It’s October 2029 and time for Alice’s quarterly check-up with her general practice. Often these appointments are online, using a video app, but recently she has been experiencing some abdominal discomfort and the nurse practitioner suggested that she come to the clinic. Already, Alice has attended her local pathology provider for blood tests ordered electronically by her practice, and has completed online an interactive health screening questionnaire. In addition, she has worn a blood glucose monitoring skin patch and blood pressure wristband for five days, with data uploaded to her MyHealthRecord version 8.
Alice is a 68-year-old retired school teacher, widowed three years ago and living independently. Her son and daughter live nearby. Alice has a history of high blood pressure and type 2 diabetes. On the morning of her appointment, Alice’s core primary care team of general practitioner, nurse practitioner and care coordinator meet to discuss their booked patients for the day. They review Alice’s health record, medications prescribed and dispensed, recent pathology reports, questionnaire responses, and blood pressure and glucose profiles. The practice software prompts that Alice is due her annual influenza vaccination. In addition, Alice had her genome sequenced last year and was found to be at high risk of developing an abdominal aortic aneurism, and should be offered an ultrasound scan to screen for this.
The core team agrees that Alice will be offered a joint appointment that day with her general practitioner and nurse practitioner for more thorough assessment of her abdominal discomfort. Details of her symptoms, along with findings from physical examination, are recorded in her health record and analysed in real time by artificial intelligence software to generate a list of likely and potentially serious causes. If the doctor and nurse practitioner agree with this list, then it will guide their advice on further investigation and management. After this diagnostic consultation, Alice spends time with the nurse practitioner to organise her vaccination and abdominal ultrasound, and to discuss management of her diabetes and high blood pressure. She has been gaining weight recently, so lifestyle including diet and exercise are a focus. Alice then meets with the care coordinator to enrol in a healthy living group.
Many consultations in general practice could be undertaken using video technology, but would not be rebatable under the current Medicare…
Although set 10 years into the future, most of Alice’s health care could be delivered now. Many consultations in general practice could be undertaken using video technology, but would not be rebatable under the current Medicare Benefit Schedule. Much of the work of general practitioners could be undertaken by nurse practitioners, freeing medical time to focus on more complex diagnostic and management issues, but the consultation items of the MBS require face-to-face interaction with the doctor. A growing number of general practices are structuring their care delivery using a core team of doctor, nurse and coordinator, who ‘huddle’ at the start of each clinical session for care planning, although such huddle time is not rebatable.
MyHealthRecord is not currently able to record blood pressure, glucose or other physiological data from consumers. Organisation of blood tests and use of a health screening questionnaire prior to a consultation require an ongoing relationship between patient and practice. Although many consumers would confirm that they have a regular general practice, this is not formalized in any way in the Australian context, or enabled financially. (This may change with the planned voluntary enrolment scheme for people aged over 70 years).
Increasingly, computers will support and enhance this process.
Currently, health professionals work with the patient to consider and assimilate multiple kinds of data – personal history, examination findings, investigation results, disease prevalence, etc – to identify diagnostic probabilities and to make preventative recommendations. Increasingly, computers will support and enhance this process. Recently, Stanford University announced machine analysis of data from whole-genome sequencing alongside information from patients’ electronic health records to develop a predictive algorithm for aortic aneurysm. Research into artificial intelligence as an aid to interpretation of x-rays and other images is starting to have clinical application. Already, rule-based software is available to assist consumers and their health professionals make decisions about disease prevention.
As we come to understand the genetic basis and causal mechanisms of diseases better, our diagnostic categories are changing and becoming more precise. Asthma, for example, is not a single disease but a condition with several different causes. Understanding the causal pathways has allowed development of precision treatments – monoclonal antibodies – specific to particular kinds of severe asthma. Several of these are already available on the Pharmaceutical Benefits Scheme. In future, we can expect more specific diagnosis and treatments for a wide range of common diseases.
The brave new world of Alice’s health care is not without its risks.
Precision therapeutics is not the only emerging aspect of personalised healthcare. Alice has enrolled in a healthy living group. This is virtual, using social media to connect her with real humans and with an avatar coach that uses artificial intelligence to personalise its messages to Alice’s needs. Such technology exists with a growing evidence base for its effective use in promoting lifestyle change.
The brave new world of Alice’s health care is not without its risks. All new technologies, not just medicines, need careful evaluation of their safety and effectiveness. Communications technologies including social media can promote connectedness, but may also remove the human engagement that many consider an essential aspect of health care. Some precision diagnostics and therapeutics carry a hefty price tag, but cost should not be a barrier to equitable access. Nevertheless, if these issues can be addressed then personalised primary care offers great potential for improving the health and wellbeing of our community.
