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Seven NA, Truitt KA, Dierkhising RA, Young NP. Electronic Consultations in a Community Neurology Practice: A Retrospective Study Informing Best Practice. Mayo Clin Proc Innov Qual Outcomes 2024; 8:17-27. [PMID: 38186924 PMCID: PMC10767252 DOI: 10.1016/j.mayocpiqo.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024] Open
Abstract
Objective To describe our practice of electronic consultations (e-consults) and assess safety and risk factors for subsequent face-to-face consultations. Patients and Methods A retrospective cohort study of all e-consults completed in a community neurology practice between May 5, 2018, and June 31, 2019, was completed. Clinical and demographic variables were compared between the successful and unsuccessful (defined by presence of subsequent face-to-face consultation) cohorts. Hazard ratios (HR) were calculated using Cox regression model. Kaplan-Meier probability analysis (with 95% CIs) of subsequent face-to-face consultation was performed. Case examples highlighting potential harm were summarized. Results In total, 302 e-consults were reviewed. The most frequent referrals were for headache (n=125, 41.4%), dysesthesia (n=40, 13.2%), and abnormal imaging finding (n=27, 8.9%). The most common e-consult questions were for treatment (57.6%) and diagnostic evaluation (48.0%) recommendations. Moreover, 24.8% (n=75) of e-consults were followed by face-to-face consultations, with primary risk factors including female sex (HR, 1.9), referral for headache (HR, 1.7), and final diagnosis of migraine (HR, 2.0) or long-term migraine (HR, 5.0). Potential harm related to delayed diagnosis/treatment was identified in 6 (2.0%) patients with migraine and 4 (1.3%) without migraine presenting to emergency department. Conclusion Utilization of e-consults may safely improve access to neurologic expertise and prevent the need for some visits, which may have required a face-to-face visit. In patients with chronic migraine, e-consults should be considered short-term and followed by face-to-face consultation as soon as access allows. Neurologists performing e-consults should be able to triage patients to face-to-face consultation, particularly when diagnosis is uncertain or the neurologic examination may help guide appropriate testing.
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Affiliation(s)
| | | | - Ross A. Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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McGowan M, Rose D, Paez M, Stewart G, Stockdale S. Frontline perspectives on adoption and non-adoption of care management tools for high-risk patients in primary care. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100719. [PMID: 37748215 DOI: 10.1016/j.hjdsi.2023.100719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/22/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Population health management tools (PHMTs) embedded within electronic health records (EHR) could improve management of high-risk patients and reduce costs associated with potentially avoidable emergency department visits or hospitalizations. Adoption of PHMTs across the Veterans Health Administration (VA) has been variable and previous research suggests that understaffed primary care (PC) teams might not be using the tools. METHODS We conducted a retrospective content analysis of open-text responses (n = 1804) from the VA's 2018 national primary care personnel survey to, 1) identify system-level and individual-level factors associated with why clinicians are not using the tools, and 2) to document clinicians' recommendations to improve tool adoption. RESULTS We found three themes pertaining to low adoption and/or tool use: 1) IT burden and administrative tasks (e.g., manually mailing letters to patients), 2) staffing shortages (e.g., nurses covering multiple teams), and 3) no training or difficulty using the tools (e.g., not knowing how to access the tools or use the data). Frontline clinician recommendations included automating some tasks, reconfiguring team roles to shift administrative work away from providers and nurses, consolidating PHMTs into a centralized, easily accessible repository, and providing training. CONCLUSIONS Healthcare system-level factors (staffing) and individual-level factors (lack of training) can limit adoption of PHMTs that could be useful for reducing costs and improving patient outcomes. Future research, including qualitative interviews with clinicians who use/don't use the tools, could help develop interventions to address barriers to adoption. IMPLICATIONS Shifting more administrative tasks to clerical staff would free up clinician time for population health management but may not be possible for understaffed PC teams. Additionally, healthcare systems may be able to increase PHMT use by making them more easily accessible through the electronic health record and providing training in their use.
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Affiliation(s)
- Michael McGowan
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA.
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA
| | - Monica Paez
- Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, USA
| | - Gregory Stewart
- Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, USA; Department of Management and Organizations, Tippie College of Business, University of Iowa, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA.
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Hellingman T, van Beneden MLH, den Bakker CM, Zonderhuis BM, Kazemier G. Perspectives of patients with colorectal cancer liver metastases on e-consultation in transmural care: a qualitative study : Is privacy really an issue? BMC Health Serv Res 2023; 23:541. [PMID: 37231462 DOI: 10.1186/s12913-023-09408-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 04/15/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Comprehensive cancer networks have been established to deliver high-quality care for patients with cancer. Logistic challenges are faced, when patients need to be referred for specialized treatments. Despite strengthened privacy legislations, digital platforms are increasingly used to consult specialists from dedicated liver centers or refer patients with colorectal cancer liver metastases (CRLM) for local treatment strategies. This qualitative study aimed to explore the perspectives of patients with CRLM regarding e-consultation of transmural specialists. METHODS A focus group study was conducted. Patients referred from regional hospitals to an academic liver center for treatment of CRLM were asked to participate. Focus group discussions were audio-recorded and transcribed verbatim. A thematic content analysis of data was conducted, comprising open, axial, and selective coding of the transcripts. The consolidated criteria for reporting qualitative research (COREQ) were used. RESULTS Two focus groups were held, involving 11 patients and 8 relatives. Three major themes were identified with regard to e-consultation in transmural care: 'data management', 'expertise', and 'information and coordination'. Confidence in the expertise of physicians appeared most important during the course of treatment, as patients experienced uncertainty after diagnosis of cancer. Despite the privacy risks, use of digital communication platforms to contact experts in the field were strongly endorsed to improve eligibility for potentially curative treatment. Moreover, e-consultation of specialists may reduce waiting times, due to effective coordination of care. CONCLUSION Initiatives to improve medical data transfer between care providers were encouraged to achieve effective coordination of oncological care. The potential hazard of privacy violation associated with digital data exchange is accepted by patients and their relatives, provided that use of digital data improves patient's own health care, research or education.
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Affiliation(s)
- T Hellingman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - M L H van Beneden
- Department of Strategy and Innovation, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - C M den Bakker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
| | - B M Zonderhuis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - G Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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Supporting Veterans, Caregivers, and Providers in Rural Regions With Tele-Geriatric Psychiatry Consultation: A Mixed Methods Pilot Study. Am J Geriatr Psychiatry 2023; 31:279-290. [PMID: 36754647 DOI: 10.1016/j.jagp.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Cross-facility tele-geriatric psychiatry consultation is a promising model for providing specialty services to regions lacking sufficient geriatric psychiatry expertise. This evaluation focused on assessing the feasibility and acceptability of a consultation program developed by a geriatric psychiatrist in a Veterans Health Administration regional telehealth hub. DESIGN Concurrent, mixed methods program evaluation. SETTING A region served by a VA health care system telehealth hub. PARTICIPANTS Patients with at least 1 geriatric mental health encounter with a geriatric psychiatrist consultant during a 1 year-period; referring providers. INTERVENTION Virtual psychiatric evaluation of Veterans with time-limited follow-up and e-consultation with providers. MEASUREMENTS Interviews with consultant, medical record data, and referring provider surveys. RESULTS Three hundred fifteen Veterans (M = 76.0 ± 9.64 years; 40% rural-dwelling) had 666 encounters (M = 2.11 ± 1.78) with most occurring via clinical video telehealth (n = 443; 67.6%), e-consultation (n = 99; 15.1%), or video to home (n = 95; 14.5%). Most encounters were related to neurocognitive disorders, depressive disorders, trauma-related disorders, or serious mental illness. Referring providers (N = 58) highly recommended the program, reported high satisfaction, followed through with recommendations, and believed that this program increased access to geriatric psychiatry. CONCLUSIONS This single program was shown to be feasible, acceptable, and valued by the referring providers. The findings highlighted the complex presentations of Veterans referred, and the current unmet need of providers of such Veterans, providing impetus for wider implementation.
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Spece LJ, Weppner WG, Weiner BJ, Collins M, Adamson R, Berger DB, Nelson KM, McDowell J, Epler E, Carvalho PG, Woo DM, Donovan LM, Feemster LC, Au DH, Sayre G. Primary Care Provider Experience With Proactive E-Consults to Improve COPD Outcomes and Access to Specialty Care. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2023; 10:46-54. [PMID: 36472622 PMCID: PMC9995235 DOI: 10.15326/jcopdf.2022.0357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background Often patients with chronic obstructive pulmonary disease (COPD) receive poor quality care with limited access to pulmonologists. We tested a novel intervention, INtegrating Care After Exacerbation of COPD (InCasE), that improved patient outcomes after hospitalization for COPD. InCasE used population-based identification of patients for proactive e-consultation by pulmonologists, and tailored recommendations with pre-populated orders timed to follow-up with primary care providers (PCPs). Although adoption by PCPs was high, we do not know how PCPs experienced the intervention. Objective Our objective was to assess PCPs' experience with proactive pulmonary e-consults after hospitalization for COPD. Methods We conducted a convergent mixed methods study among study PCPs at 2 medical centers and 10 outpatient clinics. PCPs underwent semi-structured interviews and surveys. We performed descriptive analyses on quantitative data and inductive and deductive coding based on prespecified themes of acceptability, appropriateness, and feasibility for qualitative data. Key Results We conducted 10 interviews and 37 PCPs completed surveys. PCPs perceived InCasE to be acceptable and feasible. Facilitators included the proactive consult approach to patient identification and order entry. PCPs also noted the intervention was respectful and collegial. PCPs had concerns regarding appropriateness related to an unclear role in communicating recommendations to patients. PCPs also noted a potential decrease in autonomy if overused. Conclusion This evaluation indicates that a proactive e-consult intervention can be deployed to collaboratively manage the health of populations with COPD in a way that is acceptable, appropriate, and feasible for primary care. Lessons learned from this study suggest the intervention may be transferable to other settings and specialties.
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Affiliation(s)
- Laura J. Spece
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
- VA Puget Sound Health Care System, Seattle, Washington, United States
- Department of Medicine, University of Washington, Seattle, Washington, United States
- *Co-first authors, listed alphabetically
| | - William G. Weppner
- Department of Medicine, University of Washington, Seattle, Washington, United States
- Boise VA Medical Center, Boise, Idaho, United States
- *Co-first authors, listed alphabetically
| | - Bryan J. Weiner
- Department of Health Services, University of Washington, Seattle, Washington, United States
- Department of Global Health, University of Washington, Seattle, Washington, United States
| | - Margaret Collins
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
| | - Rosemary Adamson
- VA Puget Sound Health Care System, Seattle, Washington, United States
| | - Douglas B. Berger
- VA Puget Sound Health Care System, Seattle, Washington, United States
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Karin M. Nelson
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
- VA Puget Sound Health Care System, Seattle, Washington, United States
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Jennifer McDowell
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
| | - Eric Epler
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
| | - Paula G. Carvalho
- Department of Medicine, University of Washington, Seattle, Washington, United States
- Boise VA Medical Center, Boise, Idaho, United States
| | - Deborah M. Woo
- VA Puget Sound Health Care System, Seattle, Washington, United States
| | - Lucas M. Donovan
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
- VA Puget Sound Health Care System, Seattle, Washington, United States
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Laura C. Feemster
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
- VA Puget Sound Health Care System, Seattle, Washington, United States
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - David H. Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
- VA Puget Sound Health Care System, Seattle, Washington, United States
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - George Sayre
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, United States
- Department of Health Services, University of Washington, Seattle, Washington, United States
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Asynchronous Remote Communication as a Tool for Care Management in Primary Care: A Rapid Review of the Literature. Int J Integr Care 2022; 22:7. [PMID: 36043028 PMCID: PMC9374012 DOI: 10.5334/ijic.6489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/03/2022] [Indexed: 11/24/2022] Open
Abstract
Aim: To review the available evidence on asynchronous communication models between primary care professionals and patients in different countries around the world in order to analyse the added value that this model brings to patients and professionals. Design: A rapid literature review was conducted using the World Health Organisation guidance to include a variety of studies on the concept of asynchronous communications between primary care and patients in different countries. Data sources: The search for articles was carried out in PubMed and Google Academics and with the contribution of telemedicine experts from the Catalan Institute of Health. Selection of studies: The review included 271 articles. The inclusion criteria were: publications from 2010 onwards, in English, Spanish or Catalan, focused on asynchronous communications between primary care professionals and patients to improve patient management. After discarding duplicates and applying the exclusion criteria (255 articles), 16 were included for further review. Data extraction: The rapid literature review was conducted by an evaluator; detecting 5 main general themes: reduction of face-to-face visits, available services and most frequent uses, characteristics and perceptions of primary care professionals, characteristics and perceptions of users, and barriers and facilitators for the implementation of asynchronous teleconsultation. Results: A total of sixteen studies were included, including seven quantitative studies, seven qualitative studies and two mixed studies. Conclusions: The high degree of satisfaction of both users and professionals, the outbreak of COVID-19 and the effectiveness and efficiency of asynchronous remote communications are key factors for the implementation and improvement in the management of the different healthcare systems across the world.
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Dosani T, Xiang J, Wang K, Deng Y, Connell NT, Connery D, Levin F, Roy A, Wadia RJ, Wong EY, Rose MG. Impact of Hematology Electronic Consultations on Utilization of Referrals and Patient Outcomes in an Integrated Health Care System. JCO Oncol Pract 2021; 18:e564-e573. [PMID: 34914541 DOI: 10.1200/op.21.00420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Electronic consultations (e-consults) may be a valuable tool in the current era of increased demand for hematologists. Despite the increasing use of e-consults in hematology, their optimal utilization and impact on patient outcomes and workload are largely unknown. METHODS In this retrospective cohort study, we studied the hematology consult experience at Veterans Affairs Connecticut from 2006 to 2018. We included 7,664 hematology consults (3,240 e-consults and 4,424 face-to-face [FTF] consults) requested by 1,089 unique clinicians. RESULTS We found that e-consults were rapidly adopted and used equally among physicians of different degrees of experience. The number of FTF consults did not decrease after the introduction of e-consult services. E-consults were preferentially used for milder laboratory abnormalities that had been less likely to result in a consult before their availability. Referring clinicians used e-consults preferentially for periprocedural management, anemia, leukopenia, and anticoagulation questions. Eighty-three percent of e-consults were resolved without needing an FTF visit in the year after the consult. Consults for pancytopenia, gammopathy, leukocytosis, and for patients with known malignancy were less likely to be resolved by e-consult. Among patients who were diagnosed with a new hematologic malignancy after their consult, having an e-consult before an FTF visit did not adversely affect survival. CONCLUSION In summary, e-consults safely expanded delivery of hematology services in our health care system but increased total consult volume. We report novel data on what types of consults may be best suited to the electronic modality, the impact of e-consults on workload, and their optimal use and implementation.
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Affiliation(s)
- Talib Dosani
- Yale School of Medicine and Yale Cancer Center, New Haven, CT
| | - Jenny Xiang
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kaicheng Wang
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Nathan T Connell
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | - Alicia Roy
- VA Connecticut Healthcare System, West Haven, CT
| | - Roxanne J Wadia
- Yale School of Medicine and Yale Cancer Center, New Haven, CT.,VA Connecticut Healthcare System, West Haven, CT
| | - Ellice Y Wong
- Yale School of Medicine and Yale Cancer Center, New Haven, CT.,VA Connecticut Healthcare System, West Haven, CT
| | - Michal G Rose
- Yale School of Medicine and Yale Cancer Center, New Haven, CT.,VA Connecticut Healthcare System, West Haven, CT
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Banerjee A, Pasea L, Manohar S, Lai AG, Hemingway E, Sofer I, Katsoulis M, Sood H, Morris A, Cake C, Fitzpatrick NK, Williams B, Denaxas S, Hemingway H. 'What is the risk to me from COVID-19?': Public involvement in providing mortality risk information for people with 'high-risk' conditions for COVID-19 (OurRisk.CoV). Clin Med (Lond) 2021; 21:e620-e628. [PMID: 34862222 DOI: 10.7861/clinmed.2021-0386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients and public have sought mortality risk information throughout the pandemic, but their needs may not be served by current risk prediction tools. Our mixed methods study involved: (1) systematic review of published risk tools for prognosis, (2) provision and patient testing of new mortality risk estimates for people with high-risk conditions and (3) iterative patient and public involvement and engagement with qualitative analysis. Only one of 53 (2%) previously published risk tools involved patients or the public, while 11/53 (21%) had publicly accessible portals, but all for use by clinicians and researchers.Among people with a wide range of underlying conditions, there has been sustained interest and engagement in accessible and tailored, pre- and postpandemic mortality information. Informed by patient feedback, we provide such information in 'five clicks' (https://covid19-phenomics.org/OurRiskCoV.html), as context for decision making and discussions with health professionals and family members. Further development requires curation and regular updating of NHS data and wider patient and public engagement.
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Affiliation(s)
- Amitava Banerjee
- University College London, London, UK, honorary consultant cardiologist, University College London Hospitals NHS Trust, London, UK, and honorary consultant cardiologist, Barts Health NHS Trust, London, UK
| | | | | | - Alvina G Lai
- University College London, London, UK, and associate, Health Data Research UK, London, UK
| | | | | | | | - Harpreet Sood
- Health Education England, London, UK, and general practitioner, Hurley Group Practice, London, UK
| | | | | | - Natalie K Fitzpatrick
- University College London, London, UK, and associate, Health Data Research UK, London, UK
| | - Bryan Williams
- University College London Hospitals NHS Trust, London, UK, professor of medicine, University College London, London, UK, and director, UCL Hospitals NIHR Biomedical Research Centre
| | - Spiros Denaxas
- University College London, London, UK, associate, Health Data Research UK, and research fellow, Alan Turing Institute, London, UK
| | - Harry Hemingway
- University College London, London, UK, research director, Health Data Research UK, London, UK, and director of healthcare informatics, genomics/omics, data science, UCL Hospitals NIHR Biomedical Research Centre, London, UK
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