenge. WiFi in practices and hospital environments was mandated as part of the GP Forward view, but in some areas is still developing.  With regional variations of supply and governance by CCGs as seen during the Wannacry attack in 2017 (with certain areas being compromised more than others) ensuring equitable delivery should be considered.

Much of the UK has 4G data access, it is not universal and particularly rural areas would struggle to offer coherent video consultation and data-reliant services compared to an inner city practice, particularly if practices are still stuck using internet explorer 8 due to legacy software restrictions.

Uptake by patients and public usability is also key. The NHS app currently finishing beta testing appears to have positive reviews, but if this is to be the main access point for patients to their healthcare, how will this impact patients who choose not to have a smartphone or struggle to use these devices?

Technology is a key part of healthcare. There are challenges to overcome, including the change cycles itself of implementing useable technology. However, a clear focus in the NHS 10 year long term plan means access to funding particularly for PCNs will help drive digital healthcare for all and technology-enhance primary care.