By Jonathon Carr-Brown and Matteo Berlucchi
Sponsored by Your.MD
“The term ‘primary care’ is a misnomer. The first thing citizens and patients do is think what they can do for themselves, the second is to seek advice from friends and family, and in the last twenty years, the internet. Then they seek professional help.”
Professor Sir Muir Gray
“New concepts like pre-primary
care are important
...this is the right discussion
to have as we seek new
approaches to building a
genuinely 21st Century
Rt Hon Jeremy Hunt,
The Secretary of State for Health (England)
Globally healthcare is under pressure. Developed countries are struggling to meet demand and developing nations are battling to retain healthcare professionals to deliver the most basic services.
The challenge for all is how to provide access and quality at an affordable price. For centuries doctors’ waiting rooms have remained unchanged - a time defying tableau - queues of people waiting for medical wisdom delivered face to face. The face-to-face consultation remains the gold standard for primary healthcare globally but the human tide descending on primary care practitioners is fracturing the status quo.
This report looks at how digital technology can help enable and equip a new type of provision. The traditional definitions of primary and secondary care have served us well but in a world of under-resourced and underfunded health systems is it time to define a new area of appropriate, trusted and safe provision? We need to develop a concept of pre-primary care to release the power of technology. This report sets out to make the case for creating a pre-primary care sector and describes how it will contribute to redefining global healthcare.
“For physicians who trained 20 to 30 years ago it is hard to believe that patients want these services and they are uncomfortable with these new ways of working but for young doctors they are right there already.”
Dr Molly Coye, Social Entrepreneur in Residence at the Network for Excellence in Health Innovation
The world of healthcare is changing. Developed and emerging healthcare systems are being assaulted equally by ageing populations, a tsunami of chronic conditions and increasing demand for the best technological advances.
Western medicine still favours treating illness over promoting wellness and its medical professionals are trained to diagnose, treat and cure rather than prevent. It is an industry not in collapse but at the peak of its scalability. It is a system rooted in bricks and mortar and the bureaucracy that comes with billion pound budgets and profits.
In developing countries ageing is less of a problem but chronic conditions like diabetes and asthma are hitting already chronically under-resourced healthcare systems struggling to provide rudimentary primary care to their populations.
The evidence suggests we live in a world where our existing models of healthcare are both “financially unsustainable and inequitable. 1”
In the words of Dr Fred Hersch, Chief Medical Officer of Telenor Health based in Bangladesh, neither world can “treat themselves” out of the problem 2.
“The smart phone is shaping up to be the dominant computing platform and it’s not hard to imagine that developing countries will leapfrog the PC era in much the same way that mobile communications leapfrogged fixed land lines.”
Dr Fred Hersch, Chief Medical Officer of Telenor Health
There comes a point when you have to fix what’s wrong with you before criticising others. The proverb “Physician heal thyself” encapsulates the sentiment and perhaps the motto of the pre-primary care movement – “Patient Heal Thyself”.
Patients in the developed world are quick to criticise healthcare system failures but not so prompt in correcting their own behaviours that exacerbate the burden on healthcare budgets.
In nationalised health economies like the NHS patients see it as their right to use the system they have paid for and in privatised systems consumers see it as a necessity to get their money’s worth. Different systems same behaviours, driven by different perspectives.
Your.MD – AI Personal Health Assistant
The goal of Your.MD is to democratise healthcare and place a doctor in the pocket of every citizen in the world. Using artificial intelligence the Your.MD application is learning from its users every day. Benchmark tests have shown medical accuracy at 85% for the 20 most common conditions. Medical accuracy for a further 500 conditions now sits at more than 60%.This makes Your.MD the most accurate symptom checker in the market today. Your.MD’s medical accuracy is benchmarked for diagnostic accuracy using externally verified medical test cases from Harvard University and the Royal College of General Practitioners. This is the same method used to test trainee doctors.
Your.MD has also created its own test cases that hold greater relevance to its global database of users, so testing can be more diverse and thus more accurate. Eventually, Your.MD aims to have a case for every condition so Your.MD will be medically more robust.
In developing healthcare systems, populations face scarcity of resources and disparity in provision between rural and urban areas. As a result, millions around the world already care for themselves and would value medical assistance that could be placed in their hands.
What if, in the developed world, we enabled citizens to be more responsible and accountable for their own health? What if our doctors told us we all had to take our blood pressure, weight and pulse before coming to see them?
What if, in the developing world, we trained one person in every village, armed them with a mobile phone, miniaturised testing equipment and showed them how to appropriately diagnose, treat and triage members of their community?
How is asking someone to prepare for a medical appointment different from the substantial assistance we now give to the airline industry in conducting its business: we book online, order our food and seats online and we print out tickets. When we reach the airport we increasingly check ourselves in and, lately, even check in our own bags. Our banking and shopping experiences are no different. Self-checkout at supermarkets is ubiquitous. Our service industries are now less service more self-service. With these examples citizens have been happy to trade contact and familiarity for convenience, utility and savings even if that means new inconveniences further along the customer journey.
How is skipping the primary care stage in the developed world any different from Kenya skipping over universal banking and going straight to mobile money? Paradigms change in order for the world to progress. Developing a concept of pre-primary care represents a paradigm shift for healthcare globally.
Dr Eric Topol, author of The Patient Will See You Now, says medicine has long been dominated by a “priestly class”, beginning with Imhotep, the first physician (and a priest), in Egypt some 4,600 years ago. Things have hardly changed. Two millennia later Hippocrates, widely considered the father of medicine, insisted that most medical information should be concealed from patients.
As a result, citizens continue to sit in waiting rooms with ailments seeking reassurance, diagnosis and treatment. In the 21st Century, if you want a trusted medical opinion you make an appointment with a professional who has had at least seven to 12 years’ training and is backed by an infrastructure that allows them to empirically prove their medical hypothesis through tests. In developing nations, you either suffer, wait or trek to see trained physicians that are mostly concentrated in urban areas.
It is an inefficient system with the primary care physician acting as a gatekeeper to wider healthcare in most systems. Although many countries operate a system of self-triage to specialist primary care physicians the starting point is always a doctor in a room with a stethoscope no matter what the ailment is, its severity or its longevity.
This approach works as long as you have enough physicians to deal with patients in a timely way. If every individual went to the doctor’s surgery once a year even with the growing population the historical approach might hold the line. However, as populations grow and people live longer with chronic conditions the number of consultations per health professional escalates.
The NHS now estimates that the average citizen sees a nurse or general practitioner five-and-a-half times a year, up from three times in the mid 1990s.3 In India, it is estimated that a primary health centre, which is usually run by one doctor, will be responsible for 30,000 residents4.
Over the past ten years, the challenge to meet the pressure of chronic disease in developed countries has focussed on primary care. It was assumed that strong primary care was the most effective and efficient way to address the growing problem.
However, although excellent examples of primary care management of chronic conditions have been developed across the globe scaling them is proving challenging. Inadequate facilities, a short supply of health workers and a lack of knowledge about managing chronic conditions are hampering attempts to hold back the tide.
Even efforts to apply evidence-based interventions are proving a burden in the western world. In the UK, the gold standard for Type 2 diabetes training is DAFNE (Dose Adjustment for Normal Eating) a course that requires the at-risk individual to attend 13 one-hour courses over nine months.
Omada Health – Personalised digital behaviour change
Sean Duffy, the founder and CEO of Omada Health, wants to combine the best of evidence-based behavioural science with the best in design and technology. Omada want to identify what works and then translate it into digital therapeutic approaches designed to generate outcomes. The company’s first product, Prevent, is an online weight loss and lifestyle program for pre-diabetes. It is based on Diabetes Prevention Program (DPP) studies that showed that modest weight loss, the result of regular physical activity and a low fat, low calorie diet did delay or prevent progression to diabetes.
A company-run study, published in Diabetes Educator, documented the following results:
• Participants completed an average of 13.8 out of 16 lessons
• Body weight was recorded in 90% of the core sessions
• Participants lost five per cent of their body weight during the sessions and maintained this wait loss for 12 months
• Baseline blood sugar levels (HbA1c) regressed from the pre-diabetes range to the normal range
Overall, Prevent was found to have performed as well as residential versions of the course.
NHS England has recently commissioned a £100,000,000 five-year Diabetes Prevention Programme that aims to educate 100,000 people a year using DAFNE. That represents £200 a course. Not a huge price until the scale of the problem is understood. There are five million people thought to be at high risk of contracting Type 2 diabetes in England. The cost of applying this evidence-based approach to all of them would be £1bn5.
This is a notional cost because the evidence base suggests although the courses are effective most diabetics will decline to attend because the approach doesn’t fit their lifestyle or perception of themselves. The National Audit Office in the UK reported that only 16% of newly diagnosed diabetics were offered structured education and fewer than four per cent of those offered attended the courses 6.
The provision of healthcare is complex. There are many stakeholders, each with their own objectives, motivations and incentives. Improving health outcomes is as much about provider behaviour change as it is about patient behaviour change and requires buy-in from multiple stakeholders7.
Behaviour change is the marketing concept that has driven the digital consumer revolution over the last 20 years. Retailers and other service industries realised their customers were inherently complex and willing to try a variety of appropriate delivery mechanisms and increased personal involvement to gain quick low cost access to high quality services and products.
BigWhiteWall – Patient-Guided Mental Health Management
Access to mental health provision is oversubscribed throughout the developed world. BigWhiteWall (BWW) was developed to provide immediate support for sufferers prior to and after face-to-face referrals.
In a survey of BWW members, 46% reported sharing an issue or feelings on BWW for the first time and 70% of members from local health contracts reported that using BWW improved their wellbeing in at least one way. Other findings included:
•People taking BWW GuidedSupport courses for anxiety experienced an average reduction of 3.5 points on the GAD7 (anxiety) scale
• For people taking depression courses, the average reduction in the PHQ9 (depression) scale was 3.5 points
• BWW’s LiveTherapy service has consistently shown recovery rates above the average achieved by Improving Access to Psychological Therapies provision. Of people referred into BWW’s LiveTherapy programme by their GP, 57% were moving to recovery. The national average recovery rate is 45%, according to NHS statistics.
Smart phones can now quantify your state of mind by a composite of real-time data: tone and inflection of voice, facial expression, breathing pattern, heart rate, galvanic skin response, blood pressure, even the frequency and content of your emails and texts.
A recent study by Gale Lucas in the Journal of Computers in Human Behavior11 demonstrated that people are more willing to disclose their inner thoughts to a computer avatar or virtual psychiatrist than a real one. With machines working to quantify moods and even offer virtual counselling to help make up for our profound shortage of mental health professionals, we can glimpse a new pre-primary approach to improving mental health.
While the world is currently focusing on digitally giving citizens access via video, voice or messaging to doctors this trend is quickly abating as suppliers realise the solution does not solve the shortage of qualified health professionals. A telephone or a Skype conversation is more convenient for the patient but probably takes up the same amount of time in a doctor’s day leading to only marginal productivity gains when what is needed to save healthcare is an algorithmic productivity gain.
Bruce Wilcox, a Loebner Prize12 winner and chatbot expert said: “This transfer to digital pre-primary care must happen. Mostly people get sick at night or at weekends when doctors aren’t around. That’s when they need reassurance.
“We are at least five years away but apps like Your.MD will be able to diagnose as well as the average doctor by then and I know that because artificial intelligence systems like the IBM Watson programme are already better than a doctor in specialties like radiology and pathology.
“It is inevitable that these apps are going to get better. Once you start adding sensor technology and giving people the freedom to order tests themselves it is going to be difficult to see what the doctor is adding. The Star Trek tricorder is coming. Doctors know more and they can order a test and narrow down the possibilities but that is an arbitrary restriction. What we are in the process of developing is a digital Dr House.”
At the moment, one barrier to wider adoption, particularly in the western world, is the appetite for apps is not matched by the evidence of their impact on people’s health and their interactions with healthcare providers. There are mixed feelings about them among professionals. In a global survey of doctors, despite their own use of technology (see digital channels table below)13
• 41% agreed with the statement that mobile apps could be a ‘game-changer’ for improving health
• only 36% stated that they would recommend a mobile health app in future to their patients
To date, there has been a real focus on apps and devices to improve wellness – such as step and calorie counters – as well as those focused on a single disease. There has been less of a focus on tools for complex costly patients.
One interviewee said that developers shy away from apps for complex patients. David Blumenthal, president of the Commonwealth Fund, said in a recent Cello Health Insight report: “They’re too complicated, they’re too unappealing, the ROI [return on investment] is too unclear, the time to pay off is too long [and] they need to know too much about these patients in order to develop these applications.”
A systematic review into smart phone apps for the prevention, detection and management of cancer found that, while there are a ‘considerable number’ of apps available, the evidence for them is ‘lacking’ (Bender and others, 2013).
Devices such as Fitbit and smart phones collect a huge amount of data. Patient portals such as Patients Know Best allow patients to integrate these with their EHR (electronic health record), while companies like EMIS Health and Medelinked are able to access data stored in Apple’s Health app once the end user has consented to share it. However, generally speaking there are issues around uploading app data to EHRs and even more so in meaningfully interpreting the results.
Several interviewees in the Cello survey had mixed views on the potential of wearables and apps.
David Furniss, Vice President, Global Government and Health at BT said: “There is an overemphasis on the device that people are using to capture the information and not on what am I going to do with the information now I have captured it.” There also remain security concerns around the use of mobile technology, particularly in unregulated markets.
In 2015, the UK NHS Health Apps Library carried out a systematic assessment of 79 apps certified as clinically safe and trustworthy. It found that 89% transmitted information to online services and that 66% of apps sending identifying information over the internet did not use encryption14.
Dr Hersch admitted the evidence base for digital pre-primary care is slowly evolving but he still believes “the question is not ‘if’ technology can improve access but ‘how’”. Dr Hersch explained: “I envision a technology-assisted pre-primary care eco-system that can support in an integrated manner providers, frontline health workers and patients.”
For Dr Coye the answer is rapid testing cycles: “Where a clinician is doubtful we should be doing a fast six-month test. Pull in the data and then discuss it. This will not answer every doctor’s doubts but it will grow the evidence base. But the strongest evidence over time is doctors saying this really works.”
By attacking these issues early in the patient journey, these platforms will create a whole new market space - the pre-primary care market.“
The World Bank Group, the WHO and the Bill and Melinda Gates Foundation “conservatively” estimate 400 million people on the planet do not have access to basic services usually provided by primary care.
All too often, primary healthcare is a weak link in health systems. The recent outbreak of Ebola, a disease that can be prevented through basic health measures, both exacerbated and was partially fuelled by broken or non-existent primary healthcare systems.
A Gates Foundation report also found that across 37 countries 6% of the world’s population was tipped or pushed further into extreme poverty (<$1.25/day) because they had to pay for health services out of their own pockets. When the study factored in a poverty measure of <$2/day, 17% of people in these countries were impoverished, or further impoverished, by health expenses.
Dr. Kaushik Basu, Senior Vice President and Chief Economist at the World Bank Group, commenting on the report17 said: “These high levels of impoverishment, which happen when poor people have to pay out of pocket for their own emergency healthcare, pose a major threat to the goal of eliminating extreme poverty. As we transition to a post-2015 development era, we must act on these findings, or the world’s poor risk being left behind.”
The WHO and the World Bank Group recommend that countries pursuing universal health coverage should aim to achieve a minimum of 80% population coverage for essential health services, and that everyone everywhere should be protected from catastrophic and impoverishing health payments.
Dr Hersch, explained: “In the West we latch onto primary care because it is the first line but the reality for the majority of the world is that primary care doesn’t exist. In Bangladesh where I work, you are lucky if you have three doctors for 10,000 people. The WHO classes anything below one to 1,000 as an unsafe system. The further out you go into the rural community the less primary healthcare you get. Access is a huge issue and the solution isn’t to train more doctors.”
He added: “This idea of defining pre-primary care in the global context is about empowering people to address a market failure, democratising healthcare, giving power back to people and demystifying healthcare for the consumer.
“How can we leverage digital technology to link people and support them through a journey? It doesn’t all have to be digital, it could be a technology-enabled healthcare worker in the community.
“Yes, there are certain things you need a doctor for but all sides have to be reasonable about this. We’re not diagnosing cancer with an app but we could be stopping the spread of non-communicable diseases by efficiently disseminating information. We sometimes over medicalise the medicine when what we are talking about is promoting health.
As a doctor I’m not trying to get rid of myself but I think we’ve forgotten that medicine is an art as much as a science. We’ve buried the art by trying to deliver more care, when what is needed is time for better quality of care. If doctors are pressured for time you cannot expect them to deliver holistic ‘patient-centered’ care. If we can unload pressure in the system and bring in tools to make the workload more manageable then doctors will return to being caregivers rather than reactionary decision makers.”
Dr Hersch added: “If you understand the health risks of a population (through access to good data) then you can begin to intervene more strategically and offer the right “digital therapeutics” at the right time to activate them and begin the (difficult) process of behaviour change.”
Several countries offer examples of high-performing primary healthcare. Brazil’s efforts to train and assign primary healthcare workers to specific neighbourhoods have led to dramatic gains in health, especially in the country’s poorest areas. Ghana’s efforts to implement mobile-based primary healthcare have helped the country achieve reduced infant mortality and increased life expectancy.
“The demand for primary care is such that general practitioners have nothing to fear. Their rice bowl won’t be broken, the demographic is too large.”
Dr Molly Coye, Social Entrepreneur in Residenceat the Network for Excellence in Health Innovation
WebGP – Patient Triage
Hurley Group, a London-based GP organisation, has developed a patient self-triage system.
On entering the site consumers can either make a face-to-face appointment in several days’ time or fill out one of 100 digital forms that relate to the condition they want to discuss.
That form triggers a phone call to the patient either from a nurse or GP within 24 hours (some surgeries call back within an hour).
The system was developed after Dr Arvind Madan looked at the Hurley Group’s patient data and realised most people had minor ailments, knew what was wrong with them mostly knew what to do but were seeking reassurance. An analysis of a pilot study of WebGP over six months found that:
• of the e-consults, 40% led to a prescription, 40% led to a GP appointment and 20% led to a telephone consultation
• 18% of patients self-managed an issue for which they had planned to see a GP
• for every WebGP user requiring a GP response via an e-consult, five users required online self-help only (WebGP, 2014).
Even more surprising was that 75% of all the consultations were about ten specific minor ailments: back pain; dermatitis; heartburn; nasal congestion; constipation; migraine; cough; acne; sprain and headache.
All these ailments were considered to be suitable either for a pharmacy visit or self-care but in a staggering 90% of the consultations for minor ailments patients received prescriptions worth £371m when they could have bought cheaper over-the-counter medicine.
In total, the study found that 20% of a GP’s time was being spent on minor ailments that could have been treated by a pharmacist or an individual at home with better information and pre-primary care support. Further studies suggest that between 15% and 40% of all A&E visits are for minor ailments and injuries that could have been treated at home.
In 2004, the European Self-Medication Industry Association (AESGP)19 carried out a detailed economic analysis of a move from prescribed medicines to self-medication in the UK. It concluded that the change would free up an average time of eight minutes per consultation. Time freed up as a result of the lower number of doctor visits for minor ailments represented 2.8 million doctor working hours per annum or 21 hours per doctor per year.
Research carried out by the Proprietary Association of Great Britain (PAGB) and IMS Health suggests that a focus on pre-primary care could reduce GP visits by 40%; outpatient visits by 17%; A&E visits by 50% and hospital admissions by 50%. In addition, two thirds of GP prescriptions could be transferred to cheaper over-the-counter drugs or no medicine at all.
Nicolas Roope, founder of Poke and acclaimed digital designer and entrepreneur, said: “In the NHS the conversation is about money against a seemingly fixed cost resource of doctors, practices, hospitals, beds and drugs. If you want more service, less waiting, you have to pump in more money. Attempts at efficiency gains through management restructuring have turned into a running joke in Whitehall and across the media. There seems to be no way out of this quagmire. But there is a way.
“If we could take a huge chunk of the informational quotient of doctors’ time and replace it with more distributed, more accurate, free service for everyone, doctors would be left to focus on what they really need to be there for. This would allow a refocusing of time and resources that would immediately result in more rapid and accurate solutions and much lower waiting times for those still requiring attention.
“The frontline of primary care that takes up 20% of doctors’ time can be largely improved, sped up and replaced by technology like artificial intelligence. Less cost and less burden on public healthcare, and more focus and attention on when a doctor needs to be in the same room as the patient to resolve the problem.
“Conversational artificial intelligence personalises responses from the very first question, carving up millions of diagnoses rapidly towards the result that is right and accurate for you.”
MyDirectives – Patient Voice
Driven by their grandparents’ traumatic end-of-life experiences, MyDirectives’ founders Scott Brown and Jeff Zucker from Dallas, USA have developed a multimedia approach that demedicalises, standardises and demystifies the process of describing your preferences, values and goals in the event of a health crisis. Available 24/7 anywhere in the world it frees clinicians from the burden of sitting down and recording patients’ decisions and statements and makes it easy for doctors to retrieve a patient’s statements anywhere in the world. Coordinate Care Oklahoma (CCO) has now invited more than one million of its 4.2m users in five states to create a MyDirectives’ profile. The directives created can now be accessed in 45 hospitals in the CCO family.
“Primary care is like the shed at the bottom of my garden. I’ve put so much stuff in it over the years I now can’t find the space inside to reorganise it. The only approach is to put another shed alongside it and take out the stuff that doesn’tneed to be in the first shed anymore.”
Jim Dawton, Director of Impeller Ventures and former Lead Specialist Designer at the Technology Strategy Board
Bill Gates, the founder of Microsoft, predicted: “As more people obtain access to better and cheaper digital technology, an inflection point is eventually reached, at which the benefits of providing digital services like banking and healthcare clearly outweigh the costs.”
Imagine community health workers in the developing world armed with care protocols, low-cost diagnostics and mobile phones with artificial intelligence-driven decision support software.
An army of individuals with the ability to provide care, including advice and treatments, for a range of common conditions, minor ailments and injuries and information about prevention and behaviour change digital therapeutics. Pre-primary care driven by artificial intelligence, natural language programming, high quality content and early intervention. People diagnosing themselves and ordering tests then using doctors to help them interpret the results.
To meet existing and future health challenges we will require increasing investment in pre-primary healthcare driven by digital technology. Healthcare systems will need to do more for less by deploying their biggest assets - patients doing more of the heavy lifting for the service.
As technology transforms it will increasingly be able to meet local needs and deliver multiple approaches that fit individual’s lifestyles and needs. Truly personalised healthcare at scale.
Soon we will see a global health brand based on the provision of trusted pre-primary care. As Dr Topol said in the Wall Street Journal: “Just as the printing press democratized information, the medicalized smart phone will democratize healthcare. Anywhere you can get a mobile signal, you’ll have new ways to practise data-driven medicine. Patients won’t just be empowered; they’ll be emancipated.”
Dr Coye concluded: “Primary care physicians will be more accepting of pre-primary care if they understand that valuable clinical and psychosocial services can be accomplished by technology-enabled health workers and by patients themselves, and that this will reduce the physicians’ workload, improve clinical outcomes and reduce the total cost of care.”
Pre-primary care is the solution – and it is here today.
Doctors know more and they can order a test and narrow down the possibilities but that is an arbitrary restriction. What we are in the process of developing is a digital Dr House.”
Bruce Wilcox, Loebner Prize winner