• The case of the missing 4.7 million
• ICU Tsunami • Improving ICU capacity with technology
• Dealing with the outpatient backlog
• The Outpatient Concierge
At the time of writing hospitals all over the world are struggling to meet unprecedented demand for the services and having to not just implement, but also invent, radical tactics to maximise resource and protect the wellbeing of staff and patients as best they can.
Earlier in January, The Telegraph reported on how, in the absence of national guidance, medical staff were drawing up their own plans to create guidelines for an ethical system to ration the inadequate supply of critical clinical resources.
In December, more than 116 US hospitals across thirty-five states from Alabama to Wisconsin cancelled non-essential and elective surgeries.
In the UK, routine referrals have dropped off a cliff-edge during 2020, and continue to decline. During the first months of 2020, there were 4.7 million fewer routine referrals than the year before, which is equivalent to almost a third.
It would be absurd to think that the need for these procedures has simply vanished. More likely is that the patients are holding off, and not visiting the doctors, or if they are, the referrals aren’t being made because of both the potential heightened and, perhaps, unnecessary risk to the patient, and the additional non-urgent burden it would put on the creaking system.
The NHS, like other healthcare systems has guidelines and commitments to ensure fair and equal access for patients. In particular, the NHS Constitution requires that referrals for consultant-led procedures, such as neurological, oral, orthopaedic and ophthalmic treatments should have a maximum waiting time of 18 weeks.
“While the NHS is rightly focused on the urgent task of fighting COVID-19, there is meanwhile a rising tide of unmet need which will have a significant impact on people’s health if a sustainable solution is not found. ” The Health Foundation’s Senior Policy Fellow Tim Gardner
With the pandemic, healthcare systems are being deluged in a tsunami of critically ill patients presenting acute conditions that needed constant monitoring and specialist medical intervention.
The healthcare infrastructure was never built to mange a demand of this kind. The balance of resources, such as beds in wards, intensive care unit (ICU) equipment and staff, and hospital information systems have simply not been designed to deliver against a case mix of this profile.
As such, ICU resources are virtually depleted, doctors, nurses, patients and families are exhausted and stress-ridden. It is a very bleak time for healthcare givers as well as patients.
In times of anxiety and stress, I find it comforting to remember an ancient Persian adage; This too shall pass. Reflecting the ephemerality of our being, and the things that happen to us, it reminds me that no matter how difficult things are now, at some point, some way or another, it will pass. Depending on the specific nature of the situation, it can even spark my optimism, directing me towards the opportunity and potential that awaits “after”.
For those on either the doctor or patient side of the pandemic frontline, exhaustion, desperation and anxiety are going to make it very difficult to find comfort or inspiration in these words.
For everyone who is lucky enough to not be fighting the pandemic in the in the medical trenches, it is up to us to think forward, passed the immediate crisis and help prepare for what happens after.
ICU wards have been designed to provide continuous care for the most critical of conditions. The wards are equipped with specialist equipment that can monitor a patient’s vital signs and alert specially trained staff in real-time to any changes in these. Beyond real-time critical monitoring, ICUs also provide specialist support equipment, such as the mechanical, invasive ventilators that have recently become public conversation.
However, as Frédéric Michard, MD, PhD, a visionary and well published ICU specialist notes in his open letter, much of the traditional ICU workload could shift to other wards without patient risk.
Through the use of wearable technologies, medical grade connectivity and artificial intelligence, a patient’s vital signs could be continuously monitored in non-ICU wards, providing a constant, accurate and secure stream of data and alerts to clinical staff as it is needed.
“ICU beds could be reserved to patients requiring organ support such as mechanical ventilation and renal replacement therapy. Patients who would simply need close monitoring could safely stay on the wards and benefit from smart and continuous monitoring”, Frédéric Michard, MD, PhD.
Whilst the re-tooling of intensive care will help the healthcare of the near, to mid term future, the next healthcare crises will be mental health care and dealing with the backlog of deferred non-urgent referrals.
Dealing with this backlog will require efficiency and cooperation between various departments, across traditional boundaries and will involve both public and private healthcare entities.
Given the current situation, the rise of innovative medical technology (MedTech) startups has been rapid. A majority of these companies that are getting the media attention focus on providing remote consultations through mobile apps, some are providing virtual reality technologies to deliver both consultations and therapies, there are even some using Internet of Things (IoT) technologies to monitor and engage with patients remotely.
In their shadow, other technology innovations have enabled patients to request, doctors to prescribe and pharmacies to full-fill prescriptions.
However, in between these beacons of innovation lay procedures shrouded in paperwork, snail-mail, phone calls and manual clinical note transcribing. It is these that will hinder the backlog recovery, and the area we are passionate to serve.
Let me illustrate the opportunities to innovate by building on the real-life happenings of a relatively recent, pre-pandemic non-urgent healthcare requirement of mine.
After several months of putting up with a specific symptom, I decided it wasn’t going away and I should see the doctor. When I called, the phone line was busy, so I tried again later, and again a day or so after that. Finally, I managed to get an appointment for the following week.
Arriving for my appointment ahead of time, I waited for forty-five minutes because a delay had occurred earlier in the day when a patient was late for their appointment. When I got to see the doctor, the issue was quickly diagnosed and I was told two letters would be written and sent, one to me confirming the referral and one to a specialist clinic.
A week later, I hadn’t received the letter so I called the surgery again (and again, and again). The doctor said the letter had been sent, but will ask for it to be sent again this week.
Two weeks pass and I receive four letters on the same day. Two of these are about the referral, one is an appointment and another is a cancellation of the appointment because the clinic I was referred to no longer provided that service, suggesting I speak to my doctor to arrange another referral.
When it came time for my appointment, despite leaving plenty of ‘buffer’ time I was nearly late for because the car parks were full, and the only one I could get into required payment using coins, which I didn’t have. Compounding this, when I had parked, I couldn’t find my way through the maze of the hospital. Arriving, I joined a queue of people who all had similar experiences.
The consultation proceeded, an action plan agreed, and I was sent away to receive further instructions by post.
This one experience is not unique for me, or others, and occurred at a time when resources weren’t already stretched to breaking point.
The highlighted sections of my story above are all areas where simple, yet innovative improvements could deliver significant long term benefits for patients and providers and help reduce some of the near-term pain of dealing with the enormous backlog.
Let’s imagine a new scenario.
My local doctors surgery provides me with a unique security code that I use to set securely log into MyHealthConcierge, an app designed to help manage the patient needs and experiences.
When I notice a symptom, I open the app, leaving a voice memo about my symptoms and self-scoring the urgency of my need. This is made available to my doctor, and based on the self-scored urgency, frequency of memo and medical history they decide how and when to respond. I feel comfort in the fact that the doctor now knows about my issues, and that I have a record I can call up at anytime to see how things are progressing.
Behind the scenes, artificial intelligence is able to detect changes in my voice that could indicate a worsening of a current ailment, or even provide early warning of a currently unknown condition, such as Parkinson’s Disease.
Virtual consultations with my doctor are easily set up and conducted via the app, with a referral being sent digitally to the identified specialist. In doing so, relevant medical history data is shared securely with the specialist. This data is relevant to the referral and ephemeral, auto-deleting after the case is closed.
The concierge sets an appointment in my calendar, and provides me travel information. In the lead up to the appointment, further information is sent to me, and I’m asked to provide updates on my condition and complete a pre-consultation tele-interview with a nurse.
On the day, the concierge provides me with travel options; navigation by car, or public transport schedules and connections. I chose to go by car, and it navigates me to the car park with available spaces. I don’t need to worry about having coins or a card, because the app includes payment options too, so I pay for my parking (or even public transport) via the app. All payments are securely recorded, and at a if applicable at later point could be automatically included in my private insurance claim.
Once I’ve parked the car, I see a message from my wife asking me how it's going, did I make it on time. I send her a message letting her know I’ve arrived and am on time, and for her peace of mind, I instruct the concierge to provide my wife updates for the next two hours.
In the background, the concierge has been keeping the clinic updated with my arrival time. It looks like I will actually be ten minutes early, and since a previous patient is running late, the clinic has been able to automatically shuffle the queue accordingly, maximising their resource and improving the experience for other patients.
Getting out of the car, the concierge uses augmented reality to efficiently direct me through the hospital. Along the way it tells me I am likely to be early, and the doctor is expecting me, however there is still time to pick up a refreshment if needed. That sounds like a good idea, so I make a small guided diversion to the cafe, to pick up a coffee which I already ordered via the concierge, and make my way to the consultation - on time, refreshed and as relaxed as I can be.
During the consultation, I choose to record the advice because I know that I will want to listen to the specialist again later to help me remember what they told me. Also, it will be much easier to play the recording to my wife when she inevitably asks.
After the consultation, the specialists dictates his notes using a specially trained medical chatbot that uses natural language processing (NLP) to transcribe his notes into text.
Follow up is done digitally between myself, the specialist and my local doctor, reducing the inefficiency of letters, increasing data access for the authorised parties in my treatment whilst enhancing patient confidentiality and peace of mind.
Beyond this scenario, the concierge could help family members look after their at-risk or elderly relatives, enabling them to keep track of their progress or even, with appropriate biometric-secured authority, manage and accept appointment or procedures on their behalf.
The concierge could also provide real-time translation to help overcome language barriers, and the built-in recording capability would not only help overcome the common problem of patients not fully absorbing the information at the time, but could also be used to reduce clinical insurance liabilities.
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