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ARE WE READY FOR DIAGNOSTIC AI?

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ARE WE READY FOR DIAGNOSTIC AI?

Image recognition artificial intelligence (AI) is here to stay and has the potential to transform medical diagnostics by prioritising urgent cases and identifying disease at an early stage. As the technology has developed, it has become clear that the ability to identify a broad range of pathologies is important  which means the algorithms need training on ever increasing numbers of patients.

Detecting multiple pathologies requires detailed reporting on thousands, even millions of images, a huge amount of data needs to be collected in order for programmes to ‘learn’ and improve their functionality. 

At the same time, there are questions around how diagnostic AI and clinicians should work together - who is liable for a wrong diagnosis? How do medical indemnity providers assess liability risk? How is their use going to be regulated?

What about patient data? Data protection laws insist that patient data is anonymised but the risks of a breach resulting in identifiable data being released  is always there, along with the resultant civil litigation that always accompanies these events.

The UK/EU data protection regime treats medical-related data as a “special category” - in other words, a more rigorous set of rules is applied to the way that data is collected, managed and stored.

Patients must be informed what their data is being used for and how long it is being kept. Patients may also withdraw consent and even insist that their data is destroyed. In reality the risks remain the same, it’s just the volume of data that is changing.

The reputational damage that could be caused by a data leak is very real however and the fallout from a material breach could cripple a tech company  at a critical stage of their research

In order to mitigate the risk , AI algorithms only have access to medical imaging data, details of patients including condition and outcome, remain unknown during the analytical process which further limits the application.

Ultimately, AI should be helping doctors decide on treatment strategies but to do that, the algorithm will need much more access to patient health records, clinical trial results and drug data which means, a regulatory framework and a clearer pathway through patient consent, privacy laws and data security.

If developers go down this route (and it is almost inevitable that they will), there needs to be more thought given to the nature of consent for patients. How will they respond to being part of a study or the result of an AI generated diagnosis rather than a human one? They are entitled to know whether the AI is safe and effective or at an early stage in its development. In the absence of that, the risk of legal recourse, if the outcome is not as they would wish, is pretty much guaranteed.

We don't nee AI to tell us that!

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IS MEDICAL INDEMNITY COVER IN NEED OF A RETHINK?

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IS MEDICAL INDEMNITY COVER IN THE UK IN NEED OF A RETHINK?

It has been clear for a number of years that the current UK system of medical indemnity is not fit for purpose. On the rare occasions when things go wrong, it does not always compensate patients when it should. From a consultant’s perspective it is expensive, inefficient and bureaucratic. Premia are high and often do not reflect a consultant’s track record or level of skill. 

From a patient's perspective, the process of claiming is often frustrating and lengthy.

Gaps in compensating private patients were addressed in an independent report, into Ian Paterson, the rogue surgeon who performed botched and unnecessary operations on hundreds of women. The report noted that at one stage private patients were potentially left uncompensated as a consequence of their choice to seek private treatment. 

Paterson’s indemnity cover was provided by the Medical Defence Union (MDU), who declined to contribute to the compensation fund set up to recompense patients. Dr Christine Tomkins, chief executive of the MDU, said: ‘It has always been the case that the requirement that doctors have professional indemnity is intended to provide compensation for negligence. The MDU, along with all those indemnifying or insuring doctors, pays compensation to patients for negligence, not for crime.

Spire Healthcare, where Paterson operated, contributed over £27m to the compensation fund.

The report stressed the need for private patients to know more about their options for redress if something goes wrong. It added: ‘The discretionary nature of the cover, combined with the lack of clarity about whether private healthcare providers are vicariously liable for healthcare professionals’ actions, means that there are potential gaps in clinical indemnity in the independent sector which do not exist in the NHS. ‘This risk does not appear to be transparent to private patients at the point that they choose to have their treatment in this sector.

For many newly qualified consultants, the cost of indemnity is one of the biggest barriers to setting up in private practice. The GMC requires all doctors in private practice to maintain indemnity or insurance in respect of claims from patients. Private hospital groups also now have their own detailed requirements setting out the level of cover required. In many cases, premia will run into many tens of thousands of pounds per consultant, which must be paid up front by the consultant before a single patient is treated. 

The UK indemnity market has continued relatively unchanged for over a hundred years. The market is dominated by three large mutuals, known as Medical Defence Organisations (MDOs), each of which was founded over a century ago. Between them they indemnify over 80% of consultants in private practice, and whilst they have served the profession well in the past, their mutual members’ club approach is considered by many to be no longer fit for purpose. Indeed, the sector is awaiting a response to a Government consultation which asked whether fundamental reform of medical indemnity is required.

We believe that the modern business of healthcare, operating in a fast-changing and litigious environment, demands the certainty of contractual insurance combined with a flexibility of approach to adapt to the new patient care models that are emerging.

That healthcare in the UK is going through a fundamental transition is a certainty. Post-Covid, we will see a waiting list of 10m patients (4.6m now and up to 6m as yet unreferred) and a strong demand for private healthcare will be inevitable.If clinicians are going to address this new demand, a new approach to indemnity insurance will need to be found.

At present around 20% of clinicians in private practice are insured while 80% remain with the MDOs. In a world of big data we feel this is archaic and needs to change.

We are working with leaders in the insurance market with the aim of introducing a new model of insurance that leverages new technology and ways of working to provide better value for consultants and greater certainty for patients. 

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BETTER TOGETHER – WHY GROUP PRACTICES WORK

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BETTER TOGETHER - HOW MULTI DISCIPLINED PRIVATE PRACTICES CAN OFFER VALUE TO BOTH PRACTITIONER AND PATIENT

Consultants tend to be a solitary breed. They guard their private practices jealously and consider other consultants competition. We understand, after all they may,have spent years building their business.

At Medmin we have a different view. We build clinics around specialisms rather than individuals. We team up surgeons, oncologists, radiologists, histopathologists, radiotherapists - in fact any combination of practitioners that might mean a broad range of treatments for patients.
In most cases, self pay patients start their journey to health with Google. They search for their condition (if they have already had a diagnosis) or perhaps their symptoms. That’s why we tend to brand our clinics in an easily recognisable form -  thebirminghamherniaclinic.com, birminghambowelclinic.co.uk, birminghamurologycentre.com etc. And that’s important, because search is where we find the vast majority of self-pay patients.
Once the patient has had an initial consultation, it makes sense to keep that patient’s treatment within the clinic where at all possible. Patients know that their cases are discussed at multidisciplinary meetings providing them with the reassurance that they are getting the very best opinions and given all the possible options for their treatment at all times. If a consultant is away, patients can continue to be treated within the group, the shared patient record ensuring that all clinicians are up to date with treatment and progress.
From the participants side, shared practices can build real value. Our clinics are structured as Limited liability Partnerships (LLPs) which are a widely used structure in healthcare.  There are economies of scale across the group, members can join and leave with no employee related securities tax risk and members can be individuals or corporate vehicles if they wish.
Medmin takes a stake in the business and invests in marketing and brand-building as well as providing management, admin and billing services. Clinicians can concentrate on seeing patients without the distraction of managing the business or indeed the risk in running marketing campaigns.
Of course, being part of a bigger group also makes negotiating with service providers a little easier - and that’s something we do on behalf of all of our clients. Finding theatre access during Covid for example -  a more interesting proposition for a group rather than an individual practitioner.
And then there comes the time when members want to retire - as an individual in private practice you simply walk away. As part owner of a clinic you get to realise the stake you have built up over the years or the clinic may become a target for acquisition by a hospital group or other healthcare investor.

So lone gunman or team player, at the end of the day it depends on how you like to work but we believe that 'Together is Better' both for patients and the clinicians who attend them. 

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CAN SELF PAY HEALTHCARE BE TAX DEDUCTIBLE?

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CAN SELF PAY PRIVATE TREATMENT BE TAX DEDUCTIBLE?

Many of the self-pay patients we see are looking to resolve an issue that is causing problems in their lives.

Whether it’s an unsightly skin-tag, a replacement hip, a hernia that is causing discomfort or preventing an active life - often our patients don’t want to wait to have the procedure taken care of by the NHS, particularly now when so much elective surgery has had to be postponed or cancelled.

For some patients the delay is more problematic, they need treatment to allow them to work. Often self-employed and without insurance if they are unable to work they could face real hardship. Typically these patients work in construction, farming, logistics etc. Physical jobs that need a good standard of fitness. Could the costs of their treatment be a legitimate business expense and therefore tax deductible?
The answer (like so many other questions around tax) is, it depends… The relevant area of the Business income Manual (BIM37400) states that; An expense is not disallowed by S341 because the trader (or third party) obtains an incidental or personal benefit provided that it was not part of the purpose in incurring the expense to secure such benefit.The problem you will face is how to distinguish between:
    • an incidental or unsought benefit, and
    • the furtherance of some non-trade objective
The possibility that an ‘incidental benefit’ may accrue means you cannot decide ‘wholly and exclusively’ issues by reference only to the effect(s) that follow from the payment. You must establish all of the facts from which you may infer the trader’s purpose (or purposes).
In other words, it all depends on the context and what is being treated. There is a precedent though.  
David Parsons was a stunt performer who got injured in the line of work, he paid for private surgery (that he could ultimately have obtained on the NHS) so that he could return to work more quickly - at that time there was a wait of more than a year for the surgery he needed. 
The tax tribunal decided in that situation that (whilst there was, incidentally, a private benefit) the expense was incurred for the purposes of the trade (since the private benefit could have been adequately obtained, in time, at no cost).
On the evidence, the Tribunal is satisfied that in terms of his requirements as an ordinary human being, he could have waited, and would have been content to wait, to have the operation on the NHS.  The evidence was also that in a physically less demanding job he could have carried on working in the meantime, and that it was only because of the particular demands of the kind of work that he does that he could not carry on working until the operation was done. 
The case was brought in 2010 - there is a strong case for arguing that with NHS waiting lists having got much longer, and, if the particular demands of the work a patient does, requires a procedure then it could be an allowable expense.

But if you don’t ask, you don’t get … Watch this space!

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ARTIFICIAL INTELLIGENCE, DOING THE JOBS YOU HATE!

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ARTIFICIAL INTELLIGENCE -  DOING THE JOBS YOU HATE

Patient notes and the patient record has been a large part of Medmin’s history and it would be fair to say that some consultants are considerably more verbose than others. That said, our team of med-secs have transitioned from the dictaphone to iphone audio files and for the last eighteen months, they have been using Dragon which is a speech to text transcription programme.

Medical Secretaries often have training in medical terminology and, indeed AMSPAR (The Association of Medical Secretaries, Practice Managers, Administrators and Receptionists) offers professional qualifications in the subject area.

But entry into the patient record is just one part of the story. Patients sometimes see multiple consultants during their treatment and that can also mean time spent, looking back through pages of notes, either online or as paper records. It’s time-consuming and with time in short supply a number of organisations have seen an opportunity to get involved.

For every hour doctors spend with patients, they spend two hours on paperwork and note taking.


Healthcare is big business and not surprisingly, some of the biggest players in tech have thrown their hats into the ring in a bid to offer solutions that don't involve typing.

Amazon, Microsoft, and Google have all created software to this effect.

Just like in any sector, productivity is important and if doctors can reduce time in note-taking they can see more cases and, with better access to that data, provide better outcomes for their patients.

In November 2020, Google launched open source machine learning software to help doctors make sense of patient medical records. The platform is composed of two programs. One, an API for healthcare-related natural language processing, scans medical documents for key information about a patient’s journey, puts it into a standard format, and summarizes it for the doctor. It can pull from multiple sources of information like medical records as well as transcribed doctors’ notes. The goal is to create an easy way for doctors to review a patient’s past care. 

The second, called AutoML Entity Extraction for Healthcare, is a low-code tool kit that helps doctors to pull out specific data from a patient’s record, like information about a genetic mutation.

Microsoft has Project EmpowerMD. EmpowerMD listens to clinical conversations between doctors and patients. It integrates this content with information from the patient's EHR and automatically generates a medical summary. This allows physicians to spend more face-to-face time with patients. EmpowerMD is a learning system built on Azure. It uses a rich set of machine learning (ML) algorithms to tackle complex natural language understanding challenges.

The system is highly customizable. Doctors can easily edit the summaries generated by the system to suit their own individual style. The system learns from all such interactions to achieve the best medical outcomes.

Amazon, the company that brought us Alexa, has also entered the fray. Amazon Transcribe Medical is an automatic speech recognition (ASR) service that makes it easy for doctors to add medical speech-to-text capabilities to voice-enabled applications. 

Conversations between health care providers and patients provide the foundation of a patient’s diagnosis and treatment plan and clinical documentation workflow. It’s critically important that this information is accurate. 

Driven by state-of-the-art machine learning, Amazon Transcribe Medical accurately transcribes medical terminologies such as medicine names, procedures, and even conditions or diseases. Amazon Transcribe Medical can serve a diverse range of use cases such as transcribing physician-patient conversations for clinical documentation, capturing phone calls in pharmacovigilance, or subtitling telehealth consultations.

Amazon Transcribe Medical is available as a set of public APIs that can address both batch workloads and real-time speech-to-text applications. The service prioritizes patient data privacy and security. 

Amazon Transcribe Medical provides transcription expertise for primary care and specialty care areas such as cardiology, neurology, obstetrics-gynecology, pediatrics, oncology, radiology and urology.


Finally Nvidia, which has done a lot of work with AI and imaging, has started offering medical transcription. In 2020, Nvidia launched a service called BioMegatron, which is built to recognize conversational speech. The data set is trained on over six billion medical terms and is 92% accurate.

Good though these systems are - sometimes it still needs an experienced Med-Sec to ensure that the final record is accurate - fortunately Medmin has it covered...

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THE RISE AND RISE OF AMBULATORY CARE

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THE RISE AND RISE OF AMBULATORY CARE

With Covid causing the abrupt cancellation of most elective surgery and the pressure on acute facilities in hospitals, there has been a new focus on ambulatory care across  the international healthcare industry.

Ambulatory surgical centres are often more conveniently located than hospitals and the costs to run them are considerably less than a hospital.

The Stourside hospital in Stourbridge, run by Ramsay Health is an adjunct facility to a larger hospital nearby and offers an operating theatre with two recovery bays, an ambulatory unit with six pods , 7 OPD consulting rooms, a treatment room and mobile MRI and CT scanner. The facility is typical of the shift towards ambulatory care that started long before Covid but is considered to be a rapidly growing trend in healthcare investment.

In the USA, interest in the sector has been driven by lower costs for the payers - whether insured or self-pay but also by healthcare providers who can often achieve margins that are equal to or greater than those achieved in a full-blown hospital facility.

Of more than 3.4m jobs likely to be created in the healthcare and social assistance sector over the next 7 years, half will be in ambulatory care. Market research has indicated that in the five years between 2018 and 2023, Ambulatory Surgical Centres are projected to grow at 6% a year reaching $36 billion by the end of 2023 - staggering numbers.

A similar (proportional) increase in ambulatory care facilities can be expected in the UK - driven in part by consumer demand for lower costs - the USA has shown us that typical savings on a knee or hip replacement can be 30-40% but also a growing unease about the safety of hospitals in light of the covid pandemic - with both the private sector and NHS playing their part.

Another trend that we believe we should expect to see here are shared ownership models for these facilities with Surgeons and Clinical groups becoming equity owners of outside facilities, along with potentially new investors in healthcare.

Medmin’s clinic management model, along with the patient acquisition strategy that we have developed, are particularly suited to this style of healthcare - we are therefore extremely  interested in seeing how this trend develops over the coming decade. It could be just the segmentation that the market desperately needs...

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THE CHANGING FACE OF PRIVATE HEALTHCARE

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THE CHANGING FACE OF PRIVATE HEALTHCARE

Being in Private practice in the UK has been something of a curate’s egg in recent years.

Falling insurance company reimbursements, coupled with increasing hospital and medical indemnity costs has meant reduced income for many clinicians, or increased activity to maintain the status quo .

Private Medical insurance (PMI) has been on the decline since the 2008 recession.

Largely a workplace benefit, companies started withdrawing from PMI schemes as a cost-cutting exercise. The increase in Insurance Premium Tax from 5% in 2011 to 12% in 2017, alongside rising premiums made it less cost effective for both company and private PMI customers.

There has also been a systemic shift in attitudes around insurance between Boomers, Gen X and now Millennials. With access to cheap credit, many consumers prefer to pay as they go using a credit card or bank loan rather than monthly premiums.

It is perhaps not surprising then that 89% of the UK currently do not have Private medical Insurance.

Self-pay has always been part of the mix driven by rising PMI rates, increased waiting times for NHS treatment, procedures not being covered at all by the NHS and an increasing market for aesthetic and cosmetic surgery. 

Prior to 2020, Self-pay was growing at about 6% a year and the total value of the self-pay market for private treatments was £1.8bn. We had been seeing a rising interest in those areas where waiting lists were long and procedures cost below £7000. 

Covid has been a game changer. 

What Covid has taught us is that health matters and people are prepared to pay for it. There has been a bump in PMI but by far the biggest jump has been in self-pay.

Self-pay is booming and the rate of demand is increasing month by month.

As a consequence of the COVID crisis NHS waiting times have dramatically increased and will continue to do so. The NHS is currently reviewing all patients on waiting lists to determine if they still wish to be treated and also restricting access to a growing list of specific procedures. 

Patients fear going to an NHS hospital where COVID patients will also be treated. 

Research in 2017 for BMI Healthcare found that over 53% of people had not heard of or did not understand the concept of self-pay. Keith Pollard Editor in Chief of The International Medical Travel Journal wrote in June 2019 “There’s a vast untapped market out there of middle-income consumers who can’t afford health insurance and don’t access private healthcare – they don’t understand it and they think they can’t afford it.” 

The reduction in NHS capacity combined with a permanent increase in people’s personal savings habits provides an exciting opportunity to stimulate patients’ interest in self-pay healthcare services. 

Medmin are taking on the challenge!

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DID COVID RESUSCITATE VIRTUAL HEALTH?

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DID COVID RESUSCITATE VIRTUAL HEALTH?

It was seen as the next big thing - but for 10 - 15 years, virtual health has not been the disruptor in healthcare that it was promised to be but, has Covid changed that?

We have already seen that Telehealth has been catapulted from zero to hero in a matter of weeks following the first lockdown in 2020, but virtual health is more than a video consultation with your GP.

We are defining virtual health across three categories—telehealth, digital therapeutics, and care navigation  - these are defined in the chart below (helpfully published by McKinsey).

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Care navigation is of particular interest (to us) as it may form the basis of how patients choose their treatment.

econsult was set up by a group of GPs in the UK and has been adopted by over 3000 NHS GP surgeries. eConsult is a form-based online consultation platform that collects your medical or administrative request and sends it through to your GP practice to triage and decide on the right care for you and everyone else.

ePAQ is an electronic questionnaire that patients can use to improve diagnosis and outcomes by aiding the communication process between patient and consultant. 

Developed by a consultant Gynaecologist and IT professionals ePAQ has combined the accuracy and reliability of validated self-completed patient friendly questionnaires with intelligent computer software analysis and reporting.

The conditions it deals with are particularly difficult for some patients to discuss and it has been shown to be more effective in allowing patients to describe the problems they are facing.

Apple has entered the Health space quite aggressively with the watch an integral part . Owners of the watch right back to series 1 can set it to alert if it detects atrial fibrillation with an alert to contact a physician should it detect irregularities. 

The later models can take heart readings and via an ECG app share those results with a doctor. Apple Health is also moving towards storing clinical data so all your procedures, vaccinations, lab results, medications and more will live in the app.

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Perhaps the best indication though that virtual health is really on the move is the fact that investment is pouring into the sector. K Health in the USA uses machine learning to lower the cost of care by providing the bulk of the company's health assessments. - it raised $222 million in 2020 from investors interested in its model of being a virtual primary care provider.

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TELEHEALTH – CHANGING HEALTHCARE FOREVER.

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TELEHEALTH - WHY COVID HAS CHANGED HEALTHCARE FOREVER.

Telemedicine is a part of the healthcare sector that has some pretty staggering numbers attached to it - $ 250 billion is one estimate. But Telehealth didn’t arrive out of the blue, telephone consultations have been in use for over a century and video calls were first trialled by doctors in Nebraska in 1964 (using television signals instead of the internet).

The internet made video calling a relatively straightforward proposition but the take-up had been slow - until Covid. The reluctance of GPs to have patients at their surgeries, along with a similar reluctance on the part of patients visiting those surgeries made Telehealth an obvious answer.

Ten years of change happened in one week of lockdown Covid provided a tipping point. Across the US alone, nearly half of healthcare consumers are now using telehealth, according to consultancy firm McKinsey—up from one in 10 last year. In Europe, virtual medicine has been held back by strict privacy regulations and patients reluctant to give up in-person doctor’s visits. British primary care doctors, too, have been barraged by growing workloads of late, with patients living longer and more problems being rerouted from hospitals, leaving them little time to train on virtual tools.

Technology companies are racing to capitalise on a regulatory pullback by governments as they battle the virus. Local GPs, many of them once skeptics, are rushing into the new age, too, singing the praises of virtual visits that they say save them time and offer a useful complement to physical exams. Before the virus, video appointments made up only 1 percent of the 340 million or so annual visits to primary care doctors and nurses in Britain’s National Health Service.

The NHS told thousands of clinics across the country to start switching to remote consultations lin April and said it had fast-tracked approval of digital providers to ramp up their offerings. Push Doctor, a telemedicine company, said its weekly orders had grown 70 percent since the outbreak. Docly, another company, said demand had increased by 100 percent from one week to the next as the virus spread. The shift is striking in Britain, where regulatory hurdles and a cluttered bureaucracy have left telemedicine companies complaining for years about access.

Many doctors attributed the mass adoption of remote appointments to a company called accuRx. Already a trusted tool for doctors who wanted to send text messages to patients, accuRx built a video-calling system over a weekend after the virus hit Britain. It quickly became the go-to provider for online appointments, offering a stripped-down interface and the comfort of having long been in primary care clinics. More than 90 percent of primary care clinics in England are now using it. Doctors said patients had seemed to adapt quickly, with the help of occasional coaching in how to open text messages and video links. What is clear however is that there is no going back - telehealth is here to stay and not just in primary care.

Here at Medmin - many of our surgeons have been undertaking initial consultations with patients over telephone or video call while covid has been rife. For some patients, particularly with conditions that they find embarrassing or difficult to discuss, there have been clear benefits, for others there has been a lessening in anxiety about visiting a consulting room in a hospital. For doctors who have been asymptomatic but tested positive for Covid, they have been able to continue making a contribution by seeing patients while sequestered at home

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