PAIN IS COMPLEX. When we talk about pain, we can’t help but draw from our own experience. Think about a time you might have been in pain. For me, it’s a recurrent low back pain which emerges every so often to remind me that being tall isn’t always a great thing. For you, it might be something different.Whilst you may not be able to summon up the actual sensation again, I’m sure you can recall the fear and anxiety, the worry about the implications to your personal and social life. Pain might fade over time, but the emotional and social impact often remains.
As a result, when you try and treat pain, you neglect the whole person at your peril. While drugs can ease the physical suffering, the effect of that pain on the person’s life, relationships, and their standing in the world may go neglected.
This complex interrelationship was strikingly laid bare at ‘Ugly Lies the Bone’, which I saw at the National Theatre last week.
This is the second revival of the Lindsey Ferrentino‘s play, set in the heart of Florida’s Space Coast in 2011 at the time of NASA’s last shuttle flight. It focuses on the return of Jess, a veteran of the conflict in Afghansitan, horribly injured in an IED explosion. As part of her treatment she takes part in revolutionary new Virtual Reality therapy that helps her to escape her pain. As the play progresses, just what form that pain takes becomes clearer – the physical pain of her scars, the emotional and social pain of her return to her home and the effect this has on her friends and family, and how Post Traumatic Stress Disorder never lets her fully escape
One of the characters in the play is simply listed as ‘Voice’ – the verbal presence of the therapist during Jess’ sessions in VR. Being a therapist myself I was particularly affected by her role, and it served to reflect the rather shallow focus that I’ve been guilty of in the past. Concentrating on the numerical rating of the pain, and the short-term goals of the treatment, the disembodied clinician seems to drift away from the other components of her patient’s pain, leaving her stranded once the game is complete.
VIRTUAL REALITY HOLDS REAL PROMISE FOR MANAGING PAIN. From distraction and manipulation of the senses, to the respite from reality, and the freedom from physical limitation, we’re seeing examples every day of how this new technology can help people.
Two days after the trip to the National Theatre, I was able to explore this in much more detail in a meeting held at Digital Health: London. There I met with Howard Rose, CEO of Deepstream VR, and leader in the field for over 20 years. In attendance we also had Nick Peres, creator of PatientVR.co.uk and champion of immersive VR. Richard Dolan, Innovation lead at NHS Dorset CCG.
We spent two hours experiencing COOL! and GLOW!, both Firsthand VR products used for the management of acute and chronic pain, and anxiety. Cool! was of particular relevance, as it is the direct ‘descendent’ of SnowWorld – the VR experience that played a part in inspiring the story of ‘Ugly Lies the Bone’. As with all VR, it’s a little difficult to convey the experience without it sounding daft – after all, I was throwing iridescent trout and glowing orbs at otters playing on the riverbank – but it did work to reduce my back pain.
GLOW! was particularly beguiling. In this I found myself sitting next to a stone totem with my heart rate illuminated on the rock face. A Leap Motion controller, attached to the front of the headset, meant I could see glowing outlines of my hands, which would summon and dispel fireflies as I opened and closed my hands. The stars above, the cicadas, and the babbling water, all conveyed through stereoscopic images and binaural sound had a remarkable effect on my pulse, leaving me calm and comfortable for hours afterwards.
We then moved on the PSIOUS VR, which was demo’d by Richard Dolan. Psious is a Gear VR/Laptop based mental health application used to help treat mental health problems, particularly phobias and anxiety. Linked to a stress measuring wearable, the therapist is able to tailor a variety of scenarios to expose the patient in a safe and graduated way to their fears. Accordingly, I sweated my way up a construction lift bolted to the outside of a skyscraper, whilst Nick was taken through a personal fear – preparing for take-off in a commercial jet. Whilst the graphics were more basic than those of COOL! and GLOW!, it was astonishing how they nevertheless generated that familiar discomfort. The level at which VR can deliver benefit – at which point the immersion is ‘good enough’, is a question for researchers and those evaluating VR in healthcare.
Richard works as Innovation Lead at Dorset Clinical Commissioning Group, and it was great to see such a passion for innovation, especially within the NHS. I meet many CCG staff in the Digital Health sphere, and it’s encouraging to find everyone reaching out to each other and beginning to develop networks to share learning and opportunities. Similarly, Nick Peres at Torbay NHS Trust is doing amazing work with 360 video in highlighting the important of human touch in healthcare – patientvr.co.uk. You can find out more about his story on my podcast, CURISTICA.
WE’RE ALL AFFECTED BY PAIN IN DIFFERENT WAYS. Some, like Jess, suffer the full spectrum of misery. Others have a thankfully more fleeting acquaintance. For each person, Virtual Reality has a potential role to play. What was made clear in the play, and at the meeting, was how this role could be across every facet of pain – the physical, emotional, cognitive and social. Given that VR is also not the sole preserve of the clinician, it suddenly becomes a much more interesting proposition. Unlike prescribed drugs, the tools for relief and recovery are now in the hands of the patient.
We need to work carefully to understand what evidence there is for benefit in acute and chronic pain. Are there potential risks or harms? Will VR work only while the user is immersed, or does it persist afterwards? We already have published evidence supporting VR analgesia, but precious little about how it can be scaled, and provided equitably.
For now, I go back to my day job a little wiser and more optimistic than I was before. As a Doctor,I need to step back and always consider the wider implications that pain has on an patient’s life. Maybe I can bring new hope to some of my more troubled patients, for those that have found conventional medicine lacking or limited by side effects. Maybe next time my back seizes up, I’ll reach for the headset before the tablets.
Links & Declarations
I’d like to thank Nick, Rebekah, and Yinka at Digital Health: London for their kind assistance in providing a room for the meeting. All of the participants are colleagues I’ve met through meetings and on my voyage of Digital Health discovery through Social Media. I have no financial interest in any of the companies mentioned, although I am an NHS GP and CCG governing body member (Eastbourne Hailsham and Seaford).
All costs for these events, including travel and tickets, were paid for personally. My back pain is sadly provided for free.
If knowledge is power, then from 7th century BC to the 4th century AD, the most powerful women of the classical world were undoubtedly the Oracles of Delphi.
Supplicants would travel far to seek the Pythia’s wisdom, delivered in ecstatic frenzy after inhaling the spirit of Apollo. Such was the cryptic nature of their utterances that prophets would be employed to help travelers make sense of their revelations.
Important decisions in matters of war, trade, marriage, and business, all made with reference to the divine knowledge imparted by the Oracle.
In matters of medicine, doctors have been the gateway to knowledge. With that, doctors have significant power in the war against disease.
On the afternoon of 22nd February I went to Digital Health.London’s ‘Collaborate’ event. It was a celebration of the programme’s first year’s work, an award ceremony, and innovation event all rolled into one. They were kind enough to let me speak about Virtual Reality in patient care as well.
There was a fantastic, diverse audience in attendance too, from the cutting-edge 360 live-streaming surgeon Shafi Ahmed, to my colleague Sunil Bhudia (with whom I’m working on the PREVENT-ICU-Delirium project), and the inspirational Molly Watt, who took part in a panel discussion about accessibility and digital participation. It’s also brilliant to meet people I know from twitter face-to-face, like Victoria Betton, who led a session on hacking STPs), and Dr Robert Lloyd, who skillfully MC’d the proceedings
So why the Delphi reference? Of all the talks, the most fascinating for me was the panel discussion on Artificial Intelligence.
Patients should use Artificial Intelligence to reduce the amount of time they need to spend with healthcare professionals
The panel comprised of three heavyweights in the Digital Health field:
Dr Ameet Bakhai Consultant Cardiologist Royal Free Foundation NHS Trust
Professor Nicholas Peters – Professor of Cardiology & Electrophysiologist at Imperial College London
Entertainingly and insightfully chaired by Dr Jordan Schlain , a fellow US based GP and Founder of HealthLoop, the debate fell nicely into those for, against, and balanced on the fence.
Ali Parsa began with a blistering defense of clinical AI, delivering an impassioned argument for how it can meet the yawning gap in healthcare provision around the globe. His team at Babylon have seen an 80% reduction in conversion of clinical inquiries to video consultations since the introduction of their triage AI. As far as he is concerned, there is a moral duty to implement AI to meet the care divide, and augment the diagnostic capabilities of clinicians.
It’s difficult to come back against that kind of rhetoric, although I would posit that Babylon’s UK business deals with a small proportion of range of presentations seen in General Practice, and from a significantly healthier and wealthier cohort. It might be difficult to extrapolate the 80% reduction in demand. With an ongoing trial front-ending GP in North London though, I guess time will tell.
The progress in developing world is also laudable, but I wonder whether it can ever cover the totality of care needs? Perhaps 10% of something better than 100% of nothing.
The issue of AI treating humans well and not turning them into batteries comes up time and again, and from my own point of view I swing between optimism and existential dread. It’s not unique to patient care, but does have an interesting twist in that should AI be successful in helping the patient, it may harm the doctor.
As for empathy, this is stronger ground. I certainly believe that humans need contact with other humans, particularly when it comes to the ritual of the consultation. Who’s to say that empathy is a uniquely human property though? Any pet owner will attest to the ability of their loved companions to deliver comfort without words. In time, empathy may well be better delivered by machine, especially to those raised in the post-millennial world – Homo Digitalis .
Professor Peters was left to adopt the middle ground, adding nuance to the preceding statements. I was particularly taken by his observation that the addiction that doctors have to treating patients, felt as a need deeper than simply a method of paying the bills, coloured their opinion. AI and the fear of being replaced and made worthless affect us all.
The framing of the debate made this last point ironic – there were no patients on the panel discussion the proposition. I raised this point, which was countered with an anecdote about Henry Ford who was quoted as saying that if he’d given the public what they wanted, he’d have made a faster horse. Professor Peters also referenced Molly Watts’ support of Apple’s commitment to user interface excellence & accessibility, which comes despite their famous lack of user input. All good points, but I’d still want to hear a patient make them.
The concept of Artificial Intelligence has been around since the 1950s, and we’ve seen this level of enthusiasm before. We’ve also had our hopes dashed before. I believe we’re entering a time when some of that promise will be realised, especially in narrow specialist areas. For this reason, I see the generalist physician outliving the specialist when it comes to head-to-head performance against AI in terms of patient care. Before my GP colleagues get too comfortable, even that advantage will pass in time, leaving the nurses as the most valuable humans in the healthcare system.
It may be that we will co-exist as providers of healthcare, but surely there will come a time when AI will be superior to human in a number of areas. When this happens, if we truly respect tradition of medicine, and believe we must first do no harm, maybe doctors should stop diagnosing patients?
And with that, is the best that doctors can wish for is to become gatekeepers of the knowledge – prophets at Delphi helping the patient understand the superhuman wisdom of the AI oracle? Or will this knowledge by available to the patients directly, leaving doctors shorn of their power?
It’s no surprise that our excitement is tinged with fear.
Imagine that this care was provided based on clinical need, not your ability to pay.
Imagine if we arranged it so that it was provided free at the point of delivery as well.
If we didn’t have this already, you’d laugh me out of the room
The National Health Service is the very definition of a disruptive innovation.
The NHS was born into a country emerging from the rubble of a World War, where food and basic amenities were rationed. The concept behind it was so radical that many doctors fought to prevent it coming into existence. Yet, created it was, and nearly 70 years later it continues to make good on those three founding principles.
You’d think that a health service so radically innovative would be receptive to innovation, but in the twenty years I’ve been working in the NHS I’ve come to see that it is anything but. The pressure not to mess with the formula is high.
No-one wants to be the person that broke the NHS.
Bureaucracy and the conservatism of the medical profession preserve the status quo. Any innovation has to be controlled and managed: only proven innovations are to be permitted.
That’s not really how innovation works though.
I’m a ‘lifer’ – the NHS has been caring for me since before I was born, and I’ve been raised, trained, work, and (with any luck) I’ll retire, be cared for, and eventually die in a world where the NHS continues.
I want to play my part to ensure that this be the case, but I’ve never felt that there was a recognized career path for me as a technologically minded doctor. I’ve been forced therefore, to try and bring tech in to my work “on the side”, often on my own, in my own time, and experiencing considerable resistance.
I affectionately refer to some of my attempts as: “The Good, the Bad, and the Ugly”.
The “Good” are innovations that work well within the boundaries of the NHS. I collaborated on an ingenious project called ‘MyLittleOne’ recently which, using a specially developed camera and iPad system, allows mothers to see their babies when they’re receiving care in the Neonatal ICU.
The “Bad” are those that don’t work, or don’t scale. They also tend to be the ones that are solution led, rather than problem driven. In my case, it was Google Glass that seduced me. I may have looked foolish as an early adopter, but I learned valuable lessons that have led to my CCG being on the brink of using this technology to provide remote care in local nursing homes.
The “Ugly”? Those innovations are the ones which, although born outside healthcare seem to work perfectly within. Often harvested from personal interests, my experience of one such innovation has been with the early successes I’ve had in using Virtual Reality to reduce pain in patients having wound dressings.
The common thread in the success or failure of all three types was the fact that problems need to come before solutions. This is surprisingly difficult to achieve, given the lure of new gadgets and technology.
Much like every NHS employee, locums and sessional doctors are expected to know their job, and get on with it: turning up, seeing the patients, and not upsetting the apple cart.
Yet locums probably have the most to offer when it comes to innovation. Who else sees the breadth of the NHS, working in practices large and small, in- and out-of-hours, and in some of the most challenging circumstances?
They have a unique perspective of not only the problems of their particular clinical existence, but also the issues that those working in one place might overlook. They see solutions in one place that might work somewhere else. Locums are vectors of innovative practice. They may have already developed solutions, innovations, and wanted to share them, but not know how.
The NHS needs to recognise the fantastic resource it has in the sessional workforce and provide help and opportunity for them develop their ideas further. I’ve seen evidence of change in the mindset of the leadership of the NHS, especially in the work of our National Clinical Lead for Innovation, Professor Tony Young, who heads the Clinical Entrepreneur Programme. You can also look to groups such as Doctorpreneurs.
Aren’t we also masters of self-organisation? Why don’t we upgrade our own networks to be more supportive of innovation and entrepreneurship? Perhaps that idea you have, that innovation you’re working on, could be turned into something larger with a little help or guidance?
Back in April I reported on my first RSM Medical Innovations event, which left me energised and considering a membership. In a similar but less impressive fashion to Victor Kiam, I also invested in the company, and so when I attended the 13th Innovation event, I was doing so as a fully paid up fellow of the society.
Not that this was a requirement of attending. Tickets were available for free, although it was understandably over-subscribed. One of the most refreshing features of the RSM innovation event is the diversity of the audience. We had students from a local secondary school, entrepreneurs, scientists, doctors, patients and the ever present wise heads of academia and retired clinicians.
Calmly and capably hosted by President of the RSM, Mr Babulal Sethia, the day was broken into 4 sections, and covered a wide range of medical innovations with speakers from across the world. Some focused on the problems of the developing world which took them ahead of their western peers and colleagues. Others looked to the non-medical disciplines to take a new angle on clinical challenges. There was even disruption of the standard research model, bearing fruit in areas such as regenerative medicine.
We started at the end, with an engrossing presentation from Dallas Pounds, Chief Executive of Royal Trinity Hospice ( www.royaltrinityhospice.london,@trinityhospice ). Currently undergoing a remarkable transformation of it’s own, the ground-breaking team are working hard to take information, support and advice about death and dying ‘on to the high street’, and are blurring the boundaries to allow people in to see their work first hand. We were given a preview of “OddsAndEnds” – a platform which allows people to explore and understand death and dying themselves, which launches in 2017
I’ve spoken about Mr Shafi Ahmed before, reporting on his ground-breaking live broadcast of an operation earlier this year (#VRinOR). He continues to blaze a trail in Virtual Reality education, and today he spoke passionately about the challenges facing the estimated 5 billion people across the globe that lack access to safe surgery. By delivering immersive high quality surgical training using Medical Realities ‘The Virtual Surgeon’ platform, it’s now possible to livestream operations to anywhere with a network connection. Thanks to Facebook and Google, that’s anywhere on the globe. Give it a few years, and Elon Musk will be delivering this to Mars.
It’s #medinnov day and I’ve struck gold already! Doyenne of surgical #VR @ShafiAhmed5 in the house! @roysocmed #innovation #digitalhealth #theta360 – Spherical Image – RICOH THETA
With NooraHealth (@noorahealth), the needs of the developing world also helped drive innovation. CEO Edith Elliott and MD candidate Shahed Alam, students arising from the design school methodology of Stanford, visited India and made brilliant use of the abundant resource of family to put in place an education and training programme that turned family into competent carers, with subsequent significant improvement in post-discharge outcomes. What’s really telling here is that this process would work wonders in the NHS and perhaps other ‘developed’ healthcare systems, as well as helping to improve quality and meet rising demand.
The work of Professor Helen Lee in developing a robust, simple, ‘nespresso’ style point of care test for bloodbourne viruses that would work in the heat and noise of Ghana was next. Innovation faces challenges from all sides, and the simple reality of operation and supply chain in Africa can get in the way of even the most elegant of solutions. By concentrating on the challenges faced by front-line workers, ‘Diagnostics for the Real World‘ have produced an award winning solution that can transform the diagnosis of these illnesses.
Alongside the growing problem of HIV, Iron Deficiency Anaemia affects 3.5 BILLION people across the globe. Yes, that’s a “B”. The associated health and developmental issues can significantly shorten lifespan and affect quality of life and economic output. Yet solving this problem, by providing suitable iron supplementation, has challenged even the brightest minds. Enter Dr Gavin Armstrong with the cute ‘Lucky Iron Fish’ (@luckyironfish). By providing a small iron fish which can be boiled for 10 minutes with their food, people can significantly supplement their iron intake without affecting flavour or causing significant side effects.
Once again, the idea and science might be smart, but the allied entrepreneurship, social marketing, cultural understanding and even the ‘buy 1 give 1’ plan have gone a long way to making this venture a success. Gavin was equally honest in sharing the important role of failure in learning and growing. In many ways I was put in mind of the work Lauren Braun and Alma Sana, who were one of my highlights of the previous RSM event I attended. You’ll appreciate why I immediately connected the two on twitter!
Innovation needn’t spring from within healthcare to work – in fact, looking outside traditional silos is a brilliant way of approaching problems in a novel way. For example, 3D printing technology has already found a place in traditional design and manufacture, but is increasingly being used by enterprising clinicians and scientists in surgery, training, and device manufacture. Had you ever thought about using it to produce a model of a diseased prostate to allow for surgical planning and patient education though? Thought not.
Hugo Lynch, founder of MPrint3D, and Mr Richard Hindley, Conslutant Urological Surgeon from the Hampshire Hospitals NHS Trust, have moved from the already-awesome ‘fusion’ of high resolution MRI and ultrasound (which allows for extremely accurate transperineal prostate biopsy) to having the data converted to a solid object that can be handled by surgeon and patient alike. Yes – this means a 3d printed prostate. And yes – in what must be a world-first I got a selfie with it.
What’s immediately apparent is the incredible ability of a physical object to quickly and easily allow comprehension of what is often impenetrable information for both doctor and patient. Whether 3D printing is the best solution, or whether Virtual and Augmented Reality might perform as well, we shall see.
This is a question that is being answered by 3D4Medical (@3d4medical). Their iPad Anatomy series of apps have already revolutionised what is possible with tablet based anatomy teaching, a fact not lost on Apple themselves who invited them to help launch the iPad pro 2 years ago. It’s an amazing, intuitive and interactive piece of software, something I wish I’d had as a medical student back in the 1990’s. Dr Alan Detton & Niall Johnson took us through the latest version of the app, and offered a tantalising glimpse at ‘Project Esper’, their next step into Augmented Reality.
It was great to see Mindmate (www.mindmate-app.com@MindMateApp) making an appearance as well. Developed with the support of the Digital Health & Care Institute of Scotland (@DHIScotland), Patrick Renner took us through a slick presentation highlighting the features of this app, which provides assistance for people living with Dementia. We were joined by co-founder Susanne Mitschke (@susanneMitschke) via the app itself. By working closely with patients, families, and their care providers, the founders have used their experience in business, economics, and social sciences to accelerate the growth and adoption of this platform, which now has 12’000 monthly users.
Whilst the RSM, with its 182 year history, might be built on solid academic and research foundations, but it’s not shy of showcasing radical changes to this model.
iCancer is a crowdfunding campaign that famously raised £2million in just eight months to fund an oncolytc virus into Phase 1/2a trials. Liz Scarff, Alexander Masters, and Dominic Nutt, all personally touched by the effects of Neuroendrocrine tumours, brought together crowdsourced funds to directly revive a quiescent research corner into a rare disease. They then combined with a rich donor utilising ‘the Plutocratic Principle’ – where one wealthy individual can meet the majority of the cost of a trial and not only personally benefit, by entering that trial t hemselves (or allowing a friend/family member to do so) but also allow for many more people to benefit from the work. Strict ethical guidance is brought to bear, but with the generosity of donors forgotten research can be brought back to life, with the potential of developing novel treatments for all to share.
Ever heard of Bioelectronics? No, neither had I, until today. Dr Kris Famm, President of Galvani Bioelectronics, and Dr Nishan Ramnarain, Consultant in Pharmaceutical Medicine and Experimental Medicine Director at GlaxoSmithKline (@gsk), took us through some background on the use of precision modulation of nerve signals to control organ response and, thereby, whole system disease. For example, manipulation of the sympathetic nervous system at the carotid body can, in turn, help regulate blood sugar and blood pressure. Control of the sympathetic nervous system has long been known to play a crucial part in many illnesses, and treatment. When I was a junior doctor, I recall my surgical registrar opting for a highly selective vagotomy for his stomach ulcer over taking omeprazole. A whole class of medication is used to achieve the same effects. Having a new method of
Finally, we had two extremes to highlight the value of digital research tools:
At one end – Osman Kibar from Samumed (@Samumed_LLC). A serial entreprenuer and innovator, he presented some of the first findings of research into the existing corpus of knowledge on the Wnt signalling pathway. Through careful search methods, his company claims to have found a unique group of compounds that can modulate this biochemical pathway. This, in turn, has applications in regenerative medicine, degenerative disease and cancer. Showing evidence of paralysed mice walking again is strong stuff, and elicited an excited and slightly sceptical response from the audience.
At the other end, we had Renuka Chintapalli. Still at secondary school, she published her first paper aged 15, looking at the anti-cancer properties of common garlic. As if this wasn’t humbling enough, she has gone on to identify a novel bio-marker for oesophageal cancer by searching existing databases.
It’s always difficult to pick a highlight at an event like this, but my personal favorite had to be the presentation by Dr Liberty Foreman and Dr Katie Oliver, co-founders of Beamline Diagnostics (@beamlined). The technology is impressive in its own right, using computational statistics to analyse data from infrared spectroscopy to detect the ‘chemical signature’ of early cancer changes. This has the scope to massively reduce the number of pathological samples that need formal scrutiny by allowing an accurate method of rapidly screening biopsy samples for cancerous changes. They’ve turned this into a product that can be operated at point-of-care too.
We have innovation in software, resurrection of a little used hardware modality, and a rapid practical impact on patient care in one. All of this would generally be enough to mark them out from the crowd, but what pushed them over the top was the refreshing honesty from the founders in how they formed their company – they just did it. Now faced with the tidal wave of new challenges, they push on regardless and deservedly look to make a success of their brave decision.
It’s the #JFDI* principle that is my personal mantra, and it’s a common thread in the innovations that tend to make the biggest impact. Is this because it indicates a personal characteristic in the inventor or founder of these projects? Does it mark the necessary bravery and energy required to break through the traditional barriers and inertia to change? Or is it just the troublemaker tendency in everyone that embarks on their quest to change things for the better? Whatever the answer, it makes events such as these endless entertaining, optimistic, and inspiring.
Finally, it was left to Dr Cristina de Juan (@cristina_djsj) from InnovateMedTec.com to wrap up, with a call for collaboration and connection across the globe to accelerate innovation. You can all take part, online, or in person, by attending the next event. Mark Saturday 22nd April, 2017 in your diary – I’ll see you there.
I am a fellow of the Royal Society of Medicine, mainly because I was so impressed by the venue and quality of the meetings when I came to the last event. I cover the membeship costs personally. The event was free to attend for all, and I paid all travel and food expenses, apart from the coffee served at the intervals!
Of course, I also wore my #PinkSocks – see previous post about the provenance of these fine items.
“The one thing that the NHS cannot afford to do is to remain a largely non-digital system – it is time to get on with IT”
The Health & Care Innovation Expo 2016 is now entering its third year of showcasing the very best of innovation in the NHS. Hosted by NHS England, and held in the steampunk Victorian grandeur of the Manchester Central Conference Centre, I took part in 2 packed days of talks, workshops, demonstrations and general flights of wild innovative fancy with a wide range of attendees. The importance of the event was underlined by the prestige and range of speakers, from Professor Sir Bruce Keogh opening the event and chairing numerous panels, to Professor Bob Wachter MD talking about his review into digital usage in the NHS. We even had a hirsute Simon Stevens delivering a keynote and a full hour of Jeremy Hunt’s time, where he launched the next phase of the Digital NHS roadmap.
In truth there was a little too much to wrap my head around. The show floor was packed with exhibitors large and small, and an interesting range of stands exploring the ‘feature zones’ of New Care Models, NHS Right Care, Digital Health, and Personalised Medicine. Given the long queues for some of the talks, not to mention the numerous pop-up events and side meets, the one innovation we were all in need of was more time.
The announcements were, as tradition dictates, presented in the morning papers and we heard about the coming year’s targets on the journey to a digitised NHS in 2020. Primary care is in a good place here – in fact, Jeremy Hunt commended GPs for ignoring the government advice and ploughing their own furrow when faced with Connecting for Health. Without this, he said, we would be significantly further behind. Interesting advice on avoiding governmental advice there.
The news broke down as follows:
Patients will be able to book appointments, order medications, and download records, US ‘Blue Button’ style, on a revamped www.nhs.uk to be launched at Expo 2017.
Anyone will be able to access detailed stats on performance in key areas such as dementia, diabetes, and learning disabilities
There will be online access to 111, which can lead to direct appointment, signposting, or callbacks.
By March 2017 there will be a directory of approved apps from March 2017, with subsequent support for wearables
The creation of a second round of ‘national’ excellence centres, with more detail to follow.
The creation of an NHS Digital Academy to teach Informatics skills to NHS staff and create the next generation of Clinical Chief Information Officers and Digital Health Leaders.
Response to these announcements was mixed, both at the expo and in the press. On the one hand, when you combine this with the Tech Tariff (on which there was little news), it’s yet more evidence that the NHS is making good on the promise to step into the 21st century. Entrepreneurs and startups might complain that it doesn’t go far enough, and that the route to approval is still too long-winded and narrow. There was also the usual chorus of disapproval for any non-evidenced interventions in the NHS, and possible willful misinterpretation of what was being offered as simply a way of fobbing patients off with an app instead of a doctor. Those of us with a role in innovation have a responsibility to ensure that expectations are managed appropriately: Digital Health is NOT a panacea, but is instead another weapon in our fight against illness and social problems. We also need to ensure that evidence is generated and shared whilst trying to balance the pace of technological change against that of traditional research.
My presence at the expo was as innovations lead for my CCG (Eastbourne Hailsham & Seaford, and Hastings & Rother), and so it was exciting to be able to share the stage with Professor Sir Bruce Keogh, Dr Mahiben Maruthappu(@M_Maruthappu), Mr Ashish Pradhan & Maria Slater. Our panel, ‘Achieving Innovation at scale in the NHS’ hoped to inform the debate about how we can turn small scale innovation (which the NHS is brilliant at) into widely adopted, large scale change (not so good). The vehicle of the NHS Innovation Accelerator, which I have spoken of previously, is beginning to deliver, and I was one of three speakers talking about current NIA products.
Mr Pradhan is a Consultant Subspecialist Uro-Gynaecologist at University Hospitals NHS Foundation Trust, Cambridge. Episcissors – 60 are fixed angle episiotomy scissors, which are used to assist with incisions for difficult births that avoid the complication of damage to the anal sphincter and subsequent problems with continence. Undeniably, a brilliant idea, but the point was made that a business case was hard because this cheap intervention actually reduces hospital income down the line! The NHS is littered with such perverse incentives not to innovate, all of which need addressing.
When it came to me, my story was simple – having an excellent product is NOT enough. AliveCor is, undoubtedly, a great product which works very well at identifying asymptomatic Atrial Fibrillation (AF) as well as other rhythm disturbances, but from pilot work and a wider scale roll out in my CCGs, uptake has been slow. This reinforces the need to carefully consider how to manage change when introducing innovation, as well as considering the practical aspects and the need for education and support.
Even so, with lower uptake than expected, we detected 61 new cases of AF which, if treated appropriately, would have significantly reduced the risk of stroke in the target population. In effect, we may have avoided up to 3 strokes per year even in this small group. Numbers like that surely warrant support!
It was also great to be able to celebrate East Sussex Better Together and our progress towards a single Accountable Care Organisation. By working together with acute trusts, community trusts, and social care, we are moving towards a world where the “perverse incentives” mentioned in Episcissors story are a thing of the past. Costs are no longer saved in someone else’s budget
You could have spread the event over a week and still not had the opportunity to catch the majority of the content. I attended talks about the GP Forward View, Urgent & Emergency Care Innovation, and even learning from high performance and marginal gains theory in a talk called “Black Box Thinking” from Matthew Syed(@matthewsyed). Innovation is more than just technology, and sometimes the change in mental perspective towards one of continual marginal improvement is the most difficult of all.
My personal favorite technology, Virtual Reality (VR), was a little thin on the ground. We had VR from treating Obsessive Compulsive Disorder from a company called Mindwave Ventures(@mindwave_). They are using VR to create what must be the most disgusting bathroom since Trainspotting to help patients gradually address their fears of contamination. Augmented Reality was showcased from AMA(@AMAapplications), whose Xpert Eye platform will soon be used in my area to allow doctors to remotely visit care home patients. I also have to confess that my day (and probably whole week) was made when I discovered that the MSD team had brought Microsoft Hololens(@hololens). I can only apologise to everyone that had to experience my excited swearing as I strolled around an alternate reality populated with tigers, sharks, and a ghostly vitruvian man with a glowing nervous system.
Having spoken at TEDxNHS(@TEDxNHS), it was lovely to meet Dr Jon Holley (@jonnyholley), Dr Manpreet Bains(@manpreetbains_1) and the team again at their stand. The video footage from the event is in the edit and I’m assured will be available soon. It even led to one of the more surreal moments of the event where I got pulled out of a talk on Urgent Care to demonstrate VR to Ruby Wax ahead of her talk on Mindfulness and Mental Health.
I’ve made no secret of my love for the US way of approaching innovation, and how they celebrate the possibilities whilst including patients, especially in the Stanford Medicine X conferences. Thanks to speakers like Roy Lilley(@RoyLilley) who talked energetically about the importance of innovation from the front line, challenged pretty much everyone he spoke to to think differently, and who then danced off to ‘Always look on the bright side of life’ after his talk, I think I can now see the British version of this optimism, and the contagion is spreading.
Innovation now has fewer barriers than ever in the NHS, although those that remain are substantial. It’s over to us to make sure that next year for Expo 2017 we have some real success stories to share, alongside the courage to share and learn from our failures.
DECLARATION OF INTERESTS
I attended in my role of CCG Innovation Lead & Governing Body Member of EHS/HR CCG. As a speaker, all travel, accommodation fees met by the event organisers. I received no speaker fee.
Oh, I also wore #PinkSocks throughout, in the spirit of #JFDI and #GSD. These were a gift from Eugene Borukhovic (@healtheugene)
You may characterise the NHS as many things, but I’d wager that being bold and having the ability to surprise is not one of them. Yet here we are, with another unexpected development in the world of Digital Health that is further evidence that the NHS is finally going to walk the walk, and not just talk endlessly about innovation.
I’m referring to last week’s announcement of an Innovation & Technology Tariff. Up until now, MedTech innovations had a rather convoluted and indistinct path to the patient’s bedside, with great variability between regions and no single, clear method of getting there. Even where technology has been demonstrated to benefit patients, scaling it has been frustratingly tough. At times it appeared that the NHS was actually acting against innovation, with perverse financial incentives not to change.
The mysterious new tariff became one of the talking points at the Digital Health panel at the 8th annual Future of Wireless festival. I was invited to talk about my ‘coal face’ experience of innovation in primary care, alongside Francis White (@francisww – AliveCor), Shamus Husheer (@susheer – Heartfelt Technologies), and Steve Feast (@drstevefeast – MD Eastern Academic Health & Science Network). Chaired by Nick Hunn (@nickhunn – WiFore), it was an honest and fascinating view of developing and implementing MedTech innovation in the NHS and across the world. Turns out the NHS is not quite the technological backwater we all thought it was, with markets across the planet providing their own unique challenges.
In my talk I described my own journey of discovery, from finding out about Alivecor at an innovation event in Scotland hosted by the Digital Health & Care Institute (@dhiscotland), through to testing it on myself and my patients, to finding a local specialist champion and working with him and my CCG to find the funds, and finally distributing the devices to the practices of Eastbourne Hailsham & Seaford, and Hastings & Rother. And then….nothing. Uptake of the use of the device has been slow, even in the face of good local evidence of benefit. Why is that?
It seems that just providing the device and having enthusiastic supporters is not quite enough. Alivecor is very much one of the stars of the current crop of approved innovations, but to embed it into routine practice requires many more steps – the development of a clear protocol for use by clinicians, implementing processes by which the data are reviewed and actioned, and the finding additional hardware and support resource. I’ve found all of this out at the coal face, and Alivecor have been great in working with me and sharing the knowledge to their user base. Partnering with front-line users is key.
Will the new tariff fix this? In short, it’s too early to tell, and while I’m enormously encouraged by the development, it’s clear from my experience thus far that just paying for progress is not enough. The old issues of change management are still there, and speaking from a primary care perspective, the enormous workload burden means that any innovations have to be implemented with the minimum extra investment of time and effort, whilst at the same time improving care quality AND reducing workload. No small feat.
Yet I am optimistic. I’ve seen the incredible passion for invention and delivering world-class healthcare in the NHS from patients, clinical & non-clinical staff, management, and the host of SMEs and startups basing themselves in the UK. We have the finest academics on the planet. In my own area, the East Sussex Better Together programme is bringing health and social care together to radically transform our ability to work jointly on the problems faced by local people. The new tariff might open up new possibilities here too.
There is a lot of talk about ‘Unicorn’ organisations in business – those companies that achieve a magical ‘ $1 Billion’ valuation. I’d like to reclaim the term and apply it to my NHS. It is a rare and mythical beast, with magic where it counts: a comprehensive healthcare system, provided free at the point of delivery based on need, not ability to pay. With some of the last barriers to a 21st century upgrade being removed, there’s no limit to what we can do.
You can read more at about the Innovation & Technology Tariff at
TEDx Glasgow delivered on its theme, ‘A Disruptive World’, before it even began, by itself being disrupted by a fire alarm that had the massed delegates standing in the glorious June sunshine. That this disruption had been triggered by someone having a sly smoke in the alleyway behind the building cemented the fact that this would be an anarchic, very Glasgwegian affair. The west coast warmth and banter was maintained throughout the day by presenter Janice Forsyth (@janiceforsyth) and comedian Sanjeev Kholi (@govindajeggy), who ensured the proceedings had an accessible feel both on and off stage.
TED stands for Technology Education and Design, and is a non-profit organisation started all the way back in 1984. Acting as a platform for ‘ideas worth spreading’, it has grown into a international success story. TEDx is an offshoot which seeks to promote local communities in delivering TED like experiences.
We began with a haunting, unaccompanied folk song from Kathleen McInnes, which took us to the first session. James Watt (@brewdogjames), Founder of BrewDog, spoke about his companies disruptive approach to customer culture, imploring us over a pre-10am can of lager ‘Don’t fuck up the culture’. By bringing the external internally, the dedicated customer base (of which I am one) have helped drive BrewDog to international success.
Such openness has its risks, illustrated in animated fashion by James Lyne, Global Head of Security at Sophos (@JamesLyne). The hacker of old has gone, having been replaced by the smiling social engineer of the modern cyber-criminal. When buying credit card details is as simple as visiting a dark-web online shop, itself customer rated and more secure than the banks they’ve breached, it’s clear that the traditional reliance on others to maintain our privacy has gone.
My clear first interest is Digital Health, and to that end I was particularly interested in hearing from the medical TEDx speakers.
Dr Ravinder Dahiya (@flexsensotronic) from University of Glasgow introduced the audience to the importance of touch in robotics, sharing the groundbreaking work he and his team have been undertaking in wrapping flexible ‘e-Skin’ over advanced robots and prosthetics. The critical importance of returning this sense to the wounded, and delivering it to the robotic, cannot be underestimated and bodes well for the future of both fields.
Jason Leitch (@JasonLeitch), National Clinical Director at the Scottish Government, was his usual brilliant and urbane self as he took the audience through a crash course in recording vital signs – pulse, respiratory rate, and ‘What matters to me’. This simple question has transformed the relationship between patients and staff in many Scottish hospitals, disrupting the traditional (and regressive) top-down approach to delivering care.
The medical device market, so crucial and valuable in global healthcare, is aching to be disrupted, and Dr Craig Robertson from @Epipole_ltd is doing just that, attacking Diabetic Retinopathy head-on. By developing a high quality, inexpensive fundoscope, linked to the best of cloud-based machine learning, he and his team are bringing 21st century screening to the developing world first, and seeking permission later (not the first time I heard this on the day). He also successfully delivered a live tech demo, and wins my ‘Silicon Cojones’ award. Don’t ask to see the trophy.
Marco Plas, Head of Research at the Wonder Weeks, spoke about the serial disruptions (10!) that occur in the first 20 months of a childs life. Understanding and responding to these important disruptions, and making the most of the fleeting opportunities they present, is critical in ensuring the very best for children as they grow.
The day was interwoven with frequent breaks, workshops, and speaker Q&As. My hosts, the Digital Health & Care Institute (@DHIScotland – dhi-scotland.com) took over the 2nd floor to present ‘Innovation Avenue’, a showcase of Scotland’s future, where I was able to experience first-hand some of the incredible products being supported by the Innovation Centres (@ic_Scotland – innovationcentres.scot). Two of the highlights were:
Dr David Harris-Birthill, Senior Research Fellow from St Andrews University, demonstrating touch-free pulse and oxygen saturation monitoring of up to 6 people at once using Microsoft Kinect. This could be extremely helpful in remote monitoring waiting areas in urgent care centres and emergency departments, improving safety and saving staff time and resource.
Dr Pablo Casaseca, Senior Lecturer in Signal & Image Processing from University of West Scotland, whose team is cleverly using a mobile phone app for audio analysis of coughs to help monitor respiratory health and predict exacerbations.
The appetite for disruptive and proactive innovation was absolutely clear. As one person described it, ‘We’re moving from asking permission first, and doing it then asking for forgiveness, to just doing it and not stopping until they taser you’ – I may well put this on my coat of arms.
Of course, TEDx isn’t just about medicine. Part of the magic of the event is the wide variety of speakers they assemble on one stage. The subsequent wild mixture of topics stimulates the mind and conversation even further.
So, from the art world we heard from fashion designer Pam Hogg, (@PAMHOGGcouture) talking about ‘Divine Disorder’ and the chaotic muse she serves in delivering her incredible and personal work to the catwalks of the globe. From NVA(@_nva_), Creative Director Angus Farquhar premiered a mystical video of his art installation at St Peter’s Seminary in Cardross. He spoke of ‘healing the wounded giant’: a choral piece ringing through the illuminated skeleton of this post-modern ruin. Brianna Robertson-Kirkland (@BreeRob_Kirk) explained how the Castrato, the eunuch rock-stars of the classical operatic world, led to the development of a vocal training methodology that shapes singers today.
From the world of business, we heard of the need to innovate in the conservative world of the legal profession from Ruaridh Wynne-McHardy (@RuairidhWM). Steve McCreadie (@TheLensCP) & Dr Mark Payton (@MerciaTech) gave advice on nurturing intrapreneurship and entreprenuerhsip respectively, and Ellis Watson from DC Thomson (@DC_Thomson) lit a fire under our collective backsides and just asked us to get on with it – ‘Disrupt yourself or Die Trying’
And then there’s the motivational element, for which TED and TEDx excel. Mark Muller Stuart (@BeyondBorders_) reminded everyone of global conflict, and the role that a small nation such as Scotland can play in Non-State Diplomacy. Luke Robertson (@lukeRobertson) gave a humbling talk on ‘The Other Side of Fear’, and how he recovered from having a pacemaker and brain surgery to become the first Scot to complete a solo, unsupported and unassisted expedition to the South Pole. Fear can be a powerful motivator, and he encouraged us all to take more from it than it takes from us.
Which leads me to the most touching talk of the day – Laura Beveridge (@wee_munchkin6). By day she works as development officer at Who Cares? Scotland helping young people in care. Laura came from a childhood in care herself, and she spoke bravely and honestly about how fear and bureaucracy got in the way of even the most simple activities that we all take for granted:
Risk assessments for sleepovers.
Sitting on the shore while your friends play in the sea because the wrong kind of staff are present.
Being denied a hug, or even being told that someone loves you, because you’re not a child, but a child in care.
A more stark example of the need for disruption, and to rise about fear, could not have been given. As her speech closed, the whole auditorium rose as one to give her a standing ovation.
The day finished as it started, with clear blue skies and warm early summer sun bathing the massed audience. Conversations with strangers continued into the evening, and it was clear that the mission statement of TEDx was being delivered. What is interesting about the TED approach is that, in contrast to more traditional conferences, answers aren’t provided. What you get instead are hints at solutions, and encouragement to communicate, collaborate, and boldly experiment. The call to disruption of the world starts by accepting disruption within.
The NHS has often been described as Stone Age in its adoption of technology, and whilst I wouldn’t be that harsh, it’s not far off. It’s certainly lagged behind the entire time I’ve been in the NHS (which is since my birth), but at times it has flirted with coming up to date. I’d heard rumours that we’re giving it another try, but having recently been at a talk from one of the NHS innovation leads which sounded more like he was reading from a Silicon Valley bingo card, I’ve not been entirely full of hope.
After today, I’m feeling optimistic.
Dr Steve Laitner (@stevelaitner), GP and Freelance Health Consultant and someone I’ve conversed with many times over Twitter, was kind enough to invite me to attend a meeting on ‘High Value Personalised Medicine in the NHS – now and the future‘. Personalised medicine is another buzz phrase (a box on the bingo card if you will) which is slightly hard to define. I understand it as the convergence of advances in medical informatics and biotechnology which will allow for super-personalisation of treatment for patients by segmenting populations into smaller groups (hence the other name for it: Stratified Medicine) at the popultaion level and more granular tests on individuals (including genomics) at the individual level (hence the other, other name – Precision Medicine). Of course, the NHS wants some of this, but what is not at all clear is how to best approach it.
The meeting brought together an incredible mix of patients, carers, academics, commissioners, third sector executives, scientists, and a few doctors, in an effort to begin to answer some of the questions raised. In Steve’s own words, it was a horizon scanning event, which looked to identify those technologies that could help deliver Personalised Medicine in the NHS.
Dr Fiona Carraghar, Deputy Chief Science Office (@depcsofiona) started us off with a clear explanation of Personalised Medicine, breaking it down into its alliterative components: Prevention, Precision, Prediction and Participation. There are a number of projects already well underway, including the ‘100 thousand Genome project‘ which has progressing nicely since it kicked off in December 2010. There are now 13 Genomic Medicine Centres in England, which have generated huge volumes of data that are being used for research and tailoring patient diagnosis and treatment in those with cancer and rare diseases.
Sir Muir Gray(@muirgray), director of the National Knowledge Service & Chief Knowledge Officer to the NHS, was next up. Bold and entertaining, he claimed that we stand on the verge of the third medical revolution:
The first: Public Health.
The second: (everything else in between).
The third: Mobile Phones.
He stated that the incredible processing, networking, and empowering effects of the mobile phone have transformed every aspect of our society, and now it is hard to find people who don’t have access to one. This revolutionary tool has the power to amplify both the benefits and the harms of medical investigation and treatment, so we need to be more thoughtful than ever in how we apply them.
Sir Gray is also a big fan of maps: the sort that show you the difference in treatment between hospitals. He spoke of a dream that every hospital has one on their wall, highlighting the variation in investigation and treatment of diseases. Personalisation does not mean eliminating the variation, but rather recognising we need to be asking why is there variation, and understanding the cause. As an active participant in the East Sussex Better Together programme in my home CCG, I can attest to the challenge of developing a good understanding of this data to help deliver a high quality integrated health and social care organisation to my locality.
His parting request was for everyone in attendance to help not only create and foster innovation, but also work towards adopting it widely in the NHS. This is a message I have heard many, many times: from providers, commissioners, patients and carers alike. It’s something I’m committed to helping with, and with Sir Gray’s encouragement my resolve has been suitably stiffened.
The final keynote was delivered by Lord Victor Adebowale (@voa1234), who came to ask a series of simple but powerful questions from his notebook:
Why are we pursuing Personalised Medicine, when we have so many other simpler problems to solve?
Who does it benefit?
How do we ensure that this doesn’t widen the gap we know as the Inverse Care law – that care is least available to those that need it the most?
In contrast to Sir Gray, he claimed that mobile telephony and internet access is not equitably distributed, with 8 million people in the UK have no internet access. I was surprised by this, as were some of the people following my live-tweeting. Sure enough, the ONS Internet Access survey of 2015 shows only 86% of households as having internet access.
Lord Adebowale was elected as a people’s peer for his work as chief executive of Turning Point, and I’m delighted to have someone of his focus and intelligence asking these importance questions at the highest levels of government. It certainly focused the minds of the attendees, and closed what was an truly outstanding opening session.
With that we were into the workgroups. I sat with the group discussing Patient Participation and Genomics, others looking at Personal Health Data and Population Health Management. Each session was led by a domain expert, which set us up nicely for what turned out to be lively and wide ranging discussion about how the fundamental tools of Personalised Medicine – shared high quality data, and genomics – might be used in a practical and ethical way within the NHS. Other groups considered big data and data from wearables and other sources.
There is clear tension between the realising the promise of these two rapidly advancing fields and the needs to apply appropriate controls to ensure security & confidentiality. We also need to minimise the risk of harm from its over-application. If we are to make the most of Personalised Medicine in the NHS, we need to make sure that the needs of patients are front and centre, and that we don’t simply rush ahead, justifying our pace by believing we have their best interests at heart.
I approached the consumer end of the genomics market (23 and Me) courtesy of a christmas gift from my parents. I thought little of the implications of being tested. Even with nearly 25 years of medical training and practice I’ve been baffled by some of the results, and left two locked and unviewed (my Parkinsons and Alzheimer’s disease risk). I’ve had two patients share their data with me in confusion, and I haven’t been much able to help. This is a dangerous situation, as the scope for health anxiety, fear, and unnecessary investigation and cost is great. Equally, the gold standard work of the NHS Geneticists is difficult to scale, so we’ll be left dealing with a heterogenous and inequitable situation where large scale gene sequencing may be restricted to those with money, leaving them to reap the benefit and harms, whilst those that might benefit from this the most either wait for access, or receive only a small portion of what might be possible.
I can’t deny that I’ve also personally seen a benefit from my genetic data though. I know now that I am a rapid metaboliser for Proton Pump Inhibitors (clinical grade antacids), which explains why Omeprazole has never settled my heartburn. My elevated risk of Type II Diabetes, only revealed to me when I ran my 23 and Me data through a different analysis, was certainly in my mind when I committed to weight loss using the 5:2 diet in the past few months.
As you scale up the data sets, more is possible:
An instantly accessible and accurate national organ and tissue donation registry? No problem.
A fantastically powerful disease screening system, which can be upgraded at the touch of a button? Absolutely.
Can we have cognitive computers deal with all of this while we get on with the more important stuff like speaking to patients? Of course.
When linked to other databases, the possibilities become staggering. Its certainly seductive stuff, but as Lord Abedowale asked: how do we ensure the benefits and harms are considered and equity is assured?
The other concern about Personalised Medicine, felt principally by the providers such as me, is that this adds an extra layer of complexity to our already over-stuffed workload. With burnout in GPs at a record high, it’s going to be an exceptionally tough sell to convince my colleagues that we should be doing more in the limited time we have with patients. The history of innovation in healthcare is not really characterised by the freeing up time, but rather one of making space into which more work is crammed. I certainly feel quite distant from many of my patients, often like a production line worker, which is dissatisfying for all concerned.
Could it be that Personalised Medicine is different? Assuming a patient spends 10 minutes with their GP once a week, every week of the year (an exceptionally high consultation rate by any standard), that represents less than 0.1% of the patients time. It’s not as if their health and wellbeing is paused for the remaining 99.9% of the year. By handing back greater control and ownership of healthcare to patients and their carers, perhaps we can all get much greater use of that time, saving the valuable time in each other’s company for the sharing expert knowledge, making decisions based on mutual understanding, exploring options creatively, and perhaps even having some time for empathy – something that Muir Gray feels is the one thing that mobile phones cannot replace!
The final panel drew together the discussions, with a summing up from Dan Gosling, from the NHS Personalised Medicine Core Team. He explained that this day was seen of the start of a conversation, and one that will be followed up as we move forward.
And there it was. Someone from a dedicated NHS team, attending an event convened to explore this in a serious and democratic, diverse way. This is why I have hope that the NHS is taking this seriously, and that there we can genuinely expect to see some of the incredible promise of Personalised Medicine realised for each of us in the months and years to come.
My hopes were high for some earth-shattering VR announcements from Google yesterday. As I watched the keynote on YouTube and sat through a series of announcements that, on the face of it, were rather underwhelming, I started to feel a little less hopeful.
When the VR came, it was in the form of an announcement about a new name (‘Daydream’), reference specs for VR ready handsets and headsets (‘coming this fall’) and a peek at the user interface, which looked interesting but somewhere south of what I can already get from Samsung Gear VR. The inclusion of a wiimote style controller was interesting though, and my mind went immediately to the possibility of using this in physical therapy and stroke-rehabilitation.
While the future of VR is, in my opinion, very bright and nausea-free, it was the remainder of the keynote that got my neurons firing with possibilities.
Earlier in the event, Google presented a rebranded messaging and video call pairing with Allo and Duo. Allo I could take or leave – it’s AI enhanced auto-reply seems well set to address all my dog-breed identifying woes. It does highlight the path to a more conversational, human-orientated AI interface, all of which strengthens Google’s core offering of a smart, intuitive natural language interface (more later)
Duo introduced something called ‘Knock Knock’ to video calling though, and this is where I saw some potential benefit. Essentially, it is a live video preview of the caller before you answer. This allows the recipient to know a little more about the person calling, presented as a way to gauge the mood of the caller.
Me? I saw a way of pre-triaging a patient before the call begins, without the patient needing to speak or enter data. We’ve seen video footage being used to determine pulse, respiratory rate, and even emotional state in other AI systems – could ‘Knock Knock’ even screen for facial weakness in acute stroke? Perhaps you could even analyse changes to speech against previous calls to determine subtle early changes to voice that can happen during ischaemic events. Whether this is unique to Google Duo or whether you could integrate this into existing WebRTC clients is another matter – the ‘smooth transition’ much emphasised by the presenter is less important in this situation.
Changes to Android OS (Version N – my money is on ‘Nougat’) were also discussed, but in truth the most interesting announcement of the whole event was Google Home. Having been nicely set up with a display of the advances in the natural language interface of Google Assistant, this device appears to be the voice activated front-end of home automation. There has been a slowly growing roster of Internet-of-Things (IoT) devices in the consumer market in recent years, such as Nest and Hive thermostats, Philips Hue lights, and the like. Google Home will provide voice search, internet services, and voice control of IoT home devices. Of course, Amazon got there first with Echo, but Google does have 17 years of weapons-grade search engine experience behind it.
The demo video shows the range of ways in which it could get the model family with 2.4 kids and a science project ready for their day – lovely, but much less interesting than the massive potential for health and social care.
A natural language interface could be enormously helpful in helping to meet the health & care needs of the older population:
It could be used to easily coordinate carers and update estimated time of arrival, reducing anxiety.
Food could be ordered from online grocers, reducing the need to employ carers for the simplest of care tasks (and thereby reducing cost and easing demand).
Medication reminders could be given in a friendly and simple to follow way, which could then feed back to the patient’s electronic record.
Voice control of home devices would be a gateway to increased use of IoT enabled lamps, heaters, and cooking equipment which would improve accessibility and safety, especially when it comes to family supporting their more dependent members.
In event of an emergency, Google Home could be used to summon help if the user was unable to get up after a fall, and act as speakerphone to emergency services.
The list of possibilities goes on and on, and multiplies with every connected service – something Google is very good at. Having been at the NHS Hack Day this last weekend, I’ve been struck by how little hacking appears to take place in the Social Care arena – perhaps later this year we could see events where Google Home (and Amazon Echo) are used to provide novel services at low cost?
Google Home can potentially help with something much more human though – the need for company. So many of my older patients live alone, with no-one visiting between carer appointments. This device opens the door to a easy, natural way of communicating with others, playing music, listening to audiobooks and the radio, but also interacting with someone that is always there, ready to talk, 24/7. It may start with traffic and weather reports, pre-canned jokes, and facts about astronomy from wikipedia, but the ambition of Google and Amazon, powered by the exponential growth in the field of Artificial Intelligence, means that before long the AI in your home will not just be your butler and assistant, but also a friend and companion.
This is partly down to the fact I’m sleeping on a camp bed at my brother’s home with the sunrise peeking through the curtain, but mostly because my brain has already started fizzing with ideas and excitement ahead of my second ever NHS Hack Day.
I first went to NHS Hack Day in January 2015, when it was held in Cardiff. I’d been introduced to it through tweets with AnneMarie Cunningham (@amcunningham), GP and Primary Care Director at the Aneurin Bevan Health Board, who was organising the event. Sold as an opportunity to meet like-minded hackers and geeks, I spent a whirlwind 36 hours working on GWYB – a notification system for patients which triggered communication cascades on the event of their admission to hospital. We even won the Patient Prize for our efforts.
NHS Hack Day is a free to attend event that has been running across the country at weekends since 2012. In ‘Meeting the challenge’, they ask:
How can we build an environment where world-class NHS digital services flourish?
Through leadership that understands technology and is bold enough to modernise the delivery of digital services, including embracing openness.
To this end they sent out the call to all geeks that love the NHS and bring them together in the spirit of adventure, openness, and addiction to coffee.
I arrive at 8:30 at Kings College, London, and pitch in immediately with laying out the bottle water, coffee, tea and bin-bags. Extension cables are daisy-chained together and taped to the floor. I pop my Ricoh Theta S camera onto it’s tripod and start up Tweetbot in readiness.
By 9 it’s getting busy, and 15 minutes later we’re off at pace. It’s a speed that doesn’t really drop for the subsequent 33 hours. Everyone who has contributed to the Google Document of Pitches through the week is given 60 seconds to pitch to the assembled masses. Here’s my attempt:
Yes, that’s right: I’ve just asked a room of strangers to build a customised 360 video viewing app for Google Cardboard by the next afternoon. I’m nothing if not ambitious.
The pitches range widely, from medical dictionary and haematology data visualiser, to hospital bed finder, bleep replacement, and even personal pollution monitoring. I’m suddenly aware that there are lots of other teams I’d like to join.
10:30 am and I feel like a wall-flower at a speed-dating event.
Once you’ve pitched you stand around the side of the room with a sheet of A0 paper with the project’s name on it. It starts slowly, but gradually the fact that I have a VR headset and I’m willing to share it attracts people. Several question the scale of what I’m trying to achieve, and as a result I realise that the project needs to change. With the help of some of the people the subsequently become the team, we decide to focus on using the tools at hand and skills we share to explore using VR and 360 video to help treat Phantom Limb Pain (PLP)
At this point it’s probably important to give you a little more information. PLP is a common and distressing complication of amputation. Up to 70% of people who have had an amputation can experience pain, itching, burning or distortion of their missing limb. It’s difficult to treat with medication, and as such a number of psychological and alternative therapies have been developed.
One such treatment method is MIRROR THERAPY. First described by Ramachandran in 1995, this uses mirrors to allow patients to view their injured limb as made whole again using the other limb. This has been shown to help reduce pain and distress, both during the treatment but also on an ongoing basis.
I have two patients with phantom limb pain, and even before coming to NHSHD I’d been wondering about using VR to help treat them. This weekend started to look like I might be able to make good on that.
More coffee and a time check. 11:30. We have 6.5 hours left of the day, then a further 6 hours tomorrow, to try and deliver something that will genuinely improve patient care.
My team is comprised of people with a huge range of different skills and backgrounds. Becky is a coding and digital media student from Brighton. Helen is a registered community nurse with a passion for tech and digital health. Mussadiq is a java dev with geographic information system skills. Ali a quantitative analyst. We also have Daniel and Charlotte, both software engineers. Some of the team stay for just day 1, and we’re joined on day 2 by Reno who’s switched codes from the dark side of finance to join Team Digital Healthcare. It’s an eclectic and excellent bunch – you can meet them all on our site.
Given our target group, the plan is to explore using VR, 360 video, and the Gear VR headset to simulate mirror therapy in a low cost digital way. My hope is that we can develop practical methods of deploying this in a clinical setting and share our findings with the community at large. It also means we get to have fun playing with all the toys, whilst everyone gets a chance to contribute and learn something.
The team splits into three streams:
Charlotte and Daniel start on the website, which we will use to contain our work from the weekend.
Becky, Ali and Musaddiq immediately set to work on the hard coding challenge – looking at Virtual Reality and whether we can mirror a live 360 video stream from the Theta S camera.
Helen & I began the collation of research evidence, and constructing a ‘treatment protocol’ that we could create some simple 360 video footage of which we could test with the team.
Such is the focus of a Hack Day that many of us didn’t really realise that the excellent lunch had been served until the back of the queue bumped into our table. This was despite the food being served right next to us. I guess this was the first proof of the distractive powers of Virtual Reality.
For the remainder of the day each stream worked away on their particular tasks. The website came together quickly and beautifully, built on a wordpress framework. Becky and Musaddiq heroically tackled 2 things at once:
3d modelling in Unity and then 3D Studio Max, developing some great point-of-view animations of leg therapy
Tests of live streamed 360 video using OBS and YouTube – this was sadly too slow, and there did not appear to be any open source mirror plugins.
Helen introduced me to Slack, a team collaboration tool that I dared to consider as yet another Social Network until I was sternly corrected. Using a technique shamelessly borrowed from the adult entertainment industry, I duct taped the 360 camera and Gorillapod to my chest to record 5 short series of basic mirror therapy clips. You can see them all here, and watch them yourselves using any VR headset. What was immediately apparent was that by watching and copying the movements you could experience an eerie sensation that the hands you were seeing were, in fact, your own (which in my case they were)
By 6 o’clock the pub and Eurovision were calling, so we all departed.
Day 2. 5:30 am this time. Ukraine won.
Another glorious day, so with coffee in hand I took a few photos of Embankment and set off to rejoin my slightly smaller team. This was offset by the fact that overnight we had been contacted by Reno, who asked to join us. Expanding the reach of the Hack Day using social media is fantastic, and something I hope they facilitate in future. As it was, our hashtag started trending shortly into day one, which was announced by the unwelcome hijacking of our thread by a russian dating agency.
By 9:30 everyone was up-to-date and the plan for the remaining 6 hours was in place. To up the pace and demonstrate the power of what we were doing to the team, we decided to utilise the ‘Cold Pressor’ test to see whether any of the content we had created could offset the pain of holding your hand in iced water.
The Cold Pressor test can be thought of as the bespectacled, serious cousin of the ice bucket challenge. It is used in research to help provide a controlled and safe painful stimulus. It has already been used, successfully, in demonstrating the efficacy of VR in reducing pain, so I felt it was justifiable to subject Becky, Reno and myself to a bit of light Sunday torture in the name of science.
Despite our rather crude efforts, what we found was quite startling. Becky & I recorded some point-of-view footage of ourselves with both hands inverted, our left arm in an empty bucket. The bucket was duly filled, and we were timed as to how long we could keep our left hand in the iced water.
Becky bowed out at 1 minute 30 seconds. I lasted even less, at 1 minute 10.
We were given a while to recover and then tried again using our personalised 360 video. What we found was that Becky increased the time she tolerated the pain to over 3 and a half minutes. I tried again and stopped at much the same time, with the feeling that I could have gone on if I wished. The sensory confusion of seeing both hands in the air versus the sensation of the left arm in water at near freezing clearly disrupted my perception of pain.
Reno stepped in next to experience the power of VR to distract patients from painful stimuli. Watching ‘Kurios’ by Cirqu du Soleil, he breezed through nearly 10 minutes of laboratory standard agony, smiling much of the time. Having checked his biography, I now see that he is an ultra-runner. This doesn’t diminish his achievement, but explains the smile.
Next came the crunch. I’d cunningly ensured that 3 of the time had frozen typing hands, so we awkwardly wrote up our findings, with Becky and Ali also finding the time to crack the problem of mirroring 360 footage in a simple and effective manner. It was this last development that will really help clinicians in creating effective personalised 360 mirror content for patients, and will form the basis of the next steps I take with my own patients.
3:30 arrived, and the final presentations in front of the judges began. With a brutally marshalled 3 minutes, each team spoke of what they had achieved in the last day and a half, before being grilled by the panel and audience.
We saw a great variety of differing presentations, but what tied them together was the incredible progress everyone had made, and the amazing creativity and skill that had been used in producing extremely polished applications that were, in many cases, ready to use. I was particularly impressed by ‘Outbreak’, a disease-outbreak management system in a box that used Raspberry-Pi’s and tablets to create a pop-up field network. I wasn’t the only one: they took home the star prize. Very well deserved.
So what about Virtual Analgesia? Well, I’m delighted to report that we won a ‘Highly Commended’ prize from panel judge Alan Thomas (@alanroygbiv) for our work on Patient Inclusion. Having had the idea come from patient needs, it was high praise indeed to have this recognised.
6 pm and it was all over, bar the wrestling over the goodies and dividing up the remaining bottled water. I’d been part of 36 hours of intense team work and creativity, and joined a group of new friends and colleagues. Most importantly we had a new tool that clinicians can consider using in managing Phantom Limb Pain. In the coming weeks I hope to share this work with my two patients and see whether they’d like to try this approach. Using VR in this way means that when they wake at 3 in the morning they’ll have something new to try to control the burning pain in the foot that’s no longer there.
This post is not a speech, so I won’t go into detail about how thankful I am for the help I had from my team – I’m banking on the fact that they know this already.
What this post must be is a loud celebration of the amazing work of the NHS Hack Day group, and most of all about the incredible reservoir of passion and talent in the developers, students, clinicians and patients of this country. The challenge of rising demand and shrinking funding of healthcare is not unique to the UK, but we have a National Health Service – free at the point of delivery, with care provided based on need, not the ability to pay. The NHS Hack Days demonstrate that it isn’t just the nurses and doctors that are committed to supporting this unique and precious institution, and that we don’t go into the fight unarmed – there’s an army of geeks out there, and they have some incredible tech to share.
To find out more about the next NHS Hack Day, visit their website www.nhshackday.com or follow them on twitter @nhshackday – they really are amazing events, and welcome everyone with a passion for healthcare.
All the notes from my team ‘Virtual Analgesia’ are available on www.virtualanalgesia.net . We’d love to hear from you with any feedback or comments. You can join the discussion on Facebook on ‘VR Doctors‘ – just apply to join.
Declaration of Interests
I attended this event in my own time and at my own expense. The hardware and software used was all either open source or owned and operated by the participating team members.