AMA chief on disruptive tech
Anne Trimmer: There are big policy and ethics questions around new technology in health
If your doctor whips out her smartphone to take a photo of your skin rash to share with a colleague, how will that image be protected, how long will it be stored and will your identity be protected? Will an artificial intelligence diagnostic tool pay any attention to the Hippocratic Oath?
Artificial intelligence in diagnostics, telemedicine, augmented reality to train doctors and surgeons, bionic eyes and ears, genome sequencing, genome editing, digital health records are all impacting the delivery of health services across Australia.
But are policy and process keeping pace?
The Australian Medical Association (AMA) has been the peak national body representing medical practitioners and students since the 1960s; it has a membership of 30,000 members plus 9,000 students. Nationally there are around 100,000 registered health practitioners.
Some of those could shortly face their own existential threat from technology. Sydney based analyst Faethm has forecast as many as 38 per cent of healthcare roles could face automation in the medium term, and already there are more medical students coming through the system than can be found a position on graduation.
Though it represents only a third of the entire community, in national health debates the AMA’s voice is always loudest.
Its two primary functions are to promote and advance the interests of its members and to promote the well-being of patients.
Secretary general and chief executive Anne Trimmer says; “We contribute pretty solidly to the development of health policy and work quite closely with the Department (of Health), with working groups or committees put in place to examine particular areas of health policy.”
“We contribute to parliamentary inquiries examining areas of health policy and work with the bureaucrats, government, opposition and cross benchers to influence the outcomes of health policy decision making.”
The cost of healthcare in Australia continues to soar – according to a CSIRO report into medical technology, in 2013-14 Australia spent 9.8 per cent of GDP on healthcare. That will soar to 15.7 per cent by 2040.
Rising population and a rapidly ageing demographic (between 2015 and 2030 the proportion of the world’s population aged 60 and over will rise 56 per cent) places a significant burden on the healthcare system. Continuous innovation will be essential.
Over the last four years the AMA itself has become a much more digital organisation, establishing an information portal for registered practitioners (not just AMA members) providing access to current information and online education, which is particularly targeted at meeting the need of practitioners in regional or remote areas.
The AMA has not, however, been supportive of some attempts to use digital technology to force transparency on its members.
A bid by some health insurance companies to see doctors’ fees published and their performance rated has been roundly rejected by AMA’s president Michael Gannon who has described this as “dangerous territory”.
“The consideration of clinical performance and the years of training to improve safety and quality cannot be captured in a customer ‘star rating system’. Joint replacement surgery is a bit more nuanced and complicated than an Uber ride.
“We note also that contracting arrangements with hospitals have ‘no pay’ clauses for adverse events.
“Insurers should not interfere with the established safety and quality system that is achieved via the independent accreditation agencies.
“The AMA will fight this deliberate drift towards United States style managed care - a system that performs worse than ours according to nearly every metric.”
Ms Trimmer acknowledges that there are other areas where the AMA grapples with the pace of innovation and disruption sweeping the sector.
“There have been some enormous developments in a very short space of time – using AI in oncology and so forth – which is obviously an areas that is completely disruptive of traditional radiology services.”
“It’s not something we have really yet looked at. Some of those future-gazing health care policy issues are issues that require our attention.”
She says that the option to inject AI into healthcare; “Really goes to the heart of the doctor-patient relationship and whether that can be replaced by something that is automated.
“The doctor-patient relationship is one of the oldest relationships in medicine and it does have a really firm ethical framework around it. To have a machine relating to the patient really forces us to rethink what that an ethical framework is,” Ms Trimmer said.
“We have not yet looked at that from an ethical or practical point of view but it clearly has implications for workforce, for the number of doctors coming into the workforce from medical school where we have got an oversupply as result of changes in policy over the last ten years.
"It’s very challenging when you think of the young doctors coming into the profession.”
At the same time; “We are looking at other issues like genomics which is changing the way that medicine is delivered or prescribed for individual patients and then there is the more functional areas like the MyHealth record and ensuring it is actually usable by doctors and patients – that has been a major area of focus in recent years.”
First launched five years ago as the opt-in Personally Controlled Electronic Health Record (PCEHR), the digital health record has had a revamp – is now called the MyHealth record and is about to become opt out. Uptake under the opt in regime has been slow – at time of writing 5.5 million Australians have registered for a digital health record.
Sometime this year, however, digital health records will become mandatory for anyone who doesn’t take advantage of a yet-to-be-announced opt out window.
Ms Trimmer says it is still “early days” in terms of assessing the value of the digital health record and that the AMA’s main focus is on ensuring the health record is usable and used.
“The need for interoperability not just with MyHealth record but generally in the health area is absolutely critical – the other big area of development that fits into interoperability is the plethora of health apps in recent years – some of them aimed at health care professionals some aimed at consumers.”
AMA is also giving thought to the ethical issues surrounding the use of technology in a healthcare setting.
For example while it acknowledges the importance of doctors being able to use tablets and smartphones at the bedside to access and capture information, what steps are taken to protect, for example, images of patients captured on personal technology?
Ms Trimmer says; “Smartphones have become really key to the way in which doctors behave with patients. Is it appropriate to take photos of patient conditions? Who can you share these with?
“What protections are in place from not only breach of privacy but potentially exploitative use of images that are meant only for medical purposes?”
The AMA does have guidelines for doctors regarding the collection and sharing of images available on the website – but it’s indicative of the sorts of ethical questions that continually arise as new technology is deployed and which the AMA believes need to be protect the best interests of both doctor and patient.