The patient activates himself! More involvement, better outcomes. Back to the Future, 1985

Activating the patient: more involvement, better outcomes

An interview with Dr. Lia Ali by Thomas Clark

Read intro

An interview with Lia Ali

An interview by Thomas Clark

In the popular imagination, the phrase ‘innovative healthcare’ conjures up wearables and the quantified self movement, genetic mapping, customized medicines and the bionic man. But how can these advances actually be harnessed to make people's lives better at a time of tightening resources? What are the paradigm shifts that must take place in healthcare and outside it in order to create better outcomes? What will the new relationship between health professionals and patients look like in thirty years’ time? Dr. Lia Ali gives her opinion, explaining why the most important medical resource of all is not the new technology, but the person it’s designed for.

Dr. Lia Ali is the clinical lead for Myhealthlocker, a digital service that allows people to have control over their health information and manage their own health and well-being. The platform leads the way: it has been implemented for patients at the South London & Maudsley NHS Foundation Trust in South London. Dr. Lia Ali is a practicing psychiatrist at the Trust with particular clinical interests in psychiatry at the mental health/physical health interface.
Hide intro

In thirty years’ time how will the health landscape look?

There are a number of things. If we look at other sectors there has been a revolution in the way that we use technology as part of our everyday lives. For example, the banks have put a great deal into changing the way people interact and do their financial transactions from the customer level. We’re starting to see how those things might be useful in health, but also where the problems might be. A lot of the resistance is around the fact that if you’re doing your online shopping, or paying a bill online, it has a completely different emotional tone to doing something like a health transaction. In thirty years’ time I think the landscape’s going to be completely different. There will be a lot more interactions that are happening solely online, you can look at initiatives like Big White Wall that are starting to do this with their online peer-​support platform. It provides psychological services exclusively in the virtual world which are backed up further down the line by face-​to-​face services. We’ll see more things like that coming through.

Big White Wall is about peer-​support from the world wide web. It’s essentially remote. Do you think it is a good long-​term solution? Can it really replace speaking to people around you – not only your GP, but also the family and society around you that care?

No. Something like Big White Wall is never going to replace the interaction with your family or your GP. But it does provide an opportunity for a part of the population who might be isolated, who are experiencing severe psychological distress, to connect and access psychological therapies in a way that wasn’t previously possible. We know that mental health disorders are common – one in four people have some experience of a mental illness, and yet the majority of those people don’t get anywhere near any kind of mental health service. I like to think of the World Health Organization Mind the Gap project, about increasing the level and access to mental health care globally, where people who are not mental-​health trained administer essentially mental health interventions. It looks mainly at the developing world where there is one psychiatrist for an area the size of Wales. But access is an issue in the UK, too. The project is essentially a set of algorithms, developed over time, for how to diagnose things like depression; I think it shows that when you’ve got algorithms that are well worked-​out, it doesn’t replace the diagnostic skills that you might get from a fully trained psychiatrist or a psychiatric nurse, but it does go some way to addressing the diagnostic needs of that patient group who aren’t getting access to anything.

About time to change the doctor–patient paradigm? Ancient Greek vase showing a patient visiting the physician to be treated. Source: Wikipedia Commons

About time to change the doctor – patient paradigm? Ancient Greek vase showing a patient visiting the physician to be treated. Source: Wikipedia Commons

There is something very important about human contact for our well-​being

You compared health to other industries which have implemented technology. But in those industries, when a machine can do something – not necessarily better, but when it simply can do something – then the human tends to get replaced. How do we fight the danger of replacing the human everywhere?

I think that most people would say that human contact is one of the key things for their well-​being. That human contact doesn’t necessarily have to come from a face-​to-​face interaction. There are examples of work where people say they feel connected in other ways – by being engaged in a social-​media mediated carers’ group, for example. But we can’t fully replace human contact with technology. These are themes that came out of the Francis report in the UK, the big scandal in Mid-​Staffs, in the North of England. A big reason for those failings was the culture that was set up, whereby these people were dehumanised and just became pieces to be moved about in a sort of healthcare game. I would resist any attempt to use technology in a way that makes that dehumanisation happen more, and if we listen to the lessons from the Francis report, if we listen to patients’ experiences, then I think we can avoid that.

You’ve been working within the UK National Health Service (NHS) to develop and implement the Myhealthlocker patient platform, which is a way for people to share information and talk with health professionals on a more regular basis. What is the thinking behind this?

I’ll start with your statement that Myhealthlocker is a way of talking to health professionals. We are trying to build it as a system with a slightly bigger vision than that. It comes back to trying to get patients activated and at the centre of their care. We know that if people really feel involved in their own healthcare and their own well-​being, the outcomes for them are much better. In something like diabetes, for example, we’re beginning to recognise the fact that somebody has to engage with having their blood sugar monitored, they have to engage with going to the doctor and picking up their medications, they have to engage with looking at their diet, in order to achieve good clinical outcomes, to be healthier and to live the way they want to. If we don’t recognise that and we continue with a very paternalistic way of treating people – if people are very passive in their care, we will never achieve anywhere near the kind of outcomes that we can with the collaborative approach. This involves a significant shift in the way that we think about the interaction between clinician and patient; we need to make sure that the system is built recognizing and facilitating that. 

People can achieve better mental health outcomes by labelling and recording their own symptoms and triggers. Image source: Wikipedia commons.

People can achieve better mental health outcomes by labelling and recording their own symptoms and triggers. Image source: Wikipedia commons.

What is the potential for a thing like Myhealthlocker specifically for people with mental illnesses?

Again, it comes back to values and surfacing what’s important to people. For example, I might have in the clinic someone who has depression. They don’t necessarily know they’re depressed, but they are able to tell me what functions they can’t do. They can’t get to the school on time to pick their children up, they can’t sequence their thoughts well enough to put in a job application. They’re describing depression, just not in the biological terms I might read in my textbook. So the opportunity in something like Myhealthlocker is that it allows people to do things like build surveys for things that they think are important. As the doctor I don’t build it. It’s finding and defining the measures that are important to people, and giving them the power to do that and also to put it in the context of their wider healthcare. The visualisation is really important here – people need to see it in a way that has value for them and captures their imagination.

People with severe mental health issues die about twenty years earlier than the average member of the population

The other area where mental health patients can benefit from a digital system like Myhealthlocker is in the realm of looking after their physical health. Traditionally we’ve had a real problem with the split between physical and mental health issues, so much so, that people with severe mental health issues die about twenty years earlier than the average member of the population. One of the things we focus on in Myhealthlocker is making sure that we are looking at some of these physical health parameters: the ability to monitor blood pressure, for example, or heart rate or weight and putting that, again, in the context of your wider health issues. There are some other great projects that are doing this too, such as the IMPARTS project at King’s Health Partners.

How do you see the role of health professionals changing in the future?

The whole communication part will change. We’ll end up doing, probably, more consultations virtually. I hope that we will start to recognise the importance of the information that the patients, and the patients’ carers bring to us, and that will form a much bigger part – for me it needs to be the central part – of any care plan, or of any data repository that we’re using to treat people. Once we make this shift to a more collaborative approach, then a key role for doctors will be this concept of ‘data sense maker’; they’ll have to be more adept at interpreting and utilising the increasing volume of data coming to and from patients. One thing is certain though: we’ll always need the clinicians with the deeper knowledge, they won’t disappear.

What about training for medical professionals?

I hope there’s going to be much more focus on how you use the data available to you in your everyday practice. I can remember being a Year One new doctor (house officer) and walking around with one particular book in my pocket the whole time – that’s how you identified who the new doctor was. If something wasn’t in that book, then I might miss the piece of information that I needed at that particular point in time, at that particular point of care. Now we can access a much bigger range of data, because we’re standing on the ward with our smart phone, able to look up the British Thoracic Society guidelines on managing exacerbation of a particular condition, for example.

The internet community supports services like Big White Wall that bring people solace.

The internet community supports services like Big White Wall that bring people solace. Can they compensate for loneliness and diminishing human contact in other walks of life?

How do we manage the risks of new health technologies?

I don’t have the answer to that. I don’t know that anybody has the answer to that yet – how you set a balance between safety and what is actually going to be used, and be useful to people. You don’t want to shut down innovation; at the same time we don’t necessarily want to expose people to something that is going to cause them harm. Maybe we have to accept that things that we put out there are going to have more risks to them, and we might be really uncomfortable with that, but we have to be a bit more transparent about it to make it acceptable to do. We have to streamline and speed up the way we do evaluation of these kinds of health tech. I think that it is quite important to realize that in health we don’t have all the answers, that we fail sometimes, and that that’s part of trying to grow our ability to give people good healthcare.

Is there a case for computer programmers as doctors? Do we need to get the technology development closer to the medical profession?

The technology absolutely needs to be embedded. If it’s too separated off from the clinical front line, you end up – as we had before – with technologies that might do something whizzy for a year but soon get outdated and never truly address the way our clinical work flows operate. Although the focus is on the experience of the patient, you have to factor in how you engage the clinical workforce in implementing these technologies. You need to have the clinical perspective on how the technology can be used; my role at Myhealthlocker is to provide that, in fact. It’s going to be fascinating and exciting to see what happens when we have people coming through medical school who have been trained from the start to give that feedback.

In mental health there are some real, tangible risks around sharing information, but they are actually rare cases

Do you think that healthcare innovation will happen more quickly in the developing world and that we will see their quality of healthcare surpassing the countries with more firmly established healthcare systems?

That’s an interesting and bold statement Tom! But yes, potentially. Any innovation is driven by need. So if you’ve got populations that have huge health inequalities, but growing access to certain types of technology – smart phones and 2 and 3G connectivity being one of the big things that is done better in certain parts of the developing world, then we may see some great advances there. Definitely.

Wearables and other tools are allowing people to match different kinds of health data for surprising insights

Wearables and other tools are allowing people to match different kinds of health data for surprising insights

What’s your whacky vision for the future of healthcare? What are people going to have attached to their heads, and so on?

I think one thing that will definitely happen is we’ll have much more matching together of data. There’s an amazing, really fun lady that I know called Anne Wright who developed something called Bodytrack with Fluxstream, and she walks around with a home-​made utility belt made out of plaid with all the wearables on it. She’s part of the Quantified Self movement and she tracks a whole range of things about herself, everything from heartbeat, to what she eats, to how connected she is. So we will see people putting together data a lot more and drawing insights from that. Really interestingly, people will start combining that with genomic data. Anne Wright managed to get a copy of some of her own genomic data and was able to figure out that she had a particular gene variant that meant she had a paradoxical reaction to a particular blood-​pressure drug or something similar. She therefore got a symptom that nobody else gets, and it was all to do with a particular gene variant. Those kind of miniscule insights that you would never get unless you were engaged in the most expensive research study will become much more accessible. It’s not ‘whacky’, but that’s my hopeful vision for the future.

Will privacy concerns stop the benefits that can come from sharing this information?

Yes, we’re already seeing elements of that. In mental health for example, it is true that there are some real, tangible risks around sharing information, but they are actually rare cases: only a small amount of data in the mental health field carries this risk. It would be a huge shame to let this sort of concern stop the huge advances that could be made by sharing data properly and by people being as open as they can with that data. My biggest concern is actually what insurance companies will do with this sort of stuff. It’s going to pose a number of quite tricky questions for us as a society when health insurers start saying ‘well, we can see that you’ve put on five pounds in the last six months, we’re raising your premium.’ Those are going to be the kind of barriers for people making the most of these digital technologies.

cialis vs viagra viagra for women ciprofloxacin dosage escitalopram effets secondaires viagra vs cialis vs levitra viagra vs cialis azithromycin pediatric dosing zovirax for cold sores viagra medicine generic cialis at walmart finasteride reviews lexapro withdrawal symptoms buying viagra what is azithromycin finasteride long term effects what is ciprofloxacin prescribed for canada cialis tamoxifen citrate where to buy viagra nolvadex viagra nebenwirkungen cheap viagra side effects of azithromycin vardenafil 20mg viagra coupon withdrawal from lexapro cialis 5 mg how to get off lexapro viagra sex cheap levitra viagra canada what is cipro usually prescribed for cialis 5mg daily generic viagra 100mg cipro for uti viagra wikipedia escitalopram 10mg cialis for women lexapro 10 mg cialis medication escitalopram 10 mg para que sirve cialis prices buy viagra online cipro dangers viagra bestellen what is escitalopram zithromax z-​pak ciprofloxacin 500 mg cialas azithromycin class tamoxifen side effects in women buy viagra acyclovir 800 mg 5 times a day acyclovir 400 mg acyclovir medication erectile dysfunction cialis cialis from canada cialis effects ciprofloxacin 250mg lexapro overdose what is lexapro used for cialis savings card acyclovir 800 mg cialis samples overnight levitra prices finasteride medication how to wean off lexapro without withdrawals lexapro side effects men propecia escitalopram side effects cialis pills for sale side effects of finasteride 5mg azithromycin medscape cialis pharmacy prices zithromax dosage tamoxifen nebenwirkungen equipe argentine viagra lexapro bula what is finasteride used for what is acyclovir for how much does cialis cost 200 cialis coupon is azithromycin penicillin acyclovir ointment 5 finasteride 5mg side effects mayo clinic lexapro vs wellbutrin cialis generic cialis online finasteride tablets acyclovir dosage for cold sores tamoxifen langzeitfolgen what is tamoxifen used for cialis otc lexapro weight gain azithromycin cost cialis or viagra lowest cialis prices order viagra how long for lexapro to work cheap cialis what is cipro used for side effects lexapro ciprofloxacin 500 finasteride vs dutasteride finasteride 1mg levitra erfahrungen viagra pillen kruidvat cipro and tendonitis viagra wiki cialis coupon 20 mg generic cialis cipro side effects in elderly how to use viagra cialis reviews levitra coupons azithromycin pregnancy category side effects of acyclovir propecia side effects viagra generic lexapro 5mg viagra alternative generic cialis tadalafil liquid cialis is tamoxifen chemotherapy cialis pricing viagra effects azithromycin drug class first few days on lexapro acyclovir vs valacyclovir effects of stopping lexapro suddenly utilisation viagra ciprofloxacin nebenwirkungen pfizer viagra coupons from pfizer lexapro and weight loss cialis copay card cialis coupons what is ciprofloxacin used for ciprofloxacin 250 mg cialis 20mg directions azithromycin 250 viagra activate wholesale cialis lexapro vs celexa cialis dosage recommendations cialis daily is azithromycin ciprofloxacin 500 mg for urinary tract infection generic levitra finasteride best price viagra what is azithromycin used for thuoc azithromycin side effects of lexapro 10 mg levitra vs viagra azithromycin pregnancy side effects of ciprofloxacin 500 mg azithromycin 250 mg treatment buy levitra online viagra without a doctor prescription cialis 30 day sample acyclovir dose azithromycin eye drops female viagra cialis 30 day trial coupon free cialis levitra 10 mg prezzo does lexapro cause weight gain tamoxifen and foods to avoid ciprofloxacin ophthalmic solution common side effects of ciprofloxacin 500 mg azithromycin dosage finasteride 5 mg tab herbal viagra azithromycin 250mg tablets 6 pack viagra online azithromycin for strep throat escitalopram levitra vs viagra for hardness cialis 20 mg ciprofloxacin coverage acyclovir 400mg how long for azithromycin to take effect cipro what is viagra is lexapro a controlled substance cialis free trial ciprofloxacin hydrochloride ophthalmic what bacteria does ciprofloxacin kill tamoxifen azithromycin 250mg ciprofloxacin for dogs acyclovir 200mg pfizer viagra cialis patent expiration date extended acyclovir cialis pills ciprofloxacin how does lexapro work sophia viagra women viagra finasteride and enlarged prostate lexapro manufacturer website what infections does ciprofloxacin treat online viagra azithromycin 500 how does acyclovir work zithromax antibiotic viagra 100mg tablets retail price azithromycin 500mg viagra tesco azithromycin three times a week zovirax cream what works better than viagra viagra 100 cipro side effects azithromycin tablet vardenafil vs viagra cialis coupons from manufacturer cialis price acyclovir side effects acyclovir 800 mg for shingles lexapro dosage lexapro dosages viagra generico levitra 20 mg precio farmacia acyclovir 800mg zovirax lexapro side effects in women azithromycin liquid side effects of lexapro in women cialis sample viagra costs effects of stopping finasteride how to take cialis antibiotic ciprofloxacin what does ciprofloxacin 500mg treat azithromycine 250 mg cialis 10 mg online cialis zithromax cialis for sale azithromycin for uti lexapro and weight gain finasteride 5mg azithromycin finasteride results viagra alternatives azithromycin tablets what is tamoxifen ciprofloxacin used for azithromycin uses tamoxifen and weight gain ciprofloxacin hcl 500 mg tab viagra soft buy generic levitra side effects of ciprofloxacin cialis side effects of finasteride lexapro for anxiety is ciprofloxacin a penicillin side effects of lexapro viagra vs cialis vs levitra ciprofloxacin drug class finasteride 5mg tab how to wean off lexapro azithromycin z pak cialis coupon print viagra natural what does ciprofloxacin treat generic viagra generic for cialis what is lexapro for cialis discount viagra pill acyclovir cream cialis dosage strengths levitra how does viagra work viagra uk zithromax 500 mg cialis voucher generic levitra vardenafil 20mg lexapro 20mg escitalopram nebenwirkungen cialis coupons printable viagra prices what is cipro canada viagra finasteride permanent side effects azithromycin 500 mg what is acyclovir weaning off lexapro lexapro side effects in men cialis 20mg ciprofloxacin uses buy generic viagra zovirax pills levitra 20 mg cost walmart ciprofloxacin hcl 500 mg viagra on line no prec tamoxifen interaction azithromycin 500 erfahrungen cost of viagra viagra on line viagra single packs levitra coupon what is azithromycin for lexapro reviews acyclovir dosing cialis canada side effects of cialis viagra samples what is acyclovir used for viagra finasteride 5 mg viagra en ligne livraison 24h viagra coupons when will cialis go generic celexa vs lexapro azithromycine cialis dosage viagra for sale uk azithromycin and alcohol lexapro para que sirve lexapro withdrawal cialis side effects cialis professional azithromycin for pneumonia cipro 500 levitra generic acyclovir for shingles free viagra levitra without a doctor prescription ciprofloxacin dosierung levitra bayer 20mg meilleur prix azithromycin 5 day dose pack cialis without a doctor’s prescription escitalopram 10 mg finasteride for women levitra 20mg zovirax dosage lexapro benefits for women viagra side effects cialis for daily use post finasteride syndrome cialis cheap cialis canadian pharmacy tamoxifen lawsuits ciprofloxacin 500mg antibiotics side effects cipro uses azithromycin coverage viagra cialis ciprofloxacin eye drops cialis coupons 2017 azithromycin side effects lexapro generic name how does cialis work side effects of azithromycin 250 mg lexapro medication acyclovir ointment viagra cost what is lexapro lexapro 10mg 9 levitra at walmart finasteride side effects viagra substitute cialis patent expiration 2017 viagra dosage natural viagra lexapro generic viagra kaufen ciprofloxacin hydrochloride zovirax ointment tamoxifen cost what does azithromycin treat viagra receptfritt ciprofloxacin dose viagra price lexapro dosing finasteride for hair loss viagra tablet viagra without a doctor prescription usa canadian cialis viagra tablets viamedic cialis finasteride effets secondaires lexapro coupons azithromycin without a doctor’s prescription ciprofloxacin side effects after age 60 viagra for sale ciprofloxacin class generic lexapro viagra pills cialis website what does finasteride do over the counter viagra levitra 20 mg ciprofloxacin 500mg antibiotics cialis samples tamoxifen therapy cipro dosage finasteride side effects in men ciprofloxacin side effects generic for lexapro levitra dosage finasteride dosage levitra rezeptfrei deutschland levitra online ciprofloxacin drops viagra from canada lexapro and wellbutrin combination therapy cealis revatio vs viagra what does viagra do finasteride efectos secundarios stopping lexapro cilias tamoxifen bijwerkingen cialis vs viagra cialis generic availability ciprofloxacin hcl price cialis ciprofloxacin 500mg finasteride hair loss escitalopram oxalate lexapro and weight gain in women viagra sans ordonnance cyalis finasteride 5mg side effects viagra 100 mg levitra 20 mg von bayer tamoxifen side effects side effects of viagra canadian viagra ciprofloxacin spc buy cialis cialis for bph wellbutrin and lexapro lexapro ciprofloxacin 500mg tablets cialis on line acyclovir dosage lexapro side effects viagra 100mg viagra 50mg tamoxifen and bone pain azithromycine eg 500 mg bijsluiter tamoxifen side effects in women over 55 viagra vs cialis ciprofloxacin 500 mg tabletten discount viagra cialis 5mg zoloft vs lexapro cialis coupon levitra 20mg cost per pill cialis cost side effects of tamoxifen sex viagra for women ciprofloxacin bnf cialis for men cialis alternative daily cialis escitalopram 20 mg cipro antibiotics viagra for men cialis testimonials how long does viagra last cost of cialis levitra vs viagra what is cialis buy levitra cialis patent expiration azithromycin vs erythromycin viagra ohne rezept auf rechnung cipro antibiotic levitra prezzo in farmacia lexapro vs zoloft acyclovir for cold sores what is ciprofloxacin cialis tadalafil ciprofloxacin side effects in women buy cialis online viagra ohne rezept aus deutschland what is finasteride discount cialis cialis generic tadalafil ciprofloxacin hcl 500 mg side effects azithromycin 250 mg cialis trial cipro drug class