The rapid and unprecedented uptake of digital healthcare has been integral to the strategic drive by many nations to shift care out of hospital care into the ever-expanding community-based setting. A multitude of digital technologies are being deployed to support this transition, including telemedicine, virtual reality, patient-facing apps and portals and electronic medical records. With limited access to hospitals during COVID-19, the widespread roll-out of online consultations and virtual clinics has made it possible and easier for patients to be cared for remotely.

Dr Talac Mahmud is a senior GP Partner at Healthy In Your Own Skin (HIYOS) NHS practice in Hounslow, London with nearly 25 years' industry expertise in primary care and the NHS. Mahmud has a special interest in strategic innovation in primary care with the use of digital solutions and behavioural theories and has been part of a number of projects which address the current challenges faced by primary care in the UK. He talks to Healthcare IT News about the importance of patient engagement and why we will not go back to pre-COVID care. 

On 2 December, he will be speaking at the 'Extending Health and Care beyond Hospital Walls: Real-World Case Studies Best-practices' at the HIMSS & Health 2.0 Middle East Digital Health Conference & Exhibition. Mahmud will be discussing how technology is enabling a shift to patient-centred care models of community-based care and sharing learnings from effective cases of digitally-led primary care from the UK and the Middle East. You can register your attendance and find out more here.

This interview has been edited for length and clarity.

HITN: How has COVID-19 affected your work as a general practitioner? How do you foresee it affecting primary care for years to come?

Mahmud: The impact of COVID-19 on primary care has been huge, in particular as its role as a catalyst in the use of technology. We carried out a patient survey towards the beginning of the COVID-19 pandemic which had over 2,000 responses in 3 days, and in it we asked how patients wanted to access our services. Patients showed an appetite not only for more online communication regarding their health, but also for online group events in non-health related areas – for example cooking and art. Many wanted to engage via Whatsapp, Facebook and Twitter. When asked what they could do to help during COVID-19 they showed an overwhelming willingness to help and support others.

Easier access via technology has been a game-changer

Patients have benefited from easier access to healthcare via the opportunity to use technology in a way consistent with its use in other areas of life. The knock on effect of this is also significant – it has an impact on the environment. Reduction in visits to clinics has resulted in a decrease in carbon footprint. In our practice we have calculated this as 41,280kg of CO2 per year which is equivalent to 256 trees. We have plans in place to be carbon neutral next year.

Clinicians have been able to change the way they work

From the clinicians’ perspective, the benefits of the current way of working allows for more flexible working which is a huge issue. There is much more opportunity to access training and to attend and contribute to meetings, all at a click of button. However, the drawbacks of social isolation and enhanced risk perception are palpable.

We have seen increased social isolation of both patients and workforce. In addition, health anxiety, risk of delay in seeking medical assistance with sinister symptoms, and a delay in planned surgical procedures have all inflated. For clinicians, there too have been challenges in anxiety around the ability to provide care safely. The risk of contracting COVID is a cause for concern which has been exacerbated by the challenges of securing adequate PPE.

We’ll not go back to pre-COVID care

It’s unlikely that we will return to the delivery of care that we had pre-COVID, one where we have standard 10-15minute face to face consultations, providing reactive care. That model of care will need to deconstructed and rebuilt making more use of technology to change timescales of care, communication methods, along with increased opportunities to check-in and seek guidance. We’ll be using instant messaging more. In our experience, there will always be an overwhelming preference for using the phone, but so far we have seen the use of online messaging gather traction too, with a comparatively small appetite for video conferencing.

As demand for healthcare is rising, it’s imperative that primary care supports prevention, this should be initiated by the practice. We need to make small interventions for large numbers of patients to support behavioural change - thinking of ourselves as providers of wellness rather than defenders against illness. In a study of proactive interventions done at our practice, we found that a reduction in demand happened within a few months.

We continue to work on interventions to change patient behaviour, and in this, we collaborate with other healthcare providers. We have also now started to engage with schools and employment services to build a proactive model of wellness throughout the community.

HITN: How are you driving patient engagement? How do you encourage others to do the same?

Mahmud: We live in a world where Google knows more about our thoughts and behaviour than we do. In healthcare, patient engagement is often mandated, but we ought to engage because we want to, rather than because we have to. It ought to be the cornerstone of forming strategy that we need to have the engagement of as many patients as possible, patients who share their honest opinions and suggestions but who are also challenged - presented with choices, trade offs.

Engagement needs to be smart

We have found that patient engagement works by using a combination of methods including surveys, a chatbot service and focus groups. We also found that using population groups (ie patients with families, patients who are of working age etc), rather than disease-based groups helps us consider the breadth of needs of patients – those with and without specific health needs. The key is understanding patients’ behaviour and the drivers behind it. We have used validated Patient Activation Measures (PAM) which scores patients knowledge, skills and confidence in their health. This allows us to customise the support we provide. We’ve also built ‘personas’ or fictional characters for each population group which include their social circumstances, their interests and hobbies as well their relationships. This helps us to give a deeper understanding of behaviour when analysing the results.

We’ve had some remarkable traction with patient surveys with around 2,000 patient responses to recent surveys, all within a few days. This happens by carefully considering the timing of surveys. For example we look at trigger points – both external and internal. So if a patient becomes pregnant, or is recently diagnosed with something, that may be a trigger point for communication, as may be an external event in the news.

Engagements must be simple, attractive and short. We’ve found giving patients brief simple questions but allowing them also to use free text gives us the most useful data to analyse. Free text allows us to analyse sentiments and identify issues that we may not have thought about. Increasingly we are using AI technology to support us in this analysis which has proved to be quick, reliable which has freed up time to spend on drawing conclusions. Finally, we have found that engagements work best when there is social element, where patients form relationships with each other when working in focus groups, building on each others’ ideas. Even with online questionnaires, if patients feel their voice is heard, they feel part of a movement.

It’s crucial that healthcare providers have a deep understanding of their patients’ behaviour so as to ensure that there is alignment with the needs of patients and limited healthcare resource.

HITN: Can you tell us a bit about you interest in game theory and how this can be applied in healthcare?

Mahmud: Game theory is a theoretical framework for conceiving of social situations among competing players and producing optimal decision-making of independent and competing actors in a strategic setting.

I am working on the application of Game Theory to help evaluate patient and clinician behaviour which results in better outcomes for both – using mathematical modelling. This will result in the development of a frame work which allows the delivery of proactive care whilst reducing demand.

It’s not cooperative

Healthcare is a US$12 trillion market and the interaction between doctors and patients and their relationship are often discussed (nationally and internationally) in terms of a ‘cooperative’ game. Sadly this is often not the case. Demand has increased due to an increasingly elderly population, increased investigative and treatment options and patients’ raised expectations.

At the same time, supply has become more and more limited with long lead times for training, workforce burnout, enhanced regulatory burdens and more frequent litigation. There is an inherent conflict built into the system. Patients would like to have a personalised care but clinicians are trained in generic disease ‘buckets’ (for example diabetes, hypertension etc). Patients would like quick treatment, but doctors are overwhelmed by workload and delays are common. Patients want integrated healthcare, but professionals often work in silos, even within the same clinical teams in a hospital or GP practice – where there are clinical risks around handovers.

Patients would like to have shared decision making, however, they often don’t have the knowledge and clinicians find it quicker to ‘do’ rather than explain. In summary, patients are playing a long term or infinite game and clinicians are playing a short term, finite game. Strategy documents make the realisation that clinicians need to focus on prevention, but it’s difficult when they can’t cope with current demand.

Prevention is seen by clinicians as a luxury - something they don’t have time for, whilst patients see it as essential. Given that it’s easier to measure short term activity, the incentives for both publicly and privately funded healthcare commissioners are to have a system set up to respond to short term goals. It’s very hard to measure something that hasn’t happened yet – for example prevention of stroke or heart attack, and even harder to attribute an intervention within a complex health and social care system which is responsible for that.

Breaking the cycle

I work as a general practitioner (primary care physician) in London and we have tried to break the cycle we’ve ended up in. We’ve done some work around prevention to test if this has resulted in a reduction in acute demand. We’ve created time to work on proactivity by having teams with shared goals working on projects to improve patients’ health confidence and health community involvement. Our initial results have shown that working on proactive care resulted in a reduction in acute demand by 1,700 appointments over a 12 month period. In just a few months, patient confidence improved and behaviour changed positively.

We’re now working to develop a chatbot which can help automate some of the administrative burdens of the practice to give our staff more time to be able to support the relationship with patients and support their long term goals using coaching models. There is a lot of ‘noise’ in the healthcare technology area, but unfortunately limited adoption or patient outcomes. I feel that using game theory models to evaluate healthcare services can also help when looking at what the appropriate use of technology is to try to improve outcomes for both patients and clinicians.

When it comes to planning change and getting ‘buy in’, a great deal of effort is made but an equal amount of energy needs to be spent on sustainability, as this aspect is often overlooked. We need to look at healthcare through the lens of game theory models to see if we can help deliver a better healthcare system for us all.

HITN: What are your hopes for the uptake/future of technology and innovation in primary care?

Mahmud: Technology is a key enabler for delivery of healthcare, however, we need to have a clear understanding of patient behaviour and game theory models help mathematically to calculate which areas of technology might bridge the gap between competing drivers for patients and clinicians - resulting in better outcomes for all. Technology is only one aspect however, unless we change the culture, incentives, structures and processes as well as support staff, nothing will change.

Thank you for your time. More information about the HIMSS & Health 2.0 Middle East Digital Health Conference & Exhibition taking place from 29 November – 2 December 2020 can be found here.