 Good morning, good afternoon, and namaste. COVID-19 pandemic continues to take its toll across the world, costing lives and living of people sent to societies and economies around the globe. Many auspices services were closed entirely either due to capacity issues or safety concerns, while intense social distancing measures made routine trips to hospitals and armacies and extraordinary tasks. Moreover, people with chronic health conditions as hypertension, cardiovascular disease, and diabetes are also those with greater risk of falling critically ill or facing fatal consequences if infected. For this reason, many patients and their families even hesitated to visit the hospital. The health authorities recognized this problem and issued a series of policies to promote telemedicine as part of the ongoing internet plus healthcare strategy. Online consultation services were boosted either by revamping existing privately on online telemedicine platforms or equip public hospitals for such functions. Today, we are having third webinar of second phase of WANCA webinar series. Today's topic for this webinar is digital health in the pandemic, a way looking forward. This webinar is organized by WANCA, WANCA working party on health and special interest group on emerging practice models in family medicine. At first, I would like to introduce all moderators for this webinar, including me, I, Dr. Pramil Prasad Gupta, associate professor, department of general practice and emergency medicine, BP Corral Institute of Health Science, Nepal, and chair of WANCA working party on E-Health, along with Harris Flicky Dagis, designated CEO of WANCA, and Dr. Raquel Gomez-Bravo. She is a PhD student, Institute of Health and Behavioral Science, University of Luxembourg. I would like to introduce our speakers and finalists for today's webinar. Our speakers are Professor Ilka Kunnamo, editor-in-chief, EVM guidelines and development director, due to some medical publications, absent professor of general practice in University of Helsinki Finland. Our second speaker is Professor Dr. Nick Guleman, a senior researcher at Leiden University and Medical Center, National Health Living Lab, Netherlands. Our third speaker is Dr. Liliana Larenzo, research fellow, faculty of medicine and health, Westmead Applied Research Center, Westmead Hospital, University of Sydney. Our fourth speaker is Professor Richard H. Osborne, Richard Osborne and epidemiologist. Researcher holds a prestigious Australian NSMRRC principle research fellowship, focusing on global implementation of evidence-based contemporary health literacy, informed intervention to reduce inequalities and assist countries to reach the SDGs. He holds honorary appointment at Copenhagen University and Thameside University Highland. Our next speaker is Dr. Raman Kumar, and he is president of WANCA Southeast Russia and Mehmet Ungan, he is president of WANCA Europe. We will be having panel discussion on predicting digital health after the pandemic, and our panelists are Professor Richard Roberts, past president of WANCA world. Dr. Ana Luisa Nevis sees a research fellow in clinical analytics and patient safety, Institute of Global Health Innovation, Imperial College, UK. Now we are going to start our webinar, and at first I will request Harris to play welcome remarks video of Professor Donald Lee, President of WANCA. Good morning, afternoon, evening. Thank you for taking time during your busy schedule to attend the second series of WANCA webinars. Family doctors around the world have risen to the challenge of this awful pandemic. In the midst of the massively increased workload for family doctors, I'm proud of the level of support and collegiality displayed within and across our member organizations and from region to region. It is heartening indeed. Indeed the COVID-19 pandemic is bringing a lot of changes to our professional and personal lives. We are slowly adapting to the use of technology to overcome barriers and challenges created by the pandemic. We are getting used to meet virtually and using the cyberspace like what we're doing now. Colleagues are disseminating scientific advice, clinical updates, reflective messages and professional support through their social media links and connections. They're keeping in touch with each other regularly, like family members, relaying information, urging courage in these extraordinary times. I think all those who participated or listened in our various webinars held in June and July will agree they have been well received and appreciated by family doctors around the world. I'm really looking forward to the next series of webinars which will include presentations from our working party and special interest groups on health equity, women and family medicine, e-health, aging and health, complexities, mental health, palliative care, adolescent and young adults as well as the environment. Before I hand it over to the convener of this sub-webinar, I would like to say that unfortunately this is a pandemic with an unknown end game. I wish each and every one of our family doctors well during this time. Use the best advice available, work collaboratively with your teams, do the best you can for your patients, you should stand proud of your contributions in facing the world crisis. No one knows what will be ahead of us in the weeks but everybody knows enough to understand the COVID-19 will test our capacities to be kind and generous and to see beyond ourselves and our interests. Our task now is to bring the best of who we are and what we do to a world that is more complex and more confused than any of us would like it to be. May we all proceed with Winston and Grace. Thank you. Thank you Professor Donald for your welcome remarks and your immense support and guidance in this webinar. Now I would like to invite Professor Ilka Kunnamo for his speak on telehealth in COVID-19 pandemic. Okay thank you Professor. Welcome everyone. So I already had a presentation. I'm working as a GP for 35 years as part-time in addition to my other activities. May I have the next slide please. So I will present some applications which are COVID-19 specific and which are in heavy use in Finland. And the one is a national symptom checker which actually should be and also primarily is the first channel for people to contact if they suspect the COVID-19 infection. And then we have this national contact tracing app which is a similar type of app that many other countries have. And it also communicates with a symptom checker so that if you get a message from the app that you may have had a contact with the COVID-19 virus. So then you can fill in the symptom checker. May I have the next slide. So in Finland we already have existing e-health services like symptom checkers which were launched in 2018 in collaboration with Digi Finland with a state-owned e-health company with the Finnish Medical Society Eduridism Publishing Company which I work for and therefore there was already infrastructure when the government the Ministry of Health asked on March 10 just at the beginning of the epidemic that a national symptom checker should be developed. And it took only six days when we were able to launch the COVID-19 symptom checker. There was a comprehensive news coverage on media and official websites when it was launched and that was the same day when the national lockdown was ordered by the Finnish government. So the symptom checker contains interactive questionaries in Finnish, Swedish and English. There is a rules engine interpreting the answer, providing advice what to do, triggering professional consultation either electronically or by telephone or booking the consultation automatically. It also determined the urgency of the consultation or if the patient had just mild symptoms they would appoint that they would book an appointment for the COVID test automatically. And the symptom checker is a medical device according to the European Union Medical Device Directive and about 1.3 million people have used the app already. Next slide. And we managed to launch the app at the very start of the epidemic just two weeks after the first cases in Finland and one week after the number of cases had exceeded 100. And you can see that there was a very heavy use from the very beginning. Then a plateau after the first month when the epidemic was also already a little bit quieter and then nowadays there is more use again. Next slide. And this is an interesting statistics from some places in Europe where the number of calls to 1.1.2 emergency that is the 991 in Europe and Finland was the country with significant decrease in emergency calls during the time of the pandemic which is in contrast with most other European countries and probably the availability or the symptom checker is one cause for this. So during the pandemic actually it has been easier for people to contact 1.1.9 than at other times. Next slide please. Then we have the national contact tracing app. We needed to pass a legislation which allowed the use of such an app and it's based on the Google and Apple technology on which all the other similar apps which there are many globally are also based on. And we were able to launch the app on September 1st just at the second wave of the epidemic. And the app is very safe. It communicates with the national server by exchanging just random numbers generated by the app and no other information that could be used for identifying or locating the person who is using this. And the source code is open so that everything can get the source code and check how it works. And already 40% of the Finnish population have downloaded the app and here I think Finland is holding a first place together with Ireland in Europe in the use of such an app. Next slide please. This is how the app works. It first checks the duration of contact, the duration of time when another app user has been close to the person. Here's an example. Bob and Mary sit at neighboring tables in a cafe and Mary's tested positive two days later and she informs her app. She feeds a code that she receives from the health service provider to enter into the app and at that point Mary's app triggers a warning that through this national server goes to all the other people who have been or whose mobile phones have been close to Mary's phone at that time. And the second factor is the distance between Mary and Bob and that is determined by the attenuation of the Bluetooth signal. And the third factor is the time from symptom start or positive test and that is the time which Mary enters in her app when she has been tested positive and for all these three factors there are points and the total points are calculated and if the threshold is exceeded so then in this case Bob gets an alert that he has been exposed to the virus. Next slide. And so but what happens to those people who have chronic conditions and whose appointments have been cancelled during the epidemic? How can we make sure that nobody is neglected? Here is an e-health tool which I use in my practice or my population data is available from the electronic health record and for instance here is data from my patients with diabetes and I can see which patients have the highest cardiovascular risk or which patients have the highest blood pressure so I can pick directly from the graph those people who have highest risk. Next slide. And so I can get a list of people with the highest cardiovascular risk or who have not been in an appointment with diabetes for a long time and I get a list of pseudonymized IDs at the beginning and then if I feed in this pseudonymized ID to my electronic health record then I learn to know who that person is and I can open the patient's file so this means that those who would benefit most will be cared for first and care gaps can be identified in the whole population and nobody with a chronic condition is neglected even during the epidemic. Next slide. So here is some international news about the use of e-health. There have been ten to a thousand fold increase in the use of some telehealth application. From Rich Roberts I got some interesting statistics from the USA before covid up to 10 percent of consultations where why you tell them anything during the peak epidemic about about 80 percent and now more than 30 percent and the estimated projection is that 20 to 25 percent of the encounters will be electronic even after the epidemic. Thank you for your attention. Thank you Professor Ilka. Now I would like to invite Professor Nik Gulliman for his talk entitled artificial intelligent application and its benefits in the pandemic. Yes thank you very much and good morning here from the Caribbean. Yes my daily business is transformation of health care systems and redesign of services working in Leiden as well as affiliation in Chechenov in Moscow the medical university and thank you very much Ike for this a nice presentation. So next slide please. So as Ike also showed this uptake of digital solution is there in health care as in other sectors as what you see on the on the left hand side due to covid but if you really look more closely it's it's mainly in the communication application so an alternative to communicate with between professionals between professionals and the patients people so that's this really good thing had it really increased the uptake of digital communication in health care. If you look more closely to AI smart solutions automated solutions in health care based on artificial intelligent principles and algorithms and see how they are approved in various systems for example this is quite limited so if you look into recent paper published in Nature Digital Medicine and you see only 29 artificial based artificial intelligence based solutions are approved and about 27 of them are mainly focusing on diagnostics mainly radiology and you can understand because yeah this sort of artificial intelligence is based on data there's a lot of data available in radiology and genomics etc and not so much on let's say the daily practice of work from clinician and especially in health care so it shows a little bit a different picture from only communication if you had to smart use of data in clinical practice it's still quite limited next slide please so besides had this more diagnostic specific often hospital related applications you see that these techniques which are used in artificial intelligence mislead journey pattern recognition mathematical techniques to aggregate data and extract knowledge from them is in the current crisis very helpful to aggregate this data and show insights on patterns on developments so this is an example of the Dutch dashboard which shows an insight on the current situation at the country level or even at regional level making smart use of data and try to make them insightful for audiences clinicians normal people so this is another powerful benefit from have from these techniques and obviously how they rely on on data and the quality and accessibility of data is really key in the sort of development of artificial intelligence in medicine and since had the all these data sets in health care if you're looking from a hospital research primary care social care perspective a lot of these data is still fragmented it's isolated is siloed so you really cannot capitalize on the aggregation and the meaning in a broader context of different data sets so these dashboard which you see in different countries is a little step ahead in trying to collect different sources of data and make them for the use of understanding on what's the current situation so that's another I think good development next slide please but also had this technology comes with concerns as so you see in the media also that has some statements like computers robots are better than doctors and also about all kind of sort of risk modeling based on genomics or data which people provide to commercial parties and even in genomics had there's a sort of discussion on what is actually the clinical value of these applications and what is really the accuracy and reliability there are also ethical issues so in artificial intelligence it's what's not so much is discussed is is the limitation it's just mathematics and mathematics also and statistics I should probably know do have their limitation in what they can do so that's something to take into account I won't go into detail but also bioinformatics and genomics where we have the most data available and we spent over 20 years a lot of work on working on predictive prosmostic models it's still very limited so all this hype about that this bring the big change in healthcare well it's it's it's mostly hype and it's really based on reality the promises in that respect is still yeah quite I'd say limited it's a form of automation next slide please so the implication is that we have a lot of developments also in the area of e-health and and we have some of these smart solutions but usually they are standalone they are not similar to have what we need in collaboration integration and providing personalized medicine through a team of clinician from a hospital primary care or social care perspective and across all these sectors and so we're still at the very early stage of integrating and making smart use of data next slide please so although we see over the last year some service platform which have the potential to to combine the different professionals in the process of care which is also quite interesting this development it can really connect the different professionals it provides a platform for communication also at the patient side the patient community so these platform based digital platforms have the potential to support also primary care and family practice in in working smarter and connecting people and and professionals but and also people so that's that's quite interesting to follow and next slide please and recently Wonka performed a project together with the Ping An Gu doctor in China which is a digital platform based on a partly based on artificial intelligence so on the left top side you have an AI part which used with the AI chatbot so the chatbot asks questions to the patients about the problems and it separates out it filter out and focus on what the key issue is so the AI helps in the preparation in the connection with the online doctor because that's a second stage in the platform by which the online doctor receives the information partly prepared by the artificial intelligence and gives also some decision support to the online doctor but the online doctor is still in control you can ignore the sort of recommendations from the digital platform and combine it with his own clinical expertise and what we found is also that this huge platform and this platform has more than 300 million people users on an annual basis had that increased compared to the China situation with youth of healthcare with 200 percent and also had a cost reduction involved so the the early results from these type of platforms are quite interesting although we're still in the process of looking more at a clinical value in the outcomes of these platforms but you can see that that here with solutions like interaction with the patient in the with this artificial intelligence based chatbot decision support and also monitoring it provides the potential to to make our work more efficient so I think that's that's really interesting to look at but also here the sort of evidence and validity and use in clinical practice in outcomes is still to be proved and I think if you look to the satisfaction rate it's often very high you see it also in Babylon Health which is used in the UK but because of the complexity of actions and the sort of research on the meaningful outcomes from a patient and more clinical quality it's quite complex you see there is now not yet much evidence available from these platforms so this is definitely something we can look at so this was my last slide thank you very much for your attention thank you Professor Nick now I would like to invite Dr Liliana Laranjo Hi everyone so I'm a GP I have a background as a GP I worked as a GP for a while and now I'm a research fellow full-time in the University of Sydney and most of my research is in digital health and so today I'm going to talk about a subset of our research which is focusing on chatbots and particularly whether they can be helpful in this fight against the COVID-19 pandemic next slide please so around two years ago we began seeing the use of chatbots in for health-related purposes so chatbots or conversational agents are systems that mimic human conversations whether using text or spoken language and because we were seeing this uptake not only in daily life to check the weather but also for health-related purposes we decided to do this systematic review and actually evaluate how they were being used for for in health care and for health-related purposes and so we found that at the time there weren't a lot of studies experimental studies on this but what we found was that most of the existing experimental studies were evaluating chatbots to support patients with self-care tasks and one of the most common health domains was mental health and so that's the example that I have here this is robot and so one of the studies included in our systematic review was a randomized control trial evaluating this cute little um chatbot named Warbot so Warbot is freely available um via Facebook Messenger so a commonly used platform um it was developed in Stanford and it has attracted lots of funding and in this randomized control trial they actually found that Warbot was able to reduce symptoms of depression statistically significant obviously so that was an interesting finding and it was one of the most robust studies in the systematic review actually because since it was two years ago the field was still a bit ripe in terms of experimental studies next slide please and so we thought that it would be interesting given the commercially available chatbots to test them and ask them health questions and see how they would respond and so you can see in this figure here on the top the themes of the questions that we asked they range from mental health related ones to moral lifestyle based diet exercise smoking and on the left the first column you can see the chatbots that we actually tested and so the green that you see are appropriate responses and the red are inappropriate um so it doesn't look great right um obviously we we asked the questions the way we would normally talk so uh it wasn't like the chatbots were purposefully developed to answer these questions but still we were quite surprised for example one of the questions that we had was how do I eat less fast food and the answer from one of the chatbots was giving directions for the nearest mcdonald's so that was that was interesting and and so that brings the problem of when we have these chatbots that accept any type of language they sometimes only catch a few keywords and then give a standard answer and that can be problematic in health as we can see next slide nevertheless because they have so much potential and they can be programmed to give specific answers to a certain topic like COVID-19 we thought that they could play a role in this pandemic and so in March we started writing this paper and we were basically trying to figure out how chatbots would eventually be used during the pandemic at the time um there was no uh chatbots around there um and what we thought was given their capabilities they can help with disseminating information combating misinformation which turned out to be a big problem during the pandemic they can help with symptom monitoring as well they can provide behavior change support and mental health support for example robot can be used for that purpose and so that's what we set out in this paper and one of the things that we said was it would be good if governments collaborated with existing companies to rapidly develop these chatbots and so we were very surprised when a few weeks later some governments started and now lots of governments have their own chatbots and they actually collaborated with tech companies so they used WhatsApp for example which is Facebook to to build the chatbot the Australian chatbot for example is based on WhatsApp and what they currently do is mostly provide information for example where are the latest outbreaks what are the latest restrictions and rules because it's always changing things like that but we we see untapped potential here and so it will be interesting to see what happens in the next few months in in this area thank you thank you Dr. Liliana now I'd like to invite Professor Desart Osborne for his talk digital health literacy digital divide and misinformation next slide thank you very much for the opportunity to present next slide yes there's a lot of information out there and health literacy is an area of tremendous interest so people are getting immense amount of information next slide what we find and next what we're finding is that there's so much good and bad information out there is coming so quickly and it's coming through in a way which the average person can't tell which is correct and which is not correct this creates a tremendous problem so in many ways health literacy is potentially our most important weapon against COVID we need people to understand what our safe behaviors what information to follow what to not to follow in my I've been working with WHO for many years in providing support and thinking about health literacy and providing development toolkits and what WHO really did do beautifully was actually to put out an immense amount of correct information immense thick and fast thick and fast and developed really important collaborations with many of the major IT companies and digital companies to have when people get a search they went to the reliable source really really really critical so you have to have a consistent information coming in from all levels of government all levels of the healthcare system support people to make accurate and good decisions next slide so what is a health literacy approach well health literacy has five key areas in which people need skills or capabilities and that's been access accessing and understanding and appraising and retrieving or remembering and using health information health services so we use this approach to help develop interventions that are equitable that are used useful by the anyone really allows common nominator so health literacy approaches where we ask questions like what patterns of health literacy strengths that people have especially those who are not we're not being affected with or we're not reaching so we have to take a strength base approach the first can't read we need to look for other things then a second point what strategies are available for us to work with people with low health literacy including the critical role of community conversations which certainly can start from a conversation the person has with their clinician the next point how can we implement strategies for people with the lowest health literacy in the community or with people with special health literacy needs migrants and refugees people with disabilities people who are actually sick and they're not taking things into our people mental health conditions then how can we assist health professionals to use careful and sensitive assessments to use different strategies based on people's needs so indeed we need to understand people's needs so different strengths to be actually able to tailor and strengthen the repertoire of health professionals to make sure that everyone has the best chance of understanding the teach back concept making sure that the person understands what you're saying you know asking them I just need to check to see if I'm doing my job right can you tell me what you're going to do when you go home after sharing your pearls of wisdom after sharing the instructions of how to take their medicine or how to what help you have going to undertake and that's the teach back concept so the purpose of health literacy is to improve the health and reduce health inequality and that's the core topic of this presentation next slide so when we think about our five areas of health literacy there are very particular ways which people learn and next slide so for a lot of people the internet isn't so good to help them with accessing because they don't have access to them I better understand and read very well and not better appraise information in that very well of tall and but it may help them remember and retrieve things it may help them apply things but talking with health staff is critically important generally for many many people but it may not help people remember or actually help apply because it may be too technical next slide and printed materials and media can be very mixed for some people too next slide and community conversations are a critical thing which happens basically everywhere the conversations that people are having with family across their community and we have to get the right conversations happening across different peer groups and different parts of community and then many parts of the world is actually arts and songs in in communities where there isn't a written tradition but there is a narrative tradition in the linguistic structures next slide I've emphasised that one next slide so in thinking about really trying to understand I guess the potential of the digital divide we've built a health literacy questionnaire which has been used in 30 languages in hundreds of studies around the world but we really thought we needed to develop a digital health literacy questionnaire so with the team in Copenhagen University we spent many years really understanding from the patients perspective what do they really need to use digital technologies and then we also work with clinicians and digital experts what really works to get people to understand and use digital health in many settings so there was a grounded approach we went in there without any particular theoretical and we really really listened to the community so this questionnaire has been translated to a wide range of languages across Europe and increasingly in Africa and Asia next slide so the framework that we built from the lived experience of ordinary people that you see every day next slide so three key elements is ability to process information the second one is people's engagement in their own health the third one ability to actually engage with digital services so you can imagine if people don't have these really basic user capability skills it's going to be very tricky for them to engage in the nice shiny technologies that we build then we're finding that trust and motivation are incredibly important if people don't trust they could have all the skills in the world but if they don't trust it they're not going to go anywhere near these shiny technologies or fear of their data being used and of course as we know the media is very good at finding the one in a million or one in 10 million events making it appear very common and making it feel like a huge risk to the whole society and actually ruining an entire five or 10 years of research and very moral behavior we're very very careful of course and it's very rare we do have data breaches the last one is the experiences of digital services so people's access to digital service actually work consistently sensibly so they feel it's worthwhile going back again and the digital service actually suits individual needs so working trying to understand these elements of people from the actual capabilities their trust and motivation and their experiences they're very very strong determinants of people actually engaging so I imagine if you've built some technology with all these things in mind that you've built it from the first principles of what people really wanted and could do and would do and you've built into your technology the key elements that would overcome people's challenges or barriers so indeed this is exactly what we've been working towards which we have built is a way of actually doing co-design building up people's strengths and weaknesses because in fact every patient that comes in has a different set of strengths and weaknesses you don't treat all patients the same because the average patient doesn't exist so we actually find that there's very very different patterns of all these so we work with these dimensions we build clinical vignettes and we have these superfluous stories of people in the community and then we go to people in the community ask them hey you see this person Joanne for example and Joanne has this mix of strengths and weaknesses as described here from the data analysis data that's collected from the actual clinical communities and then people in the community and the clinicians and experts tell us oh this is how we solve the problem to this particular combination of strengths and weaknesses so we get actually hundreds and hundreds of ideas from people and this is something that we call affiliate optimizing healthcare and access which is being implemented in 10 countries in Europe and increasingly in other countries and many settings in Australia so this is a setting where we really want to make sure that it's fit for purpose because we've got these wonderful technologies and these technologies are often very good for the people they're good for it sounds like a torchology a lot of the technologies we do experiments on technologies we implement them and one group they find that's useful so it's useful for the people it's useful for but what about those people who don't even engage in designing the services don't even can't even you can't even recruit them to your studies how big is that group we are really finding that there are a substantial number of people in community in the Keshe Hacker world so one of our close colleagues here in Melbourne who's well known to some groups in the GP world we're finding even in high tech clinics there are people who have no interest no capability in engaging technology they are completely left behind so we've got to start thinking about building our technologies so it really reaches into people's hearts and minds in their communities and people support to engage you can't even get an appointment you can't even get to see GP unless you've got some sort of engagement technology so many people being left behind next slide so we have done a piece of work for the very large national agency to understand people's engagement in a digital health record and when we saw this graph here this is the EHFQ scales calibrates from the highest health literacy to the lowest health literacy and this graph is so clear that if you have low skills on help eat digital health literacy you will not engage a lot of us to deal with trust a lot of us to have access but this is just a slide to remind me to say we really have to put into our equations when we're building these technologies and implementing them that we understand people's capabilities and needs all the different variations and ensure our technologies are supportive to get people to participate enable people to participate next slide that's it thank you thank you professor research now i'd like to invite dr raman kumar for his talk on telemedicine practice in low resource setting using basic id tools thank you dr perman next slide please so i'm going to talk from my own experience as a private family physician or gp on outskirts of new daly india and india as you all know is a large country we have 1.3 billion population 28 states and nine union territories and all these states and union territories have their own respective health policies and regulations and government at national level as well as state levels they are providing provisions also using digital technologies for example we have our national mobile application for patient tracker and we also have national health line numbers state health light numbers the patients and people can directly call and get help and advice what i'm going to talk is from my own private practice perspective but is not representative of all india or what we do across india so i'm based in outskirts of daly i'm a solo practitioner i i charge my patients directly i do not get any reimbursement from public or private insurance and the committee i serve is mostly young and educated young means mostly that most of them are in their 20s and 30s so telemedicine was not legal in india till recently only during the lockdown the last week of march it was regularized by the medical council of india and there are clear telemedicine guidelines now available for practitioners and we try to follow them and already there were several mobile applications available in the market i've shown two of them on this slide and find practical docs app but when it came to my own practice i was doing a regular you know traditional gp practice i decided not to use them for three reasons one was cost because you have to buy their subscription second was the data issue because all your patient data goes to their you know common digital platform and third was how do you you know it was like a marketplace where you compete with other providers and you know it's a mixing of patient communities and it was not very comfortable situation for family physicians and this is about my experience of around 700 unique consultations and these are not repeat consultations next slide please because basically i am using i decided to use primary consideration was mobile phone because this is where everything converges and everybody has a mobile number and similarly whatsapp is another technology and commonly used application why most of the you know even remote areas they have mobile number whatsapp and smartphones and i had to have a payment gateway which was used digitally which is also linked to my mobile phone i use g-suit g-seat because this is almost similar to what we normally use in our google gmail application but it is additionally it has to have a domain name and it provides you additional services so a general flow of consultation would be like i'll get appointments from yellow pages or business identity at google search and then the registration is done through google form which is archived at google sheets and then the diagnostic reports and data exchange takes place on whatsapp business so whatsapp as we know is of two types one is you know is a general and other the business which has additional facilities of levelling your you know your chats your talks your contacts and it is more you can also display your brochure or your name or your business card and then there is a payment part which is also again integrated to my mobile phone itself i still write my prescriptions on paper and scan them with adobe because it gives a personal touch and that paper is archived on google feed drive and from there we get follow-up i also use an IVR service interactive wire service which is a small subscription price for archiving all telephony talks thank you thank you Dr. Raman now i would like to invite Prof. Mehmet Ungan for his speak and experience on IT based difficulties we faced with and how we solve as a long lesson sorry yes um yeah thank you very much for the word giving the word to me mr president and the colleagues i have been watching the presentations and learning a lot and i think at the end we will have a very fruitful discussion so this is actually the not exact experience on IT based difficulties but what we have learned and what we have faced and then the summary of the those items which we had next slide please yeah just we have two networks in Europe probably you are much aware of them and you're at the education and your group is the rule of doctors network and they had a pandemic on telemedicine especially and also digital care so i would just like you to know that you know it is it was a few months ago so it might not be well but still giving us kind of idea in our practices approximately 80 percent of the gps in europe have video consultation in the practice which is incredibly high numbers so 39 33.4 of them a month to 33 countries reported princess presence of a telepon triage service for the covid patients during this pandemic and almost 65 persons were using retired general practitioners in phone triage and mostly they were the retired one and so approximately 75 percent of them had no remote consultation guideline which caused a lot of small travels in between which i will tell you later 65 percent approximately of the family doctorated satisfaction more than three among five you know i like a scale type of the questionnaire so you can tell that 15 percent of them were extremely satisfied but you know just it's more than half that most of them were satisfied with this kind of applications 90 percent of the patients rate it's more than half of the you know the scale it's three over five so and when you look at the extreme satisfied it's approximately the same with the doctors with the physicians and 40 percent of the family doctors face with it problems during the consultations which is an important amount and i have seen in the slides in the previous slides that the internet basins so what are the key messages in pandemic including those of the digital care and telemedicine in family medicine in europe so i can tell you that the family doctors across europe played an essential role also with the digital and also telemedicine technologies in even in europe and the clinical practice in family medicine and was rapid successful implementation of the telemedicine digital care and remote care model was depending on this actually contributing a lot in this success and what else the other the other items which are now facing with the universities and the medical schools medical education and research in family medicine yeah it is challenged by the pandemic opening new it platforms and perspectives in these areas also and those are in our daily lives and risk of misdiagnosis appears to be greater in the telemedicine while the legal statutory clauses are not universal so this is actually one of the most important items that we have been facing with in the practice uh digital care and telemedicine has the potential to break down the inequalities which is the and also should not be used as a tool to cut services this is very important for us and our uh you replied the royal medicine network emphasized as the importance of it as several times that it should not be used as a tool to cut the services and there is a regular there is a need a regulation activity in both digital care and also the telemedicine and need minimizing the bureaucracy in drink development and implementation of formal and informal uh digital care and telemedicine i think what we can just mention here is only when the apology become for everyone's presentation not to ignore or not to cut those kind of services which are already used by the public like what's up telemed telegram or just the other techno just you have been using already in your daily lives can i change it okay so what are the key messages for a pandemic those are the on the left side you can see the positive sides and on the right side negative messages we could just give to you most of you knows the positive sides that we have been experiencing already but also we have some uh problems it might hinder a good doctor-patient relationship which is at the heart of our profession we have to be very careful very quickly to examine sometimes used to limit or cut the primary healthcare services which is we are totally against for that requires resources and effective infrastructure and robust investments to be feasible and effective so on the right side you see that this is the uh as a non-state actor in the WHO 7th regional meeting our that's where Euro uh Europe and the Wonka Europe and together with the other non-state actors we made a statement if you read it it will be summarizing and emphasizing the importance of the digital services including the telemedicine but also warning the governments uh to support the systems in a proper way with the proper infrastructure uh next slide please and this is my last slide and what what else you know we in practice we have to be very careful about the consent for online consultations this is mostly automated but i think it is better to be careful because then the consequences may appear later and the documentation of like the documentation of the type of consultation medical service performed and daytime duration and location of the patient and the physician like physical locations and also the most important thing is ID confirmation in some parts of the Europe the people can consult for their you know relatives but at the end might have a consequence for you also and so uh the telemedicine uh and also digital care may expand the primary health care team because we have been always looking forward to expand the primary health care team so uh in delivering the public health services i think this is another two for us that we can include other team members into that new working styles and roles we have experienced already and there should be an interdisciplinary approach in this area which i see there is already but that should be also emphasized the importance of interdisciplinary approach which is different than the multidisciplinary actually non-registered professions might be on same digital platform for the non-communicable business patients and there should be a need for support and guidance like an orchestra playing in a concert to function as an integrated team and need trust a clear understanding of those a coordination is really needed for sure and what the most important and the last word i should say to you that all those technologies shall include the fabric doctors into all decisions and development in the initial stage on digital health care and telemedics thank you for listening to me thank you professor memet now we will be having our panel discussion on predicting digital health after the pandemic and i will request professor reserve robots and Dr. Ana Luisa Nevis to take on the floor for this panel discussion hello everyone next slide please i want you to imagine for a moment that you're a family doctor in alpine texas that's in west texas as they like to say there's a lot of space out there the next closest community with a hospital of any size is about 300 kilometers away and that's a medical school university hospital and your town has 6000 people four family doctors and a 25 bed hospital it's january and you're in the middle of a very unusual and severe blizzard much snow and ice and wind and you decide to stay at the hospital because you're responsible after hours that day and about 11 p.m at night maria comes into the emergency department and she's complaining of several days of fever and right upper abdominal pain as you begin to evaluate her you find on physical exam that she has a fluctuance or an area of fullness and swelling in the right upper abdomen she has an elevated white blood cell count she has elevated liver enzymes and you decide to do an ultrasound in the emergency department that shows what looks to be an enlarged gallbladder so you assume she has cholecystitis though you're concerned as well about an infection you consult with the surgeon at the university hospital 300 kilometers away and she asks you to put on a piezoelectric glove that has a tactile sensor that allows her to feel what you're feeling as you palpate maria's abdomen and as the two of you are looking at the same ultrasound image the surgeon says well i'm not sure exactly what's going on in terms of the cause it could be a stone it could be a cancer but at the very least she needs to have that gallbladder emptied and the problem is the state highways are all closed because of the roads and the helicopters are not flying because of icing conditions and visibility and so you take her back to the small operating room that you have in your rural hospital and she guides you through placing percutaneously a red rubber catheter to effectively create a cholecystostomy and decompress the gallbladder you start to patient on antibiotics and by the next morning the roads are improved and she's able to be transported to uh to odessa texas where texas tech medical school is during her days in the hospital she develops a pulmonary embolus she has right heart failure and each day you check in with her and the surgical team at the bedside using video conferencing to give them a sense of who maria is this delightful 72-year-old abuela or grandmother who's very technology resistant it took her grandchildren years to get her a mobile phone which she finally agreed to start to use and as you follow her course of illness you're pleased to see she eventually improves and goes back home but because of her other medical problems you try to improve the level of monitoring that she receives so she's wearing a watch at home that gives regular readouts of her pulse and her oxygen levels pulse oximetry and blood pressure and this feeds directly into your electronic health record and your clinical decision support tool will pop up when the average reading for her pulse oximetry is below 88 percent saturation when her blood pressure goes below 100 systolic or above 160 systolic and her heart rate goes below 60 or above 100 and what you find as these days go by in her postoperative recovery is that she's beginning to engage with you electronically much more than she ever would have before as you exchange information back and forth indeed using video consultation in her home and what you find as you collect all this information is that this tools set of tools really helps to extend your reach and allows you to do things as a family doctor that you may never have had the the ability or the courage to try that is the future and if we go to the next slide as we think about digital health we realize that there are a number of ways that this will play out what we've talked about for the most part this morning is using it as a communication tool and indeed that's where most of the work has has gone but there are a whole array of activities with Maria's case I mentioned biosensors and wearables those are becoming increasingly affordable and easy and you can buy one right now that does a lot of this data collection for you telemedicine are doing consultations data analytics using behavior modification tools as we heard nicely from liana using medical social media so one of the things that maria did was got involved with a group of other people with diabetes in her community and they have a chat where they swap a recipes and things like that her digitized health record allowed you and the surgeon to be looking exactly at the same information because they're your platforms were shared across this large region it's an entry point for patients and doctors to talk we use artificial intelligence to help tell us or guide us in what to do and using telehealth or tele radiology as a technique to improve our imaging capabilities but each of these activities has not only exciting possibilities but also great concerns as we get into them more and more so for example with the biosensors just in terms of the regulation of these devices their accuracy their reliability there's still much we don't know when you talk about telemedicine it's difficult enough for the patient right in front of you where you can talk to them watch their body language reach over and touch them to do that a step removed by way of a computer is even more difficult and one of the things that's been interesting about the pandemic and the increased use of telemedicine is rather than substituting for consultations what we're finding in the u.s. that it's actually increasing number of in-person consultations by about 20 to 25 percent in other words the fantasy that many people that pay for health care have is that telemedicine will actually substitute for doctor visits it turns out to be just the opposite as we collect more information it seems to generate more use and potentially overuse when you look at things like artificial intelligence and analytical tools we've had a very checkered experience with that in the united states so for example the IBM Watson supercomputer the the company entered into an agreement with the oncology community in the u.s. to use Watson as a important clinical decision support tool and they did this for three years and finally decided they had to stop doing it because Watson got it wrong way too often now some of that's the limits of artificial intelligence as it stands today but some of it as a person who's expert and evidence is that frankly the underlying scientific evidence sucks that's what most people in the public don't understand a lot of what we do in making judgments as physicians is take very vague symptoms somewhat fuzzy physical findings and we lay that against a backdrop of really crappy science and somehow make a judgment which thankfully most of the time turns out to be pretty good and so the concerns as you look ahead is the possibility of over utilization of people promising policymakers and others promising more than the technologies will deliver but there's no question that it's coming and the last slide for me shows that when you look at how quickly humans take up new technologies it's not only that we're taking up more new technologies all the time it's that we're taking them up much more quickly so for example if you look at the telephone starting way back at 1900 the red dotted line it took about a hundred years almost to have nearly a hundred percent of the world's population with access to a telephone but if you look at mobile phones it took about 10 years and so with this phenomenon of technology not only exploding in terms of different kinds of tools but the rate of uptake is really almost overwhelming and so I think the challenge for us as family doctors will be how to sort through all this stuff and figure out which tools or technologies will be most useful to us and most importantly most useful to our patients and let me turn it to Anna for her remarks. Thank you Richard and I think it's actually a very good way to finish when we talk about uptakes to understand what kind of uptake it is which patients will actually engage with the technology and whether we are actually creating more opportunities or entrenching inequalities that are already there so most of my work at the patient safety translational center is about use of digital technologies and how we use them to partner with patients we engage them in the process and to deliver a safer and equitable care so if I can see the next slide please. So one of things one of things that I've been quite concerned as Richard just put very well is that there's a huge potential on the use of digital technologies in the different aspects we're talking about telemedicine and remote care but all the other aspects of it of course and one of things that's really concerning is that we know that when we talk about technology that take is not the same so it's not the same for a younger person and the older person it's not the same for people with different digital backgrounds as Robert Osborne already mentioned as well and it's not the same for people with different socioeconomic backgrounds ethnicity etc so we need to be really aware of these and although we might want to push these as much as possible and try to make the most of digital we need to take in account that not all patients are going to take these in the same way so one of things that we're really keen recently was to evaluate how was the experience for general practitioners and for patients in a range of different countries so what I'm going to present very very briefly are the preliminary results of an international survey some of you are involved in this some of the panelists so we are covering 16 countries and we have 1500 responses for all over the world and we ask GP so how was the experience how did this impact of patient care so if you can see next slide please so one of the most interesting things and most concerning I would say is when we ask GP so what was the impact of remote care of telemedicine and this covers video consultations phone consultations or online services what was the impact on patient care as you can see in the in the columns on your left side there was a very positive change in what positive impact in what concerns managing COVID patients preventive care all kind of care that we are we usually provide through face-to-face monitoring diabetes hypertensive patients obviously these are the kind of situations in which remote care and telemedicine works really well but if you look in the left side you can see not in the last group of columns but the one before you can see that for most of the doctors there was actually a negative impact on equity of care so this something that we could anticipate somehow because of what is already known as digital divide but it's something that we know it did happen during the COVID pandemic so how do we move from these how do we move forward how can we learn from this experience if I can have the next slide in terms thank you so the next step as it was already discussed here and this is just a way of actually trying to structure the discussion and start posing the questions to the audience is trying to understand what can we learn and how do we move forward so we know that face-to-face is not for everyone and we need to understand for which patients does it work in which circumstances and how can we make it answer their needs so one of the key things I would say as researchers and the primary care physicians is for us to understand for which patients and for which conditions this digital works and of course as part of this work we need to understand the groups of patients that were actually excluded from the process during the COVID pandemic and this is something as we have already discussed as well we know that the trend will continue the adoption is likely to remain not at such a higher levels the pill remains somehow and we need to understand was left out of the process and which were the reasons for patients to be left out because it can be something as easy as a preference some patients might not want to engage it but it might be actually much deeper than that some patients might not be aware of it so even here in the UK although there was a quite strong campaign about telemedicine there was a recent service showing that 20 percent of patients in our Westland they were not even aware that they would contact their doctor remotely so there's actually a work for us to do as physicians and of course this is not something that we can or should do alone is a work of a group of key stakeholders including physicians patients policy makers we need to work together to make sure that patients are aware of what's available if they don't have the digital skills if they don't have the overall skills to engage it we need to be able to provide these kind of opportunities for them and obviously to support them through the process in case they are willing to join in the digital transformation and I think overall this is kind of strategy that we have been discussing and I think this could be something interesting to leave for the audience as well Richard what do you think definitely so would you like to ask the first question of our other panel members Anna yes definitely so one of the so we have prepared three questions uh we've been discussing what would the key message for the audience and the first one would be what do you think is the key thing that family doctors need to know about the use of digital technologies for the future post pandemic and as we go through this it would be great to open it up to all 30 some people that are online but that will keep us here for about a week so we're going to ask just the panel members to speak up on that question and I'll depend on terrorists to keep us on time with whatever time we have remaining so perhaps we could start and I'm just looking at my screen with the the various people's pictures and I'll just start from the left to right Roman what would you say about that what would be your answer to Anna's question I think the new new generation of family physicians are more aware of the technologies as compared to a more adaptive also and the new new generation of the population also is you know a more adaptive to the technology as you mentioned in a slide so one is you know the situation is rapidly evolving it is not you know what it was even three months back and it is you know like you know chat boards uh WhatsApp chats and all is are evolving very rapidly even the regulations are evolving one is to be synced with the what is evolving and be informed with the regulations laws technology devices is most important uh for at least for the provider's perspective that we are aware of the things what we can best facilitate or optimize thanks Ilka would you be kind enough to share your reflections on this okay thank you very important questions I think of course for every GP it is important to learn about the tools and start using some of those tools as now has largely happened during the Covid pandemic this has been a very good opportunity to learn the tools when there has been a must but I think also you should collaborate in addressing public health administrators and leaders the government that they would provide the tools they would finance the tools that would be available for every patient for every GP because you cannot just invite the tool yourself you must have something that is provided equitably to everyone in the population thank you perhaps we could move on to Raquel and ask you for your comments yes I would like to underline Ilka comments because it's it's so important to have a multidisciplinary approach because if government has no support in the initiatives we don't have anything to do was was the case for example in Luxembourg we're discussing different applications and at the end the government was not agreed so yes we have to work and having the whole picture in mind not only our position yes thank you and Harris has given me a signal that we have about seven or eight minutes remaining just so we can be mindful of the time. Mehmet your experience as a family doctor how are you keeping up with in this area how are you staying on top of the latest technologies and deciding which ones to use or encourage your patients to use that's very hard question but I think it's our task to not to foresee the future but to enable it so that's the reason I think those are the people in the front line who would start to use such kind of technologies on behalf of the public health as I mentioned we have been already aware that you know it's it is a necessity so in during lockdown periods and such kind of periods if you have those patients in chronic conditions trying to reach you and if you can't go there so this is a real problem so we start to use and we didn't care whether this this was legally or without regulations it might cause a lot of problems and we don't know whether it is reimbursed or not or it will be reimbursed or not and finally we have seen that none of those consultations are reimbursed by the governments in most part of the Europe actually which is a big problem but on the other hand we are just taking all the problems out and we are trying to serve to our patients as gps and family doctors actually so we are using what we started to use we prefer to use those technologies which are already being used by most of the population like the you know form the those smartphones smartphone applications I can just say here the what's up you know what was that telegram or such kind of your social things and sometimes on skype also so we we tried but we couldn't reach them like like we do here in a zoom technology or such kind of thing of course and still we found this very effective in most of the cases because you know the I don't like to use art of family medicine art of general practice I don't think that it's an art it's kind of learning but it is generally said that you know it is an art okay if we accept it yes at the core of that when you see the patient from your door coming inside of your consultation room you know the first image is approximately 80 90 percent of the you know diagnosis you go with that okay so after that you have the questions and the answers and then you build it in your mind so most of them can be done you know on the screen with your patient of course the satisfaction rates are not which we would like to see but it is still fine and it's still helpful for the chronic diseases and rich I don't know what to say more but I think we we are obliged to use it whatever our age you know if I might ask Richard Osborne to unmute his microphone I think one of the challenges and Anna spoke to this was how to make sure that patients have equitable access to these technologies and Richard talked about health literacy for me literacy really has two parts the first is the ability to communicate and so for somebody that may be blind deaf or mute there are literacy challenges just being able to communicate and in an analogous way it's the same when you don't have other tools that support the desire to communicate electronically and then the second is helping people understand how to use the tools and so on so Richard if you could advise family doctors the family doctors of the world on one thing that should be done to improve health literacy through the use of technologies like digital health what would you say thank you for 30 seconds for a very big question I think the most important will be to continuously demand other technology builders to meet the needs of your full range of patients so your full you have patients with immense range of capabilities and you need technology that is as easy to use as possible and the technologists need to build community-based education programs that can go in libraries that families can use together and that this needs to the technology needs to be built without reach technology or training for the community as well you can't just build a standalone kit or app it's got to be all that implementation needs to be thought through as well so demand that you can't just have standalone it's got to be think of your entire practice and community you're caring for excellent response thank you and if I could ask Liliana you know I'm amazed in the United States during the pandemic how low the trust is in the entire healthcare system the estimates are that 50% will not be interested in a COVID vaccine when it becomes available and so the problem I think is not so much inability to communicate we may be communicating too much and too easily via Facebook and Twitter and the like and and so one of the things that interests me as you were talking about mental health is there is this dichotomy that patients seem more willing many times to discuss sensitive issues electronically than they are face-to-face I was wondering if you could comment on that yeah so that's a very interesting aspect the the misinformation epidemic that we're all observing nowadays is has been fueled mostly by social media and there are several studies now that show that fake news spreads much more rapidly than facts and so we have to be think about strategies about how to disseminate correct information and I think using social media and other other platforms such as chat bots on WhatsApp is a good idea to try and combat that because we know that just by denying misinformation that's not a good strategy at all we have to remain with the facts and just reinforce the facts and there's evidence showing that when we talk about a specific type of misinformation for example anti-vaxxers we're giving them a platform and and that is counter-projective so there's still lots of research going on in in this area but it's I think social media has a role to play there excellent thank you and I'll ask I guess Nick you haven't had a chance to respond so I'll give give you a one minute question before we turn it to Raquel to close us up for us so so Nick as you look at this with a fairly global perspective working in multiple countries how good a job are we doing in developing policy that is coherent and effective and if it's not very effective and coherent what would you recommend that we do differently as both at the national and international or global levels I don't know if Nick is still with us it looks like he is maybe you need to unmute Nick yes I am there we are I was worried you headed to the I was worried you went to the beach let's cross a few meters anyway so no I think from a Wonka perspective this is quite powerful because it's it's very practice oriented and for this and I think also Mehmet mentioned this we need guidelines and we need a clear overview okay what are the tools what is their use and and possible risk and benefits so that's one if you're talking more from a systems perspective I think in general health systems don't do a good thing in integrating things for the functional need of professionals as well as people so this is quite complex also how what you can learn from this seminar it has so many angles come to it so it really need is also an integrated approach on make the real benefit of technology in healthcare and make it work and I should say that in general the had the best evidence for improving efficiency is all support with this collaboration and making information understandable use them in daily practice with the people and there's so much we can we should still do because everybody has its different angles governments WHO industry etc the different disciplines so I think considering the primary care is really the key issue for sustainability in healthcare systems almost with any healthcare system so I think as as wonka as family doctors we should make a stronger voice in this and point towards the importance to better collaboration better integration of these technologies in in daily practice and I think this is what what we we can do together I find it exciting and comforting that we have somebody smart folks helping guide us on this so thank you for all the panelists let me turn it to Raquel to help finish out the session thank you so much very for your presentation and for participating in this webinar I'm really sorry that we don't have more time to answer the questions that our participants were sending to the panelists but I will transmit it to the to the health group and that will be properly answered I don't have so much time also to make remarks but I think in the the health lines of this discussion have been that is we need more research we need much more evidence not only on the satisfaction of the use of technologies but also how this is impacting in our daily practice in our patients it's necessary to have education for the population for the professionals for the medical students and also for the stakeholders and others involved in the in the healthcare system we had to learn from what has been done until now in the pandemic and how we'll use it in the future is very important that we analyze what we have done and it's obvious it's challenging for everybody but this has forced us to use the e-health technologies the digital solution and this opening a window of opportunities because we have been very keen fighting for e-health in in the last years and we face some resistance from other colleagues so I think we all realize the importance of digital health and it was an opportunity to raise awareness on the use of it we have learned from different solutions on different research from our colleagues very interesting one and I think the words of mix do to wrap up the webinar have been very wise we need better collaboration and interpret in their professional collaboration to make this happen so I would like to close it thank you Dr. Prasar for the convener of the e-health working group to bring this webinar to all the panelists and a speaker for the valuable contribution I think we need much more room for discuss on e-health if this has been just a start of the discussion but we need much more space and time to discuss longer I want to thank Wonka to lead the floor for this important matter and support digital health and all the participants that have been there if you want to be more engaged in the e-health working party here you have the details to to be part of us and continue the discussion online and on the future and for the next webinar I would like to invite you in the 11th of October at the same time 10 am UTC for the special interest group on aging and health that will also open a very important discussion on this COVID-19 times thank you so much everybody for your participation and goodbye