Shifting to a world of prevention: A GP's story

For this post, I caught up with Dr Manpinder Sahota, a GP in Britain's NHS. We first interacted over Twitter, where we met on the topic of shifting healthcare to a world of prevention. Dr Sahota said he had a vision for building a GP practice with a focus on wellness and prevention of disease, and was curious if technology could play a role in that. So I hopped on a train to see him, and what follows is the interview at his practice, in Gravesend. For those who have never visited, Gravesend is an ancient town in north west Kent, England, situated 21 miles east south-east of Charing Cross, London on the south bank of the Thames estuary. Gravesend has one of the oldest surviving markets in the country, its earliest charter dates from 1268. For my American readers, Gravesend is where Princess Pocahontas is buried, having died there almost 400 years ago, on a ship bound for the Commonwealth of Virginia. Back to the present day, Gravesend [and the borough of Gravesham that it falls under] faces the challenge of childhood obesity, with 38.9% of 10 to 11-year-olds resident in Gravesham being overweight or obese. Demographics are changing, with 17% of the population of the borough of Gravesham having been born outside of the UK. 

Hearing about new models of care with Dr Manpinder Sahota at his GP practice

Hearing about new models of care with Dr Manpinder Sahota at his GP practice

1. What is your role & responsibilities?
I've been at the Pelham medical practice since 1999. We have 7 GPs, over 2 sites and almost 14,000 patients. I'm the Diabetes lead and a GP trainer as well. I also provide free acupuncture to some of my patients. 

2. What are the key challenges you're facing in the year ahead? 
In a place like Gravesend, where 50% of patients are not tech savvy, getting reminders on their mobile phone or 'choose and book' [Note: Choose and Book is a national electronic referral service which gives patients a choice of place, date and time for their first outpatient appointment in a hospital or clinic] doesn’t mean anything to them. Furthermore,  many can just about get to the local hospital on the cheapest bus, and often they can't afford a taxi to a hospital that is further away, so services such as 'choose and book' are of no use to them.  I'm seeing the local population getting sicker and sicker, and although some of my patients are living longer due to being on 9 or 10 drugs, they usually have very little quality of life. 

My main challenge is educating people in lifestyle changes, especially those from the lower social classes. I've found that if I can give them a practical bit of advice or even encouragement, it does lead to lower blood pressure and loss of weight.  

Patients only seem to listen when they are about to have ill health, many times there is no motivation to change behaviour, diet and exercise, especially given education levels can be quite low. 

I'm interested in pre-Diabetes and screening for pre-Diabetes, that is where the biggest change can happen. Usually, my patients know a bit about Diabetes from someone in the family, so there is some emotional trigger, which can help in our conversations. 

3. What is your big vision for moving to a world with a focus on prevention of disease?
My overall big vision is to get away from prescribing drugs, there are dangers of polypharmacy and I want to get people to rely upon themselves, and use lifestyle medicine as the first discussion point, before we go down the path of handing out tablets. I'm also thinking about depression, back pain, obesity related diseases, and am keen to provide Tai Chi classes, Yoga classes and Meditation classes at this new centre.

4. Tell us more about your new centre
My new centre is not replacing the existing GP surgery. It would be a new GP practice with a preventative component, One idea is to have a gym at the top of the surgery where Tai Chi classes could take place. I want to be able to prescribe patients a 12 week course on diet and nutrition with a personal trainer. There is a national program where certain courses for diabetes prevention can be done. No current funding, but in the future, there should be money coming from it. If the NHS wont fund my ideas, I will go to the British Heart Foundation or National Lottery. 

5. Switching over to technology, there is much talk about giving patients online access to their medical records, in the hope that it will improve the quality of care, shared decision making as well as patient outcomes. How often do patients come in and ask for a paper copy of their medical records?
Very rarely, it does happen though.

6. If today, your practice was able to offer online access to medical records for your patients, as an estimate, how many would use it?
I estimate 25% would use it. The remaining 75% aren't that educated and/or don't have computers. In fact, 10% of the patients visiting our practice need an interpreter during the visit, as they don't speak English, or don't speak it well enough. 

Our other practice is in a deprived area. Over there, the patients tend to believe the doctor knows best, and they don't want to be involved in their treatment decision, patients actually want a paternalistic healthcare system. Quite a lot of my Indian patients, believe that the doctor is God, and if you give them management options, they are not interested.

7. We hear so much about how wearable technology is changing healthcare. How many of your patients are coming in and showing you apps or wearables with respect to behaviour change (such as using a FitBit as a tool in increasing physical activity)?
Hardly any patients are showing up at appointments with this kind of technology.

8. What are your thoughts when you hear the term 'Big Data' in healthcare? How does it make you feel as a GP?
We are already overloaded with information, letters from hospitals, from agencies, if we have to look at even more information, that would be too much for us. We are doing too much administration work already, any new information would have to be controlled very well. We are literally drowning in information, as everything in the NHS gets sent to a patient's GP.

9. How might 'smarter homes'  in the future help you as a GP in terms of prevention?
Technology that could help spot rises in blood sugar, oxygen, pulse rates. Patients are already bringing in paper to their appointments showing their rising Blood Pressure levels. For current hypertensives, I'd like to see a patient's BP readings at home on my computer screen prior to the patient's visit. Patients could save admin time if they could pre-enter this information for me to see. What if we could get food diaries into patient's medical records, that would be great for preventing Diabetes. To be able to understand what they are eating on a daily or weekly basis, the carbohydrate content etc. 

10. Who influences you?
I follow Dr Aseem Malhotra and Jamie Oliver, they are both leading a national conversation. I hope to see celebrities and sports starts taking up the baton in health prevention and get involved in their local areas. What if we had footballers like David Beckham or Wayne Rooney helping to spread this message? Kids would listen to those people, rather than us. 

[Disclosure: I have no commercial ties with the individuals or organisations mentioned above]

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Data or it didn't happen

Today, there is incredible excitement, enthusiasm and euphoria about technology trends such as Wearables, Big Data and the Internet of Things. Listening to some speakers at conferences, it often sounds like the convergence of these technologies promises to solve every problem that humanity faces. Seemingly, all we need to do is let these new ideas, products and services emerge into society, and it will be happy ever after. Just like those fairy tales we read to our children. Except, life isn't a fairy tale, neither is it always fair and equal. In this post, I examine how these technologies are increasingly of interest to employers and insurers when it comes to determining risk, and how this may impact our future. 

Let's take the job interview. There may be some tests the candidate undertakes, but a large part of the interview is the human interaction, and what the interviewer(s) and interviewee think of each other. Someone may perform well during the interview, but turn out to under perform when doing the actual job. Naturally, that's a risk that every employer wishes to minimise. What if you could minimise risk with wearables during the recruitment process? That's the message of a recent post on a UK recruitment website,  "Recruiters can provide candidates with wearable devices and undertake mock interviews or competency tests. The data from the device can then be analysed to reveal how the candidate copes under pressure." I imagine there would be legal issues if an employer terminated the recruitment process simply on the basis of data collected from a wearable device, but it may augment the existing testing that takes place. Imagine the job is a management role requiring frequent resolution of conflicts, and your verbal answers convince the interviewer you'd cope with that level of stress. What if the biometric data captured from the wearable sensor during your interview showed that you wouldn't be able to cope with that level of stress. We might immediately think of this as intrusive and discriminatory, but would this insight actually be a good thing for both parties? I expect all of us at one point have worked alongside colleagues who couldn't handle pressure, and their reactions caused significant disruption in the workplace. Could this use of data from wearables and other sensors lead to healthier and happier workplaces? 

Could those recruiting for a job start even earlier? What if the job involved a large amount of walking, and there was a way to get access to the last 6 months of activity data from the activity tracker you've been wearing on your wrist every day? Is sharing your health & fitness data with your potential employer the way that some candidates will get an edge over other candidates that haven't collected that data? That assumes that you have a choice in whether you share or don't share, but what if every job application required that data by default? How would that make you feel? 

What if it's your first job in life, and your employer wants access to data about your performance during your many years of education? Education technology used at school which aims to help students may collect data that could tag you for life as giving up easily when faced with difficult tasks. The world isn't as equal as we'd like it to be, and left unchecked, these new technologies may worsen inequalities, as Cathy O’Neil highlights in a thought provoking post on student privacy, “The belief that data can solve problems that are our deepest problems, like inequality and access, is wrong. Whose kids have been exposed by their data is absolutely a question of class.”

There is increasing interest in developing wearables and other devices for babies, tracking aspects of a baby, mainly to provide additional reassurance to the parents. In theory, maybe it's a brilliant idea, with no apparent downsides? Laura June doesn't think so, She states, "The merger of the Internet of Things with baby gear — or the Internet of Babies — is not a positive development." Her argument against putting sensors into baby gear is that it would increase anxiety levels in parents, not reduce them. I'm already thinking about that data gathered from the moment the baby is born. Who would own and control it? The baby, the baby's parents, the government or the corporation that had made the software & hardware used to collect the data? Furthermore, what if the data from the baby could impact not just access to health insurance, but the pricing of the premium paid by the parents to cover the baby in their policy? Do you decide you don't want to buy these devices to monitor the health of your newborn baby in case one day that data might be used against your child when they are grown up? 

When we take out health and life insurance, we fill in a bunch of forms, supply the information needed for the insurer to determine risk, and then calculate a premium. Rick Huckstep points out, "The insurer is not able to reassess the changing risk profile over the term of the policy." So, you might be active, healthy and fit when you take out the policy, but what if your behaviour changes and your risk profile changes during the term of the policy? This is the opportunity that some are seeing for insurers to use data from wearables to determine how your risk profile changes during the term of the policy. Instead of a static premium at the outset, we have a world with dynamic and personalised premiums. Huckstep also writes, "Where premiums will adjust over the term of the policy to reflect a policyholder’s efforts to reduce the risk of ill-health or a chronic illness on an on-going basis. To do that requires a seismic shift in the approach to underwriting risk and represents one of the biggest areas for disruption in the insurance industry."

Already today, you can link your phone or wearable to Vitality UK health insurance, and accumulate points based upon your activity (e.g. 10 points if you walk 12,500+ steps in a day). Get enough points and exchange them for rewards such as a cinema ticket. A similar scheme has also launched in the USA with John Hancock for life insurance

Is Huckstep the only one thinking about a radically different future? Not at all. Neil Sprackling, Managing Director of Swiss Re (a reinsurer) has said, “This has the potential to be a mini revolution when it comes to the way we underwrite for life insurance risk." In fact, his colleague, Oliver Werneyer, has an even bolder vision with a post entitled, "No wearable device = no life insurance," in which he believes that in 5 to 10 years time, you might find not be able to buy life insurance if you don't have a wearable device collecting data about you and your behaviour. Direct Line, a UK insurer believe that technology is going to transform insurance. Their Group Marketing Director, Mark Evans, has recently talked about technology allowing them to understand a customer's "inherent risk." Could we be penalised for deviating away from our normal healthy lifestyle because of life's unexpected demands? In this new world, if you were under chronic stress because you suddenly had to take time off work to look after a grandparent that was really sick, would less sleep and less exercise result in a higher premium next month on your health insurance? I'm not sure how these new business models would work in practice. 

When it comes to risk being calculated more accurately based upon this stream of data from your wearables, surely it's a win-win for everyone involved? The insurers can calculate risk more accurately, and you can benefit from a lower premium if you take steps to lower your risk. Then there are opportunities for entrepreneurs to create software & hardware that serves these capabilities. Would the traditional financial capitals such as London and New York be the centre of these innovations? 

One of the big challenges to overcome, above and beyond established data privacy concerns, is data accuracy. In my opinion, these consumer devices that measure your sleep & steps are not yet accurate and reliable enough to be used as a basis for determining your risk, and your insurance premium. Sensor technology will evolve, so maybe one day, there will be 'insurance grade' wearables that your insurer will be able to offer you. These would be certified to be accurate, reliable and secure enough to be used in the context of being linked to your insurance policy. In this potential future, another issue is whether people will choose to not take insurance because they don't want to wear a wearable, or they simply don't like the idea of their behaviour being tracked 24/7. Does that create a whole new class of uninsured people in society? Or would their be so much of a backlash from consumers (or even policy makers) to this idea of insurers accessing this 24/7 stream of data about your health, that this new business model never becomes a reality? If it did become a reality, would consumers switch to those insurers that could handle the data from their wearables? 

Interestingly, who would be an insurer of the future? Will it be the incumbents, or will it be hardware startups that build insurance businesses around connected devices? That's the plan of Beam Technologies, who developed a connected toothbrush (yes, it connects via Bluetooth with your smartphone and the app collects data about your brushing habits). Their dental insurance plan is rolling out in the USA shortly. Beam are considering adding incentives, such as rewards for brushing twice a day. Another experiment is NEST partnering with American Family Insurance. They supply you a 'smart' smoke detector for your home, which "shares data about whether the smoke detectors are on, working and if the home’s Wi-Fi is on." In exchange, you get 5% discount off your home insurance. 

Switching back to work, employers are increasingly interested in the data from employee's wearables. Why? Again, it's about a more accurate risk profile when it comes to health & safety of employees. Take the tragic crash of the Germanwings flight this year, where it emerges the pilot deliberately crashed the plane, killing 150 passengers. At a recent event in Australia, it was suggested this accident might have been avoided if the airline were able to monitor stress in the pilot using data from a wearable device.

What other accidents in the workplace might be avoided if employers could monitor the health, fitness & wellbeing of employees 24 hours a day? In the future, would a hospital send a surgeon home because the data from the surgeon's wearable showed they had not slept enough in the last 5 days? What about bus, taxi or truck drivers that could be monitored remotely for drowsiness by using wearables? Those are some of the use cases that Fujitsu are exploring in Japan with their research. Conversely, what if you had been put forward for promotion to a management role, and a year's worth of data from your wearable worn during work showed your employer that you got severely stressed in meetings where you had to manage conflict? Would your employer be justified in not promoting you, citing the data that suggested promoting you would increase your risk of a heart attack? Bosses may be interested in accessing the data from your wearables just to verify what you are telling them. Some employees phone in pretending to be sick, to get an extra day off. In the future, that may not be possible if your boss can check the data from your wearable to verify that you haven't taken many steps as you're stuck in bed at home. If you can't trust your employees to tell the truth, do you just modify the corporate wellness scheme with mandatory monitoring using wearable technology?

If it's possible for employers to understand the risk profile for each employee, would those under pressure to increase profits, ever use the data from wearables to understand which employees are going to be 'expensive', and find a way to get them out of the company? Puts a whole new spin on 'People Analytics' and 'Optimising the workforce'. In a compelling post, Sarah O'Connor shares her experiment where she put on some wearables and shared the data with her boss. She was asked how it felt to share the data with her boss, "It felt very weird, and actually, I really didn't like the feeling at all. It just felt as if my job was suddenly leaking into every area of my life. Like on the Thursday night, a good friend and colleague had a 30th birthday party, and I went along. And it got to sort of 1 o'clock, and I realized I was panicking about my sleep monitor and what it was going to look like the next day." We already complain about checking work emails at home, and the boundaries between work and home blurring. Do you really want to be thinking about how skipping your regular session at the gym on a Monday night would look to your boss? Devices that will betray us can actually be a good thing for society. Take the recent case of a woman in the USA who reported being sexually assaulted whilst she was asleep in her own home at night. The police used the data from the activity tracker she wore on her wrist to prove that at the time of the alleged attack, she was not asleep but awake and walking. On the other hand, one might also consider that those with malicious intent could hack into these devices and falsify the data to frame you for a crime you didn't commit. 

If these trends continue to converge, I see enterprising criminals rubbing their hands with glee. A whole new economy dedicated to falsifying the stream of data from your wearable/IoT device to your school, doctor, insurer or employer, or whoever is going to be making decisions based upon that stream of data. Imagine it's the year 2020, you are out partying every night, and you pay a hacker to make it appear that you slept 8 hours a night. So many organisations are blindly jumping into data driven systems with the mindset of, 'In data, we trust,' that few bother to think hard enough about the harsh realities of real world data. Another aspect is bias in algorithms using this data about us. Hans de Zwart has written an illuminating post, "Demystifying the algorithm: Who designs our life?" Zwart shows us the sheer amount of human effort in designing Google Maps, and the routes it generates for us, "The incredible amount of human effort that has gone into Google Maps, every design decision, is completely mystified by a sleek and clean interface that we assume to be neutral. When these internet services don’t deliver what we want from them, we usually blame ourselves or “the computer”. Very rarely do we blame the people who made the software." With all these potential new algorithms classifying our risk profile based upon data we generate 24/7, I wonder how much transparency, governance and accountability there will be? 

There is much to think about and consider, one of the key points is the critical need for consumers to be rights aware. An inspiring example of this, is Nicole Wong, the former US Deputy CTO, who wrote a post explaining why she makes her kids read privacy policies. One sentence in particular stood out to me, " When I ask my kids about what data is collected and who can access it, I am asking them to think about what is valuable and what they are prepared to share or lose." Understanding the value exchange that takes place when you share your data with a provider is critical step towards being able to make informed choices. That's assuming all of us have a choice in the sharing of our data. In the future, when we teach our children how to read and write English, should they be learning 'A' is for algorithm, rather than 'A' is for apple? I gave a talk in London recently on the future of wearables, and I included a slide on when wearables will take off (slide 21 below). I believe they will take off when we have to wear them or when we can't access services without them. Surgeons and pilots are just two of the professions which may have to get used to being tracked 24/7.

Will the mantra of employers and insurers in the 21st century be, "Data or it didn't happen?"

If Big Data is set to become one of the greatest sources of power in the 21st century, that power needs a system of checks and balances. Just how much data are we prepared to give up in exchange for a job? Will insurance really be disrupted or will data privacy regulations prevent that from happening? Do we really want sensors on us, in our cars, our homes & our workplaces monitoring everything we do or don't do? Having data from cradle to grave on each of us is what medical researchers dream of, and may lead to giant leaps in medicine and global health. UNICEF's Wearables for Good challenge could solve everyday problems for those living in resource poor environments. Now, just because we might have the technology to classify risk on a real time basis, do we need to do that for everyone, all the time? Or should policy makers just ban this methodology before anyone can implement it? Is there a middle path? "Let's add in ethics to technology" argues Jennifer Barr, one of my friends who lives and works in Silicon Valley. Instead of just teaching our children to code, let's teach them how to code with ethics. 

There are so many questions, and still too few places where we can debate these questions. That needs to change. I am speaking at two events in London this week where these questions are being debated, the Critical Wearables Research Lab and Camp Alphaville. I look forward to continuing the conversation with you in person if you're at either of these events. 

[Disclosure: I have no commercial ties to any of the individuals or organisations mentioned in the post]

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Wearables: Hope or Hype?

I've been thinking about this question a lot in 2014. I'm seeing more articles proclaiming that wearable technology is a 'fad', has no 'practical' value, and in the context of health are often viewed as inferior to officially certified & regulated medical devices.

"Technology is beyond good or bad", said Tamara Sword, at yesterday's Wearable Horizons event. Now, a very common piece of technology in our kitchen, the knife, is a classic example. Used for it's purpose, it speeds up the food preparation process by slicing carrots. However, it can also be used for harm, if used to slice a finger off.

The same goes with wearable technology like Google Glass. It can do immense good, such as saving someone's life. However, it could also be used to harm, if someone wearing Glass takes a picture of your 5 year old child in Starbucks without obtaining consent from your child or yourself [credit to the visionary John Havens for making me think about the Starbucks scenario]

We all have to start somewhere

We have to remember that the market for wearables is embryonic, it's not mature in any shape or size. Every innovation I see & test is crude & clumsy, with many flaws. Thinking back to 1903, wasn't the first airplane crude & clumsy?  Wearables WILL evolve, just like the the airplane [Hopefully, it won't take 111 years like the airplane] 

I salute those willing to take a risk and develop wearable technology. From the lone entrepreneurs to Nike, what unites them is that they took a risk. They experimented. Experiments don't always turn out to be successful, noting Nike's recent withdrawal from Wearables. That's entirely normal, we can't expect everyone to succeed at their first attempt. What would our world look like today, if Steve Jobs had given up after his first attempt? 

How many of you failed your driving test the first time? Instead of dismissing the brave efforts of those willing to take a risk into the unknown, we should be encouraging & supporting them. It's those willing to take those chances, to explore unknown waters, to imagine a better world, that have helped humanity make so much progress. 

Courageous conversations

There are many questions around wearables that remain unanswered. There are uncomfortable, awkward & terrifying conversations surrounding the use of wearable technology that are sorely needed, not just within society, but within our political, legal and regulatory framework too. If we place a piece of wearable tech on a patient with dementia, how do we obtain informed consent from the patient?

When I saw the recent headline that a hospital in Boston is equipping everyone in the ER room with Google Glass, my first reaction was one of excitement, with my second reaction being one one of curiosity. What happens to the face & voice data? At 3am, when the ambulance rushes you & your sick child to the hospital, will you really stop to ask the hospital staff, what the privacy policy is, regarding the images captured using Google Glass of your child in the hospital?

I observe that many, including those in the business of creating or using regulated medical devices, look down upon some wearable technologies. Activity trackers are frequently viewed as fun toys, not 'proper' medical devices.

Let me ask you something. If an overweight & inactive person aged 40, uses a $99 Fitbit to track their activity & sleep, leading to insights that trigger behaviour change over the long term, is it still a toy? For example, what if developing the habit of walking 10,000 steps a day (versus 1,000 today), reduces their risk of a heart attack, delays the onset of Diabetes or even prevents high blood pressure? Still just a 'glorified' pedometer?

Imagining a better tomorrow

I believe wearable technology, particularly for health, is just one step on the journey in today's digital world. There will continue to be failures, and whilst there is significant froth & hype, there is also significant hope. Our ability to imagine a better future is what has gotten us to where we are today. Imagination could be one of the most useful attributes for any organisation wishing to meet the challenges facing human health in the 21st century.

It appears likely that firms which don't have roots in health could be helping us realise this new world. Perhaps this shift frightens those firms that have got their roots in health? I'm intrigued to note that Samsung, are holding an event in San Francisco later this month, promising that a new conversation about health is about to begin. Having visited South Korea a few years ago, and learning so much about Samsung's history & vision, I'm going to be watching what they do very closely. 

Is it a bad thing if wearable technology (and the resulting data, insights & education) empowers patients and makes them less dependent on doctors & the healthcare system?

Is it wrong to dream of 'smart fabrics' where our health could be monitored 24 hours a day?

Is it silly to want to develop sensors that could one day transmit data directly from our internal organs to our doctors?

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