Neil Mackay: Delay to introduction of life-saving AI software in Scotland's GP surgeries

CDS can be used by doctors to combat any form of illness or disease. The technology delves into medical data and scans patient records to help doctors come to the best decision over diagnoses, treatment and medication.

Despite a successful pilot study in Scotland, and a contract signed with the software developers, the technology is yet to be rolled out across the country. Medics are concerned that any wait risks the health of patients.

Dr Magnus Janzon, who was medical advisor to the developers of the technology in Sweden, used CDS to look for cases of Atrial Fibrillation (AF) - or irregular heart beat - in patients as an indicator of stroke risk. Using CDS increased the number of cases spotted and so improved stroke prevention.

Janzon, a professor at Linkoping University and head of cardiology at University Hospital Linkoping, said there appeared to be underestimation of the number of people suffering from AF in Scotland. The current number of AF patients in Scotland stands at 96,000, but Janzon believes the true number is higher than 146,000.

Janzon says CDS would increase the number of correct diagnoses of AF, and allow sufferers who are currently untreated to be prescribed anticoagulant drugs to help prevent stroke. Janzon has calculated this would prevent 670 strokes a year and provide total savings of more than £44 million.

During tests in Sweden, ‘the number of patients getting the right treatment was raised in a significant way’, said Janzon.

He added that if the study was extrapolated for all of Sweden, 300 strokes would have been prevented over the test period. ‘Many lives can be saved,’ Janzon said. The technology is now widely used across the country.

Janzon said the technology was an ‘easy and cheap way’ of giving patients the best treatment. It is designed to eliminate human error and the chance of a doctor failing to spot risk factors. If a patient is not receiving the correct treatment, the technology will alert the doctor and advise on risk and medication.

CDS, says Janzon, ‘follows the medical evidence, and follows the guidelines that we as doctors are not following’. Some estimates in Sweden have put costs as low as 17 pence per person per year.

Janzon’s next project is to use CDS to treat Familial hypercholesterolemia - an illness involving very high cholesterol levels. Many suffers are unaware they have the disease. CDS will spot family connections to the condition. ‘We will look at relatives,’ said Janzon. ‘If you find one person with high levels you can prevent seven other relatives [from living unwittingly with the condition] and reduce risk.’

People with Familial hypercholesterolemia are an ‘under treated group’ like AF suffers, says Janzon, as they can go undiagnosed. CDS will also be tested for early treatment of Septic anaemia.

‘It is a platform where you can build in what you want to look at,’ said Janzon, adding: ‘The software is a decision support tool for whatever you want. You can use it for stroke prevention, Familial hypercholesterolemia or whatever you want. It can be put in the direction that the government and doctors want. If there are gaps in the health care sector then you can use the software to focus on that.’

After pilot studies in Sweden, medics called Janzon’s team after the removal of the technology saying ‘they wanted it back - now it is back’, he said.

‘In Sweden, we have the goal that more than 80% of AF patients should be on the right treatment. We are far away from that but with CDS we are getting closer and closer. This tool helps us to treat patients in the right way.’

Janson wrote to Lewis Macdonald, Labour MSP and convenor of the Scottish Parliament’s Health Committee, offering to brief him on CDS and inviting him to Linkoping University. He did not get a reply.

Dr Kathrin Cresswell, Director of Innovation at Edinburgh University’s Institute of Population Health Sciences and Informatics, carried out an evaluation of a pilot study of CDS in order to ‘inform plans for its national roll-out’. The pilot was run by the Scottish government.

The evaluation found an ‘overall strong sense of support’ for the technology and ‘plans to roll it out across NHS Scotland’ from ‘a range of stakeholders including clinical leads, policy makers, pharmacists and GPs’.

Cresswell, who has evaluated health information systems in the NHS for a decade and consulted for the World Health Organisation, said: ‘There is good empirical evidence that these systems are effective in improving healthcare professional performance.’ Cresswell added that she thought the introduction of CDS technology would ‘likely be beneficial’.

Other studies have shown that ‘the risk of patients being inadvertently harmed by erroneous prescribing may be greatly reduced by the introduction of CDS systems’, Cresswell said, adding: ‘I think these systems have great potential to make a big difference, but I would caution that they should not be viewed as a panacea.’

Notes from a senior Scottish radiologist passed to the Herald on Sunday said: ‘Most clinical incidents that result in harm are a result of human decision error. CDS hopes to reduce this. The converse is true. Delaying CDS may therefore result in harm.’ The radiologist asked: ‘What steps have been taken to measure the clinical impact of the decision to delay CDS?’

Miles Briggs, health spokesman for the Scottish Conservatives, said he was ‘concerned that the Scottish NHS was so slow at adapting and adopting technologies like this’.

‘One thing we’ve seen over the last 12 years is a reluctance by SNP ministers to embrace new technology,’ Briggs said, adding: ‘All politicians are scared of risk around cost and actually investing in the future rather than being stuck in crisis mode.’

The Scottish Conservatives are developing a ‘health tech paper’ looking at ‘shifting health spend towards preventative spend’. Briggs added that CDS ‘is exactly what we should be doing’.

‘If we can identify stroke patients then there is a huge saving. When someone’s had a stroke the actual cost around care is huge compared to if we can identify them early on,’ he said. ‘We obviously need investment in health tech within GP practices.’

Briggs added there were wider concerns about technology and the Scottish NHS. ‘Our health boards can’t even speak to each other - that’s where we are when it comes to technology.’

He said: ‘We need to look towards a real national discussion in terms of what we are doing around health tech.’ Briggs added: ‘I sum it up from the fact that most of our community health nurses are out writing patient notes on paper instead of having access to iPads.’

On the issue of CDS being piloted and not yet rolled out, Briggs said: ‘There’s more health tech pilots in Scotland than there are at Heathrow Airport. The NHS lets these projects in to a GP practice but once that’s finished there’s no back up to say where will it then be taken forwards.’

He added: ‘I think it is a lack of ambition more than a failure. I think ministers have been too stuck in crisis management in terms of the health service … There’s been a lack of vision.’

The use of health tech like CDS would be a ‘real game changer in Scotland around how we tackle our well documented health inequalities’ as well as ‘not just improving the health of people today but looking towards preventative health in the future’.

Briggs said that radiographers had told him that scans from the Highland and Grampian areas were being sent to Australia and New Zealand for assessment because of shortages among staff. Radiographers told him that AI technology could be used to ease pressure.

Although CDS does not involve ‘machine learning’ - one of the key elements of Artificial Intelligence - medics and other experts describe the technology as AI due to its ability to give advice to humans after deep dives into big data sets.

Swedish healthcare company Cambio developed the CDS software used by Dr Magnus Janzon. A UK representative of the company said that after the evaluation of the CDS pilot study, a contract was signed to roll the technology out within the Scottish NHS and all GP services. The contract cost £400,000 a year over five years, the representative added. In March this year, the representative said, the roll out was put on hold.

One medic closely involved with CDS in Scandinavia and the UK said: ‘There is no system that does what this is supposed to do.’ They added that not introducing CDS meant ‘patients are coming to harm and it is costing the NHS lots of money.’

On the delayed roll out, the medic said: ‘Why on earth are they stopping it for some reason that no-one can understand? Why is it not launched now? Why isn’t it urgently put in clinical situations? By delaying it, we are potentially putting people at harm.’

The medic said he wished to speak anonymously as he did not want ‘confrontation with the Scottish authorities. I want to see them save lives. Taxpayers will pay the price for bureaucracy.’

WHAT THE POLITICIANS SAY

Health Secretary Jeane Freeman said: ‘There is growing evidence to suggest that the development and use of artificial intelligence and technology in healthcare will help patients and professionals make more informed decisions about health and social care, which is why we are supporting further research and development in this emerging field.

‘This includes understanding how we maximise the use of AI in decision support. The first phase of developing a national approach is reaching its intended conclusion. We will review the next steps, along with the evidence base, over the summer before reaching any decision. This review has always been part of our planning, and gives us the opportunity to consider against other national digital health and care priorities.’

On the issue of the pilot study and the contract, a government spokesperson added: ‘There was no commitment to a national roll-out of the Cambio pilot. The arrangement with Cambio is a Framework Agreement drawn up by NSS [National Services Scotland] which gave the option to call off for wider roll-out. The Cambio pilot also predated the Digital Health & Care Strategy and we need to consider our overall approach to decision support, of which Cambio is just one part.’

The Scottish government commissioned the Digital Health and Care Institute (DHI) to lead on the evaluation of ‘decision support’ technology. The DHI is part of the Scottish Funding Council’s (SFC) Innovation Centre Programme, and is almost wholly funded by the Scottish Government. The SFC is a non-departmental public body. The University of Strathclyde hosts DHI. The contract with Cambio is therefore with the University of Strathclyde, a Scottish government spokesperson said.

A member of staff for Lewis Macdonald, convenor of the Scottish health committee, said of CDS that he ‘isn’t aware of the exact piece of technology’ despite being written to by Dr Magnus Janzon. The committee will be following up on recommendations made in its own report on Technology and Innovation in Health and Social Care ‘in due course’. The staff member added: ‘But given [the committee’s] current work programme [they] are unlikely to have the scope to look again at technology and the NHS for some time.’