Caring in the Digital Age: Compassion for Patients, Systems, and the Planet

Morning, good afternoon or good evening to all of you depending on the uh region you are. Um welcome to the world family doctor day webinar hosted by Wonka working party on planetary health and first of all happy world family doctor day to you all. So as you know 19th of May is celebrated every year as Wanka's world family doctor day and this year uh dear colleagues the theme of the world family doctor day is compassionate care in a digital world. So celebrating the world family doctor day while celebrating our patients and also understanding the importance of digital health to our day-to-day activities day-to-day patient care while keeping the compassionate care we provide as family doctors is very important and that's why we are here today and in addition to that the care we provide to our patients, their families, the communities and also the planet. So how the digital uh health has the has the its impact to planet and also how we are going to maximize our digital uh our care in this digitalized world while we are caring for plant as well. This is our theme today. So, uh, Wonka working party on planetary health hosting its webinar under the theme of caring in the digital age, compassion for patients, systems and the planet. So, I welcome you all uh, dear colleagues and also I especially I welcome warmly our speakers. We have Gabriel Samuel and also Cla Brockbank. Gabriel is our guest today. Uh she's from the UK and uh she's a lecturer um in the uh King's College London and Cla is of one of us. She's the Africa lead of Wonga working party on planetary health. So um the first talk is from Gabby. Uh the the the topic the title of the topic is the hidden environmental impact of digital health. Gabby will introduce herself. So I'm not going to tell anything else. Over to you Gabby to go ahead and tell us about the impact of digital health to our planet. Thanks so much and I'm delighted to be here. I take it you can hear me okay but if I can't if you can't I'm sure you'll scream out. Um so I was invited uh to give a talk on the hidden environmental impacts of digital health. So if there's aspects that don't necessarily relate with to care and compassion then um I feel that we have a lot of time at the end where we can actually open up and see how we can think about these types of issues in relation to care uh care um and in particular compassionate care and I've done some work around this outside of digital health that might be able to feed into those discussions. Um, but before I do, um, I wanted to tell you who I am, who is speaking to you, um, because I think that's really important in you can kind of understanding where I'm coming from. So, my background is in the life sciences. Um, I have a PhD in genetics, not human genetics, but genetics nonetheless. Um, worked in labbased genetics for a while before I switched over and did a masters in bioeththics and biomedical ethics, medical sociology. and and ever since I completed my PhD um in that over a decade ago, I've been interested surprisingly enough in the social and ethical issues associated with genomics, genetics and genomics. Um that expanded as genomics became big data into bio banks which expanded into digital health which expanded into AI. Um, and about six or seven years ago, before anybody was talking about the environmental impacts of digital health, digital infrastructures in general, um, I noticed that they weren't being discussed in the ethical literature around digital health or in the healthcare settling at all. And so that's where I've been sitting for the last six, seven, eight years. Uh, the types of questions I ask. So I'm telling you this because you might want to come back to it in our question and answers. Our questions around dust justice, datification of data, ethics, responsibility, values, systems thinking and so forth. Okay. and I am we set up because there was so little work looking at the intersection of digital technologies in health and the environment we set up a shade research hub with my um colleague Federica Lucifer who's at the University of Oxford and here we use it to conduct research very interdisciplinary which is really important to us with clinicians and computer scientists and social scientists and so forth to really explore the dimensions where that intersection occurs. So what I wanted to talk to you today about was to argue that we have a moral obligation to consider the environmental harms of healthcare. Um when I say argue, I think that that is problematic in and of itself, but I'm going to take that as a consensus and then show you that digital health offers a useful way to do this to address this obligation, but that digital health has its own environmental harms. Um, right at the very end, I'll talk about uh some open questions about what that means for us and who the US is and how we should think about these questions. Um, but then what I'm hoping to do is that that will raise many questions that we could get into a discussion about afterwards. So um the moral obligation to consider the environmental harms associated with health care um more generally have kind of exploded in the literature in the ethics literature over the last uh maybe 5 years um and they're based if we want to go back to basics the first question we need to ask is why do we have a moral obligation to consider environmental harms and that might depend uh from person to person but we can split it into two different categories. So you might think that it's important because you are an ecoentric person or the fact that you believe in ecoentricism which means you believe that the environment has moral worth and that that moral worth is distinct from any form of human worth. So if all humans on the planet didn't exist, there was still an environmental worth that was associated with the earth. And sometimes if you haven't thought about this before, you may um you might not be sure. You may think you're egocentric and then try out some thought experiments and realize maybe not, maybe I don't think the environmental the environment has worth in and of itself. Um, what you might feel that you sit more comfortably with is an anthropocentric approach which views the environment as not having any moral worth but only humans have immoral worth. But then what you believe is that because the environment and the humans are connected or interconnected that we need to protect the environment because it affects humans. Um you may but probably not if you're on this call believe that um environment doesn't have moral worth and that human health and environmental health are not connected such as some people like ecomodernists um might have you believe. um in which case you would probably not think we have a moral obligation to consider the environmental harms of healthcare. But I'm assuming that nobody on this call is that. So you are either an ecoentric or an anthropocentric that recognizes the link between human well-being and the environment. So that basically means we need to think about humans or um the environment in our decision-m because it has moral worth. So then the question is how how do how ought we do that? And this is where if you go into the literature, you'll see just a huge plethora of literature. So some may argue that we need to consider it because of environmental justice issues. So these will be anthropocentric people because environmental justice is based on social justice and about the um inequalities between the benefits and harms of um environmental products of technological society. And you'll see this in sociological and advocacy literature and political philosophy. Um you may see other notions of justice. So intergenerational justice or ecological justice. Um if you're an ecoentric maybe e ecoentric justice so that therefore or ecological justice so that we need to consider the harms to the environment over human um benefits. Um, you may be religious and so you may believe that we need to protect the environment based on stewardship or you may be a public health um advocate. So you may align with maybe planetary or one health um or ecoity. Uh you may be working in global health in which case environmental determinance may be where you sit. Um or you may form come from indigenous perspectives um in which case traditional ecological knowledge or various indigenous perspectives. Um or you may be a feminist or um an ethicist or maybe potentially for you if you're primary care then the do no harm in medicine may stand out the most to you and where that harm is considered much more broadly. And so in these kind of perspectives that they will kind of lead you to different conclusions about how we should deal with the environmental harms. Um and on top of that there are these other factors that we need to consider. So, how do we consider these environmental harms of, for example, distant humans versus present- day humans versus the patient in front of you? How do we consider um these harms against social justice issues that may be relevant in your practices? Um or against the social value that's associated with the um health work that you do. So, these this is kind of the literature that thinks about the moral obligation to consider environmental harms. And then in the digital space um the argu there's been this increasing argument in the policy area that digital transformation is a really great way to address these environmental harms. Um three main rationes uh can be pulled out. So one is improving the operational efficiency of existing healthcare infrastructure. So um sensors for lights, controlling room temperature, forecasting resource use, so only necessary supplies are purchased and so forth. Um the second is applications and or services with lower environmental impacts. So that's for example virtual visits um versus inerson visits or replacing paper records with digital electronic health records or um finally keeping the population healthy to reduce the demand for healthcare and this is for example using large databases and um AI algorithms to support improved clinical decision-m and patient interaction. So here is a diagram which basically shows what I said which is where digital technologies can be incredibly useful increasing the efficiencies of healthare systems um which leads to less demand on the health system uh therefore less environmental impacts and also less environmental impacts might lead to improved health outcomes because of the relationship between human and environmental health which then leads to less demand on the health system and then at the top right you have prevention as well so using data NN and and AI uh to uh like drive prevention which also leads to improved health health outcomes and less demand on the health system and there's preliminary evidence to suggest that this is actually happening. So there is for example effective um remote realtime monitoring of patients which means that patients don't have to come into the clinic as much which reduces for example transport related emissions. So these are just some examples of where it has been affected. Um a lot of it is promisory but that there is this evidence that this effectiveness is being shown at least in in small scale and so it suggests that digital health is this useful tool for prevention um and decreasing the environmental impacts of healthcare. So we have this win-win situation that's going on. At the same time, it's important to remember that digitalization could um reduce environmental impact, but it's possible that these technologies may be implemented in ways that don't lead to reductions or may lead to increasing resource use um and other injustices with little change to health outcomes. And that's what I want to move on to talk about now. So, we know that there's been this huge growth um in digital infrastructure. This is an example. I just pulled this off. um the internet today to show you the increase in the amount of data that we have in the data sphere of the world. So we're up to I think last year 175 zetabytes with one zetabyte being equal to a trillion gigabytes. So we have masses and masses amounts of data that we are collecting and are continually collecting. Um digital health is no exception. is actually the fastest growing um industry in the data sphere in terms of the amount of data that's being collected. So we don't need to look far to look at technologies such as for example top left digital twins uh where we're collecting huge amounts of data to develop these digital twins that we can helpfully hopefully help against more invasive uh surgery or other kind of technologies that we might need to use. Um digital devices and sensors. So we're sensing our bodies a lot more. This is particularly in high inome countries but is increasing in low and middle inome countries. So we're seeing this move to personalized medicine. Um we are collecting huge amounts of datas through bio banks. So UK bio bank is the probably one of the biggest bio banks in in the world. So it collects data on half a million uh well it has collected data on half a million um uh UK citizens and it's actually still increasing data and collecting more and more data and even they're moving now to this real-time data but bio banks are opening up and databases are opening up all over the world in many many nations and then we're increasingly using um AI and machine learning and computer vision and deep learning to help us with um analyzing all of this data that we are collecting. This is an example from the UK um national health service which is um on well as it stands our national health service uh we are collecting huge amounts of data from there. So, Spine, which is the um kind of software that it's moving to, which supports the IT infrastructure for health and social care, and this is just in England, is joining over 44,000 healthcare IT systems. Um, and it handles over 1.3 billion messages a month and at peak times is processing more than 3,200 messages a second, not including all the data that we're collecting from patients that come to healthcare all the time. At the same time, we know that all of this digital infrastructure, all this data doesn't exist out there in a cloud. Um, but it's material. It has a digital infrastructure that is physical and material. Um, you can see on the left hand side at the top, um, the inside of a data server, the data centers where all of this data is collected, which is just rows and rows of computers. Um the bottom left is a hypers scale data center, one of the really really massive ones that are like kilometer long cuz they're so long. Um that just has rows and rows of computers. Um top right is the underwater cables that are connecting us which without we cannot speak to each other or be having this meeting. Um so you get the idea of the physicality the environmental harms that are associated with this digital infrastructure um are throughout the life cycle. So um from mining rare minerals uh which ethically in and of itself is not morally problematic but the way in which we mine um exploitative extractionist practices is um through to manufacturing and there's huge numbers of environmental justices that come from the hazardous waste produced by manufacturing digital technologies um across the world and right through to the energy and water use from data centers um and then the electronic waste that is left right at the end when we finished with the computers which we often recycle very very often within the space of 2 or 3 years and that um electronic waste often ends up in low middle- inome countries for a whole range of very complicated political reasons um and it's not always recycled in appropriate ways but at the same time what it means to recycle appropriately is problematic in and of itself because of various regulations and inequities that may emerge from there. So that's kind of what we have to think about when we're thinking about you know our digital health and the background behind it. This is just a really nice cgraphy of um Gen AI but um it I mean it stands for any digital health. The key takeaway is look how complicated the life cycle is and how much physicality is taken in from the life cycle of developing the digital hardware so that we can collect that data. So um there have been many frameworks um and guidelines and carbon calculators that have been developed to help us think through the environmental impacts of um the digital technologies we use. Um these are very often just based on the use of the digital technologies. So not the downstream and upstream issues. Um so for example developing calculators that show you that if you have a virtual care visit that that reduces admissions because somebody doesn't have to drive to hospitals um for that appointment. And then there's a lot of work around how you balance that against um fairness and equity in terms of the patients preferences and expectations and interests in terms of whether they want a virtual care appointment or an in-person appointment and how you keep the patient at the center of these these shifts to the environment and how like kind of balance patient care and equity and so forth. So there's a lot of work that's going on around that. Um and these types of tools at the same time these tools are very reductionist. Um and we need to be aware of of these reductionists. So the picture here which is the blue squiggly line is if you're trying to sort out what to do about the environmental harms of digital infrastructure um beyond just measuring one specific instance such as I didn't drive to the hospital on that day. Um so I can calculate my emissions saved. Um and this is because of the rebound and revenge effects. So um as the data sphere grows, what happens is we're collecting more and more and more data. Um and the reason we often do this is because um digital infrastructure becomes more efficient as does the software that's used. And the problem is is that because we're not constraining our behavior as things become more efficient, we change our behavior um in response to that efficiency which leads to less energy savings than we expected and in worst cases it backfires leading to rebound effects. So this would be the example of me um interview which actually happened. I interviewed a population health AI researcher and I said, "What would you do if um you know AI models became more efficient?" And he said, "I would run bigger models." Um for you, you might want to compare it to, for example, buying a more energyefficient fridge and then feeling that that's okay because we can open our fridge more often because it's energy efficient or you can use the savings to fly somewhere. So these are the types of effects that we are much more messy. They're not as easy to measure. Um, I put cleaning park benches there because an Marie Maul gave this great example of an example in the Netherlands where they tried to um reduce environmental impacts by shifting from cleaning park benches with chemicals to cleaning them with a really like a jet spray, a hot water jet spray. But the problem is is when they did this, all this all the paint of the benches came off and flew out into the greenery around uh raising an unintended consequence of that move to trying to be more environmentally sustainable. And so these types of revenge effects and rebound effects become really complicate what we how we think about our responsibilities and obligations when we're thinking about addressing environmental harms because they go way beyond our clinic. and to try so to try and address these issues um some people have some scholars talk about efficiency not being enough. So it's not just that we have to think about how to make our resources more efficient but the sustainability aspects require two more things and this is in the broader sustainability literature. So one is consistency. So this is just changing something. If you have a goal to get somewhere, you can make a change in terms of how you get there by choosing something that's less environmentally harmful. So, for example, using renewables instead of fossil fuels. So, putting all your data in a data center that is um powered by renewables versus fossil fuels would be an example of a consistent practice. Um and then the other one is sufficiency, which is very interesting. We can divide this into digital and data sufficiency. So I'd say digital sufficiency is like hardware. So reusing hardware, sharing hardware, reducing e-waste, all of these types of things which seem a bit more easy. Where it gets more complicated is when we think about data. Um because then it's asking us that we should only collect enough data for what we need because therefore if we have made something more efficient, we don't then go and collect way more data because it is efficient. We only collect what data is sufficient. But only using enough data that is sufficient is really complicated because um it we often live in a world where the accumulation of more and more and more data is seen as something that is going to improve health. So we see health as health outcomes is improved if we can collect more data. But what I would like to argue is that this often narrows what being healthy means. Um so it basically promotes the idea that better outcomes can be equated with better monitoring, analyzing, assessing um as much of our lives as possible. And and with such an affixation on the need for data to improve health, it's sometimes really easy to forget that the very act of data accumulation and analytics cannot and will not produce health benefits on its own. And this is really important because often and I don't know if any of you have experienced this at all. Um if we move towards more data, it can also detract from experiential knowledge. So for example, if you're sitting in your practice and you're you've had to look at data more than you looked at your per like the patient in front of you and what that means in terms of balancing the data which might be useful versus the person that's in front of you. um and where the amount of data is enough for you to be able to make a judgment call so that we don't become almost deskkilled because we're only relying on the data. Um and it's also really important because if when we focus on data too much and the digital health too much, it detracts attention from the need for other measures. So promising that data is going to improve health outcomes ignores the fact that we already know how to improve health outcomes, but we have social and political uh social and political contexts that don't allow us to do so. And that's what caused the inequities. So for example, we know that investing in um education and welfare will improve health outcomes, but in certain nations, we don't necessarily do that. But what we're doing is promising that we'll collect more data and that will solve our issues. And so that becomes quite complicated when we start to think about data. Um, and the argument here is that if we're just collecting data and it's not going to improve health outcomes anymore than if we didn't have that data, then you have that idea of wasted resources. And so just finishing up, this leads to a whole bunch of um questions around responsibilities. So we might have a moral obligation to address the environmental harms that are associated with health care um including digital health. But what does it mean? Especially for the really hard questions like efficiency is a little bit easier. So the question is do we have a responsibility? Like who is the Wii in this? So is it the same we if I'm in the UK as is in I'm in Botswana or if I'm in Mexico or any other country. Um how is the meaning of environment affected when I move between those countries? And is the environment as much a priority as direct health in each of those countries as we move through? And we've done a bunch of empirical research which suggests very much that's not the case. And so that we who is the Wii is really important. And it also relates to who is the Wii if I'm a primary care practitioner versus if I'm a wei an institutional manager versus the Wii as in am I a technology you know data center manager. Um it also relates to the question of responsibility. So Donna Harowway argues that we need to think about responsibility as a hyphen. So responsable. I need to have the ability to respond. So if there's not much I can do um in my practice then I'm not able to respond and so the question is is what am I able to do what am I not able to do and and consider agency in that respect um other questions relate to whether whether healthcare should receive a free pass and I would argue against that um please ask me more if you want and also the idea that if we put too much responsibility on primary health care um or individuals or doctors more generally then this sits within neoliberal notions of governance that distracts from social political issues more broadly. And then finally, like what should we do around questions around rebands? Are these small changes futile? And how can we consider questions of data sufficiency? And what does that mean in practice when we're thinking about our own patients? Um, and so I would argue that um we need to conceptualize our responsibilities in terms of collectives, in terms of citizens. And I'm happy to talk more about this. Um, but collectives need to be seen as more than the sum of individuals. So it's not necessarily about reducing our environmental impact, but it's more about advocacy um and developing collectives around the topic. So for example, coming to the seminar today or listening to it online um being part of something and also asking questions. So we developed this green digital health tool um which helps digital pract health health practitioners think about um the types of questions they would need to ask if they wanted to think about environmental harms. A lot of it is around just ask the question because by asking questions it drives people to build awareness around the issue and that might be as much as responseable as you're able to do. Um I think there's some interesting questions around citizenship but I will stop there. I'm pretty sure I'm out of time. Here are some references. Um, thank you so much. >> Thank you. Thank you very much, Gabby. I think uh that's very interesting uh talk and uh when we are talking about we we also think about our patients uh not only the doctors or the practice managers and so on. Thank you for that interesting talk and lot of uh things to uh think about but we'll uh elaborate on certain things after the next talk. Uh if you have questions uh colleagues we'll we can put it put them on the chat but let's go to the next talk for the moment. Um uh the next talk is compassion beyond the screen caring for patients and the planet. So we have uh we have our colleague Cla Brockbank who is also walking party on planetary health Africa lead. Um Cla who worked as a general practitioner in the UK before moving to Gabberon Botswana in 2012 where she now lives and practices. She's the chairperson of Botswana Association of Family Physicians and also as I told uh is very active in our working party. Dr. Dr. Brookbang also serves as a co-chair of the 9th Wanka Africa regional conference 2026 which will be held soon in September. Uh CLA is a passionate advocate for strengthening primary health care preventive lifestyle medicine and effective multidisiplinary healthcare teams. Over to you Cla to go ahead to talk about the compassion behind the screen. >> Uh thank you Sanka. Can you see my screen? Okay. >> Yes, it's visible. >> Okay, great. And thank you for the introduction. So um today when we're celebrating World Family Doctor Day and compassion uh in a digital world um I really thought we should think about our role as family physicians and that we are quite pivotal in helping our patients navigate their health journeys in an increasingly complex world with the advent of AI, new technologies, information overload amongst other things and um rising problems that we have with climate challenges. So I thought I would really share my lived experience of digital health. I am no means an expert in digital health and I really appreciate the talk we have just had but I have um more than two decades. It's touching nearly more than that now um across two countries, two continents in both of the global hemispheres. So I thought that might give us a a good perspective on um the digitization of health that's happening um and that um where perhaps Botswana and other lower and middle inome countries sit um in that journey. So for those of you who don't know where Botswana is uh Botswana is in southern Africa. It's a landlock country surrounded by South Africa, Namibia, uh Zimbabwe um and just touches onto Zambia as well. It's the size of France or the state of Texas and has a population around 2.6 million. So a very low densely populated country with a population density of about five per square kilometer. In recent years there's been much more urbanization um as with many lower middle- inome countries and now 70 76% of the population is urban. We're a very young country with a median age of under 24 and and in improving life expectancy now up to 70 years. Um this took quite a toll during the um HIV pandemic. Um but now the life expectancy is starting to rise again. Another interesting note when we're thinking about planet and our environment, Botswana is the host of more than half the region's elephants with more than 130,000 elephants sharing uh the land with us and more than a million cattle. So um I just wanted to talk a bit about the evolution of medical records and um I started my medical career with the Lloyd George records which are the file on the left. Those fat paper folders wedged full of all the notes, hospital records and um notes that we as doctors made. These started in 1911 and only were finally phased out in the um early 2000s. I think around 2020. I was also part of the cohort of GPS responsible for summarizing these notes and enabling the NHS to now have a digitized health record. This was a very painstaking process where you had to read if possible um doctor's handwriting to see what had happened at that person throughout their life, make a summary of it, try and identify what were the key points that these could then be added into very neat, tidy um computer-based summaries. We did also have um the I don't know what to call it but not the beautiful Windowsbased systems that we use now but the very green text uh screens from the old versions of EIS. So there was computerized records that we used to run alongside the paper record. But this box here would arrive on your desk when you started your day in the morning and it was neatly ordered in the um uh where you were going to see your patients. And as you can see, it was quite challenging sometimes to find what was relevant in that patient's story. Within Botswana, um patients again have handheld paper records. Some of these are beautifully kept in hardback books, laminated with a very chronological order. Others arrive in lots of little pieces of paper carried around in a plastic bag. But the um difference in Botswana to the UK is that the patients have always had handheld records. they've always owned their own medical record. Whereas in the UK, that's only now starting to happen with the NHS app and handheld records that we have digitally in the UK. Um on the right, this is what my desk looks like when I go back and do local work in the UK, which I do to maintain my license to practice. You're sitting with two, sometimes three computer screens which fill your desk. One of my most challenging uh aspects of going backwards and forwards to the UK is working out what is a new system in place. At the minute, I think we're running about five or six different programs looking at the e- health record, um an online consultation platform, a text messaging and emailing system, uh integrated document, um records that are scanned in. um these all connect to the lab results that come from the hospitals, the um imaging that we do. Then we can link to the differentarmacies around the country. So, it's a really fabulous system, but it's it's all driven by the um our screens. So, we're very dependent on our screens. The other thing that happens is one thing does not work, you very quickly can't access anything else. And that's my biggest challenge when I go back. I take about half a day to make sure everything is still talking to each other and belongs to my um identity card. One of the biggest challenges I had recently is that the uh desktop phone had got swallowed up by the computer and no longer existed. It had become an electronic phone system, but I wasn't able to log in. So, I couldn't call anyone for help. I had to physically go and find a person to help. So I think some of those challenges that happen with it um we as healthcare workers need to be well trained on that and as do our patients if they're going to use the systems. So how ready is Botswana and maybe other um southern African or lower middle inome countries ready for digital health? Um most of this data is taken from statistics Botswana and we have very high mobile phone ownership over over uh 84%. Um but most of the smartphones are owned by people younger than 45. So again we can see there are discrepancies as to who has what type of um phones. And I think across Africa and around the rest of the world mobile phone ownership has really exploded. And people didn't really go through that process of insisting on a landline to their house. they just went straight to to mobile phones. So, I'm hoping that some of that um rapid step where we're willing to embrace technology could also help with some of the other digital health things we're trying to to use. Internet access is not as good as the mobile network coverage. And despite the very large areas of um nature reserves we have in Botswana, there is more than a 90% country coverage with cell phone signal, which is actually much better on those very old Nokia phones than your smartphone. However, internet access is much uh more limited in rural areas down at 23% whereas the urban population has about a 79% uh use of internet. Most of that is used through phones. So mobile broadband accounts for 86%. Um homebased internet is actually relatively expensive in Botswana compared to the UK and Europe. On this map although it's looking more at the um type of land area, the green areas um situated in Haboni which is the capital and Moly Paloli. This is the southeastern district which um accounts for 47% of the population of Botswana giving us a population density of 14 per kilome squared. Again still quite low compared to many other countries and 39% of the rest of the country sit up in this um Haboni Mahalape up to Francis town the second city. So you can see most of the population sit in the eastern side of the country. Um the rest of the country is is much more sparsely populated. Although Botswana is now a middle lower middle- inome country, um we have unfortunately a very high um uh health and uh wealth inequality index and that will of course affect some people's access to technology. I think some of the benefits of digital health and digitizing records are well um documented, but I'll just um reflect on my thoughts on that. I think the legible writing very clear patient summaries so it's very clear when you open your screen to see what is uh what are the known medical conditions with this patient what is the prescribing history of drugs and when did they have certain prescriptions what are the drug interactions the computers are brilliant at doing this looking at lab and imaging results and also graphic uh trends um monitoring blood pressure looking at CD4 and viral load in HIV management monitoring uh chronic kidney diseases, those are really well placed in um computerized uh digital computer records. Um ongoing integration with social care records and hospital records again gives us a broader um sense of a one uh one record that belongs to that uh patient. Computers are excellent at data analysis, much better than we or most of us as humans are. They're brilliant at setting patient reminders for when your medication review is due. Um are you due a blood test? Um during uh the COVID pandemic, they also helped with the immunization campaign for um the different age groups and and recall for um cervical cancer screening, bowel cancer screening reminders. So the computer does a really excellent job at that. It's also very good at looking at um if you're ordering your medication appropriately. um is there compliance with medications? So I think the computer um has has a lot of use um without detracting from um how it benefits the patients. What are some of the challenges with digital records? Now some of these are more likely to be challenges in lower u resource settings but they can be challenges within um higher income higher income countries too. So I think for us the most obvious is whether we have reliable access to power and internet. Power outages are not uncommon across southern Africa and are likely to get worse unless we upgrade our um power structure and have different access to renewable resources. We have intermittent internet and sometimes the bandwidth is not great. So even though we um have meetings um around you know for doctors around the country we often don't have videos on we find it harder to connect with each other and that would be challenging with uh video consultations for patients. The other problem is access to affordable systems. The fabulous systems that we are able to use in the UK are just not affordable in a lower resource setting. Um and and I know because I've I've looked at trying to get them brought here, but the the cost is just not um at all manageable. And I think moving forward, if you want equitable digital health, that is something that should be addressed at a global level and not just at the incountry level. You also need modern IT equipment to run these powerful systems. So, the older computers, slower processing chips, um cloud-based access to your health records really don't work unless you've got a good internet um and a good processing speed. The other thing that happens is many uh individual practitioners in private care and in government have multiple different systems becomes very fragmented. They don't talk very well to each other. Those are again less useful for the patient and for us as healthcare providers. I've touched a little bit about equitable access particularly in the global south where we are um far behind um access to some of these digital records and digital um technologies that we um hear about the sort of continuous glucose monitoring um smartwatches um people accessing their records to update with um technology that could help us as clinicians to manage them. the reminders for health checks. Again, whilst very important, they can detract from the consultation with our patients. So, often they sit up in a pop-up screen down to the lower end of the um uh healthcare record. Um sit as reminders, have you asked for smoking? When did you last do a blood pressure? BP is out of range, do a diabetic foot check, um have you done a mental health review? So, these sort of constant reminders sit there in the background of our very short 10-minute consultation with our patients. So, are they really useful or they do they actually detract from the consultation that we have? And how do we fit them in? Again, in the UK, some of those uh quality and outcome frameworks affect your uh payment as a as a primary care provider. So, if you don't do them, uh are you uh affecting your budget that you have then to care for your patients? Some of those of course are very relevant. It is important that we ask our patients, do they smoke? Have they tried to give up? It's just how do we fit them in and how do we make sure that our consultation doesn't become doctor-driven and remains um patient driven. Some of the templates that are set up within these do uh digital systems. For example, if you um type in somebody's temperature or blood pressure that is out of range, it will set an alert up saying sepsis template. Do you want to run this template? And it will prompt us to remember to look for other um uh markers or identifying factors that would help us to decide is the patient sitting in front of us septic? Do we need to take further action? And whilst these are are good, they sometimes override clinician experience or really what the patient has come in for. So again looking at do those templates really help us and where did the data come from in um helping us devise these templates? Much of this data does not reflect the patients that we see um within our African population. They're very much based on um European and North American uh data. And some of this is very well known. For example, that Framingham cardiovascular risk score. It's not particularly accurate in certain populations. So moving forward, how do we make sure that um everybody is represented in these uh template driven uh health modelings? And the same is true of the uh increased use of AI. How is AI collecting its data and from whom will it do the same thing? Will it leave out um certain groups of the population or will the data not be um reflective of that group of people? When you have reports um flashing up frequently um one of the key ones I think in the UK at the minute is the statin use. Um do we overmedicalize patients? you know, if your cholesterol is high, but you are a 96 year old who walks into the clinic unaded, on no medication, do you really need to be on a statin or is that just a data entry point to um keep our records happy? So, I think sometimes they tend to push us towards overmedicalization and are they really patient centered and that's where we as family physicians come in try to match what the um records are telling us to do to what our patients are needing. a little bit about remote consultations. So, we touched a bit about um saving travel time and reducing the carbon impact of that. Um, interestingly, remote consultations have been talked about for many many years um in the UK, but there were lots of reasons why they were thought not to be um helpful or there are lots of risks attached with them. But of course during the COVID pandemic we very quickly switched to almost 100% um remote consultations particularly in primary care and despite um being many years past COVID now still about 33 to 35% of consultations with your GP are done remotely 25% of those are done on the telephone and about 8 or 9% done through uh text messaging and emails so that we haven't completely undone um or we haven't gone back to our pre-COVID uh era. Um we found a lot of use in some of those remote consultations. Lots of patients do still prefer face-to-face appointments uh if they could choose. Many patients prefer the reduced um travel time to the clinic, not needing to take a full day off work. Um particularly in Botswana where some of our population lives uh very far away um or might have to travel all the way to the capital city. um that obviously has significant uh cost implications for uh people needing to travel far and remote consultations may be a good use of our time. It may give you access to specialist opinions. Most of the um hospital-based specialists are based here in the capital city. A few up in the second city, Francestown, and an even fewer number up in Mo, the third city, but really the the hospital-based specialist care is very much capital city um based. So rather than somebody coming all the way to be told, oh you didn't need to come, having a remote consultation prior to that could be a useful tool. We've also used this for mentorship particularly for our young doctors who are often posted in rural areas without significant um colleague backup. So I think there are um important benefits with remote consultations. What about the challenges to that? And again, there are often ways around this, but one of the main challenges is um equitable access to technology. As we s saw in one of the earlier slides, um a large amount of the rural population do not have access to smartphones, do not have broadband internet, um so would lack the opportunity to choose to have remote consultations should they desire. Now there may be ways around that that um perhaps at their local health post there could be um an internet setup allowing them to communicate with doctors in a further town. So there are ways around it but it just requires a bit more thinking. Um one of the other important things is about confidentiality and who is in the room with that patient. When we see our patients physically in the clinic, we it's very clear who who is there and if there are other people coming in with that patient, we ask, you know, who are you and is the patient happy to have that person in the room. These have issues particularly with um gender-based violence. Is the patient safe at home to discuss the issues that they want um when other people may be in the house. Are you able to take yourself to a quiet space where you can have a confidential consultation with your health care provider? And for some people that may not be possible. When again a very long time ago when I did my obstetrics job um was still paperbased records. The women would come with their antiatal cards and in the bathroom where they had to go and provide a urine sample on the back of the door in a um paper folder was some stickers with a big notice saying if you are at risk of um domestic violence or you wish to speak to a healthcare worker alone, put a sticker on your notes. So that was very um uh clever and uh hidden message enabling women to um discreetly ask for help without um putting themselves at risk with their partner. We don't have any ways of doing that within the digital space that I'm aware of. Um women attending child immunization clinics again have access to healthare workers even though they've come with their child gives them an opportunity to ask about their own issues. Some young people may not have access to their own phone or may have to use their parents' phone. So, is that safe for them to receive text messages or help about um sexual health, drug or alcohol abuse, mental health issues um if they're now needing to use somebody else's um phone. There are some vulnerable groups who really do benefit from inerson care. Um mental health. Now, there's um either way with this. Some people do prefer having access to telephone consultations. um it saves them the anxiety of attending the clinic. Um um so many many patients I've dealt with have actually preferred a a telephone consultation rather than coming into the clinic. But it also means you don't have the opportunity to assess for other physical health options. Um patients with dementia um or other other cognitive impairment may struggle to use remote consultations um either with or without help. palative care. Some of that can be done remotely um particularly in adjusting medication and providing ongoing support for family members, but having somebody physically present is very important for that gender-based violence and adolescence we've already talked about. We also may miss relevant nonverbal cues that even on video consultation may not be so easy to pick up. We lose really the social context. Who else exists within this family? Um who brought the patient to the clinic? Did the person have any difficulty getting out of the chair? How long did it take them to get in and out of the room or on and off the couch? So, we miss some of those clues that we wouldn't um pick up if we just speak to people sitting um on their chair at home. What about beyond the screen? So, again, we are primarily a patient focused uh group of people. That's why we went into um family medicine. And although the screen now takes up a wide uh space on our desk, it does not need to dictate or dominate our consultations. We have to find ways around using it. We have to find ways of using the digital information for our benefit and our patients benefit, but still focusing on our face-to-face um contact. We have to make sure that as family physicians, we remain community-based. We are trusted health providers and people do come to us asking for opinions. We have valuable knowledge about our local communities and the family context in which people belong and these are not always easily picked up within a digital health record. We know if the carer um of an elderly person has been admitted to hospital if they're also our patient. We know if somebody's had a recent bereavement or had a childhood loss. We know um whether there's a family member who's struggling with drug and alcohol issues. These are things that we learn by having continuity of care with our patients that are often not picked up in digital health records. We also act as somebody who can bridge the inequality gap in people who don't have access to technology who may not have a voice to use it. We can be that person. So our main um aim really is caring for our patients. As family physicians, we are very good at adapting to different things that come along. Um, finding new ways around things and technology is just one of those other things that we have to learn and um, adapt with it. we should really ensure that there's equitable equitable global access and I think that's really important as we look at these huge advances um in AI and in um digital technology um robotic surgery um remote remote monitoring tools where are they within the context of the majority of the world's population so I think um if we don't address that again we just um increase um inequity As discussed before, we should en ensure that our AI and template modeling is very relevant to our communities and actually reflects the patients and people that we serve. And as family physicians, we really remain the coordinator, advisor, interpreter and guide for our patients. What do I mean by that? Patients come to us for advice. So they um if I think back again before uh easy access to the internet, people would come with pieces of paper cut out from the newspaper or something they'd heard on the news or a TV show about risk of breast cancer and HRT or worry about MMR immunization or um worried about alcohol um that they'd seen on a on an advert. So that hasn't really changed. People come to us asking for our views and our interpretation of health data. What is happening now is the u patients are much more able to access information from their own home. There's a huge amount of um information overload and often lots of misrepresentation of facts or fake news. Again, we saw that very well represented during the COVID pandemic. So, we act as a um as a filter to that, as a guide to that and help people make sense of the information they've given and how is it relevant to their setting. As family physicians, we also have a role for caring for our planet. So, we should advocate for the use of technology that helps to mitigate, not worsen, climate change. We should encourage um countries and companies who are using AI and sorry, not AI, but well, yes, AI there, that's a big use of power. Um using more and more digital technologies to actually use renewable power sources for that. We should advocate more for preventative medicine so that we um manage appropriate prescribing that we manage cost-effective care which we do as primary health care and even our lifestyle approach to many of our non-communicable diseases um have significant benefits on the planet. For example, moving more to a plant-based diet, avoiding smoking and alcohol, encouraging more walking and these things have impact on our planet. um but that weight should not sit entirely with the patient. So my one last slide is to warmly invite you all uh to Botswana in September for the 9th Wonga Africa region conference which has a theme about planet health. So we are one Africa united to advance planetary health through collaboration and resource alignment in primary care. So I hope to see some of you then. Thank you. Thank you Claire for that uh very interesting presentation. I mean you discussed about uh the pros and cons of digital health and with a family fish I you discussed how to sort of use digital health in a way that is appropriate and how also you discussed how to go ahead uh with digital health as well as um about the care of planet as well as our patients. So, thank you for that and definitely we loved your loved your pictures. They're very interesting. >> That's that's to encourage you to Botswana that you come and visit. >> I knew I knew I knew that you would put the last slide anyway. Okay. So, let's um discuss about uh we have some questions. Okay. So um Cambi would you like to talk about some of the points that have been already raised on the chat? I know that you have already um uh replied to some of them but I would like to ask about this uh large language models and using some of these uh uh sort of technologies digital technologies and how to balance and how to think uh if you are a sort of a uh planetary health guy and uh if you want to balance the harm versus uh let's say the opportunities that we have uh what do you think about that I think one of the things that you have already told is whether there's any other way of doing it so go ahead so can you >> yeah it'll be interesting to hear what CLA has to say about this as well um I normally say um I don't like this imposition of feeling worried or morally anxious that you need to think about the environmental impacts I would argue that this anxiety that we feel about trying to do it right while being a planetary health expert is put on us because of the neoliberal societies in which we live and that actually if um if we want to really think about caring for the planet and you look at the care literature and the care ethics literature ethics of care then caring should not be something that causes anxiety. So caring is reciprocity and it brings benefits to both the person that you are caring for but also the person that is doing the caring. So this idea that you're feeling worried and stressed about what you should do suggests that this isn't something that is about caring but is something that has created a neoliberal society. And so therefore if you say okay well I'm think I think one of the the ideas in the chat was to develop an app. My first question would be why why are you developing the app? What is your end purpose? So you should have an end goal and then that end goal is how do I get to that end goal? And it might be through the development of an app or it might be some other way that um is more suitable or less harmful in various ways. Um but if it isn't if the app is the best way and it is an LLM go for it. If you're trying to produce value in society then you go for it. And if there's you know you can there are certain things you can do. I was talking about asking questions and you know as much as you can try and make sure that the data center you're using is using renewable energy by asking the question if it if you can't if it's if you're in a country where there's only fossil fuels um then so be it right if asking the question is all you can do so I would really step away from this idea that you should feel anxious for doing anything I'll give you an example where I started to get worried I had someone contact me through things and she was a hospital worker in the DRC and she said, "I want to have a chat with you because everybody is using AI and I want to use it." And and I said, "Well, where are you?" She says, "I'm in the DRC and you know, we don't have a huge amount of money, but we you know, everyone's talking about how amazing AI is. What can I use it for?" I was like, "Okay, should we just take a step back and see what the problem is first? Okay. Is there a problem or an issue that you're trying to solve? then we can work backwards and see if there is uh you know AI is useful. I mean let's not withstand that AI you know in DRC is has so many issues related to having no infrastructure and raising so many inequity issues that would emerge. The fact that she was trying to take a technology and push it onto um a hospital in a country that was a low you know low resource setting was hugely problematic. So it's about turning the narrative round and saying what am I trying to do here? What is my main goal? If LLMs are the best way to do that, fine. But let me just check that they are first. >> Fantastic. I think that's the best thing I learned today is it's all about uh whether it's the best way to do and whether the the whatever the uh benefit would override the how. That's it. Um okay. So, we have a lot of questions and uh Okay, Gabit, what do you think about e-waste? What is your take on that? >> Um uh again, I see e-waste as the result of very colonial capitalist structures in in the sense that uh we have so much electronic waste which is e-waste. I mean, e-waste includes computers and digital, but it includes other electronic waste as well. But if we focus on just digital, the problem is is that as we increasingly improve the efficiency of our computers, we need to buy new computers. And not only that, but big tech um feeds in planned obsolescence into the technologies that we have, which mean these computers and laptops and phones to break um in less short like a time span than needed. So therefore we're replacing more of them. So the electronic waste, there are many many regulations around electronic waste, not at least the basil convention and many countries are now having regulations about not importing e-waste into their countries when high income countries are trying to get rid of it. But there are many loopholes. So if you can reuse the computer then you can ship it to other low and middle inome countries. But then what happens is is that low and these these countries get this these computers and they use them but the use of those technologies is very short because they've already been used. So that so they're turning over those technologies very very quickly. That's one problem. And the other problem is that there's no regulations around what it means to have a safe repurposed technology. And so um for example my colleague who who lives in Kenya said I'm trying to be really sustainable. I bought a repurposed computer. I had to buy three in a year because there are no standards. Whereas in the UK, I know that there are standards and guarantees. So here we start to see the differences in in what it means to have e-waste. And then you have countries that have that are processing this e-waste in a non regulated way, which means that people come, communities come to recycle informally this e-waste through um burning acids. And you probably know this using acid baths which causes masses amounts of environmental harm and health harm. And the solution is well let's just regulate these industries. But that regulation is really problematic in and of itself for a whole range of reasons. And it a because they tried to do it in Ghana. They flattened an e-ways community one of the biggest in the world. But what we're seeing now is that they're just coming up black market. All the communities are starting again. We're seeing in India that they're regulating um as much as possible and that's working really well. But actually what it's doing is forcing a lot of informal workers into capitalist endeavors where they didn't really want to be which is affecting their livelihoods and putting pressure on them because they can't afford their premises and various other things. And so regulation isn't necessarily a solution. So there's a lot that needs to be figured out in a much broader capacity when we think about e-waste. The best we can do is try and use our computers until they die and to take the philosophy that you should be proud to have the oldest computer in the room, not the youngest computer in the room. I didn't got anything to add to that. >> Yeah. No, I think that's veryant that that's why I couldn't link into sharing my video because my 10-year-old computer finally died and I had to buy a new one. I just there was a comment about uh increasing blackouts um that I just wanted to add on. Um one day last year when I was working in the UK there was a uh a computer outage um where power was on but all of the uh NHS system completely ground to a halt. So there was mass panic in the middle of a busy morning. when I go back and locom I work in a 10 doctor practice so we have a huge volume of patients that um come through um and then we're like well what what what can we do even the phones don't work because as I said they've now bolted themselves into the computer I said well the patients know who they're coming to see the patients know their appointment time so somebody just needs to stand in reception and write the name down of the patient who they're seeing and the time and tick them off and the patient will find their way to the doctor, you can still have a consultation. But even finding a pen and paper was difficult because they have this sort of confidentiality policy where you don't leave pieces of paper around. You don't write people's names on a piece of paper. So my sort of Botswana setting where oh there's no power again, we just go back to the paper notes was very uncomfortable for lots of the doctors there because we're so used to seeing everything handed to us on the computer screen. We actually forget a lot of the story sits inside us. The patients we know, we know their stories way beyond what's written in their patient record. And I think some of the data looking at AI transcripts has reflected that. The doctors don't feel it is actually a true representation of what they would choose to remember from the consultation. Records enormous volumes of chat, but the few key points are missed. And some of those things that we know about our patients are not necessarily recorded in the record. Um so I think we really forget the power we have as uh primary care doctors in knowing our patients and knowing their settings and the clinical skills we have. We can take a history and examine a patient and think about what we might want to do next without a computer on. That's what we trained for. So we have somehow become overdependent on that and have lost some of our thinking skills and our ability to work as a patient centered doctor when we when we hand it all back over to the computer. So I'm not sure that moving completely back to paper records is a good idea. I I would love to be more digital in what's I think those are key things. If there are big internet outages or power issues, when you've put everything into the cloud, you are suddenly left with not very much. You have to think about how we would manage that. >> Um I think I think that worries me the most cla um doctors become so reliant on data that they won't be looking at me even as a patient in that way. I've dropped uh there's a primary care academic called Trish Greenlaw in the UK. You might know her. I know you know her, right? She did a fantastic >> she's a more fun person. Yeah. >> So, she did a fantastic presentation for the Center for Personalized Medicine and I dropped the link in the chat. If you scroll through, guys, then you can see it. And it was she was specifically looking at this relationship between how do we navigate we need loads of data, but also we need to focus on the patient. And she was talking about the need for both. But she's a great storyteller if nobody's ever heard her speak. So I encourage people to listen to her. >> Thank you. >> Regarding this blackout, I have firsthand experience about that because in 202022 uh Sri Lanka we had this economic crisis and we didn't have dollars to buy fuel. So we had a lot of problems due to that. So we had no internet and we really felt how the future would be. So I mean it's not a not not I mean what we thought was like even though we are just thinking about the the homes and what would happen next but we have already experienced that so yes we can think about that especially in the LA prices I saw that something about Mexico Gabby you have thought about blackouts in Mexico yeah >> well I think I mean blackouts are happening everywhere so for example we had one in the UK cla you might know more about it I think it was guys or St Thomas St's or one of the where the data center in the hospital it because of the heat wave in London the data center crashed out and burned so we didn't they didn't have access to data but we're seeing that more and more and more and with climate change because data centers need to keep cool it's going to I think that's going to become an increasing problem in Mexico there's this in Mexico they're starting to build data centers I'm not sure what the agreement is between Trump and Mexico to be honest but they're building data centers in um and they're draining there's certainly some places where they're draining so much energy that they drained energy from the the hospital or from GP's practices which ended up meaning that patients couldn't access the GP. They couldn't get to go to hospital. I think that there was a lot of patients that ended up being quite sick because they couldn't access the electricity needed to be treated. Um and so there is this evidence that's starting to build where it is affecting health care and health workers and patients and and how and I think the biggest issue with data centers more than any other industry is that the environmental impacts are localized. Um so whereas other industries they'll be more broad with data centers is they're all built in like one area. So like Ireland I think which was mentioned in the chat I think it's like over somebody if you're in Ireland you'll know more than me but like astonishingly like 20% or more electricity is just data centers where you might have a country where it's zero and so that these localized aspects um become very pronounced in in relation to water and electricity and that's what we need to be careful of particularly as low middle inome countries are being driven to invest in data centers and AI um so how do we make sure that when we do that that we can protect our patient populations in those communities like the communities that CLA was talking about that they have enough water to implement wash and they can wash their hands and that data centers aren't taking that away from them and all other issues that you know come with that >> and I think in our >> in our in our um clinic we actually put solar panels on to um act as our sort of backup power supply and as our primary power source. we still connect to the grid. Um, but I mean that has helped a lot in our our energy usage, but unfortunately it doesn't completely um help us because if the internet is down, that's not within our system. That's somewhere else. So, you might have a power cut where the um I'm not very good at all the technology stuff, but anyway, where the internet provider is >> where the running is located. >> Yes. And then it doesn't matter that you've got your lights on in your clinic, your internet is down. Now, we can of course switch to mobile internet and dongles and we we have a wide range of those options, but I I think it's it's not straightforward which even if you think you're safe within your own power setup, it depends what's connecting. And as you showed, Gabby, all those internet cables um dragging across the bottom of the world, it doesn't it wouldn't take very much to disrupt that. that would have quite significant impacts on how we all communicate with each other like in this meeting and how we then access our our health records >> and I think we'll see this more and more this idea because I think like cyber security and cyber hacking like I know we're seeing it in the UK like the NHS is being hacked but CLA like literally I remember talking to somebody in digital sustainability and he's saying I got asked to come in and like do a pretend hack to see if I could access I think it was surveillance systems in the UK And he's like, I just said to them, you know what? I don't need to do that. I can just walk around your perimeter and cut your cable. That is what that is what I need to do. And and there have been instances of this happening. And I think more and more as we rely on data, you know, that's all you need to do is cut a cable and then you've sent a lot of people out. So I think we need it's how to protect communities, how to protect health, and how to build resilience while also slowly bringing in digital in a way that I suppose is balanced, right? not going too hoa because that's when you get the inequities and the digital divide. >> I have to acknowledge that we have our uh executive members some of them here. Enrique is there, Alan is there. Both of them are past chairs and also we have Andre our Europe lead. Um uh colleagues do you have any other questions uh specifically to be asked from Gabby or CLA or you can just u do you have anything else to add? >> Excellent presentation. Thank you very much. Congrats uh Sanka for organizing this. >> Hi Andre, thank you for joining on the way. I guess see um CL I I'll just ask a very simple question now uh with regarding teley medicine now and online consultations um how would you suggest to keep our compassion while doing an online consultation because all these communication skills would not sometimes work what we have learned or practiced in a in a physical consultation in an online consultation how would you um uh suggest to go ahead in an online consultation to y >> oh that's a great question and I'm sure I don't have all the answers to that I think from my own experience what I try to do is ask one simple question at a time and allow a longer pause than you would normally do in terms of a face toface consultation particularly if there isn't video so if you're just having a phone call um then actually allowing space asking a very clear question and again sticking back to our principles about what do you think about that? What would you like to ask me about that? So again putting it back to let the patient do more of the talking and then that feels more like a chat they would have on the phone with a family member or a friend. So I think the principles of our consultation skills remain the same but maybe some small changes in how we allow a longer pause um or how we might sometimes choose to interrupt a patient because we've lost the vis visual clues when somebody chooses to talk for 20 minutes and we need to cut them off a little bit. You have to find ways of how do we uh interrupt in a polite way so that we try to ask the uh information that's relevant. So I I think there's not a huge difference in our consultation styles speaking a little bit slower um allowing more space for the patient to answer >> and and now I think you worked in uh while you were working in the UK I think you have experienced both uh paperbased record era as well as electronic era is that so because I have never seen paper papers in the UK when I was there I know that's what I say showing my age. Um, but yeah, the the Lloyd George notes were still very much in in practice when I first started working as a GP in 2004. And then in the two or three years after that, we were physically, I'm sure you're not allowed to do this now, but taking sets of notes home and summarizing, you know, five or 10 files per night. I probably shouldn't say that, but anyway, and then taking them back to the clinic. And then we had a data entry cler who was um looking at our onepage summary to literally add that into the screen. So in the early 2000 there was some funds set aside from the government to help digitize the records. Um, many practices still have the Lloyd George in storage, but actually more of that has moved to off-site storage now and they're stored at secure, you know, fireproof spaces and they're they're in the process of being um scanned and I think read by AI to then be added into the system. So, they won't be completely uh destroyed. But, it's actually quite nice seeing some of the very old beautiful fountain pen writing. some of it completely um in illeible coffee stains on the cups um and sometimes rammed into there. So very very difficult to find the pieces of information. I think that is the biggest challenge with that handheld you know paperbased records isn't it? How do you keep them in a in a good order? And certainly certainly in Botswana, I've used the summary sheets like we see on our electronic records in the UK and I've actually printed one of those off to then fill in for our patients because some of our patients have um you know 20 years of HIV care. So they have very very fat files with huge amounts of results, lots of interesting health conditions that have followed them through that uh journey of HIV. and you you can't possibly look at that when you have a short time with the patient. So having a brief even if you've got paper notes, having a summary sheet at the beginning is really key to helping um us as doctors if the patients are new to us, but also reminding us if they're patients we haven't seen for a while. So I I nag my colleagues a little bit um about trying to update that summary sheet. So um um so when you were like working with these paperbased records and then when it switched to the electronic records how what were the challenges you had? I mean how h how how do you perceive the the care the the the the aspect of care or the the the probably the GPS I mean as GPS the the the real care that we provide. How did it change? How what do you think about that? Um I yeah I think in that um initial change over time there was a computer record but like I said it was that old green text very very brief you wrote one or two very brief words in it most of it was in the computer so for a long time we were running on this dual system which is really inefficient we had a lot of training in most GPS run on one of two systems so sort of emiss or system one and you you had a lot of training before that sort of go live you had a dummy system that was in place. You had to take time out of clinical work to learn the system. We actually had a trainer in the practice for the 3 weeks of the switch over. You had to reduce the number of patients you saw. Um there was somebody hovering outside. So if you got stuck on the computer part the way through the consultation, they would nip in and speak to you. So it really is a huge learning curve to become comfortable navigating around the record systems. And certainly now they're so much more complicated than when I took it on. I mean the the e- medicine and system one have not changed considerably, but now all these add-ons with sort of econults and acurx and health things and prescribing that's all bolted on. And I often find when I go back my f I I have half a day with the IT person saying what is new? What have you done since I last left? Because when you start your when you start your morning clinic at 10-minute appointments, you can't really spend time now saying, "Uh, I can't do a prescription because I can't send it to your pharmacy." So, I think it's it's really um that's the biggest challenge I think in in upgrading our skills. And like everything once you get used to using something it becomes second nature and we become more efficient um we become more efficient at doing it. And again in trying to type whilst talking to the patient so you haven't got the screen sitting between you and the patient is really is really key. Um but sometimes if you've got a very complicated story from the patient trying to document that whilst listening in a compassionate and empathic way is also very challenging. It looks rude if you have your back to the patient and say hold on trying to type that does break our our communication. Yeah, >> I'm sure there are others in this group that have um have thoughts on that as well. >> Yeah. Uh you can just uh unmute yourself and talk because we have we don't have a lot of people at the moment. So we can of course have a or any other questions or any other comments? A lot of comments and replies on chat. I think uh Gabby had answered almost everything. Good. Okay. Um I think we had a very fruitful discussion. Thank you both uh Gabby and for your time despite your busy schedules. I know Gabby just finished her work and joined us. Thank you very much Gabby and Cla amidst your busy schedule. So uh colleagues we we all I mean most of us except Gabby uh are family doctors who are with our patients and we always what as one of the major uh quality or value a principle of family medicine. We extend a compassionate care, the comprehensive care, and continuity of care to our patients and definitely we the digital health is inevitable and we definitely understand that it gives us more opportunities and I think it is a very good uh important tool to extend our care to our patients. But we discussed how we should utilize it in a way that we can still retain the compassionate care that always uh govern our uh our discipline family medicine or general practice. So thank you very much speakers and thank you very much uh uh everyone who joined today. We have uh recorded this uh discussion and it will be available on WA YouTube soon. Uh and thank you Anna for uh your uh Spanish simultaneous Spanish translations and see you all. Happy family doctor day and have a good day.