Supporting person-centred care in health technology through clinician engagement

In my article 'MHealth and clinical governance' (Published on LinkedIn - June 25, 2021), I discussed what issues vendors might consider "to ensure the safety, quality and clinical benefit of their product, and mitigate the risk of harm" (and therefore, medico-legal risk) - with my usual reminder that consumers should always be at the centre. I also suggested that developers "should work with clinicians in enabling mHealth to support effective partnerships with their patients".

The role of such partnerships in facilitating person-centred care - which lies at the core of contemporary clinical governance - of course applies not only to mHealth, but to any digital platform or medium which seeks to assess, monitor or manage a person's health (and indeed any type - or mode - of care, or its delivery). Whilst we support person-centred care through facilitating choice - such as the choice to withhold information from My Health Record, or the choice to monitor our vital signs via wearable technology - we also need to manage any risks associated with these choices.

As a doctor in an emergency department, I was often reliant on a patient's past records to inform my assessment and management of their presenting problem. I discussed my most prominent memory of this in another article, 'Beware the digital dinosaur' (Published on LinkedIn - June 17, 2022) - describing an episode of care when a patient's electronic record enabled me to make a life-threatening diagnosis I would have otherwise missed, given his non-specific symptoms and inability to communicate a history - simply because it revealed he had an enlarged prostate.

To this day, I shudder to think what might have transpired had I not been able to access this man's health information so promptly. What if the only record I had been able to see was My Health Record, and (for whatever reason) the patient had asked his urologist not to upload this information? As his urologist (or GP), I would have communicated the importance of this record in supporting his future medical care (eg. informing a diagnosis, or appropriate treatment) - and the risks if it was omitted (eg. missing a diagnosis, or inappropriate treatment) - so the patient could then make an informed decision about its potential exclusion.

In circumstances like these, it may be that clinicians should - in partnering with their patients - take a role in explaining to them what good record-keeping means, and why it is so crucial to their care (and clinical governance), and the risks of having an incomplete record. Although this might sound unusual, with innovation we need to think 'outside the box' (while leaning on the basics) - remembering that patient education is imperative to person-centred care and shared decision-making.

It is trite to acknowledge a thorough medical history is the gateway to accurate clinical assessment and diagnosis - and appropriate management. But today, a patient's engagement with technology (and navigating this) may be a significant aspect of that gateway. A practitioner relying on My Health Record might ask their patient if there is any past information that has been withheld (and document their response), as part of their assessment. A practitioner's duty of care will be subject only to what they knew, or reasonably ought to have known, at the time of their assessment - so practitioners should not only document what they know, but also what they don't know (and importantly, what was communicated to them).

Technology is integral to the modern therapeutic relationship, and to the modern patient (or consumer) experience - from the use of online booking engines, to the use of apps to monitor blood glucose, to the deployment of surgical robots - even virtual reality to combat loneliness, or in-home detection of unusual activity (or inactivity). Therefore, clinicians should engage with technology, in partnership with their patients (and where appropriate, their carers) - to fully support person-centredness in this contemporary era of care.

In the context of mHealth for example, a clinician might assess the extent to which their patient (as part their relevant history - and person-centred care) relies on any apps, or other technology, to monitor or manage their health (and document this). In other words, clinicians must continue to assess their patients as a whole, as in any other context - which, these days, should ideally include taking a 'digital health' history.

A 'digital health history' would include an assessment of a patient's digital and health literacy (in tandem with their health literacy) and, amongst other things, what they are capable of understanding. What health technology, if any, does the patient rely on??How and when do they use it??Is this use appropriate to their circumstances???

Clinicians can play an important role in advising whether particular technology is appropriate for their patient, by understanding not only the patient's physical and psychological condition, but their sociotechnical circumstances and ecosystem. An obvious example would be a patient who lives with patchy internet connectivity, which may undermine their experience of (and with) the technology.

Ideally, the clinician should seek to understand the product themselves (to the extent that is reasonably practicable) - identify any potential (and emerging) shortfalls, risks, benefits and alternatives. That is, approach technology as they would any other intervention (or innovative treatment, such as a new medical device) - through an understanding of available evidence (or product information), and communicating this to their patient (again, documenting this communication). Their patient would then be enabled to make an informed decision about relying on that app. Clinicians should encourage openness and transparency from their patients about their use (and understanding) of technology, to facilitate partnership in their care at an holistic level.

Further, with shared decision-making comes shared responsibility - so clinicians have a role in reminding patients of their responsibilities, in empowering them to manage their own health and well-being through the safe and effective use of technology. Together, clinicians and patients can agree the extent of guidance required (or wanted) beyond the app, or a wearable (or other technology). This will also manage patient expectations, and help clinicians understand what they can expect of their patients - so that they can agree (in partnership) appropriate strategies relating to their use of technology (or not).

What about vendors? Every time I start my car an alert pops up that says "Never rely solely on the camera system", to remind me of the potential limitations of technology - and that I remain accountable for my driving. When releasing their product to market, vendors might manage their risk by advising consumers to use their products only with the support (or at least knowledge) of their doctor, and ensure appropriate warnings are applied to the product, including material risks (rather the solely relying on clinicians to know and communicate these - see Ethicon Sarl v Gill [2021] FCAFC 29) - with perhaps a reminder (like in my car), that technology should only be used as an adjunct to clinician input.

Clinical governance in any care and support must encompass its whole. Therefore, partnering with patients and consumers in their engagement with technology should be part of person-centred care - always balanced with our duty of care (to take reasonable steps in avoiding or mitigating the risk of harm, whilst promoting autonomy and self determination). This balance can be achieved (at least in part) through ensuring effective communication and informed consent (or refusal of consent) - just as we are obliged to do with more 'orthodox' care interventions, or notions of care.

In today's digital environment, it is imperative that clinicians and care providers engage with technology in partnership with their patients, to enhance outcomes and manage risk - and it is ideal that vendors engage with both groups.

Note: some of these issues were canvassed in a recent Dutch study - see Clarifying responsibility: professional digital health in the doctor-patient relationship, recommendations for physicians based on a multi-stakeholder dialogue in the Netherlands | BMC Health Services Research | Full Text (biomedcentral.com)