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Technology in health - beauty or beast?

Lauren Cortis

Last week the Guardian published a long read article What's Wrong With WhatsApp? In it, the author William Davies argues that the ever increasing use of WhatsApp and closed Facebook groups is facilitating the spread of dangerous conspiracy theories, fake news and corrupt behaviours. It's a pretty damning read.

The evils of technology and Silicon Valley were also the central thesis of an open letter to Joe Biden published in Wired magazine on Thursday. These articles give an indication of what is a growing narrative that technology is responsible for the divisiveness, misinformation and unrest that we are seeing at the moment in our communities.

But is it really fair to blame technology for the current state of the world? I don't believe it is. I think attributing the bad things happening in the world to increased use of WhatsApp is akin to blaming the printing press for the holocaust. Technology facilitates faster and broader dissemination of information, sure. It has created new kinds of social environments online, yes. But we humans are always responsible for our behaviour, the good and the bad. We set the guidelines for use. We contribute and consume content. We interact with others.

The advantage of accepting personal responsibility for our use of technology rather than blanket condemnation is that it gives us more power to harness its benefits. To actively utilise it to achieve positive outcomes rather than passively waiting for regulation to magically fix things for us. And the reality is that technology offers us enormous opportunities in healthcare that are well worth embracing if our goal is to provide more patient-centred care.

Ask any healthcare professional about their top frustrations and I'm quite confident that communication struggles will be in their top five. We know collaboration is an essential part of contemporary practice, but is laborious to coordinate and inefficient at best. We can do better and technology can help. We can start by improving our understanding these online social environments and the tools we use.

Lets first acknowledge that the types of closed networks created by applications like WhatsApp are not really new, they're just online. Whether by discipline, specialty, sector or otherwise, clinicians traditionally organise themselves within silos of shared attributes. Healthcare is inherently tribal.

There are obvious benefits to this. Closed networks help to establish a sense of belonging, a key part of developing professional identity. They also allows for rapid knowledge exchange and efficient diffusion of information. In the general world the less favourable consequences of this are things like conspiracy theories and fake news. In health they are duplication of effort, inefficiency and inhibition of innovation.

Sociologist Ronald Burt described this social structure in his 2005 paper Structural Holes and Good Ideas. In it he explains how the inward focus of closed networks results in groups that are homogeneous in behaviours and opinions. This creates gaps in information flow between groups which Burt refers to as structural holes. In health the term fragmented is frequently used to describe this type of system. Silos of care that result in a disjointed care experience for patients, and inefficiencies for providers and system funders.

Burt argues that the connections between groups provide opportunity to develop alternative ways of thinking and behaving as well as synthesis of new ideas. This hypothesis is considered in the healthcare context in Long, Cunningham and Braithwaite's 2013 paper Bridges, brokers and boundary spanners in collaborative networks: a systematic review. In it they argue that connection between silos can help to facilitate the knowledge exchange and relationships required to deliver collaborative care.

Sounds reasonably straightforward, right? The healthcare system is fragmented so we need to build more connection between the closed networks by placing people in roles to broker information exchange across boundaries of care. Liaison officers. Transitional care managers. Patient navigators. Care get the idea.

Using individuals to build bridges is a commonly used method, but it must be recognised that such a method is not without cost. As is stated in the review, relying on individual agents to act as brokers means the system is reliant on them to act as gatekeepers which can create bottlenecks. It can also place excessive burden on individuals undertaking those roles. If we want to create a more connected health system we need to consider how a systems approach can support these more specific tactics..

Braithwaite explores this further in his 2015 paper Bridging gaps to promote networked care between teams and groups in health delivery systems: a systematic review of non-health literature. In it he identifies four core factors for appreciating networked efforts: understanding the nature of gaps, using the leverage of boundary spanners, stimulating interactive relationships and exerting power via external influences. He notes a number of approaches to stimulating interactive relationships between groups have been described in the literature, including creating informal opportunities to inter-relate, promoting dialogue and shared learning, and supporting social diversity. In my mind, this list sounds a lot like the potential benefits that can be obtained through social media...minus all the bad bit of course.

This leads to the question, how can we develop an approach to professional communications that optimises the benefits of social media and contemporary communications technology and minimises the downfalls?

To explore this, let's start by thinking about the two general categories of communication platforms you meet on the internet - open and closed. Noting that many applications can offer both depending on how they're configured or what type of subscription you maintain I'm going to talk about this based on the principles of how technology is used in communication.

Open platforms are public, meaning you never really know who you're communicating with when you interact with the application. As a result, most people adopt some sort of performative aspect to how they present themselves. It's a reputation-protecting environment. Present yourself in a way that others will look on favourably (whatever that means to you) and try to avoid being the subject of any wrath-inducing incidents. They are a bit like being on a dance floor at a nightclub. You might be there enjoying time with your friends,but who knows who is watching you from the bar? In response, perhaps you don't pull out the more outlandish dance moves within your repertoire whenever the music moves you for fear of being mocked by strangers and abandoned by your friends.

Within a closed communication platform you might not know everybody who you're interacting with, but there is some assurance that the participants in the group you're communicating with has been vouched for in some way. This could be determined by a number of things, like how you configure your privacy settings, approval to join the group, verification of identity etc.

If an open platform is like being at a nightclub, this is more like being at a house party hosted by a close friend. You have a greater level of comfort than being with a bunch of total strangers in a public place. You feel like you belong there and have an understanding of what are considered acceptable behaviours. You can feel less guarded in the way you communicate than you would be in public. But it doesn't eliminate all risk. There is the risk of going against the groupthink. Returning to the house party analogy, this is the moment where a seemingly innocent game of Cards Against Humanity turns really dark and uncomfortable when someone pushes things that bit too far and no one calls them out on it, and thus the new norm results.

While both types of environment may influence the way people behave, neither are inherently good or bad. Open platforms provide greater transparency and are more inclusive. Closed platforms provide greater privacy and trust. It would seem that some sort of combination that balances both would be desirable to get the best of both worlds.

So how can we determine what that balance should be? I believe we need to start by considering the other factors essential in healthcare communication - trust, privacy and confidentiality.

Confidentiality is the cornerstone of the therapeutic relationship and delivering quality care. Without an expectation of confidentiality few people would feel comfortable enough share sensitive health-related information with a care provider. Without access to adequate information clinicians are constrained in their clinical decision making. Promoting public trust and upholding privacy and confidentiality is clearly in everyone's best interest.

Achieving public trust in healthcare providers is not just determined by how we handle individuals healthcare information, it's also impacted by how we conduct ourselves in public. I'm not suggesting that individuals should be muzzled and forbidden to have a personal opinion just because you're a healthcare professional. Public discourse is an important aspect of advocacy and consumer engagement. But we need to be aware that there are potential consequence to public discussion. So before you unleash about your inept colleagues on a Twitter rant, take a moment to think about how the patient or their family would feel if they overheard the discussion. Would it build the trust in their care team, or diminish it? Collaborative practice isn't just about our relationships with colleagues, it's about cultivating the therapeutic relationship across the entire care team.

In terms of upholding privacy and confidentiality it should be acknowledged that no technology can provide confidentiality. Confidentiality is always a function of the agreed behaviours amongst those with access to the information being shared. What technology can do is provide us with the private and secure environment for this to occur.

Of course, just because an application provides a forum that hosts a closed network doesn't make it private and secure. It's reasonably well known that the cost of using a 'free' platform is access to the data you share. Use of these platforms for professional purposes must consider what data is being shared and whom. One way of doing this is to think about how you'd feel if you were having the conversation in real life and if you would censor in anyway if you knew there was, say, a pharmaceutical sales rep or a health insurance funder sitting in the room.

If you're sensing a theme here, you're not mistaken...a professional online environment should be considered an extension of our tangible reality. Perhaps even more so, as unlike a conversation overheard in a tea room, the internet maintains a documented record.

While we're on the topic of newsfeed style applications, there's one more thing that you need to be mindful of; the underlying algorithms. What you see on your newsfeed is curated by an algorithm informed by everything the application knows about you. What you click on, posts you like, people you consistently scroll past without review...This can create a filter bubble effect. The content visible to you is what the algorithm predicts you'll positively respond to. Exposure to content that challenges your established behaviours and beliefs is limited. As a result, your experience of engaging with a group will be very different from a colleagues. The impact of this can be quite sinister (e.g. the whole Cambridge Analytica influencing election thing). Practically speaking it means that it's much harder to create transparency and engagement across the entirety of a group.

The problems with privacy and security are mostly overcome with the use of secure messaging applications and enterprise level systems, but it is this context where the relevance of behavioural issues becomes clear. If we take an application like WhatsApp as an example, the encryption of messages may prevent administrators being able to view the content of communication and store it securely, but unless there is agreement between participants that no one will back up their conversations, take screenshots etc the encryption means little. In this circumstance, the technology is supports confidentiality, it's the protocol that's lacking.

When I use the term protocol, I'm not suggesting that there should be a step by step process endorsed by some committee from on high informing us of how we are allowed to use technology in our professional lives. This type of guideline-driven approach may be one that is often suggested but it's not one that I subscribe to. The reason being, I just don't think it works as well as those who write the guidelines think it will. Because healthcare professionals are, and should be encouraged to be, autonomous individuals.

Autonomy is a key part of being a professional and as such individuals must be entrusted to tailor their own protocol or approach to ensure they meet their legal and ethical standards of practice. Whether you prefer the traditional methods of fax, face to face meetings and phone calls or want to embrace the digital realm of secure messaging applications, video conference and social media, it can be your choice. Just make sure you use those tools appropriately. That's the professional bit. If you want to be autonomous in your choices you must also be responsible for them.

I'm not sure that enough healthcare professionals take responsibility for how we communicate and collaborate with others. I think that's one of the reasons why communication continues to be so inefficient. There seems to be a complacency about it. Like most 'soft skills' (aka essential skills that are transferable into any professional context) effective use of technology isn't considered worthy of the CPD credits. Because, lets face it, it's kind of boring. It's administrative. Few clinicians find administrative aspects of their work energising or rewarding.

So we figure that's where we can help. We're making it our work to make it easier for healthcare professionals to implement good practices. Not to be prescriptive and tell you what to do, just to reduce the friction involved with embracing digital communications in your practice. To make good choices. Help more people see the beauty of technology and diminish the beastly aspects.

We've established a community platform to provide an alternative to the usual public social media; free of algorithms and without selling data to third parties. This platform is intended to unite individuals and groups working in healthcare by providing infrastructure that can be shared. To offer the benefits of open platforms (accessibility, transparency, connection between groups) balanced with the closed (verified identity, restricted access areas, e.g. clinician only forums).

We've brought together secure messaging and video conferencing tools to enable confidential online collaboration. This makes enterprise grade security more accessible to those who aren't tied to a large organisation or individual healthcare institution. Hosted in Australia and capable of integrating with other applications, so you can communicate securely across organisational boundaries.

And we're working on more. If you've got problems relating to inter-professional communication, we want to hear them. If there's something you want to understand about how to use technology more effectively to support your practice, we want to help you with that.

We believe technology can be used as an enabler for inter-professional communication. To build greater connection across organisational boundaries. To support the healthcare workforce to focus more of their time and efforts on the patients who need it, and less on administrative responsibilities. To give them more time to focus on the work that matters.

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