 Hello everybody. Today, we are here for our special session on digital health, shaping the future of primary health care. This will be a 60 minute session and I am monitoring the session. I am Dr. Praveen Prasad Gupta, Associate Professor, Department of General Practice and Emergency Medicine, BP Coordination of Health Science in Nepal. And I am chair of one of the working party of eHealth. With me, Anna Luisa is moderating this session and she is Associate Director and Advanced Research Fellow in NIHR Imperial Patient Safety Translation Research Center and Deputy Director Imperial College MSc Patient Safety. We have our three speakers with us. So our first speaker is Professor Donal Lee. So he is the past president of One Cow World. Dr. Donal Lee is a specialist in family medicine in private practice and the sole proprietor of family medicine, medical practice in Hong Kong. He is the President of the World Organization of Family Doctors and the Sensor of the Hong Kong College of Family Physicians. He is the past president of the Hong Kong Academy of Medicine and chairman of the Government Board of Hong Kong Jockey Club Disaster Preparedness and Response Institute. He is an active member of many Hong Kong government, non-government and public health bodies. He also dedicates much of his professional time to academia and teaching. He is honorary professor in the Faculty of Medicine, the University of Hong Kong, honorary clinical professor in family medicine, as well as public health and primary care at the Chinese University of Hong Kong, and lecturer of the Diploma of Family Medicine of the Hong Kong College of Family Physicians. Dr. Lee is an examiner of the Conjoined RSGP-HK-CFP Fellowship Examination Family Medicine. Dr. Lee has been an invitee speaker at numerous local, regional, international scientific meetings. Throughout his career, he has been a leading expert and ardent advocate in promoting greater primary care and family health in Hong Kong and internationally. Dr. Lee is the director of the Hong Kong Saint's Zones Ambulance Association and member of Hong Kong Saint's Zones Ambulance Council. He is the director of Bohunia Foundation Research Center of Policy Think Tank, the chairman of the Hong Kong Saint's Zones Welfare Council and member of the Steering Committee on Primary Healthcare Developmental Food and Health Bureau, and member of the Chief Executives Council of Advisors of Innovation and Strategic Development. He is honorary advisor of the Hong Kong Award for Young People and Honorary Fellow of Agency for Volunteer Service. So, he will be speaking on digital health principles, policies, performance, and pitfalls. New technologies offer a multitude of opportunities to expand and improve delivery of good quality primary care. While I am cleanly aware of and excited about the potential benefits of new technologies, including artificial intelligence, I'm equally keenly aware of the potential weaknesses. The convenience, accessibility, and quality assurance offered by many new technologies mean that we can now offer professional improved healthcare to people who have previously not have had access to quality care. At the same time, many of the new technologies impede the empathy and emotional connection we prefer to have through face-to-face consultation with our patients. Weighing up the balance between massively improved accessibility to quality care against the core values of our profession, specifically the benefits of doctor patient face-to-face consultations, is something we have to manage. The balancing of benefits versus drawbacks on new technologies is something which both doctors and patients will continue to do. We are each other's quality assurance in terms of utilization of new technologies. All of us are more familiar than ever with using different tech forms to provide care to our patients. The pandemic massively accelerated our use of FaceTime, WhatsApp, WeChat, Teams, and Zoom consultations. Some patients have indicated that they actually prefer this type of consultation for relatively minor issues. And we can see that these types of consultation make efficient use of time both for the family doctor and the patient. For some though, particularly elderly patients who might not be familiar with or comfortable with the various apps, it may be anything but preferable. While older family members have taken relatively well to Zoom and WhatsApp during the pandemic, when they have had very limited access to family members' visits, the Zoom and FaceTime really helped to maintain contact and avoid isolation. Zoom became a lifeline for many, but the recent easiness of chance between grandparents and family members may not translate at all into a consultation between a patient and a doctor, where intimate detail of a person's condition are being discussed. So while we welcome the efficiency of visible scores with patients, they may not be appropriate for everybody. A mixture of traditional face-to-face and new methods of consulting will almost certainly be the new norm. Of course, we also become completely familiar and comfortable with using Zoom and Teams for our continuing professional development webinars, and these were really popular with all age groups or family doctors. During the pandemic, these were the go-to sources for expert trusted information, research, and collated by our own colleagues across a range of issues and topics. Our ability to keep updated on treatment protocols and diagnostic developments, as well as being alerted early to the potential and the reality for worsening mental health, for family violence, and for issues of child protection, was really important. The establishment of webinars has a means to quickly gather together to share information and knowledge has been a very welcome development. I read that we are now a bit webinar fatigue and zoomed out, but the platform remains a really useful way both to connect and to continue learning from our colleagues across the world. Indeed, we are all learning and have to learn how the use of AI is changing the way we do business. As an organization, Wonka Executive recognized that we could not hope to hold our world council and world conference face to face. After much deliberation and legal advice, we held our first extraordinary council by Zoom, specifically to seek the votes of council members to allow a world council to take place remotely, thus suspending the bylaws required for a quorum to meet in person. Like many of our member organizations, we have adapted to global circumstances and changed the way we do business. I would much prefer to be delivering this short piece face to face, sitting alongside my colleague panel members, debating with them and facing you, the audience. But our current situation means we are using available AI platforms to engage. Of course, it's not the same, but it's better than it could have been and we are grateful that we have the facilities to undertake this type of discussion and to be able to share with you a bit remotely. This is another example of how the AI platforms are developing and going to meet our needs. We have adapted to the new ways of working far at the same time, looking forward to real face to face events, not too distant. Our Wonka Working Party, Wonka E-Health, has developed a set of assessment criteria, which will allow us to develop an accreditation process for AI systems directed at primary care delivery. I want Wonka to be at the front of setting standards for AI systems for use in primary care and family medicine, rather than reacting after a product has been released into the market. We need to ensure that we set the standards rather than reacting to them and try to improve systems after the event. In many developing and more developed countries, the use of AI in the training of family doctors and other community health professionals have been underway for some years. Access to professional, quality-assured programs ensure that patients and health workers with limited access to more qualified peers and colleagues do have access to information and services they need, when they need, to enable them to diagnose and treat their patients appropriately. It is clear that the availability of such technology can make the difference between patients being able to access appropriate diagnostic services or preferred treatment plans and not having access to diagnosis or treatment due to issue of distance, transport costs, or availability of qualified personnel. As with any new development, technological otherwise, we in family medicine need to retain both our enthusiasts and our skeptics. These are both essential qualities which we use to weigh up the benefits and the drawbacks, the pros and the cons. In an ideal world, every morning every person would have access to all of the diagnostic and treatment protocols required when they are needed, where they are needed, from their family doctors face to face. Realistically, this is unlikely ever to happen globally and the timeline for us to achieve universal health coverage is quickly getting tighter. If we are serious about achieving that goal, we need to adopt every tool at our disposal. An AI may offer one tool towards accelerating that achievement. In the meantime, we should exploit the potential benefits of what new technologies have to offer and temper our enthusiasm with a healthy dose of challenge, making sure that those new technologies work for us rather than us working for them. Thank you, Donald. Now we have our second speaker and she is Professor Anna Stabdahl. Anna Stabdahl born in 1959 is a family medicine, especially in Oslo, Norway. She is part-time university teacher and she is teaching and mentoring post-graduate candidates in family medicine, especially training. Her professional base, however, is her surgery and her family practice. She has been active in public debate on health care issues and she had her own weekly column writing on family medicine issues in the major Norway tabloid for seven years. She is the former chair of the Norway College of General Practice and the first president of the Nordic Federation of General Practice. She was elected Wonka President-Elect in 2018 and will take office as Wonka President Abu Dhabi in November 2021. A main area of interest for her is how as family doctors we can adapt to current societal trends such as digital health without losing sight of the core values of our field and she will be presenting on core values of family medicine in digital era. Continuous personal and comprehensive care are the leading principles of family medicine. The impact of these core values on health outcomes is underpinned by strong evidence from research carried out in different contexts and with different methodology and more keep on coming. The personal continuity in the relationship between patient and doctor seems to be the key factor and trust a main element in explaining the strong relationship between continuity of care and better health. Values must be operationalized in time and place. Facing the digital era, how can we make sure that the core values are not diluted or vanish in fragmented algorithms? How can we use what we call digital health to increase continuity of care and hence increase the positive impact on health outcomes? Our main task as physicians is to diagnose and treat. Looking at hard epidemiological endpoints, personal continuity in the patient-doctor relationship counts for lower mortality rates from all causes of death as well as produce number of hospital admissions less used out of our health services, most likely because the doctor who knows the patient can tailor care better. My first question is can algorithms replace human doctoring? Artificial intelligence enthusiasts claim that tailor-made care is exactly what digital tools can provide. But AI algorithms are created in silico, which means that they are conducted or produced by means of computer modeling or computer simulation, hence on narrow biomedical values. Perceiving that what the computerized we think is good for you is actually what matters to you. Current AI algorithms perform narrow vertical tasks with great accuracy, but do not take into account what they don't know. Algorithms are not value based, but people's choices are. Family doctors provide person-centered care, which requires awareness of how values and preferences play out in clinical decision making. The physician needs to be aware of own values, but first of all conscious of the patient's values and preferences. And that's not the one time for all thing. The first step in the consultation is to develop a common understanding of the matter at hand and of the expectations from the patient. The dialogue between two individuals is the tool and general intelligence, the active ingredient. Artificial intelligence cannot substitute the full potential of the interaction between two human beings. Let's call it the human touch. Next step of the consultation is the diagnosing. Artificial intelligence is based on a binary interpretation, pathological or normal. That is an over simplification of the medical reality. Some would say that the real objective and potential or precision medicine is to avoid over treatment by allowing doctors to select the treatments which are most likely to help patients based on available data like genetic information. The crucial matter is where we draw the line between disease and normality. As interpreters of the patient's symptoms and illness, our first duty is to prioritize patients with conditions in need of treatment and steer patients from wrongfully being treated as sick. My second question is, can the binary oversimplification of the medical reality contribute to an increase in the silently growing global epidemic of over diagnosis and over treatment? And if yes, how do we prevent that from happening? Now, over to digital health and potential consequences for equity in health. We know from social science that health outcomes are associated with socioeconomic status. The concept of the digital divide is not only a matter of digital skills but also a matter of access to internet and electricity. On the other hand, time is money. Digital tools are much cheaper than the physician's time and full attention. So my third question is, can uncritical implementation of digital tools in healthcare lead to increasing inequity in access to health? In short, cheap and low quality care to poor people care? Yes, that's an important part of what health systems should provide and what family doctors want to provide. It is crucial that the principles and mechanisms of primary care also apply to the digital world. Introduction of digital tools calls for changing cultures in society in general and in healthcare in particular. It will be important to invest in digital innovation and transformation of community-oriented primary care services. Success is dependent on doctors and other health professionals being involved right from the design and development phases up to the implementation, adaptation, and eventually successful use of technology. And here comes my question number four. How to ensure how to ensure the involvement of people and facilitating measures to conduct a multi-level approach with a vision and an action roadmap? Bottom line, technology should for us in healthcare and our patients keep people out of the hospital rather than dragging them into the medical system by supporting healthy lifestyles and self-care. It should help us to better communicate and collaborate in order to provide integrated personalized services, which is particularly important for seniors and people with chronic conditions. Multi-morbidity being a main issue. And technology should strengthen community-based primary care services by making them also digitally accessible. And enable efficiency of collaboration and workflows across healthcare organizations and beyond, such as with social care. To achieve these goals, family doctors need to engage collectively. And we need to look at our training programs and develop a frame of reference hand in hand with practical skills to make use of what the digital era has an offer to the best for our patients and in accordance with our core values. I am looking forward to the discussion. Thank you for your attention. Thank you, Anna. Thank you for your presentation. And congratulations and best wishes for being president of Wonka. Now we have our third speaker and he is Professor Ney Gulderman. Ney has a in electric medicine and life sciences. He was an assistant at department of embryology at the faculty of medicine leading university. In 1990, he applied as an assistant on a regarding self-management of Nakam Lauda on the screening of cognitive function in children after traumatic brain injury supervised by Dr. Van Cranenberg Institute of Applied Neuroscience. He continued his study at Free University Amsterdam, the faculty medicine with the curriculum oriented on neuroscience. In 1997, he was appointed a researcher at Free University for the project, the QOL and Neuropsychological Status of Passion with Glyoma. He was assigned to department of epidemiology at NL Cancer Institute supervised by Professor Aronson. In 1999, he started as a PhD student at department orthopedic surgery, which resulted in a thesis on diabetic food complications. He was CEO and founder of the medical field lab that is health innovation for which he obtained prestigious research grants. He worked on innovation and medical curriculum development for different universities. Dr. Gulderman, senior researcher at Lydian University and professor of integrated care and technology at IM Sino, first Moscow state medical university, his policy advisor for the health ministry and consultant for various organizations like WHO, European program, EIT, KIC Digital, AAL, IMI and S2020. He is active in numerous EL programs in China, UK, Russian Federation, Italy, Norway, Poland, Germany, Belgium, Brazil, Iran, Finland, Romania and US. Often in collaboration with industry pharma like Rosé, Zenzheim, ZNJ and Gruenthal, Medtech, Philips, Metatronic and Kochi. Health IT like Microsoft, Ascom, Artec, Vodapone and Finance, RoboBank, NetWaste, RSE. He was architect of national EL and big data strategy. He is coordinator of European EIP and Health and Active Aging and member of ISU strategic advisory group of aging. Hello, I'm Nick Gulderman. I'm affiliated to University Medical Center, session of university in Russia. Today I'm going to tell you about the role of artificial intelligence in digital health from the perspective of primary care and family medicine. So first, explain about what is actually artificial intelligence. And there are three key concepts. And first is the algorithm. And the algorithm is basically a set of instructions or rules to perform actions, which eventually provide the results. Often this is numerical. It runs a software program or display a computed result on your screen or your phone automatically. It also allows software to send input. So it's active. It can send input. It can act accordingly. And it also can adapt. It can learn. Algorithms who learn from previous events, the techniques for this is called machine learning. So these automated techniques extract principles, new rules for algorithms based on previous events or new data. Algorithms and machine learning can be used in digital health in order to run it more smoothly and can send act and adapt accordingly. So digital health, e-health, algorithm, machine learning is quite related to each other. But regardless of the sort of digital technology or digital health, we have to see this from what should this sort of innovations should provide. And therefore we have to look on the change of healthcare systems we're looking at. And removing from a multidisciplinary, very institutionalized, oriented healthcare systems to a more integrated social perspective in which primary care has a stronger role, offering broad range of services. And this should be supported by digital technologies because of the information exchange, which is necessary to collaboration, but also the sort of information we have to understand from the social context. And data and understanding and translating this to actions and meaning is typically what algorithms are good at and could support this sort of transformation in healthcare. So if you look to the requirements which apps and digital health supervise and accordingly also the algorithm is that it should support people in providing them better information to educate them, making decisions, providing maybe also apps supporting in disease management. At the same applies of course for professionals, for primary care or hospital care, decision making, but often more important than just providing information on smartphones is a sort of collaboration and management if we want to move to more person-centered integrated care. And for this we need especially in primary care also the link with the local context and the connection with the patients and his social context. So usually this is much further than now is provided by digital health applications, but also we see that there are requirements also from a social care perspective. So overall this ideally should also have these technologies a sort of logistical process, the patient's care pathway and accordingly also the collaboration among different collaboration professionals in the process. And this is also typically where information exchange, decision making, etc data points, outcomes are important and for this we need also solutions in order to support this to make it more efficient. And overall ideally how this would function is also that the data, the actions and results also feed in a sort of administrative process which can be used for outcome monitoring or strategic planning. So this is the sort of picture in requirements which we ideally need from technologies and algorithms, artificial intelligence. But if you look to the current landscape we see these developments in different areas, disease areas, we also see in interaction, especially in the pandemic, in communication tools. But the reality is it's currently not the same as what we need in a sort of a team approach, an integrated approach for care provision. So often it's quite standalone, the solutions are focusing only on single aspects as diagnostics, but not supporting the more typical primary care integrated healthcare services. So we are not there yet. And also there are some serious concerns about the use of data and ethics and privacy. This is also in the news, so we see also it comes with some concerns. There's also a lot of boosting about prediction and prognosis with these algorithms but in reality the performance in accuracy is often quite poor when it becomes more complex as what we see in bioinformatics. And also when it comes to the clinical validation of algorithms, when it becomes more complex, so collaboration or covering different disease areas or symptoms, you see that there also a mathematical limitation about what AI can do. So it's very different from the sort of marketing and boasting from industry or innovation managers. However, there is some potentially positive developments when it comes to digital service platforms, digital platforms which connect different actions and technologies in order to have a better patient navigation and support for the patient care pathway, including the role of primary care and typical examples are beveled in the UK, but also in countries there are also some other examples. For example, we performed as Wonka a study in China with a platform used by more than 350 million people. And this service platform makes use of a chatbot, chatrobots, which can automatically communicate with patients and collect information about their symptoms and problems, which can help to filter out and triage patients that gives as offers decision support. Eventually, the doctor will take a decision based on his own expertise and also the system. There's a sort of monitoring in place. So initial findings is that we saw an increased capacity by the use of the technology with 200% in number of cases at the caseload efficiency. And also the cost was reduced by 60%. Numbers given by the company, which was not independent research, but it so shines that it might have a benefit. So if you look from a service perspective, there are definitely some benefits, but also some concerns which have summarized in the coming two slides. So when it comes to the outreach to patients, digital technologies and underlying algorithms might help to have a better outreach, a better provision of information to patients. However, we see in the market that transparency and objective information through this sort of digital services is not always secure. So also the 24-7 access and digital access everywhere at any place at any time is also might be a benefit. But we see also it requires digital skills. And for example, group people might not always be able to work through that sort of solutions. Overall, I think we see a high responsiveness from these platforms in order to respond to questions and challenges. So that's also a benefit for simple sort of intake and looking at problems. It requires no travelling, so that's also a benefit. But again, as so, this also requires some skills from people. We see that these services often require no or low cost, but sometimes costs are part of another element of care which is not totally visible to clients or patients. Also, the comprehensiveness of the services are not always meeting the sort of complexity of needs patients have. So usually the current services are only focusing on very simple issues and not on the very complex patients. There's information lacking about the sort of outcomes and benefits of these services when it comes to hard endpoints. So usually the benefits are only reported by the organisation themselves. So there's still a lot of work on this. And if you look from a more service perspective from a healthcare system. I apologize, Dr. I just need to let you know that we've hit 12 minutes. So if there's a way that we can start to summarise because I think we can edit a bit of it out, but just to be summarising this. Thank you very much. Yeah, then I shall skip this. Daily practice. It's still in development, it has serious limitation and it's difficult to implement in a sort of integrated approach. So accordingly family doctors should be more in the lead on how to implement and use these AI in daily practice. Thank you very much. So thank you, Nick. I'll request all the speakers and modulators to switch on the camera. So that was the presentation from Nick. Now it's my pleasure to invite Ana Luisa to proceed further for the panel discussion and question and answer session. So Ana, the floor is yours. Thank you so much, Pramendra. It's my pleasure to be part of this discussion. Just a very brief introduction. I'm a GP by background and I'm currently associate director at TBRL College London also working on digital health and patient safety. So it was really interesting to hear all these very insightful presentations. And I would just start inviting all our participants to start asking questions on the chat, please. So there were a lot of very interesting points raised here and I'll maybe start with the first question for the first presentation. And I'll just leave it open to the panel so that we can start discussion. A very interesting point raised by Dr. Donald Lee is that we need to start being proactive rather than reactive. So of course, as part of this COVID transformation, we have to come up with very quick responses, adapt to a very rapidly evolving situation. And now that things are hopefully starting to slow down a little bit, I wonder what are the current challenges in what concerns digital health? What would the panel members highlight as the three major challenges that we need to reactively address? Nika, I can see you are smiling. I don't know if you want to share some thoughts. I was smiling at Anna. So if I start then, no, I think as with many aspects in healthcare, the integration is, I think, a major challenge. And it's integration in the services we provide. Of course, in primary care, we allow dependent also on social aspects. So integration with social care, but also to secondary and tech-sharing care. So a service perspective, this applies also to technology. You see in many countries also the technology is fragmented, the data is fragmented, and even finances and policies. So if we really want to make primary care more effective, we should work on all those aspects in order to make it functioning. Because also, we saw many attempts to use technology as an interface. Also, that's not really successful. That's a really important point. And I was actually wondering, this is true at so many levels. Of course, it's important if you think about technology in its own bubble, but also if you think about digital health as a network of data sources, if you think about wearables, feed feeds, health and fitness applications, where we have all these data coming from all these different sources and actually going in so many different directions. So that's certainly a very important point. I don't know if you want to add something, Anna, if you would like to share your thoughts on this one. I'll just continue. I think Anna might be. I'll just keep monitoring the Q&As, which are a little bit silent so far, but please do feel free to share your thoughts there as well. I guess another reflection about this was about patient involvement and engagement. And I think that's also something that we have learned as part of the pandemic, and we have already experienced that in a way. We know that these solutions in order to be sustainably adopt in order to be efficient and in order to be a reality, not just something that we have in our minds as a good solution, need to be co-designed, co-developed by patients, providers and actually the end users, the people that on their daily lives, they need to work on that. And I believe that some of the research actually highlights that there's probably an opportunity for us to do that a little bit better. So I was wondering which are your thoughts about how do we tackle this challenge? How do we actually involve patients, but also how do we build systems that can be reactive to the experience of general practitioners, for instance? Yes, I suppose I have some technical problems, so I shall respond. Well, I think they are very good examples on how it could work in a very concrete practical approach, where you involve patients in the improvement of services, including digital. So I think we see examples where local settings with primary healthcare centers are supported with engagement with patient representatives, which can talk about their sort of needs and experiences and translate very practically, okay, we do this and this different. I think that's already, that is very practical. And so we shouldn't also don't make this too complex. So this, I think, modern primary care practice should be with sort of interaction with patients and see how you can further improve. So this can also apply to digital. But I think also on a more structural level, I think it's very useful and we have this example as well, where on a country level or a regional level, patient organizations are involved in the sort of process of national implementation strategies or local implementation strategies, where had a sort of service, how can we improve services from a primary care perspective, along with how to use technology enabling, have these sort of activities. And this is also, again, had the starting point are the patient needs for improving services. And along with this, you look on how technology can support, what are then the other way around that, okay, we have a nice fancy application, use this and everything would be wonderful. It doesn't work that way. We have many evidence also for that. So this, we really can make a sort of benefit in combining those aspects. That's a really important point, which is about engaging actually with these stakeholders from the very beginning. And as you said, and you explained it in a very, very clear way, if we just do that too late in the process, the engagement is not going to be optimal. So even, we know that solution is never going to be perfect from the beginning, but if the people, if patients, if providers feel part of the process, at least they feel that they have an active voice and they can influence the process. And I wonder if, I guess it's also quite important to build awareness, to build trust, to build actual collaboration as part of the process, rather than more theoretical collaboration. So I might, I might just jump to the next one. I'll just monitor very quickly if we have questions, which I think we do have. So we have a first question on artificial intelligence. So I'm sorry, Nick, I think we'll have to keep asking you as well. So there's a question from one of our participants that asks, in your own practice, what role does artificial intelligence have currently? Well, so I'm a researcher and my clinical practice was already a long time ago. That's actually what I, what I see in, so there are many examples where you can use this artificial intelligence in primary care. And so in the platforms I showed, it is often an element of a sort of chat function where very, let's say, common questions can be supported by artificial intelligence, helping people to navigate in a sort of structure of collecting information. And this already available and helps in filtering and doing the typical stuff, which is not typically very useful if you spend this a lot of time as a doctor. But if you can automate this, I think that's very helpful. I think there are some examples on sort of decision support. Although this is very early stage, and it's also, it's more support. It's not like it's doing the work for you. But it's helping, it could help in a sort of complexity in a sort of decision making along with the expertise of the doctor himself. And also talking about primary care, also in the elements of social care, physiotherapy, practice, dietary advice, you see that these sort of applications are developing. But the core is it should have a connection with the real physical world and how you use this properly. So it's still early stage and also in terms of efficiency or very complete supportive. So I think we're still in the beginning. Yeah, yeah. Of course. And I was actually thinking also about one of your previous examples about chatbots, which again is very early days. But I know that, for instance, in the UK, there are small pilots actually starting to use, and in other countries, I'm sure, trying to use chatbots as the first triage layer. Of course, a knowledging that is a preliminary solution. And of course, with a lot of concerns as we have with patient safety, which is, I would say the underlying concern when we move into remote care. And the knowledging that patient safety might be an issue there. But there's actually some pilots starting to implement artificial intelligence with chatbot, which is also an interesting route, I would say, that probably needs some refinement. I think it was really interesting. I guess, obviously, all of us that are here, we are slightly biased because we do have an interest on digital health and artificial intelligence. And just playing a little bit, the devil's advocate here, we have talked a lot about the benefits and the potential for artificial intelligence. I was wondering if maybe we could reflect a little bit about what are the challenges to actually implement digital health algorithms. Let's say thinking about a very pragmatic example, if I find an algorithm to identify high risk patients for a given disease in my context, using a given database, why is it difficult to actually move that algorithm to a different setting, to a different country? It's not about a different country and a different context. It's about the individual. Do you want to expand on that now? I mean, we are speaking about these algorithms and tools, as if this is something they are providing us something new. No, they are not. They can be helpful in what we're doing, but we have to have a real sense of what we are doing in diagnosing and treating disease. It's about individuals. So I think whether we are interested, as you say, in digital health or not, we are partly seduced, partly we sidetrack the discussion, because this is a tool. It's nothing more than a tool. People are the same. I mean, whatever tool you apply to the discussion. When you speak about triage, I'll tell you a story. When I graduated in 1987, I had a term serving as a district medical officer up north in Norway. I had a call in the middle of the night from a mother of Indigenous people in Norway, the Sami people. She said, do you have it? It's this and that. Do you have a term of measure? She called me in the middle of the night. I could have got angry. She said, are you calling me in the middle of the night? This was her entry point. I said, why? Why do you need a term? No, my kid is sick. It's very warm. This was a meningitis. Could her question have been applied to an algorithm, to a digital tool? That's my point. We are dealing with people. We have to understand how they pose their questions, how they present their ailments, their worries, their symptoms. I don't believe, and I'm not against digital tools, but I think we are making it to something, an element. I think the words that you used, I think it's a very nice way to put it. I think we're actually driving the discussion to another point, which is how does this represent a challenge to the core values of who we are and to care that we want to deliver? I know that you didn't use the word core values anywhere, but when you started by saying it's not about algorithm, it's about the patient, I felt that somehow we were going on that direction, maybe. You're right. I asked when I lost my luggage coming home from Greece a few months ago, and I was met with algorithms when I tried to search my luggage. I got so frustrated because I couldn't apply to the algorithm in the chat booth, etc. This was about a piece of luggage. Think about it when it comes to your health. I'm not against it, but I mean, come on. We're human beings here. Doctors, I'm patients. We are sick sometimes. We are healthy sometimes. We are dying. On this course, we can use the digital tools. Yes, but it doesn't change us as persons, being providers or recipients of care. President speaking here with the chain and all that and the core values, but I think we should keep this on the ground, the discussion. What do we want for cheap? Better health? I don't know if you want to respond, Nick, but I'll just throw another one just to hit a little bit. Well, hit more, the discussion. We have a question here about then how do we add patient value in artificial intelligence? Is this something that we have to discuss with the patients always openly? Well, anyway, I think it's good to be transparent, of course, in how we communicate and how we come to thoughts and conclusions and take actions. That's also in the shared decision making. I think that's a principal value and they should take these sort of perception, thoughts, ideas, feelings of patient in consideration. It's at the core. I think this also should include, of course, when you are dealing with data and what is generated by data about sort of algorithms or even literature. You say, okay, this is what the evidence is telling us or what we see now from data and that you include it in, okay, we can go this way. How do you feel about it? These are the implications. I think this could fit well in a sort of communication we already supposed to have. I think in order to achieve this, we, as doctors, as primary care physicians, should also be more in the lead on how this should function as to support our work. Because now it's a bit that also a discussion is either very on innovation, industry, well, this kind of sort of, oh, this is wonderful. Doctors are normally needed and so a lot of claims without really looking at the reality of a daily practice of a doctor. On the other hand, have this sort of understanding from doctors in this type of topics is quite complex and difficult. Also to have a sort of debate on, okay, what's really useful in this and how to judge these developments. So we have to come together. I think the current sort of values we use in medicine should apply also for here. And I think also what has so European Commission had a lot of WHO are developing sort of books and guidelines frameworks to have for the use of this technology. I think it's now more doctors should in the lead in more communicating practical, okay, how can this help more the practical things and not sort of moon shots to whatever type of innovation, but very practical useful things time consuming things which a computer is much better at than the sort of typical work a doctor should do on a daily base in discussion with the patients. So I think these priorities, this sort of practical input from okay, where the solution should be, we should be much more stronger on this. So I think there's also an opportunity to give. I think that ties really well with our last question. And it seems like you just have to mean that we're about to finish. So I'll just ask you to spend our last minute asking a question from one of our participants, which is a very pragmatic one is what do you think it will be the most important competence for a local family doctor to use AI and digital health, I would say, in his daily life, what would be the single competence that he really needs to have if there's one or one of them. I think I know you're most position to answer that. Well, I think the first question you have to answer then what's the stake? What's the problem? What's the problem? Maybe you can solve it without any aid at all. And then sometimes, but be careful. I mean, be careful, but you have to pose the question in a correct way as always. If you want to get a sensible and meaningful answer to your question, whatever context, AI or not. Yeah, I think that brings us back to who's the patient in front of us? What's the problem? And what is the best solution for him? Is it technology or does he want to use it? Does he trust it? Is he able to do it? Or is it a completely different route? And I guess we all, despite all the excitement, as both Anna and Nick were saying, we just need to try to keep the balance, understand the potential, but also understand where it fits and where it doesn't. And if for some people it doesn't, they need to have viable options rather than to be excluded from the system in a way. So I, sorry. No, I fully support also what Anna is saying. And it's, I should say technology and information of algorithm is just as any other information. If you look in a textbook or internet or a guideline, so it should be handled as that. And of course, in the clinical reasoning, you have a sort of balance on how you make this decision and what's best for the patients. So I think we don't have to over-execuate the sort of potential. We should feel confident about using these things in a proper way. So in that sense, I think we should be aware about the opportunities but also the limitation. I think that's realistic. Thank you so much, Nick and Anna. And I think we could certainly keep discussing this for more time. And I hope we have more opportunities to keep discussing as just to a little bit of a very brief summary. So we covered a lot of different aspects. I would summarize the key messages that you all have highlighted. Being proactive rather than being reactive, keep in mind that the patients, the providers, are end-users, so they need to be part of the discussion. We don't want to leave anyone behind and the concerns that they discuss around the digital divide, health inequities and all technology can actually entrench and actually aggravate these health inequities. And most importantly, how do we bring these back to the core values of general practice and how we make sure that they are never forgotten as part of the process. So I just leave you a summary of all the insights, well, a summary of a few insights that you kindly shared with us today. And I'd just like to close the discussion. Thank you so much, everyone, for joining. And hopefully we'll have more time to keep discussing this at some point soon. We'll go on. We don't pack all. Thank you very much. Thank you so much. Thank you. Bye-bye. Thank you, Nick. Thank you, Anna. Bye-bye. Thank you. Bye-bye. Thank you.